Improving Behavioral Health Care For Older Americans: If Not Now, When?

In his first State of the Union, President Joe Biden addressed the national mental health crisis, urging the nation to achieve parity between physical and mental health care. The White House published an associated brief outlining strategies to tackle the crisis, including strengthening system capacity, increasing access, and identifying priority populations. This national attention marked an extraordinary opportunity to address the mental health needs of all Americans, which include the mental health needs of older adults.

Behavioral health needs of older adults are often not identified or addressed, despite  approximately 20 percent of older adults meeting criteria for some type of mental health diagnosis. Baby boomers have higher rates of behavioral disorders than earlier cohorts of older adults. Additionally, substance use among older adults is an emerging public health issue, with high-risk alcohol use and other drug use growing among this cohort. Mental health comorbidities within older populations shorten their lifespans and have high costs to families, health systems, and society.

Scope Of Geriatric Behavioral Health Burden

Aging is associated with unique challenges that can negatively impact mental health, including loss of social support, increased illness burden, and functional decline. For many reasons, including ageism, mental health conditions such as depression among seniors often go underdiagnosed and undertreated. Many older adults with mental illnesses also have chronic physical illnesses. The reverse is also true: Living with chronic physical illnesses makes seniors even more likely to have or develop a mental health condition, which itself can be life-shortening.

Depression is the most prevalent mental health disorder experienced by seniors; in fact, seniors ages 85 and older are at the highest risk for suicide of any age group. Depression can cause similar symptoms as dementia and Alzheimer’s and can be an early warning sign of dementia. Although the rate of older adults with depressive symptoms tends to increase with age, depression is not a normal part of growing older, and is a treatable condition.

For example, a recent Lancet commission on depression identified an association between loneliness and the development of depressive symptoms, especially later in life and within the context of COVID-19. Moreover, the experience of caring for an older adult with a behavioral health condition is usually demanding and frequently an isolating experience that places caregivers at risk of becoming depressed or anxious themselves.

Key Challenges

An Inadequate Number Of Geriatric Professionals In Behavioral Health

Overall, the US has a substantial workforce gap in meeting the needs of people with behavioral health conditions. This is especially true for behavioral health professionals who have special training and expertise in geriatrics. For example, less than 1,300 geriatric psychiatrists are active in the United States with severely disproportionate allocation. More than half of geriatric psychiatrists live in one of seven states (California, Florida, Massachusetts, New Jersey, New York, Pennsylvania, and Texas); and two states (Mississippi, North Dakota) have no geriatric psychiatrists.

Additionally, many behavioral health practitioners do not accept fee-for-service Medicare, the insurance model used by most older adults. It is important to note that not all older individuals with behavioral health conditions necessarily need to be treated by geriatric specialists. As noted in the 2012 National Academies of Sciences, Engineering, and Medicine report on “The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?”, most older adults with mental health and substance use conditions are treated by generalist health care providers.

However, the report also noted that the educational, training, and certification and licensure requirements for the workforce that cares for older adults with geriatric mental health and substance use conditions are vague, inconsistent, and minimal at best. Unfortunately, few of the report’s recommendations have been implemented in the decade since its publication.

Barriers To Access

Due to lingering stigma and scarcity of services in the US, mental health care access for the general population remains difficult and is even  more constrained for the older population. Additionally, older adults with evidence of mental disorders are less likely than younger adults to be diagnosed or receive mental health services. When they do receive mental health services, they are less likely to receive care from a mental health specialist. Only 20–25 percent of older adults with mental disorders receive services from mental health professionals.

Low utilization of mental health services reflects access problems stemming from social factors such as stigma, ageism, and ignorance about mental illness and the effectiveness of treatment. Structural barriers to access include but are not limited to severe workforce and service shortages, issues of affordability, restricted access to medications, shortage of services in the home and community settings, lack of transportation, and lack of culturally competent care. While the rise of telemedicine during COVID-19 has helped circumvent transportation issues, older Americans can have difficulty affording, accessing, and using devices.

Care Is Fragmented And Often Of Uncertain Quality

For centuries, behavioral health has been separated from general medical and surgical care. Even within behavioral health, mental illness and substance abuse care are siloed off from each other. Lack of coordination is especially a problem for seniors given their high rates of comorbidity of chronic medical and behavioral conditions. While integrated care has been a recently stated goal in US health policy, progress has been slow. Recent efforts creating payment codes for integrated collaborative behavioral health care have been cumbersome to apply, and thus primary care providers have not been able to be fully reimbursed for integration efforts.

A significant factor in the lack of progress in integrating care and improving quality is a dearth of robust, evidence-based quality measures in the behavioral health arena. Quality metrics are essential, but they are especially challenging in behavioral health due to limited practical data sources. Most metrics are process/claims-based measures, and few have proven associations with health outcomes.

Furthermore, among the measures that have been implemented, there has been limited progress in demonstrating improvement in quality. There is only one formal quality measurement program specifically devoted to behavioral health, the Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program, which incentivizes reporting, not performance. IPFQR is composed primarily of process measures with limited evidence linking them to outcomes.

Moreover, there has been minimal improvement in performance on these measures. For example, one of the IPFQR measures assesses the extent to which an individual who is hospitalized for a psychiatric condition is seen in follow-up outpatient care within seven days. Nationally, less than 40 percent of those patients have an outpatient visit within a week. There has been no improvement in this measure for the past 10 years. In fact, for patients in Medicare health maintenance organizations, performance has declined.

Medical Comorbidities May Present Additional Challenges For Behavioral Health Delivery

Older adults living with serious medical illnesses such as cancer, stroke, neurodegenerative disease, kidney failure, and/or heart disease may be at particularly high risk of behavioral health comorbidities such as depression and anxiety. Conversely, older adults with preexisting behavioral health morbidities may be at higher risk of developing or exacerbating serious medical conditions, especially those individuals with serious mental illness such as psychotic disorders and bipolar affective disorder.

Older adults with medical comorbidities may have a difficult time accessing behavioral health services. However, most subspecialty medical care as well as palliative care does not integrate behavioral health services as part of their framework of care. Furthermore, clinical experts at the intersection of geriatric mental health and serious illness/multiple chronic condition care are even scarcer than general geriatric mental health clinicians. And training in serious illness or palliative care is unstandardized for geriatric mental health experts. As such, current silos between general and mental health services may reduce care use, quality of life, and overall life expectancy of older adults.

Strategies For Overcoming Barriers

Integration

Integrated care services are crucial to meet the needs of the growing numbers of individuals with multiple complex chronic conditions in need of comprehensive care in a cost-effective manner. The primary care point of access results in a substantially greater treatment engagement by older patients than referral to specialty mental health/substance abuse clinics. Mental health service delivery should be integrated into health and aging services, including primary care, serious illness care, home health care, adult medical daycare, adult homes, assisted living, nursing homes, senior centers, community-based services, and so forth.

Community-based care delivery models are a growing approach to delivering coordinated, comprehensive care to the older population that often struggles with complex needs. Community integration investment and successes can provide supports that enable older adults to age in place, as a significant proportion of the population desire.

Strong integration and delivery of mental health services enable older adults with dementia, major depression, anxiety disorders, or long-term psychiatric disabilities to remain in or return to the community and avoid institutionalization in adult and nursing homes. The Program of All-inclusive Care for the Elderly (PACE) is one promising example of a community-based care model available in some states to serve a dually eligible Medicare and Medicaid population. PACE organizations apply an interdisciplinary team approach to meet older adults’ care needs and may offer opportunities for developing innovative approaches for integrating behavioral health and general medical care.

Older adults with complex medical needs, such as those with serious medical illness or multiple chronic conditions, are in particularly high need of integrated approaches that address the complex interactions between medical and physical comorbidities. With few exceptions, integration of behavioral health care into serious illness and palliative care remains inchoate. However, new models have emerged suggesting a framework for the implementation of such integration in novel clinical programs. Such models may be adapted to the post-COVID-19 environment and may also inform the adaptation of existing integrated care approaches, such as the collaborative care model, to the care of geriatric patients with serious illness.

Accountability And Payment Models

Achieving integrated care requires a payment model that incentivizes and encourages flexibility, quality, and innovation. Leaders in health and aging policy advocate for policy changes such as bundled, capitated, and other value-based payments to promote the holistic and attentive delivery of care. However, it is essential that in applying these payment mechanisms, models should apply accountability mechanisms linked to patient outcomes that are shared both across behavioral health and general medical providers.

Technology

Telemedicine and technological procedures have important roles in the care of older adults as this population and its demand for behavioral health care grow. Despite access limitations and some age-related health challenges such as vision or hearing problems, cognitive decline, and decreased motor skills that may make telemedicine difficult for some, older adults want to follow technological developments and can successfully adapt to telemedicine.

Moreover, age-related challenges have not been shown to block older adults from successfully using telemedicine. Provider best practices have been developed and can include practice runs with specified platforms, collaborating with patient family/caregiver, using assisted technologies, and so forth. Providers can set up older adults with training and tools necessary for successful telemedicine adoption, and older adults demonstrated high stakeholder satisfaction with telemedicine.

Many older adults prefer telemedicine to face-to-face meetings because this method can be used to overpass barriers to attending in-person sessions such as transportation hurdles. The quality of telemedicine is not inferior to same-room treatment, evidenced by this study on telemedicine-delivered psychotherapy for older adults with major depression. Telemedicine allows older adults who may have health care otherwise inaccessible, connect to the care they need.

Workforce Strategies

While increasing the numbers of fully trained behavioral health providers will take decades, creative evidence-based workforce solutions can be applied now. For example, the Improving Access to Psychological Therapies (IAPT) program in the United Kingdom demonstrated transformational success for the treatment of adult anxiety disorders and depression through the use of “psychological well-being practitioners” (PWP). The program employs evidenced-based psychological therapies, routine outcome monitoring, and regular and outcomes-focused supervision. They are closely linked to more fully trained providers such as general practice physicians.

The Answer Is Now

Faced with the task of improving behavioral health care for older Americans, the question we should ask remains, “If not now, when?” In 2019, 54.1 million people in the United States were ages 65 and older, with the number projected to reach 89 million by 2050. With this drastic demographic shift, we cannot afford to wait.

In 1994, the Gerontologist published “Mental Health Care for Older Adults in the Year 2020: A Dangerous and Avoided Topic,” which accurately predicted that health care structures would be ill-equipped to effectively meet the behavioral health needs of older adults today. It failed to factor in a pandemic or the role that technology would play in clinical medicine but aimed to bring attention to this looming structural shortcoming. The reality today is that solutions for meeting the needs of this population depend on integrated health services success, especially via technology and flexile payment model strategies.

Creative evidence-based solutions are developed to confront drastic changes in our health care system, population demographics, and needs. With COVID-19 bringing unprecedented attention to the nation’s mental health and well-being, there is finally newfound hope that the mental health needs of older adults will be more fully and effectively addressed.

Authors’ Note

Harold Alan Pincus is employed by (all not-for-profit or public): Columbia University, New York State Office of Mental Health/Research Foundation for Mental Hygiene, and the RAND Corporation (adjunct staff). All research/training projects funded by not-for-profit or public sources. He is also on clinical advisory committees for: Cerebral, AbleTo, and Magellan Studi.