Older Iowans with Behavioral Health Needs: Survey of ... · PDF fileOlder Iowans with...

Older Iowans with Behavioral Health Needs:

Survey of Current Context and Training Activities

Report Submitted to the Iowa Department of Human Services, Division of Mental Health and Disability Services

Center on Aging, University of Iowa &

Iowa Coalition on Mental Health and Aging

February 2, 2012

Older Iowans with Behavioral Health Disorders 2

TABLE OF CONTENTS

Objectives………….………………………………………………………………….……. 3

Results…… ………………………………………………………………………………… 4

Common Behavioral Health Diagnoses Among Older Iowans……………….. 4

Efforts Pertaining to Identification, Diagnosis, and Treatment……………...… 6

Training Efforts for Program Administrators & Service Providers…………….. 9

Motives and Barriers for Training……………………………………………….. 11

Executive Summary …….………………..……………………………………………….. 20

Background…...…………………………………………………………………………..... 21

Prevalence of Behavioral and Psychiatric Disorders among Older Iowans…. 21

Specialty Service Use among Older Iowans with Behavioral.Health.Needs… 22

State Efforts Pertaining to Older Iowans with Behavioral Health Needs…...... 23

Preadmission Screening and Resident Review (PASRR) and MDS 3.0…….. 25

Research Study…………………………………………………………………….………. 26

Study Design……………………………………………………………………..… 26

Sample…………………………………………………………………………….... 27

Data Collection…………………………………………………………………….. 30

Survey Administration……………..……………………………………………..... 31

Analysis……………………………………………………………………………... 32

Discussion………………………………………………………………………………….. 33

Limitations of the Study…………………………………………………………………….

Recommendations………………………………………………………………………….

36

36

References………………………………………………………………………………… 40

Appendix A – Survey

Appendix B – Survey Results


RESEARCH OBJECTIVES

In January of 2011, the Iowa Department of Human Services, Division of Mental

Health and Disability Services contracted with the Iowa Coalition on Mental Health and

Aging (ICMHA), which is housed at the University of Iowa Center on Aging to develop

and field a survey of individuals and organizations who work with older adults with

behavioral health issues. .

The objectives of the survey study were to identify:

(a) common psychiatric diagnoses presented by older Iowans;

(b) efforts pertaining to the identification, diagnosis and treatment of these older Iowans with particular emphasis on provision of services in the least restrictive settings in accordance with the Olmstead Supreme Court decision;

(c) training efforts for providers of services to older adults with emphasis

on participation, topics, delivery method, and barriers, and additional emphasis placed on requirements pertaining to MDS 3.0;

In addition, the Center on Aging conducted 10 key informant interviews to

complement the survey findings, and then completed an assessment of the current

continuing education and training opportunities focusing on older Iowans with behavioral

health needs. The remainder of this report presents the methods and results pertaining

to the research, and then the findings are discussed and recommendations are

provided.


RESULTS

Common psychiatric diagnoses presented by older Iowans.

In this section, we present answers to one survey question designed to gauge

the prevalence of the aging population with behavioral and psychiatric needs in general

(Table 1), and another question used to identify the particular conditions that were most

salient to respondents (Table 2). We also included a question about the focus of

training programs in an effort to assess whether these programs were addressing the

most salient issues (Table 3).

More than half of the people who answered this survey recognized that older

adults with behavioral health needs were a prominent constituency, with nearly 40% of

individual providers claiming they served no less 25 older adults in need. Further, the

respondents confirmed that the most common disorders were anxiety, dementia, and

depression – schizophrenia and other life-long serious psychiatric disorders were not as

evident. We also noted that the disparity in the reported amount of contact with older

individuals with substance abuse disorders reflects an over-sampling of providers who

work in this field while the relative lack of contact with older individuals presenting with

altered states reflects the under-sampling of hospital-based programs. We also

observed that training topics were consistent with what might be expected given

reported prevalence rates.


Table 1. Please estimate the number of older persons who have (or probably have) a behavioral health need.

Direct Care Respondents

Administrative Respondents

Number Percentage Number Percentage

More than 100 6 5.22 11 6.92 Between 50 and 100 14 12.17 20 12.58 Between 25 and 50 29 25.22 38 23.9 Between 10 and 25 61 53.04 43 27.04

Less than 10 5 4.35 28 17.61 Unsure 6 5.22 19 11.95

Total 115 100% 159 100%

Table 2. What are the most common behavioral health needs among your clients? Please select only three. *NOTE: Open field responses also identified gambling and addictive disorders.



Number (n=116)

Percentage* Number (n=160)

Percentage*

Alzheimer’s 28 24.14 69 43.1

Other types of Dementia 28 24.14 82 51.2

Depression/bipolar disorders 87 75.00 109 68.1

Anxiety 67 57.76 74 46.3

Schizophrenia or some other type of serious mental illness

21 18.10 39 24.4 Substance abuse

38 32.76 19 11.9 Transient disorders such as

altered state and delirium 6 5.17 7 4.37


Table 3. Which diagnoses were covered during training? Select all that apply.

Direct Care Respondents Administrative Respondents

Number Responded

(n=84)

% of 84**

% of all respondents

(n=116)

Number Responded

(n=114)

% of 114**


(n=152)

Alzheimer’s 46 54.76 39.66 67 58.8 44.1

Other types of Dementia 50 59.52 43.10 66 57.9 43.4

Depression/bipolar disorders

64 76.19 55.17 59 51.8 38.8

Anxiety 53 63.10 45.69 55 48.2 36.2

Schizophrenia/other type of serious psychiatric disorder

27 32.14 23.28 25 21.9 16.4

Substance use and abuse 35 41.67 30.17 16 14 10.5

Transient disorders 20 23.81 17.24 8 7.02 5.3

Training was not targeted 7 8.33 6.03 16 14 10.5

Efforts pertaining to identification, diagnosis and treatment. Currently, the federal Preadmission Screening and Resident Review (PASRR)

program and the Minimum Data Set (MDS 3.0), and the 1999 Olmstead Supreme Court

Decision by extension, are the most clearly defined authoritative charges that pertain to

the provision of services to older adults with behavioral health needs. This was

confirmed by the survey respondents and from key informant interviewees representing

nursing and residential care facilities. Further, the authoritative nature of PASRR and

MDS 3.0 appear to be driving the very recent surge in programming and training

activity, as reported by the survey respondents and key informants.


Alternatively, the survey responses revealed that community-based programs

and individual service providers recognized no single authoritative charge to serve older

adults with behavioral and psychiatric needs living at home or in the community. In the

remainder of this section, we present answers to three questions that asked about the

provision of services to older Iowans with behavioral health needs (Tables 4-6).

Table 4.. How are older adults with behavioral health needs screened and identified by the organization? Check all that apply.


Number (n=157) Percentage

We do not actively screen or assess older adults for behavioral health needs.

53 33.8

We formally assess and diagnose older adults who have behavioral health needs regardless.

53 33.8

We use Target Case Management Assessment.

35 22.3

We use Preadmission Screening and Resident Review (PASRR) and MDS 3.0

41 26.1


Table 5. What types of programs and services do you provide to older adults with behavioral health needs? Select all that apply. Direct Care

Respondents Administrative Respondents

Number (n=116)


Percentage*

Assistance with activities of daily living 26 22.41 98 61.3 Residential Services 16 13.79 38 23.7

Rehabilitative services 15 12.93 53 33.1 Case management services 34 29.31 58 36.2

Day treatment or partial treatment 10 8.62 17 10.6 Diagnostic assessment services 26 22.41 29 18.1

Group therapy 29 25.00 22 13.8 Indiv. therapy incl. cog. and prob. solving 42 36.21 40 25

Medication management 28 24.14 89 55.6 Peer Support 32 27.59 35 21.9

Substance abuse treatment 29 25.00 18 11.3 Dietary Services 13 11.21 64 40 Other (Text Box) 19 16.38 31 19.4


Table 6. Survey respondents’ prevailing themes on how they help older adults choose to remain in their home or community or return to their home or the least restrictive setting of their choice. Question was an open field response.

a. Respondents indicated they were involved with educating individuals about options and informing them about choices available to them;

b. Respondents indicated they were involved with providing services in least

restrictive service setting or making referrals to programs that offered care in home and community based locations;

c. Respondents provided no indication if, in fact, older adults actually were receiving care or opted to receive care in least restrictive settings;

d. Lack of home and community-based options made it hard to validate if in fact the information and referral actually led to persons receiving care in least restrictive setting.

Training efforts for program administrators and service providers. The National Coalition on Mental Health and Aging proclaimed that one way to

address the large and growing gap between the number of older adults with behavioral

health disorders and the access to and use of specialty services is to increase

education and training efforts. We asked three questions (Tables 7-9) in order to

establish a baseline of training activity across the State of Iowa. The results indicated

that nearly two thirds of programs and providers have engaged in some type of training,

on average for six hours each year.


Table 7. Have you completed any formal education (e.g., courses) that addressed the behavioral health needs of older adults?


Number (n=116)

Percentage*

Yes – as part of my certification program 26 22.41 Yes - as part of my undergraduate coursework 36 31.03

Yes - as part of my graduate coursework 26 22.41 Yes – Other (Please describe) 13 11.21

No 35 30.17

Table 8. In the last three years, have you completed any professional training concerning the behavioral health needs of older adults?


Number (n=116)

Percentage*

Yes – as part of my formal education (see above) 10 8.62 Yes - as part of CEU / licensure requirements 49 42.24

Yes – as sponsored by my organization 26 22.41 Yes – I did so voluntarily 24 20.69

No 33 28.45

Table 9. In the past three years, has your agency offered any training concerning older adults with behavioral health needs?

Administrator Respondents

Number Percentage

Yes – we administer or contract training programs

114 75

No – we encourage staff to acquire training on their own 38 25

Total 152 100


NOTE: Replies indicated the average number of hours totaled 6.0.

Training Efforts for Program Administrators & Service Providers

We examined secondary sources of education and training and identified a

number of organizations within the State of Iowa and throughout the United States that

offer internet-based training relevant to the provision of care to older adults with

behavioral health needs. Some of these organizations include the Iowa Chapter of the

Case Management Society, Iowa Geriatric Education Center, Iowa Health Care

Association, Iowa Nurses Association, SAMHSA/HRSA, Senior Family Network,

Silverchair Learning Systems, and the National Association of Social Workers. These

organizations provide trainings on a wide variety of topics, and many of these provide

an option to obtain either CMEs or CEUs. While individual course costs vary, the

majority of trainings cost $10 to $50. A detailed compilation of the organizations and

particular training topics is presented in Appendix A. It also is worth mentioning that the

key informants cite many of these organizations as their sources for training and agree

that $50 per hour was a typical rate. In what follows, we presented answers to six

questions (Tables 10-15) concerning the topics of education and training programs

provided within the State of Iowa. NOTE: Questions were sorted by those that

addressed training in general and those that concerned the new MDS 3.0 requirements

in particular.


Table 10. What topics were covered during these training programs?


Number Responded

(n=84)

% of 84**


(n=116)

Number Responded

(n=114)

% of 114**


(n=152)

Best practices

47 55.95 40.52 64 55.7 42.1

How to assess & diagnose

38 45.24 32.76 22 19.1 14.5

Evaluating treatment

17 20.24 14.66 21 18.3 13.8

Medication management

24 28.57 20.69 49 42.6 32.2

Behavior management

36 42.86 31.03 72 62.6 47.4

Individual psychotherapy

14 16.67 12.07 16 13.9 10.5

Information about least restrictive placement

8 9.52 6.90 21 18.3 13.8

Mental health treatment

25 29.76 21.55 21 18.3 13.8

Case management

21 25.00 18.10 13 11.3 8.6

Information and referral

29 34.52 25.00 37 32.2 24.3

Screening and identifying

32 38.10 27.59 26 22.6 17.1

Substance abuse tx 18 21.43 15.52 11 9.57 7.2


Table 11. Indicate if you had any training on the following subjects in the last three years.



Number (n=114)


Percentage*

End-of-life issues and coping with grief

49 42.98 70 47.3

Care needs such as bathing and dressing

16 14.04 83 56.1

Working with other direct care workers

39 34.21 85 57.4

How to offer information and referral 28 24.56 35 23.6

Table 12. What are some training needs to address in the next three years?



Number (n=115)


Percentage*

End-of-life issues and coping with grief

75 65.22 75 49.3

Care needs such as bathing and dressing

13 11.30 43 28.3

Working with other direct care workers

45 39.13 79 52

How to offer information and referral

48 41.74 50 32.9

Best practices for providing care to older adults with behavioral health needs

100 86.96 133 87.5


Table 13. As part of the new MDS 3.0 (Minimum Data Set), your agency is required to ask older adults about where they want to live.



Number (n=116)


Percentage*

I have had training about MDS 3.0

11 9.48 41 28.3

I have completed online training

3 2.59 19 13.1

I completed another type of training

5 4.31 16 11

I have completed training about Olmstead

13 11.21 25 17.2

My agency has trained me on providing choice to older adults

11 9.48 34 23.4

My agency has not provided training

36 31.03 13 8.97

I have not completed any training

50 43.10 10 6.9

I do not know a lot about this topic

50 43.10 26 17.9

I do not think this topic is relevant

10 8.62 23 15.9

My agency has not provided me any information or instructions about MDS

3.0

29 25.00 8 5.52

My agency is not affected by MDS 3.0 22 18.97 48 33.1


Table 14. Do you have new or different training needs because of the new MDS 3.0?



Number (n=110)

Percentage Number (n=144)

Percentage

Yes 9 8.18 34 26.6 No 14 12.73 29 20.1

I do not know about the new MDS 3.0 41 37.27 17 11.8 I do not know the new needs re: MDS

3.0 27 24.55 19 13.2


Total 110 100% 144 100%

Table 15. What areas of training do you have because of the new MDS 3.0 rules?



Number (n=116)


Percentage*

What to do if client wants to return home

16 13.79 25 17.2

The range of placement options

23 19.83 30 20.7

How and where to refer older adults

27 23.28 25 17.2

How to make referrals for clients

19 16.38 26 17.9

How to work with primary care physicians

20 17.24 26 17.9

How to work with MH or SA services

15 12.93 25 17.2

Medication monitoring & management

8 6.90 20 13.8

Psychiatric medications and interactions

11 9.48 22 15.2

Impact of multiple medications

16 13.79 24 16.6

Recovery practices in MH and SA 21 18.10 22 15.2

I do not know about the new MDS 3.0

52 44.83 25 17.2

I do not know if there are new or different training needs because of MDS 3.0

26 22.41 15 10.3



Training Methods

Providing education and training programs can be a costly and time-consuming

activity. Whether one modality or another is more efficient must be balanced against

whether the modality is effective, in that people participate and derive positive outcomes

from the learning experience. We asked two questions about the modality of training

programs, and found the answer varied considerably (Tables 16 & 17).

The Iowa Communications Network was found to be the least utilized training

medium by administrators and was tied with self-paced programs as least utilized for

direct care workers (Table 16). Administrators found ICN to be the least desirable

training modality, while direct care workers found CDs and self-paced programs to be

less desirable than ICN (Table 17). Since both groups reported limited usage of ICN

and self-paced programs, it is difficult to determine whether these negative perspectives

relate more to negative experiences or lack of any experience. We also observed

disparity in how provider and administrators utilized other modalities. For example, while

direct care workers did not seem to value self-paced (CD, DVD) and ICN learning

programs, they appeared to be more attractive among program administrators.

Conversely, direct care providers endorsed Iowa Coalition on Mental Health and Aging

(ICMHA) offerings and other off-site training programs more so than program

administrators. Both groups valued in-person training highly. Finally, while on-line

formats were not currently available to many persons, the survey results as well as key

informant interviews suggest their use should be increasing in the next several years.


Table 16. Which teaching methods were used as part of the training?


Number (n=83)

% of 83**


(n=116)** # (n=114)

% of 114**


(n=152)**

Iowa Comm Network (ICN)

13 15.66 11.21 11 9.57 7.2

Webcasts

27 32.53 23.28 38 33 25.0

Self-paced program (CDs)

13 15.66 11.21 44 38.3 28.9

In-person training at facility

24 28.92 20.69 60 52.2 39.5

Off Site Trainings

57 68.67 49.14 47 40.9 30.9

Table 17. What are the best ways to offer training?



Number (n=116)


Percentage*

Iowa Communications Network (ICN) 39 33.62 35 22.9

Webcasts and other online programs 61 52.59 86 56.2

Self-paced packaged program (CDs) 33 28.45 73 47.7

In-person training at our facility 67 57.76 113 73.9

Off Site Trainings conducted 67 57.76 53 34.6

ICMHA sponsored conference 63 54.31 33 21.6


Motives and Barriers for Training.

We asked three questions (Tables 18-20) concerning the motivations and

barriers for training. In addition to the survey responses, key informants consistently

indicated quality of care was a critical reason to complete training. They also cited

costs, time and travel as the primary barriers though they did suggest that $50 per hour

reflected a reasonable cost for training.

Table 18. Why is it important to complete training that focuses on behavioral health needs of older adults? Check all that apply

Direct Care Respondent Administrative Respondent

Number (n=116)

Percentage Number (n=153)

Percentage

Improves my job performance 87 75.00 124 81

Helps save money for my agency 12 10.34 44 28.8

It helps meet certification & licensing 31 26.72 72 47.1

Improves how I feel about work 44 37.93 95 62.1

Improves quality of life for older adult 108 93.10 142 92.8

Improves the safety of older adults 83 71.55 128 83.7

I do not think it is important 0 0.00 0 0


Table 20. What are some barriers to taking part in training on the behavioral health needs of older adults?

Direct Care

Respondents Administrative Respondents

Number (n=116)


Percentage*

The training takes me away from my shift

40 34.48 94 63.1

I do not get paid to cover the cost

31 26.72 14 9.4

My employer does not have a budget

33 28.45 27 18.1

My employer does not offer paid time

17 14.66 13 8.72

The training is not required for my job 34 29.31 40 26.8

Table 19.How would you rate the following?

Need for training Ability to complete Interested in training

Direct % Admin % Direct % Admin % Direct % Admin %

(n=115) (n=148) (n=114) (n=148) (n=114) (n=145)

Very Low (1) 2 3 3 1 2 1

Low (2) 3 7 9 8 2 5

Average (3) 41 51 32 36 25 46

Above Avg. (4) 33 26 32 37 36 39

Very High (5) 21 13 24 18 36 8

Mean 3.68 3.39 3.66 3.62 4.03 3.48

Std Dev 0.90 0.92 1.02 0.92 0.92 0.77


EXECUTIVE SUMMARY

The State of Iowa recently began a comprehensive effort to redesign the public

mental health system. Work Groups were formed to identify and establish uniform

eligibility requirements, coordinate financing, and improve service delivery. In addition,

the State of Iowa is responding to changes in federal regulations about persons with

behavioral and psychiatric disorders being admitted to or residing in nursing and other

residential care facilities. These changes address many issues in identification,

diagnosis, treatment, and referrals for community based services. Meanwhile, within

this dynamic context, the state continues to grow older. Iowa is on the forefront of

America’s aging population boom. Iowa currently ranks first in the nation in the

percentage of citizens over the age of 85. According to the 2010 census, Iowans 65

and over represent 14.8% of Iowa’s three million people and the number is projected to

grow from 486,000 to 663,000 between now and 2020. Older adults will soon represent

1 out of every 5 persons living in the state. In this report, we examine the prevalence of

behavioral health disorders among older Iowans, review older adults access to

behavioral health services, and the use of specialty services in this population. We will

also consider the historical role of the Iowa Department of Human Services in providing

care to Iowan’s over the age of 60. We present findings from an on-line survey

completed by more than 300 individuals and discuss these findings within the current

context of public mental health system reform. This report concludes with

recommendations concerning the unique challenges presented by older adults with

behavioral health needs, and suggests training options and other efforts to improve the

readiness of Iowa’s redesigned mental health system to meet those needs.


BACKGROUND

One of the primary challenges presented by the aging of the population concerns

the growing number of older Iowans with a diagnosable behavioral health problems or

late-onset psychiatric disorder. In examining the use of health care services among

375,000 Iowans over the age of 65, we observed slightly more than 38,000 (10.2%) who

presented to a qualified Medicare provider and were diagnosed with one of six major

psychiatric disorders. Individuals with a single late-onset psychiatric diagnosis most often

presented with depression (24.2% of those with a diagnosis), altered states (20.5%), and

dementia (16.8%). Fewer individuals were diagnosed with anxiety (8.7%), schizophrenia

(2.0%), and substance abuse (0.9%). The most common co-occurring psychiatric

disorders were dementia and anxiety (48.8% of those in the sample with two or more

diagnoses), dementia and altered states (36.0% of those with two or more diagnoses), and

depression and anxiety (15.2% of those with two or more diagnoses).

Prevalence of Behavioral and Psychiatric Disorders among Older Iowans

The Online Survey Certification and Reporting System (OSCAR) indicated that

the prevalence of psychiatric illness among older Iowans living in nursing homes and

other residential facilities has steadily increased since 1995 (Cowles, 2004). OSCAR is

an administrative database of the Centers for Medicaid and Medicare Services (CMS)

collected annually by State agencies that license and certify nursing facilities. Slightly

more than 46.0% of all Iowa nursing facility residents (i.e., skilled nursing and

intermediate care facilities) were diagnosed with Alzheimer’s disease or other forms of

dementia. An additional 14.5% of nursing home residents experienced some other late-


onset psychiatric disorder, such as depression or anxiety. Since there are approximately

40,000 nursing and assisted living facility residents over the age of 65, we estimated the

number of older Iowans living in a nursing or assisted living facility and experiencing

dementia totals nearly 19,000. We estimate nearly 6,000 older nursing home and

assisted living residents may be diagnosed with depression or another type of

psychiatric illness (e.g., anxiety, schizophrenia).

As the incidence of fatal health conditions (e.g., cancer, heart disease) continue

to decrease and thereby increase life expectancy, the risk of acquiring a late-onset

mental illness will grow (Manton, Corder & Stallard, 1993). As such, we expect that the

number of older Iowans with a diagnosable psychiatric disorder will continue to grow at

a faster rate than the number of older Iowans in general over the next 20 years.

Specialty Service Use among Older Iowans with Behavioral Health Needs

Older Iowans with behavioral health needs are embedded in a highly

decentralized public mental health system in which there are very few qualified geriatric

behavioral health providers and specialty programs targeting older adults. There are

fewer than 6 geriatric psychiatrists and fewer than 50 geriatric nurse practitioners in the

State of Iowa. Throughout Iowa’s 99 counties, there is less than 1 licensed mental

health provider for every 100 older adults, and many of these have no specific training

in the area of serving older adults. There are only 5 community-based programs and 4

inpatient hospital psychiatric units across the entire state that target older adults

(Kaskie, Buckwalter, & Titler 2007). The National Technical Assistance Center for State

Mental Health Planning (Demmler, 1998) reported that use of both inpatient and


outpatient specialty mental health services by aging Iowans was much lower than the

national average.

After identifying 38,000 older Medicare beneficiaries with a diagnosed

psychiatric disorder, we determined that the majority received treatment from a primary

health care provider, not a psychiatrist or other qualified mental health professional

affiliated with the public mental health system. Efforts targeted toward behavioral health

for older adults seem to occur only in those places where the service demand is high,

administrative and clinical staff has made a concerted commitment, and/or the

organization has obtained some form of outside support. We know that older adults with

mental illness, and to an even greater extent, those with late-onset psychiatric disorders

do not fare well within decentralized and underdeveloped service systems. In this

environment, the role of the state mental health authority becomes more critical in

supporting the identification, diagnosis and treatment of older adults with behavioral

health needs.

State Efforts Pertaining to Older Iowans with Behavioral Health Needs

The Iowa Department of Human Services, Division of Mental Health and

Disability Services (MHDS) serves the administrative functions of the State Mental

Health Authority, and as such, has a primary role in oversight of the public mental health

services in Iowa. In 2002, MHDS sponsored a series of statewide educational programs

focusing on older adults with behavioral health needs. These educational programs

addressed the mental health problems associated with aging in broad ways, tried to

encourage community collaboration on how to begin addressing some of these issues,

and then reviewed effective pharmaceutical and psychosocial treatments. In 2004, the


Division of MHDS provided pilot grants to three local community mental health centers

(CMHC’s) to develop collaborative care models for older persons with mental illness.

In 2005, MHDS began supporting the Iowa Coalition of Mental Health on Aging

(ICMHA), which is housed at the University of Iowa, Center on Aging. ICMHA has a

focus on older adults beginning at the age of sixty, which aligns with the Administration

on Aging and most federal legislation language relating to “older” adults. The ICMHA

has since grown to a membership of over 500 individuals. ICMHA has hosted 20

collaborative continuing education events in all quadrants of the State, and several ICN

sessions. One ICN session, called “What’s new in Aging and Mental Health,” held in

June of 2010 was attended by over 600 individuals in more than twenty locations across

the state. ICMHA has joined with the National Coalition on Mental Health and Aging in

order to extend its capacity to learn from what is happening in other parts of the country.

ICMHA created a website that has been praised and well utilized across the state and

the country, hosted four legislative forums at the State Capital, and has worked to

inform public officials about the behavioral health challenges of the rapidly growing

population of older Iowans.

Still, the number of older Iowans served by the state’s county-based mental

health system remains negligible. In examining the service use patterns among 38,000

Medicare beneficiaries, we determined that less than 1,000 were served in CMHC’s.

The Iowa Medicaid Enterprise (IME) is the state Medicaid authority and as such,

has primary administrative responsibility for providing care to older Iowans with

psychiatric disorders, particularly those who live in nursing homes and other residential

facilities. In July 2010, the IME began a contract with Magellan Health Services to


manage the identification, diagnosis, and treatment of Iowa Medicaid beneficiaries 65

and over with behavioral health disorders. The SeniorConnect program, as it has been

named, appears to be underutilized by older Medicaid members. As of July of 2011,

Magellan provided services to less than 1% of all Medicaid beneficiaries over the age of

65 (N=170).

Preadmission Screening and Resident Review (PASRR) and MDS 3.0

In October 2010 the Center for Medicare and Medicaid Services unveiled the third

edition of the Minimum Data Set (MDS 3.0). The MDS is a data collection instrument used

by federal and state authorities to evaluate the provision of care within nursing facilities,

and consists of annual assessment of individual facility residents. One of the more

pertinent changes to the MDS 3.0 concerns the addition of a new item, which asks: “Has

the resident completed a PASRR evaluation?” PASRR refers to the federal requirement

that all individuals who are admitted to and reside in a nursing facility that accepts

Medicaid funding, must receive a “pre-admission screening” intended to identify

psychiatric needs and/or developmental disabilities. When an older adult screens

positive on the initial screening, then a subsequent and more thorough evaluation must

occur, known as a “level 2” PASRR evaluation, and this evaluation entails the

development of a plan of care to address any services that may be needed as a result

of the mental health or developmental issue. Another important element of the PASRR

process is the “resident review,” which must take place any time there is a significant

change in circumstances and at other points that may be determined by the resident

and the care team. A new item on the MDS 3.0 requires that a question be asked that

determines whether the individual has been offered information about in-home and


community based service options, other than facility placement, which may be available

in their community. If PASRR evaluations are not completed, nursing facilities may be

found out of compliance and receive a survey deficiency and possible recoupment of

Medicaid payment.

In July of 2011, the Iowa Department of Human Services contracted Ascend

Management Innovations, LLC, of Nashville, TN, to conduct PASRR Level II

evaluations. DHS has since amended the contract to add PASRR Level 1 evaluations

as well. The online system, called WEBSTARS, for PASRR screening, went into effect

in January of 2012. The explicit intent of these PASRR evaluations is to divert persons

with mental and/or developmental disabilities from being admitted to nursing facilities,

and to discharge or develop viable treatment approaches for those who are admitted or

reside in facilities. Since the contract began in July 2011, Ascend has been active in

offering training programs to individual providers and facility administrators who are

involved in the PASRR process.

METHOD

Study Design

The Center on Aging (COA) completed the study in three phases. First, the COA

developed and fielded a point-in-time survey of administrators and direct care providers

representing long-term care facilities, mental health and substance abuse programs,

hospital discharge planning, case management providers, (AAA and those involved in

the elderly waiver), and other organizations that serve older Iowans with behavioral

health needs. The survey was developed in collaboration with the Iowa Coalition on

Mental Health and Aging (ICMHA) leadership team led by Lila Starr from MHDS and


included George Dorsey of Magellan Behavioral Health, Terry Hornbuckle of the Iowa

Department on Aging, and Joel Olah of Aging Resources of Central Iowa. Once drafted,

the survey was reviewed and approved by the University of Institutional Review Board,

which also verified that all Center on Aging (COA) staff have been certified in Human

Subjects Research.

During the second phase of the study, the COA staff and ICMHA collaborators

conducted key informant interviews in an effort to strengthen our ability to generalize the

survey findings. The interview questions were developed after initial survey results were

reviewed, and questions focused on the viability of different alternatives that might be

recommended.

During the third phase, the COA staff analyzed survey responses, reviewed key

informant interviews, evaluated current education and training efforts, and then

developed a set of recommendations. Individual survey responses were summarized

and descriptive statistics (e.g., means, deviations, ranges) were generated for each

survey question. Responses to the interview questions were subjected to a content

analysis so that prevailing themes and categories were identified.

Sample

Survey administration used a snowball sampling technique. In particular,

leadership from multiple organizations across the State of Iowa were asked to link the

survey to their membership. The method sought to reach constituencies that largely

consisted of program administrators, mental health, aging, and substance abuse service

providers, and direct care workers involved with the identification, diagnosis and

treatment of older Iowans with behavioral health needs. The targeted organizations


included directors from each Iowa Area Agency on Aging, the Iowa Association of the

Area Agencies on Aging, the Iowa Caregivers’ Association, Community Mental Health

Centers, Substance Abuse Programs of Iowa, the Iowa Department of Inspections and

Appeals, the Iowa Department of Public Health, Community Colleges, the Iowa Hospital

Association, the Iowa Geriatric Education Center, the Iowa Health Care Association,

Iowa Association of Homes and Services for the Aging, the Iowa Mental Health and

Disability Services Commission, the Iowa Coalition on Mental Health and Aging

membership, and the Alzheimer’s Association of Greater Iowa.

Survey invitations also were sent directly to Central Point Coordinators, members

of the Olmstead Consumer Taskforce, graduates of the Iowa Peer Support Training

Academy, members of Magellan’s Peer Support Roundtable, DHS Targeted Case

Managers, the Iowa Caregiver’s Association, the Iowa Direct Care Workers Advisory

Council, the Iowa Association of Community Providers, members of the Iowa Disability

Advocates list serve, and the Iowa Advocates for Mental Health Recovery.

Each of these organizations or individuals received an email message and in

some cases follow-up phone calls that included a brief description of the project and an

invitation for them to pass the on-survey link to their constituents. The on-line survey

was opened on May 1, 2011 and closed on June 30, 2011.

Altogether, 315 people from across the State of Iowa completed the survey. Of

that total, 184 (58.4%) identified themselves as directors or managers of programs that

provided services to older Iowans (Table 21) and 131 (41.5%) indicated they were

involved in providing services directly to older Iowans including those with behavioral


health needs (Table 22). Table 23 shows the types of agencies where survey

respondents worked.

Table 21. Administrators/Managers survey respondents’ self-reported job titles.

Number Percentage

1. Chief Operating Officer 7 3.8 2. Chief Executive Office 10 5.4 3. Medical Director 1 0.5 4. Clinical Director 3 1.6 5. Director of Nursing 16 8.7 6. Executive Director 29 15.8 7. Program Director 25 13.6 8. Program Manager 25 13.6 9. Other: 68 37

Total 184 100%

Table 22. Direct Service Provider survey respondents’ self-reported job

titles.

Number Percentage

1. Nurse, ARNP, LPN or RN | 10 7.5 2. Direct Care Worker (CNA) 12 9.0 3. Case Manager 23 17.3 4. Licensed/Certified Mental Health 17 12.8 5. SCL (supportive community living) 5 3.8 7. Licensed/Certified Sub Abuse 23 17.3 8. Hospital Discharge Planner 1 0.8 9. Peer Support Specialist 13 9.8 10. Other 27 20.3

Total 131 100%


Data Collection

Data was collected from three different sources. First, the majority of data was

collected through the on-line survey completed by 315 individuals. Second, data was

collected from the 10 key informant interviews by ICMHA leaders. Third, data

concerning education and training opportunities was collected by Center on Aging staff

Table 23. Agencies and organizations where survey respondents self-reported

they worked.

Number Percentage

Area Agency on Aging (AAA) 14 4.42

Assisted Living Facility 4 1.26

Continuing Care Retirement Facility 4 1.26

Home and Community Based Services provider 25 7.89

Hospital 14 4.42

Intellectual Disabilities Waiver Provider 10 3.15

Intermediate Care Facility for individuals 4 1.26

Skilled Nursing Facility 45 14.2

Case Management or TCM provider 41 12.93

Rehabilitation Facility 3 0.95

Residential Care Facility (RCF) 12 3.79

Senior Center 3 0.95

Community Mental Health Center (CMHC) 22 6.94

Substance Abuse Services Provider 31 9.78

Wellness, Recovery, or Drop In Center 11 3.47

I am an independent provider 9 2.84

Other: 55 17.35

Total 315 100%


who researched on-line and other sources focusing on education and training targeting

health care workers and allied professions.

Survey Administration

To facilitate maximum response, the survey was presented on-line, questions

were written at the eighth grade reading level, and questions were formatted in multiple

choice, yes-no, and short answer formats. The survey itself consisted of 20 questions,

organized into five parts. The first part collected information on where the person

worked and their job role. The second part consisted of questions that pertained to the

older adults (age 60 and over) that were served and their behavioral health needs. The

third part collected data on the programs and services provided to the older adult. The

fourth part focused on education and training, including what is available, the different

mediums and barriers. The last part of the survey focused in aspects of the 1999

Supreme Court Olmstead decision, gathering information about how respondents help

older adults make choices about where they live and services they receive.

The survey was edited and formatted by the University of Iowa Social Science

Research Center (SSRC). The first survey draft was reviewed by the Center on Aging

and affiliated consultant team, and was piloted from a select sample of potential

respondents. The pilot assured that the survey was easy to complete in a timely

manner, and the information necessary to answer the questions was readily available to

the survey respondent. Once closed, survey answers were crosschecked for accuracy

and missing items that constituted more than 5% of any single variable response were

substituted using mean imputation, as necessary.


Key Informant Interviews

We developed interview questions after an initial analysis of survey results, and in a manner to collect addition information. In total seven questions were developed:

(1) What federal and state requirements are you aware of that necessitate staff training for older adults with behavioral health issues?

(2) What are some motives or incentives for staff training?

(3) Discuss the barriers for staff training.

(4) What are the best modalities to offer staff training (e.g., in-person, online)?

(5) What is a reasonable cost for completing two hours of training?

(6) What are topics that should be addressed in future training efforts?

(7) What could the ICMHA (Iowa Coalition on Mental Health and Aging) do to assist your efforts to provide training? The individuals were assured that their individual responses would remain

entirely anonymous. Hence, we are providing no organizational affiliation for the ten

individuals who completed the interviews. Interviewees did not receive any gift for their

participation. The interview answers were compiled on-line in a secured database at the

University of Iowa, Center on Aging. Using standard content analysis methodology,

(Government Accountability Office, 1989), the COA research team analyzed the data for

themes and categories.

Analysis

Our analysis consisted of three parts. The first part described the survey

answers, sorting them by the type of individual who responded to the survey. These

statistics were reported as basic frequencies, percentages, and proportions for


categorical and binary data. The second part of the analysis used the content analysis

to add to these survey results. The third part of the analysis provided a descriptive

summary of the education and training opportunities that are most readily available.

Missing data was limited and did not occur in a systematic pattern to bias the results.

Statistical analyses was completed with the latest version (9.2) SAS Statistical

Software. It should be noted that all questions in reference to identifying, screening,

assessing, and all questions related to training pertain specifically to older adults with

behavioral health needs.

DISCUSSION

Between January and September 2011, the University of Iowa, Center on Aging

conducted a survey of more than 300 individuals who work with older adults with

behavioral health needs. The findings confirmed that older adults do not typically

present with schizophrenia and other chronic or persistent psychiatric disorders that

appear among younger adults. Instead, a substantial number of older adults present

with diagnoses of delirium and altered states, disorders that have acute and severe

manifestations requiring urgent attention and continued observation for up to 14 days.

Older adults also present with anxiety and depression. In some cases, these appear as

recurring, life-long episodes and other times they appear for the first time after the age

of 60.

Additionally, the appearance of substance abuse in older adults is comparably

lower than younger populations. However, we remain cautious about drawing a

conclusion on this as the arrival of the baby boomers may contribute to increasing rates


of illegal substance abuse, the life-long use of alcohol may become problematic in older

persons as metabolic changes occur, and medications may create unique interaction

effects. We certainly advise that the misuse of medication, especially painkillers and

psychiatric prescriptions, should not be overlooked.

Our findings also confirmed the significant problems with service access and use.

Older adults are not routinely given access to a standard behavioral health screening

and identification process, and those with behavioral health needs more often appear in

primary health care settings where they are less likely to be engaged in an evidence-

based approach to care.

Further, our findings indicated that the majority of administrators and direct care

providers were engaged in a variety of training programs and it is unclear how much

these training programs have specific focus on behavioral health care for older adults.

Administrators were more engaged in completing training programs pertaining to the

new PASRR requirements and MDS 3.0, which are oriented to the PASRR screening

process and federal requirements. We anticipate this training will become more

common as the state’s PASRR program expands. In contrast to the administrators’

training, 28% of direct care respondents still had not completed any professional

training concerning PASRR or on the behavioral health needs of older adults.

Survey respondents indicated training was made available in multiple formats

and addressed several critical issues and diagnostic groups. Survey results and key

informant interviews found the main barriers to training were costs, time and travel.

Finally, our study revealed that individuals increasingly prefer that training efforts be

provided in person and on-line. Fixed media (e.g., compact discs) and the Iowa


Communications Network were the least popular among survey respondents, although

utilization of these formats has been quite limited. The lack of popularity of the ICN

among survey respondents is in contrast to the high attendance of past ICN Sessions

offered by ICMHA and Magellan Behavioral Health.

There are, however, many agencies in Iowa and throughout the United States

that offer internet based trainings. Some of these organizations include the Case

Management Society, Magellan Health Services, Iowa Geriatric Education Center, Iowa

Health Care Association, Iowa Nurses Association, SAMHSA/HRSA, Senior Family

Network, Silverchair Learning Systems, and the National Association of Social Workers.

The courses also have varying costs, but the majority of trainings cost about $10-$50.

It is worth pointing out that we observed differences in the results when

comparing the answers provided by administrators with those offered by direct care

workers. For example, administrators were more familiar than direct care workers with

the new MDS 3.0 rules, which are more directly related to Olmstead and community

placement than to issues of behavioral health. There also were differences in what

topics the two groups felt were important to be covered during training programs. A

greater number of administrators indicated that behavior management was covered

during these trainings and a greater percentage of administrators endorsed having

training on the care needs of older adults, such as bathing and dressing.

In contrast, a greater percentage of direct care respondents felt end-of-life issues

and coping with grief were important more so than administrators. Lastly, direct care

workers did not value and self-paced (CD, DVD, etc.) learning programs and endorsed

ICMHA and other in person and off-site training programs more than administrators.


Limitations of the Study

There are at least two limitations to this study. First, the snowball sampling

technique used led to a distinct selection bias in the types of persons who completed

the survey. For example, there was an oversampling of providers who have contact with

older individuals with substance abuse disorders and an under-sampling of hospital-

based programs. Second, there were no tests of statistical significance completed and

as such, discussions about difference between the two groups of survey respondents

should not be considered conclusive.

RECOMMENDATIONS

As the State of Iowa moves forward with a comprehensive effort to re-design the

public mental health system, there is a substantive need to consider the challenges

presented by Iowa’s aging population. Older Iowans will soon represent 1 out of every 5

persons living in the state, and in some counties, Iowans over 65 already constitute 1 of

every 4 residents. In designing the public mental health system, planning efforts must

anticipate the continued and rapid growth of the aging population – a population that

presents a unique array and substantial number of behavioral health needs. In other

words, Iowa’s redesigned public mental health system should not only resolve current

challenges and address immediate concerns, the system should be built to support

what lies ahead.

Many aspects of system re-design can and should be universal in their

application and effect, such as the use of a standard functional assessment instrument


to determine clinical acuity and service need and the provision of evidence-based

treatments such as collaborative care models, assertive community outreach and

treatment, Healthy Ideas, and Pearls. Three primary considerations should be taken into

account concerning Iowa’s aging population. First, older adults present with separate

and distinct behavioral health disorders, such as dementia and altered states.

Disorders that are common among younger adults, such as anxiety and depression,

sometimes do not appear until later in life. These late onset behavioral health disorders

may occur in older adults after one has experienced a relatively healthy adult

development. Second, the identification and provision of appropriate behavioral health

services is lacking for older Iowans to a much greater extent than for other population

groups including children and younger adults. Behavioral disorders among older Iowans

often go undetected and are more often discovered in healthcare settings (primary care

office and long term care facilities) rather than specialty behavioral health settings (i.e.,

community mental health centers). Third, the Iowa Department of Human Services,

both the Division of Mental Health and Disability Services and the Iowa Medicaid

Enterprise, have an important leadership role in educating the public, training

providers, administering and financing programs, and reimbursing and evaluating

services. Their efforts pertaining to older adults are shaped by and financed from the

federal level to a greater extent than is the case with other populations.

Responsibility for addressing the distinct challenges of older Iowans with

behavioral health needs falls largely on the Department of Human Services and those

who are collaborating with DHS to redesign the public mental health system. In addition


to supporting the inclusion of a significant focus on the needs of older Iowans within the

redesign, we recommend the following:

1) The Division of Mental Health and Disability Services (MHDS) and Iowa

Medicaid Enterprise (IME) must advance the notion that the spectrum of

behavioral health disorders changes with advancing age, and these disorders

should be considered while defining the different categories of service needs;

2) MHDS and IME should promote increasing collaborations with primary health

care providers, as these are primary service locations for identifying

behavioral health disorders in older adults and providing care to those who

are experiencing acute distress which requires observation and treatment;

3) MHDS and IME should continue finding ways to offer training to a variety of

stakeholders, including primary health care providers, aging and long term

care services providers, direct care workers, and others about evidenced-

based treatment programs for behavioral health in older adults, including

collaborative care models aimed at screening for behavioral health issues,

followed by effective treatment;

4) MHDS and IME should continue supporting the development of more

community based services to give older adults options for quality care in the

least restrictive environments;

5) MHDS and IME should consider developing a state-wide roster of individuals

who have completed training in the provision of care to older adults with

behavioral health needs and then track their engagement in providing care to

older Iowans;


6) MHDS and IME should look to use federal supports (SAMHSA/CMHS,

Medicaid, and Medicare reimbursements) to finance training, program

developments, and service delivery.

7) MHDS and IME should continue identifying, disseminating, and evaluating

training options as identified by this survey. It is clear that direct care

workers, aging and long-term care service providers, mental health,

substance use providers, and providers of services to older individuals with

developmental disabilities and co-occurring conditions share many training

needs, including those around Olmstead and how to offer community based

choices to older adults, how to identify and provide evidence based care to

older adults with behavioral health diagnoses, and how to serve older adults

so that they can live, learn, and thrive in the communities and least restrictive

service settings of their choice.


REFERENCES

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Demmler, J. (1998). Utilization of specialty mental health services by older adults: National and State profiles. National Technical Assistance Center for State Mental Health Planning. Alexandria, VA. Estes, C., Binney, E., & Linkins, K. (1994). Community mental health services and the elderly: Structure, access, and outreach. Washington, DC: Andrus Foundation. Kahn, R. L. (1975). The mental health system and the future aged. The Gerontologist, 15, 24-31.

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Kaskie, B., Buckwalter, K & Titler, M (2007). The Collaborative Model of Mental Health Care for Older Iowans: Guidebook. Iowa City, IA: University of Iowa, Center on Aging.

Kaskie B & Szescei D. Translating models of collaborative mental health care: Using Iowa’s experience to inform national efforts. Journal of Aging and Social Policy 23, 3, 258-273, 2011.

Manton, K., Corder, L., & Stallard, E. (1993). Estimates of change in chronic disabilities and institutional incidence and prevalence rates in the U.S. elderly population from the 1982, 1984 and 1989 national long term care survey. Journal of Gerontology, 48, s153-166.

U.S. Bureau of the Census (2010). Census of United States Population. Washington DC. U.S. Department of Health and Human Services (1999). Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.

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