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Mental Illness in Assisted Living: Growing Need Presents New Opportunity

By Elizabeth Ecker for ALFA Update

Senior living providers today say they are seeing much more demand for services to address the needs of residents suffering from mental illness. While they see the opportunity in providing that care, delivering it presents more of a challenge.

There are between 5.6 million and 8 million older adults in America who have one or more mental health and substance abuse conditions according to a study by the Institute of Medicine (IoM) of the National Academies. That’s roughly one in five of the older adult population.

The population surge that is expected over the next 20 years holds “profound consequences” on this front, because the nation’s current system to care for the aging population is less than prepared for those suffering from mental illness, IoM says.

Adding another level of complexity is that major depression can be difficult to differentiate from grief. Many—by some measures more than half—of assisted living residents have experienced an event that may lead to a diagnosis of depression, for example, as the result of the loss of a loved one.

Responsible in part for the rising demand, care providers say, is the raised awareness and communication about these issues among older adults and family members. This was much less the case 20 years ago, they say.

“This isn’t new,” says Jennifer Wiest, vice president of clinical services for California-based Carlton Senior Living, of the demand for services for mentally ill residents. “These issues have been here before; it’s just that the Greatest Generation didn’t vocalize them. They didn’t talk about it. Now, all of a sudden, there is communication about [mental illness].”

With many potential residents and their family members being more open about depression, bipolar disorder, anxiety disorders and other diagnosed mental illness, their ideas about the level of treatment has changed as well.

“The expectations are a lot higher,” says Michelle Hamilton, senior vice president and chief of assisted living operations for Country Meadows Retirement Communities based in Hershey, Pennsylvania. “People shop more. They come to us with the idea that other communities are offering this, and that drives their expectation.”

Depending on the state where the community is located, the ability to tailor programs around the needs of residents can be impacted.

The demand may be rising, but communities are handling the needs very differently. For some such as California, it is not much of an issue, says Wiest.

“We treat the person as a whole and look at the entire picture,” she says. “We are very particular about not focusing on the disease but the person. More and more we are teaching and training not to have that stigma.”

At Carlton, the community addresses any issues upfront to ensure that it has the right people in place to offer the treatment that is needed. If not, after an initial assessment, the community will refer the patient elsewhere.

In contrast, New Jersey-based Chelsea Senior Living offers a program specifically designated for people who suffer from mental illness. The program, called “The Crossings,” is located in the provider’s New Brunswick, New Jersey location. 

The Crossings has been in place for nine years, and is specifically geared toward residents who have a psychiatric diagnosis but not dementia. There, they can take advantage of individual or group therapy.

“There absolutely is growing demand for this as the population is living longer and is experiencing more depression,” says Edie Empirio, vice president of operations for Chelsea.

Not an acute care setting, The Crossings has access to a psychiatrist on call as well as a psychologist. And while residents do occasionally have to be referred to higher levels of care, for the most part, the 20-bed program remains full, with about half of its residents ultimately returning to the more traditional assisted living setting.

“It’s definitely needed,” Empirio says. “But we have had our challenges over time. The price point is higher and you have to really be able to sell the program.”

Further, varying state regulations regarding the care of mentally ill residents provide an additional layer of providing those services.

In New Jersey, for example, where The Crossings is based, there is more flexibility on the level of acuity that can be cared for.

In California, where the community must assess each resident’s mental state, the community must determine whether the resident's primary need for care and supervision results from either an ongoing behavior, caused by a mental disorder, that would upset the general resident.

Despite an estimated 14 to 20 percent of the nation's overall elderly population suffering from one or more mental health conditions or problems, senior living providers are still figuring out the best way to deliver the care needed. 

“There absolutely is an opportunity there,” Hamilton says. “It can be a big black hole these residents fall through. In the case of a dual diagnosis [of dementia and memory care], there is no setup to care for them.”

The Institute of Medicine stressed that lack of services based on several challenges providers face. These challenges include recognizing and identifying the issues, staffing for the proper level of therapy needed, as well as the cost.

"These conditions are relatively common, they can be costly, and they can have profound negative impacts on people's health and well-being,” said IoM committee chair Dan Blazer of Duke University Medical Center. “This report is a wake-up call that we need to prepare now or our older population and their extended families will suffer the consequences."

Those addressing the issues now may be considered pioneers on this front, but others have still largely shied away due to the financial risks involved in providing such specialized care.

“Do you have the resources to support it and do you want to put the outlay of substantial financial support to build a center designed for psychiatric care?” Hamilton says. “There is definitely a need, it’s a matter of somebody taking the leap and doing it.”

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