by Amanda Buster and J. Wesley Boyd
Maxwell Jones is in his 70s, has advanced Alzheimer’s disease, and lives in a nursing home in eastern Massachusetts. Not too long ago, he went three days without a meal because his roommate kept stealing his food, and no one stopped it from happening—either because staff didn’t notice or they didn’t have the time or training to intervene.
Nursing homes as hidden psychiatric wards
Tens of thousands of older adults spend their final days in nursing homes and other long-term care facilities in Massachusetts, where we reside.[1] And across the United States, there are currently about 1.2 to 1.3 million people who reside in nursing homes on any given day. As the population ages, demand for nursing home services is only going to rise. One national study projects that the number of nursing home residents will triple by 2050.[2] Yet, unbeknownst to many, these institutions have quietly become de facto psychiatric wards, given the large numbers of residents who experience depression, bipolar illness, schizophrenia, or, like Mr. Jones, Alzheimer’s disease. Because of this gradual progression, nursing homes are now second only to prisons and jails as the largest institutional care settings for adults with serious mental illness.[3]
Providing mental health care in nursing homes is not optional; optimal mental health is central to residents’ quality of life and physical health outcomes. Depression in older adults is associated with poorer rehabilitation, and serious mental illnesses often impede patients’ ability to be discharged to their homes.[4,5] Residents with mental illness are more likely to become long-stay residents, even when they don’t need the functional or clinical support that would typically lengthen stays.[6] Prolonged, unnecessary institutionalization erodes a person’s sense of identity and control, which in turn leads to more depression, anxiety, and behavioral dysregulation, only compounding an already bad situation. All of this translates to resource-intensive care, requiring a staff member for every five residents, especially in memory care settings.[7] However, chronic staffing shortages make it impossible for facilities to provide that level of care.
Structural barriers that keep residents institutionalized
Researchers at the University of Michigan found that this institutionalization is due in part to limited access to community resources for these individuals, leading to unnecessarily long-term stays for residents who otherwise could be living in a lower level of care, reducing strain on facilities and promoting individual autonomy.[8] The 1999 Supreme Court decision in Olmstead v. L.C. held that unjustified segregation of individuals with disabilities constitutes discrimination under the Americans with Disabilities Act. In everyday terms, this means that keeping individuals in nursing homes who could otherwise live in community settings might not just be unethical or harming their civil rights; it might also be illegal.[9]
Regulations that ignore mental health needs
According to researchers, structural barriers to discharge, including financial strain on families, unreliable access to transportation to complete outpatient psychiatric exams, and a lack of housing options with embedded mental health support, have prevented the integration of these nursing home residents into communities and allowed nursing homes to become a “de facto destination for individuals with mental illness.”[10] The major obvious problem with this development is that nursing homes are not designed to serve as psychiatric institutions, but for the reasons above, they are often unable to place residents in alternative care. At the same time, staffing levels and regulatory frameworks fail to adequately treat or prevent mental illness, resulting in prolonged institutionalization and the potential for harm. In Massachusetts, regulations narrowly focus on metrics related to physical care, including medication management and infection control, while mental health services remain inconsistently available for residents, and existing regulations overlook them.[11] And as we consider what is happening around the country, we fear that Massachusetts might be one of the states with more protections for these residents, rather than less.
Minimum staffing standards fall short
In 2024, the Centers for Medicare & Medicaid Services established the first federal minimum staffing standards for nursing homes participating in Medicare and Medicaid. These rules mandate a total of 3.48 hours of nursing care per resident day. Our home state of Massachusetts requires nursing homes to provide 3.55 hours per resident per day of nursing care. Both of these mandates—Medicare’s and the Commonwealth of Massachusetts—fall well short of the 4.1 hours of nursing care per resident per day that research shows ought to be the minimum threshold for nursing homes.[12]
Industry leaders argue that increased regulations might make it impossible to keep nursing homes open.[13] This concern is real. Any new regulations ought not mandate higher staffing rates without addressing limitations driven by reimbursement structures and capacity for training. In response, Massachusetts should pair an increased staffing requirement with targeted rate adjustments specifically aligned with behavioral health services, acknowledging existing structural barriers that prevent residents from seeking care elsewhere.
What state and federal agencies must do now
In conclusion, the question is not whether a crisis exists within nursing homes. It does. The real question is whether state and federal governmental agencies will modernize rules and regulations to ensure that nursing home residents with mental illness receive the care they need. What should these actions look like? To begin, regulations ought to be put in place to increase the nursing requirement for nursing homes to 4.1 hours. Second, reimbursement rates for nursing home services—especially those that serve large numbers of residents with mental illness—need to be raised to levels that can support increased staffing levels and training. And finally, there needs to be investment in community housing and mental-health services so that nursing homes are not the default option for those with mental illness.
Nursing home residents like Mr. Jones deserve no less.
Amanda Buster is a Master of Science in Bioethics student at Harvard Medical School
A version of this post also appears on KevinMD