Autonomy and Physical and Mental Functioning of Underserved Older Adults: Benefits of Mental Health

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Autonomy and Physical and Mental Functioning of
Underserved Older Adults Benefits of Mental
Health Care Provided Through Nine Community-Based
Programs

• Dr. Betsy McDonel Herr
• Ms. Donna Wagner
• Dr. Rodolfo R Vega
• Dr. Sue Levkoff
• Ms. Karen Cheal
• Ms. Noelle Downing
• Positive Aging Resource Center
• Funded by SAMHSA Grant SM-55043

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Targeted Capacity Expansion Initiative

• Dr. Betsy McDonel Herr

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SAMHSA U.S. Substance Abuse and Mental Health
Services Administration

• SAMHSA --federal agency devoted to improving
  behavioral health services across the nation.
• CMHSCenter for Mental Health Services, one of
  SAMHSAs 3 Centers
• CMHS funds grants contracts to support adoption
  of evidence based mental health services and
  provision of technical assistance to change and
  improve mental health systems
• Betsy McDonel Herr, Ph.D. CMHS Program Officer
  Contact for Aging programs

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Targeted Capacity Expansion (TCE) Program to
Improve Mental Health Services for Older Adults

• 3-year grant program, ending 2005, 4.5
  million/year
• 9 Services Sites to implement evidence
  basedpractices (EBPs) for older adults
• 9 Services Sites cover Arizona, California, New
  York, Texas, Missouri, Washington, D.C.,
  Wisconsin
• 9 Services Sites cover diverse populations
  including Hmong, Hispanic, Yaqui Indian and rural
  populations
• Grants fund local infrastructure support, service
  linking, partnership building, quality
  improvement, in addition to direct services
• Variety of practices and principles proposed for
  implementation

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LOGIC MODEL Older Adult TCE PROGRAM
ACTIVITIES
OUTCOMES
PROGRAM GOALS
POPULATION
Expansion of Local Services Screening Increase/Tra
in Providers Evidence Based Practice
Adoption Integrated Treatment Consumer
involvement Technical assistance Outreach,engageme
nt, case-finding Improve access for racial/ethnic
minorities, persons in rural settings Service
Linking Needs assessment Strategic
planning Quality improvement activities Cross-trai
ning Consensus building Sustainable
financing Leadership development Partnership
development Community Outreach Social
marketing Public education/Health
literacy Dissemination Consumer/Family/Advocacy
Group involvement Program Evaluation Measure
GPRA outcomes Process evaluation/Program fidelity
Simple Outcome Indicators
I. Increase existing mental health
prevention,early intervention and/or
treatment services develop and implement
new Services.
Individual Level Functioning Prevention or
delayed onset Quality of life Access to
services Healthy behaviors Program
Level Prevention/early intervention
incorporated into clinical practice Sustainability
Consumer/Family integration in
planning/implementation Reduced stigma Increased
participation by cultural/ ethnic
minorities GPRA Outcomes System Level Expanded
service base Improved coordination Partnerships Di
verse populations served Screening/Prevention/Earl
y Intervention incorporated into planning
II. Improve quality, accessibility,
and availability of mental health services
delivery.
Persons who are 65 years and older.
III. Build system infrastructure to support
expansion of services.
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Positive Aging Resource Center

• Ms. Noelle Downing

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Positive Aging Resource Center PARC

• PARC is a National Technical Assistance Center
  focused on mental health issues of older adults
• PARC assists the 9 services sites
• PARC is engaged in several projects to describe
  EBPs and principles for older adults
• PARC provides limited technical assistance to the
  field on older adult mental health issues
• PARC also sponsors a website www.positiveaging.or
  g

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The TCE Sites

• Ms. Noelle Downing

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9 National TCE Sites
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PARC Model Service Programs

• Cottage Program, Arizona Donna Wagner
• Health Improvement Program
• for the Elderly, Arizona Jane Singer
• Tiempo de Oro, Arizona Elizabeth Stadick
• University of California, San Francisco (UCSF),
  Pat Areán
• La Clinica Del Pueblo, Washington DC Gloria
  Elliott
• ElderLynk, Missouri Rene McGovern
• Senior Outreach Program, New York Jack McIntyre
• Focus Project, Texas Gabrielle Martinez
• Kajsiab House, Wisconsin Doua Vang

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TCE SitesPopulations Served

• Cottage Program, AZ
• Mexican Americans, Native Americans, and rural
  older adults from a variety of diverse racial and
  ethnic backgrounds
• Health Improvement Program for the Elderly
  (HIPE), AZ
• Hispanic, urban Native Americans, other minority
  populations
• Tiempo de Oro. AZ
• Latino
• University of California, San Francisco (UCSF)
• Residents in assisted living facilities
• La Clinica Del Pueblo, Washington DC
• Latino, primarily immigrants from Central and
  South America

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TCE SitesPopulations Served

• ElderLynk, MO
• Rural older adults
• Senior Outreach Program, NY
• Older adults
• Focus Project, TX
• Homebound Elderly, Latino
• Kajsiab House, WI
• Hmong refugees
• Unity, New York
• Primary Care

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TCE Site Demographics

• Over 75 years of age (61)
• Female (76)
• Race
• White (78)
• Asian (6)
• Black (3)
• Other (13)
• 27 Latino

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TCE Site Demographics

• Education
• High school education or less (76)
• Some college (14)
• College grad (10)
• Living situation
• Housed (86)
• Institution (13.5)
• Unemployed/retired (97)

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Interim Findings

• Ms. Karen Cheal
• Results through August 2004

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GPRA Data
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Data collection

• GPRA (Government Performance and Reporting Act)
  data
• Customized for TCE initiative
• Same measures collected at all sites
• Translated/backtranslated into Spanish and Hmong

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Data collection

• Collected by site staff as part of clients
  appointment
• Data collected longitudinally
• Intake
• Six months
• Twelve months

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Sample GPRA question

• During the past week, to what extent have you
  been experiencing difficulty in the area of
  Apathy or lack of interest in things
• a. ? No difficulty
• b. ? A little difficulty
• c. ? Moderate difficulty
• d. ? Quite a bit of difficulty
• e. ? Extreme difficulty
• f. ? Dont know
• g. ? Not Applicable
• h. ? Refused

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Analysis

• Data from 8 of the 9 sites were included
• 929 subjects
• Cross-site analyses
• Change from intake to six months

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Retention Rates

• Six-month 72
• Twelve-month 74

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Reasons for loss to follow-up

• 154 subjects (16.6) were lost to follow-up
• Death (25)
• Discharged from program (28)
• Refused to participate (20)
• Moved/unable to locate (14)
• Other (13)

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Results Family and Living Conditions
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Difficulty managing day-to-day life
experiencing NO difficulty
plt.01
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Difficulty with household responsibilities
experiencing NO difficulty
plt.001
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Difficulty with work
experiencing NO difficulty
p0.19
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Difficulty with leisure time
experiencing NO difficulty
plt.0001
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Difficulty developing autonomy
experiencing NO difficulty
plt.0001
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Difficulty with apathy
experiencing NO difficulty
plt.0001
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Difficulty with concentration
experiencing NO difficulty
plt.0001
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Difficulty with life satisfaction
experiencing NO difficulty
plt.0001
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Self-reported health status
reporting fair/poor health
plt.01
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Results service utilization
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Outpatient service utilization for physical
complaints
reporting use
p0.4
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Inpatient stays forphysical complaints
reporting use
p0.003
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Emergency room visits for physical complaints
reporting use
plt.01
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Systems Integration Data

• Dr. Rodolfo R. Vega

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Grantees Requirement

• Create service linkages between individuals and
  groups that serve the target population.

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Grantees Requirement

• Building of service networks will ensure that
  outreach, assessment, prevention, early
  intervention, and/or treatment will take place
  within target service systems or via linkages to
  specialty mental health services. The purpose for
  these linkages is to provide integrated,
  appropriate services in the multiple domains.

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PARCs requirement

• To give providers and communities resources to
  build and/or expand the local and regional
  service system infrastructure that will help to
  support new or expanded services

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PARCs requirement

• PARC Requirement
• To engage in the building of system
  infrastructure that will support the increased
  amount, quality, and accessibility of services to
  older persons.

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Underlying principles

• Help-seeking behavior occurs in a context. For
  our purposes, this context is represented by the
  systems of care.

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Definition System of Care

• The organization of health services in a
  particular community to address the multiple
  health and social needs of individuals and
  families.

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Systems integration

• Organizational strategy to reduce fragmentation
  and improve collaboration.

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Systems integration

• Bringing services together to meet multiple needs
  of the individual through a coordinated treatment
  approach

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Service integration

• Identify components.

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Our focus

• Systems integration operationalized through
  interorganizational relations

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Organizations

• Viewing organizations as comprised of individuals

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Organizations

• As such, they relate to each other in a variety
  of ways.

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Organizations

• For example, they refer clients to each other,
  coordinate services, share resources, co-locate
  services

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Evaluation approach

• Determine whether or not the components of the
  system of care are present in the community

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Components of a systems of care

• Access to affordable medications
• Advocacy
• Ambulatory care
• Case management
• Counseling Services
• Dental care
• Dental care
• Employment Services

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Components of a systems of care (cont)

• Family self-help
• HIV/AIDS education
• Homecare
• Hospice services
• Housing services
• Income assistance
• Independent living skills

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Components of a systems of care (cont)

• Leisure activities
• Medical translation
• Mental health services
• Residential hospice
• Social support
• Substance abuse services

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Inter-organizational linkages

• If they are present, what is the relation between
  our grantees and the organization providing those
  services?

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Organizational linkages

• Do you make referrals to this agency?
• Do you receive referrals from this agency?
• Length of relation

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Organizational linkages (cont)

• What type of activities does your organization
  engage in with this agency
• Coordinate activities?
• Share resources?
• Referring of clients?
• Exchange of information?
• Business development?
• Other Please specify

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Organizational linkages (cont)

• Activities
• Prompts
• Collaboration in what areas?
• Referral For what? How many?
• Exchange resources Of what type?

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Organizational linkages (cont)

• What is the basis of this activity?
• Informal arrangement
• Letter of collaboration
• MOA/MOU
• Contract

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Organizational linkages (cont)

• How frequent are your contacts or meetings with
  this agency/agencies?
• Daily
• Once a week
• Once a month
• Quarterly
• Annually
• Other Please specify

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Organizational linkages (cont)

• How do you regard your level of trust and
  confidence in the agency?
• Very high
• High
• Medium/Average
• Low
• Extremely Low

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Organizational linkages (cont)

• How culturally competent do you find the agency?
• Very high
• High
• Medium/Average
• Low
• Extremely Low

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Definition of trust

• Firm belief in the reliability, truth, ability,
  or strength of someone or something.
• Source Compact Oxford English Dictionary

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Results

• Trust was positively related to the number of
  agencies linked to the project (r .83, plt .02).
• Trust was negatively related to the number of
  services provided in-house. (r -.70, p lt .08)
• Trust was positively associated with six months
  follow-up rates (r .84, plt.01).
• Trust was positively associated with referrals to
  other agencies (r .84, plt.01).

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Results

• The proportion of reciprocal referrals was
  positively associated with
• Mental health screening (r .87, p.lt.05)
• Substance abuse screening (r .87, plt.05).
• Business Development (r .78, p lt .04)

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Results

• Business development was positively related to
• Sharing resources, (r 81, p lt.02)

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Conclusions

• The presence of mental health and social service
  providers in a community cannot be translated as
  meaning that a mental health services continuum
  of care exists.

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Conclusions (cont)

• Service providers must have access to resources
  or engage in certain types of interorganizational
  activities in order to build the necessary
  infrastructure to support these expanded services
  for meeting the diverse mental health needs of
  older persons, which is the core premise of this
  initiative.

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The COTTAGE Story

• Donna Wagner, MS GerontologyDirector, Elder
  ServicesCOPE Behavioral Services, Inc.Tucson,
  AZ
• SAMHSA Grant SM54749

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COTTAGE Goals

• Outreach
• Community Education
• Treatment
• Coalition Building

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COTTAGE Population

• Rural Urban Ethnic
• Casa de Esperanza Green Valley
• COPE Behavioral Services, Inc. Tucson
• El Rio Health Center - Tucson

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Developing the Story

• Choose your Evidence-based Practices
• Develop your outreach strategies
• Design your treatment protocols
• Choose/develop your outcome measures
• Develop your data collection systems
• Train your staff
• Ready to write the story!

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Evidence-based Practices

• EBP 1 Outreach, Community Education,
• Service Delivery
• EBP 2 Clinical Treatment

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Evidence-based Practice 1

• Outreach, Community Education
• and Service Delivery
• Geriatric Counseling Service (GCS)
• Intercommunity Action, Inc. (INTERAC)
• Philadelphia, Pa
• Promoting Older Adult Health, DHHS (SMA)
  02-3628, SAMHSA, 2002

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Outreach

• Linkage to Aging Network of Services
• Linkage to Primary Secondary Care
• Linkage to Senior Housing/Senior Centers

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Community Education

• Increasing awareness about behavioral health and
  aging issues
• Reducing stigma among consumers and service
  providers
• Providing consumer friendly fact sheets about
  signs of behavioral health problems

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Service Delivery

• Assessments and Counseling
• Care coordination with PCP and Social Services
• IN-HOME SERVICE PROVISION

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Coalition Building

• Establish community infrastructure
• Behavioral Health and Aging
• Coalition of Southern Arizona

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Measurements of Outreach and Community Education

• Quantitative
• Data tracking system
• Number and nature of contacts
• Number and source of referrals
• Qualitative
• Community feedback surveys

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Outreach at Year 2

• Presentations 148/2,398
• Literature 17,566
• (9,659 _at_ 5 months/Yr3)
• Number of Referrals 311
• Number Enrolled 222
• Engagement Rate 71
• Discharges 147

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Demographics

• Average Age 77 years old (Range 65-91)
• Female 84 Male 16
• Urban 66 Rural 34
• Euro 80 Latino 20
• English 90 Spanish 10

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Evidence-based Practice 2

• Treatment
• Cognitive Behavioral Therapy (CBT)
• (Beck, Rush, Shaw Emery, 1979 Burns,
  1980)
• CBT with Older Adults
• (Laidlaw, Thompson, Dick-Siskin
  Gallagher-Thompson, 2003)
• Strengths-based Care Mgmt Tx Planning
• (Fast Chapin, 2000)
• Grief Therapy
• (Worden, 2002)

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Measurements of Treatment

• Increased Autonomy
• Sense of Mastery Scale (Pearlin Schooler, 1978)
• Physical Health Improvement
• SF-12 HQ (Ware, Jr., Kosinski Keller, 1996)
• Mental Health Improvement
• Geriatric Depression Scale (Yesavage et al., 1983)

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Treatment Outcomes

• Improvement as a percentage change
• _at_6Tx
  _at_12Tx
• (N101/27)
  (N44/17)
• Sense of Mastery 20 16
• Depression 35 45
• Health Status 13 14
• All improvements significant at plt.001

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The OTHER Story

• Peggy Sharon - Staci Jolene
• Unable to Treat
• Adult Children
• Environment/Pets
• Boundaries/Enabling
• Death
• Pajama Therapy

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The End of the Story

• Year Three
• 5 months/97 calls/71 enrolled 73
• Continuing outreach and treatment
• The Sequel
• The BH Aging Coalition of So. Arizona
• The COTTAGE Program at COPE BHS
• The COTTAGE Model
• The COTTAGE Staff

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Policy Implications

• Dr. Sue Levkoff

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Underserved populations CAN be reached

• TCE initiative averaged 100 clients/program
• More have been enrolled since
• High retention rates

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Significant improvement

• Clients improved significantly in only six
  months, both physically and mentally
• Inpatient and ER utilization for physical
  complaints decreased