Needed: National Leadership—and Action
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 Centers for Medicare & Medicaid Services (CMS), for example, could influence the delivery of geriatric MH/ SU services, but its reimbursement rules deter, rather than facilitate, access to effective, efficient services. 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 Health Resources and Services Administration has the potential to support the training of key health personnel, yet none of its geriatric training programs require exposure to MH/ SU conditions. The Substance Abuse and Mental Health Services Administration is the lead federal agency charged by Congress to direct services and resources to people with MH/SU conditions, yet it has consistently devoted only a small fraction of its budget to older adults. And while the missions of several institutes at the National Institutes of Health relate to aging, mental health, or substance use, none focuses on geriatric MH/SU.
The committee urges Congress to fund the National Health Care Workforce Commission, which was authorized under the Patient Protection and Affordable Care Act (ACA) to serve as a national resource that focuses on evaluating and meeting the need for health care workers. Central among the commission’s top priorities should be identifying, developing, and refining methods to improve recruitment and retention of geriatric MH/SU personnel—and to build a workforce that reflects the diversity of the older adult population that it serves. Congress also should appropriate funds for the ACA workforce provisions that authorize training, scholarships, and loan forgiveness for people who work with or are preparing to work with older adults with MH/SU conditions. (See Insert.)
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. To this end, the committee also calls for revamping how the health care workforce is trained and licensed. Most organizations that educate, train, accredit, and certify the various workforce sectors are not focused on ensuring providers’ competence in geriatric MH/SU. Therefore, state licensing boards, as well as organizations responsible for accreditation, certification, and professional examination should modify standards, curriculum requirements, and credentialing procedures to require professional competence in geriatric MH/SU for all personnel who care for the diverse needs of older adults. HHS agencies should assume responsibility for building the geriatric MH/SU workforce and for facilitating its deployment. For example, CMS should evaluate alternative funding methods for personnel who provide evidence-based care to older adults with MH/SU conditions. This should include reimbursing care managers as well as psychiatrists and other mental health specialists who supervise their work. Similarly, the National Institute of Mental Health should conduct research on increasing the capacity of the mental health workforce to provide competent and effective care for older adults, whether they live in the community or in group residential settings, such as nursing homes.
For decades, policymakers have been warned that the nation’s health care workforce is illequipped— in numbers, knowledge, and skills—to care for a rapidly aging 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. These past calls to remedy inadequate training and to reverse serious shortages of personnel for MH/SU care have gone unheeded.
The breadth and magnitude of the problem have grown to such proportions 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 each of the entities that the committee identifies in its recommendations.