DESCRIPTION: To address behavioral health disparities in nursing facilities, the state of Kentucky launched a tiered quality improvement incentive program targeting facilities with the greatest need. Rather than focusing solely on clinical measures like depression, the initiative emphasized education, capacity-building, and quality improvement through the Center of Excellence for Behavioral Health in Nursing Facilities (COE-NF). Facilities progressed through structured tiers involving assessment, training, and champion development. With strong statewide engagement, over 3,500 staff were trained, leading to measurable improvements in communication and behavioral health awareness. This initiative is part of a broader strategy to enhance care for vulnerable populations and close service gaps across the state.
CASE DESCRIPTION: The state of Kentucky committed to a quality improvement incentive program for nursing facilities, targeting quality measures where the statewide average was in the bottom quartile. After reviewing these measures, the Secretary of the Cabinet for Health and Family Services requested an additional measure focused on behavioral health.
UNIQUE CHALLENGES: Initially, the state considered using depression as the primary measure but determined it might underestimate individuals’ needs and limit the effectiveness of care planning. Instead, they adopted a front-loaded, education-first approach to behavioral support, leveraging the COE-NF’s existing programs and services, while integrating a blended focus on education and Quality Assurance and Performance Improvement.
Additionally, the state identified significant gaps in access and service quality for vulnerable populations, including those in nursing homes. The incentive program is part of a broader strategy to address these disparities and improve outcomes statewide.
COE-NF SOLUTION: The program uses a progressive tiered system for engagement, assessment, education, and advancement of the nursing facilities’ knowledge and capacity to care for individuals with behavioral health challenges. The prior tier’s goal must be met before qualifying for the next progressive tier.
To meet the criteria, nursing homes must:
Tier 1: Request assistance from the COE-NF,
Tier 2: Complete the COE-NF’s Behavioral Health Needs Assessment (BHNA), and utilize results to develop an actionable plan to be forwarded and monitored by the QAPI committee,
Tier 3: Designate at least three Behavioral Health Champions (e.g., social services, nurse leader, activities staff).
- Identify relevant training courses in consultation with the COE-NF.
- Enroll Champions in at least three COE-NF training courses. “Mental Health 101, Suicide Prevention, De-escalation Strategies” is recommended.
Tier 4: Train at least two staff members from each department in COE-NF’s “Mental Health 101, Suicide Prevention & De-escalation Strategies” training.
With Alliant’s expertise in quality improvement, the COE-NF began assisting the facilities in identifying the gaps based on the BHNA. The team assisted with conducting root cause analysis and Plan-Do-Study-Act (PDSA) to educate on quality improvement principles to drive positive outcomes. The team continued to follow up with facilities to ensure completion of training and help address any barriers that may have come up.
The team created optional tools to support the facilities’ efforts, including a customized spreadsheet to track progress toward the four tiers and maintain staff training requirements, a fast-track plan facilities can follow to complete the requirements, and a PDSA template to help document the quality improvement project.
Observed challenges and insights:
- Higher rates of residents with behavioral health diagnoses
- Psychotropic usage rates (vs. antipsychotic) – as high as 80%-90%
- Gaps in nonpharmacological interventions beyond psychotherapy
- Shortage in behavioral health providers
Support provided by the COE-NF:
- Shared searchable provider databases and knowledge from other facility providers
Facility-led initiatives:
- Some facilities exceeded requirements by training five champions per department or training all staff
OUTCOME/BENEFITS: Since the launch of the initiative, the response from eligible facilities has been overwhelmingly positive. Out of 252 eligible facilities, 239 reached out to the COE-NF to request support, demonstrating strong engagement across the state.
As a result:
- 90% of facilities qualified for partial incentives, and
- 78% successfully qualified for all four tiers of the incentive program that began on July 1, 2025.
Training efforts drove measurable impact:
- 3,510 individuals completed “Mental Health 101, Suicide Prevention, and De-Escalation”, building system-wide capacity.
- The more intensive one-on-one support didn’t just transfer knowledge; it led to real changes in practice:
- 49% of participants reported improved communication with residents, and
- 43% noted increased awareness of behavioral health issues
These outcomes point to a clear shift toward a more informed, compassionate, and effective care environment across participating facilities.
