Behavioral Health Facilities Resolution

Resolution: Specialized Populations

Dignity Alliance supports lifting the DON moratorium for specialized skilled nursing facilities for substance use/mental health issues and COVID-19 rehabilitation. Any applicant which proposes to serve this population should demonstrate that it has the skills, expertise, appropriate programming, and trained staff to adequately meet the needs of the population.

We question the need for special facilities for homeless elders who should be helped to remain in their community as much as possible through rental assistance and support services from organizations such as PACE providers, Senior Care Organizations (SCO), Independent Living Centers (ILC), and Aging Service Access Points (ASAP).

We believe that the cultural and linguistic issues exist in many conventional nursing homes should be addressed through new policies and enhanced programming rather than issuing a DON for a specialized services facility


Population with Substance Use and Mental Health Disorders.

According to a May, 2017 report by Margaret Mattson, Ph.D, Rachel N. Lipari, Ph.D., Cameron Hays, M.A., and Struther L. Van Horn, M.A.,  “Although the percentage of people with substance use disorder (SUD) reflects the decline in use as people age, more than 1 million individuals aged 65 or older (“older adults”) had an SUD in 2014, including 978,000 older adults with an alcohol use disorder and 161,000 with an illicit drug use disorder. Research suggests that substance use is an emerging public health issue among the nation’s older adults. Illicit drug use among adults aged 50 or older is projected to increase from 2.2 percent to 3.1 percent.  There is a cohort of older adults who may experience the negative consequences of substance use, including physical and mental health issues, social and family problems, involvement with the criminal justice system, and death from drug overdose. Older adults are more likely than people in other age groups to have chronic health conditions and to take prescription medication, which may further complicate adverse effects of substance use.”  As the general population of older adults continues to increase through 2030, it is reasonable to expect that the specialized population with substance abuse is likely to grow at least as fast. While the need for this type of facility for older adults in this specialized population is clear, the applicant must be evaluated based on their history of misuse of anti-psychotic drugs in any conventional care facility for which they are licensed.  According to the Long-Term Care Community Coalition, the 2019Q3 federal report on inappropriate use of anti-psychotics, a significant number of Massachusetts licensed skilled nursing facilities reflect misuse well above the national average use of such substances.  Therefore, those licensees with significantly above average misuse of anti-psychotic drugs in their current facilities should not be considered a suitable applicant for a new DON to treat substance use and mental health disorders.

Population at Risk of Homelessness

The National Health Care for the Homeless Council reports in 2019 that “older adults comprise a growing proportion of the homeless population, and indeed homelessness causes premature aging.  The health care and homeless services systems are bracing for more older adults with increasingly complex needs.  Older adults who are experiencing homelessness have three to four times the mortality rate of the general population due to unmet physical health, mental health, and substance use treatment needs. The combination of issues typically associated with homelessness among older adults, such as reduced mobility and a need for assistance with daily activities associated with behavioral and substance use concerns,  is resulting in the demand for housing and services providers to develop an array of creative solutions. This population is typically experiencing poverty and unable to find safe, affordable housing.

New long-term beds dedicated to older adults at risk of homelessness may not be the best solution for this population.  Homeless adults often resist going to shelters that lack privacy and safety, however a specialized skilled nursing facility might not be the best option.  Independent living options are, with support services, such as HEARTH offers – housing specifically for people who have been homeless, or at least at-risk of homelessness.  They provide wraparound services to support these residents to keep them living independently.  Traditional nursing homes, rest home, and assisted living residences are not able to provide this.

Given the prevalence of substance use among an older homeless population, if the Department accepts applicants for a specialized program, the applicants must be evaluated based on their history of misuse of anti-psychotic drugs in any conventional care facility for which they hold licenses. 

Population with Cultural or Linguistic Needs

A 2018 article in FORBES stated that “now the oldest boomers are entering their 70’s, which means they’re starting to enter the nation’s independent living, assisted living and skilled nursing homes. However, these facilities have lagged the diversification trends. Many are not prepared to provide welcoming environments to residents from a variety of orientations, religions, and ethnic backgrounds. Simply demonstrating compliance with federal, state, and local fair housing laws does not guarantee that the environment inside senior residences will be welcoming for all people. Creating an inclusive environment requires the will to do so.”  It is important for providers to recognize that specialized, culturally-sensitive dietary services and the availability of non-traditional medical care practices are important aspects of the services to be provided.

“The National Gay and Lesbian Task Force estimates that 3 million LGBT elders live in the United States, and that number will double by 2030. Clearly, this signals a demand for LGBTQ-friendly senior housing. Add to that, the growing number of people in other diverse demographics, such as Muslims, Hindi, Buddhists and people from China, India, the Middle East and Latin America, and it becomes clear that America’s independent living, assisted living and skilled nursing homes need to step up their diversity competency to meet the needs of today’s retirees.”

Cultural competency and multi-language proficiency are among the issues which Massachusetts nursing facilities traditionally serving an English speaking, non-diverse population must address.  Increasingly, immigrants with limited English language fluency are serving English-speaking older adults in skilled nursing facilities.  This can frequently create miscommunication resulting in mismanagement of prescribed medications, rejection of various foods, and anxiety and tensions between caregiver and care receiver.  There is a heightened and immediate need to address cultural and linguistic requirements in many currently operating Massachusetts nursing homes.  Specialized nursing homes serving distinct population with specific cultural or linguistic characteristics is less desirable than setting expectations for current nursing homes to provide welcoming environments and to remove culture and / or language barriers.  Problems arise not so much because of the differences, but due to insufficient efforts to enable people from varying perspectives to live harmoniously together. Staff must be well-trained in multi-cultural awareness and practices to reduce unconscious bias tendencies.  Direct care, support, and management staff should be provided information and guidance in multiple languages.  Segregating residents of specific, relatively homogeneous sub-groups could very well violate existing federal and state fair housing laws in fact if not in spirit.  We advocate that the availability of a specialized DON for cultural and linguistic needs be dropped from the DON categories listed in the Memorandum.

Population with COVID-19

New facilities, or additions to existing facilities, to serve those recovering from COVID-19 or the needs of so-called “long haulers” who experience other mental or physical issues resulting from the virus, may be needed.  However, any facility must expressly document that management has learned the lessons that COVID-19 is teaching us.  An affected population must be housed apart from any general population of older adults that have not experienced the virus.  The characteristics of these specialized units should be comparable to those which serve persons with dementia and cognitive issues to maintain separation of the population with the disease from those without infections.  Providers must enforce visitation policies that are designed for safety while maximizing socialization. Operating plans must optimize the deployment of staff to specific populations to minimize spread of infection and ensure enough testing supplies, PPE, and appropriate medications are always available. Staff must be well-trained and supervised in infection prevention and control.

In any such specialized facility, there must be special attention to the care of both staff and residents.  Facilities serving this population must have a close, active affiliation with an acute care hospital or health system.  A DON application for a specialized COVID-19 skilled nursing facility must have a conversion and operating plan for activation when the need for such a specialized facility has dissipated.  The issuance of a DON should require a periodic full review of continuing need for the specialized services.

There must also be a requirement that should a resident require to be re-admitted to an acute care facility, the bed shall be held as long as necessary to enable the patient to return when appropriate and as desired by the patient.  Frankly, this should be a requirement in all skilled nursing facilities for residents who require hospitalization.