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Implementing Evidence Based Practices for Older Iowans with Mental Illnesses

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Implementing. Evidence Based Practices for Older Iowans with Mental Illnesses ... Susan Collins (R-ME) and Representatives Patrick Kennedy (D-RI) and Ileana Ros ... – PowerPoint PPT presentation

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Title: Implementing Evidence Based Practices for Older Iowans with Mental Illnesses


1
Implementing Evidence Based Practices for Older
Iowans with Mental Illnesses
2
Aging and Mental Illness in Iowa
3
Outpatient Care
  • Medicare?
  • Community-based Care?

4
Inpatient Care

5
Depression in Older Adults and Health Care Costs
Unutzer, et al., 1997 JAMA
6
Monthly Per Person Costs by Age Severe Mental
Illness
7
New Hampshire Total Monthly Costs Per Person Over
Age 65
4,000
Medicaid
Medicare
3,500
3,000
2,500
2,000
1,500
1,000
500
0
COPD
Diabetes
Depression
Cardiac
Dysrhymias
Dementia
Alzheimer's
Hypertension
Schizophrenia
Heart Failure
Osteoarthrosis
Cerebrovascular
8
Suicide Rate by Age Per 100,000
Older people 12.7 of 1999 population, but 18.8
of suicides. (Hoyert, 1999)
9
Outcomes ADL Decline at One Year Follow-up
10
Good Mental Health is the Foundation for Overall
Health, Quality of Life and Independence
  • Factors that increase risk of depression
  • Medical Illness (cardiovascular disease)
  • Disability
  • Cognitive Decline
  • Social Isolation
  • Loss And Other Negative Events
  • Genetic Vulnerability
  • Depression increases the risk of
  • Medical Illness
  • Disability
  • Social Isolation
  • Cognitive Decline
  • Loss Of Independence
  • Relocation/Institutionalization
  • Suicide And Deaths From Other Causes

11
Depression is treatable
  • Antidepressants as effective in older patients as
    younger patients (Reynolds et al, 2003, JAMA)
  • Psychotherapy also as effective in older patients
    as younger patients (Arean Cook, 2002 Biol.
    Psych.)

12
NATIONAL MOVEMENT
13
2005 White House Conference
14
Top 10 Recommendations of 2005 White House
Conference on Aging
  1. Reauthorize the Older Americans Act within the
    first six months following the 2005 White House
    Conference on Aging
  2. Develop a coordinated, comprehensive long-term
    care strategy by supporting public and private
    sector initiatives that address financing,
    choice, quality, service delivery, and the paid
    and unpaid workforce
  3. Ensure that older Americans have transportation
    options to retain their mobility and independence
  4. Strengthen and improve the Medicaid program for
    seniors
  5. Strengthen and improve the Medicare program
  6. Support geriatric education and training for all
    healthcare professionals, paraprofessionals,
    health profession students, and direct care
    workers
  7. Promote innovative models of non-institutional
    long-term care
  8. Improve recognition, assessment, and treatment of
    mental illness and depression among older
    Americans
  9. Attain adequate numbers of healthcare personnel
    in all professions who are skilled, culturally
    competent, and specialized in geriatrics
  10. Improve state and local based integrated delivery
    systems to meet 21st century needs of seniors

15
Positive Aging Act Reintroduced
  • May 31, 2005 Last Wednesday, Senators Hillary
    Rodham Clinton (D-NY) and Susan Collins (R-ME)
    and Representatives Patrick Kennedy (D-RI) and
    Ileana Ros-Lehtinen (R-FL) announced the
    introduction of the Positive Aging Act of 2005 to
    improve access to mental health services for
    Americas senior citizens.

16
MENTAL HEALTH FORUMS
  • Quick Fixes (1998)
  • Iowa Mental Health Forum (2000)
  • Mental Health System (2001)

17
Older Adults Roundtable
  • Many persons did not know where to seek help.
  • Include dementia
  • Implement multi-disciplinary treatment
    approaches

18
IOWA COALITION ON MENTAL HEALTH AND
AGING
  • Collaborative Models of Care

19
PRIMARY GOALS
  • Promote mental wellness among aging Iowans
  • Increase access to qualified mental health
    service providers
  • Integrate mental health services nto usual places
    of care

20
OBJECTIVES
  • Conduct screenings
  • Identify and recruit providers
  • Develop collaborative care models

21
COLLABORATIVE MODELS
  • Nursing Homes other LTC facilities
  • Primary Care Practices
  • Aging Network

22
The IMPACT Treatment Model
  • 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)

23
Usual Care
PRIMARY CARE CLINICIAN
PATIENT
MENTAL HEALTH SPECIALIST
24
Component Model (TCM)
PRIMARY CARE CLINICIAN
PHQ-9
CARE MANAGER
PATIENT
PHQ-9
PHQ-9
MENTAL HEALTH SPECIALIST
25
Typical Frequency of Patient Contacts
Care Manager Phone Call
Primary Care Clinician Visit
PCC
CM
Acute Phase
Continuation Phase
PCC
PCC
PCC
PCC
PCC
CM
CM
CM
CM
CM
1 5 6 9 12
18 24 32
36
WEEK
26
IMPACT Unutzer et al, 2002
1,801 patients 60 yrs in 18 Primary care clinics
in 8 Health care organizations.
Cadillac
model of
system change
Patients in REMISSION (HSCLlt0.5)
27
Managing Antidepressants is Like..
28
MH-PC Co-location Project
  • Pilot project funded through a federal block
    grant
  • Serves persons who are 60 years and older no
    charge
  • 2 - master degree level clinical social workers
  • Collaborate with 5 primary care practices in
    community family practice, internal medicine
    providers include MDs, DOs, PAs, ARNPs
  • Services provided include
  • mental health assessments and screenings
  • ongoing psychotherapy
  • referral to other community resources and
    services as needed
  • Spanish interpreters available

29
Case Example
  • CC elder female presents to PCP for F/U
    appointment for DM and c/o arthritis pain in
    several joints X 2 mo..
  • Labs, X-rays and physical exam neg. except early
    DJD changes in knees and muscle tension in back
    and neck
  • Before leaving office starts to cry - reports
    recent stress has been having problems with
    my kids
  • PCP put on Lexapro and referred for mental
    health assessment/therapy.

30
Case Example-Assessment
  • STRESSORS
  • poor interpersonal and psychological boundaries
  • Financial problems housing, utilities
  • Isolation - except family
  • HISTORY
  • Ashamed to tell PCP depressed for mo. that
    has dysfunctional family
  • Personal and family history of childhood sexual
    abuse
  • Multiple family members abuse substances
    (intergenerational)
  • Multiple interpersonal family conflicts
  • Worrier- chronic untreated generalized anxiety
    disorder
  • DIAGNOSES

31
Case Example- Interventions
  • SSRI meds-reduces symptoms to help make desired
    changes
  • called PCP to consider increasing Lexapro
    little improvement symptoms
  • CBT-evaluate challenge negative
    thoughts/distortions, action (behavioral) steps -
    reconnect w/church and friends - increase social
    interaction to reduce isolation
  • Connect resources to decrease financial stressors
    - energy assistance, MOW,
  • Boundaries appropriate psychological and
    interpersonal w/family
  • Self-esteem develop sense self efficacy
  • manage moods- self-awareness/monitoring, coping
    skills-relaxation, distraction, etc.
  • boundaries-empathy/love w/o taking on others
    distress

32
  • THANK YOU
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