Michele J. Karel, PhD
Psychogeriatrics Coordinator
Mental Health Services, VA Central Office
Michele.Karel@va.gov
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Need for mental health services among
homecare population
VHA Home Based Primary Care Mental Health
Initiative
Strategies and resources for addressing
behavioral and mental health concerns in the
home care setting
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Rates of depression, dysthymia, anxiety, cognitive
impairment more than twice among homebound vs
non-homebound older adults (Bruce & McNamara, 1992)
Mental health conditions contribute to excess
disability, premature institutionalization, increased
mortality, and reduced quality of life among
homebound and other older adults (Davitt & Gellis,
2011; Qiu et al., 2010; Reifler & Bruce, 2014)
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Integrated care!
◦ Improving Mood-Promoting Access to Collaborative Treatment
(IMPACT); Prevention of Suicide in Primary Care Elderly
Collaborative Trial (PROSPECT); VHA Primary Care Mental Health
Initiative
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Growing evidence base for MH interventions for older
adults, in general
◦ Psychological interventions for depression, anxiety, insomnia,
pain, sexual dysfunction, challenging behaviors in dementia,
caregiver distress
◦ Psychopharmacological treatments
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And, for homebound older adults, in particular
◦ Problem Solving Therapy for depression, including in context of
cognitive impairment; Cognitive Behavioral Therapy for
depression; Integrated models for case management in home care
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5 of 10 top diagnoses in HBPC are mental health
conditions (Edes, 2010)
◦ Depression, anxiety, PTSD, substance abuse,
schizophrenia
◦ Dementia also among top 10 diagnoses; related
behavioral and caregiving concerns
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Also, common behavioral health challenges
◦ Coping with disability, insomnia, chronic pain,
adherence
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Caregiver strain
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Difficult for Veterans in HBPC to access clinicbased mental health services
Starting in 2007: Integrate a Mental Health Provider
(psychologist or psychiatrist) onto every HBPC team
Position description duties include providing/
promoting:
◦ Screening, assessment, diagnosis, treatment of mental disorders
◦ Assessment of cognitive deficits, and decision making and
functional capacities
◦ Services for family caregivers, and couples/families
◦ Behavioral medicine interventions
◦ Communication/interaction among team members
◦ Supervision/training
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Evidence-Based
Psychological and
Psychopharm
Assessment and Intervention
Care Management
Interdisciplinary
Care
Collaborative
Care
Stepped Care
PatientCentered Care
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Depression
Anxiety
Coping with illness/disability
Caregiver/family stress
Cognitive/dementia evaluation
Adherence
Insomnia
Chronic pain
Grief and loss
Behavior management
Decision making capacity
PTSD
Weight management
Serious mental illness
Substance use
TBI
0
20
40
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80
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Top themes included:
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Helping team to increase knowledge and skills, for
understanding and working with Veterans/families with
complex behavioral and mental health issues
Increasing holistic conceptualization/approach to
patient care
Enhancing overall program quality/quality of care
Supporting team development and cohesion
Contributing to integrated team treatment planning
Being available for staff consultation and support
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Depression
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Anxiety
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PTSD
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Alcohol use
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Suicide risk
◦ PHQ-2/PHQ-9: http://www.phqscreeners.com/
◦ GDS: http://www.stanford.edu/~yesavage/GDS.html
◦ GAD7: http://www.phqscreeners.com/
◦ Primary Care PTSD Screen:
http://www.ptsd.va.gov/professional/providertype/doctors/screening-and-referral.asp
◦ AUDIT and MAST-G: http://www.ncbi.nlm.nih.gov/books/NBK64829/
o
VHA has developed suicide risk assessment tools for primary care
and other settings, including, but not limited to, a suicide prevention
pocket card and guide
(http://www.mentalhealth.va.gov/docs/VA029AssessmentGuide.pdf)
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AGS Geriatric Evaluation & Management Tools
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American Psychiatric Association
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VA/DoD Clinical Practice Guidelines
◦ Including on depression, insomnia, dementia-related behavioral
problems
◦ http://geriatricscareonline.org/toc/geriatrics-evaluationmanagement-tools/B007/
◦ Major Depression Disorder (2010):
http://psychiatryonline.org/data/Books/prac/PG_Depression3rdEd.pd
f
◦ Other guidelines and tools:
http://psychiatryonline.org/guidelines.aspx
◦ MDD, Bipolar Disorder, PTSD, Substance Use Disorder, Assessment
and Management of Patients at Risk for Suicide
◦ http://www.healthquality.va.gov/guidelines/MH/mdd/
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Ask questions about a patient’s (and caregiver’s)
mood, fears, strategies for coping, and reasons for
living. This sends message that it is okay to discuss
such issues with you.
Provide education for patients and caregivers;
normalize behavioral and mental health struggles.
Encourage patients and their caregivers to plan for
regular engagement in pleasant activities in their
lives, in a manner consistent with their abilities and
interests.
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Learn and teach patients a few simple relaxation/
mindfulness strategies.
Communicate an attitude of hope that, although
things may be difficult, there are always ways to
address a problem, either through directly altering
the problem in some way or working on one’s
ability to cope with the problem.
Help people acknowledge and utilize their
strengths, in addition to grieving for losses. Elicit
discussion about what people feel grateful for and
what gives meaning to life.
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NIA Age Pages
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American Association for Geriatric Psychiatry
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American Psychological Association Office on Aging
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Caregivers
◦ http://www.nia.nih.gov/health/publication
◦ http://www.gmhfonline.org/gmhf/consumer/index.html
◦ http://www.apa.org/pi/aging/
◦ Family Caregiver Alliance (http://caregiver.org/)
◦ VA Caregiver Support (http://www.caregiver.va.gov/)
◦ Alzheimer’s Association (www.alz.org)
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In 2010, 50% of men aged 65 and older were
Veterans
◦ (http://www.agingstats.gov/Main_Site/Data/2012_Documents/Population.aspx)
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Most Veterans are eligible for VA health care
For enrollment:
◦ Call 1-877-222-VETS(8387)
◦ http://www.va.gov/healthbenefits/apply/
VA Caregiver Support site
http://www.caregiver.va.gov/
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Alexopoulos, G. S., Reynolds, III, C. F., Bruce, M. L., et al. (2009). Reducing suicidal
ideation and depression in older primary care patients: 24-month outcomes of the
PROSPECT Study. The American Journal of Psychiatry, 166, 882-890.
Bruce, M. L., & McNamara, R. (1992). Psychiatric status among the home bound
elderly: an epidemiological perspective. Journal of the American Geriatrics Society,
40, 561-566.
Davitt, J., & Gellis, Z. (2011). Integrating mental health parity for homebound older
adults under the Medicare home health care benefit. Journal Of Gerontological
Social Work, 54, 309-324.
Edes, T. (2010). Innovations in homecare: VA home-based primary care.
Generations, 34, 29-34.
Scogin, F., & Shah, A. (Eds.) (2012). Making evidence-based psychological
treatments work with older adults. Washington, DC: American Psychological
Association.
Hicken, B. L. & Plowhead, A. (2010). A model for home-based psychology from the
Veterans Health Administration. Professional Psychology: Research and Practice,
41, 340-346.
Hunkeler, E. M., Katon, W., Tang, L., et al. (2006). Long term outcomes from the
IMPACT randomised trial for depressed elderly patients in primary care. British
Medical Journal, 332, 259-263.
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Karel, M. J., Gatz, M., & Smyer, M. (2012). Aging and mental health in the
decade ahead: What psychologists need to know. American Psychologist,
67,184-198.
Karlin B. E. & Karel, M. J. (2013). National integration of mental health
providers in VA Home-Based Primary Care: An innovative model for mental
health care delivery with older adults. The Gerontologist, doi:
10.1093/geront/gnt142, First published online: December 3, 2013.
Karlin, B. E. and A. M. Zeiss (2010). Transforming mental healthcare for older
veterans in the Veterans Health Administration. Generations, 34, 74-83.
Post, E. P., Metzger, M., Dumas, P., Lehmann ,L. (2010). Integrating mental
health into primary care within the Veterans Health Administration. Fam Syst
Health, 28, 83-90.
Qiu, W., Dean, M., Liu, T., George, L., Gann, M., Cohen, J., & Bruce, M. (2010).
Physical and mental health of homebound older adults: an overlooked
population. Journal Of The American Geriatrics Society, 58, 2423-2428.
Reifler, B., & Bruce, M. (2014). Home-based mental health services for older
adults: a review of ten model programs. The American Journal Of Geriatric
Psychiatry, 22, 241-247.
Unützer, J., Katon, W., Callahan, C. M., et al. (2002) Collaborative care
management of late-life depression in the primary care setting: A randomized
controlled trial. JAMA, 288, 2836-2845.
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