Our first hypothesis, that most older adult social services clients receiving in-home care management assessments are utilizing healthcare and human services, was partially confirmed. As expected in older adults with high levels of physical illness and functional impairment, nearly all (91%) Eldersource clients reported using healthcare services in the 90 days prior to care management assessment. However, only about half (47%) indicated human services utilization. Furthermore, the average user of healthcare services reported using almost 3 services while the average user of human services indicated using only about half as many, 1.5 services. Although fewer clients accessed human services, utilization would likely increase following agency intervention as care managers initiate supportive services for their clients.
Our second hypothesis, that being distressed is associated with greater likelihood of using healthcare and human services than being non-distressed, as well as with greater amount of use among service users, was also partially verified. The proportion of clients with any healthcare use was virtually the same for the distressed and the non-distressed (91.3% versus 90.8%). The percentage of clients who had used human services was higher for the distressed in comparison to the non-distressed subjects (51.3% versus 44.0%), but this difference was not statistically significant. Consistent with our hypothesis and with prior research on older adults in primary care (Luber et al., 2001
), distressed social service agency clients utilized more types of healthcare services (e.g., mental health, intensive medical, and other health services) than did the non-distressed clients. Among clients with any healthcare use, those who were distressed reported using an average of about 30% more healthcare services than the non-distressed, while among those with any human service use there was no difference in the intensity of human services utilization. Although distressed clients did not utilize more formal human services, it is possible that distressed clients may have relied more heavily on informal sources of support (e.g., spouses, caregivers) than non-distressed clients. The high rates of healthcare service use among the mentally distressed ASPN clients suggest that interventions to reduce clients’ psychological distress could help contain healthcare costs.
Our third hypothesis, that the majority of distressed ASPN clients have not received mental healthcare from a medical professional or mental health specialist for their mental illness, was partially confirmed as well. Relatively few distressed clients reported accessing mental health services, but over half reported discussing their mental health with a medical professional in the past year. These findings are congruent with research suggesting that older adults infrequently access specialty mental healthcare and are more willing to address their mental health concerns to a primary care doctor (Crabb and Hunsley, 2006
). Consistent with the high levels of distress among agency clients (42% had clinically significant anxiety and/or depression), a third of all clients and half of those classified as distressed were prescribed a psychotropic medication, presumably by their primary care providers in most cases. Yet clients remained symptomatic, suggesting, consistent with research conducted in primary care (Unutzer et al., 2000
; Licht-Strunk et al., 2009
), that the intensity or type of treatment received prior to agency intake may have been inadequate. The ASPN, therefore, seems well situated to detect and facilitate more effective treatment for those depressed seniors who fall through the cracks of the primary care system.
In the United States close collaboration between the ASPN and primary care sectors in the care of their mutual patients should be possible, to the added benefit of the client. However, a very small proportion of clients (both distressed and non-distressed) was referred by a primary care provider to the social services agency. Exploration of how to integrate healthcare and human service delivery for these older adults in whom combined physical and social morbidities are the rule is indicated. Furthermore, to improve mental healthcare outcomes, some have advocated the development of collaborative care models that, in addition to linking primary and mental healthcare providers, incorporate community-based social services agencies as well (Alexopoulos and Bruce, 2009
Collaborative care approaches to the treatment of depression (Unutzer et al., 2002
) and anxiety (Roy-Byrne et al., 2001
) that incorporate mental health expertise into primary care clinics have shown promise in improving mental illness treatment in a relatively cost-effective manner (Katon et al., 2005
; Unutzer et al., 2008
). Less work has been done in home health and community-based social service settings, however, and it is unclear what services in these settings would be most cost effective. There was enough evidence, however, for a national panel of community practitioners and mental health experts to strongly recommend in-home depression care management of older adults suffering from low levels of depression; social services programs could provide such care (Steinman et al., 2007
). Bruce and colleagues have shown that training of visiting nurses in assessment of depression increased referrals for diagnosis and treatment, leading to improved patient outcomes (Bruce et al., 2007
). Others have reduced depression severity among community-based social service agency clients with a multimodal intervention that included screening, patient education, and psychotherapy delivered by social services case managers (Quijano et al., 2007
Because they routinely deliver care in the home, social work care managers are well positioned to detect possible mental illness in their elderly clients, facilitate communications, contribute to the diagnostic assessment, and actively collaborate with primary care and mental health partners by supporting the clients’ adherence to prescribed care, delivering psychosocial components of care, and monitoring side effects and response to treatment. Their expertise and access to resources to address comorbid social factors may well boost response rates beyond those seen in more traditional collaborations between primary and mental healthcare sectors only (Bruce et al., 2004
; Unutzer et al., 2002
). One such example is the Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) in which community agency social workers were trained in behavioral activation and problem-solving therapy to treat minor depression and dysthymia in older adults, resulting in a significant reduction in depressive symptom severity relative to care as usual (Ciechanowski et al., 2004
Our findings have a number of limitations to consider. First, this study’s measure of service utilization is by self-report unverified by clinical or administrative records. Second, limiting our discussion of psychiatric treatment received is that we did not examine use of psychotherapy specifically or prescription medication class and dosage; we also do not know what proportion of clients who reported using services received evidence-based treatment. Third, we examined associations rather than cause and effect relationships. Fourth, we did not adjust for multiple comparisons because such adjustments can be overly conservative, inflate the risk of type II errors, and have a number of other limitations (Perneger, 1998
). Consequently, we risk spurious findings and the results should be cautiously interpreted in that light. Last, our research was conducted within a single aging services agency. Access to both healthcare and human services varies considerably by location, and there is a wide diversity of services and settings present in the ASPN. The patterns and correlates of service utilization by ASPN clients would likely differ in other regions and agencies. Our findings best generalize to social service agencies that have a gatekeeper function in that they first evaluate and then refer community-dwelling older adults to a set of services and programs suited to the clients’ unique circumstances and needs.
In summary, our findings suggest: 1) clients entering the ASPN have used multiple healthcare but few human services, 2) a large proportion of older adults receiving in-home care manager assessments are mentally distressed (i.e., anxious and/or depressed), 3) the distressed aging service clients utilize more healthcare services than the non-distressed group, and 4) the majority of the distressed clients have discussed their mental health with a medical provider and half received prescription medication for it, although few have seen a mental health professional. Innovative approaches that link the delivery of social services to primary and mental healthcare are needed to reduce the burden of mental illness among aging services agency clients. Further research is warranted to understand the longitudinal course of anxiety and depression in these seniors, the impact that ASPN services have on anxiety and depression, and the most effective and sustainable means by which the social service providers may partner with primary and mental health sector providers in the coordinated care of their older adult clients with mental illnesses.