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In Whose Hands? Recommendations for Strengthening the Mental Health and Substance Use Workforce for Older Americans

Abstract: There is a conspicuous lack of national attention both to preparing the health care workforce to care for older adults with mental health and substance use (MH/SU) conditions and to ensuring sufficient numbers of appropriately skilled personnel. The barriers to growing and strengthening the geriatric MH/SU workforce are fundamental and entrenched in the systems and programs of numerous public and private entities. The committee recommends that both Congress and the Health and Human Services Secretary act to invigorate investment in the human capital that is the geriatric MH/SU workforce, to catalyze basic system redesign to allow for effective deployment of geriatric MH/SU personnel, and to stimulate essential research to inform the education and training of personnel and workforce planning itself.

The dilemma of how to strengthen the nation’s health care workforce to meet the needs of older adults with mental health and substance use (MH/SU) conditions reflects many of the challenges burdening U.S. health care. For decades, service providers, health care researchers, workforce experts, demographers, and others have warned policy makers that the nation’s health care workforce is ill-prepared—in numbers, knowledge, and skills—to care for a rapidly aging and increasingly diverse population (IOM, 1978, 2008). In the specific disciplines of MH/SU, there



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5 In Whose Hands? Recommendations for Strengthening the Mental Health and Substance Use Workforce for Older Americans Abstract: There is a conspicuous lack of national attention both to preparing the health care workforce to care for older adults with mental health and substance use (MH/SU) conditions and to ensuring suffi- cient numbers of appropriately skilled personnel. The barriers to grow- ing and strengthening the geriatric MH/SU workforce are fundamental and entrenched in the systems and programs of numerous public and private entities. The committee recommends that both Congress and the Health and Human Services Secretary act to invigorate investment in the human capital that is the geriatric MH/SU workforce, to catalyze ba- sic system redesign to allow for effective deployment of geriatric MH/SU personnel, and to stimulate essential research to inform the education and training of personnel and workforce planning itself. The dilemma of how to strengthen the nation’s health care work- force to meet the needs of older adults with mental health and substance use (MH/SU) conditions reflects many of the challenges burdening U.S. health care. For decades, service providers, health care researchers, work - force experts, demographers, and others have warned policy makers that the nation’s health care workforce is ill-prepared—in numbers, knowl- edge, and skills—to care for a rapidly aging and increasingly diverse population (IOM, 1978, 2008). In the specific disciplines of MH/SU, there 283

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284 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS have been similar warnings about serious workforce shortages, insuffi - cient workforce diversity, and basic lack of competence and core knowl - edge in key areas (Hogan, 2003; Hoge et al., 2007; IOM, 2006; Jeste et al., 1999). In health care delivery overall, there is widespread concern about shortages of primary care providers, lack of coordination among health care providers, fragmentation of services, high cost, patient safety, and conflicting information technology systems.1 The convergence of the above issues presents unique challenges for the workforce in geriatric MH/SU care delivery. U.S. health care has always emphasized physical health over mental health (IOM, 2006). Despite some change in societal attitudes, the stigma associated with mental health and substance use conditions is persistent. Today’s health care delivery system and financing arrangements both reflect these reali- ties. For example, until recent legislation mandating parity in some (but not all) health insurance plans, coverage of MH/SU conditions has been strictly limited. The carve-out of MH/SU coverage and service delivery into separate systems is still commonplace. As Chapter 2 reports, a substantial proportion of older adults have symptoms that warrant the attention of a provider skilled in geriatric MH/SU problems. Yet, only a minority of affected individuals receive specialty care, and the primary care they receive for MH/SU conditions is often inadequate despite the existence of evidence-based screening and treatment models (Bruce et al., 2005; Unützer et al., 2002). Moreover, a growing body of research suggests that inattention to older adults’ men- tal health and substance use conditions is associated with higher costs and poorer health outcomes, particularly for individuals with multiple comorbidities (Counsell et al., 2007; Katon et al., 2005; Unützer et al., 1997). Available evidence, for example, indicates that older adults with untreated depression are less likely to complete prescription regimens for diabetes, hypertension, and coronary heart disease; more likely to be readmitted after a hospitalization for a medical problem; and more likely to have poor health outcomes after a cardiovascular event, compared to similar patients without mental health problems (Ciechanowski et al., 2000; Garner, 2010; Gehi et al., 2005; Gilmer et al., 2007; Jiang et al., 2001; Krousel-Wood et al., 2010; Lin et al., 2004; Williams et al., 2004). The barriers to growing and strengthening the geriatric MH/SU workforce are fundamental and entrenched in the systems and programs of numerous public and private entities—including multiple U.S. Depart - ment of Health and Human Services (HHS) and other federal agencies, professional organizations, medical and professional training institutions, credentialing and accreditation organizations, licensing bodies, service 1 See Chapter 1, Box 1-3, for background on the parity legislation.

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285 IN WHOSE HANDS? RECOMMENDATIONS systems, payers, and research institutions. The breadth and magnitude of the problem is such that no single approach, nor a few isolated changes in disparate federal agencies or programs, is going to adequately address the issue or bring about quick change. Overcoming these challenges will require focused and coordinated action. Leadership by the HHS Secretary will be essential. Both Congress and the HHS Secretary must act to establish a locus of responsibility for geriatric MH/SU, to invigorate investment in the human capital that is the geriatric MH/SU workforce, to catalyze basic system redesign to allow for effective deployment of geriatric MH/SU personnel, and to stimulate essential research to inform the education and training of per- sonnel and workforce planning itself. The committee recognizes that the nation faces a broader impera- tive to strengthen the primary care and overall health care workforce to meet the needs of an aging and increasingly diverse population. Primary care providers, for example, are under tremendous pressure to assume an ever-expanding set of responsibilities. Nevertheless, the committee believes that policy makers must consider competence in MH/SU issues as central to improving the quality, effectiveness, and efficiency of the American health care workforce. LOCUS OF RESPONSIBILITY There is a conspicuous lack of national attention to preparing the health care workforce to care for older adults who have MH/SU condi- tions and to ensuring sufficient numbers of personnel for the rapidly growing elderly population. HHS and its many agencies, for example, have the expertise and authority to strengthen the geriatric MH/SU workforce and to improve quality of care. Yet, responsibility for geriat - ric MH/SU is scattered across the various HHS agencies, bureaus, and departments, including the Administration on Aging (AoA), the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention, the Centers for Medicare & Medicaid Services (CMS), the Health Resources and Services Administration (HRSA), the Substance Abuse and Mental Health Services Administration (SAMHSA), and several institutes within the National Institutes of Health (NIH), including the National Institute for Mental Health (NIMH), National Insti- tute on Aging (NIA), and the National Institute on Drug Abuse (NIDA). 2 Moreover, agencies’ efforts fall far short of what is needed and appear to be dwindling. Designating a locus of responsibility is a critical first step 2 See Table 1-3 in Chapter 1 for details on selected federal programs related to geriatric MH/SU.

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286 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS toward building the nation’s capacity to generate and maintain a robust and competent geriatric MH/SU workforce. RECOMMENDATION 1: Congress should direct the Secretary of Health and Human Services (HHS) to designate a responsible entity for coordinating federal efforts to develop and strengthen the nation’s geriatric MH/SU workforce. • The committee urges Congress to fund the already authorized National Health Care Workforce Commission to serve in this capacity. In the absence of congressional action, the Secretary of HHS should act as soon as possible to designate an alternative body. • The coordinating body should have the following priorities with respect to the geriatric MH/SU workforce: Identification, development, and refinement of methods for improving recruitment and retention of geriatric MH/SU per- sonnel, including ways to build a workforce that reflects the increasingly diverse older adult population. Promotion and support of widescale implementation of evidence-based models of geriatric MH/SU care that effec- tively deploy personnel. Identification, development, and refinement of model curri- cula and curriculum development tools in geriatric MH/SU, including effective models of training for integrated rehabili- tation, 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, peer support specialists, primary care physicians, nurses (at all levels), physician assistants, substance use counselors, social workers, psychologists, rehabilitation counselors, and mar- riage and family therapists. Evaluation and dissemination of all of the above. The Role of HHS Agencies A variety of HHS agencies and programs touch on geriatric MH/SU. These efforts, however, are minimal, lack specific focus on geriatric MH/SU, and, in some cases, are being discontinued. The following are examples. AHRQ has initiated a noteworthy interagency effort—the Academy

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287 IN WHOSE HANDS? RECOMMENDATIONS for Integrating Mental Health and Primary Care—to coordinate the col- lection, analysis, synthesis, and dissemination of research on integrating MH/SU services in primary care. The initial focus will be on developing a national integration strategy, including developing core competencies for the primary care workforce. There are also plans for work on quality measurement and a survey of small primary care practices. However, funding for the academy is quite limited (less than $0.5 million) and older adults are not a priority topic.3 AoA provides funding for state and local agencies to plan and deliver a wide array of health-related and social services for older adults, includ - ing those with MH/SU conditions (O’Shaunessy, 2011). Through its com- petitive grants programs, AoA has provided funding for several states to implement evidence-based mental health programs, such as Healthy IDEAS (Identifying Depression, Empowering Activities for Seniors) and PEARLS (Program to Encourage Active and Rewarding Lives for Seniors) (AoA, 2011). It is currently collaborating with SAMHSA to provide techni- cal assistance, through webinars and other online materials, for states and communities that want to implement community-based mental health services for older people (AoA and SAMHSA, 2012). The 2006 reautho- rization of the Older Americans Act, which funds AoA, authorized the agency to designate one staff member to be responsible for aging-related mental health services (AoA, 2010a). One full-time equivalent is currently functioning in this role. The reauthorization also identifies many aging- related mental health projects the agency is authorized, but not required, to implement, including projects intended to increase public awareness of mental health disorders, provide mental health screening, remove barri - ers to diagnosis and treatment, and coordinate mental health services for older adults with community health centers and other public and private organizations (AoA, 2010b). To date, AoA has not funded such projects on a wide scale, although some states are using AoA competitive grant funds for programs intended to achieve some of these objectives. CMS, the HHS agency with perhaps the most potential to influence the delivery of geriatric MH/SU services, has a substantial range of proj- ects under way to evaluate new approaches to improving the quality and effectiveness of services provided to Medicare and Medicaid beneficiaries (Box 5-1). CMS payment policy, limited in part by statutory restrictions, is par- ticularly problematic.4 A plethora of evidence shows that current Medi- 3C. Mullican, Senior Advisor for Mental Health Research, AHRQ, personal communica - tion, October 24, 2011, and April 18, 2012. 4 More comprehensive reviews of MH/SU financing are available elsewhere (Barry et al., 2010; Fisher et al., 2009; Goldman and Grob, 2006; Levit et al., 2008; MedPAC, 2010; Sarata, 2010; Shirk, 2008; Slade et al., 2005; Unützer et al., 2006).

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288 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS BOX 5-1 Research and Demonstrations at the Centers for Medicare & Medicaid Services (CMS) CMS is sponsoring an ambitious range of demonstration projects to stimulate innovation and improve the quality and efficiency of health care delivery. Because the details of these initiatives were evolving during the committee’s deliberations, it was unclear whether older adults with mental health and substance use conditions would be a primary focus of any of the demonstration projects. However, it appears that the innovation grants have the potential to stimulate workforce improvements. Some key elements of selected innovation grants are described below. Accountable Care Organization (ACO) Initiatives • edicare Shared Savings Program (MSSP). This program will re- M ward ACOs that reduce their growth in costs while meeting stan- dards for quality care. The quality standards include depression screening and follow-up. Grant applicants must identify how their care model would transform the workforce and update the skills of existing health professionals, identify and train new types of work- ers to enhance care delivery, and/or expand the use of team-based care. • dvance Payment. Open to MSSP awardees, this demonstration will A test whether advance payments of future shared savings facilitate participation in the shared savings program. The advances will be care and Medicaid payment policies act to deter rather than to facilitate access to effective and efficient MH/SU services (Unützer et al., 2006). Some of the models of service delivery described in Chapter 4 have been demonstrated to be efficacious and possibly cost saving. However, Medicare limitations on which types of personnel can be reimbursed for providing essential elements of the models precludes key providers from offering needed services. For example, although care managers are integral to effective management of depression, they cannot be paid by Medicare. Medicaid and Medicare pay for most nursing home care, and thus CMS plays a central role in the oversight of the services, including MH/SU services, provided to older adults residing in nursing homes. As Chapter 4 describes, two Medicaid programs are particularly important to older

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289 IN WHOSE HANDS? RECOMMENDATIONS available to participating physician-owned and rural providers who make new investments to improve care and to generate Medicare savings—including investments in hiring new nurse care coordina- tors to expand care management. Health Care Innovation Challenge Under the auspices of the Center for Medicare & Medicaid Inno- vation, these challenge grants have multiple objectives, including testing new roles and skills for existing health professionals, using new types of workers to support care transformation, and employing team-based models to better use the mix of health providers. Grant applicants must focus on high-cost/high-risk populations including those with multiple chronic conditions, mental health or substance use conditions, the frail elderly, and others. Independence at Home Demonstration This demonstration adds extensive primary care services to exist- ing Medicare home care benefits for patients with multiple chronic illnesses (including mental health conditions). Medical practices that meet the program’s quality standards and generate savings may re- ceive incentive payments. To participate in the demonstration, medi- cal practices must be led by physicians or nurse practitioners with experience providing home-based primary care. SOURCES: CMMI, 2011a,b. adults with mental health conditions: the Pre-Admission Screening and Resident Review Program (PASRR) and the Minimum Data Set (MDS). Both programs provide an infrastructure with the potential to organize, deliver, and promote quality mental health services to older nursing home residents. However, the available evidence suggests that Medicaid over- sight and enforcement of both programs has been inadequate. HRSA is the central HHS agency tasked with promoting the produc- tion and training of key health personnel. The Bureau of Health Profes - sions oversees a variety of programs, described in Box 5-2, that have the potential to expand expertise in geriatric MH/SU. However, MH/SU is not a mandatory requirement in the bureau’s geriatric programs. Several NIH institutes have missions related to aging and mental health or substance use. For example, Congress has charged the NIA with

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290 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS BOX 5-2 HRSA Geriatric Training Programs The Health Resources and Services Administration (HRSA) pro- grams described below provided training and education in mental health (88 percent) and substance use (22 percent) to 93,616 indi- viduals from 2007 to 2010. Participants represented a wide range of disciplines, including nursing (24 percent), medicine (15 percent), social work (12 percent), and others (49 percent). Geriatric Training for Physicians, Dentists, and Behavioral and Men- tal Health Professionals Supports awards to schools of medicine and osteopathic medicine, teaching hospitals, and graduate medical education programs for ge- riatric training projects to train physicians, dentists, and behavioral and mental health professionals who plan to teach geriatric medicine, geriatric dentistry, or geriatric behavioral or mental health. Appli- cants must propose projects that support interprofessional training in geriatrics through one or both of the following training options: (1) a 1-year faculty retraining program in geriatrics, and/or (2) a 2-year internal medicine or family medicine fellowship program providing emphasis in clinical geriatrics and geriatrics research. The program requires participating institutions to sponsor applicants in the medi- cal, dental, and mental health arenas. The Patient Protection and Af- fordable Care Act (ACA) expanded the types of behavioral health professionals eligible to participate in the 1-year faculty retraining op- tion to include those with a graduate or postgraduate degree from an accredited institution of higher education in psychiatry, psychology, psychiatric nursing, social work, substance abuse disorder preven- tion and treatment, marriage and family counseling, or professional counseling. Geriatric Academic Career Awards (GACAs) Five-year grants to promote the career development of junior, nontenured faculty as academic geriatric specialists. Awardees must provide training in clinical geriatrics, including the training of inter- professional teams of health care professionals. Geriatrics mental health professionals are eligible to apply for the grants. The ACA authorized an expansion of the GACA program to include a wider scope of disciplines, including allopathic medicine, osteopathic medi-

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291 IN WHOSE HANDS? RECOMMENDATIONS cine, nursing, social work, psychology, dentistry, pharmacy, and allied health. The ACA also authorized that payment be made to accredited schools of allopathic medicine, osteopathic medicine, nursing, social work, psychology, dentistry, pharmacy, or allied health. Geriatric Education Centers (GECs) Institutional awards to schools of the health professions to (1) im- prove the interprofessional education and training of health profes- sionals in geriatrics; (2) develop and disseminate curricula relating to the treatment of health problems of elderly individuals; (3) pro- vide faculty training in geriatrics; (4) provide continuing education to health professionals to provide geriatric care; and (5) provide stu- dents with clinical training in geriatrics in nursing homes, chronic and acute disease hospitals, ambulatory care centers, and senior centers. Like the GACA program, the provision of interprofessional education and training in the identification and treatment of mental health and substance use disorders is optional. Currently funded GEC grantees were required to select one of five evidence-based practice areas to link their education and training activities to participant practice improvement. The five areas are delirium, depression, diabetes mel- litus, fall prevention, and pain care. Of the 45 grantees, 6 grantees are addressing delirium and 6 are addressing depression. Comprehensive Geriatric Education Program Institutional awards to an accredited school of nursing, health care facility, program leading to certified nurse assistant certification, a partnership between a school of nursing and a health care facility, or a partnership between a school of nursing and a program lead- ing to certification as a certified nursing assistant. The grants may be used to provide training to individuals who provide geriatric care for the elderly; to develop and disseminate curricula relating to the treatment of health problems of elderly individuals; to train faculty members in geriatrics; to provide continuing education to individuals who provide geriatric care; or to establish traineeships for individuals who are preparing for advanced education nursing degrees in geriat- ric nursing, long-term care, geropsychiatric nursing, or other nursing areas that specialize in geriatrics. SOURCES: HRSA, 2010a,b,c, 2012.

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292 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS providing leadership in aging research, training, health information dis- semination, and other programs relevant to aging and older people, par- ticularly related to Alzheimer’s disease. Nevertheless, geriatric MH/SU is not a focus of the institute’s activities. In the past, the NIMH funded important research to inform the effective delivery of MH/SU services to older adults. At present, the institute is scaling back grant support for interventions and services research in favor of research in basic transla- tional neuroscience. SAMHSA is the lead federal agency charged by Congress to direct services and resources to people with MH/SU conditions, yet it has con- sistently devoted only a small fraction of its budget to older adults. It is particularly disconcerting that the agency is reducing its activities related to geriatric MH/SU. For example, SAMHSA has eliminated future fund - ing for its Older Adults Targeted Capacity Expansion grants program. It has also discontinued support for a successful adaptation of the Screen - ing, Brief Intervention, and Referral to Treatment for older adults who have nondependent substance use or prescription medication problems (known as the Brief Intervention and Treatment for Elders). RECOMMENDATION 2: The Secretary of HHS should ensure that its agencies—including the Administration on Aging (AoA), Agency for Healthcare Research and Quality (AHRQ), Centers for Medicare & Medicaid Services (CMS), Health Resources and Services Administra - tion (HRSA), National Institute of Mental Health (NIMH), National Institute on Drug Abuse (NIDA), and Substance Abuse and Mental Health Services Administration (SAMHSA)—assume responsibility for building the capacity and facilitating the deployment of the MH/SU workforce for older Americans: • CMS CMS should evaluate alternative methods for funding primary care and other personnel who provide evidence-based models of care to older adults with MH/SU conditions. This should include reimbursing care managers as well as the psychiatrists and other mental health specialists providing supervision of their work. CMS should evaluate alternative payment methods to encour- age effective deployment of the workforce to provide inte- grated primary care, chronic disease self-management, and health promotion for older adults receiving care in commu- nity mental health centers and other specialty mental health settings.

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293 IN WHOSE HANDS? RECOMMENDATIONS CMS should explore approaches and strategies for improving care delivery to older adults with MH/SU conditions through its contracts with quality-improvement organizations. CMS should enforce and monitor implementation of the Pre- Admission Screening and Resident Review (PASRR) and Min- imum Data Set (MDS) nursing home requirements regarding residents’ mental health. 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 coordinating body described below. The HRSA Administrator should ensure that the Geriatric Academic Career Awards career development grants include awards to geriatric MH/SU specialists if they commit to work- ing with older adults in acute or long-term care settings. The HRSA Administrator should ensure that the Geriatric Education Centers and the Comprehensive Geriatric Educa- tion Program institutional awards fund programs that train individuals in geriatric MH/SU care. • NIMH The Director of NIMH should ensure that the institute con- ducts research on methods for increasing the capacity of the mental health workforce to provide competent and effective care for older adults who reside in the community or in nurs- ing homes or other congregate residential settings. • SAMHSA The SAMHSA Administrator should ensure that the agency devotes sufficient attention to the capacity of the behavioral health workforce to provide both geriatric mental health and geriatric substance use services. The SAMHSA Administrator should ensure that the agency restores funding of the Older Adult Mental Health Targeted Capacity Expansion Grant program. The SAMHSA Administrator should require states that receive MH/SU block grants to document and to report how the funds are used to support local capacity to serve older adults.

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294 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS INVESTMENT IN HUMAN CAPITAL The capacity of the geriatric MH/SU workforce derives from the competence that is embodied in the individual personnel (human capi - tal), the group’s overall productive potential, and the organizational and policy contexts that facilitate its growth and competence. Support or accountability for training, recruitment, and retention of key geriatric MH/SU personnel—public or private—is wholly inadequate. Chapter 3 shows that the educational, training, and certification and licensure requirements for the workforce that cares for older adults with geriatric MH/SU conditions are vague, inconsistent, and minimal at best. For individuals pursuing specialty training in mental health or substance use, few specific standards exist for competence in geriatrics. For individuals pursuing specialty training in geriatrics, few, if any, training require- ments are related to mental health or substance use. For the large group of individuals who will have the most contact with older adults—trainees in primary care—there are few requirements related to geriatric mental health and substance use. Workforce Competence in Geriatric MH/SU The concept of “core competencies” is not new to health care work- force education and training. Many expert groups, individually and in collaboration (including geriatrics, social work, family medicine, geriatric nursing, geropsychology, direct care workers, and others) have identi- fied or are developing sets of essential skills, knowledge, and attitudes that are central to their specific discipline or are common across profes - sions (Canadian Centre on Substance Abuse, 2010; Council of Professional Geropsychology Training Programs, 2011; Geropsychiatric Nursing Col- laborative, 2010a,b,c; Heflin et al., 2011; Hoge and McFaul, 2010; Karel et al., 2010; Leipzig et al., 2009; Partnership for Health in Aging, 2008; University of Minnesota Research and Training Center on Community Living, 2011). The United States needs a workforce that is able to address the com- plex health care needs of older adults, with basic knowledge of geriatric MH/SU; expertise in team-based, collaborative care; cultural competence; and multilingual skills. The previous chapters make clear that the broad spectrum of the geriatric MH/SU workforce—from the most entry-level caregiving positions to advanced practice nursing to physicians—should be aware of the signs and symptoms of MH/SU conditions in older adults as well as potential abuse and neglect situations. All these individuals should be able to respond appropriately within their level of training, scope of practice, and the range of care settings in which they encounter

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295 IN WHOSE HANDS? RECOMMENDATIONS older adults such as primary care, home care, hospitals, nursing homes, and other congregate living settings. Chapter 4 presents compelling evidence that team skills are also essential to effective geriatric MH/SU care.5 All team members should possess the skills to work in collaboration with staff at different levels. Team-based care is more than the sum of each team member’s technical proficiency; it is about being “on the same page,” checking in with one another, and knowing when to delegate and when to consult more senior staff. Credentialing and accreditation are important inducements for obtaining specific knowledge and skills. Yet, as Chapter 3 describes, the committee found only indirect and vague references to the subject of geri - atric MH/SU in published standards. Most private-sector organizations that educate, train, accredit, and certify the various workforce sectors demonstrate little or no focus on ensuring providers’ competence in geri - atric MH/SU. A special concern is that current curricula—across nearly all the relevant disciplines—largely ignore the topic of geriatric MH/SU (see Appendix C). There is little evidence of dedicated geriatric curricula in training programs for MH/SU specialists (e.g., psychiatrists, psycholo - gists, psychiatric nurses, social workers, substance use counselors) or ded- icated geriatric MH/SU curricula in training programs for primary care providers (e.g., general medical internists, family medicine physicians, geriatricians, physician assistants, advanced practice registered nurses). RECOMMENDATION 3: Organizations responsible for accredita- tion, certification, and professional examination, as well as state licens - ing boards, should modify their standards, curriculum requirements, and credentialing procedures to require professional competence in geriatric MH/SU for all levels of personnel that care for the diversity of older adults. • These efforts should include requirements for recredentialing and professional development for already licensed and certified personnel. Dearth of Support or Incentives for Training, Recruitment, and Retention in Geriatric MH/SU Chapter 3 also makes clear that few opportunities or financial incen- tives are available for individuals to pursue specialized geriatric MH/SU training, for employers to invest in improving their staff’s competence in 5 See Chapter 4, Table 4-2.

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296 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS geriatric MH/SU care, or for personnel to enter and stay in the field. The Patient Protection and Affordable Care Act (ACA)6 workforce provisions present an important opportunity for increasing the numbers of geriatric MH/SU specialists across several disciplines as well as improving the competency of nonspecialists in identifying, managing, and referring older adults for MH/SU services.7 Although these programs do not spe- cifically target geriatric MH/SU, they do not preclude investment in this area. However, nearly all are unfunded (Baumrucker et al., 2011; Heisler and Sarata, 2011; Redhead et al., 2011b).The committee urges Congress to appropriate the funds for these programs with the proviso that the responsible funding agency—HRSA—direct a share of the monies to spe- cifically support training and education in geriatric MH/SU. These sup - ports should be applied across the workforce spectrum, from the direct care workers who care for older adults in their homes or in nursing facilities to the most highly trained specialists. The following describes examples of relevant workforce planning and training in the legislation. Workforce Planning • National Health Care Workforce Commission. Establishes a com- mission to review workforce supply/demand and recommend priorities and goals for nursing, mental health, allied and public health, and emergency medicine; to oversee and report on state health care workforce development grants; to evaluate ways to finance health care education and training; and to assess reports from the National Center for Health Care Workforce Analysis. • State health care workforce development grants. Establishes a grants program to enable state- and local-level partnerships to develop strategies for health care workforce development. Workforce Pipeline and Training to Increase Competence in Geriatrics • Geriatric education and training. Expands eligibility for geriatric education center grants to new types of entities, individuals, and professions, including allied health, medicine, advanced practice nursing, clinical psychology, clinical social work, marriage and family therapy, counseling, and physician assistant programs. Grants/contracts are for short-term intensive courses on geriatrics, chronic care management, and long-term care (LTC) for medical 6 Public Law 111-148. 7 For a complete summary of the ACA workforce provisions, see Discretionary Funding in the Patient Protection and Affordable Care Act (Redhead et al., 2011a).

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297 IN WHOSE HANDS? RECOMMENDATIONS school faculty and other health profession schools—in return for teaching or practicing in geriatrics, LTC, or chronic care manage - ment for at least 5 years. Grantees must offer family caregiver and direct care provider training (at no or nominal cost to enrollees). • Nursing workforce. Modifies and reauthorizes several existing nursing education programs to support nursing workforce devel- opment, including grants and scholarship programs for gradu- ate and undergraduate nursing education in cultural competency, workforce diversity, nurse faculty members, advanced education nurses, and geriatric nursing. Includes an increase in the maximum loan amount. • Medicare Graduate Nurse Education Demonstration Program. Establishes a Medicare demonstration program for up to five eli- gible hospitals to receive reimbursement for providing advanced practice nurses with clinical training in primary care, preventive care, transitional care, and chronic care management. • Demonstration projects to address health professions workforce needs. Establishes two demonstration grants to provide low- income individuals with opportunities for education, training, and career advancement. Offers financial aid and other supportive ser- vices to states, Indian tribes, institutions of higher education, and local workforce investment boards to help low-income individuals obtain education and training in health care jobs that pay well and are in high demand. Also includes grants to states developing core training competencies and certification programs for personal and home care aides. • Training opportunities for direct care workers. Establishes a grant program for educational institutions who partner with LTC pro- viders to provide new training opportunities (i.e., tuition and fee assistance) for direct care workers in LTC settings, including nurs- ing homes, assisted living facilities, skilled nursing facilities, and home- and community-based settings. RECOMMENDATION 4: Congress should appropriate funds for the Patient Protection and Affordable Care Act (ACA) workforce pro - visions that authorize training, scholarship, and loan forgiveness for individuals who work with or are preparing to work with older adults who have MH/SU conditions. This funding should be targeted to pro- grams with curricula in geriatric MH/SU and directed specifically to the following types of workers who make a commitment to caring for older adults who have MH/SU conditions:

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298 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS • Psychiatrists, psychologists, psychiatric nurses, social workers, MH/SU counselors, and other specialists who require skills and knowledge of both geriatrics and MH/SU. • Primary care providers, including geriatricians and other phy - sicians, registered nurses (RNs), advanced practice registered nurses (APRNs), and physician assistants. • Potential care managers for older adults who have MH/SU con- ditions, including RNs, APRNs, social workers, physician assis- tants, and others. • Faculty in medicine, nursing, social work, psychology, substance use counseling, and other specialties. • 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). • Family caregivers of older adults with MH/SU conditions. BUILDING BLOCKS OF INFORMED WORKFORCE PLANNING The dearth of even the most basic data is a significant barrier to workforce planning in the United States, especially in geriatric MH/SU. As Chapters 2 and 3 indicate, little is known about the clinical and demo - graphic characteristics of older adults with MH/SU conditions, the exist - ing skills and makeup of the workforce that serves them, or the educa - tional establishment that trains the workforce. There is a particular void of information on the older adults with MH/SU conditions who reside in nursing homes and other residential settings, prisoners, rurally isolated elders, and those with severe mental illnesses. Recommendation 1 (above) describes the importance of investing in ongoing research on recruitment and retention methods, evidence- based models of geriatric MH/SU care, curriculum development, and core competencies. The committee also recommends that HHS build an information infrastructure that ensures routine collection, dissemination, and analysis of data on the older adult population with MH/SU condi - tions and the workforce that serves them. RECOMMENDATION 5: HHS should direct a responsible entity (as described above) to develop and coordinate implementation of a data collection and reporting strategy for geriatric MH/SU workforce planning. Data collection and reporting should include the following: • Prevalence data for Diagnostic and Statistical Manual of Mental Disorders (DSM)-defined disorders and other MH/SU conditions, including data on comorbidity of these conditions. Representa - tive data on the following subgroups are essential:

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