Challenges for the SUD Workforce 2013 and Beyond

1. Challenges for the SUD Workforce 2013 and Beyond Richard Rawson, Ph.D & Tom Freese, Ph.D CADPAAC Quarterly Meeting March 27, 2013

2. Current SUD Workforce • “Undefined, lacks clear parameters and cuts across multiple licensed, certified and unclassified professions” • In CA, approximately 35,000 persons are registered or certified as alcoholism and drug abuse counselors Source: OSHPD CWIB Health Workforce Development Council Issue Brief (September 2011)

3. SUD Workforce Demographics: U.S. • Average age is 48 years • 70-90% Caucasian • 70% of new entrants are female Source: OSHPD CWIB Health Workforce Development Council Issue Brief (2011)

4. PS ATTC Workforce Report • The Pacific Southwest Addiction Technology Transfer Center (PS ATTC) serves a region encompassing the states of Arizona and California • Between the two states resides 44.2 million individuals • Survey conducted in late 2011 and early 2012

5. Demographics of the SUD Workforce: CA/AZ • Clinical Supervisors: • Average age is 52 years • 80% are White/Non-Hispanic • 63% are Female • 36% stated they were in recovery Source: PS ATTC Regional Workforce Report (2012)

6. Demographics of the SUD Workforce: CA/AZ • Clinical Supervisors: • 90% work full time • 61% are licensed or certified in the field of substance use counseling • 41% have earned a Master’s degree • On average have worked 15 years in SUD treatment Source: PS ATTC Regional Workforce Report (2012)

7. Demographics of the SUD Workforce: CA/AZ • Direct Care Staff: • 77% are White/Non-Hispanic • 67% are Female • 73% work full time • 39% stated they were in recovery • 54% are currently certified/licensed • More than half (53%) are mid-career (age range: 35-55 years) Source: PS ATTC Regional Workforce Report (2012)

8. Demographics of the SUD Workforce: CA/AZ • Direct Care Staff: • Highest Education Levels: • 19.5% High-school diploma or equivalent • 19.5% Some college but no degree • 13% Associate’s Degree • 17% Bachelor’s Degree • 22% Master’s Degree • 2% Doctoral degree or equivalent • 5% Other Source: PS ATTC Regional Workforce Report (2012)

9. Demographics of the SUD Workforce: CA • According to the Bureau of Labor Statistics “Substance Abuse and Behavioral Disorder Counselors” California is second in the number of counselors in the state and their annual mean income is $37,400 (range $23,784 - $51,512).

10. Competencies SAMHSA’s TAP 21: Addiction Counseling Competencies The Knowledge, Skills, and Attitudes of Professional Practice 2008 http://store.samhsa.gov/product/TAP-21-Addiction-Counseling-Competencies/SMA12-4171

11. Understanding Addiction • Understand and recognize: • Models and theories of addiction/SUD • Social, cultural, economic and political contexts of addiction • Behavioral, psychological, physical health, and social effects of substances on person using and significant others • Potential of SUDs to mimic or co-occur with other medical and mental health conditions

12. Treatment Knowledge • Understand and recognize: • EBPs for treatment, recovery, relapse prevention, and continuing care for addiction/SUD • Importance of family and community in the treatment and recovery process • Importance of research and outcome data and their application in clinical practice • Value of an interdisciplinary approach to addiction treatment

13. Application to Practice • Ability to: • Use established criteria to diagnose SUD and place it within the continuum of care • Tailor helping strategies and treatment modalities to client’s stage of dependence, change or recovery • Provide culturally and linguistically-appropriate services • Adapt practice to treatment settings and modalities • Be familiar with pharmacological treatments for SUD

14. SAMHSA’s Career Ladder • Four categories of professional development (Career Ladder) were defined in September 2011. • Within each roles/activities are defined: • Category 1: Substance Use Disorder Technician (entry level) Associate Substance Use Disorder Counselor • Category 2: Substance Use Disorder Counselor • Category 3: Clinical Substance Use Disorder Counselor • Category 4: Independent Clinical Substance Use Disorder Counselor/Supervisor • SAMHSA. (2011). Model Scopes Of Practice and Career Ladder for Substance Use Disorder Counselors. http://store.samhsa.gov/shin/content//PEP11-SCOPES/PEP11-SCOPES.pdf

15. Office of Statewide Health Planning and Development California Workforce Investment Board Health Workforce Development Council Career Pathway Sub-Committee Final Report September 2011

16. Certification/Licensure What is it?

17. Counselor Certification in California • There are multiple organizations in California that certify counselors • Different organizations have different educational requirements and competency standards.

18. Existing Workforce Needs • Regardless of ACA implementation the SUD workforce needs to increase knowledge/skills/practices including: • Evidence Based Practices • MAT, MI, SBIRT • Integration with mental health • Prescription drug abuse problem • Harm reduction approaches • Addiction and pain • Addiction a chronic disease • Use of data to modify services

19. The Affordable Care Act

20. ACA - 2014 • New insurance for about 32 million adults. • Up to 133% of poverty level (133% was $14,484 in 2011 for an individual): Medicaid (Medi-Cal) • Up to 400% of poverty level (400% was $43,560 in 2011 for an individual), sliding subsidies to buy private insurance. • State Health Insurance Exchanges (2014): Individual and Small Group Plans. • All plans must include substance use disorder treatment.

21. ACA - 2014 • The substance use disorder treatment field will be held to the same standards and requirements as the primary health field. • Therefore, the substance use disorder treatment profession needs to be ready to document and codify its services and service delivery systems.

22. ACA-Integrating Care • Increased recognition of issues related to non-communicable diseases (including co-occurring MH/SA disorders) • Increased use of disease management for chronic health disorders • Development of evidence based practices for SUD to be implemented in primary care: SBI, medication assisted treatment, brief treatments

23. Beyond Skills in SUD

24. A Workforce with a Diverse Set of Knowledge and Skills • In primary care settings, people delivering behavioral health services (including SUD) will need a very diverse set of knowledge and skills • Knowledge and skills needed: • Preparation in SUD • Preparation in MH Disorders • Preparation in common health conditions • Preparation to have work driven by data • Preparation to work in integrated environments • Different environmental cultures, workflow • Team skills

25. Enhanced Skill Set Required Post-ACA • Evidenced based practices in SUD • Address all behavior change issues • Harm reduction mentality • Interpersonal skills: • Communication (Motivational Interviewing) • Conflict resolution • Teamwork (with MD as boss) • Quality Improvement Skills • Use of data to drive change • Technology competence

26. MH/SA Counseling Course Requirements

27. Workforce Models of the Future

28. New Roles in Integrated Care • Health Educator • Screen/Score/BI if appropriate • Use of Peers, Community Health Workers • Behavioral Health Clinician • Work with all aspects of BH change (including MH/SU) • Expanded Care Manager Dilonardo Framework prepared during the joint ONDCP/SAMHSA/HRSA meeting August 10th, 2011

29. Mountain Park Health Center

30. Mountain Park - BHC • Mountain Park Health Center is integrating behavioral health services into their existing medical service provision. • The Behavioral Health Consultant (BHC) works with patients behavioral issues referred by physician or nurse practitioner. • Behavioral Health Consultants within this system function in two distinctive roles. • Identify, triage, target treatment, and manage primary care patients with mental or behavioral health issues that complicate medical problems. • Collaborate with the medical staff to promote their behavioral health skills

31. Mountain Park – BHC • The focus is on resolving problems within the primary care service context. • BHC visits are brief (15 to 30 minutes), limited in number (1-4 with an average of between 2 & 3 visits), are provided in the primary care practice area, and are structured in a manner so that the patient views meeting with the behavioral health consultant as a routine primary care service.

32. Mountain Park - BHC • Behavioral Health Consultants (BHC) assist in the management of medical problems.

33. University of Massachusetts

34. U Mass Program • Certificate Program in Primary Care Behavioral Health • A training program for mental health and substance abuse professionals to become behavioral health professionals in primary care.

35. U Mass Program • Program consists of 36 hours of didactic and interactive training and is delivered in 6 full day workshops (one Friday per month for six months). • There are two options: • One program prepares professionals to be generalist Behavioral Health Clinicians and Care Managers in primary care settings • Second prepares professionals to work in primary care SPMI

36. UMass Program • The Certificate Program in Primary Care Behavioral Health is designed to give social workers, psychologists, counselors, nurses, psychiatrists, or primary care physicians the rigorous introduction they need to succeed as primary care behavioral health clinicians (BHCs). • Course Curricula • Workshop 1: Primary Care Culture, Behavioral Health Needs and Working with Physicians • Workshop 2: Evidence-based Therapies and Substance Abuse in Primary Care • Workshop 3A: Child Development and Collaborative Pediatric Practice • Workshop 3B: Integrating Care for People with Serious and Persistent Mental Illness • Workshop 4: Behavioral Healthcare for Chronic Illnesses, Care Management and an Overview of Psychotropic Medication • in Primary Care • Workshop 5: Behavioral Medicine Interventions: Health Behavior Change and Relaxation Response Techniques • Workshop 6: Families and Culture in Primary Care, Advice on Implementation

37. U of Michigan Program

38. U of Michigan Program • Web-based "Certificate in Integrated Behavioral Health and Primary Care". • Designed for working professionals interested in gaining skills that are critical for effective integration of behavioral health and primary care. • Each course includes cutting-edge information that forms the foundation of effective practice.

39. U of Michigan Program • Participants learn through a range ofinteractive teaching methods including case studies, team sessions, andapplied activities. • The IBHPC certificate teaches up-to-date, evidence-informed knowledge and skills that are critical to effective integrated behavioral health and primary carepractice settings and health home service delivery models.

40. Primary Care Behaviorist (PCB) • New approach co-locates expertise rather than location • PCB will be a primary care physician with advanced training and certification in diagnosis and treatment of mental and behavioral problems • Goal is to integrate expertise in behavioral disorders in a single practitioner • Feldman & Feldman JGIM 2013

41. How do we get there?

42. Development of Behavioral Health Clinicians • Over the next 10 years there will be an effort to develop policies, infrastructure, educational curriculum at schools, certification/licensing, training centers • While there will be a need for SUD counselors in the specialty care system, there will be a far bigger need for behavioral health clinicians in the broader health care system.

43. Integrated Care Competency Categories • Interpersonal Communication • Collaboration & Teamwork • Screening & Assessment • Care Planning & Care Coordination • Intervention • Cultural Competence & Adaptation • Systems Oriented Practice • Practice Based Learning & Quality Improvement • Informatics • From Annapolis Coalition Integration Report 12/12

44. Core Competencies of Behavioral Health Clinicians • Proficiency in the identification and treatment of diverse disorders; • Ability to think in terms of population management, with a large clientele in highly efficient ways; • Knowledge of evidence-based behavioral assessments and interventions relevant to medical conditions, e.g., disease management, treatment adherence, and lifestyle change; • Ability to make quick and accurate clinical assessments; • Care-management skills and knowledge of local resources for outside referrals;

45. Core Competencies of Behavioral Health Clinicians • Skill in targeted, brief psychotherapy and groups • Knowledge of basic physiology, psychopharmacology, and medical terminology; • Familiarity with the stepped care model (clients move along different levels of intervention depending on past responses); • Ability to document services in a way that is useful both to the primary care provider and to management for quality-improvement services; and • Consultation liaison skills • Recognizes essential importance of harm reduction

46. Useful Traits of Primary Care Behavioral Health Clinicians Behavioral health counselors must be able to function in the fast-paced primary care environment. To be effective, they should: • Be flexible enough to deal with noise, frequent interruptions, and constant changes in scheduling; • Be able to offer brief, targeted interventions usually lasting less than 30 minutes; • Be comfortable with short-term counseling, often lasting less than 4-6 visits; • Function well in a team-approach, accepting the fact that they are not in charge of the patient’s care;

47. Useful Traits of Primary Care Behavioral Health Clinicians Behavioral health counselors must be able to function in the fast-paced primary care environment. To be effective, they should: • Be behaviorally, rather than personality, focused; • Be able to provide behavioral interventions addressing chronic substance, mental health, and medical diseases • Be able to perform consultations and give provider feedback “on the fly”; and • Be able to effectively communicate and interact with primary care providers. • Motivational interviewing approach to behavior change

48. SUD Counselors and BH Clinicians BH Clinician • Complex problem focused, integrating medical, MH, SUD interventions • Interventions completed in 4 or fewer sessions • Service coordination across multidisciplinary services • Services provided on demand (unscheduled) • Complex interrelationship across diverse policies and billing structures. SUD Counselor • SUD focused with longer course of interventions in specialty setting • Ongoing treatment planning and delivery over months • Service coordination focused on recovery support • Planned/scheduled service delivery • Billing and ethics focused on SUD system (eg 42CFR part 2)

49. Short Term Plan • Identify training needs to help SUD/MH become effective in primary care • Specialty care needs vs. MH/SUD generalist skills • Identify SUD personnel who want to learn new skills to work in primary care

50. Training the California Workforce Content areas important to begin to build the California Behavioral Health workforce: • Providing Behavioral Health Care in a Primary Care Setting: Culture, Needs and Interdisciplinary Collaboration • Screening Brief Intervention and Referral for Substance Use, Mental Health and Medical Diseases • Understanding Chronic Medical Diseases, Basic Physiology, Terminology and Treatment Strategies • Understanding Common Mental Health Disorders—Identification and Intervention • Medical Interventions for Substance Use, Physiology of Drugs of Abuse and Medication Assisted Treatment • Care Management of Clients in a Multi-Service Setting