Challenges for the SUD Workforce 2013 and

Beyond

Richard Rawson, Ph.D & Tom Freese, Ph.D

CADPAAC Quarterly Meeting

March 27, 2013

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)

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)

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

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)

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

treatmentSource: PS ATTC Regional Workforce Report (2012)

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)

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)

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).

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

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

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

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

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

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

Certification/Licensure

What is it?

Counselor Certification in California

There are multiple organizations in California that certify counselors

Different organizations have different educational requirements and competency standards.

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

The Affordable Care Act

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.

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.

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

Beyond Skills in SUD

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

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

Course Requirement Substance Abuse Mental Health

Drug/alcohol related 87% 19%

Counseling, Treatment, client education 71% 97%

Professional ethics and responsibility 71% 97%

Screening, Assessment, Appraisal 58% 96%

Case management 39% 2%

Social/cultural foundations, diversity 29% 85%

Health Issues and Diseases 29% 4%

Crisis Management/Intervention 23% 4%

Human growth and development 19% 96%

Family and couples therapy 10% 19%

Abnormal behavior/psychopathology 6% 65%

Measurement, research, evaluation 3% 95%

Career and lifestyle development 3% 71%

Average # hours 317.87 789.38

MH/SA Counseling Course Requirements

Workforce Models of the Future

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

Mountain Park Health Center

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

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.

Mountain Park - BHC

Behavioral Health Consultants (BHC) assist in the management of medical problems.

Medical Diagnosis Behavioral Health Intervention

Hypertension Relaxation skills training, diaphragmatic breathing, problem solving

Diabetes Promote self management, goal identification and attainment, enhance mood stability, stress reduction

Asthma Identify triggers, trigger removal or management, daily monitoring, action plan

University of Massachusetts

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.

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

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

U of Michigan Program

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.

 

 

U of Michigan Program Participants learn through a range of

interactive 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.

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

How do we get there?

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.

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

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;

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

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;

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

SUD Counselors and BH CliniciansSUD 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)

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.

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

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

How do we pay for behavioral health clinicians in primary

care?

90804 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 20 TO 30 MINUTES FACE-TO-FACE WITH THE PATIENT;

90805 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 20 TO 30 MINUTES FACE-TO-FACE WITH THE PATIENT; WITH MEDICAL EVALUATION AND MANAGEMENT SERVICES

90806 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 45 TO 50 MINUTES FACE-TO-FACE WITH THE PATIENT;

90807 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 45 TO 50 MINUTES FACE-TO-FACE WITH THE PATIENT; WITH MEDICAL EVALUATION AND MANAGEMENT SERVICES

90808 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 75 TO 80 MINUTES FACE-TO-FACE WITH THE PATIENT;

90809 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 75 TO 80 MINUTES FACE-TO-FACE WITH THE PATIENT; WITH MEDICAL EVALUATION AND MANAGEMENT SERVICES

90810 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 20 TO 30 MINUTES FACE-TO-FACE WITH THE PATIENT;

90811 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 20 TO 30 MINUTES FACE-TO-FACE WITH THE PATIENT; WITH MEDICAL EVALUATION AND MANAGEMENT SERVICES

90812 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 45 TO 50 MINUTES FACE-TO-FACE WITH THE PATIENT;

90813 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 45 TO 50 MINUTES FACE-TO-FACE WITH THE PATIENT; WITH MEDICAL EVALUATION AND MANAGEMENT SERVICES

90814 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 75 TO 80 MINUTES FACE-TO-FACE WITH THE PATIENT;

90815 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 75 TO 80 MINUTES FACE-TO-FACE WITH THE PATIENT; WITH MEDICAL EVALUATION AND MANAGEMENT SERVICES

90845 PSYCHOANALYSIS90846 FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT)90847 FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT PRESENT)90849 MULTIPLE-FAMILY GROUP PSYCHOTHERAPY90853 GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP)90857 INTERACTIVE GROUP PSYCHOTHERAPY

Billing Codes

Resources

Trainings SBIRT, MI, Brief TX, MAT

Online Courses needed to meet demands CiHS course for SUD coming soon

SARC Meeting

SARC Meeting in September 2013 (exact date TBD)

Convening of experts on the behavioral health workforce of the future

CATES Series is Coming Soon!

CATES will feature Patrick Gauthier from Advocates for Human Potential.

Gauthier will be presenting on financing and reimbursementstrategies and business models for health reform.

Trainings will take place on:

May 17th (San Bernardino County)

June 28th (Alameda County)

July TBD (Kings County)

* Registration flyers coming soon!

Questions?