When we say someone is “aging in place” what do we mean? If a person remains in the same home or setting as they age, does that qualify? The New York State Office of Mental Health (OMH) has been exploring this question in the context of the service delivery system, most integrated setting initiatives, such as Olmstead, and the diverse perspectives of individuals living with mental illness. A working, and still evolving, concept of what aging in place means for individuals living with mental illness has started to emerge: Living in a place you consider your home, with friends, neighbors and family, with community-based supports that address changing mental, physical and social needs to sustain a meaningful quality of life.
Aging in Place with Mental Illness: Addressing the Double Demographic Imperative
Certainly, one of the leading reasons for increased interest is the demographic imperative is the sustained growth in older adults that necessitates national policy changes to address the special needs of aging populations. Older adults aging with mental illness creates a double or compounded call to action. Everyone is aging who is alive, and the number of individuals aging into the older adult demographic (65+) in NYS will increase to 4.63 million by 2040, bringing with it an 80% (900,000) increase in older adults with mental illness.1 Further, the percentage of older adults with mental health conditions being diagnosed with a serious mental illness (SMI) that negatively impacts their daily functioning is significantly high. During a one-week survey in 2017, 94% of the 16,381 older adults who received services from New York’s public mental health system were diagnosed with a serious mental illness and 79% reported at least one comorbid health condition.2 Added to the demographic impact, is the well-established body of research showing that individuals living with SMI and Substance Use Disorders (SUD) are at increased risk for accelerated aging and disability.3 For individuals living with SMI, it has been described as a 50-year-old being equivalent to a 75-year-old in terms of daily activity and cognitive functioning.
OMH recognizes that long term care (LTC) services, such as personal care and home health, are key supports that enable individuals living with mental illness to age in integrated settings as well as successfully return to the community after an acute care episode or transition from a more institutional setting. To address the increasing LTC needs of individuals living and aging with SMI, OMH has collaborated with home care agencies and their trade associations to identify opportunities to foster deeper partnerships between community-based long-term services and supports (LTSS) and behavioral health providers. This collaborative work resulted in legislation signed into law on October 1, 2018 that amends language in the Mental Hygiene Law related to the Geriatric Service Demonstration Program to specifically “foster and support collaboration between providers of home care services licensed or certified under article thirty-six of the public health law and mental health providers.” The encouraged collaboration between homecare and BH providers is now codified into NY’s Mental Hygiene Law, setting the foundation for partnerships that foster aging in integrated settings for New Yorkers living with mental illness.
Housing First with LTSS
Inherent in meeting the needs of an aging Boomer population is increasing access to Medicaid funded services and supports that can be provided in the home. OMH outreached to housing providers across the spectrum of OMH residential programs to identify strategies to increase access to community-based LTSS. In particular, OMH’s supportive or supported housing model inherently offers a pathway to successful aging in place through marrying affordable housing with in-home services designed to maximize recovery, independence and community integration. OMH housing providers shared anecdotes of successful collaborations of home care agencies, residential support staff and community-based medical and behavioral health providers and highlighted the significant time this advocacy requires in an often-siloed service system with competing regulations and reimbursement mechanisms. Providers identified the following LTSS needs as being most prominent in their housing programs:
- Housekeeping, personal care, home health care, skilled nursing and specialized therapies, environmental modifications to increase independence, access to elevators, medication management and administration.
- Adapting to a more-independent environment and integrating into community when transitioning • Re-instituting, applying for, and coordinating available benefits across several systems – such as aging; physical health; behavioral health; public benefits including Medicaid, Medicare, SNAP, HEAP; and the Veterans Administration.
- Managing chronic disease(s) and making lifestyle changes
To further understand the LTSS being received by OMH housing residents, OMH reviewed Medicaid service claims for the year 2017 to identify regional, demographic, housing and service type trends. Statewide, only 10% (3,026 residents out of 28,790) cumulatively over the course of 2017 received any LTSS; as approximately 53% (nearly 17,000 residents) of these residents were age 50 or older in 2017, coupled with the known risk of premature aging and disability associated with having a mental illness, it seems unlikely that all OMH housing residents with LTSS needs had them addressed. Regional differences in LTSS received are significant, with OMH’s NYC Region clearly driving up the statewide percentage.
Recognizing some regional variance, preliminary analysis of statewide Medicaid LTSS claims in 2017 shows concentrations in the following demographic and programmatic areas:
- Most fall into the Transitioning Seniors or adults age 55 to 64 years old age category (42%)
- A majority are dually eligible for Medicaid and Medicare (55%)
- Many live in OMH supportive housing (54%), the most independent level of housing designed for permanent living
- Most paid for LTSS through fee-for-service (FFS) Medicaid (34%) or MLTC partially capitated plans (33%)
Statewide in OMH supported housing community service settings, those in FFS trended toward institutional LTSS that required them to leave their residence to receive care in a skilled nursing facility, while those who enrolled in MLTC received nearly all LTSS in the community at their home or nearby neighborhood. In addition, the type of LTSS received varies widely based on managed care enrollment status, with those enrolled in MLTC having received:
- More than double the percentage of home health aide services than received by people with FFS
- Considerably more social and environmental supports designed to maximize independence
OMH shared these findings with OMH Field Offices and OMH housing providers, many of whom shared the difficulty of navigating the MLTC enrollment process and the challenges in connecting with culturally competent homecare staff trained to work with individuals living with mental illness. OMH continues to provide individualized data presentations based on specific OMH region and OMH housing community, demonstrating how to identify potential action areas to increase access to the full range of community-LTSS available as well as homecare and managed care partners who have shown success in providing these services to residents.
OMH has also begun a long-term care pilot project with State-operated residences in Long Island and Queens to identify key elements needed for successful transition and aging in place in community-level OMH housing. A collaborative model of shared responsibility enables OMH housing staff, home care agency and community providers (medical and behavioral) to work together closely to make living in the most integrated setting possible for individuals with serious mental illness.
- New York State Office for the Aging. (2011). County Data Book [Selected Characteristics].
- New York State Office of Mental Health. (2018). 2017 Patient Characteristics Survey [Data Download- Survey Week].
3. Wolkowitz, OM. World Psychiatry 2018; 17(2): 144–145.