Implementing Implementing Evidence Based Evidence Based

Practices for Older Practices for Older Iowans with Mental Iowans with Mental

IllnessesIllnesses

Aging and Mental Illness in Aging and Mental Illness in IowaIowa

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

2000 2010 2020

Outpatient CareOutpatient Care

Medicare?Medicare?

Community-based Care? Community-based Care?

Inpatient CareInpatient Care

Depression in Older Adults and Depression in Older Adults and

Health Care CostsHealth Care Costs

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

0 (n=859) 1-2 (n=616) 3-5 (n=659) 6-16 (n=423)

Levels of Chronic Disease Score

None CES-D<8Moderate CES-D=8-15Severe CES-D>16

Unutzer, et al., 1997; JAMA

Monthly Per Person Costs by Age:Monthly Per Person Costs by Age: Severe Mental Illness Severe Mental Illness

$0

$1,000

$2,000

$3,000

$4,000

15-2

4

25-3

4

35-4

4

45-5

4

55-6

4

65-7

4

75-8

4

85-9

4

95+

Age Groups

Medicaid+Medicare Medicaid Medicare

New Hampshire Total Monthly Costs Per New Hampshire Total Monthly Costs Per Person Over Age 65Person Over Age 65

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000

Schizo

phrenia

Alzheim

er's

Demen

tiaCer

ebro

vasc

ular

Depre

ssio

nH

eart

Fai

lure

COPD

Cardia

cDys

rhym

ias

Oste

oart

hrosis

Diabe

tes

Hyp

erte

nsion

Medicaid Medicare

Suicide Rate by Age Per 100,000Suicide Rate by Age Per 100,000

0%

5%

10%

15%

20%

25%

15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+Age

Older people: 12.7% of 1999 population, but 18.8% of suicides. (Hoyert, 1999)

Outcomes: ADL Decline at One Year Follow-up

11.1% 10.6%

21.0%

0%

5%

10%

15%

20%

25%

None Minor Major Depression

% with ADL Decline

Good 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

Depression is treatableDepression is treatable

Antidepressants as effective Antidepressants as effective in older patients as younger in older patients as younger patients patients (Reynolds et al, 2003, JAMA)(Reynolds et al, 2003, JAMA)

Psychotherapy also as Psychotherapy also as effective in older patients as effective in older patients as younger patients younger patients (Arean & Cook, (Arean & Cook, 2002 Biol. Psych.)2002 Biol. Psych.)

NATIONAL MOVEMENT

2005 White House 2005 White House Conference Conference

Top 10 Recommendations of 2005 White Top 10 Recommendations of 2005 White House Conference on Aging House Conference on Aging

1.1. Reauthorize the Older Americans Act within the first six months Reauthorize the Older Americans Act within the first six months following the 2005 White House Conference on Agingfollowing the 2005 White House Conference on Aging

2.2. Develop a coordinated, comprehensive long-term care strategy by Develop a coordinated, comprehensive long-term care strategy by supporting public and private sector initiatives that address financing, supporting public and private sector initiatives that address financing, choice, quality, service delivery, and the paid and unpaid workforcechoice, quality, service delivery, and the paid and unpaid workforce

3.3. Ensure that older Americans have transportation options to retain their Ensure that older Americans have transportation options to retain their mobility and independencemobility and independence

4.4. Strengthen and improve the Medicaid program for seniorsStrengthen and improve the Medicaid program for seniors

5.5. Strengthen and improve the Medicare programStrengthen and improve the Medicare program

6.6. Support geriatric education and training for all healthcare Support geriatric education and training for all healthcare professionals, paraprofessionals, health profession students, and direct professionals, paraprofessionals, health profession students, and direct care workerscare workers

7.7. Promote innovative models of non-institutional long-term care Promote innovative models of non-institutional long-term care

8.8. Improve recognition, assessment, and treatment of mental illness and Improve recognition, assessment, and treatment of mental illness and depression among older Americansdepression among older Americans

9.9. Attain adequate numbers of healthcare personnel in all professions who Attain adequate numbers of healthcare personnel in all professions who are skilled, culturally competent, and specialized in geriatricsare skilled, culturally competent, and specialized in geriatrics

10.10. Improve state and local based integrated delivery systems to meet 21st Improve state and local based integrated delivery systems to meet 21st century needs of seniorscentury needs of seniors

Positive Aging Act Positive Aging Act Reintroduced Reintroduced

May 31, 2005 – Last Wednesday, May 31, 2005 – Last Wednesday, Senators Hillary Rodham Clinton (D-NY) Senators Hillary Rodham Clinton (D-NY) and Susan Collins (R-ME) and and Susan Collins (R-ME) and Representatives Patrick Kennedy (D-RI) Representatives Patrick Kennedy (D-RI) and Ileana Ros-Lehtinen (R-FL) and Ileana Ros-Lehtinen (R-FL) announced the introduction of the announced the introduction of the Positive Aging Act of 2005 to improve Positive Aging Act of 2005 to improve access to mental health services for access to mental health services for America’s senior citizens. America’s senior citizens.

MENTAL HEALTH MENTAL HEALTH FORUMSFORUMS

Quick Fixes (1998)Quick Fixes (1998)

Iowa Mental Health Forum (2000) Iowa Mental Health Forum (2000)

Mental Health System (2001)Mental Health System (2001)

Older Adults RoundtableOlder Adults Roundtable

Many persons did not know Many persons did not know where to seek help.where to seek help.

Include dementiaInclude dementia Implement multi-Implement multi-

disciplinary disciplinary treatment treatment approaches approaches

IOWA COALITION ON IOWA COALITION ON MENTAL HEALTH AND MENTAL HEALTH AND

AGINGAGING

Collaborative Models of Collaborative Models of CareCare

PRIMARY GOALSPRIMARY GOALS Promote mental wellness among Promote mental wellness among

aging Iowans aging Iowans

Increase access to qualified Increase access to qualified mental health service providers mental health service providers

Integrate mental health services Integrate mental health services nto usual places of care nto usual places of care

OBJECTIVES OBJECTIVES Conduct screeningsConduct screenings

Identify and recruit providers Identify and recruit providers

Develop collaborative care Develop collaborative care models models

COLLABORATIVE COLLABORATIVE MODELSMODELS

Nursing Homes & other LTC Nursing Homes & other LTC facilitiesfacilities

Primary Care PracticesPrimary Care Practices

Aging Network Aging Network

The IMPACT Treatment The IMPACT Treatment ModelModel

Collaborative care model includesCollaborative care model includes::

Care manager: Depression Clinical SpecialistCare manager: Depression Clinical Specialist Patient education Patient education Symptom and Side effect trackingSymptom and Side effect tracking Brief, structured psychotherapy: PST-PCBrief, structured psychotherapy: PST-PC

Consultation / weekly supervision Consultation / weekly supervision meetingsmeetings with with Primary care physicianPrimary care physician Team psychiatristTeam psychiatrist

Stepped protocol in primary care using Stepped protocol in primary care using antidepressant medications and / or 6-8 sessions antidepressant medications and / or 6-8 sessions of psychotherapy (PST-PC)of psychotherapy (PST-PC)

Usual CareUsual Care

PRIMARY CARECLINICIAN

MENTAL HEALTHSPECIALIST

PATIENT

Component Model Component Model (TCM)(TCM)

PRIMARY CARECLINICIAN

CARE MANAGER

MENTAL HEALTH SPECIALIST

PATIENTPHQ-9

PHQ

-9

PH

Q-9

Typical Frequency of Patient Typical Frequency of Patient ContactsContacts

1 5 6 9 12 18 24 32 36

PCC

CM CM CM CMCM

PCC PCC PCC PCC

PCC CMPrimary CareClinician Visit

Care ManagerPhone Call

Acute Phase Continuation Phase

WEEK

IMPACT IMPACT Unutzer et al, 2002Unutzer et al, 2002

0%

5%

10%

15%

20%

25%

30%

35%

3-mos 6-mos 12-mos

Usual CareIntervention

Pat

ient

s in

RE

MIS

SIO

N (

HS

CL

<0.

5)

1,801 patients ≥60 yrs in 18Primary care clinics in 8Health care organizations. “Cadillac model of system change”

Managing Any Other Chronic Disease

Managing Antidepressants is Like…..

Monitor Depressive Symptoms

Educate Patient and Family

Monitor Adherence

Monitor Side Effects

Provide Support

Consult or Refer to Agency/Outside Specialist As Needed

MH-PC Co-location Project

Pilot project funded through a federal block grant Pilot project funded through a federal block grant

Serves persons who are 60 years and older – no chargeServes persons who are 60 years and older – no charge

2 - master degree level clinical social workers 2 - master degree level clinical social workers

Collaborate with 5 primary care practices in community – family Collaborate with 5 primary care practices in community – family practice, internal medicine – providers include MDs, DOs, PAs, practice, internal medicine – providers include MDs, DOs, PAs, ARNPsARNPs

Services provided includeServices provided include:: mental health assessments and screeningsmental health assessments and screenings ongoing psychotherapyongoing psychotherapy referral to other community resources and services as needed referral to other community resources and services as needed Spanish interpreters availableSpanish interpreters available

Case ExampleCase Example

CCCC: elder female presents to PCP for F/U appointment for : elder female presents to PCP for F/U appointment for DM and c/o “arthritis” pain in several joints X 2 mo..DM and c/o “arthritis” pain in several joints X 2 mo..

Labs, X-rays and physical exam neg. except early DJD Labs, X-rays and physical exam neg. except early DJD

changes in knees and muscle tension in back and neckchanges in knees and muscle tension in back and neck

Before leaving office starts to cry - reports recent Before leaving office starts to cry - reports recent “stress” – has been having “problems with my kids” “stress” – has been having “problems with my kids”

PCP put on Lexapro and referred for mental health PCP put on Lexapro and referred for mental health assessment/therapy.assessment/therapy.

Case Example-Case Example-AssessmentAssessment

STRESSORS STRESSORS poor interpersonal and psychological boundaries poor interpersonal and psychological boundaries Financial problems – housing, utilitiesFinancial problems – housing, utilities Isolation - except familyIsolation - except family

HISTORY HISTORY ““Ashamed” to tell PCP depressed for mo. & that has dysfunctional Ashamed” to tell PCP depressed for mo. & that has dysfunctional

familyfamily Personal and family history of childhood sexual abusePersonal and family history of childhood sexual abuse Multiple family members abuse substances (intergenerational)Multiple family members abuse substances (intergenerational) Multiple interpersonal family conflictsMultiple interpersonal family conflicts ““Worrier”- chronic untreated generalized anxiety disorder Worrier”- chronic untreated generalized anxiety disorder

DIAGNOSESDIAGNOSES

Case Example- Case Example- InterventionsInterventions

SSRI meds-reduces symptoms to help make desired changesSSRI meds-reduces symptoms to help make desired changes

called PCP to consider increasing Lexapro – little improvement symptoms called PCP to consider increasing Lexapro – little improvement symptoms

CBT-evaluate & challenge negative thoughts/distortions, action CBT-evaluate & challenge negative thoughts/distortions, action (behavioral) steps - reconnect w/church and friends - increase social (behavioral) steps - reconnect w/church and friends - increase social interaction to reduce isolationinteraction to reduce isolation

Connect resources to decrease financial stressors - energy assistance, Connect resources to decrease financial stressors - energy assistance, MOW, MOW,

Boundaries – appropriate psychological and interpersonal w/familyBoundaries – appropriate psychological and interpersonal w/family

Self-esteem – develop sense self – efficacySelf-esteem – develop sense self – efficacy manage moods- self-awareness/monitoring, coping skills-relaxation, distraction, manage moods- self-awareness/monitoring, coping skills-relaxation, distraction,

etc. etc. boundaries-empathy/love w/o “taking on” others distressboundaries-empathy/love w/o “taking on” others distress

THANK YOUTHANK YOU