Older Adults & Mental Health Services

in Iowa

OVERVIEWOVERVIEW

The Business Case

The Historical Record

Vision for the Future

THE BUSINESS CASETHE BUSINESS CASE

Demographic imperativeDemographic imperative

Service Use Service Use

Quality of lifeQuality of life

Financial inefficienciesFinancial inefficiencies

Iowa's Older Adult PopulationN = 436.000

64 65 66 68

81

104

582

452

384370367361

0

100

200

300

400

500

600

700

800

1990 1995 2000 2005 2015 2025

Year

Number of People (in thousands)

Population 85+

Population 65-84

US Census of the Population, 2000

Increasing Number of Older Increasing Number of Older IowansIowans

Mental Illnesses among Older Mental Illnesses among Older IowansIowans

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

2000 2010 2020

SERVICE USESERVICE USE

Community based servicesCommunity based services

Nursing homes & other residential Nursing homes & other residential settingssettings

Community based careCommunity based care

Specialty clinics – CMHCsSpecialty clinics – CMHCs

Inpatient psychiatric hospitalsInpatient psychiatric hospitals

Primary carePrimary care

Community hospitalsCommunity hospitals

County-based mental County-based mental healthhealth

Parkview Center, Sac CityParkview Center, Sac City

Kaskie et al. Study (2007)Kaskie et al. Study (2007)

Few CMHCs target programs towards Few CMHCs target programs towards older adultsolder adults

Little use of CMHCs by older adultsLittle use of CMHCs by older adults

Not a lot of specialty contact Not a lot of specialty contact (< 20% see a specialist in (< 20% see a specialist in outpt setting)outpt setting)

Inpatient Psychiatric Inpatient Psychiatric CareCare

Buckwalter UIHC Study

Admission status 65% Mood Disorder

35% Dementia 50% Mixed

Kaskie et al. (2007) Kaskie et al. (2007)

Not a lot of specialty inpatient Not a lot of specialty inpatient care care

Primary Care

Kaskie Medicare Study

Most common place to obtain careMost common place to obtain care

More than 70% of MH visits in a More than 70% of MH visits in a generalist generalist outpatient office outpatient office

Community HospitalsCommunity Hospitals

Kaskie Medicare Study

Second most common place to Second most common place to obtain careobtain care

Nearly 20% of MH visits in a Nearly 20% of MH visits in a generalist generalist inpatient and inpatient and outpatient services outpatient services

Emergency CareEmergency Care

Not codedNot coded

Care for Co-occurring DxCare for Co-occurring Dx

1 out of 5 = MH dx only1 out of 5 = MH dx only Very little co-occurring MH dxVery little co-occurring MH dx

4 out of 5 = MH + other DX4 out of 5 = MH + other DX

Oakland Estates, OaklandOakland Estates, Oakland

Residents with Mental Illness

58.8 60.6

0

10

20

30

40

50

60

70

80

US

Colorad

o

Illinois

India

naIo

wa

Main

e

Mich

igan

Minn

esot

a

New Jers

ey

Orego

n

Wisc

onsin

Ave

per

Fac

ilit

y

UCSF, 2002

Mental Illnesses in Nursing Facilities

Mental illnesses among NF residents, 2005

Depressed13%

Demented44%

Mixed11%

None32%

Targeted efforts Targeted efforts

Third most common place Third most common place to to receive TXreceive TX

Dementia Special CareDementia Special Care 65 Specialized Care Units65 Specialized Care Units 1,200 beds1,200 beds

QUALITY OF LIFE

Suicide Rate by Age Per 100,000Suicide Rate by Age Per 100,000

0%

5%

10%

15%

20%

25%

15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+Age

Older people: 12.7% of 1999 population, but 18.8% of suicides. (Hoyert, 1999)

October 7, 2000 (AP)

Actor Richard Farnsworth, a former stuntman and two-time Academy Award nominee, died of a self-inflicted gunshot wound Friday night. He was 80.

EXPENDITURES Total Medicare Expenditures: Total Medicare Expenditures:

$211.4 Billion$211.4 Billion Total MH Expenditures: Total MH Expenditures:

$1.2 Billion (0.57%)$1.2 Billion (0.57%) Outpatient Mental Health:Outpatient Mental Health:

$ 718 Million (0.34%) $ 718 Million (0.34%) CMS, 2001CMS, 2001

Medicare Expenditures 1998

99%0%

1%All Other Expenditures

Inpatient Psychiatric

Outpatient Mental Health

Iowa ExpendituresIowa Expenditures

Inefficiencies

Depression in Older Adults and Depression in Older Adults and

Health Care CostsHealth Care Costs

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

0 (n=859) 1-2 (n=616) 3-5 (n=659) 6-16 (n=423)

Levels of Chronic Disease Score

None CES-D<8Moderate CES-D=8-15Severe CES-D>16

Unutzer, et al., 1997; JAMA

Monthly Per Person Costs by Age:Monthly Per Person Costs by Age: Severe Mental Illness Severe Mental Illness

$0

$1,000

$2,000

$3,000

$4,000

15-2

4

25-3

4

35-4

4

45-5

4

55-6

4

65-7

4

75-8

4

85-9

4

95+

Age Groups

Medicaid+Medicare Medicaid Medicare

New Hampshire Total Monthly Costs Per New Hampshire Total Monthly Costs Per Person Over Age 65Person Over Age 65

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000

Schizo

phrenia

Alzheim

er's

Demen

tiaCer

ebro

vasc

ular

Depre

ssio

nH

eart

Fai

lure

COPD

Cardia

cDys

rhym

ias

Oste

oart

hritis

Diabe

tes

Hyp

erte

nsion

Medicaid Medicare

Medicare Expenditures on Medicare Expenditures on Alzheimer’s Disease Alzheimer’s Disease

AD complicates AD complicates treatment of coexisting treatment of coexisting conditionsconditions

Inability to manage careInability to manage care

Hospitalized AD patients Hospitalized AD patients stay longer, cost morestay longer, cost more

20% 22%

28% 27%

0%

10%

20%

30%

40%

50%

Cancer CHF Diabetes COPD

HISTORICAL EFFORTSHISTORICAL EFFORTS

NATIONAL MOVEMENT

2004 – Program Initiative 2004 – Program Initiative

2005 White House 2005 White House Conference Conference

Positive Aging Act Positive Aging Act Reintroduced Reintroduced

May 31, 2005 – Last Wednesday, May 31, 2005 – Last Wednesday, Senators Hillary Rodham Clinton (D-NY) Senators Hillary Rodham Clinton (D-NY) and Susan Collins (R-ME) and and Susan Collins (R-ME) and Representatives Patrick Kennedy (D-RI) Representatives Patrick Kennedy (D-RI) and Ileana Ros-Lehtinen (R-FL) and Ileana Ros-Lehtinen (R-FL) announced the introduction of the announced the introduction of the Positive Aging Act of 2005 to improve Positive Aging Act of 2005 to improve access to mental health services for access to mental health services for America’s senior citizens. America’s senior citizens.

IOWA FORUMS

Quick Fixes (1998)Quick Fixes (1998)

Iowa Mental Health Forum (2000) Iowa Mental Health Forum (2000)

Mental Health System (2001)Mental Health System (2001)

Quick Fixes (1998) Quick Fixes (1998)

Key FindingsKey Findings public mental health system is in public mental health system is in

transition…. transition…. increased use of managed increased use of managed

behavioral healthcare to behavioral healthcare to administer services…. administer services….

ProblemsProblems older adults are not involved in older adults are not involved in

managed behavioral managed behavioral healthcare…healthcare…

data is difficult to obtain…data is difficult to obtain…

Mental Health Forum Mental Health Forum (2000) (2000)

Organizational ChartOrganizational Chart (2000) (2000)

Mental Health Forum Mental Health Forum (2001)(2001)

Older Adults RoundtableOlder Adults Roundtable

Many persons did not know Many persons did not know where to seek help.where to seek help.

Dementia should be included Dementia should be included in in mental health caremental health care

Implement multi-disciplinary Implement multi-disciplinary treatment approaches treatment approaches

Training Efforts (2002)

Training to Enhance ServiceTraining to Enhance ServiceDelivery toDelivery to

Older Adults with Mental IllnessOlder Adults with Mental Illness

Lila Starr, Project OfficerFunding Period:

April 15, 2002 to September 30, 2002

Creston DubuqueOttumwa Spencer

Four Training Sessions (N=268)

Mental Health and Aging: : Programs and Services in the

State of Iowa

Ames, IA

2003

Iowa Public Health Conference

Collaborative Models of Mental Health Care Pilot

Programs

Lila Starr, DHS

2004

Iowa Department Human Services

THE IOWA COALITION ON MENTAL HEALTH AND

AGING April, 2005April, 2005

Three Workgroups Three Workgroups

www.icmha.orgwww.icmha.org

Lyon Osceola

O’BrienSioux

Plymouth Cherokee

WoodburyIda

Monona Crawford

Harrison Shelby

Pottawattamie

Mills

Fremont Page

Montgomery Adams

Taylor

Union

Ringgold

CassAdair

Madison

Decatur

Clarke Lucas

Wayne

Monroe

Appanoose

Warren Marion Mahaska

Wapello

Davis

Jefferson

Van Buren

Henry

Lee

Keokuk Washington

Louisa

Des Moines

Muscatine

Scott

Carroll

Audubon

Greene

Guthrie

Boone

Dallas

Story Marshall

Polk Jasper Poweshiek Iowa Johnson

Cedar

Clinton

Benton Linn

Jones Jackson

Tama

Sac

BuenaVista Pocahontas

Calhoun

Humboldt

Webster

Wright

Hamilton

FranklinButler

HardinGrundy

Bremer

Black Hawk Buchanan Delaware Dubuque

Fayette Clayton

AllamakeeWinneshiek

Clay

Dickinson Emmet

Palo Alto

Kossuth Winnebago Worth

Hancock CerroGordo

Mitchell Howard

Floyd Chickasaw

ICMHA Membership Roster

Calhoun

=10+

= 0

= 1-9

Outreach Efforts – Outreach Efforts – ICMHA Regional MeetingsICMHA Regional Meetings

Fall, 2007 Fall, 2007

-Council Bluffs (Southwest Council Bluffs (Southwest 8) 8) Dubuque (Scenic Valley)Dubuque (Scenic Valley)Sioux City (Siouxland)Sioux City (Siouxland)Waterloo (Hawkeye Valley)Waterloo (Hawkeye Valley)

IOWA COALITION ON IOWA COALITION ON MENTAL HEALTH AND MENTAL HEALTH AND

AGINGAGING

Education and Education and Training Workgroup Training Workgroup

PRIMARY GOALSPRIMARY GOALS

Increase public awareness Increase public awareness about mental health and aging about mental health and aging issuesissues

Expand the supply of qualified Expand the supply of qualified mental health service providers mental health service providers

IOWA COALITION ONIOWA COALITION ON MENTAL HEALTH AND MENTAL HEALTH AND

AGINGAGING

Outreach and Outreach and Clinical Services Clinical Services

WorkgroupWorkgroup

PRIMARY GOALSPRIMARY GOALS Promote mental wellness among Promote mental wellness among

aging Iowans aging Iowans

Increase supply of qualified mental Increase supply of qualified mental health service providers health service providers

Improve access to qualified mental Improve access to qualified mental health service providers health service providers

Integrate mental health services Integrate mental health services into usual places of care into usual places of care

IOWA COALITION ONIOWA COALITION ON MENTAL HEALTH AND MENTAL HEALTH AND

AGINGAGING

Policy & Administration Policy & Administration WorkgroupWorkgroup

PRIMARY GOALSPRIMARY GOALS Promote mental wellness among Promote mental wellness among

aging Iowans aging Iowans

Increase supply of qualified mental Increase supply of qualified mental health service providers health service providers

Improve access to qualified mental Improve access to qualified mental health service providers health service providers

Integrate mental health services Integrate mental health services into usual places of care into usual places of care

VISION FOR THE VISION FOR THE FUTUREFUTURE

HF2780HF2780 In 2006, the Iowa Legislature established the In 2006, the Iowa Legislature established the

Division of Mental Health and Disability Services Division of Mental Health and Disability Services (MHDS) within the Department of Human Services (MHDS) within the Department of Human Services (DHS). With the enactment of HF2780, the general (DHS). With the enactment of HF2780, the general assembly sought a service system for persons with assembly sought a service system for persons with disabilities which emphasizes the ability of persons disabilities which emphasizes the ability of persons with disabilities to exercise their own choices with disabilities to exercise their own choices about the amounts and types of services received; about the amounts and types of services received; that all levels of the service system would seek to that all levels of the service system would seek to empower persons with disabilities to accept empower persons with disabilities to accept responsibility, exercise choices, and take risks; responsibility, exercise choices, and take risks; that disability services are individualized, provided that disability services are individualized, provided to produce results, flexible, and cost-effective; and to produce results, flexible, and cost-effective; and that disability services be provided in a manner that disability services be provided in a manner which supports the ability of persons with which supports the ability of persons with disabilities to live, learn, work, and recreate in disabilities to live, learn, work, and recreate in communities of their choice. communities of their choice.

Mental Health Systems Mental Health Systems Improvement Improvement

With the recent passage of the State's bill, the With the recent passage of the State's bill, the Department of Human Services (DHS) Division of Department of Human Services (DHS) Division of Mental Health and Disability Services (MHDS) form Mental Health and Disability Services (MHDS) form planning workgroups.  These workgroups are to planning workgroups.  These workgroups are to make recommendations to the MHMRDDBI make recommendations to the MHMRDDBI commission, to the DHS director, and the commission, to the DHS director, and the legislature.  The legislation states:legislature.  The legislation states:

"In order to build upon the partnership between the state and the "In order to build upon the partnership between the state and the counties in providing mental health and disability services in the counties in providing mental health and disability services in the state, the workgroups established for purposes of this subsection state, the workgroups established for purposes of this subsection shall engage equal proportions representing the department, shall engage equal proportions representing the department, counties, and service providers.  The county and provider counties, and service providers.  The county and provider representatives shall be appointed by the statewide associations representatives shall be appointed by the statewide associations representing counties and community providers.  In addition, each representing counties and community providers.  In addition, each workgroup shall include a representative of the commission, the workgroup shall include a representative of the commission, the mental health planning and advisory council, consumers, and a mental health planning and advisory council, consumers, and a statewide advocacy organization"statewide advocacy organization"

Bureau of Older Adult Bureau of Older Adult Mental Health Services Mental Health Services

The Bureau of Older Adult Mental Health Services The Bureau of Older Adult Mental Health Services will expand and improve the care provided to older will expand and improve the care provided to older Iowans with mental illnesses and co-occurring Iowans with mental illnesses and co-occurring mental illness and substance use disorders. The mental illness and substance use disorders. The Bureau will provide program administration and Bureau will provide program administration and service management that reflects a commitment to service management that reflects a commitment to principles of accountability, decency, ease of access, principles of accountability, decency, ease of access, respect for self-determination and responsiveness to respect for self-determination and responsiveness to an older individual’s unique situation and personal an older individual’s unique situation and personal preferences. In this manner, the Bureau will preferences. In this manner, the Bureau will establish a compassionate and welcoming culture, establish a compassionate and welcoming culture, and a determination to help older Iowans overcome and a determination to help older Iowans overcome the challenges of aging and live with dignity and the challenges of aging and live with dignity and safety in the communities of their choice. safety in the communities of their choice.

BOAMHS Goal 1BOAMHS Goal 1

Ensure the provision of empathic and Ensure the provision of empathic and welcoming care to older Iowans with welcoming care to older Iowans with mental illnesses and co-occurring mental illnesses and co-occurring mental illness and substance use mental illness and substance use disorders a priority among policy disorders a priority among policy makers, program administrators and makers, program administrators and provider organizations across the provider organizations across the state of Iowa. state of Iowa.

BOAMHS Goal 2BOAMHS Goal 2

Increase the involvement of older Increase the involvement of older adult consumers, their caregivers, and adult consumers, their caregivers, and the general public with improving the the general public with improving the care of older Iowans with mental care of older Iowans with mental illnesses and co-occurring mental illnesses and co-occurring mental illness and substance use disorders. illness and substance use disorders.

BOAMHS Goal 3BOAMHS Goal 3

Increase the number of qualified Increase the number of qualified providers of evidence based mental providers of evidence based mental health and substance abuse services health and substance abuse services targeted towards older Iowans with targeted towards older Iowans with mental illnesses and co-occurring mental illnesses and co-occurring mental illness and substance use mental illness and substance use disorders. disorders.

BOAMHS Goal 4BOAMHS Goal 4

Develop early identification and Develop early identification and prevention programs targeting older prevention programs targeting older Iowans with mental illnesses and co-Iowans with mental illnesses and co-occurring mental illness and occurring mental illness and substance use disorders.substance use disorders.

BOAMHS Goal 5BOAMHS Goal 5

Increase the provision of specialty Increase the provision of specialty and emergency mental health and emergency mental health services to older Iowans. services to older Iowans.

BOAMHS Goal 6BOAMHS Goal 6

Establish a statewide system of care Establish a statewide system of care in which qualified mental health in which qualified mental health providers can serve older adults with providers can serve older adults with mental illnesses or co-occurring mental illnesses or co-occurring mental illness and substance use mental illness and substance use disorders through a referral or co-disorders through a referral or co-location process that upholds the location process that upholds the principle of “no wrong door”principle of “no wrong door”

BOAMHS Goal 7BOAMHS Goal 7

Establish an administrative culture, Establish an administrative culture, which upholds principles of which upholds principles of continuous quality improvement continuous quality improvement

Where do things stand? Where do things stand?

THANK YOUTHANK YOU