In the United States, there are signs that we are coming to terms with the growing healthcare needs of older Americans. Over the past decade, exploding Medicare costs and the federal budget deficit have forced medical professionals, policy-makers, and other stakeholders to consider the consequences of an aging population. The US Congress commissioned a report from the Institute of Medicine (IOM) on the physical healthcare needs of the elderly adults and the geriatric healthcare workforce required to meet them, resulting in the 2008 IOM report Retooling for an Aging America: Building the Health Care Workforce (IOM, 2008). Following this report, Congress recognized that the work was not finished and that more information was needed about mental health and substance use (MH/SU) disorders in older Americans. The IOM was commissioned by Congress to convene a committee to study and report on the workforce needed to care for this group. In 2012, the IOM released The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? (IOM, 2012).
The contents of the IOM report should be of great interest to readers of International Psychogeriatrics, as the document provides a thorough review of the epidemiology of MH/SU disorders in the elderly adults, characterizes the current workforce and models of care, makes clear recommendations to the governmental and credentialing agencies to improve the present system of care.
The report highlights five themes. First, the public health impact of mental illness and substance use in older adults is significant, but responsibilities for programs and policies to develop and support the workforce that is needed to relieve this burden are not effectively distributed across federal government agencies. Second, available data about the service needs of these older adults are not adequate to guide future workforce development, and more comprehensive and timely data are needed for this purpose. Third, many opportunities that exist in current federal programs have not been fully leveraged for the development and support of the geriatric MH/SU workforce. The necessary resources to ensure a viable workforce may be derived in large part from these programs. Fourth, training in essential competencies for the care of older adults with mental illness and substance use disorders must be provided across the workforce if it is to meet the challenges it faces and will face in the future. Fifth, new models of care must be put into place; some of these models have already been developed and demonstrated to be effective, and some remain to be developed.
The IOM report presents a stark reality: at least 5.6 million to 8 million older adults in America (nearly one in five) have one or more MH/SU conditions, which present unique challenges for their care. Several recommendations follow that are aimed at addressing these needs. At a systems level, the report calls on the Secretary of the Department of Health and Human Services (HHS) to designate a responsible entity for coordinating federal efforts to develop and strengthen the nation's geriatric MH/SU workforce and to develop and coordinate implementation of a data collection and reporting strategy for workforce planning. HHS agencies should assume responsibility for building the capacity and facilitating the deployment of the MH/SU workforce for older Americans. The US Congress ought to authorize and fund training, scholarship, and loan forgiveness for individuals who work with or are preparing to work with older adults who have MH/SU conditions. Outside the government, entities responsible for accrediting and licensing of clinicians caring for the elderly adults should ensure that current and future providers have adequate training in this area. Rather than merely focusing on expanding the number of geriatric specialty care providers, the report recommends that training in evidence-based treatment of MH/SU disorders should be provided to all primary care clinicians, nurses, care managers, allied healthcare and social service professionals who care for older adults, an important paradigm shift in health policy (Bartels and Naslund, Reference Bartels and Naslund2013).
For clinicians, researchers, and policy-makers interested in improving healthcare for older adults with MH/SU disorders, the IOM report should be viewed as both a resource and a call to arms. The literature review supporting the report's findings is current, thorough, and instructive. The recommendations are compelling as is the titular question “In Whose Hands?” While the report identifies governmental and non-governmental responsibilities, there is little doubt that our hands can play a role in ensuring that the proposals in the reports are implemented. We have the ability to educate our colleagues and our legislators about the report's contents. Many of us have already developed partnerships with advocacy groups with whom together we can promote the report. Furthermore, we should strengthen our ties to colleagues in the primary care system, who are after all a key focus of the report.
It is important to note for the many readers of the journal outside of the United States, the recommendations of the IOM report are applicable in international settings. The methodology for building the case for strengthening the workforce can be replicated locally, beginning with a review of epidemiological studies focusing on MH/SU disorders, then providing assessments of the current workforce and the anticipated future needs, and identifying individuals in a position to implement changes. In a similar fashion to the US experience, the process culminates in a clear and specific list of achievable, tailored recommendations for legal and policy changes at the national and regional levels.
We should be optimistic that the recommendations of the report will be implemented – optimistic, yet realistic about the financial and structural hurdles that will need to be overcome. It will take a great many hands to address the MH/SU needs of older adults, but our profession is uniquely positioned to push this initiative forward.
Conflict of interest
None.
