Struggling to Meet Seniors’ Behavioral Health Needs

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

7 Responses to “Struggling to Meet Seniors’ Behavioral Health Needs”

  1. Jim Sabin

    Hi Peter –
    Thank you for this important “call to arms” about the mental health (I’m still wedded to the “old fashioned” term for the domain) needs of the over 65 population.
    I remember with gratitude an educational session from my residency given by one of the rare geriatric psychiatrists in that era (the later 1960s). He commented on our adherence to the “YAVIS” principle – that the people likeliest to benefit from psychotherapy were Young, Attractive, Verbal, Intelligent and Successful. He told us we were wrong – that older people could often benefit significantly from relatively brief psychotherapy if the treatment built on the self awareness they had accumulated over the years. I found that this was true, and from residency on took great pleasure in seeing folks who seemed very old to me then, but who may well have been younger than I am now.
    The necessary counseling skills are not overwhelmingly difficult to teach. As you say, they should be part of the tool kit of every physician who deals with elderly patients.

    • Canoprimitivo

      The answer is that it doesn’t cost less ..if you don’t ciedosnr what the employer is paying. That’s why so many people think COBRA is expensive. COBRA isn’t expensive, it’s just that when you continue your group plan under COBRA it’s the same plan, at the same cost (plus maybe 2% for admin), but it seems expensive because your employer is no longer contributing.Individual plans ARE CHEAPER than group because you can be turned down. In group plans nobody can be turned down, so the cost to cover all the health problems escalates.The biggest mistake people make is assuming that their work coverage is more competitive without shopping. It’s not uncommon, especially for young, health people, to be able to get cheaper plans on their own even when the employer is picking up half the cost.Finally, most small companies will just have their employees buy individual plans because it’s a fraction of the cost .though either way it’s always nicer when someone else is picking up the tab.

  2. Leslie Kernisan, MD

    Peter, thanks for this post. Am curious as whether you think something like Abilto (health startup offering remote behavioral health services) might help meet this need? Last month they won the investor judges award at AARP’s LivePitch event for healthcare tech innovations. I haven’t yet seen the product demoed, but think the concept has some promise, esp if they develop expertise in addressing behavioral health in seniors and caregivers.

    • Peter Brown

      Thanks very much for the note Leslie. I believe technology can be a help, and I very much encourage the development of internet and other telecommunications products to deal with these issues. At the same time, it seems unlikely in the near future that seniors will accept an electronic substitute for their primary care provider in dealing with a combination of behavioral and general medical issues. AbilTo and others will no doubt evolve to be useful adjuncts to the primary care system. However, in the next ten years, at the moment, it seems the need to have an integrated behavioral and general health approach to seniors’ needs will still require primarily hands on care. Hence, a limited benefit to this population from the growth of such services. Younger people more attuned to continuous use of internet technology may find help in these services, which will help reduce overall demand and free some providers who might otherwise be over committed. It will take a pretty sophisticated mathematical model to calculate the net value. Thanks again for the post and the very interesting possible addition.

  3. Leslie Kernisan, MD

    Peter, I entirely agree with you. However, as you know, 60% of front-line providers are suffering burnout. They almost certainly need longer visits to address behavioral health needs, and even with longer visits, they need tools to help within the visit, plus extra teammates to refer to/help out.
    I’m in search of these tools over at Hope to find some soon!

  4. Jeremias Tamayo Paz

    I heard a couple of guys talking about this in the New York subway so I looked it up online and found your page. Thanks. I thought I was right and you confirmed my thoughts. Thanks for the work you’ve put into this. I’d love to save this and share with my friends.