    [Senate Hearing 117-269]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 117-269

                      MENTAL HEALTH CARE FOR OLDER ADULTS:
                     RAISING AWARENESS, ADDRESSING STIGMA,
                             AND PROVIDING SUPPORT

    =======================================================================

                                    HEARING

                                   BEFORE THE

                           SPECIAL COMMITTEE ON AGING

                              UNITED STATES SENATE

                        ONE HUNDRED SEVENTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 WASHINGTON, DC

                                   __________

                                  MAY 19, 2022

                                   __________

                               Serial No. 117-17

             Printed for the use of the Special Committee on Aging

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

            Available via the World Wide Web: http://www.govinfo.gov

                          ______

                 U.S. GOVERNMENT PUBLISHING OFFICE
    47-697PDF           WASHINGTON : 2022

                           SPECIAL COMMITTEE ON AGING

                  ROBERT P. CASEY, JR., Pennsylvania, Chairman

    KIRSTEN E. GILLIBRAND, New York      TIM SCOTT, South Carolina
    RICHARD BLUMENTHAL, Connecticut      SUSAN M. COLLINS, Maine
    ELIZABETH WARREN, Massachusetts      RICHARD BURR, North Carolina
    JACKY ROSEN, Nevada                  MARCO RUBIO, Florida
    MARK KELLY, Arizona                  MIKE BRAUN, Indiana
    RAPHAEL WARNOCK, Georgia             RICK SCOTT, Florida
                                         MIKE LEE, Utah
                                  ----------
                     Stacy Sanders, Majority Staff Director
                     Neri Martinez, Minority Staff Director

                             C  O  N  T  E  N  T  S

                                  ----------

                                                                       Page

    Opening Statement of Senator Robert P. Casey, Jr., Chairman......     1
    Opening Statement of Senator Tim Scott, Ranking Member...........     2

                               PANEL OF WITNESSES

    Erin Emery-Tiburcio, Ph.D, ABPP, Co-Director, Rush Center for
      Excellence in Aging, Chicago, Illinois.........................     5
    Kenneth Rogers, M.D., MSPH, MMM, State Director, South Carolina
      Department of Mental Health, Columbia, South Carolina..........     7
    Kimberly Williams, President and CEO, Vibrant Emotional Health,
      New York, New York.............................................     8
    Jim Klasen, Certified Older Adult Peer Specialist (COAPS)
      Facilitator, Elkins Park, Pennsylvania.........................    10

                                    APPENDIX
                          Prepared Witness Statements

    Erin Emery-Tiburcio, Ph.D, ABPP, Co-Director, Rush Center for
      Excellence in Aging, Chicago, Illinois.........................    31
    Kenneth Rogers, M.D., MSPH, MMM, State Director, South Carolina
      Department of Mental Health, Columbia, South Carolina..........    46
    Kimberly Williams, President and CEO, Vibrant Emotional Health,
      New York, New York.............................................    48
    Jim Klasen, Certified Older Adult Peer Specialist (COAPS)
      Facilitator, Elkins Park, Pennsylvania.........................    55

                            Questions for the Record

    Erin Emery-Tiburcio, Ph.D, ABPP, Co-Director, Rush Center for
      Excellence in Aging, Chicago, Illinois.........................    61
    Kenneth Rogers, M.D., MSPH, MMM, State Director, South Carolina
      Department of Mental Health, Columbia, South Carolina..........    63
    Kimberly Williams, President and CEO, Vibrant Emotional Health,
      New York, New York.............................................    65

                      MENTAL HEALTH CARE FOR OLDER ADULTS:

                     RAISING AWARENESS, ADDRESSING STIGMA,

                             AND PROVIDING SUPPORT

                                  ----------

                             THURSDAY, MAY 19, 2022

                                           U.S. Senate,
                                    Special Committee on Aging,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 10 a.m., via
    Webex, Room 562, Dirksen Senate Office Building, Hon. Robert P.
    Casey, Jr., Chairman of the Committee, presiding.
        Present: Senators Casey, Gillibrand, Blumenthal, Kelly,
    Warnock, Tim Scott, Collins, Braun, and Rick Scott.

                     OPENING STATEMENT OF SENATOR
                     ROBERT P. CASEY, JR., CHAIRMAN

        The Chairman. Good morning. The Special Committee on Aging
    will come to order. The hearing of this Committee will come to
    order.
        Today, we are here to discuss a topic of growing and, I
    think, urgent national concern, which is the mental health
    crisis that is ravaging our Nation, including and especially
    our Nation's seniors. It is a topic that too often is discussed
    behind closed doors due to the unrelenting and unwarranted
    stigma attached to this issue.
        It is estimated that one in four--one in four--older adults
    experiences a mental health condition, including depression,
    anxiety or substance use disorder. In 2020, Americans who were
    85 years of age or older had the highest suicide rate of any
    group of Americans.
        Many seniors are in pain and struggling to find help. In
    the year before the pandemic, more than 30,000, just by example
    in one State, 30,000 Pennsylvanians looked to the state mental
    health authority for support. I imagine that number would be
    even higher if more seniors knew this kind of care was
    available, and again, that was before the pandemic.
        The pandemic has only worsened this crisis, as older adults
    have been forced to isolate in their homes, away from their
    family and friends. The resulting social isolation and
    loneliness has taken a terrible toll on older adults across the
    country. Research shows that social isolation has the same
    adverse impact on health as smoking 15 cigarettes a day, and it
    is correlated with an increased risk of depression.
        Today we will hear from a panel of witnesses who will
    highlight the gaps in our mental health system, particularly
    for older adults, and they will offer solutions. We will hear
    from Jim Klasen from Elkins Park, Montgomery County,
    Pennsylvania. Jim and his family know the harsh realities of
    stigma all too well. He knows the unfairness of being judged
    for needing help with a mental health condition. In his
    testimony, Jim says the support he has received enables him to
    now share his experience without shame. The reality is that too
    many older adults today face fragmented systems and roadblocks
    that prevent them from accessing the support that they need.
        Both Congress, House and Senate, and the Biden
    Administration are focused on this issue, and that is good news
    but we have got to get a lot more done. President Biden
    recently announced his ``unity agenda,'' which calls for
    expansions in the mental health workforce, and also promotes
    mental health care itself in the community, so that is
    important, and it is a big step forward, but it is now time for
    Congress to act.
        Ranking Member Tim Scott and I are introducing a bipartisan
    resolution, the very first of its kind, to raise awareness
    about the impact of mental health conditions and substance use
    disorder on older adults. Today, Ranking Member Scott and I
    will also be introducing the Advancing Integration in Medicare
    and Medicaid Act, which requires states to develop a plan to
    address the fragmentation in Medicare and Medicaid. These are
    the very programs which so many older adults rely upon for
    their mental health.
        I am introducing, as well, a bill to give states funding to
    execute these plans so that individuals can have meaningful
    access to all of their health care needs. This includes primary
    care, mental health, long-term care, and more.
        We have got work to do, but we are grateful that we have
    this opportunity to have this hearing today, and I will now
    turn to our Ranking Member, Ranking Member Scott.

                     OPENING STATEMENT OF SENATOR
                       TIM SCOTT, RANKING MEMBER

        Senator Tim Scott. Thank you, Chairman Casey, for holding
    another truly important hearing. To the guest panelists, thank
    you so much for participating in this process. Without
    question, your expertise will lend itself to us uncovering more
    solutions and providing more assistance to those who are
    certainly in need of that assistance.
        I would also like to take the time to recognize the
    students behind the witnesses, the University of South
    Carolina's pharmacy students, who are part of the Walker
    Scholars Program. They have decided to join us for the next
    three or four hours. I appreciate you all sticking around for
    the entire time. That was my joke and no one thought it was
    funny, but the good news is it was not that funny, but the
    truth is I am always happy to see folks in a room from my home
    State, and thank you so much for taking your time and investing
    a part of it in this important topic, and without any question,
    as the students are here with us, it really is important for
    us, Chairman Casey, to stress the importance of the Mental
    Health Awareness Act that we have both sponsored.
        The truth is that too many of our seniors and, frankly, our
    general population, continue to feel this heavy weight on their
    shoulders, and it is one that is palpable. I think it is true
    at all ages. There is no doubt that the suicide rate amongst
    our youngest Americans is way too high, and the same is true
    with our seniors.
        I was talking to someone recently, just yesterday, and we
    were walking through one of my constituent calls, the rising
    crime and the officers that have been shot at a record level in
    the highest number of incidents focusing and targeting our
    officers in, frankly, the Nation's history.
        We watched in Buffalo another racist attack. You go to the
    gas pump, and in South Carolina the gas prices doubled in less
    than 2 years. The fact of the matter is, if you are involved in
    an accident, which actually happened to the constituent's son
    yesterday, there are no rental cars. The parents who are
    looking for formula cannot find it.
        There are reasons why Americans feel a level of burden and
    stress and challenges. It is the fact that economically, crime,
    safety, security, loneliness----I think it was Surgeon General
    Murthy who said that loneliness is like smoking 15 cigarettes a
    day----and just thinking about that is a lot for the average
    person coming out of a pandemic, and the lingering effect is
    undeniable.
        That is why I am so thankful that Chairman Casey and I have
    worked diligently in a bipartisan fashion. There are many
    Americans who think nothing in Congress ever happens with the
    two sides coming together. Simply false. The truth is, all that
    we accomplish in the U.S. Senate requires a bipartisan
    coalition, and that is a blessing to the great United States of
    America.
        One of those is the AIMM Act that Senator Casey has already
    described. Another one that I am working on is the ACADEMIC
    Act. It authorizes a comprehensive study of the long-term
    impact of COVID-19 and associated school closures, especially
    on children from low-income families. This bill is sponsored by
    Senator Rubio, Chairman Casey, and myself. Substance abuse, of
    course, and overdose deaths are skyrocketing as a result of the
    mental health crisis that we have seen.
        For the first time, overdoses have exceeded 100,000 in
    America, around 107,000, more than car accidents for the first
    time. The lifetime odds of dying from opioid overdose are now
    higher than those car accidents.
        To tackle opioid misuse and raise awareness, South Carolina
    launched a campaign called Just Plain Killers, particularly
    among the aging population who are prescribed opioids for
    chronic pain. In addition to the substance abuse, many seniors
    were plagued, as Senator Casey said, with loneliness, and I
    will do my best not to reiterate what he has said unless it is
    just necessary. Sometimes it is necessary to emphasize or re-
    emphasize the importance of the challenges that so many of our
    seniors face.
        Also, in addition to that, I mentioned the deaths of our
    law enforcement officers, and the worst situation for those
    officers is to go to a domestic situation. It is one of the
    reasons why in Richland County, law enforcement officers
    received over 2,700 calls just in a year related to mental
    health crisis--not a crime, but a crisis, so we have
    legislation that focuses on the importance of co-responders so
    that you actually have officers and mental health experts going
    to the scene so that we can address the issues in the home
    without making it necessarily a crime.
        These are some of the topics that we will discuss and some
    of the important issues that we will have to face as a
    bipartisan coalition of people who believe in the future of
    America, and we are going to get it done.
        Thank you all for being experts and providing your
    expertise with us today.
        The Chairman. Thank you, Ranking Member Scott. I will next
    turn to witness introductions. I will do several and Ranking
    Member Scott I know will do one of our introductions.
        Our first witness is Dr. Erin Emery-Tiburcio. Dr. Emery-
    Tiburcio is an Associate Professor of Geriatric and
    Rehabilitation Psychology and Co-Director of the Center for
    Excellence and Behavioral Health Disparities in Aging at Rush
    University Medical Center. She has a Ph.D in clinical
    psychology and completed her following in clinical
    geropsychology.
        Thank you, Doctor, for being here with us today and sharing
    your expertise with the Committee, and we will turn next to
    Ranking Member Scott.
        Senator Tim Scott. Thank you, Chairman Casey. It is my
    honor to introduce to all Dr. Ken Rogers. He helps South
    Carolinians navigate the mental health system as the Director
    of the South Carolina Department of Mental Health. The
    department operates 16 community-based outpatient mental health
    centers, clinics across all 46 counties, and 3 hospitals,
    including one for addiction treatment.
        He has a long history of working to expand mental health
    services to underserved populations. He collaborates with
    traditional and nontraditional partners, including law
    enforcement. He is a native of the area called Dillon, South
    Carolina, and a graduate of the University of South Carolina
    School of Medicine. He completed his general psychiatry
    residency in child and adolescent psychiatry fellowship at the
    William S. Hall Psychiatric Institute at the University of
    South Carolina.
        He earned a master of science and public health from the
    University of California Los Angeles. He is bicoastal. He holds
    a master's in medical management from the University of
    Southern California. Prior to coming back to South Carolina he
    was the Chief of Psychiatry at Parkland Health and Hospital
    Corporation in Dallas, Texas.
        In his testimony, Dr. Rogers will talk about his
    department's work in providing mental health services and the
    pandemic's impact on mental health, especially for caregivers
    and our veterans.
        We look forward to hearing your testimony and we thank you
    sincerely for being here.
        The Chairman. Thank you, Ranking Member Scott. Our third
    witness is Kimberly Williams. Ms. Williams is the President and
    CEO of Vibrant Emotional Health. She has overseen the expansion
    of Vibrant's community-based programming to support older adult
    mental health. I want to thank Ms. Williams for being with us
    today and sharing your expertise with the Committee.
        Finally our fourth witnesses is Jim Klasen from, as I
    mentioned earlier, Elkins Park, Pennsylvania, Montgomery
    County, right near Philadelphia. Jim will share his recovery
    journey with the Committee. He is a Certified Peer Specialist
    Facilitator, Advanced Level WRAP Facilitator, and Certified
    Older Adult Certified Peer Specialist trainer. He brings over
    40 years of experience in human services and in the workforce
    development field.
        Jim, I am grateful you are here with us today, and I hope
    that picture you took with me earlier does not get you into any
    trouble back home, but thanks for being with us today.
        We will turn to our first witness. Dr. Emery-Tiburcio, if
    you would present your testimony and then we will go to our
    next witnesses. Thanks very much.

                STATEMENT OF ERIN EMERY-TIBURCIO, PH.D,

                   ABPP, CO-DIRECTOR, RUSH CENTER FOR

                 EXCELLENCE IN AGING, CHICAGO, ILLINOIS

        Dr. Emery-Tiburcio. Thank you so much. Good morning,
    Chairman Casey, Ranking Member Scott, and distinguished members
    of this Committee. Thank you so much for the opportunity to
    speak with you today about mental health and substance use
    issues. My name is Erin Emery-Tiburcio and I co-direct the Rush
    Center for Excellence in Aging at Rush University Medical
    Center in Chicago.
        The White House has recognized mental health and substance
    use as critical issues for all Americans, and I am grateful
    that this Committee recognizes that older adults' needs are an
    issue of equity. Not only is stigma about mental health and
    substance a barrier to effective screening and treatment and
    assessment but that stigma is compounded by systemic ageism
    that has resulted in severely lacking access to care for older
    adults.
        Today I will point to three key issues for this Committee
    to consider in terms for the need for coordination for care for
    older adults who experience the most complex health issues, and
    access to care related to Medicare policies, and finally, the
    critical need for behavioral health workforce, trained to work
    with older adults.
        I co-direct the SAMHSA-funded E-4 Center of Excellence for
    Behavioral Disparities in Aging, which has offered policy
    academies in three states--Illinois, Nebraska, and
    Pennsylvania--in our first year and a half. These three-part
    events bring together leaders of State entities from aging,
    mental health, substance use, transportation, housing, and
    others who rarely communicate with each other in their silos,
    and we bring them together for facilitated discussion to
    identify and fill gaps in meeting the needs of older adults
    with mental health and substance use issues.
        We are honored currently to partner with the Pennsylvania
    Association of Area Agencies on Aging in our current policy
    academy. This committed and passionate group of policy academy
    members have highlighted these three issues, which we have seen
    in other states and across the country, in addition to the
    importance of telehealth and broadband access. Thank you,
    Senator Scott, for your fantastic work in this area.
        Older adults with mental health and substance use issues
    are more likely to have chronic medical conditions, multiple
    medications, multiple health care providers, and multiple
    community-based organizations providing services, all of which
    put them at incredible risk for falling into the chasms of our
    fragmented health care system, and because supportive housing
    in the community is rarely available or paid for, older adults
    with serious mental illness are more likely to be placed in an
    expensive nursing home that they do not want to be in and is
    ill-equipped to meet their needs.
        Providing reimbursement for care coordination across health
    system and across community-based organizations for older adult
    is not only critical for equitable care but has been shown to
    reduce costs, particularly for individuals who are dually
    eligible for Medicare and Medicaid. These dual-eligible older
    adults and, quite frankly, every older adult with Medicare,
    struggles to find available mental health and substance use
    services.
        Part of the reason for this is that Medicare reimbursement
    rates for older adult mental health and substance use is
    inadequate for engaging providers to enroll. Given that the
    highest rate of suicide, as you just highlight, Senator Casey,
    is among older adults, this lack of available mental health
    service is deadly.
        Allowing for market rate reimbursement for mental health
    and substance use services is critical to assure that adequate
    provider enrollment, and further, consideration must be given
    to allow master's level clinicians eligibility to enroll in
    Medicare so that therapeutic relationships do not have to end
    just because someone turns 65.
        An additional challenge is that a tiny fraction of the
    required behavioral health providers with specialized training
    in working with older adults are available, so in fact, some
    states do not even have a single board-certified
    geropsychologist or geriatric psychiatrist. I am the only one
    in the State of Illinois.
        We are so grateful to Senator Casey for being a champion
    for funding the Geriatric Workforce Enhancement Programs, or
    GWEPs, as we call them, which are tasked with educating the
    health care workforce and the community about older adult
    health, along with transforming primary care to be age
    friendly. Proposed support for additional GWEPs with larger
    budgets, and critically, increased focus on older adult mental
    health and substance use would allow every region of the United
    States to have access to that high-quality training.
        Finally, while children and families have been a consistent
    focus, which is important, Federal mandates for SAMHSA have not
    included older adults. With the unprecedented increase in older
    adult population in the U.S., legislation to mandate the
    permanent inclusion of older adults in SAMHSA priorities is
    desperately needed, along with expanding the HRSA-funded
    Graduate Psychology Education and Teaching Health Care Graduate
    Medical Education programs.
        I am grateful to this Committee for considering including
    access to care related to Medicare policies, coordination of
    care for older adults with complex health issues, and the
    critical need for expanding the behavioral health workforce
    trained to work with older adults.
        Thank you so much.
        The Chairman. Doctor, thanks so much for your testimony.
    Before turning to Dr. Rogers I want to note the presence of
    Senator Collins, former Chair of this Committee.
        Dr. Rogers?

             STATEMENT OF KENNETH ROGERS, M.D., MSPH, MMM,

               STATE DIRECTOR, SOUTH CAROLINA DEPARTMENT

               OF MENTAL HEALTH, COLUMBIA, SOUTH CAROLINA

        Dr. Rogers. Thank you Chairman Casey and Ranking Member
    Scott for the opportunity to be here today.
        The South Carolina Department of Mental Health is a
    comprehensive, statewide health system that is comprised of 16
    mental health centers that cover the entire State and provide
    whole-person care, meaning that we are focused on both the
    physical and mental health care of our patients. We work in
    concert with federally qualified health centers, health
    systems, as well as non-traditional locations of service
    including schools, churches, and other community partners.
    Additionally, we operate two freestanding psychiatric
    hospitals, an inpatient substance treatment facility, and five
    veterans' nursing homes.
        Like all states, South Carolina has seen an increase in the
    number of individuals seeking care throughout the pandemic. The
    two populations seeing the greatest increase are the youth and
    the elderly.
        We have identified several reasons for this increased
    service need. First, social isolation has had an incredible
    impact on our elderly population. The activities that seniors
    in South Carolina often find helpful, such as attending
    religious services and going to day programs, among other
    community services, have been unavailable during the pandemic.
        Second, is the sense of loss that has been experienced.
    Over a million Americans have died from COVID or its
    complications. Greater than 75 percent of COVID deaths was
    among individuals ages 65 and older. The majority of elderly
    individuals have experienced at least one personal loss over
    the past 2 years. Further complicating issues is that many
    programs serving the elderly either shut down or moved to a
    virtual platform during the pandemic.
        The expansion of telehealth has been able to fill this
    void. SCDMH, the Department of Mental Health, cares for
    approximately 100,000 individuals yearly. Twenty percent of
    those individuals are older than age 55. In April 2020, the
    department moved all of our services virtually and
    telephonically. Within 2 months, we had at least one
    therapeutic contact with 99.9 percent of all the patients that
    we were seeing pre-pandemic.
        Part of the reason is that we have been successfully
    shifting to telehealth over the course of 20 years, and is now
    the largest telehealth provider in the State of South Carolina.
    Additionally, because we are a unified service delivery system,
    we were able to track centrally all of our services that are
    being delivered throughout the system and move assets as
    needed.
        Telehealth has certainly not been a panacea, as many of our
    patients live in areas with limited broadband coverage or do
    not have devices that afforded them adequately provide care, or
    cellular plans that afford them the opportunity to connect full
    time. Thankfully, we are now fully operational and able to
    provide telemedicine as well as in-person care. We have found
    that our elderly population as adjusted very well to these
    changes.
        The challenges for providing care among aging populations
    are numerous. One of the biggest challenges has been an
    increase in substance use during the pandemic. Since Federal
    funding for substance use and mental health treatment are split
    at the Federal level, developing programs that address these
    co-occurring issues is often difficult and challenging.
        Second, many organizations do not provide both mental
    health and medical services in the same location. As a result,
    many older Americans have to visit multiple locations in order
    to obtain services. Each additional visit increases the
    likelihood that they will not obtain services or drop out of
    services.
        There are several areas where South Carolina has done an
    exemplary job. We have developed excellent partnerships with
    law enforcement to make sure that officers are provided the
    skills needed to identify and services in a mental health
    crisis. We have also increased our crisis intervention teams,
    where individuals are able to provide mental health care to the
    extent possible.
        South Carolina has been very committed to increasing
    services to our veteran population. The State has worked
    closely with the Department of Veterans Affairs to increase the
    number of veterans' nursing homes in South Carolina. The
    blending of State and Federal funding has allowed us to expand
    and make a difference.
        I appreciate the opportunity to appear before the Committee
    today, and I am proud to lead the 4,300 individuals at the
    South Carolina Department of Mental Health who strive each day
    to provide both physical and mental health care to all South
    Carolinians. Thank you.
        The Chairman. Dr. Rogers, thanks for your statement, and we
    will turn next to Ms. Williams, and I just want to note the
    presence, virtually, of Senator Rick Scott.
        Ms. Williams?

               STATEMENT OF KIMBERLY WILLIAMS, PRESIDENT

                   AND CEO, VIBRANT EMOTIONAL HEALTH,

                           NEW YORK, NEW YORK

        Ms. Williams. Thank you, Chairman Casey, Ranking Member
    Scott, and members of the Special Committee on Aging for the
    opportunity to provide testimony on the important topic of
    mental health care for older adults.
        My name is Kimberly Williams, and I am the President and
    CEO of Vibrant Emotional Health, a not-for-profit organization
    based in New York City that reaches over 3.5 million people
    every year. We work every single day to help save lives and
    help people get care anytime, anywhere, and in any way that
    works for them.
        Vibrant leads a broad-based coalition in New York that
    develops and advocates for changes in policy and practice that
    are essential to meeting the mental health needs of older
    adults. Vibrant also serves as the administrator of the
    National Suicide Prevention Lifeline, which provides crisis
    support services for individuals, including older adults
    experiencing a mental health emergency.
        The country faces what has been termed an ``elder boom,''
    or acknowledgment of the increased population growth of
    individual age 65 years and older. Older adults represent 54.1
    million individuals, roughly 1 in 7 Americans. Twenty percent
    of older adults aged 55 and older have a diagnosable mental
    health or substance use disorder. Sadly, most older adults with
    cognitive and behavioral disorders do not get adequate care and
    treatment.
        In addition, lower-income older adults who are both covered
    by Medicare and Medicaid are forced to navigate two complex
    insurance systems, each of which have different coverage and
    payment rules.
        Today I want to share with you the story of an older
    individual served by Vibrant through our Older Adult Assertive
    Community Treatment team, a community-based model that
    addresses the needs of adults with serious mental illness.
        A 62-year-old Caucasian woman located in the Bronx, New
    York, was admitted into the ACT program with serious mental
    illness and co-occurring chronic physical issues. She did not
    have stable housing and was using psychiatric hospitals as a
    housing solution due to stigma and verbal abuse she experienced
    within shelters.
        The interdisciplinary team of providers delivered her
    weekly trauma-focused therapy and assistance with taking her
    psychiatric medications. Through these and other interventions
    she was able to gain insight into her mental health condition,
    address her physical health needs, and utilize coping
    strategies.
        The ACT team advocated for her needs during appointments to
    ensure that she received appropriate treatment and resources.
    After a year in the program, her functioning improved enough to
    transition to a lower level of care. She voluntarily provides
    updates on her progress to the ACT team, and is incorporating
    many of the skills and strategies she learned within the
    program.
        Her story is but one of many success stories which
    illustrate the power of providing comprehensive, integrated,
    recovery-oriented supports tailored to the unique needs of the
    older individual. By addressing challenges holistically we are
    able to improve mental health outcomes and keep older adults
    thriving in the community, reducing the use of costly or
    inappropriate settings.
        As highlighted by this example, many older adults with
    mental health challenges also have chronic physical problems.
    Many older adults who seek treatment for late-onset mental
    health problems turn to their primary care physicians, making
    it critical to build linkages between mental health and
    physical health services, and to design integrated service
    structures.
        Similarly, many of the needs of older adults with mental
    health problems are addressed through the aging service system.
    This system offers opportunities for prevention,
    identification, sites for community-based treatment, and more.
    Linkages and new integrated service models between mental
    health and aging services are key to better service provision.
        A number of other recommendations can be implemented at the
    Federal, State, and local government levels to help improve
    older adult mental health care, including integrating mental
    health, substance use, physical health, and/or aging services,
    particularly for individuals who are eligible for both Medicare
    and Medicaid; improving access to mental health and substance
    use services including disseminating best practices; address
    the shortage of clinically and culturally competent workforce,
    in part by recruiting and training more providers, and also, in
    part, by including older adults themselves through paid and
    volunteer roles; and restricting how services are financed,
    particularly within Medicare and Medicaid so they are
    affordable, enhance integrated care and treatment, expand the
    types of providers available, and support services in the home
    and community settings.
        Vibrant stands ready to partner with members of this
    Committee, older adults with lived experience, and other
    stakeholders to implement these recommendations and improve
    mental health outcomes and quality of life for older Americans.
        Thank you again for your time and consideration of this
    very important topic.
        The Chairman. Ms. Williams, thanks very much for your
    testimony.
        Senator Blumenthal has joined us, and we will turn to our
    last witness, Jim Klasen.

                STATEMENT OF JIM KLASEN, CERTIFIED OLDER

               ADULT PEER SPECIALIST (COAPS) FACILITATOR,

                       ELKINS PARK, PENNSYLVANIA

        Mr. Klasen. Good morning Chairman Casey, Ranking Member
    Scott, and members of the Senate Special Committee on Aging.
    Thank you for allowing me to testify here today on the issue of
    older adults and mental health.
        My name is Jim Klasen. I am an older adult, 73 years old,
    who lives with mental and physical health challenges and a
    substance use disorder. Fortunately, today I am a person in
    recovery. Let me also say that I am grateful to the health care
    providers who cared for me when I needed it most. Professional
    intervention was necessary. However, it was not sufficient.
    What has sustained my recovery process over time has been what
    we call ``peer support.''
        By peer support, I mean people who have been through it,
    helping others who are going through it. This can be done
    professionally, with certified peer specialists, or informally
    as well, but peer support is not where my story started. Even
    in my 20's I knew something was wrong. Mental health challenges
    ran in my family. I did seek help and got some, but still there
    seemed to be difficulties I could not quite name.
        I moved to Philadelphia, Pennsylvania in 1986, for a great
    job opportunity, and that is when things really started to
    blossom, in ways both good and not so good. The new job was
    wonderful, but the profound depression that descended in about
    6 months' time, not so much, and to complicate matters, I
    started self-medicating in a very harmful way.
        I was a country kid who moved to the city determined to
    have the ``great urban adventure,'' and what started as a party
    blossomed into full-blown addiction, and I am talking
    Philadelphia in the mid to late 1980's, so we are talking about
    street drugs, the epidemic that preceded the current opioid
    crisis, and crack cocaine has not gone away by any means. What
    followed for several very difficult years were the devastating
    effects of my substance use on my family, the toughest part of
    my story to tell and for me to deal with to this day.
        Again I sought help, but help them focused on the drug use.
    We know now that an integrated approach to addressing mental
    health and substance use is more effective at getting at both
    the immediate troubling behavior and the underlying causes. My
    challenge was not that it was one problem or even two. I was
    navigating through this debilitating depression--my diagnosis
    is bipolar disorder. At the time, just getting a grip on the
    substance use seemed to be the most immediate priority. Old-
    school recovery just meant stop using. That was not enough,
    though, because I was using for a reason, although the exact
    underlying problem was not crystal-clear, even to me, and a
    diagnosis does not fully explain why anyone uses drugs that
    dangerous and powerful.
        Over time my recovery assumed a more comprehensive,
    integrated approach, and as I aged, so apparently did the
    field. After several hospitalizations, many ``Rehab After
    Work'' programs, medications, and several therapists, I was
    introduced to a self-help approach with an emphasis on wellness
    and less on illness.
        This appealed to me. The first question was, ``What are you
    like when you are well?'' and I can assure you no one at that
    time was asking me what I was like when I was well. They wanted
    to know what was wrong with me and why I was acting the way
    that I was. I felt hope. I felt connection with someone who
    possibly understood.
        Shortly thereafter I met two people at a wellness
    conference who introduced me to the concept of peer support,
    and that I could become a certified peer specialist and
    eventually a certified older adult peer specialist as well, so
    for 10 years now I have been a CPS, certified peer specialist,
    and a COAPS facilitator. Maybe the best thing is that I no
    longer have to manage these secret lives of addiction and
    mental illness. I can now share my experience without shame or
    stigma.
        Now as an older adult myself, though, I can relate to the
    reluctance, embarrassment, and stigma that many do face in
    dealing with and disclosing such challenges. It is hard to talk
    about. The population of older adults is growing, and we come
    with mental health, physical health, and yes, even substance
    use issues. From my personal experience and the experience of
    thousands of my peers and from research we know that peer
    support is one solution and one that is beneficial and cost
    effective.
        I am no expert on health policy, but I do share the
    concerns of other older adults for our future well-being. We
    have great programs and we know a lot more now than in the
    past, but we need more--more support and also more public
    awareness and education.
        I want to thank you for your time. I hope that sharing my
    lived experience with my mental health challenges and substance
    use can contribute, can help the policy and program
    conversation, and, of course, I look forward to answering any
    questions. Thank you..
        The Chairman. Thanks very much, Mr. Klasen, for sharing
    your personal experience. That is always of great benefit, not
    only to those who are part of this hearing but I think people
    well beyond this room, and we are grateful you are willing to
    do that, and I am so grateful for all of our witnesses.
        Before I turn to our first set of questions, I also want to
    acknowledge Senator Warnock is here with us at the hearing
    virtually.
        Jim, I will start with you, and what I just mentioned about
    you sharing your story. You talked about that terrible word
    ``stigma,'' which just has enveloped so many of these issues
    for so long, and it becomes, I guess, a barrier for folks to
    seek help or to be able to overcome the challenge that they
    have.
        You had shared that that stigma led to self-medicating and
    you described for us what that meant in your life, and that
    eventually you found the support you needed and now you are
    able to help others, not only generally with these challenges
    but also help them with this issue of stigma.
        I guess my first question is what can we do--we meaning the
    U.S. Senate, the U.S. House and Members of Congress--to address
    just that issue? There is lots to talk about, but that issue of
    stigma surrounding mental health to ensure that older adults
    feel both comfortable in seeking care but also supported when
    they try to avail themselves of that care.
        Mr. Klasen. Thank you. Thanks for the question, Senator
    Casey. I think there is a lot we all can do, but certainly,
    yes, in the Senate.
        I think that there is an issue of, you know, just public
    awareness. Increasingly, we do see people coming out and
    talking about their mental health challenges and substance use
    challenges, whether celebrities or sports figures or, you know,
    at any level in our society, and I think every time that
    happens it opens a door for someone to say, ``Maybe it is okay
    for me to talk about this.'' Maybe it is okay for me to talk
    about this with my family, maybe in my community, my faith-
    based, wherever it is, and I think it is just an incremental
    process.
        The Chairman. Is the mic not on?
        Mr. Klasen. Oh, I am sorry. There it goes. It is on now.
        The Chairman. Maybe you could just reiterate, briefly, what
    you just said.
        Mr. Klasen. Yes. Yes, thank you for your question, Senator
    Casey, and what I was saying is I think there is a lot that we
    can all do, and certainly, sure, it starts at the top of our
    society and throughout.
        For folks who are willing to come out and talk about mental
    health and substance use--and we see it increasingly. I think
    it is happening, but I also see in the media, right, in the
    mass media, mental health and substance abuse. There is just a
    lot of education that needs to happen.
        The Chairman. No question about it, and I think that is
    true across the board. I wanted to--and I will keep it in my
    time because I know we want to get to other Senators--I wanted
    to ask a question of Dr. Emery-Tiburcio about these silos that
    we often identify with regard to mental health coverage for
    individuals when they have coverage both under Medicare and
    Medicaid. You described how navigating these two separate
    health care programs results in both confusion and unnecessary
    barriers to care.
        I mentioned references to Pennsylvania. We have got about
    400,000 folks in our State who are enrolled in both programs, 9
    million seniors and people with disabilities, so it is a big
    number.
        Can you speak to how greater alignment of both programs
    would help older adults access quality mental health services?
        Dr. Emery-Tiburcio. Yes. Thank you, Senator, for an
    important question, so you are well aware of the navigation of
    Medicaid and Medicare and how complex they are on their own,
    and much more complex when an older adult has to navigate both
    for many conditions.
        It is interesting, the legislation that you and Senator
    Scott have proposed to expand the PACE program may be a key to
    this work, so PACE programs provide highly integrated care, and
    as has been highlighted, the critical nature of integrated care
    for older adults, to manage the entire benefit of dual-eligible
    individuals, thus simplifying and significantly enhancing that
    care, but because PACE programs are often not real well-
    equipped to manage mental health and substance abuse, one
    potential to manage those silos would be to create a
    partnership with HRSA and SAMHSA-funded certified community
    behavioral health centers that may be ideal to assure that all
    of the home and community-based services provided by PACE and
    the specialty services provided by these CCBHCs may be able to
    effectively coordinate that care.
        One critical element there, as well, is that additional
    training, perhaps by geriatric workforce enhancement programs,
    to both PACE programs and CCBHCs about older adult-specific
    needs may be critical, and certainly E-4 Center would be happy
    to collaborate in that effort.
        The Chairman. Doctor, thanks very much. I will turn next to
    Ranking Member Scott.
        Senator Tim Scott. Thank you, Chairman. I would like to
    continue on the discussion of the dual-eligibles. Dr. Rogers,
    can you explain the benefits of dual-eligible integration and
    how this will help states improve care once it is implemented?
        Dr. Rogers. Absolutely. If you look at South Carolina, for
    example, and you have got someone that has a mental health
    crisis and they end up in a hospital, that is often going to be
    paid for through Medicare, but let us say that person needs to
    go into the community and they need wraparound services, they
    need services if they are homeless, they need other services
    that may not be covered by Medicare. Many of those are going to
    be covered in Medicaid in South Carolina.
        I think that figuring out how to blend Federal dollars and
    State dollars has been one of the ways that South Carolina has
    been able to manage our way through that, because many of the
    services that now are not blended, the State has actually
    stepped in to cover many of those services.
        It usually is around areas such as social determinants, for
    example, coordination of care, for example, we talked earlier
    about the fact that many individuals need medical care as well
    as psychiatric care. Much of that psychiatric care is not
    necessarily provided in a doctor's office but may be provided
    in a community, it may be provided in a community residential
    treatment facility, so finding ways to actually figure out how
    to blend funding to be able to have that integrated care in a
    single setting is often very, very important.
        Senator Tim Scott. Dr. Rogers, we are talking about,
    nationwide, a significant population. Nearly 12 million senior
    Americans are dual eligible, and so this approach that we are
    seeking to establish through the AIMM Act could have a
    tremendous impact on providing an enhanced level of care and
    assistance to those who may need it the most. Is that fairly
    accurate?
        Dr. Rogers. That is very accurate because the problem we
    are seeing in South Carolina with having an elderly population
    there is the same problem that we are seeing around the entire
    country.
        Senator Tim Scott. Yes.
        Dr. Rogers. It is State to State. Oftentimes you see that
    disaggregation of care because of the way it is currently
    funded.
        Senator Tim Scott. Thank you, sir. Another question for
    you, Dr. Rogers. I think through my opening comments about the
    important role that law enforcement plays in so many crises
    around the country, and specifically at home. The importance of
    finding a path to having co-responders, mental health experts
    also responding to the challenges that law enforcement officers
    are responding to seems to me to be a very important part of a
    new apparatus that could perhaps de-escalate.
        That is one of the reasons why I have worked with Senator
    Cornyn and many others on the Law Enforcement De-Escalation
    Training Act to find a way to help those two worlds come
    together in order to serve the communities who desperately need
    perhaps more assistance.
        Dr. Rogers, could you share the outcomes that have resulted
    from the partnership between the South Carolina Department of
    Mental Health and local law enforcement?
        Dr. Rogers. Absolutely. I think this is an area where we
    really have excelled as a State. Currently we are embedded with
    17 of our local law enforcement agencies in South Carolina.
        The things that we have seen is we have our crisis
    intervention teams, where we have officers that are actually
    going out with a trained clinician, usually a master's-level
    clinician that is actually out with them in the field. If it is
    related to mental health crisis they are able to dually engage.
    We also have individuals who are in call centers, and so we are
    able to really triage those calls on the front end.
        For those areas that do not have an embedded clinician we
    have mobile crisis that is available in all 46 counties in
    South Carolina. Those mobile crisis teams can be called out by
    a family, by law enforcement, really by anyone. That allows us
    to respond, I think, to anything that is coming up in a fairly
    short period of time. If we go out, for example, and it is a
    difficult situation, law enforcement will often clear the
    scene, make sure it is a safe environment, and then mobile
    crisis will actually move in and continue to work with the
    family or individual, and it allows the officer to really move
    on to something else.
        Then third, something that we have done is we have what is
    called first teams. We recognize that law enforcement often are
    encountering individuals in very difficult times. Often there
    is not a place to talk about it, so as a department, one of the
    things that we have done is to develop mental health services
    specifically for first responders.
        Those individuals are actually able to come to a different
    location, able to engage with therapists that are specifically
    trained to work with law enforcement agents throughout the
    State. That has been a really incredible program that has
    benefited us a great deal.
        Frequently, law enforcement is engaging with folks that are
    at their worst. They are in crisis at the time, and so trying
    to figure out whatever we can do to be able to support law
    enforcement as well as the individuals who are in crisis has
    been something critical to us to do in terms of our law
    enforcement partnerships.
        Senator Tim Scott. Thank you, Dr. Rogers. One of the things
    I would like to say--I know my time has run out, Mr. Chairman--
    is the importance of that scene that you have just described,
    the ability to clear a scene, to let the mental health experts
    address the challenge, so often the folks who are calling the
    law enforcement officers to the scene are the family members
    who love the individual who needs to figure out how to de-
    escalate the situation.
        I think that is one of the reasons why it is so important
    that we do not just sugar-coat the issue by dig a little deeper
    in how we create an apparatus that actually works for the
    family who is trying to figure out how to de-escalate a
    situation, not to watch it explode in their very homes, so
    thank you very much for that answer. Chairman?
        The Chairman. Thank you, Ranking Member Scott. I wanted to
    acknowledge, as well, Senator Braun, with us at the hearing,
    and our next Senator will be Senator Gillibrand who is joining
    us virtually.
        Senator Gillibrand. Thank you, Mr. Chairman.
        According to the National Center on Elder Abuse,
    approximately 1 in 10 older adults will become victims of elder
    abuse. Elder abuse has a physical, mental, and financial impact
    on older adults.
        A 2019 Centers for Disease Control and Prevention report
    found that between 2002 and 2016, the non-fatal assault rate
    increased by 75.4 percent among men and 35.4 percent among
    women over the age of 60, and since 2020, crimes against older
    Asian American adults have become more prominent. This takes a
    toll on mental health. Racial discrimination and ageism can
    trigger chronic stress, anxiety, depression, and racial trauma.
        There is so much that needs to be done here, but funding
    for elder abuse and justice programs authorized under Elder
    Abuse Prevention and Prosecution Act, the Elder Justice Act,
    and the Older Americans Act is a first step.
        Dr. Emery-Tiburcio, how does racial discrimination and
    ageism affect someone's mental health, and what are steps that
    we can take to effectively detect, prevent, and treat elder
    abuse?
        Dr. Emery-Tiburcio. Thank you so much for that question,
    Senator, so interestingly, ageism is what prevents many older
    adults from getting screened in the first place. We are not
    aware that older adults are using drugs. As Jim so eloquently
    pointed out, this is happening. In fact, I treated a 75-year-
    old gentleman who started using drugs at the age of 75 after
    retirement because he was bored, and the idea that our ageist
    ideas prevent us from thinking about older adults using
    substances, or our ageist beliefs that depression is a normal
    part of aging--it is not--are what prevents screening,
    assessment, and treatment from happening.
        In fact, there are so many older adults, Senator
    Gillibrand, as you are pointing out around elder abuse, that
    are in their homes, and we do not see them, and we are not
    coordinating care into those homes, and so those folks end up
    being abused and not having their needs met, and so the degree
    to which ageism impacts our screening, assessment, and
    treatment is also affected by racism. In fact, African America
    and other Black and Brown folks are not assessed, not treated,
    not offered treatment, even among Medicare beneficiaries, and
    so it is critical that we address these issues by universal
    screening for depression, anxiety, substance use, at a minimum,
    that we train community-based organizations to interact with
    older adults like Meals on Wheels and homemakers who are going
    into the homes and potentially seeing some of these issues, and
    making substance use services universally available.
        We can also address ageism by increasing awareness of it,
    and to Senator Casey's point about increasing awareness of
    mental health and aging, increasing awareness of ageism even
    with our language, with frameworks like reframing aging from
    the Gerontological Society of America.
        Thank you for identifying not only mental health and
    substance use stigma but also ageism in this space.
        Senator Gillibrand. As you know, because of COVID we have
    seen so much more mental health needs grow exponentially. What
    are some of the barriers that our older adults are facing with
    regard to accessing mental health services? Are there ways we
    can improve utilization of existing services, and for older
    adults on Medicaid, how could enhancing Federal Medicaid funds
    to incentivize states to provide better community-based mental
    health services address the gaps in utilization?
        Dr. Emery-Tiburcio. Access to services is an enormous
    issue, particularly for Medicare and Medicaid, in part because
    Medicare Advantage plans have been allowed to split physical
    health and behavioral health services, and as they do that then
    those folks who are seen in primary care not able to be treated
    by psychologists like me who are embedded in that primary care
    clinic.
        As Dr. Rogers pointed out, as each successive referral that
    older adults get, they are less likely to connect to those
    services, and so if Medicare Advantage plans and Medicaid plans
    that are commercially available were encouraged or required to
    have more integrated care, that would increase access. That
    warm handoff inside the primary care clinic goes a long way to
    be able to assist that older adult to access services, and
    providing services in the communities where older adults are.
    We hear this is in our policy academies, we hear this in our
    community conversations, that folks trust people in their own
    community, whether we are talking rural Pennsylvania or we are
    talking urban Chicago, that people in their community are folks
    that they trust, and so creating those collaborations between
    faith-based organizations, between Area Agencies on Aging, and
    senior centers to be able to increase access from both a
    financial standpoint with increased access to those servicers
    as well as the collaborations.
        Senator Gillibrand. Thank you. Ms. Williams and Mr. Klasen,
    just two followup questions if there is still time. Ms.
    Williams, given your experience with Vibrant Emotional Health,
    what are the benefits with peer support programs and community-
    based mental health services? How has this approach helped
    reduce stigma and support older adults receiving behavioral
    health care?
        Mr. Klasen, thank you so much for sharing your experiences.
    It takes extraordinary courage and is incredibly important to
    bring awareness to this issue, and if there is time--the
    Chairman can tell me because I cannot see the clock--what are
    the key ways to reduce stigma and what are some examples of
    coverage gaps that you have experienced?
        Mr. Klasen. I am also hard of hearing. I am not sure I have
    the question, but what I would like to say, because this
    touches on, well, you know, what has been shared here with Dr.
    Rogers and Senator Scott, so I train folks with mental health
    challenges to help people, to become peer specialists, and
    thinking especially about the mobile crisis teams and working
    with law enforcement and all of that.
        I had one guy named Will that we had trained as a peer
    specialist, and he got a job for a major provider, and
    struggled a bit with case notes and using the computer. He did
    not get fired. He got transferred. I started to get a new set
    of phone calls from a psychologist that was on this mobile
    crisis team that he was on, and the message there was, ``We do
    not know how we did it without him.'' Because of his lived
    experience and presence, he was able to de-escalate situations
    that professionals may have been challenged with.
        Senator Gillibrand. Thank you. Ms. Williams, did you just
    want to answer the question that I asked you?
        Ms. Williams. Thank you, Senator, for the question. Peer
    support has been incredibly powerful in terms of engaging older
    individuals, whom we, and other community organizations serve.
    Peers help by destigmatizing access, allowing individuals to
    share their own stories of hope and recovery, and building
    trusting relationships with other older individuals and
    engaging them effectively in care. I speak very highly of the
    use of integrating peer support with existing services.
        Senator Gillibrand. Thank you. Thank you, Mr. Chairman.
        The Chairman. Thank you, Senator Gillibrand. We are joined
    by Senator Kelly, and now we will turn next to Senator Collins.
        Senator Collins. Thank you, Mr. Chairman. I want to thank
    both you and the Ranking Member for shining a spotlight on this
    problem. I think that when most people have an image of someone
    who is addicted they think of a young male, and they do not
    think of an older person, and yet from a previous hearing that
    I held 4 years ago when I chaired this Committee, one of the
    witnesses told us that older adults make up 25 percent of the
    long-term opioid users and that Medicare beneficiaries are the
    fastest-growing population of diagnosed opioid use disorders,
    and the drug overdose crisis has only gotten worse since then.
    In my State, in 2020, more than 630 people lost their lives to
    overdoses. Equally startling, however, is the fact that there
    were nearly 9,000 non-fatal overdoses. We also know that people
    85 and older have the highest suicide rate of any group.
        We have a real problem, and I think hearings like this help
    shine a spotlight on the problem facing older Americans, and
    building off what Ms. Williams said and Mr. Klasen's powerful
    testimony, I too want to endorse peer-to-peer counseling. I
    have visited the Bangor Area Recovery Network, which is a peer-
    to-peer program. It is very successful, but during COVID there
    have not been nearly as many face-to-face interactions, and I
    can see Mr. Klasen nodding as I am saying this. Did you say
    something you wanted to add?
        Mr. Klasen. Yes, that is true, but I think it accelerated
    us into a world of telehealth.
        Senator Collins. Yes.
        Mr. Klasen. In some ways we were able to reach people that
    were not able to before. People in rural areas that did have
    the technology or maybe were reluctant to come to a physical
    place we were able to reach, so it kind of worked both ways.
        Senator Collins. Thank you for bringing up telehealth
    because that leads me into my question, which I would like to
    hear from the rest of the panel on. We know that during COVID
    that a lot of face-to-face counseling sessions were canceled,
    and we know that isolation and loneliness can have serious,
    even deadly consequences for the health and well-being of our
    seniors. It is associated with a greater incidence of
    depression, substance abuse, diabetes, heart disease. In fact,
    studies have shown that the health risks of prolonged isolation
    are comparable to smoking an astonishing 15 cigarettes a day.
    Just think about that, so this is a call to action.
        I would like to ask Dr. Emery-Tiburcio--all of us are
    having a little trouble on the last name, for which I hope you
    will excuse us--and Dr. Rogers and Ms. Williams about the role
    of telehealth. I have worked hard in the infrastructure to get
    funding with Jeanne Shaheen so we get it out to the rural
    areas, which exists in every State.
        How can we ensure that telehealth plays a role in
    increasing access to proper screening and care for older
    adults, especially in rural areas, as we grapple with the
    ongoing shortages in the behavioral health workforce? If we
    could go straight across. Thank you.
        Dr. Emery-Tiburcio. Thank you so much, Senator Collins. It
    is a critical question, I think, particularly for older adults.
    You know, we have a program that provides cellular-enabled
    tablets to older adults for accessing telehealth and for
    accessing social media, so that they can connect, and that
    program has been incredibly powerful in reducing loneliness.
        Folks, though, who do not have that kind of a device or do
    not have access to broadband, as Dr. Rogers highlighted, those
    are individuals who require telephonic psychotherapy and
    interventions to be able to even access their primary care, and
    the annual wellness visit that Medicare provides is a wonderful
    way to be able to offer that screening telephonically, but
    continuing that Medicare coverage for telephone-only services
    is critical, so many of my patients who I continue to see only
    via telephone would not get services otherwise, and as we move
    forward, even hopefully out of this pandemic, that continued
    service will allow my patients who may have increasing medical
    issues as well that will not let them come at any given time,
    to continue to manage their mental health.
        Senator Collins. I agree with you that we need to extend
    the reimbursement for telehealth and audio as well.
        Dr. Rogers, you represent a State that has a lot of rural
    areas, the way Maine does. What has been your experience with
    telehealth?
        Dr. Rogers. You know, Dr. Emery-Tiburcio said something
    earlier that I had not really thought about as much and that is
    the whole idea of ageism. One of the things that when we were
    first starting out with telehealth there were kind of these two
    ideas. One is that older people do not use technology, and the
    second one is older people do not work because most of them are
    retired.
        One of the things that we found as we started rolling out
    telemedicine is that both of those things are false, for the
    most part. We found that a lot of our elderly population
    continue to work, and one of the things that has been really
    beneficial about telemedicine is the fact that they do not have
    to actually miss work in order to have an appointment.
        In South Carolina, many of our folks are working hourly
    jobs, so if you are taking an hour off, oftentimes you are
    having to take an entire day off, versus I have seen many
    people that are able to go out to their parking lot, sit in
    their car, have a 30-minute session with me, and then go back
    to work. That is a benefit for both the employer side but also
    the employee, who happens, in many cases, to be aged 65 or
    older.
        Senator Collins. I am going to have to cut you off because
    I know I am over my time, much as I would like to continue
    this. Ms. Williams, could you provide me with an answer for the
    record, because I really am interested in what you have to say
    as well.
        Ms. Williams. Yes. I would be glad to. Thank you for the
    question, Senator Collins. Quickly, I want to reinforce the
    extension for tele-mental health reimbursement and audio-only
    available services. We have been able to support some
    innovative programming within New York which are easily
    replicable. For example, providing treatment over the phone to
    support and engage older adults and make sure that they get
    access to the care that they need, and also working in
    partnership with the State of New York in the implementation of
    service demonstration grants which have included providing
    supports to older individuals in rural communities who are
    isolated, being able to provide them access with a laptop so
    that they can get the treatment that they need. Both of those
    examples serve as demonstration for the importance of making
    sure that we extend access to support utilization of telehealth
    services.
        Senator Collins. Thank you, and thank you, Mr. Chairman. I
    also think that telehealth helps to reduce the unfortunate
    stigma that still exists, when people can get the counseling
    and help they need in the privacy of their own homes. Thank
    you.
        The Chairman. Senator Collins, thanks very much, and I
    agree. Senator Kelly.
        Senator Kelly. Thank you, Mr. Chairman. I was going to
    followup a little bit on Senator Collins' question. I think she
    covered the issue of opioid epidemic and substance use
    disorders and how it affects older adults, and like so many
    other states, I am sure like Maine, Arizona has been hit pretty
    hard by this, and it is not surprising that we often hear from
    the aging network, for lack of a better term here, that they
    often hear from seniors asking about what sort of substance use
    disorder treatment that their Medicare plan will cover, and
    often they do not like the answer.
        If there is anything you left out about where these gaps in
    Medicare for older adults experiencing substance use disorder
    issues, if you just wanted to take a few more, like maybe a
    minute or so, to fill in the gaps there, and then I have got a
    question for Mr. Klasen.
        Ms. Williams. Thank you, Senator Kelly, for the question.
    As was highlighted, given the growing population there is a
    growing need for these services, and Medicare, unfortunately,
    has limited coverage for substance use services. The services
    are not aligned with evidence-based practices and with the full
    treatment continuum. There are remedies for addressing those
    gaps, including ensuring that the full continuum of services
    are covered, ensuring that the full range of addiction
    specialists and treatment facilities are covered, and ensuring
    that parity is applied here so that older adults do not
    experience unnecessary discrimination and financial and
    treatment limitations, and so through addressing those gaps we
    can promote better access to care for older individuals and get
    more of them on the road to recovery.
        Senator Kelly. Thank you. Mr. Klasen, as a peer specialist
    are your programs covered by Medicare?
        Mr. Klasen. Some of them are, yes.
        Senator Kelly. Some of them are, but some of them are not.
        Mr. Klasen. That is correct.
        Senator Kelly. My understanding is 60 percent of mental
    health professionals who work in rural areas, that their
    programs are not covered by Medicare. Does that sound about
    right to you?
        Mr. Klasen. That sounds about right.
        Senator Kelly. Imagine how disruptive this would be, you
    know, for somebody who ages into Medicare and then suddenly
    they find out that they cannot pay, their insurance, Medicare,
    will not pay for their provider and they have to pay out of
    pocket, and what this means to seniors in Arizona, and for them
    it feels rather arbitrary, and they often do not have
    supplemental coverage needed to make this care affordable.
        That is why I am a co-sponsor of the Mental Health Access
    Improvement Act which would allow licensed professional
    counselors and licensed marriage and family therapists to
    provide services under Medicare. We have to expand the universe
    of providers to make care accessible and affordable. I mean,
    literally lives depend on this often.
        Mr. Klasen, given your personal and professional
    experience, is there anything you would like to add to that,
    speaking to the need to bolster our workforce and ensure the
    continuum of care continues into Medicare?
        Mr. Klasen. You know, thank you, Senator Kelly. Yes, it is
    complicated. A lot of this stuff goes into a lot of older
    adults are reluctant to ask for help to begin with. You know,
    we are all about rugged individualism, and I do not need public
    benefits, so part of it is relating with them on that issue,
    and then there is the frustration. If I am seeking help and
    getting kicked around to different places or the rules are
    different or it just seems to be taking too long, folks just,
    you know, abandon it.
        I think with peer support, it is an interesting idea. I
    think of peer support more in direct service, but I think the
    idea that peers can talk to peers, older adults can talk to
    other older adults and relate to them, whether they are
    veterans or whether it is a substance abuse issue or whatever,
    and say, ``You know, it is okay, and I have some information. I
    have some resources for you.''
        Senator Kelly. Well thank you, Mr. Klasen, and I yield back
    the remainder of my time.
        The Chairman. Senator Kelly, thanks very much. We are at a
    point in the hearing where we will have some Senators coming to
    the hearing from other hearings they have had or returning to
    ask questions. In the interim I will start a second round. I
    cannot guarantee, because of the vote coming up, that every
    Senator will have a second round if they desire it, but I will
    start until we have a Senator returning.
        I wanted to go back to Ms. Williams. You said, on page 3 of
    your testimony, you related a story of a 62-year-old woman
    living with serious mental illness and chronic health issues
    who also lacked stable housing, which I cannot even imagine
    what some people have to live through when they are
    experiencing all kinds of challenges at the same time.
        You described how providing her tailored support unique to
    her mental and physical health as well as her own social
    circumstances. As a result she was able to get the care she
    needed in the community instead of a psychiatric hospital, and
    you go on to recommend better integration, as we heard before,
    of physical and mental health care with aging services.
        I have got legislation I made reference to earlier, the
    Supporting States in Integration Medicare and Medicaid Act,
    which would provide $300 million to states and CMS, Centers for
    Medicare and Medicaid Services, to develop and advance these
    integrated programs, and I guess a simple question about this
    kind of an approach. What is the value of that linkage, linking
    community-based services with medical care?
        Ms. Williams. Thank you, Chair Casey, for this really
    important question. Older individuals who have chronic physical
    conditions and functional impairments are more likely to
    experience higher-cost services and more likely to experience
    poor outcomes. Better engagement with older adults will lead to
    better health outcomes, and improved engagement includes
    linking health services with social services, particularly
    around prevention and wellness. Medical providers can work
    collaboratively with Area Agencies on Aging to help to support
    older adults in managing their chronic conditions and also to
    help address unmet social needs. It is through this linkage
    between social and medical services that we can support the
    overall quality of life of older individuals, support better
    health and mental health outcomes, thus reducing the need for
    costlier services in nursing homes and other institutional
    settings.
        The Chairman. Thanks very much. We will turn next to
    Senator Blumenthal.
        Senator Blumenthal. Thank you very much, Senator Casey, and
    thank you for holding this hearing. I am grateful to the
    witnesses for being here today on this tremendously important
    topic. As my colleagues may have remarked, and I apologize if I
    am repeating anything they have said or asked, I think this
    Nation is going through a mental health crisis. The trauma of
    COVID, the economic challenges faced by families, the deaths
    and illness that they have seen, at every age, most especially
    our children because they have been out of school, but really
    every age, and I fear our elderly Americans, as much as
    children, even though they are perhaps less vocal, and they are
    more isolated.
        I am particularly concerned--and I have just left a hearing
    of the Armed Services Committee; I am on that Committee and
    Veterans Affairs Committee--by the mental health of our
    veterans. We are only really beginning to understand how the
    impacts of trauma, seeing it, enduring it during military
    service, can be enduring and, in fact, can be increasing as age
    comes on. We now have a sizable veterans' community of advanced
    age. Due to the wonders of medical care they are living longer,
    but I wonder if the witnesses could comment on the needs and
    challenges faced by veterans as they age and what you have
    observed about the challenges they face and the programs that
    are available to them.
        Dr. Emery-Tiburcio. Certainly, Senator, as you highlighted,
    we are only just beginning to understand trauma in later life,
    and there are many older adults who experience the effects of
    trauma for the first time after retirement. They have been
    working for years and engaged in childcare and engaged in
    family, and when they slow down enough sometimes those traumas
    resurface, and that may be particularly the case for veterans.
        I happened to be working at the VA Boston Health System at
    the time of 9/11, and working in the nursing home, watching
    veterans watch the television and being incredibly distressed
    that (a) from their nursing home beds they were going to be
    called back into service, and (b) reliving those kinds of
    events over and over, and so as we watch things like the
    Ukraine war, the Russian attack on the Ukraine, so many
    veterans are experiencing those same traumas, and so increasing
    availability of services, certainly the VA has an incredibly
    powerful trauma center that has fantastic evidence-based
    programs, and there are some veterans who are not service-
    connected enough to be able to access those services
    effectively, and so assuring that those services are available
    in the community as well would be well regarded.
        Senator Blumenthal. Thank you. Any other comments?
        Dr. Rogers. Yes. I think in addition to the services that
    we know are needed by our vets, one of the things that we
    talked about earlier was the fact that we have a shortage of
    providers, so if you look at our older population and folks
    that are specifically trained to work in the geriatric area, we
    are seeing many of those folks retiring or not as many coming
    out of training, and so I think that part of what we are seeing
    is really a twofold issue. One is increase in need that we are
    seeing among the veteran population as it ages, but also the
    second piece is really not having enough trained people going
    into those areas to work with older adults.
        Senator Blumenthal. Thanks, Dr. Rogers.
        Ms. Williams. Thank you, Senator Blumenthal, for the
    question. To add to Dr. Emery - Tiburcio's comment on ensuring
    that community-based providers are equipped to support older
    adults with mental health issues, for older adults who are
    veterans, it is imperative that those providers are adequately
    trained to identify and support the specific issues that affect
    this population.
        Senator Blumenthal. Thank you.
        Mr. Klasen. Quickly----
        Senator Blumenthal. Sure.
        Mr. Klasen I mean, no one can talk to a veteran like
    another veteran. I am not a veteran, but one of my co-
    facilitators, a Marine with significant military experience and
    is a peer specialist, I mean, just to me it was a very powerful
    combination.
        Senator Blumenthal. That is an excellent point. We have
    been trying to expand the peer-to-peer program, but as you
    point out, there is no one like one veteran talking to another
    veteran. Nothing like that kind of rapport and trust. Thank
    you.
        Thanks, Mr. Chairman.
        The Chairman. Thanks, Senator Blumenthal.
        Ranking Member Scott.
        Senator Tim Scott. To add on to Senator Blumenthal's
    rapport and trust, it is having had the same experience in so
    many ways. While different, the similarities of being in
    conflict, being in theater also adds to the ability to have
    someone who understands and appreciate the significant impact
    that life and/or serving your country has had. Having a father
    who served 27 years and a brother who served 32 years, and my
    other brother who served 26 years, I oftentimes hear the
    stories of how important it is to have someone who has been
    where you are, who has walked in your boots there with you,
    going through the journey.
        Dr. Rogers, one of the things I note is in South Carolina
    we have Victory House in Walterboro, and other facilities for
    our veterans. The availability of space and capacity seems to
    be one of the challenges that we face nationwide. Would you
    talk, Dr. Rogers, for a minute about the importance of nursing
    homes and other veteran facilities in South Carolina ensuring
    this population are receiving adequate mental health services?
        Dr. Rogers. Absolutely. Thank you for that question,
    Senator Scott. One of the things that we have in South Carolina
    is we are actually in the process of building our fifth
    veterans' nursing home in the State.
        South Carolina is organized a little differently than many
    other states in that our veterans' nursing homes actually fall
    under the Department of Mental Health, and part of that is
    because the first nursing home that was opened in South
    Carolina to serve veterans in 1971, was opened by the
    department because we were trying to move people from the State
    hospital that were veterans, and many of those folks had
    significant mental health issues but many really did not, and
    so over time we have developed some degree of expertise, and
    part of that expertise is really figuring out how do we have
    the resources to really work with our older veteran population,
    so we have a number of veterans who actually work in our
    system. We also have a number of geriatric psychiatrists,
    psychologists, that are actually with us specifically with the
    veteran population, so for example, the deputy director at our
    department oversees our nursing homes is a geriatric
    psychiatrist who his very engaged and involved in making sure
    that the mental health service needs are met for that
    population.
        That focus on the veteran population as well as the aging
    population has been something that the department has been very
    focused on.
        Senator Tim Scott. Thank you, sir. Switching to another
    topic, Dr. Emery-Tiburcio--close enough?
        Dr. Emery-Tiburcio. Close enough.
        Senator Tim Scott. How do you actually pronounce it?
        Dr. Emery-Tiburcio. Emery-Tiburcio.
        Senator Tim Scott. Tiburcio.
        Dr. Emery-Tiburcio. Yes.
        Senator Tim Scott. Thank you, Doctor. The issue of
    overdoses plaguing our Nation in a way that we have not seen
    ever--107,000 deaths, as we talked about earlier, and the
    challenge of fentanyl coming across. I cannot tell you the
    number of parents that I have talked to who have lost their
    child because of the first try with something that was laced
    with fentanyl, and the number of our seniors who are having a
    similar experience as well.
        Can you talk for a minute about the importance of this
    missed challenge that we are facing?
        Dr. Emery-Tiburcio. Absolutely. Thank you for raising that
    important topic. You know, it is interesting. There was a study
    that just came out that looked at the last 10 years of data,
    and demonstrated a 1,886 percent increase in opioid overdose
    deaths, and another report just came out showing that adults
    aged 65 to 74 face the largest increase in the drug death rate
    of any age group, so this is an older adult issue.
        Interestingly, as we look at older adults, in particular,
    and why this is an issue, ageism is a piece, as I have said
    previously, this idea that we do not look at older adults and
    think drug use, so we do not screen, so we do not assess, so we
    do not treat, and the idea that part of that data, the authors
    of that JAMA study, pointed to racism as being a key factor,
    that older Black men died at a rate 10 times that of other
    groups, and older Black men, as Senator Blumenthal was just
    bringing up trauma, older Black men are much more likely to be
    victims of trauma, including a lifelong experience of racial
    trauma, lack of access to health care, and do not trust health
    providers, for good reasons. Black and Brown folks in hospitals
    do not get treated for their pain as much as white folks, and
    so with that, folks are more likely to self-medication, as Jim
    has highlighted, and so, again, we need to be screening. We
    need to be assessing. We need to be providing these services,
    and I would be remiss if I did not also point out that in
    addition to opioids, alcohol is actually the most abused
    substance by older adults in the U.S., and we do not provide
    nearly enough attention to that as well, and particularly
    during the pandemic the issue has exploded.
        Senator Tim Scott. Thank you, ma'am. Mr. Chairman?
        The Chairman. Thank you, Ranking Member Scott. I want to
    thank all of our witnesses. We are going to have to adjourn,
    but we could go on for a good while with all of the expertise
    that you bring to bear and your own either personal experiences
    or professional expertise, and in many cases both. We are
    grateful for the work you have done to bring that level of
    insight and expertise to the hearing today.
        I want to start by, as well, thanking Ranking Member Scott
    for hosting this hearing with me today and to elevate the need
    to improve mental health care for older adults. As we heard
    today, seniors face many challenges in just navigating the
    mental health system, including limited awareness about where
    to look for help and the stigma surrounding mental illness and
    treatment, stigma as it relates to both illness and treatment.
    These challenges lead these individuals, these Americans, to
    feel unsupported and very much alone and nowhere to turn.
        There are people like Jim who shared his story with the
    Committee today, and tells us why we need to have a more
    integrated approach to mental health and substance use disorder
    for older adults, and that is one of the reasons that Ranking
    Member Scott and I have introduced the Advancing Integration in
    Medicare and Medicaid Act--I will use the acronym, the AIMM
    Act--which requires states to develop a plan to address
    fragmentation in both Medicare and Medicaid. These programs
    which so many older adults rely upon for their mental health,
    both programs become so essential for people's lives, and we
    have got to make sure they are better integrated.
        I look forward to continuing to elevate solutions to our
    Nation's mental health crisis, including solutions to help our
    seniors.
        Now I will turn to Ranking Member Scott for his concluding
    statement.
        Senator Tim Scott. Thank you, Chairman, for holding another
    really important hearing. To all of our witnesses today, thank
    you for sharing your expertise, and frankly, your passion, as
    well as your experience on such an important topic, especially
    during the week where we celebration Older Americans' Mental
    Health Awareness Day.
        Whether it is the AIMM Act that I have introduced with the
    assistance of Chairman Casey, or the ACADEMIC Act, or the Law
    Enforcement De-Escalation Training Act, the one thing that I am
    confident of is that we are taking this issue more seriously
    today than we have in the past, and that is really good news
    for the future.
        Far too little has been done, and we need to push forward
    in making sure that we pass meaningful legislation that
    provides more resources to our senior population. America is
    only growing older, which means that the problem will only get
    worse unless we bring more solutions to the table, now.
        Thank you all for being here.
        The Chairman. Ranking Member Scott, thank you, and again I
    want to thank all of our witnesses for their testimony, the
    answers to the questions they provided, and of course their own
    expertise that they will continue to bring to bear on these
    issues.
        For the record, if any Senators have additional questions
    for witnesses or statements to be added to the record the
    hearing record will be kept open for 7 days until next
    Thursday, May 26th.
        Thanks everyone, for participating, and this concludes
    today's hearing.
        [Whereupon, at 11:27 a.m., the Committee was adjourned.]

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                                    APPENDIX

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                          Prepared Witness Statements

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                            Questions for the Record

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