1. Older Adults & Mental Health Services in Iowa

2. OVERVIEW The Business Case The Historical Record Vision for the Future

3. THE BUSINESS CASE Demographic imperative Demographic imperative Service Use Service Use Quality of life Quality of life Financial inefficiencies Financial inefficiencies

4. Increasing Number of Older Iowans

5. Mental Illnesses among Older Iowans

6. SERVICE USE Community based services Community based services Nursing homes & other residential settings Nursing homes & other residential settings

7. Community based care Specialty clinics – CMHCs Specialty clinics – CMHCs Inpatient psychiatric hospitals Inpatient psychiatric hospitals Primary care Primary care Community hospitals Community hospitals

8. County-based mental health Parkview Center, Sac City

9. Kaskie et al. Study (2007) Few CMHCs target programs towards older adults Few CMHCs target programs towards older adults Little use of CMHCs by older adults Little use of CMHCs by older adults Not a lot of specialty contact (< 20% see a specialist in outpt setting) Not a lot of specialty contact (< 20% see a specialist in outpt setting)

10. Inpatient Psychiatric Care

11. Buckwalter UIHC Study Admission status 65% Mood Disorder 35% Dementia 50% Mixed

12. Kaskie et al. (2007) Not a lot of specialty inpatient care Not a lot of specialty inpatient care

13. Primary Care

14. Kaskie Medicare Study Most common place to obtain care Most common place to obtain care More than 70% of MH visits in a generalist outpatient office More than 70% of MH visits in a generalist outpatient office

15. Community Hospitals

16. Kaskie Medicare Study Second most common place to obtain care Second most common place to obtain care Nearly 20% of MH visits in a generalist inpatient and outpatient services Nearly 20% of MH visits in a generalist inpatient and outpatient services

17. Emergency Care Not coded Not coded

18. Care for Co-occurring Dx 1 out of 5 = MH dx only 1 out of 5 = MH dx only Very little co-occurring MH dx Very little co-occurring MH dx 4 out of 5 = MH + other DX 4 out of 5 = MH + other DX

19. Oakland Estates, Oakland

20. Mental Illnesses in Nursing Facilities

22. Targeted efforts Third most common place to receive TX Third most common place to receive TX Dementia Special Care Dementia Special Care 65 Specialized Care Units 65 Specialized Care Units 1,200 beds 1,200 beds

23. QUALITY OF LIFE

24. Suicide Rate by Age Per 100,000 Older people: 12.7% of 1999 population, but 18.8% of suicides. (Hoyert, 1999)

25. October 7, 2000 (AP) Actor Richard Farnsworth, a former stuntman and two- time Academy Award nominee, died of a self-inflicted gunshot wound Friday night. He was 80.

26. EXPENDITURES Total Medicare Expenditures: Total Medicare Expenditures: $211.4 Billion Total MH Expenditures: $1.2 Billion (0.57%) Total MH Expenditures: $1.2 Billion (0.57%) Outpatient Mental Health: Outpatient Mental Health: $ 718 Million (0.34%) CMS, 2001 $ 718 Million (0.34%) CMS, 2001

28. Iowa Expenditures

29. Inefficiencies

30. Depression in Older Adults and Health Care Costs Unutzer, et al., 1997; JAMA

31. Monthly Per Person Costs by Age: Severe Mental Illness

32. New Hampshire Total Monthly Costs Per Person Over Age 65 $0 $500 $1,000 $1,500 $2,000 $2,500 $3,000 $3,500 $4,000 Schizophrenia Alzheimer's Dementia Cerebrovascular Depression Heart Failure COPD Cardiac Dysrhymias Osteoarthritis Diabetes Hypertension MedicaidMedicare

33. Medicare Expenditures on Alzheimer’s Disease AD complicates treatment of coexisting conditions AD complicates treatment of coexisting conditions Inability to manage care Inability to manage care Hospitalized AD patients stay longer, cost more Hospitalized AD patients stay longer, cost more

34. HISTORICAL EFFORTS

35. NATIONAL MOVEMENT

36. 2004 – Program Initiative

37. 2005 White House Conference

38. Positive Aging Act Reintroduced May 31, 2005 – Last Wednesday, Senators Hillary Rodham Clinton (D-NY) and Susan Collins (R-ME) and Representatives Patrick Kennedy (D-RI) and Ileana Ros- Lehtinen (R-FL) announced the introduction of the Positive Aging Act of 2005 to improve access to mental health services for America’s senior citizens. May 31, 2005 – Last Wednesday, Senators Hillary Rodham Clinton (D-NY) and Susan Collins (R-ME) and Representatives Patrick Kennedy (D-RI) and Ileana Ros- Lehtinen (R-FL) announced the introduction of the Positive Aging Act of 2005 to improve access to mental health services for America’s senior citizens.

39. IOWA FORUMS Quick Fixes (1998) Quick Fixes (1998) Iowa Mental Health Forum (2000) Iowa Mental Health Forum (2000) Mental Health System (2001) Mental Health System (2001)

40. Quick Fixes (1998)

41. Key Findings public mental health system is in transition…. public mental health system is in transition…. increased use of managed behavioral healthcare to administer services…. increased use of managed behavioral healthcare to administer services….

42. Problems older adults are not involved in managed behavioral healthcare… older adults are not involved in managed behavioral healthcare… data is difficult to obtain… data is difficult to obtain…

43. Mental Health Forum (2000)

44. Organizational Chart (2000)

45. Mental Health Forum (2001)

46. Older Adults Roundtable Many persons did not know where to seek help. Many persons did not know where to seek help. Dementia should be included in mental health care Dementia should be included in mental health care Implement multi-disciplinary treatment approaches Implement multi-disciplinary treatment approaches

47. Training Efforts (2002) Training to Enhance Service Delivery to Older Adults with Mental Illness Lila Starr, Project Officer Funding Period: April 15, 2002 to September 30, 2002

48.   Creston   Dubuque   Ottumwa   Spencer Four Training Sessions (N=268)

49. : Mental Health and Aging: Programs and Services in the State of Iowa Ames, IA 2003 Iowa Public Health Conference

50. Collaborative Models of Mental Health Care Pilot Programs Lila Starr, DHS 2004 Iowa Department Human Services

51. THE IOWA COALITION ON MENTAL HEALTH AND AGING April, 2005 April, 2005 Three Workgroups Three Workgroups www.icmha.org www.icmha.orgwww.icmha.org

52. Lyon Osceola O’BrienSioux PlymouthCherokee Woodbury Ida MononaCrawford Harrison Shelby Pottawattamie Mills FremontPage MontgomeryAdams Taylor Union Ringgold Cass Adair Madison Decatur Clarke Lucas Wayne Monroe Appanoose Warren Marion Mahaska Wapello Davis Jefferson Van Buren Henry Lee Keokuk Washington Louisa Des Moines Muscatine Scott Carroll Audubon Greene Guthrie Boone Dallas StoryMarshall PolkJasperPoweshiekIowaJohnson Cedar Clinton BentonLinn JonesJackson Tama Sac Buena Vista Pocahontas Calhoun Humboldt Webster Wright Hamilton Franklin Butler Hardin Grundy Bremer Black Hawk Buchanan Delawar e Dubuque FayetteClayton Allamakee Winneshiek Clay DickinsonEmmet Palo Alto Kossuth Winnebago Worth HancockCerro Gordo MitchellHoward Floyd Chickasaw ICMHA Membership Roster Calhoun =10+ = 0 = 1-9

53. Outreach Efforts – ICMHA Regional Meetings Fall, 2007 -Council Bluffs (Southwest 8) Dubuque (Scenic Valley) Sioux City (Siouxland) Waterloo (Hawkeye Valley)

54. IOWA COALITION ON MENTAL HEALTH AND AGING Education and Training Workgroup

55. PRIMARY GOALS Increase public awareness about mental health and aging issues Increase public awareness about mental health and aging issues Expand the supply of qualified mental health service providers Expand the supply of qualified mental health service providers

56. IOWA COALITION ON MENTAL HEALTH AND AGING Outreach and Clinical Services Workgroup

57. PRIMARY GOALS Promote mental wellness among aging Iowans Promote mental wellness among aging Iowans Increase supply of qualified mental health service providers Increase supply of qualified mental health service providers Improve access to qualified mental health service providers Improve access to qualified mental health service providers Integrate mental health services into usual places of care Integrate mental health services into usual places of care

58. IOWA COALITION ON MENTAL HEALTH AND AGING Policy & Administration Workgroup

59. PRIMARY GOALS Promote mental wellness among aging Iowans Promote mental wellness among aging Iowans Increase supply of qualified mental health service providers Increase supply of qualified mental health service providers Improve access to qualified mental health service providers Improve access to qualified mental health service providers Integrate mental health services into usual places of care Integrate mental health services into usual places of care

60. VISION FOR THE FUTURE

61. HF2780 In 2006, the Iowa Legislature established the Division of Mental Health and Disability Services (MHDS) within the Department of Human Services (DHS). With the enactment of HF2780, the general assembly sought a service system for persons with disabilities which emphasizes the ability of persons with disabilities to exercise their own choices about the amounts and types of services received; that all levels of the service system would seek to empower persons with disabilities to accept responsibility, exercise choices, and take risks; that disability services are individualized, provided to produce results, flexible, and cost-effective; and that disability services be provided in a manner which supports the ability of persons with disabilities to live, learn, work, and recreate in communities of their choice. In 2006, the Iowa Legislature established the Division of Mental Health and Disability Services (MHDS) within the Department of Human Services (DHS). With the enactment of HF2780, the general assembly sought a service system for persons with disabilities which emphasizes the ability of persons with disabilities to exercise their own choices about the amounts and types of services received; that all levels of the service system would seek to empower persons with disabilities to accept responsibility, exercise choices, and take risks; that disability services are individualized, provided to produce results, flexible, and cost-effective; and that disability services be provided in a manner which supports the ability of persons with disabilities to live, learn, work, and recreate in communities of their choice.

62. Mental Health Systems Improvement With the recent passage of the State's bill, the Department of Human Services (DHS) Division of Mental Health and Disability Services (MHDS) form planning workgroups. These workgroups are to make recommendations to the MHMRDDBI commission, to the DHS director, and the legislature. The legislation states: With the recent passage of the State's bill, the Department of Human Services (DHS) Division of Mental Health and Disability Services (MHDS) form planning workgroups. These workgroups are to make recommendations to the MHMRDDBI commission, to the DHS director, and the legislature. The legislation states: "In order to build upon the partnership between the state and the counties in providing mental health and disability services in the state, the workgroups established for purposes of this subsection shall engage equal proportions representing the department, counties, and service providers. The county and provider representatives shall be appointed by the statewide associations representing counties and community providers. In addition, each workgroup shall include a representative of the commission, the mental health planning and advisory council, consumers, and a statewide advocacy organization"

63. Bureau of Older Adult Mental Health Services The Bureau of Older Adult Mental Health Services will expand and improve the care provided to older Iowans with mental illnesses and co-occurring mental illness and substance use disorders. The Bureau will provide program administration and service management that reflects a commitment to principles of accountability, decency, ease of access, respect for self-determination and responsiveness to an older individual’s unique situation and personal preferences. In this manner, the Bureau will establish a compassionate and welcoming culture, and a determination to help older Iowans overcome the challenges of aging and live with dignity and safety in the communities of their choice. The Bureau of Older Adult Mental Health Services will expand and improve the care provided to older Iowans with mental illnesses and co-occurring mental illness and substance use disorders. The Bureau will provide program administration and service management that reflects a commitment to principles of accountability, decency, ease of access, respect for self-determination and responsiveness to an older individual’s unique situation and personal preferences. In this manner, the Bureau will establish a compassionate and welcoming culture, and a determination to help older Iowans overcome the challenges of aging and live with dignity and safety in the communities of their choice.

64. BOAMHS Goal 1 Ensure the provision of empathic and welcoming care to older Iowans with mental illnesses and co-occurring mental illness and substance use disorders a priority among policy makers, program administrators and provider organizations across the state of Iowa. Ensure the provision of empathic and welcoming care to older Iowans with mental illnesses and co-occurring mental illness and substance use disorders a priority among policy makers, program administrators and provider organizations across the state of Iowa.

65. BOAMHS Goal 2 Increase the involvement of older adult consumers, their caregivers, and the general public with improving the care of older Iowans with mental illnesses and co- occurring mental illness and substance use disorders. Increase the involvement of older adult consumers, their caregivers, and the general public with improving the care of older Iowans with mental illnesses and co- occurring mental illness and substance use disorders.

66. BOAMHS Goal 3 Increase the number of qualified providers of evidence based mental health and substance abuse services targeted towards older Iowans with mental illnesses and co- occurring mental illness and substance use disorders. Increase the number of qualified providers of evidence based mental health and substance abuse services targeted towards older Iowans with mental illnesses and co- occurring mental illness and substance use disorders.

67. BOAMHS Goal 4 Develop early identification and prevention programs targeting older Iowans with mental illnesses and co- occurring mental illness and substance use disorders. Develop early identification and prevention programs targeting older Iowans with mental illnesses and co- occurring mental illness and substance use disorders.

68. BOAMHS Goal 5 Increase the provision of specialty and emergency mental health services to older Iowans. Increase the provision of specialty and emergency mental health services to older Iowans.

69. BOAMHS Goal 6 Establish a statewide system of care in which qualified mental health providers can serve older adults with mental illnesses or co-occurring mental illness and substance use disorders through a referral or co-location process that upholds the principle of “no wrong door” Establish a statewide system of care in which qualified mental health providers can serve older adults with mental illnesses or co-occurring mental illness and substance use disorders through a referral or co-location process that upholds the principle of “no wrong door”

70. BOAMHS Goal 7 Establish an administrative culture, which upholds principles of continuous quality improvement Establish an administrative culture, which upholds principles of continuous quality improvement

71. Where do things stand?

72. THANK YOU