THE MENTAL HEALTH
AND SUBSTANCE
USE WORKFORCE FOR
OLDER ADULTS

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IN WHOSE HANDS?

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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
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THE MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS IN WHO SE HANDS? Committee on the Mental Health Workforce for Geriatric Populations Board on Health Care Services Jill Eden, Katie Maslow, Mai Le, and Dan Blazer, Editors

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Gov- erning Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engi - neering, 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 Ser- vices. 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. International Standard Book Number-13: 978-0-309-25665-0 International Standard Book Number-10: 0-309-25665-8 Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu/. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2012 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2012. The mental health and sub- stance use workforce for older adults: In whose hands? Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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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 govern - ment on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its mem - bers, sharing with the National Academy of Sciences the responsibility for advis - ing the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. 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. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in pro - viding services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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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 v

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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 vi

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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 pub - lished 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 vii

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viii REVIEWERS 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 construc- tive comments and suggestions, they were not asked to endorse the con- clusions 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 car- ried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final con - tent of this report rests entirely with the authoring committee and the institution.

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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 hid- den 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 ix

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x PREFACE 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 pro- viders, 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 assign- ment 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 devel - opment 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 sub - stance 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

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Acknowledgments The committee and staff are indebted to a number of individuals and organizations for their contributions to this report. The following indi- viduals 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 xi

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xiv ACKNOWLEDGMENTS 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.

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Contents SUMMARY 1 1 INTRODUCTION 17 Study Scope, 18 Methods of the Study, 21 Context for This Report, 22 Federal Influence on the Geriatric MH/SU Workforce, 28 Organization of the Report, 29 References, 36 2 ASSESSING THE SERVICE NEEDS OF OLDER ADULTS WITH MENTAL HEALTH AND SUBSTANCE USE CONDITIONS 39 MH/SU Conditions in Older Adults, 40 Prevalence of MH/SU Conditions in Older Adults, 52 Prevalence of MH/SU Conditions in Six Subgroups of the Older Population, 84 Coexisting Physical Health Conditions and Cognitive Impairment, 103 Impact of MH/SU Conditions, 106 Use of MH/SU Services by Older Adults, 111 Factors That Could Affect the Future MH/SU Service Needs of Older Adults, 129 xv

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xvi CONTENTS Summary of Findings and Implications for the Geriatric Mental Health Workforce, 138 References, 140 3 THE GERIATRIC MENTAL HEALTH AND SUBSTANCE USE WORKFORCE 159 Defining the Geriatric MH/SU Workforce, 160 Estimating Workforce Supply and Demand, 161 Review of the Geriatric MH/SU Workforce, 162 Shortage of Geriatric MH/SU Providers, 192 Recruitment of Geriatric MH/SU Specialists, 194 Inadequate Preparation of the Geriatric MH/SU Workforce, 203 Training the Geriatric MH/SU Workforce, 204 Promoting the Role of Direct Care Workers in Geriatric MH/SU Care, 215 Empowering Older Adults and Their Families, 218 Findings and Conclusions, 223 References, 226 4 WORKFORCE IMPLICATIONS OF MODELS OF CARE FOR OLDER ADULTS WITH MENTAL HEALTH AND SUBSTANCE USE CONDITIONS 241 Organization of the Chapter, 242 The Chronic Care Model, 244 Care Delivery Models for Geriatric MH/SU, 247 Models of MH/SU Care for Older Nursing Home Residents, 264 Implications for the Geriatric Mental Health Workforce, 268 Conclusions, 272 References, 273 5 IN WHOSE HANDS? RECOMMENDATIONS FOR STRENGTHENING THE MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER AMERICANS 283 Locus of Responsibility, 285 Investment in Human Capital, 294 Building Blocks of Informed Workforce Planning, 298 References, 299

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xvii CONTENTS APPENDIXES Abbreviations and Acronyms 303 A Public Workshop Agenda 309 B Required Knowledge, Skills, and Training for Mental Health, C Substance Use, and Geriatric Care Providers 313 D IOM Recommendations from Retooling for an Aging America: Building the Health Care Workforce (2008) 359 E Committee Biographies 363

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Boxes, Figures, and Tables Summary Boxes S-1 Charge to the IOM Committee on the Mental Health Workforce for Geriatric Populations, 3 S-2 Geriatric Mental Health and Substance Use Conditions Addressed in This Report, 5 S-3 Key Barriers and Issues Related to and Strengthening the Geriatric MH/SU Workforce, 8 S-4 Recommendations, 12 Chapter 1 Boxes 1-1 Charge to the IOM Committee on the Mental Health Workforce for Geriatric Populations, 19 1-2 Geriatric Mental Health and Substance Use Conditions Addressed in This Report, 20 1-3 Nongovernmental Organizations That Provided Workforce Information to the IOM Committee, 22 1-4 Parity for Coverage of Geriatric Mental Health/Substance Use (MH/SU) Services, 24 xix

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xx BOXES, FIGURES, AND TABLES Figure 1-1 Distribution of the projected older population by age for the United States, 2010-2050, 26 Tables 1-1 U.S. Census Projection of the Racial and Ethnic Makeup of the Older Adult Population, by Percentage, 2003 and 2030, 26 1-2 Selected Department of Health and Human Services (HHS) Agencies with the Potential to Strengthen the Geriatric MH/SU Workforce, 30 Chapter 2 Boxes 2-1 Symptoms of MH/SU Conditions Identified as Important for Older Adults, 42 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, 55 2-3 Posttraumatic Stress Disorder (PTSD) in Older Adults, 60 2-4 Changing Prevalence of Mental Health Conditions in Nursing Home Residents, 73 2-5 Types of Organizations and Settings That Provide Some MH/SU Services for Some Older Adults, 116 2-6 Suicide Prevention Programs in the VA, 120 2-7 Older Adults’ Use of Mental Health Services Provided by the San Diego County Public Mental Health System, 127 Tables 2-1 12-Month Prevalence Rates and Estimated Number of Community-Living Adults Age 65 and Older with 10 MH/SU Conditions, 58 2-2 12-Month Prevalence Rates and Estimated Number of Adults Age 65 and Older with Nine Additional MH/SU Conditions, 62 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, 67

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xxi BOXES, FIGURES, AND TABLES 2-4 Prevalence and Estimated Number of Nursing Home Residents Age 65 and Older with Selected Mental Health Conditions, 2009, 71 2-5 Estimated Number of Adults Age 65 and Older with MH/SU Conditions in 2010, 77 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, 82 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, 90 2-8 Proportion of Assisted Living and Residential Care Residents with Behavioral Symptoms in the Previous Week, by Mental Health Conditions and Dementia, 96 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, 101 2-10 Proportion of Community-Living Primary Care Patients Age 60 and Older with Depressive Disorders and Selected Physical Health Conditions, N = 1,801, 104 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, 107 2-12 Medicare Reimbursement for Mental Health and Other Substance Use Services for Fee-for-Service Beneficiaries Age 65 and Older, 2009, 112 2-13 12-Month Prevalence of Selected MH/SU Conditions in Community-Living People in the United States by Age Group, 130 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, 132 2-15 12-Month Prevalence of Selected MH/SU Diagnoses in Veterans Who Used VA Health Care Services in FY 2011 by Age Group, 136

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xxii BOXES, FIGURES, AND TABLES Chapter 3 Boxes 3-1 Geriatric Mental Health and Substance Abuse Workforce Professions, 161 3-2 Veterans Health Administration Peer Support Technician Domains of Competency, 191 3-3 Primary Challenges in the Recruitment of Geriatric MH/SU Specialists, 196 3-4 Key Areas for Improving Training, 204 3-5 Geropsychiatric Nursing Key Concepts, 206 3-6 Rules for Patient-Centered Care, 219 3-7 Findings on the Geriatric Mental Health and Substance Use (MH/SU) Workforce, 224 Figures 3-1 U.S. Department of Labor apprenticeships in long-term care occupations, 189 3-2 Comparison of geriatric fellowship and geriatric psychiatry fellowship growth, 193 Tables 3-1 Accreditation, Licensure, Examination, and Certification Bodies for the Mental Health and Substance Use Workforce, 164 3-2 Estimated Number of Mental Health/Substance Use Specialists, 2011, 195 3-3 Example of a Cultural Competence Tool: Korean American Life Cohort Events, 212 Chapter 4 Boxes 4-1 Peer Support, 260 4-2 Two Federal Programs Concerning the Mental Health of Older Nursing Home Residents: The Preadmission Screening and Resident Review Program and the Minimum Data Set, 266

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xxiii BOXES, FIGURES, AND TABLES Tables 4-1 Models Reviewed in This Chapter, 243 4-2 Care Settings and Core Staff for Selected Geriatric Mental Health (MH) and Substance Use (SU) Models, 269 Chapter 5 Boxes 5-1 Research and Demonstrations at the Centers for Medicare & Medicaid Services (CMS), 288 5-2 HRSA Geriatric Training Programs, 290

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