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Transforming Mental Health Services for Older Adults

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"We are focusing on the continuum of mental health services, from prevention to residential treatment, including values of consumer involvement, access, diversity in the broadest sense, integration of medical and mental health services, and outcome accountability.”

THE MENTAL HEALTH SERVICES ACT (MHSA), a ballot initiative passed by California voters in 2004 and commonly referred to as the “millionaires’ tax,” was welcomed by many mental health advocates as an important step in expanding and transforming the state’s historically underfunded county mental health care systems. With an additional 1 percent tax on income earned in excess of $1 million, the MHSA brought increased funding for California’s 58 counties to allocate to mental health programs at their discretion.

More than a decade later, a Fielding School team is in the midst of a two-year study examining the extent to which the act has facilitated or bolstered the implementation of systems of mental health care for older adults. The researchers also plan to identify opportunities for further improvements in the quality of mental health services for California’s over-60 population. 

“Many counties do not have separate programs for older people specifically; older adults are included in general adult services being delivered,” says Dr. Janet Frank, adjunct associate professor in FSPH’s Department of Community Health Sciences, faculty associate at FSPH’s Center for Health Policy Research and principal investigator of the two-year study, which is funded by the California Mental Health Services Oversight and Accountability Commission. “Ours is the first study since the act was passed that is looking at the complexities of older-adult mental health needs and systems. We are focusing on the continuum of mental health services, from prevention to residential treatment, including values of consumer involvement, access, diversity in the broadest sense, integration of medical and mental health services, and outcome accountability.”

Frank notes that one of the important differences to consider when planning and providing mental health services for older adults is the presence of multiple chronic conditions. There are two major groups of older adults in need of mental health services: those with longstanding mental health issues who have grown older – people who may be “in the system” and receiving services already, but require services that are tailored or appropriate to their older-adult status and the complexities that often evolve with older age – and older adults who develop mental health issues later in life. For this second group, recognition and access to services can be challenging. For example, Frank notes, late-life depression is an often unrecognized and yet treatable condition. If the older adult becomes depressed, and the condition is not treated, this can lead to a reduction in needed self-care activities for ongoing chronic conditions. “This type of issue is a recipe for disaster,” Frank says, “since almost all chronic conditions require intensive self-management.”

Statewide efforts to support systems of care that promote resiliency and the mental health of older adults must also take into account two types of diversity: the diversity of California’s counties – from larger urban areas such as Los Angeles to rural and frontier counties such as Siskiyou, which stretches to the Oregon border – and the diversity of the older-adult population. California is the most diverse state in the nation, and this includes not only racial and ethnic populations, but also diversity in gender identity, sexual orientation, immigration status and variations in income levels – from the millionaires funding the MHSA to people living on the streets who are hungry, Frank says.

For their analysis of how counties in California have used MHSA funding for older adults, Frank and her colleagues have focused on six – Los Angeles, San Diego, Tulare, Siskiyou, Alameda and Monterey – that reflect the regional, geographic, ethnic and income diversity of California, and are now documenting the changes these counties have put in place for meeting the needs of older adults with mental illness and promoting mental health. The assessment covers everything from service delivery, partnership development, consumer input and planning services to issues of access, gaps in care, transitions in care and referrals.

The study team is also planning to develop potential indicators for older-adult mental health outcomes and to highlight best practices and programs made possible by MHSA funding that are making a positive impact for older adults across the state. Among other things, MHSA has provided funding for Full Service Partnerships within clinical service delivery. In this intensive program, the county can organize and provide “everything it takes” to help people, such as facilitating short-term housing. The MHSA has also led to increased funding for prevention efforts. “MHSA put prevention on the map from a mental health standpoint with the funding of the prevention and early intervention component,” Frank says. “These types of programs are especially important for older adults. People may need, for example, a community-based peer counseling program, such as those funded through the MHSA, to address isolation and link them to the care they need.”