Pioneer Extends Integration To Community-Based Aging Services

As vice chair of the Department of Psychiatry at the University of Rochester, Conwell occupies an office where once sat George Engel, M.D., considered by many to be the father of the “biopsychosocial” model of care. So his vision for how to care for elders living in the community is a natural outgrowth of a long tradition at URMC of stretching the traditional biomedical model to incorporate—as Engel said in a seminal 1977 article in Science—“the patient and the social context in which he lives.”

But his work is also informed by a more personal witness to the strengths and resiliencies of older people. “What brought me into geriatric psychiatry, aside from its being a fascinating field that draws on medical training in neurology and psychiatry, were early influences in which I learned firsthand that older people who age successfully are drawing on remarkable reserves of strength and resilience,” Conwell said. “Our older citizens are survivors, and our models of care for them need to draw on their strengths and resiliencies rather than deficits.”

As director of a partnership between URMC and a community services provider network called the Senior Health and Research (SHARE) Alliance, Conwell has sought to develop collaborative systems of care integrating primary care, mental health care, and community senior service agencies in the care of seniors in the community with mental disorders.

Among his projects is a dementia care program that will link memory disorder specialty services (geriatric psychiatry, psychology, neurology, medicine, and nursing) with social work and other community-based care to optimize independent functioning and quality of life for people with dementia and their families, while reducing overall costs.

“What I have tried to do with colleagues is bring representatives of the aging services network into our clinic so they can work collaboratively in the assessment and ongoing care of patients and families struggling with dementia,” he said. “You might have a depressed older person who has some underlying brain disease and may be brittle on that basis, has partial response to the treatment you provide, and then looks a little bit better and goes home. But if they are going home to a place where they are isolated and socially disconnected, don’t have the stimulus they need, can’t afford their medication, have to worry about keeping their heat on—any number of potential social problems—the treatment we have simply isn’t going to work, or as effectively.”

Like many leaders in integrated care, Conwell says the movement to bring together mental health care, medical care, and human and social services in the community is a remarkable opportunity for psychiatrists. He urges psychiatrists to seek out their own community health centers and hospitals for ways they can contribute their special expertise to the care of patients in primary care and those with chronic medical conditions, and he said they will be welcomed by colleagues in general medicine.

“I know it to be true that so many people in the primary practice community are just worn out by their inability to work effectively across these kinds of boundaries that have been artificially imposed by the way our service systems have evolved over time,” he said. “To be able [to work across those boundaries] in some sort of population health service model is more satisfying and more fun—and not just for the psychiatrist, but for the primary care doctors who need and want our help.” ■