Care teams emphasize emotional support

By the time Christine DeFalco, a care manager for Cornerstone Family Programs, enters the lives of the senior citizens she helps, they sometimes have gone a long while without help or direction.

They're referred to Cornerstone by local hospitals about to release someone who lives alone, doctors' offices that notice a patient's clothes are disheveled, or concerned neighbors.

"I now have a client who hasn't paid her taxes and they're trying to foreclose her house," DeFalco said. Like 25 percent of DeFalco's caseload, the client is estranged from her adult children.

Once, DeFalco crawled through the window of a client's house when he didn't answer his phone or the door, only to find him in the bathtub, where he'd been for more than 24 hours.

Seniors who live on and off the social grid can become lost in a mix of problems that are fueled by—or result in—mental health issues. The keys to stopping that spiral of despair, experts say, are helping the elderly where they live and intervening before life overwhelms them or their physical and mental maladies begin to interplay.

Another Cornerstone initiative—the Senior Collaboration and Intensive Geriatric Case Management Program—works with the most disconnected seniors of all. Its care managers walk the streets and visit shelters in search of seniors who've fallen between the social cracks.

Eighty percent of the seniors in the program, which began in 2010, have no caregivers at all, according to Cornerstone CEO Patrice Picard. Annually, the program helps 110 to 125 people.

"Often they come to the table with health and untreated mental health issues," said David Haggerty, Cornerstone's director of senior services. "If somebody suffers from full-blown schizophrenia, they will probably have had services throughout their life. They are diagnosed, so they will be able to get services through all their providers."

But a lot of seniors helped by Cornerstone's Senior Collaboration and Intensive Geriatric Case Management Program, Haggerty said, have "challenging, abhorrent behaviors" that have alienated them from almost everyone in their lives.

"They're subclinical," he explained. "They haven't actually got a mental health diagnosis. Many providers in town, due to their funding, are unable to work with somebody unless they do."

Among those seniors in the program, emergency room visits are reduced by 74 percent, according to Cornerstone. Since enrolling, 85 percent of those who were at risk of homelessness found housing.

But seniors needn't have such dire circumstances to be in real trouble. Plenty of complications can befall those who, though they live in their homes and apartments, remain disconnected from supports as their physical and mental illnesses escalate.

"There are so many things to be done—going to the doctor, getting the medical consults, seeing about financial affairs," said Aaron Welt, a Morristown-based clinical psychologist with a doctorate. He sees patients in his office, in their homes, and in assisted living facilities, both privately and through Generations, a Northern New Jersey in-home care management and counseling company.

"There are physical health issues, and financial issues," he added. "This is where care management comes in. It's a maze to understand the government programs, but it can be such a blessing when a manager connects you to some of these resources."

A care manager, Welt said, can fill in for adult children who live far away or have issues of their own or limited time.

Enter substance abuse

"Things are more difficult for people as our economy has changed and our resources are less," said Dawn Thomas of Jefferson, who owns Family Support Care Management, a wholly mobile geriatric care management practice. Also a licensed clinical social worker, she offers some clients at-home therapy.

"There's a lot of drug and alcohol as well as prescription and over-the-counter medication abuse," Thomas added. "Those things compound problems and you end up with dual diagnoses—substance abuse and mental health issues."

So prevalent is substance abuse among the elderly, according to the American Psychological Association, that the number of seniors who will need treatment is projected to increase from 1.7 million in 2000 to 4.4 million in 2020.

Cornerstone reports that it, too, often finds substance abuse issues, particularly among younger seniors, ages 60 to 70.

"They have much more complex problems," Haggerty said. "They're more likely to get involved with people who take advantage of them. They have romantic relationships that spin off poorly."

Mind/body connection

But mental illness alone, without a substance abuse issue, can and does complicate seniors' physical health, according to Aruna Rao, associate director of the New Jersey chapter of the National Alliance on Mental Illness.

"Mental health disorders are often somatized," she said, "meaning they are expressed as physical symptoms."

But there's even more to it than that. Distinctly different mental and physical illnesses can exacerbate each other.

In its report "Mental Illness Surveillance Among Adults in the United States," the Centers for Disease Control and Prevention state that mental illness is associated with increased occurrence of chronic diseases, including diabetes, obesity, cardiovascular problems, asthma, cancer, and epilepsy.

"Anxiety and depression can amplify the sensation of pain," Welt said. "Often, too, there's pain from arthritis or other conditions. Chronic pain can make people feel depressed and can wear them down psychologically.

"The great advantage of psychotherapy is that you don't have to worry about medical side effects," he added. "If you can treat somebody without adding a medication to the pharmacopoeia they are already ingesting, that's a good thing."

Human connection

Among seniors living at home, hoarding has long been a problem, according to Thomas. The issue came into the limelight last spring, when the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders was released and, for the first time, classified hoarding as a mental illness. The DSM-5 is used by mental health experts to diagnose behavioral health conditions.

"So now we're identifying a lot more people in terms of hoarding, which is an issue with our elderly that has plagued my practice for 25 years," Thomas said. "The Hoarding Institute is now educating first responders and others in the community who can identify it."

But while there may or may not be lot of stuff around, most seniors find fewer and fewer people in their lives, particularly as their spouses, and others in their generation, pass away.

"As they age, people get so lonely. They lose touch partners," Thomas said. "There are fewer people to touch them on any level. To have someone hold your hand or give you a hug is a vital and important part of the aging process."

It's a part that SeniorBridge, a home health care company with an office in Morristown, understands. The company, which has 53 locations nationwide, is known for its holistic approach to care and seeks out and brings in therapists to provide in-home talk therapy for clients, when needed.

"Our health care system is so siloed," said Claudia Fine, chief of professional services for SeniorBridge. "We believe the approach to senior care needs to be very agile and very comprehensive. What is healing is not only psychotherapy but human contact, human caring."

Eleven percent of SeniorBridge clients have a mental health component to their care plans, according to Fine. Consequently, the company offers its home health aides in-service trainings designed to guide them in the care of seniors with mental health difficulties.

Aides learn how certain medications are likely to affect behavior; how to respond when a senior hallucinates or becomes violent; how to keep a suicidal client safe; how to document a senior's actions on forms designed for that purpose; how to call for help when needed, and much more.

"In addition to the in-service training, we use the caregivers to learn from each other," said Denise Bonura, a registered nurse and SeniorBridge regional manager. "So they pair up. They're given scenarios. They role play. All the caregivers in the group listen, watch, learn."

Currently, Vera Parchment, a SeniorBridge aide, is working with a client who is suicidal. Following the training, Parchment set out to discover what calms down her client and then informed the rest of the care team.

"My client, she loves to watch the old English movies," Parchment said. "This is a new one—'Life of Pi.' She loves that. She will explain everything about what is going on.

"She likes to look at her family photos. Yes. And she will explain to me, 'This is my brother, my husband, and they were so good,'" Parchment added. "She even explained about when she was working and things that went on in the workplace. Sometimes she opens up a lot."

When the client becomes agitated looking at news programs on television, Parchment changes the channel. When the client's grief over losing her husband and her two adult children wells up, Parchment listens.

"When she wants to cry, I suggest we go for a walk or ask if she'd like a cold drink," Parchment said. "I put her on another path."

Indulging the need for human touch, Parchment brought nail polishes from her home to the client's house. She laid them out on a table and watched as her client's eyes lit up. "I like that one!" she said.

"Then I polish her nails and she says, 'Oh, you make my day. You make me feel so alive. For this, Vera, you get two desserts!'" Parchment said. "Then she would laugh. It makes me feel so good. Yes."

Ana Cernadas, a registered nurse and SeniorBridge clinical manager, said there are two separate specialized trainings for aides—one for mental health, another for dementia—and the two are quite different.

"With a dementia client, you can come back 15 minutes later and he or she may have forgotten that they refused to take a bath," Cernadas said, "whereas the client with mental illness can be a more challenging client."

Paying and paying off

A total of 25 percent of SeniorBridge revenue comes from long-term care insurance, Fine said.

Seniors without such insurance must pay for aides, from any home health aide agency, out of pocket. The same is true for geriatric care managers since creating and implementing a care plan is not covered by Medicare.

However, talk therapy offered in an office or in seniors' homes is covered if it's offered by a therapist, such as Welt, who is Medicare approved.

The nonprofits offer free services. In Morris County, NewBridge@Home offers 12 weeks of free therapy for low-income older adults age 60 or older. Cornerstone's programs also cost nothing.

"People are at first apprehensive," DeFalco said. "So I build up a rapport and let them know I'm just there to see if there's any way I can help them. They really like to hear 'free.'"

Funding for the Senior Collaboration and Intensive Geriatric Case Management Program is threated, though, according to Picard, CEO of Cornerstone. To date, it's been funded through the Grotta Fund for Senior Care and The Healthcare Foundation of New Jersey. But both private grants have run out.

"So now we're seeking other funding sources," Picard said. "United Way of Northern New Jersey funds us a little bit for the program, but that's it. It's been a tough road. We've gone to the county. We've gone to the Community Development Block Grant Program. We've gone to private funders.

"Actually, I'm concerned about senior services in general," she added. "You're seeing more services on the private pay model, and I don't know how seniors are going to do it."

Yet, therapists across the county say personalized care really pays off for seniors. They've seen even very old people get better, even those older than 100.

Lorraine Ash: 973-428-6660; lash@njpressmedia.com