As our population continues to age, it is not uncommon for many of us to have an older neighbor who has become homebound and disappeared from view. Maybe once they were an active part of the community, but now as a result of life changes associated with aging, such as declining health or the loss of loved ones, their world has shrunk rendering them homebound. In addition, what if these homebound individuals are also suffering from depression, anxiety, substance abuse or other mental health illnesses? Many service providers or family members are unfamiliar with how to identify mental health or deal with these issues in regard to the frail elderly. They might call the client’s doctor regarding a physical ailment, but would they know what to do if there is a psychological issue? Would they consider this just another inevitable factor of growing old? They probably would not know that with the right intervention and treatment these isolated older adults can improve and enjoy a much better quality of life.
Since our founding in 1972 Service Program for Older People, Inc. (SPOP) has been providing comprehensive mental health services to older adults. Historically SPOP largest program has been our Clinic which offers individual and group counseling, psychiatric evaluation and supervision of medication, case management, and family/caregiver counseling. SPOP has always provided its services to older adults where they could best access the treatment. If a client was unable to come to our Clinic, we could provide services at select senior service sites throughout Manhattan. If a qualified client could not get to these sites, SPOP would arrange for clinical staff, including bi-lingual Spanish-speaking or French-speaking clinicians, to come to their home.
There are a variety of factors that can make a client homebound. The most obvious reason is physical infirmity or lack of mobility. This can be a chronic physical condition, such as someone who is in a wheelchair or bedridden. Or it can be periodic, such as the client who regularly comes to the clinic except when the elevator in their building breaks down and the clinician must come to them. This allows the client to keep up with their treatment, while also conveying to the client that they and their treatment are valuable. Similarly, a clinic client who was being treated for depression and became homebound after a knee replacement operation did not have to discontinue their treatment during this recovery period. Instead their clinician came to their home. This resulted in the client’s mental health and physical health treatment both working to the common goal of helping the client resume normal activities, such as being able to return to the Clinic. Some clients are unable to leave their homes for psychiatric reasons. For an individual suffering from agoraphobia the mere act of going to a clinic could bring on panic or anxiety attacks. For these individuals the ability to receive treatment in their home including the prescribing of the anti-anxiety medication can prove essential for maintaining them in the community.
The SPOP’s homebound services replicate what is offered to our traditional Clinic clients. For each of the homebound clients, one of the program’s social workers conducts a mental health assessment that consists of a psychosocial evaluation, a psychiatrist does a mental status examination, and together they develop a Comprehensive Treatment Plan. Based on each client’s Comprehensive Treatment Plan, the assigned social worker provides individual counseling and the psychiatrist provides medication management, as needed. Clients typically receive treatment once a week. Additional program services include family/couples counseling and support which is provided by a social worker.
Though SPOP’s Homebound program parallels services offered in our Clinic, the clinicians find significant differences in how they interact with their clients. For example, when treating a client in a traditional clinic setting the clinician is able to close the door of the treatment room and block out all other distractions focusing exclusively on the treatment itself. However, when a social worker enters a client’s home they also are stepping directly into this client’s world. The clinician gets to see firsthand the client’s living environment and the family dynamics. Is the client being mistreated or exploited? Are there visible signs of alcohol or substance abuse (i.e., empty bottles)? As one clinician stated, “You see so much when you walk into someone’s home.” Though our homebound program does not focus on case management services, it is important to help clients to advocate for themselves and to get the services they need. This is another step in the process to help the clients regain their independence. For example, the New York Times recently ran a story about a chronically depressed woman who had become a virtual recluse. When her apartment was hit with an infestation of bed bugs, her SPOP therapist helped the client to apply for funding to replace her discarded household goods.
For an isolated homebound older adult, the routine of having someone come to their home to just focus on them, is important to their own self-esteem and gives them a sense that they have some control over their lives. As a result of this treatment some patients make very dramatic progress. For example, there is an 81-year-old single, woman who came to SPOP with a long history of major depressive episodes, including two suicide attempts and several psychiatric hospitalizations. Two years ago, upon her release from a local hospital the client was referred to SPOP’s Homebound program for mental health services. This client began receiving weekly home visits from SPOP’s clinical staff, due in part to her depression which left her socially isolated and unable to leave her apartment. In addition, the client suffered from neuropathy of the spine, making ambulation difficult and painful. As a result of the home visits, this client was encouraged to see the SPOP psychiatrist, who managed the client’s psychotropic medications, stabilizing the client for the first time in years. Since then, the client has not been re-hospitalized, is attending physical therapy sessions twice a week, is re-engaged with friends, and has returned to her great love, attending the opera.
There are many challenges in running a homebound program. It requires a highly skilled staff, greater flexibility in terms of scheduling appointments than in a traditional clinic setting, and clinicians have to spend more time traveling, which means they can see fewer clients. All of this contributes to higher operating costs for the program. However, over the long run it is actually cheaper to provide timely intervention to a homebound client, thus avoiding the more costly alternative of long-term hospitalization.
Timely intervention by mental health professionals helps to deter the emergence of more severe mental health problems with all their potentially disastrous consequences, including displacement through institutionalization, loss of funds, and additional isolation.
As our frail elderly population continues to grow, so too will the demand for homebound mental health services. As SPOP has shown, this is a group that can be effectively treated with such positive outcomes as increasing socialization; reducing isolation; and preventing and reducing hospitalizations for both physical and mental health disorders, with the ultimate benefit of improving the quality of life for participants and allowing them to age in place in their community.