American Journal of Psychiatric Rehabilitation, 11: 41–60

Taylor & Francis Group, LLC # 2008

ISSN: 1548-7768 print=1548-7776 online
DOI: 10.1080/15487760701853193

Helping Older People Experience

Success: An Integrated Model of
Psychosocial Rehabilitation and
Health Care Management for Older
Adults with Serious Mental Illness
Sarah I. Pratt, Stephen J. Bartels, and Kim T. Mueser
Dartmouth Psychiatric Research Center, Department
of Psychiatry, Dartmouth Medical School, Concord,
New Hampshire, USA

Brent Forester
McLean Hospital, Department of Psychiatry, Harvard
Medical School, Belmont, Massachusetts, USA

Older adults with serious mental illness (SMI) are a rapidly growing group of
mental health consumers who are at high risk for institutionalization, excess
disability, morbidity, and early mortality. Clinical services and research has
largely neglected the pressing psychosocial and health care needs of this
group. In this article we first provide a summary of the psychosocial and
medical challenges of older people with SMI. Next, we describe a conceptual
model of psychosocial rehabilitation and health care management for older
people with SMI. We then present an integrated social rehabilitation and
health care management intervention developed by the authors (Helping
Older People Experience Success; HOPES) that was designed to meet the
rehabilitative needs of older people with SMI. Finally we describe the baseline
characteristics of older adults with SMI participating in a three-year rando-
mized clinical trial that is underway to evaluate the effectiveness of HOPES

Address correspondence to Sarah Pratt, Ph.D., Assistant Professor of Psychiatry, Dartmouth

Psychiatric Research Center, 105 Pleasant Street, Main Building, Concord, NH 03301, USA.
E-mail: sarah.i.pratt@dartmouth.edu

41
42 S. I. Pratt et al.

compared with usual care. Implications are discussed for future research of
integrated psychosocial rehabilitation and health management interventions.

Keywords: Health; HOPES; Older adults; Psychosocial rehabilitation; Skills training

Approximately 2% of adults aged 65 and older in the United States,

7 million people, have a serious mental illness (SMI), defined as (1)
a diagnosis of schizophrenia, schizoaffective disorder, bipolar dis-
order, other psychotic disorder, or treatment refractory depression
and (2) persistent functional impairment requiring ongoing sup-
portive services. Although many older people with SMI reside in
nursing homes, most live in the community (Meeks et al., 1990).
The trend toward increased community tenure will likely continue
given the expressed preferences of older people, and the recent
Supreme Court Olmstead decision upholding the rights of indivi-
duals with disabilities to live in the least restrictive setting possible
(Bartels, 2003). Multiple factors, including deficits in social and
independent living skills, and high rates of medical comorbidity,
place older people with SMI at greater risk for institutionalization
than older people without SMI.

PSYCHOSOCIAL AND MEDICAL CHALLENGES

Several evidence-based practices for SMI, including assertive

community treatment, supported employment, integrated dual diag-
nosis treatment, family psychoeducation, and the use of psychiatric
medication algorithms have been developed and empirically vali-
dated in populations of younger adults (Drake et al., 2001; Mueser
et al., 2003). Despite the potential value of these interventions across
the lifespan, the critical needs of aging persons with SMI have not been
systematically considered in the development of these practices. The
challenge of developing effective health care interventions and ser-
vices for older people has become a major concern and the subject
of national debate. However, the parallel challenge of developing
mental health services that accommodate the specific needs of older
people with SMI has received less attention. The purpose of this article
is to address this challenge by providing a summary of the psychoso-
cial and medical challenges of older people with SMI; a conceptual
model of psychosocial rehabilitation for older people with SMI;
and a description of an integrated skills training and health care
 Helping Older People Experience Success 43

management intervention designed to meet the rehabilitative needs

of older people with SMI.

Social Functioning
Longitudinal studies of the course of schizophrenia indicate that
problems in social functioning persist for many individuals as they
age, with more impaired social skills and less social support asso-
ciated with greater risk of nursing home placement (Meeks et al.,
1990). For example, the majority of people with schizophrenia in
five longitudinal studies showed overall improvement in symptom
severity, yet social adaptation was poor or fair for two-thirds of the
people (Ciompi, 1987). Cross-sectional descriptive studies also con-
firm the prevalence and severity of impaired social functioning
among older adults with SMI. For example, older adults with
SMI have impaired social skills compared with older persons with
less severe psychiatric disorders, including greater impairments in
accepting and initiating contact, communicating effectively, and
engaging in social activities (Bartels, Mueser, & Miles, 1997b). In
a recent survey of older adults with SMI, one-half of the respon-
dents assigned a high priority to improving their social functioning
in areas such as communicating more effectively, having more
friends, and feeling more comfortable around people (Auslander
& Jeste, 2002). Therefore, enhancing psychosocial functioning in
older people with SMI is an important target of treatment.

Community Living Skills

Problems with independent living skills, such as managing
money, caring for a home, and using public transportation, are
pervasive and debilitating for many older people with SMI,
resulting in greater dependence on institutional care and other
intensive services (Bartels, Mueser, & Miles, 1997a; Meeks &
Murrell, 1997; Semke, Fisher, Goldman, & Hirad, 1996). Deficits
in these skills are strong predictors of mental health service
utilization in older adults with SMI (Bartels, Miles, Dums, &
Pratt, 2003). As in the general population, living independently
is an expressed priority for most older persons with SMI (Bartels,
Miles, Dums, & Levine, 2003). For these reasons, the need for
rehabilitation interventions focusing on community living skills
is a vital component of community-based programs for older
44 S. I. Pratt et al.

persons with SMI (Atkinson, & Stuck, 1991; Blackmon, 1990;

Schaftt & Randolph, 1994).

Medical Comorbidity
Rates of medical comorbidity are high among older people with SMI
and are associated with more severe psychiatric symptoms and
increased mortality (Dalmau, Bergman, & Brismar, 1997; Dixon,
Postrado, Delahanty, Fischer, & Lehman, 1999; Goldman, 1999;
Vieweg, Levenson, Pandurangi, & Silverman, 1995). Older people
with SMI also have more severe medical disorders compared with
older people without SMI, and medical comorbidity is often
compounded by poor general medical care (Druss, Bradford, Rosenheck,
Radford, & Krumholz, 2000; Jeste et al., 1996). Poor health behaviors
(e.g., diet, caring for medical problems) and difficulty adhering to
treatment recommendations, further contribute to poor health out-
comes and the need for active coordination between medical and
psychiatric service providers (Bartels, Levine, & Shea, 1999a; Bartels,
2004; Holmberg & Kane, 1999; Moak, 1996; Vieweg et al., 1995).
Recommendations from a consensus statement on geriatric mental
health (Jeste et al., 1999) and the Surgeon General’s report on Mental
Health (U.S. Dept. of Health and Human Services, 1999) underscore
the pressing need for models of community-based rehabilitation
and health care for older persons with SMI.
In summary, deficits in community living and medical comorbidity
are associated with greater dependence on intensive services and high
risk of institutionalization. Current systems of care are ill equipped to
provide the necessary array of services to accommodate the projected
future service needs of older people with SMI (Bartels et al., 1999a;
Bartels, 2003). Many community mental health centers do not employ
practitioners with expertise in geriatrics, may not routinely assess or
coordinate vital preventive medical care, and do not offer services tail-
ored for older people. Therefore, there is an urgent need to develop
and evaluate treatment models designed to meet the health and social
rehabilitation needs of older persons with SMI.

CONCEPTUAL MODEL OF PSYCHOSOCIAL REHABILITATION

AND HEALTH CARE MANAGEMENT

To understand the potential interaction between impaired psycho-

social functioning and poor health, and to guide the development
 Helping Older People Experience Success 45

Figure 1. Conceptual model of psychosocial rehabilitation and health management for older
people with SMI.

of an intervention designed to address these needs in an integrated

fashion and improve long-term outcomes, we developed a
conceptual model of psychosocial rehabilitation and health
management for older people with SMI (Figure 1). According to
our model, mental illness affects both psychosocial skills (or competence)
and health behaviors, which in turn affect psychosocial functioning and
health and health care. As described previously, people with SMI have
poor social and independent living skills. People with SMI also
engage in unhealthy lifestyle behaviors (e.g., poor diet, failure to take
medication as prescribed) and have difficulty managing their health
problems (e.g., failure to receive routine medical screens, trouble
accessing care for acute or chronic medical problems).
Poor social skills and health behaviors can interact to affect psy-
chosocial functioning, including role functioning (e.g., independent
living in the community, work) and social functioning (e.g., inter-
personal relationships, involvement in community activities), as
well as overall health and health care. For example, poor communi-
cation skills may worsen health outcomes because of problems
interacting with physicians, such as describing symptoms and
asking questions about medication. Likewise, poor health practices
and physical limitations from medical problems may interfere with
engagement in usual social activities. The interaction of poor
psychosocial functioning with poor heath, as mentioned above,
represents a primary risk factor for institutionalization and loss of
independence in the community.
46 S. I. Pratt et al.

Within this conceptual model, two components are proposed to

enhance functioning and health care management for older adults
with SMI: psychosocial rehabilitation and health management.
Psychosocial rehabilitation efforts are directed at rectifying the inde-
pendent living and social skill impairments that lead to disability
either by restoring function in the individual (e.g., skills training)
or expanding access to sources of support (e.g., case management).
These methods are not mutually exclusive, and most effective
rehabilitation programs include both (Brandt & Pope, 1997). Health
management focuses on health promotion and health care manage-
ment by a nurse. The rationale for linking skills training and health
management to maximize community tenure stems from research
on older people with SMI demonstrating the relationships between
deficient living skills, social skills and support, on the one hand,
and medical comorbidity and institutionalization on the other
hand. Theoretically, providing older people with SMI who have
significant medical problems and deficits in living skills with both
psychosocial rehabilitation and health management would maxi-
mally enhance their ability to live independently in the community.

OVERVIEW OF THE HOPES PROGRAM

The Helping Older People Experience Success (HOPES) program

was based on a pilot program of a 12-month skills training (ST)
and health management (HM) intervention that produced positive
effects on psychosocial functioning and health care in a group of
30 people over age 60 with SMI and medical comorbidity (Bartels
et al., 2004). ST consisted of weekly skills training sessions and
biweekly in vivo community trips led by nurse case managers.
The same nurse case managers also provided HM, including
tracking and promotion of preventive health care as well as assist-
ance with accessing care for acute and chronic medical problems.
The HOPES program similarly integrates psychosocial rehabili-
tation and health management and is delivered for 24 months
by rehabilitation specialists who provide skills training and nurses
who provide health management. This program is being evalu-
ated in a randomized controlled trial that has assigned 183 people
over age 50 with SMI to HOPES or usual care (NIMH R01
MH62324: ‘‘Rehabilitation and Health Care for Elderly with
SMI,’’ Bartels, PI).
 Helping Older People Experience Success 47

HOPES Skills Training

The HOPES skills training program is based on the principles and
techniques of social skills training (Bellack, Mueser, Gingerich, &
Agresta, 2004) and includes group sessions in which skills are intro-
duced and practiced, community trips to practice skills in real world
settings, and involvement of others in the community to support the
participants’ use of targeted skills. Skills training is provided by
rehabilitation specialists for 24 months, with an intensive phase for
12 months followed by a maintenance phase for 12 months. A rehabili-
tation specialist meets with HOPES participants individually at the
beginning of the program to orient them to the program, to set positive
expectations for participation in the program, to discuss the client’s per-
sonal goals, and to identify a supportive individual in the community
who can help the participant use the skills taught in the program.

Group Sessions
HOPES skills training sessions are co-led by two rehabilitation
specialists and are held in a variety of settings, including a mental
health clinic, a rehabilitation center, and a local senior center. HOPES
participants attend weekly group sessions during the intensive phase
of the program and monthly review sessions during the maintenance
phase. The format for the group sessions, including a description of
the specific teaching activities, is summarized in Table 1.
The HOPES skills training curriculum (summarized in Table 2),
which includes 50 specific skills organized into 7 skill areas (or

TABLE 1. Format of HOPES skills training sessions

Session Activities Approximate Time (min)

Review of personal rehabilitation goals 10

Review of curriculum from prior session 5
Review of home practice 10
Introduction of new skill and curriculum: 30
Establishing a rationale for learning the skill
Group discussion of the skill
Role-play demonstration of the new skill 5
Light exercise=stretching 5–10
Lunch (provided by grant funds) 20–25
Role-play=practice of new skill by participants 45–50
Planning for community practice trip 5
Assignment of home practice 5–10
48 S. I. Pratt et al.

TABLE 2. HOPES skills training curriculum

Module 1 Making the Most of 1. Savoring the Moment
Leisure Time 2. Reminiscing
3. Anticipation
4. Putting it All Together: The 3 Stages of Fun
5. Inviting Someone to Share a Leisure Activity
6. Planning for an Outing
Module 2 Living 1. Traveling Independently
Independently in 2. Reading Maps
the Community 3. Making Positive Requests
4. Communicating Effectively on the Phone
5. Leaving an Effective Telephone Message
6. Making a Monthly Budget
7. Acquiring Important Items from the Store
8. Solving Community Living Problems
Module 3 Communicating 1. Starting a Conversation
Effectively 2. Maintaining Conversations by Asking
Questions
3. Maintaining Conversations by Giving
Factual Information
4. Sticking with a Topic of Conversation.
5. Appropriate Self-Disclosure
6. Appropriate Disclosure in Conversations
7. Ending Conversations Smoothly
8. Putting it All Together
Module 4 Making and 1. Building a Foundation for Friendship
Keeping Friends 2. Meeting New People
3. Giving and Receiving Compliments
4. Learning About Another Person
5. Making Plans with a Friend
6. Negotiating a Compromise
7. Reconnecting with Old Friends
8. Responding to Requests
Module 5 Healthy Living 1. Setting and Achieving Goals
2. Healthy Sleep Habits
3. Major Medical Problems
4. Healthy Exercise and Diet
5. Preventive Health Care
6. Anxiety Management
Module 6 Making the Most 1. Preparing for a Health Care Visit
of a Health Care 2. Sharing Health Information with Your
Visit Doctor
3. Reporting Physical Symptoms
4. Asking About Treatment Options
5. Making Treatment Decisions
6. Making a Visit to the Dentist
7. Making an Advance Care Plan
8. Naming a Health Care Agent

(Continued)
 Helping Older People Experience Success 49

TABLE 2. Continued
Module 7 Using Medications 1. Medication Basics
Effectively 2. Pros and Cons of Taking Medications
3. Strategies for Remembering Medications
4. Reading Medication Labels and Using Pill
Organizers
5. Using Electronic Devices to Remember
Medication Times
6. Reporting Medication Side Effects
7. Evaluation the Effects of Medication
8. Negotiating Medication Issues

modules), was developed by the authors in collaboration with

geriatric psychiatry experts and providers. One new skill is
introduced during each weekly HOPES session in the intensive
phase. Several skills learned during the intensive phase are
reviewed in each monthly review session held during the mainte-
nance phase. The rehabilitation specialist offers individual sessions
when HOPES participants are unable to attend group sessions. The
HOPES skills training manuals include an instructor’s guide and a
participant workbook for each of the 50 intensive phase sessions
and each of the 12 maintenance phase sessions, as well as an
introductory manual that provides information about beginning
a HOPES group and describes the teaching activities used in the
program.

Community Practice Sessions.

Although the goal of skills training is to teach more effective skills
for day-to-day living and interactions, spontaneous generalization
from skills training sessions to the community does not usually
occur (Liberman et al., 1993). Instead, deliberate strategies must
be used to program the generalization of skills taught in sessions
to the community. To accomplish this, HOPES clients participate
in biweekly community trips during the intensive phase and
monthly trips during the maintenance phase to practice the specific
skills learned in the group sessions. For example, participants prac-
tice riding the subway and bus after the sessions that focus on using
public transportation. All trips also serve to facilitate group
cohesion and provide the opportunity to practice conversational,
leisure, and friendship skills. Planning for the trips is facilitated
by the rehabilitation specialists who encourage HOPES participants
to identify appropriate community settings in which to practice
50 S. I. Pratt et al.

skills. During the maintenance phase of the program, participants

are encouraged to plan group outings outside the context of the
scheduled HOPES community trips.

Involvement of Community Supports

The community supports identified by clients are primarily family
members, residential managers, and mental health providers (e.g.,
case managers, therapists). The rehabilitation specialists meet with
community supports at least once at the beginning of the intensive
phase and maintain at least monthly contact (phone or in person)
thereafter until the end of the maintenance phase. They provide
community support persons with brief handouts describing the
skills covered in each group session and provide suggestions for
how to encourage and reinforce the clients’ use of the skills.

HOPES Health Management

Health management consists of:
1. Initial assessment of health status and identification of health care
targets.
2. Promotion of preventive health care.
3. Completion of advance directives.
4. Establishment of linkage and collaboration with the primary health care
provider.
5. Assistance with access to care for acute and chronic medical problems.
This component of HOPES is provided by psychiatric nurses who
meet with participants on a monthly basis during both the intensive
and maintenance phases of the program.

Initial Assessment of Health Status

HOPES nurses conduct a review of systems to evaluate current
health status, identify aspects of health care that may be lacking,
and to assess health self-management practices. Based on this
assessment, the nurses, together with the participants, establish a
medical problem list and goals for improving health care and
health.

Promotion of Preventive Health Care

The HOPES nurses encourage clients to receive routine preventive
health tests and procedures recommended for older individuals,
 Helping Older People Experience Success 51

including 11 preventive health targets for men and 13 preventive

health targets for women (e.g., mammography, colon cancer
screening, pneumonia vaccination, annual physical exam, etc.).
The nurses track receipt of these targets for each HOPES client
during both the intensive and maintenance phases of the program.

Completion of Advance Directives

Very few HOPES clients had written advance directives upon entry
into the program. The HOPES nurses work with participants not
only to document their wishes for medical care in the event of an
incapacitating illness, but also to identify a health care agent (or
health care proxy) to carry out their wishes. Participants learn about
advance directives and selecting a health care agent in group skills
training sessions. Establishment of advance directives is parti-
cularly critical for many older people with SMI who do not have
family members and may have few social supports other than paid
health care professionals who are not legally able to perform the
dual role of health care agent and provider.

Linkage with Primary Care

A critical function of the HOPES nurses is to provide linkage
between the mental health and the primary health care systems.
Nurses help participants who do not have an established primary
care provider to select one and schedule an appointment for an
annual exam. The nurses attend at least one office visit with each
client during the intensive phase of the program to establish a
collaborative relationship with the primary care nurse and health
care provider. This relationship and integration of care facilitates
the flow of information between the mental health and primary care
systems. Nurses also help clients to prepare for their doctor visits,
including planning and practicing how to report symptoms, ask
questions, and discuss treatment options. This reinforces the health
management skills participants have learned in group sessions.

Assistance with Access to Health Care

HOPES nurses help to monitor chronic medical conditions such as
diabetes and hypertension. For example, they take blood pressures
before or after HOPES group sessions and track the frequency and
laboratory values of tests that monitor control of diabetes. They also
intervene to address acute or emerging medical problems, such as
hypoglycemia. Assistance with access to health care includes
52 S. I. Pratt et al.

helping clients to schedule medical appointments, investigating

community health resources such as diabetes self-management
classes, and providing transportation if necessary.

Integration of Skills Training and Health Management

The skills training and health management components of HOPES
are integrated in several ways. The HOPES nurse and rehabilitation
specialist meet on a weekly basis to discuss participants in the
program. They are each aware of the personal goals that parti-
cipants have set for themselves and work to encourage and
reinforce progress toward those goals. Nurses schedule office hours
on the same days as the HOPES classes to monitor participants with
particularly unstable medical conditions. For example, participants
with unstable hypertension receive weekly blood pressure checks
from the nurse during the HOPES class lunch break.
Much of the HOPES curriculum is devoted to training in health
behaviors. For example, participants spend eight weeks learning
about how to make the most of their health care visits. They also
spend eight weeks learning about how to use medications effec-
tively. Nurses use the HOPES modules related to health to reinforce
the training as the concepts apply in real world settings. For
example, when nurses facilitate a participant’s visit to a health care
professional, they prompt and reinforce skills related to planning
for a medical appointment. Similarly, rehabilitation specialists
assist with activities related to health management. For example,
a rehabilitation specialist might help a participant to identify an
appropriate health care agent to enact an advance care plan.
Community trips planned during HOPES classes relate to health
where appropriate. For example, a HOPES class visited a diabetes
educator at a local hospital to learn about healthy eating.

CHARACTERISTICS OF THE STUDY SAMPLE FOR EVALUATION

OF HOPES EFFECTIVENESS

A randomized controlled trial is currently underway to evaluate the

effectiveness of the HOPES program in older persons with SMI
receiving mental health services at one of three public-sector mental
health centers, including one in Nashua, New Hampshire, and two
in Boston, Massachusetts. Study participants are older adults with
 Helping Older People Experience Success 53

SMI (defined as diagnosis of schizophrenia, schizoaffective dis-

order, major depression, or bipolar disorder and at least moderate
impairment in multiple areas of psychosocial functioning), who are
age 50 and older and reside in the community. Assessments are
being conducted at baseline, 1, 2, and 3-year follow-up.
A total of 183 adults (mean age ¼ 60) were successfully enrolled
and randomly assigned to HOPES (n ¼ 90) or to Usual Care
(n ¼ 93). Baseline demographic characteristics of the study sample
are presented in Table 3. Because participants were recruited from
New Hampshire and Boston, which have relatively low minority
populations, the study sample was largely Caucasian (80%). Of
note, a relatively small proportion of the sample was never married
(35%) compared with what might be expected based on epidemio-
logical studies of SMI (Bromet & Fenning, 1999). As expected, given
the age of the study participants, there were more females than

TABLE 3. Baseline demographic characteristics intervention vs. control groups

HOPES (n ¼ 90) UC (n ¼ 93)

Gender n (%) n (%)

Female 53 (58.9) 53 (57)
Male 37 (41.1) 40 (43)
Martial Status
Never married 31 (34.4) 33 (35.9)
Married or living as married 12 (13.3) 9 (9.8)
Divorced, widowed or separated 47 (52.3) 50 (54.3)
Ethnicity
White 79 (87.8) 78 (83.9)
African American 8 (8.9) 11 (11.8)
More than 1 race 1 (1.1) 3 (3.2)
Asian 1 (1.1) 1 (1.1)
American Indian 1 (1.1) 0 (0)
Hispanic 7 (7.8) 5 (5.4)
Diagnosis
Schizophrenia 25 (27.8) 26 (28.0)
Schizoaffective disorder 24 (26.6) 28 (30.1)
Major depression 24 (26.6) 20 (21.5)
Bipolar disorder 17 (18.9) 19 (20.4)
Education
< High school diploma 20 (22.2) 29 (31.2)
High school or more 70 (77.8) 64 (68.8)
Residential Status
Independent 45 (51.1) 49 (53.3)
Supported 43 (46.7) 43 (48.9)
54 S. I. Pratt et al.

males in the sample, although not significantly more. The

educational attainment of the study sample was consistent with
some epidemiological studies of schizophrenia (Rabinowitz,
Bromet, & Davidson, 2003), but higher than others (Keith, Regier,
& Rae, 1991). As anticipated, there were no significant differences
in the characteristics of participants randomized to the HOPES
intervention and those randomized to the Usual Care (UC)
condition.
Differences in baseline demographic characteristics among the
four diagnostic groups enrolled in the study are presented in
Table 4. Individuals with schizophrenia were more likely to be male
and never married, consistent with epidemiological studies of SMI
(Bromet & Fenning, 1999). Participants with schizoaffective
disorder were significantly younger, although the relative differ-
ence in age was small. Participants with mood disorders were more
likely to be older, female, and to have been married, which is
consistent with epidemiological studies of SMI (Bromet & Fenning,
1999). No differences were found across diagnostic groups with
respect to ethnicity or education. Older adults with schizophrenia
were significantly more likely to reside in supervised or supported
housing, despite the study requirement that participants with mood
disorders have persistent functional impairment.
Baseline psychosocial functioning and health status are shown in
Table 5. Participants in the four diagnostic groups did not differ
significantly on any measure of baseline psychosocial functioning.
These findings confirm the uniform application of the study eligi-
bility criteria requiring at least moderate functional impairment,
consistent with clinical eligibility for services under the category
of ‘‘serious mental illness.’’
In contrast to the similarity in psychosocial functioning across
the four diagnostic groups, differences were found with respect
to subjective health status. Individuals with major depression
reported the poorest subjective physical and mental health status.
Poorer subjective physical health status may reflect the negative
impact of depression on perceived health, independent of actual
health status (Lyness et al., 2006; Sullivan et al., 2004). The finding
of worse subjective mental health status in people with major
depression compared with schizophrenia may reflect the substan-
tial overlap of SF-36 psychological items with depression and
anxiety symptoms in individuals with chronic medical illness
(Surtees et al., 2003).
 TABLE 4. Baseline demographic characteristics by diagnostic group

Schizophrenia Schizoaffective Major Depression Bipolar

(n ¼ 51) Disorder (n ¼ 52) (n ¼ 44) Disorder (n ¼ 36) F-Test, p Level

Age (mean, sd) 60.77 (7.951) 56.89 (5.878) 61.77 (9.273) 62.07 (7.508) 4.621, .004
Chi-square,
p level
Female gender (n, %) 19 (37.3) 28 (53.8) 33 (75.0) 26 (72.2) .001
Marital Status (n, %)
Never married 29 (56.0) 25 (48.1) 6 (13.6) 5 (13.9) .000

55
Ever married 22 (44.0) 27 (51.9) 38 (86.4) 31 (86.1) .000
Ethnicity (n, %)
Caucasian 43 (84.3) 42 (80.8) 40 (90.9) 32 (88.9) .219
Education (n, %)
Completed high school 38 (74.5) 41 (78.8) 29 (65.9) 26 (72.2) .552
Did not complete high school 13 (25.5) 11 (21.2) 15 (34.1) 10 (27.8) .552
Residential Status (n, %)
Independent 14 (28.6) 26 (50.0) 31 (72.1) 23 (63.9) .000
Supervised=supported housing 37 (71.4) 26 (50.0) 13 (27.9) 13 (36.1) .000
 TABLE 5. Baseline psychosocial functioning and health status

Schizoaffective Major Bipolar F-Test,

Schizophrenia Disorder Depression Disorder p Level

Psychosocial Functioning
Independent living skills (ILLS) .64 (.107) .66 (.108) .67 (.110) .67 (.077) 1.043, .375

56
Community functioning (multnomah) 3.74 (.508) 3.74 (.465) 3.50 (.499) 3.72 (5.62) 2.309, .078
Social functioning (SBS) 33.86 (5.389) 34.71 (6.696) 33.89 (6.34) 32.11 (4.439) 1.417, .239
Health Status
Physical (SF-36 PCS) 50.19 (10.637) 46.16 (13.245) 43.02 (11.279) 48.42 (9.707) 3.389, < .05
Mental (SF-36 MCS) 45.68 (10.571) 37.80 (13.120) 36.22 (12.421) 40.45 (12.726) 5.633, .001
 Helping Older People Experience Success 57

Outcomes of the randomized trial of HOPES are pending.

However, data on retention in the intervention and study and
participation in the intervention are encouraging. Retention in the
study has been excellent, with 165 (90%) of the 183 randomized
clients still actively participating in follow-up assessments over
the 3þ years of the study. Attrition has been equal across both
groups and is primarily due to nursing home admissions (50%)
and deaths (22%). Of the 90 participants who were randomized
to the HOPES program, 86 participated in at least one session.
Attendance overall was high, with mean receipt of 72% of the year
1 sessions, including group and one-to-one skills training sessions.

CONCLUSIONS

Older adults with SMI who are receiving mental health services
have substantial needs with respect to both psychosocial function-
ing and health. The HOPES intervention is designed to address
critical skills that are necessary for living in the community, including
skills for independent living, interpersonal relationships, and
health behaviors, while also providing assistance in acquiring
needed preventive health care. Psychosocial rehabilitation interven-
tions for older adults with SMI are developing slowly, but consider-
ing the growing number of these individuals, such programs are of
critical importance for future mental health services. Experience
with the implementation of the HOPES program across three
centers in the context of a randomized controlled trial supports
the feasibility and acceptability of this integrated model of psycho-
social rehabilitation and health care management. An evaluation of
the effectiveness of the HOPES program and other models address-
ing the psychosocial and medical needs of aging persons with SMI
are needed to inform future services and health policy for this
growing population (Bartels, 2003, 2004).

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