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
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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
Limitations of the Study…………………………………………………………………….
Recommendations………………………………………………………………………….
36
36
References………………………………………………………………………………… 40
Appendix A – Survey
Appendix B – Survey Results
Older Iowans with Behavioral Health Disorders 3
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.
Older Iowans with Behavioral Health Disorders 4
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.
Older Iowans with Behavioral Health Disorders 5
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.
Direct Care Respondents
Administrative Respondents
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
Older Iowans with Behavioral Health Disorders 6
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**
% of all respondents
(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.
Older Iowans with Behavioral Health Disorders 7
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.
Administrative Respondents
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
Older Iowans with Behavioral Health Disorders 8
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* Number (n=160)
Percentage*
Assistance with activities of daily living 26 22.41 98 61.3 Residential Services 16 13.79 38 23.7
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.
Older Iowans with Behavioral Health Disorders 10
Table 7. Have you completed any formal education (e.g., courses) that addressed the behavioral health needs of older adults?
Direct Care Respondents
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?
Direct Care Respondents
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
Older Iowans with Behavioral Health Disorders 11
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.
Older Iowans with Behavioral Health Disorders 12
Table 10. What topics were covered during these training programs?
Direct Care Respondents Administrative Respondents
Number Responded
(n=84)
% of 84**
% of all respondents
(n=116)
Number Responded
(n=114)
% of 114**
% of all respondents
(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
Older Iowans with Behavioral Health Disorders 13
Table 11. Indicate if you had any training on the following subjects in the last three years.
Direct Care Respondents
Administrative Respondents
Number (n=114)
Percentage* Number (n=148)
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?
Direct Care Respondents
Administrative Respondents
Number (n=115)
Percentage* Number (n=152)
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
Older Iowans with Behavioral Health Disorders 14
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.
Direct Care Respondents
Administrative Respondents
Number (n=116)
Percentage* Number (n=145)
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
Older Iowans with Behavioral Health Disorders 15
Table 14. Do you have new or different training needs because of the new MDS 3.0?
Direct Care Respondents
Administrative Respondents
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
My agency is not affected by MDS 3.0 19 17.27 45 31.3
Total 110 100% 144 100%
Table 15. What areas of training do you have because of the new MDS 3.0 rules?
Direct Care Respondents
Administrative Respondents
Number (n=116)
Percentage* Number (n=145)
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
My agency is not affected by MDS 3.0 19 16.38 44 30.3
Older Iowans with Behavioral Health Disorders 16
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.
Older Iowans with Behavioral Health Disorders 17
Table 16. Which teaching methods were used as part of the training?
Direct Care Respondents Administrative Respondents
Number (n=83)
% of 83**
% of all respondents
(n=116)** # (n=114)
% of 114**
% of all respondents
(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?
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%
Older Iowans with Behavioral Health Disorders 30
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%
Older Iowans with Behavioral Health Disorders 31
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.
Older Iowans with Behavioral Health Disorders 32
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
Older Iowans with Behavioral Health Disorders 33
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
Older Iowans with Behavioral Health Disorders 34
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
Older Iowans with Behavioral Health Disorders 35
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.
Older Iowans with Behavioral Health Disorders 36
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
Older Iowans with Behavioral Health Disorders 37
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
Older Iowans with Behavioral Health Disorders 38
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;
Older Iowans with Behavioral Health Disorders 39
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.
Older Iowans with Behavioral Health Disorders 40
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