Community Partnerships: Ethical and Communication Issues for LTC Facility/ Hospital Transitions and Effective Care Coordination

Live event held Tuesday, March 27, 2012, 1:30 pm Eastern Time
(First in the series Mental Health and Aging Training Initiative*)

As residents in long term care facilities are living longer  the incidence of dementia and other mental health issues has been increasing.  Thus, long term care and skilled nursing centers have been faced with new and more complicated challenges.  There is a need to develop skills beyond those of “basic custodial care” which require problem solving abilities as well as the willingness and ability to implement creative interventions.  Managing behavior problems in long term care facilities goes beyond what may be identified as successful in the home environment.  This webinar identified some of the specific challenges faced by staff and approaches to successfully develop strategies for interventions.

Intended Audience   
This presentation was intended for staff from many levels, disciplines and settings ( both acute care and long term care).  Attendees included, behavioral health staff, nurse practitioners, nurses, CNAs , Nursing Home Administrators, Social Workers and Case Manages from both Acute and Long term care. 

Expected Outcomes
Staff participating in this webinar (or reviewing the recording) will have increased awareness of the need for more comprehensive communication related to the referral/transition process from Acute to Long Term Care.  They will also begin to gain skills for problem solving and strategizing utilizing a multi-disciplinary team approach to better understand and manage problem behaviors in residents of long term care facilities. 

Learning Objectives
At the end of this presentation participants wil have increased understanding related to:
  • What pertinent information is required in the referral process
  • Increased awareness of the definitions of dementia and associated problem behaviors
  • Understanding of the problem solving process known as the 4-D approach
  • Understand the need to utilize this comprehensive approach across the multi-disciplinary team. 
  • Understand the necessity of team-based approaches to safe transitions from one level of care to another.
  • Understand the regulatory challenges facing LTC/SNF providers in care of residents with “behaviors.
The Webinar
The live event was open to all and free for all.  
This event is made possible through a grant from the Virginia Center on Aging's Geriatric Training Education Initiative and supported by the Center for Excellence in Aging and Geriatric Health, the Virginia Geriatric Mental Health Partnership* and the VCU's Department of Gerontology.

Lora Epperly, RN, MSN, is the Chief Quality and Cultural Excellence Officer for Commonwealth Care of Roanoke, Inc. (CCR).  Ms. Epperly has significant experience in the long term care, acute care and home care settings, corporate health and benefits arena, as a staff nurse, nurse manager, senior management team member and consultant.  She holds a diploma in nursing from Community Hospital of Roanoke Valley School of Professional Nursing and both a BSN and MSN from Radford University.  

Currently, Lora is responsible for clinical services for 11 long term care facilities in Virginia with the Director of Clinical and Resident Services reporting to her.  Ms. Epperly’s clinical experience has included critical care and emergency nursing, holding certifications in both areas, as well as director of surgical services.  She has held positions as clinical supervisor, unit manager and department director.  

Ms. Epperly is a member of the Virginia Health Care Association and serves on the Regulatory Committee, the Quality of Care Committee and the Geriatric Mental Health Task Force working with Dept. of Mental Health in appropriate care and placement for geriatric psychiatric residents.   She has done multiple presentations on topics related to health care reimbursement and long term care issues.

Beth B. Ulrich ACSW, LCSW has recently joined the Senior Psychiatric Program at Centra/ Virginia Baptist Hospital as Community Liaison to Long Term Care. This role involves assisting patients, families  and staff in the transition process from acute to long term care in addition to providing evaluations and interventions to long term care residents experiencing various mental health problems.  

Ms. Ulrich received her Bachelors Degree and Masters Degree in Social Work from Florida State University and is a Licensed Clinical Social Worker in the state of Virginia.  She was the Director of Social Work for Centra for over 20 years before becoming the Program Manager for the  county satellite out-pt. clinics at the Central Virginia Community Services Board.

Her experience has a  combined focus in Social Work Discharge Planning and Case Management  as well as Clinical Social Work for Seriously Mentally Ill adults.

E.  Ayn Welleford, PhD, received her BA in Management/Psychology from Averett College, MS in Gerontology and PhD in Developmental Psychology from Virginia Commonwealth University. She has taught extensively in the areas of Lifespan Development, and Adult Development and Aging, Geropsychology, and Aging & Human Values. 

As an educator, researcher, and previously as a practitioner she has worked with a broad spectrum of individuals across the caregiving and long term care continuum. As Associate Professor and Chair of VCU's Department of Gerontology, she currently works to "Improve Elder Care through Education" through her Teaching, Scholarship, and Community Engagement. 

Outside of the classroom, Dr. Welleford provides community education and serves on several boards and committees.  She is the Immediate Past Chair of the Governor's Commonwealth of Virginia Alzheimer's and Related Disorders Commission. Dr. Welleford is the proud recipient of the 2008 AGHE Distinguished Teacher Award.



The Geriatric Mental Health Partnership (GMHP) is an informal, voluntary group which focuses on geriatric mental/ behavioral health care. The group began in 2007 in response to the challenges of difficult behaviors of elderly residents in long-term care (LTC) facilities. Participants of the GMHP include representatives from mental/ behavioral health, aging services, and long-term care professionals representing the private, public and academic sectors. Organizations represented include the Virginia Health Care Association; the Virginia Hospital and Healthcare Association; the Virginia Association of Nonprofit Homes for the Aging; various Community Services Boards (CSB); State agencies including the Department of Medical Assistance Services; Department of Social Services Department of Health; Department for the Aging Long-Term Care Ombudsman; Department of Corrections; Department of Behavioral Health and Developmental Services; Piedmont Geriatric Hospital; Eastern State Hospital; the Center for Excellence in Aging and Geriatric Health (CEAGH), the College of William & Mary; Eastern Virginia Medical School; Virginia Commonwealth University (VCU) Department of Gerontology; Long-Term Care Facility Providers (e.g., nursing homes); and Behavioral Health Consultants.

The GMHP has worked tirelessly to improve communication and service coordination between the mental/ behavioral health and long-term care systems, so that older adults are able to receive needed care in a timely manner in the most appropriate setting. One of the key obstacles the group has identified is a lack of relevant training for facility and community staff. In order for seniors in long-term care facilities to receive timely and appropriate mental health treatment, staff members need to understand the issues involved and the procedures necessary to address and implement appropriate treatment. Traditionally, staff persons in long-term care facilities have received training which was more focused on the daily care and clinical needs of residents. Meanwhile, the staff at the local CSBs (individuals usually involved in psychiatric hospitalization of these older adults) have traditionally focused on behavioral health issues common to adults and children, without specialized training regarding the geriatric mental health issues more common to seniors residing in long term care facilities.

The GMHP has identified six key training issues important for developing a workforce prepared to effectively address the behavioral health needs of the growing aging population.  Three of them are part of the current series titled "Mental Health and Aging Training Initiative":
  1. “Community Partnerships: Ethical and Communication Issues for LTC Facility/ Hospital Transitions and Effective Care Coordination”
  2. “Psychiatric Emergencies: a Practical Guide for LTC facility staff”
  3. “Pre-admission Screening of Older Adults with Cognitive Impairment: Considerations for Emergency Services Staff”.
The current webinar is the first in the series of three described above.




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