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ACCESS TO MENTAL HEALTH CARE FOR THE ELDERLY

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Hispanic elderly. Women (although men are at greater risk ... MENTAL HEALTH CARE FOR THE ELDERLY ... the barriers of mental health care access for the elderly ... – PowerPoint PPT presentation

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Title: ACCESS TO MENTAL HEALTH CARE FOR THE ELDERLY


1
ACCESS TO MENTAL HEALTH CARE FOR THE ELDERLY
  • JOSEPH E. GAUGLER, PH.D.
  • ASSOCIATE PROFESSOR
  • MCKNIGHT PRESIDENTIAL FELLOW
  • SCHOOL OF NURSING
  • UNIVERSITY OF MINNESOTA

2
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

3
YOUR OPINION
  • In your opinion, what is the state of mental
    health for older persons in Minnesota?

4
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/pub
    lic/IssueBrief_TheStateofMentalHealthandAginginAme
    rica.pdf

5
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)
  • Surgeons General report on mental health (DHHS,
    1999)

6
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)

7
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 5064 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).

8
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9
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).

10
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11
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 5064 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).

12
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13
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 5064 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 5064 years report a lifetime
    diagnosis of an anxiety disorder more often than
    men in this age group (16.1 compared to 9.2,
    respectively.)

14
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15
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)

16
BARRIERS TO MENTAL HEALTH CARE FOR THE ELDERLY
  • From your perspective, what are the barriers?

17
BARRIERS TO MENTAL HEALTH CARE FOR THE ELDERLY
  • From your perspective, what are the barriers?

18
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

19
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.american
    geriatrics.org/news/geria_faqs.shtml2)
  • 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/sum
    mary.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

20
BARRIERS TO MENTAL HEALTH CARE FOR THE ELDERLY
(Jeste et al., 1999)
  • Deinstitutionalization or transinstitutionalizati
    on 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

21
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

22
IMPROVING ACCESS TO MENTAL HEALTH CARE FOR THE
ELDERLY
  • What are your ideas?

23
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

24
APPRAISING EVIDENCE
From http//library.downstate.edu/EBM2/2100.htm
25
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

26
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)

27
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 persons 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

28
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
    persons 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

29
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.

30
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.

31
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.

32
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

33
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

34
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35
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 gaug0015_at_umn.edu
  • Fax 612-625-7180
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