Who’s in Charge?

The most recent Institute of Medicine report, “The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?” (https://www.iom.edu/Reports/2012/The-Mental-Health-and-Substance-Use-Workforce-for-Older-Adults.aspx) is exceptionally important for behavioral healthcare. This landmark report again raises the specter of dramatic human resource shortages for behavioral healthcare now and in the short-term future.

During the next two decades, the elderly will grow from 12 to 18 per cent of our population—a dramatic increase by any demographic standard. In numeric terms, this means that the elderly population will grow from about 36 million currently, to more than 72 million by 2030.  At the same time, the number of elderly persons with mental illness will grow from more than 7 million to more than 14 million, and the number with serious mental illness will grow from slightly more than 2 million to more than 4 million. The fundamental question raised by the IOM report: Who will provide care for all of these new cases?  

But this is just the tip of the issue—the proverbial canary in the mine. We also expect that at least 10.5 million of the 32 million new enrollees under the Affordable Care Act will have a behavioral health condition at the time that they enroll.  Currently, the specialty mental health and substance use systems combined serve around 10 million persons per year.  Can we reasonably expect to grow these systems to 15 million persons? This is highly unlikely, at least in the shorter term. Further, this projection assumes that only half of the 10.5 million new enrollees with behavioral health conditions will seek specialty care, and that the balance will go to primary care settings--an untested assumption at best.

We also must consider our current workforce. Many state, county, and local program directors are baby-boomers, who are at or are near retirement age. One of the most telling facts today is that the average age of a psychiatrist in America is now 57. This leadership succession problem is compounded by the fact that our baby-boom managers have no obvious successors. In our fields, their generation was followed by a baby-bust generation, the Gen Xers, in which few entered the behavioral health fields. The 1980s were a period in which young people preferred to enter business or law rather than the healthcare fields.

Subsequent generations of behavioral health providers, the so-called Gen Yers or Millennials, have yet to find stable positions in the behavioral healthcare fields. Many continue to have low salaries, and many “churn” from job to job.   

Hence, we come to my original question: Who’s in charge? Obviously, we need a long-term operational plan to address both clinical and leadership training problems. But we also need a short-term strategy to bridge us into the health reform era. Two obvious short-term actions are essential:

Employ Our Peers. We have a very large cadre of peers who want to become peer supporters and who are fully capable to do so. They can provide navigation for insurance, access, and care, and they can coordinate complex care as well, especially in the newly emerging health homes. Further, we can and should encourage the development of more consumer-operated service programs (COSPs) that can be attached to new accountable care organizations. We also need to recognize that many peers are professional clinicians.

Exploit New Tools. Information technology, phone apps, and social media have advanced dramatically in the past five years. They can be employed to extend our workforce as our service populations grow. Use of IT tools for screening, assessment, and actual delivery of interventions are now commonplace. Phone apps can be used to communicate health messages, provide brief assessments, and guide behavior. Social media can be used to maintain contacts, foster support groups, and provide tools for use in the community. An urgent need exists to develop a better conduit for getting “turn-key” applications into the hands of our county providers.

I again return to the question: Who’s in charge? Faced with an estimated 6 million new service users by mid decade, we all need to take charge of our own future and begin careful planning and development today.