Meeting the Mental Health Needs of the Homebound: A Psychiatric Consult Service Within a Home-Based Primary Care Program

Shortcomings of services for persons with severe and persistent mental health challenges: a qualitative study of service users and family carers

Introduction

The opinions of service users and carers are crucial to identifying ways to innovate and implement system change. This study aims to explore the views and experiences of service users and carerson the services they have used for their mental health challenges and their suggestions for service reform.

Methods

Twenty participants (15 carers and 5 service users) were interviewed for the study.

Results

Eight categories emerged from the data. They were: Several gaps in the system, Barriers to accessing services, Services are not fit for purpose, Services operate in isolation, System is not person focused, Service users and carers are treated poorly, Services are overloaded and under resourced and Recommendations for service reform. Respondents reported that a persistent lack of funding and resources for mental health services was a main cause of these shortcomings. Respondents also noted that innovations were needed to re-orient services to enable continuity of care, and training of mental health professionals was needed for a better understanding of the needs of service users and their carers.

Discussion

Additional research is needed with larger and more diverse samples to further explore these findings.

Home, but Not Homebound: A Prospective Analysis of Persons Living With Dementia

OBJECTIVES

Homebound persons living with dementia may have increased difficulty accessing needed care in the community. This study identifies factors associated with becoming homebound among a national sample of Medicare beneficiaries with newly identified dementia.

DESIGN

Prospective cohort analysis.

SETTING AND PARTICIPANTS

We used the National Health and Aging Trends Study (NHATS) 2011-2018 to identify community-dwelling older adults at the time of a new dementia diagnosis (n = 939). Dementia status was determined based on cognitive testing and self and proxy reporting.

METHODS

We compared characteristics of homebound (ie, those who never or rarely left home) and non-homebound participants at the time of dementia identification. Among non-homebound participants, we used a Fine-Gray subdistribution hazard model to identify factors associated with becoming homebound over follow-up (median follow-up 4 years), accounting for competing risks of death and moving to a nursing home.

RESULTS

20% of individuals with newly identified dementia were homebound and this group was more functionally impaired, medically complex, and socioeconomically disadvantaged as compared to the non-homebound. Over time, depression [subhazard ratio (SHR) 2.19, 95% CI 1.36, 3.54], living in an assisted living facility (SHR 2.60, 95% CI 1.35, 4.97), and Hispanic ethnicity (SHR 1.91, 95% CI 1.05, 3.47) were associated with becoming homebound.

CONCLUSIONS AND IMPLICATIONS

Most adults are not homebound at the time of dementia diagnosis. Identifying and addressing modifiable factors like depression may slow progression to homebound status and enable persons living with dementia to access needed care in the community. In order to accommodate diverse individual and family preferences for long-term care, robust systems of home-based clinical and long-term care are necessary for those who do become homebound.

Home-based primary care: A systematic review of the literature, 2010-2020

BACKGROUND

Although more than seven million older adults struggle or are unable to leave their homes independently, only a small minority access home-based primary care (HBPC). Despite substantial growth of HBPC, fueled by growing evidence supporting positive patient outcomes and cost savings, the population remains dramatically underserved and many evidence gaps still exist around scope of practice and key issues in care delivery and quality. Understanding the current state of the field is critical to the delivery of high-quality home-based care.

METHODS

We conducted a systematic search of the peer-reviewed literature on HBPC, published between January 2010 and January 2020, using Medline, CINAHL, Embase, Web of Science, and Scopus online libraries. All studies were evaluated by two members of the research team, and key findings were extracted.

RESULTS

The initial search yielded 1730 unique studies for screening. Of these initial results, 1322 were deemed not relevant to this review. Of the 408 studies deemed potentially relevant, 79 were included in the study. Researchers identified five overarching themes: the provision of HBPC, the composition of care teams, HBPC outcomes, the role of telehealth, and emergency preparedness efforts.

CONCLUSION

The need and desire for growth of HBPC has been highlighted by the recent COVID-19 pandemic. Current research on HBPC finds a diverse scope of practice, successful use of interdisciplinary teams, positive outcomes, and increasing interest in telehealth with many areas ripe for further research.

Identifying and Managing Suicidality in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome

Adult patients affected by myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) are at an increased risk of death by suicide. Based on the scientific literature and our clinical/research experiences, we identify risk and protective factors and provide a guide to assessing and managing suicidality in an outpatient medical setting. A clinical case is used to illustrate how information from this article can be applied. Characteristics of ME/CFS that make addressing suicidality challenging include absence of any disease-modifying treatments, severe functional limitations, and symptoms which limit therapies. Decades-long misattribution of ME/CFS to physical deconditioning or psychiatric disorders have resulted in undereducated healthcare professionals, public stigma, and unsupportive social interactions. Consequently, some patients may be reluctant to engage with mental health care. Outpatient medical professionals play a vital role in mitigating these effects. By combining evidence-based interventions aimed at all suicidal patients with those adapted to individual patients' circumstances, suffering and suicidality can be alleviated in ME/CFS. Increased access to newer virtual or asynchronous modalities of psychiatric/psychological care, especially for severely ill patients, may be a silver lining of the COVID-19 pandemic.

Development of a Suicide Prevention Toolkit for VA Home-Based Primary Care Teams

The U.S. Department of Veterans Affairs Home-Based Primary Care program (HBPC) serves Veterans with multiple comorbid physical and psychological conditions that can increase suicide risk. HBPC teams are uniquely able to implement suicide risk assessment and prevention practices, and the team's mental health provider often trains other team members. An online suicide prevention toolkit was developed for HBPC mental health providers and their teams as part of a quality improvement project. Toolkit development was guided by a needs assessment consisting of first focus group and then data from surveys of HBPC program directors (n = 53) and HBPC mental health providers (n = 56). Needs identified by both groups included training specific to the HBPC patient population and more resources if mental health needs could not be fully managed by the HBPC team. HBPC mental health providers within integrated care teams play a key role in clinical intervention, policy development, and interprofessional team education on suicide prevention. HBPC teams have specific learning and support needs around suicide prevention that can be addressed with a feasible, easily accessible clinical and training resource.

Psychotropic medication use patterns in home-based primary care: A scoping review

Introduction

Up to a third of patients seen by home-based primary care (HBPC) providers suffer from mental health problems. These conditions tend to be underrecognized and undertreated for patients receiving HBPC. The purpose of this scoping review is to evaluate current psychotropic use patterns for patients receiving HBPC services.

Methods

The following databases were searched for articles reporting on studies conducted in HBPC settings that identified patterns of psychotropic medication prescription and use: Ovid/MEDLINE, Cochrane Library, Embase, Scopus, Web of Science, CINAHL, and PsycInfo. Studies that only reported on patients in hospice, rehabilitation, or long-term care facilities were excluded as were drug trials, opinion pieces, case studies, case series, meeting abstracts, and other reviews.

Results

Of 4542 articles initially identified, 74 were selected for full text screening. Of these, only 2 met full criteria and were included in the data extraction and analysis. In 1 study, 41.7% patients enrolled were prescribed an antidepressant, 21.5% were prescribed an antipsychotic (12.7% prescribed both), and 5% to 7% of patients were prescribed benzodiazepines/hypnotics. In the other study, 9% of patients were prescribed an antipsychotic, and 7% were prescribed a benzodiazepine.

Discussion

There are extremely limited data on psychotropic prescribing patterns in HBPC in published studies. Because a significant number of HBPC patients suffer from mental health conditions in addition to other chronic illnesses, treatment can be complex. More studies are needed on current psychotropic prescribing trends to help determine what type of interventions are needed to promote patient safety in this setting.

Interdisciplinary Team Perspectives on Mental Health Care in VA Home-Based Primary Care: A Qualitative Study

OBJECTIVES

This qualitative study describes the structure and processes of providing care to U.S. Department of Veterans Affairs (VA) Home-Based Primary Care (HBPC) enrollees with mental health care needs; explains the role of the HBPC psychologist; and describes how mental health treatment is integrated into care from the perspective of HBPC team members.

DESIGN

HBPC programs were selected for in-person site visits based on initial surveys and low hospitalization rates.

SETTING

Programs varied in setting, geographic locations, and primary care model.

PARTICIPANTS

Eight site visits were completed. During visits, key informants including HBPC program directors, medical directors, team members, and other key staff involved with the HBPC program participated in semi-structured individual and group interviews.

MEASUREMENTS

Recorded interviews, focus groups, and field observation notes.

RESULTS

Qualitative thematic content analysis revealed four themes: 1) HBPC Veterans have not only complex physical needs but also co-occurring mental health needs; 2) the multi-faceted role of psychologists on HBPC teams, that includes providing care for Veterans and support for colleagues; 3) collaboration between medical and mental health providers as a means of caring for HBPC Veterans with mental health needs; and 4) gaps in providing mental health care on HBPC teams, primarily related to a lack of team psychiatrists and/or need for specialized medication management for psychiatric illness.

CONCLUSIONS

Mental health providers are essential to HBPC teams. Given the significant mental health care needs of HBPC enrollees and the roles of HBPC mental health providers, HBPC teams should integrate both psychologists and consulting psychiatrists.

Correlates of Depressive Symptoms among Homebound and Semi-Homebound Older Adults

This study aimed to provide a national profile of homebound and semi-homebound older adults with depressive symptoms and to compare risk factors of depressive symptoms by homebound status. A sample of 1,885 homebound and semi-homebound older adults was selected from Round 1 of the National Health and Aging Trends Study (NHATS). The prevalence of depressive symptoms was 43.9% in homebound older adults and 28.1% in semi-homebound older adults, representing over 830,000 and 1.4 million individuals in the population, respectively. Nearly two-thirds of homebound and over half of semi-homebound older adults with clinically significant depressive symptoms also had significant anxiety symptoms. Results from logistic regression showed that younger age, certain medical morbidities, severity of functional limitations, and pain were common risk factors for depressive symptoms among homebound and semi-homebound older adults. Some differences in the risk factor profile emerged between the homebound and the semi-homebound populations. Alleviating the burden of depression in the semi-homebound population may focus on early prevention that considers the diversity of this population. Home-based, integrated programs of health and mental health services that simultaneously address the medical, psychiatric, and neurologic comorbidities and disabilities of homebound older adults are needed to meet the complex needs of this population.