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Overview

Older Adult Suicide Prevention Policy September 16, 2009 Brian Altman, JD Director of Public Policy and Program Development Suicide Prevention Action Network USA (SPAN USA), a division of AFSP. Overview. Senior Living Communities – Policies and Actions State and Federal Public Policies

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Overview

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  1. Older Adult Suicide Prevention PolicySeptember 16, 2009Brian Altman, JDDirector of Public Policy and Program DevelopmentSuicide Prevention Action Network USA (SPAN USA), a division of AFSP

  2. Overview • Senior Living Communities – Policies and Actions • State and Federal Public Policies • State action • Federal action • Health reform • SAMHSA • Resources for more information

  3. What Can Senior Living Communities Do to Save Lives? Implement Suicide Prevention Programs & Measures to Keep Residents of Older Adult Communities Safe ***SPECIAL THANKS TO HEIDI BRYAN (FEELING BLUE SPC) AND LINDA LANGFORD (SPRC)***

  4. National Groups Join for Summit • October 16-17, 2008 • Organizing Partners: Center for Mental Health Services, (SAMHSA); National Institute of Mental Health (NIMH); Suicide Prevention Action Network (SPAN USA); Suicide Prevention Resource Center (SPRC); Asbury Methodist Village; and Sodexo. • Approximately 70 participants included: staff from organizing partners, experts in senior suicide research and policy, along with individuals from senior living facilities across the country. • Senior Living Facility participants included: administrators, wellness staff, clinicians, clergy, social services, marketing and RESIDENTS.

  5. Framework • 3 categories for approaches • Whole-population • At-risk • Response to crisis and suicidal behaviors

  6. Approaches for the whole population

  7. Whole Population Goal 1 - Promote Effective Coping and Functioning Goal 2 -Promote Social Networks and Social Support Goal 3 -Promote Engagement in Positive Activities Goal 4 -Decrease Access to Lethal Means

  8. Objective and Ideas for Implementation Goal 1 Objectives: 1.1 Promote coping with loss and bereavement 1.2 Promote coping with decreased functioning and role changes 1.3 Promote problem solving skills 1.4 Provide assistance with financial or other matters Other ideas for implementation • Train entire staff to help older adults cope • Train special residents in peer counseling (big brother, big sister programs) • When residents arrive, provide them with education about coping mechanisms

  9. Objective and Ideas for Implementation Goal 2 Objectives: 2.1 Encourage connections among residents 2.2 Promote a sense of community on campus 2.3 Provide or facilitate regular “check-ins” 2.4 Facilitate contacts with family members Other ideas for implementation: • Ensure a variety of activities • Facilitate clubs or groups geared towards a specific interest • Market counseling services differently to reduce stigma

  10. Objectives and Ideas for ImplementationGoal 3 Objectives: • 3.1 Provide access to spiritual or faith activities • 3.2 Promote involvement in volunteer activities • 3.3 Provide recreational activities • 3.4 Promote engagement in physical activity Other ideas for implementation: • Recruit volunteers or interns from local colleges and universities to provide activities • Have full calendar of wellness programs • Provide transportation to programs not on-site • Encourage physical activity by creating a garden/gazebo track area for residents to walk

  11. Objectives and Ideas for Implementation Goal 4 Objectives: 4.1 Limit access and/or erect fences on roofs of buildings 4.2 Replace windows or limit size of window openings 4.3 Restrict access to stored chemicals and prescription drugs 4.4 Restrict access to firearms Other idea for implementation: • Establish a safety department of residents and staff

  12. Approaches for populations at-risk

  13. At-Risk Approaches Goal 5 - Increase Help-Seeking Behaviors Goal 6 - Identify and Refer Distressed or At-Risk Residents Goal 7 - Increase Access to Mental Health and Substance Abuse Services Goal 8 - Promote Effective Treatment and Management of Mental Health and Substance Abuse Disorders Goal 9 - Effectively Address Medical Conditions and Pain

  14. Objectives and Ideas for Implementation Goal 5 Objectives: • 5.1 Increase residents’ knowledge of treatable risk factors, potential treatments, and available services • 5.2 Decrease local barriers to help-seeking • 5.3 Implement efforts to reduce stigma and normalize help seeking Other ideas for implementation: • Come at problem through a “back door” approach by addressing physical conditions and including information on mental health • Give talks on related ideas and include information on mental health • Decrease stigma by educating everyone • Create “tickets” on difficult topics for residents to hand to their doctors

  15. Objectives and Ideas for ImplementationGoal 6 Objectives: • 6.1 Increase ability of other residents, staff, and families to identify and refer for help (i.e., “gatekeeper training”) • 6.2 Increase identification of depression, substance misuse, and suicidality (i.e., screening) • 6.3 Increase clinicians’ capability to identify and refer appropriately Other ideas for implementation: • Train all staff to recognize signs • Encourage depression screenings to be held weekly • Target specific times of the year, such as holidays • Develop a “community watch” program where peers on each hall or floor are trained in signs of depression

  16. Objectives ad Ideas for ImplementationGoal 7 Objectives: • 7.1 Create linkages with community-based mental health and substance abuse services • 7.2 Provide mental health and substance abuse services or supports Other ideas for implementation: • Provide transportation to mental health providers • Give residents choices in their treatment

  17. Objectives and Ideas for ImplementationGoal 8 Objectives: • 8.1 Adhere to geriatric-specific treatment guidelines • 8.2 Utilize effective models of geriatric care management • 8.3 Assess for suicidality • 8.4 Increase regular monitoring of at-risk residents Other ideas for implementation: • Design a depression care management team or wellness team • Offer training to mental health providers that residents are referred to on older adult mental health issues

  18. Objectives and Ideas for ImplementationGoal 9 Objectives: • 9.1 Employ treatment regimens designed to reduce symptoms and pain • 9.2 Help ill residents deal with specific types of disability and functional impairment Other ideas for implementation: • Refer residents to hospice as soon as needed • Know your community referrals • Provide targeted education

  19. Approaches in response to crisis

  20. Response to Crisis and Suicidal Behaviors Goal 10 - Develop Protocols and Procedures to Promote the Safety of Distressed or Suicidal Residents and to Respond to Crisis Using Institutionalized Procedures Goal 11 - Respond to Suicides with a Comprehensive Postvention Program to Identify Survivors, Assess Level of Trauma & Risk Among Survivors, Support Survivors, and Prevent Suicide Contagion

  21. Objectives Goal 10 Objectives: • 10.1 Implement protocols and systems for effectively responding to acutely distressed or suicidal residents • 10.2 Utilize decision-making protocols and procedures regarding mental health issues & need for additional care (e.g., hospitalization, transition to assisted living) • 10.3 Ensure emergency contact notification protocols are appropriate for mental health crisis • 10.4 Institute procedures for creating and implementing post-crisis follow-up plans • 10.5 Utilize standardized procedures for appropriately documenting interactions with distressed/suicidal residents • 10.6 Train appropriate personnel in relevant protocols and procedures

  22. Ideas for Implementation Goal 10 • Encourage residents to help create protocols • Develop a holiday newsletter that promotes mental health

  23. Objectives and Ideas for ImplementationGoal 11 Objectives: • 11.1 Develop postvention protocols & procedures prior to need • 11.2 Ensure that all appropriate individuals within the community are identified as survivors • 11.3 Assess all survivors for level of trauma & risk • 11.4 Ensure that support is offered/provided to all survivors • 11.5 Work appropriately and effectively with the media • 11.6 Implement postvention strategies that discourage contagion Other ideas for implementation: • Provide access to a variety of religious services • Have a higher-level decision maker on staff assess at-risk seniors. • Adapt media guidelines and protocol. • Offer attempt survivors continuous support and follow-up.

  24. Next Steps for Senior Living Community Policies • Participants will take framework and ideas back to their own community • The Center for Mental Health Services/Substance Abuse and Mental Health Services Administration (SAMHSA) has contracted with the National Association of State Mental Health Program Directors (NASMHPD) to develop suicide prevention toolkits for selected high-risk populations. Starting in October 2008, NASMHPD began work on a toolkit, Promoting Mental Health and Preventing Suicide:  A Toolkit for Senior Living Communities, targeted at administrators, professionals, and paraprofessional staff of senior living communities—including nursing homes, assisted living, independent living, and continuing care retirement communities, as well as residents and their family members. The toolkit, scheduled for release in early 2010, offers tools to teach staff to recognize and take steps to help someone at risk for suicide and to learn how to put policies and actions in place that could improve the mental well-being of the residents.

  25. Questions and Answers

  26. Public Policy, Suicide, & Older Adults

  27. State Policy

  28. Key State Public Policy Topics • Offices of suicide prevention (SP) • Suicide prevention continuing education requirements for mental health professionals

  29. Office of Suicide Prevention • Encourage state legislatures to authorize the creation of and appropriate funding for a statewide office of suicide prevention, to include funding for full-time staff and programmatic efforts.  The office created would address the public health problem of suicide across the lifespan. • Objective 4.1 of the National Strategy for Suicide Prevention calls for states to develop and implement comprehensive suicide prevention plans. 47 states currently have a suicide prevention plan, yet many are focused solely on youth suicide prevention.  Most states have an individual who is responsible for suicide prevention, but only one-third of the states have legislatively-directed funds specified for suicide prevention efforts.  In fact, only about 10% of states have an office of suicide prevention authorized by legislation.

  30. Continuing Education Requirements for Mental Health Professionals • Encourage state licensing boards of mental health practitioners to adopt regulations which require continuing education in the field of suicide prevention for all licensed practitioners. • Objective 6.9 of the National Strategy for Suicide Prevention calls for an increase in the number of recertification or licensing programs in relevant professions that require or promote competencies in depression assessment and management and suicide prevention.  • Introduced legislatively, but did not pass in 2009 • NJ HB 2319 would require suicide prevention continuing education courses for physicians and podiatrists

  31. Pending Legislation in PA • HR 72 • Would require investigation of costs/benefits of prevention/early intervention programs to include reduction of suicide attempts

  32. Federal Legislation

  33. Federal Public Policy Overview • Health reform, health reform, and…health reform! • SAMHSA reauthorization…eventually!

  34. Health Reform • President Obama outlined eight principles for healthcare reform: • protect families’ financial health; • assure affordable, quality health coverage for all Americans; • provide portability of coverage; • guarantee choice of doctors; • invest in prevention and wellness; • improve patient safety and quality of care; • end barriers to coverage for people with pre-existing medical conditions; and • reduce long-term growth of health costs for businesses and government. • See http://healthreform.gov/support.html

  35. What is the Status? • Two committees of jurisdiction in Senate: Health Education, Labor and Pensions (HELP) and Finance. • Senate HELP Committee passed a bill on July 15th. • Finance set to release a draft this week and mark-up a bill next week. • Three committees of jurisdiction in House: Education (Ed) & Labor, Ways & Means (W&M), and Energy & Commerce. • Passed W&M and Ed & Labor on July 17th • Energy and Commerce passed on July 31st

  36. Is Health Reform Good for Older Adults? (aka, are they are cutting Medicare?) • Myth: Health care reform will hurt Medicare. • Fact: None of the health care reform proposals being considered by Congress would cut Medicare benefits or increase your out-of-pocket costs for Medicare services. • Fact: Health care reform will lower prescription drug costs for people in the Medicare Part D coverage gap or "doughnut hole" so they can get better afford the drugs they need. • Fact: Health care reform will protect seniors' access to their doctors and reduce the cost of preventive services so patients stay healthier. • Fact: Health care reform will reduce costly, preventable hospital readmissions, saving patients and Medicare money. • Fact: Rather than weaken Medicare, health care reform will strengthen the financial status of the Medicare program. • Bottom Line: For people in Medicare, health care reform is about lowering prescription drug costs for people in the "doughnut hole", keeping the doctor of your choice, improving the quality of care, and eliminating billions in waste that is causing poor care and medical errors. Source: Myths vs. Facts – Don’t’ Let Health Reform Scare You, AARP, available at: http://aarp.convio.net/site/PageNavigator/Myths_vs_Facts_splash

  37. Is Health Reform Good for Older Adults? (aka, what about those “death panels”?) • Myth: Health care reform means the government can make life-and-death decisions for you. • Fact: Health care reform will NOT give the government the power to make life-and-death decisions for anyone regardless of their age. Those decisions will be made by individuals, their doctor and their family. • Fact: No one, including the government or your insurance company, will be given power to make life-and-death decisions for you. • Bottom Line: Health care reform isn't about putting the government in charge of difficult end of life decisions. It's about giving individuals and families the option to talk with their doctors in advance about difficult choices every family faces when loved ones near the end of their lives. Source: Myths vs. Facts – Don’t’ Let Health Reform Scare You, AARP, available at: http://aarp.convio.net/site/PageNavigator/Myths_vs_Facts_splash

  38. Health Reform and Suicide Prevention* • Equitable and adequate coverage and reimbursement for mental health and substance use services. • Early identification of individuals at risk for suicide and underlying mental health and substance use conditions. • Coverage and reimbursement for both identification of need and linkage to services. • Suicide and suicide attempts as a primary indicator of health status, as well as an integral element of health care data/information collection and quality measurement. • The National Violent Death Reporting System (NVDRS) extended to all States. • *SPAN USA, a division of AFSP, has issued a White Paper entitled, Suicide Prevention and Health Care Reform, identifying five key policy priorities that focus upon suicide prevention's place in the health reform conversation. See www.spanusa.org/publicpolicy

  39. Key Senate HELP Bill Provisions – Coverage and Parity • In issuing health insurance policies, insurers will not be permitted to establish terms of coverage based on an applicant’s health status, medical condition (including physical and mental illness), claims experience…(§2706). • Affordable Health Benefit Gateways and Community Health Insurance Plan created in bill will have an essential health care benefit which shall include at least…mental health and substance abuse services. (§3103)

  40. HELP Bill Check Up Provisions • Coverage of preventative health services with a stipulation that a group or individual health insurance coverage plan shall provide coverage for and shall not impose any cost sharing requirements for items or services that have in effect a rating of “A” or “B” in the current recommendations of the U.S. Preventative Health Task Force. (§2708) • The U.S. Preventive Services Task Force (USPSTF) recommends with a “B” rating: screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings;screening of adolescents (12-18 years of age) for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up; and screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow up. • Grants for pilot programs to provide public health community interventions, screenings and, where necessary, clinical referrals for individuals who are between 55 and 64. The section specifically notes that screening activities may include mental health/behavioral health (§322).

  41. Senate HELP Bill Link to Services Provisions • Grants to establish community health teams to support a medical home model that includes social workers and behavioral and mental health providers (§212). • Grants for coordinated and integrated services through co-location of primary and specialty care in community-based mental and behavioral health settings.

  42. Senate HELP Prevention and Wellness • Creation of an interagency council dedicated to promoting healthy policies at the federal level. The Council will establish a national prevention and health promotion strategy (§301). • Establishment of a Prevention and Public Health Investment Fund to provide an expanded and sustained national investment in prevention and public health programs. This will involve a dedicated, stable funding stream for prevention, wellness and public health activities authorized by the Public Health Service Act (§302). • Expand the efforts of, and improve the coordination between, the two task forces which provide recommendations for preventive interventions (The U.S. Preventive Services Task Force and The Community Preventive Services Task Force) (§303). • Convene a national public/private partnership for the purposes of conducting a national prevention and health promotion outreach and education campaign. The goal of the campaign is to raise awareness of activities to promote health and prevent disease across the lifespan (§304).

  43. H.R. 3200 – America’s Affordable Health Choices Act 111TH CONGRESS 1ST SESSION H. R. 3200 To provide affordable, quality health care for all Americans and reduce the growth in health care spending, and for other purposes. IN THE HOUSE OF REPRESENTATIVES JULY 14, 2009 Mr. DINGELL (for himself, Mr. RANGEL, Mr. WAXMAN, Mr. GEORGE MILLER of California, Mr. STARK, Mr. PALLONE, and Mr. ANDREWS) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Education and Labor, Oversight and Government Reform, and the Budget, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned

  44. House Coverage and Parity Provisions • Non-discrimination and parity for behavioral health services would be maintained in the new Health Insurance Exchange and health care coverage and the bill includes a provision to ensure that mental health and substance use services are available to all individuals covered through the new Health Insurance Exchange (§§114 and 151). • A required core set of benefits provides coverage for essential health care services including mental health and substance abuse services (§122).

  45. House Check Up Provisions • Medicaid coverage of preventative health services and elimination of cost sharing requirements for services that have in effect a rating of “A” or “B” in the current recommendations of the U.S. Preventative Health Task Force (§1811). • Eliminate cost-sharing on recommended preventive services delivered by Medicare and insurance available in the Health Insurance Exchange (§1305). • Assumes that mental health checkups are covered as “additional preventative services”

  46. House Links to Services Provisions • Expands programs in Medicare that reward physicians for spending time coordinating care for their patients. Unlike Senate provision, this section does not currently specifically reference behavioral health providers. (§1302). • Establishes a 5-year pilot program to test the medical home concept with high-need Medicaid beneficiaries. This section does not currently specifically reference behavioral health providers. (§1722).

  47. House Wellness and Prevention Services • Sec. 3111. Prevention and wellness trust. Establishes a Prevention and Wellness Trust that authorizes appropriations from the Public Health Investment Fund (under Sec. 2002) of $35 billion from FY 2010 through FY 2019. • Sec. 3121. National prevention and wellness strategy. Requires the Secretary to submit a national strategy designed to improve the nation’s health through evidence-based clinical and community-based prevention and wellness activities within one year of enactment and at least every two years thereafter.

  48. House Wellness and Prevention cont… • Sec. 3131. Task force on clinical preventive services. Converts the existing U.S. Preventive Services Task Force into the Task Force on Clinical Preventive Services. Staffed by Agency for Health Research and Quality (AHRQ), this task force of non-governmental experts conducts evidence-based systemic reviews of data and literature to determine what clinical preventive services (e.g., preventive services delivered by traditional health care providers in clinical settings) are scientifically proven to be effective. • Sec. 3132. Task force on community preventive services. Codifies the existing Task Force on Community Preventive Services. Staffed by CDC, this task force of non-governmental experts conducts evidence-based systematic reviews of data and literature to determine what community preventive services (e.g., preventive services that are not “clinical preventive services” but are delivered by nontraditional providers in nontraditional settings) are scientifically proven to be effective.

  49. House Wellness and Prevention cont… • Sec. 3141. Prevention and wellness research activity coordination. Directs the CDC and National Institute of Health (NIH) directors to take into consideration the national strategy on prevention, recommendations from the Task Force on Clinical Preventive Services, and recommendations from the Task Force on Community Preventive Services in conducting or supporting research on prevention and wellness. • Sec. 3142. Community prevention and wellness research grants. Provides funding to CDC to support research on community preventive services. • Sec. 3151. Community prevention and wellness services grants. Establishes a grant program at CDC to fund the delivery of evidence-based, community-based prevention and wellness services across the country.

  50. Life After Health Reform – SAMHSA Reauthorization • The Substance Abuse and Mental Health Services Administration (SAMHSA) needs to be reauthorized. • This creates opportunity for new older adult suicide prevention and mental health programs to be created. • Previous bills suggesting such are the Stop Senior Suicide Act and the Positive Aging Act.

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