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Mental Health and Chronic Conditions in the Elderly Title VI Programs as Partners in Care

Mental Health and Chronic Conditions in the Elderly Title VI Programs as Partners in Care. Bruce Finke, MD IHS Elder Health Consultant Indian Health Service Elder Care Initiative For the National Title VI Forum Baltimore, MD May 2007. Today’s Topics. The IHS Chronic Care Initiative

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Mental Health and Chronic Conditions in the Elderly Title VI Programs as Partners in Care

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  1. Mental Health and Chronic Conditions in the ElderlyTitle VI Programs as Partners in Care Bruce Finke, MD IHS Elder Health Consultant Indian Health Service Elder Care Initiative For the National Title VI Forum Baltimore, MD May 2007

  2. Today’s Topics • The IHS Chronic Care Initiative • What it is… • What it means for the elders you serve…. • What it can mean for your program… • Mental Health in the Elderly • Identifying depression, dementia, and delirium • Advocating for your clients with the health system • The Senior Center as a partner in care

  3. The IHS Chronic Care Initiative

  4. Chronic Care InitiativeAim Improve the health status of those affected by chronic disease and reduce the prevalence and impact of those conditions by adapting and implementing the Chronic Care Model. • Focus on care processes that apply across multiple chronic conditions (instead of care based on managing individual diseases). • Package the lessons learned such that they can be spread throughout the Indian Health System.

  5. Tribal Cherokee Nation Health Services Choctaw Health Center Eastern Aleutian Tribes Forest County Potawatomi Health & Wellness Center Indian Health Council Urban Gerald L. Ignace Indian Health Center Federal Albuquerque Service Unit Chinle Service Unit Gallup Service Unit Rapid City Service Unit Sells Service Unit Warm Springs Service Unit Whiteriver Service Unit Wind River Service Unit Chronic Care InitiativeInnovations in Planned Care for the Indian Health System

  6. Care Model Community Health System Health Care Organization Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Productive Interactions through effective asset based partnering over time Informed, Empowered Patient and Family Prepared, Proactive Practice Team PatientDriven Coordinated Timely and Efficient Evidence-based and Safe Improved achievement of patient and community goals

  7. Care Model Informed, Empowered Patient and Family Prepared, Proactive Practice Team Improved achievement of patient and community goals

  8. Care Model Community Health System Health Care Organization Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Informed, Empowered Patient and Family Prepared, Proactive Practice Team Improved achievement of patient and community goals

  9. Care Model Community Resources and Policies Self-Management Support DeliverySystem Design Informed, Empowered Patient and Family Prepared, Proactive Practice Team Improved achievement of patient and community goals

  10. The Community in Chronic Care • Integrate community resources into care in a systematic way • Formal referral processes • Partnerships with community organizations / Tribal programs to fill in gaps in services • Advocacy and support for policies and programs to improve care • Coordinate care with providers in the community to reduce waste

  11. Self Management Support • Provide the tools for the individual to be a full partner in management of his / her own health • Education and Training • Goal setting • A plan for care • Access to expertise to help make decisions

  12. Delivery System Design • How do we deliver care in the most efficient, effective way, valuing the patient’s time and supporting the relationship between the patient and the care team? • What services can be provided as well or better in the Senior Center as in the clinic or hospital

  13. Delivery System Design Possible Care Team activities at the Senior Center… • Screening for fall risk, depression, alcohol misuse. • Foot exam • Immunizations • Assist in case management • Rehab Therapies • Group education • Guided or monitored exercise

  14. Care Model Community Health System Health Care Organization Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Productive Interactions through effective asset based partnering over time Informed, Empowered Patient and Family Prepared, Proactive Practice Team PatientDriven Coordinated Timely and Efficient Evidence-based and Safe Improved achievement of patient and community goals

  15. Mental Health in the Elderly

  16. Dementia Why identify an elder with dementia? • Family education and support • Planning • Safety • Strategies to support function and delay progression • Non-pharmacologic strategies • Medications

  17. Dementia(DSM-IV) • Multiple cognitive deficits that include memory • Other deficits : • Aphasia • Apraxia • Agnosia • Impaired Executive Functioning • Deficits impair function • Deficits do not occur only during delirium

  18. Dementia (in English)(DSM-IV) • Problems thinking that include problems with memory • Other deficits • Aphasia • Difficulty with words and speaking • Apraxia • Difficulty handling and manipulating things • Agnosia • Not recognizing things or people • Impaired Executive Functioning • Can’t figure out how to do things • Deficits impair function • Deficits do not occur only during delirium

  19. Associated Features (other things we see) • Spatial disorientation • Gets lost in familiar places • Poor judgement and insight • Makes bad decisions • Paranoia and agitation, mood lability • Gets mad, easily frustrated, cries • Disinhibition, poor hygeine • Does or says things he normally wouldn’t do • Won’t bathe. • Walking difficulties and falls • Acute deterioration with stressors • Worse when sick, or with new environment

  20. Gradual progression Stable Course Normal (baseline) attention Rapid onset Fluctuating Impaired attention Acutely ill Dementia vs Delirium Dementia Delirium Dementia is a risk factor for deliriuim

  21. Treatment in Dementia • Family is at the center of treatment plan • Focus on behaviors / function • Safety • Techniques to improve function / address behaviors • Interdisciplinary Team approach • Proactive • Medications may have a role

  22. Snapshot of Caregiving for Elders in Indian Country from the Santa Fe Service Unit Study* (1/4) • Caregiver characteristics • Median age – 50 • 88% women • 63% of caregivers for an elder are also caring for one or more children under age 18 • 15% reported health impaired caregiving to a moderate or great extent *Hennessey CH, John R, Roy LC. Long Term Care Service Needs of American Indian Elders: The Indian Health Service Santa Fe Service Unit. Centers for Disease Control and Prevention, Atlanta, GA 1999.

  23. Snapshot of Caregiving for Elders in Indian Country from the Santa Fe Service Unit Study* (2/4) • Caregiving Recipients (Elders) • 63% women • Median age 83 years old • Average 3 of 5 BADL impairments • Average 7.5 of 8 IADL impairments • Nearly half with some incontinence • Half could not be left alone for more than 1 hour • 1/3 frequently anxious or nervous • 22% constantly restless or agitated

  24. Snapshot of Caregiving for Elders in Indian Country from the Santa Fe Service Unit Study* (3/4) Caregiver Problems and Issues • Isolation of elders • Lack of respite • Caregiver health issues • Sleep interruption (45%)

  25. Snapshot of Caregiving for Elders in Indian Country from the Santa Fe Service Unit Study* (4/4) • Caregiver Needs • Regular monitoring of care recipient • Information about elder’s health, condition, and what to expect • Caregiver training • Case management • Information about health and social services • Assistance with physical care • Elder day health services • Caregiver support groups

  26. Possibilities for Enhancing Caregiver Support within the Indian Health System Universal assessment with targeted referral / intervention • Referrals: • To community / Tribal resources for respite, elder day health, etc. • For behavioral health support • Potential Interventions • Caregiver training • Assess and meet education/information needs • Group visit for caregivers • Support group

  27. Depression (PHQ-2) A Self-Care Screening Survey for Depression Awareness • During the past month have you often been bothered by: • Little interest or pleasure in doing things • feeling down, depressed, or hopeless?

  28. Depression (PHQ-9) • Little interest or pleasure in doing things • Feeling down, depressed, or hopeless • Trouble falling/staying asleep, sleeping too much • Feeling tired or having little energy • Poor appetite or overeating • Feeling bad about yourself – or that you are a failure or have let yourself or your family down.

  29. Depression (PHQ-9) • Trouble concentrating on things, such as reading the newspaper or watching television. • Moving or speaking so slowly that other people could have noticed. • Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual. • Thoughts that you would be better off dead or of hurting yourself in some way.

  30. Depression • Five or more symptoms • Lasting more than two weeks • Getting in the way of things (impairing function) • Not due to drug or alchohol • Not due to simple grieving

  31. Department of Health and Human Services Indian Health Service Office of Clinical and Preventive Services Elder Care Initiative Long Term Care Grant Program Announcement Type: New Discretionary Funding Announcement Number: ?????? Catalog of Federal Domestic Assistance Number:????? Key Dates: Letter of Intent Deadline: Late April Application Receipt Deadline: Late May Application Review Dates: Late June Application Notification: Mid July Anticipated Award Start Date: First of August DRAFT

  32. Outline of Draft IHS LTC RFA (1) • Eligiblity: Tribes or AIAN organization • Competitive Grant • Purpose: Development of sustainable LTC service (s) • Project Types: • Assessment / Planning • Implementation • 2 year funding. NOT MODEL DEVELOPMENT

  33. Outline of Draft RFA (2) Not eligible projects: • Assisted Living • Board and Care • Custodial Nursing Home Must be designed to serve AIAN elders.

  34. American Indian & Alaska Native Long Term Care Conference(3nd Annual)September 5th and 6th in Albuquerque, NM Intensive workshops on September 7th Learning from each other about what is working and and what is not in the development of Long Term Care services in Indian Country Information at: www.aianlongtermcare.org

  35. Call Your Geriatrician Bruce Finke, MD 413-584-0790 615-417-4915 (cell) bruce.finke@ihs.gov

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