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Beth B. Ulrich, L.C.S.W.
              Community Liaison
Centra 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 behavioral
long-term care
                                      problems.
  placement.
Ensure a smooth transition from Acute Care Setting to Long-Term Care Facility


Acute 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 care
facilities 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 issues



Primary 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 behaviors
Key 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 Steele



Solving behavior problems without using medications
High level of
                         commitmen
                          t required
                            from all
                           levels of
                              staff.



   Done
consistently,
                                                      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 best
TO BE CONSIDERED             approach.



                    We can identify causes and
                     determine interventions.



                    Directed “trial and error” is
                    the rule, not the exception.
Don’t immediately
jump 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




     Where?



     When?



      How?



  With Whom?



After/Before What?
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 a
Back-up
 Plan!
Consider the untoward effects of treatment.

 Patients improve for no specific reason.
Catastrophic Reactions

Uncooperative/ Resistant To Care

     Aggression/ Agitation

       Wandering/Pacing

           Delirium

Yelling/ Calling Out/ Screaming

        Mood Problems

   Hallucinations/ Illusions

   Suspiciousness/ Delusions

   Social Withdrawal/ Apathy

     Rummaging/Hoarding
Initial reaction to “lengthy” process may be that it is “just
not practical” to implement in the LTC environment due to
staffing and time constraints and limitations.

Front end investments reduce long-term problems and
expenses.

Unrealistic expectations mandated by all of the regulations
that long-term care facilities must adhere to can cause
frustrations.

Tensions between providers and regulators may be
diminished as results are realized from implementing this
approach.
Thank you!


 Beth B. Ulrich, L.C.S.W.
   Community Liaison, Centra Senior Psychiatric Program
   beth.ulrich@centrahealth.com

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Webinar 3 22_2012 Beth Ulrich Presentation

  • 1. Beth B. Ulrich, L.C.S.W. Community Liaison Centra Senior Psychiatric Program
  • 2. October 2011: Senior Care Unit Opens  12-bed unit at Centra Virginia Baptist Hospital  Acute care for patients 60 years or older
  • 3. Dementia, primarily in the advanced stages. OUR PATIENTS 60% have Mental health required and behavioral long-term care problems. placement.
  • 4. Ensure a smooth transition from Acute Care Setting to Long-Term Care Facility Acute 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
  • 5. Ensure appropriate interventions are implemented in long-term care facilities 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
  • 6. “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 issues Primary emphasis on short acute stays while keeping beds at long-term facilities filled.
  • 7. 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.
  • 8. • “Tips” for managing challenging behaviors Key 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
  • 9. adapted from Practical Dementia Care by Rabins, Lyketsos, and Steele Solving behavior problems without using medications
  • 10. High level of commitmen t required from all levels of staff. Done consistently, There is no it will “quick fix.” become automatic. 4D Approach Time and effort are Process is required to gradual. experience results.
  • 11. Behavior problems stem from multiple causes. Causes can be distinguished from one another. ASSUMPTIONS There is rarely one best TO BE CONSIDERED approach. We can identify causes and determine interventions. Directed “trial and error” is the rule, not the exception.
  • 12. Don’t immediately jump to the treatment! • Obtain history. • Examine. • List likely causes. • Define treatment options.
  • 13. 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?
  • 14. Define Decode Devise Determine Where? When? How? With Whom? After/Before What?
  • 15. 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
  • 16. 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!
  • 17. Define Decode Devise Determine What is the expected outcome? How long will it take? Who will do what . . . and when? Create a fallback plan.
  • 18. What if the interventions FAIL? Have a Back-up Plan!
  • 19. Consider the untoward effects of treatment. Patients improve for no specific reason.
  • 20. Catastrophic Reactions Uncooperative/ Resistant To Care Aggression/ Agitation Wandering/Pacing Delirium Yelling/ Calling Out/ Screaming Mood Problems Hallucinations/ Illusions Suspiciousness/ Delusions Social Withdrawal/ Apathy Rummaging/Hoarding
  • 21. Initial reaction to “lengthy” process may be that it is “just not practical” to implement in the LTC environment due to staffing and time constraints and limitations. Front end investments reduce long-term problems and expenses. Unrealistic expectations mandated by all of the regulations that long-term care facilities must adhere to can cause frustrations. Tensions between providers and regulators may be diminished as results are realized from implementing this approach.
  • 22. Thank you!  Beth B. Ulrich, L.C.S.W.  Community Liaison, Centra Senior Psychiatric Program  beth.ulrich@centrahealth.com