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ELDER INDEPENDENCE: Where Policy and Practice Meet to Define a New Standard of Care

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Fixing Depression in the Elderly: Reforming the Health Care System One Barrier at a Time
by Ilaina Edison

As the Senior Vice President of Operations for the nation's largest not-for-profit home health care organization, The Visiting Nurse Service of New York (VNSNY), I oversee programs in Behavioral Health, Children and Family Services, Long Term Home Health Care, and Rehabilitation Services among others. Everyday I'm confronted with a different "Achilles heel" in our health care system. My colleagues and I work to design viable solutions that make sense both ethically and economically.

With this new blog, I'll be sharing strategies for change that come straight from the trenches. In this debut post, we'll be looking at the very real problem of depression in the elderly. My hope is that you'll be inspired to share your own stories and that you'll ask questions--of me, of our government, of each other--and that together we can, as Gandhi said, "be the change we wish to see."

Depression is a serious and largely untreated concern for elderly Americans--one that places a significant burden on our health care system. Research shows that roughly 10-20 percent of the elderly seen by primary care doctors have clinically significant depression, and major depression is twice as common in elderly patients receiving home care than in those receiving primary care. What's more, a 2009 National Institute of Mental Health analysis shows that health care costs for Medicare beneficiaries with depression are significantly higher than costs for beneficiaries who are not depressed. Depression in the elderly leads to significantly higher rates of hospital readmissions, medication confusion and non-compliance, as well as complications associated with heart disease, diabetes and other conditions commonly found in aging populations.

Yet Medicare beneficiaries with depression receiving home health care frequently go completely untreated--a problem that becomes particularly worrisome when we consider the expected growth in our senior population over the next few decades.

The good news is that the provider community and the Medicare system can facilitate appropriate depression diagnosis and treatment in the elderly population via policy action.

Despite the fact that standard mental health assessments and treatment efficacy reports for elderly depression are widely available, primary care providers often say they are unaware of assessment and treatment protocols. This may be why so many hospitalized seniors aren't receiving routine depression evaluations--even when they have a documented history of depression.

Obviously, when hospital discharge, orders don't include evaluation for depression, physicians' orders for home care services are not likely to include depression treatment recommendations for post-hospitalization home care.

To address this issue, standards for assessing depression in the inpatient setting must be developed and implemented. This can be achieved through the Medicare hospital accreditation process as well as by amending clinical practice guidelines to include medical experts' recommendations for when and how to assess and treat depression in the elderly.

The Centers for Medicare and Medicaid Services should also consider implementation of a quality initiative to drive the dissemination of evidence-based best practices for diagnosing and treating depression in the elderly.

Home care services play a vital role in keeping the elderly connected to medical care when they are medically unstable and unable to leave their home on a regular basis. The same is true for mental health care. Studies have demonstrated that depression can be effectively treated in a home care environment, but Medicare regulations create two major barriers for home care agencies seeking to deliver and receive adequate reimbursement for depression treatment.

As of January 1, 2010, Medicare requires that assessment data (known as OASIS C) on depression symptoms be collected during the admission visit to home care. But what about those patients who don't present with depression symptoms right away? In many patients, depression is clearly revealed only after their behavior has been observed for a couple of weeks or more.

The first barrier is the payment structure. In order to receive added payment from Medicare for depression treatment, home care agencies must identify depression as a diagnosis at the point of admission to home care. As noted above, inpatient physicians rarely identify depression at hospital discharge. As a result, home care agency staff typically identify a patient's depression after home care visits have been initiated. Medicare regulations then mandate standard reimbursement rates, which do not account for the additional services associated with treating depression. These unadjusted rates create a disincentive for home care agencies to identify depression in patients who do not have an initial diagnosis of depression. Adjusting the reimbursement rates to account for treating depression regardless of when it is discovered would create an incentive for home health agencies to make the necessary investments to identify and treat depression in this highly vulnerable patient population.

In addition, not every case of depression is alike--severity varies widely and is highly individualized. Yet Medicare payment for depression reflects only the presence or absence of a diagnosis and not the utilization of therapy services.

Medicare reimbursement for depression therapy should be based on individual diagnosis and need. Elders with depression would be much better served by a utilization model like the one used for rehabilitation services, where patients receive treatment and therapy based on the care needed in order for the patient to heal.

The second barrier relates to medical oversight requirements, specifically, which professional disciplines can order depression treatment. Medicare regulations impede treatment for homebound patients who need ongoing mental health therapy after becoming homebound. Regulations require a physician to order treatment for depression, even though they commonly are not involved in providing the treatment, and there is no provision for non-physician therapists to order and oversee the delivery of a behavioral health plan of care in a home care setting.

Advanced practice nurses, such as Nurse Practitioners, who treat patients in the community should be allowed to order and oversee home care therapy for their patients with depression.

As our population ages, illnesses associated with aging will place increasing demands on America's health care system. Depression is one such demand. Elder depression leads to higher health care costs, poor quality of life, and increased caregiver burden. Yet depression in the frail elderly often goes untreated. Home health care can provide a realistic solution, but only if public policy alleviates the barriers to care and offers incentives through more appropriate regulatory and payment mechanisms. As our nation actively debates health care reform, depression in the elderly is one issue that should no longer be ignored.

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