Major changes to the behavioral health system in New York State are underway at the same time that there is rapid growth of the population of older adults. Will the transformation of the behavioral health system benefit older adults? It could, but it is not at all clear that it will because there has been virtually no attention given to the special needs of older adults with mental or substance use disorders.
What Changes Are in the Works?
One of the major goals of system redesign is to help people avoid or delay institutional care in hospitals and nursing homes by better coordinating services. NYS’ Medicaid reform efforts toward this end are vast and complex. The major Medicaid shifts that will have the greatest impact on older adults with mental health and/or substance abuse diagnoses include:
- FIDA (Fully Integrated Dual Advantage): The FIDA Program, an ACA demonstration opportunity, will provide a comprehensive package of services and coordinate all care, including behavioral health services, for individuals in the downstate region (New York City, Westchester, Nassau and Suffolk counties) who are dually eligible and are in need of 120 days or more of long-term care services. Many of the individuals served in the FIDA demonstration will be older adults with co-morbid physical and behavioral health diagnoses that will require careful care coordination.
- Mainstream Managed Care Organizations (MCOs) and HARPS (Health and Recovery Plans): MCOs and HARPs will manage care for Medicaid-only beneficiaries with serious and persistent mental illness. While the MCOS and HARPS will not cover dual eligibles and the vast majority of older adults are on Medicare, the plans will be serving an older cohort of adults (55 and over) who are experiencing medical and functional challenges that are more typical of an older adult population. This will require coordinated care with other systems including home health, day programs, and aging services.
- DSRIP (Delivery System Reform Incentive Payment): DSRIP is a Medicaid payment and system reform effort that will develop provider systems to implement projects aimed at decreasing hospitalizations by 25% over a period of 5 years. Given that older adults with poorly addressed complex needs are at high risk for emergency room and inpatient admissions (and readmissions), they are a clear target population for some of these reform projects, requiring sophistication with identifying and treating their behavioral health conditions.
Special Needs of Older Adults with Behavioral Health Conditions
Physical Needs: Older adults with chronic physical and mental disorders have different needs and challenges than younger populations with complex conditions. Normal physical age-related changes, such as sleep problems, declines in vision and/or hearing and/or mobility may require older adults to modify their activities and/or environment to adapt to these changes. Modest environmental modifications may be needed to help older adults remain at home independently. Vision, cognitive, and physical changes increase the risk of falls among older adults, which are often due to hazards that are easy to overlook. The risk of medical illnesses, particularly chronic conditions, increases with age, therefore requiring effective and integrated medical management. Good nutrition and exercise become particularly important for older adults to reduce their risk of chronic disease, lower their body weight, and improve their overall quality of life.
Psychological Needs: Dementia, which doubles every five years after the age of 60, so that nearly half of those over the age of 85 have a cognitive impairment, leads to memory loss as well as loss of executive and other functioning that interferes with the ability to manage activities of daily living. Importantly, older adults with long-term psychiatric disabilities are just as likely as their peers without serious mental illness to develop dementia as they age. Therefore, they experience additional cognitive impairment, which can make it increasingly difficult to manage activities of daily living.
Depression and Anxiety: While depression and anxiety are somewhat less common among older adults than in the general population, depression frequently co-occurs in older adults with dementia, with long-term psychiatric disabilities, with chronic physical conditions, with reduced social networks, or with reduced quality of life. Both depression and anxiety disorders are associated with increased health care utilization, poorer health outcomes, and increased functional disability; however, a majority of older adults who experience depression and anxiety disorders do not receive mental health services in traditional settings, so it is imperative that older adults are able to access services where they need to receive them, such as in primary care, aging services programs, and in long-term care.
Suicide is a major concern among older adults. They are 50% more likely to take their own lives than the general population, particularly white men of over the age of 85. Suicide is also part of the reason for the lower life expectancy of people with long-term psychiatric illness, as some adults living with psychiatric disabilities complete suicide before achieving older age. A number of factors increase the risk of suicide for older adults, including depression and other mental disorders, co-morbid physical illness, social isolation, and feeling a lack of meaning or purpose in life, among other risk factors.
Recovery, a core value in the mental health system, is as relevant and possible for older adults as it is for younger populations. Unfortunately, age discrimination leads to the false perception that older adults cannot recover and/or learn new skills. The concept of recovery for older adults should not focus primarily on attaining hope, which is more relevant for earlier developmental phases, but rather achieving integrity, which is more appropriate for the older generation. The attainment of integrity focuses more on acceptance of one’s life, a sense of current meaning in one’s life, which can be influenced by engagement in valued relationships and activities and interest in guiding future generations more than on personal future achievement. Recovery for older adults should also include the goal of living in a setting, often in the community, that promotes optimal functioning and independence.
Older adults experience a number of normal developmental transitions as they age. How these transitions are experienced and managed are critical to successful aging, which we define as older adults’ ability to feel good about their lives, even as they live with physical, emotional and social challenges. Typical developmental transitions may include voluntary and non-voluntary retirement from employment; loss of family and/or friends; shifting social and familial roles; diminished cognitive and/or physical abilities; spiritual concerns; and confronting end-of-life. Dealing with these transitions as part of programming will help support older adults’ physical and mental wellness.
Death and dying, a reality for older adults, unfortunately is rarely dealt with openly but requires careful end of life planning to prepare for properly. Preparation includes helping older adults manage their needs and wishes for end of life care, but also for helping them meet the developmental task of addressing mortality in the first place. Grief is a common problem for older adults because they are more likely to experience the deaths of family and friends as they get older. Grief, while not a mental disorder, often leads to additional mental and emotional challenges.
As people age, staying connected with family and friends and avoiding isolation is also important for well-being. Some older adults with long-term psychiatric disabilities may have close family relationships, while others have been estranged from their family and may want to reconnect. Many adults with long-term psychiatric illnesses often rely on their family members, especially parents and siblings, for support throughout their lives. Therefore, they risk losing this primary support as they get older and their family members have less ability to provide care or die. Helping older adults with long-term psychiatric disabilities connect to community supports and develop additional relationships – or strengthen existing relationships, where possible – can be particularly critical as they enter older age.
Leisure activities, which are often associated with retirement, may be particularly important for those older adults who are no longer employed. They include various activities such as the arts, cooking, gardening, exercise, religious practices, education, and more. Some older adults want to participate in volunteer work as opposed to paid employment. Volunteer work can be formal, such as within an organization, or informal, such as time spent helping a neighbor or friend. Some older adults want to engage in programming offered for their age cohort. Senior centers, for instance, offer an opportunity for older adults to access social services; education, recreational, and wellness activities; and socialization. Additionally, older adults are more likely than younger adults to be concerned with religion and spiritual issues. Being a part of a religious community is a way for older adults to stay connected and explore the meaning, value, and purpose of their life.
Social and Economic Needs
Older adults often face financial problems because pensions – or public assistance – are generally not enough to live on. Also, there are housing issues related to the possibility of aging in the community rather than in institutions. While there is specialized housing for adults living with psychiatric disabilities, such as supported housing and community residences, these are not designed to meet the needs of an aging population. Conversely, housing designed for older adults, such as senior housing, supportive housing and assisted living, are not designed to address behavioral health. As older adults with behavioral health needs increasingly live in the community, issues of cost, safety and accessibility, among other concerns, will need to be considered.
Recommendations for the Design of the New Systems
In order for system redesign efforts to effectively deliver and coordinate care for older individuals with co-morbid physical and behavioral health conditions, planning efforts must consider these unique needs, challenges, and interests of the population. Efforts should include:
- Establishing an MRT committee to identify and integrate the different needs and goals of the older adult cohort in both preparation and implementation plans
- Ensuring the NYS Geriatric Mental Health and Chemical Dependence Planning Council follows and evaluates the impact of health care reform on older adults with behavioral health issues.
- Gathering epidemiological and demographic data that is as localized as possible to ensure effective targeting and concentration of services, such as: identifying the number of older adults with behavioral health conditions impacted by particular reform changes
- Coordinating services across medical, behavioral, and social service delivery systems. This includes long-term care supports and services delivered by the aging service system
- Engaging and supporting the perspective and needs of family and other caregivers
- Incorporating the concept of “recovery” across reform efforts, particularly for older adults with long-term psychiatric disabilities that are being served in systems that do not have a recovery orientation, as long-term care and aging services are largely not built using a recovery framework
- Delivering training for care managers and other key staff so they have the skills to assess, recognize, and respond to relevant mental, physical, and cognitive changes among older adults
The specific issues facing older adults with mental health and substance abuse problems deserve careful attention and planning in the newly reformed behavioral health system. They have been neglected. Without recognizing these challenges and without making certain that the needs of older adults are suitably addressed, we not only risk the success of reform efforts and diminished quality of life for older adults, but we continue to promote an ageist society that fails to care and support the most vulnerable among us.
Kimberly Williams is Vice-President of Integrated Policy and Program Solutions of The Mental Health Association of NYC. She is also the Co-Founder and Director of the Geriatric Mental Health Alliance (GMHA) and Chairs the National Coalition on Mental Health and Aging. Lisa Furst is the Director of Education for the GMHA and the Director of the Center for Policy, Advocacy and Education of the Mental Health Association of NYC. Michael B. Friedman is the Co-founder and Honorary Chair of the GMHA. He is on the adjunct faculty of Columbia University School of Social Work.