Creating A Continuum Of Care For Older Persons With Behavioral Health Needs In Southeast Pennsylvania: continued

Proposed Continuum of Care Model

DVMHAAC proposes a continuum of care for older people within an integrated system of care based on the Community Support Program (CSP) model. Originally developed for adults with serious mental illness, the CSP model is flexible enough to adapt to the varying degrees of behavioral health needs of older adults. The CSP model calls for the development of a wide range of services, and encourages communities to utilize existing resources and facilities. Most importantly, CSP is more than just a collection of service components. Application of the model dictates an organized, coherent, and integrated service system.

CSP Principals

The CSP principles are easily adapted to meet the treatment, rehabilitation, and community services needs of older people with behavioral health needs, and reflect the following:

Services should be person-centered. They should respond to the needs of older adults, rather than those of the system or the providers.
Services should empower people. They should incorporate self-help approaches and allow older adults to retain the greatest possible control over their own lives, including active involvement in all aspects of planning and delivering services.
Services should be racially and culturally appropriate. They should be accessible, and acceptable to racial, ethnic, minority groups, and women, and appropriate to older adults' developmental stages.
Services should be flexible. They should be available when they are needed, for as long as they are needed.
Services should focus on strengths. They should be built on the assets and strengths of older adults in order to maintain their sense of dignity, identity, and self-esteem.
Services should be normalized and incorporate natural supports. They should be offered in the least restrictive, most natural setting possible. Older adults should be encouraged to use natural community supports and be integrated into normal community activities.
Services should meet special needs. They should be adapted to meet the special needs of the elderly.
Services should be accountable. They should be monitored by the state to assure quality of care and continued relevance.
Services should be coordinated. They should be coordinated through mandates and/or written agreements that require ongoing communication and linkages to ensure continuity of care across many systems at the local and state levels.

Components of the Continuum of Care

A continuum of care based on CSP principles will provide a complete range of services and supports for older adults with behavioral health needs, and should include:

Prevention/Education:

An education/ prevention program will confront myths about aging and mental health, explain the signs of mental illness and substance abuse and inform the public on how they can help older adults at risk. Some examples are:

a public campaign to recognize the signs of depression and anxiety and/or medication abuse in elderly providing a hotline number on how to help at risk seniors
a comprehensive guide to geriatric behavioral health resources in the community to help family members and professionals make appropriate referrals
a gatekeeper program to inform health community organizations, religious groups, senior centers, local businesses, utility workers, emergency medical technicians, firemen, policemen and block captains of the behavioral health issues of older adults and the resources available to help them
the Mental Health/Aging Advocacy Project's Web site, www.mhaging.org, currently informs the community of geriatric psychiatric resources

Identification, Outreach and Access:

Research indicates that older adults with behavioral health needs are reluctant to seek out services, a barrier that is frequently complicated by co-occurring physical problems. Effective outreach will engage the elderly in their own environments, be it a boarding home, personal or family residence, or hospital emergency room. Outreach services will include crisis intervention, counseling, medication checks, assistance in meeting basic needs, skills training, and referrals to appropriate community resources. Some examples include:

Develop identification mechanisms which will establish linkages with community-based entities (including boarding homes, churches, district police stations, emergency rooms, inpatient facilities, pharmacists, primary care physicians, public housing facilities, senior centers, etc.) capable of identifying and referring older people in need of services.
Incorporating a mental health screening in all regular health check-ups for seniors, with the primary care physician referring the individual to a behavioral health accessibility team for follow-up will be vital part of the identification component.
In Los Angeles, a simple card carried by police and Adult Protection workers lists steps to take when dealing with older adults thought to be at risk. Training will guide all who deal with older adults on a regular basis to identify those who need help.

Assessment and Evaluation:

The assessment process will be appropriate to the person's culture and level of acculturation, and utilize assessment tools specifically tailored to older adults. Minimally, the assessment will consist of a medical history, psychiatric history, the Mini Mental Status Exam, the Geriatric Depression Rating Scale, and the CAGE and/or HEAT index for substance abuse. Depending on the results, more specific tools may be used. Ideally, behavioral health assessments of older adults will be conducted by an interdisciplinary geriatric team.

Behavioral Health Treatment:

Treatment will be a critical component of the continuum of care. Research indicates that depression, anxiety, and/or some form of dementia are the most common mental disabilities among elderly people. Substance abuse in older persons often consists of misuse of prescription drugs, over-the counter medications, and alcohol abuse. To encourage the use of services and minimize stigma, treatment will be provided, wherever possible, in the individual's home and/or community.

In addition to psychiatric management, mental health treatment will include: counseling, medication management, and linking seniors to stimulation oriented therapies (e.g. art, horticulture, and recreation). The continuum of care for older persons with psychiatric disabilities will include: inpatient, partial hospitalization, intensive outpatient, outpatient, residential, adult day, and mobile therapy options. Specialized treatment facilities for older adults with substance abuse disorders will be needed, and will include detoxification and peer-supportive counseling to prevent relapse and develop strategies for drug-free living.

All treatment will be provided by people with geriatric psychiatric training and a sensitivity to older adult treatment needs. Particular attention will be given to the cultural and family dimensions in treatment. Since many older persons are reluctant to seek treatment in psychiatric settings, treatment in the home or in familiar settings will be preferred. The continuum of care will require that practitioners be regularly updated through continuing education opportunities in geropsychiatry.

Crisis Response Service:

Even when community support services are available, persons with behavioral health needs tend to experience recurrent crises. As a result, the continuum will include crisis assistance that immediately responds to older adults in crisis and members of their support system and that is available 24-hours a day, 7 days a week. Effective crisis services will assist in stabilizing the person and helping him or her to readjust to community living.

Crisis assistance will include telephone services, such as hotlines, and mobile crisis outreach. For individuals in crisis who cannot be assisted in their natural environments, crisis residential services will be available in non-hospital settings, including family-based crisis homes and staffed residences for small groups of older persons in crisis. Inpatient beds will be available for individuals who need a protective environment.

Crisis response staff will be able to distinguish dementia, delirium, and depression, all of which can exhibit similar symptoms in older adults. Likewise, knowledge of medication interaction effects is crucial. Another important consideration is discerning the interaction of physical and mental health problems.

Coordination with Health Care:

Older adults with mental health/substance abuse problems may also have health problems. The continuum of care will ensure a high level of integration of physical and behavioral health care. Geriatric-psychiatric specialists are needed in all district health centers. This strategy will ensure older adults are connected to both medical and behavioral health services, and improve the coordination of care.

An important aspect of coordinating health care for the elderly is insuring that the primary care practitioners are skilled in identifying mental health and substance abuse problems in older adults and in making referrals for treatment. Studies say that many physicians fail to identify depression in older adults.

As older adults with mental health needs near the end of their life, hospice care should be available at home or in an appropriate setting. Mental health supports should be integrated with other hospice services.

Housing:

Any continuum of care for older adults with behavioral health needs will place an emphasis on maintaining people in their own homes. First, affordable housing must be made available for older adults on fixed incomes. It must also include an appropriate range of supported housing options. Individual preferences and values, along with functional level, will be primary considerations in determining an appropriate housing placement. Regardless of the arrangement, the emphasis will be on the most normalizing option. In-home training, supports, and services should be available to both caregivers and the individual served to enable them to live in the residence of their choosing. Clustered apartments provide services and supports in a cost efficient manner. A variety of more structured residential settings may be needed for a small number of more seriously disabled individuals who require a greater degree of attention, supervision or structure.

Behavioral health services should be made available to all older adults confined to nursing homes because of medical conditions. The continuum of care will allow older adults with mental health problems to 'age in place' in whatever setting they desire, whether it be independent living, senior housing, assisted living, personal care homes, or nursing homes.

Care Management:

Care (i.e. case) management services are another vital component. Care management will ensure that older adults receive the services they need. Depending on individual needs and preferences, care managers could be a single person or a team who assumes responsibility for maintaining a long-term, caring and supportive relationship with the individual. All care managers that work with older adults must have training in behavioral health and aging and be skilled in working within the Behavioral Health, Medical and Aging Service systems. A care manager will serve as a friend, helper, service broker and advocate, assisting the person and his or her caregivers to meet defined service needs. Care managers' work will take place in the person's natural environment to the extent possible. In addition to performing traditional case management functions, it is particularly important that they assume responsibility for coordinating health and behavioral health services and ensure the unification of all components within the continuum of care.

Social Rehabilitation:

Social rehabilitation services will help the older adult to gain or regain practical skills needed to live and socialize in the community. Activities will be age-and culturally appropriate and tailored to individual needs and preferences. They will be available in the home or in a group setting, as preferred. These programs will be offered at various senior centers, drop-in-centers and places where seniors gather. All social rehabilitation activities should help the individuals to better deal with the physical/emotional aspects of aging and society's perceptions of older adults.

Social rehabilitation will involve assistance in developing interpersonal relationships and leisure time activities/interests that provide a sense of participation, satisfaction, and enjoyment.

All Senior Centers will have educational activities which will teach the elderly how to cope with the symptoms of their medical and behavioral health problems and with the aging process, in general; how to manage their medications; nutrition and wellness; and how to recognize danger signs.

Employment and volunteer opportunities will be available through senior organizations for those who choose to work or volunteer in the community.

Peer Support:

Peers are one of the most influential groups for older adults and provide a "non-treatment" approach most older adults prefer. Religious groups, community organizations, veteran groups, senior centers and other informal support systems will help identify at-risk adults and help them maintain their treatment. They also serve as an important source for advocating for proper treatment. Training is needed for older adults who can help support and encourage their peers.

Family and Community Support:

Families who provide support and caregiving services to older adults are important gatekeepers and support treatment. However, many caregivers are themselves vulnerable to depression and other forms of mental illness. Respite programs, support programs, and in-home family counseling must be available to families.

Internet Web sites such as www.mhaging.org, should be promoted as an important sources of information and support for family members and caregivers of consumers.

Protection and Advocacy:

Researchers estimate there are over 2 million cases of elder abuse every year, of which half are the result of self-neglect. Older persons with mental health/substance abuse problems are particularly at-risk as victims of elder abuse, but may be afraid or unable to report abuse. Police officers and Protection and Advocacy Staff should be trained in identifying symptoms of mental illness and substance abuse in older adults.

Clear and appropriate protocols that specify how to deal with older adults when there is a question of whether the person is suffering from depression, delirium, and dementia (or a combination of all three), is needed.