- 9.1 Overview of the Behaviors/Mental Health Module
- 9.2 Wandering
- 9.3 Self-Injurious Behaviors
- 9.4 Offensive or Violent Behavior to Others
- 9.5 Mental Health Needs and Substance Use Disorder Questions
- 9.6 Behavioral Information Supplement
By the end of this module the screener should be able to:
- Accurately complete the Wandering, Self-Injurious Behavior, Offensive or Violent Behavior, Mental Health and Substance Use Disorders, and Behavioral Information Supplement sections of the LTCFS.
- Document when a person with suspected mental illness or substance use issues may be in need of further mental health or substance use services.
This module relies on history, the screening interview process, and the assessment and care planning processes (including collateral contacts) to accurately gather and record information about symptoms and behaviors exhibited by a person who is being screened for functional eligibility.
Completion of any part of this module does not supersede requirements to report or refer persons for protective services, or other interventions, as specified by law or best practice.
Cognitive Impairment: A cognitive impairment in the Adult LTCFS is defined as a permanent impairment of thought due to a severe and persistent mental illness, dementia, brain injury, intellectual/developmental disability, or other organic brain disorder.
- A cognitive impairment does not include temporary impairment due to medications and/or substance use intoxication.
- A cognitive impairment does not include temporary impairment due to a temporary medical condition, such as infection, electrolyte imbalance, or dehydration.
Preventions or interventions include, but are not limited to, those:
- Requiring the presence of another person (e.g., a helper or family member) to prevent a person from exhibiting the behavior.
- Redirecting the person with behaviors when they exhibit the behavior.
- Physically preventing the person from exhibiting the behavior.
- Actively monitoring the person when they exhibit a behavior.
- Responding to problems caused by the behavior of the person being screened.
If screeners are uncertain about whether a behavior should be recorded in this module of the LTCFS, they should consult with their agency’s screen liaison, who can contact the Department of Health Services (DHS), when necessary.
When a screener needs to record a behavioral concern that does not clearly "fit" into a common category (i.e., wandering, self-injurious behavior, or offensive/violent behavior), or it is not listed among symptoms or behavior in the Behavioral Information Supplement, the behavior should be described in the Notes section of the LTCFS.
Many symptoms and behaviors that are recorded during completion of Module 9 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 written plans, but can be informal when all parties caring for the person are well aware of strategies to prevent the behavior(s) and/or intervene when the behavior is exhibited.
Examples included in each section of this module are not all-inclusive.
REMINDER: The screener should document a person’s NEEDS, not just the services or assistance the person is currently receiving. When a person with an identified need is not receiving assistance, or is refusing the service, the screener should still capture the need for the assistance while completing Module 9 of the LTCFS.
For a person with cognitive impairments, wandering is defined as: unsafely leaving or attempting to leave an immediate area, such as a home, community setting, or workplace without informing others and the behavior requires intervention. A person may still exhibit wandering behavior even when elopement is impossible due to preventative measures, such as facility security systems and bed and wheelchair alarms.
Wandering is the only behavior recorded during the completion of Module 9 on the LTCFS 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 intoxication from substance use is not included in the definition of cognitive impairment.
Check this for a person who, due to a 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 a new situation, but does not wander in routine and familiar situations.
- Elopes or attempts to elope from their 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 their 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, stop living at their residence, or avoiding court-ordered services.
- Attempts to leave, or leaves their residence, in order to use alcohol or other substances.
- Paces within their residence due to anxiety, nervousness, or boredom.
- Roams within their residence, but does not require interventions. For example, a person may roam about within their residential facility, but not attempt to elope.
- Has a sleep disorder, such as sleepwalking or sleep talking.
- Has a behavior for which the behavioral plan contains a single intervention. For example, call 911 for emergency assistance.
- Is given an as-needed (PRN) medication as the only intervention within their behavioral plan.
- Carries a global positioning system (GPS) device to permit tracking of the person.
- 0: Does not wander
- 1: Daytime wandering, but sleeps nights
- 2: Wanders during the night, or during both day and night
When completing Module 9 of the LTCFS, select the option that most accurately reflects the frequency of intervention needed for this behavior.
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 and 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 such as hitting, biting, or head banging.
- Eats inedible objects (pica).
- Has excessive thirst manifested by abnormal fluid intake (polydipsia).
- Engages in non-suicidal self-injury that requires intervention, such as cutting their 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 their 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 their 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 9 and in the Behavioral Information Supplement.
- 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 their own displays of self-injurious behavior that does not require that intervention to be initiated by another person.
- Has a behavior for which the behavioral plan contains a single intervention. For example, call 911 for emergency assistance.
- Is given an as-needed (PRN) medication as the only intervention in their behavioral plan.
Self-Injurious Behaviors options:
- 0: No injurious behaviors demonstrated
- 1: Some self-injurious behaviors that require interventions weekly or less
- 2: Self-injurious behaviors that require interventions 2 to 6 times per week OR 1 to 2 times per day
- 3: Self-injurious behaviors that require intensive one-on-one interventions more than twice each day
When completing Module 9 of the LTCFS, select the option that most accurately reflects the frequency of interventions needed for this behavior. Often, behaviors that cannot be recorded as self-injurious can be selected in the Behavioral Information Supplement section of the LTCFS.
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 or sexual advances toward others.
- Spits at or on others.
- Urinates or defecates in inappropriate places (e.g., living room, front porch) 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 the performance of a task.
- Enters another person's living space without permission.
- Has a difficult personality. Examples include, but are not limited to: a person who is obstinate, vulgar, ill-tempered, or does not get along with their 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 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.
- Has an appearance, or mannerisms, that may elicit social prejudice, such as avoidance or stigmatization. Examples include, but are not limited to: a person who mutters, talks to himself or herself, makes unusual or unexpected vocalizations, or has body ticks.
Offensive or Violent Behavior to Others options:
- 0: No offensive or violent behaviors demonstrated
- 1: Some offensive or violent behaviors that require interventions weekly or less
- 2: Offensive or violent behaviors that require interventions 2-6 times per week OR 1-2 times per day
- 3: Offensive or violent behaviors that require intensive one-on-one interventions more than twice each day (list behavior)
When completing Module 9 of the LTCFS, select the option that most accurately reflects the frequency of intervention needed for this behavior. Often, behaviors that cannot be recorded as offensive or violent can be selected in the Behavioral Information Supplement section of the LTCFS.
REMINDER: When selecting a need for assistance with a behavior requiring intervention on the Health-Related Services (HRS) section of the LTCFS, the person being screened must have a cognitive impairment. Self-injurious or offensive and violent behaviors recorded in Module 9 do not require the person being screened to have an underlying cognitive impairment. Screeners should carefully review selections to make certain that the needs of persons being screened are recorded accurately.
It is estimated that between 40 and 70 percent of long-term care consumers also have mental health concerns and/or substance use disorders.
It is recognized that many people will not divulge behavioral health information during the screening process. However, behavioral health information is important to the long-term care program in which a person chooses to enroll in order to ensure that all needs of each person are considered during assessment, care planning, and quality assurance activities. Screeners should ask about mental health and substance use needs and diagnoses when confirming physical health diagnoses and determining the need for health-related services.
Screeners should use their professional interviewing skills and observation to elicit the most accurate possible answers to these questions. The importance of a tactful and sensitive approach when interviewing people about their behavioral health needs cannot be overstated. Best practice includes the following:
- Do not read any behavioral health sections of the LTCFS to the person verbatim. Rather, use common language and non-judgmental words to elicit information from the person being screened.
- Do not provide any behavioral health sections of the LTCFS to the person being screened, their family, or caregivers in the form of a checklist for their completion. Rather, maintain familiarity with the behavioral health sections of the LTCFS and collect information to complete these sections during the course of the screening interview.
Mental Health Needs Options (screener may select only one of three options):
REMINDER: If your agency is required to complete the Behavioral Information Supplement, complete this question after completing the Supplement.
- 0: No mental health problems or needs evident. No symptoms that may be indicative of mental illness; not on any medications for psychiatric diagnosis.
- 1: No current diagnosis. Person may be at risk and in need of some mental health services. (Examples include: symptoms or reports of problems that may be related to mental illness, requests for help by the person or family/advocates, or risk factors for mental illness. Examples of risk factors are symptoms of depression that have lasted more than two weeks and/or interfere with daily life, recent trauma, or loss.)
- 2: Person has a current diagnosis of mental illness.
A current diagnosis of mental illness does not need to be limited to a major mental illness. This diagnosis may include anxiety disorders, depression, or personality disorders. 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, antidepressants are prescribed for other reasons than depression, such as chronic pain. Contact a health care professional to determine the condition for which an antidepressant is prescribed. This applies when selecting options on the Diagnoses Table as well as the mental health question on the LTCFS. Screeners are never to deduce, infer, or otherwise “make up” diagnoses.
REMINDER: If mental health needs are identified as “2: Person has a current diagnosis of mental illness,” then a corresponding diagnosis under H on the Diagnoses Table must be checked.
Substance Use Disorder Options (screener may select only one of three options):
REMINDER: If your agency is required to complete the Behavioral Information Supplement, then complete this question after completing the Supplement.
- 0: No substance use issues or diagnosis evident at this time.
- 1: No current diagnosis. Person or others indicate(s) a current substance use problem, or evidence suggests possibility of a current problem or high likelihood of recurrence without significant ongoing support or interventions. Examples include: police intervention, detox, history of withdrawal symptoms, inpatient treatment, job loss, or major life changes.
- 2: Person has a current diagnosis of substance use disorder.
The information collected from the mental health and substance use disorder questions play no role in the determination of functional eligibility. They are informational for aging and disability resource centers (ADRCs) and the long-term care program in which the person enrolls. These questions may be used for quality assurance and improvement activities to ensure that mental health or substance use disorders noted in any person’s LTCFS are being addressed by the long-term care program in which the person enrolls.
The Behavioral Information Supplement collects information about symptoms and actions that are consistent with behavioral health needs. Collection of this information will assist care management staff to identify symptoms and actions on the part of program members that may indicate a need to develop new approaches to the care and supervision provided to these individuals.
The Behavioral Information Supplement section of the LTCFS is completed by the assigned screener at a managed care organization, IRIS consultant agency, or Medicaid home and community-based services waiver program agency. The Supplement must be completed for all adults screened by these agencies. The Supplement is not completed by screeners at ADRCs. The screener must select applicable symptoms or behaviors or select the final box in the Supplement, “No symptoms or behavior identified at this time,” in order to calculate functional eligibility.
Information collected within the Behavioral Information Supplement is intended for use by care management staff and DHS; the Supplement is not a checklist for completion by, or in the presence of, the person being screened. Information collected on the Behavioral Information Supplement does not appear on the printed screen report.
The Behavioral Information Supplement identifies:
- Orientation toward person, place, time, or situation
- Symptoms, behaviors, or actions;
- Frequency of symptoms, behaviors, or actions
- Presence and frequency of interventions
- Presence of dedicated staffing
- Presence of a behavioral support plan
Information collected in the Supplement does not affect functional eligibility, other screening tools, or the budget calculated for IRIS participants.
The Behavioral Information Supplement provides the screener with the opportunity to identify behavioral concerns in greater detail than is possible within other sections of this module. Symptoms or behavior on the Supplement may be selected regardless of whether the person being screened has a cognitive impairment, requires intervention from another person, or has a behavioral plan in place.
Special considerations related to the Behavioral Information Supplement:
- Complete the Supplement only after the assessment has been completed and care planning has begun. Update the Supplement when there is a change in symptoms or behavior.
- When identifying whether the person being screened is disoriented, check all options that apply at the time the Supplement is being completed. Do not identify disorientation that occurred in the past and is no longer present.
- Symptoms or behavior identified on the Supplement may have occurred more than 12 months in the past. In many instances, successful, ongoing interventions that prevent the behavior may be in place. Record symptoms or behavior that are historical when these continue to be relevant, or when interventions are ongoing.
- Symptoms and behavior identified on the Supplement may meet the definition of offensive, violent, or self-injurious. Select these symptoms and behaviors in all applicable sections of the LTCFS. This will ensure symptoms and behaviors are included in the determination of functional eligibility, data collection, and the information that informs care management staff.
- If symptom “c: Suicide attempts or threats to attempt suicide” is selected, then the screener must enter a screen note on the Behaviors/Mental Health section of the LTCFS briefly explaining the prevention plan that is in place for the person being screened. Compliance with this requirement will be monitored by the DHS.
- For purposes of the Supplement, interventions and behavior plans are defined in the same manner as defined in section 7.10, Behaviors Requiring Interventions of the LTCFS instructions. However, cognitive impairment is not required in order to identify a person as needing and receiving interventions on the Supplement. Medication does not constitute intervention.
- Dedicated staffing is defined as a person whose sole work duties are to prevent, respond to, or manage behavioral symptoms or actions of the person being screened. This staffing may be paid, unpaid, formally or informally trained, relatives or non-relatives.
- Consequential symptoms or behaviors (see Behavior Toward Self, items “o.” and “p.”) are defined as those that jeopardize health, employment, living arrangement, financial security, or the ability to live independently.
- Personal space (see Behavior Toward Others, item “c.”) is defined as both the immediate area around the body of another person or the designated living space of another person.
- Since information in the Supplement is not used to determine functional eligibility or to determine the budget allocation for IRIS participants, the Supplement does not appear on the Functional Screen Report. Release of the Supplement to any person other than the person screened or their guardian may occur only after the person, or their guardian, has signed a release of information form that specifically identifies that the Behavioral Information Supplement may be released. Only the long-term care program agency in which the person is currently enrolled may release the Supplement.