STATEMENT OF
JENNIFER MOYE, PH.D.
DIRECTOR OF THE GERIATRIC MENTAL HEALTH/UPBEAT
BOSTON VA MEDICAL CENTER
BEFORE THE
SENATE COMMITTEE ON VETERANS' AFFAIRS
ON NON-INSTITUTIONAL ALTERNATIVES TO LONG-TERM CARE

April 25, 2002

Mr. Chairman and Members of the Committee:

My name is Jennifer Moye. I am the Director of the Geriatric Mental Health/UPBEAT clinic at the Boston VA, Brockton Campus, and an Assistant Professor of Psychology in the Department of Psychiatry at Harvard Medical School. I am pleased to testify today on the Unified Psychogeriatric Biopsychosocial Evaluation and Treatment (UPBEAT) program.

Review of UPBEAT Model

I have worked as a psychologist with medically and neurologically frail older veterans with late onset mental health concerns for the past ten years, and I speak today as a clinician. Our clinic was founded in 1995 as part of a nine site clinical demonstration project that evaluated the effectiveness of intensive outpatient case management and mental health treatment for elderly veterans with previously undiagnosed mental health problems in the context of serious medical illness. The program is based on previous research demonstrating: 1) mental health problems are under diagnosed and inadequately treated in the elderly; 2) elderly who have depression or other mental health problems have more complex medical management, a more complicated recovery from illness, and are more expensive for the health care system.

UPBEAT Cost Savings

In the UPBEAT program, patients 60 years and older admitted to medical or surgical inpatient services were screened for depression, anxiety, or alcohol abuse. 1,687 veterans with these problems were randomly assigned to a treatment versus usual care group. The treatment group received interdisciplinary assessment followed by outpatient care coordination and mental health intervention. In the year following enrollment, veterans in the treatment group had higher utilization of outpatient care, especially mental health and telephone encounters, costing $1,171 more per patient per year, than the usual care group. However this expanded outpatient cost was more than made up for by savings in inpatient costs of $3,027, resulting in a net savings of $1,856 per patient per year, or a total savings for all patients enrolled in the treatment group of approximately $1.5 million dollars. Savings were attributable to a reduced length of stay when re-hospitalized. Savings were even greater in targeted subgroups, such as those with circulatory diseases or more significant depression, estimated at $5,000 per patient per year. Additional analyses are ongoing.

UPBEAT Clinical Example

One veteran in the UPBEAT program was enrolled at our site when he was surgically hospitalized and screened positive for depression. The depression was triggered in part because the current surgery was reminiscent of the eight surgeries he received in 1945 after being injured by shrapnel in World War II. This veteran participated in six combat jumps as a paratrooper in Africa, Italy, France, and Germany, including the Battle of the Bulge, and the Anzio and Normandy invasions during which time he received the Bronze Star. Late in life when confronted with illness and vulnerability, he became overwhelmed with depression, to the point of remaining in bed constantly, compromising his health. He entered our program at the age of 75, participating at first reluctantly, then enthusiastically in case management and individual psychotherapy with psychopharmacology. With treatment he was able to manage his mood better when medically ill, and he successfully underwent a subsequent surgery without the excess disability caused by depression. Furthermore, as a result of speaking about his war experiences for the first time in psychotherapy, he began to also share these with his family. None of his family members were previously aware of any details of his military service. This newly found capacity for such communication was tremendously appreciated by both the veteran and his family.

Essentials of Case Management for At-Risk Veterans

What does the success of the UPBEAT program tell us about outpatient based case management programs? UPBEAT is a non-institutional program that reduces institutional care and reduces total cost of care. These findings are similar to other studies that find case management of at-risk geriatric patients can forestall nursing home admission. Key elements of these programs are:

1. interdisciplinary teams;
2. readily accessible primary medical care;
3. home based care and support when indicated;
4. integration of mental health treatment;
5. case management to coordinate optimal utilization of the health care system; and
6. careful targeting of patients and interventions to identify those patients most at-risk for institutional care and most likely to benefit from such programming.v

Patients with dementia require additional services including travel, caregiver support such as respite care, and adult day health care. The ultimate success of such programs will rely on appropriate caseloads for primary care clinicians and case managers, clear program goals, and performance measures for clinicians and administrators.

In closing, I have been most grateful to work with our elderly veterans, and I thank you for the opportunity to speak before you today.

Attachment

Kominski, G., et al (2001). UPBEAT: The impact of a psychogeriatric intervention at VA Medical Centers. Medical Care, 39, 500-512.

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