Care management in individuals with depression can result in highly positive outcomes, especially for socioeconomically disadvantaged older adults. Outcomes of intensive care management for homeless older adults with mental and substance use issues also are positive when accompanied by housing. But care management programs tested to date appear to have limited positive effects on people with dementia and their caregivers, as they cannot be standardized. More studies are needed to find care management models and practices that would be work with this population.
care management, depression, homelessness, intensive care management, dementia, caregivers
The prevalence of mental illness and substance misuse problems, in general, tends to be lower among older adults than it is among younger adults; however, subgroups of older adults live with a significant burden of mental illness, cognitive impairment, and/or substance misuse problems. For example, the rate of depression in older adults who are unable to leave home as a result of a disability is two-to-three times higher than in older adults without disability (Xiang et al., 2019).
Older adults with socioeconomic disadvantages, multiple chronic medical conditions, and functional impairment are especially vulnerable to depression (Choi et al., 2019). Late-life depression is treatable with evidence-based psychosocial interventions with or without pharmacotherapy, but access to treatments needs to be improved. Dementia prevalence has decreased over the past two decades in the United States; however, under-awareness and under-diagnosis among a large proportion of older adults and racial/ethnic disparities are significant concerns (Amjad et al., 2018; Langa et al., 2017). Evidence-based care for people with dementia and support for their informal caregivers are needed to improve their quality of life.
Substance misuse (e.g., binge or heavy drinking, nonmedical use of opioids and other prescription drugs, illicit drug use) and substance use treatment admissions among older adults (ages 50 and older) have steadily increased over the past decade (Chhatre et al., 2017; Fairman and Early, 2020). The group most affected by substance use disorders are homeless individuals, and the number of older adults who are homeless is rapidly increasing. Between 2004 and 2017 the number of homeless adults ages 50 and older in New York City more than doubled, and those ages 65 and older more than tripled, with similar trends noted in other large cities (Culhane et al., 2019). These older adults need housing support and treatment of mental and substance use disorders.
The growth in individuals with behavioral health conditions who are receiving long-term services and supports (LTSS) has been substantial due to increasing numbers of the older adult population. According to 2003 linked data, about half of dually eligible Medicare and Medicaid enrollees ages 18 to 64 and 80 or older had at least one mental or cognitive condition; the percentage with at least one mental or cognitive condition was closer to one-third for those ages 65 to 79 (Kasper et al., 2010). When LTSS care recipients receive treatment it most frequently involves psychiatric medication provided by a general medical provider and not a mental health provider, or a professional with expertise in geriatric care. Therefore, care managers must confront the significant negative impact of untreated behavioral health problems on the well-being, functioning, safety, and quality of life of their clients and often of their family caregivers. Even prior to the increase in rates of depression and anxiety due to COVID-19, the large cohort of baby boomers swelling the ranks of LTSS care recipients highlighted the inadequacies of behavioral health and LTSS systems.
The Institute of Medicine’s landmark report (2020), The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? urged that both legislative and executive branches of government increase investments in training more geriatric behavioral healthcare providers. However, the report also recognized that the shortfall in specialty behavioral health providers would remain. Leaders in the field have advocated for training social service personnel such as LTSS care managers to conduct screening of mental health needs and learn evidence-informed brief interventions to meet the needs of clients they serve (Bartels et al., 2014).
Although LTSS care managers often feel they do not have the time or training to address the issues raised in meeting the needs of older adults with serious behavioral healthcare needs, they play essential roles in helping such older adults to better meet their biopsychosocial needs in a range of settings. In this article, we examine the diverse types, functions, and evidence base of care management for late-life depression, dementia and dementia caregiving, and substance misuse and mental illness among homeless older adults.
Care Management for Late-life Depression
Care managers work with individuals with depression to assess depressive symptoms and associated care needs, to identify and facilitate evidence-based treatment options and resources, and to coordinate, monitor, and evaluate treatment for improved clinical outcomes. However, depending upon practice settings, the types and functions of care management for late-life depression vary widely.
Depression Care Management in Community-based Agencies
There are evidence-based care management models for individuals with depression that are designed to be delivered through existing care-management services in the community, involving aging services agencies that offer a range of services for older adults with chronic health conditions and functional limitations. In these community-based models, care managers are not mental health specialists, but often they are staff care managers trained to provide care management to individuals with depression, along with usual care management services.
Traditional care management with added components for depression is an effective intervention for community-dwelling, socioeconomically disadvantaged older adults with high medical burden and multiple care needs.
In the widely implemented Healthy IDEAS (Identifying Depression and Empowering Activities for Seniors) program, nonprofit or public aging services agency care managers are trained to provide screening and assessment, education, referral, and links to health and mental health professionals, behavioral activation ( identifying value-based behavioral goals and activities in various life areas and implementing them), and other self-care strategies (Quijano et al., 2007).
Training consists of reviewing the program manual with scripts and client handouts, articles, and videos on late-life depression; interactive group sessions involving skill demonstration and role playing; individual coaching; and semi-annual group follow-up booster trainings (Casado et al., 2008; Quijano et al., 2007). Trained care managers, under ongoing supervision and fidelity monitoring by a coach (a psychologist or social worker from an academic partner), conduct screenings and assessments and education in older adults’ homes, involving family if needed. These care managers also take the older adults to appointments with medical or mental health providers and provide behavioral activation either in-person or via telephone over a six-month period. Older-adult participants have shown reduced depressive symptoms and pain and improved knowledge about help-seeking and reducing depression (Quijano et al., 2007).
In a randomized controlled trial (RCT) of home-based care management for low-income older adults (i.e., recipients of home-delivered meals) at home with major depression, effectiveness of care management (referred to as clinical case management or CM) by master’s-level licensed social workers was compared to that of CM plus problem-solving therapy (PST) (referred to as CM-PST) (Alexopoulos et al., 2016). CM consisted of twelve one-hour meetings focusing on needs assessment, psychoeducation about depression, service planning, links to financial, legal, and housing resources, as well as other social services, help accessing healthcare, and advocacy, and exploration of barriers perpetuating needs.
CM-PST consisted of the CM components and training in the steps of the PST process: define a problem, set a goal, brainstorm ideas to solve the problem, select a solution, and create an action plan, with the expectation that the participant will use these steps to solve specific problems. The effects of CM on depressive symptom reduction at twelve and twenty-four weeks were noninferior to those of CM-PST, and problem-solving improved in both groups (Alexopoulos et al., 2016).
One intervention available to care managers working with individuals with depression is called “Get Busy Get Better” (previously known as “Beat the Blues”). In this program, senior center care management staff refer clients (low-income older adults) who scored positive for depressive symptoms in the depression module of the Patient Health Questionnaire (PHQ-9) on two separate occasions over two weeks to a licensed social worker (Kroenke el al., 2001). Using up to ten in-home sessions over four months, the social worker then provides depression education and care management (assessment of care needs and referrals or links to physical and/or mental health and financial, social, and legal services), instructs in stress reduction techniques, and uses BA to help the participant identify valued goals and provides activities to achieve them (Gitlin et al., 2012, 2016). Participants have shown clinically meaningful reduction in their depressive symptoms compared to a waitlist control group (Szanton et al., 2014).
These models show that traditional aging services care management with added components for depression care is an effective intervention for community-dwelling, socioeconomically disadvantaged older adults with high medical burden and multiple care needs for independent living. Care managers can be effectively trained in depression care management and incorporate it with usual care management.
Care Managers as Referral Sources
Care managers for low-income older adults at nonprofit or public aging-services agencies often carry high caseloads with complex health and social care needs and are not able to spend enough time working directly with their clients who have depression. While they are proficient in screening and identifying depression (usually using the PHQ-9 or its shortened version, the PHQ-2) and other mental health problems, these care managers are best situated to refer their clients to a mental health specialist within the same agency or located in another entity. For example, in the widely adopted Program to Encourage Active, Rewarding Lives (PEARLS), private or public aging-service agency care managers make referrals of eligible older adults to a PEARLS counselor or coach who are typically within the same agency (Steinman et al., 2012). The PEARLS counselors (social workers, nurses, therapists, psychologists, health educators, or community health workers), under a clinical supervisor, provide up to eight sessions, including problem-solving treatment and behavioral activation in the client’s home or at a community setting.
Another example is the RCT that the authors and their colleagues conducted with low-income older adults who are recipients of home-delivered meals (Choi et al., 2014). Our community partner, a large Meals on Wheels program that daily serves 2,200 mostly low-income individuals ages 50 and older in Central Texas, has thirteen care managers who use the PHQ-4 (a four-item measure of depression and anxiety) to screen depressive symptoms as part of their routine in-home intake and recertification assessments with these older adults. However, these care managers were very clear that given their high caseloads, they would not have time to incorporate depression care management including PST or behavioral activation. Their preference was for an in-house or contract mental health specialist to whom they could refer their clients and coordinate care with the specialist on an as-needed basis for clients’ care management needs that may arise during depression treatment sessions.
In response, a recently completed RCT (Choi et al., 2020a), embedded two PST therapists (licensed master’s-level social workers) and two BA counselors (bachelor’s-level lay providers) in the Meals on Wheels program. During their in-home assessments, care managers identified potentially eligible clients based on their PHQ-4 assessment and other relevant data, introduced the program to the clients, and with the clients’ verbal consent, referred them to treatment providers for further telephone screening and in-home baseline assessment. As needed, care managers provided the co-located treatment providers additional information on the clients’ situations.
Treatment providers also were able to check the client database to better understand these older adults before and during assessments and in five, one-hour weekly PST or behavioral activation videoconferences. (Participants were loaned a laptop with a HIPAA-compliant videoconferencing platform preloaded and a wireless card for the duration of the intervention.) Care coordination continued for client problems that can be better tackled by care management (e.g., client needed a special transit service application to attend a senior center as part of behavioral activation goals) or for those that can be better managed by both (e.g., unforeseen crisis in the family). In addition to this one-on-one care coordination, care managers and treatment providers had a monthly group meeting where they discussed recruitment strategies, shared participants’ progress, brainstormed ways to enhance treatment engagement motivation, and celebrated participants’ success.
Older adult participants gave extremely positive acceptability ratings of the program and experienced reduced depressive symptoms and disability and improved social engagement and activities (Choi et al., 2020b). Participants liked tele-delivery because they thought it better protected their privacy than did going to clinic-based therapy (Choi et al., 2020b). Care managers also reported a high degree of satisfaction with the ease of referral, care coordination, tele-treatment delivery, and participant outcomes. This study shows that co-location of and care-coordination between care managers and depression treatment providers is highly conducive to depression care management for low-income disabled older adults who need care management and depression treatment. Because homebound older adults have difficulty using clinic-based psychotherapy, care managers for these older adults had difficulty referring them out as the clients could not follow-through.
Depression Care Management in Collaborative Care Models
Because most older adults receive their healthcare from primary care providers (PCPs), many large scale RCTs over the past two decades also have evaluated the effectiveness of integrating depression care into primary care settings to promote collaboration between PCPs and mental health specialists. In these integrated care models, known as collaborative care, depression care managers with mental health expertise (nurses, social workers, psychologists) are co-located in primary care clinics for holistic care of physical and mental health, improved treatment engagement, and care coordination. Collaborative care includes a specific set of depression interventions developed directly from the Chronic Care Model and using a multi-professional approach to care, structured management plan, scheduled patient follow-up, and interprofessional communication.
Integrated and collaborative depression care models had a greater impact on patients with more severe depression and lower socioeconomic status.
This approach has been proven effective in treatment engagement, ongoing care with symptom monitoring, and teaching self-management skills (Bruce and Sirey, 2018). For example, in the IMPACT (Improving Mood-Promoting Access to Collaborative Treatment) collaborative care model with trained PCPs, embedded depression care managers, and a consulting psychiatrist, patients receive evidence-based pharmacotherapy and-or psychosocial treatments (a brief problem-solving therapy with behavioral activation components).
Care managers working with elders with depression are behavioral health specialists who work with PCPs for up to twelve months to establish a treatment plan that meets patient preferences, follow a stepped care algorithm, and follow up with the patients to monitor progress and outcomes (Unützer et al., 2002). Studies showed that integrated and collaborative depression care models had a greater impact on patients with more severe depression and with lower socioeconomic status, regardless of race or ethnicity (Bruce and Sirey, 2018). Collaborative care models have been expanded to treat other mental illnesses (e.g., anxiety and PTSD) in primary care settings (Meredith et al., 2016).
Care Management Services for Older Adults with Dementia and Their Caregivers
Care management for people with dementia and their caregivers in the community also varies widely; however, the common components include assessment, care planning, resource mobilization, and care coordination that are necessary to meet their identified needs (Corvol et al., 2017; Reilly et al., 2015). Multiple RCTs of care management for persons with dementia have not produced clear and consistent outcomes. A systematic review of thirteen RCTs involving 9,615 participants with dementia found that the care management groups were significantly less likely to be institutionalized (e.g., nursing home admissions) at six and eighteen months, but did not find effects at ten to twelve months and twenty-four months (Reilly et al., 2015).
There was some evidence of benefits showing reduced caregiver burden at six months, but no effects at twelve or eighteen months were found. Some evidence indicated that care management was more effective at reducing behavior disturbance at eighteen months, but no effects were found at four, six, or twelve months. Effects of care management on patient depression, functional abilities, and cognition were uncertain. Also, it was not clear which components of care management were associated with outcomes improvement (Reilly et al., 2015). Another systematic review of forty-three quantitative and qualitative studies found that care management had a limited positive effect on behavioral symptoms of dementia and length of hospital stay for patients, and on burden and depression for informal caregivers (Khanassov et al., 2014).
In a systematic review of twelve studies (ten RCTs and two quasi-experimental studies) that evaluated the outcomes of intensive and clinical care management for caregivers of older adults with dementia (n=10) or loss of autonomy (n=2), seven studies overall and six of ten studies that targeted dementia caregivers reported at least one valid positive outcome for caregivers (Corvol et al., 2018).
Four of the eleven studies assessing caregiver burden showed a reduction. Four of the seven studies that assessed quality of life for caregivers yielded positive results. One of the three studies on caregiver social support showed positive results. Four studies that assessed depression in caregivers found no significant differences at the end of the intervention. Thus, the results show reasonable evidence that clinical care management can lead to positive outcomes for caregivers of dementia patients, but the authors also noted difficulty in identifying aspects or components of care management that are effective versus not effective (Corvol et al., 2018).
Care Management for Homeless Older Adults with Substance Use and Mental Health Problems
An earlier systematic review of the literature on standard care management (SCM), intensive care management (ICM), assertive community treatment (ACT), and critical time intervention (CTI) for homeless adults found little evidence for the effectiveness of ICM (de Vet et al., 2013). On the other hand, SCM improved housing stability, reduced substance use, and removed employment barriers for substance users. ACT improved housing stability and was cost-effective for mentally ill and dually diagnosed persons. CTI showed promise for housing, psychopathology, and substance use and was cost-effective for mentally ill persons (de Vet et al., 2013).
In a Canadian multisite RCT of the Housing First program, however, both Housing First with ICM and Housing First with ACT demonstrated positive outcomes in housing stability (Chung et al., 2018). (Housing First is an evidence-based, supportive housing service for chronically homeless people with serious mental and substance use disorders. Housing of their choice is provided without any preconditions of housing readiness such as acceptance of psychiatric treatment or sobriety [Tsemberis et al., 2004]). Moreover, older (ages 50 and older) participants showed significantly greater improvements in condition-specific quality of life and mental health symptom severity, than did younger participants.
In ICM, a care manager who was available twelve hours a day for seven days a week worked with participants using an individualized care plan and met with them at least weekly. In ACT, participants were connected to a team comprising psychiatrists, nurses, care managers, and peer support workers, who worked collaboratively to address participant concerns and develop individualized care plans. ACT services were available twenty-four hours a day for seven days a week. This study shows that stable housing accompanied by intensive care management is essential to meet the unique and complex needs of growing numbers of homeless older adults with high rates of mental and substance use disorders on top of multiple medical comorbidities.
Our summary of care management for late-life depression, dementia, and homelessness shows its varied types, functions, and outcomes. Care management with individuals with depression, regardless of setting and function, results in highly positive outcomes especially for socioeconomically disadvantaged older adults. The outcomes of intensive care management for homeless older adults with mental and substance use issues also are positive when accompanied by housing support. However, care management programs tested to date appear to have limited positive effects on people with dementia and their caregivers. Given highly individualized dementia conditions and disease progression trajectories, care management cannot be completely standardized for people with dementia and their caregivers. However, more studies are needed to find care management models and practices that would be efficient and effective for a large segment of people with dementia and their caregivers.
In sum, for older adults with behavioral health needs and their informal support systems, care management has been an essential service that promotes their well-being by assisting them with needs assessments, care planning, links to resources, education, and treatment. With current and projected geriatric behavioral healthcare workforce shortages, care managers are likely to continue to be primary providers for older adults with behavioral healthcare needs, along with other LTSS needs. Increased support for training in and practice of evidence-based care management for these older adults will be of critical importance in a rapidly aging society.
Namkee G. Choi, PhD, is a professor and the Louis and Ann Wolens Centennial Chair in Gerontology in the School of Social Work at the University of Texas at Austin. Nancy L. Wilson, MSW, MA, is an associate professor of Medicine in the Section of Geriatrics and Palliative Care, Baylor College of Medicine, and Healthy IDEAS leader at the Baylor College of Medicine in Houston, Texas.
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