webinar may 2012 5 17

5/16/2012

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Thursday, May 17, 2012, 1:30-2:30 pm EST

Elizabeth Kirkland, [email protected]

Amy Powell, MS [email protected]

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 2

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• Unique characteristics of the LTCenvironment that need to be considered

• Special Challenges involved in treating olderadults with acute mental health issues in theLTC environment

• Issues regarding diagnoses and behaviorsrelevant to older adults that psychiatric unitsmust consider in their admissions decisions,in order for insurance to cover thehospitalization.

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12.9 % of our population are 65+,that is 1 out of every 8 people, by2030 it will drastically increase to

19% (Administration on Aging)

In 2009, 4.1% of those 65+(1.3 million) live in

institutionalized facilities.(Administration on Aging)

Out of all residents of AL and NHfacilities at least half have a

diagnosis of dementia or relateddisorders (Alzheimer's Association)

Increasecooperation

amongstproviders and

agencies

Increaseresources

available toLTC

Overcomechallenges

(creatively) incaring for the

elderly

Understandeach other's

environment,goals and

expectations.

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TO BEEFFECTIVE

PARTNERS, WEMUST ALL BE

AWARE OF OURDIFFERENCES:

DAILYPRESSURES

GOALS

EXPECTATIONSEXPERTISE

AUTHORITY

Holding on to past grievances/negative experiences are barriers to cooperation!

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BE

FO

RE

the

cris

is

With input from CSB/BHAcrisis staff and facility

staff/corporate officers,develop protocols for

partnering around geriatriccrises, e.g.:

Can facility give “heads-up”?

Can facility call crisis forconsultation?

Documentation required forprescreener response

Duration, frequency,circumstances, and

specifics of behavior

Steps taken to addressbehavior

Definition of crisis andnon-crisis

Considerations foralternative transportation

Codify protocols inwriting, and hold

bi-annualmeetings/trainings on

them

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Oth

era

ctio

ns

Consult with local hospitalregarding admission under §37.2-805.1 of Virginia Code, Advance

Directives (AD)http://lis.virginia.gov/cgi-bin/legp604.exe?000+cod+37.2-805.1

www.vsb.org/sections/hl/ 2011-VA-AMD-Simple.pdf

Allows for hospital physician to authorizepsychiatric admission for up to 10 days, if

psychiatric section filled out

Can eliminate need for prescreening

Many physicians unaware of this aspect of AD

Facility should encourage residents and theirfamilies to complete an AD, including psychiatric

component

Prescreener and facility should have copy of actualCode section, to educate physician, if necessary

Prescreening required, even with AD, for admissionto State facilities

Consider consulting with Piedmont GeriatricHospital to help clarify behavior

management strategies in the facilityAndrew Heck, Ph.D. - (434) 767-4401

[email protected]

Increase awareness of respective parties’“rocks and hard places”

Can increase desire to partnercooperatively

Can decrease miscommunications andmistrust

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Po

st-c

risi

s

Acknowledge what went right, and givecredit where it is due

Have follow-up discussion, if possible, toidentify what went wrong

Review protocols, and tweak as needed

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To demystifythe environment

of LTC thefollowing areexamples of

uniquecharacteristics:

Growing population

Increased acuity

Highlyregulated/aggressive

inspections

Large medication use

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Allocation offacility

resources

Safety

Differinglevels of staffresponsibilityand training

Turnover of staff

Population served:

Some are unable toremain at home

safely

Some are unable tocommunicate

clearly

History is usuallyincomplete

Facility staffcaught

betweencompeting

forces:

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1. AccidentPrevention

2. MedicationUse

3. AdmissionCriteria

4. Inspections/Quality/5-star

Rating

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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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F-Tag F323

"The facility must ensure that

(1) the resident environment remains as free ofaccident hazards as is possible and

(2) each resident receives adequate supervision andassistance devices to prevent accidents."

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2.Medication

Use

3.Admission

Criteria

4.Inspections/Quality/5-star Rating

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Identifying the hazard(s) and risk(s)

Evaluating and analyzing the hazard (s) and risk (s)

Implementing interventions to reduce hazard(s) and risk(s)

Monitoring for effectiveness and modifying interventions whennecessary

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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 how manypeople did it affect.

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Regulations specify that the facility is tasked with correctingthe behavior of any resident, visitor, and/or staff if it candetermine a precursor to an altercation, incident or harm toanother resident.

NOTE: The regulations states

"Even though a resident may have a cognitive impairment, he/shecould still commit a willful act."

Facility may be calling prescreener to “correct the behavior” ofa resident by initiating an inpatient admission

Facility should have “Plan B” developed, in case admission is notoutcome

Prescreener must assess if acute inpatient treatment is appropriateaccording to the Code of Virginia (more on this in Objective 3)

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Mrs. J. is running up and down the halls, gesturing wildly,and yelling at the top of her voice. Staff report that

sometimes she says she sees a little girl in her room. Otherresidents are complaining, and administrator is worried

about receiving a deficiency.

Behavior does not rise tolevel of prescreening

Facility should develop behaviorplan for Mrs. J.

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Mr. P., a large man, is walking into other residents’rooms, and going through their things. Whenanyone attempts to stop him, he yells at them,

shoves them, and storms off.

Behavior does notrise to

prescreening level

Facility shoulddevelop behavior

plan

If behavior continuesor worsens, consider

consulting withEmergency Services

staff

Facility should consider early intervention toavoid crises

Therapy (could be beneficial, depending on stage ofdementiahttp://www.alz.org/alzheimers_disease_stages_of_alzheimers.asp )

Modifications to environment or individual’s routine

Consultation with Piedmont Geriatric

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In LTC one of the most unique and misunderstood characteristics is the

Unnecessary Drug F-Tag 329. This tag states:

"Each resident's drug regimen must be free fromunnecessary drugs. An unnecessary drug is any drugwhen 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 indicatedose should be reduced or discontinued; or

(vi) any combination of the reasons above."21


2.Medication

Use

3.Admission

Criteria

4.Inspections/ Quality/5-star Rating

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GRADUAL DOSE REDUCTION

This is mandated to occur when any medication isidentified to meet the previous criteria.

On a GDR, it is important to document whenbehaviors are taking place to justify the

necessary use of the medication(s).

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The system in which this happens in most LTC environments is that:

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a consultant,contract

pharmacistperforming amonthly visit,

writes arecommendationof a GDR in their

monthlyrecommendation

report,

passed to thenursing staff to

give to physiciansto take action,

a physician signsto approve,

the nurse writesthe order at thedirection of the

physician,

the resident isremoved from the

medication.

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CONCERNS

Pharmacist isperforming

task, notgiving opinion

Nursing maybe busy andpassing onrecommen-

dationswithoutreading

Physician mayjust signwithout

reviewinghistory ordiagnosis.

Resident mayhave stable

behaviors dueto the

medicationidentified

earlier in life

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In order for facilities to manage residents on medications, it is importantthat they can

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1. get lots ofdocumentation as to

when the personstarted on the

medication

2. keep gooddocumentation withcare plans, behavior

modification,diagnosis list

3. provide gooddocumentation to

emergency servicesand hospitals

LTC Facilities have a responsibility to makesure that the resident's needs can be met, theresident's rights can be upheld and has the

resources to provide for specilized care whenneeded.

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2.Medication

Use

3.Admission

Criteria


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/pdfs/rgts%20of%20NF%20pts%202010%20COV.pdf

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LTC facilities are regulated by the State HealthDepartment that communicates with CMS.

The state performs inspections annually or asneeded in order to determine compliance toregulations and consequences of not doing so.

www.medicare.gov/NHCompare/static/tabhelp.asp?language=English&activeTab=6&subTab=0version=default 28


2.Medication

Use

3.Admission

Criteria


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Facility considerations:

• Develop protocols forobtaining history of mentalhealth treatment and allepisodes of aggression

• Contact collateral sourceswhen behaviors first beginto get more completehistory

• Document behaviorscarefully

Prescreener considerations :

• Obtain relevantinformation from collateralcontacts

• Probe for diagnoses otherthan dementia

• Document suspecteddiagnoses that could becontributing to behavior(e.g.: psychosis, delusionalthinking, anxiety D/O)

Facility may not have full history on individual

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•Training of staff regardingdocumentation of behaviors andrationale for continuingprescribed medication

•Developing behaviormodification plan

•Training staff to use creativeapproaches to care

Prescreener considerations:

•Document carefully whichmedications have been tried

•OR, why medicationinterventions have not beenattempted (if due to a GDR,facility may have limited optionsfor restarting medications)

•Assess whether individual hasbeen refusing medications, andwhat attempts have been madeto administer them

Facility may have difficulty keeping resident onstabilizing medications

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Prescreenings often begin after hours, withstaff who are less familiar with individual

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• Ensure incoming staff areadvised of individual’scondition, and that effectivecommunication practices areobserved

• Develop effective trainingschedule for new staff,particularly after-hoursworkers


• If possible, speak to staff whoknows individual best

• If possible, observeconditions that generatebehavior (e.g.: if behavioroccurs during dressing,observe that)

Cognitive impairments can decrease inhibitions andincrease impulsiveness

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•Assess environment forprecipitating factors

•Time of day

•Transference with particularstaff

•Too much stimulation

•Fear of particular people orgroups of people

•Alter precipitating factors thatcan be changed


•Dementia can cause intense,unreasonable fears, and personmay think he/she is protectingself

•Person may not be able tocommunicate reasons forbehavior

•Individual could be in pain andunable to communicate this

•Assess for precipitatingfactors/patterns

Assessment may be difficult, due to cognitiveimpairment, emotional upset, or activity in area

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• Explain to individual that someone is coming totalk to him or her

•Make sure family know of situation, and areavailable if prescreener needs to consult with them

•Inform prescreener of person’s normal limitationsand communication abilities

•Provide safe, quiet environment for assessment

•Have staff nearby


•Be friendly

•Be patient

•If possible, observe person’s behavior in milieu,but eliminate background distractions duringinterview

•Speak slowly, calmly and clearly

•Use discretion in touching person

•Some may interpret this as threatening

•Others may find a gentle touch comforting

•Use short, simple statements

•Ask one question at a time, and allow time for theperson to respond

•Use gestures and point to objects, if individualappears to have difficulty understanding you

•Write questions down, if person cannot hear you

•Realize that the person may repeat questions overand over again

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Considerations regarding ECO

Local practices vary widely as to setting ofassessment

For geriatric population, physical frailty and level ofconfusion can be complicating factor.

Attempting to assess in midst of chaotic ER maylessen chances of getting accurate read of individual

Consider assessing at facility, if this is safe.

If transportation to other location necessary, considerhaving familiar staff accompany individual

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Medical ECO: Code section: § 37.2-1103 Allows for ANY licensed physician to request ECO for

medical evaluation, providing:

Person cannot make informed decision due to MEDICALissues, and is unlikely to become capable quickly enough

Intervention is needed to prevent imminent or irreversibleharm

There is no legally authorized person who can authorizetreatment

Physician has been in electronic or personalcommunication with emergency medical personnel onscene

If person regains capacity, decision-making reverts toindividual

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Prescreener: Is TDO appropriate according to the Code of Virginia? (§37.2-809.B)

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Number 1: RULEOUT MEDICAL! If

suspect medical(delirium, UTI, etc),medical evaluation

must take place first

• Consider if facility can conduct necessary medical tests (e.g.:UA for UTI, comprehensive review of medications)

• OR, consider if medical evaluation can be at PCP’s office

TDO could bewarranted if medical

condition andbehavior are serious

enough, but

• Specify if you suspect medical condition is causing behavior,and that facility cannot correct said condition

• TDO should specify that medical evaluation needs to bedone first

• Medical evaluation and follow up treatment could result inpsychiatric admission being avoided

Consider“substantial

likelihood” of harmto self or others

• Suicidal ideation or actions? While thoughts of death may beconsidered a normal part of aging; thoughts of suicide arenot!

• Does individual have history of suicide attempts?

• Plan, intention, and access to means?

• Able to act on plan?

Aggression/homicidal ideation

towards others?

• Size, strength, and determination of individual

• History of aggressiveness (get specific: occasional orfrequent? mild shoving or grabbing wrist? using object asweapon?)

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Here are a few CDC statistics on suicide in elders:

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65+ age group complete suicide at a rateof 4:1 (attempts to completion),

compared to younger people (100-200:1)

Some risk factors are similarto other populations

• Previous history of attempts

• History of mental health disorders

• Family history of suicide

• Active substance abuse

Others are more specific toelders

• Recent losses (of loved ones, offunctioning, of role, of independence)

• Age (80+ males at highest risk)

• Those in LTC are more likely to uselong falls and hanging as methods

Prescreener: is TDO appropriate according to the Code of Virginia?

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“Unable to care forself” less likely to

result in admission,since facility is

presumed to be able tocare for them

•Usually reserved for individuals still living in community

•Must be at risk of significant harm from self-neglect

Consider “if in need ofhospitalization or

treatment”; ishospitalization the

only way to stabilizesituation?

•If less restrictive options exist, TDO is not appropriate

•If inpatient treatment will not result in improvement of symptoms,TDO may not appropriate; for example:

•previous IP medication trials have not helped

•behaviors under consideration are chronic and amenable tobehavioral interventions

•Does facility have access to psychiatrist or NP willing to prescribe?

Consider capacity toconsent and

willingness to betreated

•Dementia alone does NOT render someone incapable of making aninformed decision.

•However, if person is willing, lacks capacity, but there is a guardianor AD agent who gives consent, then hospitalization could be onvoluntary basis

•If person has cognitive impairment, does it render him/her:

•Incapable of understanding choices?

•Unwilling to agree?

•If so, TDO may be needed, if other conditions met

If hospitalization is outcome, insurance provider willdetermine payment length, but careful documentation canhelp make case for initial treatment

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• Provide accurate records thatsupport rationale for admission, andmake these available

• When behavior began

• Under what circumstances it occurs

• How often it occurs

• Specifics of behavior

• What has been done to correctproblem

• Barriers to correcting problem infacility(can’t collect specimen forUA, for example)


• Prescreening must:

• Accurately reflect severity ofsituation

• Offer probable or suspecteddiagnoses or factors that could becausative (e.g. dementia withpsychosis)

• Offer specific descriptions ofproblematic behavior

• Consider ensuring that relevant notesfrom facility are sent withprescreening

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Today’s presentation has attempted to open youreyes to all the complicated challenges that existfor all parties.

However, the most important point to take awaytoday is that we MUST all work TOGETHER toachieve that common goal, understand eachother’s daily pressures, and show compassion foreach other when completing our difficult work.

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Elizabeth Kirkland, [email protected]

Director of Behavioral Resources &Community Relations

6802 Paragon Place, Suite 201Richmond, VA 23230

(804) 282-0753

www.matureoptions.com

Amy Powell, MS [email protected]

Health Care AdministratorWestminster Canterbury on the

Chesapeake Bay3100 Shore Drive

Virginia Beach, VA 23451

www.wcbay.com/

webinar may 2012 5 17

Health & Medicine