California Moves to Evidence Based Practices in Older Adult Services: Overview of an AcademicPublic

1
California Moves to Evidence Based Practices in
Older Adult Services Overview of an
Academic-Public Partnership

• Research Network Development Core
• NIMH-Advanced Center for Interventions and
  Services Research
• Geriatric Psychiatry
• University of California, San Diego
• San Diego County Adult/Older Adult Mental Health
  System

Laurie A. Lindamer, PhD, Assistant Professor of
Psychiatry, Co-PI of RNDC, UCSD Todd Gilmer, PhD,
Assistant Professor of Family and Preventive
Medicine, UCSD Maureen Halpain, MS, Academic
Coordinator, Division of Geriatric Psychiatry,
UCSD Sally Shepherd, RN, MN, Board President,
NAMI, San Diego
2
RNDC Partnership Accomplishments

• Infrastructure Development
• Needs Assessment
• Education and Advocacy
• Research and Program Evaluation
• Other Center Projects
• Outcomes

3
Infrastructure Development

• Research Policies and Procedures
• Tracking of Research Projects
• Recruitment of Subjects
• Policy for Participation of Conservatorees
• MIS Database (utilization anaylsis)
• Technical Support for other Databases

4
A Qualitative Assessment of Need for Mental
Health Services among Older Adults in San Diego
County

• Lawrence A. Palinkas, Ph.D., Department of Family
  and Preventive Medicine, UCSD
• Viviana Criado, MPA, Older Adult Mental Health
  Coordinator, AOAMHS
• To determine needs that are currently not being
  addressed by existing services and what services
  are necessary to address these needs
• Rapid Assessment Procedures

5
Rapid Assessment Procedures

• Semi-structured interviews with 3-5 key
  informants representing 3 stakeholder groups
  from each of the 5 San Diego County CMH regions
• Participants
• Health care and social service providers
• Clients and other older adults
• Family members/patient advocates
• Informants identified via CMH Older Adult
  Services, Older Adult Task Force, and snowball
  sampling.
• Schedule October 1 November 15, 2004
• Focus Groups to validate and expand upon data
  obtained from semi-structured interviews through
  triangulation.
• Participants
• One focus group per stakeholder group per region
  (n15)
• Schedule December 1-15, 2004

6
Needs Assessment Interview Topics

• Health care needs
• Physical health
• Mental health
• Access to services
• Use of services
• Quality of services

• Other needs
• Financial needs
• Social support
• Housing
• Transportation
• Other social services

7
Needs Assessment Preliminary Results from Focus
Groups

• Most important problems faced by older adults
• Isolation
• Stigma
• Lack of information about services - access
• Lack of service coordination - access
• Housing
• Transportation
• Lack of evidence-based approaches to working with
  older adults

8
Needs Assessment Preliminary Results from Focus
Groups

• Evidence-based Practices
• Lack of understanding on how to identify and
  treat mental disorders in older adults.
• Many labeled as demented
• Lack of progress in some services (services are
  based more of provider survival than on
  evidence)
• Substantial progress in other services
  (co-occurring disorders)
• All services require consistent outcome measures
  to evaluate effectiveness.

9
Needs Assessment Recommended Solutions

• Peer counseling and support
• Addresses problems of isolation, stigma and lack
  of information
• Peers need to be trained
• Program should be evidence-based
• Coordination of Services
• Aging and Independent Services Model
• Train specialists to be generalists who can refer
  client to several different programs.
• Co-location of services
• Coordination of funding
• Provider training and education
• Addresses problems of isolation, stigma and lack
  of information
• Providers need training in
• Geriatric medicine
• Geriatric Psychiatry
• Evidence-based treatments

10
GAP Analysis

• Data to support planning under Prop 63
• Questions driven from SD County experience in
  providing services and
• UCSD experience in analyzing data
• Iterative Process
• Two questions as example

11
AMHS MIS Database

• Data from FY1999-2004
• Sociodemographic data including Medicaid
  eligibility, living situation, legal status,
  employment status
• Data on service use including clinician,
  provider, specific service, service duration in
  minutes, and admission/discharge dates,
• Some clinical information, i.e., diagnosis, GAF
  scores

12
GAP analysis questions

• To what extent do people use emergency services
  but not outpatient services?
• Who are the high utilizers?
• And what do they look like?

13
(No Transcript)
14
(No Transcript)
15
(No Transcript)
16
(No Transcript)
17
(No Transcript)
18
(No Transcript)
19
(No Transcript)
20
Education and Advocacy

• Organized and conducted the Older Adult Wellness,
  Prevention and Educational Campaign
• Jeste, Bartels, Lacro Masten, Hall
• Built an event-planning database
• Produce a quarterly newsletter (Partners)
• Presented various local and state agencies
• Participated in 3 coalitions or networks
• San Diego Older Adult Mental Health and Substance
  Abuse Coalition
• Older Adult Mental Health Task Force
• Center Community Advisory Board
• Center Latino Unit

21
Research and Program Evaluation

• Disparities in service use
• Elderly under-represented in services except CM
  where they are over-represented (Jin, et al,
  2003)
• Few gender differences when other variables
  controlled for (Lindamer, et al, 2003)
• Latinos and African-Americans less likely to use
  case management (Barrio, et al, 2003)
• Homeless more likely to use emergency rather than
  outpatient services (Folsom, et al. in press)

22
AMHS - Medi-Cal Linked Data Set

• Persons diagnosed with schizophrenia and
  receiving county services are matched to Medi-Cal
  eligibility and claims data
• County/UBH provided SSNs to DHS who returned the
  claims with encrypted identifiers
• Data from 1998-2000

23
Summary of Results

• Residing in assisted living facilities was
  associated with a favorable profile of health
  resource use (Gilmer, et al, 2003)
• Higher outpatient and pharmacy costs but lower
  costs for psychiatric and medical
  hospitalizations
• Antipsychotic Adherence (Gilmer, et al, 2004)
• Adherence negatively associated with probability
  of being member of ethnic minority, having a
  substance use diagnosis, and being homeless
• Positively associated with age, residential
  living facility
• Non-adherent more likely to have psychiatric and
  medical hospitalizations

24
Current ResearchUnder-Represented
Groups/Disparities

• Cultural competence
• Garcia, Montross, Fuentes, Yamada, et al.
• Comorbidity in a Tri-ethnic sample
• Montross et al.
• Differential Use of Services by Latinos
• Folsom, Moore, et al.
• Jail and DA data
• Folsom, Conklin, Hawthorne, Garcia, et al.
• High utilizers/ Recidivism
• Lindamer, Kim, et al.

25
Current Research Aging and Other Disorders

• Anxiety and PTSD in later life
• Wetherell, Thorp, et al
• Patterns of service use by age in patients with
  bipolar disorders.
• Depp, et al

26
Economics

• Costs among older adults
• Criado, Milan, Gilmer, et al.
• Overview of costs in a public mental health
  system
• Gilmer, Kim, et al (CPAC)
• Mental health services use and pharmacoeconomic
  outcomes.
• Gilmer, et al. (RO1)
• Costs associated with contract types
• Gilmer, Hawthorne, et al.

27
Program Evaluation

• Day treatment
• Van der Moer, Kim, Manning, et al.
• Inpatient START program utilization
• Hawthorne, et al.
• SanDMAP
• Shale, Lindamer, Lohr, Judd

28
Other Center Projects

• Functional Adaptation Skills Training (Patterson)
• PEDAL (Bucardo and Patterson)
• Medication Adherence (Lacro)
• Individualized Placement and Support for Older
  Schizophrenia Patients (Jeste and Twamley)
• Diabetes Intervention (McKibbin)
• Case Management for Homeless (Folsom)
• Treatment of Late-life Anxiety (Wetherell)
•  

29
Other Center Projects

• Cognitive Rehabilitation (Twamley)
• Informed Consent Research (Jeste, Palmer, Dunn)
• Citalopram Augmentation in Older Patients with
  Schizophrenia (Zisook)
• Treatment of Cognitive Deficits in Schizophrenia
  with Donepezil (Eyler)
• Effectiveness of CBSST (Granholm)

30
Outcomes

• MIS database outcomes
• Costs and utilization
• GAF scores
• Co-morbidity
• Conservatorship status
• SOC Outcomes
• Improvement or stabilization of community
  functioning (MHSIP 20-26)
• Improvement or stabilization in stage of
  substance abuse treatment (SAT-R)
• Maintain or improve residential status (PSR
  Toolkit)
• Maintain or improve vocational status (PSR
  Toolkit)
• Hospitalization
• Re-admission rates
• Satisfaction (Perception of Care Survey)

31
RNDC Partnership Future Directions

• Needs Assessment
• Use for Education and Training and other Systems
  of Care
• Education and Advocacy
• Train providers (nurses, LCSW, MFT, MD, PhD,
  PharmD) to increase workforce, emphasizing EBP
  and Recovery Models
• Adapt innovative training programs (MH-START,
  SRI, CRI)
• Peer Counseling (Roadmap to Recovery)
• Expand participation in advocacy groups (NAMI,
  Coalition, etc)

32
RNDC Partnership Future Directions

• Research and Program Evaluation
• Continue to identify unmet needs with database
  and needs assessment
• More program evaluation to examine effectiveness
  and possibly cost-effectiveness
• Service intervention/implementation grants
• Other Center Projects
• Increase communication about the types, designs,
  analysis, interpretation, and dissemination of
  research
• Grants for innovative interventions
• Outcomes
• Expand and develop (innovation)
• Assistance with collection (ie, training in
  administration and reliability)
• Data management, analysis, interpretation