Implementing Evidence Based Practices for Older Iowans with Mental Illnesses

1. Implementing Evidence Based Practices for Older Iowans with Mental Illnesses

2. Aging and Mental Illness in Iowa

3. Outpatient Care • Medicare? • Community-based Care?

4. Inpatient Care

5. Depression in Older Adults and Health Care Costs Unutzer, et al., 1997; JAMA

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

7. New Hampshire Total Monthly Costs Per Person Over Age 65 $4,000 Medicaid Medicare $3,500 $3,000 $2,500 $2,000 $1,500 $1,000 $500 $0 COPD Diabetes Depression Cardiac Dysrhymias Dementia Alzheimer's Hypertension Schizophrenia Heart Failure Osteoarthrosis Cerebrovascular

8. Suicide Rate by Age Per 100,000 Older people: 12.7% of 1999 population, but 18.8% of suicides. (Hoyert, 1999)

9. Outcomes: ADL Decline at One Year Follow-up

10. 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

11. Depression is treatable • 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.)

12. NATIONAL MOVEMENT

13. 2005 White House Conference

14. Top 10 Recommendations of 2005 White House Conference on Aging • Reauthorize the Older Americans Act within the first six months following the 2005 White House Conference on Aging • 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 • Ensure that older Americans have transportation options to retain their mobility and independence • Strengthen and improve the Medicaid program for seniors • Strengthen and improve the Medicare program • Support geriatric education and training for all healthcare professionals, paraprofessionals, health profession students, and direct care workers • Promote innovative models of non-institutional long-term care • Improve recognition, assessment, and treatment of mental illness and depression among older Americans • Attain adequate numbers of healthcare personnel in all professions who are skilled, culturally competent, and specialized in geriatrics • Improve state and local based integrated delivery systems to meet 21st century needs of seniors

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

16. MENTAL HEALTH FORUMS • Quick Fixes (1998) • Iowa Mental Health Forum (2000) • Mental Health System (2001)

17. Older Adults Roundtable • Many persons did not know where to seek help. • Include dementia • Implement multi-disciplinary treatment approaches

18. IOWA COALITION ON MENTAL HEALTH AND AGING Collaborative Models of Care

19. PRIMARY GOALS • Promote mental wellness among aging Iowans • Increase access to qualified mental health service providers • Integrate mental health services nto usual places of care

20. OBJECTIVES • Conduct screenings • Identify and recruit providers • Develop collaborative care models

21. COLLABORATIVE MODELS • Nursing Homes & other LTC facilities • Primary Care Practices • Aging Network

22. The IMPACT Treatment Model • Collaborative care model includes: • 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)

23. Usual Care PRIMARY CARE CLINICIAN PATIENT MENTAL HEALTH SPECIALIST

24. Component Model (TCM) PRIMARY CARE CLINICIAN PHQ-9 CARE MANAGER PATIENT PHQ-9 PHQ-9 MENTAL HEALTH SPECIALIST

25. Typical Frequency of Patient Contacts Care Manager Phone Call Primary Care Clinician Visit PCC CM Acute Phase Continuation Phase PCC PCC PCC PCC PCC CM CM CM CM CM 1 5 6 9 12 18 24 32 36 WEEK

26. IMPACT Unutzer et al, 2002 1,801 patients ≥60 yrs in 18 Primary care clinics in 8 Health care organizations. “Cadillac model of system change” Patients in REMISSION (HSCL<0.5)

27. Managing Any Other Chronic Disease Monitor Depressive Symptoms Educate Patient and Family Monitor Adherence Monitor Side Effects Provide Support Consult or Refer to Agency/Outside Specialist As Needed Managing Antidepressants is Like…..

28. MH-PC Co-location Project • Pilot project funded through a federal block grant • Serves persons who are 60 years and older – no charge • 2 - master degree level clinical social workers • Collaborate with 5 primary care practices in community – family practice, internal medicine – providers include MDs, DOs, PAs, ARNPs • Services provided include: • mental health assessments and screenings • ongoing psychotherapy • referral to other community resources and services as needed • Spanish interpreters available

29. 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.. • 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.

30. Case Example-Assessment STRESSORS • poor interpersonal and psychological boundaries • Financial problems – housing, utilities • Isolation - except family HISTORY • “Ashamed” to tell PCP depressed for mo. & that has dysfunctional family • Personal and family history of childhood sexual abuse • Multiple family members abuse substances (intergenerational) • Multiple interpersonal family conflicts • “Worrier”- chronic untreated generalized anxiety disorder DIAGNOSES

31. Case Example- Interventions • SSRI meds-reduces symptoms to help make desired changes • called PCP to consider increasing Lexapro – little improvement symptoms • CBT-evaluate & challenge negative thoughts/distortions, action (behavioral) steps - reconnect w/church and friends - increase social interaction to reduce isolation • Connect resources to decrease financial stressors - energy assistance, MOW, • Boundaries – appropriate psychological and interpersonal w/family • Self-esteem – develop sense self – efficacy • manage moods- self-awareness/monitoring, coping skills-relaxation, distraction, etc. • boundaries-empathy/love w/o “taking on” others distress

32. THANK YOU