VOLUME 14

NUMBER 1

WINTER 2004

Published by the National Association of Professional Geriatric Care Geriatric Care Management Managers 1604 North Country Club Road Tucson, Arizona 85716-3102 520.881.8008 / phone 520.325.7925 / fax www.caremanager.org

Geriatric Care Management: Integrating Community- based Services for Older Adults with Mental Disorders By Stephen J. Bartels, M.D. page ...... 2 The State of Mental in By Lea C. Watson, M.D., MPH, Malaza Boustani, M.D., MPH page ...... 4 The Role of Geriatric Care Managers in the Identification and Management of in Home By Amy E. Mlodzianowski, MS, CSW, Denise C. Fyffe, Ph.D., Martha L. Bruce, Ph.D., MPH page ...... 8 Integrated Services and Care Management for Older People with Severe Mental Illness By Sarah I. Pratt, Ph.D., Stephen J. Bartels, M.D., M.S., Kim T. Mueser, Ph.D., Aricca D. Van Citters, B.A. page ...... 12 Adapting the Concept of a “WrapAround” Model of Care to Serve Older Adults with Mental Illness By Keith M. Miles, MPA; Bernie Seifert, LICSW; Jeanne Duford, MSW page ...... 19 Caring for Older Americans with Mental Illness: Geriatric Care Management and the Workforce Challenge By Aricca D. Van Citters, B.A. and Stephen J. Bartels, M.D., M.S. page ...... 25 GCM winter 2004

13.5% of home health care recipients Geriatric Care have a major depressive illness, and provide an overview of the syndrome and associated poor outcomes, Management: Integrating including greater mortality from poor health and suicide. The presence of Community-based medical illness and functional disabili- ties contributes to under-recognition Services for Older Adults and under-treatment of depression in this high-risk population. The authors with Mental Disorders suggest that GCMs can play an important role in addressing these By Stephen J. Bartels, M.D., M.S. needs by facilitating identification, coordination, education, advocacy, support, and counseling. Over the next three decades, the mentation of services has been cited Although depression is the most number of older adults with major as among the most significant impedi- common major psychiatric illness psychiatric illnesses will more than ments to adequate and appropriate affecting older adults, older adults with double, from 7 million currently to 15 treatment (Bartels, 2003). This issue severe mental illness are a rapidly million individuals in the year 2030 presents a series of articles addressing growing subgroup. Pratt, Bartels, (Jeste, et al., 1999). Mental disorders major challenges in providing services Mueser and Van Citters describe the in older persons are associated with to older adults with psychiatric illness special needs of the growing subgroup poor health outcomes, increased living in the community, and offers of older adults with schizophrenia and morbidity, greater risk of mortality, and insights into the role of the geriatric other severe mental illnesses. This increased service use, including care manager in helping to enhance article suggests that older adults with greater rates of emergency room visits, access and coordination for services. severe mental illness comprise a challenging subgroup who have acute hospitalizations, and institution- Key settings in need of coordi- complex psychiatric presentations alization in homes (Bartels, nated and physical including psychotic symptoms such as 2002, Druss, et al., 1999, Druss, et al., health include assisted living and hallucinations and delusions, as well as 2001, Luber, et al., 2001, Unützer, et al., home health care. In the first paper of disorders of thought and . 1997, Unützer, et al., 2000). A substan- the series, Watson and Boustani These symptoms combined with tial body of research documents provide an overview of mental health medical place older adults effective approaches to the recogni- problems in assisted living, as the with severe mental illness at especially tion and treatment of late life mental fastest growing sector of long-term high risk of poor community function- disorders, yet there is a major gap care. Recent surveys reveal that one ing, poor health outcomes, and between research knowledge and the in four residents in assisted living premature placement in nursing homes. provision of adequate and appropriate have significant depressive symptoms Pratt and colleagues describe a treatments in the community (Bartels, and less than 40% of these individuals biopsychosocial model of care manage- et al., 2002). Older adults with psychi- receive treatment for their depression. ment that supports coordination of atric illness are more likely to receive Depression in Assisted Living is medical care, rehabilitative services, poor quality medical care services associated with poor outcomes, and social supports. compared to older adults without a including premature placement in (Bartels, 2002, Druss, nursing homes. Watson and Boustani In the following article, Miles, et al., 2001). Furthermore, older adults provide an overview of common Seifert, and Duford describe a commu- compared to younger adults with disorders in assisted living and nity-based wraparound model of care psychiatric illness are more likely to suggest that geriatric care managers for older adults with mental illness and receive inappropriate psychiatric can play an important role by promot- the key role of geriatric care managers. treatment (Bartels, et al., 1997). A ing screening and coordinated This model is based on an adaptation variety of barriers to care have been management of mental disorders. of successful wraparound management cited, including lack of financial of high-risk children in the community Home health care is another resources, lack of transportation, and includes a routine wraparound service delivery setting for older stigma associated with mental illness team meeting consisting of representa- adults that is associated with high and psychiatric services, ageism, lack tives from different community agen- rates of medical and psychiatric of trained providers with expertise in cies and provider groups. The authors comorbidity. Mlodzianowski, Fyffe aging and mental health, and an describe ten practices for successful and Bruce report that approximately inadequate array of services. Frag- implementation of the model. In (continued on page 3)

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Geriatric Care References Management: Integrating Bartels SJ, Horn S, Sharkey P, Levine K. “Treatment of depression in older primary Community-based care patients in health maintenance organizations.” International Journal of Services for Older Adults in Medicine. 1997;27(3):215-231. with Mental Disorders Bartels SJ. “Quality, costs, and effectiveness of services for older adults with mental (continued from page 2) disorders: a selective overview of recent advances in geriatric mental health services research.” Current Opinion in Psychiatry. 2002;15(4):411-416. addition, practical recommendations Bartels SJ, Dums AR, Oxman TE, Schneider LS, Areán PA, Alexopoulos GS, Jeste are provided based on lessons DV. “Evidence-based practices in geriatric mental health care.” Psychiatric Services. learned from implementation of this 2002;53(11):1419-1431. model in a demonstration project in Bartels SJ. “Improving the ’ system of care for older adults with mental New Hampshire. illness: findings and recommendations for the President’s New Freedom Commission Finally, Van Citters and Bartels on Mental Health”. American Journal of Geriatric Psychiatry. 2003;11(5):486-497. describe the current and future Druss BG, Rohrbaugh RM, Rosenheck RA. “Depressive symptoms and health costs challenge of care management in the in older medical patients”. American Journal of Psychiatry. 1999;156:477-479. context of a growing population of Druss BG, Bradford WD, Rosenheck RA, Radford MJ, Krumholz HM. “Quality of older persons with mental disorders medical care and excess mortality in older patients with mental disorders”. Archives of and a major workforce shortfall. This General Psychiatry. 2001;58(6):565-572. article reviews the current status of Jeste DV, Alexopoulos GS, Bartels SJ, Cummings JL, Gallo JJ, Gottlieb GL, Halpain geriatric training programs and MC, Palmer BW, Patterson TL, Reynolds CF, III, Lebowitz BD. “Consensus recruitment for mental health and statement on the upcoming crisis in geriatric mental health: Research agenda for the general health care providers. The next 2 decades.” Archives of General Psychiatry. 1999;56(9):848-853. authors conclude that substantial Luber MP, Meyers BS, Williams-Russo PG, Hollenberg JP, DiDomenico TN, reforms are needed in the training, Charlson ME, Alexopoulos GS. “Depression and service utilization in elderly primary recruitment, and reimbursement of care patients.” American Journal of Geriatric Psychiatry. 2001;9(2):169-176. geriatric providers if we are to Unützer J, Patrick DL, Simon G, Grembowski D, Walker E, Rutter C, Katon W. address the emerging mental health “Depressive symptoms and the cost of health services in HMO patients aged 65 years needs of older adults. and older.” Journal of the American Medical Association. 1997;277(20):1618-1623. Unützer J, Simon G, Belin TR, Datt M, Katon W, Patrick D. “Care for depression in The recent report on Older HMO patients aged 65 and older.” Journal of the American Society. Adults for the Presidents New 2000;48(8):871-878. Freedom Commission on Mental Health cited three major areas for policy reform in order to meet the mental health needs of older EDITORIAL BOARD Americans: (1) improving access, (2) improving quality of services, and Rona Bartelstone, MSW (3) addressing the workforce Fort Lauderdale, FL shortfall of geriatric providers Lenard W. Kaye, Ph.D. (Bartels, 2003). This timely collec- Bryn Mawr, PA tion of articles suggests that Geriatric Care Management Karen Knutson, MSN, geriatric care managers should seek MBA, RN training opportunities to become Charlotte, NC knowledgeable in the evaluation and Monika White, Ph.D. service coordination of mental Santa Monica, CA disorders and should play an important role in helping to meet the EDITOR--IN CHIEF Published by the: Marcie Parker, Ph.D. growing need. National Association of Golden Valley, MN Professional Geriatric Care Managers 1604 North Country Club Road Stephen J. Bartels, M.D., M.S. is the Tucson, Arizona 85716-3102 director of the Aging Services COMMUNICATIONS www.caremanager.org DIRECTOR Division of the New Hampshire- Published quarterly for members of GCM Jihane K. Rohrbacker Dartmouth Psychiatric Research Non-member subscriptions: $95.00 per year Tucson, AZ Center and Associate Professor of © Copyright 2003 Psychiatry at Dartmouth Medical GRAPHIC School in Lebanon, NH. He is also The GCM Journal is published as a membership benefit to members DESIGNER of the National Association of Professional Geratric Care Managers. Kristin L. Hager the Medical Director for the New Non-members may subscribe to GCM Journal for $95.00 per year. McKinney, TX Hampshire Division of Behavioral Send a check for your one-year subscription to: Subscription Depart- Health and the Director of the New ment, GCM, 1604 N. Country Club Road, Tucson, AZ 85716-3102. Hampshire Behavioral Health Policy Institute. PAGE 3 GCM winter 2004

in 2.5 years), and 70% of payments came from private funds at an average The State of Mental cost of $1800 per month. The health services included in the base fee were Health in Assisted Living highly variable, but most often consisted of provided or arranged By Lea C. Watson, M.D., MPH and (meaning the facility helped bring in the necessary services for an addi- Malaza Boustani, M.D., MPH tional fee) nursing care. Staffing issues were also found to be a large problem in AL. The cycle of low pay and staff turnover has The State of Mental What is Assisted Living? prevented recruitment of high quality Health in Assisted The term assisted living (AL) direct care staff, in many cases Living refers to any residential setting not thwarting attempts to ensure continu- Due to discontent over the licensed as a that ity of high quality care. Although current long-term care system in the provides or arranges supportive and most AL facilities employ certified United States, older adults have health care services for individuals nurse assistants (CNA’s), only 70% expressed strong preferences to who require assistance with daily employ an RN or LPN (Kovner & avoid living in nursing homes activities (Kane & Wilson, 1993). AL Harrington, 2003). Staffing ratios vary (Mattimore, et al., 1997). Assisted facilities provide congregate meals, dramatically from facility to facility, living (AL) has been put forward as laundry and housekeeping services, ranging from one staff member to 6 an alternative long-term care setting assistance with activities of daily residents to as few as one for over 100 that promotes resident autonomy living (ADLs), and some social residents at night (National Center for and choice in an attractive and activities. Such facilities are regulated Assisted Living, 1998). CNA’s were home-like environment. The by each individual state. Each state interviewed and 88% thought Assisted Living Federation of oversees AL facilities in different confusion was normal, even when it America estimated that there were ways, in some cases requiring no was of sudden onset. Seventy-eight close to one million residents of licensed nursing presence, and in percent thought that depression was assisted living in 2001 (ALFA, 2001). other cases, ensuring licensed staffing normal, 60% did know how to The annual growth rate of AL is levels similar to nursing homes. properly manage agitated behaviors estimated at 15-20% (Cummings, Because of the marked heterogeneity and a majority thought that any 2002), and it is projected that the of these facilities and lack of mandate psychiatric symptom was just a part number of AL beds will equal or to assess residents for possible mental of normal aging (Hawes & Phillips, exceed that of nursing homes by illness (in contrast, nursing homes are 2000). Although most acknowledged 2005 (Meyer, 1996; Meyer, 1998). required to screen for and relative satisfaction with their jobs, depression), very little is known about Older adults entering assisted CNA’s had a 200% turnover rate the detection and management of living are usually making this move within one year. The number one psychiatric problems in this setting. due to a decline in physical or complaint when asked about address- mental functioning. They also face A national survey commissioned ing psychiatric issues was not having significant life transitions and may by the Department of Health and enough time to do anything but the be vulnerable to depressive illness. Human Services in 1995 provided the (continued on page 5) Although often conceptualized as first overview of an alternative or intermediate step to the modern notion of assisted living nursing homes, AL facilities house a TABLE 1 significant burden of illness, in this country (Hawes & Phillips, including a high prevalence of Demographics of Assisted Living dementia with its related agitation, 2000). They found as well as depression. Because the that 67% of these 50% are over age 85 mission of AL is grounded more in a facilities had more “social” model (having emerged than 100 beds, The majority are white, widowed females from the hospitality industry, where 21% had 51-100 the focus is on attractive surround- beds, and 12% had 30% have 3 or more ADL dependencies fewer than 50 ings and available amenities) of care Half have 5 or more medical conditions than a medical model, stakeholders beds. Annual need to consider the implications of resident turnover 1/3 have serious hearing and vision problems potentially unmet mental health was 41% (with a needs in this setting. complete turnover ADL = activities of daily living

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The State of Mental Dementia reported to demonstrate agitated Health in Assisted Living Dementia is by far the most behaviors at least once a week. Thirteen percent had aggressive (continued from page 4) common psychiatric diagnosis in AL. The CS-LTC sample showed that agitated behaviors, 20% had mandatory tasks, such as feeding and greater than 50% of assisted living physically non-aggressive agitated bathing. Adequate training on the residents suffer from a dementing behaviors, 22% had verbal agitated recognition and management of illness (Figure 1), and in the study that behaviors, and 13% resisted taking mental health issues needs to be used extensive diagnostic interview- medication or assistance in care. included in any future workforce ing by trained geriatric psychiatrists, Those with dementia, depression, initiatives. there was an even higher prevalence psychosis or greater need for of 68% (Rosenblatt, et al., 2003). The assistance with ADL’s had the most What do Residents of majority of these residents had mild to problems with agitation (Gruber- Assisted Living Look moderate cognitive impairment, Baldini, et al., 2002). Like? Assisted living facilities house an old and frail population, with signifi- FIGURE 1 cant medical problems and functional deficits (Table1). It is also overrepre- Dementia status in the CS-LTC sented by white, educated and Based on the Minimum Dataset Cognition Scale (Hartmaier, et al., 1994) economically advantaged residents. More than half require help with 50 personal hygiene, the majority require 45 assistive devices for mobility, and on 40 45 average, AL residents take five to six 35 prescription medications daily 30 (Sloane, et al., 2002). 25 28 Prevalence of 20 25 Psychiatric Diagnoses 15 10 Within the context of a social model of care, several research groups 5 9 have begun trying to understand the 0 medical implications of mental health % None Mild Moderate Severe issues in AL facilities. In the Collabo- rative Studies of Long-Term Care (CS- LTC) investigators interviewed more although only 30-40% of these were Depression receiving cholinesterase inhibitor than 2000 residents living in approxi- Late-life depression is particularly mately 200 facilities from four different medications that are the standard of care for this level of dementia. difficult to detect because many older states, along with their caregivers and adults do not complain of typical facility administrators, to determine Because such medications have been shown to delay functional decline and depressive symptoms such as the overall process and quality of care sadness. We found that many in assisted living (Zimmerman, et al., preserve independence, it is in the interest of AL advocates to address residents displayed symptoms of 2001). In another study designed depression such as worrying, tearful- specifically to address psychiatric the underuse of these proven treat- ments (Boustani, et al., 2003). ness, or (Table 2). Thirteen diagnoses, a group in Maryland has percent in CS-LTC and 24% in MD-AL interviewed approximately 200 Agitation met criteria for clinically significant residents of assisted living, and is depression, although of those currently following them over time Agitation, disturbed behavior, depressed, only 18% and 42% (the MD-AL study) (Rosenblatt, et al., and behavioral problems, terms that respectively, were receiving anti- 2003). Findings from these two studies have been used to describe inappro- depressants (Watson, et al., 2003). shed light on the face of mental illness priate verbal, vocal, or motor activity in the fastest growing sector of long- exhibited by older persons with In the CS-LTC sample, depression term care. These studies do not dementia or other psychiatric disor- was more common in those having include facilities targeted to older ders (Cohen-Mansfield & Billig, 1986), more medical conditions, social patients with a predominant diagnosis are common in this setting of long- withdrawal, psychosis, or agitation. Of of schizophrenia or mental retardation. term care. In the CS-LTC sample, particular interest to those wishing to approximately one-third of subjects remain in assisted living is the (with or without dementia) were (continued on page 6)

PAGE 5 GCM winter 2004

The State of Mental are not routinely monitored, and and they can provide continuity for Health in Assisted Living impaired residents may go unrecog- patients and families trying to nized. negotiate the various services (continued from page 5) required of impaired clients. Specific association of depression with Service Utilization training on the recognition of depres- nursing home transfer. When control- Very little is known about whether sion and dementia is feasible and ling for measures of illness severity, or not residents of assisted living would further empower Geriatric Care residents depressed at baseline receive mental health services, and if Mangers not only to facilitate required transfer to a nursing home so, where they receive these services. services, but also to identify clients in 50% sooner than non-depressed Data from the MD-AL reveal that only need of mental health intervention. residents. Similar to other studies of 30% of those with depression or AL is a part of the senior housing dementia have a market that is certain to have contin- usual source of ued growth. More states are begin- TABLE 2 psychiatric care, ning to offer subsidies for AL and a negligible services, hopefully opening the door Most frequently noted signs of number receive to these facilities for individuals with depression in the CS-LTC those services in fewer economic means. Concurrent the facility where with this growth, there is much debate Anxious, rumination, worrying 37% they live. Making about how AL should be regulated, services accessible and by whom. This debate reflects the Sad expression, sad voice, tearful 25% will be central to difficult balance between assuring that Unable to enjoy pleasant events 18% the successful health needs are addressed, while management of preserving the creativity, innovation Easily annoyed, short-tempered 28% these common and autonomy that distinguish AL disorders. The from other long-tem care options. The congregate nature Adapted from the Cornell Scale for Depression in demographics reveal a population that Dementia (Alexopoulos, et al., 1988) of assisted living is looks more suited to a nursing home a wonderful than a resort, but will “medicalizing” opportunity to assisted living ensure better detection depression and mortality (Rovner, centralize these efforts by bringing in and management of mental illness? 1993; Unutzer, et al., 2002), severely mental health specialists, but will The nursing home experience has depressed residents also had 2.1 times require action on the part of facility produced mixed results (Snowden, et the rate of dying within the year managers, providers and family al., 1999), so we should not assume compared to non-depressed residents members. that merely mandating screening will (even when accounting for medical translate into improved outcomes. illness) (Watson, et al., 2003). Future Directions The U.S. Senate Special Commit- Other Psychiatric Professional geriatric care tee on Aging has established an Diagnoses managers (PGCMs) are uniquely Assisted Living Workgroup to positioned to play a valuable role in address the growing concerns about The current state of research is the fragmented system of service how these facilities are managed, and largely limited to dementia and delivery for mental health in assisted they have recently proposed guide- depression, but we know that anxiety living. They can advocate for consis- lines for operations (http:// disorders, disorders, and alcohol tent mental health screening and www.aahsa.org/alw.htm). Although dependence are common in older management for existing clients the issue of screening for health adults (Lenze, et al., 2000; Oslin, 2000). without known psychiatric conditions, issues was introduced, specific plans The MD-AL research team is begin- they can help to coordinate services to detect and manage mental health ning to analyze relevant data for these once psychiatric diagnoses are made, diagnoses, but until these and future (continued on page 7) data emerge, clinicians should consider these problems likely and treatable. Alcohol abuse and depen- Professional geriatric care managers dence is a special problem in assisted living, because in many facilities (PGCMs) are uniquely positioned to residents are allowed if not encour- play a valuable role in the fragmented aged to maintain their “normal” routines as they make this transition. system of service delivery for mental This works in favor of preserving their health in assisted living. autonomy; however, the purchase, storage, and consumption of alcohol

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The State of Mental settings. In particular, he is working Connors AF Jr, Lynn J, Oye RK. Health in Assisted Living on using an interdisciplinary team- “Surrogate and physician understanding based approach to advance the of patients’ preferences for living (continued from page 6) management of behavioral distur- permanently in a nursing home.” Journal bances related to dementia. of the American Geriatrics Society. 1997; issues are not addressed. Some level 45:818-824. of standardization is inevitable, however, and advocates for quality References Meyer H. “Egging people on. Long-term care.” Health Network. 1996; mental health care in older adults Alexopoulos G, Abrams R, Young R, 70:36-38. should not be left behind when these Shamian C. “Cornell Scale for Depression in Dementia.” Biological Psychiatry 1988; decisions are made. Meyer H. “The bottom line on assisted 23(3):271-284. living.” Hospital Health Network. 1998;72:22-26. Conclusions ALFA. Assisted Living Federation of America. 2001 Overview of the Assisted National Center for Assisted Living. The mission of AL is to help older Living Industry Supplement Report. Facts and Trends: The Assisted Living adults retain autonomy, privacy, and Faifax, Virginia: PricewaterhouseCoopers, Sourcebook. Washington, DC, American quality of life in a personalized setting. LLP. 2001. Healthcare Administration. 1998. There is growing evidence of unmet Boustani M, Sloane P, Zimmerman S, Oslin DW. “Alcohol use in late life: mental health needs in AL that may Williams C, Reed P, Gruber-Baldini A, disability and comorbidity.” Journal of prevent the fulfillment of this mission. Preisser J. "Evidence-Based Management Geriatric Psychiatry and . of Dementia Related Agitation In 2000; 13(3):134-40. One in four residents is depressed, Residential Care/Assisted Living Facili- less than 40% of these are receiving ties." (Abstract) The Gerontological Rosenblatt A, Samus Q, Steele C, Harper treatment, and depressed residents Society of America Annual Meeting: San M, Baker A, Liang K, Brandt J, Rabins require transfer to a nursing home 50% Diego, California: November 21-25, 2003. P, Lyketsos C. "Dementia and Psychiat- ric Disturbances in Assisted Living: sooner than non-depressed residents. Cohen-Mansfield J, Billig N. “Agitated Prevalence, Treatment and Conse- behaviors in the elderly. I. A conceptual The majority of AL residents have quences." (Abstract). AAGP 16th review.” Journal of the American some form of dementia, many with Annual Meeting Abstracts; Honolulu, Geriatrics Society 1986; 34:711-721. associated agitation, yet only one- Hawaii. March 1-3, 2003. Cummings SM. “Predictors of psycho- third of those eligible are receiving Rovner BW. “Depression and increased medications. Overall, very few logical well-being among assisted-living residents.” Health and Social Work. risk of mortality in the nursing home residents have any usual source of 2002; 27: 293-302. patient.” American Journal of Medicine. psychiatric care. Efforts should be 1993; 94: 19S-22S. Gruber-Baldini A, Boustani M, made to detect and treat depression, Zimmerman S, Sloane P. “Agitation in Sloane PD, Zimmerman S, Brown LC, dementia and agitation in AL, both to Assisted Living Facilities: Prevalence and Ives TJ, Walsh JF. “Inappropriate reduce suffering and prolong the Risk Factors.” Journal of the American medication prescribing in residential care/ resident’s ability to remain in their Geriatrics Society 2002; 50(Suppl 4): S98. assisted living facilities.” Journal of the American Geriatrics Society 2002; preferred environment. The PGCM is Hartmaier SL, Sloane PD, Guess HA, 50:1001-1011. exceptionally positioned to play a vital Koch GG. “The MDS Cognition Scale: a role in bridging this divide. valid instrument for identifying and Snowden M, McCormick W, Russo J, staging nursing home residents with Srebnik D, Comtois K, Bowen J, Teri L, dementia using the minimum data set.” Larson EB. “Validity and responsiveness Dr. Watson is currently a fellow in Journal of the American Geriatrics of the Minimum Data Set.” Journal of the geriatric psychiatry at Duke Univer- Society. 1994; 42:1173-1179. American Geriatrics Society. 1999; 47:1000-1004. sity Medical Center, and in July 2004 Hawes C, Phillips C. High Service or will be an Assistant Professor of High Privacy Assisted Living Facilities, Unutzer J, Patrick DL, Marmon T, Psychiatry at the University of North Their Residents and Staff: Results from a Simon GE, Katon WJ. “Depressive Carolina at Chapel Hill. In addition National Survey. Washington, DC. symptoms and mortality in a prospective to providing clinical care and Department of Health and Human study of 2,558 older adults.” American teaching, she performs research in the Services. 2000. Journal of Geriatric Psychiatry 2002; 10:521-530. detection and management of late-life Kane R, Wilson K. Assisted Living in the depression and dementia, with United States: A New Paradigm for Watson LC, Garrett JM, Sloane PD, specific focus on long-term care Residential Care for Frail Older Persons? Gruber-Baldini AL, Zimmerman S. settings. Washington, DC. AARP Public Policy “Depression in Assisted Living, Results Institute. 1993. From a Four-State Study.” American Journal of Geriatric Psychiatry. 2003; Dr. Boustani is an Assistant Professor Kovner CT, Harrington C. “Nursing care in assisted living facilities.” American 11:534-542. of Medicine and geriatrician at the Journal of Nursing. 2003; 103:97-98. Indiana University Center for Aging Zimmerman S, Sloane PD, Eckert JK. Research and Center Scientist at the Lenze EJ, Shear K, Mulsant BH, “Overview of the collaborative studies of Reynolds CF. “Anxiety disorders in late long-term care” in Editors: Zimmerman S, Regenstrief Institute, Indianapolis, Sloane PD, Eckert JK. Assisted Living: Indiana. Dr. Boustani’s research life: an evolving picture.” CNS Spectrum. 2000; 7:805-810. Needs Practices and Policies in Residen- focuses on improving the quality of tial Care for the Elderly. Baltimore, MD. life of patients with dementia in both Mattimore TJ, Wenger NS, Desbiens NA, Johns Hopkins University Press, pp long-term care and primary care Teno JM, Hamel MB, Liu H, Califf R, 117-143, 2001.

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community for diagnosing depression. The Role of Depression is a complex mental disorder consisting of multiple Geriatric Care symptoms (see Figure 1). Criteria that guide the assessment of major Managers in the depression include: (1) A diagnosis cannot be made Identification and without the presence of either depressed mood or diminished interest in work or activities Management of (the two “gateway” symptoms.) (2) Other symptoms such as sleep Depression in Home disturbance, appetite change, and difficulty concentrating Health Care must accompany the gateway By Amy E. Mlodzianowski, MS, CSW, symptoms. (3) Symptoms must be pervasive Denise C. Fyffe, Ph.D., and and lasting (present for most of the day and nearly every day Martha L. Bruce, Ph.D., MPH for a 2-week period or longer.) Introduction 13.5% (Bruce et al, 2002). (4) Symptoms are not due to the direct physiologic effects of a Home health care is a growing The discussion in this section about the assessment of depressive drug or general medical sector in today’s health care world, condition. with older adults representing the symptoms follows criteria for a Major largest percentage of home care Depressive Episode established by (5) If symptoms follow the loss of a recipients (72%) (Haupt & Jones, 1999). the Diagnostic and Statistical Manual- loved one, they must persist for The mental health needs of older home IV (DSM-IV) (APA, 1994), the longer than 2 months. healthcare patients have been mini- accepted standard in the psychiatric (continued on page 9) mally explored. In this article we will report on the prevalence of DSM-IV major depression in home healthcare FIGURE 1 patients, the nature of late-life depres- sion in this population, and the role of Criteria for Major Depressive Episode (DSM-IV) professional geriatric care managers Five (or more) of the following symptoms have been present during the (PGCMs) in addressing this public same 2-week period and represent a change from previous functioning; health issue. at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. What is Depression? 1. Depressed mood throughout most of the day, nearly every day. Depression is an illness that is 2. Markedly diminished interest or pleasure in all, or nearly all, activities characterized by psychological, most of the day, nearly every day. behavioral and functional symptoms. 3. Significant weight loss when not dieting or weight gain (e.g., a Major depression in late life is a change of more than 5% of body weight in 1 month), or a decrease or significant public health problem increase in appetite nearly every day. affecting nearly one million Americans over the age of 65 (Lebowitz, 1996). 4. or hypersomnia nearly every day. The prevalence of major depression 5. Psychomotor agitation or retardation nearly every day (observable by among older adults within the commu- others, not merely subjective feelings of restlessness or being nity varies across settings. According slowed down). to the National Institutes of Health 6. Fatigue or loss of energy nearly every day. Consensus Development Panel on 7. Feelings of worthlessness or excessive guilt nearly every day. Depression in Late Life (1992), the prevalence of major depression among 8. Diminished ability to think or concentrate, or indecisiveness, nearly older adults living in the community is every day. estimated at less than 3%, and 5% in 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal primary care settings. Among home ideation without a specific plan, or a suicide attempt or a specific healthcare patients it is estimated that plan for committing suicide. the prevalence of major depression is

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The Role of Geriatric Care Managers in the Identification and Patients’ immediate needs, including personal Management of Depression in Home care, medication management, and mobility Health Care issues, are a clear concern for patients, (continued from page 8) health professionals, and family members. There are other depressive disorders such as minor depression and adjustment disorders, which can present with similar symptoms psychiatric disorders with patients Role of the Professional as major depression, but are not as (Brown et al, 2003). Geriatric Care Manager severe or pervasive. Often patients Patients’ immediate needs, in Depression with these disorders can be treated including personal care, medication Management with supportive counseling, but management, and mobility issues, As a frontline service provider also must continue to be monitored are a clear concern for patients, to older adults, the PGCM is in the for changes in frequency or severity health professionals, and family unique position of having direct of symptoms. members. Caregivers often over- contact with older homebound look signs of depression or adults and is often the first service Nature of Depression in attribute symptoms to the professional to assist older adults Home Health Care individual’s medical problem(s) and their families in meeting care Depression among older home and/or disabilities rather than arrangements. PGCMs serve as healthcare patients is prevalent, but recognizing symptoms of depres- active participants in the lives of often is unrecognized and under sion. Medical illness, functional their patients and can have a treated (Bruce et al, 2002). Home disabilities, and psychosocial “therapeutic” and administrative healthcare patients are at higher risk stressors complicate the recogni- relationship that is unlike any other of depression due to comorbid tion of depression and create health professional. The PGCM’s medical illnesses and functional challenges in accurately assessing role is broad and encompasses many impairment. Rehospitalization, depression (Raue et al, 2002). A aspects of the patient’s life. Conse- increased service utilization, earlier prolonged course of depressive quently, PGCMs have an advantage mortality, diminished quality of life, illness as well as the risk of suicide of observing the psychological (e.g., and caregiver burden are common and mortality result from a failure to negative self-statements) and negative outcomes of untreated recognize and treat depression functional (e.g., psychomotor depression in older adults (Charney (Brown et al, 2003). retardation) outcomes of depression et al, 2003). For clinicians and Despite these challenges, the on their older patients’ well being. PGCMs, the medical and functional comprehensive knowledge of PGCMs can serve in multiple roles in burden experienced by home PGCMs makes them essential depression identification and healthcare patients are complicating players in the depression manage- management. factors in the identification and ment team. Home healthcare 1) Identification: PGCMs with management of depression. provides a treatment setting that clinical background and training promotes a multidisciplinary can assist in the assessment of Obstacles and approach between medical, psychi- depressive symptoms by Opportunities for atric, and social services. This screening for the gateway Depression setting offers the opportunity to symptoms of depressed mood Management in Older bring together the expertise of and/or diminished interest. Homebound Patients professionals from a variety of PGCMs clinical sensitivity can With the medical and func- backgrounds including nurses, be established through familiar- tional needs of older home geriatric care managers, social ity with the DSM-IV criteria as healthcare recipients at the forefront workers, psychologists and other well as an awareness of changes of care, mental health needs often health professionals. PGCMs are in patient behavior (Raue et al, go undetected. Home healthcare an important link between all 2002). These clinical observa- providers are in the position of professionals involved with the tions can indicate the need for having regular direct contact with patient. Approaching identification further evaluations. Assess- patients, but have indicated that and management of depression ment tools are available to they receive inadequate training in from a team perspective benefits the supplement clinical observa- the assessment of depression and patient and the family and lessens tions such as: the Geriatric feel uncomfortable addressing the burden of care providers. (continued on page 10)

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The Role of Geriatric Care Managers in the Identification and Educating and training PGCMs in Management of depression assessment and Depression in Home management is key in developing their Health Care strengths as active professionals in (continued from page 9) the mental health care of patients. Depression Scale (GDS; Yesavage et al, 1988), the Beck Depression Inventory (BDI; Beck & Steer, 1988), the Cornell Scale for can also serve as a link between management. For example, a Depression in Dementia (CSDD; the family and different medical, PGCM can provide support to the Alexopoulos et al, 1988), and the psychiatric, and social service patients and encourage depres- Hamilton Depression Rating Scale providers. sion treatment compliance. (Hamilton, 1960). 3) Educators: PGCMs can educate All of these roles make PGCMs 2) Coordinating Care: Older adults the patient and their families key players in the identification and often use multiple medical, about the various biological and management of older patients with psychiatric, and support services. psychosocial causes of depres- depression. Limited communication among sive symptoms, the effect of (continued on page 11) service providers results in care depression on the patient (e.g., fragmentation. Lack of contact nonadherence), as well as between medical and mental treatment recommendations and FIGURE 3 health care providers is a barrier community resources (Figure 2 to appropriate care for late life and Figure 3). depression. PGCMs can assist Mental Health with this problem through their 4) Advocacy: PGCMs can serve as Resources role in the coordination of care. advocates for depressed frail For example, PGCMs can coordi- patients who may suffer from On the Web: nate referrals to mental health limited self-responsibility and www.nimh.gov services for the patients and poor quality of life (Figure 2 and Figure 3). (National Institute of Mental family (Figure 2), as well as, Health) liaison between mental health 5) Support and Counseling: www.mentalhealth.org professionals and medical PGCMs can offer social support professionals working with the (Substance Abuse and Mental and counseling to patients and Health Information Center) patient. In addition, the PGCM their families about depression www.nami.org (National Alliance for the Mentally Ill) FIGURE 2 www.dbaaliance.org (Depression and Bipolar Mental Health Services in the Community Support Alliance)

z Family physician or health care provider z Mental health division of your local health department In Print: z Community mental health center NIH Consensus Panel on Diagnosis and Treatment of z Family services agency, such as Catholic Charities, family services, or Jewish Social Services Depression in Late-Life. JAMA, 1992; 268(8):1018-1024. z Professional counselor who works in a mental health center, outpatient, clinic, private or group practice, general or psychiatric AHCPR Clinical Guidelines for hospital or nursing home Treatment of Major Depression (Depression Guideline Panel, z Pastoral counselor/member of the clergy 1993) z Self-help or mutual support group z Mental health or crisis hotline, drug hotline, or suicide prevention center z Hospital emergency room

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The Role of Geriatric Brown EL, McAvay G, Raue PJ, Moses Care Managers in the Dr. Bruce is Professor of Sociology S, Bruce ML. “Recognition of depression in Psychiatry, Weill Medical among elderly recipients of home care Identification and College of Cornell University. Dr. services.” Psychiatric Services 2003; Management of Bruce is the principal investigator 54(2):208-213. Depression in Home of several NIMH funded grants Health Care including the Weill Cornell Bruce ML, McAvay GJ, Raue PJ, Brown Homecare Research Partnership. EL, Meyers BS, Keohane DJ, Jagoda DR, (continued from page 10) Dr. Bruce’s formal training Weber C. “Major depression in elderly home health care patients.” American Recommendations and includes medical sociology (Ph.D., Yale), health services research Journal of Psychiatry 2002;159(8):1367- Conclusions (MPH., Yale), and psychiatric 1374. The role of the PGCM in the epidemiology (Postdoctoral Charney DS, Reynolds CF, Lewis L, identification and management of Fellowship, Yale). Lebowitz BD, Sunderland T, Alexopoulos depression is critical to comprehen- GS, Blazer DG, Katz IR, Meyers BS, sive care. Educating and training References Arean PA, Borson S, Brown C, Bruce PGCM’s in depression assessment Alexopoulos GS, Abrams RC, Young ML, Callahan CM, Charlson ME, and management is key in develop- RC, Shamonian CA. “Cornell Scale for Conwell Y, Cuthbert BN, Devanand DP, ing their strengths as active Depression in Dementia.” Biological Gibson MJ, Gottlieb GL, Krishnan KR, Psychiatry 1988; 23(3):271-284. Laden SK, Lyketsos CG, Mulsant BH, professionals in the mental health Niederehe G, Olin JT, Oslin DW, care of patients. It is not the goal to American Psychiatric Association Pearson J, Persky T, Pollock BG, Committee on Nomenclature and have PGCMs formally diagnose Raetzman S, Reynolds M, Salzman C, Statistics (APA). "Diagnosis and major depression, but rather to statistical manual of mental disorders" Schulz R, Schwenk TL, Scolnick E, simply screen for symptoms of (4th ed.) (DSM-IV). Washington, DC: Unützer J, Weissman MM, Young RC. depression that may require further 1994. “Depression and bipolar support alliance consensus statement on the unmet needs evaluation and referral (Raue et al, Beck AT, Steer RA. Beck Depression in diagnosis and treatment of mood 2002). It has been shown that the Inventory Manual. San Antonio, TX: disorders in late life.” Archives of General overall health of elderly patients Psychological Corporation, Harcourt Psychiatry 2003;60(7):664-672. improves when depression treat- Brace, 1988. ment is implemented. Further Hamilton M. “A rating scale for depres- evaluation by the treating physi- sion.” Journal of Neurology and Neuro- surgical Psychiatry 1960;23:56-62. cian, psychiatric nurse, social worker, or other mental health PGCMs can Haupt BJ, Jones A. “The National Home professional is essential once signs and Care Survey: 1996 sum- and symptoms of depression are provide their mary.” Vital Health Statistics. 1999;13:1- recognized (Brown et al, 2003). 238. Incorporating depression patients, family Lebowitz B. “Diagnosis and treatment of management into PGCMs’ practice depression in late life: An overview of the can lead to overall effective care and health NIH consensus statement.” American that meets patient needs and Journal of Geriatric Psychiatry. professionals 1996;4(4):S3-S6. improves outcomes sought by the patient, family, and health profes- with invaluable National Institutes of Health Consensus sionals. PGCMs can provide their Development Panel on Depression in Late patients, family and health profes- information in the Life. “Diagnosis and treatment of sionals with invaluable information depression in late life.” Journal of the in the assessment and management American Medical Association, assessment and 1992;268(8):1018–1024. of depression and are a vital link to accessing mental health care for management of Raue PJ, Brown EL, Bruce ML. “Assess- patients. ing behavioral health using OASIS: Part 1 depression and Depression and Suicidality.” Home Healthcare Nurse 2002;20(3):154-162. Ms. Mlodzianowski is a certified social worker and serves as project are a vital link to Yesavage JA. “Geriatric Depression coordinator for the Weill Cornell Scale.” Psychopharmacology Bulletin Homecare Research Partnership. accessing mental 1988;24(4): 709-710. health care for Dr. Fyffe is a licensed clinical psychologist and a Postdoctoral patients. Research Fellow in Geriatric Psychiatry at the Weill Medical College of Cornell University.

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mental health, medical, long-term care, Integrated Services and social services to this population. Professional geriatric care managers and Care Management (PGCMs) will increasingly be called upon to help coordinate the complex array of services needed to support for Older People with community treatment for this high-risk population with special needs. Severe Mental Illness In this paper we provide an By Sarah I. Pratt, Ph.D., overview of the challenges and models of care management for older Stephen J. Bartels, M.D., M.S., adults with SMI including: (1) the Kim T. Mueser, Ph.D., and evolution of services from institutions to the community; (2) understanding Aricca D. Van Citters, B.A. SMI and the special needs of schizo- phrenia in older persons; (3) the in non-institutional community biopsychosocial model of integrated treatment; (4) health care management, Approximately two percent of settings and prefer to remain in those rehabilitation, and social support; and older Americans have a severe mental settings (Bartels, Miles, et al., 2003, (5) geriatric care management and illness (SMI), including schizophrenia George, 1992, Meeks, et al., 1990, coordinating services for older adults and other psychotic illnesses, bipolar Meeks & Murrell, 1997). In addition, with SMI. disorder, and treatment refractory 40% to 50% of older adults with SMI depression (Narrow, et al., 2002). who reside in nursing homes could be adequately served in community- The Evolution of With the aging of the general popula- Services from tion, the number of older individuals based settings, and many may seek discharge from institutional care under Institutions to the with SMI is expected to double by the Community year 2030 (Jeste, et al., 1999). Many the recent Olmstead Supreme Court older individuals with SMI have decision (Bartels, Miles, et al., 2003). In the first half of the last century, significant difficulty maintaining a Expenditures for long-term care, many older persons with SMI received supportive social network, and SMI in combined with expenditures for long-term care in the nation’s state is associated with a high ongoing mental health and medical . Beginning in the 1960s, health care, make the cost of caring for prevalence of comorbid health and closure of state hospitals and large- older individuals with schizophrenia functional problems. These risk scale “deinstitutionalization” resulted more than the cost of caring for older factors are compounded by a frag- in a shift to providing the vast individuals with any other mental mented healthcare system that was majority of services in nursing homes disorder (Bartels, Clark, et al., 2003). designed to care for younger adults and the community. Enrollment of The projected growth in the numbers (Bartels & Colenda, 1998, Estes, 1995, older adults in public mental hospitals of older persons with SMI, along with George, 1992). dropped precipitously across the high healthcare costs, present a country (American Psychiatric Most older adults with SMI reside challenge for providing coordinated Association, 1993, Atay, et al., 1995). For some older adults, deinstitutionalization resulted in TABLE 1 transinstitutionalization into nursing homes (Knight, et al., 1998). However, Diagnoses Included Under the Category of in the recent Olmstead decision, the Severe Mental Illness (SMI) U.S. Supreme Court ruled that it is a form of discrimination under the Americans with Disabilities Act to z Schizophrenia institutionalize a disabled person who z Schizoaffective Disorder wishes to live in the community when z Psychotic Disorder, NOS the individual is capable of benefiting from living in a community-based z Delusional Disorder setting (Williams, 2000). States are z Major Depression with Psychotic Features now required to provide community placements for disabled individuals if z Bipolar Disorder community placement has been z Treatment Refractory Depression deemed appropriate by state treatment (continued on page 13)

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Integrated Services and Goldstrom, et al., 1987). Home health symptoms consist of deficit symptoms Care Management for agencies often provide few mental and are characterized by lack of Older People With health services and are restricted by spontaneous or active behaviors, Severe Mental Illness reimbursement mechanisms that only emotions or thoughts. Common allow for episodes of short-term care negative symptoms include blunted or (continued from page 12) (Bartels & Colenda, 1998). Assisted flattened affect, poverty of speech professionals and the individual living facilities serve an increasing (alogia), social withdrawal (asociality), wishes to live in the community number of mentally ill older adults and lack of interest in activity (apathy), (Williams, 2000). Over 40% of older are an important provider of long-term and impaired attention. In addition to adults with SMI in nursing homes who care services. Although early findings positive and negative symptoms, do not have advanced dementia are suggested inadequate mental health affective symptoms, depression in appropriate for a home and commu- and medical services in residential particular, are common in schizophre- nity-based living setting according to care facilities (Gottesman, et al., 1991), nia. As many as 60% of adults with consumers and their clinicians recent findings suggest that individu- schizophrenia suffer a major depres- (Bartels, Miles, et al., 2003). als with schizophrenia residing in sion during the course of their illness assisted living facilities were more and individuals are at particularly high Most older adults with SMI reside likely to receive outpatient mental risk for co-occurring depression in old in the community with support from health services than those residing age (Cohen, et al., 1996). In terms of social networks (Meeks & Murrell, independently or who were homeless functional impairment, most individu- 1997). In order to maintain community (Gilmer, et al., 2003). als with schizophrenia at some time tenure, older adults with SMI typically experience problems initiating and require services from both mental Older adults with SMI are high maintaining meaningful interpersonal health and aging long-term care utilizers of health care services relationships, fulfilling major roles in systems (Moak, 1996, Robinson, (Bartels, et al., 2003, Cuffel, et al., 1996, society, and engaging in basic self- 1990). Older adults with SMI are faced Semke & Jensen, 1997), have high care or community living skills such as with navigating a fragmented system health care expenditures (Bartels, accessing medical care and maintain- of care that includes services from Clark, et al., 2003), and require ing adequate housing. primary care, long-term care, home comprehensive coordinated care from health, public health, mental health multidisciplinary providers (Moak, Longitudinal research on schizo- agencies, specialty mental health 1996). Components of appropriate phrenia indicates considerable providers, and aging network services. care include specialized variation in long-term outcome. For The lack of coordination between geropsychiatric services; integrated most individuals, the illness is providers is particularly problematic. medical care; home and community- episodic, with some residual impair- For example, mental health agencies based long-term care; psychosocial ment between exacerbations. Many frequently under-serve older adults, rehabilitation services; and residential experience a trend toward gradual are ill-prepared to address cognitive or and family support services. improvement over the years, and in medical impairments, and are often some instances even total remission. unable to provide services to indi- Understanding SMI and However, a substantial minority of viduals with cognitive impairment the Special Needs of individuals with schizophrenia has (George, 1992, Light, et al., 1986). On Schizophrenia in Older enduring symptoms that require on- the other hand, community-based Adults going clinical care. support programs such as geriatric Schizophrenia is a severe mental As models of care emphasizing social services are likely to focus on illness that is heterogeneous and community treatment have replaced individuals with chronic physical characterized by a wide variation in traditional institutional care models, disabilities and may disregard mental the type and severity of symptoms interventions focused on maintaining health functioning (Robinson, 1990). across different individuals. It is community tenure and normalizing life Primary care physicians provide the diagnosed based on the presence of a functioning have been developed. For most mental health care to older minimum number of symptoms from a younger people, this has included adults, often in the form of brief office broad constellation of positive, innovations in vocational rehabilita- visits and pharmacological treatment negative, and affective symptomatol- tion, treatment of co-morbid substance (George, 1992). For a variety of ogy, and involves impairment in one abuse, and the development of reasons, primary care physicians are or more major areas of functioning. assertive case management teams. often limited in their ability to detect Positive symptoms consist of the Development of service models and appropriately treat mental illness primary active symptoms of psycho- tailored for older adults with schizo- and have limited access to the sis, the most common among them phrenia has lagged behind develop- specialty mental health services often being delusions and hallucinations. ment of interventions for younger required by individuals with SMI Other symptoms that are considered in people with the illness. However, (Bartels, Horn, et al., 1997, Burns & this category include thought disorder some progress is being made and early Taube, 1990, Goldstein, 1994, and bizarre behavior. Negative (continued on page 14)

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Integrated Services and they age. Finally, as older individuals psychiatric conditions. For example, Care Management for develop physical problems, their need thyroid hormone deficiency may cause Older People With for assistance with self-care and symptoms of depression. Likewise, Severe Mental Illness residential support intensifies. worsening of psychiatric symptoms may lead to deterioration in physical (continued from page 13) Medical Illness health. For example, an acute psy- outcomes data exist on three Management chotic episode in an individual with promising psychosocial models Co-morbid medical illness is one diabetes may result in failure to designed for older individuals with of the major characteristics distin- monitor glucose levels or adhere to schizophrenia. guishing the older person with dietary restrictions. Optimal treatment schizophrenia from younger individu- of the older person with schizophrenia The Biopsychosocial als with the illness. Serious health therefore includes assistance from a Model of Integrated problems are common in schizophrenia medical professional who is involved Treatment and are often undiagnosed and under in care in a regular, routine manner. For example, a nurse on a mental People with schizophrenia face treated (Cohen, 1993). Common medical conditions affecting older health treatment team is in an ideal several unique challenges as they position to encourage receipt of age, which should be considered in people with schizophrenia include , heart disease, arthritis, necessary preventive tests and the context of a comprehensive services, to assist with monitoring of biopsychosocial treatment model. diabetes, chronic lung disease, anemia, gastrointestinal disease, and chronic health problems, to intervene The aging process exacerbates when acute physical symptoms arise, several of the problems that neurological disorders such as stroke, movement disorders and seizure and to teach skills for basic health represent major treatment targets for management. younger people with schizophrenia. disorders. First, older people are especially For several reasons, people with Development of Supports sensitive to the adverse side effects schizophrenia are more likely to have in the Natural of medications, which requires more difficulty obtaining medical services Environment to Reduce careful attention to choosing the and are more likely to receive poor Environmental Stress appropriate type and dosage of care (Druss, et al., 2000, Levinson medication. Second, the challenge Miller, et al., 2003). One such reason Young adults with schizophrenia of accessing health care, which is is that older people with schizophrenia who have supportive parents and needed to an increasingly greater often have difficulty communicating other family members substantially extent as people age, is greater for their medical concerns. Another reduce their risk of relapse and older adults. Third, as people age reason is that psychiatric symptoms rehospitalization. People with they lose many of the natural may interfere with receipt of medical schizophrenia are less likely to marry supports on which they have relied treatment. For example, severe social or to have children, so the aging and to assist with illness management withdrawal, negativism, and paranoia eventual death of parents who serve and relapse prevention. Fourth, can make it difficult for medical as key supports places older individu- people with schizophrenia also providers to conduct appropriate als at risk for decompensation and begin to lose their social networks physical examinations, medical tests, inability to live independently in the and have difficulty negotiating clinical procedures, and necessary community. In fact, one of the major changes in social relationships as treatments. Finally, in some instances, differences between older adults with medical doctors prescribe schizophrenia residing in the commu- different treatments for nity and those living in nursing homes their patients with and other institutions is the presence TABLE 2 schizophrenia, perhaps of family and social supports (Meeks, assuming that they will et al., 1990). Although some older Care Needs of Older not adhere to complicated people with schizophrenia maintain Adults with SMI regimens that require regular contact with family members diligence and follow-up. such as siblings or nieces and Shrinking Social Support Network nephews, these relationships often do Assessment of not serve as substitutes for support- Social Skill Deficits physical health and ive relationships with parents. Need for Residential Support adequacy of health care services are critical Broad implications for the loss of Comorbid Medical Illness elements in the evaluation natural supports are that basic living needs may not be met; identification Coordinated Services of the older person with schizophrenia. Medical of early warning signs of relapse may Assistance with Self-care Skills disorders sometimes may not occur; and social affiliative needs cause or exacerbate (continued on page 15)

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Integrated Services and communicating effectively, engaging training and cognitive behavioral Care Management for in social activities, and asking for help treatment for older adults with Older People With (Bartels, Mueser, et al., 1997). As schizophrenia (McQuaid, et al., 2000); Severe Mental Illness individuals age, there is a natural and a combined skills training and tendency for social networks to health management intervention for (continued from page 14) shrink. Poor social skills can make community-dwelling older adults with may not be met. These are com- creating and maintaining a healthy schizophrenia and other severe mental pounded by the difficulty that older social network particularly difficult for illnesses (Bartels, et al., 2004). Each people with schizophrenia have the older individual with schizophre- represents a manualized intervention negotiating changes in social nia. Helping aging individuals with with prospective outcome data relationships toward an increased schizophrenia improve skills for reported in controlled pilot studies. need for assistance. Assertive dealing with social situations can community treatment therefore is a expand their social networks, improve Integrated Care critical component of care for older their overall quality of life, and may Management and Skills adults who have lost natural sources even reduce their risk of nursing home Training for Older Adults of support and are at risk of institu- placement (Meeks, et al., 1990). with SMI tionalization owing to difficulty with Social skills training (SST) is an A randomized, controlled study of illness self-management and various approach to psychiatric rehabilitation a rehabilitative intervention that integrates health care management, mental health services, and skills TABLE 3 training for older adults with SMI (HOPES or Helping Older People Social Skills Training Experience Success) is currently underway (Pratt, et al., 2003). The Action Systematically teach interpersonal skills health care management component consists of a model of care manage- Aim 1. Achieve personal goals ment for preventive health care and 2. Function effectively in community settings ongoing health care needs. For example, the health care manager Examples of 1. Expression of feelings Targeted Social 2. Making and keeping friends ensures that preventive health care Skills 3. Basic conversational skills targets are met including routine 4. Asking for assistance physical examinations, blood pressure 5. Interacting with health professionals checks, cancer screening, and vaccinations. In addition, common health care conditions such as aspects of community functioning that involves systematically teaching diabetes, hypertension, congestive that were formerly attended to by interpersonal skills to enable individu- heart failure, and other disorders are supportive significant others. The als to achieve personal goals and to monitored for routine health care. The need to bolster family capacity and function effectively in community skill areas covered in the HOPES skills social supports is an important settings (see Table 3). Targeted social (continued on page 16) consideration in service planning for skills span a wide range of older individuals. adaptive interpersonal behaviors including the TABLE 4 Development of Social expression of feelings, Skills and Social skills for making and Networks to Improve HOPES Skills Training keeping friends, and basic Curriculum Coping Ability communication skills. Many individuals with schizo- Three promising SST 1. Making and keeping friends phrenia, young and old, experience interventions for older 2. Making a visit to the doctor profound difficulties in their social adults with schizophrenia relationships and ability to interact have recently been devel- 3. Communicating effectively with other people. Older adults with oped and systematically 4. Making the most of leisure time schizophrenia residing in the commu- evaluated. These include a nity have greater social skill deficits SST program for middle- 5. Managing medications compared to older persons with other, aged and older adults with 6. Living independently in the community less severe, psychiatric disorders, chronic psychotic disor- including greater impairments in ders (Patterson, et al., 7. Healthy living accepting and initiating contact, 2003); a combined skills

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Integrated Services and with lifelong schizophrenia have never to effectively address the needs of Care Management for had children or have long become older adults with SMI, including Older People With alienated from extended family, leaving intensive case management models Severe Mental Illness them without this care-provider (Blackmon, 1990); community support resource. Continued community programs (CSP) (Schaftt & Randolph, (continued from page 15) tenure therefore requires a combina- 1994); home and community-based training curriculum are shown in Table 4. tion of remedial skills training to outreach (Raschko, 1991, Stolee, et al., Choice of these skill areas is consistent address deficient community living 1996); outreach teams to residential with results of a recent survey of older skills, comprehensive community care facilities and nursing homes adults with schizophrenia in which at support services, and consideration of (Seidel, et al., 1992); and specialty least half of respondents identified communal living placements that offer teams and units in nursing homes improving physical health, communicat- varied levels of support and assis- (Sloane, et al., 1991) and psychiatric ing more effectively, and having more tance with basic self-care and instru- hospitals (Kunik, et al., 1996). In friends as high priorities (Auslander & mental activities of daily living. addition, there are several care Jeste, 2002). management models for individuals Geriatric Care with prior institutionalization or who Development of Self- Management and are at risk of institutionalization Care Skills and Coordinating Services (Bernstein & Hensley, 1993, Fisher, et Residential Support to for Older Adults with SMI al., 1991). These care management Improve Community models include a variety of supported Tenure Professional geriatric care residential options with patients managers who are familiar with mental receiving care from multidisciplinary Older individuals with schizophre- health, aging network, primary care, mobile service teams at their resi- nia are more likely than younger and residential care for older adults dence; case management and day individuals to have deficient self-care can perform the important task of treatment; as well as education and skills, placing them at greater risk for tying together a diverse group of support for caregivers. Evaluations of institutional these programs placement. Many suggest possible very old individuals benefits in terms of who were institu- improved patient and tionalized as young Older individuals with schizophrenia are more family satisfaction, as adults may not have well as the potential developed important likely than younger individuals to have for these programs to community living deficient self-care skills, placing them at replace the functions skills. Younger of state hospitals if individuals (in their greater risk for institutional placement. Many provided with 60s) who were adequate funding and among the first very old individuals who were institutionalized coordination. Clinical wave of patients as young adults may not have developed improvement has also that became ill when occurred among older states were closing important community living skills. adults with SMI who their long-term have been discharged wards, may have into the community developed some from long-stay ability to reside hospitals (Trieman, et independently in the community. providers, settings, and services into al., 1996). The Veteran’s Administra- However, when parents of individuals a coherent and coordinated plan of tion health care system has also with schizophrenia die, their middle- treatment for the older adult with SMI. developed a model for providing long- aged children must not only cope with Part of this responsibility includes term mental health community care, the emotional impact and loss of a adapting services to meet the specific consultation, and outreach to older primary source of social contact and needs of older persons with SMI. adults (Van Stone & Goldstein, 1993). support, but must also quickly adjust Several innovative programs Multiple interventions that almost to a dramatic reduction in financial provide mental health services to older always involve different providers, and instrumental support and poten- adults with SMI in home and commu- disciplines, and systems of care are tially loss of residence. Unlike aging nity-based settings (Knight, et al., required to address the various care individuals with Alzheimer’s disease, 1995, Kozlak & Thobaben, 1994, needs of older individuals with who often have adult children who act Lipsman, 1996). In addition, a variety schizophrenia. PGCMs who are as direct caregivers, many individuals of other programs have been reported familiar with the needs and services of (continued on page 17)

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Integrated Services and older persons with severe mental illness.” Care Management for Aricca D. Van Citters, B.A. is a Community Mental Health Journal. 2004; research assistant in the Aging 40(1):75-90. Older People With Services Division of the New Severe Mental Illness Hampshire-Dartmouth Psychiatric Bartels SJ, Miles KM, Dums AR, Pratt SI. “Community mental health service use (continued from page 16) Research Center in Lebanon, NH. by older adults with severe mental illness.” Journal of Mental Health and older adults with SMI can provide References Aging. 2003;9(2):127-139. the necessary coordination of care American Psychiatric Association. State Bernstein MA, Hensley R. “Developing that can bridge different care Mental Hospitals and the Elderly: A community-based program alternatives for Task Force Report of the American the seriously and persistently mentally ill components from a complex array of Psychiatric Association. Washington, providers. The PGCM can serve as a elderly.” Journal of Mental Health Adminis- DC: American Psychiatric Association; tration. 1993;20(3):201-207. point person to facilitate coordina- 1993. tion and communication among Blackmon AA. “South Carolina’s Elder Atay JE, Witkin MJ, Manderscheid other service providers. As many Support Program: An alternative to RW. “Data highlights on: utilization of hospital care for elderly persons with state service delivery systems move mental health organizations by elderly chronic mental illness.” Adult Residential toward privatization and fragmenta- persons.” Mental Health Statistical Note. Care Journal. 1990;4(2):119-122. tion of mental health care, the need 1995;214:1-7. for a single individual to assist older Burns BJ, Taube CA. “Mental health Auslander L, Jeste DV. “Perceptions of services in general medical care and individuals with the organization and problems and needs for service among nursing homes.” In: Fogel B, Furino A, coordination of care providers is middle-aged and elderly outpatients Gottlieb G, eds. Mental Health Policy for essential. with schizophrenia and related psy- Older Americans: Protecting Minds at chotic disorders.” Community Mental Risk. Washington, DC: American Health Journal. 2002;38(5):391-402. Psychiatric Press; 1990:63-84. Sarah I. Pratt, Ph.D., is a Research Bartels SJ, Horn S, Sharkey P, Levine Cohen CI. “Poverty and the course of Associate in the Department of K. “Treatment of depression in older schizophrenia: Implications for research Psychiatry at Dartmouth Medical primary care patients in health mainte- and policy.” Hospital and Community School and the NH-Dartmouth nance organizations.” International Psychiatry. 1993;44:951-958. Psychiatric Research Center. Dr. Journal of Psychiatry in Medicine. Pratt is the project director for the 1997;27(3):215-231. Cohen CI, Talavera N, Hartung R. “Depression among aging persons with HOPES (Helping Older People Bartels SJ, Mueser KT, Miles KM. schizophrenia who live in the commu- Experience Success) study, a “Functional impairments in elderly nity.” Psychiatric Services. 1996;47:601- rehabilitation program for older patients with schizophrenia and major 607. adults with severe mental illness. affective illness in the community: Social skills, living skills, and behavior Cuffel BJ, Jeste DV, Halpain M, Pratt C, problems.” Behavior Therapy. Tarke H, Patterson TL. “Treatment costs Stephen J. Bartels, M.D., M.S. is the 1997;28:43-63. and use of community mental health services for schizophrenia by age director of the Aging Services Bartels SJ, Colenda CC. “Mental health Division of the New Hampshire- cohorts.” American Journal of Psychiatry. services for Alzheimer’s disease. 1996;153(7):870-876. Dartmouth Psychiatric Research Current trends in reimbursement and Center and Associate Professor of public policy, and the future under Druss BG, Bradford DW, Rosenheck RA, Psychiatry at Dartmouth Medical managed care.” American Journal of Radford MJ, Krumholz HM. “Mental School in Lebanon, NH. He is also Geriatric Psychiatry. 1998;6(2 Suppl disorders and use of cardiovascular the Medical Director for the New 1):S85-100. procedures after myocardial infarction”. Hampshire Division of Behavioral Journal of the American Medical Bartels SJ, Clark RE, Peacock WJ, Dums Association. 2000;283:506-511. Health and the Director of the New AR, Pratt SI. “Medicare and Medicaid Hampshire Behavioral Health costs for schizophrenia patients by age Estes CL. “Mental health services for the Policy Institute. cohort compared with depression, elderly: Key policy elements”. In: Gatz dementia, and medically ill patients.” M, ed. Emerging issues in mental health American Journal of Geriatric Psychiatry. and aging. Washington, DC: American Kim T. Mueser, Ph.D., is a Professor 2003;11(6):648-657. Psychological Association; 1995:303-328. in the Department of Psychiatry at Dartmouth Medical School and the Bartels SJ, Miles KM, Dums AR, Fisher WH, Geller JL, Pearsall DT, Simon Levine KJ. “Are nursing homes LJ. “A continuum of services for the NH-Dartmouth Psychiatric Re- appropriate for older adults with severe deinstitutionalized, chronically mentally ill search Center. Dr. Mueser is a co- mental illness? Conflicting consumer elderly.” Administration and Policy in principal investigator on the and clinician views and implications for Mental Health. 1991;18(6):397-410. HOPES study and a study of cognitive the Olmstead Decision.” Journal of the behavioral therapy for individuals American Geriatrics Society. George LK. “Community and home care for with post-traumatic stress disorder 2003;51(11):1571-1579. mentally ill older adults.” In: Birren JE, (PTSD) and severe mental illness. He Sloane RB, Cohen GD, et al., eds. Hand- Bartels SJ, Forester B, Mueser KT, book of Mental Health and Aging. 2nd ed. is also the principal investigator of a Miles KM, Dums AR, Pratt SI, San Diego: Academic Press, Inc.; 1992. study of family therapy for individuals Sengupta A, Littlefield C, O’Hurley S, with severe mental illness and White P, Perkins L. “Enhanced skills substance abuse. training and health care management for (continued on page 18) PAGE 17 GCM winter 2004

Integrated Services and ization for older nursing home resi- controlled trial.” Paper presented at: Care Management for dents.” Journal of the American 16th Annual Meeting of the American Geriatrics Society. 1996;44:1062-1065. Association for Geriatric Psychiatry; Older People With March, 2003; Honolulu, HI. Severe Mental Illness Levinson Miller C, Druss BG, Dombrowski EA, Rosenheck RA. (continued from page 17) Raschko R. “Community mental health “Barriers to primary medical care among center elderly services.” In: Light E, Gilmer TP, Folsom DP, Hawthorne W, patients at a community mental health Libowitz BD, eds. The Elderly with Lindamer LA, Hough RL, Garcia P. center.” Psychiatric Services. Chronic Mental Illness; 1991:232-244. “Assisted living and use of health 2003;54(8):1158-1160. Robinson GK. “The psychiatric services among Medicaid beneficiaries Light E, Lebowitz BD, Bailey F. component of long-term care models.” with schizophrenia.” Journal of Mental “CMHCs and elderly services: An In: Fogel B, Furino A, Gottlieb G, eds. Health Policy and Economics. analysis of direct and indirect services and Mental Health Policy for Older 2003;6(2):59-65. service delivery sites.” Community Mental Americans: Protecting Minds at Risk. Goldstein MZ. “Taking another look at Health Journal. 1986;22:294-302. Washington, DC: American Psychiatric Press; 1990:157-178. the older patient and the mental health Lipsman R. “Services and supports to system.” Hospital and Community the homebound elderly with mental Psychiatry. 1994;45:117-119. Schaftt GE, Randolph FL. Innovative health needs.” Journal of Long-Term Community-Based Services for Older Goldstrom ID, Burns BJ, Kessler LG, Home Health Care. 1996;15(3):24-38. Persons with Mental Illness. Rockville, Maryland: Center for Mental Health Feuerberg MA, Larson DB, Miller NE, McQuaid JR, Granholm E, McClure FS, Services, Division of Demonstration Cromere WJ. “Mental health services Roepke S, Pedrelli P, Patterson TL, Programs, Community Support Section; use by elderly adults in a primary care Jeste DV. “Development of an inte- 1994. setting.” Journal of Gerontology. grated cognitive-behavioral and social 1987;42(2):147-153. skills training intervention for older Seidel G, Smith C, Hafner RJ, Holme G. Gottesman LE, Peskin E, Kennedy K, patients with schizophrenia.” The “A psychogeriatric community outreach Mossey J. “Implications of a mental Journal of Psychotherapy Practice and service: Description and evaluation.” health intervention for elderly mentally Research. 2000;9(3):149-156. International Journal of Geriatric ill residents of residential care facilities.” Meeks S, Carstensen LL, Stafford PB, Psychiatry. 1992;7(5):347-350. International Journal of Aging & Human Brenner LL, Weathers F, Welch R, Development. 1991;32(3):229-245. Semke J, Jensen J. “High utilization of Oltmanns TF. “Mental health needs of the inpatient psychiatric services by older Jeste DV, Alexopoulos GS, Bartels SJ, chronically mentally ill elderly.” Psychol- adults.” Psychiatric Services. Cummings JL, Gallo JJ, Gottlieb GL, ogy and Aging. 1990;5(2):163-171. 1997;48(2):172-176. Halpain MC, Palmer BW, Patterson TL, Meeks S, Murrell SA. “Mental illness in Reynolds CF, III, Lebowitz BD. Sloane PG, Matthew LJ, Scarborough late life: Socioeconomic conditions, M, Desai JR, Koch GG, Tangen C. “Consensus statement on the upcoming psychiatric symptoms, and adjustment crisis in geriatric mental health: Research “Physical and pharmacological restraint of long-term sufferers.” and of nursing home patients with demen- agenda for the next 2 decades.” Archives of Aging. 1997;12(2):298-308. General Psychiatry. 1999;56(9):848-853. tia: Impact of specialized units.” Moak GS. “When the seriously mentally Journal of the American Medical Knight BG, Rickards L, Rabins P, ill patient grows old.” In: Soreff SM, ed. Association. 1991;265:1278-1282. Buckwalter K, Smith M. “Community- Handbook for the treatment of the Stolee P, Kessler L, Le Clair JK. “A based services for mentally ill elderly.” seriously mentally ill. Seattle: Hogrefe & community development and outreach In: Knight B, Teri L, Wohlford P, Huber Publishers; 1996:279-293. Santos J, eds. Mental health services for program in geriatric mental health: Four older adults: Implications for training Narrow WE, Rae DS, Robins LN, Regier year’s experience.” Journal of the and practice. Washington, DC: DA. “Revised prevalence estimates of American Geriatrics Society. American Psychological Association; mental disorders in the United States: 1996;44(3):314-320. 1995:21-30. Using a clinical significance criterion to reconcile 2 survey’s estimates.” Trieman N, Wills W, Leff J. “TAPS Knight BG, Woods E, Kaskie B. Archives of General Psychiatry. Project 28: does reprovision benefit “Community mental health services in 2002;59(2):115-123. elderly long-stay mental patients?” the United States and the United Schizophrenia Research. 1996;21:199- Kingdom: A comparative systems Patterson TL, McKibbin CL, Taylor M, 208. approach.” In: Edlestein B, ed. Clinical Goldman S, Davila-Fraga W, Bucardo J, Geropsychology. Vol 7. Oxford: Jeste DV. “Functional Adaptation Skills Van Stone WW, Goldstein MZ. “Mental Elsevier; 1998. Training (FAST): A pilot psychosocial health services for older adults in the VA intervention study in middle-aged and system.” Hospital and Community Kozlak J, Thobaben KJ. “Psychiatric older patients with chronic psychotic Psychiatry. 1993;44(9):823-830. home health nursing of the aged: a disorders.” American Journal of Williams L. “Long-term care after selected literature review.” Geriatric Geriatric Psychiatry. 2003;11(1):17-23. Nursing. 1994;15(3):148-150. Olmstead v. L.C.: will the potential of Pratt SI, Forester B, Bartels S. “Integrat- the ADA’s integration mandate be Kunik ME, Ponce H, Molinari V, ing psychosocial rehabilitation and achieved?” Journal of Contemporary Orengo C, Emenaha I, Workman R. health care for older adults with SMI: Health Law and Policy. “The benefits of psychiatric hospital- From pilot study to randomized 2000;17(1):205-239.

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and family members to address needs, Adapting the Concept of collaboratively applies appropriate agency resources to serve their consumers, and continually monitors a “WrapAround” Model the status of those served. Through- out this process, the Team notes, of Care to Serve Older discusses, and addresses system barriers that are identified through the Adults with Mental Illness consideration of individual circum- stances and needs. Keith M. Miles, MPA; Bernie Seifert, Significance of the LICSW; Jeanne Duford, MSW WrapAround Process for Professional Geriatric Care Managers and Older Adults with Mental Background clients. It is particularly important in Illness The concept of “WrapAround” serving older adults with mental gained recognition in the late 1980s illnesses (MI) due to the complex Population Vulnerability and early 1990s in the area of service needs and medical co- The significance of the Elder children’s services (VanDenBerg, morbidity associated with these WrapAround concept for geriatric 1999). This approach was designed to disorders and the need to involve care managers and the population of address the multiple agencies. older adults with mental illness lies in problem of a In simplified the intense service needs of this fragmented service The significance form, the population, the inadequate way in system consisting WrapAround which they are currently served, and of multiple agen- of the Elder model involves the key role of the PGCM in coordinat- cies separately WrapAround coordinating ing a variety of important health and serving children providers and social services. Older adults with with serious concept for services to mental illness represent a population emotional distur- geriatric care collaboratively whose vulnerability is well known, and bance by develop- managers and the meet the needs of whose needs are more complicated ing “Teams” of older adults with due to the multiple problems they face. community and population of older mental health These problems are similar to those agency service adults with mental problems. Agen- faced by adults and children with MI, providers who met cies and providers including symptom management regularly to illness lies in the who are involved challenges, housing issues, and address individual intense service with serving the residential placement risks due to their consumer’s needs multiple needs of impairment and dependency. How- in an integrated needs of this the older adult ever, in the case of older adults with fashion. In the population, the population with mental illness, these challenges are mid-1990’s many inadequate way in mental illness are often faced without the presence of a states began initially identified. caregiver or advocate, as many are adopting the which they are Representatives without spouses or do not live with WrapAround currently served, from these children. Often their lack of physical approach as an agencies are mobility or transport leads to isola- integral part of a and the key role of invited to form a tion, perhaps exacerbating depressive overall “System of the PGCM in community disorders known to be prevalent Care” (1999). The WrapAround among this population. Poor health WrapAround coordinating a Team that meets practices, problem behaviors, and process is ideally variety of important regularly. The difficulty with treatment adherence suited for use by team establishes health and social further contribute to poor health professional criteria and referral outcomes and the need for active geriatric care services. procedures for coordination of medical and psychiat- managers identifying ric services (Bartels, et al., 1999, (PGCMs), who in individuals to be Holmberg & Kane, 1999, Moak, 1996, their customary role, act in a facilitat- served, sets procedures for reviewing Vieweg, et al., 1995). Service coordi- ing capacity to coordinate services to individuals’ needs and developing nation is particularly problematic for meet the needs of their older adult service plans, meets with individuals (continued on page 20)

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Adapting the Concept mental health services are treated and attempt to meld it into a coherent of a “WrapAround” within the primary care system, often whole for consumers who may be Model of Care to described as the “de facto” mental among those least proficient at Serve Older Adults health service system for older accessing the “system”. Yet, the with Mental Illness persons (Gray, et al., 2000). Older complex needs of older adults with adults may seek mental health care (continued from page 19) mental illness, and the multiple from primary care providers (PCPs) home and community-based service older adults who may be unaccus- due to both the stigma associated providers serving those needs, tomed or unequipped to navigate with receiving specialty mental health demonstrate the potential for complex service systems with multiple services and the convenience of geriatric care managers to utilize eligibility requirements. Finally, older receiving mental health care from the WrapAround Process as a adults must deal with the usual decline their medical provider (USDHHS, strategy to integrate services for the of functioning and 1999). However, older population with mental illness. increase in medical most PCPs have Indeed, the argument can be made needs associated limited training in that the coordination of agency with aging, which The vulnerability mental health services is even more important from are both greater care and have a safety perspective for older adults and more compli- of older adults limited time for with mental illness, given the cated due to the addressing the isolation and vulnerability of this documented co- due to their multitude of group, and the desire to maintain morbidity of health problems community tenure and reduce mental and complex and faced by older reliance on institutional alternatives. physical illnesses adults. These within this group multiple needs factors limit the The WrapAround (Sheline, 1990). PCP’s capacity Process for Older is coupled with a to deliver Adults – Principles and System adequate mental Practice Fragmentation health services The WrapAround concept is The vulner- service system and have based upon principles and practices ability of older contributed to that can be equally well applied by adults due to their that has evolved high rates of PGCMs to older adults with mental complex and under-diagnosis illnesses. These guiding principles, multiple needs is to meet older and under- developed by Stroul and Friedman, coupled with a treatment of are summarized in Table 1 (Stroul & service system mental health mental health Friedman, 1986). We have substi- that has evolved problems within tuted “Older adults with mental to meet older consumers’ primary care illness” for “Children with emotional mental health settings disturbances” (as italicized) to consumers’ needs (Higgins, 1994, needs in a highlight the applicability of the in a fragmented Kaplan, et al., principles to older adults. fashion. Housing fragmented 1999). More- agencies operate over, physical The WrapAround Process also senior residences, fashion. illnesses are includes ten practices deemed medical clinics often undetected necessary for successful implemen- address medical or inappropri- tation to effect system change needs, mental ately treated in (Goldman, 1999). These are summa- health clinics address mental disor- individuals receiving specialty rized in Table 2. ders, home health agencies address psychiatric care (Koranyi, 1979). home-based medical care, and senior Older adults with mental disorders Evidence of the centers serve their nutrition and are also less likely to receive needed Effectiveness of the recreational needs as best they can. health care interventions (Druss, et WrapAround Process Meals-on-Wheels, Senior Transport al., 2001) and are more likely to The effectiveness of the systems, volunteer organizations, and receive inappropriate medications WrapAround model is well-docu- others fill in the gaps. than individuals without mental mented, particularly for children, but also for older adults. Burns, et al Older persons with psychiatric illness (Bartels, et al., 1997, Bartels, (1999) reviewed fourteen published illnesses are also affected by frag- 2002). studies of children’s WrapAround mented provision of medical health Geriatric care managers are projects in nine states that contained care. Most older adults who receive familiar with this fragmented system (continued on page 21)

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Adapting the Concept TABLE 1 of a “WrapAround” Model of Care to Guiding Principles of the Serve Older Adults WrapAround Process for Older Adults with Mental Illness 1. Older adults with mental illness should have access to a comprehen- (continued from page 20) sive array of services which address their physical, emotional, social, evaluation components and met the and educational needs core requirements for the 2. Older adults with mental illness should receive individualized WrapAround process. All studies services described improvement in at least one 3. Older adults with mental illness should receive services within the area, including increased behavioral, least restrictive, most normative environment that is clinically appro- community, home, and school priate adjustment, decreased negative 4. Families and caregivers of older adults with mental illness should be behaviors, decreased restrictiveness full participants in the planning and delivery of services of living environments, and fewer 5. Older adults with mental illness should receive services that are behavioral problems (Burns, et al., integrated, coordinated and linked among agencies 1999). Evaluation studies have shown that the WrapAround model 6. Older adults with mental illness should be provided with case management to insure coordination and continuity congruent with has the potential to reduce institu- changing needs tional care and costs, to stabilize living situations in the community, 7. Early identification and intervention with older adults with mental and to offer other benefits in the illness should be promoted realms of behavioral, family, and 8. Older adults with mental illness should be assured a smooth transi- school adjustment (Goldman & Faw, tion among levels of care as needs change 1999). 9. The rights of older adults with mental illness should be protected and A related literature suggests that advocacy efforts promoted a home and community-based model 10. Older adults with mental illness should receive services that are of wraparound long-term care for sensitive to cultural differences and special needs older adults is effective as well. The PACE (Program of All-inclusive Care for the Elderly) Model of integrated care, individualized service plans, and TABLE 2 pooled funding has reduced hospital- ization of clients, length of stay, and Ten Practices for Successful Implementation nursing home use (Kunz & Shannon, 1996). The Southwestern Ontario 1. A community collaborative structure (Multiple agencies contributing Regional Geriatric Program’s Model members to a WrapAround Team, which meets regularly.) Project has also shown positive 2. An administrative management organization (to assume responsibil- effects on provider assessment ity for coordination and limited funding.) practices and confidence in address- ing the needs of older adults (Harris, 3. A referral mechanism (to identify and refer individuals whose multiple and complex needs warrant consideration by the Team.) et al., 1999). In New Hampshire, the Riverbend Community Mental Health 4. A Resource Coordinator (the PGCM) to facilitate the process and Center’s (CMHC) experience with its provide focus for the Team. Elder WrapAround Program has 5. A strengths and needs assessment (to form the basis of a service shown equally positive results, with and treatment plan.) reduced client hospital admissions and 6. Consumer and family involvement (with other caregivers included as reduced average length of hospital appropriate.) stays (Duford, 1999). Riverbend has 7. An interactive team process and formation of a partnership to received awards for the Program’s develop an individualized plan. success as a Special Program for Older Adults by the National Council of 8. Development of a crisis/safety plan (to address emergencies.) Community Behavioral Health Care, as 9. Measurable outcomes monitored on a regular basis. well as having been identified as a 10. A review of plans by the community collaborative structure (with Promising Practice by the National regular updates and follow-ups.) Council on Aging. (continued on page 22)

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Adapting the Concept Recommendations and and power of attorney assign- of a “WrapAround” Lessons Learned in the ments should be considered as Model of Care to New Hampshire needed. WrapAround Project Serve Older Adults 4. Special Needs: Problems with with Mental Illness Evaluation of the New Hamp- transportation and mobility are (continued from page 21) shire implementation process has common issues with elders, as identified several important lessons well as the need for medical The New Hampshire which may assist geriatric care equipment, personal care, and Elder WrapAround Model managers in implementing a crisis intervention in mental and Experience WrapAround program for older health emergencies. adults with mental illness. In New Hampshire, the regional 5. Substance Abuse: Medication Elder Mental Health Service Coordina- 1. Team Membership: Key team misuse, and alcohol or non- tors recognized the special needs of members usually include aging prescription drug abuse are the the older adult population with MI and and home care workers, other most prevalent substance abuse the limitations of the existing service service providers who work issues for the elderly. Interac- system to serve these needs. The with older adults, and particu- tions among prescriptions for New Hampshire experience with the larly medical and mental medical and mental disorders are WrapAround Process for older adults health staff. Children, spouses, also common and should be was modeled after the Riverbend and friends may be included in carefully assessed. Team meetings when address- CMHC’s award-winning WrapAround 6. Safety: With elders with mental ing specific clients. Program for older adults. It’s stated illness, threats to personal safety objective is: “The coordination of 2. Complications: In older adults in the home are related to efforts across systems, to provide a with mental illness, medical impaired self-care skills, self- cost-effective way to increase service complications and mental neglect, and dementia or capacity and improve community symptom-related injuries. access to services for older adults with 7. Use the mental illness. This Experience of includes collabora- “The coordination of efforts across Others: It is recom- tion among agen- systems, to provide a cost-effective mended that Teams draw on the experi- cies, community and way to increase service capacity and consumer education, ence of those who flexible funding, and improve community access to have implemented individualized services for older adults with mental WrapAround Teams treatment, with illness. This includes collaboration for older clients with priority given to mental illness. among agencies, community and Specialized needs continuity of care consumer education, flexible funding, and seamless include psychiatric symptom recognition service delivery.” and individualized treatment, with and management, This program now priority given to continuity of care and emergency interven- numbers 52 partici- seamless service delivery.” tion, medication pating agencies, adherence, and with representatives community-based from 12 core supports. A system- agencies meeting regularly to discuss health symptoms are almost atic approach to evaluating and always present, and act as agency policies and practices, funding addressing these needs is stressors. Teams and PGCMs collaboration, service coordination, as important and can aid in well as the needs of specific clients should detect and address these establishing criteria for accept- and their families. This concept is stressors and involve medical ing referrals, engaging mental being replicated in four other mental and mental health professionals health and medical participants, health regions in New Hampshire and in the process. and serving clients with impaired is being evaluated by the New 3. Cognition: Because cognitive cognitive functioning and Hampshire-Dartmouth Psychiatric impairment associated with problem behaviors. Research Center. dementia or psychiatric 8. Educate: Do not assume that symptoms can impair the ability administrators or agency of an older adult with mental participants already know about illness to provide “informed the principles of WrapAround as consent”, guardianship status (continued on page 23)

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Adapting the Concept should be specifically included. Elder WrapAround Team and in of a “WrapAround” Resources should be identified referring older adult clients with Model of Care to that address the mental health mental illness to the Team. The Serve Older Adults and co-morbid medical issues impact of such Teams on the with Mental Illness common to this population. population of older adults with mental illness can be felt in two (continued from page 22) 10. Committed Leadership is Essential: One of the keys to a ways: directly through better related to the particular needs successful WrapAround outcomes for clients and families of older adults with mental program is the presence of a served by the Teams, and indirectly illness. Educate all partici- committed coordinator to through improvements in the pants early and often about provide initiative, coherence, coordination and functioning of the the vulnerabilities and needs and practical planning for the service system caring for older of this group. Team – an ideal role for the adults with mental illness. 9. Identify Existing Resources: PGCM. Those regions and One region drew upon its teams that had this leadership Keith M. Miles, MPA, is the history of collaborative experienced fast progress, good Research Director of the Aging agency relationships, which participation, and quick Services Division for the New made it easier to begin resolution of problems. Hampshire-Dartmouth Psychiatric Research Center (PRC). He has meeting on elder mental health 11. A Core Team of Participants is recently completed evaluations of issues. Those with a vested Necessary and Evolves: Al- interest in dealing with older the Older Adult WrapAround though the mental health focus Services Program and the Out- mentally ill clients such as requires participation of nursing homes, visiting nurses, comes Based Treatment Planning mental health clinics and System (OBTP) for Older Adults area agencies on aging, and clinicians, as well as emer- geriatric mental health with Mental Illness. He is currently gency and hospital providers, a directing studies on the Resident clinicians and psychiatrists broad list of potential stake- Education, Assistance and Preven- TABLE 3 holder agencies should be tion Program (REAP) and evaluat- invited to the early meetings ing the Real Choices grant to Potential (see Table 3). From this larger transition nursing home residents Stakeholder group, a “core” group of to community-based living. Agencies agencies naturally emerges over time, and membership Bernie Seifert, LICSW, is a clinical z Legal Services evolves, as some persons or social worker for the Easter Seals z Consumers/Family Mem- agencies may find that they are Adult Day Programs and the bers/Caregivers not needed while others may Seniors Count Project in Manches- z Elderly & Adult Services later be called upon to meet the ter, New Hampshire. She was the special needs of individual director of the New Hampshire z Advocates clients. Older Adult WrapAround Program, z Senior Centers which was funded by the Substance 12. Clients and their Needs Define z Housing Abuse and Mental Health Adminis- Team Participation: While the tration and operated through the z Public Health Core team consists of those New Hampshire Division of z Law Enforcement agencies most directly involved Behavioral Health. with older adults with mental z Primary Care Providers illness, it is necessary to Jeanne Duford, MSW, is a Psychol- z Home Care Services identify for each individual ogy Professor at New Hampshire client which agencies should z Hospitals Technical College and a Sociology be invited to address the z Visiting Nurses Professor at Franklin Pierce complex and varied needs of College. She provides community z Nursing Facilities this population. education and individual and z Substance Abuse Services family psychotherapy through Summary private practice. Ms. Duford was z Mental Health Clinics The Elder WrapAround model the Director of the award-winning z Nutritional Services has significant potential as a means Elder WrapAround Program of the z Developmental Services for geriatric care managers to Riverbend Community Mental coordinate services for their older Health Center in New Hampshire. z Adult Day Care Services adult clients with mental illness. The z Welfare and Assistance role of the PGCM can be crucial in both initiating and organizing an (continued on page 24)

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Adapting the Concept Duford J, ed. Manual for Riverbend 1999;39(4):417-425. of a “WrapAround” Elders Wrap Around Team. Concord, NH: Model of Care to Riverbend Community Mental Health Koranyi EK. “Morbidity and rate of Center; 1999. undiagnosed physical illnesses in a Serve Older Adults psychiatric clinic population.” Archives of with Mental Illness Goldman SK. “The Conceptual Frame- General Psychiatry. 1979;36(4):14-19. work for Wraparound: Definition, Values, (continued from page 23) Essential Elements, and Requirements for Kunz E, Shannon K. “PACE: Managed Works Cited Practice.” In: Burns BJ, Goldman SK, eds. care for the frail elderly.” American Promising practices in wraparound for Journal of Managed Care. Systems of Care: Promising Practices in children with severe emotional distur- 1996;2(3):301-304. Children’s Mental Health, 1998 Series, bance and their families: Systems of care: Volume I-VI. Washington, D.C.: Center Promising practices in children’s mental Moak GS. “When the seriously for Effective Collaboration and Practice, health systems of care. 1998 Series, Vol. mentally ill patient grows old.” In: American Institute for Research; 1999. IV. Rockville, MD: Center for Mental Soreff SM, ed. Handbook for the Bartels SJ, Horn S, Sharkey P, Levine K. Health Services; 1999:9-16. treatment of the seriously mentally ill. “Treatment of depression in older Seattle: Hogrefe & Huber Publishers; primary care patients in health mainte- Goldman SK, Faw L. “Three Wraparound 1996:279-293. nance organizations.” International Models as Promising Approaches.” In: Journal of Psychiatry in Medicine. Burns BJ, Goldman SK, eds. Promising Sheline YI. “High prevalence of 1997;27(3):215-231. practices in wraparound for children with physical illness in a geriatric psychiatric severe emotional disturbance and their inpatient population.” General Hospital Bartels SJ, Levine KJ, Shea D. “Commu- families: Systems of care: Promising Psychiatry. 1990;12:396-400. nity-based long-term care for older persons practices in children’s mental health with severe and persistent mental illness in systems of care. 1998 Series, Vol. IV. Stroul BA, Friedman RM. A system of an era of managed care.” Psychiatric Rockville, MD: Center for Mental Health care for children and youth with severe Services. 1999;50(9):1189-1197. Services; 1999:17-59. emotional disturbances. Rockville, MD: Child, Adolescent and Family Branch, Bartels SJ. “Quality, costs, and effective- Gray GV, Brody DS, Hart MT. “Primary Center for Mental Health Services, ness of services for older adults with care and the de facto mental health care Substance Abuse and Mental Health mental disorders: a selective overview of system: improving care where it counts.” Services Administration; July 1986. recent advances in geriatric mental health Managed Care Interface. 2000;13(3):62-65. services research.” Current Opinion in USDHHS. Mental Health: A Report of Psychiatry. 2002;15(4):411-416. the Surgeon General. Rockville, MD: Harris D, Crilly RG, Stolee P, Ellett FK. U.S. Department of Health and Human “Improving a system of care for elderly Services; 1999. Burns BJ, Goldman SK, Faw L, Burchard persons in rural areas.” Gerontologist. J. “The wraparound evidence base.” In: 1999;39(3):362-367. Burns BJ, Goldman SK, eds. Promising VanDenBerg J. “History of the Wraparound Process.” In: Burns BJ, practices in wraparound for children with Higgins ES. “A review of unrecognized severe emotional disturbance and their Goldman SK, eds. Promising practices mental illness in primary care. Prevalence, in wraparound for children with severe families: Systems of care: Promising natural history, and efforts to change the practices in children’s mental health emotional disturbance and their course.” Archives of Family Medicine. families: Systems of care: Promising systems of care. 1998 Series, Vol. IV. 1994;3(10):908-917. Rockville, MD: Center for Mental Health practices in children’s mental health Services; 1999. systems of care. 1998 Series, Vol. IV. Holmberg SK, Kane C. “Health and self- Rockville, MD: Center for Mental care practices of persons with schizophre- Health Services; 1999. Druss BG, Bradford WD, Rosenheck RA, nia.” Psychiatric Services. Radford MJ, Krumholz HM. “Quality of 1999;50(6):827-829. medical care and excess mortality in older Vieweg V, Levenson J, Pandurangi A, Silverman J. “Medical disorders in the patients with mental disorders.” Archives of Kaplan MS, Adamek ME, Calderon A. General Psychiatry. 2001;58(6):565-572. schizophrenic patient.” International “Managing depressed and suicidal geriatric Journal of Psychiatry in Medicine. patients: Differences among primary care 1995;25(2):137-172. physicians.” Gerontologist.

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service delivery settings (AoA, Caring for Older 2001), increases the complexity of the health care system and often limits Americans with Mental the older adult’s ability to indepen- dently navigate through their health Illness: Geriatric Care care options. This article presents information on the current and projected shortfall Management and the in the health care workforce in a variety of health care disciplines that Workforce Challenge serve older adults with mental illness; summarizes recommendations for By Aricca D. Van Citters, B.A. and improving the capacity of health care Stephen J. Bartels, M.D., M.S. providers to meet the projected need; and identifies ways in which the geriatric care manager can ease the navigation burden imposed upon the There are serious concerns and 7% with uncomplicated dementia older adult by both fragmentation of shared by health care providers, (Jeste, et al., 1999). By the year 2030, the health care system and the consumers, and researchers that the number of older adults with major shortage of providers with geriatric current health care services are psychiatric illnesses will more than expertise. The population of older inadequate to meet the mental health double from an estimated 7 to 15 adults with mental disorders and an needs of older persons. Moreover, million individuals (Jeste, et al., 1999) . inadequate workforce of health care this shortage is expected to grow as As shown in Figure 1, relative to the providers with training in geriatrics the population of older Americans need for mental health services in presents a significant challenge for increases over the coming decades. older populations, there is a lack of care management that will only One in four older adults has a signifi- formal health care training in mental increase in the coming decades. This cant mental disorder (26.3%) including health and aging. A shortage of dilemma challenges professional 16.3% with a primary psychiatric geriatric health care providers, geriatric care managers to be illness, 3% with dementia complicated accompanied by high fragmentation especially creative in coordinating by significant psychiatric symptoms, among different provider groups and health care providers from many different sectors. Current and Future FIGURE 1 Workforce Needs Estimated Prevalence of Major Psychiatric The specialized needs of older Disorders by Age Group adults with mental illness present unique challenges that are best 16 addressed by providers with geriatric expertise. Providing appropriate and 14 effective care to older persons with 12 mental illness requires specialized knowledge and clinical skills that enable the practitioner to assess

Millions 10 complex interactions between medical 8 illness, psychiatric disorders, cognition, functioning, and the 6 general processes of aging, as well as 2000 2010 2020 2030 None the cultural, social, ethnic, and environmental factors that impact quality of life in older age. The 18-29 30-44 45-64 65> following section provides an overview of the geriatric health care Source: Bartels SJ. “Improving the United States’ system of care for older adults provider workforce in five categories with mental illness: findings and recommendations for the President’s New Freedom Commission on Mental Health”. American Journal of Geriatric Psychiatry. including psychiatrists, physicians, 2003;11(5):486-497. Copyright 2003, the American Psychiatric Association; http:// psychologists, nursing staff, and ajgp.psychiatryonline.org. Reprinted by permission. other allied health care professionals. (continued on page 26)

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Caring for Older physicians vary substantially with training positions increased from 222 Americans with respect to training in psychiatry, and to 394 in family practice and internal Mental Illness: few have advanced training in geriatric medicine and from 82 to 137 in Geriatric Care medicine. Current figures suggest that geriatric psychiatry. However, this Management and the there are 9,000 physicians with increase has not been followed by a Workforce Challenge geriatric certification in the United proportional increase in trainees. The States. However, this represents less proportion of filled positions has (continued from page 25) than half of the current need. By 2030, steadily declined over the last five to Geriatric Psychiatrists the need for geriatric physicians is six years. In academic year 2001-2002, expected to increase to 36,000. Unless only 69% of geriatric medicine Geriatric psychiatrists are reforms are enacted, the shortfall of fellowship positions were filled, and physicians who have completed a geriatricians may reach 25,000 doctors only 61% of geriatric psychiatry residency training program following (AFAR, 2002). The current ratio of fellowship positions were occupied. graduation from medical school, and approximately 2.5 geriatricians to Despite a 67% increase in the number have obtained additional expertise and every 10,000 elderly patients is of available training positions in qualifications in the field of geriatric insufficient to meet basic health care geriatric psychiatry, there has been psychiatry. Approximately 2,500 needs (AFAR, 2002). Further contrib- virtually no overall change in the psychiatrists have received certifi- uting to a projected shortfall in number of geriatric psychiatry fellows cates for added qualifications in geriatric physician providers, only six from 1996 (n=77) to 2001 (n=81) geriatric psychiatry (APA, 2002). This of the 144 US medical schools have (Warshaw, et al., 2002). number of specialists dramatically falls geriatric medicine departments short of the need. At the current rate (Warshaw, et al., 2002) and the US has Geriatric Psychologists of graduating approximately 80 new fewer than 600 medical school faculty geriatric psychiatrists each year and Only three percent of clinical (of 100,000 faculty members) with psychologists in the American an estimated 3% attrition due to specialization in geriatrics (AFAR, retirement, there will be approximately Psychological Association (APA) 2002). In 1998-1999, more than 40% of devote their practice to serving older 2,640 geriatric psychiatrists by the medical schools reported that their year 2030. While estimates vary, it adults. However, a majority (69%) of curriculum in geriatric medicine was APA members provide some psycho- has been suggested that there is a inadequate (AAMC, 2001). need for 4,000 to 5,000 geriatric logical services to older adults. psychiatrists who provide patient care In response to a recognized need Nearly 15,000 psychologists have an (NIA, 1987), as well as 1,220 physician for physicians with specialty training older adult on their caseload, which in faculty members and 920 non- in geriatrics, medical schools have aggregate equates to nearly 3,100 full- physician faculty members who increased the number of specialty time equivalent (FTE) psychologists provide training in geriatric psychiatry fellowship positions. Between 1996 serving older adults (Honn Qualls, et (Reuben, et al., 1993). and 2002, the number of geriatric (continued on page 27) In addition to geriatric psychia- trists with specialized qualifications, general psychiatrists also provide FIGURE 2 treatment to older adults; 18.1% of general psychiatrists have at least Supply and Demand for Geriatricians: 1990-2030 20% of their caseload devoted to patients age 65 and older, and only 40,000 23.0% have no older adults on their caseload (Colenda, et al., 1999). Supply Demand Despite these additional providers, the 30,000 workforce of psychiatrists who provide treatment to older adults is 20,000 inadequate to address the need. The majority of diagnostic and pharmaco- 10,000 logical treatment of psychiatric disorders in older adults is provided # of Geriatricians by primary care physicians. 0 1990 2000 2010 2020 2030 Geriatric Physicians Year

Primary care physicians provide Source: AFAR. Medical Never-Never Land: Ten Reasons Why America Is Not most treatment for mental health Ready For the Coming Age Boom. Washington, D.C.: Alliance for Aging Research; problems among older adults (George, February 2002. et al., 1988). However, primary care

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Caring for Older instruction and applied gerontological programs has decreased by as much as Americans with knowledge. Data from 1997 indicated 42% between 1996 and 2000 (Scanlon, Mental Illness: the availability of only 13 postdoctoral 2001). This decline, along with other Geriatric Care fellowships and 65 pre-doctoral factors, has contributed to an abun- Management and the internships for receiving training in dance of vacant nursing positions. Workforce Challenge geriatric psychology (Hinrichsen, et National rates of vacancies among al., 2000). nursing positions are highest for RNs (continued from page 26) (18.5%), LPNs (14.6%), and CNAs al., 2002). However, this falls short of Nursing Staff (11.9%). These rates translate into an the current need for 5,000 to 7,500 FTE The demand for providers of estimated 16,100 vacant staff RN geriatric psychologists (Jeste, et al., nursing care is expected to experience positions, 25,600 vacant LPN positions, 1999). substantial growth in the coming and 66,900 vacant CNA positions The inadequacy of training in decades. However, recent enrollment (AHCA, 2002). geriatric mental health was recognized in nursing education programs have Increasing demand for nursing by this group of providers and most declined, leading to high vacancy services and declining entrance into the felt that additional geriatric training rates in existing positions. Even more nursing profession are accompanied by was desirable. Nineteen percent of striking is the lack of geriatric or a lack of focus and training on geriatric APA members felt they needed more psychiatric training among nursing care. Less than 1% of the 2.56 million providers. training in geriatrics before they could registered nurses in the US are certified ethically provide services to older The number of licensed registered in geriatric care (AFAR, 2002). More- adults, 39% felt they needed training nurses (RNs) increased only 5.4% over, in the ten year period between in some areas, and 32% believed that between 1996 and 2000. However, 1991 and 2001, only 4,200 nurses (of an training was desirable, but not between the years 2000 and 2020, the estimated 70,000 to 80,000 advanced necessary to practice competently demand for RNs across all health care practice nurses) have been certified as (Honn Qualls, et al., 2002). Members of settings is expected to increase by advanced practice gerontological the APA were most interested in nearly 31%. During the same period, nurses (West, 2001). Training in mental educational programs that addressed licensed practical and vocational health is also limited. Among the 4,000 geriatric depression and chronic nurse (LP/VN) positions are expected members of the American Psychiatric mental illness within older adult to grow by 38.8% and certified nurses Nurses Association, only 16%, or populations (Honn Qualls, et al., aids (CNAs) positions are expected to approximately 640 members, have a sub- increase by 40.5% (Decker, et al., 2002). However, opportunities for specialization in geriatrics (APNA, 2001). clinical training in working with older 2002). adults are limited. There are few Despite projections for increased Two initiatives have been promoted formal programs that allow psycholo- need, enrollment in diploma, associate to assure geriatric proficiency among gists to acquire supervised clinical degree, baccalaureate, and master’s the general nursing workforce. These include preparing all newly licensed practicing nurses and registered nurses, FIGURE 3 as well as students graduating from nursing programs, with competency in Supply and Demand for RN FTEs: 2000-2020 geriatrics (Mezey & Fulmer, 2002). Other potential mechanisms for address- ing the shortage in the nursing 2.75 workforce include exploring recruitment and retainment efforts, improving the Supply 2.50 Demand image of nursing, and supporting legislation aimed at rectifying the 2.25 shortage (Janiszewski Goodin, 2003). Other Health Care 2.00 Providers # of RNs (millions) There is little recent data to guide 1.75 estimates on the need for other health 2000 2005 2010 2015 2020 care professionals with geriatric clinical Year certification. However, available data suggests severe workforce shortages in Source: Decker FH, Dollard KJ, Kraditor KR. “Staffing of nursing services in nursing homes: present issues and prospects for the future”. Seniors Housing and many health care disciplines. Less than Care Journal. 2001;9(1):3-26. 0.3% of physical therapists are board (continued on page 28)

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Caring for Older (Abramson & Halpain, 2002, Halpain, The Mission for Geriatric Americans with et al., 1999, Jeste, et al., 1999). How- Care Managers: Mental Illness: ever, such efforts have been limited to Addressing Mental Geriatric Care small capacity training programs. Disorders of Aging in the Management and the Developing an initiative to address the Community—Stone Soup Workforce Challenge projected shortfall in trained providers constitutes a major health policy Despite national efforts to increase (continued from page 27) priority. the number of geriatric providers, the shortage of geriatric specialists with certified in geriatrics and less than Strategies to address the current expertise in mental health will continue. and future shortfall in providers who 0.4% of pharmacists have geriatric The challenge is not unlike the fable of are trained in geriatrics and mental certification (AFAR, 2002). There is the resourceful French soldiers who also a need for a large number of health include: 1) evaluating future created a large kettle of soup with workforce needs for health care social workers with geriatric compe- enough to feed an entire town by providers in geriatric psychiatry and tency. It has been suggested that soliciting small contributions from 60,000 to 70,000 full time social in allied health professions and multiple sources under the pretence of identifying factors to improve workers will be needed by 2010 to adding flavor to a “soup” that began recruitment into geriatric specialty serve the needs of older adults. Sixty- with stones and water. The shortfall in two percent of social workers who are training programs; 2) exploring health care providers with advanced incentive programs, including loan affiliated with the National Associa- expertise in mental health and aging will repayment programs and increased tion of Social Workers report that they inevitably continue, despite modest require geriatric knowledge; however, authorization of graduate medical improvements produced by health education (GME) payments; 3) less than 3% of students pursuing a policy initiatives addressing the public expanding required training in master’s degree in social work health need (Bartels, 2003). The specialize in aging, and less than 2% geriatrics to long-term care nurses, challenge for the PGCM is to assemble certified nursing assistants, and other of other social work students pursue a team of appropriate providers who allied professionals in addressing graduate coursework in gerontology will be able to provide a network of psychiatric disorders and behavioral (Browne, et al., 2002, CSWE, 2001). community services and supports symptoms of dementia; and 4) uniquely tailored to the specialized developing approaches to increasing Addressing the needs of the older adult with psychiat- the number of providers with geriatric Workforce Shortage ric illness. mental health training including early Workforce estimates from five educational awareness of geriatrics as The geriatric care manager must major health care disciplines show a potential health care career path; develop innovative strategies to best large shortages in the number of development of multidisciplinary serve older adults using available health care providers with specialized training environments for aging and resources. Two prominent service training in the care of older adults. mental health; increasing provider models are well suited to utilizing native Even fewer health care providers have competencies through information- resources, including multidisciplinary specialized training in late-life mental technology mechanisms; and increas- treatment teams and outreach to older illness. Anticipating the growing ing the proportion of educational adults in their homes and communities. demand for geriatric mental health programs with training in the identifi- The following programs provide services will require building an cation, assessment, and management examples of these models. The PATCH adequate infrastructure by training of late-life mental disorders (Bartels, program (Psychogeriatric Assessment clinicians to provide the services that 2003). and Treatment in City Housing) trains will be demanded by older consumers “gatekeepers”, or non-traditional with mental health problems referral sources, in congregate public housing to identify older adults who TABLE 1 need mental health or substance abuse treatment. Following identification, the older adult is referred to a psychiatric Existing Resources to Coordinate in Caring for nurse who visits and assesses the older Older Adults with Mental Illness adult within their apartment, and Formal Resources Potential Informal Resources provides brief on-site treatment in consultation with a physician or, when z Area Agencies on Aging z Family Caregivers necessary, refers the individual for z Mental Health Centers z Senior Centers more intensive treatment (Rabins, et al., z Nursing Homes z Family Members (spouse, z Visiting Nurse Associations partner, children) 2000). The model of Wrap Around z Home Health Agencies z Friends Services for Older Adults offers the z Residential Care Facilities z Spiritual Leaders most adaptable approach for geriatric z Health and Primary z Other Social Support care managers. This model is built Care Clinics Networks around three core values: (1) services (continued on page 29)

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Caring for Older Conclusion Stephen J. Bartels, M.D., M.S. is the Americans with The impact of the national director of the Aging Services Mental Illness: workforce shortage is felt by every Division of the New Hampshire- Geriatric Care older American who cannot access Dartmouth Psychiatric Research Management and the or has delayed access to a health Center and Associate Professor of Workforce Challenge care provider. It is felt by every Psychiatry at Dartmouth Medical School in Lebanon, NH. He is also the (continued from page 28) older American who is treated by a physician who does not understand Medical Director for the New Hamp- must be client-centered, family- the different metabolic, social, and shire Division of Behavioral Health focused, and individually tailored; (2) and the Director of the New Hamp- psychological changes between the when possible, services should be shire Behavioral Health Policy community-based and provided in the middle-aged adult and the older Institute. least restrictive setting using natural adult. Moreover, it is felt by mem- supports, as opposed to institutional bers of the health care community References who strive to care for the older care; and (3) services should be AAMC. 2001 Medical School Graduation providing in a context of cultural person under increasing workload Questionnaire, All Schools Report. competence (Stroul & Friedman, pressures. However, the workforce Washington, DC: Association of American 1986). Wraparound teams are shortage presents geriatric care Medical Colleges, Division of Medical designed to foster collaborative care managers with an opportunity to Education; 2001. between consumers and a variety of address appropriate care of older Abramson TA, Halpain M. “Providers of service agencies. Agencies address- adults. As fragmentation across mental health services-now and in the ing issues of housing, mental health, health care disciplines increases, future.” Generations. 2002;26(1):107-110. home health, medical needs, and geriatric care managers play an AFAR. Medical Never-Never Land: Ten recreational needs should be involved increasingly important role in Reasons Why America Is Not Ready For the in serving older adults with serious coordinating the delivery of health Coming Age Boom. Washington, D.C.: mental illnesses and efforts to care. The core actions of care Alliance for Aging Research; February 2002. diminish service fragmentation and to managers including systematic AHCA. Results of the 2001 AHCA Nursing improve communication among these assessment, planning, service Position Vacancy and Turnover Survey: agencies is necessary. Finally, input coordination or referral, and monitor- Health Services Research and Evaluation; from stakeholders such as the older American Health Care Association; Feb 7 ing are essential for meeting the 2002. adult’s mature children, spouses/ multiple service needs of older partners, friends, counselors, medical adults, especially those with mental AoA. Older Adults and Mental Health: staff, and home care workers can offer Issues and Opportunities. Rockville, MD: illness. Geriatric care managers will Administration on Aging; 2001. valuable insight into providing be increasingly challenged to appropriate health care to older coordinate appropriately trained APA. “Statement of the American persons with mental illness. (See teams to provide health care services Psychiatric Association on Geriatric Table 1 for a list of potential re- Health Education and Training.” Senate to their clients. In a workforce that Special Committee on Aging Hearing. sources to call upon in providing has few providers with geriatric 2002. comprehensive care.) training, care managers will need to APNA. Member Profile. American Older adults with mental illness be ever resourceful in assembling Psychiatric Nurses Association. Available have complicated service needs, and teams of providers that meets their at: http://www.apna.org/membership/ are often dependent upon multiple clients’ needs for appropriate care. profile.html. Accessed Oct 6, 2003. agencies to meet these needs. In establishing the health care team, Bartels SJ, Levine KJ, Shea D. “Mental Current systems of care are ill- it will be important to identify at least health long-term care and the elderly: The equipped to provide or coordinate the one person with geriatric experience emerging challenge of severe and persistent necessary array of services to to help promote effective service mental disorders in an era of managed accommodate projected future service models and interventions (Kovner, et care.” 1998. needs (Bartels, et al., 1998) outside of al., 2002). Geriatric care managers are Bartels SJ. “Improving the United States’ intensive, institution-based care in a special position that allows them system of care for older adults with mental settings. As such, there is an urgent to decrease the negative impact of illness: findings and recommendations for the President’s New Freedom Commission need for geriatric care managers to fragmented service delivery by use existing resources to provide the on Mental Health.” American Journal of coordinating a multidisciplinary team Geriatric Psychiatry. 2003;11(5):486-497. highest level of care possible for of providers, with access to geriatric older adults with severe mental expertise. Browne CV, Braun KL, Mokuau N, illness. The programs described McLaughlin L. “Developing a multisite project in geriatric and/or gerontological above offer potential methods of education with emphases in interdiscipli- action for geriatric care managers to Aricca Dums Van Citters, B.A. is a nary practice and cultural competence.” both identify and refer older adults to research assistant in the Aging Gerontologist. 2002;42(5):698-704. mental health service providers or to Services Division of the New Hampshire-Dartmouth Psychiatric coordinate a health care and support (continued on page 30) team with access to a team leader or Research Center in Lebanon, NH. consultant with geriatric expertise. PAGE 29 GCM winter 2004

Caring for Older Hinrichsen GA, Myers DS, Stewart D. NIA. Personnel for Health Needs of the Americans with “Doctoral internship training opportuni- Elderly Through the Year 2020. Washing- ties in clinical geropsychology.” Profes- ton, DC: US Government Printing Office; Mental Illness: sional Psychology: Research and Practice. 1987. NIH pub 87-2950. Geriatric Care 2000;31:88-92. Rabins PV, Black BS, Roca R, German P, Management and the Honn Qualls S, Segal DL, Norman S, McGuire M, Robbins B, Rye R, Brant L. Workforce Challenge Niederehe G, Gallagher-Thompon D. “Effectiveness of a nurse-based outreach “Psychologists in practice with older program for identifying and treating (continued from page 29) adults: Current patterns, sources of psychiatric illness in the elderly.” Journal Colenda CC, Pincus H, Tanielian TL, training, and need for continuing educa- of the American Medical Association. Zarin DA, Marcus S. “Update of geriatric tion.” Professional Psychology: Research 2000;283(21):2802-2809. psychiatry practices among American and Practice. 2002;33(5):5435-5442. psychiatrists.” American Journal Reuben DB, Bradley TB, Zwaniger J, Fink Geriatric Psychiatry. 1999;7(4):279-288. Janiszewski Goodin H. “The nursing A, Vivell S, Hirsch SH, Beck JC. “The shortage in the United States of America: critical shortage of geriatrics faculty.” CSWE. A Blueprint for the New an integrative review of the literature.” Journal of the American Geriatrics Society. Millenium: Strengthening the impact of Journal of Advanced Nursing. 1993;41(5):560-569. social work to improve the quality of life 2003;43(4):335-343. for older adults and their families. Scanlon WJ. Nursing Workforce: Recruit- Alexandria, VA: Council on Social Work Jeste DV, Alexopoulos GS, Bartels SJ, ment and Retention of Nurses and ; 2001. Cummings JL, Gallo JJ, Gottlieb GL, Aides Is a Growing Concern. Testimony Halpain MC, Palmer BW, Patterson TL, before the Committee on Health, Education, Decker FH, Dollard KJ, Kraditor KR. Reynolds CF, III, Lebowitz BD. “Consen- Labor and Pensions, U.S. Senate 2001. “Staffing of nursing services in nursing sus statement on the upcoming crisis in homes: present issues and prospects for Stroul BA, Friedman RM. A system of care geriatric mental health: Research agenda for for children and youth with severe emotional the future.” Seniors Housing and Care the next 2 decades.” Archives of General Journal. 2001;9(1):3-26. disturbances. Rockville, MD: Child, Adoles- Psychiatry. 1999;56(9):848-853. cent and Family Branch, Center for Mental George LK, Blazer DG, Winfield-Laird I, Kovner CT, Mezey M, Harrington C. Health Services, Substance Abuse and Mental Leaf PJ, Fischbach RL. “Psychiatric “Who cares for older adults? Workforce Health Services Administration; July 1986. disorders and mental health service use in implications of an aging society.” Health Warshaw GA, Bragg EJ, Shaull RW, later life.” In: Brody JA, Maddox GL, Affairs. 2002;21(5):78-89. Lindsell CJ. “Academic geriatric programs eds. Epidemiology and Aging. New York: in US allopathic and osteopathic medical Springer; 1988:189-221. Mezey M, Fulmer T. “The future history of schools.” Journal of the American Medical .” Journals of Association. 2002;288(18):2313-2319. Halpain MC, Harris MJ, McClure FS, Gerontology Series A-Biological Sciences & Jeste DV. “Training in geriatric mental Medical Sciences. 2002;57(7):M438-441. West S. Caring for Older Americans: health: Needs and strategies.” Psychiatric Recommendations for building a national Services. 1999;50(9):1205-1208. program for graduate nursing education in gerontology. Washington, D.C. March 2001. PAID ADVERTISEMENT

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PAGE 30 GCM fall 2003 AAGP Membership Application

Founded in 1978, the AAGP provides psychiatrists with a special interest in mental health care for the elderly exceptional professional benefits through educational, informational, and interactive programs for its members. The membership committee will review this application and present it to the Executive Committee, which meets bi-monthly.

MEMBERSHIP CRITERIA A physician who is currently a psychiatry resident may apply as a Member-in-Training. 1. The applicant must have completed a residency in psychiatry approved by the AMA, ACGME or be certified in psychiatry by the American Board of Psychiatry and Neurology. 2. The applicant must have been or must be actively in the practice of geriatric psychiatry. 3. The applicant must have a major professional interest in the mental health care of the elderly, or devote substantial professional time in connection with the public mental health care delivery systems for the elderly. 4. Annual dues: $195 General, $65 Member-in-Training.

Please include payment and send to AAGP, PO Box 85080, Richmond, VA 23285-4133 Accepted: † Checks or † Credit Card ______exp. date ______

GENERAL INFORMATION Full Name ______Degree(s) ______Preferred Mailing Address (Check Appropriate Category: Business or Home) Phone ______Fax ______Email ______Second Address (Check Appropriate Category: Business or Home) Phone ______Fax ______

EDUCATION

My American Board of Psychiatry and Neurology certification in psychiatry is: # ______date ______

My added qualifications in Geriatric Psychiatry certificate is: # ______date ______

My medical degree was received at ______date ______My medical license number is: # ______date ______

My residency training in psychiatry was received at ______date ______

My Geriatric Psychiatry Fellowship was received at ______date ______Have you ever had your medical license revoked in any jurisdiction: † Yes † No

If yes, where? ______Please explain ______

PROFESSIONAL BACKGROUND Please indicate the organizations of which you are a member: † APA † IPA † AGS † GSA † AMA † ASA † CPA † AMDA

Do you accept referrals? † Yes † No

Please indicate if you are an employee of the: † Local † State † Federal Government

Please indicate the most applicable category: † Practicing Psychiatrist † Fellow (PGY5) † Resident (PGY 1-4)

How would you describe yourself and your work? † Clinician † Researcher † Student/Fellow

(continued on back)

PAGE 31 PRESORTED STANDARD US POSTAGE

National Association of Professional PAID Tucson AZ Geriatric Care Managers Permit NO 3178 1604 North Country Club Road Tucson, AZ 85716-3102

AAGP Membership Application (continued from front)

PROFESSIONAL INFORMATION (please complete this section) 1. What percentage of time in each work setting do you work? † Nursing Home † Assisted Living † HMO/PPO † Private Practice † University † Other ______

2. Please provide the name and location of the institution(s) where you work (i.e. nursing home name, university, etc.) ______

MEMBERSHIP INFORMATION (please check the appropriate choice) If you are interested in working with AAGP Committees, check the group in which you are interested: † Education † Annual Meeting Committee † Communications † Public Policy † Clinical Practice † Research † Membership Where did you initially hear about the AAGP? † Colleague † Training Director † AAGP Letter/Solicitation † AAGP Member † Psychiatric News Ad † Clinical Psychiatric † News Ad Are you planning to attend any of the following AAGP Annual Meetings? † 2004 Baltimore

DEMOGRAPHICS Filling out this section is optional, however, information provided by potential members enables AAGP to respond to inquiries primarily from our members about diversity in the field and membership.

Gender † Male † Female Ethnicity † Caucasian † African-American † Hispanic † Native-American † Asian † Other ______Country of origin ______Date of Birth ______

REFERENCES Please list the names, work addresses and phone numbers of two psychiatrists whom we can contact as professional references. AAGP members are preferred.

1. Full Name and Degree ______Phone Number ______

2. Full Name and Degree ______Phone Number ______

I affirm that all information provided is correct to the best of my knowledge. Signature ______Date ______If you were referred by an AAGP Member, please list the name here ______