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A Clinical and Community Perspective in Treating Older Adults

A Clinical and Community Perspective in Treating Older Adults. Dr. Stephen J. Bartels, MD, MS Vicki Rodgers, MS, LPC. 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.

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A Clinical and Community Perspective in Treating Older Adults

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  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. 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.

  5. 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

  6. Why some older adults don’t 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 • Don’t want to be a burden • Fear of dependency • Fear cost of services • Fear they may be exploited financially

  7. 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

  8. 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

  9. 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).

  10. 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

  11. Fragmentation of the Service Delivery System • Primary care • Specialty mental health • Aging network services • Home care • Nursing Homes • Assisted Living • Family caregivers“The 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)

  12. 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

  13. 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.

  14. 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

  15. Case Identification: The Gatekeeper Program (Study Descriptions)

  16. “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

  17. 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

  18. Multidisciplinary Outreach Teams (RCT Study Descriptions)

  19. Multidisciplinary Outreach Teams (RCT Study Descriptions-Cont)

  20. Results of Outreach RCTs:% Recovered from Depression* * Greater than 50% reduction in symptoms or meeting syndromal criteria

  21. 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

  22. 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 depression:Effectiveness for other disorders uncertain

  23. 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

  24. SAMHSA Initiatives • SAMHSA’s Older Americans Substance Abuse and Mental Health Technical Assistance Center • SAMHSA’s Implementation Resource Kits for Depression in Older Adults

  25. 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

  26. 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/OlderAdultsTAC/

  27. 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/OlderAdultsTAC/

  28. 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/OlderAdultsTAC/

  29. SAMHSA Initiatives • SAMHSA’s Older Americans Substance Abuse and Mental Health Technical Assistance Center • SAMHSA’s Implementation Resource Kits for Depression in Older Adults

  30. 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

  31. Components & Learning Objectives User’s 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

  32. 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

  33. 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

  34. A Community Involved Promising Practice Vicki K. Rodgers, MS, LPCJefferson Center for Mental Health

  35. 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.

  36. “Senior Reach has been fabulous! It’s 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

  37. The Partners TriWest Group

  38. 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.

  39. 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.

  40. 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.

  41. 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

  42. 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.

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

  44. 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.

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