Alicia Ault

March 29, 2016

WASHINGTON ― A 3-year-old program in the state of New Jersey has reduced emergency department (ED) visits and hospitalizations for long-term care residents who display problematic behavior.

The Statewide Clinical Outreach Program for the Elderly (S-COPE) was launched because "a disproportionate number of older adults from long-term-care nursing facilities were presenting to psychiatric emergency rooms and being hospitalized," Lucille Esralew, PhD, the clinical administrator for the program, told Medscape Medical News.

"The point of this was to reduce the unnecessary use of acute care, because it's a limited resource," she said.

The program tracks ED visits and hospitalizations and reports those numbers to the state, but, to date, it has no published data, said Dr Esralew. Although she could not cite numbers offhand, she noted that "there's been a significant reduction in people with neurocognitive disorder presenting to the state hospital because of our interventions."

An overview of the program was presented here at the American Association or Geriatric Psychiatry (AAGP) 2016 Annual Meeting.

Around-the-clock Response

Initially, the first contact S-COPE has with a nursing facility is when it is considering sending a patient who is aggressive, violent, acting out, or seemingly psychotic to the ED.

Psychiatric screening centers at hospitals or in the community, psychiatric inpatient units, and long-term care facilities are able to call S-COPE for an emergency consultation 24 hours a day, 7 days a week.

An on-site visit by one of the program's geriatric advanced nurse practitioners, geropsychologists, or master's-level clinicians to assess the case is initiated. The program members consult 9 hours a week with geriatric psychiatrist Martin Forsberg, MD, of the Rowan University School of Medicine's New Jersey Institute for Successful Aging.

Patients are assessed to determine the underlying cause of a behavioral disturbance — whether it is a cognitive impairment, delirium, or a mood disorder ― using a variety of scales.

Many staff members, and even administrators, at long-term care facilities may not realize that dementia can create both behavioral and psychological symptoms, said Dr Esralew.

"It's a range of reactions that very often presents as a psychiatric presentation, and to a naive observer at the nursing home level, they're going to think it's psychiatric," she said. People with neurocognitive disorders may have psychosis, including hallucinations and delusions.

"It is sometimes difficult for the staff at the long-term-care level to understand that doesn't mean that medication or a hospitalization is the best way to address these problems," said Dr Esralew.

Even so, most of the time, that is what nursing homes want, she said.

No Quick Fix

Dr Forsberg said that S-COPE tries to set realistic expectations about what medications can, and cannot, do and educates staff to the fact that many medications can be harmful, and in some instances, toxic.

"Just because we can prescribe doesn’t mean we should," he said. "Also, it's not that we have a really effective treatment in our pocket that we're just delaying ― which I think sometimes needs to be said."

The belief persists that a medication or hospitalization will solve the problem, but "there is no quick fix," he said. When medication and admission are removed as options, "the facility tends to take on much more ownership of the situation," he said.

Although the program is billed primarily as a crisis intervention service, S-COPE's ultimate goal is to keep situations from escalating, said Dr Esralew.

Through experience, S-COPE has found that "sometimes the emergency is not the one of the older adult ― it's the emergency of staff" that's facing a shortage or that does not know how to handle the resident, said Dr Esralew.

So the program focuses on training and on-site coaching of nursing home staff — from certified nursing assistants to housekeeping to security to administrators.

S-COPE conducts more than 100 on-site training sessions a year, Dr Esralew said. It also sponsors nine free regional training programs each year on cognitive, behavioral, and mental health problems in older nursing home residents. S-COPE also offers short-term counseling to residents and consultations with families.

Much of the staff training focuses on how neurocognitive disorders can affect behavior, Dr Esralew said.

"We're trying to help people understand that brain changes are what is causing this heightened impulsivity, reactivity, behavior disturbance."

The patient might not be able to identify what is going on, or be able to communicate what is happening, or have the coping skills to handle the stressors of their environment, she said.

Crisis Prevention

Sensory issues, such as the noise level in a busy nursing home, may overtax them, for instance. Patients might experience frequent nighttime awakening or go into others' rooms and rummage around in their belongings.

These behaviors can quickly get out of control without a nonpharmacologic strategy, said Dr Esralew.

S-COPE teams help staff build those strategies, by, for example, training them to identify and remove triggers. That could mean creating a quiet room for residents, said Deborah Klaszky, a psychiatric nurse practitioner from the New Jersey Institute for Successful Aging who has been involved in S-COPE training.

It might require establishing a regular schedule of toileting so the patient is not acting out because of discomfort or anxiety, she said. Other interventions that can help with behavioral problems include music therapy, pet therapy, exercise, and frequent naps, said Klaszky.

Dr Esralew said it may take multiple attempts to determine what works, but when something is found to be effective, it should be shared. Klaszky agreed and said effective strategies should be documented in a care plan that is accessible to all staff, which is especially crucial when there is high staff turnover.

The goal of training is to reduce the frequency and intensity of behavioral problems, said Dr Esralew.

"We may not be able to eliminate distressing behavior, but we could make it more manageable and less likely to lead to crisis presentation," she said.

S-COPE is funded by the New Jersey Department of Human Services’ Division of Mental Health and Addiction Services. Dr Esralew, Dr Forsberg, and Deborah Klaszky have disclosed no relevant financial relationships.

American Association for Geriatric Psychiatry (AAGP) 2016 Annual Meeting: Session 309, presented March 19, 2016.

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