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Appendix C Required Knowledge, Skills, and Training for Mental Health, Substance Use, and Geriatric Care Providers 313

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314 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS CONTENTS I. PHYSICIANS 316 Allopathic Physicians (MD) 316 Family Medicine (MD) 316 Geriatric Family Medicine (MD) 318 Internal Medicine (MD) 320 Geriatric Internal Medicine (MD) 320 Psychiatry (MD) 322 Geriatric Psychiatry (MD) 322 Addiction Psychiatry (MD) 322 Osteopathic Physicians (DO) 322 Family Medicine (DO) 324 Geriatrics in Family Medicine (DO) 324 Addiction in Family Medicine 326 Internal Medicine (DO) 326 Geriatric Internal Medicine (DO) 326 General Psychiatry (DO) 326 Geriatric Psychiatry (DO) 328 Addiction Psychiatry (DO) 328 II. PHYSICIAN ASSISTANTS 330 III. NURSES 332 Licensed Practical Nurses/Licensed Vocational Nurses 332 Registered Nurses (Diploma, Associate’s, and Baccalaureate) 334 Gerontological Nurses 336 Psychiatric and Mental Health Nurses 336 Advanced Practice Registered Nurses (Master’s and Doctoral) 336 Acute Care Nurse Practitioners 336 Adult Psychiatric-Mental Health Nurse Practitioners 338 Adult-Gerontology Primary Care Nurse Practitioners 338 Adult-Gerontology Clinical Nurse Specialists 338 IV. PSYCHOLOGISTS 340 Clinical Psychology 342 Counseling Psychology 342 Couple and Family Psychology 342 Rehabilitation Psychology 344 V. LICENSED COUNSELORS 344 Rehabilitation Counseling 344 Addiction Counseling 346 Clinical Mental Health Counseling 346 VI. SOCIAL WORKERS 348 Social Worker (Associate’s and Baccalaureate) 348 Social Worker (Master’s) 348 Clinical Social Work 348

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315 APPENDIX C VII. PHARMACISTS 350 Psychiatric Pharmacy 350 VIII. OCCUPATIONAL THERAPISTS 350 Occupational Therapy Assistant 350 Occupational Therapist (Master’s and Doctoral) 352 Gerontology 354 Mental Health 354 IX. DIRECT CARE WORKERS 354 Certified Nursing Assistant 354 Home Health Aide 354

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316 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS GENERAL POPULATION Co-occurring MH Mental Health (MH) Substance Use (SU) and SU I. PHYSICIANS Allopathic Physicians (MD)a Early identification and intervention of Diagnosis of None mental disorders (e.g., suicide potential, substance-related depression, alcohol/substance abuse, disorders (e.g., family involvement in schizophrenia); alcohol and other biologic markers of mental disorders substances). and mental retardation syndromes; intended/unintended effects of therapeutic interventions for mental disorders, including effects of drugs on neurotransmitters; diagnosis of mental disorders usually first diagnosed in infancy, childhood, or adolescence, schizophrenia and other psychotic disorders, mood disorders, anxiety disorders, somatoform disorders, other disorders/conditions; principles of mental disorder management (Pharmacotherapy only, Management decision, Treatment only). Family Medicine (MD)b Responsibility for the total health care Must have instruction None of the individual and family, taking and development of into account behavioral dimensions; skills in the diagnosis Family-oriented comprehensive care and management of experience, including individual behavioral alcoholism and other counseling and family counseling; substance abuse. knowledge and skills in human behavior and mental health should be acquired through a program in which behavioral science and psychiatry are integrated with all disciplines throughout the total educational experience; skills in the diagnosis and management of psychiatric disorders in children and adults, emotional aspects of nonpsychiatric disorders, psychopharmacology, the physician– patient relationship, patient interviewing skills, and counseling skills.

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317 APPENDIX C GERIATRIC POPULATION Substance Use Co-occurring MH General Care Mental Health (MH) (SU) and SU General principles of None None None senescence (normal physical and mental changes associated with aging); medical ethics and jurisprudence regarding death and dying (e.g., diagnosing death, organ donation, euthanasia, physician- assisted suicide) and palliative care (e.g., hospice, pain management, family counseling, psychosocial and spiritual issues, fear, and loneliness). Resident panels must Training must include None None include continuity the psychologic aspects experience for patients of senescence. requiring home care and care in long-term care facilities; nursing home experience must consist of at least two patients as a continuity experience over a minimum of 24 consecutive months, in addition to rotation; must perform at least two home visits with at least one being for an older adult continuity patient; educational experiences must be in both common and complex clinical problems of older patients; training must include the appropriate preventive modalities, functional assessment, and the physiologic and psychologic aspects of senescence; supervised clinical experiences dealing with common acute and chronic diseases of aging; learn about, and practically apply, a multidisciplinary approach to the care of older patients in the hospital, the family medicine center (FMC),

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318 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS GENERAL POPULATION Co-occurring MH Mental Health (MH) Substance Use (SU) and SU Geriatric Family Medicine (MD)c N/A N/A N/A

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319 APPENDIX C GERIATRIC POPULATION Substance Use Co-occurring MH General Care Mental Health (MH) (SU) and SU the long-term care facility, and the home; competence in preventive health care, promotion of independent living, and maximizing function and quality of life; competency in assessing and meeting the health care needs of declining elders, episodic, illness- related care, delivery of health care in the home, FMC, hospital, and long- term facility, and end-of- life care. Primary specialty. Ambulatory care None None experience must be designed to provide care, in a geriatric clinic or family medicine center, to elderly patients who may require the services of multiple medical disciplines, including psychiatry and social work; experience in relevant ambulatory specialty and subspecialty clinics (e.g., geriatric psychiatry and neurology) strongly recommended; identifiable structured didactic and clinical experiences in geriatric psychiatry must be included in the program of each fellow; formal instruction in physical and mental examination, topics of special interest to geriatric medicine, including, but not limited to, cognitive impairment, depression and related disorders, psychosocial aspects of aging, including interpersonal and family relationships, living situations, adjustment disorders, depression, bereavement, and anxiety, and behavioral sciences such as psychology/social work.

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320 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS GENERAL POPULATION Co-occurring MH Mental Health (MH) Substance Use (SU) and SU Internal Medicine (MD)d Clinical experience must include None None opportunities for experience in psychiatry. Geriatric Internal Medicine (MD)e N/A N/A N/A

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321 APPENDIX C GERIATRIC POPULATION Substance Use Co-occurring MH General Care Mental Health (MH) (SU) and SU Institution must have None None None patients of a broad age range, including geriatric patients; clinical experience must include an assignment in geriatric medicine; clinical experience in outpatient chronic disease management, preventive health, patient counseling, and common acute ambulatory problems with a diversity of ages. Primary specialty. Formal instruction in None None physical and mental examination, topics of special interest to geriatric medicine, including, but not limited to, cognitive impairment, depression and related disorders, psychosocial aspects of aging, including interpersonal and family relationships, living situations, adjustment disorders, depression, bereavement, and anxiety, and behavioral sciences such as psychology/social work; ambulatory care experience must be designed to provide care in a geriatric clinic or internal medicine center to elderly patients who may require the services of multiple medical disciplines, including psychiatry and social work; experience in relevant ambulatory specialty and subspecialty clinics (e.g., geriatric psychiatry and neurology) strongly recommended; Fellows must develop clinical competence in assessment of cognitive status and affective states; clinical experience in the

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322 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS GENERAL POPULATION Co-occurring MH Mental Health (MH) Substance Use (SU) and SU Psychiatry (MD)f Primary specialty. One month full-time Evaluation and equivalent organized clinical management experience focused of patients with on the evaluation and substance abuse/ clinical management dependence of patients with problems, including substance abuse/ dual diagnosis. dependence problems, including dual diagnosis. Geriatric Psychiatry (MD)g N/A N/A N/A Addiction Psychiatry (MD)h Primary specialty. Primary specialty. Primary specialty. Osteopathic Physicians (DO)i,j,k Take a comprehensive history (including Population health None symptoms, psychological factors, and concepts and social factors); perform a standard history patients with and physical examination, including mini- presentations related mental and basic neurologic examinations; to health promotion, understand the concepts and principles of chronic disease social and behavioral sciences and apply management, and these to the understanding, management, human development, and treatment of patient presentations. including detection and monitoring of

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323 APPENDIX C GERIATRIC POPULATION Substance Use Co-occurring MH General Care Mental Health (MH) (SU) and SU management of elderly patients must include understanding of the behavioral aspects of illness; identifiable structured didactic and clinical experiences in geriatric psychiatry must be included in the program of each Fellow. N/A One month full-time None None equivalent organized experience focused on the specific competencies in areas that are unique to the care of the elderly. N/A Primary specialty. Epidemiology, Epidemiology, diagnosis, and diagnosis, and treatment of all treatment of all major psychiatric major psychiatric disorders seen disorders seen in the elderly, in the elderly, seen alone and seen alone and in combination, in combination, including including substance-related substance-related disorders. disorders. N/A Clinical experience must Clinical Clinical include the opportunity experience experience to evaluate and follow must include must include a variety of patients of the opportunity the opportunity both sexes, including to evaluate and to evaluate and geriatric age groups follow a variety of follow a variety of spanning a broad range patients of both patients of both of diagnoses. sexes, including sexes, including geriatric age geriatric age groups spanning groups spanning a broad range of a broad range of diagnoses. diagnoses. Determine and monitor COMLEX-USA None None the nature of a patient’s covers patients with concern or problem presentations related to using a patient- trauma, including elder centered approach abuse. that is appropriate to the age of the patient; provide effective patient care in the outpatient, inpatient, and home

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348 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS GENERAL POPULATION Co-occurring MH Mental Health (MH) Substance Use (SU) and SU mental disorders; knows the impact of co-occurring substance use disorders on medical and psychological disorders. VI. SOCIAL WORKERS Social Worker (Associate’s and Baccalaureate)ll Typical and atypical emotional growth Differentiating the The co-occurrence of and development; the impact of physical, use of, abuse of, addiction and other mental, and cognitive impairment on and dependency disorders. human development; the interplay of on substances; the biological, psychological, social, and effects of addiction spiritual factors; assessing types of on the client; the information available from psychological effects of addiction and psychiatric educational records; on the family process of referring the client for system and other additional evaluations (e.g., psychological); relationships; eliciting The dynamics and effects of life stage sensitive information and lifecycle crises; the impact of physical (e.g., substance and mental illness on crises; dynamics and abuse). effects of trauma; dynamics and effects of loss, separation, and grief; indicators of and response to client danger to self and others; stages of crises; processes and techniques for cognitive and/or behavioral interventions. Social Worker (Master’s)mm Behavioral, cognitive, and learning Addiction theories None theories; impact of physical, mental, and concepts; and cognitive disabilities on human indicators of development; interplay of biological, substance abuse and psychological, and social factors; other addictions. dynamics of grief and loss; indicators and dynamics of abuse; psychopharmacology; components of a biopsychosocial history; symptoms of mental and emotional illness; indicators of psychosocial stress; indicators of traumatic stress and violence; current Diagnostic and Statistical Manual diagnostic framework and criteria; components and function of the mental status examination; indicators of client danger to self and others; use of cognitive behavioral techniques. Clinical Social Worknn Primary specialty. Substance abuse Assessment and and/or dependence; diagnosis of co- the effects of occurring disorders substance abuse and conditions. and/or dependence on relationships; the effects of substance abuse and/or dependence; addiction theories;

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349 APPENDIX C GERIATRIC POPULATION Substance Use Co-occurring MH General Care Mental Health (MH) (SU) and SU Older adult behavior The symptoms of None None and development; the mental and emotional interaction of age and/or illness across the life disability with behaviors, span; the indicators, attitudes, and identity. dynamics, and impact of sexual abuse, emotional abuse, neglect, physical abuse, intimate partner violence, and other forms of exploitation across the life span; the dynamics and effects of life stage and lifecycle crises; the effect of the client system’s life stage on the selection of an intervention. Aging processes; None None None influence of age on behaviors and attitudes. N/A Gerontology; None None differences in age and/ or disability factors and characteristics; the influences of age and/or disability; the impact of age and/or disability on self-image; the effects of discrimination based on age and/or disability;

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350 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS GENERAL POPULATION Co-occurring MH Mental Health (MH) Substance Use (SU) and SU the effects of drugs and alcohol on behavior; other addictions; the effects of other addictions on behavior and relationships. VII. PHARMACISTSoo None Science foundation None should include acute and chronic toxic effect of xenobiotics on the body, including drug or chemical overdose and toxic signs of drugs of abuse. Psychiatric Pharmacypp Primary specialty. Substance-related Knowledge of disorders included pharmacologic in definition treatment of of psychiatric psychiatric and disorders; evaluate neurologic disorders psychiatric services in special populations for compliance with (e.g., comorbidity). standards established by national accrediting and regulatory agencies as related to practice in health care settings (e.g., mental health, substance abuse). VIII. OCCUPATIONAL THERAPISTS Occupational Therapy Assistantqq Curriculum must prepare students to work None None with a variety of populations including, but not limited to, children, adolescents, adults, and elderly persons in areas

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351 APPENDIX C GERIATRIC POPULATION Substance Use Co-occurring MH General Care Mental Health (MH) (SU) and SU the methods used to assess needed level of care (e.g., geriatrics); the impact of aging parents on adult children. Science foundation None None None should include principles of end-of-life care; pathophysiologic and pharmacotherapy alterations, dosage calculation, and adjustments, and drug monitoring for positive/negative outcomes specific for special population patients (e.g., geriatric) for prescription and nonprescription medications; advanced pharmacy practice experiences must include primary, acute, chronic, and preventive care among patients of all ages; in general, each site used for required pharmacy practice experiences should have a patient population that exhibits diversity in age. N/A Knowledge of Substance- Knowledge of pharmacologic related disorders pharmacologic treatment of psychiatric included in treatment of and neurologic disorders definition of psychiatric in special populations psychiatric and neurologic (e.g., age); disorders in disorders. disorders the elderly (including in special medication use and populations (e.g., other psychiatric comorbidity, age). disorders not included in general list of psychiatric disorders). Demonstrate knowledge Curriculum must None None and understanding of prepare students to human development work with a variety of throughout the life span populations, including

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352 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS GENERAL POPULATION Co-occurring MH Mental Health (MH) Substance Use (SU) and SU of physical and mental health; course content must include, but is not limited to, developmental psychology; demonstrate knowledge and understanding of the concepts of human behavior to include the behavioral and social sciences (e.g., principles of psychology, sociology, abnormal psychology); demonstrate knowledge and appreciation of the role of sociocultural, socioeconomic, and diversity factors and lifestyle choices in contemporary society (e.g., principles of psychology, sociology, and abnormal psychology); understand the effects of physical and mental health, heritable diseases and predisposing genetic conditions, disability, disease processes, and traumatic injury to the individual within the cultural context of family and society on occupational performance; express support for the quality of life, well- being, and occupation of the individual, group, or population to promote physical and mental health; consider client factors, including body functions (e.g., cognitive, mental) and body structures in occupational performance evaluation; interventions must address client factors, including body functions (e.g., cognitive, mental). Occupational Therapist (Master’srr and Doctoralss) The curriculum must prepare students None None to work with a variety of populations, including, but not limited to, children, adolescents, adults, and elderly persons in areas of physical and mental health; course content must include, but is not limited to, developmental psychology; demonstrate knowledge and understanding of the concepts of human behavior to include the behavioral and social sciences. Course content must include, but is not limited to, introductory psychology, abnormal psychology, and introductory sociology or introductory anthropology; analyze the effects of physical and mental health, heritable diseases, and predisposing genetic conditions, disability, disease processes, and traumatic injury to the individual within the cultural context of family and society on occupational performance; express support for the quality of life, well-being, and occupation of the individual, group, or population to promote physical and mental health; consider client factors, including body functions (e.g., cognitive, mental) and body structures in occupational performance evaluation; interventions must address client factors, including body functions (e.g., cognitive, mental).

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353 APPENDIX C GERIATRIC POPULATION Substance Use Co-occurring MH General Care Mental Health (MH) (SU) and SU (including elderly elderly persons, in areas persons); recommended of physical and mental that the student be health. exposed to a variety of clients across the life span and to a variety of settings in Level II fieldwork. Demonstrate knowledge The curriculum must None None and understanding of prepare students to human development work with a variety of throughout the life populations, including span (including elderly persons, in areas elderly persons); of physical and mental select appropriate health. assessment tools based on client needs, contextual factors, and psychometric properties of tests. These must be relevant to a variety of populations across the life span, culturally relevant, based on available evidence, and incorporate use of occupation in the assessment process; recommended that the student be exposed to a variety of clients across the life span and to a variety of settings in Level II fieldwork.

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354 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS GENERAL POPULATION Co-occurring MH Mental Health (MH) Substance Use (SU) and SU Gerontologytt N/A N/A N/A Mental Healthuu Primary specialty. None None IX. DIRECT CARE WORKERS Certified Nursing Assistantvv Mental health and social service needs, None None including modifying aide’s behavior in response to residents’ behavior, awareness of developmental tasks associated with the aging process, how to respond to resident behavior, allowing the resident to make personal choices, providing and reinforcing other behavior consistent with the resident’s dignity, and using the resident’s family as a source of emotional support. Home Health Aideww None None None a Step2 Clinical Knowledge (CK) Content Description and General Information, USMLE 2011. b Program Requirements for Graduate Medical Education in Family Medicine, ACGME 2007. c Program Requirements for Graduate Medical Education in Geriatric Medicine, ACGME 2006. d Program Requirements for Graduate Medical Education in Internal Medicine, ACGME 2009. e Program Requirements for Graduate Medical Education in Geriatric Medicine, ACGME 2007.

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355 APPENDIX C GERIATRIC POPULATION Substance Use Co-occurring MH General Care Mental Health (MH) (SU) and SU Primary specialty. Knowledge of relevant None None evidence, including theories regarding age-related changes or pathology that affect cognitive and psychological function. N/A Synthesizes knowledge None None of how occupational performance and context influence life satisfaction, quality of life, and mental health across the life span in the design and delivery of services. Mental health and None None social service needs, including awareness of developmental tasks associated with the aging process; care of cognitively impaired residents, including techniques for addressing the unique needs and behaviors of individuals with dementia (Alzheimer’s and others), communicating with cognitively impaired residents, understanding the behavior of cognitively impaired residents, appropriate responses to the behavior of cognitively impaired residents; and methods of reducing the effects of cognitive impairments. None None None None f Program Requirements for Graduate Medical Education in Psychiatry, ACGME 2007. g Program Requirements for Graduate Medical Education in Geriatric Psychiatry, ACGME 2003. h Program Requirements for Graduate Medical Education in Addiction Psychiatry, ACMGE 2003.

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356 MENTAL HEALTH AND SUBSTANCE USE WORKFORCE FOR OLDER ADULTS i American Osteopathic Association. 2011. Basic standards for fellowship training in geriatrics in osteopathic family medicine and manipulative treatment. http://www.osteopathic.org/ inside-aoa/accreditation/postdoctoral-training-approval/postdoctoral-training-standards/ Documents/basic-standards-for-fellowship-training-in-geriatrics-osteopathic-family-practice. pdf. j NBOME 2009. Fundamental Osteopathic Medical Competencies: Guidelines for Osteopathic Medical Licensure and the Practice of Osteopathic Medicine. AOA. 2011. Specific Basic Standards for Osteopathic Fellowship Training in Internal Medicine Geriatrics. http://www. osteopathic.org/inside-aoa/accreditation/postdoctoral-training-approval/postdoctoral- training-standards/Documents/specific-requirements-for-fellowship-training-in-geriatric- medicine.pdf. k NBOME 2011, Computer-Based COMLEX Content Outline, http://www.nbome.org/intro/m_ outline.html. l Basic Standards for Residency Training in Family Practice and Manipulative Treatment, AOA and ACOFP 2011. m Basic Standards for Fellowship Training in Geriatrics in Family Practice and Manipulative Treatment, AOA and ACOFP 2011. n Basic Standards for Fellowship Training in Addiction Medicine in Family Practice and Manipulative Treatment, AOA and ACOFP 2008. o Basic Standards for Residency Training in Internal Medicine, AOA and ACOI 2011. p Specific Basic Standards for Osteopathic Fellowship Training in Internal Medicine Geriatrics, AOA and ACOI 2011. q Basic Standards for Residency Training in General Psychiatry, AOA and ACONP 2009. r Basic Standards for Residency Training in Geriatric Psychiatry, AOA and ACONP 2008. s  Basic Standards for Addiction Psychiatry, AOA and ACONP 2007. t Accreditation Standards for Physician Assistant Education, Fourth Edition, ARCEPA March 2010. u 2011 NCLEX-PN® Detailed Test Plan: Item Writer/Item Reviewer/Nurse Educator Version, NCSBN April 2011. v2010 NCLEX-RN® Detailed Test Plan: Item Writer/Item Reviewer/Nurse Educator Version, NCSBN April 2010. w Gerontological Nursing Board Certification Test Content Outline, ANCC 2010. x Psychiatric and Mental Health Nursing Board Certification Test Content Outline, ANCC 2010. y  The Essentials of Master’s Education for Advanced Practice Nursing, AACN 1996. z  The Essentials of Doctoral Education for Advanced Nursing Practice, AACN October 2006 (standards do not differ between Master’s and Doctoral levels in these areas). aa Acute Care Nurse Practitioner Competencies, National Panel for Acute Care Nurse Practitioner Competencies 2004. bb National Panel for Psychiatric-Mental Health NP Competencies, September 2003, http:// www.aacn.nche.edu/leading-initiatives/education-resources/PMHNP.pdf. cc Adult-Gerontology Primary Care Nurse Practitioner Competencies, AACN 2010. dd Adult-Gerontology Clinical Nurse Specialist Competencies, AACN March 2010. ee ASPPB Information for EPPP Candidates: Examination for Professional Practice in Psychology (EPPP), ASPPB 2011. ff  Examination Manual for Board Certification in Clinical Psychology for the American Board Of Professional Psychology, ABPP 2011. gg Examination Manual for Board Certification in Counseling Psychology for the American Board of Professional Psychology, ABPP 2010. hh Manual for Obtaining Board Certification, American Board of Couple and Family Psychology 2011. ii Certification Guidelines and Procedures Candidate’s Manual, American Board of Rehabilitation Psychology 2011. jj Accreditation Manual for Master’s Level Rehabilitation Counselor Education Programs, CORE 2011.

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357 APPENDIX C kk Council for Accreditation of Counseling and Related Educational Programs 2009 Standards, CACREP 2009. ll ASWB Examination program Knowledge, Skills and Abilities: Bachelor’s Examination, ASWB 2011. (Note: Associate candidates also take Bachelor’s Examination.) mm Examination program Knowledge, Skills and Abilities: Masters Examination, ASWB 2011. nn ASWB Examination program Knowledge, Skills and Abilities: Clinical Examination, ASWB 2011. oo Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree, ACPE 2011. pp Content Outline for the Psychiatric Pharmacy Specialty Certification Examination, Board of Pharmacy Specialties, May 2005. qq Accreditation Standards for an Educational Program for the Occupational Therapy Assistant, ACOTE 2006. rr Accreditation Standards for a Master’s Degree-Level Educational Program for the Occupational Therapist, ACOTE 2006. ss Accreditation Standards for a Doctoral Degree-Level Educational Program for the Occupational Therapist, ACOTE 2006 (standards do not differ between master’s and doctoral levels in these areas). tt Competencies, Criteria, and Client Outcomes: Gerontology Board Certification, AOTA 2009. uu Competencies, Criteria, and Client Outcomes: Mental Health Board Certification, AOTA 2009. vv C.F.R. Part 483 (Requirements for States and Long-Term Care Facilities), October 1, 2001. ww C.F.R. Part 484 (Conditions of Participation: Home Health Agencies), October 1, 2001.

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