integrated mental health assessment in ... - john simon -...

Integrated Mental Health Assessment in Home Based Primary Care

Program/Project Title: Home Based Primary Care

November 10, 2014

Integrated Mental Health Assessment in Home Based Primary Care Introduction

IntroductionIntroduction

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Purpose

This course focuses on processes for integrated behavioral and mental health assessment in Home-Based Primary Care (HBPC). The Mental Health (MH) Provider in HBPC serves both as an integrated MH provider on a primary care team, AND as a specialty MH provider who follows select patients for specialized mental health assessment and/or intervention services. The HBPC MH Provider collaborates closely with the team to manage the behavioral and mental health of the entire population of Veterans enrolled in HBPC. This approach entails collaborative screening activities, specialized mental health evaluation in select cases, and integrated interdisciplinary treatment planning.

Target Audience

The target audience for this course is MH Providers for HBPC, such as psychologists and psychiatrists. HBPC Program Directors and Medical Directors may also find this course to be helpful.

Course Outcome

Completion of this course will enhance your knowledge of the processes for integrated behavioral and mental health assessment in HBPC, thereby improving the quality of interdisciplinary, patient-centered, and collaborative care for all Veterans enrolled in HBPC.

Completion Time

This course will take you approximately two hours to complete.

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InstructionsSelect Next to continue.

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Integrated Mental Health Assessment in Home Based Primary Care Introduction

Course Structure and Terminal Learning ObjectivesScreen ID 00_002.htm Screen Type Main Page 2 of 120

The course is divided into five lessons with a separate terminal learning objective (TLO) for each lesson:

1. Integrated, Stepped Model of Care for Mental Health Assessment in HBPCTLO: Explain the integrated, stepped care model for mental health services in HBPC and its application to mental health screening and assessment in HBPC interdisciplinary care.

2. Framework for Mental Health Evaluation in HBPCTLO: Explain the framework for organizing one’s approach to mental health evaluation in HBPC.

3. Contextual Considerations for Mental Health Evaluation in HBPCTLO: Describe how to adapt the mental health evaluation to address the contextual challenges and advantages of the home setting.

4. Mental Health Assessment Tools and ResourcesTLO: Identify standardized assessment tools that are applicable for HBPC mental health evaluations, and their sources.

5. Assessment Outcomes: Feedback and Interdisciplinary Care PlanningTLO: Identify effective strategies for providing assessment feedback to Veterans, Caregivers, and HBPC teams.

The course ends with a summary of what you set out to achieve and how you should have achieved it. This is followed by a final assessment that covers material from each lesson and which you are required to pass with a score of 80 percent or higher in order to complete the course. Throughout the course, you will have an opportunity to test your understanding of the material through knowledge checks. These knowledge checks are not scored but they do provide you with feedback and remediation links that allow you to review the content pertinent to the question.

We hope you will enjoy the course and benefit from the material presented. Select Next when you are ready to begin with the first lesson, Integrated, Stepped Model of Care for Mental Health Assessment in HBPC.

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Integrated Mental Health Assessment in Home Based Primary Care Integrated, Stepped Model of Care for Mental Health Assessment in HBPC

Integrated, Stepped Model of Care for Mental Health Assessment in HBPCLesson Introduction


This lesson begins with an overview of the integrated, stepped care model for mental health care in Home Based Primary Care (HBPC). The lesson will examine steps in mental health assessment and treatment and application of the stepped care approach, illustrated through the case of a Veteran followed by the HBPC team.

Shortly, you will meet “Mr. Apple”, a Veteran whose care will be discussed during this lesson and those that follow, in order to illustrate how the stepped care model applies to mental health screening and assessment.

At times in this lesson, there are links that must be selected in order to view hidden content. You may be asked questions about this content, so be sure to visit every link.

A reminder that the terminal learning objective for this lesson is to explain the integrated, stepped care model for mental health (MH) services in HBPC and its application to mental health screening and assessment in HBPC interdisciplinary care.

To help you achieve this objective, there are three enabling learning objectives:

1. Identify the key concepts of the integrated, stepped care model for mental health services in HBPC

2. Describe four potential levels of involvement of the HBPC Mental Health (MH) Provider in working with the team to address behavioral and mental health care

3. Given a case study of a patient admitted to HBPC, apply the integrated, stepped care model’s application to initial mental health screening and assessment





Image ID Image Alt Text Image Long Descriptionmr_apple_01_001(1).jpg A file folder, shown opened, with a photo of Mr.

Apple paper-clipped to the top edge of the folder.



Meet Mr. Louis AppleScreen ID 01_002.htm Screen Type Main Page 4 of 120

Mr. Louis Apple is a 64 year-old, 100% service connected male Veteran who was diagnosed with Amyotrophic Lateral Sclerosis (ALS) approximately 2 years ago. The muscles in Mr. Apple’s legs and arms have weakened over time such that he requires assistance with most activities of daily living (ADLs) and uses a motorized wheelchair. He has limited use of his hands.

Mr. Apple completed high school and was then drafted into the Army during the Vietnam War. He reportedly experienced several heavy combat missions during his tour in Vietnam. He was honorably discharged and returned home. He completed college on the GI Bill and then taught mathematics and driver’s education at the local high school. Due to his ALS symptoms, he had to take early retirement shortly after diagnosis. He lives with his wife of 40 years in a suburban community. They have two adult children and five grandchildren. Their daughter and her two children live locally, while their son and his family live out of state.

We will return to Mr. Apple in a bit…



Image ID Image Alt Text Image Long Descriptionmr_apple_01_002(1).jpg A file folder, shown opened, with a photo of Mr. Apple paper-

clipped to the top edge of the folder. An adhesive note is attached to the photo with the supporting text: "Mr. Apple: 64 years old, 100% SC, ALS diagnosis, weakness in arms and legs."

DeveloperNotes

Placeholder for photo or video if we decide to do any video of the case(If video is used on this page, include instructions in the onscreen text.)



Stepped Care Approach for Mental Health Integration in Primary CareScreen ID 01_003.htm Screen Type Main Page 5 of 120

Integrated mental health care in HBPC is based, in part, on models of primary care mental health integration that allow for coordinated and comprehensive care for medical, behavioral, and mental health conditions. In the Patient-Aligned Care Team (PACT), including HBPC, patients receive care from an interdisciplinary team that supports them in proactive care that promotes self- (and/or Caregiver-) management of chronic health conditions in a manner consistent with patient-centered values and goals.

MH Providers in integrated, primary care settings collaborate with the interdisciplinary team to address needs of the entire population of patients served, from those with no symptoms (emphasis on prevention), sub-clinical symptoms (emphasis on monitoring), mild or moderate symptoms (emphasis on brief treatment), and severe or complex symptoms (perhaps requiring specialty referral). The team systematically screens for common mental health and behavioral symptoms (e.g., depression, substance use, posttraumatic stress disorder [PTSD]), collaborates to evaluate, monitor and/or provide brief interventions for those with mild to moderate symptoms, and facilitates specialized mental health referrals for those with more severe or complex behavioral or mental health problems.



Image ID Image Alt Text Image Long DescriptionHBPC_team.jpg Six persons representing the HBPC team posed

together with Anne, the Mental Health Provider, in the center



Stepped Care Approach for Mental Health Integration in Primary Care (continued)Screen ID 01_004.htm Screen Type Main Page 6 of 120

This stepped care approach allows for:

• A range of treatment intensities, to meet the needs of each individual patient• The least restrictive services, in terms of patient commitment and clinician time investment• Interdisciplinary collaboration in addressing behavioral and mental health needs of the population served• Review of treatment plan to determine whether more or less intensive care is needed over time

For more on this subject, visit Building a Strong Foundation, Volume 1, Foundations for Integrated Care at:

https://vaww.portal.va.gov/sites/pcmhihub/PCMHI/Document%20Repository%201/Forms/Foundations%20for%20Integrated%20Care%20Manuals.aspx?View=%7B8295F5DB%2DE7CA%2D4CB0%2D8CC6%2D5E186E4C0BEE%7D&ShowInGrid=HTML

Note that this link is inactive. If you have access to the Intranet, you can copy the URL and paste it into your browser.





Integrated Care Model in HBPCScreen ID 01_005.htm Screen Type Main Page 7 of 120

As introduced in the first web course of this series (Talent Management System [TMS] course # 18886), we envisioned the components of integrated care in HBPC as the building blocks of a house.

The foundations of the house are Interdisciplinary Care, Collaborative Care, and Patient-Centered Care. Without these team-based components of care, the house has an inadequate foundation and cannot stand! HBPC MH Providers contribute to these aspects of care for all patients served by HBPC.

Building upon those foundations are Care Management and Stepped Care approaches, which refer to strategies teams may use to monitor and determine which patients would benefit from specialized mental health services.

The “roof” of the house represents Evidence-Based Mental Health Services, offered to those Veterans who need specialized mental health evaluation and/or treatment. These services are usually provided by the HBPC MH Provider or, at times, by clinic-based specialists who are consulted to help meet specialized needs.



Image ID Image Alt Text Image Long Descriptionhouse_5.jpg Six boxes, roughly arranged to resemble the shape of a house. At the

foundation of the house-shape are three boxes, from left to right, labeled: “Interdisciplinary Care,” “Collaborative Care,” and “Patient-Centered Care.” Above these boxes, two more boxes appear, once again appearing within the house shaped area. They are labeled: “Care Management” and “Stepped Care.” Lastly, a final box appears above the last two. This box is triangle shaped and completes the



roof shape of the house. It is labeled: “Evidence-based Psychological and Psychopharmacological Assessment and Intervention.”



Stepped Care Model for Mental Health Assessment in HBPCScreen ID 01_006.htm Screen Type Main Page 8 of 120

When the HBPC Mental Health Initiative began, there were many questions about the role of the MH Provider. For example, should the MH Provider see every Veteran enrolled in HBPC for an initial mental health evaluation? If not, which Veterans should the MH Provider see directly? How can the MH Provider support the team in their evaluations of the Veteran’s psychosocial functioning?

In a stepped model of care, it is often neither necessary nor appropriate (i.e., not a good use of limited resources) for the MH Provider to complete a formal mental health evaluation with every Veteran enrolled in HBPC. Rather, the MH Provider can support the team to conduct standardized screenings, share behavioral observations, and assess risk during initial home visits. Depending upon initial data and subsequent follow-up, mental health evaluation may occur in varying ways.



Image ID Image Alt Text Image Long Descriptionmeeting1.jpg Four members of the HBPC team gathered around a

conference table



Stepped Care Model for Mental Health Assessment in HBPC: Step 1Screen ID 01_007.htm Screen Type Main Page 9 of 120

Steps in mental health assessment (and treatment) may proceed as follows:

Step 1

Standardized screenings by the HBPC Nurse and/or Social Worker during initial home evaluations. Examples of behavioral/mental health issues for which screenings should be documented include: depression, suicide risk, PTSD, alcohol use, smoking, dementia warning signs, and Caregiver strain.

Each HBPC team may add behavioral/mental health domains for standardized screening as they wish in order to meet the needs of their population (e.g., sleep, anxiety).

Select Next to go to Step 2.



Image ID Image Alt Text Image Long Descriptionann_mr_apple1.jpg Ann, the MH Provider, speaking with Mr. Apple. Mr.

Apple is shown in his wheelchair and in the foreground. Ann is facing Mr. Apple.




Step 2

If initial screening is positive, there are several options for follow-up, depending on the level of team concern and potential risk involved. Select each of the following items:

• Team follow-up on a positive screen• Team administration of brief assessment measures• Evaluation by MH Provider

With information presented about screening scores and initial team behavioral and environmental observations, the team can collaborate with the MH



Provider to determine if further mental health evaluation (e.g., psychodiagnostic interview, cognitive or capacity evaluation) is indicated in a particular case.

Select Next to go to Step 3.



Image ID Image Alt Text Image Long Descriptiontoggle_anne_w_HBPC_team.png Four members of the HBPC team seated at a

conference table

Team follow-up on a positive screenScreen ID 01_008_TL01.htm Screen Type Toggle List Item Required

On many HBPC teams, Nurses or Social Workers are well-trained to follow-up on a positive screen with additional evaluation. For example, in the case of a positive depression screen (PHQ-2), the Nurse/Social Worker may proceed to administer the PHQ-9 or, perhaps, a measure such as the Geriatric Depression Scale. Or, if the clinician has observed and documented Dementia Warning Signs*, that clinician may administer a brief cognitive assessment (e.g., Montreal Cognitive Assessment [MOCA], St. Louis University Mental Status Exam [SLUMS]) IF they have been adequately trained to do so.

*Demential Warning Signs link: http://vaww.infoshare.va.gov/sites/geriatrics/national/AH/Forms/AllItems.aspx?RootFolder=%2Fsites%2Fgeriatrics%2Fnational%2FAH%2FDEMENTIA%20MATERIALS%2FDementia%20Warning%20Signs%20Report%20and%20Toolkit%202011&FolderCTID=0x01200023199D6EAA75DD4088835A382085B7D2&View={5A8485CC-B221-4537-B876-B37158ED49F5}

Note that this link is inactive. If you have access to the Intranet, you can copy the URL and paste it into your browser.



Team administration of brief assessment measuresScreen ID 01_008_TL02.htm Screen Type Toggle List Item Required

Many HBPC MH Providers train appropriate team members to administer brief assessment tools to streamline the initial evaluation process. It may not be necessary for the psychologist, for example, to drive an hour to a Veteran’s home to administer the SLUMS. With this preliminary evaluation data, the team is able to determine the best course for follow-up.

Evaluation by MH ProviderScreen ID 01_008_TL03.htm Screen Type Toggle List Item Required

On some occasions, however, the initial team screenings and observations, and/or the Veteran’s history, will suggest that follow-up evaluation would be best done by the MH Provider. For example, if the Nurse is quite concerned about the severity of a Veteran’s depression and/or cognitive impairment at the time of the initial visit, follow-up evaluation may best be accomplished by the MH Provider.




Step 3

Specialized mental health evaluation is important when:

a. It is clear through the referring source and/or chart review that there are significant mental health concerns and/or potential risk

b. The team's initial in-home evaluation raises questions about safety, level of functioning/self-care, or level of distress

c. The case appears very complex and there are more questions than answers regarding "what is going on here" and MH Provider input is needed to inform case conceptualization and treatment planning



Image ID Image Alt Text Image Long Descriptionmeeting3.jpg Four members of the HBPC team seated around a

conference table



Applying the Integrated, Stepped Care Model in HBPCScreen ID 01_010.htm Screen Type Main Page 12 of 120

Visual Screen/Description Audio Script

We now return to the case of Mr. Apple, who has recently been admitted to HBPC. During a team meeting, the Nurse reports to the team about his initial in-home evaluation with Mr. and Mrs. Apple.

PLACEHOLDER FOR VIDEO OF TEAM MEETING

MARK (Registered Nurse): Today, I’m going to present my new admit, Mr. Louis Apple. He is a 64-year-old, Vietnam Veteran who is 100% service-connected for ALS, which was diagnosed about 2 years ago. His other previous medical history includes: osteoarthritis, gastroesophageal reflux disease (GERD), and hypertension. He has been relatively healthy except, for now, his ALS.

His medications are:

• Riluzole 50 milligrams twice daily, which was prescribed by Neurology

• Omeprazole 40 milligrams daily• Hydrochlorothiazide 25 mg daily• Atenolol 50 milligrams daily—I want to note that I’m working with

Denise to reach out to Pulmonary because this medication can lead to possible bronco-constriction. We want to be sure it’s safe for him to continue taking at this point.

• He's also taking Ibuprofen 200 mg daily 4 times a day as needed for pain

In terms of functional status—At this point he uses his electric wheelchair and requires significant assistance with activities of daily living (ADLs): bathing, dressing, toileting, he can still feed himself with some assistance. In terms of instrumental activities of daily living (IADLs) he is totally dependent except he can use the telephone with speaker. They have a home health aide come in 3 times a week to help with bathing. Mrs. Apple is not able to transfer him into the car at this point, so he requires a wheelchair van to get to VA appointments. Mrs. Apple shops and runs



other errands when the health aide is there or when her daughter visits to help cover.

He is connected with Neurology , Respiratory, and Speech Therapy clinics. He is using bilevel positive airway pressure (BiPAP) at night and sometimes during the day. He can talk but with increasing effort.

Mr. Apple was very pleasant and cooperative. Both he and his wife reported that they’re doing their best to manage, but they could use additional support. Their daughter comes 2-3 times a week and brings her two kids on the weekend… Mrs. Apple quit her retail job last year so she could care for Mr. Apple. She scored a 7 on the Zarit burden screen – just below the cut-off of 8.

In terms of his mood - Mr. Apple scored positive on the patient health questionnaire (PHQ-2) depression screen, so I administered the PHQ-9 and his score was in the mildly depressed range. He denied any suicidal ideation. He also scored positive on the 4-item PTSD screen. Mrs. Apple reports that her husband’s mood has been low since his retirement from teaching, and that he gets frustrated that he can’t play with the grandkids like he used to… She also noted he gets distracted while trying to have a conversation with him. Given those concerns about his concentration, I administered the SLUMS – he scored 23/30 – but lost a number of points because of trouble drawing the clock and speaking slowly on animal naming. His orientation and memory generally seem OK – lost just a couple of points on memory items.

To sum up, they are a really great couple and could definitely benefit from the services we provide. I have some ideas for referrals for the team, but want to hear everyone’s thoughts first.



.





Applying the Integrated, Stepped Care Model in HBPC (continued)Screen ID 01_011.htm Screen Type Main Page 13 of 120

Ann, the HBPC MH Provider, heard several areas for possible assessment and, perhaps, intervention during this presentation. These include:

• Mr. Apple’s positive depression and PTSD screens• His performance of 23/30 on the SLUMS indicating mild neurocognitive concerns• Mrs. Apple’s report of mood and cognitive changes in the Veteran• Mrs. Apple’s own report of mild Caregiver stress on the 4-item Zarit Caregiver

Burden Screen, but below the cutoff of 8 requiring offer of therapy services



Image ID Image Alt Text Image Long DescriptionAnne_1.jpg Ann, the Mental Health Provider





[[Return to picture/video of team for following discussion]] JUDY (Occupational Therapist): Well, I’ll be contacting them to make visit for the home safety evaluation. Mark, did you notice if there were wheelchair ramps?

MARK (Registered Nurse): There was just one ramp, at the back of the house next to the garage, but not to the front door. I also noticed a few spots between rooms where there are ridges that make maneuvering the wheelchair just a bit difficult. It will help to get your input.

JUDY: We’ll need to see about a 2nd ramp for access to and from the front of the house. I’ll check it out and see what other home adaptations or equipment might help them.

MARK: Thanks!

EVELYN (Social Worker): I was looking over the chart earlier and there are some possible social work needs as well. I didn’t see an advance directive on file and it’s not clear if he and his wife have had advance care planning discussions. They may be eligible for additional benefits, such as Aid and Attendance, house modification, and a handicapped vehicle, which I’ll explore with them when I go out next week. I also wonder if Mrs. Apple might be interested in local Caregiver support group and/or information about respite services. Will keep you all posted.

MARK: Great, thanks Evelyn. Ann, what are your thoughts?

ANN: Well, I’m definitely interested to learn more about his mood and cognitive symptoms.



MARK: Yeah, Mrs. Apple mentioned that his mood is lower and that he often keeps to himself when they have family get-togethers. He used to be the “life of the party” but now he retreats to the background.

ANN: And from the chart, it says that he was involved in several combat missions during his service and, like you said, he scored positive on the PTSD screen. As we’ve discussed previously, sometimes PTSD symptoms can get worse in the context of disabling illness; we should probably evaluate whether he is struggling with PTSD symptoms. It would also help to get a better sense of his cognitive changes and see if more testing is indicated. If it's OK, I’ll call them to offer a home visit to help evaluate these concerns.

MARK: That would be great, thanks Ann. Anything else?

ANN: As Evelyn mentioned, I’m concerned about Mrs. Apple, even though her Zarit was just below the cutoff. Evelyn, I’ll wait to hear from you after your visit with them and find out what types of services Mrs. Apple might be receptive to. Let me know if I can help address any Caregiver, or marital or other family concerns. We can put our heads together after we’ve both had a chance to see them.

EVELYN: Sounds good, thanks Ann.

MARK: This sounds like a great plan! Thanks everyone!



DeveloperNotes

Placeholder slide for video of team discussion of Mr. Apple




In the case of Mr. Apple, it was clear to the HBPC interdisciplinary team that the MH Provider should make a home visit. But, there will be many instances in which the MH Provider will not need to do a home visit or plan any evaluation or intervention. Let’s look at some examples of integrated, stepped care in HBPC.

Select each of the following items for more information.

• No identified behavioral/mental health needs• Watchful waiting• Home visit for further evaluation• Referral, consulting, coordination with specialty clinics/programs



No identified behavioral/mental health needsScreen ID 01_013_TL01.htm Screen Type Toggle List Item Required

The MH Provider will continue to collaborate with the team in building a holistic case conceptualization and treatment plan. The MH Provider can help to identify risk factors for mental health symptoms or poor adaptation and support team in prevention efforts with the Veteran and family.

Watchful waitingScreen ID 01_013_TL02.htm Screen Type Toggle List Item Required

This approach can be helpful if the Veteran is reporting subclinical symptoms, or if the Veteran/family is reporting feeling overwhelmed by visitors to the home. In this instance, the MH Provider may work with the team on strategies for monitoring symptoms, providing psychoeducation to the Veteran/family/Caregiver, or recommending self-care resources. To help the team monitor symptoms, the MH Provider may ask the Nurse or Social



Worker to administer a brief assessment measure (e.g., depression, anxiety), to ask specific questions of the Veteran and/or Caregiver about symptoms, or to note particular behavioral observations during the next in-home visit. The MH Provider may certainly work with the team to identify resources (e.g., readings, websites, support groups) that may be helpful to the Veteran/family.

Home visit for further evaluationScreen ID 01_013_TL03.htm Screen Type Toggle List Item Required

There are many circumstances in which an in-home mental health evaluation will make good sense. As discussed above, upon admission of the Veteran to HBPC, if there are moderate to severe mental health symptoms, questions about safety, or needs for clarification of capacity or other functional issues to inform team treatment planning, a MH evaluation is important.

There are additional circumstances in which the MH Provider may want to make a home visit to complete a mental health evaluation, including: sudden changes in functional status or safety concerns for the Veteran; psychosocial or environment changes, such as death of a spouse or other family member or changes in paid Caregivers; re-admission to HBPC after a hospitalization and related functional/adjustment concerns; or, relocation of the Veteran to a new living environment (e.g., a relative’s home, assisted living facility) that triggers emotional or behavioral concerns.

Referral, consulting, coordination with specialty clinics/programsScreen ID 01_013_TL04.htm Screen Type Toggle List Item Required

There may be times when the HBPC MH Provider helps to link the Veteran to other specialty services for evaluation or treatment. For example, the MH Provider can act as a liaison between the HBPC Program and outpatient Mental Health Clinic to ensure that a Veteran gets appropriate psychiatric care. Or, if neuropsychological testing is required but not within the HBPC MH Provider’s professional scope of competence, it would be appropriate for the HBPC MH Provider to work with the team to refer the Veteran to an outpatient Neuropsychology clinic (if available and possible for Veteran to access).

Likewise, the MH Provider may help to coordinate services between programs. For example, an HBPC Veteran with severe mental illness may also receive services from the Mental Health Intensive Case Management (MHICM) team. In this instance, home visits by the HBPC MH Provider may not be warranted, but the HBPC MH Provider can provide a key role in facilitating communication between the two programs.



Outcome of Ann's VisitScreen ID 01_014.htm Screen Type Main Page 16 of 120

Ann made a home visit to see the Apples approximately two weeks after the team discussion. The results of her visit are as follows:

• Depression• PTSD• Cognition• Support group• Overall



DepressionScreen ID 01_014_TL01.htm Screen Type Toggle List Item Required

Mr. Apple acknowledged that he is having problems with lowered mood at present. Ann administered the Geriatric Depression Scale, Short Form. He scored 6/15, which is indicative of mild depressive symptoms. Many of his responses were related to ALS symptoms, such as increased fatigue, feeling helpless due to physical limitations and difficulty starting new projects. Though further intervention was offered, Mr. Apple was not interested in individual therapy at this point in time. Ann reviewed Behavioral Activation techniques with the Apples and suggestions for modifying behaviors given his physical concerns. She also mailed the Apples several pamphlets on depression and bibliotherapy/self-help techniques, and encouraged the team to follow-up with the Apples on response to those resources.

PTSDScreen ID 01_014_TL02.htm Screen Type Toggle List Item Required



Mr. Apple shared details of several combat missions during his time in Vietnam. He reported that he occasionally experiences nightmares about his combat experiences but did not report too many daytime intrusive memories nor avoidance symptoms. Ann administered the PTSD Checklist (PCL) to the Veteran, who scored 20/80 on the measure. He did not meet criteria for a PTSD diagnosis.

CognitionScreen ID 01_014_TL03.htm Screen Type Toggle List Item Required

Both Mr. and Mrs. Apple acknowledged that the Veteran is experiencing some trouble with concentration and memory, but did not express a high level of related distress or functional concern. They were not interested in further cognitive evaluation and Ann did not feel it was critical for informing the treatment plan at this point.

Support groupScreen ID 01_014_TL04.htm Screen Type Toggle List Item Required

Mrs. Apple mentioned that Evelyn (Social Worker) connected her with a telephone support group through the VA’s Caregiver Support Initiative. She connected with the group this past week, felt very comfortable, and said she hopes to learn a lot about coping strategies and ways to engage in Caregiver self-care.

OverallScreen ID 01_014_TL05.htm Screen Type Toggle List Item Required

Overall, Veteran and wife were pleasant and coping fairly well. They agreed to a follow-up phone call by Ann in a month, but no other mental health services were indicated or desired at this time. Ann planned to remain available to the team, and to Mr. and Mrs. Apple, as needed.



SummaryScreen ID 01_015.htm Screen Type Main Page 17 of 120

In this lesson, we reviewed the integrated, stepped care model for mental health services in HBPC and its implications for screening and assessment.

The MH Provider partners with the HBPC treatment team to provide interdisciplinary, patient-centered, and collaborative care for all enrolled Veterans. Mental health screening and brief assessment activities may be part of initial in-home evaluations by nursing or social work members of the team. MH Providers may train team members to administer appropriate screening measures and to note particular behavioral observations.

For many Veterans enrolled in HBPC, direct clinical evaluation or treatment by the MH Provider is not indicated. For Veterans with moderate to severe symptoms or indications of risk, or those whose emotional, cognitive, or everyday functioning needs further evaluation to inform the interdisciplinary treatment plan, the MH Provider may complete a more comprehensive, specialized mental health evaluation.




conference table



Knowledge CheckScreen ID 01_016.htm Screen Type Main Page: Knowledge Check 18 of 120

Scenario/Question Feedback

1. Which of the following is NOT a key concept in the integrated, stepped care model in HBPC?

A. Patient-centered

B. Promotes self-management

C. Range of treatments and treatment intensities

D. MH Providers meet individually with all patients

Correct Feedback:

Correct. In the stepped care model, MH Providers work with the HBPC team to determine which patients need specialized mental health evaluation and/or treatment.

Incorrect Feedback:

Incorrect. In the stepped care model, MH Providers work with the HBPC team to determine which patients need specialized mental health evaluation and/or treatment.

2. True or false? The HBPC MH Provider can utilize results of screening and brief assessment measures administered by other team members to determine if further mental health assessment and intervention is warranted.

A. True

B. False

Correct Feedback:Correct. Nurses and social workers may administer brief

screening/assessment measures, if adequately trained, and share behavioral observations in order to inform mental health care planning.

Incorrect Feedback:Incorrect. Nurses and social workers may administer brief


3. Under what circumstances may a MH Provider complete a more comprehensive, specialized mental health evaluation? Choose all that apply.

A. The team's initial in-home evaluation raises questions about safety, level of functioning/self-care, or level of distress.

Correct Feedback:Correct. A score of 6/15 on the Geriatric Depression Scale alone is

not justification for a comprehensive mental health evaluation.

Incorrect Feedback:Incorrect. The correct answers are A, B, and D. A score of 6/15 on

the Geriatric Depression Scale alone is not justification for a



B. There are significant mental health concerns and/or potential risks to the patient

C. MH Providers must complete a comprehensive mental health evaluation for any patient that exhibits signs of depression and scores 6/15 on the Geriatric Depression Scale.

D. When cases are very complex and have many unanswered questions, a MH Provider's input is needed to provide treatment planning.

comprehensive mental health evaluation.

4. The team decides to adopt a “watchful waiting” approach for a particular patient. Which of the following activities might be performed for this level of support? Select all that apply:

A. The MH Provider works with the team on strategies for monitoring symptoms and providing psychoeducation to the Veteran/family.

B. The MH Provider may ask a nurse or social worker to administer a brief depression or anxiety assessment measure.

C. The MH Provider does a home visit to complete a psychodiagnostic evaluation with the Veteran.

D. The MH Provider may work with the team to identify resources that may be helpful to the Veteran/family, such as readings, websites, or support groups.

Correct Feedback:Yes, that is correct. Conducting a psychodiagnostic evaluation in

the home is associated with a higher level of support.

Incorrect Feedback:That is incorrect. A, B, and D are the correct answers. Conducting a

psychodiagnostic evaluation in the home is associated with a higher level of support.

PageInstructions

Select Next to continue.

DeveloperNotes

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Lesson ConclusionScreen ID 01_017.htm Screen Type Main Page 19 of 120

You have completed the first lesson in this course, Integrated, Stepped Model of Care for Mental Health Assessment in HBPC, and are now able to move forward to the second lesson, Framework for Mental Health Evaluation in HBPC.





Integrated Mental Health Assessment in Home Based Primary Care Framework for Mental Health Evaluation in HBPC

Framework for Mental Health Evaluation in HBPCLesson Introduction


Specialized mental health assessment in Home-Based Primary Care (HBPC) occurs within the context of interdisciplinary team care. The goals of mental health evaluation in HBPC are very practical in nature. Rather than simply clarifying a diagnosis or recommending a psychological or psychiatric intervention, the mental health evaluation will be most helpful when it addresses the Veteran’s everyday functioning, strengths, risks, and practical recommendations.


The terminal learning objective (TLO) for this lesson is to explain the framework for organizing one’s approach to mental health evaluation in HBPC.

To help you achieve this objective, there are two enabling learning objectives:

1. Identify the goals for mental health evaluation in HBPC.2. Explain the components of a specialized mental health evaluation framework for use in HBPC.





Framework for Mental Health Evaluation in HBPCScreen ID 02_002.htm Screen Type Main Page 21 of 120

Goals for mental health evaluation include:

1. Documenting Veteran's strengths and abilities: What intellectual, emotional, physical, spiritual, social, and life experience resources does the Veteran have to help him cope, adapt, compensate to his current circumstances? What strengths can the team optimize and build upon in working with this Veteran?

2. Documenting Veteran’s deficits and areas in need of support: In what psychological/psychiatric domains does the Veteran struggle (e.g., perception, cognition, mood, insight, judgment, decision-making, interpersonal functioning, etc.) and need additional supports for safety and well-being?

3. Documenting risk and protective factors: What is the Mental Health (MH) Provider’s assessment of risk in domains relevant to the individual, including suicidality, risk of violence to others, access to firearms, capacity for self-care, elder abuse/exploitation, driving, etc.? What protective factors are present that might be bolstered?

4. Making practical recommendations: What types of education, information, resources, or additional treatments or services may be helpful to offer to the Veteran, the family/Caregivers, and the HBPC team? Recommendations should be tailored for each of these stakeholders.





Return to Mr. AppleScreen ID 02_003.htm Screen Type Main Page 22 of 120

Mr. Apple has now been with the HBPC Program for approximately 8 months. Over this time, he has less use of his hands and arms, more difficulty speaking, some respiratory distress at night, and is experiencing changes in his personality and behavior. Initially very mild-mannered and appropriate towards HBPC staff and others, Mr. Apple has had increased instances of irritable, impulsive behavior. Team members witnessed Mr. Apple making disparaging remarks towards his wife. Mrs. Apple expressed concern that he had been inappropriate with their young granddaughter, cursing at her when she dropped her ice cream on the carpet and making her cry. Most recently, when the HBPC Occupational Therapist (OT) arrived for a scheduled appointment to teach Mrs. Apple how to use the new Hoyer Lift for transfers, he was quite irritable and did not wish the OT to demonstrate. With support and encouragement, he did calm and was willing to participate.







Return to Mr. Apple (continued)Screen ID 02_004.htm Screen Type Main Page 23 of 120

Mr. Apple is also starting to have difficulty swallowing, which is leading to weight loss. The treatment team has broached the topic of a possible feeding tube in the near future. Though Mr. Apple had indicated a preference for a feeding tube on his advanced directive, he recently stated that he’s not interested in having a feeding tube. It is not clear to his family or the HBPC team that he understands the risks and benefits of a feeding tube.

The HBPC team has also introduced to the family the potential benefits of home hospice services into the future. However, Mr. and Mrs. Apple stated that they were not yet ready to consider hospice services, reporting that it would feel “overwhelming” to have additional people in the home. Mrs. Apple also expressed concern that “Hospice means the end is coming. I don’t want Louis thinking I’ve given up on him.”







Return to Mr. Apple (continued)Screen ID 02_005.htm Screen Type Main Page 24 of 120

The HBPC team has noticed changes in Mrs. Apple as well. She appears very tired and reports she is not sleeping well, in part because she is more vigilant about his breathing. She sleeps in bed next to his hospital bed. While they have increased, daily home health services now, she reports feeling overwhelmed by the almost constant caregiving demands. Apart from attending to her husband’s personal care and support, she has also taken on full management of household finances and house/yard/car maintenance, which adds to her stress. She is often tearful during home visits and leaves multiple messages for team members in between scheduled visits. Both Mr. and Mrs. Apple are committed to his staying at home for as long as possible.







Framework for Mental Health Evaluation in HBPCScreen ID 02_006.htm Screen Type Main Page 25 of 120

The following diagram provides a framework for the HBPC MH Provider to organize her thinking about the goals, sources of information, processes, tools, and outcomes for a specialized mental health evaluation in HBPC.

Each component of this framework is described and applied to Mr. Apple’s case. If the team agreed that it would be helpful for Ann to plan a mental health evaluation with Mr. Apple at this point, what issues does she want to consider?



Image ID Image Alt Text Image Long Descriptionframework_lg.jpg This flowchart consists of three layers, the middle layer contains

seven rectangles, the bottom layer contains four triangles and a four-side polygon, and the top layer contains one triangle. The first box, on the middle layer contains the supporting text: “What is the



assessment/evaluation question?” A directional arrow points to the second box, which has the supporting text: “informed consent/assent.” Between these two boxes, in the bottom layer, is a triangle with the supporting text “clinical/ethical/legal implications.” A directional arrow points to the third box, which has the supporting text: “informed consent/assent.” Between boxes two and three, in the bottom layer, is a triangle with the supporting text “sources of information.” A directional arrow points to the fourth box, which has the supporting text: “perspectives on current situation.” A directional arrow points to the fifth box, which has the supporting text: “Veteran’s functioning.” Below the third, fourth, and fifth boxes is the polygon shape, with the supporting text: “interview Veteran,” and “interview caregiver/family/HBPC team.” Above the fifth box is a triangle with the supporting text: “standardized tests.” A directional arrow points to the sixth box, which has the supporting text: “assessment outcomes.” Between boxes five and six, in the bottom layer, is a triangle with the supporting text “environmental observations.” A directional arrow points to the seventh box, which has the supporting text: “conclusions.” Between boxes six and seven, in the bottom layer, is a triangle with the supporting text “team collaboration.”



Clarifying the Assessment QuestionScreen ID 02_007.htm Screen Type Main Page 26 of 120

One of the most important parts of completing a mental health evaluation in the context of an interdisciplinary care team is to clarify exactly what the concern is, and from whose perspective(s).

Team members may at times express relatively vague concerns or requests, such as “this Veteran has a psychiatric history, please evaluate” or “Please evaluate capacity.” In these circumstances, it can be difficult to know what information is needed and what type of recommendations would be helpful to the Veteran, family, and team.

The HBPC MH Provider can work closely with the team to clarify the nature of the concern: What has the team observed in the home? What behaviors or aspects of the environment are worrisome? Who is concerned or suffering: the Veteran? The family/Caregiver? The clinical team? Others?



Image ID Image Alt Text Image Long Descriptionfw_assessment.jpg The framework for mental health evaluation flowchart with the first

box highlighted. A callout from the first box has the supporting text: "What is the assessment/evaluation question?" and an image of the HBPC team seated at a conference table.



Clarifying the Assessment Question (continued)Screen ID 02_008.htm Screen Type Main Page 27 of 120

In the case of Mr. Apple, the team – as well as Mrs. Apple – has a number of concerns. In discussing the case with team members, the MH Provider may clarify that a mental health evaluation would be helpful to do one or more of the following:

1. To determine whether Mr. Apple has the capacity to make decisions about his medical care at this time (i.e., whether or not to use a feeding tube.)

2. To evaluate, along with the team, what factors may be contributing to his increased agitation (e.g.,depression, PTSD, ongoing neurological changes influencing mood regulation, pain, and environmental or interpersonal factors).

3. To assess Mrs. Apple’s Caregiver strain and her own coping ability and self-care at this time4. To explore Mr. and Mrs. Apple’s perspectives on his advanced illness and potential openness to hospice care if/when appropriate



Image ID Image Alt Text Image Long Descriptionfw_assessment.jpg The framework for mental health evaluation flowchart with the first

box highlighted. A callout from the first box has the supporting text: "What is the assessment/evaluation question?" and an image of the HBPC team seated at a conference table.



Clinical/Ethical/Legal Implications of the AssessmentScreen ID 02_009.htm Screen Type Main Page 28 of 120

Oftentimes, mental health evaluations in HBPC have significant implications regarding a Veteran’s needs for decision making or functional supports, or protections regarding safety. These evaluations can raise challenging ethical and/or legal issues.

For example, might an evaluation lead potentially to:

• Psychiatric hospitalization of the Veteran?• The need to make a report to Adult Protective Services?• A finding of impaired decision making capacity such that a surrogate decision maker must be involved (e.g., power of attorney for healthcare, or

finances, or establishment of guardianship)?It is critical to be aware of the possible outcomes of an evaluation and what various outcomes would mean – clinically, ethically and legally. In very complex cases, it may help to consult with colleagues or legal counsel prior to proceeding with an evaluation, to ensure that you are clear on potential implications and how to manage them.



Image ID Image Alt Text Image Long Descriptionfw_clinical_ethical.jpg The framework for mental health evaluation flowchart with the first

triangle on the bottom layer highlighted. A callout from the first



triangle has the supporting text: "Clinical/ethical/legal implications" and an image of Ann, the MH Provider examining a file.



Clinical/Ethical/Legal Implications of the Assessment (continued)Screen ID 02_010.htm Screen Type Main Page 29 of 120

Mr. Apple’s situation is quite complex in this regard.

• If he is found not to have the capacity to make a decision regarding his feeding tube, what does that mean? Do the family and team stick with his previously expressed preference, in his advance directive, to have a feeding tube? What if Mr. Apple refuses to cooperate with tube feedings and/or tries to remove the tube?

• What are his wife’s values and preferences?• How will the team ultimately work with this Veteran and family to decide what is the best plan of care?



Image ID Image Alt Text Image Long Descriptionfw_clinical_ethical.jpg The framework for mental health evaluation flowchart with the first

triangle on the bottom layer highlighted. A callout from the first triangle has the supporting text: "Clinical/ethical/legal implications" and an image of Ann, the MH Provider examining a file.



Informed Consent/AssentScreen ID 02_011.htm Screen Type Main Page 30 of 120

It is the standard of care to obtain informed consent from patients before proceeding with a mental health evaluation or course of treatment. Informed consent requires full disclosure of information, capacity of the patient to make the decision to participate, and voluntariness (freedom from coercion to participate).

• The MH Provider should make an effort to elicit informed consent, or assent, from the Veteran, before proceeding with an evaluation. It is important to explain the purpose of the evaluation, what the potential outcomes may be, and that the Veteran has choice whether or not to participate. It is also important to explain the implications of participation, or lack thereof (e.g., the MH Provider may still document his/her clinical observations, even if formal evaluation is not completed).

• The MH Provider should document the extent to which the Veteran was able to understand and appreciate this information and provide consent. In cases where the Veteran is not able to offer full informed consent, but is willing to participate with the evaluation, the Veteran’s assent can be documented (ABA & APA, 2008). Likewise, Veterans have the right to refuse to participate in an evaluation. If a Veteran refuses, it is important to document whether or not that refusal appeared to be informed (did the Veteran appear to understand what he/she was refusing?).



Image ID Image Alt Text Image Long Descriptionfw_informed_consent.jpg The framework for mental health evaluation flowchart with the



second box highlighted. A callout from the second box has the supporting text: "Informed consent/assent" and an image of Ann, the MH Provider, speaking with Mrs. Apple.



Informed Consent/Assent (continued)Screen ID 02_012.htm Screen Type Main Page 31 of 120

In the case of Mr. Apple, the family and team have questions about his medical decision making capacity.

• It will be important to inform Mr. Apple about the purpose of an evaluation; if the evaluation focuses on his medical decision-making capacity, then he would need to be informed of the implications of a finding of incapacity in this domain.

• It will be important to determine the extent to which he appears to understand the purpose, risks, and benefits of the evaluation and to document the extent to which he was able to offer informed consent, assent, and/or informed or uninformed refusal to participate.



Image ID Image Alt Text Image Long Descriptionfw_informed_consent.jpg The framework for mental health evaluation flowchart with the

second box highlighted. A callout from the second box has the supporting text: "Informed consent/assent" and an image of Ann, the MH Provider, speaking with Mrs. Apple.



History and Background of the ProblemScreen ID 02_013.htm Screen Type Main Page 32 of 120

An important role for the HBPC MH Provider can be to gather and integrate information from multiple sources in order to help “tell a story” about the Veteran’s life and functioning in a concise and coherent manner. Certainly, the interview with the Veteran and often family members, is critical and will be discussed further below.

Other important sources of information may include the following. Select each item for further details.

• A comprehensive review of the Veteran’s VA medical record• A review of any non-VA medical records that may be available• Communication with HBPC team members• Communication with other VA Providers• Medical foster home or assisted living facility staff• Community agency staff



Image ID Image Alt Text Image Long Description



fw_sources_of_info.jpg The framework for mental health evaluation flowchart with the second triangle on the bottom layer highlighted. A callout from the second triangle has the supporting text: "sources of information" and an image of Mr. Apple sitting in his wheelchair.

A comprehensive review of the Veteran’s VA medical recordScreen ID 02_013_TL01.htm Screen Type Toggle List Item Required

Sometimes there are critical aspects of a Veteran’s history that have not been “brought forth” in recent medical record documentation. For example, there may be past reports of psychiatric evaluations, neuropsychological evaluations, capacity evaluations, or documentation of mental health treatment (medications, psychotherapy) that can be extremely informative.

It can be a challenge to review lengthy medical records. Tips for efficient review include:

• Scan the list of hospital discharge summaries. In particular, are there hospitalizations for psychiatric, substance abuse, neurological, or other reasons especially relevant to mental health history and functioning?

• Scan/search progress notes for titles including Psychology, Psychiatry, Neurology, Neuropsychology, and other Mental Health/Substance Abuse program names.

Be sure to check “remote data” to see if the Veteran has received care in other VA medical centers throughout the country.

A review of any non-VA medical records that may be availableScreen ID 02_013_TL02.htm Screen Type Toggle List Item Required

It may be important to ask Veteran to sign consent (if he/she has capacity to do so) for release of records of medical or psychiatric treatment if significant care has been provided outside of the VA system.

Be aware of possible prescribing of medications by non-VA Providers.

Communication with HBPC team membersScreen ID 02_013_TL03.htm Screen Type Toggle List Item Required



Be sure to gather as much information as possible from HBPC nurses, social workers, or others who have already spent time visiting the Veteran in the home. What are their concerns? What have they observed? Have they noted changes in the time they’ve been working with the Veteran?

Communication with other VA ProvidersScreen ID 02_013_TL04.htm Screen Type Toggle List Item Required

If the course of Veteran’s history in recent years is not entirely clear (e.g., did he always have that personality or learning style? ), it can be very helpful to check with VA clinicians who have known the Veteran over time. For example, check with previous or current Primary Care Providers, MH Providers, or staff working in a range of treatment programs.

Medical foster home or assisted living facility staffScreen ID 02_013_TL05.htm Screen Type Toggle List Item Required

It’s important to gather information about daily functioning of Veterans we evaluate. When a Veteran lives in a MFH or ALF setting, it can be extremely helpful to ask staff how the Veteran is doing in terms of Activities of Daily Living, Instrumental Activities of Daily Living, and getting along with other residents.

Community agency staffScreen ID 02_013_TL06.htm Screen Type Toggle List Item Required

Likewise, it can be helpful to gather information from agency staff who know and have observed Veteran over time, such as Visiting Nurses or Elder Services home health aides.



History and Background of the Problem (continued)Screen ID 02_014.htm Screen Type Main Page 33 of 120

In the case of Mr. Apple, it will be important to gather information about his functioning over the past year. The HBPC team has already described their observations and concerns. It may be useful to:

• Review medical/neurology notes for current functional level and prognosis (e.g., regarding nutrition, respiration, life expectancy)• Talk with primary care physician (PCP) or neurologist if uncertain• Check to see if there is documentation of brain scans in his medical record



Image ID Image Alt Text Image Long Descriptionfw_sources_of_info.jpg The framework for mental health evaluation flowchart with the

second triangle on the bottom layer highlighted. A callout from the second triangle has the supporting text: "sources of information" and an image of Mr. Apple sitting in his wheelchair.



Relevant History to Gather and DocumentScreen ID 02_015.htm Screen Type Main Page 34 of 120

Most HBPC MH Providers are very familiar with conducting a thorough biopsychosocial evaluation, which includes a summary of the Veteran’s “life story” leading him or her to this point in time. It is critical to document this history to help put the person in context. That is, what have been the person’s strengths, resources, and challenges in different domains of life, and what has brought the person to the present “history of current problem”? Here is a brief outline of information of the history that it is usually helpful to include in a comprehensive mental health evaluation.

a. Medical history – including earlier life and more recent illness, injuries, surgeriesb. Psychiatric history – including any known MH and substance use diagnoses, treatments, hospitalizations, suicide attempts, episodes of violencec. Family history – of mental disorder, dementia, other serious illnessd. Developmental – early family life, history of trauma/abuse, significant losses or supportse. Educational – years of schooling, other education/training, literacy, learning problemsf. Military – Branch, years, job, overseas? trauma? SC disabilities?g. Occupational – Work history, retirementh. Social history – marriage/partners/dating, sexual history, children, other family contact, income/finances, community engagement, sources of

social support and/or conflict, Caregiversi. Cultural/religious/spiritual beliefs and observances





Image ID Image Alt Text Image Long Descriptionfw_relevant_history.jpg The framework for mental health evaluation flowchart with the third

box highlighted. A callout from the third box has the supporting text: "relevant history" and an image of Mr. Apple.



Relevant History to Gather and Document (continued)Screen ID 02_016.htm Screen Type Main Page 35 of 120

For Mr. Apple, much of this information may already be documented by the HBPC interdisciplinary team, through medical, nursing, social work, and preliminary mental health evaluations. It is important to ensure that information is up-to-date and that Mr. Apple (and family, as appropriate) has the opportunity to convey this history. For Mr. Apple, it will be important for the MH Provider to have a good understanding of the onset and progression of the amyotrophic lateral sclerosis (ALS) and Mr. Apple’s history of coping with the illness, as well as the impact of other medical problems on his functioning. Likewise, it will be important to review Mr. Apple’s history regarding mood disorders, posttraumatic stress disorder (PTSD), substance use, or other mental health concerns, as well as gain an understanding of how Mr. Apple has typically coped with problems throughout his life – what are his sources of strength, resilience, support?



Image ID Image Alt Text Image Long Descriptionfw_relevant_history.jpg The framework for mental health evaluation flowchart with the third

box highlighted. A callout from the third box has the supporting text: "relevant history" and an image of Mr. Apple.



Interview with the VeteranScreen ID 02_017.htm Screen Type Main Page 36 of 120

The MH Provider’s interview with and observations of the Veteran and his environment are perhaps the most critical part of the mental health evaluation. The interview helps to establish the Veteran’s perspective on and insight about the situation and his/her goals and priorities at this time. A good interview will include attention to these issues.

Select each item to learn more.

• The Veteran's current situation• The Veteran’s reporting of his/her medical and psychosocial history• What is most important to the Veteran at this stage of life?• What are the Veteran’s strengths?• Clinical evaluation• Observations about Veteran’s interaction with family and the home environment





Image ID Image Alt Text Image Long Descriptionfw_interview_vet.jpg The framework for mental health evaluation flowchart with the

four-side polygon on the bottom layer highlighted. A callout from the polygon has the supporting text: "interview Veteran" and an image of Ann, the MH Provider, speaking with Mr. Apple.

The Veteran's current situationScreen ID 02_017_TL01.htm Screen Type Toggle List Item Required

What is the Veteran’s “take” on his/her current situation and functioning? What problems in daily life, if any, does he/she identify? What is his/her understanding of the cause or nature of those problems and what might help?

The Veteran’s reporting of his/her medical and psychosocial historyScreen ID 02_017_TL02.htm Screen Type Toggle List Item Required

How well able is the Veteran to communicate a coherent and seemingly accurate version of his/her personal history? What stands out to the Veteran as he/she communicates their personal story – good and bad?

What is most important to the Veteran at this stage of life?Screen ID 02_017_TL03.htm Screen Type Toggle List Item Required

What are his/her most valued activities, relationships, beliefs? What are his/her priorities and preferences in terms of self-care and health care? What does he/she hope the HBPC team can help him/her with?

What are the Veteran’s strengths?Screen ID 02_017_TL04.htm Screen Type Toggle List Item Required



How has he/she coped during tough times in the past? What have been some important “lessons learned” over a lifetime? What about spiritual/religious/cultural coping strategies and supports?

Clinical evaluationScreen ID 02_017_TL05.htm Screen Type Toggle List Item Required

1. Mental Status Evaluation (MSE): What are your observations about the Veteran’s cognitive and emotional functioning? MSE may include some very brief testing, e.g., mood or anxiety scales, brief cognitive test.

2. Diagnostic evaluation: Ask about particular symptoms to help inform diagnostic impression.3. Capacity and risk evaluation: Much of the information you will gather about capacity and risk will be via interview with the Veteran. Please see

the upcoming section on assessment outcomes.

Observations about Veteran’s interaction with family and the home environmentScreen ID 02_017_TL06.htm Screen Type Toggle List Item Required

The clinical interview in the home setting provides the opportunity to observe Veterans in their everyday environment. See the following page entitled: Environmental Observations.



Interview with the Veteran (continued)Screen ID 02_018.htm Screen Type Main Page 37 of 120

For Mr. Apple, in addition to gathering his perspective on his history, it will be important to ask him about his quality of life and goals for care at this time. What makes life good now? What makes life most difficult? How is he coping with changes in functioning related to his illness? What about his life history is making it easier or harder for him to cope now (e.g., military history, life experience with ill relatives or caregiving)? How well does he appear to understand and appreciate his situation and family/team concerns?



Image ID Image Alt Text Image Long Descriptionann_mr_apple2.jpg Ann, the MH Provider, speaking with Mr. Apple, who

is seated in his wheelchair



Interview with CollateralsScreen ID 02_019.htm Screen Type Main Page 38 of 120

It can be very helpful to gather information from family members or others who know the Veteran well. Of course, it is critical to obtain the Veteran’s consent or assent to talk with others about his/her care to ensure that, to the extent the Veteran is capable, that he/she understands the purpose of obtaining feedback from others. For example, it can help to explain that the family member/Caregiver has important perspectives on how things are going, both for the Veteran and for the family, and it will help you to help him/her to understand these perspectives.



Image ID Image Alt Text Image Long Descriptionfw_interview_caregiver.jpg The framework for mental health evaluation flowchart with the

four-side polygon on the bottom layer highlighted. A callout from the polygon has the supporting text: "interview Caregiver/family/HBPC team" and an image of Ann, the MH Provider, speaking with Mrs. Apple.



Interview with Collaterals (continued)Screen ID 02_020.htm Screen Type Main Page 39 of 120

Interviewing a collateral may take place with or without the Veteran present. It is important to use your clinical judgment regarding the pros and cons of a joint versus separate interview. Factors to consider include the Veteran’s cognitive status, the relationship and extent of trust/distrust between the Veteran and collateral, and potential safety concerns which might only be voiced by a Caregiver during an individual interview.

It can be helpful to ask the collateral about several domains. Select each item to learn more.

• The Veteran's relevant history and current situation• Goals and preferences regarding the Veteran’s care• Collateral's role in the Veteran's care• Caregiver burden




four-side polygon on the bottom layer highlighted. A callout from



the polygon has the supporting text: "interview Caregiver/family/HBPC team" and an image of Ann, the MH Provider, speaking with Mrs. Apple.

The Veteran's relevant history and current situationScreen ID 02_020_TL01.htm Screen Type Toggle List Item Required

It can help to hear the collateral's perspective on the Veteran's history and current situation (medical, psychiatric, functional). In particular, if the Veteran is not a good historian, family members/Caregivers may need to help fill in details of the history.

Goals and preferences regarding the Veteran’s careScreen ID 02_020_TL02.htm Screen Type Toggle List Item Required

Inquire about the collateral's goals and preferences regarding the Veteran's care (e.g., helping to keep the Veteran at home versus seeking long-term care placement; curative versus palliative approaches to care) and the extent to which those match the Veteran’s goals and preferences.

Collateral's role in the Veteran's careScreen ID 02_020_TL03.htm Screen Type Toggle List Item Required

What does the collateral do to help the Veteran? How are they managing? Who else helps? What additional sevices may be needed?

Caregiver burdenScreen ID 02_020_TL04.htm Screen Type Toggle List Item Required

Of note, if you are interviewing an identified Caregiver and the HBPC social worker or other team member has not yet completed the Zarit Burden screening questions, you can include the questions in your interview and/or repeat the questions to evaluate current level of burden. Discussions of



caregiving strain should be followed by education and offers of additional resources or support. Caregivers should be offered the opportunity for therapeutic support, if needed.




It is important to note the collateral’s own apparent functional, cognitive and emotional capacities. While the goal is not to do a comprehensive mental health evaluation with the family member/Caregiver, it is very important for the team to be attuned to possible struggles or limitations (e.g., does Caregiver appear to have significant cognitive impairment, psychiatric illness, and/or substance abuse? Does the Caregiver have the physical or emotional ability to meet the Veteran’s care needs?) The HBPC team can help refer the family member/Caregiver for appropriate services.








In the case of Mr. Apple, it is important to interview Mrs. Apple and, perhaps, their local daughter.

• It may be useful to interview Mr. and Mrs. Apple jointly in a discussion about goals of care and how each is doing, in part to observe how they communicate with each other.

• It may also be quite helpful to ask Mr. Apple’s permission to talk further with his wife, in order to evaluate how she is doing and what additional supports she may need.







Perspectives on Current SituationScreen ID 02_023.htm Screen Type Main Page 42 of 120

It is critical to understand various “stakeholder” perspectives on the current situation. As detailed in other sections, the MH Provider seeks to assess the Veteran’s understanding of his/her current life situation and related values, goals, and preferences. However, the Veteran lives and functions in a social and community context – potentially with family/Caregivers/friends, community/agency Caregivers, the HBPC team, and other VA Providers. To the extent possible and appropriate for the particular referral concern, and with the Veteran’s consent, it can be very helpful to understand the perspectives of others who care about or are affected by the Veteran’s health and functioning, for a systemic appreciation of the situation.

As already indicated, important perspectives to appreciate – regarding treatment goals and understanding of behavioral changes – include those of Mrs. Apple, perhaps other family members, HBPC team members (note that team members may have varying perspectives) and VA specialists involved in Mr. Apple’s care.



Image ID Image Alt Text Image Long Descriptionfw_perspectives_current.jpg The framework for mental health evaluation flowchart with the

fourth box highlighted. A callout from the fourth box has the supporting text: "perspectives on current situation" and an image of Mr. Apple seated in his wheelchair.



Use of Standardized Tests/MeasuresScreen ID 02_024.htm Screen Type Main Page 43 of 120

To supplement the data gathered by record review, interviews, and behavioral observations, the mental health evaluation often includes the use of standardized assessment tools to evaluate mood, cognition, independent living abilities, and other domains of symptomatology or functioning. Lesson 4 of the course reviews helpful assessment tools for HBPC practice.

• In HBPC practice, it is important to choose measures that have reliability/validity for the population (e.g., age norms) and that will help to answer the particular evaluation question. Given the medical and/or cognitive frailty of many Veterans served in HBPC, administering long testing batteries is often not practical or necessary.

• It can be very helpful to determine what tests, if any, have been administered previously during the Veteran’s care and, if appropriate, to repeat those tests to have a point of comparison over time.

• It is critical, as well, to be aware of one’s own competencies for practice in this area and to consider consultation or referral if the type of evaluation needed exceeds one’s own professional competencies (e.g., more extensive neuropsychological testing if you have not been trained in this area).



Image ID Image Alt Text Image Long Descriptionfw_standardized_tests.jpg The framework for mental health evaluation flowchart with the

triangle on the top layer highlighted. A callout from the triangle has



the supporting text: "standardized tests" and an image of Mr. Apple seated in his wheelchair.



Use of Standardized Tests/Measures (continued)Screen ID 02_025.htm Screen Type Main Page 44 of 120

In Mr. Apple’s case, any tests administered will need to take into account his sensory, mobility, and communication abilities.

• Given Mr. Apple’s irritability and agitation, and recently expressed wish not to receive tube feedings, it will likely be useful to evaluate the extent to which he is experiencing depression and/or anxiety. Several standardized tools (e.g., Geriatric Depression scale, in public domain, and Geriatric Anxiety Inventory, copyrighted) have simple yes/no formats and can help to supplement your interview and behavioral observations.

• Given questions about his medical decision-making capacity, it will be important to determine the extent to which he may have cognitive decline (e.g., since admission administration of the Montreal Cognitive Assessment (MOCA), which showed mild cognitive impairment). For comparison purposes, it might be helpful to re-administer the MOCA and consider other cognitive tests that address the functional abilities in question (e.g., can he register and recall information presented to him?). In particular, regarding his capacity to make a decision about tube feeding, a careful interview with him regarding his understanding and appreciation of his situation, his ability to express reasons for his choices (pro and cons), and to express a consistent choice will be important (see upcoming page entitled: Assessment Outcomes for more information about capacity evaluation).



Image ID Image Alt Text Image Long Descriptionfw_standardized_tests.jpg The framework for mental health evaluation flowchart with the

triangle on the top layer highlighted. A callout from the triangle has



the supporting text: "standardized tests" and an image of Mr. Apple seated in his wheelchair.



Environmental ObservationsScreen ID 02_026.htm Screen Type Main Page 45 of 120

One of the great benefits of home-based care is the opportunity to observe the Veteran and others in the residence, if applicable, in their everyday environment. In addition to the mental status exam and standardized testing that may be conducted in the clinic setting, the HBPC MH Provider can also observe the Veteran completing actual tasks or interactions at home (e.g., setting up medication, assembling a simple meal, communicating with a spouse or adult child). And, of course, the nature of the home environment “can tell 1000 words” (e.g., cleanliness, organization, decoration, fire hazards) about the Veteran’s everyday functioning (see next section of the course). Likewise, observations of the neighborhood (e.g., upkeep, transportation options, presence or absence of people around) and potential local supports/gatekeepers (e.g., does the postal worker seem to know the Veteran? Are neighbors connected/involved?) are important sources of information about the Veteran’s life context.

The MH Provider will want to observe Mr. and Mrs. Apple’s interactions, the availability of stimulating/meaningful activity in his immediate environment, his apparent comfort or lack thereof in his chair and bed, and the safety and comfort of the home for him and his family.



Image ID Image Alt Text Image Long Descriptionfw_environmental_observations.jpg The framework for mental health evaluation flowchart with the third

triangle on the bottom layer highlighted. A callout from the third triangle has the supporting text: "environmental observations" and an image of Mr. Apple seated in his wheelchair.



Summary of Veteran's FunctioningScreen ID 02_027.htm Screen Type Main Page 46 of 120

A summary of functioning, including the Mental Status Examination (MSE), reflects a summary of your behavioral and environmental observations and the Veteran’s performance on any standardized tests you have administered. In addition to documenting the mental status exam – including mood, thinking, insight, judgment, etc. – it is important to comment on everyday functioning in the home setting. These observations are used to inform the assessment outcomes/conceptualization.

In meeting with Mr. Apple, you will want to document what you have learned about his sensory abilities, attention/concentration, learning and memory, planning and problem-solving, mood and affect, thought content and process, and insight and judgment.



Image ID Image Alt Text Image Long Descriptionfw_veterans_function.jpg The framework for mental health evaluation flowchart with the fifth

box highlighted. A callout from the fifth box has the supporting text: "Veteran's functioning" and an image of Mrs. Apple assisting Mr. Apple with a drink.



Assessment OutcomesScreen ID 02_028.htm Screen Type Main Page 47 of 120

The "bottom line" of a mental health evaluation in HBPC tends to focus on diagnostic impressions, risk assessment, and – when applicable – decision-making or other functional capacity assessment.



Image ID Image Alt Text Image Long Descriptionfw_assessment-outcomes_D_R_C.jpg The framework for mental health evaluation flowchart with the sixth

box highlighted. A callout from the sixth box has the supporting text: "assessment outcomes," as well as "diagnosis," "risk," and "capacity," and an image of Mr. Apple seated in his wheelchair.



Assessment Outcomes -- DiagnosisScreen ID 02_029.htm Screen Type Main Page 48 of 120

In the HBPC population, mental health diagnosis can be very complicated due to the role of comorbid medical, neurological, and mental health conditions. It is important to both communicate the likely impact of mental health conditions when indicated (e.g., mood disorders, PTSD, substance dependence, dementia) as well as to indicate possible diagnoses to “rule-out” with ongoing team evaluation and consultation. Interdisciplinary perspectives are often important for differential diagnosis in this population.



Image ID Image Alt Text Image Long Descriptionfw_assessment-outcomes_D.jpg The framework for mental health evaluation flowchart with the sixth

box highlighted. A callout from the sixth box has the supporting text: "assessment outcomes," as well as "diagnosis," and an image of Mr. Apple seated in his wheelchair.



Assessment Outcomes -- Diagnosis (continued)Screen ID 02_030.htm Screen Type Main Page 49 of 120

For Mr. Apple, your evaluation will help to clarify the extent to which he may be struggling with a mood disorder such as major depression, persistent depressive disorder, or bipolar disorder, and/or an anxiety disorder and/or an adjustment disorder. Your evaluation will also help to determine if this combat Veteran is struggling with increased PTSD symptoms at this time. Your cognitive evaluation will determine whether he appears to have a pattern of stability or decline in cognitive ability since his admission to HBPC, and whether cognitive deficits appear consistent with a major or minor neurocognitive disorder.



Image ID Image Alt Text Image Long Descriptionfw_assessment-outcomes_D.jpg The framework for mental health evaluation flowchart with the sixth

box highlighted. A callout from the sixth box has the supporting text: "assessment outcomes," as well as "diagnosis," and an image of Mr. Apple seated in his wheelchair.



Assessment Outcomes -- RiskScreen ID 02_031.htm Screen Type Main Page 50 of 120

All mental health evaluations address potential risk to the safety or wellbeing of the patient or others.

Mr. Apple may raise several questions of risk. For example, is his declining to consider tube feeding a sign of suicidal thinking?

Select each of the following items to learn more.

• Suicidal/homicidal risk• Elder abuse/neglect• Firearms• Driving• Independent living

Previous ID 02_030.htm Next ID 02_032.htm



PageInstructions


Image ID Image Alt Text Image Long Descriptionfw_assessment-outcomes_R.jpg The framework for mental health evaluation flowchart with the sixth

box highlighted. A callout from the sixth box has the supporting text: "assessment outcomes," as well as "risk," and an image of Mr. Apple seated in his wheelchair.

Suicidal/homicidal riskScreen ID 02_031_TL01.htm Screen Type Toggle List Item Required

In HBPC, risk assessment includes evaluation of suicidal and homicidal ideation, intent, and plan and risk factors for self-harm or violence to others. The VA Suicide Prevention resources, including suicide risk assessment templates and safety plan treatment manual are important tools for HBPC MH Providers. (see http://vaww.mentalhealth.va.gov/rc-suicideprevention.asp Note: This link is inactive. If you have access to the VA Intranet, copy and paste the link into your web browser.)

Elder abuse/neglectScreen ID 02_031_TL02.htm Screen Type Toggle List Item Required

HBPC MH Providers should be attentive to signs of elder abuse or neglect (physical, sexual, emotional, abuse, financial exploitation, abandonment, neglect by self or others). In most states, healthcare professionals are mandated reporters of elder abuse/neglect to their local Adult Protective Service agency. It is important for VA clinicians to consult local policies regarding the reporting of elder abuse to their state agencies.

FirearmsScreen ID 02_031_TL03.htm Screen Type Toggle List Item Required

Many Veterans own firearms and maintain them in the home. In most cases, firearms are stored and used safely without incident. However, in conditions of acute distress, firearm ownership may increase risk for Veterans, families, and visitors to the home. Firearm safety is a critical area of assessment (related to both suicide and homicide risk) for the HBPC MH Provider.



DrivingScreen ID 02_031_TL04.htm Screen Type Toggle List Item Required

Likewise, many Veterans served by HBPC may have medical, sensory, or cognitive deficits that affect their ability to drive safely. Some wish to continue to drive despite safety concerns. This issue is a very challenging one for Veterans, families, and care providers. Many VAMCs and/or local agencies offer simulated and/or on-the-road driving evaluations to help determine driver safety.

Independent livingScreen ID 02_031_TL05.htm Screen Type Toggle List Item Required

Risks related to independent living (e.g., fire, self-care) are often addressed in HBPC (see resources under Capacity in the following section).



Assessment Outcomes – CapacityScreen ID 02_032.htm Screen Type Main Page 51 of 120

Mental health evaluations in HBPC often entail evaluation of one or more decision-making or other functional capacities. This area of evaluation may be new to many HBPC MH Providers. We recommend that the American Bar Association/American Psychological Association framework for organizing one’s approach to evaluating functional capacities.

Image used with permission.American Bar Association Commission on Law and Aging & American Psychological Association. (2008). Assessment of older adults with diminished capacity: A handbook for psychologists. Washington, DC: American Bar Association and American Psychological Association.



Image ID Image Alt Text Image Long Descriptionscales_justice.jpg An image of the scales of justice with supporting text. The base of

the scale has the supporting text: "Legal Standard." The fulcrum of the scale has the supporting text: "Clinical Judgment." On on side of the evenly balanced scale is the supporting text: "functional elements," "diagnosis," "congitive underpinnings," and "psychiatric



and emotional factors." On the other side is the supporting text: "values and perferences," "risk considerations," and "steps to enhance capacity."



Assessment Outcomes -- Capacity (continued)Screen ID 02_033.htm Screen Type Main Page 52 of 120

A thorough capacity evaluation depends on consideration of 9 elements:

1. Legal standard2. Functional elements (e.g., for medical decision making capacity: understanding, appreciation, reasoning, choice)3. Diagnosis4. Cognitive underpinnings5. Psychiatric or emotional factors6. Values7. Risk considerations8. Steps to enhance capacity9. Clinical judgment of capacity



Image ID Image Alt Text Image Long Descriptionfw_assessment-outcomes_C.jpg The framework for mental health evaluation flowchart with the sixth

box highlighted. A callout from the sixth box has the supporting text: "assessment outcomes," as well as "capacity," and an image of Mr. Apple seated in his wheelchair.



DeveloperNotes

APA/ABA Handbook graphic left off the screen. Currently do not have permission needed to use it.



Assessment Outcomes -- Capacity (continued)Screen ID 02_034.htm Screen Type Main Page 53 of 120

In Mr. Apple’s case, the question is whether he maintains the capacity to make a serious medical decision about his ongoing care, i.e., whether or not to initiate use of a feeding tube. A good interview will help to determine his abilities related to decision making, that is, functional elements regarding his ability to understand information about his diagnosis and treatment options, to appreciate how information shared applies to him and his life, to weigh risks and benefits of options and make a decision, and an ability to express a consistent choice. The clinical interview and results of mood, cognitive and other tests administered will help to inform diagnostic impressions, cognitive and emotional strengths and weaknesses that may influence decision making and, as above, the functional elements of making a healthcare decision. This information will be considered in the context of Mr. Apple’s previously and currently expressed life values and preferences and psychosocial concerns that may influence his decisions at this time.



Image ID Image Alt Text Image Long Descriptionfw_assessment-outcomes_C.jpg The framework for mental health evaluation flowchart with the sixth

box highlighted. A callout from the sixth box has the supporting text: "assessment outcomes," as well as "capacity," and an image of Mr. Apple seated in his wheelchair.

DeveloperNotes

The Mr. Apple graphic is a placeholder.



Collaboration with Team and Other ProfessionalsScreen ID 02_035.htm Screen Type Main Page 54 of 120

To inform the final conclusions and recommendation in a mental health evaluation, it is important to consider ongoing collaboration with the team. For example, if you plan to document recommendations that require specific follow up by other professionals, you may want to confirm that your recommendations are realistic ones for them.

In particularly complex cases, as you review your assessment results, you may wish to consult with a medical, pharmacy, psychiatry, neuropsychology, or other relevant specialist to ensure that your conceptualization and recommendations are on-target. For example, are you clear on the potential impact of the patient’s medical conditions, medications, or structural brain changes evident on imaging, on the patient’s current functioning and behavior? In addition, it may be appropriate for one of your recommendations to include further evaluation by a particular specialist if additional input is needed.



Image ID Image Alt Text Image Long Descriptionfw_team_collaboration.jpg The framework for mental health evaluation flowchart with the

fourth triangle on the bottom layer highlighted. A callout from the fourth triangle has the supporting text: "team collaboration" and an image of the HBPC team seated around a conference table.



Collaboration with Team and Other Professionals (continued)Screen ID 02_036.htm Screen Type Main Page 55 of 120

For Mr. Apple, it is important to understand his prognosis at this stage of ALS progression and the implications of different treatment decisions (you’ll want to know that before conducting a capacity interview with him), which may require consultation with the PCP and/or neurologist. For example, are you clear on:

• What can the Veteran and family expect in the coming months?• What is the Veteran’s life expectancy?• What decisions likely will need to be made about his care?• When would hospice care be considered appropriate?



Image ID Image Alt Text Image Long Descriptionfw_team_collaboration.jpg The framework for mental health evaluation flowchart with the

fourth triangle on the bottom layer highlighted. A callout from the fourth triangle has the supporting text: "team collaboration" and an image of the HBPC team seated around a conference table.



Summary and RecommendationsScreen ID 02_037.htm Screen Type Main Page 56 of 120

This section of your evaluation report is very important, and may be the section of the report that team members focus on. The conclusion section of the report should include:

• DSM-5 diagnoses: In this population with multiple comorbidities, you may indicate multiple diagnoses as well as diagnoses you want to continue to “rule-out” with the team.

• Summary of the Veteran’s strengths, deficits, and areas in need of support• Practical recommendations for the team. This issue will be reviewed in detail in the final section of the course, but may include issues including:

• What does this assessment tell us about how we might modify the HBPC interdisciplinary treatment plan?• What can other team members do to modify/optimize their approach with Veteran?• What other in-home supports might be needed?• Are surrogate decision-makers needed?• Does the family/Caregiver need education/support?• Might the Veteran benefit from additional mental health intervention or other services? What kind?• What other specialist evaluation might be indicated?



Image ID Image Alt Text Image Long Description



fw_conclusions.jpg The framework for mental health evaluation flowchart with the seventh box highlighted. A callout from the seventh box has the supporting text: "conclusions" and an group photo of the HBPC team.




Specialized mental health assessment in HBPC occurs within the context of interdisciplinary team care. The goals of mental health evaluation in HBPC include documenting the Veteran’s strengths and abilities, deficits and areas in need of support, risk and protective factors, and practical recommendations for the Veteran, family/Caregivers, and the HBPC team. A framework for mental health evaluation in HBPC was presented to organize both sources of information and domains of assessment that inform assessment outcomes and recommendations. The HBPC MH Provider plays an important role in integrating multiple sources of information about history and current functioning in order to inform an integrated case conceptualization that can inform the HBPC interdisciplinary treatment plan. The framework provided here is an educational tool and certainly not required to be used in clinical practice.



Image ID Image Alt Text Image Long Descriptionframework_lg.jpg This flowchart consists of three layers, the middle layer contains



seven rectangles, the bottom layer contains four triangles and a four-side polygon, and the top layer contains one triangle. The first box, on the middle layer contains the supporting text: “What is the assessment/evaluation question?” A directional arrow points to the second box, which has the supporting text: “informed consent/assent.” Between these two boxes, in the bottom layer, is a triangle with the supporting text “clinical/ethical/legal implications.” A directional arrow points to the third box, which has the supporting text: “informed consent/assent.” Between boxes two and three, in the bottom layer, is a triangle with the supporting text “sources of information.” A directional arrow points to the fourth box, which has the supporting text: “perspectives on current situation.” A directional arrow points to the fifth box, which has the supporting text: “Veteran’s functioning.” Below the third, fourth, and fifth boxes is the polygon shape, with the supporting text: “interview Veteran,” and “interview caregiver/family/HBPC team.” Above the fifth box is a triangle with the supporting text: “standardized tests.” A directional arrow points to the sixth box, which has the supporting text: “assessment outcomes.” Between boxes five and six, in the bottom layer, is a triangle with the supporting text “environmental observations.” A directional arrow points to the seventh box, which has the supporting text: “conclusions.” Between boxes six and seven, in the bottom layer, is a triangle with the supporting text “team collaboration.”





1. What is an important first step in the HBPC mental health evaluation process?

A. Obtain the Veteran's consent to proceed with the evaluation

B. Clarify the nature of the referral/assessment question - what is the need or concern?

C. Ensure the reliability and validity of any tests you plan to administer

D. Consult with the Veteran's family/Caregiver about their concerns

Correct Feedback:Correct. The first step in the framework for mental health

evaluation is to clarify the reasons for concern in the case, and who is concerned (e.g., the Veteran? family? team members?)

Incorrect Feedback:Incorrect. The first step in the framework for mental health


2. The HBPC MH Provider often interviews “collaterals,” family members or other caregivers, with the Veteran’s permission. Which of the following is generally not an area for evaluation with a collateral?

A. Collateral’s report of Veteran’s history

B. Collateral’s goals and preferences regarding Veteran’s care

C. Psychodiagnostic evaluation and differential diagnosis of collateral’s mental health issues

D. Collateral’s needs for education or additional supportive services

Correct Feedback:Correct. Diagnosis of a collateral’s mental health issues is not part

of HBPC services.

Incorrect Feedback:Incorrect. Diagnosis of a collateral’s mental health issues is not part

of HBPC services.

3. Broad goals for a mental health evaluation in HBPC include documenting all of the following except:

A. The Veteran’s strengths and abilities

B. The Veteran’s struggles and areas in need of support

C. The Veteran’s risk and protective factors

Correct Feedback:Yes, that is correct. While it can be important to note service

connected disabilities in the mental health evaluation, the goal for the HBPC mental health evaluation is not to provide an update on particular mental health disabilities.

Incorrect Feedback:



D. The Veteran’s status in regard to service connected mental health disabilities

E. Recommendations to inform the treatment plan

That is incorrect. While it can be important to note service connected disabilities in the mental health evaluation, the goal for the HBPC mental health evaluation is not to provide an update on particular mental health disabilities.

4. Which of the following may be important sources of information to inform the HBPC mental health evaluation? Select all that apply.

A. History according to VA medical records

B. History according to non-VA medical records

C. HBPC team member observations

D. Home environment

E. Veteran interview

F. Collateral interview

Correct Feedback:Yes, that is correct. All of these sources may provide important

information to inform an integrated mental health evaluation.

Incorrect Feedback:That is incorrect. All of these sources may provide important


PageInstructions




Lesson SummaryScreen ID 02_040.htm Screen Type Main Page 59 of 120

You have completed the second lesson in this course, Framework for Mental Health Evaluation in HBPC, and are now able to move forward to the third lesson, Contextual Considerations for Mental Health Evaluation in HBPC.





Integrated Mental Health Assessment in Home Based Primary Care Contextual Considerations for Mental Health Evaluation in HBPC

Contextual Considerations for Mental Health Evaluation in HBPCIntroduction


The terminal learning objective (TLO) for this lesson is to describe how to adapt the mental health evaluation to address the contextual challenges and advantages of the home setting.


1. Adapt the mental health evaluation as appropriate to an older and/or medically compromised population2. Identify ethical and clinical considerations specific to the home setting3. Compare and contrast the traditional clinical setting and the home setting






Contextual ConsiderationsScreen ID 03_002.htm Screen Type Main Page 61 of 120

The home setting of care is new for many HBPC Mental Health (MH) Providers when starting their positions. The home setting provides both great advantages for mental health evaluation and treatment, as well as challenges. HBPC MH Providers, as part of the HBPC interdisciplinary team, must be aware of general ethical, clinical, and safety issues that can arise in the home setting, as well as how best to utilize information and adjust mental health evaluations in this non-traditional setting of care.

In addition, it is essential to adapt mental health assessment methods to the HBPC population – mostly older adults with significant medical illness and/or functional disability. Such adaptations include attention to sensory abilities and fatigue, privacy or lack thereof, and test validity.



Image ID Image Alt Text Image Long Descriptionmr_mrs_apple_drinking.jpg Mr. Apple is seated in his wheelchair. His wife, Mrs.

Apple, is holding a drinking cup with a straw up to his mouth to assisting him while drinking.



Preparing for an In-Home Mental Health EvaluationScreen ID 03_003.htm Screen Type Main Page 62 of 120

For MH Providers accustomed to working in the mental health clinic setting, it can be quite a transition to provide clinical care in the home setting. In particular, a fair amount of planning is required to “go on the road” to complete an evaluation in the home. Further, the quiet and structured environment we like to create in the clinic for standardized psychological testing is not easily achieved in the home setting!



Image ID Image Alt Text Image Long Descriptionsenior_w_children.jpg A senior woman is seated with her head in her

hands. Her body language shows a high level of anxiety. Children are playing wildly in the background.




Select each of the following items to compare and contrast the context of mental health screening and evaluation in the traditional clinic setting to the home setting.

• Screening data• Chart review• Team collaboration• Scheduling• Planning assessment strategy• Assessment tools



Screening dataScreen ID 03_004_TL01.htm Screen Type Toggle List Item Required

In a traditional mental health clinic setting In the home setting

May be the first to evaluate cognitive or mood status Mood and other mental health screens, and documentation of dementia warning signs, has likely already occurred through HBPC team

Chart reviewScreen ID 03_004_TL02.htm Screen Type Toggle List Item Required




Chart review in Computerized Patient Record System (CPRS): may be done with the patient present in the room

Potential to download information through MED before home visit; but, anticipate not having access to the electronic record. Review the record before you leave the clinic

Team collaborationScreen ID 03_004_TL03.htm Screen Type Toggle List Item Required


Other clinic staff/team may not be familiar with patient HBPC team can share their own behavioral observations and concerns to date and, bi-directionally, learn from one another and work together

SchedulingScreen ID 03_004_TL04.htm Screen Type Toggle List Item Required


Run according to the clinic schedule, and patient comes to you Verify the amount of time needed for travel; be sure to have the correct address and phone number before heading out

Planning assessment strategyScreen ID 03_004_TL05.htm Screen Type Toggle List Item Required


May be seeing the patient with little to no advance notice of needed Have information about the patient’s needs through HBPC IDT members



modifications to assessment or environment who have already seen the patient

Assessment toolsScreen ID 03_004_TL06.htm Screen Type Toggle List Item Required


Any necessary assessment instruments available Have your “go-to” assessment tools with you, based on available information about the case




In this continuation of the items from the preceding page, select each of the following items to compare and contrast the context of mental health screening and evaluation in the traditional clinic setting to the home setting.

• Team awareness• Safety and collegial support• Infection control• Stigma• Privacy and reducing distractions• Collateral input



DeveloperNotes

Content of the toggle list is currently screenshots of a table filled out in MS Word. Until the basic table functionality is activated in PAM, we're either going to have to continue with the screenshots of Word method, or determine different way to present the material.

Team awarenessScreen ID 03_005_TL01.htm Screen Type Toggle List Item Required


Clinic staff are aware that you are in your office Use your check-in/out system to ensure other HBPC staff know where you are and when you are expected to report back

Safety and collegial supportScreen ID 03_005_TL02.htm Screen Type Toggle List Item Required




Other staff available nearby; VA Police typically available in case of crisis/threat

Typically will be the only VA staff person on the home visit

Infection controlScreen ID 03_005_TL03.htm Screen Type Toggle List Item Required


Clinic is generally clean with proper testing seating and surfaces; hygiene materials/hand sanitizer readily available throughout the clinic

May need to clear/clean a surface; carry hygiene materials in car and into the home

StigmaScreen ID 03_005_TL04.htm Screen Type Toggle List Item Required


Patient may have misgivings about receiving mental health services, and you are the point of initial contact

Patient may have misgivings about mental health services, but can be introduced to these services through positive relationships already established with the HBPC team

Privacy and reducing distractionsScreen ID 03_005_TL05.htm Screen Type Toggle List Item Required


Clinic allows private room with minimal distractions May be challenging to find quiet, private space; ask others in home for



privacy for evaluation, turn off television, put dog in other room, etc.

Collateral inputScreen ID 03_005_TL06.htm Screen Type Toggle List Item Required


Collaterals, such as family members, may or may not accompany Veteran to clinic; Veteran may or may not wish them to participate in interview

Family members/Caregivers are often in the home; while Veteran must give permission to interview family member, much information may be gathered simply by observing interactions



Mr. Apple: Planning for In-Home EvaluationScreen ID 03_006.htm Screen Type Main Page 65 of 120

What might Ann wish to consider in planning her visit to the Apple home?

• Interview setting• Infection control• Safety• Selecting test instruments• Scheduling



Image ID Image Alt Text Image Long Descriptiontoggle_anne_paperwork.png Ann, the MH Provider, is seated at a desk. She is

making notes with pen and paper.

Interview settingScreen ID 03_006_TL01.htm Screen Type Toggle List Item Required

Ann should already be aware that the interview will be conducted either in the living room if Mr. Apple is up in his wheelchair, or at bedside. Given Mr.



Apple’s recent agitated behavior, careful consideration of his personal space and allowance for some physical distance may be in order.

Infection controlScreen ID 03_006_TL02.htm Screen Type Toggle List Item Required

Based on information from the team, should Ann consider taking additional hygiene barriers into the home, such as gloves or booties?

SafetyScreen ID 03_006_TL03.htm Screen Type Toggle List Item Required

Ann may wish to check with the team about any other recent episodes of agitation during home visits. Are there any other safety concerns in the home?

Selecting test instrumentsScreen ID 03_006_TL04.htm Screen Type Toggle List Item Required

Based on the referral questions and Mr. Apple’s physical deficits, Ann will need to plan carefully in selecting tests appropriate for Mr. Apple (e.g., those not requiring fine motor manipulation).

SchedulingScreen ID 03_006_TL05.htm Screen Type Toggle List Item Required

How much time should Ann set aside for this visit, which may include interview and testing with Mr. Apple as well as some interaction with Mrs. Apple?



Addressing Safety for the Home VisitScreen ID 03_007.htm Screen Type Main Page 66 of 120

NOTE: All HBPC MH Providers are encouraged to review the VA’s Prevention and Management of Disruptive Behavior (PMDP) materials for community based workers, available online at: https://vaww.portal.va.gov/sites/PMDB/Pages/CommunityBasedWorkers.aspx. Note that this link is inactive. If you have access to the Intranet, copy the URL and paste it into your browser.

Maintaining the safety of HBPC team members during home visits is paramount. It is critical for HBPC MH Providers to be aware of and to follow local policies and procedures related to home visits. It is beyond the purview of this course to review all safety considerations. Rather, several categories and examples of safety issues to consider are summarized here and can serve as a starting point for dialogue with the team.







Safety ConsiderationsScreen ID 03_008.htm Screen Type Main Page 67 of 120

LISTEN TO YOUR GUT: IF YOU FEEL UNSAFE AT ANY TIME, LEAVE IMMEDIATELY


• Neighborhood• Dress• Home safety• Clinical issues• Emergencies



Image ID Image Alt Text Image Long Descriptioncollage_hazards.jpg A collage of images with safety as a theme. There is an image of a



dimly lit street at night, an angry senior aggressively pointing and being confrontive, an emergency room entrance sign, members of the HBPC team shown appropriately dressed for a home visit by wearing casual clothing, and a selection of rifles as they would appear in a gun rack.

NeighborhoodScreen ID 03_008_TL01.htm Screen Type Toggle List Item Required

• Criminal activity?• If high crime area, visit in early morning

Image ID Image Alt Text Image Long Descriptionbad_hood.jpg A dimly lit street at night with shadows and hidden

doorways

DressScreen ID 03_008_TL02.htm Screen Type Toggle List Item Required



• Be aware of professional presentation along with choosing clothing for potentially unhygienic surroundings (i.e., cover yourself appropriately)

• Use barriers (e.g., booties, gloves) as needed if there are concerns about bedbugs or infection control• White lab coats not recommended; may give impression that you carry drugs

Image ID Image Alt Text Image Long Descriptionclothing_team.jpg Three members of the HBPC team shown wearing

professional, casual clothing appropriate for a home visit

Home safetyScreen ID 03_008_TL03.htm Screen Type Toggle List Item Required

• Do other team members feel it is safe to visit alone?• Others in the home?• Pets? Are they friendly or aggressive? Ask to have them restrained away from the visit area• Smoking: follow clinic rules regarding smoking; is patient smoking at home with oxygen?• Weapons? Be aware of unsecured guns and knives; discontinue visit until secured• Modifications for special circumstances: meet in front room or porch, reduce blind spots



Image ID Image Alt Text Image Long Descriptionguns.jpg Several rifles are shown arranged as they would be

seen if displayed in a gun rack

Clinical issuesScreen ID 03_008_TL04.htm Screen Type Toggle List Item Required

• Infectious disease? Use appropriate barrier precautions.• Assault and arrest history?• Disturbed behavior flag?• Diagnoses which may predispose to aggressive behavior• Triggers for particular patients: Be aware of patient fears/triggers and adapt accordingly (e.g., Veteran with

PTSD who feels like punching people if they get too close)

Image ID Image Alt Text Image Long Descriptionangry_senior.jpg Angry senior man being agressively confrontational

and pointing his finger

EmergenciesScreen ID 03_008_TL05.htm Screen Type Toggle List Item Required



• Know policy/procedures for calling 911, if needed• Veteran's DNR status?

Image ID Image Alt Text Image Long Descriptionemergency_sign.jpg An emergency room entrance sign with an

ambulance in the background



Mr. Apple: Safety ConsiderationsScreen ID 03_009.htm Screen Type Main Page 68 of 120

Given what we know about Mr. Apple, what are potential safety issues to consider in planning for the in-home evaluation?

Based on information from other visiting staff, does the neighborhood present safety concerns? Does the team feel safe in that surrounding area? Are there any parking considerations?

Does anyone in the home have access to unsecured weapons? Does the arrangement in Mr. Apple’s living room or bedroom present problems for a safe, swift exit?

Are there any infection control and related barrier precautions to be aware of?



Image ID Image Alt Text Image Long Descriptionann_mr_apple2.jpg Ann, the MH Provider, is seated in a living room chair

and facing Mr. Apple, who is seated in his wheelchair.



Privacy and ConfidentialityScreen ID 03_010.htm Screen Type Main Page 69 of 120

Privacy and confidentiality, so critical for mental health assessment and treatment, are more challenging to ensure in home-based, interdisciplinary practice. The Veteran often lives in a residence shared by others, and he/she receives healthcare in a team context where information sharing occurs regularly.


• Privacy in the home setting• Confidentiality of information



Image ID Image Alt Text Image Long Descriptiontoggle_anne_mr_apple.png Ann, the MH Provider is shown from behind, seated

and facing Mr. Apple. Mr. Apple is seated in his wheelchair and is facing Ann.

Privacy in the home settingScreen ID 03_010_TL01.htm Screen Type Toggle List Item Required

In some home settings, privacy can be difficult to arrange as others are in the home, within earshot. Sometimes family members or other Caregivers



assume they can take part in the interview/evaluation. It is important to use your clinical judgment regarding when it may or may not be helpful to have others participate in an interview (or part of an interview) with the Veteran, and to include the Veteran in making decisions regarding who could/should be present. When privacy is important, it will help to educate family members about the need to spend some (quiet, uninterrupted) time alone with the Veteran, for example, in order to understand his perspectives and/or to reliably administer tests.

Confidentiality of informationScreen ID 03_010_TL02.htm Screen Type Toggle List Item Required

Likewise, in the context of interdisciplinary (and often, family-based) care, it is important to clarify with the Veteran who will have access to what information you are gathering. Also, it is important to let the Veteran know what information you will be documenting in the medical record and/or otherwise sharing with the team. For example, you will not be able to keep “secret” medical or functional issues that directly relate to the team’s plan of care (e.g., not taking medications, multiple falls). It is also important to understand from the Veteran what personal issues he/she may not choose to share with the team, such as historical sources of shame or guilt that do not have direct relevance for the current interdisciplinary treatment plan.



Mr. Apple: Privacy and ConfidentialityScreen ID 03_011.htm Screen Type Main Page 70 of 120

Mr. Apple’s case raises many potential challenges for privacy and confidentiality. His wife is very involved with his care and is certainly a stakeholder in the outcome of the evaluation. It will be important to determine with Mr. Apple when Mrs. Apple’s presence is and is not helpful or desired during the evaluation, and what information can be shared with her afterwards. If others are in the home at the time of the evaluation, how can privacy be optimized?

Likewise, results of the evaluation will be shared with the HBPC team and this needs to be made clear to Mr. Apple during an informed consent process. It will be important to determine with him whether there is any information he shares with you that he does not wish to be shared with others.



Image ID Image Alt Text Image Long Descriptionproof5.jpg Ann, the MH Provider, is seated in a living room chair, and is facing

Mr. Apple. Mr. Apple is seated in his wheelchair and is facing Ann. Mrs. Apple is seated on the sofa between them and has her head turned toward Ann.




Within the HBPC population, physical and sensory deficits may present a barrier to effective assessment. The MH provider should be prepared for adaptions “on the fly” to address patient needs.

Adaptations to consider include:

• Sensory deficits• Motor and speech deficits• Mental conditions and fatigue• Test norms



Sensory deficitsScreen ID 03_012_TL01.htm Screen Type Toggle List Item Required

• Hearing loss? Verify whether the Veteran has hearing loss and whether hearing aides are being used and/or available. Consider whether hearing is better in one ear versus the other. Modulate your voice tenor and volume as needed. Consider using a pocket talker.

• Vision loss? Verify if there is vision loss or visual neglect. Ensure Veteran is using available eyeglasses. Use large print materials. Adjust distance of materials as needed.

Motor and speech deficitsScreen ID 03_012_TL02.htm Screen Type Toggle List Item Required

• Be aware of impact of fine motor deficits on test results (e.g., inability or very slow completion of certain test items)• Likewise, be aware of receptive or expressive speech difficulties that may affect test performance



Mental conditions and fatigueScreen ID 03_012_TL03.htm Screen Type Toggle List Item Required

• Patients with chronic/advanced illnesses may be easily fatigued and have difficulty sustaining effort on testing; monitor and check with patient, take breaks as needed, plan brief evaluation

• Be aware of impact of medical conditions on test performance. For example, is patient with pulmonary illness using O2 as prescribed? Is pain or discomfort distracting the person from the evaluation?

Test normsScreen ID 03_012_TL04.htm Screen Type Toggle List Item Required

• Many Veterans served in HBPC are in their 70s, 80s, and 90s. Be aware of whether tests are normed for these older age groups.• Be aware of educational and cultural background that may affect test performance



Mr. Apple: Adapting the EvaluationScreen ID 03_013.htm Screen Type Main Page 72 of 120

In the case of Mr. Apple, Ann should already be aware that he has motor deficits, specifically upper and lower extremity weakness. He also has persistent fatigue.

She will need to consider both the length/demand of the evaluation sessions and the test selection. It may be more useful to plan two shorter visits to conduct the evaluation, and to plan those visits during a time of day that Mr. Apple reports feeling relatively alert and engaged. It will be important to choose or adapt tests that do not demand fine motor coordination, e.g., writing or manipulation of objects.








The home environment is a non-traditional setting for mental health practice, and can offer both advantages and disadvantages for mental health evaluation and treatment. This lesson compared the home setting to the traditional outpatient mental health clinic setting, in terms of strategies needed to plan for mental health evaluation in the home. It is critical for HBPC MH Providers to consider safety issues in the home and community, and to collaborate closely with the team in planning for any safety concerns. Privacy and confidentiality pose challenges for home-based, interdisciplinary care; HBPC MH Providers discuss these issues clearly and openly with Veterans. Mental health evaluations in the home setting must be adapted to the needs and abilities of the population being served, in terms of potential sensory loss, motor or speech deficits, fatigue, or other functional changes related to aging or medical conditions.




Mr. Apple. Mr. Apple is seated in his wheelchair and is facing Ann. Mrs. Apple is seated on the sofa between them and has her head turned toward Mr. Apple. She is looking at Mr. Apple sympathetically, and has her hand resting on his knee.





1. During your first in-home evaluation with a Veteran, his adult daughter enters the adjoining room and occasionally hollers out answers to the questions you are asking the Veteran. Which of the following responses would be appropriate? Choose all that apply.

A. Ignore her

B. Invite her to join the evaluation interview

C. Ask the Veteran if he would like his daughter to join part of the evaluation interview (as appropriate)

D. If privacy is important, ask the Veteran and daughter how best to arrange for privacy (e.g., daughter or you/Veteran moving to another room)

Correct Feedback:Correct. Your clinical judgment and intervention may be important

for ensuring the Veteran’s desired level of privacy during the interview.

Incorrect Feedback:Incorrect. Your clinical judgment and intervention may be

important for ensuring the Veteran’s desired level of privacy during the interview.

2. Indicate whether the following contexts are more characteristic of a traditional mental health clinic setting or an HBPC home care setting:

A. Predictable schedule

B. Team can provide background on patient before first mental health contact

C. Review of, and documentation in, CPRS during patient visit

D. Generally private, quiet spaces

E. Family member participation

1. Clinic setting

2. HBPC setting

Correct Feedback:Correct. The clinic setting will generally allow for a more

predictable schedule, allow review of CPRS during patient visits, and provide a quiet, private environment. The HBPC setting will more easily allow family participation and team involvement prior to first mental health contact.

Incorrect Feedback:Incorrect. The clinic setting will generally allow for a more




Answer: A = 1, B = 2, C = 1, D = 1, E = 2

3. Which of the following is fairly typical of mental health practice in home-based care?

A. Needing to attend to infection control issues

B. Working in a private, quiet environment with minimal distractions

C. Meeting patients with whom little to no information is available regarding history and presenting problems

D. Meeting infrequently with family members

Correct Feedback:Correct. Members of the HBPC team should consider taking items

such as disinfectants, gloves and booties into the home environment.

Incorrect Feedback:Incorrect. Members of the HBPC team should consider taking items


4. True or False. When considering team collaboration, the home setting can be advantageous because it allows the HBPC team to share their own behavioral observations and concerns to date, and allows the team to learn from one another.

A. True

B. False

Correct Feedback:Correct. The home setting has these advantages. Conversely, in a

clinic setting, other staff/team may not be familiar with the patient.

Incorrect Feedback:Incorrect. The home setting has these advantages. Conversely, in a


PageInstructions





You have completed the third lesson in this course, Contextual Considerations for Mental Health Evaluation in HBPC, and are now able to move forward to the fourth lesson, Mental Health Assessment Tools and Resources.





Integrated Mental Health Assessment in Home Based Primary Care Mental Health Assessment Tools and Resources

Mental Health Assessment Tools and ResourcesIntroduction


Mental health evaluation in Home-Based Primary Care (HBPC) often includes use of standardized assessment tools. Use of such tools helps to supplement clinical interviews and environmental observations with objective data regarding individual performance on standardized scales or tests. When based on appropriate normative data, these data help to characterize a Veteran’s functioning along relevant domains of interest. This lesson identifies and describes standardized assessment tools that can be used to support evaluations in HBPC. A knowledge check will provide an opportunity for self-assessment and remediation.


The terminal learning objective (TLO) for this lesson is to identify standardized assessment tools that are applicable for HBPC mental health evaluations, and their sources.

To help you achieve this objective, there are two enabling learning objectives:

1. Identify the purpose and applicability of individual assessment tools2. Identify sources for obtaining these tools for use in clinical practice





Mental Health Assessment Tools and ResourcesScreen ID 04_002.htm Screen Type Main Page 77 of 120

The assessment tools covered in this section were selected based on population relevance and common scope of practice for Mental Health (MH) Providers in HBPC. This overview of tools is not intended to be prescriptive nor restrictive in nature. The tools identified may not be appropriate for use with all patients and/or situations, and many other tools exist that may be quite helpful to inform mental health evaluation in HBPC. MH Providers must use their clinical judgment, and be aware of their own scope of competence, when choosing assessment tools to use in any given clinical situation.

Assessment tools reviewed in this section are divided by category and described by content and source. Tools available through the CPRS Mental Health Assistant (MHA) are identified; links are provided for those not available through MHA*. Some tools are commercial and some are in the public domain. When permission has been secured, tools listed below that are not available through VA MHA are archived at the HBPC Mental Health SharePoint site: https://vaww.portal.va.gov/sites/OMHS/MH-HBPC/default.aspx. Note that this link is inactive. If you have access to the Intranet, you can copy the URL and paste it into your browser.

* The MHA is an option in the VA computerized health record (CPRS) that allows a clinician to choose one of many assessment tools, and automatically puts the patient's answers to each question into the clinical progress note.



Image ID Image Alt Text Image Long Descriptionassessment_tools.jpg A series of six boxes, each with supporting text. From left to right,

the first box contains the supporting text: "risk assessment," the second box: "psychological functioning," the third box: "neurocognitive functioning and disorders," the fourth box: "decision-making and functional capacities," the fifth box: "family



caregiving," and the sixth box: "other conditions."



Risk AssessmentScreen ID 04_003.htm Screen Type Main Page 78 of 120

HBPC MH Providers often work with their teams to help evaluate and manage Veterans at increased risk for harm to self and/or others. HBPC MH Providers should be aware of VHA suicide prevention resources and utilize these resources as needed, including the Suicide Risk Pocket Card and Assessment Guide, Safety Plan Pocket Card and Treatment Manual, and related resource guides, which are available at:http://www.mentalhealth.va.gov/community providers/clinic_suicideprevention.aspas well as at:http://vaww.mentalhealth.va.gov/rc-suicideprevention.asp.Note that this second link is inactive. If you have access to the Intranet, you can copy the URL and paste it into your browser.

All HBPC MH Providers are encouraged to follow local policies regarding assessment, documentation, and management of suicide risk, and to collaborate with local Suicide Prevention Coordinators as needed. The measures to follow are possible supplements to established national and local VHA policies regarding suicide risk assessment.



Image ID Image Alt Text Image Long Descriptionassess_risk_assess.jpg The mental health assessment tools chart with the

first box, "risk assessment" highlighted.Developer Each green box on screen (Suicide, Firearms and Driving, Elder Abuse) should be a clickable link or button to a new window displaying the content.



Notes

Please indicate a visited state for each New Window.



Risk Assessment, SuicideScreen ID 04_004.htm Screen Type Main Page 79 of 120

Suicide RiskThe HBPC population has many demographic and clinical features that are associated with higher suicide rates (e.g., older age, poor health, cumulative losses, high rates of depression, firearm ownership) than general primary care populations. Mental health evaluation in HBPC should always include screening and evaluation for suicide risk. The tools listed here may supplement evaluation and help to monitor Veterans over time.


• Beck Hopelessness Scale (BHS)• Reasons for Living – Older Adults Scale (RFL-OA)• Suicidal Behavior Questionnaire – Revised (SBQ-R)



Image ID Image Alt Text Image Long Descriptionassess_risk_assess_drop1.jpg The mental health assessment tools chart with the first box, "risk

assessment" highlighted. A directional arrow originates from the "risk assessment" box and points to two smaller boxes on a lower level, indicating that the two smaller boxes are sub-categories. The



supporting text in the first sub-category box is "suicide," and in the second box "firearms and driving." The first sub-category box "suicide" is highlighted.

Beck Hopelessness Scale (BHS)Screen ID 04_004_TL01.htm Screen Type Toggle List Item Required

• Brief Description: The BHS is a 20-item (true/false) self-report measure of positive and negative feelings about the future, loss of motivation, and expectations.

• Source/Availability: Pearson; VA Mental Health Assistant• Reference: Beck & Steer (1993)

Reasons for Living – Older Adults Scale (RFL-OA)Screen ID 04_004_TL02.htm Screen Type Toggle List Item Required

• Brief Description: The RFL-OA is a 69-item, Likert scale, self-report measure of reasons for living among older adults at risk for suicide.• Source/Availability: With permission from primary author; Contact: Barry Edelstein – [email protected]• Reference: Edelstein et al. (2009)

Suicidal Behavior Questionnaire – Revised (SBQ-R)Screen ID 04_004_TL03.htm Screen Type Toggle List Item Required

• Brief Description: The SBQ-R is a 4-item, Likert scale, self-report measure evaluating lifetime suicidal ideation and/or attempts, frequency of suicidal ideation, threat of suicide attempt, and likelihood of suicidal behavior in the future. The SBQ-R was not developed specifically for use with older adults but has some evidence of reliability/validity with adult clinical populations and may be helpful with younger HBPC patients.

• Source/Availability: Public domain; HBPC SharePoint site:https://vaww.portal.va.gov/sites/OMHS/MH-HBPC/default.aspx.Note that this link is inactive. If you have access to the Intranet, you can copy the URL and paste it into your browser.

• Reference: Osman, Bagge, Guitierrez, Konick, Kooper & Barrios (2001)



Risk Assessment, Firearms and Driving SafetyScreen ID 04_005.htm Screen Type Main Page 80 of 120

Researchers have concluded that firearms in the home are associated with increased risk of harm to self or others as well as death, and these risks increase among individuals with cognitive impairment. Functional and cognitive impairment is also associated with diminished driving ability and increased risk for accidental harm or death to self or others. Given the high prevalence of older adults with complex medical and/or cognitive impairment in HBPC, MH Providers are encouraged to collaborate with the HBPC team for evaluation and management of these potential safety concerns.

DVA Firearms & Driving Questionnaire (VA Form 10-0435, 2005)

• Brief Description: VA Form 10-0435 is a brief provider-rating formdesigned to standardize assessment of firearm possession and safety (4 items) and current driving practices and safety (8 items) among older veterans.


• Reference: LoConte, Gleason, Gunter-Hunt, Carlsson, & Siebers, 2008



Image ID Image Alt Text Image Long Descriptionassess_risk_assess_drop2.jpg The mental health assessment tools chart with the first box "risk



assessment" highlighted. A directional arrow originates from the "risk assessment" box and points to two smaller boxes on a lower level, indicating that the two smaller boxes are sub-categories. The supporting text in the first sub-category box is "suicide," and in the second box "firearms and driving." The second sub-category box "firearms and driving" is highlighted.



Psychological Functioning – Depressive DisordersScreen ID 04_006.htm Screen Type Main Page 81 of 120

Depression

Evaluating late life depression can be a complex task due to concomitant medical and neurological factors as well as pharmacological agents. Depression in later life may present differently than in younger adults and include greater reporting of physiological symptoms (e.g., somatic complaints, sleep disruption, memory complaints), an apathetic presentation with less expressed sadness, guilt, or worthlessness, and/or co-occurring anxiety. Depression also may present differently across racial/ethnic backgrounds. MH Providers are encouraged to assess depression using an interdisciplinary approach and tools appropriate for an aging medical population.


• Patient Health Questionnaire (PHQ-9)• Geriatric Depression Scale (GDS; GDS-15)• Beck Depression Inventory-II (BDI-II)• Cornell Scale for Depression in Dementia (CSDD)




PageInstructions


Image ID Image Alt Text Image Long Descriptionassess_psycho_function_drop1.jpg The mental health assessment tools chart with the second box,

"psychological functioning" highlighted. A directional arrow originates from the "psychological functioning" box and points to three smaller boxes on a lower level, indicating that the three smaller boxes are sub-categories. The supporting text in the first sub-category box is "depressive disorders," in the second box "anxiety, trauma, stress-related," and in the third "substance-related addictive disorders." The first sub-category box "depressive disorders" is highlighted.

Patient Health Questionnaire (PHQ-9)Screen ID 04_006_TL01.htm Screen Type Toggle List Item Required

• Brief Description: The PHQ-9 is a 9-item, Likert scale, self-report measure for screening and measuring the severity of depression based on DSM-IV criteria. One additional item measures the impact of symptoms on daily functioning. This measure was developed for primary care but not older adults; however, there is good evidence for the reliability/validity of the PHQ-9 with older adults in primary care settings.

• Source/Availability: Pfizer; VA Mental Health Assistant, HBPC SharePoint site:https://vaww.portal.va.gov/sites/OMHS/MH-HBPC/default.aspx.Note that this link is inactive. If you have access to the Intranet, you can copy the URL and paste it into your browser.

• Reference: Kroenke, Spitzer, & Williams (2001)

Geriatric Depression Scale (GDS; GDS-15)Screen ID 04_006_TL02.htm Screen Type Toggle List Item Required

• Brief Description: The GDS is a 30-item (yes/no) self-report measure of depression in older adults. There also is a 15-item (yes/no) version of the measure that has similar psychometric properties. The GDS does not contain somatic complaint items, which should be evaluated separately (e.g., sleep, appetite).

• Source/Availability: Public domain; VA Mental Health Assistant, HBPC SharePoint site:https://vaww.portal.va.gov/sites/OMHS/MH-HBPC/default.aspx.Note that this link is inactive. If you have access to the Intranet, you can copy the URL and paste it into your browser.



• Reference: Yesavage, Brink, Rose, & Lum (1983); Lesher & Berryhill (1994)

Beck Depression Inventory-II (BDI-II)Screen ID 04_006_TL03.htm Screen Type Toggle List Item Required

• Brief Description: The BDI-II is a 21-item, Likert scale, self-report measure used for evaluating severity of depressive symptoms in adults. The BDI-II has eight items assessing somatic complaints, which may elevate scores in some older adults. In addition, its 4-point, Likert type scale format may be difficult for those with limited literacy or cognitive impairment.

• Source/Availability: Pearson; VA Mental Health Assistant• Reference: Beck, Steer, & Brown (1996)

Cornell Scale for Depression in Dementia (CSDD)Screen ID 04_006_TL04.htm Screen Type Toggle List Item Required

• Brief Description: The CSDD is a 19-item, clinician-rated measure that can be used for evaluating depression in individuals with dementia. It entails completing two semi-structured interviews, with an informant and with the patient. It was designed for identifying severity among those with a diagnosis of depression, rather than identifying the disorder, but may be useful as part of an evaluation of mood among Veterans with dementia.

• Source/Availability: With permission from primary author; HBPC SharePoint site:https://vaww.portal.va.gov/sites/OMHS/MH-HBPC/default.aspx.Note that this link is inactive. If you have access to the Intranet, you can copy the URL and paste it into your browser.

• Reference: Alexopoulos, Abrams, Young, Shamoian (1988)



Psychological Functioning – Anxiety, Trauma, Stress-RelatedScreen ID 04_007.htm Screen Type Main Page 82 of 120

Anxiety, Trauma and Stress-Related; and Obsessive-Compulsive and Related Disorders

Anxiety disorders are prevalent among older adults and often associated with chronic medical conditions such as cardiac or respiratory illness, dementia, and functional impairment. Anxiety disorders pose risk for and are frequently comorbid with late life depression. Avoidance symptoms core to anxiety disorders can be more difficult to recognize due to decreased social engagement in the HBPC population.




"psychological functioning" highlighted. A directional arrow originates from the "psychological functioning" box and points to three smaller boxes on a lower level, indicating that the three smaller boxes are sub-categories. The supporting text in the first sub-category box is "depressive disorders," in the second box "anxiety, trauma, stress-related," and in the third "substance-related addictive disorders." The second sub-category box, "anxiety, trauma, stress-related," is highlighted.



Psychological Functioning – Generalized Anxiety DisorderScreen ID 04_008.htm Screen Type Main Page 83 of 120

Generalized Anxiety Disorder

Generalized anxiety is the most researched anxiety disorder among older adults. Excessive worry may be lifelong or develop in later life, and be associated with declining health, changes in family and/or financial status, and other late-life changes.


• Beck Anxiety Inventory (BAI)• Geriatric Anxiety Inventory (GAI)• Generalized Anxiety Disorder Scale (GAD-7)




"psychological functioning" highlighted. A directional arrow originates from the "psychological functioning" box and points to



three smaller boxes on a lower level, indicating that the three smaller boxes are sub-categories. The supporting text in the first sub-category box is "depressive disorders," in the second box "anxiety, trauma, stress-related," and in the third "substance-related addictive disorders." The second sub-category box, "anxiety, trauma, stress-related," is highlighted.

Beck Anxiety Inventory (BAI)Screen ID 04_008_TL01.htm Screen Type Toggle List Item Required

• Brief Description: The BAI is a 21-item, Likert scale, self-report measure of somatic and cognitive symptoms of anxiety.• Source/Availability: Pearson; VA Mental Health Assistant• Reference: Beck, Epstein, Brown, & Steer (1988)

Geriatric Anxiety Inventory (GAI)Screen ID 04_008_TL02.htm Screen Type Toggle List Item Required

• Brief Description: The GAI is a 20-item (agree/disagree) self-report measure of anxiety symptoms commonly reported among older adults.• Source/Availability: Copyrighted by authors; http://www.gai.net.au/.• Reference: Pachana et al. (2007)

Generalized Anxiety Disorder Scale (GAD-7)Screen ID 04_008_TL03.htm Screen Type Toggle List Item Required

• Brief Description: The GAD-7 is a 7-item, Likert scale, self-report measure of anxiety symptoms based on DSM-IV criteria. This measure was developed for primary care and not specifically for older adults; however, there is some evidence for the reliability/validity of the GAD-7 with older adults.

• Source/Availability: Pfizer; VA Mental Health Assistant, HBPC SharePoint site:



https://vaww.portal.va.gov/sites/OMHS/MH-HBPC/default.aspx.Note that this link is inactive. If you have access to the Intranet, you can copy the URL and paste it into your browser.

• Reference: Spitzer, Kroenke, Williams, & Löwe (2006)



Psychological Functioning – Trauma-Related and Stressor-Related DisordersScreen ID 04_009.htm Screen Type Main Page 84 of 120

Trauma-Related and Stressor-Related Disorders

Older veterans with PTSD may develop the disorder based on earlier life or more recent traumatic experience. PTSD associated with earlier life trauma (e.g., combat) may represent a chronic condition or late-life exacerbation. MH Providers are encouraged to evaluate lifetime exposure to combat and non-combat traumatic events.


• Life Event Checklist – 5 (LEC-5)• Primary Care PTSD Screen (PC-PTSD)• PTSD Checklist for DSM-5 (PCL-5)






"psychological functioning" highlighted. A directional arrow originates from the "psychological functioning" box and points to three smaller boxes on a lower level, indicating that the three smaller boxes are sub-categories. The supporting text in the first sub-category box is "depressive disorders," in the second box "anxiety, trauma, stress-related," and in the third "substance-related addictive disorders." The second sub-category box, "anxiety, trauma, stress-related," is highlighted.

Life Event Checklist – 5 (LEC-5)Screen ID 04_009_TL01.htm Screen Type Toggle List Item Required

• Brief Description: The LEC-5 (standard version) is a 17-item, Likert scale, self-report measure of potentially traumatic events across a respondent’s entire life. The LEC-5 assesses 17 events known to be distressing (e.g., natural disaster, assault) and can be rated based on direct experience, witnessing an event, knowledge of an event, exposure due to job responsibilities, etc. There also is an extended self-report version (contains 10 additional questions to identify worst event, if more than one, and an interview that contains questions seeking clarification on each endorsed item on the LEC-5 to establish worst event and if Criterion A is met.)

• Source/Availability: Public domain; HBPC Sharepoint site:https://vaww.portal.va.gov/sites/OMHS/MH-HBPC/default.aspx.Note that this link is inactive. If you have access to the Intranet, you can copy the URL and paste it into your browser.

• Reference: Weathers, Blake, Schnurr, Kaloupek, Marx, & Keane (2013)

Primary Care PTSD Screen (PC-PTSD)Screen ID 04_009_TL02.htm Screen Type Toggle List Item Required

• Brief Description: The PC-PTSD is a 4-item (yes/no) self-report screening measure of PTSD for Veterans seen in VA primary care settings based on DSM-IV criteria. This measure is being updated for the DSM-5 but is not currently available.

• Source/Availability: Public domain; HBPC SharePoint site:https://vaww.portal.va.gov/sites/OMHS/MH-HBPC/default.aspx.



Note that this link is inactive. If you have access to the Intranet, you can copy the URL and paste it into your browser.• Reference: Prins, Ouimette, & Kimerling (2003)

PTSD Checklist for DSM-5 (PCL-5)Screen ID 04_009_TL03.htm Screen Type Toggle List Item Required

• Brief Description: The PCL-5 is a 20-item revision of the PCL based on the DSM-5 criteria and can be administered with or without an extended Criterion A assessment (5 items) and/or with the LEC-5. The PCL-5 scoring system is undergoing validation study; it will be posted to the VA Mental Health Assistant when available.


• Reference: Weathers, Litz, Keane, Palmieri, Marx, & Schnurr (2013)



Psychological Functioning – HoardingScreen ID 04_010.htm Screen Type Main Page 85 of 120

Hoarding

Compulsive hoarding is a condition characterized by difficulty discarding non-essential possessions, clutter, and distress. Researchers note that hoarding appears different from obsessive-compulsive disorder but is comorbid with other mental health conditions such as mood and anxiety disorders. Given the nature of HBPC services, HBPC team members likely encounter hoarding behaviors more frequently than they are recognized in clinic-based settings.


• Hoarding Rating Scale (HRS)• Savings Inventory-Revised (SIR)




"psychological functioning" highlighted. A directional arrow originates from the "psychological functioning" box and points to



three smaller boxes on a lower level, indicating that the three smaller boxes are sub-categories. The supporting text in the first sub-category box is "depressive disorders," in the second box "anxiety, trauma, stress-related," and in the third "substance-related addictive disorders." The second sub-category box, "anxiety, trauma, stress-related," is highlighted.

Hoarding Rating Scale (HRS)Screen ID 04_010_TL01.htm Screen Type Toggle List Item Required

• Brief Description: The HRS is a 5-item, Likert scale, measure that can be used as a questionnaire or semi-structured interview to identify probable hoarding problem. The HRS evaluates clutter, difficulty discarding, excessive acquisition, and distress and impairment resulting from hoarding behaviors.

• Source/Availability: Public Domain; HBPC SharePoint site:https://vaww.portal.va.gov/sites/OMHS/MH-HBPC/default.aspx.Note that this link is inactive. If you have access to the Intranet, you can copy the URL and paste it into your browser.

• Reference: Tolin, Frost, & Steketee (2010)

Savings Inventory-Revised (SIR)Screen ID 04_010_TL02.htm Screen Type Toggle List Item Required

• Brief Description: The SIR is a 23-item, Likert scale, self-report measure evaluating features of probable hoarding problems including: excessive acquisition, difficulty discarding, and clutter. The measure contains mean scores for clinical and nonclinical samples.

• Source/Availability: Public Domain;HBPC SharePoint site:https://vaww.portal.va.gov/sites/OMHS/MH-HBPC/default.aspx.Note that this link is inactive. If you have access to the Intranet, you can copy the URL and paste it into your browser.

• Reference: Frost, Steketee, & Grisham (2004)



Psychological Functioning – Substance-Related and Addictive DisordersScreen ID 04_011.htm Screen Type Main Page 86 of 120

Substance-Related and Addictive Disorders

Veterans served in HBPC may have chronic, recurring, and/or later onset substance use disorders. Chronic substance use can underlie some medical conditions in later life; however, even moderate use may complicate other medical, neurological, or psychiatric conditions.

Alcohol misuse is a common problem; many older adults are not aware of aging-related changes in the body’s ability to metabolize alcohol and the associated health, cognitive, and functional risks of drinking.


• Alcohol Use Disorder Identification Test (AUDIT)• Michigan Alcoholism Screening Test-Geriatric Version (MAST-G)






"psychological functioning" highlighted. A directional arrow originates from the "psychological functioning" box and points to three smaller boxes on a lower level, indicating that the three smaller boxes are sub-categories. The supporting text in the first sub-category box is "depressive disorders," in the second box "anxiety, trauma, stress-related," and in the third "substance-related addictive disorders." The third sub-category box, "substance-related addictive disorders," is highlighted.

Alcohol Use Disorder Identification Test (AUDIT)Screen ID 04_011_TL01.htm Screen Type Toggle List Item Required

• Brief Description: The AUDIT is a 10-item, Likert scale, self-report measure of alcohol use over the past year that was developed by the World Health Organization for use in primary care. The AUDIT has been validated for use with older adults. There is also a 3-item version pertaining to alcohol consumption (AUDIT-C).


• Reference: Babor, de la Fuenta, Saunders, & Grant (1992)

Michigan Alcoholism Screening Test-Geriatric Version (MAST-G)Screen ID 04_011_TL02.htm Screen Type Toggle List Item Required

• Brief Description: The MAST-G is a 24-item (yes/no) self-report measure designed to identify alcohol abuse and/or dependence among older adults. There is also a 10-item version (SMAST-G).

• Source/Availability: Public Domain, HBPC SharePoint site:https://vaww.portal.va.gov/sites/OMHS/MH-HBPC/default.aspx.Note that this link is inactive. If you have access to the Intranet, you can copy the URL and paste it into your browser.

• Reference: Blow et al. (1992)



Neurocognitive Functioning and Disorders – DeliriumScreen ID 04_012.htm Screen Type Main Page 87 of 120

Delirium

Delirium is an acute confusional state commonly associated with acute medical illnesses and may co-occur in those with neurocognitive disorders. Urinary tract infections, medication changes, dehydration, fever, and other medical issues can precipitate delirium, which is a medical crisis in need of immediate treatment. Delirium should be evaluated whenever there is acute onset of global cognitive impairments or marked behavioral changes. Note that people with neurocognitive impairment are at relatively high risk for delirium; the delirium can and should be treated.


• Confusion Assessment Method (CAM)• The Delirium Rating Scale-Revised (DRS-R-98)



Image ID Image Alt Text Image Long Descriptionassess_neurocog_drop1.jpg The mental health assessment tools chart with the third box,

"neurocognitive functioning and disorders" highlighted. A directional arrow originates from the "neurocognitive functioning and



disorders" box and points to two smaller boxes on a lower level, indicating that the two smaller boxes are sub-categories. The supporting text in the first sub-category box is "delirium," and in the second box "neurocognitive disorders." The first sub-category box, "delirium," is highlighted.

Confusion Assessment Method (CAM)Screen ID 04_012_TL01.htm Screen Type Toggle List Item Required

• Brief Description: The CAM is a widely-used, standardized method for identifying delirium that correlates with DSM criteria for delirium. It is a 4-item, observer-rated measure, which the author recommends should be used in conjunction with a brief cognitive test (e.g., Mini-Cog) and measure of attention (e.g., digit span).


• Reference: Inouye et al. (1990)

The Delirium Rating Scale-Revised (DRS-R-98)Screen ID 04_012_TL02.htm Screen Type Toggle List Item Required

• Brief Description: The DRS-R-98 is a 16-item, clinician-rated scale that contains 3 diagnostic items and 13 severity items. The severity section can be used as a separate scale for serial assessment.

• Source/Availability: With permission from author; HBPC SharePoint site:https://vaww.portal.va.gov/sites/OMHS/MH-HBPC/default.aspx.Note that this link is inactive. If you have access to the Intranet, you can copy the URL and paste it into your browser.

• Reference: Trzepacz et al. (2001)



Neurocognitive Functioning and Disorders – Neurocognitive DisordersScreen ID 04_013.htm Screen Type Main Page 88 of 120

Neurocognitive Disorders

Cognitive decline is a common problem among the HBPC population, and MH Providers are encouraged to become familiar with the differences between normal and abnormal cognitive aging. Cognitive impairment influences Veteran and Caregiver well-being, medical understanding and/or adherence, and everyday functioning. The following measures are recommended when dementia warning signs are present (e.g., difficulty engaging in self-care activities). Given the psychometric limitations associated with brief cognitive assessment measures in general, standardized cognitive assessment is only recommended when there is reason for concern such as dementia warning signs, rather than as a screening tool for an entire group of Veterans, e.g., all HBPC patients.


• Blessed-Orientation-Memory Concentration Test (BOMC)• Dementia Rating Scale-2 (DRS-2)• Montreal Cognitive Assessment (MoCA)• Repeatable Batter for the Assessment of Neuropsychological Status (RBANS); RBANS Update• St. Louis University Mental Status Exam (SLUMS)




PageInstructions


Image ID Image Alt Text Image Long Descriptionassess_neurocog_drop2.jpg The mental health assessment tools chart with the third box,

"neurocognitive functioning and disorders" highlighted. A directional arrow originates from the "neurocognitive functioning and disorders" box and points to two smaller boxes on a lower level, indicating that the two smaller boxes are sub-categories. The supporting text in the first sub-category box is "delirium," and in the second box "neurocognitive disorders." The second sub-category box, "neurocognitive disorders," is highlighted.

Blessed-Orientation-Memory Concentration Test (BOMC)Screen ID 04_013_TL01.htm Screen Type Toggle List Item Required

• Brief Description: The BOMC is a 6-item measure that contains items for orientation, verbal recall, and attention.• Source/Availability: Public Domain; VHA Mental Health Assistant• Reference: Blessed, Tomlinson, & Roth (1968)

Dementia Rating Scale-2 (DRS-2)Screen ID 04_013_TL02.htm Screen Type Toggle List Item Required

• Brief Description: The DRS-2 is a brief test battery of global cognitive ability that was developed to avoid floor effects in patients with clinically significant impairment as opposed to ceiling effects in high functioning patients. It is normed on healthy adults ranging from 56 to 105 years of age. The test measures attention, initiation/perseveration, construction, conceptualization, and memory.

• Source/Availability: Psychological Assessment Resources (PAR); http://www4.parinc.com/Default.aspx• Reference: Jurica, Leitten, & Mattis (2001)

Montreal Cognitive Assessment (MoCA)Screen ID 04_013_TL03.htm Screen Type Toggle List Item Required

• Brief Description: The MoCA contains items for visuospatial ability, executive functioning, naming, memory, attention, language, abstraction, and orientation, and is scored up to 30 total points. The MoCA has been translated into many languages and has a version for use with the blind.



There also is a multi-paged version with enlarged stimuli.• Source/Availability: Public Domain; HBPC SharePoint site:

https://vaww.portal.va.gov/sites/OMHS/MH-HBPC/default.aspx.Note that this link is inactive. If you have access to the Intranet, you can copy the URL and paste it into your browser.

• Reference: Nasreddine et al. (2005)

Repeatable Batter for the Assessment of Neuropsychological Status (RBANS); RBANS UpdateScreen ID 04_013_TL04.htm Screen Type Toggle List Item Required

• Brief Description: The RBANS or RBANS Update is a brief neurocognitive battery of global cognitive ability that measures immediate and delayed memory, attention, language, and visuospatial ability. The RBANS was developed for individuals aged 20-89. The RBANS Update extended the age range downward to 12 and now includes subtest scores, which were formerly calculated by hand for the original RBANS.

• Source/Availability: Pearson; http://www.pearsonclinical.com/psychology.html• Reference: Randolph (1998); Randolph (2012)

St. Louis University Mental Status Exam (SLUMS)Screen ID 04_013_TL05.htm Screen Type Toggle List Item Required

• Brief Description: The SLUMS contains items for orientation, recall, memory, visuospatial ability, language, attention, abstraction, and executive functioning, and is scored up to 30 total points. There is a parallel form version that changes the occupation of the main character in the story from stockbroker to farmer.

• Source/Availability: Public Domain; HBPC SharePoint site:https://vaww.portal.va.gov/sites/OMHS/MH-HBPC/default.aspx.Note that this link is inactive. If you have access to the Intranet, you can copy the URL and paste it into your browser.

• Reference: Tariq, Tumosa, Chibnall, Perry, & Morley (2006)



Decision-Making and Functional CapabilitiesScreen ID 04_014.htm Screen Type Main Page 89 of 120

Decision-Making and Functional Capabilities

HBPC MH Providers often provide a crucial service for the interdisciplinary team by providing evaluation of a Veteran’s ability to continue to reside independently in the community, make medical and/or financial decisions, or consent to certain aspects of care. These evaluations inform the interdisciplinary treatment plan, to be consistent with the Veteran’s values, abilities, and social context. There are no standardized tools that can serve as a “capacimeter,” i.e., the score telling you whether or not an individual has the capacity in question. These and other tools may contribute to an integrated evaluation process (ABA & APA, 2008).


• Functional Assessment Staging (FAST)• Independent Living Scales (ILS)• Katz Index of Activities of Daily Living Scale (Katz ADL)• Lawton-Brody Instrumental Activities of Daily Living Scale (IADL)



Image ID Image Alt Text Image Long Descriptionassess_decision_making.jpg The mental health assessment tools chart with the

fourth box, "decision-making and functional



capacities" highlighted.

Functional Assessment Staging (FAST)Screen ID 04_014_TL01.htm Screen Type Toggle List Item Required

• Brief Description: The FAST is a clinician-rating scale that can be used to quickly evaluate and stage the progressive functional deterioration observed in Alzheimer disease.

• Source/Availability: Public Domain; VHA Mental Health Assistant• Reference: Reisburg (1988)

Independent Living Scales (ILS)Screen ID 04_014_TL02.htm Screen Type Toggle List Item Required

• Brief Description: The ILS is a broad measure of abilities associated with caring for oneself and/or property. The ILS contains 70-items across five subscales: memory/orientation, managing money, managing home and transportation, health and safety, and social adjustment. The entire measure can be used to obtain an overall score or select subscales can be administered.

• Source/Availability: Pearson; http://www.pearsonclinical.com/psychology.html• Reference: Loeb (1996)

Katz Index of Activities of Daily Living Scale (Katz ADL)Screen ID 04_014_TL03.htm Screen Type Toggle List Item Required

• Brief Description: The Katz ADL is 6-item, clinician rating scale used to assess a patient's functional status by measuring his/her ability to perform activities of daily living independently versus with assistance. Functions assessed include bathing, dressing, toileting, transferring, continence, and feeding.

• Source/Availability: Public Domain; VHA Mental Health Assistant• Reference: Katz, Ford, Moskowitz, Jackson, & Jaffee (1963)



Lawton-Brody Instrumental Activities of Daily Living Scale (IADL)Screen ID 04_014_TL04.htm Screen Type Toggle List Item Required

• Brief Description: The IADL is a 11-item, clinician rating scale used to assess a patient's functional status by measuring his/her ability to perform more complex tasks of daily living across 8 domains: telephone, shopping, food preparation, housekeeping, laundry, mode of transportation, medication management, and management of finances.

• Source/Availability: The Gerontological Society of America; VHA Mental Health Assistant• Reference: Lawton & Brody (1969)



Family CaregivingScreen ID 04_015.htm Screen Type Main Page 90 of 120

Family Caregiving

One mission of the HBPC program is to aid and empower family or other informal Caregivers to assist in a Veteran’s care, allowing Veterans to remain in a least restrictive environment for as long as possible. Caregiving can be stressful and have a negative impact on a Caregiver’s physical and mental health. HBPC MH Providers can assist in providing Caregiver evaluation and support services.


• REACH-II Risk Appraisal Measure (RAM)• Zarit Burden Interview (ZBI)



Image ID Image Alt Text Image Long Descriptionassess_family_caregiving.jpg The mental health assessment tools chart with the

fifth box, "family caregiving" highlighted.

REACH-II Risk Appraisal Measure (RAM)Screen ID 04_015_TL01.htm Screen Type Toggle List Item Required

• Brief Description: The RAM is a 16-item, Likert scale, self-report measure used to assess well-being and identify needed areas of support for



Caregivers of patients with dementia such as access to dangerous objects, driving, wandering, smoking, or being left home alone. This measure was adapted for use in REACH-VA, but the Risk Assessment Tool used in REACH-VA also contains other tools such as the PHQ-9 and the Zarit (Nichols et al., 2011).

• Source/Availability: With author's permission;HBPC SharePoint site:https://vaww.portal.va.gov/sites/OMHS/MH-HBPC/default.aspx.Note that this link is inactive. If you have access to the Intranet, you can copy the URL and paste it into your browser.

• Reference: Czaja et al. (2009); Nichols, Martindale-Adams, Burns, Graney, & Zuber (2011)

Zarit Burden Interview (ZBI)Screen ID 04_015_TL02.htm Screen Type Toggle List Item Required

• Brief Description: The ZBI is a 22-item, Likert scale, self-report measure developed to assess subjective burden among Caregivers with dementia. The questions are worded subjectively to focus on the affective response of the Caregiver. The ZBI also has a short version (12-items) and a 4-item screening version. The short and screening versions are available through the VHA Mental Health Assistant.

• Source/Availability: Permission to the VA; VHA Mental Health Assistant• Reference: Zarit, Reever, & Bach-Peterson (1980)



Other Conditions That May Be a Focus of Clinical Attention – BereavementScreen ID 04_016.htm Screen Type Main Page 91 of 120

Bereavement

Bereavement is another risk factor for depression as grief over the loss of a loved one in later life can be magnified by cumulative losses (e.g., in functioning, relationships, roles). Complicated grief (or, persistent complex bereavement disorder) remains a condition for further study in DSM-5; it is another possible consequence of bereavement, characterized by marked daily separation distress and trauma-related symptoms.


• Prolonged Grief Disorder (PG-13)• Texas Revised Inventory of Grief (TRIG)



Image ID Image Alt Text Image Long Descriptionassess_other_drop1.jpg The mental health assessment tools chart with the sixth box, "other

conditions" highlighted. A directional arrow originates from the "other conditions" box and points to two smaller boxes on a lower level, indicating that the two smaller boxes are sub-categories. The supporting text in the first sub-category box is "bereavement," and



in the second box "behavioral disturbance." The first sub-category box, "bereavement," is highlighted.

Prolonged Grief Disorder (PG-13)Screen ID 04_016_TL01.htm Screen Type Toggle List Item Required

• Brief Description: The PG-13 is a 13-item, Likert scale, self-report measure of prolonged grief in reaction to the loss of a loved one. It was derived from the Inventory of Complicated Grief (ICG; Prigerson et al., 1995), a 19-item measure of bereavement-related thoughts and behaviors measuring pathological grief symptoms such as disbelief, anger, and hallucinations. The PG-13 measures symptoms (feelings, thoughts, actions) associated with Prolonged Grief Disorder, which was proposed but not included in the DSM-5. The test author noted PGD will be included in the ICD-11.

• Source/Availability: With permission from primary author; HBPC SharePoint site:https://vaww.portal.va.gov/sites/OMHS/MH-HBPC/default.aspx.Note that this link is inactive. If you have access to the Intranet, you can copy the URL and paste it into your browser.

• Reference: Prigerson & Maciejewski (2008)

Texas Revised Inventory of Grief (TRIG)Screen ID 04_016_TL02.htm Screen Type Toggle List Item Required

• Brief Description: The TRIG is a 21-item, Likert scale, self-report measure of grief associated with loss of a loved one and is divided into two measures: present grief (TRIG-Present, 13-items) and past difficulties due to loss (TRIG-Past, 8-items).

• Source/Availability: With permission from contact author; HBPC SharePoint site:https://vaww.portal.va.gov/sites/OMHS/MH-HBPC/default.aspx.Note that this link is inactive. If you have access to the Intranet, you can copy the URL and paste it into your browser.

• Reference: Faschingbauer (1981); Faschingbauer, Zisook, & DeVaul (1987)



Other Conditions That May Be a Focus of Clinical Attention – Behavioral DisturbanceScreen ID 04_017.htm Screen Type Main Page 92 of 120

Behavioral Disturbance

Veterans with neurocognitive disorders, delirium, or other acute medical conditions may present with behavioral disturbances that are clinically significant and may impact differential diagnosis, treatment planning and management, and caregiving. The DSM-5 identifies behavioral disturbance as psychotic symptoms, mood disturbance, agitation, apathy, or other behavioral symptoms according to severity of impairment to daily functioning (i.e., mild, moderate, or severe).


• Cohen-Mansfield Agitation Inventory (CMAI)• Revised Memory and Behavior Problems Checklist (RMBPC)



Image ID Image Alt Text Image Long Descriptionassess_other_drop2.jpg The mental health assessment tools chart with the sixth box, "other

conditions" highlighted. A directional arrow originates from the "other conditions" box and points to two smaller boxes on a lower



level, indicating that the two smaller boxes are sub-categories. The supporting text in the first sub-category box is "bereavement," and in the second box "behavioral disturbance." The second sub-category box, "behavioral disturbance," is highlighted.

Cohen-Mansfield Agitation Inventory (CMAI)Screen ID 04_017_TL01.htm Screen Type Toggle List Item Required

• Brief Description: The CMAI is a 29-item measure designed to assess the frequency and demonstration of agitated behaviors in older adults. The CMAI was developed for use in long term care, but there is a 14-item version, a community version, a version for relatives, and a disruptiveness version.

• Source/Availability: With permission from copyright owner;HBPC SharePoint site:https://vaww.portal.va.gov/sites/OMHS/MH-HBPC/default.aspx.Note that this link is inactive. If you have access to the Intranet, you can copy the URL and paste it into your browser; may also contact the copyright owner [email protected]

• Reference: Cohen-Mansfield, Marx, & Rosenthal (1989)

Revised Memory and Behavior Problems Checklist (RMBPC)Screen ID 04_017_TL02.htm Screen Type Toggle List Item Required

• Brief Description: The RMBPC is a 24-item, Caregiver-report measure of behavioral difficulties observed in patients with dementia. It may be used to obtain a total score and 3 subscale scores (memory-related, depression, and disruptive behaviors). Scores also may be obtained for he Caregiver's reaction to each of the behaviors.

• Source/Availability: With permission from author; HBPC SharePoint site:https://vaww.portal.va.gov/sites/OMHS/MH-HBPC/default.aspx.Note that this link is inactive. If you have access to the Intranet, you can copy the URL and paste it into your browser.

• Reference: Teri et al. (1992)




Specialized mental health evaluation in HBPC often includes the use of standardized assessment tools. This section of the course reviewed a range of tools that may help to inform the evaluation of common behavioral and mental health issues in HBPC. Most assessment tools reviewed are available through the CPRS Mental Health Assistant (MHA), the HBPC MH Provider SharePoint site, or both. MH Providers must use their clinical judgment, and be aware of their own scope of competence, when choosing assessment tools to use in any given clinical situation.







1. Which of the following assessment tools should always be utilized in an HBPC mental health evaluation?

A. Geriatric Depression Scale (GDS)

B. Montreal Cognitive Assessment (MOCA)

C. Generalized Anxiety Disorder Scale (GAD-7)

D. No particular psychological assessment tools are requred for an HBPC mental health evaluation (i.e., after required screenings have been completed)

Correct Feedback:Correct. MH Providers must use their clinical judgment, and be

aware of their own scope of competence, when choosing assessment tools to use in any given clinical situation.

Incorrect Feedback:Incorrect. MH Providers must use their clinical judgment, and be


2. In addition to suicide risk, what are other risk issues that must commonly be evaluated in the HBPC population?

A. Delirium

B. Presence of firearms in the home

C. Driving

D. Independent living capacity

E. All of the above

Correct Feedback:Correct. All of these issues present risks that must commonly be

evaluated.

Incorrect Feedback:Incorrect. All of these issues present risks that must commonly be

evaluated.

PageInstructions





You have completed the fourth lesson in this course, Mental Health Assessment Tools and Resources, and are now able to move forward to the fifth lesson, Assessment Outcomes: Feedback and Interdisciplinary Care Planning.







Integrated Mental Health Assessment in Home Based Primary Care Assessment Outcomes: Feedback and Interdisciplinary Care Planning

Assessment Outcomes: Feedback and Interdisciplinary Care PlanningLesson Introduction


This lesson identifies effective strategies for providing assessment feedback to Veterans, Caregivers, and treatment teams. A framework is presented for structuring feedback, and is illustrated through a feedback session that the psychologist has with Mr. and Mrs. Apple in the ongoing case study. The lesson reviews strategies for providing feedback to the team, including how the results of a mental health evaluation can inform the interdisciplinary treatment plan. A knowledge check will provide an opportunity for self-assessment and remediation.


The terminal learning objective (TLO) for this lesson is to identify effective strategies for providing assessment feedback to Veterans, Caregivers, and HBPC teams.


1. Describe a framework that HBPC Mental Health (MH) Providers might use to structure their feedback to Veterans and Caregivers2. Describe how mental health assessment findings can be translated into recommendations for the interdisciplinary team3. Identify functional implications and associated treatments strategies that can be integrated into the interdisciplinary treatment plan, for a range

of behavioral and mental health conditions





Assessment Outcomes: Mr. AppleScreen ID 05_002.htm Screen Type Main Page 97 of 120

Based on the identified assessment questions regarding (1) Mr. Apple’s agitated behavior and (2) Mr. Apple’s medical decision making capacity, Ann chose to supplement her clinical interview with measures of mood, anxiety, Posttraumatic Stress Disorder (PTSD), cognition, and capacity.

Here is a summary of assessment results:

• Depression• Anxiety• PTSD• Cognition• Capacity



DepressionScreen ID 05_002_TL01.htm Screen Type Toggle List Item Required

The clinical interview and measures of depression indicated mild depression. Symptoms of depression included anhedonia, mildly depressed mood, irritability, moderate sleep disturbance, and feelings of helplessness and worthlessness. Mr. Apple denied any past or present suicidal ideation (SI) and



he denied feeling hopeless about the future; he expresses strong and helpful spiritual beliefs. He scored 7/15 points on the Geriatric Depression Scale.

AnxietyScreen ID 05_002_TL02.htm Screen Type Toggle List Item Required

Mr. Apple also endorsed mild anxiety symptoms, scoring 20/63 points on the Beck Anxiety Inventory. Symptoms endorsed include nervousness, difficulty breathing, heart racing, feeling scared, difficulty relaxing, and fear of losing control.

PTSDScreen ID 05_002_TL03.htm Screen Type Toggle List Item Required

A PTSD evaluation remained negative. While Mr. Apple admitted to having some bad memories about his combat service in Vietnam, and to reminiscing more about his military service (good and bad), he denied most clinical symptoms of PTSD.

CognitionScreen ID 05_002_TL04.htm Screen Type Toggle List Item Required

On measures of cognition, Mr. Apple demonstrated prominent executive dysfunction and scattered, inconsistent memory impairment, consistent with a diagnosis of frontotemporal dementia.

CapacityScreen ID 05_002_TL05.htm Screen Type Toggle List Item Required

In addressing the question of capacity to make a decision about initiation of a feeding tube, Ann assessed whether Mr. Apple had an understanding of his choices and their risks and benefits, whether he demonstrated an appreciation for how these risks and benefits would apply to him personally, whether he could reason with this information to come to a choice, and whether he could verbalize a consistent choice regarding whether to have a feeding tube placed.



Mr. Apple was able to verbalize that he does not wish to have a feeding tube. When reviewed with him, he was able to convey understanding of the likely consequences of choosing to have or not to have a feeding tube. He understood that, without a feeding tube, he could become weaker and that he may die from poor nutrition/hydration or other complications (aspiration, urinary tract infection). He verbalized an understanding that a feeding tube could prevent malnutrition and potentially prolong his life, but that his ALS symptoms would likely progress (e.g., more difficulty breathing). He stated that he prefers not to have additional life-sustaining measures and is ready to die “When the good Lord takes me.” He was able to verbalize how this decision was consistent with his life values and goals.



Providing Feedback on Assessment ResultsScreen ID 05_003.htm Screen Type Main Page 98 of 120

The next step in the assessment process is for Ann to provide feedback on the results.

Feedback on assessment results should be provided to the Veteran, Caregivers (with appropriate permission from the Veteran), the HBPC team, and additional providers as appropriate.

The American Psychological Association Ethics Code stipulates that patients have a right to assessment feedback, and it is the Psychologist’s responsibility to ensure that feedback is prompt and understandable to the patient.

The Mental Health (MH) Provider should also ensure that the feedback answers the referral question, identifies Veterans’ strengths as well as weaknesses, and presents results in terms of functional implications for the Veteran.



Image ID Image Alt Text Image Long Descriptionmeeting1.jpg Four members of the HBPC team are seated around a

conference table



Framework for Providing Feedback on Assessment ResultsScreen ID 05_004.htm Screen Type Main Page 99 of 120

The following is a framework that HBPC MH Providers might use in structuring their feedback to Veterans and Caregivers.



Image ID Image Alt Text Image Long Descriptionfeedback_framework.jpg This is a flowchart consists of five rectangles with directional arrows

and supporting text. From left to right, the first box contains the supporting text, “respond to the referral question.” A directional arrow points to the second box, which contains the supporting text



“discuss functional implications of assessment findings.” A directional arrow points to the third box, which contains the supporting text “discuss treatment options.” A directional arrow points to the fourth box, which contains the supporting text “identify who will be involved in treatment.” A directional arrow points to the fifth box, which contains the supporting text “specify a follow-up plan.” Between boxes one and two are two triangle-shapes with supporting text. One triangle contains the supporting text “identify strengths and weaknesses,” and the second triangle contains the supporting text “identify diagnoses as appropriate.” Below the row of rectangles and triangles is one rectangle that spans the entire width, indicating that this process occurs throughout the entire timeframe of the flowchart. This rectangle contains the supporting text “incorporate veteran and caregiver questions and feedback throughout.”



Guidelines for Veteran and Caregiver FeedbackScreen ID 05_005.htm Screen Type Main Page 100 of 120

Direct feedback to the Veteran and Caregiver is an essential component of the assessment process. In-person feedback is usually most effective for older adults. Let’s look at how a feedback session might be used in the case of Mr. Apple. Before listening/viewing the session, here are some guidelines to keep in mind:

1. It is important to provide feedback as concisely as possible, consistent with the Veteran’s and family’s level of understanding and interest.

2. Frame feedback in terms of identified Veteran and/or Caregiver concerns3. Consider involving other trusted HBPC team members in the feedback session

a. Note: Confirm your program’s policy on joint visits among staff members4. You might also consider separate feedback for the Caregiver, which can be an

additional opportunity for clarifying recommendations for care, evaluating Caregiver needs and concerns, providing psychoeducation and support, and/or discussing referral for additional services.




Mr. Apple. Mr. Apple is seated in his wheelchair and is facing Ann. Mrs. Apple is seated on the sofa between them and has her head turned toward Ann.



Video 3Screen ID 05_006.htm Screen Type Main Page 101 of 120


Ann meets with Mr. Apple and his wife in their home to discuss the results of the assessment. Select Play to run the video.

Ann: Hi Mr. and Mrs. Apple, thank you for having me back at your home. I have the results of the assessment we completed last time – I’d like to discuss the results with you and we can go over some options for addressing some of these issues. Mr. Apple, is it ok with you if Mrs. Apple joins us for the feedback session?

Mr. Apple: Fine.

Ann: As you will both recall, we worked together to evaluate some of your cognitive, or thinking, skills, your mood, and your ability to make important medical decisions at this time. We wanted to address your concerns as well as some questions from the team…

Mrs. Apple: Um-hmmm…

Ann: [To Mr. Apple] When we spoke last time, you shared with me that you are feeling irritated with all the people coming to your house. You’ve had a lot of changes in your health and it has been really hard to adjust, and you told me that sometimes your mind doesn’t feel as clear as it used to.

Mr. Apple: Right.

Ann: And Mrs. Apple, you reported that Mr. Apple’s memory is not as good as it used to be, and you’re noticing some changes in his behavior and personality – he is short-tempered and sometimes says things that are out of character for him.

Mrs. Apple: Yes, it’s been really hard on me.



Ann: Definitely. ALS can sometimes lead to changes in thinking and behavior, and we learned some other things during the assessment that I think might address both of your concerns.

First, it’s important to emphasize, Mr. Apple, that you have many strengths – in your attitude, coping, and thinking skills. One of the things that really shone through during the assessment was your tremendous ability to cope with adversity. You have dealt with a lot of stress and change in recent years, and it’s clear that you’ve tried to maintain a positive attitude and worked hard to stay as independent as possible.

Mr. Apple: Yes, I’ve tried.

Ann: One thing we learned from the assessment is that you have mild depression and some mild anxiety. Depression makes it harder to deal with frustrations in day to day life – I wonder if that is making you feel more short-tempered. Anxiety can also make you feel on-edge and uncomfortable. Both depression and anxiety can make it harder to concentrate and think clearly – this could be part of the reason why you feel that your thinking is not the same as it used to be.

Mr. Apple: I guess, but I still think my wife is just not telling me everything.

Ann: I can see why it would feel that way – when you can’t focus clearly, it’s hard to know if there was something you missed or if people just aren’t telling you things. We can talk more in a few minutes about ways to help you both keep track of information together.

Mrs. Apple: OK.

Ann: The assessment also showed that you have trouble in what we call “executive functioning,” controlled by the front part of your brain. This



part of the brain helps to control emotions and keeps you organized and focused. This is a common change for people with neurological illnesses, including ALS.

Mrs. Apple: Really?

Ann: [nods] Yes, and it may be why you may have more trouble following conversations or keeping track of all the information the team gives to you and your family. It may also help to explain why your family has noticed some changes in your personality and why you may feel more irritated and impatient.

Mr. Apple: I don’t think I’ve changed.

Ann (nods, smiles empathically): Sometimes people who care about us notice changes that we aren’t even aware of ourselves…It’s also possible that the ALS is affecting your memory in addition to your concentration, which makes it harder to keep track of new information. This could be why your family has noticed that you are sometimes forgetful.

Mrs. Apple: So, what can we do?

Ann: Well, I have some ideas for ways we can make things a bit easier for both of you…





Image ID Image Alt Text Image Long Descriptionvideo_placeholder.jpg



Video 3 FeedbackScreen ID 05_007.htm Screen Type Main Page 102 of 120

Notice that Ann opened the feedback session by confirming with Mr. Apple that it was OK for his wife to be present. Ann then reminded the Apples of the assessment and reviewed some of their biggest concerns, gathered from her clinical interview. This approach helps to frame assessment results in terms of the Veteran’s and Caregiver’s actual experience, and will likely enhance understanding. Notice also that Ann avoided using jargon, that she provided one piece of feedback at a time, and she allowed the Apples to react and ask questions throughout the process.









Let’s join Ann at the feedback session as she begins to discuss the issue of capacity. Select Play to run the video.

Ann: Another issue that we discussed was the question about a feeding tube. Your doctor is concerned that you’re no longer able to get the nutrition you need by eating. As you know, one way for people who have trouble swallowing to get nutrition they need is through a feeding tube. You have let HBPC team know that you do not wish to have a feeding tube at this time...

Mr. Apple: I don’t want anything like that.

Mrs. Apple: (looking upset) But Louis, the doctor says you could die without one!

Ann: I know this is a very hard situation for everyone, and one of the goals of the assessment was to get some information on Mr. Apple’s ability to make his own choices when faced with complicated life decisions like this. Mr. Apple, we found that you are able to understand the risks and benefits of this decision and come to a conclusion for yourself on whether to accept a feeding tube and that, at least for now, you don’t feel that is the right decision for you.

(To Mrs. Apple): Sometimes the people we love make decisions that we disagree with, but at this time he has the ability to make a decision in this situation. Of course, the decision affects all of you… It’s important to remember that this is not the final conversation we’ll have about this.

(To Mr. Apple): You always have the right to change your mind and the team will check in periodically with you both to see what plan of care is best for you. We’ll continue to work together as a team to make sure we’re



addressing your comfort and well-being.

Mr. Apple: OK.

Mrs. Apple (to Mr. Apple): I still don’t understand how you could make a choice like this.

Ann: I wonder if it might help to plan a family meeting to talk about this decision, to help everyone know where you’re coming from and for your family to share their feelings too?

Mr. Apple: That’s fine

Mrs. Apple: Yes, if you think that would be helpful. The kids have been really worried about this too!

Discussion continues as Ann helps both Mr. and Mrs. Apple express their feelings about the feeding tube and answers some questions that they have.






Video 4 FeedbackScreen ID 05_009.htm Screen Type Main Page 104 of 120

Given the complexity of this case, Ann is aware that the feedback process may be ongoing, and both she and the team will continue to follow up with the Apples to ensure that their needs are being met. For example, in addition to the family meeting, Ann will likely offer individual psychotherapy to Mr. Apple, and discuss with the team the possibility of antidepressant medication. Ann and the team will also monitor Caregiver stress in Mrs. Apple, offering individual and/or couples support as needed.

It is often helpful to provide a written summary of feedback to older adults and their Caregivers, summarizing results, recommendations, and treatment plans. Feedback letters should be at an appropriate reading level for the Veteran, and they should be brief, focusing on the main points of the feedback. Select the image to examine an example of a feedback letter Ann might send to Mr. and Mrs. Apple.

[[Link to Feedback letter in Appendix.]]



Image ID Image Alt Text Image Long Descriptionletter_ann.jpg Document with text (non-legible) intended to

represent a feedback letter



Guidelines for Team and Provider FeedbackScreen ID 05_010.htm Screen Type Main Page 105 of 120

In addition to providing feedback to the Veteran and Caregiver, it is critical that MH Providers give feedback to the HBPC team and other professionals involved in the Veteran’s care.

1. Who should receive feedback?

• Referring provider• Primary Care Provider• Team members who work with the Veteran

2. How should feedback be provided?

• Written report• Make recommendations clear and specific• May collaborate with team members BEFORE posting report, to get their input on recommendations• May consider directing recommendations to specific disciplines (e.g., “It may be helpful for nursing staff to leave written instructions in large

print for patient at each visit, as he likely has difficulty recalling information presented verbally”)• Verbal feedback – do not assume your report has been read!

• Team meeting• Phone calls





Using Assessment Results to Inform Interdisciplinary Treatment PlanningScreen ID 05_011.htm Screen Type Main Page 106 of 120

Given the integrated model for mental health care in HBPC, it is important for mental health assessment results to be incorporated into interdisciplinary treatment planning. The MH Provider should review the team’s treatment goals for the Veteran and tailor recommendations accordingly.

In the case of Mr. Apple, the HBPC team’s goals include:

• Increased nutritional intake and decreased weight loss• Continued close monitoring of vital signs, medication adherence, and breathing• Reduced Caregiver stress in Mrs. Apple• Increased willingness from Mr. Apple to participate in home visits

Ann might recommend that team members:

• Continue to rule out other possible causes of cognitive compromise• Review case with primary care provider (PCP) and psychiatrist to determine if antidepressant medication is warranted• Utilize behavior management strategies for responding to challenging behaviors (and detail what strategies might help); model these strategies

for Mrs. Apple• Assist Mrs. Apple in writing a protocol for managing common concerns regarding Mr. Apple’s condition (e.g., what steps can she take on her own

in the face of certain problems, when to call the nurse, when to go to the emergency room)• Continue to review goals of care, treatment decisions, and possible transition to hospice care with Mr. and Mrs. Apple





Addressing Specific Behavioral and Mental Health Conditions in Interdisciplinary Care PlanningScreen ID 05_012.htm Screen Type Main Page 107 of 120

In communicating assessment results, the HBPC MH Provider can also provide education to the team regarding the functional and treatment implications of mental health conditions. This education helps the team to understand how mental health conditions may affect the Veteran’s day-to-day functioning and participation in the treatment plan. It allows the team to adapt their approach in ways that are consistent with the Veteran’s cognitive and emotional needs and abilities. Here are examples of functional implications and treatment strategies related to common mental health conditions that the MH Provider might review with the team and/or include in an assessment report. These recommendations may be integrated into the interdisciplinary treatment plan.

Select each disorder from the following list to learn more.

• Mood disorders• Anxiety• Posttraumatic stress disorder• Substance abuse disorders• Personality disorders• Delirium• Memory impairment• Language impairment• Executive dysfunction• Visuospatial impairment• Decision-making and/or other functional incapacity• Caregiver burden





Mood disordersScreen ID 05_012_TL01.htm Screen Type Toggle List Item Required

Behaviors Team Might Observe

• Low motivation, difficulty “getting going”• Concentration problems or apparent forgetfulness• Appetite disturbance• Low energy, not engaged in home visits• Report of boredom• Withdrawing from activities• Irritability

Strategies Team Might Use

• Help the patient set realistic, achievable goals; focus on one goal at a time• Educate Veteran and family about depression• Monitor for suicidality• Encourage behavioral activation; schedule pleasant activities• Write down simple reminders and summaries of home visits• Monitor for medical conditions/medications that may affect mood

AnxietyScreen ID 05_012_TL02.htm Screen Type Toggle List Item Required


• Many expressed worries, repeated questions• Frequent phone calls• Sensitivity to physical symptoms• Avoidance of feared activities (e.g., reluctance to walk if afraid of falling)• Compulsive behaviors (e.g., collecting items, repeated checking)




• Establish a consistent point of contact for patient concerns• Explain all procedures and medication changes thoroughly and patiently• Allow time for patient to express concerns and ask questions• Allow extra time for the visit and provide reassurance• Identify a plan with the patient for when phone calls will be returned• Monitor for medical conditions/medications that may affect anxiety

Posttraumatic stress disorderScreen ID 05_012_TL03.htm Screen Type Toggle List Item Required


• Concerns about safety and security (e.g., wishing to keep firearm accessible)• Irritability, anger, difficulty relaxing, trouble concentrating• Disrupted sleep• Avoidance of triggering places or activities• Difficulty trusting providers


• Establish a consistent point of contact, work to develop rapport and trust• Educate Veteran and family about PTSD• Encourage Veteran to make choices about the visit (e.g., preferred seating arrangement so that he/she feels safe)• Teach and encourage use of relaxation and other coping strategies

Substance abuse disordersScreen ID 05_012_TL04.htm Screen Type Toggle List Item Required




• Drug seeking behaviors (early refills of pain medications, frequent phone calls)• Altered mental status/intoxication during home visits• Lack of adherence to medications• Lack of adherence to boundaries/limits during home visits


• Work closely with Primary Care Provider regarding limits on refills• Set consistent boundaries/limits (e.g., review team policy regarding Veterans who are under the influence during home visits)• Incorporate evidence-based techniques to enhance readiness for change (e.g., Motivational Interviewing)• Monitor safety• Refer for appropriate substance abuse treatment

Personality disordersScreen ID 05_012_TL05.htm Screen Type Toggle List Item Required


• Pushing of boundaries with team members (e.g., asking for atypical favors)• Difficulty “connecting” with patient• “Splitting” of team members (e.g., praising one nurse while criticizing another)• Inconsistent motivation and follow-through• Noticing strong and unusual emotional reactions in oneself (e.g., anger, pull for over-involvement with patient’s care)


• Set and maintain clear boundaries• Maintain consistent approach and message across team members• Educate and support team members• Meet regularly to review plan of care, monitor countertransference, reinforce boundaries



DeliriumScreen ID 05_012_TL06.htm Screen Type Toggle List Item Required


• Waxing/waning mental status• Acute change in mental status


• Immediate medical attention is required

Memory impairmentScreen ID 05_012_TL07.htm Screen Type Toggle List Item Required


• Difficulty recalling recent information• May or may not benefit from reminders• Repeated questions• Irritability or paranoia in response to memory lapses (e.g., accusing others of stealing items if cannot recall where they are)


• Written reminders (brief, simple language)• Visual reminders• Establish a calendar• Help Veteran eliminate excess clutter• Help Veteran identify consistent places to keep important communication and medications

Language impairmentScreen ID 05_012_TL08.htm Screen Type Toggle List Item Required




• Difficulty making needs known• Difficulty following directions


• Allow plenty of time for communication• Use simple, one-step commands• Model desired behavior physically (i.e., gesture to demonstrate what you want)

Executive dysfunctionScreen ID 05_012_TL09.htm Screen Type Toggle List Item Required


• Poor judgment• Disinhibition• Difficulty following through on tasks despite remembering instructions• Difficulty organizing• Impulsivity• Poor insight• Emotional dysregulation


• Ensure safety in the home (e.g., should Veteran use stove, should Social Worker assist in securing alternate transportation)• Simplify routine, reduce clutter• Do not argue if insight is poor• Involve Caregiver

Visuospatial impairmentScreen ID 05_012_TL10.htm Screen Type Toggle List Item Required




• Difficulty finding way around building• Difficulty locating needed items• Reluctance to leave the home, attend appointments, initiate new activities


• Address safe transportation• Ensure clutter-free environment with adequate space for ambulation• Organization to ensure needed items are in consistent places within easy reach• Recognize that resistance may be a response to anxiety

Decision-making and/or other functional incapacityScreen ID 05_012_TL11.htm Screen Type Toggle List Item Required


• Apparent lack of understanding of risks and benefits of life decisions• Signs of financial exploitation (e.g., giving large sums of money to friends/charities)• Alarmingly poor self-care, neglect• Decisions reflect apparently poor judgment regarding safety/well-being


• Optimize Veteran capacities to extent possible (e.g., help make decisions with use of memory/visual aids)• Involve designated surrogate decision maker• Explore possible need for additional home services or transition to higher level of care• Consult with local Ethics Advisory Committee if there are team concerns or disagreements re: how best to support Veteran with limited capacity

Caregiver burdenScreen ID 05_012_TL12.htm Screen Type Toggle List Item Required




• Caregiver may appear anxious and/or depressed• Caregiver may have high need for control• Team members may themselves feel burned out/stressed• Veteran may exhibit an increase in challenging behaviors• There may be signs of elder abuse or neglect


• Encourage Caregiver self-care (e.g., getting medical, mental health services)• Educate Caregiver about community resources• Use motivational interviewing to encourage respite for Caregiver• Refer Caregiver for education/support (via readings, internet, class/group)• Monitor for signs of elder abuse/neglect



Team Recommendations for Mr. AppleScreen ID 05_013.htm Screen Type Main Page 108 of 120

In the case of Mr. Apple, Ann might review the ways in which depression, anxiety, and executive dysfunction are likely to affect his behavior toward the team. She might remind team members not to personalize the Veteran’s behaviors, to provide reinforcement for desirable behaviors (such as participation in the nursing assessment), and to utilize behavioral management strategies for dealing with challenging behaviors. For example, if Mr. Apple is particularly agitated, it may help to calmly recognize his distress and agree to take a brief break.

Ann will also address the issue of Mr. Apple’s decision-making capacity and team reactions to the Veteran’s care decisions at this time. She can reinforce that medical decision-making can evolve over time, so it is important that team members continue to review Mr. Apple’s goals of care and ensure that his wishes continue to be known.




conference table





Let’s listen as Ann discusses the capacity assessment results with the team. Select Play to run the video.

Ann: We did find that Mr. Apple has the capacity to make his own choice regarding the feeding tube – despite some of his cognitive deficits, he is able to speak about the risks and benefits of accepting or declining tube feeding, and he is able to apply them to his own situation and come to a reasoned decision.

OT: But he could die without the feeding tube… I’m just not sure he really gets how this would affect his family.

Social worker: I don’t know, I can see why he is making this choice…

Ann: I am guessing that we all have our own individual reactions to Mr. Apple’s choice – it’s such a complicated and personal decision. It’s hard for me too when some Veterans make a decision I don’t agree with… I really try to understand where they are coming from and why those decisions are best for them given their life story and situation… Also, we need to keep in mind that these types of advanced illness or end-of-life care decisions can evolve over time – we’ll continue to check in with Mr. Apple to see how he’s feeling about things, and we can all support the family as they come to terms with his condition and their own grief.






Assessment Follow-UpScreen ID 05_015.htm Screen Type Main Page 110 of 120

The MH Provider’s intervention does not end with the feedback session. There are many ways in which the HBPC MH Provider might follow up with Veterans, Caregivers, or the team after the assessment is complete.

Veteran/Caregiver follow-up

• Consider brief session or sessions with Veteran/Caregiver to review implementation of management strategies• Often, assessment results lead to referral for brief psychotherapy (e.g., to treat depression)• Monitor Veteran’s condition over time; Ann may consider monthly phone check-ins after the Veteran has completed the active phase of HBPC

MH treatment

Team/Provider follow-up

• Monitor whether team members have responded to recommendations (e.g., has the primary care physician (PCP) placed consult for Neurology work-up? It can help to follow up.)

• Check in with team to monitor how interventions are working and provide support (e.g., during team meetings or through 1:1 in-person or telephone contacts)

• Work with team to monitor Veteran’s preferences about his medical treatment, and monitor for signs that decision-making capacity may have changed

• Expect to troubleshoot as new problems/questions arise, and encourage team to be flexible and creative





Assessment Follow-Up (continued)Screen ID 05_016.htm Screen Type Main Page 111 of 120

In the case of Mr. Apple, Ann will likely work with him individually to address his depression if he is willing. She will check in with him about medical care decisions to ensure that his values and goals are known. She may contact the Veteran’s PCP to determine whether it is appropriate to review his antidepressant medications. The HBPC team reviews Mr. Apple’s case every 90 days, and Ann uses the opportunity to briefly remind staff members of effective techniques for responding to challenging behaviors.



Image ID Image Alt Text Image Long Descriptionmr_apple2.jpg Mr. Apple seated in his wheelchair




HBPC MH Providers have a clinical and ethical responsibility to provide timely feedback to Veterans on assessment results. Providing effective feedback to Veterans and their Caregivers may involve meeting in-person, reviewing results in the context of the Veteran’s presenting concerns, discussing functional implications of assessment results, and providing additional feedback sessions and/or written summaries to ensure understanding. Feedback should also be provided to the HBPC team and any other referring providers.

HBPC MH Providers should consider the ways in which their assessment results can inform interdisciplinary care of the Veteran and tailor recommendations to the team that will enhance the entire team’s ability to address Veterans’ cognitive and mental health concerns. Finally, MH Providers should be aware that follow up is often needed after assessment and feedback is complete, via ongoing work with HBPC team members, direct care provided to the Veteran and/or Caregiver, or feedback and follow-up with primary care or specialty providers.







1. Which of the following is NOT a strategy the MH provider might recommend staff use for a Veteran with executive dysfunction?

A. Help the Veteran simplify their daily routine

B. Attempt to reason with the Veteran when he/she demonstrates poor insight into their condition

C. Involve a Caregiver when possible

D. Reduce clutter in the home

Correct Feedback:Correct. Poor judgment and difficulty following through on tasks

are behaviors that patients with executive dysfunction may exhibit. Therefore, attempting to reason with the Veteran is not a recommended strategy.

Incorrect Feedback:Incorrect. Poor judgment and difficulty following through on tasks


2. Effective feedback on assessment results should:

A. Answer the referral question

B. Identify Veterans’ strengths as well as weaknesses

C. Present results in terms of functional implications for the Veteran

D. All of the above

Correct Feedback:Correct. The MH Provider should ensure that the feedback answers

the referral question, identifies Veterans’ strengths as well as weaknesses, and presents results in terms of functional implications for the Veteran.

Incorrect Feedback:Incorrect. The MH Provider should ensure that the feedback

answers the referral question, identifies Veterans’ strengths as well as weaknesses, and presents results in terms of functional implications for the Veteran.

3. Which of the following is the BEST example of using assessment results to inform interdisciplinary treatment planning?

A. Ann gives feedback to the Veteran and provides psychotherapy for his depression.

B. Ann lets the PCP know that the Veteran has prominent executive

Correct Feedback:Correct. Providing assessment results to the HBPC team, and

discussing the possibility of antidepressant treatment with the patient’s PCP is the best way to manage this patient’s depression.

Incorrect Feedback:Incorrect. Providing assessment results to the HBPC team, and



dysfunction and scattered, inconsistent memory impairment.

C. Ann works with the Veteran’s family to help them process their feelings about his decision to refuse a feeding tube.

D. Ann provides assessment feedback to the team, discusses the possibility of antidepressant treatment with the Veteran’s PCP, and helps the team develop a protocol for managing any challenging behaviors demonstrated by the Veteran.


PageInstructions





You have completed the fifth lesson in this course, Assessment Outcomes: Feedback and Interdisciplinary Care Planning, and are now able to move forward to the post-test.






Post-testScreen ID 05_020.htm Screen Type Main Page: EOC Assessment 115 of 120


1. Which of the following is NOT a key concept in the integrated, stepped care model in HBPC?

A. Patient-centered

B. Promotes self-management

C. Range of treatments and treatment intensities

D. MH Providers meet individually with all patients

Correct Feedback:

Correct. In the stepped care model, MH Providers work with the HBPC team to determine which patients need specialized mental health evaluation and/or treatment.

Incorrect Feedback:

Incorrect. In the stepped care model, MH Providers work with the HBPC team to determine which patients need specialized mental health evaluation and/or treatment.

2. True or false? The HBPC MH Provider can utilize results of screening and brief assessment measures administered by other team members to determine if further mental health assessment and intervention is warranted.

A. True

B. False

Correct Feedback:Correct. Nurses and social workers may administer brief


Incorrect Feedback:Incorrect. Nurses and social workers may administer brief


3. Under what circumstances may a MH Provider complete a more comprehensive, specialized mental health evaluation? Choose all that apply.

A. The team's initial in-home evaluation raises questions about safety, level of functioning/self-care, or level of distress.

Correct Feedback:Correct. A score of 6/15 on the Geriatric Depression Scale alone is

not justification for a comprehensive mental health evaluation.

Incorrect Feedback:Incorrect. The correct answers are A, B, and D. A score of 6/15 on

the Geriatric Depression Scale alone is not justification for a



B. There are significant mental health concerns and/or potential risks to the patient

C. MH Providers must complete a comprehensive mental health evaluation for any patient that exhibits signs of depression and scores 6/15 on the Geriatric Depression Scale.

D. When cases are very complex and have many unanswered questions, a MH Provider's input is needed to provide treatment planning.

comprehensive mental health evaluation.

4. Which of the following assessment tools should always be utilized in an HBPC mental health evaluation?

A. Geriatric Depression Scale (GDS)

B. Montreal Cognitive Assessment (MOCA)

C. Generalized Anxiety Disorder Scale (GAD-7)

D. No particular psychological assessment tools are requred for an HBPC mental health evaluation (i.e., after required screenings have been completed)

Correct Feedback:Correct. MH Providers must use their clinical judgment, and be


Incorrect Feedback:Incorrect. MH Providers must use their clinical judgment, and be


5. In addition to suicide risk, what are other risk issues that must commonly be evaluated in the HBPC population?

A. Delirium

B. Presence of firearms in the home

C. Driving

D. Independent living capacity

Correct Feedback:Correct. All of these issues present risks that must commonly be

evaluated.

Incorrect Feedback:Incorrect. All of these issues present risks that must commonly be

evaluated.



E. All of the above

6. What is an important first step in the HBPC mental health evaluation process?

A. Obtain the Veteran's consent to proceed with the evaluation

B. Clarify the nature of the referral/assessment question - what is the need or concern?

C. Ensure the reliability and validity of any tests you plan to administer

D. Consult with the Veteran's family/Caregiver about their concerns

Correct Feedback:Correct. The first step in the framework for mental health


Incorrect Feedback:Incorrect. The first step in the framework for mental health


7. Which of the following is NOT a strategy the MH provider might recommend staff use for a Veteran with executive dysfunction?

A. Help the Veteran simplify their daily routine

B. Attempt to reason with the Veteran when he/she demonstrates poor insight into their condition

C. Involve a Caregiver when possible

D. Reduce clutter in the home

Correct Feedback:Correct. Poor judgment and difficulty following through on tasks


Incorrect Feedback:Incorrect. Poor judgment and difficulty following through on tasks


8. During your first in-home evaluation with a Veteran, his adult daughter enters the adjoining room and occasionally hollers out answers to the questions you are asking the Veteran. Which of the following responses would be appropriate? Choose all that apply.

A. Ignore her

B. Invite her to join the evaluation interview

Correct Feedback:Correct. Your clinical judgment and intervention may be important

for ensuring the Veteran’s desired level of privacy during the interview.

Incorrect Feedback:Incorrect. Your clinical judgment and intervention may be

important for ensuring the Veteran’s desired level of privacy during the



C. Ask the Veteran if he would like his daughter to join part of the evaluation interview (as appropriate)

D. If privacy is important, ask the Veteran and daughter how best to arrange for privacy (e.g., daughter or you/Veteran moving to another room)

interview.

9. Examples of behavioral/mental health issues for which screenings should be documented include (choose all that apply):

A. Depression

B. Suicide risk

C. Posttraumatic stress disorder (PTSD)

D. Alcohol use

E. Psychotic symptoms, dementia warning signs

F. Caregiver strain

Correct Feedback:Yes, that is correct. Although it is important to evaluate psychotic

symptoms among at-risk patients, there is not a formal screening process for documenting the presence or absence of psychotic symptoms among all HBPC patients.

Incorrect Feedback:That is incorrect. Although it is important to evaluate psychotic

symptoms among at-risk patients, there is not a formal screening process for documenting the presence or absence of psychotic symptoms among all HBPC patients.

10. True or False: The MH Provider must complete a formal mental health evaluation for every Veteran enrolled in HBPC.

A. True

B. False

Correct Feedback:Yes, that is correct. In a stepped model of care, it is often neither

necessary nor the best use of resources for the MH Provider to complete a formal mental health evaluation with every Veteran enrolled in HBPC. (Note that some smaller HBPC programs do ask the MH Provider to evaluate every Veteran; local programs may choose to do so, but it is not required).

Incorrect Feedback:That is incorrect. In a stepped model of care, it is often neither

necessary nor the best use of resources for the MH Provider to complete a formal mental health evaluation with every Veteran enrolled in HBPC. (Note that some smaller HBPC programs do ask the MH Provider to evaluate every Veteran; local programs may choose to do so, but it is not



required).

11. The HBPC MH Provider can provide several levels of support to the team when addressing behavioral and mental health care needs. Match the level of involvement with the patient condition associated with that level of involvement.

A. No identified behavioral/mental needs

B. Watchful waiting, monitoring of symptoms

C. Home visit for further evaluation

D. Referral, consulting, coordination with specialty clinics/programs

1. The patient exhibits moderate to severe mental health symptoms, safety concerns, or need for clarification of capacity.

2. The patient has no identified behavioral or mental health needs.

3. The patient has need for services beyond what HBPC can provide (e.g., neuropsychological testing if MH Provider does not have training in that area).

4. Patient reports subclinical symptoms and/or the patient/family is not ready for mental health provider visit to the home.

Answer: A = 2, B = 4, C = 1, D = 3

Correct Feedback:Yes, that is correct. You have properly aligned the level of

involvement with the patient’s needs/condition.

Incorrect Feedback:That is incorrect. The correct alignment is: A,2 – B,4 – C,1 – D,3

12. The team decides to adopt a “watchful waiting” approach for a particular patient. Which of the following activities might be performed for this level of support? Select all that apply:

A. The MH Provider works with the team on strategies for monitoring symptoms and providing psychoeducation to the Veteran/family.

Correct Feedback:Yes, that is correct. Conducting a psychodiagnostic evaluation in

the home is associated with a higher level of support.

Incorrect Feedback:That is incorrect. A, B, and D are the correct answers. Conducting a



B. The MH Provider may ask a nurse or social worker to administer a brief depression or anxiety assessment measure.

C. The MH Provider does a home visit to complete a psychodiagnostic evaluation with the Veteran.

D. The MH Provider may work with the team to identify resources that may be helpful to the Veteran/family, such as readings, websites, or support groups.

psychodiagnostic evaluation in the home is associated with a higher level of support.

13. The HBPC MH Provider often interviews “collaterals,” family members or other caregivers, with the Veteran’s permission. Which of the following is generally not an area for evaluation with a collateral?

A. Collateral’s report of Veteran’s history

B. Collateral’s goals and preferences regarding Veteran’s care

C. Psychodiagnostic evaluation and differential diagnosis of collateral’s mental health issues

D. Collateral’s needs for education or additional supportive services

Correct Feedback:Correct. Diagnosis of a collateral’s mental health issues is not part

of HBPC services.

Incorrect Feedback:Incorrect. Diagnosis of a collateral’s mental health issues is not part

of HBPC services.

14. Broad goals for a mental health evaluation in HBPC include documenting all of the following except:

A. The Veteran’s strengths and abilities

B. The Veteran’s struggles and areas in need of support

C. The Veteran’s risk and protective factors

D. The Veteran’s status in regard to service connected mental health disabilities

E. Recommendations to inform the treatment plan

Correct Feedback:Yes, that is correct. While it can be important to note service


Incorrect Feedback:That is incorrect. While it can be important to note service




15. True or False: A Veteran may assent to a mental health evaluation even if he or she is not able to provide full informed consent.

A. True

B. False

Correct Feedback:Yes, that is correct. It is important to make the effort to elicit

informed consent, or assent, before proceeding with an evaluation (explain the purpose, potential outcomes, and Veteran’s choice to participate). If the Veteran does not appear fully able to understand and appreciate this information but agrees to proceed, his/her assent can be documented.

Incorrect Feedback:That is incorrect. It is important to make the effort to elicit

informed consent, or assent, before proceeding with an evaluation (explain the purpose, potential outcomes, and Veteran’s choice to participate). If the Veteran does not appear fully able to understand and appreciate this information but agrees to proceed, his/her assent can be documented.

16. Which of the following may be important sources of information to inform the HBPC mental health evaluation? Select all that apply.

A. History according to VA medical records

B. History according to non-VA medical records

C. HBPC team member observations

D. Home environment

E. Veteran interview

F. Collateral interview

Correct Feedback:Yes, that is correct. All of these sources may provide important


Incorrect Feedback:That is incorrect. All of these sources may provide important


17. True or False. When providing assessment feedback to a Veteran and/or Caregiver, it is important to incorporate their questions and reactions throughout the feedback session.

A. True

B. False

Correct Feedback:Correct. Incorporating the Veteran’s and/or Caregiver’s questions

and reactions is an essential component of the assessment feedback process.

Incorrect Feedback:Incorrect. Incorporating the Veteran’s and/or Caregiver’s questions



and reactions is an essential component of the assessment feedback process.

18. Effective feedback on assessment results should:

A. Answer the referral question

B. Identify Veterans’ strengths as well as weaknesses

C. Present results in terms of functional implications for the Veteran

D. All of the above

Correct Feedback:Correct. The MH Provider should ensure that the feedback answers

the referral question, identifies Veterans’ strengths as well as weaknesses, and presents results in terms of functional implications for the Veteran.

Incorrect Feedback:Incorrect. The MH Provider should ensure that the feedback

answers the referral question, identifies Veterans’ strengths as well as weaknesses, and presents results in terms of functional implications for the Veteran.

19. Which of the following is the BEST example of using assessment results to inform interdisciplinary treatment planning?

A. Ann gives feedback to the Veteran and provides psychotherapy for his depression.

B. Ann lets the PCP know that the Veteran has prominent executive dysfunction and scattered, inconsistent memory impairment.

C. Ann works with the Veteran’s family to help them process their feelings about his decision to refuse a feeding tube.

D. Ann provides assessment feedback to the team, discusses the possibility of antidepressant treatment with the Veteran’s PCP, and helps the team develop a protocol for managing any challenging behaviors demonstrated by the Veteran.

Correct Feedback:Correct. Providing assessment results to the HBPC team, and


Incorrect Feedback:Incorrect. Providing assessment results to the HBPC team, and


20. Indicate whether the following contexts are more characteristic of a traditional mental health clinic setting or an HBPC home care setting:

Correct Feedback:Correct. The clinic setting will generally allow for a more



A. Predictable schedule

B. Team can provide background on patient before first mental health contact

C. Review of, and documentation in, CPRS during patient visit

D. Generally private, quiet spaces

E. Family member participation

1. Clinic setting

2. HBPC setting

Answer: A = 1, B = 2, C = 1, D = 1, E = 2


Incorrect Feedback:Incorrect. The clinic setting will generally allow for a more


21. Which of the following is fairly typical of mental health practice in home-based care?

A. Needing to attend to infection control issues

B. Working in a private, quiet environment with minimal distractions

C. Meeting patients with whom little to no information is available regarding history and presenting problems

D. Meeting infrequently with family members

Correct Feedback:Correct. Members of the HBPC team should consider taking items


Incorrect Feedback:Incorrect. Members of the HBPC team should consider taking items


22. Which of the following may present a barrier to effective assessment in older and/or medically compromised patients? Select all that apply.

A. Ability to see clearly

B. Motor functions

C. Ability to hear

Correct Feedback:Yes, that is correct. Vision, motor function, hearing and fatigue

each can affect an assessment in an older or ill patient. Although a patient’s inability to drive may relate to advance age or medical illness, it presents no barrier to an effective assessment.

Incorrect Feedback:That is incorrect. Vision, motor function, hearing and fatigue each



D. Ability to drive a car

E. Fatiguecan affect an assessment in an older or ill patient. Although a patient’s inability to drive may relate to advance age or medical illness, it presents no barrier to an effective assessment.

23. True or False. When considering team collaboration, the home setting can be advantageous because it allows the HBPC team to share their own behavioral observations and concerns to date, and allows the team to learn from one another.

A. True

B. False

Correct Feedback:Correct. The home setting has these advantages. Conversely, in a


Incorrect Feedback:Incorrect. The home setting has these advantages. Conversely, in a


PageInstructions




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Scharre, D. W., & Trzepacz, P. T. (2013). Evaluation of cognitive impairment in older adults. Focus: The Journal of Lifelong Learning in Psychiatry, 11, 482-500.

Segal, D.L., Coolidge, F.L., & Rosowsky, E. (2006). Personality disorders and older adults: Diagnosis, assessment, and treatment. Hoboken, N.J.: John Wiley



& Sons.

Zarit, S.H., & Zarit, J.M. (2007). Mental disorders in older adults: Fundamentals of Assessment and Treatment (2 nd ed.). New York: The Guilford Press.

WebsitesGeroCentral: http://gerocentral.org/clinical-toolbox/See also readings re: geropsychology assessment knowledge and skill competencies at:http://gerocentral.org/competencies/articles-by-competency/assessment-knowledge/http://gerocentral.org/competencies/articles-by-competency/assessment-skills/American Psychological Association Office on Aging: http://www.apa.org/pi/aging/American Psychological Association Caregiver Briefcase: http://www.apa.org/pi/about/publications/caregivers/index.aspx





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Babor, T. F., de la Fuenta, J. R., Saunders, J., & Grant, M. (1992). AUDIT: The Alcohol Use Disorders Identification Test: Guidelines for its use in primary health care. Geneva, Switzerland: World Health Organization.

Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893-897.

Beck, A. T., & Steer, R. A. (1993). Manual for the Beck Hopelessness Scale. San Antonio, TX: The Psychological Corporation.

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Blow, F. C., Brower, K. J., Schulenberg, J. E., Demo-Dananberg, L. M., Young, J. P., & Beresford, T. P. (1992). The Michigan Alcoholism Screening Test-Geriatric Version (MAST-G): A new elderly-specific screening instrument. Alcoholism: Clinical and Experimental Research, 16, 372.

Cohen-Mansfield, J., Marx, M. S., & Rosenthal, A. S. (1989). A description of agitation in a nursing home. Journal of Gerontology: Medical Sciences, 44(3), M77-M84.

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Edelstein, B. A., Heisel, M. J., McKee, D. R., Martin, R. R., Koven, L. P., Duberstein, P. R., & Britton, P. C. (2009). Development and psychometric evaluation of the Reasons for Living-Older Adults Scale: A suicide risk assessment inventory. The Gerontologist, 49, 6, 736-745.

Faschingbauer, T., Zisook, S., & DeVaul, R. (1987). The Texas Revised Inventory of Grief. In S. Zisook (Ed.), Biopsychosocial Aspects of Bereavement (pp. 111-124). Washington, D. C.: American Psychiatric Press, Inc.

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LoConte, N. K., Gleason, C. E., Gunter-Hunt, G., Carlsson, C. M., & Siebers, M. (2008). Standardized note template improves screening of firearm access and driving among veterans with dementia. American Journal of Alzheimer’s Disease and Other Dementias, 23, 313-318.

Leob, P. A. (1996). Independent Living Scales manual. San Antonio, TX: Pearson.

Nasreddine, Z. S., Phillips, N. A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I., …Chertkow, H. (2005). The Montreal Cognitive Assessment (MoCA): A brief screening tool for mild cognitive impairment. Journal of American Geriatric Society, 53, 695-699.

Nichols, L. O., Martindale-Adams, J., Burns, R., Graney, M. J., & Zuber, J. (2011). Translation of a dementia caregiver support program in a health care system-REACH VA. Archives of Internal Medicine, 171, 353-359.

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Randolph, C. (1998). Repeatable Battery for the Assessment of Neuropsychological Status. San Antonio, TX: The Psychological Corporation.

Randolph, C. (2012). Repeatable Battery for the Assessment of Neuropsychological Status Update. San Antonio, TX: Pearson Education.

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Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166, 1092-1097.

Tariq, S. H., Tumosa, N., Chibnall, J. T., Perry, H. M., III, & Morley, J. E. (2006). The Saint Louis University Mental Status (SLUMS) examination for detecting mild cognitive impairment and dementia is more sensitive than the Mini-Mental State Examination (MMSE): A pilot study. American Journal of Geriatric Psychiatry, 14, 900-910.

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AppendixScreen ID 05_023.htm Screen Type Main Page 118 of 120

Dear Mr. Apple,

Thank you for meeting with me in your home yesterday. Here is a summary of the results of the assessment which we reviewed together yesterday. As we discussed, we completed the assessment in order to help clarify your cognitive, emotional, and decision-making strengths as well as areas in which you may need assistance at this time.

Your strengths include:

• A long history of strong coping skills in the face of medical challenges• Family support• Language – you clearly understand what others mean when they speak to you• Visual memory – your ability to remember what you see• Understanding of your medical condition and treatment options

Area in which you may need assistance:

• Verbal memory – your memory for things that you hear• When you have reminders or cues, your memory improved

• Executive functions – your ability to keep focused and organized and keep control over emotional reactions• Changes in executive functioning may help to explain some of the personality changes your family has noticed

• Your mood – you struggle with mild symptoms of depression and anxiety, consistent with a diagnosis of mild depression with anxious features• Depression is treatable and we can follow-up on this together

Making medical decisions

We have been speaking about difficult medical decisions that you are facing at this time, given you are having more trouble getting adequate nutrition. Based on the assessment results, your healthcare team does believe you can make decisions about your health care and treatment at this time. Our team will continue to work with you to make sure you have all the information and support you need to make decisions that are right for you.

Our recommendations include:

• We recommend that you use visual reminders around the house to help you remember important information – for example, you might consider



using a dry erase board with pictures to remind you of the day’s schedule• We recommend that you follow-up with me to discuss treatment for depression, in order to help optimize your quality of life and help you think

as clearly as possible about important decisions• The HBPC team will continue to support you and your family to find ways of compensating for the changes in your thinking and memory

The HBPC team will continue to work closely with you and your family. We will monitor your thinking, mood, and adjustment to help ensure you are receiving whatever supports you need.

Thank you again for the opportunity to work with you! Please feel free to call me any time if you have questions. We scheduled our next meeting for Thursday, February 27th, at 9:00 a.m., and I will plan to see you then.

Sincerely,

Ann MinkinHBPC PsychologistAnyCity VA Medical CenterPhone: 123-456-7890





Appendix - Assessment ToolsScreen ID 05_024.htm Screen Type Main Page 119 of 120

Assessment tools reviewed in this appendix are divided by category and described by content and source. Tools available through the CPRS Mental Health Assistant (MHA) are identified; links are provided for those not available through MHA. Some tools are commercial and some are in the public domain. When permission has been secured, tools listed below that are not available through VA MHA are archived at the HBPC Mental Health SharePoint site:https://vaww.portal.va.gov/sites/OMHS/MH-HBPC/default.aspx

Note. This overview of tools is not intended to be prescriptive nor restrictive in nature. The tools identified may not be appropriate for use with all patients and/or situations, and many other tools exist that may be quite helpful to inform mental health evaluation in HBPC. MH Providers must use their clinical judgment, and be aware of their own scope of competence, when choosing assessment tools to use in any given clinical situation.

I. Risk AssessmentHBPC MH Providers often work with their teams to help evaluate and manage Veteran’s at increased risk for harm to self and/or others. HBPC MH Providers should be aware of VHA suicide prevention resources and utilize these resources as needed, including the Suicide Risk Pocket Card and Assessment Guide, Safety Plan Pocket Card and Treatment Manual, and related resource guides, which are available at:http://vaww.mentalhealth.va.gov/rc-suicideprevention.aspas well as athttp://www.mentalhealth.va.gov/communityproviders/clinic_suicideprevention.asp.

All HBPC MH Providers are encouraged to follow local policies regarding assessment, documentation, and management of suicide risk, and to collaborate with local Suicide Prevention Coordinators as needed. The measures listed below are possible supplements to established national and local VHA policies regarding suicide risk assessment.

A. Suicide RiskThe HBPC population has many demographic and clinical features that are associated with higher suicide rates (e.g., older age, poor health, cumulative losses, high rates of depression, firearm ownership) than general primary care populations. Mental health evaluation in HBPC should always include screening and evaluation for suicide risk. The tools listed here may supplement evaluation and help to monitor Veterans over time.

1. Beck Hopelessness Scale (BHS)a) Reference: Beck & Steer (1993)b) Brief Description: The BHS is a 20-item (true/false) self-report measure of positive and negative feelings about the future, loss of motivation, and



expectations.c) Source/Availability: Pearson; VA Mental Health Assistant

2. Reasons for Living – Older Adults Scale (RFL-OA)a) Reference: Edelstein et al. (2009)b) Brief Description: The RFL-OA is a 69-item, Likert scale, self-report measure of reasons for living among older adults at risk for suicide.c) Source/Availability: With permission from primary author; Contact: Barry Edelstein – [email protected]

3. Suicidal Behavior Questionnaire – Revised (SBQ-R)a) Reference: Osman et al. (2001)b) Brief Description: The SBQ-R is a 4-item, Likert scale, self-report measure evaluating lifetime suicidal ideation and/or attempts, frequency of suicidal ideation, threat of suicide attempt, and likelihood of suicidal behavior in the future. The SBQ-R was not developed specifically for use with older adults but has some evidence of reliability/validity with adult clinical populations and may be helpful with younger HBPC patients.c) Source/Availability: Public domain; HBPC SharePoint

B. Firearm & Driving SafetyResearchers have concluded that firearms in the home are associated with increased risk of harm to self or others as well as death, and these risks increase among individuals with cognitive impairment. Functional and cognitive impairment also is associated with diminished driving ability and increased risk for accidental harm or death to self or others. Given the high prevalence of older adults with complex medical and/or cognitive impairment in HBPC, MH Providers are encouraged to collaborate with the HBPC team for evaluation and management of these potential safety concerns.

1. DVA Firearms & Driving Questionnaire (VA Form 10-0435, 2005)a) Reference: LoConte, Gleason, Gunter-Hunt, Carlsson, & Siebers (2008)b) Brief Description: VA Form 10-0435 is a brief provider-rating form designed to standardize assessment of firearm possession and safety (4 items) and current driving practices and safety (8 items) among older veterans.c) Source/Availability: Public domain; HBPC SharePoint

II. Psychological Functioning

A. Depressive DisordersThe HBPC population has numerous risk factors for late life depression and related disorders due to the prevalence of medical conditions such as heart



disease, diabetes, and neurodegenerative illnesses, marked functional impairment, social isolation, and/or stressful interpersonal circumstances.

1. DepressionEvaluating late life depression can be a complex task due to concomitant medical and neurological factors as well as pharmacological agents. Depression in later life may present differently than in younger adults and include greater reporting of physiological symptoms (e.g., somatic complaints, sleep disruption, memory complaints), an apathetic presentation with less expressed sadness, guilt, or worthlessness, and/or co-occurring anxiety. Depression also may present differently across racial/ethnic backgrounds. MH Providers are encouraged to assess depression using an interdisciplinary approach and tools appropriate for an aging medical population.

a) Patient Health Questionnaire (PHQ-9)(1) Reference: Kroenke, Spitzer, & Williams (2001)(2) Brief Description: The PHQ-9 is a 9-item, Likert scale, self-report measure for screening and measuring the severity of depression based on DSM-IV criteria. One additional item measures the impact of symptoms on daily functioning. This measure was developed for primary care but not older adults; however, there is good evidence for the reliability/validity of the PHQ-9 with older adults in primary care settings.(3) Source/Availability: Pfizer; VA Mental Health Assistant, HBPC Sharepoint

b) Geriatric Depression Scale (GDS; GDS-15)(1) Reference: Yesavage, Brink, Rose, & Lum (1983); Lesher & Berryhill (1994)(2) Brief Description: The GDS is a 30-item (yes/no) self-report measure of depression in older adults. There also is a 15-item (yes/no) version of the measure that has similar psychometric properties. The GDS does not contain somatic complaint items, which should be evaluated separately (e.g., sleep, appetite).(3) Source/Availability: Public domain; VA Mental Health Assistant, HBPC SharePoint

c) Beck Depression Inventory-II (BDI-II)(1) Reference: Beck, Steer, & Brown (1996)(2) Brief Description: The BDI-II is a 21-item, Likert scale, self-report measure used for evaluating severity of depressive symptoms in adults. The BDI-II has eight items assessing somatic complaints, which may elevate scores in some older adults. In addition, its 4-point, Likert type scale format may be difficult for those with limited literacy or cognitive impairment.(3) Source/Availability: Pearson; VA Mental Health Assistant

d) Cornell Scale for Depression in Dementia (CSDD)



(1) Reference: Alexopoulos, Abrams, Young, & Shamoian (1988)(2) Brief Description: The CSDD is a 19-item, clinician-rated measure that can be used for evaluating depression in individuals with dementia. It entails competing two semi-structured interviews, with an informant and with the patient. It was designed for identifying severity among those with a diagnosis of depression, rather than identifying the disorder, but may be useful as part of an evaluation of mood among Veterans with dementia.(3) Source/Availability: With permission from primary author; HBPC SharePoint

B. Anxiety, Trauma and Stress-Related, and Obsessive-Compulsive and Related DisordersAnxiety disorders are prevalent among older adults and often associated with chronic medical conditions such as cardiac or respiratory illness, dementia, and functional impairment. Anxiety disorders pose risk for and are frequently comorbid with late life depression. Avoidance symptoms core to anxiety disorders can be more difficult to recognize due to decreased social engagement in the HBPC population.

1. Generalized Anxiety DisorderGeneralized anxiety is the most researched anxiety disorder among older adults. Excessive worry may be lifelong or develop in later life, and be associated with declining health, changes in family and/or financial status, and other late-life changes.

a) Beck Anxiety Inventory (BAI)(1) Reference: Beck, Epstein, Brown, & Steer (1988)(2) Brief Description: The BAI is a 21-item, Likert scale, self-report measure of somatic and cognitive symptoms of anxiety.(3) Source/Availability: Pearson; VA Mental Health Assistant

b) Geriatric Anxiety Inventory (GAI)(1) Reference: Pachana et al. (2007)(2) Brief Description: The GAI is a 20-item (agree/disagree) self-report measure of anxiety symptoms commonly reported among older adults.(3) Source/Availability: Copyrighted by authors; http://www.gai.net.au/

c) Generalized Anxiety Disorder Scale (GAD-7)(1) Reference: Spitzer, Kroenke, Williams, & Löwe (2006)(2) Brief Description: The GAD-7 is a 7-item, Likert scale, self-report measure of anxiety symptoms based on DSM-IV criteria. This measure was developed for primary care and not specifically for older adults; however, there is some evidence for the reliability/validity of the GAD-7 with older adults.(3) Source/Availability: Pfizer; VA Mental Health Assistant, HBPC Sharepoint

2. Trauma- and Stressor-Related Disorders



Older veterans with PTSD may develop the disorder based on earlier life or more recent traumatic experience. PTSD associated with earlier life trauma (e.g., combat) may represent a chronic condition or late-life exacerbation. MH Providers are encouraged to evaluate lifetime exposure to combat and non-combat traumatic events.

a) Life Event Checklist for DSM-5 (LEC-5)(1) Reference: Weathers, Blake, et al. (2013)(2) Brief Description: The LEC-5 (standard version) is a 17-item, Likert scale, self-report measure of potentially traumatic events across a respondent’s entire life The LEC-5 assesses 17 events known to be distressing (e.g., natural disaster, assault) and can be rated based on direct experience, witnessing an event, knowledge of an event, exposure due to job responsibilities, etc. There also is an extended self-report version (contains 10 additional questions to identify worst event, if more than one, and an interview that contains questions seeking clarification on each endorsed item on the LEC-5 to establish worst event and if Criterion A is met.)(3) Source/Availability: Public domain; HBPC Sharepoint

b) Primary Care PTSD Screen (PC-PTSD)(1) Reference: Prins et al. (2003)(2) Brief Description: The PC-PTSD is a 4-item (yes/no) self-report screening measure of PTSD for Veterans seen in VA primary care settings based on DSM-IV criteria. This measure is being updated for the DSM-5 but is not currently available.(3) Source/Availability: Public domain; HBPC SharePoint

c) PTSD Checklist for DSM-5 (PCL-5)(1) Reference: Weathers, Litz et al. (2013)(2) Brief Description: The PCL-5 is a 20-item revision of the PCL that is based on the DSM-5 criteria and can be administered with or without an extended Criterion A assessment (5 items) and/or with the LEC-5. The PCL-5 scoring system is undergoing validation study; it will be posted to the VA Mental Health Assistant when available.(3) Source/Availability: Public domain; HBPC SharePoint

3. HoardingCompulsive hoarding is a condition characterized by difficulty discarding non-essential possessions, clutter, and distress. Researchers note that hoarding appears different from obsessive-compulsive disorder but is comorbid with other mental health conditions such as mood and anxiety disorders. Given the nature of HBPC services, HBPC team members likely encounter hoarding behaviors more frequently than they are recognized in clinic-based settings.



a) Hoarding Rating Scale (HRS)(1) Reference: Tolin, Frost, & Steketee (2010)(2) Brief Description: The HRS is a 5-item, Likert scale, measure that can be used as a questionnaire or semi-structured interview to identify probable hoarding problem. The HRS evaluates clutter, difficulty discarding, excessive acquisition, and distress and impairment resulting from hoarding behaviors.(3) Source/Availability: Public Domain; HBPC SharePoint

b) Savings Inventory-Revised (SIR)(1) Reference: Frost, Steketee, & Grisham (2004)(2) Brief Description: The SIR is a 23-item, Likert scale, self-report measure evaluating features of probable hoarding problems including: excessive acquisition, difficulty discarding, and clutter. The measure contains mean scores for clinical and nonclinical samples.(3) Source/Availability: Public Domain; HBPC SharePoint

C. Substance-Related and Addictive DisordersVeterans served in HBPC may have chronic, recurring, and/or later onset substance use disorders. Chronic substance use can underlie some medical conditions in later life; however, even moderate use may complicate other medical, neurological, or psychiatric conditions.

1. AlcoholAlcohol misuse is a common problem; many older adults are not aware of aging-related changes in the body’s ability to metabolize alcohol and the associated health, cognitive, and functional risks of drinking.

a) Alcohol Use Disorder Identification Test (AUDIT)(1) Reference: Babor, de la Fuenta, Saunders, & Grant (1992)(2) Brief Description: The AUDIT is a 10-item, Likert scale, self-report measure of alcohol use over the past year that was developed by the World Health Organization for use in primary care. The AUDIT has been validated for use with older adults. There is also a 3-item version pertaining to alcohol consumption (AUDIT-C).(3) Source/Availability: Public domain; HBPC SharePoint

b) Michigan Alcoholism Screening Test-Geriatric Version (MAST-G)(1) Reference: Blow et al. (1992)(2) Brief Description: The MAST-G is a 24-item (yes/no) self-report measure designed to identify alcohol abuse and/or dependence among older adults. There is also a 10-item version (SMAST-G).



(3) Source/Availability: Public Domain, HBPC SharePoint

III. Neurocognitive Functioning and Disorders

A. DeliriumDelirium is an acute confusional state commonly associated with acute medical illnesses and may co-occur in those with neurocognitive disorders. Urinary tract infections, medication changes, dehydration, fever, and other medical issues can precipitate delirium, which is a medical crisis in need of immediate treatment. Delirium should be evaluated whenever there is acute onset of global cognitive impairments or marked behavioral changes. Note that people with neurocognitive impairment are at relatively high risk for delirium; the delirium can and should be treated.

1. Confusion Assessment Method (CAM)a) Reference: Inouye et al. (1990); Inouye (2003)b) Brief Description: The CAM is a widely-used, standardized method for identifying delirium that correlates with DSM criteria for delirium. It is a 4-item, observer-rated measure, which the author recommended should be used in conjunction with a brief cognitive test (e.g., Mini-Cog) and measure of attention (e.g., digit span).c) Source/Availability: Public domain; HBPC SharePoint

2. The Delirium Rating Scale-Revised-98 (DRS-R-98)a) Reference: Trzepacz et al. (2001)b) Brief Description: The DRS-R-98 is a 16-item, clinician-rated scale that contains 3 diagnostic items and 13 severity items. The severity section can be used as a separate scale for serial assessment.c) Source/Availability: With permission from author; HBPC SharePoint

B. Neurocognitive DisordersCognitive decline is a common problem among the HBPC population, and MH Providers are encouraged to become familiar with the differences between normal and abnormal cognitive aging. Cognitive impairment influences Veteran and Caregiver well-being, medical understanding and/or adherence, and everyday functioning. The following measures are recommended when dementia warning signs are present (e.g., difficulty engaging in self-care activities). Given the psychometric limitations associated with brief cognitive assessment measures in general, standardized cognitive assessment is only recommended when there is reason for concern such as dementia warning signs, rather than as a screening tool for an entire group of Veterans, e.g., all HBPC patients.

1. Blessed-Orientation-Memory-Concentration Test (BOMC)



a) Reference: Blessed, Tomlinson, & Roth (1968)b) Brief Description: The BOMC is a 6-item measure that contains items for orientation, verbal recall, and attention.c) Source/Availability: Public Domain; VHA Mental Health Assistant

2. Dementia Rating Scale-2 (DRS-2)a) Reference: Jurica, Leitten, & Mattis (2001)b) Brief Description: The DRS-2 is a brief test battery of global cognitive ability that was developed to avoid floor effects in patients with clinically significant impairment as opposed to ceiling effects in high functioning patients. It is normed on healthy adults ranging from 56 to 105 years of age. The test measures attention, initiation/perseveration, construction, conceptualization, and memory.c) Source/Availability: Psychological Assessment Resources (PAR); http://www4.parinc.com/Default.aspx

3. Montreal Cognitive Assessment (MoCA)a) Reference: Nasreddine et al. (2005)b) Brief Description: The MoCA contains items for visuospatial ability, executive functioning, naming, memory, attention, language, abstraction, and orientation, and is scored up to 30 total points. The MoCA has been translated into many languages and has a version for use with the blind. There also is a multi-paged version with enlarged stimuli.c) Source/Availability: Public Domain; HBPC SharePoint

4. Repeatable Battery for the Assessment of Neuropsychological Status (RBANS); RBANS Updatea) Reference: Randolph (1998); Randolph (2012)b) Brief Description: The RBANS or RBANS Update is a brief neurocognitive battery of global cognitive ability that measures immediate and delayed memory, attention, language, and visuospatial ability. The RBANS was developed for individuals aged 20-89. The RBANS Update extended the age range downward to 12 and now includes subtest scores, which were formerly calculated by hand for the original RBANS.c) Source/Availability: Pearson; http://www.pearsonclinical.com/psychology.html

5. St. Louis University Mental Status Exam (SLUMS)a) Reference: Tariq, Tumosa, Chibnall, Perry, & Morley (2006)b) Brief Description: The SLUMS contains items for orientation, recall, memory, visuospatial ability, language, attention, abstraction, and executive functioning, and is scored up to 30 total points. There is a parallel form version that changes the occupation of the main character in the story from stockbroker to farmer.



c) Source/Availability: Public Domain; HBPC SharePoint

IV. Decision-Making and Functional CapacitiesHBPC MH Providers often provide a crucial service for the interdisciplinary team by providing evaluation of a Veteran’s ability to continue to reside independently in the community, make medical and/or financial decisions, or consent to certain aspects of care. These evaluations inform the interdisciplinary treatment plan, to be consistent with the Veteran’s values, abilities, and social context. There are no standardized tools that can serve as a “capacimeter,” i.e., the score telling you whether or not an individual has the capacity in question. These and other tools may contribute to an integrated evaluation process (ABA and APA, 2008).

A. Functional Assessment Staging (FAST)1. Reference: Reisburg (1988)2. Brief Description: The FAST is a clinician-rating scale that can be used to quickly evaluate and stage the progressive functional deterioration observed in Alzheimer disease.3. Source/Availability: Public Domain; VHA Mental Health Assistant

B. Independent Living Scales (ILS)1. Reference: Loeb (1996)2. Brief Description: The ILS is a broad measure of abilities associated with caring for oneself and/or property. The ILS contains 70-items across five subscales: memory/orientation, managing money, managing home and transportation, health and safety, and social adjustment. The entire measure can be used to obtain an overall score or select subscales can be administered.3. Source/Availability: Pearson; http://www.pearsonclinical.com/psychology.html

C. Katz Index of Activities of Daily Living Scale (Katz ADL)1. Reference: Katz, Ford, Moskowitz, Jackson, & Jaffee (1963)2. Brief Description: The Katz ADL is 6-item, clinician rating scale used to assess a patient's functional status by measuring his/her ability to perform activities of daily living independently versus with assistance. Functions assessed include bathing, dressing, toileting, transferring, continence, and feeding.3. Source/Availability: Public Domain; VHA Mental Health Assistant

D. Lawton-Brody Instrumental Activities of Daily Living Scale (IADL)1. Reference: Lawton & Brody (1969)



2. Brief Description: The IADL is a 11-item, clinician rating scale used to assess a patient's functional status by measuring his/her ability to perform more complex tasks of daily living across 8 domains: telephone, shopping, food preparation, housekeeping, laundry, mode of transportation, medication management, and management of finances.3. Source/Availability: The Gerontological Society of America; VHA Mental Health Assistant

V. Family CaregivingOne mission of the HBPC program is to aid and empower family or other informal Caregivers to assist in a Veteran’s care, allowing Veterans to remain in a least restrictive environment for as long as possible. Caregiving can be stressful and have a negative impact on a Caregiver’s physical and mental health. HBPC MH Providers can assist in providing Caregiver evaluation and support services.

A. REACH-II Risk Appraisal Measure (RAM)1. Reference: Czaja et al. (2009); Nichols, Martindale-Adams, Burns, Graney, & Zuber (2011)2. Brief Description: The RAM is a 16-item, Likert scale, self-report measure used to assess well-being and identify needed areas of support for Caregivers of patients with dementia such as access to dangerous objects, driving, wandering, smoking, or being left home alone. This measure was adapted for use in REACH-VA, but the Risk Assessment Tool used in REACH-VA also contains other tools such as the PHQ-9 and the Zarit (Nichols et al., 2011).3. Source/Availability: With permission from author; HBPC SharePoint

B. Zarit Burden Interview (ZBI)1. Reference: Zarit, Reever, & Bach-Peterson (1980)2. Brief Description: The ZBI is a 22-item, Likert scale, self-report measure developed to assess subjective burden among Caregivers with dementia. The questions are worded subjectively to focus on the affective response of the Caregiver. The ZBI also has a short version (12-items) and a 4-item screening version. The short and screening versions are available through the VHA Mental Health Assistant.3. Source/Availability: Permission to the VA; VHA Mental Health Assistant

VI. Other Conditions that May Be a Focus of Clinical Attention

A. BereavementBereavement is another risk factor for depression as grief over the loss of a loved one in later life can be magnified by cumulative losses (e.g., in functioning, relationships, roles). Complicated grief (or, persistent complex bereavement disorder) remains a condition for further study in DSM-5; it is another possible consequence of bereavement, characterized by marked daily separation distress and trauma-related symptoms.

a) Prolonged Grief Disorder (PG-13)



(1) Reference: Prigerson, Vanderwerker & Maciejewski (2008)(2) Brief Description: The PG-13 is a 13-item, Likert scale, self-report measure of prolonged grief in reaction to the loss of a loved one. It was derived from the Inventory of Complicated Grief (ICG; Prigerson et al., 1995), a 19-item measure of bereavement-related thoughts and behaviors measuring pathological grief symptoms such as disbelief, anger, and hallucinations. The PG-13 measures symptoms (feelings, thoughts, actions) associated with Prolonged Grief Disorder, which was proposed but not included in the DSM-5.(3) Source/Availability: With permission from primary author; HBPC SharePoint

b) Texas Revised Inventory of Grief (TRIG)(1) Reference: Faschingbauer, Zisook, & DeVaul (1987)(2) Brief Description: The TRIG is a 21-item, Likert scale, self-report measure of grief associated with loss of a loved one and is divided into two measures: present grief (TRIG-Present, 13-items) and past difficulties due to loss (TRIG-Past, 8-items).(3) Source/Availability: With permission from contact author; HBPC SharePoint

B. Behavioral DisturbanceVeterans with neurocognitive disorders, delirium, or other acute medical conditions may present with behavioral disturbances that are clinically significant and may have implications for differential diagnosis, treatment planning and management, and caregiving. The DSM-5 identifies behavioral disturbance as psychotic symptoms, mood disturbance, agitation, apathy, or other behavioral symptoms according to severity of impairment to daily functioning (i.e., mild, moderate, or severe).

1. Cohen-Mansfield Agitation Inventory (CMAI)a) Reference: Cohen-Mansfield, Marx, & Rosenthal (1989)b) Brief Description: The CMAI is a 29-item measure designed to assess the frequency and demonstration of agitated behaviors in older adults. The CMAI was developed for use in long term care, but there is a 14-item version, a community version, a version for relatives, and disruptiveness version.c) Source/Availability: With permission from copyright owner; HBPC SharePoint

2. Revised Memory and Behavior Problems Checklist (RMBPC)a) Reference: Teri et al. (1992)b) Brief Description: The RMBPC is a 24-item, Caregiver-report measure of behavioral difficulties observed in patients with dementia. It may be used to obtain a total score and 3 subscale scores (memory-related, depression, and disruptive behaviors). Scores also may be obtained for the Caregiver's reaction to each of the behaviors.



c) Source/Availability: With permission from author; HBPC SharePoint





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References

Alexopoulos, G. S., Abrams, R. C., Young, R. C., & Shamoian, C. A. (1988). Cornell Scale for Depression in Dementia. Biological Psychiatry, 23, 271-284.

Babor, T. F., de la Fuenta, J. R., Saunders, J., & Grant, M. (1992). AUDIT: The Alcohol Use Disorders Identification Test: Guidelines for its use in primary health care. Geneva, Switzerland: World Health Organization.

Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893-897.

Beck, A. T., & Steer, R. A. (1993). Manual for the Beck Hopelessness Scale. San Antonio, TX: The Psychological Corporation.

Beck, A. T., Steer, R. A., & Brown, G. K. (1996). The Beck Depression Inventory-Second Edition. San Antonio, TX: The Psychological Corporation.

Blessed, G., Tomlinson, B. E., & Roth, M. (1968). The association between quantitative measures of dementia and of senile change in cerebral grey matter of elderly subjects. British Journal of Psychiatry, 114, 797-811.

Blow, F. C., Brower, K. J., Schulenberg, J. E., Demo-Dananberg, L. M., Young, J. P., & Beresford, T. P. (1992). The Michigan Alcoholism Screening Test-Geriatric Version (MAST-G): A new elderly-specific screening instrument. Alcoholism: Clinical and Experimental Research, 16, 372.

Cohen-Mansfield, J., Marx, M. S., & Rosenthal, A. S. (1989). A description of agitation in a nursing home. Journal of Gerontology: Medical Sciences, 44(3), M77-M84.

Czaja, S. J., Gitlin, L. N., Schulz, R., Zhang, S., Burgio, L. D., Stevens, A. B. ... (2009). Development of the Risk Appraisal Measure: A brief screen to indentify risk areas and guide interventions for dementia caregivers. Journal of the American Geriatric Society, 57, 1064-1072.

Edelstein, B. A., Heisel, M. J., McKee, D. R., Martin, R. R., Koven, L. P., Duberstein, P. R., & Britton, P. C. (2009). Development and psychometric evaluation of the Reasons for Living-Older Adults Scale: A suicide risk assessment inventory. The Gerontologist, 49, 6, 736-745.

Faschingbauer, T., Zisook, S., & DeVaul, R. (1987). The Texas Revised Inventory of Grief. In S. Zisook (Ed.), Biopsychosocial Aspects of Bereavement (pp. 111-124). Washington, D. C.: American Psychiatric Press, Inc.

Frost, R. O., Steketee, G., & Grisham J. (2004). Measurement of compulsive hoarding: Saving Inventory- Revised. Behaviour Research and Therapy,



42, 163–1182.

Inouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P., Horwitz, R. I. (1990). Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirum. Annals of Internal Medicine, 113, 941-948.

Inouye, S. K. (2003). The Confusion Assessment Method (CAM): Training manual and coding guide. New Haven, CT: Yale University School of Medicine.

Jurica, P. J., Leitten, C. L., & Mattis, S. (2001). The DRS-2: Dementia Rating Scale-2 Professional Manual. Lutz, FL: Psychological Assessment Resources, Inc.

Katz, S., Ford, A., Moskowitz, R., Jackson, B., & Jaffee, M. (1963). Studies of illness in the aged: The Index of ADL, a standardized measure of biological and psychosocial function. Journal of the American Medical Association, 185, 914-919.

Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16, 606-613.

Lawton, M. P., & Brody, E. M. (1969). Assessment of older people: Self-maintaining and instrumental activities of daily living. The Gerontologist, 9, 179–186.

Lesher, E. L., & Berryhill, J. S. (1994). Validation of the Geriatric Depression Scale-Short Form among inpatients. Journal of Clinical Psychology, 50, 256-260.

LoConte, N. K., Gleason, C. E., Gunter-Hunt, G., Carlsson, C. M., & Siebers, M. (2008). Standardized note template improves screening of firearm access and driving among veterans with dementia. American Journal of Alzheimer’s Disease and Other Dementias, 23, 313-318.

Leob, P. A. (1996). Independent Living Scales manual. San Antonio, TX: Pearson.

Nasreddine, Z. S., Phillips, N. A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I., …Chertkow, H. (2005). The Montreal Cognitive Assessment (MoCA): A brief screening tool for mild cognitive impairment. Journal of American Geriatric Society, 53, 695-699.

Nichols, L. O., Martindale-Adams, J., Burns, R., Graney, M. J., & Zuber, J. (2011). Translation of a dementia caregiver support program in a health care system-REACH VA. Archives of Internal Medicine, 171, 353-359.

Osman, A., Bagge, C. L., Guitierrez, P. M., Konick, L. C., Kooper, B. A., & Barrios, F. X. (2001). The Suicidal Behaviors Questionnaire-Revised (SBQ-R): Validation with clinical and nonclinical samples. Assessment, 8, 443-454.



Pachana, N. A., Byrne, G. J., Siddle, H., Koloski, N., Harley, E., & Arnold, E. (2007). Development and validation of the Geriatric Anxiety Inventory. International Psychogeriatrics, 19, 359-365.

Prigerson, H. G., Maciejewski, P. K., Reynolds, C. F., Biefhals, A. J., Newsom, J. T., Fasiczka, A., …Miller, M. (1995). The Inventory of Complicated Grief: A scale to measure maladaptive symptoms of loss. Psychiatry Research, 59, 65-79.

Prigerson, H. G., Vanderwerker, L. C., & Maciejewski, P. K. (2008). Prolonged grief disorder: A case for inclusion in DSM-V. In: M. Strobe, R. Hansson, H. Schut, & W. Stroebe (Eds.). Handbook of bereavement research and practice: 21st century perspectives (pp. 165-186). American Psychological Association Press; Washington DC: 2008. pp. 165–186.

Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P., Hugelshofer, D. S., Shaw-Hegwer, J., Thrailkill, A., Gusman, F.D., Sheikh, J. I. (2003). The primary care PTSD screen (PC-PTSD): Development and operating characteristics. Primary Care Psychiatry, 9, 9-14.

Randolph, C. (1998). Repeatable Battery for the Assessment of Neuropsychological Status. San Antonio, TX: The Psychological Corporation.

Randolph, C. (2012). Repeatable Battery for the Assessment of Neuropsychological Status Update. San Antonio, TX: Pearson Education.

Reisburg, B. (1988). Functional Assessment Staging (FAST). Psychopharmacology Bulletin, 24, 653-659.

Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166, 1092-1097.

Tariq, S. H., Tumosa, N., Chibnall, J. T., Perry, H. M., III, & Morley, J. E. (2006). The Saint Louis University Mental Status (SLUMS) examination for detecting mild cognitive impairment and dementia is more sensitive than the Mini-Mental State Examination (MMSE): A pilot study. American Journal of Geriatric Psychiatry, 14, 900-910.

Teri, L., Truaz, P., Logsdon, R., Uomoto, J., Zarit, S., & Vitaliano, P. P. (1992). Assessment of behavioral problems in dementia: The Revised Memory and Behavior Problems Checklist. Psychology and Aging, 7, 622-631.

Tolin, D., Frost, R., & Steketee, G. (2010). A brief interview for assessing compulsive hoarding: the Hoarding Rating Scale-Interview. Psychiatry Research, 178, 147-152.

Trzepacz, P. T., Mittal, D. Torres, R., Kanary, K., Norton, J., & Jimerson, N. (2001). Validation of the Delirium Rating Scale-Revised-98: Comparison to the Delirium Rating Scale and Cognitive Test For Delirium. Journal of Neuropsychiatry and Clinical Neuroscience, 13, 229–242.

Weathers, F. W., Blake, D. D., Schnurr, P. P., Kaloupek, D. G., Marx, B. P., & Kean, T. M. (2013). The Life Events Checklist for DSM-5 (LEC-5). Retrieved



from National Center for PTSD at: http://www.ptsd.va.gov/professional/assessment/te-measures/life_events_checklist.asp

Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, P. A., Marx, B. P., & Schnurr, P. P. (2013). PTSD Checklist for DSM-5 (PCL-5). Retrieved from National Center for PTSD at: http://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp

Yesavage, J. A., Brink, T. L., Rose, T. L., & Lum, O. (1983). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17, 37–49.

Zarit, S. H., Reever, K. E., Back-Peterson, J. (1980). Relatives of the impaired elderly: correlates of feelings of burden. The Gerontologist, 20, 649-65.

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Additional ResourcesScreen ID additionalResources.htm Screen Type New Window: Additional Resources Resources

Resources

American Bar Association Commission on Law and Aging & American Psychological Association. (2008). Assessment of older adults with diminished capacity: A handbook for psychologists. Washington, DC: Author. Available at: http://www.apa.org/pi/aging/programs/assessment/index.aspx

American Geriatrics Society 2012 Beers Criteria Updated Expert Panel. (2012). American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatric Society, 60, 616-631. Available at: http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf

American Psychological Association (2014). Guidelines for psychological practice with older adults. American Psychologist, 69, 34-65. Available at: http://www.apa.org/practice/guidelines/older-adults.pdf

American Psychological Association (2012). Guidelines for the evaluation of dementia and age-related cognitive decline. American Psychologist, 67, 1-9. Available at: http://www.apa.org/practice/guidelines/dementia-age.pdf

Attix, D. K., & Welsh-Bohmer, K. A. (2006). Geriatric neuropsychology: Assessment and intervention. New York, NY, US: Guilford Publications.

Blazer, D. G. (2012). The psychiatric interview of older adults. In D. G. Blazer, D. C. Steffens (Eds.) , Essentials of geriatric psychiatry (2nd ed.) (pp. 47-62). Arlington, VA, US: American Psychiatric Publishing, Inc.

Bush, S. S. & Martin, T. A. (Eds.) (2005). Geriatric neuropsychology: Practice essentials. New York: Taylor & Francis.

Edelstein, B. A., Martin, R. R., & Gerolimatos, L. A. (2012). Assessment in geriatric settings. In J.R. Graham & J.A. Naglieri (Eds.), Handbook of psychology: Assessment psychology (pp. 425-448). Hoboken NJ: John Wiley & Sons, Inc.

Edelstein, B. A., Woodhead, E. L., Segal, D. L., Heisel, M. J., Bower, E. H., Lowery, A. J., & Stoner, S. A. (2008). Older adult psychological assessment: Current instrument status and related considerations. Clinical Gerontologist: The Journal of Aging and Mental Health, 31, 1-35.

Family Caregiver Alliance and Benjamin Rose Institute on Aging (2012). Selected caregiver assessment measures: A resource inventory for practitioners, 2nd edition. Available at https://www.caregiver.org/selected-caregiver-assessment-measures-resource-inventory-practitioners-2012.

Gerolimatos, L. A., Gregg, J. J., & Edelstein, B. A. (in press). Interviewing older adults. In N. A. Pachana & K. Laidlaw (Eds.), The Oxford handbook of clinical geropsychology: International perspectives. Oxford University Press.


http://www.apa.org/practice/guidelines/dementia-age.pdf

http://www.apa.org/practice/guidelines/older-adults.pdf

http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf

http://www.apa.org/pi/aging/programs/assessment/index.aspx


Gordon, B. H., & Karel, M. J. (In press). Psychological assessment of veterans in home based primary care. In S. Bush (Ed.) Psychological assessment of veterans. New York, NY: Oxford University Press.

Hinrichsen, G. A. (2006). Why multicultural issues matter for practitioners working with older adults. Professional Psychology Research and Practice, 37, 29-35.

Jamora, C., Ruff, R. M., & Connor, B. B. (2008). Geriatric neuropsychology: Implications for front line clinicians. Neurorehabilitation, 23, 381-394.

Lichtenberg, P. A. (2010). Handbook of assessment in clinical gerontology (2nd ed.). San Diego, CA, US: Elsevier Academic Press.

Mast, B. T. (2011). Whole person dementia assessment. Baltimore, MD, US: Health Professions Press

Mast, B. T. (2012). Methods for assessing the person with Alzheimer's disease: Integrating person-centered and diagnostic approaches to assessment, Clinical Gerontologist, 35, 360-375.

Mcgee, J.S., & Bratkovich, K.L. (2011). Assessment and cognitive-behaviorally oriented interventions for older adults with dementia. In K.H. Sorocco and S. Lauderdale, (Eds.) Cognitive behavioral therapy with older adults (pp. 219-261). New York: Springer Publishing Company.

Meeks, T. W., Lanouette, M., Vahia, I., Dawes, S., Jeste, D. V., & Lebowitz, B. (2009). Psychiatric assessment and diagnosis in older adults. Focus, Psychiatry On-line, 7, 3-16.

Mohlman, J., Sirota, K. G., Papp, L. A., Staples, A. M., King, A., & Gorenstein, E. E. (2012). Clinical interviewing with older adults. Cognitive and Behavioral Practice, 19, 89-100.

Qualls, S. H. & Smyer, M. A. (2007). Changes in decision-making capacity: Assessment and intervention. [Wiley Series in Clinical Geropsychology]. Hoboken, NJ: Wiley Publishing.

Scharre, D. W., & Trzepacz, P. T. (2013). Evaluation of cognitive impairment in older adults. Focus: The Journal of Lifelong Learning in Psychiatry, 11, 482-500.

Segal, D.L., Coolidge, F.L., & Rosowsky, E. (2006). Personality disorders and older adults: Diagnosis, assessment, and treatment. Hoboken, N.J.: John Wiley & Sons.

Zarit, S.H., & Zarit, J.M. (2007). Mental disorders in older adults: Fundamentals of Assessment and Treatment (2 nd ed.). New York: The Guilford Press.

Websites



GeroCentral: http://gerocentral.org/clinical-toolbox/See also readings re: geropsychology assessment knowledge and skill competencies at:http://gerocentral.org/competencies/articles-by-competency/assessment-knowledge/http://gerocentral.org/competencies/articles-by-competency/assessment-skills/American Psychological Association Office on Aging: http://www.apa.org/pi/aging/American Psychological Association Caregiver Briefcase: http://www.apa.org/pi/about/publications/caregivers/index.aspx

Feedback Letter

Dear Mr. Apple,

Thank you for meeting with me in your home yesterday. Here is a summary of the results of the assessment which we reviewed together yesterday. As we discussed, we completed the assessment in order to help clarify your cognitive, emotional, and decision-making strengths as well as areas in which you may need assistance at this time.

Your strengths include:

A long history of strong coping skills in the face of medical challengesFamily supportLanguage – you clearly understand what others mean when they speak to youVisual memory – your ability to remember what you seeUnderstanding of your medical condition and treatment options

Area in which you may need assistance:

Verbal memory – your memory for things that you hearWhen you have reminders or cues, your memory improvedExecutive functions – your ability to keep focused and organized and keep control over emotional reactionsChanges in executive functioning may help to explain some of the personality changes your family has noticedYour mood – you struggle with mild symptoms of depression and anxiety, consistent with a diagnosis of mild depression with anxious featuresDepression is treatable and we can follow-up on this together

Making medical decisions

We have been speaking about difficult medical decisions that you are facing at this time, given you are having more trouble getting adequate


http://gerocentral.org/competencies/articles-by-competency/assessment-skills/

http://gerocentral.org/competencies/articles-by-competency/assessment-knowledge/

http://gerocentral.org/clinical-toolbox/


nutrition. Based on the assessment results, your healthcare team does believe you can make decisions about your health care and treatment at this time. Our team will continue to work with you to make sure you have all the information and support you need to make decisions that are right for you.

Our recommendations include:

We recommend that you use visual reminders around the house to help you remember important information – for example, you might consider using a dry erase board with pictures to remind you of the day’s scheduleWe recommend that you follow-up with me to discuss treatment for depression, in order to help optimize your quality of life and help you think as clearly as possible about important decisionsThe HBPC team will continue to support you and your family to find ways of compensating for the changes in your thinking and memory

The HBPC team will continue to work closely with you and your family. We will monitor your thinking, mood, and adjustment to help ensure you are receiving whatever supports you need.

Thank you again for the opportunity to work with you! Please feel free to call me any time if you have questions. We scheduled our next meeting for Thursday, February 27th, at 9:00 a.m., and I will plan to see you then.

Sincerely,

Ann MinkinHBPC PsychologistAnyCity VA Medical CenterPhone: 123-456-7890

Appendix, Assessment Tools

Assessment tools reviewed in this appendix are divided by category and described by content and source. Tools available through the CPRS Mental Health Assistant (MHA) are identified; links are provided for those not available through MHA. Some tools are commercial and some are in the public domain. When permission has been secured, tools listed below that are not available through VA MHA are archived at the HBPC Mental Health SharePoint site:https://vaww.portal.va.gov/sites/OMHS/MH-HBPC/default.aspx

Note. This overview of tools is not intended to be prescriptive nor restrictive in nature. The tools identified may not be appropriate for use with all patients and/or situations, and many other tools exist that may be quite helpful to inform mental health evaluation in HBPC. MH Providers must use



their clinical judgment, and be aware of their own scope of competence, when choosing assessment tools to use in any given clinical situation.

I. Risk AssessmentHBPC MH Providers often work with their teams to help evaluate and manage Veteran’s at increased risk for harm to self and/or others. HBPC MH Providers should be aware of VHA suicide prevention resources and utilize these resources as needed, including the Suicide Risk Pocket Card and Assessment Guide, Safety Plan Pocket Card and Treatment Manual, and related resource guides, which are available at:http://vaww.mentalhealth.va.gov/rc-suicideprevention.aspas well as athttp://www.mentalhealth.va.gov/communityproviders/clinic_suicideprevention.asp.

All HBPC MH Providers are encouraged to follow local policies regarding assessment, documentation, and management of suicide risk, and to collaborate with local Suicide Prevention Coordinators as needed. The measures listed below are possible supplements to established national and local VHA policies regarding suicide risk assessment.

A. Suicide RiskThe HBPC population has many demographic and clinical features that are associated with higher suicide rates (e.g., older age, poor health, cumulative losses, high rates of depression, firearm ownership) than general primary care populations. Mental health evaluation in HBPC should always include screening and evaluation for suicide risk. The tools listed here may supplement evaluation and help to monitor Veterans over time.

1. Beck Hopelessness Scale (BHS)a) Reference: Beck & Steer (1993)b) Brief Description: The BHS is a 20-item (true/false) self-report measure of positive and negative feelings about the future, loss of motivation, and expectations.c) Source/Availability: Pearson; VA Mental Health Assistant

2. Reasons for Living – Older Adults Scale (RFL-OA)a) Reference: Edelstein et al. (2009)b) Brief Description: The RFL-OA is a 69-item, Likert scale, self-report measure of reasons for living among older adults at risk for suicide.c) Source/Availability: With permission from primary author; Contact: Barry Edelstein – [email protected]

3. Suicidal Behavior Questionnaire – Revised (SBQ-R)a) Reference: Osman et al. (2001)b) Brief Description: The SBQ-R is a 4-item, Likert scale, self-report measure evaluating lifetime suicidal ideation and/or attempts, frequency of


http://www.mentalhealth.va.gov/communityproviders/clinic_suicideprevention.asp

http://vaww.mentalhealth.va.gov/rc-suicideprevention.asp


suicidal ideation, threat of suicide attempt, and likelihood of suicidal behavior in the future. The SBQ-R was not developed specifically for use with older adults but has some evidence of reliability/validity with adult clinical populations and may be helpful with younger HBPC patients.c) Source/Availability: Public domain; HBPC SharePoint

B. Firearm & Driving SafetyResearchers have concluded that firearms in the home are associated with increased risk of harm to self or others as well as death, and these risks increase among individuals with cognitive impairment. Functional and cognitive impairment also is associated with diminished driving ability and increased risk for accidental harm or death to self or others. Given the high prevalence of older adults with complex medical and/or cognitive impairment in HBPC, MH Providers are encouraged to collaborate with the HBPC team for evaluation and management of these potential safety concerns.

1. DVA Firearms & Driving Questionnaire (VA Form 10-0435, 2005)a) Reference: LoConte, Gleason, Gunter-Hunt, Carlsson, & Siebers (2008)b) Brief Description: VA Form 10-0435 is a brief provider-rating form designed to standardize assessment of firearm possession and safety (4 items) and current driving practices and safety (8 items) among older veterans.c) Source/Availability: Public domain; HBPC SharePoint

II. Psychological Functioning

A. Depressive DisordersThe HBPC population has numerous risk factors for late life depression and related disorders due to the prevalence of medical conditions such as heart disease, diabetes, and neurodegenerative illnesses, marked functional impairment, social isolation, and/or stressful interpersonal circumstances.

1. DepressionEvaluating late life depression can be a complex task due to concomitant medical and neurological factors as well as pharmacological agents. Depression in later life may present differently than in younger adults and include greater reporting of physiological symptoms (e.g., somatic complaints, sleep disruption, memory complaints), an apathetic presentation with less expressed sadness, guilt, or worthlessness, and/or co-occurring anxiety. Depression also may present differently across racial/ethnic backgrounds. MH Providers are encouraged to assess depression using an interdisciplinary approach and tools appropriate for an aging medical population.

a) Patient Health Questionnaire (PHQ-9)(1) Reference: Kroenke, Spitzer, & Williams (2001)



(2) Brief Description: The PHQ-9 is a 9-item, Likert scale, self-report measure for screening and measuring the severity of depression based on DSM-IV criteria. One additional item measures the impact of symptoms on daily functioning. This measure was developed for primary care but not older adults; however, there is good evidence for the reliability/validity of the PHQ-9 with older adults in primary care settings.(3) Source/Availability: Pfizer; VA Mental Health Assistant, HBPC Sharepoint

b) Geriatric Depression Scale (GDS; GDS-15)(1) Reference: Yesavage, Brink, Rose, & Lum (1983); Lesher & Berryhill (1994)(2) Brief Description: The GDS is a 30-item (yes/no) self-report measure of depression in older adults. There also is a 15-item (yes/no) version of the measure that has similar psychometric properties. The GDS does not contain somatic complaint items, which should be evaluated separately (e.g., sleep, appetite).(3) Source/Availability: Public domain; VA Mental Health Assistant, HBPC SharePoint

c) Beck Depression Inventory-II (BDI-II)(1) Reference: Beck, Steer, & Brown (1996)(2) Brief Description: The BDI-II is a 21-item, Likert scale, self-report measure used for evaluating severity of depressive symptoms in adults. The BDI-II has eight items assessing somatic complaints, which may elevate scores in some older adults. In addition, its 4-point, Likert type scale format may be difficult for those with limited literacy or cognitive impairment.(3) Source/Availability: Pearson; VA Mental Health Assistant

d) Cornell Scale for Depression in Dementia (CSDD)(1) Reference: Alexopoulos, Abrams, Young, & Shamoian (1988)(2) Brief Description: The CSDD is a 19-item, clinician-rated measure that can be used for evaluating depression in individuals with dementia. It entails competing two semi-structured interviews, with an informant and with the patient. It was designed for identifying severity among those with a diagnosis of depression, rather than identifying the disorder, but may be useful as part of an evaluation of mood among Veterans with dementia.(3) Source/Availability: With permission from primary author; HBPC SharePoint

B. Anxiety, Trauma and Stress-Related, and Obsessive-Compulsive and Related DisordersAnxiety disorders are prevalent among older adults and often associated with chronic medical conditions such as cardiac or respiratory illness, dementia, and functional impairment. Anxiety disorders pose risk for and are frequently comorbid with late life depression. Avoidance symptoms core to anxiety disorders can be more difficult to recognize due to decreased social engagement in the HBPC population.

1. Generalized Anxiety DisorderGeneralized anxiety is the most researched anxiety disorder among older adults. Excessive worry may be lifelong or develop in later life, and be



associated with declining health, changes in family and/or financial status, and other late-life changes.

a) Beck Anxiety Inventory (BAI)(1) Reference: Beck, Epstein, Brown, & Steer (1988)(2) Brief Description: The BAI is a 21-item, Likert scale, self-report measure of somatic and cognitive symptoms of anxiety.(3) Source/Availability: Pearson; VA Mental Health Assistant

b) Geriatric Anxiety Inventory (GAI)(1) Reference: Pachana et al. (2007)(2) Brief Description: The GAI is a 20-item (agree/disagree) self-report measure of anxiety symptoms commonly reported among older adults.(3) Source/Availability: Copyrighted by authors; http://www.gai.net.au/

c) Generalized Anxiety Disorder Scale (GAD-7)(1) Reference: Spitzer, Kroenke, Williams, & Löwe (2006)(2) Brief Description: The GAD-7 is a 7-item, Likert scale, self-report measure of anxiety symptoms based on DSM-IV criteria. This measure was developed for primary care and not specifically for older adults; however, there is some evidence for the reliability/validity of the GAD-7 with older adults.(3) Source/Availability: Pfizer; VA Mental Health Assistant, HBPC Sharepoint

2. Trauma- and Stressor-Related DisordersOlder veterans with PTSD may develop the disorder based on earlier life or more recent traumatic experience. PTSD associated with earlier life trauma (e.g., combat) may represent a chronic condition or late-life exacerbation. MH Providers are encouraged to evaluate lifetime exposure to combat and non-combat traumatic events.

a) Life Event Checklist for DSM-5 (LEC-5)(1) Reference: Weathers, Blake, et al. (2013)(2) Brief Description: The LEC-5 (standard version) is a 17-item, Likert scale, self-report measure of potentially traumatic events across a respondent’s entire life The LEC-5 assesses 17 events known to be distressing (e.g., natural disaster, assault) and can be rated based on direct experience, witnessing an event, knowledge of an event, exposure due to job responsibilities, etc. There also is an extended self-report version (contains 10 additional questions to identify worst event, if more than one, and an interview that contains questions seeking clarification on each endorsed item on the LEC-5 to establish worst event and if Criterion A is met.)(3) Source/Availability: Public domain; HBPC Sharepoint


http://www.gai.net.au/


b) Primary Care PTSD Screen (PC-PTSD)(1) Reference: Prins et al. (2003)(2) Brief Description: The PC-PTSD is a 4-item (yes/no) self-report screening measure of PTSD for Veterans seen in VA primary care settings based on DSM-IV criteria. This measure is being updated for the DSM-5 but is not currently available.(3) Source/Availability: Public domain; HBPC SharePoint

c) PTSD Checklist for DSM-5 (PCL-5)(1) Reference: Weathers, Litz et al. (2013)(2) Brief Description: The PCL-5 is a 20-item revision of the PCL that is based on the DSM-5 criteria and can be administered with or without an extended Criterion A assessment (5 items) and/or with the LEC-5. The PCL-5 scoring system is undergoing validation study; it will be posted to the VA Mental Health Assistant when available.(3) Source/Availability: Public domain; HBPC SharePoint

3. HoardingCompulsive hoarding is a condition characterized by difficulty discarding non-essential possessions, clutter, and distress. Researchers note that hoarding appears different from obsessive-compulsive disorder but is comorbid with other mental health conditions such as mood and anxiety disorders. Given the nature of HBPC services, HBPC team members likely encounter hoarding behaviors more frequently than they are recognized in clinic-based settings.

a) Hoarding Rating Scale (HRS)(1) Reference: Tolin, Frost, & Steketee (2010)(2) Brief Description: The HRS is a 5-item, Likert scale, measure that can be used as a questionnaire or semi-structured interview to identify probable hoarding problem. The HRS evaluates clutter, difficulty discarding, excessive acquisition, and distress and impairment resulting from hoarding behaviors.(3) Source/Availability: Public Domain; HBPC SharePoint

b) Savings Inventory-Revised (SIR)(1) Reference: Frost, Steketee, & Grisham (2004)(2) Brief Description: The SIR is a 23-item, Likert scale, self-report measure evaluating features of probable hoarding problems including: excessive acquisition, difficulty discarding, and clutter. The measure contains mean scores for clinical and nonclinical samples.(3) Source/Availability: Public Domain; HBPC SharePoint

C. Substance-Related and Addictive Disorders



Veterans served in HBPC may have chronic, recurring, and/or later onset substance use disorders. Chronic substance use can underlie some medical conditions in later life; however, even moderate use may complicate other medical, neurological, or psychiatric conditions.

1. AlcoholAlcohol misuse is a common problem; many older adults are not aware of aging-related changes in the body’s ability to metabolize alcohol and the associated health, cognitive, and functional risks of drinking.

a) Alcohol Use Disorder Identification Test (AUDIT)(1) Reference: Babor, de la Fuenta, Saunders, & Grant (1992)(2) Brief Description: The AUDIT is a 10-item, Likert scale, self-report measure of alcohol use over the past year that was developed by the World Health Organization for use in primary care. The AUDIT has been validated for use with older adults. There is also a 3-item version pertaining to alcohol consumption (AUDIT-C).(3) Source/Availability: Public domain; HBPC SharePoint

b) Michigan Alcoholism Screening Test-Geriatric Version (MAST-G)(1) Reference: Blow et al. (1992)(2) Brief Description: The MAST-G is a 24-item (yes/no) self-report measure designed to identify alcohol abuse and/or dependence among older adults. There is also a 10-item version (SMAST-G).(3) Source/Availability: Public Domain, HBPC SharePoint

III. Neurocognitive Functioning and Disorders

A. DeliriumDelirium is an acute confusional state commonly associated with acute medical illnesses and may co-occur in those with neurocognitive disorders. Urinary tract infections, medication changes, dehydration, fever, and other medical issues can precipitate delirium, which is a medical crisis in need of immediate treatment. Delirium should be evaluated whenever there is acute onset of global cognitive impairments or marked behavioral changes. Note that people with neurocognitive impairment are at relatively high risk for delirium; the delirium can and should be treated.

1. Confusion Assessment Method (CAM)a) Reference: Inouye et al. (1990); Inouye (2003)b) Brief Description: The CAM is a widely-used, standardized method for identifying delirium that correlates with DSM criteria for delirium. It is a 4-item, observer-rated measure, which the author recommended should be used in conjunction with a brief cognitive test (e.g., Mini-Cog) and measure of attention (e.g., digit span).



c) Source/Availability: Public domain; HBPC SharePoint

2. The Delirium Rating Scale-Revised-98 (DRS-R-98)a) Reference: Trzepacz et al. (2001)b) Brief Description: The DRS-R-98 is a 16-item, clinician-rated scale that contains 3 diagnostic items and 13 severity items. The severity section can be used as a separate scale for serial assessment.c) Source/Availability: With permission from author; HBPC SharePoint

B. Neurocognitive DisordersCognitive decline is a common problem among the HBPC population, and MH Providers are encouraged to become familiar with the differences between normal and abnormal cognitive aging. Cognitive impairment influences Veteran and Caregiver well-being, medical understanding and/or adherence, and everyday functioning. The following measures are recommended when dementia warning signs are present (e.g., difficulty engaging in self-care activities). Given the psychometric limitations associated with brief cognitive assessment measures in general, standardized cognitive assessment is only recommended when there is reason for concern such as dementia warning signs, rather than as a screening tool for an entire group of Veterans, e.g., all HBPC patients.

1. Blessed-Orientation-Memory-Concentration Test (BOMC)a) Reference: Blessed, Tomlinson, & Roth (1968)b) Brief Description: The BOMC is a 6-item measure that contains items for orientation, verbal recall, and attention.c) Source/Availability: Public Domain; VHA Mental Health Assistant

2. Dementia Rating Scale-2 (DRS-2)a) Reference: Jurica, Leitten, & Mattis (2001)b) Brief Description: The DRS-2 is a brief test battery of global cognitive ability that was developed to avoid floor effects in patients with clinically significant impairment as opposed to ceiling effects in high functioning patients. It is normed on healthy adults ranging from 56 to 105 years of age. The test measures attention, initiation/perseveration, construction, conceptualization, and memory.c) Source/Availability: Psychological Assessment Resources (PAR); http://www4.parinc.com/Default.aspx

3. Montreal Cognitive Assessment (MoCA)a) Reference: Nasreddine et al. (2005)b) Brief Description: The MoCA contains items for visuospatial ability, executive functioning, naming, memory, attention, language, abstraction, and orientation, and is scored up to 30 total points. The MoCA has been translated into many languages and has a version for use with the blind. There also is a multi-paged version with enlarged stimuli.


http://www4.parinc.com/Default.aspx


c) Source/Availability: Public Domain; HBPC SharePoint

4. Repeatable Battery for the Assessment of Neuropsychological Status (RBANS); RBANS Updatea) Reference: Randolph (1998); Randolph (2012)b) Brief Description: The RBANS or RBANS Update is a brief neurocognitive battery of global cognitive ability that measures immediate and delayed memory, attention, language, and visuospatial ability. The RBANS was developed for individuals aged 20-89. The RBANS Update extended the age range downward to 12 and now includes subtest scores, which were formerly calculated by hand for the original RBANS.c) Source/Availability: Pearson; http://www.pearsonclinical.com/psychology.html

5. St. Louis University Mental Status Exam (SLUMS)a) Reference: Tariq, Tumosa, Chibnall, Perry, & Morley (2006)b) Brief Description: The SLUMS contains items for orientation, recall, memory, visuospatial ability, language, attention, abstraction, and executive functioning, and is scored up to 30 total points. There is a parallel form version that changes the occupation of the main character in the story from stockbroker to farmer.c) Source/Availability: Public Domain; HBPC SharePoint

IV. Decision-Making and Functional CapacitiesHBPC MH Providers often provide a crucial service for the interdisciplinary team by providing evaluation of a Veteran’s ability to continue to reside independently in the community, make medical and/or financial decisions, or consent to certain aspects of care. These evaluations inform the interdisciplinary treatment plan, to be consistent with the Veteran’s values, abilities, and social context. There are no standardized tools that can serve as a “capacimeter,” i.e., the score telling you whether or not an individual has the capacity in question. These and other tools may contribute to an integrated evaluation process (ABA and APA, 2008).

A. Functional Assessment Staging (FAST)1. Reference: Reisburg (1988)2. Brief Description: The FAST is a clinician-rating scale that can be used to quickly evaluate and stage the progressive functional deterioration observed in Alzheimer disease.3. Source/Availability: Public Domain; VHA Mental Health Assistant

B. Independent Living Scales (ILS)1. Reference: Loeb (1996)2. Brief Description: The ILS is a broad measure of abilities associated with caring for oneself and/or property. The ILS contains 70-items across five subscales: memory/orientation, managing money, managing home and transportation, health and safety, and social adjustment. The entire measure


http://www.pearsonclinical.com/psychology.html


can be used to obtain an overall score or select subscales can be administered.3. Source/Availability: Pearson; http://www.pearsonclinical.com/psychology.html

C. Katz Index of Activities of Daily Living Scale (Katz ADL)1. Reference: Katz, Ford, Moskowitz, Jackson, & Jaffee (1963)2. Brief Description: The Katz ADL is 6-item, clinician rating scale used to assess a patient's functional status by measuring his/her ability to perform activities of daily living independently versus with assistance. Functions assessed include bathing, dressing, toileting, transferring, continence, and feeding.3. Source/Availability: Public Domain; VHA Mental Health Assistant

D. Lawton-Brody Instrumental Activities of Daily Living Scale (IADL)1. Reference: Lawton & Brody (1969)2. Brief Description: The IADL is a 11-item, clinician rating scale used to assess a patient's functional status by measuring his/her ability to perform more complex tasks of daily living across 8 domains: telephone, shopping, food preparation, housekeeping, laundry, mode of transportation, medication management, and management of finances.3. Source/Availability: The Gerontological Society of America; VHA Mental Health Assistant

V. Family CaregivingOne mission of the HBPC program is to aid and empower family or other informal Caregivers to assist in a Veteran’s care, allowing Veterans to remain in a least restrictive environment for as long as possible. Caregiving can be stressful and have a negative impact on a Caregiver’s physical and mental health. HBPC MH Providers can assist in providing Caregiver evaluation and support services.

A. REACH-II Risk Appraisal Measure (RAM)1. Reference: Czaja et al. (2009); Nichols, Martindale-Adams, Burns, Graney, & Zuber (2011)2. Brief Description: The RAM is a 16-item, Likert scale, self-report measure used to assess well-being and identify needed areas of support for Caregivers of patients with dementia such as access to dangerous objects, driving, wandering, smoking, or being left home alone. This measure was adapted for use in REACH-VA, but the Risk Assessment Tool used in REACH-VA also contains other tools such as the PHQ-9 and the Zarit (Nichols et al., 2011).3. Source/Availability: With permission from author; HBPC SharePoint

B. Zarit Burden Interview (ZBI)1. Reference: Zarit, Reever, & Bach-Peterson (1980)2. Brief Description: The ZBI is a 22-item, Likert scale, self-report measure developed to assess subjective burden among Caregivers with dementia.


http://www.pearsonclinical.com/psychology.html


The questions are worded subjectively to focus on the affective response of the Caregiver. The ZBI also has a short version (12-items) and a 4-item screening version. The short and screening versions are available through the VHA Mental Health Assistant.3. Source/Availability: Permission to the VA; VHA Mental Health Assistant

VI. Other Conditions that May Be a Focus of Clinical Attention

A. BereavementBereavement is another risk factor for depression as grief over the loss of a loved one in later life can be magnified by cumulative losses (e.g., in functioning, relationships, roles). Complicated grief (or, persistent complex bereavement disorder) remains a condition for further study in DSM-5; it is another possible consequence of bereavement, characterized by marked daily separation distress and trauma-related symptoms.

a) Prolonged Grief Disorder (PG-13)(1) Reference: Prigerson, Vanderwerker & Maciejewski (2008)(2) Brief Description: The PG-13 is a 13-item, Likert scale, self-report measure of prolonged grief in reaction to the loss of a loved one. It was derived from the Inventory of Complicated Grief (ICG; Prigerson et al., 1995), a 19-item measure of bereavement-related thoughts and behaviors measuring pathological grief symptoms such as disbelief, anger, and hallucinations. The PG-13 measures symptoms (feelings, thoughts, actions) associated with Prolonged Grief Disorder, which was proposed but not included in the DSM-5.(3) Source/Availability: With permission from primary author; HBPC SharePoint

b) Texas Revised Inventory of Grief (TRIG)(1) Reference: Faschingbauer, Zisook, & DeVaul (1987)(2) Brief Description: The TRIG is a 21-item, Likert scale, self-report measure of grief associated with loss of a loved one and is divided into two measures: present grief (TRIG-Present, 13-items) and past difficulties due to loss (TRIG-Past, 8-items).(3) Source/Availability: With permission from contact author; HBPC SharePoint

B. Behavioral DisturbanceVeterans with neurocognitive disorders, delirium, or other acute medical conditions may present with behavioral disturbances that are clinically significant and may have implications for differential diagnosis, treatment planning and management, and caregiving. The DSM-5 identifies behavioral disturbance as psychotic symptoms, mood disturbance, agitation, apathy, or other behavioral symptoms according to severity of impairment to daily functioning (i.e., mild, moderate, or severe).

1. Cohen-Mansfield Agitation Inventory (CMAI)a) Reference: Cohen-Mansfield, Marx, & Rosenthal (1989)



b) Brief Description: The CMAI is a 29-item measure designed to assess the frequency and demonstration of agitated behaviors in older adults. The CMAI was developed for use in long term care, but there is a 14-item version, a community version, a version for relatives, and disruptiveness version.c) Source/Availability: With permission from copyright owner; HBPC SharePoint

2. Revised Memory and Behavior Problems Checklist (RMBPC)a) Reference: Teri et al. (1992)b) Brief Description: The RMBPC is a 24-item, Caregiver-report measure of behavioral difficulties observed in patients with dementia. It may be used to obtain a total score and 3 subscale scores (memory-related, depression, and disruptive behaviors). Scores also may be obtained for the Caregiver's reaction to each of the behaviors.c) Source/Availability: With permission from author; HBPC SharePoint

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