Steve Wiland , LMSW, ICADC - DWMHA Pasquale Vignola, MA, LLP - VCE Sheila Blair, AA – VCE

1. Overcoming Barriers to Provide and Sustain Evidence-Based, Best and Promising Practices Through Technology-Supported Workforce Development Steve Wiland, LMSW, ICADC - DWMHA Pasquale Vignola, MA, LLP - VCE Sheila Blair, AA – VCE

2. The Challenge of Competence • Complexity • Uses multiple skills simultaneously • Adopts a multifactorial understanding • Application • Skills and understanding are applied to a consumer situation • Application retains a sense of goal achievement and consumer need • Action • Practitioners must adopt an active response to create movement or resolution Source: Eastern Michigan University

3. Dimensions of Competence Source: Eastern Michigan University

4. The Problem with Graduates • Policy makers insist on EBPs but practitioners do not have requisite competencies (Sburlati et al., 2011) • Graduates from all types of university programs do not possess the necessary competencies for effective CMH practice (Biesma et al., 2010; Heiwe et al., 2005; Nelson & Graves, 2011; O’Donovan et al., 2005) • Graduate shortcomings are particularly acute in the areas of Evidence-Based Practices (Manuel et al., 2009; Sigel & Silovsky, 2011 Source: Eastern Michigan University

5. The Disconnect • There is a disconnect between the teaching in universities and the needs of community mental health (Biesma et al., 2008; Rugs et al., 2011) • University programs do not prioritize EBPs even though these are priority competencies in community mental health (Blumenthal et al., 2001; Hoge et al., 2002) • University programs are often reticent to change curriculum in response to shortcomings identified in the field (Akister, 2011) Source: Eastern Michigan University

6. University Realities • University systems undervalue teaching students in favor of research and external funding (Hoge et al., 2002) • Universities tend to use knowledge transfer approaches to teaching rather than expecting students to demonstrate competencies (Crits-Cristoph et al., 1995; Nelson, 2001; Wilson & Kelly, 2010) • Universities rely on internship experiences for competence development but these experiences are not uniform or consistent (Heiwe et al., 2011; Lehman et al., 2011) Source: Eastern Michigan University

7. The CMH Realities • When graduates enter CMH agencies • CMH settings are under-resourced and overburdened making it hard to compensate for educational shortfalls (Heiwe et al., 2011; Lehman et al., 2011) • CMH providers may expect practitioners to have pre-requisite competencies for practice • New graduates tend to abandon school-based learning and rely on nearby colleagues (Lombardozzi & Casey, 2008) Source: Eastern Michigan University

8. Common Responses • Most common response is to provide training • Provider systems hire trainers to help the workforce achieve basic competence levels • MDCH provides training to support the statewide workforce in providing effective interventions • Professional organizations mandate practitioners to continue development • University partnerships or technology transfer centers are used to support integration of EBPs Source: Eastern Michigan University

9. Knowledge-Based Training • Lectures • Self-study: Journal articles and books • Auditing classes • Conversation with colleagues and experts • Attendance at interactive training events (NOTE: all strategies transfer knowledge from the perceived expert to the practitioner) Source: Eastern Michigan University

10. Online Knowledge-Based Learning • Relatively new format • Opportunity for disseminating up-to-date information without travel costs • Can be completed at work, home or anywhere with internet access • Work at own pace • With videos and interactive exercises can also develop skill elements Source: Eastern Michigan University

11. Attitude-Based Training • Training events with videos and activities to challenge thinking • Experiential training events using emotional power to create dissonance between status quo and ideal situations • Typically learning strategies involve experience followed by group discussion Source: Eastern Michigan University

12. Pseudo-Skills-Based Training • Includes provision of knowledge coupled with modeling and/or opportunities to practice skill elements • Modeling may involve use of video or live demonstrations of skills with discussion • Often involves breaking into groups, applying skill elements and then reporting back • Motivates participants to continue practicing the involved skills Source: Eastern Michigan University

13. Problems with Training • Training is best for advancing knowledge and attitudes, but typically unsuccessful at developing competence • There is an immediate drop-off in motivation and application within days • Competence development is a longer process requiring frequent input and support • While some training protocols with EBPs have such protocols, most training fails to extend input or support (aka “coaching”) Source: Eastern Michigan University

14. Supervision to Develop Competencies • There is often an expectation that front-line supervisors promote competence • Supervisors believed to be assisting practitioners in developing knowledge and skills for effective practice • Supervisors are positioned to be the guarantor or to provide the organizational protection against sub-standard practice Source: Eastern Michigan University

15. Types of Supervision • Clinical • Administrative • Supportive • Competence-based Source: Eastern Michigan University

16. Clinical Supervision • Support and teaching to develop practitioner knowledge and competence. • Enables the practitioner to assume responsibility for their own practice. • Enhances consumer protection and the safety of care in complex clinical situations. Source: Eastern Michigan University

17. Administrative Supervision • Ensures that • work is performed, • paperwork is complied with, • billing and administrative procedures occur • Administrative supervision is crucial to agency functioning • In a busy environment, administrative functions can exert high demands on supervisors as the priority focus Source: Eastern Michigan University

18. Supportive Supervision • Operates concurrent with clinical and administrative supervision • Individualized support • Decreases burnout • More mutuality in the relationship • It can be provided whenever the practitioner needs support, on an as-needed basis. Source: Eastern Michigan University

19. Competence-Based Supervision • Observes the practitioner’s skill performance • Evaluates the performance based on accepted standards • Provides immediate feedback on the skill performance • Explores skill adjustments for subsequent improved applications Source: Eastern Michigan University

20. Ideal Elements for All Types • Safe environment in which a supervisee can discuss thoughts and feelings • Trusting relationship modeling the openness of the helping alliance with consumers • Regular time frames with clear and respected expectations • Reflective feedback to think meaningfully about one’s work, one’s self (Shahoom-Shanok, Gilkerson, Eggbeer & Fenichel, 1995) Source: Eastern Michigan University

21. Supervisory Prerequisites • Pre-existing competencies to develop feedback • Ability to describe observations to avoid defensive reactions • An exploratory approach for developing alternatives with the supervisee • Development of reflective exchanges with supervisee Source: Eastern Michigan University

22. Prerequisites Continued… • Ability to contribute new knowledge to the practitioner • Ability to motivate, and understand practitioner motivational needs • Ability to apply discussions back to practitioner situations • Ability to establish next steps and implementation plans Source: Eastern Michigan University

23. Time Challenges in CMH • Ideal supervision requires time and mutual investment • Job demands can interfere with optimal supervision • Interference is likely to diminish the importance of developmental input • Developmental work shifts input to colleagues, which may represent less-than-optimal feedback Source: Eastern Michigan University

24. Expertise Challenges with EBPs • Supervisor may not have the requisite information and skills for competence-development (credentialing issues) • Administrative and support functions are demanding • Often the EBP-related input is minimized, rendering it less important • Competence development suffers because of competing demands on supervisor and supervisee Source: Eastern Michigan University

25. Managing Expertise Source: Eastern Michigan University

26. When Supervisor is Expert • Uses expert knowledge to provide feedback and input • Relationship ideally identifies the supervisory expertise • Roles are clear regarding learner and teacher during supervision Source: Eastern Michigan University

27. When Supervisee is Expert • Supervisor adopts administrative and supportive roles • Clinical supervision can be provided in general areas • Supervisee operates autonomously within the area of clinical expertise • Supervisee may operate as a mentor to other staff – elevates profile on the team • Administrative and legal requirements remain with the supervisor Source: Eastern Michigan University

28. When Both are Expert • When topics of mutual expertise emerge exchange is collegial rather than hierarchical • Often different approaches lead to divergent thinking on consumer situations • Must have an agreement about how to handle differences • Requires high levels of maturity to manage the relationship Source: Eastern Michigan University

29. When Neither are Expert • Consumer situations result in guessing and trial-and-error responses • Past practice becomes normative and habitual responses dominate • Expertise must come from outside the team or agency • Requires resources and advocacy to prioritize the expenditure Source: Eastern Michigan University

30. Managing Challenges Without Compromise • To ensure workforce competence, development-related input is needed • It is unrealistic to believe that a supervisor can manage all elements • It is equally unrealistic to believe that training by itself will improve workforce development • Important shifts are needed in the work environment Source: Eastern Michigan University

31. The Importance of Repeated Feedback • Competence requires applied action followed by immediate feedback • Feedback should be customized for each person to meet their developmental needs • Application and feedback should repeat multiple times with adjustment during each cycle Source: Eastern Michigan University

32. Building Competence Source: Eastern Michigan University

33. Structuring for Competence • Pick your trainers well • Avoid one-time events • Ensure application, observation and feedback • Level Specific Training Plans • Have plans for each level in the organization • Dovetail the plans to reinforce each other • Scaffold your training plan • Develop training benchmarks and milestones • Use benchmarking to integrate training • Identify activities between events to reinforce competence Source: Eastern Michigan University

34. Integrating Training & Practice • Training should reflect work • Focus training opportunities (in-house?) • Build training applications into supervision agendas • Pair supervisors and workers in training plans • Infuse training content into agency patterns • Integrate training/teachable moments into group supervision or team meetings • Structure innovation discussions into meeting schedules Source: Eastern Michigan University

35. Workforce Training Survey • Survey of trainings selected by staff • Conducted in 2011 • 1000 surveys returned in the first month • Average age = 46 years • Average years in the field = 14.16 Source: VCE Workforce Development Survey, 2011

36. Most Common Job Categories • Social Worker 41.9% • Administrative 29.0% • Case Manager 10.2% • Direct Care/CMH 8.8% • Professional Counselor 8.6% • Psychologist 6.3% Source: VCE Workforce Development Survey, 2011

37. License Type • Social Work (MSW) 50.8% • Social Work (BSW) 17.6% • Licensed Professional Counselor 13.0% • Psychology 12.2% • Certified Addictions Counselor 11.3% • Nursing 4.5% Source: VCE Workforce Development Survey, 2011

38. Types of Trainings Taken • Recipient Rights (online/required) 79.1% • HIPAA (online/required) 75.3% • Person-Centered Planning (online/required) 64.2% • Medicaid Hearings etc (online/required) 59.0% • Ethics/Pain Management (SW licensing) 41.5% • Children’s Mental Health Grand Rounds 41.3% • Special Topics (online) 41.0% • Suicide Prevention Trainings 33.1% • Trauma Learning Series 27.7% (NOTE – most focus in on required trainings or easy access) Source: VCE Workforce Development Survey, 2011

39. Institute for Medicine Recommendations • 2001 Report “Crossing the Quality Chasm” • 2005 Report “Improving the Quality of Health Care for Mental and Substance-Use Conditions”

40. Challenges in Training: • State requires specific Social Work credits, not NASW • Trainings are rarely relevant or provide new information • Work schedule and budget will not allow much training time or fees • Hard to keep track of credits when earned

41. Ensuring a Competent Workforce: From Training to Practice • Benefits of Online Knowledge-Based Learning: • Opportunity for disseminating up-to-date information without travel costs • Can be completed at work, home or anywhere with Internet access • Work at own pace • Can include skill elements, with the use of videos and interactive exercises Source: Eastern Michigan University

42. Distance Learning: • Types offered: • Live video conferencing capability with five established sites and portable equipment to expand to 20 live sites • Synchronous web-streaming • Asynchronous learning (credit and non-credit) • Popular distance learning websites: • College of Direct Support (Elsevier) • Improving MI Practices • Relias (formerly E-Learning) • Virtual Center of Excellence (VCE)

43. Cost Benefit Analysis: • Conducted by Plante Moran in 2011 • Discoveries: • In 2011, VCE’s online training offerings saved Detroit Wayne Mental Health Workforce $1.6 MILLION in travel time and mileage; an additional amount saved that was not in this calculation was revenue lost when employees were unable to see clients because they were at a training • Cost per credit decreases over time as more people take trainings Source: Plante Moran

44. Benefits of Combining Live and Online Training: • Social Workers can only obtain 10 hours of their 45 licensure hours online • Some learners prefer a live format • Some training formats that are very audience interactive do not translate well into online trainings • VCE obtains Social Work credits for nearly all of its live trainings • VCE offers some live events in six or more locations at once for the convenience of participants

45. Continuing Education Credits (CECs): • VCE is an approved provider of CECs for licensed social workers (through MI-CEC), licensed professional counselors (through NBCC) and certified alcohol and drug counselors (through MCBAP. • Partner with WSU School of Medicine for CME • Partner with Hospice of Michigan for CNE • Other credits available through VCE: • CRC • MCOLES • AFC

46. Fiscal Year 2012/2013: • 61,700 individuals participated in VCE’s live and online trainings • 75,628 Social Work Continuing Education Credits were earned • 73,472.5 Counseling Credits were earned • 44,848.5 CMHP Credits were earned • 17,501.5 Medical Staff Education Credits were earned • 18,891 Substance Use Education Credits were earned

47. Feedback Loop & Expertise: • Work with Universities • Workforce Development Committees • Workforce Surveys & Event Evaluations • Establish curricula with non-university organizations such as: • Michigan Association for Infant Mental Health (MI-AIMH) • The Center for Self-Determination • Michigan Public Health Institute (MPHI)

48. Learning Organizations Such as Elsevier, Improving Michigan Practices, Relias, and VCE • Live and Online: • Annual required trainings by MDCH for CMH employees • Employer-required trainings, eliminating the need to do so much in-house and new-hire training • Evidence-Based Practices • Licensure-required trainings • Discipline-based required training (TBI, Self-Determination, etc.) • Child Mental Health Professional Trainings (get all 24 of your annual credits online) • School-based trainings (subjects on bullying, autism, suicide prevention, etc.)

49. References • Akister, J. (2011). Protecting children: The central role of knowledge. Practice: Social Work in Action, 23(5), 311-323. • Becan, J., Knight, D., & Flynn, P. (2012). Innovation adoption as facilitated by a change-oriented workplace. Journal of Substance Abuse Treatment, 42(2), 179-190. doi:10.1016/j.jsat.2011.10.014 • Biesma, R.G., et al. (2007). Using conjoint analysis to estimate employers’ preferences for key competencies of master level Dutch graduates entering the public health field. Economics of Education Review, 26(3), 375-386. • Biesma, R.G., et al. (2008).Generic versus specific competencies of entry-level public health graduates: Employers’ perceptions in Poland, the UK, and the Netherlands. Advances in Health Sciences Education, 13(3), 325-343.

50. References • Blumenthal, D., Gokhale, M., & Campbell, E.G. (2001). Preparedness for clinical practice: Reports of graduating residents at academic health centers. Journal of the American Medical Association, 286(9), 1027-1034. Retrieved from: http://peds.stanford.edu/faculty-resources/documents/JAMA_resident_prep_2001.pdf • Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders Board on Health Care Services. (2006). Increasing workforce capacity for quality improvement (Chapter 7). Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series. Washington, D.C.: Institute of Medicine of the National Academies – The National Academies Press. • Crits-Cristoph, P., Chambless, D.L., Frank, E., Brody, C., & Karp, J.F. (1995). Training in empirically validated treatments: What are clinical psychology students learning? Professional Psychology: Research and Practice, 26, 514-522. • Hager, M., Russell, S., Fletcher, S.W., (eds.). (2007). Continuing Education in the Health Professions: Improving Healthcare Through Lifelong Learning, Proceedings of a Conference Sponsored by the Josiah Macy, Jr. Foundation; 2007 Nov 28 - Dec 1; Bermuda. New York: Josiah Macy, Jr. Foundation; 2008. Accessible at www.josiahmacyfoundation.org.