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Rosscare Northeast Integrated Geriatrics Care Project


Rosscare Northeast Integrated Geriatrics Care Project Presented by: Lisa Harvey-McPherson RN, MBA, MPPM EMHS Vice President Continuum of Care The Geriatric Challenge ... – PowerPoint PPT presentation

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Title: Rosscare Northeast Integrated Geriatrics Care Project

Rosscare Northeast Integrated Geriatrics Care
  • Presented by
  • Lisa Harvey-McPherson RN, MBA, MPPM
  • EMHS Vice President Continuum of Care

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

EMMC Continued
  • EMMC purchased 11 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

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

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

Maine has the highest NF depression scores in the
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

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 Alzheimers Assn
  • Resident mobility supported in unit
  • Higher complement of nursing assistants
  • Focused activities
  • Regular rounding with Acadia Psychiatrist
  • Consistent Hospitalist Coverage

  • 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
  • Ross Manor
  • Stillwater Health Care
  • Dexter Health Care
  • Colonial Health Care

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

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
  • EMMC Westside Court
  • Current Rosscare patients

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

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
  • 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/interventi

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

Acadias 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

Acadias 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

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
  • pain and palliative care issues in older adults
  • assessing for and managing dementia, delirium and
  • building therapeutic alliances

Acadias Success
  • STRONG positive feedback from nursing facility
  • 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

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

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
  • 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 NFs for

Year One Nursing Home Patient Clinical Outcomes
Additional Lessons Learned
  • Two additional gaps in geriatric psychiatric care
  • Homecare homebound patients
  • Geriatric patients with behavioral/psychiatric
    challenges that can not co-mingle with other
  • Credentialing challenges with geriatric specialty
    clinicians not treating the general psych
  • 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