Geriatric Psychiatrist Honored for Innovative Care Strategies

“It comes as absolutely no surprise to any older person struggling with depression that their social context—social connectedness or social isolation—is an enormous issue in their lives,” said geriatric psychiatrist Yeates Conwell, M.D., in an interview with Psychiatric News. “And it should come as no surprise to us as clinicians that effective care is going to hinge on our ability to address those social issues in an overall treatment plan.”

Courtesy Yeates Conwell, M.D

No mystery though it may be to aging patients, the value of social connectedness in the management and treatment of depression in the elderly is a concept that clinicians and health systems have been slower to grasp. And that’s why Conwell, as a representative of the University of Rochester Medical Center (URMC), was chosen in December 2011 to be one of 73 “innovators” (and the only psychiatrist) in the Innovation Advisors Program (IAP) sponsored by the federal Centers for Medicare and Medicaid Innovation. (For a description of the IAP, see “Program Nurtures Health Care Innovation” below.)

As director of a partnership between URMC and a community services provider network called the Senior Health and Research (SHARE) Alliance, Conwell will seek to develop collaborative systems of care integrating primary care, mental health care, and—most uniquely—community senior service agencies in the care of depressed seniors in the community.

His first project is a dementia care program that will link memory disorders specialty services (geriatric psychiatry, psychology, neurology, medicine, and nursing) with social work and other community-based care to optimize independent functioning and quality of life for people with dementia and their families, while reducing overall costs.

The IAP and Conwell’s vision as an Innovator Advisor dovetails with a growing movement toward “integrated care,” merging primary care and mental health treatment, often in colocated facilities. Integrated care is the theme of APA President John Oldham, M.D.’s, presidential year and this year’s annual meeting in Philadelphia. And today, a small but dedicated cadre of psychiatrists is advancing the cause of integrated care and the participation of psychiatrists in collaborative-care models (Psychiatric News, October 21, 2011).

APA has established the Work Group on Integrated Care, chaired by Lori Raney, M.D., medical director of the Axis Healthcare System in Durango, Colo., and a number of symposia and workshops are planned around integrated care at this year’s annual meeting, including a forum led by Raney titled “The Future Is Now: The Evolving Role of Psychiatry in the Integration of Behavioral Health and Primary Care.” That forum will take place on Sunday, May 6, at 2:30 p.m.

“The CMMI and the Innovation Advisor Program are indicative of a realignment in how we think about health care organization,” Conwell told Psychiatric News. “The idea is to provide incentives for the development of partnerships between health care providers and experts in social and contextual diagnosis and management to achieve a three-part aim: better health, better-quality care, and lower cost.

“Our model is one in which primary care and mental health care are integrated with the aging-services network, that group of agencies that is replicated throughout the United States by funding through the Older Americans Act and the federal Administration on Aging.”

Conwell is vice chair of psychiatry and director of the geriatric psychiatry program at URMC. His research has focused on suicide prevention and, as a service-level approach to prevention, the incorporation of community-based services into a more comprehensive model of collaborative care for older adults.

Central to Conwell’s unique vision is the insight, supported by years of research, that social isolation and social connectedness are critical factors in the risk for suicide among the elderly. “Our work with suicide has underscored very powerfully for me the role of social factors—social isolation and social connectedness—in determining the risk for suicide. It’s clear to me that one consequence of social disconnectedness is an increased risk for depression and that social connectedness is protective against depression and suicide.

“And for those whom we identify and treat, it seems equally clear that if there are unresolved social issues, the treatment is going to be less effective,” Conwell said.

“So we arrived at the idea that even more nuanced and integrated models of collaborative care were needed that didn’t stop at the coordination of primary and mental health services but reached out to the community to engage experts in social connectedness.”

The IAP encourages Conwell and other innovators to propose and conduct a project that will yield results around each component of the three-part aim—better health, better quality care, and lower costs—within a relatively short period. So a prominent goal of the dementia care project proposed by Conwell is to treat elderly people with dementia in an outpatient setting for certain ambulatory health care issues that often result in unnecessary hospitalization.

A prominent example of such a condition is urinary tract infection. It is a common cause of functional and behavioral decompensation among people with dementia; diagnosis is often delayed and the situation rapidly becomes more complex. Delirium sometimes ensues along with worsening infection, resulting in an emergency department visit and hospital admission. All of which, Conwell believes, is potentially avoidable with better at-home care.

He told Psychiatric News that a powerful stimulus for this goal is an article that appeared in the January 11 Journal of the American Medical Association by Phelan and colleagues titled “Association of Incident Dementia With Hospitalizations.” The study found that among a cohort aged 65 or older, incident dementia was significantly associated with increased risk of hospitalization, including hospitalization for “ambulatory care–sensitive conditions”—conditions that would otherwise more typically be cared for in an outpatient setting.

So Conwell hopes to reduce hospitalization—a disruptive and often disorienting event for seniors—for ambulatory problems in patients with dementia.

His approach, integrating the services of senior service agencies in the community, cuts against the conventional grain where health and social services have existed in silos. “The biggest obstacle we face is cultural,” he said. “We live and work in a fee-for-service environment in which the contribution of social and contextual factors to the health of older people has been insufficiently appreciated and therefore not systematically addressed.”

An abstract of “Association of Incidence Dementia With Hospitalization” is posted at http://jama.ama-assn.org/content/307/2/165.

Program Nurtures Health Care Innovation

In December 2011, the Centers for Medicare and Medicaid Innovation (CMMI) selected 73 individuals out of 920 applicants through a competitive process to participate in the Innovation Advisors Program (IAP). The first innovation advisors started their six-month intensive orientation and applied research period in January.

The CMMI and the IAP are initiatives of the Patient Protection and Affordable Care Act.

The IAP is intended to inspire individuals in the health care system to deepen several key skill sets, including health care economics and finance, population health, systems analysis, and operations research. These individuals will support the Innovation Center in testing new models of care delivery, use their knowledge and skills in their home organization or area in pursuit of the three-part aim of improving health, improving care, and lowering costs through continuous improvement, as well as develop new ideas or innovations for possible testing by the Innovation Center.

Innovation advisors will work with the CMMI to test new models of care delivery in their own organizations and create partnerships to find new ideas that work and share them regionally and across the United States.

More information about CMMI and the IAP is posted at http://innovations.cms.gov/initiatives/Innovation-Advisors-Program/index.html.