Home Health Skilled Nursing Care: Teaching and Training for Dementia Patients with Behavioral Disturbances - Medical Policy Article

Indications and Limitations This medical policy article addresses a specific category of skilled nursing care currently available to Medicare home health beneficiaries who have dementia with behavioral disturbances. The category of skilled nursing care is called “teaching and training activities.” Teaching and training activities are defined in the CMS Manual System (see citation under CMS National Coverage Policy listed under the Other Comments section of this article) and in the case of the beneficiary population with dementia and behavioral disturbances, could be part of a unique beneficiary-centered care plan directed at teaching the family or caregiver how to manage the behavioral disturbances. Behavioral disturbances often complicate the medical management of beneficiaries with dementia, including Alzheimer’s disease. At baseline many individuals with dementia manifest activity limitations in such domains as communication and self-care. The occurrence of behavioral disturbances, if not addressed in a comprehensive and systematic manner, may further compromise the activity limitations present at baseline - resulting in sub-optimal clinical outcomes. Each behavioral disturbance should be fully characterized and answers to the following questions should be documented in the patient’s medical records: What is the specific behavioral disturbance being addressed? What is the frequency of the behavior? Are there specific situations or activities that “trigger” the behavior? When does it occur? Where does it occur? Who is involved? Are there other possible explanations for the behavior (e.g., pain, infection, change in medication, disruption in schedule, swallowing difficulties, catastrophic reaction induced by environment or personal interaction)? What are the consequences of the behavior? What interventions have been successful in addressing this behavior in the past? What other techniques or interventions can be used to address the behavior? Teaching and training interventions should be based on the answers to the above questions, the specific impairment(s) and activity limitation(s) identified for each beneficiary, and the ability of the family or caregiver to learn and implement the proposed interventions. Environmental factors impacting the identified behavior(s) and the resultant care plan must also be considered. Use of the World Health Organization’s International Classification of Functioning Disability and Health (ICF) would facilitate the identification and documentation of specific impairments, activity limitations, and environmental factors. In the home health setting, skilled education services are no longer needed if it becomes apparent, after a reasonable period of time, that the patient, family, or caregiver could not or would not be trained. Further teaching and training would cease to be reasonable and necessary in this case, and would cease to be considered a skilled service. Notwithstanding that the teaching or training was unsuccessful, the services for teaching and training would be considered to be reasonable and necessary prior to the point that it became apparent that the teaching or training was unsuccessful, as long as such services were appropriate to the patient's illness, functional loss, or injury. Sample Case Scenarios: Scenario #1 A beneficiary with moderate Alzheimer’s Disease is unable to bathe and groom herself. The family describes the beneficiary as “uncooperative”. The primary caregiver is a daughter who is trying her best to provide assistance and feels frustrated by the situation, but would like to learn how “to work with her mother” and keep her at home. The beneficiary’s physician has determined that the “uncooperativeness” is the result of receptive language impairments, perceptual misinterpretations, and impairments in learned motor skills – all due to the Alzheimer’s Disease. The teaching services are reasonable and necessary for the beneficiary’s treatment, and to maintain proper hygiene and skin care. Potential Behavioral and Environmental Interventions: 1. Teach the patient’s daughter the primary symptoms of Alzheimer’s disease (amnesia, aphasia, apraxia, and agnosia), and how each of these symptoms can influence the patient’s level of cooperativeness with bathing and grooming activities. A learning objective for the daughter would be to define amnesia, aphasia, apraxia, and agnosia, and to give a clinical example of each symptom that she has encountered while caring for her mother. 2. Teach the daughter how to simplify the patient’s environment to maximize the chance for successful activities of daily living (ADL) encounters. (Examples include, but would not be limited to: daughter having all bathing and grooming supplies ready and available for use before approaching patient, unnecessary items that clutter the bathroom/bedroom are moved out of the way, if a shower is used then add a hand-held shower nozzle so water can be directed and will not frighten the patient by spraying on her face, put liquid soap on washcloths ahead of time, so they can be handed to the patient to use, make sure the environment is the appropriate temperature, bath sponges are often easier for patients to hold and use than washcloths). 3. Use a method of bathing that is familiar to the patient. For example, if the patient always took baths and did not take showers, use a bath now. Consider the time (e.g., morning or evening) that the individual habitually bathed. If she resists shampoos in the home, but historically had her hair done at a beauty shop, consider taking her to one for a shampoo. Consider separating bathing from hair washing, if doing them both together causes agitation. 4. Keep communication simple. Break activities down into steps. Provide one direction at a time. Keep verbal instruction to a minimum and “model” (i.e., demonstrate on yourself) what you want the patient to do, such as pretend to wash your face then hand the patient the washcloth and nod telling her “now you try.” Alternatively you could try guiding the individual’s hand in doing the activity, then removing your hand and letting them try. 5. Be creative with your approach. If she won’t get in the shower or tub on a particular day, wait and try again, or have her wash up at the sink, or wherever she is comfortable. Tell her that mother and daughter are having a “spa day of beauty.” Start with a manicure, which is often less threatening, then move to a facial, pedicure, etc. 6. For dressing, lay clothes out in the order in which she should put them on and have other clothes out of the way. 7. Teach the daughter that the patient will easily pick up on her daughter’s emotions, so the daughter should try to remain as calm as possible, appear relaxed, and smile. 8. The nurse should first demonstrate these techniques to the daughter by doing them with the patient first, then on another visit, the daughter can provide a return demonstration for the nurse to observe. Scenario #2 A physician has ordered skilled nursing care for teaching behavioral techniques to a care-giving niece of a patient with moderate Alzheimer’s disease to gain the patient’s cooperation during mealtime. Due to the patient’s wandering behaviors, she will not stay seated for a meal and the niece believes she is “trying to be difficult.” The patient has been gradually losing weight (10 pounds over 2 months) and she is less coordinated with her utensils due to her underlying dementia as well as a new onset tremor. The teaching services are reasonable and necessary for the patient’s treatment and adequate nutritional intake. Potential Interventions 1. Teach the patient’s niece the primary symptoms of Alzheimer’s disease (amnesia, aphasia, apraxia, and agnosia), and how each of these symptoms can influence the patient’s functional ability and level of cooperativeness at mealtime. 2. Explore strategies to decrease the patient’s wandering at mealtime (toilet before meals; take the patient for a walk before meals to expend excess energy; wait to seat patient when the meal is actually ready and on the plate; position the patient in a comfortable, supportive chair positioned directly in front of the table). 3. If wandering persists or if the use of utensils is challenging for the patient due to apraxia, consider adding finger foods such as sandwiches, slices of fruit, chicken strips, etc. 4. Limit the number of utensils and items on the table to decrease confusion and distractions. 5. Give the patient one item of food at a time, so that the presentation of the food is not overwhelming and then the patient is less likely to become frustrated and walk away from the table. 6. Limit verbal cueing to one step at a time. Physical cueing such as putting the cup in the patient’s hand, initially guiding the spoon to the patient’s mouth may also be helpful for initiation of the self-feeding activity. 7. Eliminate unnecessary environmental stimulation that may distract or upset the patient (turn off television, avoid eating with large numbers of other people, etc.) 8. Consider fortified supplements after a meal if intake is poor. Or consider multiple small meals or other finger foods throughout the day, to ensure adequate intake. 9. Initially to stimulate appetite, give the patient her favorite foods to eat. 10. Consider adaptive feeding equipment such as weighted utensils, no spill cups, bumper plates to increase the patient’s independence with eating. 11. Cut or prepare food in a manner and consistency that maximizes the patient’s ability to eat it. 12. Look for signs of poor dental hygiene, gingivitis and refer to dentist when appropriate. Pain when chewing may be affecting the patient’s oral intake. If the patient has oral heat and/or cold sensitivities, provide liquids and some food more at room temperature. If the patient routinely wore dentures, make sure the patient has them in her mouth and that they fit properly. 13. Assess the patient’s medication regim