Conversations about the mental health of older adults frequently revolve around two things: Alzheimer’s and dementia.

While it makes sense that cognitive disorders such as these would occupy a prominent place in the public imagination, the picture they paint of the mental health challenges encountered in old age is nowhere near complete. Of the many losses that befall us in later stages of life, memory is only one. Mobility, normal functioning, friends and family—the list goes on, as do accompanying feelings of isolation, loneliness, and grief.

If left unattended, the growing pains of growing old can dig deep and fester, eventually developing into depression, anxiety, or substance abuse. Older adults need people in their lives who know them well enough to detect the beginnings of a downward spiral and care enough to pull them out. Home care workers, by virtue of providing services regularly and in situ, are uniquely positioned to take on this task.

Many home care workers are ill equipped to detect and discuss the mental health symptoms of their older patients. It’s not that they’re not capable—far from it. Rather, a lack of designated overlap between home care and mental health systems leaves them critically unsupported.

The Problem

According to the Centers for Disease Control and Prevention, an estimated one of every five adults aged 55 or older experiences mental health concerns. For older adults who receive home care, the ratio is higher. A 2016 study analyzing the data of about 30,000 home care patients determined the prevalence of mental health disorders like depression and anxiety to be as high as 40 percent. Of those who reported experiencing mental health symptoms, however, only a third also reported receiving mental health supports and services.

Another 2016 study, this time of the home care assistants who attend to older adults living in community, outlined the barriers that prevent home care workers from fully addressing the mental health needs of their patients. One is the absence of established knowledge sharing practices that allow stories, advice, and best practices to circulate not just between care professionals, but between members of a single care team. Given that mental health and home care delivery systems are typically understaffed and overburdened, sufficient time and supportive tools must be allotted for meaningful dialogue to occur.

The same goes for meaningful dialogue between care providers and patients. Even though home care assistants who participated in the aforementioned study might pick up on signs—abandoned routines, unopened food boxes, empty wine bottles, overall despondency—that warrant intervention or at least conversation, strict timetables built to the minute around itemized tasks leave little breathing room to air out any unscheduled concerns. The omittance is discouraging, the participating home care assistants said, since the process of becoming a “dialogue partner” to patients produced noticeable gains in their mental health.

This speaks to a much larger, and very insidious, phenomenon—namely, that mental health disorders among older adults often go undetected or unmanaged. It is presumed “normal” or “natural” for the life of the aging mind to languish when, on the contrary, the reasons for languishment are actually preventable or treatable. A general lack of awareness of what depression, for example, looks and feels like—particularly when it co-occurs with other chronic diseases—might also be reason enough for either home care providers or home care patients to minimize symptoms.

The Solution

Given the scope of the problem, it should not fall on home care workers to become mental health experts when their plates are full enough as is. Nor should it fall on their patients to endure their mental health symptoms alone.

Systems level solutions, though seemingly several steps removed from the individual homes and individual people at the heart of this industry, may very well be the surest way to meet everyone where they’re at. Figuring out how to fully integrate home care and mental health systems, however, begins with knowing how to coordinate home care and mental health services. And successful care coordination, of course, begins with giving care professionals the freedom and resources they need to forge adaptive and resilient care networks.

With those networks in place, the time, energy, and knowledge otherwise lost to gaps and redundancy can flow back into patient provider relationships. Take, for instance, the Service Program for Older People, a community based agency that serves elderly New Yorkers. In partnership with hospitals like Mount Sinai and, more recently, New York Presbyterian, the Service Program dispatches psychiatrists, psychiatric nurse practitioners, and other service providers to the homes of clients who cannot reach their clinics.

The Service Program uses collaboration, resource sharing, and a robust referral system to bring mental health providers into the fold of existing home care networks. The Program to Encourage Active, Rewarding Lives (PEARLS), on the other hand, is a home based model for managing late life depression that can be adopted by the likes of the Service Program for Older People. In New York City, that parent organization is the home care agency Visiting Nurse Service of New York, which uses the PEARLS model to bring depression screenings and education into the lives of homebound patients.

A survey conducted by SCAN Health Plan last year found that older adults want, more than anything, to age in place. Yet aging in place, the same survey tells us, is broadly viewed as an unattainable pipe dream. By aligning and supporting the existing capacities of care workers, innovative care coordination makes this dream more achievable—and the mental health needs of their patients, deservedly more visible.