Mental Health Policy: It’s Not As Hard As You Don’t Think

Mental-health-problems-007In my work with healthcare providers and community-based services organizations over the past two years there is one recurring theme that continues to present itself at multiple levels – i.e., personally, professionally and socially: that is the growing awareness of how critically important it is to  integrate mental and behavioral health services with primary care.

Unfortunately, at a popular level mental health in the US has long been synonymous with a disease state – something that needs to be fixed, or at least treated.  The irony of this of course is that we have spent decades worrying about how to fix our healthcare system while all the while forgetting that what we have really had for years is a sick-care system. We care for people when they are ill – we don’t really have an effective system in place to keep them well.

And yet there really isn’t compelling evidence that indicates social investments in health and wellness provide good return on those investments. Education and awareness haven’t had the intended impact. Why?

Could it be that the same underlying drivers impeding the success of health and wellness activities are also manifested as root causes of a variety of physical illness and disease? In other words, in only regarding mental health as a means to cure a problem rather than the promotion of a desired natural state of being are we neglecting a critical element of healthcare reform? I think so.

Admittedly, the policy considerations surrounding mental and behavioral health services are extremely complex, in large part because they interact with so many other policy areas; e.g., Housing, Employment, Criminal Justice and FDA Oversight – just to name a few. Nowhere is this more evident than with one of the most proliferate and threatening elements of mental and behavioral health in America today: addiction.

Rather than try and put forth a meager attempt here to explain the hows and wherefores of addiction, mental health and public policy, I would rather refer Pub visitors to a wonderful post by the One Crafty Mother, Ellie Schoenberger.  In what she titles the most important post she’s ever written, Ms. Schoenberger does a fantastic job of putting a framework around the impact addiction has on society – and how it must be understood from an individual, social and public policy perspective if we are to develop effective policy to address this growing epidemic.

I think it’s a great place to start a discussion, and I hope you will take the time to read it.

Cheers,
  Sparky

IOM Report on Mental Health & Substance Use in Older Adults


The Institute of Medicine yesterday issued a new report, The Mental Health and Substance Use Workforce for Older Adults.  It provides the results of a study commissioned by the Department of Health and Human Services, as directed by Congress, examining the emerging and projected crisis our nation faces as a result of an insufficient geriatric healthcare workforce – specifically the capacity of that workforce to address caregiving needs resulting from behavioral/mental health conditions and substance abuse in the senior population.

It is estimated that one in five older adults in this country have one or more mental health/substance use (MH/SU) conditions.  And these conditions typically exist in individuals that also have other health problems, making diagnoses, treatment and long-term care all the more challenging.  The most common of these conditions include depressive disorders and dementia-related behavioral and psychiatric symptoms.

But substance abuse is a substantial and growing problem as well.  According to a 2009 report from the National Survey on Drug Use and Health – published by the Office of Applied Studies, Substance Abuse and Mental Health Services Administration (SAMHSA) – it has been predicted that by the year 2020, the number of persons needing treatment for a substance abuse disorder will double among persons aged 50 and older.  Unfortunately, that growth is above the linear projection owing simply to aging demographics.

Currently, however, the number of direct caregivers at varying levels of experience and responsibilities reflect the lack of historical investment in Geriatric MH/SU training and education.  As identified in the IOM report based upon their research, future caregivers will need to have expertise in the following areas:
     systematic outreach and diagnosis,
     patient and family education and self-management
       support,
     provider accountability for outcomes and
     close follow-up and monitoring to prevent relapse.

The report was also resoundingly critical of several federal agencies.  The Centers of Medicare and Medicaid Services (CMS), the Health Resources Services Administration (HRSA), SAMHSA and the National Institutes of Health (NIH) were all criticized for their failure to use their public policy influence to encourage and direct investments in workforce training in this critically underserved area.

The IOM encouraged Congress (which includes the Republican held House that again today apparently had nothing better to do than vote – what is it now, the 31st time? – to symbolically repeal the Affordable Care Act) to fund the National Health Care Workforce Commission established under that Act.  The report noted that under the Affordable Care Act, the Commission is authorized, “to serve as a national resource that focuses on evaluating and meeting the need for health care workers . . . and to build a workforce that reflects the diversity of the older adult population that it serves.”

And finally, the report provided five recommendations that together are designed to focus policy making efforts on the need for leadership, agency coordination and the accelerated development of education and training that reflects the unique needs of a senior population in need of MH/SU services and care.  In addition, the IOM believes such efforts should be directed in thematic alignment with the Affordable Care Act (i.e., being able to evidence the relative value of investments in this area of need).

What will come of this? Well, we know it’s certainly not an ideal environment to be lobbying for new expenditures, even when/if those investments were theoretically already initiated through the Affordable Care Act.  And pragmatically, it seems reasonable to assume that the House is not likely to fund the National Health Care Workforce Commission any time soon.  And we also know that as 32 million new Americans come on line with healthcare coverage (whether through Medicaid expansion or insurance exchanges) the demands of the primary care workforce will grow substantially.

But the senior population in need of MH/SU caregiving have several distinct advantages over the younger generation driving primary care investments: namely, a great deal more wealth, better insurance and a dominant voting bloc.  So while in the short run governmental funding of workforce investments may not be able to meet the projected demand for MH/SU services and care, private investment – whether from nonprofit or for profit organizations – could be richly rewarded.

And as a practical reality, those organizations that provide post-acute and long-term care to seniors are already sharply aware of the need for MH/SU as a core element of their overall approach to achieving better outcomes.  As we continue along the path toward integrated care delivery models, the inclusion of MH/SU will have to be developed and provided as a matter of necessity to achieve relatively better outcomes than competitive providers.  Knowing (accepting) that reality should be sufficient incentive to drive private investment in workforce training and education, irrespective of public policy initiatives.  The challenge will be in figuring out how to do it in a way that achieves the requisite return on investment.

  ~ Sparky

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