Aging is an inevitable part of life. As we get older, we often think of physical problems such an aching back or pain in our knees. But the elderly also have considerable mental health needs, as well.
Here at the Office of Mental Health (OMH), we’ve been looking at innovative interventions to address the mental health issues that New York State residents face as they as they age. And we are working to ensure that older New Yorkers who require services have access to appropriate treatment, whether they’re living independently in their community, require services in their homes, or need the care provided by a skilled nursing facility. In order to provide a continuum of care to patients as they age, OMH has been working to develop effective programs through the Interagency Geriatric Mental Health and Chemical Dependence Planning Council, and important demonstration projects such as Certified Community Behavioral Health Clinics and the Mental Health Aging in Place initiative.
OMH has been working to strengthen the resources available to support community caregivers. During the past five state fiscal years, the plan has been re-balancing the agency’s resources by developing community-based mental health services – focusing on prevention, early identification and intervention, and evidence-based clinical services and recovery supports:
Home and Community Based Services are designed to allow enrollees to participate in a vast array of habilitative services. Participants have been granted access to skill–building activities while having various necessary rehabilitative needs met. Services include: care coordination, skill building, family and caregiver support services, crisis and planned respite, prevocational services, supported employment services, community advocacy and support, youth support and training, non-medical transportation, habilitation, adaptive and assistive equipment, accessibility modifications, and palliative care.
Managed Long-Term Care is streamlining the delivery of long-term services to people who are chronically ill or disabled and who wish to stay in their homes and communities. These services, such as home care or adult day care, are provided through managed long-term care plans that are approved by the Department of Health.
Through its Partnership Innovation for Older Adults program, OMH has been working with mental health providers throughout the state to establish “triple partnerships” in their communities to help adults age 55 or older whose independence or survival is in jeopardy because of a mental health, substance use, or aging-related concern. Triple partnerships are designed to pull together the resources of mental health, substance use disorder, and aging services. The Partnership Innovation program is administered by OMH, the State Office for the Aging and other state agencies, and awards grants to providers in the areas of community integration, improving quality of treatment, integrating services, workforce, family support, finance, specialized populations, information, and staff training.
Help at Home
For seniors living with mental illness who are homebound, OMH has been working with OMH residential providers and with the home health care industry to gain insight into the type of needs that home care providers were encountering with residents, barriers to accessing services, and strategies used to increase access to home care and make aging-in-place possible. Ideas included:
- Cultivating relationships with home health agencies – use existing residential, behavioral health staff, and case managers to partner with home health agencies and specific aides serving residents.
- Promoting “cluster care,” highlighting a home health/personal care agency’s ability to serve multiple clients within the same building.
- Advocating for residents in need of (additional) home health and personal care help – leverage professionals in regular contact with residents to consult with physicians writing orders for home/personal care.
- Providing efficient access to psychiatric, substance use treatment, and medical support (onsite/co-located, nearby, telehealth/tele-psych) enables people to age-in-place and avoid (re) hospitalizations and unnecessary ER visits.
- Reviewing care coordination and insurance plan options available to residents that may assist in more efficient access to psychiatric and medical care.
- Collaborating with managed care and community-based service providers to develop a value-based payment proposal that targets residents with complex or intense needs to help pay for needed services or building adaptations that address the social determinants of health.
- Connecting with informal caregivers and families, noting that when these trusted people were available, they were key members of the wrap-around support team needed for individuals living with mental illness to join, return, or remain in their communities.
Skilled Nursing Facility Care
For some individuals, care in the community or in their homes is not an option, and they require the care of a skilled nursing facility. OMH has found that, while skilled nursing facilities were quite able to provide quality medical care to clients, many were hesitant to address their behavioral health needs. These disorders represent significant public health challenges – including impaired quality of life, increased healthcare utilization, cost, morbidity, and mortality. However, specialty care for late-life psychiatric and memory disorders is associated with better outcomes and lower costs.
OMH is working with the University of Rochester to address this issue now, with an innovative program called the Extension of Community Healthcare Outcomes in Geriatric Mental Health in Long Term Care for Skilled Nursing Facilities, called “Project ECHO GEMH” for short.
Project ECHO GEMH provides training through a “virtual clinic” using videoconference technology. Best practices are shared through a combination of short didactic presentations and case-based discussions with content experts. The clinic sessions connect frontline nursing home staff with clinical experts at academic medical centers. Staff collaborate to identify the residents to take part in the program, address physical health needs of residential clients, help prepare long-stay patients for discharge, and explore alternative strategies to placement.
Project ECHO GEMH and the allocation of 24 Community Mental Health Nurses are the major components of the OMH Skilled Nursing Facility Enhanced Support Project. The goals of the Skilled Nursing Facility Enhanced Support Project are to:
- Increase timely discharge of individuals in state-operated psychiatric centers who meet criteria for skilled nursing facility placement.
- Support the skilled nursing facilities to meet the psychiatric needs of individuals accepted from OMH facilities during the transition period.
- Use ECHO GEMH’s model to help skilled nursing facilities build and sustain capacity to meet the needs of people with serious mental illness.
The Skilled Nursing Facility Project is managed by the OMH Office of Coordinated Nursing Services. Coordinators have been assigned for upstate and downstate regions. There are project teams at 14 adult civil facilities. The program is currently staffed by 24 community mental health nurses, working in close collaboration with social workers, discharge planning teams, and Mobile Integration Teams.
The ECHO GEMH project can be especially helpful patients of state psychiatric centers who no longer require the intensive care provided by the psychiatric center but would benefit from skilled nursing care. Because of ECHO GEMH, individuals who had difficulty being accepted into such a facility as a result of behavioral issues are welcomed because of the support ECHO GEMH provides.
Once approved for placement – through a number of processes including the Enhanced Preadmission Screening and Resident Review (PASRR), community mental health nurses, discharge planning staff in close collaboration with clients, and family work to find placement in the community. Upon discharge, psychiatrist at each facility is available to provide psychiatric consultations as needed during the transition period.
Community mental health nurses in their role as psychiatric nurse engagement specialists continue to support the skilled nursing facility staff with the provision of enhanced supports for two years’ post discharge of the client to the skilled nursing facility. Data on the program is collected monthly from each facility. Regionally, facilities are currently working to address issues such as a limited number of skilled nursing facilities that will accept OMH clients and a lack of psychiatric consultation at some facilities. Others, in the meanwhile, have been effective in developing relationships with local area skilled nursing facilities.
OMH Transformation Plan
As I’d indicated before, these programs are a part of OMH’s Transformation Plan, an initiative to re-balance the agency’s institutional resources by strengthening community-based mental health services throughout the state and providing support for community providers to meet the psychiatric needs of clients who are making a transition from state-operated psychiatric centers to community-based services. OMH has used reinvestment funding to develop new mobile crisis teams, expand clinic services, provide additional peer support services, and fund additional supported housing units. Through the Transformation Plan, OMH is helping to move long-stay individuals with complex medical and behavioral health needs to more integrated and less-restrictive settings.