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Policy Initiatives for the Substance Abuse Workforce. Presented to the Johnson Institute Workforce Development Forum October 27, 2006 By Henrick Harwood The Lewin Group. Substance Abuse Workforce Policy “Should Do’s”. - PowerPoint PPT Presentation
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Policy Initiatives for the Policy Initiatives for the Substance Abuse Substance Abuse
WorkforceWorkforce
Presented to the Johnson InstitutePresented to the Johnson InstituteWorkforce Development ForumWorkforce Development Forum
October 27, 2006October 27, 2006By By
Henrick HarwoodHenrick HarwoodThe Lewin GroupThe Lewin Group
Substance Abuse Workforce Substance Abuse Workforce Policy “Should Do’s”Policy “Should Do’s”
Providers: Increase pay levels; Hire more minorities; Providers: Increase pay levels; Hire more minorities; Get more efficient Get more efficient
Payers: increase funding (per client/unit svc; # clients)Payers: increase funding (per client/unit svc; # clients)
Federal agencies: research practitioners Federal agencies: research practitioners
Field: define competencies for more levels/types of staff Field: define competencies for more levels/types of staff
States: license additional staff levels; define scopes of States: license additional staff levels; define scopes of practice; monitor use of staff w/in scope of practicepractice; monitor use of staff w/in scope of practice
Congress: authorize Council on the Mental and Congress: authorize Council on the Mental and Substance-Use Health Care WorkforceSubstance-Use Health Care Workforce
What Has Gone BeforeWhat Has Gone Before National Treatment Plan: Changing the National Treatment Plan: Changing the
ConversationConversation Annapolis Coalition: Strategic Plan for Behavioral Annapolis Coalition: Strategic Plan for Behavioral
Health WorkforceHealth Workforce CSAT/Partners for Recovery meetings on workforceCSAT/Partners for Recovery meetings on workforce IOM ReportsIOM Reports
• Crossing the Quality Chasm Crossing the Quality Chasm • Improving the Quality of Health Care for Mental and Improving the Quality of Health Care for Mental and
Substance-Use ConditionsSubstance-Use Conditions ATTC workforce studiesATTC workforce studies CSAT Practice Services Networks: CSAT Practice Services Networks:
• 6 major BH Practitioner Assn’s6 major BH Practitioner Assn’s SAMHSA addition of workforce development to SAMHSA addition of workforce development to
“strategy matrix”“strategy matrix”
Perceived ProblemsPerceived Problems
High turnover of counselors High turnover of counselors Loss to field of qualified staffLoss to field of qualified staff
• Leave field or retireLeave field or retire Minorities under representedMinorities under represented Low status/esteem of field (stigma?)Low status/esteem of field (stigma?) Inadequate career ladderInadequate career ladder
The Root Cause: Low wages?The Root Cause: Low wages?
The Parties to this SituationThe Parties to this Situation
PatientsPatients Counselors, and their associationsCounselors, and their associations Providers (the employers)Providers (the employers) PayersPayers
• Federal, state, local gov’t, private insuranceFederal, state, local gov’t, private insurance State accreditation/licensure authoritiesState accreditation/licensure authorities Educators (degree-granting, CME)Educators (degree-granting, CME) Subsidizers/funders of educationSubsidizers/funders of education Researchers and research funders Researchers and research funders
Desired OutcomesDesired Outcomes Clients: affordable access to good Clients: affordable access to good
treatmenttreatment
Payers: adequate supply of “good” SAT at Payers: adequate supply of “good” SAT at low costlow cost
Providers: supply of well qualified staff at Providers: supply of well qualified staff at low costlow cost
Counselors: rewarding careers, respect, Counselors: rewarding careers, respect, adequate payadequate pay
Counselor Employment, Annual Replacement Counselor Employment, Annual Replacement Rate and Salaries, and ComparisonsRate and Salaries, and Comparisons
2004-05 Occupational Employment Statistics from the US Bureau of Labor Statistics
SA/ behav. dis. counselors 72,210 10.6% $34,800
Mental health counselors 87,220 10.6% $37,470
Child, family social workers 256,430 8.7% $38,780
Medical social workers 112,220 8.7% $42,690
MH and SA social workers 120,140 8.7% $36,920
Social/ hum. svc assts 313,210 12.5% $26,600
Social/ comm. svc mgrs 112,910 9.1% $53,920
Psychologists, clinical 98,820 3.9% $63,960
Psychiatrists 23,450 4.3% $146,150
The Field Has Professionalized, The Field Has Professionalized, However . . .However . . .
The field started with non-degreed The field started with non-degreed community workers, many recoveringcommunity workers, many recovering
Now over 50% of credentialed SA Now over 50% of credentialed SA counselors have graduate degrees, but counselors have graduate degrees, but few in SA counseling few in SA counseling
Fields such as counseling, psychology, Fields such as counseling, psychology, social work provide training to our staffsocial work provide training to our staff• little if any training on addictionslittle if any training on addictions• 10 to 20% of their clients present with 10 to 20% of their clients present with
addictionsaddictions Most SA training and credentialing is by Most SA training and credentialing is by
“continuing education”“continuing education”
The Formal Education Pipeline is The Formal Education Pipeline is too Small to Supply 8,000 too Small to Supply 8,000
Counselors/yearCounselors/yearAlcohol/ Drug Abuse Counseling PhD 7
Alcohol/ Drug Abuse Counseling MA 86
Alcohol/ Drug Abuse Counseling BA 109
Alcohol/ Drug Abuse Cnsling AA (1998) 852
Social Work MSW 16,613
Psychology MA 17,898
Counseling Psychology MA 6,070
General Psychology MA 4,576
The fact that the vast majority of The fact that the vast majority of formally degreed counselors have formally degreed counselors have degrees in broader fields means that degrees in broader fields means that they have broader career options.they have broader career options.
Counseling and social work are much Counseling and social work are much larger than SAT, and have somewhat larger than SAT, and have somewhat better salaries.better salaries.
Career LadderCareer Ladder
Major issue is small providersMajor issue is small providers• little room for advancementlittle room for advancement• inefficient and high costsinefficient and high costs
Possible solution: merge into/affiliate Possible solution: merge into/affiliate with other providerswith other providers
CredentialingCredentialing Potential to define a career ladder Potential to define a career ladder
Based on skills and competenciesBased on skills and competencies
Should be related to “scope of practice” Should be related to “scope of practice” provisions and provider regulationsprovisions and provider regulations
Might focus on specialized clinical skills for, e.g., Might focus on specialized clinical skills for, e.g., MICA, criminal justice, adolescents, tobacco, MICA, criminal justice, adolescents, tobacco, gambling gambling
Recognize specialized credentials for, e.g., Recognize specialized credentials for, e.g., professional counselors and clinical social workersprofessional counselors and clinical social workers
CredentialingCredentialing
States license health professions, and States license health professions, and define scope of practicedefine scope of practice
Two national organizations assist statesTwo national organizations assist states• ICRC credentials 30,000 professionalsICRC credentials 30,000 professionals
AODA, AAODA, CCS (CCJP, CPS)AODA, AAODA, CCS (CCJP, CPS)
• NAADAC credentials 15,000 professionalsNAADAC credentials 15,000 professionals NCAC I, NCAC II, MAC, (TAC, SAP)NCAC I, NCAC II, MAC, (TAC, SAP)
About 20 states have 1 or 2 credentialsAbout 20 states have 1 or 2 credentials About 30 states have 3 or moreAbout 30 states have 3 or more
The California Certification & The California Certification & Career LadderCareer Ladder
Registered Student (RS)Registered Student (RS)
Registered Recovery Worker (RRW)Registered Recovery Worker (RRW)
Registered Alcohol & Drug Intern (RADI)Registered Alcohol & Drug Intern (RADI)
Registered Alcohol & Drug Technician I (RADT-I)Registered Alcohol & Drug Technician I (RADT-I)
Registered Alcohol & Drug Technician II (RADT-II)Registered Alcohol & Drug Technician II (RADT-II)
Certified Alcohol Counselor and Drug Counselor I (CADC I)Certified Alcohol Counselor and Drug Counselor I (CADC I)
Certified Alcohol and Drug Counselor II (CADC II)Certified Alcohol and Drug Counselor II (CADC II)
Clinical Supervisor Certification (CCS)Clinical Supervisor Certification (CCS)
NIH Can Do MoreNIH Can Do More
Services research Services research “can” study “can” study counselors, but counselors, but rarely doesrarely does
Counselors usually Counselors usually treated as “inter-treated as “inter-changeable” rather changeable” rather than an active than an active element of therapy element of therapy to studyto study
0
5
10
15
20
2006
2003
2000
1997
1994
1991
NIAAA NIDA
Grant abstracts that mention counselors
Researchable QuestionsResearchable Questions What do typical counseling careers look like?What do typical counseling careers look like? What attracts entrants to the field?What attracts entrants to the field? What makes mentoring and clinical supervision What makes mentoring and clinical supervision
work?work? When they leave the field what do they go to?When they leave the field what do they go to? How should we measure counselor effectiveness?How should we measure counselor effectiveness? How much does effectiveness vary across How much does effectiveness vary across
counselors?counselors? How can/should providers monitor counselor How can/should providers monitor counselor
effectiveness and use it for CQI?effectiveness and use it for CQI? Are various types of counselors more effective Are various types of counselors more effective
with certain types of clients?with certain types of clients? Are types of SAT training more/less effective?Are types of SAT training more/less effective?
Are states laboratories for Are states laboratories for counselor workforce policy?counselor workforce policy?
• What is different: What is different: Credentialing Credentialing Scope of practice (e.g., dual diagnosis)Scope of practice (e.g., dual diagnosis) Funding Funding Provider regulationsProvider regulations
• Are some state policies better/worse?Are some state policies better/worse? How would we know? How would we know?
• Turnover? Turnover? • Wage levels?Wage levels?
Center on Substance Abuse Center on Substance Abuse TreatmentTreatment
Addiction Technology Transfer Centers Addiction Technology Transfer Centers 1993-present1993-present
National Treatment Plan 2000National Treatment Plan 2000 Partners for Recovery Hearings 2004Partners for Recovery Hearings 2004 Annapolis Coalition Workforce Strategic PlanAnnapolis Coalition Workforce Strategic Plan Practice Services Network w AssociationsPractice Services Network w Associations
• 3 surveys 1999-20043 surveys 1999-2004• SA counselors, 4 MH professionsSA counselors, 4 MH professions
SAMHSA Priorities Matrix added Workforce SAMHSA Priorities Matrix added Workforce DevelopmentDevelopment
NAADAC InitiativesNAADAC Initiatives Major Problems:Major Problems:
• High turnover of counselors & administratorsHigh turnover of counselors & administrators• Counselors have excessive caseloads, modest compensation; inadequate Counselors have excessive caseloads, modest compensation; inadequate
training limits quality improvementtraining limits quality improvement• Close treatment gap & ensure high quality careClose treatment gap & ensure high quality care
Congressional InitiativesCongressional Initiatives• Loan forgivenessLoan forgiveness• Parity: cut down discriminatory reimbursement practices and improve odds Parity: cut down discriminatory reimbursement practices and improve odds
patients complete treatmentpatients complete treatment• Congressional Caucus: supporting, recruitingCongressional Caucus: supporting, recruiting• Include SA-related professions under Health Professions Act (Health Professions Include SA-related professions under Health Professions Act (Health Professions
Education Partneship Act) Education Partneship Act) • Ohio Workforce Development Center (internet and educational events)Ohio Workforce Development Center (internet and educational events)
Nationwide certification: relieve paperwork, save money/time, aid Nationwide certification: relieve paperwork, save money/time, aid professionalsprofessionals
Lobbied to have workforce development made a high priority at SAMHSA (it Lobbied to have workforce development made a high priority at SAMHSA (it was put in the Strategy Matrix)was put in the Strategy Matrix)
NASADAD InitiativesNASADAD Initiatives Service delivery gapService delivery gap Recovery is real (services are effective)Recovery is real (services are effective) Priorities for 2005Priorities for 2005
• Strengthen SSAsStrengthen SSAs• Expand access to prevention and treatment servicesExpand access to prevention and treatment services
Promote policies that create incentives for improved performancePromote policies that create incentives for improved performance• Imple an outcome and perf mgt data systemImple an outcome and perf mgt data system• Ensure clinically appropriate careEnsure clinically appropriate care• Promote effective policies related to co-occurring populationsPromote effective policies related to co-occurring populations
NASADAD Policy Position Paper: Workforce Competency (June NASADAD Policy Position Paper: Workforce Competency (June 2003)2003)• NASADAD endorsed counselor “minimum competency standards” NASADAD endorsed counselor “minimum competency standards”
as outlined in TAP 21 (Addiction Counseling Competencies) and as outlined in TAP 21 (Addiction Counseling Competencies) and calls for this to be revised, updated and reissued.calls for this to be revised, updated and reissued.
Electronic Health RecordsElectronic Health Records• A challenge to afford and train staff to use effectively and protect A challenge to afford and train staff to use effectively and protect
privacyprivacy
Therapeutic Communities of Therapeutic Communities of AmericaAmerica
Five prioritiesFive priorities• Addiction and co-occurring services for veterans and their Addiction and co-occurring services for veterans and their
family membersfamily members• Additional resources for services and researchAdditional resources for services and research• Elimination of the Medicaid IMD exclusionElimination of the Medicaid IMD exclusion• Expansion of criminal justice institutional and community Expansion of criminal justice institutional and community
treatment servicestreatment services• Address workforce shortage, which limits treatment expansion Address workforce shortage, which limits treatment expansion
and quality of care byand quality of care by Career ladders for advancement within the field Career ladders for advancement within the field Loan repayments Loan repayments Scholarships and other collaborative efforts with the education Scholarships and other collaborative efforts with the education
community community Public service announcements and utilization of other marketing Public service announcements and utilization of other marketing
tools tools Mentoring programs Mentoring programs Training of other caregivers specifically in evidence-based Training of other caregivers specifically in evidence-based
substance abuse treatment substance abuse treatment Apprenticeship programsApprenticeship programs
Crossing the Quality ChasmCrossing the Quality Chasm RecommendationsRecommendations
• Healthcare constituencies’ purpose: reduce illness, injury, disability, Healthcare constituencies’ purpose: reduce illness, injury, disability, improve health & functioningimprove health & functioning
• Healthcare constituencies pursue 6 major aimsHealthcare constituencies pursue 6 major aims• Healthcare constituencies embrace 10 rulesHealthcare constituencies embrace 10 rules• Congress charge DHHS to monitor quality Congress charge DHHS to monitor quality • Redesign healthcare on basis of 10 rulesRedesign healthcare on basis of 10 rules• AHRQ identify 15 major health problems and use NQF to convene AHRQ identify 15 major health problems and use NQF to convene
stakeholders and formulate action plansstakeholders and formulate action plans• Congress establish a healthcare quality innovation fundCongress establish a healthcare quality innovation fund• AHRQ/foundation workshops on care coordination/teamsAHRQ/foundation workshops on care coordination/teams• DHHS program to translate research into practiceDHHS program to translate research into practice• Use HIT to eliminate hand-written health information Use HIT to eliminate hand-written health information • Health purchasers use reimbursement to create incentives for qualityHealth purchasers use reimbursement to create incentives for quality• CMS/AHRQ research agenda on reimbursement and qualityCMS/AHRQ research agenda on reimbursement and quality• Health professions summit on restructuring clinical education & assess Health professions summit on restructuring clinical education & assess
implications for health educationimplications for health education• AHRQ research on regulatory and legal issuesAHRQ research on regulatory and legal issues
Crossing the Quality ChasmCrossing the Quality Chasm Six aims Six aims
• SafeSafe
• EffectiveEffective
• Patient-centered Patient-centered
• TimelyTimely
• EfficientEfficient
• EquitableEquitable
Ten rulesTen rules
• Care based on continuous healing Care based on continuous healing relationshipsrelationships
• Customization based on patient needs Customization based on patient needs and valuesand values
• The patient as the source of controlThe patient as the source of control
• Shared knowledge and the free flow of Shared knowledge and the free flow of informationinformation
• Evidence-based decision makingEvidence-based decision making
• Safety as a system propertySafety as a system property
• The need for transparencyThe need for transparency
• Anticipation of needsAnticipation of needs
• Continuous decrease in wasteContinuous decrease in waste
• Cooperation among cliniciansCooperation among clinicians
Improving the Quality of Health Care for Mental Improving the Quality of Health Care for Mental and Substance-Use Conditions: Increasing and Substance-Use Conditions: Increasing
Workforce Capacity for Quality ImprovementWorkforce Capacity for Quality Improvement 7-1 Congressionally authorized Council on the Mental and 7-1 Congressionally authorized Council on the Mental and
Substance-Use Health Care Workforce as a public-private Substance-Use Health Care Workforce as a public-private partnership to develop a comprehensive plan.partnership to develop a comprehensive plan.• Identify clinical competenciesIdentify clinical competencies• Develop national standards for credentialing and licensure to eliminate Develop national standards for credentialing and licensure to eliminate
differences across statesdifferences across states• Propose programs to address issues such as: diversity; cultural Propose programs to address issues such as: diversity; cultural
relevance; faculty development; shortages of clinicians and relevance; faculty development; shortages of clinicians and administratorsadministrators
• Monitor workforce trends, issues and financingMonitor workforce trends, issues and financing• Report progress on the plan and workforce status annuallyReport progress on the plan and workforce status annually• ““Solicit technical assistance” to support work of CouncilSolicit technical assistance” to support work of Council
7-2 Licensing boards and accrediting bodies should incorporate 7-2 Licensing boards and accrediting bodies should incorporate competencies and standards set by Councilcompetencies and standards set by Council
7-3 Federal government should support M/SU faculty leaders in 7-3 Federal government should support M/SU faculty leaders in medical and nursing schools and for M/SU professionsmedical and nursing schools and for M/SU professions
7-4 Institutions of higher education should do more 7-4 Institutions of higher education should do more interdisciplinary didactic and experiential learning, bringing interdisciplinary didactic and experiential learning, bringing together faculty and students across various programstogether faculty and students across various programs
Council on Graduate Medical Council on Graduate Medical EducationEducation
Authorized by Congress in 1986; appointed Authorized by Congress in 1986; appointed members from stakeholder groups and DHHSmembers from stakeholder groups and DHHS
Ongoing assessment of physician workforce Ongoing assessment of physician workforce trends, training issues and financing policies (16 trends, training issues and financing policies (16 reports): reports): • Supply and distribution of physiciansSupply and distribution of physicians• Current and future shortages or excesses in specialtiesCurrent and future shortages or excesses in specialties• Issues related to international medical school graduatesIssues related to international medical school graduates• Federal policy on financing of UGME & GME Federal policy on financing of UGME & GME • Recommend changes in nature of GMERecommend changes in nature of GME• Recs to schools of medicine, hospitals, accrediting Recs to schools of medicine, hospitals, accrediting
bodiesbodies• Recs on data policy to monitor above Recs on data policy to monitor above
Recommends appropriate federal and private Recommends appropriate federal and private sector efforts on these issuessector efforts on these issues
Substance Abuse Workforce Substance Abuse Workforce Policy “Should Do’s”Policy “Should Do’s”
Providers: Increase pay levels; Hire more minorities; Providers: Increase pay levels; Hire more minorities; Get more efficient Get more efficient
Payers: increase funding (per client/unit svc; # clients)Payers: increase funding (per client/unit svc; # clients)
Federal agencies: research practitioners Federal agencies: research practitioners
Field: define competencies for more levels/types of staff Field: define competencies for more levels/types of staff
States: license additional staff levels; define scopes of States: license additional staff levels; define scopes of practice; monitor use of staff w/in scope of practicepractice; monitor use of staff w/in scope of practice
Congress: authorize Council on the Mental and Congress: authorize Council on the Mental and Substance-Use Health Care WorkforceSubstance-Use Health Care Workforce