In the final session of the workshop, participants met in eight breakout groups to discuss ideas to move workforce issues forward and the stakeholders that need to be involved in these efforts. These possible next steps were offered as suggestions intended to stimulate further discussion of the best ways to prepare and maintain the workforce needed to enhance the cognitive, affective, and behavioral health of children. Each of the breakout sessions focused on one of eight topics and the stakeholders who might be involved in that area:
- Behavioral health promotion and risk prevention through multigenerational surveillance
- Incorporating exposure to evidence-based practices into content and assessment of training programs focused on the need for changing systems to support implementation
- Fostering integrated, interprofessional care
- Training the future child health care workforce to meet the needs of children with disabilities and chronic medical conditions
- Engaging patients and parents in copromotion of behavioral health to improve care
- Enhancing training through the power of accreditation, certification, and credentialing
- Enhancing training for health care professionals to improve the behavioral health of children, youth, and families involved in other child-serving systems
- How current reimbursement for training and clinical care impacts the focus on behavioral health for children, youth, and families.
The group that considered behavioral health promotion and risk prevention through multigenerational surveillance explored ideas around competencies, curriculum development, and training programs. Deborah Klein Walker reported four ideas emerged from the session: (1) discipline-specific competencies could be reviewed for behavioral health promotion and risk prevention through multigenerational surveillance to identify cross-disciplinary overlap and gaps, with any competencies that have gaps being updated (examples of competencies include taking complete family histories, parent/family involvement, positive parenting, motivational interviewing, and care across the continuum from prevention to treatment); (2) curricula, tools, programs, and centers could be developed to incorporate competencies in training; (3) federal training grant programs for child behavioral health could be expanded; and (4) stakeholders might include families and the public, providers of behavioral health care for children and youth in any setting, education and accreditation organizations, and foundations, congress, and other funders.
In the breakout group that considered incorporating exposure to evidence-based practices into content and assessment of training programs, Hendricks Brown, Northwestern University, reported on participants’ ideas for changing systems to support implementation, including the importance of input, agreement, and engagement from community organizations who are implementing evidence-based practices within their local communities. Group members suggested the following: (1) a shared work plan could be developed for embedding training on evidence-based practices into educational change efforts; (2) a “lessons learned” document could be created on the incorporation of evidence-based practices into training systems; (3) workshops could be held on the development and roles of backbone and intermediary organizations that can support and sustain systems change; and (4) stakeholders might include research funders and programs; intermediary organizations; city, state, and regional governmental organizations (including the National Association of State Alcohol and Drug Abuse Directors and the National Association of State Mental Health Providers); and federal agencies.
The group that considered fostering integrated, interprofessional care focused on advocacy for training models as well as incorporating these models in preprofessional education. Harolyn Belcher, a member of the workshop planning committee, reported on the main ideas from this group: (1) multiple sectors and populations could be engaged in advocating for and participating in integrated interprofessional health care training experiences, including discipline-specific training funders, developers and implementers, parents and patients, community providers, insurance companies, and faith-based communities; (2) integrated, interprofessional health care education and training opportunities could be included in preprofessional education and in clinical training experiences; (3) integrated, interprofessional care could be developed in settings defined both physically and culturally; and (4) stakeholders might include the American Psychological Association, the members of the Integrated Primary Care Alliance, the Centers for Medicare & Medicaid Services, education and accreditation organizations, and insurance companies.
For the group that focused on training the future child health care workforce to meet the needs of children with disabilities and complex health conditions, Mary Ann McCabe reported the main ideas that emerged from the discussion: (1) alternative payment models could be created that are consistent with transdisciplinary and interprofessional training and practice; (2) available models and metrics could be mobilized on the cost effectiveness and health outcomes of preventive models of care for children with disabilities and chronic medical conditions; (3) quality training experiences could be developed and disseminated across the career span that broaden exposure to lived experiences with diverse family situations and cross-sectoral partnerships; and (4) stakeholders might include families, providers, education and system administrators, payers, and policy makers.
The group that considered engaging patients and parents in copromotion of behavioral health to improve care centered its discussion on parent and family engagement in all aspects of training, as well as identifying measurable outcomes of their involvement. Kristina West, Office of the Assistant Secretary for Planning and Evaluation, reported on the main ideas from this discussion: (1) families could be engaged in all aspects of
training programs, such as advisory boards, training simulation models, and the development of clinical care satisfaction surveys; (2) gaps and best practices could be identified for parent and patient involvement, including payment incentives; (3) outcomes of parent and patient involvement could be measured, including culture change in organizations and systems; and (4) stakeholders might include parents and patients, practitioners and administrators, whole systems, professional associations, and federal agencies.
Two ideas that emerged from the group that considered enhancing training through the power of accreditation, certification, and credentialing were reported by Costella Green, Substance Abuse and Mental Health Services Administration: (1) accreditation models and financing could be prioritized by the Forum on Promoting Children’s Cognitive, Affective, and Behavioral Health, thereby helping to change medical education from the beginning to develop an effectively trained workforce; and (2) stakeholders might include policy makers, funders, accrediting officials, consumers and families, students in the health professions, faculty, and schools.
The group that considered enhancing training for health care professionals to improve the behavioral health of children, youth, and families involved in other child-serving settings focused on systems transformation and team development. José Szapocznik reported on the main ideas from this group: (1) systems could be transformed to create a culture of shared benefits through such tools as three-dimensional matrixes of competencies (reflecting disciplines, settings, and systems); (2) as part of this transformation, trainees could be taught to become facile with system transformation and to work in teams; (3) practice coaching could be provided to support the development of teams and system transformation; and (4) stakeholders might include payers, policy makers, competency-developing organizations, education and health care organizations, and the National Academies of Sciences, Engineering, and Medicine (as not only a competency-developing, but also a convening organization).
The main ideas that emerged from the group that considered how current reimbursement for training and clinical care affects the focus on behavioral health for children, youth, and families were reported by Mary Jane Rotheram-Borus, University of California, Los Angeles. The ideas included
the following: (1) positive models of value-based care could be evaluated and identified that optimize a broad range of outcomes and ensure quality improvement; (2) incentives could be created for training programs, systems, and accrediting agencies to shift their programs to enhance the delivery of optimal and cost-effective care; and (3) stakeholders might include payers and businesses (including such groups as the Pacific Business Group on Health, the National Coalition on Heath Care, the United States Chamber of Commerce, and America’s Health Insurance Plans), teams from academic institutions that conduct training, foundations and institutes that fund innovative care models, and organizations like the National Alliance on Mental Illness.
At the end of both days of the workshop, workshop organizers and several presenters offered their reflections on some points made at the workshop.
Comments from the Planning Committee Cochairs
Laurel K. Leslie provided additional comments on a number of levers for change to improve workforce training, including:
- Research and evaluation: Research methodologies other than randomized clinical trials could be used to move forward when looking at outcomes, including quality improvement implementation science.
- Continuing the dialogue: The National Academies of Sciences, Engineering, and Medicine could use its power of convening to bridge stakeholders across sectors and disciplines to continue this conversation.
- Shared competencies: Shared and collaborative competencies across disciplines could be developed for the child health care workforce.
- Information sharing: An interdisciplinary clearinghouse could be developed so disciplines can share curricula, research, and data that can be adapted and implemented for use in other settings.
Referring to the goal of the workshop to examine the training of the health care workforce to promote better cognitive, affective, and behavioral health for the next generation, Thomas Boat, the other cochair of the workshop planning committee, said, “If we don’t do this better, we’re going to be stuck with even greater problems in the future. It’s imperative that we figure out how to do it.”
Interdisciplinary work will be critically important, he said. He described a model from Cincinnati Children’s Hospital Medical Center developed by pediatric psychologist Rachel Herbst. She and her colleagues instituted a universal child and family behavioral and parenting component into well-child visits for 0- to 5-year-olds. It has succeeded, said Boat, because it is geared to a particular setting and the people involved. The program also provides an opportunity to train residents and other health care providers. “They can observe, but then they also can become the behaviorist. That kind of experience is going to be very important in creating a workforce that [can] deal with the cognitive, affective, and the behavioral dimensions of health,” Boat said.
The outcomes of such programs need to be documented, he continued. In Cincinnati, this is done in part through electronic health records—for example, by tracking such measures as the use of the health care system and social-emotional development of the child. This is one way of capturing outcomes in a way that is affordable and does not require additional personnel.
Boat also emphasized the importance of getting input from all quarters. Not everyone can be a leader, he commented, but everyone can participate “in such a way that it makes a difference and changes the outcome.” Today, medical students, residents, and fellows do not learn how to work with families on behavioral health as well as they need to. “But there is a great opportunity for contributions by other disciplines, whether it’s social workers or nurses who have experience in primary mental health or psychologists. . . . How do we configure our approaches to health care and to training in health care in such a way that everybody is included and we don’t miss out on important inputs?” he said.
Boat particularly emphasized the roles of parents and families. Whether care is family focused or family driven, he said, parents are the caregivers for their children and are at the center of being able to provide input. But parents also need training, he said. “How do we prepare parents to be nurturing parents, parents who can take care of the behavioral as well as the physical health care needs of their children?” In addition, parents cannot fill this role if their own health and well-being is impaired. “If we don’t pay attention to the wellness of the family and the parents,” he said, “we’re not going to get done what we need to do.”
Finally, pediatricians experience high rates of burnout, Boat noted. They need to take care of themselves and each other. “That’s an important component that we have to build into training, and we have to figure out how to do that, because we don’t do that very well right now,” he said.
Boat closed by citing the need for both patience and persistence. The people who get to the finish line are the winners, he said, even if the race is long.
Closing Words from Parents
The workshop closed with the observations of parents and advocates who have been caring for children with behavioral health issues.
Rebecca Mueller reiterated that parents and caregivers are essential members of a team, but parents “don’t get an instruction manual when we become parents. I would encourage your efforts to include parents and to make training easily available online or in communities so that we can educate ourselves for the benefit of our children.”
Johanna Bergan pointed to the need to encourage and listen to the voices of young people. “The young person who’s sitting in the chair across from you is our future, and they need to be the driver of the rest of their lives. That doesn’t start when they turn 18 or 21 or 26,” she said. Peers can act as a conduit for those voices, adding, “Think about the role peers can play in our frontline workforce and how much empathy they can offer to individuals we’re caring for, and what burden they can reduce from the rest of us. There are so many people hungry to be in this work with us.”
Finally, Breck Gamel thanked the workshop presenters and participants for their efforts. She told a story about a drawing her son made during psychoeducational testing. He drew a spaceship, with himself at the front window looking out for danger. “I was thinking about what would I tell him about my conference. I would tell him that there are so many other people who are on the spaceship looking out for danger,” she said.
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