Throughout the 1990s, psychiatric home care seemed to be on the verge of exploding. The number of in-patient psychiatric beds decreased; hospital stays became shorter; and patients were being maintained in the community with a much higher symptom burden than before. At the same time, traditional community psychiatric services, rapidly becoming overwhelmed, were looking to alternative providers to bolster their services.
However, current Medicare home health coverage guidelines have precluded treatment of patients with mental illness by home health agencies (HHAs). Conditions such as restrictive psychiatric clinician qualification requirements, restrictive homebound criteria relative to patients with mental illness, lack of an easily identifiable end point to the disease process of mental illness, and difficulty identifying a skill reimbursable by Medicare make treating this patient population difficult. More specifically, home care practitioners in general fail to recognize the effect of psychiatric conditions on how patients experience medical illness and how these comorbid psychiatric conditions affect patient functioning, engagement in treatment, treatment compliance, and recovery.
This interaction of psychiatric and medical conditions affects home care agency outcomes across a variety of domains including patient functioning, number of visits per episode, medication compliance, and hospitalization rates. Failure to recognize the interface between the cognitive, emotional, and physical capacity of patients to manage activities of daily living (ADLs) and instrumental activities of daily living (IADLs) can lead to lower scores on Outcome and Assessment Information Set (OASIS) assessments, with subsequent reductions in reimbursement to the HHA.
Because of these issues, the potential contribution of psychiatric clinicians and psychiatric programs tends to go unrecognized by many HHAs when, in fact, they can be of great utility to all aspects of care provided by home care agencies. The role of the psychiatric home care clinician (PHCC) in home care can be seen to affect a number of areas.
Patients With Mental Illness
Since the deinstitutionalization of mentally ill patients began in the 1960s, there has been a steady growth in the number of people living with mental illness in our communities (Box 1). Although this policy started out with aspirations to provide comprehensive community mental health services, such aspirations have not been realized (Lamb, 2000). This failure was highlighted quite forcefully in the President's New Freedom Commission Final Report when the chairman of this report stated that
…for too many Americans with mental illness, the mental health services and supports they need remain fragmented, disconnected and often inadequate, frustrating the opportunity for recovery. Today's mental healthcare system is a patchwork relic—the result of disjointed reform and policies. Instead of ready access to quality care, the system presents barriers that all too often add to the burden of mental illness for individuals, their families, and our communities. (New Freedom Commission on Mental Health, 2003)
It is safe to say that little has changed since the publication of this report. Psychiatric home care offers a viable alternative to this fragmented system of care. The PHCC can influence patient care at the following levels.
Because the practitioner travels to the patient's home, the issue of access is minimized. Today's psychiatric clinicians are sophisticated practitioners, able quickly to gain the patient's trust and form therapeutic relationships. With this level of access, the psychiatric clinician is well placed to affect the important issue of treatment and medication adherence.
Nonadherence to antipsychotic medication is a common problem. As many as 60% of patients with schizophrenia do not take their medication as prescribed (Velligan & Weiden, 2006). By providing environmental supports such as medication containers, calendars to track appointments, notebooks for recording side effects to be discussed with the doctor at the next clinic appointment, and cognitive behavioral therapy with a focus on adherence, the PHCC is the ideal clinician to effect improvement in adherence to medications, outpatient clinic appointments, and medical appointments (Turkington, Kingdon, & Turner, 2002).
Care of Medical Conditions
There is a growing body of research literature pointing to a high prevalence of medical conditions among people with serious mental illness (Bartels, 2004). High rates of comorbid conditions are found among patients with both psychotic and affective disorders (Sokal et al., 2004), with even higher rates among older adults with serious mental illness (Gierz & Jeste, 1993). Conditions such as diabetes, cardiovascular disease, gastrointestinal disorders, skin infections, asthma, chronic obstructive pulmonary disease, and liver disease are common. Recognition and treatment of these conditions are complicated by the fact that primary medical care for people with serious mental illness is inadequate, often making the PHCC the first to recognize and report medical symptoms in these patients.
With enhanced access to patients, competency in issues related to psychiatric illness (Box 2) and treatments and medical issues, and flexible scheduling, the PHCC is ideally situated to coordinate patient care across the mental health continuum and a whole range of healthcare providers. As employees of home care agencies, PHCCs have access to the full range of services provided by agencies: physical therapy, occupational therapy, speech therapy, social workers, home health aides, and home makers. By taking a leadership role in the care of this patient population, the PHCC provides direction to the home care multidisciplinary team and coordinates care among and between other multidisciplinary teams upon whom the patient relies for care (e.g., primary medical care providers, psychiatric providers, laboratory, transport, case management, entitlement providers, social/recreational services, and vocational and rehabilitation services). The PHCC evaluates patient responses to treatment, recognizes signs of decompensation, and identifies and engages the appropriate treatment team in a timely manner so that unnecessary emergency room visits and hospitalizations are avoided.
I believe this is a most autonomous and exciting position to be in as a healthcare provider today. The psychiatric clinician with training in relationship building, experience in managing behavior, and ability to communicate with multiple providers maximizes this autonomy for the enhancement of care to one of the most marginalized and underserved healthcare populations today.
Patients With Medical Illness and Comorbid Mental Illness
Current research literature demonstrates that psychiatric conditions such as anxiety and major depression are prevalent in many medical conditions:
- ▪Depression is twice as common in the home health population as in the primary care population (Bruce et al., 2002).
- ▪Home healthcare clinicians have difficulty making accurate assessments of depression among older home care patients (Brown, McAvay, Raue, Moses, & Bruce, 2003).
- ▪Up to 42% of patients continue to meet criteria for major depressive disorder 1 month after admission to home care, and a further 27% achieve only partial remission (Raue et al., 2003).
- ▪Patients' low perceived social support is significantly related to suicidal ideation (Rowe, Yeates, Schulberg, & Bruce, 2006).
- ▪The needs of homebound elders with mental illness are not being met by HHAs (Zeltzer & Kohn, 2006).
Patients who are depressed suffer from apathy, decreased energy, decreased sleep, headaches, psychomotor changes, gastrointestinal problems, changes in appetite, and vague aches and pains. The presence of major depressive disorder and its related symptoms has an impact on patients' ability to engage physically, cognitively, and emotionally in their care, resulting in increased need for services, longer recovery time, increased hospitalization rates, and medication nonadherence.
Functional assessment of patients is vital to the home care agency because it is so closely linked to payment through the OASIS assessment. Failure to recognize the effect of cognition (M0560), confusion (M0570), anxiety (M0580), depression (M0590), and memory (M0610) on the patient's ability to plan, organize, and complete tasks related to ADLs and IADLs has a serious negative effect on HHAs' income and outcomes. Nonpsychiatric clinicians have difficulty asking these M0 questions. This difficulty is 2-fold. First is the reticence actually to ask such personal questions, and second is the actual form in which the question is posed to the patient. Many see these questions as a checklist, and few are equipped to understand the implications of the patient's responses.
The U.S. healthcare system lacks adequate screening programs to identify older adults with mental health issues (Bartels, 2003). Psychiatric home care practitioners have long been critical of the Neuro/Emotional/Behavioral questions (M0560-620) on the OASIS assessment. However, these questions do provide the home care setting with what Bartels suggests is missing elsewhere: appropriate screening tools.
Question M0560 examines the patient's current level of alertness, orientation, comprehension, concentration, and immediate memory. If patients score a 1 or a 2 on this question, this should alert the clinician to pay particular attention to completing M0610. Response number 1 on M0610 addresses memory deficits. Asking this question in a different form than stated in the question might help identify patients with cognitive impairment. For example, answering “yes” to the question “During the past few months have you had increasing problems with severe memory loss?” has been shown to do just this (HMO Workgroup on Care Management, 2002). Question M0570 screens for confusion, and again, should possibly direct the clinician's attention to M0610. Question M0580 addresses anxiety and, given the degree of anxiety's coexistence with depression, should alert the clinician to the possible presence of depression.
Question M0590 addresses the 2 cardinal signs for depression: mood changes and apathy. Asking patients whether they have often felt “sad or blue” has been shown to have predictive value comparable with the Geriatric Depression Scale (Yesavage et al., 1983). In addition, asking the 2 questions, “During the past months have you often been bothered by feeling down, depressed, or hopeless?” and “During the past month have you often been bothered by little interest or pleasure in doing things?” are as accurate in identifying major depressive disorder as more extensive screening instruments (Whooley, Avins, Miranda, & Browner, 1997).
The second of these questions addresses the issue of apathy. Apathy is present in depression and may exist without other affective symptoms. It affects the patient's ability to self-motivate, resulting in inability to organize or complete tasks. An affirmative answer to these questions should alert the clinician to assess the patient's cognitive and emotional ability to plan, organize, and execute tasks as well as his or her physical ability to do so.
These M0 questions set the psychiatric clinician up in 3 distinct roles within the agency. As an educator, the psychiatric clinician can teach other disciplines how to approach the sensitive issues of mental illness and how to manage the stigma surrounding it. In this role, the psychiatric clinician also can create a process for consultation with the patient when the screening questions are answered affirmatively. As a consultant, the psychiatric clinician can provide expert assessment and evaluation to colleagues from other disciplines and collaborate with these clinicians to interpret their findings in relation to the cognitive and emotional aspects of the functional assessment. They can offer suggestions as to how nonpsychiatric clinicians might approach patients with mental health issues and coordinate treatment for these conditions. As a clinician, the psychiatric practitioner can provide therapy to the patient and family and provide meaningful dialogue with medical treaters regarding the patient's response to treatment interventions.
Alcohol and drug dependency are addressed as “high-risk factors” in M0290, but no screening questions are included in the OASIS assessment to establish the presence of such risk factors. The psychiatric clinician is able to recognize the signs of these dependencies and is skilled enough to administer an appropriate screening tool such as the CAGE (Rabins et al., 2000).
Older Adult Home Care Patients
Although some issues relating to older adult home care patients were addressed earlier, and although this population may fall into either of the previous groups, it is worth addressing this population separately. As the U.S. population continues to age, there is a corresponding increase in the number of people living with Alzheimer's disease (AD) and other dementias. The Alzheimer's Association (www.alz.org) estimates that there currently are 5 million people living with AD in the United States, 70% of whom live at home.
The manifestation of AD and other dementias in behavioral form places them squarely in the realm of psychiatry and psychiatric nursing. The behaviors exhibited by patients with AD present serious challenges to both formal caregivers and family members. Managing these behaviors at home can lead to caregiver frustration as well as physical and emotional exhaustion. Pharmacologic treatment may be helpful in the treatment of these behaviors, but recent research suggests otherwise (Sink, Holden, & Yaffe, 2005). Findings have shown nonpharmacologic interventions to have benefits and many are very suited to the home care setting (Ayalon et al., 2006; Forbes, Peacock, & Morgan, 2005; Graff et al., 2006).
Research also suggests that characteristics of caregivers influence the behavior of those to whom they provide care, and that increasing caregivers' confidence and sense of self-efficacy can have a positive impact on the individual with dementia (Gitlin et al., 2001; Sink et al., 2006).
The PHCC is critical to the process of working with both the person with AD and the caregiver. The psychiatric clinician understands how the patient's illness, the environment, and the caregiver's responses interact to affect patient behavior. He or she understands that behavior is part of the illness and that all behavior has meaning. Because of this knowledge and training, the PHCC can work with the caregiver to create an understanding of the individual, the illness, the behavior, and the patient's environment. This enables the PHCC to lead a systematic and multidisciplinary approach to managing these challenging behaviors.
Challenges and Opportunities
Possibly the greatest challenge comes from within the psychiatric nursing community itself. Traditionally, psychiatric clinicians have kept themselves separate from other disciplines. They have in many ways allowed the stigma and discomfort that nonpsychiatric disciplines feel about mental illness to create this separation and have become comfortable with it. Psychiatric clinicians point to how “different their patients are” or how “psychiatric patients do not fit into the mainstream patient population.” It is true that there are differences in how psychiatric clinicians approach their patients, but to state constantly that “our patients are different” is not entirely accurate. There is a growing body of research pointing to the coexistence of psychiatric and medical conditions in all home care patients. We are finally beginning to understand that medical conditions are underrecognized and undertreated in the psychiatric patient, and that psychiatric conditions are underrecognized and undertreated in the medical patient. Whichever is the case, patient functioning, independence, and recovery are affected as well as agency revenue and outcomes. The challenge to psychiatric clinicians in home care is to become involved in the life and activity of the agency. They must become educators, consultants, treaters, and role models to other disciplines. They must put the paradox of being a specialist to rest and recognize that “specialist” does not mean “separate.” The assessments, evaluations, treatments, and understandings psychiatric clinicians possess must be shared with their colleagues in other disciplines, and evidence gathered that shows how effective they are.
The second major challenge comes from the aforementioned coexistence of medical and psychiatric illness. Treaters in the more traditional psychiatric settings have not addressed the increasing burden of medical illness in psychiatric patients. Psychiatric patients continue to attend outpatient clinics and appointments, showing signs of weight gain, diabetes, heart failure, and the like, only to have these problems ignored. Likewise, medical patients visit primary care clinicians with evidence of depression, anxiety, and cognitive decline and have these issues ignored. The challenge to the PHCC is to become versed in the basic medical/surgical conditions so that he or she can recognize these conditions early, provide basic care, and use his or her unique position to coordinate all care and advocate for the “whole” patient, not just the part with which he or she has the most comfort.
The general opinion that, at least in the case of Medicare, psychiatric home care is not a viable revenue source is our next challenge. Psychiatric home care is seen to produce a low case mix weight, with resulting low reimbursement to the HHA. Working with other disciplines to create understanding of the emotional and cognitive issues around all aspects of patient functioning and addressing these issues in the assessments of psychiatric patients will help alter this mind-set. In addition, the fact that psychiatric home care has a low visit frequency for a 60-day episode, uses few supplies, and works collaboratively with physical therapy, occupational therapy, and speech therapy, and thus meets the therapy threshold increases economic viability even more.
Psychiatric clinicians should be advocating very strongly not only to preserve M0610 as a case mix weight question, but to have questions M0560-590 and M0780-800 added to case mix weight. The fact that home care fails to recognize how to incorporate these questions into the complete assessment does not make these bad questions. Adding these questions to case mix weight would give mental health issues parity with physical health issues in home care assessments and improve the image of mental health from a fiscal viewpoint. Despite the attention the national mental health parity debate gets, mental health home care is not treated on par with medical home care in the eyes of Medicare. Other payers are gradually changing, and we must be strong in advocating similar changes with Centers for Medicare and Medicaid Services.
Finally, with our knowledge of behavior and behavioral management, we must become champions and agents of change within our agencies and industry. Change is the one constant in home care today. Change brings stress around new ideas and processes as well as grief at the loss of old ways. It has an impact on individual behavior as well as on small and large group behavior. It affects the relationships between the professional disciplines and between clinicians, administrators, managers, and other agency staff. As positive proponents of change, by being clear on its effects and willing to lead the relationship building and modifications that change brings, psychiatric clinicians can have a major influence on the agency environment.
Much of the aforementioned assessment, evaluation, care plan formulation, and care coordination requires the skills of an advanced practice nurse (APN). By virtue of their training, APNs are ideal to act as educators, consultants, treaters, and care coordinators.
On another level, APNs can bring to home care that which it is currently lacking: the ability to diagnose and treat. This is particularly important in light of the developing emphasis on care coordination. Given that patients currently navigate a complex healthcare system, most suffer from multiple chronic conditions, and can benefit from self-management programs, and given that such programs and activity are education and behavior based, the APN working in home care is the ideal clinician to coordinate the care for this complex group of patients.
Weimberg, Lusenhop, Hoffer-Gittell, and Kautz (2007) report that relational coordination between formal providers and caregivers improved caregiver preparation, and patients in turn have reported improvements in pain, functional status, and mental health.
Advanced practical nurses who can diagnose, plan, teach, treat, and organize care across a range of disciplines, coordinate care across a range of providers, communicate meaningfully with primary care physicians, and recognize barriers to self-management (e.g., apathy, depression, or cognitive impairment) could in the future become the ideal “medical home” for these patients. Working in an HHA provides the APN the opportunity to work without the expense of operating a private practice and easy access to a range of allied healthcare providers.
The prevailing view within the home care industry of Medicare as a primary payer source may be limiting our vision of other potential revenue sources. Other payers are finally beginning to acknowledge that a day of home care is a less costly alternative to a day in the hospital. Managed care companies are seeing that the long lists of patients waiting to see psychiatrists are not working and that psychiatric home care is a means by which gaps in care can be closed effectively. Opportunities also are present in the exploration of various treatment programs such as crisis intervention, in-home detoxification, collaborative community-based programs provided by state agencies, and disability case management.
The opportunities are virtually limitless and often created by asking the simple question, “What is it you need that you are currently not getting?” of everyone—patients, physicians, administrators, or managed care companies—and then finding the means to meet that need. Access to these opportunities will be affected by psychiatric clinicians' willingness to partner with everyone, demonstrate value and viability, and think beyond traditional lines of thought.
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