title: Are nursing homes appropriate for older adults with severe mental illness? Conflicting consumer and clinician views and implications for the Olmstead decision.
abstract: OBJECTIVE
  In response to the recent Olmstead decision, to compare consumer and clinician perspectives on the appropriateness of nursing home settings for older adults with severe mental illness (SMI) in relation to clinical characteristics and care needs.
  
  
  METHODS
  Cross-sectional, descriptive, correlational study.
  
  
  METHODS
  Ten community mental health centers and two state-funded nursing homes specializing in long-term care for older persons with SMI.
  
  
  METHODS
  Consumers of mental health services in the community (n=115) and in nursing homes (n=106), aged 60 and older, with SMI. Sixty-four clinicians (51% registered nurses, 29% masters-level clinicians, and 20% certified social workers) conducted ratings.
  
  
  METHODS
  Consumers and their clinicians were independently asked to determine the most appropriate care setting for each consumer based on care needs from three alternatives: nursing home, congregate (group) living setting, or individual apartment/home. Clinical characteristics of participants with SMI were rated using the Mini-Mental State Examination, Brief Psychiatric Rating Scale, Specific Level of Function Scale, Cumulative Illness Rating Scale for Geriatrics, a modified memory and orientation subscale from the Clinical Dementia Rating Scale, and an item from the Minimum Data Set related to reasoning.
  
  
  RESULTS
  Of nursing home residents with SMI who did not have severe cognitive impairment, 40% (n=42) and 51% (n=54) were considered by consumers or by their clinician, respectively, to be more appropriate for a community-based setting, but there was a low level of agreement (only 27.6%; no better than chance) between consumers and clinicians on which nursing home residents were most appropriate for living in the community. Determinations by clinicians were associated with clinical need (diagnosis and less-severe behavioral problems), whereas there was no association between clinical needs and level of care determinations by consumers. Finally, clinicians considered a group home necessary for 93.7% of nursing home residents judged to be more appropriate for a community-based setting, whereas 90.5% of consumers stated that an apartment or individual home was indicated.
  
  
  CONCLUSIONS
  State implementation of the Olmstead decision will need to consider major differences in perspectives between clinicians and consumers on the most appropriate long-term care setting for older persons with SMI.
authors.affiliation: New Hampshire-Dartmouth Psychiatric Research Center, Lebanon, New Hampshire 03766, USA. stephen.j.bartels@dartmouth.edu
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Bartels
authors.forename: Keith M
authors.initials: KM
authors.lastname: Miles
authors.forename: Aricca R
authors.initials: AR
authors.lastname: Dums
authors.forename: Kristin J
authors.initials: KJ
authors.lastname: Levine
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D000704:Analysis of Variance; D040561:Assisted Living Facilities / Q000331:legislation & jurisprudence / Q000458:organization & administration; D001291:Attitude of Health Personnel; D016009:Chi-Square Distribution; D003258:Consumer Behavior; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007326:Institutionalization / Q000331:legislation & jurisprudence; D016015:Logistic Models; D008297:Male; D001523:Mental Disorders / Q000451:nursing*; D009735:Nursing Homes / Q000331:legislation & jurisprudence / Q000458:organization & administration; D011569:Psychiatric Status Rating Scales; D012720:Severity of Illness Index