Older adults in the Rochester and surrounding Finger Lakes area report more “poor mental health” days than their peers across the state, a fact compounded by a shortage of behavioral health providers in the region. A new interprofessional collaborative program has the potential to better address seniors’ complex health needs.

A grant from the National Center for Interprofessional Practice and Education will provide initial start-up funding for a geriatric home visit initiative that pairs a local nurse practitioner and medical students with social workers to provide in-home behavioral screenings to older adults, leading to the development of an integrated physical, behavioral and social support care plan.

“This is a very special opportunity to partner with older adults and their family members and collaborate across professions and organizations to break down silos and improve the integration of community-based care,” said Tobie Olsan, professor of clinical nursing at the University of Rochester School of Nursing and principal investigator on the grant. “Interprofessional teams are the key to safe, high-quality, patient-centered care. Our focus has been in the hospital. This initiative is about learning and working together to accelerate the use of best team practices in the home, which is increasingly where we are caring for older adults.”

The project broadens access to behavioral health assessments among vulnerable older adults while building a workforce of health professionals better able to identify and collaboratively manage the population’s health needs using new models of care delivery.

“I am particularly excited about the proposed Geriatric Home Visit initiative, because it will build on and powerfully extend what is already happening at Rochester to better meet the behavioral health needs of vulnerable elders in our community,” said Mark Taubman, CEO of the University of Rochester Medical Center and dean of the School of Medicine and Dentistry. “The initiative reinforces efforts to reframe our academic community and culture to critically apply an integrated, holistic, patient- and family-centered lens to professional education and practice.”

The GHV initiative brings together nurse practitioner students from the UR School of Nursing, third-year medical students from the University of Rochester School of Medicine and Dentistry and community-based professional social workers from Lifespan, a local aging services agency, for an in-home, interprofessional, team-based learning experience. The four-week cohort experience consists of five components: preliminary online training modules, in-home visiting, collaborative assessment and development of integrated care recommendations, follow-up contact and a debriefing with supervising medicine and nursing faculty from the University of Rochester and social work faculty from SUNY Brockport’s College of Education and Human Development.

“The College at Brockport is committed to playing an important role in developing this interprofessional model of in-home assessment to address the complex needs of our aging population,” said Thomas Hernandez, interim dean for the college of education and human development. “Each discipline — social work, nursing and medicine — brings an equally important skillset to the table.”

As many as 40 interprofessional teams will have the opportunity to participate over the course of the two-year project, which includes a $50,000 grant from the National Center and $200,000 in total funding, including matching resources from the partner organizations.

“This grant creates a wonderful opportunity for us to extend our previous work in interprofessional education — largely anchored in Strong Memorial Hospital and within the schools of medicine and nursing — to the community,” said Sarah Peyre, assistant dean for interprofessional education at URMC. “This is a novel, innovative program that will change and determine the course of interprofessional study for both our nursing and medical students moving forward.”

The Rochester team was one of 16 chosen by an advisory council of national leaders to receive funding for the Accelerating Interprofessional Community-Based Education and Practice program. Each recipient team is led by a graduate nursing program and includes one or more professional schools and a community partner.

“We are profoundly aware that the future of health professions education will necessarily be interprofessional, community-based and community-driven,” said Kathy Rideout, dean of the UR School of Nursing and vice president of URMC. “The GHV initiative moves forward our work in these domains and excitingly moves us to a new model for the involvement and co-education of our nursing and medical students, along with social work professionals, toward improved patient and family care and outcomes.”

Unmet behavioral health needs of older adults impose significant health, social and financial costs to communities. A 2016 report by the Finger Lakes Health Systems Agency noted that mental health and substance abuse disorders are associated with 45 percent of the region’s hospital admissions, and suicide ranks as the leading cause of years of potential life lost. Adults ages 65 and older account for 15 percent of the region’s population, with projections indicating that the number could reach 22 percent by 2025. Older adults already face constricted access to behavioral health services due to shortages in the number of providers, exacerbated by poorly integrated systems of physical and behavioral health care.

Lifespan social workers serve older adults who are among the most vulnerable and underserved in the region — 45 percent have income less than $15,000. The agency conducts an increasing number of behavioral health screens each year, totaling 426 in 2015.

“Across our programs, we see an escalating need for improved behavioral health identification and intervention,” said Ann Marie Cook, president and CEO of Lifespan, which assists 31,000 clients annually. “Daily, we hear from our clients and their families that they are struggling with complex behavioral issues.”

“It is gratifying to see the return of home-based health care,” said Eric Caine, chair of the department of psychiatry at the UR School of Medicine and Dentistry. “Too often we wait for people to come to our hospital or clinic door. Now students will learn the skills of going to the doors of older people who face multiple health challenges, individuals who often do not have the ability or support to readily seek care. For persons with mental health concerns, this is especially important.”