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Medical Direction Pearls March 17, 2006 3:30-5:00 AMDA 29 th Annual Symposium Optimizing Outcomes and Ensuring Quality Care Clinical and Management Issues.

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Presentation on theme: "Medical Direction Pearls March 17, 2006 3:30-5:00 AMDA 29 th Annual Symposium Optimizing Outcomes and Ensuring Quality Care Clinical and Management Issues."— Presentation transcript:

1 Medical Direction Pearls March 17, :30-5:00 AMDA 29 th Annual Symposium Optimizing Outcomes and Ensuring Quality Care Clinical and Management Issues Leo J. Borrell, MD Medical Director of Senior PsychCare in affiliation with Senior Psychological Care Houston and San Antonio

2 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Faculty Disclosures: Dr. Leo J. Borrell Forest Laboratories: Speakers Bureau Bristol-Myers: Honoraria Janssen Laboratories: Honoraria

3 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

4 Patient Quality Chain Get to & from hospital Deal with stress Find out patient status Pay Bills Provide post d/c care Value -Loss of Income While Visiting -Little Help Available -Unfamiliar, Complex Activities -Costs Value ChainProblems -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 Post Discharge Care -Bills are Difficult to Understand -Insurance is Difficult to Understand -Insufficient Resources

5 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Register Patient Care DischargeMarketingService Value Physician Pharmacy Nursing Diagnostic Imaging Lab Physical Therapy General Quality Chain

6 Nursing Quality Chain AssessCare Provide Care Discharge Planning Document Value Value ChainProblems -All Manual -Increasing requirements from JCAHO -Everything must be documented Assess Care Plans Provide Care Discharge Prep 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

7 Physician Quality Chain Locate Patient Make Diagnosis Orders and results Treat patient Document in chart Value Value ChainProblems -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 Document in 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

8 Quality From Medicares Perspective Documentation Guidelines B –Medical necessity a must –Documentation must support level of service given –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

9 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Documentation - 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.

10 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care General 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

11 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care 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

12 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 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

13 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

14 PROGRESSION OF SYMPTOMS BY YEARS Jost BC, et al. Journal of American Geriatric Soc. 1996;44: 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

15 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Necessary 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

16 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care 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

17 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Necessary Drug Protocol-F429 Pharmacist MUST review each residents 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

18 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care 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.

19 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 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.

20 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Survey 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

21 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 Environment Therapeutic Activities Quality of Life Managing Behavior Dementia Special Care Quality of Care Culture of Care

22 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Goal of Quality Mental Health Care A Psychiatrists Perspective Global States of Well-being Sense of Worth Sense of Agency Social Confidence Hope

23 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Quality - A Patient Perspective Enhancing Quality of Life Identity Belonging And Inclusion Intimacy And Love Self- Esteem Psycho- Social Needs Meaning And Purpose Dignity Sense Of Control Sense Of Security

24 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Benefits 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

25 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Facilitating 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

26 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Factors Contributing to Poor Compliance Illness-Related Paranoid ideation Negative symptoms/reduced motivation Depression Demoralization Lack of insight Cognitive impairment Substance abuse Grandiosity

27 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Factors 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

28 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Factors Contributing to Poor Compliance Environment-Related Lack of psychocosial support Isolation Stress Stigma

29 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care 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 BPSDBaseline + $1800 Resident with AD and aggressive BPSDBaseline + $5300

30 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Annual Cost of Therapy Depakote ER 500 mg QD$ 588 Depakote 500 mg mg$ 912 Depakote ER 500 mg – 2 tabs$1174 Risperdal 2 mg QD$1596 Risperdal 0.5 or 1.0 mg QD$ 960 *Risperdal 0.5 or 1.0 mg BID$1920 Zyprexa 5mg QD$2052 Zyprexa 10 mg QD$3120 *50% Risperdal RXs BIDAWP 12 Months RX

31 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care 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!

32 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Total Cost Savings From Quality Care Management of Aggressive BehaviorCost Savings Per 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

33 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

34 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care 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

35 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Short Term Goals to Comply with 501 Core 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

36 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 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

37 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 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

38 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Implications 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.

39 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Implications 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.

40 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Implications 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.

41 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Implications 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 issues Practices Resident issues

42 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Change in the Role of Medical Director Process 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

43 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Medical Director F-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

44 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care 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

45 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 Dont Know Enough About Patient Care to Dictate Clinical Practice Mental Health Practitioners Have A Right to Practice As They See Fit

46 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care 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 Presidents Commission on Aging

47 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Quality and Best Practices in Geriatric Psychiatric Services (Presidents Commission on Aging) 1. A multidisciplinary team approach 2. Specific geriatric expertise and competence 3. Individualized assessment and treatment planning with routine follow-up, ideally using standardized outcome measures 4. Collaborative treatment planning between the consultant and the nursing home staff 5. A strong educational component

48 Quality Required Quantity Future Visits Determined By Complexity of Decision FUTURE VISITS DETERMINED BY COMPLEXITY OF DECISION LowModerateHigh Medical Problem Severity (+3 - more than 3 Dx) 123 Number of Psychiatric & Medical Dx and Management Options (+2/3 Suicidal Thought) 123 Amount & Complexity of Data Including Previous Medical Record Family Issues 123 Risk of Complications ( Meds) 123 Total Score Visits1xMo1xWk2xWk

49 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Quality Care From A Physicians Perspective

50 Complex Decisions That Appear Simple: Interaction of BioPsychosocial Psychological Social Factors Bio-Medical Factors Valued but not effective Effective but not valued Compliance Effective Valued Non- Compliance

51 PROGRESSION OF SYMPTOMS BY YEARS Jost BC, et al. Journal of American Geriatric Soc. 1996;44: 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

52 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 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%)

53 Medical Direction Pearls March 17, :30-5:00 AMDA 29 th Annual Symposium Causes of Psychiatric Symptoms and Behavior Can Overlap Frontal Lobe Impairment Major Depression Psychotic Disorder Impulsivity Hyperactivity Agitation Anxiety Dysphoria Restlessness Irritability Verbal Aggression Withdrawal Physical Aggression Delusions Hallucinations

54 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care 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

55 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

56 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care 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

57 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 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.

58 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.

59 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 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

60 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care A 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

61 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care A Simple Way To Improve Quality From A Patients 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

62 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care 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 Dont Inform Patients and Family

63 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care 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

64 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care 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

65 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Reality of Disclosure and Individuals 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

66 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care 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 identified12 (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%)

67 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Quality in the Future Special 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)

68 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care 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.

69 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care SCU - Other Outcomes Family Outcomes Higher satisfaction More involvement Staff Outcomes Greater satisfaction More training in dementia More stable staff assignments Consistent staff, lower turnover More frequent support group attendance

70 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Diagnosing Quality Care A Management Perspective

71 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Quality :Requirements for Changing for The Better Pressure for Change +++ Shared Driven Vision Capacity for Focused Change Actionable First Steps = Successful Change

72 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Dx 1: Why Quality Initiatives Fails +++ Shared Driven Vision Capacity for Focused Change Actionable First Steps = Bottom of the in box Low Priority

73 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Dx 2: Why Quality Initiatives Fails Pressure for Change +++ Capacity for Focused Change Actionable First Steps = A Fast Start That Fizzles Directionless

74 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Dx 3: Why Quality Initiatives Fails Pressure for Change +++ Shared Driven Vision Actionable First Steps = Anxiety, Frustration, Loss of Competitive Edge

75 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Dx 4: Why Quality Initiatives Fails Pressure for Change +++ Shared Driven Vision Capacity for Focused Change = Haphazard Efforts, False Starts, Uncoordinated

76 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Overcoming 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

77 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Twelve Innovations That Shaped Modern Management 1.Scientific management (time and motion) 2.Cost accounting and variance analysis 3.Commercial research lab (industrialization of science) 4.ROI analysis and capital budgeting 5.Brand management 6.Large-scale project management 7.Divisionalization 8.Leadership development 9.Industry consortia (multicompany collaborative structures) 10.Radical decentralization (self-organization) 11.Formalized strategic analysis 12.Employee-driven problem solving

78 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care The Five Phases of Growth Phase 1Phase 2Phase 3Phase 4Phase 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 ?

79 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Change 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.Immobilization Shock, disbelief, guilt Mismatch of Expectation and new reality 2.Denial of change Temporary retreat Emphasize old competencies 3.Incompetence Awareness that change is necessary Not sure how to deal with it Frustration Depression

80 Motivations and Emotions in Change Phases of Emotions - Awareness 06 Months 12 Denial Realization

81 Motivations and Emotions in Change Phases of Emotions - Dependence 06 Months 12 Dependent Independent

82 The Course of Success in Change Self Perceived Motivation Start of Change Time Acceptance Of new reality Letting go of past Relief Tentative movement Testing New behaviors New approaches Stereotyped shoulds Internalize Quiet and reflective Seek meaning and understanding Integration Incorporate new ways into values, beliefs to become automatic through practice

83 Motivations and Emotions in Change Phases of Emotions - Feelings 06 Months 12 Numb Busy Angry Sad Acceptance and Well Being

84 Senior PsychCare in affiliation with Senior Psychological Care A Better Quality of Life Through Integrated Mental Health Care Selecting A Quality Medical Director Seeing 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.

85 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 1.Insensitivity and arrogance 2.Inability to deal with medical staff 3.Overmanaging (inability to delegate and collaborate) 4.Inability to adapt to a boss 5.Fighting the wrong battles 6.Being seen as untrustworthy (having questionable motives 7.Failing to develop a strategic vision 8.Being overwhelmed by the job 9.Lacking specific skills or knowledge 10.Lacking commitment to the job


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