April 24, 2015

AOTA Conference

Jeanna Conder, MBA, OTR/LJeanna.conder@Rehabcare.com

Understanding and Treating

Mental Illness in Long-Term Care

Ensuring Success with Cross

Disciplinary Intervention

• Communication

• Education

• Care Planning

• Discharge

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Evaluation and Assessment

• What Are the Challenges in Evaluating a Patient With Mental Illness?

– Patient Challenges

• Lack of concentration/short attention span/distraction

• Lack of interest/difficult to engage

• Inability to recognize they have deficits

• Inability to follow requests by therapist to complete the assessment

• Inappropriate behaviors or verbalizations

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Evaluation and Assessment

• What Are the Challenges in Evaluating a Patient

With Mental Illness?– Therapist Challenges

• Lack of understanding and comfort with the symptoms

and behaviors being exhibited• Uncertainty of the correct assessment to utilize

• Difficulty with determining appropriate areas to assess

• Difficulty with goal writing and documenting progress

• Unsure how to integrate physical dysfunction,

communication and cognition as well as mental illness

deficits into the evaluative process

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Evaluation and Assessment

• Areas That Are Crucial for a Successful Evaluation– Be knowledgeable regarding patient diagnosis

– Establishing a rapport

– Be approachable

– Not reacting or responding negatively to inappropriate behavior or verbal dialogue

– Be patient, do not try to rush the evaluation

– Be calm and reassuring

– Gain trust

– Be prepared to redirect as indicated

– The patient may not be appropriate for point of service documentation if they exhibit behaviors such as paranoia

– Provide choices when appropriate

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Areas to Assess

• Eye Contact

• Orientation

• Gross Movement

Patterns

• Postural Control and

Balance

• Social Skills

• Daily Living Skills

• Leisure Interests and

Skills

• Stereotypical Behaviors

• Sensory Awareness

• Judgment

• Safety Awareness

• Problem Solving

• Coping Skills

• Skills/Interests/Values

• Attention/Concentration

• Memory

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Assessment Tools

• Allen’s Cognitive Level Test

– The ACL is can be utilized to estimate the patient’s

cognitive functioning and capacity to learn and

to guide treatment and goal setting. Requires

approximately 20 minutes to administer

• Kohlman Evaluation of Living Skills

– This tool is designed to provide a quick and simple

evaluation of a patient’s ability to perform basic

living skills. Although not comprehensive, it can

help to determine the degree of the patient’s

independence and suggest appropriate living

situations that will maximize independence

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Assessment Tools

• Bay Area Functional Performance Test– This tool assesses cognitive, affective, and performance skills in

social interactions. The results are intended to reflect the patient’s

level of function, behaviors that affect task function and social

interaction skills. Consists of two components: Task Oriented

Assessment and Social Interaction Scale. These can be utilized

separately or together – 40 to 50 minutes per test

• Routine Task Inventory– The RTI was developed as a measure of impairment as it relates to

the performance of activities of daily living. This method of

describing performance uses the ratings from Allen’s theory of

cognitive levels. Time to administer varies dependent on patient

skill level. Three methods may be used to administer the RTI –

caregiver report; self report; observation of performance

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Treatment and Management

• Limit Setting – the reasonable and rational setting of

parameters for patient behavior that provide control

and safety

• Redirection – changing or “redirecting” a patient

focus to one that is safer and more socially

appropriate and acceptable

• Group vs. Individual – Patients may treated either in a

group or individually dependent on the diagnosis

and patient comfort

• Safety Concerns – Patient and therapist safety should

always be of utmost concern. Never underestimate

the patient’s abilities

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Limit Setting

• Define your behavior expectations clearly and consistently

• Demonstrate confidence and control

• End the session if the patient is not obeying the limits that have been agreed upon

• Provide parameters that are understandable to the patient (I.e. Not tolerating foul language, they will be allowed a 10 minute break but will then complete the session, establishing and maintaining a schedule)

• Demonstrate an even temperament –avoid taking it personally if the patient does not respond positively to the treatment session

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Redirection

• Engage the patient in a different topic

• Introduce another activity

• Take a break; offer water or a snack

• Refocus on task at hand

• Compliment progress and successes

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Group Treatment vs. Individual

• Use Group Intervention When:

– The patient has good socialization skills

– Can follow directions

– Is not threatened by the presence of others

– Can interact appropriately (at least some of the time)

– Enjoys success oriented activities

• Use 1:1 Intervention When:

– The patient is uncomfortable around others

– Has difficulty with personal boundaries

– Demonstrates inappropriate behaviors the majority of the day

– Has paranoid ideation

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Types of Groups

• Cooking

• Craft

• Life Skills

• Coping Skills

• Home Management

• Self – Esteem

• Money Management

• Time Management

• Anger Management

• Current Events

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Safety

• Make sure all scissors, knives and other sharp instruments are in a locked drawer or cabinet

• Keep all craft supplies secure and out of reach

• Be aware of patient mood and affect; watch for sudden changes

• Be conscious of patient triggers; what causes outbursts and aggressive behavior

• Always be consistent in your approach; Be kind, supportive and firm in your requests

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Evaluation is Completed ~ Now

What?

• Commonly Used Terms:

– Affect

– Emotionally Labile

– Flight of Ideas

– Tangential Thought

Processing

– Incoherent

– Psychomotor

Retardation

– Disorientation

– Obsession

– Phobia

– Delusion

– Hallucination

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Evaluation is Completed ~ Now

What?

• Generalities– Length of stay for a patient

with mental illness is typically 2 – 4weeks (will vary dependent on diagnosis)

– Goals are objective and specific in nature

– Goals are marked by changes in socialization, affect, eye contact, decrease in symptoms or behaviors, increase in independence, improvement in coping skills, demonstration of appropriate emotional response

• Broad Areas for Goal

Development Are:

– Motor

– Sensory

– Cognitive

– Intrapersonal

– Interpersonal

– Self Care

– Productivity

– Leisure

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Documenting Medical Necessity

• Documenting medical necessity is critical for

this population

• Be sure to define clearly the deficits that are

noted and how they impact the patients:

– Overall Function

– Quality of Life

– Interpersonal Relationships

– Independence

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Documenting Progress

• Remember to focus on your problem list

• Always assume small gains in psychiatric illness;

grade goals accordingly

• Patient function should be documented in the

goals

• Progress is as essential in psychosocial

dysfunction as in physical dysfunction

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Sample Goals

• The patient will maintain appropriate eye contact for

at least half the treatment session (at least 15

minutes) to increase socialization skills

• The patient will not verbalize inappropriate or foul

language during the treatment session to improve

appropriate socialization

• The patient will complete a task activity with no more

than 3 verbal redirections required during a 30

minute session to increase attention span

• The patient will bathe independently with only one

verbal reminder from therapist prior to time of bath to

improve personal hygiene

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Sample Goals

• Patient will choose a leisure activity when given

the choice of two to improve decision making

skills

• Patient will participate in therapy session with no

more than 3 verbal prompts required to increase

patients interaction and socialization

• Patient will not demonstrate aggressive behavior

during therapy session (at least 45 minutes)

• Patient will respond to redirection to task without

negative verbal responses or outbursts

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Activity Analysis – Grading

• Grade activities for successes

• Be aware of cognitive levels

• Crafts can be utilized but also home management activities

• Remember task analysis – assess the number of steps required to complete an activity

• Patients will be more willing to participate in activities in which they are successful – they are familiar with failure

• Work with them to find activities they enjoy

• Always be supportive and encouraging

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Discharge Considerations

• Safety is always of utmost concern

• Patient’s functional ability must be considered

• Patient’s judgment and insight is crucial in determining an appropriate discharge destination

• Prepare the patient for the discharge

• Try and minimize complications or problems

• Be as structured as possible

• Engage all parties in the discharge

• If remaining in the facility – educate the staff in regard to the treatment plan and program that has been successful

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Closing

• Difficult population that is frequently overlooked and not provided the assistance they need

• You may be the only person who has the skills to intervene

• Be confident, self assured and compassionate

• Mental illness is as devastating as a physical disability

• Be supportive, learn and teach others

• Remember, you can make a positive difference in the patient’s life

• The rewards are great for both you and the patient

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References

• Hemphill B.J., (1982). The evaluative process in psychiatric occupational

therapy. Slack, New Jersey.

• Allen C.K.,(1987). Cognitive disabilities: measuring the consequences of

mental disorders. Clinical Psychiatry 48(5): 185-190.

• Reed K. (2003) Quick reference in occupational therapy. Aspen,

Maryland.

• Cole M. (2005). Group dynamics in occupational therapy: the theoretical

basis and practice application of group intervention. Slack, New Jersey.

• The American Occupational Therapy Association. (1997). The

psychosocial core of occupational therapy. American Journal of

Occupational Therapy, 51, 868-869.

• The American Occupational Therapy Association. (2002). Occupational

therapy practice framework: Domain and process. American Journal of

Occupational Therapy, 56, 609-639.

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