F 740 F 745 Behavioral Health and Dementia

F 740 -F 745 Behavioral Health and Dementia Care Interdisciplinary Team

Behavioral Health F 740 § 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 wellbeing, 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. https: //www. cms. gov/Medicare/Provider-Enrollment-and. Certification/Guidancefor. Laws. And. Regulations/Downloads/Advance. Appendix-PP-Including-Phase-2 -. pdf This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

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. https: //www. cms. gov/Medicare/Provider-Enrollment-and. Certification/Guidancefor. Laws. And. Regulations/Downloads/Adva nce-Appendix-PP-Including-Phase-2 -. pdf This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

Behavioral Health • Meaningful activities are those that address the resident’s: – Customary routines, – Interests, – Preferences, etc. and – Enhance the resident’s well-being; This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

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/Guidancefor. Laws. And. Regulations/Downloads/Advance. Appendix-PP-Including-Phase-2 -. pdf This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

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 This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

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. This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

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-assessmentinstruments/Nursing. Home. Quality. Inits/MDS 30 RAIManual. html This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

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. This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

Definitions • Highest practicable physical, mental, and psychosocial well-being: is defined as the highest possible level of functioning and wellbeing, 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. This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

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. This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

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. This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

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 • • This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

F 741: 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…. This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

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. This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

Staff Competencies • All staff will need knowledge and skill sets to interact effectively with the residents: – Communication – Residents Rights – Meaningful Activities This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

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) This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

DEMENTIA CARE This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

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 This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

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/About. Dementia/definition. html) This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

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 This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

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 This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

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. This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

Dementia causes significant intellectual functioning impairments that interfere with life, including activities and relationships. This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

Dementia Residents with Dementia may lose their ability to: • Communicate • Solve Problems • Cope with Stressors This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

Dementia • Residents with Dementia may experience: – Fear – Confusion – Sadness – Agitation This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

Dementia • Memory loss alone does not necessarily mean a resident has dementia • Dementia is not a normal part of the aging process This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

Dementia • Residents with Dementia may also experience co-existing symptoms: – Paranoia – Delusions – Hallucinations – Psychiatric conditions • Depression • Bipolar Affective Disorder This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

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. This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

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 This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

Facility Response • • Understand Inform Limitations Monitor Understand Limitations Inform This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

Understand – Regulation o Ensure adequate medical care, diagnosis, and supports o Ensure care and services are person-centered and reflect resident’s goals o Maximize dignity, autonomy, privacy, socialization, independence, choice and safety o Utilize non-pharmacy approaches to care such as meaningful activities This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

Understand - Dementia • Residents with dementia require specialized services and supports – Activities – Nutrition – Environmental modifications This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

Understand – Loss of Ability • To communicate • To solve problems • To cope with stressors • Increases fear, confusion, sadness, and agitation This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

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 This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

Inform – Provide Education • Provide education and support to: – Residents – Representatives – Families – Staff members – Volunteers – Contracted Service Employees This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

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 This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

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 This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

Monitor • • • Resident Interviews Resident Observations Medication Review Problem/Concern Process Audit Systems QAPI This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

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 This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

Questions? This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

References • CMS, State Operations Manual, Appendix PP: Guidance to Surveyors for Long Term Care Facilities: • https: //www. cms. gov/Medicare/Provider-Enrollmentand. Certification/Guidancefor. Laws. And. Regulations/Downlo ads/Advance-Appendix-PP-Including-Phase-2 -. pdf • CMS, MDS 3. 0 RAI Manual: • https: //www. cms. gov/Medicare/Quality-Initiativespatient-assessmentinstruments/Nursing. Home. Quality. Inits/MDS 30 RAIMan ual. html This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017

THANK YOU FOR PARTICIPATING IN THIS EDUCATION SESSION! This document is for general informational purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only - 2017