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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 Medicare? Community-based Care? Inpatient Care 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: • • • • • • 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 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.) 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 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 Quick Fixes (1998) Iowa Mental Health Forum (2000) 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 Promote mental wellness among aging Iowans Increase access to qualified mental health service providers Integrate mental health services nto usual places of care OBJECTIVES Conduct screenings Identify and recruit providers Develop collaborative care models COLLABORATIVE MODELS Nursing Homes & other LTC facilities Primary Care Practices Aging Network 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) 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 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 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. Case ExampleAssessment 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 Case ExampleInterventions 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 THANK YOU