Improving Access to Geriatric Psychiatric Services

1. Improving Access to Geriatric Psychiatric Services James A. Greene, MD & John Robert Greene, MBA March 27, 2010, 1:00 pm

2. Growth in Population Age 65 and Over (in millions)

3. The Growing Geriatric Psychiatric Need Geriatric psychiatric services meet the demands of the fastest growing market � the elderly population in your service area. The risk for depression in the elderly is four times greater than for the general population. Of those individuals 65 and older, 15% suffer life-impairing depression with the majority of this group never getting any professional help. Clinical depression eludes diagnosis by mimicking other illnesses. 20% of the elderly population has mental illnesses that are untreated at this time. The elderly population accounts for 20% of all suicides while they comprise 13% of the total population. Research has shown that depression in the elderly greatly increases the risk for heart attack. Major depression increases the likelihood of death by 59%.

4. Why is there a need for more focused geriatric psychiatry care? 16% of senior adults take medication that is inappropriate and dangerous for their age group. 18% of the 30 million non-institutionalized Medicare beneficiaries were found to have used at least one drug identified as generally unsuitable for senior adults. Adverse drug reactions are a major cause of hospitalization in the senior adult population, responsible for 17% of their admissions. Depressed patients are more likely to be admitted to a long-term care facility. 63% of individuals over 65 with psychiatric disorders do not receive services for their psychiatric diagnoses. Population ages 65 and over comprised 12.5%of the total resident population and accounts for 19.1% of the total economic costs of mental illnesses. The costs are expected to increase as the population continues to age. The problems addressed by geropsychiatric outpatient programs are noted in a report released by the General Accounting Office which noted that one-sixth (1/6) of the nation�s senior adults take medication that is inappropriate and dangerous for individuals in their age group. The report further cites data, which found 18 percent of the 30 million non-institutionalized Medicare beneficiaries were found to have used at least one drug identified as generally unsuitable for senior adults. Another study highlights adverse drug reactions as a major cause of hospitalization in the senior adult population, responsible for 17 percent of their admissions. Depressed patients are more likely to be admitted to a long-term care facility. One of the most significant indicators of demand for outpatient mental health services is that 63 percent of individuals over 65 with psychiatric disorders do not receive services for their psychiatric diagnoses. Finally, the population ages 65 and over comprised 12.5 percent of the total resident population and accounts for 19.1 percent of the total economic costs of mental illnesses. The costs are expected to increase as the population continues to age.The problems addressed by geropsychiatric outpatient programs are noted in a report released by the General Accounting Office which noted that one-sixth (1/6) of the nation�s senior adults take medication that is inappropriate and dangerous for individuals in their age group. The report further cites data, which found 18 percent of the 30 million non-institutionalized Medicare beneficiaries were found to have used at least one drug identified as generally unsuitable for senior adults. Another study highlights adverse drug reactions as a major cause of hospitalization in the senior adult population, responsible for 17 percent of their admissions. Depressed patients are more likely to be admitted to a long-term care facility. One of the most significant indicators of demand for outpatient mental health services is that 63 percent of individuals over 65 with psychiatric disorders do not receive services for their psychiatric diagnoses. Finally, the population ages 65 and over comprised 12.5 percent of the total resident population and accounts for 19.1 percent of the total economic costs of mental illnesses. The costs are expected to increase as the population continues to age.

5. One of the most effective ways to reach this group is through the development of Intensive Outpatient Psychiatric Programs ( IOPs) in the local community. Intensive outpatient psychiatry (IOP) programs are an intermediate step in the continuum of care between the need for acute inpatient care and individual outpatient care. IOP programs are a cost-effective alternative to traditional inpatient care and are less restrictive which allows a more holistic approach to treatment of the senior adult suffering from mental health problems. The IOP program provides an environment where both the physical and emotional needs of the senior adult can be managed by a multidisciplinary team of professionals. The goals of the IOP program are: 1. To provide diagnosis and treatment of individuals in the least restrictive environment. 2. To provide services prescribed by a physician and provided under an individualized written plan of treatment. 3. To restore individuals to their highest level of mental, physical, and emotional functioning possible. 4. To eliminate the need for inpatient treatment by providing a less restrictive, less emotionally traumatic, less costly alternative. 5. To assist in identifying and developing family support and/or community resources to assist the individual in retaining independent living for as long as possible, or to help the individual and/or family in finding appropriate placement. Anyone can make a referral to the IOP program. Once the referral has been made, a trained, licensed and/or certified staff member will make the initial contact with the patient and family to schedule a pre-screening assessment. After the pre-screening assessment is completed, the attending psychiatrist reviews all of the information. The attending psychiatrist is the only individual who can order an admission to the program if the patient meets all admission criteria. Once the patient is admitted to the program, the psychiatrist completes a full psychiatric evaluation within 24 hours. In addition to the psychiatric evaluation, the multidisciplinary team will complete a full battery of assessments and diagnostic tests. The long-term and short-term treatment goals described in the treatment plan are the basis for evaluating the patient�s response to treatment. The average length of stay in the IOP program is 30 treatment days. Intensive outpatient psychiatry (IOP) programs are an intermediate step in the continuum of care between the need for acute inpatient care and individual outpatient care. IOP programs are a cost-effective alternative to traditional inpatient care and are less restrictive which allows a more holistic approach to treatment of the senior adult suffering from mental health problems. The IOP program provides an environment where both the physical and emotional needs of the senior adult can be managed by a multidisciplinary team of professionals. The goals of the IOP program are: 1. To provide diagnosis and treatment of individuals in the least restrictive environment. 2. To provide services prescribed by a physician and provided under an individualized written plan of treatment. 3. To restore individuals to their highest level of mental, physical, and emotional functioning possible. 4. To eliminate the need for inpatient treatment by providing a less restrictive, less emotionally traumatic, less costly alternative. 5. To assist in identifying and developing family support and/or community resources to assist the individual in retaining independent living for as long as possible, or to help the individual and/or family in finding appropriate placement. Anyone can make a referral to the IOP program. Once the referral has been made, a trained, licensed and/or certified staff member will make the initial contact with the patient and family to schedule a pre-screening assessment. After the pre-screening assessment is completed, the attending psychiatrist reviews all of the information. The attending psychiatrist is the only individual who can order an admission to the program if the patient meets all admission criteria. Once the patient is admitted to the program, the psychiatrist completes a full psychiatric evaluation within 24 hours. In addition to the psychiatric evaluation, the multidisciplinary team will complete a full battery of assessments and diagnostic tests. The long-term and short-term treatment goals described in the treatment plan are the basis for evaluating the patient�s response to treatment. The average length of stay in the IOP program is 30 treatment days.

6. Intermediate step in the continuum of care between the need for acute inpatient care and individual outpatient care. Cost-effective alternative to traditional inpatient care Can be set up in a Critical Access or other rural Hospitals Diagnose and treat in the least restrictive environment. Allows a more holistic approach to treatment of the senior adult suffering from mental health problems. Can allow the patient to stay closer to home The IOP program provides an environment where both the physical and emotional needs of the senior adult can be managed by a multidisciplinary team of professionals. (Primary Care MD, Psychiatrist, RN, Licensed Therapist)

7. What is an Intensive Outpatient Psychiatric (IOP) Program? An IOP is a short-term outpatient psychiatric program designed specifically for older adults who are experiencing behavioral or emotional difficulties. Services must be incident to a physician�s service, which is why they are hospital based Reasonable and necessary for the diagnosis or treatment of a patient�s condition Services must be prescribed by a physician Individualized treatment plan must state type, amount, frequency and duration of services Must provide reasonable expectation for improvement of the patient�s condition Set up as a Medicare Part A reimbursement program (Hospital based) A valuable additional product line to a Hospitals menu of available services

8. Program designed to the patient�s needs The treatment plan is individualized to meet the needs of the patient, but typically would include: Minimum of three hours of therapy a day times three days per week Individual therapy for 25 to 45 minutes once weekly Lunch served daily. Weekly review of progress with psychiatrist and treatment team.

9. Active Treatment Modalities Group Therapy Process, Interactive, Cognitive Activity Therapies Music, Movement, Art, Problem-Solving Education/Training (Medical with Psych) Drug Education, Prevention, Disease States Multifamily/Family Therapy Individual Psychotherapy

10. Intensive Outpatient Programsample schedule Three times a week 9:00 � 9:45 10:00 � 10:45 11:00 � 11:45 11:45 � 12:30 12:30 Other two days a week Family and Individual Psychotherapy as needed Goals Process Group Symptoms Process Group Wrap-up Process Group Lunch Return Home

11. Master Treatment Plan Identifying Data 5-Axis Diagnosis Strengths/Liabilities Reason for Admission Presenting Problem(s) Long Term Goals Short Term Goals Patient Objectives Multidisciplinary Interventions/Goals Discharge Criteria Discharge Plan

12. What are the Intensive Outpatient services? In a gero-psychiatric intensive outpatient program, the following services are provided: Psychiatric Evaluation Nursing Assessment Nutritional Screening Individual & Group Therapy Discharge Planning History and Physical Psychosocial Assessment Medication Monitoring and Management Family Education and Therapy Aftercare Planning

13. It all starts with the referral to the IOP 1) Anyone can make a referral to the IOP program. 2) A trained, licensed and/or certified staff member will make the initial contact with the patient and family to schedule a pre-screening assessment. 3) After the pre-screening assessment is completed, the attending psychiatrist reviews all of the information. The attending psychiatrist is the only individual who can order an admission to the program if the patient meets all admission criteria. 4) Once the patient is admitted to the program, the psychiatrist completes a full psychiatric evaluation within 24 hours. 5) In addition to the psychiatric evaluation, the multidisciplinary team will complete a full battery of assessments and diagnostic tests. 6) The long-term and short-term treatment goals described in the treatment plan are the basis for evaluating the patient�s response to treatment. 7) The average length of stay in the IOP program is 30 treatment days.

14. Accepted diagnoses within an IOP Acceptable diagnoses which fall into the ICD-9 codes that support medical necessity include: Major depressive disorder, single episode Chronic alcoholism Major depressive disorder, recurrent Post traumatic stress disorder Depressive disorder, NEC Other acute reaction to stress Manic depressive psychosis, other and unspecified Paranoid and/or hallucinatory states induced by drugs Bipolar affective disorder, manic Opioid-type dependence Bipolar affective disorder, depressed Psychostimulant dependence Bipolar affective disorder, mixed Sedative or hypnotic drug dependence Bipolar affective disorder, unspecified Combination opioid-type drug w/other drug use Schizophrenia, catatonic type Drug-induced organic affective syndrome Schizophrenia, disorganized type Shared paranoid disorder Schizophrenia, paranoid type Grief Schizophrenia, schizo-affective type Bereavement Schizophrenia, undifferentiated type Stress

15. What are the admission criteria? Psychiatric diagnosis Functional impairment Potential for gain in functional status Endurance to participate Motivation of patient Potential for successful community re-entry outcome

16. The role of the Medical Director Supervision of Program Program Oversight Clinical Supervision Proctoring Groups Planning Treatment Planning Counseling Peers

17. Program partnership Referring/Admitting Psychiatrist Physician Interdisciplinary Treatment Team

18. Results of this partnership Accurate Diagnosis Level of Care Recommendation Treatment/Management of Symptoms, Behaviors, Medical Conditions Education of Patient/Family Diagnosis Prognosis Community Support Services

19. Geriatric Depression Scale Results

20. Benefits to the patient

21. How can these services reach small rural communities without a Psychiatrist? Implementing Tele-psychiatry is the answer (Different from Telemedicine) Ensuring MD support plus can help tremendously in poor weather areas Does not require a sophisticated T1 line and can be set up using DSL Only pieces of equipment required are the following: Computer Monitor with speakers and microphone Telephone & fax machine (Used as Back Up) Unique DSL line used only for this service VPN security system (Only where applicable) Lower cost to set up compared to telemedicine based on level of data being sent back and forth Cost can range from $200 a month to $1500 a month depending on provider of service Equipment should only cost maximum of $5000 to install both the hospital and Psychiatrist. Investment can be recouped based on the Medicare Reimbursement for usage. (Facility Fee = approx. $21 per patient per day)

22. Data Flow process for Tele-psychiatry

23. Sample schedule using Tele-psychiatry with the Attending Psychiatrist NURSING REPORT - FIRST � PATIENT TIME 30� -45� SESSION (initial visit) 15� DOCUMENTATION (Fax or input on secure intranet) 10� -20� SESSION (subsequent sessions) 5� DOCUMENTATION (Fax or input in secure intranet) 30� -45� SESSION (day of discharge � includes time with family to ask questions) 15� DOCUMENTATION (orders and discharge summary) (Fax or Intranet) � EXIT INTERVIEW WITH NURSING

24. If you are a Medical Professional with more questions feel free to contact me or other providers of this service, such as Horizon or PSI John Robert Greene Psychiatric Medical Care, LLC jr@psychmc.com & 479-553-7327