ACCESS TO MENTAL HEALTH CARE FOR THE ELDERLY. JOSEPH E. GAUGLER, PH.D. ASSOCIATE PROFESSOR MCKNIGHT PRESIDENTIAL FELLOW SCHOOL OF NURSING UNIVERSITY OF MINNESOTA. SPECIFIC AIMS. Provide an overview of the state of mental health and aging in the U.S.
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JOSEPH E. GAUGLER, PH.D.
MCKNIGHT PRESIDENTIAL FELLOW
SCHOOL OF NURSING
UNIVERSITY OF MINNESOTA
What are your ideas?
Various outreach models have been developed to enhance access and improve mental health outcomes for older persons
Evaluation has been limited
Lack of high quality evidence (e.g., randomized controlled, quasi-experimental, or cohort studies) demonstrating whether certain approaches can overcome the barriers of mental health care access for the elderly
A large body of research has emerged documenting the effectiveness of various approaches to treatment mental health outcomes in older persons: but the issue of access continues to complicate translation
Outreach services are defined as “the detection and treatment of mental health problems in settings where older adults live, spent time, or seek services.” (p. 1238)
These services have been targeted at primarily non-institutionalized older persons
Key components of outreach services include “case finding, assessment, referral, treatment, and consultation.” (p. 1238)
Some broad examples include early intervention, approaches to facilitate access to preventive services, provide evaluation, refer individuals to appropriate treatment and support programs, and offer services to promote aging in place
Case identification strategies
The gatekeeper model, or, the use of nontraditional community referral sources when compared to traditional referral approaches (primary care providers, family members/caregivers, etc.)
Gatekeeper approaches appeared to reach those who were widowed and more likely to be negatively influenced by economic or social isolation, suggesting that such approaches reach those most at risk for underutilization (Florio et al., 1996, 1998; Raschko, 1997)
1-year follow-up results also suggested that these individuals did not place overly high service demands on providers (I am not sure what to make of this finding)
Multidisciplinary teams who develop a care management protocol; subsequent services are provided in the older person’s place of residence
Variance in implementation, treatment recommendations, services provided (e.g., assessment and referral, direct implementation of recommendations by clinicians on the team)
Four high quality studies (e.g., RCTs) employed various providers as part of their multidisciplinary teams, such as nurses, case managers, physicians/residential staff, and social workers
All of these interventions resulted in a reduction in depressive symptoms
Cohort studies of multidisciplinary teams that provided in-home assessments followed by referral and linkage to outpatient treatment appeared associated with improved global functioning, reduced psychiatric symptoms, fewer behavior problems, and caregiver satisfaction
The review suggests that gatekeeper models, which use unconventional case finding approaches that are integrated with mental health referral may improve access to older persons
Multidisciplinary programs offered in an older person’s home are potentially effective in improving psychiatric outcomes
Lack of high quality data
At the time, other unique outreach approaches, such as video-based outreach to rural areas, most studies focused on feasibility only
Because older adults may be more likely to utilize primary care services, it is imperative that appropriate training be provided to physicians and other healthcare professionals to identify mental health concerns.
It is important that these healthcare professionals be encouraged to collaborate with, and refer to, other health professionals who have expertise in mental and behavioral concerns.
Providers from various disciplines who serve the older adult community must work together as an interdisciplinary health care team to provide a collaborative model of care for older adults.
In order to meet the mental health needs of older adults, it is essential that there be parity for mental health services under Medicare. Currently, Medicare only reimburses for 50% of outpatient mental health care as compared to 80% for medical care.
Centers for Disease Control and Prevention and the Kimberly-Clark Corporation. Assuring Healthy Caregivers, A Public Health Approach to Translating Research into Practice: The RE-AIM Framework. Neenah, WI: Kimberly-Clark Corporation, 2008.
Available at: www.cdc.gov/aging/ and www.kimberly-clark.com
Challenges of translation
Secure participation of settings
Secure participation of older persons with mental health problems
Implement the program consistently
Maintain the program over time