California Mental Health Older Adult System of Care Project Janet C California Mental Health Older Adult System of Care Project Janet C. Frank, DrPH, MSG Kathryn G. Kietzman, PhD, MSW CBHDA MHSA Coordinators Meeting June 5, 2017

California Mental Health Older Adult System of Care Project What We’ll Cover Overview of Research Question and Methods for Study Preliminary Study Findings Planned Dissemination Products

California Mental Health Older Adult System of Care Project Primary Research Question What progress has been made since the passage of the MHSA toward implementing an integrated and comprehensive system of care for older adults with serious mental health needs?

Participating Study Counties Siskiyou Alameda Monterrey Tulare Los Angeles San Diego

TRIANGULATION OF STUDY METHODS Stakeholder Interviews Focus Groups Secondary Data Analyses

Secondary Analyses Data REPORT TYPE YEARS NUMBER REPORTS REVIEWED NUMBER of REPORTS ANALYZED Mental Health Services Oversight & Accountability Commission (MHSOAC) contracted reports and evaluations 2004-2015 37 16   Stakeholder reports and evaluations 2000- 2015 7 Three-Year Program and Expenditure Plans and Annual Updates Three-Year Plans FY 2014- 2017 and Annual Updates FY 2015-2016 56 12 (2 per county) TOTALS 100 35

Key Findings: Secondary Review Development of an OASOC pre-dated the MHSA, ~ 25% of counties have MHSA has generated $13 billion dollars, ~ 25% of mental health service funding MHSA outcomes reporting is inadequate and should be strengthened Seniors and veterans least common stakeholder groups that took part in MHSA planning Data showed a steady improvement in the numbers of older adults receiving services since MHSA Great unmet need across all MHSA services One study reported data from 45 counties, showing 15 counties (33%) using PEI programs to serve older adults. Those age 60 and above accounted for 1.5% of those receiving prevention services. Of the 40 counties reporting early intervention services, 32 counties (80%) served older adults. Clients age 60 and above were 13.1% of those receiving early intervention services. However, when older adults are linked to services, for example FSP, they show clinical improvements and reduced costs of care, such as hospitalizations. Based on state FSP data, reports documented important outcomes for older adults, including reductions in emergency room visits, psychiatric hospitalizations, arrests and incarcerations and homelessness.

County-Level Key Stakeholder Interviews Stakeholder Type 15 Consumers, Family Members Mental Health Administrators 12 Clinicians/Direct Providers: Mental Health/Aging Services 14 Aging Services Administrators 2 Advocates (professional) 1 Health and Human Services Administrator 59 = TOTAL COUNTY-LEVEL STAKEHOLDERS 6 Counties: Alameda Los Angeles Monterey San Diego Siskiyou Tulare

State-Level Key Stakeholder Interviews Stakeholder Type 1 Administrator, Public Health Administrator, Health Care Services 2 Administrators, Aging Services 4 Administrators: State-Level Association, Council, or Commission State-Level Advocates (professional) Administrators, Office of Statewide Health Planning and Development Other State-Level Perspective 13 = TOTAL STATE-LEVEL STAKEHOLDERS

Key Stakeholder Interview Findings: Domains

Key Stakeholder Interview Findings Overview Variation in OASOC: no state mandate or funding allocation All counties have programs (not systems of care) either specific for older adults, or inclusive of older adults All counties offer services that are responsive to the needs of older adults and reflect the individual values promoted by the OASOC and MHSA

Key Stakeholder Interview Findings Overview (continued) Counties reported limited service penetration with older adults Outreach efforts vary by county More needs to be done to reach out to older adults who are not making their way to services Most older adults being served have been living with SMI, often for many years, and have aged within the system

Key Stakeholder Interview Findings: Barriers to Care Unmet basic needs (e.g., food, housing), geographic disparities (especially rural vs urban areas), transportation and housing deficits, insufficient and untrained workforce, bureaucratic constraints, and insurance coverage and care costs Gaps in services: older adults with cognitive impairment, long-term case management, transition/step-down services, and culturally-appropriate services

Key Stakeholder Interview Findings: Facilitators Facilitators to accessing care include increased awareness about MH, increased consumer knowledge about the system and services available, home-based service provision, smooth referral pathways, and improved transportation Integrated care, the co-location of mental health services with primary care, is an important innovation to improve access Across the board, the co-location of mental health services with primary care was described as an important innovation that has improved access to care, especially for older adults who are more likely to have multiple chronic conditions.

Focus Group Sample Family Members (n=11) Consumers (n=33) Age 66 years (average) 54 - 85 years(range) Female = 20 (61%) Race/ethnicity Hispanic/Latino 16 (48%) African American 14 (42%) White 2 (6%) Multiracial 1 (3%) Spanish-speaking = 16 (48%) History of homelessness 20 (61%) Family Members (n=11) Lives with consumer 4 (36%) Female = 8 (73%) Race/ethnicity African American 8 (73%) Multiracial 2 (18%) Hispanic/Latino 1 ( 9%) History of homelessness (consumer) 7 (64%)

Key Findings: Focus Groups What matters most to older adult consumers and family members? COMMUNITY: social engagement, through support groups, neighborhood, church FAMILY: help with knowledge/access, invaluable in recovery, value intergenerational relationships RELIGION: Recovery as a spiritual journey, a source of strength and fulfillment

Key Findings: Focus Groups What impedes recovery? Distrust of the system, especially in marginalized communities Cultural beliefs that stigmatize mental illness Lack of appropriate and experienced providers Geographic disparities in service availability Bureaucratic barriers: lots of paperwork, long waits when applying, delays for referrals  

Key Findings: Focus Groups What supports recovery? Information and services from trusted sources Support groups with peers One stop shopping: integration of physical health, mental health, and substance use services Incorporating family and spirituality into recovery Services for family members Providers with compassion  

Take Away Messages MHSA Programmatic Benefits PEI programs Peer-led programs FSP programs and services Additional resources for county services Increased services networks Innovation projects – integrated programs very beneficial

Take Away Messages (continued) Recommendations for Improvement A need for leadership at every level Address geographic disparities in access Promote integrated systems and care Address resource needs Use outreach strategies, specific to older adults Workforce preparation and adequacy Need for both tracking and outcomes data Increase the political will for older adult MH issues State leadership regarding settings standards and expectations for OA services; County-level Leadership and Advocacy across sectors; Agency-level leadership: champions at every level Huge issues of geographic disparity: “zip code lottery”, unequal access and care Integrated systems and care: especially important for OA with multiple chronic conditions; across agency partnerships; across providers: behavioral health/substance abuse, MH and primary care; reduce redundant bureaucracy burden on client Workforce: trained to work with OA; culturally competent; adequate numbers/types; Data: Tracking of numbers of OA served; also Data collection practices and measures specific to/ inclusive of OAs (indicators work)

California Mental Health Older Adult System of Care Project Dissemination Products Two Policy Briefs: Key Indicators for MH Services for Older Adults Main Study Findings Three Fact Sheets: Promising Programs Main Study Results (English & Spanish)

California Mental Health Older Adult System of Care Project What Questions or Comments Do You Have? Janet: jcfrank@ucla.edu Kathryn: kietzman@ucla.edu