Mental Health Disorders of Home Care Elders in the United States

Home care has been the fastest growing sector in the U.S. healthcare system for over three decades. In 2012, there were over 4.7 million home care patients in the United States. Most of these patients were elders (4 million); and this number is expected to increase as the U.S. population continues to age. One major health concern in this elderly home care population is mental health disorders (MHDs), which have been noted with increasing rates and substantial consequences in local data. However, much of our knowledge on this topic was generated from local studies that had a number of methodological limitations. These include over reliance on local and outdated data, a lack of theoretical foundation, and a lack of statistical justification, which may well account for the high variability across findings. To date, no national investigation has been conducted on this topic, supporting the need for a large-scale study which employs recent data to better understand the prevalence, risk factors and impact of MHDs among home care elders in the U.S. This dissertation study addressed these gaps by using the de-identified national home care dataset, Outcome and Assessment Information Set (OASIS), to: 1) examine the national prevalence of MHDs and MHD-caused medical events in the U.S. elderly home care population, and 2) identify factors associated with MHDs and MHD-caused medical events in this population. The 5% random sample used in this study was consisted of 28,475 elderly home care patients: their average age was 79.41; patients were mostly female, white, Medicare beneficiaries, referred from short-stay acute hospitals, and living with others at home. Approximately 38% of this sample had MHDs, mostly depression (28.0%) and anxiety (18.9%). Compared with other patients, those with MHDs were younger, more likely to be female, smokers, frail, living alone, referred from psychiatric hospitals, cognitively or sensually impaired, in poorer general health, had a recent history of falls or multiple hospitalizations, and evidenced insufficient social support. Among patients identified with MHDs, less than one third (31.8%) received mental health services, including psychiatric nursing services (n=317) and depression interventions (n=4,459). During the 60-day home care episode, 16.95% of the sample had subsequent hospitalizations and 12.72% had subsequent emergent care events; 0.45% of these medical events were directly caused by MHDs. In addition, depression intervention was the strongest risk factor for these subsequent medical events, associated with an approximate two-fold risk for all-cause hospitalizations (HR: 1.943) and emergent care events (HR: 1.974). However, 61.61% (n=2,747) of these high-risk depression intervention recipients did not screen positive for depression at admission. Findings in this dissertation study revealed the high national prevalence of MHDs in the elderly U.S. home care population, and the strong association between these disorders and subsequent all-cause medical events. However, these MHDs were largely under-detected and under-managed in this population, highlighting the need for closer monitoring and targeted intervention through enhanced psychiatric training among front-line home care nurses. Recommendations for further work are made, including the development of an electronic algorithm of identified MHD correlates and risk factors as useful in the development of a nationwide monitoring system for geriatric MHDs in the home care setting.