Strategies for the Aging Network to Address Behavioral Health Jo - - PowerPoint PPT Presentation

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Engage, Assess, Treat: Strategies for the Aging Network to Address Behavioral Health

Jo Anne Sirey, Ph.D. Department of Psychiatry Institute for Geriatric Psychiatry Weill Cornell Medicine

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Funding

Funding

• National Institute of Mental Health - ALACRITY

P50113838, R01MH087562

• NYC Department for the Aging

– Contract# 20191406829 and 20171416622

• No conflicts

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Background: Need for services

• Tremendous mental health need expected with the aging

population

– 20.4 percent of adults aged 65 and older met criteria for a mental disorder, including dementia during the previous 12 months (Karel, Gatz & Smyer, 2012).

• Older adults underutilize mental health services:

– inadequate insurance coverage; workforce shortage; lack of coordination among primary care and mental health providers – stigma surrounding mental health and its treatment; denial of problems; and access barriers (Bartels et al., 2004).

• Older adults often prefer psychotherapy to psychiatric

medications (Koh et al., 2010; Areán et al., 2002).

• Need alternatives to serve the mental health needs of older

adults.

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Why not seek mental health care?

• Depression viewed as a natural part of aging.
• Heterogeneity of depression (doesn’t look as expected)
• Hard to self-identify
• Unaware of the deleterious outcomes

– Leads to disability (Murray et al., 2012) – suicide (Conwell et al., 2010) & non-suicide mortality (Gallo et al., 2005) – excess use of health care, increased placement in nursing homes and higher annual health care costs (Barry, Murphy, & Gill, 2011; Charney et

al., 2003; Eggermont et al., 2012).

• Lack of awareness of available services
• Services not accessible (too far, not in my language, too costly)
• Most important --- beliefs about symptoms and treatment

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• Among persons with objective mental health need,

attitudinal barriers were more common than structural barriers in the WHO International mental health surveys

(Andrade et al., 2013).

– Low perceived need is the most common barrier to access

• Stigma is associated with early drop-out and nonadherence

among depressed ambulatory older adults (Sirey et al., 2001)

• In depressed homebound older adults, older age, race and

greater anticipated stigma was associated with lower likelihood of a mental health referral by aging staff (Sirey,

Franklin, McKenzie, 2014)

Attitudes can drive access

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Depression screening increases detection

• If done systematically, it can reduce bias

– Offered in 26 languages

• Screening tools offers a language to discuss need
• PHQ-9 is a mirrors the DSM-V criteria for depression

– Easily administered – Provide cut-off scores and severity – Can be done as a self-report

• It is not a diagnosis; it is a recommendation for follow-up

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Screening

• Can be done easily, and at any time
• Do not need a mental health background to screen

– Can use PHQ-8 if not want to screen for suicide – Still use 10 or greater to identify major depression

• Cornell offers free on-line training at:

https://mentalhealthtrainingnetwork.org/PHQ

• Track using simple programs like Excel

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Engagement in care: Sometimes screening and a referral is not enough

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Getting into mental health care

Background - - age, gender

• race/ethnicity
• language
• symptoms
• functioning
• medical burden
• cost
• accessibility
• prior experience

Depression identified by community worker or health care professional or family member

Referred for evaluation Depression self- identified Modifiable Individual Factors Attitudes and Beliefs: knowledge and acceptance of depression, perceived need for treatment, stigma Treatment Preferences: desire for type of treatment, desire for type of provider, fears, myths Treatment Expectations: treatment regimen, effectiveness, speed of response, treatment safety

Early Initiation and Treatment engagement and participation

Outcomes

Treatment Decision-Making / Treatment Acceptance

Provider factors

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Can we improve engagement rates?

Building on screening to detect, the goal is to help older adults with depression and suicidal ideation initiate care Goal was to support treatment initiation, a first visit with a provider who can offer care Crossing service systems Challenges include availability of services, but even when available, referrals are difficult

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IMPROVING MENTAL HEALTH TREATMENT INITIATION: THE OPEN DOOR STUDY

(R01 NIMH 079265)

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Open Door intervention

• Open Door is a brief intervention to improve treatment initiation

among homebound older adults with depression

• 3 brief sessions delivered in the home to set a goal, identify barriers,

and support treatment initiation

• Design: Randomized controlled trial where Open Door is compared

to an attention control referral condition

• Sample: Case management clients who screen positive for

depression

• Bronx and Westchester County

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Open Door Intervention

• After research assessment:

1) recommend referral 2) conduct barriers assessment 3) define a personal goal 4) provide education about depression, treatment options and identify preferences 5) Collaboratively problem solve to address the barriers to care.

• Three sessions in the home

– First session is evaluation/baseline assessment and referral – Two additional follow-up visits were brief – Additional telephone call if needed

• Tested in a randomized controlled trial against a control

with a referral and support (same number of visits).

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Open Door results

• Controlling for gender, Open Door and depression severity predicted

treatment initiation (Model Chi square = 14.30, df=2, p=.001). (Sirey et al, 2015)

– 74% of Open Door clients versus 56% of support initiated care

• Among the 43 clients with suicidal ideation, those in Open Door were

more likely to initiate than those clients in the control group (90.9%

• vs. 66.7%, p=.06)
• Initiation rates of Black clients is better than White clients (82.4%

vs.72%) but not significant

• Need and intervention predict initiation

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Summary

• Adding screening into routine assessments or paperwork

increases detection

• However, it requires tracking, and follow up
• Open Door approach is a way of standardizing the

referral process and increase the likelihood of treatment initiation

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New service delivery models: Integrating mental health into aging services SMART-MH TRIO

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SMART-MH

• Arrives in NYC October 29, 2012
• About 17 percent of New York City’s

total land mass, or 51 square miles, was flooded

• Redesign the flood lines in NYC

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Hurricane Sandy –why older adults?

They were :

• trapped in apartments without electricity
• lost services
• poorer communication
• highest mortality

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Sandy Mobilization Assessment Referral and Treatment for Mental Health

• Disaster work has a history of launching new evidence-

based models

• A service delivery project funded by FEMA via a large New

York State Block Grant (1.2 million) to design services

• Partners include New York City Department for the Aging

(DFTA), Aging in New York Fund (503c) & Hunter College

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SMART-MH design

• Service delivery model components:

– Outreach to community (senior centers, faith based communities) – Brief needs assessment – Referral made using Open Door – Offer a brief psychotherapy to adults with depression (PHQ-9)

• Needs assessment data

– PHQ-9 and suicide risk – Storm impact

• Data collected in Chinese, Russian, Spanish or English
• Entered in DFTA database with analysis done with de-

identified dataset

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SMART-MH goals

Identify the current mental health needs of NYC older adults living in areas impacted by Superstorm Sandy (11/1/14-9/31/16) Test a service delivery model

a) To improve identification and engagement among older adults who cannot not access care b) To bring a brief psychotherapy developed from neurobiological models of depression to the community

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ENGAGE therapy - 6 sessions offered

• Engage is a treatment for late-life depression

developed to match the skills of community clinicians

• Based on the theory that depression is associated

with dysfunction in positive valence systems in the brain

• Engage uses "reward exposure" (exposure to

meaningful activities) and assumes that repeated activation of reward networks will normalize these systems.

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SMART-MH Engagement rates

• 12.3% (333/2715) screened positive for clinically

significant symptoms of depression

• Among the 333 individual participants who screened

positive for depression (PHQ-9>10), 102 were already receiving either psychotherapy, medication, or both to address their need.

• Of the remaining 201 individuals, 141 (70.1%) agreed to

receive ENGAGE therapy.

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Sirey et al, Disaster Medicine and Public Health Preparedness, 2015

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ENGAGE Psychotherapy (N=141)

• Delivered in 4 languages
• Most (77%) received 6 sessions of ENGAGE

psychotherapy

• Mean PHQ-9 = 13.78 (SD=3.81) and reduced 7.57 points
• Most of the participants (68.1%) had a 5-point reduction on

the PHQ-9 and a final PHQ-9 < 9

• Reductions comparable to PHQ-9 documented in our clinic

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Depressive symptom reductions (PHQ-9)

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Mixed-effects model for reduction in PHQ-9 scores over the course of ENGAGE therapy

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Lessons learned

• With strong partnerships you can take risks and be

innovative

• Bringing outreach and case identification together with

evidence-based referral strategies and direct ytherapy services allowed us to reach and treat hard to find older adults

• Becomes the prototype for the New York City Department

for the Aging Geriatric Mental Health program funded by ThriveNYC

November 16, 2016 GSA 2016

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https://thrivenyc.cit yofnewyork.us/

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Geriatric Mental Health

• 1 of 2 initiatives targeting older adults
• Roll out mental health services in 25 senior centers
• Mental health includes

– Engagement activities – Assessments – Direct services

• Funding supports clinicians
• Billing for services to build sustainability

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TRIO for Successful Aging

• One of the providers in GMH
• Weill Cornell supports 9 senior centers (Brooklyn and

Staten Island)

• Integrate a bilingual clinician (Polish, Russian, Spanish,

Cantonese) into a senior center 2 days a week

• Centers selected based on size (big) and interest

– Collaborative effort

• SMART-MH model is extended

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TRIO for Successful Aging

Learning more about this population of older adults TRIO is platform for examination of multiple needs

• n elder abuse, palliative care planning, innovative group depression

health interventions

In the past year:

• Talked to 4703 older adults in outreach activities
• Assessed 500 plus older adults
• Delivered 882 individual and group sessions
• 115 sessions monthly
• Worked with staff at Centers

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Need to date based on assessments (N=429)

• Mostly female (68.6%)
• 73.9 years old
• 45.3 live alone,
• 23% Hispanic, 64.8% Caucasian, 19.5% Asian,
• 45% use a cane, walker or wheelchair

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Clinical PHQ-9 positive range 22.9% to 6% mean=15.5% GAD-7 positive range 40.8% to 12% mean=22.7% Endorse hoarding behavior 14.4% Cognitively impaired (MOCA) 34.5%

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Advance Care Planning Needs in TRIO

• Use of the Community-Based Palliative Care Screening Tool as part
• f routine assessments (Ghesquiere et al., 2018) to identify unmet

needs.

• Up to 75% of seniors have unmet PC needs, especially in the domain
• f advanced care planning and goals of care (Koslov, 2018).
• Lower education and higher medical need was associated with

unmet palliative care needs.

• Among clients on Medicaid (N=93), 87% have unmet palliative care

needs

• They had greater medical burden (54.4% >5 medical conditions)

and greater depression (23%) (Chalfin & Scher, 2018)

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Elder Abuse

• High rates of endorsement of being a victim of a type of abuse

16.7% among English speaking center participants (Minor & Sirey, 2018)

• Mental illness, social isolation, and mobility limitations correlated

with elder abuse

• Living with other, lower income, cognitive impairment, and poor

physical health were unrelated in this sample

• Challenge with acknowledging elder abuse among clients who

speak a language other than English

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Summary

• Clinical questions drive research
• Partnerships are fundamental
• Seed money allows the program to be launched
• But thinking about sustainability is critical
• At the individual level
• Screening provides a language to introduce mental health

need, it is an important first step

• Open Door addresses barriers
• At the system level, seamless integration of mental

health is feasible and leads to good outcomes

• Multilingual clinicians are essential in immigrant

community

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Summary

• It is a challenge to integrate mental health into aging

services

• It is a process with the hurdles of time, money and

training

• A chance to address the growing needs of the older

adults population, where they are rather than expecting them to come to us

• Academic/community partnerships and aging/mental

health collaborations offer opportunities

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Thank you! Questions?

jsirey@med.cornell.edu

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