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

OBRA and regulatory requirements demand vigilant attention, and timely review of psychotropic medications ensures compliance. By maintaining the overall health and well-being of residents for as long as possible, cost and time savings are realized thereby enhancing profit margins. Simultaneously, decreased deficiencies translate to improved ratings and, ultimately, affect admissions. Nursing staff appreciates the ability to actively provide input to the APRN on site. The natural environment of the LTC setting provides a fertile source to observe maladaptive behaviors and interactions crucial to developing behavioral management recommendations. Occasionally, residents cannot tolerate transport to an office setting, and others needing assistance with emergent issues can often be seen more quickly at the facility rather than scheduling an office visit. Administrators, directors of nursing, social workers, and direct care providers have verbalized positive perceptions of GO benefits to facilities and residents alike. One administrator states: “Through the Geriatric Outreach Program we are able to…promote or maintain the resident’s highest…mental, physical, and psychosocial well-being.” Another administrator adds, “We have found the Geriatric Outreach program to be an amazing resource, they have done remarkable things with our patients.”

Current challenges concern placement of individuals with mental illness in LTC settings and those who require nursing home care because of advanced age or medical decline. Diligent direct resident care and coordination of psychiatric services through the GO program provides timely treatment interventions and is available as a 24/7 resource.

Continuity of care is enhanced as the GO practitioners partner not only with facility staff, but also with primary medical providers and LTC pharmacists. Many of these professionals endorse some level of discomfort with the use and monitoring of psychotropic medications. They welcome or actively seek opportunities to consult with the GO APRNs regarding medications, psychiatric diagnoses, and behavioral management. Comprehensive care includes laboratory monitoring parameters in keeping with current best practice guidelines, drug-drug interaction screening, and trial-dose reductions as per regulatory mandates, all with the added benefit of observing residents in their home environment. GO has proven valuable in assisting with the management of behavioral disturbances associated with dementia. Other populations served by GO are the elderly with mood disorders and residents affected by stroke, head injury, or traumatic injuries resulting in mood or behavioral sequelae.

The GO program demonstrates a long-term commitment to the larger regional community by one nonprofit hospital in rural Nebraska to assist in meeting the needs of vulnerable patients, their loved ones, and caregivers. This seamless integration of services is a unique solution to an ever-growing need in long-term care.