Supporting the Behavioral Health of Older Adults: Evaluating a Multi-Site,Multi-Actor,Multi-Agency Initiative

Abstract

Policymakers often overlook people living with physical disabilities and older adults’ behavioral health (BH) needs. Older adults experience alarmingly high rates of mental illness and substance use disorders, which often intersect with neurocognitive challenges. Emerging evidence suggests the SARS-COV-2 pandemic has exacerbated these disparities. BH needs amongst older adults and people living with physical disabilities have major implications for policy and service delivery. While a multitude of local interventions to support BH exist, few state-level programs focus on this population. In 2015, Oregon established the Behavioral Health Initiative for Older Adults and People with Physical Disabilities (referred to as the Initiative) with this specific purpose. A multi-year evaluation of this Initiative suggests several important improvements have occurred. Yet, barriers remain that hinder optimal service provision and enable siloed aging and BH services between agencies. The findings indicate ways the Initiative can leverage initial successes to further support this population.

Keywords

behavioral health aging medicaid medicare serious mental illness state policy

Introduction

Federal and state policymakers often overlook people living with physical disabilities and older adults’ behavioral health (BH) needs. In the United States (U.S.), older adults experience alarmingly high rates of mental illness and substance use disorders, which frequently intersect with neurocognitive changes (Chhatre et al., 2017; Eden et al., 2012; Lynch et al., 2021). Access to BH services is often poor. Underserved populations, including older adults from communities of color, experience severe barriers to access and use of BH services (Zhang et al., 2021). Emerging evidence suggests the SARS-COV-2 (COVID-19) pandemic has exacerbated these disparities, with as many as one-fourth of all older adults now reporting anxiety or depression (Krendl & Perry, 2021; Koma et al., 2020). Due to the COVID-19 pandemic’s disproportionate impact on older adults, there has been increased national attention on the need for significant interventions. For instance, the pandemic has highlighted the need to implement policies that address the highly uncoordinated long-term services and supports system, as well as the lack of supports available to family care partners and for people living with Alzheimer’s disease and related dementias (ADRD) (Beach et al., 2021; Brown et al., 2020; Dawson et al., 2021). Indeed, the prevalence of BH issues amongst the older adult population has serious implications for public programs that provide and pay for BH care services. While many local interventions exist to better support BH, few state-level programs have been implemented with a specific focus on the BH needs of older adults and people living with physical disabilities.

Similar to other U.S. states, Oregon is experiencing an increasingly aged population. In 2019, adults 65 and older made up 18.2% of Oregon’s population (U.S. Census Bureau, 2019). Projections indicate that the number of adults 65 and older will make up 22% of Oregon’s population by 2030 (Oregon Office of Economic Analysis, 2019). The aging population experiences a variety of BH concerns, some of which they experience at a higher rate than younger adults, such as isolation, loneliness, grief, and comorbidities such as Alzheimer’s disease and related dementias (ADRD). Older adults also experience a greater rate of substance use disorders, which can further exacerbate BH symptoms. Among adults 65 and older in Oregon, there is a 10% alcohol misuse prevalence rate and a 15% depression prevalence rate (America’s Senior Health Rankings, 2020). The number of people living with ADRD is also large and increasing, with an estimated 69,000 Oregonians 65 and older currently living with ADRD and 84,000 projected by 2025 (Alzheimer’s Association, 2021). Further compounding these challenges, Oregon has the highest rate in the U.S. of individuals 65 and older hospitalized for opioid-related issues such as overdose, use, and dependence (Oregon Health Authority, 2018; America’s Senior Health Rankings, 2020). Figure 1 illustrates these comparisons.

The BH needs of adults in Oregon are high. In Oregon, out of 30 days, adults aged 18 and up reported 4.8 poor mental health days, compared to 3.8 poor mental health days reported nationally (County Health Rankings, 2020). There is a 180:1 mental health provider ratio across the state (County Health Rankings, 2020), compared to a 400:1 ratio nationwide (See Figure 1). While lower than the national average, persistent challenges in access to these types of providers remain high in Oregon. Challenges associated with aging and mental health are particularly acute in rural and frontier areas (defined as counties with six or fewer people per square mile) of the state, where the population is aging at a faster rate, and there is a lack of BH providers and aging-specific clinicians (e.g., geriatricians, neuropsychologists) available to support this population (Hemeida et al., 2019; Oregon Medical Board, 2020). The ratio of mental health providers ranges from 110:1 to 630:1 across Oregon’s 36 counties (County Health Rankings, 2020). The prevalence of serious mental illness (SMI) amongst Oregonians ages 18 and up is 5.3% (Substance Abuse and Mental Health Services Administration, 2019). Tragically, 27% of Oregon adults who die by suicide are 65 and older, compared to 17% of adults 65 and older who die by suicide nationally.

To address older Oregonians’ BH needs, Oregon established the Behavioral Health Initiative for Older Adults and People with Physical Disabilities (referred to as the Initiative). Since 2015, this program has focused on improving coordination of BH services across Oregon for this target population through stakeholder engagement, workforce development and community trainings, complex care consultations, and the creation of multidisciplinary teams and other workgroups. This paper provides an overview of these efforts and outcomes of the Initiative based on data collected from program staff, stakeholders, and other community partners from 2014 to 2020.

Background of the Initiative

The Initiative is funded by the Oregon Health Authority (OHA) and comprises 24 Older Adult Behavioral Health Specialists (referred to as BHS in this article) who facilitate outreach and services to older adults and people living with disabilities experiencing mental health and substance use disorders in every Oregon county. In 2015, the Initiative was formed based on a needs assessment conducted by a team of researchers at the Institute on Aging at Portland State University (Oregon Behavioral Health Initiative, 2021). The needs assessment involved 35 in-depth interviews with stakeholders representing aging services, mental health agencies, health care, quality improvement, and advocacy organizations. Findings from these interviews highlighted several issues that could be addressed by the Initiative directly or could be documented and shared with policymakers and other key decision makers to facilitate change. Key issues identified include the pervasiveness of mental health issues, fragmented systems, and the mental health needs of older adults were not seen as a priority. In addition, there were knowledge gaps regarding typical aging (vs. atypical aging) and a lack of understanding regarding how to implement evidence-based best practices. Overall, lack of community access and availability of resources and funding (e.g., housing, qualified therapists, and clinicians) for older adults and people living with disabilities who experience BH needs was a persistent challenge.

Based on these findings, the Oregon State Legislature received a report that described gaps in services and coordination, and it made recommendations for implementing the Initiative, the roles of the BHS, and for supporting agencies. There was consensus among stakeholders that the primary role of the BHS should be to bridge multiple systems that provide services to older adults and people living with disabilities. Stakeholders also envisioned that BHS would provide or coordinate training, consult on complex cases, as well as identify and document unmet community needs. As a result, the Oregon Legislature allocated funding to non-profit agencies and community mental health programs in order to contract with and hire BHS to implement these goals across Oregon.

The overall goal of the Initiative is to better meet the needs of older adults and people living with disabilities by improving timely access to care from qualified providers who work together to provide coordinated, quality, and culturally responsive BH and wellness services (See Figure 2). The BHS′ primary role is to reduce gaps in services for older adults and people living with physical disabilities who have BH needs. The three core job functions of BHS are (1) to promote collaboration and coordination among core stakeholders and community partners, (2) to provide complex care consultation regarding older adults and people living with disabilities who have BH needs, and (3) to offer training to support workforce development, community health and wellness promotion.

Every county in Oregon is covered by at least one BHS (See Figure 3). Most regions are covered by one BHS, although two or more BHS may be serving in higher population areas, based on a formula developed for the initial needs assessment that assigns one BHS for every 30,000 adults 65 and over. Therefore, a BHS may cover multiple counties, while other individual counties may have multiple BHS due to the population of older adults.

Methods

In 2016, the Institute on Aging at Portland State University was contracted by the OHA to evaluate the Initiative through a variety of data sources that were developed and gathered from BHS and other stakeholders involved with the Initiative. Throughout the past five years, data collection instruments have been refined based on feedback from the BHS and project director. The BHS and key stakeholders provide data for the evaluation through qualitative and quantitative quarterly reports, complex care consultation records, detailed descriptions of training events, and semi-structured telephone interviews.

Quarterly Reports

The BHS submit reports quarterly. Three of the four quarterly reports mostly consist of open-ended qualitative questions about successes and challenges related to BHS′ core job functions. The reports are also used to collect information about multidisciplinary teams, evidence-based practices, community education training events, and plans for the upcoming quarter. One of the four quarterly reports consists mostly of quantitative scaling items to assess perceptions of progress in systems change and outcomes, the state of BH services for older adults and people living with physical disabilities in their local communities, and coordination and collaboration among community partners.

Complex Care Consultation

Complex care consultation is a core job function of the BHS. Behavioral Health Specialists assist providers (e.g., primary care providers, hospital staff, and emergency responders) in addressing the needs or concerns about the care or treatment plan for older adults or adults living with physical disabilities who have BH needs. They promote multidisciplinary teams and a person-centered, multi-morbidity approach to ensure older adults and people living with disabilities receive the appropriate help at the right time and at the right level of care. When feasible, families and consumers are involved in these consultations and are included in the decision-making process. Detailed records of these consultations inform the Initiative and stakeholders of the types of issues experienced by consumers, and the outcomes of consultation meetings in communities throughout Oregon.

From October 2017 to March 2020, BHS used a reporting instrument to provide information about each complex care consultation in which they participated. This instrument collected information about the consumer’s gender, age, disability status, veteran status, the structure of the meeting, the consumer’s reasons for a consultation (diagnosed or suspected issues), as well as information on the outcome of the consultation (e.g., a change in residence to a higher level of care, and a review of current medications). No identifying information was collected about consumers in these reports.

Workforce Development

The BHS conduct, sponsor, and host training events for the workforce in their local communities. These trainings focus on a range of BH and aging topics (e.g., dementia, social isolation, and hoarding) for a variety of workforce populations (e.g., emergency first responders, case managers, and long-term care facility staff). Workforce development training aims to enhance the BH-related knowledge and skills of aging services, health services, BH services, and other related professionals, based on community needs. The BHS developed training materials in response to the COVID-19 pandemic on topics such as “Memory Care and COVID: Keeping Strong Connections,” “Gripped by Fear: Anxiety and Worry in the Time of COVID-19,” and “Loneliness in Older Adults During COVID-19.”

Training participants received an electronic post-training survey from the evaluation team. These questionnaires ask about the quality of the training, the knowledge gained from the training, and their confidence to use the content in their work. Training participants also received a two-month follow-up survey that assesses how they have incorporated knowledge learned from training into their professional practice. When the data are longitudinal (i.e., case-specific identifiers can be tracked across time), fixed-effects models are used in the analysis. Otherwise, cross-sectional regression models are applied. When count data are analyzed, either chi-square or Fisher’s exact test are used to assess independence based on the levels of the variables and minimum cell counts. All significance tests are conducted at the alpha = .05 level.

Behavioral Health Specialist Interviews

In 2020, telephone interviews were conducted with each BHS to gather information about local-level projects they created and developed. Behavioral Health Specialists were asked about the purposes of their projects, how community partners contribute to the projects, and types of strategies they used to overcome project challenges. BHS were also asked for their opinions on what would make the Initiative more successful.

Stakeholder Survey

The stakeholder survey is another long-standing data source on the Initiative, which has been administered annually from 2017 to 2019. In 2017, 2018, and 2019, the survey was distributed to a variety of stakeholders who mostly worked in BH and aging services, along with other Initiative stakeholders such as emergency medical technicians (EMT), local law enforcement, and faith community groups. This sample was obtained by the evaluation team from the BHS, who were asked to identify decision makers or people who are influential with decision makers, such as stakeholders in their communities. These lists were supplemented with stakeholder names and email addresses provided by the Initiative’s Project Director, Advisory Council members, and searches by the evaluation team through agency staff listings to ensure similarity in coverage across different communities.

The evaluation team contacted potential survey participants by email about participating in an electronic (Qualtrics) survey and provided details of the evaluation. In 2019, 1784 questionnaires were successfully sent out and 26% (or 456 stakeholders) partially completed or fully completed the survey, which was somewhat lower compared to the rate in previous years (33% in 2017 and 32% in 2018).

Key Informant Interviews

In 2020, the evaluation team administered a brief survey and conducted telephone interviews with a select group of key stakeholders of the Initiative (referred to as “key informants”). The three aims were to capture their perceptions of what has changed as a result of the Initiative, determine how the Initiative can be improved, and assess the level of involvement of the Initiative’s partner organizations. Most of these stakeholders worked as mid-level managers or agency leaders for aging services or BH agencies that interact with the BHS, most often local Aging and People with Disabilities (APD) offices, Area Agencies on Aging/Aging and Disability Resource Centers (AAA/ADRCs), and Community Mental Health Programs (CMHPs). The evaluation team aimed to include an equal number of key informants who worked within these agencies in both urban and rural regions of the state and who had varying degrees of prior involvement with the Initiative. The team contacted potential interview participants to provide information on the evaluation, confirm their voluntary participation by written consent, and set a date for a telephone interview.

Results

Quarterly Reports

In their quarterly reports, BHS identified the top five barriers to serving older adults and people living with physical disabilities. These included a lack of affordable housing (97%), restrictive eligibility criteria (83%), lack of BH services in long-term care (69%), lack of integration between services (69%), and distance to services (69%). The BHS' reporting of several important service and program barriers significantly improved from September 2016 to June 2019 based on binary fixed-effects regression models, including lack of BH services in long-term care (B = −.01, p = .002), lack of BH services specific to this population (B = −.06, p < .001), lack of in-home services (B = −.03, p = .029), waitlists being too long (B = −.05, p = .007), and other long-term supports needed but unavailable (B = −.07, p < .001). Understanding the barriers to better service delivery and outcomes for this population helps the Initiative and BHS optimally focus their efforts.

Complex Care Consultations

From October 2017 through March 2020, the BHS reported participating in a total of 3711 consultations that took place in at least 30 of Oregon’s 36 counties. Seventy-six percent of consumers experienced three or more issues at the time of the consultation. The top issues experienced among consumers in each category of issues were co-occurring conditions (48%; physical/medical issues), poor family or natural supports (48%; social/individual issues), system navigation (47%; systems issues), SMI (27%; behavioral health issues), and lack of capacity and dementia (both 17%; neurological/cognitive issues).

In 2020, the BHS began providing data on how older adults have been impacted by the COVID-19 pandemic. Most BHS reported that the pandemic has led to an increase in depression and/or anxiety, isolation and loneliness, lack of ability to transfer, or move to more appropriate settings (e.g., memory care facility and community-based care), and lack of ability to access needed services (e.g., in-person therapy and shelter).

Workforce Development

Between October 2017 and March 2020, BHS planned, conducted, or sponsored 662 workforce development training events, with an average of 66 events per quarter. Between October 2017 and March 2020, a total of 3986 training participants (not unique cases) completed the online evaluation survey (44.6% response rate out of 9950 valid emails). In their post-training evaluation surveys, 88% of participants reported gaining knowledge that will be useful in their work, and 95% of those reported confidence to use the knowledge gained in their work. Additionally, from October 2017 through March 2020, average ratings of the quality of BHS workforce development events (e.g., training met expectations, presented information that will be useful in their work, is an area supported by their employer, prepared them to work with older adults, and people living with disabilities with BH needs) remained consistently high with all five items being rated four or more out of five.

Two months after the training event, training participants also received a follow-up survey that assesses how they incorporated knowledge learned from training into their professional practice. This survey has a lower response rate, ranging from 19% to 26%. As of October 2017, a total of 1734 training participants (not unique cases) completed the follow-up training evaluation.

Behavioral Health Specialist Interviews

BHS have developed various projects aimed at reducing social isolation and loneliness, promoting health and wellness, improving access to services, and expanding innovative service options. BHS have flexibility to design their own projects, often leveraging other community partners and resources. Examples of these projects include the Oregon Senior Peer Outreach program (Community Counseling Solutions, N.D.), a multi-county program which links trained volunteers with people aged 55 and older (or who are physically disabled) who would benefit from regular telephone calls that focus on increased hope, self-care, engagement, and reducing the experience of loneliness; Mental Health First Aid (National Council for Mental Wellbeing, ND), an 8 hour course designed to give non-clinical individuals the skills they need to reach out and provide initial help and support; and Residential Services Navigator Pilot (Homes for Good), a program designed to help individuals living in low-income housing access social and BH services, reduce social isolation, and expand their self-management skills.

BHS projects were analyzed and grouped into four categories: (1) improving access to BH care, (2) increasing workforce knowledge and skills, (3) engaging community partners, and (4) working upstream on primary prevention. Findings from the BHS interviews were also used to develop systems-level recommendations for policymakers as well as Initiative-level recommendations.

Stakeholder Surveys

The online stakeholder survey focused on challenges and successes concerning coordination and collaboration with key agencies and organizations, availability of and access to services, knowledge and skills of direct service staff, and use of evidence-based practices. Findings from the stakeholder survey are intended to contribute to a better understanding of the capacity of communities and the State of Oregon to meet the BH needs of older adults and people living with physical disabilities and to help provide direction in making the Initiative successful at achieving its intended goals.

The findings in the 2019 stakeholder survey revealed several positive results. About three-quarters of stakeholders agreed or strongly agreed that gaps in services have been identified and 86% of respondents agreed or strongly agreed that participants remain committed to improving BH services. Continuing challenges were also reported. Specifically, complex care consultations were seen as having had only some success in resolving the problems or concerns about the care or treatment plan of the older adult or adult with physical disabilities. Lack of affordable housing was agreed to be a challenge by 95% of respondents, followed by lack of BH services available in licensed long-term care settings (83%).

Key Informant Interviews

In 2020, the evaluation team administered a brief survey and conducted interviews with 49 key stakeholders (referred to here as key informants) of the Initiative. One primary aim of these interviews was to capture perceptions of systemic changes needed to improve BH services for older adults and people living with physical disabilities in Oregon. Several themes describing significant systemic barriers emerged from these data, which are also supported by findings from stakeholders and the BHS.

Physical Infrastructure

A lack of affordable housing persists as a top barrier to better service provision identified by key informants (a similar finding to the Specialists’ quarterly reports and stakeholder survey). Transportation was also identified as a significant barrier. Oregon is a geographically large state with a relatively small population. Thirty-three percent of Oregon’s population lives in rural counties, with two percent living in frontier counties (Oregon Office of Rural Health, 2021). Services are often many miles away from where people live. Transportation becomes an even greater issue given these conditions.

Lack of Services and Programs

An additional barrier according to both key informants (83%) and BHS (79%) was the lack of BH services available in licensed long-term care settings such as nursing facilities and assisted living communities. Additionally, a lack of in-home care services was identified as a challenge by three-quarters of stakeholders in all three survey years, and by 86% of Specialists in Q4 2016, which is down to 50% in Q4 2018.

Policy and Systems Issues

Restrictive eligibility criteria that prevent people living with significant or complex needs from qualifying for services was reported by 76% of BHS and 79% of stakeholders as a barrier in their communities, with no significant change in either group. About three-quarters of stakeholders noted a lack of credentialed BH providers who accept Medicare reimbursement for BH services as a barrier in both 2017 and 2019. An additional policy and systems-level barrier identified was a lack of integration of BH and physical health services, which was reported by two-thirds of key informants throughout the period. In contrast, 77% of BHS identified this as a barrier in 2016, compared to fewer than 50% in Q4 2017 and Q4 2018 (although this improvement was not statistically significant).

All issues related to a lack of providers involved training or expertise of providers with respect to BH issues. The share of BHS who reported a lack of personnel with the required expertise to provide quality BH services as a barrier in their communities declined from 76% in 2016 to 47% as of Q4 2018, a statistically significant improvement.

Discussion

After five years, evaluation findings indicate the Initiative has delivered a number of complex care consultations, innovative collaborations, workforce trainings, and other educational opportunities aimed at supporting the BH of older adults and people living with disabilities in Oregon. Since the Initiative began, stakeholders have indicated a belief that BH services for this population have improved. These are welcome findings, yet they do not confirm whether or not the Initiative directly brought about these changes. Due to multiple factors impacting the successes and challenges associated with BH services for this population, it is difficult to assess the direct impact of the work of the Initiative, although evaluation efforts have aimed to assess what is working well and how the Initiative can be more successful in supporting the BH needs of this population. Further assessment of the Initiative’s impact on the BH needs of older adults and people living with physical disabilities in Oregon is needed.

Several systemic barriers to greater coordination and better outcomes persist. Public funding of BH remains chronically under-resourced. Underinvestment in and shortages of affordable housing remain persistent issues. Further, the BH needs of older adults and people living with physical disabilities cannot be met by one agency or organization alone. As long as partner organizations remain siloed in their funding, training, and referral processes, this population will continue to be underserved. For Medicare beneficiaries, access to services is further exacerbated by restrictive reimbursement criteria for BH providers. Federal action, either through administrative rulemaking or legislation, is required to address the barriers of access to BH services through Medicare. Unfortunately, this is beyond the scope of state agencies and policymakers to address.

A limitation of this analysis is an inability to demonstrate a causal link between improved BH outcomes and the Initiative. Future evaluative efforts could explore adding outcomes-based assessments of the Initiative, including outcomes of community-level quality improvement projects initiated by the BHS. In particular, evaluation efforts could collect more detailed consumer-level data to demonstrate how Initiative projects can improve the BH of older adults and people living with disabilities. Additionally, cost-savings data could be collected on these effective projects. These outcome-based data would likely be influential with state policymakers and could support a case for more programs and services aimed at reaching this population. A detailed, multi-agency quality improvement framework could guide the BHS in collecting outcome-level data for their innovative programs based on their community’s specific needs. This would offer a local-level approach for improving coordination and support in which BHS could directly participate.

The findings presented within this paper point to several ways the Initiative can build on the successes of the initial years of operation to enhance the program’s ability to achieve its intended purpose (See Figure 4 for the recommendations). A multi-level approach could help facilitate these continued improvements in BH of older adults and people living with disabilities. This might include ways to support the Initiative at a community-level but also BH at a statewide level. There is also a need to focus on enhancing the role of the Initiative and the BHS, to augment some of the BHS job functions (e.g., increasing collaborations between local aging and BH agencies), develop a systematic process to elevate complex cases up a chain of authority, carry out additional marketing and outreach to better promote the Initiative, and a need to continue to focus on addressing gaps in BH services for this population across Oregon.

Policies and programs that support the BH needs of older adults will be of increasing importance as the U.S. population ages. The disproportionate effect of the COVID-19 pandemic on this population makes this an even more salient and urgent need. Coordinated state-level efforts focused on supporting the BH of older adults and people living with disabilities are rare in the United States. Yet, Oregon’s experience with implementing a statewide program focused specifically on this population suggests that more targeted support can be beneficial and can facilitate better outcomes. Other states could consider carrying out an initial needs assessment, which might help identity any gaps in access and delivery such as workforce and then adopt a similar approach to better support the BH needs of older adults and people living with disabilities. Oregon’s experience may offer a particularly insightful roadmap to states with a similar urban–rural–frontier geographic division.

Footnotes

Acknowledgments

The authors wish to acknowledge Oregon’s Behavioral Health Specialists for their steadfast commitment to improving the systems and services that support older adults and people living with disabilities who have behavioral health needs. It is through their work and continuous reporting that we can assess the progress of the Initiative to date and recommend actions for sustained improvement. The authors also thank the Initiative’s Project Director, Nirmala Dhar, for her leadership of the Behavioral Health Initiative as well as Diana White and Linda Dreyer for providing insightful background on the Initiative’s historical development. The authors are also profoundly grateful to Margaret Neal for her thorough review of the manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this project was provided by the Oregon Health Authority contract # 159418. IRB Approval; This work was approved by the Portland State University Institutional Review Board (approval # 206791-18).

ORCID iDs

Jaclyn Winfree

Walter D. Dawson

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