Policy Initiatives for the Policy Initiatives for the Substance Abuse Substance Abuse

WorkforceWorkforce

Presented to the Johnson InstitutePresented to the Johnson InstituteWorkforce Development ForumWorkforce Development Forum

October 27, 2006October 27, 2006By By

Henrick HarwoodHenrick HarwoodThe Lewin GroupThe Lewin Group

Substance Abuse Workforce Substance Abuse Workforce Policy “Should Do’s”Policy “Should Do’s”

Providers: Increase pay levels; Hire more minorities; Providers: Increase pay levels; Hire more minorities; Get more efficient Get more efficient

Payers: increase funding (per client/unit svc; # clients)Payers: increase funding (per client/unit svc; # clients)

Federal agencies: research practitioners Federal agencies: research practitioners

Field: define competencies for more levels/types of staff Field: define competencies for more levels/types of staff

States: license additional staff levels; define scopes of States: license additional staff levels; define scopes of practice; monitor use of staff w/in scope of practicepractice; monitor use of staff w/in scope of practice

Congress: authorize Council on the Mental and Congress: authorize Council on the Mental and Substance-Use Health Care WorkforceSubstance-Use Health Care Workforce

What Has Gone BeforeWhat Has Gone Before National Treatment Plan: Changing the National Treatment Plan: Changing the

ConversationConversation Annapolis Coalition: Strategic Plan for Behavioral Annapolis Coalition: Strategic Plan for Behavioral

Health WorkforceHealth Workforce CSAT/Partners for Recovery meetings on workforceCSAT/Partners for Recovery meetings on workforce IOM ReportsIOM Reports

• Crossing the Quality Chasm Crossing the Quality Chasm • Improving the Quality of Health Care for Mental and Improving the Quality of Health Care for Mental and

Substance-Use ConditionsSubstance-Use Conditions ATTC workforce studiesATTC workforce studies CSAT Practice Services Networks: CSAT Practice Services Networks:

• 6 major BH Practitioner Assn’s6 major BH Practitioner Assn’s SAMHSA addition of workforce development to SAMHSA addition of workforce development to

“strategy matrix”“strategy matrix”

Perceived ProblemsPerceived Problems

High turnover of counselors High turnover of counselors Loss to field of qualified staffLoss to field of qualified staff

• Leave field or retireLeave field or retire Minorities under representedMinorities under represented Low status/esteem of field (stigma?)Low status/esteem of field (stigma?) Inadequate career ladderInadequate career ladder

The Root Cause: Low wages?The Root Cause: Low wages?

The Parties to this SituationThe Parties to this Situation

PatientsPatients Counselors, and their associationsCounselors, and their associations Providers (the employers)Providers (the employers) PayersPayers

• Federal, state, local gov’t, private insuranceFederal, state, local gov’t, private insurance State accreditation/licensure authoritiesState accreditation/licensure authorities Educators (degree-granting, CME)Educators (degree-granting, CME) Subsidizers/funders of educationSubsidizers/funders of education Researchers and research funders Researchers and research funders

Desired OutcomesDesired Outcomes Clients: affordable access to good Clients: affordable access to good

treatmenttreatment

Payers: adequate supply of “good” SAT at Payers: adequate supply of “good” SAT at low costlow cost

Providers: supply of well qualified staff at Providers: supply of well qualified staff at low costlow cost

Counselors: rewarding careers, respect, Counselors: rewarding careers, respect, adequate payadequate pay

Counselor Employment, Annual Replacement Counselor Employment, Annual Replacement Rate and Salaries, and ComparisonsRate and Salaries, and Comparisons

2004-05 Occupational Employment Statistics from the US Bureau of Labor Statistics

SA/ behav. dis. counselors 72,210 10.6% $34,800

Mental health counselors 87,220 10.6% $37,470

Child, family social workers 256,430 8.7% $38,780

Medical social workers 112,220 8.7% $42,690

MH and SA social workers 120,140 8.7% $36,920

Social/ hum. svc assts 313,210 12.5% $26,600

Social/ comm. svc mgrs 112,910 9.1% $53,920

Psychologists, clinical 98,820 3.9% $63,960

Psychiatrists 23,450 4.3% $146,150

The Field Has Professionalized, The Field Has Professionalized, However . . .However . . .

The field started with non-degreed The field started with non-degreed community workers, many recoveringcommunity workers, many recovering

Now over 50% of credentialed SA Now over 50% of credentialed SA counselors have graduate degrees, but counselors have graduate degrees, but few in SA counseling few in SA counseling

Fields such as counseling, psychology, Fields such as counseling, psychology, social work provide training to our staffsocial work provide training to our staff• little if any training on addictionslittle if any training on addictions• 10 to 20% of their clients present with 10 to 20% of their clients present with

addictionsaddictions Most SA training and credentialing is by Most SA training and credentialing is by

“continuing education”“continuing education”

The Formal Education Pipeline is The Formal Education Pipeline is too Small to Supply 8,000 too Small to Supply 8,000

Counselors/yearCounselors/yearAlcohol/ Drug Abuse Counseling PhD 7

Alcohol/ Drug Abuse Counseling MA 86

Alcohol/ Drug Abuse Counseling BA 109

Alcohol/ Drug Abuse Cnsling AA (1998) 852

Social Work MSW 16,613

Psychology MA 17,898

Counseling Psychology MA 6,070

General Psychology MA 4,576

The fact that the vast majority of The fact that the vast majority of formally degreed counselors have formally degreed counselors have degrees in broader fields means that degrees in broader fields means that they have broader career options.they have broader career options.

Counseling and social work are much Counseling and social work are much larger than SAT, and have somewhat larger than SAT, and have somewhat better salaries.better salaries.

Career LadderCareer Ladder

Major issue is small providersMajor issue is small providers• little room for advancementlittle room for advancement• inefficient and high costsinefficient and high costs

Possible solution: merge into/affiliate Possible solution: merge into/affiliate with other providerswith other providers

CredentialingCredentialing Potential to define a career ladder Potential to define a career ladder

Based on skills and competenciesBased on skills and competencies

Should be related to “scope of practice” Should be related to “scope of practice” provisions and provider regulationsprovisions and provider regulations

Might focus on specialized clinical skills for, e.g., Might focus on specialized clinical skills for, e.g., MICA, criminal justice, adolescents, tobacco, MICA, criminal justice, adolescents, tobacco, gambling gambling

Recognize specialized credentials for, e.g., Recognize specialized credentials for, e.g., professional counselors and clinical social workersprofessional counselors and clinical social workers

CredentialingCredentialing

States license health professions, and States license health professions, and define scope of practicedefine scope of practice

Two national organizations assist statesTwo national organizations assist states• ICRC credentials 30,000 professionalsICRC credentials 30,000 professionals

AODA, AAODA, CCS (CCJP, CPS)AODA, AAODA, CCS (CCJP, CPS)

• NAADAC credentials 15,000 professionalsNAADAC credentials 15,000 professionals NCAC I, NCAC II, MAC, (TAC, SAP)NCAC I, NCAC II, MAC, (TAC, SAP)

About 20 states have 1 or 2 credentialsAbout 20 states have 1 or 2 credentials About 30 states have 3 or moreAbout 30 states have 3 or more

The California Certification & The California Certification & Career LadderCareer Ladder

Registered Student (RS)Registered Student (RS)

Registered Recovery Worker (RRW)Registered Recovery Worker (RRW)

Registered Alcohol & Drug Intern (RADI)Registered Alcohol & Drug Intern (RADI)

Registered Alcohol & Drug Technician I (RADT-I)Registered Alcohol & Drug Technician I (RADT-I)

Registered Alcohol & Drug Technician II (RADT-II)Registered Alcohol & Drug Technician II (RADT-II)

Certified Alcohol Counselor and Drug Counselor I (CADC I)Certified Alcohol Counselor and Drug Counselor I (CADC I)

Certified Alcohol and Drug Counselor II (CADC II)Certified Alcohol and Drug Counselor II (CADC II)

Clinical Supervisor Certification (CCS)Clinical Supervisor Certification (CCS)

NIH Can Do MoreNIH Can Do More

Services research Services research “can” study “can” study counselors, but counselors, but rarely doesrarely does

Counselors usually Counselors usually treated as “inter-treated as “inter-changeable” rather changeable” rather than an active than an active element of therapy element of therapy to studyto study

0

5

10

15

20

2006

2003

2000

1997

1994

1991

NIAAA NIDA

Grant abstracts that mention counselors

Researchable QuestionsResearchable Questions What do typical counseling careers look like?What do typical counseling careers look like? What attracts entrants to the field?What attracts entrants to the field? What makes mentoring and clinical supervision What makes mentoring and clinical supervision

work?work? When they leave the field what do they go to?When they leave the field what do they go to? How should we measure counselor effectiveness?How should we measure counselor effectiveness? How much does effectiveness vary across How much does effectiveness vary across

counselors?counselors? How can/should providers monitor counselor How can/should providers monitor counselor

effectiveness and use it for CQI?effectiveness and use it for CQI? Are various types of counselors more effective Are various types of counselors more effective

with certain types of clients?with certain types of clients? Are types of SAT training more/less effective?Are types of SAT training more/less effective?

Are states laboratories for Are states laboratories for counselor workforce policy?counselor workforce policy?

• What is different: What is different: Credentialing Credentialing Scope of practice (e.g., dual diagnosis)Scope of practice (e.g., dual diagnosis) Funding Funding Provider regulationsProvider regulations

• Are some state policies better/worse?Are some state policies better/worse? How would we know? How would we know?

• Turnover? Turnover? • Wage levels?Wage levels?

Center on Substance Abuse Center on Substance Abuse TreatmentTreatment

Addiction Technology Transfer Centers Addiction Technology Transfer Centers 1993-present1993-present

National Treatment Plan 2000National Treatment Plan 2000 Partners for Recovery Hearings 2004Partners for Recovery Hearings 2004 Annapolis Coalition Workforce Strategic PlanAnnapolis Coalition Workforce Strategic Plan Practice Services Network w AssociationsPractice Services Network w Associations

• 3 surveys 1999-20043 surveys 1999-2004• SA counselors, 4 MH professionsSA counselors, 4 MH professions

SAMHSA Priorities Matrix added Workforce SAMHSA Priorities Matrix added Workforce DevelopmentDevelopment

NAADAC InitiativesNAADAC Initiatives Major Problems:Major Problems:

• High turnover of counselors & administratorsHigh turnover of counselors & administrators• Counselors have excessive caseloads, modest compensation; inadequate Counselors have excessive caseloads, modest compensation; inadequate

training limits quality improvementtraining limits quality improvement• Close treatment gap & ensure high quality careClose treatment gap & ensure high quality care

Congressional InitiativesCongressional Initiatives• Loan forgivenessLoan forgiveness• Parity: cut down discriminatory reimbursement practices and improve odds Parity: cut down discriminatory reimbursement practices and improve odds

patients complete treatmentpatients complete treatment• Congressional Caucus: supporting, recruitingCongressional Caucus: supporting, recruiting• Include SA-related professions under Health Professions Act (Health Professions Include SA-related professions under Health Professions Act (Health Professions

Education Partneship Act) Education Partneship Act) • Ohio Workforce Development Center (internet and educational events)Ohio Workforce Development Center (internet and educational events)

Nationwide certification: relieve paperwork, save money/time, aid Nationwide certification: relieve paperwork, save money/time, aid professionalsprofessionals

Lobbied to have workforce development made a high priority at SAMHSA (it Lobbied to have workforce development made a high priority at SAMHSA (it was put in the Strategy Matrix)was put in the Strategy Matrix)

NASADAD InitiativesNASADAD Initiatives Service delivery gapService delivery gap Recovery is real (services are effective)Recovery is real (services are effective) Priorities for 2005Priorities for 2005

• Strengthen SSAsStrengthen SSAs• Expand access to prevention and treatment servicesExpand access to prevention and treatment services

Promote policies that create incentives for improved performancePromote policies that create incentives for improved performance• Imple an outcome and perf mgt data systemImple an outcome and perf mgt data system• Ensure clinically appropriate careEnsure clinically appropriate care• Promote effective policies related to co-occurring populationsPromote effective policies related to co-occurring populations

NASADAD Policy Position Paper: Workforce Competency (June NASADAD Policy Position Paper: Workforce Competency (June 2003)2003)• NASADAD endorsed counselor “minimum competency standards” NASADAD endorsed counselor “minimum competency standards”

as outlined in TAP 21 (Addiction Counseling Competencies) and as outlined in TAP 21 (Addiction Counseling Competencies) and calls for this to be revised, updated and reissued.calls for this to be revised, updated and reissued.

Electronic Health RecordsElectronic Health Records• A challenge to afford and train staff to use effectively and protect A challenge to afford and train staff to use effectively and protect

privacyprivacy

Therapeutic Communities of Therapeutic Communities of AmericaAmerica

Five prioritiesFive priorities• Addiction and co-occurring services for veterans and their Addiction and co-occurring services for veterans and their

family membersfamily members• Additional resources for services and researchAdditional resources for services and research• Elimination of the Medicaid IMD exclusionElimination of the Medicaid IMD exclusion• Expansion of criminal justice institutional and community Expansion of criminal justice institutional and community

treatment servicestreatment services• Address workforce shortage, which limits treatment expansion Address workforce shortage, which limits treatment expansion

and quality of care byand quality of care by Career ladders for advancement within the field Career ladders for advancement within the field Loan repayments Loan repayments Scholarships and other collaborative efforts with the education Scholarships and other collaborative efforts with the education

community community Public service announcements and utilization of other marketing Public service announcements and utilization of other marketing

tools tools Mentoring programs Mentoring programs Training of other caregivers specifically in evidence-based Training of other caregivers specifically in evidence-based

substance abuse treatment substance abuse treatment Apprenticeship programsApprenticeship programs

Crossing the Quality ChasmCrossing the Quality Chasm RecommendationsRecommendations

• Healthcare constituencies’ purpose: reduce illness, injury, disability, Healthcare constituencies’ purpose: reduce illness, injury, disability, improve health & functioningimprove health & functioning

• Healthcare constituencies pursue 6 major aimsHealthcare constituencies pursue 6 major aims• Healthcare constituencies embrace 10 rulesHealthcare constituencies embrace 10 rules• Congress charge DHHS to monitor quality Congress charge DHHS to monitor quality • Redesign healthcare on basis of 10 rulesRedesign healthcare on basis of 10 rules• AHRQ identify 15 major health problems and use NQF to convene AHRQ identify 15 major health problems and use NQF to convene

stakeholders and formulate action plansstakeholders and formulate action plans• Congress establish a healthcare quality innovation fundCongress establish a healthcare quality innovation fund• AHRQ/foundation workshops on care coordination/teamsAHRQ/foundation workshops on care coordination/teams• DHHS program to translate research into practiceDHHS program to translate research into practice• Use HIT to eliminate hand-written health information Use HIT to eliminate hand-written health information • Health purchasers use reimbursement to create incentives for qualityHealth purchasers use reimbursement to create incentives for quality• CMS/AHRQ research agenda on reimbursement and qualityCMS/AHRQ research agenda on reimbursement and quality• Health professions summit on restructuring clinical education & assess Health professions summit on restructuring clinical education & assess

implications for health educationimplications for health education• AHRQ research on regulatory and legal issuesAHRQ research on regulatory and legal issues

Crossing the Quality ChasmCrossing the Quality Chasm Six aims Six aims

• SafeSafe

• EffectiveEffective

• Patient-centered Patient-centered

• TimelyTimely

• EfficientEfficient

• EquitableEquitable

Ten rulesTen rules

• Care based on continuous healing Care based on continuous healing relationshipsrelationships

• Customization based on patient needs Customization based on patient needs and valuesand values

• The patient as the source of controlThe patient as the source of control

• Shared knowledge and the free flow of Shared knowledge and the free flow of informationinformation

• Evidence-based decision makingEvidence-based decision making

• Safety as a system propertySafety as a system property

• The need for transparencyThe need for transparency

• Anticipation of needsAnticipation of needs

• Continuous decrease in wasteContinuous decrease in waste

• Cooperation among cliniciansCooperation among clinicians

Improving the Quality of Health Care for Mental Improving the Quality of Health Care for Mental and Substance-Use Conditions: Increasing and Substance-Use Conditions: Increasing

Workforce Capacity for Quality ImprovementWorkforce Capacity for Quality Improvement 7-1 Congressionally authorized Council on the Mental and 7-1 Congressionally authorized Council on the Mental and

Substance-Use Health Care Workforce as a public-private Substance-Use Health Care Workforce as a public-private partnership to develop a comprehensive plan.partnership to develop a comprehensive plan.• Identify clinical competenciesIdentify clinical competencies• Develop national standards for credentialing and licensure to eliminate Develop national standards for credentialing and licensure to eliminate

differences across statesdifferences across states• Propose programs to address issues such as: diversity; cultural Propose programs to address issues such as: diversity; cultural

relevance; faculty development; shortages of clinicians and relevance; faculty development; shortages of clinicians and administratorsadministrators

• Monitor workforce trends, issues and financingMonitor workforce trends, issues and financing• Report progress on the plan and workforce status annuallyReport progress on the plan and workforce status annually• ““Solicit technical assistance” to support work of CouncilSolicit technical assistance” to support work of Council

7-2 Licensing boards and accrediting bodies should incorporate 7-2 Licensing boards and accrediting bodies should incorporate competencies and standards set by Councilcompetencies and standards set by Council

7-3 Federal government should support M/SU faculty leaders in 7-3 Federal government should support M/SU faculty leaders in medical and nursing schools and for M/SU professionsmedical and nursing schools and for M/SU professions

7-4 Institutions of higher education should do more 7-4 Institutions of higher education should do more interdisciplinary didactic and experiential learning, bringing interdisciplinary didactic and experiential learning, bringing together faculty and students across various programstogether faculty and students across various programs

Council on Graduate Medical Council on Graduate Medical EducationEducation

Authorized by Congress in 1986; appointed Authorized by Congress in 1986; appointed members from stakeholder groups and DHHSmembers from stakeholder groups and DHHS

Ongoing assessment of physician workforce Ongoing assessment of physician workforce trends, training issues and financing policies (16 trends, training issues and financing policies (16 reports): reports): • Supply and distribution of physiciansSupply and distribution of physicians• Current and future shortages or excesses in specialtiesCurrent and future shortages or excesses in specialties• Issues related to international medical school graduatesIssues related to international medical school graduates• Federal policy on financing of UGME & GME Federal policy on financing of UGME & GME • Recommend changes in nature of GMERecommend changes in nature of GME• Recs to schools of medicine, hospitals, accrediting Recs to schools of medicine, hospitals, accrediting

bodiesbodies• Recs on data policy to monitor above Recs on data policy to monitor above

Recommends appropriate federal and private Recommends appropriate federal and private sector efforts on these issuessector efforts on these issues

Substance Abuse Workforce Substance Abuse Workforce Policy “Should Do’s”Policy “Should Do’s”

Providers: Increase pay levels; Hire more minorities; Providers: Increase pay levels; Hire more minorities; Get more efficient Get more efficient

Payers: increase funding (per client/unit svc; # clients)Payers: increase funding (per client/unit svc; # clients)

Federal agencies: research practitioners Federal agencies: research practitioners

Field: define competencies for more levels/types of staff Field: define competencies for more levels/types of staff

States: license additional staff levels; define scopes of States: license additional staff levels; define scopes of practice; monitor use of staff w/in scope of practicepractice; monitor use of staff w/in scope of practice

Congress: authorize Council on the Mental and Congress: authorize Council on the Mental and Substance-Use Health Care WorkforceSubstance-Use Health Care Workforce