Putting Health back into Clinical Mental Health Counseling

1. Putting Health back into Clinical Mental Health Counseling Presented by: Jim Messina, Ph.D. , NCC, CCMHC At: Utah Mental Health Counselors Association Date: May 10, 2013

2. From Dream to Reality in 1976 On an impulsive whim Nancy and Jim: • Coined term “Mental Health Counselor” • Coined Association Title: The American Mental Health Counselor’s Association As the process caught fire • Established the Profession of Mental Health Counseling • Set out to create its “Hallmarks of a Profession”

3. What are the Hallmarks of a Profession? • Professional Membership Organization • Code of Ethics • Certification and Licensure • Accreditation • Research into Effectiveness of Service Delivery

4. History Timeline of Creation of Mental Health Counseling Profession • 1976 – Coining of term Mental Health Counselor and formation of American Mental Health Counselor’s Association as Division of ACA • 1979 – Creation of the National Academy of Certified Clinical Mental Health Counselors • 1981 – First State Law to license Mental Health Counselors put into effect in Florida • 1985 – AMHCA had over 12,000 members • 2011 – AMHCA put out its newest Standards of Practice in Mental Health Counseling-Helping to put Health back into Clinical Mental Health Counseling • 2013 – AMHCA has over 7,000 members

5. The National Professional Association of Clinical Mental Health Counselors American Mental Health Counselors Association Founded in 1976 when term Mental Health Counselor was coined

6. Initial Definition of Scope of CMHC Practice The 1979’s initial AMHCA’s Journal of Mental Health Counseling included first published definition of mental health counseling as: “an interdisciplinary, multifaceted, holistic process of: • Promotion of healthy lifestyles • Identification of individual stressors & personal levels of functioning • Preservation or restoration of mental health” (Seiler & Messina, 1979)

7. AMHCA’s Revised Scope of Practice in 1986 The 1986 AMHCA Board of Directors adopted: “Clinical mental health counseling is the provision of professional counseling services involving the application of principles of: • Psychotherapy • Human Development • Learning Theory • Group Dynamics • Etiology of mental illness & dysfunctional behavior to individuals, couples, families and groups, for the purpose of promoting optimal mental health, dealing with normal problems of living and treating psychopathology…

8. 1986 Scope of Practice (2) The practice of clinical mental health counseling includes, but is not limited to: • Diagnosis & treatment of mental & emotional disorders • Psycho‐educational techniques aimed at the prevention of Mental & emotional disorders • Consultations to individuals, couples, families, groups, organizations & communities • Clinical research into more effective psychotherapeutic treatment modalities.”

9. State Chapters of AMHCA Regional Chapters of State MHCA’s

10. AMHCA Belongs to American Counseling Association Was known as APGA-American Personnel and Guidance Association in1976 and in 1983 as AACD American Association of Counseling and Development until 1992 when it changed to ACA

11. CODES OF ETHICS GoverningClinical Mental Health Counselors

12. National Certification

13. NBCC’s National Certifications for Mental Health Counselors • NCC: National Certified Counselor – Over 48,000 • CCMHC: Founded 1979- Certified Clinical Mental Health Counselor – Today only 1,000 + are CCMHC’s which needs to change if we are to put Health back into the professional identity of Clinical Mental Health Counseling

14. State Licensure for Counselors and Related Fields In USA • 120,429 Licensed Professional Counselors • 54,785 Licensed Marriage & Family Therapists • 202,924 Licensed Social Workers All 50 States have Licensed Professional Counselors but only 15 have Mental Health Counseling in their Title (Major way of taking Health out of Clinical Mental Health Counseling!)

15. 15 States with MHC’s in Title • Delaware-License Professional Counselor of Mental Health (LPCMH) • Florida-Licensed Mental Health Counselor (LMHC) First Licensed 1981 • Hawaii-Licensed Mental Health Counselor (LMHC) • Indiana-Licensed Mental Health Counselor (LMHC) • Iowa-Licensed Mental Health Counselor (LMHC) • Massachusetts-Licensed Mental Health Counselor (LMHC) • Nebraska-Licensed Independent Mental Health Practitioner (LMHP) • New Hampshire- Licensed Clinical Mental Health Counselor (LCMHC) • New Mexico-Licensed Mental Health Counselor (LMHC) • New York-Licensed Mental Health Counselor (LMHC) • Rhode Island-Licensed Clinical Mental Health Counselor (LCMHC) • South Dakota-Licensed Professional Counselor-Mental Health (LP-MH) • Tennessee-Licensed Professional Counselor-Mental Health Service Provider (LPC/MHSP) • Utah-Licensed Clinical Mental Health Counselors (LCMHC) as of 2012 • Vermont-Licensed Clinical Mental Health Counselor (LCMHC) • Washington-Licensed Mental Health Counselor (LMHC)

16. Major Recommendation to Promote Professional Identity of CMHC’s Given only 15 out 50 states licensed CMHC’s, it is imperative that we who have LMHC licensure encourage the LPC’s in the other 35 states to gain Certified Clinical Mental Health Counselor (CCMHC) status through the NBCC which would be a clear way of putting HEALTH into Clinical Mental Health Counseling and a way to get counselors in all 50 states enabled to call themselves Clinical Mental Health Counselor

17. AMHCA’s Online Newsletter

18. Research in the field is Reported in AMHCA’s Journal

19. Accreditation: Standards for Training of CMHC CACREP (The Council for Accreditation of Counseling & Related Educational Programs) 1988 CACREP set out its first Standards for accreditation of CMHC Programs using 60 hour requirement put out in 1979 by AMHCA – But it also had Community Counseling Programs with up to 48 hours – Most went Community Counseling 2009 CACREP adopted standards for CMHC which included 60 hour requirement

20. 2009 CACREP Standards for CMHC Required both core CACREP areas & specialized training in clinical mental health Core CACREP areas include: • Professional Orientation and Ethical Practice • Social and Cultural Diversity • Human Growth and Development across the lifespan • Career Development • Helping Relationships • Group Work • Assessment • Research and Program Evaluation

21. 2009 CACREP Standards for CMHC Specialized CMHC Training: • Ethical, Legal & Practice Foundations of CMHC • Prevention & Clinical Intervention • Clinical Assessment • Diagnosis & Treatment of Mental Disorders • Diversity & Advocacy in Clinical Mental Health Counseling • Clinical Mental Health Counseling Research & Outcome Evaluation These areas of CMHC preparation address clinical mental health needs across the lifespan (children, adolescents, adults and older adults) & across socially & culturally diverse populations.

22. AMHCA 2011 Standard Additional Requirement for CMHC Training The 2011 AMHCA standards also recommend these additional areas of training for CMHC Training programs: • Biological Bases of Behavior (including psychopathology and psychopharmacology) • Specialized Clinical Assessment • Trauma • Co-Occurring Disorders (mental disorders and substance abuse)

23. Implications of AMHCA’s 2011 Expanded Clinical Standards for Training of CMHC’s • Evidenced-Based Practices • Diagnosis and Treatment Planning using EBP’s • Diagnosis of Co-Occurring Disorders & Trauma • Biological Basis of Behaviors • Knowledge of Central Nervous System • Lifespan Plasticity of the Brain • Psychopharmacology • Behavioral Medicine • Neurobiology of Thinking, Emotion & Memory • Neurobiology of mental health disorders (mood, anxiety, psychosis) over life span • Promotion of optimal mental health over the lifespan

24. Accreditation-CACREP in 2009:74 Clinical Mental Health Counseling In Florida they are: • Argosy Sarasota • Barry University • Florida Atlantic University • Florida Gulf Coast University • Florida International University • Florida State University • Rollins College • Troy University Southeast Region • University of Central Florida • University of Florida • University of North Florida • University of South Florida Online: • Cappella University • Walden University In Utah: University of Phoenix-Mental Health Counseling NOTE: things will change now that Utah has in 2012 implemented the LCMHC

25. CACREP 2016 Standards for CMHC 1. FOUNDATIONS A. development of mental health counseling B. theories and models related to mental health counseling C. principles of mental health counseling, including prevention, intervention, consultation, education, and advocacy, and networks that promote mental health D. medical foundation and etiology of addiction and co-occurring disorders E. principles, models, and documentation formats of biopsychosocial case conceptualization and treatment planning

26. 2. CONTEXTUAL DIMENSIONS F. etiology, process, nomenclature, treatment, referral, and prevention of mental and emotional disorders G. mental health service delivery modalities such as inpatient, outpatient, partial treatment and aftercare and the mental health counseling services networks H. diagnostic process, including differential diagnosis, and the use of current diagnostic tools, such as the current edition of the (DSM) I. potential for substance use disorders to mimic and/or co-occur with a variety of medical and psychological disorders J. impact of crisis on individuals diagnosed with mental illness K. classifications, indications, and contraindications of commonly prescribed psychopharmacological medications for appropriate medical referral and consultation L. public policy and government relations on local, state, and national level to enhance equity funding and promote programs that affect the practice of mental health counseling M. cultural factors relevant to mental health counseling N. professional organizations, preparation standards, and credentials relevant to the practice of mental health counseling O. legal and ethical considerations specific to mental health counseling P. record keeping, third party reimbursement, and other practice and management issues in mental health counseling

27. 3. PRACTICE Q. intake interview, mental status evaluation, biopsychosocial history, mental health history, and psychological assessment for treatment planning and caseload management R. strategies for interfacing with the legal system regarding court referred clients S. techniques and interventions related to a broad range of mental health issues • What does this tell us? Little change is being recommended for the next round of CACREP Standards & AMHCA’s 2011 Standards have had little impact on what is being proposed at the current time. • Let’s see if this will matter based on future trends.

28. The Growth of Mental Health Counseling as a Profession • In 2008, according to US Department of Labor: 120,000 Mental Health Counselors were employed & only 6.7% of them were self-employed • By 2018 43,000 jobs will be added (for a for a total of 163,000), representing a 36.3% growth •  Median annual wages in 2008 for Mental Health Counselors was $38,150. This is High when compared to other jobs.

29. Parity with the Other Mental Health Professions The median reimbursable fee for service: • Clinical Mental Health Counselors is $63 • Psychologists is $75 for psychologists • Clinical Social Workers & Marriage and Family Therapists is $60 (January 2006 study by Psychotherapy Finances)

30. SO! What do Mental Health Counselors Currently Do? Mental Health Counselors offer full range of services: • Assessment & diagnosis • Treatment planning and utilization review • Psychotherapy • Brief and solution-focused therapy • Alcoholism and substance abuse treatment • Psycho-educational & prevention programs • Crisis management • Trauma Intervention

31. ACA’s 20/20 Commission’s Definition of Counseling Counseling is a professional relationship that empowers diverse individuals, families and groups to accomplish mental health, wellness, education and career goals They also established: The counseling profession shall establish uniform licensing standards with LPC as an entry-level title for counselor licensure.

32. BUT THINGS ARE GOING TO CHANGE! The emerging health needs of Americans is changing and as a result the roles and function of mental health practitioners will be changing as well

33. New AMHCA Clinical Standards Help CMHC to Get Ready for Changes in System The Affordable Care behavioral medicine interventions 1. ACA calls for the coordination and integration of medical services through the primary care provider for a “whole person orientation” to medical treatment - model currently implemented at some level in VA & Federally Qualified Health Centers (FQHC’s) 2. The ACA calls for creation of Affordable Care Organizations (ACO’s) to provide comprehensive services to Medicare recipients with a strong primary care basis 3. The ACA model includes integration of mental &behavioral health services into the Patient-centered medical home (PCMH) which can enhance patient outcomes 4. The ACA model integrates mental, behavioral and medical services under one roof with potential of controlling the costs for patients 5. The ACA integrated behavioral medical approach opens a massive opportunity for clinical mental health counselors 6. To be prepared to fill this evolving behavioral medicine role, it is imperative that clinical mental health counseling training programs establish training for future practitioners in these integrated medical settings.

34. The Affordable Care Act (ACA) • Beginning 2014 ACA increases access to quality health care including coverage for mental health & substance use disorder services • All new small group & individual private market plans will be required to cover mental health & substance use disorder services as part of the health care law's “Essential Health Benefits” categories

35. The Affordable Care Act (ACA) • Behavioral health benefits will be covered at parity with medical & surgical benefits • Insurers will no longer be able to deny anyone coverage because of a pre-existing behavioral health condition • ACA already ensures that new health plans cover recommended preventive benefits without cost sharing, including depression screening for adults & adolescents as well as behavioral assessments for children

36. Results of the Affordable Care Act • Primary care providers receive 10% Medicare bonus payment for primary care services • A new Medicaid state option is created to permit certain Medicaid enrollees to designate a provider as a health home & states taking up the option receive 90% federal matching payments for two years for health home-related services. • Small employers receive grants for up to five years to establish wellness programs

37. Results of the ACA continued: • The Center for Medicare & Medicaid Innovation launches the Accountable Care Organization (ACO) Model & Advance Payment ACO Model, which offers shared savings & other payment incentives for selected organizations that provide efficient, coordinated, patient-centered care • Some States established American Health Benefit Exchanges & Small Business Health Options Program Exchanges to facilitate purchase of insurance by individuals & small employers • Teaching Health Centers are established to provide payments for primary care residency programs in community-based ambulatory patient care centers

38. Two Healthcare Organizational Models which are Driving Change Two New Medicare/Medicaid models are driving a change in healthcare delivery: • Patient Centered Medical Homes • Accountable Care Organizations (ACO’s)

39. Medical Homes • Patient Centered - Empowers them with Information and Understanding • Comprehensive - Co-location of care providers in physical and behavioral health • Coordinated Care - Through Health Information Technology all providers are kept in touch • Accessible – same day appointment & 24/7 availability through technology online • Committed to Quality & Safety – Quality Improvement Goals which are tracked

40. Benefits of Medical Homes • Patients seek out the right care which is needed-which is often behavioral vs. physical • Less use of ER’s or delays in seeking care • Less duplication of tests, labs & procedures • Better control of chronic diseases & other illnesses improving health outcomes • Focus on wellness & prevention – reduce incidence & severity of chronic disease or illnesses • Cost savings less use of ER’s & Hospitals

41. What is moving the Patient Centered Home Health Model In April 2013 the Patient-Centered Primary Care Collaborative Pointed out on it website these factors driving the Home Health Model • Unsustainable cost increases in health care delivery • Growing availability of data • Vast change in the way we communicate Example: In Denmark, more than 80 percent of health-care encounters & transactions are electronically based & vastly different method of communicating is coming online and it's coming fast, driven by younger generations of patients and physicians.

43. Potential Role of Mental Health Counselors in Medical Homes • Address the stressors which lead folks to seek out medical attention in the first place • Assist in increasing compliance of patients with the medical directives given them by primary care staff • Wellness educational programming to help ward off chronic or severe illnesses • Assisting clients to cope with the medical conditions for which they are receiving medical attention

44. Primary and Behavioral Health Integration Grants based on Medical Home Model in ACA In Utah: Weber Human Services-Ogden, Utah In Florida: • Apalachee Center–Tallahassee • Community Rehabilitation Center-Jacksonville • LifeStream Behavioral Center-Leesburg • Lakeside Behavioral Center–Orlando • Coastal Behavioral Health Care-Sarasota • Miami Behavioral Health Center-Miami

45. Accountable Care Organizations • Have a look at the CMS video which overviews the ACO model: http://innovation.cms.gov/initiatives/aco/ • Now let’s look at the announcement of the Role Out of the ACO rules in 2011 to see what is hoped for in this model: http://www.healthcare.gov/news/factsheets/2011/03/accountablecare03312011a.html

46. Goal of ACO’s The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.

47. So what are ACO’s • ACO assumes financial risk rather than 3rd party payers (government, business or insurance companies) for group of patients assigned to it • Consists of more than one hospital & number of primary care clinics with full array of medical & health specialists-who self-refer to their own specialists • Control costs by being responsible for full care of patients • Integration of mental & behavioral health services into Patient-centered medical homes • Enhance patient outcomes through emphasis on prevention, compliance, and immediate 24/7 attention • Utilize an integrated behavioral medical approach

48. How will ACO’s Work? The Affordable Care Organizations (ACO’s) is a large local health system • It usually includes more than one hospital and a number of primary care clinics. • It is this whole system which is in charge of the care of its patients • The providers refer to other specialists inside of their own system • These ACO’s have their own group of providers (which could include Clinical Mental Health Counselors) &by referring within the system controls costs • ACO’s are then responsible not only for their costs but also for the quality of their services to their patients • Providers are paid a flat fee that is risk adjusted for the severity of the issues facing the patients • The ACO organization assumes the financial risk rather than the government, business or insurance companies • Where Clinical Mental Health Counselors work and how they will be paid may change greatly in the future as these ACO’s become reality after full implementation of the ACA in 2014

49. Utah’s Efforts under ACA • Utah is one of 16 states which proposes to design an innovative statewide initiative to facilitate improved physician/patient communication & care coordination • Goal of improving health care quality & lowering costs • The state will convene a multi-stakeholder group that will address strategies for healthcare transformation in five key areas: • Expanded health information technology • Adequate healthcare workforce • Wellness & healthy lifestyle promotion • Payment reform • Medical malpractice & dispute resolution.

50. Key Players in Utah working on ACA innovations Organizations • IHC Health Services (Intermountain Health Care) • Trustees Of Dartmouth College • State of Utah Hospital working on ACA innovation Salt Lake Regional Medical Center Utah’s Innovation Advisors • Nancy Murphy MD • Victoria Wilkins MPH, MD • Sarah Woolsey MD,