F740-F745 Behavioral Health and Dementia Care This training is designed to provide you with an overview of the new regulations with behavioral health and dementia care Interdisciplinary Team

Behavioral Health F740 §483.40 Behavioral health services. Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident’s whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. Providing behavioral health care and services is an integral part of the person-centered environment. This involves an interdisciplinary approach to care, with qualified staff that demonstrate the competencies and skills necessary to provide appropriate services to the resident. Individualized approaches to care (including direct care and activities) are provided as part of a supportive physical, mental, and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a resident’s distress or loss of abilities. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Advance-Appendix-PP-Including-Phase-2-.pdf

Services that NEED to be Provided • Ensuring that the necessary care and services are person-centered and reflect the resident’s goals for care, while maximizing the resident’s dignity, autonomy, privacy, socialization, independence, choice, and safety; • Ensuring that direct care staff interact and communicate in a manner that promotes mental and psychosocial well-being. • Providing meaningful activities which promote engagement, and positive meaningful relationships between residents and staff, families, other residents and the community. The purpose of this policy is to define and set expectations regarding behavioral health services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident’s whole emotional and mental well-being, therefore an individualized approach to care is essential. This involves an interdisciplinary approach, with qualified staff that demonstrate the competencies and skills necessary to provide appropriate services to the resident. Individualized approaches to care (including direct care and activities) are provided as part of a supportive physical, mental, and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a resident’s distress or loss of abilities. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Advance-Appendix-PP-Including-Phase-2-.pdf

Behavioral Health Meaningful activities are those that address the resident’s: Customary routines, Interests, Preferences, etc. and Enhance the resident’s well-being;

Services that NEED to be Provided • Providing an environment and atmosphere that is conducive to mental and psychosocial well-being; • Ensuring that pharmacological interventions are only used when nonpharmacological interventions are ineffective or when clinically indicated. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Advance-Appendix-PP-Including-Phase-2-.pdf

Behavioral Health Individualized Assessment and Person-Centered Planning: In addition to the facility-wide approaches that address residents’ emotional and psychosocial well-being, facilities are expected to ensure that residents’ individualized behavioral health needs are met, through the Resident Assessment Instrument (RAI) Process All areas are to be addressed through the: • Minimum Data Set (MDS); • Care Area Assessment Process; • Care Plan Development; • Care Plan Implementation; and • Evaluation. Sections of the MDS related to behavioral health needs that may be helpful include, but are not limited to: • Section C. Cognitive Patterns; • Section D. Mood; • Section E. Behavior; and • Section F. Activities. Utilizing Care Areas such as Psychosocial Well-Being, Mood State, and Behavioral Symptoms will also help to ensure the assessment and care planning processes are accomplished. It is also important for the facility to use an interdisciplinary team (IDT) approach that includes the resident, their family, or resident representative.

Definitions Anxiety: Anxiety is a common reaction to stress that involves occasional worry about circumstantial events. Anxiety disorders include symptoms such as excessive fear and intense anxiety and can cause significant distress. Anxiety disorders are prevalent among older adults and may cause debilitating symptoms. Delirium: Acute confusional state. The distinction between general anxiety and an anxiety disorder is subtle and can be difficult to identify. Accurate diagnosis by a qualified professional is essential. Anxiety can be triggered by loss of function, changes in relationships, relocation, or medical illness. Importantly, anxiety may also be a symptom of other disorders, such as dementia, and care must be taken to ensure that other disorders are not inadvertently misdiagnosed as an anxiety disorder (or vice versa).

Definitions Behavior: Behavioral symptoms that may cause distress or are potentially harmful to the resident, or may be distressing or disruptive to facility residents, staff members or the environment. Delusion: a fixed, false belief not shared by others that the resident holds even in the face of evidence to the contrary Hallucination: The perception of the presence of something that is not actually there. It may be auditory or visual or involve smells, tastes or touch. CMS, MDS 3.0 RAI Manual: https://www.cms.gov/Medicare/Quality-Initiatives-patient-assessment-instruments/NursingHomeQualityInits/MDS30RAIManual.html

Definitions Depression: Although people experience losses, it does not necessarily mean that they will become depressed. Depression is not a natural part of aging, however, older adults are at an increased risk. Symptoms may include fatigue, sleep and appetite disturbances, agitation, expressions of guilt, difficulty concentrating, apathy, withdrawal, and suicidal ideation. Late life depression may be harder to identify due to a resident’s cognitive impairment, loss of functional ability, the complexity of multiple chronic medical problems that compound the problem, and the loss of significant relationships and roles in their life. Depression presents differently in older adults and it is the responsibility of the facility to ensure that an accurate diagnosis is established.

Definitions Highest practicable physical, mental, and psychosocial well-being: is defined as the highest possible level of functioning and well-being, limited by the individual’s recognized pathology and normal aging process. Highest practicable is determined through the comprehensive resident assessment and by recognizing and competently and thoroughly addressing the physical, mental or psychosocial needs of the individual.

Definitions Mental Disorder: A syndrome characterized by a clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental process underlying mental function.

Definitions Non-pharmacological intervention: refers to approaches to care that do not involve medications, generally directed towards stabilizing and/or improving a resident’s mental, physical, and psychosocial well-being.

Examples of Non-Pharmacological Interventions Hydration and nutrition Exercise Pain Relief Individualized sleep and dining routines Homelike environment Consistent staff assignment Individualized activities based on preferences, routines, etc. Massage, art, music, aromatherapy Even assistance with residents with substance use disorders to access counseling programs to the fullest degree possible

F741: Sufficient and Competent Staff - Behavioral Health Needs The facility must have sufficient staff who provide direct services to residents with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident…. As determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with §483.70(e). These competencies and skills sets include, but are not limited to, knowledge of and appropriate training and supervision for caring for residents with mental and psychosocial disorders (as well as residents with history of trauma or PTSD effective Nov. 28, 2019)

Staff Competencies Nurse Aides, as well as all facility staff members are required to complete documentation for training and competency evaluation: • Communication and interpersonal skills; • Promoting residents' independence; • Respecting residents' rights; • Caring for the residents' environment; • Mental health and social service needs; and • Care of cognitively impaired residents. The facility must identify the skills and competencies needed by staff to work effectively with residents (both with and without mental disorders and psychosocial disorders). Staff need to be knowledgeable about implementing non-pharmacological interventions.

Staff Competencies All staff will need knowledge and skill sets to interact effectively with the residents: Communication Residents Rights Meaningful Activities

Documentation It is imperative that staff document: The comprehensive assessment process Person-Centered Care Plan Resident Behaviors All Behaviors, objective description, investigation of root cause Interventions Non-pharmacological and Pharmacological Notifications Practitioner, Resident Representative Follow up and revisions to the care plan (if any) Documentation will include behavior flow sheets, nurses notes, prn medication records, etc.

Dementia Care

Overview of the Regulation §483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable, physical, mental, and psychosocial well-being

Dementia “Dementia” is a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons. However, dementia is not a specific disease. There are many types and causes of dementia with varying symptomology and rates of progression. (Adapted from: “About Dementia.” Alzheimer’s Foundation of America. 30 Nov 2016. Accessed at: https://www.alzfdn.org/AboutDementia/definition.html) There are several diseases that can cause symptoms of dementia (e.g., Alzheimer’s disease, vascular dementia, Lewy body dementia). Other conditions can also cause dementia or dementia-like symptoms (including, e.g., reactions to medications, metabolic problems and endocrine abnormalities, nutritional deficiencies, and heart and lung problems).

Dementia We are required to provide person-centered care to support the highest quality of life: Requires a multidisciplinary approach Includes supporting meaningful relationships and engagement Qualified staff competent to implement individualized care plan approaches Remember, Meaningful activities are those that address the resident’s: Customary routines, Interests, Preferences, etc. and Enhance the resident’s well-being;

Dementia The facility must provide treatment and services for dementia care: Ensuring adequate medical care Provide necessary care and services that are person-centered and maximizes the resident’s dignity, autonomy, privacy, socialization, independence, choice and safety Utilize individualized, non-pharmacological approaches The facility is expected to follow a systematic care process to ensure residents with Dementia have their needs met

Dementia Residents living with dementia require specialized services and supports, (e.g., specialized activities, nutrition, and environmental modifications) that vary, based on the individual’s abilities and challenges related to their condition.

Dementia Dementia causes significant intellectual functioning impairments that interfere with life, including activities and relationships.

Dementia Residents with Dementia may lose their ability to: Communicate Solve Problems Cope with Stressors

Dementia Residents with Dementia may experience: Fear Confusion Sadness Agitation

Dementia Memory loss alone does not necessarily mean a resident has dementia Dementia is not a normal part of the aging process For residents with new or acute memory loss, a comprehensive assessment and evaluation by the IDT including the physician is imperative to determine the underlying cause – if possible.

Dementia Residents with Dementia may also experience co-existing symptoms: Paranoia Delusions Hallucinations Psychiatric conditions Depression Bipolar Affective Disorder .Progressive dementia may exacerbate these symptoms and conditions

Dementia Behavioral or psychological expressions are occasionally related to the brain disease in dementia; however, they may also be caused or exacerbated by environmental triggers. Such expressions or indications of distress often represent a person’s attempt to communicate an unmet need, discomfort, or thoughts that they can no longer articulate.

Dementia Medications may be unnecessary Medications may actually cause harm when administered without appropriate clinical rationale When indicated, medications may be effective when the reason for distress is identified and non-pharmacologic approaches were ineffective All approaches to care, non-pharmacological and pharmacological, need to be person-centered, monitored for efficacy, risks, benefits, and harm, and revised as necessary.

Facility Response Understand Inform Limitations Monitor Understand Our response to these updated regulations includes: Understand – understanding the new regulations and our Behavioral Health and Dementia care policy as well as our residents rights to appropriate care and services for dementia. Todays training will walk us through the changes and our roles and responsibilities. Inform – how we will inform our residents, families and staff members of the behavioral health and dementia care policy Limitations and Concerns – we will discuss how we handle any limitations and concerns Monitor – we will monitor our policy via our QAPI program as applicable

Understand – Regulation Ensure adequate medical care, diagnosis, and supports Ensure care and services are person-centered and reflect resident’s goals Maximize dignity, autonomy, privacy, socialization, independence, choice and safety Utilize non-pharmacy approaches to care such as meaningful activities

Understand - Dementia Residents with dementia require specialized services and supports Activities Nutrition Environmental modifications Residents living with dementia require specialized services and supports, (e.g., specialized activities, nutrition, and environmental modifications) that vary, based on the individual’s abilities and challenges related to their condition. Dementia causes significant intellectual functioning impairments that interfere with life, including activities and relationships.

Understand – Loss of Ability To communicate To solve problems To cope with stressors Increases fear, confusion, sadness, and agitation People living with dementia may lose their ability to communicate, solve problems, and cope with stressors. They may also experience fear, confusion, sadness, and agitation. While memory loss is a common indication of dementia, memory loss by itself does not mean that a person has dementia.

Understand - Common Dementia is common in very elderly residents but it is not a normal part of the aging process Several diseases can cause symptoms of dementia Alzheimer’s disease Vascular dementia Lewy body dementia Other conditions such as medication side effects or heart and lung problems Although it is common in very elderly individuals, dementia is not a normal part of the aging process. There are several diseases that can cause symptoms of dementia (e.g., Alzheimer’s disease, vascular dementia, Lewy body dementia). Other conditions can also cause dementia or dementia-like symptoms (including, e.g., reactions to medications, metabolic problems and endocrine abnormalities, nutritional deficiencies, and heart and lung problems).

Inform – Provide Education Provide education and support to: Residents Representatives Families Staff members Volunteers Contracted Service Employees

Understand - Medications May be unnecessary in dementia May cause harm if dose is high or if given for a long period of time Non-pharmacy approaches are recommended as a first line of treatment along with meaningful activities Medications may be unnecessary and are likely to cause harm when given without a clinical indication, at too high of a dose, for too long after the resident’s distress has been resolved, or if the medications are not monitored. However, medications may be effective when the underlying cause of a resident’s distress has been determined and non-pharmacologic approaches to care have been ineffective or for expressions of distress that have worsened. All approaches to care, non-pharmacological and pharmacological, need to be person-centered, monitored for efficacy, risks, benefits, and harm, and revised as necessary.

Limitations – Dementia Care Completed comprehensive assessments Developed person centered care plan Provided person centered approaches Created a person centered environment Provided activities and nutrition services to meet the needs of dementia residents If all of the above have been provided and the resident has a progressive disease, dementia symptoms are sometimes unavoidable Surveyors must determine whether the failure to attain or maintain the highest practicable physical, mental, and psychosocial well-being (in accordance with the comprehensive assessment and care plan) was avoidable or unavoidable. An unavoidable facility failure refers to a situation where the IDT has completed comprehensive assessments, developed and implemented individualized, person-centered approaches to care through the care-planning process, revised care plans accordingly, and residents are unable to attain or maintain their highest practicable physical, mental, and psychosocial well-being.

Monitor Resident Interviews Resident Observations Medication Review Problem/Concern Process Audit Systems QAPI

How we comply with the regulations Assess resident treatment and service needs through the Resident Assessment Instrument (RAI) process; Identify, address, and/or obtain necessary services for the dementia care needs of residents; Develop and implement person-centered care plans that include and support the dementia care needs, identified in the comprehensive assessment; Develop individualized interventions related to the resident’s symptomology and rate of progression (e.g., providing verbal, behavioral, or environmental prompts to assist a resident with dementia in the completion of specific tasks); Review and revise care plans that have not been effective and/or when the resident has a change in condition; Modify the environment to accommodate resident care needs based upon resident/resident representative involvement

Questions?

References CMS, State Operations Manual, Appendix PP: Guidance to Surveyors for Long Term Care Facilities: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Advance-Appendix-PP-Including-Phase-2-.pdf CMS, MDS 3.0 RAI Manual: https://www.cms.gov/Medicare/Quality-Initiatives-patient-assessment-instruments/NursingHomeQualityInits/MDS30RAIManual.html

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