1. PROBLEM

   Well-being refers to feelings about self and social relationships. Positive attributes include initiative and involvement in life; negative attributes include distressing relationships and concern about loss of status. On average, 30% of residents in a typical nursing facility will experience problems in this area, two-thirds of whom will also have serious behavior and/or mood problems. When such problems coexist, initial treatment is often focused on mood and
   behavior manifestations. In such situations, treatment for psychosocial distress is dependent on how the resident responds to the primary mood/behavior treatment regimen.

2. TRIGGERS

   Well-being problem (P) or need to maintain psychosocial strengths (S) suggested if one or more of following present:

• Withdrawal from Care/Activities (Problem)*    [E1o = 1,2]

• Conflict with Staff (Problem) [F2a = checked]

• Unhappy with Roommate (Problem)   [F2b = checked]

• Unhappy with Other Resident (Problem)  [F2c = checked]

• Conflict with Family/Friends (Problem)  [F2d = checked]

• Grief Over Lost Status/Roles (Problem)  [F3b = checked]

• Daily Routine is Very Different from Prior Pattern in the Community (Problem)  [F3c = checked]

• Establishes Own Goals (Strength)  [F1d = checked]

• Strong Identification with Past (Strength)   [F3a = checked]

____________
* Note: This item also triggers on the Mood State RAP.

3. GUIDELINES

   Sequentially review the items found on the RAP KEY.

Confounding Problems

Treatments for mood/behavior problems are often immediately beneficial to well-being.

• Does the resident have an increasing or persistently sad mood?

• Does the resident have increasing frequency or daily disturbing behavior?

• Did the mood/behavior problems appear before the reduced sense of well-being?

• Has the resident's condition deteriorated since last assessment?

• Have ongoing treatment programs been effective?

Situational Factors that May Impede Ability to Interact with Others

Environmental and situational problems are often amenable to staff intervention without the burden of staff having to “change the resident.”

• Have key social relationships been altered/terminated (e.g., loss of family member, friend or staff)?

• Have changes in the resident's environment altered access to others or to routine activities -- for example, room assignment, use of physical restraints, new dining area assignment?

Resident Characteristics that May Impede Ability to Interact with Others

These items focus on areas where the resident may lack the ability to enter freely into satisfying social relationships. They represent substantial impediments to easy interaction with others and highlight areas where staff intervention may be crucial.

• Do cognitive/communication deficits or a lack of interest in activities impede interactions with others?

• Does resident indicate unease in social relationships?

Lifestyle Issues

Residents can withdraw or become distressed because they feel life lacks meaning.

• Was life more satisfactory prior to entering the nursing facility?

• Is resident preoccupied with the past, unwilling to respond to the needs of the present?

• Has the facility focused on a daily schedule that resembles the resident's prior lifestyle?

Additional Information to Clarify the Nature of the Problem

Supplemental assessment items can be used to specify the nature of the well-being problem for residents for whom a well-being care plan is anticipated. These items represent topics around which to phrase questions and to establish a trusting exchange with the resident. Each item includes the positive and negative end of a continuum, representing the possible range that staff can use in thinking about these issues. Staff can use or not use the items in this list. For those items selected, the following issues should be considered:

• How do staff/resident perceive the severity of the problem?

• Has the resident ever demonstrated (while in the facility) strengths in the area under review?

• Are corrective strategies now being used? Have they been used in the past? To what effect?

• Is this an area that might be improved?

7. PSYCHOSOCIAL WELL-BEING RAP KEY (For MDS Version 2.0)

TRIGGER – REVISION

GUIDELINES

Well-being problem or need to maintain psychosocial strengths suggested if one or more of following present:

• Withdrawal from Activities of Interest (Problem)* [E1o = 1, 2]

• Conflict with Staff (Problem) [F2a = checked]

• Unhappy with Roommate (Problem) [F2b = checked]

• Unhappy with Other Resident (Problem) [F2c = checked]

• Conflict with Family/Friends (Problem) [F2d = checked]

• Grief Over Lost Status/Roles (Problem) [F3b = checked]

• Daily Routine is Very Different from Prior Pattern in the Community (Problem) [F3c = checked]

• Establishes Own Goals (Strength) [F1d = checked]

• Strong Identification with Past (Strength) [F3a = checked]

Confounding problems:

• Increasing/Persistent Sad Mood [E2, E3]

• Increasing/Daily Disturbing Behavior [E4, E5]

• Resident's Condition Deteriorated Since Last Assessment [Q2]

Situational factors that may impede ability to
interact with others:

• Loss of Family Member, Friend, or Staff Close to Resident [F2f, from record]

• Initial Use of Physical Restraints [P4]

• New Admission [AB1, A4a], Change in Room Assignment [A2] or Change in Dining Location or Table Mates [from record]

Resident characteristics that may impede ability
to interact with others:

• Delerium/Cognitive Decline [B5, B6]

• Communication Deficit/Decline [C4, C5, C6, C7]

• Not at Ease Interacting with Others [F1a]

• Locomotion deficit/use of wheelchair [G1c-f, G5b,c,d]

• Diseases that Impede Communication – Mental
  Retardation [AB10], Alzheimer's [I1q], Aphasia [I1r], Other Dementia [I1u], Depression [I1ee]

• Uninvolved Activities [N2, N4]

Lifestyle issues:

• Incongruence of Current and Prior Style of Life [AC, F3c]

• Strong Identification with Past Roles/Status [F3a]

• Length of Time Problem Existed [from record]

Supplemental problem clarification issues (from

resident/family if necessary):