Transcript Social Services in the Long

Role of the Nursing Home
Social Worker in Depression
Care Management (DCM)
Presenters: Bob Connolly, MSW, LCSW-C
Paige Hector, LMSW
1
Presentation Outline
1. Why Minimum Data Set (MDS) 2.0 Mood Section was
Changed to use the PHQ 9?
2. Homecare Depression Care Management (DCM)
Protocol
a.
A Model for Nursing Home Social Work
3. Role of the Social Worker in DCM
DARE Criteria:
A Tool for Interdisciplinary Planning
2
Why were MDS 2.0 Mood Items
Replaced in the MDS 3.0?
 Old mood item:
 Repeatedly shown to have poor correspondence
with independent mood assessment
 Does not comport with accepted standard of
self-report
 Requires time consuming systematic
observations of ALL residents across all shifts.
Difficult to achieve.
 Questionable utility for gauging response to
treatment, since appropriate approach is targeting
DSM-IV signs and symptoms
3
Why Mood Items Replaced (Cont’d)
 New cognitive item (PHQ-9)
 Based on DSM-IV criteria
 Validity well established in other settings

Increasing use and recognition by clinicians

Allows threshold definition AND severity definition
that can track change over time

Has been used in outpatient elders, hospital,
rehabilitation (post stroke) and home health
populations in addition to younger adult populations
4
Research and NH Validation Study
Staffs rated MDS 3.0 Section Improved

87% nurses and interdisciplinary facility staffs rated
the mood section as improved over 2.0 section
 Only 22% reported that 2.0 section was easy to
complete accurately

88% felt PHQ-9 interview was better than 2.0
observation for capturing resident mood

84% felt the items could inform care plans

86% reported that items provided new insights into
mood

77% felt that all residents who answered understood
items (6% disagreed)

78% rated ability to calculate score helpful (4%
disagreed)
5
Evidenced-Base for the Homecare Depression
Care Management (DCM) Protocol
 Training in Assessment of Depression (TRIAD) trial found
that HHA nurses can be effectively trained in depression
assessment.
- Martha Bruce, Journal of the American Geriatric Society, 2007
 Depression care management (DCM) protocol, called the
Depression CARE of PATients at Home (CAREPATH)
intervention, can be used as part of routine care and can
be integrated into HHA software.
- Bruce, Home Healthcare Nurse July 2011
 Components and utility of DCM and CAREPATH, the PHQ
9
cut points and antidepressant are described in a follow-up
article.
- Bruce, Home Healthcare Nurse Sept. 2011
7/16/2015
6
Nursing Home Depression Care Management Flow Diagram
Adapted 10/23/2012 from:
Homecare Depression Screening Protocol
Weill Cornell Homecare Research Partnership
Conduct Assessment
Using PHQ-9/D0200
PHQ-9 Score /D0300: <10
&
no suicide ideation
PHQ-9 Score/D0300: ≥10
Suicidal Ideation
PHQ “item 9” (≥1)
• Instruct patients with
Depression Education Toolkit
• Repeat PHQ-9 between MDS 3.0
assessments if indicated or needed
Follow Depression Care Management
when PHQ-9 is positive (≥10) or if
suicidal ideation emerges
Depression Care
Management (DCM)
• Follow NH Suicide Risk Protocol
when indicated
Patient Depression
Education Toolkit
8
Components of the
Home Care DCM Protocol
1.
2.
Assessment of depression severity using the PHQ 9
Case Coordination
a.
b.
3.
Medication Management
a.
4.
Special consideration with antidepressant medications involve monitoring for side effects and
adherence for patients taking antidepressants
Education of Patients and Families
a.
5.
Consult with the patient’s physician about possible about possible initiation or changes in
medication and/or psychotherapy treatment, as well as possible consultation or referral to a
psychiatric nurse (if available), social worker, or outside mental health specialist; this includes
ensuring that depression care continues after discharge.
The DCM protocol requires that clinicians re-contact the patient’s physician or mental health
specialist when depressive symptoms or suicide ideation emerges or worsens, patients have
adverse side effects to medications, or if there has been no change in symptoms after 4 weeks
or otherwise clinically indicated
As with other conditions, nurses educate patients about depression and its treatment, working to
dispel myths and stigmata.
Patient Goal Setting
a.
While not psychotherapists, nurses & social workers typically assist patients in goal setting and
activation to help patients set and review weekly goals for self care, pleasurable activities, and
social contact visit.
9
Homecare Depression Care Management Protocol
A Care Planning Model for Nursing Home Social Workers
Admission/Annual MDS 3.0
Quarterly MDS 3.0
Discharge MDS 3.0
Assess
Monitor
Monitor
depression severity using the PHQ-9
depression severity using the PHQ-9
depression severity using the PHQ-9
Coordinate
Coordinate
Coordinate
care by preparing the Depression
Case Presentation Template and
contacting physician or specialist
(per agency guidelines)
as needed
Manage
antidepressants:
dosage, adherence, side effects
Instruct
patients and family with the
Depression Education Toolkit
Assist
next level of care by giving patient
Depression Care Summary and
review referral options with patient
and family
Manage
antidepressants:
dosage, adherence, side effects
Recontact
Instruct
patients and family about ongoing
depression care
Assist
patient by reviewing goals for self
care and pleasurable activities
Physician or Mental Health
Specialist when:
• PHQ-9 score remains the same
or worsens over 4 weeks
• Suicide ideation (PHQ-9 item 9 )
emerges or worsens
• Patient reports significant
side effects
• Otherwise clinically indicated
patients in goal setting: self care
and pleasurable activities
Adapted 10/23/2012 from:
Homecare Depression Screening Protocol
Weill Cornell Homecare Research Partnership
Role of the Social Worker
in Depression Care
Management
Using DARE Criteria
Strengthening Assessment &
Documentation
11
Importance of Assessment &
Documentation
 A thorough assessment as the foundation
 Documentation – taking credit for all your
hard work!
Use Behavior/Mood
Assessment
Algorithm
Request
Psych
Consult
Establish foundation for
referral:
Assessments
Summary note
Give verbal report to
provider
Documentation
should be easily
found in progress
notes and
care plan
Identify possible reason(s) for behavior:
Hunger? Thirst? Fear? Constipation? Noise? People?
Pain? Excessive temp? Infectious process? Medication
Rx? Unusual stressors or change in routine? Over/under
stimulation? Frustrating or disliked activity? Chaotic
environment? Smells? Lights? Communication?
Perception of unfair treatment? Enforcement of rules?
Prolonged waiting? Shame or humiliation? Bad news?
Perception of not being heard?
Possible
Reversible
causes
Accurate Description of Behavior:
What is happening? Is it new?
How often? Patterns? Times of day?
Triggering factors (before bath, after visit from daughter, one hour after
meds are given)? What relieves it? Consequences and rewards?
13
Case Study
 Mrs. M is 78 years old and has lived in the
facility for one year. She has mild cognitive
impairment, depression, and scoliosis that
requires use of a wheelchair and pain
management. She has one daughter and she
does visit but the relationship is strained. Mrs.
M used to work at a department store and
enjoyed interacting with customers. Being
active in her church was important and she
participated in several committees.
14
Case Study, cont.
 Prior to moving into the nursing home, she was
independent with her daily cares but required
assistance with transportation, financial matters and
housekeeping. As the scoliosis progressed, she
began falling at home and although she verbalizes
that she knew she couldn’t live at home any longer,
she is vocal about her anger at having to move. With
limited income she relies on Medicaid to pay for the
nursing facility. She had minimal input into the
decision to move in. Currently she requires moderate
assistance with ADLs. Periodically she gets upset
with staff and yells but recently the yelling has
increased.
DARE Criteria
 Use the DARE criteria as a mental format to
write a narrative entry in the medical record
D: Data, Details
 A: Assessment, Action
 R: Response, report
 E: Evaluation, education

Beicher, Tra, RNC, ARM, HRM, CWS, Defensive Documentation for Long-Term Care:
Strategies for creating a more lawsuit-proof resident record, HCPro, Inc, 2003
16
Data, Details
 What information is needed to establish a baseline?


Vitals, labs, percentage food consumed, pain scale,
investigative information, etc
PHQ-9 score
 What did the patient say?
 What do caregivers report?
 What did the family or other team members share?
Beicher, Tra, RNC, ARM, HRM, CWS, Defensive Documentation for Long-Term Care: Strategies for creating a more lawsuit-proof
resident record, HCPro, Inc, 2003
17
Data, Details Example
 Yelling behavior occurs periodically throughout day but is worse
right after lunch. Yelling is not new but it has gotten worse for a
few weeks. Interview with resident revealed that she and her
daughter had an argument three weeks ago and that the
daughter threatened to not let the grandkids visit anymore. Mrs.
M said her grandkids are one of the most important parts of her
life. She further shared that she has urgency to use the restroom
after lunch and “hates having to wait for help.” She has orders for
PRN pain medication for the scoliosis but review of the
Medication Administration Record (MAR) reveals that she has
only received medication five times in the past week, mostly at
night. She takes Zoloft and the dose has not changed since
admission. PHQ-9 score on last MDS (5 weeks ago) was 6
indicating mild depression. PHQ-9 score on this date was 18
indicating moderately severe depression. She denies suicidal
ideation.
18
Assessment, Action
 Review the data and details and decide on
action steps
 Decide if you can handle the situation by
yourself

Are you outside your “scope of practice?”
 What is facility policy and how does it apply?
Beicher, Tra, RNC, ARM, HRM, CWS, Defensive Documentation for Long-Term Care:
Strategies for creating a more lawsuit-proof resident record, HCPro, Inc, 2003
19
Social Worker “Scope of Practice”
 Different Scenario:
 What if Mrs. M had indicated thoughts of suicide or that
life wasn’t worth living?

Do you know what to do?
 Are you skilled at assessing suicidality?
 What is your policy and procedure?
 Are you comfortable documenting this situation?

What resources (internally and externally) do you have
available?
 Is facility administration responsive to requests for
assistance, either for staff or residents?
Response, Report
 How did the resident respond to the action(s) taken?

The overall goal is a sense of well-being, not a
cure-all
 Who else needs to have the data, assessment, actions
and responses?

Nursing management, administrator,
physician, care plan team, family

“Report pertinent information once you have
it.”
Beicher, Tra, RNC, ARM, HRM, CWS, Defensive Documentation for Long-Term Care:
Strategies for creating a more lawsuit-proof resident record, HCPro, Inc, 2003
21
Evaluation, Education
 Review everything you have done during the
care process
 Does the documentation contain all necessary
information to support good judgment?
 Do you need to educate anyone, i.e. techs,
aides, housekeeping, family, etc?
Beicher, Tra, RNC, ARM, HRM, CWS, Defensive Documentation for Long-Term Care: Strategies for creating a more
lawsuit-proof resident record, HCPro, Inc, 2003
22
Example: Assessment, Action - Response,
Report - Evaluation, Education

“Mrs. M agreed to meet with social worker 2x/wk to discuss issues
r/t to LTC placement, feelings of depression, relationship with
daughter, utilization of strengths and strategies to adapt to facility
life. She expressed interest in having a job at the facility. The
charge nurse will speak with Mrs. M about the possibility of taking
routine pain medication and will contact the physician. Resident
gave permission for social worker to call daughter and stated that
she welcomes her input. Activity Director will meet with resident to
determine what type of job she would like in the facility. Care
conference scheduled in two weeks. Physician notified of
assessment and will visit Mrs. M this week. Care plan team
notified of Mrs. M’s feelings of depression and pain. Social worker
to offer the Depression Education Toolkit to the daughter.”
Care Plan Implementation:
Documenting Response
 “After meeting with resident for four weeks, she shared her fear of
declining health and when she sees other residents who are more
debilitated than she is, she feels afraid and angry….”
 Or, “Social worker has tried meeting with Mrs. M for three weeks
at different times of the day but states she does not think it is
necessary.”
 “Resident has demonstrated the ability to speak politely to staff
when she has a request.”
 Or, “Observed Mrs. M yelling at charge nurse today…”
 “Resident stated she loves her new job and that she feels important
again.”
 Or, “Mrs. M is not enjoying her job as facility greeter and would
prefer to assist with administrative duties such as putting
welcome packets together or serving on a committee.”
24
Contributory Negligence
 Actions
or omissions by residents or
the responsible parties that are also
proximate causes of their injuries

Declining meds and treatments
 Taking off T.E.D. (Thrombo Embolic Deterrent) stockings
 Not following diet
 Returning to “position of comfort” soon
after turning and repositioning by staff
Challenging Situation
 “I guess the biggest challenge we are faced
with on the mood interviews is residents who
are consistently depressed and over time the
symptom frequency is always the same. They
repeat the same answers time and time
again. We ask them to assist in their care
plan by asking what suggestions they have to
help them feel better. They have no
recommendations on what would help them
feel better. So we have consistent high
scores for mood interview.”
The Common Thread – A Framework
 For everything you do: interviews, documentation, assessments,
crisis intervention, behavioral interventions, meetings, care plans
and conferences
 Use this framework:







What is the facility policy on this issue?
What is the regulation?
Am I using critical thinking skills?
Is my clinical judgment sound?
Am I demonstrating competent practice?
Is my documentation defensible?
Have I met the critical elements of care (with documentation)?

Assessment, Care Plan, Implementation of Care Plan by
Qualified Persons, Revisions of Plan, Provision of Services
Excellent Resources

The University of Iowa Nursing Home Social Worker Listserv
 http://www.uiowa.edu/~socialwk/NursingHomeResource/index.html

Depression Education Toolkit by Weill Cornell Homecare Research Partnership
 http://www.champ-program.org/static/Patient%20Education%20booklet%20121010.pdf

Davis, E., Greenwald, S., Pareti, T., (2011). The New Care Plan Answer Book for Activity,
Psychosocial and Social Work Programs MDS 3.0 Edition. Glenview, IL: SocialWork
Consultation Group Publishing.

Greenwald, S. (1999) Social Work Policies, Procedures and Guidelines for Long-Term Care.
Glenview, IL: SocialWork Consultation Group Publishing.

Beaulieu, E. (2012) A Guide for Nursing Home Social Workers, 2nd Edition. New York, NY:
Springer Publishing Company, LLC.

Revolutionary OBRA & JCAHO Formatted Care Plans by Health Care Partnership 2011
 Provides 140 pre-written care plans

Nolta, M. (2012) MDS 3.0 Psychosocial Care Plan Almanac. San Diego, CA: Recreation
Therapy Consultants.
28