For Older Persons With Behavioral Health Needs In Southeast Pennsylvania, the position paper prepared by the Delaware Valley Mental Health Aging Advocacy Committee of the Mental Health Association of Southeastern Pennsylvania.
Creating A Continuum Of Care For Older Persons With Behavioral Health Needs In Southeast Pennsylvania
The Delaware Valley Mental Health Aging and Advocacy Committee (DVMHAAC) is a coalition of 60 aging and mental health administrators, service providers, consumers and advocates from Philadelphia and the adjoining suburbs established in 1989 to "advocate for the expansion, improvement, and development of affordable, appropriate, and accessible behavioral health services for Pennsylvanians 60 years of age and older and their families.
Statement of Need
Although elderly persons with psychiatric disabilities are recognized as a "special needs population" and Pennsylvania has one of the nation's highest proportions of older residents, funding allocations to address their needs of this group have not been a priority in the Commonwealth's budget.
Data on older Pennsylvanians presents a demographic imperative for increasing the funding for behavioral health services. According to the Pennsylvania Department of Aging:
- 2.5 million people age 60 and over represent 15 percent of the population
- The fastest growing age group, people 85 and over, consists of almost 255,000
- 520,000 older individuals live alone, an increase of 29 percent from 1980 to 1990
- 22 percent of older adults live near or below the poverty level
Philadelphia statistics portray this picture:
- People age 60 and over constitute 20 percent of the population
- About 40 percent of older persons in Philadelphia live alone
- 33 percent of older adults are non-white
- 16 percent of older adults live in poverty
- Only 2.8 percent use the Mental Health System
Epidemiologists estimate that psychiatric impairment affects 18 to 25 percent of the nation's senior citizens. Despite this, mental health service utilization by this group is minimal; only four to six percent of adults served by community mental health centers in the nation are elderly. Another alarming statistic is the elderly suicide rate, the highest for any age cohort. An average of 17 elderly persons commit suicide per day, approximately 7,000 per year. In 1996-97, 67 older Philadelphian's committed suicide.
For older adults, substance abuse is defined as excessive use or misuse of alcohol, drugs or medication despite persistent personal or interpersonal problems caused or exacerbated by the effects of the substance, which lasts for at least one month or which has occurred repeatedly over a long period of time (DSM-IV). The Philadelphia Corporation for Aging reports that hospitalization for alcohol-related problems occurs more frequently than those for heart attacks, and cost Medicare more than $230M a year. Over 65 year olds are second only to 45-65 year olds for alcohol-related hospitalizations. Research indicates that as many as 20 percent of individuals over the age of 65 have some problem with alcohol.
Misuse of everyday medications is another problem the elderly are particularly vulnerable to, and costs "billions of dollars and thousands of lives" every year, according to the Alliance for Aging Research (AAR). An AAR study in 1998, When Medicine Hurts Instead of Helps, reports that older adults are more at-risk for drug reactions due to the number of medications they take and the biological changes that occur with aging and disease. Adverse medication effects include increased risk for memory loss, hip fractures, and/or automobile-related injuries.
In spite of this distressing information and evidence of need, neither the public sector nor private behavioral health systems have given this problem sufficient attention or resources. Elders with behavioral problems living in their own homes, in boarding homes, or with relatives, tend to be overlooked and undeserved. The lack of mental health care for nursing home residents is even more acute. Likewise, there is need for services that are culturally sensitive and multi-lingual as the elder population becomes more ethnically diverse.
Behavioral health services are those that include mental health and substance abuse services. Because of the special needs of older adults with behavioral health problems, practitioners trained in these issues and skilled working with this population deliver the most effective care. Geriatric specific behavioral health services are services provided by practitioners who have been informed by current gero-psychological data and trained in assessment, treatment and intervention strategies appropriate to older adults. Geropsychiatric practitioners must be versed in the myths and realities of aging and knowledgeable about the problems that older adults face. They must be aware of the barriers that have kept older adults from seeking or receiving help. They must be cognizant of the unique interaction of physical and mental health in older adults. And they must know the particular perspectives that diverse cultures bring to their understanding of mental health and aging.
Geriatric experts concur that older people do not seek help for their psychological distress for the following reasons: the stigma of mental illness; limited information about the benefits of psycho-social interventions; limited access to available services, the tendency of physicians to attribute physical and psychiatric symptoms to the aging process; minimal outreach to older adults; inadequate reimbursement from Medicaid and Medicare; and lack of public awareness.
Proposed Continuum of Care Model
DVMHAAC proposes a continuum of care for older people within an integrated system of care based on the Community Support Program (CSP) model. Originally developed for adults with serious mental illness, the CSP model is flexible enough to adapt to the varying degrees of behavioral health needs of older adults. The CSP model calls for the development of a wide range of services, and encourages communities to utilize existing resources and facilities. Most importantly, CSP is more than just a collection of service components. Application of the model dictates an organized, coherent, and integrated service system.
The CSP principles are easily adapted to meet the treatment, rehabilitation, and community services needs of older people with behavioral health needs, and reflect the following:
Services should be person-centered. They should respond to the needs of older adults, rather than those of the system or the providers.
Services should empower people. They should incorporate self-help approaches and allow older adults to retain the greatest possible control over their own lives, including active involvement in all aspects of planning and delivering services.
Services should be racially and culturally appropriate. They should be accessible, and acceptable to racial, ethnic, minority groups, and women, and appropriate to older adults' developmental stages.
Services should be flexible. They should be available when they are needed, for as long as they are needed.
Services should focus on strengths. They should be built on the assets and strengths of older adults in order to maintain their sense of dignity, identity, and self-esteem.
Services should be normalized and incorporate natural supports. They should be offered in the least restrictive, most natural setting possible. Older adults should be encouraged to use natural community supports and be integrated into normal community activities.
Services should meet special needs. They should be adapted to meet the special needs of the elderly.
Services should be accountable. They should be monitored by the state to assure quality of care and continued relevance.
Services should be coordinated. They should be coordinated through mandates and/or written agreements that require ongoing communication and linkages to ensure continuity of care across many systems at the local and state levels.
Components of the Continuum of Care
A continuum of care based on CSP principles will provide a complete range of services and supports for older adults with behavioral health needs, and should include:
An education/ prevention program will confront myths about aging and mental health, explain the signs of mental illness and substance abuse and inform the public on how they can help older adults at risk. Some examples are:
- a public campaign to recognize the signs of depression and anxiety and/or medication abuse in elderly providing a hotline number on how to help at risk seniors
- a comprehensive guide to geriatric behavioral health resources in the community to help family members and professionals make appropriate referrals
- a gatekeeper program to inform health community organizations, religious groups, senior centers, local businesses, utility workers, emergency medical technicians, firemen, policemen and block captains of the behavioral health issues of older adults and the resources available to help the Mental Health Aging Project
Identification, Outreach and Access:
Research indicates that older adults with behavioral health needs are reluctant to seek out services, a barrier that is frequently complicated by co-occurring physical problems. Effective outreach will engage the elderly in their own environments, be it a boarding home, personal or family residence, or hospital emergency room. Outreach services will include crisis intervention, counseling, medication checks, assistance in meeting basic needs, skills training, and referrals to appropriate community resources. Some examples include:
Develop identification mechanisms which will establish linkages with community-based entities (including boarding homes, churches, district police stations, emergency rooms, inpatient facilities, pharmacists, primary care physicians, public housing facilities, senior centers, etc.) capable of identifying and referring older people in need of services.
Incorporating a mental health screening in all regular health check-ups for seniors, with the primary care physician referring the individual to a behavioral health accessibility team for follow-up will be vital part of the identification component.
In Los Angeles, a simple card carried by police and Adult Protection workers lists steps to take when dealing with older adults thought to be at risk. Training will guide all who deal with older adults on a regular basis to identify those who need help.
Assessment and Evaluation:
The assessment process will be appropriate to the person's culture and level of acculturation, and utilize assessment tools specifically tailored to older adults. Minimally, the assessment will consist of a medical history, psychiatric history, the Mini Mental Status Exam, the Geriatric Depression Rating Scale, and the CAGE and/or HEAT index for substance abuse. Depending on the results, more specific tools may be used. Ideally, behavioral health assessments of older adults will be conducted by an interdisciplinary geriatric team.
Behavioral Health Treatment:
Treatment will be a critical component of the continuum of care. Research indicates that depression, anxiety, and/or some form of dementia are the most common mental disabilities among elderly people. Substance abuse in older persons often consists of misuse of prescription drugs, over-the counter medications, and alcohol abuse. To encourage the use of services and minimize stigma, treatment will be provided, wherever possible, in the individual's home and/or community.
In addition to psychiatric management, mental health treatment will include: counseling, medication management, and linking seniors to stimulation oriented therapies (e.g. art, horticulture, and recreation). The continuum of care for older persons with psychiatric disabilities will include: inpatient, partial hospitalization, intensive outpatient, outpatient, residential, adult day, and mobile therapy options. Specialized treatment facilities for older adults with substance abuse disorders will be needed, and will include detoxification and peer-supportive counseling to prevent relapse and develop strategies for drug-free living.
All treatment will be provided by people with geriatric psychiatric training and a sensitivity to older adult treatment needs. Particular attention will be given to the cultural and family dimensions in treatment. Since many older persons are reluctant to seek treatment in psychiatric settings, treatment in the home or in familiar settings will be preferred. The continuum of care will require that practitioners be regularly updated through continuing education opportunities in geropsychiatry.
Crisis Response Service:
Even when community support services are available, persons with behavioral health needs tend to experience recurrent crises. As a result, the continuum will include crisis assistance that immediately responds to older adults in crisis and members of their support system and that is available 24-hours a day, 7 days a week. Effective crisis services will assist in stabilizing the person and helping him or her to readjust to community living.
Crisis assistance will include telephone services, such as hotlines, and mobile crisis outreach. For individuals in crisis who cannot be assisted in their natural environments, crisis residential services will be available in non-hospital settings, including family-based crisis homes and staffed residences for small groups of older persons in crisis. Inpatient beds will be available for individuals who need a protective environment.
Crisis response staff will be able to distinguish dementia, delirium, and depression, all of which can exhibit similar symptoms in older adults. Likewise, knowledge of medication interaction effects is crucial. Another important consideration is discerning the interaction of physical and mental health problems.
Coordination with Health Care:
Older adults with mental health/substance abuse problems may also have health problems. The continuum of care will ensure a high level of integration of physical and behavioral health care. Geriatric-psychiatric specialists are needed in all district health centers. This strategy will ensure older adults are connected to both medical and behavioral health services, and improve the coordination of care.
An important aspect of coordinating health care for the elderly is insuring that the primary care practitioners are skilled in identifying mental health and substance abuse problems in older adults and in making referrals for treatment. Studies say that many physicians fail to identify depression in older adults.
As older adults with mental health needs near the end of their life, hospice care should be available at home or in an appropriate setting. Mental health supports should be integrated with other hospice services.
Any continuum of care for older adults with behavioral health needs will place an emphasis on maintaining people in their own homes. First, affordable housing must be made available for older adults on fixed incomes. It must also include an appropriate range of supported housing options. Individual preferences and values, along with functional level, will be primary considerations in determining an appropriate housing placement. Regardless of the arrangement, the emphasis will be on the most normalizing option. In-home training, supports, and services should be available to both caregivers and the individual served to enable them to live in the residence of their choosing. Clustered apartments provide services and supports in a cost efficient manner. A variety of more structured residential settings may be needed for a small number of more seriously disabled individuals who require a greater degree of attention, supervision or structure.
Behavioral health services should be made available to all older adults confined to nursing homes because of medical conditions. The continuum of care will allow older adults with mental health problems to 'age in place' in whatever setting they desire, whether it be independent living, senior housing, assisted living, personal care homes, or nursing homes.
Care (i.e. case) management services are another vital component. Care management will ensure that older adults receive the services they need. Depending on individual needs and preferences, care managers could be a single person or a team who assumes responsibility for maintaining a long-term, caring and supportive relationship with the individual. All care managers that work with older adults must have training in behavioral health and aging and be skilled in working within the Behavioral Health, Medical and Aging Service systems. A care manager will serve as a friend, helper, service broker and advocate, assisting the person and his or her caregivers to meet defined service needs. Care managers' work will take place in the person's natural environment to the extent possible. In addition to performing traditional case management functions, it is particularly important that they assume responsibility for coordinating health and behavioral health services and ensure the unification of all components within the continuum of care.
Social rehabilitation services will help the older adult to gain or regain practical skills needed to live and socialize in the community. Activities will be age-and culturally appropriate and tailored to individual needs and preferences. They will be available in the home or in a group setting, as preferred. These programs will be offered at various senior centers, drop-in-centers and places where seniors gather. All social rehabilitation activities should help the individuals to better deal with the physical/emotional aspects of aging and society's perceptions of older adults.
Social rehabilitation will involve assistance in developing interpersonal relationships and leisure time activities/interests that provide a sense of participation, satisfaction, and enjoyment.
All Senior Centers will have educational activities which will teach the elderly how to cope with the symptoms of their medical and behavioral health problems and with the aging process, in general; how to manage their medications; nutrition and wellness; and how to recognize danger signs.
Employment and volunteer opportunities will be available through senior organizations for those who choose to work or volunteer in the community.
Peers are one of the most influential groups for older adults and provide a "non-treatment" approach most older adults prefer. Religious groups, community organizations, veteran groups, senior centers and other informal support systems will help identify at-risk adults and help them maintain their treatment. They also serve as an important source for advocating for proper treatment. Training is needed for older adults who can help support and encourage their peers.
Family and Community Support:
Families who provide support and caregiving services to older adults are important gatekeepers and support treatment. However, many caregivers are themselves vulnerable to depression and other forms of mental illness. Respite programs, support programs, and in-home family counseling must be available to families.
Protection and Advocacy:
Researchers estimate there are over 2 million cases of elder abuse every year, of which half are the result of self-neglect. Older persons with mental health/substance abuse problems are particularly at-risk as victims of elder abuse, but may be afraid or unable to report abuse. Police officers and Protection and Advocacy Staff should be trained in identifying symptoms of mental illness and substance abuse in older adults.
Clear and appropriate protocols that specify how to deal with older adults when there is a question of whether the person is suffering from depression, delirium, and dementia (or a combination of all three), is needed.
Recommended Action at State and Local Levels
Appoint staff from the Department of Aging and the Office of Mental Health and Substance Abuse Services to create a mechanism that addresses proactively the changing demographics and promotes closer inter-system collaboration. Joint planning to facilitate systems integration at the state level could include: developing written common objectives; funding joint pilot programs; creating permanent staff positions within departments devoted to behavioral health and aging issues; and creating mechanisms to encourage/require collaborative service delivery at the local level.
Appoint staff from the Philadelphia Office of Mental Health and the Philadelphia Corporation on Aging to develop and implement a joint plan to create a continuum of care for older adults with behavioral health needs based on the Community Support Program (CSP) model. The plan should outline goals, objectives, action steps, timeframes, and a research/evaluation component. It should also provide guidelines for written agreements on local collaboration, including how to resolve cross-system disagreements. Resource allocation also should be a focus. This joint planning effort will lay the foundation for the systems integration necessary to create the continuum of care.
Establish dedicated funding for services to older adults with behavioral health needs (such as exists for children) within the next budgeting cycle for the state and the county. A higher level of flexibility than currently exists should be built into this new funding stream in order to develop an array of services sensitive to the individual needs of older adults.
- The 2000-01 state mental health budget includes funding for two geriatric pilot projects that will require integration of the behavioral health and aging systems. This commitment is an important step in addressing the needs of this underserved population; however, it is only the first step. Starting with the 2001-02 budget, the state should set aside additional new funding each year.
- At the local level, Community Behavioral Health (CBH) should make behavioral health services for older adults a priority in its annual plan for the allocation of CBH reinvestment dollars. An infusion of new funding from CBH will be necessary to make the continuum of care a reality.
Develop comprehensive, integrated protocols for the health, aging, and behavioral health systems that ensure continuity of care in serving older adults. Representatives from all three systems should participate on committees and task groups, including the Delaware Valley Mental Health/Aging Advocacy Committee, the Pennsylvania Coalition on Mental Health and Aging, and the Southwest Pennsylvania Partnership on Aging.
Create a state and city task force that identifies what federal policies need to be changed in order to create a continuum, and advocate for these changes. At minimum:
- Medicare should establish parity for outpatient behavioral health services benefits;
- Medicaid should increase professional behavioral health services' funding to the market value; and
- Federal programs such as Qualified Medicare Beneficiary (QMB) and state programs such as PACE should be made more accessible and affordable for older adults.
Restructure managed care and Medicare advisory boards to better address the myriad of needs of older adults with behavioral health issues by including, at minimum, one gerontologist and one geriatric psychiatrist. This will ensure a higher level of sensitivity to, and reimbursement for, the complex, interacting medical and behavioral health treatment needs of older adults.
Require that staff in both systems of care be familiar with cross-systems collaboration procedures. Service providers and other professionals should be cross-trained to understand (and identify) behavioral health, physical health, and aging issues and how to access appropriate resources. Regular joint meetings between staff of both systems are needed to identify opportunities for collaboration, including how to resolve difficult situations involving individual elderly.
Require that all nursing and medical students be trained in identifying behavioral health issues, referral processes, and treatment modalities as they relate to older adults. This will enable all physicians and nurses to identify mental health needs in the elderly and promote effective treatment services.
Require training for all personal care and nursing home direct care on mental health and aging issues, including: aging sensitivity, understanding mental illness, dealing with behavioral problems, and knowing how to get help for older adults.