Transcript Slide 1

Implementing
Evidence Based Practices
for Older Iowans with
Mental Illnesses
Aging and Mental Illness in Iowa
700,000
600,000
500,000
400,000
300,000
200,000
100,000
0
2000
2010
2020
Outpatient Care
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Medicare?
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Community-based Care?
Inpatient Care
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Depression in Older Adults and
Health Care Costs
Unutzer, et al., 1997; JAMA
Monthly Per Person Costs by Age:
Severe Mental Illness
$4,000
$3,000
$2,000
$1,000
Age Groups
Medicaid+Medicare
Medicaid
Medicare
95+
85-94
75-84
65-74
55-64
45-54
35-44
25-34
15-24
$0
New Hampshire Total Monthly Costs Per
Person Over Age 65
$4,000
$3,500
$3,000
$2,500
$2,000
$1,500
$1,000
$500
$0
Medicaid
Medicare
Suicide Rate by Age Per 100,000
Older people: 12.7% of 1999 population, but 18.8% of suicides.
(Hoyert, 1999)
Outcomes: ADL Decline at One Year Follow-up
25%
21.0%
20%
% with ADL
Decline
15%
11.1%
10.6%
None
Minor
10%
5%
0%
Major Depression
Good Mental Health is the Foundation for
Overall Health, Quality of Life and Independence
Factors that increase risk of depression:
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Medical Illness (cardiovascular disease)
Disability
Cognitive Decline
Social Isolation
Loss And Other Negative Events
Genetic Vulnerability
Depression increases the risk of:
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Medical Illness
Disability
Social Isolation
Cognitive Decline
Loss Of Independence
Relocation/Institutionalization
Suicide And Deaths From Other Causes
Depression is treatable
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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.)
NATIONAL MOVEMENT
2005 White House Conference
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
Positive Aging Act Reintroduced
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May 31, 2005 – Last Wednesday, Senators
Hillary Rodham Clinton (D-NY) and Susan
Collins (R-ME) and Representatives
Patrick Kennedy (D-RI) and Ileana RosLehtinen (R-FL) announced the
introduction of the Positive Aging Act of
2005 to improve access to mental health
services for America’s senior citizens.
MENTAL HEALTH FORUMS
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Quick Fixes (1998)
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Iowa Mental Health Forum (2000)
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Mental Health System (2001)
Older Adults Roundtable
 Many
persons did not know
where to seek help.
 Include dementia
 Implement multi-disciplinary
treatment approaches
IOWA COALITION ON
MENTAL HEALTH AND AGING
Collaborative Models of Care
PRIMARY GOALS
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Promote mental wellness among
aging Iowans
Increase access to qualified mental
health service providers
Integrate mental health services nto
usual places of care
OBJECTIVES
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Conduct screenings
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Identify and recruit providers
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Develop collaborative care models
COLLABORATIVE MODELS
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Nursing Homes & other LTC facilities
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Primary Care Practices
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Aging Network
The IMPACT Treatment
Model
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Collaborative care model includes:
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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)
Usual Care
PRIMARY CARE
CLINICIAN
PATIENT
MENTAL HEALTH
SPECIALIST
Component Model (TCM)
PRIMARY CARE
CLINICIAN
PHQ-9
CARE MANAGER
MENTAL HEALTH
SPECIALIST
PHQ-9
PATIENT
Typical Frequency of Patient Contacts
PCC
Care Manager
CM Phone Call
Primary Care
Clinician Visit
Acute Phase
PCC
CM
1
PCC
PCC
CM
5 6
Continuation Phase
CM
9
PCC
CM
12
18
WEEK
PCC
CM
24
32
36
Patients in REMISSION (HSCL<0.5)
IMPACT Unutzer et al, 2002
1,801 patients ≥60 yrs in 18
Primary care clinics in 8
Health care organizations.
35%
“Cadillac
model of
system
change”
30%
25%
20%
Usual Care
Intervention
15%
10%
5%
0%
3-mos
6-mos
12-mos
Managing Any Other Chronic Disease
Monitor Depressive Symptoms
Educate Patient and Family
Monitor Adherence
Monitor Side Effects
Provide Support
Managing Antidepressants is Like…..
Consult or Refer to Agency/Outside Specialist As Needed
MH-PC Co-location Project
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Pilot project funded through a federal block grant
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Serves persons who are 60 years and older – no charge
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2 - master degree level clinical social workers
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Collaborate with 5 primary care practices in community – family practice,
internal medicine – providers include MDs, DOs, PAs, ARNPs
Services provided include:
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mental health assessments and screenings
ongoing psychotherapy
referral to other community resources and services as needed
Spanish interpreters available
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..
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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.
Case ExampleAssessment
STRESSORS
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poor interpersonal and psychological boundaries
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Financial problems – housing, utilities
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Isolation - except family
HISTORY
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“Ashamed” to tell PCP depressed for mo. & that has dysfunctional family
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Personal and family history of childhood sexual abuse
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Multiple family members abuse substances (intergenerational)
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Multiple interpersonal family conflicts
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“Worrier”- chronic untreated generalized anxiety disorder
DIAGNOSES
Case ExampleInterventions
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SSRI meds-reduces symptoms to help make desired changes
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called PCP to consider increasing Lexapro – little improvement symptoms
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CBT-evaluate & challenge negative thoughts/distortions, action (behavioral) steps reconnect w/church and friends - increase social interaction to reduce isolation
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Connect resources to decrease financial stressors - energy assistance, MOW,
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Boundaries – appropriate psychological and interpersonal w/family
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Self-esteem – develop sense self – efficacy
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manage moods- self-awareness/monitoring, coping skills-relaxation, distraction, etc.
boundaries-empathy/love w/o “taking on” others distress
THANK YOU