Gold Award: Providing Accessible, Affordable, and Stigma-Free Behavioral Health Care for Older New Yorkers
All over the country, communities are searching for better ways to provide mental health services for the growing number of older Americans, many of whom have difficulty leaving their homes. Without treatment, this population is at risk of unnecessary hospitalization and excessive use of emergency services.
Fortunately, there are good models of community-based mental health services for older adults. One of the best, according to the American Association for Geriatric Psychiatry, is the Service Program for Older People (SPOP) in New York City (NYC). Founded in 1972, SPOP provides comprehensive mental health care for adults ages 55 and older, with a particular emphasis on seniors who are homebound, socially isolated, or even terminally ill.
SPOP’s flagship program is an Article 31 clinic, which offers individual and group therapy and features such age-friendly services as home visits, community-based appointments at satellite sites, outreach and education through senior centers, treatment in Spanish and other languages, caregiver support, 24-hour emergency help, and medication management.
In recent years SPOP has expanded its focus, coordinating services whenever possible with medical care and social service supports. The clinic is now in the second year of a strategic partnership with Mount Sinai Visiting Doctors (MSVD), a home visiting program associated with Mount Sinai Health System in NYC, to provide coordinated medical and mental health care to homebound adults. The agency is home to New York State’s only personalized recovery-oriented services (PROS) program exclusively for older adults with severe mental illness. One of the agency’s signature programs is its free peer-led bereavement support program for adults of all ages and walks of life.
In recognition of its commitment to providing accessible, affordable, and stigma-free behavioral health care for older New Yorkers, SPOP was selected to receive APA’s 2016–2017 Gold Psychiatric Services Achievement Award in the category of community-sponsored programs.
Removing Barriers, Expanding Services
“Clients in our program tend to be at high risk of hospitalization due to frailty, social isolation, and, in many cases, poverty,” according to Nancy Harvey, L.M.S.W., Chief Executive Officer of SPOP. Yet many avoid seeking help because of stigma related to mental illness and fear of treatment, she noted.
SPOP has learned that one key to fostering independent living in this extremely fragile population is to eliminate barriers to mental health care. The first step is to identify seniors in need and respond quickly, before emergency care becomes necessary. The clinic follows protocols for rapid engagement, with priority to hospital referrals and high-risk or crisis situations, with a goal for the client to be seen by the case opener within three to five days.
The medical director, psychiatrist, and psychiatric nurse practitioner (NPP) play a critical role in intake and treatment for all clinic clients. The psychiatric staff performs initial assessments and periodic reviews, provides treatment, prescribes and monitors psychotropic medications, determines the client’s ability to engage in insight-oriented psychotherapy (which is important in a population where cognitive decline is common), determines eligibility for homebound service, and collaborates with the clinic staff in the development of a treatment plan. The NPP also provides health management services, reviews health screenings, monitors chronic medical conditions, and coordinates overall care and medication protocols.
Clients enroll for individual or group therapy based at the clinic, at one of 12 community-based satellite sites, or in the home if the individual is deemed homebound. Some 20% of clinic clients have a history of alcohol or drug use, and SPOP offers specialized counseling if substance use disorder is the secondary diagnosis. Many clinicians are proficient in a second language, and SPOP offers treatment in English, Spanish, French, Cantonese, and other languages.
The goals of treatment vary, depending on the patient’s needs, explained Chief Program Officer Catherine Thurston, L.C.S.W. “Frances,” for example, began receiving services at the age of 78. At the start of treatment, she was socially isolated and in danger of eviction from her apartment due to severe clutter. After meeting each week with an SPOP therapist, she gained the skills to better manage her tendency to accumulate belongings, and after some time she agreed to have her apartment cleaned. She also became engaged in social activities at her neighborhood senior center and is no longer as isolated.
“Carol,” on the other hand, has struggled with depression and alcohol her entire life. She was abused as a child and had several family members with untreated severe mental illness. As a young adult, she left home, attended college, and became an artist. Carol was referred to SPOP at age 74; at the time of admission she was depressed, isolated, drinking heavily, and mourning the recent death of her partner. Working with her therapist, she articulated treatment goals to reduce or stop alcohol consumption, manage her anger, and improve her self-care. Today Carol is sober, engaged in a 12-step program, and active in her church. She is also painting again and has made plans to sell or donate her artwork to her church community.
Over the past year, the SPOP clinic served over 700 clients and provided some 14,500 appointments. One-third of all services were conducted in the home, with another 17% at community-based satellite sites. Some 60 adults of all ages participated in bereavement support groups, which are led by highly trained volunteers and supervised by clinical social workers. In addition, education and training in the basics of geriatric mental health was provided to more than 100 employees of other organizations.
Access to Social Services
Although appointments are usually held in the program’s Manhattan clinic, a growing number take place at one of the program’s satellite sites, where clients also have access to a range of social services. “Being able to offer appointments in a familiar setting that is close to home has helped us reach out to seniors, address stigma through education, and provide workshops and therapy that improve their overall health,” said Geordana Weber, L.C.S.W., Senior Vice President for Community Services.
At the Educational Alliance Sirovich Senior Center, one of the program’s newer satellite locations, older adults have access to a hot lunch five days a week and a wide variety of programs, classes, and social activities. Topics include monitoring and maintaining a healthy lifestyle, weight management support, stress and relaxation programs, life transition workshops, and health screening. In January 2017, SPOP opened four new clinic satellite offices in Manhattan with the support of the NYC Department for the Aging and ThriveNYC, a citywide initiative to eliminate stigma associate with mental illness. The sites are all licensed to provide comprehensive behavioral health care for older adults, including assessments, individual and group psychotherapy, and medication reconciliation. Services were recently expanded at two long-standing sites, the Carter Burden Center for the Aging and the Stanley M. Isaacs Senior Center.
“Developing and launching satellite sites is a high priority,” said Ms. Harvey. The partnerships have been effective in providing services, she noted, as well as generating referrals and educating prospective clients. The SPOP staff work with staff of the senior centers to present workshops and educational meetings about the basics of mental health and emotional well-being.
A New Model of Home-Based Health Care
Like many states, New York State is confronting an elder boom. The baby boom generation is aging, people are living longer, and most people express a desire to remain in their homes as they grow older. A unique combination of factors in NYC—apartment living, proximity of family and friends, meal delivery and friend-visiting programs, and visiting doctor services—means that seniors can live at home even while managing complex or even terminal medical conditions.
Aware of these trends, SPOP recently entered into a partnership with MSVD to provide a new model of home-based health care for older adults. MSVD is the largest academic home-visit program in the nation. Each year its doctors provide high-quality, patient-centered primary and end-of-life care to 1,300 homebound patients in Manhattan. MSVD is based at Mount Sinai Hospital, a world-renowned 1,171-bed tertiary-care facility that is ranked third in the country for geriatrics. Since the arrangement began, the hospital has become a leading source of referrals for the SPOP clinic.
The partnership between SPOP and MSVD addresses the comprehensive health needs of some of the region’s most frail and isolated seniors. “In virtually any other setting, this patient population would require nursing home care,” according to Ms. Harvey.
“Sarah” is typical of the partnership with MSVD and SPOP, said Ms. Harvey. Determined to live out her days in her small New York City apartment, she is able to remain in her home thanks to a network of formal and informal services, including caregivers, neighborhood shops that deliver groceries, a friendly visiting program through her synagogue, assistance from her building staff, and daily calls and visits from her adult children who live nearby. Weekly visits from her SPOP therapist focus on mindfulness, relaxation techniques, and strategies to manage her relationships. In nice weather Sarah goes out in her wheelchair, but there is one place she never goes: the doctor’s office. Sarah receives all of her medical care at home from MSVD physicians—and she hopes that she never sees the inside of a medical office or hospital again. She appreciates and enjoys the visits from the nurse, doctor, or social worker, which often brighten up a long day.
Recovery for Seniors
In 2013, SPOP converted its continuing day treatment program into PROS, the first recovery-based program in New York State exclusively for older adults with serious mental illness. “No one was certain how to define ‘recovery’ for seniors, said Ms. Thurston, “considering that life goals change with age.” Are work and education goals appropriate for older clients? What about clients who had spent years in hospitals or institutional settings? What would their life goals look like?
With few, if any, models, to build on, PROS chose to emphasize counseling and education. Led by Senior Vice President Robert Franco, M.A., a staff of social workers, a nurse, psychiatrist, and rehabilitation counselors works with clients to articulate personal life role goals, identify barriers to success, and develop strategies to overcome challenges. Participants choose from an extensive schedule of classes and programs. Topics include cooking, creative arts, and banking, as well as identifying and working toward individual goals, life skills training, and reestablishing connections with family and friends. Many groups are conducted in Spanish, and each participant is able to determine his or her own schedule of groups.
“Like most older people, older adults with mental illness are concerned about cognitive decline,” said Mr. Franco. PROS activities are designed to keep the brain active and can range from more formal cognitive remediation to board games and other efforts to keep people thinking and connecting with each other.
“We could not be more proud of what we have learned about recovery in older adults,” said Ms. Thurston. Eighty-two clients enrolled in the program in its first year alone. Participants have secured employment, reestablished contact with family members, acquired computer and communication skills, secured better housing, and increased engagement at traditional senior centers or treatment through the SPOP clinic.
An Example for Others
As communities around the country grapple with global aging, SPOP stands out as a cost-effective and comprehensive model for supporting older adults who wish to age in place. Each client is provided access to affordable mental health care, either at a convenient location in the community or at home. Clients with serious mental illnesses are able to pursue recovery, using the remaining years of their lives to set goals and learn new skills. Bereavement groups help clients cope with the inevitable losses of aging.
SPOP receives support from various agencies and foundations, including New York State Office of Mental Health, New York City Department of Health and Mental Hygiene, New York City Department for the Aging, the Altman Foundation, the New York Community Trust, the Fan Fox and Leslie R. Samuels Foundation, and the van Ameringen Foundation, to name just a few. Many other foundations, corporations, and individuals contribute to SPOP, with the understanding that reimbursements from Medicare, Medicaid, and third-party insurance do not cover actual costs. “Funding is our greatest challenge,” stated Ms. Harvey, “and the uncertainty about the future of Medicare and Medicaid makes us—and those we serve—especially vulnerable.”
As SPOP marks its 45th anniversary, there is cause for celebration, said Ms. Harvey, noting that much work still lies ahead. “We want to make certain that every older adult has access to affordable mental health care,” she said. “After all, emotional well-being is important at every age, and even our most fragile clients are able to benefit from the services we offer.”
