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Issues in Geriatric Mental Health Policy:
A Report of the Observations of Advocates,
Providers, Researchers, Academics,
Government Officials and Older Adults
Introduction
The Center for Policy and Advocacy of The Mental Health Associations of New York
City and of Westchester established The Geriatric
Mental Health Alliance of New York at the end of 2003 because the current mental
health system does not serve older adults with mental health conditions adequately and
because there has been so little preparation to respond to the growth of mental health
needs that will emerge during the elder boom. (We are grateful to the New York
Community Trust and The Stella and Charles Guttman Foundation for their financial
support of the first phase of the development of the Alliance.) The purpose of the
Alliance is to advocate for changes in mental health policy that will result in
improvements of current mental health services for older adults and for changes that will
lay the groundwork for the development of an adequate response to the mental health
needs of the elder boom generation.
The goals of the Geriatric Mental Health Alliance are to:
- Promote innovative practices to meet the mental health needs of older adults
- Develop proposals for policy changes needed to facilitate innovative practice
- Build a working alliance of people with diverse backgrounds who will advocate to
meet the mental health needs of older adults
- Aggressively advocate for policy changes
- Provide public education
As a first step, The Center for Policy and Advocacy convened four discussion groups
with people from a very broad range of fields including representatives of mental health
agencies, psychiatric hospitals, settlement houses and senior centers, nursing homes,
home health care agencies, governmental leaders from both aging and mental health,
researchers, academics, and advocates. The groups met in November 2003.
Participants in the discussion groups each received a briefing book, which contained
information regarding demographics, prevalence of mental disorders, utilization of
services, etc. The Briefing Book is available on this website in pdf
format. You will need Acrobat Reader to download this document. Copies of the
briefing book can be obtained by contacting center@mhaofnyc.org.
In addition to the discussion groups, Center staff met with the Joint Public Affairs
Committee for Older Adults (JPAC) and The Older Women’s League (OWL).
Approximately 80 older adult advocates representing senior centers and advocacy groups
throughout New York City attended this joint meeting. Center staff also interviewed
more than 40 older adults, geriatric experts, and advocates. Read the list of participants
in the discussion groups and people interviewed.
The discussion groups were tremendously successful. 85 people participated (a response
rate of about 80%). They made literally hundreds of important observations and
suggestions about the nature of mental health problems older adults experience, about
service needs and models, about caregivers especially family caregivers, about human
resource needs, about finance, about the roles and responsibilities of government and of
the private sector, about quality assurance, about research needs, and about strategies for
bringing about change.
In addition to providing great substance with which to begin The Alliance’s work,
approximately 100 of the participants in the discussion groups and of the people
interviewed have agreed to join the Alliance, and approximately 40 of them have
volunteered to participate in a workgroup, which will begin meeting in February. Read a
list of current Alliance members.
This report provides an overview of the broad themes that emerged from the discussion
groups, the interviews, and the meeting with older adult advocates. It does not do justice
to the number, diversity, subtlety, or depth of the participants’ observations. We hope,
however, that we have captured enough in this report to serve as a useful guide as we
begin the Alliance’s next phase of work, which will focus on setting priorities, building
consensus, and developing strategies for action. Read Preparing for the Elder Boom,
a concise summary of major issues originally
published in the Winter issue of Mental Health News and available on this site.
Major Themes
An Urgent Issue
Perhaps what is most clear from our contacts is the shared sense of the importance, even
urgency, of geriatric mental health policy issues. We had initially anticipated a single
meeting with 20-25 people interested in mental health policy and advocacy. But, as we
talked with people in the community, more and more asked to be invited to our meetings
and to participate in the advocacy efforts. A plan for one meeting grew to a plan for three
meetings, and they were immediately oversubscribed. We added a fourth, and still there
were people who wanted to participate who could not.
Our meeting with JPAC and OWL, groups of older adult advocates with only tangential
interest in mental health, revealed a similar sense of intense interest. We were invited to
a general meeting of about 100 representatives of senior centers and advocacy groups and
allotted 45 minutes to talk with them about mental health issues. One after another
people took the microphone to talk about mental health problems and concerns. The
people chairing the meeting finally had to stop the discussion after it had run
considerably overtime. JPAC has now decided to form a mental health subcommittee
because its members are so clearly concerned about the issues.
It is particularly striking that the sense of urgency about mental health policy issues is not
limited to the mental health community. We learned that both settlement house and
senior center leaders in New York City have identified mental health needs as their
number one concern. We heard from home health providers that they are overwhelmed
by the mental health needs of their clients. We heard from housing providers that many
of the people for whom they provide housing are mentally ill and that, as a result, some
of them exhibit behaviors and attitudes, such as hoarding and paranoid distrust, which
make them very difficult to house. We heard from public officials from the local
departments of aging in New York City and Westchester that addressing mental health
needs is increasingly critical from their point of view. And we heard from several people
knowledgeable about the private sector that the corporate community is increasingly
concerned about lost productivity due to workers’ family responsibilities for elderly,
disabled relatives, many of whom suffer from dementia and other mental disorders.
Clearly the mental health problems of older adults are not just a concern for the mental
health provider system. They are a concern shared across health, aging, housing, as well
as mental health in the public sector and have spread as a concern to the private sector as
well. We found that virtually everyone with whom we spoke believes that the failure to
address mental health problems adequately now, and the failure to plan for the elder
boom, reflect dreadful policy failures and that the time to address them is now.
Community Support
Our discussions revealed widespread hope that older adults with mental disorders could
be helped to lead satisfying lives in the community rather than routinely relying on
institutions. That is not to say that supervised, congregate living facilities are
unnecessary. Clearly some people with very limited ability to care for themselves—
particularly those who are poor and do not have families to care for them—need to be in
congregate living facilities. Nor does the general agreement that people should remain in
the community if at all possible indicate that there is agreement about who should live in
institutions and who in the community. But overwhelmingly the people with whom we
spoke believe that a fundamental goal of helping older adults with mental disorders is to
help them to live where they prefer, in the community. There is, that is to say,
widespread agreement that the fundamental job of a system of services for older adults
with mental health problems is to provide support for them to lead satisfying lives in the
community.
Access to Treatment and Supports
Our conversations also revealed widespread confidence that effective treatments — both
medications and psychosocial interventions— are now available and that they can help
people sustain satisfying lives in the community. Treatments for anxiety and mood
disorders are highly effective. Treatments for schizophrenia and other severely disabling
disorders can help people function well enough to lead satisfying lives in the community,
especially when combined with modern rehabilitative interventions and community
housing programs. Even those who specialize in serving people with Alzheimer’s and
other dementias are increasingly confident that there are treatments and interventions,
which will slow the sadly inevitable process of deterioration of cognitive functioning.
New drugs slow the decline a bit; good medical and psychiatric care can reduce
symptoms of cognitive dysfunction which mimic the symptoms of dementia; and activity
and social interaction help to sustain functioning as long as possible.
Unfortunately, however, access to effective treatments is highly limited; and many older
adults and their families do not seek treatment even when it is accessible.
Lack of access to good mental health interventions reflects a variety of factors:
- The severe shortage of trained mental health professionals
- High out-of-pocket costs because of inadequate and discriminatory Medicare
coverage as well as other funding inadequacies
- The trend for private and public insurance carriers to limit access to
state-of-the-art medications
- The lack of mobile services to reach out to people who cannot or will not leave
their homes for treatment in a mental health setting
- Lack of cultural competence not only with regard to minorities but also for those
who are deaf or visually impaired and for those who are lesbian, gay, bisexual, or
transgender (LGBT)
Low utilization of mental health services reflects not only problems of access but also
choices that older adults with mental health problems and their families make. They do
not choose to go to mental health professionals for a variety of reasons:
- They prefer to go for help to primary care physicians, the clergy, to social services
providers, or to other helping figures in their community.
- They, and their families, do not believe that they have mental illnesses or would
regard it as shameful if they did (internalized stigma).
- They, and their families, believe that symptoms of mental illness, such as
depressed mood, are a normal part of aging (internalized ageism).
- They do not know that treatment can be effective.
- They do not know where to go for treatment, especially affordable treatment.
- For many members of minority cultures and immigrant groups, especially illegal
immigrants, going for treatment may be culturally alien or they may fear exposure
and deportation.
Low utilization also reflects the fact that many people who could refer older adults for
treatment simply do not know how to recognize signs and symptoms of mental illnesses
or do not make an effort to identify them. Most primary care physicians, members of the
clergy, social service providers and others to whom people turn for help do not do routine
screenings for mental illnesses and frequently do not steer people to treatment.
Public Education
Recognizing that many people with mental health problems do not choose to go for
treatment that would be helpful to them, many participants in the discussion groups
emphasized the need for public education designed to overcome stigma about mental
illness and about old age. They also noted the importance of providing information about
the potential effectiveness of treatment and about where to go for help as well as to
reassure immigrants and others about the benefits to which they are entitled. Finally they
stressed the importance of training primary care physicians and other helping
professionals who come in contact with older adults to identify mental illnesses and to
make appropriate referrals.
A Diverse Population With a Broad Range of Needs
Perhaps because the people who attended our discussion groups and others whom we
interviewed were such a diverse group, it was exceedingly clear that older adults with
mental health needs are an extremely diverse population. It includes:
- People with serious and persistent mental illnesses
- People with disabling dementias such as Alzheimer’s
- People who suffer from anxiety and mood disorders which contribute to isolation
and inactivity
- People who abuse alcohol, prescription drugs, and (to a very limited extent)
illegal drugs
- People with mild and/or transient mental disorders
- People who are not currently mentally ill but who are at risk of becoming
mentally ill
- People who are at risk of suicide
- Family caregivers
In addition there is considerable diversity with regard to:
- Functional abilities, ranging from total independence to total dependency
- Living circumstances, ranging from comfortable private homes to apartment
houses to lifecare and assisted living communities to nursing and adult homes to
prisons to homelessness
- The availability of family support, ranging from living with family devoted to
their care to periodic contact to having no family support at all
- Socio-economic status, ranging from rich to middle-class to dependent on public
assistance
Clearly such a diverse population requires a very broad and diverse range of services
including high quality medical and mental health treatment, in-home treatment and
supports, rehabilitative day programs, opportunities for social activity and interaction,
housing, and more.
The Need for Service Integration
Over and over again in our discussions, people commented on the fact that the needs of
older adults overlap a number of different service systems.
It is especially important that co-occurrence of mental and physical illnesses is
commonplace. In part this reflects the fact that so many older adults have chronic health
conditions. But it also reflects the facts that some physical illnesses, such as heart
disease, Parkinson’s, Alzheimer’s, HIV+/AIDS, and others, are highly correlated with
mental illnesses such as depression, anxiety, and cognitive dysfunction and that
becoming physically disabled creates difficult psychological challenges. In addition it
reflects the fact that people with mental illnesses appear to have more physical
illnesses—some because of somatization, some because of reactions to psychiatric
medications, and some for reasons that are not yet known.
The use of health services, some participants observed, creates opportunities to improve
mental health services. Physicians who are trained to screen for mental illness or who
have mental health professionals working on-site with them could reduce the number of
undiagnosed and untreated older adults with mental illnesses. Home health workers
frequently come in contact with depressed and/or anxious older adults who live in
isolation. With training in identification and referral, home health workers could provide
an important linkage to isolated people with mental illness.
Several people we interviewed from behavioral managed care and health insurance
companies noted that efforts are now underway to use insurance claims data to flag
people for whom coordination of physical and mental health treatment is extremely
important.
Older adults, of course, also need the kinds of services, which are made available through
the aging system—meals-on-wheels, senior centers, subsidized housing, adult protection,
a response to elder abuse, etc. These services also create opportunities for identification
and referral. Many participants, however, suggested that it was more effective to have
clinical social workers on-site in senior and social service centers. Indeed “one stop
shopping” has become a goal for many providers and advocates.
Given the overlap of needs and services ordinarily within the province of the health,
mental health, or aging systems, participants universally stressed the importance of
developing integrated service structures.
Quality of Care
Several participants noted that the quality of care and treatment available to older adults
with mental illnesses is uneven. Some providers are well trained and skilled at the use of
state-of-the-art treatment techniques. Others are not up-to-date. Participants agreed that
there needs to be a great push to improve the quality of care and treatment in general. It
was also noted that Winds of Change, the New York State Office of Mental Health’s
initiative to improve practice, does not include anything regarding the treatment of older
adults.
Several participants were particularly concerned about the quality of mental health
services available to residents of institutions—especially skilled nursing facilities and
adult homes. Apparently most nursing homes rely on outside providers to come to the
home periodically to provide psychiatric assessments and treatment—mostly medication.
Even representatives of nursing homes we spoke with were troubled by this approach.
They prefer having mental health professionals on staff but noted that, although better,
the homes that take this approach are unable to afford enough staff to provide adequate
coverage. Adult homes, of course, have been the subject of a recent expose about poor
conditions and services. Advocates who work in adult homes who participated in our
discussions acknowledged that some homes provide reasonably good services but that
many provide exceedingly poor mental health care.
There was also considerable concern voiced regarding problems of cultural
competence—including shortages of staff who speak languages other than English, of bi-
cultural staff, and of staff trained in understanding the values and expectations of
different cultures.
The Need To Reconceptualize The Service System
Recognition of the broad range of needs, of the need for integration, and of the need to
improve quality of care and treatment contributed to the conviction that grew through the
discussion groups that the service systems currently in place to help older adults need to
be significantly reconceptualized. Participants realized that current systems are not only
hamstrung by inadequate financing and lack of qualified personnel but also by models of
care which do not adequately reflect the diversity of the population of older adults and
the specific nature of their needs.
Thus, for example, several participants who work with people with serious and persistent
mental illness suggested that the concept of “recovery”, which has become the central
goal of services for this population, might need to be reshaped to take into account
different social expectations and abilities of older adults. Similarly, several experts on
housing models for people with serious and persistent mental illnesses suggested that
expectations regarding independence and staffing models might have to be revised.
Similarly, participants who work with people who are depressed and isolated observed
that the design of the current mental health system is based on the assumption that people
with mental illness will come to an office where they will talk with a mental health
professional and perhaps get medication. This design, they noted, is entirely
unsatisfactory for people who rarely, if ever, leave their homes, for people who do not
think of themselves as mentally ill, for people who are ashamed to need psychiatric
treatment, for immigrants afraid to leave their local communities and others. For these
populations services need to be designed to reach out to people in their homes and
communities and to attempt to engage them on their own terms.
Finally several people suggested that service choices need to go beyond the traditional
array and that there are a variety of opportunities to use “alternative” therapies, such as
pet therapy.
Mental Health Promotion and Mental Illness Prevention
Many participants in our discussions were enthusiastic about opportunities to promote
mental health and prevent mental illness. They noted that good medical treatment helps
to prevent mental illnesses, especially those linked with physical illnesses and the
inappropriate use of medication. Older adult advocates with whom we met expressed
strong concern about over-medication for both physical and mental disorders.
Participants also noted the importance of lifestyle. Good nutrition, exercise, and
especially avoiding isolation and inactivity contribute greatly to maintaining mental
health.
Planning for old age can also be enormously helpful. Retirement is often a time of great
developmental stress, which can be ameliorated to some extent with careful planning
regarding finances, where to live, and what to do.
In addition preparing for the end of life appears to be of great importance to many older
adults. For example, the mental health committee of residents of a lifecare community,
which we visited, recently took on the task of helping residents to make end-of-life
decisions and to share them with their children, who would have to carry them out.
For people with serious, recurrent mental illnesses, the prevention of relapses is important
and achievable. For example, family psycho-education has been demonstrated to result
in reduced rates of relapse.
Life Expectancy of People With Mental Illness
One participant, a person with a serious recurrent mental illness, noted that people with
such mental illnesses have lower life expectancy than the general population. He
advocated for access to better health care and help maintaining a healthy life style—often
difficult for people who are poor, especially if they are isolated.
Suicide Prevention
Older adults commit suicide 50% more often than the general population overall and at
considerably higher rates as they age, peaking at six times the national average among
white men over the age of 85. Research indicates that these suicides are highly correlated
with undiagnosed and untreated depression. It appears, therefore, that there are
significant opportunities to reduce the rate of suicide among older adults.
Everyone with whom we spoke supported the development of an aggressive suicide
prevention program for older adults.
Palliative Care
However some also noted that some suicides reflect rational decisions that people make
as they know that they are reaching the end of life or the end of their abilities to function
with any independence. Several participants suggested that providing more
opportunities for people to opt for palliative care would be a significant help to people
who struggle with decisions about life and death.
Family Support
The importance of the care that families provide (or fail to provide) to older adults who
need assistance came up repeatedly in our conversations. Several participants suggested
that more efforts should be made to reach out to estranged family members. Everyone
agreed that when older adults rely heavily on their families, it can be extremely disruptive
and stressful. Family caregivers need support—including help during crises, respite,
psycho-education, and respect as partners in care, financial assistance, etc.
Human Resources
The severe shortage of personnel trained to provide services for older adults with mental
health problems was a major theme of our discussions. Participants noted that there are
not enough trained mental health professionals—psychiatrists, psychologists, social
workers, and psychiatric nurses. They also noted that primary care physicians and other
health care professionals are, in general, poorly prepared to identify, diagnose, or provide
treatment for mental illnesses, especially those that are more serious. Participants also
noted that there is a need for sensitivity and skill in working with older people with
mental health problems in settlement houses, senior centers, houses of worship, courts,
and many other places in the community where older adults get services.
Many participants suggested that professional education programs—medical schools,
social work schools, nursing schools, graduate schools of psychology, and post-graduate
psychotherapeutic institutes—should provide more education regarding older adults,
stressing that their needs and interests are as different from those of younger adults as the
needs of children differ from those of adults.
Participants also noted that working with older adults generally has lower status than
working with children or adults and stressed the need to create incentives that would
attract helping professionals into geriatric fields.
Participants also predicted that there would never be enough mental health professionals
to meet the needs of the growing population of older adults and that it will never be
possible to substitute services by mental health professionals for all mental health
services provided by primary care physicians and other health personnel. Therefore,
some participants suggested, major efforts must be made to train primary care physicians
in the identification, diagnosis, and treatment of minor mental illnesses while
encouraging referral of more serious cases. Several participants suggested ways to
reduce the load on physicians by, for example, using nurse practitioners to prescribe
medication or by co-locating health and mental health professionals.
In general, participants suggested that it is very important to shift the roles of
professionals to make the most efficient use of their skills, particularly as supervisors and
trainers. They also suggested that it would be important to explore using volunteers—
especially older volunteers—to provide services. In essence, it appears to be important to
explore the viability of using self-help approaches more extensively both because it can
be tremendously effective and because it would free professionals’ time to focus on tasks
that they are uniquely prepared to perform.
Participants also noted that changing understanding about how to provide treatment and
to organize and deliver mental health services for older adults will result in significant
changes in professional practices and roles and that this will create a significant need for
ongoing training in state-of-the-art practices.
Finance
Public Funding
Participants in our meetings were especially vociferous in their concerns about public
funding of mental health services for older adults. Many argued that there is not enough
funding. Others, particularly public officials, contended that there is enough funding in
the public mental health system but that it is poorly allocated. Everyone agreed that the
funding structure is out of alignment with the goals of care and treatment and with the
way in which services need to be provided and organized in order to serve older adults
well.
There were particular concerns about the failure of the public sector to provide adequate
funding for mobile services, older adult day services, and respite services and other
supports for families.
In addition to excessively low Medicaid rates for in-home mental health services,
participants pointed to the Medicaid neutrality cap and the processes of prior approval in
New York State as obstacles to new program development. It was also noted that
Medicaid’s rules for nursing homes to get approval to use new medications delay older
adults getting the best medications for years.
There was also widespread criticism of Medicare, including of the new Medicare
Prescription Drug legislation. Participants believe that Medicare presents significant
barriers to providing mental health services for older adults.
- Even after the new law goes into effect, there will be limited coverage for
prescription drugs.
- The new law may result in reduced coverage under EPIC and Medicaid.
- Medicare does not provide parity between health and mental health services.
Currently there is a 50% co-pay for outpatient mental health services vs. a
20% co-pay for outpatient physical health services.
- Medicare rates are so low and the requirements so onerous that many
psychiatrists have opted out of the program.
- Medicare provides very limited coverage for in-home mental health services.
- Medicare does not cover “wrap-around” community-based services of the
kind that are needed by many adults.
Private Funding
A number of participants voiced doubts that substantial additional funds would become
available from the public sector and suggested that an effort needs to be made to enhance
the role of the private sector. In part they meant that increased philanthropy could help;
but, more significantly, they meant that it is important to understand why the private
market does not take care of mental health needs, especially of people who can afford
mental health care—as some people to whom mental health services are not “accessible”
surely can. In addition they argued that we should explore possible partnerships with the
private sector—both corporations and unions—regarding elder care, retirement planning,
and the development of mental health “products” which older adults or their families
would choose to buy. They also suggested that the creation of more attractive long-term
care insurance policies might provide an infusion of funding for the care of people who
develop psychiatric disabilities, including dementias.
Roles of Governmental Agencies and the Public and Private Sectors
As noted above, several participants in our discussions believe that it would be useful to
explore our general assumptions about the appropriate roles of the private and the public
sectors.
However, the bulk of discussion about the societal structures through which the needs of
older adults can be met focused on the public sector.
In general participants observed that the current division of labor among mental health,
health, and aging systems did not support the kind of integration of services so clearly
needed to improve care.
They also noted that there is no clear responsibility for planning to meet the mental health
needs of older adults or for organizing and developing new services using appropriate
models.
Even more serious, some participants observed, is the extent to which the cacophony of
current laws and regulations impedes the provision of state-of-the-art, integrated services.
In general, participants believe that meeting the mental health needs of older adults calls
for major governmental restructuring.
Research
The greatest hope for being able to meet the mental health needs of the elder boom
population is a major breakthrough in research. One person with whom we spoke noted,
for example, that if the onset of Alzheimer’s could be delayed by five years it would
result in a significant reduction of the incidence and prevalence of dementia. If it could
be delayed by 10 years, Alzheimer’s would almost be eradicated (given current life-
expectancy).
Several participants stressed that it is critical to pursue bio-medical and clinical research
aimed at vastly reducing the incidence and prevalence of mental disorders and that it
would also be valuable to develop more effective preventive interventions.
For policy purposes, better epidemiological data are important. The current data are 20
years old. New data should be released over the next few years. Given likely differences
from generation to generation it is critical to remain current about epidemiology.
Advocacy Strategies
The recommendations for change, which emerge from the discussions reported above, are
extremely ambitious. They include:
- Mounting major public education programs to reduce stigma and promote
understanding of mental health services
- Expanding a broad range of services so as to be able to serve a population that
will double over the next quarter century
- Restructuring service systems stressing integration and enhanced quality
- Mounting programs to prevent suicide, to prevent mental illnesses, and to
promote mental health
- Mounting family support initiatives
- Increasing the number of well-trained mental health, health, social service, and
other helping professionals and redefining professional and non-professional
roles
- Expanding the funding base and restructuring funding sources
- Clarifying the roles of governmental agencies, clarifying responsibility, and
developing new divisions of responsibility that will promote integrated, effective
services for older adults with mental health needs
- Engaging the private sector in innovative ways
- Increasing research regarding geriatric mental health
To even approach achieving these goals will take a major advocacy effort spread over the
next decade. It requires the development, therefore, of a multi-year advocacy plan, which
must be based both on identification of priorities for action and on the identification of
“leverage points”, i.e. changes which are feasible now and which will lay the groundwork
for more extensive changes over the years.
Shaping an advocacy strategy is the major task of the second phase of this project, but
during our discussions participants made a number of important initial suggestions.
Constituency Building
- It will be critical to build a broad-based coalition of advocates from the mental health,
health, aging, and other human service communities and also from other communities
such as civic organizations, houses of worship, unions, and “captains of industry”.
- It will be critical to work closely with other health and human service advocacy
coalitions—to support their activities and to win their inclusion of our goals on their
advocacy agendas.
- Advocacy organizations of, and for, older adults can be very important allies.
- An effort should be made to mobilize families of older adults with mental illnesses.
Consensus Building
Providers, advocates, journalists, government officials, etc. often have different
perceptions about the mental health needs of older adults and about public policies to
respond to these needs.
- It is critical to try to build common perceptions about the mental health needs of older
adults and about policies, which will support meeting these needs.
- This entails improved communication between advocates and with the media and
public officials.
Public Education
Participants generally agreed that building public support for policy changes would
require a major public education effort. This campaign, they suggested, should be aimed
at elected and appointed public officials, the press, families, older people, and the general
public. Several people stressed that an effective public education campaign will require
professional marketing and public relations work.
Making The Case
Participants all agreed that achieving change will depend to a significant extent on
making a powerful case about the importance of mental health issues for older adults and
about the need for change. There was particular concern about how to make a case
powerful enough to generate a greater public and private financial commitment. Several
people suggested that this would require a persuasive cost-benefit analysis. Others
argued that cost-benefit analysis will not create an effective argument and that the appeal
should be focused instead on society’s responsibilities to its older members.
Setting Priorities
Participants in our discussions agreed that it will be important to set priorities, but did not
agree about what the priorities should be.
- Some participants suggested focusing exclusively on people with serious mental
illnesses rather than on meeting the broad needs of older adults with mental illnesses
or on prevention of mental illnesses or mental health promotion.
- Some insisted on the importance of prevention and promotion.
- Some argued that the Geriatric Mental Health Alliance should not try to bring about
changes in all the systems which affect older adults with mental illnesses—health,
aging, housing, etc.—as well as mental health; but we should focus only on the
mental health system.
- Other participants argued that there is a need to restructure governmental
responsibility for older adults with mental illnesses so as to enhance integration and
quality of services. This, they argued, entails working across the various systems.
- Some participants suggested that the Alliance focus initially on changes in
reimbursement rates and in program development processes that would enable
providers to expand mobile and other special services now.
- Other participants argued that overall restructuring is critical and should be a much
higher priority than tinkering with the current system.
Leverage Points
Several suggestions emerged from our discussions regarding starting points for the
advocacy campaign. They include:
Taking steps to get geriatric mental health on the “radar screen” of the public and
private sectors, e.g.
- Pressing for governmental plans regarding geriatric mental health, e.g. for OMH
to include a geriatric section in its five-year plan
- Pressing for designation of public officials responsible for geriatric mental health
- Pressing for legislative hearings
- Identifying a legislative “champion”
- Setting up events to which public officials are invited to discuss geriatric mental
health
Taking steps to build communication among systems by, for example, setting up
events to bring together public officials from mental health, aging, and health
Pressing for initiatives to spread state-of-the-art practices, such as Winds of Change,
to include geriatric mental health.
Conclusion
The themes that emerged from our discussion groups, meetings, and interviews make it
clear that issues of geriatric mental health policy are extremely important and extremely
complex. The very challenging task ahead of us is to sort through the wealth of
observations made during the first phase of the process of establishing The Geriatric
Mental Health Alliance of New York and to craft an advocacy plan with focused
priorities, a realistic strategy, and a selection of effective actions. The suggestions
outlined above set the stage for the discussions that began early in February.
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