Area nursing homes now deal more with mental health issues

Geriatric mental health issues are increasingly at the forefront of nursing home care as Maine grapples with the distinction of having the oldest population in the nation, with Washington County being one of a handful of counties with the oldest populations in the state.
Compounding the issue is the lack of geriatric psychiatric facilities in the state, with the only one being in Portland at the Maine Medical Center, to help with diagnosis, research and care solutions, explains Nathan Brown, administrator of the Eastport Memorial Nursing Home (EMNH). "It's not a population that gets attention," he adds. "There's less political will to force funding, even when they [the legislature] look at the demographics."
Dementia and its many aspects are a gradual progression, Brown points out, and it's probably one of the toughest issues facing the nursing home community. In the past, aging patients with mental health issues went to state institutions. Brown is happy to see that model has been disappearing. But he explains, "Geriatric mental health care has never been the intention of nursing homes." However, it is becoming the norm because of the age of residents entering the system.
Brown sheds light on a related problem. "Once you're diagnosed with dementia, it takes precedence over other diagnosis of mental health." For example, he says, if a patient was diagnosed as bipolar but then diagnosed with dementia, the bipolar condition "gets masked behind the dementia."
Changes in caring for the elderly, with the stress now on finding home‑based solutions, means that when the elderly do need to come to nursing homes they are usually far older than was the custom 30 years ago. "We'll see a higher acuity in a person when they arrive at the nursing home. They were cared for at home successfully, but when it's time to transition to the nursing home, it's usually because something has happened." Brown explains, "We're aging longer. The neurological side of things starts manifesting."
In less than a decade Washington County has lost three of out of its six nursing homes, with the number of beds decreasing from about 230 to 111. The 26‑bed Eastport Memorial Nursing Home, along with the two other nursing homes based in Machias and Milbridge, is rising to the challenge of meeting the increased pressures of the county's aging population, but it has not been easy.
Brown and his family were involved with running the for‑profit Oceanview Nursing Home in Lubec for many years until it closed in 2014. He has been on the job at EMNH four months and is pleased with how things are going. "We have a waiting list now. That hadn't happened for years." Nursing homes need to operate at full capacity, he explains. The operational costs don't go down proportional to the number of residents. However, having a waiting list is an indication of the larger issue facing the county. "The waiting list means we don't have the capacity in the community to meet the demand. That's a statewide problem. There are pockets of need."
In the past the nursing home saw swings of about 20% in its census. "That's 5.2 people," Brown points out. "So at 80% we were still spending the same. We can't absorb those swings. A small census change is big." With the waiting list the home isn't forced to react all the time, he adds.

A financial juggling act
The financial health of the nursing home is a juggling act based on the level of acuity and care needed and associated costs and reimbursements. The Eastport nursing home has a cost‑based reimbursement structure. "We wouldn't be able to have the managerial level that we have" without that structure in place, Brown says. The home is able to have activities and social services on hand that would be cut to 13 hours per week each if the home was configured on the more commonly used reimbursement structure. "That's not sufficient" to meet the needs of residents, he adds.
However, the cost‑based model has its own set of challenges. The costs for last year determine the reimbursements for the following year. Brown comments that if costs increase, the nursing home must either request legislative intervention for increasing the budget or spend more. Spending more means having a flush revenue stream, and when the majority of residents are on MaineCare, revenue streams are tight.
"The public or private patient will have some portion that they have to pay" for residing at the home, Brown says. He explains that for most patients all but $40 of their monthly Social Security check goes towards paying for their room and board. The $40 is for the resident's personal items. If Social Security doesn't cover the full cost of room and board, "then the differential is paid by the State of Maine."
Brown is grateful that the nursing home has its cost‑based model. "It has enabled us to weather the storms." And he has nothing but kind words to say for the residents, the staff and for the deep commitment of community members who serve as volunteers on the EMNH Auxiliary and on the EMNH Board of Directors. "I really appreciate their knowledge of the corporate history and the intent of the mission." He adds of the board, "They've been wonderful to work with."