[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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