Taking Charge of Your Health

[music] [music] [Narrator]: Retirement is supposed to
mark the beginning of our golden years, a chance to pursue new
interests and spend time with family. But for a growing number of
seniors the reality is bleaker. Struggles with maintaining
health, loss of family and work roles, and coping with the deaths
of peers and loved ones has led to increasing levels of depression. With the number of seniors increasing
every year, this rise in depression among older adults presents a growing
challenge for our health care system. [Ina]: I find with even, even senior
friends, the loneliness sometimes gets to them. Because we are used to
being very active in our lifetimes and then all of a sudden, it’s not there. [Cynthia Zubritsky]: There are very, very high
rates of depression in older adults, 20-25%. It’s being untreated. [Narrator]: This rise in depression among
older adults has led to decreasing levels of functioning, reduced quality of
life, and worsening health conditions. [music] [Jerry Johnson]: Depression and
anxiety disorders – what we sometimes call the generalized anxiety disorder – are two of the most important
problems that primary care physicians face. [Joseph Lurio]: From my standpoint, especially
with my elderly patients, I talk about… the fact of depression as being
something that complicates medical problems. [Narrator]: In fact, health care costs for
seniors with depression are about 50% higher than for those without depression. One challenge is that older adults are not
likely to seek treatment for depression. [Cynthia Zubritsky]: I think the real
issue for older consumers is a stigma issue. A lot of people grew up, that are in
this cohort, grew up thinking that if you were depressed it
was sort of your fault. [Connie]: Most people who have
depression are afraid to admit it because they think someone’s
going to think they’re crazy. [Narrator]: Fear of stigma among
older adults is not the only inhibitor of successful diagnosis and treatment –
providers often overlook signs of depression or are uncomfortable asking
about mental health issues. [Virna Little]: There was this big
misconception that because these folks were maybe isolated, because they weren’t feeling
well sometimes or they had these chronic illnesses or just by virtue of being seniors
– of course they were going to be depressed. [Jerry Johnson]: Sometimes there’s a tendency
in medicine to focus on one part of the human. To focus on the physical
part and not the mental part. But, in fact, particularly in
older adults we see both so commonly, occurring at the same time that in order to provide high quality
care, we really do have to be considerate of ways of treating the mental
and the physical concurrently. [Narrator]: Researchers around the
country are finding ways to do it. The Substance Abuse and
Mental Health Administration’s Center for Mental Health Services has
identified evidence-based practices (or EBPs) in use around the country that are succeeding. Evidence-based practices
include psychotherapy interventions and the use of antidepressant medications. These can be used individually or
in conjunction to improve symptoms. They can also be used within
models of outreach services and collaborative and
integrated mental and physical care. [Joseph Lurio]: One of the issues
was how to identify patients early on and how to provide the best kind of treatment
given time constraints in primary care. [music] [Nurse]: Brown, Mary. [Narrator]: One model of care for diagnosing
and treating depression in older patients is IMPACT, which stands for Improving
Mood, Promoting Access to Collaborative Care. The Institute for Family Health
partnered with the developers of IMPACT to implement the model in New York City. [Doctor Gayle]: Yes, it’s Dr. Gayle. [Daniel Blumkin]: The mission of
the Institute for Family Health is to deliver private practice level quality primary care to an indigent population. [Virna Little]: IMPACT is a
collaborative model of care that seeks to identify and treat depression in older adults in a primary care setting. [music] [Clinic staff]: Good
afternoon. How can I help you? [Patient]: Yes, good
afternoon. I’m here to see Dr. Gail [Clinic staff]: Okay…
have a seat here, please. Okay, can I just have
your date of birth, please? [Wendy Barr]: The IMPACT model helps
promote a holistic view of patient care by integrating depression screening into chronic disease management. [Virna Little]: It is the first time
that there was a really publicized research-based model that supported
something, which is near and dear to me, which is the integration of primary
care and mental health services. [Nurse]: Today you’re here for your
physical, and part of what we do here is we ask all patients coming
in for a physical to fill out, or to answer questions about depression. [Daniel Blumkin]: Project IMPACT attracted
me and our organization because it enabled us to provide services to our geriatric
population that were not being addressed
previously. [Narrator]: The two key features of
the IMPACT model are screening for and tracking depression in a primary care
setting with a patient health questionnaire, and onsite collaborative care
with the patient’s physician. [Virna Little]: When a patient comes in, they are checked in at the front desk, they are then transferred to nursing for an intake or a triage process. And during that triage process
we’ve actually incorporated the Patient Health Questionnaire-2 (PHQ-2). 0 [Nurse]: Okay, I have a few
personal questions to ask you. This is completely confidential and
it’s for the use of the doctors only. Okay. [Nurse]: Over the last two weeks have you
been bothered by any of the following problems: little interest or pleasure in doing things… [Eric Gayle]: And if they
score one question positive, it triggers us doing the PHQ-9. [Nurse]: This is a form called PHQ-9 and I
need you to read this and fill this out. [Eric Gayle]: PHQ-9 is a patient health
questionnaire that has nine questions that are scored from 0 to 3. And
the patients themselves answer it. So you’re not diagnosing the
patient; they’re diagnosing themselves as to whether or not they
have true depression or not. And often times they’re
scoring with moderate depression, they are scoring 10 and above. And those are the patients that
usually you’re seeing much more frequently than you would expect to. These are the patients that are having more
problems with their co-morbid conditions, their diabetes, their high blood
pressure and so on and so forth. And once you start treating those patients
with scores of 10 and above in the PHQ-9, you start to see the improvements
in the rest of their wellbeing. [Doctor]: Well, my nurse told me that she
gave you a patient health questionnaire for depression, so I’m just going to spend
a couple of seconds and score to see how far along the curve you are. [Regina Epperhart]: We offer them
problem-solving therapy, we offer them meetings with our psychiatrist to follow up
on any kind of psychopharmacology, and we also offer them just touching base once a month by phone because some people
who might not want these other interventions we want to, you know, keep on our
radar and we want to make sure that we’re monitoring them on a monthly basis. [Doctor]: I’m going to talk to you a
little bit about what the course of management is going to be. I’m going to
give you the medication today and I’m going to ask that you
follow up with me in about two weeks. Anytime during those two weeks if
you’re having trouble with the medication, you can call me. I’m going to get our psychosocial
services colleague to sit with you. She’s going to be talking to you about the
course of management she will have with you. And I expect to see you
again in two weeks and… [Joseph Lurio]: Because we
have the tools of the PHQ-9, I’m able to give a score, share that with the patient and then we can say, “Well, you know, we tried this last time but even though
you say you’re feeling better, it doesn’t really seem like
your score has improved. Maybe we really should
have you talk to somebody.” [Narrator]: The physician can
collaborate with the depression care manager and psychiatrists who are located onsite. [Regina Epperhart]: In the Project
IMPACT model the depression care managers can be either nurses or
they could be social workers. [Care manager]: So out of all
those things that you mentioned, what is one that you would like to work on? [Patient]: I’d like to go
back to the way I used to be, where I used to look forward
to getting up in the morning, getting dressed and going out
there, being around people. I don’t feel that way anymore. I feel
like… another day, I’ve gotta get dressed. Where am I going? I don’t
wanna go out. I don’t like that. I want… [Care manager]: That energy. That energy… that I had. [Regina Epperhart]: We want to make sure first
that they’re not in any danger to themselves and then we, you know, set up a protocol
where we offer them problem-solving therapy. [Care manager]: Well, the goal that we can
work on is to get you back to where you were three weeks ago. That will be great, right? [Patient]: Yes. [Care manager]: And to get you from
being depressed to feeling like your normal self again. And those baby steps
are called “self-management goals.” So they’re goals that you
establish for yourself. [Regina Epperhart]: And it gives the
patient the opportunity to come up with what some of their problems
are and how they even want to, you know, get through some of
the barriers that they’re facing. The patient has a big say in, okay, so
how do we get from here to here to here to really, you know, slowly start to decrease these depressive symptoms. And it all – it comes from them. [Katarzyna Haberko ]: It’s very
difficult for older adults to seek treatment, to seek counseling on their own. And to – the primary care office, it’s a very good entry point for the patients to be to be identified as depressed if they are, which usually older
adults would go undiagnosed. [Care manager]: …we help to
reduce their depression… [Joseph Lurio]: What I found with
this particular model is that it did identify patients before sometimes I was
aware that they were suffering from depression. [Suzanne]: He told me the
results of his interview. The… I said you saw all that? He said yes. I said, well, I better think about it
cause I wasn’t aware that I had a problem. But he thought I did and
he probably was right. And I enjoyed talking about my daily
life which has been changed so very much. And it was a wonderful experience. [Regina Epperhart]: Most of these patients
have functioned well for most of their life, and they just really need some
extra support now in how to get, you know, from the problem to feeling better. [Care manager]: I met with Ms. Brown. [Doctor]: Yeah. Thanks for seeing
her. I wanna see her in two weeks. How did your interaction go with
her cause I’m concerned about? [Care manager]: It went well
and she’s willing to come in… [Eric Gayle]: Now part of
the challenge for me is finding the time to spend to manage this patient. And if I can reach across the hall and get my social service
specialist on board to say, “Listen, I don’t have time right
this minute. Can you spend some time with this particular
patient while I go do that? By the time you’re finished
with her, I can come back and perhaps discuss other
management of the patient, including medications and so forth,”
it makes the flow so much easier. You’re not having the patient running
around to different areas trying to find the services that you can
provide right on the premises. [Regina Epperhart]: I would say the number
one thing is getting the doctors on board and the doctors to buy into the program
and recognize how it’s going to both help their patients and,
you know, help the practice. [Joseph Lurio]: Having the
social worker integrated into the whole process provided a strong support for the primary
care providers and also made it easier for them to intervene because
they didn’t feel like they were carrying this whole burden on their own. [Daniel Blumkin]: The use of the screening
tools for Project IMPACT has enabled us to demonstrate the
improvement in the PHQ-9 scores for the patients in the project. [Eric Gayle]: We like to measure things,
and you can measure the PHQ-9 score, you can measure the diabetes evaluation and the
hemoglobin A1c, whether or not they’re getting better. You can see that the
blood pressure is getting better. All of these things make it more
satisfying in treating our patients. [Katarzyna Haberko ]: This program is
very easy to implement when it’s – once it’s rolling. It’s very simple to screen
patients and provide them with needed medication or counseling and
support to improve their lifestyle. [Joseph DiLullo]: All that
integration of the medical information and the psychiatric can be very nicely utilized to form as accurate a picture of
the patient’s diagnosis as possible. [Linda Tillman]: So it really
was Depression 101 to discuss what are the signs of depression, what is helpful for a patient to
reduce their depression in order to help their medical condition so the
patient is not coming through the door every two weeks for another problem. [Katarzyna Haberko ]: If we can make it easier
for them to access services that they need, I think that’s very exciting. [Narrator]: Integrated mental and physical
health care services have been proven to work to work well in reaching many older adults. But what about older adults who may be falling
through the cracks of primary health care? [music] Psychogeriatric Assessment and
Treatment in City Housing (PATCH) is a mobile treatment program developed at
the Johns Hopkins Hospital in Baltimore. It targets older
individuals with mental illness whose needs are not being met by
the traditional healthcare system. It combines the mobile treatment
model and the Spokane gatekeeper model and adds elements that address
the medical and social challenges that are so prevalent in this group. [Peter Rabins]: People who
lived in public housing sites had three times the rates of depression and several other psychiatric disorders as elderly people living in the
community. So we knew we had a very high risk, high prevalence population in public housing. [Beatrice Robbins]: We’re serving the
most vulnerable elderly population. It’s the impoverished elderly with mental illness who are socially isolated for the most part and who
won’t access traditional care. [Nurse]: Hello, good to see you again… [Mary Minor]: The persons that
we work with for the most part are not going to seek traditional mental health services. [Narrator]: With social, physical, and
psychiatric issues compounding each other, the needs of these older
adults often go unaddressed. [Peter Rabins]: And you come to realize that
the best way to improve the quality of life for seriously ill older individuals is
to simultaneously try to address their social, medical, and mental health needs. [Doctor]: Now are you tired during the day? [Resident]: I get tired. [Doctor]: Do you fall asleep – take catnaps? [Resident]: Yeah I do. [Doctor]: Sometimes, I know it’s hard but
if you can keep yourself from doing that, you’ll probably sleep better at night. [Resident]: That’s right. [Peter Rabins]: We developed the program
about 20 years ago after actually failing, to reach this population
through more traditional programs. And then the idea of providing both mobile
treatment, but also using what was called the gatekeeper model in which people in
the community were used to identify people who might need mental health
services, we combined those two together and launched the program back in 1986. [Narrator]: The “gatekeepers” for the
PATCH program are Housing Authority staff who have been trained to recognize potential
signs of mental illness in older residents. [Rebecca Rye]: The nurses
will initially provide educational programs for staff that work in the Housing Authority
buildings and this would include managers, counselors, security
staff, anybody that may come in contact with a resident that is ill
and in need of services. [Maintenance staff]: How you doing Ms.
Rachel? How’s the tub-shower we gave you? [Resident]: Huh? [Maintenance worker]: The shower
tub we gave you, is that alright? [Resident]: Oh, it’s ok. [Maintenance staff]: You like it? [Gail Danik]: The
maintenance staff is also involved. They may be the first contact in some cases. [Maintenance staff]: I’m glad you can use it. [Resident]: Yeah. [Maintenance staff]: Alright. Take care. [Resident]: Thank you very much. [Maintenance staff]: Alright. [Fadeelah Keyes]: The PATCH
program has been very, very helpful with identifying as well as following up on things that we identify to help people not be evicted, not be in their
units without taking their meds, not being there without anyone to speak
with as far as making doctor appointments or even eating on a day-to-day basis. [Gail Danik]: Once we’ve recognized, or
think that we’ve recognized a particular situation, then I call PATCH, ask them
to come out, and they will do an intake to verify and then hopefully beginning to support that particular individual. [Narrator]: The PATCH teams include a nurse,
a geriatric psychiatrist, and a case manager who bring services directly
to residents in their homes. Once housing authority staff identify a
resident who may be in need of services, a visit from a PATCH program
nurse is usually the next step. [Peter Rabins]: The reason we’ve chosen at
the beginning to use nurses is because many of these patients turn out to have unmet
medical need as well as unmet psychiatric need. [Mary Minor]: We do a
mini-mental on everyone initially as well as a depression scale and a psychotic type of scale. [Nurse]: Do you know the name of the
program that I’m with? It’s called PATCH. [Resident]: Uh huh. [Nurse]: Yeah, Patch. The
brochure I gave you… [Beatrice Robbins]: We’re asking
demographic information, medical history, psychiatric history, medication list if
it’s possible, then a general listing of, it’s sort of a yes/no listing of all possible
medical diagnosis that the folks may have. [Nurse]: Did you bring this whole
card in when you went to see him? [Resident]: Yeah, I took this to the doctors. [Nurse]: The pink one is called Depakote. [Resident]: Depakote? I didn’t know the name. [Peter Rabins]: The second element then
is to have a trained geriatric clinician make contact with the person,
offer our services, do an assessment. [Nurse]: That’s good. Very good. [Doctor]: So, we’ve got to get – So,
have you been in the nursing home lately? A lot of times? [Resident]: Haven’t been there. [Doctor]: That’s what miss Mary was saying that
you had to go to the nursing home a few times. [Resident]: Well yes,
sometimes I do. It’s a habit. [Doctor]: Habit… yeah I got
a lot of bad habits myself. [Sharon Handel]: The minute you walk in
someone’s house you know more than you’ll ever learn in, you know, following
somebody for years in a clinic. [Doctor]: And then this one…
how’s your reading? Do you read ok? [Beatrice Robbins]: And the psychiatrist
does a standard psychiatric diagnostic visit and then together with the
client develops a treatment plan. And that’s when we decide
whether we really want to include the services of the case manager. [Nurse]: You’ve done very well, actually. [Doctor]: Alright Mr.
Williams, it was good meeting you. [Resident]: Same here, same
here. Nice talking to you. [Nurse]: See you later. [Doctor]: Bye. [Narrator]: In addition to
addressing the medical and psychiatric needs of their patients, the PATCH team
can include a case manager to address social and financial challenges that
may exacerbate their other needs. [Case manager]: Her certification
interview with mobility is scheduled for the 24th of March. So that’s
already been set up as well so… [Narrator]: Buck Weeks is a PATCH case
manager who works with the treatment team to address these challenges. [Case manager]: You get social
security each month… for your money? [Resident]: Mmm hmm… [Beatrice Robbins]: So he’ll come in and
help with entitlements, transportation, making arrangements for meals, I mean the
list is endless for what he does. [Case Manager]: Do you
remember discussing that? [Buck Weeks]: What I help do is work
as part of the team with the nurses and the psychiatrist coordinating
services for the people we serve, helping take care of medical appointments,
monitoring medical appointments, helping solve any problems with benefits, entitlements,
and resolve any conflicts that occur. [Case manager]: …And this is just so you
know how they came up with that number. [Resident]: Ok, now. [Buck Weeks]: Sometimes there’s not a
whole lot of communication between different doctors, different
services, and the family. And when people are getting older they’re having trouble remembering who they spoke to, who told them what. They don’t always accurately relay
the information to other doctors, other family members. So by being in touch with every treatment
team member and being able to be like the hub, it gives me a chance to make sure
that all the services are complete. [Narrator]: Not all residents are immediately
receptive to services – even services that are brought directly to their homes.
The nurses and case managers have found that developing a relationship with the client
and being able to help them with even one of their problems can help make that
client more interested in other services. [Rebecca Rye]: They will let a nurse in the
door. Many people are used to home health nurses coming out or public health nurses
coming out and if you somehow find a way to help them with something that they
think is necessary which usually is not their medical illness or
their psychiatric illness. Then you have a way in to get the
rest of their needs addressed. So sometimes it takes a
while to establish a rapport. Do you know where your wife is buried? [Resident]: Sure don’t. If they could help you find out
where your wife is buried… [Resident]: Yeah. …and maybe having your niece or
nephew go find where she is… [Resident]: I would like to know… I think that’s a good idea. [Mary Minor]: Time spent listening, hearing
what someone’s saying, knowing them over time, so that you actually can anticipate or
even name what others just are not seeing. I think that’s a key piece to
persons beginning to stabilize. Because often times they don’t
feel that they’ve been heard. [Rebecca Rye]: If we can initially get medical
problems or their social problems treated then they’re more receptive to
getting the psychiatric problems treated. [Narrator]: The goal of PATCH is to stabilize
older adults through in-home treatment and then transition them to traditional
mental health services after 6 months. [Theresa Neal]: Once PATCH becomes involved
with a resident, we see them coming out more, we see them coming out more, we see them interacting more, in the lobby area with our staff. [Wilber]: When they come in I’m cheerful,
I’m happy. I know they going to be there. Especially, I know she be there every Tuesday. [Peter Rabins]: And we found that we
could decrease rates of depression and depressive symptoms by about 20%
in the buildings we intervened in, whereas the buildings that we did not intervene in actually depression rates went up over two years. [Gail Danik]: Without the PATCH
Program, I could see individuals being placed in nursing homes. I can see individuals becoming homeless because of dementia. I can see individuals simply shutting down. [Peter Rabins]: As a
nation, as a healthcare system, here’s a group of people we
can make a huge difference with by relatively simple but focused programs and I’m proud of the state and
the city that for almost 20 years they’ve been willing to
support this from the state level. [music] [Marie Ickrath]: People can
be treated. People can have full and good lives… but not if they’re not
treated, if they’re not identified. [Peter Rabins]: We hear this
all the time, that we make, that we’ve made a difference in people’s lives and we’ve improved their quality of
life and that helps us keep going. [Narrator]: Depression does
not have to be a part of aging. The IMPACT and PATCH models are just
two examples of the many practices that are being put to use to
successfully identify and treat depression. If you would like more
information about evidence-based practices for treatment of depression in older adults, go to or call 1-877-SAMHSA-7. [Trudy]: I think people should
realize that because you’re older it doesn’t mean you have to be depressed. [music]

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