CLINICAL AND RESEARCH REPORTS

Psychogeriatric
Services at Certified
Home Health
Agencies
Case Reports and
Guidelines for

Psychiatric Consultants
Gary J. Kennedy, M.D.
Nelly Katsnelson, M.D.
Leila Laitman, M.D.
Ernesto Alvarez, M.S. W.
Because oftbe unmet menta/health needs
ofolderpersons in the community, Medicare-certifted bome health agendes are
increasingly taking the role of health
providers. Here tbe authors review their
experience and argue that tbe pathology
seen in bome mental health care situations is similar to tbat seen by special.
ized mental health outreach teams. Also
the relations between tbe bome care team
and the psychiatric consultant require
skillful management even when the team
are mentalhealth specialists. The autbors
offer guidelines for psychiatric consultants, given the extent to which bome care
services survive in a volatile, cost-containedenvironment. (AmericanJoumal of
Geriatric Psychiatry 1995; 3:339-347)

C

onsiderable information is available
on specialized outreach programs for

mentally ill elderly patients,I-7 but these
programs are not in the context of Medicare-certifled home health agencies,
which have traditionally limited theirsenrices to nursing. social work, and physical
or occupational therapy," Existing studies
ofoutreach to mentally ill elderly patients
are descriptive, with few controlled comparisons of interventions, personnel, or
outcomes that might be used to establish
the indications, benefits, cost offsets, or
critical aspects of team composition.
Nonetheless, they demonstrate a compelling need and document a variety of practical interventions and viable team
configurations.
Less than 5% of older community
residents in need of mental health services receive care," Because of the stigma
of mental illness and biases about the
efficacy of mental health services in old
age, older adults are less likely to be offered and to accept a referral for psychiatric care." Also, older adults are reluctant
to seek services for fear that disclosing
their impainnents would sacrifice their
liberty.. II Case-finding by social service
agencies is also inadequate in that area
agencies on aging and the mental health
delivery systems lack systematic linkage. 12
As a result, Medicare-certified home
health agencies are likely to encounter
substantial unmet mental health needs
among their older clients.
Among nonpsychiatric home care
studies, measures of cost offsets, mortality,. functional status, cognition, and rates
of nursing home admission yield equivocal results. Failure to target appropriate
patients and to manage care and the care
team may account for the observation
that more home care means more cost
without much improvement in the older
person's funcnoning,"

Received May 4, 1994; reWicd January 9. 1995; accepsed March 14. 1995. From Monlefiore Medical
Center/Albert Einslein College orMedicine. Address com:spondence to Dr. Kennedy, Department orPsychiatry, Montefion:: Medical Center. 111 East 210th Sua:t, Bronx. NY 10467.
Copyright e 1995 American Association for Gc:riattic Psydliatry
mE AMERICANJOURNAL Of GERIATRIC PSYCHIATRY

339

Guidelinesfor Home Health Care

Between 1980 and 1990, the number
of Medicare-ecrtified home health agencies almost doubled, reaching an estimated annual cost of$4 billion. However,
since 1987 more agency providers have
left the Medicare market than entered it
because of tighter controls on eligibility
criteria for the medical necessity of their
services and the resultant uncertain profitability.. I .. In the present cost containment
envtronment, home care advocates will
likely tum to other arguments, such as
unmet needs, I'ue, consumer satisfaction, Ii
and the increase in late-life sutcides'" to
champion their cause. Empirical guidelines for psychiatric consultants will be a
critical element in advocating for In-home
geriatric mental health services.

METHODS
To formulate guidelines for psychiatric
consultants to home heahh agencies, we
compared two Medtcare-cernfled home
health agencies, their referrals, and the
experience of psychiatric consultants as
they initiated work with agency staff. We
also selected exemplary cases, and describe ethical dilemmas that arise from
practice in the community. Because home
health agencies have focused more on
physical services than mental health care,
we sought to characterize the differences
in referrals for psychiatric evaluation between an agency with a major mental
health component and one with a more
limi[ed mental health mission.
The Agencies
The Visiting Nurse Service of New
York is the largest Medicare/Medicaid Certified Home Health Agency in the nation.
In 1986 the VISiting Nurse Service was
awarded a contract from the City of New
York Department of Mental Health, Mental Retardation, and Alcohol Services to
provide Mobile Crisis Services to persons

who would not or could not accept clinicor office-based psychiatric care, The
award was occasioned by the death of an
elderly, deluded Bronx resident who was
shot to death in her apartment while police were carrying out an order to evict,
City authorities reasoned that tn-home
mental health services might have
avoided her tragic death.
The outreach teams covering the
Bronx, the Mobile Crisis Management
Team, and the In-horne Geriatric Mental
Health Programs arc composed of a fulltime psychiatric nurse, social worker, and
social work assistant, as well as a parttime psychiatric consultant. Referrals
come from clinics, community-based
agencies, and the much larger non-mental health components of the parent
agency. In-horne care is envisioned as crisis intervention, evaluation, and referral,
with services terminated most often
within 1-2 months.
The Montefiore Home Health Agency
is the first hospital-based home health
agency in the United States. Most referrals
come from Montefiore Medical Center, an
acute-care hospital that is a major affiliate
of the Alben Einstein College of Medicine. The Agency9 s clientele arc mainly
isolated, physically disabled older persons. Despite efforts to screen persons
whose primary disabling condition is a
mental disorder, the mental morbidity
encountered as a result of adjustment reactions and depressive and anxiety disorders, as well as the onset of dementia, is
considerable. With the exception of the
Director ofSocial Services, staff have little
formal training in mental health.
A grant from the Federation ofjcwish
Philanthropies provided for a part-time
psychiatric consultant. However the psychiatrist had no salaried hours at the
medical center; this situation limited contact with the hospital-based primary care
physicians and psychiatrists. Few patients
received more than an evaluation, and
much of the psychiatrtst's time was spent
VOLUME 3

• NUMBER", • fAll. 1995

sennedy e: al.
pursuing primary care physicians by
phone. The philanthropic organization
threatened to terminate the grant if a
more direct link to the medical center
were not forged.
A psychiatric consultant from the
Medical Center's Division ofGeriatric psychiatry was assigned to devote a 30%,
full-time equivalent effort to the Home
Health Agen~ part of which was to be
spent at the Ml.-dical Center to ensure
liaison with both the primary care and
mental health providers across the various clinical disciplines.
The Psychogeriatric Consultants'
Initial Experience
At.the Montefiore Agency the new psychiatrist took a more aaive role, including

direct treatment of a limited numbe of
...
patients, educational conferences with
staf[ and introduction of a team approach
to difficult cases. The consultant also coordinated psychiatric hospitalization and
emergency room assessments. Initially this
approach encountered resistance. First, me
Agency retained a falsedichotomy between
mental and physical disorders and identified its mission as attention to the latterand
an avoidance of the former. Effons to
screen out mentally ill patients before admission reinforced the illusion that mental
health problems were beyond the scope of
staff's responsibilities. Second, staffbad received little training in mental health care.
Because they did not expect to provide
mental health services, they did not always
appreciate the need for mental health care
skills. Finally, staff harbored unrealistic expectations regarding the psychiatrist, expecting to be magically relieved of
problems once the psychiatrist "took over."
Case conferences were used to teach
staff to recognize early signs of depression and dementia and to learn effective
responses to suicidality. Field teaching experience with referring staff applied concepts introduced in the conferences to
11iE AMERICANJOURNALOf GERIATRICPSYCHIATRY

the actual home visits. The conferences
imparted mformation and allowed staffto
acquire a sense of mastery.. Staff became
less likely to act out uncertainty by denying the problem or shifting it to the psychiatrist.
When a new psychogeriatric consultant joined the VISiting Nurse Service, she
entered an established team of mental
health specialists but encountered similar
problems. Differences in perspectives and
priorities among the various disciplines
were not uncommon. Referrals to the psychiatrist were most often focused on questions of impaired judgment, suidde risk,
and need for hospitalization, or initiation of
phannacotherapy prior to linkage to the
clinic. The decision to hospitalize or not
determined the immediacy of action. As a
result, other treatment options were
deemed less important because the team
rarely provided other than brief; supportive
psychotherapy. Also, referral sites were expected to perform any procedures necessary for diagnosis and treatment, so that the
psychiatrist's interest in the diagnosis was
viewed as a peripheral concern when the
central question was whether or not to
refer. Nonetheless, efforts to clarify the diagnosis, particularly when physical and
mental disorders Coexisted, remained essential to a more nuanced referral or initiation of steps that might facilitate the
acceptance ofservices.
At the outset, both staff and patients
resisted an in-home visit from the psychiatrist. The fanner because their work
became the subject of review by an as-yet
unincorporated team member, the latter
because the nurses and social workers
were seen as Jess of a threat than the
psychiatrisL In response, the new psychiatrist used ongoing team meetings to
invest herself in the group, to develop a
collaborative educational expectation
from colleagues, and to avoid overly rigid
role definitions. It became clear that each
clinical discipline brought a unique perspective to patient care, but that much of
341

Guidelinesfor HOllie Health Care
their techniques and goals were overlapping. By acknowledging the shared character of clinical authority in the field, the
psychiatrist's expertise was enhanced
rather than devalued. The psychiatrist
also began to meet periodically with
chiefs of the various geriatric psychiatry
and medicine clinics serving as reception
sites for referrals as well as sources of
ests
requt.. for in-home evaluations. These
meetings reinforced cross-agency
collaboration by clarifying referral procedures and admissions criteria. personalizing the bureaucracy of care, and resolving
disputes about the appropriateness of patient referrals.
In summary; at both agencies the incoming p~-ychiatricconsultants needed to
fonn alliances and adapt their personal
styles to the needs of the team and the
administrative structure of the organization. Opportunities for leadership and
teaching expanded once the dynamics of
team interactions were stabilized and the
socialization ofnew members was accomplished. Two practitioners' guidelines
emerge from the consultants' experience
with their teams.
• You have no control over events in
the community without the patient
or a third party authorizing your actions or acting on your behalf. Behave as an invited guest and team
player and you will less often be
seen as a meddling intruder.
• Your role in the agency is consultant even though you may be fully integrated into an existing team.
Given the Ouidity of clinical authority in home care settings, consultants may lead, but more often, they
follow.
Survey of Referrals

Between July 1991 and December
1992, we surveyed mental health referrals
from the Monteflore Home Health
342

Agency and two of the Visiting Nurse Service's Community Mcntal Health Outreach teams. Both entities are certified
home health agencies and serve the
Bronx, in which 150,000 persons age 65
or older reside. Despite thcircontrasting
missions, the SUrvL'Y of referrals (Table 1)
shows more similarities than differences
between the two agencies, In both programs, one-third ofreferrals were for persons 80 years of age or older, and more
than two-thirds were womcn. The most
frequent diagnoses were disorders of
mood or cognition, with anxiety and adjustment disorders amounting to less
than one-flfth of all referrals. Suicidality
was a problem of similar proportions, although the percentage of persons hospitalized by the Visiting Nurse Service
Mental Health team was twice that of the
Montefiore Home Health Agency. Also,
more psychotic community residents
were seen by the Visiting Nurse Service,
Neither program was particularly successful in referring patients to outpatient clinics, a finding that was not surprising,
given the nature of the referrals.
For the Visiting Nurse Service Mental
Health Outreach team, 427 cases from
referrals age 55 and older were opened.
Slightly less than one-third were referred
for mental health consultation from
within the parent home health agency.
Close to one-quarter ofcases were triaged
to other agencies before consultation or
not contacted because hospitalization or
death intervened. Most of this group were
persons requiring emergency medical
care, the guardianship procedures of the
Protective Services CorAdults agency, or
home health aid services Cor uncomplicated cases of dementia. More than onethird of patients either refused further
services or resolved their presenting
problems with one intervention. A
number of these patients consented only
to follow-up treatment by their primary
care physician. We suggest the following
guideline based on our survey of referVOWME 3 • NUMBER 4 • FAll 1995

Kennedyet al
Characteristics of rcfemals Cor
in-bome psychiatric: c:nIuatJons. %

TABLE 1.

Visiting
Nurse
Service

Mootefiore

Home
HealthAgeocy
(1'=50)

\lUmen
Age~80

Dcfem.-d.n

,,3

Diagnoses.
Cognilh;e disonlers
Afl'l."Cti,,'C disonJc:rs
Psychotic disorders
Anxiety dlsorders
Personality disorder
Adjustment disonler
Orne'"
Disposilionc
Ps)'Chblric clinic
Ps)'chi:llric hospiraJ
Othe...d
Suicidaliry

(n

=

427)

68

75

34
(not
applicable)

110

34

50
22

317

38

24

24

18

6

6

.

16

2
6

not
identified
14
17

12
8
14
12

5
19
39
15

a Some patients n .. eived more than one dbgnosis.
e
b Substance abuse, bereavement, nonpsychblric
diagnoses.
C Some patients reeelved more than one
disposition.
d Inciudl."Ssocial ~-n;ce, intr:l-:agcnc:y. nursing

rats: Referrals ofpersons with persistent
psychotic disorders and dementia rna)'
require considerable resources bu: tbey
represent tbe minority of the caseload
and should notjustify an agency~ reluclance 10 provide menial health services.
Review of Select Cases
The following cases were chosen to
highlight aspects of psychiatric consultation
ratherthan to be a representative sample. ~
purposely excluded cases of dementia I:Je.
ClU5e difficulties caring (or dementia patients in the community have been
extensively covered. However the guidelines
we suggest apply equally to them.
Case1: A recently widowed woman with
crippling cardiac valve disease had neglected
THE AMERICANJOURNALOF GERIATRICPSYCHIATRY

her nutrition, hydration. and medication
and admitted "I would jump out the window but I haven't the courage." Her son in
Tennessee was contacted and informed that
hospitalization seemed the only safe treatment plan, given her deteriorating cardiac
status and suiddal expressions. She accepted psychiatric hospitalization only to reject it the next day. Because of uncenainty
as to her safety both from cardiac collapse as
well as suldde, the VISitingNurse Service determined that continued in-home service
was not reasonable; this determination precipitated a crisis. An order (or an involuntary
emergency room evaluation was obtained,
and the patient was admitted over her objection to a psychiatric facility. Her son arrived
threatening suit if she were not discharged
to his CU'e. She recanted her suicidal intent.
and accepted a home health aide and case
management services that her son arranged
before returning south. She did not pursue
psychiatric follow-up, but developed an efIecnve dependency on the home health aide
and remains well.

This case illustrates several ethical dilemmas. Civil procedures available to co-eree the vulnerable person into a safecare
plan are bureaucratic, time-consuming,
and may be traumatic. The powerto coerce
care inevitably means that some parties will
be unhappy with the process even when
the results seem ideal. The imperatives of
respect for patient autonomy and the physidan's responsibility not to abandon an
imperiled person pose a dilemma that can
be managed but not alwaysresolved. Risk
management that merely avoids malpractice actions is neithersatisfying for the clinicians nor adequate for agency poliqr.
Consultants in ethics affiliated with an academic medical center otrer added perspectives on rights, responsibilities, risklbenefit
analyses, and the decision-making process
th~mo~n~t~~ilieoo~me~

perplexing snuanons," We suggest the following guidelines.
• Access to a consultant in law and
ethics from an academic medical

343

Gutdeltnes for Home Health Care
center should be sought out to clarifythe dilemmas. Avoidance of tort
liability is not a 5ufficicndy high
standard for excellence in care.
• In-home treatment is not risk-free.
You may minimize the chances of
an adverse outcome, but risk cannot be eliminated. The most useful
model is the informed consent
model, in which risks, benefits, and
alternatives are prioritized for the
patient to accept or reject.
• Precipitating a crisis may be the only
way to resolve an unsafe or intolerable situation. Altering the household
equilibrium may threaten an enmeshed familyfor economic as well
as psychodynamlc reasons,

case 2:

A retired pharmacist, discharged
from the hospital after hip fracture repair,
found his disability unacceptable and his
\\ife: unsympathetic, He threatened suicide
with pills. The home health agency psychiatrist found the patient with major depression and arranged for his wife 10 monitor
sedatives, The: patient responded positively
to a "no-suidde" contract with the psychiatrist. However after several episodes of diarrhea requiring his wife's asslstance, he felt
humlltated and threatened suidde when she
was about to leave the house. a threat she
brushed off with characteristic sarcasm. He
look 15 pills. was discovered by the: home
heealth aide. and taken to the hospital by
Emergency Medial Service ambulance. After
his short Sl3}' on the psychiatric unit the
home care team attended discharge planning and welcomed him back to their service. the first time the agency had reinstituted
care for a pS}'Chiatrlc admtsslon,

This suggests the following guideline:
Liaison with entities tba! send and receive
your agellc)'s referrals is an essential aspect oftbejob, greatlyJadlitating nlanagement ofemergencies and admissions.
Case3: A man with end-stage renal disease
and coronary atherosclerosis. who was apathetic. irritable. and slept poorly denied depression and the need for treatment, After
344

six sessions of In-home psychotherapy he accepted antidepressant medication. His
mood improved and his internist agreed to
monitor the medication. A shan course of
psychotherapy from the consulting psychiatrist had been necessary to gain acceptance
of antidepressant medtcation.

This case demonstrates the following
guideline: With support from tbeagency
orfanlilj~ you will be able to administer
a wide range of treatments from brief
PSJ'cbolberapy 10 the in-bome ",anagement ofsuicidal/I)'.
Case 4: A woman with severe pulmonary
disease and history ofstroke left her nursing
home after securing the services of the
Home Health AgL-ncy. However she was condescending and imolerant of home health
aides who were not of her race. so much so
that she ultimately refused all asslstance,
Ieading the agency to consider discharging
her. The consulting psychiatrist was asked to
prescribe medication to make her more tractable. The psychiatrist and director ofsod:aJ
services made a joint visit but medication
was not prescribed and the request to dtscharge the patient waschallenged. Instead,
the approach was shifted tOW2m explanation of the patient's narcissi-titie personality
disorder. her propensity to split staff into rescuers or persecutors. and hLT overblown
sense of entitlement, which jeopardized her
care. A tt.."'3ID approach was adopted (0 manage her personality disorder rather than her
bigotry.

We suggest the following guideline: Review cases intensely before J'OU visit to
idetltifJ' crittcal issue: and nwkeyour cotleagues latent agenda manifest. Biomedical andpsychological dynamics nzay be of
little use ifyou are unaware ofthe social;
team; andfinancial d)"nall1ics.

DISCUSSION
Four points emerge from our study. First,
it is unsettling to serve sodally isolated
older persons with medical and psychlatVOWME 3 • NUMBER 4 • FAIl. 1995

Kennedyet al.
ric vulnerability in a context where the
providers have little control over the
circumstances of care. Often a party
other than the patient is requesting the
service. As a result, patient trust and
motivation may be less than desired.
The psychiatrist may feel pulled between "two masters," the patient and
the agency. Decisions to initiate or withhold treatment may be challenging. The
agency may not be able to continue
treatment indefinitely. Moreover, without the capacity to monitor compliance
and adverse reactions, medication may
not be safe. Ultimately the patient and
physician may find themselves working
at cross-purposes.
Second, home health agencies may
encounter pathology similar to that seen
by specialized mental health outreach
teams, However they are unlikely to be
overwhelmed by a clientele that may have
dementia and/or" be seriously and persistently mentally ill. Arguing from experience with rural populations, Abraham et
al." found that despite differing demographic, economic, cultural, and ethnic
characteristics between two model outreach programs, one in Iowa and me
other in Vuginia, the diagnostic mix was
similar. Mood disorders were more prevalent than dementias but "coping/adjustment" disorders were the most frequently
encountered diagnoses, with anxiety,
thought disorders, and substance abuse
each accounting for five percent or less.
Those in the coping/adjustment category
were persons struggling with physical illness and disability themselves or the care
of a relative with dementia or djsabili~
Our experience with a decidedly urban
sample demonstrates similar proportions
of the major diagnostic categories. Most
Importantly persons with mood disturbances and copingtadjustment disorders
should be relatively responsive to recognized, perhaps even modest interventions. They represent the group most
likely to demonstrate cost offsets and the
TIlE AMERICANJOURNALOf GERlATIUCPSYCHIATRY

greatest gains in well-being as a result of
mental health home care.
Third, for effective referrals, the linkage across clinical disciplines and
provider agencies requires foresight and
incentives to be effective. Physicians are
not well prepared for field work in the
communiqr. Less than halfofall American
medical schools require a home care
.experience of their studentsr" Fellowship-trained physicians from geriatric
medicine orgeriatric psychiatry programs
have been required to work with a health
care team znd make house calls, but their
numbers will never be adequate to meet
the need. Providing a continuum of care
for home-bound, isolated older community residents may require physicians to
take on more of a case-manager role. The
burden of setting aside time for liaison
activities both within the team and outside the agency is considerable and represents a sizable challenge to funding
sources.
Fourth, the relations between the
home care team and the psychiatric consultant require skillful management, even
when the team members are mental
health specialists. It was our experience
that the Monte6ore Home Health Agen~
with a mission of care for physical disorders, tended to refer more patients than
necessary for psychiatric evaluation and
follow-up. In contrast, me VISitingNurse
Service's Geriatric Mental Health team
needed encouragement to seek the psychiatric consultant's input beyond evaluations for admission, impaired decisional
capacity, or involuntary care.
Whatever the outcome of health care
reform, it is doubtful that the number of
older adults in need of in-home psychiatric care will decrease or that me interdisciplinary, interagency problems we
identified will disappear. Practice guidelines are needed both for research and
quality assurance. To the extent that
home care services survive in a cost-eontained environment, we summarize our

Guidelinesfor Home Health care

TABLE2.

GuiddtPcs for psycbiabic consultants engaged by home health agcndes

1. Consultants have no control over events in the community without the patient or a third
pany authorizing their aaions or acting on their behalf. By behaving as an invited guest
and team player, the consultam will less often be seen as a meddling intruder,
2, El'en when fuUyintegrated into an existing team, the consultant's role in the agency remains that of consultant. Given the fluidity of clinical authority in home care, consultants
may lead, but more often lIlt.. foUow.
-y
3, Referrals of persons with persistent psychotic disorders and dementia may require considerable resources, but they represent the minority of the caseload and should not justify an
agency's reluctance to provide mental health services,
·t Consultants should review C1SCS intensely before the home visit to identify critical issues
and to make their colleagues' latent agenda manifest. Biomedical and psychological dynamics may be of little use without an awareness of the sodal and financial dynamics,
5. In-home treatment is not risk-free. The consultant may minimize the chances ofan adverse
outcome, but risk cannot be ellmmated. The infonned-consent model, in which risks, benefits, and alternatives arc prioritized for the patient and family to accept or reject, is most
useful.
6. Pn.-dpitating a crisis may be the only W3.y to resolve an unsafe or intolerable situation. Altering the household equilibrium may threaten an enmeshed family for economic as well as
psychodynamic reasons.
7. Respect for patient autonomy and the ph)'Sician's responsibility not to abandon imperiled
persons pose an ethical dilemma that may be managed but not always resolved.
8. Access to a consultant in Jaw and ethics from an academic medical center should be sought
out to clarify the ethical dllemmas, Avoidance of tort liability is not a sufficiently high stand- '
ard for excellence in care.
9. Uaison with entities that give and receive the home care agency's referrals is an essential aspect of the consultant's job. Management of emergencies and admissions will be gn..-ady facilitated.

10. With support from the agency or family, the consultant will be able to administer a wide
range of treatments-from brief psychotherapy to the in-home management ofsuiddalil}'.

guidelines for psychiatric consultants in
Table 2.
The authors warmly acknowledge tile encour-

agement of Kathryn Hyer. DPA, \'ice President for BusinessDevelopmentoftile Visiting
NurseService ofNew York,and SUSQIl Schulmerich, RN. MA. Executive Director 0/ tile

MontejioreHomeHealthAgellc)',lVeare also
indebted to David C. U"dy. Yisiting Nurse
Service Chief Psychiatrist,for his critique of
all earlier versionofthe manuscript,
This work was supported ill part by the
Federation of Jewish Phllanthropieslllnited
Jewish Appeal.

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