An Outline for the Draft Report of the
Subcommittee on Older Adults

January 8, 2003

The Issues and Their Context

The number of older adults with mental illness is expected to double to 15 million in the next 30 years. Mental illness has a significant impact on the health and functioning of older persons and is associated with increased health care utilization and costs. The current mental health service delivery system is inadequate and unprepared to address the needs associated with the anticipated growth in the number of older persons requiring treatment for late-life mental disorders. This report identifies three policy areas that must be addressed to ensure adequate and appropriate mental health care for older adults: access and continuity of services, quality of services, and workforce capacity. For each area, barriers are identified, model programs are described, and policy options are presented to inform future health care policy.

Barriers that impede access or continuity of care include:

A fragmented service delivery system;

Out of date Medicare policies;

Stigma due to mental illness and advanced age;

A mismatch between services that are covered and those preferred by older persons; and,

A lack of adequate preventive interventions and programs that aid early identification of geriatric mental illness.

Improving quality of services is also a major priority. There is a lack of services that respond to consumer preferences for recovery, a gap between research findings on interventions that are proven to be effective and current practices by providers, and an inadequate research infrastructure dedicated to mental health and aging. Finally, there is a dramatic shortfall in providers with expertise in geriatrics or mental health and aging, and there are inadequate support services provided to informal caregivers.

Three primary policy options are presented. The first highlights the importance of revising policy and reimbursement to improve access and continuity of services by supporting comprehensive outreach mental health services in home and community-based settings where older persons seek services and reside. This will necessitate redesigning the mental health system to respond to the preferences and needs of older persons and the mismatch between covered and preferred services. The second focuses on improving quality of services though a national initiative to implement evidence-based practices in geriatric mental health care. Finally, the third identifies the pressing need to develop a workforce with specialized training in gerontology and geriatric mental health. In addition, seven other options have been developed. These focus on the themes of access and continuity of services (service coordination, Medicare services, stigma and cultural sensitivity, and screening and prevention), quality (mental health and aging research, and promotion of wellness and recovery), and workforce development (caregiver and peer support programs).

Policy Options

This section provides an overview of policy options and actions that address the three identified priorities to improve mental health treatment for older adults:  (1) improve access and continuity, (2) improve quality, and (3) develop workforce and caregiver capacity.  In addition, the Subcommittee has one overarching policy option for National leadership:

• Develop a National Leadership Partnership to Improve the Mental Health Service Delivery System for Older Adults.  With leadership from the Department of Health and Human Services (HHS), develop a national partnership for leadership including the federal government, other public and private sector organizations, consumers, and families.  The improvements needed are broad in scope and can best be accomplished through the combined efforts of all the stakeholder groups.

Improve Access and Continuity of Care

Primary Policy Option

• Support Outreach and Integrated Services. Urge the HHS and its relevant agencies to evaluate programmatic and payment policies to support integrated, comprehensive mental health services in the full range of home and community-based settings where older persons seek services or reside.

Other Policy Options to Improve Access and Continuity of Care

• Coordinate Services.  Urge HHS and other relevant Federal agencies to develop mechanisms to coordinate services across aging network, mental health, general health, and long-term care sectors. HHS should have a particular focus on care management and care plan oversight for community-based services for older persons to include coordination of providers and systems delivering mental health, medical, social, and long-term care services.
• Review Current Medicare Reimbursement Policies. There is concern that the current Medicare system and reimbursement policies have not kept up to date with advances in care and therefore do not provide timely access to mentally necessary care.  If a Medicare prescription drug benefit is contemplated, it is crucial to include psychotropic medications, as they are a key component in the array of mental health treatments.
• Address Stigma and Cultural Sensitivity. Initiate and support a public education campaign under HHS and other appropriate agencies to address stigma and educate consumers, family members, providers, and the public on the identification and promise of effective treatments for mental health problems in older persons. Deliver culturally sensitive and age-appropriate mental health services for older persons.
• Provide Screening and Focus on Prevention. Designate prevention of depression, suicide, substance abuse, and medication misuse in older persons as priority areas for preventive programs and research under appropriate Federal agencies.

Improve Quality

Primary Policy Option

• Implement Evidence-Based Practices. Broaden the current national initiative for dissemination and implementation of evidence-based practices to include an initiative specific to geriatric mental health care.  Particular attention should be focused on collaborative models of care that have been demonstrated to be highly effective in improving access and outcomes for older adults.  These models feature a mental health provider in the primary care setting who provides assessment and clinical treatment services, and coordinates with the primary care provider.

 Other Policy Options to Improve Quality

• Support Mental Health and Aging Research. Support an increased focus within HHS and designate research support infrastructure dedicated to mental health and aging.
• Promote Wellness and Recovery. Services should be designed to incorporate the preferences of consumers in shaping the goals of mental health treatment.

Develop Workforce and Caregiver Capacity

Primary Policy Option

• Develop Workforce Capacity in Geriatrics. Direct HHS, state mental health authorities, and other entities to support an initiative to develop a workforce with specialized skills in providing services to older persons with mental disorders, including psychiatrists, psychologists, nurses, social workers, and frontline service providers.

Other Policy Options to Develop Workforce and Caregiver Capacity

• Enhance Caregiver and Peer Support Programs. Enhance family-caregiver and peer support services