Authors: Kelsey Brykman, Center for Health Care Strategies

Nearly three percent of adults over 65 experience major depression, while roughly 13 percent experience minor depression. Depression is particularly common among older adults with lower incomes, functional limitations, those living alone, and individuals who are dually eligible for Medicare and Medicaid. Beyond its direct impact on quality of life, depression can also reduce older adults’ ability to manage other chronic conditions and contribute to higher health care and nursing home utilization.

While depression is prevalent at all stages of life, physical, cognitive, and social changes that are associated with aging can uniquely impact mental health. For example, older adults are more likely to be socially isolated than other age groups, which can increase risk for depression. Barriers to treatment may also differ by age due to a range of factors, such as varying insurance systems, differences in how mental health symptoms present in older adults, and shortages in providers with geriatric expertise.

What Do Care Models for Managing Depression in Older Adults Look Like?   

As with other populations, models integrating behavioral health care into primary care are effective for treating depression in older adults. Integrating behavioral health care into primary care is an important strategy for appropriately identifying behavioral health conditions and providing wider access to care. One of the models with the most robust evidence base is the Collaborative Care model (CoCM), which involves collaboration between a primary care provider, behavioral health care manager, and psychiatric consultant to monitor depression symptoms and provide evidence-based medication or psychosocial treatment. The CoCM model, as well as other evidence-based behavioral health care integration models, typically include features such as multi-disciplinary teams, holistic patient assessment, self-management supports, care planning, and care coordination.

There is also increasing recognition that treating depression in older adults often requires going outside of clinic walls to address social needs, understand patient needs, build trust, and provide access to care for patients who cannot or prefer to not receive treatment in medical settings. For example, the California-based Care Partners Project supported primary care clinics and community-based organizations (CBOs) in developing partnerships to more effectively address social needs of older adults with depression. During this initiative, CBOs supported the primary-care based CoCM through means such as directly providing social support, helping engage patients in care, and supporting core components of the CoCM model, such as behavioral health activation and motivational interviewing. Through the Program to Encourage Active, Rewarding Lives (PEARLS) model, trained coaches provide home-based education and skill building to help older adults manage depression symptoms. Coaches also monitor depression symptoms through PHQ-9 screening and coordinate with primary care or behavioral health care providers as needed to coordinate treatment.

How Can Medicaid Support Behavioral Health Integration for Older Adults?

For children, youth, and younger adults, there are a variety of approaches for Medicaid agencies to support behavioral health care integration into primary care, such as covering billing codes for CoCM, requiring managed care organizations to support behavioral health care integration, and supporting provider trainings on behavioral health care integration. However, Medicaid’s role in addressing the behavioral health care needs of older adults is less clear. Approximately eight percent of Medicaid enrollees are age 65 or older, but nearly all of these people are also enrolled in Medicare. For these dually eligible individuals, Medicare is the primary payer for their medical care and much, but not all, of their behavioral health care. Integrating primary care and community-based depression interventions for this population is more challenging than for older adults covered by Medicare alone.

That said, there are opportunities for states to advance behavioral health care initiatives for older adults served by Medicaid. For example, states may assess the access barriers for this population and support workforce training on the behavioral health needs of older adults and relevant care models. Oregon’s Behavioral Health Initiative for Older Adults and People with Physical Disabilities is an example of a program that takes such an approach for older adults across the state.

States may also work to advance primary care and community-based behavioral health care models within the context of programs that serve a high proportion of older adults. For example, states may consider how to advance behavioral health supports through Medicare Advantage dual eligible special needs plans (D-SNP) — specialized health plans for people served by both Medicare and Medicaid. States may use contracting strategies with these plans such as requiring behavioral health training for care coordinators or other providers; behavioral health care provider inclusion in interdisciplinary care teams; and behavioral health questions as part of health risk assessments. Finally, states may consider clarifying or implementing policies to support payment for community-based behavioral health care models. For example, Washington State Medicaid allows reimbursement for the PEARLs model through a home- and community-based services waiver.

What is the Evidence on Primary Care and Community-Based Depression Care Models for Older Adults?

Evidence shows that primary care and community-based depression care models can support reductions in depression symptoms. Some models have been shown to reduce hospital and nursing home utilization and support quality-of-life improvements.

What Do Depression Care Models for Older Adults Look Like in Practice?

The following resources offer insights into how organizations are implementing or supporting behavioral health care programs for older adults in primary care and community-based settings.

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