Policy Initiatives for the Substance Abuse Workforce

1. Policy Initiatives for the Substance Abuse Workforce Presented to the Johnson Institute Workforce Development Forum October 27, 2006 By Henrick Harwood The Lewin Group

2. Substance Abuse Workforce Policy “Should Do’s” • Providers: Increase pay levels; Hire more minorities; Get more efficient • Payers: increase funding (per client/unit svc; # clients) • Federal agencies: research practitioners • Field: define competencies for more levels/types of staff • States: license additional staff levels; define scopes of practice; monitor use of staff w/in scope of practice • Congress: authorize Council on the Mental and Substance-Use Health Care Workforce

3. What Has Gone Before • National Treatment Plan: Changing the Conversation • Annapolis Coalition: Strategic Plan for Behavioral Health Workforce • CSAT/Partners for Recovery meetings on workforce • IOM Reports • Crossing the Quality Chasm • Improving the Quality of Health Care for Mental and Substance-Use Conditions • ATTC workforce studies • CSAT Practice Services Networks: • 6 major BH Practitioner Assn’s • SAMHSA addition of workforce development to “strategy matrix”

4. Perceived Problems • High turnover of counselors • Loss to field of qualified staff • Leave field or retire • Minorities under represented • Low status/esteem of field (stigma?) • Inadequate career ladder • The Root Cause: Low wages?

5. The Parties to this Situation • Patients • Counselors, and their associations • Providers (the employers) • Payers • Federal, state, local gov’t, private insurance • State accreditation/licensure authorities • Educators (degree-granting, CME) • Subsidizers/funders of education • Researchers and research funders

6. Desired Outcomes • Clients: affordable access to good treatment • Payers: adequate supply of “good” SAT at low cost • Providers: supply of well qualified staff at low cost • Counselors: rewarding careers, respect, adequate pay

7. Counselor Employment, Annual Replacement Rate and Salaries, and Comparisons 2004-05 Occupational Employment Statistics from the US Bureau of Labor Statistics

8. The Field Has Professionalized, However . . . • The field started with non-degreed community workers, many recovering • Now over 50% of credentialed SA counselors have graduate degrees, but few in SA counseling • Fields such as counseling, psychology, social work provide training to our staff • little if any training on addictions • 10 to 20% of their clients present with addictions • Most SA training and credentialing is by “continuing education”

9. The Formal Education Pipeline is too Small to Supply 8,000 Counselors/year

10. The fact that the vast majority of formally degreed counselors have degrees in broader fields means that they have broader career options. • Counseling and social work are much larger than SAT, and have somewhat better salaries.

11. Career Ladder • Major issue is small providers • little room for advancement • inefficient and high costs • Possible solution: merge into/affiliate with other providers

12. Credentialing • Potential to define a career ladder • Based on skills and competencies • Should be related to “scope of practice” provisions and provider regulations • Might focus on specialized clinical skills for, e.g., MICA, criminal justice, adolescents, tobacco, gambling • Recognize specialized credentials for, e.g., professional counselors and clinical social workers

13. Credentialing • States license health professions, and define scope of practice • Two national organizations assist states • ICRC credentials 30,000 professionals • AODA, AAODA, CCS (CCJP, CPS) • NAADAC credentials 15,000 professionals • NCAC I, NCAC II, MAC, (TAC, SAP) • About 20 states have 1 or 2 credentials • About 30 states have 3 or more

14. The California Certification & Career Ladder • Registered Student (RS) • Registered Recovery Worker (RRW) • Registered Alcohol & Drug Intern (RADI) • Registered Alcohol & Drug Technician I (RADT-I) • Registered Alcohol & Drug Technician II (RADT-II) • Certified Alcohol Counselor and Drug Counselor I (CADC I) • Certified Alcohol and Drug Counselor II (CADC II) • Clinical Supervisor Certification (CCS)

15. NIH Can Do More Grant abstracts that mention counselors • Services research “can” study counselors, but rarely does • Counselors usually treated as “inter-changeable” rather than an active element of therapy to study

16. Researchable Questions • What do typical counseling careers look like? • What attracts entrants to the field? • What makes mentoring and clinical supervision work? • When they leave the field what do they go to? • How should we measure counselor effectiveness? • How much does effectiveness vary across counselors? • How can/should providers monitor counselor effectiveness and use it for CQI? • Are various types of counselors more effective with certain types of clients? • Are types of SAT training more/less effective?

17. Are states laboratories for counselor workforce policy? • What is different: • Credentialing • Scope of practice (e.g., dual diagnosis) • Funding • Provider regulations • Are some state policies better/worse? • How would we know? • Turnover? • Wage levels?

18. Center on Substance Abuse Treatment • Addiction Technology Transfer Centers 1993-present • National Treatment Plan 2000 • Partners for Recovery Hearings 2004 • Annapolis Coalition Workforce Strategic Plan • Practice Services Network w Associations • 3 surveys 1999-2004 • SA counselors, 4 MH professions • SAMHSA Priorities Matrix added Workforce Development

19. NAADAC Initiatives • Major Problems: • High turnover of counselors & administrators • Counselors have excessive caseloads, modest compensation; inadequate training limits quality improvement • Close treatment gap & ensure high quality care • Congressional Initiatives • Loan forgiveness • Parity: cut down discriminatory reimbursement practices and improve odds patients complete treatment • Congressional Caucus: supporting, recruiting • Include SA-related professions under Health Professions Act (Health Professions Education Partneship Act) • Ohio Workforce Development Center (internet and educational events) • Nationwide certification: relieve paperwork, save money/time, aid professionals • Lobbied to have workforce development made a high priority at SAMHSA (it was put in the Strategy Matrix)

20. NASADAD Initiatives • Service delivery gap • Recovery is real (services are effective) • Priorities for 2005 • Strengthen SSAs • Expand access to prevention and treatment services • Promote policies that create incentives for improved performance • Imple an outcome and perf mgt data system • Ensure clinically appropriate care • Promote effective policies related to co-occurring populations • NASADAD Policy Position Paper: Workforce Competency (June 2003) • NASADAD endorsed counselor “minimum competency standards” as outlined in TAP 21 (Addiction Counseling Competencies) and calls for this to be revised, updated and reissued. • Electronic Health Records • A challenge to afford and train staff to use effectively and protect privacy

21. Therapeutic Communities of America • Five priorities • Addiction and co-occurring services for veterans and their family members • Additional resources for services and research • Elimination of the Medicaid IMD exclusion • Expansion of criminal justice institutional and community treatment services • Address workforce shortage, which limits treatment expansion and quality of care by • Career ladders for advancement within the field • Loan repayments • Scholarships and other collaborative efforts with the education community • Public service announcements and utilization of other marketing tools • Mentoring programs • Training of other caregivers specifically in evidence-based substance abuse treatment • Apprenticeship programs

22. Crossing the Quality Chasm • Recommendations • Healthcare constituencies’ purpose: reduce illness, injury, disability, improve health & functioning • Healthcare constituencies pursue 6 major aims • Healthcare constituencies embrace 10 rules • Congress charge DHHS to monitor quality • Redesign healthcare on basis of 10 rules • AHRQ identify 15 major health problems and use NQF to convene stakeholders and formulate action plans • Congress establish a healthcare quality innovation fund • AHRQ/foundation workshops on care coordination/teams • DHHS program to translate research into practice • Use HIT to eliminate hand-written health information • Health purchasers use reimbursement to create incentives for quality • CMS/AHRQ research agenda on reimbursement and quality • Health professions summit on restructuring clinical education & assess implications for health education • AHRQ research on regulatory and legal issues

23. Six aims Safe Effective Patient-centered Timely Efficient Equitable Ten rules Care based on continuous healing relationships Customization based on patient needs and values The patient as the source of control Shared knowledge and the free flow of information Evidence-based decision making Safety as a system property The need for transparency Anticipation of needs Continuous decrease in waste Cooperation among clinicians Crossing the Quality Chasm

24. Improving the Quality of Health Care for Mental and Substance-Use Conditions: Increasing Workforce Capacity for Quality Improvement • 7-1 Congressionally authorized Council on the Mental and Substance-Use Health Care Workforce as a public-private partnership to develop a comprehensive plan. • Identify clinical competencies • Develop national standards for credentialing and licensure to eliminate differences across states • Propose programs to address issues such as: diversity; cultural relevance; faculty development; shortages of clinicians and administrators • Monitor workforce trends, issues and financing • Report progress on the plan and workforce status annually • “Solicit technical assistance” to support work of Council • 7-2 Licensing boards and accrediting bodies should incorporate competencies and standards set by Council • 7-3 Federal government should support M/SU faculty leaders in medical and nursing schools and for M/SU professions • 7-4 Institutions of higher education should do more interdisciplinary didactic and experiential learning, bringing together faculty and students across various programs

25. Council on Graduate Medical Education • Authorized by Congress in 1986; appointed members from stakeholder groups and DHHS • Ongoing assessment of physician workforce trends, training issues and financing policies (16 reports): • Supply and distribution of physicians • Current and future shortages or excesses in specialties • Issues related to international medical school graduates • Federal policy on financing of UGME & GME • Recommend changes in nature of GME • Recs to schools of medicine, hospitals, accrediting bodies • Recs on data policy to monitor above • Recommends appropriate federal and private sector efforts on these issues

26. Substance Abuse Workforce Policy “Should Do’s” • Providers: Increase pay levels; Hire more minorities; Get more efficient • Payers: increase funding (per client/unit svc; # clients) • Federal agencies: research practitioners • Field: define competencies for more levels/types of staff • States: license additional staff levels; define scopes of practice; monitor use of staff w/in scope of practice • Congress: authorize Council on the Mental and Substance-Use Health Care Workforce