Mental Health Services at Home

Michele J. Karel, PhDPsychogeriatrics Coordinator

Mental Health Services, VA Central OfficeMichele.Karel@va.gov

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Need for mental health services among homecare population

VHA Home Based Primary Care Mental Health Initiative

Strategies and resources for addressing behavioral and mental health concerns in the home care setting

Objectives

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Rates of depression, dysthymia, anxiety, cognitive impairment more than twice among homebound vs non-homebound older adults (Bruce & McNamara, 1992)

Mental health conditions contribute to excess disability, premature institutionalization, increased mortality, and reduced quality of life among homebound and other older adults (Davitt & Gellis, 2011; Qiu et al., 2010; Reifler & Bruce, 2014)

Mental Disorders among Homebound Older Adults

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Integrated care!◦ Improving Mood-Promoting Access to Collaborative Treatment

(IMPACT); Prevention of Suicide in Primary Care Elderly Collaborative Trial (PROSPECT); VHA Primary Care Mental Health Initiative

Growing evidence base for MH interventions for older adults, in general◦ Psychological interventions for depression, anxiety, insomnia,

pain, sexual dysfunction, challenging behaviors in dementia, caregiver distress

◦ Psychopharmacological treatments And, for homebound older adults, in particular

◦ Problem Solving Therapy for depression, including in context of cognitive impairment; Cognitive Behavioral Therapy for depression; Integrated models for case management in home care

Evidence-Based Mental Health Interventions Exist

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5 of 10 top diagnoses in HBPC are mental health conditions (Edes, 2010)

◦ Depression, anxiety, PTSD, substance abuse, schizophrenia

◦ Dementia also among top 10 diagnoses; related behavioral and caregiving concerns

Also, common behavioral health challenges◦ Coping with disability, insomnia, chronic pain,

adherence Caregiver strain

Mental Health in VHA Home Based Primary Care Population

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Difficult for Veterans in HBPC to access clinic-based mental health services

Starting in 2007: Integrate a Mental Health Provider (psychologist or psychiatrist) onto every HBPC team

Position description duties include providing/ promoting:◦ Screening, assessment, diagnosis, treatment of mental disorders◦ Assessment of cognitive deficits, and decision making and functional

capacities◦ Services for family caregivers, and couples/families◦ Behavioral medicine interventions◦ Communication/interaction among team members◦ Supervision/training

VA Home Based Primary Care Mental Health Initiative

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Integrated Care Model for Mental Health Services in HBPC 

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Interdisciplinary Care

Care Management Stepped Care

Collaborative Care

Patient-Centered Care

Evidence-Based Psychological and

Psychopharm Assessment and

Intervention

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2010 Survey: Clinical Issues Addressed “Often” or “Frequently” by HBPC MH Providers

TBI

Substance use

Serious mental illness

Weight management

PTSD

Decision making capacity

Behavior management

Grief and loss

Chronic pain

Insomnia

Adherence

Cognitive/dementia evaluation

Caregiver/family stress

Coping with illness/disability

Anxiety

Depression

0 10 20 30 40 50 60 70 80 90 100

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2010 Survey: HBPC Program Directors “Impact of having an HBPC MH Provider as part of your HBPC team?”Top themes included:

Helping team to increase knowledge and skills, for understanding and working with Veterans/families with complex behavioral and mental health issues

Increasing holistic conceptualization/approach to patient care

Enhancing overall program quality/quality of care Supporting team development and cohesion Contributing to integrated team treatment

planning Being available for staff consultation and support

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Depression◦ PHQ-2/PHQ-9: http://www.phqscreeners.com/ ◦ GDS: http://www.stanford.edu/~yesavage/GDS.html

Anxiety◦ GAD7: http://www.phqscreeners.com/

PTSD◦ Primary Care PTSD Screen:

http://www.ptsd.va.gov/professional/provider-type/doctors/screening-and-referral.asp

Alcohol use◦ AUDIT and MAST-G: http://www.ncbi.nlm.nih.gov/books/NBK64829/

Suicide risko VHA has developed suicide risk assessment tools for primary care

and other settings, including, but not limited to, a suicide prevention pocket card and guide (http://www.mentalhealth.va.gov/docs/VA029AssessmentGuide.pdf )

Tips for the Home Care Medical Provider:Integrate Screening/Assessment for Common Mental Health Conditions

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AGS Geriatric Evaluation & Management Tools◦ Including on depression, insomnia, dementia-related behavioral

problems◦ http://geriatricscareonline.org/toc/geriatrics-evaluation-management-

tools/B007/

American Psychiatric Association◦ Major Depression Disorder (2010): http://

psychiatryonline.org/data/Books/prac/PG_Depression3rdEd.pdf◦ Other guidelines and tools: http://

psychiatryonline.org/guidelines.aspx

VA/DoD Clinical Practice Guidelines◦ MDD, Bipolar Disorder, PTSD, Substance Use Disorder, Assessment

and Management of Patients at Risk for Suicide◦ http://www.healthquality.va.gov/guidelines/MH/mdd/

Be Aware of Treatment Guidelines

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Ask questions about a patient’s (and caregiver’s) mood, fears, strategies for coping, and reasons for living. This sends message that it is okay to discuss such issues with you.

Provide education for patients and caregivers; normalize behavioral and mental health struggles.

Encourage patients and their caregivers to plan for regular engagement in pleasant activities in their lives, in a manner consistent with their abilities and interests.

Offer Simple Non-Pharmacological Interventions

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Learn and teach patients a few simple relaxation/ mindfulness strategies.

Communicate an attitude of hope that, although things may be difficult, there are always ways to address a problem, either through directly altering the problem in some way or working on one’s ability to cope with the problem.

Help people acknowledge and utilize their strengths, in addition to grieving for losses. Elicit discussion about what people feel grateful for and what gives meaning to life.

Offer Simple Non-Pharmacological Interventions

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NIA Age Pages◦ http://www.nia.nih.gov/health/publication

American Association for Geriatric Psychiatry◦ http://www.gmhfonline.org/gmhf/consumer/index.html

American Psychological Association Office on Aging◦ http://www.apa.org/pi/aging/

Caregivers◦ Family Caregiver Alliance (http://caregiver.org/)◦ VA Caregiver Support (http://www.caregiver.va.gov/)◦ Alzheimer’s Association (www.alz.org)

Resources for Patient/Family (and Provider) Education

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In 2010, 50% of men aged 65 and older were Veterans◦ (http://www.agingstats.gov/Main_Site/Data/2012_Documents/Population.aspx)

Most Veterans are eligible for VA health care For enrollment:

◦ Call 1-877-222-VETS(8387)◦ http://www.va.gov/healthbenefits/apply/

VA Caregiver Support site http://www.caregiver.va.gov/

VA Services for Eligible Veterans

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References Alexopoulos, G. S., Reynolds, III, C. F., Bruce, M. L., et al. (2009). Reducing

suicidal ideation and depression in older primary care patients: 24-month outcomes of the PROSPECT Study. The American Journal of Psychiatry, 166, 882-890.

Bruce, M. L., & McNamara, R. (1992). Psychiatric status among the home bound elderly: an epidemiological perspective. Journal of the American Geriatrics Society, 40, 561-566.

Davitt, J., & Gellis, Z. (2011). Integrating mental health parity for homebound older adults under the Medicare home health care benefit. Journal Of Gerontological Social Work, 54, 309-324.

Edes, T. (2010). Innovations in homecare: VA home-based primary care. Generations, 34, 29-34.

Scogin, F., & Shah, A. (Eds.) (2012). Making evidence-based psychological treatments work with older adults. Washington, DC: American Psychological Association.

Hicken, B. L. & Plowhead, A. (2010). A model for home-based psychology from the Veterans Health Administration. Professional Psychology: Research and Practice, 41, 340-346.

Hunkeler, E. M., Katon, W., Tang, L., et al. (2006). Long term outcomes from the IMPACT randomised trial for depressed elderly patients in primary care. British Medical Journal, 332, 259-263.

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Karel, M. J., Gatz, M., & Smyer, M. (2012). Aging and mental health in the decade ahead: What psychologists need to know. American Psychologist, 67,184-198.

Karlin B. E. & Karel, M. J. (2013). National integration of mental health providers in VA Home-Based Primary Care: An innovative model for mental health care delivery with older adults. The Gerontologist, doi: 10.1093/geront/gnt142, First published online: December 3, 2013.

Karlin, B. E. and A. M. Zeiss (2010). Transforming mental healthcare for older veterans in the Veterans Health Administration. Generations, 34, 74-83.

Post, E. P., Metzger, M., Dumas, P., Lehmann ,L. (2010). Integrating mental health into primary care within the Veterans Health Administration. Fam Syst Health, 28, 83-90.

Qiu, W., Dean, M., Liu, T., George, L., Gann, M., Cohen, J., & Bruce, M. (2010). Physical and mental health of homebound older adults: an overlooked population. Journal Of The American Geriatrics Society, 58, 2423-2428.

Reifler, B., & Bruce, M. (2014). Home-based mental health services for older adults: a review of ten model programs. The American Journal Of Geriatric Psychiatry, 22, 241-247.

Unützer, J., Katon, W., Callahan, C. M., et al. (2002) Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. JAMA, 288, 2836-2845.

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