PSYCHIATRIC ASSESSMENTS OF NURSING-HOME RESIDENTS UNDER OBRA-87 - SHOULD PASARR BE REFORMED

OBJECTIVE: As part of nursing home practice reforms, OBRA-87 mandates formal psychiatric assessments (PASARR) of nursing home residents susp ected of having mental disorders, a responsibility it delegates indivi dually to states. We describe the initial year of implementation of th e PASARR process in King County, Washington, and characterize the ment al disorders and mental health services needs of nursing home resident s referred for psychiatric screening. DESIGN: Cross-sectional study. S ETTING: The 54 Medicare-certified King County nursing homes (total bed s = 7013). PARTICIPANTS: All patients referred for psychiatric evaluat ion under PASARR (n = 510). MEASUREMENTS: A systematic, multidimension al evaluation including a semistructured psychiatric diagnostic examin ation, validated measures of cognitive dysfunction, depression, and gl obal psychopathology, functional variables relevant to need for nursin g home care, and selected mental health services indicators.RESULTS: F ewer than 10% of all nursing home residents were referred for psychiat ric evaluation. A primary mental illness, evenly divided between psych oses and mood disorders, was found in 60% of the sample, and a psychia tric disorder associated with dementia or mental retardation was found in 25%. Six percent had complex neuropsychiatric features defying cla ssification, and 4% had no mental disorder. Other disorders, such as s ubstance abuse, were rare. Cognitive impairment and global psychopatho logy were prevalent in all diagnostic groups, and depressive symptoms were common even in patients without affective diagnoses. Eighty-eight percent of the sample were appropriately placed, based on their needs for daily care. Fifty-five percent had unmet mental health services n eeds. CONCLUSIONS: The PASARR referral process detected a group of ser iously mentally ill, functionally disabled patients, most of whom requ ired the level of care that nursing homes provide. Depressed and psych iatrically impaired dementia patients were underrepresented in the ref erral pool as measured against widely accepted prevalence figures for mental disorders in nursing home populations. The PASARR process as cu rrently configured appears to be most efficient in identifying schizop hrenic patients, who represent a small minority of nursing home reside nts, and the skewed sample it generates fails to provide an adequate b asis for estimating overall mental health services needed in nursing h omes. The PASARR process should be altered to improve referral rates f or depressed and behaviorally disturbed dementia patients.