- [Announcer] ncIMPACT is a PBS North Carolina production in association with the University of North Carolina School of Government.

Funding for ncIMPACT is made possible by: - [Presenter] Changing the course of people's lives.

That's the impact UNC Health and the UNC School of Medicine work to deliver every day.

Our 40,000 team members across the state of North Carolina are committed to caring for you, our patients and communities, as well as educating the next generation of healthcare professionals.

Individually, we can do a little, but collectively we can do a lot to create impact.

- Hello and welcome to ncIMPACT.

I'm Anita Brown-Graham.

As people age, they sometimes experience life changes that affect their mental health; rates of anxiety, depression, and isolation, especially increased in older adults during the COVID-19 pandemic.

ncIMPACT's Evan Howell visited a community in Western North Carolina.

He introduces us to a program that uses a personal approach to healthcare.

- [Evan] Linda Falcone found that once she hit 65 years old, there was no way Social Security was gonna support her.

- I'm actually living below the poverty level.

- [Evan] So she moved into a low-income development in Weaverville, a small community just outside of Asheville.

But she had another challenge, and that was when she was diagnosed with mid-stage Alzheimer's disease.

Alzheimer's, a brain disease, is not a mental health condition, but depression is.

And depression is very common among people with Alzheimer's, especially during the early and middle stages.

- Everything I forget, and that's frustrating to me.

- [Evan] She has no family and no support in the area.

But her doctor referred her to a small community healthcare organization that helps people like Falcone remain healthy and in their home.

Falcone remembers the night she had to spend at the hospital.

- So they kept saying, "Who can I call?"

I said, "Call Kathey Avery."

I gave them the number, and Kathey was the one who came to pick me up.

She even slept on the floor that night because I had to have somebody stay overnight.

She slept on the damn floor for me.

I could not believe it.

- But what you need to look at- - [Evan] Kathey Avery says she was simply filling a gap between the hospital system and patients who may not have access to traditional health services.

- Well, community health workers and community nurses work in the community, which is a concept that's been around a while, but not utilized.

- [Evan] It's called the community health worker model, which is an independent grant-funded solution.

- We can come out and assess what she needs and give it to her, and we don't have to worry about, oh, I have to turn in this report so that we get reimbursed, which is the normal healthcare system.

Which is nothing wrong with that for the healthcare system, but it's not good for the client.

- [Evan] Many of Avery's elderly clients endure isolation, which can bring on issues like anxiety or depression, while others have some type of cognitive impairment such as dementia from strokes or Alzheimer's.

- That she trust us and know that we have her best interest at heart and that she'll listen to what we say.

- [Evan] This type of long-term support is thanks to a partnership with the Mountain Area Health Education Center, or MAHEC, which provides training and retention of healthcare professionals across Western North Carolina.

Falcone says without the support of Kathey and the community health worker model, she wouldn't be able to stay in her home, and said it's less about the program and more about the people behind it.

- She's a wonderful person.

and I know she helps a lot of other people too.

- [Evan] For ncIMPACT, I'm Evan Howell.

- Hot.

- Joyce, we just saw in that story the community health worker model, which is meant to be part of a system or to fill gaps within the system.

Before we talk about that, what causes there to be gaps in the mental health care system to begin with?

- So there are lots of issues.

And one of them is simply that there are not enough people trained in geriatric mental health to provide services that understand the impacts of aging on our overall well-being, and the things that can impact us as we go through later life.

And so that resource is not there.

And I think the other thing is, and I'm so glad they pointed it out in the video, people understanding what a mental health problem might be.

Dementia and cognitive impairments are not mental illnesses and shouldn't be treated as such.

But I think part of what the issue is, providers who may be helping a person may not know how to help them access the resource that will be helpful to them.

And the isolation that they mentioned is clearly an issue for many older adults.

- Thank you for that.

And Kelly, For many older adults, they're relying on public insurance to support them.

And as we saw in the video, maybe some of the processes aren't necessarily very customer friendly, shall we say.

What are improvements to be made?

- That's a great question.

And, you know, Joyce, I wanna agree with what Joyce said about about people being trained.

A lot of folks, we actually have a really robust mental health system, a public system.

So if you happen to have Medicaid, if you happen to have Medicare, we actually have a wide array of services.

Now, we have workforce struggles, which I think we'll talk about in a bit.

But there are kind of two really big barriers though.

One is really stigma.

So it is folks being okay talking about mental health issues, caregivers, family, community members being able to recognize the signs of mental health in an older adult.

And then access to the system.

So even though your insurance might cover a service, it doesn't mean you know how to navigate the system or who to call or how to find treatment.

So a lot of people think I need a psychiatrist, which is scary.

You probably don't.

You probably need a counselor, a social worker, or even talk to your pastor at your church.

But that navigation and entry into the system is kind of confusing.

So when you talk about improvements, I think we do have workforce shortages, certainly in rural areas.

As Joyce mentioned, we don't always have a lot of folks trained and who can specialize in mental health treatment for older adults.

But just the stigma of engaging in care, and then trying to figure out how to navigate the care system are kind of two places that we need to work on and improve.

And there are areas that we are trying to work on and improve.

One more thing I'll mention is that, you know, besides just navigating your insurance, even if you do have a robust benefit, we have a new crisis line in North Carolina which is 988.

It's like 911, but it's 988 for mental health crises.

Thousands of people are calling every day.

5,000-plus people call every month.

One of the smallest groups that are calling are adults 55 and older.

So we're not getting the message out to them this exists, and/or they don't feel comfortable calling yet.

So some resources that are available need to be better marketed, and we need to make sure they're meeting the needs of older adults.

- Amber, let me turn to you for a moment.

The elderly population frequently encounters physical health challenges.

I know this from personal experience: hearing, vision loss, and then of course there are the chronic conditions like arthritis or heart disease.

How does the physical health of our seniors affect their mental well-being?

- Okay, I think, good question.

I think we need to look at, they both really go hand in hand.

Physical health can affect mental health.

And mental health, undiagnosed, can also affect the physical health as well.

So I think that's important to recognize.

There may be signs or symptoms, whether it's somebody's chronic pain that they may have, and we need to look at like the root cause of that.

It may not be just because that they have a physical impairment.

It may be strictly related to maybe there is persistent depression or anxiety that's emulating in some of the physical health.

And I think, you know, some of the issues that we may have as a lot of older adults, they may just say, "Oh, this is a normal part of aging.

I'm having the aches and pains."

But they're not really recognizing that it may be contributing to their mental health.

So they go to their physician.

And their physician is really maybe possibly just looking at the physical aspect and not in turn asking those questions of what life changes have happened.

What about your emotional health?

Instead, they may be just treating the symptom of that physical health, which then maybe in turn go to added medication.

They may not have needed that added medication.

So I think when we look at overall healthcare, mental health is part of healthcare, and that's what we gotta start looking at.

- It's what makes this collaborative model so exciting.

Because, you know, everybody's trained in their little area, but if you're part of an entire group, then other people might see things that you don't see.

So very exciting.

Unique challenges require unique approaches.

The PEARLS program is a pilot program in Charlotte that is helping older adults who struggle with depression and isolation.

And ncIMPACT's David Hurst shows us how it's helping older adults maintain their health, happiness, and independence.

- Well, I know it's early, but I'll be another year in March.

- [David] After living in Maryland her whole life, Romina Campbell recently moved to Charlotte to be closer to her son.

- So to move and come into a strange town, I was a little scared.

But I would like to try to drive to the movies.

- [David] The move proved to be overwhelming.

She missed her family and friends in Maryland and struggled to navigate the unfamiliar roads in Charlotte.

[traffic roaring] She drifted into isolation.

But then she got connected to the PEARLS program.

- The purpose of the program is actually to work with older adults to reduce depressive as well as isolation symptoms that they may be experiencing right now.

- [David] PEARLS is an evidence-based program being piloted in Mecklenburg, Cabarrus, and Gaston counties.

It's a partnership between the NC Center for Health and Wellness at UNC Asheville and the Centralina Area Agency on Aging.

The program uses what's called the PHQ-9 scale.

It's a questionnaire that assesses an individual's degree of depression.

- Each time that we meet with them, we use a PHQ-9 depressive scale where we are seeing if their symptoms are decreasing over each session.

We also tackle each problem that they're facing into bite-sized pieces using the seven-step approach.

By doing so, where we identify the problem, we go through solutions to set a goal for the problem.

- [David] PEARL's coaches also help individuals find social and physical activities to help them stay engaged and active.

- They're more confident in themselves in facing challenges, and they're not afraid to ask for help anymore.

They're connecting with others that they used to not connect with before.

They're just happier.

- [David] Romina Campbell's PEARL's coach is helping her adjust to the move.

- But this has been a lifesaver to me, that program, 'cause it was like I didn't know which way to go.

- [David] Campbell now feels confident driving and has a thriving social life in her new community.

For ncIMPACT, I'm David Hurst.

- Amber, a large part of the PEARLS program works to reduce this issue of social isolation.

Let's talk some more about what is the importance of this, and what kind of negative health impacts go along with social isolation?

- Yeah, addressing social isolation and solutions to improve it are critical.

They're critical for every age, but especially with older adults because there's so many life changes that occur later in life.

Social isolation, the studies and the evidence show that social isolation really can even be as damaging or more damaging as if somebody smoked 15 cigarettes a day.

- [Anita] Stop.

Say that again.

- Social isolation, as studies have shown, can be as damaging or more damaging as if, the same as somebody smoking 15 cigarettes a day.

So that's a huge, it goes back to the physical side of it that we talked about earlier.

But not only with social isolation; of course, it's gonna lead to higher risk of depression, anxiety, weight loss even, cognitive decline.

There's so many implications of that.

Working at a multipurpose senior center, that we look at the holistic approach of individuals.

And when we looked at, you know, what do we do, what works, how can we enhance it, but more importantly, we recently focused on where are the gaps in services?

And one of the large gaps in services were providing direct mental health support.

And so while we had a team of social workers and we went to, you know, homebound individuals 'cause we do home delivered meals, or individuals would come to the senior center, we kept seeing over and over again that people needed more.

Not only did they need the social connections, so we increased, you know, opportunities, whether it was for in-person activities, but also virtual opportunities for individuals who are homebound to be able to make those social connections, as well as being able to provide direct mental health support when that was needed.

- And I appreciate you saying that.

Because obviously, the social connectedness may be important but not sufficient for dealing with whatever the underlying issue is.

'Cause, Kelly, it seems as though social isolation may go along with geographic isolation, and that rural communities where people live far distances apart and transportation may be a challenge may be particularly difficult for the elderly.

Can you talk to us a little bit about that.

And what are the opportunities for addressing those unique challenges?

- Yeah, absolutely.

So just in general, we know people in rural health just have less access, or in rural areas have less access to healthcare.

So they have less, they're less insured.

And it is actually just much harder to get basic healthcare, let alone specialty healthcare.

And mental health has been considered specialty care for a long time, although I think it's basic healthcare.

So it can be really hard to have insurance, and then to have a really robust array of mental health services in rural areas.

And then we talked about the social isolation component.

I think it's very different if you live in, and you've got neighbors on either side of you who can say hello to you in the morning when you're getting your paper, or if they don't see you for a day, maybe knock- Kelly, people don't go get their paper in the morning anymore.

- I do.

Do they not do that?

Okay, I do.

Okay.

Well, maybe it's my, well, I don't dunno.

I found my milk- - Sorry.

Sorry.

- I found my milk this morning, but maybe I'm old school.

But I do think about, I get my mail every day, and I see Mr. Ray across the street every day, and I see Mr. Ray when he walks across the block.

And if I don't see Mr. Ray for a couple of days, I wonder what happened to Mr. Ray: I do.

That's just part of my life.

So I think if your neighbor is a mile down the road, I mean, you just don't have that kind of natural support around you.

And I think there are opportunities though, right?

I'll mention the technical one first, and then maybe the less technical one.

But I do think we learned during the public health emergency that things like telehealth are extraordinary.

So technology, this is probably not the panel to talk about challenges with technology, but a lot of good can come of technology.

And we found a lot of people during the public health emergency really embracing technology for mental health care.

It really helped with stigma issues for a lot of people.

So they felt comfortable logging on and talking to someone.

We just saw massive amounts of telehealth utilization for mental health care during the public health emergency, and people are still asking for it.

So I think that's a real opportunity for people in rural areas who don't maybe have access to a counselor right away.

I do think rural areas do present an opportunity for us to be smarter about mental health care, meaning I think about my own grandma, right?

Love my grandma so much.

Part of her connectedness to her community, and we grew up in a very rural area, her connectedness was her church, her faith.

And so her faith was helpful too, but like that notion of pastoral counseling and having those kind of community partnerships.

And I think there's so many local community opportunities for us to think about how mental health care can work better with local community partners in rural areas.

And I think the faith community is like a really, really a good opportunity for us to do that better in rural areas.

So I think really, you know, things like technology I think are great, but also just expanding our reach doesn't have to be within the traditional walls.

We can use community health workers.

We can use faith partners or other social agency partnerships just to be able to reach more people.

- All right.

Ready for hard questions.

I just warmed them up for you.

Now they're ready to go.

- This question's for anyone who wants to answer.

What if any role do you think ageism plays in the prevalence of social isolation, loneliness, and elevated suicide risk among older adults?

And if you do believe it plays a role, what are your thoughts on addressing it?

- Great question.

- Yeah, we own that one.

We at the Division of Aging and Adult Services are working very hard to do what we call reframe aging.

As Governor Cooper said back when we we had a gathering to begin some work that we were doing, you know, 60 is the new 40.

And it's true.

We have to rethink what our ages are, and we have to learn to be our age.

You had to learn to be five to tie your shoes, and learn to be 15 to go on a date, or 16.

And you have to learn to be 60.

And so if we, and I'm speaking of all ages, don't consider that as we begin to face that next stage, then ageism can set in, as a real, very, very invasive kind of problem that older adults do to themselves even, because it's been so practiced over the years; that when you're old, you know, you shuffle around or you do this or you get dementia.

No, that's not normal aging.

And so we are working very hard to get people to rethink how they say things.

It's the words you use that matter.

Like rather than saying senior, senior citizen, maybe older person, mature adult.

And every time I hear somebody say, "I've had a senior moment," no, you just forgot something.

And trying to turn that into a more positive image of what aging is.

Because, let's face it, it's part of our life cycle.

And there are many, many opportunities that come with growing older.

One of them is many of us feel a lot freer to express our own opinions.

And some of those are really good and helpful opinions.

- I love it.

So yeah, there's a lot to be done, and there's a lot that we wanna work on to reverse that thinking and to bring generations together in this space, yeah.

- We have time for one more question.

Who's up?

- I think one barrier we haven't talked about yet to accessing mental health treatment is cost.

And so I think particularly for older adults who, you know, I'm thinking about folks who fall in that line of too much to qualify for Medicaid and get some of those Medicaid-funded services, but the folks who, a 20% co-insurance for a Medicare-accepting provider, if you can find one, is a bit too much.

So either systemic solutions or short-term resources to share.

- Yeah.

- A great question.

- Oh my gosh, what a fantastic thing.

And I can't help but seeing Senator Burr, you know, there.

[Anita laughing] But I think, like, and I think we have a long way to go in healthcare parity.

I know there's federal parity laws and there's new ones introduced, but this notion that you should be able to access mental health care and have it be paid for in a reasonable way, we have a long way to go.

Now, that isn't a solution for you, but I mean, I too, I'm blessed, right?

I have insurance.

My copays for behavioral health are four times what they are if I would go see my primary care doc.

Why is that?

And I go to see my primary care twice a year, right?

Mental health, that is not how it works.

You need a course of treatment: eight sessions, 16 sessions, $85 a copay?

And I have insurance.

So yeah, like we have to acknowledge that, like mental health I think is a basic right.

You need it.

We do need insurers to just be cool with that and recognize that mental health is health.

It's pretty cheap actually.

We don't pay therapists a lot, let's be honest.

We don't.

But then when a person has to pay $85 out of pocket, or even full pay because of co-insurance and things like that.

So I just kind of griped about the problems in our system.

But it is hard to find resources.

And I will say there is wonderful, the generosity of the General Assembly is a wonderful thing.

We do get state dollars to help defray the costs.

There's only so much, but we are able to have some insurances for un and underinsured.

And sometimes those go to people with insurance, because their insurance is not paying for basic mental health coverage, or the copay is excessively high.

So there are wonderful things like state dollars.

A lot of clinicians are just great people.

They offer sliding scales.

Community centers will have, I know Amber has social workers at her clinic.

So like a lot of communities do really wonderful things free of charge.

Churches have pastoral counseling free of charge.

Those things can be hard to find.

But yeah, we do need just better parity in healthcare.

It should just be like primary care: 50 visits a year, no copay, $5 copay.

It's worth the investment.

- Yeah, I thought that was a great question with access.

And that's probably also one of of the reasons why maybe older adults aren't accessing mental health services, because they're already anxious about their financial barriers.

- [Kelly] That's right.

- I know in our community in particular, our community saw the investment in themselves from taxpayer dollars, investing in having a mental health program in the senior resource center.

We first used our American Rescue Plan Act dollars to fund that.

And then we saw the outcomes of that.

We saw the need.

We saw how many people utilize the service.

And so our county saw the investment, and we are continuing that service to be able to sustain it.

And with that, we don't charge copays, because we know that that's a financial barrier for individuals.

We don't ask income questions with that because that's also difficult.

We might have individuals, you know, that are paying high rent costs, food costs, and their income may be pretty decent, what we think is decent, but when you look at the inflation and the cost of things, we wanna make sure that that the individuals that are being served are being served well with quality service, but that they don't have to worry about that financial burden.

- Thank you.

To our audience, thank you so much for those terrific questions.

It took a little bit of work to get you up to the mic, but once you got there you were awesome.

Kelly, Amber, Joyce, thank you for joining us this evening.

Thank you for the words of wisdom and the affirmation, the total lovefest chemistry on this panel.

And of course we wouldn't end the show without thanking those people who appeared in videos, who trusted us to tell their stories of local innovations.

And of course, finally, to our audience, thank you for joining, for listening, for engaging.

I'm Anita Brown-Graham.

This is ncIMPACT.

[upbeat music] [upbeat music continues] - [Announcer] ncIMPACT is a PBS North Carolina production in association with the University of North Carolina School of Government.

Funding for ncIMPACT is made possible by: - [Presenter] Changing the course of people's lives.

That's the impact UNC Health and the UNC School of Medicine work to deliver every day.

Our 40,000 team members across the state of North Carolina are committed to caring for you, our patients and communities, as well as educating the next generation of healthcare professionals.

Individually, we can do a little, but collectively, we can do a lot to create impact.