Nursing home “no returns” policy, when residents are discharged to the emergency department at 4 am: what does the law say?

In reply: We thank Forbes and Ferraro for noting that rights around security of tenure in nursing homes apply equally to residents with mental illness as to those with dementia. As illustrated in the case presented by the authors, advocacy is particularly needed for residents with mental illness with the triple jeopardy of being aged, and having mental illness and dementia.1 A combination of stigma, lack of specialised expertise and inadequately resourced facilities may culminate in nursing homes seeking recourse to precipitous discharge for lack of other solutions, noting that hospitalisation rate per se is often used as a quality indicator of care in facilities.2 However, as we have previously noted, this practice is inconsistent with legislated guidelines under Division 2, User Rights Principles 2014 (section 96‐1, Aged Care Act 1997).3

Stigma occurs across all sectors — general hospital and mental health services are often loath to assist older patients in general and especially those with neurocognitive disorders. Forbes and Ferraro provide an example of the flip side of the coin: aged care services stigmatising older people with mental health problems, such stigma being a type of “mentalism” akin to ageism. As stated above, some of this stigma arises from lack of education and specialised input and services in nursing homes, and the fact that patients with mental illness often require more time from direct care staff, which has been shown to have an adverse effect on other residents.2

The struggle to optimise treatment and care of nursing home residents with mental illness has been noted since the early days of the deinstitutionalisation movement;4 all the more so now with initiatives such as the Pathways to Community Living Initiative. This initiative is a coordinated New South Wales state‐wide approach to supporting people, often elderly, with serious mental illness who have been hospitalised for more than 12 months to, when possible, re‐establish their lives in the community, often in residential care.5 As stated by Forbes and Ferraro, such a vulnerable population warrants greater support, as do the nursing homes that provide their care.

Ageism and mentalism should both be unacceptable to all health professionals, in all settings.