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TOPIC THE ULTIMATE NURSING HOME CHALLENGE: Dual and Triple Diagnosed Persons in Long Term Care
PREFACE The establishment of a nursing home for persons with AIDS/HIV and substance abuse histories, as well as mental illness, which are considered dual and triple diagnose conditions, presents a challenge to those who administer the program, and also for those who care for these residents, on a daily basis. HCFA (CMS) regulations were written primarily to protect the elderly and the extremely vulnerable. A resident population of young, independent substance abusers in an inner city, many of whom have recently been released from prison because of their HIV status, or who have spent long terms in psychiatric facilities, sets up a dynamic within the nursing home that can appear to be an impossible situation.
HISTORY Casa Promesa is a 108 bed, JCAHO accredited, long-term care facility for persons with AIDS in the Bronx, New York City. It was established in 1995 as part of Promesa, Inc., a community-based organization whose original mission was to serve the needs of the underserved Latino population of the inner city by establishing education programs, housing, employment opportunities and drug treatment programs. With the spread of HIV to the drug addicted community, Promesa, Inc., saw a need to serve the under-served of the Bronx through a skilled nursing facility to provide the medical, nursing, social service and educational needs of this group. From its inception, there was awareness on the part of the administrative and clinical staff that this was not ever going to be a “typical” nursing home. The resident population was young (25-45 yrs.). They were mostly male, substance abusers, who had been involved with the penal system because of drug use or the sale of narcotics. Many of the residents also had a psychiatric diagnosis, or had been admitted to a psychiatric unit because of suicidal attempts or accidental overdose. But the biggest challenge seemed to be the commitment of caring for a population of people who were accustomed to covering their feelings with drugs, and who would act out in many different ways in order to obtain the drugs they “needed” to maintain that coping mechanism. These residents now found themselves in a facility in order to be treated for, what would most likely be, a terminal disease. and they were expected to remain drug free while in treatment. Many of the residents had been ill for quite a while, but had never been treated. Many were too fearful to be tested for HIV, and had only recently been diagnosed. On admission to Case Promesa, many of the residents were emaciated, weak and near death. Aggressive treatment by the medical team brought strength and relative health; but this new found strength also brought with it a desire on the residents’ part to return to earlier patterns of behavior.
STAFFING CHALLENGES The clinical staff at Casa Promesa came from two distinct groups. Members of the nursing staff were primarily young women whose only work experience was employment in traditional nursing homes. The counseling staff came primarily from the Therapeutic Community tradition with a strong emphasis on abstinence from drugs and behavioral techniques used to accomplish a “drug-free” life. Many of the counselors were themselves graduates of the Therapeutic Community system. Each of these groups of professionals – nurses and counselors – brought specific gifts and skills to the job, but neither group had experience working with HIV/AIDS or with persons who were dual or triple diagnosed. The nursing staff tended to see the resident from a clinical perspective: What is the disease entity? What needs to be done to cure it? On the other hand, the counselors saw the resident as a drug addict who needed to abstain from their addiction; but this person was not at Casa Promesa for treatment specifically geared to addiction. The resident was here for treatment of HIV/AIDS. Addiction would be addressed, but not as a primary diagnostic category. This dynamic was also complicated by the fact that many of the workers were from the same neighborhood and life experience as the residents. Some of the workers had been friends with the residents in the community. They spoke the same language, had gone to school together, and in some cases, had even been in familial relationships. Many of the staff had experienced substance abuse in their families and had lost relatives to HIV/AIDS. Needless to say, this created an environment “ripe” with the possibilities for counter-transference between staff and residents. This was not the kind of nursing home situation for which HCFA (CMS) regulations were written. THE PLAN During the first year of operation, it became clear that administration would have to develop a plan to deal with the numerous behavioral problems that arose. There were verbal and physical fights among the residents. There was drug use, drug sales and elopement in order to attain drugs. There was the risk of injury to residents and staff and an increase in administrative discharges. There was also frustration on the part of the staff pertaining to drug use by the residents and fear of accidental overdose or physical assault. The initial attempt at a resolution on the part of administration was to hire a Mental Health Registered Nurse with experience working with this population. The main focus of this position was to train the staff to work effectively with the residents and raise their level of awareness about mental illness and dual diagnosis. This approach was helpful, but more needed to be done in the form of a multi-faceted approach. Within a year, Promesa, Inc., the parent company, hired a psychiatrist as Vice President of Clinical Affairs for the entire organization. Shortly thereafter, he called together a team of clinicians and administrators to examine the problem, and develop a plan to better assess residents on admission in order to anticipate problems, rather than dealing with crisis after the occurrence.
MEETING THE CHALLENGE This team, made up the Nursing Home Administrator, Directors of Medicine, Nursing, Social Services, Pastoral Care, the Mental Health Nurse and the V.P. of Clinical Affairs, examined the Occurrence Reports to determine the type of behavior problems and the most common times of day in which incidents tended to happen. After much discussion and analysis the team developed a three-pronged approach to resolving the problem:
RESULTS The outcome of this approach, over the course of a year, resulted in a major improvement in staff competency. There was a diminution in occurrences and administrative discharges. Early signs of disruptive behavior were identified and care planned. Counter-transference issues decreased dramatically as staff members became aware of their own feelings when dealing with the residents. The identification of high-risk clients at the time of admission provided an opportunity to plan for their behavioral treatment before occurrences took place. The Mental Health Team became an integral part of the day-to-day clinical setting.
CONCLUSION It has been proven over the course of the past two years that staff education; assessment for potential of behavioral issues and on-going support and planning for both staff and residents is an effective method of dealing with difficult clients, in a long-term care facility; but Casa Promesa is a unique environment within the nursing home system. Since all of the residents are dual or triple diagnosed, the administration and the staffing must meet these specific needs. This is extremely time consuming and an expensive proposition, and one that not all nursing homes may be able to embrace; however, in nursing homes where there is a mixture of residents and less potential for violent or acting out behavior, some of the techniques that have been developed here, might easily be accomplished without undue expense. The employment of a Registered Nurse with experience in Mental Health or Psychiatry might effectively assess residents based on past or recent history of behavior. The Behavior Monitoring Tool can be modified to incorporate treatment modalities that are already in place. Staff education, which is required in all nursing home settings, can include issues such as methods for dealing with difficult residents, behavior modification tools and the importance of self-care and self-awareness. There is a great deal of information readily available on each of these subjects. As the Nursing Home population becomes more diverse with mixed ages and treatment needs, and as stays become longer, we believe, it will be of a paramount importance to be more creative and clinically astute in dealing with an ever-changing population of persons needing both medical and psychological care.
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