The Mental Health and Substance Use Workforce for Older Adults In Whose Hands? (2012) / Chapter Skim
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4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions
4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions
Pages 241-282
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From page 241... ...
Research on effective delivery of MH/SU care for individuals residing in nursing homes and other residential settings, prisoners, rurally isolated elders, and older adults with severe mental illnesses is urgently needed. The previous chapters described the mental health and substance use (MH/SU)
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From page 242... ...
Research on effective delivery of MH/SU care is particularly lacking for older adults in nursing homes, residential treatment settings, and other congregate living arrangements as well as for prisoners, rurally isolated elders, and older adults with serious mental illnesses. For settings with several intervention models, the committee chose the model that had the most robust evidence.
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alcohol and substance misuse Primary Care Research in Older primary care patients with Substance Abuse and Mental symptoms of depression, anxiety, Health for the Elderly (PRISM-E) and at-risk drinking Serious Mental Illness (SMI)
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. The selected models include interventions for managing depression in primary care and in home care settings, for addressing substance use, for assisting older adults with severe and persistent mental illness, and for managing the psychiatric and behavioral symptoms of dementia in primary care.
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involved in a patient's care to 2 For example, most of the research on chronic care management focuses on single chronic conditions in limited types of settings for only short periods of time. As a result, the findings may not be generalizable to real-world settings with more limited resources, motivation, or expertise.
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For most primary care practices, implementing care coordi nation requires system-level practice redesign and personnel retraining programs as well as electronic health records for shared access to patients' clinical data, individualized decision support, and easy communication between providers.
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for depression, substance use, serious mental illness, and psychiatric and behavioral symptoms related to dementia. Several of the models began as RCTs, which yielded clinically significant results and have since been implemented in numerous sites around the country.
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. The RCT, funded by several foundations, compared usual care with a collaborative, stepped-care treatment model for 1,801 older adults who met DSM-IV-TR criteria4 for major depression or dysthymia.
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. The Kaiser Nurse Telehealth Care Model has been implemented and evaluated in 13 unaffiliated primary care clinics in Maine (Pearson et al., 2003)
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compared usual physician care, telehealth care, and telehealth care plus peer support to evaluate two augmentations of antidepressant treatment in an unbalanced randomized trial7 in two large primary care clinics. Participants included adults, ages 19 to 90, who were beginning antidepressant treatment for major depressive disorder or dysthymia.
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From page 251... ...
The sessions include problem-solving treatment, in which participants are taught to recognize depressive symptoms, to define problems that may contribute to their depression, and to devise steps to solve those problems; and behavioral activation such as social and physical activity planning and pleasant event scheduling. Staffing The DCMs in the original PEARLS trial were two trained master's-level social workers and a registered nurse.
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From page 252... ...
These include when older adults fill out new intake forms, during health care appointments, in emergency departments and urgent care clinics, during visits with home care nurses and social workers, and visits to senior centers and other social service agencies. This section describes two programs -- SBIRT and PRISM-E -- that use screening and brief interventions to address geriatric substance use.
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From page 253... ...
The objective of the pilot -- referred to as Brief Intervention and Treatment for Elders or BRITE -- was to identify older adults who had nondependent substance use or prescription medication problems and to provide them with effective interventions before they needed more specialized treatment. The project's success led to a SAMHSA SBIRT grant for an additional 5-year program that eventually included 31 sites in 18 counties, includ ing retirement communities, senior centers, general and trauma hospitals, primary care and urgent care clinics, VA medical facilities, and federally qualified health centers (Florida BRITE Project, 2009)
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Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E) PRISM-E was a multisite comparative trial of two models of care for treating at-risk drinking (as well as depression and anxiety)
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In the enhanced referral care model, MH/SU services were provided in a physically separate specialty MH/SU clinic designated by the pri mary care clinic. In contrast to the more typical referral process for specialty care, patients received enhanced referral support and case manage ment.
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. Models for Older Adults with Serious Mental Illness As Chapter 2 describes, a growing number of older adults have serious mental illnesses (SMIs)
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The trial compared usual care to integrated mental health and primary care. In the integrated care model, the mental health clinic had clinical responsibility for individuals' primary care.
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The HOPES trial demonstrated that it is feasible to engage older adults with SMI in an intensive skills training and medical management pro gram. Compared with usual care, HOPES participants were more likely to remain in the program and to improve their social skills, psychosocial and community functioning, negative symptoms, and self-efficacy (Mueser et al., 2010)
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The individuals who received the intervention experienced significantly greater declines in psychiatric symptoms compared with the control group. However, the intervention had no impact on tenure in the public housing site perhaps because, as the investigators suggest, some study participants were found to be living in unsafe conditions and placed into nursing homes or board and care facilities.
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Integral to the peer support philosophy is the concept of recovery, which refers to an ongoing process of learning to live with one's disability and gradually rebuilding a sense of purpose, agency, and meaning in life despite the limitations of the disorder. The growth of peer support services has been impressive.
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The literature suggests that individuals can boost the recovery of their peers with serious mental illnesses, substance use disorders, or dual diagnoses. Patients report enhanced experiences when usual care is supplemented by peer-delivered services.
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The focus is on helping people manage their mental illness independent of any more formal health care services they may receive. The curriculum stresses that, with a highly individualized plan for recovery, individuals can do more than simply manage their symptoms; they can also create a meaningful life in the community.
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, nursing home placement, and higher health costs. The PREVENT protocol is an example of an educational intervention tested within a collaborative care management model.
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Staffing Geriatric nurse practitioners acted as care managers. The nurse practitioner focused on the patient's behavioral symptoms and coordinated management of the patients' other chronic conditions with the pri mary care physician.
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More recently, nursing homes have begun to use nurse-centered models in which a psychiatric nurse visits the nursing home to evalu ate residents' mental health needs and to manage their mental health services. Typically, the nurse is supervised by a psychiatrist and acts as an "extender" of the psychiatrist's services.
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re cently assessed 73 randomly selected nursing home admissions and addressing the needs of nursing homes for means to train and educate staff. Although federal and state regulations require nursing homes to have an administrator, medical director, and director of nursing services, the rules do not require specialized mental health personnel nor do they
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Survey data indicate that about 25 percent of nursing homes report having mental health providers on staff and 24 percent use on-call providers.
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Care managers are integral to the team's effectiveness. In models such as IMPACT, Kaiser Nurse Telehealth Care, PREVENT, PRISM-E, and SBIRT, the care manager has the most interaction with the patient and serves as the central care coordinator.
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Models Care Setting Core Staff Psychiatrist Mental Primary or Other Peers or Primary Health Other Care Care MH Family Model Care Settinga Home Settingsb Team Provider Managerc Specialist Caregivers ✔ ✔ ✔ HOPES ✔ ✔ ✔ ✔ ✔ IMPACT ✔ ✔ ✔ ✔ ✔ ✔ ✔d Kaiser Nurse Telehealth Care ✔ ✔ ✔ PATCH ✔ ✔ ✔ ✔ ✔ PEARLS ✔ ✔ ✔ ✔ ✔ ✔ PREVENT ✔ ✔ ✔ ✔ PRISM-Ee ✔ ✔ ✔ ✔ SBIRT ✔ ✔ WRAP a Specialty settings include private offices of psychiatrists, psychologists, social workers, and other mental health professionals and community mental health centers. b Other settings include emergency departments, community senior centers, social service agencies, mobile outreach programs, health fairs, hospitals, and urgent care clinics.
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These models increasingly call for primary care providers to comanage patients with MH/SU providers instead of simply referring out for specialty manage ment. For example, antidepressant prescriptions are the purview of the primary care provider in IMPACT and the Kaiser Nurse Telehealth Care
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From page 271... ...
For models based in primary care (e.g., IMPACT, Kaiser Nurse Telehealth Care, PREVENT, and PRISM-E) , sharing of office space will be necessary and primary care information systems will need to incorporate identification and monitoring of MH/SU problems.
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From page 272... ...
Progress in these areas is not likely to be achieved, however, without practice redesign and change in Medicare payment rules. There is a fundamental mismatch between older adults' need for coordinated care and Medicare fee-forservice reimbursement that precludes payment of trained care managers and psychiatry consultation.
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From page 273... ...
However, they will require intensive training in evidence-based program treatment as they are likely to have limited knowledge of MH/SU. Finally, research on effective delivery of MH/SU care for certain older populations is urgently needed, especially for individuals residing in nursing homes and other residential settings, prisoners, rurally isolated elders, and older adults with severe mental illnesses.
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2009. Psychosocial rehabilitation and quality of life for older adults with serious mental illness: Recent findings and future research directions.
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2009. Collaborative care interventions for depression in the elderly: A systematic review of randomized controlled trials.
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2012. Results of a randomized controlled trial of mental illness self-management using wellness recovery action planning.
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2000. Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care.
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2006. Use of PASRR programs to assess serious mental illness and service access in nursing homes.
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2010. Randomized trial of social rehabilitation and integrated health care for older people with severe mental illness.
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2004. Telephone psychotherapy and telephone care management for primary care patients starting antidepressant treatment: A randomized controlled trial.
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2002. Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial.
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2012. Psycho social care in nursing homes in the era of the MDS 3.0: Perspectives of the experts.
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