摘要：Objectives. We assessed whether reductions in inpatient psychiatric beds resulted in transinstitutionalization to nursing home care of patients with serious mental illness (SMI) within the Veterans Health Administration (VHA). Methods. We assessed trends in national and site-level inpatient psychiatric beds and nursing home patient demographics, service use, and functioning from the VHA National Patient Care Database, VHA Service Support Center Bed Control, and VHA Minimum Data Set. We estimated nursing home admission appropriateness using propensity score analyses based on Michigan Medicaid Nursing Facility Level of Care Determinations ratings. Results. From 1999 to 2007, the number of VHA inpatient psychiatric beds declined (43 894–40 928), the average inpatient length of stay decreased (33.1–19.0 days), and the prevalence of SMI in nursing homes rose (29.4%–43.8%). At site level, psychiatric inpatient bed availability was unrelated to SMI prevalence in nursing home admissions. However, nursing home residents with SMI were more likely to be inappropriately admitted than were residents without SMI (4.0% vs 3.2%). Conclusions. These results suggest the need for increased attention to the long-term care needs of individuals with SMI. Additional steps need to be taken to ensure that patients with SMI are offered appropriate alternatives to nursing home care and receive adequate screening before admission to nursing home treatment. Over the past half century, the locus of psychiatric care has shifted from long-term inpatient psychiatric hospitals to community-based outpatient care settings, 1 with this “deinstitutionalization” movement resulting in a sharp decline in state psychiatric hospital beds. 2 This movement is regarded as a “disaster of the past,” 3 in part because of the inadequacy of outpatient services to meet the needs of symptomatic psychiatric patients. 3,4 In the absence of adequate community-based services, deinstitutionalization in name often resulted in transinstitutionalization in practice, as symptomatic patients were shifted to other institutional settings, such as general hospitals and nursing homes. 1 Research investigating transinstitutionalization has mixed results. A 3-year follow-up of patients discharged from a state psychiatric hospital found rates of more than 20% admission to community inpatient psychiatric units, with an average of more than 75 yearly inpatient days per patient. 5 Similarly, a large-scale longitudinal evaluation of the Canadian mental health system found that reductions in inpatient psychiatric beds were associated with increased utilization of general hospital psychiatric beds, a pattern that continued for more than 2 decades until community mental health services expanded to meet the needs of psychiatric patients. 6 However, another evaluation of discharged state psychiatric patients found decreased rates of postdischarge jail and general hospital psychiatric unit utilization relative to the use of these services during the time that patients received state psychiatric care. 7 There has been limited investigation into transinstitutionalization to community nursing home settings. The only large-scale study of transinstitutionalization to nursing home care was conducted in Norway, in which the effects of downsizing psychiatric hospitals were evaluated for more than 50 years. During the first 2 decades, there was evidence for transinstitutionalization because patients previously treated in state-run psychiatric facilities were enrolled in increasing numbers in nursing homes. Similar to the Canadian evaluation, this pattern continued until community-based mental health services evolved to meet the needs of these psychiatric patients, with transinstitutionalization to nursing home care ending by the early 1970s. 8 Many nursing homes are unable to offer the specialized treatment required by patients discharged from state mental hospitals. 9 Concerns about such shortcomings led to the Omnibus Budget Reconciliation Act of 1987 (OBRA-87). This legislation set guidelines for standardized mental health screening and treatment within nursing homes, with the goal of reducing inappropriate admissions and improving the care of patients with psychiatric conditions already enrolled in nursing home care. Although OBRA-87 had positive effects, 10,11 it also has its shortcomings. 12 Despite OBRA-87, available data suggest that nursing homes continue to have sizeable proportions of residents with serious psychiatric disorders. In a study of more than 9000 Veterans Health Administration (VHA) nursing home residents, nearly one fifth of residents (17.9%) met criteria for serious mental illness (SMI). 13 Similar levels of SMI prevalence were found in nursing home populations outside of the VHA. 14,15 It is unclear at this time whether these patients were placed appropriately into nursing home care or inappropriately admitted in the absence of adequate inpatient psychiatric services. Reductions in psychiatric inpatient bed availability have continued in recent years. There has been a national reduction from 99 223 psychiatric beds in 1990 to 55 576 beds in 2009 within hospitals. 16 Meanwhile, nursing home bed availability has increased. The number of available beds within skilled nursing homes increased from 512 107 in 1990 to more than 1.5 million in 2009. 16 Transinstitutionalization demonstrates the interconnectedness of institutional settings. 17 To date, however, few studies assessed relationships between psychiatric inpatient and long-term care services in a single health system. Although transinstitutionalization to nursing homes was observed in previous decades, it is unclear whether these patterns continued in recent years. This study examined trends in psychiatric inpatient resources in the VHA health system, in association with VHA-funded nursing home care, which includes both VHA-owned nursing homes (which are today known as Community Living Centers) and VHA-contracted community nursing homes. To further evaluate the potential for transinstitutionalization between these settings, changes in the process of inpatient psychiatric care were tracked to evaluate evidence for unmet psychiatric needs. This study had 3 primary objectives: (1) to assess trends in VHA inpatient psychiatric beds from fiscal year 1999 (FY99) to FY07, (2) to assess relationships between changes in VHA inpatient psychiatric bed supply and the prevalence of SMI in VHA nursing home residents, and (3) to assess potential relationships between VHA psychiatric inpatient bed availability and the appropriateness of VHA nursing home admissions for patients with SMI.
