3

The Geriatric Mental Health and
Substance Use Workforce

Abstract: The geriatric mental health and substance use (MH/SU) workforce is a loosely defined set of providers who assess, diagnose, treat, manage, and care for older adults who have or are at risk for MH/SU conditions. Members of this workforce have shifting and overlapping roles, as older adults may see many types of health providers to deal with their complex array of physical and mental health concerns. Current education and training for most health care providers do not cover the skills and competencies necessary to provide adequate care for older adults who need MH/SU care. 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 workforce. Training for these groups is less systematic and thus more difficult to analyze. Though the challenges facing the geriatric MH/SU workforce are numerous and complex, many stakeholders have initiated efforts to build and strengthen the workforce, with various degrees of success.

This chapter addresses the Institute of Medicine (IOM) committee’s most fundamental challenge: to assess the capacity and competence of the mental health and substance use (MH/SU) workforce to meet the needs of the rapidly growing older population. Yet, this workforce is not easy



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3 The Geriatric Mental Health and Substance Use Workforce Abstract: The geriatric mental health and substance use (MH/SU) workforce is a loosely defined set of providers who assess, diagnose, treat, manage, and care for older adults who have or are at risk for MH/SU conditions. Members of this workforce have shifting and overlapping roles, as older adults may see many types of health providers to deal with their complex array of physical and mental health concerns. Cur - rent education and training for most health care providers do not cover the skills and competencies necessary to provide adequate care for older adults who need MH/SU care. 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. Training for these groups is less systematic and thus more difficult to analyze. Though the challenges facing the geriatric MH/SU workforce are numerous and complex, many stakeholders have initiated efforts to build and strengthen the workforce, with various degrees of success. This chapter addresses the Institute of Medicine (IOM) committee’s most fundamental challenge: to assess the capacity and competence of the mental health and substance use (MH/SU) workforce to meet the needs of the rapidly growing older population. Yet, this workforce is not easy 159

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160 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS to define, document, or examine. The term “workforce” often connotes a cohesive, definable group of professionals, paraprofessionals, and oth - ers who are employed with a common purpose. However, the geriatric MH/SU workforce is more aptly described as a de facto group (Robiner, 2006) of diverse professionals and others who care for older adults in a wide variety of settings under many different working conditions. Some members of the MH/SU workforce are highly trained individuals with advanced graduate training while others have associate’s or bachelor’s degrees, high school diplomas, or less formal education (Hoge et al., 2007). Each profession has its own history, unique educational requirements and curriculum, career path, certification and licensure requirements, earning potential, and employment options, though these may vary significantly within some professions. 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 prac- tice nurses and physician assistants, and counselors and social workers, often have overlapping roles and scopes of practice, which may differ by state. Many researchers have described the difficulties in trying to ascertain the nature, location, qualifications, and size of the MH/SU workforce for patients of any age (Hoge et al., 2007; IOM, 2006; Robiner, 2006). Focusing on the workforce with specific skills who are providing geriatric MH/SU services is even more of a challenge. The committee discussed these challenges at its first meeting and addressed two questions: first, how to define the geriatric MH/SU workforce and, second, how to estimate workforce demands and supply. These decisions are explained below. The chapter then presents a review of the key sectors of the workforce. The following sections will describe some of the primary challenges in improving the geriatric MH/SU workforce and include relevant efforts that have been implemented to strengthen the workforce. DEFINING THE GERIATRIC MH/SU WORKFORCE1 Older adults are diagnosed and treated for MH/SU conditions by an array of providers in a wide variety of settings, including primary care offices, hospitals, individuals’ homes, long-term care facilities, and specialty settings (both outpatient and residential), which makes defining the “geriatric MH/SU workforce” difficult. The committee focused on those who provide services specifically in the diagnosis, treatment, care, 1 This report uses the term “geriatric MH/SU workforce” to refer to the full range of per - sonnel providing services to older adults with mental health and substance use conditions.

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161 THE GERIATRIC MENTAL HEALTH AND SUBSTANCE USE WORKFORCE BOX 3-1 Geriatric Mental Health and Substance Abuse Workforce Professions • Physicians Primary care physicians Psychiatrists • Nurses Licensed practical nurses Registered nurses (RNs) Advanced practice RNs • Physician assistants • Psychologists • Social workers • Marriage and family therapists • Counselors • Pharmacists • Occupational therapists • Peer support specialists • Community health workers • Direct care workers • Family and other unpaid caregivers and management of MH/SU conditions in the geriatric population. 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. Many other groups also work closely with older adults and are integral to the overall health and well-being of this population. Their role in identifying MH/SU symptoms and referring older adults to appropri - ate services is vitally important, but will not be discussed in this review. ESTIMATING WORKFORCE SUPPLY AND DEMAND Questions about demand/need and their relationship to supply emerge naturally in any discussion of workforce issues. At first blush, it might seem straightforward to translate data on illness prevalence into estimates of service need and then, in turn, to estimates of required work - force supply. Throughout the history of health care, however, such efforts

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162 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS have been fraught with methodological challenges and serious questions about the validity of estimates that have been generated. A previous IOM committee, which focused on the provision of psy- chosocial services to cancer patients, grappled with this issue and drew the following conclusions: Ideally, one might want to estimate carefully the level of need for these services and then attempt to predict accurately the necessary workforce supply to meet that need. However, experts in health care workforce is - sues note decades of failure of efforts to estimate the size, composition, and distribution of the nation’s health care workforce. . . . Even in coun - tries with centrally managed, universal health care systems, progress in medical technology and changes in the organization of care can create large forecasting errors. Predicting workforce supply in the United States is further complicated by the fact that demand for services is not tightly controlled, and the distribution of the workforce is neither controlled nor actively shaped through reimbursement mechanisms. . . . To complicate the matter, data on health professions are not collected in a routine, standardized fashion across the multiple disciplines . . . and the dramatic growth in selected disciplines, such as clinical psychology and counsel - ing, has reshaped the composition of the health care workforce. Another limitation on a forecasting effort is that the same function (e.g., care coordination, case management, or patient navigation) may be carried out by different types of professionals, paraprofessionals, or volunteers in different organizations or systems. Thus, workforce needs are heavily influenced at the local level by the assignment of functions to provid - ers. For these and other reasons . . . the development of estimates of the overall workforce capacity required to meet psychosocial health needs through modeling or other methods was not a feasible activity for this study. (IOM, 2008a, pp. 287-288) Data on the geriatric MH/SU workforce is even more elusive because the majority of workers who provide services to the geriatric population do not have recognized credentials in this specialty, and are thus more difficult to count, track, and analyze. The committee used information from professional organizations, government agencies such as the Bureau of Labor Statistics (BLS) and the Health Resources and Services Admin- istration (HRSA), and other sources to obtain estimates of the existing workforce. However, the committee chose not to make predictions of workforce capacity or demands because the data to inform these estimates are severely lacking. REVIEW OF THE GERIATRIC MH/SU WORKFORCE This portion of the chapter will provide an overview of the main pro- fessions that comprise the geriatric MH/SU workforce. Each section will

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163 THE GERIATRIC MENTAL HEALTH AND SUBSTANCE USE WORKFORCE describe the general scope of the profession, the nature of the profession’s work with older adults and patients or clients with MH/SU conditions, and workforce characteristics. Required training and competency in geri- atric MH/SU will be discussed briefly for each group. Detailed require- ments for each profession in the areas of older adult care, mental health, substance use, co-occurring MH/SU conditions, and geriatric MH/SU are listed in Appendix C. Overview on Accreditation, Licensure, Examination, and Certification A wide variety of organizations and entities, at both the national and state levels, play a role in setting standards and requirements for the education and training of health care providers. Accreditation, licensure, examination, and certification are the primary processes used to ensure quality training and minimum competencies for a provider. The process, structure, and requirements for each vary among professions. However, there are some commonalities, and they will be described generally here. The entities responsible for accreditation, licensure, examination, and certification for each profession are listed in Table 3-1. Accreditation is the primary process by which higher education insti - tutions and programs ensure quality to the public. Accreditation is carried out by private, nonprofit organizations. Institutions, specific programs, or freestanding schools (e.g., schools of medicine) may be accredited. While accreditation is voluntary, it is often used as an indicator of academic quality, and may be a condition of federal and state funding or profes - sional licensure. Accreditation bodies are held accountable by receiving recognition from the Council for Higher Education Accreditation (non- governmental) or the U.S. Department of Education (Eaton, 2011). Licensure is state regulated and required for individual practitioners. Where a profession is licensed, it is illegal for an individual to practice without a license (Hartigan, 2011). State licensing boards establish scopes of practice, minimum standards for education and training, examina- tion requirements, and standards for professional behavior and ethics (NCSBN, 2011b). Examination is a process that is typically required for licensure. 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. However, individual state boards may have different criteria for passing.

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TABLE 3-1 164 Accreditation, Licensure, Examination, and Certification Bodies for the Mental Health and Substance Use Workforce Certification Workforce Licensure (Voluntary Sector Accreditation Licensure Examination Credentialing) Physicians: Liaison Committee State medical boards Federation of State American Board of Allopathic on Medical Education Medical Boards and Medical Specialties (MD) (undergraduate); National Board of Accreditation Council Medical Examiners for Graduate Medical (U.S. Medical Education (graduate) Licensing Exam) Physicians: American State medical boards National Board American Osteopathic Osteopathic of Osteopathic Osteopathic (DO) Association Medical Examiners Association Specialty (Comprehensive Certifying Boards Osteopathic Licensure Examination) 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 National Council American Nurses Registered nursing; Commission nursing of State Boards of Credentialing Center nurses (RNs) on Collegiate Nursing (National Nursing Education Council Licensure (voluntary); Examination for National League of Registered Nurses) Nursing Accrediting Commission (voluntary) 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) Physician Accreditation Review State PA or medical National Commission National Commission assistants Commission on boards on Certification of on Certification of (PAs) Education for the Physician Assistants Physician Assistants Physician Assistant (PA National Certifying Exam) Psychology American State boards of Association of Association Board Psychological psychology State and Provincial of Professional Association Psychology Boards Psychology Commission on (Examination for Accreditation Professional Practice in Psychology) 165 continued

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TABLE 3-1 Continued 166 Certification Workforce Licensure (Voluntary Sector Accreditation Licensure Examination Credentialing) Social work Council on Social State boards of social Association of National Association Work Education work, behavioral Social Work Boards of Social Workers health professionals (bachelor’s, master’s, advanced generalist, and clinical social work licensure examinations) Marriage Commission on State boards of Association of None and family Accreditation for MFT, counseling, or Marriage and Family therapists Marriage and Family behavioral health Therapy Regulatory (MFTs) Therapy Education professionals Boards (AMFTRB Examination in Marriage and Family Therapy) 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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Rehabilitation Counselor Certification (Certified Rehabilitation Counselor Examination) Pharmacists Accreditation State boards of National Association Board of Pharmacy Council for Pharmacy pharmacy of Boards of Specialties; Education; American Pharmacy Commission for Society of Health (North American Certification in System Pharmacists Pharmacist Licensure Geriatric Pharmacy (residency programs) Examination, Multistate Pharmacy Jurisprudence Examination); state boards of pharmacy (may have separate state jurisprudence examination) 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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TABLE 3-1 Continued 168 Certification Workforce Licensure (Voluntary Sector Accreditation Licensure Examination Credentialing) Direct care State boards State boards Evaluation developed None workers, of nursing or of nursing or by state regulatory departments of public departments of public body; some states certified health; Medicare- or health use National Council nurse Medicaid-qualified of State Boards of assistants nursing homes Nursing program must follow federal (National Nurse Aide requirements for Assessment Program) 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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Personal and Most states do not Most states do not Most states do not National Association home care regulate personal credential personal require evaluation for Home Care and aides and home care aide or home care aides; or examination of Hospice (Home Care training programs federal legislation personal or home Aide Certification); requires states to care aides Direct Care Alliance establish personnel (Personal Care and qualifications for Support Credential); Medicaid-funded CertifiedCare (Basic personal care Caregiving, Advanced services, but does Health and Safety, not establish specific and Alzheimer’s- standards Dementia Specialist Certification) SOURCES: 42 C.F.R. Parts 483 and 484, State Medicaid Manual (Chapter 4, Section 4480, paragraph E). 169

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230 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS Becker, G. S. 1962. Investment in human capital: A theoretical analysis. Journal of Political Economy 70(5 Part 2):9-49. Bernard, M. A., W. J. McAuley, J. A. Belzer, and K. S. Neal. 2003. An evaluation of a low intensity intervention to introduce medical students to healthy older people. Journal of the American Geriatrics Society 51(3):419-423. BLS (U.S. Bureau of Labor Statistics). 2009a. Occupational outlook handbook, 2010-11 edition, counselors. http://www.bls.gov/oco/ocos067.htm (accessed March 28, 2012). ———. 2009b. Occupational outlook handbook, social workers. http://www.bls.gov/oco/ ocos060.htm (accessed October 19, 2011). ———. 2010. Occupational employment and wages, May 2009. 29-2061 Licensed practical and licensed vocational nurses. http://www.bls.gov/oes/current/oes292061.htm (accessed January 19, 2012). ———. 2011. Occupational employment and wages, May 2010. 29-2061 Licensed practical and licensed vocational nurses. http://www.bls.gov/oes/current/oes292061.htm (accessed October 10, 2011). ———. 2012a. Occupational employment and wages, May 2011. 19-3031 Clinical, counseling, and school psychologists. http://www.bls.gov/oes/current/oes193031.htm (accessed April 6, 2012). ———. 2012b. Occupational employment and wages, May 2011. 21-1011 Substance abuse and be - havioral disorder counselors. http://www.bls.gov/oes/current/oes211011.htm (accessed April 13, 2012). ———. 2012c. Occupational employment and wages, May 2011. 21-1013 Marriage and family therapists. http://www.bls.gov/oes/current/oes211013.htm (accessed April 13, 2012). ———. 2012d. Occupational employment and wages, May 2011. 21-1014 Mental health counselors. http://www.bls.gov/oes/current/oes211014.htm (accessed April 13, 2012). ———. 2012e. Occupational employment and wages, May 2011. 21-1023 Mental health and sub - stance abuse social workers. http://www.bls.gov/oes/current/oes211023.htm (accessed April 13, 2012). ———. 2012f. Occupational employment and wages, May 2011. 29-1066 Psychiatrists. http:// data.bls.gov/cgi-bin/print.pl/oes/current/oes291066.htm (accessed April 13, 2012). ———. 2012g. Occupational employment and wages, May 2011. 29-1122 Occupational therapists. http://www.bls.gov/oes/current/oes291122.htm (accessed March 29, 2012). ———. 2012h. Occupational outlook handbook, occupational therapy assistants and aides. http:// www.bls.gov/ooh/Healthcare/Occupational-therapy-assistants-and-aides.htm (ac - cessed March 29, 2012). Bluebird, G. 2008. Paving new ground: Peers working in inpatient settings. Alexandria, VA: National Association of State Mental Health Program Directors. Bobby, C. L., and R. I. Urofsky. 2008. CACREP adopts new standards. Counseling Today 51(2):59-60. Bookman, A., and M. Harrington. 2007. Family caregivers: A shadow workforce in the geriatric health care system? Journal of Health Politics, Policy and Law 32(6):1005-1041. Boston University Institute for Geriatric Social Work. 2011. Online training programs. http:// www.bu.edu/igsw/online-training-programs/ (accessed June 11, 2012). BPS (Board of Pharmacy Specialties). 2005. Content outline for the Psychiatric Pharmacy Specialty Certification Examination. http://www.bpsweb.org/pdfs/content_outline_ psychiatric.pdf (accessed December 5, 2011) ———. 2011. Pharmacists certified by the Board of Pharmacy Specialties. http://www.bpsweb. org/resources/BPSInformationalSlides.pdf (accessed December 5, 2011). Brown, C., H. C. Schulberg, and M. J. Madonia. 1996. Clinical presentations of major de - pression by African Americans and whites in primary medical care practice. Journal of Affective Disorders 41(3):181-191.

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231 THE GERIATRIC MENTAL HEALTH AND SUBSTANCE USE WORKFORCE Bruce, M. L., E. L. Brown, P. J. Raue, A. E. Mlodzianowski, B. S. Meyers, A. C. Leon, M. Heo, A. L. Byers, R. L. Greenberg, and S. Rinder. 2007. A randomized trial of depression assessment intervention in home health care. Journal of the American Geriatrics Society 55(11):1793-1800. Brugna, R., J. Cawley, and M. Baker. 2007. Physician assistants in geriatric medicine. Clinical Geriatrics 15(10):22. CAADAC (California Association of Alcoholism and Drug Abuse Counselors). 2011. Califor- nia Certification Board of Alcohol and Drug Counselors (CCBADC) requirements for certifica - tion. https://www.caadac.org/ladder/ (accessed October 20, 2011). CACREP (Council for Accreditation of Counseling and Related Educational Programs). 2010. Council for Accreditation of Counseling and Related Educational Programs 2009. h ttp://www.cacrep.org/doc/2009%20Standards%20with%20cover.pdf (accessed March 28, 2012). ———. 2011. Scope of accreditation. http://67.199.126.156/template/page.cfm?id=52 (ac- cessed October 20, 2011). CalSWEC (California Social Work Education Center). 2011a. Evaluation and research. http:// calswec.berkeley.edu/CalSWEC/MH_EvalRes.html (accessed December 22, 2011). ———. 2011b. Mental health curriculum resources. http://calswec.berkeley.edu/CalSWEC/ MHInitiative_CurricRes.html (accessed December 22, 2011). Cates, M. E., M. R. Monk-Tutor, and S. O. Drummond. 2007. Mental health and psychiatric pharmacy instruction in U.S. colleges and schools of pharmacy. American Journal of Pharmaceutical Education 71(1):1-5. CCGP (Commission for Certification in Geriatric Pharmacy). 2011. Exam content. http:// www.ccgp.org/pharmacist/certification/disease.htm (accessed September 27, 2011). Center to Champion Nursing in America. 2010. Preparation and roles of nursing care providers in America. http://championnursing.org/resources/preparation-and-roles-nursing-care- providers-america (accessed December 5, 2011). Chadiha, L. A., E. Brown, and M. P. Aranda. 2006. Social work practice with older African Americans and other black populations. In Handbook of social work in aging, edited by B. Berkman. New York: Oxford University Press. Champagne, T., and K. Gray. 2011. Occupational therapy’s role in mental health recovery. http:// www.aota.org/Practitioners/PracticeAreas/Aging/Tools/MH-Recovery.aspx?FT=.pdf (accessed April 12, 2012). Christian, S., C. Dower, and E. O’Neil. 2007. Chart overview of nurse practitioner scopes of practice in the United States. San Francisco, CA: UCSF Center for the Health Professions. Clay, R. 2006. Geropsychology grants in peril. Monitor on Psychology 37(4):46. CMS (Centers for Medicare & Medicaid Services). 2007. State Medicaid Director Letter #07- 011. http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/ SMD081507A.pdf (accessed December 13, 2011). CNC (Commission on Nurse Certification). 2011. Frequently asked questions about CNL® certi- fication. http://www.aacn.nche.edu/leading-initiatives/cnl/cnl-certification/pdf/faq. pdf (accessed October 13, 2011). Colenda, C. C., J. E. Wilk, and J. C. West. 2005. The geriatric psychiatry workforce in 2002: Analysis from the 2002 National Survey of Psychiatric Practice. American Journal of Geriatric Psychology 13(9):756. Commission for Accreditation of Marriage and Family Therapy Education. 2005. MFT educational guidelines. http://www.aamft.org/imis15/Documents/COAMFTE_MFT_ Educational_Guidelines.pdf (accessed October 24, 2011). CORE (Council on Rehabilitation Education). 2010. CORE accreditation standards. http:// www.core-rehab.org/Files/Doc/PDF/COREStandards20120204.pdf (accessed March 29, 2012).

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232 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS Corwin, S. J., K. Frahm, L. A. Ochs, C. E. Rheaume, and E. Roberts. 2006. Medical student and senior participants’ perceptions of a mentoring program designed to enhance ge - riatric medical education. Gerontology & Geriatrics Education 26(3):47-65. Council on Credentialing in Pharmacy. 2009. Scope of contemporary pharmacy practice: Roles, responsibilities, and functions of pharmacists and pharmacy technicians. Washington, DC. http://www.accp.com/docs/positions/misc/ccpwpscope_pharmacy_practice_ 2-2009.pdf (accessed December 5, 2011). Couture, S., and D. Penn. 2003. Interpersonal contact and the stigma of mental illness: A review of the literature. Journal of Mental Health 12(3):291-305. Covinsky, K. E., R. Newcomer, P. Fox, J. Wood, L. Sands, K. Dane, and K. Yaffe. 2003. Patient and caregiver characteristics associated with depression in caregivers of patients with dementia. Journal of General Internal Medicine 18(12):1006-1014. CRCC (Commission on Rehabilitation Counselor Certification). 2011. Rehabilitation coun- seling. http://www.crccertification.com/pages/rehabilitation_counseling/30.php (ac - cessed March 29, 2012). Crystal, S., U. Sambamoorthi, J. T. Walkup, and A. Akincigil. 2003. Diagnosis and treatment of depression in the elderly Medicare population: Predictors, disparities, and trends. Journal of the American Geriatrics Society 51(12):1718-1728. CSAT (Center for Substance Abuse Treatment). 2005. A national review of state alcohol and drug treatment programs and certification standards for substance abuse counselors and prevention professionals. Rockville, MD: Substance Abuse and Mental Health Services Administration. Cummings, S. M., G. Adler, and V. A. DeCoster. 2005. Factors influencing graduate-social- work students’ interest in working with elders. Educational Gerontology 31(8):643-655. Daniels, A. S., E. Grant, B. Filson, I. Powell, L. Fricks, and L. Goodale. 2010. Pillars of peer support: Transforming mental health systems of care through peer support services. http:// www.power2u.org/downloads/PillarsOfPeerSupportServiceReport.pdf (accessed De - cember 15, 2011). Daniels, A. S., L. Fricks, and T. P. Tunner. 2011. Pillars of peer support-2: Expanding the role of peer support services in mental health systems of care and recovery. www.pillarsofpeersup- port.org (accessed April 12, 2011). Direct Care Alliance. 2011a. Direct Care Alliance personal care and support credential. http:// www.directcarealliance.org/document/docWindow.cfm?fuseaction=document.view Document&documentid=19&documentFormatId=21 (accessed April 12, 2012). ———. 2011b. Direct Care Alliance personal care and support credential 2011 candidate handbook. http://directcarealliance.org/document/docWindow.cfm?fuseaction=document.view Document&documentid=2&documentFormatId=2 (accessed October 10, 2011). Direct Service Workforce Resource Center. 2011. Building capacity and coordinating support for family caregivers and the direct service workforce: Common goals and policy recommendations emerging from the CMS leadership summit on the direct service workforce and family caregiv - ers. http://dswresourcecenter.org/tiki-index.php?page=Reports (accessed October 11, 2011). DOLETA (U.S. Department of Labor Employment and Training Administration) Office of Apprenticeship. 2012. Registered apprenticeship training in long-term care. Washington, DC: U.S. Department of Labor. Donald W. Reynolds Foundation. 2011. Description of geriatrics training grants approved in June 2006. http://www.dwreynolds.org/Programs/National/Aging/Cohort3.htm (ac- cessed December 20, 2011). Eaton, J. S. 2011. An overview of U.S. accreditation. Washington, DC: Council for Higher Education Accreditation. http://www.chea.org/pdf/Overview%20of%20US%20Accreditation% 2003.2011.pdf (accessed April 9, 2012).

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