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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
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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1. AccidentPrevention
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
1. AccidentPrevention
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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1. AccidentPrevention
2.Medication
Use
3.Admission
Criteria
4.Inspections/ Quality/5-star Rating
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
1. AccidentPrevention
2.Medication
Use
3.Admission
Criteria
4.Inspections/ Quality/5-star Rating
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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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Facility considerations:
•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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Facility considerations:
• Ensure incoming staff areadvised of individual’scondition, and that effectivecommunication practices areobserved
• Develop effective trainingschedule for new staff,particularly after-hoursworkers
Prescreener considerations:
• 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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Facility considerations:
•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
Prescreener considerations:
•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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Facility considerations:
• 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
Prescreener considerations:
•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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Facility considerations:
• 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)
Prescreener considerations:
• 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/
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