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Prevention Research Centers (PRC)-Healthy Aging Research Network (HAN) Webinar Series Evidence-Based Mental Health Practices for Older Adults: The Latest Data, Strategies and Funding Options December 2, 2008, 3: 00 - 4: 30 P. M. EST Margaret Moore, MPH, MSSW, CDC Stephen J. Bartels, MD, MS Dartmouth Moderated by: Doris M. Clanton, MA, JD, GA DHR/DAS Not Pictured: Suzanne Bosstick, MS & Mary Sowers, CMS
Audio Portion of this Presentation n If you are having difficulty accessing the audio portion of this call and received the “The Conference is Full” message, please dial the backup number listed below: Backup Phone Line 888 -209 -3778
Sponsors Prevention Research Centers. Healthy Aging Research Network http: //www. prc-han. org/ National Council on Aging http: //ncoa. org/index. cfm
Funding National Association of State Mental Health Program Directors, Office of Technical Assistance (NASMHPD OTA) http: //www. nasmhpd. org/ntac. cfm through funding for the Georgia Department of Human Resources, Division of Aging Services and Division of Mental Health, Developmental Disabilities and Addictive Diseases http: //aging. dhr. georgia. gov http: //mhddad. dhr. georgia. gov
This webinar will… n highlight recent CDC findings related to the mental health of older adults; n identify roles for public health, mental health, aging network systems to promote older adult mental health; n identify recently developed SAMHSA implementation resource kit materials that can be used by administrators, clinical providers, consumers, and program managers to help guide the process of selecting and implementing evidence-based interventions and services for depression in older adults; n highlight practical information about Medicaid coverage/reimbursement for evidence-based depression programs for older adults; and n identify issues, risks, strategies and potential funding sources for evidence-based programs and practices.
Evidence-Based Mental Health Practices for Older Adults: The Latest Data Maggie Moore, MPH CDC Healthy Aging Program December 2, 2008
Mental Health as an Emerging Public Health Issue n Evolution of the public health mission n Mental health (MH) essential to overall health n Links between MH and chronic conditions n Now part of priority setting
Public Health’s Roles n Monitor MH indicators n Support development, translation, implementation, and dissemination of evidence-based programs n Identify risk factors Source: Marshall Williams S, Chapman D, Lando J (2005). The role of public health in mental health promotion. MMWR 54(34): 841 -842.
Public Health’s Roles n Increase awareness / reduce stigma n Eliminate health disparities n Improve access to services Source: Marshall Williams S, Chapman D, Lando J (2005). The role of public health in mental health promotion. MMWR 54(34): 841 -842.
CDC Healthy Aging Program’s Current Projects n Examining MH indicators n Supporting the translation, implementation, and dissemination of evidence-based programs n Sharing what we’ve learned
Using Data for Action n What gets measured, gets done! n Needs to be easily accessible n Data needed for: Grant writing n Planning/priority setting n Measuring progress n
Examining the Data n 2006 Behavioral Risk Factor Surveillance System (BRFSS) n Core questions and Depression and Anxiety Module n Adults aged 50+
6 Indicators Core BRFSS § Social and emotional support Dep/Anx Module § Current depression § Life satisfaction § Lifetime diagnosis of depression § Frequent mental distress § Lifetime diagnosis of anxiety disorder
Social and Emotional Support US Virgin Islands District of Columbia 0 – 7. 87% 7. 88 – 9. 41% 9. 42 – 11. 18% 11. 19 – 17. 74% Percentage of adults aged 50 or older who reported that they “rarely” or “never” received the social support that they needed Source: CDC, BRFSS 2006
Social and Emotional Support Highlights n Nearly 90% of adults 50+ receive adequate amounts of support n Adults 65+ were more likely than those 50 -64 to report not receiving adequate support n Men 50+ were more likely than women to report not receiving needed support
Life Satisfaction US Virgin Islands District of Columbia 0 – 4. 06% 4. 07 – 4. 57% 4. 58 – 5. 04% 5. 05 – 7. 16% Percentage of adults aged 50 or older who responded that they were “dissatisfied” or “very dissatisfied” with their lives Source: CDC, BRFSS 2006
Life Satisfaction Highlights n Nearly 95% of adults 50+ reported being “satisfied” or “very satisfied” with their lives n Adults 50 -64 were more likely than those 65+ to report being dissatisfied with their lives n White, non-Hispanic adults in all age groupings were least likely to report dissatisfaction with their lives
Frequent Mental Distress US Virgin Islands District of Columbia 0 – 7. 23% 7. 24 – 8. 52% 8. 53 – 9. 82% 9. 83 – 14. 45% Percentage of adults aged 50 or older who, in the past 30 days, experienced frequent mental distress Source: CDC, BRFSS 2006
Frequent Mental Distress Highlights n Greater than 90% of older adults do not experience Frequent Mental Distress (FMD) n Hispanic adults 50+ reported more slightly more FMD than other racial/ethnic groups n Women in all age groupings reported more FMD than men
Current Depression US Virgin Islands District of Columbia No Data 0 – 5. 41% 5. 42 – 6. 66% 6. 67 – 8. 57% 8. 58 – 12. 43% Percentage of adults aged 50 or older who had current depression (defined by a PHQ-8 score of 10 or greater) Source: CDC, BRFSS 2006
Current Depression Highlights n Only 7. 7% of adults 50+ reported current depression n Hispanic adults 50+ reported more current depression than other racial/ethnic groups n Women 50+ reported more current depression than men
Lifetime Diagnosis of Depression US Virgin Islands District of Columbia No Data 0 – 5. 41% 5. 42 – 6. 66% 6. 67 – 8. 57% 8. 58 – 12. 43% Percentage of adults aged 50 or older with a lifetime diagnosis of depression Source: CDC, BRFSS 2006
Lifetime Diagnosis of Depression Highlights n Adults 50 -64 reported more Lifetime Diagnosis of Depression (LDD) than those 65+ n Women 50+ reported more LDD than men
Lifetime Diagnosis of Anxiety US Virgin Islands District of Columbia No Data 0 – 5. 41% 5. 42 – 6. 66% 6. 67 – 8. 57% 8. 58 – 12. 43% Percentage of adults aged 50 or older with a lifetime diagnosis of anxiety disorder Source: CDC, BRFSS 2006
Lifetime Diagnosis of Anxiety Disorder Highlights n More than 90% of adults 50+ did not report a Lifetime Diagnosis of Anxiety Disorder (LDAD) n Adults 50 -64 were more likely to report a LDAD compared to those 65+ n Women 50 -64 were more likely to report a LDAD than men
Next Steps for the CDC Healthy Aging Program n Disseminating Issue Brief #1 n Developing The State of Mental Health and Aging in America Issue Brief #2: Depression Programs and Resources n Releasing an interactive data website based on the data in Brief #1
Next Steps n Working with state health departments to see what roles they can play in MH n Encouraging inclusion of MH questions on BRFSS and the use of this data by states
For more information Maggie Moore, MPH mmoore [email protected] gov www. cdc. gov/aging
Evidence-Based Integrated Models of Care for Older Adults with Mental Health Needs Stephen Bartels, MD, MS Professor of Psychiatry and Community and Family Medicine Director, Dartmouth Centers for Health and Aging
Overview n Background: Evidence-based Practices n Integration of Mental Health Services in Primary Care n Community Outreach n Technical Support Implementation Resource Materials
Setting Priorities for Older Adults Improving Access: n Integration of Mental Health and General Health Care n Home and Community-based Services Improving Quality: n Evidence-based Practice Implementation n Trained Healthcare Workforce with Expertise in Geriatrics
Integrated Mental Health Services in Primary Care The Vast Majority of Mental Health Services Provided to Older Persons are in Primary Care
Three RCT Studies of Integrated Mental Health in Primary Care n PRISMe (SAMHSA-VA) n PROSPECT (NIMH) n IMPACT (Hartford Foundation)
PRISMe Study: Primary Care Research in Substance Abuse and Mental Health for the Elderly Older Adults with Depression or At-Risk Alcohol Use Randomized Trial Comparing: n Integrated/Collaborative Care n Co-Located, Concurrent, Collaborative n Enhanced Referral to Specialty Mental Health and Substance Abuse Clinics n Preferred Providers and Facilitated appointments, transportation, payment
Rates of Engagement in MHSA Care: By Diagnosis/Condition (n=2022, mean age 73. 5)
Implications n Engagement in treatment is substantially better for integrated MH and Substance abuse services in primary care n Under the most optimal of circumstances, enhanced referral to specialty providers results in successful engagement less than half of the time
The IMPACT Treatment Model n Collaborative care model includes: n Care manager: Depression Clinical Specialist n. Patient education n. Symptom and Side effect tracking n. Brief, structured psychotherapy: PST-PC n Consultation / weekly supervision meetings with n. Primary care physician n. Team psychiatrist n Stepped protocol in primary care using antidepressant medications and / or 6 -8 sessions of psychotherapy (PST-PC)
Substantial Improvement in Depression (≥ 50% Drop on SCL-20 Depression Score from Baseline) P<. 0001 3 Unutzer et al, JAMA 2002. 6 12 Unützer et al, JAMA 2002; 288: 2836 -2845.
PROSPECT Improvement in Depression (≥ 50% Drop on HDRS Depression Score from Baseline) P<. 05 P<. 001 4 P<. 05 8 P<. 05 12 Bruce et al, JAMA, 2004; 291: 1081 -1091
Integrated Care is More Cost Effective Than Usual Care IMPACT participants had lower mean total healthcare costs: $29, 422 compared to usual care patients: $32, 785 over 4 years.
Impact Model Implementation Resources http: //impact-uw. org/
Effectiveness of Community-Based Mental Health Outreach Services for Older Adults Results from a Systematic Review
Case Identification and Referral Models n “Gatekeeper” Model n Trains community members to identify and refer community-dwelling older adults who may need mental health services n Effective at identifying isolated elderly, who received no formal mental health services Florio & Raschko, 1998 n However…no empirical data on depression outcomes for referral model
Combined Case Identification and Treatment n Psychogeriatric Assessment and Treatment in City Housing (PATCH) program. n Serving Older Persons in Baltimore Public Housing n 3 elements n Train indigenous building workers (i. e. , managers, janitors, ) to identify those at risk n Identification and referral to a psychiatric nurse n Psychiatric evaluation/treatment in the residents home n Effective in reducing psychiatric symptoms § Rabins, et al. , 2000
RCTs of Geriatric Mental Health Community Outreach Models % Recovered from Depression* * Greater than 50% reduction in symptoms or meeting syndromal criteria
Home and Community Depression Treatment For Older Adults n 8 Home-based sessions of manualized problem-solving therapy (PST) over a 19 week period n Social & physical activation, pleasant events scheduling n Clinical supervision by a psychiatrist, recommendations for medication (if needed) management by phone contact with physician and/or participant n Follow-up phone calls (1/month, for 6 months)
PEARLS 12 -Month Outcomes: Depression Symptom Reduction and Depression Remission %
Federal Technical Assistance Initiatives n SAMHSA’s Older Americans Substance Abuse and Mental Health Technical Assistance Center n SAMHSA’s Implementation Resource Kits for Depression in Older Adults
Online Resources www. samhsa. gov/Older. Adults. TAC/
Overview of Substance Abuse & Mental Health Problems and EBPs 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. www. samhsa. gov/Older. Adults. TAC/
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. www. samhsa. gov/Older. Adults. TAC/
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; 2008. Available soon at: http: //www. samhsa. gov/Older. Adults. TAC/
EBP Implementation Guide: Table of Contents PART 1: Implementation Science & Prevention with Older Adults 1. 2. 3. 4. 5. Introduction National Imperative to Implement Evidence-Based Practices Summary of the State-of-the-Art of Implementation Science Adaptation of Existing Implementation Materials Characteristics of Older Adult Populations PART 2: Implementation of Evidence. Based Practices for Older Adults 6. Prevention and Early Intervention Among Older Adults 7. Adapting Implementation to Older Adult Settings and Providers 1. Implementation Principles 2. Core Implementation Components 3. Implementation Process 8. Training for Service Providers Working with Older Adults 9. Summary and Key Recommendations
Medicaid: Background, Basics and Evidence-Based Depression Interventions for Older Adults Suzanne Bosstick Mary Sowers Division of Community and Institutional Services Disabled and Elderly Health Programs Group Center for Medicaid and State Operations Centers for Medicare & Medicaid Services
Medicaid Basics n Medicaid is a State/Federal Partnership to provide health care and long term care services to individuals who are poor and individuals with disabilities, including many elders.
Title XIX of the Social Security Act n Established in 1965 as a companion program to Medicare n “Grants to States for Medical Assistance Programs” ---- Medicaid n Federal/State entitlement partnership program – to individuals & States n Emphasized dependent children and their mothers, older adults, & individuals with disabilities
The Beginning of Medicaid n Initially mostly covered primary/acute health care services n LTC limited to Skilled Nursing Facility (SNF) services – e. g. nursing homes n Institutional bias - eventual addition of community-based services---home health, personal care, home and community-based services (HCBS) in the 1980 s
Medicaid in Brief n States determine their own unique programs n Each State develops and operates a State plan outlining the nature and scope of services; the State Plan and any amendments must be approved by CMS n Medicaid mandates some services, States elect optional coverage n States choose eligibility groups, services, payment levels, providers
Federal Medical Assistance Percentages (FMAP) & Enhanced Federal Assistance Percentages n Calculated each year for Medicaid/SCHIP n Reimbursement rate for “services” n Based on average State income person and the nation as a whole n Minimum 50 percent match rate n Highest 2007 FMAP: Mississippi, Arkansas, West Virginia, New Mexico (70%+) n Enhanced FMAP for some programs/activities n Indian Health Service facilities – 100 % FMAP n Additional information at: http: //aspe. hhs. gov/health/fmap 07. htm
Key State Plan Requirements n States must follow the rules in the Act, the Code of Federal Regulations (generally 42 CFR), the State Medicaid Manual, and policies issued by CMS n States must specify the services to be covered and the “amount, duration, and scope” of each covered service n States may not place limits on services or deny/reduce coverage due to a particular illness or condition n Services must be medically necessary n Third party liability rules require Medicaid to be the “payer of last resort”
Additional State Plan Requirements n Generally, services must be available Statewide n Freedom of choice of providers n Enrolled all willing and qualified providers n Provider qualifications n Payment for services (4. 19 -B pages) n Reimbursement methodologies must include methods/procedures to assure payments are consistent with economy, efficiency, and quality of care principles
Medicaid Benefits in the Regular State Plan MANDATORY - Physician services - Laboratory & x-ray - Inpatient hospital - Outpatient hospital - EPSDT - Family planning - Rural and federally-qualified health centers - Nurse-midwife services - NF services for adults - Home health OPTIONAL - Dental services - Therapies – PT/OT/Speech/Audiology - Prosthetic devices, glasses - Case management - Clinic services - Personal care, self-directed personal care - Hospice - ICF/MR - PRTF for <21 - Rehabilitative services
Case Management n States have options within the Medicaid Program regarding how they offer case management. n States may offer case management as a State Plan service. States choosing this approach must meet certain requirements related to Targeted Case Management (as it is called under the State Plan). n States may also choose to offer case management for individuals in a Home and Community Based waiver as a waiver -covered service. Different requirements apply when case management is covered as a waiver service. n Please be advised that there is currently a rule under moratorium that may impact future rules regarding Case Management in Medicaid.
Section 1915(c) Home and Community Based Services Waivers n Title XIX permits the Secretary of Health & Human Services - - through CMS - to waive certain provisions required through the regular State plan process: Comparability (amount, duration, & scope) Statewideness Income and resource requirements These waivers allow States to design programs to meet the unique needs of certain groups. There are many 1915(c) waivers across the country designed to serve individuals who are aging.
Section 1915(c) Home and Community Based Services Waivers n A State may design service packages to meet the specific needs of the group served in a waiver. n These services are usually designed to supplement or complement the services already available through the State Plan.
Section 1915(c) Home and Community Based Services Waivers, Continued n In HCBS waivers, States must meet a number of requirements, including assuring the health and welfare of individuals served through the waiver. n Case managers play an important role in helping States meet this obligation.
How Could States Incorporate Depression Interventions for Older Adults into Their Medicaid Program? n Through 1915(c) Home and Community Based Services Waivers n. States can define the services to be offered under the waiver. n. Case managers often play a pivotal role in screening, information and referral, and linkages. n. Existing HCBS waivers may present a unique opportunity for an overlay of these interventions. n. Things to remember: Important to define the activities involved. If the service requires skilled interventions, State should consider identifying those elements separately within the waiver.
How Could States Incorporate Depression Interventions for Older Adults into Their Medicaid Program? n States may have another option to consider regarding the incorporation of these interventions into their Medicaid Program. n Through a variety of State Plan services n Discreet, specific activities within the interventions may be Medicaid-coverable services. So, identifying the component elements will be helpful in mapping where coverage for those services may occur within the State Plan. n The State may also wish to evaluate whether using the HCBS as a State Plan Option is an option. n Things to remember: Service must be well-defined, and should not include a “bundle” of services.
Next Steps n Contact your State’s Medicaid Agency if you are interested in discussing how these interventions may be included in your Medicaid Program. n The State Medicaid Agency would be the entity in your State who must submit any State Plan or Waiver document. n CMS stands ready to provide technical assistance and guidance to States on the authorities available that will best meet their objectives.
Questions & Answers
Archived Webinars This, and all past webinars in the PRC-HAN webinar series are available for download: § Overcoming Stigma, October 1 st § IMPACT, October 16 th § PEARLS, October 23 rd § Healthy IDEAS, October 29 th § Money Matters, November 13 th § Latest Data, Strategies, Funding, December 2 nd Download any or all of these webinars at: http: //ncoa. org/content. cfm? sectionid=379 Alphabetically listed under “NCOA Presentations”