Frederick Smith is in his 70s, has advanced Alzheimer’s disease, and lives in a nursing home just south of Boston. He has not had a meal in three days because his roommate is stealing his food and no one has stopped it, either because staff have not noticed or do not have the time or training to intervene.

Tens of thousands of older adults spend their final days in nursing homes and other long-term care facilities. As the population ages, demand for nursing home services is only going to rise. One study projects that the number of nursing home residents will triple by 2050. Over time, these institutions have quietly become de facto psychiatric wards, given the large numbers of residents who experience depression, bipolar illness, schizophrenia, or like Mr. Smith, dementia. Nursing homes are now second to only prisons and jails as the largest institutional care setting for adults with serious mental illness.

The growing mental health crisis in nursing homes

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. Residents with mental illness are more likely to become long-stay residents, even when they do not need the functional or clinical support that would typically lengthen stays. These conditions translate to resource-intensive care, requiring a staff member for every five residents, especially in memory care settings. However, chronic staffing shortages make it impossible for facilities to provide that level of care.

Researchers at the University of Michigan have found that this institutionalization is due in part to limited access to community resources, leading to unnecessary long-term stays for residents who otherwise could be living in a lower level of care, reducing strain on facilities and promoting individual autonomy. 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. By that standard, keeping individuals in nursing homes who could otherwise live in a community setting might not just be unethical, it might be illegal as well.

Structural barriers and regulatory failures

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 residents into communities, and allowed nursing homes to become a “de facto destination for individuals with mental illness.” This creates a paradox: Nursing homes are not designed to serve as psychiatric institutions, yet fail 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.

The Massachusetts Department of Public Health requires nursing homes to provide 3.55 hours per resident per day of nursing care, even though research indicates that 4.1 hours of nursing care per resident per day should be the minimum threshold for nursing homes. Additionally, Massachusetts state regulations only require a nursing home to have two staff members, which seems absurdly low and allows facilities themselves to “determine appropriate staffing levels.”

Industry leaders argue that increased regulations might make it impossible to keep nursing homes open. This concern is real. Any new regulations ought not mandate higher staffing rates without addressing limitations caused 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.

A path forward for reform

In conclusion, the question is not whether a crisis exists, but instead whether or not Massachusetts will modernize rules and regulations to ensure nursing home residents with mental illness receive the care they need. As such, the Massachusetts Department of Public Health needs to take decisive action:

• Increase its nursing requirement for nursing homes to the 4.1 hours research deems necessary.
• Increase Medicaid and state reimbursement rates for nursing home services, especially those that serve large numbers of folks with mental illness, to levels that can support increased staffing levels and training.
• Invest in community housing and mental health services so that nursing homes are not the default option for those with mental illness.

Nursing home residents across our country like Mr. Smith deserve no less.

Amanda M. Buster is a bioethics student and J. Wesley Boyd is a psychiatrist.