Geriatric Mental Health
2007 Annual Report
To The Governor and Legislature of New York State

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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 an Interagency Geriatric Mental Health Planning Council, a geriatric service demonstration program, and a requirement for an annual report to the Governor and the Legislature with a long term plan regarding the geriatric mental health needs of the residents of New York. In this report we focus and build upon the priorities identified in our initial report.

Interagency Geriatric Mental Health Planning Council

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.

With two new Co-chairs – Michael F. Hogan, PhD, Commissioner of the New York State Office of Mental Health (OMH), and Michael J. Burgess, Director of the New York State Office for the Aging (NYSOFA) – the appointed members of the Council met during 2007 to develop annual recommendations regarding geriatric mental health needs. Council meetings also included overviews of the first geriatric service demonstration program grants to be awarded, discussions of planning and prioritized recommendations, NYSOFA presentations on a single point of entry for long term care in New York State and on assisted living, and State agency summaries of their work with older adults.

Geriatric Service Demonstration Program

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 in order to support the provision of mental health services to the elderly. The program is administered by OMH in cooperation with NYSOFA.

In January 2007, an agency record number of proposals were received by OMH in response to Requests for Proposals for “Gatekeeper Program” and “Physical Health – Mental Health Integration Program” geriatric service demonstration project grants.

• A Gatekeeper Program is designed 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.
• A Physical Health – Mental Health Integration Program is designed to provide physical and mental health care for older adults whose independence, tenure, or survival in the community is in jeopardy because of a behavioral health problem; it entails either the co-location of mental health specialists within primary care or the improvement of collaboration between separate providers.

A total of 66 proposals were evaluated and scored in a process that involved integrated teams of OMH, NYSOFA, and New York State Department of Health reviewers. Subject to appropriations, awards totaling approximately $2,000,000 a year for five years were made in April 2007 for the three Gatekeeper programs and six Mental Health/ Physical Health Integration programs described below. The Office of the State Comptroller approved the procurement in August 2007.

Gatekeeper Program Grant Awardees

• St. Vincent's, Manhattan

  Working in partnership with Village Care of New York and with significant help from building superintendents and Chinatown community based agencies, St. Vincent's – Manhattan Downtown Gatekeeper Program seeks to reach those at greatest risk, socially isolated mentally ill older adults. The program plans to capitalize on the clinical skills and outreach capabilities of its partners to identify, establish trust, and initiate help for socially isolated seniors with mental illness living in downtown Manhattan neighborhoods. Merchants, building superintendents, home repair volunteers, and emergency department staff will be trained as gatekeepers and receive ongoing coaching, support, and individual case feedback.

• Family Services of Westchester

  Family Services of Westchester is the lead agency representing the Westchester Geriatric Mental Health Coalition, whose key partners are Westchester Jewish Community Services; Weill Cornell Institute of Geriatric Psychiatry; and the Westchester County departments of Senior Programs and Services, Public Safety, and Community Mental Health. The program plans to train police officers and senior center staff as gatekeepers to recognize, identify, and refer adults with behavioral health problems so that they may be assessed and linked with needed services. The approach is based on a successful Westchester County inter-departmental training initiative on elder abuse. Full-time staff dedicated to the program will receive referrals, ensure linkages, and oversee the community response system.

• Onondaga County

  The Onondaga County Department of Aging and Youth/Office for the Aging and the Onondaga County Department of Mental Health are partners in establishing a Gatekeeper program replicating the original Gatekeeper Program in a county with both rural and urban populations. Building on prior initiatives to identify high risk elderly populations, the project has developed partnerships with agencies and businesses whose daily work brings them into contact with older adults, including major local cable and public utility providers, law enforcement, and apartment and mobile home court managers. The program plans to establish a formal process enabling gatekeepers to complete a referral with one phone call.

Physical Health – Mental Health Integration Program Grant Awardees

• Metropolitan Hospital Center

  In partnership with the Jewish Board of Family and Children's Services, Metropolitan Hospital Center will co-locate mental health with physical health services in the hospital's new geriatric outpatient center to primarily serve the underserved, socio-economically disadvantaged, mostly minority communities within its East Harlem, Northern Manhattan, South Bronx, and West Queens service area. Mental health services will include pharmacological interventions, as needed individual and family counseling, and group counseling to assist seniors in dealing with chronic diseases, alcohol abuse, and depression. The program plans to employ a coordinated chronic care management model to facilitate integration of care and evaluate treatment outcomes.

• Flushing Hospital Medical Center

  The Department of Ambulatory Care and the Department of Psychiatry and Addiction Services at Flushing Hospital Medical Center will expand the integration of mental health care within the hospital's primary care clinic to co-locate culturally appropriate services, provide on site case management and support services, and implement outreach and educational programs. The program expects that the provision of culturally competent integrated health care will better serve and help establish a medical home for the culturally diverse geriatric population that lives in the eight unique racial and ethnic neighborhoods in Queens that comprise the hospital's service area.

• New York-Presbyterian Hospital

  On the Weill Cornell Medical Center campus of New York-Presbyterian Hospital, the Irving Sherwood Wright Medical Center on Aging will co-locate mental health screening, assessment, and treatment services with its existing outpatient geriatric primary care services. The program also plans to integrate mental health services in the Wright Center's geriatric medical housecall program, which provides primary care for homebound older adults, and to implement a case consultation approach for assessing and addressing the mental health needs of elder abuse victims referred by the Weinberg Center for Elder Abuse Prevention, a shelter providing services to elder abuse victims.

• Warren and Washington Counties

  The Office of Community Services for Warren and Washington counties will oversee the multi-site implementation of a health integration program that combines both integrated and coordinated models of care in two rural counties covering an area of 1,775 square miles. Contracting with a network of federally qualified health centers, the program will increase the capacity to provide site based integrated primary and mental health care and create the capacity to provide mobile integrated primary and mental health care for older adults living in the community. The program also plans to conduct cross systems care coordination meetings for individuals with particularly complex physical and mental health needs, provide consultation to community providers, and conduct in-kind home based mental health assessments.

• University of Rochester

  To address the physical and mental health needs of homebound elders in Rochester and its suburbs, the Older Adults Service of the Geriatric Psychiatry Program at the University of Rochester established partnerships with the Jewish Home of Rochester and Jewish Family Service of Rochester to deliver integrated physical and mental health assessment and/or treatment to homebound elderly in their own homes. Training and resources provided by the Older Adults Service and Jewish Family Service will be added to the Jewish Home's new geriatric primary care home visit practice to improve the mental health case finding skills of primary care providers, mobilize psychiatric assessment, bring treatment to the home, and provide continued counseling, care coordination, and outcome monitoring.

• South Oaks Hospital

  South Oaks Hospital plans to work with Eastern Long Island Hospital, the Town of Southold, and the Mental Health Association in Suffolk County to increase access to mental health services and improve the integration of physical and mental health care for older adults on the North Fork of Long Island. The program will hire a mental health practitioner to provide screening, assessment, and referral to mental health services for residents in their homes, primary health care offices, Eastern Long Island Hospital, and the Town of Southold Senior Services Center. Contracts with partners will support project marketing, senior center transportation, and a support group.

Though not funded with monies allocated to the geriatric service demonstration program, Greene County is implementing a Physical Health – Mental Health Integration Program at the initiative of its Department of Mental Health and participates fully in OMH evaluation, consultation, and oversight activities designed for the service demonstration projects.

• Greene County

  The program design involves the co-location of an LCSW from the Greene County Mental Health Center for one day per week in a rural primary care physician's office and another LCSW for one day per week in a primary care physician's office in Catskill. Services offered include case consultation, screening, assessment, and short term mental health treatment. A Senior Care Coordinator is overseeing the implementation and operation of the program.

Program Evaluation

Success of the geriatric mental health grant projects is contingent upon successful program implementation. In July 2007, OMH evaluation and research staff presented an overview to the Council of how they plan to evaluate the service demonstration projects in the following areas:

Implementation

• Develop an organizational implementation fidelity scale;
• Monitor fidelity to the implementation model over time;
• Identify challenges, facilitators, and strategies in advancing through implementation stages and in establishing core implementation components; and
• Examine relationship between organizational implementation fidelity and client outcomes.

Outcomes

• Identify a minimum set of outcomes to be collected across projects and within project type;
• Support programs in developing methods for collecting outcome data; and
• Establish a monthly telephone conference call for awardees to share and discuss outcome data, current status, and lessons learned.

Implementation and Oversight Activities

OMH Bureau of Program and Policy Development staff in the Adult Community Care Group initiated implementation consultation and oversight activities with a day-long grant awardees meeting in October 2007. Bureau staff have responsibilities for assigned projects and have since visited each site to support program development. All service demonstration projects participate in monthly conference calls and in scheduled face-to-face meetings on a quarterly basis with OMH staff.

Priority Recommendations

Last year's Geriatric Mental Health Annual Report included a large number of recommendations based on the initial work of the Council and its workgroups. This year, however, in considering the current and long term geriatric mental health needs of the residents of New York State, those recommendations have been prioritized to four:

• Depression Screening Education for Primary Care Physicians

  Conduct a statewide education and training program designed to improve depression screening conducted by primary care physicians and physical health providers who serve older adults in New York State. OMH, in collaboration with NYSOFA, would implement a training plan to (1) establish regional partnerships with physical health providers; (2) conduct a series of regional training forums on depression screening; (3) provide ongoing training, consultation, and supervision as requested; and (4) compile, distribute, and make available information about routine screening for depression and other mental health disorders for older adults.

  The prevalence of depression in this population is substantial, with an estimated 20 percent of older adults experiencing symptoms of depression. Several studies have found that many older adults who die by suicide – up to 75 percent – have visited a primary care physician within a month of their suicide; nearly one half had a physician visit within a week of their suicide. These findings point to the urgency of improving the detection and treatment of depression as a means of reducing suicide risk among older persons.

  Primary care physicians often report a lack of knowledge about mental health problems in older adults. Inadequate recognition and treatment of depression has important implications for social services, medical, and mental health service use, and for the allocation of health care resources.

  There are various screening instruments that can be used to identify the mental health needs of older adults, particularly depression and anxiety. These include, but are not limited to, the Patient Health Questionnaire (PHQ-9), Geriatric Depression Scale, the Center for Epidemiological Studies Depression Scale, the Cornell Scale for Depression in Dementia, the Clinical Anxiety Scale, the Beck Anxiety Scale, and the Worry Scale for Older Adults.

• Medicare Optimization

  The financing mechanisms and fiscal viability of services and programs developed for older adults must be considered so that services can be replicated and sustained. Medicare represents a relatively underutilized source of fiscal support that should be more fully utilized, especially in consideration of the upcoming elder boom.

  Strategies include (1) the optimization of reimbursement and identification of the full array of mental health services that can be provided with Medicare support, (2) the provision of technical assistance to providers on billing Medicare services, and (3) the exploration and assessment of demonstration/waiver options that may be appropriate for an older adult population.

• Service Demonstration Projects

  The geriatric service demonstration program established by the Geriatric Mental Health Act should be continued, and the types of projects currently being funded (Gatekeeper and Physical Health – Mental Health Integration programs) should be expanded to other areas of the State.

• Center for Excellence

  The establishment of a Center for Excellence in Geriatric Mental Health could directly and indirectly support work related to the three priority recommendations above. Core functions of the Center would include (1) training in geriatric mental health practices for mental health and aging services providers to help build capacity to serve older adults with mental disorders and (2) workforce development initiatives to recruit and retain culturally competent staff.

  In addition to staff training and workforce development, other possible functions include interfaces with professional education, technical assistance, and serving as an information clearinghouse.

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.