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. • Summarize barriers to mental health access to older persons • Review evidence to enhance access to mental health care for older persons: what works? • Translating evidence-based interventions into practice: RE-AIM
YOUR OPINION • In your opinion, what is the state of mental health for older persons in Minnesota?
KEY REFERENCE • Center for Disease Control and Prevention and National Association of Chronic Disease Directors. The State of Mental Health and Aging in America Issue Brief 1: What Do the Data Tell Us? Atlanta, GA: National Association of Chronic Disease Directors; 2008. • Available: http://www.chronicdisease.org/files/public/IssueBrief_TheStateofMentalHealthandAginginAmerica.pdf
MENTAL HEALTH AND HEALTH • Health is “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (World Health Organization, 1948) • Psychological, epidemiological, and psychiatric research has emphasized the important interplay of mental health with overall health/quality of life. • Mental health is becoming a key health outcome to target: • Healthy People 2010 (DHHS, 2000) • White House Conference on Aging (DHHS, 2006) • Surgeon’s General report on mental health (DHHS, 1999)
MENTAL HEALTH PROBLEMS IN OLDER PERSONS • “1/5 of persons 55 years of age and over have some type of mental health concern (American Association of Geriatric Psychiatry, 2008)” • Most common conditions are anxiety, severe cognitive impairment, and mood disorders such as depression • Depression is the most common mental health concern among older adults • It is associated with physical, mental, and social functional impairment, complications in treatment of other diseases, and increased service utilization • Data from the 2006 CDC Behavior Risk Factor Surveillance System (BRFSS)
SOCIAL SUPPORT • “How often do you get the social and emotional support you need?” The response options included: “always”, “usually”, “sometimes”, “rarely”, or “never.” • “Almost all (nearly 90%) of adults age 50 or older indicated that they are receiving adequate amounts of support.” • “Adults age 65 or older were more likely than adults age 50–64 to report that they “rarely” or “never” received the social and emotional support they needed (12.2% compared to 8.1%, respectively). • “Approximately 20% of Hispanic and other, non-Hispanic adults age 65 years or older reported that they were not receiving the support they need, compared to about one-tenth of older white adults.” • “Among adults age 50 or older, men were more likely than women to report they “rarely” or “never” received the support they needed (11.39% compared to 8.49%).”
FREQUENT MENTAL DISTRESS • “Now thinking about your mental health, which includes stress, depression and problems with emotions, for how many days during the past 30 days was your mental health not good?” People who reported 14 or more days of poor mental health were defined as having frequent mental distress (FMD).” • Most older persons did not indicate FMD on the BRFSS: the prevalence of FMD was 9.2% among those 50 or over and 6.5% among those age 65 or older • Hispanic prevalence of FMD: 13.2%; White, non-Hispanics: 8.3%; black, non-Hispanics: 11.1% • “Women aged 50-64 and 65 or older reported more FMD than men in the same age groups (13.2% and 7.7% compared to 9.1% and 5.0%, respectively).”
DEPRESSION • PHQ-8 score of 10 or greater • Widowhood, low formal education, impaired functional dependence, and heavy alcohol consumption are associated with depression in old age (DHHS, 1999) • One of the most successfully treated mental health problems • Adults age 50 and over were not currently depressed; only 7.7% are currently depressed and 15.7% indicated lifetime diagnosis • “Adults age 50–64 reported more current depression and lifetime diagnosis of depression than adults age 65 or older (9.4% compared with 5.0% for current depressive symptoms and 19.3% compared with 10.5% for lifetime diagnosis of depression, respectively).“ • “Hispanic adults age 50 or older reported more current depression than white, non-Hispanic, black, non-Hispanic adults, or other, non-Hispanic adults (11.4% compared to 6.8%, 9.0%, and 11%, respectively).“ • Women age 50 or older reported more current and lifetime diagnosis of depression than men (8.9% compared to 6.2% for current depressive symptoms; 19.1% compared to 11.7% for lifetime diagnosis).
ANXIETY • Along with depression, the most prevalent mental health problem in older adults • Often is concurrent with depression • Anxiety is not as well understood in old age; it is estimated to be as high in older persons as in younger age populations • One of the most successfully treated mental health problems • “More than 90% of adults age 50 or older did not report a lifetime diagnosis” • “Adults age 50–64 reported a lifetime diagnosis of an existing anxiety disorder more than adults age 65 or older (12.7% compared to 7.6%). • “Hispanic adults age 50 or older were slightly more likely to report a lifetime diagnosis of an anxiety disorder compared to white, non-Hispanic, black, non-Hispanic, or other, non-Hispanic adults (14.5% compared to 12.6%, 11% and 14.2%, respectively).” • “Women age 50–64 years report a lifetime diagnosis of an anxiety disorder more often than men in this age group (16.1% compared to 9.2%, respectively.) “
SUMMARY • Overall, older persons in the U.S. do not report high prevalence rates of mental disorders, particularly when compared to other age groups • Minnesota appears to have low prevalence of mental disorders in its aging population • There exist key subgroups of older persons that appear at greater risk for mental disorders • Hispanic elderly • Women (although men are at greater risk for suicide)
BARRIERS TO MENTAL HEALTH CARE FOR THE ELDERLY • From your perspective, what are the barriers?
BARRIERS TO MENTAL HEALTH CARE FOR THE ELDERLY • From your perspective, what are the barriers?
BARRIERS TO MENTAL HEALTH CARE FOR THE ELDERLY • Older persons with mental disorders often contact a primary care physician, and not a mental health care specialist (Jeste et al., 1999) • PCPs often do not detect and treat key mental health issues • 55% of internists felt confident in diagnosing depression, 35% felt confident in prescribing anti-depressants, and 75% of physicians felt depression was “understandable” in older persons (Callahan et al., 1992; Higgins, 1994; Jeste et al., 1999) • Dementia screening in the primary care setting
BARRIERS TO MENTAL HEALTH CARE FOR THE ELDERLY • There are not enough professionals available to adequately treatment mental illness in older persons • As of 1999, there were 2425 board-certified geriatric psychiatrists (Jeste et al., 1999); as of April 2008 there were 1657 (http://www.americangeriatrics.org/news/geria_faqs.shtml#2) • As of 1999, there were 200-700 geropsychologists (Jeste et al., 1999); as of 2002 there were approximately 700 (http://www.apa.org/pi/aging/summary.html) • No federally funded training programs exist for geropsychologists as of 2002, except for a small program in the VA • It is agreed that by 2020 there is a need for at least 5,000 in each specialty
BARRIERS TO MENTAL HEALTH CARE FOR THE ELDERLY (Jeste et al., 1999) • Deinstitutionalization or “transinstitutionalization” of older adults with severe mental illness from state hospitals • Into nursing homes, where mental health care treatment is reduced (Knight et al., 1998) • Or into the community, where supports may be lacking or uncoordinated • Many individuals with mental illness in the prison system will age there, requiring an additional area for mental health intervention
BARRIERS TO MENTAL HEALTH CARE FOR THE ELDERLY (Jeste et al., 1999) • While psychiatric outpatient service use has climbed, there is continued underutilization • Community mental health organizations do not adequately serve older persons (Light et al., 1986) • Community mental health organizations also tend to lack staff trained to address medical needs, and sometimes exclude persons with cognitive impairment • Medicare: will part D help? • Managed health care: what is the role of cognitive or psychosocial rehabilitation, or identify the appropriate mix of services necessary to keep the older person at home • Other reasons as well: physical frailty, stigma, isolation, and transportation difficulties (Administration on Aging, 2001), reimbursement, lack of organized support
IMPROVING ACCESS TO MENTAL HEALTH CARE FOR THE ELDERLY What are your ideas?
IMPROVING ACCESS TO MENTAL HEALTH CARE FOR THE ELDERLY (Citters & Bartels, 2004) 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
APPRAISING EVIDENCE From http://library.downstate.edu/EBM2/2100.htm
IMPROVING ACCESS TO MENTAL HEALTH CARE FOR THE ELDERLY (Citters & Bartels, 2004) 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
IMPROVING ACCESS TO MENTAL HEALTH CARE FOR THE ELDERLY (Citters & Bartels, 2004) 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)
IMPROVING ACCESS TO MENTAL HEALTH CARE FOR THE ELDERLY (Citters & Bartels, 2004) 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
IMPROVING ACCESS TO MENTAL HEALTH CARE FOR THE ELDERLY (Citters & Bartels, 2004) 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
IMPROVING ACCESS TO MENTAL HEALTH CARE FOR THE ELDERLY: APA RECOMMENDATIONS (2003) 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.
IMPROVING ACCESS TO MENTAL HEALTH CARE FOR THE ELDERLY: APA RECOMMENDATIONS (2003) • Medicare limits need to be extended for inpatient mental health coverage to care for older adults with persistent mental disorders. Currently, Medicare only allows for 190 days of psychiatric hospitalization in one's lifetime. • Medicaid coverage needs to be expanded to include older adults as a "categorically needy" group. Currently over half of Medicaid-covered older persons are classified as optional. In addition, the 50% Medicare co-payment is fully reimbursed by Medicaid in a very limited number of states. • Efforts need to be made to reduce the stigma that is often associated with mental disorders and treatment. • The geriatric mental health workforce must be expanded to accommodate the growing number of older adults in need of services. • Increased funding and support is necessary for basic and applied behavioral research and the incorporation of empirically-based interventions into clinical practice with older persons.
IMPROVING ACCESS TO MENTAL HEALTH CARE FOR THE ELDERLY • Medicare “carve out?” • “One way to increase benefits without an explosion in costs is by contracting with managed behavioral health care organizations (MBHOs, or carve-outs). Carve-outs essentially substitute utilization review, pre-authorization and other direct care management strategies for financial need in managing demand.” (Schoenbaum et al., 2003) • “Possible disadvantages: administrative complexity, cost-shifting, reduced provider participation due to lower reimbursement rates, and worse continuity of care.” • “Potential advantages: reduction in adverse selection if single-vendor contracting is used, a reduction in moral hazard due to direct care management, protection of funding, and quality improvement as a result of specialization.” • “May also facilitate disease management programs by creating a locus of responsibility for getting patients into care or coordinating communication among providers.”
TRANSLATING EVIDENCE TO PRACTICE 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
TRANSLATING EVIDENCE TO PRACTICE 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
CONTACT INFORMATION • Joseph E. Gaugler, Ph.D. • University of Minnesota • 6-153 Weaver-Densford Hall, 1331 • 308 Harvard Street S.E. • Minneapolis, MN 55455 • Telephone: 612-626-2485 • Email: firstname.lastname@example.org • Fax: 612-625-7180