Older adults are at an increased risk for experiencing depression. Many have at least one chronic health condition and often have two or more. Depression is more common in people who have other illnesses or limited functions. Depression in older adults is often misdiagnosed and undertreated; mistaken as a natural reaction to illness or life changes as adults’ age. Not understanding that they might be suffering from depression and could feel better, older adults often accept how they feel as part of the normal aging process and don’t seek help. Depression is a treatable medical condition, not a normal part of aging.
CMS has recognized psychiatric home care as a reimbursable service since 1979, but nationwide proportionately fewer home health agencies actually provide this service. To provide this service, CMS states, agencies must employ ‘psychiatrically trained nurses …who have special training and/or experience beyond the standard curriculum required for a registered nurse.” Finding nurses with the required skills is difficult and caring for the psychiatric patient is frequently more time consuming and complex. This challenge is further complicated by the psychiatric patients’ questionable homebound status.
Center for Disease Control and Prevention “Depression is Not a Normal Part of Growing Older”,
Medicare Learning Network® “Screening for Depression” Booklet.
Medicare Learning Network® “The ABCs of the Annual Wellness Visit (AWV)” Educational Tool.
Medicare Learning Network® “The ABCs of the Initial Preventive Physical Examination” Educational Tool.
Centers for Disease Control and Prevention “Mental Health and Aging” Website.
Mental Health America– Mental Health Month sponsor.
Frequently Asked Questions
Someone who is depressed has feelings of sadness or anxiety that last for weeks at a time. He or she may also experience–
- Feelings of hopelessness and/or pessimism
- Feelings of guilt, worthlessness and/or helplessness
- Irritability, restlessness
- Loss of interest in activities or hobbies once pleasurable
- Fatigue and decreased energy
- Difficulty concentrating, remembering details and making decisions
- Insomnia, early–morning wakefulness, or excessive sleeping
- Overeating or appetite loss
- Thoughts of suicide, suicide attempts
- Persistent aches or pains, headaches, cramps, or digestive problems that do not get better, even with treatment
- Older adults are at increased risk.We know that about 80% of older adults have at least one chronic health condition, and 50% have two or more. Depression is more common in people who also have other illnesses (such as heart disease or cancer) or whose function becomes limited.
- Older adults are often misdiagnosed and undertreated. Healthcare providers may mistake an older adult’s symptoms of depression as just a natural reaction to illness or the life changes that may occur as we age, and therefore not see the depression as something to be treated. Older adults themselves often share this belief and do not seek help because they don’t understand that they could feel better with appropriate treatment.
CMS states, that a patient with a psychiatric problem may be considered homebound if “the illness … is of such a nature that it would not be considered safe to leave home unattended, even if he or she does not have any physical limitations.” Homebound status may need to be evaluated as a clinician would evaluate a patient suffering from dementia. That patient may have few or no physical limitations and yet would be deemed unsafe to leave his/her home unattended. The patient, in this example, could be considered homebound. However, if the patient with a psychiatric condition leaves home regularly for reasons other than to visit the physician, he/she may not be considered homebound. An example may be that of partial hospitalization.
CMS Publication 100-2, Chapter 7, §430.1.1
The good news is that the majority of older adults are not depressed. Some estimates of major depression in older people living in the community range from less than 1% to about 5% but rise to 13.5% in those who require home healthcare and to 11.5% in older hospital patients.
Medicare provides payment for several preventive services that can be used to help monitor your patients’ mental health.
Screening for Depression in Adults
- Medicare covers annual screening for depression in adults in primary care settings that have staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment, and follow-up.
- For the purposes of this screening benefit, Medicare defines a primary care setting as one in which there is provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Ambulatory surgical centers, emergency departments, hospices, independent diagnostic testing facilities, inpatient hospital settings, inpatient rehabilitation facilities, and skilled nursing facilities are not considered primary care settings under this definition.
Refer to Screening for Depression for more information about this service.
Annual Wellness Visit Providing Personalized Prevention Plan Services (AWV)
- Available once per year if the beneficiary has been enrolled in Medicare Part B for longer than 12 months.
- The AWV is a visit focused on prevention and furnishing of personalized health advice and referrals, as appropriate, to screening services, health education and preventive counseling.
- The AWV includes and takes into account the results of a health risk assessment. Among other things, the health risk assessment includes self-assessment of psychosocial risks, including but not limited to, depression/life satisfaction, stress, anger, loneliness/social isolation, pain, and fatigue.
- The first annual wellness visit includes an element for review of the beneficiary’s potential (risk factors) for depression, including current or past experiences with depression or other mood disorders.
Refer to The ABCs of the Annual Wellness Visit (AWV) for more information about the elements included in the AWV.
The Initial Preventive Physical Examination (IPPE)
- Commonly referred to as the “Welcome to Medicare” Preventive Visit, is a visit focused on prevention and furnishing, as appropriate, of education, counseling, and referrals for the screening and other preventive services covered under Medicare Part B.
- Available one time when the beneficiary is new to Medicare (within the first 12 months of Medicare Part B (enrollment).
- Among other things, the IPPE includes an element for review of the beneficiary’s potential (risk factors) for depression, including current or past experiences with depression or other mood disorders.
Refer to The ABCs of the Initial Preventive Physical Examination for more information about the elements included in the IPPE.
Most older adults see an improvement in their symptoms when treated with antidepression drugs, psychotherapy, or a combination of both. If you are concerned about a loved one being depressed, offer to go with him or her to see a health care provider to be diagnosed and treated.
If you or someone you care about is in crisis, please seek help immediately.
- Call 911
- Visit a nearby emergency department or your health care provider’s office
- Call the toll-free, 24-hour hotline of the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255); TTY: 1-800-799-4TTY (4889) to talk to a trained counselor