Transcript Integrating Behavioral Health into Long Term Care

Integrating Behavioral Health
into Long Term Care
Sara Honn Qualls, Ph.D.
University of Colorado Colorado Springs
WHAT’S ALL THE BUZZ IN
INTEGRATED CARE ABOUT?
Residents of LTC
80% have moderate to severe
behavioral difficulties including
agitation, disorientation, forgetfulness,
aggression, anxiety, and depression
LTC Settings
“Characteristics of the long term care
environment are known to interact with medical
and cognitive illnesses of those admitted to the
facilities in a manner that limits residents’
personal control over daily routines and
reinforces their dependency on others.”
APA, Blueprint for Change
Residents’ Rights
Least restrictive environment +
Least restrictive intervention +
Avoidance of physical and chemical
restraints
=
Need for nonpsychopharmacologic, behavioral
approaches to the care of chronically ill elders
Mrs. Jones is a 91 year old woman in a nursing home who has
advanced dementia and is completely dependent upon the
nursing home staff for all her care. Due to her dementia, she
has lost her ability to communicate cannot tell others what
she wants or needs. She calls out “nurse, nurse!” throughout
the day, but when staff try to respond, Mrs. Jones cannot tell
them what she needs. Mrs. Jones’ calling out is upsetting to
other residents, frustrating to the staff and Mrs. Jones herself
frequently appears distressed and upset. Yet, no one can
figure out how to soothe her or diminish her calling out. The
doctor suggests asking the psychologist for assistance.
However, due to the advanced dementia, Mrs. Jones has
limited ability to participate in an assessment and is not a
candidate for counseling or other traditional intervention.
How can the we help?
APA Committee on Aging, 2011
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The psychologist possesses a range of specialized skills that can be of assistance, but
none of the interventions are reimbursed under Medicare. The interventions that
could be helpful include:
Creating a behavior tracking system to determine if there is a trigger to Mrs. Jones’
calling out. Once identified, the trigger could be eliminated or an alternative approach
could be used to decrease her distress.
Education for staff on how to interact with an individual with advanced dementia.
Relying less on verbal skills and more on non-verbal cues and interactions can be
helpful to improve understanding when language is diminished.
Creating an individualized plan of care for responding to the challenging behavior.
Interventions by staff that take into account who Mrs. Jones’ is, what she likes and
dislikes and the triggers to her behavior can help to reduce the frequency and intensity
of her calling out.
In a case just like this one, the consulting psychologist conducted a behavior tracking
system that helped to identify the cause of the client’s calling out. She had an infected
tooth that was causing her pain, but that she could not describe to others, had caused
her distress. Taking care of the tooth and then providing her with simple activities to
engage her during the day eliminated the calling out.
APA Committee on Aging, 2011
WHAT CHALLENGES IN LTC DO YOU
RECOGNIZE IN CARE OF MRS. JONES?
Key Challenges in LTC
• High rates of
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Cognitive impairment
Medical co-morbidity
Social and identity loss
Interrupted well-being
• Low levels of
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Social support for independence
Planning for improvement
Engaging activity choices
energy
Key Challenges in LTC
• Institutional environment
– Low rates of control over basic life structure
– Low rate of control over staff work structure
– High rates of turnover among staff
– Staff ratios are too low for behavioral
interventions that put demands on staff
– Operates 24-7 with very different perspectives
across shifts
– Poor communication tracking systems
PIKES PEAK MODEL COMPETENCIES
What do we bring to our partners?
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Screening
Evaluation
Intervention
Consultation and training
Program design and evaluation
Screen
• Case finding
• Brief
Diagnostics
• Depth of psych info
• Contextual info
• Multidisciplinary info
Intervention
design
• Heavy on context info
Outcome
assessments
• User-friendly
• Outcome focused
• Brief
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Example: Cognitive Impairment
Screen
Profile for
General Planning
• MoCA
• SLUMS
• Dementia Rating Scale
• CogniStat
Diagnostic
Decisions
• Neuropsychological Evaluation
Legal Capacity
• Neuropsychological Evaluation
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Example: Depression
Screen
• WHO-5
• PRIME-MD
Diagnostics
• SCID – research level
• Clinical INterview
Intervention
Design
• Pleasant Events Scale
• Suicidal Beliefs
Outcome
Assessments
• GDS-15 item
• Staff observer scale for dementia
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Principles to Guide
• Biopsychosocial Model
• Person-Environment Fit
• Principle of Least Intrusion
Biopsychosocial Frame
• Physiological aging
– systemic changes
– Illnesses
– functional change
• Social contexts
– Aging social stimulus value
– Social structures (or lack of) in later life in particular societies
– Roles and role transitions, social support
• Psychological aging
– Cognitive changes
– Emotional processing changes
– Stress and coping responses
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Person-Environment Fit
Person-Environment Fit
• Optimal outcomes occur when person’s
capacities are optimally supported and
optimally stressed by the environment
• Environment is more salient when level of
competence is lower
Minimally Intrusive Interventions
• Low intensity
– Mild environmental changes
– Cues/prompts
– Scheduling changes for medications/activities
– Motivational enhancements
– Preference assessments
Assessment Tools
• Classic screening tools
– Interview rather than written format
– Simplified tools needed, for ex:
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PHQ2
Pleasant Events Schedule-AD
Quality of Life-AD
MoCA or SLUMS
ORS
Interventions
Modify Tx Plan
Set goals appropriate to capacity
Enhance motivation
Determine pacing of intervention – speed,
intensity of demands
Identify appropriate outcome measures
Determine role of caregivers
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Behavioral Strategies
• Basic principles to increase rate of desired
behavior or decrease undesired behavior
– Reward desired behavior
– Extinguish undesired behavior
– Engage person in behavior that is incompatible
with undesirable behavior (distraction)
– Shape the context in which behavior is exhibited
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Successful Referral for Significant
Intervention: Change in Residence,
Add Medication, Specialty Consult
• Assessment driven
• Sharing data with patient/family/staff as
needed to create change
• Engaging the patient in hope
• Engaging the family in need
• Referral follow-through
• Referral follow-up
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Interventions
Criteria:
- Evidence-based
- Brief; focus in quickly on problem
Specific options:
- Problem-Solving Therapy
- Brief Problem-Focused Solution
- Motivational Interviewing
Key Concern: Apply findings to Daily
Life Context
• Apply to engagement in health and life
• Determine role of patient vs others in
implementing recommendations
• Establish benchmarks/milestones
• Anticipate next transitions
• Use community resources
Key Concern: Staff Burnout
• Psychological problems require adaptations
– Strategy
– Expectations
– Measurement of outcomes
• Mutual support strategies needed
– Combat isolation of the work
– Innovate in most challenging cases
– Tag team for tough moments
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MH Provider Role(s)
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Who hired you to do what?
Who is paying?
With whom will you communicate what?
How does team view you?
How do you get the “on the floor” knowledge
of what is happening?
 Where does family fit? E.g., families are
keepers of the history and advocates for
potential