Integrating Behavioral Health into Aging Communities 2: Social, Legal, and Financial

Service Collaborations

Sara Honn Qualls, Ph.D.University of Colorado Colorado Springs

WHAT’S ALL THE BUZZ IN INTEGRATED CARE ABOUT?

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

PEARLSProgram 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 regardingantidepressant 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

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

CU Aging Center Integrated Care Partnerships

Partner Agency Integrated Care Team

Silver Key Senior Services Home 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 Exchange Disabilities Services (Supportive Living Services, Primary Care)

Palisades at Broadmoor Park – Senior Housing Campus

Wellness Center Integrated Care (Primary care, physical wellness, psychosocial wellness)

3rd Age -> 4th Age -> Final Age

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WHO IS SERVED? VARIATION ACCORDING TO THE “AGES” OF AGING

The 3rd Age

•Active engagement with community and family•Busy life•Onset of physical changes that are manageable

•Engaged, socially connected lifestyle–Planned, intentional–Restorative after death of spouse or retirement

•Safety net–Reduced demands–Availability of services

Community life

•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: 3rd –> 4th Age

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

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.

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Mrs. Kingman

The 4th Age

•Stability in purpose and meaning but far more limited personal resources•Assistance needed

•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

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!

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WHO ARE THE PARTNERS?AGING SERVICES NETWORKS

Legal Assistance

Adul

t Day

Pro

gram

s

Informatio

n 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 C

are

Counseling

Leisure Services

Where do you find information?

• Area Agency on Aging– www.eldercare.gov – to find local agency– Info and Referral phone lines– Services listing

• Geriatric Care Managers– www.caremanager.org

• Site visits – space, work flow, personnel identity and training, who becomes a “problem”?

Housing

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Own Home

Own Home with Services

Senior Congregate Housing

Assisted Living

Nursing Home

Acute Care

RESOURCE: AAA, Ombudsman

Social Services

Meals on Wheels Respite Care House repair Case or Care Management Transportation Day Programs

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Legal Services

• Guardianship• Conservatorship• Advance Directives– Power of Attorney– Durable Health Power of Attorney– Living Will

• Estate Planning• TrustsNOTE: MORE INFO IN RESOURCE HANDBOOKS on

www.apa.org/pi/aging22

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

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Health Care Services

• Education and health counseling• Acute care hospitals• Nursing homes• Rehabilitation centers• Home health care• Prevention – wellness promotion

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WHAT DO WE OFFER?

• Screening• Evaluation• Triage and Intervention • Consultation and Training • Program design and evaluation

What do we bring to our partners?

Early identification Earlier treatment

Less loss of function

Better well-being

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Rationale: Early detection helps older adults

Early identification

Modification of Tx Plan

Less resistance

Less staff burnout28

Rationale: Early detection helps providers

HOW DO WE INTERVENE?

Principles to Guide

• Biopsychosocial Model• Person-Environment Fit• Principle of Least Intrusion

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

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Person-Environment Fit

Person-Environment Fit

• 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

Balance Autonomy and Safety

Across the lifespan, caring requires balance of ethical principles

•Autonomy•Beneficence• Justice

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Balance of Autonomy and Safety often engages:Community <-> Family

• Community based service providers usually are interfacing with older adults and their families

Modern families: fewer in each generation; overlapping generations

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

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Example: Dementia Trajectory

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1 Memory 1 2 3 4 5 6 7 18 Aggressive Behavior 1 2 3 4 5 6 7

2 Concentration 1 2 3 4 5 6 7 19 Suspiciousness 1 2 3 4 5 6 7

3 Planning 1 2 3 4 5 6 7 20 Personality Changes 1 2 3 4 5 6 7

4 Decision-making 1 2 3 4 5 6 7 21 Finances 1 2 3 4 5 6 7

5 Follow through on plans 1 2 3 4 5 6 7 22 Medical Care 1 2 3 4 5 6 7

6 Mood 1 2 3 4 5 6 7 23 Safety Issues 1 2 3 4 5 6 7

7 Anxiety/Worry 1 2 3 4 5 6 7 24 Household Tasks 1 2 3 4 5 6 7

8 Irritability 1 2 3 4 5 6 7 25 Self-care/Hygiene 1 2 3 4 5 6 7

9 Sadness 1 2 3 4 5 6 7 26 Appointments 1 2 3 4 5 6 7

10 Depression 1 2 3 4 5 6 7 27 Driving 1 2 3 4 5 6 7

11 Apathy 1 2 3 4 5 6 7 28 Medical Problems 1 2 3 4 5 6 7

12 Suicidal Thoughts 1 2 3 4 5 6 7 29 Falls/Balance 1 2 3 4 5 6 7

13 Homicidal Thoughts 1 2 3 4 5 6 7 30 Nutrition 1 2 3 4 5 6 7

14 Social Relations 1 2 3 4 5 6 7 31 Appetite 1 2 3 4 5 6 7

15 Isolation 1 2 3 4 5 6 7 32 Incontinence 1 2 3 4 5 6 7

16 Withdrawal 1 2 3 4 5 6 7 33 Sleep 1 2 3 4 5 6 7

17 Inappropriate behavior 1 2 3 4 5 6 7 34 Energy 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.

Instrumental/ Activities of Daily Living Assessment FormPlease 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.

1 Ambulation 1 2 3 4 5 6 7 10 Laundry 1 2 3 4 5 6 7

2 Bathing 1 2 3 4 5 6 7 11 Medication Administration 1 2 3 4 5 6 7

3 Dressing 1 2 3 4 5 6 7 12 Food Preparation 1 2 3 4 5 6 7

4 Transfers 1 2 3 4 5 6 7 13 Heavy Chores 1 2 3 4 5 6 7

5 Toileting 1 2 3 4 5 6 7 14 Telephone 1 2 3 4 5 6 7

6 Eating 1 2 3 4 5 6 7 15 Financial Management 1 2 3 4 5 6 7

7 Grooming 1 2 3 4 5 6 7 16 Household Tasks 1 2 3 4 5 6 7

8 Transportation 1 2 3 4 5 6 7 17 Appointment Management 1 2 3 4 5 6 7

9 Shopping 1 2 3 4 5 6 7 18 Access Resources 1 2 3 4 5 6 7

• 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)

No Cogn Impairment Mild Dementia Severe Dementia05

101520253035404550

Cognitive disabilities increase caregiving time needed

Hrs/Wk

• 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

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.

Family questions engage them with community agencies

• Housing• Social Services• Transportation• Health care systems

Family Interface with Larger Systems

Primary Care

Social Services

Housing

• Screening• Evaluation• Triage and Intervention • Consultation and Training • Program design and evaluation

Our partners FIND the need, we need to address it…

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