Family and Community Collaborative Care for Older Adults and Their Family Caregivers

1. Session # E1a Friday, October 16, 2015 Family and Community Collaborative Care for Older Adults and Their Family Caregivers S Barry J. Jacobs, Psy.D. John Rolland, MD Lauren DeCaporale,-Ryan, PhD Janelle Jensen, MS, LMFTA Collaborative Family Healthcare Association 17thAnnual Conference October 15-17, 2015 Portland, Oregon U.S.A.

2. Faculty Disclosure The presenters of this session • currently have the following relevant financial relationships (in any amount) during the past 12 months: • 20% of Barry Jacobs’ salary is covered by a proof-of-concept grant from Independence Blue Cross of Philadelphia for his work with the Crozer-IBC Medicare Advantage Super-Utilizer Program

3. Learning ObjectivesAt the conclusion of this session, the participant will be able to: --Identify the clinical challenges and competencies of working with a burgeoning geriatric population --Describe the Family Systems-Illness Model and its application to integrated care for older adults --Outline key concepts in providing psychotherapy for older adults’ family caregivers --Describe population health approaches to caring for older adults, including a primary care-based transitions model and a super-utilizer program for frail elderly patients

4. Bibliography / References --Burke, R.E., & Coleman, E.A. (2013). Interventions to decrease hospital readmissions: keys for cost-effectiveness. JAMA; 173(8): 695-8. --”Caregiving in the US 2015,” a National Alliance for Caregiving/AARP report available at http://www.caregiving.org/caregiving2015/ --Coburn, K. et al. (2012). Effects of a community-based nursing intervention on chronically ill older adults: a randomized control trial. PLoS Medicine , 9(7) --Jacobs, BJ (2006). The emotional survival guide for caregivers—looking after yourself and your family while helping an aging parent. New York: Guilford Press. --Ottenbacher KJ, Karmarkar A, Graham JE, et al. (2014). Thirty-Day Hospital Readmission Following Discharge From PostacuteRehabilitation in Fee-for-Service Medicare Patients. JAMA.;311(6):604-614. doi:10.1001/jama.2014.8. --Rolland, J.S. (2016). Mastering family challenges with illness & disability: An integrative practice model. New York: Guilford. --”Working with the Super-Utilizer Population: The Experience and Recommendations of Five Pennsylvania Programs,” 2015, available at http://www.aligning4healthpa.org/pdf/High_Utilizer_Report.pdf

5. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted at the end of this presentation.

8. Implications of an Aging Population • Higher prevalence of chronic illnesses and functional limitations • Greater demand for family caregiving and healthcare/social services (high-tech; hands-on) • Higher societal costs • Clinical workforce not prepared for geriatrics

9. Core Clinical Competencies • Knowledge: normal developmental changes of aging; background on specific diseases (e.g., diabetes, heart disease, dementia); common psychological issues (e.g., meaning-making, increased dependence), dynamics of late-life families; community/residential services • Skills: biopsychosocial approach; cognitive assessment; running family meetings • Attitudes: curiosity, respect, enjoyment

10. Families, Caregivers, & Later Life : An Integrative Model John S. Rolland, M.D., MPH Northwestern University Feinberg School of Medicine john.rolland@northwestern.edu Chicago Center for Family Health www.ccfhchicago.org

11. Need for Family Psychosocial Map • Family functioning: Beliefs, organization, communication • Psychosocial understanding of illness • Understanding developmental processes

14. Multigenerational Developmental Perspective • Individual and family development • multigenerational experiences with illness & loss, including stories of resilience • Current timing • Impact on future individual and family life cycle planning

15. Family Health & Illness Belief Systems Challenge: Family create meaning for illness experience that promotes mastery & wellbeing

16. Key Family Health Beliefs Normative Illness Experience Communication Mastery, Control, Acceptance Cause of Illness Course & Outcome Ethnic & Cultural Beliefs Gender Spirituality Integrative Healing Practices Fit with Health Care Providers

17. Psychotherapy for Family Caregivers Janelle Jensen, MS, LMFTA Northwest Family Therapy Alzheimer’s Association, Care Consultant Seattle, WA

18. Who is Caregiving?NAC/AARP Caregiving in the US 2015 Report • In the last year, 34.2 million Americans have provided unpaid care to an adult age 50 or older • Majority of caregivers are female • Average age: 49 • 49% of those caring for a family member care for a parent/parent-in-law • 22% of caregivers report decline in overall health • 1/3 of caregivers say a health care provider has asked about what was needed to care for their recipient. Half as many caregivers say a health care provider has asked what they need to take care of themselves

19. We are conditioned to not discuss aging/death • We = All of us - Families and Professionals • Stigma • Do not plan accordingly – we become reactive vs proactive, more costly physically, mentally, and financially • Difficult to accept changes – creates anxiety • Do not identify as family caregivers – do not seek available supports • Added stress and burden on relationships • Becomes unacceptable to engage in grief/loss • Miss out on opportunities to more fully support our clients/patients

20. Psychotherapy with Family Caregivers: The Caregiver • Does not identify as a caregiver – reluctant to enter therapy • Balancing multiple roles: • Daughter/son • Parent • Partner/spouse • Professional • Decision maker/Power of Attorney • Chauffer – doctor visits, groceries, pharmacy • Cook – family meals on wheels provider • Activity Director – keeping loved one active, engaged in social events • Expert – all knowing of medical conditions, dx, meds • Executive assistant – scheduling appts, organizing community services, managing housing situation, coordinating Medicare and Medicaid applications and services

21. Psychotherapy with Family Caregivers: The Caregiver • Anxiety and Depression • Burn out • Frustration • Health concerns • Relationship dissatisfaction • Couple/partner difficulties • Grief/loss • Leave of Absence/job disruptions/financial strain

22. Psychotherapy with Family Caregivers: 2 Intervention Models • New York University Caregiver Intervention (NYUCI) • 2 individual counseling sessions • 4 family counseling sessions • Encouragement to participate in weekly support groups • Follow up counseling as needed for crisis, change in status, progressive nature of conditions • Resources for Enhancing Alzheimer’s Caregiver Health II Intervention (REACH II) • Multi-component, psychosocial/behavioral training intervention • Reduce burden and depression/ Improve self-care • Education, bx management skills, reframe negative emotional responses, strategies for managing stress • Role-playing, skills training, telephone support groups

23. Psychotherapy with Family Caregivers: The Therapist • Roles: • Emotional support • Educate • Advocate • Consult • Refer • Breathing/Mindfulness/Self-compassion • Acceptance and Validation of experience • Boundaries • Collaborate with other health professionals • Support groups/online caregiver support • Identifying family health and caregiving hx – rules and values

24. Primary Care Team-Based Care Transitions Program Lauren DeCaporale-Ryan, PhD Departments of Psychiatry, Medicine & Surgery

25. State-Specific Hospital Readmission Rates (Ottenbacher et al., 2014)

26. Discharge Pilot to Reduce Readmission Acknowledgements: Nabila Ahmed-Sarwar, PharmD, BCPS, CDE, Katie Lashway, RN, BSN, Magdalene Lim, PsyD, Karen Mahler, RN, BS, RobbynUpham, MD, MSEd

27. Discharge Pilot Findings

28. System Outcomes • Challenges: • Expense/sustainability of the model • Location: where do we fit a team of this size • Documentation: one encounter or two? • Billing • Successes: • Good clinical outcomes • Behavioral health critical to the process • Plan to implement this weekly (hopefully soon!) • Recognition that on the inpatient side, we are not adequately addressing psychosocial patient concerns

29. A Frail Elderly Super-Utilizer Program Barry J. Jacobs, Psy.D. Crozer-Keystone Family Medicine Residency Program Springfield, PA

30. Frail Elderly Super-Utilizer Program • In spring of 2013, the SU team at the Crozer-Keystone Family Medicine Residency Program was approached by a physician executive at Independence Blue Cross, the largest Philadelphia area insurer, to create a proof of concept SU intensive care coordination program for 10 IBC Medicare Advantage patients with PCPs in the Crozer Keystone Health System

31. Launched January 2014; renewed for 2nd year • As of 5/15, team saw 16 patients; avg age=80 • Dxs: CHF, COPD, DM, dementia • 40% decrease in inpt admissions, 70% decrease in OBS

32. Crozer-IBC Model • Based on work of Drs. Ken Coburn (“warm spotting”; nurse as point person), Dave Moen (home visit), and Dan Hoefer (palliative care) • Hired nurse case manager as point person—weekly home visits, medical accompaniment, family meetings • Interprofessional team of advisors/interveners—family medicine, psychology, social work, pharmacy, volunteer • Weekly huddles; EMR

33. Carmella, IBC PT • 89 year old widow who lives in a multi-generational rowhome. • Co-morbidities include: DM, CHF, HTN, CAD, Obesity, Peripheral Neuropathy & edema • 5 inpt/OBS/ER admits in 6 months prior to enrollment • Last 18 months in program—1 inpt admit

34. Interventions Weekly RN visits (and frequent phone calls with family members) Weekly Psy.D. student behavioral health visits Coordination of home PCP visit (through residency program) and home lab draw Home medication reconciliation RN accompaniment to medical visits Team worked toward decreased family caregiver burden/increased family organization

35. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!