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. References 1. Philipps C. Uberman RP: Community Support in Ps)'Chi:uricRehabilit:ation of Chronic Mental Patients. Editt.-d by Liberman RP. U'ashington. DC. American Ps}'chiatric Press, 1988. PP 285-311 2. Reifler BV, Kethlt."Y A. O'Neill p. ct at: Fi\'C.)"CaJ' experience of a community outreach progr.1m for the elderly. Amer J Psychi:ltl'}' 1982~ 139:220-223 3-i6 3. Parish 8, bndbcrg G: Developing a gc.-riatric menl:ll health outreach unh in a rural communilY. Journal of Geriatric Social Work 1984: 7:75-82 4.u.-vy MT: Psychiatric assessment of elderly patients in the home. J Am Geriatr Soc 1985; 33:9-12 5.Maddox GL, Gbss TA: The continuum of care: movement toward the community. in Geriatric VOLUME 3 • NUM8ER4· FAll 1995 Kennedyet al. Ps~'Chiatry. Edited by Busse EW. Blazer DG. American Ps)'t:hiatric Press, Washington, DC. 1989. pp 635-667 6. Cohen C: Integrated c:ommunity services. in Comprehensi..C Rt."Yie:w of Geriatric Ps)-chialty. ' EdilL-d by Sad:n'Oy J. Lazarus LW. Jarvik LF. Wa.o;,hington. DC. American Ps)-chiatric PR$5. 1990. pp 613-634 7. The American Ps)'Chi:ttricAssociation Task Force on ModeLo;, of Practice in Geriatric Ps)"Chiatry: Community-based models of mental health 5t.-rviccsfor the eldt.orl)': outreach and respite care programs. in SeIt.'Cted Models ofPraetice in Geriatric Psychiatry. Ediled by Goldstcin M7 ... Colenda ce. KL"Ilncdy GJ. et a1: Washington.. DC. Amcrian Ps)-chiatric Aoisocialion. 1993. pp 9-20 8. KOfL"Il MJ: Home can:-Who c:an.-s? Nc.."\1r· Englj Med 1986: 'l·h917-920 9. Bums BJ, Taube: CA: Menral hr:;dth services in genL-r.l[ medial care and nUDing homes. in Mental Heahh Policv for Older Americans. F.d· ired by Fogel B. Furino A, Gottlieb G. Washing· ton. DC. AmL"I1c:an PS)-chialric Press, 1990. pp 63-83- 12. Lc:bowilz 08. Ught F Bailkcy F: Menbl hl,':alth .. center servin'S (or the elderly: the impact of coordination with area agencies on aging. Gerontologist 1987; 27:699-702 13. CummingsJ£. Wca..Cr FM: Cost-cfTceti ..1:ness of ' home care. Clio Gc:riatr Med 1991; 7:865-873 14. Scalzi ce, ZinnjS. GUilfoyle:MJ.er al: Medicarec:cnified home heath sc:rvia:s: national and regiorud supply in the 19805. Am J Public Health 1994; S':16-'6-1648 IS.Steele KS. Bissonette A: The home as a model setting for geriatric assessment, Rockville, MD. NIH Consensus Dc:velopmc:nt Conference October 1987 16. Ramsden JW. Swan jA. Jackson jEo er al: 111e )ield of a home visit in the assessment of geriatric patic:nts.J Am GenaU' Soc 1989; 37:17-24 17. Mc:m..-r 50: Elder Suicide A National Survey of Prevention and Intervention Progr:uns. Washington. DC.Americ:ln Association o(Relired Persons. 1989 18.Hamc:nnan D. Kennedy RD, Schulmerich S. et al: The academic medical center and the community: health c;uc for the elderly. Pride Instinne journal of Long-Tenn Home Health Can: 10. Lasoski Me: Rc:L'IORS for low utilization of ment:lI health services b}' the elderly. in Clinical Gcrontolog)': A Guide to As."K."S."ioment and Inlet..r ention, FAitt.od by Brink 11.. Binghamton. NY. 19.Abraham IL Buckwalter KC. Snusrad DG. et aI: Psychogerialric outreach to nltal families: the Iowa and Virginia models. Int P5ychogeriatr Haworth, 1986. pp 1-18 11.lbtsko et al: As..'iCrth"C at-home case management for impain-d elderly persons. limp Commun Psychiatry 1988; 39:1201-1202 1993. 5:203-211 20. Steel RK. Muslinger M. Boling PA:To the editor: medical schools and home cue. Nt.'W Enslj Mc..-d 1994: 331:1098-1099 TIlE AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY 1991: 10:42-52 347