Learn

Understanding, Preventing and Managing Challenging Behaviors – A Cognitive Link
By Pat Jakubiec, Clinical Resource

Challenging behaviors are one of the most stressful aspects of care giving. They result in caregiver stress, excess disability and increased care costs. Recent research suggests that pharmologic approaches are not always effective and they can cause potentially harmful secondary side effects, including an increased risk for falls. Research shows promise for engagement in meaningful activity tailored to an individual’s ability can reduce depressive and agitated behaviors as well as reduce caregiver stress.

Behavior is a way individuals express a need or desire. It can result from an emotion, and sometimes the behavior remains the focus not the emotion (Pollard, 2005). Individuals with cognitive disabilities can be misunderstood and sometimes blamed for their behavior. The reason is usually related to underlying neuro-biological causes that include global cognitive abilities, speed of brain function and personality traits.

Every change in a person’s environment will require the individual to cope and adapt, using extra effort and energy. Many people with cognitive impairment are not able to learn to adapt to new routines, procedures and physical changes in the environment. The individual biologically has difficulty noticing and processing information, therefore they cannot use the information to influence behavior. Functional performance beyond an individual’s ability cannot be expected especially in novel situations. When this occurs, performance failures can be anticipated.

Some researchers describe the anterior cingulate cortex of the brain as a key area between thought emotion and the body’s response to what the brain is feeling. An individual’s responses represent value judgments within a social context. The individual with cognitive disability often times has difficulty understanding the full scope of the social environment and difficult behaviors can represent this challenge. When the brain declines in its ability to work as a global unit, agitation can be viewed as a loss of control over behavior and the ability to process the environment.

There is a fine balance between doing too much for the individual that may lead to depression, excess disability and a decreased sense of self. Doing too little can result in agitation, problematic behavior and an increased risk for accidents. It is important to assess an individual’s abilities and personal factors in the context of holistic assessment. The degree or level of behavioral reaction can be attributed to an individual’s personality traits and how they have handled life situations.

In 1995 Cohen-Mansfield described behavioral symptoms into 4 groupings:

• Physical aggressive behaviors
• Verbally aggressive behaviors
• Non-aggressive physical behaviors
• Non-aggressive verbal behavior

A careful medical assessment needs to be included. Certain conditions and illnesses, unmanaged pain, and medication changes all need to be considered.

Environmental assessment and management become critical. Changes in the physical environment can cause challenges as the person may have difficulty processing the physical space. Consistent nurse aide assignments with ongoing team education provide a supportive human environment. Integrating lifelong habits and routines promotes cognitive strengths and a sense of self. An integrated environment promotes overall feelings of well-being and security.

Use of the cognitive disabilities model allows healthcare clinicians to understand different levels of global brain activity. The six levels (ACL scale) describe distinct patterns of behavior that can be anticipated. These behaviors can be measured and managed by skilled clinicians, offering a cognitive systematic approach to management and intervention. Strategies can be developed integrating personal factors that can be employed by everyone. This provides a pro-active approach to care and may prevent some challenging behaviors before they occur.

Behavior Patterns Observed in the ACL Scale

Bathing Challenges/Process

Resisting care, especially during bathing is a common challenge that causes distress for both the individual and the caregiver. Interventions are meant to be used as a guideline and are meant to be modified by the treating therapist in the context of a comprehensive holistic assessment.

Reasons for referral

• Recent decline in function and or participation
• Resisting care- verbal or physical aggression
• Refusing or withdrawal
• Individuals requiring more than one nurse aide to complete bathing /showering
• Issues of safety associated with bathing and showering

Evaluation

• Complete a comprehensive holistic assessment
• Establish a functional cognitive level through the use of at least 2 standardized tools and observe a stable pattern of behavior
• Have the family complete an Advance Lifestyle Directive “Life Story gathering instrument.” Gather as much data related to the person’s lifelong bathing/ showering habits to include time of day, types of products used, frequency, preferences etc.
• Observe the person and caregiver in the actual task environment
• Identify problem behaviors observed and any identifiable patterns of difficult behaviors. (frequency, duration intensity)

Intervention

Clinical analysis of behaviors. Many behaviors can be an expression of an unmet need. This may include:

• Feeling cold; fear; pain
• Embarrassment/vulnerability
• Loss of control
• Not able to process the environment, or understand what is happening
• Fatigue
• Unable to understand what the caregiver is communicating

Compare cognitive level with actual task participation. If excess disability is present determine why and what therapy interventions can be done to improve participation. When excess disability is cognitively related sometimes the caregiver approach can be modified to improve outcomes. This is often witnessed when people are functioning in Allen Cognitive Level (ACL) 3.

Develop a plan to reduce problematic behaviors, maximize patient participation and profile effective communication. Things to include in the plan are:

• Time of day (avoid bathing when fatigue is present, life habit)
• Use of familiar items
• Integration of preferences and lifelong habits/ mode of bathing
• Communication strategies
• Physical environment considerations (room temperature, water temperature, unfamiliar location or change, privacy, noise level, past familiar environment, comfort)
• Pain management strategies
• Strategies for participation
• Safety

Provide treatment sessions to implement and modify strategies and to train the caregiver in the actual task environment.

Document the plan and caregiver training.

Develop a functional maintenance program.

Follow-up with caregivers during and after the procedures have been completed, and note what has been successfully achieved.

Conclusion

This information was adapted from the VCIM Clinical Guide for Understanding, Managing and Preventing Challenging Behaviors. Some of the facilities using this approach have shown a reduction in falls, combative behaviors, reduced use of restraints and reduced use of psychotropic medications. For more information, contact Pat Jakubiec at pjakubiec@ensigngroup.net. Onsite clinical development and training sessions and skype case study consultation are available. Staff development and training is tailored to individual program needs.

One of the most popular personality tests is the True Colors Personality Test. This personality test has participants choose words that best describe themselves. The test will then rate one’s personality as either a blue, green, orange or gold personality type.

You may be a combination of two colors, but usually an individual will exhibit one primary color. By using a personality test, it allows leaders to understand the personality attributes associated with various team members.

As managers and leaders, we may operate as one primary color for the most part, but high levels of stress and other environmental factors can shift one’s personality type for short intervals.

As a rule of thumb, you should recognize your strong attributes and keep in mind the attributes that irritate people.

www.true-colors.com

Introducing True Colors to the world over 30 years ago, True Colors International is the originator of using colors to represent the four personality styles, and remains the preeminent source for workshops and certifications in the True Colors methodology across the world.

The trend toward contracts with managed care agencies for the administration of health care benefits in SNFs is increasing in popularity. The high cost of caring for chronically ill patients and aging of the general population highlights LTC as the prime target for reform by the managed care industry. Managed care organizations (MCOs) will be breaking new ground in controlling and reducing costs associated with providing care to clients with prolonged needs. Payers can improve the delivery of health care and manage costs better by holding providers more accountable for the care of chronic patients. Therefore, it is important to predict the fluid nature of health care and prepare for the changes ahead. Payers and providers need to commit to a system of payment that rewards high-quality, coordinated, cost-efficient care.

The process of accepting Managed Care members into our facilities for SNF care starts with a managed care contract. When a contract is structured with rates/levels there is a contractual definition of each Level of Care, including clinical needs, therapy utilization, and what is included/excluded from the per diem rate. This information is used to negotiate the appropriate rate upon admission. Therapy requirements include how many days a week therapy is required, and the amount of therapy provided per treatment day. For example, the contract may specify that therapy is required 5/6 days a week, up to 1 hour/day or up to 2 hours/day, depending on the level authorized.

Preparing the facility to “manage” the Managed Care is just as important as the contract. It is imperative to evaluate the systems of each facility, including operational systems, clinical systems and billing systems.

Things to look at:

Operational Systems

Admissions process and communication systems

Assessment systems

MCOs want quick acceptance of the referral: Is there staff in the facility or out in the hospitals with clinical expertise to quickly assess clinical documentation and make the decision on whether to accept the patient?

Clinical Systems

Evaluate the communication system between departments.

Quality care and coordination: Are all departments obtaining the information they need?

Outcome Data: Are you utilizing data to show patient outcomes?

Physician involvement: is your Medical Director involved in patient care? Does your facility have a Physiatrist? Specialty Wound care physician/ nurse?

Case Management

Whether your facility has a designated Case Manager or not, it is important to utilize the Case Management process to manage patients effectively. Case Managers or a Case Management designee will:

Assess patient needs

Obtain Authorization for admission to facility

Negotiate level of care/rate, per facility contract

Understand contractual exclusions

Therapy utilization: Negotiate higher rates when additional therapy is appropriate.

Utilization Review: Provide clinical updates needed for continued stay

Monitor progress

Evaluate alternative options and services to meet an individual’s health needs

Promote quality cost-effective outcomes.

Assist in fostering a positive relationship between facility and health plan. This process results in appropriate admissions, better assessment of needs, and better initial treatment and discharge planning.

Billing Systems

Does the BOM understand the exclusions and how to bill them? Is the correct rate/revenue code being billed?

Does your BOM have a provider manual from each health plan providing detailed information for billing and appeals?

Marketing

Educate the hospital about contracts. Ask questions about MCO needs (services needed/difficult placements)

Understand the goal is reduced LOS with quality outcomes

Share success stories with the hospital

Understand which physicians have these patients and communicate with them regarding innovative treatments and successful outcomes.

Establish a relationship of trust with Insurance CM’s so they will think of you when assisting in the placement of the patient.

MCO Expectations:

Decreased Length of Stay

Quality outcomes with supportive data

One knowledgeable contact who is easily reached

Good surveys; they review all CMS surveys during the initial credentialing process prior to a contract and during re-credentialing (every 3 years or greater).

Things to consider:

Provide staff with Managed Care training

Dedicate a unit for short-term rehab providing sub-acute services, including medical director involvement, physiatrist and wound care physicians

Develop a Case Management process utilizing a Case Manager or clinical designee

Increase communication between all departments

Sounds complicated. Why would we want to embrace Managed Care at all?

There are several reasons:

The number of Medicare beneficiaries is growing every year

Census growth

Revenue enhancement

Growth of overall number of referrals. Admissions of sometimes difficult to place managed care patients can lead to the referral of less complicated patients.

Let’s start by talking about how the therapy days and minutes will be reported on MDS 3.0.

Each therapy discipline will continue to report the number of days and minutes therapy was provided in the last 7 calendar days. However, they will now be required to separate the type of therapy delivered into the following modes of therapy:

Individual
Concurrent
Group

Individual minutes are minutes provided to a resident one-on-one.

Concurrent minutes are described as the treatment of 2 residents at the same time, when the residents are not performing the same or similar activities, regardless of payer source, both of whom must be in line-of-sight of the treating therapist or assistant. For Part B, residents may not be treated concurrently; minutes provided with 2 or more residents would be recorded as group minutes. CMS is very clear that there is a limit of 2 residents for concurrent therapy. If the therapist is treating 3 residents at the same time, not performing the same or similar activities, no minutes can be coded on the MDS for any of the residents during that treatment time.

Group therapy minutes are described for Part A as the treatment of 2 to 4 residents, regardless of payer source, who are performing similar activities, and are supervised by a therapist or an assistant who is not supervising any other individuals. For Medicare Part B, treatment of two patients (or more) at the same time regardless of payer source is documented as group treatment.

The days that therapy was provided continue to be as important to the RUGS calculation as the number of minutes. In order to count a day of therapy, at least 15 minutes of skilled therapy must have been provided during the calendar day. 15 minutes or more of concurrent therapy would qualify for a therapy day even though the grouper will divide the total minutes in half. If the total number of individual, concurrent and group minutes equal zero, skip this item and leave blank.

The therapy start date is the date the initial therapy evaluation is conducted regardless if treatment was rendered.

The therapy end date is the last date the resident received skilled therapy treatment. Enter dashes if therapy is ongoing.

One of the biggest changes in MDS 3.0 is the elimination of Section T—estimated days and minutes of therapy projected to be provided during the resident’s first 15 days from admission.

Selecting What Type of Assessment

If a therapy RUG can be obtained using the standard 5-day PPS assessment, that is usually the best assessment choice for payment. When the resident has been in the facility less than 8 days and has not received enough days or minutes of therapy to qualify for a Rehab RUG on the 5-day PPS assessment, a short stay assessment may be possible. There are 8 requirements that must be met before a short stay MDS can be completed.

The 8 requirements are:

1. The assessment must be a Start of Therapy OMRA (SOT). This assessment may be completed alone or combined with any OBRA assessment or combined with a PPS 5-day assessment. The SOT OMRA may not be combined with a PPS 14-day, 30-day, 60-day, or 90-day assessment. The SOT OMRA should also be combined with a discharge assessment when the resident discharges from the facility. However, if the resident expires in the facility or is transferred to another payer source while in the facility, do not combine the SOT OMRA with the discharge assessment.
2. A PPS 5-day or readmission/return assessment has been completed. The PPS 5-day or readmission/return assessment may be completed alone or combined with the Start of Therapy OMRA.
3. The ARD of the SOT OMRA must be on or before the 8th day of the Part A Medicare stay. The ARD minus the start of Medicare stay date must be 7 days or less.
4. The ARD of the SOT OMRA must be the last day of the Medicare Part A stay. The SOT OMRA ARD must be the end of the Medicare stay date. The end of the Medicare stay date is the date Part A ended.
5. The ARD of the SOT OMRA may not be more than 3 days after the start of therapy date. This is an exception to the rules for selecting the ARD for a SOT OMRA, as it is not possible for the ARD for the Short Stay Assessment to be 5-7 days after the SOT since therapy must have been able to be provided only 1-4 days.
6. Rehabilitation therapy (speech-language pathology, occupational therapy or physical therapy) started during the last 4 days of the Medicare Part A covered stay (including weekends). The end of Medicare stay date minus the earliest start date for the three therapy disciplines must be 3 days or less.
7. At least one therapy discipline continued through the last day of the Medicare Part A stay. At least one of the therapy disciplines must have a dash-filled end of therapy date, indicating ongoing therapy or an end of therapy date equal to the end of covered Medicare stay date. Therapy is considered to be ongoing when:Resident was discharged and therapy was planned to continue had the resident remained in the facility
   Resident’s SNF benefit exhausted and therapy continued to be provided
   Resident’s payer source changed and therapy continued to be provided
8. The RUG group assigned to the Start of Therapy OMRA must be Rehabilitation Plus Extensive Services or a Rehabilitation group. If the RUG group assigned is not a Rehabilitation Plus Extensive Services or a Rehabilitation group, the assessment will be rejected.

If all eight of these conditions are met, then MDS Item Z0100C (Medicare Short Stay Assessment indicator) is coded “Yes.” The assignment of the RUG-IV rehabilitation therapy classification is calculated based on average daily minutes actually provided:

15-29 = Rehab Low
30-64 = Rehab Medium
65-99 = Rehab High
100-143 = Rehab Very High
144 or greater = Rehab Ultra High

Interviews

The addition of the resident interviews, which requires completion of the interviews on or before the ARD, impacts the ability to move the ARDs in the PPS windows. The therapy director and MDS coordinator will need to continue to work closely and maintain good communication with the entire IDT team.

The addition of the discharge assessment adds another dimension to the MDS 3.0 process. The discharge assessment includes therapy days and minutes and can affect payment when combined with other PPS assessments. Be sure to keep your team informed of changes in discharge dates, therapy start dates and therapy end dates.

A Comprehensive Balance and Mobility Training Program

Congratulations to the following therapists in Milestone who have completed the FallProofTM program and have become Certified FallProofTM Balance and Mobility instructors:

Mary Egbert, DOR
Draper Rehabilitation and Care

Sam Baxter, DOR
Orem Rehabilitation and Nursing

Scott Crider, DOR
Pinnacle Nursing & Rehabilitation Center

Jill Schuette, DOR
Pocatello Care and Rehabilitation Center

The FallProofTM Certificate Program is the first program of its kind to be offered in the United States. FallProofTM was founded by Dr. Debra Rose, Professor in the Department of Kinesiology at California State University, Fullerton, Director of the Center for Successful Aging and Co-Director of the Fall Prevention Center of Excellence. Dr. Rose is nationally and internationally recognized for her work in the area of fall risk reduction programming.

The FallProofTM program was created to provide professionals the knowledge and practical skills necessary to implement an evidence-based balance and mobility training program for older adults. It is designed for community dwelling and residential care setting populations. This provides our therapists and facilities the opportunity to outreach into our surrounding communities and offer a needed service. The program is taught in a group setting; twice a week over several weeks. Dr. Rose is currently developing and tailoring this program for the more frail and higher fall-risk individuals.

The certification course is divided into two sections. Students complete the didactic portion by completing seven learning modules via the internet, including video or audio-base lectures, learning labs and case studies.
The second portion is a three-day on-site training where the FallProofTM faculty provide instruction and feedback. Students who participate are given a Pass, Conditional Pass or Not Pass score following a practical exam.

Therapists who are Certified FallProofTM instructors have more “tools in the bag” to tailor the knowledge and skills learned from this program to provide more creative and pertinent treatment in individual and group settings.

Clinical and field tests were taught to provide our therapists ways to objectively assess, document and determine improvement within our clientele. These tests include the Fullerton Advanced Balance (FAB) Scale, Berg Balance Scale, 30-foot walk, Senior Fitness Test, 8-foot Up and Go Test, and the Walkie-Talkie test.