More than half of the older adults who receive behavioral health care receive it from their primary care physician. There has been much recent interest in the medical or health home model that provides comprehensive care, and in which a primary care physician (PCP) leads a team, which may include nurse practitioners or physician assistants. The team is responsible for providing all the patient’s health care and, when necessary, arranges for appropriate care with other physicians. This model integrates behavioral health and primary care.
The New York State Office of Mental Health is currently supporting a group of Geriatric Demonstration Projects that have shown the value of behavioral and primary health care integration for the elderly. Primary care physicians have found that added assessment and treatment services provided by a mental health professional (MHP) are not only helpful in addressing varied behavioral health problems, but also may improve physical health and care delivery (e.g., better adherence to treatment plans, reduced frequency of unnecessary phone calls and office visits to MD). The MHP in a primary care practice or health home provides a practice component for identifying behavior related issues and dealing with them.
Important behavioral conditions that have been identified and addressed in the primary care setting by these projects are symptoms of depression and anxiety, some of the psychiatric disorders described in DSM IV, and behavior related issues like smoking and obesity. These are all problems by themselves, but they can also have a significant impact on an individual’s physical and mental health.
In addition to these symptoms, disorders and behavioral problems, certain types of psychosocial needs or stresses are often found; problems related to domestic conflict, care taking responsibilities, housing, financial management, home health support, safety, nutrition, social isolation, health insurance, and medication management appear with great frequency. They are elements in a complex set of needs of older adults who are “aging in place.” These difficulties are particularly prevalent for the elderly who live alone without family or other support and feel that they have nowhere to turn for help.
Primary care practitioners often struggle with these patient needs, because they can complicate medical care and patient follow through, including proper adherence to care recommendations and because they often cause stress with consequent anxiety and depression. These needs can lead to serious deterioration of a patient’s physical condition, unnecessary office visits, or time-consuming phone calls to the doctor. Sometimes emergency room visits, hospitalizations and other forms of intensive, intrusive and costly medical intervention can occur because of the psychosocial difficulty and the stress they cause.
Such problems may be well known to the patient’s doctor, but he/she may have neither training nor time to deal with them. When effective professional intervention does occur it often takes the form of what is called case management, because they are mainly psychosocial problems for which the patient needs help from family or social service agencies, or other sources that lie outside the usual range of medical services.
However, patients often do not know that help is available or how to obtain it. Or they may resist help for a variety of reasons. There is a need for intermediate flexible intervention by a physician or physician’s representative. When successful, this may be followed by more sustained support from an agency or other non-medical source, but the initial intervention (which may involve expertise in overcoming resistance and forming a supportive relationship, identifying problems and potential types of aid, knowledge of available services, and immediate practical help) must come from the people responsible for the patient’s medical or mental health care.
The following case examples are taken from one of the OMH Geriatric Demonstration Projects. In these projects an MHP was available in a primary care setting to identify and address the mental health needs of older adults. In a number of cases, however, the patient needs identified had largely involved psychosocial issues.
Case 1: Mrs. S is an 88-year-old widow whose present medical problems include congestive heart failure, spinal stenosis with back pain and an unstable gait, and depression with periods of paranoia, The PCP contacted the MHP to request assessment because of concern over increased calls to the office during which she sounded somewhat confused and agitated. The family has also been calling the PCP not knowing what to do to help their mother.
Assessment: Phone contact was made with the patient who agreed to an initial home visit because it was recommended by her physician. It was evident that she was struggling to maintain her home and, though she still had a car, recognized she should no longer be driving. She seemed to realize she needed help with transportation, her bank account, and other ADLs. During the initial visit the MHP provided support and assured her that she was not there to have her removed from her home.
Intervention: The MHP established a relationship with further home visits. She learned that the patient had four children who all lived a distance away. She had a paranoid belief that one of her daughters was coming into the house at night and stealing from her. Mrs. S at first became very upset at the thought of her children having contact with the PCP or MHP and did not want people talking about her “behind her back”. The MHP finally got permission to speak with her son. A dialogue was established with the family on how to deal with her paranoid ideas. She allowed her son to take over her bill paying. A caregiver was hired to assist with ADL’s and transportation through a local home companion agency. The PCP was updated regularly on the status and needs of the patient so collaborative care could be provided and so the patient would recognize that the changes made had the support of her doctor.
Outcome: The relationship with her children improved and she began to speak with the daughter she was estranged from due to her delusion. She is now comfortable with her caregiver and reports feeling better both physically and emotionally. Her agitation and the number of unnecessary, time-consuming calls from the patient and family to the PCP have been greatly reduced. No psychiatric medications or conventional psychiatric treatments were necessary.
Comment: The initial assessment suggested that much of her anxiety and some of the paranoid tendency derived not from medical or psychiatric symptoms, but from her fear that she was losing her independence and control of her daily life. Time was necessary to establish a working relationship with patient and family, and the backing of the patient’s physician was critical in order to get her to accept the practical advice and help she needed. The main interventions with patient and family were primarily case management. The psychosocial improvements yielded a considerable reduction in her agitation and in the family’s worry.
Case 2: Mr. N is a 68-year-old single male with a medical history including severe heart disease and significant weight loss. His PCP requested assessment because of concern about medication non-compliance and possible psychosocial stressors, and the stability of his medical condition. He had recently lost his job of 23 years.
Assessment: The MHP completed assessment and found that the patient was struggling with his recent job loss and loss of prescription drug coverage. He was illiterate which made navigating “the system” very difficult. He was also eating very poorly which increased his risk factors.
Intervention: The MHP helped the patient apply for assistance for high cost meds and assisted in securing prescription coverage through Medicare Part D. Mr. N was referred to a senior center for meals, and new opportunities for activity and socialization were identified. His financial resources were very limited, but a plan was developed which allowed for retirement. The MHP was able to provide counseling to assist with adjustment of losing his job and transitioning his concept of unemployment to one of retirement. Information was shared with the PCP during weekly case review to plan psychosocial interventions.
Outcome: There were positive changes in Mr. N’s physical state and care, including better medication compliance and stabilization of medical conditions. He has engaged in the congregate dining program at the local senior center which provides socialization and additional support.
Comment: The working relationship with the patient was satisfactory at the onset in part because he viewed the MHP as representing his physician. Again, it appeared that his worsening medical condition and difficulties with treatment planning and compliance derived from his anxiety about several realistic concerns regarding his life situation. He needed help with high cost medication and practical assistance with retirement planning. The interventions were mostly case management, although the MHP also provided counseling to alleviate the stress and shame of feeling “unemployed” and viewing himself as “retired”.
The psychosocial problems illustrated by these cases:
- Come to the attention of the patients’ doctor or someone in his/her office, through observation, patient request or family concern expressed to the doctor.
- Are not “medical” problems, but do significantly affect patient health and medical care.
- Had not been resolved because the patients lacked information or lacked the cognitive or financial capacity to resolve them, or because they resisted the decisions or actions needed.
The interventions made by the MHP:
- Do not fit the usual categories of medical care, but benefit from the patients’ recognition that their physician is involved and supports the intervention
- Are flexible and aim to do whatever necessary to support better health and better care
- Are sometimes resisted by the patient at first, but can be overcome with psychological expertise.
- Cannot initially be referred for conventional services because of patient resistance.
In a Health Home or integrated primary care practice, an MHP can:
1) Screen and assess for symptoms such as depression, anxiety, and specific psychiatric disorders, and then provide
- Short-term counseling or therapy, sometimes with medication from the PCP
- Referral to more extended care when necessary
2) Screen and assess for other behavioral issues such as dietary habits, smoking, and alcohol use that affect health and medical care, and then provide
- Short-term counseling and other brief interventions aimed at behavior change or preparation for referral
- Referral to longer term intervention aimed at behavior change
3) Screen and assess for psychosocial problems that affect health and care, and then provide
- Short term brief case management
- Referral to more extended case management care and assistance
Brief Case Management
Brief case management as discussed above can include any or all of the following:
- Evaluating the need for help and services
- Establishing a working relationship
- Getting family support and involvement
- Overcoming resistance when necessary
- Providing information
- Providing assistance
- Arranging for a sustainable case management plan, with help and services from family or other professional sources
Reflections
Case management interventions like the above prove clinically valuable; they result in better care and increased patient satisfaction. They can also decrease the overall cost of care because they obviate later more expensive medical interventions or placement in a nursing home.
