Integrating the Community into Geriatric Case ...

Copyright 1991 by The Cerontological Society of America The Cerontologist Vol. 31, No. 4,556-560

Gatekeepers, or nontraditional referral sources, have proven to be an effective means of case finding and outreach for the mental health needs of isolated senior citizens. A two-year project administered by the Public Health Division of the Health Services Department in a San Francisco Bay Area county found the gatekeeper concept to be an effective means of case finding in the public health setting. Program statistics showed similar profiles of individuals referred by gatekeepers and other referral sources except that gatekeepers referred more individuals living alone. Key Words: Gatekeepers, Case finding, Outreach

Integrating the Community into Geriatric Case Management: Public Health Interventions1

The last 10 years have seen a great expansion of services to the frail elderly population. Adult day health care centers, social model day programs, as well as geriatric assessment and case management programs have all made great strides to expand community-based services for the frail elderly. Most of these programs work on the premise that the at-risk older person will either seek out this assistance, or will utilize family, friends, or other informal support systems to make these linkages for them. This is true, perhaps, for the fortunate segment of the population with a support system strong enough to identify individual need and then seek assistance from the health and social service system. A population of very isolated, frail older people exists, however, that will not seek services or assistance. This is particularly true for those living alone and without a personal support system (Raschko, 1990a). It has been shown that those most at risk do not present themselves and their problems to agencies designed to help (Comptroller, 1979). This population may not self-refer due to denial or resistance (Raschko, 1990a) and may be resistant to any type of intervention (Cantor & Mayer, 1978). This resistance may be generated by feelings of shame, suspicion of "the system," fear of losing control over one's life, or fear of forced institutionalization (Raschko, 1990a). The unrealistic expectation that this population will refer itself to mental health or other social services has led to community agencies grossly under-

1 This project was supported by grants from the California Department of Health Services, Office of County Health Services, Special Needs and Priority Funds. We thank Linda Watts for her help in reviewing the manuscript. Address reprint requests to Charles A. Emlet, LCSW, Solano County Health Services Department, 355 Tuolumne St., Vallejo, CA 94590. 2 Senior Medical Social Worker, Solano County Health Services Department, Public Health Division, Vallejo, CA; Solano and American River Colleges, Suisun and Sacramento, CA. ••Public Health Nurse, Solano County Health Services Department,. Public Health Division, Vallejo, CA.

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serving the frail elderly population (Raschko, 1984). The fragmentation and complexity of the health care system further necessitates the need for outreach services that can create a link between the older person and the health care system (Yedidia, 1990). Community-based organizations must be proactive and assertive if they wish to locate high-risk individuals who are without support (Simson & Wilson, 1987). If programs wait to be contacted by this population, an estimated 40% of the target population will go unserved (Raschko, 1990a). For example, although the Solano County (California) Health Services Department has provided geriatric assessment and case management services to the county's senior population since 1982, only 4% of the over 800 individuals served by this program were self-referred (Solano County Health Services Department, 1989). Many mental health and aging programs seeking out isolated, community-dwelling elders have used the concept of gatekeepers (Raschko, 1984; McDonald et al., 1986). The gatekeeper concept was developed by Raymond Raschko or the Community Mental Health Center of Spokane, Washington in 1978 (Raschko & Coleman 1989). Gatekeepers are persons who, by the nature of their day-to-day work, come into routine contact with many people, some of whom may require assistance. These potential gatekeepers, if properly recruited and trained, can serve as case finders and as a referral mechanism into the health and social service system. Mental health systems and providers of services to the aged in many locations throughout the nation have developed gatekeeper programs. Even so, it is a concept that has not been extended to many public health settings. Public health professionals are, however, a major provider of care for community-dwelling elders. Twenty-six percent of the 8,105 home health agencies that operated throughout the United States as of June 30, 1989 were government based (Marion Laboratories, 1989). In California, 47 out of The Gerontologist

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Charles A. Emlet, MSW, LCSW2 and Ann Marie Hall, PHN, MPH:

60 local health departments indicated in their 19871988 plans that they provided public health nursing services to the elderly (California Department of Health Services, personal communication, November 20, 1990). The gatekeeper model, successfully implemented by mental health and service providers to the aged, can also serve as an appropriate and successful method of case finding for the public health system.

Response to the Need

Training of Gatekeepers One critical element of a successful gatekeeper program is the development of a relevant and thorough training curriculum. That curriculum, however, must be flexible enough to meet the different needs of individuals or organizations. For example, some agencies such as the gas and electric company require more formal training sessions for large groups of employees. This may necessitate a training agenda, audiovisual materials, and a classroom setting. Other gatekeepers, such as a one-person pharmacy or mobile home park manager, require a "quick and dirty" presentation: usually no more than one-half hour in length with the essential details communicated succinctly. In the latter circumstances, it is important to have written materials and handouts with lists of signs and symptoms indicating problems, the purpose of gatekeepers, and the specific referral process. Vol. 31, No. 4,1991

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Solano County, California is a suburban/rural county consisting of 837 square miles located in the northeastern San Francisco Bay area. It includes seven cities and has a total population of 339,807. The 60 and over population is approximately 11% of the total county population, with city percentages ranging from 4.1% to 23%. The number of communitydwelling elders, dependent in at least one activity of daily living, is estimated to be six times the nursing home population (Crimmins, 1990). Thus with the nursing home population in Solano county being approximately 925, the target population could be as high as 5,550. The Solano County Health Services Department had very few self-referred individuals to the department's geriatric nurse case management program. Funding for the development of additional programs has been severely limited in recent years. These factors led to the department's decision to use onetime state funding through the California Department of Health Services to initiate a public healthoriented gatekeeper program, known as the Senior Outreach Project. The Senior Outreach Project began in July of 1987 with a staff of one public health nurse and a half-time medical social worker as the project coordinator. The goal of the project was to identify, recruit, and train individuals throughout Solano County to function as gatekeepers. These individuals would then identify isolated, older individuals with functional limitations and refer them into the mainstream of the health care system.

Project staff carefully chose the curriculum areas, taking into account the limited time available for some gatekeepers. Training ranged in time from IV2to 2-hour sessions in more formal settings to approximately V2- to 1-hour sessions with individual gatekeepers. Each training session was broken down into four major segments. The first segment reviewed information on the specific health and social needs of the frail older population and why this target population goes unserved. The second, and perhaps most important segment of the training, involved the identification of the signs and symptoms that should trigger referrals. Dirty clothing, inability to communicate appropriately, or recent changes in living patterns, including the care of pets, yard work, or other well-established life patterns were all identified as possible indicators of problems. The third section of the training curriculum focused on inappropriate referrals. Approximately one-third of the time in each training session was spent on this topic. Issues covered with inappropriate referrals included referrals on individuals who were high functioning and situations needing immediate emergency care, like a stroke or heart attack. (This program was not an emergency service.) Project staff also discussed with gatekeepers the proper procedure for acting in an emergency, including the use of the local emergency medical response system. The final segment of the training consisted of an individualized plan for each agency or organization making referrals. Some organizations preferred to funnel all referrals through one individual, whereas others had each gatekeeper contact the Health Services Department individually. Each gatekeeper was provided a flowchart showing how the referral process worked for their particular agency and the mechanisms employed once a referral was made (see Figure 1). Each gatekeeper was also provided with a wallet-sized card with the names and phone numbers of project staff so that this information could be easily carried in the field. Project staff found that for larger organizations, such as the U.S. Postal Service and the gas and electric company, referrals were best funneled through one individual, usually a unit supervisor or customer service representative. This not only maintained a clear procedure for making referrals, but also eliminated the problems of gatekeepers who spent much of their time in the field engaging in "phone tag" with project staff. During the first 3 months project staff enlisted five separate gatekeeper organizations, including the U.S. Postal Service (in one city), three separate offices of the gas and electric company, and a senior housing complex. Staff successfully trained 70 individuals in four of the seven communities in Solano County, through 10 separate training sessions. During the second year of the project (1988-1989), staff focused on the rural areas of the county and smaller cities that were not targeted the first year. Gatekeepers targeted in the second year included individuals such as mobile home park managers, pharmacies (in particular, those that deliver), and attorneys whose

Identified as "at risk" by gatekeeper

Referring gatekeeper reports to:

Agency contact or gatekeeper notifies County Health Department

Health Department initiates assessment

Senior found not to need further services

Senior requires help from this and/or other agencies/programs

Case closed

Senior provided with follow-up and referrals

Figure 1. Flowchart of gatekeeper referral and outreach.

practices deal with probate issues. The number of gatekeepers trained during the second year was much smaller (only six), but all gatekeepers required one-to-one training at their place of business. By the end of the second year, a minimum of one gatekeeper agency or business existed in each community throughout the county.

Results

Nursing and Psychosocial Assessments Once a referral is made to the Health Services Department by a gatekeeper agency, the public health nurse schedules a home visit for an individual initial assessment. Every attempt is made at the time of the initial referral to obtain permission from the gatekeeper to disclose the source of the referral to the client, if asked. If the gatekeeper will not authorize permission to disclose the source of the referral, the client is told the referring source asked not to be identified. The nursing assessment focuses on general risk factors associated with institutionalization. A review of body systems — that is, cardiopulmonary, musculoskeletal, and sensory— is completed in relation to their influence on the person's ability to perform activities of daily living. Particular attention is placed on assessing bowel and bladder incontinence because incontinence is a significant predictor of withdrawal from close contact with friends and family (Ebersole & Hess, 1981). By reviewing the client's medications, the nurse can obtain a past medical history and evaluate medi558

During the first 2 years of the project, the geriatric assessment program received 167 referrals on individuals 55 years and older requiring nursing assessment and linkages to other agencies. Although 4% of these individuals were self-referred during the first year (a consistent figure with other years), the project found that 15% of all referrals received during the 1987-1988 fiscal year were from gatekeepers trained by project staff. During the second year of the project (1988-1989), the number of gatekeeper referrals increased to 18% of the total. No individuals were self-referred into the project during the second year. Project staff had no explanation for the decrease in self-referrals during this period. This fact, however, did serve to reinforce the assumption of unwillingness or inability of this population to self-refer. Evaluating the effectiveness of the project included a comparison of those individuals referred by gatekeepers with those referred by more traditional referral sources. An assessment was made to determine if the profile of gatekeeper referrals looked different from the individuals referred by mainstream health or social service agencies. A comparison of persons referred by gatekeepers with those from other referral sources showed little difference in their profile as related to age, gender, or ethnicity (see Table 1). The one area in which a substantial difference was noted was in the percentage of persons living alone. The Gerontologist

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cation compliance. Health habits, such as frequency of contact with a primary physician, as well as eating and sleeping patterns, provide further clues to potential risk factors and allow staff to assess the initial educational needs of the client. The home visit helps the nurse identify possible support systems. Unmet needs, such as the need for attendant care, problems with medication compliance, or poor cognitive functioning, can also be identified. Once risk factors and gaps in services are identified, a care plan is developed. Difficult financial problems or issues concerning the client's mental status are referred to the medical social worker assigned to the project for more in-depth follow-up. Project staff then works as it does with other clients in the geriatric case management program to provide linkages to other health and social services, and to monitor the clients over time. The frequency of monitoring can range from monthly to quarterly face-toface contacts, depending on the needs and risk factors of the client. After individual assessments are completed, communication with the gatekeepers is maintained. This gives gatekeepers positive reinforcement for appropriate referrals and provides an opportunity to discuss referrals that are inappropriate or too vague, such as name and address only. To protect client confidentiality, specific information regarding the client's medical condition is not revealed to the referring gatekeeper. Feedback is limited to general statements about the client's progress.

Senior citizen in the community

Table 1. Comparison of Client Characteristics of Those Referred by Gatekeepers and Other Referral Sources Gatekeeper referrals (n = 24)

Other referral sources (n = 139)

15.5% 10.0 74.5

10.6% 23.8 65.6

Cender Female Male

56.0 44.0

59.0 41.0

Race/ethnicity White Black Hispanic Asian Other

83.0 10.0 0.0 3.5 3.5

79.0 19.5 0.5 1.0 0.0

Lives alone

51.3

37.0

Client characteristic

Age 55-64 65-74 75 +

Integration into the Community

Because the funding for the development of the gatekeeper project in Solano County was time limited, it was important to develop a strategy of integration into the community so that the inroads made by the project were not lost. An effective gatekeeper system requires a systematic community effort (Raschko, 1985) and must be seen as an access vehicle to the community service system (Lidoff, 1984). Raschko (1990a) suggests that the gatekeeper concept needs to be "owned" by the long-term care system rather than by any one agency or business. We also felt that an ethical problem is created by developing programs that meet a community need but are then terminated when funding ceases. Most areas of the United States use the senior information and referral (I&R) network funded by the Older Americans Act as an entry point into the geriatric service system. The Solano County Senior I&R system had expressed great interest in the concept of gatekeepers and was interested in continuing and expanding on the work done by the Health Services Department. The project staff met with the senior network and made a decision to develop a "training for trainers." This was designed to accomplish two main objectives. First, it allowed for the continuation of gatekeeper training by another agency as the funding for original project staffing ceased after the second year of operation. Second, it allowed for the Vol. 31, No. 4,1991

Summary

Solano County's Senior Outreach project has shown that gatekeepers can assist in identifying individuals who live alone and are less likely to utilize mainstream health and social services. The experience of the Solano County Health Services Department has also shown that the gatekeeper model, previously used by mental health services, can be successfully used in a public health setting. Public

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Thirty-seven percent of individuals referred by traditional referral sources during the first period lived alone. In contrast, 51% of persons referred by gatekeepers lived alone. One possible explanation for this difference is that persons living alone were, in fact, more isolated and less likely to either self-refer or to have access to other, more traditional providers. This finding supports the premise that persons who live alone are more likely to be identified and located by gatekeepers (Raschko, 1990b) and require more complex social services in order to remain in the community (Emlet, 1984).

further integration of gatekeeper services into the community health and social service system. A 21/2-hour training program was developed by the original gatekeeper staff (a public health nurse and medical social worker). A training manual was developed by the presenters using the University of Iowa Curriculum as a model. The training curriculum covered areas such as the need for gatekeepers, the identification of prospective gatekeepers, communication skills, confidentiality, identifying potential clients, and making referrals. The trainees were broken up into small groups and provided with case histories. Using group process, they were asked to identify problems in the case, determine if intervention was appropriate, and develop a plan for intervention. Each group then presented its plan to the larger group for discussion and critique by the trainers. This process served to reinforce the identification of signs and symptoms of potential problems as well as provided the trainees an opportunity for problem solving. The training session was videotaped by the unified school district for use in future training. Thirteen individuals, trained as trainers, were provided with the information and knowledge to seek out, identify, and train gatekeepers in order to expand the network developed by this project. All participants who completed the training were awarded a "training the trainers" certificate by the County Health Services Department. Followingthe training, a bicounty Gatekeeper Task Force, sponsored by the Solano-Napa Agency on Aging Advisory Council, was developed. This multiagency task force identified the future goals of the gatekeeper program in Solano and Napa counties and informed the community of these program goals through a brochure. The task force developed an outreach list of over 300 potential gatekeepers; informational letters were sent to these individuals or businesses in three separate mailings. Since the emergence of the original training for trainers, participants have identified and trained approximately 75 additional gatekeepers. These new gatekeepers have included people from the postal service, public safety agencies (fire and police), and a city water company. The gatekeeper task force continues to meet quarterly to assess progress and develop new targets for gatekeepers. Individuals with significant health or cognitive impairments continue to be referred to the Health Services Department for evaluation by public health nursing and medical social work staff.

References Cantor, M. H., & Mayer, j . J. (1978). Factors in differential utilization of services by urban elderly. Journal of Cerontological Social Work, 7, 47-61. Comptroller General. (1979). Report to the Congress of the United States. Conditions of older people: National information system needed. Washington, DC: U.S. Government Printing Office. Crimmins, E. M. (1990). Implications of demographic and epidemiological trends in California's long term care policies. In P. S. Liebig & W. W. Lammers (Eds.), California policy choices for long term care. Los Angeles: University of Southern California. Ebersole, P., & Hess, P. (1981). Toward healthy aging: Human needs and nursing response. St. Louis: C.V. Mosby. Emlet, C. (1984). Coordinating county based services for the frail elderly: A tri-departmental approach. Journal of Cerontological Social Work, 8, 5-13.

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Lidoff, L. (1984). Program innovations in aging: Vol. 10. Mobilizing community outreach to the high-risk elderly: The gatekeepers approach. Program Innovations in Aging. Washington, DC: National Council on the Aging. McDonald, T. L., Buckwater, K., Smith, M., Stewart-Dedmon, M., & Van Hoozer, H. (1986). Gatekeeper training manual: Mental health of the Rural Elderly Outreach Program. Iowa City: University of Iowa. Marion Laboratories. (1989). Long term care digest, home health care edition. Kansas City: Author. Raschko, R. (1984). Gatekeepers reach out to elderly in Spokane. Perspectives on Aging, 13, 9-11. Raschko, R. (1985). Systems integration at the program level: Aging and mental health. The Cerontologist, 25, 460-463. Raschko, R. (1990a). Gatekeepers do the casefinding in Spokane. Aging, 361, 38-40. Raschko, R. (1990b). The gatekeeper model for the isolated, at-risk elderly. In N. L. Cohen (Ed.), Psychiatry takes to the streets. New York: Guilford Press. Raschko, R., & Coleman, F. (1989). Gatekeeper training manual: The key to community based care for high-risk elderly. Spokane, WA: Spokane Community Mental Health Center. Simson, S., & Wilson, L. B. (1987). Prevention planning in mental health. In J. Hermalin & J. A. Morell (Eds.), Sage studies in community mental health. Newbury Park, CA: Sage. Solano County Health Services Department. (1989). Coordinated patient care program statistics 1982-1989. Vallejo, CA: Author. Yedidia, P. (1990). Outreach programs for older adults: Implications and opportunities. Journal of Ambulatory Care Management, 13, 27-32.

health nurses with good assessment and health education skills can provide training to gatekeepers as part of geriatric case management services. In providing direct services to clients, public health nurses have the broad abilities to be involved in patient education, nursing diagnosis, psychological support, and liaison with other health care professionals.