A Clinical and Community Perspective in Treating Older Adults

1
A Clinical and Community Perspective in Treating
Older Adults

• Dr. Stephen J. Bartels, MD, MS
• Vicki Rodgers, MS, LPC

2
Why are Senior programs needed?

• By 2020, the 60 population will have more than
  doubled.
• As they age, some seniors have little or no
  support from family and friends.
• The average person is not aware of resources in
  their community.
• Seniors face specific age-related challenges.

3

• Connecting these seniors to resources may improve
  their lives.
• Depression is not a normal part of aging and
  research shows seniors are as responsive to
  treatment as young adults.
• High prevalence of
• suicide.

4
(No Transcript)
5
Mental Health Concerns

• Higher rates of minor depression.
• 27 have depressive symptoms causing some
  impairment.
• 20 of elders have a debilitating level of
  anxiety with even higher rates among the very
  old.
• 63 of those age 65 presenting for Senior Reach
  services have an unmet need for mental health
  services.
• Alcohol/drug abuse is a growing problem among
  older adults.

6
Access Barriers Seniors Face

• Ageism
• Health or physical limitations
• Loss of self (cognition, independence, purpose)
• Loss of family, friends, home
• Fear of dependency and fear of death
• Lack of money or knowledge of resources

7
Why some older adults dont ask for assistance

• Stigma in seeking help
• Concern over loss of independence or control over
  their life
• Fear of being placed in a nursing home
• Dont want to be a burden
• Fear of dependency
• Fear cost of services
• Fear they may be exploited financially

8
Is Community-Based Mental Health Outreach for
Older Adults an Evidence-based Practice?

• A Systematic Review of the Research Evidence
• Steve Bartels MD, MS
• Director, Dartmouth Centers for Health and Aging

9
Overview

• Older Adults with Mental Disorders in the
  Community and Unmet Need
• Models Case Identification and
  Multidisciplinary Outreach Teams
• Systematic Review of the Evidence
• SAMHSA Implementation Initiatives and Resource
  Kits

10
Unmet Need for Community Treatment

• Less than 3 of older adults receive outpatient
  mental health treatment by specialty mental
  health providers
• (Olfson et al, 1996).
• Only 1/3 of older persons who live in the
  community and who need mental health services
  receive them
• (Shapiro et al, 1986).

11
Falling Through the Cracks

• Community Mental Health Services
• Under-serve older persons
• Lack staff trained to address medical needs
• Often lack age-appropriate services
• Principal Providers Primary Care and
  Long-term Care
• Medicare
• No general outpatient prescription
• drug coverage lack of mental health parity

12
Fragmentation of the Service Delivery System

• Primary care
• Specialty mental health
• Aging network services
• Home care
• Nursing Homes
• Assisted Living
• Family caregiversThe advantages of a decisive
  shift away from mental hospitals and nursing
  homes to treatment in community-based settings
  today are in jeopardy of being undermined by
  fragmentation and insufficient availability of
  services. (Admin. on Aging, 2000)

13
Outreach Models

• Case Identification Identifying older persons in
  need and linking them to appropriate services
• Multidisciplinary Outreach Treatment Teams
  Providing MH/SA services to older persons were
  they live or spend time in the community

14
Case Identification Overview of Findings

• 2 studies
• 1 controlled prospective study
• 1 comparison group study
• Support for use of gatekeepers (non-traditional
  referral sources) in identifying socially
  isolated mentally ill older adults.

15
Outreach Case Identification Programs

• Gatekeeper Model
• Trains community members to identify and refer
  community-dwelling older adults who may need
  mental health services
• Identifies isolated elderly who are not receiving
  formal mental health services
• Florio Raschko, 1998

16
Case Identification The Gatekeeper Program
(Study Descriptions)
17
Gatekeeper Case Identification Evaluation of
the Evidence-base

• An observational and pre-post study find
  differences between older persons identified by
  gatekeepers and those identified by conventional
  approaches
• However, studies do not use a randomized design
  and are conducted by the same research group

18
Multidisciplinary Outreach Teams Overview of
Findings

• 12 studies
• 5 RCTs
• 1 quasi-experimental study
• 6 uncontrolled cohort studies
• Home and community-based treatment of psychiatric
  symptoms improved or maintained psychiatric
  status.
• All RCTs Improved depressive symptoms
• 1 RCT Improved overall psychiatric symptoms

19
Multidisciplinary Outreach Teams (RCT Study
Descriptions)
20
Multidisciplinary Outreach Teams (RCT Study
Descriptions-Cont)
21
Results of Outreach RCTs Recovered from
Depression
Greater than 50 reduction in symptoms or
meeting syndromal criteria
22
Outreach Programs (Example)

• Psychogeriatric Assessment and Treatment in City
  Housing (PATCH) program.
• Serving Older Persons in Baltimore Public Housing
  
• 3 elements
• Train indigenous building workers (i.e.,managers,
  janitors,) to identify those at risk
• Identification and referral to a psychiatric
  nurse
• Psychiatric evaluation/treatment in the residents
  home
• Effective in reducing psychiatric symptoms
• Rabins, et al., 2000

23
Multi-disciplinary Outreach TeamsEvaluation of
the Evidence-base

• Multiple RCTs by different research groups find
  better outcomes for depression compared to care
  as usual control groups
• Combined Case Identification and Outreach
  treatment also effective
• Evidence supports effectiveness for
  depressionEffectiveness for other disorders
  uncertain

24
Conclusions and Implications for Services

• We know that community outreach teams are
  effective in the treatment of depression for
  older persons
• The Gatekeeper model of case identification may
  be effective in identifying and referring at-risk
  isolated older persons
• The Challenge Dissemination, Implementation, and
  Financing of Outreach Mental Health Services for
  Older Persons

25
SAMHSA Initiatives

• SAMHSAs Older Americans Substance Abuse and
  Mental Health Technical Assistance Center
• SAMHSAs Implementation Resource Kits for
  Depression in Older Adults

26
Older Americans Substance Abuse Mental Health
Technical Assistance Center

• Provide technical assistance with respect to the
  prevention and early intervention of
• Substance abuse
• Medication misuse and abuse
• Mental health disorders
• Co-occurring disorders
• Dissemination and implementation of
  evidence-based and promising practices

27
Overview of Substance Abuse Mental Health
Problems in Older Adults
Bartels SJ, Blow FC, Brockmann LM, Van Citters
AD. Substance Abuse and Mental Health Among Older
Adults The State of Knowledge and Future
Directions. Older Americans Substance Abuse and
Mental Health Technical Assistance Center. 2005.
Available at http//www.samhsa.gov/OlderAdultsTA
C/
28
Review of Prevention EBPs for Older Adults
Blow FC, Bartels SJ, Brockmann LM, Van Citters
AD. Evidence-Based Practices for Preventing
Substance Abuse and Mental Health Problems in
Older Adults. Older Americans Substance Abuse and
Mental Health Technical Assistance Center. 2005.
Available at http//www.samhsa.gov/OlderAdultsTA
C/
29
EBP Implementation Guide
Bartels SJ, Blow FC, Brockmann LM, Van Citters
AD. A Guide for Implementing Evidence-Based
Practices to Prevent Substance Abuse and Mental
Health Problems among Older Adults Older
Americans Substance Abuse and Mental Health
Technical Assistance Center 2006.
Available at http//www.samhsa.gov/OlderAdultsTA
C/
30
SAMHSA Initiatives

• SAMHSAs Older Americans Substance Abuse and
  Mental Health Technical Assistance Center
• SAMHSAs Implementation Resource Kits for
  Depression in Older Adults

31
Target Audiences

• Consumers of Services
• Mental Health System
• State Administrators, Provider Agency
  Administrators, Clinicians
• Area Aging Networks
• State Administrators, Local Administrators
• Primary Care Offices Physicians and Care Managers

32
Components Learning Objectives

• Users Guide
• How to use the toolkit
• What each target audience can expect to learn and
  find in the toolkit
• Key Issues
• Understand the issues of treatment for older
  adult depression

33
Components Learning Objectives

• What Services/Interventions are Available to
  Treat Older Adult Depression?
• What it means to be evidence-based
• Identify available evidence-based and promising
  practices
• What training resources are available and where
  to find themTool Kits for
• Consumers
• Direct Care Clinicians
• State Local, and Regional Administrators

34
(No Transcript)
35
(No Transcript)
36
(No Transcript)
37
(No Transcript)
38
Summary

• Two ongoing initiatives funded by SAMHSA to
  provide resource materials aimed at facilitating
  implementation of evidence-based practices for
  settings and providers that care for older adults
• Prevention and Early Intervention for substance
  abuse, depression, anxiety, and suicide
• Evidence-based Treatment Interventions for
  Depression

39
A Community Involved Promising Practice Vicki
K. Rodgers, MS, LPCJefferson Center for Mental
Health
40
What is Senior Reach?

• A community based program that trains volunteers
  to identify seniors needing help.
• A research project to advance this SAMHSA
  promising practice.
• A simple way for older adults to get help before
  a crisis develops.
• A strong partnership between professionals,
  businesses, and community members.

41

• Senior Reach has been fabulous! Its been a
  lifesaver for us. They helped our families cope
  with many problems and they have helped our
  senior population with crisis intervention.
• Adrienne Franseen,
• Director of In-Home Care Services
• Seniors Resource Center

42
The Partners
TriWest Group
43
Focus

• Identify and provide services to seniors needing
  help who have not come to the attention of aging
  services or mental health systems.
• Develop and train persons in the local
  communities who can reach out to these seniors
  and contact Senior Reach on their behalf.

44
And to

• Offer support and mental health treatment to
  identified older adults through a team of
  professionals.
• Build a strong collaborative partnership between
  agencies that enhance ongoing services to older
  adults.
• Make a positive impact on outcomes of isolation,
  depression, level of functioning, hope, and
  optimism.

45
(No Transcript)
46
Community Input and Advice

• The Advisory Group consists of members from the
  four agencies, members of the target population,
  and about 30 different organizations and agencies
  representing these counties or the state.
• We ask them to support/refer to the project,
  review reports, and provide honest feedback about
  our progress.

47
Involvement of Older Adults

• Advisory Board
• Senior Consultants
• Focus groups were used at 3 agencies during
  project start-up to review development and
  implementation plan
• Consumer Focus Groups
• Consumers review marketing media
• Consumers help with newsletter
• Volunteers

48
How does the Senior Reach Program help older
adults?

• Expands the resources available in the community
  for older adults.
• Trains professionals and community members in the
  needs of older adults.
• Expands community
• coordination of services.

49

• Senior Reach has met with overwhelming community
  response and has exceeded all expectations in
  training and outreach efforts.

50
Fidelity to the Model

• Two previous programs have produced research in a
  Gatekeeper model in Iowa and Washington.
• They provided information demonstrating that this
  model is a SAMHSA promising practice.
• We are hopeful that our research will inform so
  that this model can be considered an evidenced
  based practice.

51
New components to Gatekeeper

• Collect data from the Geriatric Depression Screen
  and Colorado Assessment outcomes to help define
  the positive impact this program has on
  depression.
• Provide treatment and resources for mental health
  needs.
• 50 of those referred in the previous models
  could have benefited from mental health services.
  
• Senior Reach data indicates about 70 need and
  accept mental health services.

52

• We have had significant (lt.05) outcomes using
  this Senior Reach treatment model in
• Degree of social isolation
• Level of emotional disturbance
• Risk for suicide
• Geriatric Depression Scale outcomes
• Positive activities with others
• Overall level of functioning and
• Optimism about future outcomes

53
Recruiting Community Partners

• Building relationships with area agencies and
  organizations
• Marketing materials
• Newspaper articles

• Cold calls to area businesses, professionals
• working with older adults and non-traditional
  referral sources.
• Senior fairs, health care fairs

54
Partners are trained to

• Identify/refer older adults in need by
• personal appearance,
• mental and emotional states,
• personality and physical changes,
• poor health,
• social problems, social isolation,
• substance abuse,
• caregiver stress,
• abuse or neglect,
• financial hardship, and
• risk factors of suicide.

55
Who are Senior Reach Partners?

• Employees of agencies, corporations (UPS) and
  businesses (the local diner)
• Older adult volunteers
• Utility workers
• Landlords
• Bankers
• Staff at senior centers

• Apartment managers
• Postal carriers
• Clergy/congregation members
• Pharmacists
• Grocery clerks
• Policy officers
• Firemen
• Civic club members
• Senior peer counselors
• Home health staff

56
Referral sources say

• Im glad there is a program to turn to that
  will help with my mom.
• Tom, Adult Son
• Intervention by Senior Reach has made a
  tremendous difference for my client.
  Veronica, Case Manager
• Our partnership really made the
  difference in this persons life.
• Diane, Adult
  Protection

57
Clients say

• Senior Reach has been my life-line!
  Mike, age 62
• One angel sent another angel at a time I most
  needed help.
• Betty, age 79
• I dont know what Id do without you during this
  crisis.
• Alma, age 62

58
How to implement a similar program in your
community Use a best practice model for change!
59
Step 1 The vision

• Review what your
• community offers for
• older adults.
• Look for gaps in community services.
• Identify successful programs in similar
  communities.
• Bring together all the players.
• Be willing to compromise, share and look for
  resources.
• Get a commitment from collaborators.

60
Step 2 Infrastructure activities to support
services

• Refine needs assessment
• Strategic planning for project development and
  limit scope creep.
• Review ways to increase case finding and
  referrals from ethnic and racial minorities.
• Determine what the community understands about
  suicide, mental illness and older adults.

61
Step 3 Install in your community

• Continue building consensus with other agencies
  and groups.
• Use realistic and older adult-friendly flow of
  services to provide linkage and coordinated
  service planning.
• Invite ongoing involvement
• from target populations,
• families, and advocates.
• Start community awareness
• projects to recruit and train.

62
Thanks for letting us share our thoughts about
services to older adults with you!