President’s Column: Advocating for the IOM Recommendations on the Geriatric Mental Health Workforce
|AAGP President Paul D.S. Kirwin, MD|
On September 19th, a standing room only congressional briefing was held to disseminate the findings of the recent IOM report, The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?, to congressional and federal agency staff. The report 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 briefing, Building the Mental Health Workforce for America’s Diverse Aging Population, was sponsored by the American Association for Geriatric Psychiatry, the American Psychological Association, the National Association of Social Workers, and the American Psychiatric Association. Congresswoman Rosa DeLauro (D-Conn.), who co-sponsored and pressed for legislation to authorize funding for the study, was pivotal in setting up the hearing. Past AAGP President Dan Blazer, MD, PhD, chaired the IOM committee, and also chaired the congressional briefing. Presenting with Dr. Blazer were Michael Hoge, PhD, director of psychology training and professor at the Yale University School of Medicine, a mental health workforce expert who represented the American Psychological Association; and Maria Aranda, PhD, MSW, associate professor at the USC School of Social Work, and an expert in mental health interventions and services to underrepresented populations, from the National Association of Social Workers. Both Drs. Hoge and Aranda were members of the IOM committee. The presentations were interdisciplinary and collaborative, reflecting the IOM’s emphasis on building a mental health workforce reliant on expertise from a variety of health care disciplines. Each presenter spoke from the richness of the IOM report but also from their career experience serving those at the margins, striving to better the lives of those suffering from mental illness, and pushing the boundaries of our knowledge through scholarly excellence.
Dan Blazer began by emphasizing the committee’s charge to: “Determine the mental and behavioral health care needs of older Americans and then make policy and research recommendations for meeting those needs through a competent and well-trained mental health workforce.” He stressed several key findings of the IOM study, picked up by several news reports subsequent to the report’s release:
- About 1 in 5 older Americans has a mental health/substance use (MH/SU) condition
- 8 million older adults have one or more MH/SU conditions
- 2 million older adults have a serious mental illness (SMI)
- Depressive disorders and behavioral problems secondary to dementia are most prevalent
- Older veterans are more likely to have MH/SU conditions than the general older adult population
In addition, when looking to the future Dr. Blazer stressed that:
- There will be greater numbers of African Americans and Hispanic/Latinos with MH/SU
- There will be more older adults with dementia and associated behavioral and psychological symptoms
- Use of illicit drugs is likely to increase, especially marijuana use and non-medical use of prescription drugs
The IOM committee revealed “that the sheer number of providers entering, working in, and remaining in the fields of primary care, geriatrics, mental health, substance use, and geriatric MH/SU is disconcertingly small.” And that “the rate of specialized providers entering the workforce is dwarfed by the pace at which the population is growing.” The report brings these stark realities into public awareness--facts known to us on the front lines for years, and emphasized by the 2008 IOM report on the general geriatric workforce.
Michael Hoge shared with staffers the staggering mental health workforce deficits facing this nation. He stressed the report’s recommendations that workforce development must strenuously occur simultaneously on several fronts including:
- Training in: geriatrics for MH/SU specialists; MH/SU for specialists in geriatrics; and MH/SU and geriatrics for primary care providers
- Faculty recruitment and development
- Training for direct care workers, family caregivers, and peer support providers
- Reduced stigma of working with this population
- Incentives that attract and retain providers for this work
- Focused recruitment of individuals from diverse backgrounds to the workforce
A radical political and societal sea change is needed to actualize the far-reaching IOM recommendations to ensure strategically funded efforts in education, provision of care and research to provide for the health care needs of our elderly. The committee observed that there is a fragmented approach at the federal level to address these issues. Maria Aranda conveyed at the briefing that the IOM recommended a fundamental restructuring of the federal approach and that “Congress should direct the Secretary of HHS to designate a responsible entity for coordinating federal efforts to develop and strengthen the nation’s geriatric MH/SU workforce (e.g., National Health Care Workforce Commission).” She said the report stressed that “the Secretary of HHS should ensure that its agencies—including AoA, AHRQ, CMS, HRSA, NIDA, NIMH, and SAMHSA—assume responsibility for building the capacity and facilitating the development of the MH/SU workforce for older Americans.” For each of these federal entities Dr. Aranda outlined the IOM’s specific suggestions on how to increase the skill and capacity of the MH/SU workforce, and ways that each entity could incentivize training in geriatric mental health. In addition, several opportunities are available through the Affordable Health Care Act to “fund training, scholarship, and loan forgiveness for individuals who work with or are preparing to work with older adults who have MH/SU conditions. Funding should target programs with geriatric MH/SU curricula.” The IOM implored Congress to press for these changes immediately.
Subsequent to the congressional briefing the AAGP organized several meetings to begin laying the groundwork for legislative and regulatory initiatives to bring to fore the IOM’s recommendations. AAGP and APA staff, and Michael Hoge and I met with Congresswoman Rosa DeLauro and senior staff immediately following the briefing. Congresswoman DeLauro serves as ranking member on the House Subcommittee on Labor, Health and Human Services, Education, and Related Agencies whose oversight power is critical to actualizing the IOM recommendations. Congresswoman DeLauro brings her passionate commitment to these issues and has been a forceful partner with the AAGP on several legislative initiatives to better the lives of our elder citizens.
We next met with Senator Richard Blumenthal’s legislative staff to inform them of the IOM recommendations. Senator Blumenthal (D-Conn) serves on the Senate Committee on Health, Education, Labor and Pensions and the Special Committee on Aging. The Senator’s staff was eager to work with the AAGP as Senator Blumenthal continues to fiercely advocate for the needs for the elderly.
We next met with Jan Heinrich, PhD, director, Bureau of Health Professions, HRSA to discuss programmatic initiatives to incentivize trainees to gain MH/SU experience and bolster collaborations with mental health and primary care. Staff at HRSA was receptive to IOM suggestions including:
Devote sufficient attention to geriatric MH/SU through the National Center for Health Care Workforce Analysis
- Ensure that Geriatric Academic Career Awards, career development awards, include geriatric MH/SU specialists
- Fund programs that train individuals in geriatric MH/SU care through the Geriatric Education Centers and the Comprehensive Geriatric Education Program institutional awards
AAGP will continue to work closely with HRSA on these issues.
Our last meeting was with Toni Zeiss, PhD, chief consultant, Office of Mental Health Services, and Bradley Karlin, PhD, National Mental Health Director for Psychotherapy and Psychogeriatrics, both at the Veterans Affairs Central Office. They too welcomed the IOM recommendations. In a recent article Drs. Karlin, Zeiss, and Burris stated, “The VHA is major provider of care to older adults; approximately 45 percent of veterans enrolled in care in the VHA are at least 65 years of age. In FY 2009, the VHA provided care to more than 2.3 million veterans ages 65 or older. Care for older veterans is anticipated to become an increasing focus of the VHA, largely because of the aging of the Vietnam era cohort of veterans.” (Journal of the American Society on Aging, Volume 34, Number 2, 2010.) The VHA has been a leader in developing novel programs for the care of older veterans, efforts that encourage expert evidenced-base care, training and research programs focused on geriatric MH/SU.
The AAGP’s advocacy and education efforts on Capitol Hill were pivotal in getting the funding necessary for this prescient IOM study. Our organization remains at the forefront of efforts to draft legislation and institute regulatory reform to bolster our nation’s geriatric mental health workforce. We have to take the long view on change, with the AAGP at the table pushing for novel approaches to build, strengthen, and incentivize a workforce skilled in geriatric mental health.