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Suggested Citation:"Front Matter." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

THE MENTAL HEALTH
AND SUBSTANCE
USE WORKFORCE FOR
OLDER ADULTS

image

IN WHOSE HANDS?

image

Committee on the Mental Health Workforce
for Geriatric Populations

Board on Health Care Services

Jill Eden, Katie Maslow, Mai Le, and Dan Blazer, Editors

INSTITUTE OF MEDICINE
                OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu

Suggested Citation:"Front Matter." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

This study was supported by Contract No. HHSP23320042509XI between the National Academy of Sciences and the Department of Health and Human Services. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the organizations or agencies that provided support for the project.

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Suggested citation: IOM (Institute of Medicine). 2012. The mental health and substance use workforce for older adults: In whose hands? Washington, DC: The National Academies Press.

Suggested Citation:"Front Matter." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

“Knowing is not enough; we must apply.
Willing is not enough; we must do.”

                                                                       —Goethe

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INSTITUTE OF MEDICINE
                         OF THE NATIONAL ACADEMIES

GoetheAdvising the Nation. Improving Health.

Suggested Citation:"Front Matter." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

THE NATIONAL ACADEMIES

Advisers to the Nation on Science, Engineering, and Medicine

The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.

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The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.

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Suggested Citation:"Front Matter." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

COMMITTEE ON THE MENTAL HEALTH
WORKFORCE FOR GERIATRIC POPULATIONS

DAN G. BLAZER (Chair), J.P. Gibbons Professor of Psychiatry and Behavioral Sciences, Vice Chair for Education and Academic Affairs, Duke University Medical Center, Durham, NC

MARGARITA ALEGRÍA, Director, Center for Multicultural Mental Health Research, Cambridge Health Alliance and Harvard Medical School, Somerville, MA

MARÍA P. ARANDA, Associate Professor; Chair, Older Adult Subconcentration, School of Social Work, University of Southern California, Los Angeles

STEPHEN BARTELS, Director, Dartmouth Centers for Health and Aging, Lebanon, NH

CHRISTINE E. BISHOP, Atran Professor of Labor Economics, Heller School for Social Policy and Management, Brandeis University, Waltham, MA

FREDERIC C. BLOW, Professor and Director, Mental Health Services Outcomes & Translation Section, Department of Psychiatry, University of Michigan; Director, National Serious Mental Illness Treatment Resource Center, Department of Veterans Affairs, Ann Arbor

KATHLEEN C. BUCKWALTER, Professor Emerita, University of Iowa College of Nursing; Codirector, National Health Law and Policy Resource Center, University of Iowa College of Law, Iowa City

CHRISTOPHER M. CALLAHAN, Professor, School of Medicine, Indiana University, Scientist, Regenstrief Institute, Inc., Indianapolis

ANNI CHUNG, President and Chief Executive Officer, Self-Help for the Elderly, San Francisco, CA

GARY L. GOTTLIEB, President and Chief Executive Officer, Partners HealthCare System, Inc., Boston, MA

MICHAEL A. HOGE, Professor of Psychiatry (in Psychology), Yale University School of Medicine, New Haven, CT

OCTAVIO N. MARTINEZ, Executive Director and Clinical Professor, Hogg Foundation for Mental Health, The University of Texas at Austin

WILLARD MAYS, Mental Health and Aging Consultant, Indianapolis, IN, and Past Chair, National Coalition on Mental Health and Aging

PETER V. RABINS, Richman Family Professor, Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD

MARK SNOWDEN, Associate Professor, Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle

Suggested Citation:"Front Matter." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

ROBYN STONE, Senior Vice President of Research, LeadingAge, Washington, DC

Study Staff

JILL EDEN, Study Director

MAI LE, Research Assistant

KATIE MASLOW, Scholar-in-Residence

MATT ALDAG, Mirzayan Fellow (September–December 2011)

AMY ASHEROFF, Senior Program Assistant (through August 2011)

JILLIAN LAFFREY, Board Assistant (from August 2011)

ROGER HERDMAN, Director, Board on Health Care Services

Suggested Citation:"Front Matter." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

Reviewers

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:

HENRY ACOSTA, Executive Director, National Resource Center for Hispanic Mental Health; Chair, Alliance for Latino Behavioral Health Workforce Development

BARBARA BOWERS, Helen Denne Schulte Professor, Institute on Aging; Associate Dean for Research and Charlotte Jane and Ralph A. Rodefer Chair, School of Nursing, University of Wisconsin–Madison

LOIS K. EVANS, van Ameringen Professor in Nursing Excellence, University of Pennsylvania School of Nursing

MARGARET GATZ, Professor of Psychology, Department of Psychology, University of Southern California

ROBYN L. GOLDEN, Director of Health and Aging, Rush University Medical Center

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Suggested Citation:"Front Matter." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

C. SETH LANDEFELD, Professor of Medicine, Chief, Division of Geriatrics, Director, UCSF-Mt. Zion Center on Aging; Associate Chair for Strategic Planning and Implementation, Department of Medicine

EDWARD O’NEIL, Director and Professor, Center for the Health Professions, University of California, San Francisco

DAVID W. OSLIN, VA Associate Chief of Staff for Behavioral Health Director, VISN 4 MIRECC; Associate Professor, Perelman School of Medicine, University of Pennsylvania

CHARLES F. REYNOLDS, UPMC Endowed Professor in Geriatric Psychiatry; Director, Advanced Center for Interventions and Services Research for Late-Life Depression Prevention; Director, John A. Hartford Center for Excellence in Geriatric Psychiatry, University of Pittsburgh, Western Psychiatric Institute and Clinic (WPIC)

WILLIAM A. VEGA, Provost Professor; Director, Edward R.

Roybal Institute on Aging, School of Social Work, University of Southern California

TERI FOX WETLE, Associate Dean of Medicine for Public Health and Public Policy; Professor of Medical Science, Department of Public Health, Brown University Medical School

NANCY L. WILSON, Assistant Professor, Department of Medicine, Section of Geriatrics; Assistant Director, Huffington Center on Aging; Assistant Professor, Center for Medical Ethics and Health Policy, Baylor College of Medicine

Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Mary E. Tinetti of the Yale University School of Medicine and Nancy E. Adler of the University of California, San Francisco. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

Suggested Citation:"Front Matter." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

Preface

The burden of mental illness and substance use disorders in older adults in the United States borders on a crisis. Yet, this crisis is largely hidden from the public and many of those who develop policy and programs to care for older people. In contrast, concerns about the physical health care needs of the growing number of older Americans abound, even in the face of exploding Medicare costs and the federal budget deficit. Concerns about how to meet these needs led Congress to commission a report from the Institute of Medicine (IOM) on the physical health care needs of this population and the geriatric health care workforce required to meet them, resulting in the 2008 IOM report Retooling for an Aging America: Building the Health Care Workforce.

Following the release of the 2008 report, Congress wisely recognized the largely hidden crisis of mental health and substance use disorders in older adults and commissioned the IOM to convene a committee to study and report on the workforce needed to care for these older Americans. I was privileged to chair the committee that developed this report. The IOM assembled an outstanding committee with broad-ranging expertise, demographic and disciplinary diversity, total dedication to the project, and willingness to work hard to gather the relevant evidence, draft the report, and formulate recommendations. Our committee was supported by an exceptional team from the IOM, including Roger Herdman, Jill Eden (our guiding force as study director), Katie Maslow, Mai Le, Jillian Laffrey, Matt Aldag, and Amy Asheroff.

The task of caring for vulnerable older adults with mental health

Suggested Citation:"Front Matter." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

and substance use conditions is complex, and different disciplines hold divergent views about the best approaches to accomplish the task. Yet, our committee recognized from the outset that we must learn from each other and the consumers, mental health and substance use service providers, and government and private program administrators who shared their perspectives and experience with us, and work as a team to develop recommendations that cut across disciplines and other barriers to enhance the geriatric mental health and substance use workforce.

Overarching themes run through our report and recommendations. First, the public health impact of mental illness and substance use in older adults is significant, but responsibilities for programs and policies to develop and support the workforce that is needed to relieve this burden are not effectively distributed across federal government agencies. The federal government can gain efficiencies and effectiveness by clear assignment and coordination of responsibilities for geriatric mental health and substance use workforce development across agencies. Second, available data about the service needs of these older adults are not adequate to guide future workforce development. More comprehensive and timely data are needed for this purpose. Third, many opportunities that exist in current federal programs have not been fully leveraged for the development and support of the geriatric mental health and substance use workforce. The necessary resources to ensure a viable workforce may be derived in large part from these programs. Fourth, training in essential competencies for the care of older adults with mental illness and substance use disorders must be provided across the workforce if it is to meet the challenges it faces and will face in the future. Finally, new models of care must be put into place. Some of these models have been developed and demonstrated to be effective, and some remain to be developed.

It is with pleasure that we present this report.

Dan G. Blazer, Chair
Committee on the Mental Health
Workforce for Geriatric Populations

Suggested Citation:"Front Matter." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

Acknowledgments

The committee and staff are indebted to a number of individuals and organizations for their contributions to this report. The following individuals provided testimony to the committee:

Moe Armstrong, Founder, Vet to Vet

Carol Colleran, Retired Director of Public Policy and National Affairs, Hanley Center—Addiction Counselor

Mary Ellen Copeland, Wellness Recovery Action Planning (WRAP)

Tim Engelhardt, Director, Demonstration Program, Centers for Medicare & Medicaid Services (CMS) Federal Coordinated Health Care Office (Duals Office)

Stephen Ferrante, Director, Aging Academy, Florida Atlantic University—Screening, Brief Intervention, and Referral to Treatment (SBIRT) Model for Older Adults with Substance Use Problems

Robyn Golden, Director of Older Adult Programs, Rush University Medical Center

Enid Hunkeler, Senior Scientist and Codirector, Inter-Divisional Depression Initiative, Kaiser Permanente Northern California Division of Research

Julie Jensen, Program Manager, Older Adult Services, HEROS Program, Good Samaritan Behavioral Health, Puyallup, WA—Gatekeeper Model

Suggested Citation:"Front Matter." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

Kathy Kuhn, Director of Workforce Development, Institute for Geriatric Social Work, Boston University—Social Workers, Case Managers, and Outreach Workers

Harold Pincus, Codirector, Irving Institute of Clinical and Translational Research and Professor, Department of Psychiatry, Columbia University

Patrick J. Raue, Associate Professor of Psychology in Psychiatry, Weill Cornell Medical College—Home Care Nurses

Marian Scheinholtz, Public Health Advisor, Community Support Programs Branch, Substance Abuse and Mental Health Services Administration (SAMHSA)

Michael Schoenbaum, Senior Advisor for Mental Health Services, Epidemiology, and Economics, Office of the Director, National Institute of Mental Health (NIMH)—Providing Depression Care in a Primary Care Setting—IMPACT

Bernadette Seifert, Coordinator of Older Adult Services, National Alliance on Mental Illness, New Hampshire

Dan Timmel, Medicaid Long-Term Care Policy Analyst, CMS Disabled and Elderly Health Programs Group

Jurgen Unutzer, Professor, University of Washington Department of Psychiatry

We also extend special thanks to the following individuals who were essential sources of information, generously giving their time and knowledge to further the committee’s efforts.

Scott Barstow, American Counseling Association

Carlos Blanco, Columbia University College of Physicians and Surgeons

Kipling M. Bohnert, Department of Veterans Affairs

Alice Bonner, CMS

Elizabeth Bragg, American Geriatrics Society

Shubing Cai, Brown University

David Chambers, NIMH

Robin E. Clark, University of Massachusetts Medical School

Teresa A. Coughlin, Urban Institute Health Policy Center

Nicholas Croce, Jr., American Psychiatric Nurses Association

Paola Daly, American Academy of Physician Assistants

Chris deVries, American Association for Geriatric Psychiatry

Deborah DiGilio, American Psychological Association

Meredith Eisenhart, Council on Social Work Education

Jovier Evans, NIMH

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Suggested Citation:"Front Matter." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
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James Finley, American Mental Health Counselors Association

Beth Han, Center for Behavioral Health Statistics and Quality, SAMHSA

Rodney Harrell, AARP

Seiji Hayashi, Bureau of Primary Health Care

Jennifer Hohman, American Academy of Physician Assistants

Bob Hornyak, Administration on Aging

Gail Hunt, National Alliance for Caregiving

Jill Kagan, ARCH National Respite Network and Resource Center

William Lang, American Academy of Colleges of Pharmacy

Katharine Levit, Thomson Reuters

Lydia W. Li, University of Michigan School of Social Work

Cherry Lowman, National Institute on Alcohol Abuse and Alcoholism

Linda Lysoby, National Commission for Health Education Credentialing

Tami Mark, Thomson Reuters

Kristi Martinsen, Office of Rural Health Policy

Paul Moore, Health Resources and Services Administration (HRSA)

Vincent Mor, Brown University

Tom Morris, Office of Rural Health Policy

Mariquita G. Mullan, HRSA

Charlotte Mullican, Agency for Healthcare Research and Quality (AHRQ)

Tim Nanof, American Occupational Therapy Association

George Neiderhe, NIMH

Toru Okura, Bajikoen Clinic, Tokyo, Japan

Eunice Park-Lee, National Center for Health Statistics, Centers for Disease Control and Prevention

Alex Ross, HRSA

M. Katherine Shear, Columbia University School of Social Work

Susie Sherman, American Geriatrics Society

Shannon Skowronski, Administration on Aging

Jennifer Solomon, Center for Substance Abuse Prevention, SAMHSA

Anita Soni, AHRQ

Rebecco Spitzgo, National Health Service Corps

Melinda Anne Stanley, Baylor College of Medicine

Leonila Vega, Direct Care Alliance

Gil Weidenfeld, Annapolis, MD

Joan Weiss, Bureau of Health Professions, HRSA

Tracy Whitaker, National Association of Social Workers

Nancy L. Wilson, Baylor College of Medicine

Li-Tzy Wu, Duke University Medical Center

Suggested Citation:"Front Matter." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

Funding for this study was provided by the Office of the Assistant Secretary for Planning and Evaluation (ASPE). The committee appreciates the opportunity and support extended by ASPE for the development of this report.

Finally, many within the Institute of Medicine were helpful to the study staff. We would like to thank Clyde Behney, Laura Harbold DeStefano, William McLeod, Abbey Meltzer, Vilija Teel, Lauren Tobias, and Sarah Ziegenhorn.

Suggested Citation:"Front Matter." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
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Figure

1-1     Distribution of the projected older population by age for the United States, 2010-2050

Tables

1-1     U.S. Census Projection of the Racial and Ethnic Makeup of the Older Adult Population, by Percentage, 2003 and 2030

1-2     Selected Department of Health and Human Services (HHS) Agencies with the Potential to Strengthen the Geriatric MH/SU Workforce

Chapter 2

Boxes

2-1     Symptoms of MH/SU Conditions Identified as Important for Older Adults

2-2     Selected Population-Based Surveys of Mental Health and Substance Use Conditions in Nationally Representative Samples of Community-Living Adults in the United States

2-3     Posttraumatic Stress Disorder (PTSD) in Older Adults

2-4     Changing Prevalence of Mental Health Conditions in Nursing Home Residents

2-5     Types of Organizations and Settings That Provide Some MH/SU Services for Some Older Adults

2-6     Suicide Prevention Programs in the VA

2-7     Older Adults’ Use of Mental Health Services Provided by the San Diego County Public Mental Health System

Tables

2-1     12-Month Prevalence Rates and Estimated Number of Community-Living Adults Age 65 and Older with 10 MH/SU Conditions

2-2     12-Month Prevalence Rates and Estimated Number of Adults Age 65 and Older with Nine Additional MH/SU Conditions

2-3     Proportion of Community-Living Adults and Nursing Home Residents Age 71 and Older with Normal Cognition or Dementia Who Had Associated Behavioral and Psychiatric Symptoms in the Previous Month

Suggested Citation:"Front Matter." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
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2-4     Prevalence and Estimated Number of Nursing Home Residents Age 65 and Older with Selected Mental Health Conditions, 2009

2-5     Estimated Number of Adults Age 65 and Older with MH/SU Conditions in 2010

2-6     Number and Proportion of Massachusetts Medicare and Medicaid Beneficiaries Age 65 and Older with Serious Mental Illness, Other Mental Illness, and No Mental Illness by Age, Gender, Place of Residence, Insurance, and Coexisting Dementia, 2005, N = 679,182

2-7     12-Month Prevalence of Selected Mental Disorders in Community-Living Adults Age 65 and Older in the United States in Four Racial and Ethnic Groups

2-8     Proportion of Assisted Living and Residential Care Residents with Behavioral Symptoms in the Previous Week, by Mental Health Conditions and Dementia

2-9     Prevalence Rates and Number of Veterans Age 65 and Older Who Used VA Inpatient or Outpatient Health Care Services in FY 2011 and Had Diagnoses of Selected MH/SU Conditions

2-10    Proportion of Community-Living Primary Care Patients Age 60 and Older with Depressive Disorders and Selected Physical Health Conditions, N = 1,801

2-11    Proportion of Community-Living Adults Age 65 and Older with Selected Physical Health Conditions, Mental Health Conditions, and Cognitive Impairment in Two Michigan Home Care Programs, N = 18,939

2-12    Medicare Reimbursement for Mental Health and Other Substance Use Services for Fee-for-Service Beneficiaries Age 65 and Older, 2009

2-13    12-Month Prevalence of Selected MH/SU Conditions in Community-Living People in the United States by Age Group

2-14    12-Month Prevalence Rates for Alcohol- and Drug-Related Conditions in Adults Age 65 and Older in 2000, 2002, 2004, 2006, 2008, and 2010

2-15    12-Month Prevalence of Selected MH/SU Diagnoses in Veterans Who Used VA Health Care Services in FY 2011 by Age Group

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The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? Get This Book
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 The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?
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At least 5.6 million to 8 million—nearly one in five—older adults in America have one or more mental health and substance use conditions, which present unique challenges for their care. With the number of adults age 65 and older projected to soar from 40.3 million in 2010 to 72.1 million by 2030, the aging of America holds profound consequences for the nation.

For decades, policymakers have been warned that the nation's health care workforce is ill-equipped to care for a rapidly growing and increasingly diverse population. In the specific disciplines of mental health and substance use, there have been similar warnings about serious workforce shortages, insufficient workforce diversity, and lack of basic competence and core knowledge in key areas.

Following its 2008 report highlighting the urgency of expanding and strengthening the geriatric health care workforce, the IOM was asked by the Department of Health and Human Services to undertake a complementary study on the geriatric mental health and substance use workforce. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? assesses the needs of this population and the workforce that serves it. The breadth and magnitude of inadequate workforce training and personnel shortages have grown to such proportions, says the committee, that no single approach, nor a few isolated changes in disparate federal agencies or programs, can adequately address the issue. Overcoming these challenges will require focused and coordinated action by all.

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