The Mental Health and Substance Use Workforce for Older Adults In Whose Hands? (2012) / Chapter Skim
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Service providers, health care researchers, workforce experts, demographers, and others have long warned policy makers that with the aging of the baby boomer population, the nation faces a "silver tsunami" with the potential to overwhelm the nation's health care system. Similar calls have been made to address the nation's inadequate training and shortages of personnel for mental health and substance use (MH/SU)
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This includes • MH/SU specialists such as general psychiatrists, psychologists, social workers, psychiatric nurses, and substance use counselors who may provide services to patients of any age; • primary care providers, such as general internists, family medi cine practitioners, advanced practice registered nurses, and physi cian assistants who may provide services to patients of any age (but may have daily contact with older adults who have MH/SU conditions) ; • primary care providers with specialized training in the care of older adults, such as geriatricians and geriatric nurses; • MH/SU providers with specialized training in the care of older adults, such as geriatric psychiatrists, gerontological nurses, gero psychologists, and gerontological social workers; • direct care workers (DCWs)
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will convene an ad hoc committee to determine the mental and behavioral health care needs of the target population -- the population of Ameri cans who are age 65 years and older -- and then make policy and research recommendations for meeting those needs through a competent and well-trained mental health workforce, especial ly in light of the projected doubling of the aged population by 2030. The committee will • Provide a systematic and trend analysis of the current and projected mental and behavioral health care needs of the target population.
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Many older adults who have MH/SU conditions also have acute and chronic physical health conditions, and some have cognitive and functional impairments. The interaction of physical health conditions, cognitive and functional impairments, and MH/SU conditions is a defining feature of the geriatric mental health and substance use fields and has critical implications for the workforce.
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These unique characteristics of geriatric MH/SU create important requirements for workforce competencies, including the ability to detect possible MH/SU conditions in older people with coexisting physical health conditions and cognitive and functional impairments; ability to diagnose the conditions or knowledge about how to refer the person for a diagnostic evaluation; and ability to adapt treatments and ongoing management to accommodate the coexisting conditions. Several demographic trends -- growing population diversity, change in the makeup of the older population and characteristics of the baby boomer cohort -- are likely to affect the prevalence of MH/SU conditions and the need for services in the coming decades.
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According to SAMHSA, 61 percent of the 1.1 million emergency department visits for adverse drug reactions involved a person age 65 or older in 2008, and nearly a fourth of these emergency visits involved central nervous system drugs, including narcotic and nonnarcotic pain relievers. Use of MH/SU Services Older adults have been less likely to use MH/SU services compared with younger people with similar conditions.
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The prevalence of co-occurring conditions in the elderly and the shift toward collaborative models of care make interprofessional training essential to overall training in geriatric MH/SU care. The increasing racial, ethnic, and linguistic diversity of the geriatric population also makes cultural competence imperative.
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Workforce roles are often poorly defined and overlapping. Estimating Workforce Supply and Demand • The standardized workforce data trended over time that are re quired to make accurate predictions of workforce supply and de mand are not available.
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Strengthening the Role of Direct Care Workers (DCWs) in Geriatric MH/SU Care • Complex factors, including poor working conditions, low wages, lack of training, and limited opportunities for advancement, deter the development of a stable DCW workforce.
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Primary care providers, such as physicians, advanced practice registered nurses, and physician assistants have not been trained in collaborative care and do not work in a practice or system supportive of comanagement, colocation, screening, and outcome monitoring required by these models. Frontline workers within the aging provider network agencies may be a potential source of care managers.
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Adequate supervision and coaching support of staff are also essential. Finally, research on effective delivery of MH/SU care for certain older populations is urgently needed, especially for individuals residing in nursing homes and other residential settings, prisoners, rurally isolated elders, and older adults with serious mental illnesses.
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Identification, development, and refinement of model curricula and curriculum development tools in geriatric MH/SU, includ ing effective models of training for integrated rehabilitation, health promotion, health care, and social services for older adults with serious mental illness. Identification, development, and refinement of core compe tencies in geriatric MH/SU for the entire spectrum of person nel who care for older adults, including direct care workers,
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CMS should evaluate alternative payment methods to encour age effective deployment of the workforce to provide integrat ed primary care, chronic disease self-management, and health promotion for older adults receiving care in community mental health centers and other specialty mental health settings. CMS should explore approaches and strategies for improving care delivery to older adults with MH/SU conditions through its contracts with quality-improvement organizations.
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The agency should also ensure that PASRR and MDS mental health assessments inform residents' care plans and that nursing home personnel implement the care plans accordingly. • HRSA The HRSA Administrator should ensure that the National Center for Health Care Workforce Analysis devotes sufficient attention to geriatric MH/SU with guidance from the national coordinat ing body described below.
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• Direct care workers and other frontline employees in home health agencies, nursing homes, and assisted living facilities (including personal care attendants not employed by an agency)
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Coexisting physical health conditions Coexisting cognitive and functional impairments Geographic area • Use of MH/SU services for the above subgroups. • Comprehensive and comparable information on the full range of geriatric MH/SU personnel with sufficient detail to assess the workforce supply by race and ethnicity; language skills; geographic location and distribution; qualifications, training, and certification; areas of practice; and hours spent in the care of older adults.
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