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Finally! A seamless geriatric outreach program that works

August 1, 2008
by Catherine Phillips, MS, CS, APRN-BC and Kathleen T. McCoy, DNSc, APRN-BC
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One hospital organization shares its vision of achieving community service through its geriatric outreach program

The U.S. Census Bureau reports that people 85 years of age and older encompass the most rapidly expanding segment of the U.S. population.1 With the rising age of geriatric populations, general life expectancy will continue to ascend along with healthcare needs and services. In 2005, there were 12,480 skilled nursing facility (SNF) residents in Nebraska.2 For the purposes of this article, all residents will be classified as long-term care (LTC) regardless of setting.

A decade ago, through a collaborative multidisciplinary and local multi-agency effort, there was an agreed need to establish geriatric outreach (GO) services encompassing south central Nebraska, the area served by Mary Lanning Memorial Hospital (MLMH), located in Hastings, Nebraska. Goals included management of psychotropic agents to foster behavioral stability, provision of ongoing behavioral resources for LTC staff, residents, and families, and reduction of inpatient hospitalizations. The Behavioral Services Unit (BSU) of MLMH, established in 1986, serves as the optional inpatient agency for decompensated residents requiring psychiatric treatment. Inherent in the symbiotic relationship between the GO program and its contracted facilities was that BSU would provide inpatient services as needed, and facilities would reserve placement for residents ensuring their return to LTC after discharge from inpatient treatment.

Initially, one SNF invited the BSU staff to consult on the specialized needs of its geriatric behavioral residents. GO began with on-site multidisciplinary team visits of three to four professionals. Ultimately, the program was streamlined to using Advance Practice Registered Nurses (APRNs) for all direct resident care. Today, approximately 500 residents in 22 facilities receive GO services.

The APRN role is uniquely suited to meet the overall needs of the GO program. Psychiatric diagnostic evaluations and ongoing psychotropic medication management are the hallmark services provided. The APRN is the gatekeeper in referring to and using the vast array of complementary BSU support services and resources. Currently, a pool of six APRNs with American Nurses Credentialing Center certification as Clinical Specialists in Adult Psychiatric and Mental Health Nursing and/or Adult/Family Psychiatric and Mental Health Nursing offer professional services.

Integrated services provided

The BSU at MLMH is currently certified for 26 beds, with availability determined by census and acuity. On average, the inpatient geriatric population comprises 15-20% of the beds where this more delicate population is protected, nurtured, and stabilized. In 2006, the average length of stay for Alzheimer's dementia patients was 11.4 days.3

The BSU staff encompasses the entire spectrum of behavioral health professions including nursing, recreational and occupational therapy, social work, psychology, and psychiatry. Referrals come from a plethora of sources, including the contracted GO facilities, as well as local and regional providers. Designed for acute presentations, inpatient stays provide stabilization with discharge to the next level of intensity needed. The Day Treatment Partial Hospitalization program is available as a direct admission option for less-acute needs, or as a step-down modality following inpatient discharge.

Dovetailing into the BSU continuity of care spectrum are services found at the Lanning Center, the psychiatric outpatient clinic of MLMH. Here, therapies such as the Silver Thread Group for outpatient elders, as well as other group, family, and individual treatment modalities are provided. Medication management and therapy following BSU discharge are available, as well as psychological testing/assessments and in-home emergency community support. The GO program seamlessly links these inpatient and outpatient services. Geriatric Outreach services include:

  • Psychiatric consultation/evaluation

  • Medication management

  • Treatment options for resident/staff implementation strategy recom-mendations

  • Staff development in-services

  • Referral for outpatient individual/group therapies or appropriate evaluations

  • Referral for inpatient treatment, if needed

The program also provides an array of evaluations including:

  • Mental Status Exam

  • Cognitive assessments

  • Behavioral assessment and recommendation strategies

  • Milieu/environment management

  • Psychological or neuropsychological testing

  • Family consultation

  • Behavioral plans of approach4

Now in its 11th year, the GO program continues to evolve. Word-of-mouth and interagency referrals contribute to ongoing requests from regional LTC facilities to be considered as contracted recipients. Specific program benefits identified include reduction of injuries to residents, visitors, and staff; decreased hospitalizations; and increased staff retention. These benefits are commensurate with Evercare's findings that APRN administered care reduces overall costs.5