Journal of Gerontological Nursing

For Nursing Homes: A Linkage System to Mental Health Centers

Janet Pavkov, RN, MA; Joseph Walsh, ACSW

Abstract

The administrative problems that may develop among interacting social service agencies are commonly known to most workers in these systems. In the past two decades, many types of service delivery systems have developed, largely independently of each other, creating problems in attempts to coordinate them. For example, public health services, mental health centers, psychiatric hospitals, and nursing homes all have distinct service components but-Wty, in fact, overlap in service delivery. There often is confusion among staff members of these agencies regarding the roles of the other agencies and how they best might interact to prevent duplication of services or to prevent service gaps.

In short, there is a widely-recognized need today for social agencies to work toward functional coordination. Many states are quite active in addressing this organizational problem on state, county, and city levels. Despite this activity, it also is clear that social service components on lower organizational levels face their own challenges in clarifying their roles in relation to those of other agencies in their respective communities.

This paper describes one example of a linkage system that was developed between a geriatric out-patient service of a mental health center and three nursing homes. The authors, employed by the Columbus Area Community Mental Health Center, recently have written a three-page description of their service linkage procedure, which has been distributed to the nursing homes that use the center's geriatric mental health services. This process of delineating appropriate goals, objectives, and methods may be of interest to Other social service workers who face a similar problem oi service coordination with similar agencies. The processes discussed here have helped the nursing home and nursing service administrators to understand the roles of the geriatric services staff and have resulted in a more appropriate use of the services by the homes.

As part of a comprehensive community mental health center, the staff members of the Older Adult Service Unit, known as the Geriatric Evaluation and Treatment Team (GET), have the responsibility for providing mental health services to persons aged 60 years and older in the catchment area. The three-member team is comprised of a nurse and two social workers, all with master's degrees and theoretical and clinical practice in gerontology. Services provided include counseling, crisis intervention, and community consultations and referrals.

The GET team members make a special effort to maintain close contact with the administrative staff of the three nursing homes in the catchment area. Each home makes referrals to the program for their residents who have a past history of psychiatric disorders or hospitalizations, or who exhibit new evidence of emotional illness. When a referral is made, a worker travels to the site within five working days to make an assessment and outline recommendations for a treatment plan. Ongoing counseling in the nursing home generally is the preferred treatment modality; however, residents occasionally are transported to the center for a medication or psychiatric evaluation by a staff psychiatrist.

The process mentioned earlier in this article has been done rather informally in the past, however, with no set policies being followed by either facility. The lack of clear policy has caused several common problems, including inadequate communication of client information between the agencies, lack of clarity about the role of the mental health workers, and occasional inappropriate referrals for mental health services. The GET staff decided that a clarification of policies and procedures was necessary to provide optimal services to the nursing home residents more efficiently.

The Purpose

The initial step in the linkage procedure was to write down the purposes of the proposed exercise so that the GET team and the…

The administrative problems that may develop among interacting social service agencies are commonly known to most workers in these systems. In the past two decades, many types of service delivery systems have developed, largely independently of each other, creating problems in attempts to coordinate them. For example, public health services, mental health centers, psychiatric hospitals, and nursing homes all have distinct service components but-Wty, in fact, overlap in service delivery. There often is confusion among staff members of these agencies regarding the roles of the other agencies and how they best might interact to prevent duplication of services or to prevent service gaps.

In short, there is a widely-recognized need today for social agencies to work toward functional coordination. Many states are quite active in addressing this organizational problem on state, county, and city levels. Despite this activity, it also is clear that social service components on lower organizational levels face their own challenges in clarifying their roles in relation to those of other agencies in their respective communities.

This paper describes one example of a linkage system that was developed between a geriatric out-patient service of a mental health center and three nursing homes. The authors, employed by the Columbus Area Community Mental Health Center, recently have written a three-page description of their service linkage procedure, which has been distributed to the nursing homes that use the center's geriatric mental health services. This process of delineating appropriate goals, objectives, and methods may be of interest to Other social service workers who face a similar problem oi service coordination with similar agencies. The processes discussed here have helped the nursing home and nursing service administrators to understand the roles of the geriatric services staff and have resulted in a more appropriate use of the services by the homes.

As part of a comprehensive community mental health center, the staff members of the Older Adult Service Unit, known as the Geriatric Evaluation and Treatment Team (GET), have the responsibility for providing mental health services to persons aged 60 years and older in the catchment area. The three-member team is comprised of a nurse and two social workers, all with master's degrees and theoretical and clinical practice in gerontology. Services provided include counseling, crisis intervention, and community consultations and referrals.

The GET team members make a special effort to maintain close contact with the administrative staff of the three nursing homes in the catchment area. Each home makes referrals to the program for their residents who have a past history of psychiatric disorders or hospitalizations, or who exhibit new evidence of emotional illness. When a referral is made, a worker travels to the site within five working days to make an assessment and outline recommendations for a treatment plan. Ongoing counseling in the nursing home generally is the preferred treatment modality; however, residents occasionally are transported to the center for a medication or psychiatric evaluation by a staff psychiatrist.

The process mentioned earlier in this article has been done rather informally in the past, however, with no set policies being followed by either facility. The lack of clear policy has caused several common problems, including inadequate communication of client information between the agencies, lack of clarity about the role of the mental health workers, and occasional inappropriate referrals for mental health services. The GET staff decided that a clarification of policies and procedures was necessary to provide optimal services to the nursing home residents more efficiently.

The Purpose

The initial step in the linkage procedure was to write down the purposes of the proposed exercise so that the GET team and the nursing staff would understand why the written linkage procedure was being initiated at this time. Also, staff felt that this step would aid in a later prioritizing of goals and objectives. Although the five listed purposes seemed elementary, the GET staff felt that this initial process added direction to the linkage task more substantially than a simple assumption that a policy system was necessary. The purposes were formulated as follows:

1) To increase the center staff's awareness of the nursing homes, their needs, services, and interdisciplinary staff members.

2) To provide information about center services to the nursing home staff.

3) To explore present utilization of center services by each institution and identify additional areas for center service provision.

4) To provide the nursing home with a definite procedure for appropriately accessing mental health services within the catchment area.

5) To validate the establishment of contracts with nursing homes for direct client care or consultation services provided by the center.

The GET staff felt thé first listed purpose could be fulfilled adequately by meeting with nursing homes and/or nursing service administrators and discussing the problems and potential of a linkage procedure - an activity that was continuous as the linkage plan was developed. The second and third purposes were addressed through the task of listing the types of nursing home residents whose problems could be handled by the Older Adult Service Unit members.

Table

FIGURE 1COLUMBUS AREA COMMUNITY MENTAL HEALTH CENTER TREATMENT PLAN WORKSHEET

FIGURE 1

COLUMBUS AREA COMMUNITY MENTAL HEALTH CENTER TREATMENT PLAN WORKSHEET

As noted earlier, nursing homes had, at times, made referrals for residents whose needs were out of the realm of mental health service provision. In this activity, GET staff researched its "log book," in which all referrals made to the department from all sources are included. Those types that came from the nursing home staff were listed. From that list, six types of clients most frequently referred for mental health services in nursing homes who were seen as appropriate referrals for mental health intervention were drawn. These six types were included on the final draft of the linkage form to be used as a guideline for the nursing homes for future referrals. The final listing read as follows:

1) New residents with a prior history of emotional illness or who have been admitted to the home directly from a psychiatric facility.

2) Residents experiencing relocation trauma.

3) Residents reacting with nonacceptance of signs of physical deterioration as evidenced by depression, anxiety, or withdrawal from others.

4) Residents who have become management or behavioral problems.

5) Residents, their families, and/or staff who show a need for consultation or counseling on dying and death issues.

6) Residents having adverse, synergistic, or atypical reactions to medication prescribed.

The above types of referrals potentially can create mental health problems and could benefit from assessment and/or intervention by GET staff.

Goals and Objectives

When the Geriatric Evaluation and Treatment Team began operating as an abstract component of the mental health center nearly four years ago, goals and objectives were outlined to lend direction to the workings of the department. To assist in clarifying the roles of the agency's geriatric component to the nursing home, the GET staff decided to include these in the linkage form. These were amended somewhat so they would address the particular circumstances of the nursing home setting. The general statement of objective was revised to read, "to preserve the dignity and enhance the individuality of the elderly clients by A) increasing the level of functioning of the client who is a nursing home resident and B) enabling the client to function as independently as possible and thus obtain or retain personal fulfillment, maintain growth potential, and enjoy life to its fullest in spite of physical impairment."

The objective is quite general but is meant to reinforce the notion that the mental health workers are oriented primarily toward enhancing the clients' functional freedom rather than taking some form of control over their lives. The seven goals, however, are more specific and outline the types of services that the GET staff members are trained to utilize. As listed below, they inform nursing home staff of the range of interventions that potentially will be initiated in the homes. Drawn again from the GET team goals, the specific goals include:

1) To assess the mental status, determine the needs, and write a plan of care for the nursing home residents referred to the GET team.

2) To raise the level of, and prevent deterioration of, the functioning of the nursing home residents through individual counseling so that they may participate more actively in their community.

3) To act as an advocate and facilitator in giving support to clients by referring them to other community service agencies for assistance in meeting their overall needs more effectively.

4) To provide support and direction to family members in the placement of their senior members into nursing homes.

5) To provide consultation, education, training, and support to nursing home staff in increasing their awareness of residents' mental health needs.

6) To provide service to family members throughout the client's placement and facilitate more family interactions and visitations with the client.

7) To insure the availability of a significant other person (i.e., volunteer, neighbor, friend) so that the client is able to maintain the larger community if no significant family members are available.

The objectives and goals of mental health intervention summarize what the GET feels it is qualified to offer to the nursing home residents above and beyond that which the nursing home staff members are able to provide. The identification and specification of services provided to nursing homes are included as part of the linkage form that serves to insure appropriateness of the referrals made to the center's staff and allows them to utilize fully their expertise in working with the elderly who have mental health problems.

Methods

The remainder of information included in the nursing home linkage policy form was designed to explain the specific methods by which the clients would be treated with regard to the established objectives and goals. It was crucial to be specific about methods. Delineated in them are some responsibilities that must be agreed upon and carried out by the nursing home staff members and the GET team members. They denote that, in some instances, a pooling of resources by both agencies will be necessary. An introductory note on service delivery methods reads:

Staff members from the Geriatric Evaluation and Treatment Team are responsible for visiting each of the nursing homes in the catchment area and for gathering data about the needs of each home. Information about mental health services and written procedures for accessing these services are discussed and given to nursing home staff. The Geriatric Evaluation and Treatment Team of the mental health center is the pruhary contact unit for nursing homes in referring clients for assessment and determination of appropriate mental health services. Ongoing therapy or consultation to the nursing home is provided for appropriate clients; this may be done by 'he Older Adult staff or referred to other units within the center. (It has been our experience that services are provided solely by the GET team.)

Next, specific information about the proper referral procedure was detailed. This policy was particularly important to relay to the homes because, in the past, referrals were made from a variety of members of the interdisciplinary staff. Frequent problems developed concerning the provision of feedback to appropriate nursing home staff members as well as serving proper authorization to make site visits for assessment of the residents. The formalization of the referral procedure, devised by the GET staff, had the immediate positive result of insuring the flow of information on both sides through proper channels. The established referral procedure states:

1) Geriatric Outpatient Service coordinator receives the referral via phone call or collaboration with the appropriate or designated nursing home staff member.

2) A request for consultation sheet must be completed by the nursing home staff member.

3) An assessment of the resident's behavior and mental status will be completed,

4) Feedback to the referrer will be given verbally and the completed consultation report will be returned to the nursing home with recommendations íor a plan of care.

Table

FIGURE 2MENTAL HEALTH PROFILE

FIGURE 2

MENTAL HEALTH PROFILE

FIGURE 3MENTAL HEALTH MONTHLY TREATMENT PLAN REVISION

FIGURE 3

MENTAL HEALTH MONTHLY TREATMENT PLAN REVISION

5) A xerox copy of the client's treatment plan formulated by the evaluator will be sent to the nursing home. (See Figure I)

6) A mental health profile sheet also will be sent to the nursing home to be placed on the resident's chart and be utilized each time the mental health consultant visits the client. (See Figure 2)

7) A monthly treatment plan revision form will be placed on the resident's chart and completed each month. (See Figure 3)

As noted in the beginning of this paper, it has been customary for residents to come to the mental health center for medication and/or psychiatric evaluations by a staff psychiatrist when deemed necessary by the GET worker. Such an activity removes the resident for a short time from the nursing home environment, so it was essential to outline a standard procedure for this process for the benefit of the nursing home staff. The policy, which completes the information included in the linkage form, was detailed as follows:

1) The nursing home is responsible for transporting the client to the agency.

2) An initial health assessment and intake summary will be completed by the agency worker when the worker visits the nursing home prior to the client's visit to the agency. When no mental health worker has seen the client in the nursing home, and the client is brought to the agency on an unscheduled emergency basis, a continuity of care form (See Figure 4) should accompany the client to the agency and the intake summary will then be completed by a worker at the mental health center. In the absence of a GET staff member at the center, the intake summary will be completed by a worker from another service component such as Emergency Services or Intake Service.

3) The nursing home will send a medication order sheet and/or consultation sheet with the client upon which the agency physician will write medication orders, changes, or recommendations.

4) The agency worker will xerox a copy of the physician's entry on the medication order sheet or consultation sheet and place it'in the client's agency chart. The original will be returned to the nursing home in a sealed envelope so it can be added to the client's chart at the nursing home.

5) The GET staff member will provide the mental health services indicated following the psychiatrist's evaluation and collaboration with the GET staff member regarding the nursing home resident's need.

SUMMARY

This discussion of methods concludes the scope of the nursing home linkage procedure. The three-page exposition provided for reference use by nursing home staff and administrators is intended to outline the specific roles of the Geriatric Evaluation and Treatment Team of the mental health agency in the nursing home setting. The underlying assumption in the development of the linkage system is that confusion or responsibility is a high risk when social service agencies/interact. The GET staff members feel that this potential problem can be precluded by a simple formal documentation of roles.

Much of what is included in this article.is merely the written documentation of the Geriatric Evaluation and Treatment Team's policies already in practice but, in many areas, particularly objectives and methods, there were misunderstandings about service delivery techniques. As a result of this exercise, nursing home and nursing service administrators who have received the information form report greater confidence in the interactions of our staff with the residents and staff members. The Geriatric Evaluation and Treatment Team is convinced that taking the time to produce such a document is beneficial to building positive interagency staff relationships and facilitating delivery of the best possible mental health services for the involved older adults who are nursing home residents

FIGURE 4REFERRAL FOR CONTINUITY OF PATIENT CARE FROM HOSPITAL-SKILLED NURSING FACILITY-HOME HEALTH SERVICE

FIGURE 4

REFERRAL FOR CONTINUITY OF PATIENT CARE FROM HOSPITAL-SKILLED NURSING FACILITY-HOME HEALTH SERVICE

FIGURE 4REFERRAL FOR CONTINUITY OF PATIENT CARE FROM HOSPITAL-SKILLED NURSING FACILITY-HOME HEALTH SERVICE

FIGURE 4

REFERRAL FOR CONTINUITY OF PATIENT CARE FROM HOSPITAL-SKILLED NURSING FACILITY-HOME HEALTH SERVICE

FIGURE 1

COLUMBUS AREA COMMUNITY MENTAL HEALTH CENTER TREATMENT PLAN WORKSHEET

FIGURE 2

MENTAL HEALTH PROFILE

10.3928/0098-9134-19820701-06

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