Webinar May 2012 5 17 Final

7/31/2019 Webinar May 2012 5 17 Final

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Pre-admission Screeningof Older Adults with

Cognitive Impairment:

Considerations forEmergency Services Staff

Thursday, May 17, 2012, 1:30-2:30 pm EST

Elizabeth Kirkland, LCSW

Amy Powell, MS LNHA


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Abbreviations used in thisdocument

AD- Advance Directive

AL- Assisted Living

CDC-Centers for Disease Control

CMS-Center for Medicare & Medicaid Services

CSB-Community Services Board / BHA-Behavioral Health Authority

D/O- Disorder

ECO- Emergency Custody Order

IP-inpatient

LTC-Long Term Care

NH Nursing Home

NP-Nurse Practitioner PCP-Primary Care Physician

PGH-Piedmont Geriatric Hospital

POA- Power of Attorney

TDO-Temporary Detention Order

UA-Urinalysis UTI-Urinary Tract Infection 22


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OBJECTIVES

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All in the numbers...

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s s mos e y no asurprise to you, but in

preparation for the futureof LTC we MUST.....

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Improving the Crisis Nexus

66Holding on to past grievances/negative experiences arebarriers to cooperation!


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Improving theCrisis Nexus

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mprov ng e r s s exus

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Objective 1:Unique Characteristics of LTC

Environment

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Objective 1:Unique Characteristics of LTC

Environment

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Population served:

Some areunable toremain at

home safely

Some areunable to

communicateclearly

History isusually

incomplete

Facilitystaff

caughtbetweencompeting forces:


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Objective 2:Special Challenges involved in treating

older adults with acute mental health issuesin the LTC environment

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WHAT IS AN F-TAG?

The Centers for Medicaid and Medicare Services(CMS) has regulations that will be referred to

during this presentation as F-Tags.

These F-Tags are categories that theinspectors/surveyors cite when deficiencies occur.

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P ti A id t


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Preventing Accidentsthrough:

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If the facility fails to do theabove....

It is considered "avoidable" and can lead tonegative consequences for the facility.

Deficiencies are rated on a severity scale todetermine if harm occurred and/or howmany people did it affect.

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Does Behavior = Accident/Incident?

Regulations specify that the facility is tasked with

correcting the behavior of any resident, visitor, and/orstaff if it can determine a precursor to an altercation,incident or harm to another resident.

NOTE: The regulations states

"Even though a resident may have a cognitiveimpairment, he/she could still commit a willful act."

Facility may be calling prescreener to correct thebehavior of a resident by initiating an inpatientadmission

Facility should have Plan B developed, in case admission isnot outcome

Prescreener must assess if acute inpatient treatment isa ro riate accordin to the Code of Vir inia more on this in

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Does Behavior =Accident/Incident?


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Facility should consider early interventionto avoid crisesTherapy (could be beneficial, depending on

stage of dementiahttp://www.alz.org/alzheimers_disease_stages_of_al)

Modifications to environment or individualsroutine

Consultation with Piedmont Geriatric

2020

http://www.alz.org/alzheimers_disease_stages_of_alzheimers.asphttp://www.alz.org/alzheimers_disease_stages_of_alzheimers.asp


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2. Medication Use

In LTC one of the most unique and misunderstoodcharacteristics is the Unnecessary Drug F-Tag 329. This tag

states:

"Each resident's drug regimen must be free

from unnecessary drugs. An unnecessary drugis any drug when used:

(i) in excessive dose (including duplicate therapy);or

(ii) for excessive duration; or(iii) without adequate monitoring; or

(iv) without adequate indications for its use; or

(v) in the presence of adverse consequences which

indicate dose should be reduced or discontinued;2121


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GDR

GRADUAL DOSE REDUCTION

This is mandated to occur when anymedication is identified to meet the previous

criteria.

On a GDR, it is important to document whenbehaviors are taking place to justify the

necessaryuse of the medication(s).

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RealityThe system in which this happens in most LTC environments is that:

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scenario...

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DOCUMENT DOCUMENT DOCUMENT

In order for facilities to manage residents on medications, it is

important that they can

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Resident Rights

Residents of LTC facilities have the rights to: to be free from abuse

to be free from restraints (to include

chemical) See handout, Resident Rights, for full list

www.vdh.virginia.gov/OLC/Laws/documents/2010/pdf

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http://www.vdh.virginia.gov/OLC/Laws/documents/2010/pdfs/rgts%20of%20NF%20pts%202010%20COV.pdfhttp://www.vdh.virginia.gov/OLC/Laws/documents/2010/pdfs/rgts%20of%20NF%20pts%202010%20COV.pdf


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4. Inspections/Quality/5-starRating

LTC facilities are regulated by the StateHealth Department that communicates with

CMS.

The state performs inspections annually or

as needed in order to determine complianceto regulations and consequences of notdoing so.

www.medicare.gov/NHCompare/static/tabhelp.a2828

Obj ti 2
http://www.medicare.gov/NHCompare/static/tabhelp.asp?language=English&activeTab=6&subTab=0version=defaulthttp://www.medicare.gov/NHCompare/static/tabhelp.asp?language=English&activeTab=6&subTab=0version=defaulthttp://www.medicare.gov/NHCompare/static/tabhelp.asp?language=English&activeTab=6&subTab=0version=default


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Objective 2:Special Challenges of LTC environment

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Facility may not have full history onindividual


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Facility may have difficulty keeping resident onstabilizing medications


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Prescreenings often begin after hours,with staff who are less familiar withindividual


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Cognitive impairments can decrease inhibitions andincrease impulsiveness


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Assessment may be difficult, due tocognitive impairment, emotional upset,or activity in area


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Considerations regarding ECOLocal practices vary widely as to setting ofassessment

For geriatric population, physical frailty andlevel of confusion can be complicating factor.

Attempting to assess in midst of chaotic ERmay lessen chances of getting accurate read ofindividual

Consider assessing at facility, if this is safe.If transportation to other location necessary,

consider having familiar staff accompanyindividual

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Medical ECO: Code section: 37.2-1103Allows for ANY licensed physician to request ECO

for medical evaluation, providing:

Person cannot make informed decision due to

MEDICAL issues, and is unlikely to become capablequickly enough

Intervention is needed to prevent imminent orirreversible harm

There is no legally authorized person who can

authorize treatmentPhysician has been in electronic or personal

communication with emergency medical personnelon scene

If person regains capacity, decision-making

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Prescreener Is TDO appropriate according to the Code of Virginia?


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Prescreener: Is TDO appropriate according to the Code of Virginia?(37.2-809.B)

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Elder Suicide StatisticsHere are a few CDC statistics on suicide in elders:

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Prescreener: is TDO appropriate according to the Code of


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pp p gVirginia?

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Objective 3:


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Objective 3:Admission Practicalities

If hospitalization is outcome, insurance provider willdetermine payment length, but carefuldocumentation can help make case for initialtreatment

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In Closing

Todays presentation has attempted to openyour eyes to all the complicated challengesthat exist for all parties.

However, the most important point to takeaway today is that we MUST all work

TOGETHER to achieve that common goal,

understand each others daily pressures,and show compassion for each other whencompleting our difficult work.

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Q&A

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Elizabeth Kirkland, LCSW

[email protected]

Director of BehavioralResources & Community

Relations6802 Paragon Place, Suite

201Richmond, VA 23230

(80 ) 282 0 3

Amy Powell, MS LNHA

Health CareAdministrator

Westminster Canterburyon the Chesapeake Bay

3100 Shore DriveVirginia Beach, VA

23451
mailto:[email protected]:[email protected]

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Webinar May 2012 5 17 Final