In the home health arena, we occasionally receive referrals for patients who have been hospitalized due to behavioral outbursts related to the dementia process. Often the client returns home with a prescription for needed medications to address an underlying anxiety or depression. However, if the client returns home to face the same frustrations that were present prior to the hospitalization, behavioral issues may continue. Ideally, medication management should be coupled with caregiver education. The families have the desire and commitment to keep their loved one at home, but they lack the skills required to provide the necessary interventions and environmental changes needed to prevent the behavioral outbursts.
In many cases, the caregivers, with the best of attentions, have taken over all of the steps of routine or valued tasks for the client. When the caregivers provide total care, they unwittingly remove the client's sense of independence or accomplishment. We call this excess disability. The caregivers have imposed excess disability on their loved one. Invariably this lack of a sense of productivity or accomplishment results in behavioral outbursts or symptoms of depression. The person may not be able to verbalize his/her frustration, so the client expresses this frustration behaviorally.
(Music please). This is the perfect scenario for a team of home care professionals, educated in care for the person with dementia, to make a difference in the lives of the person with dementia and his/her loved ones. Remember, it is Medicare reimbursable for occupational therapists to treat behavior problems, if these problems result in a decline in function and/or safety.
As always, to receive reimbursement, the documentation must reflect the status of the person's performance in the home prior to the home health intervention and the improved status upon the discharge. This must begin with an accurate scoring of the initial OASIS.
Remember (source: OASIS in Detail A Clinician's Pocket Guide, published by Briggs Corporation, 10/03)
- All (OASIS) items refer to the patient's usual status or condition at the time period or visit under consideration.
- The response should be selected that describes the patient's status most of the time during the specific day under consideration.
- In many instances a combined observation-interview approach is necessary. For example, by speaking with the patient or informal caregiver while conducting the assessment, the provider can determine whether the observed ability to ambulate is typical or atypical at that time.
We know, as dementia capable care providers that we might be able to facilitate a higher ability to perform an ADL task just by providing the appropriate approach or modifying the environment, on the initial visit. However, this is not the usual status of the patient. Often, the patient is displaying resistance to functional tasks with the consistent caregiver. To accurately assess the client in these areas, the professional should observe the caregiver assisting the client in a typical manner. Or, the assessment may be completed by interviewing the caregiver.
There is a five-day window from initial evaluation, or start of care, until these OASIS scores are "locked." During that time it is essential that all disciplines have input into the scores. After completing the initial therapy assessment, the therapist should review the scores with the initial assessor or home care coordinator to insure agreement and accuracy. The scores should reflect the excess disability present; the goals should reflect the prediction that removal of the excess disability will result in a decrease of behavioral outbursts and improvement in the client's ability to assist with basic and/or valued tasks.
Treatment should consist of further discovery of the client's abilities and valued activities, environmental adaptations as needed, and the training of the caregivers in the amount and type of cues the client requires completing tasks or engaging in activity.
For example, I worked with a client who attended day care five days a week. He was cooperative in the day care environment, but had become more and more combative with his wife in the home and was very resistant to bathing and dressing, attempting to strike out at his wife. Upon initial evaluation, I found he was performing at Allen Cognitive Level High 3. At the time of evaluation, the wife told me that she provided total care for all ADLs and that he demanded her consistent attention throughout the evening and weekends. The caregiver expressed significant frustration and exhaustion; however, she stated that she did not want to place her husband in a facility.
On the OASIS items for dressing and bathing he scored a 3, indicating total dependence. However, his Allen Cognitive Level score indicated the cognitive ability to perform these tasks with setup and consistent cueing for accuracy and quality.
His wife was grateful to learn that he could assist with basic tasks, and began using the cueing needed to help the client to help himself.
During the treatment sessions, I also discovered that he had enjoyed working with puzzles as a leisure activity. I brought a small box of Legos (the box stated it was for ages 9 to 99). He initially sat with those Legos for 45 minutes, sorting the objects by color and putting a few pieces together. His wife found she could use this activity with him every evening; he would feel productive and it gave her time to do things she needed to complete.
Upon discharge, the scores for bathing and dressing improved from a score of 3 to a score of 2; the score for frequency of behavior problems changed from 5 (at least daily) to 3 (several times each month). In addition, the caregiver expressed feeling less frustrated and more able to enjoy her time with her husband.
With these clients, the services of a social worker are essential to help discover any other community resources and support groups that may be available for the client and caregivers.
There appears to be a significant need for dementia capable care health care professionals to assist the caregivers in their desire to keep their loved one in the home as long as possible. Managing behavioral issues is reimbursable in home care. More importantly, home care intervention can reduce the caregiver burden and improve the quality of life of the person with dementia and his/her caregiver.