Transcript Collaborative Service Delivery Models

Mental Health Services for
Seniors in Primary Care
Scott J.Kloberdanz, DPM, LMSW
Senior Outreach Counseling
Psychosocial Needs of Seniors
Primary Care Providers (PCPs)-most seniors with mental health
complaints/needs present to their PCP when seeking help.
– Usually have long term relationship - can note any changes in their
physical and mental functioning
– Less stigma w/PCP – more likely to discuss distress
• Addressing psychosocial needs/concerns - may lower distress and
help maintain independence. e.g. isolation, home safety, ADLs and
IADLs, meals, home nurse and/or homemaker
• Psychotherapy works in conjunction with meds to help work through
personal issues, negative thoughts, poor coping skills, provides
psychoeducation, improve relationships, increase resiliency
Rationale for Change In Delivery of
Mental Health Services
Depression Under Diagnosed - up to 50% patients that have
signs of depression, and present to primary care providers, are
not diagnosed or treated. (Recognition, management, and outcomes of
depression in primary care. Archives of Family Medicine, 1995, 4, 99-105)
Depression and heart disease – Depression may be
independent risk factor for death in seniors with history of an
MI and in patients with coronary heart disease. (Schulz R, et al:
Association between depression and mortality in older adults. Arch Intern Med 2000; 160: 17611768)
Suicide Risk – 20% of seniors that commit suicide saw their
PCP that day, 40% were seen within a week of their suicide,
and 70% had been seen within one month of committing
suicide. (Older adults: Depression and suicide facts. NIH Publication no. 99-4593)
Treatment Barriers For Seniors
For Mental Health Services
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Stigma of mental illness
Lack of awareness of mental health problems
Denial or underreporting of symptoms
Attribute problems to medical illness
Under diagnosis of problems and underutilization
of mental health services
• Challenges in accessing free standing mental
health clinics – e.g. transportation
• Financial-larger co-payment mental health
President’s New Freedom Commission
On Mental Health - Recommendations
Increase screening for mental disorders in
primary health care and connect to treatment
and supports.
Early assessment and treatment critical to
prevent progression mental health problems.
Integrated and collaborative treatment strategies
pairing mental health professionals with primary
care providers is a more effective treatment
approach .
Mental Health Services
Traditional Care
– Medical and mental health providers provide services independently
– minimal to no communication and/or coordination of care - e.g. PCP providers
often may not know that MH providers are treating their patients
– Psychosocial needs/concerns often not be addressed by PCPs
Collaborative/Integrated Care
– Medical and mental health providers provide MH services collaboratively
– regular communication and coordination of care
direct PCP provider - MH provider discussions in person or by phone
MH provider - PCP staff communication
PCP receives regular progress reports on their patients progress
– Medical and psychosocial needs/concerns addressed
Research Supporting
Collaborative/Integrated Care Model
More Effective Clinical Results - A nationwide clinical trial for tx. late-life
depression (IMPACT model) concluded that the collaborative care model is significantly
more effective for depression, functioning, and quality of life than usual care in primary
care practices.
(Collaborative care management of late-life depression in the primary care setting: a randomized controlled
trial. JAMA, 2002, Dec 11; 288(22):2836-2845)
Seniors Preferred Counseling to Medication – A trial of 1602 seniors tx for depression
in primary care practices revealed that a collaborative care model greatly improved access to
patient’s preferred tx., esp. counseling, which was preferred 57% to 43% over medication.
(Depression treatment preferences in older primary care patients. Gerontologist, 2006 Feb., 46 (1): 14-22)
PCPs Prefer Integrated Mental Health Services - Trial involving 127 PCPs
preferred integrated (provider co-located in office) over referral for mental health care
for many aspects of mental health treatment with elderly patients.
(Primary Care Clinicians Evaluate Integrated and Referral Models of Behavioral Health Care For Older
Adults: Results From a Multisite Effectiveness Trial (PRISM-E). Annals of Family Medicine, 2004, 2, (4),
305-309)
Benefits to Collaborative/Integrated
Model
Primary Care Providers
Reduce staff and provider time-detailed assessment and/or referral other community
resources done by MH provider
Patients more closely monitored for progress and medication response/side effects
External referral not necessary-maintain gatekeeper role
Enhanced communication between PCP and MH provider
More comprehensive services for patients-combine medical and psychosocial tx.
Home environment can be assessed for self neglect and/or safety issues
Patients
Research - combined medical and psychotherapy approaches often most effective
treatment esp. for depression and/or anxiety
Obtain information about community services and resources
Increase opportunity to communicate concerns and questions
Less stigma regarding mental health care
Signs/Symptoms (Suggesting)
Mental Health Problems
Primary care providers may detect the
following problems
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Noncompliance with medications
Memory problems
Vague complaints with frequent visits
Multiple somatic c/o disproportionate to examination
Multiple grief/loss issues associated with aging
Chronic pain
Depression/anxiety
Relationship problems
Suicidal thoughts
Isolation/loneliness
Mental Health Screening
– Depression with seniors difficult to detect (e.g.-somatization,
pseudodementia) – “Danger of inappropriate txs”.
(Predictors of Bereavement Depression & Its Health Consequences. Medical Care, 1988, 26,
882-893.)
– Depression undetected in up to11% of all seniors - screening tests should
be considered in routine assessments of seniors
(Screening Recommendations for Elderly Americans. American Journal Public Health, Sept.
1991, 81, 1131-1140.)
– Screening tests led to increased detection of major depression in seniors at a rate of five times that usually detected in primary care practices
(Screening for depression among a well elderly population. Social Work, May 1995, 40(3), 295304.)
Senior Mental Health (Integrated Care) Project
Pilot project funded through a federal block grant administered through DHS renewed 10/1/05
Senior Outreach Counseling – Des Moines
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outreach program of Eyerly-Ball Community Mental Health Services
one of two Iowa agencies currently contracted
Serves persons who are 60 years and older – no charge
2 - master degree level clinical social workers
Collaborate with 5 primary care practices in community – family practice, internal
medicine – providers include MDs, DOs, PAs, ARNPs
Services provided include:
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mental health assessments and screenings
ongoing psychotherapy
referral to other community resources and services as needed
Spanish interpreters available
Senior Mental Health Integrated Care
Project
Patients/clients can be seen in provider’s office or in their own homes
PCPs identify referrals through clinical hx. & exam and/or mental health
screens
– MH provider calls patient/client & arranges appointments in their home or at PCP
office
– PCP and MH provider both tx concurrently
Mental health educational presentations
– Primary care providers (family practice/internal medicine) and staff
– Other medical and mental health providers
– Community groups of seniors or serve seniors
Outcome evaluations and data collection will:
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affect future funding sources
help develop evidence-based practices
shape future models of mental health delivery for seniors.
Case Example
CC: elder female presents to PCP for F/U appointment for
DM and c/o “arthritis” pain in several joints X 2 mo..
Labs, X-rays and physical exam neg. except early DJD
changes in knees and muscle tension in back and neck
Before leaving office starts to cry - reports recent
“stress” – has been having “problems with my kids”
PCP put on Lexapro and referred for mental health
assessment/therapy.
Case Example-Assessment
Stressors:
poor interpersonal and psychological boundaries - has significantly
dysfunctional family problems
Financial problems – housing, utilities
Isolation - except family
Significant hx:
“Ashamed” to tell PCP depressed for mo. & that has dysfunctional
family
Personal and family history of childhood sexual abuse
Multiple family members abuse substances (intergenerational)
Multiple interpersonal family conflicts
Low self-esteem, isolated (except family)
“Worrier”- chronic untreated generalized anxiety disorder
Case Example- Interventions
SSRI meds-reduces symptoms to help make desired changes
called PCP to consider increasing Lexapro – little improvement symptoms
CBT-evaluate & challenge negative thoughts/distortions, action (behavioral) steps reconnect w/church and friends - increase social interaction to reduce isolation
Connect resources to decrease financial stressors - energy assistance, MOW,
housing options
Boundaries – appropriate psychological and interpersonal w/family
Self-esteem – develop sense self – efficacy
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manage moods- self-awareness/monitoring, coping skills-relaxation, distraction, etc.
boundaries-empathy/love w/o “taking on” others distress