1 Collaboration Between Acute Care, Primary Care and Home CarePresented by Montefiore Home Care

2 Learning Objectives Illustrate need to implement specialized programsDescribe how to develop a program Illustrate a collaborative approach with primary care and hospital settings Discuss how these models can be replicated in your agency

3 Speakers Angela Schonberg, PT Moderator Amy Ehrlich, MDMedical Director, MHC Wojciech Rymarowicz, PT Director of Rehabilitation Services Roberta Duke, RN Program Manager, Heart Failure Janice Korenblatt, LCSW Director of Social Work Mirnova Ceide, MD Geriatric Psychiatry

4 Montefiore Health SystemAmy Ehrlich, MD Medical Director, MHC Associate Chief, Division of Geriatrics Montefiore Medical Center

5 The Bronx Ixtayul.blogs.com Van Cortlandt Lake. Photo: Daniel AvilaCourtesy, NYC Parks & Recreation

6 The Bronx .. Thesurrealestate.org

7 The Bronx Huge Impoverished Ethnically diverse Morbidity burden1.4 million residents Impoverished 30% persons below poverty level Ethnically diverse 53% speak language other than English at home Morbidity burden Rated lowest in NY State for health outcomes High rates of obesity, asthma, diabetes

8 Montefiore Medical CenterThis is a a picture of Montefiore Medical Center

9 Montefiore Medical Center Urban Safety Net & Integrated Health System4 hospitals with 1,491 beds > 90,000 annual admissions 11 % from NFs 80% Medicare and/or Medicaid 2nd busiest ED in the nation > 1/3 million annual visits 21 community based primary care clinics > 800,000 annual visits 17 school based clinics 88,000 patients aged > 65

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11 Montefiore’s Care Management Organization (CMO)Established in 1996 Wholly-owned subsidiary of Montefiore Performs care management delegated by health plans 15 years full risk managed care experience 94,000 risk lives (2010) ,000 (2013) Over 1,900 physicians in the network

12 Accountable Care OrganizationsACOs: Groups of physicians, hospitals and other providers who accept responsibility for the quality and cost of care for a population Triple Aim: Better care for individuals Better health for populations Reduced expenditures

13 Accountable Care OrganizationsQuality Performance Pay for performance Rewards for higher quality Penalties for poor quality Shared cost savings Denied if quality performance is low Dropped from the ACO Financial risk if poor quality and/or inefficiency

14 Pioneer ACO Program Center for Medicare and Medicaid Services (CMS) initiative designed for organizations with experience managing populations Serves Medicare fee-for-service beneficiaries Start January last 3-5 years Quality scoring across multiple domains Potential shared savings with substantial financial risk and gain The Pioneer ACO Model was designed for health care organizations and providers that are already experienced in coordinating care for patients across care settings 32. Montefiore’s was awarded a Pioneer ACO which started in January 2012 and is scheduled to last 3-5 years.

15 Quality Evaluations 33 quality metrics in 4 domains:Patient/Caregiver experience Care Coordination/Patient Safety Preventive Health At-Risk Populations Performance compared relevant US benchmarks Quality scoring across multiple domains includes patient satisfaction , care coordination and patient safety, preventive helth and caring for a population at risk DM, HTN, CVD. including patient satisfaction and quality standards will prorate savings

16 Montefiore’s Pioneer ACOCMS assigned 23,000 Medicare Fee-for-service (FFS) beneficiaries 18% aged < 65 59% aged 65-84 23% aged > 85 Physicians 70% community-based MDs 30% Montefiore-employed MDs

17 Montefiore’s ApproachIdentify high risk patients Analyze CMS claims data Sentinel events: ED visits, hospitalizations, dialysis Develop new initiatives across the network In-Patient, ED, NFs, ambulatory setting

18 High Risk ACO Patients Highest-risk beneficiaries identified (1,906)9% of population = 55% of medical cost 9% dual eligible 55% mental health diagnosis Approximately 70% cared for by voluntary physicians

19 Care Guidance

20 New Initiatives Care Guidance (care management)Emergency Department Case Management Transition Programs & Post-discharge calls Nursing Facility (NF) initiatives Home Care initiatives Medical Home Visit Program Integration medical & behavioral care management Clinical pathways - back pain, heart failure, chest pain Geriatrics Hospitalist Program Consultation Services (Geriatrics, Palliative care) There are a group of different and innovative intiaties So thse are Care Guidance (care management) Emergency Department Case Management Transition Programs & Post-discharge calls Nursing Facility (NF) initiatives Medical Home Visit Program for the most challenging patients in our network Integration medical & behavioral care management – which increases the access to mental health professionals in Primary care settings Clinical pathways - back pain, heart failure, chest pain Geriatrics Hospitalist Program Consultation Services (Geriatrics, Palliative care) some of the initatives

21 Montefiore Home Care Established in 1947 as the nation’s first hospital-based home care agency Created to allow patients the benefits of at-home recuperation It was an innovative concept, referred to as a "hospital without walls" Certified Home Care Agency accredited by JCAHO Care from infancy caring for newborns and their mothers- to our patients over 100 years old

22 Montefiore Home Care 11, 573 admissions annuallyAverage Daily Census: 2,600 Skilled visits annually : Nursing: 113, 012 Rehabilitation Therapy: 37, 989 Social Work: , 078

23 Montefiore Home Care Unique ProgramsComplex Case Weekly multidisciplinary rounds Physicians call-in Pharmacy consultations Referrals by clinical staff to PharmD MHC-CMO Joint RN Collaborate across the network

24 Montefiore Home Care Disease Specific ProgramsElective Joint Replacement Heart Failure Behavioral Health Maternal Child Health Wound Care Palliative Care

25 Home Care Joint Replacement Rehab ProgramPresented by Wojciech Rymarowicz MS PT Director of Rehabilitation Service

26 Home Care Joint Replacement Rehab ProgramPrimary diagnosis - Osteoarthritis > 7 million Americans 2.3 % of total population live with an artificial joint 4.7 million/1.5% knee 2.5 million/0.8% hip Age 50 4.6% TKR /2.3%THR Age 80 10% TKR/6% THR Women > men American Academy of Orthopedic Surgeons March 2014

27 Home Care Joint Replacement Rehab ProgramIncrease Incidence past 10 years < age 64 TKR > 120% THR > 73% Revision TKR > 133% Revision THR > 27% Increase related to disproportionate growth in utilization by younger patients and overall population growth Patients discharged with home health care service Total Joint Replacements 2000 =19 % > 41 % American Academy of Orthopedic Surgeons March 2014

28 Home Care Joint Replacement Rehab ProgramImplications for new healthcare delivery model “Baby boom” generation living to eighth decade and beyond Medical conditions with greatest impact on the system degenerative conditions - severe arthritis afflicting over 15% estimated to surpass 20% (or 60 million people) by 2020 We need to be ready!!!

29 Home Care Joint Replacement Rehab ProgramPROGRAM GOALS: Increase discharges to home Decrease hospital length of stay Improve pre-operative teaching Achieve functional outcomes Improve patient satisfaction

30 Home Care Joint Replacement Rehab ProgramPROGRAM DEVELOPMENT Assess Community - Identify need for specialty program Address Healthcare reform- ACO and bundled payments Partner with Orthopedic Centers or Departments Collaborate with orthopedic surgeons in development of clinical pathways and protocols Establish close relationship with inpatient/outpatient departments /vendors Educate staff including Home Health Aides Implement program Collect and analyze data Present program to payers to facilitate prior HC authorizations Market program

31 Home Care Joint Replacement Rehab ProgramHOW DOES IT WORK? Patients referred by inpatient team for next day admission (SOC) Patients receive initial visits / RN and PT first day after hospital discharge Home Health Aide placed as needed Patients receive daily PT visits /minimum 7 days Focus on ROM, transfers, and gait training RN for Medication reconciliation, anticoagulation administration and teaching

32 Home Care Joint Replacement Rehab ProgramHOW DOES IT WORK? Case management role: transition from RN to PT week 1 Orthopedic Surgeons updated routinely on patient progress Rehab intervention frequency decreases as patients achieve rehab targets First post op surgical visit staples removed (7-10 days) prescription for out patient rehab (to avoid delays with appointments) change in weight bearing status /ambulatory device

33 Home Care Joint Replacement Rehab ProgramHOW DOES IT WORK? Rehab interventions focus on Functional status Gross motor mobility Strengthening Communication with surgeon and outpatient department to facilitate transitions

34 Home Care Joint Replacement Rehab ProgramResults: Prior to the program: 28% discharged home After the program: % discharged home admissions Hospital length of stay (LOS): Prior to the program: 4.1 +/- 2.3 days After the program: /- 1.1 days

35 Home Care Joint Replacement Rehab ProgramResults: Average utilization 4 RN visits,10 PT visits, < 1 OT, < 1 MSW visits 10 hours of HHA Average LOS on MHC 24 days Functional status Improved one level per OASIS functional assessment Patient satisfaction Press Ganey: 95th percentile

36 Home Care Joint Replacement Rehab ProgramFINANCIAL IMPACT Discharged patients Home Care Only $3,200 (average home care length of stay 24 days) Skilled Nursing Facility $8,000 (average short term rehab length of stay 21 days)

37 Home Care Joint Replacement Rehab ProgramCHALLENGES Authorizations vs service delivery Change in patient perception Pain management Staffing-weekend coverage Patients concerns/anxiety Physician “buy in”

38 Home Care Joint Replacement Rehab ProgramFUTURE Shorter Acute care LOS Bundled payments and managed care Ambulatory procedures Younger and more active population Other treatment options platelet rich plasma (PRP) stem cells

39 Montefiore Homecare Heart Failure ProgramPresented by Roberta Duke RN Program Manager

40       Background:                        Heart failure (HF) - most common reason for 30 day re-hospitalizations Over 2/3 of HF hospitalizations are preventable Readmissions related to Inappropriate medications Medications not fully optimized Patient self-titrating Nonadherence to disease management Failure to seek care                           

41                                 Program Goals:                              Provide nursing interventions utilizing evidence based practice Educate patients and caregivers Foster adherence to disease management Transition patients to caring for themselves Reduce avoidable re-hospitalizations Collaborate with network on bundled payments Improve patient satisfaction

42 Program Development: CollaborationCollaboration across Montefiore Network Heart Failure specialty teams Ileana Pina, MD-Vice Chair Cardiology Director: N-HeFT (National Heart Failure Training Program) “Brown Bag Clinics” Pharmacist lead program for medication reconciliation at time of discharge CMO HF team Acute care cardiology units

43 Program Development: Clinician EducationSpecialized clinician training RNs: Clinical Rotations: HF clinics, Brown Bag Clinics, Inpatient HF rounds CMO HF team: Telephonic management American Association for Heart Failure Nurses (AAHFN) National Heart Failure Training Program (N-HeFT) Self-learning module: Pathophysiology Pharmacology Evidence-based practices.

44 Program Development: Clinician EducationHome Health Aides Collaboration with vendors to train HHA to recognize signs and symptoms HF: Clinical signs: Number of pillows used Dietary compliance Weight checks PT/OT Clinical monitoring of HF patients

45 Program Development: Patient/Caregiver EducationSpecialized patient/caregiver training Patient education booklet Individualized counseling on behavioral modification techniques

46 Program Development: Clinical ProgramsNew clinical tools: Clinical pathways in the EMR Standards of practice Telephonic visit template Compliance measures: Chart reviews Observational visits Telephonic monitoring of patient comprehension and adherence HF specific reports/tracking Weekly case conference

47 Program Development: Clinical ProgramsNew clinical measurements: Scales Abdominal tape measures Kansas City Cardiomyopathy Questionnaire (KCCQ)

48 Heart Failure Population Heart Failure population on MHC: 2013: 228 HF active patient 51% (117/228) have an EF < 40% and/or > 2 hospitalizations in the past 6 month 75% (88/117) were not followed by a HF physician 52% (118/228) not on an ACE or ARB

49 Heart Failure Program: ImplementationPatient selection: EF< 40% and/or > 1 HF hospitalizations in the past 6 months Key Components: Enhanced clinical monitoring Nurse visits are front-loaded with telephonic visits performed in between Education Collaboration with HF specialists

50 The Role of Home Care in HFHomecare offers a unique opportunity to educate patients, families & caregivers HF trained nurses are the best candidates to identify early signs of de-compensation and with MD collaboration prevent a re-hospitalization HF trained home health aides(HHA) assist in the plan

51 Challenges Coordination of care for patients with complex psycho-social needs Physician buy-in Attaining authorizations from HMO Continuing education for staff

52 Future Projects: Cardiac Rehabilitation

53 Behavioral Health Presented by Mirnova Ceide, MD Geriatric Psychiatrist Janice Korenblatt LCSW, Director of Social Work

54 Embedding Psychiatry into Home Care< 3% of adults see a mental health professional 2/3 of PCPs had trouble accessing mental health services Older adults are less likely to receive follow up mental health care Major Depression: 13.5% of elderly home health care 6.5% of older primary care patients Bartels et al 2004 Improving Access to Geriatric Mental Health Services. Cunningham et al 2009 Beyond Parity: Primary Care Physicians on Access to Mental Health Care. Gilmer et al Access to public mental health services among older adults with severe mental illness

55 Suicide in the Elderly Significant increase in the past 10 years. Health experts blame untreated depression. 16% of all suicide deaths are adults aged > 65 The National Alliance for the Mentally Ill (NAMI) reports statistics that underscores the lack of depression screening by many primary care physicians: Adults age > 65 who commit suicide: 20% saw a doctor the day they die, 40% the week they die 70% in the month they die. www. Aplace formom.com 2014, April 14 N.I.H. Decide which one you like better

56 Unmet Behavioral Health Needs Lead to …Noncompliance: noncompliance with plan of care 3x more likely Morbidity: Increases morbidity from chronic medical illnesses DM twice as likely to have depression Depressed adults twice as likely to be at risk for OSA 36% of hospitalized older adults with HF have MDD DiMatteo et al 2000 Depression Is a Risk Factor for Noncompliance With Medical Treatment:  Meta-analysis of the Effects of Anxiety and Depression on Patient Adherence Twelve articles about depression and 13 about anxiety met the inclusion criteria. The associations between anxiety and noncompliance were variable, and their averages were small and nonsignificant. The relationship between depression and noncompliance, however, was substantial and significant, with an odds ratio of 3.03 (95% confidence interval, ). Anderson et al 2001 The prevalence of comorbid depression in adults with diabetes a meta-analysis. Comorbid depression increase hyperglycemia. Also people with DM are twice as likely to have depression Ceide et al Obstructive Sleep Apnea Risk and Psychological Health among Blacks in the MetSO Cohort Koenig Depression in hospitalized older patients with congestive heart failure A consecutive sample of 542 patients age 60 or over admitted to inpatient services of Duke University Medical Center were systematically screened by a psychiatrist for depression using the Dignostic Interview Schedule; 342 depressed cases and nondepressed controls were identified. Of these, 107 had a primary or secondary diagnosis of CHF. Among patients with CHF, major depression was identified in 36.5%, a rate that was significantly higher than for patients without CHF (25.5%); the difference was largely explained by low rates of major depression in cardiac patients without CHF (17.0%) who had less severe physical illness. Minor depression was also present in 21.5% of CHF patients, but was not more prevalent than in patients without CHF (17.0%). Compared with nondepressed CHF patients, those with depression were more likely to have comorbid psychiatric disorder, severe medical illness, and severe functional impairment. Depressed patients used more outpatient and inpatients medical services, although this was largely due to the severity of their health problems. Patients often remained depressed for a prolonged period, and over 40% failed to remit during the year following discharge. Factors predicting slower remission included nonhealth-related, stressful life events and low social support; physical health factors at baseline had effect. The majority of depressed CHF patients did not receive treatment for their depression with either antidepressants or psychotherapy, and did not see mental health specialists any more frequently than did the nondepressed. These findings are of concern and have important implications for the diagnosis and treatment of depression in older patients with heart failure.

57 Unmet Behavioral Health Needs Lead to…Hospital Costs: Depression and anxiety increases re-hospitalization. Unplanned hospital 30 day readmission 3x as likely in elderly with history of depression. 6 months readmission 3 x as likely in older adults with depressive symptoms. Mortality: Major Depression associated with increased mortality 43% increase of risk of all cause death 2.6x risk of CVD death Marcantonio et al 1997 Factors associated with unplanned hospital readmission among patients 65 years of age and older in a medicare managed care plan Five factors were independently associated (P <0.05) with unplanned readmission within 30 days. These included four baseline patient characteristics: age 80 years or older [odds ratio = 1.8; 95% confidence interval (CI), 1.02–3.2], previous admission within 30 days (odds ratio = 2.3; 95% CI, 1.2–4.6), five or more medical comorbidities (odds ratio = 2.6; 95% CI, 1.5–4.7), and history of depression (odds ratio = 3.2; 95% CI, 1.4–7.9); and one discharge factor: lack of documented patient or family education (odds ratio = 2.3; 95% CI, 1.2–4.5). Mudge et al 2011 Recurrent readmissions in medical patients: A prospective study A total of 55 participants (38.7%) had a further unplanned hospital admission within 6 months. In multivariate analysis, chronic disease (adjusted odds ratio [OR] 3.4; 95% confidence interval [CI], , P = 0.002), depressive symptoms (adjusted OR, 3.0; 95% CI, , P = 0.01), and underweight (adjusted OR, 12.7; 95% CI, , P = 0.004) were significant predictors of readmission after adjusting for age, length of stay and functional status Onge et al 2014 The Relationship Between Major Depression and Nonsuicide Mortality for U.S. Adults: The Importance of Health Behaviors. We aim to elucidate the role of health behaviors and health conditions in the association between depression and mortality. First, we examine the relationship between major depression and nonsuicide mortality among U.S. adults aged 50 and older. Second, we examine therelationship between major depression and cardiovascular disease and cancer, by baseline disease status. Third, we examine the role of health behaviors as potential mediators of the association between major depression and cause-specific mortality. METHODS: We use data from the 1999 National Health Interview Study linked to the 2006 National Death Index (N = 11,369; M age = 65, deaths = 2,162) and Cox proportional hazards models to describe the relationships among major depression, health behaviors (alcohol use, cigarette smoking, physical activity), and nonsuicide mortality. We examine cause-specific mortality (cardiovascular and cancer) by baseline disease status. RESULTS: Major depression remains associated with a 43% increase in the risk of death over the follow-up period, after we account for sociodemographic characteristics, health behaviors, and health conditions. Major depression is associated with 2.68 times the risk of cardiovascular disease mortality among those who did not have cardiovascular disease at baseline and 1.82 times for those with baseline cardiovascular disease. Health behaviors reduce the hazard ratio by 17% for all nonsuicide mortality, 3% for cardiovascular disease mortality, and 12% for cancer mortality.Discussion.Our results provide evidence of the important role of health behaviors and health conditions in thedepression-mortality relationship and highlight the importance of identifying risk factors for depression among aging adults.

58 Integrating Behavioral Health into Home CareConsult liaison psychiatry: One time consultations or very limited follow up. Strategies: Collaborative model: IMPACT multisite trial Validated in the elderly 50% decrease in thoughts of suicide Colocation: Small scale model in Home Care and Inpatient settings Most cost effective in capitated or cost sharing systems. IMPACT trial was a randomized multisite trial aimed at treating depression in the primary care setting. Pt watch a 20 minute video and met with depression care manager. Then a depression clinical specialist did an evaluation. The cases were discussed. The collaborative care model as been validated in the elderly as well with a OR 0.55 decreased thoughts of suicide Chang-Quan et al 2009 Collaborative care interventions for depression in the elderly To determine the effective components and the feasibility of collaborative care interventions (CCIs) in the treatment of depression in older patients. METHODS: Systematic review of randomized controlled trials, in which CCIs were used to manage depression in patients aged 60 or older. RESULTS: We identified 3 randomized controlled trials involving 3930 participants, 2757 of whom received CCIs and the others received usual care.Collaborative care interventions were more effective in improving depression symptoms than usual care during each follow-up period. Compared with baseline, thoughts of suicide in subjects receiving CCIs significantly decreased (odds Ratio [OR], 0.52; 95% confidence intervals [CI], ), but not that in those receiving usual care (OR, 0.85; 95% CI, ). Subjects receiving CCIs were significantly more likely to report depressiontreatment (including any antidepressant medication and psychotherapy) than those receiving usual care during each follow-up period. Collaborativecare interventions significantly increased depression-free days, but did not significantly increase outpatient cost. At 6 and 12 months postintervention, compared with those receiving usual care, participants receiving CCIs had lower levels of depression symptoms and thoughts of suicide. Moreover, participants receiving CCIs were significantly more likely to report antidepressant medication treatment, but were not significantly more likely to report psychotherapy. Collaborative care interventions with communication between primary care providers and mental health providers were no more effective in improving depression symptoms than CCIs without such communication. CONCLUSIONS: Collaborative care interventions are more effective for depression in older people than usual care and are also of high value. Antidepressant medication is a definitely effective component of CCIs, but communication between primary care providers and mental health providers seems not to be an effective component of CCIs. The effect of psychotherapy in CCIs should be further explored. Weiss and Schwartz Lessons learned from a colocation model using psychiatrists in urban primary care settings Works best in capitated reimbursement systems rather than fee for services Tiemens et Al 1996 recognition of depression does mot change outcome if treatment is unavailable.

59 Model for Geriatric Psychiatry in Home CareIdentify and treat the homebound elderly with depression Model program to integrate psychiatry into Home Care 2004: Home Care established collaboration with Dept. of Psychiatry at Montefiore. New York Cornell Westchester provided the training for clinical staff on recognizing symptoms of depression. Educational program for geriatric psychiatry fellows, residents and medical students This is the only program in greater New York in which a geriatric psychiatrist is integrated into a home care agency," said Gary Kennedy, MD, director of the initiative and chief of Montefiore's Geriatric Psychiatry program. "Even though one in eight elderly home care patients suffers from depression, few home care agencies incorporate mental health services into their programs -- and fewer still provide psychiatric care.

60 Embedded Psychiatrist Dual RolePsychiatric Hospitalist In hospital consultation Education Geri Psych fellows, Psych Residents, medical students Home Care Psychiatrist In home consultation This diagraphm again emphasizes my dual role on the inpt hospitalist unit and in home. 3 days a week are spent on the medicine unit. Consultations are identified proactively while discussing all the patients on the unit with nursing and PAS. 2 days week are spent with the home care team, in the geraitric psychiatry program. This program was establishe in I meet weekly with the home care SW team regarding new referrals which are generated during RN and SW screeing of patients. PMD are comtacted prior to consultation and recommendations are shared with the PMD and home care team. As part of the larger Montefiore system patients seen in the hospital may be seen in home care as needed or vice versa. We will discuss this more in the case examples.

61 Training Program PHQ2 and PHQ-9Assessment instrument for of both screening and evaluating They have both been validated in primary care populations. Sensitivity > 80% Training utilized the Outcome and Assessment Information Set (OASIS) CMS instrument required of home health agencies for reimbursement This allowed depression screening and treatment to be captured in the reimbursement for Home Care Kroenke etal 2001 The PHQ-9: validity of a brief depression severity measure. a PHQ-9 score > or =10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively. Results were similar in the primary care and obstetrics-gynecology s

62 Scoring and Screening for DepressionPHQ-2: scores range from 0- 6 86% sensitive and 78% specific for major depression Score of > 3 requires further evaluation for depression Referred to Home Care social worker who completes PHQ-9

63 Reasons for Referrals to Geriatric PsychiatryDepression Anxiety Psychosis Hoarding Dementia with behavioral disturbance Capacity evaluation

64 Geriatric Psychiatry Home Care ProgramGoals : Establish a program to provide care to population that underutilizes mental health services Improve collaboration with hospital and primary care providers Outcome measures: Reached men and minorities who underutilize mental health treatment Timeliness of evaluations Reached the population for which the institution has taken financial risk Enhanced collaboration with hospital and primary care

65 Demographics: 100 patients evaluated between July1, 2013-12/31/2013AGE N=100

66 Gender Men are less likely than women to seek help from a mental health professional for mental health concerns. N=100 Age Mackenzie et al 2006 Age, gender, and the underutilization of mental health services: the influence of help-seeking attitudes The objectives of this study were to explore age and gender differences in attitudes toward seeking professional psychological help, and to examine whether attitudes negatively influence intentions to seek help among older adults and men, whose mental health needs are underserved. To achieve these objectives 206 community-dwelling adults completed questionnaires measuring help-seeking attitudes, psychiatric symptomatology, prior help-seeking, and intentions to seek help. Older age and female gender were associated with more positive help-seeking attitudes in this sample, although age and gender interacted with marital status and education, and had varying influences on different attitude components. Ageand gender also influenced intentions to seek professional psychological help. Women exhibited more favourable intentions to seek help frommental health professionals than men, likely due to their positive attitudes concerning psychological openness. Older adults exhibited more favourable intentions to seek help from primary care physicians than younger adults, a finding that was not explained by age differences in attitudes. Results from this study suggest that negative attitudes related to psychological openness might contribute to men's underutilization of mentalhealth services. Help-seeking attitudes do not appear to be a barrier to seeking professional help among older adults, although their intentions to visit primary care physicians might be. These findings suggest the need for education to improve men's help-seeking attitudes and to enhance older adults' willingness to seek specialty mental health services.

67 Ethnicity Hispanics and African Americans are less likely to find antidepressants acceptable. Berkman et al Concepts of Mental health and Mental Illness in Older Hispanics Cooper et al 2003 Ethnic minority patients are less likely than white patients to receive guideline-concordant care for depression. It is uncertain whether racial and ethnic differences exist in patient beliefs, attitudes, and preferences for treatment. METHODS: A telephone survey was conducted of 829 adult patients (659 non-Hispanic whites, 97 African Americans, 73 Hispanics) recruited from primary care offices across the United States who reported 1 week or more of depressed mood or loss of interest within the past month and who met criteria for Major Depressive Episode in the past year. Within this cohort, we examined differences among African Americans, Hispanics, and whites in acceptability of antidepressant medication and acceptability of individual counseling. RESULTS: African Americans (adjusted OR, 0.30; 95% CI ) and Hispanics (adjusted OR, 0.44; 95% CI, ) had lower odds than white persons of finding antidepressant medications acceptable. African Americans had somewhat lower odds (adjusted OR, 0.63; 95% CI, ), and Hispanics had higher odds (adjusted OR, 3.26; 95% CI, ) of finding counseling acceptable than white persons. Some negative beliefs regarding treatment were more prevalent among ethnic minorities; however adjustment for these beliefs did not explain differences inacceptability of treatment for depression. CONCLUSIONS: African Americans are less likely than white persons to find antidepressant medication acceptable. Hispanics are less likely to find antidepressant medication acceptable, and more likely to find counseling acceptable than white persons. Racial and ethnic differences in beliefs about treatment modalities were found, but did not explain differences in the acceptability of depression treatment. Clinicians should consider patients' cultural and social context when negotiating treatment decisions for depression. Future research should identify other attitudinal barriers todepression care among ethnic minority patients N=100

68 Diagnoses N=100

69 Timeliness of Evaluation Visits

70 VALUE RISK RELATIONSHIP

71 Treatment Options MedicationsDepression/Anxiety: Selective Serotonin Reuptake Inhibitors (SSRI’s) are most commonly prescribed or Serotonin Norepinephrine Reuptake Inhibitors and other drug classes. Dementia with Psychosis/Behavioral Disturbance: Antipsychotics-atypical or typical. Psychological Interventions Counseling provided by home care social workers Out patient mental health providers for continued care Adult Day Program/ Senior Centers Pts with Medicaid are eligible for day programs. Minimizes agitation, improves depression, improves sleep.

72 Ms. A ID/CC: 64 DHF newly admitted to Monte Home Care with depression in the setting of medication non compliance and chronic pain. HPI: Tearful and anxious Ruminating about her children Demoralized by back pain and lower extremity ulcer Decreased sleep with delayed onset Increased anxiety at night No PMD and ran out of Citalopram and Clonazepam a few months prior.

73 Ms. A PPH History of Major Depressive Disorder4 psychiatric hospitalizations for SI, One suicide attempt History of auditory hallucinations Past treatment SSRIs and Benzodiazepines History of heroin dependence now on methadone SH: Immigrated from Puerto Rico in teens 8 children, 6 in NY. Dtr visits daily and son would sleep over due to her anxiety. In process of applying for long term home care.

74 Ms. A PMH DM, CHF, Asthma, left lower extremity ulcer MSEAnxious appearing Hispanic woman Psychomotor agitated Depressed mood No SI, no hallucinations or delusions. MMSE 25/30

75 Ms. A A/P Diagnoses: MDD, Unspecified Anxiety disorder, Opioid use disorder on maintenance Restarted on Clonazepam and started on Duloxetine. Follow up She was later admitted to the hospital for increased left foot pain, suicidality and reported her daughter was abusive. Upon consultation was able to speak with primary team and explained that there has been no previous reports or signs of abuse in the home. Pt later rescinded her accusation and SI and was quite happy with daughter and son. She was started on Duloxetine which she has not been taking and was discharged home. Upon follow up home visit was doing well.

76 Ms. B ID/CC: 90 DHF with h/o anxiety seen for gradual decline in memory and paranoia HPI: Per son, pt getting more suspicious about neighbors and daughter in law. Barricading herself in house. Stopped taking medications. Thought people were stealing her clothes and trying to get her apartment. (Complicated scenario related to her ex husband).

77 Ms. B PPH H/o panic attacks Recently diagnosed with Dementia SH:Lives alone with HHA for 3 hrs when she allowed HHA to come. Daughter in law primary caregiver because son lived in Florida. No power of attorney (POA) PMH Vit D deficiency Glaucoma Pre diabetic

78 Ms. B MSE: Thin, temporal wasting; Home untidy, Pigeons kept in a laundry basket with a broom to weigh it down. Bedroom windows covered in cardboard and lots of clutter. Barricade near door Lots of Meals on Wheels entrees in freezer with chair against fridge to keep it closed. Forgetful, poor attention, rapid speech, tangential Persecutory delusions MMSE 12/30

79 Ms. B A/P: Dementia with behavioral disturbanceSW very involved in case. APS was called and declined case. Pt found not to have capacity. Risperidone started for delusions. Follow up: Pt refused meds from daughter in law and son had to return from Florida to care for her. He felt unable to get POA or take her to NH. Joint visit with RN: EMS called, ER informed, Pt went calmly. Pt placed in NH from ER.

80 Conclusion: Triple AimAccountable Care Organization: Triple Aim Better care for individuals Better health for populations Reduced expenditures Demonstrated the benefits of a colocation model of mental health integration in order to: Identify high risk patients Provide timely evaluation and care Increase access to mental health care

81 Conclusion: Triple AimBetter health for populations: engage hard to reach populations (i.e. men and minorities) Reduced expenditures Transition to appropriate settings (i.e. Hospice, SNF, Adult Day) Collaborate with primary care, hospital and community agencies

82 Adapting the Model Partnering with department of psychiatry or mental health providers Training site for learners Forging relationship with community agencies Aligning with recent CMS payment and policy updates Bundled payments Value Based Purchasing Shared cost models

83 QUESTIONS