[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
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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
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Stacy Sanders, Majority Staff Director
Neri Martinez, Minority Staff Director
C O N T E N T S
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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
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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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