Transcript Integrating Behavioral Health into Aging Communities 2
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
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
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
Partner Agency CU Aging Center Integrated Care Partnerships Integrated Care Team
Silver Key Senior Services Peak Vista Community Health Senior Clinics Program of All-Inclusive Care of the Elderly (PACE) The Resource Exchange Home Based Services Team FQHC Primary Care with Integrated Behavioral Health Adult Day Health Managed Care Palisades at Broadmoor Park – Senior Housing Campus Disabilities Services (Supportive Living Services, Primary Care) Wellness Center Integrated Care (Primary care, physical wellness, psychosocial wellness)
WHO IS SERVED? VARIATION ACCORDING TO THE “AGES” OF AGING
3 rd Age -> 4 th Age -> Final Age 7
The 3
rd
Age
• • Active engagement with community and family Busy life • Onset of physical changes that are manageable
Community life
• • Engaged, socially connected lifestyle – Planned, intentional – Restorative after death of spouse or retirement Safety net – Reduced demands – Availability of services
Transitions: 3
rd
–> 4
th
Age
• 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
Independence requires ability to care for self • • •
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
Mrs. Kingman
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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The 4
th
Age
• • Stability in purpose and meaning but far more limited personal resources Assistance needed
The Last Age
• 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
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!
WHO ARE THE PARTNERS?
AGING SERVICES NETWORKS
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Senior Housing Care Management Telephone Reassurance Leisure Services Home Delivered Meals Transportation Financial Assistance Information & Assistance Respite Care Caregiver 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
Own Home Own Home with Services Senior Congregate Housing Assisted Living Nursing Home Acute Care RESOURCE: AAA, Ombudsman 20
Social Services
Meals on Wheels Respite Care House repair Case or Care Management Transportation Day Programs 21
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 22
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
Health Care Services
• • • • • • Education and health counseling Acute care hospitals Nursing homes Rehabilitation centers Home health care Prevention – wellness promotion 24
WHAT DO WE OFFER?
What do we bring to our partners?
• • • • • Screening Evaluation Triage and Intervention Consultation and Training Program design and evaluation
Rationale: Early detection helps older adults
Early identification Earlier treatment Less loss of function Better well-being 27
Rationale: Early detection helps providers
Early identification Modification of Tx Plan Less resistance Less staff burnout 28
HOW DO WE INTERVENE?
Principles to Guide
• • • Biopsychosocial Model Person-Environment Fit Principle of Least Intrusion
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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
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
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Balance Autonomy and Safety
Across the lifespan, caring requires balance of ethical principles • Autonomy • Beneficence • Justice
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
Illness Onset Pre-CG Family Structure Transition to CG CG Period Early CG Structure Middle CG Structure Late CG Structure Patient Death Post-CG Structure
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Example: Dementia Trajectory 38
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 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.
Memory Concentration Planning Decision-making Follow through on plans Mood Anxiety/Worry Irritability Sadness Depression Apathy Suicidal Thoughts Homicidal Thoughts Social Relations Isolation Withdrawal Inappropriate behavior Other: 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 Aggressive Behavior Suspiciousness Personality Changes Finances Medical Care Safety Issues Household Tasks Self-care/Hygiene Appointments Driving Medical Problems Falls/Balance Nutrition Appetite Incontinence Sleep Energy Level Other: 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7
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.
1 2 3 4 5 6 7 8 9 Ambulation Bathing Dressing Transfers Toileting Eating Grooming Transportation Shopping 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 10 Laundry 11 Medication Administration 12 Food Preparation 13 Heavy Chores 14 Telephone 15 Financial Management 16 Household Tasks 17 Appointment Management 18 Access Resources 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7
• • • •
Families are typically stressed by the costs of Caregiving
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
VALUE TO SOCIETY: $375 BILLION Which is more than spent on Medicaid ($311b) and close to Medicare ($432b)
Cognitive disabilities increase caregiving time needed 50 45 Hrs/ 40 Wk 35 30 25 20 15 10 5 0 No Cogn Impairment Mild Dementia Severe Dementia
Family stressors that predict burden are mental health issues • • 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 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
Our partners FIND the need, we need to address it…
• • • • • Screening Evaluation Triage and Intervention Consultation and Training Program design and evaluation
• • • • •
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