Where Care Meets Compassion: Behavioral Health in Post-Acute

Welcome to SNF This, the podcast where we pull back the bedsheets on skilled nursing facilities, educating, entertaining, and occasionally risking being reported to HR. Awesome, we're excited to be back today with my friend Bruno on this episode of SNF This, and we'll get into probably some heavy stuff, but we'll try to keep it a little light. Our discussion today is really going to revolve around behavioral health and SNF setting. A lot of these things can, there's so many ways to take this, but I'm excited to talk about maybe just some simple remedies and things that we can do to really help some of these patients in a skilled nursing facility setting. But first I'll have you introduce yourself, kind of your background, how do you get stuck in long-term care? What are you doing here? That is a great question, and that should be asked to anybody who works in long-term care. Why are you staying? Why am I still here? So I started off, so I'm a nurse practitioner. I do the psych, and then also a license for family practice, and so nurse practitioners can get several types of licenses, similar to other medical professionals, and I started out in the cosmetic space, there's more money in the cosmetic space. A lot more money, and it's sexier, right? Maybe like, "Oh, I do like this, or I do this, or that." I can do some Botox injections, right? Right, and it's the most hollow environment I've ever been in. It's just so superficial, and all that stuff. And here's the thing, there are awesome professionals that get it into the nitty gritty of cosmetics and stuff like that, but that's just not me. I can't do the mental gymnastics to make myself really like it. And so I did that for a while, and then I just got pulled away because at the time I was doing probably 14-hour days in the cosmetic space, and when you're doing the cosmetics, typically your hands are occupied. And so I never saw my family, my kids, and all this stuff. I did it for a couple of years, and I was like, "Oh, I don't know about this," and then something just came along. I was kind of like putting my feelers out there, and it was psychic care in sniffs. It was with this company, Base Out of Las Vegas, and they were kind of coming into the Utah market, and they hired me, and I was like one of the first guys that went in, and so that's how I got into it. And a little bit of business background made me a particularly good fit for them, coming into a market that they had no footprint. And so, and then that kind of I came in as a provider, but also on the business development side. I think the combination of the two made me stick around, and that's kind of why I'm still here. But if it was like a clinical only experience right off the get-go, I may have not been super excited about it, but anyway, that's how I got it. Yeah, I think behavioral health and mental health in general can be really heavy. It's really hard, and it can kind of impact you in a lot of ways. So probably the number one question we get in terms of trying to help is like, how can we help these patients in a skilled nursing facility setting that have some sort of implication or impact from mental illness? And I did some like quick research, and one of the things interesting to me is like mid to late, like 20th century, when there was still these psychiatric hospitals, they were trying to de-institutionalize psychic care. And so they started shuttering these down to try to make these patients less isolated. Unfortunately, they didn't really have funding or processes in place, and so a lot of these patients ended up in the skilled nursing facility setting. And so there was really a population shift really in the 1980s, 1990s that really impacted kind of the post-acute care, because this industry wasn't really equipped to be able to take care of these types of patients. And a lot of crazy statistics, like 90% of the patients in a post-acute setting have some sort of impact from behavioral health or mental health, whether that's anxiety, depression, to serious mental illness. And so our providers are now tasked with the responsibility and care to care for these patients, and some of them don't even have training yet. And so it's like, I know it's really daunting for a lot of these medical professionals to like take care of these patients and really know. So I hopefully today talking with you Bruno, we're not going to like solve the mystery of like this magic pill or this magic thing that we're going to do for these patients, but hopefully give our provider some tools and understanding about the setting who the patients are and so maybe take away tools that we can really help them. So we're super excited to have you today. Awesome. Yeah, I'm excited to be here. And I think that's a great question. Excellent starting point with what you mentioned the shuttering of like the like the behavioral health institutions. What happened or let me back up a little bit here, if you broke a hip or if something happened and you end up in a sniff, you are likely not very happy. You are anxious or depressed. Everyone wants to go home. Yeah, I was like, yeah, yeah, you get there. You're like, I don't want to live here. And so if they weren't depressed or anxious before, now they are. Absolutely. And that's what that's kind of my mentality. And I kind of joke with people when people ask me like what I do, I went from like all the cool sexy cosmetic stuff to I try to keep people in skilled nursing facilities from being depressed and anxious, which is kind of impossible is what I see their mind telling them like like the people that I'm speaking with are like, like what are you, what are you going to do? To make matters a little bit worse from what you had mentioned with, you know, providers who are now exposed to these patients have this huge truckload of psychiatric issues with them along with their broken hip or whatever they're dealing with are the regulations that came into effect. And so essentially when all those patients transitioned to long-term care, what happened was people wanted to keep their staff and you have all these fermented people walking around trying to escape to the window and it makes it really hard to keep nice like night shift staff, day shift staff and it's just people are like, I have so many patients to care for and now this guy is derailing my entire day. And so the reaction was let's give these people medications that will calm them down and what does that extremely well? How do all. How do all is a fantastic way to tranquilize a human being and even monkeys and stuff. So what happened is we said, okay, we need to keep this long-term care facility staff to care for people and we don't want this mass exodus because the caring for patients is so difficult. So then the halidol became more and more ubiquitous in the space. It's not only halidol, of course, or circle anything that would work. And so then Medicare and Medicaid came in and said, hey, this isn't okay. Like you can't just like give everybody these meds and have tranquilized people just laying in bed all day. Right. It's easier to take care of them though. It's stuff like. Oh yeah. No, we have stuff. It's great because I know like it's like one in five staff who work in a long-term care setting are physically like assaulted and like from punch to kicked to like spat on. And so like it's it's a real problem in terms of like these patients and these staff really taking care of them. And at anyone who's like familiar with the industry knows that it's so hard to keep staff. And a lot of is just that mental English of taking care of 30, 40 patients sometimes. And then you add in a couple of three, four who unfortunately are sundowning or have some sort of behavior and attack them and kick them. There's no reason why they're not gonna stay. So absolutely. And it's like as humans, we want this like a reciprocation. Like you and me like if I take you out to lunch, I buy you a sandwich or like, hey, Bernal's a cool guy, he's like, bought me a sandwich. Like next time we go out, you're like, do let me buy you a sandwich this time. Like the reciprocation. And we look at that in our employment opportunities as well. And so I feel like people who are getting spat on and spit on in whatever for $18 an hour, they're like, there is no reciprocation here. It's worth that I promise. Right. Just stick around. You know, like or whatever. And it's like it's this very difficult thing. And so going back to, you know, the 70s, we're giving all these people these anti-psychotics to calm them down, retain our staff and create some type of like constant, like consistent employment pool for our facility. Medicare Medicaid says, hey, like you can't just tranquilize people. So then what we started doing was we started adding on psychotic disorders to justify the use of anti-psychotics. Because you have to have a, you have to have a diagnosis to match the prescription, right? Bingo. And without that, then you get in trouble. So then exactly to be able to give the medication, you're going to give them a diagnosis. Yep. And so sometimes inappropriate. So yeah, oftentimes and back then it was. And so we had like 87-year-old John Smith, who was like a productive engineer his entire life, like lived a good life, raised his family, came down with Alzheimer's or whatever. And now all of a sudden he's schizophrenic, you know, unspecified. And 87. And that's when the omnimus budget reconciliation happened. - In fact, Oprah of 1987 came sliding in and everything we're gonna talk about today is a sliver of Oprah. And basically that is going to come down on you in surveys for the facility and things like this. And so basically what we're looking at is in order to prescribe an anti-psychotic or a psychotropic medication, which is not an anti-psychotic. So like a dementia patient with major depressive disorder that had major depressive disorder before they came down with Alzheimer's or whatever, they could be prescribed an anti-depressant. That is a psychotropic medication. An anti-psychotic is not necessarily the same thing and they're treated a little bit differently in the space. But essentially what we're looking at is if you are going to prescribe an anti-psychotic, that patient, Oprah wants you to justify that with an actual diagnosis. So if you ask a friend, and typically you're going to have had like an event early in life, like 17 to 25 or something happened. You were naked running around in the mountains, you were stealing some sort of barring from Albracans and you ended up in the hospital or in jail or something. If that doesn't exist, it becomes a little bit trickier to justify adding on delusional or psychotic diagnosis late in life. And a lot of times that's what Oprah and the surveyers are trying to find. If you did prescribe this, where's the history? A lot of times we can find that in the past. So we were talking about that a little bit before. - Yeah. I think one of the things that also complicates this, so like they're in acute settings. So they go to the hospital, they broke their hip. So they're already in an environment that they're not comfortable with. In the hospital setting, if you're having some of this agitation behavior, there's those medications that appropriately use, like sometimes held off, sometimes serqual, sometimes like trasodone to really just help get some of that sleep. They've been fine because they've been on those medications and now like, they're doing better, not quite good enough to go home. Let's send them now to a skilled nursing facility, but now to skilled nursing facility, I don't have those tools to be able to really take care of them. And now the individual doesn't have those as adjunctive therapy medications to be able to help them. They're not in their regular environment. Maybe they've already been dealing with some mental health issues at home, but masking it, or they have like early onset dementia or suffering from dementia but cut, but they're in their own space. So they can kind of mask it and the family doesn't notice maybe little things, but now we're in an environment where this is like full blown and like they're completely out of it. And sun downing and they're screaming and they're like, my mom's like not like that. And they have this poor CNA or nurse who was again taking 30 patients who like is just kind of desperate and they're reaching out to a provider and saying, help. - Yeah, what do we do? - Like what? And we don't have those tools readily available. Plus there's not enough training or funding for staffing, but also education on how to help this, these poor staff to be able to take care of these patients. So it's really difficult. - That's exactly right. That's exactly right. And I do have some comments on that on the funding aspect of things, but you're 100% correct. And I wanted to wiggle into some books and papers that people that are way smarter than I am wrote about this topic and what should be done. But ultimately, let's jump into the actual tools that we can utilize about getting in trouble. I'd like to go over to that and then we'll go into the non-pharmacologic. - Yeah, yeah. - And interventions of pause. - Because I think the scenario is, I've been on call hundreds of thousands of hours. You get a phone call at two in the morning. I'm like, oh man, Mary, who just admitted yesterday for a hip fracture is running around the facility. Well, not literally running. She's a hip-broker hip, but she's trying to and she's yelling and she's hitting, is there something I can give her to help her sleep or help her come in? And I think most of the intention behind it really is a good intent. One, we want to keep them safe who she's walking around and gonna fall. That's not good for them. But we also need to help the rest of the patient sleeps. And so it's really, some of the medications I normally, I work in a acute care setting sometimes through the hospital. I'd have a lot of tools in there. But then I feel like a lot of ways my hands are tired and in a nursing facility. Because I'm like, well, we can try melatonin and that doesn't really work. Maybe we can stretch out and use hydroxazine for itching, which is in the Benadryl family. And maybe that'll make them a little bit sleepy. But the bear's criteria kind of negates that too. And we don't want that to build up in their system. So like, previous in a lot of ways, people would just send them to the hospital. So like, I can't take care of them here. Like, they're not safe, they're disrupting. And so that's obviously not a good tool for them too. So what are some like medications that are like generally good things to like reach for? - Yes. - So that's a great comment. And one comment there, like when we do send the patient out to the hospital, there are implications, like costs to our medical system. And I know that like we say that, nobody really cares. But just creating a more efficient society is like I find that to be somewhat motivating with my job. And then as far as the facility goes when they're sending people out constantly, it actually hurts them in their prospects for like better patients. And so sometimes-- - Sometimes they like moving parts. - They're so moving parts. - But let's jump in. So one of the major things that we're looking at is as a provider, you can prescribe those things. Chance. It's just there are-- - I'm terrified to that. - I've been to our implications, right? - There are implications. And there are issues like when it comes to like the benefit versus the cost to the patient with using those kinds of things. Like for example, if you're prescribing benzodiazepines for a patient like this, you know, you're given them all Prasaline or something, 1 milligram, Q12 due to their behaviors or whatever. If that becomes routine for that patient, then we don't know if they're agitated because they have Alzheimer's or they're agitated because they want more benzos or they're-- - They felt drawing from them. - They felt good. - Right, it's like then we're adding another variable. That's one of the issues that it's bad. But let's talk about some things. Hydroxyline isn't a terrible option as a PRN. Typically, I'll like to load with something. So I know depacote is coming under a little bit more scrutiny right now with CMS, but there are patients that have done really well where you can load with like 500 or 750 milligrams if kidneys and liver and everything allow or permit. And then the hydroxyline tends to have a little bit more impact if they have a little bit of that load. - Rather than just like hydroxyline bites. - Yeah, rather than hydroxyline bites self. But you have to be careful because not all mood disorder medications are going to create that impact. So lemotrigen tends to be more activating. And so you can't just reach into the behavioral or to the mood disorder family and just pull stuff out. And so like for example lithium, like these are frail individuals. Let's just gonna wreck their kidneys. It has actually a lot of research behind it for the elderly and it has some decent outcomes. I think people are scared of it because you have to do all this monitoring and get lithium, plasma levels and all that stuff. But the depocote loading with something like a, like a, the anti-histamine tends to have more impact. Something else that I've noticed in facilities here in like Utah and central Utah is giving NAMENDA to patients. So you start at like five milligrams BID and then increase the 10 milligrams BID. Nothing that I say today is going to be a home run every single time. And is like NAMENDA is that does it have to have like a proper like psychological diagnosis with that? That's what my understanding was behind that. Or is that can be like an adjunct of PRN just for agitation? It would be PRN, it would be schedules. It would be scheduled. And so you typically want some type of cognitive disorder associated with it. And so we're not typically prescribing it as a supplement. But yeah, we'll start at five milligrams BID. We'll go up to 10 milligrams BID. And I would say 30% of the time it is night and day and it is sustained success for these patients. So we've had patients that are naked, they're throwing feces on the wall and stuff like this. Three weeks on this like NAMENDA train. And you know, a year later it's night and day. You know, people will still talk about it. And so I've had that, I've had success here in the Provo area, I've had success with that recently. Like as recent as the last four weeks in Cedar City in Utah. And so that's a really off the beat in path. Like, you know, this is an anecdotal, I can't say that I can point to a lot of research. Yeah. That backs us up. But from my perspective and working in these buildings with these facilities, that is something that has had success in one location and recently we're like bleeding it out and others as well. Yeah, I, what I've also found is like, I think providers in this setting are a little bit more comfortable reaching for like, Oh, the benzodiazepines. Benzodiazepines. but they're like a lot more comfortable to reach for like those medications rather than like try to like spend a little bit of time to like research maybe some of these other medications that will help them over in a long-term case. - Yes. - But even like, even before that, I'm always telling providers like, let's try to take like two steps back, right? So sometimes these patients were on medications at home and that inadvertently got stopped while they're in the hospital. It wasn't caught in the hospital. They were discharged. And so like doing a little bit of digging often helps. Like, oh man, we kind of abruptly stopped this medication that their body was used to in terms of like processing but I think the other really important part too is like, why do we think they're like behaving this way? And one of the things that I found really in this setting is really pain related. So like some of these patients are just really acting out. Not quite sure how to communicate like something's off or they fill off or and so like, making sure that we're addressing pain appropriately. We're like, we're not missing like a fever. We're not missing some sort of UTI management as well. And we're not just chalking it up to some sort of mental health or break or agitation in that setting. So looking at the bigger picture, I think is like, the point of like, Obra, even though I think there's a lot of like, Incster and Obra, like, negatively. - Negative reason. - Yeah, overstepped a little bit. - But like, people get scared. And so then like, you can't depend on the swings on the other direction. So making sure that we're looking at the overall bigger picture in terms of like reaching for medications. But also being careful because you can reach for a pain medication and that can be sedating too. And maybe that's also not inappropriate. Like, can't just reach for oxycodone to sedate a patient. - You're completely right. And I think that sometimes, so what happens, chances vital care providers are getting the result of a broken system, right? Like that's like the, and so we're trying to band-aid something that broke a long time ago, like in the cascade of the treatment. And so sometimes people try to do things that are going to be helpful. Like, oh, this patient had major depressive disorder like back then, maybe if we can, maybe they're depressed. You know, maybe if we treat their depression, their behaviors will come down. Let's throw some search-learn Adam, 100 milligrams or 150 milligrams. Well, some of the psychotropic medications have activating qualities. So like fluoxetine, prozac, search-learn, zoloph, those medications often result in greater activation of a demented patient, causing them to stay up late, causing them to walk around. And so you think you're helping and you're like, and like you're kind of toying with things. You're actually making it worse in that situation. And so you want to do a little bit of research. It won't take long. We got a lot of cool tools, Chad G.P.D. or whatever, to figure out which psychotropics are going to be activating for the patient and opt for others that won't, if you do think that the kind of reason that they're acting out is anxiety or depression or whatever. I wanted to plug that in there, but let's, I mean, if you would allow the most important thing that we're going to do here and the reason there isn't a solution to this yet is because the solution is likely non-pharmacologic in nature and implementing that system wide. That is why this has been a problem for dozens of years and we still don't have like a solid solution. So I'd like to explain what I've noticed. And you guys have been in a bunch of different facilities. I think you'd agree with me. Rural facilities tend to be closer knit, not only the staff, but with the patients. Like they see-- - Well, the staff knows their family. They like to report their family. - Absolutely. - They have a little bit, - Absolutely. - A bit or like a bigger understanding of who the patient is. - And the most effective, cleanest, just like just great team environment, great patient outcomes, even in locked units, are in rural communities. And so if you think about that, like everything that I have to say about non-pharmacologic interventions, branches off of that tree is great. So we have a team that has been a team for a long time because there's not as much turnover in the rural facilities. We have teams that work together. They know they're gonna be together for a long time. Therefore, they can make that reciproc-- Like they can reciprocate with each other like we discussed earlier. And they say, "I'm not just gonna leave Mary in the locked unit just getting wrecked all day and that could be out here eating like my RB sandwich." - Yeah. - They work together. They know that they're gonna have to work together for a long time and they have those community relationships with the patients. And so they have like these ingredients that all the books that I've read on non-pharmacologic interventions for dementia management and all this stuff is essentially saying that is, there has to be some type of buy-in, if not for the patient for the team and working together. That's why it's so hard in an urban environment to recreate that. There's too many employment opportunities. Nobody knows each other. And when things get hard, they just bounce. And that creates this like disarray in a locked unit that when the patient lands, that then the CNA has 30 patients. They didn't want an admit. They're already pissed that there's an admit. And now the admits doesn't know what's going on. They're off of Sir Quill that they were on in the hospital and they don't see any of their loved ones. And so this is something that I would say, I'd like to break it down for the listeners to understand what the components are of that. And so number one is what we need to understand is what creates sundowning. And typically what creates sundowning is the appearance of chaos to the demented individual. And so when things are chaotic and things like this, they want to escape. It's uncomfortable they want to leave. - Like survival mode. - Yeah, survival. I need to get the freak out of here. - And they have pain. On top of that, they may have some stuff that they're carrying with them as far as behavioral health goes. - They don't know where they're at. It's like a new environment. - They don't notice people, everyone's in rush, in the flustered. And so they're just like, "Give me out of here." Like this is freaking me out. And so number one is what the research shows is front loading the day with activities and things and structure is extremely beneficial to avoiding sundowning. And so if the demented patient feels like at the end of the day we're trying to play catch up or trying to rush on the dinner, rush them back, like still finishing up showers 'cause we were late. - First, there's shift change at six or seven PM. That all is contributing to sundowning. - You're like explaining a normal everyday, skilled nursing facility environment. - Absolutely. - Like this happens every day. - Absolutely. But chance, in the rural communities, it doesn't happen to the same degree. They can almost like keep a lid on it all the time. They have a pulse on it. And I think they know it. They know, they don't like, systematically do this, but just by the nature of being a team, they're like making shift change not seem like such a big deal. 'Cause the patients, it's like a little bit quieter and things like this. So number two, so that's number one, is like front load the day with stuff. - We also have like the day shift, who's like, "Whew, Mary's sleeping." We're just gonna let Mary sleep. She's a lot easier to deal with if she just sleeps. And then she sleeps all day and then they're like, "Yup, shift change." - Yeah, I'm gonna make up Mary and Mary's like, "Where am I?" And then they freak out, but day shifts like, "Well, I'm going home." - That's right. - For night shifts. - Yeah, they go. - Right. - And that's the truth. And that's actually another, some of the experts in this area, they also mentioned that NAPS are not a good thing for a limited people, which is like, that's like what they're hoping for. Like when I go, and I'm like, "Please take a nap." - That's like having a child again. - Yeah, like, "Oh my gosh, please take a nap." - Please just take a nap. I have so much to do, I'm late on my charting. And so when I show up, they're like, "No, don't see John, he's sleeping." - Like, "No, I'm like, I'm like, I'm like, I'm like, I gotta talk to him." So that is another issue is, it's a whole cultural revolution. That this what we would need to essentially do. So what I would say is parallel to the skill nursing facility or the long-term care facility, there has been great improvement in caring for a demented individual at home. And so when people do implement all of this stuff that I'm gonna say, it actually does yield results. It's just very difficult to do it system-wide in a skilled nursing facility. And I wanna speak to some solutions to that as well. So, front loading activities in the day, making sure that we're winding down by the time dinner hits. We call music, familiar smells. Like you could have a diffuser or something. That's eucalyptus and it turns on at like 4.30 every day. They don't know it, and then you can dim the lights and then some sequences could occur with that trigger that tells that patient, "Oh, the eucalyptus is coming out, it's time to chill." And they'll essentially play ball if you can do this consistently. Something else is some structure. to the schedule, like every single day. It's the same thing. That will help the patient avoid deviations from that structure. Like they want it. The demented person wants structure and when they don't have it, that's when all the chaos happens. And other things like simple language and research shows that the language isn't as important as the tone. And so if you're just like, Barry, dude, stop. Just go back into your room. Like it's over. You lost, you know? If you're like, Barry, where are you going? Like where are you going, man? And like kind of playful or that kind of calm. That typically will result in like some type of improvement in like the frequency and intensity of sundowning. And so those are some things where people are just like, how? Like how exactly are you going to do that? And that's where I want to talk to you a little bit about funding, like new funding that's coming in through states and things like this. That could be very beneficial to something like this. Get more boots on the ground. You know, and I don't know, chance. I'm sure you've seen, like there's always a carrot dangling in front of skilled nursing facilities with a new funding program. Right. Right. And so I'm very hesitant with this kind of stuff. Well, because someone has to fill it out. Someone has to track it. Someone has to report it. So like it's not as easy as it sounds like, here's money for that. So it's uncomplicated. It's just unrealistic for a lot of facilities to take it on themselves. And so there is a successful program at a Nevada where there was a bunch of homeless people and they were, it ended up in SNFs and they're like, we don't want to deal with this. And so they ship them off to California. And then they all go to the skid row and then it becomes like this metropolis of homelessness and all this stuff. And so California's like, hey, you guys got to figure it out. And so they came up with this program where they incentivize, financially incentivize facilities for keeping those kinds of patients that behave really complex patients. And it's a meaningful amount of money that's coming into the facility. And the purpose is for additional staffing to get an all star that can teach the nursing staff, the nurses, the CNAs and everybody, the stuff that we just talked about, but not only teach it, but like be a constant presence of that. And that's what we'll need as an all star who is like at a skilled nursing facility for years, not months teaching this stuff over and over and over again. And it becomes like a standing environment, like a change in environment for the employees where they come to expect this type of work life when you work in a skilled nursing facility. Like the eucalyptus stuff and the lights and like all this stuff, it's got to be a longstanding thing. And so the purpose or the idea with this funding is that you can find those highly skilled individuals that can not only implement the interventions, but can teach it effectively and have them in facilities all the time. And so part of my job here at Gadsome is to help facilitate partner with facilities to create something like this. A constant educational presence in the facilities that isn't just, that isn't fleeting and changing the actual like culture associated with working in SNF, if that makes sense. - Yeah, that's awesome. I think there's so many resources available out there. It's just knowing and having the time to be able to do it, right? And that also sounds pretty prune-o. But like 2 a.m. Like Mary's freaking out. Like eucalyptus, like you're gonna blow eucalyptus at her. Like you're gonna like, - What's that's funny? - What are you gonna like talk quietly and calmly? Like it's such a hard struggle, especially in the acute kind of setting and nature of like kind of that mental health like or dementia with agitation. 'Cause like really you're this poor nurse and this poor scene and we've talked about it a ton already today is like they're just like overwhelmed and they and so like on the provider side, you're like, well, just like do eucalyptus. And I'm not meaning to mock you at the things because I think those are all very important things. Like what are some like tools in like that acute setting where I'm like, I'm at my wits end right now. I wanna do the best I can and my provider's not gonna give me how they'll. Like what are some things that I can do in that setting to like that would help redirect appropriately and maybe like put them in a better safer environment for the patient. - Sure. So there's two things. I totally agree with you. And even if you do everything that I said perfectly, you have like all-star Donna who just like knows what she's doing, teaches all the staff, there's these minions that are doing everything that they should, you will still have sundowning, you will still have people going off the rails, 100%. So I agree with you. So number one, I wanna skip to like the more aggressive approach here, which is they're gonna hurt themselves. Like they're gonna, they're trying to stop people with a pencil, we need to keep them safe. And so you can use pharmacologic intervention in those situations, but you need to be good at charting and you need to understand what CMS is looking for. And so if somebody is going to hurt themselves or other people, and I have been in facilities, I know that you have as well where people will like have gotten beaten up by a demented guy. - Right. - A situation like that needs to be avoided. It just needs to show in your charting. So you say these are the interventions that we tried. We tried eucalyptus, we tried calming music, we tried turning the lights down. - Bruno, tell me to do all these things. - Bruno said it didn't work. - I did, it didn't work. So Bruno sucks. And now I'm dealing with Susie at 2 a.m. Bruno says, sleeping. - Yeah, and yeah, he's chilling. Yeah, and he's going to the ball game tomorrow morning on Saturday. - He's doing fine. - Yeah. And so in a situation like that, the provider needs to know what they're doing and they need to say, we have, they need to lay out the interventions that we've tried. So like the provider, a vitical provider, somebody was, we'll talk to the 2 a.m. nurse and say, what have we tried? And you would document that stuff. Oh, we've tried this, this, this, and this and this. Okay, in my note, we have tried these non-pharmacologic interventions for Susie and it's just not working. She's escalating and is getting to a point where she's going to cause physical harm to herself, other residents or staff. Okay, that wordage right there is going to, I mean, the facility's still going to get some type of implication for using anti-psychotic, or whatever, for a non-psychotic patient, but that's going to keep them from getting like a serious tag, like an F-tag or a D-tag or something like this. And so if you can justify it and there is some type of termination after, like we, this was like a one off thing. We're just trying to like take care of Susie, it doesn't happen all the time. Then you're okay, you can do that. You just need to justify. - I think the other thing that becomes complicated, especially when you're using pharmacologic interventions is like these become open-ended. So like a well-intended acute setting provider starts a medication to help, and then it gets left on the floor. And then like five years later, they're like, how they've been taking this medication every day and they're great. But really, like you said, I think documenting appropriately, like this is why I did this, this is how I did it. And this is like kind of the parameters that I want to operate that within, like three days total, until maybe a more psych professional can come in or the medical director can come in and do a broader evaluation, working with a pharmacist or whatever. And so what I like to do is like, even if I do have to reach for like a Benzo for safety reasons, one document appropriately, like you said, but also like put a stop date on it. - Absolutely. - So like I'm only gonna let you have it twice. So like you can use it once now, I mean three, four, maybe six hours later, you can use one more dose if needed and then stop. And I think that's the other thing is a lot of these patients are just on so much medication. So like again, while intended, like we're gonna start this to help and now they're just kind of left on it. And now they have no joke 30, 40, 50 medications on their mar and who knows what medications doing what. And so making sure we're strategic on the medications we're giving, but also giving like parameters, strict parameters on how those are given. - Absolutely. And what should happen is a good psych provider should come in behind you in that situation when the two days is up and you know, perform a psychiatric assessment. Like what's this patient's background? Like what would be helpful? What kind of like systems could we put in place or teach the staff to do to decrease the prevalence of the sundowning or the acuity of the sundowning for the specific patient. And then the facility and the psych provider that's working with the facility should be holding monthly meetings. We call them like psychotropic meetings or GDRs in reviewing what happened. Okay, we see that chance, you know, through a 25 milligrams circle two times that dropped off two weeks ago. You know, staff, what happened? How did that go? And have a discussion on like, is this something that, you know, we should go back to in the future only when needed, you know, maybe the success or the failure of that could be, you know, could result in some new treatment formula that we come up with as a team. Like, you know, that shouldn't happen. If you have good people that are helping direct the psychotropic situation of the facility. Yeah, and I think the more you get to know the patient too. And I appreciated when you talked about like that more rural setting, what they understood who the patient was, everyone. and kind of knew them. I like, we thought actively, while we were talking, I thought about this patient that we were trying all these things and they were just really horrible until like two or three in the morning. And then we discovered like his whole life he stayed up till two in the morning. That was like, that was his schedule. - Yeah, that's what he did. - And oil workers over there. - And so what they found is like, if the staff were like, actually brought him out and they just kind of kept him around the nurses station. And then around like one, 30 to like we start winding down. I mean, this is kind of a different setting, but like then he was fine. But in his like whole life he spent, he stayed up till two. So I think in the other term, and if we had the time, right? Like we want to get to know these patients who they are and kind of their background. I think that helps. And that's why this is so complicated 'cause like every patient's so different. - Yes. - I'm like, every staff is like different and not to mention. And I think it's worth mentioning like some of these staff members are also dealing with some mental health issues. Like healthcare is like riddled with like anxiety and depression. They have things that are going on out to their life. And now you bring them into this acute stressful situation and they're supposed to be calm. Just to, and so like it's just compounding. And so I think mental health across the board is like really difficult. And then you put them in a skilled nursing facility setting that's just exacerbated like across the realm. And so yeah, I think overall the topic is just so hard. - It's extremely difficult and it takes, it's just not a, I think everybody wants just like this one size fits all solution. But if it were that, it would have already been solved. And I, you know, I stand by the reason this is so challenging is you have to change the culture of the sniff. And you have to come up with some type of protocol that is educational and is actually absorbed by staff. That is very challenging. Like people always are doing like these staff trainings. Like here's the fire hydrant. This is where you exit if this happens. - Well, you have to do that. You have to mark it for your survey. - Exactly. And it will become just that. But this is something that like people need to understand. If we implement like legit non-farm interventions like a cascade of things that we do. And like rinse and repeat at every facility and like don't let off the gas. It will make work easier for everybody who works in a sniff and it will make life better for all the dementia patients that are present in a sniff. And it'll, you know, vital care won't get as many of those 2am calls for that reason. And so it's so challenging, but I've seen it done on small scale in rural communities. It can be done. It's just really hard to replicate that. And so part of why I'm still in sniff is like, it's a problem that like I think you can work on all those forever. And I think you can improve, but it is, you need so much buying from so many different people, so many different walks of life. But yeah, it's a challenge, but we've seen, I've seen success. I've seen it done right. - That's awesome. - No, thanks Bruno. I think in summary today, like the thing I try to help people understand is like, there is some pharmacological like interventions. And they're necessary sometimes. To not be too afraid of them, but be strategic and like document your thought process so that it's explained for others who are following. And making sure you're putting really strict parameters on that so that it's just doesn't get stuck on their mark. But also pushing kind of like this culture change that you talk about in terms of the sniff. Like these are real individuals who like were doctors and engineers and like really cool people who did really cool stuff. And that's what keeps me in the setting is like, I think we really in this setting can really make a huge difference. So I appreciate your insight in today. So we're gonna switch a little gear just to end up here 'cause we love doing this. I'm gonna have you, the title of our podcast is Sniff This. So you gotta sniff a couple things. Kay Bruno, are you up for this? - Yeah, so let's do it, Moon. - Okay, so you can smell it and just see if you can name the smell for me. - You're in collection cup? - You have to, it's like part of it. - What's these items like alcohol? - It's pretty close, just hand sanitizer. - Like that's like, I'm not gonna like do something gross here for you. - That'd be wild if you can't. - Yeah, that'd miss me out, you know? - Or maybe another time. That's it, that smells like, you could taste it if you want. I'm not tasting that. (laughing) Hmm. Man, that is a smelly smell that I've smelled before. I'm trying to think. - Do you have kids? - Yes, I do have kids. It's like a chair, there's like a chairy like cough medicine type situation here. - It's Tylenol. - Tylenol. - Which is actually like, in terms of liquid Tylenol, that's what we're using the Sniff Setting today. - Dude, that's pretty good. - Awesome, thanks for being with us today Bruno. I think we'll probably have to skiddle another one. There's so many ways we could go with this. - I actually have like two pages of notes that we didn't even touch. So I had like specific doctors and PhDs and stuff like that. - I wrote like books, but most of the books are for at home use. They're not for Sniff's. All the books also, by the way. - Which is really irrelevant. I think people would be interested in that. - Oh, I think it's necessary because we can borrow some of that stuff, but all of the books say, when all it's fails, don't feel bad for sending them to a facility and then we're sitting here having a podcast about what happens. - On that happens, yes. - Well, what we can do is we can link some of that to our podcast if people want to dive into a little bit more. - Yeah, I can send that information. And we'll put your information if people want to reach out. - Okay. - I'm too, but really thanks for being on today. And excited for next week, please join us for our next episode of Sniff's. Before we conclude, huge thanks to our sponsor, Vitacare Connect. Whether you're burning the midnight oil or just trying to survive another 2am call, Vitacare Connect provides on-call medical director support whenever you need it. Nights, weekends, and holidays with coverage nationwide. They're leading the way and post-acute care, elevating quality, expanding access, and supporting well-being for all. Learn more at vitacare.org. Thank you for joining us for this episode of Sniff This. Show this show with your favorite CNA or anyone who's survived in all staff meeting fueled by cold coffee. Until next time, I'm Chance and skilled nursing. If you sniff something, say something.