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

• 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 – Cognitive impairment– Medical co-morbidity– Social and identity loss– Interrupted well-being

• Low levels of – 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

• Screening• Evaluation• Intervention• Consultation and training • Program design and evaluation

What do we bring to our partners?

•Case finding•BriefScreen•Depth of psych info•Contextual info•Multidisciplinary info

Diagnostics

•Heavy on context infoIntervention design

•User-friendly•Outcome focused•Brief

Outcome assessments

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•MoCA•SLUMSScreen•Dementia Rating Scale•CogniStat

Profile for General Planning

•Neuropsychological EvaluationDiagnostic Decisions

•Neuropsychological EvaluationLegal Capacity

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Example: Cognitive Impairment

•WHO-5•PRIME-MDScreen•SCID – research level•Clinical INterviewDiagnostics•Pleasant Events Scale•Suicidal Beliefs

Intervention Design

•GDS-15 item•Staff observer scale for dementia

Outcome Assessments

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Example: Depression

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:• PHQ2• Pleasant Events Schedule-AD• Quality of Life-AD• MoCA or SLUMS• ORS

Interventions

Set goals appropriate to capacityEnhance motivationDetermine pacing of intervention – speed,

intensity of demandsIdentify appropriate outcome measuresDetermine role of caregivers

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Modify Tx Plan

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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• 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

Successful Referral for Significant Intervention: Change in Residence, Add Medication, Specialty Consult

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Interventions

Criteria:- Evidence-based- Brief; focus in quickly on problemSpecific 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

• 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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Key Concern: Staff Burnout

MH Provider Role(s) 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