President’s Column: IOM Report Outlines Critical Issues and Plants Firm Guideposts

Published Friday, August 31, 2012
AAGP President Paul D.S. Kirwin, MD

In early July the Institute of Medicine (IOM) released a long anticipated report, The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?, which documents the prevalence of mental health and substance use issues among older adults, the interaction between these issues and physical health, and the changes needed in legislation, training, and reimbursement to provide quality care for the nation’s older adults.

The AAGP was a key and persistent force compelling Congress to approve the first IOM study in 2008, Retooling For An Aging America:  Building The Health Care Workforce, a broad study on the geriatric health care workforce. The 2008 IOM report superbly outlined the broad scope of the workforce crisis in geriatric health, but in defining the extensive challenges at issue it precluded an in-depth consideration of the workforce needed to address mental and behavioral health. Subsequent to this report, the AAGP vigorously advocated for Congress to approve an additional study to focus specifically on the mental health and substance abuse issues among older adults. In Fiscal Year 2010, the Labor-Health and Human Services Appropriations bill contained a provision providing $900,000 in funding for an IOM study on the mental health workforce for aging and ethnic populations. Joined by the American Psychiatric Association, the American Psychological Association, and the National Association of Social Workers the legislation was championed by Representatives Rosa DeLauro (D-Connecticut), Patrick Kennedy (D-Rhode Island), and Senator Herb Kohl (D-Wisconsin).

The 16-member IOM committee that produced this elegant and comprehensive report was chaired by Dan Blazer, former AAGP president, and made up of several AAGP members, including Steve Bartels and Gary Gottlieb, both former AAGP presidents, and included experts from psychology, nursing, social work, direct care, and members with epidemiology, finance and health care delivery expertise. The 376-page IOM report is ambitious in scope with very specific recommendations for reforms in policy, workforce, and health care delivery to meet the dramatic leap in our elderly population over the next 20 years. The U.S. Census Bureau projects that the population of adults age 65 and older will jump from approximately 40.3 million today to 72.1 million in 2030. Consummate with the committee’s charge from Congress it “considered forces that shape the healthcare workforce, such as education, training, modes of practice, and the financing of public and private programs.”

In setting the scope of the specific mental health care needs of the older persons, the IOM committee identified 27 mental health and substance abuse conditions that have significant impact on a person’s emotional well being and function—with depressive disorders and dementia-related behavioral and psychiatric symptoms most prevalent. They estimated that “5.6 million to 8 million older adults have one or more of these conditions—about 14 to 20 percent of the overall elderly population.” They emphasized that these illnesses detract from a person’s quality of life and have a significant impact on the financing and delivery of health care to our nation’s elderly.

The report reiterated the call from the 2008 IOM report that preparing a workforce to adequately meet these burgeoning health care needs requires urgent attention to educate and train more geriatric mental health and substance abuse specialists, but also immediate action to create opportunities and standards for training in geriatric mental health for other physicians, psychologists, nurses, social workers, and health aids on the front lines.  It also encouraged novel federal and private approaches to more adequately prepare family members to assist in identifying mental health needs and assisting in caring for those needs in an informed fashion. 

The report gives a sobering description of the heretofore piece meal and silo approach that federal and private entities have given to workforce issues regarding geriatric mental health.  Funding for innovative research and novel approaches to workforce and care delivery strategies contribute to our evidence base but are meager and unpredictable in their sustainability. The IOM calls for targeted and vigorous action by Congress and the HHS Secretary to “establish a locus of responsibility for geriatric MH/SU, to invigorate investment in the human capital that is the geriatric MH/SU workforce, to catalyze basic system redesign to allow for effective deployment of geriatric MH/SU personnel, and to stimulate essential research to inform the education and training of personnel and workforce planning itself.” The IOM report brings critical issues to the fore and plants firm and comprehensive guideposts to guide our government to underpin and expand efforts to care for the mental health needs of the elderly.

Within the AAGP membership we have a significant brain trust to help advocate for and actualize the IOM recommendations. Our experts have broad experience and specialized knowledge in clinical, educational and research endeavors that can inform those empowered to make critical legislative and regulatory reforms to enhance and incentivize our nation’s health care system to meet the needs of our elders.  We have the charge to enact educational reforms to better train the next generation of providers and incentivize them to enter our field.  We have the responsibility to promote research funding and to foster research careers to deepen our understanding of neuropsychiatric illnesses and to inform our clinical care.  We can devise novel and collaborative models of delivering health care which treat illness while promoting independence within a nurturing community.  We have the opportunity to contribute to and educate the body politic on old age mental health as well as emphasize examples of lives well lived in later years.  The convergence of the streams of escalating clinical need and emergent fiscal restraint stress the need for thoughtful, effective and evidenced-based interventions to provide vital care to our most vulnerable citizens. The IOM report is a prescient and clarion call to action.

Back to July/August/September 2012 Geriatric Psychiatry News