Family and Community Collaborative Care for Older

Adults and Their Family CaregiversS

Barry J. Jacobs, Psy.D.John Rolland, MD

Lauren DeCaporale,-Ryan, PhDJanelle Jensen, MS, LMFTA

Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.

Session # E2aFriday, October 16, 2015

Faculty Disclosure

The presenters of this session• currently have the following relevant

financial relationships (in any amount) during the past 12 months:

• 20% of Barry Jacobs’ salary is covered by a proof-of-concept grant from Independence Blue Cross of Philadelphia for his work with the Crozer-IBC Medicare Advantage Super-Utilizer Program

Learning Objectives

At the conclusion of this session, the participant will be able to:

--Identify the clinical challenges and competencies of working with a burgeoning geriatric population--Describe the Family Systems-Illness Model and its application to integrated care for older adults--Outline key concepts in providing psychotherapy for older adults’ family caregivers--Describe population health approaches to caring for older adults, including a primary care-based transitions model and a super-utilizer program for frail elderly patients

Bibliography / References

--Burke, R.E., & Coleman, E.A. (2013). Interventions to decrease hospital readmissions: keys for cost-effectiveness. JAMA; 173(8): 695-8.

--”Caregiving in the US 2015,” a National Alliance for Caregiving/AARP report available at http://www.caregiving.org/caregiving2015/

--Coburn, K. et al. (2012). Effects of a community-based nursing intervention on chronically ill older adults: a randomized control trial. PLoS Medicine , 9(7)

--Jacobs, BJ (2006). The emotional survival guide for caregivers—looking after yourself and your family while helping an aging parent. New York: Guilford Press.

--Ottenbacher KJ, Karmarkar A, Graham JE, et al. (2014). Thirty-Day Hospital Readmission Following Discharge From PostacuteRehabilitation in Fee-for-Service Medicare Patients. JAMA.;311(6):604-614. doi:10.1001/jama.2014.8.

--Rolland, J.S. (2016). Mastering family challenges with illness & disability: An integrative practice model. New York: Guilford.

--”Working with the Super-Utilizer Population: The Experience and Recommendations of Five Pennsylvania Programs,” 2015, available at http://www.aligning4healthpa.org/pdf/High_Utilizer_Report.pdf

Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.

Implications of an Aging Population

• Higher prevalence of chronic illnesses and functional limitations

• Greater demand for family caregiving and healthcare/social services (high-tech; hands-on)

• Higher societal costs• Clinical workforce not

prepared for geriatrics

Core Clinical Competencies

• Knowledge: normal developmental changes of aging; background on specific diseases (e.g., diabetes, heart disease, dementia); common psychological issues (e.g., meaning-making, increased dependence), dynamics of late-life families; community/residential services

• Skills: biopsychosocial approach; cognitive assessment; running family meetings

• Attitudes: curiosity, respect, enjoyment

Families, Caregivers, & Later Life :An Integrative Model

John S. Rolland, M.D., MPHNorthwestern University Feinberg School of Medicine

john.rolland@northwestern.edu

Chicago Center for Family Healthwww.ccfhchicago.org

Need for Family Psychosocial Map

• Family functioning:

Beliefs, organization, communication

• Psychosocial understanding of illness

• Understanding developmental processes

Multigenerational Developmental Perspective

• Individual and family development • multigenerational experiences with illness &

loss, including stories of resilience

• Current timing

• Impact on future individual and family life cycle planning

Family Health & Illness Belief Systems

Challenge:

Family create meaning for illness experience that promotes mastery &

wellbeing

Key Family Health Beliefs

• Normative Illness Experience

• Communication

• Mastery, Control, Acceptance

• Cause of Illness

• Course & Outcome

• Ethnic & Cultural Beliefs

• Gender

• Spirituality

• Integrative Healing Practices

• Fit with Health Care Providers

Psychotherapy for Family Caregivers

Janelle Jensen, MS, LMFTANorthwest Family Therapy

Alzheimer’s Association, Care ConsultantSeattle, WA

Who is Caregiving?NAC/AARP Caregiving in the US 2015 Report

• In the last year, 34.2 million Americans have provided unpaid care to an adult age 50 or older

• Majority of caregivers are female• Average age: 49• 49% of those caring for a family member care for a

parent/parent-in-law• 22% of caregivers report decline in overall health• 1/3 of caregivers say a health care provider has asked about

what was needed to care for their recipient. Half as many caregivers say a health care provider has asked what they need to take care of themselves

We are conditioned to not discuss aging/death

• We = All of us - Families and Professionals• Stigma• Do not plan accordingly – we become reactive vs proactive,

more costly physically, mentally, and financially• Difficult to accept changes – creates anxiety• Do not identify as family caregivers – do not seek available

supports• Added stress and burden on relationships• Becomes unacceptable to engage in grief/loss• Miss out on opportunities to more fully support our

clients/patients

Psychotherapy with Family Caregivers: The Caregiver

• Does not identify as a caregiver – reluctant to enter therapy

• Balancing multiple roles: – Daughter/son– Parent– Partner/spouse– Professional– Decision maker/Power of Attorney– Chauffer – doctor visits, groceries, pharmacy– Cook – family meals on wheels provider– Activity Director – keeping loved one active, engaged in social events– Expert – all knowing of medical conditions, dx, meds– Executive assistant – scheduling appts, organizing community services, managing

housing situation, coordinating Medicare and Medicaid applications and services

Psychotherapy with Family Caregivers: The Caregiver

• Anxiety and Depression• Burn out• Frustration• Health concerns• Relationship dissatisfaction• Couple/partner difficulties• Grief/loss• Leave of Absence/job disruptions/financial

strain

Psychotherapy with Family Caregivers: 2 Intervention Models

• New York University Caregiver Intervention (NYUCI)– 2 individual counseling

sessions– 4 family counseling sessions– Encouragement to participate

in weekly support groups– Follow up counseling as

needed for crisis, change in status, progressive nature of conditions

• Resources for Enhancing Alzheimer’s Caregiver Health II Intervention (REACH II)– Multi-component,

psychosocial/behavioral training intervention

– Reduce burden and depression/ Improve self-care

– Education, bx management skills, reframe negative emotional responses, strategies for managing stress

– Role-playing, skills training, telephone support groups

Psychotherapy with Family Caregivers: The Therapist

• Roles: – Emotional support– Educate– Advocate– Consult– Refer

• Breathing/Mindfulness/Self-compassion• Acceptance and Validation of experience• Boundaries• Collaborate with other health professionals• Support groups/online caregiver support • Identifying family health and caregiving hx – rules and values

Primary Care Team-Based Care Transitions Program

Lauren DeCaporale-Ryan, PhD

Departments of Psychiatry, Medicine & Surgery

(Ottenbacher et al., 2014)

State-Specific Hospital Readmission Rates

Discharge Pilot to Reduce Readmission

Acknowledgements: Nabila Ahmed-Sarwar, PharmD, BCPS, CDE, Katie Lashway, RN, BSN, Magdalene Lim, PsyD, Karen Mahler, RN, BS, Robbyn Upham, MD, MSEd

Phone engagement by Care Manager

Discharge Clinic visit – introduced to team by MA/Primary Care Provider

Assessment by Behavioral Health Provider – cognition & mental health

Medication Management by Pharmacist

Summary of needs by team

PainMood

Medica

tion Reconcill

iation

Genera

l Hea

lth

2 or more

0

1

2

3

4

5

6

7

Patient Identified Concern

N

Psych Dx In Care Referral0

2

4

6

8

10

12

14

16

18

Behavioral Health Need

N

Discharge Pilot Findings

Readmission Type

AvoidableUnavoidableNone

System Outcomes

• Challenges: – Expense/sustainability of the model – Location: where do we fit a team of this size– Documentation: one encounter or two? – Billing

• Successes: – Good clinical outcomes– Behavioral health critical to the process– Plan to implement this weekly (hopefully soon!)– Recognition that on the inpatient side, we are not

adequately addressing psychosocial patient concerns

A Frail Elderly Super-Utilizer Program

Barry J. Jacobs, Psy.D.Crozer-Keystone Family Medicine

Residency ProgramSpringfield, PA

Frail Elderly Super-Utilizer Program

• In spring of 2013, the SU team at the Crozer-Keystone Family Medicine Residency Program was approached by a physician executive at Independence Blue Cross, the largest Philadelphia area insurer, to create a proof of concept SU intensive care coordination program for 10 IBC Medicare Advantage patients with PCPs in the Crozer Keystone Health System

• Launched January 2014; renewed for 2nd year

• As of 8/15, team saw 20 patients; avg age=80

• Dxs: CHF, COPD, DM, dementia

• 50% decrease in inpt admissions, 80% decrease in OBS

Crozer-IBC Model

• Based on work of Drs. Ken Coburn (“warm spotting”; nurse as point person), Dave Moen (home visit), and Dan Hoefer (palliative care)

• Hired nurse case manager as point person—weekly home visits, medical accompaniment, family meetings

• Interprofessional team of advisors/interveners—family medicine, psychology, social work, pharmacy, volunteer

• Weekly huddles; EMR

Carmella, IBC PT• 89 year old widow who

lives in a multi-generational rowhome.

• Co-morbidities include: DM, CHF, HTN, CAD, Obesity, Peripheral Neuropathy & edema

• 5 inpt/OBS/ER admits in 6 months prior to enrollment

• Last 18 months in program—1 inpt admit

Interventions

• Weekly RN visits (and frequent phone calls with family members)

• Weekly Psy.D. student behavioral health visits• Coordination of home PCP visit (through residency

program) and home lab draw• Home medication reconciliation• RN accompaniment to medical visits• Team worked toward decreased family caregiver

burden/increased family organization

Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!