Access to psychiatric care is critical for the elderly, especially if they live in urban public housing. A recent study found that 27 percent of elderly individuals living in Baltimore public housing projects have a psychiatric disorder, yet 58 percent of those are not being treated.

Barriers include living on low fixed incomes, comorbid medical conditions, and no means of transportation, according to Peter Rabins, M.D., a professor of psychiatry in the community psychiatry program at Johns Hopkins University Hospital in Baltimore.

Another barrier to care is that Medicare covers only 50 percent of psychiatric expenses, compared with 80 percent of other medical expenses.

To bring psychiatric care to this population, Rabins designed the Psychogeriatric Assessment and Treatment in City Housing (PATCH) program in 1986.

The linchpin of the program is a mobile team of psychiatric nurses from the community psychiatry program at Johns Hopkins. They make weekly rounds of public housing buildings for resident referrals, assessments, counseling, and education.

The nurses train building staff, including resident managers, janitors, and medical assistance counselors, to identify and refer elderly residents with potential psychiatric illnesses to them. Specifically, the nurses teach them to distinguish between normal and pathological signs of aging; the signs and symptoms of cognitive, mood, psychotic, and substance abuse disorders; and the intricacies of the involuntary commitment process. Rabins found these four disorders to be the most prevalent among this population in a 1996 study.

Becky Rye, a psychiatric nurse who has been with PATCH since 1994, has an average monthly caseload of 28 elderly residents spread out among 10 public housing buildings. Another psychiatric nurse manages the caseload for seven other buildings in the program.

"Educating the building staff two or three times a year helps us establish a relationship with them and makes referrals and communication easier. The building staff and residents now know me as the nurse who deals with behavioral problems," said Rye.

When the building staff identify a resident with a potential psychiatric illness, they fill out a referral form and select one of the four prevalent disorders. Rye noted that the staff nearly always identifies the correct diagnosis.

When Rye picks up a referral form, she evaluates the resident at that time if possible, but no later than three weeks after.

"A resident manager or other building staff usually accompanies me to meet the resident the first time or makes the initial phone call if the resident has a telephone," said Rye.

"I introduce myself as a nurse rather than a psychiatric nurse because residents seem more familiar with that role and are more likely to accept my help," said Rye.

Rye does the initial assessment of the resident then returns with Rabins to conduct a joint psychiatric evaluation.

They draw up a treatment plan that may include medications prescribed by Rabins. "If there are comorbid medical conditions, we will consult with or refer to a general practitioner in one of the building’s on-site medical clinics," said Rye.

"I typically see an elderly resident with bipolar disorder who is habitually noncompliant with his or her medications or a resident with a psychiatric condition and comorbid medical conditions such as diabetes, high blood pressure, or congestive heart failure who has trouble keeping track of different medications," said Rye.

She meets with the patient initially once a week for education and counseling and then less often once the person is stable.

"Our goal is to help the residents live independently for as long as possible. I usually transfer their psychiatric care to an outpatient psychiatric clinic after six months or to a medical day-treatment program if they have dementia. However, if these options are not feasible, I will continue to care for the person with a chronic mental illness as long as necessary," said Rye.

The public health approach to treating the elderly in the PATCH program appears to be effective in reducing psychiatric symptoms. A study by Rabins and colleagues at Johns Hopkins reported in the June 7 Journal of the American Medical Association shows a significant reduction of symptoms among the PATCH group compared with the control group of elderly residents with psychiatric disorders in public housing.

The participants were aged 60 and older, predominantly African American, female, and living alone in one of six public housing buildings in Baltimore. Sixty-six residents were randomized to the PATCH program and 96 residents were randomized to the control group.

Nearly one-third of each group was diagnosed with a psychiatric disorder according to DSM-III-R. The most prevalent were cognitive (dementia) and mood disorders, followed by psychotic and substance abuse disorders, according to the researchers.

Although a secondary goal of PATCH was to prevent evictions and undesirable moves to long-term care, the study showed the PATCH group had roughly the same number of both as did the control group, according to Rabins.

Ira Katz, Ph.D., and James Coyne, Ph.D., with the departments of psychiatry and family practice, respectively, at the University of Pennsylvania suggest in an editorial in the same issue of JAMA that a move to long-term care is not necessarily an undesirable outcome.

They noted that some patients with Alzheimer’s or other irreversible causes of disability may be overwhelmed by the demands of independent living and may be reluctant to recognize how much support they require. "In such cases, helping patients recognize their impairments and accept the need for long-term care should be viewed as a positive outcome of mental health care."

They agreed with Rabin’s proposal that Medicare should cover programs like PATCH under its home-care benefits to make them accessible to more elderly people. "The public health model suggests the importance of modifying current public policy to bring care for mental disorders out of the traditional mental health care system and integrating it with housing, long-term care, and medical care systems."

The authors encouraged the replication of PATCH in communities with large populations of vulnerable older adults. Rabins told Psychiatric News that replication is occurring in suburban and rural communities in Maryland with funding from the state department of mental health. Meanwhile, the PATCH program continues to operate in Baltimore with a grant from the state—C.L.