1. Beth B. Ulrich, L.C.S.W.
Community Liaison
Centra Senior Psychiatric Program

2. October 2011: Senior Care Unit Opens
 12-bed unit at Centra Virginia Baptist
Hospital
 Acute care for patients 60 years or older

3. Dementia,
primarily in the
advanced stages.
OUR
PATIENTS
60% have
Mental health
required
and behavioral
long-term care
problems.
placement.

4. Ensure a smooth transition from Acute Care Setting to Long-Term Care Facility
Acute Care Unit Long-Term Care Facilities
(nursing homes, assisted living facilities)
Evaluate individuals living
in long-term care facilities
for mental health and
behavioral issues
MY ROLE
as a liaison

5. Ensure appropriate interventions are implemented in long-term care
facilities to minimize acute admissions.
Community Liaison
• Psychotherapy for patients
and their families
• Equipping staff with skill-sets
to more successfully manage
mental health and behavioral
challenges

6. “Get ‘em in, get ‘em out!”
Less attention paid to:
• adjustment issues
• emotional and
behavioral issues
More attention paid to:
• physical level of
functioning
• financial coverage issues
Primary emphasis on short acute stays while
keeping beds at long-term facilities filled.

7. Revolving door
80% of nursing home residents
have mental health issues.
Long-term care staff are traditionally
ill-equipped to deal with these issues.
There is a high likelihood of admissions
to Emergency Departments when mental
health issues arise.

8. • “Tips” for managing challenging behaviors
Key Function: • Based on observations and interventions
Plan of Care successfully implemented during hospitalization
Pain
management
Patients’
Sleeping
personal
habits
preferences
Input
welcomed from
Food patients’ ADLs and
preferences families/key IADLs
support
systems

9. adapted from
Practical Dementia Care
by Rabins, Lyketsos, and Steele
Solving behavior problems without using medications

10. High level of
commitmen
t required
from all
levels of
staff.
Done
consistently,
There is no
it will
“quick fix.”
become
automatic.
4D
Approach
Time and
effort are
Process is
required to
gradual.
experience
results.

11. Behavior problems stem from
multiple causes.
Causes can be distinguished
from one another.
ASSUMPTIONS There is rarely one best
TO BE CONSIDERED approach.
We can identify causes and
determine interventions.
Directed “trial and error” is
the rule, not the exception.

12. Don’t immediately
jump to the treatment!
• Obtain history.
• Examine.
• List likely causes.
• Define treatment options.

13. 4D-Approach
• Observations, Determine
details, facts Decode • Treatment
• Where, when, Plan: What • What
how, with • What may be are we going outcome is
whom, after/ contributing to do? expected?
before what? to cause the • Do the
problem? interventions
Define Devise work?

14. Define Decode Devise Determine
Where?
When?
How?
With Whom?
After/Before What?

15. Define Decode Devise Determine
What are the contributing causes?
Cognitive impairments: aphasia, apraxia,
agnosia, amnesia, executive dysfunction
Other psychiatric syndrome or disorder:
depression, anxiety, psychosis
Medical illness; neurological illness
Medications: The Beers List
Environment
Caregiver approach

16. Define Decode Devise Determine
Is the problem really a problem?
Why?
What contributing cause(s) can
be eliminated or modified?
Anecdotal treatments?
Empirical treatments?
Let’s use common sense!

17. Define Decode Devise Determine
What is the expected outcome?
How long will it take?
Who will do what . . . and when?
Create a fallback plan.

18. What if the
interventions
FAIL?
Have a
Back-up
Plan!

19. Consider the untoward effects of treatment.
Patients improve for no specific reason.

20. Catastrophic Reactions
Uncooperative/ Resistant To Care
Aggression/ Agitation
Wandering/Pacing
Delirium
Yelling/ Calling Out/ Screaming
Mood Problems
Hallucinations/ Illusions
Suspiciousness/ Delusions
Social Withdrawal/ Apathy
Rummaging/Hoarding

21. Initial reaction to “lengthy” process may be that it is “just
not practical” to implement in the LTC environment due to
staffing and time constraints and limitations.
Front end investments reduce long-term problems and
expenses.
Unrealistic expectations mandated by all of the regulations
that long-term care facilities must adhere to can cause
frustrations.
Tensions between providers and regulators may be
diminished as results are realized from implementing this
approach.

22. Thank you!
 Beth B. Ulrich, L.C.S.W.
 Community Liaison, Centra Senior Psychiatric Program
 beth.ulrich@centrahealth.com