Geriatric Mental Health
2006 Annual Report
To The Governor And Legislature of New York State

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The projected growth of the older adult population in New York State will increase the number of adults 65 and older who have mental disorders by 56 percent in 2030 (see Table 1).  This dramatic increase raises concerns about the ability of health, mental health, and aging services to provide adequate access to services that respond to the unique needs of older adults in a coordinated way.  The projected growth of cultural minorities in the older adult population, the projected decrease in the proportion of working age adults, and the fact that fewer than 25 percent of older adults with mental disorders currently receive treatment from mental health professionals present additional challenges.

As part of the growing attention and interest at all levels of government to advance geriatric mental health care, New York State enacted the Geriatric Mental Health Act on August 23, 2005.  The law, which took effect on April 1, 2006, authorized the establishment of (1) an Interagency Geriatric Mental Health Planning Council, (2) a geriatric service demonstration program, and (3) a requirement for an annual report to the Governor and the Legislature.

Interagency Geriatric Mental Health Planning Council

Description

The Interagency Geriatric Mental Health Planning Council consists of 15 members, as follows:

• The Commissioner of Mental Health, co-chair of the Council;
• The Director of the State Office for the Aging, co-chair of the Council;
• One member representing the Office of Alcoholism and Substance Abuse Services;
• One member representing the Office of Mental Retardation and Developmental Disabilities;
• One  member representing the Commission on Quality of Care and Advocacy for Persons with Disabilities;
• One member representing the Department of Health;
• One member representing the Education Department and the Board of Regents;
• One member representing the Office of Children and Family Services;
• One member representing the Office of Temporary and Disability Assistance;
• Two members appointed by the Governor;
• Two members appointed by the Temporary President of the Senate; and
• Two members appointed by the Speaker of the Assembly.  

The Council is to meet at least four times per calendar year to develop recommendations to be submitted to the Commissioner of the Office of Mental Health (OMH) and the Director of the State Office for the Aging (NYSOFA) regarding geriatric mental health needs.

Work Completed in 2006

• Fourteen members of the Council were appointed prior to its first meeting.  The final appointment was still pending clearance.
• The Council met four times during 2006.
• To make recommendations regarding priority areas to be addressed in the context of the demonstration projects, the Council formed three workgroups: (1) Integration, which focused on community integration and integration of services; (2) Screening, Assessment, and Treatment; and (3) Workforce Development, Staff Training, and Information Clearinghouse.  Workgroup reports were presented to the Commissioner of OMH and the Director of NYSOFA at the Council’s September 29, 2006 meeting.

Geriatric Service Demonstration Program

Description

To support the provision of mental health services to the elderly, the Geriatric Mental Health Act called for OMH to establish a geriatric service demonstration program to provide grants, within appropriations, to providers of mental health care to the elderly.  The program is administered by OMH in cooperation with NYSOFA.

Grants may be awarded for purposes which may include one or more of the following:

• Community integration - programs which enable older adults with mental disabilities to age in the community and prevent the unnecessary use of institutional care;
• Improved quality of treatment - programs for older adults which improve the quality of mental health care in the community;
• Integration of services - programs which integrate mental health and aging services with alcohol, drug, health and other support services;
• Workforce - programs which make more efficient use of mental health and health professionals by developing alternative service roles for paraprofessionals and volunteers, including peers, and programs that are more effective in recruitment and retention of bi-lingual, bi-cultural or culturally competent staff;
• Family support - programs which provide support for family caregivers, to include the provision of care to older adults by younger family members and by older adults to younger family members;
• Finance - programs which have developed and implemented innovative financing methodologies to support the delivery of best practices;
• Specialized populations - programs which concentrate on outreach to, engagement of, and effective treatment of cultural minorities;
• Information clearinghouse - programs which compile, distribute and make available information on clinical developments, program innovations and policy  developments which improve the care to older adults with mental disabilities; and
• Staff training - programs which offer on-going training initiatives including improved clinical and cultural skills, evidence-based geriatric mental health skills, and the identification and management of mental, behavioral and substance abuse disorders among older adults.

Work Completed in 2006

• Recommendations developed by three Council workgroups regarding priority areas to be addressed in the context of the demonstration projects were utilized in developing two Request for Proposals (RFPs) to invite eligible applicants to submit proposals for establishing demonstration projects.
• The RFPs, one to establish a Gatekeeper Program and the other to establish a Physical Health – Mental Health Integration Program, were developed by OMH in consultation with NYSOFA and released on December 11, 2006.  The target population is older adults 65 years old and older whose independence, tenure, or survival in the community is in jeopardy because of a behavioral health problem.  A joint review process by OMH and NYSOFA will be used to select successful grant recipients, with contracts expected to be awarded in early 2007.

Recommendations to Improve Mental Health Services for Older Adults

Description

The Commissioner of OMH and the Director of NYSOFA are to jointly report to the Governor, the Temporary President of the Senate, and the Speaker of the Assembly no later than March 1, 2007, and annually thereafter, with a long-term plan regarding the geriatric mental health needs of the residents of the State and recommendations to address those needs.  Recommendations may include those of the Interagency Geriatric Mental Health Planning Council.

Improving Services for Older Adults

In keeping with OMH’s Statewide Comprehensive Plan for Mental Health Services 2006-2010, the overall planning goal is to improve services for older adults, identifying needs and formulating recommendations to address those needs.  The focus of this first annual report is on services/programs that enable older adults with behavioral health problems to age in the community and prevent the unnecessary use of institutional care.  The recommendations below are based on the work of the Council’s three workgroups, and were later endorsed by the Council.  It is recognized that its recommendation are extensive, and many are of a complex nature, therefore, as part of the council’s ongoing efforts, these recommendation will be discussed in greater detail, with the goal of identifying short term versus long term recommendations, and prioritizing items within those categories.

Improving the Availability and Quality of Mental Health Treatment

To address the need to improve the quality of mental health treatment available for older adults, priorities include the early identification of mental health issues, screening, assessment, and – acknowledging the importance of research and translating research into practice – the application of evidence-based and promising practices through interdisciplinary team work.

Recommendations:

• Detect mental disorders and intervene with services before mental health problems become severe and jeopardize community tenure.
• Establish community gatekeeper programs to proactively identify at-risk older adults in the community who are not connected to the service delivery system.  (Gatekeepers are non-traditional referral sources who come into contact with older adults through their everyday work activities.)
• Utilize the PHQ-9 screening tool for depression.  With items that follow the DSM-IV depression category, this tool includes nine criteria assessing clinical depression and has been used in multiple community settings, though most commonly in primary care.  Advantages include rapid administration and easy scoring algorithm.  It can be administered by a health or mental health professional and by other non-medical personnel with some training.
• Identify and utilize screening tools for other mental health conditions.
• Provide or make available a more detailed assessment of late life depression and intervention plans for older individuals who are screened for mental health needs.
• Utilize interdisciplinary team work for effective mental health care management and service delivery in settings where older adults reside (i.e., community urban-rural healthcare settings such as home care and primary care, senior housing, nursing homes, assisted living, and retirement communities).
• Utilize effective evidence-based interventions for late life psychiatric illnesses, such as major depression, minor depression, subthreshold depression, and generalized anxiety disorders.  Evidence-based interventions may include medication or psychosocial interventions or their combination, such as antidepressant medication (SSRIs, SNRIs), problem solving therapy, cognitive behavioral therapy, and interpersonal therapy.
• Though further evaluation of their effectiveness is needed, consider promising interventions for late life depression for their potential innovation, feasibility, and ability to replicate.  Promising interventions include friendly visiting such as might be provided in a naturally occurring retirement community, telephone support, physical activity/exercise, and supportive psychotherapy.

Services Integration

More than half of older adults who receive mental health care receive such services from their primary care physician (see Table 2), the advantages of primary care for older adults including convenience and coordination of mental and medical disorders.  However, no one service system is equipped to address all of the needs of older adults with mental illness.  Improving services coordination and collaboration between and among mental health and physical health providers is a priority.

Recommendations:

• Integrate mental health screening and assessment with physical health care, i.e., primary, specialty, and home health care.
• Screening and referral for assessment, treatment, and support services should be available in locations such as senior apartments, assisted living, retirement communities, naturally occurring retirement communities (vertical or horizontal) and meals on wheels.
• Examine models of integrated physical and mental health care for opportunities to improve care.  Models of integrated physical and mental health care are varied and include co-located primary and mental health care, integrated teams of primary and mental health professionals, care management (including peer medical care management), training for primary care providers, and telepsychiatric support for primary care providers and specialists.

Integrated physical and mental health care is all the more important given a 2006 technical report from the National Association of State Mental Health Program Directors that concluded that people with serious mental illness served by public mental health systems died, on average, 25 years earlier than the general population.

• Address the mental health needs of older adults with chronic disease.  The unmet mental health needs of this population is a complicating factor in chronic disease management.
• Integrate services for older adults with co-occurring mental health, substance abuse, and chronic illness.
• Integrate mental health and aging services to expand mental health education, on-site screening, referral, and on-site treatment.  Aging services programs which offer such opportunities include case management (such as expanded in-home services for the elderly), senior centers, naturally occurring retirement community – supportive service programs (NORC-SSPs), and social adult day care.
• Connect older adults diagnosed with serious mental illness with day programs that integrate health and mental health services using various models, such as wellness programs; primary health care in psychiatric rehabilitation, personalized recovery-oriented services programs, and continuing day treatment programs; adult medical day care and social adult day care adapted to meet mental or behavioral needs; and new models integrating psychiatric rehabilitation approaches with adult medical day care.
• Support recipient wellness self-management practices that help individuals with mental illness cope more effectively and manage their symptoms, prevent relapse, reduce stress, strengthen social relationships, and support their own recovery.
• Include the mental health needs of older adults in discussions of long-term care reform, such as mega waiver, nursing home diversion and transition waiver, and single point of entry for long-term care services.

Community Integration

Reflecting the focus of this annual report, the need to create services that assist older adults lead lives of dignity in the community in both rural and urban settings is a major priority.  The importance of services and programs enabling older adults with behavioral health problems to age in their communities and prevent the unnecessary use of institutional care must be considered.

Recommendations:

• Adapt mental health service delivery strategies to accommodate the unique challenges of providing such services to older adults in rural and urban settings.  In a rural environment, resource options are limited and individuals are more self-reliant and less likely to seek help, except perhaps from their primary care physician.  In urban areas, more options are available although there may not be the sense of community otherwise found in rural areas.
• Address the need for accessible transportation.
• Utilize new models such as telehealth and in-home screening, assessment, and treatment to increase the individual attention to personal health, mental health, and medication that is so important for service delivery to older adults.  These models exist in New York State, particularly in home health care, naturally occurring retirement communities, and meals on wheels programs.
• Develop housing options that are accessible to people with mental and/or physical disabilities – “smart home” technology, for example, and other state of the art options that provide “falls prevention” construction, and ADL and other supports, but also allow independence.
• Adapt community-based psychiatric rehabilitation models for individuals with serious and persistent mental illness to the developmental needs of older adults.
• Make available legal services in order to prevent eviction, obtain government entitlements, obtain home health services, and provide assistance with financial management.
• Make available the humane, end-of-life care needed to make continuing contact with community-based caregivers possible.
• Develop a public awareness and education initiative addressing stigma.

Family Support

Family caregiving is a critical ingredient of community integration that itself requires care and support.  The importance of providing respite and culturally competent psychoeducation and support for family caregivers in a variety of roles needs to be addressed.

Recommendations:

• Provide family support for aging family members caring for younger family members with mental disabilities, for younger family members caring for older adults with physical and/or mental disorders, and for spouses, siblings, and children of older adults with mental disorders.
• Provide culturally competent family support for minority communities.  This is particularly important because many of these communities rarely place family members in institutions.
• Assess caregiver needs during home visits.  Caregivers typically have psychoeducation needs and might benefit from educational offerings regarding older adults similar to those designed for providers.  Local Area Agencies on Aging operate caregiver resource centers across the State.
• Address the need for respite care to benefit both caregivers and those they care for.

Staff/Caregiver Training and Workforce Development

An investment in staff/caregiver training and workforce development (see Table 3) related to helping individuals with geriatric mental health needs is required to implement the priorities included in this report.  These recommendations include providing staff/caregiver education on basic skills and evidence-based practices for older adults with mental illness, assessing training needs, incorporating cultural competency, and providing competency-based skills training for identified staff and non-staff caregivers.

Recommendations:

• Address provider need for education related to screening, making referrals, and otherwise assisting or treating the target populations in health (e.g., primary care, home healthcare, community healthcare), general mental health, and social services (e.g., senior services), settings. 
• Provide training in late life depression management for those who administer depression screening instruments to older adults.  This is very important as the manner and methods employed to administer an instrument have significance on the validity of the screening results.
• Assist primary care physicians increase their knowledge of geriatric mental health.
• Support the effective integration of mental health and aging services by providing adequate training regarding mental health for aging services providers.
• Provide ongoing training and supervision for community agencies on the implementation of specific evidence-based interventions and practices.
• Incorporate cultural competency, awareness, and sensitivity for a diverse and often specialized aging population in developing training or workforce development initiatives.
• Conduct a geriatric mental health training needs assessment for identified staff and non-staff caregivers (such as family members, friends, clergy, and volunteers) in identified treatment, residential, or other settings.  Starting with basics, access and/or develop competency-based core training materials on geriatric mental health skills that can be tailored to the training needs of identified staff and non-staff caregivers.
• Work with professional education programs on curricula development related to geriatric mental health.
• Create incentives, such as loan forgiveness programs, for people to enter the workforce to help individuals with geriatric mental health needs.
• Develop new workforce roles for paraprofessionals and peers, especially older adults.
• Recruit and retain bilingual, bicultural providers and professional interpreters.

Finance

Ongoing financial support and the development of fiscally viable program models is a critical ingredient in the creation of both core and innovative geriatric mental health services and programs that enable older adults with behavioral health problems to age in the community.

Recommendations:

• The financing mechanisms and fiscal viability of services and programs developed for older adults must be considered so that models can be replicated and sustained either by existing systems and resources, or through innovative financing models.
• Develop a cross-agency study group to explore financing models that support evidence-based practices, best practices, and innovation; promote integration; provide parity; and/or create incentives to enhance the workforce.

Comments or questions about the information on this page can be directed to the Bureau of Program and Policy Development/ Special Populations Unit/ Division of Adult Services.