Behavioral Health Services ( 483.40) Presenter: Sabine Dettlinger-Metropoulos Summary New Section CMS became aware of concerns that behavioral health services Were either not always being addressed or Not addressed to the extent required, in LTC facilities. 1
Summary New Section The requirements in this new section is intended to Emphasize the importance of behavioral health, and Ensure that LTC facilities address these issues Summary New Section The requirements in 483.40 Behavioral health, as well as the other requirements on staffing finalized in this rule, Do not require any LTC facilities to admit any resident for whom the facility cannot provide appropriate care 2
Previous Items The previous Mental and Psychosocial functioning requirement in the Quality of Care regulatory set required the facility to o Provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well being of each resident o To ensure that a resident who displays mental or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem Previous Items Facilities with less than 120 beds did not require a social worker A qualified social worker is an individual with A bachelor s degree in social work or a bachelor s degree in a human services field including (but not limited to); Sociology, special education, rehabilitation counseling, and psychology.. 3
Previous Items..and One year of supervised social work experience in a health care setting working directly with individuals Revised Items New section 483.40 addresses behavioral health services and includes requirements for social workers. CMS believes these provisions work in conjunction with other provisions including those related to reducing the inappropriate use of psychotropic medications. 4
Revised Items Skilled nursing facilities and nursing facilities with 120 or more beds Must have a full time social worker with at least a bachelor's degree in social work or similar professional qualifications Employed to provide or assure the provision of social services Revised Items The requirements for social workers will vary depending on The needs of the resident population. and Data gathered from the facility wide assessment Smaller LTC facilities might not need a full time social worker. 5
Differences Larger facilities or facilities with residents with complex needs might require either more than one full time social worker or more staff to assist the social worker. As discussed, the facility assessment performed by the LTC facility should identify the social services the resident population requires. The facility should then determine how to ensure that those social services are provided. Revised Items CMS made it clear that individuals with a bachelor's degree in a human services field, including but not limited to, sociology, special education, rehabilitation counseling, and psychology can be qualified social workers and added Gerontology to the list of acceptable degrees 6
Revised Items In this final rule, CMS does not require that the individuals who provide behavioral health care and services have specific degrees or certifications; However, the facility must have sufficient staff with the appropriate competencies and skill sets to provide nursing and related services to residents in need of behavioral health care and services. Revised Items These requirements do not mandate that a LTC facility admit any resident with a serious mental disorder. However, if a resident does have behavioral health issues, the LTC facility is responsible for providing the appropriate care for that resident. 7
Each resident must receive and the facility must provide The necessary behavioral health 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. Key Requirement And, for a resident whose assessment did not reveal a mental or psychosocial adjustment difficulty o They do not display a pattern of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors unless. The resident s clinical condition demonstrates that such a pattern was unavoidable 8
Behavioral health encompasses a resident s whole emotional and mental well being, which includes, but is not limited to The prevention and treatment of mental and substance use disorders The facility must have sufficient staff who provide direct services to residents With the appropriate competencies and skill sets to provide nursing and related services to assure resident safety, and In order to attain or maintain the resident s highest practicable physical, mental, and psychosocial well being 9
The facility must have sufficient staff who provide direct services to residents As determined by resident assessments and individual plans of care, and Considering the number, acuity and diagnoses of the facility s resident population These competencies and skill sets include, but are not limited to, knowledge of and appropriate training and supervision for Caring for residents with mental and psychosocial disorders Caring for residents with a history of trauma and/or posttraumatic stress disorder, that have been identified in the facility assessment, and Implementing non pharmacological interventions 10
Non pharmacological or behavioral interventions are required in an attempt to reduce or eliminate psychotropic medications But only if these nonpharmacological methods are not clinically contraindicated for the resident Based on the resident s comprehensive assessment, the facility must ensure that a resident who Displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or Has a history of trauma and/or post traumatic stress disorder o Receives appropriate treatment and services to correct the assessed problem, or o Attains the highest practicable mental and psychosocial well being 11
And, the facility must ensure that a resident whose assessment Did not reveal or who does not have a diagnosis of a mental or psychosocial adjustment difficulty, or A documented history of trauma and/or post traumatic stress disorder, does not o Display a pattern of decreased social interaction, and/or o Increased withdrawn, angry, or depressive behaviors Unless the resident s clinical condition demonstrates that development of such a pattern was unavoidable Based on the resident s comprehensive assessment, the facility must ensure that a resident who displays or is diagnosed with dementia Receives the appropriate treatment and services to; o Attain or maintain their highest practicable physical, mental, and psychosocial well being 12
If rehabilitative services are required in the resident s comprehensive plan of care, such as (but not limited to); Physical therapy Speech language pathology Occupational therapy Rehabilitative services for mental disorders and intellectual disability. the facility must Provide the required services, including specialized rehabilitation services, or Obtain the required services from an outside resource from a Medicare and/or Medicaid provider of specialized rehabilitative services 13
The facility must provide medically related social services To attain or maintain the highest practicable physical, mental and psychosocial well being of each resident Implementation Deadline Behavioral Health Services Most of this section will be implemented in Phase 2 November 28, 2017 Except for: Comprehensive assessment and medically related services, Phase 1 November 28, 2016 As related to residents with a history of trauma and/or post traumatic stress disorder, Phase 3 November 28, 2019 14
QUESTIONS? Workgroup Probes Facility Assessments What will need to be included? Do they need to be revised? How can you utilize assessments you are already using? Consider combining information from the MDS and the Social History to determine level of resident need. Staff Competency What topics will you need to educate your staff in? How will you demonstrate their competency? Do you have curriculums that cover documentation, Dementia and Behavior, Mental Illness/Behavior, Addiction/Behavior 15
Workgroup Probes Non pharmacological interventions what does this mean? What are they? How will you determine which ones to use? How to address there is no decline in psychosocial/mental health while in facility? The New Interdisciplinary Team who will it include to ensure behavior health services are provided? Will you be able to utilize your psychiatric team to help you stay in compliance? Do you have access to a psychiatric team? Does a Policy/Procedure need to be developed or revised? Resources The Council on Social Work Education, NASW s standards and indicators for cultural competence available at http://www.socialworkers.org/practice/standards/index.asp The National Standards for Culturally and Linguistically appropriate Services in Health and Health Care (developed by the Office of Minority Health in HHS). The survey and certification letter (S&C: 13 35 NH) contains valuable guidance for LTC facilities concerning care for their residents with dementia. 16