|
Aging, Mental Illness, and the FrontierLetter to the Field No. 21by James W. Stockdill, MA and James A. Ciarlo, PhD Table of Contents IntroductionThe Frontier Mental Health Services Resource Network (FMHSRN), under a contract with the Center for Mental Health Services (CMHS) of the Substance Abuse and Mental Health Services Administration (SAMHSA), was created to gather, analyze and disseminate information about mental health needs and services in "frontier" areas. These isolated rural areas, defined for purposes of this contract as having fewer than 7 persons per square mile, are almost all located in the western states and Alaska. Eleven western states have substantial areas considered to be "frontier" (Ciarlo, Wackwitz, Wagenfeld, Mohatt, & Zelarney, 1996). This paper reports on the findings from a study group meeting held in a frontier rural area to discuss the mental health service needs of the older adult population. A National Association of State Mental Health Program Directors Task Force on Mental Health and Aging recently declared that "the elderly remain the most underserved and inappropriately served population in mental health services" (Wilson, Kazieczko, & Kast, 1997). This problem is exacerbated in rural and frontier areas, where vast distances, mountainous terrain, poverty, and inadequate human resources serve as severe barriers to access for rural and frontier residents. Several major concerns must be considered in examining the quality of care for older persons with serious mental illness living in frontier rural areas: 1) older adults have difficulty in accessing health and mental health services because of stigma, vast distances, lack of transportation, limited finances, and a lack of community education about geriatric mental illness; 2) delayed diagnosis and treatment means subsequent disability is more severe, requiring more expensive and restrictive long-term care; 3) older persons frequently have serious mental illness in combination with chronic health problems; and 4) support and coping skills needed to deal with life stresses caused by social, economic, and housing conditions are critical. To confirm and further examine these concerns, the FMHSRN invited older adult mental health consumers and family members, from two contiguous western-state counties, to participate in a study group to discuss mental health problems, service availability, and service access issues. Profile of the Service AreaThe two counties selected are served by the same mental health center, located in the larger of the two counties. The larger county had an estimated population of 12,000 in 1995 with 10% of its population over 65 years of age. This older age group is increasing. Its largest minority groups were Hispanic at 5% of the county population and Native Americans at 0.9 % in 1990. This larger county is a frontier-like rural county with a population density of 8.9 persons per square mile. Approximately 12% of the population are estimated to be below the poverty line. The smaller, neighboring county had an estimated population of 2,600 in 1995 with 19% of the population estimated to be over 65 years of age. The smaller county has a smaller minority population, with 3% Native Americans and 1.4% Hispanics in 1990. The smaller county is a "frontier" county with a population density of 0.9 people per square mile. Approximately 17% of its population are estimated to be below the poverty line (U.S. Census, 1990). The two counties have a combined population density of approximately 3.7 persons per square mile. The mental health center operates two satellite locations, one in the contiguous county and one in the larger county. The larger county has two senior centers; the smaller county has one. The directors of the senior centers in both counties, and the director of the mental health center, which serves both counties, put a high priority on improving the mental health care of older adults. The two counties need to work together on mental health and health services in order to maximize their resources as they have a small population in a huge area. Description of the Study GroupThe eight-person study group consisted of five older adult mental health service consumers and three family members of older adults with mental health problems. One of the consumers also had a seriously mentally ill family member whom she sometimes cares for. At least four of the consumers also had serious medical problems or physical disability problems. One of the consumers was dually diagnosed with alcoholism and mental illness. All of the consumers were women, while two of the three family members were men. The group met at a senior center on a weekday afternoon in the fall of 1998. The session lasted for close to three hours and was audio taped. Questions had been prepared in advance, and the major group responses were summarized on a flip chart. However, the group bonded very well and some of the most interesting points made were generated by the group interaction and were not necessarily in response to any one question. The group seemed to enjoy the interaction and some clearly felt that the opportunity to share experiences with their peers and these two FMHSRN strangers from out of town was therapeutic in itself. Questions and DiscussionThe sequence of questions posed by the group facilitator will be used to highlight the major findings: 1. Based on your own experience or the experience of others, what are the main things you think we should know about what it is like for an older person living in an isolated or frontier area here in this state? Surprisingly, at least to the facilitator, the major response to this question dealt with the weather. Immediate reference was made to the winter "gloom" in this state. The "cloudy gray days affect elder moods". The weather was also mentioned in terms of the long distances that sometimes have to be traveled on slippery winter roads in order to obtain services and/or meet basic needs such as buying groceries. However, the major emphasis was placed on the feeling of being shut-in in the wintertime.
2. In your opinion, how does living in a frontier or rural area in this state affect your ability to get to and obtain services for a mental health or substance abuse problem? Again, in response to this more specific question, they cited the long distances that sometime must be traveled to get services and the winter weather that affects the driving conditions. However, the major issue presented was the shortage of mental health specialists. One participant noted: "we have physicians, not mental health specialists". No psychiatrists are actually located in the service area. The point was made, and reemphasized several times, that the general practitioners in their area are not well trained to provide mental health services and, in addition, there are no geriatric medical specialists. It was brought out that, as a result, many older persons are not adequately or accurately diagnosed, and because of the lack of qualified providers, older adult consumers get medications only (maintenance approach), with little counseling, psychotherapy, or other interpersonal mental health care. One of the participants indicated that older adults get "over-treated for medical problems and under-treated for mental health problems". However, it was pointed out that there were some "good counselors" available through the mental health center that had been helpful to some of the participants of the study group. The professional level of training of these counselors was not known. It was indicated by another participant that "you must go a long way for real therapy" — that is to the nearest large town, from 45 to over 100 miles away, depending on your location in the service area. Two examples illustrated the effect a combination of a lack of mental health specialists and the long distances to larger communities where they might be available can have. One family traveled over 250 miles (one way), to another state, to get specialized mental health treatment for their older adult family member. In another case, when a well-liked family care doctor moved to a larger town outside the county, his satisfied consumers had to travel longer distances to continue to receive services from him. 3. What types of mental health services for elderly persons can be found in your county? Consensus was reached among the group that the following services were available within the two-county area:
The study group developed the following list of services that are not available within the two counties:
The lack of inpatient beds and emergency services seemed to be of particular concern to both the mental health consumers and family members. The lack of quick access to inpatient or emergency assistance usually meant an exacerbation of the illness. Members of the study group indicated that the lack of emergency service on weekends was particularly problematic because of the difficulty in getting transportation to the nearest psychiatric emergency services (again, located in a town, 45 to 100 miles away). 4. Of the services that are not available in the service area, which would you recommend as being the most important for elderly residents to have available? The majority of the study group expressed their belief that local access to psychiatric inpatient beds and emergency services were of the highest priority. Also important to the group were the availability of special home-based services for mental health and substance abuse consumers and respite care to assist family caretakers. There was also an interest in learning more about Medicare coverage for specialized day treatment for the elderly. Group members believed that most of these services were available in a town of with a population of about 50,000 in an adjacent county — but they were neither accessible nor affordable. 5. What types of rural or frontier-area caregivers do you think can (or would) provide the services that are most important to an older adult consumer? The group seemed resigned to the reality that the numbers and types of mental health specialists will not change any time soon. However, they did discuss the possibility that psychiatrist time might be provided by traveling psychiatrists from larger communities on specified days (the "circuit rider" approach). Still, what they expressed most strongly was a need for more education on mental health and substance abuse treatment for the primary care doctors and their support staff. One participant also discussed the possibility of more extensive use of psychiatric nurse practitioners to meet the needs of older adults. Trained, affordable, home mental health care workers was also given as a priority. 6. How do most elderly persons pay for mental health and substance abuse services in the two counties — does Medicare cover most needed services? Are many persons eligible for Medicaid? Have these resources been available to you? Medicare covered most mental health and substance abuse costs of the members of our study group and they paid out of pocket for what Medicare did not cover. Their big concern was that they did not always understand how Medicare worked. As one participant put it—"If you know all of the little hoops and loops that you have to go through you come out all right— if not, you can get stung for extra costs." They expressed concern that there was no coverage of psychiatric or general medical medications under Medicare. Their highest priority was getting the Medicare and Medicaid bureaucratic policies and regulations simplified and standardized to the point where they could understand them, and medications that were at least partially and consistently reimbursed. They were also concerned that Medicare supplemental insurance policies were not affordable, and that many of the elderly may someday have to spend or give away their assets to be eligible for basic Medicaid coverage. 7. Are there any problems in accessing medical services that an elderly person might need — do you receive general medical care, dental care, eye exams/glasses, hearing aids that might be needed? How far do you have to go for these services? There was general satisfaction with access to general medical care. In some cases, where medical specialists were required, they had to travel outside the service area to a larger community in an adjoining county (45 to 100 miles away). At least two of the study group members also traveled outside the service area to see their general practitioners because of their preference for a particular individual. Two participants expressed the feeling, however, that they had had general practitioners who were "embarrassed" to have them in their office for medical treatment because the doctor knew that they also had a mental health and/or substance abuse problem. One person traveled outside the service area for general medical services because of this stigma issue. 8. How satisfied are you with whatever mental health and substance abuse services you have received? And, in your opinion, how can services for older persons with mental illness be improved? What would you like to see changed? The group indicated general satisfaction with the counseling services provided by the mental health center. These counseling services were sometimes recommended by their primary care doctors. They were also generally positive about their primary health care services including dental care and optometry. They insightfully observed, however, that there was a great need for mental health specialists and for education of primary caregivers in order to "treat the whole person" (this point got particularly strong emphasis in relation to older adults with substance abuse problems). They were very positive about the services provided by the senior centers. There was general consensus around one participant's comment that "the Senior Center is the touch point for the elderly". The following changes or improvements were cited as priorities, along with filling the gaps in services:
9. Are there any consumer-operated or consumer-sponsored services in the service area at the present time? Should they be encouraged? Interestingly, they could not think of any and did not seem to understand the concept. Other Comments and DiscussionIn response to some specific sub-questions throughout the meeting it seemed clear that the group had little or no knowledge of the following mental health related topics:
There were miscellaneous important thoughts expressed throughout the meeting that seemed to define the human condition:
Despite the tenor of these comments, the group appeared to bond very well to each other, and individual members used humor throughout. Laughter was quite prevalent, suggesting that their sense of humor also helps them survive and cope with their problems on a daily basis. SummaryAs indicated above, in terms of filling gaps in services, the study group put a high priority on having local access to psychiatric inpatient and emergency services. They also put a high priority on having more availability of psychiatrists to provide outpatient psychotherapy. However, it was also clear that the highest "immediate priority" of this study group of older adult consumers and family members from a frontier area was improved communication and education about geriatric mental illness. This improved communication is needed between and among consumers, family members, mental health center staff, primary health care providers, senior center staff and advocates for the elderly. Education about geriatric mental illness must be directed at the general community and the groups listed above, with an emphasis on primary health care providers. Technical assistance and education about the financing of mental health services for the elderly is also a high priority. It is interesting to note that the high priority for improving the mental health education of primary health care providers is consistent with the findings of a previous FMHSRN study group that dealt with primary care providers and mental health services. Geller (1998) reported that "the literature suggests and the focus group confirms, these providers (primary caregivers) do the best they can, they often feel uncertain and less than fully prepared to serve the mental health needs of their patients". Indeed, one of the physician participants from this earlier study group is reported as saying, ‘And I think that, just speaking freely, I don’t think I’m adequately trained to do a lot of what I do’. And, more to the subject of this paper, another primary care provider is quoted: ‘I have a pretty clear idea of how far I can go with a depressed patient….but the place I really get stuck all the time is with geriatrics". It seems clear from this earlier report that the primary caregivers in rural and frontier areas themselves feel the need for mental health treatment education and technical assistance. There are indications that the federally funded Geriatric Education Centers Program is a promising resource for providing mental health education and training activities to primary care providers, consumers, family members, and other stakeholders in frontier areas. In an earlier Frontier Network knowledge-synthesis paper, Wagenfeld (1998) reported on a collaborative geriatric education center in Iowa. He indicated that, "the Iowa Geriatric Education Center (IGEC) provides training and education programs for primary care physicians, public health nurses, social service workers, and related caregivers in service delivery models for the elderly". A similar model should be developed for frontier areas. Perhaps the increased utilization of telemental health technology, in combination with the geriatric education center model, will be the answer to improving the quality of mental health services for older adults living in remote rural and frontier areas. Advocacy for the growing percentage of older adults in rural areas is very much needed. It is hoped that increased communication among stakeholders, and the implementation of new educational activities concerning mental illness and substance abuse, will facilitate the availability and/or accessibility of inpatient services, emergency services, and home-based care for older adults in frontier areas. ReferencesCiarlo, J.A., Wackwitz, J.H., Wagenfeld, M.O., & Mohatt, D. F. (1996). Focusing on "frontier": isolated rural America (Letter to the Field No 2). Denver, CO: Frontier Mental Health Services Resource Network. Geller, J.M. (1998). The role of rural primary care providers in the provision of mental health services: Voices from the Plains (Letter to the Field No. 10). Denver, CO: Frontier Mental Health Services Resource Network. U.S. Bureau of the Census. (1997, December). Estimates of the population of counties by age, sex, and race/Hispanic origin: 1990-1996. Washington, D.C. : Author. Wagenfeld, M.O. (1998). Mental health services in frontier areas: Models of service delivery and special populations (Knowledge Synthesis Paper). Denver, CO: Frontier Mental Health Services Network. Wilson, R., Kazieczko, I., & Kast, B. (1997, December) Memorandum re Task Force recommendations and work plan (Task Force, Older Persons Division). Alexandria, VA: National Association of State Mental Health Program Directors.
Frontier Mental Health Resource Network |
|||
