THE MENTAL HEALTH
USE WORKFORCE FOR
IN WHOSE 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
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, 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 Services. 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.
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Suggested citation: IOM (Institute of Medicine). 2012. The mental health and substance use workforce for older adults: In whose hands? Washington, DC: The National Academies Press.
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OF THE NATIONAL ACADEMIES
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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
ROBYN STONE, Senior Vice President of Research, LeadingAge, Washington, DC
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
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 published 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
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 constructive comments and suggestions, they were not asked to endorse the conclusions 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 carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
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 hidden 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
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 providers, 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 assignment 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 development 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 substance 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
The committee and staff are indebted to a number of individuals and organizations for their contributions to this report. The following individuals 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
Kathy Kuhn, Director of Workforce Development, Institute for Geriatric Social Work, Boston University—Social Workers, Case Managers, and Outreach Workers
Harold Pincus, Codirector, Irving Institute of Clinical and Translational Research and Professor, Department of Psychiatry, Columbia University
Patrick J. Raue, Associate Professor of Psychology in Psychiatry, Weill Cornell Medical College—Home Care Nurses
Marian Scheinholtz, Public Health Advisor, Community Support Programs Branch, Substance Abuse and Mental Health Services Administration (SAMHSA)
Michael Schoenbaum, Senior Advisor for Mental Health Services, Epidemiology, and Economics, Office of the Director, National Institute of Mental Health (NIMH)—Providing Depression Care in a Primary Care Setting—IMPACT
Bernadette Seifert, Coordinator of Older Adult Services, National Alliance on Mental Illness, New Hampshire
Dan Timmel, Medicaid Long-Term Care Policy Analyst, CMS Disabled and Elderly Health Programs Group
Jurgen Unutzer, Professor, University of Washington Department of Psychiatry
We also extend special thanks to the following individuals who were essential sources of information, generously giving their time and knowledge to further the committee’s efforts.
Scott Barstow, American Counseling Association
Carlos Blanco, Columbia University College of Physicians and Surgeons
Kipling M. Bohnert, Department of Veterans Affairs
Alice Bonner, CMS
Elizabeth Bragg, American Geriatrics Society
Shubing Cai, Brown University
David Chambers, NIMH
Robin E. Clark, University of Massachusetts Medical School
Teresa A. Coughlin, Urban Institute Health Policy Center
Nicholas Croce, Jr., American Psychiatric Nurses Association
Paola Daly, American Academy of Physician Assistants
Chris deVries, American Association for Geriatric Psychiatry
Deborah DiGilio, American Psychological Association
Meredith Eisenhart, Council on Social Work Education
Jovier Evans, NIMH
James Finley, American Mental Health Counselors Association
Beth Han, Center for Behavioral Health Statistics and Quality, SAMHSA
Rodney Harrell, AARP
Seiji Hayashi, Bureau of Primary Health Care
Jennifer Hohman, American Academy of Physician Assistants
Bob Hornyak, Administration on Aging
Gail Hunt, National Alliance for Caregiving
Jill Kagan, ARCH National Respite Network and Resource Center
William Lang, American Academy of Colleges of Pharmacy
Katharine Levit, Thomson Reuters
Lydia W. Li, University of Michigan School of Social Work
Cherry Lowman, National Institute on Alcohol Abuse and Alcoholism
Linda Lysoby, National Commission for Health Education Credentialing
Tami Mark, Thomson Reuters
Kristi Martinsen, Office of Rural Health Policy
Paul Moore, Health Resources and Services Administration (HRSA)
Vincent Mor, Brown University
Tom Morris, Office of Rural Health Policy
Mariquita G. Mullan, HRSA
Charlotte Mullican, Agency for Healthcare Research and Quality (AHRQ)
Tim Nanof, American Occupational Therapy Association
George Neiderhe, NIMH
Toru Okura, Bajikoen Clinic, Tokyo, Japan
Eunice Park-Lee, National Center for Health Statistics, Centers for Disease Control and Prevention
Alex Ross, HRSA
M. Katherine Shear, Columbia University School of Social Work
Susie Sherman, American Geriatrics Society
Shannon Skowronski, Administration on Aging
Jennifer Solomon, Center for Substance Abuse Prevention, SAMHSA
Anita Soni, AHRQ
Rebecco Spitzgo, National Health Service Corps
Melinda Anne Stanley, Baylor College of Medicine
Leonila Vega, Direct Care Alliance
Gil Weidenfeld, Annapolis, MD
Joan Weiss, Bureau of Health Professions, HRSA
Tracy Whitaker, National Association of Social Workers
Nancy L. Wilson, Baylor College of Medicine
Li-Tzy Wu, Duke University Medical Center
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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Boxes, Figures, and Tables
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