Altshuler’s Center For Education & Research (CER):

Bridging the Workforce Gap in the Public Sector

Elisa Rees, MA LPCDirector, CER

Dr. John BurrussCEO, Metrocare

Dr. Philip BalfanzPast Fellow , CER

CER at Metrocare

Metrocare Mission Statement

“To serve our neighbors with

developmental or mental health

challenges by helping them find

lives that are meaningful and

satisfying.”

Dallas County’s Growth

• 2006: Metrocare served 25,000

• 2013: Metrocare served 50,000

NorthSTAR/Dallas Statistics

Approximately 132,000 individuals below

federal poverty line and experience

severe to moderate health issues

Around 75,000 individuals receive

services

Leaving 57,000 individuals not receiving

services

Assessment of the Community Behavioral Health Delivery System in Dallas County:

Detailed Report

Texas Statistics

20% population growth from 2000 to 2010.1

In 2006, “the mental health workforce supply

has decreased in almost every geographic

area of Texas and for almost every mental

health profession.” 2

In 2010, 98% of Texas psychiatrists who are

enrolled as Medicaid providers will not see

new Medicaid patients. 3

1Regional Healthcare Partnership 9 Community Needs Assessment

2 TX Department of State Health Services Center for Health Statistics

3 Texas Health and Human Services Commission

US Projections in Healthcare

1/2 of the occupations that are expected

to grow are healthcare related.

Employment in the healthcare industry is

projected to add the most jobs in the US,

increasing 10.8%, or 15.6 million in the

next decade.

US Bureau of Labor Statistics

“Healthcare” Identified

• Psychiatrists

• Medical Doctors

• Licensed Psychologists (PsyD)

• Nurses (APN/RN)

• Licensed Counselors & Social Workers (LPC/LMSW)

• Dieticians

• Occupational Therapists (OT)

• Physical Therapists (PT)

• Board Certified Behavior Analysts (BCBA)

• Medical Assistants

• Pharmacy Techs

What Can We Do?

Altshuler Center for Education & Research

• Purpose: To close the workforce gap which

is steadily increasing, leaving providers

unable to maintain stable, adequately-trained

staffing to provide quality services for the

public sector.

• Mission: To create & nurture an environment

in which physicians and other professional

clinicians are encouraged to embrace the

pursuit of quality & research geared toward

public sector patients with behavioral &

developmental challenges.

Altshulter Center History

• Established in 2010

• Began as joint project between Metrocare & UTSW

• Primary focus on Medical School: Residencies & Fellowships

Psychiatry 101

Medical School = 4 Years

General Psychiatry Residency = 4 Years

Fellowship = 1-2 Years

CER: Year One

Fellows PsychiatricResidents

Behavioral HealthInterns

Nursing Trainees

0

2

4

6

8

10

12

14

16

182010-2011

Rotations

• Training programs are divided into rotations

for specific experiences.

• A period of time spent in a specific area of

interest in order to gain perspective on an

organization.

• To provide real world experiences to apply

knowledge, abilities & interests

Public Sector Workforce Growth

Public Psychiatry Fellowship of

Columbia University has a very “well-

established track record for

developing psychiatrists who continue

to work in the public sector” by

allowing opportunities for new ideas

and specific areas of focus.

American Association of Community Psychiatrists

17 Unique Experiences Offered

• Outpatient Clinics Adults/C&A diagnosed

with IDD/ MH

• Homeless at Stewpot

• Assertive Community Treatment (ACT)

• Dual Diagnosis Residential Treatment

Center (DDRTC)

• Early Childhood Intervention (ECI)

• Birth – Six Treatment Services

Unique Experiences Offered (Cont)

Eligibility Determination Unit (EDU)

Center for Children with Autism at

Metrocare (CCAM)

Behavioral Treatment Center (BTC)

Behavioral Treatment Services (BTS)

Career Design & Development Services

(CDDS)

Unique Experiences Offered (Cont)

Special Needs Offender

Program (SNOP)

Family Preservation Program

(FPP)

Program for Juvenile

Offenders

Fostering

Pharmacy

Medical Clinic

Medical Rotations

PGY1 – 1 month rotations at our Homeless

Services

PGY2 – 1 month rotations at Adult MH

Outpatient Clinic for ACT & SNOP

PGY3 – 3 month rotations at C/A Outpatient

Clinics

PGY4 or Fellow –12 month rotations at C/A

Outpatient Clinics & Juvenile Offenders

Program

Medical Rotations (Cont)

Medical Student Rotation – 4 week

exposure at various Clinics

Pediatric Resident Rotation – 1 day

focused IDD exposure at C/A

Outpatient Clinic

Psychiatry Interest Group/Volunteers

(Residents or Medical Students) –

>1 week at DDRTC

Behavioral Health Rotations

Psychologist Interns – 6 months to 1 year at

EDU or Outpatient Clinics

Counseling/Social Work Interns – 6 months

to 1 year at Outpatient Clinics, DDRTC,

CDDS, or B-6

Board Certified Behavior Analyst (BCBA)

Interns – BTC or CCAM

Early Intervention Specialist (EIS) Interns -

ECI

Other Healthcare Rotations

Nursing Interns (APN, NP, RN)- various clinics

Pharmacy Technicians Trainees- various

clinics

Medical Assistants Trainees- various clinics

Occupational Therapists (OT) Interns- ECI

Physical Therapists (PT) Interns- ECI (coming

in Fall 2014)

Dieticians Interns- ECI (coming in Fall 2014)

CER Growth

0

20

40

60

80

100

120

Fellows PsychiatricResidents

MedStudents

BehavioralHealthInterns

NursingTrainees

PharmacyTechs

OT Volunteers

2013-2014

2012-2013

2011-2012

2010-2011

CER Growth

0

20

40

60

80

100

120

140

160

2010-2011 2011-2012 2012-2013 2013-2014

Number of Trainees

Trainee Survey Outcomes

Likelihood to Work in Public Sector After Training at CER

Very Likely

Likely

Neutral

Unlikely

Very Unlikely

1st Steps to Building Center

Create a CONTACT PERSON for center

Identify licensed SUPERVISORS within your

agency who have a passion to work with

trainees

RESEARCH local training facilities

(GOOGLE)

Build RAPPORT with local department

chairs to MARKET your center

Next Steps to Building Center

Contact through email, phone & in person

Polite persistence

RAPPORT, RAPPORT, RAPPORT

Current Training Facility Rapports

• University of Texas

Southwestern Medical

School (UTSW)

• Children's Medical Center

• Southern Methodist

University (SMU)

• University of North Texas

at Denton (UNTD)

• University of North Texas

at Arlington (UNTA)

• Texas Women’s University

(TWU)

• University of Texas at

Arlington (UTA)

• Dallas Baptist University

(DBU)

• Texas Tech University

• Texas A&M

• Bellevue University

Current Training Facility Rapports

• Midwestern State

University

• El Centro Dallas County

Community College

• Liberty

• Stony Brook

• University of South

California

• CCI

• Argosy

• Pratt

• Everest

• Kaplan

• Abilene College

• Capella University

• Tarleton

Challenges

• Time Management: Obtaining

professional and passionate

supervision from staff

• Onboarding: Developing

orientation for interns

• Consistent Structure to

rotations

• Beneficial to All: Building

learning & productive

rotations

Rotations Beneficial to All Parties

• SUPPORT agency’s needs

• SUPPORT trainee’s needs &

interests

• SUPPORT supervisor’s needs &

interests

• SUPPORT positive learning

environment for trainee

Adding ‘Unique’ Experiences

• CER Lectures

• New Onset Program (NOP)

• Research Component

CER Lectures

• Goal: Embrace trainee’s passion by

teaching through didactic learning

• Expose trainees to various mental

health departments, professionals and

current topics

• Support positive experience!!

2013-2014 Lecture Topics

• High Utilizers: Data-Mining for

System Analysis & Quality

Improvement

• DADS and DARS Services

• Emergency Psychiatry in the

Community Setting

• Transcultural Psychiatry

• Substance Abuse: Integrated

Care in the Public Sector

• Community-based Treatment of

IDD and Autism Spectrum

Disorders

• Forensic Populations

• Putting it all together – Case

Studies

• Public Psychiatry Funding in

Dallas and Texas

• The “System” – TriWest Zia

Report

• Advocacy and Peers: Mental

Health America

• Fundraising and Development

• The Role of the Medical Director

• The Role of the Board in Public

Psychiatry

• Children’s Services

• High Utilizers: Data-Mining for

System Analysis & Quality

Improvement

New Onset Program (NOP)

• Criteria

Over the age of 16

1st onset of psychosis

No Axis II or severe Substance Abuse Diagnosis

• Services Offered

Computer Based: Brain Fitness -Computer

Based

Group: Social Cognition & Interaction Training

(SCIT)

Group: NOP Case Management

Medical Management

1:1 Individual/Skills

Family Group

Research Component

• Metrocare Institutional

Review Board (IRB)

• Five Research Studies in

Progress, Two Pending

• Collaborating with three

Universities: UTSW, SMU &

A&M

Current Research

• UTSW

Lurasidone effects on tissue glutamate in

schizophrenia

Antidepressant treatment at an inner city

asthma clinic

Mechanisms and brain circuits underlying

fragile x syndrome deficits in cognition, motor

abilities and sensory processing

Resource Utilization Prior to and Subsequent to

Diagnosis of Psychogenic Nonepileptic

Seizures in a Level-4 Epilepsy Monitoring Unit

from 1997 to 2012

Current Research (Cont)

• SMU

Social cognitive psychometric

evaluation.

Pathways through Care: Decision-

Making and Treatment Drop-Out in Early

Psychosis.

• A&M

The effectiveness of individual

education portfolios in communicating

and monitoring the education needs of

students living in foster care.

Connecting with our Community

• Booths at School Fairs

• Booths at Conferences

• Case Conferences

• 2014 Spring Conference

Nurture A Learning Environment.

So How Much Does This Cost?

Reality of Academic Healthcare Finance:

Teaching and Research always costs more than they can bring in.

So How Much Does This Cost?

• Space and Infrastructure

• Program Staff

• Time from Supervisors

• Trainee Salary & Benefits

• Research Staff

• Misc

So How Much Does This Cost?

• Program Director

– Minimum of 50% time

– Could also supervise

• Medical Director

• Most Trainees are not paid

– Residents $75,000 – 90,000

– Psychology $18,000 – 25,000

How do I pay for it?

• Revenue Sourceso Clinical Income

o Philanthropy – Foundation & Individual

o Grants

• DSHS

• SAMHSA

• Research

Phillip Balfanz, M.D.

What are you going to do with your life after 9 years in training after an undergraduate degree and over $200,000 in debt?

What is the real world like?

Experiences

Mentors

Practice Philosophy

Director ’11-’12: Osman Ali, M.D. Columbia University Influenced Model

Guidelines for Developing and Evaluating Public and Community Psychiatry Training Fellowships: http://www.communitypsychiatry.org/publications/clinical_and_administrative_tools_guidelines/fellowship.aspx

Fellowship Model:

2010-2011: Post Residency, Junior Faculty

2011-2012: Child Fellow with Community Focus

Categorized as UT Southwestern Child and Adolescent Psychiatry Fellow

2nd year of Child Fellowship Metrocare Clinical Projects Administrative Experience Didactics and Projects

UT Southwestern Child Fellowship Therapy Family Therapy Didactics Administrative: Chief Fellow Duties

Children’s of Dallas Call/Consults

Monday Tuesday Wednesday Thursday Friday

AM Clinical Sites

Therapy SupervisionUTSW DidacticsNeurology

Clinical Sites

Clinical Sites Therapy,Project,Research

PM Clinical Sites

UTSW DidacticsTherapy

Garland School Clinic

CER Didactics BPS Services

Evening Therapy Supervision Salesmanship Club: Family Therapy

Child and Adolescent Intensive Services: Patients

▪ Birth to Six: Children Age 3-6yo▪ Foster▪ TCOOMMI▪ Promise House – Children Shelter▪ Garland School Clinic – Housed in Cooperative Behavior Center▪ BPS (Behavioral and Psychiatric Services)

Administrative▪ Birth to Six – also clinical improvement project/supervision▪ Foster▪ TCOOMMI▪ BPS

History of Modern Public Psychiatry Funding of Public Human Services Administration and Fiscal Mangement Regulation and Accreditation Comprehensive Elements of Systems Design Transformation in the Structure of Public

Behavioral Health Public Mental Health Advocacy Community Based Research and Scholarship

AACP practice Guidelines

Congruence Model

P H I L L I P B A L F A N Z , M . D .

S E P T E M B E R 8 , 2 0 1 1

Congruence Model of Child and Adolescent Fellowship Program

at UT Southwestern

Inputs

EnvironmentResources

History Strategy

Informal Organization

Tasks

Individuals

Formal Organizational Arrangements

OrganizationGroup

Individual

Inputs

Transformation Process

Outputs

Project

Atypical Antipsychotic Use in Young

Children:

A Proposed Paradigm for Monitoring

Metabolic Effects

Phillip Balfanz, M.D.

May 25, 2012

BACKGROUND:

Stimulus for Project

• Metabolic syndrome related to atypical antipsychotics is a well known problem in adult patients.

• These medications are used in the child population but there is relatively sparse information regarding their effects.

• There is increasing use of atypical antipsychotics in younger populations to treat aggression.

BACKGROUND:

SGA Prescribing Practices

– In the US there was a 6 fold increase in antipsychotic prescriptions for patients ≤ 20 years of age between 1993 and 20021

– In the UK there was a doubling in antipsychotic prescriptions between 1992 and 20051

– From 2004 to 2008 for US patients 0-17 prescriptions increased 22%2 (3.9 million 4.8 million)• Age 3-6 had a 3% increase

• Risperidone had 11.3% increase

• 2% of Risperidone prescriptions for those 0-17 are dispensed to children aged 3-6

– Significant off label use 1 Almandil, Wong2 Governale, Mehta

Goals

• Create a method to aid the child and adolescent provider in assessing metabolic risk and to facilitate decision making regarding both mental and physical health. Specifically for age 3-6 years.

• Improve documentation of metabolic evaluations

Intervention

1. Presentation to providers (done December 2011/January 2012). Provided prescribers with information. Asked prescribers to enter data at time of visit.

2. Use of medical assistant student to aid in collection of data with instructions as to purpose and goals of collection

3. Informal discussions in staffing with behavioral specialists who do in-home/in-school behavioral treatment

4. Use of tool developed at Bellevue for monitoring metabolic parameters in adults with adjustments for child parameters

Tool to aid in decision making

Mission: "Promoting Independence, Community Integration, and Recovery."

Understanding Role, History, and Speculating on the Future

Recovery Orientation Team Approach Opportunity for Leadership Unique Treatment Modalities: Community

Exposure to the clinical setting is vital, but insufficient

Positive Experiences, Seeing People Improve Understanding how to Argue for Change

Models

Multidisciplinary Networks Need for a Positive Organizing Theme

For me that was Recovery