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
 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 CentersHealthy 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…
 highlight recent CDC findings related to the mental health of older
adults;
 identify roles for public health, mental health, aging network
systems to promote older adult mental health;
 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;
 highlight practical information about Medicaid
coverage/reimbursement for evidence-based depression programs
for older adults; and
 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
 Evolution of the public health mission
 Mental health (MH) essential to overall health
 Links between MH and chronic conditions
 Now part of priority setting
Public Health’s Roles
 Monitor MH indicators
 Support development, translation, implementation, and
dissemination of evidence-based programs
 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
 Increase awareness / reduce stigma
 Eliminate health disparities
 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
 Examining MH indicators
 Supporting the translation, implementation, and
dissemination of evidence-based programs
 Sharing what we’ve learned
Using Data for Action
 What gets measured, gets done!
 Needs to be easily accessible
 Data needed for:
 Grant writing
 Planning/priority setting
 Measuring progress
Examining the Data
 2006 Behavioral Risk Factor Surveillance System
(BRFSS)
 Core questions and Depression and Anxiety Module
 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
 Nearly 90% of adults 50+ receive adequate amounts of
support
 Adults 65+ were more likely than those 50-64 to report
not receiving adequate support
 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
 Nearly 95% of adults 50+ reported being “satisfied” or
“very satisfied” with their lives
 Adults 50-64 were more likely than those 65+ to report
being dissatisfied with their lives
 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
 Greater than 90% of older adults do not experience
Frequent Mental Distress (FMD)
 Hispanic adults 50+ reported more slightly more FMD
than other racial/ethnic groups
 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
 Only 7.7% of adults 50+ reported current depression
 Hispanic adults 50+ reported more current depression
than other racial/ethnic groups
 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
 Adults 50-64 reported more Lifetime Diagnosis of
Depression (LDD) than those 65+
 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
 More than 90% of adults 50+ did not report a Lifetime
Diagnosis of Anxiety Disorder (LDAD)
 Adults 50-64 were more likely to report a LDAD
compared to those 65+
 Women 50-64 were more likely to report a LDAD than
men
Next Steps for the CDC Healthy
Aging Program
 Disseminating Issue Brief #1
 Developing The State of Mental Health and Aging in
America Issue Brief #2: Depression Programs and
Resources
 Releasing an interactive data website based on the data
in Brief #1
Next Steps
 Working with state health departments to see what roles
they can play in MH
 Encouraging inclusion of MH questions on BRFSS and
the use of this data by states
For more information
Maggie Moore, MPH
mmoore6@cdc.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
 Background: Evidence-based Practices
 Integration of Mental Health Services in Primary
Care
 Community Outreach
 Technical Support Implementation Resource
Materials
Setting Priorities for Older Adults
Improving Access:
 Integration of Mental Health and General Health
Care
 Home and Community-based Services
Improving Quality:
 Evidence-based Practice Implementation
 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
 PRISMe (SAMHSA-VA)
 PROSPECT (NIMH)
 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:
 Integrated/Collaborative Care
 Co-Located, Concurrent, Collaborative
 Enhanced Referral to Specialty Mental Health and
Substance Abuse Clinics
 Preferred Providers and Facilitated appointments,
transportation, payment
Rates of Engagement in MHSA
Care: By Diagnosis/Condition
(n=2022, mean age 73.5)
Integrated
Referral
Percent Engaged
100%
75%
50%
25%
0%
Overall
Depression Anxiety
At-risk
drinking
Dual
diagnosis
Implications
 Engagement in treatment is substantially
better for integrated MH and Substance
abuse services in primary care
 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
 Collaborative care model includes:
 Care manager: Depression Clinical Specialist
Patient education
Symptom and Side effect tracking
Brief, structured psychotherapy: PST-PC
 Consultation / weekly supervision meetings with
Primary care physician
Team psychiatrist
 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)
Re s pons e (³50% drop on SCL-20 depre s s ion s core from bas e line )
60
P<.0001
50
P<.0001
percent
40
30
P<.0001
20
10
0
33
66
12
12
month
Usual care
Unutzer et al, JAMA 2002.
Intervention
Unützer et al, JAMA 2002; 288:2836-2845.
PROSPECT
Improvement in Depression
(≥50% Drop on HDRS Depression Score from Baseline)
Re s pons e (³50% drop on SCL-20 depre s s ion s core from bas e line )
60
P<.05
50
percent
40
P<.001
P<.001
P<.05
P<.05
P<.05
30
20
10
0
3
4
86
12
12
month
Usual care
Intervention
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
 “Gatekeeper” Model
 Trains community members to identify and refer
community-dwelling older adults who may need mental
health services
 Effective at identifying isolated elderly, who received no
formal mental health services
Florio & Raschko, 1998
 However…no empirical data on depression outcomes
for referral model
Combined Case Identification
and Treatment
 Psychogeriatric Assessment and Treatment in City Housing (PATCH)
program.
 Serving Older Persons in Baltimore Public Housing
 3 elements
 Train indigenous building workers (i.e.,managers, janitors,)
to identify those at risk
 Identification and referral to a psychiatric nurse
 Psychiatric evaluation/treatment in the residents home
 Effective in reducing psychiatric symptoms

Rabins, et al., 2000
RCTs of Geriatric Mental Health Community
Outreach Models
% Recovered from Depression*
70%
60%
50%
40%
30%
20%
10%
0%
Waterreus
Ciechanowski
Intervention
Banerjee
Llewelyn-Jones
Control
* Greater than 50% reduction in symptoms or meeting syndromal criteria
Home and Community
Depression Treatment
For Older Adults
 8 Home-based sessions of manualized problem-solving
therapy (PST) over a 19 week period
 Social & physical activation, pleasant events scheduling
 Clinical supervision by a psychiatrist, recommendations for
medication (if needed) management by phone contact with
physician and/or participant
 Follow-up phone calls (1/month, for 6 months)
PEARLS 12-Month Outcomes: Depression
Symptom Reduction and Depression
Remission
60
50
%
40
PEARLS
Usual Care
30
20
10
0
50% HSCL reduction
Remission
Federal Technical Assistance
Initiatives
 SAMHSA’s Older Americans Substance
Abuse and Mental Health Technical
Assistance Center
 SAMHSA’s Implementation Resource Kits for
Depression in Older Adults
Online Resources
www.samhsa.gov/OlderAdultsTAC/
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/OlderAdultsTAC/
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/OlderAdultsTAC/
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/OlderAdultsTAC/
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 EvidenceBased 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
 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
 Established in 1965 as a companion program to
Medicare
 “Grants to States for Medical Assistance
Programs” ---- Medicaid
 Federal/State entitlement partnership program –
to individuals & States
 Emphasized dependent children and their
mothers, older adults, & individuals with
disabilities
The Beginning of Medicaid
 Initially mostly covered primary/acute health
care services
 LTC limited to Skilled Nursing Facility (SNF)
services – e.g. nursing homes
 Institutional bias - eventual addition of
community-based services---home health,
personal care, home and community-based
services (HCBS) in the 1980s
Medicaid in Brief
 States determine their own unique programs
 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
 Medicaid mandates some services, States elect
optional coverage
 States choose eligibility groups, services, payment
levels, providers
Federal Medical Assistance Percentages
(FMAP) & Enhanced Federal Assistance
Percentages
 Calculated each year for Medicaid/SCHIP
 Reimbursement rate for “services”
 Based on average State income per person and the
nation as a whole
 Minimum 50 percent match rate
 Highest 2007 FMAP: Mississippi, Arkansas, West
Virginia, New Mexico (70%+)
 Enhanced FMAP for some programs/activities
 Indian Health Service facilities – 100 % FMAP
 Additional information at:
http://aspe.hhs.gov/health/fmap07.htm
Key State Plan Requirements
 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
 States must specify the services to be covered and the “amount,
duration, and scope” of each covered service
 States may not place limits on services or deny/reduce
coverage due to a particular illness or condition
 Services must be medically necessary
 Third party liability rules require Medicaid to be the “payer of last
resort”
Additional State Plan Requirements
 Generally, services must be available Statewide
 Freedom of choice of providers
 Enrolled all willing and qualified providers
 Provider qualifications
 Payment for services (4.19-B pages)
 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
 States have options within the Medicaid Program regarding how
they offer case management.
 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).
 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.
 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
 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
 A State may design service packages to meet
the specific needs of the group served in a
waiver.
 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
 In HCBS waivers, States must meet a number of
requirements, including assuring the health and
welfare of individuals served through the waiver.
 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?
 Through 1915(c) Home and Community Based
Services Waivers
States can define the services to be offered under
the waiver.
Case managers often play a pivotal role in
screening, information and referral, and linkages.
Existing HCBS waivers may present a unique
opportunity for an overlay of these interventions.
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?
 States may have another option to consider regarding the
incorporation of these interventions into their Medicaid Program.
 Through a variety of State Plan services
 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.
 The State may also wish to evaluate whether using the
HCBS as a State Plan Option is an option.
 Things to remember: Service must be well-defined, and
should not include a “bundle” of services.
Next Steps
 Contact your State’s Medicaid Agency if you are
interested in discussing how these interventions may
be included in your Medicaid Program.
 The State Medicaid Agency would be the entity in
your State who must submit any State Plan or Waiver
document.
 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 1st
 IMPACT, October 16th
 PEARLS, October 23rd
 Healthy IDEAS, October 29th
 Money Matters, November 13th
 Latest Data, Strategies, Funding, December 2nd
Download any or all of these webinars at:
http://ncoa.org/content.cfm?sectionid=379
Alphabetically listed under “NCOA Presentations”