As part of the growing attention and interest at all levels of government to advance geriatric mental health care, New York State enacted the Geriatric Mental Health Act in 2005. One of the law’s provisions authorized the New York State Office of Mental Health (OMH) to establish a geriatric service demonstration program to provide grants to providers of mental health care for older adults. The grant program established can provide grants in the following areas: community integration; improved quality of treatment; integration of services; workforce development; family support, finance, specialized populations, information clearinghouse, and staff training.
In 2007, OMH awarded six service demonstration grants for physical health/mental health integration programs. A seventh program also participated in the OMH evaluation, consultation and oversight activities. The goal of this program model was to establish and enhance integration of mental health screening, assessment and treatment processes into physical health care settings. Mental Health Integration programs were targeted for older adults whose independence, tenure, or survival in the community was in jeopardy because of a behavioral health problem.
Although the seven mental health/physical health programs operated in a variety of settings they could all be characterized as either coordinated or co-location integrated care models. (Collins et. Al., 2010). Co-location models are characterized as having primary care and behavioral health services located in the same facility, a referral process for individuals screened in primary care to receive priority access to a behavioral specialist, enhanced informal communication between primary care and behavioral health, and active consultation between primary and behavioral health which enhance skills in both groups. Coordinated care models are characterized by: routine screening for behavioral health problems conducted in primary care settings, a referral relationship between primary care and behavioral health settings, routine exchange of information between both treatment settings and primary care delivery of some behavioral health interventions.
An OMH evaluation of these mental health/physical health demonstration projects focused on two major elements – program design and implementation and outcomes for individuals served. Approaches to design where captured by interviews with program administration at each site and retrospective reflections on implementation, integration of service delivery and treatment and program sustainability during the final year of the demonstration projects.
Although all programs were unique in their design, they all shared a basic structure. In all programs, individuals were screened for mental illness when they initially came into contact with their primary care provider. Information collected at the time of screening included demographic characteristics such as sex, age, race/ethnicity and living situation. Programs were also asked to administer the 9-item Patient Health Questionnaire (PHQ-9) and the 7-item Generalized Anxiety Disorder (GAD-7), screening tools for depression and anxiety. Programs also submitted follow-up PHQ-9 and GAD-7 data on individuals who received their mental health treatment either directly at the program or at programs to which individuals were referred.
Between November 2007 through September 2011, these programs screened 8,283 individuals, 60 years and older for mental illness. Approximately 30% of these individuals were screened multiple time bringing the total number of screens conducted to 14,162. Thirty-five percent of individuals screened were recommended for more in-depth mental health assessment. Seventy-three percent of these individuals actually received an assessment and 91%, or 1,941, of these individuals were recommended for treatment. Overall, 23% of individuals screened aged 60 years and over were recommended for treatment.
Assessments conducted by clinicians at these sites included evaluation of patient needs. For mental health need, 15% of assessments conducted identified a “high” level of need, 45% “moderate” and 27% “low.” For those individuals whose level of need was “high”, 25% were already receiving services at the time of assessment while 68% were not receiving services and were referred.
The impact of treatment on symptoms of depression and anxiety was monitored using the PHQ-9 and the GAD-7. Change on the PHQ-9 was evaluated as change in depression severity category (mild, moderate, moderately severe, severe) between initial screening and most recent follow-up assessment. Of individuals with severe depression at baseline, 81% were evaluated as “improved” and, 19% as “unchanged.” For moderately severe individuals 89% improved and 77% improved for moderate depression category. Overall, high rates of improvement were seen for individuals who were initially rated with moderate, moderately severe, and severe symptoms of depression.
Change on the GAD-7 was evaluated as change in anxiety severity category (mild, moderate, severe) between initial screening and most recent follow-up assessment. Follow-ups were also submitted at three-month intervals or when treatment was terminated. Seven percent of individual screened using the GAD-7 fell into the category of Severe Anxiety Disorder at initial screening, and of those, 86% showed improvement at most recent follow-up with 14% “unchanged.” Of the individuals who showed moderate symptoms of anxiety, 80% were seen as “Improved,” 16% “Unchanged” and 4% “Declined.”
Over the course of the demonstration project feedback was gathered from program staff on implementation, integration of service delivery and treatment and sustainability. Lessons learned include:
- Obtain high-level organizational and administrative support: Mental health/physical health demonstration projects operated in different organizational settings ranging from large hospital centers to primary care physician offices and a home-based geriatric primary care practice. Co-located programs housed in hospital settings have cited the importance of a champion for mental health/physical health integration high within the administrative hierarchy. Supporters placed strategically in important administrative positions can disseminate the vision of integration and facilitate resolution of barriers to integration that inevitably arises.
- Understand the culture of primary care: Successful integration of mental health into primary care depended on securing effective access to the primary care service delivery setting. This presented a variety of challenges at demonstration sites. At the onset of integration efforts, protocols for conducting mental health screening, communication with primary care staff (clinical and administrative) needed to be established. An understanding of traditional office processes was crucial to the development and implementation of integration protocols acceptable to primary care staff.
- Prepare for resistance from primary care: Resistance to integration of mental health in primary care was cited in various ways and at various levels of intensity by all demonstration sites. The importance of discussing and demonstrating the benefit of integration for primary care was evident. Primary care physicians were often described as feeling too busy to incorporate formal screening into their routine practice. In addition, the value of formal screening was underappreciated as primary care physicians felt they were able to identify mental health problems in the course of a routine office visit. Many sites described the diligence needed to ensure that screening protocols were adhered to.
- Use multidisciplinary teams: Integration of mental health and physical health resulted in the identification of issues that call for the professional expertise from a variety of health care disciplines. A number of co-location sites developed teams consisting of primary care physicians, psychiatrists, nurse practitioners, social workers and case managers that met regularly to review new and ongoing cases. These processes added to more seamless referrals between the primary care and mental health sectors, improved relationships between practitioners and a greater acceptance of the mental health interventions in physical health settings.
- Monitor patient reaction to integration: As the demonstration project was implemented, a common concern was that stigma associated with mental illness would result in patient reluctance to engage in the issue of their mental health. Project staff report that through the establishment of a screening protocol and successful interaction between mental health and physical health practitioners, patients came to accept the attention to mental health. Sites reported that patients were comfortable in the location where they receive their primary health care and that ultimately, primary care involvement in mental health has reduced any stigma that may been associated with discussion of mental health concerns.
- Prepare to uncover unmet psychosocial needs: The identification of behavioral health concerns uncovered many complex psychosocial situations that needed to be addressed. Sites found that in many cases psychosocial interventions involving housing, transportation, family caregiving, financial problems and other such needs, may be more important than psychotherapy or medication. At some programs, providers felt that addressing these needs was beyond their expertise. Compounding the issue was the difficulty programs found in being reimbursed for these services. Planners of an integrated physical health/mental health delivery system should anticipate that these psychosocial services will be important and plan for how they can provide them directly or through a linked social service agency.
- Plan for sustainability: All sites reported that shifting to a culture of billing was difficult, underscoring the importance of planning for fiscal viability and program sustainability prior to implementation. After program models became operational, sites received extensive technical assistance in navigating and negotiating service reimbursement systems. In some cases, programs needed to make changes to already established staffing patterns.
For models that operated using satellite locations, sustainability is best assured if productivity is monitored on an ongoing basis. Clinical staff in primary care office settings should monitor the balance of the assignment of client cases and clinician credentialing in each location to ensure reimbursement for services is captured.
The mental health/physical health integration demonstration projects all successfully implemented depression and anxiety screening protocols in primary health care settings. Although the project focused on older individuals, some programs also screened younger patients. As a result, higher rates of recommendation for treatment were observed for individuals 50-59 years of age compared to patients 60 and older.
Although the demonstration sites pursued different approaches to bringing mental health screening and treatment into primary care most sites succeeded in establishing a culture of integration. With modifications most programs have been able to continue the work started as a result of grant funding.
Program Follow-Up Evaluation
Two years following funding, OMH conducted a follow up evaluation to determine the extent in which the service demonstration experience had a lasting impact each participating program. The evaluation consisted of a set of phone interviews at each demonstration site. Interview questions were established to determine factors influencing program functionality and sustainability; while assessing the agencies’ overall experience as a service demonstration participant.
Findings regarding functional status conclude that each program developed under the service demonstration grant remain operational, with nearly half planning to expand or in the process of expanding. In correspondence with the wide success of program sustainability, all program directors conveyed that their participation in the demonstration grant was a valuable experience and prepared their organization for the impending changes to the healthcare system. Moreover, participants found the initial lessons learned developed during implementation to still be relevant to their program’s success and sustainability. As such, emphasis was made on the necessity to adapt program models based on the cultural needs of clients, as well as staff. This, in turn, allowed the program participants to establish a seamless service delivery system and culture of integration.
Additional finding from the post follow up included an expressed value in participating within the service demonstration learning collaborative and data collection process. These tasks were required by the OMH in order to measure program outcomes. As a result, participating agencies felt that the technical assistance provided and supportive learning environment enabled them to build a strong program foundation before funding ended; which ultimately led to minimal issues encountered afterwards. Furthermore, many programs found the collected data regarding client screenings, treatment, and outcomes to be essential in obtaining a higher level of administrative support and establishing an argument for the necessity of integrated behavioral health/ physical health services.
Steve Huz is a Research Scientist at the New York State Office of Mental Health’s Bureau of Performance Management and Evaluation. Donald Zalucki is Director of the New York State Office of Mental Health’s Bureau of Program and Policy Development. Emily DeLorenzo and Nina Candels are members of the team at the New York State Office of Mental Health’s Bureau of Program and Policy Development.