7
Increasing Workforce Capacity for Quality Improvement

Summary

The health care workforce treating mental and/or substance-use (M/SU) conditions is not equipped uniformly and sufficiently in terms of knowledge and skills, cultural diversity and understanding, geographic distribution, and numbers to provide the access to and quality of M/SU services needed by consumers. This has long been the case and has been persistently resistant to change despite recurring acknowledgments of the problems and repeated recommendations for major improvements to address them.

Although similar to those that afflict the general health care workforce, these problems require special attention in the M/SU workforce not only because of the high prevalence and serious consequences of M/SU problems and illnesses (see Chapter 1), but also because of the great variation in the types of clinicians licensed to diagnose and treat M/SU conditions and substantial variations in their training. In contrast to general health care, in which the diagnosis and treatment of medical conditions are typically provided by physicians, individuals licensed to diagnose and treat M/SU problems and illnesses include a wide range of practitioners—psychologists, psychiatrists, primary care and specialist physicians, social workers, psychiatric nurses, marriage and family therapists, addiction therapists, and a wide variety of counselors (e.g., psychosocial rehabilitation, school, addiction, and pastoral counselors), many of whom are licensed to provide M/SU services in independent



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Improving the Quality of Health Care for Mental and Substance-Use Conditions 7 Increasing Workforce Capacity for Quality Improvement Summary The health care workforce treating mental and/or substance-use (M/SU) conditions is not equipped uniformly and sufficiently in terms of knowledge and skills, cultural diversity and understanding, geographic distribution, and numbers to provide the access to and quality of M/SU services needed by consumers. This has long been the case and has been persistently resistant to change despite recurring acknowledgments of the problems and repeated recommendations for major improvements to address them. Although similar to those that afflict the general health care workforce, these problems require special attention in the M/SU workforce not only because of the high prevalence and serious consequences of M/SU problems and illnesses (see Chapter 1), but also because of the great variation in the types of clinicians licensed to diagnose and treat M/SU conditions and substantial variations in their training. In contrast to general health care, in which the diagnosis and treatment of medical conditions are typically provided by physicians, individuals licensed to diagnose and treat M/SU problems and illnesses include a wide range of practitioners—psychologists, psychiatrists, primary care and specialist physicians, social workers, psychiatric nurses, marriage and family therapists, addiction therapists, and a wide variety of counselors (e.g., psychosocial rehabilitation, school, addiction, and pastoral counselors), many of whom are licensed to provide M/SU services in independent

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Improving the Quality of Health Care for Mental and Substance-Use Conditions practice. These practitioners are trained apart from each other—in different schools by different faculties, with curriculums encompassing few if any core competencies and little interdisciplinary training. Further, despite the wide variety of theories and therapies that have been developed to deal with M/SU problems and illnesses (see Chapter 4), there are no mechanisms in place to ensure that any given clinician has been adequately educated and trained to offer any specific therapy. Such a process is essential to the provision of safe, effective, and efficient care. The wide variety of provider types and treatments makes it difficult to provide consumers of M/SU health care with information on the competencies of any particular practitioner and to assist them in finding the right clinician for help, a key element of patient-centered care. Variations in state licensing requirements further complicate efforts to reduce inappropriate variations in care. There is a long history of short-lived and unheeded commissions, expert panels, reports, and recommendations to improve the capacity and quality of the M/SU workforce. Reports dealing with the general health care workforce typically have failed to address the unique issues in M/SU health care. Those that have done so have addressed either mental health or substance use, but not both. Substance use, despite its magnitude and high rate of comorbidity with mental health problems, is often neglected in the professional training of all the major mental health disciplines and the training received by primary health care practitioners as well. Training does not sufficiently emphasize the advances made in evidence-based practice for treatment of mental and substance-use conditions, nor does it include enough content on self-help groups, community systems of support, and social services. Teaching methods across all the schools in which the M/SU disciplines are trained vary substantially as well, reflecting little cognizance of the advances that have been made in evidence-based teaching methods and lifelong learning. Past recommendations calling for changes in the curriculums and methods for educating and training M/SU practitioners have typically been ignored. As a result, there continues to be a large gap between what is known, what is taught, and therefore what is done in practice. Sustained, multiyear attention and resources have been applied successfully to the education and training of physicians and nurses through the Council on Graduate Medical Education and the National Advisory Council on Nurse Education and Practice. A similar sustained, multiyear strategy, as well as action by institutions of higher education, licensing boards, accrediting

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Improving the Quality of Health Care for Mental and Substance-Use Conditions bodies, the federal government, and purchasers, is needed to increase the M/SU workforce’s competencies to deliver high-quality care. CRITICAL ROLE OF THE WORKFORCE AND LIMITATIONS TO ITS EFFECTIVENESS Previous reports of the Institute of Medicine (IOM) and other authoritative bodies have documented the critical roles played by the health care workforce in the delivery of high-quality health care. Crossing the Quality Chasm identifies the health care workforce as the health system’s most important resource, and critical to improving the quality of care (IOM, 2001). All of the recommendations of the previous chapters—providing patient-centered, safe, effective, and coordinated care and taking advantages of the opportunities offered by information technology—require a workforce sufficient in numbers, with the necessary competencies, and enabled by the environments in which they practice to deliver care consistent with these competencies. However, the entire health care workforce—including those who provide care for mental and substance-use conditions—faces numerous obstacles to delivering high-quality care. These include a shortage and geographic maldistribution of workers (see Box 7-1), work environments that thwart clinicians’ delivery of quality health care (AHRQ, 2003; IOM, 2004b), a lack of ethnic diversity and cultural expertise (IOM, 2004a) (see Box 7-2), outdated education and training content and methods (IOM, 2003), state-to-state variation in scopes of practice and assurance of competency, and concerns about legal liability (IOM, 2001). Although the M/SU health care workforce faces all of the same problems as the health care workforce overall, building its capacity to deliver higher-quality care for M/SU conditions is particularly problematic because of the greater variety of types of M/SU health care providers and an even greater variation in how they are educated, licensed, and certified/credentialed for practice. While recognizing the importance of such problems as workforce shortages, geographic maldistribution, and insufficient diversity that afflict the M/SU and general health care workforces alike, this chapter focuses on the special problems resulting from the greater diversity of the M/SU health care workforce, their varying education and training, and the difficulties of delivering high-quality patient care in the solo practices that are more typical among those who treat M/SU conditions. GREATER VARIATION IN THE WORKFORCE TREATING M/SU CONDITIONS Caregivers who provide care to individuals with M/SU problems and illnesses, like those who care for those with general health care problems

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Improving the Quality of Health Care for Mental and Substance-Use Conditions BOX 7-1 Workforce Shortages and Geographic Maldistribution Shortages and maldistribution of M/SU treatment professionals, as in the general health care workforce, are a major and long-recognized problem. In 1999, the Surgeon General’s report on mental health stated: “The supply of well-trained mental health professionals is inadequate in many areas of the country, especially in rural areas. Particularly keen shortages are found in the numbers of mental health professionals serving children and adolescents with serious mental disorders, and older people” (DHHS, 1999:455). Echoing this statement, in 2003 the President’s New Freedom Commission on Mental Health reported: “In rural and other geographically remote areas, many people with mental illnesses have inadequate access to care [and] limited availability of skilled care providers…” (New Freedom Commission on Mental Health, 2003:51). Despite recognition of the problem and various attempts to motivate people to work in underserved areas, however, little progress has been made. In the east south central region of the United States (Alabama, Kentucky, Mississippi, and Tennessee), for example, there are 8.2 psychiatrists per 100,000 population, compared with 22.1 per 100,000 in the mid-Atlantic region (New Jersey, New York, and Pennsylvania). Similarly, there are 53.0 psychologists per 100,000 people in New England, compared with 14.4 per 100,000 in the west south central states, such as Arkansas, Oklahoma, and Texas (Duffy et al., 2004). Shortages of clinicians with expertise in caring for certain groups, such as children and adolescents (Koppelman, 2004) and older adults (New Freedom Commission on Mental Health, 2003), also persist nationwide. This variation reflects the historical tendency of highly skilled professionals to locate in urban areas (Morris et al., 2004). Similar problems in the substance-use treatment workforce have been documented. Low salaries are accompanied by high turnover rates in both managerial and clinical positions (McLellan et al., 2003). This situation can compromise continuity of care for patients and also threatens to leave the field without a leadership infrastructure through which advances in care can be infused. Moreover, the stigma experienced by individuals with substance-use illnesses is sometimes felt by their treatment providers (Kaplan, 2003). and illnesses, include licensed clinicians; unlicensed, paid providers (both certified and uncertified); volunteers; and the patient’s family and informal supports. The roles of patients and their families in care and illness management, as well as those of individuals in recovery who offer peer and recovery support services, are addressed in Chapter 3. In this chapter we focus on the role of the licensed M/SU treatment workforce.1 1   Although the role of unlicensed and voluntary care providers is substantial and important, the committee focuses here on licensed caregivers because the education and oversight structures for unlicensed voluntary caregivers are less well developed at present. Moreover, the committee believes that a well-trained and -educated licensed and credentialed workforce, through its leadership and modeling of best-care practices such as patient-centered care, can do much to strengthen the knowledge, skills, and abilities of the unlicensed workforce and volunteer supports.

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Improving the Quality of Health Care for Mental and Substance-Use Conditions BOX 7-2 Insufficient Workforce Diversity Like the health care workforce overall (IOM, 2004a), the M/SU workforce does not reflect the increasing ethnic and cultural diversity of the population it serves. At the beginning of the 1900s, only one of every eight Americans identified himself or herself as a race other than “white.” At the end of the century, one of four did so, as the white population grew more slowly than every other racial/ethnic group. Increasing diversity accelerated in the latter half of the century. From 1970 to 2000, the population of races other than “white” or “black” grew considerably, and by 2000 was comparable in size to the black population. The black population represented a slightly smaller share of the total U.S. population in 1970 than in 1900, while the Hispanic population more than doubled from 1980 to 2000. The racial/ethnic composition of the U.S. population according to the 2000 census was as follows: 75.1 percent white, 12.3 percent black, 3.6 percent Asian or Pacific Islander, 0.9 percent American Indian or Alaska Native, 5.5 percent claiming a race other than those already cited, and 2.4 percent claiming two or more races. Individuals (of any race) claiming Hispanic origin constituted 12.5 percent of the U.S. population (Hobbs and Stoops, 2002). Despite this increasing diversity and decades of concern about the failure of the health care workforce to reflect it, there are still far too few minority M/SU professionals. The 2001 supplement to the Surgeon General’s report on mental health, Mental Health: Culture, Race, and Ethnicity, stated: “Racial and ethnic minorities continue to be badly underrepresented, relative to their proportion of the U.S. population, within the core mental health professions—psychiatry, psychology, and social work, counseling, and psychiatric nursing” (DHHS, 2001:167). The President’s New Freedom Commission on Mental Health echoed that observation: “Racial and ethnic minorities are seriously under-represented in the core mental health professions [and] … many providers are inadequately prepared to serve culturally diverse populations, and investigators are not trained in research on minority populations” (New Freedom Commission on Mental Health, 2003:50). Similarly, members of the substance-use treatment workforce do not reflect the gender, racial, and ethnic composition of those they treat (Mulvey et al., 2003). As noted above, clinicians licensed to diagnose and treat M/SU problems and illnesses are uniquely varied. Although the diagnosis and treatment of general health conditions are typically limited to physicians, advanced practice nurses, and physician assistants,2 M/SU health care clinicians include psychologists, psychiatrists, other specialty or primary care physicians, social workers, psychiatric nurses, marriage and family therapists, addiction therapists, psychosocial rehabilitation therapists, sociologists, and a variety of counselors with different education and certifications 2   Dentists, chiropractors, and podiatrists also are licensed to diagnose and treat, but typically within prescribed domains.

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Improving the Quality of Health Care for Mental and Substance-Use Conditions (e.g., school counselors, pastoral counselors, guidance counselors, and drug and alcohol counselors), each with differing education and training. The effect on clinical practice of this variation in provider types and in the corresponding education and training is unknown; however, variation in the education and training of different types of physicians who deliver care for mental illnesses has been shown to result in variations in the quality of care (Young et al., 2001). Also, although many different therapies have been developed for M/SU problems and illnesses (see Chapter 4), there is no mechanism in place to ensure that any given clinician has been adequately educated and trained to offer any specific therapy. Such a process is essential to the delivery of safe, effective, and efficient care. The wider variety of provider types also has implications for the ability to provide consumers with the information they need to select a clinician to help them—a key element of patient-centered care—as it is difficult to provide consumers with information on the competencies of any individual practitioner and to guarantee a uniform, safe level of abilities across all types of clinicians. In spite of this, no mechanisms exist for routinely capturing adequate information on the characteristics of the M/SU workforce comparable to, for example, the National Sample Survey of Registered Nurses regularly conducted by the National Advisory Council on Nurse Education and Practice. Moreover, administrative data routinely collected as part of health care claims or billing do not include a code for provider type. Although it may not be necessary to capture this information in general health care, in which the great majority of billing clinicians are physicians, the failure to do so for M/SU services neglects a substantial opportunity to learn about the M/SU workforce and its patterns of care. The Substance Abuse and Mental Health Services Administration (SAMHSA) has organized periodic efforts to collect data on mental health practitioners (see Table 7-1) (Duffy et al., 2004), but the information collected is incomplete, collected inconsistently across professions, and insufficient for policy and workforce analysis. This and the few other available data sources provide only limited information about specialty and general health care clinicians providing M/SU treatment services. Specialty Mental Health Providers Specialty mental health providers include psychiatrists, psychologists, and psychiatric nurses possessing formal graduate degrees in mental health. They also include social workers, counselors, nurses, and therapists who either have received additional, specialized training in treating mental problems and illnesses prior to their professional practice, or have chosen to practice in a mental health care setting and gained advanced knowledge in treating mental problems and illnesses through experience (West et al.,

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Improving the Quality of Health Care for Mental and Substance-Use Conditions TABLE 7-1 Estimated Number of Clinically Active (CA) or Clinically Trained (CT) Mental Health Personnel and Rate per 100,000 Civilian Population in the United States, by Discipline and Year Discipline Number Rate per 100,000 U.S. Civilian Population Reporting Year Counseling 111,931 (CA) 49.4 2002 Psychosocial Rehabilitation 100,000 (CT) 37.7 1996 Social Work 99,341 (CA) 35.3 2002 Psychology 88,491 (CT) 31.1 2002 Marriage and Family Therapy 47,111 (CA) 16.7 2002 Psychiatrya 38,436 (CT) 13.7 2001 School Psychology 31,278 (CT) 11.4 2003 Psychiatric Nursing 18,269 (CT) 6.5 2000 Pastoral Counseling Data not available     aBased on clinically active psychiatrists in the private sector; excludes residents and fellows. SOURCE: Duffy et al., 2004. 2001). Individuals with more severe mental illnesses are more likely to receive care from specialty mental health providers (Wang et al., 2000). Psychiatrists, for example, are likely to treat individuals with illnesses such as schizophrenia and bipolar disorder (West et al., 2001). SAMHSA’s most recent estimates of the numbers of clinically trained and clinically active3 mental health personnel are shown in Table 7-1. Specialty Substance-Use Treatment Providers Data on the specialty substance-use treatment workforce overall are sparse; no database systematically collects such data (Kaplan, 2003). SAMHSA’s 1996–1997 Alcohol and Drug Services study (Phase I) published in 2003 (SAMHSA, 2003) collected data on the credentials of staff working in a national inventory of hospital, residential, and outpatient substance-use treatment facilities and programs (Mulvey et al., 2003). However, subsequent national surveys of substance-use treatment services have not collected data on staff licensure and certification (SAMHSA, 2004), and in studies of the health care workforce overall, “the addiction treatment workforce is generally overlooked” (McCarty, 2002:1). Experts also note the paucity of data on the preparation of this workforce (Morris et al., 2004). 3   “Clinically trained” personnel include those who, because of formal training and experience, could provide direct clinical care for mental health conditions, whether or not they do so. “Clinically active” personnel are those actively providing such care.

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Improving the Quality of Health Care for Mental and Substance-Use Conditions It is known, however, that the specialty substance-use treatment workforce includes individuals from all of the above mental health professions (IOM, 1997) but is predominantly composed of counselors (McLellan et al., 2003). In 1998 approximately half of the staff delivering substance-use treatment services in about 13,000 outpatient clinics was licensed as substance-abuse counselors. The remainder were about equally composed of unlicensed counselors and “other” professionals who were predominantly master’s-level social workers, mental health counselors, marriage and family therapists, and psychologists with no certification or licensure as substance-use treatment providers; these “other” professionals also included psychiatrists and specialty-certified primary care physicians and nurses (Harwood, 2002). A more recent 2003 survey of 175 directors of inpatient/residential, outpatient, and methadone maintenance programs across the nation also found that apart from counselors, very few professional disciplines were represented among the treatment staff of these programs. With respect to program directors, 15 percent had no college degree; 58 percent had a bachelor’s degree, and 20 percent had a master’s degree. One program was under the direction of a physician (McLellan et al., 2003). General Medical/Primary Care Providers M/SU problems and illnesses are also treated by general internists, family medicine physicians, pediatricians, other medical specialists, and advanced practice nurses who have not been certified as mental health or substance-use treatment specialists and are delivering primary or specialty health care in office-based practices, clinics, acute general hospitals, and nursing homes. These providers are often the first point of contact for many adults with mental problems or illnesses. There is also some evidence that they are consumers’ preferred point of first contact for care: the majority of consumers initially turn to their primary care providers for mental health services (Mickus et al., 2000), and use of general medical providers for treatment of M/SU problems and illnesses increased more than 150 percent between 1990–1992 and 2001–2003—a significant shift away from other sectors of care (Kessler et al., 2005). An equal (DHHS, 1999) or greater (Wang et al., 2000) number of adults with M/SU problems and illnesses receive care from general medical providers relative to specialty mental health providers in a given year. Primary care physicians and physician specialists other than psychiatrists also prescribe the majority of psychotropic medications (Pincus et al., 1998). However, there also is evidence that the care provided by general, primary care physicians is less often consistent with clinical practice guidelines than that provided by psychiatrists (Friedmann et al., 2000; Young et al., 2001).

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Improving the Quality of Health Care for Mental and Substance-Use Conditions The diversity of professions and disciplines within the M/SU workforce has implications for quality of care. First, it is difficult for consumers to know which type of clinician has the best knowledge and skills to provide them with the safest, most effective, and most efficient care. This might not be a problem if all types of practitioners had a minimum level of competency and the special added competencies of the different types of clinicians were reliably known. This however, is not the case, as discussed in the next section. Professional licensure and ongoing assurance of competencies in specific therapies involve many different bodies. Experts in the education of the M/SU workforce report that prelicensure education is uneven, as are licensure standards and the use of postlicensure competency evaluation mechanisms (Daniels and Walter, 2002; Hoge, 2002; Hoge et al., 2002). PROBLEMS IN PROFESSIONAL EDUCATION AND TRAINING4 Providers in the above multiple disciplines, many of whom are licensed to practice independently, differ in the amounts of education and training they receive prior to professional practice. The content of the education they receive and the places in which they are educated also differ. This section reviews these variations, as well as deficiencies in the professional education of the M/SU workforce overall. Variation in Amounts and Types of Education Psychiatry Eligibility for board certification in psychiatry requires 4 years of college, 4 additional years of medical education leading to a medical degree, followed by a minimum of 4 years of residency training. Psychology Although the doctoral degree in psychology is the standard educational path for independent clinical practice, individuals with a master’s degree in psychology also can practice under the direction of a doctorally prepared 4   This section incorporates content from a paper commissioned by the committee on “Workforce Issues in Behavioral Health,” by John A. Morris, MSW, Professor of Clinical Neuropsychiatry and Behavioral Science at the University of South Carolina School of Medicine; Eric N. Goplerud, PhD, Research Professor at the School of Public Health and Health Services at George Washington University Medical Center; and Michael A. Hoge, PhD, Professor of Psychology (in Psychiatry) at Yale University School of Medicine.

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Improving the Quality of Health Care for Mental and Substance-Use Conditions psychologist, or independently as school psychologists or counselors (American Psychological Association, 2003; Duffy et al., 2004). To become a licensed clinical psychologist, graduates from doctoral programs also must complete supervised postdoctoral training (Olvey and Hogg, 2002). Practicing as a school psychologist requires a minimum of a master’s degree, followed by additional training leading toward certification or licensure at the state level or nationally by the National Association of School Psychologists (Morris et al., 2004). Social Work Although social workers can practice with a bachelor’s, master’s, or doctoral degree, the Master of Social Work (MSW) is considered the routine degree for practitioners and is the most common academic requirement for licensure. Obtaining an MSW degree usually requires 2 years of postundergraduate study and field placements/practica (Morris et al., 2004). Psychiatric Nursing Individuals may become a registered nurse (RN) through three different educational pathways: a 2-year program leading to an associate’s degree (AD) in nursing, a 3-year program (usually hospital-based) leading to a diploma in nursing, or a 4-year college or university program leading to a bachelor’s degree in nursing. Those completing all of these programs are eligible to take the RN licensing examination after graduation. Psychiatric nurses may have this basic level of education or a graduate degree. Specialty certification for psychiatric nurses at all levels is provided by the American Nurses Credentialing Center. Psychiatric nurses are certified at both the basic (“C” after RN) and advanced (“CS” or “BC” after RN) levels. The majority of psychiatric nurses are prepared at the basic level of education; advanced-level certification requires that the nurse have either a master’s or doctoral degree. Many nurses working in psychiatric settings do not have advanced certification in psychiatric nursing (Morris et al., 2004). Counseling The master’s degree is the most common practice degree in counseling and enables licensure as a counselor. Accredited graduate programs require a minimum of 72 quarter hours or 48 semester hours of postundergraduate study leading to a master’s degree. Doctoral degree programs usually require a minimum of 2 additional years of study (Morris et al., 2004).

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Improving the Quality of Health Care for Mental and Substance-Use Conditions Marriage and Family Therapy Marriage and family therapists are trained in three different ways: master’s degree (requiring 2–3 years of postundergraduate training); doctoral program (requiring 3–5 years of postundergraduate training); or a postgraduate clinical training program following training in psychology, psychiatry, social work, nursing, pastoral counseling, or education (Morris et al., 2004). Pastoral Counseling Persons credentialed as clinical pastoral counselors are either ordained or otherwise recognized by identified groups of religious faith and have completed a course of study approved by the Association for Clinical Pastoral Counseling. There are only 2,812 certified pastoral counselors nationwide, making them one of the smallest specialty provider groups in mental health (Morris et al., 2004). Psychosocial Rehabilitation Psychosocial rehabilitation is an approach to working with individuals with severe mental illnesses to teach them the skills they need to achieve their goals for living in the community. This type of care typically includes some combination of residential services, training in community living skills, socialization services, crisis services, case management, vocational rehabilitation, and other related services. Educational options for psychosocial rehabilitation workers are diverse and range from training following high school to an associate’s, bachelor’s, master’s, or doctoral degree in psychosocial rehabilitation. Recent statistics indicate that 2 percent of these workers have a doctoral degree, 24 percent a master’s degree, 13 percent some college or an associate’s degree, and 22 percent a high school diploma (Duffy et al., 2004). Substance-Use Treatment Counseling As described above, most of the substance-use treatment workforce consists of counselors. The composition of this workforce is shifting from those whose expertise is experience-based (from their personal experience with substance-use problems or illnesses and recovery) to those with more formal education at the graduate level (McCarty, 2002). However, a representative survey of all state-recognized substance-use treatment programs found that 26 percent of counselors did not have a bachelor’s degree, 32 percent possessed a bachelor’s degree only, and 42 percent possessed a

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Improving the Quality of Health Care for Mental and Substance-Use Conditions 1993. SAMHSA issues Workforce Training and Development for Mental Health Systems. 1999. Mental Health: A Report of the Surgeon General again documents the inadequate supply of well-trained mental health professionals, especially those serving children and adolescents and individuals with severe mental illnesses, and those providing specific forms of psychotherapy effective for many types of mental illnesses (DHHS, 1999). 2000. SAMHSA’s National Treatment Plan Initiative for Improving Substance Abuse Treatment calls for a National Workforce Development Office to secure valid, nationwide workforce data to guide policy making and support development of the substance-use treatment workforce at the national level. That office’s efforts would address the implementation of core competency guidelines, credentialing standards, and other education and training activities (SAMHSA, 2000). 2001–2002. The American College of Mental Health Administration (ACMHA) and the Academic Behavioral Health Consortium (ABHC) initiate the Annapolis Coalition on Behavioral Health Workforce Education to build national consensus on the nature of the problems facing the M/SU treatment workforce and improve the quality and relevance of their education and training. The coalition’s findings and recommendations are published in 2002 (Adams and Daniels, 2002; Daniels and Walter, 2002; Hoge, 2002; Hoge and Morris, 2002; Hoge et al., 2002). 2002. The HRSA–AMERSA–SAMHSA/CSAT Interdisciplinary Project to Improve Health Professional Education in Substance Abuse issues a strategic plan to enable the nation’s health professions workforce to care for individuals with substance-use problems and illnesses. The plan makes 12 recommendations for the Secretary of DHHS, the U.S Surgeon General, other federal agencies, and agencies and organizations in the public and private sectors, calling for, in part, the creation of a Secretary’s Advisory Committee on Health Professions Education on Substance-Use Disorders; a Surgeon General’s report on the state of substance abuse prevention and treatment, similar to the Surgeon General’s report on mental health; the convening of a national forum on health professions education on substance-use disorders; the creation of national centers of excellence for leadership in interdisciplinary faculty development; and other mechanisms to strengthen workforce competencies in substance-use health care (Haack and Adger, 2002). 2003. In its report Health Professions Education: A Bridge to Quality, the IOM makes 10 recommendations for improving all health professions education to support improvements in health care quality (IOM, 2003). 2003. The President’s New Freedom Commission on Mental Health (2003) reports that “the Commission heard consistent testimony from con-

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Improving the Quality of Health Care for Mental and Substance-Use Conditions sumers, families, advocates, and public and private providers about the ‘workforce crisis’ in mental health care. Today, not only is there a shortage of providers, but those providers who are available are not trained in evidenced-based and other innovative practices. This lack of education, training, or supervision leads to a workforce that is ill-equipped to use the latest breakthroughs in modern medicine” (p. 70). The commission further states that the mental health field needs “a comprehensive strategic plan to improve workforce recruitment, retention, diversity, and skills training” and calls on DHHS to “initiate and coordinate a public-private partnership to undertake such a strategy” (p. 75). 2004. The Annapolis Coalition on Behavioral Health Workforce Education convenes a national meeting that generates 10 consensus recommendations to guide the development of M/SU health care workforce competencies (Hoge et al., 2005a). 2005. SAMHSA contracts with the Annapolis Coalition on the Behavioral Health Workforce to develop a national strategic plan on workforce development by December 2005. NEED FOR A SUSTAINED COMMITMENT TO BRING ABOUT CHANGE Some changes have taken place as result of the initiatives described above. In general, however, M/SU health care professionals are trained the way they have been for many years, and problems such as maldistribution and the lack of representation of minorities in the workforce have improved only slightly, if at all. Despite significant efforts, attempts to train non-psychiatric physicians to do a better job of caring for people with M/SU problems and illnesses have not been particularly effective. Broader efforts to bring about similar changes in the M/SU treatment workforce overall have had similar results. The committee finds, as others have before, that without a properly trained, culturally relevant, and appropriately distributed M/SU health care workforce, significant improvements in the quality of care are not likely. The committee further finds that the problems that attenuate the effectiveness of the M/SU health workforce in America are so complex that they require an ongoing, priority commitment of attention and resources, as opposed to the short-term, ad hoc initiatives that have often characterized responses to the problem in the past. As noted above, the committee recommends that the approach used to educate and train other key providers (physicians and nurses) in the health care workforce, as described below, be employed to marshal the sustained attention, collaboration, and resources needed to produce a stronger M/SU health care workforce.

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Improving the Quality of Health Care for Mental and Substance-Use Conditions Council on Graduate Medical Education The Council on Graduate Medical Education (COGME) was authorized by Congress in 1986 to “provide an ongoing assessment of physician workforce trends, training issues and financing policies, and to recommend appropriate federal and private sector efforts to address identified needs” (HRSA, 2002). Council members include “representatives of practicing primary care physicians, national and specialty physician organizations, international medical graduates, medical student and house staff associations, schools of medicine and osteopathy, public and private teaching hospitals, health insurers, business, and labor. Federal representation includes the Assistant Secretary for Health, the U.S. Department of Health and Human Services (DHHS); the Administrator of the Centers for Medicare and Medicaid Services; and the Chief Medical Director of the Veterans Administration.” COGME advises and makes recommendations to the Secretary of DHHS; the Senate Committee on Health, Education, Labor and Pensions; and the House of Representatives Committee on Commerce. The charge to COGME is broader than its name implies. Its authorizing legislation requires its advice and recommendations to address the following (HRSA, 2002): The supply and distribution of physicians in the United States. Current and future shortages or excesses of physicians in specialties and subspecialties. Related federal policies, including the financing of undergraduate and graduate medical education programs and the types of medical education and training in the latter programs. Efforts to be carried out by hospitals, educational institutions, and accrediting bodies with respect to these matters, including changes in undergraduate and graduate medical education programs. Improvements needed in databases concerning the supply and distribution of, and postgraduate training programs for, physicians in the United States and steps that should be taken to eliminate those deficiencies. COGME periodically studies and issues reports on these issues that have been influential in health care policy arenas. While these reports have sometimes been controversial (Phillips et al., 2005), they have been successful in focusing national attention on the issues and stimulating policy responses. National Advisory Council on Nurse Education and Practice The National Advisory Council on Nurse Education and Practice (NACNEP) was established as the Advisory Council on Nurse Training in 1964 and renamed in 1988. It similarly advises the Secretary of DHHS and

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Improving the Quality of Health Care for Mental and Substance-Use Conditions the U.S. Congress on policy issues related to the nursing programs administered by HRSA’s Bureau of Health Professions Division of Nursing, including nurse workforce supply, education, and practice improvement. Among its reports are the following: Basic Registered Nurse Workforce, National Informatics Agenda for Nursing Education and Practice, Collaborative Education to Ensure Patient Safety, A National Agenda for Nursing Workforce Racial/Ethnic Diversity, Federal Support for the Preparation of the Nurse Practitioner Workforce through Title VIII, and Federal Support for the Preparation of the Clinical Nurse Specialist Workforce through Title VIII. The efforts of COGME and NACNEP have resulted in a number of accomplishments in workforce development. With respect to furthering interdisciplinary education and practice, for example, the two worked together to produce the report Collaborative Education to Ensure Patient Safety (COGME and NACNEP, 2000), which makes recommendations pertaining to faculty development, quality improvement, interdisciplinary collaboration, and competency development. These recommendations fostered cooperative agreements with public and private nonprofit entities that were cosponsored by HRSA’s nursing and medicine divisions (NACNEP, 2002). Recommendations To secure sustained attention and resources for the development of the M/SU treatment workforce similar to what has been accomplished for the physician and nurse workforces, the committee makes the following recommendations: Recommendation 7-1. To ensure sustained attention to the development of a stronger M/SU health care workforce, Congress should authorize and appropriate funds to create and maintain a Council on the Mental and Substance-Use Health Care Workforce as a public–private partnership. Recognizing that the quality of M/SU services is dependent upon a highly competent professional workforce, the council should develop and implement a comprehensive plan for strengthening the quality and capacity of the workforce to improve the quality of M/SU services substantially by: Identifying the specific clinical competencies that all M/SU professionals must possess to be licensed or certified and the competencies that must be maintained over time. Developing national standards for the credentialing and licensure of M/SU providers to eliminate differences in the standards now

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Improving the Quality of Health Care for Mental and Substance-Use Conditions used by the states. Such standards should be based on core competencies and should be included in curriculums and education programs across all the M/SU disciplines. Proposing programs to be funded by government and the private sector to address and resolve such long-standing M/SU workforce issues as diversity, cultural relevance, faculty development, and continuing shortages of the well-trained clinicians and consumer providers needed to work with children and the elderly; and of programs for training competent clinician administrators. Providing a continuing assessment of M/SU workforce trends, issues, and financing policies. Measuring the extent to which the plan’s objectives have been met and reporting annually to the nation on the status of the M/SU workforce. Soliciting technical assistance from public–private partnerships to facilitate the work of the council and the efforts of educational and accreditation bodies to implement its recommendations. Recommendation 7-2. Licensing boards, accrediting bodies, and purchasers should incorporate the competencies and national standards established by the Council on the Mental and Substance-Use Health Care Workforce in discharging their regulatory and contracting responsibilities. Recommendation 7-3. The federal government should support the development of M/SU faculty leaders in health professions schools, such as schools of nursing and medicine, and in schools and programs that educate M/SU professionals, such as psychologists and social workers. The aim should be to narrow the gaps among what is known through research, what is taught, and what is done by those who provide M/SU services. Recommendation 7-4. To facilitate the development and implementation of core competencies across all M/SU disciplines, institutions of higher education should place much greater emphasis on interdisciplinary didactic and experiential learning and should bring together faculty and trainees from their various education programs. The committee calls particular attention to two components of recommendation 7-1. First, the recommendation calls for a public–private partnership to address the problems plaguing the M/SU workforce. Federal leadership can provide sustained national policy attention to these problems and unique influence with the educational institutions and their

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Improving the Quality of Health Care for Mental and Substance-Use Conditions accreditors, licensing bodies, health professions associations, and health care organizations that need to be engaged in resolving the issues involved. At the same time, private-sector organizations such as AMERSA (Samet et al., 2006) and, more recently, the Annapolis Coalition on Behavioral Health Workforce Education can offer the expertise, collaboration, and flexibility necessary to collect and analyze additional evidence that needs to be brought to bear on these issues. Therefore, the committee strongly recommends that the council seek out AMERSA and the Annapolis Coalition as partners in this process. Second, with respect to the portion of recommendation 7-1 that calls for the Council on the Mental and Substance-Use Health Care Workforce to provide “an ongoing assessment of M/SU workforce trends, issues, and financing policies,” the committee underscores the paucity of comprehensive and reliable data on the M/SU workforce that it encountered in conducting this study. Thus the committee strongly recommends the inclusion of a mechanism or mechanisms for collecting better data on the M/SU workforce as a part of the process for assessing workforce trends and issues. REFERENCES Aanavai MP, Taube DO, Ja DY, Duran EF. 1999. The status of psychologists’ training about and treatment of substance-abusing clients. Journal of Psychoactive Drugs 31(4):441–444. Abrams Weintraub T, Saitz R, Samet JH. 2003. Education of preventive medicine residents: Alcohol, tobacco, and other drug abuse. American Journal of Preventive Medicine 24(1):101–105. Adams N, Daniels AS. 2002. Sometimes a great notion…a common agenda for change. Administration and Policy in Mental Health 29(4–5):319–324. Addiction Technology Transfer Centers National Curriculum Committee. 1998. Addiction Counseling Competencies: The Knowledge, Skills and Attitudes of Professional Practice. DHHS Publication No. (SMA)98-3171. Technical Assistance Publication Series 21. Rockville, MD: U.S. Department of Health and Human Services. [Online]. Available: http://www.nattc.org/pdf/accksa.pdf [accessed June 28, 2005]. AHRQ (Agency for Healthcare Research and Quality). 2003. The Effect of Health Care Working Conditions on Patient Safety: Summary. AHRQ Publication Number/03-E024. [Online]. Available: http://www.ahrq.gov/clinic/epcsums/worksum.pdf [accessed July 1, 2005]. American Psychological Association (APA). 2003. Psychology: Scientific Problem Solvers—Careers for the 21st Century. [Online]. Available: www.apa.org/students/brocure/brochurenew.pdf [accessed June 28, 2005]. Washington, DC: American Psychological Association. APA Committee on Medical Education. 1956. An outline for a curriculum for teaching psychiatry in medical schools. Journal of Medical Education 31(2):115–128. Association of State and Provincial Psychology Boards. 2000. Handbook of Licensing and Certification Requirements for Psychologists in the U.S. and Canada. Montgomery, AL: Association of State and Provincial Psychology Boards.

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