What’s the Deal with Potassium?

Author: Mark Parkinson BsPharm:  President  AFC-CE

Credit Hours 2 - Approximate time required: 120 min.

Educational Goal

Teach the basics of potassium metabolism. 

Educational Objectives

• Teach about the importance and physiology of potassium. 
• Provide a basic understanding about the pathophysiology of sodium.  
• Teach caregiving techniques on how to manage blood potassium.
• Tell about potassium supplements and medications.

Procedure:

Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.

Disclaimer

   The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

What’s the Deal with Potassium?

What’s the deal with potassium? You have probably heard stories about the stuff and wonder just how important is it? More significantly, as a caregiver should you even care? What does it have to do with in-home caregiving anyway? Well, it turns out that potassium is very important for our bodies to function properly. And surprisingly, in-home caregivers have an unusual amount of control in its therapeutic application. But with the power to control comes the responsibility to act appropriately. Let’s give you that knowledge.

What is Potassium?

Potassium is a silvery-white metal that has the atomic number 19 and the chemical symbol K. It has several chemical properties that make it very useful to our bodies. 

It readily dissolves in water. It easily loses its outermost electron, giving it a positive charge. It freely combines with other elements, often forming different kinds of salts. It is abundant in nature.

How is Potassium used by the body?

Potassium is an essential mineral used by every single cell of our body. It is also an important cofactor in several enzyme and membrane channel functions. Potassium keeps the heart pumping, the muscles contracting and relaxing, nerves firing and bowels digesting. Simply put without potassium our bodies would not function. The main reason why this occurs results from potassium’s positive change when dissolved in a fluid. This chemical property makes potassium an electrolyte.  

An electrolyte is any material that breaks apart into ions (charged particles) in solution, making it capable of conducting electricity. For example, Potassium Chloride when placed in water will break apart into K+ and CL- ions. All the charged particles floating around create a pathway for the electricity to follow. The charge jumps from ion to ion. 

That is how nerve signals are created and sent down nerve fibers in the nervous system. The nerve cell pumps sodium and potassium ions in and out of the cell membrane. Sodium has a greater charge than potassium thus creating a difference in electrical charge potential. By changing the balance between two ions the cell creates a charge potential pathway for the nerve signal to follow. After the signal is sent, the cell moves around the ions to “reset” the cell membrane for the next signal charge. 

The ion charge also explains why water follows salt. Water molecules have partial magnetic poles. There is a potential weak positive and negative end to each water molecule. Throw in a positive potassium ion (K+) and all the negative ends of the surrounding water molecules will be drawn to it. The more K+ ions the greater the magnetic pull. That magnetic attraction is one of the main driving forces of water flow due to osmosis. If the body wants water to flow past a membrane it pumps salt ions past the membrane and the water naturally follows. 

For example, when the body needs to cool off, it pumps the salt ions into the sweat glands and the water follows. The water then evaporates and cools the body. The salts remain behind creating a salty crust on the skin. It is also a major factor in how the kidneys function. 

Keeping the right balance of the salt ions around the body and each individual cell is critical for proper bodily functions.  

Storage and Control

Potassium is found throughout the body’s fluids. We will divide those fluid areas into three parts. Intracellular (within the cell), Interstitial (the spaces in between the cells), and blood plasma. Knowing the details and potassium concentrations are not that important for caregivers. What is important to know is that most of our potassium is stored in the intracellular space. If the cell needs some action done, it will pump out the potassium into the interstitial space through ion pump channels in the cell’s membrane. 

This potassium storage inside the cell is strictly controlled by the body’s homeostatic mechanisms. As potassium is lost (mainly through the urine) it is replaced from the foods we eat. If there is too much potassium around, the hormone aldosterone will make the body urinate more to get rid of the excess. If we don’t take in enough potassium in our diet, our kidneys will try to retain more potassium from the urine. 

Of course, the potassium metabolism is a lot more complicated than what I just explained. Some significant concepts that I did not explain are:  

• Potassium is also lost in sweat and feces. 
• There are mechanisms that move potassium in and out of the individual cells. 
• There is a strong relationship between potassium and the pH of bodily fluids. 

The caregiving takeaway is potassium is so important to the body that it has multiple ways it takes care of it under normal conditions. So usually, the caregiver does not have to worry about potassium levels except for supplying a good diet.  More about that later.

The Hyper and Hypo of Potassium

“Under normal conditions”, I bet you would love things to be normal. But if you are involved in taking care of someone else, things are not normal. In-home caregiving is all about striving to take an abnormal situation and getting as close to normal as possible. In-home caregiving is all about monitoring the patient and utilizing all the resources available to make things right when things seem to go wrong. 

When things go wrong  

Interesting fact- Potassium was originally called kalium. That is why potassium’s chemical symbol is K and why disorders involving potassium often have "kal" in their names. 

A caregiver can count on the body to take care of its own potassium stores and balances. But some things can with interfere potassium homeostatic mechanisms. Fortunately, In-home caregivers do not have to diagnose the problem or find ways to remedy the situation. That is the doctor’s worry. Your worry is to look for the signs and conditions that will lead you to suspect there is a problem. Then you push the medical system until your worries are relieved or the problem is being treated. The trick is to know what to look for. 

Too Much Potassium

Determining how much potassium is in the cell and interstitial spaces is just too hard. That leaves monitoring how much potassium is in the blood. Not the ideal way to monitor for problems but it’s the best we got. 

If there is too much potassium in the blood, then the patient has Hyperkalemia. I love medical terminology. Just knowing how a word is put together tells you what is going on. 

• Hyperkalemia
  • Hyper= too much
  • kal= potassium
  • emia= pertaining to the blood

Yeah I know, I’m a nerd for getting excited about such things. 

What caregivers should look for to suspect Hyperkalemia

The symptoms of hyperkalemia are:

• Weakness and fatigue
• Nausea and vomiting
• Shortness of breath
• Chest pains
• Heart palpitations and irregular heartbeats
• A burning or prickling sensation in the extremities

I know what you are thinking. Those signs are pretty general and could be caused by a lot of conditions. To make things more complicated many times the patient will be asymptomatic (without outward signs of symptoms) until the problem is very severe. How can caregivers narrow things down a bit? You don’t want to be the one who cried wolf too many times. 

As I said earlier, you can count on the body to take care of itself regarding potassium levels. It’s only when the body’s homeostatic mechanisms are messed up that caregivers should start being concerned about the signs and symptoms of too much potassium. 

Who is at risk for Hyperkalemia?

So when do you start to worry about hyperkalemia? It’s all about those who are having problems being able to pee and those who take drugs that affect potassium levels. The kidneys and the adrenal gland which makes the hormone aldosterone are key potassium control organs. For those with chronic kidney disease or adrenal insufficiencies, caregivers will have to monitor for the signs of hyperkalemia. Contact the primary care physician for this info. 

Medical science has learned how to manipulate how to body uses water to reduce blood pressure. The drug classes ACE inhibitors (angiotensin-converting enzyme inhibitors), ARBs (angiotensin receptor blockers), or potassium-sparing diuretics all can lead to too much potassium. Read the drug information sheets that come with the prescription or just ask the pharmacist. 

Those with uncontrolled diabetes (especially type 1), congestive heart failure, and liver disease should also be monitored for hyperkalemia. 

Too Little Potassium

• Hypokalemia
  • Hypo -too little or under
  • kal- potassium
  • emia- pertaining to the blood

For the longest time, I had trouble with the hypo thing. I kept thinking of shots and needles, not poking under the skin. 

What caregivers should look for to suspect Hypokalemia

This time it’s all about not taking in enough potassium and or losing too much potassium from the body. Muscle cramps are the symptom of low potassium that everyone knows about. Also, look for muscle weakness and fatigue, and constipation. In more severe cases paralysis and heartbeat irregularities occur. Still pretty general symptoms but now you know what type of patient you are looking for. 

Who is at risk for Hypokalemia?

Possible at-risk groups are much broader in scope than Hyperkalemia. The most common cause of excessive potassium loss is due to prescription diuretic medications that increase urination. They are also known as water pills. Caffeine is also considered a diuretic. Chronic vomiting and or diarrhea can also result in extra potassium loss. Mental Health homes will need to monitor their anorexic and bulimic patients who are having trouble with their therapies. Pica patients who eat clay are also at risk. The clay binds up the dietary potassium and it passes straight through the patient.

Potassium is pretty common in the foods we eat so it is pretty rare that the primary reason for low potassium is from poor diet. Cases I can think of are bedridden patients that are fed through NG tubes. They are pretty rare in the In-Home setting but not unheard of.    

What concerned caregivers should know is that multiple contributing factors have accumulative effects. Those with poor diets who have a case of diarrhea and take water pills are naturally at higher risk. Caregivers must keep their eye on the bigger picture when symptoms start to occur. For example, water pill patients who usually have no muscle cramps may get them after a case of chronic vomiting. 

Interesting Fact- Licorice has a chemical that can mimic aldosterone, the hormone that controls how much potassium we lose through urination. Those who chronically consume a lot of licorice can eat themselves into hypokalemia. Pretty rare I know but I actually know of an elderly gentleman who used to buy black licorice pipe candy by the case lot who got sick. 

Caregiving skills and Potassium

Now let’s talk about how In-home caregivers have an unusual amount of control of therapeutic potassium. When the body uses up its potassium stores it pulls in what is needed from the foods we eat. If a caregiver starts to suspect hyper or hypo K+ problems they can compensate by altering the menu. This is a first-line therapy that does not need a prescription. Often minor cases of potassium problems can be alleviated in this way. But, this gets kind of tricky and can land you and the patient in a lot of hot water if things go wrong. So, don’t be lazy and mess up. 

Caregiving techniques that will help you not to mess up

• Know your patient. Pay attention to your people until you know what is normal for them. Create a file for them. List all the medical problems, medications histories, and observations. Just the mere fact that you write all this down will kick up your caregiving a notch or two. After you have written things down, actually use the info. Bring the file with you to the doctor. Use it to train substitute caregivers. Use it when dealing with any member of the care team, therapists, and government regulators. 
• Increase monitoring when abnormalities occur. When strange things happen first ask yourself, “Why is this happening?” Review the side effects of all the drugs being taken. Note any recent causation events like illnesses, strenuous events, hot weather, etc. Look for patterns in behaviors especially events that repeat themselves. The Mars and the PRN log will be very important data to monitor.  
• Act with a plan in mind. You are essentially implementing a medical experiment. Do so in an orderly fashion. 

• • What is the goal of the experiment? 
  • What steps are you going to take?
  • What are you going to measure?
  • When does the experiment stop?

• Every intervention is just temporary in nature. You are just trying to help the body solve little hiccups in events. If things become chronic then a doctor needs to be involved. 
• Reoccurrences require the doctor’s attention. When events repeat themselves, they are probably a symptom of other medical problems. After the doctor has taken a look at things ask if you need standing orders to intervene in the future. Educate the doctor on what you can do and even make suggestions in writing for his yes or no approval. Include the standing orders in the patient’s file. More about what you can do later on. “When in doubt send them out” Get the doctor's attention when you have a worry. Emails are a great way of communicating and documenting at the same time. If this doesn’t work, try the nurse or work thru the pharmacist. (They are the back door to the doctor’s attention)

If a diagnosis of Hyper or Hypokalemia is given by the doctor you will have to work with the them on what to do. He may not even consider you in his therapy decisions. It never hurts to remind him that you are there and can have a big impact on what can be done. Let’s talk about that concept now. 

How much Potassium is needed?

Giving an exact figure for how much potassium is needed by a body is just too hard. There are too many variables involved. But the National Institute of Health, Office of Dietary Supplements has published an “Adequate Intake” guideline. Source https://ods.od.nih.gov/factsheets/Potassium-HealthProfessional/

From an In-home caregiver's point of view, such tables and guidelines are practically worthless. You are not measuring out mg of potassium or looking up how much food contains what amount. A more useful guideline is based on potassium being abundant in nature. It’s pretty easy to obtain normal amounts if you- Cook from scratch. Have a balanced diet. Include lots of color on the plate. Have two servings of fruits or vegetables at the main meal and at least one serving for lunch and breakfast. Include whole grains, dairy, and seafood (including tuna fish) 

Interesting fact- Potassium and sodium are closely interconnected but have opposite effects on the body. Both are essential nutrients that play key roles in maintaining physiological balance, and both have been linked to the risk of chronic diseases, especially cardiovascular disease. High salt intake increases blood pressure, which can lead to heart disease, while high potassium intake can help relax blood vessels and excrete sodium while decreasing blood pressure. Our bodies need far more potassium than sodium each day, but the typical U.S. diet is just the opposite: Americans average about 3,300 milligrams of sodium per day, about 75% of which comes from processed foods, while only getting about 2,900 milligrams of potassium each day. Source https://www.hsph.harvard.edu/nutritionsource/potassium/

Foods that have Potassium

Now that we have got the “Adequate Intake” covered let’s look at how to manipulate the diet when more potassium is needed. Or conversely what foods to avoid if you need to cut back. I have been where you are now. I have taken the education courses and told myself, “This sounds easy enough, I can do this potassium thing”. But, when I was standing in my kitchen deciding what to cook it all fell apart. In my opinion, there were three reasons why I failed.

1. I did not have enough of the right foods in my kitchen in the first place.
2. Trying to save money I shopped for whatever was the cheapest, not what was the most nutritious.
3. Spur of the moment deciding what to cook is a terrible way to plan a menu. Appetites and conveniences usually win out over specific nutrition plans. 

Here is one plan that will make it easier to make this potassium menu thing happen much easier. First, start by knowing what foods are high in potassium. Print out a list of the foods that you and the ones you cook for like. Second, with this list in hand sit down with the weekly grocery store sales ads and make up your shopping list. Take note of which items are on your potassium list that are on sale. Third, after you know what you are going to buy, plan out your menu for the week. I always found it was much easier to sit down at the computer with a form that I could fill in. Something like the following. 

__________________________________________________

Monday

Main dish-

Veg 1-

Veg 2-

Dessert-

___________________________________________________

You can build this form out any way you want and include breakfast and lunch too. Then print it out and place it in the kitchen or pantry. Then next week when the sales ads come out do the same thing over again. The bottom line is having some budget-friendly stocks of potassium-rich foods and a preplanned menu before you get into the kitchen to cook. 

Table 2: Potassium Content of Selected Foods

Source https://ods.od.nih.gov/factsheets/Potassium-HealthProfessional/

We all have heard that bananas are high in potassium, but you will notice what foods have more potassium per serving. Potatoes with the skins on have even more potassium than what is listed above. Who knew that a side dish of Potato JoJos or a handful of raisins in your oatmeal would be better than a banana, at least as far as potassium is concerned. 

There are other lists out there on the internet detailing how much potassium is in certain foods. If you want, look them up yourself. The real caregiver magic comes from grocery sales ad- potassium-rich food, menu planning. If you have a specific potassium need, shop for your groceries with that need in mind. Then cook your way to making your patient’s temporary potassium problems away. All while saving money. Pretty cool isn’t it?     

In-Home Caregivers Secret Weapons

The following are three extra ways to kick your potassium-rich menu into overdrive when you need it too. If you are wondering when that would be think of cases of leg cramps.

1. Daily Values. In America, prepackaged foods are required to have a Nutrition Facts panel printed on the package. It includes how many milligrams of potassium per serving and what percent of the total daily requirement (DV) each serving has. That makes it really easy to pick up a package of “Classic Caeser Croutons” and notice that it has only 6mg of potassium per serving or 0% DV. Safe food for Hyperkalemia but not so great for Hypokalemia. 
2. Snack therapy for Hypokalemia. An easy way to add potassium to the diet is by providing potassium-rich snack foods like a can of low sodium V8 vegetable juice (900 mg), a ½ cup of dried apricots (1,101 mg), or ½ cup dried prunes (699mg). 
3. Salt substitutes products are straight potassium chloride instead of sodium chloride. Just a ¼ tsp contains 690 mg or 20% of the DV. Look for products like N0-Salt, NU Salt, or Morton’s Salt Substitute in the spice aisle of the grocery store. A caution to remember when using a lot of these products. Potassium triggers stomach acid production which may lead to an upset stomach. The remedy is antacid tablets or saltine crackers. 

Medications and Potassium

I’m a pharmacist by training so you know I am going to talk about drugs. It’s what I do. Let’s start with supplements. 

Supplements

You might be thinking if potassium is so important why don’t I just go buy an over-the-counter mineral supplement. After all, there has got to be a “pill for every ill”, right? Yes, you can purchase potassium supplements and potassium is added to most multivitamins and other combination supplements. But read the label. You will never find a pill that contains more than 99mg. Why? The National Institute on Health website says the following.

“Many dietary supplement manufacturers and distributors limit the amount of potassium in their products to 99 mg (which is only about 2% of the DV) because of two concerns related to potassium-containing drugs. First, the FDA has ruled that some oral drug products that contain potassium chloride and provide more than 99 mg potassium are not safe because they have been associated with small-bowel lesions. Second, the FDA requires some potassium salts containing more than 99 mg potassium per tablet to be labeled with a warning about the reports of small-bowel lesions”                Source: https://ods.od.nih.gov/factsheets/Potassium-HealthProfessional/

Two percent of the DV is nothing. An insignificant amount if you are looking for a temporary solution for hypokalemia problems. Small bowel lesions risk is another reason why excessive dietary potassium therapy should be temporary in nature. Anything more permanent has got to go through the doctor. 

Drugs with potassium concerns

I’ll make this simple for you by listing all the drugs on a table. 

Table 3. Drugs with potassium concerns

Special Note. ARBs and ACE inhibitors are combined with hydrochlorothiazide (HCTZ), like in lisinopril/HCTZ and valsartan/HCTZ. The hypo and hyperkalemia effects sort of cancel each other out. 

If you start to see abnormality symptoms and are suspect any of the above-listed drugs, bring it to the attention of the doctor or pharmacist. Talk in specifics backed up by measurable data and you’ll get their attention easier. The doctor may or may not do anything. If the problems continue or get worse, you may have to push for a blood test. In the case of HypoK+, the doctor may just order a potassium prescription. 

Potassium Prescriptions

Potassium prescriptions come in 8mEq, 10 mEq and 20mEq strengths. The brand names are Klor-Con or K-Tab. They are produced in delayed-release tablets or capsules and powder packets. They are made delayed-release to reduce the stomach upset side effect of potassium. 

What is important for In-home caregivers to know is that you cannot crush break or chew the tablets. Too much potassium will be released at one time into the stomach. The tablets have been known to stick in the throat so take them with plenty of water. 

Potassium tablets/capsules and NG feeding tubes have problems. If there is an NG tube, if your patient is a tablet chewer or if there is a swallowing difficulty (the tabs are kinda big) I suggest you talk to the doctor about the following suggestions. 

• Powder packets. Add to a liquid and administer the medication. 
• Capsules. You can pull apart the capsules and mix the time-release beads into pudding or a liquid that is easier to swallow.  
• Ktab 8mEQ are smaller tabs and are easier to swallow whole. 

Final notes, Taking potassium prescription with food reduces the chances of an upset stomach. Also, you might find a tablet in the stools. Don’t worry, all the potassium has been released and digested by the time the tablet reaches the toilet.  

Conclusion

Potassium is a big deal. Every cell of our body counts on potassium being around in a very controlled concentration. Though the body is very good at regulating intracellular and extracellular quantities of potassium by itself sometimes things can go wrong. Medication and illness can throw off potassium’s balance. When symptoms of Hypo or Hyperkalemia start to manifest themselves in patients, In-home caregivers can reduce the problem through diet modification. If skill is used caregivers can handle minor occurrences and work with the doctor on bigger potassium issues. 

As always good luck in your caregiving

Mark Parkinson BsPharm 

References:

1. James L. Lewis III, MD. Overview of Potassium's Role in the Body. Merck Manuals Consumer Version. Oct 2021 https://www.merckmanuals.com/home/hormonal-and-metabolic-disorders/electrolyte-balance/overview-of-potassiums-role-in-the-body
2. Barbie Cervoni MS, RD. What Is Potassium? Benefits, Side Effects, Dosage, and Interactions Verywell Health. May 14, 2020. https://www.verywellhealth.com/health-benefits-of-potassium-4588613
3. Body fluids and electrolytes. https://www.youtube.com/watch?v=__97EkVevb0&t=294s
4. Potassium Chloride. Drugs A to Z, Drugs.com https://www.drugs.com/potassium_chloride.html
5. Potassium. Linus Pauling Institute at Oregon State University https://lpi.oregonstate.edu/mic/minerals/potassium
6. Potassium. MedlinePlus.NIH. Oct 20 2017. https://medlineplus.gov/potassium.html
7. Potassium Fact Sheet for Consumers. NIH National Institutes of Health Office of Dietary Supplements. Mar 22, 2021 https://ods.od.nih.gov/factsheets/Potassium-Consumer/
8. Potassium Fact Sheet for Health Professionals. NIH National Institutes of Health Office of Dietary Supplements. Mar 26, 2021 https://ods.od.nih.gov/factsheets/Potassium-HealthProfessional/
9. Potassium. The Nutrition Source. Harvard T H Chan, School of Public health. https://www.hsph.harvard.edu/nutritionsource/potassium/
10. Potassium. Wikipedia, the free encyclopedia. Nov 4 2021 https://en.wikipedia.org/wiki/Potassium#Nutrition
11. Potassium Content of Foods List. Drugs.com Nov 1, 2021. https://www.drugs.com/cg/potassium-content-of-foods-list.html
12. Potassium. Health Encyclopedia, University of Rochester Medical Center Rochester https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=19&contentid=potassium

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Complaints and Grievances, A Different View

Author: Mark Parkinson BsPharm:  President  AFC-CE

Credit Hours 2 - Approximate time required: 120 min. 

Educational Goal

Provide a new perspective on the complaints and grievances process.

Educational Objectives

• Review the negative paradigm of the Complaint Process.
• Explain how to turn the complaint process into a positive experience.
• Teach good customer service principles.
• Suggest a plan of action for complaint filing and resolution.

Procedure:

Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.

Disclaimer

   The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

Complaints and Grievances, A Different View

I have had several requests for Complaints and Grievances training from Mental Health homes. It is a requirement that they have to fulfill once a year. For those who work in Geriatric and DD homes, hang in there with me. I will make it worth your while. You will see that this course is going to really help you out. It’s all about caregiving customer service principles.  Or how to turn grouchy clients into happy customers. If you want more content residents and improved reputations with the State, then take this course. 

In researching this topic, I met with a Quality Improvement Specialist of the OHA/AMH Division. He described for me what the complaints and grievances process was. As he explained what the State wanted care providers to do and why, I had an insightful revelation. This was not another burdensome program of documenting complaints to get people in trouble. This was a systematic way of identifying the root causes of troubling issues and resolving them. For heaven’s sake, what Sam was talking about was just good customer service techniques. The complaints and grievances requirement was really a caregiver tool that could be used to make their residents content with their life. As an added benefit this was also a way to prove to the state inspector that you do care about the people in your charge, and you have some serious problem-solving skills. 

The Requirement

I am not going to quote what the administrative rule is concerning complaints. My goal is to get you to look beyond the wording. I want to inspire you to look at this requirement from a different angle all together. First, let’s change your current thinking. The complaint and grievance process is not a negative, we just make it that way. 

I found the following at https://www.oregon.gov/oha/HSD/AMH/Pages/AMH-Complaint.aspx

The Health Systems Division is responsible for investigating complaints about mental health treatment facilities/homes and outpatient behavioral health services, as outlined in Oregon Administrative Rules 309-035 and 309-019. Please submit a complaint when you:

• Are not satisfied with your experience with a behavioral health care provider, and
• Have filed a complaint with your provider, but the provider did not resolve your complaint, or
• Could not file a complaint with your provider because the provider does not have an accessible complaint process.

Questions? Contact the Health Systems Division.

How to submit a complaint

Fill out the Official Complaint Form and click the "Submit" button at the end of the form. A staff member will contact you.

• Official Complaint Form (English)
• Formulario oficial de queja (Spanish)
• Процесс подачи жалобы (Russian)
• Tiến trình Khiếu Nạ (Vietnamese)

Other ways to submit a complaint

For complaints involving:

• The Oregon State Hospital - Contact the Director for Consumer and Family Services at 503-947-8109.
• Abuse - Contact the Office of Adult Abuse Prevention and Investigation at 503-945-9702.
• Civil Rights - Contact the Office of Equity and Inclusion, Civil Rights Coordinator at 971-673-2000.
• Services covered by Medicaid - Contact Oregon Health Plan Client Services at: 1-800-273-0557.
• Services provided by the Oregon Department of Human Services - contact the Governor's Advocacy Office at 1-800-442-5238.

I have to admit, on the surface, this looks scary for care providers. The information on this page was confusing to me though. In my interview with Mr. Dickson, he told me there was no form that was required. I came to the conclusion that what the above was in essence saying is if the caregiver/facility is not taking your complaint seriously the state will. Just notify us and we’ll look into it. For your convenience, you can use this online form to contact us, or you can just give us a call. 

The Response

After the complaint is received what is the first thing the state is going to do? They will come to visit your home and ask, “What is going on?” Unfortunately, it is just human nature to unthinkingly respond with, Oh, it’s nothing for you to be concerned over. It was just so and so being grouchy, and I took care of it.” Oh Boy, that certainly makes you look like you’re hiding something. Naturally, the county inspector will start to think, “Oh really! Well, just see about that.” I’ve spouted this bonehead response myself when I operated homes. It is little wonder that an Us versus Them paradigm starts to develop.

AFH and DD homes are also all too familiar with how this unspoken conversation plays out. Everyone puts up their dukes and is ready to fight. As a result, it is so much harder to get anything done and everyone thinks the other side are twits. Good luck with getting a positive outcome on the next complaint that is investigated. Under this way of thinking, each successive problem that arises gets harder and harder to resolve. There has got to be a better way.

A Better Way

Here is the new angle I suggest you look at the complaints and grievances process from. Think of them as a positive opportunity. Yes, complaints are opportunities dressed in work clothes. With every issue solved your reputation increases. Residents start to look at you as some kind of superhero that they can count on. They love living at your home because they feel safer and protected from problems. The county inspectors, home health nurses, and other professionals think, “finally, here is someone who knows what they are doing. They are more willing to lean into any future problems with you and help you out. Friends and family members see the positive outcomes and they start spreading the word about this caregiver they know who is a good, really good. This frame of mind makes you go from zero to hero every single time, but only if you are prepared and take the right steps to resolve the issue. 

The Caregiver Tool  

There have been thousands of books written about issue resolution. What I am going to tell you is not the only way to solve problems. But, after 40 plus customer service awards in two different industries, I think I’ve got a pretty good method developed. It starts by viewing problem solving as a series of steps, not as a single event. Once you got the system perfected you now have a potent caregiver tool that you can use over and over again. It works in any circumstance, on any issue. 

Step 1. It’s not about you, it’s about them. 

As we discussed earlier, in a conflict it’s normal for an Us versus Them mentality to arise. You perceive that you are being attacked. But as a professional caregiver, it’s not about you. It’s about using your caregiving skills and role as a patient advocate to help a needy person in your care who has a problem. Let’s resolve right now that you are going to resist the “Us versus Them” mentality and replace it with a “We against the problem” mindset. No matter what is said, you will not take it personally and start to defend yourself. Instead, you are going to roll up your sleeves and get to work finding solutions to the problem. That’s what good professionals do. 

Understand why people complain. 

To help get into the “We against them problem” mindset let us contemplate complaining itself. Let’s start with something you know a lot about- YOU. Why do You complain? What are You trying to get by stating an issue out loud? According to psychologists, there are several reasons why people complain.

The three reasons I want to concentrate on are:

1. You need to Vent. Problems lead to frustration. Frustration leads to emotions. Over time, excessive buildup of emotions needs to be vented. So, we vent to feel better and get our emotions back under control.             
2. You are seeking validation of your self-worth. Having troubles is a blow to your ego. We think less of ourselves for having problems that we think others don’t have. Also, we see others getting help and think, “I am just as important as they are. Why am I not getting help?” So, we complain to placate our bruised pride. 
3. You are trying to recruit help. It’s the old “a squeaking wheel gets the grease” thing. You complain to make sure you get the attention of those who you think can help make the problem go away. 

If those are the reasons why You complain, don’t you think that the person complaining to you is trying to do the same things? I hope you are having a big “Wow, now I understand” moment that will lead to the “We against the problem” mindset. Let the complainer vent completely. They’ll feel better afterward. Build up their depleted ego after the venting by paying attention to them with respect. By listening to the whole complaint and all they have to say about the matter shows them respect. Most importantly, start to work on resolving the problem. 

Tips to use that will get you on their side of the issue

I am going to let you in on some of my “secret sauce’ tricks that have made me so successful in the past.

A. Match communication style.

People communicate in different ways. By mirroring their communication style, it will make it feel like you are one of them. Self-defense barriers will come down and you will communicate more deeply and effectively. I have noticed 4 general styles of communication. 

1. The Alpha- they are direct and to the point. No long explanations and little emotions unless they have to. It feels like they have no time for excuses or emotions. They just want the facts and a quick resolution. Be direct right back. Don’t waste time trying to make them feel anything. If you try they will most likely not be interested in participation. After the complaint they will leave it up to you to handle the details. They are prone to like step-by-step approaches and promised times of resolution. Make them feel like they are in control. 
2. The Thinker- they like a lot of explanation and time to think before responding. Be prepared to hash over details. Readily talk about the whys and hows. Include them in all procedure development and idea generation. 
3. The emotional- They think with their feelings and want to express their emotions a lot. Apply large amounts of empathy and show your feelings as well. Take the time for long discussions about the emotional results of actions. They will be worried about how their complaining will make you feel. Thank them for their consideration before proceeding.  
4. The socializer- They are the talkers. It will feel like they take forever to get to the point. They like storytelling and lots of examples. They develop thoughts on the fly during the conversation and are easily distracted. Have patience and be very flexible. Give them stories about how you solved similar problems. It’s okay to interrupt them with stories to show you understand.

B. Listen Actively

Anyone can listen but what I call active listening is a skill that has to be developed. Active listening is paying attention to all the verbal and non-verbal clues the help you understand what the intention is behind the words being said. Complainers are trying to get you to do something which may or may not be in harmony with what they just said. For example, angry complainers sounds like they are trying to pick a fight. But their intent is to get your attention. They feel that they will not get your help without yelling. Another example is quite complainers that look everywhere but in your face are actually telling you they are unsure of your reaction. There actions are saying, “I’m afraid that you are judging me for needing help”. 

Here are three important techniques that will help you develop your active listening skills.  

1. Non-defensive listening. It’s all about what you do with your brain as you listen. Use your brain to determine what is being requested not for defending yourself against a complaint. Be thick-skinned. Resist the urge to think of a rebuttal as you listen to a complaint. Professionals focus on the needs of their patients, not their own personal egos. Do not take the bait.Often when a person complains their emotions are very high and they want to fight someone. They dangle baiting phrases designed to draw you into a “me against you” fight. Some examples are: You’re just like all the other idiots I’ve had to suffer with. Are you paid to be that dumb? I’ve heard all the bad stories about you, I guess they’re true. Do not fall for such traps. Do not respond in kind. Blast right past the negativity and get to the real heart of the issue. 

2. Be the Sherlock Holmes. As you listen to the words, you are using all the clues they are sending out to determine what they actually want you to do. Watch their body language. Listen to the tone of their voice, and how it changes at the end of a sentence. Keep in mind the context and the environment they are coming from. What are they not saying that normally would be said? Always, always ask yourself, what do they really want, as you listen to the words of complaint. 

3. Rephrase to ensure meaning.After they are done talking, rephrase or paraphrase what they said and include what you think they want you to do. Then ask them if that was right. Using different words and adding perceived intentions forces the complainer into a different mindset. They are now working with you instead of against you to ensure the correct interpretation of what they just complained about. If it takes more than one go-around, apologize for the failure to understand. Then try again until you get it right. 

C. Do not claim the problem. 

The most direct path to “Us versus them” is to start with excuses worded as if you caused the problem. As an example, pharmacy techs will often say. I can’t fill your prescription. It’s too early to refill it. You’ll have to come back later. 

If there is an angry response coming, there is only one target. The tech who just claimed they are the cause of the issue. In truth, none of us go out of our way to make things difficult for others on purpose. So why make it sound like we did? If you are going to state the reasons why things happened, then be more specific about the causes. Find a way to lay the blame on the person who is not there to argue with. Make it look like you were just the messenger. Once the complainer understands that you were not out to get them, step in with some possible solutions. People tend not to argue with some who understands the root cause of an issue and is trying to find a solution. To continue the pharmacy tech example, they should have said, “I see that the insurance company you chose will not pay for the prescription so soon. Did you lose the medication? Going on a trip? Did the doctor change the dose? Let me call the insurance company to see if I can get an override.” Who’s going to yell at a tech who said that? (From zero to hero in one easy step). 

If you are the root cause of the problem, then quickly apologize and mention that it was never your intention to harm. Show that you mean it by starting right away to find the proper resolution of the issue. 

D. Tell them that you believe them and you are on their side.

I think it is important that you verbalize that you believe what they are telling you is the truth. Tell them you think the problem is important enough to you that you are going to start to do something about it right now. If it is a clear-cut us versus them case, as with an outside party, then tell them that you’re on their side. That is one of the strengths of being an In-Home caregiver. You are small enough to get very focused on one person and be their advocate with everyone else. 

E. Get the complainer to laugh. 

Humor is a tool that can be used to dissipate tension. Laughing or even just smirking is an entirely different mindset from complaining. It can divert emotions away from the negative so a complainer can start to think clearly. Also, try to leave with a laugh. It establishes a positive backdrop for future interactions. Jokes that work can be reworded and used over and over again. For example- Well that certainly was a bonehead thing to do, no wonder you’re complaining. I guess I will have to cancel my polka dancing lesson (insert any over-the-top silly thing) because now I have some serious work to do. Well, that (insert core complaint) certainly will not ensure any popularity awards, maybe the stupidity (foot in mouth, etc…) award though. Make fun of yourself a lot. 

F. Promise to follow up.

Saying that you are on their side is not good enough. You have to show them you are on their side by following up with them. Tell them “I believe you. That is a real problem, so here is what I am going to do for you. Then lay out the overall general plan of action. Set some general time frame expectations for when you will follow up. If you set a time frame, then stick to it. I personally used the following verbiage when I am contacting them later, “I promised I would follow up with you, this is what I have done so far…”. 

That sentence is “I’m on your side” gold. It worked every single time that I used it with any communication style. Even when I had nothing to report. Good follow-up communication happens so rarely in our lives that when it happens it really sticks out and puts you squarely on the zero hero path. 

These secret sauce tips require some practice to get really good at using. Not all of them are required in every situation. You will probably only have to use all of them at once on just the toughest of cases. Once you have established a “We against the problem” mindset it’s time to stop placating the complainer. Over-kill will only make you look disingenuous. Once everyone is on the same page, it’s time to work on the problem. 

Step 2. The plan of action. 

A. Write it down. 

Complaints and Grievances are different from Incident reports. In general incidents are the big significant events that need to be reported on. Complaints and Grievances are everything else. They cover not only complaints against you but with other residents, family, jobs, hospitals, and doctors. Literally everything else. When you hear of any complaint from one of your residents, write it down. 

My thoughts for Mental Health homes.  

You know the state and county inspectors are going to come to your home and ask if your residents had any complaints or grievances in this year. They are not asking the questions to dig up dirt on you, even though it feels like it. Their job is to watch over mental health patients to ensure they are well taken care of. Remember, this is the group of patients that were hidden away in institutions, drugged into submission, electrocuted, and or had portions of their brains cut out as “therapy”. The administrative law and your very In Home care industry were developed to not let that happen again. So stop sweeping problems under the rug or saying there were no problems. 

You got to start acting like care professionals and not expensive room and board motels. Just because there were complaints does not mean you are a bad caregiver. Every government inspector knows there will be issues. Complaints are just part of your industry. They know that complaints and grievances are just as likely to be manifestations of the symptoms of mental health diseases as complaints about bad care. 

That is a lesson that AFH and DD homes should also take to heart. 

When (not IF but When) complaints happen, handle them openly. Treat them like symptoms of bigger or hidden issues, because they probably are. Record everything like they were therapy case notes. That is how Mental Health Hospitals operate and so should you. Recordkeeping also has the added benefit of documenting just how effective a caregiver you are. They prove to everyone that the reason why your house has no problems now is because you’re just that good of a care provider. I have to ask, why would any serious care home operator act in any other way? 

Regarding the business side of your home, it’s stupid of you not to advertise your skills in this fashion. If your residents do have legitimate grievances with the way you run your home, take advantage of these complaints to improve your business methods. Happy customers are the only thing keeping you in business. 

B. Determine what is really wanted.

 What is the outcome the complainer is actually looking for? It may be different than what was first complained about. Write it down as a separate note in the report. 

C. Pass the complaint along when needed. 

Not every complaint needs to be passed on to the state. If it is significant, report it. If it involves a third party out of your direct control, report it. When the resident wants others to know, report it. When in doubt, report it. If the complaint would trigger an investigation you might want to use the more formal incident report instead. Serious issues should be reported within 24-48 hours. 

• The resident may be shy or afraid to complain in an official way. You can write the report yourself as a witness or the resident can report the complaint anonymously, but the report must have the resident’s name in the subject matter field. 
• Reporting to the state is a way to get help from the calvary on tough cases. Sometimes you got to call in the big guns. 
• The complaint does not have to go to the county inspector. See the above page I quoted for other agencies. The complaint may have to be formatted in a certain way for that agency. (bureaucracies… go figure) Help the resident file the paperwork in the proper fashion.

D. Take time to think about the why's and how comes. 

Get to the rotting root of the matter. Do not find yourself just concentrating on the dead leaves caused by the rotten root. It may take some guesswork and investigation to find the heart of the matter. Write down your theories and discoveries. 

E. Act.

It’s time to do your caregiver magic to make the problem disappear. It may require you to put on your patient advocate super suit and do battle with the powers that are causing the issue. If the problem is a tough one or is long and complicated, find something to measure. Measuring outcomes will help you determine if there is improvement happening. Naturally, keep a record of your activities. 

F. Follow through to resolution and beyond

Check in with the complainant to see how things are going. Question them to see if they are satisfied or if any other issues have cropped up. Keep your records in the patient files for possible use in the future. Review them periodically to see if a pattern is emerging. Notify other involved parties as a courtesy and as often as needed. 

Here is another secrete sauce tip

Politely suggest to the satisfied resident, their friends, and family that they tell others of your success. Discretely spread the word yourself by sending thank you notes to third parties that helped or gave information. Definitely keep the county inspector or other involved government agency informed. They are expecting a follow-up report from you anyway. This is business advertising gold people, use it often.

AFH and DD Homes, are you paying attention to all the methods and principles that you could use in your homes and care practice? 

Final Note

If you have been paying attention, the following concern will be of no concern to you. To be complete in this training though I have to say it. The fastest way to lose your license to operate a care home is in finding a way to punish a complainer for complaining. If that scares you--- good, don’t do it. 

Conclusion

This was probably not the nut and bolts type of CE that you were expecting. I wanted to change the popular opinion of the complaints and grievances requirement. I wanted you to view it as a means to improve your professional status. So many things we see as a negative in this industry could actually be utilized as a positive instead by savvy caregivers. The one hard fact that I want you to take away from this CE is- The only thing keeping you in business is happy customers, so utilize everything you can to keep them that way. 

As always Good Luck in your caregiving efforts. 

Mark Parkinson BsPharm

References

https://www.psychologytoday.com/us/blog/significant-results/201706/the-three-types-complaining

https://www.oregon.gov/oha/HSD/AMH/Pages/AMH-Complaint.aspx

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