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

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

2. Dr. Betsy McDonel Herr Targeted Capacity Expansion Initiative

3. SAMHSA: U.S. Substance Abuse and Mental Health Services Administration • SAMHSA --federal agency devoted to improving behavioral health services across the nation. • CMHS—Center for Mental Health Services, one of SAMHSA’s 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

4. 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

5. LOGIC MODEL Older Adult TCE PROGRAM PROGRAM GOALS POPULATION ACTIVITIES OUTCOMES Expansion of Local Services Screening Increase/Train Providers Evidence Based Practice Adoption Integrated Treatment Consumer involvement Technical assistance Outreach,engagement, case-finding Improve access for racial/ethnic minorities, persons in rural settings Service Linking Needs assessment Strategic planning Quality improvement activities Cross-training 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 Diverse populations served Screening/Prevention/Early 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.

6. Ms. Noelle Downing Positive Aging Resource Center

7. 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.org

12. Ms. Noelle Downing The TCE Sites

13. 9 National TCE Sites

14. 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

15. 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

16. 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

17. TCE Site Demographics • Over 75 years of age (61%) • Female (76%) • Race • White (78%) • Asian (6%) • Black (3%) • Other (13%) • 27% Latino

18. 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%)

19. Ms. Karen Cheal Results through August 2004 Interim Findings

20. GPRA Data

21. 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

22. Data collection • Collected by site staff as part of client’s appointment • Data collected longitudinally • Intake • Six months • Twelve months

23. 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.  Don’t know g.  Not Applicable h.  Refused

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

25. Retention Rates • Six-month: 72% • Twelve-month: 74%

26. 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%)

27. Results: Family and Living Conditions

28. Difficulty managing day-to-day life % experiencing NO difficulty p<.01

29. Difficulty with household responsibilities % experiencing NO difficulty p<.001

30. Difficulty with work % experiencing NO difficulty p=0.19

31. Difficulty with leisure time % experiencing NO difficulty p<.0001

32. Difficulty developing autonomy % experiencing NO difficulty p<.0001

33. Difficulty with apathy % experiencing NO difficulty p<.0001

34. Difficulty with concentration % experiencing NO difficulty p<.0001

35. Difficulty with life satisfaction % experiencing NO difficulty p<.0001

36. Self-reported health status % reporting fair/poor health p<.01

37. Results: service utilization

38. Outpatient service utilization for physical complaints % reporting use p=0.4

39. Inpatient stays forphysical complaints % reporting use p=0.003

40. Emergency room visits for physical complaints % reporting use p<.01

41. Dr. Rodolfo R. Vega Systems Integration Data

42. Grantee’s Requirement • “Create service linkages between individuals and groups that serve the target population.”

43. Grantee’s 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.

44. PARC’s 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

45. PARC’s 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.

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

47. 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.

48. Systems integration Organizational strategy to reduce fragmentation and improve collaboration.

49. Systems integration Bringing services together to meet multiple needs of the individual through a coordinated treatment approach

50. Service integration Identify components.