State Health Lawmakers' Digest: Mental Health and Aging (Vol. 3, No. 1), What Works

WHAT WORKS

Integrating Mental Health and Substance Abuse Services with Primary Health Care

With less than 3 percent of older adults reporting that they are being treated by a mental health professional, the majority of older adults who seek mental health services do so through their primary health care provider. The problem of relying on primary caregivers to provide mental health services is that most are not adequately trained in diagnosing and treating mental health problems. Primary care physicians often equate mental health problems with the process of aging or other physical problems and may mis-prescribe psychotropic medications. Older adults are less likely to receive mental health referrals than younger patients. Many physicians have stated that they do not feel comfortable diagnosing depression. A 1992 Indiana University survey of primary care physicians found that only 35 percent felt confidant in prescribing antidepressant medications to older adults. Several studies have found that nearly 70 percent of older adults who committed suicide had seen their primary care physician in the previous month. The Over 60 Health Center in California and the Mental Health Bridge Program in New York are addressing the problems of under diagnosing mental health problems and the underuse of mental health services in the elderly population by integrating mental health services into primary care settings.

Source: A Profile of Older Americans: 2001. Administration on Aging. (AOA. Washington, D.C.: 2001). http://www.aoa.gov/aoa/STATS/profile/2001/2.html

California

At the Over 60 Health Center, a federally qualified health center (FQHC) headquartered in Berkeley and with two other sites in Oakland, elderly patients have been receiving primary care and mental health services since the mid-1980s. Interdisciplinary teams comprised of a clinical psychologist, a clinical social worker, a primary care physician and a nurse work together to coordinate care for older adults with mental health services needs. The Over 60 Health Center, founded as a community-based alternative to nursing home care, is the first community-based geriatric health care center in the country; it relies on patient referrals from community organizations and private physicians.

The center offers a variety of mental health services, including assessment, individual and group counseling, medication management, Alzheimer's disease diagnoses and behavioral health services. The physicians at the Over 60 Health Center have received training in mental health assessment, and strong emphasis is placed on continuous education of staff who work with older adults. During patient visits, the physicians conduct informal assessments and make referrals to mental health staff. The physicians work with psychologists and social workers on site to assess treatment options and plan for on-site or outside care. The Over 60 Health Center also collaborates with other community-based programs for older adults to improve service delivery.

The majority of patients at the Over 60 Health Center have incomes below 200 percent of the federal poverty level, and the primary sources of the program's funding are Medicaid and Medicare. The center also receives funds from grants, demonstration projects, indigent care funds and the area agency on aging.

"We see 4,500 people per year at all three sites," reported Marty Lynch, chief executive officer of Lifelong Medical Care, which operates the clinics. "The users average between seven to eight visits per year, and 15 percent of the users have mental health issues where they are receiving services," he said.

As part of the Primary Care Research in Substance Abuse and Mental Health for the Elderly Study (PRISMe), patient outcomes from the center will be compared to a private practice that employs a more traditional, referral approach to care. "We've successfully been able to integrate care coordination," said Lynch. "Some of the preliminary research from PRISMe is showing that more seniors are getting mental health services than they would otherwise, and consumers are telling us that it's easier for them to access services," he added.

New York

In the Asian American population, there is a stigma relating to mental health problems that stops many members of the community from seeking mental health care. This is an especially big problem among Asian American elderly. According to a 1994 study on Asian and Pacific Island Elders published in Social Work, the Chinese American elderly are 10 times more likely than white American elderly to commit suicide. Recognizing that Asian Americans have the lowest mental health service utilization rates of any ethnic group and rely almost exclusively on primary care providers for their health care needs, the Chinatown Health Clinic and the Flushing Primary Care Center in New York City developed the Asian American Primary Care and Mental Health "Bridge Program" to help integrate mental health services into primary care settings.

The Bridge Program, founded in 1995, partners with public and private hospitals, local medical associations, private physicians, faculty at medical and nursing schools and various foundations to connect elderly Asian Americans with mental health services. The program has three main objectives: 1) to increase patient access to mental health services by integrating primary care and mental health services on site; 2) to upgrade the skills of primary care providers in the community and at program sites; and 3) to raise community awareness of mental health and reduce the stigma of mental health disorders.

The Bridge Program serves only individuals who are already registered patients at the Chinatown Health Clinic and the Flushing Primary Care Program. Primary care physicians, trained to provide both mental health assessment and culturally appropriate services, care for patients at the clinics. Physicians make referrals to on-site mental health clinicians who have experience working with Asian Americans patients. According to Theresa Jung, program coordinator, "most of our patients are in house, so they see an internist who uses a mental health assessment survey and then refers the patient to our mental health team."

To date, the program has trained 75 physicians and has increased the number of mental health encounters by clinic patients by 300 percent. The program also has succeeded in referring 66 percent of those with mental health needs to outside mental health services for long-term therapy.

The program serves as a model for other community health centers. The South Cove Community Health Center in Boston, Massachusetts, already has received funding from the Pfizer Foundation to replicate the program.

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