Addressing Disparities in Nursing Homes for People with Serious Mental Illness and Alzheimer's Disease and Related Dementias - Abstract: Nursing homes (NHs) care for a growing proportion of adults with serious mental illness (SMI) such as schizophrenia, leading some to call NHs “de facto mental health care.” Despite legislative efforts to reduce institutionalization for those with SMI, the prevalence of SMI in NHs has increased by approximately 80% in the last 10-years. Those with SMI have significantly greater odds of also having comorbid Alzheimer’s disease and related dementias (AD/ADRD) compared to those without SMI. Individuals with SMI and comorbid AD/ADRD are a particularly vulnerable group because SMI can complicate the identification and treatment of dementia, and SMI symptoms cause distress and amplify dementia-related behaviors and disabilities. The prevalence of SMI alone and SMI with comorbid AD/ADRD varies by race/ethnicity, with Black, Indigenous and people of color (BIPOC) having higher diagnosed rates of SMI. These concurrent trends reflect healthcare disparities, with NHs often serving as the provider of last resort in the absence of other viable options. To address these disparities, we need an evidence base for high-quality equitable NH care in these complex care situations. To properly develop such an evidence base, it is vital to understand the extent of SMI prevalence alone and SMI with comorbid AD/ADRD in NHs and assess quality outcomes for those with SMI alone and SMI with comorbid ADRD by race/ethnicity. We also need to identify modifiable organizational factors that can facilitate care for these groups. Yet, research on SMI in NHs is nearly a decade old and relies largely on federally mandated NH clinical assessment data (the Minimum Data Set, MDS). The MDS measures physical and cognitive health for care planning and may misrepresent SMI estimates. To address this gap, we will create a new, integrated dataset—MDS in combination with mental health screenings mandated on hospital discharge (Preadmission Screening and Resident Review, PASRR) and Medicaid/Medicare claims—for a comprehensive analysis of SMI, AD/ADRD, and health disparities in NHs. This application has three specific aims. In Aim 1, we will assess patterns of prevalence for SMI, AD/ADRD, and SMI with AD/ADRD in NHs over time (2013-2019 vs 2021-2022). We will generate longitudinal estimates of SMI with AD/ADRD in NHs and estimate how rates differ for those with and without AD/ADRD and by race/ethnicity. In Aim 2, we will estimate quality of life, a key person-centered measure, and quality of care for those with SMI with and without AD/ADRD (2011-2019 vs 2021-2022). In Aim 3, we will conduct qualitative case studies, including facility observations in 10 high- proportion SMI NHs of with varying proportions of residents with AD/ADRD and racial/ethnic composition (identified from Aim 1), coupled with 50 resident and 50 staff interviews. In meeting these aims, we will address a critical need for evidence on the prevalence, care needs, and organizational barriers to care for two NIH priority populations: NH residents with SMI, with and without ADRD, and BIPOC older adults.
