Well, anyway, so hi, I'm the third one on this list. I don't know why Bob, this was supposed to be Bob Rocha's part, he's at Johns Hopkins, he's like vice president for academic advancement or something like this, but we are here representing geriatric psychiatrists from the Committee on Aging for the Group for the Advancement of Psychiatry. And let's see, so as Bob here, I'm going to set the stage for why we are presenting this and we think it's important, because even if you're not all geriatric psychiatrists, you will see older adults in your practice, right? And there is just, there is no way we can train enough geriatric psychiatrists, right, to take care of the population. So we wanted to talk about a couple of ways we're trying to fill that gap. So we all know that there are a lot of older adults, right, coming and the problem is, you know, we've got all these older adults, this is the tsunami, right, that they always call it. What we hated, you know, I heard someone talk about it in an ageism talk recently about how they don't want us to call it the tsunami anymore, because that's like a disaster, right? And that, like, aging should not be a disaster, right? Oh, hello to you in the back. No, it doesn't have to be, it doesn't have to be a disaster, it should be a wonderful time in your life, right? And if you wonder why I'm here, two of the speakers had medical emergencies in their family, so they're not here, so that's why I am not Bob Rocha, and the last speaker is stuck in an Uber outside somewhere. So here I am, I'm E.J. Santos, I am the Chief of Geriatric Psychiatry at the University of Rochester. I was going to get to my intro of myself later. Oh, MBD is here, yay! She is our fourth speaker. I'm doing Bob slides now. The introduction to why everybody should be compelled to be here, and why the tsunami, the silver tsunami, we have to think of a different name for it because it's not a disaster, right? It should not be considered a disaster of older people coming to take over and, you know, wipe out the population. You know, there's a lot of older people, no matter what you're doing, you are going to see older adults, right? Even if you're a child psychiatrist, I don't know how many of my older adults are actually taking care of their grandchildren, right? There are a lot of people. So I'm getting calls from child psychiatrists looking to get help for the older adults that they see, right? And the workforce is definitely not going to support, you know, the growth of older adults. There are only 1,244 members of the American Association for Geriatric Psychiatry right now. And as of last year, per ABPN, the number of active board-certified geriatric psychiatrists, there's almost like 2,000 board-certified geriatric psychiatrists, but if you think of like who's actually in practice, it's only 1,354, which is very sad, right? Which includes like three of us in this room, yeah. So we are a very special group. If you want to join us, I'm happy to talk to you about this. Actually, Dr. Erica Garcia-Pittman here is the Director of the Geriatric Psychiatry Fellowship at Dell Medical School in Austin. So we are not training enough people to become geriatric psychiatrists, right? Certification began for geriatric psychiatry in 91. It only started in 1994 that you needed to do a fellowship to take the board. And the pipeline is not getting any better, let me tell you. We only trained 58 fellows in last year, in 2022. And it's usually between 50, the height was like at one time 102 psychiatrists. I remember that distinctly because it was when I was a fellow and my friend Lisa and I were like, oh, we're the last two. We counted ourselves as 101 and 102. But it's just getting worse right now. So what we're going to present today are hopefully some solutions to help you guys. You know, we don't expect you all to become geriatric psychiatrists, though we would love that. But we have to build on the workforce that we have, right? And kind of create some non-expertise workflows. So we are going to talk about workflows in terms of settings. The first one is going to be like primary care. The second one is going to be in skilled nursing facilities. And Dr. Dix is going to talk about expertise in the inpatient settings, all right? So Dr. Nash, who could not be here, she is in Oregon and she is the director. She's actually a psychiatrist and an internist, right? So she did a Psych and IM fellowships. And she runs the PACE program, the Program for All-Inclusive Care of the Elderly in Oregon. And we're going to present her slides. I'm E.J. Santos. I am, like I said, geriatric psychiatrist, chief of geriatric psychiatry at the University of Rochester in upstate New York, not the Rochester where Mayo is in Minnesota. People do get on the wrong planes and end up at each of our institutions and we send them back to the right place. And I'm going to talk about Project ECHO and using telepsychiatry in long-term care. And Dr. Dix here is a geriatric psychiatrist at Yale. And she is going to talk about some of the innovations she's done to help the non-geriatric psychiatrists take care of geriatric patients in inpatient settings. Hello, everyone. I'll be talking about expanding access to expertise through innovating to share our knowledge psychiatric consultation to PACE as a part of integrated healthcare on behalf of Dr. Maureen Nash. She has no financial disclosures to discuss. She's a medical director for the Providence Elder Place Oregon PACE program. So the learning objectives for this portion of the talk are to describe three factors about the PACE program, which is the program of all-inclusive care for the elderly, that make it an ideal setting for expanding psychiatric expertise to improve care, describe a path to evolve integrating behavioral health into PACE programs, and describe two outcomes of integrating behavioral health expertise in PACE. And at the end of this talk, it is Dr. Nash's hope that we all understand a little bit more about how PACE programs work and why they are the perfect place to have sort of a psychiatrist's consult and liaise with primary care providers. So the PACE program, the program of all-inclusive care for the elderly, it's a specific Medicare product, whereby there's an integration of all healthcare across multiple medical and psychiatric conditions. Adults greater than 55 and up meet criteria to live in a nursing home at the time of enrollment but are stable enough to live in a community with PACE supports. And this requires a large interdisciplinary team, similar to what one finds in a nursing facility. There's a sort of a tri-agreement between CMS, state Medicaid, and the PACE organization, and essentially all of the care is bundled within this lovely little sort of microcosm, and so they control all of the care. And this is a very great program for people with severe mental illness, chronic mental illness as they're aging, and need sort of wraparound services. Get meals, transportation, assistance with their activities of daily living, medical care. The other great part of this is that, you know, the PACE regulations are in the same section as the Medicare Advantage regulations, but it's a very different product. Similar to some of the other programs, PACE is Medicare A, B, C, D, and I think Medicaid, and, therefore, there are some states that do not have PACE programs, but if you are interested in trying to get one in your state, you can talk to your state Medicaid representative. But this is really a truly good way to integrate care. We've got 147 organizations and 306 PACE centers, over 60,000 participants, and as you can see from this model, 95% live in the community, which is great. This is really a great way to integrate care and enable people to live in the community rather than in facilities. Here's the sort of breakdown of what people usually need. About a third need help with most of their basic activities of daily living, and about 87% are eligible for both Medicaid and Medicare, 13% Medicaid only. And on average, these patients take about nine trips per month, that's from appointments. They're on at least six prescriptions per month, and they get five visits to the PACE center per month. PACE is in 32 states and rapidly growing. As I mentioned before, it's not in every state, and it's kind of like a combo senior center for activities and socialization plus rehab and primary care and behavioral health. And primary care providers tend to be, geriatrics trained have a lot of knowledge about caring for frail older adults with medical comorbidities, but because of the high penetrance of Medicaid, there is significant prevalence of those with comorbid serious mental illness, like dementia for instance. And the fact that PACE has the ability to pay and has to pay for both acute and chronic care, the incentives, this incentivizes the PACE organization to provide excellent management of all chronic conditions. Here's a brief breakdown of what participants look like roughly, and some of the comorbid medical and psychiatric conditions. Here's a breakdown of quality and cost. It's a very cost-effective way of providing integrated care. It keeps these patients out of the hospital, lower utilization of emergency room visits, coordinating the care that includes behavioral and physical care, medications, transportation. It really just, it does a lot for the patients, and the state Medicaid programs are actually paying less for a higher quality of care. The time is now. Why is it so important? Obviously, as we mentioned, the population is aging, and we have many, many aging individuals with chronic mental illness and comorbid medical conditions, and they need wraparound services, and an integrated care approach would be preferable and the most cost-effective. Coordination of care is more vital than ever, and if people who have worked through a VA have ever seen how there's a collaborative care within those systems. So similarly, looking at those kinds of outcomes, the same carries over for the PACE program. And this also helps to bring the behavioral health aspect into programming and to have the psychiatrists involved in caring for these patients. If we don't have these PACE programs, then what happens is we have high levels of need that are, again, overtaxing our emergency departments and possibly keeping patients institutionalized longer than is necessary. So PACE patients are frail. Again, the next few slides are just going to highlight the level of complexity in these patients who are older adults, have multiple medical conditions, and chronic mental illness. And obviously, you know, it's a no-brainer that a collaborative care approach is really what is most effective and efficient for everyone. You know, and it's especially for those who are not necessarily geriatric psychiatrists or geriatric medicine, internal medicine providers, may not really understand how so many people with chronic and severe mental illness do end up frail and needing more ADL supports. You know, this population of individuals oftentimes will end up being diagnosed, you know, with cognitive impairment and functional impairment a little earlier than one might expect in the general population. Providence Elder Place PACE in Oregon, these are the rates of behavioral health diagnoses. And as you can see, about 70% have dementia. And, you know, that's a pretty large proportion. And I presume those people with dementia probably need some sort of assistance with their activities of daily living, transportation, so on and so forth. This is a little snapshot of what some of the staffing might look like over time. And, you know, it doesn't look like a lot, but being that there are only how many geriatric psychiatrists in the country? About 1,300, you know, and with the population aging, you know, these numbers will definitely need to be higher. And so with the psychiatric mental health, there are nurse practitioners that are heavily involved in this work. And as I mentioned, behavioral health shortage of providers who are either trained in geriatric psychiatry or comfortable with geriatric psychiatry. And so we are heading into a situation in which taking care of older adults will be very essential for all healthcare workers really to have some experience and knowledge with. Again, these are just a few more slides speaking to the ways in which we are able to sort of deinstitutionalize people with serious mental illness through these types of programs. and unfortunately, again, it's not available everywhere in the country. And this also affects annual medical expenses, hospital-length of stay. There's a link here, I think, to look at the benefits of a cost analysis. I will say that some of the slides, some of the data was actually from the University of Rochester Medical Center, and a lot of PACE programs are really run by geriatric internists, so geriatricians, right? But if you're interested in helping, they do still have a very high burden of mental health problems, so going and asking your local geriatric medicine colleagues if they need assistance really could help you integrate into their system. They may not even know that you're interested in helping. Every time I have gone to like AGS, the American Geriatric Society, they're very excited for any kind of mental health people that want to help them. So if you don't have a PACE program in your area or anything like that, but you're interested in helping older adults where they're at, working in a kind of collaborative care model within a primary care setting with geriatric medicine is very, very welcome. So I just encourage you all to look in your area and see, because as you noticed, her last slide said that there are four states without any geriatric psychiatrists at all. »» And again, that's just the practicing ones. There are many states like Connecticut where there are lots of psychiatrists, however many are not necessarily in practice. »» So a few more informational slides about some of the key elements of the integrated health care that's provided within the PACE programs. You know, again, sharing the care coordination and management is really probably the key to all of this and helps it come together. Rationale, again, I think I'm probably preaching to the choir at this point, but essentially this is, you know, synchronously addressing an individual's physical, mental, and behavioral health needs and in a way that's just more efficient and more cost-effective. And these are a few slides here showing how the behavioral integration within the PACE programs have evolved over time from a consultative model to a co-located model, a collaborative model. And you know, sort of more recently it's been a bit of a combination of a consultative and a co-located model. These are some of the benefits and I'll probably go through some of these slides. »» And I know Dr. Nash, you know, she really wishes she could be here. If you have questions specifically about PACE, she's very unique because she is a psychiatrist and an internist. I'm sure she would be happy to have you email her any questions or anything. So if you want her information afterwards, I have no doubt we could give it to you. »» Yes. It is maureen.nash at providence.org. And so by 2017, which I suppose is the most recent model, the collaborative model, involves choosing a correct psychiatrist and a psychiatrist that's, if not double-boarded, then well-versed in chronic medical comorbidities. So a geriatric psychiatrist, psychiatrist who is double-boarded in internal medicine or even consultees on psychiatrists. And they usually work with the trained mental health nurse practitioners and collaborate between social work and other staff. This is how collaborative care for geriatric psychiatrists works. And some of the reasons why this collaborative care model works, although again, we have a very low number of practicing geriatric psychiatrists in the country. Other roles, in addition to providing consultation and supervision of nurse practitioners, there's also education to the entire team. And I will be talking in another portion of today's talk a little bit about how the geriatric psychiatrist can, in essence, educate everyone if necessary on managing some of these patients. All right. So I think we're almost at the end. And some of the examples of some of the standardized tools that are used in PACE. Looks like they are moving away from the GDS, the Geriatric Depression Scale, and using other specific scales to just sort of standardize their data across the different multiple disciplines involved. And right now, there's an example of a data analysis leading to practice change, so it's very important to be able to use standardized scales so that data can be extracted from electronic medical records. And it looks like one example of that is a chart review of patients with dementia presenting to the ED with agitation and aggression in 2015. This whole analysis, and there was a very high Charleston comorbidity index, resulting in two deaths within two months of ED presentation. And when the PACE participant went with advanced dementia presents to the ED, it's a completely different scenario. They are quickly linked in with palliative care, and that obviously reduces length of stay and cost to the system. Here's another lovely graph of inpatient psychiatric days and how those are impacted by having a PACE program. So this is basically saying that I need to get on the phone with a state Medicaid official in Connecticut so that I can reduce my inpatient psychiatry length of stays on my geriatric unit. And that's it. So I'm going to talk next about how we've used Project ECHO and telepsychiatry in nursing homes. So now we're moving the focus from outpatient like primary care to long-term care, right. So as I said before, I'm E.J. Santos. I am the Chief of Geriatric Mental Health and Memory Care at the University of Rochester in upstate New York, not the Rochester in Minnesota. And I'm going to talk to you a little bit about how we addressed the problem of the need for geriatric psychiatry expertise in skilled nursing facilities. So New York State actually has been a lot in the news in the last three years. You've probably heard something about our nursing home situation. There are 624 nursing homes in New York State now. Many nursing homes actually because of staffing shortages, they may still exist, but maybe they're at half the capacity or a third of the capacity because of staffing shortages by the way. COVID has been really devastating for us in many, many ways. But we still have the problem, of course, of nursing home admissions being a very high proportion of people with mental illness, right. So it's really changed over the years. Before it used to be more acute medical illness in nursing homes, right, which is what they were basically designed for. But now as, you know, we're doing a great job keeping everybody alive, right, with mental illness now, but also many of our medications cause a lot of medical comorbidities and cause people to age a little bit faster, needing nursing home level of care maybe at a younger age too. So maybe in their 50s or 60s, we're seeing a very high burden of mental illness in skilled nursing facilities that they were not prepared for in any way. And similarly to the population in the PACE program, you know, there's at least 50%, and sometimes it's just because they haven't been diagnosed, of people who are residents in skilled nursing facilities have cognitive impairment, right, whether or not they were diagnosed with dementia. And of course they're at higher risk for hospitalizations. So traditionally, how I was trained, you know, you do geriatric psychiatry consultation in nursing homes, because there are not that many of us, it was probably a general psychiatrist who would go, maybe a psych nurse practitioner. It was all in person, right. And of course when they're calling you, they're focusing usually on medication adjustments. Oh, this person is sick and they need a new med, right. What can you do? Just come in, change their meds and everything will be fine, right. Depending on where you are, I mean it could be any day of the week, I actually still know somebody who does nursing home consultation on Saturdays because, you know, he works a regular full-time job and the only time he can go is Saturday. Sometimes he comes in, you know, late in the evening. So he's not always there when most of the staff is there, right, which can cause a problem. That's why there's limited input from staff. Now you might say somebody needs actually psychotherapy, right. Could you get that in a skilled nursing facility? It's hard to do, as you can imagine. There are some groups that will do that. But it can be very limited and, you know, what can they do? How do you bill for it? What's their training to do psychotherapy in a nursing home? That's also difficult. And it's not always that useful for dementia, right. So what kind of therapy are you doing? You may say, oh, they need it. But if they're not trained to deliver psychotherapy to somebody who has some cognitive impairment, or they don't understand how someone could absorb that information, then it can be not so useful, right. And they didn't used to be focused on behavior plans or staff education, right. Because they were just going in, giving meds, doing med changes, and then leaving. And they might say, oh yeah, you need psychotherapy, and then leave it at that, and not tell you how to get it. So another concern that I'm sure all of you have heard about, you know, there was a big article in the New York Times not too long ago about the overuse of psychotropics in nursing homes, right. So one of the reasons that we came up with this program is because one in five, oh, it's not even in the right place, but one in five of these people are given psychotropics, right. Are one in five people, though, like schizophrenic? Do they need psychotropic medication? I'm talking usually antipsychotics, really. Well not usually, right. But there's a lot of overuse of antipsychotics in nursing homes, right. Especially when you're not really targeting what you're using the antipsychotic for. So if you're still going with like the old model where you just need medication to keep them quiet and the staff is like, they're overworked, you know, everybody's screaming, they have some kind of psych history, I don't know, and he's crazy, but he's keeping up the other 30 people on the unit, right. Many, many times you would see that they call the person on call and just say, can you give them Haldol, right. And they don't know anything about why you're giving them Haldol, they just want everything to be quiet. So but why is there pushback for antipsychotic use in nursing homes, right. Well there's significant safety concerns, right. Most of us here have prescribed an antipsychotic for somebody. You know about metabolic syndrome and cerebrovascular events, EPS, right, and even death. With older adults especially, they may be already very physically frail. You know, I did these slides earlier, there were no FDA-approved medications for dementia with behaviors. I think there is, Reg Zelti just got an indication like last week, right, for this. I have not used it by the way, because I work in a CMHC, which is a community mental health center. And same as skilled nursing facilities, they don't have the money to pay for Reg Zelti. So that might be great. I mean, the same goes for Pimivansirin, which is you know, for like psychosis with Parkinson's disease. I've tried to prescribe this for people. No one can pay for it, right. So that's great that we could put Reg Zelti there now. But I can't imagine, you know, the capitated payments that go to skilled nursing facilities or the patients that I have that have a very limited income, right, that they're not going to be able to pay for this. Of course Tier 5 drug that is non-formulary, that is, well we'll see if it works, it's still going to have other problems. But in skilled nursing facilities, I bet it's not going to be on their radar anytime soon because it costs way too much. So in skilled nursing facilities, there are only three approved reasons to use antipsychotics, right. If you have schizophrenia, schizoaffective disorder, Tourette's syndrome or Huntington's disease. Now, you can get away sometimes with bipolar disorder if you document well that they have failed lots of other, you know, trials of mood stabilizers and stuff. But really, if the state comes in, definitely in New York, and does a chart review, right, and they don't see schizophrenia or Tourette's syndrome or Huntington's disease and they see an antipsychotic on that list, that skilled nursing facility is going to get dinged, right. And so that's a little bit of the difference between, you know, I did not know that in general psychiatry training, right. In geriatric psychiatry, we learn about the different settings of care and what kind of, you know, the F tags and other regulations that skilled nursing facilities have on them. And so when a psychiatrist who is not trained in geriatrics tries to give recommendations in a skilled nursing facility and they don't understand the differences in their regulations, there can be a lot of butting of heads, okay. And so this has resulted in dementia patients being newly diagnosed with schizophrenia. Now I cannot say, I have diagnosed two people with schizophrenia who did not carry those diagnoses in a skilled nursing facility. But that's only because they were like kind of hidden in their homes. We think they had schizophrenia their whole lives. They were just kind of managed on the farm, you know. If you look at their, they had schizophrenia before, they just really didn't have any kind of medical history at all. so when I wrote it on the chart, it wasn't that, oh yeah, I just discovered this person has schizophrenia, no. I'm just actually writing it down into a record, and everyone's like, oh yeah, this person had schizophrenia, just nobody ever wrote it. But it usually doesn't show up in older adults, right? So the rash of people being diagnosed with schizophrenia to get out from under the regulations has been highlighted recently in the news, right? So that being said, we know there are not that many people that have antipsychotics, that have schizophrenia, right? Or Huntington's, or Tourette's syndrome, and yet 15% of long-term stay individuals receive antipsychotics, right? So what did we do to combat this? Because we would see, I also ran the psych emergency at this time, and I would see people coming into the emergency room from skilled nursing facilities, in all kinds of states of delirium, the nursing homes didn't want them back. They're like, oh no, these are your people, you have to manage them, they need to go to inpatient psychiatry, and we didn't know what to do, how to help people in these situations stay where they need to be, because they're medically complex, not crowd our inpatient psychiatry units, but also still receive appropriate psychiatric care without being over-medicated with antipsychotics. So knowing all that we talked about with workforce shortage, my team came up, well, we didn't come up with, we found Project ECHO, this was over 10 years ago. We were searching for, okay, what can we do? There will never be enough of us. I run the only geriatric psychiatry program in upstate New York, so there's a lot of psychiatrists in New York, they're just not upstate, they're mostly down in New York City. So the rest of the state is mine. We found Project ECHO, the Extension for Community Healthcare Outcomes, and this was developed by Dr. Sanjeev Arora at the University of New Mexico in Albuquerque, and probably now a lot of you have heard about this, Google Project ECHO, it's in over 40 countries around the world, but when I found this with my team in the early 2010s, there were no Project ECHOs in New York State at all. This was the first one, so we had to convince everybody that this was a good idea, and we started out with the same kind of model that they did in New Mexico. The original JAMA articles about Project ECHO are related to hepatitis, right? So basically the idea was he's a hepatologist, Dr. Arora, and he was seeing a lot of people when they needed liver transplants already, and he said, well, why are these people coming to me so late in the game? How can we educate primary care physicians to take care of them in the rural areas and not need the specialty care when it's too late? So we took the same idea and tried to apply it to geriatric mental health, and to do this, we started out with primary care physicians all over upstate New York, and we got 40 primary care physicians. There was one lone practitioner in the very top of New York, which was great, but we also got people from like SUNY Binghamton, SUNY Buffalo, Niagara Falls, places where there were actually a lot more people because they wanted to learn how to take care of older adults with mental health problems. And the idea of Project ECHO is actually tele-mentoring, right? It's the idea of one to many. Okay, I'll show you how it works here at U of R. Now, we started out with primary care physicians. It was so successful with them that we transitioned to skilled nursing facilities. So this is actually the third iteration right now that I'm gonna talk about. We still do the other Project ECHOs as well, but we have this hub site, which is, it doesn't have to be at a university, right? For us, it happens to be at the university, and there's a geriatric psychiatrist, who is me, a geriatrician, a psychologist, or some kind of therapist, a social worker, and someone actually from the Alzheimer's Association works with us as well, and a PharmD, who are all on the expert hub site, right? And we actually use Zoom. So we were using Zoom since like 2014. So we were, thank God, before Zoom, I already knew how to use it. So actually, my whole team trained our whole department in a week, in March of 2020. So it was great. And we use Zoom to reach out to all of these skilled nursing facilities, and the way it works is that you have a case that's presented. We changed, the original Project ECHO idea is 90 minutes. You present cases, and you have a didactic as well. And so they get free CME credit from this. And there's no cost to the providers, the skilled nursing providers or social workers, no one. But we found out in skilled nursing facilities, they pass lunch, right, at noon. So it used to be noon to 1.30. So now it's only one hour from one to two, because that actually works for them, and it's every other week. They present one case, because they're so complicated, maybe we have a case update, and then we do, and we also do a 15 to 20 minute didactic. We always do a deprescribing didactic every six months. But then all the other ones are based on whatever we feel like they need, or the evaluation say, like I just did one on personality disorders, or how to deal with narcissists, behavioral care planning, and such. So it was the second iteration of Project ECHO that we started with just long-term care facilities in the Finger Lakes in upstate New York, and that was 2015 to 2019. The way we were able to do this was actually from grant funding. That always comes up, how did you afford, how could you do this? And we did get a grant to do this. We used disrupt funding. So New York State got money to do a Medicaid expansion projects, and to try to lower costs, and number three was for skilled nursing facilities. We did not know that we were the only ones who took up that project, because you don't know what everyone else is doing, but we were the only ones apparently, and it was apparently very successful, and so the Office of Mental Health in New York State asked us to do it for them in the middle of the project. So we had already filled our goals for the three years of the disrupt project within the first year, and the Office of Mental Health came knocking and said, okay, we want you to do this for us. You're doing it for all these nursing homes, and we're like, what are you talking about? So you can't really say no to the Office of Mental Health in New York State. So I did not, and so concurrently, we still have actually the two ECHOs, one just for skilled nursing facilities, and now I also run the ECHO-GEM Office of Mental Health program, which is skilled nursing facilities and psychiatric centers. So if you know anything about psychiatric centers in New York State, they are trying to deinstitutionalize a lot of our older adults, or not even that they're older, a lot of their patients in the psych centers because of the medications that they use. They've had a lot of strokes, a lot of metabolic syndrome, right? They have aged very quickly, and so need skilled nursing level of medical care, right? So what we do is kind of bridge the gap between psych centers and skilled nursing facilities. So they had discharged maybe successfully, I was told, less than 10 people from psych centers around the state to skilled nursing facilities, and they were having trouble, and that's why they wanted us to help. Since we've done Project ECHO with psych centers and skilled nursing facilities, this is their, according to them, I have no data of this on my own, we have helped them place over 500 people successfully from state psych centers to skilled nursing facilities. We actually, I thought, I knew we were helping, and I thought maybe it was 100, but last year they told us it was over 500, so I was like, oh wow. So that's why they pay for this program, okay? And what we do is we have the same, actually the same hub site, the same expert hub site, and now we have psych centers and skilled nursing facilities both presenting cases, right? So they will, and in doing this, they learn how different they are, right? So psych centers have psych techs, right? They know how to manage behaviors, they're doing all these things, but they also use like three antipsychotics, right? Two mood stabilizers, three antidepressants, I mean, they have some, for lack of a better word, impressive psychotropic medication lists at the psych centers in New York State. Skilled nursing facilities cannot manage those medications, right? So they get very scared, they see this huge list of medications, and also often, you know, history of violence, fire setting, they killed their mom 20, when they were 20 years old, but now they're 60, right? So a lot of things in the history scare skilled nursing facilities, even though this is a very different person now, right? Who often has dementia or some other geriatric syndromes, right? And the skilled nursing facility is scared, though, of the psych center patients. So that's where we come in. We talk about these patients, or residents in nursing facilities, the skilled nursing facilities really do know how to manage behaviors, by the way, they just don't realize they do. They have been managing behaviors with dementia patients for decades, that's what they do, right? But once they see the schizophrenia diagnosis or, you know, the three antipsychotics, they get really scared and say, we can't do it. So we're able to help them kind of bridge that gap and understand their own strengths. And so we have been doing this since 2017 with Project ECHO in psych centers and skilled nursing facilities. And we've had over 125 clinics and sometimes places, you know, there'll be like 10 people in the room. So there'll be like 50 people on the Zoom or 50 sites, but there's a lot more people that are actually there, right? But what happened is, so we were giving them recommendations at Project ECHO and I write them all up, right? But we found out is a lot of the skilled nursing facilities don't actually have psychiatric help, right? Or if they do, it was woefully inadequate. And so what we discovered is we need to actually develop a telepsychiatry program to help them implement some of these, the recommendations that we were at the multidisciplinary team in Project ECHO presenting to them, right? So what's very different about this model, as you'll see is we have the tele-mentoring is the Project ECHO. Telepsychiatry is similar to what you would think, but it's focused on geriatric psychiatry knowledge, but also having a psychiatric nurse engagement specialist. And I'll explain how different that is. We do use Project ECHO as a way to triage some of the cases to identify some of the residents that might need our help. Our telepsychiatry program is staffed by geriatric psychiatrists. We do have nurse practitioners and we have geropsychologists. So if I mentioned earlier, we would say that somebody needed therapy, right? We actually do supply many of the places with therapy and we have a training program for marriage and family therapists, as well as psychologists at the University of Rochester. And they are able, the trainees, to do some of the therapy. We are not an urgent care service. So we are Monday through Friday, 8.30 to 5. But the nurse engagement specialist is really the key difference here. And they reach out at least once a month for some places that are having some acute issues. It could be even weekly. And they meet with the facilities and provide onsite training and support to nursing homes and their treatment teams. They help create behavior care plans, right? So non-pharmacologic treatment for people. Most of what we do, if you see our recommendations, I start with the non-pharm things that we talk about, which in the middle of taking care of these very complex patients, you know, people don't always think like, oh, maybe I should find out what they like, right? And use that to create different activities for them. Or they don't know what kind of questions to ask their previous providers. But also, then it's often deprescribing is the next part of the recommendations always. I cannot, usually I would say I have two or three things that we say right away to just stop and discontinue in terms of medications. But our nurse engagement specialists follow up with these very individualized care plans and they do a lot of education. And I will show you some of the things we give them. The tele-psychiatry model was also started then in 2017, concurrently with our Project ECHO in skilled nursing facilities and OMH. And we've had over, let's see, so this was a couple months ago. It's definitely over 13,000 visits already. And some of the educational flyers that we put up for the staff there, like the onsite trainings that we do, and some of them are by Zoom too, of course, because these are places that are maybe even four hours away, right? So we do go out there at least a couple times in person so they know who we are. But we do a lot of things by Zoom as well. But we create educational flyers for their staff. And this is one example about exit seeking. Here's another one about de-escalation tips, right? Because again, they're not trained to do de-escalation. And I'm just gonna finish with, this is the, one of our nursing homes, how, this is an example of how we decreased the antipsychotic use in this one nursing home from about 17, almost 18, actually 18%, to about almost 11% in this one nursing home, just mostly with education and doing a lot of de-prescribing. That's actually, that was, that's in all of the nursing homes in our program. That was all the nursing homes. And then in one, this one nursing home, they had a very high use. As you can see, at one point, it was almost 35% of their nursing home. And then by the end of this, by 2019, there were only 11% of that nursing home was using antipsychotics. And here are some of the milestones. And I'm gonna pass it to you, Ebony. Okay. Oh, you have to put your, don't you? Everyone, I'm going to give you a gift. I'm going to speak for maybe like 10 minutes or less, and I'm happy to pass along my slides to anyone who would like to see them. I'm going to talk very briefly about behavioral and psychological symptoms of dementia and a proposed algorithm to manage in acute care settings. I work in Connecticut at Yale New Haven Hospital, and we have lots of older adults who come into the emergency rooms from various settings and are agitated and end up restrained or given IM, Gerperdal, and that's problematic. So this is a project that I worked on with multiple people over at my institution. Firstly, I really don't have anything to disclose other than a small honorarium for a lecture, and the mention of medications in this talk is for educational purposes only. I'd like to acknowledge many of my colleagues who participated in this work, and this ranges from nurses to PharmDs to geriatricians, psychiatrists, and both regular psychiatrists or not geriatric psychiatrists, so I'd like to just give a shout out to those individuals who participated in this. Essentially, the objectives are here today are to define and categorize these symptoms of agitation. We put the word agitation as this big umbrella, but it could mean so many different things and really trying to get a sense of what is appropriate management and kind of trying to standardize it in a way so that it can be shared across disciplines. Now for those of you who may have electronic health records, the way that we were able to do this at Yale was to come up with a way to sort of embed an algorithm into our electronic medical records. So for instance, if your institution has a standard of how to replete IV magnesium, there might be a way to put that in and poof, you can do it without calling for a consult. And so the inspiration behind this was actually a project that was done over at Harvard South Shore, the psychopharmacology algorithm project, and was done a couple years ago, and this is what their, one of the beginnings of their algorithm looked like. So similarly, we kind of all met together as a consensus group, read all of the literature and all the data, and came up with, you know, sort of this first, this is like just a little taste of what our pathway kind of looks like. So if you can just put it in, it's your epic, and okay, what do you do? You have a patient with dementia and agitation, and hopefully you've determined that they do have dementia, and there's, you know, another part of the algorithm you can't see here where we go through sort of the differential diagnosis and that kind of stuff. But the first step is, okay, define, determine what, how severe is it? Is it dangerous or not dangerous? Okay. Is the behavior something where they need to be, you know, given something intramuscularly, right? Or can we just, you know, give them sort of a verbal warning? So we have two arms of the algorithm, emergent, non-emergent, again. Harm is imminent in the emergent pathway, and the symptoms are usually pretty clear. And then the non-emergent symptoms are just those that are usually just annoying in a nuisance and not usually something that needs to be treated straight away. So very quickly, again, we have this background for the emergent, why are we doing the emergent pathway? And this is, of course, an old slide, because just about a month ago, Brex-Piprazole was approved for agitation in Alzheimer's disease. But of course, Alzheimer's is not the only type of dementia. And if you look at all of the guidelines and recommendations, there really aren't any specific recommendations for meds or classes of drugs, right, to use in a demented patient who are agitated. And again, symptoms are usually pretty obvious, although sometimes you'll hear a staff saying, oh, the patient was very agitated. And I want to know, what does that mean? Well, they were taking their clothes off. Okay. So let's describe what that means. Because again, that doesn't mean that they need IM-Droper at all, which of course we don't recommend. And so with this algorithm, and I will go through these slides very quickly, but within the algorithm that we've created, and it can probably be done in other health care systems to help inform treatment for people in the emergency department, hospitalists, interns on the medical floors, the algorithm allows you to sort of click through the options and you have your paths, if it's dangerous or not dangerous, okay, what's the next step? And it kind of really spells through things for you, okay, what do you do next? And this is something that can hopefully help people who don't necessarily have the time or the ability to just call for a psychiatry consult. And these are just really, it's informative, and it's hopefully going to help all of the people at the hospital who have to be faced with these challenges. And again, it goes through all of the sort of tricks and things that one can do and sort of consider when they have a patient presenting in an acute care setting. And of course the general principles, we try to go low, start low, go slow, and we try to give oral medications as much as possible rather than IM-Droper at all, again, which I don't know, I think it was because there was a Haloperidol shortage for some period of time. So again, we go through some of the reasons when it's time to call for a consult and why, how do we even determine what medication? Well, we came up with data and we have it embedded into our system. And we came up with this data based on all of the papers and all of the research that exists to date, consultation with the PharmDs on everything from time to onset to half-lives and came up with an agreeable method of how to dose these medications, starting with very small doses and how frequently you should be giving them, so on and so forth. So this is really, I think, very helpful. Again, I think if you're somebody trying to manage hyponatremia, there's an algorithm. You know what labs to order and you have guidelines for cutoffs and things of that nature. So this is just an example of what is actually in there. And I've actually used this just for teaching purposes of trainees because it's very handy, I'd have to say. And so again, these are just more sort of data points. And again, I'm happy to send slides to anyone who's interested. The next note on this, of course, is the not dangerous behaviors, which I think we all sort of know sometimes can escalate very quickly. And because of this, the number one first-line treatment is usually non-pharmacological. And in our algorithm we have, yet again, literally an outline of the things to do that don't involve medications, the things that you can do. And I mean, of course, I think probably we'd prefer to have one of Dr. Santos's little cheat sheets with the smiley face on it and sort of like, you know, but, right, so set limits, but use a calm, reassuring voice kind of thing. So does anybody have any specific questions? Because I will not bore you with the rest of my presentation. And you can ask questions and I can send you these slides. And again, we're also happy to share the information from Dr. Nash's portion as well. I don't think so, and in my limited experience with brexpiprazole, because brexpiprazole and aripiprazole are very, very similar, and so I don't know. I mean, of course, neither of us were involved with any of the research involved with this, so we're just talking about our work as geriatric psychiatrists, and there's two, at least that I know right here, in geriatric psychiatrists who may want to answer as well, but I agree with that. I have not seen any more efficacy. I mean, there must be something. I have not looked at what... Oh, I'm sure it won't be right »» I don't expect it, again, I mean, primarily because of economic reasons, I don't expect that New York State's going to be able to say, oh, yeah, in nursing homes, yeah, you're going to be able to use this. And I don't think any of my patients are going to be able to afford it, frankly. Because even when I try to, even if it has the FDA indication, insurance doesn't pay for it. Right? »» Right. »» And a lot of hospitals don't have it on a formulary, so similar to Pimavansirin. »» Maybe, I mean, I just recently tried to use Pimavansirin for Parkinson's psychosis after trying many other medications. And even though it was, the insurance said, oh, yeah, that's approved because it has the FDA approval, they wanted $1,000 a month. With the approval. And of course, not knowing that it's going to help at all, I told the family, well, I mean, they could not afford it. There's no way. And that I wouldn't even push it. Because I have not seen it be that so much more helpful, either, you know. I'm not, I don't work for any kind of pharmaceutical company. I take care of actual patients and their families. And I cannot, you know, tell anybody that, oh, yeah, it's worth this much money, right? I mean, even if it's over $50, actually, for my patients, I'm like, maybe we shouldn't try it. You know, let's figure out what's better. I work a lot with palliative care. I don't know about you. »» Yes, I do. »» You know, doing a lot of advanced care planning. And I don't, I was very surprised by the RegZelty indication. I got to say, when it came out last week, I was like, what? I thought I read it wrong. I don't know about you. »» Yeah. Yeah. »» Yeah. Yeah. All right. Any other questions? I mean, we actually do a lot of other work, if you want to talk about that, too. »» Yeah. But if people, it is time for a nap and or happy hour, I'm sure, for most people who have been here all day. So I... »» We appreciate y'all showing up. I mean, thank you for having some interest in this. Thanks. »» Thanks.

geriatric psychiatry

aging population

specialist shortage

Project ECHO

telepsychiatry

antipsychotic reduction

non-pharmacological care

PACE model

dementia management

collaborative care