Title: Implementing Evidence Based Practices for Older Iowans with Mental Illnesses
1Implementing Evidence Based Practices for Older
Iowans with Mental Illnesses
2Aging and Mental Illness in Iowa
3Outpatient Care
- Medicare?
- Community-based Care?
4Inpatient Care
5Depression in Older Adults and Health Care Costs
Unutzer, et al., 1997 JAMA
6Monthly Per Person Costs by Age Severe Mental
Illness
7New 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
8Suicide Rate by Age Per 100,000
Older people 12.7 of 1999 population, but 18.8
of suicides. (Hoyert, 1999)
9Outcomes ADL Decline at One Year Follow-up
10Good 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
11Depression 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.)
12NATIONAL MOVEMENT
132005 White House Conference
14Top 10 Recommendations of 2005 White House
Conference on Aging
- Reauthorize the Older Americans Act within the
first six months following the 2005 White House
Conference on Aging - 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 - Ensure that older Americans have transportation
options to retain their mobility and independence - Strengthen and improve the Medicaid program for
seniors - Strengthen and improve the Medicare program
- Support geriatric education and training for all
healthcare professionals, paraprofessionals,
health profession students, and direct care
workers - Promote innovative models of non-institutional
long-term care - Improve recognition, assessment, and treatment of
mental illness and depression among older
Americans - Attain adequate numbers of healthcare personnel
in all professions who are skilled, culturally
competent, and specialized in geriatrics - Improve state and local based integrated delivery
systems to meet 21st century needs of seniors
15Positive 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.
16MENTAL HEALTH FORUMS
- Quick Fixes (1998)
- Iowa Mental Health Forum (2000)
- Mental Health System (2001)
17Older Adults Roundtable
- Many persons did not know where to seek help.
- Include dementia
- Implement multi-disciplinary treatment
approaches
18IOWA COALITION ON MENTAL HEALTH AND
AGING
- Collaborative Models of Care
19PRIMARY GOALS
- Promote mental wellness among aging Iowans
- Increase access to qualified mental health
service providers - Integrate mental health services nto usual places
of care
20OBJECTIVES
- Conduct screenings
- Identify and recruit providers
- Develop collaborative care models
21COLLABORATIVE MODELS
- Nursing Homes other LTC facilities
- Primary Care Practices
- Aging Network
22The 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)
23Usual Care
PRIMARY CARE CLINICIAN
PATIENT
MENTAL HEALTH SPECIALIST
24Component Model (TCM)
PRIMARY CARE CLINICIAN
PHQ-9
CARE MANAGER
PATIENT
PHQ-9
PHQ-9
MENTAL HEALTH SPECIALIST
25Typical 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
26IMPACT 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)
27Managing Antidepressants is Like..
28MH-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
29Case 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.
30Case 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
31Case 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