Advances in Geropsychiatric Nursing: A Decade in Review

Abstract

This article provides a brief overview of the early development of geropsychiatric nursing (GPN) as background for examining its advancement subsequent to the 2010 Future of Nursing (FON) Report. The FON’s education, practice and leadership recommendations form the three pillars that have supported geropsychiatric nursing’s continuing evolution, framed within a practice and policy perspective. Lessons learned are relevant to developing the next phase of FON recommendations. The importance of overcoming challenges faced by the field of GPN is supported by the aging global population, the directions of nursing as a discipline, and the clear necessity of an intra- and inter-professional approach to mental health and aging.

Introduction

Mental health is integral to promoting and sustaining optimal physical health and well-being in late life (Stephens, Evans, Bradway & Buckwalter, 2018). Currently, nearly 8 million older Americans have one or more mental health conditions (Institute of Medicine [IOM], 2012). Many of these can be prevented and/or effectively managed in primary, acute, long term and community care settings with proper attention to protective strategies, timely recognition and diagnosis, and delivery of individualized interventions that are acceptable to older adults and their families (Beck, Buckwalter, Dudzik & Evans, 2011). Erroneous provider beliefs regarding the ‘normalcy’ of late life confusion and depression as well as the artificial separation of mental and physical health care, however, have posed serious barriers (Salzman, 2006) to achieving this end.

Further, as stressed by the 2012 IOM Report, The Mental Health and Substance Use Workforce: In Whose Hands?, the existing workforce--across all disciplines-- lacks the education/training and expertise in geriatric mental health to meet the unique needs of this rapidly growing population. This deficiency in the preparation of mental health and substance use providers further supports the critical need for access to Advanced Practice Registered Nurses (APRNs) with geropsychiatric education and training to promote the overall health and well-being of older adults, their families and caregivers (Beck et al., 2011).

In 2010, the Future of Nursing (FON) Report made recommendations to overcome barriers preventing nurses’ full participation in increasing the health of Americans. These were broadly related to scope of practice, educational preparation, interdisciplinary practice, and leadership, workforce planning, and information infrastructure. With the 10th anniversaries of both the FON (2010) and IOM (2012) Reports upon us, it is prudent to reflect on the progress made in Geropsychiatric Nursing (GPN) over this period and to outline recommendations for the 2020 FON panel.

Background: Brief Historical Overview of Geropsychiatric Nursing

Geropsychiatric Nursing emerged in the 1970s as a subspecialty blending psychiatric and gerontological nursing. Geropsychiatric nurse pioneer Dr. Mary Starke Harper recognized the need (Minority Nurse, 2013) and advocated for building a cadre of prepared geropsychiatric nurses. Subsequently, the National Institute of Mental Health (NIMH) supported a limited number of mentored research-in-aging traineeships for psychiatric nurses and small grants to schools of nursing to enhance geriatric mental health inclusion/integration in graduate psychiatric mental health nursing curricula. These strategies resulted in a cadre of visionary GPN leaders and a small cohort of APRNs engaged in GPN practice (Beck et al. 2011). Two subsequent national conferences on the state of GPN and three national surveys on educational preparation for GPN practice drew attention to the emerging field (Abraham, Buckwalter, Harper & Hight, 1994; Evans & Buckwalter, 2006; Garand & Buckwalter, 1994; Hoeffer, 1994; Kurlowicz, Puentes, Evans, Spool & Ratcliffe, 2007; Murphy & Hoeffer, 1987; Stein, 2006). In 2008, just prior to the FON Report release and with four years of funding from the John A. Hartford Foundation, the Geropsychiatric Nursing Collaborative (GPNC) was launched. This ambitious project was directed by nurse leaders from three of the Hartford Centers of Gerontological Nursing Excellence and housed within the American Academy of Nursing (Beck et al., 2011). Consistent with the FON recommendations, the GPNC’s overarching goal was to improve the mental health of older Americans by preparing all levels of nurses with geropsychiatric knowledge and skills (Beck et al., 2011). Following project completion in 2012, the now volunteer-driven GPNC has continued to fill many voids and eliminate gaps and disparities in geriatric mental health within its current home in the National Hartford Center of Gerontological Nursing Excellence (NHCGNE).

A Decade in Review: Progress, Challenges and Opportunities

Of the four major recommendations made in the FON report, the three related to education, practice and leadership have most relevance to the progress in GPN. Each of these is addressed in light of accomplishments and challenges, with particular attention to geropsychiatric and interprofessional education.

Progress in Advancing GPN & Interprofessional Education

Since its inception, a core GPNC effort has focused on ways to foster the integration of geropsychiatric nursing (GPN) in entry level and advanced practice nursing education rather than specialty preparation. This effort was largely influenced by the launch of the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education (LACE)( National Council of State Boards of Nursing, 2008 & 2014; see APRN 2008 Consensus Model Report, p.10, available at www.ncsbn.org). Among its many changes for APRNs, LACE merged Adult and Gerontological Nursing, thereby eliminating the Gerontological Nurse Practitioner certification. In psychiatric/mental health, the focus was redesigned to include the entire adult life span (Mayo, Harris, & Buron, 2016). Further, LACE required that all APRNs providing care to the adult population be prepared to also meet the growing needs of older adults. Thus, these educational programs were encouraged to include didactic and clinical education necessary to prepare APRNs with enhanced knowledge and skills in aging. Notably, however, the need to integrate GPN content across the programs was not clearly specified, and neither were certification examinations or accreditation criteria modified to reflect this new expectation.

In anticipation of the regulatory changes, and in keeping with the FON recommendations for competency-based and interprofessional training to prepare APRNs, the GPNC chose not to propose a new GPN specialty/subspecialty area. Rather, it focused on facilitating GPN preparation for a broader spectrum of nurses through recommending GPN-specific competency enhancements for each specialty whose graduates would be caring for older adults. These enhancements were shared with the relevant professional groups for inclusion as they updated their competency statements and also published along with key GPN concepts and relevant curriculum materials for educators’ use on the free access Portal Of Geriatric Online Education (POGOe) (Beck et al., 2011).

Responding to the FON recommendation to support nurses to achieve higher levels of education and training, GPNC leaders also collaborated with other key stakeholder organizations to advance GPN educational efforts. This included, for example, co-producing a series of eight Geropsychiatric Nursing Initiative (GPNI) continuing education modules in collaboration with the American Association of Colleges of Nursing and the Hartford Institute of Geriatric Nursing. These GPNI modules covered such topics as serious and persistent mental health conditions in older adults, reducing iatrogenic brain injury, and health disparities in GPN practice (https://consultgeri.org/education-training/e-learning-resources/geropsychiatric-nursing-initiative-modules). Further, GPNC consultants provided support to faculty in select schools of nursing for integrating this content (Batchelor-Aselage, et al., 2014). The GPNC also engaged with specialty organizations, such as the American Association of Geriatric Psychiatry, American Geriatrics Society and the Gerontological Advanced Practice Nursing Association (GAPNA) (see Table 1). GAPNA’s GPN special interest group recently published a position paper in support of geropsychiatric nursing as a subspecialty for APRNs to meet the aforementioned workforce needs (Harris et al., 2019).

Table 1.

Selected Geropsychiatric Nursing & Mental Health Education & Practice Resources

PARTNERSHIPS & ORGANIZATIONS	RESOURCES PRODUCED	HOW TO ACCESS
Administration for Community Living; SAMHSA Mission Analytics Group Human Services Research Institute	“Behavioral Health & Suicide Prevention Among Older Adults: Training Resource Guide”	Training Guide available at https://sagelink.ca/sites/default/files/clinical-resources/Resource_Guide_Behavioral_Health_and_Suicide_Prevention_FINAL_0.pdf
GPNC & American Association of Colleges of Nursing	“Expert Panel on Aging supports geropsychiatric nursing”	Policy Brief on geropsychiatric nursing published in Nursing Outlook. Available at https://www.nursingoutlook.org/article/S0029-6554(11)00406-4/fulltext
American Association of Geriatric Psychiatry (AAGP)	APRN Caucus is supported by the American Association of Geriatric Psychiatry.	APRN Caucus is an special interest group for APRNs caring for older adults with mental illness
American Association of Geriatric Psychiatry (AAGP) together with NHCGNE, GAPNA, American Psychiatric Nurses Association, the American Medical Directors Association and other organizations.	Gray Matters Coalition uses its collective voice to advocate for policies that support older adults with brain health needs.	More information about AAGP can be found at www.aagponline.org
American Nurses Association (ANA)	A diverse group of gerontological nurse experts contributed to the revised Scope and Standards of Gerontological Nursing Practice which now includes geropsychiatric nursing	Revisions to the 2010 ANA Scope and Standards of Gerontological Nursing Practice are in press https://www.americannursetoday.com/gerontological-nursing/
Geropsychiatric Nursing Collaborative (GPNC) was initially funded by the John A. Hartford Foundation and housed in the American Academy of Nursing	GPNC Geropsychiatric Nursing Definition, Key Concepts and Competency Enhancements for nurses working with older adults	American Academy of Nursing: https://www.aannet.org/initiatives/early-initiatives/geropsychiatric-nursing-collaborative/gpnc-background-and-resources GPNC Geropsychiatric Nursing Definition, Key Concepts and Competency Enhancements available at the Portal of Geriatric Online Education (POGOe) https://www.pogoe.org/productid/20660
Geropsychiatric Nursing Collaborative (GPNC) is a special interest group of the National Hartford Center of Gerontological Nursing Excellence (NHCGNE)	The GPNC plays a role in the NHGCNE Leadership Conference and hosts the annual Geropsychiatric Nursing Breakfast during the Gerontological Society of America Annual Scientific Meeting	NHCGNE Leadership Conference information available at https://www.nhcgne.org/ADCaregivingConference
Geropsychiatric Nursing Initiative (GPNI) is a partnership between NHCGNE, Hartford Institute of Geriatric Nursing & American Association of Nursing to support online learning for nurses.	GPNI Series includes nine mental health topics on older adults such as depression, serious mental illness, bipolar disorder, geropsychiatric nursing and other topics.	GPNI Series available at https://consultgeri.org/education-training/e-learning-resources/geropsychiatric-nursing-initiative-modules
Geropsychiatric Nursing Special Interest Group (GPN SIG) is supported by the Gerontological Advanced Practice Nursing Association (GAPNA)	The GPN SIG published a position paper in support of geropsychiatric nursing as a subspecialty for advanced practice nurses to meet workforce needs.	The position statement can be found at https://www.gapna.org/sites/default/files/documents/pos-stat/Final_gapnaPS_Geropsychiatric-Nursing.pdf
Institute of Medicine (IOM)	The Committee on the Mental Health Workforce for Geriatric Populations convened to address workforce needs for older adults; its findings are published in this report: The Mental Health and Substance Use Workforce for Older Adults In Whose Hands?	The 2012 IOM report is available at https://www.ncbi.nlm.nih.gov/books/NBK201410/pdf/Bookshelf_NBK201410.pdf
National Center for Interprofessional Education and Practice (NCIEP)	The NCIEP is supported by Health Resources and Services Administration Cooperative Agreement and funded in part by the Robert Wood Johnson Foundation, the John A. Hartford Foundation, the Josiah Macy Jr. Foundation, the Gordon and Betty Moore Foundation and the University of Minnesota.	Executive summary available at https://nexusipe.org/accelerating/executive-summaries
National Coalition on Mental Health and Aging, National Council on Aging, National Chronic Disease Self-Management Education Resource Center	Produced National Coalition on Mental Health and Aging Webinar Series on topics such as suicide and health promotion in older adults.	Webinars available at https://www.ncoa.org/organizer/center-for-healthy-aging/
National Council on Aging, SAMHSA, Administration on Aging	Older Americans Behavioral Health Series are Issue Briefs on various topics re: geriatric mental health	https://www.ncoa.org/center-for-healthy-aging/behavioral-health/older-americans-behavioral-health-series/
The Commonwealth Fund	Funded Toolbox development for Improving Behavioral Health in Nursing Homes Project	www.nursinghometoolkit.com

Support from the Health, Resources and Services Administration (HRSA) for Geriatric Education Centers (GECs) and the new Geriatric Workforce Enhancement Programs (GWEPs) has enabled many schools of nursing to enhance mental health inclusion in their non-psychiatric program curricula and to train current faculty and providers in mental health care. Further, the Veteran’s Affairs Centers for Excellence in Primary Care Education provided new opportunities for geropsychiatric nurses to give older adults a voice in the design of their mental health care at the community health systems level. The Centers for Medicare and Medicaid Services (CMS) also stimulated development and dissemination of training resources to bridge the delivery of high-quality care with an emphasis on non-pharmacological care strategies used by expert geropsychiatric nurses in nursing homes (Sefcik & Kolanowski, 2014; Table 1).

The GPN Breakfast at the annual scientific meeting of the Gerontological Society of America typically attracts 35–45 attendees from across the globe. Over the past ten years, these meetings have been instrumental in strategic planning, knowledge dissemination, networking and moving forward the overall GPNC goals which are also in sync with those of the FON.

Finally, the recent resurgence of commitment to interprofessional education (IPE) for practice has provided yet another avenue of influence to advance GPN education, with increasing recognition that quality geriatric mental health care requires an interdisciplinary or interprofessional approach (Farrell, Luptak, Supiano, et al., 2018; IOM, 2012). Comprehensive care for older adults and their families over a chronic, often unpredictable and changing clinical course necessitates health and social service providers who work together in a collaborative and complementary fashion. While geriatrics-focused education has long been inherently interdisciplinary in nature, this renewed interest in IPE, which is consistent with the focus of the FON and IOM reports, has helped strengthen efforts to prepare the workforce to meet the needs of older adults with mental health and substance use concerns. As Table 1 reveals, GPN leaders have engaged in numerous interprofessional organizational collaborations to generate resources toward this goal. One key example is a paper and commentary from the 2017 GPNC-spearheaded interprofessional and international NHCGNE Leadership Conference on Aging, Dementia and Mental Health that focused on interprofessional educational approaches (Farrell et al., 2018; Harris, 2018).

Challenges in GPN and Interprofessional Education.

As previously noted, implementation of the Consensus Model over the past decade has had a major ripple effect throughout the field of gerontological nursing more broadly, and within GPN specifically. Losing the older adult population-specific specialty has left many experts in the field deeply concerned about the leadership gap needed to support the pipeline of geriatric or geropsychiatric-trained experts, thus, negatively impacting future generations of clinicians, educators and scholars.

To ascertain faculty perceptions of the influence that the Consensus Model has had to date on preparing the next generation of APRNs to meet the needs of older adults as well as the presence, nature and extent of GPN content across program curricula, Stephens and colleagues (2015) conducted a fourth national survey of all 363 U.S. schools of nursing. Despite findings of positive perceptions about the influence of the Consensus Model on the level of preparation and infusion of GPN content into curricula, there has been little to no change in the proportion of schools offering GPN content in one or more clinical programs since the 2004 Kurlowicz et al. (2007) study (67.5% in 2004 and 68% in 2014). And while the presence of some GPN content had generally increased across all APRN programs, the majority of it was still offered in non-Psychiatric/Mental Health Nursing (PMHN) programs (e.g., family or adult-gerontology NP programs). Moreover, and consistent with the earlier Kurlowicz et al. (2007) survey, very few schools offered a GPN program, track or minor (7.3% in 2004 vs 8.4% in 2014). There had been, however, a positive and substantial increase in the proportion of PMHNP programs that included some GPN didactic or clinical content in their curricula (38% in 2004 vs 84% in 2014).

Notwithstanding extensive efforts to infuse geriatric mental health enhancements into existing competency statements, gaps persist in APRN programs’ implementation, particularly within PMHN programs (Stephens et al., 2015). These challenges to meeting FON goals in educational preparation for nurses are largely attributed to a lack of faculty with expertise and clinical experience in geriatric mental health, as well as lack of funding and institutional desire to add a GPN program, track or minor to the curriculum (Harris, Buron, & Stephens, 2018). Additionally, lack of funding and support have contributed to limited resources including few current GPN textbooks at the graduate level from which educators can choose and lack of currency of many of the aforementioned developed web resources, such as those posted on POGOe.

The FON Report (IOM, 2010) supports the unique role of APRNs as members of the interprofessional team to transform mental health care for older persons. But without subspecialty GPN certification and the requisite numbers of expert GPN faculty as role models, however, it will be near impossible to cultivate student interests, develop and maintain resources, and foster the workforce pipeline needed to meet the population demand.

Progress in Advancing GPN Practice in Full Partnership with Others

APRNs are well-positioned to provide high quality care for older adults with mental health issues. FON (2010) recommends interprofessional collaboration and nurses’ involvement in care delivery redesign (IOM, 2010). APRN practice initiatives (with a focus on nurse-led practices) that promote and deliver quality care for older adults with dementia and other mental health issues as well as innovative interprofessional team-based care models are presented here as exemplars of advances toward this goal.

A growing literature on nursing and interprofessional collaboration in geropsychiatric care redesign (Kaas & Beattie, 2006; Callahan, et al., 2018; Farrell, et al., 2018; Harris, 2018) suggests that APRNs readily adapt successful models of care to provide a structure that guides practice. The person-centered care (PCC) model is an approach whereby psychosocial needs and the older individual’s identity and preferences are made central to care provision (Van Haitsma, Abbott, Arbogast, et al., 2020). PCC shifts from the traditional medical model, in which the physician is the primary decision maker, to one where individuals (patients) and those important to them inform medical decision-making (American Geriatrics Society Expert Panel on PCC, 2016). Within this framework, goals of care are established based on patient preferences and values. The Integrated Memory Care Clinic (IMCC) at Emory University is one example of how the PCC model has been successfully expanded in the practice setting (Clevenger, Cellar, Kovakeva, et al., 2018). IMCC is the first APRN-led patient-centered medical home providing care to older adults with dementia. In this setting, APRNs lead a multidisciplinary team to deliver comprehensive care wherein PCC principles are implemented to provide a dementia-informed, person-centered, palliative approach. Although newly established, encouraging preliminary descriptive data, such as reduced hospitalizations and high caregiver satisfaction, highlight the strengths of this innovative APRN-led practice model and provide support for similar comprehensive healthcare models that focus on common geriatric mental health conditions.

Interprofessional collaborative practice models have also been proposed as a solution for high-quality team-based care that is delivered to older adults with complex health care needs such as those with mental health issues (Callahan et al., 2018). An important example of a successful collaborative care model is The University of California, Los Angeles (UCLA), Alzheimer’s and Dementia Care (ADC) program. This comprehensive nurse practitioner co-management program (Reuben, Evertson, Wenger et al., 2013) delivers high-quality, cost effective dementia care to community-dwelling older adults (Jennings, Turner, Keebler et al., 2019). In this model, APRNs partner with a physician to develop and implement individualized dementia care plans for patients and caregivers and to provide ongoing monitoring and management of dementia-related health needs.

Challenges to GPN Practice and Partnerships.

Comprehensive geriatric mental health care team models continue to be subject to a gap in replication and diffusion into routine care for older adults with dementia and mental health issues (Callahan, et al., 2018). Lack of access to learn in collaborative practice models reduces and, thus, delays opportunities to prepare the next generations of APRNs for a role as full partners in redesigning health care (IOM, 2010) for this population.

Expanding the availability of comprehensive geriatric mental health services also requires new solutions that allow APRNs to provide broader coverage of geropsychiatric care. So far, these opportunities are few, but we offer one exemplar that may serve to motivate others. Iowa, like many rural states, is plagued by poor mental health care and insufficient numbers of providers (Iowa Health Professions Tracking Center, 2012). This challenge is particularly pronounced for its large number of older adults (16.4% of the total population), many of whom suffer from psychiatric/mental health disorders (Older Iowans, 2018; 2019) and/or chronic medical diseases with co-morbid behavioral health conditions. Thus, older adults face challenges in accessing adequate, appropriate care, especially in primary care settings where many disorders go unrecognized and untreated. Stigma associated with mental illness, inadequate transportation, and long-distance travel for multiple visits with numerous providers add additional challenges. The results are poor treatment responses, a chronic illness course, higher complication rates, increased service use and resulting higher health care costs (Speer & Schneider, 2006). To better address these problems, the University of Iowa has developed eight dual advanced-practice graduate and post-graduate certification programs, four of which are relevant to geropsychiatric nursing education and practice: Adult Gerontology Acute Care/Psych Mental Health Nurse Practitioner; Adult Gerontology Primary Care/Psych Mental Health Nurse Practitioner; Family/Psych Mental Health Nurse Practitioner and Family /Adult Gero Acute Care Nurse Practitioner (https://nursing.uiowa.edu/academics/dnp/plans-of-study).

Despite ongoing system barriers (e.g., visits to the psychiatrist are only for psychiatric care, and to the primary care physician only for medical care), dually certified NPs/DNPs are prepared to provide exceptional integrated behavioral health and primary care. Further, while still somewhat a rarity, these nurses will be important drivers of improved care when the health care system and payers fully recognize their potential. To promote that recognition, students as well as providers and graduate program instructors/administrators champion the dual role and practice. They strategically educate payers on cost savings, not only to insurance companies, but also to community social service systems, the system in which these APRNs work, emergency services and departments, and police and judicial systems. Students in the dual certification program are taught how to navigate reimbursements and partnerships and advised to (once they begin their practice) retain months of billing with payments and/or denials, and to provide payers with evidence to support their practice.

Preliminary outcomes for students graduating from the DNP dual certification programs demonstrate improvements in their attitudes, knowledge and comfort level working with older patients with mental disorders and increased knowledge about how to work with patients with mental disorders. Additional cost, quality, satisfaction and adherence outcomes are currently under evaluation (Conley & Judge-Ellis, 2018). Such a nurse-designed individual, family and community-centric care model is relationship-based and represents a shift from episodic, individual care to a continuous group or public health approach (Conley & Judge-Ellis, 2018). Further, it represents a prime leadership opportunity for nursing and interprofessional colleagues in health care redesign (FON, 2010)

Progress in Advancing GPN Leadership in Workforce Planning & Policy-Making

A key recommendation of the FON report (2010) is effective workforce planning and policy efforts. Integral to such efforts, however, is building the pipeline of future leaders to continue the forward momentum of the field. One significant example of GPNC leadership in capacity building was the previously mentioned 2017 two-day conference: State of the Future in Global Aging, Dementia and Mental Health: Bridging Leadership, Science, Practice and Policy. With support from the National Institute on Aging, this first ever NHCGNE leadership conference specifically focused on mental health and aging and brought together clinicians and scholars from six disciplines and seven countries. The conference goals were to take stock of the field in its current state, identify needs and reveal promising avenues for moving it forward through science, practice, education and training, and policy. As part of ‘building the pipeline,’ the conveners deliberately and strategically integrated mentoring of emerging GPN leaders/scholars into the overall conference design and programming including co-authorship and publication of the commissioned papers and commentaries and participation in a ½ day follow up participatory Think Tank.

An important outcome was the April 2018 supplemental issue of the Journal of the American Geriatrics Society (Stephens, Evans, Bradway, & Buckwalter, 2018) that includes four interprofessional white papers and accompanying brief commentaries encompassing science (Massimo, Kales, & Kolanowski, 2018; Gilmore-Bykovski, 2018; Manning & Steffans, 2018; Wright, 2018), practice (Callahan, et al., 2018; Sturdevant, 2018), education and training (Farrell, et al., 2018; Harris, 2018) and policy (Cacchione, Pike, Spaeth-Rublee, & Pincus, 2018). The invitational Think Tank included conference speakers and selected attendees (experts, stakeholders, emerging leaders/scholars in the field) who were asked to focus on three themes: Building the Science, Training Current & Future Generations, and Designing Practice Models. Workgroup reports informed consensus discussions and action plan drafts. Workgroup leaders reconvened several months later to revisit recommendations, and to present findings to additional stakeholders as summarized in a forthcoming publication. These collective efforts have not only formed the back drop for ongoing and future initiatives, but they have also helped support the emergence of a new cadre of interprofessional and GPN leaders in research, education, clinical practice and policy.

The Health & Aging Policy Fellows (HAPF) program is another mechanism through which the pipeline of interprofessional mental health and aging policy leaders has been effectively fostered and developed. Since the interdisciplinary HAPF program’s inception in 2008, 20% of fellows have specifically focused on policy issues related to mental health and aging (Cacchione, et al., 2018). Examples of efforts in the areas of dementia and mental health policy to improve the lives of older Americans include the participation of six fellows in writing the Affordable Care Act to ensure inclusion of mental health parity and that of three fellows who contributed to improvements in the Program of All Inclusive Care for Elders (PACE), one of whom focused on inclusion of mental health as a required service (see Table 2).

Table 2.

Examples of Dementia and Mental Health Policy Activities in Which Health and Aging Policy Fellows Participated During Fellowship Placement

Name	Discipline	Cohort	Policy Contribution
Gretchen Alkema	Social work	2008–09	Affordable Care Act
Elizabeth Bragg	Nursing	2008–09	Affordable Care Act
Brian Hensel	Public health	2008–09	Affordable Care Act
Kathryn Kietzman	Social work	2008–09	Affordable Care Act
Toni Miles	Medicine	2008–09	Affordable Care Act
Judy Zerzan	Medicine	2008–09	Affordable Care Act
Greg Hinrichsen	Psychology	2008–09	Improving access to community-based mental health care within the Department of Veterans Affairs
Xin Qi Dong	Medicine	2010–11	Mental health and cognitive impairment screening guidelines; elder abuse
Eileen Sullivan-Marx	Nursing	2010–11	PACE expansion
Sally Sterns	Health policy and management	2010–12	Addressing overuse of hospice services in dementia care
Susan Lynch	Law	2010–13	Reducing overuse of antipsychotic drugs in nursing homes
Tara Cortes	Nursing	2010–14	PACE innovation act bill
Victoria Walker	Medicine	2010–15	Support for family caregivers
Latrice Vinson	Psychology	2010–17	Improving services for veterans with complex cognitive impairment, serious mental illness, and comorbid medical problems
Jamie Kuhne	Social work	2015–16	Long-term care services for veterans, (report published by the Congressional Research Service)
Hiral Shah	Medicine	2015–16	Best practices for human rights protections for individuals with cognitive impairment and dementia
Robert Ferguson	Public health	2015–16	Behavioral health integration
Brian Kaskie	Health policy	2016–17	Fighting Fraud: Senate Aging Committee Identifies Top 10 Scams Targeting Our Nations Seniors
Pamela Cacchione	Nursing	2016–17	PACE Innovation Act: Infusing Mental and Behavioral Health into PACE as required service
Gary Epstein-Lubow	Psychiatry	2016–17	Improving Quality of Care for Persons with Dementia and Other Mental Health Conditions in Nursing Homes
Madeline Naegle	Nursing	2016–17	Comprehensive Alcohol Policy of Harm Reduction in Jamaica and other Caribbean Countries
Gary Stein	Social Work Law	2016–17	Treatment Decisions for Incapacitated Older Adults

PACE = Program of All-inclusive Care for the Elderly.

Table adapted from Cacchione, Pike, Spaeth-Rublee & Pincus (2018)

Challenges to Achieving the Workforce Planning and Policy Goal.

Clearly, much more needs to be done from a leadership development and policy perspective to address the current and future needs of this vulnerable population, and to realize nursing’s full participation in achieving care goals. Addressing such health and aging policies will require a cadre of passionate and skilled professionals with the intellectual capital to influence policy and bring about change.

Recommendations for the 2020 FON Report

The recommendations below emerged from a reflection on a decade of progress in the field of GPN, guided by key elements of the 2010 FON Report and an aim to identify important implications for the forthcoming 2020 FON Report. The progress of GPN toward achieving FON goals over the past ten years has been, at best, both modest and uneven. The campaigns to change geropsychiatric education, practice and leadership through policy remain small, short lived, under the radar, underfunded and under-supported, both in nursing and in the broader health professions. Some examples of movement toward APRN preparation for interprofessional practice to better meet the mental health needs of people as they age have been noteworthy. Likewise, some models of integrated practice now exist, but their replication has been slow, and nurses with preparation to influence policy in areas that would affect needed change are still too few. Our recommendations to FON for the next ten years, however, build on these most promising successes.

1. Advance GPN & Interprofessional Education to Develop the Workforce.

The nation desperately needs more advanced practice nurses prepared in mental health and aging, but programs with relevant faculty expertise in the field are few. By creating geropsychiatric nursing as a subspecialty for advanced practice nurses caring for adults, as put forth in the recent GAPNA position statement (2019), we can better ensure the pipeline of future experts to educate both nurses as well as interprofessional teams to meet the critical workforce needs for this population. Development of a GPN subspecialty, however, has inherent challenges, including, for example: 1) universal lack of NP certification for subspecialties in advanced practice nursing; 2) nationwide variations in both content and timing of subspecialty coursework; 3) issues related to enrollment eligibility for subspecialty coursework; and 4) credentialing and marketability. Although the authors recognize these challenges, we believe the advantages of GPN subspecialization outweigh these concerns and thus remain committed to its development, prepared to address challenges that emerge.

Despite these potential subspecialty challenges, 100% of graduate nursing schools should be providing GPN content in their curricula. Yet, as the most recent national survey revealed, fewer than 70% of schools include any such content and there has been no change over the past 10 years (Stephens, et al., 2015). Similar barriers persist over time: lack of funding for curriculum development or student stipends, lack of faculty preparation, and lack of strong endorsement for GPN education (Harris, et al., 2018). Currently, a major revision in the Essentials for advanced practice nursing education is underway. Collaboration among the GPNC and GPN special interest groups in the relevant APRN specialty nursing organizations will be critical to assure that mental health and aging is addressed as new competency statements are developed. Educating those who help prepare the certifying examinations about the importance of GPN inclusion is another effective strategy to increase uptake of GPN content by schools of nursing.

It is further critical that nurse educators and policy makers increase their advocacy for greater allocations of federal and other sources of private foundation funding to support development and replication of successful GPN infusion models for curricula while also preparing faculty and practicing clinicians (Harris et al.,2017). The National Institutes of Health (e.g., NIMH, NIA, NINR, SAMHSA) and private foundations should be encouraged to develop and support opportunities for research on innovative practice change collaboration and integration models in mental health and aging, as well as require research on outcomes of nurse-led interventions to include follow-up evaluation components in educational and practice infusion. Faculty incentives to submit training grants (that do not “buy out” teaching time) should be fostered by collegiate offices of nursing research to support these programs in their institutions, and administrators reminded to seek private support for GPN scholarships and to fund tuition forgiveness programs once GPN graduates are practicing in the field. Within schools of nursing and universities, faculty need to advocate for curricular changes among their nursing peers while also identifying and developing opportunities for greater interprofessional training in geropsych, both in the classroom and in the practice setting.

To that end, there is an urgent need for GPN leadership and support for evidence-based interprofessional curricular design and clinical training in geriatric mental health, particularly for primary care providers who lack specialized preparation in these areas. Congruent with the FON and IOM reports, value-driven care will require teams of health professionals who are capable of functioning in high-performing teams and competent in geriatric and geriatric mental health principles. Funding is needed for interprofessional team-based education and practice models to ensure all health professions students achieve Interprofessional Education Collaborative (IPEC) Core Competencies for Interprofessional Collaborative Practice. Additional ingredients for success include identifying appropriate clinical sites (particularly where an interprofessional practice model is in place), as well as training clinical preceptors in mental health of older adults and maximizing opportunities to participate in learning that is intentionally interprofessional (Evans, et al., 2012; Harris et al., 2018; IOM, 2010; IOM, 2012). For example, by expanding collaborations among GWEPs, VA programs and professional organizations, leaders can more effectively further their impact.

2. Advance GPN Practice in Full Partnership with Others.

In order to advance GPN practice in full partnership with others, it is critical first to reframe the overarching field of psych mental health and normalize mental and cognitive health as a core feature of general health care. Ideally, by moving from a stigma and disability focus to more of a strengths-based, health promotion focus on “brain health”, we can more actively engage older adults and their families to work with educators, health providers, health systems, payers, and policy makers in the co-design of agendas and interventions. A systematic, intentional approach by health science educators, healthcare system leaders, and clinicians – in partnership with older adults and their families – is essential to advance innovation for positive outcomes for older adults. Initiatives such as the Patient Centered Medical Home, Medicare Quality Payment Program, and Accountable Care Organizations already include elements of interprofessional collaborative practice (IPCP) and generally assume that the workforce is capable of functioning in high-performing teams and competent in fundamental geriatrics principles (Farrell et al, 2018). Therefore, it is critical to support collaborative practice redesign with incentives for team-based care.

Programs preparing APRNs for dual certification, like that at the University of Iowa, have potential to change the health care system, while simultaneously fulfilling many of the recommendations from the 2010 FON report. These include: promoting full scope of practice, improving access to care for vulnerable populations, particularly in rural settings, fostering leadership roles for nurses in delivery of care, and transforming nursing education. Full enactment of the practice potential of such APRNs and recognition of the subspecialty of geropsychiatric nursing are critical solutions to bridge gaps in care for older adults. This would be greatly aided, as per FON recommendation 1, by developing APRN residencies in integrated care settings (including long term care, homeless shelters and residential settings for older adults with serious, persistent mental illness) where the new roles are being enacted. Faculty practice plans can encourage NPs already in collaborative practice environments to have students work with them and dually certified practitioners practicing in a variety of settings can create NP student practicum experiences/apprenticeships that provide exposure to new roles along with mentorship. Partnerships between nurse faculty and nurses practicing in these settings could more quickly produce research-based outcomes in cost and quality that will be influential with payers as well as uptake by others.

3. Support leadership development in mental health policy.

We must continue efforts toward diffusing, disseminating, and implementing GPN innovations into education, practice, research and policy arenas and developing strategies to achieve sustainability (Callahan et al., 2018). Encouraging colleagues to become fellows in the Health and Aging Policy Fellows (HAPF) program, or other policy-strengthening programs that do not have a particular aging focus (e.g., Robert Wood Johnson Foundation’s Health Policy Program, White House Fellowships), will further ensure the pipeline of change agents to inform and influence health policies that impact the mental health for older persons. Efforts by the American Academy of Nursing to facilitate appointment of nurses to policy influencing roles should include nurses with expertise in mental health and aging. Schools of nursing can partner with state agencies on aging to host legislative days in state capitols for students and faculty. GPN faculty can be encouraged to fulfil their service commitments with local aging task forces, as well as explore opportunities to collaborate with colleagues in colleges of law that set forth policy changes in state statutes and legislation related to geriatric mental health, such as re-writing anachronistic laws related to conservatorships/guardianships for chronically mentally ill older adults or those with cognitive impairment. Faculty who serve on NIH advisory councils should be encouraged to work with their state Congresspersons and their staffers to see that Institute initiatives and issues of concern to GPN get introduced and written into law. They can also seek opportunities to testify before influential committees such as the Senate Subcommittee on Aging and at congressional breakfast meetings. More opportunities to both bring together and train together professionals with interest and passion in this field can help build leadership for state and national level participation to better address care needs for vulnerable older people.

Conclusion

The FON Report (IOM, 2010) supports the unique role of APRNs as interprofessional team members critical to transforming mental health care for older persons. While significant strides have been made in the field of GPN over the past decade, more work is clearly needed. It is urgent that we find solutions to the identified remaining challenges – in practice, education/training, practice and health care systems leadership and policy – in order to disrupt significantly the current trajectory and to ensure we meet the population health needs of our older adults with dementia, mental health and substance use issues (Stephens et al., 2018). Clearly, a geropsychiatric workforce that includes well-prepared nurses is needed to address the cognitive and emotional disorders and comorbid physical diseases that results in disability, functional decline and decreased quality of life and well-being of older adults, their families and caregivers (Hyman, 2001; Morris & Mentes, 2006; IOM, 2012; Stephens et al., 2018).

The GPNC has been instrumental in launching many of the developments in the field of GPN over the past decade, advancing education/training, policy and practice initiatives in a collaborative way. Moreover, it has served as an exemplar of advocacy for the vulnerable population of older adults. By ‘building the pipeline,’ it has positioned others to move forward to help set and address the FON 2020–2030 goals. By linking with existing professional and governmental organizations to pursue mutual goals while continuing to support one another and our interprofessional colleagues, GPN-prepared nurses can ensure success in advancing high quality care and achieving positive outcomes for older adults.