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Prevention Research Centers (PRC)-Healthy Aging Research Network (HAN) Webinar Series. Evidence-Based Mental Health Practices for Older Adults: The Latest Data, Strategies and Funding Options. December 2, 2008, 3:00 - 4:30 P.M. EST. Margaret Moore, MPH, MSSW, CDC.

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Prevention Research Centers (PRC)-Healthy Aging Research

Network (HAN) Webinar Series

Evidence-Based Mental Health Practices for Older Adults: The Latest Data, Strategies and Funding Options

December 2, 2008, 3:00 - 4:30 P.M. EST

Margaret Moore,

MPH, MSSW, CDC

Stephen J. Bartels, MD, MS

Dartmouth

Moderated by: Doris M. Clanton,

MA, JD, GA DHR/DAS

Not Pictured: Suzanne Bosstick, MS & Mary Sowers, CMS


Audio portion of this presentation
Audio Portion of this Presentation

  • If you are having difficulty accessing the audio portion of this call and received the “The Conference is Full” message, please dial the backup number listed below:

    Backup Phone Line

    888-209-3778


Sponsors
Sponsors

Prevention Research Centers-Healthy Aging Research Network

http://www.prc-han.org/

National Council on Aging

http://ncoa.org/index.cfm


Funding
Funding

National Association of State Mental Health Program Directors, Office of Technical Assistance (NASMHPD OTA)

http://www.nasmhpd.org/ntac.cfm

through funding for the

Georgia Department of Human Resources, Division of Aging Services and Division of Mental Health, Developmental Disabilities and Addictive Diseases

http://aging.dhr.georgia.gov

http://mhddad.dhr.georgia.gov


This webinar will
This webinar will…

  • highlight recent CDC findings related to the mental health of older adults;

  • identify roles for public health, mental health, aging network systems to promote older adult mental health;

  • identify recently developed SAMHSA implementation resource kit materials that can be used by administrators, clinical providers, consumers, and program managers to help guide the process of selecting and implementing evidence-based interventions and services for depression in older adults;

  • highlight practical information about Medicaid coverage/reimbursement for evidence-based depression programs for older adults; and

  • identify issues, risks, strategies and potential funding sources for evidence-based programs and practices.


Evidence based mental health practices for older adults the latest data

Evidence-Based Mental Health Practices for Older Adults: The Latest Data

Maggie Moore, MPH

CDC Healthy Aging Program

December 2, 2008


Mental health as an emerging public health issue
Mental Health as an Emerging Public Health Issue

Evolution of the public health mission

Mental health (MH) essential to overall health

Links between MH and chronic conditions

Now part of priority setting


Public health s roles
Public Health’s Roles

Monitor MH indicators

Support development, translation, implementation, and dissemination of evidence-based programs

Identify risk factors

Source: Marshall Williams S, Chapman D, Lando J (2005). The role of public health in mental health promotion. MMWR 54(34):841-842.


Public health s roles1
Public Health’s Roles

Increase awareness / reduce stigma

Eliminate health disparities

Improve access to services

Source: Marshall Williams S, Chapman D, Lando J (2005). The role of public health in mental health promotion. MMWR 54(34):841-842.


Cdc healthy aging program s current projects
CDC Healthy Aging Program’s Current Projects

Examining MH indicators

Supporting the translation, implementation, and dissemination of evidence-based programs

Sharing what we’ve learned


Using data for action
Using Data for Action

What gets measured, gets done!

Needs to be easily accessible

Data needed for:

Grant writing

Planning/priority setting

Measuring progress


Examining the data
Examining the Data

  • 2006 Behavioral Risk Factor Surveillance System (BRFSS)

  • Core questions and Depression and Anxiety Module

  • Adults aged 50+


6 indicators
6 Indicators

Core BRFSS

  • Social and emotional support

  • Life satisfaction

  • Frequent mental distress

Dep/Anx Module

  • Current depression

  • Lifetime diagnosis of depression

  • Lifetime diagnosis of anxiety disorder


Social and Emotional Support

US Virgin Islands

District of Columbia

0 – 7.87%

7.88 – 9.41%

9.42 – 11.18%

11.19 – 17.74%

Percentage of adults aged 50 or older who reported that they “rarely” or “never” received the social support that they needed

Source: CDC, BRFSS 2006


Social and emotional support highlights
Social and Emotional SupportHighlights

  • Nearly 90% of adults 50+ receive adequate amounts of support

  • Adults 65+ were more likely than those 50-64 to report not receiving adequate support

  • Men 50+ were more likely than women to report not receiving needed support


Life Satisfaction

US Virgin Islands

District of Columbia

0 – 4.06%

4.07 – 4.57%

4.58 – 5.04%

5.05 – 7.16%

Percentage of adults aged 50 or older who responded that they were “dissatisfied” or “very dissatisfied” with their lives

Source: CDC, BRFSS 2006


Life satisfaction highlights
Life SatisfactionHighlights

  • Nearly 95% of adults 50+ reported being “satisfied” or “very satisfied” with their lives

  • Adults 50-64 were more likely than those 65+ to report being dissatisfied with their lives

  • White, non-Hispanic adults in all age groupings were least likely to report dissatisfaction with their lives


Frequent Mental Distress

US Virgin Islands

District of Columbia

0 – 7.23%

7.24 – 8.52%

8.53 – 9.82%

9.83 – 14.45%

Percentage of adults aged 50 or older who, in the past 30 days,

experienced frequent mental distress

Source: CDC, BRFSS 2006


Frequent mental distress highlights
Frequent Mental DistressHighlights

  • Greater than 90% of older adults do not experience Frequent Mental Distress (FMD)

  • Hispanic adults 50+ reported more slightly more FMD than other racial/ethnic groups

  • Women in all age groupings reported more FMD than men


Current Depression

US Virgin Islands

District of Columbia

No Data

0 – 5.41%

5.42 – 6.66%

6.67 – 8.57%

8.58 – 12.43%

Percentage of adults aged 50 or older who had current depression

(defined by a PHQ-8 score of 10 or greater)

Source: CDC, BRFSS 2006


Current depression highlights
Current DepressionHighlights

  • Only 7.7% of adults 50+ reported current depression

  • Hispanic adults 50+ reported more current depression than other racial/ethnic groups

  • Women 50+ reported more current depression than men


Lifetime Diagnosis of Depression

US Virgin Islands

District of Columbia

No Data

0 – 5.41%

5.42 – 6.66%

6.67 – 8.57%

8.58 – 12.43%

Percentage of adults aged 50 or older with a lifetime

diagnosis of depression

Source: CDC, BRFSS 2006


Lifetime diagnosis of depression highlights
Lifetime Diagnosis of DepressionHighlights

  • Adults 50-64 reported more Lifetime Diagnosis of Depression (LDD) than those 65+

  • Women 50+ reported more LDD than men


Lifetime Diagnosis of Anxiety

US Virgin Islands

District of Columbia

No Data

0 – 5.41%

5.42 – 6.66%

6.67 – 8.57%

8.58 – 12.43%

Percentage of adults aged 50 or older with a lifetime

diagnosis of anxiety disorder

Source: CDC, BRFSS 2006


Lifetime diagnosis of anxiety disorder highlights
Lifetime Diagnosis of Anxiety DisorderHighlights

  • More than 90% of adults 50+ did not report a Lifetime Diagnosis of Anxiety Disorder (LDAD)

  • Adults 50-64 were more likely to report a LDAD compared to those 65+

  • Women 50-64 were more likely to report a LDAD than men


Next steps for the cdc healthy aging program
Next Steps for the CDC Healthy Aging Program

  • Disseminating Issue Brief #1

  • Developing The State of Mental Health and Aging in America Issue Brief #2: Depression Programs and Resources

  • Releasing an interactive data website based on the data in Brief #1


Next steps
Next Steps

  • Working with state health departments to see what roles they can play in MH

  • Encouraging inclusion of MH questions on BRFSS and the use of this data by states


For more information

Maggie Moore, MPH

[email protected]

www.cdc.gov/aging


Evidence based integrated models of care for older adults with mental health needs

Evidence-Based Integrated Models of Care for Older Adults with Mental Health Needs

Stephen Bartels, MD, MS

Professor of Psychiatry and Community and Family Medicine

Director, Dartmouth Centers for Health and Aging


Overview
Overview with Mental Health Needs

  • Background: Evidence-based Practices

  • Integration of Mental Health Services in Primary Care

  • Community Outreach

  • Technical Support Implementation Resource Materials


Setting priorities for older adults
Setting Priorities for Older Adults with Mental Health Needs

Improving Access:

  • Integration of Mental Health and General Health Care

  • Home and Community-based Services

    Improving Quality:

  • Evidence-based Practice Implementation

  • Trained Healthcare Workforce with Expertise in Geriatrics


Integrated mental health services in primary care

Integrated Mental Health Services in Primary Care with Mental Health Needs

The Vast Majority of Mental Health Services Provided to Older Persons are in Primary Care


Three rct studies of integrated mental health in primary care
Three RCT Studies of Integrated Mental Health in Primary Care

  • PRISMe (SAMHSA-VA)

  • PROSPECT (NIMH)

  • IMPACT (Hartford Foundation)


Prisme study primary care research in substance abuse and mental health for the elderly
PRISMe Study: CarePrimary Care Research in Substance Abuse and Mental Health for the Elderly

Older Adults with Depression or At-Risk Alcohol Use Randomized Trial Comparing:

  • Integrated/Collaborative Care

    • Co-Located, Concurrent, Collaborative

  • Enhanced Referral to Specialty Mental Health and Substance Abuse Clinics

    • Preferred Providers and Facilitated appointments, transportation, payment



Implications
Implications Care

  • Engagement in treatment is substantially better for integrated MH and Substance abuse services in primary care

  • Under the most optimal of circumstances, enhanced referral to specialty providers results in successful engagement less than half of the time


The impact treatment model
The IMPACT Treatment Model Care

  • Collaborative care model includes:

    • Care manager: Depression Clinical Specialist

      • Patient education

      • Symptom and Side effect tracking

      • Brief, structured psychotherapy: PST-PC

    • Consultation / weekly supervision meetings with

      • Primary care physician

      • Team psychiatrist

  • Stepped protocol in primary care using antidepressant medications and / or 6-8 sessions of psychotherapy (PST-PC)


Substantial improvement in depression 50 drop on scl 20 depression score from baseline
Substantial Improvement in Depression Care(≥50% Drop on SCL-20 Depression Score from Baseline)

P<.0001

P<.0001

P<.0001

3

6

12

Unutzer et al, JAMA 2002.

Unützer et al, JAMA 2002; 288:2836-2845.


Prospect improvement in depression 50 drop on hdrs depression score from baseline
PROSPECT CareImprovement in Depression(≥50% Drop on HDRS Depression Score from Baseline)

P<.05

P<.05

P<.05

P<.05

P<.001

P<.001

4

8

12

Bruce et al,JAMA, 2004;291:1081-1091


Integrated Care is CareMore Cost Effective

Than Usual Care

IMPACT participants had lower mean

total healthcare costs: $29,422

compared to usual care patients: $32, 785

over 4 years.


Impact Model Implementation Care

Resources

http://impact-uw.org/


Effectiveness of community based mental health outreach services for older adults

Effectiveness of Community-Based Mental Health Outreach Services for Older Adults

Results from a Systematic Review


Case identification and referral models
Case Identification and Referral Models Services for Older Adults

  • “Gatekeeper” Model

    • Trains community members to identify and refer community-dwelling older adults who may need mental health services

    • Effective at identifying isolated elderly, who received no formal mental health services

      Florio & Raschko, 1998

    • However…no empirical data on depression outcomes for referral model


Combined case identification and treatment
Combined Case Identification Services for Older Adultsand Treatment

  • Psychogeriatric Assessment and Treatment in City Housing (PATCH) program.

    • Serving Older Persons in Baltimore Public Housing

  • 3 elements

    • Train indigenous building workers (i.e.,managers, janitors,) to identify those at risk

    • Identification and referral to a psychiatric nurse

    • Psychiatric evaluation/treatment in the residents home

  • Effective in reducing psychiatric symptoms

    • Rabins, et al., 2000


Rcts of geriatric mental health community outreach models recovered from depression
RCTs of Geriatric Mental Health Community Outreach Models Services for Older Adults% Recovered from Depression*

* Greater than 50% reduction in symptoms or meeting syndromal criteria


Home and community depression treatment
Home and Community Depression Treatment Services for Older Adults

8 Home-based sessions of manualized problem-solving therapy (PST) over a 19 week period

Social & physical activation, pleasant events scheduling

Clinical supervision by a psychiatrist, recommendations for medication (if needed) management by phone contact with physician and/or participant

Follow-up phone calls (1/month, for 6 months)

For Older Adults



Federal technical assistance initiatives
Federal Technical Assistance Initiatives Depression Remission

  • SAMHSA’s Older Americans Substance Abuse and Mental Health Technical Assistance Center

  • SAMHSA’s Implementation Resource Kits for Depression in Older Adults


Online Resources Depression Remission

www.samhsa.gov/OlderAdultsTAC/


Overview of substance abuse mental health problems and ebps
Overview of Substance Abuse & Mental Health Problems and EBPs

Bartels SJ, Blow FC, Brockmann LM, Van Citters AD. Substance Abuse and Mental Health Among Older Adults: The State of Knowledge and Future Directions.Older Americans Substance Abuse and Mental Health Technical Assistance Center. 2005.

www.samhsa.gov/OlderAdultsTAC/


Review of prevention ebps for older adults
Review of Prevention EBPs for Older Adults EBPs

Blow FC, Bartels SJ, Brockmann LM, Van Citters AD. Evidence-Based Practices for Preventing Substance Abuse and Mental Health Problems in Older Adults.Older Americans Substance Abuse and Mental Health Technical Assistance Center. 2005.

www.samhsa.gov/OlderAdultsTAC/


Ebp implementation guide
EBP Implementation Guide EBPs

Bartels SJ, Blow FC, Brockmann LM, Van Citters AD. A Guide for Implementing Evidence-Based Practices to Prevent Substance Abuse and Mental Health Problems among Older Adults:Older Americans Substance Abuse and Mental Health Technical Assistance Center; 2008.

Available soon at: http://www.samhsa.gov/OlderAdultsTAC/


Ebp implementation guide table of contents

PART 1: Implementation Science & Prevention with Older Adults

Introduction

National Imperative to Implement Evidence-Based Practices

Summary of the State-of-the-Art of Implementation Science

Adaptation of Existing Implementation Materials

Characteristics of Older Adult Populations

PART 2: Implementation of Evidence-Based Practices for Older Adults

Prevention and Early Intervention Among Older Adults

Adapting Implementation to Older Adult Settings and Providers

Implementation Principles

Core Implementation Components

Implementation Process

Training for Service Providers Working with Older Adults

Summary and Key Recommendations

EBP Implementation Guide: Table of Contents


Medicaid background basics and evidence based depression interventions for older adults

Medicaid: Background, Basics and Evidence-Based Depression Interventions for Older Adults

Suzanne Bosstick

Mary Sowers

Division of Community and Institutional Services

Disabled and Elderly Health Programs Group

Center for Medicaid and State Operations

Centers for Medicare & Medicaid Services


Medicaid basics
Medicaid Basics Interventions for Older Adults

  • Medicaid is a State/Federal Partnership to provide health care and long term care services to individuals who are poor and individuals with disabilities, including many elders.


Title xix of the social security act
Title XIX of the Social Security Act Interventions for Older Adults

  • Established in 1965 as a companion program to Medicare

  • “Grants to States for Medical Assistance Programs” ---- Medicaid

  • Federal/State entitlement partnership program – to individuals & States

  • Emphasized dependent children and their mothers, older adults, & individuals with disabilities


The beginning of medicaid
The Beginning of Medicaid Interventions for Older Adults

  • Initially mostly covered primary/acute health care services

  • LTC limited to Skilled Nursing Facility (SNF) services – e.g. nursing homes

  • Institutional bias - eventual addition of community-based services---home health, personal care, home and community-based services (HCBS) in the 1980s


Medicaid in brief
Medicaid in Brief Interventions for Older Adults

  • States determine their own unique programs

  • Each State develops and operates a State plan outlining the nature and scope of services; the State Plan and any amendments must be approved by CMS

  • Medicaid mandates some services, States elect optional coverage

  • States choose eligibility groups, services, payment levels, providers


Federal medical assistance percentages fmap enhanced federal assistance percentages
Federal Medical Assistance Percentages (FMAP) & Enhanced Federal Assistance Percentages

  • Calculated each year for Medicaid/SCHIP

  • Reimbursement rate for “services”

  • Based on average State income per person and the nation as a whole

  • Minimum 50 percent match rate

  • Highest 2007 FMAP: Mississippi, Arkansas, West Virginia, New Mexico (70%+)

  • Enhanced FMAP for some programs/activities

  • Indian Health Service facilities – 100 % FMAP

  • Additional information at: http://aspe.hhs.gov/health/fmap07.htm


Key state plan requirements
Key State Plan Requirements Federal Assistance Percentages

  • States must follow the rules in the Act, the Code of Federal Regulations (generally 42 CFR), the State Medicaid Manual, and policies issued by CMS

  • States must specify the services to be covered and the “amount, duration, and scope” of each covered service

  • States may not place limits on services or deny/reduce coverage due to a particular illness or condition

  • Services must be medically necessary

  • Third party liability rules require Medicaid to be the “payer of last resort”


Additional state plan requirements
Additional State Plan Requirements Federal Assistance Percentages

  • Generally, services must be available Statewide

  • Freedom of choice of providers

  • Enrolled all willing and qualified providers

  • Provider qualifications

  • Payment for services (4.19-B pages)

  • Reimbursement methodologies must include methods/procedures to assure payments are consistent with economy, efficiency, and quality of care principles


Medicaid benefits in the regular state plan

MANDATORY Federal Assistance Percentages

Physician services

Laboratory & x-ray

Inpatient hospital

Outpatient hospital

EPSDT

Family planning

Rural and federally-qualified health centers

Nurse-midwife services

NF services for adults

Home health

OPTIONAL

Dental services

Therapies – PT/OT/Speech/Audiology

Prosthetic devices, glasses

Case management

Clinic services

Personal care, self-directed personal care

Hospice

ICF/MR

PRTF for <21

Rehabilitative services

Medicaid Benefits in the Regular State Plan


Case management
Case Management Federal Assistance Percentages

  • States have options within the Medicaid Program regarding how they offer case management.

  • States may offer case management as a State Plan service. States choosing this approach must meet certain requirements related to Targeted Case Management (as it is called under the State Plan).

  • States may also choose to offer case management for individuals in a Home and Community Based waiver as a waiver-covered service. Different requirements apply when case management is covered as a waiver service.

  • Please be advised that there is currently a rule under moratorium that may impact future rules regarding Case Management in Medicaid.


Section 1915 c home and community based services waivers
Section 1915(c) Federal Assistance PercentagesHome and Community Based Services Waivers

  • Title XIX permits the Secretary of Health & Human Services - through CMS - to waive certain provisions required through the regular State plan process:

  • Comparability (amount, duration, & scope)

  • Statewideness

  • Income and resource requirements

    These waivers allow States to design programs to meet the unique needs of certain groups. There are many 1915(c) waivers across the country designed to serve individuals who are aging.


Section 1915 c home and community based services waivers1
Section 1915(c) Federal Assistance PercentagesHome and Community Based Services Waivers

  • A State may design service packages to meet the specific needs of the group served in a waiver.

  • These services are usually designed to supplement or complement the services already available through the State Plan.


Section 1915 c home and community based services waivers continued
Section 1915(c) Federal Assistance PercentagesHome and Community Based Services Waivers, Continued

  • In HCBS waivers, States must meet a number of requirements, including assuring the health and welfare of individuals served through the waiver.

  • Case managers play an important role in helping States meet this obligation.


How could states incorporate depression interventions for older adults into their medicaid program
How Could States Incorporate Depression Interventions for Older Adults into Their Medicaid Program?

  • Through 1915(c) Home and Community Based Services Waivers

    • States can define the services to be offered under the waiver.

    • Case managers often play a pivotal role in screening, information and referral, and linkages.

    • Existing HCBS waivers may present a unique opportunity for an overlay of these interventions.

    • Things to remember: Important to define the activities involved. If the service requires skilled interventions, State should consider identifying those elements separately within the waiver.


How could states incorporate depression interventions for older adults into their medicaid program1
How Could States Incorporate Depression Interventions for Older Adults into Their Medicaid Program?

  • States may have another option to consider regarding the incorporation of these interventions into their Medicaid Program.

    • Through a variety of State Plan services

      • Discreet, specific activities within the interventions may be Medicaid-coverable services. So, identifying the component elements will be helpful in mapping where coverage for those services may occur within the State Plan.

      • The State may also wish to evaluate whether using the HCBS as a State Plan Option is an option.

      • Things to remember: Service must be well-defined, and should not include a “bundle” of services.


Next steps1
Next Steps Older Adults into Their Medicaid Program?

  • Contact your State’s Medicaid Agency if you are interested in discussing how these interventions may be included in your Medicaid Program.

  • The State Medicaid Agency would be the entity in your State who must submit any State Plan or Waiver document.

  • CMS stands ready to provide technical assistance and guidance to States on the authorities available that will best meet their objectives.


Questions answers
Questions & Answers Older Adults into Their Medicaid Program?


Archived webinars
Archived Webinars Older Adults into Their Medicaid Program?

Download any or all of these webinars at:

http://ncoa.org/content.cfm?sectionid=379

Alphabetically listed under “NCOA Presentations”

This, and all past webinars in the PRC-HAN webinar series are

available for download:

  • Overcoming Stigma, October 1st

  • IMPACT, October 16th

  • PEARLS, October 23rd

  • Healthy IDEAS, October 29th

  • Money Matters, November 13th

  • Latest Data, Strategies, Funding, December 2nd


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