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CNAs and Vaccination: An Issue of Trust<p>​Although COVID-19 vaccination rates for certified nurse assistants (CNAs) have increased significantly since the beginning of the year, many CNAs remain unvaccinated, for a variety of reasons.<br></p><p>As someone who worked for many years as a CNA and who now heads the largest professional association for CNAs, I believe that doctors who serve as medical directors for nursing homes hold the key to persuading those CNAs who are persuadable to get vaccinated and protect residents, their co-workers, their loved ones, and themselves.<br></p><p>Why do I say that? Because trust is a huge issue for CNAs, and they are more likely to trust the medical directors at their facilities to give them accurate, honest information about the vaccines than just about anyone else.</p><h2>Medical Directors are Local Experts</h2><p>According to a <a href="https&#58;//www.ahrq.gov/nursing-home/materials/prevention/vaccine-trust.html" target="_blank">new guide</a> from the federal government for building CNAs’ confidence in the COVID-19 vaccines, CNAs who are most resistant to getting vaccinated also tend to trust their employers the least. Among those they trust most&#58; local medical experts. This is critical, because CNAs get a lot of their information—and misinformation—on social media, especially Facebook.<br></p><p>Not only do CNAs view their medical directors as their local medical experts, but many also see them as their personal physicians. This is especially common in rural areas that are short on doctors.<br></p><p>CNAs typically have good working relationships with their facility medical directors, who respect their hands-on experience and expertise, as well as their compassion for the residents they care for. This respect is greatly appreciated by CNAs, who are among the lowest-paid workers in health care and who often feel underappreciated. In addition, medical directors aren’t nursing home employees, and CNAs see them not only as credible but also as more independent than other nursing home leaders.</p><h2>COVID Ups the Stakes</h2><p>CNAs have a tough time, and COVID-19 has made it tougher. Even before the pandemic, they worked long hours, often at multiple jobs. But this past year has been hell for them. Many have been sick themselves; they’ve also lost residents they cared for and co-workers as well. Their jobs have been incredibly stressful and demanding, even as the demands on them at home have increased.<br></p><p>There are many reasons why CNAs aren’t getting vaccinated. Some have taken a “wait and see” attitude, while others harbor fears and concerns that they feel haven’t been addressed. Some would like to get vaccinated, but they can’t afford to take unpaid time off from work, especially if they get sick from side effects, or they don’t have transportation or child care.<br></p><p>And remember&#58; CNAs have been on the front lines of battling this virus and watching it unfold for over a year. Either they’ve gotten it and survived, or they haven’t gotten it at all.&#160; The way they see it, they don’t need the vaccine. If they’ve gotten this far without it, why would they need it now?</p><h2>Meeting Early, Lingering Concerns</h2><p>I myself was wary of getting vaccinated at first. I thought those first vaccines came out too fast. They couldn’t be safe. But then my organization did a <a href="https&#58;//www.youtube.com/watch?v=QJhk71PLRBk" target="_blank">vaccine education webinar</a> with AMDA, which represents medical directors serving long term care facilities and whose panelists were not only credible but open and respectful. They answered all my questions, so I came out in support of the vaccine and made my declaration to our members.<br></p><p>That’s who CNAs need to hear from&#58; trusted medical experts at their facilities who will listen to their concerns about the vaccines and address them fully and respectfully. Very few administrators have time to do that—and I know, because I used to be a nursing home administrator, too.<br></p><p>I believe that the best way to persuade CNAs is to appeal to their desire to do good and protect others, especially their residents and co-workers. But they need to be heard out, and some of them may need logistical help as well.<br></p><p>Medical directors can play a strong role here. They can do one-on-ones with CNAs, either in person or virtually. They can speak at staff meetings or give webinars. They can be the go-to contact person at the facility for workers who have questions about the vaccines and respond via email or phone or in person.<br></p><p>To fully protect nursing home residents and workers against COVID-19, we need to vaccinate more CNAs. Medical directors of America, we trust you to answer our questions. When can we talk?<br></p><p><em><strong>Lori Porter </strong>is co-founder and chief executive officer of the National Association of Health Care Assistants (NAHCA). She can be reached at</em> <a href="mailto&#58;lporter@nahcacna.org" target="_blank">lporter@nahcacna.org</a>. <br></p>2021-06-29T04:00:00Z<img alt="" src="/Topics/Guest-Columns/PublishingImages/LoriPorter.jpg" style="BORDER&#58;0px solid;" />COVID-19;WorkforceLori PorterAlthough COVID-19 vaccination rates for certified nurse assistants (CNAs) have increased significantly since the beginning of the year, many CNAs remain unvaccinated, for a variety of reasons.
Conducting Thorough Investigations<p><img src="/Monthly-Issue/2021/June/PublishingImages/DeniseWinzeler.jpg" alt="Denise Winzeler" class="ms-rtePosition-1" style="margin&#58;5px;width&#58;120px;height&#58;156px;" />​When a resident at facility A sustained a bruise of unknown origin on his right forearm, the director of nursing services (DNS) completed what she felt was a thorough investigation of the injury. However, during a subsequent facility visit, surveyors did not find evidence the DNS adequately investigated the incident and cited the facility for inadequate investigation.<br></p><p>Does this scenario sound familiar? Inadequately investigating an incident can trigger repercussions, including citations for noncompliance, inadvertently supporting plaintiffs’ legal claims, and, above all, negative effects on the resident’s well-being.<br></p><p>Thoroughly investigating all allegations and incidents is vital to gain facts, prevent recurrence, and maintain resident safety. Facility leaders should implement these tips to ensure their investigations are detailed and thorough.</p><h2>Organization is Key </h2><p>Merriam-Webster defines investigation as a “study by close examination and systematic inquiry.” To inquire systematically and examine all factors thoroughly, organization is key. Facility leaders must plan and prioritize, recognizing that some parts of an investigation will require more time than others.<br></p><p>Often, facility leaders conduct multiple investigations simultaneously, because they know that all allegations and incidents should be reviewed or investigated, not just those confirmed or involving a crime.<br></p><p>An organized approach enables the thorough review necessary for regulatory requirements, even when conducting multiple investigations. The 4-step process below can help facility leadership remain organized so they can conduct thorough investigations.<br></p><h3>Step 1&#58; Determine the purpose for the investigation. </h3><p>The first step of the process is determining the purpose(s) of the investigation and answering, “Why is an investigation being conducted?” Articulating purpose helps guide the investigator to avenues the investigative process should explore. <br></p><p>For example, a bruise of unknown origin investigation may include the following purposes&#58;<br></p><ul><li>To determine why the bruise occurred</li><li>To determine if abuse occurred</li><li>If abuse occurred, to identify the perpetrator for disciplinary action</li><li>To identify other residents who may be similarly affected </li><li>To learn why a bruise of unknown origin was not promptly reported per facility policy.</li></ul><p></p><h3>Step 2&#58; Develop a plan for the investigation.</h3><p>First and foremost, facility leadership must ensure the residents involved or affected are safe. Next, facility leaders should develop an investigation plan by asking&#58;<br></p><ul><li>Were all required entities notified, such as the department of health, local authorities, boards, etc.? </li><li>Who will lead this investigation?</li><li>Will anyone else be needed to assist? </li><li>What evidence should be reviewed? </li><li>Who should be interviewed? </li><li>Who will conduct the interviews? </li><li>Are staff involved, and does that involvement require temporary suspension pending the investigation’s findings? </li></ul><p></p><h3>Step 3&#58; Review tangible evidence and conduct interviews.</h3><p>Relevant tangible evidence may include in-house documents, like medical records, billing statements, staffing records, personnel files, schedules, or policies and procedures.<br>Other documents might come from outside sources, such as hospital or emergency medical service records or police reports. Evidence like camera footage, incident reports, or digital call- light printouts may also be needed to help the investigator determine what happened and the root cause(s).<br></p><p>Tangible evidence to review for a bruise of unknown origin may include&#58;<br></p><ul><li>Resident A’s medical record, including diagnosis, recent diagnostics, nurses’ notes, </li><li>and medication and treatment sheets</li><li>Assessment and observations of </li><li>Resident A</li><li>Incident report</li><li>Visitor log</li><li>Staffing assignments and staff schedule</li><li>Equipment used to aid the resident to ensure it is in working order and does not need repairs</li><li>Assessments and medical records of residents in similar situations, often referred to as “like residents,” to determine if other residents also have similar injuries.</li></ul><p></p><h2>Conduct Interviews</h2><p>Although it may not always be possible, try having two interviewers in each interview, one to ask the questions and another to write the statement or note-take.<br></p><p>It is best practice to have at least one interviewer present for all interviews. This is important for two reasons. First is consistency, so that all interviewees are asked the questions the same way. Second is the need to assess witness credibility, especially if it is one person’s word against another. It may be necessary to interview some people multiple times, especially if there are contradictions. <br></p><p>Before the start of the interview process, the interviewer should have standard questions to ask the interviewees, such as “Have you worked on A wing in the last month?” or “Have you ever cared for Resident A?” After easing into those questions, the interviewer can probe the situation in more detail.<br></p><p>Any residents involved in the incident should be interviewed unless they are semi-comatose or comatose. An investigator might erroneously not interview residents with impaired cognition, believing the impairment prevents the resident from giving any pertinent information. <br></p><p>Generally, this is mistaken. When interviewing residents, the interviewer is trying to determine if the resident perceives they have experienced harm, as well as details that help establish timelines and may identify root causes. Those with cognitive impairment can still contribute their perspective.<br></p><p>The interviewer may wish to consult with corporate staff or legal counsel before interviewing family members and visitors to receive any special instructions on how to conduct the interviews—such as who should conduct it or if the interview should occur with family members separately or as a group. <br></p><p>Each interview should yield a written statement. For people who are interviewed multiple times, prepare a separate statement for each interview and clearly mark each with the date and time. If there are contradictions in the statements, documenting this way will help to show discrepancies.<br></p><h2>Interview More People</h2><p>A common mistake investigators make is not interviewing enough people. Leadership must ensure the interview process is exhaustive and includes all who may be involved, including those who may have witnessed or been affected by the incident. For example, in the bruise of unknown origin scenario, leadership may wish to interview&#58;<br></p><ul><li>Resident A</li><li>Resident A’s roommate</li><li>Like residents</li><li>Staff and volunteers with access to Resident A who worked during the two-week period when the bruise is believed to have occurred</li><li>Visitors who had access to Resident A in the same time period.</li></ul><p></p><h3>Step 4&#58; Conclude and follow up.</h3><p>After reviewing the evidence collected and conducting interviews, the investigator conducts a root-cause analysis. Once the investigator makes a reasonable determination of cause, the facility must follow up to close the investigation. <br></p><p>Follow-up may include completing mandatory reports, such as the facility-reported incident (FRI) sent to the department of health, education needs, disciplinary actions, or policy and process changes.<br></p><p>The nursing home administrator or designee may wish to again consult corporate staff or legal counsel before conversations with family members, especially if the information being relayed is negative. Facility leaders should also inform the medical director of the investigation’s outcome. Then, update the medical record and provide any reimbursement, as necessary, in cases of theft or misappropriation.<br><br>Conducting a thorough investigation ensures no details are missed and that the voices of all involved in the allegation or incident are heard. It also mitigates risk of survey issues, litigation, and recurring safety issues. Facility leaders should prioritize thorough investigations and reassess processes now to avoid the possible repercussions of inaction or inadequacy.&#160; <br><br><strong>Denise Winzeler, BSN, RN, LNHA, DNS-CT, QCP,</strong> <em>is curriculum development specialist for the American Association of Post-Acute Care Nursing (AAPACN). She can be reached at <a href="mailto&#58;dwinzeler@aapacn.org" target="_blank">dwinzeler@aapacn.org</a>.<br></em></p><p><em><br></em></p><p style="text-align&#58;center;"><em><a href="http&#58;//aapacn.org/" target="_blank"><img src="/SiteCollectionImages/logos/AAPACN.jpg" alt="AAPACN " style="margin&#58;5px;width&#58;235px;height&#58;71px;" /></a><br></em></p><p><em><br></em></p><p><em>References<br></em></p><ul><li><em><a href="https&#58;//www.cec.health.nsw.gov.au/__data/assets/pdf_file/0018/259011/what_is_a_patient_safety_incident.pdf" target="_blank">Clinical Commission (Australia). (2014). Clinical excellence commission open disclosure handbook&#58; What is a patient safety incident? </a></em></li><li><em><a href="https&#58;//www.merriam-webster.com/dictionary/investigate" target="_blank">Merriam-Webster. Merriam-Webster.com dictionary. Retrieved March 23, 2021.</a><br></em></li><li><em><a href="https&#58;//www.compliance.com/resources/26-tips-experts-conducting-witness-interviews/" target="_blank">Strategic Management Services LLC. (2015, January). 26 Tips from experts on conducting witness interviews. Compliance.com. </a></em></li></ul>2021-06-01T04:00:00Z<img alt="" src="/Monthly-Issue/2021/June/PublishingImages/0621_Caregiving.jpg" style="BORDER&#58;0px solid;" />Caregiving;LegalDenise Winzeler, RNMerriam-Webster defines investigation as a “study by close examination and systematic inquiry.” To inquire systematically and examine all factors thoroughly, organization is key.
COVID Highlights Importance of Leadership<p></p>The COVID-19 pandemic seems to be settling down at the time of writing this article, but no one knows what the future may hold as far as variants, future surges, duration of vaccine immunity, and many other unknowns go. What is known is that COVID-19 has been absolutely devastating in post-acute and long term care centers, first and foremost to residents and their families, but also to staff.<br><div><br></div><div>Providers have also learned some lessons from the pandemic about leadership (and lack thereof) on many levels, about infection prevention and control, and about the courage and dedication their frontline workers have demonstrated.</div><br>It is impossible to express how grateful providers are to their nurse assistants, nurses, and all of the other heroes who have placed themselves and their families at personal risk day after day. <br><div><br></div><div>Probably every reader can appreciate the magnitude of the pandemic’s swath through long term care settings in the United States and worldwide. Even as health care professionals edge back toward normalcy, there will be profound and enduring changes to the way they do things. The full gravity of this pandemic will not be understood and appreciated for years to come. </div><h2>What the Pandemic Revealed</h2>The pandemic has clearly shed light on some of the shortcomings of the current paradigms in long term care. Providers have learned the vital importance of emergency preparedness, robust infection prevention and control measures, and the need for ample personal protective equipment (PPE).<br><div><br></div><div>There have been many calls for an overhaul of the long term care industry and increasing scrutiny on issues of equity, staffing, workforce, and infection prevention and control. </div><br>One lesson some nursing centers and corporations have learned is that medical leadership from the facility medical director can be of immense value. While there has been a federal mandate since 1975 for every nursing center to have a medical director, and while the duties of the medical director have been defined since the Omnibus Budget Reconciliation Act of 1987 (implementation of resident care policies and coordination of medical care in the facility—a tall order), there is huge variability in the extent to which medical directors actually fulfill their duties. <br><h2>The Plus Side</h2>Some nursing centers employ medical directors who demonstrate clear dedication, engagement, knowledge of geriatric medicine and infectious disease principles, and awareness of the complex regulatory framework in which they operate. <br><div><br></div><div>These medical directors for the most part have stepped up throughout the pandemic, helping residents, families, staff, and the administration navigate the difficult, confusing, often frankly contradictory guidance on PPE, cohorting, testing, vaccination, and visitation from a variety of agencies and public health authorities. </div><br>These leaders have helped create and roll out mitigation plans and other policies and procedures to protect their residents and staff and have helped ensure that goal-concordant medical treatments have been provided whenever possible—including attention to comfort and dignity with appropriate advance care planning.<br><h2>Different Approaches, Results</h2>Many medical directors have been in direct contact with survey teams and representatives of local and state public health departments. Many of these dedicated medical directors have also devoted their time and passion to helping educate staff about vaccination, and these efforts have been evidenced in an increased vaccine uptake among staff. <br><div><br></div><div>Conversely, there are medical directors who appear to have little interest in performing their federally mandated duties of implementing resident care policies and coordinating the medical care in their nursing centers. <br></div><div><br></div><div>There have been many tragic consequences of lapses on the part of these medical directors, perhaps none as infamous as what occurred at one nursing center in the northeast, where staff were directed to let symptomatic presumed COVID-positive residents eat in a common dining room with asymptomatic, COVID-negative residents.</div><div><br></div><div>But a common thread in facilities where strike teams from Doctors Without Borders had to come in and assist was that the medical directors of these facilities were largely missing in action.</div><h2>Tightening Ship</h2>Historically, some nursing centers and corporations have sought to retain medical directors who can drive census, such as doctors affiliated with hospitalist groups, Accountable Care Organizations, or other entities. There’s nothing wrong with having a medical director who will refer patients to a nursing center, but that medical director needs to also have some basic competencies, and many do not.<br><div><br></div><div>Other nursing centers have chosen to retain medical directors who have little knowledge or interest in geriatrics or long term care (sometimes retired surgeons or pediatricians) and who will essentially not “make waves” and just sign whatever paperwork they are handed. </div><div><br></div><div>This is no longer going to be acceptable, and this would be a good time to plan ahead to avoid future problems.</div><div><br></div><div>The sheer devastation related to COVID-19 in nursing centers has brought attention to the role of the medical director, and federal authorities are among those taking notice. It is reasonable to expect now that routine surveys are getting underway that there may be more of a focus on the role of the medical director in the Infection Prevention and Control Program and Quality Assurance/Performance Improvement (QAPI), and nursing centers should prepare for this.</div><h2>Value of Certification</h2>So, how does a nursing center find a qualified, competent medical director? One simple strategy is to make certification (available through the <a href="http&#58;//www.abplm.org/" target="_blank" title="www.abplm.org">American Board of Post-Acute and Long term Care Medicine</a>,) a requirement for the position, either as a condition of initial hire or as an expectation within a set time frame.<br><div><br></div><div>The Certified Medical Director (CMD) certification requires about 40 hours of continuing medical education specific to the nursing care setting, including more than 20 core areas that encompass clinical, regulatory, bioethical, and other topics.</div><div><br></div><div>California has legislation pending (AB 749) that will require all licensed skilled nursing facilities to engage a medical director who has a CMD certificate within five years, and a handful of other states have similar requirements for minimal credentialing or knowledge.</div><div><br></div><div>Short of the actual certification, nursing centers can also contractually require their medical directors to be members of medical societies like AMDA – The Society for Post-Acute and Long Term Care Medicine and maintain a minimum number of annual educational hours from such organizations that focus on geriatrics and long term care.</div><div><br></div><div>Some facilities also engage an associate medical director (or director of post-acute or a variety of other titles) to assist with quality initiatives, and this can be helpful.</div><div><br></div><div>Considering the high acuity of the case mix these days in most nursing centers, and especially in light of hard lessons learned from the pandemic, this would be an excellent time for all nursing centers to assess their current medical director’s level of dedication, engagement, knowledge base, and accessibility—and if lacking, strongly consider remediation or replacement. </div><div><br></div><div>Nursing centers pay reasonable stipends for these duties and deserve to have qualified, competent medical directors. Their residents, families, and staff deserve nothing less. </div><br><strong>Karl Steinberg, MD, CMD, HMDC, </strong><em>is president of AMDA – The Society for Post-Acute and Long Term Care Medicine. He has been a nursing home and hospice medical director in the San Diego area since 1995 and is chief medical officer for Mariner Health Central and Beecan Health. </em><br>2021-06-01T04:00:00Z<img alt="" src="/Monthly-Issue/2021/June/PublishingImages/0621_meddirector.jpg" style="BORDER&#58;0px solid;" />Management Karl Steinberg, MD, CMDThe COVID-19 pandemic seems to be settling down at the time of writing this article, but no one knows what the future may hold as far as variants, future surges, duration of vaccine immunity, and many other unknowns go.
Creating a Behavior Enhancement Program<p>​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. <br></p><p>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.</p><h2>Other Impediments</h2><p>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.<br></p><p>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.<br></p><p>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. <br></p><p>Fortunately, through commitment and dedication from ownership and the entire facility team, this cycle can be broken. </p><h2>Behavior Enhancement Plan</h2><p>So what are the key ingredients to a successful Behavior Enhancement Program and how does a community implement one?<br></p><p>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.<br></p><p>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. <br></p><p>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</p><h2>Establishing Standards</h2><p>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. <br></p><p>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.</p><h2>Staff and Training</h2><p>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. <br></p><p>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. <br></p><p>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.</p><h2>Recreation Program Options</h2><p>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. <br></p><p>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?<br></p><p>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.<br></p><p>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.<br></p><p>Other program considerations may include use of Behavior Contracts, Smoking Program overview, and Alcoholics Anonymous or similar substance abuse support as necessary.</p><h2>Many Benefits</h2><p>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. <br></p><p>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.<br></p><p>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. <br><br><strong><img src="/Monthly-Issue/2021/May/PublishingImages/cgiving_RonDenti.jpg" class="ms-rtePosition-1" alt="" style="margin&#58;5px;width&#58;116px;height&#58;150px;" />Ron Denti, LNHA,</strong> is a nursing home administrator with more than 30 years of experience who has developed the DIAMONDS<sup>©</sup> Behavior Enhancement Program geared toward residents in the post-acute care setting. For more information, go to <a href="http&#58;//www.behaviormanagementltc.com/" target="_blank">www.behaviormanagementltc.com</a>.</p>2021-05-01T04:00:00Z<img alt="" src="/Monthly-Issue/2021/May/PublishingImages/0521-cgiving.jpg" style="BORDER&#58;0px solid;" />ClinicalRon Denti, LNHAAs 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.