2008 Annual Report to the Governor
and Legislature of New York State
on Geriatric Mental Health
and Chemical Dependence

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New York State Interagency Geriatric Mental Health and Chemical Dependence Planning Council

New York State Office of Mental Health
Michael F. Hogan, PhD
Commissioner

New York State Office of Alcoholism and Substance Abuse Services
Karen Carpenter-Palumbo
Commissioner

New York State Office for the Aging
Michael J. Burgess
Director

New York State Division of Veterans’ Affairs
James D. McDonough
Director

March 2009

I: Background

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.

II: Geriatric Mental Health Act Amendments

In 2008, amendments to the Geriatric Mental Health Act expanded the scope of the Council to include chemical dependence and veterans. The amendments (1) changed the name of the Interagency Geriatric Mental Health Planning Council to the Interagency Geriatric Mental Health and Chemical Dependence Planning Council; (2) increased membership of the Council from 15 to 19 members; (3) added the Commissioner of Alcoholism and Substance Abuse Services and the Director of the Division of Veterans’Affairs as Co-chairs of the Council; (5) added the Adjutant General for the State of New York as an Ex-Officio member of the Council; (6) changed requirements for Council recommendations and joint agency annual reports to include the Commissioner of Alcoholism and Substance Abuse Services, the Director of the Division of Veterans’Affairs, and the Adjutant General and to address geriatric mental health and chemical dependency needs.

The expanded Council’s first meeting was held on October 2, 2008 at the New York State Office of Mental Health (OMH).

III: 2008 Highlights

Service Demonstration Projects

Recipients of nine geriatric service demonstration project grants for Gatekeeper or Physical Health – Mental Health Integration programs entered their second contract year in July 2008. All programs were operational in 2008, including one additional Physical Health – Mental Health Integration program not funded with service demonstration project grant monies.

A listing and updated description of service demonstration projects is provided in Section IV of this report.

Medicare Optimization

The 2007 Geriatric Mental Health Annual Report identified Medicare optimization as a priority recommendation and noted: "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. "

Derek Jansen, PhD, a national expert on Medicare, Medicaid, and other sources of federal funding, provided an overview to service demonstration program and State staff in July 2008 of how Medicare funding can be optimized in the demonstration programs. Dr. Jansen’s presentation focused on the opportunities to increase behavioral health and other services provided for older adults by fully utilizing existing Medicare reimbursement policies.

OMH is supporting an initiative to provide technical assistance to recipients of the service demonstration project grants and training to other mental health programs to develop program services that optimize Medicare funding. A fundamental goal of this initiative is to help mental health, health, and aging services providers optimize funding for geriatric mental health services from existing funding streams, with an emphasis on Medicare.

Promoting Integrated Health Care

The New York State Department of Health (DOH) and OMH established new Certification of Need rules in 2008 that promote the integration of primary and mental health care while ensuring appropriate agency lead authority for certification rules and surveillance. For Article 28 hospital outpatient departments and diagnostic and treatment centers, OMH certification will be required at any site that exceeds 10,000 annual mental health visits or where more than 30 percent of annual visits are for mental health services. This is significant as most older adults would prefer to receive mental health care in a primary care setting. In addition,Article 31 mental health clinics will be able to provide up to five percent of their visits for medical services without obtaining DOH certification.

Geriatric Mental Health Website

The Geriatric Mental Health website – http://www.omh.state.ny.us/omhweb/geriatric/ – was developed in 2008 to provide and link the public to information and resources related to geriatric mental health. Part of the OMH website, the geriatric site includes information and resources for caregivers, chemical dependence, community resources, depression, long-term care, mental health publications, prescription drug program, suicide prevention, veterans, and wellness. It also includes information and links related to (1) the Geriatric Mental Health Act; (2) the Interagency Geriatric Mental Health and Chemical Dependence Planning Council; (3) the geriatric service demonstration program; (4) archived annual reports; (5) upcoming and archived web-casts of Council meetings and presentations; and (6) upcoming geriatric conferences and training.

IV: Service Demonstration Projects

Gatekeeper Programs

Gatekeeper programs are 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.

• Family Services of Westchester Family
  Services of Westchester and Westchester Jewish Community Services implemented a Gatekeeper program that targets older adults living in Westchester County who have mental disorders but are not receiving treatment because they have not been identified as in need of mental health services due to a variety of factors. The program has trained police officers, senior center staff, clergy, and others as gatekeepers to recognize, identify, and refer these adults who have behavioral health problems so that they can be assessed and linked to mental health treatment services that will enable them to improve and maintain their independent functioning in the community.
• Onondaga County: Project REACH
  Onondaga County’s Department of Aging and Youth and Department of Mental Health are partners in a Gatekeeper program that seeks out at-risk elderly whose independence and safety may be in jeopardy because of mental health and/or substance use conditions. The program utilizes early intervention and community support to help decrease unnecessary placement in nursing homes or adult residential facilities. Community gatekeepers from National Grid,Time-Warner Cable, and the Syracuse Housing Authority have been trained on such topics as age-related changes, cultural diversity and competence, communication, behavioral/mental health, and how to make a referral to project staff.
• St . Vincent’s – Manhattan: Downtown Gatekeeper Program
  The Downtown Gatekeeper program implemented by St . Vincent’s Hospital and Village Care of New York focuses on socially isolated mentally ill older adults in downtown Manhattan neighborhoods on the Lower East Side and in Greenwich Village and Chelsea. A Gatekeeper Co-coordinator who speaks Cantonese, Mandarin, and Taosanese is able to overcome what would otherwise constitute language and cultural barriers to engagement, assessment, and treatment of older adults in the Chinatown neighborhood. Outreach efforts in the Village and Chelsea include socially isolated lesbian, gay, bisexual, and transgender seniors who often have no adult children or permanent life partner and frequently face prejudice and discrimination.

Physical Health – Mental Health Integration Programs

Physical Health – Mental Health Integration programs are 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.

• Flushing Hospital Medical Center
  Flushing Hospital is expanding the integration of mental health care within the hospital’s primary care clinic to co-locate culturally appropriate services and provide support, outreach, and educational services. The program’s objectives are to de-stigmatize mental illness for people of all cultures over age 65, increase their access to mental health care, increase interdisciplinary collaboration, and promote long life and healthy living. Ambulatory Care Clinic patients over age 65 are screened for depression, anxiety, and cognitive impairments; those who screen positive are assessed; and those who need treatment are offered individual/group therapy, including lifestyle modification, and pharmacotherapy as needed.
• Metropolitan Hospital Center
  Metropolitan Hospital co-located mental health with physical health services in the hospital’s new geriatric outpatient center to primarily serve the underserved, socio-economically disadvantaged, mostly minority populations within East Harlem and other communities in its service area. In support of goals to integrate services and provide one-stop shopping for medical, emotional, and supportive services, current activities include mental health screening in the geriatric outpatient center and for patients over 65 years of age in primary care clinics; additional assessment and social work services based on that assessment; as needed psychiatrist services; and outreach to community centers and other agencies.
• New York-Presbyterian Hospital
  New York-Presbyterian’s Irving Sherwood Wright Medical Center on Aging has begun to co-locate mental health screening, assessment, and treatment services with its existing outpatient geriatric primary care services and to integrate mental health services in its geriatric medical house call program. The program is also implementing a case consultation approach for assessing and treating the mental health needs of elder abuse victims seeking services. Program design includes the utilization of a Geriatric Psychosocial Screening Tool the Center has developed to screen for a range of psychological and social problems undermining the health, mental health and well-being of older adults.
• South Oaks Hospital
  The South Oaks program seeks 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 project’s mental health practitioner is co-located at a primary care physician’s office that now screens patients over 65 for depression and relies on her for additional assessment, treatment recommendations, and/or referral. She is also co-located in offices at Eastern Long Island Hospital and at the Town of South Oaks Senior Services Center, where she provides depression screening and assessment for the local senior population on a weekly basis.
• University of Rochester: GEMM Care Program
  The University of Rochester, Jewish Home of Rochester, and Jewish Family Service of Rochester are integrating physical and mental health care in a homebound, older adult population beginning with initial mental health screening by the primary medical team. Full diagnostic assessments are completed by the mental health team. Mental health services include psychopharmacology, psychotherapy, supportive counseling, and community resource referrals. Interdisciplinary medical and mental health team communication and consultation are coordinated by a mental health case manager and facilitated by regular interdisciplinary team meetings and periodic training sessions. The program is also using the Zarit Caregiver Burden Interview to screen for caregiver burden associated with this population.
• Warren and Washington Counties
  The Office of Community Services for Warren and Washington counties is overseeing the implementation of a collaborative physical and mental health integration program in two large rural counties . A network of federally qualified health centers, a county public health department, a county home care program, and a hospital-affiliated internal medicine practice are collaborating to screen older adults for depression and anxiety, assess those who screen positive, and treat those with mental health issues that need to be addressed. The program also includes a care coordinator who is available to assist patients whose needs or circumstances are particularly complicated or when multiple providers are involved.
• Greene County
  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 consultation, oversight, and evaluation activities designed for the service demonstration projects.

  Greene County’s program is designed to provide mental health assessment and treatment in primary care physician offices to reach people – especially the elderly – who would not otherwise seek or be able to access mental health clinic treatment services. Social workers from the Greene County Mental Health Center clinic are co-located one day a week at four primary care practice sites which screen for depression, anxiety, and alcohol use as a routine part of physical health screening (these sites are also OMH-approved satellites of the clinic). Two psychiatric nurses from the clinic are available as needed, as is psychiatric consultation for primary care physicians currently providing psychotropic medication.

Program Consultation and Oversight

OMH Bureau of Program and Policy Development staff in the Adult Community Care Group continued to provide ongoing program development support for the service demonstration projects in 2008. Bureau staff have responsibilities for assigned projects that include on and off-site consultation and oversight; for example, staff working with the Gatekeeper programs developed a scorable 20-item Gatekeeper Program Assessment Scale (GPAS) to help project staff measure the implementation of their programs.

All service demonstration projects participate in monthly conference calls and in quarterly, day-long learning collaborative meetings with OMH staff. As noted, Derek Jansen, PhD, presented on Medicare optimization at a July 2008 learning collaborative meeting. Stephen Bartels, M.D., Director of the Centers for Health and Aging at Dartmouth Medical School and Co-Scientific Director of the Older Americans Substance Abuse and Mental Health Technical Assistance Center, presented on evidence-based practices in geriatric mental health and consulted with project and State staff at a learning collaborative meeting held in October 2008. The outcome of these consultations has re-focused OMH’s efforts to provide the tools needed to increase staff competency in the provision of evidence-based practices over the remainder of the grant period.

Program Evaluation

OMH Evaluation Research staff in the Office of Performance Management began conducting an evaluation of the service demonstration projects in 2008. Overall, the goals of the evaluation are to assess the implementation of the projects and describe characteristics of and outcomes for, individuals who are served. To promote success, program evaluation data are regularly shared with programs for use in quality improvement efforts. Evaluation activities during the past year included (1) conducting an initial round of site visits to assess progress in implementation; (2) developing an evaluation site visit protocol which focuses on degree of fidelity to program model characteristics; (3) developing and disseminating a standardized evaluation data collection protocol to all programs; (4) initiating data collection processes whereby data are submitted to OMH on a monthly basis; and (5) initiating development of a set of performance indicators to assist programs in quality improvement.

V: Planning

Current and long-term planning to address the geriatric mental health needs of the residents of New York State requires focus on the mental and physical needs of at least two major sub groupings of the geriatric population: (1) the aged with new mental health needs; and (2) aging mental health recipients, whose medical co-morbidity is associated with worse medical outcomes and higher mortality compared with individuals without mental illness.

Because no one service system is equipped to meet the multiple and complex needs of these major sub groupings, the effective provision of services requires collaboration and coordination among providers of aging, mental health, health care, substance use, and social services. It also requires a full range of home and community-based services – such as coordinated or integrated physical and mental health care, outreach and early intervention, caregiver support, and long-term care – and the application of evidence-based practices in models of care that are both cost effective and efficacious across cultures.

Planning is being informed by the geriatric service demonstration projects, reflecting Council discussions in 2008 that urged capitalizing on the projects to identify lessons learned and innovative practices to set the base for geriatric mental health and chemical dependence care in the future. In addition, the Research Foundation for Mental Hygiene is supporting a Geriatric Mental Health and Chemical Dependence Planning Day in 2009 to assist in the development of a long-term plan for the delivery of care to geriatric populations in New York State. Service demonstration project staff and a group of distinguished national experts will be assembled to share research and experiences that will help inform this process.

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.