Nursing Homes

 

Please be advised that use the term “LTCF” in place of “Skilled Nursing Facility”. 

I believe we should expand the criteria for nursing home level of care (long-term care facilities – “LTCFs”) to those with mental illness, who are too symptomatic to live in a community group home and/or supportive housing living arrangement, regardless of whether or not they have medical problems and/or self-care deficits.  Oftentimes, people with severe mental illnesses are housed in State Hospitals or keep returning to Emergency Rooms or correctional facilities through the revolving doors, seeking treatment of a longer duration than is available in regular short term psychiatric facilities.

With many States privatizing their State Hospitals, it is safe to predict that at least some of these individuals will be left to fend for themselves in a dangerous world. Many hospitals will discharge individuals to a homeless shelter. This is not ideal whatsoever. Homelessness is a big problem for those with mental illness and having a continuum of housing options, including more restrictive options, such as LTCFs, would be a better solution. 

In LTCFs, there is the infrastructure to have various rehab programs, run by a full treatment team, including nurses, direct care staff, medical security officers, psychiatrists, psychologists, behavior analysts, medical doctors, family specialists, social workers, counselors, dieticians, and peer support specialists. In other settings, these programs and the full treatment team may not be readily available.

Letting people go around hurting themselves and/or others without professional intervention in a safe setting is a violation of everyone’s right to a safe environment. In LTCFs, there is more external control for those with a high suicide and/or violence risk and who lack internal impulse control. In a group home or supported housing, you can just walk out and hurt someone. In an LTCF, the doors are usually locked, and you need supervision to leave. Also, LTCFs may have the full repertoire of restraints and seclusion, including physical holds, seclusion, mechanical restraints, and chemical restraints. Having a setting with a full repertoire of restraints and seclusion is ideal for those who continue to need these interventions for dangerous behavior. Calling 911 or 988 will not suffice as individuals may be arrested or brought to the Emergency Room, which results in very expensive jail and hospital admissions. We need a “safety net” treatment setting for those who cannot live in a community setting; yet, do not need a hospital (such as those with chronic mental illness, rather than a single acute episode).

LTCFs may become an option for those on Forensic Status (i.e., with criminal charges), when the individual is found Not Guilty by Reason of Insanity or Incompetent to Stand Trial. In this case, we need special highly secure forensic LTCF units, with video surveillance monitoring, security control centers, secure rooms/cells, electronically controlled doors, more security officers on staff, etc. These are mental health-equipped units, possibly funded and staffed by the local sheriff’s office, similar to the Bergen Regional Medical Center Forensic Unit in Paramus New Jersey.

They would need to reconfigure units in current facilities into specialized units (without building new buildings) in LTCFs for those with mental illness with admissions to these units stipulated by the results of an individual’s Pre Admission Screening and Resident Review (PASRR). We need to add a category to the PASRR for special services within a nursing facility, not just the option of psychiatric hospitals or community services. This should allow more robust individuals with or without medical problems and/or self-care deficits to be admitted to an LTCF when they need custodial care beyond what a group home can provide.

As suggested, some people will always require custodial care in a congregate care setting. LTCFs will help fill this gap in care for those with the most severe, disabling, and debilitating mental health conditions. Medicaid should fund LTCFs, through LTSS monies, to care for those with mental illness, so they can be discharged from hospitals to a safe setting, that has the resources to treat their mental illness, rather than homeless shelters.

Also, the State should modify its civil commitment laws to allow individuals to be committed to LTCFs, such that individuals cannot leave when they are not capable of self-preserving in the community independently without supervision.

As for me and many others, people linger in hospitals for extended periods waiting for an appropriate placement that never comes. Our system just doesn’t have the infrastructure to maintain people with mental illness in LTCFs. There needs to be an in-between step between hospitals, group homes, and supported housing. Doctors like to play it safe and avoid discharging these individuals because there is just nowhere better for them to go. An LTCF would have been an excellent alternative for people like me. Group homes and supported housing do not cut it for many people with the most severe mental illness.

We have almost 90 pages of LTCFs in New Jersey. Why can’t some of them pitch in to help those with developmental disabilities and mental illness?

The New Jersey Comprehensive Assessment Tool (NJ CAT) Needs Improvements

Why the NJ Division of Developmental Disabilities Comprehensive Assessment Tool (NJ CAT) Needs Improvements: 

First, the NJ CAT (“New Jersey Comprehensive Assessment Tool”)is a mandatory needs assessment to determine what and how much funding will be allocated for services and supports related to developmental disability. After completing the NJ CAT, a tier level is assigned. Tiers include A, B, C, D, and E. Acuity factored tiers include Aa, Ba, Ca, Da, and Ea. Acuity means there are significant clinical needs for either medical or behavioral issues. The A tiers are the highest functioning individuals and receive the least funding. The E tiers are the lowest functioning individuals and receive the most funding. The tiers translate into a budget for the service recipient to purchase services and supports and a reimbursement rate for providers to get paid for helping the individual. 

The NJ CAT does not accurately portray the service recipient's needs. First, many of the questions are black or white, all or nothing, or yes or no. While this multiple-choice format allows for easy scoring, sometimes there is a “yes, but...” answer. There needs to be space for a brief explanation of the individual's needs if needed.

Also, the assessment does not address the individual’s strengths. We need to address the individual’s strengths, not just weaknesses and deficits. 

There needs to be more transparency for the individuals, families, and providers about the NJ CAT scoring method. This will help aid in the answering of questions if the respondents know the weight of each question when the final score is given. 

The NJ CAT needs to be changed to better service those with developmental disabilities, by taking an accurate look at individuals’ needs and strengths.  

Neurobehavioral Programming

Just posting this information about what a neurobehavioral milieu looks like in practice. This contains info from my experience at the Meridell Achievement Center (several years ago) and info from the Internet. Meridell offers two types of programming: traditional behavioral and neurobehavioral. This describes the qualities of a neurobehavioral program for higher-functioning individuals without an intellectual disability (Full-Scale IQ over 70). 

• Assessments should be conducted at admission to determine appropriate strategies and goals, including medication selections. 

• The assessment process should start with a neurophysiological examination, involving a Quantitative EEG with Evoked Potential (QEEG) or Cognitrace Study, reviewed by a Neurologist in consultation with a Neuropsychiatrist / Neuropsychopharmacologist, to determine the presence of a neurological-based psychiatric disorder. The Cognitrace Study, or Complex EEG with Auditory and Visual Evoked Potentials, is a non-invasive (no needles), brain imaging examination interpreted by a Neurologist trained in neurobehavioral disorders especially those related to aggression. 

• Positive findings will allow for precise medication selection which can offer more immediate relief of impulsive, explosive aggression. 

• Testing typically takes about one hour. 

• A Neuropsychiatrist will recommend medications to treat the affected brain areas and stabilize behavior based on the Neurologist’s report. 

• When the individual is stabilized on medication, there should be neuropsychological testing, including tests for IQ, Memory, Executive Functioning, Language, Motor, Achievement, Psychological Testing, and Diagnostic Interview. 

• There should be projective psychological testing to determine symptoms of psychiatric illness and type of personality. 

• There should be Neuropsychiatrists, Clinicians (LCSW, LPC, etc.), Program Staff, Discharge Planners, Neuropsychologists and Neurologists, on the treatment team. 

• There should be suites for QEEG testing and neurophysiological evaluation in the medical areas for higher-functioning individuals. 

• Intensive programming is provided each day, including psychoeducational groups, skills groups, processing groups, recreational therapy groups, and additional recreational, therapeutic activities. 

• Therapy interventions are evidenced-based and informed by models including Cognitive Behavioral Therapy, Systemic Family Therapy, Collaborative Problem Solving, Dialectical Behavioral Therapy, EMDR, and other trauma and relational models. Individual and family therapy is offered every week.

• Therapy includes individual therapy, goals groups, feelings groups, reflection groups, issues groups, psychoeducational Social Thinking and Zones of Regulation groups, recreation therapy, etc.

• There is a drastic difference between a traditional behavioral and neurobehavioral milieu for this population, as described below:

  Neurobehavioral	Behavioral
  Redirecting (without confrontation) Behavioral Contracts (motivate) Modeled behavior by staff Positive Reinforcement Watch for lack of capability Watch for impulsive action The patient receives guided direction The patient was given responsibility/small steps More individual instruction A soothing, less stimulating environment Slower pace Structured transitions (with prompts)	Confronting (empathetic guidance) Interpreting (uncovering insights) Positive peer culture Logical and natural consequences Watch for manipulation (staff splitting) Watch for planned action Patient becomes self-directed Patient takes responsibility Group and individual instruction Lively & cheerful (posters, music, noise) Normal pace Frequent/fluid transitions
  Therapies	Therapies
  Small groups (non-verbal activities) Short sessions (to match short attention span) Experiential (learn by doing) Behavioral	Large groups (with verbal processing) Long sessions (to match normal attention) Solution-focused Cognitive Behavioral

• Sophisticated neuropharmacological treatments geared stabilizing brain function and providing adequate control of explosive aggression and impulsivity, to remove or overcome the neurological barriers to successful treatment of these psychiatric disorders. Medication is targeted at specific areas of the brain.

• While chemical restraints may be used for safety, the goal should be to treat the underlying brain disorder. 

• The treatment environment is also modified to take into account the fact that individuals with neurodevelopmental disorders are easily overstimulated. 

• The milieu is quieter and slower-paced, with many rest periods built into the schedule. 

• Limit setting is accomplished without confrontations that can lead to rage behavior. 

• It is a nurturing, rather than an authoritarian milieu, with an emphasis on redirection.

• There should be positive praise when control is achieved. 

• There should be a concerted effort to avoid a punitive program, and all negative behavioral consequences (not necessarily safety precautions) should be kept brief (15 minutes to 24 hours at a maximum). 

• Social skills training and anger management should be an integral part of all nursing plans. 

• There should be a focus on avoiding power struggles, by encouraging negotiation to obtain needs and decreasing negative attention, by “picking battles”. 

• Staff use a positive approach, by telling service recipients what to do, rather than what not to do. 

• Staff should help service recipients gain insight into their coping skills and work to increase trigger awareness.

• The Safe Behavior System is used, where the emphasis is on safe behavior and then more advanced treatment goals. 

• When someone is unsafe the only goal is to get safe. The 2/4 rule is used. 2 hours away from peers to de-escalate and 4 hours restricted to the unit.

• Once safe, the goal is to be “on plan” or meeting goals. Once “on plan” the goal is to stay “on plan”. 

• A variety of teaching and behavioral shaping methods are used, including

• Redirection- staff tells the service recipient what to do, not what to stop doing

• Modeling and Demonstration

• Mentoring- a certain staff provides individualized support for one service recipient.

• Co-regulation- staff shows caring and affection, predicts needs and wants, and provides caring support during times of stress or crisis

• The 2/4 rule

• Activity by Activity- The service recipient will be held back from the next activity if disruptive or unsafe during the previous activity

• Time-outs

• Direct teaching

• Role-playing

• Redos or Do-overs

• Restorative actions or repairs

• Collaborative Problem Solving- engages staff and service recipients in a discussion to find more effective responses to impulsive misbehaviors

• Staff uses an 80/20 rule which means 80% of the time they are providing praise and positive reinforcement and only 20% of the time, mild and brief consequences

• Service recipients accumulate points to turn in at a points store for small tangible items and/or weekly points that can be cashed in for “big ticket” special privileges and rewards. 

• Service recipients do not lose points; they only earn points

• Service recipients do not need to earn treatment or daily activities, such as meals off the unit and passes with family.

• Well-defined logical consequences leveled at the severity of the problem behavior may be used in moderation. 

• Each unit has two dayrooms. Service recipients are assigned to a dayroom based on their developmental age, level of functioning, and diagnosis. 

• Sometimes there is not a good fit, and a dayroom reassignment may be considered and/or undertaken.

• Developmentally younger service recipients who have more severe skills deficits are assigned to a dayroom with program and group content suited to their needs. 

• There is a highly structured daily schedule.

•  To effectively help these service recipients navigate transitions between activities, staff gives 15, 10, and 5-minute warnings before the change of activity. 

• The physical environment is modified to take into account safety concerns, have lots of space, address sensory concerns (e.g. noise),  and reduce traumatic associations. 

• There is a staff-to-service recipient ratio of 1:5.

All programming is modified to take into account the patient’s neuropsychological limitations as identified on initial assessments

The Truth About Adult Psychiatric Units

 The Truth About Adult Psychiatric Units

Just posting this information for those who have never been to an adult psych unit, but were in a child/adolescent unit and who were threatened with and wondering about the adult system. 

The following points are major differences between a child/adolescent unit and an adult unit: 

1. Adult psychiatric units do not do “points and levels”. Behavior modification is typically accomplished through transfers to worse and worse facilities and increases in psychotropic medication to make you quiet. 

2. You can only remain in the hospital for as long as you are dangerous to yourself or others. They legally cannot hold you in the hospital against your will if you are not going to physically harm someone or yourself. Usually civil commitment orders last for 3 months. 

 

3. Sometimes people get arrested and then referred for psychiatric treatment and evaluation by the court. This is called “forensic commitment”. This includes Incompetent to Stand Trial and Not Guilty by Reason of Insanity, which are much longer term than civil commitment. 

4. If you are actively hurting yourself or others, nurses reserve the right to restrain you. This may be a restraint chair (like the ones you see on jail shows on TV) or bed restraints. Hospitals are moving away from physical hold restraints and more toward chemical restraints. 

5. If you are a safety risk in the hospital to yourself and/or others, the treatment team may put you on a 1:1 status. This means there is always a staff member within arm's length distance from you.  When 1:1 is ineffective in keeping you and others safe, they may increase it to 2:1 or even 3:1 staffing where 2 or 3 staff members are assigned to watch you. 

6. They assign roommates randomly rather than based on a good fit. This means, you may get a roommate you dislike and there may or may not be anything you can do about it. 

7. Group therapy is optional in adult units. However, it would look good if you could attend. Aftercare placements, especially group homes, seek people interested in improving their lives and symptoms.  

8. If you do not take medication, they will give you forced injections until you take it orally. 

9. You may be transferred to a state hospital if you need long-term care for a psychiatric illness. Difficult-to-manage units and forensic facilities are for the worst of the worst service recipients. 

10. Social workers generally do not need to warn you of a transfer to a state hospital or other facility; an ambulance may just show up and take you away in less than an instant. 

Clinicians and staff need to stop threatening adolescents with an adult unit. All that happens because of this is that people become scared and don’t ask for help. In my experience, I was so afraid of an adult unit that I resisted going and had to be restrained. I probably would’ve been far less fearful and more cooperative if I hadn't been threatened with the adult unit as an adolescent. 

Return Home NJ and its Failure

Return Home NJ was an initiative launched in 2012 by the NJ Division of Developmental Disabilities NJ DDD designed to return all residents of New Jersey who are receiving DDD services and living in out-of-state specialized residential facilities to group homes and supervised apartments in New Jersey. 

While this was good for some, it proved disastrous for others. For instance, one young man with severe disabilities was returned from Woods Services in Pennsylvania to a New Jersey group home. Unfortunately, a group home setting was not appropriate for him. Subsequently, he was sent to multiple  hospitals and jail because he could not tolerate the homelike  setting. He needed more structure than a group home offered and he received that much-needed structure in jail. He was arrested after the police became fed up with bringing him back and forth to the hospital each day sometimes more than once per day. Financial resources shifted from Woods to the jail and police systems. 

Also, some individuals ended up in the State Psychiatric Hospital system, which is not ideal for those with severe disabilities.  

New Jersey has minimal facility-based programs, including the 5 Developmental Centers, one ICF in Bergen County, and the Bancroft campuses. We have nowhere like Woods Services.

DDD thought that Return Home NJ would make it easier for families to visit together in New Jersey. It is not easier to visit in a hospital or jailhouse. Many families prefer to visit in an out-of-state setting than to return to NJ and face all sorts of problems. 

Deinstitutionalization may be ideal for some higher-functioning individuals but for those with more complex behavioral and medical needs, it can be a disaster. Many out-of-state facilities are less institutional than a State Hospital or jail. A lot of specialized facilities look like gated communities, college campuses, and other “normal” settings. It may be less institutional to stay out of state rather than return to New Jersey. 

Fortunately, Governor Chris Christie put an indefinite moratorium on Return Home NJ, and many people were allowed to leave New Jersey and return to their specialized facilities. However new individuals are not allowed to leave New Jersey on New Jersey funds, which can be problematic if New Jersey does not develop more facility-based programs and ICFs, especially for those with severe behavioral and mental health concerns. NJ Division of Developmental Disabilities does not under any circumstances send people to out-of-state residential programs and NJ Children's System of Care only occasionally sends people out of state when all options inside New Jersey have been exhausted. This is not ideal for those for whom group homes do not work. All New Jersey has is group homes, group homes, and more group homes... 

We need more facility-based programs in New Jersey including campuses (also known as Intentional Communities) and dormitory-style locked units for those with special behavioral and mental health needs with a developmental disability and we need to allow out-of-state placements in specialized residential facilities for those with dual diagnosis.