REDUCING PSYCHIATRIC HOSPITALIZATIONS FOR ASSISTED LIVING RESIDENTS USING AN INTEGRATED BEHAVIORAL HEALTH / PRIMARY CARE MODEL

Abstract

Introduction There is a high burden of psychiatric illness in Assisted Living Facilities (ALFs), and a tremendous unmet need for psychiatric care within their “social model”. Existing models of psychiatric care for ALF residents include: 1) outpatient behavioral health clinic visits, often precluded by comorbid medical, cognitive, and functional limitations, 2) on-site psychiatric care that is neither team-based nor formally integrated with primary care, and 3) ER visits for acute psychiatric needs. Hospitalizations, in particular psychiatric hospitalizations, can be distressing for caregivers, disruptive to resident routines, and can be associated with functional decline, deconditioning, delirium, and hospital-acquired infections. It is no surprise, therefore, that many ALF residents and their families wish for “aging in place,” to the extent possible. Methods In July 2018, a collaborative care practice was established for homebound and ALF-residing elders (Perfect Health, Boston Metro North), consisting of a geriatrician, a geropsychiatrist, two geriatric NPs, a geriatric social worker (SW), an RN, and medical assistants. At any given time, 30-40 patients were members of a Medicare Advantage plan (average age 78.7). By late 2018, the team examined specific factors that may have related to potentially avoidable psychiatric hospitalizations. Distillation of these factors led to the development of a Behavioral Health (BH) referral system framed around 1) systematic screenings (e.g. for depression, dementia, substance use disorders), with thresholds for BH referral, or 2) requests for psychiatric consultation by a patient, caregiver, or the geriatrician. BH consultations began with an in-depth assessment by LICSW, followed by diagnosis and treatment planning with the following outcomes: 1) brief psychosocial interventions with patient, caregiver, and/or ALF staff, 2) telephone consultation by the social worker with the geropsychiatrist, and/or 3) referral for geropsychiatrist visit at the ALF. This face-to-face consultation would result in recommendations to the PCP, and specific instructions for follow-up by the RN and/or SW. Select patients would be seen in follow-up by the geropsychiatrist. Weekly interdisciplinary team rounds were held, to triage patients perceived to be at high risk for hospitalization, and to prevent crises. In addition to biweekly rounds with the BH team, ALFs were provided with 24/7 psychiatric support via the practice. Results Prior to full implementation of the interdisciplinary BH model in early 2019, 3 Medicare Advantage (MA) patients were psychiatrically hospitalized for a total of 4 hospitalizations from July through December 2018, for a total of 77 hospitalized days, exceeding MA-wide psychiatric hospitalization rates. Once the above model was implemented, this number decreased to 0 MA psychiatric hospitalizations in 2019. During 2019, hospitalized days were markedly reduced over MA-wide psychiatric hospitalization rates. Factors identified as contributing to early psychiatric hospitalizations included: 1) inadequate or inaccurate psychiatric diagnosis, risk assessment, and treatment planning, 2) lack of timely access to psychiatric care, 3) deficits in coordination among facilities, pharmacies, and family, 4) inadequate “respite” options for ALF staff and residents from high-needs patients and families, 5) cyclical patterns of behavioral difficulty in otherwise stable patients, with apparent lack in contingency planning, and 6) overestimation by families and ALF staff of potential benefits-versus-risks of psychiatric hospitalization. Referral and intervention models are continually being revised as the team retrospectively assesses factors leading to psychiatric hospitalizations and ER transfers. This has led to a working “Behavioral Health Risk Score” which is currently utilized to enhance staff awareness of static and dynamic factors suggestive of patients at high risk, leading to more timely referrals. As an additional benefit, case-based learning about core geriatric psychiatry topics during interdisciplinary rounds has allowed PCPs and other staff members to rely less on the BH team for routine psychiatric issues, holding promise for future scalability. Conclusions Patients, their families and caregivers, and ALFs are strongly motivated to keep residents embedded in their communities. In implementing an integrated behavioral and primary care approach to assessment and treatment, the Perfect Health Boston Metro North practice has seen a substantial decrease in resident hospitalizations. Future research directions include refinement and implementation of the BH Risk Score towards directing BH referrals. Future implementation directions include marketing these encouraging findings to stakeholders such as patients, families, and ALF leadership. The novelty and value of ALFs offering on-site BH is likely appealing to the consumer, and might attract ALF leadership based on maintenance of higher resident occupancy and satisfaction, with fewer losses due to transitions (e.g. extended hospitalizations, rehabilitation, and long-term care stays). This research was funded by: None.