Many community members are well-acquainted with Levindale Hebrew Geriatric Center and Hospital, tucked-away on the Sinai-Lifebridge Health campus on Belvedere Avenue. It is a Baltimore icon dating back to 1890 (when it was called Hebrew Friendly Inn). Fewer of us are familiar with one of its programs, which originated in the 1990s, called the Partial Hospitalization Program (PHP). I had the pleasure of speaking to Director of Outpatient Behavioral Health Services, Hannah Kilburg, and PHP Admissions Liaison, Bracha Poliakoff, about the great number of outpatient successe they have witnessed in this program.
“A lot of people get turned off because the word hospitalization in the title, but it is actually an outpatient program,” notes Ms. Kilburg. “Inpatient hospitalization is what we seek to avoid, so it is ideal for folks in the community experiencing some worsening symptoms that interfere with their daily life and put them at risk of inpatient hospitalization.” PHP also takes patients who have been hospitalized and made some progress in the hospital but still have a way to go. The program helps them get back to baseline.
“It is a level of care that lives between outpatient and inpatient, where we offer treatment at the same intensity as inpatient – people are here all day long, from 10 a.m. to 3 p.m., Monday to Friday – but they get to sleep in their own beds at night,” adds Ms. Kilburg, who mentions that Levindale offers transportation to and from the program to most areas, as well as a free, hot, kosher lunch daily.
Group Support
Therapies are mostly group based. There are four groups a day – two in the morning and two in the afternoon – and patients participate in all of them. Each participant receives an individualized care plan that reflects his or her own challenges and goals. Treatment includes group psychotherapy; cognitive-behavioral group; mental health management group; and expressive therapy group. The program also offers individual therapy, family therapy, medication management, and discharge planning. Levindale’s team includes psychiatrists, psychologists, licensed social workers, and certified psychiatric nurses.
“It’s a long day; it’s a tough day, but that is where we often make the best changes – by doing hard work,” states Ms. Kilburg.
Outside referrals are welcome from doctors, behavioral health professionals, assisted living/group home facilities, retirement communities, nursing homes, family members, and other involved people, or from the patient him/herself.
Mrs. Poliakoff notes that many of the staff members who work at PHP are Jewish and/or sensitive to Jewish religious and cultural practices and how they may affect a client’s life and behavioral health condition.
“Even so, older adults in our community have a hard time accessing this help because they do not know about it and aren’t aware of the resources being offered,” adds Mrs. Poliakoff. “I am excited about getting the word out about the services we offer at PHP so that individuals can get the help they need to live their best possible lives even as they are aging and dealing with the various changes and challenges that come with that.”
“We also have a psychiatric nurse practitioner on staff who manages the psychiatric medications,” mentions Ms. Kilburg. “The benefit of doing that here is that, if you are relying on your typical outpatient provider to manage medications, it may be a month or more between appointments. When a person comes to us daily, we can make those changes in real time, observe their reactions, and make adjustments as needed.”
Notes Ms. Kilburg, “We are one of the few geriatric PHPs around, and we get patients as young as their 50s until well into their 90s. Sometimes patients tell us that they’ve been to a PHP before but were sitting around the table with a bunch of 18-year-olds. It really wasn’t comfortable or relatable since they were in such different stages of life. The advantage of being in a geriatric setting is that you are with your peers, who are experiencing similar issues, such as loss and adjustment.”
How it Works
Issues that prompt PHP care include anxiety around aging: loss of independence and not being able to do things the way you always have. People experience losses, like deaths in the family. Some people may never have felt depression before but are now feeling it for the first time. Others have been behaviorally ill their whole lives, and this program offers them a place where they can explore treatment with their peers.
There are typically up to 10 people per group, comprised of both men and women. Ms. Kilburg explains how group therapy works: “Unlike an adult daycare, where participants would be doing more activities, like Bingo and taking field trips, our program is all therapeutic. These groups teach the participants to develop coping skills to deal with depression, anger management, grief, and loss – even managing anxiety through origami. We also have a nurse on staff who does a lot of psycho-educational groups, teaching people about behavioral health and the best way to manage their medications and their general health.”
PHP does not have a set curriculum; it adjusts the groups to the needs of the clients. So, if staff notices that certain themes are coming up a lot – for example, many participants have recently lost a spouse – that is something the groups would address.
“I have been blown away by the progress that people have made in the program and how much it helped them,” shares Mrs. Poliakoff. ”People come in who are struggling with a lot of loss, grief, depression, and other issues going on in their lives, and when they leave, they feel so much better. I attribute that to the power of the group – a group therapy model, where people feel supported by others who have been in their situation or a similar situation. Even if they are from different backgrounds – not everyone is Jewish – they realize how much they have in common. They are able to help and support each other through it.”
The average length of stay in the program is short – about four to six weeks – designed to get people through their current crisis. There is a lot of discharge planning as well, looking at resources in the community that participants can use to support their wellness. Referrals are made to senior centers, adult daycare centers, and volunteer organizations, among other places.
“We want to make sure that when people are discharged, they have a good plan for what they are going to do with themselves – hopefully, finding something that is meaningful to them,” remarks Ms. Kilburg.
When people are finished with PHP, the program will also typically refer them to its outpatient mental health clinic or to a provider of their choice. “That is always the client’s choice, but it’s nice to keep them in-house, because if they do have a relapse, we can bring them back into PHP,” says Ms. Kilburg. “This is not a one-shot deal; people can use this program as a resource for avoiding the hospital.”
Telltale Signs, Success Signs
How can you tell if it’s time to suggest that your elderly loved one seek treatment? Mrs. Kilburg advises looking for changes in sleep, appetite, and mood – whether an elevated mood that seems inappropriate or a very low mood. Certainly, if there is any sort of expression of suicidal ideation, even if someone is just making sort of a passive death wish, saying, ‘I wish I wouldn’t wake up in the morning!’ you should be concerned. If someone is saying, ‘I’m suicidal; I have a plan to walk out in traffic,” that is a situation that warrants bringing that person to the emergency room, immediately. Other red flags are if someone is so anxious they are not able to make a decision or carry through activities of their daily life, or if they are experiencing auditory or visual hallucinations, delusions, or paranoia.
“I am always happy to talk to anyone on the phone to preliminarily assess the situation and see if the person might be appropriate for our program,” offers Ms. Kilburg. “If it seems likely, we’ll take a closer look. If not – for example, if a person has a more severe dementia issue – I may refer him/her to our clinic to see the psychiatrist and, perhaps, to an adult day care.”
Ms. Kilburg finds her job is very rewarding because of the significant changes and improvements she sees. She shares two true scenarios:
“We had a patient in assisted living who was very depressed and experienced some paranoia. There was something that didn’t feel quite right to me about the assisted living provider, but there was no concrete evidence that the patient was being neglected or abused in any way – until one day she came in and revealed to one of our volunteers that she had injured her hand because the assisted living provider had slammed it in a door. Here we were, trying desperately to treat her mental health issue, but she was in this terrible environment. That very day, we were able to make a report to Adult Protective Services, get her to the emergency room, and get her out of that situation so she could be placed somewhere appropriate. That was definitely one of the more extreme situations that we had, and heartbreaking, but we were so glad that she was coming here, engaged with an outside resource, because had she just been staying at home at the assisted living, this never would have been discovered.
“I also remember a woman who came in very, very depressed and didn’t want to talk. By the time she left, she had moved into a new senior apartment building and had become very involved in a lot of the activities there, including joining the choir. She herself was amazed and told me, ‘I’m 75 years old, and I have never sung before, particularly in public, but, here I am, really enjoying this!’ It was lovely to see her emerge from that depression and discover this new passion.”
Concludes Mrs. Poliakoff, “In Judaism and in the Jewish community, there is a big focus on pikuach nefesh (saving a life) taking precedence over other mitzvos and obligations. As a result, we put significant focus on our health and making sure that, as a community, we have access to medical resources. I think our community is starting to recognize that behavioral health issues often fall into this category as well. We’ve had members of our community who are very serious about their Yiddishkeit (Judaism) realize that, in order for them to serve Hashem properly and live their life well, they needed to get their mental health in a better place – and that is where we come in!”
Levindale’s programs are often partially covered by Medicare and Medicaid and many health insurance companies. For more information, please call 410-601-2358.
SIDEBAR:
Depression in the Senior Population
by Margie Pensak
Dr. Lisa Hollander is a psychiatrist specializing in adult psychiatry in private practice in Pikesville, Maryland. “Depression is really common in the elderly for two different reasons that often overlap,” she says. “All kinds of brain illnesses, brain injuries related to stroke, chronic high blood pressure, diabetes, Parkinson’s, etc., predispose people to depression.
“It’s not just because the illnesses are depressing, but the damage they cause makes people more biologically prone to depression. This is especially true of strokes and stroke-related illness with mini-strokes,” explains Dr. Hollander. “At the same time, losses and pain also make people more prone to depression. In old age it is inevitable that there are a series of losses. Some of them are losing family members and spouses, but there is also losing a sense of independence and stability and having to face disappointments.”
Dr. Hollander explains that some people experiencing these losses are resilient and don’t get depressed, but other people find that, emotionally, they can’t keep their head above water.
“One hard thing with brain-related illnesses is that apathy is very common and hard to distinguish from depression,” notes Dr. Hollander. “Apathy is a very neurologically-based symptom. It is a state where people aren’t sad, but they aren’t motivated and don’t seem to care. So sometimes people will say, ‘I think my mom/dad is very depressed,’ but when I meet with them, I’m not feeling that there is sadness. There’s not negativity, not resistance, just no cooperation, motivation, or moving forward. Sometimes it is hard to tell the difference.”
Dr. Hollander adds, “Some people make the mistake of thinking that depression is common and normal, so why bother treating it? But, it is important to treat. Left untreated, those who have it not only suffer, but also lose opportunities, and that can snowball.”
As an example, Dr. Hollander mentions the case of someone who is depressed and stops going to the senior center. Being less active, the person’s general health condition suffers. People stop calling and including this person because s/he is not seen anymore.
“It’s important to take care of depression, and there is a biological part with medication, which is sometimes necessary, not always,” remarks Dr. Hollander. “You have to make sure that the person has a thorough medical workup, to ascertain that there aren’t medical factors either causing or contributing. The therapy part is very important – often therapy with what is called a cognitive-behavioral component, where you are teaching people to understand what is making them depressed and what is keeping them depressed, to try to break patterns.”
Dr. Hollander mentions that she is frequently asked by people of all ages, “When can I stop my medicine?” In response to this, she notes that younger people sometimes are very successful coming off medicines. For older people who get depressed, it will usually be recommended that they stay on it long-term, because depressed brains have some recovery but they are not cured and are prone to relapses. Since older people generally take longer to respond to medications, you don’t want it to get worse and be less treatable.
Dr. Hollander provides the following suggestions and tips:
- Try to ensure that medications are being given as intended. It is so important to treat medical conditions such as heart disease, diabetes, and thyroid conditions on an ongoing basis as directed. I’ve met with people who never refilled their thyroid prescription. They’ve become hypothyroid, which can cause or worsen depression.
- Try to optimize hearing and vision correction to reduce factors that isolate and prevent optimal sensory input, which is important for adequate stimulation and safety.
- Sometimes, when people are depressed, they can almost look like they have dementia, and sometimes when you treat the depression, you find out that they are actually in very good shape cognitively. If you can imagine a garden that is beyond hope; when you water it, you find it comes back to life.
- Aging and depression do not necessarily go hand in hand. A lot of it has to do with outlook, and people who are willing to adapt to losing control don’t get as depressed.
- Plan for a successful retirement. It is a very big, challenging life transition stage. It’s important that people make plans to make sure they feel useful, that they get out regularly, and stay in contact with people.
- If you are considering having someone assessed for depression, it is important to be as honest as possible with the assessor. Reporting family stressors, alcohol or substance usage, prior history of mental health problems, and family history are really important and helpful for the person doing the treating. Anything that is relevant that’s not known becomes a complication, e.g., if someone is drinking.
