elderly

Neftali
Psychologist Neftali Serrano remembers when the concept of integrated care—the combination of behavioral health and primary care—clicked with him.

Dr. Serrano was working in a health center, down the hall from the primary care physicians. He only had two or three patients a day. “I was open for business and had no one coming in,” he said.

Out of that futility, he said he started spending time with providers instead of sitting alone in his office. This evolved to walking into exam rooms and working with patients directly.

“Within 30 seconds, patients were opening up about their behavioral health issues and getting to things that would usually take hour long visits or even a series of visits,” said Serrano.

Dr. Serrano said he connected faster to patients in a primary care setting. “They trusted their primary care doctors and they extended that trust to me,” he said.

Dr. Serrano now works with the Center of Excellence for Integrated Care, a program of the Foundation that trains health care professionals and providers to treat behavioral and physical health in one setting.

[box type=”bio”] “They trusted their primary care doctors and they extended that trust to me.”[/box]

Integrated care can work especially well among the aging population. Two out of three Americans aged 65 and over have chronic illnesses, which are often coupled with mental health distress. The Centers for Disease Control and Prevention estimates that 20 percent of adults over 55 have a mental health concern. Decreased mobility, isolation and health complications can cause anxiety, depression, and severe cognitive impairment among our aging community members.

Integrated care can offer older adults a safe place to get help with these behavioral health issues.

“Some older adults are not as willing or able to go outside the walls of a primary care office to see a therapist,”” said Dr. Serrano. “Having a behavioral health consultant right there is a more culturally appropriate way to deliver care for folks who are more comfortable with primary care.”

[box type=”bio”] Integrated Care can offer older adults a safe place to get help with behavioral health issues.[/box]

Initial research trials among the elderly combined psychiatric therapy with primary care, and proved to be very successful, said Dr. Serrano. For example, cardiovascular health, a common concern for the elderly, can improve by treating depression. “There are clear links between heart health and depression,” said Dr. Serrano.

Another advantage of integrated care is the free flow of patient information. The patient’s medical history is on hand, and can better inform the behavioral therapist, instead of having to start from the beginning with every patient.

Integrated care can also help primary care physicians make better assessments for their patients. For example, depression is often masked by physical health issues. Patients with vague pain may be suffering from isolation or loneliness.

“Oftentimes primary care doctors will do a whole lot of work to address the physical problems but fail to address the root issues,” said Dr. Serrano.

There is also a certain threshold a patient must meet for referral to a mental health therapist. Many people that need behavioral health assistance may not have acute behavioral health issues, but would benefit from the input of a therapist in their primary care office.

Dr. Serrano said it will take a lot of broad training across specializations to prepare the medical profession for an older population. Mental health professionals in particular, according to Dr. Serrano, will need to reconfigure their mindset and work-flow. “Mental health professionals are more accustomed to sitting in an office by themselves than working on a team,” he said.

The Center of Excellence for Integrated Care (COE), a program of the Foundation, helps providers make this adjustment. They have practical training programs on all aspects of integrating the silos of behavioral health and primary care in any setting where health care is delivered. COE is also dedicated to reducing the stigma associated with behavioral health issues. Accessing therapy through a primary care doctor can help reduce any discomfort of feeling of shame about needing help. The integrated approach to elderly care is important to recognize and replicate as our population continues to age.

Oral health disparity affects all age groups, but is particularly difficult for the elderly. The complications of frail and failing teeth are compounded by the inability to access care. Insurance coverage for oral health is spotty, and Medicare, the public insurance available to the elderly, does not cover oral health.

Many of our aging community members, especially vulnerable and underserved populations, did not grow up with the benefit of water fluoridation, and 25 percent of adults aged 60 are missing many of their original teeth. Besides the painful side effects of oral health issues, missing or weak teeth affect nutrition, as older adults choose softer and potentially less nutritious foods. Twenty-three percent of the elderly population in the U.S. also suffer from gum disease, which is more common in disadvantaged populations.

In North Carolina, we are fortunate to have caring organizations working to collaborate on solutions to the problem of oral health disparity among the elderly. One of these organizations is Access Dental Care, a dentist office on wheels. Access Dental is a non-profit organization that travels to long-term care facilities to meet the needs of elderly patients.

Zulayka Santiago, director of the NC Oral Health Collaborative, reflected on the experience of a day with Access Dental:

“As a newcomer to the world of oral health, I had heard great things about the work of Access Dental Care. Given that words so often fall short in communicating the impact, it was important for me to witness their work in real time. I met them at Rex Health and Rehabilitation in Apex, a new site for them. It was a cloudy Monday morning, but what I witnessed that day would brighten most any day.

I met the van in the parking lot and helped them unload all of their equipment. In just a few minutes a full dental office set up in one of the dining areas! The ease and flow of process signaled to me that those three individuals had performed this routine many times. Providing dental care to individuals who are frail, elderly or who have intellectual or developmental disabilities is not easy (to state the obvious). My brief time with Access Dental Care definitely affirmed this fact. But more importantly, what the experience illuminated for me was that this type of work requires a certain strength of character and commitment to ensure that each patient receives the care they need with compassion and a lightness of heart.

Dr. Bill Milner (dentist), Betsy White (dental hygienist) and Rhonda Little (dental assistant) made a big impression on me that day. As we work to ensure access to optimal oral health for all North Carolinians, it is essential to celebrate the models that are working well and doing a good job of reaching the most vulnerable. I applaud and am inspired by the work of Access Dental Care. I am grateful to have such strong partners within the NC Oral Health Collaborative.”

The Foundation, through the expertise of the NC Oral Health Collaborative, acts as a convener for oral health disparity issues in the state. We work with partners like Access Dental Care to develop strategies and action plans to improve the oral health status of all North Carolinians. For more information on the Oral Health Collaborative, click here.

To learn more about Access Dental Care, visit http://www.accessdentalcare.org/

In western North Carolina, the number of adults aged 65 and over is expected to double in the next 40 years, becoming the largest demographic by 2030.

Sarah Thach, a Bernstein Fellow alumni, helps pilot programs aimed at helping primary care doctors prepare for the influx of elderly patients. “We are never going to have enough geriatricians so it falls to the primary care doctor to manage care for older adults.”

Care for the elderly requires a team-based approach. As our population ages, the framework for care delivery will adjust to include communication among a team of professionals including nurses, physician assistants, pharmacists, and behavioral therapists.

One of Thach’s areas of interest is preparing doctors for a team-based approach to care delivery for aging patients. She works for the Center for Healthy Aging, a program of the Mountain Area Health Education Center (MAHEC) in Asheville, North Carolina.

Thach and her colleagues hosted focus groups with primary care physicians in the region about the joys and challenges of working with the elderly. There was a constant theme—doctors need more time with elderly patients.

[box type=”bio”] Care for the elderly requires a team-based approach.[/box]

If an elderly patient visits the doctor because their shoulder hurts, then the doctor will address the shoulder, and may not have time to address the other needs of the patients. And elderly patients tend to have many health complications.

As we age, our illnesses tend to become more chronic and complex. Most of us will need more medication. “The average older adult is on eight medications,” said Thach. It takes time to help a patient manage their medications. To free up time for primary care doctors, Thach, along with her Bernstein Fellowship mentor Dr. Suzanne Landis and colleagues implemented a system of team-based care to increase the number of older adult patients receiving Medicare Annual Wellness Visits, an annual preventative care checkup for older adults. Nationwide, only 14 percent of older adults get this service, but MAHEC’s team has been able to reach 45 percent of older adult patients. They have accomplished this by having a clinical pharmacist or a licensed practical nurse provide the visits and calling patients to invite them in for the visit. “Medicine is moving from reactive to proactive scheduling to enhance patient care,” said Thach.

These yearly wellness visits address preventive services, screening and vaccinations for the elderly, so that the primary care doctor can focus on acute and chronic needs, like a hurt shoulder.
“Doctors can focus on patients’ priorities, knowing prevention issues are being addressed by their colleagues,” said. Thach The Center for Health Aging also encourages older adult patients to think about and document their end-of-life preferences. “Most people don’t want to be on chemotherapy at the end of their life, and they want to die at home and not in a hospital,” said Thach. “And it’s helpful for families to know their loved one’s wishes, so it’s not all on them when the time comes.”

Thach recently graduated from the Foundation’s Jim Bernstein Community Health Leadership Fellowship, a program that engages emerging health leaders and encourages their work with funding and development training. The Foundation is proud to support innovative leaders like Thach, who champion new ideas and assist communities in cultivating better health outcomes.

The Benefits of Integrated Care for the Elderly: Thoughts from Dr. Neftali Serrano