POLICY: Bertha

I just do the best I can. You know, it’s hard for me ’cause I can’t get around very well. But, you do what you gotta do. It’s hard. Like, not too long ago I, even thought there was nobody here but me ’cause the provider wasn’t here at that particular time in the evening, I fell out of the bed. And then I couldn’t get up and it was hard. And I finally figured a way to get up. I finally did get up on my bed and that’s the way I made it up but… see I don’t have anyone in the afternoon. I just have someone in the mornings.

(Sometime later Bertha was hospitalized for several weeks with pneumonia and congestive heart failure. The hospitalization marked a significant deterioration in her health, one that she struggled to recover from.)

This is hard to explain, but the illness and going to the hospital, it did something to my depression, I am very depressed after that, it did something to me, and I get very sad and very lonely and I can’t tell you why, but I just get those feelings…I didn’t recognize being here, I didn’t have the comfortable feeling of being home, I don’t understand myself, but I’ve been feeling that way since I’ve been home and I’m trying to get back to feeling normally, like I had. 


policybertha Kathryn G. Kietzman, PhD, MSW, interviewing "Bertha" during an evaluation for home health care services.

“Bertha” – A Case Study

by Kathryn G. Kietzman, PhD, MSW
Hartford Social Work Doctoral Fellow
Research Scientist
University of California, Los Angeles
Center for Health Policy Research

Bertha is a 78-year-old woman who receives home care services from the publicly funded In-Home Supportive Services (IHSS) program. She struggles with diabetes and mobility problems from chronic knee pain. She needs help with housework, preparing meals, shopping, and laundry. Bertha’s needs vary throughout the day but she is alone in the afternoons. She tries her best to adjust and does very little once her caregiver has left for the day.

Bertha’s hospitalization and health deterioration resulted in some temporary and long-term changes to the types of supports she receives. Bertha needs more personal help with bathing and grooming, which her IHSS caregiver provides. Informal supports are limited for Bertha.

With her declining health, Bertha has become increasingly isolated, which can lead to depression. Despite the limited social supports and challenges she experiences living at home with a disability, there is no other place Bertha would choose to live. Bertha’s caregiver provides much more than just doing chores and running errands. The caregiver provides motivation and companionship to help Bertha start her day and get through the afternoons when she is alone. 

policy11 Proposed budget cuts would eliminate 24 hours per week of caregiver services that Bertha depends on for help with tasks such as housework and shopping.

Social Workers as Public Health Policy Advocates

“A 20 percent cut in caregiver hours would be devastating to disabled seniors’ health and well-being.”
Kathryn G. Kietzman, PhD, MSW
Hartford Social Work Doctoral Fellow
Research Scientist
University of California, Los Angeles
Center for Health Policy Research
To improve mental health care for older adults it is necessary to develop and implement proven treatments, and to provide more comprehensive education for health care providers. But there is one more piece that must fall into place, and that is policy. “Evidence-based interventions must become imbedded in systems of care, and there must be mechanisms to reimburse for them,” says Philip McCallion, PhD, ACSW, Professor, School of Social Welfare, University at Albany, State University of New York, and a Hartford Geriatric Social Work Faculty Scholar.

For this reason, the Hartford Geriatric Social Work Faculty Scholars and Hartford Doctoral Fellows in Geriatric Social Work are encouraged to become involved in policy work by Dr. Berkman and James E. Lubben, DSW, MPH, The Louise McMahon Ahearn Chair, Boston College, and Director of the Doctoral Fellows Program.

One area in which Hartford-funded Scholars and Fellows are making an impact relates to policies that help older adults continue to live safely at home. Home health care has grown rapidly during the past two decades, enabling many older adults to live independently. Medicare is the largest single payer of the annual $57.6 billion in home care services in the United States, providing home-based services to over 15 million older adults with acute illness, chronic medical conditions, and disability. Some state-funded programs pay for caregiver services for low-income older adults with disabilities.

Depression is common among homebound older adults, affecting 13 to 27 percent of older adults receiving home care. Yet depression often goes unrecognized and untreated in this group. A range of factors account for this, including the stigma around mental health conditions, financial difficulties, and transportation problems. In some cases, addressing physical limitations, social isolation, and medical problems can help alleviate depression.

Helping Low-Income Seniors Remain at Home

Kathryn G. Kietzman, PhD, MSW, Research Scientist, UCLA Center for Health Policy Research, and a Hartford Social Work Doctoral Fellow (2006-2008), wants to make sure older adults receive the services they need to live independently while maintaining both their physical and mental health. For example, a study she and her colleagues conducted was influential in stopping, for now, the state of California from cutting funding to a crucial program for low-income seniors.

The HOME Project (Helping Older adults Maintain IndependencE) is a year-long study that documented the experiences of 33 older Californians with disabilities who depend on fragile arrangements of paid public programs and unpaid help to live safely and independently at home. It was supported by a grant from The SCAN Foundation in 2011.
The study, called the HOME Project (Helping Older adults Maintain IndependencE), documented the experiences of 33 older Californians with disabilities who depend on home care services
In a recent survey, only 37 percent of older adults reported that they had been asked about their mood by their doctor or health care provider in the past year. 
through the state-funded program In-Home Supportive Services (IHSS). The study was supported by a grant from The SCAN Foundation. “The written materials we are generating from this study are targeting policymakers in California, to give them stories so they can under-stand who is impacted by the decisions they’re making about program funding,” says Dr. Kietzman.

Bertha is one of the 33 older adults in the study and one of over 400,000 low-income Californians who depend on support from an IHSS caregiver for help with personal care (such as bathing), domestic tasks (such as meal preparation), and other assistance (such as transportation to medical appointments).

Like many people in her situation, Bertha struggles with both physical and mental health issues. “Not only was she coping with the physical recovery process (after hospitalization for pneumonia and congestive heart failure), but she also faced emotional challenges,” wrote Dr. Kietzman in the case study of Bertha. “A hospitalization can cause significant disruptions to the physical and emotional well-being of older adults.” Dr. Kietzman and her colleagues found that mental health issues were relatively common among the participants in the HOME study, and that having assistance from a caregiver was essential to maintaining their overall physical and mental health.

When a $100 million cut in funding (which would result in a 20 percent reduction in the number of caregiver hours) was proposed by the California state legislature, Dr. Kietzman and her colleagues took action. “In the long run, this could cost the state more, because ailing seniors will increasingly end up in expensive emergency rooms, hospitals, and nursing homes,” says Dr. Kietzman. 

Dr. Kietzman’s colleague Steven P. Wallace, PhD, Associate Director, UCLA Center for Health Policy Research, used data from the HOME study in a lawsuit, which helped to convince a judge to issue a temporary restraining order to prevent the funding cuts. (The final outcome has not yet been determined.) “It’s an interesting example of how research, in this case in the words of the individuals affected, can be used to inform policy,” says Dr. Kietzman.

Dr. Kietzman’s background as a Social Work Scholar and as an Atlantic Philanthropies-funded Health and Aging Policy Fellow (2008-2010) in the office of United States Senator Debbie Stabenow of Michigan helped to prepare Dr. Kietzman for her current career in health policy. In 2008 when health care reform was being debated in Congress, Senator Stabenow wanted to make sure that mental health issues were not neglected in the discussions. She gave Dr. Kietzman the task of working with organizations with an interest in mental health (such as the American Association for Geriatric Psychiatry and the American Psychological Association) to draft legislation to establish a national network of centers of excellence for the treatment of depression and bipolar disorders.

“I worked on reconciling the varied interests among the groups because their support was important for moving the legislation forward,” says Dr. Kietzman. “Senator Stabenow was dedicated to making it a bipartisan bill, recognizing that depression and other mood disorders affect everyone,” says Dr. Kietzman. These efforts paid off. The bill received bipartisan support in both the Senate and the House of Representatives and was ultimately incorporated into the overall health care reform bill (the Patient Protection and Affordable Care Act).Congress has not yet appropriated the funding.

“Because the policy process is so dynamic and unpredictable, efforts to influence policy must be continuous to find the windows of opportunity essential for advancing change,” says Dr. Kietzman.

A Small Change Makes a Big Difference

“Making this policy change means that an older adult doesn’t have to wait through one episode of depression before receiving services for a recurrence.”
Dr. Leslie K. Hasche
Hartford Faculty Scholar 
University of Denver 
Graduate School of Social Work
In the state of Missouri an older adult Medicaid recipient who experiences major depression for the first time is now eligible to receive mental health services. Before 2010 this was not the case. In the past, Medicaid would pay for treatment only for people with a history of serious persistent depression. Making this change took a year of effort on the part of James Cook, PhD, Project Coordinator, Missouri Institute of Mental Health, University of Missouri-St. Louis, with assistance from Hartford Doctoral Fellow Leslie K. Hasche, PhD, who is now a Hartford Faculty Scholar at the University of Denver, Graduate School of Social Work.

This impacts low-income older adults who require in-home services because of health problems and functional disabilities. They are eligible for Medicaid but they were not being seen by community mental health agencies unless they had a documented history of depression. Dr. Hasche performed literature reviews and helped Dr. Cook write issue briefs. She provided findings of a study she participated in which found that 25 percent of older adult Medicaid recipients had significant depression but low use of mental health services.

Integrating Mental and Physical Health Care Services

Zvi D. Gellis, PhD, Director and Associate Professor, Center for Mental Health & Aging, School of Social Policy & Practice, University of Pennsylvania, and a Hartford Faculty Scholar (2002-2004), is also dedicated to influencing social and health policy. His work is focused on the mental health care needs of older adults who are homebound and receiving home care services for chronic medical conditions.

In 2002 when Dr. Gellis was an assistant professor at the University at Albany – SUNY and a Hartford Faculty Scholar he found that home health care staff (nurses, physical therapists, and occupational therapists) recognized that many older adults they cared for had depression or anxiety, but the staff members did not have the knowledge or training to know how to help. Dr. Gellis and his colleagues responded by developing a depression care model, called DART-HOME (Depression Assessment Referral and Treatment in Home Care) to screen and treat late-life depression in homebound older adults.

Only nine percent of licensed social workers identify aging as their primary field of practice.
Using this model, a visiting nurse making an initial visit to an older adult receiving home care services asks questions about depression and anxiety in addition to the usual battery of questions used for assessment. If the answers indicate the person may have depression or another mental health issue, a social worker visits to more thoroughly assess the patient, use evidence-based therapies for depression, and make any necessary referrals.

In studies of the DART-HOME model, this intervention significantly reduced depression scores, increased treatment satisfaction, and improved problem-solving skills. A majority of patients (63 percent) reported that they preferred talking with a social worker about their depression than taking an antidepressant medication.

As a result of this research and his other work, Dr. Gellis was appointed by New York Governor George Pataki in 2005 to sit on the Governor’s Interagency Planning Council for Health and Mental Health Services for Older Persons. The council recommended that the New York State Office of Mental Health establish demonstration sites across the state to provide training on how to integrate a depression assessment and screening model into a variety of agencies and health care settings that serve older adults (including hospital clinics, geriatric outpatient centers, nursing homes and visiting nurse agencies).

Older adults with medical conditions such as heart disease have higher rates of depression than those who are medically well.
Dr. Gellis is not alone in advocating for the integration of mental and physical health care services for older adults. As a result of a large body of work, the Centers for Medicare and Medicaid Services (CMS) was persuaded in 2008 to make changes to their procedures. When a Medicare beneficiary begins receiving home care services, the first step involves an assessment, usually by a nurse. CMS requires that the nurse complete a questionnaire called the Outcome Assessment Information Set. This assessment now includes a two-item Patient Health Questionnaire as a screen for depression. If the patient answers yes to these two questions, a longer assessment tool can then be used.

Dr. Gellis’s current research is looking at taking the DART-HOME model and moving it into the realm of home telehealth technologies. “Instead of going to the home, the nurse uses the telephone and Web-based communication systems to interact with the patient,” says Dr. Gellis.


policy4 (Top, middle) Cindy Jordan, LCSW, visiting a homebound patient as part of home health care services. (Bottom) Dr. Zvi Gellis reviews study data with Sr Jean McGinty.
When Dr. Zvi D. Gellis wanted to test the feasibility of the DART-HOME model, an intervention aimed at improving the recognition and treatment of depression in homebound older adults, he reached out to Sr. Jean McGinty, RN, MS, Director of St. Peter’s Home Health Care Program in Albany, New York. This became the site for the study.

In conducting the research, a nurse performing initial assessments of recipients of home health care services asked questions about depression and anxiety. A high score triggered a visit from the social worker, Cindy Jordan, LCSW, for further evaluation. Patients were divided into two groups. One group received depression education, problem-solving skills, help with scheduling activities and weekly tele- phone calls for six weeks. The other group received the usual care.

The dramatic improvement in depression scores among patients receiving the intervention convinced Sr. McGinty to require this depression screening tool for all home care patients. “Ultimately, Medicare made a similar change in their assessment tool, and we were ready,” says Sr. McGinty.