Unintended
Consequences:
COVID-19
Behavioral
Health Issues
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Speakers
Kathy Adkins OTR/L, CPC-A, RAC-CT, CDP
Director of Quality
Leta Kant PT, RAC-CT, ATP
Director of Quality
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Objectives
• Identify causes/risk factors of behavioral health
issues due to social isolation from COVID-19
• Identify the role of rehabilitation to work with
individuals with behavioral health issues
• Educate facility staff on routines, activities and
meaningful activities to improve quality of life
• Demonstrate how behavioral health affects your
quality measures
“There is now
compelling evidence
that the health risk of
social isolation is
comparable to the risks
of smoking, high blood
pressure and obesity,
even after controlling
for other variables
known to affect health”
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Omnibus Budget Reconciliation Act (OBRA)
“each resident must receive and the facility
must provide the necessary care and services
to attain and maintain the highest practicable
physical, mental and psychosocial well-being in
accordance with the comprehensive
assessment and plan of care”
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483.40 Behavioral Health Services-
F742/F743
§ 483.40 Behavioral health services. Each resident
must receive and the facility must provide the
necessary behavioral health care and services to attain
or maintain the highest practicable physical, mental,
and psychosocial well-being, in accordance with the
comprehensive assessment and plan of care.
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483.25 Quality of Care-F699/F676
§ 483.25(m) Trauma-informed care
The facility must ensure that residents who are trauma
survivors receive culturally competent, trauma-informed
care in accordance with professional standards of
practice and accounting for residents’ experiences and
preferences in order to eliminate or mitigate triggers
that may cause re-traumatization of the resident. [§ 483.25(m) will be implemented beginning November 28, 2019 (Phase 3)]
“Social Isolation
Can Hike Risk of
Death from All
Causes”
“Social Isolation
increases risk for
Covid-19, Other
health problems”
“Social isolation
will help stop
coronavirus”
“Loneliness and social
isolation linked to serious
health conditions”
“10 “Eye-Opening
Statistics on the mental
health impact of the
coronavirus pandemic”
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Brenda
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Brenda’s Schedule Pre-COVID-19
• Likes to participate in games and crafts in the common room
• Loves to have visits with her family who comes by daily
• She loves going to the cafeteria to eat her means with her best
friend Mildred
• She really likes doing her OT with John and PT with James and
usually comes to rehab gym early to socialize with all the
therapy department
• She loved activities especially church, music and pet therapy
• This schedule came to a screeching halt
on March 25, 2020
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Brenda’s Schedule-Post COVID-19
• Now her schedule is dramatically different
• She eats alone in her room so no longer gets to see Mildred
• Therapy is minimal and has to be done in her room. Her
favorite therapist are not longer in the facility due to quarantine.
• Her day consists of endless TV programs
• Her roommate was moved out
• Her favorite staff no longer have time for conversation
• Family only get to wave through the window
• She spends most of her day now looking out the window
waiting for her family to come!!!!
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Statistics
1000% increase SAMSHA hotline since April (emotional
distress)
65% increase in clients for Talkspace
70% increase in stress
15% distress in >65 older
48% increase in alcohol sales since pandemic with people “day
drinking”
1% increase unemployment1% increase in suicide 3%
increase in substance/opioid use
1/3 Americans anxiety, depression or both (18 to 29 year olds)
14-15 suicides daily (elderly) 1 every hours and half 18%
suicides
Social Isolation vs. Loneliness
Social Isolation State of complete or near-
complete lack of control
between an individual and
society
Loneliness Temporary and involuntary lack
of contact with other humans in
the world-lack of sense of
belonging (how you feel when
you are alone-perceived
isolation)
Causes/Risk Factors-Social
Isolation
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Why is social isolation so difficulty for
humans to withstand?
• Humans are incredibly social species
• Yossi Ginsberg (Israeli adventurer/author survived weeks in
Amazon and create imaginery friend to keep himself company
• Dr. John Cacioppo (Neuroscientist from University of Chicago)
said “Research showed effect of social isolation is as real as
thirst, hunger or pain”
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OUR BRAINS ARE SOCIAL IN
NATURE!!!!
Wi-FiGenes turn off
Sleep Disruption
Hallucinate
Executive Function
Stress
Anthromorphize objects
Depression, anxiety, PTSD,
psychosis
Problems with motor
cortex
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Situational Depression
• “Short-term, stress-related type of
depression. Develops after you
experience a traumatic even or series of
events. It is a type of adjustment
disorder.”
• This can happen when a resident
moves into a facility but is currently
what is happening with pandemic.
Risk Factors-Social Isolation
• Physical Inflammation of joints
Headaches/migraines
Fatigue
Breathing difficulties
Stomach/digestive issues
Increased BP
Heart muscle overworks-heart
palpitations/pounding
Sweating
Worsening of existing medical
problems
Muscle tension
Pain
• Emotional Changes in sleep cycle
Depression
PTSD
Anxiety
Suicidal
Restlessness
Decreased self-worth
Despair
Decreased confidence
Suicidal
Loss in meaning of life
Negative
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Other Symptoms with Social
Isolation
• Difficult/Aggressive behavior
• Disorganized thoughts/speech
• Cognitive Dysfunction
– Short term memory loss
– Difficulty problem solving
– Difficulty planning
• Self-harm
• Swallow Issues
• Suicide
• Substance/Nicotine Abuse
• Loss of meaning of life!!!!!
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“COVID-19 May Trigger Emotions
from Past Trauma.”• Each person experiences conditions based on our unique histories, strengths
and vulnerabilities
• Past trauma has a powerful effect on our reactions to this pandemic
• If you have a history of trauma you may be experiencing a reactivation of your
past trauma
• Some of your reactions may be:
– Intrusive Memories (may be triggered by TV)
– Problems with Sleep
– Being Constantly on Guard
– Difficult Emotions
– Feeling Numb
– Avoidance
– Negative Thoughts
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Trauma
• Pandemic counts as trauma
• Trauma causes changes to brain chemistry (neurotransmitters)
– Depression
– Anxiety
– Insomnia/Sleep disturbances
– Appetite fluctuations
– Panic attacks
– Lack of interest in activities/hobbies
– Suicidal thoughts
– Feel overwhelmed
Role of Rehabilitation-Social
Isolation
“I found myself
running around for 5
minutes looking for a
pencil to give to
someone to write a
letter.”
“We have to
slow down and
look at
everything.”
“I found myself
holding
someone’s hand
for 5 minutes.”“We have to stop
and watch what is
going on.”
“ I found myself
putting PPE back on
to go back to room
to pick up a reacher
he dropped.”“I find myself doing
extra things,
maintenance, CNA,
housekeeping,
passing trays but it is
what is needed.”
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Traditional rehab doesn’t work with individuals who
have behavioral health issues
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Medicare does not turn on the presence or absence of a
beneficiary’s potential for improvement from the therapy,
but rather on the beneficiary’s need for skilled care. While
a beneficiary’s particular medical condition is a valid factor
in deciding if skilled therapy services are needed, the
beneficiary’s diagnosis or prognosis cannot be the sole
factor in deciding that a serviced is or is not skilled.
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How do we identify residents who benefit from rehab
during quarantine (social isolation)?
• Walking rounds during meals
• Casper report information
• Quality Measures
• CNA information
• MDS calendar
• Screen roommate of residents on caseload
• Nursing documentation
• Word of mouth from managers/housekeeping/maintenance
• Screen everyone who hasn’t been on therapy for a while for
functional decline
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Patient Identification
• Observe
• Listen
• Watch
• Environment
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Keys to Success
Comprehensive evaluations and
treatment
Optimal patient outcomes
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Comprehensive Evaluations
Focus
Lifestyle of individual
Make resident’s goals
our priority
Assessment
Determine clinical needs
Personal goals
Approach
Collaboration between
therapist and resident
Partnership for health and happiness
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Comprehensive Evaluations• Occupational Therapy Profile
Interests
Values
Experiences
Occupational history
Needs
Personal goals
• Personal Interest Inventory
Helps get to know the person
Nickname, where they were born
Favorite job
Who is closet family member
Favorite food/sport/place
Best friend
Hobbies
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Standardized Test/Assessments
• Geriatric Depression Scale
• Generalized Anxiety Disorder (GAD-7)
• Global Deterioration Scale
• Allen Cognitive Level (ACL)
• Pain Scale
• Perceived Stress Scale (PSS-10)
Physical Therapy-Functional
Deficits/Underlying Impairments
• Postural Control
• Balance
• Fall Risk
• Fall Recovery
• Community Mobility
• Bed Mobility
• Wheelchair mobility
• Medication Assessment
• Gait
– Pattern
– Deviations
– Speed/Quality
• Assistive device Use
• Functional transfers
• Safety Awareness
• Literacy Level
Occupational Therapy-Functional
Deficits/Underlying Impairments
• Eye Contact
• Orientation
• Gross Movement Patterns
• Social Skills
• Participation in Occupations
(ADL/IADL, sleep, rest,
leisure, etc.)
• History of trauma
• Hearing screen
• Medication Assessment
• Sensory Awareness
• Safety Awareness
• Judgment
• Skills/Interest/Values
• Problem Solving
• Coping Skills
• Sleep Patterns
• Literacy Level
• Cognitive Skills
Speech Therapy-Functional
Deficits/Underlying Impairments
• Pragmatics
• Eye Contact
• Orientation
• Sequencing
• Social Skills
• Leisure Interest/Skills
• History of trauma
• Hearing Screen
• Judgment
• Attention/Concentration
• Cognition
• Problem Solving
• Coping Skills
• Memory
• Literacy Level
• Safety Awareness
• Reading Comprehension
• Medication Assessment
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Goals-All disciplines
• Objective, functional and measureable
• Focus on:
– Functional deficits/underlying impairments
– Effect on individual’s overall function
– Quality of life
– Interpersonal relationships
– Independence
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Rehabilitation Strategies
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Depression
• Keep goals low
• Work slowly
• Use touch as encouragement
• Encourage to participate in activities
• Offer support, patience and encouragement
• Praise daily for achievements
• Encourage outside activities
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Suicide
• Take every suicidal threat seriously
• Report immediately
• Keep patient as calm as possible
• Make sure they are in environment is
safe and free from self harming objects
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Anxiety
• Focus on coping strategies
• Participate in meaningful activities
• Eliminate source of anxiety
• Have them help identify the trigger point
for anxiety
• Relaxation techniques
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Physical Exercises
• Helps boost confidence and relieves stress
• Helps maintain mental fitness
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Insomnia/Sleep Issues
• Exercise at least 30 minutes
• Sleep routine
• Go to bed and wake up same time
every day to help keep body’s natural
rhythms on a schedule
• Get out in the sunlight because it helps
maintain the sleep-wake cycle.
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Case Study-Brenda
• Make sure she got a comprehensive
rehabilitation evaluation!
• Why was she referred?
• What disciplines would work with her?
• What interventions would work the best
for her?
Staff Education
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Important Components
Ensure success
with cross disciplinary intervention
Communication
Education Care Planning
Discharge
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Meaningful Activities
• Leisure activities
• Calming activities-music, movies,
books, rocking chairs
• One-on-one time-sharing stories
• Group activities-cards, bowling, cocktail
hour
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Empower the resident
• Help them do the things are important and
meaningful to them
• Focus on prevention, not reacting to crisis
• Allow them enough time to speak
• Allow them enough time to do for him/herself
• Offer choices
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“You Are Powerful”
Give them:
Choices
Meaningful activities
Time to speak
Time to do activities
Opportunity to participate
Ability to be independent
Connect with activities they want to do
How do this help you?
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• Optimize patient care
• Improve interaction/socialization with other
residents/patients
• Readiness for discharge home or placement back
into the community
• Education for therapist around behavioral health
issues
• How therapist can interact and treat patients with
behavioral health diagnoses
• Staff/family education
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Benefits-Quality Measures
• Depressive Symptoms
• Who Received Antipsychotic Medications
• Who Used Antianxiety or Hypnotic Medication
• Prevalence of Behavioral Symptoms
Affecting Others
• Discharge to Community
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RehabCare’s comprehensive behavioral health program trains
administrative, clinical and support staff members utilizing a five-tiered
approach. This program begins with the identification and evaluation of
people with behavioral health diagnosis to determine their highest
functioning level for daily living.
The goal is to provide person-centered care that leads to each individual
functioning at their highest mental, physical and psychosocial level. This
includes determining what type of setting will allow them to live as
independently as possible.
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Resources
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For more information on
RehabCare please contact:
Randy Wadley, M.B.A.-Healthcare Administration
Director of Business Development
Phone: 330.301.1573
Email: [email protected]
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References
• https://www.nia.nih.gov/news/social-isolation-loneliness-older-people-pose-
health-risks
• https://www.psychologytoday.com/us/blog/reading-between-the-
headlines/201504/loneliness-and-death
• https://www.businessinsider.com/how-a-coronavirus-quarantine-affects-your-
body-and-brain-2020-3
• https://www.sciencedaily.com/releases/2018/05/180517113856.htm
• https://www.sciencenews.org/article/loneliness-isolation-brain-changes
• https://blogs.webmd.com/mental-health/20200407/the-covid19-crisis-may-
trigger-emotions-from-past-trauma
• https://my.clevelandclinic.org/health/articles/8133-stress-10-ways-to-ease-
stress