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Reflecting on the journey of psychiatric home care is a nostalgic process, one that could easily result in despair for those who passionately believe in its importance not only first and foremost to the patients who benefit from this unique care, but also to the financial well-being of a home health agency.


In the early days of psychiatric home care, the focus was on patients with a diagnosis of severe mental illnesses, those with schizophrenia, bipolar affective disorder, major depressive disorder, and anxiety disorders. Many of these patients were covered by both Medicare and Medicaid, so there was flexibility in providing care to those who did not meet the homebound criteria. However, times change, and as the home care industry moved further away from Medicaid and embraced Medicare as the preferred payer, the focus shifted to the elderly with mental health issues, primarily those with depression.


The World Health Organization concluded from its massive Global Burden of Disease Study that among adults, major depressive disorder ranked second only to ischemic heart disease in magnitude of disease burden in established market economies (WHO Initiative on Depression in Public Health, 2001). Among the elderly, those most often served by home healthcare, depression is a huge, largely untreated problem that exists as a primary debilitating diagnosis. However, it also coexists alongside intractable pain, diabetes, heart failure, chronic obstructive pulmonary disease, cancer, and problems of mobility, to name just a few. If depression is not addressed through appropriate medications and some type of therapy, clinical outcomes are negatively influenced. Rehospitalization rates, deaths resulting from suicide, and nonadherence to the medication regimen or the treatment plan all result from untreated depression.


In this issue of Home Healthcare Nurse, Patrick A. Cunningham cites current research that supports depression as a common occurrence among home healthcare patients (Bruce et al., 2002). This research also shows that home care clinicians lack the skills to assess adequately for the presence of depression (Brown, McAvay, Raue, Moses & Bruce, 2003), that up to 42% of patients admitted to home healthcare still meet the criteria for major depressive disorder a month into care (Raue et al., 2003), and that the needs of homebound elders with mental illnesses are not being met by home health agencies (Zelder & Kohn, 2006).


It is clear that meeting the mental health needs of all our patients is important to clinical outcomes, but what is the impact of a mental health focus on the business of home healthcare? Do agencies "lose their shirts" by offering mental health services? Is there any financial benefit to addressing the mental health needs of patients? Are there other benefits to having psychiatric nurses as part of the home healthcare team?


Although it is true that under current Medicare reimbursement rules, mental health diagnoses are poorly reimbursed and that the Outcome Assessment Information Set (OASIS) does not accurately capture the acuity of the psychiatric patient, this is not the whole picture. When the mental health needs of patients are addressed, it is possible to recertify these patients appropriately for multiple episodes. Furthermore, the costs of direct care are minimal, and the gross margin is more than acceptable-it is excellent!!


Another business benefit of having a psychiatric home healthcare program is that it sets the agency apart in the marketplace. Every home healthcare agency provides services to patients with diabetes, heart failure, wounds, strokes, and rehabilitation needs. However, most agencies do not provide psychiatric services. The ability to do so opens doors and reaps referrals.


Even if a home healthcare agency does not want to support a full psychiatric home care program, the value of having at least one psychiatric clinician on the staff of an agency should not be underestimated. This clinician is able not only to meet the mental health needs of medical patients, but also to support the medical staff confronted with behaviors they do not understand and find difficult to handle. This support can contribute to greater staff satisfaction and a lower turnover rate.


Therefore, as individual home healthcare providers, what are you doing to address the absence of mental health services for your patients? Do you advocate for the inclusion of psychiatric home care clinicians as part of your team? Do you or your team of clinicians assess for depression? Do you advocate for antidepressant medications with physicians? Do you recertify a patient for additional episodes so that depression can be addressed, or do you discharge a patient with goals unmet based on the faulty conclusion that the patient was nonadherent?


Remember, that the best quality of care occurs when all the patient's needs are addressed-medical, emotional, cognitive, social, rehabilitative, and spiritual. Oh, and do not forget mental health needs as well!!




Brown, E. L., McAvay, G., Raue, P. J., Moses, S., & Bruce, M. L. (2003). Recognition of depression among elderly recipients of home care services. Psychiatric Times, 54(2), 208-213. [Context Link]


Bruce, L. B., McAvay, G. J., Raue, P. J., Brown, E. L., Barnett, S. M., Keohane, D. J., et al. (2002). Major depression in elderly home healthcare patients. American Journal of Psychiatry, 159(8), 1367-1374. [Context Link]


Raue, P. J., Barnett, S. M., McAvay, G. J., Brown, E. L., Keohane, D., & Bruce, M. L. (2003). One-month stability of depression among elderly home care patients. American Journal of Geriatric Psychiatry, 11(5), 543-550. [Context Link]


World Health Organization. (2001). WHO Initiative on Depression in Public Health. Retrieved August 6, 2007 from [Context Link]


Zeltzer, B. B., & Kohn, R. (2006). Mental health services for homebound elders from home health nursing agencies and home care agencies. Psychiatric Services, 54(2), 208-213. [Context Link]