Behavioral Health Workforce Development in the Age of Healthcare Reform: Change is in the Air

1. Behavioral Health Workforce Development in the Age of Healthcare Reform: Change is in the Air Perspectives from the Annapolis Coalition on the behavioral health workforce John A. Morris, Executive Director Navigating the new landscape Maryland addictions directors council Ocean city, md ~~ May 11, 2011

2. It will be quite a ride…

3. Context for this presentation BEHAVIORAL HEALTH: 1969 – 2011 • Trans- and de-institutionalization • Major transition from state mental health authorities to Medicaid as the driver of services for people with mental illnesses (and increasingly for substance use conditions as well) • Move from 12-step models of recovery to more ‘professionalized’ models • The rise of the consumer movement in MH • Better But Not Well…Frank & Glied

4. Better but not well • Mental Health “exceptionalism” vs. mainstream integration • Substance use treatment and prevention are a greater priority while these fields are changing paradigms to better address the often chronic nature of the illnesses and the need for more recovery focused care. • “Behavioral health” moving closer to being a reality • Now behavioral health/primary care integration (including bi-directional integration) is an accelerating reality

5. Better but not well Historical Barriers to BH and SU integration to consider in developing unified workforce: * Etiology of nature of MH and SU and their treatment philosophies and techniques * Practitioners from MH and SU have trained differently and often are unwilling or unprepared to treat MH, SU or COD * Competition for scarce resources - White/Davidson, 2006

6. Better but not well BUT – Individual, family recovery and community health and resilience are the common denominators …the unifying principles of our work … we cannot lose them! Each person must be the agent of his or her own recovery, each community must bolster its strengths.

7. Behavioral health/primary care integration • Do we really know what this will mean? • Are providers in either sector really prepared? • What are the dynamics likely to be?

8. Agreed. There is a lot at stake. The history of behavioral health integration has some scary precedents… • Reduced access and benefits • Inappropriate limits on visits and medications • Dramatically under-priced reimbursement rates • Narrow definitions of medical necessity that negatively impacted using natural supports and peers; resistance to inclusion of substance use treatment in basic coverage • Loss of recovery focus in care to medical management

9. On the other hand. • Data on mortality and morbidity for people diagnosed with major mental illnesses, including comorbid substance use disorders = a scandal for our field • Life expectancy reductions of 20+ years cannot be allowed to continue

10. The way forward: Reasons for optimism • Health care reform—improved potential for access for millions (ACA 2010) • Behavioral health actually has something to bring to the table (more on this later) • Co-occurring disorders are increasingly recognized as the norm not an anomaly • The new buzz word in federal integration circles is “bidirectional”: not a foregone conclusion that the mergers or integration will all be from behavioral health into primary care.

11. Lessons from the rest of healthcare • The history of how we arrived at the current general healthcare “system” is every bit as haphazard as ours. • Atul Gawande, MD: Health care development was “path-dependent”, following the paths of least resistance • M.C. Escher might have envisioned this history thus…

12. Can we all say “non-linear”?

13. Wisdom from rural behavioral health • Behavioral health Exceptionalism… never an issue in rural America • Practical realities have always encouraged if not required collaboration, co-location, integrated approaches • But what about the PEOPLE needed to make it all work?

14. Workforce development • For decades we have been using methods that don’t work • In the Annapolis Coalition Work, we refer to these as the PARADOXES OF WORKFORCE DEVELOPMENT IN BEHAVIORAL HEALTH

15. THE PARADOXES OF WORKFORCE DEVELOPMENT • Paradox 1: We train graduates of our professional programs for a world that no longer exists • Paradox 2: Those who spend the most time with consumers receive the least training • Paradox 3: Training programs persist in utilizing ineffective teaching strategies…in continuing education

16. THE PARADOXES OF WORKFORCE DEVELOPMENT • Paradox 4: We train only where willing crowds gather • Paradox 5: Consumers and families receive little educational support… and their lived experience doesn’t inform the rest of the workforce • Paradox 6: The diversity of the current workforce doesn’t match the diversity of those served

17. THE PARADOXES OF WORKFORCE DEVELOPMENT • Paradox 8: We do not systematically retain or recruit staff • Paradox 9: Once hired, little supervision or mentoring is provided • Paradox 10: Career ladders and leadership development are haphazard • Paradox 11: Service systems thwart the competent performance of individuals

18. So what’s to be done?What direction do we head in?

19. National Action Plan

20. The planning process • Two years & 5,000 participants • Federally funded • Mental health & addictions • Treatment & prevention • Seeking to identify: • A core set of strategic goals & objectives • High priority ACTION items by stakeholder • A planning resource • Call to action

21. The players • SAMHSA • The Annapolis Coalition • Senior consultants • Expert panels & Advisory Groups (12) • Reviews of existing recommendations • Planning sessions in existing meetings • Specially convened planning sessions • Targeted requests and open calls for recommendations

22. The seven major goals • GOAL 1: Significantly expand the role of individuals in recovery, and their families when appropriate, to participate in, ultimately direct, or accept responsibility for their own care; provide care and supports to others; and educate the workforce. • GOAL 2: Expand the role and capacity of communities to effectively identify their needs and promote behavioral health and wellness.

23. The 7 major goals • GOAL 3: Implement systematic recruitment and retention strategies at the federal, state, and local levels. • GOAL 4: Increase the relevance, effectiveness, and accessibility of training and education. • GOAL 5: Actively foster leadership development among all segments of the workforce.

24. The 7 major goals • GOAL 6: Enhance the infrastructure available to support and coordinate workforce development • GOAL 7: Implement a national research and evaluation agenda on behavioral health workforce development

25. GOAL 1: It’s all about individuals and families Objectives: • Increased educational supports for them • Shared-decision making with them • Expand peer & family support by them • Greater employment as paid staff • Formal engagement as educators of the workforce “Healthcare reform cannot happen on the backs of M.D.s and Ph.D.s alone.” – Mike Flaherty, Executive Director IRETA

26. Goal 2: It’s all about communities Objectives: • Competency development with communities • Competency development of the behavioral health workforce in community collaboration • Strengthening connections between behavioral health organizations and their communities

27. Goal 3: RETAIN and recruit Objectives: • Implement & evaluate interventions: • Salary, benefits, & financial incentives • Non-financial incentives & rewards • Job characteristics • Work environment • Develop career ladders • “Grow your own” workforce • Cultural & linguistic competence • Public relations campaigns • Too often our approach might be seen as

28. TRAINING: Relevance, effectiveness, accessibility. Objectives: • Competency development • Curriculum development • Evidence-based training methods • Substantive training of direct care workers • Technology-assisted instruction • Addiction and co-occurring competencies in every staff member • Systematic support to sustain newly acquired skills

29. And are we perpetrating what we call RHETORIC INFORMED CARE?

30. Nothing to it…. We seek to provide: person-centered, consumer- and family-driven, recovery and resilience oriented, strength-based, trauma-informed, gender-specific, age appropriate, developmentally relevant, community-based, co-occurring, time-limited, culturally and linguistically competent, transformational, health- and wellness-oriented, wrap-around, evidence-based care.

31. And now we are going to do that ALONG WITH providing primary healthcare. Did I mention we need to fasten our seatbelts….?

32. Goal 5: Leadership development Objectives: • Identify leadership competencies tailored to behavioral health • Competency-based curricula • Succession planning • Formal, continuous leadership development in all sectors beginning with supervision (or is it “surveillance”?)

33. Goal 6: Infrastructure change Selected Objectives: • A workforce plan for every agency • Data-driven CQI on workforce issues • Strengthen HR & training functions • Improve the economic market for services • Improve IT support for training, workforce support, & tracking • Decreased paperwork burden: variable, redundant or purposeless reporting

35. Goal 7: Research and technical assistance Objectives: • Federal and state inter-agency research collaboratives • Technical assistance to field on evaluation of workforce practices

36. Help is coming..!!! • SAMHSA/HRSA Center for Integrated Health Solutions • An important federal leadership partnership • Led by the National Council for Community Behavioral Health • Partners with broad workforce experience in behavioral health and primary care..across the life span • Designed to provide practical, implementable solutions to the challenges of addressing the whole person

38. Change in the real world. • What role can we play in shaping the change? • We have learned a lot about engaging healthcare consumers in self-care, peer-supports, and non-medical supports and recovery services. We need to build on this and bring more competent workers into our ranks at ALL levels.

39. Change in the real world -2 • The Institute of Medicine has been pushing “person-centered care” for years—substantive convergence around the whole person. • E-health and the Internet are arming healthcare consumers with vastly more knowledge…but it’s changing the behavior that improves health outcomes. New practitioners (e.g. interventionists) and practices (e.g. phone follow-up and outreach) are emerging.

40. The change process… • Change always occurs in some real-world context • ‘Managing’ change is not an illusion, but it is also non-linear • One man’s theory of change…

41. Policy pinball.

42. The message for us: Be prepared for the • Political dimensions • Economic dimensions • Practice dimensions • Need to keep building measurable resiliency, wellness and recovery in the impending change. And there is even some helpful science: an emerging body of literature on integration, and successful models, too.

43. Some models to look at

44. In closing • The True North of healthcare reform has got to be improved health outcomes for real people in the real world—which means people who have multiple health conditions. • There can be no health without behavioral health. • Therefore we are positioned to provide leadership and context as we navigate the various “paths” that Gawande alerts us lie ahead.

45. The Annapolis Coalition Motto I get up every morning determined to change the world AND to have one hell of a good time. Sometimes this makes planning the day difficult…* * Adapted from E.B. WHite

46. Thanks for listening, and…

47. Be in touch www.annapoliscoalition.org jmorris@tacinc.org