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Mental Illness…What is it?
How Does It Relate To The Revised RCF Regulations?
“I wander”…”Do some of the residents in my assisted living community qualify as having a “serious mental illness” according to the RCF regulations” ? Mrs. Jones moved in six months ago to my facility and she has been taking the anti-depressant medication Lexapro for her depression for at least six months? Mr. Smith, age 72, has a diagnosis of bipolar disorder and he has been taking lithium for the past thirty years…and then there is Mr. C whose physician has identified multiple medical diagnoses, such as congestive heart failure, prostate cancer, osteoarthritis…and he also has a diagnosis of schizophrenia and is taking zyprexa… I found that these were some of the most frequently asked questions during the recent OALA winter conference in which the question of serious mental illness was explored. The answer to the above questions is a resounding: “It depends”. “Serious mental illness” (SMI) is defined in the RCF regulation (3701-17-50) as an illness classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IIIR) that meets at least 2 of the 3 following criteria for diagnosis, duration, or disability. Individuals who have diagnoses categorized as mood disorders, schizophrenia, dissociative, organic mental disorders, or others will need to be evaluated based on the above criterion to see if their condition qualifies and is included in the special population designation. Serious mental illness is one of the three qualifying conditions designated as a “ special population”, along with individuals who suffer with either late stage cognitive impairment with significant needs for ADL assistance and/or with cognitive impairments with increased emotional needs and behaviors. Inclusion of the SMI diagnoses is therefore included in your facility’s overall calculation of a special population defined as either admitting 10 or more individuals or 20% of your facility census, whichever is greater. Generally, mental illnesses are considered serious brain disorders affecting mood, thinking, emotion, behavior, cognition and perception. Before evaluating the “3 D’s” of diagnosis, duration, and disability in the
definition, it will be important to access various elements in the residents health history, such as a current history & physical designating primary and secondary diagnoses, a list of medications (i.e. antipsychotic, antidepressant, anti-mania, or anti-anxiety medications) , and current level of functioning. Access to this information is necessary in order to substantiate the criterion. So, lets drill down on the “ 3 D’s” of diagnosis, duration, and disability within the SMI definition remembering that the resident must meet 2 of the 3 criteria. Diagnosis
The presence of a primary Diagnosis of depression: major depression, single
episode or recurrent, dysthymia (a less severe form of depression) bipolar disorder/bipolar disorder II (manic depressive illness) or schizophrenia would be a few of the more common mental illnesses to consider in the assisted living setting. Other disorders may include somatoform (psychological pain disorder), eating, dissociative and/or other psychotic disorders in which the person experiences hallucinations or delusions. Questions to ask at this point are; what is the primary diagnosis that the primary care physician, nurse practitioner, or other mental health professional have listed? Since multiple diagnoses are common in the elderly person, you may find that depression is really a secondary diagnosis as opposed to primary therefore it would not qualify under this criteria. Residents may be on a variety of psychotropic medications categorized as antidepressant, antipsychotic, anti-mania, anti-convulsant, or anti-anxiety medications. The presence of these medications on the resident’s medication list either self-administered by the resident or staff administered would be an indication for further investigation regarding the diagnosis. Listed below are some of the medications that may be prescribed by the primary care physician, nurse practitioner or psychiatrist for various mental illnesses. • Mood Disorders (i.e. depression): prescribed antidepressants may include lexapro, celexa, paxil, remeron, zoloft, effexor, wellbutrin, desyrel, or cymbalta, etc. • Mood Disorder/Bipolar Disorder: anticonvulsant and anti-mania medications prescribed may include lithium carbonate, depakene, depakote, tegretol, neurontin, lamictal, etc. • Schizophrenia: antipsychotic medications such zyprexa, risperdal, seroquel, • Other disorders may require anti-anxiety medications such as xanax, buspar, The second criterion to be considered is that of Duration. How long has the
resident suffered with the illness either through documented medical history or through
self-reporting of the illness? Duration in the RCF regulation refers to the length of the
problem that can be assessed by either the occurrence of inpatient hospitalization or
outpatient treatment, the reported length of impairment by the resident/family, or some
combination, including at least two prior hospitalizations greater than 21 days or any
number of hospitalizations (more than one) totaling 42 days or more than 90-365 days in
a hospital or nursing home within three prior years or a major functional impairment
greater than 2 years, resulting in utilization of outpatient mental health services on an
intermittent basis, a continuous basis, or both. This can appear to be confusing in the
calculation with all of the “or’s” in the definition, but quantifying the length of time is
possible when you have the resident’s self reports and clinical information.
Disability is the third criteria for the defined serious mental illness. For disability,
the main issue becomes one of severity and functionality. The severity of the disability must be established by a disruption in 2 or more life activities. Life activities such as having the ability to care for self, managing stress, having the cognitive ability to make decisions, establishing independent residence and/or the ability to be connected to people in social and personal relationships. Has the mental illness interfered with the residents past or current ability to function day to day? Has the illness produced a disruption in the persons’ ability to care for them self and their physical needs? Has their employment been disrupted, therefore interfering with their ability to contribute to their own financial support? I think it is important to remember that “functionality” is especially relevant to the elderly person. What functions can they perform? Most importantly for the geriatric population, are these functional deficits or limitations in ability to perform ADL’s due to the mental illness or perhaps a physical condition such as rheumatoid arthritis or a heart ailment? These are important questions to ask and answer. In an effort to help answer some of these questions, I have drafted a “Decision Making Worksheet for SMI” that may be helpful if you are unsure about how to answer the questions for some your residents. This worksheet is posted at the end of this article. So, “ I wander”…. Mrs. D is an 80 yr old woman who recently moved into the assisted living facility on November 3, 2007. She has a primary diagnosis of Congestive Heart Failure, & secondary dx of Past TIA/Stoke (right side), Hypertension, Diabetes Mellitus type II, Degenerative Joint Disease and Major Depression. In January 2005, Mrs. D experienced a stroke that resulted in right-sided weakness. She was hospitalized for 12 days and then discharged to a rehab center/NH for 45 days. She returned home to be with her husband, Sam, where he cared for her until late March 2005. She was married to Sam for 57 years & traveled extensively with her husband. Sam died suddenly in March 2005 (2 ½ years ago) at which time she moved in with her only daughter, Sarah. Sarah has been assisting her mother but doesn’t know “how much longer she can care for her mother”. Mrs. D was diagnosed with Major Depression in late 2006 by her PCP and treated with Lexapro. She was hospitalized for thoughts of suicide in December 2006 for 8 days and then readmitted in Jan 2007 for 10 days. She has been taking her medications as prescribed. She is happy about coming to live in the assisted living community and looks forward to being around people Mrs. D is able to take care of many of her physical needs except that she does require assistance with dressing, grooming, and toileting due to right-sided weakness. She ambulates with a walker/cane. Mrs. D worked for 40 years as a second grade school teacher. The question is, Does Mrs. D meet 2 of the 3 criteria for diagnosis, duration, and disability? If your answer was “no”, then you are correct. Her mental illness did not qualify under any of the 3 criteria. So, if you are thinking now of a resident in your facility and are wandering, take action by gathering your documented clinical information, talk with the resident and/or family, assemble the team, the nurse, the caregivers and begin to answer the questions relevant to serious mental illness in your facility. LuAnne Leistner MS, RN, BC, CNA, BC Certified Assisted Living Nurse/NADONA/NALNA Regional Director of Clinical & Resident Services/West Ohio Brookdale Senior Living OALA Board of Trustee Decision Making Worksheet for
Determination of Special Population SMI (RCF 3701-17-50 (hh)

Serious Mental Illness (SMI): illnesses classified in the DSM-IIIR that meets at least 2 of the 3
following criteria for diagnosis, duration, and disability.

Resident Name
Diagnosis Yes
listed the mental illness as a primary diagnosis? * See below Duration Yes
> 21 days or any # of
or more or 90-365 days in a
years or a major functional
Total length of time: ______
Disability Yes
severity of disability by the disruption in 2 or more of the following life activities? Circle those that apply: Disruption in employment, contributing substantially to own financial support, independent residence, self care, perception & cognition, stress management or coping skills, and interpersonal/social relationships? Comments
Conclusion: Does this resident meet 2 of
* Mental illness diagnosis may include the following disorders: Mood Disorders 296,300,301,311, depression, bipolar disorder, (295): schizophrenia, or other disorders, such as delusional disorder, dissociative disorders, eating disorders, organic mental disorders, personality disorders (paranoid, borderline, histrionic, obsessive compulsive), somatoform or pain disorders, selective mutism and oppositional defiant.



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