This article is part of State of Health, a series about how Michigan communities are rising to address health challenges. It is made possible with funding from the Michigan Health Endowment Fund.
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Senior Resources of West Michigan, the Area Agency on Aging serving Muskegon, Oceana, and Ottawa counties, staff realized in-home services were needed to better serve clients who faced mobility or transportation challenges. To meet this need, Senior Resources first offered its Primary Care at Home program, offering mobile x-ray, EKG, laboratory services and more in clients' homes. While the program was a success, it did not adequately address homebound participants' behavioral health needs.
"Through many years of experience with the population, we learned that we were not able to impact those social, emotional, and mental health needs of the individuals with medical needs," says Sheyenne Cole, Senior Resources' MI Choice Waiver director and corporate compliance officer. "What we were seeing was a huge increase in emergency room visits due to mental health situations such as high anxiety, depression, and so on."
So Senior Resources launched its Behavioral Health at Home program, joining other Muskegon-area organizations in bringing behavioral health services to older adults in need. An older adult living in Grand Haven, Lesa Jordan looks forward to her at-home behavioral health sessions with Cole, who is also a trained counselor.
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Lesa Jordan talks to Sheyenne Cole (in foreground).
"She has been a great help to me," Jordan says. "I have Parkinson's, and I don't get around easily sometimes. Having her come is more comfortable for me. She's like having a cheerleader. She says nice things, things I might not have thought of. She comes over and makes it all good."
First staffed by Cole, nurse practitioners, and community health workers, the program has grown to add an additional full-time and part-time counselor.
"We go in person to the participant's environment regardless of where they're residing. If they're in assisted living or if they live with a family member, we meet them where they're at," Cole says. "We provide 50 minutes of psychotherapy that is very solution-focused. The goal is to meet their goals and help them get to whatever place they would like to be. The most common goal that we see is getting back in the community, reducing social isolation and reducing loneliness."
Senior Resources' Behavioral Health at Home program is open to adults aged 60 and over — and bills their health insurance directly.
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Sheyenne Cole.
"We were able to expand this program outside of the current population that we serve. We can serve individuals in the community that aren't part of our Primary Care at Home programs," Cole says. "They do need to be home-limited or homebound. And they also have to have a mental health diagnosis. If they're in crisis, we as counselors can determine what that diagnosis is."
PACE partner extends care to more older adults
Another Muskegon-based agency,
LifeCircles PACE serves older adults in Muskegon County and portions of Ottawa and Allegan counties. Although they are separate entities, LifeCircles PACE and Senior Resources have offices in the same building and often work together in meeting the needs of the region's older adults.
For example, LifeCircles refers older adults who do not qualify for its programs to Senior Resources and vice versa. A federal program,
PACE stands for Program of All-Inclusive Care for the Elderly. PACE programs provide comprehensive medical and social services, including behavioral health services, at low or no cost to older adults who live at home.
"For some, services at home are just kind of a convenience. But for others, it really makes the difference between getting access to behavioral health care or not," says Dr. Allison Ilem, LifeCircles PACE behavioral health director.
LifeCircles offers its participants therapy, counseling, and general support with life changes – for example, coping skills or learning how to adapt to medicines prescribed for psychiatric issues.
"One big part of our behavioral health services is to help coach the other people in the patient's life so that they understand better what they're dealing with and get some guidance on how to approach their loved one that they're supporting," Ilem says.
Seeing people in the comfort of their own homes not only overcomes mobility and transportation issues, but also allows the care team to assess other issues that may impact the participant's safety and quality of life.
"That can give us a lot of information that we wouldn't have if they were being seen in the clinic — and that allows us to tailor what their supports look like," Ilem says. "[For] one example, if people are having trouble managing their medication, we might not know that unless we're in the home. We can tailor some prompts or reminders. It also gives us easier access to those care partners — the family members or family of choice — and really help them focus on what matters most to the person and how they can best live their life in this chapter."
LifeCircles developed its care partner coaching program with support from the Michigan Health Endowment Fund. The focus is on care partners who support an older adult at home. Caring for a loved one creates a great deal of stress, whether it be handling finances, insurance coverage, housework, or providing round-the-clock personal care. Caring for a loved one with dementia adds another layer of stress.
Cole reports that family caregivers have given her positive feedback about how their spouses or family members look forward to sessions.
"It definitely lightens the emotional load for caregivers," she says. "And they may share a different perspective than what the patient is sharing. They may say, 'Well, Mom's been really depressed,' while Mom might say, 'Oh, I've been fine.' That information helps us to really get to the core root of the situation."
Virtual at-home visits address safety concerns
Cole shares that some participants do not want people in their homes — and that wish is respected. Instead, one of Senior Resources' community health workers knocks on the client's door, hands them an iPad, and sets them up for a telehealth visit with their counselor. When the session is over, they go back to the door to retrieve the iPad.
"That's a really great partnership. We still have patients who have significant COVID fears and they're not ready for those in-person visits," Cole says. "We also make sure to link them to other services to meet their needs."
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Lesa Jordan and Sheyenne Cole.
Ilem agrees that tailoring behavioral health services to the participant creates healthier results.
"By adding flexibility in where the services happen, being able to go out to the home, and coordinating closely with the health care team, we're able to get services to four times more people than we would if we required them to come into a clinic," she says.
According to data that Senior Resources recently compiled, all participants who completed 90 days of therapy not only increased their quality-of-life score by nearly 100% but also had reduced nursing home placements — and none have made emergency room visits related to behavioral health issues or pain.
"There's a lot of stigma when it comes to older adults and mental health care, in particular," Ilem says. "This is a really important part of health. Health is not just the absence of frailty or physical problems. It's this bigger picture — wellness."
Estelle Slootmaker is a working writer focusing on journalism, book editing, communications, poetry, and children's books. You can contact her at Estelle.Slootmaker@gmail.com or www.constellations.biz.
Photos by Tommy Allen.