In July the Institute of Medicine issued a report, The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? The point of the report was to call serious attention to the growing inability of the health care workforce to meet the behavioral health needs of the senior population.
The report pointed out the ranks of those of us over 65 will grow by 74% – from 40.3 million to 72.1 million – in the next 18 years. It said nearly one in five have a mental health or substance use problem. We now have pretty good evidence of the negative effects of the combination of chronic diseases such as diabetes, heart failure and chronic obstructive pulmonary disease with depression, substance use, and other behavioral health problems. It is clear behavioral health problems make other diseases worse, and chronic diseases make the behavioral health problems worse. There are good ways to treat this highly toxic combination of problems, but most of the time caregivers don’t know how to address them.
The IOM report pointed out:
“Across the (care giving) workforce, there is little, if any, training in geriatric MH/SU. (Mental Health and Substance Use) Overall, the number of individuals working in or entering fields related to geriatric MH/SU is disconcertingly small. Geriatric MH/SU specialists, who are the most highly trained to handle complex MH/SU cases, are in very short supply. In addition to the lack of a pipeline producing the type of workforce that is needed, many federal agencies with significant influence over the makeup, competence, and capacity of the workforce to deliver MH/SU services fail to exert that influence in the way they could or should, the committee notes.”
The report also criticized the way care is organized, with psychiatry consultation not being included in a team approach to care. “There is a fundamental mismatch between older adults’ need for coordinated care and Medicare’s fee-for-service reimbursement, which precludes payment for trained care managers and psychiatry consultation,” the report stated. Importantly, the report was critical of the way non-specialty providers are trained to deal with seniors. “Each member of the broad workforce that encounters older adults, from primary care doctors to geriatric specialists, needs to have the basic knowledge, skills, and competence to meet the needs of older adults with MH/SU conditions,” the report said. “To this end, the committee also calls for revamping how the health care workforce is trained and licensed.”
The simple description of the dramatic change in demographics and the current lack of training programs is a stark warning of the difficulties ahead for seniors. However, there are a couple of other phenomena which seem likely to further affect the availability of this behavioral health care. First, the health care reform legislation adds a major additional population to those now being served. Currently, people with drug and/ or alcohol abuse problems often are not able to obtain Medicaid-funded services. That will change as the Affordable Care Act takes effect, adding a substantial new demand for specialty services.
The second and more subtle issue likely to arise is the added demand for behavioral health services in patient-centered medical homes and their more extensive big brothers, the accountable care organizations. These two arrangements of care are focal points of change in health care from the ACA, designed to improve service and reduce costs. Many primary care offices have begun to realize that a lot of the problems that patients bring to primary care providers have a behavioral health component. In order to keep costs within their lump sum reimbursement, medical homes and accountable care are going to have to become better able to address these behavioral issues. For some, that may help deliver better care, but since few providers are trained to serve the senior population this influx of specialists into primary care seems unlikely to meet senior needs. It will almost certainly add to the strain on the behavioral health workforce as all sorts of organizations begin to want behavioral health providers for the first time.
It would be in everyone’s best interest – people over and under 65 – to start encouraging our doctors to add behavioral health to their repertoire, as well as to support the development of additional training programs both for specialists and primary care providers in understanding and treating behavioral health issues. It will be wasteful and ineffective to have untrained doctors and nurses trying to address the problems.
Without these changes, potentially treatable depression, substance use, and other behavioral health problems will go untreated, and, as a result, chronic conditions like heart failure and diabetes will be worse than they have to be. Patients will be unable to manage the treatment regimens they are prescribed by their care givers, leading to increased morbidity and greater costs.
Peter C. Brown, 71, is executive director of the Institute for Behavioral Healthcare Improvement