Medical Direction Pearls March 17, 2006 3:30-5:00 AMDA 29th Annual Symposium
Optimizing Outcomes and Ensuring Quality Care
Clinical and Management Issues
Optimizing Outcomes and Ensuring Quality Care
Clinical and Management Issues
Leo J. Borrell, MDMedical Director of
Senior PsychCare in affiliation with Senior Psychological CareHouston and San Antonio
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Faculty Disclosures:Faculty Disclosures:
Dr. Leo J. Borrell
Forest Laboratories: Speakers Bureau
Bristol-Myers: Honoraria
Janssen Laboratories: Honoraria
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Quality Care Is In The Eye Of The Beholder
Clinical Issues
Quality Care Is In The Eye Of The Beholder
Clinical Issues
Patient Quality ChainPatient Quality ChainGet to &
from hospital
Deal with stress
Find out patient status
Pay Bills
Provide post d/c
careValue
-Loss of Income While Visiting-Little Help Available-Unfamiliar, Complex Activities-Costs
Value Chain Problems-Location-Language-Financial Situation
-May not have Support at Home-Few “in-hospital” support systems
-Difficult to Talk to Attending Physician-Conflicting Statements from Multiple Sources-Unfamiliar Vocabulary & Concepts
Get to and From Hospital
Deal With
Stress
Find Out Patient Status
Pay Bills
Give PostDischarge Care
-Bills are Difficult to Understand-Insurance is Difficult to Understand-Insufficient Resources
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
RegisterPatient
Care Discharge Marketing Service Value
ValuePhysician
Pharmacy
Nursing
DiagnosticImaging
Lab
PhysicalTherapy
General Quality ChainGeneral Quality Chain
Nursing Quality ChainNursing Quality Chain
Assess Care ProvideCare
Discharge Planning
Document Value
Value Chain Problems
-All Manual-Increasing requirements from JCAHO-Everything must be documented
Assess
CarePlans
ProvideCare
DischargePrep
Document
-Shortage of nurses-Documentation is time-consuming
-Time-consuming-Not used as a communication tool-Supplemented with oral
-Not enough equipment-Not enough time and nurses-Nurses do non-nursing tasks-Manual documentation takes time
-High acuity makes coordination difficult
Physician Quality ChainPhysician Quality ChainLocate
Patient
Make Diagnosis
Orders and results
Treat patient
Documentin chart Value
Value Chain Problems
-Must go to hospital for dictation-Paperwork required for JCAHO, legal dept., HCFA-Reimbursement and coverage paperwork
Locate patient
Make diagnosis
Orders& results
Treat patient
Documentin chart
-Privileges not clarified-Get the wrong room-Bed unavailability-No coverage or restricted coverage
-Delays in obtaining medical records-Delays in getting consultants
-Delays in waiting for test to be performed-Results not delivered on time
-Scheduling conflicts for treatment rooms-Medications not given on time
Quality From Medicare’s Perspective Documentation Guidelines
Quality From Medicare’s Perspective Documentation Guidelines
• 15501 B– Medical necessity a must– Documentation must support level of service
given
• 15509.1– Will pay for visits necessary for Medicare
required assessments– For psychiatric visits, patient must be able to
benefit, must NOT be suffering from a severe enough cognitive impairment to prevent effectiveness of service
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Documentation - Timing of VisitsDocumentation - Timing of Visits
• Medicare will only pay for necessary and reasonable preventive/routine care.
• Necessary and reasonable defined as what is needed, according to the attending physician, to professionally “assess, plan, manage and monitor the health care of a resident or patient in the facility” within accepted principles of medical practice.
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
General Principles of DocumentationGeneral Principles of Documentation
Medical Records Criteria– Complete and legible– Include date of service, a plan for care– Include past and present diagnoses– Include progress, response to treatment, and
compliance– Written plan with treatment, frequency of
visits, and medications & dosage– Support level of evaluation performed
MUST DOCUMENT NECESSITY OF SERVICE
Senior PsychCare in affiliation with Senior Psychological Care
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Quality from a Surveyor Perspective Quality Indicators of Validity
Quality from a Surveyor Perspective Quality Indicators of Validity
• Prevalence of Indwelling Catheter• Bladder/Bowel Incontinence• UTIs• Infections• Inadequate Pain Management• Pressure Ulcers• Late-loss ADL Worsening• ADL Worsening• Locomotion Worsening• Improvement in Walking• Worsening Bladder Incontinence
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Quality Mental Health Care From A Medical Director Perspective
Quality Mental Health Care From A Medical Director Perspective
1. Understanding Implications of F Tags for The Mental Health Team
2. Qualifications of Mental Health Care Professionals
3. Responsibilities for Documentation
4. Understanding The Biosocial Approach: Communication, Collaboration, Evaluation, Education (Psychotherapy Requires MMSE >10)
5. Quality Is in The Eye of The Beholder
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Quality from A Medical Director and Primary Care Physician
Perspective
F329, F429 Tags
What It Means for Psychiatrists and Mental Health Practitioners
Quality from A Medical Director and Primary Care Physician
Perspective
F329, F429 Tags
What It Means for Psychiatrists and Mental Health Practitioners
1 2 3 4 5 6 7 8
90
80
70
60
50
40
30
20
10
0
PROGRESSION OF SYMPTOMS BY YEARS
Jost BC, et al. Journal of American Geriatric Soc. 1996;44:1078-1081.
Depression
Diurnal Rhythm
Social Withdrawal
Anxiety
Paranoia
Suicidal Ideation
Agitation
Wandering Aggression
Hallucinations
Socially Unacceptable
Peak of Occurrence (% Patients)
Frequent Fluctuation of Symptoms of Alzheimer Disease Progression Requires
Weekly Monitoring and Medication Adjustment
Senior PsychCare in affiliation with Senior Psychological Care
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Necessary Drug Protocol-F329Necessary Drug Protocol-F329
• Eliminate Unnecessary Drugs – Potential for Severe Adverse Reactions (F329)
• Review Drug Regimens – Potential for Less Severe Adverse Reactions (F429)
• No Excessive Doses• Must Use Only As Long As Necessary to
Achieve Outcome• MUST BE MONITORED AND
DOCUMENTED
Senior PsychCare in affiliation with Senior Psychological Care
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Necessary Drug Protocol (cont.)Necessary Drug Protocol (cont.)
• Must Have Indications for Use
• No Long-Acting Benzodiazepines– Short Acting Agents Must Be Attempted First– Exception: Use Retains Functional Status
No Use of Hypnotics
• Must Limit Dose of Antipsychotics
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Necessary Drug Protocol-F429Necessary Drug Protocol-F429
• Pharmacist MUST review each resident’s drug regimen once a month
• Pharmacist must report irregularities to physician and DON
• Reports require notification of MD and acknowledgement, but not action, agreement, or provision of rationale from MD
Senior PsychCare in affiliation with Senior Psychological Care
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Cardiac Safety with Psychotropic Antipsychotics
Cardiac Safety with Psychotropic Antipsychotics
• Prolong QT Syndrome (Mellaril)• Thioridiazine 35.8 m.sec• Geodon 20.6 m.sec• Seroquel 14.5 m.sec• Least Effect Haldol 4.7sec (Haloperidol)
– Electrocardiograph
• Approximately 25% of patients Taking Pherothiazine have ABNORMALITIES.
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Controlling Risk of Diabetes with Atypical Antipsychotics
Controlling Risk of Diabetes with Atypical Antipsychotics
• Screen all patients for history of diabetes.– Those with DM or impaired fasting glucose must have
antipsychotics chosen carefully
• Monitor patients on atypical antipsychotics for any symptoms of diabetes. – Educate those at risk and run a baseline fasting
glucose, repeating it quarterly.
• Any abnormalities should be referred to PCP.– Only consider changing meds after consulting patient
and other caregivers.
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Survey Process-Quality IndicatorsSurvey Process-Quality Indicators
Psychotropic Drug use• Frequency of antipsychotic drug use• Frequency of antianxiety or hypnotic drug
use– Hypnotics used more than 2 times in previous
week,then regular and psychotherapy
Quality of Life• Use of daily physical restraints• Little or no activity for resident
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Quality Mental Health Care A Nursing Home Perspective
Focus Areas
Quality Mental Health Care A Nursing Home Perspective
Focus Areas
Environment
TherapeuticActivities
Quality ofLife
ManagingBehavior
Dementia Special
Care
Quality of Care
Culture of Care
Senior PsychCare in affiliation with Senior Psychological Care
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Goal of Quality Mental Health CareA Psychiatrist’s PerspectiveGlobal States of Well-being
Goal of Quality Mental Health CareA Psychiatrist’s PerspectiveGlobal States of Well-being
Sense of Worth
Sense of Agency
SocialConfidence
Hope
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Quality - A Patient PerspectiveEnhancing Quality of Life
Quality - A Patient PerspectiveEnhancing Quality of Life
Identity
BelongingAnd
Inclusion
IntimacyAndLove
Self-Esteem
Psycho-Social Needs
MeaningAnd
Purpose
Dignity
SenseOf
Control
SenseOf
Security
Senior PsychCare in affiliation with Senior Psychological Care
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Benefits of Quality Well-beingBenefits of Quality Well-being
• Assert Desire • Exhibit Self-respect
• Experience & Express
Emotion
• Evidence Humor• Evidence Creativity
• Initiate Social Contact • Evidence Self-expression
• Show Affection • Evidence Pleasure
• Show Social Sensitivity• Exhibit Helpfulness
• Accepts Others with
Dementia
• Able to Experience Relaxation
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Facilitating Well-beingFacilitating Well-being
• Recognize each person as unique
• Give residents choices
• Stress “working together”, not “doing for”
• Interact and express self spontaneously
• Stimulate the senses
• Celebrate task accomplishment
• Allow resident to give reciprocally to staff
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Factors Contributing to Poor ComplianceFactors Contributing to Poor Compliance
Illness-Related• Paranoid ideation• Negative symptoms/reduced motivation• Depression• Demoralization• Lack of insight• Cognitive impairment• Substance abuse• Grandiosity
Senior PsychCare in affiliation with Senior Psychological Care
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Factors Contributing to Poor ComplianceFactors Contributing to Poor Compliance
Treatment-Related• Inadequate therapeutic alliance• Side effects• Inconvenient regimen• Multiple drugs• Cost• Lack of psychoeducation• Misperception of therapeutic effect• Ineffective treatment
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Factors Contributing to Poor ComplianceFactors Contributing to Poor Compliance
Environment-Related
• Lack of psychocosial support
• Isolation
• Stress
• Stigma
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Quality From an Administrator Perspective
Quality From an Administrator Perspective
Average resident: No behavioral and psychological symptoms in dementia (BPSD), requires only verbal cues from staff for behavior.
Baseline Resident Cost
Resident with non-aggressive BPSD Baseline
+ $1800
Resident with AD and aggressive BPSD Baseline
+ $5300
Senior PsychCare in affiliation with Senior Psychological Care
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Annual Cost of TherapyAnnual Cost of Therapy
Depakote ER 500 mg QD $ 588Depakote 500 mg + 250 mg $ 912Depakote ER 500 mg – 2 tabs $1174Risperdal 2 mg QD $1596Risperdal 0.5 or 1.0 mg QD $ 960*Risperdal 0.5 or 1.0 mg BID $1920Zyprexa 5mg QD $2052Zyprexa 10 mg QD $3120
*50% Risperdal RXs BID AWP 12 Months RX
Senior PsychCare in affiliation with Senior Psychological Care
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Quality Care for Dementia Makes Dollars and Sense
Quality Care for Dementia Makes Dollars and Sense
Annual Costs of Caring for Residents with and without AD
– 26.4% had documented dementia
– Average additional 229 hours of care per year
– Average additional $4700 per patient with dementia per year
•Problem behaviors add costs to LTC•Cholinesterase inhibitors may reduce this cost•Residents with this medication, $49.60 a day•Residents who discontinued it, $55.16 a day
Patients who continued donepezil incurred $6.90 less per day, cost savings of over $2500 per year!
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Total Cost Savings From Quality CareTotal Cost Savings From Quality Care
Management of Aggressive Behavior Cost SavingsPer Year
Utilizing medications and psychotherapy $3500/year
Utilizing Depakote rather than atypical antipsychotics
$2500/year
Maintaining a use of Donepezil $2500/year
Total Cost Savings
Per Patient Per Year$8500/ year
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
F501 Tag
What It Means for Psychiatrists and Mental Health Practitioners
F501 Tag
What It Means for Psychiatrists and Mental Health Practitioners
Senior PsychCare in affiliation with Senior Psychological Care
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Short Term Goal:Establish Responsibilities
Short Term Goal:Establish Responsibilities
• Provide appropriate resident care
• Make periodic visits to the facility
• Provide medical orders
• Provide coverage
• Provide support for transfers
• Provide documentation
• Collaborate with other members of Treatment Team defining Treatment Goals
Senior PsychCare in affiliation with Senior Psychological Care
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Short Term Goals to Comply with 501Core Areas to Establish
with Policy and Procedures
Short Term Goals to Comply with 501Core Areas to Establish
with Policy and Procedures
• Develop criteria/policies relating to care• Set standards for appropriate physician and
mental health professional services• Review credentials of all professionals & CME• Review performance providing feedback• Liaison between mental health providers and
facility staff and managers• Mental health and psychiatrist participate in
quality assurance
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Long Term Goal: Establishing A Performance Improvement
Committee
Long Term Goal: Establishing A Performance Improvement
Committee• Medical Director and QM Director Lead• Identify Staff to Be at Quarterly Meetings• Define Expected Practice Standards• Identify Process for Morbidity/Mortality
Reviews• Develop Standardized Forms• Utilize Available Resources: Involve
Everyone in PI Process
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Long Term Goals Goals to Comply with 501 Through the Performance
Improvement Committee
Long Term Goals Goals to Comply with 501 Through the Performance
Improvement Committee
• Develop criteria/policies relating to care• Set standards for appropriate physician and
mental health professional services• Review credentials of all professionals & CME• Review performance providing feedback• Liaison between mental health providers and
facility staff and managers• Participate in quality assurance
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Implications of 501 GuidelinesImplications of 501 Guidelines
According to the CMS Guidelines on coordination of medical care, the Medical Director should:– provide information
– identify educational needs
– assist in obtaining services
– evaluate services
– get feedback from physicians.
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Implications of 501 GuidelinesImplications of 501 Guidelines
• Medical Director is connected to the staff and should share mutual respect, communication, cooperation, accountability, feedback, and care.
• Collective leadership implies coordinating care with attending physicians.
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Implications of 501 GuidelinesImplications of 501 Guidelines
• Change needed in medical director/staff interfacing.– Medical Director should be included in:
quality assurance, staff education, and facility organizational issues.
• Include Medical Director as integral part of leadership team.
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Implications of 501 GuidelinesImplications of 501 Guidelines
Surveyors are not our enemies.
We must work towards a collaborative, positive relationship in which the Medical Director can provide information on:
Physician issuesPracticesResident issues
Senior PsychCare in affiliation with Senior Psychological Care
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Change in the Role of Medical DirectorProcess Rather Than Context
Change in the Role of Medical DirectorProcess Rather Than Context
• Medical directors must embrace dual mental models (values)
• Medical model focuses on clinical expertise, medical care, individualized thinking.
• Organizational leadership model focuses on physicians as leaders working in collaboration to achieve quality care goals in 3 areas: individual, team/group, and organization
Senior PsychCare in affiliation with Senior Psychological Care
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Medical DirectorF-Tag 501 Implications for Mental Health
Medical DirectorF-Tag 501 Implications for Mental Health
New Responsibilities:1. Collaboration rather than only compliance.2. Involvement of psychiatrist and mental
health in the quality assurance process identifying staff educational meetings.
3. Asking and clarifying expectations regarding mental health services.
4. Coordination of service with nursing staff, families, and primary care physician.Reference: Collaboration is Key to Success with F-Tag 501, Caring for the Ages, Dee Dixon, February, 2006, 8-9
Senior PsychCare in affiliation with Senior Psychological Care
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F-Tag 501 Has Major Implications for Mental Health
F-Tag 501 Has Major Implications for Mental Health
• The CME Interpretive Guidelines emphasizes:
1. Coordinating of medical care
2. Providing information and medical director identifying educational needs of staff
3. Obtaining adequate services with qualified professionals
4. Evaluating the quality of mental health services delivered
5. Obtaining feedback from mental health providers and patients and family
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Reasons to Avoid Quality Standards for Psychiatrists and Mental Health
Practitioners
Reasons to Avoid Quality Standards for Psychiatrists and Mental Health
Practitioners
• Don’t Know Enough About Patient Care to Dictate Clinical Practice
• Mental Health Practitioners Have A Right to Practice As They See Fit
Senior PsychCare in affiliation with Senior Psychological Care
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The Different Type of Quality Psychiatric and Psychotherapy Care Model
The Different Type of Quality Psychiatric and Psychotherapy Care Model
1. Consultation Acceptable
2. Individual Provider Good
3. Team Approach Better
4. Integrated Comprehensive Best
and Mental Health Care
Recommended by the
President’s Commission on
Aging
Senior PsychCare in affiliation with Senior Psychological Care
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Quality and Best Practices in Geriatric Psychiatric Services
(President’s Commission on Aging)
Quality and Best Practices in Geriatric Psychiatric Services
(President’s Commission on Aging)
1. A multidisciplinary team approach2. Specific geriatric expertise and competence3. Individualized assessment and treatment planning with routine follow-up, ideally using standardized outcome measures4. Collaborative treatment planning between the consultant and the nursing home staff5. A strong educational component
Quality Required Quantity Future Visits Determined By
Complexity of Decision
Quality Required Quantity Future Visits Determined By
Complexity of DecisionFUTURE VISITS DETERMINED BY COMPLEXITY OF DECISION
Low Moderate High
Medical Problem Severity (+3 - more than 3 Dx)
1 2 3
Number of Psychiatric & Medical Dx and Management Options (+2/3 Suicidal Thought)
1 2 3
Amount & Complexity of Data Including Previous Medical Record Family Issues
1 2 3
Risk of Complications (+3 12-20 Meds) 1 2 3
Total Score 1-4 4-8 8-12
Visits 1xMo 1xWk 2xWk
Senior PsychCare in affiliation with Senior Psychological Care
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Quality Care From A Physician’s Perspective
Quality Care From A Physician’s Perspective
Complex Decisions That Appear Simple:
Interaction of BioPsychosocial
Complex Decisions That Appear Simple:
Interaction of BioPsychosocial
Psychological Social Factors
Bio-Medical Factors
Valued but not
effective
Effective but not valued
ComplianceEffectiveValued
Non-Compliance
1 2 3 4 5 6 7 8
90
80
70
60
50
40
30
20
10
0
PROGRESSION OF SYMPTOMS BY YEARS
Jost BC, et al. Journal of American Geriatric Soc. 1996;44:1078-1081.
Depression
Diurnal Rhythm
Social Withdrawal
Anxiety
Paranoia
Suicidal Ideation
Agitation
Wandering Aggression
Hallucinations
Socially Unacceptable
Peak of Occurrence (% Patients)
Frequent Fluctuation of Symptoms of Alzheimer Disease Progression Requires
Weekly Monitoring and Medication Adjustment
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
80% of Nursing Home Residents Have Psychiatric Symptoms That Progress Unless
Properly Treated
80% of Nursing Home Residents Have Psychiatric Symptoms That Progress Unless
Properly Treated
•Hallucinations (5-15%) •Withdrawal (30-40%)
•Aggression (10-20%) •Anxiety (30-50%)
•Delusions (20-40%) •Blunted Affect (40%)
•Dysphoria (20-40%) •Mood Liability (40%)
•Hostility (30%) •Agitation (40-60%)
•Suspiciousness (30%) •Apathy (50-70%)
•Disinhibition (30-40%)
Medical Direction Pearls March 17, 2006 3:30-5:00 AMDA 29th Annual Symposium
Causes of Psychiatric Symptoms and Behavior Can Overlap
Causes of Psychiatric Symptoms and Behavior Can Overlap
Frontal LobeImpairment
MajorDepression
Psychotic Disorder
ImpulsivityHyperactivity
Agitation
AnxietyDysphoria
RestlessnessIrritability
VerbalAggression
WithdrawalPhysical Aggression
DelusionsHallucinations
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
AD Quality Care Requires: Diagnosing AD
AD Quality Care Requires: Diagnosing AD
Advantages of early diagnosis– Doctors rule out conditions that may cause
dementia– Coordinate care and families involved in plan
for future and care and support they need
Clinical Assessment Tools– Folstein Mini Mental Status Exam– Clock Drawing Test– Executive Function Measures
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Reducing Psychotropic Drug Use
Evidence Based Medicine
Reducing Psychotropic Drug Use
Evidence Based Medicine
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Quality Care of Depression and Dementia
Quality Care of Depression and Dementia
• Only 25% of those receiving medication alone from a PCP improved
• 51% receiving medication plus psychotherapy improved
• 58% with depression alone receiving comprehensive intervention recovered within 6 months
• Post stroke depression can last from 6 months-2 years
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Quality Care of Depression and Dementia-Conclusions
Quality Care of Depression and Dementia-Conclusions
Patients using psychotherapy did 100% better than those on medication alone.
Without treatment:–20% exhibited behavioral symptoms one
or more times in two weeks–34% had one or more behavioral
symptoms at least once a week.
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Patients with Depression and Dementia without Treatment had
behavioral symptoms :
• 13% exhibited aggressive symptoms• 20% had physically non-aggressive
symptoms• 22% showed verbal behavior symptoms• 13% resisted medication and care• 36% with behavioral symptoms
evidenced depression or psychosis.
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Management of Dementia Symptoms: Agitation, Aggression, and Resistance to Care
Management of Dementia Symptoms: Agitation, Aggression, and Resistance to Care
• Differentiate between spontaneous or provoked disturbing behavior.
• Evaluate sensory impairment: vision, hearing, and ambulation.
• Transition from a care-giving model to a care-partner model.
• Appropriate diagnosis of type of dementia: frontal lobe, temporal lobe, Lewy-Body disease, vascular and psychiatric illness, i.e. depression or psychosis.
• Reference: Looking Beyond Aggressiveness and Dementia, Ladislav, Volicer, MD, Caring for the Ages, Feb. 2006, 6
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A Simple Way To Improve QualityA Simple Way To Improve Quality
Inform Patients
– Respect their autonomy– Explains symptoms– Allows participation in decisions while able– Eases acceptance of assistance– Provides opening to discuss patient concerns– A professional has an obligation to find ways
to explain condition in terms they understand
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A Simple Way To Improve Quality From A Patient’s Perspective
A Simple Way To Improve Quality From A Patient’s Perspective
• Inform Family Members
– Explain symptoms– Encourage family to use time that is left wisely– Enhance family collaboration in planning for
future– Encourage practical and emotional support– Provide opportunity for genetic counseling
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• Motivations Not to Inform Individuals
– Consistent with therapeutic privilege– Avoids burdening patient with bad news– Diagnostic uncertainty– Lack of effective treatments for condition– Avoids uncomfortable conversations
A Simple Way To Not Improve Quality
Don’t Inform Patients and Family
A Simple Way To Not Improve Quality
Don’t Inform Patients and Family
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A Simple Way To Not Improve Quality
A Simple Way To Not Improve Quality
Reasons Not to Inform Families
– Breaks patient confidentiality– Individuals may want to inform family– Family may treat patient differently– Potential abuse or abandonment– Burden of seeing decline– Overreaction
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A Study of Disclosure of Dementia by Professionals
A Study of Disclosure of Dementia by Professionals
• Only 44% of psychiatrists inform patients• 56% professionals in memory clinics disclose
diagnosis• 75% geriatricians and geriatric psychiatrists
disclose AD or dementia• Stage of dementia predicting variable• 39% general practitioners disclose dx
50% PRACTITIONERS DO NOT DISCLOSE DEMENTIA DIAGNOSIS
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Reality of Disclosure andIndividuals with DementiaReality of Disclosure andIndividuals with Dementia
• Only 47% knew correct diagnosis
• 66% said no one ever spoke with them about their illness
• 92% wanted to know to plan for the future and enjoy present while they could
• 65% were told after family was told
• 51% “reacted poorly” per family
Senior PsychCare in affiliation with Senior Psychological Care
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What Can Be Accomplished in LTC in Diagnosis and Management of Dementia
What Can Be Accomplished in LTC in Diagnosis and Management of Dementia
Pre-intervention
N=23
Post-intervention
N=22
P Value
Etiology of dementia identified 12 (52%) 20 (91%) .007
Evidence of dementia management plan by MD
8 (35%) 19 (90%) <.001
Evidence of dementia management plan by other providers
5 (22%) 13 (62%) .013
Evidence of pharmacological treatment
2 (8%)
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Quality in the FutureSpecial Care Unit Background
Quality in the FutureSpecial Care Unit Background
• SCU development in 1980s
• (1987) 7.6% of NH beds
• (1991) 9.6%
• (1995) 22%
• Includes dementia, rehabilitation, other
• Dementia SCU is 7% of NH beds and represents most SCU beds
Special Care Units (SCU)
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Resident Outcomes:SCU vs. Non-SCU
Resident Outcomes:SCU vs. Non-SCU
• Functional decline rate same• ADLs same• Cognitive decline same• SCU
– Decreased use of physical restraints, increased use of chemical restraints.
– Slight increase in sociability and activity– Fewer behavior problems– Benefit to residents with no cognitive impairment.
Senior PsychCare in affiliation with Senior Psychological Care
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SCU - Other OutcomesSCU - Other OutcomesFamily Outcomes• Higher satisfaction• More involvementStaff Outcomes• Greater satisfaction• More training in dementia• More stable staff assignments• Consistent staff, lower turnover• More frequent support group attendance
Senior PsychCare in affiliation with Senior Psychological Care
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Diagnosing Quality Care
A Management Perspective
Diagnosing Quality Care
A Management Perspective
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“A Better Quality of Life Through Integrated Mental Health Care”
Quality :Requirements for Changing for The Better
Quality :Requirements for Changing for The Better
Pressure for
Change+ + +
SharedDriven Vision
Capacity for
Focused Change
ActionableFirstSteps
= Successful Change
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Dx 1: Why Quality Initiatives FailsDx 1: Why Quality Initiatives Fails
+ + +SharedDriven Vision
Capacity for
Focused Change
ActionableFirstSteps
= Bottom of the “in box” Low Priority
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Dx 2: Why Quality Initiatives FailsDx 2: Why Quality Initiatives Fails
Pressure for
Change+ + +
Capacity for
Focused Change
ActionableFirstSteps
= A Fast Start That Fizzles Directionless
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Dx 3: Why Quality Initiatives Fails Dx 3: Why Quality Initiatives Fails
Pressure for
Change+ + +
SharedDriven Vision
ActionableFirstSteps
= Anxiety, Frustration, Loss of Competitive Edge
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Dx 4: Why Quality Initiatives Fails Dx 4: Why Quality Initiatives Fails
Pressure for
Change+ + +
SharedDriven Vision
Capacity for
Focused Change
= Haphazard Efforts, False Starts, Uncoordinated
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Overcoming Challenges To ChangeOvercoming Challenges To Change
• Establish planning team• Include care staff representative• Do you homework• Establish goals for facility, staff, family and
resident and measure and give feedback• Allow sufficient time for change and
monitor changes• Practice what you preach
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Twelve Innovations That Shaped Modern Management
Twelve Innovations That Shaped Modern Management
1. Scientific management (time and motion)2. Cost accounting and variance analysis3. Commercial research lab (industrialization of science)4. ROI analysis and capital budgeting5. Brand management6. Large-scale project management7. Divisionalization8. Leadership development9. Industry consortia (multicompany collaborative
structures)10. Radical decentralization (self-organization)11. Formalized strategic analysis12. Employee-driven problem solving
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
The Five Phases of GrowthThe Five Phases of GrowthPhase 1 Phase 2 Phase 3 Phase 4 Phase 5
Evolution stages
Revolution surges
Size of organization
Large
Small 1. Growth through CREATIVITY
1. Crisis of LEADERSHIP
2. Growth through DIRECTION
2. Crisis of AUTONOMY
3. Crisis of CONTROL
4. Crisis of RED TAPE
3. Growth through DELEGATION
4. Growth through COORDINATION
5. Growth through COLLABORATION
5. Crisis of ?
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Change and Self Perceived CompetenceChange and Self Perceived Competence
Self
Perceived
Competence
Start of Change Time
4. Acceptance of “new reality” Letting go of past Relief Tentative movement
5. Testing New behaviors New approaches Stereotyped “shoulds”
6. Internalize Quiet and reflective Seek meaning and understanding
7. Integration Incorporate new ways into values, beliefs to become automatic through practice
1. ImmobilizationShock, disbelief, guiltMismatch of Expectation and “new reality”
2. Denial of changeTemporary retreatEmphasize old competencies 3. “Incompetence”
Awareness that change is necessaryNot sure how to deal with itFrustrationDepression
Motivations and Emotions in ChangePhases of Emotions - Awareness
Motivations and Emotions in ChangePhases of Emotions - Awareness
0 6 Months
12
DenialRealization
Motivations and Emotions in ChangePhases of Emotions - Dependence
Motivations and Emotions in ChangePhases of Emotions - Dependence
0 6 Months
12
Dependent
Independent
The Course of Success in ChangeThe Course of Success in Change
Self
Perceived
Motivation
Start of Change Time
AcceptanceOf “new reality”
Letting go of pastRelief
Tentative movement TestingNew behaviors
New approachesStereotyped
“shoulds”
InternalizeQuiet and reflectiveSeek meaning and
understanding
IntegrationIncorporate new ways into values, beliefs to
become automatic through practice
Motivations and Emotions in ChangePhases of Emotions - Feelings
Motivations and Emotions in ChangePhases of Emotions - Feelings
0 6 Months
12
NumbBusy Angry
Sad
Acceptance and Well Being
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
Selecting A Quality Medical DirectorSeeing the Trees and Not the ForestSelecting A Quality Medical DirectorSeeing the Trees and Not the Forest
The greatest problem is using the wrong criteria to select the medical director. They select a terrific independent investigator who can get government grants, a good researcher, a good teacher, a good clinician, or the biggest admitter.
Senior PsychCare in affiliation with Senior Psychological Care
“A Better Quality of Life Through Integrated Mental Health Care”
The Ten Deadly Flaws of Medical Directors in Implementing Quality Initiatives
The Ten Deadly Flaws of Medical Directors in Implementing Quality Initiatives
1. Insensitivity and arrogance2. Inability to deal with medical staff3. Overmanaging (inability to delegate and collaborate)4. Inability to adapt to a boss5. Fighting the wrong battles6. Being seen as untrustworthy (having questionable
motives7. Failing to develop a strategic vision8. Being overwhelmed by the job9. Lacking specific skills or knowledge10. Lacking commitment to the job