Beth B. Ulrich, L.C.S.W. Community LiaisonCentra Senior Psychiatric Program
October 2011: Senior Care Unit Opens 12-bed unit at Centra Virginia Baptist Hospital Acute care for patients 60 years or older
Dementia, primarily in the advanced stages. OUR PATIENTS 60% have Mental health required and behaviorallong-term care problems. placement.
Ensure a smooth transition from Acute Care Setting to Long-Term Care FacilityAcute Care Unit Long-Term Care Facilities (nursing homes, assisted living facilities) Evaluate individuals living in long-term care facilities for mental health and behavioral issues MY ROLE as a liaison
Ensure appropriate interventions are implemented in long-term carefacilities to minimize acute admissions. Community Liaison • Psychotherapy for patients and their families • Equipping staff with skill-sets to more successfully manage mental health and behavioral challenges
“Get ‘em in, get ‘em out!” Less attention paid to: • adjustment issues • emotional and behavioral issues More attention paid to: • physical level of functioning • financial coverage issuesPrimary emphasis on short acute stays while keeping beds at long-term facilities filled.
Revolving door 80% of nursing home residents have mental health issues. Long-term care staff are traditionally ill-equipped to deal with these issues. There is a high likelihood of admissions to Emergency Departments when mental health issues arise.
• “Tips” for managing challenging behaviorsKey Function: • Based on observations and interventions Plan of Care successfully implemented during hospitalization Pain management Patients’ Sleeping personal habits preferences Input welcomed from Food patients’ ADLs and preferences families/key IADLs support systems
adapted from Practical Dementia Care by Rabins, Lyketsos, and SteeleSolving behavior problems without using medications
High level of commitmen t required from all levels of staff. Doneconsistently, There is no it will “quick fix.” become automatic. 4D Approach Time and effort are Process is required to gradual. experience results.
Behavior problems stem from multiple causes. Causes can be distinguished from one another. ASSUMPTIONS There is rarely one bestTO BE CONSIDERED approach. We can identify causes and determine interventions. Directed “trial and error” is the rule, not the exception.
Don’t immediatelyjump to the treatment!• Obtain history.• Examine.• List likely causes.• Define treatment options.
4D-Approach• Observations, Determine details, facts Decode • Treatment• Where, when, Plan: What • What how, with • What may be are we going outcome is whom, after/ contributing to do? expected? before what? to cause the • Do the problem? interventions Define Devise work?
Define Decode Devise Determine What are the contributing causes? Cognitive impairments: aphasia, apraxia, agnosia, amnesia, executive dysfunction Other psychiatric syndrome or disorder: depression, anxiety, psychosis Medical illness; neurological illness Medications: The Beers List Environment Caregiver approach
Define Decode Devise Determine Is the problem really a problem? Why? What contributing cause(s) can be eliminated or modified? Anecdotal treatments? Empirical treatments? Let’s use common sense!
Define Decode Devise Determine What is the expected outcome? How long will it take? Who will do what . . . and when? Create a fallback plan.
What if the interventions FAIL?Have aBack-up Plan!
Consider the untoward effects of treatment. Patients improve for no specific reason.
Catastrophic ReactionsUncooperative/ Resistant To Care Aggression/ Agitation Wandering/Pacing DeliriumYelling/ Calling Out/ Screaming Mood Problems Hallucinations/ Illusions Suspiciousness/ Delusions Social Withdrawal/ Apathy Rummaging/Hoarding
Initial reaction to “lengthy” process may be that it is “justnot practical” to implement in the LTC environment due tostaffing and time constraints and limitations.Front end investments reduce long-term problems andexpenses.Unrealistic expectations mandated by all of the regulationsthat long-term care facilities must adhere to can causefrustrations.Tensions between providers and regulators may bediminished as results are realized from implementing thisapproach.
Thank you! Beth B. Ulrich, L.C.S.W. Community Liaison, Centra Senior Psychiatric Program firstname.lastname@example.org