BUILDING STATE AND COMMUNITY MENTAL HEALTH AND AGING COALITIONS A "HOW-TO" GUIDE Prepared By The National Coalition on Mental Health and Aging _________________________________________________________________ Acknowledgements The National Coalition on Mental Health and Aging would like to pay special recognition and thanks to the following individuals and resources for their contributions in the preparation of this manual: Mark Narvaez, AARP Area Health Representative, and Bob Rawlings, Director, OBRA and Long-Term Care, Oklahoma Department of Mental Health and Substance Abuse Services, for their work in designing and developing the manual; Jo Anna Deighton, AARP Health Advocacy Services State Coordinator for her initiative in establishing the Oklahoma Mental Health and Aging Coalition, a model of state coalition-building around this issue, and for her "seasoned" input in the preparation of this manual; LaDonna Reeves, AARP Administrative Assistant, for patience and persistence in shaping the manual through several drafts to completion; Nancy Coleman, Chairperson of the Coalition, for her on-going leadership, support and suggestions; and Charlotte Mahoney, AARP Senior Program Specialist, Social Outreach and Support, for her advocacy, editing and encouragement in completing the final product and. Finally, the Coalition would like to acknowledge the "Handbook on Coalition Building" developed by the Ohio Center for Action on Coalition Development and adapted by the National Association of Area Agencies on Aging for the Administration on Aging, which served as a reference and resource in the preparation of this manual. For additional copies of this manual, or for more information about the Coalition on Mental Health and Aging, contact the Coalition on Mental Health and Aging, c/o Social Outreach and Support, AARP, 601 E St. NW, Washington, DC 20049, 202-434-2260. December 1994 _________________________________________________________________ TABLE OF CONTENTS Section I: Mental Health and Aging Issues: The Case for Community Coalition Building Section II: Purpose and Benefits of Establishing State and Community Mental Health and Aging Coalitions Section III: Building State and Community Mental Health and Aging Coalitions: Components and Considerations * Identification of Players and Partners * The Initial Meeting * Beyond the Initial Meeting: Tips for Maintaining Momentum * Turf Issues * In Conclusion _________________________________________________________________ MENTAL HEALTH AND AGING ISSUES: THE CASE FOR COMMUNITY COALITION BUILDING There are currently about 32 million persons age 65 years or older in the United States, or about 12.5% of the population. While the majority of older persons are functioning quite well physically, emotionally, psychologically, economically, and socially, leading satisfying and productive lives, a significant portion, estimated at 10% to 20% in a given year, have mental health problems that affect the way they live, their family and social relationships and their involvement in the community. It has been estimated that currently there are between 3.2 and 6.4 million older Americans whose mental and emotional problems are serious enough to warrant either professional care or involvement in organized self-help programs. Among the most prominent mental health conditions experienced by older persons are the following: * Depression is a prevalent mental health problem among older persons living both in the community and in nursing homes. It is estimated that approximately 15% of community residents suffer from depressive symptoms and 1 to 2% from major clinical depression. The rates of minor or major depression among nursing home residents range from 15% to 25%. * Suicide by the older persons is a major mental health concern in the United States, with older persons committing 20% of all suicides, while comprising 12.5% of the total population. In addition, the suicide rate for those persons aged 65-74 was 16.9 per 100,000; 23.5 for persons 74- 84, and 24.0 for those 85 years or older. * Alcohol abuse is estimated to be a serious problem for 1.2 to 2.3 million older people. * Polypharmacy and misuse of prescription medications is another concern, with older persons consuming more over-the-counter drugs than any other age group. * Anxiety disorders are estimated to affect 5% of older adults, with anxiety symptoms affecting between 10%-20% of persons age 65 and over. * Many persons with chronic serious mental illness now live into old age, with many joining the ranks of the homeless or being placed in board and care homes. * Cognitive impairment is found in as much as 15% of persons aged 65 and over, and in as many as 30% of those over age 80. * Dementia increases from less than 1% of people under age 65, to about 1% for those 65-74, 7% of those age 75-84, and 25% of those over age 85. * Other related emotional difficulties often experienced by older persons include bereavement and coping with personal loss, social isolation, sleep disorders, psychosexual disfunction and caregiver issues. And yet, while the majority of mental health conditions and emotional difficulties experienced by older persons can be successfully treated through a variety of community-based out-patient interventions, the sad fact is that the mental health needs of American's older population are going largely unattended. The most prevalent impediments to mental health service delivery, intervention and treatment for older persons are the following: * Older persons are often reluctant to seek service due to the stigma associated with emotional disorders and mental illness; * Ageism, or the commonly held belief that specific mental health conditions experienced by older persons are part of normal aging, and are not treatable; * The lack of federal and state support for community-based prevention mental health programs for older persons, and the concurrent scarcity of institutional treatment programs specifically targeted at older residents; * Inadequacy of private health insurance coverage of mental health treatment and limitations in the Medicare program in providing for out- patient mental health benefits; * Fragmentation and lack of coordination between mental health and aging services networks; * Lack of an organized constituency to advocate for expanded funding and the development and provision of mental health service, intervention and treatment for older persons; * Scarcity of coordinated caregiver support services including caregiver instruction and support groups, available respite care, and coordinated information and referral services of community based intervention and treatment programs, and * Lack of professional staff trained in geriatric mental health issues and treatment modalities, including physicians, mental health professionals, and persons working in programs for the aged. For these and many other reasons, the establishment of state and local coalitions that are focused on issues of mental health and aging, and comprised of a broad base of concerned citizens, public and private practitioners, mental health and aging service providers, advocacy organizations, public officials and others, is indeed timely and greatly needed. Only through such coordinated efforts can increased awareness and attention be brought to bear, such that appropriate programming, legislative and fiscal remedies are discussed and developed in addressing the significant needs of older persons experiencing mental health difficulties. It is hoped that this "how-to" guide to building state and local coalitions on mental health and aging will serve as a useful resource to those interested in providing increased leadership and enhanced coordination in improving the availability, accessibility and quality of mental health preventive and treatment services to older Americans and their families. _________________________________________________________________ PURPOSE AND BENEFITS OF ESTABLISHING STATE AND COMMUNITY MENTAL HEALTH AND AGING COALITIONS We presently find ourselves at a point in time when we are increasingly being asked to do more with less. Human service networks and delivery systems, like the private sector, are more and more caught up in the ethic of making our organizations "leaner and meaner," while being asked to "work smarter, not harder." The day of diminishing resources in the shadow of expanded expectations and increased competition, has been felt in both the private and public sectors, and has resulted in an interest, and indeed, necessity, to develop new strategies, while updating old approaches to fulfilling our various organizational missions and objectives. In this milieu, the knowledge that the whole is greater than the sum of its parts, has contributed to a renewed recognition of the value and benefits of coalition-building. Coalition is a process by which "organizations work together in a common effort for a common purpose in order to make more effective and efficient use of resources. Coalitions tend to bring together unlike organizations within an informal structure." Usually, but not always, coalitions differ from other similar structures such as alliances, in the duration of their activity or in the range of activities in which the member organizations are involved. The potential benefits of working in coalition which are often cited included: * Resource coordination: Coordination of the resources of several agencies or organizations can serve to expand both the reach and the effectiveness of the resources that may be available through a single program. Resources which can be shared and mutually enhanced include staff skills, publications, media contacts, provider networks, equipment and facilities, services, knowledge and experience. * Improved collaboration: Through the process of sharing information, organizations and agencies can become more aware of each others' programs, the relationship among each others' services, and thereby address the fragmentation and lack of coordination which often exists through lack of awareness and misconception. This is especially true in the arena of mental health and aging, where though the "aging network" is probably the most expansive and coordinated network in human services, its experience in collaborating with the "mental health network" is a relatively new frontier, especially as concerns meeting the mental health needs of older persons. * Professional development: By interaction with colleagues from other organizations and service networks, staff members' knowledge-base of available resources can be enhanced, which can significantly impact the overall quality of service delivery to each one's client population. * Credibility and clout: When human service organizations from several service networks come together to pursue common goals and objectives, their credibility in the eyes of the general public, public officials, legislators and others is enhanced. With such enhanced public image and profile, the total impact or "clout" of the coalition can be significant, especially in the areas of building a more broad-based constituency, increasing public awareness of the issues, activities and services represented by the coalition, impacting public policy through more effective legislative advocacy, and influencing expenditures, appropriations and grant opportunities in both the public and private sectors. * Strategic planning: The development of more comprehensive needs assessment information can also be a real benefit of coalition-building. Through mutual sharing of each coalition members' needs assessment and service planning information, more accurate and effective short- and long-term range strategic planning can take place. In addition, existing service gaps can be better identified and addressed, and prioritizing of critical issues to be worked on by the coalition can be discussed. The potential for successful and effective coalition-building around issues of mental health and aging is especially timely and promising. While the "aging network" has flourished since the dawn of the Older Americans Act, only recently has focused attention been given to addressing the mental health needs and issues facing older persons and their families. We have only begun to recognize the potential and benefits of collaboration between the "aging network" and partners in the mental health arena at the state and local level. To some extent this has been due to the lack of an organized and identifiable mental health and aging constituency. However, it is more likely due to the reality that service networks and their professional staff members are as vulnerable to commonly held age biases, stereotypes and misconceptions, as is the general public. The climate of awareness is, however, changing, and is particularly ripe at this time for a variety of networks, organizations, advocates and individuals to coalesce on behalf of older persons and their families in addressing critical mental health and aging needs and issues. In the following section, we will outline some of the considerations and activities which may contribute to building successful and effective state and community mental health and aging coalitions. _________________________________________________________________ BUILDING STATE AND COMMUNITY MENTAL HEALTH AND AGING COALITIONS: COMPONENTS AND CONSIDERATIONS The decision to form a coalition is generally the result of the initiative taken by an individual or organization, having recognized the necessity to address a particular need or issue. In making this decision, there is also the recognition that reaching a specific outcome or completing a particular project would be facilitated through the collaborative effort of several agencies, organizations or human service networks rather than unilateral action or a temporary alliance of a few project partners. The establishment of a state or community mental health and aging coalition may be a deliberate pre-planned event in anticipation of achieving a number of long-term outcomes, or may be an outgrowth of an immediate, specific activity or project involving initially only a handful of collaborators. So too, can a state-wide coalition be borne out the success achieved by a more regional or community coalition. The success in forming a coalition also hinges to a great degree on the level of credibility and commitment demonstrated by the individual or organization initiating the activity. Similarly, if the involvement of either aging or mental health networks is minimal or perfunctory, the shared commitment and vision which acts as the "glue" for coalition stability may be threatened, and the credibility of the coalition will be suspect. Identification of Players and Partners Successful collaboration and coalition-building rests on the tenet that each person or organizational member represents a reservoir of resources, knowledge, experience and ideas, and has something of value to offer to the effort. Assuring for broad-based representation on the coalition is critical, not only for reasons of establishing credibility, but also for securing broad-based grassroots support for the activity, making sure coalition membership is representative of the variety of aging and mental health constituent and client groups, and keeping the coalition aware of possible "blind spots" in its direction and activities. All coalition members should feel that they play an integral part in the life and momentum of the coalition, and have a stake in its on-going vitality, and movement towards mutually identified outcomes. In identifying coalition members, it is important to recruit not only natural allies who share a particular vision or common concern or viewpoint, but also all manner of individuals, organizations and networks who have a stake in the issue or activity and are likely to be impacted by it, whether positively or negatively. In recruiting prospective coalition members, the individual or organization taking the initiative must be clear about how the members of other agencies, their particular organizational missions, their public image and profile, or the common issue or activity, will be enhanced through their participation in the coalition. This must be clearly communicated to each prospective member, as well as possible short and long term goals. While communicating the scheduled date, time and location of the initial meeting, it might also be useful to ask that each prospective member come to the initial meeting prepared to briefly state their anticipated stake in the effort, what they could contribute to the cause or activities, and what they would like to get out of their involvement. It should always be remembered that for all individuals and organizations time is at a premium and is a valuable commodity. The following is a list, though not inclusive, of prospective partners in a mental health and aging coalition: * Hospitals * Private Practitioners * State Units on Aging * Religious Organizations * The Veterans Administration * Area Agencies on Aging * Adult Protective Services * Home Health Care Agencies * Adult Day Health Care Centers * Minority Advocate Organizations * Physicians and Nurse Practitioners * Community Mental Health Programs * Universities and Community Colleges * Legal Aid and Assistance Representatives * Health Reporters and Media Representatives * Alcohol and Drug Abuse Treatment Centers (inpatient and outpatient) * Geriatric and Mental Health Social Workers * State and Community Mental Health Alliances * State and Community Public Health Departments * State and Community Departments of Human Services * State Departments of Mental Health and Substance Abuse * State and Local Extensions of the Alzhiemers Disease and Related Disorder Associations * State Representatives, Public Officials and other Legislators * Senior Advocate Organizations such as AARP, NARFE, Older Womens League, etc. * Senior Centers and Congregate Nutrition Sites for Older Persons * Many others The particular range of prospective coalition members will of course be dependent on the scope of the coalitions activities, the duration of its activity, and the specific short- and long-term goals and objectives which have been mutually identified and agreed upon. The Initial Meeting During the initial phases of the establishment of a mental health and aging coalition, it is important to address several specific organizational issues which may serve as the foundation of the coalition's work and ultimately contribute to its vitality, momentum and success. These organizational considerations include: Coalition Goals: Probably the most important single activity in establishing a mental health and aging coalition is the determination of its goals and objectives. Sufficient time should be taken at the initial meeting for a discussion of group goals and how each members' individual goals may be blended into the coalition goals. In considering the diversity of individual goals which may be discussed, it may be prudent to mutually agree on a "mission statement" and a set of guiding "principles" under which the coalition could conduct their activities. It may also be useful to agree on immediate, short-term goals as well as future, long-term goals, based on mutually agreed upon priorities. In general, the agreed upon goals should be attainable, tangible, time- defined, and should represent a "win-win" outcome for both the coalition, as well as each member. It may be necessary and recommended that a review of the coalition's mission and goals be conducted on a regular basis, making appropriate modifications as areas of emphasis change, anticipated outcomes are achieved, or new goals identified. All such revisions should of course be done with the consensus of coalition representatives. Finally, a group's goals are never totally compatible with the goals of each organization or person involved. Each member, therefore, must be willing to compromise or modify his or her commitment to specific goals. Examples of coalition goals might be: * To work together to improve access to community mental health services for our state's older citizenry and their families. * To strive to improve the system of community-based care. * To advocate for public policy changes in Medicaid regulations governing reimbursement rates to mental health centers. * To create more community awareness of mental health issues facing older persons and their families, while debunking inaccurate stereotypes and commonly held misconceptions of mental health and normal aging. Progress towards goals, and a shared sense of accomplishment cannot be overstated as a primary driving force in maintaining coalition cohesion, cooperation and momentum. It is therefore important to structure measurable objectives addressing goals, and related action steps in such a way that "little victories" and successes are achieved at regular intervals. For this reason, it is suggested that short-term goals be designed in small "bite-size" increments, and are interwoven with activity on more global, long-term goals. An example here might be: * To have at least three workshop sessions on mental health and aging issues included at this year's state conference on aging. - or - * To conduct at least one in-service training on mental health and aging issues, and available community resources, with senior center directors, utilizing coalition expertise as trainers. There is no better avenue by which to assure coalition stability, momentum and member enthusiasm than the development of sound, realistic and attainable goals. Identifying and Coordinating Member Resources: Coalition members bring with them a wealth of resources to share, all or many of which may facilitate movement towards agreed upon coalition goals. These resources could range from staff expertise, experience, and key media and legislative contacts, to more material resources such as equipment, facilities, publications, needs assessment data, demographic information and other more tangible resources. It may be worthwhile, at the outset of coalition development, to conduct a formal survey of what each organization is willing to "bring to the table." Such a survey may be conducted in interview fashion or through written input. Either way, all coalition members should be provided, in short time, with a listing of the resources which each is willing to coordinate on behalf of the coalition's mission and goals. A roster of all members with contact information should, of course, be provided to all as soon as possible, and should be updated as a matter of course. Identifying On-Going Activities: Once the coalition mission statement and/or specific short and long term objectives have been determined, it is then important to decide on measurable objectives, and related activities which will further the coalition's "agenda." As has been indicated earlier, it is recommended that the coalition outline both short- and long-term objectives and related action steps, as a way of assuring incremental successes, maintain coalition momentum, and thus, "keep the wheels turning." It is also recommended that on-going activities be diversified. Outcomes in some areas such as public policy change or advocating for increased appropriations to community mental health programs for the aged, may be harder and take longer to attain. In contrast, objectives in other areas such as increased media attention, enhanced public awareness of mental health and aging issues, or distribution of available community resource information at a local health fair are usually more readily attainable. Examples of general categories of prospective mental health and aging coalition concentration and specific activities within each are: Public Awareness/Media Coordination + Improve accessibility and utilization of state and community mental health services for older people through increased public awareness. + Develop a directory of community mental health and aging services for the older person for distribution to senior centers, nutrition sites, public housing programs, health fairs and other settings and opportunities as appropriate. + Develop brochures, for statewide distribution, which address commonly- held mental health and aging myths, stereotypes and misconceptions, and which promote the activities of the coalition. + Establish a 1-800 telephone number for information and referral to state and community mental health and aging services. + Work with local electronic media to develop public service announcements aimed at dispelling commonly-held myths, stereotypes and misconceptions of mental health and aging issues, while promoting available community programs. + Identify and participate in local radio and television "talk shows" in order to discuss mental health and aging issues, and promote local services and resources. + Work with local newsprint media to develop a regular mental health and aging column to discuss pertinent issues, dispel misconceptions and promote available services. Education + Develop a "track" at the state conference on aging and state mental health convocation on a variety of current mental health and aging issues. + Establish a speakers bureau of coalition member expertise and promote their availability to speak before civic and community groups, service organizations, in-service training, etc. + Develop regular "gatekeeper" community education training aimed at creating more awareness of mental health and aging issues, symptomatology and available community resources, and targeted at natural community gateskeepers such as postal workers, apartment managers, utility workers, physicians and others. + Establish provider cross-training opportunities whereby coalition member and other identified experts can instruct senior center staff, nutrition program directors, nursing home personnel and others on mental health and aging issues, symptomatology, referral sources and community resources. + Plan, develop and conduct a community caregiver conference aimed at educating family caregivers and interested others on mental health and aging issues, coping skills and strategies, and available community resources. Interagency Coordination + Increase linkages and partnerships between aging, mental health, consumer, family, professional and governmental organizations and networks. + Sponsor regular regional gatherings of mental health, aging and other human service organizations and providers to discuss service coordination, existing service gaps and other continuum of care issues. + Promote and facilitate the establishment of regional and community mental health and aging coalitions. Research + Work with state, public and private educational institutions to promote increased attention and sponsorship of social science research focused on mental health and aging service delivery and utilization issues, caregiver considerations, etiology of mental illness among the aged, effective treatment and intervention factors, and factors contributing to mental wellness, etc. Legislation + Conduct visitations with state legislators in order to educate and increase their awareness and commitment to addressing mental health and aging issues through enlightened public policy development. + Establish a legislative data bank of sample public policy from other states which may serve to provide a focus for the development of an in- state legislative advocacy agenda on public policy development, revision and regulation. + Advocate to increase state Medicaid reimbursement to mental health service providers involved in the treatment of older persons with mental and emotional illness. + Promote the proclamation of an annual state-wide Mental Health and Aging Awareness Day in conjunction with numerous advocacy and educational activities at the Capitol focused at creating expanded awareness among legislators of aging mental health issues, needs and services. + Organize an annual Mental Health and Aging Day at the Capitol featuring mental health and aging service provider information booths, a rally, briefings for legislators and the general public on salient issues, needs and enlightened public policy etc. + Sponsor, plan, organize and conduct a Mental Health and Aging Legislative Public Hearing at Capitol House chambers to solicit expert and general public testimony on mental health and aging issues, needs, service utilization, funding, public policy, programs, etc. Planning + Coordinate available demographic, service utilization and needs assessment data for purposes of developing a comprehensive state-wide planning document of aging mental health needs, service delivery utilization, gaps and characteristics, client population profiles, public policy priorities, etc. Resource Development + Identify and work with private and public sector organizations, businesses, foundations and other funding sources to advocate for increased targeting of resources for mental health and aging services, programs and coalition activities. Resources may include grants, volunteer support, corporate sponsorships, in-kind contributions, contributed services and others. In addressing the various categories of on-going activities and projects, the coalition may choose to establish sub-committees or ad hoc task forces to address them and assure follow-through. Coalition members may either be appointed to or self-select sub-committee involvement based on their interests, experience and/or particular skill. The committees may be permanent or "standing" in nature, or "ad hoc," depending on the anticipated duration of its activity. Sub-committee chairpersons may also be appointed by the coalition chairperson, facilitator or convener, may be identified through general consensus of coalition members, or may be selected by members of that particular sub-committee. Beyond the Initial Meeting: Tips for Maintaining Momentum Just as with any human enterprise, the coalition functions as a "living organizational organism" and is therefore subject to the same, natural peaks and valleys of interest, activity and commitment. Through carelessness, lack of appropriate and timely communication, disregard for on-going consensus building, and a shared sense of direction, accomplishment and recognition, a coalition may flounder and, ultimately cease to function effectively, and at worst, disband. There are, however, a number of on-going practices and procedures which may be institutionalized to constantly maintain the vitality, vibrancy and renewed commitment within the coalition and its members: * Determine early in the coalition-building process, mechanisms for sending out notices, recording and disseminating meeting minutes, and procuring reports from established standing and ad hoc sub-committees. * Provide opportunities for all coalition members to suggest items for discussion in shaping each meeting's agenda. * Consider setting up a "telephone tree" structure in the instance that an emergency meeting is required or immediate legislative advocacy action is required. * Consider establishing an executive committee including a coalition chairperson or facilitator, co-chair or vice president to maintain communication with sub-committees and a permanent or rotation secretary to coordinate and disseminate meeting minutes. Determine if a member of the group could provide some part-time staffing. * Permit ample time at coalition meetings for general discussion of all agenda items. * Review the coalition's mission statement, goals and progress towards objectives on a regular basis in order to renew commitment, maintain focus and redirect as needed. * Recognize coalition members as a whole, particular individual contributions, and sub-committee accomplishments on a regular basis. * Recognize external coalition contributions on the part of individuals, organizations, businesses, foundations, legislators, public officials, media and others. * Organize non-business-related activities where coalition members may be able to interact more informally. Coalition involvement can also be fun, while networking is reinforced. Turf Issues "Turfism" is defined as a state or situation of non-cooperation or conflict between organizations with seemingly common goals or interests who in most circumstances would be expected to work together. The term "turf issues" originally comes from street gang terminology, and refers to the territory or "turf" in which a particular gang operates. In like fashion, each organization also has its own domain in which it operates, the parameters of which are generally defined by its stated mission, goals and objectives as well as available resources. On occasion, organizations involved in partnerships or coalition perceive a threat to their organizational goals and resources which may result in a perceived need to defend one's turf or a "turf battle." Such conflicts generally represent the feeling by one or more organizations that it has more to lose from continued cooperation or participation in coalition than if it were to go its own way. "Turf battles" may arise for several reasons. Among the most common are: * The perception by one organization that another is a competitor for resources which are not likely to be shared fairly or equally. Such resources may include funds, staffing, supplies, coalition support, facilities, etc. In some cases, the issue may not concern how much an organization gains by collaboration, but instead how much it stands to lose or is expected to contribute. * A determination by an organization that there may be a significant "cost" in money, time, energy or public perception which outweighs the relative benefits of collaboration. * Often while collaborating organizations may be in agreement over a mutually determined mission, goals and objectives, they may differ considerably on the methods in reaching them. In many instances, identified methods may be viewed as overly aggressive, potentially counter-productive or ultimately ineffective. * The most common reason for turf conflict is generally found when a particular coalition goal is perceived to "go against the grain" of a member's organizational goals, or when they feel their individual organizational goals are not being furthered or addressed by the coalition. In all these cases, there are considerations and practices which may circumvent the rise of turf conflicts: * Reminding members that while the mission of any coalition is to assist, support and further the goals of individual organizations, this can never be done with 100% compatibility to the coalition's mutually determined goal. Compromise is the key, and "give and take" is always necessary. * It is a good idea and practice to "check-in" with coalition members, at regular intervals, on their perception of the direction in which the coalition is moving, revisit and revise goals where necessary and assess methods, strategies and outcomes. Such a practice keeps goals and objectives timely and meaningful, reinforces member "buy-in" to the coalition, and helps to maintain a vitality and "freshness" to coalition activity. * Establishing subgroups, committees or ad hoc task forces keep all members active and involved in the life of the coalition, rather than passive, non-contributing partners. * Making sure that those organizations invited to become coalition members can provide support for the coalition's mission is critical. The effectiveness of the coalition does not fall on the breath of its membership, but instead on the depth of its cohesiveness and feeling of common cause. Immutable organizations which have only a partial or marginal relationship to the coalition mission may nullify its momentum, create dissension, and ultimately be destructive to coalition cohesion, direction and effectiveness. While differences between organizational members of a coalition can be expected, in a well planned effort and with on-going "maintenance and sustenance" practices, these differences and disagreements can actually serve to reinforce, renew and revitalize a coalition's on-going activity, momentum and movement toward its stated mission. In Conclusion Building coalitions at the state and local levels provides unique opportunities to break through existing barriers in mental health and aging -- be it ageism, stigma, lack of understanding, inadequate funding, and limited services. All of those with a stake in mental health and aging -- the aging network, the mental health community, consumer groups, legislators, government agencies, professional groups, religious groups -- can become partners and work together through public education, public awareness, and education of policy makers to bring accessible, affordable, quality mental health services to older people and their families in their own communities. For more than a decade, the mental health and aging field has experienced important developments, including the mental health recommendations at the 1981 White House Conference on Aging and the follow-up to them, the coalescing of national groups through the Coalition on Mental Health and Aging, the growth of public awareness of the efficacy and effectiveness of mental health services for people of all ages, and the health care reform debate, with Tipper Gore providing the mental health leadership. And, State and regional mental health and aging events and convenings on the occasion of the 1995 White House Conference on Aging, including the Emerging Issues in Mental Health and Aging Mini-Conference, will continue to forge new directions. We urge you to build upon this new paradigm. Build state and community coalitions -- an effective strategy to keep this momentum going as we move toward the next century