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 CoalitionPrepared 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!!!

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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

ageImplications for Alzheimer’s DiseaseImplications for “care-giving”Implications for “care facilities”Issues of stigmaMultidisciplinary issues – “silos” of careImplications 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

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

Aging and Behavioral Health Collaboration

Collaborative Care Needs ofOlder Adults – Behavioral Health

Behavioral Health disorders among the elderly often go unrecognized or are masked by somatic complaints.Medical treatment for psychiatric illness –

ineffectual careClinical 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 PreventionSupportive interventions including screening,

psycho-education and group activitiesTelephone-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

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.)

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

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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 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

treatmentSAMHSA Strategic plan Substance Abuseand 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.

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.

Google Groups• The Google group is set up and working!

• When you receive the invitation please feel free to join the Google group.

• If you do not received an invitation to the Google groups please email rebecca@olderpa.org.

• When responding to a message on the Google Group we encourage you to respond to ALL in order to share information.

• You may respond to sender only if you only want the information to go to an individual only.

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Please use the GoogleGroup to network with each other, ask for advice, give advice,

share resources, etc.