MEETING SUMMARY
National Coalition on Mental Health and Aging
October 14, 2003

Sanford Finkel, Chair of the National Coalition on Mental Health and Aging, called the meeting to order and welcomed the 25 members and two guests in attendance.

Senate Special Subcommittee on Aging Legislative Update

Our guest, Lauren Fuller, Chief Investigative Counsel, Special Committee on Aging presented on The Elder Justice Act (S.333/H.R.2490). Senators John Breaux (D-LA) and Orrin Hatch (R-UT) introduced the bill in the Senate on February 10, 2003. There are currently 33 cosponsors in the Senate and 60 cosponsors in the House. The cases of three elder abuse victims were highlighted through an audiovisual presentation and the rationale for the Act was provided. Lauren stated that of the total federal dollars spent on abuse and neglect, 91% was spent on child abuse, 7% on domestic abuse and 2% on elder abuse. There are no full time federal employees who work to prevent elder abuse, neglect and exploitation.

The Elder Justice Act's goals are to: elevate national awareness about the problem, increase knowledge, train as many disciplines as possible, prosecute when appropriate, combat elder abuse with grants, demonstration projects, research, and new programs in LTC. An overarching goal is to elevate elder abuse, neglect and exploitation to the national stage by establishing: offices of Elder Justice at HHS and DOJ, a public-private Coordinating Council, and a Federal Office for Adult Protective Services. The proposed reauthorization period of the Act is seven years. National Coalition members raised a number of issues. It was felt that mental health issues should be more fully considered - for example, the impact of mental disorders on abuse, and how specialized mental health services can be a tool for prevention and recovery from abuse It was noted that many child abuse victims come into the protective services system via mental health settings - as many older adults do not access the mental health system, how do we reach out to them, what are effective case-finding methods? Other issues discussed were: linking CMS nursing home ratings to elder abuse reports, chemical restraints and seclusion, the critical need to train "front line" workers, and improving the criminal justice system. For general information about the Elder Justice Act and Elder Justice Coalition, go to: http://www.elderabusecenter.org/default.cfm?p=elderjustice.cfm. To view the Senate Elder Justice bill go to http://thomas.loc.gov and enter S. 333 in the bill number box. To recommend comments or revisions on the bill contact: Lauren_Fuller@aging.senate.gov. To join or contact the Elder Justice Coalition, contact: Robert Blancato, Chair or Amy Hooper, Associate at (202) 682-4140 or elderjustice@erols.com.

Legislative and Regulatory Update

Nicholas Meyers, Deputy Director, Congressional Relations, American Psychiatric Association provided the legislative update. The first topic covered was Medicare modernization efforts. He provided updates on the debates regarding dual eligibles, whether drug premiums should be "means-tested", drug reimportation, and forced competition between traditional Medicare and private health plans. [Ed. note: Many of the specifics we discussed have evolved (or devolved) since our meeting including not meeting the October 17 self-imposed deadline for the Conference committee to resolved the differences between the House and Senate bills. Sources for up-to-date information include the Kaiser Family Foundation http://www.kff.org and NAMI http://www.nami.org.]

Sandy Finkel, AAGP raised the issue of Medicare provider payment cuts and the impact on care for older adults. He noted that many board certified geriatric psychiatrists no longer accept Medicare and that another 4.6% reduction would lead more specialty trained persons to exit the field. He stated this has especially serious implications for dual eligible persons attempting to secure mental health services.

Nick reported that The Senate Committee on Health, Education, Labor and Pensions, Subcommittee on Substance Abuse and Mental Health Services was scheduled to hold a hearing on the New Freedom Mental Health Commission on October 22nd. [Ed. Note: The hearing was held Nov. 4th. More information on the hearing is available at http://www.senate.gov/~labor/bills/034_bill.html.]

Related to policy issues, Leslie Fried, ABA Commission on Law and Aging, informed the group that Social Security has proposed criteria for evaluating mental disorders. The proposed rule was in the March 17, 2003 Federal Register. Town meetings will be scheduled before publication of the proposed rules. She encouraged members to participate. Leslie also noted that Medicare Local Medical Review Policies (LMRP) play a large role in access to mental health care for older adults. There are two new draft LMRPs related to psychiatric and psychological services up for public comment. The first, Nordian Administrative Services' Psychiatry and Psychological Services and "Incident To" These Services LMRP, applies to Alaska, Arizona, Colorado, Hawaii, Iowa, Nevada, N. Dakota, Oregon, S. Dakota, Washington and Wyoming. Deadline for comments is December 15th. The second draft LMRP, Palmetto GBA's Outpatient Psychiatry and Psychological Services, applies to North Carolina. Deadline for comments is November 15th. All draft LMRPs nationwide are available at http://www.draftlmrp.net/. This is a CMS web site that lists all contractors' proposed draft LMRPs and provides one mechanism for offering comments to the respective contractors during the public review and comment period.

Deborah DiGilio mentioned the American Psychological Association Office on Aging has a web-based Medicare LMRP tool kit that provides information and guidance for those interested in understanding Medicare provisions for psychiatric and psychological services and providing input into their development. Components include an explanation of the LMRP development process, opportunities for advocacy, and tools such as samples of correspondence with insurance intermediaries. The toolkit can be accessed at: http://www.apa.org/pi/aging/lmrp/.

ABA Commission on Law and Aging: Incapacitated and Alone: Health Care Decision-Making for the Unbefriended Elderly

Naomi Karp, Associate Staff Director, ABA Commission on Law and Aging provided an overview of the study and the resultant publication, Incapacitated and Alone: Health Care Decision-Making for the Unbefriended Elderly coauthored by Erica Wood. This was a one-year study with the goal of determining the current state of the law and practice in health care decision making for the unbefriended elderly and to identify workable solutions. "Unbefriended" is defined as: a patient who does not have decisional capacity to give informed consent to the treatment at hand; has not executed an advance directive and has no capacity to do so; and has no legally authorized surrogate, or family or friend to assist in decision-making. In most states, the legal framework for making treatment decisions on behalf of these individuals is insufficient, and as a result they may be subject to over or under-treatment, or treatment that does not reflect their values or address their well-being. There is little existing research in this area and data is lacking on the size of this population, but estimates show the number is significant. Experts have speculated that about 3-4% of the total nursing home population is unbefriended and this coincides with observations made during the study. Unbefriended patients are people who frequently have been socially isolated much of their lives. There appears to be four legislative paths to health care decision making for the unbefriended: Eight states have enacted statutory authorization for health care consent when no surrogate is available - many of these provisions give a key role to the attending physician; Three states have enacted laws authorizing external committees of trained volunteers to make decisions; Many states have enacted public guardianship programs for both health care and financial decision-making, and; At least five states have enacted a court process to seek consent or appoint an individual to give consent (one route is "temporary medical treatment guardian"). Policy suggestions include: analysis of federal data on long-term care residents to shed light on this population; LTC staff should play a greater role in investigating and conveying resident values and preferences; health care professionals should improve techniques for assessing and enhancing decisional capacity; facilities should develop and strengthen internal decision-making mechanisms; states and communities should develop external bodies to make decisions for those without surrogates; demonstration projects involving ethics committee decision-making should be funded; states with surrogate decision-making systems should test their use with unbefriended older adults; temporary medical treatment guardianship programs should be expanded; states should support adequately funded and staffed public guardianship programs: state health consent laws and their application to the unbefriended merit further study; and further study should include a focus on cultural diversity and health care decision-making.

NIMH's September National Advisory Mental Health Council Meeting

Debbie DiGilio, APA and Anita Rosen, CSWE attended the Open Policy Session of this September 12th meeting when the Council's Aging Research Workgroup's Final Report, Mental Health for a Lifetime: Research for the Mental Health Needs of Older Americans was discussed. At the meeting, Charles Reynolds, the Workgroup's Chair, reviewed the group's charge to assess the Institute's extramural aging research and training portfolio and identify strategies for developing: 1) promising research areas, 2) researchers skilled in aging issues, 3) NIMH program staff expertise, and 4) collaboration with other stakeholders. Many mental health and aging constituent groups were visible at the meeting, including AGS, AAGP, IASWR, both APAs, NAMI, and the VA and they were united and vocal in their support for reinstitution of the Aging Branch at NIMH and for the other recommendations outlined in the report. The report is now available online at: http://www.nimh.nih.gov/council/agingreport.cfm. The National Coalition plans to invite Barry Lebowitz or Enid Light from NIMH to speak at our next meeting.

Get Connected! Linking Older Adults with Medication, Alcohol and Mental Health Resource Toolkit

Alixe McNeil, of the National Council on Aging (NCOA) described this new toolkit, a collaborative project of NCOA, AOA and SAMHSA. The kit provides guidance and resources to service providers and older adults needing information and services related to medications, alcohol and mental health issues. Tips and strategies are offered for building health promotion programs and educating staff and consumers, and a wide variety of videos, brochures and professional resources are highlighted. To order the Get Connected! Toolkit (NCADI Inventory #GCKIT), call SAMHSA's National Clearinghouse for Alcohol and Drug Information at 1-800-729-6686 or e-mail info@health.org.

Member Updates

National Association of State Mental Health Program Directors - Willard Mays: There will once again this year be a "Coalition" track at the 2004 ASA/NCOA Annual Meeting in San Francisco. The track will be held on April 15th. ASA's Mental Health and Aging Network (MHAN) has over 900 members. Anita Rosen, Council for Social Work Education, is the current chair of MHAN.

Maryland Coalition on Mental Health and Aging - Kim Burton: They are trying to squeeze monies to fund staff training conferences on mental health issues in long term care settings. As she stated at the last meeting, only 2% of foundation monies are allocated to aging issues, compared with 80% for children. She appealed to the Coalition for assistance in identifying funding streams and to foster a line of communication with other state and local coalitions.

Kim's remarks stimulated a discussion of the status of the state and local coalition building effort. Currently there are approximately 30 coalitions. These efforts are currently not coordinated. In the late 1990s, CMHS supported the development of state and local coalitions w. grants to the AARP Foundation and NASMHPD. The grants helped establish and provide technical assistance and training to emerging coalitions. A How-to Manual was also developed and a networking meeting of all existing coalitions was convened. This support is not available today and it appears that some of the coordination between mental health and aging coordination is being lost. It was decided that the National Coalition would send a letter to the CMHS director requesting that the state and local coalitions once again be supported through the Positive Aging Resource Center or some other entity, with CMHS funds or in partnership with other SAMHSA centers and/or HRSA or CMS.

Older Adult Consumer Mental Health Alliance - John Piacitelli (President): There is a need for ongoing communication regarding grass roots advocacy on older adult mental health issues between OACMHA and state and local coalition members. OACHMA encouraged the Presidents' New Freedom Commission to address older adult needs and two of its members testified. John asked that members educate their own memberships about OACHMA via blurbs in their newsletters. In addition, if organizations can fund an OACMA member to attend their annual conferences or initiate a consumer attendance fee, that would be very helpful. Linda Powell (Executive Director) informed the group that focus groups were conducted in three states related to the Older Adult System of Care Framework being developed.

Gerontological Society of America and Psychologists in Long Term Care - David Powers: GSA's Annual Meeting is Nov 21-25 in San Diego. PLTC will have a booth at GSA. It was noted that GSA would be a good place to distribute the Get Connected toolkit.

National Depressive and Bipolar Support Alliance - Mildred Reynolds: Copies of their new publication, Coping with Mood Changes Later in Life were distributed.

American Association of Geriatric Psychiatry - Stephanie Reed: AAGP's Board of Directors and Committee members will actively lobby Congress on the mental health parity issue when they are next in DC.

National Association of State Units on Aging - Sara Aravanis: They are currently focusing on Older Americans Act appropriations including family caregiver support. The National Center for Elderabuse has been refunded. They have received an AOA grant to provide technical assistance to the I&R network to upgrade their services in ways that they are more accessible to consumers.

American Occupational Therapy Association - Marian Scheinholtz: They are developing training packages in conjunction with their project with the NHTSA on driver safety (the forgotten IADL). They are also involved with OT needs of individuals with dementia and are developing evidenced based fact sheets for practitioners in areas such as stroke, brain injury and tip sheets for consumers on fall prevention, hip replacements and others.

Council on Social Work Education - Anita Rosen: CSWE is an active participant of a leadership Coalition funded by the Hartford Foundation related to workforce issues, particularly reinforcing the need for training monies outside of the traditional medical model. They also have a new Executive Director, Julia Watkins, who has a specialization in gerontology.

National Association of Social Workers - Jim Finley: They are actively advocating around issues of Medicare prescription drug benefit, mental health parity, Medicaid issues and respite care.

National Council on Aging - Alixe McNeil: With AOA, RWJ and the Hartford Foundation, twelve prevention programs have been funded that incorporate evidence based practices into programs to address the general health and mental health needs of older adults.

American Psychological Association - Debbie DiGilio, Diane Elmore and Deborah Cotter: APA cosponsored a congressional briefing, "Providing Lifespan Respite Care: Vital Support for Family Caregivers" on July 30, with the National Lifespan Respite Care Task Force." Panelists included Congressman Dennis Byars (R-NE), geropsychologist, William Haley, Ph.D., who presented, "What the Research Tells Us", and three family caregivers who provided care for individuals across the lifespan. Policy efforts related to the New Freedom Commission, the Positive Aging Act, and the Elder Justice Act continue. The APA Council of Representatives approved the Guidelines for Psychological Practice with Older Adults as APA policy in August.

Positive Aging Resource Center - Sue Levkoff: PARC was established in 2002 as part of the Targeted Capacity Expansion (TCE) initiative of SAMHSA. PARC provides technical assistance to nine SAMHSA-funded model, evidenced-based, mental health service programs for older adults. Next year they will focus on their resource center, web page and web-based training for nurses, social workers and occupational and physical therapists. A discussion ensued as to how the Center and the National Coalition could collaborate, perhaps work to support state and local coalitions and draw upon Coalition members' resources in their work.

Visitor - Patrick Cody is a communications consultant currently working with the Older Women's League on Older Adult Mental Health Week and OACHMA on the Older Adult System of Care Framework.

Open Discussion on Aging Policy Issues with Robyn Golden, Heinz Senate Fellow, Senator Hilary Rodham Clinton Office

Robyn, who is an ASA representative to the National Coalition, is currently a fellow in Senator Clinton's (D-NY) Washington office. She gave an overview of the efforts the Senator is involved with that are relevant to the group, including being a cosponsor of the Lifespan Respite Act. They are currently working to secure Republican support in the House. The Act focuses on the coordination of respite services statewide and locally (rather than funding direct service provision). The Grandfamilies Rally is scheduled for Oct 15th to raise awareness of the significant role of grandparents play in the rearing of children, and the lack of support and resources they often face. Other issues discussed included: the critical need to train current mental health professionals in geriatric mental health issues; and that new training needs to be supported by adequate funding. It is difficulty to encourage professionals to expand their scope of practice to older adults and then have poor funding under Medicare. Interest in the field of older adult mental health is growing, however some providers can't afford to practice with older adults.

Other issues:

Prior to adjournment, the discussion turned to the National Coalition's website. Members are encouraged to view the website (http://www.ncmha.org). The website is graciously maintained through the volunteer efforts of Larry Dupree, Professor & Chair of the Dept of Aging & Mental Health, University of South Florida. A variety of resources are posted including minutes of our meetings, links to our organizations, listings of state and local coalitions, and resources. It was noted that it needs to be updated and expanded - it is provides a wonderful venue for information dissemination that we do not fully utilize. One potential use would be to list major publications in our field. A subcommittee of Anita Rosen, Willard Mays, Sue Levkoff, Bob Rawlings and Debbie DiGilio agreed to look at the site and make recommendations as to other information that should be included.

It was also noted that AARP has not been an active participant in the Coalition during the past two years and that additional outreach should occur to encourage their involvement. Robyn Golden volunteered to pursue this on the Coalition's behalf. In addition, it was recommended by a member that the coalition try to secure more consumer involvement.

Next Meeting

The next Coalition meeting will be held on Wednesday, February 4th, 2004 from 8:30 am -12:30 pm at the offices of the American Psychological Association. Please note the recently changed starting time for all future Coalition meetings. The meeting length has been expanded by one hour due to the increasing volume of items on each meetings agenda. Hope to see you then!

Minutes prepared by:
Deborah DiGilio
Office on Aging
American Psychological Association