The Mental Health and Substance Use Workforce for Older Adults In Whose Hands? (2012) / Chapter Skim
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3 The Geriatric Mental Health and Substance Use Workforce
3 The Geriatric Mental Health and Substance Use Workforce
Pages 159-240
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From page 159... ...
Geriatric MH/SU specialists, who are the most highly trained to handle complex MH/SU cases, are in very short supply. Direct care workers, peer support providers, and consumers and their families are playing increasingly vital roles in the MH/SU work force.
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From page 160... ...
In addition, the MH/SU workforce is blurred by the ambiguous boundaries among the numerous professions. Mental health providers, such as psychiatrists and psychologists, advanced practice nurses and physician assistants, and counselors and social workers, often have overlapping roles and scopes of practice, which may differ by state.
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From page 161... ...
This includes primary care providers, MH/SU professionals, and profession als providing other types of therapies for MH/SU conditions, direct care workers (DCWs) , community providers, and family caregivers, as listed in Box 3-1.
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. and the dramatic growth in selected disciplines, such as clinical psychology and counsel ing, has reshaped the composition of the health care workforce.
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Because state licensing boards are the primary user of exam scores, many licensing exams are created by nonprofit associations of state licensing boards, such as the Association of Social Work Boards and the National Coalition of State Boards of Nursing. Most professions use the same exam nationwide to ensure consistency and to improve the portability of credentials across state lines.
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Nursing: State boards of State boards of National Council None Licensed nursing; National nursing of State Boards of practical League of Nursing Nursing (National nurses Accrediting Council Licensure Commission Examination for (voluntary) Practical Nurses)
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Nursing: State boards of State boards of None American Nurses Advanced nursing; Commission nursing Credentialing Center; practice RNs on Collegiate American Academy Nursing Education of Nurse Practitioners; (voluntary) ; American Association National League of of Critical-Care Nursing Accrediting Nurses Certification Commission Corporation (voluntary)
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Counselors Council for the State boards of National Board for National Board for Accreditation of counseling, or Certified Counselors Certified Counselors; Counseling and behavioral health (National Counselor Commission on Related Educational professionals Examination, National Rehabilitation Programs; Council Clinical Mental Counselor on Rehabilitation Health Counseling Certification Education Examination, Examination for Master's Addiction Counseling) ; Commission on
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Occupational Accreditation Council State boards of National Board National Board therapists for Occupational occupational therapy for Certification in for Certification Therapy Education Occupational Therapy in Occupational (NBCOT Certification Therapy, American Examination) Occupational Therapy Association 167 continued
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minimum training Medicare- or Medicaid-qualified nursing homes must follow federal requirements for evaluation Home health State boards of Some states do not Evaluation None aides nursing, departments credential home requirements of public health; health aides; where established by state Medicare- or credentialing exists, it regulatory body Medicaid-qualified is regulated by state Medicare- or home health agencies boards of nursing or Medicaid-qualified must follow federal departments of public home health agencies requirements for health must follow federal minimum training requirements for evaluation
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; Medicaid-funded CertifiedCare (Basic personal care Caregiving, Advanced services, but does Health and Safety, not establish specific and Alzheimer's standards Dementia Specialist Certification)
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. However, the extent of medical students' specific exposure to geriatric mental health is not well documented.
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From page 171... ...
Geriatric fellowships typically require didactic and clinical experience in geriatric psychiatry, including knowledge of depressive, psychotic, anxiety, personality, and substance disorders and treatment options as well as the assessment of physical and mental status in older adults (ACGME, 2006, 2007; AOA, 2011b)
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They work with older adults, families and caregivers, and other health professionals to address co-occurring medical conditions, medication management, family concerns, and social or environmental issues specific to older adults (Geriatric Mental Health Foundation, 2012)
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. Nursing homes employ the largest number of LPNs, followed by hospitals, physician offices, home health services, and com munity care facilities for the elderly (BLS, 2011)
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. RNs are also commonly employed by nursing facilities, home health agencies, physician offices, schools, and public health clinics.
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. Physician Assistants Physician assistants (PAs)
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. Accreditation curricu lum standards include instruction on detection and treatment of substance abuse; palliative and end-of-life care; basic counseling and patient educa tion; issues of death, dying, and loss; and psychiatric/behavioral condi tions.
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; 27 percent in hospitals; 3 percent in nursing facilities or other long-term care settings; and 16 percent in other settings including industry and nonpatient care (Midwest Pharmacy Workforce Research Consortium, 2010)
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From page 178... ...
Psychologists are licensed by the professional board for psychology in the state in which they practice. To independently practice as a clinical or counseling psychologist, most states require a doctoral degree in psychology, postdoctoral experience, and passing of a licensing exam.
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The exam also covers comorbidity of mental illness with substance abuse and medical disorders, including rates of occurrence and age ranges affected (ASPPB, 2011a)
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From page 180... ...
Social workers play a large role in the care of older adults in nursing homes. Federal law requires that skilled nursing facilities provide medically related social services.5 Nursing homes with more than 120 beds are required to employ a full-time social worker with at least a bachelor's degree in social work or "similar professional qualifications." Facilities with 120 beds or fewer must still provide social services, but do not need to have a full-time social worker on staff (Social Work Policy Institute, 2010)
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From page 181... ...
Social workers who practice in the fields of mental health and/or substance abuse typically assess and treat individuals in recovery from mental illness and/or substance abuse, and provide a bridge to needed services and resources in the community. These services may include outreach and engagement; assessment and service planning; case management; treatment with individuals, families, and groups; discharge planning; and program planning and implementation across home, community-based, and institutional settings.
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. NASW also offers credentials in gerontology for advanced social workers and clinical social workers, which require an MSW, 2 years of postgraduate experience, 20 (advanced)
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. Addiction and Substance Abuse Counseling Counselors specializing in addiction and substance abuse counseling are typically licensed by a state agency or board different from mental health counselors.
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work with individuals with physical, mental, developmental, and cognitive conditions to help them improve their ability to perform daily living and vocational tasks. The most common sites of employment for OTs are hospitals, outpatient settings, schools, nursing facilities, and home health care services.
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Candidates for certification in men tal health must demonstrate professional experience and competence in mental health across the life span, the impact of psychiatric conditions on occupational performance, and current biomedical and occupational therapy practices used to minimize the adverse effects of psychiatric con ditions (AOTA, 2009)
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From page 186... ...
There are currently no data on the actual number of DCWs who care for older adults with MH/SU conditions. In 2008, there were an estimated 1.47 million nursing assistants, 922,000 home health aides, and 817,000 home care/personal care aides providing services to people of all ages in institutional and community-based settings (PHI, 2011)
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Nine out of 10 workers employed in nursing homes, home health, and home care are women. A substantial proportion of these workers are nonwhite, ranging from 51 percent in nursing homes and personal care/home care to 58 percent in home health care.
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. The DCA began offering the exam in spring 2011 with the goal of credentialing 3,000 personal care workers by the end of the year (Direct Care Alliance, 2011b)
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Home health aides can specialize in disabilities and mental illness (DOLETA Office of Apprenticeship, 2012)
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; care coordination within a comprehensive, individualized plan of care; and training and creden tialing, including continuing education, that ensure providers have the competencies necessary to deliver peer support services (CMS, 2007)
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Peer support technicians must pass a competency test or obtain certification as a peer provider from a state or agency, and engage in 15 hours of continuing education annually. Competency domains are listed in Box 3-2.
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. Promotores working in mental health may have roles similar to those of peer support providers, such as facilitating support groups and sharing experience in managing mental health issues (RhettMariscal, 2008)
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From 1996 to 2011, the number of geriatric psychiatry fellows filling these slots decreased by 50 percent. This decline, juxtaposed 700 600 500 400 300 200 100 0 4 11 10 7 8 9 0 1 2 3 5 6 07 8 9 0 99 0 0 0 99 0 99 0 0 0 0 0 20 0 20 20 20 20 0 20 20 20 –2 0 –2 –1 –1 –1 –2 –2 9– 10 6– 1– 2– 4– 5– 8– 3– 96 97 98 0 07 99 0 0 20 0 0 0 0 0 0 0 19 19 19 20 20 20 20 20 20 20 20 20 20 19 Geriatric Psychiatry Fellowships Geriatric Fellowships Geriatric Psychiatry Positions Filled Geriatric Fellowship Positions Filled FIGURE 3-2 Figure 3-2 Comparison of geriatric fellowship and geriatric psychiatry fellowship growth.
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From page 194... ...
As discussed earlier in the chapter, assessing the precise shortage of geriatric MH/SU providers is not possible because of unclear definitions of the geriatric MH/SU workforce and because up-to-date, comprehensive data on the workforce do not exist across all professions. Estimating geriatric MH/SU specialists proves particularly difficult because only two types of mental health professionals may currently obtain specialty credentials in geriatrics: psychiatrists and clinical social workers.
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is drawn from the 2008 National Sample Survey of Registered Nurses. All other estimates are from the U.S.
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. Contact with individuals with mental illnesses, as opposed to instruction or factual information, appears to be the most effective way to reduce stigma tizing attitudes (Couture and Penn, 2003)
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Accredited allopathic medical schools are required to have psychiatry clerkships (Liaison Committee on Medical Education, 2011) , but there is no way to know whether students interact with geriatric patients during their rotations.
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Linking training subsidies to service obligations may also potentially mitigate some attrition. South Carolina's Geriatric Loan Forgiveness Program and California's Mental Health Social Work Stipend Program are examples of how financial incentives can build and retain the geriatric MH/SU workforce to meet local needs.
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The program has also received support from local foundations. Limited Opportunities for Specialization in Geriatric MH/SU The number of specially trained geriatric mental health providers is small in part because there are few ways to pursue specialization in this area.
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Specialist Certificate Program which, if funded, will define the scope and preparation for specialty practice and credentialing at the graduate/postgraduate level in line with the new APRN Consensus Model (APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee, 2008)
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. Early Career Support and Mentorship Programs Initiatives such as the Geriatric Mental Health Foundation (GMHF)
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GSWI of the John A Hartford Foundation collaborates with social work programs, organizations, and other funders around the country to prepare social workers to improve the care and well-being of older adults and their families.
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For example, in FY 2011 the Substance Abuse and Mental Health Services Administration provided $4.7 million in minority fellowship program grants to the American Nurses Association, American Psychiatric Asso ciation, American Psychological Association, Council on Social Work Education, and American Association for Marriage and Family Therapy to use over 3 years (SAMHSA, 2011b)
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BOX 3-4 Key Areas for Improving Training • Integrating geriatric mental health and substance use compe tencies into education for all health professionals • Training for existing providers • Training in cultural competency • Interprofessional training
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As stated in the earlier discussion on recruitment, inclusion of an initiative in this chapter does not represent an endorse ment from the committee because evidence to support the effectiveness or analyze the outcomes is often not available. Integrating Geriatric MH/SU Competencies into Education for All Health Professionals The development and integration of core competencies in health care education and training have increased with the recognition that critical skills, knowledge, and attitudes must be more precisely defined for more consistent advancement of the field.
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From page 206... ...
The competencies are aspirational in nature and are intended to guide entry-level psychologists with specialized practice with older adults. The Council of Professional Geropsychology Training Programs created the Pikes Peak Geropsychology Knowledge and Skill Assessment Tool for supervisors to assess trainees or for psychologists who wish to do a self-assessment (Karel et al., 2010a)
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Knowledge of geriatric mental health/illness c. Lifelong learning d.
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All but one of the grantees developed teaching modules related to mental health or substance use. The teaching modules cover diverse topics, including depression, anxiety, paranoia, mental health in older Latinos, polypharmacy, mental health in skilled nursing facilities, informal sources of mental health care in Native American traditions, and co-occurring MH/SU conditions.
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In-Service Training One example of geriatric mental health in-service training is a program called Training in the Assessment of Depression (TRIAD)
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From page 210... ...
Topics include geriatric assess ment, mental health and aging, substance abuse, compulsive hoarding, suicide prevention, among many others relevant to geriatric MH/SU. Social workers can take these online training courses to earn a certificate in Mental Health and Aging, which requires six courses (Boston University Institute for Geriatric Social Work, 2011)
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From page 211... ...
It holds monthly webinars on clinical ethnogeriatric topics, including depression and mental health, which physicians, nurses, psychologists, social workers, or MFTs may use for continuing education credit. The SGEC also offers a 10-module curriculum for teaching culturally appropriate depression and demen tia care for older adults at risk for diabetes.
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From page 212... ...
212 TABLE 3-3 Example of a Cultural Competence Tool: Korean American Life Cohort Events Current Age of Older Adult 55-65 Years 65-75 Years 75-85 Years 85+ Years Historical Events Experienced by Years Korean American Elders Life Stage at Time of Event 1980- Increased fractionalization among Young Middle aged, Young-old, Old present Koreans adults, Young-old old middle aged Post–Rodney King decision focuses on Korean Americans Number of women continues to outnumber men Continued population influx: 1980 population was 354,600; 1990 population exceeded 800,000 1970s Influx of Koreans after the Immigration Adolescents, Young Middle aged, Young-old, and Nationality Act of 1965 young adults adults, young-old old middle aged Women continue to outnumber men, 10:7 Educated, middle-class immigrants Stereotypes: liquor store operators and green grocers Korean towns emerge in urban areas
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1940- Slow move out of Chinatowns Children, Adolescents, Young Middle aged, 1960 adolescents young adults adults, young-old Awareness of war brides and orphans middle aged as fallout from Korean War Population change, more women to men, 10:7 1950-1953 Korean War; war brides and war orphans 1920- Lived in rural areas and Chinatowns Children Children, Adolescents, Young 1940 adolescents young adults adults, Lumped with Asian groups as middle aged "Oriental" Some families, and small communities in Hawaii and California Population was 4 men for each woman 1924 Immigration Act stops picture brides 1900- Laborers moved to West Coast of -- Children Children, Adolescents, 1920 United States adolescents young 1906 -- beginning of picture brides adults Immigrants were 10 men for each woman 1902 -- immigration to Hawaii Pre- Limited information about immigration -- -- Children Children, 1900 to the United States is available; adolescents numbers of immigrants few or none SOURCE: Adapted from Stanford Geriatric Education Center, 2004.
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, which identified 23 competencies within 6 domains as essential for the following health professionals: physicians, dentists, nurses, occupational therapists, pharmacists, physical therapists, physician assistants, psychologists, and social workers. The competency domains are health promotion and safety, evaluation and assessment, care planning and coordination across the care spectrum (including end-oflife care)
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From page 215... ...
Most professions are recognized through credentials, such as certificates, licenses, and degrees, that verify an individual has received training and is able to perform the duties required of the profession. As discussed in the review of the direct care workforce, credentialing for direct care workers is limited.
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From page 216... ...
In 2010 the state of Alaska formed a public-private collaborative to address the challenge of training DCWs. It created the Alaskan Core Competencies for Direct Care Workers in Health and Human Services, a set of competencies relevant across diverse health care sectors that include long-term care, mental health, addictions, developmental disabilities, and traumatic brain injury.
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From page 217... ...
Psychiatric technicians must complete 30 hours of continuing education every 2 years to maintain licensure. The professional recognition of psychiatric technicians emerged from advocacy efforts of psychiatric "attendants" and "aides" from state men tal institutions who organized into the California Society of Psychiatric Technicians in 1950.
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From page 218... ...
Several states offer DCW development initiatives, some of which include opportunities for specific training in working with older adults with MH/SU conditions. For example, the state of Iowa created a Direct Care Workforce Advisory Council that is mandated with collecting data on the DCW workforce, implementing a HRSA grant-funded pilot training and credentialing program, and making recommendations for advancing this workforce.
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From page 219... ...
SOURCE: IOM, 2001. Expanding Peer-Led Support Programs for Older Adults The demand for more consumer-led, recovery-oriented services has increased in past decades and continues to grow, and evidence supporting the benefits of these services is emerging.14 However, information on the availability and impact of MH/SU peer support for older adults is sparse, although some noteworthy programs provide consumer-oriented, peer 14 See Box 4-1 (in Chapter 4)
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From page 220... ...
. In a study of Vet-to-Vet attendance indicators, Resnick found that older age, more negative atti tudes toward recovery, and lower levels of functioning were positively correlated with more frequent attendance, suggesting that this peer sup port model reaches veterans who may otherwise not typically access peer support services (Resnick, 2010)
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From page 221... ...
While more research is needed to explore the efficacy of different modes of psycho education delivery, McFarlane and colleagues concluded that support, information, guidance, and sharing of burden are the most critical aspects of family education. The CMS Leadership Summit on the Direct Care Workforce and Family Caregivers recommends that training for family caregivers should be flexible, optional, accessible, "just in time," selfpaced, and customized to meet the needs of individual caregivers and people receiving care (Direct Service Workforce Resource Center, 2011)
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From page 222... ...
UPAC operates a counseling and treatment center for monolingual and limited Englishproficient Asian and Pacific Islander adults and older adults with mental illness. The center focuses on helping individuals and their families to better understand the effects of posttraumatic stress, depression, and social isolation.
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SPRY holds weekly men's and women's peer support groups, sponsors social activities, and provides professional counseling and case management. Montrose has launched a community campaign that encourages anyone to become an advocate for LGBT seniors.
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Training general health care professionals and direct care workers is pivotal to improving the workforce because they are the most likely to have contact with older adults with MH/SU conditions. The extent to which training and education are provided for these groups is not well documented.
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Strengthening the Role of Direct Care Workers (DCWs) in Geriatric MH/SU Care i.
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http://www.aacn.nche.edu/news/articles/ 2004/dnp-release (accessed October 12, 2011)
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http://www.american geriatrics.org/ags_state_affiliates/state_affiliate_handbook/loan_forgiveness_toolkit/ (accessed December 22, 2011)
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http://www.nursecredentialing.org/PsychNurse-TCO2012.aspx (accessed October 12, 2011)
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2011. Filling the void in geriatric mental health: The Geropsychiatric Nursing Collaborative as a model for change.
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21-1023 Mental health and sub stance abuse social workers. http://www.bls.gov/oes/current/oes211023.htm (accessed April 13, 2012)
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requirements for certifica tion. https://www.caadac.org/ladder/ (accessed October 20, 2011)
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2011a. Direct Care Alliance personal care and support credential.
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. Geriatric Mental Health Foundation.
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2010. Strengthening the direct care workforce in North Caro lina.
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2008. Minnesota peer support implementation consultant's report.
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2012. Continuing education for social workers.
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2011. Peer support implementation in DV mental health A programs; maximizing the effectiveness of mental health services in the prevention of suicide.
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Columbia, SC. http://aging.sc.gov/providers/Pages/GeriatricLoan ForgivenessProgram.aspx (accessed December 22, 2011)
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Special report: Social work services for older adults. Washington, DC: National Association of Social Workers.
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