Mirnova Ceïde, MD

The role of psychiatry within medicine is ever changing. The high prevalence of mental health complaints in medical and primary care settings is now recognized: 20% of older adults have a mental health need, but only 3% of them will seek care from a mental health specialist.

 The majority of older adults will receive treatment for a mental health problem in a medical setting. Untreated mental illness is associated with treatment nonadherence; worse somatic morbidity; increased utilization costs, such as hospital readmissions; and increased mortality from illnesses (eg, heart disease).

Even more alarming is the fact that although adults 65 years and older make up 13% of the population, 15.6% of all suicide deaths are attributable to adults who are older than 65.

 Of those who committed suicide, 20% saw a primary care physician (PCP) the day they died; 40% saw a PCP the week before they died.

 As a result, hospital systems are integrating mental health services into medical settings such as primary care and oncology clinics. Positive findings associated with collaborative care studies, such as Improving Mood: Promoting Access to Collaborative Treatment (IMPACT),

 and a multicondition collaborative care intervention known as TEAMcare,

 highlight the need for incorporating mental health into the fabric of various medical settings.

The need to integrate psychiatric treatment with somatic care puts psychosomatic medicine in a unique position to focus on older patients who would not otherwise seek specialized treatment. To accomplish this, one model embeds or collocates the psychiatrist in medical settings. Using this collocation model, the Montefiore Medical Center has piloted a program to embed a psychiatrist in two different medical settings.

In 2004, the United Jewish Appeal Federation of New York funded an innovative program between Montefiore Home Care and the department of psychiatry at Montefiore Medical Center to treat homebound elderly persons who have depression by embedding a geriatric psychiatrist in the home care team.

New York Cornell Westchester provided training for home care nurses and clinical staff on recognizing symptoms of depression. Nursing staff were taught to complete the Patient Health Questionnaire (PHQ)-2 during their initial assessment of a homebound elderly person. If the score was 3 or higher or if they noted another mental health issue, the patient was referred to the social work department.

Social workers were also trained to complete the PHQ-9. Over time, the program expanded from depression screening to various mental health concerns. The social workers now complete a more thorough assessment and screen for depression, anxiety, psychosis, and substance abuse. A team consisting of a geriatric psychiatrist, social workers, and nurses meet weekly to discuss patients. Those who require further psychiatric evaluation are identified and the geriatric psychiatrist completes an in-home evaluation that is shared with the clinical team and PCP. Over the years, this program has been well received by patients and PCPs and has been sustained beyond the life of the original grant funding.

In July 2013, this collocation model evolved to incorporate a hospital-based component by embedding a geriatric psychiatrist in a medical hospitalist unit. The geriatric psychiatrist attends interdisciplinary rounds with the medical hospitalist team 3 days per week. All admitted patients are discussed, and patients with mental health needs are proactively identified and evaluated. Discharge planning is conducted in a collaborative setting with the psychiatrist, medical team, and inpatient social worker incorporating patient/family preferences via family meetings. The same psychiatrist is embedded in the home care agency 2 days per week.

The now dual-embedded model presents an opportunity for continuity of care for patients discharged to home care or home care patients admitted to the hospital. In addition, psychiatry residents rotate on both the inpatient medical unit and the home care visits, gaining exposure to an integrated psychiatry model. The dual-embedded psychiatry program offers an opportunity for comprehensive care planning between the psychiatrist and the medical team.

Mr A, an 80-year-old with Parkinson plus syndrome is admitted to a hospitalist unit after becoming aggressive with his home health aide. On discussion with the social workers during interdisciplinary rounds, the psychiatrist is informed that the home care agency is no longer willing to provide a home health aide because of Mr A’s aggressive behavior (they had been providing 12 hours of service daily).

After consultation and further discussion with the home care agency, it is learned that the patient has been agitated and had recently started exhibiting aggressive behavior. The agency had reached out to Mr A’s daughter, but she never returned their calls. The psychiatrist met with Mr A’s daughter and her husband. The daughter reported that her father had received a diagnosis of Parkinson plus syndrome about a year earlier. At that time, a combination of levodopa/carbidopa was started, and he was meant to have a follow-up visit with a neurologist a few months later. However, because of the daughter’s work schedule, she was unable to make a follow-up appointment. Mr A became more irritable as the year progressed, and his medication adherence was poor. He was described as being increasingly impatient and quick to anger; some of his actions were seen as threatening when, in fact, his behavior was due to frustration rather than aggression.

The daughter explains that because she could not take personal calls at work, she had asked that the agency call her husband. At this point, it is clear that there was miscommunication between the home care agency and the patient’s family. The psychiatrist recommends a meeting with the home care agency and the family.

During the hospitalization, Mr A has no incidents of aggression. A few days into the hospitalization, the medical team restarts levodopa/carbidopa. The next day, Mr A becomes irritable and aggressive with the nursing staff. The psychiatrist recommends consulting a neurologist to assess discontinuing levodopa/carbidopa, which is likely causing the agitation. The neurologist agrees, and it is tapered.

The psychiatrist, the social work team, and the patient’s family hold a conference call with the home care agency, which provides a forum for Mr A’s daughter and the agency staff to voice frustrations. The psychiatrist uses this opportunity to explain Mr A’s diagnosis to the home care agency. In addition, the psychiatrist is able to comment on the hospital course and medication changes, which is likely to improve behavior.

The daughter explains that her husband is available for emergencies and is willing to meet with the home health aides to guide them on the best ways to interact with Mr A. However, the home care agency expresses concerns regarding HIPAA. The social work team and the psychiatrist have Mr A complete a health care proxy in which he identifies his daughter and her husband as health care agents. Copies are given to the agency and the patient’s daughter. Subsequently, the long-term–care agency decides to resume services, and Mr A is discharged home with no further problems.

This case illustrates the ability of the psychiatrist to work in concert with the medical team as a liaison rather than simply as a consultant. In cases such as this, close follow-up with family and staff is integral to clarifying a patient’s mental status and behavior. The role of a dually embedded psychiatrist proactively addresses mental health or social stressors that worsen morbidity and increase duration of hospital stay and medical readmissions. Psychosomatic services such as these address the mental health needs of elderly persons by inserting a psychiatrist into non–mental health settings, such as hospitals and home care, rather than putting the onus on families and primary care providers to procure mental health specialty care.

Models such as the embedded psychiatrist program described above are difficult to sustain in a fee-for-service system. Montefiore Medical Center has been experienced in care management since 1996, and in 2013, it was chosen as a pioneer accountable care organization that allows for the development of mental health interventions. The results are real savings across the health care system.

With the implementation of the Patient Protection and Affordable Care Act (2010) and the subsequent expansion of the Mental Health Parity and Addiction Equity Act (2008), more Americans will have mental health and substance abuse coverage that should equal their medical coverage. As a result of these changes, integrated psychiatry programs have the opportunity to address the needs of elderly persons with mental health and medical needs by improving patient care through collaboration and decreasing health care costs.

Dr CeÃ¯de is Assistant Professor and Dr Kennedy is Professor in the department of psychiatry and behavioral sciences at the Montefiore Medical Center in New York. The authors report no conflicts of interest concerning the subject matter of this article.

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