Transcript Behavioral Management and Psychosocial Interventions

The Need for an Inter-Professional
Approach for Working with
Older Persons
Linda K. Shumaker, R.N.- BC, M.A.
Lynne Nessel, LCSW
Pennsylvania Behavioral Health and Aging
Coalition
Effective and adequate treatment
requires a multidisciplinary approach
that will address the multiple needs of
persons as they age and decline in
physical, cognitive, and emotional
ways. More emphasis needs to be
placed on the importance of
cooperation and mutual respect
among the professional and lay caregivers, and integration of the various
levels and types of care.
Aging of America…
 Those 65 and older represent the fastest
growing age group in America.
 Growth will be from 12% to 21% of the
population by 2030 –estimated 70.1 million.
 Rapid growth is expected to occur among
the oldest & frailest population groups.
 More diverse racially and ethnically
 Will live longer
 Will have multiple complex health problems
 Need for the inter-professional team model!!!
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Aging Pennsylvania – Need for
Collaborative Care
 Third highest aging population in the country
 One of the highest population of rural aged
 More racially diverse population
 The fastest growing population is over 85 years of
age
Implications for Alzheimer’s Disease
Implications for “care-giving”
Implications for “care facilities”
Issues of stigma
Multidisciplinary issues – “silos” of care
Implications in public policy
Aging of America
 Supply of healthcare workers does not address current
demand and will fall short of the expected increase of
demand.
 The vast majority of health professionals have little
geriatric training:
 4% of social workers
 Less than 1% of physician assistants
 Less than 1% of registered nurses
 Less that 1% of pharmacists
 Dramatic increases in the number of geriatric specialists
are needed in ALL health professions.
Barriers to Care!
Patient/Family Barriers
 Isolation
 Ageism – belief that depression, confusion are
normal conditions of aging
 Preference of primary care
 Focus on somatic complaints
 Stigma
 Reluctance to discuss psychological symptoms
 Lack of information and/or misinformation
Provider Barriers
 Ageism – “normal aging” stereotypes
 Training barriers – silos of professional
disciplines
 Focus on “medical issues”
 Lack of awareness of “geriatric-specific” clinical
symptoms
 Complexity of health problems & treatment
issues
 Reluctance to inform patients of diagnosis
 Lack of access to behavioral health care
 Lack of information and/or misinformation
System Barriers
 Fragmentation
 Inter-system boundaries
 e.g. Exclusion of dementia from many
community mental health programs
 Time constraints
 Lack of access to geriatric specific services/
treatment
 Reimbursement issues – including a mismatch
between covered services and a changing
system of long-term and community-based
care
 Cultural diversity needs
Collaborative Care!
Medical Homes
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Personal Physician
Physician directed medical practice
Whole person orientation
Care is coordinated and/or integrated
Quality and safety are hallmarks
Enhanced access
Medical Homes (cont.)
• Coordinated care that emphasizes wellness
• Focus on Prevention and “prompt” attention
to emerging problems
• Meets the needs and preferences of patients
– “Patients are more active, prepared and
knowledgeable participants in their care.”
(JAMA, May 2009)
• Patients and doctors work together
• Having a consistent “healing” relationship
with a personal physician significantly
improved health outcomes.
Benefits of Collaborative Care –
Dementia Care
• Attending a memory clinic is associated
with improved quality of life for patients
as well as for those caring for patients,
and reduces behavioral symptoms.1-2
• Interdisciplinary memory clinics are able
to diagnose patients with memory
disorders earlier than standard
evaluation services.3
1Loguidice,
et. al. Int J Geriatr Psychiatry. 1999
2Banerjee. et. al. Int J Geriatr Psychiatry. 2007
3Luce, et. al. Int J Geriatr Psychiatry. 2001
Benefits of Collaborative Care –
Dementia Care (cont.)
• Collaborative care of patients with Alzheimer
disease improves quality of care and
behavioral and psychological symptoms of
patients and their caregivers.4
• Using a guideline based dementia care
program improves quality of care for patients
with dementia.5
• Using an interdisciplinary approach to
diagnosis leads to significant improvement in
diagnostic accuracy.6
4Callahan,
et. al. JAMA. 2006
5Vickery, et. al. Ann Intern Med. 2006
6Verhey, et. al. J Neuropschiatry Clin Neurosci. 1993
Aging and Behavioral
Health Collaboration
Collaborative Care Needs of
Older Adults – Behavioral Health
 Behavioral Health disorders among the elderly
often go unrecognized or are masked by somatic
complaints.
 Medical treatment for psychiatric illness –
ineffectual care
 Clinical presentations of health disorders in the
elderly may be different, making diagnosis of
treatable illnesses more difficult.
 Medical disease?
 Psychiatric disease?
 Either or both?
 Detection may also be complicated by co-existing
medical disorders, isolation and lack of “social
connections”.
Community Outreach to Older Adults
• Building Collaborative Relationships
• Outreach and Education
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Risk of disease and disability
Maintain mental and physical function
Normalizing the aging process
Discuss issues of stigma
Available services
• Civic Engagement
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Family
Community groups
Volunteerism
Church/ faith based initiatives
Linkages
Collaborative Approaches for Caring
for Older Adults
Healthy Aging Initiatives:
• “Building Healthy Communities for Active
Aging” – EPA
• “The Healthy Brain Initiative” – CDC and the
Alzheimer’s Association – National Public
Health Road Map to Cognitive Health
• Chronic Disease Self-Management Program
(CDSMP) – Physical, emotional and healthrelated quality of life, healthcare utilization
and costs
Collaborative Approaches for Caring
for Older Adults (cont.)
Colorado’s Senior Reach
• Community-involved identification of older
adults who need physical or emotional care and
connection to community services
• 70 % of seniors had “fallen through the cracks”.
• 90 % referred have accepted mental health
services.
• Accessing service needs before serious problems
arise
• Building strong collaborative relationships that
enhance ongoing services to older adults is the
key.
Evidence-Based Practices for Older
Adults with Behavioral Health
Issues
 Depression in Older Adults
 PEARLS -(Program to Encourage Active
Rewarding Lives for Seniors) – Utilizes existing
community-based programs.
 Problem solving treatment, social and physical
activation, PEARL’s counselor offers visitation.
 Gatekeeper Program – Trains non-traditional
sources to identify and refer older community
residing elders
Collaborative Approaches for Older
Adults with Behavioral Health
Issues
• Outreach Programs
• Multidisciplinary outreach services takes services
to where older adults reside – home and
community based settings
– Psycho geriatric Assessment and Treatment in City
Housing - PATCH – Baltimore, MD – Gatekeeper
program with “assertive community treatment”
Evidence-Based Practices for Older
Adults with Behavioral Health
Issues
 Depression in Older Adults
 Healthy IDEAS - (Identifying Depression,
Empowering Activities for Seniors) – Integrates
depression awareness and management into existing
case management services.
 Screens, educates, links to services and utilizes
behavioral approaches
 Evidenced based Disease Self Management for
Depression – NCOA Model Health Program
Evidence-Based Practices for Older
Adults with Behavioral Health
Issues
 Depression in Older Adults
Interventions for Family Caregivers –
(Mittelman) – combination of counseling
sessions, support group, education and
ongoing support
 Assists in delaying nursing home placement
 Improved caregiver depression and health
outcomes
Evidence-Based Practices for Older
Adults with Behavioral Health Issues
• Psychosocial and pharmacological
treatment for depression and dementia
• Integrated mental health services in
primary care
• Mental health outreach services
• Brief alcohol interventions for at-risk use
• Family/caregiver support interventions
Draper, 2000; Unutzer, it al., 2001;
Schulberg, et al., 2001; Sorenson, et
al., 2002; Bartels, et al., 2002, 2003
Integrating Mental Health Services
in Primary Care
PRISM-E (SAMHSA) –(Primary Care Research in
Substance Abuse and Mental Health for the Elderly)
comparing two types of care models for delivery of
mental health services to older adults
 50 clinical settings – managed care, community
health clinics, VA system and group practice settings
 Diverse ethnic/ minority and rural/ urban populations
 Largest study of depression and alcohol uses in older
adults
 The firsts effectiveness study of integration in older
adults
Evidence-Based Practices for Older
Adults with Behavioral Health
Issues
Suicide Prevention
Supportive interventions including screening,
psycho-education and group activities
Telephone-based supportive interventions
Protocol driven treatment delivered by a case
manager (IMPACT; PROSPECT)
Integrating Mental Health Services
in Primary Care
 IMPACT (Hartford Foundation) - (Improving Mood -Promoting Access to Collaborative Treatment for Late
Life Depression)
◦ Identification of older adults in need
◦ 12 month access to depression care manager and
support
◦ PCP manages anti-depressant medications
◦ Brief psychotherapy
◦ Case supervision by a psychiatrist
Integrating Mental Health Services
in Primary Care
 PROSPECT (NIMH) - Prevention of Suicide in
Primary Care Elderly: Collaborative Trial
◦ Sought to decrease risk factors including barriers
to accessing health care and the presence of
untreated mental illness
◦ Identification of older adults in need
◦ Case management links to appropriate service
◦ Depression – care management and suicide
prevention
Pennsylvania’s
Approach
Pennsylvania’s Cross System
Approach
2006 – Cross System development with
the Pennsylvania Department of Aging
and Office of Mental Health and
Substance Abuse Services, of a Suicide
Prevention Strategy for Pennsylvania
that specifically addresses the needs of
older adults.
Pennsylvania’s Cross System
Approach
2006 - Mental Health Bulletin was
released from the Deputy Secretary of
Mental Health on the rights of older
adults, even those with dementia, to
receive mental health treatment
(Bulletin issued, February 2006.)
Why Aging and MH Collaboration?
• OMHSAS’s vision (principle): “The MH and SA Service
System will provide quality services and supports that
will: be responsive to individuals’ unique needs
throughout their lives.”
• PDA’s mission: “…Enhance the quality of life of all older
Pennsylvanians by empowering diverse communities,
the family and the individual…”
PDA & OMHSAS Memorandum of
Understanding (MOU)
The 2006 Program Directive MOU required
PDA Office of Community Services and
Advocacy and the OMHSAS to collaborate
and to develop MOUs between each
county’s MH/MR program and the
county’s Area Agency on Aging.
PDA & OMHSAS Memorandum of
Understanding (MOU)
• To better prepared the Aging system and the
Mental Health system to serve older adults who:
– Have chronic and/or complicated mental illness;
– Develop mental illness in late life; and/or
– Have dementia and co-occurring treatable mental
illnesses
Pennsylvania’s Cross System
Approach (cont.)
 Many Counties have built effective crosssystems Aging and Mental Health
programs to meet the needs of their
citizens as a result of the MOU intent.
 All cross system initiatives should include
all systems of care that interface with
older adults – truly Multidisciplinary!
Pennsylvania’s Approach:
• ICCS (Integrative Case Conference Series) –
originally funded by PDA
• Geriatric Education Center Case Review – County
cross system review of “individual cases” with
difficult multi-system needs – now funded by Penn
State GEC Grant
– Single Counties Authorities!
– Other Systems of care!?
Pennsylvania’s Cross System
Approach
 Cross systems collaboration is necessary
to serve the older adult population.
 MOUs between behavioral health and
aging provide an agreed-upon roadmap
to establish and build collaboration.
Pennsylvania’s Cross System
Approach
 Many Counties have built effective crosssystems Aging and Mental Health programs
to meet the needs of their citizens as a result
of the MOU intent.
 All cross system initiatives should include all
systems of care that interface with older
adults – truly Multidisciplinary!
Geriatric Resource Nurse:
Key Position
 Provides and communicates standards for
best, evidence-based care for older adults
 Assists with strategies for identifying older
adults at risk of decline
 Assists with assessing the development of
symptoms related to geriatric issues
 Coordinates team-based techniques for care
across health professions
 Connects service providers and links
community services
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Geriatric Resource Nurse:
Key Position (cont.)
 Team Leaders in their communities with the
knowledge and skills to address the multiple
needs of older people
 Leaders of community-based Interprofessionals in delivering care to
community-residing older adults
 Educators across all levels of the community
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Professionals
Service providers
Family members
Older adults
The “Community” itself
Addressing Physical and Behavioral
Health Needs of Older Adults
 Inter-professional approach
 Consumer input
 Stakeholder-generated principles –
CSP/CASSP
 Culturally competent
 All levels of interagency collaboration
 Work toward the aim of dispelling stigma
 Integration at the community level
 Continuum of care from prevention to
treatment
SAMHSA Strategic plan Substance Abuse
and Mental Health Issues facing Older Adults 2001 - 2006
Need for Inter-professional Approach
 The challenges associated with aging, physical
illness, increasing infirmity, dependency and
limited financial resources place the older adult
at high risk for behavioral health issues.
 Proactively addressing these issues requires
that we attempt to intervene at the community
level, in order to prevent the older adult from
having to be hospitalized or transferred to a
nursing home for extended care.
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Need for Inter-professional
Approach (cont.)
 No single service agency has the skills and
resources to effectively address all areas of
need.
 Successful intervention requires a
comprehensive and coordinated system of
care!
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Need for Inter-professional
Approach (cont.)
 Effective and adequate treatment requires a
inter-disciplinary approach that will address
the multiple needs of persons as they age
and decline in physical, cognitive, and
emotional ways.
 More emphasis needs to be placed on the
importance of cooperation and mutual
respect among the professional and lay
care-givers, and integration of the various
levels and types of care.
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IMPORTANT!
Without effective and adequate interprofessional care, older adults are at risk for
significant disability and impairment,
including:
Impaired independent and community- based
functioning
Compromised quality of life
Cognitive impairment
Increased caregiver stress
Poor health outcomes
Increased mortality
Accessing Services
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Primary Care
Community Mental Health Centers
Crisis Intervention/emergency services
Inpatient Psychiatric Services
Area Agency on Aging
Home Nursing Agencies
Community Social Workers
Private consultants
Patient’s pharmacist
Physical/Occupational/Speech Therapist
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Roles of Geriatric Resource Nurse:
Key Points
Assess individual needs for community
resources
Explore options with client and family
Take a multi-faceted approach
Foster partnerships between agencies
Give support and information to providers
throughout referral process
Ensure follow-up across systems
Build inter-professional linkages in the
community!
We are ALL
Geriatric Resource Nurses!!
Thank you for your attention,
hard work, and commitment
to helping older persons in
your community receive the
best care possible through a
collaborative, interprofessional team approach.
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