In This Issue

• National Grief Awareness Day
• Centers for Medicare and Medicaid Services PHQ2-9 Video Tutorial
• Nursing Facility Guidance: Comprehensive Care Plan
• SME Article: Best Practices in Bereavement Care: Helping Nursing Home Communities Cope with Grief
• Research Article: Care Following Nonfatal Overdose Among Medicare Beneficiaries - Study Identifies Intervention and Gaps
• Office Hours
  • Managing Substance Use Disorders in Nursing Facilities 
  • CARES® Serious Mental Illness™
• COE-NF Resources
  • Major Depressive Disorder Bite-Sized Learning
  • Identifying and Supporting Residents with Major Depressive Disorder Module
• Did You Know?
• Save the Date: Upcoming Trainings
• You Matter – Self-care for Health Care Providers

National Grief Awareness Day, also known as National Bereavement Day, is recognized every year on August 30. It is designed to raise awareness of the ways grief can manifest (the experience of grief), which can encompass a complex range of emotions and impact mental well-being. Grief is caused by some form of loss, which may include the death of a loved one, learning about a chronic illness or condition, loss of a career, death of a pet, or divorce. 

There are several stages of grief. However, they do not occur in any order, and each person experiences grief differently. The stages of grief generally include the following:

• Denial – Struggle to consciously or unconsciously acknowledge the death or loss.
• Anger – Feelings associated with being abandoned, the extent of associated pain and that life is changed.
• Bargaining – Difficulty accepting that nothing can be done to change things. It can include making deals with a higher power or others.
• Depression – Realizing and feeling the true extent of the death or loss.
• Acceptance – Being ready to move forward after death or loss.

Effects of Grief on Mental Wellness
Grief can affect the mental and physical health of residents. Symptoms may present as emotional, physical, and/or behavioral:

• Emotional signs may include depression, anxiety, anger, and numbness.
• Physical effects may include sleep disturbance, weight gain, weight loss, tension and muscle aches.
• Behavioral signs may include periods of forgetfulness and withdrawal.

Considerations
Nursing facilities are very familiar with grief and loss. Careful consideration should be given to the distinction between normal sadness and grief versus a major depressive episode. When grief and major depressive symptoms co-exist, the grief is more severe, and the prognosis is worse compared to grief that is not accompanied by major depressive disorder (MDD). Grief and MDD have some similarities but are also very different in important ways. A trained clinician who can distinguish between grief and MDD must evaluate residents to provide the most appropriate treatment. Special emphasis should be placed on differentiating between major depression and normal grief. The Grief Impairment Scale can be used to measure grief, and the Patient Health Questionaire-9 to measure depression severity.

Bereavement-related major depressive episodes tend to occur in individuals with other vulnerabilities, such as those who have already experienced significant loss or have other mental disorders (DSM-5-TR).

To recognize National Grief Awareness Day in your facility, host a support group to allow time for reflection. Connect residents who are having difficulty coping with a loss to an online therapist or in-person support person trained in grief management. Nursing facilities that understand the unique needs of residents, especially those with behavioral health conditions, can better support residents during times of grief and loss.

References:
American Psychiatric Association Major Depressive Disorder and the “Bereavement Exclusion” https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM-5-Depression-Bereavement-Exclusion.pdf

Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR TM

The Centers for Medicare & Medicaid Services (CMS) released a video tutorial for completing D0150, Patient Mood Interview (PHQ-2 to 9) and D0160, Total Severity Score. This video depicts two scenarios that demonstrate the coding of the PHQ-2 to 9 for the purposes of completing D0150, Patient Mood Interview (PHQ-2 to 9) and D0160, Total Severity Score. Two patient vignettes are depicted, one in which the PHQ-2 is demonstrated and one in which the entire PHQ-2 to 9 is completed. Watch Video

The State Operations Manual, §483.21(b)(1), states that the facility must develop and implement a comprehensive person-centered care plan for each resident. This plan must be consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), and it should include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment. Additionally, §483.21(b)(3) requires that the services provided or arranged by the facility, as outlined by the comprehensive care plan, must be culturally competent and trauma-informed.

This regulation is intended to ensure each resident has a person-centered comprehensive care plan developed and implemented to meet their preferences and goals and address their medical, physical, mental, and psychosocial needs.

Deficient practice at F656 is cited when the facility fails to develop and implement a care plan that addresses the unique behavioral health needs of the resident. This includes measurable objectives, interventions, and timeframes for how staff will meet the resident’s needs. It also describes the care/services that will be furnished, including any specialized services as a result of the PASRR Level II.

What you can do TODAY to ensure necessary behavioral health care and services are provided to residents.

• Use the Tips to Manage Challenging Situations to help address the unique behavioral needs of residents with challenging behaviors.
• Meet with a COE-NF behavioral specialist to coordinate training for your staff on Person-Centered Care.
• Request no-cost assistance from the COE-NF to develop and implement a comprehensive person-centered care plan for residents with behavioral health needs.

In 2017, CMS leadership in Georgia (Region IV) implemented a project called Changing the Culture of Death and Dying in the Nursing Home Setting. The project aimed to develop the Best Practices in Bereavement Care Tool.

“Grief and loss are an emerging public health problem. We believe that nursing homes can teach us how to diminish the negative health effects associated with grief by hearing from persons who care for others.” Toni Miles, Professor Emeritus University of Georgia and Pope Eminent Scholar, Rosalynn Carter Institute for Caregivers

Why bereavement care?  
Grief often begins long before a death occurs, so bereavement care should not be limited to the time following death. Quality bereavement care promotes healing by addressing the emotional needs of all persons involved. Keep in mind that grief can be worse for individuals with a mental illness. 

Bereavement care is needed for all members of the community within a building, including residents and staff at all levels who provide care to them. However, each person experiences grief differently, and every practice does not work for everyone. For example, some residents may benefit from support groups, while others may prefer one-on-one conversations. Consider making bereavement care part of the overall care plan. 

Best practices for long-term care
Here are some ways to support residents through the process:

• Create support groups for residents and family members. 
• Schedule memorials to honor the lives of those who have passed away and to recognize those who have cared for them.
• Train staff to talk to residents, families and colleagues who may be emotional about the loss.  Avoid phrases like ‘I know how you feel’ or ‘He/she is in a better place now.’ Simply say, ‘I am sorry for your loss.’  Quietly being available to listen may be the best approach.
• Have a protocol for preparing the body for final viewing by family and friends. This creates a caring and respectful process for handling the deceased. 
• Develop a protocol for notifying other residents, staff, and family shortly after a death. This includes attending physicians and others who regularly cared for the resident. The protocol should assign specific tasks to workers in the building to ensure everyone knows. 
• Create a bereavement team to assist the primary staff caregiver when a resident dies.  
• Many residents have given thought to their end-of-life treatment preferences. Ask residents, "If you could plan a service honoring you, what would it look like?” 
• In any conversation, emphasize that dying is a natural process. 
• Include the direct care staff in care plan meetings. They need to understand End of Life preferences. Foreknowledge helps them understand that they have done the right thing. This reduces their stress. 

Reference: “Changing the Culture of Death and Dying in the Nursing Home Setting.”

Research Article: Keeping you up-to-date with the latest research, advancements, and best practices in managing and addressing behavioral health conditions in nursing facilities.

Researchers from the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Institutes of Health’s (NIH) National Institute on Drug Abuse (NIDA), the Centers for Medicare and Medicaid Services (CMS), and the Centers for Disease Control and Prevention (CDC) found that among a cohort of 137,000 Medicare beneficiaries who experienced a nonfatal overdose in 2020, almost 24,000 (17.4%) experienced a subsequent nonfatal overdose. About 1,300 (1%) died from overdose in the following year. Results were published recently in JAMA Internal Medicine, identifying both effective interventions and significant gaps in care. 

Have mental illness and substance use questions? We have the answers! Join us for office hours to talk with the experts.

Managing Substance Use Disorders in Nursing Facilities

Interested in receiving expert answers to substance use challenges you are facing in your nursing facility? Join Dr. Jen Azen and Dr. Swati Gaur, Subject Matter Experts, as they answer questions related to your complex cases. No question is too big or too small!   
  
Join our monthly office hours on the third Friday of each month from 1-1:30 p.m. ET to get answers directly from the experts working in nursing facilities!  
  
Audience: Appropriate for clinicians, nurses, administrators, and social workers. 

CARES® Serious Mental Illness™   
 
The COE-NF is making the CARES® Serious Mental Illness™ Online Training Program available to CMS-certified nursing facilities at no cost. CARES® Serious Mental Illness™ focuses on how to develop care strategies for individuals diagnosed with a Serious Mental Illness (SMI) and how an SMI differs from dementia.  
 
Interested in learning more about CARES® Serious Mental Illness™ before committing, or have general questions about the program?  
 
Join our ongoing monthly office hours meeting on the fourth Wednesday of each month from 2:30-3 p.m. ET for an open discussion on implementation, benefits, case studies, and successes. 
 
Audience: Appropriate for staff at all levels of care  

The COE-NF developed the following resource that nursing facilities can use to educate the team about behavioral health conditions.

Major Depressive Disorder Bite-Sized Learning: This video defines Major Depressive Disorder (MDD), shares the signs and symptoms of this disorder, reviews treatment options, and identifies ways to support residents diagnosed with MDD. Watch Video

Identifying and Supporting Residents with Major Depressive Disorder Module: This module provides effective tools to support residents with Major Depressive Disorder (MDD). You’ll discover how to recognize common signs and symptoms and warning signs, understand risk and protective factors, identify screening tools, and develop personalized care plans. Watch Video 

There are certain factors that increase the risk of prolonged grief, such as individuals with previous psychiatric disorders, previous suicidal threats or attempts, low self-esteem, low trust in others, and lower perceived social support. Learn More

• Describe at least two risk factors and protective factors for suicidal ideation in long-term care settings.
• Discuss best practices for screening and comprehensive assessment of suicidal ideation in long-term care settings.
• Develop an initial management plan for a long-term care resident who is experiencing suicidal ideation.

• Participants will be able to recognize the 15 action steps for providing CLAS standards.
• Participants will gain an awareness of practical ways to implement CLAS standards to enhance behavioral health equity.
• Participants will be able to identify resources to help improve CLAS implementation.

• Define trauma and trauma-informed care. 
• Learn what happens to the traumatized body and why trauma behavior is misunderstood.
• Discover the basic concepts of trauma-informed care.

This session provides a MHFA certification for three years.

The training covers: 

• Common signs and symptoms of mental health and substance use challenges.  
• How to interact with a person in crisis. 
• How to connect a person with help.  
• Expanded content on trauma, substance use and self-care.

The training is divided into three parts:

Part 1 starts AFTER initial registration has been APPROVED by the instructor. Approved registrants will be emailed instructions on how to create an online profile using MHFA Connect and complete a pre-survey/quiz followed by a two-hour self-paced online course. Registrants MUST complete Part 1 no less than 48 hours (two business days) prior to the scheduled Part 2 session.

Part 2 is a 5.5-hour live instructor-led virtual training. Participants are required to be on camera the entire time.

Part 3 participants will return to MHFA Connect to complete the post-test and evaluation, which is required to receive a certificate of participation. 

To register for the Mental Health First Aid training, please send your name, email address, agency and training date to coeinfo@allianthealth.org by Friday, August 16, 2024.

• Describe specific challenges that exist when transitioning a person with SMI from an acute care setting to the nursing home and from the nursing home to an acute care setting or the community.
• Review effective discharge management processes for patients with SMI, ensuring smooth transitions and continuity of care.
• Identify the psychological and psychiatric supports that are needed before, during and after transitions and determine when a referral to a psychiatric facility is needed. 
• Implement tools to ensure optimal communication between the behavioral health provider, medical provider, nursing, administrator, social worker, and other members of the interprofessional team.

Ideal for medical directors, primary care physicians, physician assistants, nurse practitioners, nurses, social workers, pharmacists, certified nursing home administrators working in long-term care facilities.

Working in a nursing facility can be incredibly rewarding, but it can also be physically and emotionally demanding. It is important to recognize the importance of self-care as a component of your overall well-being. 

Take a moment to relax by viewing this two-minute video, Self-Care for Health Care Providers, created by Alliant Health Solutions’ Quality Improvement and Innovation Organization (QIN-QIO).

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