The first wave of the baby boom generation turns 65 this year. In New York State, the number of older adults will grow 50% over the next twenty years from 2.7 million in 2011 to 3.9 million in 2030. 20% of these individuals have diagnosable mental and/or substance use disorders. As a result of this population growth, the number of older adults with mental disorders in New York State will grow from 540,000 to 780,000. Are we ready to confront the mental health challenges of this demographic shift?
Over the past few years, we have made some important strides in NYS to prepare for the mental health needs of the elder boom. We have the nation’s first Geriatric Mental Health Act, landmark legislation that is leading the way in addressing the unmet mental health problems of older adults. The Act’s Interagency Geriatric Mental Health and Chemical Dependence Planning Council, which is chaired by the Commissioners of the Office of Mental Health, Office for the Aging, Office of Alcohol and Substance Abuse Services and Division of Veterans Affairs with representation from six other state departments as well as six public appointments is conducting long-term planning regarding the mental health needs of older adults. NYS provides $2 million per year for the Act’s service demonstration programs—innovative community-based projects in two areas, (1) integrating mental health into primary care and (2) educating and training community gatekeepers to identify at-risk older adults and connect them with services. An effort is also underway to assist these projects to structure their services and billing systems to bring in entitlement funding, mostly Medicare, so they can become financially sustainable once the grant funding ends. Important regulatory changes, such as the lifting of Medicaid neutrality, have also paved the way for potential significant service expansion. In New York City, The City Council has recognized the critical need for more geriatric mental health services by providing over $12 over the past six years to fund the expansion of community-based mental health services for older adults in non-traditional settings. A range of diverse supports have been mounted including mental health education; outreach and engagement; screening, assessment and onsite treatment or referral; supports for family caregivers, and more.
Although we have had some significant accomplishments in New York State, for which we should be proud, the elder boom is here, and we are not yet ready. We still have, as the saying goes, “miles to go before we sleep.” We need more meaningful planning and substantial expansion and restructuring of services to adequately prepare for the increase of geriatric mental health problems over the next several years. Our goals should be to:
- Enable older adults with mental health and/or substance use problems to age in the community
- Improve access to services through service expansion and by offering more services in the home and community-based settings where older adults congregate such as senior centers and NORCs (naturally occurring retirement communities)
- Enhance quality of care and treatment in the community and in long-term care facilities
- Integrate health, mental health, and aging services to provide comprehensive, coordinated care tailored to the needs of the individual
- Build a workforce of clinically and culturally competent mental health, health and aging service providers and more extensively engage older adults in peer-to-peer service roles
- Provide support for family caregivers
- Provide public education and outreach to address ageism, stigma, and lack of knowledge of and fears about treatment and its effectiveness
- Improve research on effective prevention, intervention, and recovery support strategies
- Design finance models that support best and innovative practices, integrated service delivery, and incentives to enter, and remain in, the workforce
- Promote governmental and private sector readiness including dedicated leadership, interdepartmental planning, and program development
Given the current economic restraints, accomplishing these lofty but critically important goals will be exceedingly difficult. We have great challenges ahead, but we also have reason for hope.
At the federal level, mental health parity in Medicare will be fully implemented in 2014, which will support expansion of geriatric mental health services. In addition, federal health care reform offers opportunities for better mental health care for older adults. It improves coverage of physical health care, which will benefit older adults with co-occurring mental and physical health disorders. There is also improved coverage of mental health services, expanded integration of health and mental health care, and enhanced long-term provisions. Ensuring the success of health care reform, however, will be difficult, to say the least.
In NYS, the health and mental health care systems are experiencing additional reform of their own. Out-patient mental health clinics are undergoing programmatic and fiscal restructuring, and a newer form of programming called Personalized Recovery Oriented Services (PROS), which focuses on recovery and rehabilitation, has been expanding in recent years. With this restructuring, we need to be sure that services effectively meet the clinical and programmatic needs of older adults and are fiscally sound so they can result in increased service capacity for the geriatric population.
Medicaid is also being re-conceptualized. In an effort to help close a $10 billion budget gap, NYS Governor Cuomo has formed a Medicaid Redesign Team to find ways to cut cost and improve efficiency in the program. Geriatric mental health initiatives can help. For example, long-term care services for older adults and individuals with disabilities are a major driver of Medicaid costs. What is rarely understood, however, is the high prevalence of mental illness among individuals with long-term care needs and the extent of unnecessary placements in expensive institutional settings due to the failure to address mental health issues of those who are disabled and of their families, who are at high risk for mental disorders that limit their ability to provide the care their family members need to remain in the community. In reforming Medicaid, we must see to it that mental health is effectively integrated into long-term care restructuring efforts so as to reduce cost and improve the quality of life of older adults both now and in the years ahead.
We should also optimize the use, and fight for the preservation, of the existing structure and leadership of the Geriatric Mental and Chemical Dependence Planning Council. With the Governor’s Commission to reduce the size of government by 20%, the continuation of the Council, although established by law, is not at all certain. The Council’s work is not yet done, and its efforts to foster interagency coordination and ensure effective service delivery for older adults are all the more vital as the population grows over the next several years. The geriatric mental health demonstration programs are also providing us with significant insight about successful organization and delivery of care. Their continuation and expansion will be important for the dissemination of state-of-the-art models that support older adults with mental disorders to age in the community across the state.
It’s an uncertain time, but a critical time for us to be rethinking the structure and financing of health and human services. As we confront the challenges and seek opportunities for progress in the midst of crisis, all of us who care about the mental health of older adults will need to be vigilant and dedicated to assuring that geriatric mental health gets the attention, planning, and funding it deserves. And, time is of the essence. The elder boom has already begun.
Kimberly Williams is the Director of the Center for Policy, Advocacy, and Education at the Mental Health Association of New York City and the Director of the Geriatric Mental Health Alliance of New York. She can be reached at kwilliams@mhaofnyc.org.
