Too Many Walls and Not Enough Bridges: Care Transitions Models to Support Older Adults with Mental Illness and Cognitive Impairment

Abstract

Challenges in transitions of care can lead to increased morbidity, mortality, and increased health care costs. In particular, older adults with mental illness (MI) or cognitive impairment (CI) are particularly vulnerable when transitioning from different health care settings and back to the community. For instance, almost half of older adults with cognitive impairment who are discharged home from the emergency department return within 30 days. Similarly, older adults with MI and CI admitted to a skilled nursing facility are less likely to be discharged and, if discharged, spend less time in the community. Importantly, these outcomes mediated by the presence of depression, agitation, and functional impairment, highlighting the need for interventions that provide symptom management and address frailty.Some interventions have been shown to improve transitions from acute care to post-acute care. The Institute for Health Improvement Age Friendly Health System Initiative incorporates the 4 M model of what matters most, mobility, medications, and mentation framework in order to bring to together evidenced based initiatives that improve safety and outcomes for older adults. These interventions embed comprehensive geriatric care throughout the care continuum: hospitals, transitions out of hospitals, and post-acute and long-term care facilities. Other interventions have utilized home visits upon discharge to minimize readmission and increase time at home. Less is known about initiatives which address the role of subspeciality care and community-based organizations (CBOs) in maintaining older adults with MI and CI in the community.Montefiore Einstein is a fully integrated academic health system including 11 hospitals including a rehabilitation hospital, 65 primary care sites, 18 mental health/ substance abuse treatments clinics, a care management organization, and a home health program. Montefiore's Center of Excellence for Alzheimer's Disease (CEAD) has successfully expanded the delivery of comprehensive, high-quality, cost-effective care for people with CI. The CEAD is staffed with board-certified neurologists, geriatricians, psychiatrists, neuropsychologists and social workers. Our focus on the early diagnosis of Alzheimer's disease and related dementias helps patients and their caregivers prepare for the future and better manage the cost of care, potentially avoiding costly, unnecessary emergency room visits and hospitalizations. It was also recently designated an IHI-designated Age Friendly system. Montefiore Home Care (MHC), established in 1947, is the nation's first hospital- based certified home health agency. 40% of homebound older adults have MI and CI but have limited access to appropriate evaluation and treatment. Accordingly in 2004, MHC developed a consultative geriatric program in collaboration with the Division of Geriatric Psychiatry to provide comprehensive social work and geriatric psychiatry assessments in the home after discharge from hospital. In addition to the collaboration with MHC, Montefiore Division of Geriatric Psychiatry has leveraged foundational funding to collaborate with CBOs to bring evidence-based mental health services to seniors over the past two decades.During this session, presenters will describe several ongoing and new Montefiore initiatives to address care transitions for older adults with MI and CI. Dr. Zwerling will describe how the CEAD is spearheading the transition for Montefiore Einstein to an Age Friendly system. Ms. Korenblatt will highlight how the MHC Geriatric Psychiatry Program social work team serves as a bridge between acute care and CBOs to minimize hospital readmissions. Finally, Dr. Ceïde will highlight a specific example of an evolving partnership with one specific CBO in order to maintain older adults with MI and CI in the community.