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Northeast Integrated Geriatrics Care Supporting Primary Care in Long-term Care Settings Author: Natalie Truesdell, MPH, MBA
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Introduction Between 2007 and 2009, as part of its statewide Integration Initiative, the Maine Health Access Foundation (MeHAF) funded 24 Clinical Implementation and 19 Planning or Systems Transformation grants that support innovative approaches to integrating behavioral health and primary care services. Of the diverse projects funded, the Northeast Integrated Geriatrics Care program was especially unique because it focused on older adults in acute care and nursing home environments. This case study establishes the context of the program and outlines the partnership across multiple health care providers and the implementation process. For others interested in this approach, the case study shares the short-term outcomes, and the considerations for others interested in pursuing this approach to integration.
Context of the Northeast Integrated Geriatrics Care Program
Eastern Maine Health Systems is a large health network that includes ownership of Eastern Maine Medical Center (EMMC), a medical hospital in Bangor, Maine; the Acadia Hospital for acute and outpatient behavioral health, also in Bangor; and the Rosscare Nursing Homes, Inc. network. EMMC staff faced the challenge of older adults with mental health and/or dementia diagnoses staying in its inpatient setting for extended periods of time. From October 2008 through June 2009, there were 14 geriatric extended-stay patients who were in the hospital a total of 557 days with an average cost of stay for each patient of $724,100. These patients were not discharged to nursing homes, even though their acute medical needs had been met. In addition, their mental health deteriorated partly because of the noise and disorientation of being in the hospital for twice as long as other patients. Clearly, care plans were not meeting these patients’ needs. Mental illness, dementia, and behavioral health conditions in the nursing home environment are well recognized as both clinical and policy issues. Despite initiatives such as the 1987 Nursing Home Reform Act as part of the Omnibus Budget Reconciliation Act,1 there continue to be shortages in the availability of quality mental health services. Nurses and nursing home staff often lack appropriate training to care for patients with complex behavioral health needs.2 Further, access to psychiatric evaluation of patients in nursing homes has been problematic. Historically, nursing home patients only had a psychiatric evaluation when entering the health care system through the emergency room.
What the Program Did
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High prevalence of behavioral health conditions: Adults in a nursing
home setting experience a very high percentage of depression and/or dementia. It is estimated that between 65% and 91% of nursing home residents have a significant mental disorder; further, the state of Maine has the highest nursing home depression prevalence in the country. Rosscare Nursing Homes, Inc. have found that in each of its four nursing homes in the Bangor area, the percent of residents who are depressed or anxious is consistently over the national average.3 While the most common behavioral health diagnosis in the nursing home is dementia, the other prevalent behavioral illnesses include major depression and other serious mental illness such as schizophrenia.4 In 2009, Fullerton and colleagues published data indicating an increase in nursing home admissions with mental illnesses other than dementia.5
Reluctance among nursing home staff and administrators to care for individuals with behavioral health conditions: There is a great deal of reluctance among nursing home staff about caring for patients with behavioral health conditions. The truth, however, is that many of their patients already have mental health needs that are not being addressed sufficiently. At Rosscare’s four nursing homes, care is managed by the medical director and, in a few cases, by the primary care provider. The medical director acknowledged that neither provider has the capacity or training to address complex geriatric behavioral health needs comprehensively. Nursing home administrators fear that by building their expertise to better address behavioral conditions, their nursing homes will become a place to send patients with more acute mental illnesses that they do not feel equipped to manage. Many of the program’s components address both administrator and staff concerns about caring for older adults with behavioral health conditions. Description of the Innovation To address the limited behavioral health services for older adults in the Bangor regional area, the Northeast Integrated Geriatrics Care Program aimed to enhance the availability of mental health services for older adults in both the acute hospital setting (West Side Court within Eastern Maine Medical Center) and in the four nursing homes part of Rosscare Nursing Homes, Inc. 1. West Side Court Purpose: Improve the acute care hospital environment for older adults with behavioral health needs.
The first goal was to redesign the environment making it more patient-friendly. The hospital created West Side Court, located within the neurology wing, designed and staffed specifically for older adults with high
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acuity behavioral health needs. This renovated inpatient unit, formerly an intensive care unit (ICU) with six beds, was developed to care for patients with Alzheimer’s disease, dementia, psychiatric diagnoses, and patients with difficult behaviors. The environment is drastically different than other areas of the hospital – painted in colors with visual cues included in the design of the facility (e.g., colored toilet seats to help individuals see them).
A second goal has been to provide specific training to staff members working in the unit, so that they will work more effectively with patients living with mental and behavioral disorders, especially dementia, cognitive disability, and disruptive behaviors. This has included training provided by the local Alzheimer’s Association chapter and by Acadia Hospital, the inpatient psychiatric hospital. After visiting another hospital’s behavioral health wing, West Side Court now employs more nursing assistants who are focused on engaging patients in activities. Other staff changes included consistent hospitalist coverage and regular “rounds” at West Side Court conducted by the geriatric psychiatrist from Acadia.
Geriatrics consult team: An interdisciplinary geriatric team provides
consultations for older adult patients with more complex issues. This team is made up of a primary care physician, a psychiatrist, nurses, and social workers. Additionally, a licensed clinical social worker (LCSW) supports the nursing staff managing the varying behaviors of these older patients.
Care plans developed for transition to nursing home care: The
LCSW is available to work with hospital staff to develop a care plan that will support the transition of patients from West Side Court to a nursing home. This typically includes the “packaging” of medical and mental health information to facilitate timely and appropriate discharge.
2. Rosscare Nursing Homes, Inc. Purpose: Improve access to behavioral health in the nursing home environment for older adults with behavioral health needs.
Behavioral health counseling and treatment in the nursing home: The LCSW provides on-site therapy and support to residents identified with mental illness, persistent sadness, or dementia in Rosscare’s four nursing homes. She also supports patients with behaviors that nursing staff has difficulty working with, as well as with patients who pose potential danger to themselves or others. The LCSW is employed and supervised by Acadia Hospital (a mental health specialty setting that includes inpatient and outpatient services), but she works with patients in the nursing
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homes and at EMMC. This enables her to provide continuity of care across multiple care settings. The LCSW is supported by a geriatric psychiatrist who provides psychiatric assessments and ongoing treatment in person and through telemedicine. He also supports the medical director in the nursing facility in medication management and prescriptions for treatment of mental illnesses.
Ongoing care available in person and through telemedicine:
More frequent psychiatric evaluations andfollow-up behavioral health care is available from a geriatric psychiatrist and through telemedicine for those patients with urgent or particularly challenging needs. Telemedicine technology is set up and available at all four nursing homes.
Training of nursing facility staff: Curricula were developed, and a
train-the-trainer model was implemented to improve the behavioral health knowledge and skills of staff at all four participating nursing homes. All staff members were trained, including clinical and ancillary team members
Topics of Enhanced Behavioral Health Training Workshops*
Building Therapeutic Alliances to Manage Aggressive Behaviors Dealing with Sexual Behaviors Dementia, Delirium, and Depression in Older Adults Effective Communication with Older Adults Pain Palliative Care and Care of the Caregiver Resistance to Care Sexuality and Aging
*These workshops were offered after reviewing staff responses to a survey asking about additional education needs. Two of the workshops were not provided as part of the general education but were developed based on needs at specific facilities (“Resistance to Care” and “Dealing with Sexual Behaviors”).
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Did the Program Work?
Results The program increased the number of adults that could be appropriately cared for in the nursing home environment with the result of reducing average length of stay for adults with behavioral health conditions in the hospital. Nursing home administrators are now better able to accept patients with more significant behavioral health conditions, and nursing home staff now have more capacity and support to care for these patients. Senior leaders from the large health network Eastern Maine Health Systems that owns EMMC, EMMC, Acadia Hospital, and Rosscare have been collaborating and problem solving across their respective organizations that serve different populations and operate under different regulations, staffing mix, and management. The patients that have been enrolled in this program are primarily insured through Medicare (78%); however, a small percent are insured through MaineCare - Medicaid (13%), and private insurance (1%).1 Patient Demographics Gender Payer Mix
Average length of stay: The program reduced the average length of stay
from 45 days to 8.58 days for geriatric patients with acute medical and behavioral health conditions.
Patient satisfaction: The dedicated geriatric inpatient unit (West Side
Court) has the highest patient satisfaction of any unit in EMMC.
Improved prescribing of antipsychotics: The benchmark of zero “PRN”
(as needed) antipsychotic medications used in patients in West Side Court was met between January 2010 and June 2010. The number of anti-psychotic medications used remained at zero through June 2011.
1 One percent of patients’ insurance coverage was not reported.
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Reduced Emergency room visits: Patients in the program have made
no visits to the emergency room for behavioral health reasons since the program was implemented. Prior to the program, psychiatric evaluations were available to nursing home patients only by sending them to the emergency room. With the availability of a geriatric psychiatrist on site and via telemedicine (when on-site evaluation is not readily accessible), the program has limited emergency room transfers for psychiatric evaluation. Over a two-year period from 2009-2010, four “near misses” in ER transfers and possible hospital admissions were averted through the availability of behavioral health services at the nursing homes.
Improved mood and behaviors: Among patients receiving integrated
behavioral health services at the four participating nursing homes, there was improvement across both mood and behavior in five of six measured Minimum Data Set (MDS) Assessment findings. In 2009, 42% of patients had an improvement in crying, and 33% of patients participating had an improvement in verbal abuse. (See Figure 1.)
Referrals to provide behavioral health care in the nursing home:
Nursing homes are now accepting patients from Acadia and EMMC they previously would have denied due to the fact that they were on medication regimens prohibited under nursing home regulation, and concern for staff capacity to provide adequate care for patient. For example, a patient who had been at Acadia Hospital for over 100 days because no facility would accept him was successfully transitioned to a Rosscare nursing home with the support of the LCSW. Critical components of the program have
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contributed to this change: 1) the elimination of PRN Haldol (or other antipsychotic medications) prescribing at Westside Court, 2) enhanced nursing home staff capacity through training, and 3) regular and consistent support at the nursing homes from the LCSW and geriatric psychiatrist. The caseload of the LCSW is over 50 patients, demonstrating the need for her services and the effective referral system.
- Enhanced nursing home staff skills: The program has received
strong positive feedback from nursing home staff: “Immediate use of skills learned.” With the skills gained through training and ongoing support, nursing staff now have the ability to implement behavioral health treatment plans developed by the LCSW. In addition, with the skills acquired in trainings, they can better manage sudden onsets of aggressive behavior and altercations. Finally, staff works more effectively with less communicative patients or with those who argued regularly with staff.
LCSW Services Support Nursing Home Staff
A patient in a wheelchair was frequently only moving backwards in his wheelchair. Nursing staff worried for his safety, as well as for other patients. However, telling him to only move forward was not working. The LCSW was able to identify with the patient several needs that were being unmet and to understand that the patient was using the “rolling backwards” to ask for attention and help.
Patient-centered care: Staff now has skills and the support to meet the
acute and daily needs of patients with behavioral health conditions. Previously, these patients might have been sent to the emergency room.
- Improved environment: The inpatient environment has been
modified to be less disorienting and more “home-like” to support patients’ recovery.
- Care in the “right” place: The presence of a LCSW assures
nursing home staff members that they have the support to care for patients who otherwise might be forced to stay in a hospital. Similarly, the LCSW facilitates community transitions for patients who traditionally would have remained in the long-term care facility for extended periods.
- Patient advocate: The LCSW acts as an advocate for her patients,
ensuring that nursing home and hospital staff meets patients’ needs respectfully and supports their recoveries fully.
Northeast Integrated Geriatrics Care | 3 LCSW Acting as Patient Advocate
Often a few small changes can help patients feel more at home in a
nursing home setting. One role the LCSW has played is to think about what can be changed to accommodate patients and support their transitions to a new environment. For example, one had a favorite TV show that was not available on the television channels available at the nursing home. The LCSW worked with administrative staff to obtain pre-recordings of the patient’s favorite show. This made the patient happier and, ultimately, helped her to heal. One patient indicated his stay was greatly improved when staff listened to his request and began providing him with his favorite brand of orange juice. He was then able to focus on important therapeutic goals.
For other patients, the LCSW has worked with staff to customize meal
times and sleep-and-wake schedules to support their recovery.
How the Northeast Integrated Geriatrics Care Program Made a Difference
Planning and Development Process The Northeast Integrated Geriatrics Care Program is a collaboration across several health care organizations, requiring new relationships, policies, and procedures. Key elements of the planning and development process included:
Leadership: Strong leadership at the parent organization and executive
staff at all three major partners—EMMC, Acadia, and Rosscare’s nursing homes—was instrumental in the planning effort. Key staff met on a regular basis.
Hiring a LCSW with geriatric behavioral health experience: The
project hired a LCSW committed to and comfortable working with geriatric adults, even though many MSW programs do not provide sufficient training in this area.
Training: Training of nursing home and hospital staff on behavioral health
was crucial to improving services in both environments. To plan the curricula for these trainings, staff was surveyed on both its knowledge of behavioral health and its caring for individuals with these conditions.
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Changing inpatient medication prescribing: The program worked with
staff at the hospital to reduce and eliminate prescribing antipsychotic medications on an as-needed (PRN) basis. Nursing homes regulations require that PRN dosing of antipsychotics medications is supported by an assessment of the resident’s condition; this was a barrier to hospital discharge. A geriatric pharmacist and geriatric LCSW provided nursing staff at EMMC’s Westside Court information on psychopharmacological medications and the elderly. The LCSW is able to make appropriate referrals for medications management and able to support staff with information to assist with the administration of medications.
Historically, Haldol was administered on a PRN basis at the hospital. This type of administration of Haldol is a red flag for nursing homes, and by regulation they cannot care for patients on this drug-dosing regimen without access to psychiatric clinicians. Because of nursing home regulations, PRN dosing of any medication is rare. These regulations to promote the safety of residents require strict diagnostic criteria for scheduled dosing of medications. In order to prescribe psychiatric medications, there are documentation requirements that include comprehensive assessments of psychiatric and behavioral symptoms. Further, there is regulated tapering and gradual dose reduction of psychiatric medications. Unfortunately, most nursing homes do not have the psychiatric resources to provide these assessments, and as a result do not accept patients on these types of medications.
Site visits: Executives of the planning team visited another hospital in
Maine with an inpatient unit designed for geriatric adults with cognitive impairment. During the visit, the team gained insight on how to improve the multiple inpatient environments for these patients. This included:
- Developing an environment that has the look and feel of a nursing - Creating an environment where patients can be mobile safely. - Increasing the staffing levels with nursing assistants. - Developing focused activities for patients while they stay in the unit. - Training staff to have expertise in working with adults with cognitive
impairment and behavioral health conditions.
Addressing staff turnover: In developing the program, the planning team
recognized the reality of staff turnover in nursing homes and created a “train the trainer” model for their educational programs on behavioral health.
Referral protocols: In the nursing home environment, many types of staff
work with patients and can be the first point of contact identifying the need
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for a behavioral health consultation. It is important to develop referral protocols that do not rely exclusively on the medical director making a referral for behavioral health services, as other staff can also identify the need for a consultation.
Resources Used and Skills Needed
Staffing: A LCSW and either a psychiatrist or psychiatric nurse
practitioner are critical to this program. Although the plan had been to hire a psychiatric nurse practitioner to support the LCSW, fortuitously, a geriatric psychiatrist relocated to the area. The program is more likely to flourish if a LCSW passionate about working with this population is hired.
Telemedicine: Telemedicine is a component that is not yet fully
developed, but is part of the long-term plan for the program. Telemedicine enables the psychiatrist to provide more regular and frequent care at the four nursing homes. The challenge has been meeting current Centers for Medicare and Medicaid Services (CMS) guidelines for areas that qualify for reimbursable telemedicine services.
Considerations for Adopting This Innovation
Getting Started With This Innovative Program
Leadership, trust, and collaboration are needed to incorporate services successfully across organizations. Communities where providers are willing to come together could adopt components or all of this approach to care based on their populations’ needs and resources. In communities where there are both hospital and nursing homes, this approach to care is possible, but only if trained social workers and either a psychiatric nurse practitioner or psychiatrist are available to provide essential support to both inpatient and nursing home staff.
Leadership and planning: Focus on strong leadership and planning to
coordinate the many partners, staff, and organizations needed to develop this type of program.
Staff hiring: Take time to hire the “right” LCSW with experience or
training with geriatrics care. Currently, not many LCSWs are trained to work in nursing homes specifically.
Staff supervision: Assign appropriate support and supervision for the
LCSW. These are not always readily available to LCSWs working with older adults.
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Credentialing: Research the credentialing hurdles that the LCSW must
overcome to provide behavioral health services in both inpatient and nursing home environments.
Address stigma and knowledge gaps: Building relationships with
nursing homes to overcome stigma of mental illness among administrators and staff is necessary. A survey of staff members to understand their gaps in behavioral health knowledge and what education is needed will help ensure that appropriate education is implemented. Geropsychiatric resources are welcomed yet feared by nursing home staff/administration. Using the word “geropsychiatric” was identified as a barrier in both hospital and nursing home settings in planning meetings with administrators and their staff. Shifting to language that included “mental, behavioral, and physical health needs of older adults” was highly effective to engage administrators in the program, and overcome the fear that by adding additional mental health services the settings would then become a magnet for patients with more complex behavioral health needs. Instead, the planning team emphasized that the resources would be used to improve capacity with existing patients.
Acknowledge existing nursing home regulations related to patients with behavioral health conditions: Nursing homes have regulations related to administration of antipsychotic medications. These must be acknowledged and addressed through ensuring appropriate staff support is available in the nursing home, and that a patient is on a medication regimen that can be administered in the nursing home. Sustaining This Innovation
Maintain communication: Excellent and regular communication among
Policy advocacy: Further, policy work is needed to overcome current
reimbursement challenges for LCSWs who work in nursing homes and for telemedicine provided in a nursing home. CMS nursing home regulations identify social work as a core service. The regulations do not recognize the geriatric behavioral health expertise of specially trained LCSWs, thus CMS will not allow reimbursement for LCSW services. The goal is to change the current CMS rules that prohibit reimbursement for LCSW behavioral health services and psychiatric telemedicine in Penobscot County. Currently, CMS does not provide reimbursement for telepsychiatry because Penobscot County does not have the federal designation of being an underserved mental health service area.
Continue community-level planning: Develop a community-wide
perspective on how collaboration can ensure that nursing homes have the
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support and skills needed to care for older adults with behavioral health conditions.
Staff capacity: Increase the number of LCSWs trained to work with older
adults in acute care and long-term care settings.
Telemedicine: Continue to research and build evidence for the
effectiveness of telepsychiatry in the nursing home setting.
Staff training: Build on current training efforts to increase nursing home
Patient and family feedback: Continue soliciting and using feedback
from patients and families to improve the quality of behavioral health services.
Community support: Build on what the knowledge and relationships the
program has established to expand older adults’ access to behavioral health in the community.
1 Grablowski DC, Aschbrenner KA, Rome VF, Bartels SJ. Quality of Mental Health Care for Nursing Home Residents: A Literature Review. Medical Care Research and Review. 11 March 2010. 2 Reichman, WE, Coyne, AC, Borson S et al. Psychiatric consultation in the nursing home: A survey of six states. American Journal of Geriatric Psychiatry. 1998 6;320-327. 3 Data from the Minimum Data Set 2.0. 4 Grablowski DC, Aschbrenner KA, Rome VF, Bartels SJ. Quality of Mental Health Care for Nursing Home Residents: A Literature Review. Medical Care Research and Review. 11 March 2010. 5 Fullerton CA, McGuire TG, Feng Z, Mor V and Grabowski DC. Trends in mental health admissions to nursing home residents. Issues in Mental Health Nursing. 2009 (29); 863-872.
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