Module 8: Behaviors/Mental Health

Contents

• 8.1 Overview of the Behaviors/Mental Health Module
• 8.2 Wandering
• 8.3 Self-Injurious Behaviors
• 8.4 Offensive or Violent Behavior to Others
• 8.5 Mental Health Needs and Substance Use

Objectives

By the end of this module you should be able to:

• Accurately complete the Wandering, Self-Injurious Behavior, Offensive or Violent Behavior or Mental Health and Substance Use sections of the LTC FS.
• Distinguish behaviors as defined on the LTC FS from choices that are simply unhealthy.
• Document when a person who is mentally ill or has substance use issues needs further mental health or substance use services.

8.1 Overview of the Behaviors/Mental Health Module

This module relies on both history and the screening interview process to accurately gather and record information about behaviors exhibited by an individual who is being screened for functional eligibility.

In this module, "cognitive impairment" includes impairment of thought due to severe mental illness, dementia, brain injury, intellectual/developmental disabilities, or other organic brain disorders. It does not include temporary impairment due to intoxication from substance use.

Preventions or interventions include, but are not limited to, those that:

• Require the presence of another person (e.g., helper, family member) to prevent an individual from exhibiting the behavior.
• Redirecting the individual with behaviors when he or she exhibits the behavior.
• Physically preventing the person from exhibiting the behavior.
• Monitoring the person when he or she exhibits a behavior.
• Responding to problems caused by the behavior of the individual being screened.

If the screener is uncertain about whether a behavior fits one of the categories above, he or she should consult with his or her agency’s screen liaison or assigned state staff.

When a screener needs to record a behavioral concern that does not clearly "fit" into a common category (wandering, self-injurious behavior or offensive/violent behavior), the behavior should be described in the notes section of the LTC FS.

Most behaviors that are recorded during completion of Module 8 will be included in a written behavioral plan. A behavioral plan can be developed by a psychiatrist, psychologist, behavioral specialist interdisciplinary team or a long-term care participant’s family. These plans typically involve the use of professional or non-professional caregivers. They are typically formal, written plans, but can be informal if all parties caring for the individual participant are well aware of strategies to prevent the behavior(s) and/or intervene when behavior is exhibited.

Examples included in each section of this module are not all-inclusive.

REMEMBER: A screener should document an individual's NEEDS, not just what services/assistance he or she is currently receiving. When a person with an identified need is not receiving assistance (including refusing the service, etc.), the screener should still capture the need for the assistance while completing Module 8 of the LTC FS.

8.2 Wandering

For a person with cognitive impairments, wandering is defined as unsafely leaving or attempting to leave an immediate area (home, community setting, workplace, etc.) without informing others and requiring intervention. A person may still exhibit wandering behavior even if elopement is impossible due to preventative measures, such as facility security systems, bed and wheelchair alarms, etc.

Wandering is the only behavior recorded during completion of Module 8 on the LTC FS for which a cognitive impairment must be present. A cognitive impairment includes impairment of thought due to a severe and persistent mental illness, dementia, brain injury, intellectual/developmental disability or other organic brain disorder. Temporary impairment due to substance use intoxication is not included in the definition of cognitive impairment.

Check this for a person who, due to cognitive impairment:

• Wanders and requires a behavioral plan to prevent the behavior or to intervene when the behavior is exhibited.
• Wanders and requires a behavioral plan when in new situation, but does not wander in his or her routine and familiar situations.
• Elopes or attempts to elope from his or her residence and requires a behavioral plan.

Regardless of whether an individual being screened has a cognitive impairment, do NOT check this for a person who:

• Purposefully tries to leave his or her immediate area (residence, community setting, workplace, etc.). Examples may include, but are not limited to, attempts by a person without a cognitive impairment to elope, no longer live at his or her residence or avoid court ordered services.
• Attempts to leave or leaves his or her residence in order to use alcohol or other substances.
• Paces within his or her residence due to anxiety, nervousness or boredom.
• Roams within his or her residence, but does not require interventions. For example, a person may roam about within his or her residential facility, but not attempt to elope.
• Has a sleep disorder (e.g., sleepwalks, sleep talks).
• Has a behavior for which the behavioral plan contains a single intervention: Call 911 for emergency assistance.
• Is given an as needed (PRN) medication as the only intervention within his or her behavioral plan.

Wandering Options:

• Does not wander
• Daytime wandering, but sleeps nights
• Wanders at night or day and night

When completing Module 8 of the LTC FS, select the option that most accurately reflects the frequency of intervention needed for this behavior.

8.3 Self-Injurious Behaviors

Self-injurious behavior is defined as behavior that causes or is likely to cause injury to one's own body and requires intervention. Self-injurious behaviors are physical self-abuse; they do not include the absence of self-care or behaviors that may have unhealthy consequences.

Check this for a person who:

• Exhibits self-abuse that causes or is likely to cause self-injury (e.g., hitting, biting, head banging).
• Eats inedible objects (pica).
• Has excessive thirst manifested by abnormal fluid intake (polydipsia).
• Engages in non-suicidal self–injury that requires intervention (e.g., person cuts his or her skin).

Do NOT check this for a person who:

• Smokes, uses alcohol or other substances or misuses medications.
• Is sexually promiscuous.
• Makes poor eating choices, given his or her physical health. Examples include consumption of a diet high in sugar by a person with insulin dependent diabetes mellitus and failure to follow a recommended low-fat diet.
• Has a habit that is harmless and is unlikely to offend others. Examples include repetitive tapping, rocking or finger waving.
• Has or seeks multiple body tattoos or piercings.
• Rubs his or her skin or scabs without the need for medical intervention beyond application of a bandage.
• Recently attempted suicide, has a history of attempting suicide or has suicidal ideations. These actions or thoughts should be captured in the Mental Health section of Module 8.
• Has anorexia- or bulimia-related behaviors.
• Has a self-managed, self-help plan of action to prevent self-injurious behavior or a plan that includes steps to take in response to his or her own displays of self-injurious behavior that does not require that intervention is initiated by another person.
• Has a behavior for which the behavioral plan contains a single intervention: Call 911 for emergency assistance.
• Is given as needed (PRN) medication as the only intervention in his or her behavioral plan.

Self-Injurious Behaviors options:

• No injurious behaviors demonstrated
• Some self-injurious behaviors that require interventions weekly or less
• Self-injurious behaviors that require interventions 2 to 6 times per week OR 1 to 2 times per day.
• Self-injurious behaviors that require intensive 1-on-1 interventions more than twice each day.

When completing Module 8 of the LTC FS, select the option that most accurately reflects the frequency of interventions needed for this behavior.

8.4 Offensive or Violent Behavior to Others

Behavior that is offensive to others or violent toward others is defined as behavior that causes or can reasonably be expected to cause discomfort or distress to others or threatens to cause emotional or physical harm to others. The disturbing behavior impacts others in the person’s community, including other residents in a facility, neighbors or community at large and requires a behavioral plan to either prevent the behavior or intervene when the behavior is exhibited.

Check this for a person who:

• Disrobes or masturbates in front of others.
• Engages in inappropriate touching, sexual advances toward others.
• Spits at or on others.
• Urinates or defecates in inappropriate places (e.g., living room, front porch, etc.) or on another person or the act of spreading urine or feces.
• Screaming incessantly.
• While conversing, uses profanity that is offensive and threatening to a point where law enforcement is typically contacted to intervene.
• Verbally and physically threatens others, including, but not limited to, aggressive gestures or a raised fist, to a point where law enforcement is typically contacted to intervene.
• Tortures, maims or otherwise abuses animals.
• Strikes out at, hits, kicks, bites or otherwise batters others.
• Commits or has a history of sexual aggression, pedophilia or arson, and the behavior continues to be an active concern.

Do NOT check this for a person who:

• While conversing, uses profanity that is not offensive or threatening to a point where law enforcement would typically be contacted to intervene.
• Uses profanity or racial slurs on a routine basis.
• Hoards items.
• Has poor housekeeping or cleaning skills or practices.
• Steals items.
• Has poor personal hygiene. Examples may include, but are not limited to, excessive body odor, including strong urine or fecal odor.
• Is uncooperative with performance of a task.
• Enters another person's living space (e.g., person is a “busy body”).
• Has a difficult personality. Examples can include, but are not limited to, a person who is obstinate, vulgar, ill-tempered or does not get along with his or her family members or caregivers. Exhibits behavior(s) that may indicate a need for medical treatment, mental health treatment or substance use treatment, but does not require an intervention. Examples may include, but are not limited to, a person with an anxiety disorder who needs frequent reassurance or a person with obsessive compulsive disorder who frequently checks whether a door is locked.
• By appearance or mannerisms, etc. may elicit social prejudice such as avoidance or stigmatization. Examples may include, but are not limited to, a person who mutters, talks to himself or herself, makes unusual or unexpected vocalizations or has body ticks.

When completing Module 8 of the LTC FS, select the option that most accurately reflects the frequency of intervention needed for this behavior.

REMINDER: When selecting a need for assistance with a behavior requiring intervention on the HRS Table section of the LTC FS, the individual being screened must have a cognitive impairment. Self-injurious or offensive and violent behaviors recorded as part of screening in Module 8- Behaviors/Mental Health of the LTC FS do not require the individual being screened to have an underlying cognitive impairment. Screeners should carefully review selections to make certain that the needs of individuals being screened are recorded accurately.

8.5 Mental Health Needs and Substance Use

It is estimated that from 40 to 70% of long-term care consumers also have mental health and/or substance use issue.

It is recognized that many people will not divulge this information during the screening process. However, the information is important to share with the LTC program in which the consumer chooses to enroll and for rate-setting and quality assurance purposes. Screeners should ask about mental health and substance use diagnoses when confirming other diagnoses, health-related services, and target group questions.

Screeners should also use their professional interviewing skills and observation to elicit the most accurate possible answers to these questions.

Mental Health Needs Options:

• No known diagnosis of mental illness--no mental health problems or needs evident
   
• No known diagnosis of mental illness-person may be at risk and in need of some services
  • “Person may be at risk and in need of some mental health services” is an opportunity for the screener to indicate their professional judgment that the person may be at risk and in need of some mental health services. Frequent crying, hand wringing, frowning, poor eye contact, flat affect, expressions of despair, self-hate or hopelessness, etc., can all be signs of depression or unresolved grief with which the person may need help. The screener is not diagnosing anything, they are merely indicating that the person “may be at risk and in need of mental health services.” Current system problems (such as cultural or funding barriers to access of mental health services) should not prevent the screener from indicating what is perceived in the applicant's demeanor and situation.
     
• Person has current diagnosis of mental illness that is currently stable
  • Stable” here means the person is functioning well with routine periodic oversight/support, and is currently receiving such oversight/support
     
• Person has current diagnosis of mental illness that is currently not stable
  • The person needs intensive mental health services (whether they are currently getting them or not--they need them.)

A current diagnosis of mental illness does not need to be limited to a major mental illness. This diagnosis may include anxiety disorders, depression, personality disorders, etc. Psychiatric diagnoses must be confirmed with a health care provider or medical record.

Screeners should not deduce a diagnosis from a list of medications. For example, anti-depressants are prescribed for other reasons than depression, such as chronic pain. Contact a health care professional to find out the condition for which the antidepressant is prescribed. This applies when selecting options on the diagnosis table as well as the mental health question on the LTC FS. Screeners are never to deduce, infer or otherwise “make up” diagnoses.

An unstable mental health condition is not a requirement for enrollment in a Community Support Program (CSP). Many individuals who receive CSP services have stable mental health conditions. Indicators of mental health instability include, but are not limited to, mental health hospitalization more than once per year and exacerbation of positive symptoms (hallucinations, delusions) to the point where symptoms interfere with work or other activities of daily living and disrupts relationships. Other indicators of instability include the need for frequent adjustments in psychotropic medications or frequent emergency room visits.

If mental health needs are identified as a 2 or 3 (current diagnosis), a corresponding diagnosis under H on the diagnosis page should be checked.

Substance Use Options:

• No active substance use problems evident at this time
• Person or others indicate a current problem, or evidence suggests possibility of a current problem or high likelihood of recurrence without significant on-going support or interventions
• In the past year, the person has had significant problems due to substance use. (Examples: police interventions, detox, inpatient treatment, job loss, major life changes.)

The information collected from the mental health and substance use questions play no role in the eligibility logic. They are informational for the LTC program enrolled in by the consumer. These questions may be used for quality assurance and improvement studies to see that mental health or substance use problems noted in the LTC FS are being addressed by the LTC program in which the consumer enrolls.

Last Revised: March 14, 2013
Wisconsin Department of Health Services
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