Deborah DiGilio, Chair of the National Coalition on Mental Health and Aging and Director of American Psychological Association Office on Aging called the meeting to order. There were 30 NCMHA members in attendance.
Medicare Mental Health Equity Coalition Presentation
Deborah introduced Clare Jenkins Koller, the Co-Chair of the Medicare Mental Health Equity Coalition. She is also Deputy Director of Government Relations at the American Psychiatric Association and staffs its Council on Aging.
The Coalition started during the 109th Congress with a total of 12 members including the American Association for Geriatric Psychiatry, American Psychiatric Association, American Psychological Association, Medicare Rights Center, National Alliance for the Mentally Ill, National Association of State Mental Health Program Directors, National Committee to Preserve Social Security and Medicare, National Mental Health Association, The Seniors Coalition, and the Suicide Prevention Action Network USA.
During the 109th Congress, the Medicare Mental Health Copayment Equity Act of 2005 was reintroduced. U.S. Representatives Strickland and Murphy introduced the House bill (H. R. 1125 in March 2005) and Senators Snowe, Kerry, Smith and Collins introduced the bill to the Senate (S. 1152, May 2005). It would have phased mental health parity into Medicare over a six year period. This bill has not yet been reintroduced, but the Medicare Health Equity Coalition is excited about possible movement on this issue in the 110th Congress.
During this Congress, the Equity Coalition plans to target the Senate Finance and House Ways and Means Committees. They may also target the Budget Committees to put Medicare parity monies into the budget. Currently they are strategizing on a number of approaches including: working Medicare parity into conversations regarding general and commercial parity, the physician payment fix, or any additional changes to Part D; phasing in implementation of the bill over eight years rather than six; and determining whether parity might first be applied to specific older adult populations, for instance nursing home residents, before going for total coverage. It is estimated that the cost to implement this measure will be $5.8 billion over 10 years.
After presenting, Clare opened the floor to questions. Bob Bernstein, Executive Director of Bazelon Center for Mental Health Law, asked if there were any arguments against Medicare parity other than fiscal ones. Kohler replied that the science base for this issue has progressed dramatically since Medicare's origin in 1965, so opposition is really finance based. The value of mental health services is not in question. Brian Altman, Director of Public Policy, Suicide Prevention Action Network USA (SPAN), asked about the Medicare Mental Health Modernization Act of 2005 introduced by Representative Stark and Senator Corzine. It is a bill that included broader mental health issues, such as including marriage and family therapists and counselors as Medicare providers. Clare did not have the most current information on the Stark-Corzine bill to share at this meeting. In closing, it was pointed out that the fundamental challenge is in understanding the lack of political will to address this issue.
Community Health Mental Services and Older Adults
Deborah DiGilio informed NCMHA members that Joyce Berry, Director of the Division of State and Community Systems Development, Center for Mental Health Services, SAMHSA, could not attend the meeting as previously scheduled.
Jim Morrow from SAMHSA extended his apologies on behalf of Joyce Berry for her absence. He began the discussion by pointing out that the need to include older adults in the Mental Health Block Grant Program has been an issue for a long time. Coverage is currently mandated for two groups: mentally ill adults and children. Funding is in the Congressional budget for 2007 and efforts continue to secure this funding for 2008. An exciting development relates to the CMHS Annual Conference in May for the state block grant and mental health statistics programs. A noticeable part of the event will be related to older adults, including a major plenary. They are also considering conducting a training effort for individuals in attendance on state mental health planning councils and the importance of including of older adult issues and representation on these councils. Conference participants will include three representatives from each state - a state planner, a planning council member, and a data person. It is an open conference, so others who can cover their own expenses should be able to attend. The conference will be May 30-June 1 at the Renaissance Hotel in Washington DC. Information regarding the conference will be posted on the web. Jim noted the eloquent statement that Trudy Persky made on the behalf of the Older Adult Consumer Mental Health Alliance at last year's conference.
The discussion ensued on the topic of the absence of aging in federal block grants. States are not required to address aging issues nor are they required to have an aging representative in state planning efforts. Further, there is no mandate to address older adult substance abuse and treatment which leaves only 17 facilities nationwide that address this issue. Bob Rawlings emphasized that older adults are clearly being denied consumer services. One of the major problems in addressing older adults' needs is that the planning council statute states that services be provided to "adults" defined as those 18 years and older. Older adults are often ignored, even though their needs call for more specialized attention. This is a very good justification for conducting the proposed training effort to inform state mental health planners of the need to have a greater focus on older adults.
Aging Policy Advocacy
Stephanie Reed of the American Association of Geriatric Psychiatry reported that she and Diane Elmore of the American Psychological Association had discussed starting up a mental health and aging policy group that will focus on federal policy and advocacy issues which lie outside of the scope of NCMHA's mission. [As stated in the NCMHA bylaws, its member organizations "work together towards improving the availability and quality of mental health preventive and treatment strategies to older Americans and their families through education, research and increased public awareness." In addition as NCMHA has federal organizations as members, it limits its federal advocacy activities]. A number of members expressed interest and Stephanie will follow up with more details. The current plan is that the group is to be informal with communication occurring when key older adult mental health issues arise that might benefit from coordinated action. Others interested can e-mail Stephanie Reed at email@example.com.
Seclusion and Restraint
Bob Bernstein spoke about seclusion and restraint, an issue with huge implications for older adults. Within the Medicare Modernization Act was a requirement that CMS finalize interim rules on seclusion and restraint (in existence since 1999), or these rules would expire. In the 1999 rule, it was acknowledged that seclusion and restraint was not a part of treatment. SAMHSA provided guidelines on the procedure and the lynchpin was that a patient had to be examined by a medical doctor, face to face, within an hour to determine that seclusion and restraint was needed. This time frame created a "hassle factor" and the use of these measures diminished significantly. CMS issued final rules in December that stated not only physicians, but nurses can also authorize seclusion and restraint. Nurses who would be able to issue a seclusion and restraint order would not be mandated to receive specific training; the rule only states that they would have "appropriate" training. This rule applies only in psychiatric hospitals and residential treatment centers, not in nursing homes.
We need to consider what this means, it is not a stand alone issue. Older adults subjected to seclusion and restraints suffer psychologically and physically. There has been significant success in the reduction of seclusion and restraint in the public sector; it is one of the most effective public policy changes in terms of impact "on the ground." A question was raised whether a change in regulation or statute change would be required to stop this. The reply was that all that is needed is a change in the regulations that CMS has proposed.
2005 White House Conference on Aging and Member Update
Deborah requested that member updates include any efforts related to implementation of the WHCoA recommendations. She stated that after the updates we will have a better sense of how best the Coalition might proceed with its next concerted effort.
National Association of State Mental Health Program Directors - Willard Mays announced that his organization held its annual conference for older adults in September in Indianapolis. He has created a PowerPoint presentation about the activities of NCMHA and the resulting outcomes of the WHCoA. It focuses on the need for continued action and collaboration between state units on aging, state and local coalitions, and WHCoA delegates. The presentation was sent to state mental health authorities across the country.
Mental Health America (formerly National Mental Health Association) - Dianne Dorlester acknowledged that over the past year they have not been as involved in older adult issues due to internal restructuring. They are still at the information collecting stage and determining the best strategies for their organization and its affiliates address to older adult issues.
Center for Medicaid and Medicare Services - Peggy Clark did not have much to report on activities related to the WHCoA. However, a recent success was the Deficit Reduction Act of 2005 which provided funds for demonstration projects for alternatives to psychiatric residential treatment for children. Ten states have been awarded these "money follows the person" grants and now 17 additional states will receive demonstration grants. Many of the states are looking at all persons with disabilities across the lifespan including those with mental illness.
National Association of State Units on Aging - Sara Aravanis reported that many of their state directors were involved and supported the mental health WHCoA resolution. At their December 2006 membership meeting, they dedicated a half-day to mental health and aging. Steve Bartels did a presentation on aging policy issues and the role of state directors, and evidence based practices. Selected states (e.g. New York and Connecticut) that have been successful with mental health transformation grants were involved in a panel presentation. Their policy agenda for the next three years includes keeping state aging directors involved in the mental health and aging issues.
American Psychological Association - David Powers reported that Diane Elmore is in the process of setting up a congressional briefing to follow up on the implementation of the WHCoA mental health resolutions.
Center for Mental Health Services - Paul Wolford spoke about the CMHS annual conference and the mental health transformation grants that they are working on. He proposed that the conference have a showcase of all states that have done good work in the provision of mental health services. He mentioned that the transformation grants explicitly include efforts across the lifespan.
Geriatric Mental Health Alliance of NY - Kim Steinhagen reported that the Geriatric Mental Health Act of New York had passed and $2 million was allotted to demonstration programs. The projects will focus on gatekeeper and integration of physical and mental health initiatives. Funding will begin in April. Further, as a component of the Geriatric Mental Health Act there is an Interagency Geriatric Mental Health Council consisting of seven state departments and chaired by the Director of State Office on Aging and the Commissioner of the Office of Mental Health. They are currently making recommendations to various state departments on mental health service provision for older adults.
American Association for Geriatric Psychiatry - Stephanie Reed noted that they incorporate and cite the WHCoA mental health and workforce resolutions in all that they do.
Pennsylvania Behavioral Health and Aging Coalition - Lynne Nessel stated that their state Coalition's accomplishments include: advocating successfully for the inclusion of information about elderly adults in the requirements for the 2004 County Mental Health Plans resulting in an increase of older adult representation; a $30,000 grant in 2004 from the Pennsylvania Department of Public Welfare to facilitate 20 focus groups throughout the Commonwealth to identify barriers to mental health and substance abuse services for at-risk older adults and make recommendations for improving outreach and services; and receiving a $7,000 grant from Open Minds/Open Doors to provide anti-stigma presentations on mental health and aging issues. In 2006, the Coalition and the Older Adult Committee of the Mental Health Planning Council advocated for a Mental Health Bulletin on the rights of older adults and for Memorandums of Understanding between the Pennsylvania Department of Aging and Office of Mental Health and Substance Abuse Services as well as the county mental health and aging systems. In 2007, the Coalition is working with the Pennsylvania Department of Aging to encourage county-wide cooperation between the aging and mental health systems and planning a statewide conference on late life depression in October.
Jewish Federation of Metropolitan Chicago - Amy York noted that their organization works on a range of policy issues related to the WHCoA recommendations. In particular, the Lifespan Respite Care Act has passed but the bill still needs funding.
Substance Abuse and Mental Health Services Administration - Lisa Park stated that they are developing a paper on how to implement evidence based practices. (She will email Deborah when the paper is available toward the end of February.) They are also developing a CD on evidence-based practice implementation. This remains one of their priorities for Fiscal Year '07. Lisa asked NCMHA members that have potential EBP programs that they would like to nominate, to submit them by February.
American Association for Marriage and Family Therapy - Brian Rasmussen stated that expanding Medicare provider status to include marriage and family therapists continues as their key priority issue. They have also been working in support of the Lifespan Respite Act.
Administration on Aging - Diana Lawry noted that one key impact drawn from WHCoA was the language for the Positive Aging Act being incorporated into the OAA. They also often draw upon the WHCoA report to support their mental health planning efforts. AOA is currently working on is a long-term plan on mental health based on the PAA provisions. Several staff members are involved and they would be willing to come to a future NCMHA meeting to share the plan and secure NCMHA input.
National Council on Aging - Bob Tiller believed that the final report from the WHCoA was a huge disappointment. The report did not do justice to all of the work put into it and he believes, unfortunately; it will sit on a shelf. They are in the process of building an electronic network of WHCoA delegates. The list currently comprises 700 of the 1200 delegates. NCOA is also in the process of identifying public policy priorities for the 110th Congress. The top three priorities are: increasing appropriations for the Older American Act, long-term care, and increasing access of low-income people to Medicare Part D (e.g. elimination of asset test for qualification). In terms of the WHCoA, he believes that we should acknowledge that it occurred a long time ago and to tie future recommendations to its Final Report really doesn't seem relevant. We should look ahead, not back.
American Bar Association - Ellen Klem, representing Leslie Fried of the Commission on Law and Aging stated that she attended this meeting to learn more about mental health and aging and NCMHA's activities.
Suicide Prevention Action Network - Brian Altman reported that they are working on public policy issues for the 110th Congress including how to reduce suicide in the elderly population. They are creating resources for their state and local members, and larger constituent groups. Altman reiterated the importance of having a forward-looking approach toward advancing aging and mental health issues rather than dwelling on the past.
National Association of Area Agencies on Aging - Amy Gotwals recommended that we need to work collaboratively with the area agencies on aging. Leverage points are critical. We need to narrow the number of recommendations and implementation strategies resulting from the WHCoA that we want to focus on and decide which level we are going to target.
National Council on Aging - Alixe McNeill distributed flyers for the 2007 Joint Conference of ASA/NCOA to be held on March 5-11 in Chicago. She will be moderating a session on Shaping Mental Health Organization Structure and Programs through Coalitions which will look at evidence-based practice programs in Houston and Wisconsin.
American Society on Aging - Anita Rosen described the Mental Health and Aging Network (MHAN) of the American Society on Aging, one of its largest constituent groups. This year there will be a special, all-day program, "Mental Health and Aging Coalitions: Effective Approaches and Innovative Practices," presented by MHAN, NCMHA and NCOA. It will include three workshops. The first is, The Current Status of Mental Health and Aging Coalitions: Activities and Outcomes Related to Mental Health after the White House Conference on Aging. It will summarize the successful strategies used to assure attention to mental health and substance abuse at the White House Conference on Aging and the successful outcomes that were achieved. Presenters are Anita Rosen, Deborah DiGilio and Willard Mays. The second is Mental Health and Aging Coalitions: Making a Difference at the State and Local Level that will highlight the success of mental health and aging coalitions in the states of Florida and New York and provide an opportunity for other coalitions to share their activities and/or to seek advice on enhancing an existing coalition or forming a coalition where none currently exist. Presenters are Bob Rawlings, Larry Dupree, and Michael Friedman. The third is, Shaping Mental Health Organizational Structure and Programs through Coalitions. It will describe the formulation of coalitions of aging and mental health service leaders together and university faculty to develop new strategies and practical, evidence-based programs for improving mental health services to older adults. Presenters are Alixe McNeill, Esther Steinberg, and Cathy Swanson-Hayes. In addition an award will be given to Larry Dupree, PhD. His special lecture is titled, Recognizing Depression in Older Adults as a Public Health Challenge: Physical and Life Span Consequences.
State and Local Coalition Representative to the Executive Committee and Member at Large - Bob Rawlings described efforts in Oklahoma that have resulted in new rules more inclusive of aging and mental health evaluation and referrals. The Oklahoma Coalition presents data and other information on mental health and aging each February to new state legislators. The state has also received a CMS transformation grant. His recommendation to the NCMHA regarding WHCoA follow-up is to develop a fact sheet that summarizes important issues addressed by the group.
Older Adult Consumers Mental Health Alliance - Trudy Persky described her experiences in Pennsylvania related to aging and mental health planning. Initially, she was the only member of the mental health planning council with an interest in aging. Now there are three interested members. She spoke about the lack of funding for older adult issues due to great competition for mental health monies and insufficient advocacy on aging issues. She encourages groups like NCMHA to show support and interest in state and local mental health aging efforts as it usually gets lonely "out there."
American Mental Health Counselors Association - Beth Powell said that they had not been that involved with WHCoA. They are working on getting their members reimbursed for Medicare.
American Association of Marriage and Family Therapy - Melissa Stamps noted that their organization had a representative at the WHCoA and that marriage and family therapists are included in the resulting recommendation and implementation strategies.
National Citizens' Coalition for Nursing Home Reform - Julia Meashey noted that the success of the WHCoA delegates in getting mental health issues as a top WHCoA resolution spurred their interest in putting mental health on their organization's agenda. They are taking the WHCOA implementation strategies and looking at how they interact with what their organization is doing. Mental health advocacy is a topic of interest for state ombudsman programs. They now have web-based information on this topic, including resources by Dr. Gifford Weary, Chair of the Psychology department at Ohio State University.
Older Adults Mental Health Work Group - Anne Marie Hermann attended the NCMHA meeting for the first time. She is the chair of this Northern Virginia group, which is part of a strategic planning partnership that focuses on mental health issues. Their burning issue is the development of a proposal for pilot programs for community-based services which would include teams to treat older adults "in place." They are looking for funding to carry out the pilot project which will ultimately minimize hospitalization and institutionalization.
Next Steps to Build Upon the Attention Brought to Mental Health and Aging by the 2005 WHCoA
The Chair asked, based on the reports of our member organizations, what can NCMHA do to bring continued attention to the issues raised by the WHCoA. Bob Tiller suggested that the Coalition should search for ways of advocating for the issues raised without tying them to the WHCoA. Bob Bernstein pointed out that reports are "what they are" and that although reports like the WHCoA Final Report are often not read, they serve as credentials which are also an important factor in addressing the issue.
The group concurred that whatever product(s) we decide to develop should be forward-looking, and that any recommendations made should be grounded in the work that has been done thus far. It was noted that the WHCoA report is the most recent building block in the growing structure of mental health and aging that includes the Surgeon General's Report on Mental Health, the President's New Freedom Commission, etc.
The next issue discussed was who could best use a resource such as this? To whom should it be targeted - those at the federal or state and local levels? It was decided that although NCMHA should work towards developing resources that could be used at multiple levels, our initial efforts should target the more grass-roots level. The discussion then turned to what specific type of a resource is needed. Trudy Persky asserted that we need a good conveyor of education, something that could justify the validity of securing other resources like funding. It should be a tangible, user-friendly product that would suggest feasible steps and potential solutions to key yet very specific mental health and aging issues.
It was decided to begin development of a series of one page fact sheets and letter templates that groups can use to advocate for mental health services and issues. Each would:
Anita Rosen recommended that a segment of the workshop, The Current Status of Mental Health and Aging Coalitions: Activities and Outcomes Related to Mental Health after the White House Conference on Aging, to be held at ASA/NCOA, could be dedicated to identifying key fact sheet messages and content. NCMHA concurred with the value of doing this. Dan Foley, SAMHSA, emphasized the need to pay strong attention to the sources of the stated facts and recommendations made. He noted the importance of looking into the science to provide leverage to our efforts. In closing the discussion, it was noted that development of these fact sheets is going to require the concerted efforts of all NCMHA members. Members wishing to become involved in their development should contact Deborah DiGilio at firstname.lastname@example.org.
In closing, Deborah stated that Paul Wolford will be retiring from CMHS in 3 weeks. She noted his decades of work in support of older adult mental health and thanked him for those efforts. The Coalition responded with a round of applause and best wishes.
The meeting was adjourned at 12:30 p.m. The next NCMHA meeting will be held on Monday April 23rd at the offices of the American Psychological Association in Conference Room 7296.