Nurse leaders who want to improve behavioral health management often get stuck in the “I don’t know where to start” or “I don’t know what that should look like” phase, points out Jacob Berelowitz, LNHA, LMSW, CPHQ, CCM, program director of the Center of Excellence for Behavioral Health in Nursing Facilities (COE-NF) at Alliant Health Solutions in Atlanta, GA. “The key for nurse leaders to understand how to approach the behavioral health needs of nursing home residents is to think of them as what they are—another chronic health condition that requires interdisciplinary management.”
Similar to planning and managing the care for diabetes or any other chronic condition, behavioral health management begins with the interdisciplinary team screening and assessing the resident to identify that there is a condition, explains Berelowitz. “The next step is to learn about the history of that condition, including the resident’s treatment history and what typically triggers the condition. Then, your team has to develop a plan of care to meet everything that you have learned about the resident’s condition within a person-centered care framework that accounts for that resident’s individual goals and preferences.”
Note: While technical assistance will no longer be available after the COE-NF contract ends on Sept. 29, 2025, the COE-NF’s tools and resources will remain accessible here through September 2026 and also will be made available on the Centers for Medicare & Medicaid Services (CMS) website.
Taking the following steps can assist nurse leaders to implement effective behavioral health management that promotes nonpharmacological interventions instead of—or in conjunction with—psychotropic medications depending on each resident’s unique behavioral health needs:
Conduct a behavioral health needs assessment
“Under F-tag 838 (Facility Assessment) in Appendix PP of the State Operations Manual, nursing homes are required to evaluate the resident population’s behavioral health needs as part of the facility assessment that must be conducted at least annually and as needed,” points out Berelowitz. “How well you incorporate behavioral health needs into the facility assessment feeds into your success operationalizing federal regulations, specifically 42 Code of Federal Regulations (CFR) §483.40 (Behavioral Health), which includes F740 – F745, and 42 CFR §483.95(i) (Behavioral Health Training), which is covered in F949.”
One way to achieve this requirement is to conduct a behavioral health needs assessment, says Berelowitz. “The COE-NF developed a behavioral health needs assessment tool to guide nursing homes through this process. Basically, the tool will provide you with a framework for taking an inventory of what you need vs. what you have from a behavioral health management perspective.”
The inventory starts with understanding how many residents who are currently admitted to the facility have behavioral health needs, says Berelowitz. “And, what types of needs do they have? For example, do they have schizophrenia, bipolar disorder, or substance use disorders?”
Providers also should include anticipated residents in the inventory, suggests Berelowitz. “What behavioral health needs do you anticipate occurring in the next year based either on the referrals that are coming in or on the needs of the community that’s around your facility?”
The second step is to assess the current capacity of the facility to support the identified population-specific behavioral health needs, says Berelowitz. “What is the best way to meet your residents’ needs based on current standards of clinical practice, and do you have the capacity to meet those needs?”
The resulting inventory can then be used to identify any gaps that indicate opportunities for improvement and to develop an overall plan for staff behavioral health training, says Berelowitz. “Gaps could be related to training (e.g., educating interdisciplinary team members on how to incorporate behavioral health needs into care plans), but they also could involve making connections with additional community resources, whether that’s finding behavioral health providers to come into the facility or identifying other types of behavioral health providers across the continuum of care that may be worthwhile collaborators.”
While conducting a behavioral health needs assessment does involve upfront labor, the process helps nurse leaders work with the rest of the leadership team to identify the opportunities in advance, suggests Berelowitz. “Nursing homes have so many different competing priorities that you want to make sure that whatever time is being spent on behavioral health improvement is worthwhile.”
Note: The COE-NF offers this screening tool in two formats: Behavioral Health Needs Assessment (Without Examples) and Behavioral Health Needs Assessment (With Examples). In addition, Berelowitz provided an in-depth look at the components of a behavioral health needs assessment in the April 2024 webinar A Facility Assessment Approach to Behavioral Health. Access the recording and slide set here.
Review screening protocols
Screening protocols are essential to behavior health management, says Berelowitz. “You need to find out what behavioral health needs screening protocols your interdisciplinary team is currently using (1) before admission, (2) right after admission, and (3) during their stay as needed. For example, are you screening for mental illnesses? Are you screening for substance use disorders? Do your screening or assessment tools follow current standards of clinical practice?”
Note: Screening resources available from the COE-NF include the Guide for Substance Use Screening in Nursing Facilities, the Opioid Risk Tool, the Generalized Anxiety Disorder (GAD-7) screening tool, and the Columbia Protocol suicide screening tool.
Highlight screener/assessor training
“Who is doing screenings or assessments for behavioral health needs can really make or break screening accuracy,” says Berelowitz. “Those staff members should be trained on how to complete behavioral health screenings or assessments.”
Very often, residents with behavioral health needs that may not be listed out clearly in their medical record won’t self-report the information needed to help them unless they feel comfortable, points out Berelowitz. “For example, residents with a substance use disorder often have had many negative prior experiences when they disclosed about their condition. Screeners and assessors need proper training to ensure that these residents feel like your staff want to help and support them.”
Screening for behavioral health conditions involves asking residents and families to share some very personal information, adds Berelowitz. “So, screeners and assessors have to conduct these interviews in a private, calm, and comfortable space—and give residents a little bit of time to think, react, and respond to questions. Residents need to feel reassured that whatever they share will only be used to assist your team to help them while they are in your nursing home.”
Ask the interdisciplinary team to always go beyond the diagnosis
“Over the past few years of CMS’s schizophrenia audits, nursing homes have become pretty focused on ensuring that residents have accurate behavioral health diagnoses,” says Berelowitz. “However, it’s also important that the interdisciplinary team gets to know the resident’s treatment history, not just their diagnosis, once you have identified that the resident has a behavioral health condition.”
That treatment history should include finding out which treatments worked—and which didn’t—in the past, stresses Berelowitz. “Knowing this information will help the interdisciplinary team be more successful in supporting the resident. You want to understand both the resident’s nonpharmacological treatment history and their medication treatment history.”
Very often, the resident or their family member or friend may be able to provide insights on their treatment history, says Berelowitz. “Sometimes, you also may be able to track down a prior behavioral health provider. If you follow HIPAA privacy practices and obtain permission to talk to that provider, you can learn a lot about the resident’s treatment history so that you can best care for them.”
Learn each resident’s triggers
“Very often, residents with behavioral health conditions wax and wane between more mild symptoms and more intense symptoms,” notes Berelowitz. “Sometimes, their more intense symptoms may be triggered by, for example, environmental stressors or certain holidays or seasons.”
The interdisciplinary team needs to try to learn what the resident’s triggers are, stresses Berelowitz. “Obviously, doing what you can to understand their specific triggers will improve resident care. You can either try to help the resident avoid their triggers altogether, or you can do your best to mitigate the triggers when you know that they will occur. It’s very similar to how you eliminate or reduce the impact of re-traumatization triggers when you provide trauma-informed care. That same process applies across most behavioral health conditions.”
Focus on the day to day—not just crisis response
Staff education on crisis response—understanding what interventions are available to de-escalate the situation when a resident experiences a crisis—is important, says Berelowitz. “These are critical skills for staff to have for the safety of the resident, for the safety of the staff members themselves, and for the safety of others around the resident.”
Note: The COE-NF offers a variety of resources on de-escalation education, including a bite-sized learning training video, an educational module, an in-service toolkit, and a flyer.
However, understanding the resident’s behavioral health needs involves more than recognizing their triggers and implementing crisis de-escalation techniques, says Berelowitz. “Staff also must know how to identify the keys to stability for someone with a behavioral health condition.”
In other words, staff need to learn what they can do on a daily basis to help this resident not reach the point of crisis, stresses Berelowitz. “How can you help them remain stable? What routine will be most helpful to them on a daily schedule?”
Using a person-centered care approach will help the interdisciplinary team identify a good daily schedule for the resident, suggests Berelowitz. “Ask the resident or their family what is helpful to them. If you talk with someone who has been living with a behavioral health condition for a while, they usually know a lot about their condition, and very often they will share information with you if they think that you’re asking because you want to support and help them.”
Take a whole-house approach to reducing stigma and growing empathy
“At a minimum, you should identify which team members will most often be working with residents who have behavioral health needs and ensure that they actually care about people with behavioral health conditions,” says Berelowitz. “However, the ultimate goal is to educate all facility staff to reduce stigma against mental illnesses and substance use disorders.”
Most residents have had enough life experiences that they can tell if someone really cares about them, says Berelowitz. “They will not open up to a staff member who they feel doesn’t really care about them, and they also probably won’t react well in a crisis to a staff member who is trying to intervene if they get the sense that that staff member does not really, truly care about them.”
One way that executive leadership can encourage staff to prioritize positive behavioral health management for residents is to create an environment that prioritizes mental health and wellness for staff, suggests Berelowitz. “When staff experience that type of support themselves, they will be more likely to integrate it into their work and convey real caring to your residents.”
Note: The COE-NF also offers educational resources that can reduce stigma and increase empathy among staff, including a bite-sized learning video, a flyer, and a five-week training plan.
Conduct ongoing behavioral health tracking and rounds
“Weekly wound care rounds where staff identify the current size and stage of the wound, look at interventions and make adjustments, and document about the wound in real time are a relatively common practice in nursing homes,” points out Berelowitz. “Nurse leaders should consider implementing a similar practice of routine behavioral health tracking and rounds.”
Conducting behavioral health rounds will help to ensure appropriate, timely monitoring and adjustment of care plan interventions, explains Berelowitz. “The interdisciplinary team can assess in real time the resident’s status in the past week (e.g., whether the resident’s symptoms have been mild or intense, or they have developed new symptoms).”
The interdisciplinary team then can review whether different care plan interventions are being implemented as documented on the care plan and evaluate how those interventions are going, says Berelowitz. “Have they been successful or ineffective, or did staff not use them for some reason? Your team can make any needed adjustments—and provide timely documentation of the resident’s condition and changes in their treatment plan.”
Many nurse leaders may think, “I don’t have time for another set of rounds,” acknowledges Berelowitz. “However, you don’t always need separate rounds. Most facilities already have some level of clinical rounding (e.g., a once-weekly meeting) for residents with certain conditions. If you only have, for example, five residents with a serious mental illness in your building, they can be added onto that existing meeting.”
However, nursing homes that have a significant number of residents with serious mental illness (e.g., 30 – 40 residents) should consider standalone behavioral health rounds, suggests Berelowitz. “A large group of residents with serious mental illness would likely warrant having a separate weekly meeting to make sure that you are supporting their behavioral health needs.”
Audit to double-check staff implementation of screening protocols
Managers should conduct routine behavioral health audits of care plans and the medical record, recommends Berelowitz. “You want to check that staff are following the protocols that you have in place to screen for mental illnesses and substance use disorders. This could be a good item to include in your facility’s Quality Assurance and Performance Improvement (QAPI) program reporting to ensure that any issues are identified and addressed quickly.”
Perform a root-cause analysis of any behavioral health crisis
“Whenever a resident experiences an incident or a crisis related to behavioral health, nurse leaders should use the staff’s response to that crisis as an opportunity to evaluate systems,” suggests Berelowitz. “You need to do a root-cause analysis and figure out if you can improve your systems to make sure that all behavioral health needs are met.”
Consider a comfort menu of nonpharmacological interventions
Nonpharmacological behavioral health interventions are not one-size-fits-all, notes Berelowitz. “These interventions should be patient-centered, so it’s important to work upfront with the resident or their family (or front-line staff if necessary) to identify nonpharmacological interventions that could support the resident whenever they need support.”
The COE-NF created a Comfort Menu tool with more than 60 suggestions in different categories (e.g., relaxation, sleep, entertainment, etc.) to help nursing homes develop a patient-centered nonpharmacological toolbox, says Berelowitz. “This tool doesn’t substitute for a written care plan, but it does help staff collaboratively identify a plan that can be kept in the resident’s chart.”
Then when the resident is not feeling well, staff can bring the Comfort Menu to the resident and ask, “Which one of these would you like to try?’” explains Berelowitz. “This menu is a way of ensuring that the nonpharmacological interventions that staff actually attempt are the ones that you identified.”
Some nursing homes may want to implement the Comfort Menu facility-wide, says Berelowitz. “Another option is to determine which specific residents you think would benefit the most from having a Comfort Menu.”
Don’t forget that psychotropic medications can be good clinical practice
“There is a heavy focus throughout Appendix PP on using nonpharmacological interventions to meet behavioral health needs,” says Berelowitz. “In particular, some guidance in F605 (Right to Be Free From Chemical Restraints) has made some nursing homes concerned that the use of psychotropic medications opens them up to risk. That guidance states that ‘alternative interventions should be used or attempted first, unless clinically contraindicated, because they are less dangerous to a resident’s health and safety’ and that ‘without evidence that nonpharmacological interventions had been ruled out to treat the resident, the psychotropic medication would be deemed not necessary to treat the resident, and noncompliance would be cited.’”
However, a resident who needs a psychotropic medication for a serious mental illness must receive that medication, stresses Berelowitz. “Consider a scenario where you are admitting a resident who has been diagnosed with schizophrenia for 30 years, and they have been stable on XYZ medication for the last 18 years.”
It is not appropriate clinical practice to take this resident off of their psychotropic medication and try nonpharmacological interventions first, explains Berelowitz. “You just need documentation from the physician on the rationale for the clinical contraindication. But like many residents with behavioral health needs, they will probably benefit from nonpharmacological interventions in addition to their medication.”
Note: COE-NF resources about nonpharmacological interventions include a nonpharmacological depression management bite-sized learning video and flyer, as well as a Psychosis Management Through Nonpharmacological Interventions in Nursing Facilities evidence-based tool.
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