Community Care Teams

Program Description

The Community Care Team (CCT) model engages interdisciplinary healthcare teams led by a mental health (MH) professional to guide and support behavioral interventions and environmental change to support frail elders. The CCTs are designed as a vehicle to infuse the principles, techniques and resources from behavioral health into the highly medical-model oriented Long Term Care settings. National data reveals 49% of residents in nursing homes have a diagnosis of depression and more than 60% suffer from moderate to severe dementia. These individuals also face multiple medical co-morbidities, functional deficits and personal losses, and therefore require comprehensive “wrap around” care delivered by well integrated interprofessional teams. CCTs ensure person-centered, integrated care by engaging the leadership of MH professionals who provide training, behavioral consultation, and group facilitation skills to guide the team members in creative behaviorally oriented care planning and quality improvement activity. The care plans, which include a variety of concrete and specific interventions guided by the strengths, preferences and interests of the elder, are shared with all staff and family to ensure care addresses psychosocial and spiritual needs, as well as medical needs. Moreover, the quality improvement activity supports environmental and culture change to ensure behavioral and psychologically informed care.

Creativity

Community Care Teams are creative in both design and function. This non-traditional model was designed as an innovative way to bring behavioral health insights and interventions to an underserved population desperately in need. This model is offered as a partnership between the mental health provider and the long term care (LTC) organization under a consulting agreement. The CCT is successful because it offers LTC staff with the structure and technical assistance needed to engage in creative dialogue as they identify strategies for meeting the needs and preferences of their residents. As evidenced in a recent process evaluation of CCTs, staff expressed their appreciation for the opportunity to get to know their residents as individuals and engage their creativity and teamwork in offering more individual and psychosocially informed care. The creativity of the model is amplified by engaging the creativity of multiple professionals from different disciplines and levels of the organization.

Leadership

The CCT model provides an illustration of ways MH providers can share their expertise and reach underserved populations within healthcare settings. The model has been disseminated to mental health and aging service providers through professional presentations, publications and consulting services. The CCT model, its inspiration and the underlying theory are the subject of a book titled “Transforming Long Term Care: Expanded Roles for Mental Health Professionals” (Carney and Norris, 2017) by APA press. CCTs, as the cornerstone of the Eldercare Method model, are described as a best practice on the CMS National Partnership to Improve Dementia Care website. In partnership with academicians, we have researched the clinical outcomes and implementation processes associated with the model, and these findings have been shared through reports and publications. The model and its outcomes have fostered interest among MH and LTC professions to better integrate behavioral health expertise into healthcare to enhance person-centered care.

Sustainability

The CCT model, developed by a geropsychologist, was originally offered as a consultative service to long term care providers. The model has subsequently been adopted by Phoebe Ministries, an aging services provider, and 11 CCTs are offered across all of Phoebe’s campuses and levels of care. The model is embraced across the organization because of the support it provides for our mission, quality of care, strategic goals related to person-centered care and dementia care, as well as medical cost offset. Phoebe has found that the model is a worthwhile investment and is now offering the model to other long term care providers in the region. Since CCTs were first offered in 2000, approximately 12 long term care settings have invested in the model. Phoebe is actively engaged in developing new partnerships with other long term care and mental health providers to expand the reach of CCTs to other settings.

Replicability

Given that the need for behavioral health expertise is so great within healthcare settings serving older adults; our goal has been to increase awareness of this innovation via presentations and publications on CCTs. Phoebe recognizes that we cannot reach all LTC and healthcare settings in need of behavioral health expertise, so the aforementioned book on Transforming Long Term Care offers detailed instructions to guide MH professionals in developing and implementing the CCT model. The book includes a comprehensive description of the model and CCT processes, sample forms and business tips to assist those who would like to adopt the model. The model is being shared with LTC providers to raise awareness of the value of infusing MH expertise into LTC, with the specific goal of enhancing creative and individualized care in these traditionally medical settings and encouraging openness to partnership with MH professionals to address the complex needs of elders.

Results/Outcomes

The outcomes of the CCT model have been examined and improved by incorporating quality improvement data, process evaluation and stakeholder satisfaction surveys. While these are not randomized and controlled studies, the preponderance of data indicates the outcomes are beneficial for clients, caregivers and the institution. For example, in settings with CCTs in place, we have documented decreased falls, reduced utilization of psychotropic medications, and increased resident engagement. We have noted improved interdisciplinary collaboration, caregiver efficacy in addressing behavioral challenges, and staff satisfaction. When asked about their perception of the CCT process, administrators have pointed to reduced costs resulting from CCT led initiatives. CCT members note the value of knowing their residents better, having the opportunity to engage in creative problem solving, and enhanced team collaboration. In our short-term rehabilitation setting with a CCT, we have found improved functional outcomes and increased likelihood of discharge to the previous living environment.