Julianne Voss, LCSWSocial Work Case Manager

PACE Organization RI

Cyndi ForcierChief of Strategy & Development

PACE Organization RI

Rosemarie BolgerDay Center Director

PACE Organization RI

ObjectivesAt the conclusion of the presentation, the attendee will be able to:• Integrate the primary care expertise of the PACE with community

behavioral health services to promote available, coordinated, and accessible care for individuals with both significant behavioral health diagnoses and complex medical conditions.

• Build effective business relationships and contract terms to successfully integrate care for this participant co-hort.

• Implement effective strategies to minimize disruptive behaviors in the day center and increase job satisfaction for staff caring for participants with persistent behavioral health issues.

Behavioral Health Services

• Treat diagnosed mental illness

• Address habits, behaviors, and symptoms (e.g. stress, worry) that interfere with daily functioning

• Assist participant with emotional concerns related to changes in health status

Behavioral Health Services• Evaluation/Screening• Preventive services• Treatment

• Early intervention• Referral to specialists• Maintenance (Reduce relapse & recurrence)

• Education for staff

Common Mental Health Disorders of Older Adults

• Depression• Anxiety• Dementia

• 30- 40% of persons with Alzheimer’s dementia experience behavioral symptoms (agitation, psychosis and depression)

• Substance Use Disorders(Source: Bartels, et al. , 2002)

Consequences of Untreated Mental Health Disorders of Older Adults • High healthcare utilization• Lower quality of life• Increased complexity in illness disability and impairment• Increased caregiver stress• Risk of suicide• Mortality

(Source: Substance Abuse and Mental Health Services Administration & Administration on Aging, 2012)

NPA Behavioral Health Survey

• Task Force was formed to assess the needs and current models of mental health service delivery among PACE programs

• Paper survey was disseminated to all PACE organizations, 89 PACE centers responded

Results - 77% had no formal behavioral health programming

(Source: Gibson & Ilem, 2016)

Levels of Integration

• Coordinated Care - communication

• Co-located Care - physical proximity

• Integrated Care - practice change and collaboration, team-oriented

(Source: National Institute of Mental Health, 2017)

PACE RI Behavioral Health Program• Social Work screening for depression, anxiety, substance use every

6 months• In-house counseling provided by LCSW or contract provider from

CMHC• Access to contract psychiatrist on a weekly basis• Coordination with in-house medical staff• Coordination with outside providers (nursing homes, hospitals, etc.)• BH liaison - point person coordinates services among staff and

contracted providers • Emergency or Inpatient psychiatry

Case Studies

Case Study #1• S is a 59 y/o divorced woman • Referred by inpatient psychiatric unit after an admission for suicidal

ideation with plan• Diagnoses include: Intellectual disability; PTSD, MDD, Panic

Disorder with Agoraphobia, Cocaine Dependence, in remission, Nightmare Disorder, Restless Leg Syndrome, Obstructive Sleep Apnea, COPD, asthma.

• Addiction in remission for 2 years, treatment prior to joining PACE• Supportive services delivered in first 6 months of enrollment

• Housing assistance• Managing finances • Routine medical care • Psychiatry and counseling services

Case Summary #2:• D is a 66 y/o widowed woman• Long-term SPMI Bipolar Disorder in her 20s; Other dx include: Anxiety

Disorder, Personality Disorder, Diabetes, COPD, Asthma• Currently lives in a psychiatric group home• Maintenance of stability of psychiatric symptoms, stability of chronic

health conditions and improved self-regulation skills are the goals of care for D

• PACE MSW acts as a liaison with residential care providers and psychiatric RN

• Weekly ½ hour meetings for counseling.• Psychiatric medications managed by CMHC• D has a Behavior Intervention Plan at PACE

Behavior Plans

Managing Behavior Plans

• Identifying a Need

• RESPECT Committee

• Operationalizing a System

• Managing Progress

Identifying a Need

• Participants demonstrating aggressive behaviors• Impacting other participants• Impacting Staff

• Managing personalities and diagnoses • Staff expressed there were feelings of disrespect permeating day

centers• Solution: Create the RESPECT Committee

RESPECT Committee• A committee of multiple disciplines:

Transportation ActivitiesDay Center CNAs Social WorkBehavioral Health Operations

• Those participants identified by the IDT as benefitting from a behavior plan have care plans brought before the RESPECT Committee to devise and work on the behavior plans.

Operationalizing a System• RESPECT Committee creates Behavior Plan for participant• IDT reviews plan for approval• All staff who provide direct care to the participant are made aware

of behavior plan & educated on participant• Behavior Plans attached to the electronic medical record & hard

copy securely stored in Day Center• Note in Care Plan “behavior plan is enacted” • Behavior Plan reviewed every six months and as needed

Monitoring Progress• Behavior Plans only effective if used consistently – all staff

responsible for consistency & compliance• Effective education of all new direct care staff critical

• Avoiding trigger discussions & situations• Distraction techniques • Steps to mitigate

• Notes well maintained if behavior plan enacted and deemed ineffective, due to personality or diagnosis

• RESPECT Committee meets regularly and as needed for crisesResults: Staff feels empowered, participants maintain dignity

Results: staff feel empowered & participants needs honored

What’s Next?

• New Stretch Goals Driven By..• New Strategic Plan• Marketplace demand• Engagement of healthcare partners• Census growth

Comfort Zone C’s

• Choice• Common Vision• Connect & Collaborate

• Conflict• Contracting• Continue or Close

Choice

• Do we “build” internal expertise?

• Do we “buy” external expertise?

Common Vision

• Belief that working in partnership rather than alone has benefits that outweigh the cost

• Developing a shared vision means being prepared to explore new options for services

• Strong level of mutual trust• Some history of collaboration

Connect & Collaborate

• Open and frequent communication• Establish buy-in early• Partnership plan and clear deliverables

Conflict

• On a practical level, different agencies have different structures and established processes

• Cultural clashes can be expected between professionals from different organizations and backgrounds

• Staff may perceive a loss of autonomy or decision-making authority

Contracting

• Create robust and clear partnership agreements / contracts• Multiple drafts as partners negotiate roles, rules and funding• Fund administrative costs as well as direct service delivery costs

Continue or Close

• Keep momentum going beyond a “demonstration project” phase• Plan an exit strategy – maybe the partnership was not the best

approach

Lessons Learned to Date• Pace of developing PACE partnership

can be slow• Skilled leadership• Process of managing change must

be done well

Just when you think you’re close to the finish line … it moves again!

Questions?

References• Bartles, S. J.,Dums, A.R., Oxman, T.E., Schneider, L.S., Arean, P.A., Alexopoulos, G.S., &

Jeste, D. V. (2002). Evidence-based practices in geriatric mental health care. Psychiatric Services, 11(53), 1419-1431.

• Gibson, S., Ilem, A. (2016, October). NPA Behavioral Health Survey Quantitative and Thematic Analysis. Presented at the meeting of the National PACE Association, San Francisco, CA.

• National Institute of Mental Health. (2017). Integrated care. Retrieved from: https://www.nimh.nih.gov/health/topics/integrated-care/index.shtml

• Substance Abuse and Mental Health Services Administration & Administration on Aging. (2012). Older Americans Behavioral Health Issue Brief: Series Overview. Retrieved from: https://www.ncoa.org/resources/issue-brief-older-americans-behavioral-health-series-overview/