Train staff to identify psychiatric disorders

Maryland study points to benefits of referrals

A Baltimore program that trains public housing staff to identify elderly residents with undiagnosed psychiatric symptoms could have relevance for home health agencies, one of its coordinators says.

"We believe that nurses are in the best position to be able to look at folks and make an assessment and bring the psychiatric issues to the attention of the primary medical provider," says Beatrice Robbins, RN, CSP, manager of geriatric outpatient mental health services in the community psychiatry program at Johns Hopkins Bayview Medical Center in Baltimore.

"Our point in educating the folks in the housing situations was not to teach them to diagnose, but to help them recognize unusual behavior as not just being nuts,’ but a sign that a person may have some serious medical psychiatric problems."

Robbins says that uncovering undiagnosed psychiatric problems can result in an outcome near and dear to home health nurses’ hearts — keeping a patient in the home longer. She says the erratic speech and behavior associated with such mental health problems as dementia, depression, and schizophrenia often lead to public housing residents’ evictions.

"If we can get them assessed and get them on medications, they can lead a very pleasant, normal life and stay aging in place."

Outreach program leads to treatment

According to the U.S. Department of Health and Human Services, the prevalence of mental illnesses among the elderly is approximately 20%. That number would include patients with early-onset disorders such as schizophrenia, as well as later-onset dementias and other illnesses.

Psychiatric disorders aren’t easily diagnosed

Unfortunately, Robbins says, those disorders aren’t always quickly diagnosed, even if a patient is seeing a doctor regularly. It’s a twofold problem, she says: Physicians aren’t quick to pick up on the clues, and patients are reluctant to share their fears about mental illness.

"I think the general medical providers are just not as alert to the symptoms of mental illness as they should be," Robbins says. "The primary care providers seem to focus on medical issues and just don’t see the psychiatric components. Someone who has a depression can present by being sluggish, not motivated, etc., and [doctors] look for the medical cause rather than the psychiatric cause.

"At the same time, I think the geriatric population is not ready to come forward with mental health issues."

A team from Johns Hopkins responded with a new approach: A grant-funded psychogeriatric outreach program targeted at elderly residents of high-rise public housing buildings in Baltimore.

The Psychogeriatric Assessment and Treatment in City Housing (PATCH) program relies on specially trained public housing staff — everyone from management and social workers to cashiers and maintenance staff — to identify seniors who may need help.

The resident then would be contacted by a psychiatric nurse, who would ask to come to the resident’s home to do an evaluation. During that visit, the nurse would take down a psychiatric, medical, and social history. The case would be presented to a team psychiatrist, who would accompany the nurse on a subsequent home visit and develop a treatment plan that includes further in-home visits.

More residents take advantage of system

In its 13 years, the program has expanded to all of Baltimore’s 17 public housing developments for the elderly. Robbins says that within individual sites, more residents have taken advantage of the referral system, referring spouses and even themselves.

"For someone to feel comfortable enough with us to self-refer that was the most incredible outcome measure," Robbins says. "It really demonstrated that we, the nurses in the program, were doing something right, to be able to approach us."

Clearly, agencies already stressed by the outpatient prospective payment system and other budget strains may lack the resources to mount a program as expansive as Johns Hopkins’. But Robbins says home health staff, who meet with patients over time and see them more intimately than a physician would, are in an ideal position to take note of possible psychiatric symptoms and notify the primary physician.

"An educational program is the way to start with home health staff, the aides and nurses — they are the front line, they are the ones who see people most often in the home health situation," Robbins says.

The PATCH program uses a series of monthly inservices for public housing staff, in which PATCH nurses cover a range of topics including depression, dementia, schizophrenia and substance abuse.

They discuss the emergency petition process for emergency interventions, as well as scheduling additional inservices for other topics suggested by the staff.

Once trained, the lay "case finders," are surprisingly good at identifying patients with problems. A study done in the early years of the PATCH program showed that 89% of residents who were referred did end up having a psychiatric diagnosis.

Some of the cases were fairly extreme: an elderly couple who accused neighbors of subjecting them to X-rays, or an 83-year-old schizophrenic woman who described hallucinations.

But other problems picked up on by housing staff were subtler, Robbins says. "The staff thought one lady was pretty strange because she would go out and walk around the building at certain times of the day in certain patterns," she says. "They just thought that she was kind of odd and unusual, while in fact she was a person who was diagnosed with schizophrenia that wasn’t being treated. So she’s being talked about as this kooky, eccentric person when in fact she was a person who had a significant need for treatment."

Reach out to other geriatric organizations

Robbins suggests agencies seek out community resources, particularly any local geriatric psychiatry resources. Those professionals can act as consultants to develop educational programs, as well as becoming a resource when a patient requires intervention.

Robbins says she’d like to see the PATCH program extended outside of its roots in public housing, in order to reach seniors in the general population. It would be a more difficult task to identify seniors who need the help — a role she suspects would be a perfect fit for home health.

Related reading

• Rabins P, Black B, Roca R, et al. Effectiveness of a nurse-based outreach program for identifying and treating psychiatric illness in the elderly. JAMA 2000; 283:2,802-2,809.

• Beatrice Robbins, Manager of Geriatric Outpatient Mental Health Services, Community Psychiatry Program, Johns Hopkins Bayview Medical Center, Mason Lord Building, D3-East, 4940 Eastern Ave., Baltimore, MD 21224. Phone: (410) 550-0019. Fax: (410) 550-1748. E-mail: [email protected].