Building the Geriatric Mental Health and Substance Use Workforce

Abstract:

The United States must act now to strengthen the geriatric healthcare workforce to meet the mental health and substance use (MH/SU) needs of a growing older adult population. Older adults have complex MH/SU needs. The geriatric specialist shortage means we need innovative and multileveled solutions. This article describes national efforts that have been implemented to address this shortage and offers recommendations key to preparing the geriatric MH/SU workforce. These strategies include increasing geriatric specialists through unique pathways, building knowledge of older adult MH/SU in generalists, promoting diversity in providers, engaging non-licensed providers, and reforming Medicare/Medicaid billing structures.

Key Words:

mental health, substance use, geriatric, older adult, workforce

Demographic shifts in the United States toward a growing older adult population create challenges in our healthcare system and workforce. We are underprepared to meet the healthcare needs of older adults and the imbalance in this supply and demand for older adult services is projected to swell. This is especially true for mental health and substance use (MH/SU) services. This shortage creates important opportunities for us to prepare and strengthen the MH/SU workforce in an effort to adequately address the complex needs of older adults.

Older adults and mental health/substance use (MH/SU)

Although rates of mental health disorders and substance use decrease with age, older adults who experience these issues generally endure a greater functional impact. For example, depression is linked to increased morbidity; reduced physical, cognitive, and social functioning; and increased mortality in older adults (Maier et al., 2021; Wei et al., 2019). In older adults, even subclinical levels of depression can impact functional impairment (Wei et al., 2019). Older adults also experience complex interactions between mental health, medical conditions, and functional impairment. Older adults with mental illness are more likely to develop medical comorbidities and die 5 to 20 years sooner than those without mental illness (Olfson et al., 2015).

Substance use is increasing with the Baby Boomer generation (Mason et al., 2022; Substance Abuse and Mental Health Services Administration [SAMHSA], 2021), particularly alcohol use in the context of the COVID-19 pandemic (Eastman et al., 2021; Leventhal et al., 2022). In 2019, approximately 10,292 opioid overdose deaths were in people ages 55 and older (Mason et al., 2022). Older adults with chronic medical conditions, pain, and disability also are at risk for prescription drug misuse and even prescribed drugs like opioids and benzodiazepines can cause cognitive side effects and increase fall risk. Given age-related changes in metabolism, any amount of alcohol or drugs may affect older adults adversely.

Older adults also have a higher risk for suicide (SAMHSA, 2021). Older adults who attempt suicide are much more likely to die from attempts at self-harm compared to younger adults (National Center for Injury Prevention and Control, 2023); in fact, older White men have the highest risk of completed suicide compared to all other age groups (Luoma et al., 2002). Data show that most older adults who completed suicide had seen a primary care provider in the previous month, but many primary care providers miss opportunities to screen older patients for mental health needs (Luoma et al., 2002).

Behavioral health disparities in older adults

Older adults are 40% less likely than younger adults to pursue or engage in mental health treatment. When they do seek treatment, older adults are less likely to receive adequate services and often are treated by providers with little training in geriatrics (Wang et al., 2000). This disparity also is true for substance use disorders (SUDs; Institute of Medicine [IOM], 2012; Sorrell, 2016; Wang et al., 2000).

Among older adults with SUDs, only 28% receive treatment (Huang et al., 2013). While older adults are twice as likely to engage in integrated primary care models for at-risk drinking than referral services (Bartels, 2003), these programs are rarely available. Several factors contribute to this disparity in older adult MH/SU treatment, including mental health stigma, ageism, lack of trained professionals, and limited financial incentives, transportation, and Medicare payment structure for mental health services.

National Efforts to Build and Strengthen a Geriatric MH/SU Workforce

2012 IOM Commission: Committee on the Mental Health Workforce for Geriatric Populations

The need to enhance the geriatric healthcare workforce is not a new issue. In 2008, the IOM issued a report highlighting U.S. requirements for expanding and preparing the geriatric healthcare workforce to meet the needs of an older population. Shortly after, Congress mandated that the IOM conduct a study specifically addressing the MH/SU workforce needs for older adults. The report focused on engaging a broad range of professional disciplines and training and education levels, but also engaging peer supporters and informal caregivers.

Important recommendations outlined in this IOM commission report (IOM, 2012) include:

• Modifications to the Medicare and Medicaid payment structure and rules to include coverage for key mental health services including counseling, care management, and other mental health services;
• Emphasis on updating accreditation requirements for the broader healthcare workforce that serves older adults to recognize signs and symptoms of mental health and substance misuse and provide basic care and referrals; and
• Promote national attention toward building and strengthening a workforce that can meet the needs of an aging population by engaging the Secretary of Health and Human Services (HHS) to designate a responsible entity to address this issue and ensure that its agencies—including the Administration on Aging, Centers for Medicare & Medicaid Services (CMS), SAMHSA, etc.—assume responsibility in their capacities to address this issue.

The IOM report also outlined the barriers to building and strengthening the geriatric MH/SU workforce. Some of these barriers include a lack of interest in geriatrics due to cultural stigma, lack of financial incentives and pay structures for service provision, lack of specialty training opportunities in geriatrics, lack of support and mentorship in this area, and limited diversity in the current geriatric care workforce.

What has been done since?

Congress passed the OMNIBUS federal budget and the Consolidated Appropriations Act (2023) that was signed into law by President Biden on Dec. 29, 2022. This legislation included new programs and policies addressing mental health needs of older Americans.

Important 2023 Omnibus Legislation policy investments include:

• Provider Expansion: Beginning in January 2024, services provided by mental health counselors and marriage and family therapists will be covered by Medicare Part B, significantly expanding the geriatric workforce. There also are provisions for Medicare-funded residency positions and Health Resources and Services Administration (HRSA) Substance Use Disorder Treatment and Recovery loan repayment program.
• Increased Service Coverage: The omnibus also expands Medicare access to telehealth, intensive outpatient, crisis psychotherapy, and behavioral health integration services.
• PEERS Act: The law authorizes funding in grants to provide peer-supported mental health services, including virtual support. It includes provisions from the PEERS Act to ensure that peer support specialist services will be covered by Medicare.

There also have been some recent changes in the CMS Fee Schedule that benefit MH/SU service provision for older adults. Relevant updates in the CMS 2023 Physician Fee Schedule include:

• Behavioral Health Integration (BHI): The “incident to” regulation now allows behavioral health services to be provided under the general, rather than direct, supervision of a physician or non-physician practitioner, when these services or supplies are furnished by auxiliary personnel, such as licensed professional counselors and licensed marriage and family therapists (LMFTs).
• A new General BHI code describes a service personally performed by clinical psychologists or clinical social workers to account for monthly care integration where the mental health services furnished by a psychologist or social worker serve as the focal point of care integration. CMS is finalizing the proposal to allow a psychiatric diagnostic evaluation to serve as the initiating visit for the new general BHI service.
• Chronic Care Management and Interprofessional Consultation: Healthcare for older adults often requires a team-based approach. New Chronic Care Management codes facilitate this critical aspect of care.

In addition, CMS now includes options for payment of interprofessional consultation, a necessary component of team-based care for older adults.

• Opioid Treatment Programs: The Calendar Year (CY) 2023 Physician Fee Schedule final rule includes revised pricing for the drug component of the methadone weekly bundle and the add-on code for take-home supplies of methadone. Additionally, CMS is changing the payment for the bundle to reflect 45 minutes of psychotherapy, an increase over the current standard of 30 minutes. There also are modifications allowing for certain audio-visual, audio-only, and mobile unit services.
• Chronic Pain Management Services: Chronic pain is prevalent, especially in adults older than age 65. New CMS codes expand billing for pain management services, including behavioral interventions. Note that mental health providers are to use Health & Behavior codes.

How We Can Rise to the Occasion

Broadly defining the geriatric MH/SU workforce

The complex interface between older adult mental and physical health issues means that team-based, interdisciplinary approaches are critical. Older adults are diagnosed and treated for mental health and substance use issues by a broad variety of providers in many settings. For example, older adults receive MH/SU services from their primary care providers, hospitals, long-term care facilities, and specialty MH/SU settings. Therefore, enhancing the geriatric MH/SU workforce must include engaging professionals who interface with older adults across settings and disciplines.

The IOM lists several types of professionals included in this workforce, including physicians, psychiatrists, nurses, direct care workers, counselors, pharmacists, psychologists, social workers, and counselors, to name a few. Further, to increase the impact and availability of meeting MH/SU needs, we also must engage unlicensed parties to act on this issue, including community agencies and organizations, peer supporters, community health workers, and family caregivers.

Need for more geriatric specialists

While the behavioral health workforce is vastly understaffed for all ages, by 2030, it is estimated that we will only have 27% of needed psychiatrists, 9% of needed social workers, and 5% of needed psychologists with specialized training in working with older adults (IOM, 2012; Jeste et al., 1999). The need may be even greater as trends are showing a more than 10% decline in psychiatrists from 2003 to 2013 (Bishop et al., 2016). As of 2018, the national average was 2.6 geriatric psychiatrists for every 100,000 adults older than age 65 (Beck et al., 2018), and there are currently only 112 board-certified geropsychologists in the United States (American Board of Geropsychology, 2022).

An additional barrier to effective training of healthcare providers to meet the needs of older adults is a pipeline problem. Students are rarely exposed to older adults early in their educational careers, which could be addressed with intergenerational learning. Once in graduate programs, there are few training opportunities due to Medicare restrictions on billing for trainees, which contributes to the lack of mental health providers entering geriatrics as a specialty. While consideration must be given to allowing “incident to” billing for mental health trainees under the direct supervision of qualified licensed mental health clinicians, increased funding for training and incentives for entering geriatrics also is critical. Examples include expanding the HRSA-funded Graduate Psychology Education and Teaching Health Center Graduate Medical Education programs directed toward training in geriatrics, along with increasing focus on loan repayment programs for working with underserved older adults.

Need for training generalists

In addition to the task of increasing the number of trained geriatric specialists, we must simultaneously engage all healthcare professionals and community-based organizations that provide support services to older adults to have basic competency in older adult mental health. This is especially urgent for counselors and LMFTs, per the new CMS allowance to bill. As these providers historically haven’t been able to bill, their training programs rarely include older adult training. This trend also exists across mental health disciplines. Few doctoral psychology programs include geropsychology training opportunities or specialties. The Council of Professional Geropsychology Training Programs lists 13 programs with geropsychology training. APA has accredited a total of 417 programs, leaving only 3% with a dedicated geropsychology training program.

One part of the solution is increasing funding for and availability of a variety of training options, e.g., asynchronous, synchronous, varied levels of time/investment. One such example is “CATCH-ON,” the Geriatric Workforce Enhancement Program (GWEP) based at Rush University Medical Center. CATCH-ON offers an online certificate program for generalist mental health clinicians to attain foundational competency in older adult mental health. This program also offers an annual in-person fellowship training to smaller cohorts of mental health clinicians to build both knowledge and skill in this area.

If all GWEPs were to increase focus on the MH/SU needs of older adults, every region of the United States would have access to high quality training. Further, GWEPs are required to build partnerships with community-based organizations, including Area Agencies on Aging, which are ideal for expanding such training to the aging network and direct care workforce, as well as potentially other community organizations, first responders, and others who meet the needs of older adults. Proposed support for additional GWEPs with larger budgets would allow for these critical needs of older adults to be more effectively met. While most states have GWEPs, this additional funding may allow for every state to benefit from this essential workforce development program.

Rush University Medical Center’s SAMHSA-funded Engage, Educate, and Empower for Equity: E4 Center of Excellence for Behavioral Health Disparities in Aging has engaged more than 20,000 professionals between live and recorded educational events. The Center has focused efforts on creating educational materials for older adults and the geriatric workforce. It also has engaged eight states thus far in policy academies that bring together state entities that rarely communicate with each other, including mental health, substance use, aging, transportation, housing, Medicaid, and local chapters of the National Alliance on Mental Illness, to identify gaps in meeting the needs of older adults and generating a plan to begin to fill the gaps. For more details on this Center’s mission, goals, and progress, please see the accompanying article in this issue of Generations Journal.

Need for training culturally and linguistically diverse clinicians

Census data show that older Americans are becoming more racially and ethnically diverse over time (Caplan & Rabe, 2023). We need a workforce that reflects the diversity of the population being served. Efforts in building cultural competence and humility also need to focus on supervisor training to ensure that adequate supervision can be in place.

Need for engaging non-licensed providers and peer supporters

Innovative models of care are needed as we aim to meet the demands in older adult MH/SU in the future. In addition to cultivating geriatric specialists and training generalists to meet the MH/SU needs of older adults, training and engaging non-licensed providers to deliver services can help expand the reach of services. One model that has been proposed involves deploying bachelor’s-level therapists (supervised by doctorate-level providers) to deliver treatments for certain mental health conditions.

This model of care is cost-saving and optimizes professional practice at the top of one’s skills and training. Research supports the effectiveness of such a model in the mental health context, as well as in other healthcare sectors, however, it comes with barriers. Infrastructure at the organizational and national levels must be in place to support implementation of such a model. This includes the standardization of treatment protocols, defining scope of practice and roles, and training for licensed providers on supervising non-licensed providers. Federal and state policies and appropriate payment structures also must be in place (Kunik et al., 2017).

Peer supporters also are an important part of the geriatric MH/SU workforce. Peer supporters can help expand reach of services and support to address the shorting of trained providers. Peer support models of care involve training older adults with lived experience in MH/SU to provide basic support and assistance for older adults with MH/SU needs, throughout their treatment. Peer support models can be implemented in a variety of ways including in-person, virtual/telephone support, and in groups. Evidence is growing on the impact and scalability of such models of care (Thombs & Carboni-Jiménez, 2021). Community health workers with or without lived experience of MH/SU also can play a critical role in service support.

Need for improved Medicare and Medicaid reimbursement

Very little progress can be made until the proper billing structures are in place. Historically, MH/SU services have been poorly reimbursed, creating a major bottleneck in service provision for older adults. Medicare and Medicaid have lower rates of reimbursement than many commercial insurance companies, disproportionately disincentivizing providers from service provision to older adults, particularly those who are economically disadvantaged. In fact, psychiatrists are less likely than other types of physicians to accept all types of insurance (including Medicare and Medicaid), contributing to this gap in care (Bishop et al., 2014).

Without providers opting in, older adults don’t get services (CMS, 2015). This is especially true for individuals who are eligible for both Medicare and Medicaid (“dual eligibles”), many of whom have serious mental illness, often with comorbid substance misuse, because they are required to navigate two separate and confusing systems, and rarely have the resources to consider out-of-network options.

CMS billing structures also must accommodate and promote integrated, team-based care. Optimal care for all adults coordinates mental and physical health care (Druss et al., 2017). This is particularly the case for older adults with disorders ranging from depression (Unutzer et al., 2002) to serious mental illness (Druss et al., 2017; Vanderlip et al., 2014, 2017), to substance misuse (Englander et al., 2019).

Unfortunately, Medicare Advantage plans have been allowed to split contracts for physical and behavioral health services so that older adults often cannot receive services in one coordinated setting. Moreover, older adults seeking treatment for MH/SU concerns at their primary care providers may leave empty-handed, as many primary care providers don’t know where to send older adults for care and can’t make proper referrals.

Conclusions

The MH/SU needs of older adults are complex and with a growing population of older Americans, we must take immediate action to build and strengthen the broad MH/SU workforce through various strategies at practice and policy levels. Key areas for impact include broadly engaging a variety of professionals and supporters to provide MH/SU care for older adults, increasing training opportunities to support growth in geriatric specialists, equipping generalists with basic competencies in older adult MH/SU issues, increasing diversity and cultural competency in the geriatric MH/SU workforce, engaging non-licensed providers and peer supporters, and calling for improved Medicare and Medicaid reimbursement for pertinent services and policy reform to address cracks in the current payment structures. Although some progress has been made since the 2012 IOM report, there is much more progress to be made.

Susan Buehler, PhD, is an assistant professor at the Rush University Medical Center in Chicago, Ill. She may be contacted at susan_buehler@rush.edu. Erin E. Emery-Tiburcio, PhD, ABPP, is a professor at the Rush University Medical Center.

Photo credit: Shutterstock/Frame Stock Footage

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