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Mental Health Services at Home

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Presentation on theme: "Mental Health Services at Home"— Presentation transcript:

1 Mental Health Services at Home
Michele J. Karel, PhD Psychogeriatrics Coordinator Mental Health Services, VA Central Office ©AAHCM

2 Objectives 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 ©AAHCM

3 Mental Disorders among Homebound Older Adults
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

4 Evidence-Based Mental Health Interventions Exist
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

5 Mental Health in VHA Home Based Primary Care Population
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

6 VA Home Based Primary Care Mental Health Initiative
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

7 Integrated Care Model for Mental Health Services in HBPC
Evidence-Based Psychological and Psychopharm Assessment and Intervention Care Management Stepped Care Model Summary: Mental Health Providers are integrated team members who support team in developing holistic, biopsychosocial conceptualization for all Veterans served by team MH Providers work with team to identify select Veterans who would benefit from specialized mental health services MH Providers provide evidence-based behavioral and mental health assessment and intervention From webcourse: The foundations of the house are Interdisciplinary Care, Collaborative Care, and Patient-Centered Care. Without these team-based components of care, the house has an inadequate foundation and can not stand! Building upon those foundations are Care Management and Stepped Care approaches, which refer to strategies teams may use to monitor and determine which patients would benefit from specialized mental health services. The “roof” of the house represents Evidence-Based Mental Health Services, offered to those Veterans who need these specialized mental health services. Many Mental Health Providers’ training focused on the “roof” of the house, i.e., evidence-based mental health assessment and intervention. In HBPC, MH Providers also need to appreciate the critical foundations and building blocks for integrated mental health care. Interdisciplinary Care Collaborative Care Patient-Centered Care ©AAHCM

8 2010 Survey: Clinical Issues Addressed “Often” or “Frequently” by HBPC MH Providers

9 Increasing holistic conceptualization/approach to patient care
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 ©AAHCM

10 Tips for the Home Care Medical Provider: Integrate Screening/Assessment for Common Mental Health Conditions Depression PHQ-2/PHQ-9: GDS: Anxiety GAD7: PTSD Primary Care PTSD Screen: type/doctors/screening-and-referral.asp Alcohol use AUDIT and MAST-G: 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 ( ©AAHCM

11 Be Aware of Treatment Guidelines
AGS Geriatric Evaluation & Management Tools Including on depression, insomnia, dementia-related behavioral problems management-tools/B007/ American Psychiatric Association Major Depression Disorder (2010): f Other guidelines and tools: VA/DoD Clinical Practice Guidelines MDD, Bipolar Disorder, PTSD, Substance Use Disorder, Assessment and Management of Patients at Risk for Suicide ©AAHCM

12 Offer Simple Non-Pharmacological Interventions
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. ©AAHCM

13 Offer Simple Non-Pharmacological Interventions
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. ©AAHCM

14 Resources for Patient/Family (and Provider) Education
NIA Age Pages American Association for Geriatric Psychiatry American Psychological Association Office on Aging Caregivers Family Caregiver Alliance ( VA Caregiver Support ( Alzheimer’s Association ( NIA Age Pages on topics including depression, bereavement, alcohol use, dementia, caregiving, sexuality, sleep AAGP: Consumer Materials The Geriatric Mental Health Foundation publishes a series of brochures for older adults, family members, and caregivers on late-life mental illnesses. View these brochures at and purchase through AAGP's bookstore. Brochure topics inclue: Alcohol/Drug Abuse/Misuse Alzheimer's Disease Anxiety Caregiving Depression Disaster Preparedness and Response Geriatric Psychiatry Healthy Aging Sleep ©AAHCM

15 VA Services for Eligible Veterans
In 2010, 50% of men aged 65 and older were Veterans ( Most Veterans are eligible for VA health care For enrollment: Call VETS(8387) VA Caregiver Support site ©AAHCM

16 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, Bruce, M. L., & McNamara, R. (1992). Psychiatric status among the home bound elderly: an epidemiological perspective. Journal of the American Geriatrics Society, 40, 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, Edes, T. (2010). Innovations in homecare: VA home-based primary care. Generations, 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, 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, ©AAHCM

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

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