Millions of baby boomers will likely face difficulties getting diagnoses and treatment for mental health conditions and substance abuse problems unless there is a major effort to significantly boost the number of health professionals and other service providers able to supply this care as the population ages, says a new report from the Institute of Medicine. The magnitude of the problem is so great that no single approach or isolated changes in a few federal agencies or programs will address it, said the committee that wrote the report.
The report calls for a redesign of Medicare and Medicaid payment rules to guarantee coverage of counseling, care management, and other types of services crucial for treating mental health conditions and substance use problems so that clinicians are willing to provide this care. Organizations that accredit health and social service professional schools and license providers should ensure that all who see older patients -- including primary care physicians, nurses, physicians' assistants, and social workers -- are able to recognize signs and symptoms of geriatric mental health conditions, neglect, and substance misuse and abuse and provide at least basic care, the committee said.
Top leaders of the U.S. Department of Health and Human Services need to promote national attention to building a work force of sufficient size that is trained in geriatric mental health and substance abuse care. They should ensure that all the department's relevant agencies are devoting sufficient attention and resources to these conditions.
"There is a conspicuous lack of national attention to ensuring that there is a large enough health care work force trained to care for older adults with mental health and substance use conditions," said committee chair Dan G. Blazer, J.P. Gibbons Professor of Psychiatry and Behavioral Sciences and vice chair for faculty development, Duke University Medical Center, Durham, N.C. "These conditions are relatively common, they can be costly, and they can have profound negative impacts on people's health and well-being. This report is a wake-up call that we need to prepare now or our older population and their extended families will suffer the consequences."
The committee conservatively estimated that between 5.6 million and 8 million older Americans -- 14 percent to 20 percent of the nation's overall elderly population -- have one or more mental health conditions or problems stemming from substance misuse or abuse. Depressive disorders and dementia-related behavioral and psychiatric symptoms are the most prevalent. Rates of accidental and intentional misuse of prescription medications are increasing. Although the rate of illicit drug use among older individuals is low, studies indicate that it will likely increase as the baby boomers age.
Inattention to older adults' mental health conditions and substance misuse is associated with higher costs and poorer health outcomes, the report notes. For example, older individuals with untreated depression are less likely to properly take medications for diabetes, high blood pressure, and heart disease, and they are more likely to require repeated costly hospital stays.
Training in geriatric care for these problems is necessary, the committee emphasized. Age alters the way people's bodies metabolize alcohol and medications, increasing the general risk for overdoses; these changes also can worsen or cause alcoholism and addiction. Older adults are also more likely to have physical conditions and impairments in thinking and ability to function that can complicate the detection and treatment of mental health problems and substance misuse or abuse. For example, cognitive impairments can affect an older person's ability to comply with medication directions.
Medicare and Medicaid payment policies deter effective and efficient care for substance abuse and mental health conditions by limiting which personnel can be reimbursed and which types of services are covered, the committee found. Effective care includes helping patients self-manage their conditions and monitoring to prevent relapses, services that can be provided by a range of trained providers and in a variety of care settings. The Centers for Medicare and Medicaid Services should evaluate alternative payment methods that would better reflect and fund effective services and coordinated team-based care for mental health and substance abuse, the report says.
Most primary care providers will have frequent contact with older patients, yet their training includes little if any education on geriatric mental health and substance use, the report notes. Few opportunities exist to specialize in geriatric care for these conditions, and financial incentives and mentorships are not in place to encourage health professionals to enter or stay in this field. Health professionals' training across all disciplines should include competence in these areas, and they should be expected to be able to respond appropriately to signs of mental health or substance use problems to the full extent of their scope of practice, the committee said. Congress should appropriate the funds to carry out the provisions in the Patient Protection and Affordable Care Act that support loan forgiveness and scholarships for individuals who work with or are preparing to work with older adults with mental health conditions or substance use problems.
Resources for HHS programs that have supported or could support geriatric care for mental health and substance abuse have been dwindling and in some cases are being eliminated, the committee noted. The report urges HHS leaders to ensure each agency provides sufficient attention and funds to grants and other programs to build an adequate work force able to provide this care.