Michele J. Karel, PhD Psychogeriatrics Coordinator Mental Health Services, VA Central Office [email protected]

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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

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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) ©AAHCM 3

   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 ©AAHCM 4

   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 ©AAHCM 5

   ◦ ◦ ◦ ◦ ◦ ◦ 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 ©AAHCM 6

Evidence-Based Psychological and Psychopharm Assessment and Intervention Care Management Stepped Care Interdisciplinary Care Collaborative Care Patient Centered Care ©AAHCM 7

Depression Anxiety Coping with illness/disability Caregiver/family stress Cognitive/dementia evaluation Adherence Insomnia Chronic pain Grief and loss Behavior management Decision making capacity PTSD Weight management Serious mental illness Substance use TBI 0 20 40 ©AAHCM 60 80 100 8

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 ©AAHCM 9

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

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

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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.pd

◦ f 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/ ©AAHCM 11

 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.

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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

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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

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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

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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

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For enrollment:

Call 1-877-222-VETS(8387) http://www.va.gov/healthbenefits/apply/ VA Caregiver Support site http://www.caregiver.va.gov/ ©AAHCM 15

       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. Health, 28, 83-90.

population. Journal Of The American Geriatrics Society adults: a review of ten model programs. , 58 Fam Syst 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 , 2423-2428. Reifler, B., & Bruce, M. (2014). Home-based mental health services for older 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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