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The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? (2012)

Chapter: 4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions

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Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
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4

Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions

Abstract: This chapter reviews nine models of care delivery for older adults who have depression, substance use conditions, serious mental illness, or psychiatric and behavioral symptoms related to dementia. Mental health and substance use (MH/SU) care—particularly for depression and at-risk drinking—is most effective for older adults when it includes systematic outreach and diagnosis, patient and family education and self-management support, provider accountability for outcomes, and close follow-up and monitoring to prevent relapse. These elements are best obtained when care is patient-centered, in an easily accessed location (e.g., in primary care, senior centers, or individuals’ homes), and coordinated by trained personnel with access to specialty consultation. These aims are not likely to be achieved, however, without significant practice redesign, critical changes in Medicare payment rules, and substantial efforts to train and retrain the workforce appropriately. Research on effective delivery of MH/SU care for individuals residing in nursing homes and other residential settings, prisoners, rurally isolated elders, and older adults with severe mental illnesses is urgently needed.

The previous chapters described the mental health and substance use (MH/SU) needs of older adults and the available information on the health care workforce that serves them. The messages of the chapters are

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

clear. The MH/SU needs of older adults1 are complex, typically co-occur with other health problems, and are often inadequately addressed by today’s health care system. Moreover, the health care workforce is insufficiently prepared to address the MH/SU needs of the geriatric population.

The committee agreed early in its deliberations that the effectiveness and efficiency of the geriatric mental health workforce derives not only from the skills, knowledge, and size of the workforce, but also from how care is organized and delivered. The objective of this chapter is twofold: first, to review what is known about how to optimize the capacity of the workforce to yield better outcomes, especially in light of the chronic nature of geriatric MH/SU conditions and, second, to consider the implications of such models for workforce training and deployment of health care workers.

ORGANIZATION OF THE CHAPTER

The chapter begins with a brief description of the chronic care model—the central framework for many promising innovations in MH/SU care delivery. The next section reviews nine models of care delivery for older adults who have MH/SU conditions (Table 4-1). The committee had neither the resources nor the time to conduct a systematic review of model interventions. The nine models were selected to include common geriatric MH/SU conditions as well as the important settings where older adults often receive services. The models make clear that there is indeed an evidence base demonstrating that patient outcomes can improve with reorganization of care. Thus, the committee urges that workforce planners and policy makers should move beyond dismissive summaries that “nothing works for these patients” and consider the implications of the models for workforce education, training, credentialing, and licensure.

However, the robustness of evidence does vary across care settings and older adult populations; some published evidence had to be available in order to be included in this review. Research on effective delivery of MH/SU care is particularly lacking for older adults in nursing homes, residential treatment settings, and other congregate living arrangements as well as for prisoners, rurally isolated elders, and older adults with serious mental illnesses.

For settings with several intervention models, the committee chose the model that had the most robust evidence. For example, the Prevention of Suicide in Primary Care Elderly Collaborative Trial (PROSPECT)

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1 This report uses the term “older adults” to refer to adults age 65 and older. “Mental health workforce” refers to the full range of personnel providing services to older adults with mental health and substance use conditions.

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

TABLE 4-1
Models Reviewed in This Chapter

Model Target Population
Depression
Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) Older adult population with major depression, dysthymic disorder, or both
Kaiser Nurse Telehealth Care Model Adult population (all ages) starting antidepressant drug therapy
Program to Encourage Active and Rewarding Lives for Seniors (PEARLS) Older, community-residing adults with minor depression and dysthymia who are receiving social services
Substance Use
Screening, Brief Intervention, and Referral for Treatment (SBIRT) Older adult population at risk for alcohol and substance misuse
Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E) Older primary care patients with symptoms of depression, anxiety, and at-risk drinking
Serious Mental Illness (SMI)
Helping Older People Experience Success (HOPES) Older adults with SMI residing in the community
Psychogeriatric Assessment and Treatment in City Housing (PATCH) Older adults with SMI living in urban public housing
Wellness Recovery Action Planning (WRAP) Adults (all ages) with severe and persistent mental illness
Psychiatric and Behavioral Symptoms Related to Dementia
Providing Resources Early to Vulnerable Elders Needing Treatment (PREVENT) Older adults with Alzheimer’s and their caregivers
Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

was an effective intervention, but did not have as large a sample size or geographic diversity as the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial (Bruce et al., 2004). Similarly, the Healthy IDEAS (Identifying Depression, Empowering Activities for Seniors) trial of home-based depression treatment was not a randomized controlled trial (RCT) like the PEARLS trial, although it did show some evidence of effectiveness (Casado et al., 2008; Quijano et al., 2007). The selected models include interventions for managing depression in primary care and in home care settings, for addressing substance use, for assisting older adults with severe and persistent mental illness, and for managing the psychiatric and behavioral symptoms of dementia in primary care. For additional research on models for delivering MH/SU interventions to older adults, see the following reviews: (Bruce et al., 2005; Chang-Quan et al., 2009; Eklund and Wilhelmson, 2009; Frederick et al., 2007; Skultety and Rodriguez, 2008; Skultety and Zeiss, 2006; Snowden et al., 2008; Steinman et al., 2007).

The chapter concludes with a discussion on the implications of the models for developing the workforce.

THE CHRONIC CARE MODEL

U.S. health care delivery remains in a mode of care with origins in the early 20th century, when health care problems were typically acute and life expectancy was significantly shorter than today (Grumbach and Bodenheimer, 2002; IOM, 2001; Wagner et al., 1996). However, an acute care orientation is not appropriate for much of geriatric care (IOM, 2008). For the older adult, chronic illness is the norm, not the exception—for both mental and physical health conditions. An estimated 34 million of the 38 million older adults (89 percent) in the United States in 2009 had at least one chronic health condition (Alecxih et al., 2010). As a consequence, older adults most often seek medical care for chronic conditions such as diabetes or hypertension rather than acute problems such as respiratory infections or fractures. Yet most primary care practices that care for older adults continue to be designed to respond to the needs of patients with time-limited, acute health care problems (Berenson and Horvath, 2003; Grumbach and Bodenheimer, 2002). The gap between the type of care needed and the type of care available is particularly troublesome for older persons with mental illness (WHO, 2003). Research on treatment preferences also suggests that older adults with some MH/SU conditions, such as depression, prefer to receive mental health services in a primary care setting rather than via referral to a psychiatric specialist (Gum et al., 2006). However, primary care physicians detect and adequately treat or refer only 40-50 percent of patients with MH problems (Speer and Schneider, 2003). Moreover, surveys of primary care physicians indicate that fewer

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

than half of the patients they refer for mental health treatment actually receive services (Callahan et al., 1994; Lindley et al., 2010).

Thus the committee agreed that its assessment of how to strengthen the geriatric MH/SU workforce should assume a chronic care framework for delivering services. The committee also agreed that the Chronic Care Model (CCM), developed by Wagner and colleagues (2001), is an appropriate conceptual framework for integrating geriatric MH/SU services into primary care (Bodenheimer et al., 2002a,b; McDonald et al., 2007).

While the research on the CCM has limitations, the model has been demonstrated to lead to better outcomes across a variety of patient populations and care settings (Coleman et al., 2009; McDonald et al., 2007).2 Moreover, the model is flexible by design so that it can vary across organizations, settings, and time. Nevertheless, successful implementation requires fundamental changes in provider behavior and practice redesign to support the longitudinal, coordinated care of populations. The committee believes that a CCM approach has far more potential to reach more older adults more effectively and efficiently than today’s usual approach of referral to specialists and separation—sometimes carving out individuals’ mental health concerns—from other aspects of their care.

Care Coordination

The overarching principle of the CCM is that chronic illness care is best delivered with coordinated teams of providers working in systems and within communities that support the care of populations (Coleman et al., 2009; Epping-Jordan et al., 2004; McDonald et al., 2007; Wagner, 1998; Wagner et al., 2001). Care coordination, sometimes referred to as “disease management” or “care management,” is at the heart of most of the MH/SU models reviewed in this chapter. Numerous definitions of care coordination have been suggested. The committee adopted the following definition proposed by McDonald and colleagues (2007, p. 6) in a systematic review of quality-improvement strategies:

the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to

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2 For example, most of the research on chronic care management focuses on single chronic conditions in limited types of settings for only short periods of time. As a result, the findings may not be generalizable to real-world settings with more limited resources, motivation, or expertise. Evidence to support the cost-effectiveness of CCM-based interventions is also limited (Katon et al., 2005; Peikes et al., 2009). Given that most persons with chronic conditions, including those with mental illness, suffer from more than one chronic condition, there is a need for testing the broader model among populations with multiple chronic conditions. This may be particularly true for older adults who are more likely to suffer from multiple chronic conditions (Boult et al., 2010).

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care.

In the context of models of care for geriatric MH/SU, the essential components of care coordination with respect to workforce roles, skills, and competencies are

•  A patient-centered approach that recognizes the goals, culture, language, communication level, and needs of the individual patient or client.

•  Team-based care with each team member having the appropriate skills and resources as well as understanding of his or her role on the team. The team is led by a primary care provider (e.g., generalist physician or nurse practitioner). A critical focus of the team’s efforts is on engaging patients and clients in their care by helping them set goals and solve problems for improved self-management.

•  Stepped care; simpler interventions are tried first, more intensive interventions are considered if a good outcome is not achieved. Inherent in the stepped-care approach is the understanding that some patients will require input, comanagement, or management by specialist physicians.

•  Longitudinal tracking of the patient’s care and outcomes. Continuous follow-up of care is integral to stepped care, relapse prevention, and team members’ accountability for patient outcomes.

•  Access to specialty care or other exceptional resources for those patients whose goals cannot be met with the earlier steps in the stepped-care approach. CCM does not eliminate the need for specialists. Rather, it seeks to improve the appropriate use of this limited resource.

These components are clearly interrelated and suggest other key resources that should be available to the care team such as an infrastructure to support communication with the patient and among other health care providers; the capacity to tailor the treatment to individual patient needs; information technology to allow tracking of the process and outcomes of care and decision support; and access to appropriately trained human resources. For most primary care practices, implementing care coordination requires system-level practice redesign and personnel retraining programs as well as electronic health records for shared access to patients’ clinical data, individualized decision support, and easy communication between providers.

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

CARE DELIVERY MODELS FOR GERIATRIC MH/SU

This section of the chapter reviews nine models for providing MH/SU services to older adults (Table 4-1). It includes a brief review of MH/SU services in nursing home residents (despite the dearth of research on this very vulnerable population). As noted earlier, the models presented here reflect a variety of interventions (with variable levels of evidence) for depression, substance use, serious mental illness, and psychiatric and behavioral symptoms related to dementia. Several of the models began as RCTs, which yielded clinically significant results and have since been implemented in numerous sites around the country.

Models for Managing Depression

As Chapter 2 describes, depression during later life is prevalent and adversely affects many aspects of the person’s life, including physical health, disability, quality of life, health services usage, and mortality (Blazer, 2003, 2009; Hybels et al., 2009).3 Nevertheless, only a minority of older adults affected by depression receive adequate care (Garrido et al., 2011). This is despite more than two decades of research demonstrating the effectiveness of certain depression treatments such as antidepressant medications and some forms of psychotherapy for older adults (Blazer, 2009). More recent research—including well-executed RCTs—has also shown that there are effective models of care for delivering these treatments to ensure good outcomes for a variety of diverse, older adult populations (Arean et al., 2005a,b; Cavanagh et al., 2006; Ciechanowski et al., 2004; Frederick et al., 2007; Hunkeler et al., 2000, 2006; Katon et al., 2006; Proudfoot et al., 2003; Schonfeld et al., 2010; Steinman et al., 2007; Unützer et al., 2003; Williams et al., 2004). This body of evidence clearly suggests that the integration of mental health services into the primary care setting—where older adults receive the majority of their medical care—is an effective and efficient approach to improving the outcomes for older adults who have depression at the population level. Compared with usual care, these innovations have been shown to improve older adults’ treatment outcomes and satisfaction with care. In addition, primary care physicians report greater satisfaction with their ability to meet the needs of patients with depression.

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3 See Chapter 2 for detailed epidemiological data.

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

Improving Mood-Promoting Access to Collaborative Treatment (IMPACT)

IMPACT was one of the most robust trials ever conducted to assess the effect of collaborative depression care for older adults (Unützer et al., 2002). The RCT, funded by several foundations, compared usual care with a collaborative, stepped-care treatment model for 1,801 older adults who met DSM-IV-TR criteria4 for major depression or dysthymia. Eighteen primary care clinics in urban and semi-rural settings representing eight health care organizations in five states5 participated in the trial (IMPACT, 2011a). The clinics included a wide variety of health care delivery systems, including several health maintenance organizations (HMOs), traditional fee-for-service clinics, an Independent Provider Association (IPA), an inner-city public health clinic, and two Veterans Affairs (VA) clinics. Following the intervention, IMPACT patients reported greater improvement in depression, greater remission rates, improved quality of life, and satisfaction with care. An analysis of study participants in two HMO settings found that the model reduced total health care costs by about $3,300 per person over a 4-year period (Unützer et al., 2008).6

The IMPACT model has been replicated in other trials, demonstrating its generalizability, effectiveness, and suitability for introduction into primary care practices nationwide (Ell et al., 2008, 2010; Gilmer et al., 2008; Grypma et al., 2006; Katon et al., 2004). The program has been either implemented or implementation is under way in 38 states (not all of the programs target the older adult population). Nevertheless, barriers such as Medicare payment policy, lack of infrastructure, and a dearth of trained personnel have prevented widespread implementation for older adults.

Intervention In the IMPACT model, potential patients are either referred to treatment by their primary care provider (PCP) or are identified via routine depression screening. During the initial treatment visit, a depression care manager (DCM) completes an assessment, provides education about treatments, and asks the participant about his or her preference for depression treatment: antidepressant medications or psychotherapy. The DCM is supervised by a psychiatrist. All patients are encouraged to engage in some form of behavioral activation, such as physical activity or scheduling pleasant events. The IMPACT treatment algorithm suggests an initial choice of an antidepressant medication made by the psychiatrist

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4 DSM, or DSM-IV-TR, refers to the Diagnostic and Statistical Manual of Mental Disorders. During the course of this study, the Fourth Edition-Text Revision (DSM-IV-TR) was in use. A fifth edition is expected in 2013 (American Psychiatric Association, 2012).

5 The five states were California, Indiana, North Carolina, Texas, and Washington state.

6 Cost data were not available at the other study sites.

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

upon review of the patient with the DCM or a course of “Problem Solving Treatment in Primary Care,” a brief structured psychotherapy delivered by the DCM in the primary care office setting (Hegel and Arean, 2003).

The DCM follows up in person or by telephone approximately every 2 weeks during the intensive phase and approximately monthly for the remainder of the program. The duration of the intervention is 1 year.

Staffing Training is required to become an IMPACT DCM. The Advancing Integrated Mental Health Services Center at the University of Washington offers two training options: a 2-day in-person course or free online training (IMPACT). While most trainees have been social workers, psychologists, counselors, marriage and family therapists, psychiatrists, PCPs, nurses, and nurse practitioners, others are eligible for training. An IMPACT certificate program is under development and planned for release in 2012 (IMPACT, 2011b).

In primary care settings, IMPACT requires a partnership with a consulting psychiatrist (or other mental health specialist) who can provide regular consultation and supervision. If implemented in a mental health setting, a partnership is needed with the participant’s primary care provider. The DCM works with the primary care provider and receives additional support from the psychiatrist, who focuses on difficult cases and individuals not responding as expected.

Kaiser Nurse Telehealth Model

Older adults often have difficulty getting to providers’ offices because of cost, limited transportation options, or availability of services where they live (e.g., in rural areas). There is an emerging literature suggesting that telephone counseling and Internet-based programs may help overcome obstacles to accessing care and at substantially lower cost (Bee et al., 2008; Dieterich et al., 2004; Gellis et al., 2012; Hunkeler, 2011; Leach and Christensen, 2006; Pearson et al., 2003; Simon et al., 2004; Tutty et al., 2005). However, little related research specifically focuses on older adults. Patients receiving telecare must have affordable phone service with good connectivity and a private place to speak (Hunkeler, 2011). They must also hear well over the telephone, which could be a limitation for some older adults. Nurse telehealth care—including behavioral activation, supportive counseling, and monitoring of a patient’s response to pharmacotherapy—has been tested in a variety of settings (Meresman et al., 2003). The Kaiser Nurse Telehealth Care Model has been implemented and evaluated in 13 unaffiliated primary care clinics in Maine (Pearson et al., 2003) with similarly positive results, although with a younger, under-65 patient population.

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

Intervention The Kaiser Nurse Telehealth Model was developed and evaluated in the northern California region of Kaiser Permanente as an adjunct to depression treatment (although not specifically for older adults). Hunkeler and colleagues (2000) compared usual physician care, telehealth care, and telehealth care plus peer support to evaluate two augmentations of antidepressant treatment in an unbalanced randomized trial7 in two large primary care clinics. Participants included adults, ages 19 to 90, who were beginning antidepressant treatment for major depressive disorder or dysthymia. The patients receiving the intervention (with or without peer support) were more likely to experience improvement in depression and mental functioning compared to patients using usual Kaiser services.

Staffing Care was provided by a primary care physician and nurse and, in one arm of the trial, peer counselors (i.e., trained Kaiser members recovered from depression) as well. The nurses made 10 6-minute calls to the patients over a 4-month period. During the calls, the nurse answered patients’ questions about the medication, gave advice on dealing with side effects, and reinforced the importance of continuing the medication. The nurses also offered emotional support, encouraged patients to engage in pleasurable activities, reviewed the activities of the previous week, and helped the patient plan for future activities. Peer support was provided by volunteer health plan members who had been treated successfully for depression. They received approximately 20 hours of training and were matched with individuals of similar age and sex.

Program to Encourage Active and Rewarding Lives for Seniors (PEARLS)

Depression is particularly common among older adults who are socially isolated and have medical comorbidities or physical impairments. The PEARLS (Program to Encourage Active and Rewarding Lives for Seniors) program is a home-based intervention specifically designed for homebound, frail older adults with chronic medical conditions. The PEARLS trial, funded by the Centers for Disease Control and Prevention (CDC), was one of the first studies to demonstrate the feasibility of collaborating with community service organizations to identify and effectively treat depressed, homebound older adults primarily with counseling rather than prescription drugs (Ciechanowski et al., 2004). Community service organizations in 14 states provide the PEARLS programs.8

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7 In an unbalanced randomized trial, more patients are put in the treatment group when there is a strong suggestion it will prove superior.

8 See http://www.pearlsprogram.org.

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

The original PEARLS trial included 138 adults with minor depression or dysthymia who were recruited from community senior service agencies in Seattle, WA. The participants had an average of five chronic medical conditions. Racial and ethnic minorities made up 42 percent of the study population. More than half of the study population (58 percent) had annual incomes of less than $10,000. Patients with minor depression or dysthymia were randomized to the intervention or usual care. Intervention patients had significantly greater improvement in depression symptoms and quality of life compared to usual care patients and they showed a trend of fewer (self-reported) hospitalizations.

PEARLS has also been tested and found effective in reducing depression and suicidal ideation in adults of all ages with epilepsy (Ciechanowski et al., 2010a).

Intervention A DCM supervised by a psychiatrist provides six to eight depression management sessions in the patient’s home over a 5-month period and follows up with up to six brief monthly telephone contacts. The sessions include problem-solving treatment, in which participants are taught to recognize depressive symptoms, to define problems that may contribute to their depression, and to devise steps to solve those problems; and behavioral activation such as social and physical activity planning and pleasant event scheduling.

Staffing The DCMs in the original PEARLS trial were two trained master’s-level social workers and a registered nurse. In posttrial implementation, a wide selection of bachelor’s-level workers, typically drawn from the staff of the community organization implementing the program, have been trained. PEARLS training includes 2 days of in-person instruction in how to deliver the problem-solving treatment, as well as techniques that encourage physical and social activation. Training is available in sites around the country (http://www.pearlsprogram.org/Training.aspx). A PEARLS toolkit is available online and an online toolkit is being developed (Ciechanowski et al., 2010b).9

Substance Use Models

Substance use10 is often unappreciated as relevant to geriatric care even though, as the previous chapter reports, many older adults misuse

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9 Go to: http://www.pearlsprogram.org/LinkClick.aspx?fileticket=X-rXfpFDF0Q%3d&tabid=69.

10 This report uses the term “substance use” to refer to misuse of alcohol and drugs (prescription, over the counter, and illicit).

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

prescription medications and over-the-counter drugs, engage in at-risk drinking, and, to a lesser extent, use illicit substances. Relatively few older adults are screened for substance use conditions; even fewer who need treatment receive it (Schonfeld et al., 2010). This may be due, in part, to the unique challenges in addressing geriatric substance use. Diagnosis, for example, can be difficult because older adults’ chronic medical conditions and related symptoms may mimic the effects of substance misuse or be misinterpreted as normal signs of aging by both providers and older adults themselves. In addition, older adults may experience greater shame and guilt over their alcohol use and thus are less inclined to report problems. Because lower levels of drinking have dangerous health effects in older people compared to younger people, older at-risk drinkers may not perceive their alcohol use as risky (Blow, 1998).

Over the past two decades, findings from intervention studies conducted in a variety of medical and social service settings have shown that standardized screening and brief interventions can be effective in reducing nondependent substance use in adults of all ages, including older adults (Babor et al., 2007; Blow and Barry, 1999; Fleming et al., 1999; Lin et al., 2010; Moore et al., 2011; Schonfeld et al., 2010; Whitlock et al., 2004). In particular, screening and brief interventions have shown reduced alcohol consumption among older adults over an extended period of time (up to 18 months) in an array of health care and social service settings (Fleming et al., 1999; Moore et al., 2011; Schonfeld et al., 2010). One of the largest clinical studies of brief interventions in a primary care setting, the Trial for Early Alcohol Treatment (Project TrEAT), found that individuals in the intervention group had fewer hospital days and emergency department visits compared to the controls (Fleming et al., 1999). These effects were still significant after 2 years of follow-up (Fleming et al., 1999). A number of successful brief intervention studies also have been conducted in emergency department settings (Havard et al., 2008).

Because older adults receive services in a variety of settings and interact with numerous providers, there are many opportunities for screening and intervention. These include when older adults fill out new intake forms, during health care appointments, in emergency departments and urgent care clinics, during visits with home care nurses and social workers, and visits to senior centers and other social service agencies. This section describes two programs—SBIRT and PRISM-E—that use screening and brief interventions to address geriatric substance use.

Screening, Brief Intervention, and Referral for Treatment (SBIRT)

SBIRT is an early intervention and treatment model for persons who have substance use disorders. It is particularly noteworthy that Medicaid,

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

Medicare, and some commercial payers reimburse certain providers for providing SBIRT services in certain settings unlike other evidence-based MH/SU models (CMS, 2011; IRETA, 2010). Medicare, for example, covers SBIRT services provided by physicians, physician assistants, nurse practitioners, clinical nurse specialists, clinical psychologists, and clinical social workers for services delivered in physicians’ offices and outpatient hospitals (CMS, 2011).

The SBIRT model has three parts:

•  Screening to identify at-risk individuals, to assess the severity of misuse, and to determine the appropriate intervention.

•  A brief intervention to increase individuals’ awareness regarding substance misuse and to motivate behavioral change. In the primary care setting, brief interventions range from a brief dialogue between the provider and patient to concise counseling sessions with follow-up via telephone. For example, for the patient who engages in high-risk drinking behaviors, the provider may express concern, inform the patient that his or her current alcohol consumption levels are above recommended limits, and advise the patient to reduce or stop drinking (NIAAA, 2005).

•  Referral to treatment to provide further assessment and care for persons with severe problems.

In 2003, in response to the state legislature’s concern about substance use by the state’s elderly population, the Florida Department of Children and Families Substance Abuse Program initiated a 3-year screening and brief intervention pilot program for older adults in four counties (Schonfeld et al., 2010). Schonfeld and colleagues developed the program based on Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Improvement Protocols (TIPs) and other research. TIPs are consensus-based, field-reviewed guidelines on various substance abuse treatment topics (SAMHSA, 1998). The Florida team revised the SBIRT source materials to be age appropriate and available in both English and Spanish. The objective of the pilot—referred to as Brief Intervention and Treatment for Elders or BRITE—was to identify older adults who had nondependent substance use or prescription medication problems and to provide them with effective interventions before they needed more specialized treatment.

The project’s success led to a SAMHSA SBIRT grant for an additional 5-year program that eventually included 31 sites in 18 counties, including retirement communities, senior centers, general and trauma hospitals, primary care and urgent care clinics, VA medical facilities, and federally qualified health centers (Florida BRITE Project, 2009). From 2007 until the

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

SAMHSA grant ended in September 2011, there were more than 85,000 screenings of adults age 55 and older. An estimated 20 percent11 of those screened later received one or more brief interventions. An evaluation of the program demonstrated significant 6-month improvements in misuse of alcohol and medications as well as depression. Future funding of BRITE is uncertain.12

Intervention13 Outreach, screening, and counseling services were provided by BRITE counselors employed by four state agencies. Outreach presentations and screenings were conducted at health fairs, retirement communities, and senior housing sites. Bilingual counselors used a brief prescreening interview to identify individuals who might need further intervention. In addition, because substance misuse and depression often co-occur in older adults, individuals were also screened for depression and suicide risk. At-risk individuals were encouraged to maintain regular contact with primary care, social, aging, and other service providers.

Staffing13 Addictions specialists, nurses, social workers, and mental health counselors completed 4 hours of training to become certified as a BRITE counselor. Certified counselors also attended annual follow-up training workshops. Training included use of screening methods, brief intervention with a “Health Promotion Workbook,” and brief treatment. The counselors were instructed to initiate the brief intervention immediately after a positive screen. If the client appeared too tired, the intervention was scheduled for a follow-up visit. Individuals with severe substance use problems were referred to other agencies for detoxification or treatment.

Primary Care Research in Substance Abuse and
Mental Health for the Elderly
(PRISM-E)

PRISM-E was a multisite comparative trial of two models of care for treating at-risk drinking (as well as depression and anxiety) among older adults seeking primary care services in the VA health care system.14 The study is the largest comparative trial ever conducted on MH/SU care for

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11 The 20 percent statistic is from the first 3 years (Rodriguez et al., 2010).

12 Lawrence Schonfeld, University of South Florida, College of Behavioral and Community Sciences, personal communication, February 2, 2012.

13 These details on the intervention and staffing are specific to BRITE because it was tailored to an older adult population.

14 For more information on the trial’s findings related to depression and anxiety, see Arean et al., 2008; Bartels et al., 2004; Gallo et al., 2004; Kaskie and Buckwalter, 2010; Krahn et al., 2006; Levkoff et al., 2004.

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

older adults. It was funded by a unique collaborative effort of four federal agencies: SAMHSA, the VA, the Health Resources and Services Administration, and the Centers for Medicare & Medicaid Services. Because PRISM-E was a comparative trial, response to treatment could not be assessed. The objective was to compare the clinical outcomes of an integrated care model versus “enhanced referral” to specialty care.

The PRISM-E trial included 560 primary care patients age 65 and older who screened positive for at-risk alcohol use. They were then randomized to one of two models of care: integrated MH/SU services or enhanced referral to a specialty mental health setting (Levkoff et al., 2004; Oslin et al., 2006). Men who reported more than 14 drinks per week, women who reported more than 12 drinks per week, or anyone who reported more than 3 drinks 4 or more times during the past 3 months (i.e., binge drinking) were considered at-risk drinkers. The study participants were primarily male (92 percent) and white (70 percent). Patients with both at-risk drinking and a mental disorder were treated for both disorders. Ten VA sites15 participated, including primary care clinics and mental health specialty clinics nationwide (Levkoff et al., 2004).

Intervention In the integrated care model, services were colocated in a primary care setting where there was no apparent distinction—such as signage, clinic names, or staff—between the primary care and MH/SU care locations. At-risk drinkers received a brief, standardized treatment protocol that included three 20- to 30-minute alcohol intervention counseling sessions (Oslin et al., 2006). The protocol included a structured workbook with information on drinking cues, reasons for drinking, reasons to reduce or stop drinking, and a drinking “agreement” similar to a prescription form.

In the enhanced referral care model, MH/SU services were provided in a physically separate specialty MH/SU clinic designated by the primary care clinic. In contrast to the more typical referral process for specialty care, patients received enhanced referral support and case management. There was a clear referral process from the primary care clinic to the MH/SU specialist, transportation to the referral clinic was ensured, and an appointment was guaranteed within 4 weeks of randomization. In addition, the primary care clinic was notified if patients failed to make the first visits and patients were contacted if they missed any subsequent appointments. A process was also in place for emergency or urgent consults.

The investigators found no significant differences in at-risk alcohol

____________

15 Only 9 sites were included in the analysis of the trial because fewer than 10 individuals participated in the tenth site (Oslin et al., 2006).

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
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use between the two models (Oslin et al., 2006). Participants in both treatment groups reported significantly lower average weekly drinking as well as binge drinking. The investigators concluded that older at-risk drinkers can substantially modify their drinking over time, but neither model of care was superior in achieving the result. Participating primary care clinicians, however, reported preferring the integrated care model primarily because of improved communication between themselves and mental health specialists, decreased stigma, and better coordination of mental and physical health care (Gallo et al., 2004).

Staffing In the integrated model, providers (e.g., psychiatrist, psychologist, clinical social worker, or nurse with MH/SU training) had different levels of expertise in treating substance use. They received special training and worked in collaboration with older adults’ PCPs (Levkoff et al., 2004). Services in the specialty clinic were provided by licensed MH/SU clinicians, including psychiatrists, psychologists, social workers, nurses, or case managers with MH/SU training (Levkoff et al., 2004).

Models for Older Adults with Serious Mental Illness

As Chapter 2 describes, a growing number of older adults have serious mental illnesses (SMIs) such as schizophrenia, delusional disorder, bipolar disorder, and severe, recurrent, or treatment-refractory depression. Few representative data describe this particularly vulnerable population, although they are likely to have the most complex needs of any other subgroup of adults over age 65. Available studies suggest that older adults with an SMI have substantially higher rates of diabetes, lung disease, cardiovascular disease, and other comorbidities that are associated with early mortality, disability, and poor function (Bartels, 2004; Lin et al., 2011). They also have significant impairments in psychosocial functioning and are likely to experience loss of social supports as they age (Bartels and Pratt, 2009; Meeks et al., 1990b; Semke et al., 1996). Not surprisingly, older SMI patients account for disproportionately high costs and service use compared to other older adults (Borson et al., 2001). Lin and colleagues (2011) analyzed Medicare and Medicaid claims data and found that more than 40 percent of Massachusetts older adults with SMI were dually eligible for Medicare and Medicaid coverage.

In addition, lifestyle and behaviors (e.g., tobacco and alcohol use, sedentary) may put older adults with SMI at greater risk for metabolic side effects of antipsychotic medications and lead to obesity and the chronic conditions noted above (Bartels, 2004). Yet, unlike treatment interventions and services for younger persons with SMI, relatively little is known about effective service models for this population. However, evidence suggests

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
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that integration of MH/SU and primary care may lead to better outcomes for older adults with SMI (Druss et al., 2001; Mueser et al., 2010). In one RCT, for example, Druss and colleagues assessed differences in the physical and mental health outcomes for 120 middle-aged, male veterans16 enrolled in a VA mental health clinic. The trial compared usual care to integrated mental health and primary care. In the integrated care model, the mental health clinic had clinical responsibility for individuals’ primary care. A nurse practitioner, under supervision by a family practice physician, managed the patients’ basic medical care. The medical clinic was located next to the mental health clinic (Druss et al., 2001). In addition to the nurse practitioner and a part-time family practice physician, staffing included a nurse case manager and administrative assistant. A provider from the integrated clinic maintained close contact via e-mail and phone and met weekly with the mental health team. The mental health providers were kept updated on patients’ medical status and were encouraged to reciprocate with the integrated care team regarding patients’ psychiatric status. Clinic staff made concerted efforts to coordinate medical and mental health visits and to remind patients (and family members if necessary) about appointments. The patients receiving the intervention had significant gains in health outcomes and use of primary and preventive care services compared with the control group. They also had lower costs and fewer visits to emergency departments.

Three notable models, HOPES, PATCH, and WRAP, that integrate psychiatric and medical care for older persons with SMI are described below.

Helping Older People Experience Success (HOPES)

Most older adults with SMI live in the community, although they are at high risk of costly institutionalization, especially in nursing homes (Meeks et al., 1990a; Semke et al., 1996). Social supports and age-appropriate psychosocial rehabilitation services can be key to helping older individuals with SMI to function better and to remain in the community (Meeks et al., 1990a). Although significant progress has been made in psychiatric rehabilitation for younger persons, little attention has been paid to developing psychosocial rehabilitation services for older adults with SMI (Mueser et al., 2010).

The HOPES model is an integrated psychiatric rehabilitation and

____________

16 Only one study participant was female. The mean age of the intervention group was 46; the mean age of the control group was 45. Most older adults with SMI live in the community, although they are at high risk of institutionalization, especially in nursing homes (Meeks et al., 1990a; Semke et al., 1996).

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

health management program specifically developed to improve psychosocial functioning and to reduce the medical needs of older persons with SMI (Bartels et al., 2004). The model was assessed in an RCT of 183 older adults with SMI who were age 50 and older. The study participants were recruited from three public mental health agencies in New England.

Intervention The model combines skills training (independent living skills, social skills) with management of medical care needs and promotion of preventive health care, thought to be essential for continued residence in the community. Delivered over 2 years, HOPES is designed to improve psychosocial functioning and reduce long-term medical burden for older adults with SMI. The first year uses a seven-part curriculum that focuses on intensive skills training and health management. Psychiatric nurses meet monthly with participants and manage individual’s overall health care needs (Pratt et al., 2008). Rehabilitation specialists provide weekly group skills training in a variety of settings, including mental health clinics, rehabilitation centers, and senior centers. The second year is less intensive and focuses on maintenance. Participants attend skills classes, go on community practice trips, and meet with a nurse monthly. The HOPES trial demonstrated that it is feasible to engage older adults with SMI in an intensive skills training and medical management program. Compared with usual care, HOPES participants were more likely to remain in the program and to improve their social skills, psychosocial and community functioning, negative symptoms, and self-efficacy (Mueser et al., 2010).

Staffing HOPES uses community mental health nurses with training in both psychiatric and medical care. Community practice sessions and community supports (e.g., residential managers, case managers, and therapists) are integral to the HOPES model. As noted above, psychiatric nurses and rehabilitation specialists are essential members of the care team.

Psychogeriatric Assessment and Treatment in City Housing (PATCH)

Mobile outreach and treatment can be effective means of delivering MH/SU services to chronically ill, older adults with SMI who reside at home, but are unable or unwilling to access care through traditional means (e.g., community mental health or primary care centers). The roots of the PATCH program are two proactive, community-based models for adults with SMI who are experiencing serious challenges to living independently: the Assertive Community Treatment (ACT) Model (Stein and Test, 1980) and the Gatekeeper Model (Raschko, 1990).

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

A central concept of Gatekeeper is that lay community members, such as utility employees, bank tellers, postal carriers, and others, can be trained to identify and refer older adults who need services (Jensen, 2011). ACT is a model of community care for persons with SMI who have a recent history of psychiatric hospitalizations, criminal justice involvement, homelessness, or substance abuse (Test and Stein, 2000). The origins of ACT are in the deinstitutionalization era of the 1960s and 1970s, when mental health providers and community service agencies recognized that SMI residents of psychiatric hospitals needed help preparing for life in the community (ACTA, 2007). Both Gatekeeper and ACT have been implemented throughout the United States and internationally.

Like Gatekeeper, PATCH uses nontraditional referral sources who receive special training to learn how to identify and to refer at-risk older adults for multidisciplinary home-based mental health and community services. The model has three essential components (Robbins et al., 2000): (1) training of local workers, such as building managers, social workers, groundskeepers, and janitors, who have everyday opportunities to identify at-risk individuals; (2) referral of potential cases by these workers to a psychiatric nurse for follow-up; and (3) multidisciplinary psychiatric evaluation and treatment in residents’ homes. PATCH has been operating in Baltimore public housing since 1986 (Johns Hopkins Office of Community Services, 2011).

The PATCH model originated with a prospective randomized trial, funded by the National Institute of Mental Health, to assess whether a mobile case finding and treatment program in Baltimore city public housing sites could help seriously mentally ill residents remain in their homes (Rabins et al., 2000). The trial focused on older public housing residents (average age 74) with SMI because they are at great risk of eviction or termination of lease (Barker et al., 1988; Bernstein, 1982; Rabins et al., 2000; Robbins et al., 2000). Most of the 945 study participants were African American; 78 percent were women who lived alone. The individuals who received the intervention experienced significantly greater declines in psychiatric symptoms compared with the control group. However, the intervention had no impact on tenure in the public housing site perhaps because, as the investigators suggest, some study participants were found to be living in unsafe conditions and placed into nursing homes or board and care facilities.

Intervention In PATCH, nurses meet with building managers and other personnel to describe the program and initiate a structured educational program for building staff (Robbins et al., 2000). Training is organized into seven 1-hour monthly sessions, beginning with descriptions of common mental health conditions and alcoholism and ending with two sessions

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

on the emergency petition process and death and dying. The nurses also make presentations to building residents and tenant organizations. Upon receiving a referral, the nurse contacts the resident to schedule a home visit. The first home visit is a protocol-driven patient assessment. A team psychiatrist joins the nurse on a subsequent home visit to interview and evaluate the resident. If the team decides mental health services are needed, the nurse serves as case manager and direct care provider.

Staffing Trained “indigenous” workers, including building managers and workers, social workers, groundskeepers, and janitors who encounter older adults where they live, act as case finders. A psychiatric nurse is the primary service provider and a psychiatrist acts as supervisor and consultant.

BOX 4-1
Peer Support

With the advent of the Community Support Movement in the 1970s, there has been a growing realization of the need to re-create a therapeutic milieu “without walls” in the community. Peer services are an outgrowth of that movement; the core philosophy has been “nothing about us without us.” Peer support has evolved in various forms over the decades, and only recently has it begun to be more formally incorporated into treatment programs within mental health systems. This development is in addition to the importance and use of peer support in the treatment and recovery from substance use that goes back to the early part of the past century. These peer-delivered services are based on the premise that an individual with a “lived experience” is uniquely able to contribute to the rehabilitation and recovery of a person needing services. Integral to the peer support philosophy is the concept of recovery, which refers to an ongoing process of learning to live with one’s disability and gradually rebuilding a sense of purpose, agency, and meaning in life despite the limitations of the disorder.

The growth of peer support services has been impressive. A national survey published in 2006 found 7,476 peer programs nationwide, including 3,315 mutual support groups serving over 41,000 individuals;

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
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Wellness Recovery Action Planning (WRAP)

As noted earlier, self-management is a core component of chronic care management and care coordination. Self-management support—also referred to as self-care, self-help, and illness management—may include activities that are solely consumer directed; involve informal social supports such as family or friends; or include self-help activities that are guided by peers or professionals (Box 4-1). Self-management support for mental health conditions typically includes a wide variety of activities such as medication support, participation in self-directed components of psychotherapy, physical activity, recovery maintenance, relapse prevention, or vocational skills training. In the WRAP program and other peer-led support models, the peer and professionals do not assume responsibility for the individual’s care. This distinction can be very important to individuals because it removes the implied hierarchy in the relationship between the professional and the person with the mental illness (Mueser et al., 2002).

3,019 self-help organizations serving more than 1 million individuals; and 113 consumer-operated programs serving over half a million individuals. These numbers indicate that peer support services are becoming an important component of the health care system and the health care workforce.

Peers offer unique and distinctive skills and experiences not provided by other members of the usual care treatment team. The literature suggests that individuals can boost the recovery of their peers with serious mental illnesses, substance use disorders, or dual diagnoses. Patients report enhanced experiences when usual care is supplemented by peer-delivered services. However, research on clinical outcomes remains inconclusive.

The committee did not identify any peer support research focusing on older adults with mental health and substance use conditions. Research is clearly needed to help assess how and whether peer support services facilitate older adults’ recovery. Data are also needed on the peers themselves—those who provide services as well as those who receive services. These data should include race/ethnicity and language, given the current demographic trends.

SOURCES: Barber et al., 2008; Bluebird, 2008; Castelein et al., 2008; Chinman et al., 2008; Davidson et al., 1999; Goldstrom et al., 2006; Legal Action Center and Abt Associates, 2010; Money et al., 2011; Pfeiffer et al., 2011; Resnick and Rosenheck, 2008, 2010; Resnick et al., 2004; Rogers et al., 2012; Young et al., 2005.

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

In the WRAP program, trained peer facilitators teach individuals with SMI the skills, attitudes, and behaviors to self-manage their condition (Cook et al., 2009, 2012). The program targets adults of all ages. The focus is on helping people manage their mental illness independent of any more formal health care services they may receive. The curriculum stresses that, with a highly individualized plan for recovery, individuals can do more than simply manage their symptoms; they can also create a meaningful life in the community. WRAP peer instructors use examples from their own lives so that participants can witness how others have benefited from the program. They are trained not to use psychiatric or medical jargon to describe individuals’ needs. WRAP programs have been implemented in every state and internationally. Information on WRAP is currently available at http://copelandcenter.com/what-is-wrap/.

Cook and colleagues recently reported the results of the first randomized trial comparing the WRAP intervention to usual care (Cook et al., 2012). The 519 participants (average age 46) were recruited from a variety of mental health delivery settings in six Ohio communities, including community mental health centers, outpatient clinics, and residential programs. More than a third (37 percent) of the study participants were black, Hispanic/Latino, or another racial/ethnic minority. At 6 months, self-reports of improved symptoms, hopefulness, and quality of life were significantly higher among the WRAP participants compared to the control group.

Intervention In the WRAP RCT, the intervention included eight weekly 2.5-hour classes (Cook et al., 2012). The sessions were led by trained WRAP facilitators and included lectures, group discussions, instructional materials, and individual and group exercises. Self-guided wellness and recovery resources are available online.

Staffing Volunteer peer instructors make up the WRAP workforce. WRAP can also be solely consumer driven and self-managed. The program is managed by the Copeland Center for Wellness and Recovery in Rutland, VT. Five-day training sessions are available around the country. The fee is $1,200 to become a certified WRAP Facilitator and then be able to facilitate trainings to individuals in their community. Advanced training to become a certified Advanced-Level WRAP Facilitator costs $1,400. This training teaches those who have been WRAP Facilitators to train and certify other new facilitators.

Psychiatric and Behavioral Symptoms Related to Dementia

As Chapter 2 describes, older adults with dementia and other forms of cognitive impairment commonly exhibit disturbing behaviors and

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

psychiatric symptoms such as delusions, agitation, verbal and physical aggression, depression, euphoria, inappropriate sexual behavior, and unsafe wandering (Chan et al., 2003; Okura et al., 2010). If left untreated, these behaviors and symptoms can compromise the health and quality of life of not only the affected individuals, but also their caregivers (Callahan et al., 2006). Evidence also shows they may lead to caregiver burnout (family members as well as paid staff), nursing home placement, and higher health costs.

The PREVENT protocol is an example of an educational intervention tested within a collaborative care management model.

Providing Resources Early to Vulnerable Elders Needing Treatment (PREVENT)

PREVENT was an Agency for Healthcare Research and Quality– funded RCT that assessed the psychiatric impact of a collaborative care management model on 153 older adults with Alzheimer’s disease (and their caregivers). The trial compared a model (based on the IMPACT trial intervention) with augmented usual care at primary care practices in seven urban and racially diverse primary care practices in Indianapolis (Callahan et al., 2006). The primary care physicians treating the usual care group were free to provide any service they deemed appropriate.

Most of the study participants suffered from multiple comorbid medical conditions in addition to dementia. The program included a screening and diagnosis program to identify subjects eligible for the trial even if their primary care physicians had not yet diagnosed the dementing illness.

At 12 and 18 months after the intervention, the treatment group had significantly fewer behavioral disturbances, were more likely to receive cholinesterase inhibitors and antidepressants, and were more likely to rate their primary care as very good or excellent compared with the usual care group. There were no differences in functional decline. The intervention caregivers also reported significant improvements in distress at 12 months and sustained improvement in depression at 18 months.

The PREVENT protocol has been reengineered recently to improve its applicability and feasibility in the typical primary care practice and to facilitate its implementation in a real-world clinical practice (Boustani et al., 2011; Callahan et al., 2011). To accomplish these goals, the team developed a treatment manual with more attention to de novo implementation of the program in primary care, designed a new care model that delivers most of the intervention in the home while remaining a primary care–based service, and developed a specialty dementia clinic designed to support comanagement with primary care.

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
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Intervention Both study groups completed a counseling visit with an advanced practice nurse who provided education about Alzheimer’s disease and referral to community resources. Over the following year, intervention patients received care management by an interdisciplinary team led by a nurse practitioner (Austrom et al., 2004). Initially, the care manager met with the patient and caregiver bimonthly. Later, visits were scheduled more frequently (monthly). The intervention was carried out over 1 year.

Staffing Geriatric nurse practitioners acted as care managers. The nurse practitioner focused on the patient’s behavioral symptoms and coordinated management of the patients’ other chronic conditions with the primary care physician. The team used standard protocols to identify, monitor, and treat eight behavioral and psychological symptoms of dementia (primarily without prescription medications). The protocols included personal care, repetitive behavior, mobility, sleep disturbances, depression, agitation or aggression, delusions or hallucinations, and the caregiver’s physical health. The intervention targeted the patient’s caregiver as the primary conduit by which the patient received hands-on care.

MODELS OF MH/SU CARE FOR OLDER
NURSING HOME RESIDENTS

The absence of effective models for addressing the needs of older adults who live in long-term care settings is especially worrisome. As Chapter 2 documents, a substantial proportion of older adults reside in long-term care settings. An estimated 50 percent of nursing home residents age 65 and older have depression.17 Many nursing home residents also exhibit the behavioral symptoms associated with cognitive impairments (American Health Care Association, 2010). In contrast to the numerous RCTs on managing depression in older adults living in the community, informative research on how best to deliver MH/SU services to older adults in nursing homes is lacking. Psychiatric consultation is the most common approach to delivering specialty mental health services to nursing home residents (Bartels et al., 2002). This section provides a brief review of the evolution of consultative MH/SU services in nursing homes. Box 4-2 describes Preadmission Screening and Resident Review (PASRR) and the Minimum Data Set (MDS), two federally required programs

____________

17 Shaping Long Term Care in America Project and Brown University, unpublished data provided to the IOM committee, funded in part by the National Institute on Aging (1P01AG027296), 2011.

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

that influence the delivery of MH/SU services in long-term care facilities.

Consultation Model

In the past, solo psychiatrists visited nursing homes upon request to evaluate individual residents’ mental health and to make treatment recommendations if needed. By the mid-1980s, team-based consultation, with a psychiatrist at the center or in a supervising role, was common. These teams often included bachelor’s- and master’s-level mental health counselors, case managers, or mental health nurses. While continuing to address the needs of only the residents they were asked to see, the team had the opportunity to help nursing home staff with nonpharmacological care planning, staff education, and training. The consultative teams also provided counseling and mental health case management services to ensure that treatment recommendations were understood and followed (Conn and Silver, 1998; Loebel et al., 1991). There are too few psychiatrists, however, to support widescale implementation of this approach.

More recently, nursing homes have begun to use nurse-centered models in which a psychiatric nurse visits the nursing home to evaluate residents’ mental health needs and to manage their mental health services. Typically, the nurse is supervised by a psychiatrist and acts as an “extender” of the psychiatrist’s services. Although less common, the psychiatrist and nurse may come to the facility together and residents are triaged to either the nurse or psychiatrist, depending on individual need. This model might have the potential to compensate for the scarcity of psychiatrists, but fee-for-service payment arrangements are a barrier to its adoption. Medicare, for example, does not reimburse psychiatrists for supervisory services nor will Medicare pay for MH/SU services provided by nurses working in the absence of a physician (Berenson, 2003; Ostrow and Manderscheid, 2010)

Evidence on the effectiveness of any of these consultation variations is quite limited. In a 2002 review, Bartels and colleagues (2002) identified only one RCT that assessed the effectiveness of specialty consultation. The trial was at a single site and included 93 subjects. The investigators found that the majority of consultants’ recommendations were not followed. They concluded that the consultative model did not show clear benefit for nursing home residents with mental health conditions.

Observational research suggests that 50 to 75 percent of residents who receive MH/SU consultation services improve in some aspect. Interdisciplinary team models are generally viewed as best practice because they allow for innovative approaches for providing ongoing care while

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
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BOX 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

Enacted in 1987, the Nursing Home Reform Acta introduced two federal programs with direct implications for the mental health status and care of nursing home residents: (1) the Preadmission Screening and Resident Review Program and (2) the Minimum Data Set. Neither program has specific requirements related to the mental health or substance use training or qualifications of nursing home staff. However, as the text below describes, both programs have largely untapped potential to identify and to facilitate the appropriate care of older nursing home residents.

Preadmission Screening and Resident Review (PASRR)

PASRR requires all individuals to be screened for mental health conditions prior to admission to a nursing home. If a mental disorder is identified, a mental health specialist must further assess the patient to determine if the nursing home admission is appropriate. If the patient is admitted, the specialist must also provide follow-up treatment recommendations for the patient’s mental health care. This second-level screening is often performed by a master’s-level PASRR professional whose evaluation and recommendations are reviewed by a consulting psychiatrist. However, the PASRR screener typically has neither clinical responsibility for the patient nor any ongoing relationship with the nursing home’s clinical staff.

Numerous studies have demonstrated significant shortcomings in PASRR’s implementation. Borson and colleagues (1997), for example, found that fewer than 10 percent of nursing home residents in King County, Washington, had received a complete PASRR evaluation. Snowden and colleagues (1998) reported very poor compliance (35 percent) with PASRR treatment recommendations for patients with mental disorders, especially for nonpharmacological interventions and for patients with depression. Molinari and coworkers (2011) recently assessed 73 randomly selected nursing home admissions and

addressing the needs of nursing homes for means to train and educate staff.

Although federal and state regulations require nursing homes to have an administrator, medical director, and director of nursing services, the rules do not require specialized mental health personnel nor do they

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

found that although 85 percent of the patients were on a psychotropic medication, none of these patients had received the required level-2 PASRR mental health evaluation. Linkins and colleagues (2006) have documented that fewer than half of the states appear to incorporate clinically relevant PASRR information into patients’ nursing home care.

Minimum Data Set (MDS)

The MDS is a mandatory nursing home patient data collection and screening instrument used to assess patients’ physical and mental health status (including the behavioral symptoms of dementia). Every nursing home resident must receive an MDS assessment upon admission, every 90 days thereafter, and whenever there is a major change in the resident’s status. Thus, in contrast to PASRR, the MDS provides a routine, regularly scheduled mechanism for identifying nursing home residents with mental health needs. The MDS instrument has been updated and improved since its introduction. Compared with earlier formats, MDS 3.0 (now in use) contains better validated assessments of cognition, quality of life, and depression and more resident participation and input into the assessment. However, like PASRR, the MDS assessment does not require appropriate follow-up and treatment for patients needing mental health services. Although federal rules require residents to have a repeat PASRR evaluation if their MDS assessment changes significantly, the evidence suggests that this occurs rarely.

Thus, while offering some potential as a means of providing an infrastructure for organizing and delivering mental health services, the MDS would need to be integrated into nursing home treatment protocols and quality-improvement activities to reach this potential.

____________

a Public Law 100-203.

ADDITIONAL SOURCES: Borson et al., 1997; Callahan et al., 2002; CMS, 2012; Linkins et al., 2006; Molinari et al., 2011; Rahman and Applebaum, 2009; Snowden et al., 1998; Zimmerman et al., 2012.

require any nursing home staff to demonstrate minimum competence in geriatric MH/SU. Survey data indicate that about 25 percent of nursing homes report having mental health providers on staff and 24 percent use on-call providers.

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

IMPLICATIONS FOR THE GERIATRIC
MENTAL HEALTH WORKFORCE

The research presented in this chapter has critical implications for the deployment and training of personnel who care for older adults with MH/SU conditions. The traditional and most common model for delivering MH/SU services to older adults is one in which patients are referred to a specialist who is physically located in a setting separate from the patient’s usual source of care. Yet, the evidence clearly indicates that the effective delivery of MH/SU services—particularly for depression and nondependent substance use—requires a different delivery model. What works for many older adults who need MH/SU services is a patient-centered, team-based, primary care–centered model that is proactive and employs a coordinated team of personnel with specific roles and special training. Care managers are integral to the team’s effectiveness. In models such as IMPACT, Kaiser Nurse Telehealth Care, PREVENT, PRISM-E, and SBIRT, the care manager has the most interaction with the patient and serves as the central care coordinator. The psychiatrist or other mental health specialist is available for consultation and supervision, but only provides direct care for a minority of the more complex patients.

See Table 4-2 for a summary of the care settings and core staff in the models reviewed in this chapter. The following section describes the key staff roles in effective MH/SU treatment models.

Care Managers

Care managers are central to the effective intervention models. Whether they are categorized as traditional mental health case managers (as in the older literature from community mental health center models) or care managers as in more recent interventions presented here, they are the workers who directly provide and/or coordinate the treatment intervention. The education and background of these individuals vary widely, especially as one moves from examination of the research effectiveness trials to examination of posteffectiveness trial dissemination and implementation research. Care managers need to have interest and empathy for the elderly, and be comfortable caring for physically ill clients. In addition, the models typically require these workers to be trained in diagnosis and triage of MH/SU conditions, cognition screening, elder abuse/neglect and self-neglect, suicidality, using standardized tools for outcome assessment/ monitoring, recognizing medical decompensation, assessing and integrating cultural and linguistic issues, and effective use of supervision.

Some existing models now offer training to personnel with a variety of educational backgrounds (Ciechanowski et al., 2010b; IMPACT, 2011a,b; Kaskie and Buckwalter, 2010). Thus, programs that began as

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

TABLE 4-2
Care Settings and Core Staff for Selected Geriatric Mental Health (MH) and Substance Use (SU) Models

Model Care Setting Core Staff
Primary Care Mental Health Settinga Home Other Settingsb Team Primary Care Provider Care Managerc Psychiatrist or Other MH Specialist Peers or Family Caregivers
HOPES
IMPACT
Kaiser
Nurse
Telehealth
Care
d
PATCH
PEARLS
PREVENT
PRISM-Ee
SBIRT
WRAP

a Specialty settings include private offices of psychiatrists, psychologists, social workers, and other mental health professionals and community mental health centers.

b Other settings include emergency departments, community senior centers, social service agencies, mobile outreach programs, health fairs, hospitals, and urgent care clinics.

c Care managers may be nurses, psychologists, social workers, or other depression care specialists.

d Peer counselors were used in one arm of the trial.

e PRISM-E findings refer only to the at-risk drinking intervention.

SOURCES: Austrom et al., 2004; Bartels et al., 2004; Callahan et al., 2006; Ciechanowski et al., 2004; Cook et al., 2012; Florida BRITE Project, 2009; Frederick et al., 2007; Hunkeler et al., 2000; IMPACT, 2011b; Levkoff et al., 2004; Oslin et al., 2006; Pratt et al., 2008; Rabins et al., 2000; Robbins et al., 2000; Schonfeld et al., 2010.

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

RCTs that used nurses or master’s-level social workers as care managers are increasingly training a broader group to best fit the setting and personnel resources available. These workers are typically in much greater supply and thus become logical targets for interventionists to match the growing population of older adults. To the extent care managers can be drawn from existing aging network providers, the models can use people who have some general aging background and training and who are already “touching” the lives of the elderly population often in need of MH/SU services.

The available research does not clearly delineate the “minimum” requirements necessary to serve as an effective care manager. With adequate training and supervision as called for in the models, the advantage of flexibility and workforce availability may balance the concerns regarding possibly limited skill set and autonomy. How these workers relate to the existing certified or licensed geriatric care managers authorized to bill for services in some settings is not clear, though overlap likely exists. From the perspective of the interventions reviewed here, it is more important to view the role or function of this category of worker than the existing designation they have in the current fee-for-service environment.

Additionally, as one sees different training backgrounds in potential care managers, the models can be more flexible in the type and number of conditions to be addressed. For example, a nurse care manager can be trained to intervene in mental health conditions such as depression and primary care medical conditions such as diabetes and hypertension (Katon and Seelig, 2008). Social work training, which typically includes intensive training in care management, can easily tailor the curriculum to include older adults with MH/SU issues. However, it is not as clear that a social services agency case manager with no medical background or case management could serve as easily in a model designed for patients or clients with multiple chronic conditions.

Primary Care Providers

PCPs are key figures in several of the reviewed models. This is logical given two factors: (1) the greater abundance of primary care providers compared to MH/SU specialists; and (2) the central role primary care providers play in managing chronic conditions outside of MH/SU problems. The reviewed interventions clearly indicate that effective treatments are available for MH/SU problems for primary care patients. These models increasingly call for primary care providers to comanage patients with MH/SU providers instead of simply referring out for specialty management. For example, antidepressant prescriptions are the purview of the primary care provider in IMPACT and the Kaiser Nurse Telehealth Care

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

Model, and the depression care management team guides the antidepressant use via recommendations. Thus, training programs for primary care providers should require training in basic management of MH/SU problems to maximize the comfort level and skill set that primary care providers will have in team-based care.

For models based in primary care (e.g., IMPACT, Kaiser Nurse Telehealth Care, PREVENT, and PRISM-E), sharing of office space will be necessary and primary care information systems will need to incorporate identification and monitoring of MH/SU problems. The U.S. Preventive Services Task Force cautions that screening for depression in primary care settings should only be done in settings with the capacity for treatment with an intervention model like those described here. Therefore, while it may seem feasible and logical for all settings to screen and identify, the data do not support this as an effective strategy (USPSTF, 2011).

Specialists

Specialists are typically the member of the team with the highest degree of training for the MH/SU issue of interest. In some models, this is a psychiatrist (e.g., IMPACT) or geriatric psychiatrist, but could be a psychiatric nurse practitioner, general internist, or licensed clinical social worker, depending on the setting and treatment condition.

As the previous chapter described, there will never be sufficient numbers of MH/SU specialists to provide direct specialty care to older adults. This chapter shows that if the role of MH/SU specialists is redefined to one in which they serve in a supervisory and/or consultative function, care is likely to be both more efficient and more effective. There are critical barriers to changing the specialists’ role:

•   MH/SU specialists are often not trained in their fellowship or certification programs to manage a population of patients they never or rarely see.

•   Under current rules, Medicare fee-for-service payment will not reimburse MH/SU specialists for supervisory activity.

•   Practice settings must acquire the information technology systems for screening and monitoring patient-level outcomes and for communication with patients as well as other providers.

•   Practice settings will often need to colocate the MH/SU providers with primary care providers. While it is clear that colocation alone is insufficient, as demonstrated in the PRISM-E trial, engagement is clearly improved via colocation versus specialty sector referral for patients who are not already involved in specialty care settings.

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

Patients

The models reviewed often have as a core component the education and activation of the patient (and/or caregiver) as a more engaged participant. The most promising MH/SU models include patient education and activation, with the goal of having the patient more actively participate in care choices and learn to self-manage his or her own condition. While viewed as an advantage by many of the baby boomer generation who are not as likely to simply accept the judgment of their health care provider, this may not be an attitude of some current older adults who feel it is appropriate to seek the advice and defer to the opinions of their primary care provider. Equally important, especially given the diversity of the population, is how engagement is achieved within the context of the participant’s culture and language.

CONCLUSIONS

A persuasive body of evidence, drawn from two decades of research, shows that two common MH/SU disorders among older adults—depression and at-risk drinking—are most effectively addressed when care is organized to include these essential ingredients: (1) systematic outreach and diagnosis, (2) patient and family education and self-management support, (3) provider accountability for outcomes, and (4) close follow-up and monitoring to prevent relapse. Moreover, these elements are best obtained when care is patient centered (integrating patient preferences, needs, and strengths), in a location easily accessed by patients (e.g., in primary care, senior centers, or patients’ homes), and coordinated by trained personnel with access to specialty consultation. There is also evidence suggesting great promise in telehealth and Web-based interventions for older adults with MH/SU conditions. Progress in these areas is not likely to be achieved, however, without practice redesign and change in Medicare payment rules. There is a fundamental mismatch between older adults’ need for coordinated care and Medicare fee-for-service reimbursement that precludes payment of trained care managers and psychiatry consultation.

The committee concluded, as have many other studies, that the delivery of and payment for health care services to older adults must be reorganized to reflect the chronic nature of MH/SU and other health conditions prevalent in the 21st-century geriatric population (IOM, 2008). The workforce implications are daunting. Registered nurses are particularly well suited to coordinate MH/SU and physical health care, but they need additional training to serve in this capacity. Primary care providers, such as physicians, advanced practice registered nurses, and physician assistants are an integral component of these models, yet, many of them have

Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
×

not been trained in collaborative care and do not work in a practice or system supportive of comanagement, colocation, screening, and outcome monitoring.

Frontline workers within the aging provider network agencies may be a potential source of care managers. However, they will require intensive training in evidence-based program treatment as they are likely to have limited knowledge of MH/SU.

Finally, research on effective delivery of MH/SU care for certain older populations is urgently needed, especially for individuals residing in nursing homes and other residential settings, prisoners, rurally isolated elders, and older adults with severe mental illnesses.

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Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
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Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
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Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
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Suggested Citation:"4 Workforce Implications of Models of Care for Older Adults with Mental Health and Substance Use Conditions." Institute of Medicine. 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. Washington, DC: The National Academies Press. doi: 10.17226/13400.
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At least 5.6 million to 8 million--nearly one in five--older adults in America have one or more mental health and substance use conditions, which present unique challenges for their care. With the number of adults age 65 and older projected to soar from 40.3 million in 2010 to 72.1 million by 2030, the aging of America holds profound consequences for the nation.

For decades, policymakers have been warned that the nation's health care workforce is ill-equipped to care for a rapidly growing and increasingly diverse population. In the specific disciplines of mental health and substance use, there have been similar warnings about serious workforce shortages, insufficient workforce diversity, and lack of basic competence and core knowledge in key areas.

Following its 2008 report highlighting the urgency of expanding and strengthening the geriatric health care workforce, the IOM was asked by the Department of Health and Human Services to undertake a complementary study on the geriatric mental health and substance use workforce. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? assesses the needs of this population and the workforce that serves it. The breadth and magnitude of inadequate workforce training and personnel shortages have grown to such proportions, says the committee, that no single approach, nor a few isolated changes in disparate federal agencies or programs, can adequately address the issue. Overcoming these challenges will require focused and coordinated action by all.

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