Patricia Hanrahan

Criteria for Enrolling Dementia Patients in Hospice

OBJECTIVE: Because survival time varies greatly, it is difficult for dementia patients to meet a key criterion for eligibility for the Medicare hospice benefit: a 6‐month survival time. We have developed criteria for the Medicare hospice benefit that include the characteristics of advanced dementia and related medical complications. The purpose of the study was to determine survival time among dementia patients who met these criteria. Additionally, because the National Hospice Organization (NHO) developed its own guidelines while the study was in progress, we retrospectively examined the application of these guidelines to our sample.

What Is Appropriate Health Care for End-Stage Dementia?

Objective: This study sought to determine the kind of health care that professional and family caregivers viewed as appropriate for end‐stage dementia patients.

Access to Hospice Programs in End-Stage Dementia: A National Survey of Hospice Programs

OBJECTIVE: Because care of end‐stage dementia is a significant clinical problem for which alternative modes of care are needed, this study examined the extent to which hospice programs served dementia patients.

Repetitive behaviors in chronically institutionalized schizophrenic patients

Repetitive dysfunctional behaviors (e.g., polydipsia, bulimia, hoarding, mannerisms) are frequently observed in chronically institutionalized schizophrenics, cause significant morbidity and are readily reproduced in animal models. The goal of this study was to assess the frequency and severity of these behaviors. Thirty-two chronic schizophrenics on an extended treatment unit were rated on the Elgin Behavioral Rating Scale, which includes eight repetitive behaviors and eight positive and negative symptoms. Forty-seven percent of the patients exhibited at least one severe, or 2 moderate, repetitive behaviors, while 63% exhibited at least one severe or 2 moderate positive or negative symptoms. The mean total score (+/- SD) on the eight repetitive behaviors (10.3 +/- 6.1) was about 2/3 that for the eight positive and negative symptoms (15.3 +/- 8.9, t = 4.1, p = .0001). Interrater reliability for the repetitive behaviors was similar to that for the positive and negative symptoms. Repetitive behaviors were positively related to male gender, white race and total length of hospitalization. Repetitive dysfunctional behaviors are frequently observed and can be reliably rated in chronically institutionalized schizophrenics.

Palliative Excellence in Alzheimer Care Efforts (PEACE): A Program Description

Hospice is the standard method for providing quality end-of-life care in the United States. However, studies reveal that persons with dementia are infrequently referred to hospice, that barriers exist to increasing hospice utilization in this population, and that patients with dementia would benefit from hospice or hospice-like services earlier in the disease course. The Palliative Excellence in Alzheimer Care Efforts (PEACE) program responds to these deficiencies, striving to improve end-of-life care of persons with dementia and to integrate palliative care into the primary care of patients with dementia throughout the course of the illness. The PEACE program is a disease management model for dementia that incorporates advance planning, patient-centered care, family support, and a palliative care focus from the diagnosis of dementia through its terminal stages. PEACE is coordinated through the primary care geriatrics practice of the University of Chicago. Patients and caregivers are interviewed every 6 months for 2 years, and a postdeath interview is conducted with caregivers. These interviews assess care domains important for the optimal care of persons with dementia and their caregivers. A nurse coordinator reviews interviews and provides feedback to physicians, facilitating enhanced individual care and continuous quality improvement for the practice. Initial feedback suggests patients have adequate pain control, satisfaction with quality of care, appropriate attention to prior stated wishes, and death occurring in the patients location of choice. Families voiced similar high marks regarding quality of care. This program demonstrates an innovative model of providing quality palliative care for dementia patients and their caregivers.

Criteria for enrolling dementia patients in hospice: a replication.

Because survival time varies greatly in dementia, it is difficult for dementia patients to meet a key criterion for the Medicare Hospice Benefit, a six-month survival time. In a previous study, the authors examined guidelines for admitting dementia patients to hospice; the National Hospice Organization (NHO) guidelines were found to work well in identifying appropriate candidates for hospice among dementia patients. This was especially true for those patients whose deficits had progressed in an ordinal fashion consistent with Functional Assessment Staging (FAST) and who had reached stage 7C. The purpose of this study was to examine the utility of the NHO guidelines in identifying dementia patients who are appropriate for hospice; the limitations of these guidelines regarding non-ordinal patients; and the importance of the actual care plans used—as opposed to our previous study, which only examined initial treatment plans. Forty-five dementia patients enrolled in Hospice of the Great Lakes in Illinois were studied longitudinally over two years; this included a follow-up period of at least six months for all patients. Measures included: survival time; FAST; a medical complications checklist, which consisted of common complications of end-stage dementia; and co-morbid medical conditions and aggressive care, which consisted of feeding tubes, antibiotics, and Foley catheters used during the course of the study. Patients who had reached Stage 7C at intake had a mean survival time of 4.1 months; and the majority (71 percent) died within six months. Non-ordinal patients lived significantly longer at a mean of 10.9 months (p < .01), and and the minority (30 percent) died within six months. Foley catheters decreased survival time; and the use of antibiotics did not make a difference. This study echoed our previous findings regarding the usefulness of NHO guidelines in identifying dementia patients with a survival time of six months or less, specifically those at stage 7C or greater. The findings also suggest that the nature of the palliative care plan influences survival time.

Jail linkage assertive community treatment services for individuals with mental illnesses.

Persons with mental illnesses who are released from jail or prison are at high risk of psychiatric decompensation and re-arrest. This paper describes an ACT jail linkage program for this population that won an American Psychiatric Association Gold Award (2001). Based on interviews with its first 24 participants, we illustrate how they experience factors that contribute to recidivism and decompensation. Pre- and post-data are examined to explore program outcomes. Results suggest that it is possible to identify, engage, and retain people in treatment who struggle with many risk factors. We conclude that this program should be expanded and replicated.

Feasible criteria for enrolling end-stage dementia patients in home hospice care.

Hospice care is considered appropriate for end-stage dementia patients (Luchins & Hanrahan, 1993), yet less than 1 percent of hospice patients have a primary diagnosis of dementia (Hanrahan & Luchins, 1995). This pilot study tested the feasibility of providing palliative care for dementia patients. A common eligibility requirement for admission to hospice is that the patient is likely to die within six to seven months. The uncertain survival time of dementia patients thus prevents access to hospice programs. Therefore, enrollment criteria were developed based on the characteristics of advanced dementia and a history of medical complications. With these criteria established, it was then possible to enroll 11 patients over two years. The enrollment criteria proved successful in that the median survival time was five months, with an average of seven months. Eight of the 11 patients died during the study. Hospice care was well accepted by family caregivers and appeared to meet the patients needs.

Representative Payeeship and Mental Illness: A Review

Representative Payeeship (RP) is intended to help individuals who are unable to manage disability payments appropriately to meet their basic living needs. This paper reviews the literature on whether RP is effective among individuals with mental disorders. We also review RPs mental health effects and its use as leverage in achieving behavioral goals. RP appears to be effective in helping clients meet their basic living needs; it also may decrease hospitalization and improve treatment compliance. Finally, we propose a research design to disentangle the role of clinical leverage from the more basic money-management function of RP.

Choosing Effective Interventions

Recent evaluations of social work have provided evidence for the effectiveness of a variety of treatment methods. This development has greatly aided in the establishment of a scientific basis for the profession but has not significantly influenced the decision making of practitioners. One reason for this is the difficulty of rendering such information into a form that is useful to practitioners. This article suggests guidelines that practitioners can follow in assessing and utilizing research findings.