Conquering Covid Fear By Gabriel Crawford, RN MSN PMHNP-BC

Signs of Stress

● Physical Symptoms ○ Increased or racing heart rate○ Headache○ Muscle Tension○ Sweating○ Back pain○ Increased or decreased appetite○ Digestive problems○ Agitation○ Insomnia

Signs of Stress

● Mood Symptoms○ Anxiety○ Depression○ Irritability○ Fearfulness○ Anger

Signs of Stress

● Cognitive Symptoms○ Forgetfulness○ Disorganization○ Preoccupation with Negative Thoughts○ Increased Risk of Substance Use

Strategies for Dealing with Physical Symptoms

● Improved diet● Increase exercise● Increase VItamin C● Ensure Good Sleep Hygiene ● Meditate● Learn Yoga● Breathing or Breath Control● Use of Essential Oils

Strategies for Improving Mood Symptoms

● Take some time away from everything (COVID information especially)● What is your relaxation technique (Learn yours, know yours, and use yours)● Positive self talk (Do it, it works)● Social Support (We are all in this together, lean on each other)● Laugh (Not at the current situation, but enjoy the light times and use our

healthcare deranged sense of humor) ● Focus on what you can control (Are you following the guidelines, taking

precautions, taking care of yourself?)

Strategies for Dealing with Cognitive Concerns

● Increased planning (Make your plan and follow it)● Get involved in facility task force (Be part of the solution)● Follow a schedule● Fight off the instant negative thoughts● Stay out of the negative conversations and panic talk

Using Mindfulness

● Concentrate on the Moment (Right now, not tomorrow, not yesterday)● This is for now, not forever.

○ Things may change forever, but this current situation will pass.

● Use alternative thinking patterns to reset your thoughts○ Fight the ideas that force fear and replace them with what you know

● Automatic negative thought patterns○ Instant thoughts---> thought blocking techniques○ Accepted negative beliefs----> Challenge those thoughts○ Lower or depressed mood ----> Positive self talk/ positive thoughts

CBT modalities

● Behavior- What behaviors are you presenting. ● Affect- Can you be the one that shows the positive affect● Sensation- Understand that physical attributes help you improve your

mental aspects● Imagery- Positive imagery helps change perception● Cognition- develop healthy routines and follow these during times of stress● Interpersonal Factors- Know that your surroundings and the voices of

those arounds, help shape our perception.

C RY S TA L P L A N K , R N , B S N , R A C - C T C O N S U L T A N T / Q U A L I T Y E D U C A T O R

M U M D S A N D Q U A L I T Y R E S E A R C H T E A M

S I N C L A I R S C H O O L O F N U R S I N G

Q I P M O

What is PASRR?

The PASRR process applies to all individuals entering a Medicaid certified bed.

The Level II portion of the PASRR screening or reviewing is of individuals with mental illness or

Intellectual Disability who apply or reside in a Medicaid certified SNF bed regardless of payment

source.

Preadmission Screening and Resident Review

DA-124 C (Level I) Application Submission

For a person’s first admission to a nursing facility

If the person has been out of a nursing facility 60 days or greater

If FSD requests for re-applying for Medicaid (indicate re-applying for Medicaid on

DA-124 A/B)

If the resident (with MI) has had a Significant Change in Status per the MDS 3.0.

(indicate the Change of status on the DA-124 A/B)

Encrypted email: COMRU@health.mo.gov

Can overnight or regular mail also.

DA-124C

What would trigger a Level II review?

Anyone admitted to a Medicaid certified bed that meets at least one of the

following criteria:

1) Has had inpatient psychiatric treatment in the past 2 years; should have a Major

Mental Illness diagnosis.

2) Indication of being dangerous to self and others; serious behavioral problems;

suicidal or homicidal, even if Dementia is the primary psych diagnosis;

3) Legal Issues; incarceration or history of, charges of assault, murder, sex offence;

etc

4) Has a diagnosis of Intellectual Disability

(diagnosed before age 18);

5) Has a Developmental Disability (DD) condition related to Intellectual Disability

(Onset before age 22). Examples: TBI, Cerebral Palsy, seizure disorder, etc.

DA-124 A/B

Points are assigned for the amount of assistance required, the complexity of care and

the professional level of assistance necessary, based on the level of care criteria.

The resident is assessed and if determined to have a point level of 24 points or above

can be admitted to the SNF.

Points come from: dietary,

restorative services,

monitoring, medication,

behavioral,

treatments,

personal care,

rehabilitative services.

Mobility Dietary Restorative Services Monitoring Medication Behavioral Treatments Personal Care Rehab Services

Points Assistance for transfers or

mobility

Nutritional requirements &

need for assistance or

supervision with meals

Specialized services by trained

& supervised individuals to

help maintain or obtain

optimal highest practicable

functioning potential

Observation/Assessment of

physical/mental condition (lab-

digoxin/coumadin, BS, I&O,

weight, other monitoring

procedures

Drug regimen: monitoring

due to the complexity of

medication.

Individual's social or mental activities Course of nursing procedure ordered

by the attending physician.

ADL including hygiene, personal

grooming, dressing, bathing, oral nd

personal hygiene, hair & nail care,

shaving and B&B functions.

Restoration of a former or normal

state of health through medically-

ordered therapeutic services either

by direct/ supervision of a qualified

professional. Not limited to PT,

OT,SLP, & Audiology. Must be

ordered by physician, individually

planned & implement program with

written goals &response/ progress

documented.

Zero No assistance with transfers

or mobility (may use assistive

device)

Independent in dietary needs/

no assistance in eating

No program required Only routine monitoring such as

monthly wt, temps, B/P, vitial

signs & routine supervision

No medication or had not

required PRN meds within 30

days prior to review and

eval.

Requires little or no behavioral assistance No treatments ordered by physician No assistance with personal care.

Independent.

Require no ordered rehab services

Three Minimum assist Minimum assist (cutting

food/verbal encouragement)

(Diets for stablized conditions)

Minimum services to maintain

level of functioning

Minimal monitoring: periodic ax

due to mental impairment,

monitor mild confusion or both

Requires regular scheduled

meds and exhibits a stable

condition

Requires minimal behavioral assistance in

the form of supervision or guidance on a

periodic basis. (may display some memory

lapses or occasional forgerfulness due to

mental or developmental disabilities

(needs occasional emotional support)

Minimal type-ordered tx. Includes non-

routine & preventative tx such as

whirlpool bath or other services

Minimal assistance with personal

care/personal grooming &/or

infrequent incontinency (once a

week of less).

Require minimal-ordered rehab one

time per week.

Six Moderate assistance (even

when using assist device)

Moderate assist (Constant

supervision during meals or

actual feeding)

Moderate services in order to

restore to a higher level of

function

Moderate monitoring: recurring

ax of routine procedure due to

unstable physical or mental

condition

Requires moderate

supervision of regular

scheduled medicaiton- daily

monitoring by licensed

personnel

Requires moderate behavioral assist-

supervision due to disorientation, mental

or developmental disabilities or

uncooperateive behaviors

Moderate type-ordered tx requiring

daily attention by licensed personnel.

Tx include daily dressing, PRN O2, oral

suctioning, catheter maintenance

care, tx of stasis or PU, wet/moist

packs, maximist etc.

Moderate assist with personal

care/personal grooming, requiring

close supervision or exhibits

frequently incontinency (incontinent

of bladder daily but has soe control

or incontinent of bowel 2-3 times per

week or combination of these.

Require moderate-ordered rehab

services of 2-3 per week.

Nine Maximum assistance (total

dependent)

Maximum assist (extensive

assist for special dietary needs

or eating. Includes enteral

feedings or parenteral fluids)

Maximum services to restore

to a higher level of

functioning. Intensive services-

requiring professional

supervision or direct services

Maximum monitoring: intensive

due to unstable physical or

mental condition

Maximum supervision fo

regular scheduled meds, a

complex med regimen,

unstable pysical or mental

status or meds require

professional obervation & Ax

Requires manimum behavioral assist

(extnsive supervision due ot psychological,

developmental disabilities or TBI with

confusion, incometency, hyperacativity,

hosptility, severe depression or other

behavioral characteristics. (Includes

frequent bizarre behavior, verbal/physical

abusive, or incapable of self-direction.

Maximum type ordered tx of an

extensive nature requiring povision,

direct supervision by professional

personnel. Tx intratrachial suctioning,

SP catheter insertion or maintenance,

O2 contiously, new or unregulated

ostomy care, deep draining lesion

dressing more than once daily, care of

extensive skin disorders-advanced PU

or necrotic lesions etc.

Maximum assistance of personal

care/total personal care and/or

exhibits continuous incontinency all

or most of the time.

Maximum-ordered rehab of 4 ore

more times per week.

*Uncontrolled behavior that is dangerous

to the themselves or others must be

transferred immediately.

Qualifying care services may include:

1. Administration of Levine tube or gastrostomy tube feedings;

2. Nasopharyngeal and tracheotomy aspiration;

3. Insertion of medicated or sterile irrigation and replacement catheters;

4. Administration of parenteral fluids;

5. Inhalation therapy treatments;

6. Administration of injectable medications other than insulin, if required other

than on the day shift; and

7. Requirement of intensive rehabilitation services by a professional therapist at

least five (5) days per week.

SNF and ICF’s following the following process for new admissions into a Medicaid-certified bed:

1. May enter prior to completion of the Level II PASRR eval or Special Admission Category.

2. The hospital will send the completed DA 124C to the SNF prior to d/c. SNF needs to review to ensure the

Level of Care (24 points) are met prior to admission and has info to determine if they can meet the medical

and behavioral needs of the individual.

3. SNF will submit entire DA124 (A/B &C) with a Special Admission Category form indicating “Waiver due to

COVID-19”. SNF needs to indicate whether the client will resident at the SNF after 30 days.

4. DHSS recommends DA 124 application to COMRU within 14 days of admission to the SNF.

5. COMRU will determine if applicant meets Level of Care and refer applicants requiring a Level II PASRR

screening to DMH.

6. After 30 days, new admissions with mental illness (MI) or intellectual disability (ID) will receive a Resident

Review as soon as resources become available.

CPR GUIDANCE

UPDATED REPORTING PROTOCOL

RESOURCES

DA-124 A/B & C applications are on the COMRU home page:

www.health.mo.gov/seniors/nursinghomes/pasrr.php

https://health.mo.gov/seniors/nursinghomes/pdf/580-2460.pdf

https://www.sos.mo.gov/cmsimages/adrules/csr/current/19csr/19c30-81.pdf

https://www.sos.mo.gov/cmsimages/adrules/csr/current/19csr/19c30-81.pdf

Questions regarding this process can be directed to COMRU@health.mo.gov