1. Integrating Behavioral Health into Aging Communities 2: Social, Legal, and Financial Service Collaborations Sara Honn Qualls, Ph.D. University of Colorado Colorado Springs

2. WHAT’S ALL THE BUZZ IN INTEGRATED CARE ABOUT?

3. Mrs. Evelyn DiSilvio is an 81-year-old widowed Italian-American mother of two grown daughters, living alone but regularly eating lunch at a seniors’ nutrition center in an urban area of a large Northeastern city. The center director became concerned after Mrs. DiSilvio appeared increasingly disheveled and depressed over a span of three months. Her concerns deepened when Mrs. DiSilvio confided that she was under government surveillance. The center director consulted a psychologist working with a local aging services agency to see whether some type of evaluation could be provided. Because Mrs. DiSilvio refused to see any mental health professional in an office-based setting, the psychologist began seeing her twice a month at the senior center for assessment and subsequent supportive psychotherapy. As part of the assessment, she worked with Mrs. DiSilvio’s primary care provider to confirm that medical causes for her condition had been ruled out. A dual diagnosis of delusional disorder and minor depression was established after cognitive testing ruled out dementia and other cognitive disorders. APA, Blueprint for Change

4. PEARLS Program to Encourage Active, Rewarding Lives for Seniors (PEARLS; Ciechanowski et al., 2004) WHAT: Community-integrated intervention for detecting and managing minor depression WHO: individuals receiving aging services or living in senior public housing HOW: Screened for depressive symptoms Brief problem-solving therapy (PST) Social and physical activation Psychiatrist consulted with primary care providers as needed regarding antidepressant medication if psychotherapy was ineffective. OUTCOMES: Compared to the usual care group, 50%+ reduction in symptoms, remission from depression, and/or greater improvements in functional and emotional well-being About a third of participants experienced full remission

5. Gatekeeper Programs Recognize that older adults’ problems may become visible to community service providers long before they are known to health care Typical model – Broad, consistent training to utilities, newspaper delivery, trash delivery – Phone triage service to receive calls – Outreach workers to investigate concerns – Referral into the care systems

6. CU Aging Center Integrated Care Partnerships Partner AgencyIntegrated Care Team Silver Key Senior ServicesHome Based Services Team Peak Vista Community Health Senior Clinics FQHC Primary Care with Integrated Behavioral Health Program of All-Inclusive Care of the Elderly (PACE) Adult Day Health Managed Care The Resource ExchangeDisabilities Services (Supportive Living Services, Primary Care) Palisades at Broadmoor Park – Senior Housing Campus Wellness Center Integrated Care (Primary care, physical wellness, psychosocial wellness)

7. 3 rd Age -> 4 th Age -> Final Age 7 WHO IS SERVED? VARIATION ACCORDING TO THE “AGES” OF AGING

8. The 3 rd Age Active engagement with community and family Busy life Onset of physical changes that are manageable

9. Engaged, socially connected lifestyle – Planned, intentional – Restorative after death of spouse or retirement Safety net – Reduced demands – Availability of services Community life

10. Stability in meaning and purpose but decline in daily functioning because of – Physical, sensory, and cognitive decline – Slower or limited mobility, energy, cognition Use of assistance from family, friends, or formal providers to compensate for losses Transitions: 3 rd –> 4 th Age

11. Instrumental Activities of Daily Living Shopping Cooking Housekeeping Finances Transportation Medication Management Activities of Daily Living Mobility Bathing and hygiene Transfers Toileting Dressing Feeding self Independence requires ability to care for self

13. At 77, Mrs. Kingman has so much hearing loss that she can barely participate in a conversation. She tries to read lips, but often asks you to repeat what you are saying. Conversing is a major effort for both of you. You notice that she has a lot she wants to tell you, but that she is not particularly sensitive to others around her. Sometimes she is downright suspicious of people, almost paranoid. Her long term friends find it hard to be with her, so she has a lot less contact than she did throughout her life. 13 Mrs. Kingman

14. The 4 th Age Stability in purpose and meaning but far more limited personal resources Assistance needed

15. Final 18-36 months Substantial decline Increasingly frequent acute problems require out-of-home service in hospital, rehabilitation, nursing home In-home services needed to maintain stability The Last Age

16. Mental and behavioral health problems and services vary by the older adult’s …level of functioning, health conditions, community resources, and personal resources, culture, etc. Community agencies need mental health to bring wide range of skills and services to the partnership!

17. 17 WHO ARE THE PARTNERS? AGING SERVICES NETWORKS

18. Legal Assistance Adult Day Programs Information Services Care Management Caregiver Support Emergency Call Services Respite Care Support Groups Financial Assistance Senior Housing Telephone Reassurance Home Delivered Meals Transportation Caregiver Services Information & Assistance Personal Care Counseling Leisure Services

19. Where do you find information? Area Agency on Aging – www.eldercare.gov – to find local agency www.eldercare.gov – Info and Referral phone lines – Services listing Geriatric Care Managers – www.caremanager.org www.caremanager.org Site visits – space, work flow, personnel identity and training, who becomes a “problem”?

20. Housing 20 Own Home Own Home with Services Senior Congregate Housing Assisted Living Nursing Home Acute Care RESOURCE: AAA, Ombudsman

21. Social Services  Meals on Wheels  Respite Care  House repair  Case or Care Management  Transportation  Day Programs 21

22. Legal Services Guardianship Conservatorship Advance Directives – Power of Attorney – Durable Health Power of Attorney – Living Will Estate Planning Trusts NOTE: MORE INFO IN RESOURCE HANDBOOKS on www.apa.org/pi/aging www.apa.org/pi/aging 22

23. Family Support Services  Illness based organizations (e.g., Alzheimers or Stroke) – education, support, counseling  Caregiver support groups  Home health services  Counselors  Hospital social workers  Hospice nurses and chaplains  Faith-organization staff 23

24. Health Care Services Education and health counseling Acute care hospitals Nursing homes Rehabilitation centers Home health care Prevention – wellness promotion 24

25. WHAT DO WE OFFER?

26. Screening Evaluation Triage and Intervention Consultation and Training Program design and evaluation What do we bring to our partners?

27. Early identification Earlier treatment Less loss of function Better well-being 27 Rationale: Early detection helps older adults

28. Early identification Modification of Tx Plan Less resistance Less staff burnout 28 Rationale: Early detection helps providers

29. HOW DO WE INTERVENE?

30. Principles to Guide Biopsychosocial Model Person-Environment Fit Principle of Least Intrusion

31. Biopsychosocial Frame Physiological aging – systemic changes – Illnesses – functional change Social contexts – Aging social stimulus value – Social structures (or lack of) in later life in particular societies – Roles and role transitions, social support Psychological aging – Cognitive changes – Emotional processing changes – Stress and coping responses 31

32. Person-Environment Fit

33. Optimal outcomes occur when person’s capacities are optimally supported and optimally stressed by the environment Environment is more salient when level of competence is lower

34. Balance Autonomy and Safety Across the lifespan, caring requires balance of ethical principles Autonomy Beneficence Justice 34

35. Balance of Autonomy and Safety often engages: Community Family Community based service providers usually are interfacing with older adults and their families

36. Modern families: fewer in each generation; overlapping generations

37. Caregiver Journey with Chronic DIsease Patient Death Post-CG Structure Illness Onset Pre-CG Family Structure Transition to CG CG Period Early CG Structure Middle CG Structure Late CG Structure 37

38. Example: Dementia Trajectory 38

39. 1Memory1 2 3 4 5 6 718Aggressive Behavior 1 2 3 4 5 6 7 2Concentration 1 2 3 4 5 6 7 19Suspiciousness 1 2 3 4 5 6 7 3Planning 1 2 3 4 5 6 7 20Personality Changes 1 2 3 4 5 6 7 4Decision-making 1 2 3 4 5 6 7 21Finances 1 2 3 4 5 6 7 5Follow through on plans 1 2 3 4 5 6 7 22Medical Care 1 2 3 4 5 6 7 6Mood 1 2 3 4 5 6 7 23Safety Issues 1 2 3 4 5 6 7 7Anxiety/Worry 1 2 3 4 5 6 7 24Household Tasks 1 2 3 4 5 6 7 8Irritability 1 2 3 4 5 6 7 25Self-care/Hygiene 1 2 3 4 5 6 7 9Sadness 1 2 3 4 5 6 7 26Appointments 1 2 3 4 5 6 7 10Depression 1 2 3 4 5 6 7 27Driving 1 2 3 4 5 6 7 11Apathy 1 2 3 4 5 6 7 28Medical Problems 1 2 3 4 5 6 7 12Suicidal Thoughts 1 2 3 4 5 6 7 29Falls/Balance 1 2 3 4 5 6 7 13Homicidal Thoughts 1 2 3 4 5 6 7 30Nutrition 1 2 3 4 5 6 7 14Social Relations 1 2 3 4 5 6 7 31Appetite 1 2 3 4 5 6 7 15Isolation 1 2 3 4 5 6 7 32Incontinence 1 2 3 4 5 6 7 16Withdrawal 1 2 3 4 5 6 7 33Sleep 1 2 3 4 5 6 7 17Inappropriate behavior 1 2 3 4 5 6 7 34Energy Level 1 2 3 4 5 6 7 Other: 1 2 3 4 5 6 7 Other: 1 2 3 4 5 6 7 Behavior Problem Checklist In what areas do you find your family member having difficulty? Please rate the degree of problems your family member is experiencing by circling the appropriate number in each of the following areas on a scale from 1(no problem) to 7 (frequent problem or intense problem). Place a check beside the areas of functioning that have changed with in the past four to six months.

40. Instrumental/ Activities of Daily Living Assessment Form Please rate the degree of problems your family member is experiencing by circling the appropriate number in each of the following areas on a scale from 1(no assistance) to 7 (full assistance). Place a check beside the areas of functioning that have changed with in the past four to six months. 1Ambulation 1 2 3 4 5 6 7 10Laundry 1 2 3 4 5 6 7 2Bathing 1 2 3 4 5 6 7 11Medication Administration 1 2 3 4 5 6 7 3Dressing 1 2 3 4 5 6 7 12Food Preparation 1 2 3 4 5 6 7 4Transfers 1 2 3 4 5 6 7 13Heavy Chores 1 2 3 4 5 6 7 5Toileting 1 2 3 4 5 6 7 14Telephone 1 2 3 4 5 6 7 6Eating 1 2 3 4 5 6 7 15Financial Management 1 2 3 4 5 6 7 7Grooming 1 2 3 4 5 6 7 16Household Tasks 1 2 3 4 5 6 7 8Transportation1 2 3 4 5 6 717Appointment Management 1 2 3 4 5 6 7 9Shopping1 2 3 4 5 6 718Access Resources 1 2 3 4 5 6 7

41. Health Financial – $5,531 out of pocket/year – Long-distance: $8,728 – Reduced hours or quit job Reduced self-care Role strain – Job – Family – Friends – Self Families are typically stressed by the costs of Caregiving VALUE TO SOCIETY: $375 BILLION Which is more than spent on Medicaid ($311b) and close to Medicare ($432b)

42. Cognitive disabilities increase caregiving time needed Hrs/ Wk

43. BI -> aggressive behavior Dementia -> Passivity and low mood Jackson, D., et al., (2009). Acquired brain injury and dementia: A comparison of carer experiences. Brain Injury, 23, 433-444. Family stressors that predict burden are mental health issues

44. Family questions are practical…. When should we be worried? – How do you know when it is time to step in? – How can I possibly know what really goes on? Is she really at risk? – What if someone tries to take advantage of her? – What if she falls and can’t call us? I’m getting depressed – When I can’t do this anymore, then what? – The doctors want me to take charge but it is his life… My sister and I disagree – she thinks Mom should move but I think she needs to stay at home and get some help.

45. Family questions engage them with community agencies Housing Social Services Transportation Health care systems

46. Family Interface with Larger Systems Primary Care Social Services Housing

47. Screening Evaluation Triage and Intervention Consultation and Training Program design and evaluation Our partners FIND the need, we need to address it…

48. Competencies for Practice in Community Knowledge of service system Knowledge of legal rights of older adults and their families Knowledge and skills in brief assessment and intervention High level of communication skill to interface respectfully with broad range of providers on their turf Skills in training agency personnel to manage mental and behavioral health