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Promoting Older Adult Health

Promoting O

lder Adult H

ealth Aging Network Partnershipsto Address Medication, Alcohol,

and Mental Health Problems

DEPARTMENT OF HEALTH AND HUMAN SERVICESSubstance Abuse and Mental Health Services Administrationwww.samhsa.gov

DHHS Publication No. (SMA) 02-3628Substance Abuse and Mental Health Services AdministrationPrinted 2002


Aging Network Partnerships to AddressMedication, Alcohol, and Mental Health Problems

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration

5600 Fishers Lane

Rockville, MD 20857

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A c k n o w l e d g m e n t s

Numerous people contributed to the publication of this guide. Alixe McNeill, AssistantVice President for Program Development at the National Council on the Aging, Inc.(NCOA), and Mary Brugger Murphy, Senior Advisor to NCOA, served as the leadresearchers and authors. Project direction was provided by Jennifer Fiedelholtz, Govern-ment Project Officer, SAMHSA. Expert advice and guidance was provided by Eileen Elias(SAMHSA), Jennifer Solomon (SAMHSA), Nancy Whitelaw (NCOA), Melanie Starns(Administration on Aging), David Turner (NCOA Health Promotion Institute), RonSchoeffler (NCOA National Institute of Senior Centers), Willard Mays (National Coali-tion on Mental Health and Aging), and Frederic Blow, Ph.D. (University of Michigan).

Thanks are also extended to the national organizations that assisted in the identifica-tion of promising practices, the individuals who made the effort to describe and nominateprograms, and all the individuals from the nominated programs who provided the infor-mation needed for review of the nominations.

The volume would not have been possible without the energy and patience of thecontact persons for the 15 programs profiled in this guide. They spent considerable timedescribing their programs, responding to many questions, and reviewing and revising thedescriptions. Their willingness to serve as a resource to the readers of this guide is mostappreciated.

This guide was prepared by the National Council on the Aging, Inc. (NCOA), for theSubstance Abuse and Mental Health Services Administration (SAMHSA), U.S. Depart-ment of Health and Human Services (HHS), under purchase order #99M00632601D,Jennifer Fiedelholtz, Government Project Officer. The content of this publication doesnot necessarily reflect the views or policies of SAMHSA or HHS, nor does it necessarilyreflect the views of NCOA.

P u b l i c D o m a i n N o t i c eAll material appearing in this report is in the public domain and may be reproducedor copied without permission from the Substance Abuse and Mental Health ServicesAdministration. Citation of the source is appreciated. This publication may not bereproduced or distributed for a fee without specific, written authorization from theSAMHSA Office of Communications, U.S. Department of Health and Human Services.

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At the dawn of a new millennium, we takestock of where we have been and where wemay be going. Not surprisingly, as we moveinto the 21st century, this Nation can antici-pate dramatic changes. One of the most sig-nificant is the demographics of the Americanpeople. By 2030, people over the age of 65are expected to account for 20 percent ofthe population, up from 13 percent today.The effect is already being felt in social andhealth care support systems at the local,State, and Federal levels. We cannot waitfor tomorrow to address these changes.

Perhaps nowhere is the need for atten-tion more evident than in the areas of sub-stance abuse prevention, addiction treat-ment, and mental health services. Relativelyfew people are focused on or aware of thesignificance of alcohol, medication, andmental health-related problems amongolder adults. Yet as many as 17 percent ofolder adults are affected by alcohol and/orprescription drug misuse, and an estimated20 percent of older adults experience men-tal disorders that are not a normal part ofaging. These problems affect not only thelength of life but also the quality of life.

The good news is that these problemsare preventable and treatable. They areperhaps even more responsive to treatmentthan other chronic illnesses, such as heartdisease and diabetes. The bad news is that,like other populations across the age spec-trum, older adults are often reluctant toseek assistance from the substance abuseand mental health service delivery systems.

To help bridge the gap between olderadults and the mental health and substanceabuse services they may need, the SubstanceAbuse and Mental Health Services Adminis-tration (SAMHSA) and the National Coun-

cil on the Aging, Inc. (NCOA), sought theadvice of service providers and older con-sumers. We learned that substance abuseand mental health service providers areworking successfully with aging servicesorganizations in a number of communitiesto meet the needs of older people, providingmodels that can be adopted and adapted inlocations across the country.

This publication is designed to helpolder adults gain access to needed substanceabuse and mental health services by pro-moting new linkages between well-known,trusted, and heavily utilized providers ofaging services and relevant substance abuseand mental health services. By joining thesesystems, we can more successfully identifyolder adults who are at risk for problemswith alcohol, medication, and mental disor-ders and connect them with the prevention,education, outreach, and treatment servicesthat can dramatically improve their lives.

SAMHSA and NCOA are proud tohave partnered in the development of thispublication. Our partnership, and the Stateand local partnerships identified in thispublication, can serve as models for ourcolleagues around the country. The resultof this collaboration will be measured inthe improved quality of life for countlessmillions of older Americans, both todayand for decades to come.

Charles G. Curie, M.A., ACSWAdministratorSubstance Abuse andMental Health Services Administration

James Firman, Ed.D.President and CEOThe National Council on the Aging, Inc.

F o r e w o r d

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C o n t e n t sSection 1 - Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Section 2 - Education and Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Healthy Aging Program in senior centers incorporates substance abuse education, prevention, screening, referral, and continuing support (Salt Lake County, UT) . . . . . .15

Health Enhancement Program helps seniors identify goals for their own health, adopt healthy behaviors, and avoid unhealthy behaviors (Seattle/King County, WA) . . .19

Nutrition and senior centers serving Hispanic elders offer tailored mental health services (Miami/Dade County, FL) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

Section 3 - Outreach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

Public service and local businesses collaborate with an integrated mental health and aging agency to train workers in daily contact with elders (Spokane, WA) . . . . . .31

Congregate public housing gatekeepers identify elders in need of mental health or substance abuse treatment (Baltimore, MD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

Interdisciplinary mental health team provides in-home crisis intervention and helps stabilize elders (Seattle/King County, WA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

Section 4 - Screening, Referral, Intervention, and Treatment . . . . . . . . .45

Multiservice agency offers mental health and substance abuse screening, treatment, and long-term support for seniors (Boston, MA) . . . . . . . . . . . . . . . . . . . . . . . . . . . .48

Community health center integrates mental health and substance abuse services with primary health care (Berkeley, CA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

Geropsychiatric agency collaborates with aging services to reach elders with substance abuse problems (Chicopee, MA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

Public hospital-based mental health center offers geriatric mental health services on- and off-site (New York, NY) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63

Substance abuse treatment center collaborates with a geriatric clinic and a neighborhood services agency (Ann Arbor, MI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68

Community mental health center, in a joint venture with a fiscal court and an area agency on aging, operates an adult day health program (Adair County, KY) . . . .73

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Section 5 - Service Improvement Through Coalitions and Teams . . . . . .77

County government supports a comprehensive array of alcohol and drug prevention services (Fairfax County, VA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79

Wrap-around team from more than 12 agencies ensures that no elders in need fall through the cracks (Concord, NH) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84

Regional mental health and aging coalition offers cross-training in the fields of aging, mental health, and substance abuse (Indiana, Kentucky, Ohio) . . . . . . . . . . . . .88

Appendix 1 - Nominations of Additional Promising Practices . . . . . . . .93

Appendix 2 - National Partner Organizations . . . . . . . . . . . . . . . . . . . .105

Appendix 3 - Select Federal Agencies and National Organizations Providing Resources to Address Medication, Alcohol, and Mental Health Problems Among Older Adults . . . . .109

Appendix 4 - Directory of Mental Health and Aging Coalitions . . . . . . .113

Appendix 5 - Short Michigan Alcoholism Screening Test—Geriatric Version . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121

Appendix 6 - Fax Back Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .123

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Two frequently overlooked health problemsamong older adults are the often inadver-tent misuse and abuse of alcohol and med-ications, including both over-the-counterand prescription medications. Mental healthproblems, such as depression and anxietydisorders, also are frequently overlookedamong adults over the age of 65 but canhave a significant impact on their health.The Substance Abuse and Mental HealthServices Administration (SAMHSA) andthe National Council on the Aging (NCOA)have joined together to confront and helprespond to these issues by creating thisguide for community-based organizationshelping at-risk seniors.1

In 1999 and early 2000, SAMHSA andNCOA convened a series of meetings withservice providers and older consumers togather their input regarding priorities foraction related to alcohol and medicationmisuse/abuse and mental health problemsof older adults. Both groups articulated aneed for greater understanding of theseproblems among older adults as well asstrategies for addressing them. SAMHSA

and NCOA were specifically asked to pro-vide concrete, practical guidance on howmental health, substance abuse, primarycare and aging services providers can col-laborate to provide education, prevention,screening, and referrals to treatment forseniors who may be experiencing or at riskfor these problems.

Older adults often are reluctant to seekservices from traditional substance abuseand mental health providers for a varietyof reasons, including the stigma associatedwith these issues. Organizations providingsocial, health or supportive services forolder adults, including primary careproviders, are uniquely positioned to playa vital role in linking elders at risk foralcohol or medication misuse/abuse ormental health problems to the full contin-uum of service: education, prevention,screening, and treatment.

The Aging Services Network—57 Stateagencies, 655 area agencies, and more than27,000 seniors centers, adult day services,nutrition programs and other service pro-viders—is a tremendous resource to helpaddress substance misuse and mental healthproblems among American seniors. Eachyear, this network serves approximatelyseven million of the 35 million older adultsin this country. Many of those seniors maybe having problems with alcohol or medica-tions, or may be experiencing mental health

S e c t i o n 1 I n t r o d u c t i o n

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1 The aging process varies from individual to indi-vidual. For this reason, no one term can be usedto describe all people as they grow older. Thisvolume uses the terms “older adult,” “elder,”and “senior” interchangeably. These terms arenot intended to imply diminished capacity or lossof independence. Rather, they describe peopleexperiencing the normal aging process.

problems. The organizations in the AgingServices Network can play a critical role ineducation, identification, screening andreferral to other services.

Primary care providers are in an out-standing position to reach older adults withor at risk for mental health problems aswell as for alcohol or medication misuse orabuse. Education, screening, and preventiveinterventions easily can be provided duringregular visits with a primary care provider.Many older people prefer to receive treat-ment for mental health or substance abuseproblems in primary care settings, althoughsome people will require the more special-ized services offered by mental health andsubstance abuse service providers.

Partnerships between organizationsproviding social, health and supportiveservices (“aging services providers”) forseniors, mental health providers and sub-stance abuse providers have significantpotential to enhance the availability andaccessibility of the full continuum of serv-ices needed by older adults with or at riskfor mental health problems or problemswith alcohol and medication misuse orabuse. SAMHSA and NCOA have devel-oped this guide to facilitate collaborationsamong mental health, substance abuse,and aging services providers. The guide:

• identifies programs across the countrythat are linking with community part-ners to provide seniors with neededsupport without requiring individualorganizations to commit large amountsof staff time or money;

• highlights how these programs operateand offers lessons from their successes;and

• shows how a direct approach to address-ing substance abuse and mental healthproblems among older adults can

enhance the capabilities of aging servicesand foster vital aging in older adults.

The guide is grounded in a belief thatexperience is the best teacher. While inclu-sion in this volume does not imply a formalendorsement of a program by SAMHSAor NCOA, it is hoped that the informationprovided will be of assistance to others indeveloping and implementing programsto address the alcohol and medicationmisuse/abuse and mental health needs ofolder adults.

The profiles in this guide offer a broadrange of models to address substanceabuse and mental health problems in olderadults. Some partnerships involve formal-ized contractual arrangements betweenmultiple organizations. Others are basedon informal working relationships.Regardless of the approach that has beentaken, these organizations have learnedmany important lessons about how toinitiate and maintain partnerships withothers on behalf of the older adults thatthey serve. It is worth noting that manyof the service providers profiled in thisguide had no previous experience in help-ing older adults with alcohol, medicationand mental health problems. They devel-oped the ability to counter these problemsby building community alliances.

Alcohol, Medication, andMental Health ProblemsAmong Older AdultsThe good news is that substance abuseand mental health problems are highlytreatable and often preventable. Researchhas shown that older adults who engagein risky drinking (e.g., drinking beyondrecommended limits or while takingcertain medications), but who are not

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dependent on alcohol, can reduce alcoholuse and related problems through rela-tively simple, brief interventions. Olderadults with more significant alcohol prob-lems (i.e., alcohol dependence) alsorespond well to treatment, completingtreatment at higher rates than do youngeradults (SAMHSA 1998). The efficacy oftreatment for mental health problems iswell documented, and a range of effectivetreatments exists for most mental disor-ders (DHHS 1999, Chapter 5). Nonethe-less, older adults often need assistance toidentify and respond to these problems.The promising practices profiled in thisguide work because aging servicesproviders are well positioned to reacholder people in need of help. Theseproviders have time-honored relationshipswith their clients that allow them to dis-cuss difficult issues, offer hope, and pro-vide support as their clients face mentalhealth problems or problems related tomedication and alcohol misuse or abuse.This guide offers a window on innovativeapproaches to address these problems bypromoting partnerships between agingservices organizations, that have the accessto older adults, and the substance abuseand mental health organizations thathave the expertise in addressing substanceabuse and mental health problems.

Health and social services providersoften do not recognize the warning signsof substance abuse and mental healthproblems. They may attribute the symp-toms of a substance abuse or mental healthproblem among older adults to the naturalcourse of aging. They also may avoid thetopic because of the stigma associated withsubstance abuse and mental illness. Insome cases, providers may believe thatthey’re not capable of helping, or theymay believe that treatment doesn’t work—that it’s not even worth trying. As a result,

seniors in need of assistance may neverreceive adequate care, even though treat-ment is effective and has tremendouspotential to improve the health andquality of life of many older adults.

Alcohol ProblemsAs people grow older, their bodies are lessable to handle alcohol safely. Alcohol-related problems (including interactionswith prescription and over-the-counterdrugs) account for most of the knownsubstance-related problems experiencedby older adults. Estimated communityprevalence rates range from three to25 percent for “heavy alcohol use” andtwo to 10 percent for “alcohol abuse”(SAMHSA 1998).

The National Institute on AlcoholAbuse and Alcoholism (NIAAA), part ofthe National Institutes of Health, offersrecommendations for low-risk drinking.According to NIAAA, seniors who donot drink should not start; those who takemedications for sleeping, pain, or anxietyalso should abstain from alcohol. Forother individuals over the age of 65,NIAAA recommends no more than onedrink per day (NIAAA 1998).

Recommended drinking limits arelower for people over 65 because changesin the aging body—a decrease in watercontent, lower tolerance to alcohol, anddecreased ability to metabolize alcohol—can make even small amounts of drinkingrisky. Given these physiological changes,alcohol use can trigger or exacerbate seri-ous problems among older adults, includ-ing increased risk for hypertension, heartproblems, and stroke; impaired immunesystem and capacity to combat infectionand cancer; liver disease; decreased bonedensity; gastrointestinal bleeding; depres-sion, anxiety, and other mental health

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problems; malnutrition; and sleep distur-bances (SAMHSA 2000).

Senior centers and other providers ofservices for older adults often are in contactwith people with late-onset problemsrelated to alcohol abuse.2 Prevention andeducation programs profiled in this guidehave successfully reached out to people withor at risk for late-onset problems, a groupthat is highly receptive to education efforts.Some senior centers collaborate with Alco-holics Anonymous and other peer supportgroups to help older people who are inrecovery. Elders with early-onset problemswho continue to abuse medications or alco-hol may be isolated and may be reachedby trained intervention teams. Many times,these people already have been in contactwith substance abuse and mental healthservice providers.

Medication ProblemsAs people age, they consume more pre-scribed and over-the-counter medications.Persons over the age of 65 consume moremedications than any other age group inthe United States. Thirty percent of theseindividuals take eight or more prescriptiondrugs daily and consume other over-the-counter drugs. A large share of prescrip-tions for older adults are for psychoactive,mood-changing drugs that carry the poten-tial for misuse, abuse or dependency.About one fourth of all people over age65 report use of a psychoactive drug inthe past year, and they appear to be morelikely to continue use of these drugsfor longer periods of time than youngerindividuals (SAMHSA 1998).

Older adults account for more than halfof all reported adverse drug reactions thatlead to hospitalization. The sheer volume ofmedicines taken by older individuals createsan increased risk for drug interactions,including interactions with alcohol andother medications. Physiological changesthat accompany aging can render drugsharmful even at low levels of consumption(SAMHSA 1998).

Medication misuse occurs when aperson uses medication at an unsuitabledose; when medication is used forcontraindicated purposes; when a drugis used in combination with other medi-cations with undesirable interactions;when a person skips doses; and whenmedications are used with alcohol. Mostolder adults do not intend to misusemedications or alcohol. However, evenwhen misuse is inadvertent, it can resultin decreased functional and cognitivecapacity, placing an older person at greaterrisk for falling, hospitalization or place-ment in a nursing home (Roy and Griffen1990). Attention, memory, physiologicalarousal, and psychomotor abilities oftenare impaired; drug-related delirium ordementia may be wrongly labeled asAlzheimer’s disease (SAMHSA 2000).

A variety of risk factors influence theuse and potential for misuse or abuse ofpsychoactive prescription drugs and over-the-counter medications by older adults.The aging process with its physiologicalchanges, accumulating physical healthproblems, and other psychosocial stressorsmake prescription drug use both morelikely and more risky. The most consis-tently documented correlates of psycho-active prescription drug use are old age,poor physical health, and female gender.Among older women, use of psychoactivedrugs is correlated with middle- and late-

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2 Problems that people develop at early ages arecalled “early-onset” and those that develop inlater life are called “late-onset.”

life divorce, widowhood, less education,poorer health, higher stress, lower income,and more depression and anxiety. Majorlosses of economic and social supports,as well as previous or co-existing drug,alcohol or mental health problems alsoseem to increase vulnerability for misusingor abusing prescribed medications(SAMHSA 2000).

Mental Health ProblemsMental disorders also affect many olderadults. The first Surgeon General’s Reporton Mental Health, issued in 1999, statedthat almost 20 percent of people over theage of 55 experience mental disorders thatare not part of “normal aging.” The mostprevalent mental disorders among olderadults include anxiety disorders, whichaffect an estimated 11.4 percent of peopleover age 55. Severe cognitive impairmentaffects 6.6 percent of the population overage 65. Mood disorders, including majordepression and other forms of depression,affect about 4.4 percent of people in thisage group. Unrecognized or untreated, thesedisorders can cause severe impairment andcan even be fatal. Suicide frequently is aconsequence of depression. Older adults—particularly older white men—have thehighest suicide rate in the United States.White men over age 65 have a suicide rateup to six times that of the general popula-tion (DHHS 1999).

Among primary health professionals,there is often the misperception that symp-toms of mental disorders (e.g., feelingdepressed) are merely a normal aspect ofaging, or that clinically significant depres-sion is “just a grief reaction” to the lossesof aging rather than a genuine problemrequiring clinical help. Health and socialservices providers may believe the problemis not worth treating in older adults, or

simply find it too difficult to address thisissue (DHHS 1999).

At the same time, the Surgeon General’sreport noted that the majority of olderadults are able to cope constructively withthe limitations and losses of later life. Thereport also observed that mental health andhealth care providers increasingly are ableto suggest successful strategies for olderadults who are striving to make this stageof life satisfying and rewarding (DHHS1999).

Creating This GuideTo develop this guide, SAMHSA andNCOA asked service providers across thecountry to identify local or State programsthat were addressing medication, alcohol,and mental health problems among seniorsin effective and unique ways. Nominationswere solicited from NCOA members andconstituent units; from Federal health agen-cies; from national organizations in theaging, mental health, and substance abusefields; from the National Coalition onMental Health and Aging; and from thepublic via the Internet.

Over 40 responses were received.With input from leaders in the field, thelist was narrowed to the 15 promisingpractices profiled here. The result is abroad and varied selection of excellentprograms. All of the submissions wereinsightful, and many of those not selectedfor inclusion in this guide are identified inAppendix 1 for reference. Criteria used toselect the programs included:

• Reliance on community linkages andeffective collaboration among involvedaging services organizations and sub-stance abuse or mental health servicesproviders;

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• Use of convenient service location(s);

• Successful outreach;

• Emphasis on cultural competence;

• Use of a strong client-centered approach;

• Increased service capacity over time;and

• Use of few or carefully definedresources.

Each program was asked to providesome evidence of success, ideally throughprogram evaluation or documented analy-sis of successful outcomes. Few programswere able to meet this standard. However,each of the programs profiled has beenable to provide information about achieve-ments, recognition by external organiza-tions, or other descriptors of success.

Each program is distinctive andunique. Some programs take a holisticapproach to prevention and treatment,addressing medication misuse and mentalhealth as an integral component of theiroverall programming. Other programsare more specialized. Some reach outaggressively and directly to older adultsin need of service, while others concentrateon assisting specialists to reach seniorswith substance abuse or mental healthproblems.

Extensive efforts were made to includea comprehensive array of programs andservice populations. However, not everytype of program sought was found. Forexample, a program that targeted NativeAmerican elders with mental health ormedication and alcohol-related problemswas not found. However, a very usefulissue paper on serving Native Americanelders developed by the National IndianCouncil on Aging is available. Organiza-tions interested in starting such a programare encouraged to contact the NationalIndian Council on Aging. Contact infor-

mation for this organization and othernational groups offering assistance to thisendeavor is provided in Appendix 2.

How to Use This GuideThis guide provides information on howseveral different programs work, how theygot started, and the resources needed foroperation. Program Directors have offeredideas and initial direction to those inter-ested in developing or expanding services.Their insights are designed to help otherproviders add these components to alreadyestablished health programs. The guidefurther allows service providers to browseand search for particular components ofindividual programs. One aspect of aprogram might be suitable, while othersmay not.

The guide is organized into sectionsaccording to the steps that serviceproviders use to respond to substancemisuse and mental health needs:

• Education and Prevention

• Outreach

• Screening, Referral, Intervention,and Treatment

• Service Improvement ThroughCoalitions and Teams

Profiles in each section outline exemplaryactivities related to the section topic. Eachprofile includes a description of the pro-gram (including an overview of the specificpromising practice, as well as a discussionof outreach and recruitment, services,and client monitoring and assessment),linkages with other organizations, evidenceof success (including program assessmentand external recognition), resources andfunding, and lessons learned about howto get a similar program started.

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Contact information is included foreach program. Program representativesare enthusiastic about sharing their infor-mation with others in the field. They wantto see their programs used to help theircolleagues.

The guide is not designed to create anew role or treatment capability for agingservices providers. Rather, it is a resource.It offers pathways, through communitylinkages, to help organizations serving olderadults provide education, make effectivereferrals, and create connections to neededservices in order to improve the lives ofolder adults.

Lessons LearnedIn reviewing the promising practices inthis guide, a number of themes or “lessonslearned” can be identified. They are out-lined below. The main lesson learned isthat community linkages are essential tosuccessful practices. By building partner-ships with other health, academic, andgovernment resources, service providersare able to improve the lives of the olderadults they serve. These linkages alsoposition organizations serving older adultsas an attractive and vital resource in thecommunity.

The role of organizations providingservices targeted to older adults—asopposed to the role of substance abuseand mental health organizations—isdefined by the programs in these profiles.At some points in the service continuum,such as education, screening and referralto services, these organizations are inti-mately involved in the process. At otherpoints, such as assessment, diagnosis, andtreatment, these aging services organiza-tions play a more peripheral role. Regard-

less of the point at which they enter theservice continuum, several specific charac-teristics define successful programs.

PersistenceEssential to all programs is the needfor persistence on the part of the staff.Whether service providers regularly visitthe home of a client whose neighborsthink they detect a problem or returnto a client with follow-up questions ona particular issue, persistence pays off.

Consumer-Friendly ServicesThe most common statement made by indi-viduals interviewed for these profiles is thatolder adults with medication and alcohol-related problems or with mental healthproblems are unlikely to self-refer. One wayto counteract their reluctance is to makeservices available in a setting in which olderadults are comfortable, such as a seniorcenter they are already attending, or in thesetting in which they regularly receive otherhealth care, such as a primary care clinic.

Cultural CompetenceCultural competence is a recurring themein these promising practices. It covers abroad range of issues, from treating olderadults with respect to speaking the languageand dialect of individual clients and under-standing their heritage. Staff at successfulprograms take into account the diversityof their clients.

Multi-Service ProgrammingOne effective approach is to make theseservices part of a larger, comprehensiveservice program. For example, one ProgramDirector described how a client recoveringfrom depression was encouraged first to

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join a group, then to add another group,then to add lunch, then to take on a class—all under the same roof. Another programmade household repairs to decrease falls inthe home. After building trust with theclients, providers were able to address otherreasons for falls, such as medication andalcohol-related problems.

Health PromotionMost of the providers discuss these health-related issues within the context of sessionson general well-being or living with chal-lenges of aging. A long-term approach thatbuilds trust and sends persistent messagesover time empowers older adults to seekhelp for substance abuse and mentalhealth problems.

Comprehensive Assessmentand Consumer DirectionAnother approach to substance abuse andmental health problems is to include thesetopics in the assessment process and toaddress them in the manner—and at thetime—most appropriate for staff and client.In most client-centered programs, for exam-ple, the individual may spend months onchanging eating habits and other responsesto stress in order to build up the strengthto tackle something as difficult as a drink-ing problem. When they do take it on, it istheir decision and they are ready to change.

Peer Support, Staffing,and EvaluationThese programs mobilize a variety of staffto meet each community’s needs. Peervolunteers—members of the same agegroup—can speak to seniors on commonground. Other programs use interdiscipli-nary teams, often a social worker andnurse working in tandem. In some cases,

staff members reach out to older adults intheir own homes. Promising practices putemphasis on the importance of staff selec-tion, as well as training, evaluation, andoutcomes assessment.

Collaboration at All LevelsModels of collaboration show how State-level activities can be complemented bylocal initiatives. In one case, three differentStates support programs in a single metro-politan area. Another program for olderadults engages up to 40 different agenciesand providers to offer a therapeuticapproach that encompasses all the needsof each individual client.

Cross-TrainingCommunity linkages also encourage cross-training. Substance abuse and mentalhealth providers need training to under-stand how to work with older adults; like-wise, aging services providers need trainingto identify mental and behavioral healthissues. One promising practice cross-trainsaging services providers, mental healthcounselors, and alcohol and medicationmisuse professionals, creating a networkthat is linked in three places.

University LinksMost promising practices include a link toat least one university. By participating inresearch projects, programs can examineand document their work. One programwith three distinct components undertookthese components only after conductingstudies to determine their effectiveness.Another approach to university linkageinvolves placement of students in agingservices centers, thereby enhancing staffcapacity.

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ResourcesMany programs profiled in this guideuse materials that may be helpful to otheraging services, mental health, or substanceabuse providers as they initiate programsand services for older adults. Where possi-ble, these materials are identified in theprogram profiles.

Three key publications focused onaging, mental health and substance-relatedissues are available from the Federalgovernment and may also be of assistance:

• Mental Health: A Report of the SurgeonGeneral takes a lifespan approach inconsidering mental health and mentalillness, examining how age, genderand culture influence the diagnosis,course and treatment of mental illness.The report highlights the fact that arange of effective, well-documentedtreatments exists for most mentaldisorders. The report also proposesbroad courses of action to improvethe quality of mental health in thenation. It is available on the Internetat www.surgeongeneral.gov. Copiesmay be purchased from the Superin-tendent of Documents at the Govern-ment Printing Office. The ExecutiveSummary is available free of chargeby calling 1-877-9-MHEALTH.

• Older Adults and Mental Health:Issues and Opportunities is a com-panion document to Mental Health:A Report of the Surgeon General.A major emphasis of the report ison the delivery of mental health andsupportive services to older Americans.It describes community mental healthservices, mental health services in pri-mary and long-term care, and Medicareand Medicaid financing of mentalhealth services. Supportive services

discussed in the report include respitecare, adult day services, support groupsand peer counseling programs, wellnessand health promotion programs, mentalhealth outreach services, and caregiverprograms. It is available on the Internetat www.aoa.gov/mh/report2001. Alimited number of copies are availablefrom the National Aging InformationCenter at 202/619-0724.

• Substance Abuse and Older Adults:Treatment Improvement Protocol #26aims to advance the understanding ofthe relationships between aging andsubstance abuse and to provide practi-cal recommendations for incorporatingthat understanding into practice. Thereport covers identification, screeningand assessment, as well as treatmentand outcomes for adults age 60 andover. The volume is part of a seriesof best practice guides produced forhealth care and substance abuse treat-ment providers. It is available on theInternet at www.samhsa.gov. Printedcopies may be obtained by calling theNational Clearinghouse for Alcoholand Drug Information (NCADI) at1-800-729-6686. Companion publi-cations targeted specifically to socialservice providers, primary careproviders, and physicians have beendeveloped, as well, and are availablefrom NCADI.

In addition, several Federal agenciesand national organizations provide a widearray of resources (including consumereducation materials, publications, data, andtechnical assistance materials) that may beof assistance to organizations seeking toenhance their ability to address mentalhealth and substance-related problemsamong older adults. Appendix 3 includesa listing of select Federal agencies and

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national organizations and a description ofinformation available on-line from thoseagencies and organizations.

Several States and communities acrossthe country have established coalitionsof mental health, aging, primary careand substance abuse organizations. Thesecoalitions, listed in Appendix 4, are anadditional resource for organizationsinterested in expanding services for olderadults. They have been successful in suchareas as development of educational mate-rials on the mental health needs of olderadults, provision of cross-training activi-ties, and identification and resolution ofsystems barriers to substance abuse andmental health services by older adults.

ReferencesNational Institute on Alcohol Abuse and

Alcoholism. Alcohol and Aging. AlcoholAlert 40, April 1998.

Roy, W., and M. Griffen. PrescribedMedications and the Risk of Falling.Topics in Geriatric Rehabilitation5(20):12–20, 1990.

Substance Abuse and Mental HealthServices Administration. TreatmentImprovement Protocol (TIP) Series #26.Rockville, MD: U.S. Department ofHealth and Human Services, SubstanceAbuse and Mental Health ServicesAdministration, 1998. (Order free fromNational Clearinghouse for Alcohol andDrug Information, 800/729-6686.)

Substance Abuse and Mental HealthServices Administration. Substance AbuseAmong Older Adults: A Guide for SocialService Providers. Rockville, MD: U.S.Department of Health and HumanServices, Substance Abuse and MentalHealth Services Administration. MS670,2000. (Order free from National Clear-inghouse for Alcohol and Drug Infor-mation, 800/729-6686.)

U.S. Department of Health and HumanServices. Mental Health: A Report ofthe Surgeon General. Rockville, MD:U.S. Department of Health and HumanServices, 1999.

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IntroductionEducation programs equip older adultswith information vital to understandingsubstance misuse/abuse and mental healthproblems. Prevention measures are effortsto intervene either to prevent a problemfrom occurring in the first place, or toreduce the severity and consequences of aproblem once it has occurred. Educationand prevention are integral componentsof all programs that address medication,alcohol, and mental health problems inolder adults. These health promotion,wellness, and self-efficacy programs offeran opportunity for aging services profes-sionals to provide tips to older adults onrecognizing and addressing medicationand alcohol-related problems and mentalhealth issues.

The later years of life may bringstresses that can lead to increased risk formedication and alcohol-related problems.The loss of spouses, friends, and otherloved ones; changing social roles; increasedisolation; and decreased physical capacityand illness present many challenges toolder adults who may need help copingwith these difficulties. Education and

prevention programs focused on buildingcoping skills can help prevent problemswhen these losses occur. Programs alsoneed to convey details about the dangersof substance misuse and abuse (MichiganOlder Adult Substance Abuse NetworkWeb Site, 2001).

Older adults coping with new physicallimitations, cognitive changes, and variouslosses often are susceptible to mental dis-orders. Unrecognized or untreated, disor-ders such as depression, anxiety, and schiz-ophrenia can be severely impairing, evenfatal. There is growing awareness of thevalue of prevention in the older adult pop-ulation. Primary prevention programs areaimed at preventing problems such asdepression or suicide from occurring bytargeting interventions to high risk olderadults. Treatment-related prevention pro-grams aim to prevent relapse or recurrenceof underlying mental disorders. Other pre-vention efforts target avoidance of exces-sive disability, encouraging older adults tomaximize function. Another importantgoal of prevention programs is to avoidpremature and unnecessary institutional-ization (Michigan Older Adult SubstanceAbuse Web Site, 2001).

S e c t i o n 2 E d u c a t i o n a n d

P r e v e n t i o n~

In addition to providing basic informa-tion, effective prevention programs mustaddress the attitudes, values, relationships,environmental factors, and social relation-ships that characterize the lives of olderadults. Further, prevention needs to focusnot only on deterring self-destructive orharmful behaviors, but also on promotinghealth and wellness (Michigan Older AdultSubstance Abuse Network).

Common elements of successful edu-cation and prevention programs include:

• outreach to seniors in settings wherethey are most comfortable;

• the establishment of peer supportsystems;

• the use of age-appropriate materials;

• a commitment to healthy aging;

• family and care provider involvement;

• principles of adult learning(rather than didactic teaching);

• an active role for the older adult;

• the involvement of an expert or theuse of recognized resources;

• primary strategies that focus on theimprovement of health habits;

• health screening, including checksfor poor nutrition and medicationside effects;

• targeted (or secondary) preventionthat focuses on groups at risk, so asto promote positive behavior; and

• systems-focused approaches that takeinto consideration the complex arrayof service needs of most older adults(Michigan Older Adult SubstanceAbuse Network).

Promising Practices inEducation and PreventionThe promising practices featured in thissection were found in a network of seniorcenters and nutrition sites in Miami/DadeCounty, FL, and in groups of seniorcenters and public housing facilities inSalt Lake County, UT, and Seattle/KingCounty, WA.

These programs share several elements.They encourage older adults to take anactive role in their own health and well-being; they show a commitment tosupporting the individual in his or herquest for good health and services; andthey integrate mental health and medi-cation and alcohol-related problems intooverall health promotion programming.

The programs urge providers to seizethe opportunity to identify problems byincluding medication- and alcohol-relatedproblems and mental health issues in rou-tine health screening, health educationand other health promotion activities. Bycasting the net broadly, problems thatmight otherwise go undetected are identi-fied. Staff members try to present educa-tional information in a positive context.As one director said, “If we schedule asession on depression, no one will come.But if we have a session on ‘Making theMost of Your Life,’ many will join—andwe can talk about depression as an obsta-cle to overcome.”

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Implications for theAging NetworkEducation and prevention practices canbe added easily to most aging services pro-grams without placing undue burden onstaff or financial resources. These servicescan be offered in senior centers, seniorhousing sites, and sites offering congregatemeals. By addressing these issues througheducation and prevention—ideally by link-ing with programs that address medicationand alcohol-related problems and mentalhealth resources in the community—serviceproviders acknowledge the presence ofthese problems and encourage older peopleto adopt healthy lifestyles. In the end,seniors in need of treatment are connectedto appropriate providers.

ResourcesAging services programs interested indeveloping education and preventionefforts that include mental health and sub-stance abuse issues are encouraged to con-tact service providers in their communitiesto discuss the potential for collaboration.In addition to providing needed servicesfor clients who may be at risk for or expe-riencing problems with medication or alco-hol misuse or abuse, staff at substanceabuse or mental health organizations maybe available to assist with educationalworkshops, provide informational materi-als or provide other types of assistance.Several Federal agencies and nationalorganizations provide consumer informa-tion, publications, data and other materialsthat may be useful in developing educationand prevention activities. A list of theseFederal agencies and national organiza-tions is provided in Appendix 3.

ReferencesMichigan Older Adult Substance Abuse

Network. Growth at Any Age. (MichiganDepartment of Community Health–Division of Substance Abuse Quality andPlanning) www.michigan-maturenet.org/SANG/growthat.htm. Accessed August2001.

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Contact:Carolyn Scharffenberg, Program ManagerSalt Lake County Aging Program2001 South State, #S-1500Salt Lake City, UT 84190-2300Phone: 801/468-2473Fax: 801/468-2769email:[email protected] site: www.slcoagingservices.org/

healthy.htm

Sponsoring OrganizationSalt Lake County Aging Program, an areaagency on aging, sponsors the HealthyAging Program.

DemographicsThe program serves a large populationof older persons in Salt Lake County. Thecounty has one of the highest percentagesof individuals age 85 and older in theNation, and it projects extremely highnumbers for 2020 and beyond. While thearea’s long-term population is primarilyScandinavian, there are also significantnumbers of recent immigrants fromRussia, Bosnia, Vietnam, and elsewhere.

RecognitionThe program has received three achieve-ment awards from the National Associationof Counties.

About thePromising PracticeThe Healthy Aging Program is based on theprinciples of education and empowermentof the older adult. It integrates substanceabuse and alcohol education and preven-tion, screening, and referral into its overallprograms of disease prevention services,dynamic health promotion and education,clinical screening and referral to treatmentand follow-up support. Through the pro-gram, medication and alcohol-related pre-vention strategies are used to help olderadults understand and successfully copewith the physiological and social changesthey may be experiencing without resortingto drugs or alcohol. The Healthy AgingProgram provides services to 17 county-administered senior centers and 29 seniorhousing centers. In calendar year 1999(through November) the program had18,575 client encounters.

How It WorksThe Healthy Aging Program serves olderadults who attend senior centers, live insenior housing, or are referred to the pro-gram by other community based organi-zations that serve older adults. It encour-ages participants to recognize unhealthybehaviors and to adopt healthier lifestyles.

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P r o m i s i n g P r a c t i c e :

Healthy Aging Program, Salt Lake County, UT

Healthy Aging Program at senior centers and senior housingincorporates substance abuse education, prevention,

screening, referral, and continuing support.

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It offers prevention education, counseling,and support, as well as referral to treat-ment and follow-up support.

Program participants also attendweekly classes, facilitated by health edu-cators, that address lifestyle factors suchas diet, stress management, exercise, andmedication. The program offers Englishlanguage and life skills programs for elderswho immigrated late in life to help themavoid the problems that can result fromisolation.

Outreach and RecruitmentOlder people are referred to the programand its substance abuse screening bysenior housing managers, senior centerstaff, and others who work with olderpersons. Healthy Aging Program staffand volunteers also reach out to eldersby offering health screening andhealth education sessions throughoutthe county.

ServicesProject Lift, the program’s substanceabuse assessment and referral service,offers comprehensive assessments toolder people referred to the program.A licensed counselor conducts the assess-ment, which includes the Michigan Alco-hol Screening Test–Geriatric Version(MAST-G). (See Appendix 5 for detailson MAST-G.) Individuals identified asexperiencing the early stages of medica-tion and alcohol-related problems areserved directly by the Healthy AgingProgram. If the initial assessment indi-cates that a person has a significantproblem with substance dependence,the appropriate referral to an appropri-ate substance abuse treatment programis made.

After treatment, the Healthy AgingProgram stays in contact and encouragesindividuals to participate in follow-upactivities that provide support in adjustingto a new lifestyle. Staff foster involvementin exercise classes, health educationclasses, and senior center activities tohelp prevent relapse. The program worksinformally with each participant to setgoals to prevent relapse.

Primary prevention and relapse pre-vention efforts use group education, individ-ual counseling, and group counseling. Theseservices foster increased coping skills andencourage adoption of healthy lifestyles.Education offers information on the bene-fits of eliminating misuse and abuse of alco-hol, medications, and other substances.

Participants are mentored by peersand staff on increasing self-awarenessand self-efficacy. Elders are encouragedto participate in other program activities,establish healthy relationships with peersand others, and contribute to their com-munity through volunteer service. Abimonthly support group is available.

These prevention services are inte-grated with other components of theHealthy Aging Program, including:

• broad health education and promotion

• a brown bag medication review andseminar

• the Senior Scholar program, aimed atenhancing mental acuity

• English as a second language, includ-ing practical life skills for recentimmigrants

Health education programs includephysical health issues and mental healthtopics such as Mind Your Meds; Copingwith Stress; Vitamins and Herbal Treat-

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ments; Alzheimer’s and Parkinson’s;Humor; Dog Days of Summer; GoodGrief; and A New Light on Depression.Seniors help select topics through surveysand focus groups. Among the resourcesused for the educational programs arethe health promotion materials distrib-uted by the National Council on theAging and its Consumer InformationNetwork. Health education materialalso is distributed monthly to Meals-on-Wheels clients.

Brown bag medication reviews arecoordinated with senior pharmacy stu-dents from the University of Utah. Par-ticipants bring their prescription andover-the-counter medications, vitamins,and herbal treatments to the seminarfor a discussion of side-effects, cautions,and concerns.

Monitoring and ReassessmentThe Healthy Aging Program workswith clients who have problems withboth alcohol and medications, includingherbal medications (not an insignificantissue in this geographic region). Alcoholabuse prevention support is offeredwhen clients are observed to be understress and vulnerable. Case management,health education, and exercise are offeredas alternatives to alcohol use. As partof the pharmacy program, medicationsand herbal supplements are reviewed interms of needs and use. Chronic diseasemanagement is covered, because this isanother area that can lead to substancemisuse.

The Healthy Aging Program alsoconducts pre- and post-tests as part of itseducation series; a nurse assesses physio-logical status; a health educator tests forhealth knowledge.

LinkagesThe Healthy Aging Program educatesprofessionals who work with the seniorpopulation about substance abuse and theelderly. In carrying out this mission, staffpresent extensively at gerontology confer-ences, aging programs, the Salvation Army,hospitals, provider networks, and housingand home health agencies.

Healthy Aging services are coordinatedthrough formal agreements with the Univer-sity of Utah (student placements), the ValleyMental Health Masters Program (seniorswith depression), and Salt Lake CountySubstance Abuse Prevention/Treatment andother health care providers. Informal agree-ments with local housing authorities andprivate housing organizations are utilized toprovide housing-related services, and addi-tional students placements are arrangedinformally with a variety of educationalprograms.

Many referrals, both formal and infor-mal, are made to local practitioners, pro-viders of other aging services, and to theservices offered by the county Office onAging. Some people with alcohol use prob-lems are referred to the Salvation Army andto treatment programs. In addition, referralsare made to the Community Service Coun-cil for resources such as a food bank andservices such as home maintenance.

Program AssessmentThe agency is working to improve its pro-gram evaluation measures. Collaborationwith the clinical section has strengthenedevaluation of the health interventions. Thenext step is to assess the program’s impacton visits to the emergency room and physi-cians. The agency is designing a study andseeking support to assess education as a

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method of changing health habits amongolder adults with chronic health problemswho use medications and alcohol.

Resources and FundingThe program uses about 400 volunteerseach year, including students. Many aredrawn from nearby schools of nursing andsocial work. Students are attracted by theopportunity to work with older adults seek-ing an independent, healthy, and dynamiclifestyle. Older volunteers, including retirednurses, lead many of the educational ses-sions. Critically important is the healtheducator, with alcohol and substance abusecredentials, for screening and individualcounseling.

Current funders of the program’s nearly$400,000 annual budget include Salt LakeCounty Substance Abuse, Salt Lake Countygovernment, the Utah State Division ofEducation, and the Federal Older Ameri-cans Act. (Contact the program for addi-tional information on its resources andfunding.)

Getting Started inSalt Lake CountyThe Healthy Aging Program, with its men-tal health and substance abuse components,was created in 1983, when the foundingdirector sought county funds for educa-tional programs for seniors—programsbased on the premise that if seniors feltbetter about themselves and their personalstrengths, they would handle the losses oflater life in a manner more compatiblewith good health. The initial $30,000 grantcovered the cost of a lunchtime educationprogram in the 12 senior centers in thecounty and in housing units.

As the educational program evolvedand expanded over the years, so did theclinical program. Several health screenswere added to the health education pro-grams. With the growth of the programcame increased professionalism, moretechnology, a higher grade of health edu-cators, and greater ability to tap into thecommunity and schools, including inter-generational programming.

Getting Started inOther CommunitiesThis program could be replicated in mostsenior centers with an interest in integratingsubstance abuse prevention services withhealth promotion. The program managerrecommends involvement with colleges anduniversities and notes the importance of atrained health educator with a backgroundin substance abuse.

Materials available from the HealthyAging Program include consumer healtheducation brochures (one for Project Liftincludes warning signs and information onsubstance abuse), clinical protocols, infor-mation handouts, and testing results sheets.Monthly calendars list classes and resourcesand offer health education on a selectedtopic.

Keys to SuccessAccording to the program staff, the mostsignificant key is the intentional educationand empowerment of the older adult client.Cultural competence also is critical. TheSalt Lake County program serves not onlythe primarily Scandinavian long-term popu-lation, but also the growing numbers ofolder adults who have emigrated fromRussia, Bosnia, Vietnam, and elsewhere.

Contact:Susan Snyder, Director,

Senior Wellness ProjectSenior Services of Seattle/King County1601 Second Ave., Suite 800Seattle, WA 98101Phone: 206/727-6297Fax: 206/448-5766web site: www.seniorservices.org

Sponsoring OrganizationSenior Services of Seattle/King County isWashington State’s largest not-for-profitagency serving seniors. It offers an arrayof services to seniors in the Seattle/KingCounty area, including information andassistance, a senior wellness program, sen-ior rights assistance, nine senior centers,six adult day health centers, numerouscongregate meal sites and home-deliveredmeals, volunteer transportation, home-sharing, minor home repair, and AfricanAmerican outreach.

DemographicsSenior Services serves Seattle/King County.The Northshore Senior Center, which initi-ated the promising practice, the HealthEnhancement Program, serves a primarilyCaucasian community. Other centers serve

Asian and African American populations.The materials for these programs are beingadapted for different cultures and trans-lated into other languages.

RecognitionArticles about randomized controlledstudies documenting the program’s successin reducing hospital stays and emergencyroom and doctor visits have appeared inthe Journal of Gerontology, the Journalof Gerontological Nursing, and the Journalof the American Geriatrics Society (seeReferences below). Results also have beenreported extensively in the popular press.

About thePromising PracticeThe Health Enhancement Program helpsolder people recognize health improve-ment opportunities, adopt healthy behav-iors, and minimize behaviors that arenot healthy. The program is highly client-centered and client-driven. It is one ofthree complementary programs thatmake up the Senior Wellness Program.The others address exercise and chronicdisease self-management.

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Health Enhancement Program, Seattle/King County, WA

Health Enhancement Program, operating at senior centers andpublic housing sites, helps seniors identify goals for their

own health, adopt healthy behaviors, and avoid behaviors thatare not healthy, including substance abuse.

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How It WorksThe Health Enhancement Program is aproven intervention to prevent functionallimitations and reduce unnecessary orinappropriate health care use.

Outreach and RecruitmentThe Health Enhancement Program oper-ates in 20 service sites frequented primarilyby seniors, including the North ShoreSenior Center and four other sites. Par-ticipants begin by completing a detailedself-evaluation of health status, attitudes,and behaviors. They choose the issuesthey are ready to work on, using areadiness-to-change model. In 1999, 700elders and 80 peer mentors participated.

ServicesAfter completing the self-evaluation, par-ticipants undergo a comprehensive healthand social assessment which helps themidentify health improvement opportunitiesthat they can pursue by modifying theirpersonal behavior. A nurse offers feedbackon areas of concern as well as strengths,and helps participants design personalhealth action plans. For each area ofconcern, participants have short-termgoals and become managers of their ownprograms for behavioral change. Theyrate their own health initially and at6 months and 12 months.

They also work with a social workerand may choose to work with a healthmentor. The health mentor is a trainedpeer volunteer who has been a participantin the program. Most of the program’ssocial workers have advanced degrees insocial work. All are trained by the clinicalsupervisor, a nurse.

Frequently, in the course of strivingto meet one goal—improved physicalfitness, for example—participants may“discover” that other factors, such astobacco, alcohol abuse, or mental healthproblems, are interfering with their efforts.Through this process of self-realization,individuals often become much moremotivated to work on the underlyingproblem with the assistance of theirmentor and program staff.

Most mental health concerns are iden-tified and addressed through counselingand self-management programs offeredat the sites. Referrals are made, as needed,to mental health and substance abuseprograms in the community.

A Health Enhancement Program socialworker provides individual and groupcounseling, offers support groups, andconducts classes on topics that are identi-fied in the groups. She has found thatoffering these programs in communitycenters rather than in a medical settinghelps reduce the stigma surroundingmental illness and substance abuse issuesthat often prevents individuals from seek-ing assistance. If an individual is referredto an outside provider of mental healthor substance abuse services, staff maintaincontact, as they would with any otherprovider.

The program offers support groupsfor social activation, depression, anxiety,and memory problems. It identifies treat-ment possibilities and provides outlinesfor group sessions.

Many of the participants also benefitfrom a Chronic Disease Self-ManagementProgram offered at the sites. Originallydesigned by Kate Lorig, Ph.D., and associ-ates at the Stanford University PatientEducation Center, the program has

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achieved documented improvement inhealthful behaviors and health status,and a decrease in days of hospitalization.The findings of the original randomizedstudy were corroborated in test resultsfor enrollees at the Seattle NorthshoreCenter. Three hundred older adults tookpart in this program in 1999.

For those whose individual goals callfor improving physical fitness, the LifetimeFitness exercise program offers low-cost,1-hour supervised classes for ongoing5-week sessions of three classes per week.Components include strength training,aerobics, balance, and stretching. Theprogram was piloted and tested, and hasbeen found to produce marked improve-ments in physical and social functioningas well as in the relief of pain, fatigue,and depression.

Monitoring and ReassessmentParticipants are monitored on an ongoingbasis by program staff and volunteer men-tors. They meet at least every 6 monthswith their nurse or social worker to evalu-ate their progress and to reassess goals forthe next 6-month period. In addition, theirhealth action plan is sent to their primarycare physician, who has an opportunity tomake recommendations.

During this process, participants mayidentify new goals to meet or behaviorsto modify. Their health action plans areadjusted accordingly. This process is aidedby comprehensive client-tracking software.

Program AssessmentThe Health Enhancement Program meas-ures outcomes by tabulating participants’reports of the number of days of hospitalcare, bed rest, and restricted activity; the

number of emergency room and doctorvisits; progress on specific issues; andhealth status. A randomized, controlledstudy using the health enhancement inter-vention found a reduction of 38 percentin the number of seniors hospitalized; areduction of 72 percent in the number ofhospital days; a reduction of 36 percentin the use of psychotropic medications;significantly higher levels of physicalactivity; and improved functioning inactivities of daily living. In another study,peer mentors active in the program them-selves reported significant improvementin frequency of exercise, range of socialactivities, and ability to manage chronicconditions.

Senior Wellness and its Lifetime FitnessProgram have been evaluated rigorouslyas senior center-based disability preventionprograms. One hundred adults wererecruited for a randomized, 6-month clini-cal trial, during which all members of theexperimental group received exercise inter-vention, nutrition counseling, and a homesafety assessment. Smoking and alcoholinterventions were delivered to at-risk sub-jects. Eighty-five percent of interventionsubjects completed the 6-month program.Adherence was excellent. After 6 months,the intervention group scored significantlybetter than the control group on seven ofeight subscales of the Medical OutcomesStudy Short Form (SF-36). The SF-36measures such outcomes as physical func-tioning, role limitations due to physicalhealth, role limitations due to emotionalproblems, bodily pain, mental healthstatus, energy, and fatigue. The interven-tion group also displayed fewer depressivesymptoms as measured by the Center forEpidemiologic Studies Depression Scale(CES-D).

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LinkagesPrimary linkages include the client’s primarycare physician, psychiatrist, or case managerthrough formal agreements between SeniorServices and participating health systems.These linkages are used with the client’sconcurrence to enhance care. There are alsoformal linkages with the health department,the housing authority, and the area agencyon aging in the form of contracts and fund-ing agreements.

As the success of the ongoing programsdemonstrates, partnerships are key. Forexample, very few senior centers have anurse on-site. The Health EnhancementProgram has nurses in 20 senior centers,through support from the county healthdepartment, area hospitals, health caresystems, city government, a private founda-tion, and other organizations. Linkageshave also been established with the GroupHealth Cooperative, Stanford University,and managed care organizations. TheUniversity of Washington has funded evalu-ations of the program. The high level ofsupport from health care systems is a directresult of the program’s success in reducinghospitalization and its linkage to primarycare physicians.

Resources and FundingWhen the study phase of the HealthEnhancement Program was completed,the first source of outside funding wasthe area agency on aging. This agencycontinues to support the programs, as dothe health care organizations, hospitals,and health departments.

Other resources include the Universityof Washington’s Northwest PreventionEffectiveness Center (funded by the FederalCenters for Disease Control and Preven-

tion), which provides a geriatrician toevaluate the program annually. Nursesare provided by participating health servicenetworks. The program receives grantsfrom private foundations and othersupport from the county department ofhealth. The senior centers in which theprograms operate provide such resourcesas space, equipment, and staff time fortraining and operations.

The program can provide additionalinformation on its resources and funding.

Getting Started inSeattle/King CountyThe Health Enhancement Program hasits roots in the Senior Wellness Project,initiated by the Northshore Senior Centerto test Lifetime Fitness, the exercise pro-gram described above. Senior Wellness wasa collaborative project with the Universityof Washington and the Center for HealthStudies at Group Health Cooperative.Compared with controls, participantshad greater improvements in measures ofphysical function. Depressive symptomsalso significantly improved. Replicationbegan in other centers in 1995.

Building on the success of the LifetimeFitness program, the Northshore Centerdeveloped the Health Enhancement Pro-gram in collaboration with several part-ners, including three health systems—Group Health Cooperative, PacificCare,and Evergreen Health Care.

Getting Started inOther CommunitiesIn addition to expanding to 20 sites in theSeattle/King County area, the program hasexpanded to 10 sites in nearby counties, aswell as to two sites in the State of Virginia.

Training, technical assistance, andmaterials are available to foster successfulreplication. Materials include the licensesto use the extensive computer programs totrack individual client progress. SusanSnyder at Senior Services is knowledgeableabout contractual arrangements, opportu-nities, and fees. Her advice on funding forthose interested in starting such a programis to contact health care providers, get toknow them, and develop partnerships withthem that will be mutually beneficial.

Keys to SuccessThe Senior Wellness Project demonstrateshow local aging services agencies can useevidence-based public health strategies toimprove the health status and functioningof their clients.

Some administrative factors in theprogram’s success include:

• use of controlled studies as programsare initiated

• significant partnerships with universitiesand the health care community

• the ability to link programs andresources within one organization

Key program factors include:

• participant-centered approach

• range of program offerings

• careful approach to staffing (whichrequires a part-time to full-time nurseand social worker whose belief systemsallow them to work comfortablyalongside trained peer volunteers)

• emphasis on social interaction

• use of trained volunteers to enhancehealth promotion in a cost-effectivemanner

ReferencesDavis, Connie, Suzanne Leveille, Susy

Favaro, and Marianne LoGerfo. Benefitsto volunteers in a community-basedhealth promotion and chronic illnessself-management program for the elderly.Journal of Gerontological Nursing24(10): 16–23, Oct. 1998.

Leveille, Suzanne G., Edward H. Wagner,Connie Davis, Lou Grothaus, JeffreyWallace, Marianne LoGerfo, and DanielKent. Preventing disability and managingchronic illness in frail older adults: arandomized trial of a community-basedpartnership with primary care. Journalof the American Geriatrics Society46(10): 1191–1198, Oct. 1998.

Wallace, Jeffrey I., David M. Buchner,Lou Grothaus, Suzanne Leveille, LyndaTyll, Andrea Z. LaCroix, and Edward H.Wagner. Implementation and effectivenessof a community-based health promotionprogram for older adults. Journals ofGerontology: Series A: Biological Sciencesand Medical Sciences 53A(4):M301–M306, July 1998.

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Contact:Ariela Rodriguez, Ph.D., L.C.S.W.Director, Health and Social ServicesLittle Havana Activities and Nutrition

Centers of Dade County, Inc.700 SW 8th St.Miami, FL 33130Phone: 305/858-0887, ext 238Fax: 305/854-2226

Sponsoring OrganizationLittle Havana is one of the Nation’slargest multipurpose nonprofit agencies,serving disadvantaged elders and youngerfamilies. It offers a comprehensive arrayof 70 services to more than 63,000 peopleeach year through 21 multiservice com-munity centers.

The centers provide preventive social,health, nutrition, and mental healthservices to a population that is at riskfor isolation due to socioeconomic andlanguage limitations—isolation that canlead to physical and mental deterioration.

Little Havana’s health program includeshealth promotion, screening, assessment,disease prevention, health education, men-tal health services (including counseling),

and primary health care. Group meals,nutrition, physical fitness, home injurycontrol, and transportation services roundout the program. Health services are deliv-ered through the agency’s activity andnutrition centers, including senior centers,congregate meal sites, four adult dayhealth care centers, a primary care clinic,a mobile medical unit, an employmentagency, and two intergenerationalpreschool child care centers.

DemographicsMiami and metropolitan Dade Countyare urban areas with a large populationof adults age 60 and over and the highestconcentration of Cuban Americans in theUnited States. Most of the elderly clientbase emigrated to the United States asmature adults. The median age is 79.Many live alone, in substandard housing,with incomes of about $530 a month.

RecognitionLittle Havana was recognized as one ofeight “exemplary” practices by the West-ern Interstate Commission for HigherEducation, a national organization basedin Boulder, CO.


Little Havana Health Program, Miami/Dade County, FL

Nutrition and senior centers serving Hispanic elders offertailored mental health services to meet specific needs

identified through comprehensive assessment.

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About the Promising PracticeLittle Havana offers mental health servicestailored to meet the specific needs of eld-erly participants. These needs are identi-fied through a comprehensive health andsocial assessment. The assessment, whichincludes targeted mental health questions,is conducted with participants in theAgency’s nutrition program, senior cen-ters, and other service programs. Morethan 700 elders received mental healthoutreach and services in 1999.

How It Works

Outreach and RecruitmentProgram participants are contacted orrecruited through community outreachfor isolated elders, through the meal pro-gram, and through all other services ofLittle Havana.

Comprehensive Assessmentand Service PlanAll program participants are requiredto undergo a comprehensive health andsocial assessment with assistance from atrained caseworker. The Little Havanaclinic’s primary care physician, volunteerpsychiatrist, and other volunteer profes-sionals work with participants to developtailored plans of services, based on thefindings of the initial assessment andprofessional evaluation. All servicesare integrated internally so that clients,through the caseworkers, have access toall they might need, if it is available inthe community.

Intake and assessment forms ask forinformation about the individual’s back-ground, finances, monthly expenses,medical insurance, health status, medi-

cations, health habits (including alcoholand tobacco), ability to perform activitiesof daily living (ADLs), and instrumentalactivities of daily living (IADLs). Theassessment includes an orientation screenon time and place, the Center for Epi-demiological Studies’ 11-item depressionscreen, a nutrition screen, and a socialhistory.

Trained caseworkers score the assess-ment and identify participants at risk fordepression or other mental health prob-lems. Participants identified with potentialmental health problems are referred to thesupervising mental health professional,a clinical social worker who directs case-worker contacts with clients’ families aswell as follow-up referrals to the primarycare clinic. These professionals adviseclients on services or treatment needed toaddress their conditions.

When an assessment indicates that aserious mental disorder requiring immedi-ate treatment may exist, staff asks theclient’s permission to contact the client’sfamily or physician. When possible, assess-ment findings are shared with the physi-cian so that treatment can begin or areferral can be made. Some clients areencouraged to seek help from a nearbycommunity mental health center. LittleHavana’s primary mental health servicesare tailored to older people with a varietyof mental health problems. For thosereceiving outside treatment services,Little Havana’s services support theirtreatment with an array of nutritionand social support services.

ServicesParticipants whose assessments indicatesymptoms of depression are counseledby Little Havana clinical staff and by

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retired professional volunteers. At-riskparticipants also are offered consultationand treatment with the program’s volun-teer psychiatrist. When isolation or lossis found to be a major factor, clients areencouraged to participate in therapeuticactivities offered by Little Havana seniorcenters and adult day health centers con-ducted, in part, by peer counselors trainedby the clinical social worker. Participantsalso may be encouraged to serve in avolunteer role to increase opportunitiesto establish or enhance social supportsystems.

Medication misuse is considered amajor problem for the population servedby this program. Countering such prac-tices and educating on proper medicationuse is a key activity of the medical staff,as are medication reviews and counseling.

When symptoms of Alzheimer’sdisease are present, participants areencouraged to take part in the LittleHavana demonstration site of theHispanic Alzheimer’s Disease Initiative,a national demonstration begun in 1992that offers center- or home-based respiteservices. Center-based respite servicesare offered in one of the four adult dayhealth care centers. Transportation isoffered to all who participate in theadult day health care centers.

Monitoring and ReassessmentAll those attending a senior center,adult day health center, or other pro-gram are observed for changes in theirphysical or mental status. Reassessmentand referrals are made as needed.

LinkagesLittle Havana has developed bothexternal and internal linkages in buildingits extensive capacity to address themental health needs of disadvantagedelders. Little Havana receives fundingand referrals through its formal contractuallinkage with the local area agency on aging,Alliance for Aging, Inc. The network ofaging services providers in the two-countyarea also provide referrals.

Little Havana works extensively withMiami Behavioral Health, a provider ofoutpatient mental health services, referringparticipants for services through a formallinkage agreement. Informal linkages withthe mental health association have resultedin speakers for education programs, peri-odic “charlas” or “little talks,” and mentalhealth educational presentations at thesenior centers.

Internally, all of Little Havana’s servicesand centers are linked formally through theorganizational structure and the serviceplan development process. Little Havanaalso formally collaborates with sponsors ofcommunity employment programs, servesas a training site for senior employmentservice workers, and hires many of thosewho complete the training.

Program AssessmentLittle Havana health and social servicesprograms offer timely interventions forpeople beginning to show signs of mentalproblems. The services provided, alongwith peer support and the opportunity todiscuss concerns in an accepting environ-ment, assist many participants in avertingavoidable deterioration.

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The local area agency on aging—the Alliance for the Aging, Inc. (AAI)—monitors Little Havana’s services andissues reports on their performance asproviders of services funded underthe Older Americans Act. Consumersatisfaction is monitored and includedin these performance reports. The exec-utive director of the AAI has indicatedthat the monitoring reports on LittleHavana are consistently outstanding.

Resources and FundingThe total agency budget of $8.7 millionis funded primarily through governmentgrants (Federal 70 percent, State 13 per-cent, and local 6 percent). The remaining11 percent is funded by United Way, par-ticipant contributions, private donations,and fundraising efforts. The costs ofoutreach, screening, assessment, referral,and mental health services are not sepa-rated out.

One unusual source of funding flowsfrom the State Office of Children andFamilies but originates with the FederalOffice of Refugee Resettlement. This isthe first time such funding has been usedfor elderly refugees. Other organizationsserving refugees are encouraged to assessthe availability of these funds by contact-ing the Federal office or the State unithandling these concerns.

The agency staff numbers 193. Ofthe total, 116 are age 60 or over, andmore than 60 percent work part-time.In addition, there are 517 volunteers.

Florida State law extends “sovereignimmunity” to retired professionals, whichallows them to practice without liabilityinsurance as long as they do not charge fortheir services. This means that older physi-cians, including a volunteer psychiatrist,can (and do) work in the clinic. In addi-tion, some services are provided by profes-sionals who bill Medicare directly, the onlyMedicare reimbursement for services atLittle Havana.


Getting Started inMiami/Dade CountyLittle Havana has been in operation since1972. The comprehensive assessment andtreatment program began in 1992, whena strategic decision was made to hire alicensed clinical social worker, Dr. ArielaRodriguez, to direct the agency’s healthand social services unit. Through herefforts, the comprehensive assessmentprocedures were established. She and staffworked with the National Institute ofMental Health to develop an appropriateassessment form, with screens for mentalhealth and dementia. Over time, the com-prehensive assessment form was modified,but the mental health screen was retained.

The only resistance to the additionof the mental health components in 1992came from staff who felt that the compre-hensive intake form was too detailed andincluded too many personal questions.As staff expertise has grown, staff havecome to value and rely on the informationcollected in the assessment process.

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Getting Started inOther CommunitiesAccording to Dr. Rodriguez, any organi-zation can offer tailored mental healthservices. The resources needed includea clinical professional on-site, retired pro-fessionals, a corps of trained volunteers,and an information system to track clientassessments, service planning, monitoring,and follow-up.

Descriptive program material is avail-able through Little Havana. The organi-zation also makes available its comprehen-sive intake and assessment form, includingthe mental health screens. This form isbilingual in Spanish and English.

Keys to Success• Cultural competence and sensitivity

• Transportation for all who need it

• A comprehensive assessment forall clients

• An integrated array of services

Cultural competence is the heart of thisprogram. Competence involves more thanspeaking the same language as the clients.There must be sensitivity to the clients’culture, the clients’ origins, and, in theLittle Havana area, the refugee or immi-grant experience. An important considera-tion in the Cuban culture is the traditionof accepting anything said or done by anelder. Many younger staff members preferto ignore inappropriate behavior ratherthan address it as a possible symptom ofdementia and risk offending an elder.Modifying this mindset is critical if theseproblems are to be acknowledged andaddressed. Knowing the culture intimatelyallows the Little Havana staff to pick upcues that might otherwise be missed. Forexample, Cuban elders traditionally dressmeticulously when attending the center,much as they would dress for church.Any sharp change in an individual’sappearance thus alerts the staff to beconcerned about possible mental healthdeterioration in that individual.

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IntroductionOutreach is an effort to identify older adultsin need of mental health or substance abuseservices and to help them get the care theyneed. Aging services providers can play aninstrumental role in these efforts by reach-ing out to older adults with serious prob-lems who are not likely to seek formalservices on their own. They may deny thatthey have a problem, be too ill to recognizetheir need, or avoid seeking substance abuseor mental health services because of thestigma attached to such problems.

It often falls to others to notice signsof problems and point the way to appropri-ate services. “Others” in this case mayinclude the staff and trained volunteers of asenior center, a senior residence, or an areaagency on aging. Often, it can include thosewho interact with older adults in crisis: adultprotective service workers, police officers,and housing inspectors. It also can includemembers of the community at large: publicand private employees whose work, thoughunrelated to senior services, brings theminto regular contact with older adults—mail carriers, repair persons, power com-pany employees, bank tellers, and others.

While outreach programs are designedto help older adults, these programs can

be extremely beneficial to aging servicesorganizations as well. By receiving theservices and support they need, clients of aging services providers are often ableto remain in their homes and maintaintheir independence.

Promising Practices in OutreachReaching older adults sometimes requiresan innovative outreach approach. Two ofthe promising practices outlined in this sec-tion train public and private workers whoare in frequent contact with isolated olderadults to observe potential signs of trouble.When a problem arises, the observers canmake a single telephone call to alert person-nel prepared to serve older adults in crisis.These so-called “gatekeeper” programsoffer a tested strategy to mobilize publicand private sector workers to build commu-nity outreach. These individuals are notexpected to screen, assess, or even interview.They simply pass on their observations.The key is to have a well-coordinatedresponse system and an adequate servicestructure in place when calls come in.

One of the practices outlined hereinvolves an intervention team that followsup on calls from gatekeepers. The secondtrains public housing employees to act asgatekeepers; they, in turn, contact trained

S e c t i o n 3O u t r e a c h

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nurses and psychiatrists, who respond within-home assessment and services. The thirdprogram in this section uses an interdiscipli-nary team to provide in-home crisis inter-vention to stabilize older adults throughlinkages with community services. The teamis composed of a nurse, a psychiatrist, andgeriatric mental health specialists.

Just as outreach is essential to reacholder adults with substance abuse or mentalhealth needs, persistence is crucial to con-nect these individuals with services. Thesepromising practices offer prime examples ofthe need to “meet people where they are.”According to Raymond Raschko, developerof the gatekeeper concept, there are twogeneral rules about seniors in need: Themore at risk they are, the less likely theyare to recognize the problem and ask forhelp; the more at risk they are, the lesslikely they are to get help unless someoneelse intervenes on their behalf.

Implications for the Aging NetworkThe gatekeeper concept is relatively easyfor aging services programs to implementbecause of its simplicity, the limited roleof community partners, and the extensivematerials already available. This type ofinitiative requires little added staff time ormoney. At the same time, it requires littlefrom the gatekeepers; they are asked onlyto be vigilant and to make one phone callif they discover a potential problem. Therole of the aging services network is to workwith substance abuse and mental healthservice providers to have the appropriateservices and systems in place to react toreferring calls. This type of outreach offerssubstantial benefits. It helps clients stayin their own homes and improves theirself-care. If the community does not havesuch a program, it may be desirable to startone. Successful implementation requiresbroad commitment throughout the com-munity. If a gatekeeper-type program does

not exist in a community, aging servicesproviders can work with local mentalhealth and substance abuse agencies toget one started.

ResourcesThe training materials for Gatekeepers areparticularly useful in starting an outreachprogram. They include:

• “Elder Services/Gatekeeper TrainingVideo.” Spokane, WA: Spokane MentalHealth. 1998.

• Raschko, Raymond and FrancieColeman. Gatekeeper Training Manual.Spokane, WA: Spokane Mental Health,Elder Services. 1998.

Aging services organizations that areinterested in developing outreach effortstargeted to older adults at risk for alcohol,medication or mental health problems arestrongly encouraged to work with localsubstance abuse and mental health agenciesin this endeavor. The availability of appro-priate assessment and intervention servicesis crucial to the success of any outreacheffort. Local substance abuse and mentalhealth programs can provide these neededservices. The area agency on aging oftencan be of assistance in identifying appropri-ate substance abuse or mental healthproviders. Local mental health and agingcoalitions are another good starting point.Appendix 4 provides a listing of State andlocal mental health and aging coalitionsknown to SAMHSA at the time of publi-cation. In the absence of a State or localcoalition, service providers can work withState or local colleagues to convene such agroup. Materials developed by the AARPFoundation on building aging, mentalhealth, substance abuse, and primary carecoalitions are available from the AmericanPsychological Association, Office on Aging(202/336-6046).

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Contact:Julie E. Jensen, Ph.D.Washington Institute, Western Branch9601 Steilacoom Blvd., SWTacoma, WA 98498-7213Phone: 253/756-3988Fax: 253/756-3987email: [email protected]

Sponsoring OrganizationThe parent organization of the originalGatekeeper program was the ElderServices Program of the Spokane Com-munity Mental Health Center. Informa-tion and resources for the model arenow found at the Washington Institutefor Mental Illness Research and Train-ing, sponsored by Washington StateUniversity and the Washington StateMental Health Division.

DemographicsSpokane County is 80 percent urban/suburban and 20 percent rural. Thepopulation is primarily Caucasian.Minorities comprise 5 percent of thepopulation age 60 and older.

RecognitionIn 1992 the Kennedy School of Govern-ment at Harvard University, in conjunctionwith the Ford Foundation, selected ElderServices from among 1,600 applicantorganizations to receive one of tennational $100,000 awards as an Innova-tive Program in State and local govern-ment. In 1999, the mental health programof the Western Interstate Commission forHigher Education received funds fromSAMHSA’s Center for Mental HealthServices for an exemplary practices iden-tification project. The center identifiedGatekeeper’s case-finding model as one ofeight “exemplary practices in the deliveryof mental health outreach services to olderadults.” Gatekeeper has received otherawards from the National Council onthe Aging and the American PsychiatricAssociation. The work of the programand evaluation findings are reported inprofessional articles published in Journalof Case Management, The Gerontologist,Hospital and Community Psychiatry, andThe Annals of Pharmacotherapy. Thesearticles are listed below under References.

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Gatekeeper, Spokane, WA

Public service personnel and local businesses collaborate withan integrated mental health and aging agency to train workers

who are in daily contact with elders to observe signs ofserious problems and place a call for help.

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About thePromising PracticeGatekeeper is a community-wide systemof proactive case-finding to identify high-risk older adults. The model was devel-oped in 1978 by Raymond Raschko,director of Elder Services for SpokaneMental Health. The target populationof the Gatekeeper case-finding practiceis community-dwelling adults over age60 who are experiencing any or all ofthe following:

• serious and persistent mental illness

• emotional or behavioral problems

• poor physical health

• individual living situation (i.e., living alone)

• absence of a support system

• abuse or neglect

• substance abuse

• reluctance or inability to seek help

How It WorksGatekeepers are nontraditional referralsources who are organized and trainedto identify high-risk older adults living inthe community. They are employees ofcorporations, businesses, and communityorganizations who come into contact witholder adults through their everyday work.They include postal service workers,meter readers, police and sheriff depart-ment personnel, bank tellers, cable televi-sion installers, pharmacists, resident apart-ment managers, property appraisers,code enforcement workers, emergencymedical response teams, ambulancecompany personnel, humane societies,and many others.

Outreach and RecruitmentWith training, using the extensive materialsdeveloped over the years, gatekeepers learnhow to become keen observers of an olderperson’s appearance, mental and emotionalstate, personality changes, physical changesand losses, social problems, and potentialsubstance abuse; conditions of the home;caregiver stress; financial hardship; and riskfor suicide. Gatekeepers are trained to callthe community agency designated to acceptreferrals when they encounter an olderadult who appears to need assistance. Thesource of the referral is kept confidential toprotect that individual’s relationship withthe older person.

ServicesAfter initial referral, a multidisciplinaryteam conducts a comprehensive assessmentthat includes physical, mental, emotional,social, and support system components.The primary care physician is contacted aswell. Once the assessment is complete andservice needs are determined (with inputfrom the older person), a service plan isdeveloped in collaboration with members ofthe team and staff from existing communitysupports, including appropriate communityservice agencies. Not all gatekeeper referralsrequire a comprehensive assessment andservice plan. For some, simple linkage toa community-based service, such as choreservices, is all that is needed. Gatekeeperprogram staff inform the gatekeeper whomade the initial referral that contact wasmade with the older adult. However, toprotect the older adult’s right to privacy,the specific life circumstances and serviceplan remain confidential.

Elder Services, which operates the Gate-keeper program, provides ongoing clinicalcase management. This consists primarilyof a clinical case manager who has accessto a team leader, a psychiatrist, and a phar-

macist to make home visits for evaluationas well as for treatment and services. Ser-vices such as home health, personal care,respite, Meals-on-Wheels, and supportgroups are brokered and coordinated bythe clinical case manager.

Program staff members do encounterisolated individuals who refuse contactand services. In many cases, staff work tobuild rapport and trust, engaging in con-crete activities that result in positive out-comes. Persistence and outreach frequentlylead to acceptance and subsequent treat-ment and services.

Because gatekeepers are trained onlyas observers, not as clinicians, the develop-ment of an integrated and coordinated men-tal health, aging, and social service systemis essential to program success, as are arelevant multidisciplinary response system,crisis response, and coordinated in-homeservices.

Monitoring and ReassessmentThe clinical case manager maintains closecontact through ongoing home visits andhas primary responsibility for counseling,treatment and service plan coordination,and monitoring and reassessment. Contactis maintained with all agencies providingservices as well as with the primary carephysician.

Program AssessmentResearchers (from Washington State Univer-sity and the University of Washington) stud-ied the population reached by Gatekeepers.They analyzed older people referred to theElderly Services Division of Spokane MentalHealth by Gatekeepers as well as traditionalreferral sources, including medical/healthagencies, family, friends, social servicesagencies and other sources. Findings indicatethat clients referred by gatekeepers were

more frequently socially isolated, economi-cally disadvantaged, more likely to livealone and less likely to have physical healthproblems. They were also less likely to havea physician, though this differential did notexist after one year in the program. At thetime of referral, those referred by gatekeep-ers had greater service needs; after one year,they did not use more services than thosereferred by other sources. Conclusionsdrawn from evaluation research are that theGatekeeper model is inexpensive to imple-ment and can benefit communities throughincreased collaboration among serviceproviders. It was also reported that adop-tion of the Gatekeeper model does notresult in high service utilization. A secondpublished process evaluation of the demon-stration project involving 10 rural sites inthe State of Washington may be of specialinterest to organizations considering replica-tion. Copies can be obtained from Dr.Jensen, who is the program contact for theGatekeeper program. Funding for the proj-ect came from SAMHSA’s Center for Men-tal Health Services Community ActionGrant program. Dr. Jensen will soon becompleting a second process evaluation,which will be entitled “Gatekeeper Modelof Case Finding At-Risk Older Adults:Implementation in Ten Rural Sites inWashington State.”

Quality of life outcomes have beenconsidered and are addressed in some ofthe articles listed below that have been pub-lished since the program began. Accordingto program founder, Raymond Raschko,outcomes related to knowledge, attitude,and behavior have not been considered inthe articles because the population servedis at such high risk. They have noted evi-dence of improved attitudes and behavioron the part of caregivers. Service-relatedoutcomes also have been considered andnoted in the articles.

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LinkagesIn Spokane, Elder Services, the leadagency, has formal agreements with 16community agencies to provide the coor-dinated system of care. These agenciesinclude:

• mental health agencies

• the area agency on aging

• home and community services

• adult protective services

• substance abuse agencies

• crisis services

• adult day health

• home health agencies

Formal and informal linkages withlocal businesses and public services sup-port the recruitment, training, and work of the gatekeepers.

Community ownership of the modelis critical since the model affects all sys-tems. Program developers recommendthat communities wanting to replicate themodel create formal mental health andaging coalitions to work together to meetthe specific needs of their community.

Resources and FundingAt the individual level, gatekeepers aretold that their involvement will notcost them anything but their time. Theysimply do what they normally do—but with heightened sensitivity. If theyobserve a potential problem, all theyhave to do is make a phone call toreport their concerns.

At the community level, cooperatingbusinesses and agencies provide resourcesin the form of staff time for training.Agencies and organizations involved inreferral and service delivery also mustcommit sufficient resources to maintainan effective response system. In addition,staff time is necessary to take on thecommunity-wide organizing activitiesneeded to get the system up and running.It is possible to start with one-quarterof an employee. However, it is likely thata full-time position eventually will beneeded. Another consideration is thecost of providing training and trainingmaterials.

Funding for the Gatekeeper programin Spokane comes from the area agencyon aging through both Older AmericanAct and Washington State Senior CitizensServices Act funds. Other funds come fromthe Spokane Regional Support Network,the regional mental health authority.

The program can provide additionalinformation on resources and funding.

Getting Started in SpokaneThe Gatekeeper model was created in1978 in Spokane in response to the inade-quate level of mental health services pro-vided to older adults. It was developedto address fundamental reasons for theproblem: that neither the aging nor themental health systems provided the neces-sary off-site outreach needed to bringolder adults into care. Gatekeeper wasdesigned to approach the older adultsdirectly and draw them into the system.It has continued to operate in Spokanesince its initiation.

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Getting Started inOther CommunitiesThe Gatekeeper program has been repli-cated in many sites. In 1996, the modelwas adapted in Pierce County, WA, andrenamed HEROS (Helping Elders throughReferral and Outreach Services) to empha-size its uniqueness in that community andpromote its ownership there. In 1997 and1999, grants from the Substance Abuseand Mental Health Services Administra-tion (SAMHSA) made it possible to intro-duce the model to an additional ten coun-ties in the State. Other known sites ofreplication can be found in Arizona,Florida, Maryland, Michigan, Oklahoma,Oregon, Pennsylvania, Wisconsin,Wyoming, and British Columbia.

Successful replication relies on anadequate and responsive service systemin which aging and mental health serviceshave been linked. Before recruitment andtraining begin, communities must haveformalized referral and service responsesystems in place. A single point of entryfor incoming referrals must be identifiedand agreed upon by the community.

Gatekeeper recruitment may varyfrom one community to the next. It is im-portant to target corporations, businesses,and community organizations whoseworkforces have the greatest opportunitiesfor interacting with older adults. Coldcalls, face-to-face contacts, letters, andpublic media announcements all havebeen used to introduce the concept topotential Gatekeepers. Training sessionstypically are held at the workplace,last up to one hour, and are flexible toaccommodate work schedules and timedemands of the workforce. Retrainingalso is scheduled periodically.

Materials, including a trainingmanual and video, are available to assistin the replication. These materials arelisted in the references below. Programstaff can provide information on howto obtain these materials.

Other descriptive videos include:

• “ABC World News Tonight,American Agenda. Elder ServicesGatekeeper Program,” December 22,1992, 4 minutes.

• HEROS (Helping Elders throughReferral and Outreach Services),Pierce County, Washington.Gatekeeper Replication Program.

• “Gatekeeper Program/Old Friends.”Produced by the Washington StateBureau of Aging and Adult Services,1988, 15 minutes.

Keys to SuccessRaymond Raschko, the program founder,cited the keys to Gatekeeper’s success asthe integration of major systems; thetargeting of an at-risk population; theuse of both traditional and nontraditionalapproaches to identify clients; the use ofcrisis intervention; the use of interdiscipli-nary teams; the integration of fundingstreams; and the development of screeningand triage protocols. Obviously, successfulgatekeepers must represent, or at leastunderstand and respect, the ethnicity andculture of the troubled older individualsbeing sought out.

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References(The following materials are availablefrom the Spokane, WA, program, c/o Dr. Julie Jensen.)

Blow, F.C. Substance abuse and olderadults: A treatment improvementprotocol. Dimensions: Newsletterof ASA’s Mental Health and AgingNetwork 7: 4–6 (Summer 2000).

Florio, Evelyn R., Michael S. Hendryx,Julie E. Jensen, Todd H. Rockwood,Raymond Raschko, and Dennis G. Dyck.Comparison of suicidal and nonsuicidalelders referred to a community mentalhealth center program. Suicide andLife Threatening Behavior 27(2):182–193, Summer 1997.

Florio, E., J.E. Jensen, and M. Hendryx.Suicide-risk in community-dwelling elders.Dimensions: Newsletter of ASA’s MentalHealth and Aging Network 3(3): 1–8,1996.

Florio, Evelyn R., Julie E. Jensen, MichaelHendryx, Raymond Raschko, and Kath-leen Mathieson. One-year outcomes ofolder adults referred for aging and mentalhealth services by community gatekeepers.Journal of Case Management 7(2): 74–83,Summer 1998.

Florio, Evelyn R. and Raymond Raschko.Gatekeeper model: implications forsocial policy. Journal of Aging andSocial Policy 10(1): 37–55, 1998.

Florio, Evelyn R., Todd H. Rockwood,Michael S. Hendryx, Julie E. Jensen,Raymond Raschko, and Dennis G.Dyck. A model gatekeeper programto find the at-risk elderly. Journal of CaseManagement 5(3): 106–114, Fall 1996.

Jensen, J.E. and E. Florio. Identifyingisolated at-risk community-dwellingolder adults. Dimensions: Newsletterof ASA’s Mental Health and AgingNetwork 2: 2–3 (Winter 1995–1996).

Jinks, Martin J. and Raymond R. Raschko.A profile of alcohol and prescription drugabuse in a high-risk community-basedelderly population. DICP, The Annalsof Pharmacotherapy 24(10): 971–975,Oct. 1990.

Raschko, R. Living alone with Alzheimer’s:a growing challenge for providers.Dimensions: Newsletter of ASA’s MentalHealth and Aging Network 5: 2, 8(Winter 1998).

Raschko, Raymond. Systems integrationat the program level: aging and mentalhealth. Gerontologist 25(5): 460–463,Oct. 1985.

Raschko, Raymond. Assertive in-home casemanagement for impaired elderly persons:Elderly Service Program, Spokane (WA)Community Mental Health Center.Hospital and Community Psychiatry 39:1201–1202, 1988.

Raschko, R. and J.A. Shultz. Delusionaldisorder in older adults: Identification,intervention and treatment. Dimensions:Newsletter of ASA’s Mental Health andAging Network 6: 3, 8 (Winter 1999).

Contact:Peter V. Rabins, M.D., M.P.H.Johns Hopkins HospitalMeyer 279, 600 North Wolfe St.Baltimore, MD 21287-7279Phone: 410/955-6736Fax: 410/614-1094email: [email protected]

Sponsoring OrganizationThe project is led by the Johns HopkinsSchool of Medicine’s Department ofPsychiatry in collaboration with itsSchool of Public Health’s Departmentof Health Policy and Management, theBaltimore City Mental Health Department,the Mental Hygiene Administration ofthe State of Maryland, and the HousingAuthority of Baltimore City.

DemographicsThe program primarily serves an inner-cityarea with a significant population of olderadults and African Americans. Residentsevaluated in the initial study phase of thisprogram were predominantly female andAfrican American, lived alone, and hadincomes of less than $7,000 per year.Mean age was 72.4; 25 percent were atleast 80 years old.

RecognitionArticles in peer-reviewed journals, includingthe Journal of the American Medical Asso-ciation, describe outcomes achieved by pro-gram participants compared with similarpopulations not involved in the program.Detailed outcome assessments have helpeddemonstrate the value of the program andhave contributed to replication of the pro-gram throughout the State of Maryland.

About thePromising PracticePATCH, or Psychogeriatric Assessment andTreatment/Teaching in City Housing, is amobile treatment program that serves eldersliving in high-rise public housing sitesthroughout Baltimore. It combines elementsof the gatekeeper model and the mobiletreatment model that brings treatment toolder people at places that are convenientfor them.

How It Works

Outreach and RecruitmentAn 8-week education program is providedto staff working in congregate publichousing, among them building managers,

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PATCH, Baltimore, MD

Gatekeepers in congregate public housing identify elders in need ofmental health or substance abuse treatment and notify interventionpersonnel, who go to the site, assess the individuals, provide brief

on-site treatment, and refer for more intensive treatment.

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janitors, and tenant services workers. Thosestaff members serve as “case finders,” refer-ring individuals about whom they are con-cerned to a nurse who visits each site weekly.

ServicesInitial evaluation focuses on a tenant’s per-ception of the situation. Over one or moresubsequent visits, the nurse obtains a psychi-atric history, medical history, and familysocial history. Blood pressure and pulse arerecorded, as are the medications currentlybeing used by the tenant. The CAGE ques-tionnaire is administered to screen for poten-tial alcohol abuse or misuse. Activities ofdaily living (ADLs) and instrumental activ-ities of daily living (IADLs) are also meas-ured. A depression scale, the Montgomery-Asbery Depression Scale, is used to measuremood, and the Mini-Mental Status Exami-nation assesses cognitive ability.

This information and an initial formu-lation are presented to the team physician.The nurse and the physician then assess theresident in his or her home and develop anindividualized treatment plan with specific,time-related goals. The patient and nursechoose from a variety of interventions tomeet the chosen goals.

PATCH focuses on assessment,psychotherapy and medications, and“connecting services,” that include pro-viding transportation to medical appoint-ments, arranging for an increase in thelevel of financial assistance, and linkingindividuals to other community services,including services for the aging whereappropriate. The nurse acts as an advocatefor the client in the health care system.

In the initial study phase, the targetpopulations showed substantial depend-ency. Among 1,303 elderly residents at thefour sites, there were 124 referrals, 85completed evaluations, and 585 follow-upvisits. Interventions included immediate

psychiatric hospitalization, some withemergency petitions; referral for alcoholtreatment; referral to local communityhealth centers or alternative sources ofcare; medical evaluation for dementia;treatment for medical problems; andreferral to medical day care programs.A significant number of the individualsagreed to regular visits from the nurse.

Monitoring and ReassessmentThe goal of the program is that after 6months of work with individuals, 75 per-cent of those in need of care will attend theclinic (the Geriatric Psychiatry OutpatientClinic at the Johns Hopkins Hospital orBayview Medical Center) or use otherservices. Some residents need ongoingcare in the home. PATCH involvement isterminated when a system that providesneeded resources is in place.

Program AssessmentA recent assessment (Rabins et al. 2000)found a significant decrease in depressionand other mental illness in residents ofhousing units included in the PATCH pro-gram, compared with those in other units.The assessment also examined quality oflife, knowledge, attitude, and behavior.

Of special interest is the high preva-lence of previously untreated psychiatricmorbidity in this setting, and the accuracyof the congruence between the referringindividual’s identification of the problemand eventual diagnosis. The findings illus-trate that the “recognition of psychiatricsymptoms by housing management doesnot necessarily lead to eviction and mayinstead serve as a route of access to appro-priate treatment” (Roca et al. 1990).

In subsequent studies of the populationserved by PATCH, many findings related tothe need for mental health and substanceabuse services as well as to implications for

service delivery. For example, follow-upresearch on alcohol abuse within this popu-lation found that “the high prevalence ofalcohol disorder and its strong influence onmortality in this predominantly African-American female population demonstratethe need for programs designed to preventand treat alcoholism in public housingdevelopments for the elderly” (Black et al.1998a). Another study found that elderlyresidents of public housing suffer higherrates of psychiatric morbidity than olderpeople living independently in the commu-nity (Rabins et al. 1996).

In addition to high rates of psychiatricmorbidity among older residents of publichousing, research has shown that many of these individuals are not receiving themental health or substance abuse servicesthey need. Black and colleagues, for exam-ple, found that 37 percent of the samplestudied needed mental health services, andthat 58 percent of those had unmet needs.This unmet need is of particular concern,given the fact that functional status andmental status are major contributors tonursing home placement (Black et al.1997; Black et al. 1999).

In contrast to elderly African Ameri-cans in general, those in public housingtend to rely on formal rather than infor-mal sources of care for mental healthproblems, although neither source ofcare fills the unmet need. In response,“interventions to increase identification,referral, and treatment of elderly publichousing residents in need should targetgeneral medical providers and clergyand include assertive outreach by mentalhealth specialists” (Black et al. 1998b).

Findings also indicate that treatingemotional distress may prevent unneces-sary hospitalization, homelessness, andpremature nursing home placement. Inaddition, treating emotional disordersmay improve residents’ adjustment to

and acceptance of aging. Improving lifesatisfaction in psychologically ill residentsmay also have subsequent effects on thelife satisfaction in psychologically wellresidents (Cook et al. 2000).

LinkagesThe PATCH project combines the effortsof many public and a few private agencies,including the Johns Hopkins Departmentsof Psychiatry and Health Policy and Man-agement, the Baltimore City Mental HealthDepartment, the Mental Hygiene Adminis-tration of the State of Maryland, and theHousing Authority of Baltimore City. Link-ages are documented in written agreementsidentifying the roles and responsibilities ofeach organization. Care is coordinatedamong these and other agencies, as well.

Resources and FundingFunding is primarily from the State Depart-ment of Mental Hygiene. Costs of about$100,000 per year support staff salaries.In addition, research grants have supportedprogram evaluations. Additional informa-tion on resources and funding for thePATCH program can be obtained fromthe program directly.

Getting Started in BaltimoreThe program was initiated in 1986because of the significant numbers ofolder psychiatric patients from publichousing coming to the hospital for care.In time, it has expanded. Nonetheless,the program operates, as describedabove, without significant change.

Getting Started inOther CommunitiesThe State of Maryland has supportedreplication of the PATCH program infour additional sites in Baltimore, Mont-gomery County, western Maryland, and

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the Maryland Eastern Shore. The newprograms have not been linked to JohnsHopkins. PATCH nurses have had someinvolvement in the startup of the othersites. For the purpose of replication, afull-time nurse and at least one-tenth ofthe time of a psychiatrist are required.

Materials available to aid in under-standing the program include project descrip-tions and brochures as well as the journalarticles listed under References below.

Keys to SuccessA key element in the PATCH program’ssuccess is the role of the nurse in the thera-peutic relationship. The nurse, more thana social worker, police officer, or casemanager, can gain entry, establish rapport,build trust, and begin to help with thecomplex health problems of the potentialclients. Trust and the supporting relation-ship are at the heart of the program.

According to a program description,achieving the goals of the PATCH programrequires two complementary changes. Resi-dents and their families need assistance andencouragement to use community resourceseffectively. At the same time, these potentialresources need to understand the needs ofolder adults with mental illness.

Cultural competence is another keyto the success of the PATCH program.In particular, because the target populationis primarily African American, staff sensitiv-ity to the cultural values and health carepractices of the African American commu-nity has been essential.

ReferencesBlack, Betty Smith, Peter V. Rabins, Pearl S.

German, Marsden McGuire, and RobertRoca. Need and unmet need for mentalhealth care among elderly public housingresidents. Gerontologist 37(6): 717–728,Dec. 1997.

Black, Betty Smith, Peter V. Rabins, andMarsden H. McGuire. Alcohol use dis-order is a risk factor for mortality amongolder public housing residents. Interna-tional Psychogeriatrics 10(3): 309–327,Sep. 1998a.

Black, Betty Smith, Peter V. Rabins, Pearl S.German, Robert Roca, Marsden McGuire,and Larry J. Brant. Use of formal andinformal sources of mental health careamong older African-American public-housing residents. Psychological Medicine28: 519–530, 1998b.

Black, Betty Smith, Peter V. Rabins, andPearl S. German. Predictors of nursinghome placement among elderly publichousing residents. Gerontologist 39(5):559–568, Oct. 1999.

Cook, Joan M., Betty Smith Black, Peter V.Rabins, and Pearl German. Life satisfac-tion and symptoms of mental disorderamong older African American publichousing residents. Journal of ClinicalGeropsychology 6(1): 1–14, Jan. 2000.

Rabins, Peter V., Betty Black, Pearl German,Robert Roca, Marsden McGuire, LarryBrant, and Joan Cook. Prevalance of psy-chiatric disorders in elderly residents ofpublic housing. Journals of Gerontology:Series A: Biological Sciences and MedicalSciences 51A(6):M319–M324, Nov. 1996.

Rabins, Peter V., Betty Smith Black, RobertRoca, Pearl German, Marsden McGuire,Beatrice Robbins, Rebecca Rye, and LarryBrant. Effectiveness of a nurse-based out-reach program for identifying and treatingpsychiatric illness in the elderly. Journal ofthe American Medical Association283(21):2802–2809, June 7, 2000.

Roca, Robert P., Dean J. Storer, BeadtriceM. Robbins, Mary E. Tlasek, and Peter V.Rabins. Psychogeriatric assessment andtreatment in urban public housing.Hospital and Community Psychiatry41(8): 916–920, Aug. 1990.

Contact:Karen KentClinical SupervisorGeriatric Regional Assessment TeamEvergreen Healthcare5701 Sixth Ave., South, Suite 502Seattle, WA 98108Phone: 206/215-2850Fax: 206/215-2890email: [email protected]

Sponsoring OrganizationKing County Public Hospital District #2,DBA Evergreen Healthcare is a communitymental health program offering services ina variety of community settings. Homelessclients, for example, are met and servedwherever they choose—a community cen-ter, a restaurant, even a tavern. Althoughcalled a center, the program does not oper-ate a clinic.

DemographicsKing County is a major metropolitanarea in the Northwest, a prosperous area,rich in services, with responsive localgovernments. It is a center for the high-tech industry. The county covers 2,131square miles and has a population of1.8 million, 13 percent of them elders.

Among the older adult population inthe county, 3 percent are Asian, 9 percentAfrican American, 5 percent Hispanic, and0.5 percent Native American. There alsohas been a recent influx of Eastern Euro-peans, especially Russians.

RecognitionIn June 1999, The Seattle Times publishedan article about an interdisciplinary teamstarted by the police department thatincludes the geriatric team. It highlightedthe importance of collaboration amongthe police, attorneys, protective servicesworkers, and geriatric specialists in han-dling cases of domestic and elder abuse.

About thePromising PracticeEvergreen Health Care sponsors GeriatricCrisis Services, a specialized crisis inter-vention and stabilization service availableto older adults in the Seattle area of KingCounty. The service is provided by theGeriatric Regional Assessment Team thatincludes a nurse, geriatric mental healthspecialists, and a psychiatrist. The teamworks collaboratively to provide in-homemedical, psychosocial, and functionalassessments for persons age 60 and older

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Geriatric Regional Assessment Team, Seattle/King County, WA

An interdisciplinary mental health team provides in-homecrisis intervention and helps stabilize elders through

linkages with community and aging services.

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who are in crisis, who are not currentlyenrolled in the mental health system, andwho meet eligibility criteria.

To meet the criteria for service, theindividual must be one or more of thefollowing:

• physically or medically compromised

• lacking support to ensure healthand safety

• resistant to necessary services

• at risk for involuntary psychiatrichospitalization

• in need of an assessment fordifferential diagnosis

Typically, clients are isolated, hiddenolder adults—about to be evicted oralready homeless, suffering from dementia,dependent on the care of neighbors,referred to the health department becauseof the unsanitary environment in whichthey live, or alienated from other people.

How It WorksProgram services include:

• assessment

• crisis intervention and stabilization

• prompt referral and linkage to providers

• consultation

• guardianship evaluations

• care planning

• education for professionals, families,and other care providers

Outreach and RecruitmentMost clients come to the program’sattention through reports from neighbors,police, health department workers, or otherpeople with whom they come in contact.

ServicesThe assessment is comprehensive, cover-ing psychiatric, medical, social, and func-tional domains. Screens include the Geri-atric Depression Scale and the FolsteinMini Mental State Exam. Assessmentsare conducted by the Geriatric RegionalAssessment Team. Team members exploreclients’ religious beliefs and culturalvalues as part of the assessment process,if the client is open to the discussion.

Team members educate the client,family, and caregivers about the diagno-sis and medications, and refer the indi-vidual to appropriate agencies and sup-port groups. The agency accepting thereferral develops a service plan. Followingassessment and referral, the team staysinvolved until the crisis is stabilized.Most often, referrals are made to theAging and Disability case managementprogram, medical clinics, the Alzheimer’sAssociation, Adult Protective Services,in-home mental health services, andphysicians. Many of the clients havenot seen a doctor in years.

The team also provides consultationand training for the King County Agingand Disability Services case managementprogram.

Services of the Geriatric RegionalAssessment Team are focused primarilyon mental health, and clients served arethose with mental health needs. Thestaff, for example, includes a nurse witha background in gerontology, mentalhealth professionals, and a psychiatristwho is available half a day each weekfor home visits and case consultations,and otherwise available for emergencyconsultation by phone. Services includeassessment, diagnosis, crisis interventionand stabilization, counseling, medica-tions, and referral.

Until recently, substance abuse andmental health were handled by separatedepartments, but now they have beencombined in the County Mental HealthDepartment, promising greater integrationin the future. Currently, if the GeriatricRegional Assessment Team identifies aclient with only a substance abuse problem,the team refers that person to substanceabuse services.

Monitoring and ReassessmentOngoing monitoring and reassessmentare carried out by the agencies to whichthe individual has been referred. The clientmay easily be re-referred if a change incondition occurs.

LinkagesThe program works closely with aging anddisability services, adult protective services,police departments, senior informationand referral, the involuntary mental healthteam, voluntary geropsychiatric units,physicians’ clinics, and private physicians.Team members also serve as informal con-sultants to the agencies they work with.Most linkages are informal, but there arefour formal linkages through contractswith aging and disability services (the areaagency on aging); a 24-hour crisis clinic;the Senior Information and AssistanceLine (the number one source of referrals);and the Homeless Outreach, Stabilization,and Transition Team.

Training is provided to case manage-ment staff of the area agency on agingand to the Adult Family Home Network.Training also is offered in conjunctionwith the University of Washington SocialWork Department, and through the Uni-versity of Washington’s Institute on Aging,which provides rural education throughoutthe Northwest.

Program AssessmentQuality assurance case reviews areconducted quarterly. Outcomes consideredare primarily service-related. Because mostof the clients have undiagnosed dementiaand are not surveyed for consumer satis-faction, the referring agencies are surveyedannually, and the information provided bycase managers is used to make programchanges.

Reviews, including the annual reviewsby the State and county, are outstanding.The parent hospital is accredited by theJoint Commission on the Accreditation ofHealthcare Organizations, whose represen-tatives decided not to include the crisisservices in the most recent survey.

Case reviews are peer assessments. Allteam members participate in every quarterlyreview. The value is both in team-buildingwith new staff and in ongoing team edu-cation with questions, answers, and briefdiscussion. There may be longer discussionsat team meetings, based on interest or need.An additional benefit is the fact that indi-vidual problems are caught early in theprocess.

Resources and FundingThe services are funded by King CountyMental Health and, therefore, are providedwithout charge to clients and families.The terms of the county contract includea guaranteed response time of 3 days—a recent increase from a 2-day response,necessitated by an increase in referralswithout an increase in funding.

Interestingly, neither a clinic nor exten-sive office space is necessary. However, lap-top computers are needed to enable deliveryof services in multiple community settings.


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Getting Started in Seattle/King CountyIn 1992, King County formed a planningand advisory committee of mental healthand aging representatives to evaluate theexisting geriatric mental health systemand to develop an improved continuumof services for older adults. Work groupslooked at models from around the country.The county initiated a request for proposalsand eventually contracted with EvergreenHealthcare, a division of Evergreen Hos-pital and Medical Center. The GeriatricRegional Assessment Team was formed in1994 and has had an increasing numberof referrals each year.

The number of admissions to teamservices has also increased steadily. In 1997,admissions averaged 19 a month; in 1998the average was 29 a month; in 1999, 31;and by September 2000, 37. Demographicssuggest that the numbers will continue toincrease.

As the program has evolved, there havebeen a few changes. At one point, extrafunding was provided for a 24-hour crisisstabilization function, but after only a6-month trial, that component was dropped.Initially, staffing included a number ofpart-time workers, but that has changed tostabilize the program’s staffing and servicedelivery. At this time, staffing includes 3.8full-time professionals.

Getting Started inOther CommunitiesThe clinical director believes that this pro-gram can be offered in other settings andmakes himself available for consultation tosites interested in replication. Beyond theinterest in establishing such a program, suc-cessful implementation required availabilityof staff and adequate funding. Staffing inSeattle is very lean, with 3.5 clinicians and0.3 time for a supervisor/administrator;additional staffing is recommended. Feed-back from participants in the program isvery positive.

MaterialsA comprehensive assessment and intakeform, a quality assurance case reviewform, an annual referral source satisfactionsurvey, and a sample curriculum outlineare available and convey a strong sense ofthe quality of the program.

Keys to SuccessAs identified by the team, the keys tosuccess include free services; flexibility;strong, experienced clinicians; quickresponse to those making referrals; anda creative approach to initial encounters.

Team members develop cultural compe-tence through taking part in annual culturalsensitivity training and through consultationwhen needed.

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IntroductionBecause of their daily proximity to olderadults, aging services providers are wellpositioned to be actively involved in screen-ing older adults for substance abuse andmental health problems and referring themto skilled professionals for further assess-ment and treatment. Early intervention andtreatment can dramatically improve thelives of these adults. This section describesprograms that focus on the process ofscreening—determining whether it is likelythat a person has a given problem—andorganizing referrals to facilitate treatmentfor identified problems.

The aging services programs profiledin this section are successfully screeningand referring older adults with mentalhealth and substance abuse problems.Some also offer intervention and treat-ment. Although not all aging services canoffer the full array of services, it is impor-tant for aging services staff to recognizethe value of creating linkages with treat-ment providers in the community orregional area.

Screening is a preliminary assessmentor evaluation that attempts to measurewhether key features of a given problem

(e.g., substance abuse or mental disorder)are present in an individual. This processdoes not yield a clinical diagnosis. Rather,it indicates whether there is a probabilitythat the condition looked for is present.A comprehensive assessment, on the otherhand, is a thorough evaluation, the pur-pose of which is to establish the presenceor absence of a specific diagnosable disor-der or disease.

Recommended treatment interventionsfor alcohol and medication misuse/abuseamong older adults have been outlined inthe Substance Abuse Among Older Adults,Treatment Improvement Protocol Series#26. Treatment for problem drinkers mayinclude detoxification, inpatient or residen-tial rehabilitation, or outpatient services.Treatment approaches for older adultsmay include cognitive-behavior approaches;group-based approaches; individual coun-seling; medical/psychiatric approaches;marital and family involvement and familytherapy; and case management/community-linked services. Research shows thatolder people who misuse alcohol canreduce alcohol use successfully after abrief intervention by a trained clinician,social worker, home health care worker,or professional counselor.

S e c t i o n 4S c r e e n i n g , R e f e r r a l ,

I n t e r v e n t i o n , a n d Tr e a t m e n t~

Mental Health: A Report of the Sur-geon General discusses approaches totreating mental disorders among olderadults. These approaches include pharma-cological interventions as well as psycho-social interventions. While the pharmaco-logical and psychosocial interventions usedto treat specific mental disorders amongolder adults may be the same as those foryounger adults, characteristics unique toolder adults are important considerationsin treatment selection. Physiologicalchanges due to aging must be consideredin selecting appropriate medications anddosages for older adults. These changesinclude increased vulnerability to sideeffects, the potential impact of multiplemedications, potential interactions withother disorders, and other age-relatedbarriers such as impaired vision (whichmay make it difficult for the older adultto read instructions on the label) orcognitive impairment. Several types ofpsychosocial interventions have beenproven effective with older adults, thoughthe research is more limited than that onpharmacological interventions. In additionto helping address the symptoms of manymental disorders among older adults,psychosocial interventions also can helpstrengthen coping mechanisms andpromote healthy behavior.

Promising Practicesin Screening, Referral,Intervention, andTreatmentMany older adults prefer to receive treat-ment for mental disorders from theirprimary care providers. One of the prom-ising practices profiled here offers mentalhealth and substance abuse services in the

context of a primary care setting. Anotheroffers these services in a multifacetedsenior service center. A third collaborateswith aging services to reach out to olderadults and to offer screening, referral,and treatment support services. In eachinstance, linkages with community part-ners have resulted in the effective deliveryof needed services. One of the practicallessons from these programs is that itis preferable to offer these services in acomfortable and natural setting for theolder adults in need.

Implications for theAging NetworkThese promising practices show that,through the creation of links with com-munity partners, aging services can helpolder adults identify mental health andmedication and alcohol-related problemsand seek appropriate help. Because thepractices are built on community linkages,they can be instituted without requiringaging services staff to become eitherexperts in the field or direct treatmentproviders. Through partnerships, theseprograms have helped meet the needs ofelders without major commitments oftime or resources.

ResourcesThe screening tools used by many of thepromising practices in this publication areidentified in the program profiles. Someof the screens most commonly used arethose for dementia, because presentingbehavior is often thought to be related todementia. Screens that check for depres-sion in older adults also are frequentlyused by the programs profiled in this

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section. One of the simplest is the GeriatricDepression Scale. The Center for Epidemi-ologic Studies Depression Scale (CES-D)is another depression screen used by someof the programs profiled here.

The Michigan Alcoholism ScreeningTest–Geriatric Version (MAST-G) is ascreen specifically designed to test foralcohol misuse in older adults. The fullscreen (24 questions) and a short version(10 questions) have both been tested andvalidated for use with older adults. TheMAST-G can be used as a self-screen.Several of the programs profiled in thispublication use the CAGE questionnaire.This four-question screen is not as usefulwith older adults as either version of theMAST-G, but it has the advantage ofbeing quite short.

The Geriatric Depression Scale, theCES-D, the long MAST-G, and the CAGEare described and replicated in the publi-cation, Substance Abuse Among OlderAdults: Treatment Improvement ProtocolSeries #26. This publication is part of aseries of publications (also known as TIPs)providing best practice guidelines for thetreatment of substance abuse. The TIPs,published by the Substance Abuse andMental Health Services Administration’s(SAMHSA) Center for Substance AbuseTreatment, are available free of chargefrom SAMHSA’s National Clearinghousefor Alcohol and Drug Information (1-800-789-2647). The short version of theMAST-G was developed after TIP #26was published and was, therefore, notincluded in the TIP. It is, however, repro-duced in Appendix 5 of this publication.

In addition to the depression screenscontained in Substance Abuse AmongOlder Adults, National Mental HealthAssociation (NMHA) has developed a

national community education and screen-ing program called “The Blues: Not aNormal Part of Aging.” Information aboutthe program is provided in Appendix 1.

Referrals to treatment, and treatmentitself, vary among the programs includedin this publication. Many programs pro-vide mental health services through theirown professional staff. Others refer sen-iors to private psychiatrists, communitymental health centers, or to other mentalhealth providers with a capacity to servethis population. One of the best waysto identify treatment resources in a com-munity is to contact a local Mental Healthand Aging Coalition (listed in Appendix4), a local/State chapter of the NationalMental Health Association, the State/County mental health or substanceabuse department, or State aging servicescoordinator.

Appendix 2 includes contact infor-mation for several national organizationsthat have assisted SAMHSA and NCOAin developing this guide. These organiza-tions may be of assistance to identifyState or local resources. Many of themhave State or local affiliates which canbe identified through their web pages.

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Contact:Georgia NeillKit Clark Senior Services1500 Dorchester Ave.Dorchester, MA 02122Phone: 617/825-5000, ext 119Fax: 617/288-5991email: [email protected]

Sponsoring OrganizationKit Clark Senior Services is a multipurposeelder services agency providing a full spec-trum of services to Boston’s senior commu-nity. It is a multiethnic and multilingual,community-based agency whose missionis to enable older adults to maintain them-selves with dignity in the community.

Kit Clark offers mental health andaddictions services that include assessmentand treatment planning; individual andgroup therapy; case management; outreachand home visits; and information, referral,and education for seniors, family members,community groups, and service providers.Other services include transportation;nutrition programs and home-deliveredmeals; home repair; housing and homelessprograms; exercise, health education, andother classes; adult day services; primaryhealth care; and social opportunities.

DemographicsKit Clark’s constituents number around4,000 seniors living throughout the greaterBoston area. Seventy-eight percent of theseniors served are 65 or older; 22 percentare under 65. Fifty-seven percent arefemale; 43 percent are male. Forty-onepercent are Caucasian; 40 percent areAfrican American; 11 percent are Asian;and 7 percent are Latino. At least 85 per-cent of constituents are of low income.Common languages spoken at Kit Clarkinclude English, Vietnamese, Spanish,Haitian Creole, and Cape Verdean Creole.Approximately 25 percent of constituentsare homebound.

RecognitionKit Clark is seen as a leader in the field ofgeriatric substance abuse, gambling addic-tion, and mental health services. Its pro-grams have been featured in several docu-mentaries and training videos, including“It Can Happen to Anyone: Problemswith Alcohol and Medications AmongOlder Adults,” produced by AARP andthe Hazelden Foundation in 1996; and“The Doctor Is In: Substance Abuse inthe Elderly,” produced by Dartmouth-Hitchcock Medical Center for PBS in 1999.It also has been featured in major news-papers including The New York Times,


Kit Clark Senior Services, Boston, MA

Multiservice agency offers mental health and substance abusescreening, treatment, and long-term support for seniors.

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the Boston Herald, and the Boston Globe.Its staff have made presentations to pro-fessional and community groups in theUnited States and Canada.

About thePromising PracticeKit Clark Senior Services believes it takescommunity collaboration to address addic-tions and mental health problems of olderpeople. Working closely with other serviceproviders and the community, Kit Clarkhas created a network that is responsiveto seniors’ mental health and addictionsissues. As a result, elders throughoutBoston are more likely to learn about andparticipate in prevention, intervention, andtreatment opportunities. Kit Clark collabo-rates with the area agency on aging, homecare corporations, clergy, hospitals, andothers. It has trained outreach workers,direct care staff, and administrators ofaging services to recognize substance abuseand mental health issues, discuss themwith older adults, and make referrals.

Kit Clark Senior Services offers outpa-tient treatment programs for older adultswith addictions or mental illness. Its Geri-atric Mental Health Clinic has operatedsince 1980, Alcohol and Substance AbuseServices for Older Adults since 1981, andGambling Treatment for Older Adultssince 1997.

The Kit Clark programs are part of theagency’s continuum of services. Most clientscome in not only for individual or groupsessions, but also to socialize in the seniorcenter, have a meal, and receive other serv-ices. Kit Clark strives to offer a communitythat accepts and values its participantswhile helping them decrease social isolationand loneliness. Its clients are in varyingstages of recovery—from individuals who

have been identified as having a problembut are in denial to those who have main-tained sobriety for many years.

Recognizing that individuals have differ-ent needs, the center’s staff remain flexibleand tailor an approach to each individual.The staff of the addiction programs includesocial workers with expertise in addictions,mental health, and aging.

The caseload varies from 40 to 60clients at any given time. Since 1981 morethan 2,000 individuals have received clinicalservices and thousands more have partici-pated in outreach and education activities.The usual length of addiction treatment is 2to 3 years. Treatment tends to be relativelylong-term, intense during the early stagesand decreasing as clients recover. Manyseniors remain engaged, serving as volun-teers or taking part in relapse preventionservices.

How It Works

Outreach and RecruitmentReferrals for mental health and addictionsprograms come from the more than 35programs offered throughout Boston byKit Clark Senior Services. Staff in allagency programs are trained to identifyaddictions and mental health problems,talk with individuals about their concerns,and refer them for services. Staff also pro-vide ongoing support to seniors, encourag-ing them to get help or to continue therecovery process. Staff members includehome health aides, adult day services staff,housing counselors, senior center staff,and other staff with direct contact withseniors. Clinical social workers, outreachworkers, and student interns make homevisits to isolated individuals. Referralsalso come from external service providerssuch as case managers, senior housing

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managers, home health care nurses,discharge planners, and primary carephysicians.

Outreach and training are conductedwith other agencies and community groupsto create a safety net for seniors with men-tal health or addictions problems. The atti-tudes and the stigma associated with mentalillness and addictions among older peoplemust be overcome so people can identifyand refer seniors for services.

After participating in the program fora while, clients often recall how frightenedand ashamed they felt when they first cameto the center—ostracized by family andneighbors. At the senior center, however,they found a warm welcome, other peoplewho share their experiences, and the helpthey needed to change their lives.

ServicesEach senior is offered a comprehensivehealth and social needs assessment—theSenior Health Education and Access Assess-ment (SHEA)—which is being developedcollaboratively among Kit Clark SeniorServices, Tufts Senior Health MaintenanceOrganization, and Beth Israel DeaconessMedical Center. It uses a detailed clienttracking system to assess progress in meet-ing client needs. During the intake process,a complete social and health history istaken, and clients undergo screenings formental status, gambling addiction, and sub-stance abuse. If a problem is detected, amore detailed assessment is completed,including the MAGS (Massachusetts Gam-bling Screen) and the Michigan AlcoholScreening Test–Geriatric Version (MAST-G).Information from collateral providers andfamily members also is collected. An inter-disciplinary team of clinical social workers,a psychiatrist, and a nurse work with the

seniors to develop a treatment plan basedon the client’s assessment information.Clients are connected with the other pro-grams that Kit Clark provides and coordi-nates—primary health care, nutrition, trans-portation, and adult day services. Referralsare made to other sources as needed.

Kit Clark mental health and addictionsprograms provide individual and grouptherapy, outreach, and psycho-education.These services also are provided in homevisits for older adults who are unable tocome to the center. Self-help recoverygroups meet regularly at the Kit Clarksenior center.

Substance abuse and mental healthservices are offered in a supportive stigma-free environment. Because of all the otherprograms going on at the center at anygiven hour, there is also a great deal ofanonymity.

On a typical day, a client may movethrough a number of activities, somedirectly related to mental health and sub-stance abuse, others not. For example, aclient might attend an individual therapysession, go to an exercise class, have lunchwith friends, and then attend a computerclass. The next day the same client mighttake part in a therapeutic group session.Transportation services often are an essen-tial ingredient for success.

Kit Clark Senior Services reaches diversepopulations and pays special attention tocultural competency and language needs.Bilingual, bicultural staff conduct bothtreatment and social groups for Vietnamese,Cape Verdean, Haitian, and Hispanicseniors.

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Monitoring and ReassessmentThe interdisciplinary staff team reviewsthe progress of each participant quarterly,at which time care plans are updatedand revised. As part of the treatmentplan review, there is a multiaxial assess-ment of the client’s status. Client progressis reported monthly and results are evalu-ated based on the outcome indicators ofthe logic model (see Program Assessmentbelow). Service and programmatic out-comes are a critical component in thelogic model.

LinkagesKit Clark Senior Services has establishedboth internal and external linkages. Themental health and addictions programsare integrated into the continuum of carewithin the agency. SHEA provides a com-prehensive health and social assessment forclients in the mental health and addictionsprograms to link them to other neededservices. This tool also is used in otherKit Clark programs. It can identify existingor potential mental health or addictionsproblems so that seniors can be referredfor further evaluation.

Kit Clark participates in the monthlymeetings of the Massachusetts GeriatricSubstance Abuse Task Force. Other addic-tions and senior service providers, theMassachusetts Department of PublicHealth, and the Executive Office of ElderAffairs collaborate to address issues ofawareness, funding, policy, and resources.The agency works collaboratively withthe Boston Commission on the Affairs ofthe Elderly (the Boston area agency onaging) and other community resources toimprove awareness and identify seniorsin need of help.

Program AssessmentKit Clark Senior Services uses the UnitedWay of America’s Logic Model and Out-come Measurement Plan. A logic model is aconceptual map of the program, describingprogram inputs, activities, outputs, initialoutcomes, intermediate outcomes, and long-term outcomes. An outcome measurementplan outlines the process and progress fortracking one or more desired outcomes.The measurement plan tracks the desiredoutcome, indicators, influencing factors,and details on data collection.

Outcome indicators are used for pro-gram improvement, strategic planning, andreporting purposes. Examples of particularoutcome indicators measured by Kit Clarkare the following:

• Concurrent medical problems areaddressed.

• Environmental stressors are addressed.

• Global assessment of functionimproves or maintains.

Resources and FundingServices are paid for through insurancereimbursement that includes Medicareand Medicaid, and through funds fromthe Massachusetts Department of PublicHealth Bureau of Substance Abuse Services.Additional foundation and grant money isrequired to cover total costs of programs.The program can provide additionalinformation on its resources and funding.

Getting Started in BostonOver the 20 years that Kit Clark has offeredmental health and addictions services inBoston, the integration of these services intoother Kit Clark programs and with otherBoston providers has been essential for

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success. Once clinical programs were estab-lished, other agency services were addedto create a multidimensional approachand to reach an optimal number of elders.There was also a focus on building thewhole community’s capacity to offerprevention, intervention, and treatment toelders with mental illness and addictions.Throughout the City of Boston and theCommonwealth of Massachusetts, KitClark Senior Services is a collaboratorand resource to address mental healthand addictions issues for seniors.

Getting Started inOther CommunitiesSeveral key components are needed to rep-licate this program in other communities:

• outreach to seniors through one-to-onecontact and group education

• collaboration among agencies andservices that have contact with elders

• identification and intervention trainingfor staff and community members

• a referral network that can addressthe range of needs of seniors withmental health and addictions problems

• a linkage to a mental health clinic anda psychiatrist because of the frequencyof dual diagnoses

Extensive training and outreach mate-rials have been developed. They includemultilingual brochures, satisfaction sur-veys, curricula and handouts for nonclini-cal staff to use in making presentations,handouts for elders, intake and assessmentforms, and staff training materials. Anexcellent curriculum has been developed,Passing It On, A Handbook for PeopleWho Care About Elders. It offers practicalinformation on medications, tobacco use,alcohol, intervention, HIV/AIDS, and stress.

Keys to SuccessThe message from this comprehensiveservice program is that it “takes a com-munity to address addictions and mentalillness with this population.” Whileresearch has shown that older peopledo well in treatment, the Kit Clark pro-gram has found that they often do notenter treatment without:

• repeated mentions of the problemby the client’s friends and family

• addressing the client’s entire life

• ongoing support

• plenty of time and patience to builda relationship and establish trust

Contact:Marty Lynch, Ph.D.Lifelong Medical CareP.O. Box 11247Berkeley, CA 94712-2247Phone: 510/704-6010, ext 261Fax: 510/883-1667email: [email protected] site: www.lifelongmedical.org

Sponsoring OrganizationLifelong Medical Care, a federally quali-fied health center (FQHC), was foundedby the Gray Panthers 25 years ago toprovide primary care and comprehensivehealth services. It was formed when theoriginal Over 60 Health Center Corpora-tion merged with two other health centers.Lifelong includes five licensed sites, threeof which are Over 60 Health Center sites,and a satellite site.

Using an interdisciplinary teamapproach, Over 60 Health Center sitesoffer “one-stop shopping” for a full rangeof services including health promotion,disease prevention, screening, diagnosis,and treatment. Though mental healthhas been part of the program since the

mid-1980s, mental health and substanceabuse services have become more signifi-cant in recent years.

DemographicsAmong the clients served by Over 60Health Center sites, the average age is78; women outnumber men two to one;60 percent are African American, 30 per-cent are Caucasian, and the remaining10 percent are Asian and Hispanic. Asignificant number are homeless, 95 per-cent have incomes below 200 percent ofthe Federal poverty level, and many arebelow 100 percent. Most have severalchronic diseases, and depression is notuncommon.

RecognitionCenter Director Marty Lynch receivedthe Robert Wood Johnson FoundationCommunity Health Leadership Awardfor his work with the Over 60 HealthCenter. Over 60 has received specialrecognition from the America Societyon Aging, Sisters of St. Joseph of Orange,and others.

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Over 60 Health Center, Berkeley, CA

Community health center integrates mental health and substanceabuse services with primary health care and also provides referrals to

community mental health and substance abuse services.

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About thePromising PracticeThe Over 60 Health Center combinesprimary care and mental health servicesso consumers do not have to travel toreceive treatment. It is the first community-based geriatric health care center in thecountry, and it has always offered anintegrated and multidisciplinary systemof health care service delivery. All of theprimary care physicians are trained torecognize mental health issues. The centeruses a consumer-directed approach inoffering its mental health and substanceabuse services.

How It Works

Outreach and RecruitmentAs a long-established health center,Over 60 draws older consumers fromthroughout the community. Many arereferred by community organizations andprivate physicians. Others are attractedto the clinic through the health educationprograms on mental health, exercise,smoking cessation, weight control, andhypertension that Over 60 conducts insenior centers.

Community programs referring toOver 60 include South Berkeley SeniorCenter, Bay Area Community ServicesMeals-on-Wheels, Alzheimer’s Servicesof the East Bay, Emeryville Senior Center,Legal Assistance for Seniors, and theAlta Bates Hospital emergency room.

ServicesPhysicians providing primary care in theOver 60 Health Center conduct an informalscreen during patient visits andmake appropriate referrals to mental healthclinical staff. The primary care physiciansand the mental health clinical staff, includ-ing psychologists and social workers, shareresponsibility for treatment planning toensure that consumers in need of mentalhealth services either get them on-site or arereferred and receive treatment.

Physicians and other staff can referpatients to mental health, social, andsubstance abuse services. Users also canself-refer. Patient needs are assessed in asocial work intake process after which anappointment is set with an appropriateprovider at Over 60 or a referral is made.Users may be referred to outside servicesif internal capacity is at its limit or ifthe patient’s insurance requires it. Com-plexity is not normally a reason forreferring out.

Over 60 offers assessments, individualand group counseling, medication manage-ment, Alzheimer’s disease diagnoses,and behavioral health services. Alcoholtreatment will soon be provided on-site.Lifelong Medical Care offers a range ofservices, some of which are available toOver 60 clients—such as acupuncturetreatment to support detoxification andmaintenance of sobriety. The Over 60interdisciplinary team includes a clinicalsocial worker, a clinical psychologist,and a primary care physician, in additionto a nurse.

Over 60’s consumer-directed approachto mental health services is reflected inits age-specific treatment; treatment fordepression that addresses loneliness and

loss; inclusion of family and caregiverinvolvement when appropriate; treatmentprovided in a manner and at a pace thatis comfortable for older adults; emphasison staff training and conducting educa-tion in working with older adults; and astrong emphasis on working with othercommunity-based services for elders.

Lifelong Medical Care, working withthe University of California at San Fran-cisco, is a site for a national demonstra-tion project funded by the SubstanceAbuse and Mental Health Services Admin-istration that compares the effectivenessof integrating mental health and substanceabuse services with primary care to theeffectiveness of a traditional referralmodel. The goal is to enroll 150 to 200individuals, serve one group directly, andrefer the other to a service provider inthe community that has been used suc-cessfully for referrals in the past.

This project provides an opportunity tosupplement services, collect outcome data,and examine the effectiveness of servicesintegration in contrast to referrals. Mentalhealth services focus on individuals withdepression and anxiety, excluding thosewith more severe diagnoses. SAMHSA andthe Health Resources Services Administra-tion are funding this project, which is alsobeing conducted in six other primary caresites and five Veterans Administration sites.The study is looking specifically at depres-sion and anxiety and alcohol use. Althoughpeople with psychoses are excluded fromthe study, they still receive the services.

Monitoring and ReassessmentOngoing monitoring and reassessment isprovided by five social workers who serve50 clients on a monthly basis.

LinkagesOver 60 has worked closely for 20 yearswith the area agency on aging and with thecoalition of providers in the aging servicesnetwork. The center also maintains closeconnections with other community healthcenters and community service providers.These relationships foster consumer refer-rals and joint program efforts. Cooperativeendeavors include providing legal assistanceand medical services to individuals who areserved by the Meals-on-Wheels program.For example, if problems are detected in theMeals-on-Wheels application, elders arereferred to case managers who conducthome visits and arrange for needed services.Because of this process, some in-homemental health services are being provided.

The medical center has active linkagewith numerous community organizations,including a demonstration project in whichteams offer mental health, substanceabuse, and health care services in singleresident occupancy hotels where manyolder adults reside.

Through another partnership, Over60 is developing a package of care forindividuals at high risk but not yet eligiblefor the Medicaid-supported Program forAll-inclusive Care for the Elderly (PACE).Initial funding has come from the RobertWood Johnson Foundation and the Califor-nia Endowment. The State health depart-ment is also considering support.

Over 60 has moved to a new buildingto partner and collocate with the Centerfor Elders Independence, operated by thenational PACE program, and with theDepartment of Housing and Urban Devel-opment’s program that provides funding forvery low-income senior housing sponsoredby a local nonprofit housing developer.

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Program AssessmentOver 60 collects outcome data in all cate-gories: quality of life, including healthand functional status; knowledge, attitude,and behavior; service-related; community-level; and cost/utilization. When the Centersurveyed the patients served, feedback con-sistently showed they were most satisfiedwhen someone was willing to take timewith them.

Lifelong and Over 60 are licensedand monitored by the State as communityclinics. In addition, because LifelongMedical Care is an FQHC, the FederalBureau of Primary Care monitors withits extensive Primary Care EffectivenessReview (PCER). The PCER includesdata on diagnoses, payer mix, and ninemeasures of compliance.

Resources and FundingThe primary source of funding for theseservices is third-party reimbursementfrom Medicare and Medicaid (at ratesestablished for FQHCs), Older AmericansAct funds from the area agency on aging,demonstration projects, other grants,indigent care funds from the county, andother fund-raising efforts. The programcan provide additional information onits resources and funding.

Getting Started in BerkeleyThe Over 60 Center was established as anoutpatient clinic in the mid-1970s, becausethe founders wanted to offer a community-based alternative to the nursing homecare that many older adults were receiving.The first services offered were “preven-tive.” Nurses worked directly with olderadults to manage chronic conditions and

handle such mental health problems asdepression and anxiety. Primary care serviceswere added later, when it became evidentthat the patients served did not have ordid not see physicians on their own.

In the 1980s a geropsychologist wasadded to the staff, as were short-term ther-apy and assessments. The interdisciplinaryteam approach continued, and assistancewith practical problems became part of theservices offered. As mental health servicesevolved, the services of a clinical socialworker, an additional clinician, and asubstance abuse counselor were added.

Getting Started inOther CommunitiesCommunity health centers throughout thecountry are making new efforts to serveelders. This presents aging services theopportunity to create linkages to increasecommunity health and mental healthservices. Some communities could bringtogether a PACE program, a multiserviceorganization, and housing; others canapply the principles of Over 60 to meettheir goals.

Over 60 uses physicians, nurse practi-tioners, physician assistants, and medi-cal support. It also uses a psychiatrist,social workers, and geriatrically trainedclinical psychologists. For FQHCs, clinicalsocial workers are a covered benefit underMedicare and Medicaid; they are notcovered under traditional Medicare. Over60 also uses a certified substance abusecounselor for individual and group work.The director believes that a health centercould begin an integrated approach witha good licensed clinical social worker.

Descriptive materials are available.

Keys to Success• One key is FQHC status. Lifelong

Medical Care is a community healthcenter charged with providing a rangeof services in a medically underservedarea and is overseen by a consumer-directed board. It receives this designa-tion through the Public Health Service’sBureau of Primary Health Care andbenefits from somewhat increasedMedicare and Medicaid reimbursement.

• Another key is consumer direction.Consumers comprise the majority onLifelong’s board of directors.

• A third key is cultural competence,for the program as a whole and for itsspecific projects. Hiring and trainingemphasize the importance of maintain-ing the capacity to “effectively reach,serve, and satisfy an ethnically diversecommunity, the majority of whom areAfrican American.” When necessary,changes are made to ensure culturalcompetence. For example, efforts areunder way to refine the screening instru-ment for the integration project toensure the inclusion of all ethnic groups.

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Contact:Jim CallahanMaureen PerreaultHawthorn Services, Inc.93 Main St.Chicopee, MA 01020Phone: 413/592-5199Fax: 413/594-8693email: [email protected] site: www.HawthornServices.org

Sponsoring OrganizationHawthorn Services is a multiservicegeropsychiatric organization that has beenin place for 20 years. In addition to theElder Substance Abuse Outreach Program,Hawthorn offers a residential program pro-viding a structure for elders who need24-hour care while maintaining a flexiblesystem to accommodate a wide range ofneeds and levels of functioning. In addition,a community elder support program servesmentally ill elders who live independentlyin the community. A wide range of servicesare offered directly. Additional services areprovided by other community organizationswhile collaboration is maintained to providecomprehensive services.

DemographicsThe elderly population in Chicopee is pri-marily Caucasian and African American.There is a growing Hispanic populationin nearby Holyoke. They are served bya substance abuse counselor who speakssome Spanish and works closely with localproviders accepted in the community.

In the first two years of operation, 50referrals were made to the Elder SubstanceAbuse Outreach Program—26 men and22 women. The age range of clients was58 to 92, but most were in the range of 68to 75. Currently, the weekly support groupis economically mixed and includes a retiredphysician as well as blue-collar workers.

RecognitionIn 1993, Hawthorn Services received aPartners in Eldercare Award from AARPand the Administration on Aging. Its pro-grams were presented as models at the 1991annual meeting of the American Society onAging and the 1994 annual meeting of theGerontological Society of America. Theywere also referenced in the 1999 MentalHealth: A Report of the Surgeon General.In 1995 the Outreach Program was chosenby the Judge David L. Bazelon Center forMental Health Law as a Best Practice.


Elder Substance Abuse Outreach Program, Chicopee, MA

Geropsychiatric agency collaborates with aging services toreach elders with substance abuse problems and offers

screening, referral, and treatment support services.

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About thePromising PracticeThe Elder Substance Abuse OutreachProgram began as a cooperative projectbetween Hawthorn Services and BrattleboroRetreat, an inpatient substance abuse treat-ment agency. It offers a community-basedapproach to the treatment of substanceabuse for the elderly. The program incorpo-rates three facets of treatment. Workingwith other community-based agencies, it:

• identifies elders at risk

• uses an experienced clinician to initiatecontact with the elder in his or herown home

• offers the support of weekly substanceabuse therapy and peer support groupmeetings

Program components include outreach,individual and group counseling, socializa-tion, peer support, and education.

Care plans are developed for each per-son referred to the program, and progressis charted. The goal is to use support fromprofessionals and peers to produce a betterquality of life for each individual. Theprogram has succeeded in supporting per-sonalized goals, including achieving sobri-ety, securing appropriate and safe housing,attending literacy classes, and, for some,participation in Alcoholics Anonymous.

How It Works

Outreach and RecruitmentOutreach, or client identification, can beginwith a referral from a community organiza-tion such as the visiting nurse association,a council on aging, local police department,or local elder housing complexes. When aninformed gatekeeper identifies a potential

problem, he or she contacts Hawthorn.Usually within 24 hours, Hawthorndispatches an outreach worker—eitherthe part-time substance abuse counselor(a social worker with substance abusecredentials) or the full-time social workerwho also has substance abuse expertise.The counselor’s initial contact is an out-reach visit to the client’s home. The philos-ophy of the program is to be persistent,anticipating that clients will have difficultyaccepting the need for intervention. Anumber of repeat visits may be necessaryto engage the client in a relationship in anonthreatening and nonconfrontationalmanner.

ServicesThe outreach worker makes the initialassessment, often using the MAST-G forsubstance abuse as well as a depressionscreen, though instruments and approachesvary case by case. Often the substanceabuse problem is confirmed, but occasion-ally a more thorough assessment detects adifferent problem. Care plans are developedby the social worker with substance abusecredentials.

Hawthorn is not a crisis program, nordoes it provide formal treatment for sub-stance abuse. Its weekly therapy groups tryto get individuals to recognize the problemand link up with an appropriate resource.

Hawthorn’s Elder Substance AbuseOutreach program includes a therapy andpsycho-educational group that relies oneducation coupled with peer interaction toprovide support. Most sessions spend timeeducating the group on physical as well aspsychological ramifications of addiction.Emphasis is not on abstinence but onunderstanding, finding resources, andreconnecting socially.

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Hawthorn always refers those in crisisto an inpatient unit. Staff members do notassist consumers in detoxification or recom-mend that they accomplish it without pro-fessional help. On intake, individuals areencouraged to consider various servicesavailable to them. Hawthorn focuses oneducating the consumer, as well as provid-ing support and a therapeutic setting.

The program provides a range of serv-ices for those dealing with their problem orin need of support, prevention, and relapseprevention. Clients can be seen as often asonce a week by the counselor or socialworker, and regular contact is maintainedwith the person who made the referral.

Group counseling includes a weeklysubstance abuse therapy and peer supportgroup. The meetings, held at the ChicopeeCouncil on Aging’s senior center, are acombination of education, support, therapy,and socialization. This group encouragesmembers to review their past, come tobetter terms with their current situation,and understand the impact of alcohol ontheir lives. Socialization is provided atthe end of the session, when a meal isoffered. This serves as an incentive whileproviding nutrition and strengthening thecommunity support system.

Peer support complements the coun-selor visits and group work. HawthornServices trains older volunteers recruitedby the local councils on aging to providesupport to elders with emotional diffi-culties or depression, often linked to sub-stance abuse. Volunteers receive trainingbefore they are placed with an elder; theymeet monthly with clinical staff for addi-tional guidance. They also may serve asbridges to treatment.

Hawthorn makes frequent presentationsto educate service providers and health careprofessionals as well as older adults and

their caregivers about the prevention, recog-nition, and treatment of alcoholism anddepression in the elderly.

The program also focuses on reachingthe gatekeepers, providing in-service train-ing for area agency on aging case managerson such issues as how to identify a potentialproblem, warning signs of which to beaware, and the services that are availableonce need is confirmed.

As they have become known in thecommunity, Hawthorn staff have takenon the role of case consultants for otherservice providers who call for advice andguidance when they detect a problem.Hawthorn helps them distinguish problemsof substance abuse from dementia, depres-sion, or medication mismanagement.

Hawthorn also offers a residentialprogram and the Community Elder Sup-port program. These programs are relatedto the Elder Substance Abuse Outreachprogram because they have the samemission: to provide whatever services areneeded to keep elders active and at homeas long as possible and to provide carefor those who otherwise would be under-served. The residential and CommunityElder Support programs are in a closedreferral system controlled by the Depart-ment of Mental Health. The residentialprogram is a mental health, rather thana substance abuse, program. If a referredclient is dually diagnosed, the problemsare addressed residentially and by ElderSubstance Abuse Outreach.

The Community Elder Support pro-gram differs from Elder Substance AbuseOutreach in that it is primarily a mentalhealth program designed to provide sup-port for older people living in the commu-nity. It addresses issues of activities of dailyliving (ADL) and instrumental ADL issues,as well. Many of the Elder Substance

Abuse Outreach program consumers aretreated by psychiatrists or are taking med-ications for depression.

Monitoring and ReassessmentA care plan is developed for each partici-pant that includes general goals that thecounselor and the participant will worktoward. Each group session is documentedso that group members’ progress can benoted. Consumer contact sheets are usedfor individuals receiving home visits soprogress can be tracked.

LinkagesLinkages involve:

• services such as the detoxification unitfor seniors at Brattleboro

• referrals from the visiting nurses,hospital discharge planners, councilson aging, area agencies, police, andfamily members

• follow-up services to programs(such as that offered by Brattleboro)and community education

The Elder Outreach counselor spendsa portion of each week talking withother agencies to educate them aboutthe program. Periodic in-service trainingis held at various places such as housingdevelopments and offices on aging toraise awareness of the program andalso to alert other agencies about the“hidden problem” and to help thembegin to recognize symptoms.

Under contracts with hospitals forservices and many informal arrangementswith local agencies and hospitals, ElderOutreach provides education and servicesand the partners provide the referral and,in some cases, treatment.

Program AssessmentHawthorn is licensed and monitored by theDepartment of Mental Health. Its residen-tial program is accredited by the nationalRehabilitation Accreditation Commission(CARF), and its adult day health programwill soon apply for CARF accreditationas well.

The program has conducted participantsatisfaction surveys and collected consider-able anecdotal information. There has beenno formal collection of outcomes databecause of a variety of complicating factors.Because participation in the group is nottime-limited, posttests are difficult. Also,some evaluation criteria would considerhospitalization a negative outcome, whileothers would view it as positive. Staff mem-bers feel that increased community aware-ness and recognition as well as successfullinkages to hospitals and community gate-keepers are indicators of success.

Resources and FundingThe program’s services are providedwithout charge, and the program actuallybegan with no funding. The decision not tocharge patients came out of the program inConnecticut that served as this program’smodel. The clinical social worker on thatstaff was able to bill Medicare for services,but when the clients received their state-ments from Medicare that documentedthe substance abuse services, they stoppedthe services. Staff believe the stigma ofthe documented diagnosis and care wastoo great a barrier. Staff continue to feelthat this is an appropriate way to initiatethe service and worth the cost of gettingthe program off the ground.

Sources of funding include funds fromBrattleboro, direct fund-raising efforts,grants from the area agencies, and fundsfrom the Center for Community Recovery

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Innovations (part of the MassachusettsHousing Finance Agency) specifically forindividuals in public housing. Revenueis expanding now through linkages withhospital systems, thus opening up thepotential for funds from the State Depart-ment of Public Health for “psycho-educational ambulatory care” coveringcommunity-based prevention and edu-cation for individuals who have notreceived inpatient care.

Getting Started in ChicopeeThe Elder Substance Abuse Outreach pro-gram in Chicopee was initiated in 1997. Itwas modeled after a program in Connecti-cut that also emphasized aggressive out-reach, although that program’s linkage withmedical services was more formalized thanthe Chicopee project.

The impetus for the program was therecognition of unmet need in the commu-nity for outreach and assessment and forservices specifically geared to older adults.Providers in the community realized thatolder adults were in need of substanceabuse services but that they were not refer-ring themselves to programs, nor were theycomfortable in settings dominated by youth.Staff also felt that specialized services wereneeded because of the link between sub-stance abuse and depression and issues thatoften led to or exacerbated the problem,such as loss and isolation.

Staff have tried various means of reach-ing the physicians in the community, whocould play a pivotal role in identifying sub-stance abuse problems in the elderly, buthave not been successful in getting theirattention or referrals. It is hoped that newcollaboration with the hospital systems willadd a level of credibility and may capturetheir attention.

Getting Started inOther CommunitiesStaff’s advice on replication: “Just do it!Don’t worry about the funding!” Initialsupport for Elder Outreach was requestedin a proposal to a local foundation butwas rejected because of a perception thatthis was not a problem in the community.Denial can be anticipated. Because theprogram developers felt strongly that itwas a problem, they have found otherways to proceed.

A certified alcohol and substanceabuse counselor is essential to the programbecause of his or her knowledge of theissues. It is also important to have strongclinical leadership over the program inorder to manage other issues that can existalong with substance abuse problems—for example, depression and mental illness.

Descriptive materials are available fromthe program.

Keys to SuccessAn element that program staff have foundimportant is that the program does notinsist on sobriety as a requirement forparticipation. Some reduction in drinkingand improvements in self-management areacceptable for continued involvement inthe program.

The staff’s holistic approach to theirclients has been an effective philosophy forworking with older adults. The approachused by the program allows the outreachworkers to get a foot in the door, establishrapport, and learn about the person’s wholelife and circumstances before attempting todeal with these issues.

ContactGouverneur Department of Behavioral

HealthCenter for Older Adults and Their FamiliesEdgar Velasquez, MD227 Madison St., #397New York, NY 10002Phone: 212/238-7384Fax: 212/238-7399

Sponsoring OrganizationGouverneur Hospitals, a municipal healthcare facility, is part of the New York CityHealth and Hospitals Corporation andis affiliated with New York University’sBellevue Medical Center. The Center forOlder Adults and Their Families is thegeriatric service of the Gouverneur Diag-nostic and Treatment Center’s Departmentof Behavioral Health.

DemographicsThe Center serves an extremely diverse,urban population in Manhattan. Programparticipants include lifelong U.S. citizens,primarily Caucasians, Hispanics, andAfrican Americans, as well as an immigrantpopulation from Asia, Russia, Latin Amer-ica, Europe, and other areas of the world.The languages, cultures, and socioeconomiccharacteristics are highly variable, makingcultural competency a continuing challenge.

RecognitionThe program has received the highest level of certification, a 3-year award, and a commendation for its Patients Bill ofRights from the State of New York. Arti-cles in leading professional journals (seeReferences below) document the Center’ssuccess. Perhaps most significant, 85 per-cent of patients report that Center treat-ment has helped them.

About the PromisingPracticeThe Center for Older Adults and TheirFamilies provides comprehensive geriatricmental health services for people age 55and older and their families. The Centeruses a family-centered approach to careand emphasizes the provision of culturallycompetent services to a diverse population.Its program components include:

• an elder outreach team conductinghome visits for assessment andengagement

• a clinic program offering assessment,evaluation, therapy, and case manage-ment

• a day treatment program with allclinical services plus activities in atherapeutic milieu

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Center for Older Adults and Their Families, New York, NY

Public hospital-based mental health center offersgeriatric mental health services on-site and off-site

through senior centers and to elders at home.

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• psychiatric consultation for theGouverneur Nursing Facility

The Center serves an average of 300 clientseach year.

How It Works

Outreach and RecruitmentThe Center’s elder outreach program makesolder adults aware of mental health servicesavailable to them and works to reduce thestigma associated with these services. Theprogram also reaches out to elders in need.Staff go into homes, including public hous-ing, to conduct assessments, both for thosewho have never had contact with mentalhealth services and for former patients whomay need to be re-engaged. Staff are avail-able for training and education and go intothe community to talk with both lay groupsand professional organizations about geri-atric mental health.

It was expected initially that referralsto the program would come from seniorcenters, but that has not been the case.Rather, referrals come mostly from primarycare physicians, from in-patient psychiatricfacilities, and from friends and familiesbringing in their loved ones for treatment.Family and friend referrals usually areappropriate, indicating the communityhas an accurate understanding of whatthe program is and whom it can help.

ServicesComprehensive mental health and sub-stance abuse assessments are conducted bypsychiatrists, social workers, psychologists,and nurses for all older adults enteringthe programs. Psychosocial assessmentsaddress current and past biological, psy-chological, and social functioning. Therange of mental health problems in theclient population includes depression

and other affective disorders, anxietydisorders, and psychotic disorders thatimpede functioning.

Screening for alcohol problems is con-ducted using the CAGE, a questionnaire onalcohol abuse validated for use with olderadults. A more detailed substance abuseassessment is provided, if indicated. Somepatients are identified as dually diagnosedwith both a substance abuse problem anda mental illness.

Families are included in theassessment, with special recognition oflater-life families and their issues. Thefunctioning of the family system, includingits capacity to carry out the expecteddevelopmental tasks of the family with anolder member is also assessed. A culturalassessment addresses issues such as immi-gration status and culturally rooted healthbeliefs.

Based on the comprehensive psycho-social assessments, treatment plans aredeveloped that address the clients’ biologi-cal, psychological, and social functioning,including family functioning. When theCenter identifies a problem it is notequipped to handle, referral is made to acommunity resource. For example, peoplewith both substance abuse and mentalhealth problems are referred to a programthat offers an integrated model of care fordually diagnosed individuals. Althoughthe Center has no licensed substanceabuse treatment program, it often contin-ues to support patients with such prob-lems by including them in recovery andsupport groups.

The Center provides mental healthservices on-site, in a senior center, andthrough home visits. On-site servicesinclude day treatment, which providesa 5-hour-per-day program in a therapeuticenvironment offering psychotherapy and

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other services. The clinic program offerssingle appointments for psychotherapysessions. It was added so pscyhotherapycould be offered to clients for whom theday program is not appropriate, or whoare not comfortable with such anapproach.

Services provided by the multiethnicare available in English, Spanish, Man-darin, Cantonese, Portuguese, and Slovak.Innovative multicultural service deliverymethods are encouraged—for example,bilingual and trilingual groups. The weeklycommunity meeting of all clients and staffin the adult day treatment program is con-ducted in three languages. On a rotatingbasis, each language is the primary lan-guage and the meeting is translated for theother two. The result has increased patientparticipation in the meetings.

The program’s senior center servicesare provided by a single on-site staff mem-ber who conducts assessments, providescounseling, and offers community educa-tion. These services are in such demandthat, if funding were available, a full-timeperson could be fully occupied. The cur-rent staff person has a master’s degree inpsychiatric rehabilitation and prior expe-rience and training in geriatrics. She isbilingual and bicultural. The senior centerprogram is called the Grand Coalition ofSeniors at Grand Street. There are severalsuch demonstration projects—at leastone in each of the five boroughs ofNew York City.

The senior center’s approach to careis ecological, emphasizing the older adult’scapacity to function within his or herown social system. Efforts are directedto improving not only the individual’swell-being, but also functioning withinthe family, the community, and healthsystems.

Monitoring and ReassessmentWhen patients have been treated success-fully in this program, the next step may beto rely on the support of other communityprograms, including senior centers. TheCenter maintains good relations with seniorprograms. Therefore, after a brief periodof formal follow-up, informal contact orre-referral is simple. However, medical ill-ness or nursing home placement ultimatelypreclude their continuance in the Center.

LinkagesThe Center works closely with communityagencies and is a participating member oflocal provider and consumer advocacygroups, including the Inter-Agency Councilof the New York City Department of Agingand the Manhattan Geriatrics Committee.It also is closely linked with acute carehospitals and community aging and socialservices agencies. Most of these relationshipsare documented in writing and strengthenedthrough staff collaboration. These relation-ships foster referrals into the program andout to other community services and alsosupplement program resources.

Program AssessmentThe program is licensed, certified, andmonitored by the State. It is also reviewedby the New York City Department ofMental Health.

Patient satisfaction survey data revealthat patients overwhelmingly (85 percentof respondents) state that the Center’s treat-ment has helped them. In particular, patientsclearly specify (75 percent) that “the psy-chotherapy services offered by the programare helpful to them.” The Center also trackschanges in health habits, and it is reviewinghow it might measure outcomes. Recently,the Center has begun administering the Brief

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Symptom Inventory, using it at pretreatmentand every 6 months for follow-up.3

Resources and FundingSources of support are numerous. Theyinclude Medicare and Medicaid; a commu-nity support systems grant that covers someof the costs of the clinic and day treatmentprograms; funding from Gouverneur; fund-ing from the New York City Departmentof Mental Health; demonstration grants;and private pay (funding from non-publicsources such as third party insurance andappropriate co-pays and co-insurance).Remaining funding is provided by NewYork’s Health and Hospitals Corporation,the second largest public health care systemin the world.

In addition, support for the Elder Out-reach program comes from State reinvest-ment funds—money saved by the Statewhen its large inpatient psychiatric facilitieswere closed and their patients were chan-neled to the local level. Medicaid coverspart of the cost of services and also paysfor some transportation costs. Gouverneursupports some of the transportation costs—vehicles and drivers—needed by patientswho travel from well beyond the normalcatchment area boundaries.

The Center partners with HunterCollege to train social work students ingeriatrics through funding from the Hart-ford Foundation, with a strong emphasison including minority clinicians. Thispartnership further expands the program’sresources.


Getting Started in New YorkThe senior center project began afterthe citywide geriatrics committee of theNew York City Federation for MentalHealth, Mental Retardation, and Alco-holism Services identified the need tomake mental health services available innatural settings, such as senior centers.The City’s Departments of Mental Health,Mental Retardation, and Alcoholism Ser-vices worked together, with help from theNew York University School of SocialWork and others, to assess the feasibilityof providing these services on-site. Nowthat the center is in place, it is considereda very successful demonstration of thevalue of providing these services in sucha setting. The services are providedthrough existing resources.

The Federal Community MentalHealth Centers Act of 1965 prompteddevelopment of many outpatient centersacross the Nation. This program grewout of that movement and was establishedin 1974. It was not licensed at first; itbegan as a socialization program with apsychiatric component, using borrowedsocial work staff. Eventually, it wasenhanced and licensed as a day treatmentprogram, and then it added a clinic pro-gram. Although the Federal mandaterequired a geriatric service component,such services are not found in abundancein New York or elsewhere. This programis located on the Lower East Side ofManhattan. There is a second geriatricmental health program on the UpperWest Side, and a third in Harlem.

Getting Started inOther CommunitiesThis practice demonstrates that commu-nity aging services can collaborate withbehavioral health services and psychiatric

3 This tool is available in English and Spanish.It was developed by Leonard R. Dergatis, Ph.D.,in 1975; it has been published and distributedby National Computer Systems since 1993.

hospitals to reach out to isolated eldersto meet their mental health needs, bothin the natural setting of a person’s homeand in senior centers.

These services can be offered in aculturally appropriate manner. The keysare the use of natural settings and a trueunderstanding of a culture, well beyondcommunicating in the same language.Though the need for a common languagebetween patient and clinician is clear ina therapeutic environment, identifyingand recruiting professionals with thoselanguages can be a challenge. In themeantime, accommodations such as theuse of interpreters can fill the gap.

Developing the clinical team as amulticultural organization in which allstaff strive to be knowledgeable of othercultures and to support them enhancesand supports clinicians who treat patientsfrom diverse cultural backgrounds.

Staffing requirements may vary fromState to State; generally States regulatestaffing of mental health programs ifthird-party billing is involved. In general,however, it is essential to have at leastone half-time psychiatrist, professionalsocial workers, and a psychiatric rehabili-tation counselor or Ph.D. psychologist.Transportation is essential. Nurses andactivity aides enrich the program as well.

Materials and articles developed andused by Gouverneur staff are available toaid other programs, including a descriptivebrochure, the family evaluation (includinga Genogram), the cultural assessment(brief and extended), the substance abuseevaluation (brief and extended), and thetreatment plan review. The substanceabuse evaluation includes questions aboutsubstance consumption and is validatedfor use with the elderly.

Keys to SuccessThe Gouverneur program has identified thefollowing as keys to the program’s success:

• true cultural competence and multi-cultural organizational development

• consumer empowerment

• community education and outreach

• use of natural settings

Cultural competence is a primary dis-tinguishing feature of this program, whichuses a staff with a wide array of culturesand languages to serve patients. Keys tocompetence are the cultural evaluation thatis part of intake, the use of multiculturalgroups, and the use of a rotating primarylanguage for day treatment communitymeetings. The rotating language practicehas resulted in greater equality among thelanguage groups, with no one languagebeing perceived as dominant. It has alsocreated a deeper understanding of eachculture, beyond mere linguistics.

Consumer empowerment is fosteredthrough the active participation of clientsas members of the patient satisfaction com-mittee.

ReferencesSullivan, M.A. The homeless older woman

in context: alienation, cutoff and recon-nection. Journal of Women and Aging3(2), 1991.

Sullivan, Martha Adams. Look back andwonder: developing family-oriented men-tal health programs for the elderly. AFTANewsletter (American Family TherapyAcademy) 70 (Winter 1997–1998): 23–28.

Wong, G. The cross cultural group: a multi-lingual, multicultural group. Pride Insti-tute Journal of Long Term Human HealthCare 12(1), 1993.

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Contact:Jeff SmithOlder Adult Outreach and Education

ServiceChelsea Community Hospital955 West Eisenhower Circle, Suite HAnn Arbor, MI 48103Phone: 734/665-5070Fax: 734/665-6487email: [email protected]

Sponsoring OrganizationChelsea Community Hospital operates asubstance abuse outpatient treatment pro-gram, the Older Adult Recovery Center,and an outreach program, the Older AdultOutreach and Education Service. Thisservice, in place since 1995, is conductedin close collaboration with the Universityof Michigan Turner Geriatric Clinic andwith Neighborhood Senior Services, a non-profit social services agency dedicated tooutreach and support for seniors living inthe community.

DemographicsAnn Arbor, a city of about 110,000, is rela-tively prosperous and has a growing popu-lation of older adults. It has been voted oneof the top five retirement communities in

the United States in two national surveys.It is home to the University of Michiganand the high-tech and cultural center ofSoutheastern Michigan.

RecognitionThe Older Adult Outreach and EducationService received a local collaborationaward in 1998. It has been featured instories by the Associated Press, the DetroitFree Press, the Ann Arbor News, ABC’sPrime Time Live, the 700 Club, and localnews programs. Stories have also beencarried on local affiliates of Fox and NBC.The service was also featured in a syndi-cated news story shown on more than300 stations nationally in June 2000.

About thePromising PracticeThrough various linkages, the OlderAdult Outreach and Education Serviceprovides inpatient and outpatient sub-stance abuse and mental health treatment,counseling, and aggressive outreach. Itscollaborating agencies are its sponsor,Chelsea Community Hospital, with itstreatment facility, the Older Adult Recov-ery Center; the University of Michigan


Older Adult Outreach and Education Service, Ann Arbor, MI

Substance abuse treatment center collaborates with ageriatric clinic and a neighborhood services agency

to provide outreach and comprehensive connected services.

~

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Turner Geriatric Clinic; and Neighbor-hood Senior Services. The program hassuccessfully integrated services providedby the collaborating agencies, deliveringnon-overlapping resource assistance toolder individuals. The agencies are ableto refer clients seamlessly and with aminimum of red tape.

How It WorksThis hospital-based substance abuse treat-ment program trains its partners and pro-viders of services for the aging to recognizepotential substance abuse and mentalhealth issues among the older adults theyserve. Outreach services are provided forindividuals unable or unwilling to accepta referral to substance abuse or mentalhealth services.

The geriatric clinic, the neighborhoodservices agency, and other aging servicescall on the Older Adult Outreach andEducation Service to meet in the homesof older people who may need substanceabuse services. Numerous visits often arerequired before an individual is ready toaccept substance abuse treatment. TheOutreach and Education Service alsocollaborates closely with its partners toensure that other needs of elders theyserve are addressed.

Once individuals are in contact withany of the collaborating organizations,they have ready access to all servicesoffered by the collaborators, includinginpatient or outpatient treatment for sub-stance abuse and mental health concerns,geriatric medical care, and services ofthe University of Michigan health system.Individuals also have access to the neigh-borhood services agency and its socialworkers, who link elders to appropriateresources for any needs they identify.

These needs range from home safetyassessments and installation of safetyequipment or assistive technology tohelp in securing entitlements.

Clinical supervision for the collabo-ration is provided through Chelsea Com-munity Hospital’s Older Adult RecoveryCenter. All persons involved in the collab-oration have been trained in matters ofcultural competence. Where appropriate,referrals are made to specialized therapists,resources, and other organizations forfurther support and assistance.

Outreach and RecruitmentThe Older Adult Recovery Center sponsors“The OARC Players,” a group of elderswho earlier received substance abuse treat-ment and today perform vignettes aboutsenior chemical dependency for profession-als and peers. They offer monthly perform-ances providing education to senior cen-ters, nursing homes, social and religiousgroups, and professional conferences. Theskits demonstrate techniques for talkingwith older adults about substance abuseand sometimes include volunteers’personal stories.

With this collaboration in place, thegeriatric clinic and neighborhood serviceagency make the most referrals to theOlder Adult Recovery Center. In addition,referrals come from the following sources(in order of frequency):

• family members (usually a daughteror daughter-in-law)

• physicians, home care aides, or otherhealth care workers

• the legal system

• other social service agencies

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Reaching physicians is an ongoingchallenge. The Outreach and EducationProgram was unable to attract many physi-cians to a training session that offered con-tinuing education credits. The programnow focuses on educating physicians andtheir staffs in the medical offices. When aphysician refers a patient for substanceabuse evaluation of treatment, programstaff visit the doctor’s office and updatehim or her on the patient’s progress.

ServicesIn addition to outreach, Chelsea Commu-nity Hospital offers inpatient, outpatient,day treatment, family therapy, and grouppsycho-educational services. The treatmentprogram is a full-spectrum, intensive chem-ical dependency treatment program, offeredsince 1986. Older adults in recovery whohave completed the treatment program arean integral part of treatment services. Theyparticipate as peers in therapy groups andaid in outreach calls. These elders mayuse other resources in the community forongoing support.

The Turner Geriatric Center has pro-vided comprehensive geriatric care, healthpromotion, learning programs, and commu-nity resource information for more than 20years. Turner also runs support groups forseniors on a variety of issues and concerns,writing groups, computer literacy classes,and continuing education presentations.

Neighborhood Senior Services startedas a grassroots organization serving asingle neighborhood in Ann Arbor andhas grown to serve the senior populationof the entire county with a broad array ofservices, including home-chore assistance,transportation, volunteer services, andresource advocacy (case managementand entitlement assistance).

LinkagesAs noted, the partners of Chelsea Commu-nity Hospital, the sponsoring group, arethe Turner Geriatric Clinic and Neighbor-hood Senior Services. These three partnersdo not operate in a vacuum. Local mentalhealth resources, transportation, foodbanks, Meals-on-Wheels, apartment com-plexes, Section 8 housing providers, theFamily Independence Agency (a socialwelfare agency), and other nongovern-mental social services providers, alongwith legal resources and charitable organ-izations, are all involved at various levelswith clients, especially through the out-reach component.

Recently the director of the OlderAdult Recovery Center testified on issuesof older adults and substance abuse in ahearing held by the area agency on aging.As a result, he was to begin training theagency’s case managers on the identifi-cation of problems in older adults andeffective techniques for motivating themto seek treatment. Part of this effortinvolves teaching them to integrate ques-tions from the Michigan Alcohol Screen-ing Test–Geriatric Version (MAST-G) intotheir interviews. He hopes to strengthenhis ties to both the area agency on agingand the adult protective services agency.Both Turner and Neighborhood SeniorServices receive funding from the areaagency on aging, and that linkage hasserved to connect the substance abuseand aging fields.

Program AssessmentOutcomes measured are primarily service-related. The Older Adult Outreach andEducation Service measures its success inthe productive connections made between

older people and the services they need.Numbers of older people receiving needednew services indicate success. Results aredocumented in quarterly reports, includ-ing demographic data on race, ethnicity,gender, age, income, disability status,and locale. The State agency providesevaluation and monitoring and preparessemiannual reports. The communityhospital is licensed and certified by theState and accredited by the Joint Com-mission on the Accreditation of Health-care Organizations.

Resources and FundingThe outreach effort is funded by the Statewith block grant funds received from theSubstance Abuse and Mental Health Ser-vices Administration (SAMHSA). Treat-ment services are paid for by Medicare,Medicaid, private insurance, and someState funding. The SAMHSA grant isexclusively used for outreach, predicatedon the assumption that the Older AdultRecovery Center could provide treatment.

It should be noted that Turner hasa resource not found in every clinic—amaster’s level social worker trained inpre-treatment counseling. Pre-treatmentcounseling involves working with individ-uals to explore their motivation for seek-ing treatment and encouraging them toproceed, and providing harm-reductioncounseling for individuals who are not yetready to seek further treatment. Becausereferral to a medical clinic carries lessstigma than referral to a mental healthcenter, this is often the crucial contact inpreparing the individual for the “real”referral.

The program can provide additionalinformation about its resources and funding.

Getting Started in Ann ArborThe community hospital initiated this col-laborative outreach and education effortbecause, as its founder put it, “You can’tdo anything in substance abuse for olderadults without an outreach component.”Staff at both the geriatric clinic and theneighborhood services agency were awareof the problem but did not know what todo. The neighborhood services agency, forexample, would repeatedly be called todeal with cleaning up an apartment—butnot to address the underlying problem ofsubstance abuse.

The Older Adult Outreach and Edu-cation Service has a half-time staff personwith substance abuse experience whooffers training and education.

The program has evolved, based ondevelopments in the field of older adulttreatment and client response and reaction.Today, it educates older adults on risks ofmedication and alcohol-related problemsand focuses on helping those with problemdrinking or other substance use to reducetheir consumption to a “safe” or appro-priate level. An abstinence model (thatencourages total abstinence) is used forpeople who are dependent on alcohol andother mood-altering substances.

A key factor in the program’s success isstaff persistence. Many staff members werefrustrated initially because they expected astandard intervention built around immedi-ate confrontation with an individual to besufficient. It was not. Instead, experiencehas shown a consistent presence is neces-sary. It may take 6 months to a year to finda “teachable moment” when the individualis amenable to treatment or when the fam-ily is ready to encourage the elder to seektreatment. This often involves a crisis or anaccident, when the family is called in andforced to confront the problem.

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Getting Started inOther CommunitiesIt is possible to replicate this effort withstrong partners and start-up funding tosupport the costs of outreach workers’time and training. As noted, there isexpansion planned—principals hope toexpand geographically to a second geri-atric clinic and two senior housing units.A research component will be part of thenew project, comparing effectiveness ofreferrals to direct service delivery.

Limited materials are available fromthe program.

Keys to SuccessOutreach is the key to serving older adults.It is essential to reach those individuals inthe aging community who are resistant torecognizing the problem. Other keys tosuccess are the linkages to the other criticalpartners and the availability of outstandingresources in the community.

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Adair Elder Care, Adair County, KY

Community mental health center, in a joint venture witha fiscal court and an area agency on aging, operates anadult day health program addressing substance abuse

and mental health needs of elders.

~ContactDr. Lynda WilkersonAdair Elder Care127 N. Reed St.Columbia, KY 42728Phone: 270/384-5351Fax: 270/384-6971

Sponsoring OrganizationAdanta, the regional mental health author-ity, operates the community mental healthcenter that established this adult dayhealth program. The authority serves thesame 10-county area as the local areaagency on aging.

DemographicsAdair County, Kentucky, which is served bythis program, has a population of 16,447,of whom 2,573 are 65 and older. Educa-tional attainment is low; the poverty rate ishigh. At one time, families were primarilyengaged in subsistence farming. The gar-ment industry was a major employer for afew decades. Its demise left behind manyelders with limited resources. A compound-ing factor is that many middle-aged womenwho had been caring for their elderly rela-tives moved away when they lost their jobsin the garment trade.

RecognitionThe Center was recognized as the 1994Center of the Year by the Kentucky AdultDay Services Association. It has beenfeatured twice in the elders section of thelocal newspaper, and its many specialevents have received press coverage.The program enjoys broad communitysupport and has earned the loyalty ofcounty political leaders.

About thePromising PracticeThe Adair Elder Care program is a jointventure of the Adair fiscal court, the finan-cial arm of the county government; thecommunity mental health center; and thearea agency on aging. It is the only adultday health center in the State operated bya mental health agency. The Center servesolder adults with substance abuse andmental health needs, providing counselingand support groups, and ensuring thatappointments are kept.

The mission of this “medical model”adult day program is to provide cost-effective adult care and a variety of sup-port services that improve the quality oflife for older and dependent adults whochoose to remain in the community.

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Sixty percent of the clients served havesubstance abuse or mental health issues,30 percent are physically frail, and 10 per-cent have developmental disabilities. Manyof the clients with chronic mental illnesscoped successfully with their problems foryears but now face new issues that theycannot manage alone. Others, includingthose with alcohol and substance abuseproblems, may have hidden their condi-tions for years only to have them exposedwith the death of a spouse or anotherchange in living conditions.

How It Works

Outreach and RecruitmentIn this small community, most residentsare known, and referrals often come fromneighbors.

Assessment and Service PlanAn interdisciplinary team conducts theassessment and develops the plan. Includedare a nurse, a social worker, a recreationtherapist, certified nursing assistants,master’s level students, and a psychiatrist,if necessary. In addition, the client or aclient’s representative participates fully inthe development and implementation ofthe individualized plan of care.

ServicesAdair provides services 6 days a week,6 hours a day in a facility that can acceptup to 45 participants. The services includeassistance with daily activities, nursing

services, stimulating and therapeutic activi-ties, personal care, advocacy services, andmeals (breakfast, lunch, and snack).

Both individual and group counselingare offered at the center. Direct referralscan be made to the hospital. Linkageagreements exist with the local hospitals,self-help groups, nursing homes, rehabili-tation programs, and physicians.

Services are available for caregivers aswell. If staff are aware of a potential prob-lem, they will conduct an assessment andreferral to service. If necessary, they mayaccompany the caregiver and supportefforts to resolve the problem—for exam-ple, arranging for respite care. There arealso caregiver support groups.

Clients served in the program are frailelderly or individuals with developmentaldisabilities. Preference is given to thosewith mental health or substance abuseproblems. An individual’s potential to ben-efit from the program also is considered.Many of those referred do not meet all ofthe criteria, and efforts are made to linkthem with other appropriate services.

Monitoring and ReassessmentQuality of life issues are assessed at intake,at 6 months, and at the end of one year.Outcomes considered include changes innutritional status for those with alcoholissues and decreased hospitalizations. Theprogram has demonstrated a decrease inhospitalization among its participants.

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LinkagesBeyond the linkages that created the Cen-ter, active collaboration has been devel-oped with the State housing authority,including a volunteer program that pro-vides home repairs for elders. The healthdepartment sends staff for screenings aswell as seminars. The Center and the healthdepartment recently collaborated on agrant proposal for breast cancer screeningsfor middle-aged and older women.

There is also a Triad program in whichAdair staff work with seniors, State police,sheriffs’ association, and local police coun-cil to address crimes against the elderlyand to make seniors more aware of poten-tial threats.

Linkages also exist with the area agencyon aging. For example, the area agencycovers the cost of care for many clients andthe director serves on the Triad board.

Alcoholics Anonymous meets nextdoor, and Al-Anon meets in the center oneevening a week. There is ongoing collabo-ration with the senior center. Informallinkages take place through the involve-ment of the director in the community.The director serves on many boards inthe community and otherwise activelycultivates partnerships.

This community offers a full continuumof care, and this center is an important partof the network.

Program AssessmentThe director is a surveyor for Adult DayServices for CARF, the national Rehabilita-tion Accreditation Commission, and ispreparing this program for the accreditationprocess in 2002. Satisfaction surveys aredistributed to caregivers, participants, andthird-party payers. Responses are then usedin the quality assurance process.

Resources and FundingStaff include a geropsychiatrist, availablewhen needed and on-site 4 hours a month,as well as two RNs, both psychiatric nurseswith backgrounds in geriatrics. In addition,there are contracts with five universities forplacements for social workers, nurses, andhuman services professionals. Each semesterthere is at least one master’s-level studentand two at the bachelor’s level. Althoughone university is close by, two of the five are100 miles away.

As noted, the Center itself was theproduct of collaboration. The fiscal courtprovided the funding to save the site; itholds the deed, and it is paid $1 each yearfor rent. Additional funding comes fromthe county and the city, donations fromcommunity groups, and revenue-generatingactivities.

The program fee is kept at $20 for aless than 6-hour day so that no one needbe turned away. Scholarships, sponsor-ships, and grants also are available. Somepatients receive reimbursement througha Medicaid waiver, though it covers only80 percent of the cost and the State isconsidering a substantial reduction in therate. There is no Medicare reimbursementand no private insurance.


Getting Started in ColumbiaThis center started 9 years ago when theAdair Fiscal Court and Adanta joinedtogether to reclaim the old county healthdepartment building and to make it into“the place” for older adults in the area.Their goal was to create a resource tomeet a wide range of needs for olderadults, including those with alcohol andsubstance abuse problems. A separateboard was established to oversee the

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Center; it includes representatives of thehospital, clergy, mayor’s office, caregivers,consumers, and elders. In the first 3 yearsof the program the board served as advis-ers and designed the services that would beoffered, including caregiver support.

Getting Started inOther CommunitiesThe program already has been replicatedin an additional site and is currently beingreplicated in three others, all in Kentucky.A limited number of materials, includinga training manual, are available from thecenter.

The staffing ratio at Adair is an unusu-ally high 1:2. A minimal ratio for replica-tion is 1:5, a rate that is still higher than inmany adult day centers. Essential staffingconsiderations include background, train-ing, and experience in both geriatrics andmental health or substance abuse.

Keys to SuccessPublic support, active efforts to keep theprogram in the public eye, and commit-ment on the part of local elected officialshave been essential to program success.One county commissioner, in particular,has been very supportive of the program.To that end, center staff have participatedin community activities designed to buildsupport, such as health fairs, caregiversupport groups, and community forums.

Staff have extensive training and anexcellent retention rate.

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S e c t i o n 5Service Improvement Through

Coali t ions and Teams~

IntroductionMany service providers have increased theircapacity to help older adults by buildingcoalitions and teams to coordinate andimprove services. Today, many area agencieson aging and senior centers include educa-tion, prevention of medication and alcohol-related problems, and mental health serv-ices. They develop working relationshipswith local specialists to help train staff,educate older people, and refer individualsin need of treatment and special services.

Aging services leaders, along withmental health and substance abuse serviceproviders, may conclude that the servicesavailable in the community are inadequateto address the full range of needs amongolder adults in the area. The services maynot be available or affordable to those inneed. Throughout the country, the agingnetwork is working with the substanceabuse and mental health communities tomeet this challenge by creating coalitionsto define the needs of older adults andexpand the existing base of services.

Promising Practices inService ImprovementThrough Coalitionsand TeamsSeveral of the promising practices reviewedin this section created coalitions or teamsin response to an identified weakness inthe service arena. State and local coalitionsaddressing mental health, substance abuse,and aging are now being developed in manyStates and localities across the country.They involve joint task forces or work-groups with clear accomplishments at theState level; most of them have also identi-fied local, county, or regional activities aspart of the overall effort.

These practices are models of collabo-ration. They focus on public education,cross-training, case coordination, and sys-tems planning. They can be implementedunder a variety of auspices, most readilythrough local government, or in a voluntarycollaborative atmosphere when the commu-nity has a history of such an approach.

One of the practices links mental health,aging, and substance networks throughcross-training. This practice has managedto operate in a complex environment—a tri-State area with varying laws, authori-ties, and funding streams.

A common element in the practicesprofiled here is the placement of the olderadult at the center of the delivery system.Rather than focusing on specific servicesor agencies, they focus on the client—and systems are designed to respond tothe client’s needs.

Implications for theAging NetworkCoalitions, at both the State and locallevels, offer an ideal opportunity for theaging network to fulfill its advocacy roleas envisioned in the Older Americans Actand in the evolution of the network.The most significant implication for theaging network is that local, service-centered coalitions create an opportunityto enhance service capacity dramatically.

ResourcesMany of these programs, as noted in theirprofiles, are prepared to make materialsavailable to guide the development ofsimilar programs elsewhere. For example,the curriculum design used by the Ohio-Indiana-Kentucky Coalition for cross-training is a good resource for similaractivities. The extensive materials of theWrap-Around Program Team (Concord,NH)—including the report card—areavailable through that program and soonwill be available online.

SAMHSA’s Center for Mental HealthServices has worked closely with theAARP Foundation to support the devel-opment of State and local coalitions onmental health and aging. Materials devel-oped by the AARP Foundation on buildingaging, mental health, substance abuse, andprimary care coalitions are available fromthe American Psychological Association,Office on Aging (202/336-6046).78

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Alcohol and Drug Services—Prevention for the Elderly,Fairfax County, VA

County government supports a comprehensive array ofalcohol and drug prevention services through

interagency collaboration.

~Contact:Margaret KollayAlcohol and Drug Services—Prevention

for the Elderly ProgramCounty of Fairfax3900 Jermantown Rd., Suite 200Fairfax, VA 22030-4013Phone: 703/934-8772Fax: 703/934-8742web site: www.co.fairfax.va.us/service/

csb/ads/adsmain.htm

Sponsoring OrganizationThe Prevention for the Elderly program issponsored by the Fairfax-Falls Church, VA,Community Services Board/Alcohol andDrug Services. The Fairfax-Falls ChurchCommunity Services Board is part of theFairfax County Human Services system.

DemographicsFairfax County frequently is cited as havingthe highest per capita income in the nation.With a population of nearly one million, itis the largest and wealthiest jurisdiction inthe Washington, DC, area. Its population isrelatively young—fewer than 9 percent ofthe people are over 65—and increasinglydiverse: 13 percent Asian, 9 percent His-panic, 8 percent African American. Educa-tion levels are high; 56 percent hold college

degrees. Yet significant numbers of citizensneed housing, financial assistance, healthcare, and human services. Historically, thecounty government has been very respon-sive to these needs, and it offers a richarray of services.

RecognitionThe program has received awards, certifi-cates of appreciation, and letters of com-mendation from the regional Council ofGovernments (1993), the Fairfax CountyCommission on Aging (1995), the UnitedWay (1996), and the program’s sponsoringagency (1997).

About thePromising PracticeIn a rapidly growing region dominatedby relatively affluent younger persons, itcan be difficult to muster the resourcesto combat substance abuse and mentalhealth problems in the aging. The Alcoholand Drug Services’ Prevention for theElderly program utilizes a tightly inte-grated program of interagency coopera-tion and collaboration to raise publicawareness, educate professionals, andconduct prevention and outreachprograms throughout the country.

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How It WorksThe Alcohol and Drug Services’ Preventionfor the Elderly program intentionally buildsinteragency collaboration through a rangeof activities in the following areas:

• Community Networking—facilitatingidentification of older adults whoshould be encouraged to acceptsubstance abuse and mental healthtreatment

• Case Consultations—offered by phone,on staffing teams, and in person

• Prevention and Outreach—usinghome visits and phone calls to reacholder adults who are thought to becandidates for screening

• Education and Training—including asix session Wellness Discussion Seriesfor Seniors and training for humanservice professionals to raise awarenessof substance abuse and mental healthissues and provide information aboutcommunity resources

The Prevention for the Elderlyprogram’s community networking, caseconsultation, and prevention and outreachactivities are managed through weeklygeriatric team meetings and monthly inter-disciplinary team meetings that addressa broad range of needs and services,including alcohol and drug abuse.

The program’s primary activities focuson prevention, extending the team’s mes-sages regarding alcohol and medicationmisuse and abuse through:

• booths/exhibits at senior fairs andthe county fair

• distribution of public informationmaterials

• sponsorship of a substance abuseawareness campaign involving as manyas 15 to 20 workshops a month

• promotion of Older Americans Monthin May to build public awareness

Alcohol and Drug Services recentlyworked with the area agency on aging toincrease awareness through a cover storyon substance abuse in the area agency’spublication that has a circulation of 40,000.The program also mailed information to250 physicians, alerting them to the typesof lab results that might require furtherinvestigation and suggesting ways toapproach older adults about potentialalcohol and medication misuse and abuse.This was modeled after a similar programin Oregon.

Alcohol and Drug Services also takespart in a Triad group, a regional organiza-tion including the sheriff, chiefs of police,and representatives of all the towns andcities as well as the county itself. The groupmeets to address crime issues. It is particu-larly relevant because older adults whoabuse alcohol or drugs are more susceptibleto harm or exploitation.

Since 1991, the program has sponsoreda series of wellness discussions in seniorcenters throughout the county. These ses-sions have become a major element in rais-ing awareness. Sessions are offered once amonth, with about six centers covered in acalendar year. In this way, each center iscovered roughly every 2 to 3 years. Alcoholand medications are addressed in all of thesessions. Topics include “Wise Use of Med-ications,” “How to Talk to Your Doctor,”“Habits Over a Lifetime,” “Stress andRetirement,” and “Emotions and Whatto Do with Them.” The series includes aworkshop that addresses alcohol moredirectly, usually titled “When One Drink

Is Too Many.” This discussion coverssuch topics as “How to Talk with andHelp Someone with a Problem” and“How Alcohol Affects Others.”

Training about older adults and sub-stance abuse is offered at least every otheryear to the staff of other county agencies,including the area agency on aging; theHealth Department; the Department ofFamily Services; Adult Protective Services;and the staff of Geriatric Mental Health,the senior centers, and the Housing Depart-ment. Offering the training on a regularbasis helps expose new staff to the issues.

The program director cites a need foradditional mental health outreach and low-cost treatment options. This view is rein-forced, perhaps, by the finding in the mostrecent county needs assessment: 63,000residents (19 percent of the population)responded that a family member has asubstance abuse or mental health problem.

ServicesClients are brought into care through thefollowing process:

• A call is made to the county Informa-tion Line (the starting point for allcounty residents regardless of age andtype of need), where it is screened.

• If the caller is an older adult, he or sheis referred to the area agency on aging,the Recreation Department, or thegeriatric team.

• A nurse conducts an outreach visit.

• The nurse brings the case to a teammeeting.

• If substance abuse seems to be anissue, staff make an outreach visit.

Access to treatment is described asdifficult because only one program in thecounty specializes in older adults. Mostprograms are geared to younger peopleand focus primarily on the abuse ofcocaine, heroin, and marijuana. Sometherapists have an interest in older adults,but programs tend to be expensive, andresidential programs require individualsto be able to care for themselves. Onlyone hospital accepts Medicare for detox-ification. If the patient is admitted foranother problem, detox might be coveredas a secondary need.

Program outreach results in screeningsand referrals, but the volume continues tobe relatively low. Clients identified throughthe home outreach program usually are inlate stages of a major problem and oftenneed to use Adult Protective Services.

Monitoring and ReassessmentIndividual care planning sessions, as well assessions focused on specific challenges pre-sented by an individual client to an agency,take place at weekly 2-hour meetings of 12to 15 professionals. This geriatric team, alsoknown as Care Network, includes nurses,social workers, and mental health profes-sionals. Monthly meetings of an interdisci-plinary team take place as well. Cases maycome to the team because of requests forservices such as chore or in-home care thatthen lead to the identification of a need forsubstance abuse or mental health services.

Confidentiality is an important concernto the program. The geriatric team protectsconfidentiality through use of a consentform that is part of Virginia’s universalassessment tool for all public programs. Theinterdisciplinary team does not use names.

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LinkagesA wide range of agency representativesparticipate in weekly geriatric team staffingas well as in monthly interdisciplinaryteams. The agencies involved include thearea agency on aging, Mental Health Ser-vices (the Community Services Board),the Department of Family Services, AdultProtective Services, the Community andRecreation Department (for senior centers),the Department of Housing and Commu-nity Development, the Health Department,and others as needed.

Program AssessmentProgram evaluations are undertakenannually. Data also are collected throughthe State’s assessment instrument, andfeedback is solicited from older peopleand their families and from the variousagencies involved.

Documented numbers of participantsand results are available for the past 2years. An evaluation is completed at theend of each wellness discussion. Feedbackalmost always says that the presentationwas on target. In fiscal year 1999, of the1,277 seniors participating in the wellnessdiscussion series, 100 percent said thatthey benefited from the series, that theylearned new concepts, and that the pre-senter was well prepared.

The senior center directors also eval-uate the sessions. It was their feedbackthat prompted the addition of two ofthe six sessions, namely those dealingwith emotions and stress. They havealso recommended a session on grief.

In fiscal year 1999, 409 serviceprovider consultations were providedthrough geriatric team staffing. Twenty-four older adults were screened for sub-stance abuse or mental health outreach;of those, 18 were referred to treatmentor other services. Six interventions werecompleted, and four individuals went onto treatment.

Transportation is a serious issue inthis large, 399-square-mile county. Thecounty’s large size and its severe trafficcongestion create time and travel difficul-ties for both older persons and countystaff. The situation is especially severe inthe case of home care workers who alsoare difficult to recruit and retain.

Resources and FundingThis initiative, begun with grant fundingin 1993–94, is based on the foundationof case management services for thoseage 60 and older who are eligible fornursing home care. It continues to operateprimarily with county funding, coupledwith some funding from the Older Amer-icans Act. Clients are encouraged to useMedicare benefits or apply for Medicaidwhen appropriate. Additional fundingcomes from the Federal Substance AbusePrevention and Treatment Block Grantto the State.

Fairfax County has one positionallocated for this program. The programwould not be as successful as it is withoutthe Care Network, which includes twonurses, a mental health specialist, foursocial workers, and a supervisor. Thosepositions are funded by the Departmentof Family Services.

The program can provide additionalinformation on resources and funding.

Getting Started in FairfaxThe position of Substance Abuse Coun-selor II, functioning as a prevention spe-cialist, was created in Fairfax County in1991. In 1989–90, the Virginia GeneralAssembly had become concerned aboutthe high rate of elderly suicides in theState and encouraged local areas to beginto examine both suicides and alcoholabuse. It encouraged the use of SubstanceAbuse Prevention and Treatment BlockGrant funds for addiction preventionprograms; Alcohol and Drug Servicescontinues to operate with these blockgrant funds. The trainer program andmaterials were developed throughVirginia Commonwealth University.

Alcohol and Drug Services’ Preventionfor the Elderly program began in Fairfaxin 1993 with a 5-year grant from the State.Three demonstration sites existed in theState: a rural area, a city, and this countywith its mix of urban, suburban, and ruralareas. The key question was, what is thebest way to serve constituents?

Getting Started inOther CommunitiesPortions of the program are easy andinexpensive to replicate. One example is thewellness discussions—especially if presentersare prepared through a “train the trainer”approach (preparation of a cadre of trainerswho are prepared to a standard curriculumin a consistent format to train a significantnumber of students). Establishing geriatricteams is more difficult, since agencies mustbe willing to commit staff for significantamounts of time.

Primary materials are available fromother sources, in particular those producedby Virginia Commonwealth Universityand the Hazelden Foundation. The Vir-ginia Universal Assessment form is usedfor referrals, screening, and tracking.

Keys to SuccessKeys include a responsive local govern-ment and agencies that are both commit-ted and open to collaboration. Thegeriatric team demonstrates culturalcompetence by communicating fully inSpanish as well as English and also workswith other cultures—collaborating, forexample, with the Korean CommunityCenter and with the Center for Multi-Cultural Services, a nonprofit organiza-tion through which interpreters for anylanguage can be contracted.

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Elders Wrap-Around Team, Concord, NH

Wrap-around team from more than 12 agencies ensures thatno elders in need fall through the cracks.

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Contact:Jeanne DufordElders Community CoordinatorRiverbend Community Mental HealthP.O. Box 2032Concord, NH 03302-2032Phone: 603/228-2101Fax: 603/228-2100email: [email protected] site: www.riverbendcmhc.org

Sponsoring OrganizationRiverbend Community Mental HealthCenter is the parent organization forRiverbend Elder Services, which is thelead agency for the Elders Wrap-AroundTeam. Riverbend Community MentalHealth Center is over 25 years old, witha staff of 270. It served more than 6,000people in 1999 with outpatient and emer-gency services, crisis stabilization, chil-dren’s services, and three satellites.

Riverbend Elder Services has been inplace since 1993. With a staff of 11, itserves more than 430 people, offeringpsychosocial and psychiatric assessmentand evaluation; counseling for groups,individuals, couples, and families; med-ication assessment and monitoring; case

management; education and workshops;information and referral to communityresources; community outreach; and con-sumer advocacy. This program has a clearcommitment to developing and buildingcollaborative relationships.

DemographicsThe target population is adults age 60 andolder. Concord is an urban area with anelderly population of 12 percent. The areais doing well economically and continuesto develop services creatively.

RecognitionIn spring 2000, the Riverbend Elder Ser-vices program received an award fromthe National Council for CommunityBehavioral Health Care for Special Pro-grams–Older Adults for its leadership increating the Elders Wrap-Around Team.In addition, the parent organization, theRiverbend Community Mental HealthCenter, received the Behavioral HealthcareLeadership Award from Eli Lilly and Co.and the Year 2000 Effective, EfficientProvider Organization award from theNational Council for Community Behav-ioral Health, also in spring 2000.

About thePromising PracticeBecause of the complex needs of olderadults, many Riverbend clients are involvedwith more than one community agency.This can cause confusion and duplicationof services. It also can lead to the danger-ous assumption that another organizationis taking care of a particular problem.

The Elders Wrap-Around Team pro-vides coordination of services to ensurethat no elder slips through the cracks.

How It WorksThe Elders Wrap-Around Team includesrepresentatives of 12 core agencies whomeet for two hours each month to reviewspecific cases and discuss communityissues. Professionals from another 40 agen-cies are invited to join the group, whenappropriate. Consumers and families alsoare invited to participate. Other activitiesinclude family education and support, andcommunity educational programs for eld-ers and staff of service organizations.

The wrap-around intervention iscommunity-based, cuts through traditionalagency boundaries, and is centered on thestrengths, needs, and desires of the olderperson and family. It supports independ-ence as long as possible and includes thedelivery of individualized services in threeor more domains of an elder’s life. It is nota service but a process that provides careand safety by “wrapping services around”the individual.

Referrals to the team may be anony-mous or may take the form of the moretraditional client referral. An anonymousreferral often stimulates a brainstormingsession that looks at direction rather than

solution. Because names are not used,confidentiality remains intact. The secondtype requires both a client informationform and a consent form. The consentform indicates the agencies and personsinvolved in the case. The client and familyare made aware that confidentiality ismaintained by all involved. The decisionabout how to provide treatment is madeby the team as a whole, giving priority tothe most prominent need.

ServicesTeam services include education, training,screening, and treatment.

• Education is provided through work-shops, presentations, and educationalopportunities targeted to a wide audi-ence, including consumers, families,caregivers, students, and professionals.

• Training is offered to nursing staff,students, and other professionals inthe community. It encompasses thephysical, emotional, and social aspectsof elder care.

• Screening is offered throughoutMerrimack County and includesdepression screening, memory lossclinics, social anxiety screening, andsubstance abuse screening. Referralcomes from physicians, hospitals,police, retirement communities, families,and any of the agencies involved inthe wrap-around process. If screeningindicates further evaluation is war-ranted, a letter is sent, with the indi-vidual’s permission, to the primarycare physician.

• Treatment can be agency-specific ora collaborative effort of the Wrap-Around Team. The team, family,and client work together to developa treatment plan.

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Because of the stigma associated withmental illness, elders often are reluctant toseek treatment. The wrap-around processhelps minimize stigma, because the EldersWrap-Around Team (rather than the Com-munity Mental Health Center) is identifiedas the entity with whom the client will beworking.

Monitoring/ReassessmentSubstance abuse and mental health statusare assessed, whenever indicated. Raisingawareness of these issues among all ofthe agencies and their staffs is an ongoingactivity.

Program AssessmentEarly data show that hospital admissionsdeclined, as did length of stay. Total refer-rals to other community services increasedsignificantly. An increase in team membersfrom 12 to more than 50 appears to be agood indication of the commitment to theprocess by community agencies.

The program recently completed itsfirst year and a half and has servedapproximately 18 consumers. Staff reportthat the informal brainstorming andanonymous referrals have been significant.The program has been tested with severalprovider groups with positive results.

LinkagesThe program involves 52 agencies, includ-ing the Department of Elderly and AdultServices; providers of health care, humanservices, housing, and transportation;police; the public guardian; a long-term carecoordinator; senior centers; church groups;elders; families; visiting nurses; and legaland financial providers. Additional agenciesare involved on a client-specific basis.

The linkages among community agen-cies and the collaborative nature of theWrap-Around Team effort have allowed forgreater access to services for elders and theirfamilies. Many times, families have faceddifficult decisions and have been unsurewhere to turn for assistance. This processhelps to eliminate confusion and feelings ofhelplessness involved in finding out whichservices may be available to them. Addition-ally, the wrap-around process seeks out thegaps in the system and tries to eliminatethem by finding alternative and creativemeans of solving problems.

Resources and FundingOne staff position for development andcoordination of the program has beenfunded by the State. Adequate staff timefor meetings and collaborations is required.Additional costs are minimal.

The Wrap-Around Team does not billdirectly. Providers bill independently forthose elements of the program that arereimbursable under Medicaid andMedicare. Informal supports and gapsin eligible services are provided throughin-kind contributions, resource sharing,flexible funding, and small grants.

Getting Started in ConcordThe project, developed as an expansionof existing efforts, was built on establishedcollaborative efforts with other area pro-viders and also on a similar wrap-aroundapproach to serve children. Providingwrap-around services for older adultsproved to be more complex, because:

• Parents, teachers, and counselorsare available to assist in dealingwith children

• Children seldom have major medicalcomplications

• Older adults generally have morecomplex transportation andequipment needs

In the initial stage, team organizerswere met with skepticism. There were turfissues and political agendas as well. Somepeople were concerned that RiverbendElder Services would “own” this process.It took a lot of networking, knocking ondoors, telephone conversations, and mail-ings to reach an understanding that River-bend did not intend to control cases orreferrals. In time, the entire team took onownership of the process with the commit-ment of its members.

Initially, follow-through seemed to bea problem. Therefore, an early modifica-tion was the use of an agenda format thatincorporates assignments, identificationof the responsible party, and a follow-upreview date. This was reinforced with theintroduction of the Wrap-Around ReportCard, which tracks the process.

Getting Started inOther CommunitiesThis process can be replicated. Consulta-tion and materials have already beenprovided to interested cities and townsthroughout New Hampshire. Staff advisesthe designation of a person (at least halftime) dedicated to the design and develop-ment, especially in the beginning stageswhere networking is a critical component.It will be important to protect that time.

Documentation is made available tothe New Hampshire Department of Healthand Human Services and also to othersinterested in developing a similar program.Extensive materials are available, includingthe Wrap-Around Report Card, and therehave been requests to replicate the materi-als. These materials will soon be accessibleon-line and available to all.

Keys to SuccessThe key is the willingness of all agenciesand representatives to abide by the tworules:

• Always act in the best interest of theclient

• Leave turf issues behind

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Contact:Jessie ThomasProgram SpecialistHamilton County Community

Mental Health Board801-A W. 8th St.Suite 500Cincinnati, OH 45203Phone: 513/621-3045Fax: 513/632-7160email: [email protected]

Barbara GunnExecutive DirectorSenior Services of Northern Kentucky1032 Madison Ave.Covington, KY 41011Phone: 606/491-0522Fax: 606/491-4590email: [email protected]

Marietta Cappelletti, Project DirectorElderReach5837 Hamilton Ave.Cincinnati, OH 45224Phone: 513/541-7577Fax: 513/541-5895email: [email protected] site: www.elderreach.org

Sponsoring OrganizationThe two primary partner organizations forthe Mental Health and Aging Coalition arethe Hamilton County (OH) CommunityMental Health Board and the Council onAging of Southwestern Ohio.

DemographicsThe region covered by the program includesmultiple counties in Ohio, Kentucky, andIndiana. The total population served is esti-mated at 1.7 million, 24 percent of whomare over age 50. The region’s population is87 percent Caucasian, 11 percent AfricanAmerican, and 2 percent “other.”

RecognitionNationally, a poster presentation of theCoalition’s ElderReach project was pre-sented by Ann Perrin of the Health Foun-dation of Greater Cincinnati at the annualconference of the Grantmakers in Healthin spring 2000. Another presentation, byMarietta Cappelletti, Director of Elder-Reach, was made in October 2000 at theGrantmakers of the Aging Society’s annualconference. ElderReach was recognizedlocally by the Tri-Health Senior Link quar-terly as a new and coming practice. It also


Mental Health and Aging Coalition, Indiana, Kentucky, Ohio

Regional mental health and aging coalition offers cross-training inthe fields of aging, mental health, and substance abuse.

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was recognized by a local suburban com-munity, the Village of Woodlawn, for workwith the village police department.

About thePromising PracticeThe mission of this regional coalition is topromote education, advocacy, and access tobehavioral health services, including bothsubstance abuse and mental health services.It also provides support services for olderadults, their families, and caregivers toenhance their quality of life. Its 42 memberorganizations represent the aging network,substance abuse and mental health boards,advocacy organizations, hospitals, andother providers.

The Coalition focused its first effortson planning and cross-training, whichwere found to be an important means ofintroducing professionals from variousservices to one another. With a grant fromthe Health Foundation of Greater Cincin-nati, Coalition members have developedthe ElderReach project, an initiative thatcross-trains professionals in all three net-works in the subjects of normal aging aswell as mental health and substance abuseproblems in older adults. The goal is toprovide training about older adults’ needsto professionals in mental health, aging,and substance abuse so they can secureappropriate help for their clients. It alsoprovides a more effective way to addressthe needs of older adults by enhancing serv-ices, promoting appropriate use of thoseservices, and creating easy access througha perceived “single system” of care. TheElderReach project is a collaborationbetween the Mental Health and AgingCoalition and Gateway Behavioral HealthNetwork, a consortium of substance abuseand chemical dependency organizations.

How It WorksThe Coalition’s member organizations meetmonthly in a forum, enabling members toreach a large number of service providers.Through the work of three committees—on education, advocacy, and systems net-work—the coalition is forging ways foraging, mental health, and substance abusenetworks to link together in a tri-Statearea.

Although many substance abuse andmental health providers are available inthis geographic area, the Coalition isworking through the ElderReach projectto encourage these providers to addressthe needs of older adults. The Coalition’sElderReach project makes four kinds ofpresentations for four different audiences:

• cross-training for professionals

• public education for staffs of otherorganizations or groups that might bein contact with individuals in need—for example, public service staff

• presentations to elected officials tosecure ongoing support

• presentations to other networks—such as the Inclusion Network,which represents those who servethe elderly disabled population—to advocate integrating the networks

ServicesEnhanced age-appropriate services andincreased use of services are expected toresult from the efforts of the ElderReachproject as case managers become morefamiliar with resources and more comfort-able with referrals. At the same time,behavioral health care providers increas-ingly are responsive to older adults.

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Monitoring and ReassessmentThe Coalition’s focus is on education,advocacy and systems networking/linkages.The Coalition does not directly assessclient clinical status or monitor individualclient progress.

Program AssessmentThe ElderReach project uses formative andsummative evaluation processes to developclear objectives and measurable outcomes.For example, one of the five objectives isto facilitate change within the infrastruc-tures of the organizations that participatein the Mental Health and Aging Coalition.The outcome is that 20 agencies will haveimplemented at least three change processesrecommended by the Mental Health andAging Coalition.

The ElderReach project continues tocollect data on the training needs of pro-fessionals and in-home workers who carefor older adults. In consultation with theScripps Gerontology Center, ElderReachis evaluating the effectiveness of the cross-training provided to the professionals inthe three fields. Results of the evaluationare expected in 2001.

Preliminary indicators are promising.For example, staff of the area agency onaging, formerly frustrated by encounterswith clients with mental health needs, nowreport being better prepared to identifyproblems, approach clients, and makeappropriate referrals. Another exampleis the creation of a resource manual formembers. This was done by adding mentalhealth resources to an existing manualproduced by the Cincinnati Area SeniorServices. The manual is now circulatedto those in the mental health field as well.

LinkagesForty-two organizations from three Statesare involved in the coalition and the Elder-Reach project and take an active part in itsefforts. They represent mental health boards;alcohol and drug addiction services boards;area agencies on aging; and providers ofaging, mental health, and substance abuseservices. The ElderReach project is directedby four partners: the Hamilton CountyCommunity Mental Health Board, theCouncil on Aging of Southwestern Ohio,the Gateway Behavioral Health Network,and core behavioral health centers, whichserve as the fiduciary agent.

Interagency planning is under way toimprove coordination and collaborationbetween behavioral health and aging serv-ices providers. Currently, principals are try-ing to secure funds to link the agencies ina more formal arrangement, hoping eventu-ally to use the project as a focal pointor clearinghouse for all related referrals.

Resources and FundingAll organizations participating in theCoalition contribute staff time and effort.Initial funding for the ElderReach projectcame from the Health Foundation ofGreater Cincinnati to support curriculumdevelopment and evaluation of cross-training on mental health, aging, and substance abuse topics.


Getting Started in CincinnatiImpetus for the formation of the Coalitionand the subsequent development of theElderReach project was the inability of casemanagers (Mental Health Board) and caremanagers (Council on Aging) to communi-cate about clients they had in common.

The care managers in the aging networkwere finding clients with mental illness andsubstance abuse issues but did not knowhow to go about seeking solutions. Simi-larly, the mental health staff members werenot confident in their ability to serve olderadults. Representatives of these two organi-zations began collaborating. Their timelyparticipation in a State-sponsored trainingseminar on coalition building helped informing their own coalition. They invitedall of the participants in that seminar tojoin them as they developed a mission state-ment and goals and began to work in com-mittees: education, advocacy, and systemsnetwork development.

The systems network committee beganby surveying the aging services case man-agers on their knowledge of mental healthneeds and services for the elderly andclearly identified the need for informationand training in this area. Further, the Coali-tion identified the need for increased inte-gration of mental health and aging services.All of these needs could be addressed bybringing the staffs of the two networkstogether to begin a dialogue and take partin cross-training. The principals then soughtfunding to support such an endeavor. Whenpresenting the concept to a local founda-tion, they were encouraged to broadentheir collaboration to include the substanceabuse network. The partnership was thenextended to a fourth organization that ful-fills the fiduciary role for the ElderReachgrant project. Further, the geographic scopeof the project was extended to the border-ing States of Kentucky and Indiana.

Training sessions are now underwayand have received a high level of interestand enthusiastic feedback from participat-ing staff members who relish the opportu-nity to learn new information and to forgerelationships with the professionals in theother two fields.

Expanded efforts involve training thepolice and fire department representativeswho investigate potential problems iden-tified by the “Are You OK? Program,”a telephone check-in program for eldersliving alone.

Getting Started inOther CommunitiesThe formation of a mental health andaging coalition can occur in any commu-nity that has an interest in collaboration.The ElderReach project, in particular,could be replicated with sufficient interestand commitment. At a minimum, it wouldrequire a small amount of start-up fundingor in-kind support to cover costs of suchnecessities as supplies, mailings, meetingplaces, and gratuities for trainers.

Materials available to other groupsinterested in developing a coalition includea brochure, descriptive articles, a quarterlynewsletter, and a curriculum design for thecross training.

Keys to SuccessCultural competency is required in servingthe predominantly Caucasian, AfricanAmerican, and Appalachian clients. Inaddition, service providers recognize theincreasing numbers of immigrants ofAfrican, Asian, Russian, and Hispanicorigin. They are challenged with addressingthe specific cultural needs of these individu-als, as well as new language barriers. Staffcapacity in other languages is not readilyavailable, but translation is provided forseveral languages through the assistanceof the Jewish Community Center andTravelers’ Aid.

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In developing “Promoting Older AdultHealth,” The Substance Abuse and MentalHealth Services Administration, theNational Council on the Aging, and theiradvisers searched for promising practicesthat best reflected success in building thecapacity of the aging services network tomeet the substance abuse and mentalhealth needs of older people. Many strongnominations were received. Not all couldbe selected to be profiled in this guide aspromising practices. This section presentssynopses of programs that were nominatedfor inclusion in the guide but not selectedfor profile development. These programsoffer additional resources for those inter-ested in developing community and Stateprograms.

These program synopses have beenorganized in the same four categories usedto organize the four sections of the guide:

• Education and Prevention

• Outreach

• Screening, Referral, Intervention,and Treatment

• Service Improvement ThroughCoalitions and Teams

Education and Prevention

Depression Educationand Screening Materials

The Blues: Not a Normal Part of AgingNational Mental Health AssociationContact Person: Shela Halper1021 Prince St.Alexandria, VA 22314-2971Phone: 703/838-7533Fax: 703/684-5968email: [email protected]

The Blues: Not a Normal Part of Aging is anational community education and screen-ing program on clinical depression. It wasdeveloped through a partnership betweenthe National Mental Health Association’sCampaign on Clinical Depression and theAmerican Society on Aging (ASA). The pro-gram aims to raise awareness about clinicaldepression and treatment options amongolder adults and their family members andto facilitate free depression education andscreening sessions for older adults. The pro-gram tool kit contains detailed instructionsas well as a 20-minute video and infor-mation on organizing a confidential depres-sion screening. It includes a sample geriatricdepression screening form and other

A p p e n d i x 1N o m i n a t i o n s o f A d d i t i o n a l

P r o m i s i n g P r a c t i c e s

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materials for duplication and distribution.The program is a resource for ASA mem-bers, mental health associations, and otherlocal health organizations to use in theirown communities.

Medication ManagementEducation

Maui Center for Health Care EducationContact Person: Cindy Krenk53 Pulinene Ave., #120Kahului, HI 96732Phone: 808/877-2109Fax: 808/877-2430email: [email protected]

Since 1996 the Maui Center for HealthCare Education has provided health careeducation programs to seniors, primarilythrough medication review programsusing one-on-one consultations betweenpharmacists and patients. The reviewcovers prescription medications, over-the-counter medications, and herbal prod-ucts; health status; and lifestyle and habits.It offers education and information, indi-vidualized counseling, and follow-up andreferral. The program has reduced mis-management of prescription and over-the-counter medications by older adults aswell as unnecessary hospitalizations andnursing home admissions. Communityagencies, service programs, senior housingdevelopments, and local health care pro-fessionals participate.

Older Adults Reaching Out

Positive Aging TheaterContact Person: Vacant200 Fordham Ave.Madison, WI 53704Phone: 608/246-7606, ext 157

The Positive Aging Theater is an energeticgroup of older adults who voluntarily

create an annual entertainment revueperformed throughout Dane County, WI.The show changes each year, reflecting theunique talents of that year’s players anddirectors, but the themes continue fromyear to year: live life to the fullest; dispelstereotypical myths about aging; supportand enhance community and individualspirit and well-being; prevent alcohol anddrug abuse; and promote good practicesof medication management. Performancestake place at senior centers, adult day carecenters, coalitions for the elderly, AARPgroups, and low-income housing units.Creative forms of presentation, low-budgetprogramming with extensive volunteerinvolvement, and universally positive audi-ence response are promising aspects ofthe program. Audience members reportthe performances give them a feeling ofempowerment.

Prevention Servicesin Senior Centers

Indianapolis Senior Citizens’ Center, Inc.Contact Person: Rochelle Cohen708 E. Michigan St.Indianapolis, IN 46202Phone: 317/263-6272Fax: 317/655-0035email: [email protected]

The Indianapolis Senior Center, one of theoldest in the country, was opened in 1961.It provides prevention, social, and healthservices and activities designed by and forolder individuals to help prevent prematuredependence. Ten years ago it developed aprogram to provide mental health andaddiction treatment and prevention. A full-time master’s-level social worker providestreatment and prevention services at thecenter. She also trains seniors to be peercounselors so they can reach those whocannot get to the center. Both individual

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and group therapy services are offered. Thistreatment can focus on bereavement, addic-tion problems, and depression, and can alsohelp with family and marital problems.

Substance Abuse Preventionand Treatment

Project A.L.E.R.T. Adult Well-BeingServicesContact Person: Central Access Person1423 Field Ave.Detroit, MI 48214Phone: 313/833-3765Fax: 313/833-3783

Adult Well-Being Services is a private,not-for-profit organization that offers avariety of services and programs to reduceor eliminate problems that interfere withoptimal functioning of older adults. Thesubstance abuse program provides servicesranging from prevention to treatment.Other programs offer education, treatment,information and referral, nutrition andhealth education, and case management ina supportive manner. They are specificallypaced to meet the needs of older adults andfocus on specific psychological, social, andhealth problems of the elderly. Services areprovided in an age-appropriate manner insettings that are not threatening to olderadults or difficult for them to reach. AdultWell-Being Services is dedicated to promot-ing optimal independence and social well-being of adults who are at risk because ofage, income, mental or physical health,developmental disability, education, copingability, or environment.

Substance Abuse ServicesThrough Multiservice Agency

Alcohol and Drug Action ProgramJewish Family Service of Los AngelesContact Person: Jasmina Moore8846 Pico Blvd.Los Angeles, CA 90035Phone: 310/247-1180Fax: 310/858-8582email: [email protected]

The Alcohol and Drug Action Program ofJewish Family Services is a comprehensiveprogram designed to address substanceabuse issues, especially within the Jewishcommunity. Services include preventionand general substance abuse education,counseling, information, and referral;social/spiritual events; L’Chaim 12-stepmeetings (open to anyone in any 12-stepprogram); training; and technical assis-tance. The Alcohol and Drug Action Pro-gram provides training to other programsthat work with older adults. It is designedto educate staff about substance abuse ingeneral and issues specific to older adults,including medication and alcohol-relatedproblems. Social workers are availablefor consultation on specific cases. JewishFamily Services operates numerous otherprograms, including meals and adult dayservices, and provides training to othersenior organizations.

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Outreach

Mental Health Services forNursing Home Residents

Indiana PASRR ProgramBureau of Aging In-Home ServicesContact Person: Pat Cassanova, R.N.402 West Washington St., W353Indianapolis, IN 46204-2739Phone: 317/232-1731Fax: 317/232-7867

Indiana has taken the federally mandatedPASRR (Preadmission Screening and Resi-dent Review) program one step further.PASRR is a Medicaid program that isintended to ensure that people who havea serious mental illness are not “ware-housed” in Medicaid nursing facilities.The PASRR program assesses the serviceneeds of nursing facility applicants and resi-dents and considers appropriate alternativesto nursing home care. Indiana PASRR notonly identifies mentally ill nursing homeapplicants and residents and determinesappropriate placement, it also identifiestheir needs for services, recommends appro-priate service providers, and follows up toensure that appropriate services are pro-vided. This information becomes a part ofthe resident’s nursing facility file and thefacility is held responsible for providing orarranging the necessary services. The Statehas developed three separate systems toensure that services are provided. The Men-tal Health Agency, the Office on Aging, theHealth Department, the Medicaid office,the Medicaid intermediary, a CommunityMental Health Center, and the areaagency on aging are involved.

Mental Health Services inSeniors’ Homes

Geriatric Outreach and CounselingContact Person: Ruth AdelmanTrinitas Hospital (previously

Elizabeth Geriatric Medical Center)655 E. Jersey St.Elizabeth, NJ 07206Phone: 908/994-7313 Fax: 908/994-7342

This program brings mental health servicesto seniors who are unable to go to the hos-pital’s geriatric outpatient clinic. Fundedby a grant from the Union County, NJ,Department of Human Services, the pro-gram arranges up to eight home visits forpatients, with the ultimate goal of linkingthem to appropriate community services.Staff include an advanced practice nurseand a clinical specialist in geropsychiatry.They can conduct assessments, diagnoseproblems, provide therapy, and prescribeand monitor medications. The programmaintains linkages with the visiting nurseservices, hospital inpatient and outpatientprograms, Alcoholics Anonymous, andadult day care. It also has developed rela-tionships with social workers and man-agers in three senior citizen apartmentcomplexes and one local church.

Substance Abuse ServicesOutreach

Rushford Center Senior Outreach ProgramContact Person: Edwina Ranganathan1250 Silver St.Middletown, CT 06457Phone: 860/346-0300Fax: 860/346-6417

Rushford Center’s outreach program targetsseniors with substance abuse problems.Staff meet with seniors in their homes andin community settings and have links to

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the major psychiatric outpatient programsat hospitals in the region. The program hasa strong prevention component, aimed atraising health care workers’ awareness ofthe unique problems of this population.Presentations are made to social workers,housing managers of senior residences,home health organizations, and visitingnurse associations. Through extensivenetworking, the center builds awareness,maintains links, and enables mutual refer-rals, providing convenient service locationsfor residents and resources that might nototherwise be available.

Screening, Referral,Intervention, and Treatment

Addictions Treatment in HolisticLife Enrichment Program

Lifestyle Enrichment for Senior AdultsContact Person: Betty MacGregor420 Cooper St.Ottawa, Ontario L2P 2N6 CanadaPhone: 613/233-5430Fax: 613/233-2062email: [email protected]

The Lifestyle Enrichment for Senior Adultsprogram is an addictions treatment pro-gram specifically designed to help seniorswith problems related to use of alcoholor other psychoactive medication or gam-bling. The program is holistic and client-centered. Alcohol and medication use areviewed within the context of the person’slife. Interventions are guided by clients’ pri-orities that may or may not be related totheir alcohol or other psychoactive druguse. The program has used a harm reduc-tion approach since its inception in 1979.Abstinence, while often recommended,is not a criterion for admission to theprogram. Client success is defined in termsof reduced intake and improved quality of

life. Often, the client will focus on otherareas of concern such as nutrition or socialisolation before gaining confidence toreduce or stop using alcohol or psychoactivemedications. Not dealing directly with alco-hol or drug use minimizes clients’ resistanceto change. Evaluation of the program indi-cates that this approach is very successfulwith seniors. Counseling and support areprovided in individual and group settings.In-home visits are available, as is a Helpline for the region and gambling telephonecounseling for the province. Services areoffered in English and French.

Community-Based SubstanceAbuse Prevention and Treatment

Community Mental Health SubstanceAbuse ServicesContact Person: Richard Petty, C.S.W.,

A.C.S.W.812 E. Jolly Rd., G14Lansing, MI 48910Phone: 517/346-8268Fax: 517/346-8290

This program of treatment and preventionof substance abuse among older adults, inplace since 1983, has developed a systemof mutual referral and support with otherservice providers to older adults. Theagency supports a monthly meeting withmembers of the aging network to exchangeinformation and make appropriate referrals.Staff regularly inform clients of availableservices such as Meals-on-Wheels, seniortransportation, senior companions, profes-sional mental health programs, and com-munity support groups. Staff also offerin-service presentations to mental healthcounselors at hospitals and counselingcenters on substance abuse issues andeffective treatment with older adults, andprovide similar instruction to students atcommunity colleges and Michigan State

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University. Outreach involves screening andtreating individuals for substance abuseand mental health problems in their homes,homeless shelters, day-care centers, hospi-tals, psychiatric units, and in the office.

Comprehensive Screening

Aging and Disability Research Centerof Marathon CountyContact Person: Deb Menacher1000 Lakeview Dr.Wausau, WI 54403Phone: 715/261-6070Fax: 715/201-6090email: [email protected]

The Aging and Disability Resource Centerof Marathon County provides informationand assistance and serves as the gatewayto the county’s long-term care resources.It provides a comprehensive assessmentfor individuals with complex or multipleneeds, including help for mental healthand substance abuse problems. Fundedservices are available at little or no costfor individuals who need them. Eachperson works with a Resource Centerprofessional to clarify the individual’scircumstances, identify potential services,and formulate an action plan. If theperson needs additional assistance, theResource Center will provide advocacyin securing services and coordinatingresources. The Department of SocialServices, private social service agencies,home health care agencies, a hospital,and a medical provider are available asneeded.

In-Home Mental Health Services

San Fernando Valley CommunityMental Health CenterContact Person: Ian Hunter, Ph.D.14535 Sherman CircleVan Nuys, CA 91405Phone: 818/901-4830Fax: 818/785-3446email: [email protected]

The San Fernando Valley CommunityMental Health Center’s HomeboundProgram has been providing mentalhealth services to older adults in the SanFernando Valley since 1979. Services areprovided in the client’s home or at theclinic, depending on the client’s needs.In-home services include therapy, support-ive counseling, crisis intervention, casemanagement, assessment, and resourceidentification and linkage. All clients havea serious mental illness. Many have sub-stance abuse issues as well. Interventionsinclude cognitive behavioral therapy, stressmanagement, life review, and ongoingmonitoring of the safety of the home envi-ronment and of the client’s functioning.The program works closely with homehealth agencies and confers with medicalproviders when indicated. Dually diag-nosed clients who are mobile enough toattend are referred to 12-step groups atthe center’s club house program or in thecommunity. Other treatment referralsinclude one residential and two partialhospitalization programs, all servingseniors with substance abuse and mentalhealth needs. Medication evaluation andmonitoring are provided at the clinic.

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Integration of Mental Healthand Substance Abuse Serviceswith Primary Care

Bucksport Regional Health CenterContact Person: John CorriganP.O. Box 447Bucksport, ME 04416Phone: 207/469-7371Fax: 207/469-7306

Aging in Place is a program of primary carewith integrated mental health and substanceabuse services. Care is delivered to olderadults at home in this very rural area by ageriatric nurse practitioner. The program’sgoal is to delay or prevent institutionaliza-tion. Creative approaches have been used tomaximize the flexibility of service delivery,to hire qualified clinicians, and to make useof all possible resources. The program hassucceeded in filling gaps in service availabil-ity and in providing a high volume of serv-ices to an otherwise underserved populationat comparatively moderate cost.

Mental Health Services atSenior Activity Center

Swanson CenterContact Person: Larry Miller450 St. John Rd., Suite 501Michigan City, IN 46360Phone: 219/879-4621Fax: 219/873-2388

Swanson Center is a local communitymental health center that has operated anactivity center for older adults in La Porte,IN, since 1976. More than 500 memberstake part in its programs each year. It hasdeveloped an advisory board to strengthenthe planning process and sharpen thesenior center focus, which has includedexamining ways to expand mental healthservices and intergenerational services tofamilies. The Swanson Center is also

charged with screening persons enteringnursing facilities, and it provides mentalhealth and substance abuse services. Ser-vices include intensive case management,partial hospitalization, residential care,and outpatient counseling. The activitycenter is also involved in many activitieswithin the community and offers healtheducation programs, socialization activi-ties, and information and referral services.

Mental Health Services atSeniors Sites and In-Home

New York Service Program for OlderPeople - Senior Outreach ProgramContact Person: Arleen Stern1888 W. 88th St.New York, NY 10024Phone: 212/787-7120, ext. 133Fax: 212/580-0533

The first program of its kind in New YorkCity, the Senior Outreach Program of theNew York Service Program for Older Peo-ple (SPOP) is a cost-effective, innovativeway to provide much-needed mental healthservices to older adults. SPOP started theprogram in five senior organizations inJune 1997 and now provides services at11 places frequented by seniors—seniorcenters, naturally occurring retirementcommunities, and other sites. The pro-gram’s social worker spends one day aweek at each of the participating sites,providing individual and group counselingand making home visits to seniors wholive near the sites but are homebound. Byproviding this service on-site, the SeniorOutreach Program establishes a “transferof trust” from the senior center or organi-zation to the mental health professionalthat facilitates the acceptance of mentalhealth services by this population. Thistransfer of trust is accomplished by pro-viding comprehensive information to site

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staff and by the regular presence of thesocial worker, creating a positive per-ception of the program among clients.

Mental Health Servicesfor Asian Americans

Chinatown Health ClinicContact Person: Henry Chung, MD125 Walker St.New York, NY 10013Phone: 212/226-8866Fax: 212/226-2289

The Asian American Primary Care andMental Health “Bridge Program” of theChinatown Health Clinic in New Yorkhas three goals: to provide mental healthservices in a primary care setting, toimprove the skills of primary care pro-viders in the identification and treatmentof mental disorders, and to provide com-munity health education on mental healthissues. The program was designed to breakdown the barriers to delivering mentalhealth care to the Asian American com-munity. This is important because AsianAmericans, in comparison with otherethnic groups, underutilize mental healthservices and have the greatest delay inreceiving needed care, resulting in poortreatment outcomes. Reluctance to seekcare is attributed to cultural stigma aswell as the dearth of bilingual and bicul-tural treatment. Because this populationuses primary care physicians for all care,the focus was to increase access at thatpoint while upgrading the mental healthskills of those providers.

Mental Health Services In-Homeand at Senior Centers

Geriatric Counseling ProgramIntercommunity Action (INTERAC)Contact Person: Cynthia Wishovsky6012 Ridge Ave.Philadelphia, PA 19128-1697Phone: 215/487-1750Fax: 215/487-3716email: [email protected]

The Geriatric Counseling Service at Inter-community Action in Philadelphia providesa variety of mental health services to olderadults in community settings. The goal is toensure access and minimize stigma. It aimsto provide a spectrum of mental health ser-vices to the elderly in the community in asupportive and nonthreatening manner andto bridge the gaps between the systems serv-ing elders. Because older adults have notused the traditional community mentalhealth system, this program uses alternatesettings to provide mental health assess-ments; individual and family therapy; refer-ral for medical treatment; supportive grouptherapy; and screening, educational, andpreventive mental health programs. Servicesare most often offered at consumers’ homesor at senior community centers. Services atthe centers include support groups and anannual depression screening, as preventivemeasures. The program also has a clinicianpresent in the senior center on a regularbasis.

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Treatment for Alcoholism,Drug Addiction, Related Diseases

Hanley-Hazelden Center at St. Mary’sContact Person: Carol Colleran, C.A.P.,

I.D.A.D.C.5200 East Ave.West Palm Beach, FL 33407-2374Phone: 561/841-1131Fax: 561/841-1151email: [email protected]

Hanley-Hazelden Center at St. Mary’s, partof the internationally recognized HazeldenFoundation that pioneered the model ofcare for alcoholism, drug addiction, andrelated diseases, is the leader that estab-lished the treatment model specificallydesigned for older adults. This model is amultidisciplinary residential treatment pro-gram that provides quality rehabilitation,education, and professional services in asetting that meets the needs of an olderpopulation. The specialized services includeextended detoxification and medical stabi-lization, slower transition between levels ofcare, and increased individual staff contact.Hanley-Hazelden also provides extendedcare, family programs, and education andprevention programs.

Veterans AdministrationSubstance Abuse Services

GET SMART/UPBEAT (GeriatricEvaluation Team: Substance Misuse/AbuseRecognition and Treatment (GET SMART)and Unified Psychogeriatric Biopsychoso-cial Evaluation and Treatment (UPBEAT))Contact Person: Catherine Royer, L.C.S.W.West Los Angeles Veterans Administration

Healthcare Center11301 Wilshire Blvd.Los Angeles, CA 90073

This program serves veterans age 60 andolder with problems of substance abuse,

depression, or anxiety. Because many arescreened and referred from non-psychiatricsources, ongoing education of medical staffand community-based agencies is empha-sized. The program seeks to connect theveterans with treatments appropriate tothe range of their psychosocial and med-ical issues, resulting in increased quality oflife and appropriate use of services. Treat-ment modalities include pro-active andpreventive care coordination; use of sup-port groups and other group treatment;a “Health Effects of Substance Use” moti-vational group; and a cognitive-behavioralgroup. Treatment includes working closelywith Veterans Administration and com-munity resources to provide basic servicessuch as coordinated medical care, housing,transportation, Alcoholics Anonymous,and sobriety support programs.

Service ImprovementThrough Coalitionsand Teams

Statewide Training for Local GeriatricServicesContact Person: Maureen Haugh-StoverIllinois Department of Human ServicesOffice of Mental Health400 Stratton Bldg.Springfield, IL 62765Phone: 217/785-6023Fax: 217/785-3066email: [email protected]

In coordination with the State Departmentof Human Services Office of Mental Health,the State Department on Aging, and a20-member statewide Advisory Committeeon Geriatric Services, Illinois has imple-mented a training practice to enhance thecoordination, linkage, communication, anddelivery of mental health services to olderadults. A Mental Health and Aging Team

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Building and Skill Enhancement Traininginitiative targets selected areas of the Stateand brings the mental health and aging serv-ices providers together for a 6-week trainingprogram that focuses on system integrationand skill enhancement in the provision ofmental health and aging services to olderadults with mental health needs. These train-ing initiatives have been successful inenhancing skill competencies in the area ofgeriatric mental health, enhancing network-ing and coalition building, and increasingmental health services to older adults.

Linking of Aging Agenciesand Mental Health/SubstanceAbuse Networks

Wisconsin Office of Mental HealthContact Person: Cathy Swanson HayesOffice of Mental HealthDepartment of Health and Social ServicesP.O. Box 7851Madison, WI 53707-7851Phone: 608/267-7288Fax: 608/267-7793email: [email protected]

The Wisconsin Office of Mental Health hasa strong aging initiative with a statewidecoalition that uses Mental Health and Sub-stance Abuse Block Grant dollars to sup-port public awareness of mental health andsubstance abuse issues of older persons,skill development training conferences, andlocal coalition building activities. Areaagencies on aging played a major role inorganizing and hosting these conferences,and an agency director is the chair of theState coalition and has addressed the StateMental Health and Substance Abuse Coun-cils. Area agencies have hosted gatheringswith State and Federal legislators, and sup-ported local coalition building activities.Other collaborative efforts by mental healthand aging advocates resulted in State legis-

lation creating a new in-home mental healthand substance abuse service that makesassistance and treatment accessible, accept-able, and affordable for older persons. Thiseffort to tailor in-home services to the men-tal health and substance abuse needs ofolder persons began in 1986 with a localcollaborative effort of the Aging and Men-tal Health/Substance Abuse networks inDane County, supported by a Federal grant.When the grant ended, advocacy efforts ledto ongoing support with county funds. Ele-ments of this model project shape the newin-home service available to all age groups.Eleven counties have local initiatives underway, actively linking the aging and mentalhealth/substance abuse networks.

Professional Educationand Cooperation

Health Promotion InitiativeContact Persons: Gerry Mackenzie, Marilyn

EngstromNew Jersey Department of Health and

Senior ServicesP.O. Box 807Trenton, NJ 08625Phone: 609/588-3466Fax: 609/588-3601

The Health Promotion Initiative is a coop-erative project of the New Jersey Depart-ment of Health and Senior Services, theGeriatric Education Center at the Univer-sity of Medicine and Dentistry of New Jer-sey (School of Osteopathic Medicine), andcounty health and aging coalitions. Theprogram has two goals: to provide profes-sional education at the local level to healthand aging services providers, and to fostergreater working relationships among healthand aging professionals. Under the initia-tive, 2 days of professional education areprovided to 30 professionals. The partici-pants, chosen by a local planning group,

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represent both health and aging services.The local planning group selects one ofthree topics for training: mental health andaging, falls assessment and prevention, ordrug use/misuse. Following the training,the coalition implements a program initia-tive or structural/procedural change in theservice area identified. Health departments,offices on aging, crisis centers, mentalhealth providers, community-based ser-vice providers, police departments, visit-ing nurse associations, and senior centersare involved.

State Mental HealthService Models

Michigan Department ofCommunity HealthContact Person: Irene Kazieczko320 South WalnutLansing, MI 48913Phone: 517/373-2845Fax: 517/241-2969email: [email protected]

The focus of the Michigan Department ofCommunity Health has been to developservice models that serve older personswith lifelong chronic mental illness/sub-stance abuse and those with late-onsetconditions. The department launched anumber of initiatives to increase the capac-ity of the State and local service system.One was to include this group as anunderserved population in the State’s com-prehensive plan for mental health services;another was to include individuals withdementia plus depression, delusions, orbehavioral disturbance in the State’s defini-tion of serious mental illness. Block grantfunds and Alzheimer’s demonstration fund-ing were used to leverage resources fordevelopment of new collaborative servicemodels for older adults. Six suicide pre-vention programs were funded, all focused

on community education to raise aware-ness of depression symptoms and reducebarriers to treatment. Michigan has anothersix statewide best practice initiatives(including a statewide library of resources)and five local best practice models.

Statewide Task Force onSubstance Abuse Awareness

Massachusetts Geriatric Substance AbuseTask ForceContact Person: Ruth GrabelOffice of Elder HealthMassachusetts Department of Public Health250 Washington St., 4th floorBoston, MA 02108Phone: 617/624-5411Fax: 617/624-5075email: [email protected]

The Massachusetts Geriatric SubstanceAbuse Task Force was established in 1987by a small group of health professionalsconcerned about the lack of attention tosubstance abuse and the elderly. The groupoperates with support from the Departmentof Public Health’s Bureau of SubstanceAbuse Services, Bureau of Family andCommunity Health, and Office of ElderHealth. The Task Force conducts monthlymeetings with speakers in the field of sub-stance abuse and addiction among olderpeople. It offers workshops and presenta-tions at conferences and meetings, includ-ing the annual statewide conference of theCouncils on Aging. It also disseminatesinformation and materials, participates instatewide assessment and planning activi-ties, and convenes a yearly statewide Agingwith Dignity conference on elders and sub-stance abuse. The conference bringstogether representatives of the councils onaging and elder service network with healthprofessionals from health care institutionsand consumer groups.

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Administration on Agingwww.aoa.govMelanie Starns200 Independence Avenue, SWHHH Building, Room 309-FWashington, DC 20201Phone: 202/401-4547

AARPwww.aarp.orgCarol Cober601 E Street, NWWashington, DC 20049Phone: 202/434-2263

American Managed Behavioral HealthCare Associationwww.ambha.orgPamela Greenberg, Ph.D.700 13th Street, NWSuite 950Washington, DC 20005Phone: 202/434-4565

American Society on Agingwww.asaging.orgPatrick Cullinane833 Market StreetSuite 511San Francisco, CA 94103-1824Phone: 415/974-9642

Bazelon Center for Mental Health Lawwww.bazelon.orgRobert Bernstein, Ph.D.1101 15th Street, NW, Suite 1212Washington, DC 20005Phone: 202/467-5730

Gerontological Society of Americawww.geron.orgCarol Schutz1030 15th Street, NWSuite 250Washington, DC 20005-1503Phone: 202/872-1275

Constance L. Coogle, Ph.D. andNancy Osgood, Ph.D.Virginia Commonwealth UniversityP.O. Box 980229520 North 12th StreetRichmond, VA 23298Phone: 804/828-1525

Hanley-Hazeldon Center at St. Mary’swww.hazelden.orgCarol Colleran5200 East AvenuePalm Beach, FL 33407Phone: 561/841-1131

A p p e n d i x 2National Partner Organizations

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Health Promotion Institute (NCOA-HPI)www.ncoa.orgDavid Turner2001 S. State, Suite S-1500Salt Lake City, UT 84190-2300Phone: 801/468-2764

Legal Action Centerwww.lac.orgJulia Sutherland236 Massachusetts Avenue, NEWashington, DC 20002-4980Phone: 202/544-5478 ext. 11

National Alliance for the Mentally Ill(NAMI)www.nami.orgAgnes Hatfield2107 Wilson BoulevardSuite 300Arlington, VA 22201Phone: 703/524-7600

National Asian Pacific Center on Agingwww.napca.orgKen BostockMelbourn Tower1511 3rd AvenueSuite 914Seattle, WA 98101Phone: 206/624-1221

National Association of Area Agencieson Agingwww.n4a.orgJanice Jackson1112 16th Street, NW, Suite 100Washington, DC 20036Phone: 202/296-8130

Janet Flora125 Stoner AvenueWestminster, MD 21157Phone: 410/876-3363

National Association of State Alcoholand Drug Abuse Directorswww.nasadad.orgAlan Moghul, Ph.D.808 17th Street, NW, Suite 410Washington, DC 20006Phone: 202/293-0090

National Association of StateMental Health Program Directorswww.nasmhpd.orgTodd RinglesteinDivision of Behavioral Health ServicesOffice of Community Mental Health

Service105 Pleasant StreetConcord, NH 03301Phone: 603/271-5094

National Association of State Unitson Agingwww.nasua.orgSara Aravanis 1225 I Street, NW, Suite 725Washington, DC 20005Phone: 202/898-2578

National Coalition on Mental Healthand AgingSanford Finkel, MD, ChairDirector, Geriatric InstituteCouncil on Jewish Elderly3003 W. TouhyChicago, IL 60645Phone: 773/508-4745

Willard Mays, Former Chair402 West Washington StreetIndianapolis, IN 46204-2739Phone: 317/232-7894

National Council on the Aging, Inc.www.ncoa.orgAlixe McNeill409 Third Street, SW, Suite 200Washington, DC 20024Phone: 202/479-6671

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National Council for CommunityBehavioral Healthcarewww.nccbh.orgPope Simmons12300 Twinbrook ParkwaySuite 320Rockville, MD 20852Phone: 301/984-6200

National Hispanic Council on Agingwww.incacorp.com/nhcoaMarta Sotomayor 2713 Ontario Road, NW, Suite 200Washington, DC 20009Phone: 202/745-2521

National Indian Council on Agingwww.nicoa.orgDave Baldridge 1501 Montgomery Boulevard, NESuite 210Albuquerque, NM 87111Phone: 505/292-2001

Bill BensonNICA7106 Maple Avenue #2Silver Spring, MD 20912Phone: 202/225-2001

National Institute of Senior Centers(NCOA)www.ncoa.orgRonald W. Schoeffler 535 15th StreetAugusta, GA 30901Phone: 706/826-4480

National Mental Health Associationwww.nmha.orgShela Halper 1021 Prince StreetAlexandria, VA 22314-2971Phone: 703/838-7533

Substance Abuse and Mental HealthServices Administrationwww.samhsa.govJennifer Fiedelholtz 5600 Fisher LaneParklawn BuildingRoom 12C-05Rockville, MD 20857Phone: 301/443-5803

Eileen Elias5600 Fishers LaneParklawn BuildingRoom 13C-20Rockville, MD 20857Phone: 301/443-8742

Jennifer SolomonCenter for Substance Abuse Prevention5600 Fishers Lane920 Rockwall Building IIRockville, MD 20857Phone: 301/443-6924

University of MichiganAlcohol Research CenterFrederic C. Blow400 East Eisenhower Parkway, Suite AAnn Arbor, MI 48108-3318Phone: 734/930-5139

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Substance Abuse and MentalHealth Services Administrationwww.samhsa.govThe Substance Abuse and Mental HealthServices Administration (SAMHSA) worksto strengthen the Nation’s health carecapacity to provide prevention, diagnosis,and treatment services for substance abuseand mental illnesses. SAMHSA works inpartnership with States, communities, andprivate organizations to address the needsof people with substance abuse problemsand mental illnesses as well as the commu-nity risk factors that contribute to theseillnesses. Organizationally, SAMHSAserves as the umbrella for the Center forMental Health Services (CMHS), theCenter for Substance Abuse Prevention(CSAP), and the Center for SubstanceAbuse Treatment (CSAT).

SAMHSA’s web site features generalinformation on the agency’s current ini-tiatives and program areas, includingoverviews of programs and activities ineach of its three centers, as well as infor-mation to assist in locating substanceabuse or mental health treatment programs.The web site also provides access to theSAMHSA information clearinghouses—the National Mental Health Services

Knowledge Exchange Network (KEN),the National Clearinghouse for Alcoholand Drug Information/PREVLINE, andthe Treatment Improvement Exchange(TIE) Network. These clearinghouses area key source of information for a range ofaudiences, and most of SAMHSA’s publi-cations can be ordered free of charge fromthese clearinghouses. The web-based statis-tical resources of SAMHSA’s Office ofApplied Studies (OAS) can also be accessedthrough the SAMHSA web page. The OASresources include highlights from the latestOAS reports and data on specific drugs ofabuse, as well as public use data files.OAS publications can be ordered onlinefrom this web site.

Center for Mental HealthServiceswww.samhsa.gov/centers/cmhs/cmhs.htmlSAMHSA’s Center for Mental HealthServices (CMHS) works to create aneffective community-based mental healthservice infrastructure in the United States.CMHS’s foremost goals are to improvethe availability and accessibility of high-quality care for people with or at riskfor mental illnesses and their families.

A p p e n d i x 3Select Federal Agencies and National OrganizationsProviding Resources to Address Medication, Alcohol,

and Mental Health Problems Among Older Adults

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In addition to information aboutCMHS’s major programs and activities,the CMHS web site provides informationand resources on a range of mental healthtopics, including information about specialpopulations such as older adults. CMHSalso provides access to the National Men-tal Health Services Knowledge ExchangeNetwork and links to other public andprivate sources of information on mentalhealth issues.

Center for Substance AbusePreventionwww.samhsa.gov/centers/csap/csap.htmlSAMHSA’s Center for Substance AbusePrevention (CSAP) is the Nation’s focalpoint for the identification and promotionof effective strategies to prevent substanceabuse—whether illicit drug use, misuse oflegal medications, use of tobacco, or exces-sive or illegal use of alcohol. To that end,CSAP works to give all Americans thetools and knowledge they need to helpreject substance abuse by strengtheningfamilies and communities and by develop-ing knowledge of the types of preventionthat work best for different populations atrisk for substance abuse.

CSAP’s web site provides general infor-mation about the programs and activitiessponsored by CSAP as well as links toCSAP’s Model Prevention Programs website and the new CSAP Decision SupportSystem (DSS). The DSS guides States andcommunity-based organizations in identi-fying effective substance abuse preventionprograms and adapting them to the spe-cific needs of the State or community.CSAP’s web site also links to the SAMHSANational Clearinghouse for Alcohol andDrug Information, which provides a widerange of publications, videotapes, andother prevention resources to the public,most of which are available free of charge.

Center for Substance AbuseTreatmentwww.samhsa.gov/centers/csat/csat.htmlSAMHSA’s Center for Substance AbuseTreatment (CSAT) is leading the Nation’seffort to enhance the quality of substanceabuse treatment services and ensure theiravailability to people who need them. Itworks to identify, develop, and supportpolicies and programs that enhance andexpand science-based, effective treatmentservices for individuals who abuse alcoholand other drugs and that address individu-als’ addiction-related problems.

CSAT’s web site includes generalinformation about CSAT’s programs andactivities, as well as statistics, researchfindings, training resources, publications,and other web-based information on avariety of topics related to substance abusetreatment. In addition to linking withSAMHSA’s National Clearinghouse forAlcohol and Drug Information, the CSATweb site links with the Treatment Improve-ment Exchange (TIE), a CSAT-sponsoredresource to exchange information amongFederal, State, and local alcohol and sub-stance abuse agencies and others on sub-stance abuse related topics.

The National Councilon the Aging, Inc.www.ncoa.orgNCOA is the Nation’s first association ofprofessionals dedicated to promoting thedignity, self-determination, well-being, andcontributions of older persons. NCOA’smembers include senior centers, area agen-cies on aging, adult day services, faith con-gregations, senior housing, health centers,employment services, and consumer organ-izations. NCOA helps community organi-zations to enhance lives of older adults byturning creative ideas into programs andservices that help older people in hundreds

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of communities. NCOA is a national voiceand powerful advocate for public policies,societal attitudes, and business practicesthat promote vital aging.

The NCOA web site is divided into twomajor sections, the visitors’ and members’sites. The visitors’ section provides generalinformation about NCOA and its affiliates,as well as information about NCOA’s pro-grams, advocacy and public policy informa-tion relating to older adults, research find-ings, and linkages to a variety of nationalorganizations and programs addressingaging-related issues. Member Central, themembers-only section, links members to thelatest NCOA and aging networks news,alerts to new services, and discussion topicson the NCOA online forums.

Administration on Agingwww.aoa.govThe Administration on Aging (AoA) is theFederal focal point for services to olderAmericans. Under the Older AmericansAct, the AoA and its nationwide networkof State and Area Agencies on Aging,Tribal Organizations, and service providersplan, coordinate, and develop community-level systems of services that help vulner-able older persons to remain in theirhomes and communities. A range of OlderAmericans Act-supported services areoffered at the State and local levels, includ-ing nutrition, transportation, informationand assistance, the long-term care ombuds-man program, and legal services.

AoA’s web site contains informationfor older persons and their families,practitioners, the aging network, andresearchers and students, including aresource directory of organizations rele-vant to older persons and an online guidefor caregivers.

National Institute on Aging, NIHwww.nih.gov/niaThe National Institute on Aging (NIA),part of the National Institutes of Health(NIH), conducts interdisciplinary research,provides medical and scientific training,and disseminates health-related informa-tion to professionals in the field of agingprocesses and age-related diseases, includ-ing Alzheimer’s disease.

The NIA web site contains informationon recent news and events, extra- and intra-mural research programs, research grants,and resources relating to Alzheimer’s dis-ease. The site also includes links to health-related publications and resources, trainingopportunities, and the affiliated NationalAdvisory Council on Aging.

AARPwww.aarp.orgAARP is the Nation’s leading organizationfor people age 50 and older. It serves theirneeds and interests through informationand education, advocacy, and communityservices, which are provided by a networkof local chapters and experienced volun-teers throughout the country. The organi-zation also offers members a wide rangeof special benefits and services, includingModern Maturity magazine and themonthly Bulletin.

AARP’s web site features a wide rangeof resources for members as well as thegeneral public. In particular, AARP providesinformation and other resources on a vari-ety of issues relating to health and wellnessfor older adults, including stress manage-ment, grief and bereavement, proper nutri-tion, alcohol abuse, and prescription druguse. Publications and other materials areavailable for many of the topics addressedonline, and resources are provided for arange of audiences, from health profession-als to members of the public.

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A p p e n d i x 4Directory of Mental Health and Aging Coalitions

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ALABAMA Phone FAXState Contact: Roxanna Bender (205) 759-0900

[email protected] Sheila Blackshear

State Coalition Contact: Rebecca Ray Perl (256) 582-3203Local Coalition Contact: None at this time

ARIZONA Phone FAXState Contact: Karla Averill (602) 553-9010 (602) 553-9159

[email protected] Coalition Contact: Cheryl Becker (480) 994-4407 (480) 994-4744

[email protected] Coalition Contact: None at this time

ARKANSAS Phone FAXState Contact: Kaye Kundahl (501) 686-9178 (501) 686-9910

[email protected] Coalition Contact: Betty French (501) 682-8150 (501) 682-8155


CALIFORNIA Phone FAXState Contact: Jane Laciste (916) 654-3529 (916) 653-6486

[email protected] Coalition Contact: None at this timeLocal Coalition Contact: Mental Health & Aging Coalition

[email protected]

COLORADO Phone FAXState Contact: Fred Acosta (303) 866-7403 (303) 866-7428

[email protected] Coalition Contact: None at this timeLocal Coalition Contact: None at this time

CONNECTICUT Phone FAXState Contact: Jennifer Glick (860) 418-6643 (860) 418-6693


DELAWARE Phone FAXState Contact: Renata J. Henry (302) 577-4461 (302) 577-4484


FLORIDA Phone FAXState Contact: James Noble (850) 413-0930 (850) 413-6887

[email protected] Coalition Contact: Mary Brennan (888) 822-4464 (813) 974-1968


GEORGIA Phone FAXState Contact: Cherryl V. Finn (404) 657-6087 (404) 657-2160

[email protected] Coalition Contact: None at this timeLocal Coalition Contact: Ken Brandon (912) 430-3017 (912) 430-4098

ILLINOIS Phone FAXState Contact: Maureen Haugh (217) 785-6023 (217) 785-3066

[email protected] Coalition Contact: Beth Schoenholtz (847) 741-0404 (847) 741-2163Local Coalition Contact: None at this time

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INDIANA Phone FAXState Contact: Andrew P. Klatte (317) 232-7935 (317) 233-3472

[email protected] Coalition Contact: Andrew Klatte (317) 232-7935 (317) 233-3472


IOWA Phone FAXState Contact: James D. Overland (515) 281-8908


KANSAS Phone FAXState Contact: Nancy Trout (913) 782-2100 (913) 782-1186

[email protected] Coalition Contact: Nancy Trout (913) 782-2100 (913) 782-1186

[email protected] Coalition Contact: Annette Graham, LMSW (316) 383-7298 (316) 383-7757

[email protected]

KENTUCKY Phone FAXState Contact: Phyllis Parker (502) 564-4448 (502) 564-9010

[email protected] Coalition Contact: Phyllis Parker (502) 564-4448 (502) 564-9010


LOUISIANA Phone FAXState Contact: Mary Bradford (225) 342-2679 (225) 342-5066

[email protected] Coalition Contact: None at this timeLocal Coalition Contact: Karen Blake (504) 543-4036

[email protected]

MAINE Phone FAXState Contact: Theresa Turgeon (207) 287-4245 (207) 287-4268


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MARYLAND Phone FAXState Contact: Marge Mulcare (410) 767-2541 (410) 333-5402

[email protected] Coalition Contact: Linda Raines (410) 235-1178 (410) 235-1180


MASSACHUSETTS Phone FAXState Contact: Walter Polesky (617) 626-8070 (617) 626-8077


MICHIGAN Phone FAXState Contact: Irene Kazieczko (517) 373-2845 (517) 241-2969

[email protected] Coalition Contact: None at this timeLocal Coalition Contact: Ben Robinson (313) 823-7700 (313) 823-8635

MISSOURI Phone FAXState Contact: Benton Goon (573) 751-3035 (573) 751-7851

[email protected] Coalition Contact: Benton Goon (573) 751-3035 (573) 751-7815


MONTANA Phone FAXState Contact: Rusty Redfield (406) 444-4924 (406) 444-4435


NEVADA Phone FAXState Contact: Lauri Moore, MSG, LASW (702) 486-6000 (702) 486-6248


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NEW HAMPSHIRE Phone FAXState Contact: Todd Ringelstein (603) 271-5094 (603) 271-5040

[email protected] Coalition Contact: Margaret Morrill, Chair (603) 271-4683 (603) 271-4643

[email protected] Coalition Contact: Heather Hesse-Stromberg (603) 742-0630 (603) 749-9257

[email protected]

NEW JERSEY Phone FAXState Contact: Carol I. Weiss (609) 777-0821 (609) 777-0662

[email protected] Coalition Contact: Carol I. Weiss (609) 777-0821 (609) 777-0662


NEW MEXICO Phone FAXState Contact: Carol Ross (505) 827-2641 (505) 827-0097

[email protected] Coalition Contact: Carol Ross (505) 827-2641 (505) 827-0097


NORTH CAROLINA Phone FAXState Contact: Bonnie Morell (919) 571-4980 (919) 571-4984


OKLAHOMA Phone FAXState Contact: Bob Rawlings (405) 522-3848 (405) 713-2407

[email protected] Coalition Contact: Kaye Rote (405) 840-0607 (405) 840-4177Local Coalition Contact: Peter Blanchard (918) 299-1778

OREGON Phone FAXState Contact: Lynda Crandall (503) 945-5918 (503) 947-5046


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PENNSYLVANIA Phone FAXState Contact: Jane Bishop, RNC (717) 772-7452 (717) 772-7827

[email protected] Coalition Contact: Linda Shumaker, RN (717) 531-8183 (717) 531-1578

[email protected] Coalition Contact:– Central Region: Linda Shumaker, RN (717) 531-8183 (717) 531-1578

[email protected]– Northwest Region: Tom Volkert (215) 751-1800 (215) 636-6300

[email protected]– Northeast Region: Dennis Gourley (570) 823-5144 (570) 829-5054– Southeast Region: Kim Stucke (814) 878-2170 (814) 453-4757

[email protected]– Southwest Region: Mary Anne Kelly (724) 779-3200 (724) 779-2131

[email protected]

RHODE ISLAND Phone FAXState Contact: Dept. of MHRH, (401) 462-1564

Div. of Integrated MH ServicesState Coalition Contact: None at this timeLocal Coalition Contact: None at this time

SOUTH CAROLINA Phone FAXState Contact: Ed Spencer, MED, MSW (803) 898-8579 (803) 898-8347


SOUTH DAKOTA Phone FAXState Contact: Jade Weideman (605) 773-5991 (605) 773-7076

[email protected]/isState Coalition Contact: Carla Leiferman (605) 773-3656 (605) 773-6834


TENNESSEE Phone FAXState Contact: Pam Sylakowski (615) 532-6767 (615) 532-6719


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TEXAS Phone FAXState Contact: Galen Brewer (512) 206-4854 (512) 206-4784

[email protected] Coalition Contact: Galen Brewer (512) 206-4854 (512) 206-4784

[email protected] Coalition Contact: Laura Lee Harris (817) 335-5405 (817) 334-0025

[email protected]

UTAH Phone FAXState Contact: Linda Hunt (801) 538-9857 (801) 538-9892

[email protected] Coalition Contact: Linda Hunt (801) 538-9857 (801) 538-9892


VERMONT Phone FAXState Contact: John Pierce (802) 241-2609 (802) 241-3052


VIRGINIA Phone FAXState Contact: Joslynn M. Young (804) 371-0769


WASHINGTON Phone FAXState Contact: John D. Piacitelli (206) 902-8070

[email protected] Coalition Contact: None at this timeLocal Coalition Contact: Lesley Rigg (360) 676-2220 (360) 676-7750

WASHINGTON, DC Phone FAXState Contact: Joylette L. Porter, LICSW (202) 364-3422 (202) 364-4886


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WEST VIRGINIA Phone FAXState Contact: Barbara C. Edmonds (304) 558-1128 (204) 558-1008


WISCONSIN Phone FAXState Contact: Cathy Swanson-Hayes (608) 267-7288 (608) 267-7793

[email protected] Coalition Contact: Barb Mamerow (920) 469-8967Local Coalition Contact: James F. Truchan (414) 272-9278 (414) 272-7159

[email protected] Coalition Contact: Jane Alexopoulos (414) 289-6376 (414) 289-8590

[email protected]

WYOMING Phone FAXState Contact: Pablo R. Hernandez, M.D. (307) 777-7997 (307) 777-5580


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A p p e n d i x 5Short Michigan Alcoholism Screening Test—

Geriatric Version (S-MAST-G)© The Regents of the University of Michigan, 1991

~YES (1) NO (0)

1. When talking with others, do you ever underestimate how much you actually drink? ________ ________

2. After a few drinks, have you sometimes not eaten orbeen able to skip a meal because you didn’t feel hungry? ________ ________

3. Does having a few drinks help decrease yourshakiness or tremors? ________ ________

4. Does alcohol sometimes make it hard for you to remember parts of the day or night? ________ ________

5. Do you usually take a drink to relax or calm your nerves? ________ ________

6. Do you drink to take your mind off your problems? ________ ________

7. Have you ever increased your drinking after experiencing a loss in your life? ________ ________

8. Has a doctor or nurse ever said they were worried or concerned about your drinking? ________ ________

9. Have you ever made rules to manage your drinking? ________ ________

10. When you feel lonely, does having a drink help? ________ ________

TOTAL S-MAST-G SCORE (0–10) _____________________

Scoring: Two or more “yes” responses is indicative of an alcohol problem.

For information, contact Frederic C. Blow, Ph.D., University of Michigan Alcohol ResearchCenter, 400 E. Eisenhower Parkway, Suite A., Ann Arbor, MI 48104, 734-998-7952.

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A p p e n d i x 6Fax Back Form

~

To: National Council on the Aging—Mental Health Programs / Fax 202-479-0735

From:_________________________________________________________________________

Organization: __________________________________________________________________

Address: ______________________________________________________________________

Telephone:_________________________________ Fax: ______________________________

Type of organization: ___________________________________________________________

Date: _________________________________________________________________________

Reactions to Promoting Older Adult Health: Aging Network Partnerships to AddressMedication, Alcohol, and Mental Health Problems

Is this guide helpful to you?________________________________________________________

________________________________________________________________________________

Do you plan to use material in this publication? ______________________________________

________________________________________________________________________________

How do you plan to use the information in this guide? ________________________________

________________________________________________________________________________

If you have contacted programs described here, has this been helpful? ___________________

________________________________________________________________________________

Does your organization have contact with substance abuse service providers? _____________

________________________________________________________________________________

Does your organization have contact with mental health service providers? _______________

________________________________________________________________________________

What other types of information would be helpful to you and your organization? _________

______________________________________________________________________________


Promoting O

lder Adult H

ealth Aging Network Partnershipsto Address Medication, Alcohol,

and Mental Health Problems

DEPARTMENT OF HEALTH AND HUMAN SERVICESSubstance Abuse and Mental Health Services Administrationwww.samhsa.gov

DHHS Publication No. (SMA) 02-3628Substance Abuse and Mental Health Services AdministrationPrinted 2002