Practice Concepts. Lisa P. Gwyther, MSW, Editor

Copyright 1992 by The Gerontological Society of America The Cerontologist Vol. 32, No. 6, 849-852

A consultation-liaison psychiatry program in a teaching nursing home helped implement six guiding principles including: make the patient human to the staff; assume no behavior is random; look for depression or psychosis as a source of problems; reduce medications and medication doses; create a more homelike environment; and use conditions in which learning still occurs in dementia. Key Words: Staff training, Models of caregiving, Mental disorders

Kenneth M. Sakauye, MD, 1 and Cameron J. Camp, PhD: When psychiatric disorders are directly assessed, the estimates of resident psychiatric problems in most nursing homes generally exceed 50%. For example, an early survey of two typical nursing homes in Minnesota (using a semistructured interview to obtain DSM-III diagnoses) found that 85% of the Medicaid patients had significant psychiatric disorders and almost two-thirds of these disorders had not been diagnosed (Teeter et al., 1976). The 1977 National Nursing Home Survey estimated the rate of mental disorders in nursing homes as above 50%. In a study of 454 consecutive new nursing home admissions, Rovner and colleagues (1990) reported that 80% had a psychiatric disorder when dementia was considered as a psychiatric/behavioral disorder, and 40% of demented patients had psychiatric syndromes such as delusions or depression. Despite this prevalence of psychiatric disorders, according to the 1984 National Nursing Home Survey Pretest only 2% of residents were receiving help from a mental health specialist (Burns et al., 1988). Furthermore, very little has been published about psychiatric services in nursing homes in major geriatric journals over the past 5 years (Beardsley et al., 1989). But now that new regulations (part of the Nursing Home Reform Act of 1987) mandate active psychiatric treatment and freedom from restraints in nursing homes, effective models for introducing psychiatric care into these institutions must be found.

The dilemma is what the time and cost of implementing these models will be, and where the medical manpower will come from. Kane and colleagues (1991) described nursing homes as a "medical pariah" because of problems such as minimal payment for nursing home visits under Part B of Medicare, fewer trained staff in nursing homes than in hospitals, and low professional prestige associated with such institutions. Social work (Brody, 1977), psychiatry (Bienenfeld & Wheeler, 1989; Crossberg et al., 1990), psychology (Smyer, 1989; Smyer, Brannon, & Cohn, 1992), and nursing (Santmyer & Roca, 1991; Taube, Burns, & Kessler, 1984) have all proposed models for delivering better psychosocial care in the nursing home setting. These models share the following aims: to involve psychiatric professionals in residents' daily care; to improve the diagnosis of residents' mental disorders; to direct the psychiatric treatment for residents with mental health problems, including assessing appropriate use of psychotropic medications and assisting in program and milieu development; and to provide an active liaison instead of limited consultations for emergency situations. Our consultation-liaison model synthesizes earlier delivery models. Program Development

The psychiatric consultation-liaison program was implemented in a 103-bed, nonprofit, religious nursing home in New Orleans affiliated with a medical school gerontology staff in 1989. The facility initiated a request for on-site psychiatric consultation to reduce the use of emergency room or psychiatric hos-

1 Ceriatric Psychiatry, LSU Medical Center, New Orleans, and Woldenberg Center for Cerontological Studies, Department of Psychiatry, Touro Infirmary, 1401 Foucher St., New Orleans, LA 70115. department of Psychology, University of New Orleans.

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Introducing Psychiatric Care into Nursing Homes

Advanced trainees (PGY-5 fellows) from the university psychiatry fellowship program serve as primary consultants under the supervision of a senior faculty member. The PGY-5 geriatric fellow spends 2 half-days per week in the home. Monthly on-site rounds by the senior psychiatrist are conducted in addition to off-site supervision through case and system issue discussions. During the senior consultant's visits, case conferences and seminar programs involve the aides, nursing staff, and ancillary personnel, and often include patient interviews. In addition, an interdisciplinary meeting is held monthly with the senior consultant, the fellow, an administra-

Table 1. Principles of Consultant Behavior 1. Be authoritative. • Do not voice too many self-doubts. • Phrase deficits of information as requests for information (e.g., "We need two pieces of information before I can make a recommendation. Can you ask Xabout V? Can you get the information by Monday?" Do not just leave it as "I'm not sure yet." • Offer to explain your rationale for recommendations (e.g., "You look skeptical. Do you understand why I feel it is important to do this?") 2. Try not be authoritarian. • Do not push a plan onto staff in the face of numerous doubts (e.g., if staff meet recommendations with "Yes, but . . . " more than once, there is an obvious need to work out an alternative management plan or do more background work to obtain staff understanding and cooperation). 3. Be conscious of group process and resistance by staff. • Pay attention to splitting due to disagreement among staff or with your recommendations. • Consider who needs to be involved in meetings and who needs to be consulted for input and in what order. • Know how information is transmitted best in the home (e.g., when face-to-face discussions must occur). • Give feedback. 4. Call special meetings to establish a consensus or to address problems in implementing treatment plans. 5. Always follow up to be sure orders have not been misunderstood or ignored (e.g., ask "What happened when you tried out my suggestion to do X?"). 6. Help define and redefine the consultant role. For example, if there are only a few referrals, ask to review medication lists or observe a treatment group. If there are too many referrals, present suggestions for how to handle the overload (e.g., changing the triage criteria, creating new programs led by staff). 7. Serve more as a case manager for residents under your active care. This means being sure you know who is responsible for implementing recommendations and touching base with other treatment team members.

tor for the home, the director of nursing, the head of therapeutic recreation services, the physical therapist, the staff social worker, and selected line staff to review all cases in active psychiatric treatment. Telephone and emergency room coverage is provided on a 24-hour basis. The fellow's time is structured so that two-thirds of his/her time is spent in direct patient care. Patients are seen in their rooms unless they request a different setting. The other third is spent with staff in a variety of formats. Working with the Staff

What Is Taught The in-services, staff consultation, and case conferences provide experiential, case-related information to improve staff empathy and provide examples of management approaches that can also be generalized to the care of other residents. Six guiding principles are emphasized to get staff to think more about behavioral management options (Table 2). Most staff request more information about psychotherapeutic approaches once they begin to view behavioral disturbances from a more psychological 850

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pitalization and to address the inability or unwillingness of psychiatric consultants to respond quickly to consultation requests in the home. This program also met the university's need for a training site as part of its geriatric psychiatry fellowship program. Referrals must be ordered by the attending physician to be eligible for reimbursement and to insure recommendations will be seriously considered. Social service and nursing staff often initiate the process by asking the doctor to refer residents, and they always discuss the need for the consultation with the patient and/or family before the psychiatrist sees them. A single nursing staff member is responsible for scheduling appointments and coordinating cases with the consultant. A formal case review with the director of nursing and the social worker is held at the end of each consultation visit. In addition to a formal consultation note, decisions made at the case review are written into the individual treatment plan by the social worker to insure implementation and outcome monitoring. Inservices by the consultants are provided monthly for RNs and aides. Direct patient care by the consultant is important. In many settings consultants handle problems by telephone and make irregular patient visits to the home. Without direct involvement by the consultant, staff often feel they control psychotropic medication through their requests, question the reasonableness of many medication orders, and often fail to understand how to implement psychosocial plans. Providing direct care is necessary to insure accurate assessments, to evaluate medications and the impact of coexisting disease, and to direct the plan of treatment. It also reassures the line staff that the consultant understands the problems they face in working with the residents. However, the most critical feature of the program is an active liaison. In making regular visits to the facility, the consultant meets with staff for case discussions and tries to generalize principles learned from individual cases. The liaison format also allows the consultant to get to know the staff by name, to provide staff with a rationale behind recommendations, and to develop sensitivity to limitations in the setting. (A set of guidelines we developed for consultants is included in Table 1.) The strong influence of neurological and medical factors on cognitive performance and mental health makes the role of a psychiatrist, who does have medical training, especially important in a nursing home treatment team.

Table 2. Psychiatric Principles to Guide Nursing Home Staff MAKE THE PATIENT H U M A N (to the staff)

A case conference presenting the life history, residences, work history, interests, and habits of the resident is helpful in making the resident a real person to the staff. ASSUME THAT N O BEHAVIOR IS R A N D O M

In a low-verbal population, assume even pathological behavior is a communication of something. LOOK FOR THE EXISTENCE OF DEPRESSION OR PSYCHOSIS

Major psychiatric disorders are often very responsive to psychotropic medication. In nondemented elderly, the rate of spontaneous recovery from a late-onset major depression or psychosis is almost zero. REDUCE MULTIPLE MEDICATIONS A N D MEDICATION DOSES

Chronic delirium is common due to both psychotropic and other medications. Elderly persons also often respond to lower doses and are more at risk for drug interactions. CREATE A HOMELIKE ENVIRONMENT

The concepts about therapeutic communities from psychiatry can be readily applied. This concept assumes a home is more dependent on how people interact (less hierarchical relations between patients and staff) than on what the physical structure is like.

Finances The home contracts with the university at a fee that covers salary and overhead expenses for those involved. The non-patient-care component (meetings and staff consultation) is not reimbursable under Medicare Part B but can be covered as part of the daily cost structure. Under the agreement, the physicians sign a waiver to allow the home to bill and collect for patient services under Medicare Part B. This fee-for-service billing offsets about two-thirds of the contracted fee. The remainder is considered part of the operating expense and incorporated into the daily or ancillary charges. The home bills for consultations (Clinical Procedural Terminology — CPT — 99200 series codes) or psychiatric services (CPT 90800 series codes) as dictated by the consultant.


Teas may be better than bingo or crafts. "Mixers" may be needed to help encourage social interaction. Patients should be able to help define the range of programs. LEARNING STILL OCCURS

Even individuals in advanced stages of dementia may be capable of learning new information or responding to positive reinforcement, though they may not be fully aware that they have learned anything (e.g., Camp & McKitrick, 1992).

perspective. This usually allows us to clarify for them the goals of psychotherapy and to point out effective approaches to communicating with residents with dementia.

Effects of the Program The complex nature of the nursing home service environment makes it difficult to assess a single program's impact. However, several indirect measures verified that the program was addressing the intended problems. First, better recognition of psychiatric problems was confirmed by the number of consultation requests received over time. Consultations were requested on over 60% of the residents in the home. The range of diagnoses and reasons for referral reflected rising recognition of depression in the population and sensitivity to potentially reversible causes of behavioral disturbances in dementia. Second, although improved knowledge and practice patterns are difficult to confirm from indirect measures, we could make inferences of improvement. Staff attended in-services readily and often suggested patients and topics for future meetings, in addition to seeking out informal discussions with the consultants. Patients welcomed follow-up care, came to us in the halls, or discussed us with other residents. Only a handful of residents refused to see the psychiatrist, usually due to offhanded rejection of psychiatry as a useful discipline or denial of problems. Staff and administration also began to openly

How It Is Taught From prior experience, we know that information must be anchored in clinical and personal experience to be appropriately utilized (see, e.g., McDonald et al., 1989). We seek to help staff empathize with the resident and blur the hierarchical boundary between professionals and clients. We utilize case discussions and specifically try to discuss nonpharmacologic solutions to problems, although medical and medication options are summarized by the consultant at some point. A successful approach to changing the staff's view of residents from "clinical entities" to seeing them as "people" is to present life histories of residents seen as egocentric or demanding, and/or to interview those residents in front of the group. This life review with staff often leads to an immediate understanding of the continuity and predictability of preferred coping styles across an individual's life span, carried into the present life situation. During discussions, an empathy-building technique is to ask the staff to describe what it would take to make them feel insecure or to ask how they would react if they were in the same situation. Typical problem areas where it is Vol. 32, No. 6,1992


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important to ask these questions involve displaced anger, wandering (in search of something), or demandingness. Avoiding metapsychological formulations and terminology, emphasizing empathy for the resident's situation, and modeling interventions proved to be far more effective in shaping staff behavior and attitudes than lectures (the degree of dementia does not preclude this basic orientation). Evaluation of medical issues, medications, and biological aspects are done prior to the meeting and reviewed as a secondary focus. Staff members, especially those providing most direct care, have many questions and observations to share in case conferences and do not seem especially inhibited before "authority figures" in a nonthreatening learning atmosphere. By addressing case-related problems and solutions, staff became more open to dealing with conceptual issues.


Replication A psychiatric program such as this does not require special staffing other than the addition of a psychiatric consultant. The nursing home described was well staffed, including a full-time activity worker, a fulltime social worker, and contract staff to supply physical therapy and dental care. However, the program can be implemented with fewer staff since its primary emphasis is on proper orientation to care rather than specific new programs. The critical feature of such a program is obtaining the administrative support to assign staff to participate and reinforce the expanded role and authority of the consultant. Contact with and support by the governing board is usually important to insure continuation. With support, such a program can be implemented in a wide variety of facilities. In addition, the effect of staff turnover is not necessarily unstabling. In this facility, there was a change in administrative directors, two directors of nursing, and some line staff within a 2-year period. However, the board was consistent, the philosophies of care remained the same, and after some of the changes, there was actually an improvement in the milieu. We observed no increase in consultation needs, and feel that the importance of continuity of caregivers is weighted by that individual's actual decision-making influence and personal meaning to residents. Our facility initially found it difficult to involve good consultants if the reimbursement was restricted to private billing for patient care. Medicare only covers 50% of approved charges for psychiatric care by psychiatrists, psychologists, and social workers. Secondary insurance (medigap or Medicaid) 852

Beardsley, R. S., Larson, D. B., Lyons, J. S., Gottlieb, C. L., Rabins, P., & Rovner, B. (1989). Minireview: Health services research in nursing homes: A systematic review of three clinical geriatric journals, journal of Gerontology: Medical Sciences, 44, M30-35. Bienenfeld, F., & Wheeler, B. G. (1989). Psychiatric services to nursing homes: A liaison model. Hospital and Community Psychiatry, 40(8), 793-794. Brody, E. M. (1977). Long-term care of older people: A practical guide. New York: Human Sciences. Burns, B. J., Larson, D. B., Goldstrom, I. D., Johnson, W. E., Taube, C. A., Miller, N. E., & Mathis, E. S. (1988). Mental disorder among nursing home patients: Preliminary findings from the National Nursing Home Survey Pretest. International journal of Geriatric Psychiatry, 3, 27-35. Camp, C. J., & McKitrick, L. M. (1992). Memory interventions in AD populations: Methodological and theoretical issues. In R. L. West & J. D. Sinnott (Eds.), Everyday memory and aging: Current research and methodology (pp. 155-172). New York: Springer-Verlag. Gendlin, E. T. (1981). Focusing (2nd ed.). New York: Bantam. Goldfarb, A. I. (1967). Psychiatry in geriatrics. Medical Clinics of North America, 57(6), 1515-1527. Grossberg, G. T., Rakhshanda, H., Szwabo, P. A., Morley, ]. E., Nakra, B. R. S., Bretscher, C. W., Zimny, G. H., & Solomon, K. (1990). Psychiatric problems in the nursing home, journal of the American Geriatrics Society, 38, 907-917. Group for the Advancement of Psychiatry. (1988). The psychiatric treatment of Alzheimer's disease. New York: Bruner/Mazel. Grunes, G. (1981). Reminiscences, regression, and empathy — A psychotherapeutic approach to the impaired elderly. In S. I. Greenspan & G. H. Pollock (Eds.), The course of life: Psychoanalytic contributions toward understanding development, Vol. 3: Adulthood and the aging process. Washington, DC: Department of Health and Human Services. Kane, R. L., Garrard, J., Buchanan, J. L., Rosenfeld, A., Skay, C , & McDermott, S. (1991). Improving primary care in nursing homes, journal of the American Geriatrics Society, 39, 359-367. McDonald, M. V., McGuire, M. M., Sakauye, K. M., Schwartz, B. L., White, E. S., & Rosendahl, E. (1989). Caring touch: Training nurse aides to enhance quality of life. In J. M. Day & H. J. Berman (Eds.), Successful nurse aide management in nursing homes (pp. 76-87). Phoenix: Oryx. Rovner, B. W., German, P. S., Broadhead, J., Morriss, R. K., Brandt, L. )., Blaustein, J., & Folstein, M. F. (1990). The prevalence and management of dementia and other psychiatric disorders in nursing homes. International Psychogeriatrics, 2, 13-24. Santmyer, K. S., & Roca, R. P. (1991). Geropsychiatry in long-term care: A nurse-centered approach, journal of the American Geriatrics Society, 39,156-159. Smyer, M. A. (1989). Nursing homes as a setting for psychological practice: Public policy perspectives. American Psychologist, 44(10), 1307-1314. Smyer, M. A., Brannon, D., & Cohn, M. (1992). Improving nursing home care through training and job redesign. The Gerontologist, 32, 327-333. Taube, C. A., Burns, B. ] . , & Kessler, L. (1984). Patients of psychiatrists and psychologists in office-practice: 1980. American Psychologist, 39, 14351447. Teeter, R. B., Garetz, F. K., Miller, W. R., & Hieland, W. F. (1976). Psychiatric disturbances of aged patients in skilled nursing homes. American journal of Psychiatry, 733(12), 1430-1434. Verwoerdt, A. (1981). Individual psychotherapy in senile dementia. In N. E. Miller & G. D. Cohen (Eds.), Clinical aspects of Alzheimer's disease and senile dementia (Aging Vol. 16, pp. 187-208). New York: Raven.

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should cover the coinsurance portion up to the approved limits, but Medicaid often refuses such outpatient coverage. Also, many residents do not have coinsurance, and residents or their families may balk at paying the coinsurance portion if the consult request is initiated by the nursing home rather than by them. When nonpayment is coupled with unreimbursed staff liaison time, one can better understand why many professionals are reluctant to consult at nursing homes regularly without special provisions. Although our program involved a contract with a university, the use of private consultants or a local CMHC consultant is not precluded. The important aspect is maintaining the role, liaison focus, and goals we have described. However, a linkage with a university teaching program might offer additional advantages to a home because of resources and the usual clinical research interests of a university, which should further improve the quality of care.

encourage psychiatric consultation with families. In addition, several staff began to apply principles taught in meetings by generating new ideas for management. For example, dietary staff started a program for the dining room aides to try to reduce staff behaviors that might have been fueling undue complaining by residents about the food. Aides were trained to deliver meals as if they were "waiting" on clients' tables, were taught social skills, and were shown better methods for handling more demanding residents. Psychotropic medications were already being used conservatively in the home before the consultation project was initiated, so medication reduction was not a good index of improved knowledge or practice. However, a small increase in the use of antidepressants and reduction of antihistamine use as a sleeping medication over the course of the initial year of consultation reflects an improved recognition of depression in the home, and knowledge of medications that increase confusion. More specific scales to measure initial severity of illness initially and outcome are being contemplated, in part to meet OBRA documentation requirements when psychotropic medications are utilized. The minimum data set items do not seem adequately detailed for our purposes.

Introducing psychiatric care into nursing homes.

A consultation-liaison psychiatry program in a teaching nursing home helped implement six guiding principles including: make the patient human to the ...
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