Everyone wants to work with children, but what about the people who have spent their lives caring for children, grandchildren, and are now in their waning years facing dementia, depression, grief when a spouse dies, and more – often alone and without any professionals trained to help them? That is the unasked question behind a new Institute of Medicine (IOM) report, which found that there aren’t nearly enough people to provide geriatric mental health/substance use (MH/SU) diagnosis and treatment, even as the ranks of older Americans who will need such treatment continue to swell.
The IOM’s report, called “The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?” clearly shows that professionals working with the older population need special training – older people with MH/SU problems have many unique issues and can be more difficult to diagnose and treat than other patients. And, the report said that the number of professionals in this workforce at all is “disconcertingly small.”
Dementia-related problems and depression are at the top of the list among behavioral health problems for this population, according to the report. SU disorders are also significant, in part because age changes the way people metabolize alcohol or drugs and because the medications used by older people often complicate treatment.
There are losses that occur in old age, for which many people are not prepared—the death of a spouse, for example, may trigger depression (or make preexisting depression worse)—with symptoms that can be severe and debilitating. How to tell whether a person in this situation has major depression or grief is difficult.
In addition, cognitive, functional, and sensory impairments also complicate the diagnosis of MH/SU disorders in the geriatric population.
Currently, the geriatric workforce includes workers with a broad variety of skills and training, ranging from people with minimal education to psychiatrists and neurologists. But across the entire workforce there is “little, if any, training” in MH/SU for this population. “MH/SU specialists are not trained in geriatrics, and geriatric specialists are not trained in MH/SU,” the report states. “Primary care and other essential providers are not trained in either area.”
Effective delivery of treatment for mental health and substance use disorders in the geriatric population—especially for depression and substance use—must consist of 1) systematic outreach and diagnosis, 2) patient and family education and self-management support, 3) provider accountability for outcomes, and 4) follow-up and monitoring to prevent relapse.
The key to delivering these elements is for care to be patient-centered, the report says. It should be in an easily accessible location, such as a primary care office, senior centers, or the patients’ home and coordinated by trained care managers with access to specialty consultation, the report said.
This is not a new problem, but it’s getting worse, and through lack of attention it’s going to mean unneeded suffering for older Americans, the report said. “The breadth and magnitude of the problem have grown to such proportions that no single approach, nor a few isolated changes in disparate federal agencies or programs, can adequately address the issue.” What is needed is “coordinated action” by agencies of the Department of Health and Human Services (HHS), the report said.
The report took Medicare to task for having reimbursement rules which discourage, rather than facilitate, access to effective services. “There is a fundamental mismatch between older adults’ need for coordinated care and Medicare’s fee-for-service reimbursement, which precludes payment for trained care managers and psychiatry consultation,” the report said.
Also censured: the Substance Abuse and Mental Health Services Administration (SAMHSA), which “has consistently devoted only a small fraction of its budget to older adults. “
Even at the National Institutes of Health, where there is research related to aging, mental health, and substance abuse, there is no targeted focus on geriatric MH/SU, the report notes.
The IOM urged Congress to fund the National Health Care Workforce Commission, authorized under the Affordable Care Act, and said a top priority of the commission should be on improvement recruitment and retention of personnel who can diagnose and treat geriatric MH/SU.
There are also ACA workforce provisions Congress should fund, the report said, including those that would authorize training, scholarships, and loan forgiveness for people who work with or a planning to work with older adults with MH/SU.
Standards, curriculum requirements, and credentialing procedures should be modified to require competence in geriatric MH/SU for everyone who cares for the various needs of older adults, the report said. State licensing boards as well as accreditation, certification, and professional examination organizations should make these changes, the report said.
And CMS should look at other reimbursement methods, so that care managers and supervising mental health specialists, including psychiatrists, can be paid.