| Buyer's Market | <h3>Flex Connects Two Platforms to Solve Health Care Staffing Challenges</h3><p>As the workforce crisis continues in health care and front-line workers prefer to work in a flexible environment, the health care industry has struggled to find an effective workforce management solution. <br></p><p><img src="/Issues/2023/Summer/PublishingImages/sum23_buyers2.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;width:200px;height:200px;" />For this reason, Charles Mann, Accushield founder and a former senior living community operator, and Curtis Khan, BookJane founder and a staffing agency founder, have developed a fully integrated mobile-first solution to address staffing shortages, agency transparency, and high turnover in senior living communities, skilled nursing facilities, hospitals, and other health care organizations. Mann and Khan’s combined experiences and diverse perspectives brought them together to create Flex, the first kiosk-based workforce scheduling solution designed to provide flexibility, personal autonomy, and balance in the changing health care landscape.<br></p><p>Flex combines a top workforce scheduling platform with the industry’s leading kiosk-based sign-in and entry management system for visitors, staff, and third-party health care providers. The collaboration will provide long term care providers with a simple and unique alternative to traditional management of staff scheduling, call-outs, and time and attendance tracking.<br></p><p>Launching under the Accushield brand, Flex offers automatic shift fulfillment; instant call-out alerts to fill urgent shifts; use of the Accushield kiosk for internal and agency staff to clock in and out; a single dashboard that builds, manages, and accesses schedules; instant communication with the entire staff; and more.<br></p><p>Combining these two successful platforms streamlines multiple staffing functions into one solution. Built on a cloud-based platform, Flex allows users to create and post open shifts in minutes so that staff, who are notified immediately, can respond through the Flex mobile app. Employees at nearby partner locations can also be notified about open shifts in case extra help is needed outside the core internal team. <br></p><p>For more information, visit <a href="http://www.accushield.com/solutions/flex" target="_blank">www.accushield.com/solutions/flex.</a><br></p><h3>New Financing Fuels Nationwide Launch, Team Expansion for CareWork</h3><p>Digital health startup CareWork has announced the nationwide availability of the CareWork platform. The company closed on $1.5 million raised in seed funding led by digital health investor Valor Ventures. The infusion of capital will fuel the expansion of the platform and customer growth. <br></p><p>Over the past several years, there has been a paradigm shift in how long term care and senior living organizations view technology. Operators struggle to operate efficiently amid increased regulatory requirements and oversight, intense staffing shortages, and sharp drops in revenue. Long term care and senior living organizations need to do more with fewer resources.  <br></p><p>Through its comprehensive, integrated, and easy-to-use platform, CareWork empowers providers to do more with less and work quickly, efficiently, and with more insight.  <br>CareWork’s vision is to provide a platform that is so easy to use it becomes the home base for all senior living and long term care organizations, where duplicate work iseliminated and the advancement of the long term care ecosystem through innovation, advocacy, and value is championed. <br></p><p>For more information, visit <a href="http://www.mycarework.com/" target="_blank">www.mycarework.com.</a> <br></p><h3>CareAcademy Acquires a Learning Platform for Certified Nursing Assistants</h3><p>CareAcademy, a care enablement platform for home care and home health organizations, has announced it has completed the strategic acquisition of assets from NextStep, an innovative digital health care training and job placement company for certified nursing assistants (CNAs). CareAcademy will acquire NextStep’s video-based content and learning management technology to expand its footprint as the training solution of choice across the caregiver ecosystem.<br></p><p><img src="/Issues/2023/Summer/PublishingImages/sum23_buyers1.jpg" class="ms-rtePosition-2" alt="" style="margin:5px;width:200px;height:200px;" />With this acquisition, CareAcademy is strengthening its offerings to create amazing opportunities for new and existing health care workers to level up and become CNAs, a nationally recognized and transferable health care worker role. With this new certification training solution, health care facilities can more readily recruit and retain top talent, while workers can advance their skills and deliver optimal, quality care.<br></p><p>CareAcademy’s mission is to accelerate the world’s transition to a caregiver-centric health care system by empowering caregivers to provide the best care possible. <br></p><p>For more information, visit <a href="http://careacademy.com/" target="_blank">careacademy.com.</a></p> | 2023-05-30T04:00:00Z | <img alt="" src="/Issues/2023/Summer/PublishingImages/sum23_buyers2.jpg" style="BORDER:0px solid;" /> | | | Flex | CareWork | CareAcademy |
| Filling in the Landscape of the Future | <p><img src="/Issues/2023/Summer/PublishingImages/sum23_LTC.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;width:200px;height:200px;" />In many ways, looking years down the road is like viewing a blank canvas. You can imagine anything you want taking shape on it. In reality, the future is part abstract images, part white space, and part realistic landscape. In the end, we follow the numbers, the trends, the voices of the public and other stakeholders, experts, and visionaries to create a picture we can plan for with room for new brushstrokes as the future takes shape.</p><h3>Start with the Numbers</h3><p>Clearly, the numbers point to the future needs for post-acute and long term care, and they are significant. According to the U.S. Department of Health and Human Services, someone who is age 65 today has a 70 percent chance of needing long term care services at some point. Additionally, there could be a need for more than 3,000 new nursing homes in the coming years to keep up with the needs of the rapidly growing older population. In Arizona alone, the number of citizens over age 65 is expected to grow by 41 percent by 2030, and this state, as well as Florida and Nevada, may need to add 40 beds per facility to meet needs.<br></p><p>In fact, Washington, D.C., is the only location in the U.S. where the older population is likely to decline. Some states, including Alaska, Wyoming, Hawaii, and Vermont, likely will need only a few additional facilities. <br></p><p>“In five to 10 years, we will have an interesting dynamic,” said Bill Kauffman, senior principal at the National Investment Center for Seniors Housing & Care. “Given the current health care infrastructure, senior properties will have to play a role with higher-acuity residents. We saw a lot of this before COVID-19 and will continue to see more.” This presents an opportunity for communities to take on niche roles and specialize in areas such as ventilation units or diabetes care. <br></p><p>While the federal government provided significant amounts of stimulus money during the pandemic, Kauffman cautioned facilities against counting on the government to solve their challenges. Instead, they need to be seeking ways to gain market share and address staffing issues.</p><h3>Mapping Staffing Strategies</h3><p>According to American Health Care Association/National Centers for Assisted Living (AHCA/NCAL) data from 2022, 87 percent of nursing homes are dealing with moderate to high staffing shortages. According to the Centers for Medicare & Medicaid Services, nursing turnover in this sector was 53 percent between November 2021 and November 2022. <br></p><p>Since the pandemic, providers have become more creative in their strategies to attract staff. Looking years ahead, they should plan to continue to be aggressive in these efforts. “We need to find talent and find it early. We have to make efforts like we’ve never done before,” said Kauffman. <br></p><p>He further advised, “You need to go to universities and talk about how to encourage interest among students.” This may mean going to business schools and explaining to students there how they can run a property right after graduation. “You also need to think outside the box about rewards packages and ways to build loyalty,” he added. <br></p><p>Sherrie Dornberger, BA, RN, GDCN, IP-BC, FACDONA, executive director at the National Association of Directors of Nursing Administration/Long Term Care, cautioned that providers need to realize that directors of nursing (DONs) can’t wear five hats, even though many had to do so during the pandemic. “We are having DONs burn out at unhealthy rates, and they are leaving long term care,” she said, adding that those organizations getting support for DONs are more successful at attracting and keeping good nurse leaders.<br>Watch for changes in education requirements for various roles to address staffing shortages down the road. <br></p><p>For instance, physician practices partnering with nurse practitioners and physician assistants to care for nursing home residents will likely continue. <br></p><p>Elsewhere, we are starting to see licensed practical nurses (LPNs) take on responsibilities previously held solely by registered nurses (RNs), and certified nurse aides are being trained to take on roles such as medication administration assistant and assistant infection preventionist. Dornberger said, “Often facilities think they need to hire nurses with masters or doctorate degrees to be a DON, but many times I would rather have a nurse who has experience and certification in long term care. I think sometimes we get caught up with degrees.” She suggested that this will need to change if providers are going to attract more people to meet the needs of the wave of older adults coming down the pike.<br></p><p>Penny Cook, chief culture officer at Center for Innovation in Linthicum, Md., noted, “We will see more investment in an empowered workforce if we are going to achieve long-term stability. There will need to be improvements in wages and benefits but also the work environment.” <br></p><p>She agreed with Dornberger that there will be changing roles for RNs, LPNs, and others in similar roles. She also noted, “I’m seeing more states put an emphasis on education in all fields to get more people in the workforce and working with older adults.” </p><h3>Accommodating Affordability</h3><p>While saving for retirement was a lofty goal for baby boomers, many found themselves helping to support aging parents as well as adult children. Today, according to the Center for Retirement Research at Boston College, approximately 18 million middle-income baby boomers will be unable to pay for long term care needs for themselves, and their families are ill-equipped to help. <br></p><p>“Massive numbers of individuals in the boomer generation can’t afford to pay for long term care out-of-pocket and will count on the government and Medicaid. If more people are counting on the Medicaid system, how that will play out is still a question mark. We need to be talking more about this,” said Kauffman. There will need to be a middle-market product for this cohort, or these individuals will continue to spend down assets and count on Medicaid. <br></p><p><img src="/Issues/2023/Summer/PublishingImages/MiltaLittle.jpg" alt="Milta Little" class="ms-rtePosition-1" style="margin:5px;" />“We need to look at ways to make care more affordable. This is critical,” said Milta Oyola Little, DO, CMD, president of AMDA – The Society for Post-Acute and Long-Term Care Medicine. “This may mean a national long term care health plan to enable people to pay for this care. We need more transparency about where money is being spent and look at ways to restructure financing.” There will be greater efforts to seek innovative ways to finance and provide care. <br></p><p>Look for providers to seek insights from hospitality and other industries for ways to accommodate customers’ needs and interests while managing costs. Little stressed, “It is critically important to plan for the financial future. Medicare and Medicaid are not sustainable, and people may find themselves in a situation where they need care and the money isn’t there. We need more national conversation about long term care insurance, how it will work, and how it will be provided.”</p><h3>Tech Touches Lives</h3><p>Senior communities, Kauffman said, will need to be creative about ways to engage and integrate technology in-house to manage mundane tasks and make better and more efficient use of limited staffing. <br>“From an IT perspective, the industry has enormous opportunities. Those who think they will be able to make do with the same old thing will be left behind,” said Kauffman. Increasingly, older adults and their families, as well as senior- living and long term care staff, will expect technological innovations that are designed to keep them safe and make their lives easier, better, and more efficient. <br></p><p>At the very least, residents and others will expect high-speed Wi-Fi and the ability to plug in and charge their devices wherever they go. In addition, they will want smart-home technology that can be used for hands-free and voice-activated lighting, door locks, air conditioning and heating, and more. <br></p><p>Expect to see more virtual reality that enables residents to “visit” any place within the safety and security of their room or apartment. Personalized online programming and entertainment geared toward the older population also will be commonplace, and baby boomers will want access to state-of-the-art videoconferencing and the ability to have a virtual front-row seat to concerts and performances.<br></p><p>Wearables and fitness trackers will continue to be popular and important ways to help families and practitioners monitor vital signs and various conditions virtually. More facilities will have telehealth rooms with the equipment necessary to enable these visits and let family members participate from wherever they are. <br></p><p><img src="/Issues/2023/Summer/PublishingImages/MikeGirard.jpg" alt="Mike Girard" class="ms-rtePosition-2" style="margin:5px;" />Watch for the use of remedies such as wearable patches, not only for pain but for calming and increasing energy. There also will be greater and more cost-effective use of genetic tests to determine how individuals metabolize various medications. As a result, prescribers will be able to do a better job of pinpointing the best interventions for each resident. This shows promise, suggested Mike Girard, managing director of Quantum Wellness Technologies in Dallas, for saving money and increasing the opportunity for better outcomes and fewer adverse events. <br></p><p>“There is a tremendous amount of innovative technology, some of which has been around for a while,” said Girard, adding, “We need to educate people about technology, but on whatever level they want to be educated on. Some individuals and organizations want to dig in and understand super granular details, while others just want the basics. We need to meet people where they are.”<br></p><p>Investing in technology doesn’t have to mean a huge and costly commitment. “It’s important not just to use tech for tech’s sake. It needs to create value and meet a need,” Girard said. He also noted that technology can have a positive impact on adult children, as well as residents. They are looking for technology that keeps their parents safe and engaged but also makes a difference in their lives, for instance, wearables to transmit information directly to them, apps that enable them to monitor a loved one’s finances, or genetic tests that can identify health risks they need to address.</p><h3>Infrastructure Innovations</h3><p>Perhaps the greatest challenge for providers will be the long-term trend toward infrastructure changes. Alice Bonner, PhD, RN, FAAN, chair of the Moving Forward Coalition and senior advisor for aging at the Institute for Healthcare Improvement, said, “We hear a lot from older adults who want to stay in their community or neighborhood as they age, even with health challenges. They want to be with people they care about.” The future, she said, needs to be designed based on what older adults say they want.<br></p><p>To design buildings and communities that will accommodate and appeal to residents in five or 10 years, it is important to ask older adults about their goals and what they would want in a senior community or long term care setting. These questions shouldn’t just be asked of people over age 65 but of their adult children and younger individuals who may be residents in the next decade and beyond. “We have to ask people about broader goals, including what they see for themselves in the next five years,” said Bonner. <br></p><p>Cook suggested the need for more creative alternatives involving home health and programs of all-inclusive care for the elderly to enable people to stay in their homes longer. However, she said, “there will always be a role for nursing home level of care.” Nonetheless, she added, “for various reasons, including lack of resources and staff, I think we will see fewer nursing homes and more closures in the coming years.”<br></p><p>While there is likely to be a greater demand for home- and community-based services, there will still be a critical need for nursing homes and other long term care facilities. However, expect to see facilities such as small group homes, with six people and home care staff providing care, or larger communities with smaller neighborhoods and pods, with six to seven residents in a pod with one aide.<br></p><p><img src="/Issues/2023/Summer/PublishingImages/SherrieDornberger.jpg" alt="Sheri Dornberger" class="ms-rtePosition-1" style="margin:5px;" />Home- and community-based care and nursing homes shouldn’t be competitors moving forward, said Bonner. Instead, the focus needs to be on how to have the right size care in each community that best meets the needs and desires of older adults and enables them to make informed choices. This means age-friendly health systems with the four Ms—what matters, medications, mentation, and mobility—at the center.<br></p><p>Whatever the setting, a renewed focus on creating a homelike environment is needed. Dornberger said, “Before the pandemic, we pushed homelike environments, and now facilities are far from that.” She suggested that the facility of 2030 will have found a way to balance safety with a homelike environment, with amenities like state-of-the-art air filtration and HVAC systems, and flooring, curtains, and furniture that will help minimize the spread of bacteria and viruses. At the same time, private rooms will be the norm and not a luxury.</p><h3>Climate Challenges</h3><p>Just about every week, there is news about a climate-related crisis, and one recent study suggests that nursing homes are at high risk yet ill-prepared. Yale School of Medicine researchers concluded that about 10 percent of nearly 6,000 nursing homes in some parts of the country are at risk of being affected by weather-related disasters, while about a third lack emergency preparedness. <br></p><p>Natalia Festa, MD, the study’s lead author and a research fellow at the National Clinician Scholars Program and Yale Program on Aging, said, “We speculate that improved coordination between nursing homes and municipal and regional emergency planning authorities may improve facilities’ risk awareness and preparedness. We also suggest that regulators may be able to coordinate with emergency planning authorities to identify nursing homes in areas with a higher risk of hurricane-related inundation and prioritize these facilities for remediation of outstanding or severe administrative emergency-preparedness deficiencies.”<br></p><p>According to data from the Gross Domestic Climate Risk, Florida, California, and Texas are the U.S. states most at risk from climate change, with potential for issues such as flooding, forest fires, and sea-level rise. Planning for new buildings or communities in these areas could be problematic and possibly ill-advised. <br></p><p>“Planning of new facilities requires an understanding of where high hazard zones are and what new ordinances and rules have been written related to climate,” said Darren Azdell, AIA, NCARB, LEED AP, principal at OUTSIDEIn Architecture. “We have existing facilities that need to expand or add units to be sustainable, but they can’t get additional space because they are in a high hazard zone determined by FEMA flood maps,” he said. Critical buildings such as nursing homes, hospitals, and fire stations can’t be built in these zones. He added that weather is becoming a problem everywhere. Among other concerns, there is a fault line from Florida to Washington, D.C., that resulted in a crack in the Washington Monument several years ago.<br></p><p>“It’s important to plan now. It only takes one disaster to destroy a facility,” Azdell said. Tornadoes are happening across the country. There has been flooding in areas that never flooded before, wildfires are on the rise, and gas lines could break because of seismic activity. Power stations are exploding and catching fire across the country.<br></p><p>Traditional generators aren’t the solution, Azdell said. He suggested, “We need to understand and embrace the technology available and being used effectively. If you have your own power and water treatment on-site, it gives you an advantage if there is a disaster.”<br></p><p>Cook noted, “I think we will see some communities renovated or newly built using green building technology and materials to counter or reduce the effects of climate change. We also will be seeing more efforts regarding things like recycling and composting being driven by residents.”</p><h3>Addressing Ageism</h3><p>The pandemic revealed an ugly undercurrent of ageism in the United States, and Little insisted this will need to change to care for future generations of older adults. She said, “I hope we can learn. We don’t do a good job of valuing things that come with age. It’s so much easier to hide our own aging and hide our aging adults and have few intergenerational homes. If we don’t address this, we are marginalizing a huge group of society who have made valuable contributions, and we do younger generations a disservice by depriving them of opportunities to engage with older adults.” </p><p><em>Joanne Kaldy is a freelance writer and communications consultant based in New Orleans.</em><br></p> | 2023-05-30T04:00:00Z | <img alt="" src="/Issues/2023/Summer/PublishingImages/sum23_LTC.jpg" style="BORDER:0px solid;" /> | Caregiving | Joanne Kaldy | Providers need to consider long-term trends in demographics, staffing, affordability, and infrastructure to secure the longevity of their facilities. |
| Advancing Policies That Support Real Workforce Solutions | <p><img src="/Issues/2023/Summer/PublishingImages/sum23_workforce.jpg" class="ms-rtePosition-2" alt="" style="margin:5px;width:200px;height:200px;" />Nursing homes are currently grappling with a historic labor crisis. Over the course of the pandemic, nursing homes lost more than 200,000 caregivers, or about 15 percent of the workforce. This job loss is worse than the losses incurred by any other health care sector, and, at the current pace, it is not expected to rebound until 2027. Workforce challenges in long term care existed prior to the outbreak of COVID-19, and the pandemic exacerbated them into a full-blown crisis. Caregivers are burned out after fighting the virus for more than two years, and nursing homes lack the resources to compete for workers due to chronic government underfunding.<br></p><p>As a result of these labor shortages, more than half of nursing homes are limiting new admissions, and nearly two-thirds are concerned their facility may have to close due to the staffing crisis. More than 450 nursing homes have closed over the course of the pandemic—many due to staffing shortages—and hundreds more may soon close. <br></p><p>The domino effect on seniors, their families, and our entire health care system is troubling. Seniors wait for days or weeks in hospitals for a space at a facility, and families are having to travel farther to visit their loved ones in long term care. Many hospitals are overwhelmed with patients who are ready to be discharged to receive post-acute care, but nearby skilled nursing centers cannot admit them. </p><h3>The Challenges of a Staffing Minimum</h3><p>Nursing homes would love to hire more nurses and nurse aides but are currently grappling with a historic labor crisis, and the workers are not there. Increasing staffing requirements at a time when facilities can’t find the people to fill open positions is poor public policy. Nearly every nursing home in the country is having trouble hiring staff due to a lack of interested or qualified candidates. Providers have dedicated numerous resources to recruiting and retaining caregivers, including increasing wages and offering bonuses. But nursing homes still struggle to compete with hospitals, other health care providers, and private businesses for qualified workers. Chronic underfunding by Medicaid causes current soaring labor costs to be unsustainable. Complying with an unfunded federal staffing mandate would be impossible under current conditions. <br></p><p>Increasing staffing minimums will make it harder for seniors to find the long term care they need. Ultimately, setting minimum staffing ratios without corresponding resources will further limit access to care for seniors. Nursing homes will have to continue to reduce the number of patients they can serve in order to meet ratio requirements, or close entirely. Hundreds of thousands of residents could be at risk for displacement as facilities would be forced to reduce their census to meet staffing ratios or close entirely.</p><h3>Advocating for Solutions</h3><p>A federal staffing mandate requires a significant, ongoing investment in our front-line caregivers. An analysis found that staffing minimums would require billions of dollars to hire nearly 200,000 additional nurses and nurse aides. These proposals need to be fully funded, and with proper resources, nursing homes can offer front-line caregivers more competitive wages and benefits.<br></p><p>However, the long term care industry also needs a comprehensive approach to recruit and retain long term caregivers. An enforcement approach will simply not solve this long term care labor crisis. Meaningful solutions that address the root causes of these chronic staffing challenges are needed. <br></p><p>The American Health Care Association/National Center for Assisted Living (AHCA/NCAL) encourages long term care professionals to advocate for direct aid and policies that will help us build a pipeline of dedicated caregivers. AHCA’s Care for Our Seniors Act includes thoughtful workforce policies that will help address nationwide nursing shortages, attract more caregivers to the profession, and support care professionals in developing a career in long term care. It includes proposals such as loan forgiveness, tax credits, affordable housing, child care assistance, and immigration reform.<br></p><p>Additionally, there needs to be a comprehensive approach to staffing beyond numbers. Every resident and nursing home is different, and a one-size-fits-all approach is not the solution. Nursing homes need to be able to assess the appropriate staffing levels based on their number of residents and specific needs. <br></p><p>Moreover, providers must advocate for policies that invest in full-time, dedicated caregivers, not just increase the use of costly agency or temporary staff in order to fill quotas.</p><h3>Building a Pipeline of Caregivers</h3><p>One proposal supporting a more comprehensive approach and our caregivers is the Building America’s Health Care Workforce Act (H.R. 468). This bill provides an extension in the time allowed for temporary nurse aides (TNAs) to become certified nurse assistants (CNAs). <br></p><p>During the pandemic, the 1135 waiver on training and certification of nurse aides allowed vital support to critical staffing needs for care of residents in nursing homes. Hundreds of thousands of individuals answered the call to serve our seniors in their hour of need and supported them with nonclinical tasks, such as helping with activities of daily living; delivering meals; assisting with dining, ambulation, and range of motion; and offering companionship to help residents stay connected and engaged. <br></p><p>The TNA role has attracted individuals who have wanted to serve in direct care capacities but might not have had a pathway previously. The TNA role also supports our nation’s refugees and immigrants in receiving vital training to enter the long term care field.<br></p><p>Over the course of the pandemic, TNAs have gained thousands of hours of on-the-job, supervised training and experience in providing critical services and support to residents in nursing homes and assisted living communities. The 1135 waiver ended June 6, 2022, and only four months were given for TNAs to become CNAs or they would not be able to continue working in long term care communities. <br></p><p>State capacities were not sufficient to accommodate the training and testing needs of thousands of TNAs in this short time frame. H.R. 468 would extend the time to 24 months for TNAs to train and test to become CNAs. </p><h3>Take Action</h3><p>Advocating for meaningful, supportive solutions to the workforce challenges facing long term care facilities is critical. Let’s rebuild and strengthen the long term care workforce and protect seniors’ access to care. <br></p><p>1. Tell key decision-makers (i.e., the Centers for Medicare & Medicaid Services and the Biden administration) that an unfunded nursing home staffing minimum requirement won’t solve the long term care labor crisis and will only threaten access to critical long term care for our nation’s seniors. Recommend AHCA’s Care for Our Seniors Act as a better policy for our industry. <br></p><p>2. Advocate for the passage of H.R. 468 to allow time for TNAs to train and test to become CNAs, a vital part of the caregiver workforce. <br></p><p>For more information on AHCA/NCAL advocacy efforts and how you can help, go to <a href="http://www.ahcancal.org/Advocacy" target="_blank">www.ahcancal.org/Advocacy</a>.<br></p> | 2023-05-30T04:00:00Z | <img alt="" src="/Issues/2023/Summer/PublishingImages/sum23_workforce.jpg" style="BORDER:0px solid;" /> | Workforce | | An unfunded staffing minimum would place a heavy burden on long term care providers. But there are other options to help build the workforce. |
| A New Dawn in Behavioral Health Management | <p><img src="/Issues/2023/Summer/PublishingImages/sum23_behavior.jpg" class="ms-rtePosition-2" alt="" style="margin:5px;width:200px;height:200px;" />Behavioral health has been on the radars of long term care facilities and their teams for years, but the COVID-19 pandemic brought it front and center. According to data from the American Geriatrics Society, between 65 percent and 90 percent of nursing home residents have a mental or behavioral health issue. <br></p><p>“We’ve learned that facilities have to prioritize mental health as well as physical conditions,” said Lisa Lind, PhD, ABPP, chief of quality assurance and compliance at Deer Oaks – The Behavioral Health Solution. This requires a person-centered, team approach to care with an eye toward innovative interventions and tools. </p><h3>Changing the Paradigm</h3><p>Long gone are the days when behavioral health management meant picking up the phone and asking a physician for medication. This was a quick fix that often had negative implications and didn’t have good long-term outcomes. To determine the best solution for sustained results, “you have to know the resident, the staff, the system, and geriatrics,” said Elizabeth Santos, MD, MPH, DFAPA, DFAAGP, clinical chief, Division of Geriatric Mental Health and Memory Care at the University of Rochester School of Medicine and Dentistry.<br></p><p>Lind said, “There is a tendency to assume a behavior is mental health-related, but we need to look at all factors—changes in medications, unrecognized pain, infections, etc.” It is essential to look at medical reasons for behaviors, as well as possible trauma-related triggers. The good news, she said, is that “facilities are asking questions they weren’t asking a few years ago. We’re moving in the right direction.”</p><h3>Moving the Needle</h3><p>Lind suggested several steps that can improve behavioral health care:<br></p><ul><li>Be proactive instead of reactive. She said, “We often get referrals for crisis situations, such as a resident expressing suicidal ideation or becoming significantly agitated or hostile. When we do our evaluation, we often find that the individual has a long-standing history of a mental health condition, but they weren’t initially referred for mental health services because they appeared stable on admission.” </li></ul><p>It is important to identify and document a mental health history on admission and refer residents for psychiatric services as necessary. The consultant pharmacist should be engaged to review the individual’s medication regimen, paying special attention to psychotropics or other psychiatric drugs the resident may be taking. It also is important to identify and communicate with the team any situations that may trigger a change in emotional status, such as the loss of a loved one.<br></p><ul><li>Respond calmly. “As in most areas of our life, using a calm approach when communicating with others will be more beneficial in obtaining the achieved outcome and will also minimize anxiety for anxious residents. Staff should never respond in an angry, defensive, or demeaning manner, as this can easily trigger a negative response from residents,” Lind said.</li></ul><ul><li>Focus on person-centered care. There is no question that residents have their own unique life experiences, personality traits, coping strategies, medical conditions, mental health history, levels of support and family connections, job history, and so on. Lind said, “It is important to refrain from making generalizations based on age, observed cognitive level, cultural background, diagnoses, or other characteristics.” Instead, the care team needs to get to know residents as individuals, and this information needs to be shared as necessary and appropriate so clinicians and caregivers know what interventions have been tried, which ones have worked, and which ones haven’t.</li></ul><ul><li>Communicate and document. “One of the most common situations is being told of a resident’s perceived maladaptive behaviors and then finding no documentation of the events in nursing notes and a lack of consistent communication among staff,” said Lind. When there are gaps in communication and/or documentation, it is more time-consuming for staff to identify and address behavioral issues successfully, and it increases the risk of survey citations and concerns from family members.</li></ul><ul><li>Refrain from unintentionally reinforcing unwanted behaviors. Residents sometimes learn that negative behaviors get the attention they want. For instance, say a resident who is a former coach blows a whistle when he wants something. Instead of ignoring him, chastising him, taking away his whistle, or jumping every time he makes noise, consider reminding him to use the call light and explaining that when things get busy, it may take a few minutes to respond. Thank him for his patience and cooperation.</li></ul><h3>Nonpharmacologic Focus</h3><p>A focus on nonpharmacologic efforts to manage behaviors takes time. When you’re short-staffed and everyone already has a full plate, this can be challenging. However, there are many fairly simple activities, interventions, and ideas that can be integrated into daily routines. At best, these can help prevent behaviors. At the least, they can help staff address behaviors before they become problematic.<br></p><p>On admission, consider working with the family to create the resident’s life story. This can be as simple as completing a worksheet or one-pager that offers information about the resident’s former occupation, hobbies and preferred activities, morning and evening routines, pet peeves, and favorite foods, music, and movies. This information can be kept secured in a book, and people who care for the residents should review this information before interacting for the first time and when there is an issue or problem. <br></p><p>This knowledge of the resident also can be integrated into the care planning process with efforts such as pet visits, headsets with a music playlist, art therapy sessions or classes, and personalized videos (e.g., clips of Fred Astaire and Ginger Rogers for a woman who loved dancing). <br></p><p>Small details can make a big difference. For instance, one facility had a woman who got very agitated when her caregiver tried to put socks on her. Talking to her family, caregivers discovered that she always put her socks on inside out because she hated the way the seam felt on her toes. Once they accommodated this personal preference, she became cooperative.<br></p><p>Happy memories can be positive distractions and can help improve mood when someone gets agitated. For instance, Lind suggested hanging a shadow box on the resident’s wall with important reminders of the past or providing a photo album to peruse. Let residents hold things that seem to bring them comfort, such as a war medal, favorite blanket, trophy, doll, or stuffed animal. Have families leave recorded messages that you can play for residents when they get upset or agitated. <br></p><p>It is important to remember that people’s interests and tastes may change, especially as their cognition declines. For instance, a resident who used to love her doll now throws it in the corner and says it’s not her baby. In this case, instead of correcting or arguing with the resident, try to pivot the conversation and find something else that makes her happy or brings her comfort.<br></p><p>Don’t forget that even people with dementia need a sense of purpose. Lind suggested, “Provide active engagement that is meaningful. Assign roles to residents who could benefit from a sense of usefulness and purpose while reducing idle time and boredom.” Consider having activity stations throughout the building where residents can do things such as putter in a play kitchen or workshop, arrange flowers, or play games.<br></p><p>It is important for staff to realize that well-intentioned efforts can have negative consequences. Lind recalled a normally docile nonverbal resident in memory care who started yelling, scratching at her legs, and covering her head with her blanket. A chart review indicated no infection or other issues that could explain the behavior. Lind noticed that there were paper spiders and cotton cobwebs in the corner of the resident’s room, put there by staff as Halloween decorations, and she was able to confirm the decorations were put up right before the resident’s behaviors started.<br></p><p>Lind instructed staff to take the spiders and webs down with the resident in the room to watch them and tell her they were taking the paper spiders away. They then replaced the spiders with flower decorations. Lind said, “The next time I was at the facility, I was told that her yelling and swatting had stopped, and she was no longer putting the blankets over her head.”</p><h3>When Medications Are Needed</h3><p>While behaviors should be managed with nonpharmacologic interventions whenever possible, this doesn’t mean medications will never be necessary. However, the care team can work with clinicians to make sure the right drugs are being used in the right doses. <br></p><p>For instance, one facility had a resident who was screaming in the middle of the night and accusing staff of trying to kill her. She also claimed that she had killed someone. Talking to her family, Santos discovered the resident had been sexually assaulted as a young woman, and she had stabbed one of her attackers. </p><p>Ultimately, it was determined that the woman had undiagnosed post-traumatic stress disorder. Santos treated her with antidepressants and cognitive therapy, a type of psychotherapy that seeks to alter unwanted behavior patterns. The resident stopped screaming and acting out and seemed more content.<br></p><p>Another resident with schizophrenia and a history of violence was on multiple antipsychotics. Santos and her team were able to reduce her regimen to a low dose of one antipsychotic by providing staff with behavioral techniques and encouraging them to be consistent in their care. They also played the resident’s favorite music when they came in her room to take her to activities or bathe her. Staff were provided with scripts so they could use language that was comfortable for the resident. </p><p>Read More: <a href="/Issues/2023/Summer/Pages/Telehealth-Increases-Access-to-Specialists.aspx" target="_blank">Telehealth Increases Access to Specialists</a>
<br></p> | 2023-05-30T04:00:00Z | <img alt="" src="/Issues/2023/Summer/PublishingImages/sum23_behavior.jpg" style="BORDER:0px solid;" /> | Management;Behavioral Health | Joanne Kaldy | A person-centered approach to behavioral health,
including nonpharmacologic efforts, integrated medication programs, and access to telehealth, creates better long-term outcomes for residents. |