Background We report on the feasibility and effectiveness of an integrated community collaborative care model in improving the health of seniors with depression/anxiety symptoms and chronic physical illness. Methods This community collaborative care model integrates geriatric medicine and geriatric psychiatry with care managers (CM) providing holistic initial and follow-up assessments, who use standardized rating scales to monitor treatment and provide psychotherapy (ENGAGE). The CM presents cases in a structured case review to a geriatrician and geriatric psychia­trist. Recommendations are communicated by the CM to the patient’s primary care provider. Results 187 patients were evaluated. The average age was 80 years old. Two-thirds were experiencing moderate-to-severe depres­sion upon entry and this proportion decreased significantly to one-third at completion. Qualitative interviews with patients, family caregivers, team members, and referring physicians indicated that the program was well-received. Patients had on average six visits with the CM without the need to have a face-to-face meeting with a specialist. Conclusion The evaluation shows that the program is feasible and effect­ive as it was well received by patients and patient outcomes improved. Implementation in fee-for-service publicly funded health-care environments may be limited by the need for dedicated funding.

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Background: We present a new format for geriatric case presentation called the 12 Ds of Geriatric Medical-Psychiatry that facilitates an integrated discussion of both the physical and mental health issues that pertain to any geriatric patient. The format can be used to replace or to complement traditional medical model case presentation and can also be used as a teaching aid to provide the parameters for a holistic view of the geriatric patient. Methods: We developed the 12 Ds of Geriatric Medical-Psychiatry for case presentation by modifying the SBAR (situation, background, assessment, recommendations) with 12 clinical considerations that apply to any geriatric patient. Following implementation of the 12 Ds of Geriatric Medical-Psychiatry case presentation in our integrated team of geriatric medicine and psychiatry healthcare providers, we successfully used the 12 Ds model to present more than 180 patients and found the model easy to use and well received by learners and colleagues. Conclusion: The 12 Ds of Geriatric Medical-Psychiatry provides a comprehensive format to discuss the pertinent issues facing geriatric patients. When used in an SBAR format, it appears to be an efficient means for integrated case presentation and/or can be used as a tool for teaching and understanding a holistic view of complex geriatric cases.

This study reports findings from an evaluation of a 3-year collaborative care pilot project implemented in a Canadian primary care setting to assess and treat seniors (age ≥ 65) living at home with a chronic physical illness and co-morbid depressed mood or anxiety. Data were collected using semi-structured interviews with seniors and family caregivers who had participated in the project (n = 14). Descriptive qualitative analysis revealed the significance of the care manager’s role in offering social and emotional connection and non-stigmatizing support to seniors living at home and self-managing their physical and mental health.