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: Randy.Wadley@rehabcare.com

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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