Mohammed T. Abou-Saleh

UNITED STATES SYSTEM OF CARE 6951960s, older adults have had universal access to acute health careand their demand for services has driven the development of ahighly capitalized, technologically advanced but severely fragmentedsystem. This interaction has contributed to the extensionof life expectancy, a probable improvement in life quality formany, and staggering growth of expenditure. The last two decadeshave been consumed by efforts to contain and reduce costs,despite continued technology growth that has had marginal effecton efficiency. Throughout this period, mental health has been, atbest, a poor stepchild. While enjoying advances in science andrecognition of its importance, the care of older people with latelifemental disorders has evolved services that reflect modestreimbursement schemes while attempting to meet a minimalsubset of population needs. The provision of mental healthservices for the elderly is inextricably linked to primary care and,for the frail elderly, must attend to the problems of medical–psychiatric co-morbidity. Recent reforms in the organization andfinancing of health care are beginning to address co-morbidityissues through integrated acute and long-term care deliverysystems, such as PACE, S/HMOs and the Evercare programs.State Medicaid managed care initiatives are also creatingopportunities to reallocate support to the development ofhome- and community-based alternative models of care, withthe goal of supporting least restrictive and less costly long-termcare services. Demonstration projects must examine behavioraloutcomes and analyze their effects on general health, mentalhealth, functional capacity and quality of life. 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