Chapter 127. The United States System of Care

Summary

The delivery of mental health services to the elderly in the United States continues to be influenced by economic, service system and political agendas. While enjoying therapeutic advances stemming from sound clinical and basic science research, the care of older people with late life mental disorders remains fragmented and reflect modest reimbursement schemes that meet a minimum subset of population needs. The efforts to reduce global medical expenditures in the 1990s centered on application of managed care principles and practices and government cutbacks. The emphasis has been on cost reduction, not systems integration. In this chapter we will provide an update and overview of the current system of mental health care for older persons in the United States with a specific emphasis on the organization and financing of services. The following components and trends will be addressed: (1) the structure and organization of mental health services for the elderly; (2) fee-for-service financing of mental health services for the elderly, (3) mental health managed care for older adults, and (4) emerging and future trends in integrated services and financing. Importantly, the provision of mental health services for the elderly is inextricably linked to primary care, and for the frail elderly, problems of medical-psychiatric comorbidity must be attended to.