Resources for on-site mental health services.

The prevalence of mental illness and behavioral problems among elderly nursing home residents, which may be as high as 90%, is not widely recognized. These individuals suffer from many types of mental illness, including adjustment disorders, organic mental disorders, affective disorders and psychosis. Mosher-Ashley (1994) found that only 20% of the residents receiving outpatient psychological services in a long-term care facility were diagnosed with organic brain disorder. Even when a dementing illness is the primary reason for nursing home placement, many residents frequently have one or more behavioral problems that can be managed through case consultation with staff.

Most long-term care residents with psychological problems tend to be dealing with issues comparable to those faced by their community-dwelling peers, namely, life changes and traumatic issues such as isolation and increasing dependency, often from the loss of loved ones and/or physical and mental health problems. These factors increase the likelihood of psychiatric disorders and are often present upon admission to a nursing home in addition to the health problems that directly necessitate the admission.

Despite the evidence supporting a demand for psychotherapeutic intervention in these facilities -- and the OBRA mandate for those interventions -- only a small percentage of nursing home residents actuary receive necessary mental health services because of insufficient funding, lack of appropriate training programs, lack of referrals and a general knowledge deficit with respect to the methods for implementing a mental health program in a long-term care setting.

Comprehensive Geriatric Services and American Geriatric Services are two for-profit programs in Massachusetts that have had success in providing mental health services to elders in long-term care facilities. Although the programs differ somewhat structurally, both serve as excellent models of providing quality mental health care to this population in a feasible and cost-effective manner.

Comprehensive Geriatric Services

In existence since 1986, Comprehensive Geriatric Services provides services to upwards of 500 residents of approximately 50 facilities each year. Approximately 25% of the cases referred involve elders with histories of long-standing psychiatric hospitalization.

The 30-member professional staff includes masters-level social workers, as well as therapists, psychiatrists, registered psychologists and psychiatric nurses. The range of mental health services provided includes individual therapy (the majority of the intervention), group therapy psychological and neuropsychological testing, medication management, behavioral programs, help in dealing with family-related age issues, in-service training for nursing home staff, and assistance with psychiatric hospitalization, as well as a 24-hour emergency service. Approximately 70% of the funding has come from Medicaid, with Medicare covering approximately 28%, and a very small percentage collected from private insurance.

Once a referral is made, usually a primary care physician, Comprehensive Geriatric Services conducts a diagnostic evaluation and determines whether or not the resident is an appropriate candidate for psychotherapeutic intervention. Many elderly individuals with severe dementia or advanced Alzheimer's disease cannot benefit from all the available psychotherapeutic services, and a careful evaluation and diagnosis are needed to determine the proper treatment direction.

Each facility served is assigned a clinician who takes responsibility for all the cases in that establishment. The duration of therapy varies according to individual need, and treatment sessions vary in length (from 30 to 50 minutes) and are held in a private on-site area.

Depression is the most common reason for referral. Loneliness, isolation, lack of socialization, adjustment or family problems, or stress due to dissatisfaction with aspects of the facility setting may also prompt referral.

Comprehensive Geriatric Services does not provide screenings as part of PASARR; these screenings are normally completed by the nursing home staff. In some facilities, Comprehensive Geriatric Services clinicians are included in interdisciplinary meetings to discuss their clients, progress and promote a team approach to treatment. Because working with the mentally ill elderly can be very stressful, the clinicians at Comprehensive Geriatric Services provide on-going support-type services for the nursing home staff as well as for the residents.

American Geriatric Services

In existence for just over ten years, American Geriatric Services is a for-profit provider of diagnostic and mental health services to elderly residents of nursing homes, rest homes and adult day programs. A skilled staff of approximately 90 practitioners includes licensed psychologists, three of which are neuropsychologists, 12 part-time and one full-time psychiatrist, nurse practitioners, neurologists, and master-level social workers and psychologists. Approximately 70% of the funding comes from Medicaid, 20 to 25% from Medicare, and the remainder from commercial insurance companies, HMOs and private billing.

American Geriatric Services currently provides services to approximately 4,500 residents of 200 facilities. Fifteen to twenty percent of these residents have a history of long-standing psychiatric hospitalization.

Services include diagnostic evaluation, behavioral management planning, medication review, neurological evaluation, family services and individual or group psychotherapy. Because most referrals come directly from the nursing home, most often for symptoms of dementia and issues related to medication, American Geriatric Services does not provide screenings as part of PASARR. Other reasons for referral include depression and psychosis or associated behaviors, marked changes in behavior and problems related to isolation and wandering.

American Geriatrics assigns a clinical team (a psychiatrist, nurse practitioner, masters-level therapist and psychologist) to each facility. Every client referred to the program undergoes a comprehensive diagnostic evaluation performed by a licensed psychologist. From this assessment, recommendations are made for a specific therapeutic intervention.

A full-time director of quality assurance coordinates multidisciplinary meetings that include a psychiatrist, a nurse practitioner and a psychotherapist, to review each new case, treatment plan and clinical recommendations and determine medical necessity and clinical appropriateness. Limits are set to the amount of time allotted to treat each client, given the presenting problem. If a therapist believes more time is needed for effective treatment, he/she must provide justification.

The majority of the cases referred to American Geriatric Services involve some type of medication management, at least Psychotherapy and behavior management services are also frequently implemented. Group therapy, a recently added service, is limited, but it is anticipated that utilization of this service win increase. In keeping with a firm policy to employ the least invasive means of treatment, medication is utilized judiciously, often as an adjunct to psychotherapy or behavior management when those interventions, alone or in combination, are not successful.

The recommendation for follow-up work determines which practitioner(s) is assigned to the case. If the client requires medical or neurological treatment, a psychiatrist or nurse practitioner is sent in. Treatment plans or other psychotherapeutic intervention for behavioral problems are handled by a master's or doctoral-level psychologist.

Counseling sessions take place in the resident's room or in a therapy room provided by the facility. The average client is provided with 12 counseling sessions, each lasting 30 to 60 minutes, one to three times per week. Each case is assessed thoroughly every three months to monitor the progress of treatment, and periodic maintenance sessions are provided as necessary.

In the past year or so, American Geriatric Services has expanded its services into Rhode Island and Connecticut, where their services are funded primarily through Medicare Part B.

Conclusion

It is projected that 25% of Americans will spend a portion of their fives in a nursing home. This prediction, along with the prevalence of mental illness in the elderly, demonstrates the need for various types of psychotherapeutic interventions in this setting. Comprehensive Geriatric Services and American Geriatric Services are two examples of programs that are successfully treating this population of mentally ill individuals in Massachusetts, allowing many elderly individuals to remain in nursing homes, avoid costly psychiatric hospitalizations and live out their later years more comfortably.

Profile: Sterling Partners in Care

Partners in Care is the newest component of Sterling Healthcare Corporation's ten-state network of integrated behavioral health care systems. Launched in September, 1995, Pacific Partners in Care provides on-site mental health services on a contractual basis to eight long-term care facilities in the Portland, Oregon area and is actively negotiating with several additional area facilities.

Pacific Partners subcontracts for the services of psychiatrists, psychologists, clinical social workers and nurses, who provide diagnostic evaluations, medication management, and individual, group and family therapy, and psychological and neuropsychological testing services to its client facilities. Services are reimbursed primarily through Medicare Part B, with some additional funding through HMOs and self-pay.

Referrals are made by the nursing home administrators or their clinical designees, who contact the Pacific Partners program director assigned to their facility. To date, the majority of the referrals have been for diagnostic evaluation and medication management. PASARR evaluations are conducted by a separate entity.

While the duration and frequency of therapeutic interventions vary according to individual needs, the average individual or group therapy intervention typically consists of approximately six weekly sessions.

Our service delivery was structured as a user-friendly system that provides LTC facilities with timely access to services on an emergency basis or by appointment. In addition, our clinicians provide in-service training for the nursing home staff which focuses on recognition of behaviors requiring intervention and techniques useful in managing various behaviors associated with psychiatric conditions.

The Partners in Care program was a needed component of our comprehensive program of senior services, which includes inpatient treatment, partial hospitalization, residential care, outpatient counseling, wellness programs and, in some states, home health services. Sterling has plans to expand the program throughout its service area and has just launched Koala Partners in Care in Indiana.

To our nursing home clients, the Partners m Care services do more than merely fulfill the OBRA mandate for ongoing mental health care. Nursing home administrators and management staff are seeing the results of our interventions with residents and staff education programs and this, in turn, reinforces the realization that nursing home residents with psychiatric problems can be helped in some very tangible ways.

Profile: Integrated Behavioral Health

Systems

Integrated Behavioral Health Systems (IBHS) provides mental health services to more than 2,000 residents of 25 Florida skilled nursing facilities and is funded primarily through Medicare and Medicaid. IBHS was spun off of parent company Behavioral Health Options 1-1/2 years ago in order to focus on the specific mental health needs, or mental health "overlay," of the geriatric population.

IBHS is physician-driven, meaning that a psychiatrist/medical director oversees and maintains the quality of the overlay program within each facility and oversees the work of the system's network of providers. The network includes psychologists, licensed clinical social workers and nurse practitioners. Medical directors are on 24-hour call in case of emergency.

Within 72 hours of receiving a referral, the medical director assigned to the facility conducts a full diagnostic psychiatric evaluation and begins to formulate a treatment plan. If individual or group therapy are indicated, the resident is referred to a psychologist or clinical social worker who conducts a psychosocial evaluation, meets with the IBHS medical director to discuss treatment options, and formulates a treatment plan that meshes with that of the medical director.

The reasons for referral tend to vary according to the type of facility. In facilities that offer rehabilitation services, we tend to see a high rate of depression among the predominantly younger patients. In the traditional long-term care setting, we tend to treat organic psychotic disorders primarily.

IBHS clinicians provide a range of services including admission screenings and reviews, individual and group therapy, medication management, behavior management and staff training. Individual and group therapy interventions generally last for six to eight weeks and the frequency of sessions, usually once or twice per week, is determined by the provider.

IBHS employs a team approach to patient care, reviewing all cases with the nursing home staff on a routine basis. Medication reduction is one of our highest priorities, and our medical directors generally meet with the facility director of nursing, director of social services and consultant pharmacists each month to review the psychotropic drug profiles of all patients in the facility. Our goal is to use the least amount of medication necessary and to stabilize patients within the facility itself. Should a resident require transfer to an acute care or psychiatric hospital, IBHS physicians continue to follow that resident throughout his or her hospitalization. We are now m the process of collecting data on the rates of hospitalization among the residents in treatment. To date, my clinical experience has indicated there are much lower rates of hospitalization since the implementation of the overlay program.

The program is allowing us to better address the reality of the significant rates of psychiatric problems among nursing home residents and facility-based rehabilitation patients. This is especially critical in light of the fact that the over-65 age group comprises 10% of the nation's population and 25% of successful suicide attempts.

Profile: HCI Services

HCI Services of Atlanta provides behavioral health and medical services to nursing facilities nationwide. In July 1994, HCI was awarded a contract with the state of Georgia to deliver a state-wide mental health program, funded on a capitation basis, to more 2,000 Medicaid recipients residing in Georgia nursing facilities. Shifting the provision of these services from the state to the private sector has the potential to save the state several million dollars. Meanwhile, the arrangement is providing individualized mental health services to nursing home residents diagnosed with mental illness, retardation or developmental disabilities.

The need for intervention is determined first by an independent company, also under contract with the state, which carries out the PASARR evaluation process. This assessment helps to determine the type of intervention required and then triggers HCI to implement those recommendations. HCI providers then devise a comprehensive treatment plan, working in conjunction with the nursing home staff and, when appropriate, the resident's family.

The most common reasons for intervention through PASARR have been medication management and subsequent treatment of residents' behavioral disorders. HCI's staff of psychiatrists, psychologists, clinical social workers, nurses, counselors and behavior specialists also offer psychiatric assessment, group and individual therapy, crisis intervention, behavior change intervention and skills training. The frequency and duration of therapy is treatment plan-driven.

The Transition

HCI's transition into this capitated Medicaid arrangement was made easier by the fact that we were already providing mental health services to Medicare recipients in nursing homes. For the rehabilitation program, we divided the state into eight areas (using the same boundaries as the Georgia Nursing Home Association) and assigned an area manager to each region. The managers are responsible for assisting in training and developing their network of service providers.

Finding staff in some very rural areas of Georgia that were extremely underserved with respect to health care manpower and essentially stranded without mental health services was a challenge. To accomplish this, HCI had to change some of its contractual arrangements to fee-for-service in order to do a better job of recruiting professionals who were willing to work in those areas.

Outlook

At this point, it is difficult to predict whether this type of contractual arrangement will serve as a model for other states. It certainly falls in line with current trends in health care and publicly funded programs by guaranteeing a level of service to nursing facilities while reducing the rest of such services as compared to traditional funding mechanisms. PASARR is listed as a continued service under the proposed Medigrant legislation, but what that legislation fails to address is how specialized or rehabilitative services will be handled. Ultimately, if a program such as HCI's fails to have far-reaching effects, it will be more a function of the political arena than of the need for services.

Profile: Wellness Senior Services

Wellness Senior Services is a Miami-based, clinician-owned and operated mental health outreach program staffed by licensed psychologists and licensed clinical social workers. In anticipation of the 1990 changes in OBRA that allowed psychologists and social workers to render therapeutic (in addition to diagnostic) services, the company changed its focus from that of a large clinical practice to one devoted entirely to serving the elderly in residential long-term care. Today, Wellness Senior Services provides mental health services to over 1,000 residents in approximately 35 Florida skilled nursing and assisted living facilities as a Medicare Part B provider.

Referrals to Wellness Senior Services are by physician order. While the company does not have any PASARR contracts, referrals can also arise from the required screenings and evaluations. Once a referral is made and the appropriate intervention is determined, Wellness Senior Services providers integrate themselves into the nursing facility staff. They do so by attending care planning, rehabilitation and medication/restraint reduction meetings to ensure that a team approach is employed. The nursing facility is obliged only to provide us with access to its referred residents and a location for the therapy sessions.

While no data have been kept on the rate of hospitalization before and after the provision of these services, it is our impression that the need for hospitalizations has been reduced. This anecdotal finding concurs with the published research on the topic which dearly indicates that effective "outpatient" interventions can significantly reduce the rate of psychiatric hospitalization.

Interventions

A large number of the referrals made to our providers are for depression. We see a tremendous amount of anxiety and fear among nursing home residents and, indeed, a great deal of our work with residents with dementia is aimed simply at reducing their sense of terror. Our staff offers a wide range of interventions, determined, in many respects, by the resident's cognitive status.

Individual Therapy. Individual therapy for the higher functioning resident is very much like the psychotherapy conducted in other settings. One important difference: we favor brief individual sessions (20-25 minutes), rather than the long therapy hour used in private practice. We feel we can accomplish more and have a greater impact -- especially with residents with short attention spans -- in brief sessions held twice weekly than in a longer session held only once a week.

Group Therapy. Group therapy is indicated primarily to decrease isolation and enhance a sense of peer support. Sessions are for approximately one hour, with anywhere from six to ten members in each group. Duration of treatment is affected by a number of factors, the most important being medical necessity.

Behavior Management. Full-scale behavior management programs focus on short-term interventions to decrease negative behaviors (ie, violence) or increase positive behaviors (ie, routine dining habits), while preventing other medical problems. Wellness Senior Services has designed a number of specialized behavior management programs, including one to improve eating habits in dementia residents who are losing weight and the Dementia Quieting Program, in which tools such as behavioral cues and specially designed relaxation tapes are used to reduce agitation. In some cases, this program has resulted in a reduction in the dosage of psychotropic drugs.

The duration of these behavioral interventions is based on a series of guidelines and parameters recently developed by Wellness Senior Services. Those guidelines suggest, for example, that if one intervention fails to produce the desired change in a specific behavior after several weeks (usually about 30 to 45 days), another intervention must be attempted.

In all the behavior programs offered, our intent is to train the facility staff -- primarily the CNAs -- to utilize the approaches we employ once they've been implemented and deemed effective.

Rehabilitation Support Program. Designed specifically for the short-term rehabilitation patient, this six-session group program focuses on issues that may affect patients' progress during the rehabilitation process: motivation to change, adjustment, depression, pain management, etc. When scheduling conflicts make group sessions impractical, the same issues are dealt with during one-on-one sessions.