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. Author manuscript; available in PMC: 2015 Jan 27.
Published in final edited form as: Generations. 2014 Fall;38(3):68–74.

New Hampshire REAPs Results: Tailored Outreach Program Assists Older Adults at Risk for Mental Health Conditions and Substance Misuse

Renee Pepin 1, Jessica Hoyt 2, Lucille Karatzas 3, Stephen J Bartels 4
PMCID: PMC4307807  NIHMSID: NIHMS654179  PMID: 25635156

Abstract

A model community-based outreach program overcomes barriers to screening and case identification of vulnerable older adults in psychiatric distress.

Older adults with mental health conditions are unlikely to seek specialty mental health services (Mackenzie et al., 2008). Transportation challenges, stigma, lack of availability of a trained workforce, and cost are barriers to mental health services for older adults (Pepin, Segal, and Coolidge, 2009). Depressed mood occurs in up to 26 percent of community-dwelling older adults in the United States (Substance Abuse and Mental Health Services Administration [SAMHSA], 2011), and mild to severe alcohol use disorders occur among up to 5 percent (Rehm et al., 2014).

Neglecting to address depressive symptoms not only results in adverse consequences, such as decreased quality of life and poor health outcomes, but also increases the use of medical services, increasing societal economic burden (Luppa et al., 2012; Meeks et al., 2011). Untreated alcohol use disorders result in more years of life lost to disability, and premature mortality (Rehm et al., 2014). To engage older adults at risk for mental health conditions in appropriate services, there must be effective strategies to screen and identify at-risk older adults.

The Referral Education Assistance & Prevention (REAP) program was designed to address barriers to mental health services by providing outreach prevention services to older adults at risk for mental health and substance misuse disorders throughout the rural state of New Hampshire. New Hampshire has a disproportionately greater population of older adults that is unevenly dispersed, with rural growth rates exceeding urban growth rates (Johnson, 2012). The REAP program is specifically tailored to address the needs of rural older adults at risk for mental health and alcohol use disorders. This article describes the strengths, limitations, and challenges of this program that targets older adults dwelling in this rural state, to aid case identification and referral practices. By examining the process of mental health screening and referral in community-based settings, we may also identify potential avenues for improvement and refine current case identification practices for at-risk older adults.

New Hampshire’s REAP Program

New Hampshire’s REAP program, initiated in 1992, is a state wide educational, wellness, and brief mental health and substance misuse program for older adults. REAP counselors provide free services to older adults, caregivers, and professionals throughout New Hampshire within community-based settings (e.g., at home and in senior centers). REAP offers individual and family counseling; group education for older adults in community settings; and technical assistance to professionals, such as senior center staff, who provide services to older adults and their families.

REAP is financed through a novel blended funding arrangement from four state sources: the New Hampshire Housing Finance Authority, and three program areas within the Department of Health and Human Services (The Bureau of Drug and Alcohol Services, the Bureau of Elderly and Adult Services, and the Bureau of Behavioral Health). By spreading funding across four agencies, participants are not billed for screening or outreach, eliminating a critical barrier to program participation. A program director, program coordinator, and multi-stakeholder workgroup oversee the program. There are now about forty REAP counselors across the state. All REAP counselors are subcontracted through New Hampshire community mental health centers (CMHC) and hold either bachelors or masters degrees. CMHC staff determines which of their employees will be designated as their region’s REAP counselors. A REAP counselor position generally is considered a permanent, part-time position. Most REAP counselors have both REAP and CMHC caseloads.

REAP’s Scope and Method

REAP has been active in the community for more than twenty years, and promotes services through word of mouth, community education sessions, and participation in social service collaboration teams.

The REAP counseling and referral intervention

REAP counseling and referral sessions are available to adults ages 60 years or older, residents living in senior housing who are younger than age 60, and caregivers of older adults. Clients are offered up to five free sessions annually. REAP accepts referrals for counseling sessions from medical providers, mental health providers, resource coordinators who assess service eligibility, and community members.

Referrals are made to the REAP program director, the program coordinator, a REAP counselor, or the local community mental health center. A REAP counselor then contacts the client directly to arrange a time for an initial assessment. During assessment, the REAP counselor focuses on the presenting problem; screens for depressive symptoms, alcohol abuse, and cognitive impairment; identifies risk factors; identifies protective factors; and, collaboratively develops participant goals. Subsequent sessions are focused on providing the participant with appropriate education (i.e., about depressive symptoms, medications, at-risk alcohol use, etc.) and supportive counseling, and connecting participants to entitlement services or to a referral (i.e., to primary care, specialty care, or mental health services).

Program participants

The participant group discussed in this article consists of clients enrolled in REAP counseling services from January 1, 2010, through December 31, 2012. REAP provided counseling services to n=1,284 individuals from 2010 to 2012. The majority of participants were older than age 65 (80.6 percent, n=1,035), female (62.9 percent, n=807), and white (96.8 percent, n=1,246).

Program materials

Participants referred for counseling services were screened using the following two instruments:

  1. Short Form Geriatric Depression Scale (GDS). Derived from the original thirty-item Long Form GDS (Yesavage et al., 1982), the Short Form GDS is a fifteen-item screening instrument designed to detect depressive symptoms in older adults (Sheikh and Yesavage, 1986). A score greater than or equal to six indicates symptoms of depression (Sheikh and Yesavage, 1986).

  2. Short Michigan Alcoholism Screening Instrument—Geriatric Version (SMAST-G). Derived from the original twenty-four-item MAST-G (Blow et al., 1992), the SMAST-G screening instrument comprises ten positively scored items and is designed to detect alcohol abuse in older adults (Blow et al., 1998). A score greater than or equal to two indicates alcohol abuse is likely (Blow et al., 1998).

Evaluation procedure

De-identified participant counseling data were abstracted directly from the REAP reporting website, launched on July 1, 2005, to document REAP encounters. The site creates de-identified reports of program and participant information. We focused on the counseling portion of REAP because these sessions represent the bulk of REAP program activity, and these data were estimated to be most complete. Univariate analyses were conducted with participant data collected from 2010 through 2012.

Program data

Complete screening data ranged from 53 percent to 100 percent of cases, depending upon the variable. Data were most complete for session use and least complete for screening results. Due to the large proportion of missing data, we have presented results both in terms of raw percentage (percent) and the proportion of the sample that was complete for the variable analyzed (valid percent).

Program results

Approximately two-thirds of program participants were screened for alcohol abuse and depressive symptoms (65 percent and 61 percent, respectively), with more than half of participants screened for co-occurring depressive symptoms and alcohol abuse (52 percent). Of those participants screened, 4.47 percent screened positive for alcohol abuse only, 55.57 percent screened positive for depressive symptoms only, and 9.91 percent screened positive for both alcohol abuse and depressive symptoms (see Table 1 on page 71).

Table 1.

Clinical Information of Participants Presented by Number, Valid Percent, and Percent

Metric Total (2010–2012)
Alcohol Misuse Only N N=827 Valid % N=1,284 %
MAST-G (<2) 790 95.53 56.30
MAST-G (≥2) 37 4.47 8.10
Missing Data 457 35.60
Depression Only N N=776 Valid % N=1,284 %
GDS (≤5) 344 44.33 21.57
GDS Positive (≥6) 432 55.67 38.86
Missing Data 508 39.56
Co-Occurring N N=676 Valid % N=1,284 %
MAST-G Negative (<2)+
GDS Negative (≤5)+		 609 90.09 47.43
MAST-G (≥2) +
GDS Positive (≥6)		 67 9.91 5.22
Missing Data 608 47.35
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Participants who screened positive for depressive symptoms only did not differ significantly in GDS scores (M=10.16, SD=2.50), compared to GDS scores for participants who screened positive for both depressive symptoms and alcohol abuse (M=9.72, SD=2.58), t(497)=1.34, p=.18. Participants who screened positive for alcohol abuse only had significantly lower MAST-G scores (M=3.70, SD=2.12), compared to MAST-G scores for participants who screened positive for both alcohol abuse and depressive symptoms (M=4.87, SD=2.22), t(102)=−2.60, p=01. Females were more likely to score positive for depressive symptoms than males, χ2=(1, N=674)=9.94, p=.002, whereas males were more likely to score positive for alcohol abuse than females, χ2 =(1, N=690)=25.12, p<.001.

Participants were referred to REAP from a variety of sources. Frequent referral sources include family and friends (12.3 percent, n=158), Bureau of Elderly and Adult Services (i.e., Adult Protective Services) (11.8 percent, n=152), self-referral (11.7 percent, n=150), and home health workers (9.4 percent, n=121). Approximately one-third of participants used one session only (36 percent), one-quarter used two sessions (26 percent), and the remainder (38 percent) used three or more. Participants who scored positive for depressive symptoms used significantly more sessions than those who did not screen positive for depressive symptoms, t(774)=−3.32, p=.001. There was no statistically significant difference in session use between participants who scored positive for alcohol abuse and those who did not.

Discussion of REAP Outcomes

Since 1992, REAP has improved access to mental health services for older adults throughout New Hampshire by offering free screening, referral, and education services in community-based settings. Through community outreach targeting older adults, from 2010 through 2012, REAP counselors saw 1,284 participants. In the course of routine outreach activities, approximately two-thirds of program participants were screened for alcohol abuse and depressive symptoms and half of participants screened for co-occurring depressive symptoms and alcohol abuse. Screening resulted in high rates of positive case identification: of those screened, approximately 56 percent of participants screened positive for depressive symptoms only, approximately 5 percent screened positive for alcohol abuse only, and approximately 10 percent screened positive for both depressive symptoms and alcohol abuse.

This suggests that when clinicians elect to screen for depressive symptoms in older adults via community-based outreach they are likely to confirm high rates of depression. In contrast, lower rates of alcohol abuse are likely to be detected in this context. These findings support screening older adults for at-risk drinking rather than alcohol abuse (Gómez et al., 2006). Of note, approximately 10 percent of those screened had co-occurring depressive symptoms and alcohol abuse. This group also was differentiated by having more severe alcohol abuse compared to those screened positive for only alcohol abuse. This finding adds additional support to the increased risk and poor outcomes more frequently observed with co-occurring depressive symptoms and alcohol abuse (Najt, Fusar-Poli, and Brambilla, 2011).

More than half (62 percent) of REAP participants were seen for two or fewer sessions, underscoring the most common use of this service as either for screening alone, or screening and referral. Although we are unable to determine from the collected data the extent to which these brief contacts also represented refusal for subsequent treatment or referral, it is noteworthy that greater severity of depressive symptoms was associated with a greater number of visits. But it appears that it was challenging to engage older adults with alcohol abuse in additional sessions, this group tended to have fewer visits. This reflects prior reports underscoring the greater difficulty of engaging older adults in treatment for alcohol use disorders, compared to treating them for depressive symptoms (Bartels et al., 2004).

As previously stated, REAP uses a community-based outreach approach to identify older adults who experience psychiatric distress. Advantages of this approach include engaging hard-to-reach, at-risk older adults across a rural state, and providing a large proportion of these older adults with mental health screening and referral to additional services. We observed two limitations to this approach: it is challenging to institute universal screening procedures within community-based outreach services across a rural state; and, case identification and referral is an insufficient strategy to engage older adults in mental health services.

REAP counselors were well-positioned to identify older adults who are experiencing psychiatric distress. Despite the documentation of high rates of distress in their target population, counselors failed to screen more than 30 percent of REAP participants. In addition, for almost 10 percent of cases, depressive symptoms screening information was entered incorrectly (i.e., falling outside of range), resulting in a large amount of discarded data (9 percent of participants’ GDS scores); consequentially, there was missing depression screening data for 40 percent of cases. Discussion with program staff revealed a number of reasons why screenings were not completed. Common concerns were the belief that introducing a screening instrument would threaten rapport, take too much time, and result in clients’ refusals to participate.

There are several strategies that might improve rates of screening in a busy clinical environment where counselors must juggle competing demands and prioritize activities within their workflow. To ensure the completion of clinical activities, screening should be seamlessly embedded into routine services. Providers should be given clear expectations of required activities, be given training to accomplish these tasks, and, whenever possible, the burden of documentation should be decreased.

The REAP website reporting system aided the collection of certain variables (i.e., number of sessions, participant age) by requiring their entry, and this requirement could be expanded to include screening. Also, participants and counselors could benefit from using tablet computers in sessions to enter responses in real time, thus eliminating the need for counselors to enter this information when documenting their session. Finally, counselors were trained to provide mental health and substance-use screening as a core component of REAP, but screening was not monitored and there was no feedback to counselors on rates of screening. Real-time audit and feedback have been shown to be effective for increasing rates of adherence to evidence-based practices by clinician providers (Edmunds, Beidas, and Kendall, 2013; Jamtvedt et al., 2006).

By employing community-based outreach, REAP counselors have engaged older adults who would not necessarily access specialty mental health services in case identification and supportive services. Our analysis showed that REAP participants who screened positive for depressive symptoms use more REAP sessions than those who screened negative, suggesting that these individuals require more sessions to meet their needs. REAP has not tracked how older adults followed through with referrals made for additional mental health services. Research from primary care settings suggests that older adults who screen positive for depressive symptoms or substance use disorders are unlikely to follow through with a referral to specialty mental health services (Bartels et al., 2004).

While screening is essential to identify older adults with psychiatric symptoms, it is not sufficient in addressing the issue if there is a lack of availability of effective interventions (Lum et al., 2013). In the future, REAP should track referrals it provides to participants, as well as referral outcomes. Additionally, REAP’s goal is to enhance its services by adding the provision of brief, evidence-based mental health interventions to their community-based outreach screening and referral model.

Conclusion

REAP is an example of how community-based outreach programs can overcome barriers to screening and case identification of vulnerable rural older adults. This program has achieved remarkable sustainability through a unique funding strategy and has resulted in the identification of a large number of older adults who experience psychiatric distress. Despite the strengths of this approach, REAP could potentially achieve even broader case identification by ensuring more uniform screening. Most importantly, REAP could have a greater impact by providing brief interventions, and only referring individuals to specialty care who fail to respond to treatment or who are in need of acute treatment.

Capitalizing on this opportunity, we are currently engaged in training REAP outreach clinicians to provide evidence-based brief interventions for older adults with depressive symptoms and at-risk drinking. A long-term evaluation of this enhanced version of REAP will explore the potential effectiveness of providing in-home case identification and brief interventions through a state-funded program specifically designed for at-risk rural older adults who are otherwise unlikely to seek or receive mental health services.

Contributor Information

Renee Pepin, Geisel School of Medicine at Dartmouth, in Lebanon, New Hampshire.

Jessica Hoyt, National Center for PTSD, Department of Veterans Affairs, in White River Junction, Vermont.

Lucille Karatzas, Seacoast Mental Health Center in Portsmouth, New Hampshire.

Stephen J. Bartels, Dartmouth Institute and serves as director of the Dartmouth Centers for Health and Aging in Lebanon, New Hampshire.

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