• A Survey of Mental Health Service Providers

• A Survey of Substance Abuse Providers

• A Compilation of Public Comments

• A Survey of Agencies Serving Older Persons (non-mental health or substance abuse)

• An Analysis of Maine Medicaid Claims Data

• An Analysis of Long-Term Care Assessment Data (nursing facility, residential care, and in-home care)

Following are key findings by study. Tables with more complete data can be found in the Appendix.

This survey asked licensed mental health service providers to identify existing and needed mental health services (exclusive of substance abuse services). Findings were as follows:

• The most common service offered to individuals over 60 was medication management. This was provided to 1,647 individuals by 14 agencies, or 31% of responding providers. The second most common was case management (938 individuals) provided by 18 agencies, or 40% of respondents. The third was individual therapy (749 individuals), provided by 24 agencies, or 53% of respondents.
• Less than 20% of the agencies providing individual therapy indicated that they provide aging-related training to their staff.
• Intensive case management is a service directly provided by DMHMRSAS. As of December 27, 1999, the number of active cases across the state was 466 with five of those individuals over the age of 60. As of December 28, 1999, the AMHI class membership totaled 3,498. Of these, 384 are aged 60 or over.
• Sixty percent (60%) of the respondents reported that the most critical service gaps were insufficient PT services and in-home supports of all kinds.
• Seven of the ten most often cited needed services are or can be delivered as in-home services.
• There were few waiting lists for the mental health services indicated as most needed (exclusive of substance abuse and PTs).

This survey asked licensed substance abuse providers to evaluate existing and needed substance abuse services. Findings, which were similar those of the mental health providers survey, were as follows:

• 79% of responding agencies indicated the percentage of elderly served by their current caseload is between 1% and 10%. No agency indicated they had an elderly case load of over 20%.
• Fifty-five percent (55%) of responding agencies said their services were not very or somewhat effective, 35% said they are moderately effective, and 10% said they were very effective.
• Fifty-nine percent (59%) of the respondents indicated that their staff received training specifically related to serving elders. However, a need for more training was also indicated.
• Sixty-five percent (65%) of responding agencies indicated they are not familiar, or are only somewhat familiar, with programs/counselors who specialize in providing services for the older person. When asked if these services were available in their community, 40 agencies (80%) said "yes," while seven agencies (14%) said "no." In addition, providers noted that there were not enough specialized elderly services, that resources (such as money) are limited; that waiting lists for services are long, and that services are difficult to find and access.
• Providers were asked to identify systemic barriers preventing elders from receiving needed substance abuse services. The most serious barriers were a lack of assistance in accessing services; limited insurance coverage for services; and lack of home-based outreach services.
• Providers were asked to rank personal issues that might prevent elders from seeking substance abuse services. The issues rated most serious were denial or lack of awareness of having a substance abuse problem, unwillingness to admit a need for help or ask for help; and stigma associated with substance abuse treatment.

Comments were taken via a toll-free number that was set up to provide the public with an opportunity to express their concerns about issues and needs. A total of 23 calls were received, over a one month period, from most regions of the state. About half of the callers stated they were calling on behalf of themselves, and others said they were calling on behalf of a parent. Slightly more than half of those that called stated that had previously attempted to get help, and almost as many said they had found it difficult to do so. The major issues cited by callers were:

• The costs of medication;
• The fact that neither the public nor, in some instances, agencies providing services to elders are aware of all the available services to elders;
• Isolation ( there are few day or evening activities available to elders);
• A need for more and better respite for caregivers;
• The fact that providers, primary care physicians, and family care providers need better training in older adult issues, as well as better information about existing services and how to access them.
• The lack of :
• transportation;
• support groups;
• medical and dental services;
• daycare or partial hospitalization;
• any substance abuse services for elders;

This survey asked providers in a variety of settings -- ranging from adult protective services to hospital social work departments to homeless shelters -- to identify serious problems in the older adult mental health service delivery system and to recommend corrective action. Respondents self-selected (chose to respond to the survey), and thus are not necessarily a statistically representative sample.

Respondents were asked to estimate the number of older clients they serve with serious mental health, memory disorder, or substance abuse problems. ("Serious mental health problems" were defined as "persistent disturbances of mood or thinking," such as depression, anxiety and other symptoms). There was a wide range of responses among provider segments. For example, Adult Protective Services reported that 62% of their clients suffered from a serious memory disorder while RSVP/SEARCH provider stated an incidence of only 2%. However:

• Overall, respondents reported that 9% suffered from a serious mental health disorder, 24% suffered from a memory disorder, and 1% from substance abuse.
• When asked to estimate the percentage of individuals receiving treatment for these conditions, an average of all respondents noted that for mental health conditions, 16% of clients were definitely receiving treatment, and 8% were definitely not receiving treatment. For 76% of their clients, respondents weren't sure if treatment was being received.
• Respondents stated that 10% were receiving treatment for memory disorders, 8% weren't receiving treatment, and they weren't sure if 82% were receiving treatment.
• For substance abuse, treatment was being received by a reported 25% of clients, treatment was not being received by 28%, and respondents weren't sure about 46%.

Respondents were asked to rank potential problems in the mental health service and substance abuse delivery systems that might keep clients from receiving needed care. To accomplish this, respondents were asked to rate 11 key issues using a scale of one to three (most serious to least serious). The most frequently mentioned issues in mental health services (exclusive of substance abuse) were:

• A lack of home-based mental health or substance abuse services,
• Limited insurance coverage (including limited Medicaid or Medicare reimbursement), and
• A lack of community providers trained in older adult services.

The most frequently mentioned issues in substance abuse services (exclusive of other mental health interventions) were:

• A lack of home-based mental health or substance abuse services,
• Limited insurance coverage, and
• A lack of separate, specialized mental health or substance abuse services for older adults were rated most highly for substance abuse.

Next, Respondents were asked to consider personal problems older adults might face that might keep them from receiving needed services. They were presented with 11 key issues, and asked to rate them on the same one to three scale. In both the mental health and substance abuse categories, the issues rated the most serious were the same. These were:

• Denial or lack of awareness of a problem, stigma associated with receiving services or a fear of being identified as mentally ill or a substance abuser, and
• An unwillingness of older adults to ask for or accept help.

A list of key services that could help older adults with mental health or substance abuse needs stay in their current living situations was presented. Respondents were asked to rank these using the same one to three scale. In both the mental health and substance abuse categories, the top three responses were the same (though their ranking was slightly different). These were:

• In-home mental health or substance abuse services;
• Case management; and
• Availability of 24-hour-a-day/7-day-a-week services.

Finally, respondents were asked an open-ended question: "What is the one thing that would most help reduce the unmet mental health or substance abuse needs of the older adults?" Several themes emerged:

• More in-home services
• More public and client education
• Greater availability of services in general
• More money for services

This section provides highlights from the analysis of Medicaid claims data for beneficiaries age 60 and older residing in all settings. These data focus on beneficiaries with a diagnosed mental illness or pharmacy claim for mental health- related medications, and who had claims for services submitted to Medicaid in 1998, (unless otherwise specified).

• Approximately 23% (or 7,892) of the 34,140 Medicaid beneficiaries age 60 and older had a diagnosed mental illness in 1998; 1,434 or 4% of older beneficiaries had diagnosed mental illness and diagnosed dementia, while 228 older beneficiaries (under 1%) had a diagnosed mental illness and diagnosed mental retardation.
• Using a broad definition of mental health problems, including use of psychotropic medications and/or behavioral health services, and diagnoses of dementia and substance abuse, in addition to diagnosed mental illness, an additional 9,632 older beneficiaries (28%) have a mental health-related problem.
• Of the 17,524 older Medicaid beneficiaries identified using the broader definition, 6,954 (40%) received nursing facility services under Medicaid.
• Traditional behavioral health services, such as counseling and evaluation, billed to Medicaid for older adults are provided infrequently. For example, services provided by psychiatrists (such as counseling and evaluation) were provided to only 8% of older adults beneficiaries who had a diagnosed mental illness.

This study looked at assessment data for 17,668 residents of nursing facilities, 2,506 individuals in residential care facilities, and 5,871 consumers of home-based long term care services. All of these individuals were high-risk adults age 60 and older. Analyses of data provide information on met and unmet mental health needs and help estimate the prevalence of mental illness among this population. Findings were as follows:

• Diagnosed mental illness was more common among older adults in residential care facilities (38%) than among long-term care (LTC) consumers served in nursing facilities or in their own homes (27% and 26% respectively).
• Using the broader definition of mental illness discussed earlier which includes dementias, the percentage of long term care consumers with problems increases significantly. Seventy-six (76%) percent of all residential care consumers, 68% of nursing facility residents, and 56% of long-term care consumers served at home, have mental health problems.
• Among LTC consumers with a diagnosed mental illness (excluding dementia), the most frequent diagnosis was depression. Between 20% and 22% of consumers of LTC in all three settings had a diagnosis of depression.
• The second most frequent mental health diagnosis among LTC consumers was anxiety disorder. Among nursing facility residents, 7% were diagnosed with an anxiety problem, while 9% of residential care consumers and 10% of home care consumers had diagnosed anxiety disorders.
• Among consumers in residential care facilities, diagnoses of schizophrenia were nearly as prevalent as diagnosed anxiety disorders, with 8% and 9% diagnosed with schizophrenia and anxiety disorders, respectively.
• Use of medications (anti-depressants, anti-anxiety, anti-psychotics, or hypnotics) to treat LTC consumers with mental health problems ranged from 18% of consumers receiving home care, to 20% and 24% of residential care and nursing facility residents, respectively.
• Fewer than 4% of these high-risk consumers also received other treatment, such as counseling.
• Among those included in the more broadly defined group, 24% to 27% of long term care consumers had an indication of mental illness but no diagnosis of mental illness.
• Difficult behaviors such as physical and verbal aggression, displayed by LTC consumers in each setting, also provide insight into the challenges of providing adequate assistance to older adults with mental health and related problems. In general, a greater percentage of these consumers in residential care and nursing facilities had "problem" behaviors, compared to home-care consumers.