Transcript TITLE GOES HERE - Minnesota Board of Psychology

ACCESS TO MENTAL HEALTH
CARE FOR THE ELDERLY
JOSEPH E. GAUGLER, PH.D.
ASSOCIATE PROFESSOR
MCKNIGHT PRESIDENTIAL FELLOW
SCHOOL OF NURSING
UNIVERSITY OF MINNESOTA
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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
YOUR OPINION
• In your opinion, what is the state of mental health for
older persons in Minnesota?
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/public/IssueBrief_The
StateofMentalHealthandAginginAmerica.pdf
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)
• Surgeon’s General report on mental health (DHHS, 1999)
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)
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 50–64
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%).”
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).”
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 50–64 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).
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 50–64 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, nonHispanic, black, non-Hispanic, or other, non-Hispanic adults (14.5%
compared to 12.6%, 11% and 14.2%, respectively).”
• “Women age 50–64 years report a lifetime diagnosis of an anxiety
disorder more often than men in this age group (16.1% compared to
9.2%, respectively.) “
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)
BARRIERS TO MENTAL HEALTH
CARE FOR THE ELDERLY
•From your perspective, what are the barriers?
BARRIERS TO MENTAL HEALTH
CARE FOR THE ELDERLY
•From your perspective, what are the barriers?
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
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.americangeriatrics.org/news/geria_faqs.shtml#2)
• 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/summary.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
BARRIERS TO MENTAL HEALTH
CARE FOR THE ELDERLY (Jeste et al.,
1999)
•Deinstitutionalization or “transinstitutionalization” 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
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
IMPROVING ACCESS TO MENTAL
HEALTH CARE FOR THE ELDERLY
•What are your ideas?
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, quasiexperimental, 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
APPRAISING EVIDENCE
From http://library.downstate.edu/EBM2/2100.htm
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 noninstitutionalized 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
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)
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 person’s 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
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 person’s home
are potentially effective in improving psychiatric outcomes
•Lack of high quality data
• At the time, other unique outreach approaches, such as videobased outreach to rural areas, most studies focused on feasibility
only
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.
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.
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.”
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
TRANSLATING EVIDENCE TO
PRACTICE
• Challenges of translation
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Secure participation of settings
Secure participation of older persons with mental health problems
Implement the program consistently
Maintain the program over time
CONTACT INFORMATION
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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: [email protected]
Fax: 612-625-7180