​As more states move increasingly toward the deinstitutionalization of patients from the long-term acute psychiatric setting, post-acute care communities find themselves struggling with the multiple challenges of appropriately managing this population.

This is especially true for those residents who are younger, many of whom have substance use issues, don’t qualify for Medicare, and who are more cognitively intact. This is compounded in some states by less than adequate Medicaid reimbursement for necessary mental health professionals, often resulting in less than adequate services.

Other Impediments

Poor communication from staff to the mental health team regarding specific targeted behaviors requiring interventions, or poor internal communication to staff regarding the mental health team’s recommendations, presents additional barriers.

With lack of continuity of care and minimal mental health training to the line staff, the interdisciplinary team often finds itself constantly dealing reactively with the fallout from the same repetitive undesirable behavioral patterns rather than proactively identifying and addressing root causes to improve them.

This results in multiple negative outcomes to residents, families, staff, and the long term care community as a whole. Repetitive transfers to a short-term acute psychiatric setting are of no benefit to anyone, especially the affected resident. The other long term care residents and their family members will likely voice concerns regarding the impact of certain resident behaviors. Staff will become vocal, feeling a sense of frustration and lack of support on how to manage these residents.

Fortunately, through commitment and dedication from ownership and the entire facility team, this cycle can be broken.

Behavior Enhancement Plan

So what are the key ingredients to a successful Behavior Enhancement Program and how does a community implement one?

The best starting point is to establish an interdisciplinary committee consisting of key managers and line staff from all departments, as well as the facility’s mental health professionals and medical director so all team members have input into developing the critical policies and parameters of the program.

It will be vital that this committee remain in place and meet weekly to discuss all program criteria, including policies, assigned staff, staff training monitoring, and specific residents’ behavioral progress. It is highly recommended that a dedicated, secured unit be established for the program for optimum opportunity for success.

The ultimate mission of the Behavior Enhancement Program would be to provide a structured environment that invites resident participation, promotes dignity and respect, and encourages positive behaviors, leading to successful residents “graduating” from the program and being transferred off-unit where they can engage socially in acceptable, meaningful interactions throughout the facility

Establishing Standards

The interdisciplinary committee will want to establish unit/program admission criteria to include residents with a mental health diagnosis and at least one challenging behavior, as well as a BIMS (Brief Interview for Mental Status) score high enough for the resident to appropriately participate in the program.

Once the admission criteria are developed, the team can then work together to identify residents they feel meet them and who may benefit from the program. Involving residents and their family members throughout the process is a critical factor for success.

Staff and Training

The team’s next challenge will be to identify line staff who exhibit the right qualities and have the desire to work with this population. As with any specialty program, it is important that only the primary and back-up staff designated and trained to work on this unit are assigned to work there, which will require good communication to the staffing coordinator and off-shift nursing supervisors as well.

The next step is to outline program training requirements to include overall program philosophy and policies, definitions of the basic mental health disorders, and to ensure each team member on all shifts is aware of each resident’s specific targeted behaviors, triggers to those behaviors once identified, and interventions to proactively minimize those triggers from occurring.

This is where a strong relationship between the facility’s mental health team and line staff is extremely beneficial. The clinical team will also be focusing on developing policies regarding critical assessments such as the Trauma Assessment Tool or Functional Assessment Observation Form they may want to implement in order to best document resident behaviors, the interventions implemented, and their rates of success.

Recreation Program Options

No Behavior Enhancement Program will be successful without a structured, individualized recreation program ideally seven days a week between the hours of 9 a.m. and 8 p.m. Managing residents’ behaviors by providing nursing staff with additional support especially on the 3 p.m. to 11 p.m. and weekend shifts is completely necessary. Various groups can be fused into the recreation calendar.

While psychotherapy groups are highly effective, the benefit of other groups involving team members should not be underestimated. For example, does one of the certified nurse assistants have a musical background and would like to lead a weekly music group for the residents?

Additionally, incorporating residents’ life skills to better engage them can have significant positive effects on behavior reduction. Perhaps one of the residents has a background in maintenance. Assigning the resident basic beneficial maintenance tasks such as identifying stained ceiling tiles and loose handrails and even offering them participation in the facility’s Safety Committee can help reinstate the resident’s sense of self-worth and esteem.

Finally, it is highly recommended that the facility establish behavior session and recreation attendance goals for the residents, offering reasonable rewards of the resident’s choice upon successfully achieving one of these goals, including increasing off-unit privileges per program policy.

Other program considerations may include use of Behavior Contracts, Smoking Program overview, and Alcoholics Anonymous or similar substance abuse support as necessary.

Many Benefits

There are many post-acute care communities that have placed effort and focus on developing structured, person-centered specialty dementia units/programs for residents with cognitive impairments, and the same can be accomplished for higher-functioning residents who are cognitively intact but with psychiatric diagnoses and behavior challenges as well.

A holistic, well-structured Behavior Enhancement Program will have positive ripple effects on many levels. Significant reduction in behavior transfers can be expected through proactive versus reactive behavior management methods. A decrease in psychotropic medications is also highly likely for a number of participating residents. Other benefits include enhanced collaboration between mental health professionals and the facility team, reduction in staff stress, and diminished resident- and family-related complaints. Increased revenue potential through the patient-driven payment model may be achieved by capturing depression or other related mental health diagnoses, or increased Part A census potential by admitting residents into the program who also have other skilled service needs.

But, most importantly, the greatest benefit is to the residents who realize more positive behavior outcomes, self-worth, and an improved sense of quality of life through participation in a Behavior Enhancement Program.

Ron Denti, LNHA, is a nursing home administrator with more than 30 years of experience who has developed the DIAMONDS© Behavior Enhancement Program geared toward residents in the post-acute care setting. For more information, go to www.behaviormanagementltc.com.