Implementing Evidence-Based Psychotherapies in Settings Serving Older Adults: Challenges and Solutions

Evidence-based psychotherapies, such as cognitive-behavioral therapy, interpersonal therapy, and problem-solving therapy (1), for late-life mental health problems are considered first-line treatments, but implementation of psychotherapy remains a significant challenge on multiple levels. Older adults often prefer psychotherapy to medication—up to 60%, according to one study (2). However, these treatments have been poorly translated into community settings (3), and when they are available in the community, psychotherapy tends to be delivered in mental health clinics—settings that older adults tend to avoid because of the stigma associated with mental illness. As a result, only 25% of older adults who need treatment receive psychotherapy (4).

One way to improve older adults' access to psychotherapy is to integrate these interventions into programs that serve older adults, specifically residential care, home health care, and day treatment, as well as primary care settings. Although the implementation and maintenance of psychotherapies in these settings is an appealing option, it is not easy and is complicated by insurance limitations, staff and setting limitations, and problems in treatment implementation and long-term fidelity to treatment models (5). In this Open Forum, we discuss how these complications affect the use of psychotherapy and how to best address these barriers.

Insurance limitations

Despite the wide recognition that older adults are underrepresented in mental health settings and are rarely treated by mental health providers, many insurers do not reimburse mental health services delivered by non-mental health providers or by nontraditional means (such as by telephone). As we noted above, only 25% of older adults needing mental health care use psychotherapy (their preferred treatment), and according to Wei and colleagues (4), improvement in access to psychotherapy should involve broader geographical distribution of this treatment to older adults. Furthermore, Choi (6) has argued that provision of services in the home or by telephone could be a means for broader distribution and thus greater access to psychotherapy. Arean and colleagues (7) demonstrated that integration of psychotherapy into primary care medicine not only resulted in improved outcomes but also improved access to psychotherapy for older adults from ethnic minority groups. Unfortunately, insurers do not reimburse for telephone-based treatments, despite their efficacy (8), and many insurers do not cover travel time for home visits. Finally, most Medicare supplemental insurance plans will not cover psychotherapy services delivered in non-mental health settings, such as primary care settings or senior centers. Thus, despite the promise of integration, the current reimbursement system is not set up to support this model of care.

Staff and setting limitations

Two major limitations in the implementation of psychotherapies in services for aging populations are the complexity of some psychotherapies and the organizational culture of many aging-services agencies. In an attempt to address the dearth of trained professionals, and as a cost-saving measure, many agencies employ non-master's-level providers to provide mental health services. This solution creates other costs in implementing evidence-based psychotherapy, and it particularly affects the quality of the intervention delivery. When agencies that deliver services to older adults attempt to implement an evidence-based psychotherapy, they may find the treatment ineffective partly because staff members lack the skills needed to conduct psychotherapy appropriately. Limitations of the service setting further complicate implementation. With few exceptions, psychotherapies are developed for providers who have control over their case mix and have the resources to provide the treatment (such as private space and access to expert review). Many aging-services providers have large, complex caseloads and insufficient time for consultation regarding the implementation of psychotherapy for complex cases.

Training and sustainability

Most aging-services settings and insurance providers (such as Medicare) do not provide incentives for training staff in an evidence-based psychotherapy, which generally involves participation in a workshop, followed by observational review of cases by experts in the intervention. Although training can be inexpensive in terms of direct costs, the process in community settings can be complicated by the inability of clinicians to identify individuals who are willing to have their sessions audio-taped, lack of extra time for supervision, and staff turnover requiring retraining and recertification, all to be done without a reimbursement incentive from Medicare. The fact that no incentive value is placed on specialized training minimizes many clinicians' desire to expend the effort to learn these interventions. Even when training is supported, clinicians' treatment fidelity often drifts over time (9). Suboptimal long-term fidelity results from lack of ongoing support from experts and lack of accountability from insurers and from organizational leadership for following treatment guidelines.

Solutions for overcoming implementation barriers

Although the implementation of psychotherapy is challenging, a number of policy and practice innovations can facilitate access to high-quality psychotherapy for older adults. The Patient Protection and Affordable Care Act (ACA) heralds changes in both national policy and funding for psychotherapy and opportunities to grow the workforce through incentives, education, and training grants. These policies could be strengthened by clear definitions of the skills needed to implement psychotherapy. One promising development is the American Psychological Association's recently appointed task force to develop clinician guidelines for treatment of mental illnesses, particularly psychotherapy, for all demographic and age groups. These guidelines can instruct states and organizations on the level of provider training needed to implement psychotherapy and training resources. Guidelines can also be helpful in delineating the effectiveness of psychotherapies delivered in nontraditional ways, such as by phone or in the home. The Institute of Medicine's Geriatric Workforce Development in Mental Health work group is another policy forum that could help in defining the credentials needed for clinicians to successfully deliver psychotherapy and inform policy regarding what service innovations specific to older populations are needed and which clinicians should be reimbursed.

In regard to implementation and long-term fidelity of psychotherapy, training programs for middle-level managers in aging-services agencies on the effective implementation of psychotherapy are showing promising results. Successful managers who implement new practices learn the model, solicit feedback from their staff, hold staff accountable for being trained in the intervention, and are clear about why the intervention was selected (6). In our experience implementing problem-solving treatment, counties that have held providers accountable for becoming certified within three months of program rollout are more likely to have a fully trained team than counties without timely certification mandates. Organizations that have created incentives for staff to become certified have overcome providers' initial reluctance to learn a new psychotherapy. Further, organizations that factor in costs of ongoing consultation and technical assistance sustain the new practice better than those that stop investment after certification (10).

Access to certification and technical assistance has benefited considerably from technologies that provide accessible training, supervision, and fidelity evaluations via the Internet. We have dealt with difficulties in certification and long-term fidelity by using a fidelity-monitoring tool for structured case supervision. For rural and international collaborations, we have used Skype technologies to observe in vivo treatment interactions. Other promising technologies for ensuring fidelity to treatment include the use of computerized support tools for clinicians, such as the Coordinated Anxiety Learning and Management (CALM) program for the treatment of anxiety in primary care (11). The CALM program overcomes clinicians' skill limitations by providing a computerized treatment program that the clinician and patient review together. Technology-based support of psychotherapy holds considerable promise in reducing the problems associated with provider drift from fidelity.

Conclusions

The implementation and sustainability of psychotherapies in systems of care that serve older adults is challenging but not impossible. Policy makers and organizational leaders need not decide to limit investment in successful interventions that are also preferred by older adults simply because of these challenges. Changes in policy, better recognition of evidence-based psychotherapies, and better access to technical assistance make psychotherapy a viable intervention choice for all older adults.