Barriers to Discharge for Nursing Home Residents With Serious Mental Illness

Importance Nursing homes deliver rehabilitative and long-term care for people with serious medical illnesses, functional impairment, and/or cognitive impairment. The population of nursing home residents with serious mental illness (ie, bipolar disorder, schizophrenia, other psychotic disorders) has grown substantially. Other than prisons and jails, nursing homes are the largest institutional care setting for adults (aged ≥18 years) with serious mental illness. Nursing home residents with serious mental illness become long-term residents despite less functional impairment, which may be a function of difficulty discharging these individuals to the community. Objective To examine barriers associated with discharging nursing home residents with serious mental illness back to the community from the perspective of frontline staff and administrative leaders. Design, Setting, and Participants This qualitative study included semistructured interviews conducted by phone and videoconferencing with staff members at nursing homes across the US between August 29, 2024, and January 9, 2025. Nursing homes that deliver care to patients with serious mental illness were identified using LTCFocus. Main Outcomes and Measures Themes and subthemes that represented barriers to discharge were analyzed from interview notes and transcripts using a rapid qualitative analysis approach. Results Interviews were conducted with 15 staff members (mean SD age, 44.7 12.6 years; 13 women 86.7%) from 8 nursing homes. Staff roles included social services directors (8 participants 53.3%), social workers or related roles (3 participants 20.0%), and administrators or other roles (eg, executive director, memory care coordinator, behavioral unit manager of a lock unit) (4 participants 26.7%). Participants identified multiple barriers to discharge at individual (eg, behavioral issues, medication compliance, withholding information, refusal to leave, comorbidities), relational (eg, lack of family support, strain on professional relationships), and structural (eg, limitations of insurance coverage, barriers to facility admissions, lack of substance and psychiatric treatment, waiting lists, transportation) levels, which together limited pathways to community discharge for residents with serious mental illness. Conclusions and Relevance This qualitative study found that multiple intersecting barriers are associated with discharging nursing home residents with serious mental illness back to the community, which may lead to clinically inappropriate long-term stays for those who could theoretically have been in a lower level of care setting. These findings suggest that enabling successful discharge to the community for nursing home residents with serious mental illness may require collaborative strategies that address individual, relational, and structural factors.