Community Needs Assessment

Recommendation #2

Hospital leaders should review and evaluate the organization's behavioral health plan in light of identified community needs, the behavioral health needs of their patients, and available community resources.

Meeting the Mental Health Needs of the Elderly Homebound through a Geriatric Psychiatry Outreach Program
Wake Forest University Baptist Medical Center, Winston-Salem, NC

Summary
Many elderly patients have difficulty getting to a health care setting to receive treatment due to frailty, disability, physical illness, or psychiatric illness. To meet the needs of these patients, Wake Forest University Baptist Medical Center established an outreach program for the frail elderly who need psychiatric services in their homes.

Community and Hospital
Winston-Salem, county seat of Forsyth County, is the fourth-largest city in the state of North Carolina. It is part of the Piedmont Triad region, an area comprised of the twelve central North Carolina counties surrounding the cities of Greensboro, Winston-Salem, and High Point. Winston-Salem's estimated population is 213,889, with a median income of $41,202 per household. Approximately 18.6 percent of the population lives below Federal Poverty Levels.

Wake Forest University Baptist Medical Center is an integrated health care system that operates 1,238 acute care, rehabilitation, and long-term care beds, outpatient services, and community health and information centers. The Medical Center has 23 subsidiary or affiliate hospitals and provides a continuum of care that includes primary care centers, outpatient rehabilitation, dialysis centers, and home health care. Its primary service area is a 26-county region in northwestern North Carolina and southwestern Virginia.

Program Overview
Behavioral health leaders at Wake Forest University Baptist Medical Center (WFUBMC) are keenly aware of the needs of the elderly homebound population in their communities. North Carolina ranks tenth among states in the number of persons age 65 and older. In a recent U. S. Census Bureau report, North Carolina ranked fourth in the increase of the number of persons age 65 and older between April 2000 and July 2003. The rapidly growing number of seniors brings with it increased utilization of physical health resources as well as the need to address the cognitive and behavioral disorders associated with aging.

Many elderly patients, especially those who are over 80 years of age, have difficulty getting to a health care setting to receive treatment due to frailty, disability, physical illness, or psychiatric illness. They often live in isolation, without access to services that could improve the quality of their lives. To address this need, WFUBMC began an outreach program for elderly homebound patients who need psychiatric services. Housed in the Department of Psychiatry and Behavioral Medicine, the Kate Mills Snider Geriatric Psychiatry Outreach Program (GO) was established in 2005 through an endowment. The goal was to create a model of patient-centered mental health care for the frail elderly in their homes. The design of the program was modeled in part after successful programs in Europe and Canada.

The GO team partners with other community organizations working with the elderly, including the local Alzheimer's Association, Meals on Wheels, Department of Social Services Adult Protective Services Division, Area Agency on Aging, home health agencies, adult day care organizations, and others. They have trained the staff of these organizations to be knowledgeable of the GO program and to identify those who may need this type of service as they interact with a wide variety of clients. Referrals to GO may also come from primary care physicians, hospital medical staff, the geriatric clinic, or the hospital's psychiatric consultation service.

The GO program staff consist of a social worker/case manager, nurse practitioner, and psychiatrist. They also draw from the program for clinicians in training at WFUBMC's  J. Paul Sticht Center on Aging and Rehabilitation for additional clinical support. When a referral comes to the GO team, medical records are reviewed and an interview is scheduled in the home with the nurse practitioner. A packet of resources is prepared for the caregiver. Within the next couple of weeks, a visit is made by the psychiatrist. Patients are monitored closely throughout the medication adjustment process. Once patients are considered stable on their medication, follow-up is conducted as needed until they move to another setting or pass away. Because these patients are isolated and may not be of aware of available resources, the GO team helps the patient and family or caregiver build a network of support by linking them to other services as appropriate.

The goal of the GO program is to allow the elderly to stay in their homes as long as possible, able to live independently. Services are not available to individuals in assisted living settings or nursing homes. There are usually around 35 patients, with a total of approximately 150 patients over the life of the program. The demographic characteristics of GO patients mirror that of the county, demonstrating that GO addresses the needs of all population segments. Because of the financial support of the endowment, staff are able to spend quality time with the family, conducting follow-up after visits and building support around the patient and family.

Program Impact
The GO program extends the reach of the hospital in a way that otherwise would not be possible. Program staff serve as a resource for physicians who treat geriatric patients but who do not have a significant level of training in treating dementia or other behavioral health illnesses. Even when a patient is not a candidate for the GO program, staff can provide information on other resources available in the community.

The positive impact on patient, families, and caregivers is unmeasurable. Providing services to homebound patients may prevent hospitalization or premature placement in a nursing home. For caregivers, having access to someone who understands what they are going through and who is knowledgeable of available resources provides a sense of security and relief.

Program Funding
Primary funding for the program is through an endowment established by Arnold H. Snider of Princeton, NJ, in appreciation for the home care that was extended to his mother by WFUBMC staff. The endowment for the GO program covers program expenses, including administrative costs, travel, and follow-up time; however, visits to Medicare patients have to be billed through Medicare. If a patient cannot afford the co-pay, it is supplied from other funds. For patients in Medicare HMOs, GO has a contract for each patient.

WFUBMC provides billing services and basic information technology support. The GO team has collaborated with other departments, drawing on the expertise of the hospital public relations office for assistance with promotional activities, the development office for the annual stewardship report, and the public health sciences division in designing and conducting research.

The endowment is viewed as adequate to sustain the program over time. At this point, program leaders are not looking at other means of support.

Obstacles or Challenges

• Expectations. Because the GO program is so accessible, families can sometimes have higher expectations for treatment outcomes. It is important to establish realistic expectations up front and to ensure that families/caregivers understand that there is more to treating geriatric psychiatric issues than prescribing medication. Other factors, such as family dynamics and the effects of delayed treatment, can also have an impact on outcomes.
• Overcoming the stigma associated with mental illness. The stigma often prevents families from seeking help for treatable conditions. Sometimes, families keep these conditions hidden, with the result that problems simply compound themselves over time. 
• Introducing a new program into a tightly knit senior services community. In order to build trust, the GO staff continually made themselves available and visible in the community. Being under the umbrella of the hospital was a significant advantage in terms of community stability and longevity.

Success Factors

• The availability of GO staff to see patients, train clinicians, and give presentations. Staff are active in the senior community and frequently attend events targeted to seniors so that they can interact with seniors and other organizations and share information about the GO program.
• Promoting the program internally as well as externally. When the program was launched, GO staff provided lunches for all the physicians within the psychiatry department to explain the purpose of the program, how it works, and how to make referrals.
• Exercising patience with regard to the community's willingness to refer. It takes diligence, communication, and availability to establish yourself as a community resource.
• High quality staff. The GO program leadership have significant experience in the field and a high level of respect in the community. They work well together around a common goal. 

Lessons Learned and Advice to Others
For others interested in this type of initiative, the Wake Forest Baptist Medical Center experience provides some helpful advice:

• Learn the rules first. GO program developers originally envisioned that services would be provided free of charge, but Medicare rules prevented that.
• Learn what your community needs. Meet all the people serving your population and listen to what they tell you.
• Coordinate your services with other organizations and be open to new referral sources.
• Articulate your service clearly so that you don't create unfulfilled expectations. The GO team found that patients and families were sometimes confused between GO services and those of home health agencies.

Contact
Melissa Smith
Program Coordinator
Kate Mills Snider Geriatric Psychiatry Outreach
(GO) Program
Wake Forest University Baptist Medical Center
melsmith@wfubmc.edu
336-716-0690