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

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Presentation on theme: "Michele J. Karel, PhD Psychogeriatrics Coordinator Mental Health Services, VA Central Office ©AAHCM."— Presentation transcript:

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

2  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 2 ©AAHCM

3  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) 3 ©AAHCM

4  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 4 ©AAHCM

5  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 5 ©AAHCM

6  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 6 ©AAHCM

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

8 8

9 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 9 ©AAHCM

10  Depression ◦ PHQ-2/PHQ-9: ◦ GDS:  Anxiety ◦ GAD7:  PTSD ◦ Primary Care PTSD Screen: type/doctors/screening-and-referral.asp type/doctors/screening-and-referral.asp  Alcohol use ◦ AUDIT and MAST-G:  Suicide risk o 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 ( 10 ©AAHCM

11  AGS Geriatric Evaluation & Management Tools ◦ Including on depression, insomnia, dementia-related behavioral problems ◦ management-tools/B007/ management-tools/B007/  American Psychiatric Association ◦ Major Depression Disorder (2010): f 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 ◦ 11 ©AAHCM

12  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. 12 ©AAHCM

13  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. 13 ©AAHCM

14  NIA Age Pages ◦  American Association for Geriatric Psychiatry ◦  American Psychological Association Office on Aging ◦  Caregivers ◦ Family Caregiver Alliance ( ◦ VA Caregiver Support ( ◦ Alzheimer’s Association ( 14 ©AAHCM

15  In 2010, 50% of men aged 65 and older were Veterans ◦ (  Most Veterans are eligible for VA health care  For enrollment: ◦ Call 1-877-222-VETS(8387) ◦  VA Caregiver Support site 15 ©AAHCM

16  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. 16 ©AAHCM

17  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. 17 ©AAHCM

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