COUNCIL OF THE CITY OF PHILADELPHIA PUBLIC HEARING COMMITTEES ON PUBLIC HEALTH AND HUMAN SERVICES AND COMMITTEE ON PUBLIC SAFETY - - - Room 696, City Hall Philadelphia, Pennsylvania Monday, May 12, 2003 10:30 a.m. - - - RESOLUTION NO. 030174 - A resolution authorizing City Council Committee on Health and Human Services to conduct hearings on the current status of mental health services for senior citizens in the City of Philadelphia. - - - PRESENT: COUNCILWOMAN MARIAN B. TASCO, Chair COUNCILMAN ANGEL L. ORTIZ COUNCILMAN FRANK RIZZO, JR. COUNCILWOMAN BLONDELL REYNOLDS BROWN - - - V A R A L L O Incorporated Litigation Support Services Eleven Penn Center 1835 Market Street, Suite 600 Philadelphia, PA 19103 (215) 561-2220 (215) 567-2670 2 I N D E X NAME: JOEL STREIM, M.D. 8 HIKMAH GARDINER 27 JOSEPH ROGERS 33 GLADYS STEWARD 36 MICHAEL COVONE 49 PEARL GRAUB 60 MARY HURTIG 79 TOM VOLKERT 84 CYNTHIA WISHKOVSKY 89 MARY ANN WALL 107 VERGI VIACAVA 111 GARY SCHOENBERG 117 LOIS SEMANISION 121 SANDRA SMITH 130 TRUDY PERSKY 134 ALMENA TUGMAN 140 ROSE BRADLEY 143 EUN SOOK KANG 146 DAVID DOWNEY 150 3 5/12/03 - Health/Human Services - Resolution 030174
Good morning. I would like to welcome you here today regarding this discussion on mental health of older Philadelphians. I would like to note that the following Council members are present, the sponsor of this resolution, Councilwoman Blondell Reynolds Brown, Councilman Ortiz and Councilman Frank Rizzo. This hearing is held today at the request of Councilwoman Blondell Reynolds Brown. She introduced a resolution to have these hearings to bring forth the issues to the public and to this City Council. I do believe that she does now have a statement that she will present. Before we begin, we must read the resolution.
Resolution authorizing City Council Committee on Health and Human Services to conduct hearings on the current status of mental health services for senior citizens in the City of Philadelphia.
Thank you very much. The Chair recognizes Councilwoman Blondell Reynolds Brown. 4 5/12/03 - Health/Human Services - Resolution 030174
Thank you, Madam Chairman. To the Chair of this Committee on Health and Human Services and to my colleagues in attendance today and to all of you, welcome to this very, very important milestone in our City as it relates to the constituency we care about, seniors. We have a lot to do, so I will be brief. Philadelphia should be proud that it has the highest percentage of older adults in its populations of all major cities in the entire United States. Pennsylvania is second only to Florida in percentage of older adults. Statistics are as follows: People age 60 plus constitute percent 16 of the population. This is based on the 2000 17 census. 40 percent of older adults live alone. 16 18 percent of older adults live in poverty. The population of 85 plus jumped percent since 1990. 20 A key to understanding the mental health needs of older adults is to recognize that physical health and mental health are very much interconnected. For instance, people who have physical problems like heart problems and diabetes are more likely to develop mental health problems. 5 5/12/03 - Health/Human Services - Resolution 030174 Likewise, people with depression or anxiety are more likely to develop physical problems. In addition, older adults with mental health problems may experience them as physical problems such as lack of energy or stomach problems or difficulty concentrating. For this reason, many older adults and even healthcare professionals may mistakenly identify depression, anxiety and other mental health problems as physical troubles. Studies have shown that between to percent of older adults 12 experience some form of mental health problems such 13 as depression, anxiety or cognitive problems. About 14 10 percent of older adults have substance abuse 15 problems. Nursing homes have rates of depression up 16 to 75 percent. It's amazing. 17 Older adults have the highest suicide 18 rate. In Philadelphia one out of every four 19 suicides is committed by an older adult. 80 percent 20 of older adults who commit suicide have seen their 21 doctor within a month. 71 percent of older adults 22 who experience neglect have mental health issues. 23 Older adults with depression spend up to three times 24 as much on medical costs as those without 25 depression. I'm going to repeat that. Older adults 6 5/12/03 - Health/Human Services - Resolution 030174 with depression spend up to three times as much on medical costs as those without depression. Mental health, health and aging systems need to change, thus the reason for our meeting this morning. Despite this great need, mental health service utilization by this population is minimal. Of the 55,000 people served by the Office of Mental Health in our City, only 4000 were older adults and many of those are people who have chronic mental health issues. The managed care agency of Medical Assistance Community Behavioral Health, Inc. 1 percent of them were older adults. A major reason for the underutilization is that services are not available in a way that is convenient for those that need them. Sometimes that means the services are not available in their section of the City. Sometimes that means that home visits are required and necessary. Ultimately we need to do a better job. We have government representation here today. We have advocates represented here today. We have what I call experts and gurus who live this issue here 7 5/12/03 - Health/Human Services - Resolution 030174 and then we have seniors and adults who have experienced some of the things we are talking about. It is my hope that at the conclusion of this hearing we will have a roadmap to vastly improve the way we are delivering mental health services to our seniors and that I have learned already we can improve the interconnect between agencies so that we can provide services in a more integrated way and thus raise the level of making a difference for those that we are talking about, the seniors in our City.
Thank you very, very much for your attention and I will return it to the Chair of our committee.
Thank you very much, Councilwoman. I open the floor to comments from other Council members if they would like to make comments. Okay. No comments. Our first person to testify is Dr. Joel Streim, geriatric psychiatrist and president of the American Association of Geriatric Psychiatrists, University of Pennsylvania. You have a slide presentation. Would you like to move your screen a little more over. We 8 5/12/03 - Health/Human Services - Resolution 030174 have some heads in the way over there.
Thank you, Councilwoman Tasco and Members of Council. I'm Dr. Joel Streim, and I appreciate Councilwoman Reynold Brown's comments about the public health crisis that we face in Philadelphia and I'm here to enlist the help of Council in addressing the problem of mental health and aging here in Philadelphia. 3 percent of adults over age 65 in the United States have psychiatric disorders such as depression, anxiety disorders, schizophrenia and other serious mental illness. Another 10 percent have dementia, which is not just a memory disorder. In more than a third of cases this is complicated by depression, psychosis or behavioral symptoms even when it's due to Alzheimer's disease. Another 3 percent have frank alcohol abuse and dependence and that figure doesn't include other older adults who have substance abuse and who have at-risk drinking, which is estimated at about 10 to 15 percent, but the overall prevalence rate of mental disorders in older adults approaches 30 percent. That's even more impressive when we 9 5/12/03 - Health/Human Services - Resolution 030174 consider it in the context of changing demographics and the aging of our society nationwide and here in Philadelphia. S. S. population and that figure is projected to 7 go up to 18 percent. The absolute numbers will more 8 than double by the year 2030, but Philadelphia is 9 already at the point where nearly one in five 10 members of the population is an older adult. We are 11 clearly a generation ahead of the national curve in 12 terms of aging in Philadelphia. 13 So this presents not only challenges but also opportunities for leadership. Here in Philadelphia we have about 270,000 persons over age 60. 80,000 have clinically significant mental health problems. We also estimate that 50,000 elders in Philadelphia are homebound. There is tremendous overlap between these two groups. Now, what's unique about mental disorders in older adults? Why do we need to address this and treat them differently than younger adults with mental health problems? First, there are the effects of aging on the course of illness and its response to treatment. Perhaps the most 10 5/12/03 - Health/Human Services - Resolution 030174 obvious aspect of this is that as we get older our bodies metabolize medications differently, but there are other aging effects as well. Mental disorders commonly co-occur with medical illnesses. Most older adults have multiple chronic conditions, medical conditions that lead to physical disabilities and they also have a very high prevalence of cognitive disorders, dementias such as those due to Alzheimer's disease. To manage all of these conditions older adults use multiple medications. In many cases they are taking more than three to five medications. As an example, depression is associated with poor health outcomes in late life especially when it's associated with these medical problems that are so common in late life. Research has shown worse outcomes from hip fracture. After surgical repair of hip fractures those older adults who are depressed have poorer recovery rates during rehabilitative care and are less likely to regain their ambulatory status compared to those who are not depressed. Those after myocardial infarction or heart attack are twice as likely to suffer another cardiac event if they are depressed compared to 11 5/12/03 - Health/Human Services - Resolution 030174 those who are not depressed. Those with cancer have more pain, greater number of hospitalizations and poorer quality of life as demonstrated in research compared to those who are not depressed. There are many other conditions like this where we see the cost of care, as Councilwoman Reynolds Brown has told us, increases when the depression is not treated. We also see increased mortality rates shown in a number of epidemiologic studies.
Mortality goes up after heart attack in those who are depressed compared to those who are not and mortality rates have consistently shown to be higher in residents of long-term care facilities particularly in nursing homes, but that is just the nonsuicide mortality. What about suicide? You have already heard that older adults; that is, those over age 75 constitute the largest proportion of suicides per hundred thousand population compared to any other age group. S. population, they account for about 19 percent of suicides and here in Philadelphia that has been estimated to be closer to one in four suicides. 12 5/12/03 - Health/Human Services - Resolution 030174 Effective treatments for depression in late life and other mental disorders in late life do exist. Science has shown that they really work, but they are not reaching those in need, and this is really the tragedy. Nationwide fewer than 3 percent of older adults receive outpatient mental health treatment by specialty mental health providers and here in Philadelphia older adults consume only 6 percent or less of community mental health services, yet they constitute 18 percent of our population. This is clearly a major disparity. Why are we seeing this? Part of it has to do with the stigma of attending a mental health clinic. Imagine being a frail 83-year-old woman and sitting in the waiting room of a community mental health center next to a 22-year-old patient who has schizophrenia with active hallucinations or next to a 30-year-old heroin addict. That is not only discomforting, but for many frail older adults it is frightening, so these aren't the appropriate places for them to get their care and they will not come to the community mental health centers. Cognitive disorders occur and interfere with memory and ability to access the mental health 13 5/12/03 - Health/Human Services - Resolution 030174 system unless there is a caregiver in place and even then it is difficult. Many elders are homebound, as I mentioned, due to chronic medical illnesses or physical disabilities. Some are homebound due to paranoia disorders. They have delusions that make them afraid to go out. Some have realistic fears. They are frail and vulnerable to predators in their neighborhoods. What's really practical and acceptable to consumers? Well, for the older adults that are homebound, they are more likely to receive mental health services if they are provided at home. Some older adults will accept services if they are offered in senior centers or in places of worship or other familiar community sites where they are comfortable. There are also many of those older adults who do seek mental health services, although it is a small number, but they prefer to receive them in the primary care setting where they get their general healthcare. But that's not the solution. At least at this point we have seen that currently primary care physicians don't do an adequate job. One of the most disturbing things in the psychiatric and epidemiological literature is 14 5/12/03 - Health/Human Services - Resolution 030174 that older adults who commit suicide have been seen by their primary care physician in up to 47 percent of cases within a week of their suicide and up to 75 percent of cases within a month. This is a tragedy. It is also an opportunity for prevention if we do it better. Most primary care providers just don't have adequate psychiatric expertise or access to integrated geriatric mental health services on site where they provide care for older adults. Conversely, most mental health clinics don't have geriatric medical expertise that these patients need or age-appropriate services. There is evidence, though, for the success of integrating mental health services in primary care settings. There are currently three national studies that are ongoing.
Preliminary results have shown increased engagement in mental healthcare and improved treatment response rates when mental health screening and coordinated followup care are provided within the primary care setting. Integrated care. We also are fortunate in Philadelphia to have several demonstration 15 5/12/03 - Health/Human Services - Resolution 030174 projects that show that integrating mental health and aging services works. We can improve access by providing geriatric mental services in home, in senior centers, in district health centers in Philadelphia. We are actually doing this but on a very, very small scale with shoestring budgets that are vulnerable to lack of renewal year to year. We are only getting to a very small percentage of Philadelphians in this way and these programs must be expanded to reach those without access to services. We also have some training initiatives between mental health and aging agencies in Philadelphia, but these are quite limited too. We really recognize that aging agency personnel, to do a good job, must know about geriatric mental health. Conversely, mental health providers have to know about aging. PCA, the Philadelphia Corporation for Aging, has shown some leadership in cross-training and taken some initiative in this area, but we need much more co-funding and collaboration between PCA and the Philadelphia Office of Mental Health if we are going to do it right. So in Philadelphia we have challenges 16 5/12/03 - Health/Human Services - Resolution 030174 and we have opportunities. We have more seniors, as you have heard, in terms of proportion of the population than any other major City in this country, than New York and Los Angeles. We know what the cutting edge models are and we have access to the expertise to do it. We should be a national model for this, not a national disgrace, and so I call upon City Council to help us rise to the occasion and support our efforts in improving the lot of older adults in Philadelphia who have mental health problems. Thank you for your attention. )
Thank you very much. Are there any questions from Members of Council? Councilwoman Brown?
Thank you for that very important backdrop in putting this issue in context. Might you have a copy of your Power Point presentation?
And you said there 17 5/12/03 - Health/Human Services - Resolution 030174 are other national models. Is that cited in the literature you are going to share with us?
Actually, the other models are cited in the slides and I will get you references as we have them. These are ongoing studies sponsored by the Substance Abuse and Health Services Administration, by the National Institute of Mental Health and also by the Hartford Foundation, and these studies have been presented at national meetings. These are interim results but very striking results showing effectiveness of these models. We are just beginning to see publications resulting from these studies. This is hot and it's new, but the data is extremely robust and compelling. These models really work.
And it's timely for us as we move to ultimately craft recommendations on things we should do better, so if you could please make sure that that information gets to the Chair to be distributed to the committee members, it would be appreciated.
Thank you very much 18 5/12/03 - Health/Human Services - Resolution 030174 for your testimony.
We have data actually showing double the rate of access and doubling in response rates with these models.
Doctor, in terms of Philadelphia, because that is what we impact upon in City Council, can you tell us and describe to us where we are at in terms of what you just described. Councilwoman Blondell Reynolds spoke about setting a roadmap. What is it that we as a Council here need to be able to ask of our mental health institutions and our health department and our community health centers --
-- to do and what programs, and if we can fix a price tag on it also, it might help so we can have that sort of framework to work from?
I will leave the details of the price tag to the speakers who follow me and who 19 5/12/03 - Health/Human Services - Resolution 030174 are going to testify this morning, but what we need from City Council more than anything is support and approval of funding for the Office of Mental Health to work more collaboratively with Philadelphia Corporation for Aging and to really help support programs like the ones I'm describing which will allow us to reach all the underserved older adults.
But what is the current condition? If you say that we need to do certain things, we must not be doing them.
And if we have to do it, what is it that we need to be able to put into place?
Right now we see that only a small fraction of the patients, of the people in Philadelphia who are older and have mental health problems are actually receiving care. At this point --
Well, we know that 6 percent or less of mental health services in Philadelphia actually go to older adults even though 20 5/12/03 - Health/Human Services - Resolution 030174 they are only -- they represent 18 percent of the population. So we know we are underserving those older adults. We also know that many older adults living in boarding homes and living alone in the community have mental health problems that haven't even been detected yet, so in terms of our success rate so far it's an embarrassment and at this point we really need to see a quadrupling of the resources that we currently have. You will hear about some programs this morning that are actually based in community mental health centers. Comhar, Interac, the Southeast Mental Health Association, all have programs, but they are not nearly funded at the level that they need to be in order to reach more than just 10 or less percent of older adults.
Do we have this type of program in each and every one of our community health centers?
No. At this point we only have a couple of community mental health centers that are employing these model programs and you will hear later from Cindy Wishkovsky from Interac that their program of mental health outreach for seniors 21 5/12/03 - Health/Human Services - Resolution 030174 living at home who are homebound and also to provide programs in senior centers in Philadelphia only reach a very small number. They will give you the actual numbers of programs that they are actually servicing, but at this point they are only reaching certain --
How about CBH? What is the relationship programmatically of CBH and what does CBH do to expand and implement this area of health service?
My understanding is that at this point they are primarily limited by budgetary concerns and also there are some aegis decisions that have been made to put resources into the care of younger recipients of mental healthcare. Part of the problem is that older adults are often forgotten and neglected in the system even when there are resources. So I think this is always a sensitive issue, that there are competing factions for resources. You know, we would like to propose that mental health services be available across the life span, for children, for young adults with severe mental illness, but also for older adults with concurrent medical problems and physical 22 5/12/03 - Health/Human Services - Resolution 030174 disabilities.
So you are telling me that CBH has made a conscious policy decision to concentrate some or a majority of the resources to younger population that is suffering from mental health problems rather than the more elder --
Yes, I'm saying that there are budgetary choices that get made and that over the years we have been losing ground in treating older adults because we also need to be treating children and young adults as well. And those are tough decisions, but we are all here today to make the point that older adults receive proportionately less from the mental health system than any other age group and that really is a wrong that must be righted.
If we get to it -- and I don't think you have the answer, but I hope somebody gives us the answer -- I want to know what it is and how much of our City resources and these resources that we get from the state and the federal government we spend on --
I was here to give you the medical background. 23 5/12/03 - Health/Human Services - Resolution 030174
The agency directors and program directors are here in the room this morning for the hearing and I would suggest you ask them directly for the data that you want from the City.
Thank you. Don't go yet. I think Frank Rizzo has something to say.
Thank you, Doctor. Thank you for being here this morning. Doctor, you commented on Philadelphia Corporation for Aging. I have had my differences with that organization and personally -- and this is only my personal opinion -- there is a lot to be desired there. I have had some very bad experiences, and you used the word "cutting edge" I believe or they are out there on some initiatives. Every time a local elected official tries to deal with the Philadelphia Corporation for Aging, we constantly hear that it is a state-funded organization and basically they do what the state representatives and they do what the state senators primarily have an interest in, and I'm hoping some day -- and I might be part of that -- to really look at that agency and see where that money is spent because as an elected official here 24 5/12/03 - Health/Human Services - Resolution 030174 in the City of Philadelphia, I don't have a clue other than what I read that they publish on exactly what they do. So there might be people here happy, and again, my personal opinion, I'm not happy because I have been involved in too many issues that I believe they didn't handle well.
Let me take this opportunity to clarify for the record. What I said was that PCA has shown some initiative in cross-training, but that it is woefully inadequate, that in fact we need much more in the way of collaboration and co-funding between the Agency on Aging and the Office of Mental Health and I think that many people in this room have been frustrated that we haven't had more on both fronts, from both PCA and the Office of Mental Health by way of collaborative efforts. So I think I wanted to acknowledge that there are models that they have had some programs and initiatives, but it falls short.
Doctor, thank you for that because I think that I'm very close to asking for hearings to look very carefully at that organization because we take a bad rap constantly. 25 5/12/03 - Health/Human Services - Resolution 030174 Philadelphia Corporation for Aging, people don't realize that that is not a City agency, that that is pretty much a state agency as I look at it, and if they want to call themselves Philadelphia Corporation for the Aging, they better start acting like that. So, again, I don't think you have heard the last from me on this issue. Thanks.
I believe Mr. Williams will be testifying as well this morning. He's the executive director of that organization.
Thank you very much. Are there any other questions? We appreciate your testimony this morning. You provided us with the necessary documentation and statistics that we need to frame this discussion today and I would like to applaud Councilwoman Brown for putting this issue on the table because there is always a beginning and there has to be a beginning and so for the lack of coordination of services, then we begin here today to talk about that, what do we do to better serve our older adults, which I am a member, and so certainly we care about the kind of services that are available and also just as someone aging 5/12/03 - Health/Human Services - Resolution 030174 beginning to understand yourself and what is happening to you and I tell you it's a real shock. (Laughter.)
It's not easy. You often wonder why you probably have a pain or why you feel this way, but it is the aging process, and the way we help people adjust to that and to get services is very important, so as we move into our senior years, we are much more mindful of the need for the services of people who may not have access including yours truly who might not know where to go to get those services. So I certainly thank you for coming and for your presentation. We have now my friend Hikmah Gardiner from the Older Adult Center.
Take your time. We have a panel here I understand. So we have Hikmah, the Mental Health Association of Pennsylvania, Joe Rogers. Would you please identify yourself for the record as you make your testimony. We will have each of you make your testimony and then the members 27 5/12/03 - Health/Human Services - Resolution 030174 of Council will ask you questions at the end. Who's going first?
Since you called me first, I will go first, unless there is an objection.
Is this better? I especially want to thank those of you from City Council who took the time to come. I realize that this is primary election time, but we are the folks who are going to vote for you all, and I'm glad you came. I'm glad you came. We were over here last Thursday or last Friday to visit each one of you individually to keep you abreast of what is going on and why we are here, and we thank you once again for coming out to hear us.
Let me say that Councilman Cohen is not here because he had to do certain things, but you know he would be here. He 28 5/12/03 - Health/Human Services - Resolution 030174 is taking care of some things at home.
Let me also make clear that this is a committee of Council. This is not a Committee of the Whole. So all Council 8 members are not required to be here, only five. 9 There are maybe two more members who are not here, 10 so you have the majority of the committee here. 11
We do appreciate those 12 who came out nevertheless. 13 Of all the mental diseases that strike 14 senior citizens depression by far leads the race and 15 yet if it is treated properly, there is an 80 16 percent chance of successful treatment. Contrary to 17 popular belief depression is not, repeat, it is not a part of normal aging and I ought to know. I'm 74 years old. I was damn near born with depression. I have had it since I was 10 years old. So it is not, and that's a scientific fact. However, depression oftentimes gets overlooked and it is untreated. You may ask why this is so. Well, first of all, those who have it do not recognize it. It is believed by society in 29 5/12/03 - Health/Human Services - Resolution 030174 general that mental illness, especially depression in elders, is just a part of normal aging. And if the old-timers have some inkling of an idea of what's going on, there is so much stigma involved, mental illness, so much stigma. I know I don't want to go to my local mental health center. No, I don't. I would much rather go to a private practitioner. Today I'm in the position to do this. Tomorrow it may be another story altogether. Consider these facts. If the following symptoms appear, and they do vary in severity and duration among different peoples, if at all possible they should seek professional help. Now, if you find that you or someone that you love is persistently sad, anxious or have empty feelings, if you find yourself sleeping too much or too little, if you suffer with loss of appetite or increased appetite plus weight gain, if you find yourself restless and irritable, if you have difficulty remembering things, concentrating on things and/or making decisions about certain things, if there is a persistent physical illness that does not respond to treatment such as headaches, chronic pain and digestive disorders, fatigue or loss of energy, 30 5/12/03 - Health/Human Services - Resolution 030174 feeling guilty and hopeless or worthless, thoughts of suicide or death, you better check it out with somebody. Any three of these things could definitely mean that you have some form of depression. In the land of perfect healthcare there would be well-trained professionals to give treatment to this segment of our society. By "this segment" I'm speaking specifically about old-timers. There would be healthcare professionals doing outreach to those who could not or would not come to their local mental health centers. The Office of Mental Health, the Office of Drug and Alcohol Abuse, the Philadelphia Corporation of the Aging and the Health Department would form a friendly alliance. Oh, would that were true. This would ensure that our seniors were being properly treated for mental health diseases, physical problems, and substance abuse problems. I want to tell you something. A lot of folks don't know that old-timers hit the bottle real seriously. We hit the bottle. I used to get away with it a lot because I found the secret. Vanilla has 35 percent alcohol. Did you know that? Wee... And my kids 31 5/12/03 - Health/Human Services - Resolution 030174 used to call me the cookie lady because that's why I liked cookies because I was drinking vanilla. We find our ways to get around. We need those who are responsible -- let me read that again. We need those who are responsible for the distribution of government and quasi-government funds to be aware that there is a dire need for ample monies to treat the ailments of the elderly. We need these folks to come together to form some kind of friendly, firm coalition to treat these old folk. As an old-timer myself who is able to still be productive, I realize in today's society elders are more and more being pushed to the rear. There is not a care for people in my age bracket as there was when I was a child. I don't know what has happened to our society. And I'm not talking about Philadelphia. I'm talking about nationwide.
We don't seem to care for the old ducks anymore and I'm one of them and this disturbs me very much, very much, and it should you, because you all are not always going to be as young and pretty as you are now. You are coming up down the line. That's right. 32 5/12/03 - Health/Human Services - Resolution 030174
You know what? I believe if there is a problem and I'm aware of it and I don't do anything about it, 60 percent of the fault lies at my door, and so I'm spending the rest of my life talking to these old ducks, getting them off their backsides and being aware of what is going on. We are the ones who vote. Old people in this country vote many, many more times than young people do. We are the ones who vote, and we need to start speaking out about these injustices. We were trained as children to be quiet. I was not allowed to say anything as a child in my mother's house. You better not. That is the way we grew up. We have to get out of that. We have to get out of that. We have to band together and speak out against these injustices and come present our cases to people such as you all to help us do something about it. I have worked almost 60 years of my life. I have a right to be treated like a human being and not like a second-class citizen. I have that right. (Applause.) 33 5/12/03 - Health/Human Services - Resolution 030174
We need to become more politically astute in these matters and we need to learn how we can address these issues. You want more information, you can contact the Mental Health Association of Southeastern Pennsylvania and our little effort is called Mental Health and Aging, and we reside at 1211 Chestnut Street, 12th Floor, and you may call this number, 215-751-1800. Now, there is an extension involved, 266, 207, 206, and 297. And someone will be there to help you gladly. Thank you. Thank you again. (Applause.)
Can I say something on what Hikmah was just talking about?
Thanks to all of the Council people for being here. This is, of course, an issue I think that probably is very dear to many of our hearts. I think Councilman Rizzo kind of touched on one of the issues, which is how do we get people to coordinate, different agencies that have different funding mandates, different authorities that they report to, and I think that's a kind of a 34 5/12/03 - Health/Human Services - Resolution 030174 cross-population problem. We are here talking about aging people, but we find it with children, we find it with adults, that when someone has a serious emotional problem, it is very hard to just address them as one sort of entity. You need to have awareness at least, if not coordination of resources across all programs and all agencies. And that's particularly true when you are talking about the aging population. And you have heard the reasons. One of the biggest reasons is the fact that you can set up within the community mental health system the best geriatric mental health program in the world and for the most part you would not be reaching older folks. As has been pointed out, older folks really don't identify with the idea of going to a mental health clinic for services. So one of the things that we are talking about here is really kind of breaking the mold and beginning new ways and alternative ways to provide mental health services. And our hope is that you as City Council by asking the questions and urging the funding to be appropriately utilized, that we begin to see some of that mold being broken where mental health services are provided over here and aging 35 5/12/03 - Health/Human Services - Resolution 030174 services over here and even library services over there because older folks in our community can be treated. That's the really good news that we have to bring here is that there are treatments, psychosocial treatments. These are treatments where people are befriended. A lot of folks that have a psychiatric problem and mental illness end up isolating themselves from their church and their family and with sometimes relatively small amounts of outreach efforts we can break that isolation and have a huge impact. There are medications that are becoming more and more targeted. There is more and more research on how to target it for folks who are older folks. So we have real hope and the thing that we are hoping that you can concentrate on and look at is encouraging through your powers that exist to see better coordination of services, and, like I said, all the way from our library system, our education system, there is a role for all of these systems in reaching out to older folks in helping them seek the help that they might need and helping them identify some of the problems. Thank you all. (Applause.) 36 5/12/03 - Health/Human Services - Resolution 030174
Thank you very much. Would you identify yourself for the record, please?
Good morning. My name is Gladys Steward, and I'm a client with the Interac --
You have to speak into the microphone. We can't hear you. We have old ears.
Good morning. I said my name is Gladys Steward. I'm a client with the Interac mental health program. When I first met my counselor, I was suffering from vertigo. I had trouble walking and standing by myself because three months before I met my new counselor I had lost my sight. Also, I was suffering with my blood pressure and diabetes. I was having a bad time, a very bad time. So, you see, without the help and support of the counselor, I don't know what I would have done. So in my opinion I feel that the mental health program should remain because there are many older adults and senior citizens who really need this type of service. Without it I don't know what 37 5/12/03 - Health/Human Services - Resolution 030174 I would have done. I hate to think of what would have happened to me. Before I met my counselor from the Interac mental health program, I had been in Chestnut Hill Hospital. After meeting my counselor from the Interac mental health program, she was a blessing in my life. If I needed her, I can call her office and leave a message. She will always return my call. I would like to thank all of you for giving me this opportunity to express my gratitude and feeling of my real life experience. With the Interac program, my counselor is truly a God-sent person. There should be more counselors, more concerned counselors like her. Again, thank you for giving me the opportunity to express my thoughts. Thank you. (Applause.)
We thank you all for your testimony. If you had a wish list and you were only given one item, one improvement you wanted to see happen as we move from these hearings, what 38 5/12/03 - Health/Human Services - Resolution 030174 would that be? Because we have heard a number of different needs and a number of different problems.
I think one of the Council members, I think Councilman Ortiz asked, is there a mental health program in all of our health clinics that serve the seniors, and we don't have one in every mental health clinic. We don't have psychiatric geriatric specialists in all of our clinics. Again, bringing the type of mental health services we are talking about into the primary care setting could go a long way to the degree that we can fund it. The biggest problem with that -- and my friend from the Office of Mental Health said this is all wonderful and they are looking at budget cuts right now from the state, but the reality is if we could do that and in the long run the money we actually save in services that we end up wasting, health services, because we don't meet those psychiatric needs early on, could actually pay for it, but it is organizing that and coordinating that is sometimes very difficult because you are talking about multiple funding sources that sometimes the federal government or the state government says, well, you can spend it here but you can't spend it 39 5/12/03 - Health/Human Services - Resolution 030174 there, so that is where we need your help as the leaders of our community, helping to make some of those changes.
Let me ask you a question. I heard this morning about the coordination of services. My question becomes who do you want to do that? Those of you who are in the mental health field providing services, have you had a coming together to discuss the issues? All the agencies that are testifying today, have you had dialogue about what is needed, who might do it, how it is done? Because certainly we don't do it, but we need to know how that gets done and who takes the initiative and who calls the meeting.
Councilperson, I'm sure you are. That's what we are dealing with. And if I'm stepping on toes or hurting feelings, I offer no 23 apologies because I tell it like I see it. Each entity is concerned about their own situation. Rightly or wrongly, that's the way the situation is. 40 5/12/03 - Health/Human Services - Resolution 030174 There have been some feeble attempts at some getting together, but by and large they are feeble. By and large they are feeble.
So who provides the coordination effort? I mean someone has to do it.
I think this is a battle we fought with the homeless issue when the homeless mentally ill was on the table. We said, "Who steps up to the plate? We are fighting it with the jail and prison issue. Whose issue is it? And I think that we really are looking at having to -- one of the things is we are lucky in that we have a new administration. Estelle Richman is now our new secretary of Department of Public Welfare and I think it is going to be on the state level and we are already in conversations with her. She has talked about her number one issue as the new secretary of the Department of Public Welfare is to get rid of the boxes, to break the boxes down so that we can see coordination. So you almost could pick. You could pick the Department of Aging. You could pick the Department of Mental Health. It really doesn't matter as long as someone is taking the leadership 41 5/12/03 - Health/Human Services - Resolution 030174 and convening the other groups.
And that's because other groups not only -- some of them don't just get funds from the City. They get state funds and federal funds.
So the City is not in the position to call the meeting.
Well, I think one of the various City programs do call those meetings and we do have efforts of coordination. I don't want to downplay that fact, that there have been efforts at coordination, and I think what most of you will hear today is that we really have some serious funding problems in taking the coordination and making it realized as a program, but your Office of Mental Health can play a major role because we are talking about a mental health issue and it tends to be identified, but I think if you don't have all the players at the table, some of it is going to get lost in the shuffle. That's your job in some ways, to mandate that the players come together. You know, it took in this City us elevating the issue to having a homeless czar to 42 5/12/03 - Health/Human Services - Resolution 030174 begin seeing homeless addressed in a coordinated way across all City agencies. Maybe we need to talk about some sort of aging mental health czar, but unfortunately that sometimes is what it seems to take, is to create some power that knocks heads together and makes things happen. But hopefully we can do something without having to go to that extreme.
Point of information. Can I follow up on that, Madam Chair?
Recently there has been some media coverage on various issues that affect our senior citizen community and it kind of tested the system about the turf issue and there were some criticisms at various agencies but specifically Philadelphia Corporation of Aging and I had some things -- I was fairly outspoken in the media about that, and I was confident that they would reach out to me to try to discuss the issues about coordination, about the relationship that they really have with the health department and the various agencies within the health department because, unfortunately, there are some folks in our 43 5/12/03 - Health/Human Services - Resolution 030174 health department that would like to speak out publicly but don't. They keep their comments within closed doors. And because I didn't receive any followup from any of that criticism that I made, I know if somebody is critical of me I quickly pick up the phone and say, "Hey, we need to get together because maybe you just don't understand the issue." That never happened, and that really troubled me that that agency didn't seem to care because, let me tell you, there is no group of citizens in the City of Philadelphia that I care more about than our senior citizens because you have been there, you have given, you have done everything to make this place a better place and I want to be part of making you comfortable and doing what I have to do. Whatever it takes I will do it like my colleagues that are here today, but I'm very disappointed and, again, I have information that there are other people that are disappointed, and if we have to make that public today, I'll do that. If we can do it and get something accomplished privately, I will do that, but, again, I thank you for being so candid here today and, again, saying it like it is. Thank you. 44 5/12/03 - Health/Human Services - Resolution 030174
Let me say that the issue of coordination -- and I asked before Dr. Streim about CBH because I want to know what role the City, since that is where our influence is mostly going to be felt, what is CBH, the Department of Health doing to bring about a greater percentage of services to the elderly. The Bush administration sort of is beginning what I call the new Missouri Compact type of situation. When the Constitution was being formed, Africans, African-Americans, were considered two-thirds of a person, and I think that was the Missouri Compact. And now the Bush Administration in terms of the elderly is thinking about considering how much resources to give to the elderly, to consider them two-thirds of a person because you are approaching that time in their lives in which they will pass on, so they are cutting their lives like in thirds I guess, and as we appropriate resources, we do not consider the elderly a whole person, but only two-thirds of a person in order for resources, and that is something -- that is a policy that is very --
Somebody is here on the CBH board who might be able to give you an answer. 45 5/12/03 - Health/Human Services - Resolution 030174
-- and that is something that is a very dangerous situation. What I would like to know is where our resources are being done, what is the coordination occurring and what is it that we need to do as a legislative body because Hikmah said about turf. Well, this is where the turf ends supposedly and we should be able to bring all of those different turfs together to work in conjunction and hopefully out of these hearings we might be able to achieve a meeting of the different turfs, Philadelphia, the Corporation for the Aging, CBH, the Mental Health Center, so on down the line, but I would like to find out where are we and what we need to do to get it better.
Mike Covone, deputy commissioner for Mental Health and Mental Retardation, Councilman. I will touch on this a little more in my testimony that I am going to give later. Community Behavioral Health has the responsibility for those individuals who are elderly and on Medicaid. Many of the problems that we experience today, and it hasn't been touched on yet, are individuals who are on Medicare and getting Medicare to pay their fair share of the behavioral 46 5/12/03 - Health/Human Services - Resolution 030174 health services that are necessary. Community Behavioral Health is actually the funder of many of the services that do exist today through reinvestment funding in the early years and we have been able to continue those services on through reconfiguring dollars within the Office of Mental Health and there are a couple of other things that CBH is doing to expand access to services and in-home access for individuals who are Medicaid eligible, but their purview does not extend into those elderly individuals who are primarily covered by Medicare.
Let me tell you something. Medicare/Medicaid. The problem is that we have elderly that have a problem and we have to be able to come together and say we are going to take hold of this problem. We are going to come up with a solution. Medicare/Medicaid, SMEAR, whatever it is. That's our problem. They live in this City.
And I guess we have direct control of that Medicaid issue with CBH being part of the City where we need to do -- further outreach is to engage the Medicare portion of this.
We have to bring 47 5/12/03 - Health/Human Services - Resolution 030174 everybody together and be on the same page and have the same programs, so that I think, like Hikmah says, turf issues are not the things that are preventing services from getting to people.
You spoke about President Bush. I am a senior citizen and I didn't have insurance or nothing in Philadelphia. I sent my medical record and Faxed everything to President Bush. I wish I had brought the letter to you that he wrote me back from Washington, D.C., and then he also had a speaker here in Philadelphia, Michael Cruz, in Philadelphia to contact me and for the Welfare people to give me a medical card. I'm a diabetic. I had all of these problems. I couldn't even get a medical card here in Philadelphia. And it is really sad. When President Bush wrote the letter, he did send someone to speak for me through the welfare department and the lady from the welfare department, she turned around and said, Why did you have to call the White House? Because I had no -- I couldn't get nothing done. (Applause.)
I couldn't get nothing done here in Philadelphia. I couldn't get nothing 48 5/12/03 - Health/Human Services - Resolution 030174 done. Her name was Mrs. Scott. She was very nasty. So I took it to the head of the household and the head of the household is President Bush. I wish I had my letter.
I think we are going to have everybody write a letter to President Bush.
I did and I sent him my medical records. I did. Back to the senior citizens, I have a counselor that comes in to see me. I went to three colleges, but I had brain damage. I had brain trauma and that's why I'm not working, because the car bust my head open. I still have the scar here. There are workers out here who treat older adults with disrespect like they are so much better than you and they are coming to take care of you. So who is going to oversee the person that you send out to take care of the older adults? I worked in the field and some of them have no respect for you. They treat you any kind of way, so who is going to overlook the people that you send out to take care of the older adults? You don't want to go to the center because they look down on you and I have pride and I have dignity and I don't like to be 49 5/12/03 - Health/Human Services - Resolution 030174 talked to any kind of way just because you have a job. I had a job too. I had a job at 1315 Walnut Street on the 8th Floor under Dr. Pasasco. I was a counselor there. I'm a mental health worker, alcohol and drug counselor. I had one year to get my bachelor's in psychology, and I had one year to get my degree in mental health and psychology at LaSalle University. So these people come out here and talk to you any kind of way. They don't have no respect for you, but who is going to oversee them? You pay them and they got the job, but they don't treat you with respect.
I just hope that everyone in Philadelphia doesn't have to write President Bush.
Thank you so much for your testimony. We have another panel. I don't know if it's a panel or not, Mr. Rodney Williams for the Philadelphia Corporation for Aging, Michael Covone, Department of Mental Health.
Good morning, Members of 50 5/12/03 - Health/Human Services - Resolution 030174 Council. I'm Michael Covone, deputy health commissioner for Mental Health and Mental Retardation and I'm joined by Tom O'Hara for our mental health policy and planning department and I'm pleased to testify on the Mental Health Association's plan for improving access to mental health services for older adults in Philadelphia. The need for expanded behavioral health services to the elderly is one that has existed in Philadelphia and the nation for many years. The behavioral health system has been working with the Philadelphia Corporation for the Aging and others to address the unmet needs of senior citizens. Often many individuals who are elderly are hesitant to seek out much needed behavioral healthcare services. We need to continue to develop creative ways to bring services to them. Changes in Medicare regarding definitions of eligible providers, part of a national effort to limit behavioral health billing, has eliminated numerous partial hospitalization programs over the last five years and decreased the availability of the largest insurer of older adult services in reimbursing for service provision. 51 5/12/03 - Health/Human Services - Resolution 030174 Furthermore, in many parts of the City elderly have not had access to in-home mental health services. Services need to be expanded to be geographically accessible. The expansion of these services will require a collaborative effort among the Behavioral Health System, the Philadelphia Corporation for the Aging, the Department of Public Welfare and the State Department of Health as well as the Medicare HMOs. All must accept responsibility for the continuation of existing services and for funding of new initiatives to reach those in need. No one entity can shoulder the burden for funding services that are the legitimate responsibility of multiple payers. This indeed is a key challenge of developing and maintaining services to the elderly. Behavioral health funded services. Utilizing Health Choices reinvestment funds, the Behavioral Health System has developed new initiatives to improve access to services through in-home treatment, case management and co-location of services and health centers. Despite the lack of significant external financial support, the behavioral health system has been able to 52 5/12/03 - Health/Human Services - Resolution 030174 provisionally maintain two of the programs initially funded with reinvestment dollars. We also fund other initiatives that provide treatment for older adults in several residential and outpatient programs. Among the services currently funded are the geriatric counseling service at Interac. They have been meeting the behavioral health needs for older adults for ten years. Since older adults have not utilized traditional mental health services, Interac provides services in alternative settings which include homes and senior centers. The Behavioral Health Accessibility Team was financed with reinvestment funding. This recent service initiative provides mental health treatment and other assistance in consumers' homes. Our hope in adopting this model has been that the behavioral health will pay for the behavioral health aspects of the model and that the aging system will pay for the services that the team performs that it typically purchases. We have had positive discussions with PCA regarding this but have not yet finalized ongoing financial commitments. A geriatric support specialist is 53 5/12/03 - Health/Human Services - Resolution 030174 deployed at four health centers to identify, assess, refer and treat elderly patients who present with mental health needs. The co-location of behavioral health and mental services is also intended to reach older adults who may not otherwise seek treatment at a community mental health center. Once again, this model was recommended by the service and advocacy community.
We also fund several specialized residential programs for older adults with serious mental illness. They include a long-term structure residence for older adults operated by Albert Einstein Hospital. In addition, we have several specialized clustered apartment settings that provided intensive behavioral health services to seniors, many of whom are medically fragile. In June we will sponsor a training for physicians related to the diagnosis of Alzheimer's disease. This presentation will include a discussion of pharmacological treatment including antipsychotic and antidepressant medications. In addition, when we initiated a number of these initiatives, we became aware of the extent of the population who did not have coverage under 54 5/12/03 - Health/Human Services - Resolution 030174 Health Choices, or CBH in Philadelphia's case. Therefore we funded a consultant to work with providers to begin to gear up for billing Medicare for these needed services. Furthermore, we require providers to seek access to the Medicare HMO panels. Subsequently when we became aware of how difficult it is to access these panels, we interceded with Medicare HMOs to advocate for inclusion of these providers on the panels. We have been able to maintain the services previously referenced despite having recently been hit with what has been described as Draconian budget cuts by the secretary of public welfare. Despite the lack of appropriate funding from other funders, we have prioritized older adult services and have chosen not to do any reduction in this area as we approach the new fiscal year. )
This reflects our ongoing commitment to older adults. Nonetheless, sustainable support for these programs and the expansion of these types of programs require that other funders pay their fair 55 5/12/03 - Health/Human Services - Resolution 030174 share of the expenses. We will continue to work with the advocacy community in attempting to secure additional resources at both the state and federal level. The Behavioral Health System is committed to its continued support in the development of an advocacy for services to older adults. While progress has been slow, there have been some positive steps taken and some successful collaboration efforts made with PCA, the HMOs and others. Collaboration with PCA has resulted in the development of a number of cross-training programs. In addition, PCA has recently made a one-time contribution to the Behavioral Health Accessibility Team. This is an important contribution which we hope will continue on an annualized basis to support integrated in-home services. Similarly, two of the HMO Medicare providers have recently agreed to open admission to behavioral health providers. However, it has been very difficult to enroll behavioral health providers in these panels and we need an expedited process to ensure that this can happen in the future. 56 5/12/03 - Health/Human Services - Resolution 030174 Finally, a joint plan which addresses some common problems and strategies for the future. In the past mental health services to seniors has been developed separately by PCA and the Behavioral Health System despite growing dialogue between the two organizations. This has happened in response to state and federal regulations and the requirements of different funders. Better coordination is needed at both the state level and locally. PCA and the Behavioral Health System have pledged to commit to common goals and to develop a joint plan for their implementation. This plan will include mutually agreed upon goals, objectives and actions needed to achieve these objectives. Below are some preliminary thoughts from the Behavioral Health System's perspective on the development of such a plan. The Behavioral Health System proposed in the planning process to address the following goals: No. 1, to coordinate and integrate access to services available through the Behavioral Health System and Philadelphia Corporation of the Aging; No. 2, to address the geographical inequities in access to services; No. 25 3, to improve the overall capacity of behavioral 57 5/12/03 - Health/Human Services - Resolution 030174 health providers to serve older adults and; fourth, to improve collaboration in areas of planning, funding and advocacy for these services. I will touch briefly on each of those areas and close my testimony. First, in the coordination and integration of access, we have had preliminary discussions with PCA regarding the prospect of utilizing their central intake for services as a central access point for Behavioral Health Services. This access point would furthermore assist with the coordination of service delivery between the two systems. Also, we are in the process of modifying the CBH intake and member service process to ease and expedite access to behavioral health services for older adults. This centralized information center will have information on the types of services available, provider agency, location of a service and accessibility. The Behavioral Health Information Center will be located at Community Behavioral Health and will be staffed by adult specialists who will coordinate services for CBH members. CBH will also increase the use of in-home service providers for Health Choices members to 58 5/12/03 - Health/Human Services - Resolution 030174 address some of the geographical issues which were addressed earlier.
Secondly, to improve capacity and develop new funding strategies, we are proposing again through a coordinated effort to explore mechanisms both organizations use for funding in-home counseling and treatment. Based on this understanding, we will endeavor to coordinate current funding mechanisms that allow us to better utilize PCA-accessed Medicaid waivers for the provision of in-home counseling and treatment services in coordination with in-home services reimbursed by both the Behavioral Health System, Office of Mental Health and Community Behavioral Health. We also propose to work with Corporation for the Aging to develop contact persons at each organization and procedures for sharing of information about consumers served by both systems. This is needed to eliminate the barriers to effect the service provisions that currently exist. Finally, we are proposing cross-training of Behavioral Health staff and PCA staff as a required part of this plan to assure that staff may 59 5/12/03 - Health/Human Services - Resolution 030174 better understand the services, policies and procedures of both systems. Training on service access, capacity and mechanisms for service coordination will be developed and implemented during the upcoming year. An additional aspect of the plan is for the Behavioral Health System to work with PCA to improve our efforts to inform the community about our respective services. We will increase our efforts to explain behavioral health services for older adults at a number of the health fairs that are upcoming in the City. In summary, it is essential that all involved in providing services to the elderly, PCA, Medicare, Behavioral Health System, and the state and federal government accept responsibility for continuing and developing accessible behavioral healthcare services. We at BHS will continue to be part of the effort and look forward to a renewed commitment from others to address the unmet mental health needs of many of our most vulnerable citizens. Thank you for the opportunity to testify today. 60 5/12/03 - Health/Human Services - Resolution 030174
Thank you. Would you identify yourself for the record, please?
Sure. Pearl Graub. I'm director of professional services at the Philadelphia Corporation for Aging.
G-R-A-U-B, Pearl Graub. Good morning. PCA thanks the Members of City Council for the opportunity to offer testimony in support of the Mental Health Association's plan for improving access to mental health services for older Philadelphians. Designated as the area agency on aging for Philadelphia, PCA plans, funds and administers services for over 70,000 older persons and people with disabilities each year. A strong advocate for low income and minority elderly, PCA is committed to improving the quality of lives for older Philadelphians by planning appropriate resources and delivery of services to those in need. Some older people have mental health problems and PCA is concerned that access and availability of care are 61 5/12/03 - Health/Human Services - Resolution 030174 insufficient throughout the City. The City of Philadelphia's Office of Mental Health and PCA has collaborated on several projects. The aging and mental health certificate program, a cross-training program, is widely recognized as an excellent method to enhance the knowledge and skills of the professionals of both the aging and mental health systems. PCA has assisted in funding mental health special projects to support the goals of increased accessibility and coordination of services. The special projects include Project Hope through Catholic Social Services, and the Geriatric Clinicians Program through Intercommunity Action, Incorporated. They provide in-home therapeutic-based evaluations and counseling, social work care, management and support teams. However, these resources only partially cover the City and there are many older adults who don't have access to services. West Philadelphia is not covered at all and South and North Central Philadelphia are only partially covered. Funding is insufficient and we urge City Council to appropriate more funding, new funding, not taking away from other programs, but 62 5/12/03 - Health/Human Services - Resolution 030174 new funding for these needed services. OMH needs to be given additional funds if coverage to serve older Philadelphians is to extend throughout the entire City. The issues are as follows: There is an inequity in geographical access, overall capacity to meet needs, and a lack of sufficient funding. PCA Common Vision and Plan. PCA pledges to continue to work with the Office of Mental Health to develop a common vision, goals and planning in order to tackle the issues and creatively implement solutions. Older Philadelphians, unfortunately, underutilize the mental health system. The perceived stigma acts as a barrier and individuals in need with acute and chronic conditions are in jeopardy. Losses associated with the aging process may lead to depression and isolation, which are linked to their physical well-being, functional abilities and mental health. Yet unless an individual is known to Community Behavioral Health, CBH, they often do not receive assistance. PCA is known in the City by older adults as the entity to assist with heat emergencies, information concerning utility assistance programs, 63 5/12/03 - Health/Human Services - Resolution 030174 health promotion, senior centers, home delivered meals, access to care-at-home programs, et cetera. All are easily accessed through a single point of entry, the PCA help line. OMH and PCA are proposing that in-home evaluations and counseling for older adults for nonemergent situations be referred through PCA's help line. It is our belief that older adults will be more comfortable being identified to PCA. We would serve as a conduit to refer for mental health services and simultaneously assess whether or not these individuals have any additional unmet needs. This can only happen if and when the service delivery system for in-home counseling becomes available citywide.
PCA in conjunction with OMH will develop a strategic plan to accomplish the following goals: Single point entry after citywide expansion has occurred, in-home mental health services for Medicaid recipients. PCA will work with OMH to utilize the Pennsylvania Department of Aging waiver services for those with short-term counseling needs and, two, medical assistance, CBH resources for those with more intensive needs. There is a hole in the service delivery 64 5/12/03 - Health/Human Services - Resolution 030174 system for nonMedicaid eligibles. Individuals on Medicare who do not have medical assistance have few options available for mental health treatment. Behavioral health providers have had difficulty being enrolled by Medicare HMOs and therefore little mental health service is offered on Medicare HMO panels. PCA will also work with OMH to attempt to meet the needs of those individuals. Our commitment to older Philadelphians and meeting their needs is strong. PCA staff will try to identify funds to continue both the Project Hope and the Geriatric Clinicians Program mentioned above despite the level of funding we have received. However, comprehensive citywide coverage and access to programs will only occur when all other parties including the Behavioral Health System, OMH, HMOs, and the state and federal government come to the table to create a plan to meet the needs. PCA wants to express its gratitude to the Mental Health Association for facilitating this hearing and applaud City Council members for embracing this critical topic so diligently. Thank you.
Thank you very 65 5/12/03 - Health/Human Services - Resolution 030174 much. (Applause.)
We have heard a lot here today, and as I listen to you talk about the services and you talked about the inequity of services, how are the areas for service determined? Are all the services contracted out?
Yes. The City doesn't provide direct services in the behavioral health end. There is a provider network that provides those services.
So Miss Graub said, or you might have said, there are no services in West Philadelphia, South Philadelphia and North Central?
Part of what we are trying to increase with the additional in-home behavioral health services that CBH is establishing is to address the in-home services in that area. There are generic outpatient services that exist all through the City. It's the specialized nature of the services that we are talking about that aren't in all the areas.
So how do you go 66 5/12/03 - Health/Human Services - Resolution 030174 about accessing those services? Do you ask people to come forth and you contract out with them?
There are actually two providers right now who provide in-home behavioral health services and they are going to expand to the two areas of the City.
IAMA and Personal Touch. They are currently under contract with Community Behavioral Health as an in-home service provider and we have had specific discussions with them about this population as well.
And what kind of staffing do they have? Do they have trained --
They plan to increase their services citywide. They had been more regional previously and they are now willing to go to all parts of the City.
Where do they concentrate now? 67 5/12/03 - Health/Human Services - Resolution 030174
Just a slight correction. They have been taking referrals citywide and they have seen some older adults, but these two services, CBH has been authorizing them, but it hasn't been organized to make sure all the folks who have older adult needs in the community know about this, so by having the call into the number at CBH and making sure the staff is trained about all of these resources, these two agencies that have been used on a citywide basis will be used by much more frequently with older adults as the referrals come in.
My name is Tom O'Hara, mental health administrator for policy and planning at OMH.
I think of a senior citizen. You know, we don't know that we are mentally ill. Okay? We don't know that we may need some service. So who identifies the fact that someone may need service? Is it a family member, a 68 5/12/03 - Health/Human Services - Resolution 030174 next-door neighbor or what?
Or a primary care physician. Part of the reason why we did expand to the district health services was that very reason. Part of the training we are also providing to physicians is for that very reason because senior citizens are likely to come in touch not with the traditional mental health system but through a variety of other avenues and the other reason why we want to expand some specific outreach at the community fairs and a variety of community events is that very reason, so that families will also have information and know where to contact.
And, Miss Graub, you talked about PCA being the initial contact point using your hot line or help line for families to call to be referred to the various services. Would that mean services from the Mental Health Association, from the Health Department? Would you have all the contracting agencies listed where they could be referred to? Is that what you are talking about?
For nonemergent situations, yes. Older individuals, their families, the 69 5/12/03 - Health/Human Services - Resolution 030174 professional community are very used to the single point of entry, the senior help line, and the thought is because there is less stigma that they be more comfortable accessing the behavioral health services for the in-home counseling programs through PCA, but again these are nonemergent. CBH would still be involved for the more acute, critical behavioral health situations.
Do you in any way monitor the contracting agencies with you for quality of service?
Do we have enough people, individuals, who are trained to provide these services, in-home services?
This is an aside, because I know someone who was dealing with a family 70 5/12/03 - Health/Human Services - Resolution 030174 member who needs a home care nurse and just can't get a quality nurse, qualified home healthcare aid, so I was just wondering what the field is in terms of the number of individuals who are available to provide this in-home service.
That clearly is an issue that cuts across not only the mental health system but the mental retardation system, the in-home service system. We have attempted over the last year to really do some outreach to that direct care work through community colleges, through some of the high schools to engage people in wanting to work in this field, but clearly there needs to be a long-term recruitment and retention strategy that exists for all direct care workers in the social service fields.
If we are contracting with these agencies to provide services to seniors in their home, what monitoring do we provide of the agency relative to the quality of service that these agencies provide?
I guess there's a couple different layers. One is many of the services require state licensure to begin. 71 5/12/03 - Health/Human Services - Resolution 030174
Secondly, CBH also has credentialing requirements which will result anywhere in a six month to annual certification. If an agency doesn't fully meet up to a year's certification, then CBH will provide them with technical assistance during that period of time and ongoing monitoring of the services so that they can be recredentialed down the road. So there is a fairly intensive credentialing process that agencies who are a part of the Behavioral Health System go through.
While I have you, Miss Graub, are you responsible for providing transportation to senior citizens from their homes to take them to senior citizen services or take them to wherever they want to go, this transportation system?
Most transportation in the City accessed by seniors is accessed through two mechanisms. One is via the Shared Ride Program where lottery dollars are paying for I believe it is 85 or 90 percent of the cost of that transportation. 72 5/12/03 - Health/Human Services - Resolution 030174 The second is for medical assistance, individuals on medical assistance going to doctor's appointments or other appointments, through the Wheels program and that's a medical assistance program and that's through a state contract. So PCA does not directly provide transportation. PCA does have a program called the Attendant Service Program for individuals who need two individuals on the van to assist with individuals coming down steps. Transportation is door to door through the Shared Ride Program, but if an individual needs assistance door through door, PCA does administer the Attendant Service Program.
Shared Ride Program is monitored by PCA as well as the Pennsylvania Department on Aging.
What is your impression of the Shared Ride Program? Is it a quality program effectively run, responsive to seniors?
The transportation program provides an incredible amount of service, but I 73 5/12/03 - Health/Human Services - Resolution 030174 don't know of many seniors or many professionals who haven't at some point teared their hair out in regard to transportation. It's a very difficult resource to manage and to improve.
If you monitor it, then what penalties are in place for those who have contracts with PCA that are not delivering a quality service?
There are penalties. There is a process in terms of who bids, who gets awarded contracts, but there is also an issue of available quality resources.
Resources in terms of dollars or resources in terms of individuals, companies, to provide the service?
And Mr. Rodney 74 5/12/03 - Health/Human Services - Resolution 030174 Williams is not here because?
I heard both of you speak about collaboration, which is, we know, welcome and necessary and I would add the word "required." However, we also heard from Miss Hikmah earlier that turf wars exist. Could any of you or all of you address that? Is that real? Is collaboration something new? We know it is not well integrated because we would not be here if that were the case. So what is your view?
I think it is a fair assessment that we wouldn't be here if this was a seamless system as it exists now, but I also think there are multiple turfs that exist and some of the key players in those turfs have to do with the Medicare issue and many of the elderly individuals who have their health coverage and therefore their behavioral health coverage only through Medicare and the state resources that exist or don't exist from both the State Department of Aging and the State Department of Public Welfare. They are two other critical partners in this and certainly folks who we need to engage in that discussion as well. This 75 5/12/03 - Health/Human Services - Resolution 030174 will not be an issue that the City in and of itself can sit here and fix. There is not a magic bullet from the City alone.
One other specific issue. I think it's fair to say there have been turf issues relating to funding responsibilities and that's been an active issue over the past year or more than a year. We have had a tentative agreement at one point with PCA about a way of dividing up responsibility for funding in-home services. That is something that we really need a joint plan and a joint commitment on, and if we are able to do that, I think that will diminish some of the turf issues. It has been an issue for us of trying to get other parties involved, which we have said over and over again, in the funding aspect of this because we heard advocates about three and a half years ago develop model programs and we funded three of them. Our primary goal then was to make sure we could adequately fund them so if we could fund those three, we could expand them. We have not been able to develop the stable funding for the first three, so that's where some frustration I think exists and these hearings hopefully will help us to be able to 76 5/12/03 - Health/Human Services - Resolution 030174 deal with those issues.
Finally, I did hear Miss Graub speak of new City funds. You are willing to be supportive of new City funds. What is the current activity at PCA for new state funds?
Right now we have noticed that our funding is level; however, we are committed to work with the Pennsylvania Department on Aging, the Department of Welfare and statewide as well as City agencies to come up with additional funding resources for these programs.
And what does that mean, "We are committed"? Does that mean you are currently in discussion? Does that mean you have an action plan? What does that mean?
We are currently in discussions. We have committed to develop a strategic joint plan where there is a joint vision and joint goals where there haven't been in the past and we have talked about doing that short term to effect some long-term change.
And the anticipated date of this action plan is when?
Well, we haven't -- Tom 77 5/12/03 - Health/Human Services - Resolution 030174 O'Hara and I have begun the process and we don't have a set date. That is something we can develop, a set date, a time line. In addition, through the Pennsylvania Department of Aging waiver program -- those are waiver services that PCA care manages and administers -- we are looking at additional counseling for in-home needs for our seniors.
We will look forward to a written document that sort of outlines a recommended roadmap on how we can look to improve the issues we discussed here today.
Just to follow up on that, we all believe that that dialogue does need to include some of the folks you heard from earlier today from the Mental Health Association and --
If we are serious about the integration of services, then absolutely, yes, all of the stakeholders need to be at the table. Thank you very much for your testimony.
We will hold the 78 5/12/03 - Health/Human Services - Resolution 030174 record open so you can come back and report. Just let me ask you one question. What percentage of City funding do you receive? Do you receive any City funding at all?
Very little. We receive a small grant for housing services for younger disabled and an adaptive modification program and some mental health and aging services and mental health money for the domiciliary care program, but very little City funding.
I want to underscore Madam Chairperson's request that we will look forward to a tangible document that speaks to the work you will do over the summer because we do expect to -- in order for us to complete our next steps, it is best to have input -- when I say "our," I mean this committee -- input from you, those who live and breathe the issue, so we are leaving this open for that report.
Thank you. The Chair now recognizes Mary Hurtig, Geneva Black and Tom Volkert. 79 5/12/03 - Health/Human Services - Resolution 030174 Are you going first, Mary? Would you like to state your name, please.
Good afternoon to my friends on Council. I sit here wearing two hats. You both remember that my career prior to coming to the Mental Health Association, in 1997 I worked with the Mayor's Commission on Aging, so I have an older hat that says aging and a newer hat that says mental health. Specifically I think I would like to start by saying we sit here this morning really because of the efforts of two men, three people. This is one of them, Tom Volkert -- Corbett, where are you -- Corbett Banks and Hikmah Gardiner. When I was hired at the Mental Health Association in 1987, the forgotten population was children and I shared an office with a woman named Glenda Fine, who had started Parents Involved Network. She was the parent of a child with a serious emotional disorder. And parents screamed and yelled and chipped away until they are indeed a very full partner in the Behavioral Health System today and children are given a very high priority by Philadelphia Behavioral Health System and we 80 5/12/03 - Health/Human Services - Resolution 030174 struggle to improve the system of care, but they certainly receive equal attention. Well, when Tom Volkert was hired, there was not very much attention being paid to older adults and I just want to say for the record that there have been three voices and others, but these three primarily that have brought this issue to public attention, and it is important that we do bring it to public attention because, Councilman Ortiz, when you asked, for example, has CBH discriminated, have they overlooked this population? Not intentionally. And anybody who requires or comes to the attention of Philadelphia's behavioral health system -- we actually don't say CBH. If Estelle Richman was here, she would wrap your knuckles. We say Philadelphia Behavioral Health System. CBH is one arm and it is the place where you walk through the door, but it is only one arm of the Behavioral Health System. No one is turned away for care by this system, but you have to try to get care, and as was evidenced earlier, most older adults who suffer from a mental illness, particularly depression, are not even aware that there is anything the matter. 81 5/12/03 - Health/Human Services - Resolution 030174 So what we are talking about is involving a broad array of social systems, formal and government controlled and funded as well as informal churches, to recognize that depression is not a normal part of aging. And I think most of us think it is. Then you have to ask why do some people lose a spouse, get a chronic illness, have a devastating tragedy happen and they can survive and they are rebound and they are resilient and some people, they sink into depression. We want to blame it on life's experience, but it is not. It is something called late life onset depression and it is a debilitating illness that needs attention and care, and that's why we are sitting here today. So if that silent majority who don't know there is anything the matter thinks it is simply part of aging to not want to get up in the morning, to become paranoid, to start to not eat, to stop going to church, major changes in life behavior, if we stopped thinking it was normal and started reaching out, we could bring them to the Philadelphia Behavioral Health System and only then would we know if they were being discriminated against or not receiving the care they need to 82 5/12/03 - Health/Human Services - Resolution 030174 receive. My colleagues, Mike Covone and Tom O'Hara, have just told you that this is a multipayor system and Medicare is the big culprit. I will give you information that we have in Congress right now, Senator Corzine's bill, S646, the Medicare Mental Health Modernization Act. It is Senator Corzine's bill. The House version is Pete Stark's, and that is HR1340 and it is the Medicare Mental Health Modernization Act. It's not new. It has been introduced in other sessions.
Right now Medicare only pays 50 percent of a visit to a mental health professional. It pays 80 percent of a visit to a physical health professional but only 50 percent. As you can imagine, that means that mental healthcare is out of the reach of almost everybody that is on Medicare. That is discrimination of the worst sort. This bill would undo that. So if we had a Medicare system that truly paid for healthcare, not discriminating, it would go a long way to addressing some of the needs that have been talked about. I'm going to conclude my testimony by giving you something specific that I think Council 83 5/12/03 - Health/Human Services - Resolution 030174 can do and that is we run a very effective system of healthcare clinics and, as you have been told, we have a model program, I mean a pilot program, in one of the health centers? Four of nine. But it is not every day. Am I correct? We have a psychiatric nurse who visits these health clinics one day a week to do depression screens, but those depression screens, my understanding is, are fairly voluntary. So if Dr. Hurtig is examining Miss Reynolds and he suspects she has depression, he may send her to the psychiatric nurse. The most effective thing that Council could do is to either require of the primary care physicians in the health centers that they be trained to give a depression screen. It's not long. It's five minutes I think. I'm not sure. Tom will address it more specifically. Short-term treatment. But if we had every senior 60 years and older no 20 matter how they presented, even if they are peppy like Mary Hurtig, if you required every primary care physician and/or psychiatric nurse for every person over 60 to have a depression screen, we could uncover some of these hidden depressions. Mary Hurtig may be peppy, but you have 84 5/12/03 - Health/Human Services - Resolution 030174 no idea what is really going on inside and I may go home and kill myself in hours as you saw on that 4 slide. I think we owe it to people over 60 that 5 everybody get a depression screen and I think you 6 can have input on making that happen. Thank you 7 very much. 8
I'm Tom Volkert, director 11 of aging advocacy at the Mental Health Association. 12 I have given you testimony. I just want 13 to summarize a couple things. Mary is very kind, 14 but there is actually over 60 different 15 organizations and I just facilitate the work of 16 those groups. Some are senior groups; some are 17 provider groups. Many are advocates and it is out 18 of that that we have been working for years to 19 increase services to older adults. We recognize and 20 you have heard again and again that a couple of the 21 main issues are access to appropriate mental 22 healthcare as a problem for older adults in 23 Philadelphia, particularly those who are homebound 24 or non-English speaking. We have some very good but very small 85 5/12/03 - Health/Human Services - Resolution 030174 programs that don't serve the City. About half of the City is served leaving out significant portions of west, southwest, South Philadelphia and central City. If you can picture a piece of Swiss cheese shaped like Philadelphia with huge holes, you get the idea of the service area for mental health services for older adults. We need to provide those services for every older adult in the City. A second issue that you picked up well is the need for coordinated services geared to the unique needs of older adults. Older adults with mental illnesses rarely have just one problem. Rather they will go to their doctor complaining of physical symptoms or lack of energy or confusion that won't go away. The primary care physician needs to be linked to the mental health system. Moreover, they often have a combination of physical, mental health and social needs. Each of these needs is served by a different system which has different regulations, different funding, different locations and on and on. This is difficult for any person to navigate, but for someone frail and depressed to have to go to multiple places, fill out many forms and see many 86 5/12/03 - Health/Human Services - Resolution 030174 strangers, it is near impossible. Many older adults just give up. We need to develop links so that every door is the right door and the system connects older adults to the services they need. What should be done? Our Mental Health and Aging Coalition submitted a plan for funding that will expand the present services so they will extend to all older adults in Philadelphia. That involves some staff people that would be coordinated with the present existing system. Second, this plan will result in the integration of mental health services with the health and aging services to form a continuum of care for older adults with mental illness in Philadelphia. This plan is based on one that was submitted by the Geriatric Counseling Program to SAMHSA, which is the Substance Abuse Mental Health Services Administration of the Federal Government. It received high ratings, but unfortunately was not funded. It would have expanded services to the whole City and coordinated, and Cynthia Wishkovsky was the author of that plan and so she is able to speak to that issue. To create the system of care that will 87 5/12/03 - Health/Human Services - Resolution 030174 service our parents, grandparents, and some day us we need to develop a set of funding partnerships and clinical partnerships. There is need to develop funding partnerships. Currently the few programs are largely funded by the Philadelphia Office of Mental Health, but we are fearful with the recent budget cuts these programs may be on the line. We were very happy to hear this morning that none of these programs will be cut. That is certainly a step in the right direction. The Philadelphia Corporation for Aging also needs to become an equal partner in funding these programs. It must make a commitment to fund the nontreatment portion of these programs that are so important to coordinating systems. See, these programs are often multidisciplinary.
They have mental health services, treatment services, but they also have care management services. One type of services is supported by the Office of Mental Health and another set of services is often supported by the PCA, and to get those services in a team approach needs to have co-funding. We also need to be able to tap into other sources, Medicare, Medicare HMOs to health 88 5/12/03 - Health/Human Services - Resolution 030174 systems, and so forth. Our goal is that the necessary partnership that would be developed would be clinical and funding. In addition, a cross-systems leadership committee made up of consumers, providers, decision-makers from the various systems that affect access and services for older people will be initiated to develop the infrastructure needed. There needs to be an infrastructure to pull all of this together. This committee would troubleshoot programmatic or cross-system problems that interfered with complicated cases, investigate policy barriers, develop policies that enhance access to appropriate services and investigate funding opportunities. An essential part of our plan will be to develop staff and services that are multicultural and bilingual in order to accommodate all citizens in the community. Moreover, the plan has been designed and will continue to be shaped by older adult consumers who understand mental illness and how to reach out to those who have difficulty accepting help. 89 5/12/03 - Health/Human Services - Resolution 030174 We are fortunate in our community to have tremendous resources. We have met many of them and you will continue to meet them this morning. It includes geriatric psychiatrists, program planners and therapists. 30 for every older adult in the City. There are 270,000 older adults. 30 to implement this program. That goes to about $350,000 on top of the present money that's being allocated. I think that's well worth it and I think that money would come back to the City quite quickly. Our city is blessed with many gifts including good geriatric psychiatrists and clinicians. If we don't care for our older adults, we have no excuses. Our city is very blessed by the treasure of older adults. We need to honor them. Thank you very much. )
Cynthia Wishkovsky. I'm the director of aging services for Intercommunity Action, known as Interac, in Northwest Philadelphia. 90 5/12/03 - Health/Human Services - Resolution 030174 It is a pleasure to be here today. Thank you very much for convening this hearing. Interac is proud to be a pioneer in providing accessible services to senior citizens in Philadelphia. It has taken the dedicated commitment on the part of our funders, agency, staff and other community agencies to be able to build bridges to be able to meet the serious gaps of services regarding the several systems that are older adults utilize in the community.
No, but I'm not a great public speaker. The Geriatric Counseling Service provides mental health services to people over age 60 who reside in designated service areas who have attended the community centers that participate with our program. The program is funded by the Philadelphia Office for Mental Health with training and support from the Philadelphia Corporation for 91 5/12/03 - Health/Human Services - Resolution 030174 Aging. Interac received part-time funding, along with a few other agencies, about years ago, 5 so we have been in this business for 20 years. I 6 have personally been in this business for 32 years, 7 so I'm aging along with my clients. However, the 8 money was never enough to satisfy the need even 9 then. It is the same situation today. 10 Our program has grown slightly over the 11 last few years by adding one additional case manager 12 to our team of clinicians and supervisor and we also 13 have a psychiatrist who you met earlier this 14 morning, Dr. Streim. We also have received some 15 funding from PCA to provide services to six senior 16 centers in South Philadelphia, as clinicians are not 17 allowed to visit people in their homes, so we are 18 bound by that contract. 19 The structure and protocols of the 20 program have been developed and we would be able to expand if additional workers could be funded within our structure. We are currently serving primarily North Central and Northwest Philadelphia. Thus remains a significant part of the city that is not covered. We have a full caseload and we have a 92 5/12/03 - Health/Human Services - Resolution 030174 waiting list of two to four weeks for services at this present time, so without much advertising the need is tremendous. If we did a mass education process, we could never meet the need of people who would need the service. We have written many proposals over the last number of years, both governmental and foundation proposals, but we have not been successful. We would like to note that our geriatric counseling service was cited as a promising practice in a publication entitled "Promoting Older Adult Health: Aging Network Partnerships to Address Medical, Alcohol and Mental Health Problems" issued by the United States Department of Health in 1992. We were also used as the model practice for two agencies that received SAMHSA funding in Arizona. They were successful in receiving the funds and they based the program on ours, but we were not successful in receiving the expansion grant that we hoped to receive. Who do we serve?
Sure did. 93 5/12/03 - Health/Human Services - Resolution 030174 With so many people over the age of 60, we heard all the statistics before, so I'm not going to repeat, but I will also reiterate that the majority of the seniors do not use the traditional community mental health system and I work in a community mental health agency and know this to be true. Even the seniors who come to our center when they can utilize, go down the street to our outpatient department, often choose not to do so. The stigma of entering into a mental health facility is just not part of their culture. We are dealing with a generation of very proud, independent people, and this goes against the grain of what they have been raised to believe. So by forcing that doesn't necessarily help them accept the services or to utilize it. What we do know about our services, we are serving approximately 300 people a year, which is a fairly high number, and 90 percent of this population have never ever had contact with mental health agencies in the past. However, upon assessment, 40 percent of those meet the functional definition for severe mental illness. So we are seeing a very, very high need population and even 94 5/12/03 - Health/Human Services - Resolution 030174 amongst those who don't identify -- who are not scored as high as SMI are really truly at risk. Older people are very much affected by stigma and they also fear the need to ask for help. They don't want to be seen as vulnerable. They are fearful of showing their vulnerability. Obviously people do get hurt sometimes, get forced into decisions that they don't necessarily want. They are afraid of losing their homes. They are afraid of all kinds of things that systems can sometimes -- in their mind that can happen to them and particularly when they don't have caregivers or they have fragmented services in their home. They feel very vulnerable. They do try to articulate those problems, but they are often reluctant to even seek help without a lot of support or encouragement. Consider Mrs. G who we saw at the age of 72, a widow living alone in a house. She lived alone for over 50 years. Her children live out of state and she has very few family supports. With high blood pressure, diabetes, crippling osteoarthritis, Mrs. G retired at the age of 60, young age, as a teacher's aid position. Her income is very limited. She receives some services from 95 5/12/03 - Health/Human Services - Resolution 030174 the aging system, from PCA, who actually referred Mrs. G to us because she started crying one time upon a visit. An assessment revealed that Mrs. G scored out of symptoms for major depression 6 including frequent thoughts of death. She refused 7 to see a psychiatrist, however, even when we 8 approached her because she felt insecure about that. 9 However, she did consent to see our clinician who 10 slowly over time developed a relationship with her, and after a couple of months Mrs. G allowed the therapist to contact her physician who prescribed the antidepressants for her. With the combination of medication and treatment Mrs. G's condition began to improve. It should be noted that to treat older adults sometimes takes longer than it does for younger people. They do respond very favorably to treatment, but it takes a little more nurturing of a relationship to make this happen. So the idea of short-term treatment is sort of an oxymoron with this population. The other issue that is difficult for this population is really how dementia is viewed. Dementia is often viewed as a mental condition and 96 5/12/03 - Health/Human Services - Resolution 030174 not a mental health condition. Yet we do see a larger number of adults with dementia or early onset stages of dementia with significant depression or delusional disorders that can be helped to create at least a better quality of life for what they have for the days that they have.
We also have difficulty sometimes getting people emergency treatment who sometimes when you are dealing with delegates or hospitalizations see the issue of dementia as being not appropriate. So we have had some people who have been in serious situations who have needed to be 302'd and we have had difficulty convincing the delegate that in fact this is a serious mental health issue because they keep thinking because they are old they may have dementia, so there are training issues that need to happen here as well. In fact, many older people who have identified primary care physicians will first seek help from him or her. We often know that physical complaints are often overlooked as a symptom of depression. It is a sad fact that many older people who actually commit suicide consult their physician in the last few weeks of life. This was mentioned 97 5/12/03 - Health/Human Services - Resolution 030174 earlier, but I find that such a difficult issue. Since older people view their medical providers with trust, it is important to integrate emotional help with physical help to the extent possible to serve older people well. In addition, other issues that affect access for older people include isolation, mobility problems, income and limited English abilities. Caregivers of the frail and elderly are also people at risk and need support and care. This is why a program such as our Geriatric Counseling Service and some of the others you are hearing about today are so important. All of these programs take the services into the community by providing them where older people can access them, in their natural environments, through their homes or churches or healthcare centers, senior centers, or other places that seniors gather. They are also staffed by specialists, people that understand the complexities and special needs of this population. By making these services available and accessible, stigma is decreased and the mental health treatment becomes normalized for this particular population. You don't have to call it a 98 5/12/03 - Health/Human Services - Resolution 030174 behavioral health disorder. We can call it something else. It doesn't have to be framed that way, but you approach the problems the same way using the language of the consumer. The use of geriatric specialists ensures the population's special needs are addressed within the context of providing these services. Outreach and education is extremely important to assist older people and their families and community members to understand the nature of mental health problems among the elderly and not to assume that this is a normal part of aging. We have not had the funding to conduct broad educational campaigns; however, the invitation to hold this hearing is an important step to be able to offer hope and encouragement to many people afflicted by mental health concerns. There is hope. In addition, our staff routinely consults with families, community physicians, senior centers, care management staff, PCA, as well as home health agencies and hospital personnel on behalf of our clients. We also regularly conduct depression screenings in public areas as well as help promotion lectures trying to help people to self-identify. 99 5/12/03 - Health/Human Services - Resolution 030174 The reimbursement issue was brought up earlier and that is a very important issue. I appreciate that you identified, that Mr. Covone identified, that CBH is for Medicaid population. Most of our clients do have Medicare as their primary payor, but 30-some percent are now in HMOs. This is a significant barrier. The cost of care is extraordinary. It is extraordinary for people of any age to privately fund mental healthcare, but the disparity of reimbursement is really just not acceptable. We find the co-pays again are 50 percent versus percent that people need to pay 14 for their physical healthcare.
15 Also, from an agency's point of view 16 financing community-based initiatives have to take 17 into account that there is little coordination of 18 benefits for this population so often as an agency 19 we get stuck with a lot of nonpayment. It also 20 doesn't ever touch the issue that Medicare reimbursement is for strictly the face-to-face contact with that client. It could be 60 minutes, an hour, or 90 minutes if it is an extended issue. It does not cover the cost of getting the therapist to the people, the mobile aspect of therapy. It 100 5/12/03 - Health/Human Services - Resolution 030174 doesn't deal with all the accountability issues of documentation for both systems and it doesn't deal with the issues of the need for case management. I'm a little concerned when I hear the planning that has been going on between PCA and the Office of Mental Health regarding care management because the care management that we understand from the behavioral health side is very different from the care management that comes from PCA. It's a different philosophy. We are dealing with very vulnerable people who are afraid. They are not able to -- the PCA's program is really very much looking at all the services and trying to plug those services in, but this is a clinical perspective and it is a little more hands on, much more hands on -- much more helps people get from place to place. You can't get an older person to try a partial program or to come to a senior center who has been afraid to leave their house for four months by telling them to get on a SEPTA bus and to arrive there on their own. It does not happen. You cannot give them a phone number and say have you or your family call. It is not how the person accesses the services. They really need someone to take them the 101 5/12/03 - Health/Human Services - Resolution 030174 first couple of times to get over that fear and work along with the treatment plan. So I ask you just to think about that. It is a little broader perspective of what this means to me in terms of the clients we serve. I really am glad to hear that planning is going on between the Office of Mental Health and PCA. It is important to us because we tend to talk to both systems and it is really difficult. I do encourage you, though, as part of the planning to include providers and consumers and advocates into the mix. Some of what you are thinking about we have had experience with like using a single entry is a method for accessing services. It has not worked in all the neighborhoods around Philadelphia. Some of those services just don't get delivered oftentimes in the community the way it is seen from a central point of view. But I would like to encourage you as part of this before you get too far along in your decision-making. Thank you. )
I think the gentleman heard you. Certainly it is important to include those people who provide and supervise the 102 5/12/03 - Health/Human Services - Resolution 030174 services. In your discussion about outreach and education, you listed a number of sources. I think you ought to include the churches. A lot of senior citizens go to church. So list the support of the clergy. They do have various -- like today, now, they have a meeting about a hundred ministers. You might want to make a presentation to the clergy in Philadelphia so that --
And continue to stay on it. One of the issues -- I can't remember who talked about it -- I think you did, Tom -- was about serving different populations, particular ethnic populations. You know, Philadelphia is a diverse city and I'm thinking about my district, which has a very large Asian population and a number of them are senior citizens. Just how do we reach them and are we training personnel to be able to reach out and communicate? There's the language barriers, cultural issues, and so how do we reach that population?
That's an excellent question and actually we have a couple of speakers 103 5/12/03 - Health/Human Services - Resolution 030174 that are going to be coming down the line, one from the Hispanic neighborhood community and one from the Jaisohn Center, which is a Korean community center, so they will be speaking. And you are exactly right. The whole concept of mental health is very different in different cultures, the language barrier and the words that are used. There can be tremendous amount of stigma. The approach rather than working with individuals, we are working with families. These are all very different in different cultures and must be respected if you are going to have effective treatment. For instance, in the Asian community something like 40 percent of the people are caregivers while in the Caucasian community it is only like about percent. So the value of having 18 somebody live in the home and having their parents 19 or grandparents stay in the home and therefore they are much more involved in the caregiving and in the mental health support and environment. So I would defer to those folks to talk further, but you are very right. And I know that the agencies have tried to hire people of bilingual and multiple languages to deal with that particular 104 5/12/03 - Health/Human Services - Resolution 030174 issue.
Thank you. Cynthia, you did mention something about the service in South Philadelphia and you are not allowed to go into the homes?
This is a program funded by the Philadelphia Corporation of Aging through their program management department and the contract is to be accessible to the referrals from the six senior centers that are in South Philadelphia; however, we are not allowed to go into the in-home area.
Right. We work with the senior centers. Actually we have one clinician who is extremely busy with just the five centers that she visits doing assessments as well as treatment and doing health promotional activities for the folks who come there.
So if anyone needs 105 5/12/03 - Health/Human Services - Resolution 030174 some followup services, they would have to come back to the centers, right?
Right. However, there are some occasions when someone is referred from the senior center. Sometimes people don't want to be seen there either for a lot of reasons. They feel their friends may know they are talking to the professional. We will meet them wherever. Sometimes it is in the coffee shop. Sometimes it's the library. Sometimes it's in their home. We pretty much try to look to what helps the client.
I'm sorry. I don't mean to monopolize this. Any other questions or comments?
You mentioned $350,000, $1.30 for every older adult in the City. As Mary Hurtig shared with us, the one recommendation Council could act upon, in your view if you had a wish list and you only got one wish, what could we as Council do to impact this issue?
I think the plan that we have mentioned which would expand to all the whole City services, and part of that 350,000, most of it, would go for therapists. But part of the whole idea 106 5/12/03 - Health/Human Services - Resolution 030174 is that it is not just finding the therapists and putting them out there, but it is the connecting and it is the coordinating that is built into the program. So I would say that.
There is a summary of the plan that you should have received.
And there is a 20version which we made available, and if you would like us to send it to you, we can do that.
We probably have it. We are in the middle of budget hearings at the same time, so we will get to it and certainly, as I said, the record is open on this. So we won't close it out today. Certainly we will need to come back and have further discussion and we will look at the plan. It's probably here. Yes, we have it. After the 20th you can get our attention, okay? 107 5/12/03 - Health/Human Services - Resolution 030174
Let's go to the next group, Mary Ann Wall and Vergi Viacava. We would like you all to summarize your testimony.
My name is Mary Ann Wall. I'm program director at Catholic Social Services for HOPE, Homebound Outreach Program for the Elderly. I thank the Council for giving me the opportunity to present testimony on the needs of Philadelphia's older adults. My comments today will address the clients seen by Catholic Social Services behavioral health accessibility team, renamed the HOPE team that has been referred to here prior to my testimony today. I am sure you are aware of the long history of service that CSS has of providing services to senior citizens at its five senior centers in Philadelphia. In addition, CSS also provides help to individuals of all ages and their families through our network of family service centers, three of which are located in Philadelphia. All three of these family service center sites in Philadelphia are licensed by the Commonwealth of Pennsylvania as outpatient psychiatric clinics. Catholic Social 108 5/12/03 - Health/Human Services - Resolution 030174 Services was one of the two organizations designated as a recipient of the reinvestment funds available to provide services for homebound senior citizens with behavioral health needs. The HOPE team is comprised of a full-time program director -- that's myself, and I'm also a clinical social worker -- and a full-time clinical social worker, full-time case manager, full-time secretary and a consulting psychiatrist, all of whom are aware of the mental health needs of senior citizens and myself and the case manager have been through the program referred to here, which is a joint project between Philadelphia Appropriation for the Aging and also the Office of Mental Health. It is important to note that although the Office of Mental Health requested that the HOPE team concentrate its efforts on Northeast and Far Northeast Philadelphia, it currently has on its rolls clients in South, Southwest and West Philadelphia. Part of the original requirements were that the team accept referrals from throughout Philadelphia and we have assessed and provided services to clients where other services do not exist. As I would go on to say, this becomes 109 5/12/03 - Health/Human Services - Resolution 030174 problematic given the limited number of folks on the team. The mental health service provided is primarily individual in-home therapy for clients with various depression, anxiety and adjustment problems. The case manager provides services to the clients who do not already have case managers from other agencies. The logistics of providing in-home therapy, though, greatly reduces the number of clients that can be seen in a day especially with the geographic distribution we have with our ongoing clients. That's why it's really important that there be more teams available to serve the entire area of Philadelphia, the entire county, and that it not be just focused in a few areas. Since the program began in July of 2000, over 300 referrals have been made to the program. Over 120 clients have been seen for behavioral health services on an ongoing basis. We maintain 30 to 40 open cases at any given time. Some of these referrals resulted in in-home assessments which did not become active cases because the person was not eligible for services or changed their mind about receiving services. We currently have 17 people 110 5/12/03 - Health/Human Services - Resolution 030174 awaiting in-home assessments. The interaction of changing situations, changing physical conditions and capabilities and loss of family, friends and functioning often combine to confront our clients with what seems to them insurmountable problems. The HOPE team is able in many instances to provide information about new resources and assistance in understanding the rationale for change and the positive impact that change may have. In summary then, I believed in the concept of behavioral health accessibility teams at the point we developed the proposal.
With nearly three full fiscal years of operational experience, I continue to believe it is a much needed and valuable service. I believe the continuation and expansion of this program will provide needed behavioral health services to the homebound elderly. This will result in few psychiatric hospitalizations, medical hospitalizations, and will allow some people to take advantage of existing outpatient services as they overcome their accessibility barriers. I believe this can only be accomplished if the Office of Mental Health and the Philadelphia 111 5/12/03 - Health/Human Services - Resolution 030174 Corporation for Aging work effectively and efficiently together to meet this end. With the need for such services throughout Philadelphia, we could more efficiently provide services if each section of the City were served by such teams as HOPE and Interac's in-home services to older adults. Thank you for allowing me to present these comments.
Thank you. Next? Please identify yourself for the record.
I appreciate very much the opportunity given to me to testify this afternoon on behalf of COMHAR and the Latino population. My name is Vergi Viacava, and I work as a mental health clinician for COMHAR, which is a community mental health and mental retardation center that was incorporated in 1975. It was funded by a contract with the City of Philadelphia, the Department of Public Health, Office of Mental Health and Mental Retardation as well as the Commonwealth of Pennsylvania and the Federal Government. The OATS 112 5/12/03 - Health/Human Services - Resolution 030174 program, Outreach, Assessment and Treatment Services, began in January 2000 and is funded by the Pew Charitable Trust. OATS provides services to elders 60 years and over residing in the north and northeast areas of Philadelphia with great emphasis in providing services to the Latino community who have already primary mental health diagnosis. Our mental health services are provided to the elderly in their own homes, in housing projects, churches, senior centers. We provide as well psychoeducational groups in various senior centers and churches. Groups provide a very safe environment without the stigma attached of being identified as having mental health issues. We provide as well caregiver support and educational sessions in their own homes not only to help them to learn about signs of depression, but to enhance their caregiver role. Many of our elderly are Latinos, as I said, and one of the reasons why the Latino population has very -- I shouldn't say "very," but limited involvement in the mental health system is because there is a stigma attached to it and, therefore, many of them become withdrawn and 113 5/12/03 - Health/Human Services - Resolution 030174 isolated. We feel that greater exposure to programs such as ours are essential to the Latino community. Latinos will care for their own families. They very much love and they will care for the elders, but oftentimes they are not able to recognize signs of depression and mental illness and that also applies to health providers and oftentimes they fail to refer them for proper treatment. I would like to share with you a couple of statements that were made by two of the wonderful elders that we serve. One comes from an elder that attends the support groups, the psychoeducational groups, and she has been participating in the groups for a few months. She had suffered from anxiety and depression and after a few months of being a part of the group and participating very actively, she came with a very poetic statement and I'm going to read it to you. "Let me shine. Let me live each day at a time and show you that I can still shine because I'm here and I'm a part of this group. I belong. " 114 5/12/03 - Health/Human Services - Resolution 030174 The next one is from a statement from a homebound client that had suffered overwhelming losses and they came very quickly and abruptly, didn't have time to process them, and their losses were related to physical functioning, deterioration of her health, loved ones, loss of loved ones, productivity, mobility. After a few months of individual counseling she was able to work through with her losses and her feelings and she found the courage to learn to love herself again and love life itself and she quoted the following: "And all this time I couldn't smile or perhaps I had chosen not to smile. These years I fool myself, believing that I couldn't talk freely, that I refused to have pictures taken of myself. I refused to socialize because of my facial paralysis. I learned today with very much support, love and being allowed and given permission to express my joy and my sorrow. I learned that I can smile and my smile comes from deep in my heart. I learned that I can smile. Today I talk, I smile, and my family can take a picture of me. I learned that I'm beautiful and I'm lovable and I'm capable.
" 115 5/12/03 - Health/Human Services - Resolution 030174 These are only two of the wonderful cases that we have and those clients, I want to mention, they really wanted to come here and I'm very blessed to have two of my Latino clients here. I want to thank you then. Philadelphia ranks at the top among the country's largest city in its percentage of residents over 65 years of age. It is crucial to take into consideration that the Latino elderly are the fastest growing groups with pockets of extreme poverty. They come from a very, very large percentage of the group, the large amount of elderlies in this City. There is a crucial need for expansion of mental health services, social services, art therapy programs, assisted living facilities for Latinos that are deteriorating in their health, but we need integrated services. And also we have to take into consideration that these programs also need to be made culturally sensitive. For organizations that are providing support for mental health consumers, the ability to reach out effectively and appropriately to elders of different cultural backgrounds is crucial, is central to meeting the needs of such a diverse 116 5/12/03 - Health/Human Services - Resolution 030174 community. It is very important also the hiring of mental health clinicians, bilingual and bicultural. As the aging population increases, so does the number of people who face caregiving responsibilities and the issues of loss are very inevitable. We need services for Hispanic caregivers. There are not caregiver support groups in the areas we serve. Materials need to be translated in Spanish and we need as well Spanish hot lines. Our strong presence is very much needed in the community, in the Latino community, to help the growing population with the challenges they face and they will face. Let us nurture our community through recognition of their diversity and acknowledge the multiple and various needs they have. Let us help to offer services that we promote their ability to our elders to remain in their homes, in their community, to be functional and to prevent costly institutionalization. Our mission as providers in the community is to do the best, the best that we can in serving our older adults with a lot of compassion and to serve this population and to be aware and to keep in mind that death doesn't come with old age 117 5/12/03 - Health/Human Services - Resolution 030174 but in fact death comes with the fact that someone is isolated, neglected and forgotten. Thank you very much. )
Thank you very much. We appreciate your testimony. When you talk about having more staff for --
I'm not on the docket, but I work with Vergi. I'm her supervisor. I'm with COMHAR. My name is Gary Schoenberg and my title is director of continuing care services and I'm also the project director for the OATS program, which is funded, as Vergi had mentioned, through the Pew Charitable Trust. I just wanted to emphasize the funding for this program is two years at a time. We get $130,000 from the Pew Charitable Trust for providing outreach services to the elderly, mental health services to the elderly. This funding is in jeopardy because it only goes for a two-year period of time. The services for this program which has been running since 2000, January of 2000, is in jeopardy, constant jeopardy of being cut. The program is designated to be over December 31, 2003. 118 5/12/03 - Health/Human Services - Resolution 030174 We do not have any sure recognition or we don't have any verification that we will continue getting funding. It is a grant that requires continuing to rewrite and resubmit a grant application.
No, from the Pew Charitable Trust is where the funding from this comes. The concern is the level of jeopardy. We service approximately over 250 clients over a two-year period of time. A majority of these individuals have mental health diagnoses. They all have mental health diagnoses. They have to have a mental health diagnosis to qualify for the treatment. But the question is how do you measure the quality of life because one of the things that this program does and many of the programs that people are speaking about today is it improves the quality of life and some of these things that are done, some of the various services that are provided, involve the relationship that is developed between the person who feels isolated, who feels withdrawn and feels disconnected and fragmented and improving their quality of life and all of us need that in order to feel life is worth living. It 119 5/12/03 - Health/Human Services - Resolution 030174 gives them hope and a feeling of belonging to something. So Vergi is only one person and she provides individual counseling, group sessions, outreach, case management, does all the various linkages, referrals, assessments, research, home visits among the few things that she does. It is difficult to replicate Vergi because she is only one person, but the funding, what we are doing here is a model program, and what I would like to suggest is for more of these kind of programs to be developed and to be recognized for what they offer throughout the city because of the quality that they provide.
Thank you very much. I guess I was going to ask -- my question was to Vergi about the need for additional staffing. I guess my question is -- and you just talked about the lack of funds and maybe the loss of this program, but if you did have the funding, is there personnel out there for you to recruit and hire to do the work from the Latino community and, if not, what is being done in the Latino community to encourage young people to go into psychiatric, social work or whatever the career track would be? 120 5/12/03 - Health/Human Services - Resolution 030174
I think that is probably a long-term issue in terms of ways to do more proactive recruitment, to provide education resources for minorities, for various subcultures, Latino, Asian, and I think that's something that will take a certain amount of effort, initiative across the board. I think what we are talking about is creating an infrastructure of some sort that has and provides coordinated care on every level, looking at staffing, looking at the quality of services that are being provided, funding resources, and I think what we have is a fragmented system that does not have a strong infrastructure where there is coordinated care, and I think what you are mentioning is one facet that is certainly a part of that.
If I may, Madam Chair, what about the community-based organizations such as APM and Congreso and Consilio who deal and have programs in terms of mental health; is there coordination with them?
Not with older adults. Most of those centers are stand-alone facilities 121 5/12/03 - Health/Human Services - Resolution 030174 where people have to go and walk in for services.
So what about the older adult centers that we have such as Norris Square and the Mann Center and so on?
I do provide services to various senior centers and one is Norris Square Center and Mann Adult Center and I'm there once a week and I do individual counseling and I do groups there and also at a church at the old Kensington pavilion, which is a housing project. Those services are provided there. And what happens sometimes is Congreso has referred all of their adult clients to us for mental health services.
Are there any other questions or comments? Our next panel will be Lois Semanision, Sandra Smith and Trudy Persky.
I have worked in Philadelphia as a social worker for the past 28 years. I just want to say I consider what I do a privilege. I really love working with poor people and trying to enhance their quality of life. Right now I am working at a number of different capacities, two of which are working part time with both Aid for Friends and the Family Life Wholeness 122 5/12/03 - Health/Human Services - Resolution 030174 Center which is a center operating out of a church in North Philadelphia at 11th and Nedro, and I volunteer in a center in South Philadelphia as well.
That's my district, 11th and Nedro. What's the center?
It's the Saints Tabernacle Community Church and they have the family center there and they are near the El stop, if that means anything to you. But those are a couple of the things I do. The people that I'm working with through Aid for Friends and the Family Life Wholeness Center are receiving a meal program that Aid for Friends provides. The one thing that is different about Aid for Friends that other meal programs like PCA, we don't -- there is no income requirements. There is no health insurance requirements. The requirement is that the person is isolated and homebound and either elderly or disabled. I think Aid for Friends is serving about 2000 people currently and my primary function is to do outreach to those who are mentally ill and I have worked with over 200 people since I have been working in this capacity, so that's a lot of people. 123 5/12/03 - Health/Human Services - Resolution 030174 The people that are served by Aid for Friends are all over Philadelphia but also some of the surrounding counties. In working with the homebound mentally ill, I have run into many challenges. I think some of these have been mentioned already. There is a limited number of resources available even to those that are not homebound and persons that are homebound, getting to the facilities that have been described are major challenges. I think the one lady who was sitting on this side talked about the difficulty of just providing transportation, getting there, accompanying the person to the visit, et cetera. What I found sometimes is agencies give numbers and say go here, go there, but not taking into account that may be a major hurdle for the person to get there. Aid for Friends in addition to myself, and I only work part time, they have a worker who is bilingual who works one day a week. She came in as an intern, a graduate intern for social work, and I supervised her and she has been working a day a week, but now she will be looking for other employment, so I'm not sure if they are going to be 124 5/12/03 - Health/Human Services - Resolution 030174 able to replace her or not. I'm really concerned when I work with the homebound and the elderly disabled. It seems that the majority seem to get their prescriptions from a general practitioner and one general practitioner said to one of my clients "I'm going to give you a happy pill" and didn't tell the client anything about the pill. She took it. She didn't feel it helped her. She had someone look up information on it and then she decided to stop taking it. I think that's a really poor way to handle her mental health situation and in her case it is depression. So she is not getting any help at all. Another example that I have, I have a lady whose doctor said "Take six of these a week," so she thought let me just take six on the first day of the week and get it over with and you can imagine what havoc that wreaked in her system. That same person had to be rushed to the hospital at a later time because they had a bleeding ulcer. Just the confusion about medications, et cetera. What would help me greatly because you have been asking people for suggestions, we at one 125 5/12/03 - Health/Human Services - Resolution 030174 time had a nurse intern and we had a volunteer nurse. If we could have the City make a nurse available from the health centers to go out to visit people, do an evaluation on the medication, just make sure that they are taking the medication as prescribed, you know, help them sort through the little pill bottles, educate them about their illness, things like that, when we had that available, it was very, very helpful, and I think that is something that the City could make available to agencies such as ours, a nurse that could go and do education and just checking on the medications, make sure the person understands what they are taking, also, write out questions. "When you go to the doctor, these are the questions you need to ask," that kind of thing.
I do that a limited amount, but that is not my area. I'm a social worker. I'm not a nurse, but I do look up medications for clients. " The doctor changed the medication and the nightmares went away. I mean that was an intervention that I think was very significant. If that hadn't been done, maybe the doctor would have given him something for anxiety or given him another medication to treat the symptom. One of the things that has already been mentioned, sometimes people are denied services because they don't fit into the category. I had a lady who was suffering from agoraphobia -- that is a person who is afraid to go out -- and she was told she was not eligible for the homebound service because they were not permitted to treat that diagnosis. She had to go into a center. The chances of her going into a center are pretty slim. She is having trouble getting out of her house. But the agency couldn't treat her because of their guidelines. What I have personally found most effective is where I work in faith-based organizations, but where -- and that is what I really feel is effective, where you can treat the whole person, where you can be comprehensive, you 127 5/12/03 - Health/Human Services - Resolution 030174 can be flexible. Everybody doesn't have to fit into all of these little categories. You let the client tell you or show you what they need rather than you try to get them to fit into this little category. And I understand funding constraints and all of that, but... The other thing that I have encountered that I really wanted to mention is in addition to the mental health issues are the substance abuse and gambling addictions and I know you are going to be looking at gambling in the city. Gambling addiction is a big problem with seniors. Please hear me on this. Let give me an example. A couple that I was working with, they needed help in getting a new heater and when I added up the amount of money that was being invested in that house, it was 5 to 6,000 a year. A new heater costs a portion of that. They didn't have money for a heater and they were bugging all the agencies to help with that. Fortunately some help was obtained, but gambling addiction is a big problem with seniors and I really have a problem with all the senior centers and senior programs, what kind of entertainment do they provide to the seniors? Bingo and trips to Atlantic City, not 128 5/12/03 - Health/Human Services - Resolution 030174 realizing these seniors don't have that extra money to spare. And gambling addiction is a problem in addition to substance abuse, misuse of medications and misuse of alcohol. The other thing I run into a lot is domestic violence by natural exploitation. You will have the adult children living in the household or siphoning off mom or grandmom's money and fortunately OESS and the Corporation for Aging both have services where they can intervene and take over management of the money. In one particular situation where the intervention took place, it is working real well. The child no longer has access to mom's money and they are getting along very well, but when he had access to mom's money, he was spending the bill 18 money all the time and that made mom anxious and depressed, et cetera, et cetera.
My son doesn't steal my money but I give it to him and I'm still depressed, just to add a lighter note. Children do that.
The other thing that seniors and the disabled that are homebound -- 129 5/12/03 - Health/Human Services - Resolution 030174
Yes. They are always running in crisis. The doctor is giving them bad news. Things are always happening. I find that just being that person that can give support, who can debrief, who can hopefully line up some other agencies, that role is really important. My role is not so narrow that I can't be flexible in addressing. The other thing, I don't hear you asking a whole lot about research and just you need to research the people who are receiving these services. I mean Penn, Temple, all of those schools do have research programs. They could easily do a research program with the recipients of these services and see what the problems are that the clients are encountering. You are hearing from the service providers, but I also hear from the clients and I think a research project would be worthwhile before you make a lot of decisions in terms of how you are going to expend City Council's money.
Good point. Thank you. 130 5/12/03 - Health/Human Services - Resolution 030174
My name is Sandra Smith. I'm an intensive case manager. I have worked as a care manager in Philadelphia for years. For the 5 first two years I did intake and community liaison. 6 I mention that because that is something, to quote 7 Estelle Richman, that is a thing of the past, and 8 that is something that I feel is very important 9 because when I was the community liaison, when a 10 phone call came, I could go to someone's home to do 11 an intake. As an intensive case manager, I work 12 primarily with the elder population, but that is 13 changing as budget changes. 14 I personally don't like to work with 15 people under 40. I'm being honest. I always say if they are born before 1940 I don't want to see them. I much prefer to work with the elderly population.
I'm sorry. After. You know, I much prefer to work with the elder population. 131 5/12/03 - Health/Human Services - Resolution 030174 But as an intensive case manager I won't say that I have seen it all because every day you see something new and I just wanted to share one story because the time is so short of some of the things that don't happen. As case managers we are told that we are supposed to link and monitor. Well, the difficulty with linking is tremendous. I heard a lot of comments here today and I was wondering because I have made calls to CBH and have not been able to get the services of the two companies that were mentioned. It is very difficult to get services. But I wanted to share this one story with you. There was a couple. They both experienced mental illness and they were receiving services. As they got older, their health deteriorated. It came to a point where the husband in the family became wheelchair bound and his weight increased so it was very difficult to get him to his psychiatric appointment. What happened, I arranged for the ambulance to take him to the psychiatrist's office. He had to be taken in on a gurney. It went well for a couple months. Then I was told by the therapist that we could no longer bring this 132 5/12/03 - Health/Human Services - Resolution 030174 gentleman here because we passed the geriatric program and it was too disturbing to the clients in the program to see someone coming in in a wheelchair. You have no visiting psychiatrists -- if there are, I haven't heard of them lately -- in Philadelphia. So this man lost his services because what we had to do was, at risk of Tom O'Hara where I work, there was actually a psychiatrist who went to this person's home to prescribe medication for him because there were so many really severe problems. And my problem is that, yes, they say you are a case manager. This population is served. Not true. The services are not there. We cannot link them to someone because there is nowhere to link. You know, they talk about all the entities working together. I can sit here and tell you at my level, myself, the PCA care manager, and the home health aides, we can work together. As a matter of fact, Trudy Persky can tell you. I managed to pull together a meeting -- there were seven of us in that meeting -- to address the issues of this same individual because the funding wasn't there to provide that service, but each person 133 5/12/03 - Health/Human Services - Resolution 030174 involved had a vested interest because the need was so great that we were able to provide this. I know, Miss Reynolds Brown, that this all came as a part of no services to West Philadelphia. I can tell you I was one of the people who was hired to work with Horizon House and then the program was cut by the City. So that's what took away the services in that part of Philadelphia and, believe me, I begged, but nothing worked, but the reality is we have people who have mental illness and have physical ailments who need services and we just can't get them for them. I can tell you this is what you get. You call PCA, they say that is a mental health issue. You call Mental Health and they say that is a PCA issue. Fortunately, I was able to get the two of them to like get some funding from one group and some from the other, but the reality is we do need coordination.
She's the best as a case manager. I can testify to that. 134 5/12/03 - Health/Human Services - Resolution 030174
I'm Trudy Persky, and, as you can see, I'm a senior citizen. No Botox. And I have been a mental health aging advocate for over 7 years and it has certainly made me age faster than I 8 would if I hadn't been doing this. 9 Now, the question that has troubled me 10 for a long time and I would like to move this not 11 totally out of Philadelphia, but to say that there 12 are broader issues that I think we in Philadelphia 13 also have to address. The question is why, why is 14 it so difficult for millions of people in this 15 country to get adequate mental healthcare? Because 16 we have data from all over the United States, and 17 while some cities may be progressing faster than 18 Philadelphia, the fact is that mental health 19 services are extremely limited. Older people don't 20 go and the services that are available are not responsive to their needs. So I would just like to list some of these major issues which are the media portrays older people in very undignified ways or they idealize them. And this comes from the Annenberg 135 5/12/03 - Health/Human Services - Resolution 030174 School of Communications, which states that when you look at TV, you either see older people that are on a cruise, they are on a golf course, or you see somebody in a wheelchair in a nursing home who seems incapable of even speaking one sentence. So people do not get an accurate picture of what it is like to be an older person. So this preoccupation with youth I think has really been very difficult for advocates because if people don't want to think about getting older, if people don't want to even -- the business with the living wills, it's going to really put enormous obstacles in the path of an advocate. Now, you have heard before there is a tendency of many physicians to dismiss any illness as aging. I have heard doctors say, well, what do you expect, she's old, when the person may be depressed, may be highly anxious, but this is a prevalent response from many physicians. Also, as mental health advocates we have not had a strong advocacy group. We have not had a group like the Alliance for the Mentally Ill or Alzheimer's Foundation that is going to really advocate for people with mental health problems, 136 5/12/03 - Health/Human Services - Resolution 030174 particularly for older people with mental health problems. I'm glad to say that we are in the process of forming a national organization now, but it is going to be a long time before we really have the kind of effectiveness that you see, say, from the Alliance for the Mentally Ill or AMI, as they are called. Older adults with physical or mental incapacities are certainly not going to be active advocates, so for the time being we have to depend on other groups. For the past decade funding of priorities on the federal, state and local level have been for, quote, seriously and persistently mentally ill and children. Now, despite the generous mental health state budget, I can tell you last year it was one billion eight hundred thousand dollars and the amount that was allocated for older new programs even came from a block grant from the Feds, not from the mental health state budget. So when you asked what can we do, I think certainly one thing that Council can do is bring pressure on the state that considering the population here, the numbers, that we have to have more money if we are going to 137 5/12/03 - Health/Human Services - Resolution 030174 provide any adequate services. You have heard before the reimbursement, Medicare reimbursement, it is absolutely a mess. I mean economists agree there is no worse system than the Medicaid reimbursement for mental health. Only a total of 3 percent of the Medicare budget, which is an enormous budget, goes for mental health and that is primarily for people in hospitals. I think that also the mental health programs have to be more responsive.
It is true we have data showing that older people will not go to mental health centers and so we have to have more outreach programs to identify people with mental disorders. Now, I think what can we do? Here are some recommendations and I would urge the Council to consider what you can do. Urge the state Office of Mental Health, as I said, to include older people as a priority population. For years I was on the mental health planning council for the State of Pennsylvania. " and they say, "No. We have these priorities. We have to adhere to those priorities," and when I talk to 138 5/12/03 - Health/Human Services - Resolution 030174 the federal government they say, "No, you really don't have to but they are the priorities of the federal, state and local government," and when you hear, as Sandra said, there are people that don't get services, it is because they don't fit into particular classifications for the seriously and persistently mentally ill and they are certainly not children. So I hope you will give that careful consideration. Another problem with the mental health and aging process is that we don't have adequate people. There are not enough trained people and these budget cuts have resulted in many people losing their jobs and not being able to provide adequate services. We have heard -- I don't want to repeat this -- that mobile programs are very effective and we certainly have data that that is true. I think too that I will say this, the federal government is developing programs, trying to have programs for primary care physicians so that they will better understand the issues of older people, and we did have such a program here in Philadelphia for four years. There was a program at 139 5/12/03 - Health/Human Services - Resolution 030174 the University of Pennsylvania which permitted people to have mental healthcare when they were getting their primary medical care. It worked out very well. People were much more responsive. If this is an issue of your general health, they will be much more responsive to accepting mental healthcare. So I also would like to say this: There has to be some strong encouragement for better collaboration at the state level of Mental Health and Aging. This is something that has been -- we tried for years, but it has been extremely difficult to get these two organizations together and to develop plans that are interactive. Now we have two new people in those positions and maybe that will make a change. I certainly hope so. The other thing I wanted to say that I think we have lacked is a public educational campaign which really helps people to be more aware, to stimulate awareness about the issues of older people. We haven't had a general educational campaign and one reason is it is very difficult to get funding for that. I would just like to close with this one 140 5/12/03 - Health/Human Services - Resolution 030174 thought, that we should keep in mind that we have very good data that the treatment of older people suffering from depression and anxiety and other diagnostic problems has been found to be just as effective as with young adults and middle-aged people. Supportive therapy with drug treatment can be safely administered with very beneficial results.
Thank you very much. Any questions or comments from members of the Council? (Applause.)
Thank you very much. We next have Almena Tugman, Rose Bradley. Are they here? Dr. Bloom? He's not here.
Good afternoon. My name is Almena Morgan Tugman. I'm nervous today. I'm going to let Debbie Huff read it for me.
No, you talk for yourself. Tell me what you wanted to tell me. Tell us what you wanted to tell us.
Hi. I'm Debbie Huff. I'm the advanced practice nurse that does the health 141 5/12/03 - Health/Human Services - Resolution 030174 district center project and Almena is one of my consumers and she is extremely nervous today, so she asked me to read her testimony. We are thankful that she is here.
"My name is Almena Morgan. I am a patient of the Health Center No. 4. On December 5, 2001 I lost my grandson. He was strangled at 3 years old. I was helpless. I went to the clinic and my doctor advised me to seek professional help. On the same day I was able to see Miss Huff. I was really depressed. I could not eat. I could not sleep. The only thing I was capable of doing was crying day and night. I eventually went to see Dr. Curlik, the geriatric psychiatrist of the program, who assisted me in coping with my depression. I am still receiving help from the center. "Mental health affects thousands of people each year. Some lose jobs. Some lose a friend or a relative to death. Some are sick and some are retired. Lives are lost each day due to some aspect of mental illness. Suicide is the most 142 5/12/03 - Health/Human Services - Resolution 030174 frequent method used to escape depression. If these individuals were treated and shown ways to cope with the uncertainties of life, they would be here today. There are also those who are ignorant to the different forms of mental illness and don't know that help is available. "The weather is getting warmer outside and summer is almost here. After being in the house all winter older adults would love to get outside and enjoy the sunshine but are afraid to do so. They lock themselves up in their houses and apartments, often locking windows and doors, also stopping airflow. Some die. This happens because they are afraid to come out of their homes. Sometimes all that is needed is a friendly face with a smile or a gentle touch or maybe a hug or just someone to say I love you. Where can they go for help? Fear can bring on panic attacks. It also leads to mental illness which can affect every part of life. We need to find a way to open the doors and assist those in need. "The Health Center has so many life management programs available, all within the same location. We need more funding to improve and save 143 5/12/03 - Health/Human Services - Resolution 030174 the lives of our older adults. We may need to spread the good news that older adults have an avenue to assist them in the many complexities of life and I am grateful for Miss Huff's program and I'm glad they were there to help me."
Thank you very much for the testimony. We are very sorry about your grandson.
My name is Rose Bradley and I'm a senior citizen myself. I have two elderly people that I take care of. One is 101 and the other one is 100, okay, and they sent me a counselor to help me because I have a lot of anger in me. I really did. And I have come here to thank her today for what she has done for me. That is what I came to do. And I want to thank her for her support that she has given me and I also want to thank you for understanding that. She gave me things I could control and things that I can't control and I wanted to give her thanks for the support that she gave me 144 5/12/03 - Health/Human Services - Resolution 030174 in dealing with my family and my kids and I also want to thank the Intercommunity Action Corporation for sending her to me, and I thank you all, too, for hearing me.
The elderly people you are keeping, are they family members?
No, my mother-in-law, I put her in a home, but I still have my mother. I had my mother-in-law for seven years and I have had my mother for four.
I can understand that can be quite a responsibility and we thank you so much for coming down to thank those people who provided supportive services to you.
And thank you for 145 5/12/03 - Health/Human Services - Resolution 030174 staying so long. You have been here the entire time, all of you have, and we really appreciate it, but once we get into the discussion, it becomes very long. It doesn't look long on paper, but when we begin these hearings, we can get kind of lengthy, so we thank you so much for your testimony, both of you.
We have Eun Sook Kang, Jennifer Romanski and David Downey. These three members are the last panel members unless we have other people to testify. You let us know.
While we are waiting for the other panelists to be seated, it is really the testimony of the last two ladies that we heard, Rose Bradley and Almena Tugman, that really underscore and reaffirm the reason. The question is give me a reason. The testimony of the last two individuals certainly compels us to, as the chairwoman has said, leave this open because there is much work that will be required in the followup to these hearings.
Thank you very 146 5/12/03 - Health/Human Services - Resolution 030174 much. Would you like to identify yourself for the record please and begin your testimony?
Yes. Good afternoon. My name is Eun Sook Kang and I am currently director of development at the Phillip Jaisohn Center, a Korean medical center and a community medical center under one roof. It has been in Philadelphia since 1975 and I wanted to say a brief commentary on Asian American adults and particularly those in Philadelphia County. I concur with all of the researchers and facts and data regarding the older adults and the population that they take up. The population of Asian American older adults in Philadelphia are comparable to that of the mainstream older adults. Asian Americans make up nearly 70,000 in Philadelphia County and in the past ten years between 1990 and the year 2000 there has been a nearly 78 percent increase in the number of Asian Americans. However, though we have much data and information on mainstreaming older adults and the fact that so much need exists and very little of 147 5/12/03 - Health/Human Services - Resolution 030174 that need is being addressed and met, with Asian American older adults there is no research data on the numbers of seniors who need mental health services or seniors who may be suffering from depression, schizophrenia and other psychiatric disorders or emotional disorders. So with that Asian Americans, even though they only take up about 4 percent of the total population here in Philadelphia, there is a need and the numbers of Asian Americans are growing. The percentages of Asian American seniors is comparable to that of the percentage of seniors here in Philadelphia County in the mainstream. Out of that 70,000 Asian Americans nearly percent of that are made up by Asian 17 American seniors, and what I propose is even though 18 there is no data, I belong to a coalition within PCA 19 called the subcommittee on mental health on Asian 20 Americans. The committee is PCA Asian advisory 21 committee subcommittee on mental health. So we just 22 began to form some working data on how to do any 23 needs assessment on Asian American seniors in Philadelphia County because all the social workers and different social service agencies obviously see 148 5/12/03 - Health/Human Services - Resolution 030174 a need. We can't prove the need because there is no 3 data because we keep going around in circles. We need to begin to do some sort of hard work as a coalition, doing some coordinated comprehensive work in Philadelphia to address not only the mainstream need, but we are trying to do some work together as a coalition to at least conduct some kind of needs assessment by a social services agency so at least we can get a small amount of data and prove so we can get funding to address the needs of Asian American older adults here in Philadelphia. And as just a social worker and case manager at the Phillip Jaisohn Center, I just on a daily basis see and hear many Asian American/Korean American older adults who have gone from the extended family where the children are the social security, to second generation Korean American or other Asian American older adults. They go from living in the extended family situation where the kids and the grandkids take care of their mother to now more and more you see a prevalence of these older Asian Americans moving into Section 8 housing or moving away from their kids' homes and living by themselves because they are bored, and more and more 149 5/12/03 - Health/Human Services - Resolution 030174 there is a need for the formalized support network, and their access is quite limited because of the language and culture and that is why these ethnic organizations such as Congreso, Nueves Braze, Jaisohn Center and maybe Mexicanas back in South Philly are all very pivotal and crucial as well as the churches in meeting those needs and identifying at the grass roots level people in the community who they know very well by working daily. Even though we don't have data, we know there is a need, but there is no research and there is no money and so here we are.
I only represent 4 percent of the Asian population, but I see how I'm just a little tiny speck in this huge -- it is going to take us a while and we are going to just keep plugging away and trying to get any money, any resources possible, to try to at least address the huge growing need. I think even 1990 to 2000 there was an increase of 78 percent in the Asian Americans in Philadelphia County. We are going to see a higher, same, consistent comparable increase between 2000 and 2010 and the number of 70,000 Asian Americans is going to increase, possibly double even more, and 23 percent of them are seniors and we have no data and 150 5/12/03 - Health/Human Services - Resolution 030174 no resources to assist them, particularly the growing number of seniors. That's all I have to say. Thank you. )
Thank you very much and thank you for coming. Your center is in my district.
Good afternoon. My name is David Downey and I'm with the Visiting Nurse Association of Philadelphia and I think I'm in maybe a unique position here because we actually do provide psychiatric home care services to homebound Medicare patients, so we are in a position to seek reimbursement from Medicare and from the Medicare HMOs. However, having said that, we do run into a fair deal of difficulty because we see the patients probably in the very acute stage of their psychiatric illness, and where we run into difficulty is getting the services when the acute stage of the illness has passed where we are ready to move them back into the community, back into the community centers and what have you. That's where we run into problems. 151 5/12/03 - Health/Human Services - Resolution 030174 So I guess you have had all the statistics and the percent and the growing 4 population in Philadelphia. I think overall what we 5 really would need to do -- and people talked about 6 the turf wars -- is stop the turf wars, pull 7 everybody together and get all the services that are 8 available. I don't believe I'm the only agency that 9 can bill for the home part status of the Medicare 10 patients, but we do need some kind of coordination 11 of all the services where we can put all of those 12 mental health services together and talk to each 13 other for the interest of the older adults with 14 mental health problems. 15 I have heard all the other testimony, 16 but I think I don't want to be the person who 17 summarizes it all up, but from what I have heard 18 today I think that's what we need to do.
And I would like to thank you for that opportunity to say that and thank you again.
Thank you very much. We are very familiar with the Visiting Nurses Association way back in my early days. 152 5/12/03 - Health/Human Services - Resolution 030174
United Way committee that monitored the visiting nurses. Are your nurses psychiatric nurses?
My team of nurses are all psychiatric nurse providers. I have a team of ten nurses. We are not geographically limited in the city. We provide psychiatric services to homebound clients all over the city, north, south, east, west.
How does someone contact you? Are you contacted by social workers in a facility or family?
Various agencies. We have an active outreach program that will identify homebound elders. We have a program with the block captains and they will identify homebound patients. We get referrals from hospitals, primary physicians, so various and sundry agencies will refer to us to go and see the client in their home.
Thank you. Are there any questions or comments? Is there anyone else here to testify here today? 153 5/12/03 - Health/Human Services - Resolution 030174 We will have closing remarks from Councilwoman Brown.
I will certainly be brief. I want to thank everyone who, like us, saw fit to, A, be here and, B, recognize the importance of today's hearings. The record should show that this was not a solo act. I would be remiss not to thank my own staff, David Ford, who worked hand in glove with both Corbett Banks and Tom Volkert. So thank all of you. The record should also reflect that this is Chapter One. There are still many more chapters that have to be written in terms of a hard document that we are anticipating and then recommendations that will be crafted and sent to the administration, so know that. We are going to have to work together collaboratively and not just talk about it, but be about it when it comes to addressing this issue of linkage and the like. Thank you all very, very much. (Applause.)
Thank you all for coming. We appreciate it. We thank the observers who came to listen. We will recess this committee 154 5/12/03 - Health/Human Services - Resolution 030174 until the call of the Chair. Thank you. (The hearing ended at 1:50 p.m.) 155 CERTIFICATE I HEREBY CERTIFY that the foregoing proceedings of the Committee on Public Health and Human Services of the Council of the City of Philadelphia of May 12, 2003 were reported fully and accurately by me and that this is a correct transcript of same. ______________________________ Cynthia A. Whyte, RPR (The foregoing certification of this transcript does not apply to any reproduction of the same by any means, unless under the direct control and/or supervision of the certifying reporter.)