Providing Home Care for Older Adults

A Professional Guide for Mental Health Practitioners

Danielle L. Terry, Michelle E. Mlinac, Pamela L. Steadman-Wood, Danielle L. Terry, Michelle E. Mlinac, Pamela L. Steadman-Wood

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000173109
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

A practical guide to providing home-based mental health services, Providing Home Care for Older Adults teaches readers how to handle the unique aspects of home-based care and apply and adapt evidence-based assessment and treatment within the home-based setting.

Featuring contributions from experienced, board-certified home care psychologists, social workers, and psychiatrists, the book explains the multifaceted role of a home-based provider, offers concrete and practical considerations for working within the home, and highlights adaptations to specific evidence-based methods used in treating homebound older adults. Also covered are special topics related to hoarding, safety, capacity evaluations, caregivers, case management, and use of technology. Each chapter includes engaging case examples with practical tips that illustrate what it is like to work in this new and exciting frontier.

Psychologists, counselors, and other mental health practitioners in home settings will be able to use this guide to provide effective home-based care to older adults.

Part 1

What Is Home Care?

1 Introduction to Home-Based Mental Health Care

Models, Roles, and Reflections

Tamarra Crawford, Michelle E. Mlinac, Pamela L. Steadman-Wood, and Danielle L. Terry

Dr. Judy Chan, a psychologist who works as part of home care team, drives down a gravel road in the country to meet a new patient, Mr. Brown. His home care nurse hoped Dr. Chan could help Mr. Brown, an 83-year-old recently widowed man with chronic post-traumatic stress disorder (PTSD) and advancing Parkinson’s disease, better follow his treatment plan. The visit was challenging at first. Mr. Brown was reluctant to answer questions, and told Dr. Chan that having doctors in his home made him nervous. Dr. Chan asked Mr. Brown what brought him joy despite his many health problems and recent loss of his husband. Mr. Brown shared that his beloved horses depended on him for care. Dr. Chan asked for a tour of the barn and to meet the horses, and Mr. Brown smiled with relief and escorted her to the stables. They agreed that whenever possible, future home care visits would be held in there, where Mr. Brown felt most comfortable. During their first psychotherapy visits together, Mr. Brown taught Dr. Chan how to feed, water, and brush the horses. As the therapy relationship developed, Mr. Brown opened about his frustrations with his limitations and fear that if he declined further (physically or mentally) he would be unable to care for his horses. Dr. Chan helped Mr. Brown focus on his value of taking care of his horses and appreciate that accepting assistance and taking his medications as prescribed would help him stay strong enough to do so. With increased trust, Mr. Brown was willing to meet with other members of the team, and over time agreed to engage in evidence-based treatment to better address his PTSD symptoms. With symptom improvement, Mr. Brown eventually agreed to have home health aides assist him in better caring for himself. His medical and psychiatric symptoms stabilized, and Mr. Brown was able to spend several months caring for his horses independently. When unable to care for them alone, he hired help to do so. With the trust of the home care team, Mr. Brown was able to identify his end-of-life wishes and treatment preferences. When the time came, he accepted a referral to home hospice. With their support, he was able to spend his last days in a hospital bed in the sunroom of his home overlooking the barn, when he took his last breath, peacefully and with dignity.

This case illustrates the value of a home care service that includes an integrated mental health (MH) provider who can address the unique needs of older adult patients. Individuals receiving home care often have complex health and behavioral health care needs, including advanced illness, comorbid psychiatric conditions, and complex psychosocial issues. They may be high utilizers of the health care system, having frequent hospitalizations, emergency room visits, and rehabilitation stays. Care delivered in the home seeks to address these complexities, to improve access to MH treatment, to align delivered care with the patient’s personal goals, and to reduce unneeded or overly burdensome healthcare.

MH providers, including psychologists, psychiatrists, psychiatric nurse practitioners and nurses, counselors, and clinical social workers, have a vital role to play in meeting the MH care needs for this population of older adults. This book is the first to describe this evolving model of geriatric MH practice within the patient’s home. The aims of this book are: to spark the reader’s interest in this type of clinical work, to describe practical strategies for assessment and treatment, and to highlight the powerful impact that can be made when patients are met in their homes. While home-based care can be challenging, it is counterbalanced by the privilege of being invited into the homes of patients and their families, by the joys of working with an engaged interdisciplinary team or flying solo as a provider, and by the successes of resources to help older adults meet their goals of aging-in-place. This book is written primarily by experienced home care psychologists, with contributions from psychiatry and social work providers. Each chapter includes case examples and practical tips that illustrate what it is like to work in this new frontier of MH care. We invited authors with expertise and passion for this type of work to contribute to this book, with the hope it will engage future practitioners in home care.

Overview of the Book

This book is divided into three main sections. Part 1 focuses on the foundational and practical aspects of home-based MH care. Later in this chapter, we review models of home care for older adults, and identify the many roles and skills the MH provider brings to the job. Chapter 2 further explores the home care MH provider’s role within the healthcare team. Chapter 3 describes the process of developing a therapeutic relationship when providing home-based MH care, with important ethical and cultural considerations in treatment. Part 2 focuses on the practical aspects of home care. Chapter 4 explores how working out of each patient’s home and using a mobile office differ from traditional clinic-based work. In Chapter 5, a psychologist shares her experiences of developing her own home-based MH private practice, an innovative model that could be replicated by other providers interested in this type of work. Safety issues in providing home care, including driving hazards, infection control, and home oxygen, are reviewed in Chapter 6, with recommendations on how to be prepared for unexpected situations. Hoarding is a common concern in home care, and a brief review of assessment and intervention strategies are found in Chapter 7. Unique considerations for social workers and psychiatry providers who provide home care are explored in chapters 8 and 9 respectively. Part 3 covers assessment and interventions in the home. Logistics of providing home-based psychodiagnostic and cognitive evaluations in the home are illustrated in Chapter 10. Many patients in home care require evaluations of decision-making capacity for issues related to health care, independent living, and financial management, as reviewed in Chapter 11. Chapter 12 gives consideration to evidence-based psychotherapy delivered in the home. Chapter 13 provides a guide to caregiver interventions that are critical in supporting the home care patient’s family and friends who serve in these stressful roles. Home care provides an important learning environment for MH trainees, and Chapter 14 describes the roles of the MH practitioner in educating both trainees and the team. Finally, Chapter 15 explores emerging areas in home care: suicide prevention, behavioral medicine interventions, telehealth, and end-of-life care.

Home-Delivered Healthcare in the Twenty-First Century

House calls, once commonplace, were on the decline for much of the twentieth century. Over the past several decades, home care for older adults has been making a comeback. Reasons for the revival of this model in the United States include increased demand for home-based service provision, health care reform, and the evidence demonstrating the benefits of home-based care (Schuchman, Fain, & Cornwell, 2018). Older adults are the most rapidly growing sector of the population as people are living longer and preferring to age-in-place. The subset of older adults served by home-based health care programs such as home-based primary care (HBPC) or home hospice are generally those whose complex health issues are not well-met by more traditional outpatient care. The incidence of chronic medical conditions increases with age and contributes to functional impairment that makes it difficult to access outpatient care. These health and functional challenges can increase the risk of psychiatric disorders such as depression and anxiety. Access to MH care treatment for older adults with complex medical conditions and functional limitations is limited (Borson et al., 2019). These access issues lead to missed appointments, fragmented care, and sub-optimally controlled medical conditions. Poor access to care leads to increased health care utilization (e.g., emergency room visits, extended hospital lengths of stay and nursing home placement etc.), which is costly. Integrated home-based care helps improve access to medical and MH care, reduce health care utilization, and delay nursing home placement (Schuchman, Fain, & Cornwell, 2018).

Models of Home Care

Home care models come in all shapes and sizes but can be categorized as government-funded (Medicare, Department of Veterans Affairs), hospital-based or academic-affiliated, and free-standing programs. HBPC provides patient-centered, comprehensive, longitudinal care in the homes of patients with complex medical, psychiatric, and functional-related conditions not managed effectively by routine outpatient care. All HBPC programs differ on the mission, payment structure, and role within the health system. In contrast to the services provided by visiting nurse agencies (which are typically short-term and problem-focused), HBPC teams aim to foster a long-term patient care relationship that incorporates end-stage disease care management, caregiver support, and emerging technologies like telehealth.

The Veterans Administration (later the Department of Veterans Affairs, or VA) developed one of the first HBPC services in 1972 to address the increasing population of Veterans with chronic complex illness and associated functional impairment (Beales & Edes, 2009; Karlin & Karel, 2014). Off-shoots of the VA model have been implemented by Medicare to address the needs of individuals recently discharged from a hospital admission to reduce the risk of readmission, and provision of care to individuals living in assisted-living facilities and group homes. Hospital-based programs have implemented HBPC programs targeting patients with the most complex and costliest conditions (Mount Sinai Visiting Doctors Program, or MSVDP; Reckrey et al., 2014). Many of these home-based programs started out with a focus on stabilizing chronic medical conditions. More recently, home care programs like VA HBPC and MSVDP have recognized the need for addressing the psychosocial needs of patients served by home care services, including Independence-at-Home (Center for Medicare Services’ HBPC demonstration program). As such, programs integrating mental and behavioral health services have been shown to be efficacious in improving access to medical and MH care, reducing health care utilization, and delaying nursing home placement.

Home-based care is a dynamic system of services, needs, and interprofessional work. Hospitals and medical systems, such as the VA, integrate MH practitioners (psychologists and psychiatrists) and social workers within home-visiting primary care and geriatric teams made up of physicians, registered nurses, nurse practitioners, physician assistants, dieticians, rehabilitation therapists, and pharmacists. MH home care may be provided within an interdisciplinary medical or primary care team. For other organizations or community agencies, care is provided as an adjunctive service, or even as a stand-alone service (Reifler & Bruce, 2014). Home-based MH work may also be the focus or part of a private practice. As this evolving model of integrated health care emerges, it may also be new and surprising for patients, families, and fellow health care providers. This may require enthusiastic and frequent education about home-based MH care to others outside (and sometimes inside!) the MH field.

Home hospice (or home-based palliative care – an emerging model) may be more familiar to patients and their families, and the composition and general day-to-day functioning of the team may be similar. In these programs, social workers, chaplains, or psychologists may provide both direct in-home MH care to patients (and their loved ones) at the very end of life and offer bereavement support to grieving families after the patient dies. Home hospice and palliative care teams may be augmented with other types of complementary care, such as art or music therapy.

Roles of the Home-Based MH Provider

Diagnostician

Being a front-line service provider in the home requires wearing many hats. A primary responsibility is to conduct a comprehensive MH assessment, determine a psychiatric diagnosis, and offer clinical recommendations. Home-based MH providers must effectively translate psychodiagnostic information and recommendations so that they are jargon-free and may be understood and effectively implemented by patients, families, and team members. For example, the MH provider may advise the team how to teach the patient medical information in a way that they can understand, utilize written materials or caregiver supports, or make slow, simple changes to dietary or exercise behaviors.

Psychotherapist

An MH provider will naturally be aware of potential points of intervention for a variety of MH disorders. The challenge for the home-based provider is to assess how to deliver effective, evidence-based interventions in the context of intersecting medical, functional, and social complexities often unique to a home-based setting.

Team Member

Whether or not they are formally a part of a team, the MH provider will often collaborate and work closely with nurses, nurse practitioners, rehabilitation therapists, dieticians, physicians, pharmacists, or other providers to deliver effective care. Thus, MH providers should be able to engage in effective team communication, problem evaluation, and collaborative solution-finding.

Caregiver Support and Family Therapist

Training in family systems and group therapies can be helpful, as the home-based MH provider often intervenes with families and caregivers, providing psychoeducation, coaching in behavior management for dementia, assisting with communication dynamics, and identifying goals of care.

Care Manager

Often another team member (such as a nurse) may act as the primary manager of the patient’s care, while the MH provider collaborates with the team around shared care management activities (appointment reminders, facilitating transportation, etc.). In some cases, in order for a community or legally based intervention to be successfully addressed, the MH provider may need to be the primary point of contact. For example, intensive care management may be required for someone presenting with severe self-neglect due to dementia (i.e. forgetting to eat, engaging in wandering, use of a stove or other burn/fire hazards) who is living alone without available caregivers. The MH provider may interface frequently with an adult protective services (APS) worker, or court-appointed guardian, to directly advocate for the patient’s needs and develop a collaborative care plan.

Risk Manager

Due to the intimate nat...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Notes on Contributors
• Foreword
• PART 1: What Is Home Care?
• PART 2: Practical Considerations
• PART 3: Assessment and Treatment Considerations
• Index