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 Sponsored by the Geriatric Education Center of Pennsylvania Consortium (GEC-PA) (Penn State University, University of Pittsburgh, & Temple University) Presented by: Linda K. Shumaker, RN, MA Pennsylvania Behavioral Health and Aging Coalition Prepared by Dr. Noel Ballentine, Dr. David Gill, Linda Shumaker

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 care- givers, 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!!! 3

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 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 1 Loguidice, et. al. Int J Geriatr Psychiatry Banerjee. et. al. Int J Geriatr Psychiatry Luce, 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 4 Callahan, et. al. JAMA Vickery, et. al. Ann Intern Med Verhey, 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 – Risk of disease and disability – Maintain mental and physical function – Normalizing the aging process – Discuss issues of stigma – Available services Civic Engagement – 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 health- related 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

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

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.) Pennsylvania’s Cross System Approach

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 cross- systems 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 cross- systems 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 39

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 Inter- professionals in delivering care to community-residing older adults  Educators across all levels of the community  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

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. 42

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! 43

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.

IMPORTANT! Without effective and adequate inter- professional 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 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

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, inter- professional team approach.

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