webinar may 2012 5 17 final
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Pre-admission Screeningof Older Adults with
Cognitive Impairment:
Considerations forEmergency Services Staff
Thursday, May 17, 2012, 1:30-2:30 pm EST
Elizabeth Kirkland, LCSW
Amy Powell, MS LNHA
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Abbreviations used in thisdocument
AD- Advance Directive
AL- Assisted Living
CDC-Centers for Disease Control
CMS-Center for Medicare & Medicaid Services
CSB-Community Services Board / BHA-Behavioral Health Authority
D/O- Disorder
ECO- Emergency Custody Order
IP-inpatient
LTC-Long Term Care
NH Nursing Home
NP-Nurse Practitioner PCP-Primary Care Physician
PGH-Piedmont Geriatric Hospital
POA- Power of Attorney
TDO-Temporary Detention Order
UA-Urinalysis UTI-Urinary Tract Infection 22
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OBJECTIVES
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All in the numbers...
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s s mos e y no asurprise to you, but in
preparation for the futureof LTC we MUST.....
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Improving the Crisis Nexus
66Holding on to past grievances/negative experiences arebarriers to cooperation!
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Improving theCrisis Nexus
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mprov ng e r s s exus
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Objective 1:Unique Characteristics of LTC
Environment
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Objective 1:Unique Characteristics of LTC
Environment
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Population served:
Some areunable toremain at
home safely
Some areunable to
communicateclearly
History isusually
incomplete
Facilitystaff
caughtbetweencompeting forces:
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Objective 2:Special Challenges involved in treating
older adults with acute mental health issuesin the LTC environment
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WHAT IS AN F-TAG?
The Centers for Medicaid and Medicare Services(CMS) has regulations that will be referred to
during this presentation as F-Tags.
These F-Tags are categories that theinspectors/surveyors cite when deficiencies occur.
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P ti A id t
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Preventing Accidentsthrough:
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If the facility fails to do theabove....
It is considered "avoidable" and can lead tonegative consequences for the facility.
Deficiencies are rated on a severity scale todetermine if harm occurred and/or howmany people did it affect.
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Does Behavior = Accident/Incident?
Regulations specify that the facility is tasked with
correcting the behavior of any resident, visitor, and/orstaff if it can determine a precursor to an altercation,incident or harm to another resident.
NOTE: The regulations states
"Even though a resident may have a cognitiveimpairment, he/she could still commit a willful act."
Facility may be calling prescreener to correct thebehavior of a resident by initiating an inpatientadmission
Facility should have Plan B developed, in case admission isnot outcome
Prescreener must assess if acute inpatient treatment isa ro riate accordin to the Code of Vir inia more on this in
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Does Behavior =Accident/Incident?
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Does Behavior =Accident/Incident?
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Facility should consider early interventionto avoid crisesTherapy (could be beneficial, depending on
stage of dementiahttp://www.alz.org/alzheimers_disease_stages_of_al)
Modifications to environment or individualsroutine
Consultation with Piedmont Geriatric
2020
Does Behavior =Accident/Incident?
http://www.alz.org/alzheimers_disease_stages_of_alzheimers.asphttp://www.alz.org/alzheimers_disease_stages_of_alzheimers.asp -
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2. Medication Use
In LTC one of the most unique and misunderstoodcharacteristics is the Unnecessary Drug F-Tag 329. This tag
states:
"Each resident's drug regimen must be free
from unnecessary drugs. An unnecessary drugis any drug when used:
(i) in excessive dose (including duplicate therapy);or
(ii) for excessive duration; or(iii) without adequate monitoring; or
(iv) without adequate indications for its use; or
(v) in the presence of adverse consequences which
indicate dose should be reduced or discontinued;2121
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GDR
GRADUAL DOSE REDUCTION
This is mandated to occur when anymedication is identified to meet the previous
criteria.
On a GDR, it is important to document whenbehaviors are taking place to justify the
necessaryuse of the medication(s).
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RealityThe system in which this happens in most LTC environments is that:
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scenario...
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DOCUMENT DOCUMENT DOCUMENT
In order for facilities to manage residents on medications, it is
important that they can
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Resident Rights
Residents of LTC facilities have the rights to: to be free from abuse
to be free from restraints (to include
chemical) See handout, Resident Rights, for full list
www.vdh.virginia.gov/OLC/Laws/documents/2010/pdf
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http://www.vdh.virginia.gov/OLC/Laws/documents/2010/pdfs/rgts%20of%20NF%20pts%202010%20COV.pdfhttp://www.vdh.virginia.gov/OLC/Laws/documents/2010/pdfs/rgts%20of%20NF%20pts%202010%20COV.pdf -
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4. Inspections/Quality/5-starRating
LTC facilities are regulated by the StateHealth Department that communicates with
CMS.
The state performs inspections annually or
as needed in order to determine complianceto regulations and consequences of notdoing so.
www.medicare.gov/NHCompare/static/tabhelp.a2828
Obj ti 2
http://www.medicare.gov/NHCompare/static/tabhelp.asp?language=English&activeTab=6&subTab=0version=defaulthttp://www.medicare.gov/NHCompare/static/tabhelp.asp?language=English&activeTab=6&subTab=0version=defaulthttp://www.medicare.gov/NHCompare/static/tabhelp.asp?language=English&activeTab=6&subTab=0version=default -
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Objective 2:Special Challenges of LTC environment
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Facility may not have full history onindividual
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Objective 2:Special Challenges of LTC environment
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Facility may have difficulty keeping resident onstabilizing medications
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Prescreenings often begin after hours,with staff who are less familiar withindividual
Objective 2:Special Challenges of LTC environment
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Cognitive impairments can decrease inhibitions andincrease impulsiveness
Objective 2:Special Challenges of LTC environment
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Assessment may be difficult, due tocognitive impairment, emotional upset,or activity in area
Objective 2:Special Challenges of LTC environment
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Considerations regarding ECOLocal practices vary widely as to setting ofassessment
For geriatric population, physical frailty andlevel of confusion can be complicating factor.
Attempting to assess in midst of chaotic ERmay lessen chances of getting accurate read ofindividual
Consider assessing at facility, if this is safe.If transportation to other location necessary,
consider having familiar staff accompanyindividual
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Objective 2:Special Challenges of LTC environment
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Medical ECO: Code section: 37.2-1103Allows for ANY licensed physician to request ECO
for medical evaluation, providing:
Person cannot make informed decision due to
MEDICAL issues, and is unlikely to become capablequickly enough
Intervention is needed to prevent imminent orirreversible harm
There is no legally authorized person who can
authorize treatmentPhysician has been in electronic or personal
communication with emergency medical personnelon scene
If person regains capacity, decision-making
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Objective 2:Special Challenges of LTC environment
Prescreener Is TDO appropriate according to the Code of Virginia?
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Prescreener: Is TDO appropriate according to the Code of Virginia?(37.2-809.B)
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Elder Suicide StatisticsHere are a few CDC statistics on suicide in elders:
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Prescreener: is TDO appropriate according to the Code of
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pp p gVirginia?
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Objective 3:
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Objective 3:Admission Practicalities
If hospitalization is outcome, insurance provider willdetermine payment length, but carefuldocumentation can help make case for initialtreatment
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In Closing
Todays presentation has attempted to openyour eyes to all the complicated challengesthat exist for all parties.
However, the most important point to takeaway today is that we MUST all work
TOGETHER to achieve that common goal,
understand each others daily pressures,and show compassion for each other whencompleting our difficult work.
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Q&A
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Elizabeth Kirkland, LCSW
Director of BehavioralResources & Community
Relations6802 Paragon Place, Suite
201Richmond, VA 23230
(80 ) 282 0 3
Amy Powell, MS LNHA
Health CareAdministrator
Westminster Canterburyon the Chesapeake Bay
3100 Shore DriveVirginia Beach, VA
23451
mailto:[email protected]:[email protected]