A Rural Solution to the Geriatric Mental Health Crisis

00;00;00;08 - 00;00;18;01
Tom Haederle
Welcome to Advancing Health. Today we learn about geriatric psychiatric programs offered by two rural New England hospitals, and how both organizations are leaning in to meet the mental health needs of older adults in their communities.

00;00;18;04 - 00;00;43;10
Rebecca Chickey
My name is Rebecca, and I'm the vice president of the Health and Trustee services for the American Hospital Association. And it's my honor today to be joined by three leaders at rural hospitals who are improving access to mental health services in their rural communities. I am joined by Holly McCormack, who is president and chief executive officer of Cottage Hospital.

00;00;43;13 - 00;01;24;09
Rebecca Chickey
I'm also joined by Doctor who is a consultant psychiatrist and medical director at senior Behavioral Health unit at Sharon Hospital, which is part of Northwell Health, and as well the CEO and president of Sharon Hospital, part of Northwell Health. Christina McCullough rounds out this wonderful panel discussion today. So I'm going to jump right in. And Holly, I'm going to start with you, if I may share with the listeners a little bit about Cottage Hospital and why you decided to open your unit for older adult behavioral health care called the Ray of Hope.

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Holly McCormack, DNP, RN
Sure. Happy to. So Cottage Hospital is an independent critical access hospital located in Woodsville, New Hampshire. We were founded in 1903, and at the time, the community built this hospital to respond to a lot of surgical type needs that were happening, from injuries related to working in logging and other industry in the area. And so we have been here supporting our community for over 123 years now.

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Holly McCormack, DNP, RN
We are a 35 bed critical access hospital, and that's because we have our 25 bed hospital with our med surge unit and our ICU beds, but we also have a ten bed distinct part unit that is focused on geriatric behavioral health. And so we call that unit the Ray of Hope unit. We also have multi-specialty rural health clinic across the street from a hospital campus which has internal medicine, podiatry, endocrinology and behavioral health integrated into the care there as well.

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Holly McCormack, DNP, RN
So the Ray of Hope unit was opened in 2016 as a response to the behavioral health crisis that was happening in New Hampshire. We found that a lot of hospitals were boarding behavioral health patients in the emergency department, and we decided to do something to become part of the solution. The demographic of Woodsville, New Hampshire, tends to be older, and we have a lot of older adults in our community and in communities that we serve.

00;02;44;17 - 00;03;05;10
Holly McCormack, DNP, RN
So this made a lot of sense for us. So early in 2016, we had a unit that we were using for physical therapy. We moved them to a different part of the building, and we were able to redesign this unit to safely house acute beds for ten Jerry psych patients. And so on October 1st of 2016, the unit opened.

00;03;05;16 - 00;03;15;16
Rebecca Chickey
What is the unit look like for the listeners? If you can paint a picture of what it looks like and also how it's staffed, because with only ten beds, I know that can be a challenge.

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Holly McCormack, DNP, RN
Yeah. So the unit has ten private bedrooms. The unit is painted in calming colors that you would see in nature. So sage green, a lovely cream yellow color that we find to be very soothing. The artwork on the walls is inspired from local landmarks, but also things that might inspire. Reminiscing when patients are to tour the unit. One of the pictures is very popular is we have a photo of older trucks that look like they're rusting in a field, but you wouldn't believe how many patients actually gather on the picture and talk about having had a truck like that in their younger years, or knowing what kind of truck that was, or knowing somebody that

00;03;53;28 - 00;04;16;01
Holly McCormack, DNP, RN
had that truck. So it's very interesting. We have an activities room. We have a quiet room so that we can separate patients if they need a space that's quieter while we're doing group therapies. And then we also have an outside area with a patio where patients can go and be in a covered space outdoors. And we have raised garden beds so that they can work in the garden beds.

00;04;16;01 - 00;04;51;11
Holly McCormack, DNP, RN
Or sometimes we'll just do our morning activities and our morning stretch out there. The unit is staffed with registered nurses, lens nursing assistants. We have a recreational therapist, a licensed clinical social worker, and we have a psychiatrist that is affiliated with the local academic medical center that oversees the aprons, who are on site seven days a week, and that relationship with the local academic medical center, providing the expertise has been a way for us to have this specialized care locally, where we don't have to transfer people to a higher level of care.

00;04;51;13 - 00;05;14;24
Rebecca Chickey
I think that is great. I grew up in rural Alabama, and so I know how important it is for individuals to be able to stay close to their community, to stay close to their homes. And that provides a healing element that I think is hard to measure. But when you talk to the patients, equally important. And so that's my next question to you.

00;05;15;00 - 00;05;26;00
Rebecca Chickey
What type of patients do you treat in terms of diagnoses, and what impact have you seen? What's been the response from the community and from the families that you've helped as well of those you treat?

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Holly McCormack, DNP, RN
The patients and families that we treat are very thankful to be able to have a place in the state of New Hampshire where we can care and provide the specialty care for them. But we've not only cared for patients in the state of New Hampshire, we provide care to patients in the state of Vermont and also Maine and Massachusetts as well.

00;05;42;10 - 00;06;10;21
Holly McCormack, DNP, RN
These specialty units are very hard to come by, and typically we'll have a waiting list for patients to get into the beds on our unit. In the state of New Hampshire, there are 221 towns, and we have represented patients from 110 of those towns so far. And we typically see diagnosis such as depression, bipolar or dementia schizophrenia. But the providers on the unit describe Jerry psych as complex and involving overlaps of psychiatry and neurology, internal medicine and palliative care.

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Holly McCormack, DNP, RN
Those are the types of things when you see patients in this particular age group.

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Rebecca Chickey
It's interesting. There's been a lot of discussion over the last couple of decades around med psych units. And I think that geriatric psychiatric units by default are medical psychiatry units, because by the time you're over 65, more than likely you have more than one comorbid physical condition, much less a mental illness or addiction. So such an important aspect of care to bring to a critical access hospital, to any rural hospital itself.

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Rebecca Chickey
So thank you so, so much. It is my honor now to transition to Sharon Hospital. So doctor, tell us a little about Sharon Hospital and why the organization decided to open your senior behavioral health unit.

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Sabooh Mubbashar, M.D.
It was established more than 20 years ago, and this was in response to a growing recognition that the rural communities, they really lacked adequate resources for older adults suffering from severe psychiatric and neurobehavioral illnesses. And as Holly mentioned, this is truly an area of great need. Just given the statistics of geriatric psychiatric problems that we are dealing with, which are actually expected to double in the coming decade.

00;07;30;08 - 00;07;59;24
Sabooh Mubbashar, M.D.
I personally have been involved in this role as the medical director with a unit for about 18 years. Probably also goes to show how much I believe in the work that we're doing. Despite the hospital and the unit being located in a rural community. You know, we started out with an 11 bed geriatric unit, and the demand increased so significantly that we then expanded into a 17 bed inpatient unit, as Holly was mentioning.

00;07;59;26 - 00;08;30;17
Sabooh Mubbashar, M.D.
We received referrals from much larger metropolitan areas, including New Haven, Hartford, Albany, upstate New York areas, Massachusetts. And I think some of that all to do with the unique location of Sharon Hospital, because we're at the northwest border of Connecticut. So we are right at the at the border of New York and Massachusetts. But also it has a lot to do with the with the very unique patient population that we serve.

00;08;30;22 - 00;08;38;16
Sabooh Mubbashar, M.D.
Expansion is really part of, as I said, much larger national reality with the patient population that we serve.

00;08;38;22 - 00;09;01;23
Rebecca Chickey
Well, the baby boomers are aging. And I think I heard a statistic about something like 10,000 people turned 65 every day. So if one out of every four of those has a psychiatric or substance use disorder in the year, then the math is clear that the demand is going to increase. Holly shared what her unit looks like physically and how it's staffed.

00;09;01;24 - 00;09;06;01
Rebecca Chickey
Can you share some similar perspectives for the listeners?

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Sabooh Mubbashar, M.D.
Absolutely. So, you know, I think that given the uniqueness of this population, as Holly was describing it, I could hear a lot of overlapping themes. So what makes geriatric psychiatry unique is that, you know, their symptoms in psychiatry are rarely isolated from the rest of medicine. These are patients with significant medical frailties, mobility limitations, swallowing difficulties, chronic medical illnesses.

00;09;35;04 - 00;10;13;08
Sabooh Mubbashar, M.D.
So as far as the multidisciplinary care model is concerned, all patients getting admitted to our 17 bed unit get evaluated by a psychiatrist and an internist within 24 hours of admission, or multidisciplinary team has physical therapy, occupational therapy, speech therapy, and these evaluations are all completed within 24 to 48 hours of admission. Because these are again frail patients from nursing homes, sometimes from community, high aspiration risks functional decline around their mobility.

00;10;13;09 - 00;10;51;23
Sabooh Mubbashar, M.D.
So we really like to get a sense from the get go about what we're working with from the moment they come in. A staffing includes registered nurses, licensed practical nurses, mental health workers, full time social workers, activity therapists and we also actually incorporate massage therapy several days per week. And we also have pet therapy several times a month as part of our therapeutic environment, because we find that both these modalities actually go a really, really long way in helping some of these patients.

00;10;51;23 - 00;11;16;14
Sabooh Mubbashar, M.D.
So the structure of the unit is that we have five private rooms, we have six semi-private rooms, we have two large day rooms and two small TV rooms. We also have a quiet room, as Holly mentioned, which is to, you know, separate if a patient is looking for a relatively low stimulation environment. So we can utilize that from time to time as well.

00;11;16;16 - 00;11;39;17
Rebecca Chickey
Both of those units sound so phenomenal, both in their structure, their staffing, and the incredibly integrated way in which you treat the whole person, not just their mental illness or addiction, but all of their health and getting upstream about it when they're first admitted so that you're not dealing with complications later on. Thank you so much for that.

00;11;39;18 - 00;12;03;06
Rebecca Chickey
I'm going to turn now to Christina, president of Sharon Hospital. And Christina, the two programs that have been described here are really for older adults in need of acute inpatient psychiatric care. But Sharon has begun to go upstream to provide prevention services. Can you share a bit about the senior meals program for adults aged 65 and older?

00;12;03;08 - 00;12;40;02
Christina McCulloch, RN
Yes. Thank you Rebecca. So our senior meals program has really been an honor to stand up here at Sharon Hospital. Our journey really started over a year ago and looking at our community through our community health needs assessment, through assessing our service area that we serve. And there were a few themes that were identified through that assessment. The first is really emphasizing that we are serving an aging population, and we really needed to implement new measures and initiatives to really support the full well-being of the seniors in our community.

00;12;40;07 - 00;13;17;18
Christina McCulloch, RN
28% of Sharon Hospital's service area is age 65 or greater, compared to the average 19% nationally, the significantly higher. And when we look at our future predictions, we know that that population is only going to grow as both Holly and doctor had mentioned. Also, through our assessment, we identified two other opportunities, one being food security, especially in a rural setting where transportation isn't as easily accessible as some other communities in the in the last being mental health.

00;13;17;19 - 00;13;46;25
Christina McCulloch, RN
And so when we looked at these opportunities, we saw a program at one of our sister hospitals that they called the Senior Supper Program, and we set forth to implement that program on a small scale. Here in Sharon, we call it the Senior Meals Program. We started with providing meals at lunchtime at a discounted rate. So we were able to provide affordable, healthy meals to seniors in our community here at the hospital.

00;13;47;02 - 00;14;12;28
Christina McCulloch, RN
We saw that there was great interest in the program. There was a lot of demand. So over the year we grew. We added days that the service was available. We added educational seminars, we invited clinicians, we hosted dinners, and the program really has grown into what it is today, which we call the C program. It's a senior education and engagement program.

00;14;13;04 - 00;14;38;18
Christina McCulloch, RN
We're looking to further expand this program so that we can have these offerings outside of the hospital, out in the community. We've already hosted a couple of events at different settings in different towns in our community, where seniors can go out to a venue, have a nice meal, listen, connect with one of our clinicians on a topic related to aging.

00;14;38;21 - 00;14;59;08
Christina McCulloch, RN
We've done seminars on heart healthy fall prevention, and so our goal over the next year is really to continue to expand. In addition to having affordable, accessible meals, this is really helping to combat that social isolation that so many of our seniors are facing in our community.

00;14;59;09 - 00;15;35;20
Rebecca Chickey
So it sounds to me that you're addressing the loneliness epidemic that you are addressing food insecurity that you're able to perhaps prevent, as you indicated, the social isolation, which can often trigger depression, and really getting into the prevention mode so that perhaps you won't have to expand the unit again by more beds. I'd like to ask each of you to maybe give a sentence or two of what call to action would you share with the listeners?

00;15;35;21 - 00;15;37;11
Rebecca Chickey
Holly, I'll start with you.

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Holly McCormack, DNP, RN
Well, I think what we've already discussed regarding the aging of our country and how important it is that we provide services for patients that need our help, especially the geriatric community. But it's not only the patients, it's the families. What we see with the caregivers often is there's a high degree of burnout trying to care for their loved one, trying to find the services they need for their loved one for many, many years now.

00;16;00;26 - 00;16;18;23
Holly McCormack, DNP, RN
And they are feeling guilty about not being able to provide that support. And so that's something that we need to consider. And it's also important for us when our patients come to us, they're frightened. They're often grieving. They're confused. Sometimes there's a loss of independence. And so we need to help them cope with that. And we need to help families cope with that.

00;16;18;24 - 00;16;40;13
Holly McCormack, DNP, RN
The last thing I'd like to leave with all of you about the Ray of hope is we say that we measure success differently at the ray of hope, and this came directly from my nurse practitioner that works on the unit. She likes to say we help people sleep through the night. We reduce fear, we reduce stress, we avoid restraints, and we return them safely to their community or to long term care environment.

00;16;40;13 - 00;16;46;20
Holly McCormack, DNP, RN
And we provide families with hope and guidance so that we can help them get through a very overwhelming time period.

00;16;46;22 - 00;17;06;00
Rebecca Chickey
I mean, if each and every one of us could go home every day saying that that's what we did with our time, what a beautiful place this would be. So thank you for that very much, doctor. I'll turn to you. How would you inspire others to go on this journey, since you've been doing it for 18 of the 20 years that the unit has been open?

00;17;06;02 - 00;17;47;25
Sabooh Mubbashar, M.D.
Yeah, I really believe that when it comes to serving this patient population, rural hospitals can make a profound difference when it comes to treating older adults with dignity, humanity and clinical sophistication. With the right model development that I'm very proud that we have been able to emulate at senior behavioral health, multidisciplinary infrastructure and a long term institutional commitment, rural programs can actually develop a highly specialized, niche serving population at times that larger tertiary care hospitals come to rely upon.

00;17;47;25 - 00;18;12;06
Sabooh Mubbashar, M.D.
So this only is not only is an area of great need, this can actually be a lifeline on many levels for rural hospitals. And I think I strongly feel that this is how it should be looked at as not only a clinical need, but something that actually would probably help the bottom line of most rural and small hospitals that are struggling.

00;18;12;10 - 00;18;40;19
Sabooh Mubbashar, M.D.
I'm very aware of the almost crisis like shortage of specialists, especially psychiatrist. Not well. Health now also has a residency program and we actually have residents rotate for about three months. And I can tell you as a as a teacher and mentor that they will routinely say that out of all of their rotations, working with geriatric patients is actually some of the most satisfying work that they do.

00;18;40;19 - 00;18;46;02
Sabooh Mubbashar, M.D.
So there is plenty of hope for us to be able to deal with this shortage of psychiatrists as well.

00;18;46;05 - 00;18;59;04
Rebecca Chickey
We need to get that message to every medical school across the country. So, Christina, I'd like you to bring us home. What are you going to leave the listeners with in terms of inspiring them to go on this journey with you?

00;18;59;04 - 00;19;31;04
Christina McCulloch, RN
So my call to action is for more advocacy. We need advocates not only for seniors and their families, but we need advocates for our hospitals, our communities. We need funding. We need resources in order to provide these services that have such a great impact on this population. And so advocacy is critical. And so my call to action is advocate for your community, advocate for your hospital, both at a local, state and federal level.

00;19;31;05 - 00;19;42;13
Christina McCulloch, RN
Because in order for us to provide these this comprehensive care to support the full well-being of our seniors, what we all do is crucial.

00;19;42;16 - 00;20;07;07
Rebecca Chickey
That's phenomenal. So, Holly, Christina, doctor, thank you so much for being willing to share your time and expertise with the listeners to inspire them to consider the fact that their rural hospital can become a center of excellence for the treatment of older adults with mental illness and or addiction. Thank you so much for what you do each and every day.

00;20;07;09 - 00;20;16;01
Tom Haederle
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