Reducing Barriers to Mental Health Care: Bringing Evidence-Based Psychotherapy Home.

OBJECTIVES: Barriers to treatment for depression and anxiety are prevalent among older adults and caregivers living in the community. We designed and implemented an evidence-based psychotherapy program to reduce obstacles to care. DESIGN: A practice improvement initiative providing no-fee evidence-based mental health care at home in clients' primary languages. SETTING: Independence at Home, a community service of SCAN Health Plan in Southern California. PARTICIPANTS: Diverse older adults and adult caregivers of older people with age-related disability (mainly dementia). INTERVENTION: Redesign of an existing supportive counseling program to improve access to validated models of psychotherapy for depression and anxiety. MEASUREMENTS: We describe program content, phases of development, equity in participation from referral to program completion, clinical outcomes, and estimated direct program delivery costs. RESULTS: Insights successfully served demographically diverse clients experiencing a broad range of barriers to mental health care. A total of 211 clients completed therapy using one of three evidence-based approaches in the first 33 months of operation (2015-2018). Clinical efficacy was high and equivalent across demographic groups and therapy models. Depression, anxiety, quality of life, self-rated disability, and patient activation all improved significantly. We supported therapists' transition to the new model, modified workflows, and used clinical outcome data and therapist focus groups to improve referral, selection, and enrollment processes and simplify treatment assignment. With program maturation, treatment duration and direct costs both declined. CONCLUSION: The Insights model could add value to healthcare organizations seeking to provide effective, equitable mental health services for older adults and caregivers who have difficulty accessing care for depression, anxiety, or difficult life challenges. J Am Geriatr Soc 67:2174-2179, 2019.

Systems Delivery Innovation for Alzheimer Disease.

OBJECTIVE: The authors describe a comprehensive care model for Alzheimer disease (AD) that improves value within 1-3 years after implementation by leveraging targeted outpatient chronic care management, cognitively protective acute care, and timely caregiver support. METHODS: Using current best evidence, expert opinion, and macroeconomic modeling, the authors designed a comprehensive care model for AD that improves the quality of care while reducing total per capita healthcare spending by more than 15%. Cost savings were measured as reduced spending by payers. Cost estimates were derived from medical literature and national databases, including both public and private U.S. payers. All estimates reflect the value in 2015 dollars using a consumer price index inflation calculator. Outcome estimates were determined at year 2, accounting for implementation and steady-state intervention costs. RESULTS: After accounting for implementation and recurring operating costs of approximately $9.5 billion, estimated net cost savings of between $13 and $41 billion can be accomplished concurrently with improvements in quality and experience of coordinated chronic care ($0.01-$6.8 billion), cognitively protective acute care ($8.7-$26.6 billion), timely caregiver support ($4.3-$7.5 billion), and caregiver efficiency ($4.1-$7.2 billion). CONCLUSION: A high-value care model for AD may improve the experience of patients with AD while significantly lowering costs.

Innovation in care for individuals with cognitive impairment: Can reimbursement policy spread best practices?

There is now an unprecedented opportunity to improve the care of the over 5 million people who are living with Alzheimer's disease and related dementias and many more with cognitive impairment due to brain injury, systemic diseases, and other causes. The introduction of a new Medicare care planning benefit-long sought openly by advocacy organizations and clinicians and badly needed by patients and families-could greatly improve health care quality, but only if widely and fully implemented. We describe the components of this new benefit and its promise of better clinical care, as well as its potential to create a new platform for clinical and health outcomes research. We highlight external factors-and some that are internal to the benefit structure itself-that challenge the full realization of its value, and we call for broad public and professional engagement to ensure that it will not fail.

Toward Assessment of Dementia Caregiver Activation for Health Care: An Integrative Review of Related Constructs and Measures.

The purpose of this integrative literature review was to establish the rationale for a new measure of dementia caregiver activation for health care. Little is known about how caregivers form working partnerships with clinicians to manage the health of individuals who, because of cognitive impairment and functional limitations, can no longer actively manage their own health. Building on three sources-the construct of patient activation, an empirical health care framework for individuals living with dementia, and a set of dementia care quality indicators-the construct of dementia caregiver activation for health care was defined and initial relevant domains were specified. An integrative literature review was performed to identify related constructs and assess currently available measures with respect to their inclusion of these key health care domains. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 647 citations were reviewed and reduced to 17 studies, which were included in the analysis and qualitative synthesis. No existing measure was found that captures all of the domains required for caregiver-clinician partnership, establishing the need for a novel measure of caregiver activation focused on the health care of individuals living with dementia. [Res Gerontol Nurs. 2016; 9(3):145-155.].

Measuring caregiver activation for health care: Validation of PBH-LCI:D.

Improving the quality of health care for individuals living with dementia is a central goal of the National Alzheimer's Plan, and requires the participation of informed family caregivers as active members of the patient's health care team. "Caregiver activation" is an emerging concept for which dementia-specific measures are lacking. We developed and validated a new self-report index of caregiver activation, Partnering for Better Health - Living with Chronic Illness: Dementia ( PBH-LCI: D). PBH-LCI: D has high content validity and good internal consistency and test-retest reliability, with 32 items and a strong six-factor structure reflecting all major health care domains of dementia caregiving. Comparisons with measures of related constructs and potential caregiver and patient predictors of activation indicate that PBH-LCI: D measures a unique construct and therefore should be useful as a marker of caregiver needs for education and behavioral change coaching, and as the foundation for developing interventions to enhance caregiver activation and successful partnership with clinicians.

Prevalence and correlates of suicide ideation in patients with COPD: a mixed methods study.

PURPOSE: The purpose of this study was to examine the prevalence and correlates of suicidal ideation (SI) in patients with stable moderate to very severe chronic obstructive pulmonary disease (COPD). PATIENTS AND METHODS: We conducted an exploratory mixed methods analysis of data from participants in a longitudinal observational study of depression in COPD. We measured depression with the Patient Health Questionnaire-9 (PHQ-9), which includes an item on SI. We compared participants with and without SI in relation to sociodemographics, symptoms, anxiety, and healthcare resource use with independent t-tests and chi-square tests. Content analysis was performed on qualitative data gathered during a structured SI safety assessment. RESULTS: Of 202 participants, 121 (60%) had depressive symptoms (PHQ ≥6); 51 (25%) had a PHQ-9 ≥10, indicating a high likelihood of current major depression; and 22 (11%) reported SI. Compared to the 99 depressed participants without SI, those with SI were more likely to be female (59% vs 27%, P=0.004); had worse dyspnea (P=0.009), depression (P<0.001), and anxiety (P=0.003); and were also more likely to have received treatment for depression and/or anxiety (82% vs 40%, P<0.001) and more hospitalizations for COPD exacerbations (P=0.03) but had similar levels of airflow obstruction and functioning than participants without SI. Themes from the qualitative analysis among those with SI included current or prior adverse life situations, untreated or partially treated complex depression, loss of a key relationship, experience of illness and disability, and poor communication with providers. CONCLUSION: Our findings suggest that current SI is common in COPD, may occur disproportionately in women, can persist despite mental health treatment, and has complex relationships with both health and life events. Adequate management of SI in COPD may therefore require tailored, comprehensive treatment approaches that integrate medical and mental health objectives.

Dementia Services Mini-Screen: a simple method to identify patients and caregivers in need of enhanced dementia care services.

OBJECTIVE: Improving dementia care in health systems requires estimates of need in the population served. We explored whether dementia-specific service needs and gaps for patients and caregivers could be predicted by simple information readily captured in routine care settings. METHOD: Primary family caregivers (n = 215) rated their own current stress, challenging patient behaviors, and prior-year needs and gaps in 16 medical and psychosocial services. These were evaluated with other patient and caregiver characteristics in multivariate regressions to identify unique predictors of service needs and gaps. RESULTS: Caregiver stress and patient behavior problems together accounted for an average of 24% of the whole-sample variance in total needs and gaps. All other variables combined (comorbid chronic disease, dementia severity, age, caregiver relationship, and residence) accounted for a mean of 3%, with none yielding more than 4% in any equation. We combined stress and behavior problem indicators into a simple screen. In early/mild dementia dyads (n = 111) typical in primary care settings, the screen identified gaps in total (84%) and psychosocial (77%) care services for high stress/high behavior problem dyads vs. 25% and 23%, respectively, of low stress/low behavior problem dyads. Medical care gaps were dramatically higher in high stress/high behavior problem dyads (66%) than all others (12%). CONCLUSION: The Dementia Services Mini-Screen is a simple tool that could help clinicians and health systems rapidly identify dyads needing enhanced dementia care, track key patient and caregiver outcomes of interventions, and estimate population needs for new service development.

Improving dementia care: the role of screening and detection of cognitive impairment.

The value of screening for cognitive impairment, including dementia and Alzheimer's disease, has been debated for decades. Recent research on causes of and treatments for cognitive impairment has converged to challenge previous thinking about screening for cognitive impairment. Consequently, changes have occurred in health care policies and priorities, including the establishment of the annual wellness visit, which requires detection of any cognitive impairment for Medicare enrollees. In response to these changes, the Alzheimer's Foundation of America and the Alzheimer's Drug Discovery Foundation convened a workgroup to review evidence for screening implementation and to evaluate the implications of routine dementia detection for health care redesign. The primary domains reviewed were consideration of the benefits, harms, and impact of cognitive screening on health care quality. In conference, the workgroup developed 10 recommendations for realizing the national policy goals of early detection as the first step in improving clinical care and ensuring proactive, patient-centered management of dementia.

Alzheimer's Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting.

The Patient Protection and Affordable Care Act added a new Medicare benefit, the Annual Wellness Visit (AWV), effective January 1, 2011. The AWV requires an assessment to detect cognitive impairment. The Centers for Medicare and Medicaid Services (CMS) elected not to recommend a specific assessment tool because there is no single, universally accepted screen that satisfies all needs in the detection of cognitive impairment. To provide primary care physicians with guidance on cognitive assessment during the AWV, and when referral or further testing is needed, the Alzheimer's Association convened a group of experts to develop recommendations. The resulting Alzheimer's Association Medicare Annual Wellness Visit Algorithm for Assessment of Cognition includes review of patient Health Risk Assessment (HRA) information, patient observation, unstructured queries during the AWV, and use of structured cognitive assessment tools for both patients and informants. Widespread implementation of this algorithm could be the first step in reducing the prevalence of missed or delayed dementia diagnosis, thus allowing for better healthcare management and more favorable outcomes for affected patients and their families and caregivers.

A pilot study to assess cognition and pillbox fill accuracy by community-dwelling older adults.

OBJECTIVE: To assess pillbox fill accuracy and cognition among community-dwelling older adults. DESIGN: A descriptive, cross-sectional study. SETTING: Retail pharmacy. PARTICIPANTS: Convenience sample of English-speaking adults older than 60 years of age without dementia, taking more than four medications, and naive to Mediset use. INTERVENTIONS: In face-to-face interviews, subjects provided demographic, medical, and medication information, completed the Mini-Cog and Medi-Cog (combination of Mini-Cog and medication-transfer screen [MTS]), and filled their own medications in a pillbox. Data were analyzed using descriptive statistics and stepwise regression analysis with correctly filled pill count (PC) as the dependent variable and the cognitive screens as independent variables. MAIN OUTCOME MEASURES: Accuracy of the Mini-Cog, MTS, and Medi-Cog in predicting PC. RESULTS: Among 50 subjects (58% female, mean age 76.4 years), only one subject failed to pass the Mini-Cog and two failed to reach the criterion level of correctly filled PC. The mean (standard deviation) Mini-Cog score for the sample was 4.38 (0.81), MTS score was 4.1 (1.31), Medi-Cog score was 8.48 (1.82), and the mean PC was 97% (8%). The Mini-Cog and MTS individually accounted for about 30% of the variance (P < 0.001); the Medi-Cog accounted for 44% of the variance (P < 0.001), indicating strongest PC prediction. CONCLUSION: Nearly all study participants filled pillboxes accurately. The Medi-Cog was the strongest predictor of pillbox fill accuracy. Future studies of medication self-management abilities among community-dwelling older adults should include representative samples of this population, comprehensive assessment of health status, cognitive screening, pillbox fill accuracy, and the utilization of medications in filled pillboxes.

The future of financing for long-term care: the Own Your Future campaign.

The purpose of this study was to examine the outreach effort and impact of a joint federal-state campaign, Own Your Future, promoting awareness and planning for long-term care (LTC) in the state of Washington. The study applied survey methodology to evaluate the extent of campaign dissemination, evidence of its impact on LTC planning behaviors, and barriers to purchasing private LTC insurance. A total of 3,198 survey responses from a randomly selected community sample and a Washington State employee sample (ages 51 to 71) were analyzed. Results indicated that the impact of the campaign was limited, both with respect to awareness of the campaign itself and to initiation of LTC planning behaviors. Quantitative data revealed a high prevalence of health-related problems (e.g., obesity, diabetes), inadequate knowledge of basic LTC-related information (e.g., cost, payers), and negative attitudes toward purchasing LTC insurance among respondents. Qualitative analyses suggested that respondents perceived significant problems related to affordability and accountability within the current LTC insurance industry. These possible barriers to the purchase of LTC insurance suggest targets to be addressed by policy makers seeking to find ways to offset the public costs of LTC.

Assessment of older adults' knowledge of and preferences for medication management tools and support systems.

BACKGROUND: A variety of strategies are available to assist older adults who have difficulties managing medications. Little is known about older adults' knowledge of or willingness to use these strategies. OBJECTIVE: To assess older adults' current use of, knowledge of, and preferences for medication management tools and supports. METHODS: A cross-sectional study was conducted at a continuing care retirement community. All 152 independent-living residents were approached for participation. We developed a 6-page survey to gather information about knowledge of and preferences for medication management tools (eg, medi-sets, bubblepacks) and supports (eg, family, caregivers, regimen simplification). Information on demographic variables, medication management capacity, cognition, self-reported difficulty taking medications, and medication use were collected along with survey answers during an in-home interview. chi(2) and t-tests were used to compare knowledge and preferences by complexity and organizer use. RESULTS: Our sample consisted of 109 participants ranging in age from 73 to 98 years (average 85.9). Most of the subjects were well educated (average 15.5 y of education), 98% were white, and 80% were female. The majority (82%) were using a medication tool, mainly simple, self-filled medi-sets (62%) and easy-open vials (55%). Knowledge about, use of, and preferences for other devices, including pharmacist-filled tools and programmable devices, were low. Participants who used medication organizers rated self-filled medi-sets higher than did non-users (4.7 vs 1.6; p < 0.01). Only 18% of participants had asked a provider to simplify their medications, while 40% did not realize that they could do so. Of those who did ask a provider, 80% asked a physician. CONCLUSIONS: Educational strategies are needed to increase awareness of the pharmacist's role in facilitating medication management and the option of simplifying complex regimens. It is within the scope of pharmacy to provide this type of medication education.

Psychotherapy in long-term care: A review.

Psychological distress in long-term care (LTC) settings is highly prevalent and crosses many conventional psychiatric diagnostic boundaries. Mental health professionals who consult in LTC facilities have experienced firsthand the impact of a variety of nonpharmacological therapeutic approaches on individual residents, yet these are rarely investigated in a systematic fashion, and even less commonly reported in the literature. The present report summarizes the state-of-evidence of "talk therapies" for depression and psychological well-being in LTC facilities by reviewing controlled trials of psychotherapy for LTC residents published in English-language peer-reviewed journals. We excluded studies of nonpharmacological approaches designed primarily to curb behavioral disturbances of dementia, and those psychosocial interventions using an approach other than "talk therapy" in individual or group format since they have been reviewed in detail elsewhere. A majority of the 18 studies that met our inclusion criteria reported significant short- and, in some cases, longer-term benefits on instruments measuring depression, hopelessness, self-esteem, perceived control, and a host of other psychological variables. However, these findings must be interpreted within the severe methodological limitations of many studies, including small sample sizes, variable study entry criteria, short duration of trials, heterogeneous outcome assessment methods, and lack of detail on intervention methods. Nevertheless, the positive efficacy of these approaches, when understood within the framework of potential serious complications of pharmacotherapy for frail elders with multiple comorbidities, polypharmacy, and a narrow therapeutic index, suggests a strong need for methodologically rigorous trials of psychotherapy in the LTC setting, especially in combination with pharmacotherapy.

Reduction of caregiver burden in Alzheimer's disease by treatment with galantamine.

Alzheimer's disease is a progressive condition characterized by a loss of cognition, altered behavior, and a loss of functional ability, such as bathing, dressing, toileting, and organizing finances. Family and friends provide nearly three quarters of all care for patients with Alzheimer's disease. This informal care results in significant burden to caregivers. Caregiver burden is the set of physical, psychological or emotional, social, and financial problems that family members may experience when caring for impaired older adults. Caregivers of Alzheimer's disease patients report higher rates of physical symptoms, mortality, depression, and fatigue, as well as adverse effects on employment compared with those who are not caregivers for Alzheimer's disease patients. In many cases, the same family members are responsible for both out-of-pocket expenditures and caregiving duties. For this article, a MEDLINE search using the key words "caregiver and Alzheimer's disease" and "cost and Alzheimer's disease" was performed. The purpose of this article is to review the literature on caregiver burden, the components of caregiver burden, effects of caregiving on the health of caregivers, the cost of Alzheimer's disease on the caregiver and society, and the benefits attainable with treatment.

Depression and Bipolar Support Alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in late life.

OBJECTIVES: To review progress made during the past decade in late-life mood disorders and to identify areas of unmet need in health care delivery and research. PARTICIPANTS: The Consensus Development Panel consisted of experts in late-life mood disorders, geriatrics, primary care, mental health and aging policy research, and advocacy. EVIDENCE: (1) Literature reviews addressing risk factors, prevention, diagnosis, treatment, and delivery of services and (2) opinions and experiences of primary care and mental health care providers, policy analysts, and advocates. CONSENSUS PROCESS: The Consensus Development Panel listened to presentations and participated in discussions. Workgroups considered the evidence and prepared preliminary statements. Workgroup leaders presented drafts for discussion by the Consensus Development Panel. The final document was reviewed and edited to incorporate input from the entire Consensus Development Panel. CONCLUSIONS: Despite the availability of safe and efficacious treatments, mood disorders remain a significant health care issue for the elderly and are associated with disability, functional decline, diminished quality of life, mortality from comorbid medical conditions or suicide, demands on caregivers, and increased service utilization. Discriminatory coverage and reimbursement policies for mental health care are a challenge for the elderly, especially those with modest incomes, and for clinicians. Minorities are particularly underserved. Access to mental health care services for most elderly individuals is inadequate, and coordination of services is lacking. There is an immediate need for collaboration among patients, families, researchers, clinicians, governmental agencies, and third-party payers to improve diagnosis, treatment, and delivery of services for elderly persons with mood disorders.

Assessment of late life depression.

This article focuses on diagnostic and nosologic challenges intrinsic to geriatric depression, including characteristics interfering with symptom and syndrome ascertainment, the impact of medical and cognitive disorders, the usefulness of screening instruments, and barriers imposed by treatment settings. The article also identifies gaps in existing knowledge and outlines a research agenda. Nosologic characterization of depressives syndromes contributed by specific medical disorders may lead to effective strategies for prevention and treatment of depression. Studies need to examine whether treatment of depression can improve the outcome of medical illnesses requiring active patient involvement in treatment. Considering disability a distinct aspect of health status may add an important dimension to the assessment of depression and result in complementary interventions aimed at depression and disability concurrently. The provisional criteria for depression of Alzheimer's disease, if validated, may facilitate treatment research. Studies need to characterize cognitive dysfunctions associated with later development of dementia or poor treatment response in patients with depression. Care managers working together with primary care physicians can improve the recognition and treatment of depressed elderly patients by obtaining the training in using validated instruments and treatment algorithms.