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Dr. Betsy McDonel Herr Ms. Donna Wagner Dr. Rodolfo R Vega Dr. Sue Levkoff Ms. Karen Cheal Ms. Noelle Downing Positive Aging Resource Center Funded by SAMHSA Grant # SM-55043 .

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Dr. Betsy McDonel Herr

Ms. Donna Wagner

Dr. Rodolfo R Vega

Dr. Sue Levkoff

Ms. Karen Cheal

Ms. Noelle Downing

Positive Aging Resource Center

Funded by SAMHSA Grant # SM-55043

Autonomy and Physical and Mental Functioning of Underserved Older Adults: Benefits of Mental Health Care Provided Through Nine Community-Based Programs

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Dr. Betsy McDonel Herr

Targeted Capacity Expansion Initiative

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SAMHSA: U.S. Substance Abuse and Mental Health Services Administration

  • SAMHSA --federal agency devoted to improving behavioral health services across the nation.

  • CMHS—Center for Mental Health Services, one of SAMHSA’s 3 Centers

  • CMHS funds grants & contracts to support adoption of evidence based mental health services and provision of technical assistance to change and improve mental health systems

  • Betsy McDonel Herr, Ph.D. CMHS Program Officer & Contact for Aging programs

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Targeted Capacity Expansion(TCE) Program to Improve Mental Health Services for Older Adults

  • 3-year grant program, ending 2005, $4.5 million/year

  • 9 Services Sites to implement evidence basedpractices (EBPs) for older adults

  • 9 Services Sites cover Arizona, California, New York, Texas, Missouri, Washington, D.C., Wisconsin

  • 9 Services Sites cover diverse populations including Hmong, Hispanic, Yaqui Indian and rural populations

  • Grants fund local infrastructure support, service linking, partnership building, quality improvement, in addition to direct services

  • Variety of practices and principles proposed for implementation

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Expansion of Local Services


Increase/Train Providers

Evidence Based Practice Adoption

Integrated Treatment

Consumer involvement

Technical assistance

Outreach,engagement, case-finding

Improve access for racial/ethnic minorities, persons in rural settings

Service Linking

Needs assessment

Strategic planning

Quality improvement activities


Consensus building

Sustainable financing

Leadership development

Partnership development

Community Outreach

Social marketing

Public education/Health literacy


Consumer/Family/Advocacy Group


Program Evaluation

Measure GPRA outcomes

Process evaluation/Program fidelity

Simple Outcome Indicators

I. Increase existing

mental health


intervention and/or

treatment services;

develop and

implement new


Individual Level


Prevention or delayed onset

Quality of life

Access to services

Healthy behaviors

Program Level

Prevention/early intervention

incorporated into clinical practice


Consumer/Family integration in


Reduced stigma

Increased participation by cultural/

ethnic minorities

GPRA Outcomes

System Level

Expanded service base

Improved coordination


Diverse populations served


Intervention incorporated into


II. Improve quality,

accessibility, and

availability of

mental health

services delivery.

Persons who are

65 years and older.

III. Build system

infrastructure to

support expansion of services.

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Ms. Noelle Downing

Positive Aging Resource Center

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Positive Aging Resource Center: PARC

  • PARC is a National Technical Assistance Center focused on mental health issues of older adults

  • PARC assists the 9 services sites

  • PARC is engaged in several projects to describe EBPs and principles for older adults

  • PARC provides limited technical assistance to the field on older adult mental health issues

  • PARC also sponsors a website www.positiveaging.org

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Ms. Noelle Downing

The TCE Sites

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PARC Model Service Programs

Cottage Program, Arizona – Donna Wagner

Health Improvement Program

for the Elderly, Arizona – Jane Singer

Tiempo de Oro, Arizona – Elizabeth Stadick

University of California, San Francisco (UCSF), Pat Areán

La Clinica Del Pueblo, Washington DC – Gloria Elliott

ElderLynk, Missouri – Rene McGovern

Senior Outreach Program, New York – Jack McIntyre

Focus Project, Texas – Gabrielle Martinez

Kajsiab House, Wisconsin – Doua Vang

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TCE SitesPopulations Served

  • Cottage Program, AZ

    • Mexican Americans, Native Americans, and rural older adults from a variety of diverse racial and ethnic backgrounds

  • Health Improvement Program for the Elderly (HIPE), AZ

    • Hispanic, urban Native Americans, other minority populations

  • Tiempo de Oro. AZ

    • Latino

  • University of California, San Francisco (UCSF)

    • Residents in assisted living facilities

  • La Clinica Del Pueblo, Washington DC

    • Latino, primarily immigrants from Central and South America

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TCE SitesPopulations Served

  • ElderLynk, MO

    • Rural older adults

    • Senior Outreach Program, NY

    • Older adults

  • Focus Project, TX

    • Homebound Elderly, Latino

  • Kajsiab House, WI

    • Hmong refugees

  • Unity, New York

    • Primary Care

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TCE Site Demographics

  • Over 75 years of age (61%)

  • Female (76%)

  • Race

    • White (78%)

    • Asian (6%)

    • Black (3%)

    • Other (13%)

  • 27% Latino

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TCE Site Demographics

  • Education

    • High school education or less (76%)

    • Some college (14%)

    • College grad (10%)

  • Living situation

    • Housed (86%)

    • Institution (13.5%)

  • Unemployed/retired (97%)

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Ms. Karen Cheal

Results through August 2004

Interim Findings

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Data collection

  • GPRA (Government Performance and Reporting Act) data

    • Customized for TCE initiative

    • Same measures collected at all sites

    • Translated/backtranslated into Spanish and Hmong

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Data collection

  • Collected by site staff as part of client’s appointment

  • Data collected longitudinally

    • Intake

    • Six months

    • Twelve months

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Sample GPRA question

During the past week, to what extent have you been experiencing difficulty in the area of: Apathy or lack of interest in things

a.  No difficulty

b.  A little difficulty

c.  Moderate difficulty

d.  Quite a bit of difficulty

e.  Extreme difficulty

f.  Don’t know

g.  Not Applicable

h.  Refused

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  • Data from 8 of the 9 sites were included

  • 929 subjects

  • Cross-site analyses

    • Change from intake to six months

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Retention Rates

  • Six-month: 72%

  • Twelve-month: 74%

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Reasons for loss to follow-up

  • 154 subjects (16.6%) were lost to follow-up

    • Death (25%)

    • Discharged from program (28%)

    • Refused to participate (20%)

    • Moved/unable to locate (14%)

    • Other (13%)

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Difficulty managing day-to-day life

% experiencing

NO difficulty


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Difficulty with household responsibilities

% experiencing

NO difficulty


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Difficulty with work

% experiencing

NO difficulty


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Difficulty with leisure time

% experiencing

NO difficulty


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Difficulty developing autonomy

% experiencing

NO difficulty


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Difficulty with apathy

% experiencing

NO difficulty


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Difficulty with concentration

% experiencing

NO difficulty


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Difficulty with life satisfaction

% experiencing

NO difficulty


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Self-reported health status

% reporting

fair/poor health


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Inpatient stays forphysical complaints

% reporting



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Dr. Rodolfo R. Vega

Systems Integration Data

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Grantee’s Requirement

  • “Create service linkages between individuals and groups that serve the target population.”

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Grantee’s Requirement

  • Building of service networks will ensure that outreach, assessment, prevention, early intervention, and/or treatment will take place within target service systems or via linkages to specialty mental health services. The purpose for these linkages is to provide integrated, appropriate services in the multiple domains.

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PARC’s requirement

  • To give providers and communities resources to build and/or expand the local and regional service system infrastructure that will help to support new or expanded services

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PARC’s requirement

PARC Requirement

  • To engage in the building of system infrastructure that will support the increased amount, quality, and accessibility of services to older persons.

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Underlying principles

Help-seeking behavior occurs in a context. For our purposes, this context is represented by the systems of care.

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Definition System of Care

The organization of health services in a particular community to address the multiple health and social needs of individuals and families.

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Systems integration

Organizational strategy to reduce fragmentation and improve collaboration.

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Systems integration

Bringing services together to meet multiple needs of the individual through a coordinated treatment approach

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Service integration

Identify components.

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Our focus

Systems integration operationalized through interorganizational relations

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Viewing organizations as comprised of individuals

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As such, they relate to each other in a variety of ways.

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For example, they refer clients to each other, coordinate services, share resources, co-locate services

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Evaluation approach

Determine whether or not the components of the system of care are present in the community

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Components of a systems of care

  • Access to affordable medications

  • Advocacy

  • Ambulatory care

  • Case management

  • Counseling Services

  • Dental care

  • Dental care

  • Employment Services

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Components of a systems of care (con’t)

  • Family self-help

  • HIV/AIDS education

  • Homecare

  • Hospice services

  • Housing services

  • Income assistance

  • Independent living skills

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Components of a systems of care (con’t)

  • Leisure activities

  • Medical translation

  • Mental health services

  • Residential hospice

  • Social support

  • Substance abuse services

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Inter-organizational linkages

If they are present, what is the relation between our grantees and the organization providing those services?

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Organizational linkages

Do you make referrals to this agency?

Do you receive referrals from this agency?

Length of relation

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Organizational linkages (con’t)

What type of activities does your organization engage in with this agency:

  • Coordinate activities?

  • Share resources?

  • Referring of clients?

  • Exchange of information?

  • Business development?

  • Other: Please specify

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Organizational linkages (con’t)

  • Activities

  • Prompts:

  • Collaboration: in what areas?

  • Referral: For what? How many?

  • Exchange resources: Of what type?

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Organizational linkages (con’t)

What is the basis of this activity?

  • Informal arrangement

  • Letter of collaboration


  • Contract

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Organizational linkages (con’t)

How frequent are your contacts or meetings with this agency/agencies?

  • Daily

  • Once a week

  • Once a month

  • Quarterly

  • Annually

  • Other Please specify

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Organizational linkages (con’t)

How do you regard your level of trust and confidence in the agency?

  • Very high

  • High

  • Medium/Average

  • Low

  • Extremely Low

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Organizational linkages (con’t)

How culturally competent do you find the agency?

  • Very high

  • High

  • Medium/Average

  • Low

  • Extremely Low

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Definition of trust

Firm belief in the reliability, truth, ability, or strength of someone or something.

Source: Compact Oxford English Dictionary

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Trust was positively related to the number of agencies linked to the project (r = .83, p< .02).

Trust was negatively related to the number of services provided in-house. (r = -.70, p < .08)

Trust was positively associated with six months follow-up rates (r = .84, p<.01).

Trust was positively associated with referrals to other agencies (r = .84, p<.01).

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The proportion of reciprocal referrals was positively associated with:

Mental health screening (r = .87, p.<.05)

Substance abuse screening (r = .87, p<.05).

Business Development (r = .78, p < .04)

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Business development was positively related to:

Sharing resources, (r = 81, p <.02)

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  • The presence of mental health and social service providers in a community cannot be translated as meaning that a mental health services continuum of care exists.

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Conclusions (con’t)

Service providers must have access to resources or engage in certain types of interorganizational activities in order to build the necessary infrastructure to support these expanded services for meeting the diverse mental health needs of older persons, which is the core premise of this initiative.

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Donna Wagner, MS GerontologyDirector, Elder ServicesCOPE Behavioral Services, Inc.Tucson, AZ

SAMHSA Grant #SM54749


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  • Outreach

  • Community Education

  • Treatment

  • Coalition Building

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COTTAGE Population

Rural – Urban – Ethnic

  • Casa de Esperanza – Green Valley

  • COPE Behavioral Services, Inc. – Tucson

  • El Rio Health Center - Tucson

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Developing the Story

  • Choose your Evidence-based Practices

  • Develop your outreach strategies

  • Design your treatment protocols

  • Choose/develop your outcome measures

  • Develop your data collection systems

  • Train your staff

    Ready to write the story!

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Evidence-based Practices

  • EBP #1 – Outreach, Community Education,

    Service Delivery

  • EBP #2 – Clinical Treatment

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Evidence-based Practice #1

Outreach, Community Education

and Service Delivery

Geriatric Counseling Service (GCS)

Intercommunity Action, Inc. (INTERAC)

Philadelphia, Pa

Promoting Older Adult Health, DHHS #(SMA) 02-3628, SAMHSA, 2002

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  • Linkage to Aging Network of Services

  • Linkage to Primary & Secondary Care

  • Linkage to Senior Housing/Senior Centers

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Community Education

  • Increasing awareness about behavioral health and aging issues

  • Reducing stigma among consumers and service providers

  • Providing consumer friendly fact sheets about signs of behavioral health problems

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Service Delivery

  • Assessments and Counseling

  • Care coordination with PCP and Social Services


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Coalition Building

Establish community infrastructure

Behavioral Health and Aging

Coalition of Southern Arizona

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Measurements of Outreach and Community Education


  • Data tracking system:

  • Number and nature of contacts

  • Number and source of referrals


  • Community feedback surveys

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Outreach at Year 2

  • Presentations = 148/2,398

  • Literature = 17,566

    (9,659 @ 5 months/Yr3)

  • Number of Referrals = 311

  • Number Enrolled = 222

  • Engagement Rate = 71%

  • Discharges = 147

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Average Age = 77 years old (Range 65-91)

Female 84% Male 16%

Urban 66% Rural 34%

Euro 80% Latino 20%

English 90% Spanish 10%

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Evidence-based Practice #2


  • Cognitive Behavioral Therapy (CBT)

    (Beck, Rush, Shaw & Emery, 1979; Burns, 1980)

  • CBT with Older Adults

    (Laidlaw, Thompson, Dick-Siskin & Gallagher-Thompson, 2003)

  • Strengths-based Care Mgmt & Tx Planning

    (Fast & Chapin, 2000)

  • Grief Therapy

    (Worden, 2002)

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Measurements of Treatment

Increased Autonomy

Sense of Mastery Scale (Pearlin & Schooler, 1978)

Physical Health Improvement

SF-12 HQ(Ware, Jr., Kosinski & Keller, 1996)

Mental Health Improvement

Geriatric Depression Scale (Yesavage et al., 1983)

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Treatment Outcomes

Improvement as a percentage change

@[email protected]

(N=101/27) (N=44/17)

  • Sense of Mastery 20% 16%

  • Depression 35% 45%

  • Health Status 13% 14%

    All improvements significant at p<.001

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The OTHER Story

Peggy – Sharon - Staci – Jolene

Unable to Treat

Adult Children




Pajama Therapy

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The End of the Story

  • Year Three

  • 5 months/97 calls/71 enrolled = 73%

  • Continuing outreach and treatment

    The Sequel

  • The BH & Aging Coalition of So. Arizona

  • The COTTAGE Program at COPE BHS

  • The COTTAGE Model

  • The COTTAGE Staff

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Dr. Sue Levkoff

Policy Implications

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Underserved populations CAN be reached

  • TCE initiative averaged 100 clients/program

  • More have been enrolled since

  • High retention rates

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Significant improvement

  • Clients improved significantly in only six months, both physically and mentally

  • Inpatient and ER utilization for physical complaints decreased