Social Focus Cohort Caring for Older Adults with ...

[Pages:59]San Francisco Veterans' Affairs Social Focus Cohort _________

Caring for Older Adults with Psychiatric and Medical Co-Morbidities: A Novel Multi-Disciplinary, TransDiagnostic Program in a Skilled Nursing Facility.

Anne French LCSW Cindy Chan RTC, CTRS Laura Collins MD Lynn Martin RN, PMH-CNS

"...the 560,000 nursing home residents with a mental illness other than dementia dwarf the 51,000 individuals in beds at psychiatric hospitals."

"Trends in mental health admissions to nursing homes: 1999-2005." Psychiatry Services, July 2009. Fullerton, Catherine Anne MD/MPH et al.

Picture here of CLC

The San Francisco VA Community Living Center (CLC)

SFVA CLC Admission Criteria

REQUIRES ONE OF THE FOLLOWING: - Skilled nursing care - Hospice goals of care - Physical Rehabilitation - Supportive health services which cannot be provided in a community

setting - Needs assistance with 3 or more Activities of Daily Living (ADLs) or ADL

needs unable to be managed in a residential care facility

AND: - Is medically/psychiatrically stable - Can be managed safely in CLC's open environment - Does not present an elopement risk - Does not disrupt care of self or other residents

2012 Mental Health Diagnoses at CLC

70%

60%

50%

40%

30%

20%

10%

59%

34%

64%

44%

11%

0%

Neuro

Both Axis I (at least Challenging Personality d/o

cognitive Neurocognitive

1)

behaviors

& Axis I

History of the Social Focus Cohort

? 1999 Veteran suicide ? 2000 VA mandate for full-time Psychologist at CLCs ? 2004 Needs Assessment presented to SFVAMC leadership ? 2007 Program Launch

Comorbidity: Psychiatric and Medical Illness

Social Focus Cohort (SFC) Team

? Medical Provider ? Psychiatric Clinical Nurse Specialist (CNS) ? Social Worker ? Recreational Therapy ? Geropsychologist ? Occupational Therapy ? Consultant Psychiatrist

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