Community Integration for Older Adults with Mental Illnesses: Overcoming Barriers and Seizing Opportunities

Olmstead v. L.C., the 1999 U.S. Supreme Court decision which held that unnecessary segregation of individuals in institutions is discriminatory, challenges States and communities to find appropriate alternatives for older adults with serious mental illnesses. Older adults are doubly stigmatized by their mental disorder and by their age, and they fall victim to a general lack of long-term care opportunities for older Americans.

This report, Community Integration for Older Adults with Mental Illnesses: Overcoming Barriers and Seizing Opportunities, is the third in a series of reports prepared by the National and Statewide Coalitions to Promote Community-Based Care under Olmstead project, sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services. It is designed to help State and local Olmstead coalitions understand the barriers that older adults face and learn about the innovative solutions being adopted and adapted across the country.

A Vulnerable Population

The number of older adults in this country is increasing rapidly, and so, too, are their needs for long-term mental health services and supports. Seven million people age 65 and older in the United States (20 percent of the older adult population) have a psychiatric illness, and that number is expected to double to 15 million in the next three decades. Older adults with serious mental illnesses receive lower quality of care and have higher mortality rates than older adults without a mental disorder. They are also three times more likely to be placed in nursing homes.

Frequently, older adults with mental disorders have comorbid medical conditions that complicate their treatment and long-term stability; they also may have alcohol-related or drug use problems. One in six older adults lives in poverty, and they are increasingly likely to be members of minority groups. Suicide rates are highest among Americans age 65 and older.

Most older adults with mental disorders live at home. However, among older adults with serious mental illnesses in institutions, 89 percent reside in nursing homes. Many older adults who left State psychiatric hospitals under deinstitutionalization were actually “transinstitutionalized” into nursing homes. Community services for people with serious mental illnesses failed to materialize, and financial incentives, rather than individual needs or desires, drove placement decisions.

The Preadmission Screening and Resident Review (PASRR) provisions of the Nursing Home Reform Act of 1987 have led some States to identify people with serious mental illnesses who can be more appropriately treated in the community and plan services for them. Other States comply minimally with the PASRR requirements.

Barriers to Community Integration

Numerous fiscal, service system, clinical, and societal barriers make it difficult for older adults with serious mental illnesses to find long-term, community-based treatment, housing, and supports. Current reimbursement and fiscal policies tend to favor inpatient versus outpatient care; medical versus psychological care; acute versus chronic care; and more restrictive versus less restrictive care. In particular, Medicaid funding is largely focused on institutional services, and Medicare coverage for mental health services is limited.

Older adults with serious mental illnesses may be particularly ill-served in managed care programs. Many managed care plans lack the full array of community support and residential rehabilitation options that older adults with serious mental illnesses require, and such plans may have fiscal incentives to avoid individuals who have comprehensive, long-term treatment needs.

A significant number of older adults with serious mental illnesses and substance use disorders remain unrecognized and untreated. Service system fragmentation and lack of training for both mental health and primary care practitioners are partially to blame. Many older adults prefer to receive their mental health care from their primary care providers, but most primary care practitioners lack training in geriatrics or mental health, and far too few mental health specialists lack training in geriatrics as well.

Though older adults represent 13 percent of the U.S. population, they receive only 6 percent of community mental health services. Even when services are available, older adults face transportation, language, and cultural barriers. In addition, housing options are particularly limited for older adults. For lack of alternatives, many older adults with serious mental illnesses live in facilities that are not specifically designed for people with mental disorders, such as assisted living facilities, or in facilities that may be poorly regulated and offer few services, such as board and care homes.

The stigma of mental illnesses and substance use disorders, and the lack of understanding that these problems can be successfully treated in older adults, keep many older Americans from seeking the help they need. Insufficient attention to prevention of mental disorders and excess disability associated with mental disorders also limits the type and scope of services that older adults receive.

Prevention

The Surgeon General’s 1999 report on mental health defines prevention broadly as the development of interventions for “reducing the risk of developing, exacerbating, or experiencing the consequences of a mental disorder” (p. 341). Preventive interventions focus on decreasing risk factors—such as isolation, poverty, and bereavement—that place older adults at risk for developing mental disorders or suffering a relapse of a current condition—and increasing protective factors that guard against negative outcomes. Protective factors for older adults include family support; formal support groups; health and social services; and opportunities for new, productive social roles.

Both support groups and peer counseling have been shown to be effective for older adults at risk for depression. Bereavement support groups, in particular, can help improve mental health status for widows and widowers. Older adult consumer counselors can talk to their peers from firsthand experience about the symptoms of mental illnesses and substance abuse disorders and the fact that treatment works.

Because caregiver distress is a significant risk factor for institutionalization, those interventions that support caregivers and give them needed respite have been shown to be effective in delaying or preventing nursing home placement for older adults with mental disorders. In general, interventions for caregivers that are individual and intensive have proven more effective than less potent and focused interventions.

Successful Practices

Progress in the treatment of mental disorders and in the care of older adults means that older adults with serious mental illnesses no longer must be consigned to live out their lives in institutional care. Increasingly, long-term care for older adults with serious mental illnesses is conceived of as a range of services needed to maintain an individual in the least restrictive setting possible.

Meaningful services for older adults with serious mental illnesses are based on the following underlying principles: services should be accessible, culturally sensitive, comprehensive, flexible, coordinated, multidisciplinary, and continuous. Successful programs feature accurate assessment, outreach, interdisciplinary treatment, education, collaboration with other agencies, and home care services.

States and communities have implemented a number of evidence-based and promising practices for older adults with serious mental illnesses. These include the following:

Screening and Assessment. Routine screening by health care providers for cognitive, behavioral, and emotional disorders is recommended to ensure access to quality mental health care. Evidence for the effectiveness of standardized screening is provided by evaluation of an integrated toolkit that is now a standard part of care in the public mental health system in New Hampshire. This toolkit also is being piloted in other States.

Home and Community-Based Mental Health Outreach Services. Older adults receiving outreach services have shown increased likelihood of receiving case management services, decreased mental health symptoms, and decreased incidence and length of psychiatric hospitalization. Services modeled after the Gatekeepers program, which uses community members as frontline assessors, have been successfully implemented in both urban and rural areas.

Mental Health Treatment. Older adults with serious mental illnesses can benefit from both pharmacological and psychosocial approaches. Community-based, multidisciplinary mental health treatment teams are effective with older adults. Psychiatric home care can benefit older adults who have functional impairments that limit their ability to live independently.

Integrated Models of Service Delivery in Primary Care. Evidence supports incorporating behavioral health care into medical settings. Medication, psychotherapy, and psychiatric consultation can reduce medical costs, with the greatest savings among older adults.

In addition, several promising approaches provide direction for future development of community-based services. These include supported housing, attention to cultural competence in service delivery settings, and a focus on consumer involvement and empowerment. The Older Adult Consumer Mental Health Alliance has become an effective advocate for older Americans with serious mental illnesses and is promoting a message of hope and recovery through support for legislation, education, fundraising, and a national membership drive.

Finally, because no one service system is equipped to meet the multiple and complex needs of older adults with serious mental illnesses, effective services require coordination and collaboration among providers of aging, mental health, health care, substance abuse, and social services. Community coalitions have been instrumental in bringing disparate resource together to provide coordinated services. These coalitions exist at the local, State, and national level.

Conclusion

The vision of the Substance Abuse and Mental Health Services Administration, which oversees Olmstead planning for people with serious mental illnesses, is “a life in the community for everyone.” This goal closely mirrors the vision articulated in the Final Report of the President’s New Freedom Commission on Mental Health, which emphasizes that all people with mental illnesses should have access to effective treatment and supports to enable them to live, work, learn, and participate fully in their communities.

Though progress has been made in the care of older adults with serious mental illnesses, much remains to be done to achieve the fundamental systems transformation envisioned by the New Freedom Commission and to support full community integration. In the past, communities may have wanted to further integrate older adults with mental illnesses into community life. Today, the Olmstead decision and the New Freedom Commission provide specific guidance for accomplishing this goal.