The affects of mental illness on ADLs and IADLs

 

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Purpose

This is a technical document of proprietary nature that brings clarity and may be used as a guide when completing the ‘Justification for a Protective Living Arrangement’ section on the PAA Medical Form 4350 such that it adequately relays the fact of how the mental health condition(s) adversely affects an individual’s ability to live independently making the need for a protective living arrangement (assisted living) a medical necessity.   

One should read this document in detail in order to gain an understanding of what the Local Department of Social Services looks for when screening a mental healthcare practitioner’s justification of an individual’s need for a protective living arrangement. 

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Background

HolBrock Estates is a network of assisted living programs licensed by the Maryland Department of Health and Mental Hygiene Office of Health Care Quality under COMAR 10.07.14.  Our program has found a niche in providing assisted living services to low-income, chronically homeless vulnerable adults who suffer from mental health disabilities.  As you know, the mental health condition for the vast majority of these adults is the primary contributing factor to their homelessness and inability to sufficiently care for themselves independently without professional supervision and assistance.  Homeless adults, regardless of their mental capacity, tend to focus solely on survival while homeless as opposed to seeking treatment for their mental illness which then contributes to the crime, extreme poverty and blight in cities like Baltimore.  It is our aim to help eliminate such blight by continuing to provide these needy, disabled vulnerable adults with the mental health and medical treatment (or access to such treatment) they require in a protective, therapeutic group living arrangement while assisting them with activities of daily living, instrumental activities of daily living and community integration.  Our model has proven that if an individual’s basic survival needs are met they would most likely recover if provided with the appropriate support and assistance.   

Consistent with COMAR 10.07.14.02(B)(11)(a), Maryland defines an assisted living program as a residential or facility-based program that provides housing and supportive services, supervision, personalized assistance, health-related services, or a combination of these services to meet the needs of individuals who are unable to perform, or who need assistance in performing, the activities of daily living or instrumental activities of daily living, in a way that promotes optimum dignity and independence for the individuals.  COMAR is the Code of Maryland Regulations.   

From a mental health treatment perspective, we know that an individual’s mental health condition(s) can affect ones cognitive ability to perform the activities of daily living (ADLs) and instrumental activities of daily living (IADLs) to the extent that the individual is not able to sufficiently manage a household or even lead a healthy, safe life independently.  This is why almost the entire homeless population in Baltimore City consists of individuals who have been diagnosed with persistent mental illness.   

COMAR 10.07.14.02(B)(2) defines activities of daily living (ADLs) as normal daily activities which include: eating or being fed; grooming, bathing, oral hygiene including brushing teeth, shaving, and combing hair; mobility, transfer, ambulation, and access to the outdoors, when appropriate; toileting; and dressing in clean, weather-appropriate clothing. 

COMAR 10.07.14.02(B)(37) defines instrumental activities of daily living (IADLs) as home management skills, such as shopping for food and personal items, preparing meals, or handling money.  To further clarify the definition of instrumental activities of daily living, one may refer to the Lawton Instrumental Activities of Daily Living Scale (Lawton & Brody, 1969), a widely accepted, appropriate instrument to assess an individual’s independent living skills and ability to perform the instrumental activities of daily living.  Application of this tool allows one to determine level of functioning in a particular IADL category.  The higher the score, the more independent the person is in that area.  It is from this tool, we expand our definition of instrumental activities of daily living to: (a) the individual’s ability to use the telephone and look up numbers independently, (b) the individual’s ability to shop independently such that their needs are adequately met, (c) the individual’s ability to prepare food and plan meals such that their nutrition needs are adequately met, (d) the individual’s ability to perform their own housekeeping proactively, (e) the individual’s ability to do laundry, (f) the individual’s ability to travel independently, (g) the individual’s ability to take responsibility for their own medications, (h) the individual’s ability to handle their own finances.   

It would follow that if an individual needs supervision and assistance with activities of daily living (ADLs) or the instrumental activities of daily living (IADLs), or a combination of the two categories as a result of their mental health disability, the individual fits the criteria as having the medical need for an assisted living program (protective living arrangement) such as HolBrock Estates.    

Generally speaking, most assisted living programs in Maryland, though they are in the business of assisting disabled vulnerable adults with IADLs and/or ADLs will not render service if they are not compensated.  It costs to provide these services.  So where does that leave the vulnerable disabled adults who have either low or no income at all – in the homeless shelters, on the streets needing treatment and support without any direction?  Fortunately, the Maryland General Assembly provided for individuals who lack sufficient resources but are in need of financial assistance to cover the cost of assisted living services in the Annotated Code of Maryland, Human Services Article §§5-401 – 5-409.  Paraphrasing, the law states that if an individual is eligible for the Public Assistance to Adults Program (PAA) if the individual (1) lacks sufficient income or benefits to maintain a reasonable subsistence compatible with decency and health; and (2) is potentially eligible for or receives cash benefits under Title XVI of the federal Social Security Act (SSI/SSDI benefits).   

The Annotated Code of Maryland here also allows COMAR 07.03.03 and COMAR 07.03.01 to serve as the document that regulates how the PAA program is to be carried out by the Local Department of Social Services.  The PAA program, pays for an eligible adult to receive stable housing and assisted living services (protective living arrangement) in a program such as HolBrock Estates.  It also provides the individual with a monthly cash stipend, food stamps and full medical assistance benefits which is essential to the provision of continued wrap around services and support.     

So, from this, it would follow that an individual can receive PAA benefits to cover housing, mental health treatment, wrap-around and assisted living services if the individual has a mental health diagnoses that limits their ability to maintain gainfully employment AND the mental health diagnoses limits their ability to maintain stable adequate housing independently AND the mental health diagnoses limits their ability to function and perform the instrumental activities of daily living / activities of daily living independently without supervision and assistance.   

The adequate documentation of the individual’s diagnosis, associated symptoms and how the symptoms manifested in the individual adversely affect the individual’s ability to live independently and perform the instrumental activities of daily living (IADLs) and activities of daily living (ADLs) independently, without supervision and assistance makes the individual eligible for PAA benefits AND potentially eligible for  SSI/SSDI benefits.  It is with this premise your position is so essential to the individual’s ability to maintain stable housing, treatment and supportive services.  

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Required Action and Protocol Implementation

As it pertains to your scope as a mental healthcare practitioner who renders evaluation and treatment services to our residents, you must consider the fact that in order for an individual to maintain eligibility for PAA benefits and remain in our program, you must adequately document the individual’s mental health condition by accurately diagnosing the individual’s symptoms AND relay how the individuals mental health condition and symptoms limit the individual’s ability to independently perform the IADLs and ADLs without assistance and supervision.  During our screening process, and through our observation of our residents, I can confidently say that all of our residents have a mental health condition with symptoms that impede their ability to function independently for various reasons.   

Example 1:  For example, an individual is severely depressed (diagnosis) and feels sad, tired and depressed way most of the time (symptoms of diagnosis) won’t get up and clean up behind themselves, bathe or prepare their meals, won’t take their medicine without trying to overdose or miss doses (how the symptoms of the diagnoses impede the person’s ability to independently perform IADLs).  Therefore the person is expected to be disabled for more than 12 months and needs assistance and supervision with instrumental activities of daily living offered by the protective living arrangement / assisted living program to ensure they remain compliant with medications, therapy, meal preparation, and housekeeping or it will adversely affect their recovery and ability to maintain a healthy, stable lifestyle (the justification for the protective living arrangement). 

Example 2:  Another example would be an individual who is bipolar with psychotic episodes (diagnosis) and feels sad and withdraws half of the time and is irritable and potentially violent the other half of the time (symptoms of diagnosis).  When the individual is on the low side of their mood he is not motivated to interact with peers, bathe, prepare meals for himself or take his medication.  When the individual has an episode, his violent eruptions cause altercations with his peers and impede his social functioning.  The numerous altercations as a result of the individual’s violent episodes have made it difficult for the client to maintain stable housing and treatment.  The periodic manifestations of the individual’s psychotic episodes have also been the main contributing factor to the client’s recent jail sentences.  The client refuses to comply with treatment and defies authority during psychotic episodes (how the symptoms of the diagnoses impede the person’s ability to independently perform IADLs).  The client is expected to be disabled for more than 12 months and requires a protective living arrangement / assisted living services to supervise the client and provide assistance as necessary with the instrumental activities of daily living.  The protective living arrangement staff will administer/monitor the clients medication intake, provide the client with access to necessary mental health treatment, provide the client with support during his episodes (the justification for the protective living arrangement). 

Example 3:   A final example would be a client who is diagnosed with PTSD and OCD (diagnosis).  She is reluctant to interact socially and makes life altering decisions impulsively (symptoms of diagnosis).  When she has money, she will experience an anxiety attack if she doesn’t purchase the item she wants and rather takes money to buy alcohol as opposed to paying rent, utilities and covering the cost of household expenses.  Client has a history of medication overdose.  Client also during impulsive episodes sell food stamps and order take out at the beginning of the month instead of grocery shopping leaving the client without food for the majority of the month (how the symptoms of the diagnoses impede the person’s ability to independently perform IADLs).  The client is expected to be disabled for more than 12 months and requires protective living arrangement and assisted living because the program manages the client’s funds and ensures the clients living expenses are paid. The client will also receive assistance with shopping and meal planning and supervision while preparing meals.  The assisted living program staff will encourage the client on a consistent basis to interact with the other clients and engage in therapeutic group activities.  Protective living staff would also administer the clients medications when necessary (the justification for the protective living arrangement). 

You are considered the gatekeepers so to speak as to whether or not an individual is granted access to our program and the services we offer that they need!  If you do not adequately document in the ‘Justification for Protective Living Arrangement’ section of the DSS medical form 4350 the fact that individual’s mental health diagnoses an associated symptoms impede the individual’s ability to either perform the activities of daily living (ADLs), the instrumental activities of daily living (IADLs), or both, the individual will not be eligible for the PAA benefit and could lose their chance at obtaining SSI/SSDI benefits and a stable lifestyle.   

With this newfound knowledge, we have established a foundational philosophy as to how to complete the Medical Form 4350 and the justification for protective living arrangement section.   

In the appropriate spaces in the Section III Medical Report of the Form 4350: 

Be certain to check the fact that a protective living arrangement (assisted living program) is necessary 

Be certain to adequately document the presenting symptoms in detail 

Document at least one preferably the two mental health diagnoses which have the greatest effect on the individual’s ability to function independently 

Select the fact that the individual does suffer from mental illness 

Describe in further detail the individuals mental illness 

Select the fact whether or not the individual has violent tendencies, the potential for violence, and/or a history of violence.  Document here also the fact that this is a symptom of the mental health diagnoses if appropriate 

Disregard the Section IV Visual Limitations of the Form 4350.   

In the Justification for Protective Living Arrangement section of the Form 4350 and in the Additional Comments Section, (***using the 3 examples given in the boxes on page 3 of this document as a guide):

Restate the individuals diagnosis(es) 

Briefly restate the manifesting, history of, and potential symptoms of the individual’s diagnosis(es) 

If appropriate, state in detail how the symptoms adversely affect the individual’s ability to interact with others (social functioning) 

State in detail how the symptoms impede or adversely affect the individual’s ability to perform specific activities of daily living (ADLs) or instrumental activities of daily living (IADLs); state as many as you can think of – refer to the listing of ADLs and IADLs on the bottom of page 1 and the top of page 2 of this document to get specific 

State the fact that the individual is disabled and as a result of his/her disability, cannot engage in   substantial gainful employment for a period of 12 months or more 

Give specific examples as to how the services offered by the protective living arrangement (assisted living program) would address (a) the symptoms manifested by the individual and (b) the impediments of the individual’s ability to perform the ADLs and IADLs independently 

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