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Over the last 2 decades, specialty geriatric mental health outreach programs have expanded across Canada. Although there are studies examining their effectiveness, little has been written about what informs best practices. The more recent focus on shared care, educational strategies, and program and systems development further contributes to the gap in knowledge concerning what constitutes geriatric mental health best practices. Three strategies provide a basis for defining best practices in geriatric mental health. These are analyzing the older population and their health care needs and analyzing trends in mental health reform; examining research and theoretical foundations relevant to shared care, education, and systems development; and exchanging field experience within a contextual understanding of unique local realities. Strategy 1: Older Persons in CanadaCanada’s population, like that of most countries around the world, is aging. In 2001, 1 in 8 Canadians were aged 65 years and over. By 2031, 21.8% of the Canadian population will have reached age 65 years. The older population is more diverse in nature than any other group. Sex, family status, social class, ethnicity, occupation, life history, and health and disability all contribute to the individuality of each person (1). Persons aged over 85 years comprise the fastest growing group of older persons. For this group, there is an increased likelihood of chronic and other health problems requiring health and social service management, either in the community or in long-term care facilities (2,3). Mental health disorders are prevalent among the older population. Jeste and others estimate that 1 in 5 persons aged over 65 years have a mental disorder, including dementia, depression, psychosis, bipolar disorders, schizophrenia, and anxiety disorders (4). The National Institute of Mental Health Study reveals the following incidence of new psychopathology cases for each age group: 2.3 new cases among persons aged 15 years and over, 76.3 among those aged between 25 and 34 years, 93.0 among those aged between 35 and 45 years, and 236.1 among those aged 65 years and over (5). The Canadian Study of Health and Aging indicates that 2.5% of persons aged between 65 and 74 years, 11% of persons aged between 75 and 84 years, and 35% of persons aged 85 years and over have a dementing illness. It is estimated that by 2031, over 750 000 Canadians will have Alzheimer’s disease or related dementias (6). Concerning service delivery, only one-third of older persons with a mental illness living in the community receive mental health services (7). Most of this psychiatric care is provided by the primary and long-term care sectors (5,7). Regarding long-term care facilities, prevalence rates are more alarming. Rovner and others (8) report that 80% of all residents have a mental health problem, yet few are receiving services (7,9,10). For older persons, symptoms of mental illness often differ from those experienced by younger persons, making accurate diagnosis and treatment difficult (9). Even mild problems may interfere with independent functioning, given the increased likelihood of physical illness or social isolation (11). Further, agism and stigma are serious issues affecting this population and the development of services required to meet their complex and ever-changing needs (12). Thus, the literature captures the need to address the ever-increasing number of diverse and complex mental health disorders among older persons. Also evident is the need for service and human resources with a diverse repertoire of knowledge and skills designed to care for these individuals. A significant challenge to the health care system, then, is to create mechanisms that will allow essential knowledge and skills to be developed and supported across a range of settings. Trends in Mental Health Reform Despite the limited evidence concerning clinical or cost-effectiveness (10,15–18), common elements of a comprehensive care system were considered to be community assessment and treatment (including case management), consultation services, day care and day hospital care, inpatient care, continuing care, and education and training. Professional care was deemed most desirable when delivered by multidisciplinary teams, preferably to persons living in their own home (13). Other overarching principles were ensuring accessibility, availability, client-centredness, and coordination of service networks (5,10,13). In the 1990s, several influential documents were published to confirm care directions for individuals with mental illness, including the elderly. Critically, in 1996, the World Health Organization and the World Psychiatric Association (WHO–WPA) published a technical consensus document on the organization of psychiatric care for older persons. For the first time, opinion leaders from across the world collaborated to acknowledge specialty psychiatry for the elderly, the characteristics of psychiatric morbidity in old age and their treatment, the organization of multidisciplinary services, the need for training schemes across health and social care workers, and the benefits of research activities. Multidisciplinary community mental health outreach teams were given prominence alongside an emphasis on domiciliary assessments (19). Consistent with advancing mental health and primary care reform in Canada, the WHO–WPA statement placed new emphasis on service accountability (20). Mental health reform in Ontario made significant gains during this time. Fundamental developments in adult mental health resulted from a 10-year strategy for reform that was outlined in Putting People First: The Reform of Mental Health Services in Ontario (21); the role and function of specialty geriatric mental health services within a restructured system were addressed. Shortly thereafter, the Policy Framework and Implementation Guidelines for Mental Health/Long Term Care was released (22). One of its significant contributions was its reiteration of the diverse target population (that is, individuals with dementia and an associated mental illness, with physical problems and associated psychiatric disorders, with concurrent disorders, and of late age with primary mental health problems). Further contributions included recognition of the pivotal role of family caregivers, of core elements of service provision at both local and regional levels, and of the requirement for increased capacity in the long-term care and community sectors to allow the provision of continuing care. Specialty outreach teams were recognized as the essential link in the continuum of comprehensive services. As well as having a clear understanding of what constitutes quality or effective clinical care, clinicians were required to share care as effective consultants and to exchange or transfer knowledge with their colleagues in other sectors and settings. In early 1998, the Ontario Minister of Health moved forward with the implementation of mental health reform. Making it Happen: Implementation Plan for Mental Health Reform (23) and Making it Happen: Operational Framework for the Delivery of Mental Health Services and Supports (24) reviewed the context for overall reform and focused on how core services would be delivered according to best practices and levels of need. Best practices were intended to regulate planners and providers in the design and delivery of services, in defining staff roles and competencies, in training approaches, in mechanisms for establishing and funding service priorities, and in ensuring system accountability (25). Levels of need focused on the range of consumer needs, which then determined the necessary services. Specialized programs and services were provided in community or hospital settings for individuals with a serious mental illness who had complex, rare, and (or) unstable disorders. Geriatric mental health services were positioned here, emphasizing care for individuals who required ongoing support, more structured and intensive treatment, or higher levels of coordinated care. The plan also directed providers in other levels who were working with the target population to seek consultation and backup from the specialized programs (23,24). Though limited, research on the effectiveness of specialty geriatric mental health outreach teams has identified reduced rates of placement both for older persons living alone and for those in care (26). Outreach services have demonstrated a reduction in psychiatric hospitalization by as much as 60% (27). This care model also indicated a lessening of psychiatric disability in the home (28). In addition, Banerjee and others reported that interdisciplinary geriatric teams improved health among 58% of the patients treated, compared with improvement among only 25% of those treated in standard family practice (29). Draper reviewed randomized controlled trials and quasi-experimental designs, concluding that community outreach psychiatric teams provide an effective means of helping older persons (10). There are conflicting results in the literature, however, and other studies have demonstrated less robust changes resulting from outreach intervention (30). Mental health reform for older persons and related research describe an essential position for outreach services within the continuum of mental health care. Specifically, role functions have been articulated as including shared care, education, and program and systems development. The reform further highlights the distinctiveness and heterogeneity of the population and identifies multidisciplinary approaches as becoming a resource for the community, long-term care, and acute care sectors. Strategy 2: Research and Theoretical FoundationsA critical question concerns what we know about the theoretical frameworks informing effective implementation of shared care, education, and program and systems development. Three perspectives establish a theoretical foundation and inform the development of new roles for specialty geriatric mental health outreach: the mental health consultation model, approaches to adult education and performance improvement, and notions regarding knowledge transfer and exchange. Each of these perspectives also draws on approaches to organizational change. Mental Health Consultation Caplan’s model of mental health consultation is directed toward community development and is an effective mechanism for using scarce resources for maximum support (33). Though developed in the early 1970s, his model has been successfully applied as a foundation for outreach service development in some areas (5,32). Cohn and Smyer (34) have further expanded Caplan’s model for nursing home consultations and follow-up. One benefit of this model is its multilevel approach, which concurrently offers elements of shared care, education, and systems development. Key elements from Caplan’s conceptualization that are relevant to specialty geriatric mental health outreach are as follows: First is the element of marginality. Here the consultant is connected to the organization but is able to perceive issues externally. Second is the client and consultant match, which allows consistent interactive engagement between the specialist and the consultee. Third is activity integration, comprising clinical services with education and system changes. Fourth is a nonhierarchical approach wherein the specialist is the “content expert” and the client is the “situational expert.” Fifth is knowledge exchange, which encourages the bilateral exchange of knowledge between consultant and client. Adult Education Adult learning theory has evolved over the years. Its most notable contributor is Malcolm Knowles, who championed the concept andragogy. Andragogy is concerned with facilitating knowledge acquisition through guided interaction rather than just content transmission. Several assumptions about adults as learners form the basis of andragogy. Adults are considered to be autonomous and self-directed, to have a life history of experience, and to be practical and goal- oriented. Thus 4 learning principles are included within this framework: 1) adults should be involved in the planning and evaluation of their instruction, 2) experience provides the basis for learning activities, 3) adults are most interested in learning topics that have immediate relevance to them, and 4) adult learning is problem- and task-oriented rather than content-oriented (35,36). These principles provide an important conceptual framework for service learning strategies and should be considered within the context of on-site participatory learning. This reinforces what is commonly referred to as a learning cycle, which comprises the appropriate repetition of experiencing (doing), followed by processing (sharing observations), generalizing (deriving meaning from experience), and application (taking action with new learning) (37). Similarly, the seminal work of Davis and colleagues about continuing medical education reports that the most effective learning results from more active approaches (38,39). Davis and others (39) and Osgoode (40) further identify the value of relevant, case-based education that builds on the knowledge of the learner, combining it with that of the specialist, and further involves strategies that permit supportive application and feedback. Knowledge Transfer The literature identified the necessity of the message content’s being congruent with subjects’ experience and values (41–43) and relevant to their lived context (43,44). Similarly, the subject should have the opportunity to observe the knowledge applications (41,42), thus reinforcing the claim that knowledge exchange is more effective during one-on-one encounters (45,46). However, many strategies are identified as being critical to information communication, depending on the target audience (42,47,48). Finally, Sherrod states that ongoing communication links among key stakeholders are necessary to ensure knowledge is used following transfer (49). Strategy 3: Best Practices From Field ExperienceThis section details specialty geriatric mental health outreach initiatives in shared care, education, and systems development in Ontario communities. These specific field-based initiatives include education-focused clinical consultations, temporary assignments with a specialty geriatric mental health outreach team, and targeted educational projects in the community and long-term care sectors. Education-Focused Clinical Consultations Another means of ensuring a more coordinated service and enabled knowledge transfer was to engage in joint visits with other sector providers as often as possible. The focus of these case-based encounters was a bilateral exchange of knowledge between the 2 professionals. To counteract any perception of poor resource use and to promote the benefits of systems development, senior management within the organizations supported these joint visits. Regarding the consultation service with the educational component, annual referrals to the program almost doubled in the first 4 years; however, this was not a direct measure of the team’s successful development of other community resources. Other indicators provided some evidence that capacity enhancement in the community occurred. Of the total number of referrals, there was an increase in purely informational requests. Direct client contacts decreased over time, while indirect case-management contacts increased, possibly indicating increased reliance on local resources. To ensure that learning occurred with the more traditional, client-centred consultation, an analysis of the key elements was undertaken and the following 4 requirements were revealed: 1) high levels of knowledge and skill among team members to ensure effective delivery of educational initiatives; 2) inclusion of senior leaders of the outreach service to continually reinforce education as an integral part of the consultation process; 3) evaluation of the education-focused clinical consultation; and 4) understanding among community organizations and practitioners that education is an integral part of the consultation process. Temporary Assignments Clinicians who participated in the rotation were selected by each organization according to the clinicians’ interest in the target population, their established learning goals, and their ability to act as an in-house educational resource for peers. When the rotation was complete, the clinicians were asked to provide written feedback regarding the strengths and weaknesses of the experience. Continued backup at the clinicians’ workplace was offered upon return. This initiative resulted in the development of in-house resources for participating agencies and facilities and a more effective use of outreach teams (including a decrease in direct consultations). It also illustrated the need for sponsoring agencies’ commitment to developing internal change champions who would act as clinical and educational resources for the agency. Targeted Educational Projects in the Community and Long-Term Care Sectors The CRG strategy was an approach to help community clinicians work together as a team. Complex cases from the community were referred to the CRG for consultation. The group provided a forum for community-based health and social service clinicians to share knowledge, skills, and experience gained from their professional expertise and from their practice in a particular environment (53). In addition, clinical, systemic, and educational issues were identified. Surveys about the CRG members, their supervisors, and their peers were conducted. At the time of the survey, CRG members had participated in the group for an average of 30 months. Respondents from 7 participating agencies were asked whether they felt the CRG was overall worthwhile and to rate its usefulness in achieving its goals. Results are shown in Table 1.
As a further assessment of the effectiveness of the CRG, a “paper-problem scenario” was administered to current and former CRG members and to a randomly selected group of other agency staff. It was expected that the team members would score significantly higher on the problem than would other agency staff. Twenty-four paper problems were returned: 11 from current and former CRG members and 13 from other agency staff. A 10-point rating scale was used to assess the content of the answers, and an overall score out of 100 was calculated. To determine rating reliability, the paper problems were assessed using the standard criteria by 2 independent expert raters. Reliability of the overall score was 0.82 (intraclass correlation coefficient), indicating an acceptable level of reliability (54). An average overall score of both raters was used when the results were analyzed. The overall mean paper problem score was 59.1 (SD 18.0), with scores ranging from 20/100 to 89/100. Mean scores did not vary significantly by agency (P = 0.98) or by the discipline of the respondents (P = 0.75). As expected, CRG team members scored significantly higher than did the agency team. The CRG’s mean score was 71.3 (SD 13.0), compared with 48.8 (SD 15.3) for other agency staff (P = 0.0009). Facility Sector The first phase of the project involved introducing the initiative and selecting the pilot facility. Both the outreach program and the facility committed resources to support the initiative. In addition to the usual consultation service, a geriatric psychiatrist and a case manager devoted 1 half-day every 2 weeks to the facility, involving other outreach team members when necessary. The facility dedicated part-time social work and clerical support. An administrative committee was formed with the senior administrators of the facility. This committee implemented the management and administrative changes necessary to support the project. Using a review of 40 initial client consultations and a survey of resident characteristics, facility needs and desired outcomes were further defined in the second phase. Meeting with the in-house personnel provided a mechanism for identifying needs; for developing a common understanding of models, roles and responsibilities; and for sharing the knowledge and experience of in-house and outreach personnel. In-house case managers were developed through case-based teaching and formal educational sessions. They gained additional experience through a temporary assignment with other programs. The in-house case managers developed knowledge and skills in mental health assessment and management, consultation, small-group interdisciplinary learning, and evaluation. A major part of the educational development program involved defining and targeting the learning needs of care providers, including family doctors, nursing staff, health care aides, and family members. Table 2 provides a summary of the main educational activities used within each group, the content areas that were emphasized, and the evaluation data that were collected.
In addition to the initiatives described above, the following program and administrative changes were implemented: 1) a joint project for cognitively impaired residents that identified environmental needs and developed strategies related to the monitoring of behaviour and restraint use; 2) modification of the admission procedure and assessment form to ensure relevant mental health issues were identified; 3) enhanced service arrangements with outside resources; and 4) seminars for all staff on behavioural and cognitive problems. Interviews with administrative personnel, medical directors, and members of the in-house team indicated a positive reaction to the program. The third phase of the project involved “disengagement” to help ensure the sustainability of educational impacts and resources. The disengagement strategy included the establishment of a permanent in-house consultant who would serve as an educational resource, introduction of monthly educational sessions on aggressive behaviour, launch of a resource library, and implementation of a certificate program for staff on mental health and behaviour problems. The in-house consultant also participated in staff and committee meetings at the facility where mental health concerns were evident. The use of restraint orders was a major focus of this educational intervention. To assess whether the pilot project had been successful in reducing restraint orders, chart review data were collected 17 months apart. Similar to Mohide and others’ assessment of quality assurance interventions (55), data from 2 other variables that were not the foci of the education (that is, incontinence and psychotropic drug use) were also collected. It was expected that if patient outcomes and care practices were affected by the intervention and were not a secular trend, restraint orders would decline and the other variables would remain relatively constant (Table 3).
Though restraint orders dropped significantly over this period, there were no significant changes in the proportion of residents with incontinence or in the use of psychotropic medication. Two years later, when in-house resources had been further developed and a restraint policy put into place, there were restraint orders for only 16% of the residents. Three years later, a follow-up was conducted to see whether the impacts of the project were sustained. There continued to be an in-house specialist and educational programs conducted by in-house resources. Though there was a resurgence of aggressive-behaviour incidents following disengagement of the outreach program, with sustained activity by in-house resources, aggressive behaviour dropped from 110 incidents to 38 incidents. ConclusionsThe growing number of older persons with severe mental illness warrants a concerted effort to develop effective, efficient, and accountable service systems to meet their complex and ever-changing needs. As health care delivery continues to evolve into community-centred care, the roles and functions of specialty geriatric mental health outreach services must respond to the new challenges presented to them. Examination of the target population, the trends in mental health reform, the research and theoretical developments, and the field experience provides a sound basis for establishing best practices in specialty geriatric mental health outreach services. However, this more global approach should be considered within the local context, which further influences development according to resource availability, catchment area, specific population characteristics, and need. Underpinning this method is the awareness of the principal functions for service delivery, including shared care, education, and systems and program development. What evolves is a best-practice framework grounded in the systematic examination of the above-noted areas and, importantly, an emphasis on knowledge exchange as fundamental to all practice approaches. To determine and to implement best practices for specialty outreach, we recommend that the following elements of knowledge exchange be identified within existing and developing models of program delivery (Figure 1):
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Med Care 1988;26:554–65. Author(s)Manuscript received and accepted January 2004. 1. Director, Health Services Research, Division of Geriatric Psychiatry, Queen’s University, Kingston, Ontario; Program Evaluator, Geriatric Psychiatry Services, Providence Continuing Care Centre, Kingston, Ontario. 2. Administrative Director, Geriatric Psychiatry Services, Providence Continuing Care Centre, Kingston, Ontario. 3. Professor and Chair, Geriatric Division, Department of Psychiatry, Queen’s University, Kingston, Ontario; Clinical Director, Specialty Geriatric Psychiatry Program, Providence Continuing Care Centre, Kingston, Ontario. 4. Associate Professor, Epidemiology and Biostatistics, University of Western Ontario, London, Ontario; Manager, Program Research and Evaluation, Southwestern Ontario Regional Geriatric Program, St Joseph’s Health Care London–Parkwood Site, London, Ontario. 5. Assistant Professor, Associate School of Graduate Studies, Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, Ontario. Address for correspondence: Dr MP Sullivan, Program Evaluator, Geriatric Psychiatry Services, Providence Continuing Care Centre, 752 King Street West, Kingston, ON K7L 4X3 e-mail: sullivam@pccchealth.org
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