Rosscare Northeast Integrated Geriatrics Care Project

1. RosscareNortheast Integrated Geriatrics Care Project Presented by: Lisa Harvey-McPherson RN, MBA, MPPM EMHS Vice President Continuum of Care

2. The Geriatric Challenge • In 2007 EMMC experienced a significant increase in geriatric patients with extended hospitalization days • Geriatric patients with • Alzheimer's • Dementia • Gero-Psych Challenges • Difficult Behaviors

3. EMMC Continued • EMMC purchased 1:1 staffing support for geriatric patients with challenging behaviors • Nursing homes were also challenged in caring for these patients • Increased physical altercations targeting other residents and nursing facility staff • State/Federal deficiencies regarding safety • ER bounce back with re-admissions • NF regulations regarding anti-psychotic medications

4. The Haldol Challenge • Haldol administered PRN at EMMC – Red Flag for nursing homes and a barrier for acute discharge • Nursing Facility Regulations • PRN dosing is rare; requires extensive psychiatric assessment and documentation • Strict diagnostic criteria for scheduled dosing • Documentation requirements including comprehensive assessments of psychiatric and behavioral symptoms • Regulated tapering and gradual dose reduction ***** Nursing Homes Have No Psychiatric Resources Available at the Facility

5. EMMC Challenge is not Unique • 2006 Report to Maine Legislature • 61% of Nursing Facility residents have mental health diagnosis • 2007 EMHS Community Health Needs Assessment • Elevated rates of depression among the elderly • Emergency room visits by elders for behavioral health issues

6. Maine has the highest NF depression scores in the country

7. Visit to Maine Medical Center P6 Gero-Psych Unit • Annette Adams joined visit to P6, is a gero-psych unit the solution? • P6 Lessons Learned • Nursing facility like environment • Resident mobility in secure unit • Increased staffing with nursing assistants • Focused activities • Staff expertise • Prior experience with NF based gero-psych teams

8. EMMC Westside Court • Goal to create an environment of care supporting patients with Alzheimer's, Dementia and psychiatric diagnosis and difficult behaviors • Small ICU (6 bed unit) vacant on Grant 5 • Environment of Care – Colors, visual cues • Staff education provided by the Alzheimer’s Assn • Resident mobility supported in unit • Higher complement of nursing assistants • Focused activities • Regular rounding with Acadia Psychiatrist • Consistent Hospitalist Coverage

9. Rosscare • Improving inpatient care will not solve the geriatric discharge challenge • Need to “build the bridge” between EMMC and Rosscare nursing facilities and provide ongoing behavioral health resources at the nursing facilities • Ross Manor • Stillwater Health Care • Dexter Health Care • Colonial Health Care

10. A Challenging Lesson • EMMC geriatric patient with advanced dementia, difficult aggressive behaviors, does not speak English • Long Lengths of Stay at EMMC (months) with ER bounce backs • 1:1 staffing arranged for NF placement • Acadia Psychiatrist onsite NF consultation • Evaluation at Maine Med P6 Unit • 15 recorded assaults/incidents during NF stay

11. Northeast Integrated Geriatrics Care • MEHAF Funded Grant • Three year project • $296,426 over 3 years • Partners EMMC, Rosscare Nursing Facilities and Acadia Hospital • Creates a new model of care integrating behavioral health with primary care for geriatric patients • EMMC Westside Court • Current Rosscare patients

12. Early Lesson Learned • STRONG negative stigma associated with “Gero-psych” patient population • Administrative Leaders • Primary Care Physicians • Nursing Staff • Assistants • “Integrated behavioral health” removed negative bias

13. MEHAF Grant Year One • “Building the Bridge” • LCSW with gero-psych expertise hired to support Westside Court patients with transition to Rosscare Nursing Facilities. • Behavioral interventions implemented in acute setting • Care plans developed to transition to NF care • “Packaging” of patient information for care management presentation of referrals to NF • LCSW follows patients in NF setting supporting staff education, clinical care planning/intervention

14. Year One Addressing the Education Gap • Nursing Facility staff generally do not have behavioral health clinical experience • Predominant level of staffing – nursing assistants with NO behavioral training • When psychiatric consultations are available staff do not have skills to independently implement behavioral recommendations • Unintended exacerbation or triggering of resident behaviors

15. Acadia’s Educational Role • Baseline survey of nursing facility staff • LESSON LEARNED – nursing facility staff respond best to paper based survey tools • STRONG need for behavioral health education • Not limited to nursing staff, housekeeping, maintenance and dietary staff self identified need for behavioral health training

16. Acadia’s Nursing Facility Program • Physical, Mental, and Behavioral Health Integration for Older Adults Curriculum Development Team: • Annette Adams • Paula Tan, PMH-NP • Deborah MacLean, PMH-NP • Becky Bell, RN • Sue Cullen, RN, MSN

17. NF Educational Programs Cont. • Four onsite modules offered at each facility • Based on Evidence Based Curriculum Developed by the Hartford Foundation • Module Content: • communication with older adults • caring for the caregiver • abuse prevention in long term care settings • cultural considerations in caring for the older adult • pain and palliative care issues in older adults • assessing for and managing dementia, delirium and depression • building therapeutic alliances

18. Acadia’s Success • STRONG positive feedback from nursing facility participants • “Immediate use of skills learned” • Ability to implement behavioral health treatment plans developed by the LCSW • Train the trainer program for sustainability of educational modules for new staff

19. MEHAF Grant Years 2 & 3 • Year two of the grant begins 1/1/2010 • Continue with LCSW • Add Acadia Psychiatric NP’s via Telemedicine at Rosscare NF’s • Year three • Clinical model revisions if needed • SUSTAINABILITY FOCUS * Limited ability to bill for LCSW & NP NF services * Telepsychiatry not covered by Medicare for NF’s in Penobscot County

20. Year One Impact • EMMC October 2008 Thru June 09 • 14 Geriatric Long Length of Stay Patients • 557 Extended Days • Cost of Extended Stay $724,100 • Westside Court Opens Spring 09 • MEHAF LCSW begins May 09 • Today: • Westside Court Length of Stay 10-14 Days • Highest Satisfaction Scores at EMMC • NO ER Bounce Backs from Rosscare Nursing Homes • Acadia Patient with LOS over 100 days successfully transitions to Rosscare Nursing Facility • Rosscare NF effectively manages sudden onset of aggressive behavior/altercation resulting in resident fx • LCSW geriatric caseload totals over 50 patients served, waitlists developed at Rosscare NF’s for evaluation/treatment

21. Year One Nursing Home Patient Clinical Outcomes

22. Additional Lessons Learned • Two additional gaps in geriatric psychiatric care continue • Homecare homebound patients • Geriatric patients with behavioral/psychiatric challenges that can not co-mingle with other residents • Credentialing challenges with geriatric specialty clinicians not treating the general psych population • Significant communication & engagement at all levels is needed up front and ongoing • Gero-Psych care resources are welcomed and feared by nursing facility staff/administration • Hospital medical record documentation (EMMC & Acadia) creates a behavioral health acuity picture that does not facilitate resident transfer to NF care • TRUST, TRUST, TRUST