Clin-STAR Journey Story

Bridging Disciplines: Combining Behavioral Sciences with Gerontology to Shape Health Outcomes for Underserved Older Adults

Karen L. Fortuna, PhD, LICSW, is an Assistant Professor in the Department of Psychiatry at Dartmouth’s Geisel School of Medicine. She has built her career by developing innovative interventions for people with serious mental illness (SMI). This population rarely reaches chronologic old age, experiences earlier disease onset, a myriad of comorbidities, and premature nursing home placement. Curious about what this might suggest about the aging process, Dr. Fortuna decided to apply for a Clin-STAR pilot grant.

“We have known about this health disparity for over 100 years—that people with SMI generally die around the age of 50,” she said. “Even when I decided to submit the Clin-STAR grant application, I thought, ‘does this even count as an aging-related project?’” Recognizing the health disparities faced by “older” adults with SMI, Dr. Fortuna designed a study to promote aging in place. “Like any other older adult, people with SMI also want to age in place,” said Fortuna. Collaborating with a supportive housing organization, the Bridge, in New York City, her team deployed a 12-week intervention program that combined a mobile app with peer support.

“We know from decades of research that peer support specialists can get other people to engage in intervention programs. That is what they do,” she said. She tapped the power of peer support by hiring and training older adults with a lived experience of mental health challenges to deliver evidence-based practices to other people with SMI.

The big surprise—especially because Dr. Fortuna serves on the American Psychological Association’s Office of Health Care Innovation National Advisory Committee for Mental Health Technology—was that participants didn’t care about the app. “They wanted human connection---they wanted telephone calls from their peers,” she said. “They wanted to interact with people who were similar to them. So we dropped the app and went straight to telephone calls.”

Throughout the 12-week program, the results showed promising evidence of promoting aging in place and improved medication adherence. The results proved so promising that she submitted an R01 application to the National Institute of Mental Health to expand the program.

The program’s approach is not only innovative but also scalable. “I developed this training and tapped into insurance through Medicaid and Medicare. Peer support is now Medicare reimbursable in all 50 states, which is exciting for scale.” Fortuna acknowledges the challenges in establishing robust evidence for her interventions. “As far as the science, I have to hold back a bit because we don’t have the big 500-person randomized controlled trial showing that it’s effective,” she said. “But people are already saying ‘Give me this. I want this,’ which is exciting.”

Dr. Fortuna described the pivotal role that Clin-STAR played in expanding her professional horizons as “one of my top career-changing experiences.” “I met people at the annual meeting that have literally changed my life over the course of the year,” she said. “It’s the people at the Clin-Star meeting, through their focus on mentorship and their network, who afforded me an opportunity to take aging research and apply it to more vulnerable populations.”

For example, after listening to Dr. Thomas Gill’s presentation, his work inspired me to conduct a study on frailty in individuals with serious mental illness. I had never thought about frailty in people with SMI before his talk. We designed and implemented a study that showed that their rates of frailty were 20% higher than in the general population, and frailty manifested earlier in this vulnerable subgroup! This is a huge unmet need that has not adequately been explored with a population of people with health disparities. Now, as a Health and Aging Policy Fellow, Dr. Fortuna is integrating policy into her research and calling for integrating primary care into community settings to support older adults.

She also ran a study with her mentee, Ms. Julia Hill, on accelerated aging in people with SMI. In a forthcoming systematic review, they found that behavioral interventions impact biomarkers of accelerated aging.

She acknowledged the great intellectual divide between her social work background and the gerontological focus of others. “We speak different languages. They’re talking about the mechanisms of aging, and I’m a health services researcher looking at hospitalizations and integrated care within community settings,” she said. “But I’m a risk taker. Why not combine the two and look at something that’s rarely been explored?”

Disciplines aside, Dr. Fortuna was struck by the collaborative atmosphere of the Clin-STAR program—and how that led to new collaborative partners. “At the Clin-STAR meeting, people kept coming up to me saying that I needed to meet Malaz [Boustani]. They kept saying ‘You guys think similarly,’” she said. Her collaboration with Dr. Boustani has continued beyond the Clin-STAR program. “Malaz has changed the way I think about research and the world. I am beyond grateful for him and his mentorship.” Dr. Fortuna was invited to enroll in Indiana University’s Agile Implementation Science Course, and she has met with Dr. Boustani every week for two years and has learned how to integrate agile science into health systems.

As a gerontological social worker, Dr. Fortuna emphasized how Clin-STAR has broadened her perspective. “This is not the normal aging stuff that I had been previously exposed to. It took my thinking to another level,” she said. “It’s expanded my knowledge, which I am trying to disseminate to my mentees who are in the process of getting their social work and public health degrees.”

Dr. Fortuna envisions better integrating behavioral sciences into her research, with a focus on gerontology to empower patients on a broad scale. “We want to merge the behavioral sciences with gerontology to create a patient-powered research network that investigates early death in people with SMI,” she said. This is a similar setup to the super-agers study that she learned about at the Clin-STAR annual meeting. She plans to develop a database with patient partners to explore longevity with SMI.

“We can rapidly run comparative effectiveness studies with a database that’s built by people with SMI on our governance board and they can propose research questions that we have not considered.”

Her passion for integrating different perspectives orients her vision for both advancing scientific knowledge and improving the well-being of aging populations. “Because of Clin-STAR, I can now ask questions of my new network of collaborators; and together, we can make new discoveries that advance the care of people with SMI.”