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The Critical Role of Training in Behavioral Health Workforce
Development in Illinois
Janet Liechty, PhD, LCSWMember, IL Behavioral Health Workforce Task Force 2019 Associate Professor | School of Social Work | UIC College of Medicine Carle-IL College of Medicine |Division of Nutritional SciencesPrincipal Investigator/Project Director, BHWELL
Illinois • Illinois - 6th most
populous state in the US • Chicago holds ~75% of
state population• Yet 1.5 million people live
in rural & non-metro counties in IL
• Most counties in IL are classified as non-metropolitan (60%)
(Census Bureau, 2018)
Mental Health Provider Shortage Areas
Counties in blue are Health Professional Shortage Areas (HPSAs) for Mental Health.
Blue dots are MH facilities with shortages.
(HRSA, 2016)
HRSA, 2016; https://datawarehouse.hrsa.gov/Tools/MapToolQuick.aspx
Source: https://healthpolicy.usc.edu/wp-content/uploads/2018/07/IL-Facts-and-Figures.pdf
Rural Barriers to BH Care
• Accessibility – affordability, transportation, long distances, lack
of insurance • Availability
– BH workforce shortages, service fragmentation • Acceptability
– stigma, lack of awareness of BH symptoms or of treatment options
(SAMHSA, 2013)
Rural – Urban Contrasts/Similarities
• Urban counties -- higher wages, employment, education than rural.• Rural areas -- less access to health/mental health care, public
transportation, broadband Internet, & lower K-12 funding. • Rural diversity -- disability, race, LGBQ+ identities, immigration,
language, political and religious differences. • Rural stressors – like urban areas, family conflicts, parenting, job
stress and layoffs, SUD, sexual and gender discrimination, IPV, income inequality, poverty; depopulation & erosion of rural economies.
• Rural residents can be fiercely independent, resourceful, private, and skeptical or unaware of MH symptoms or services.
IL Institute for Rural Affairs http://www.rwhc.com/mediasite/6-App-Chris%20Merrett_Plenary%20am.pdf
What can we do?
Training Strategies 1. Train to expand BH workforce via targeted degree programs
– counselors, clinical social workers, psychologists, psychiatrists, and psych NPs – HRSA BHWET grants, SUD grants
2. Train students for specific areas of practice and EBPs needed – Curricula – SAMHSA grants, SBIRT– HRSA grants for integrated care, interprofessional, trauma-informed care
3. Train professionals to strengthen existing BH workforce – CEU, CME training in best practices, EBPs, new care delivery models
4. (proposed) Statewide coordination and support of all of the above– Build capacity within and across sectors– Train students and professionals together for seamless capacity building – Train to add support staff such as peer recovery specialists into workflow, teams – Consider state-wide coordination to training and implementing new delivery models
Training Strategies 1. Train to expand BH workforce via targeted degree programs
– counselors, clinical social workers, psychologists, psychiatrists, and psych NPs – Leverage federal dollars when available, e.g., HRSA BHWET grants, SUD grants
2. Train students for specific areas of practice and EBP models – Curricula – SAMHSA grants, SBIRT– HRSA grants for integrated care, interprofessional, trauma-informed care
3. Train professionals to strengthen existing BH workforce – CEU, CME training in best practices, EBPs, new care delivery models
4. Statewide coordination and support of all of the above– Build capacity within and across sectors– Train students and professionals together for seamless capacity building – Train to add support staff such as peer recovery specialists into workflow, teams – Consider state-wide coordination to training and implementing new delivery models
HRSA Example HRSA Behavioral Health Workforce Education & Training Grant (BHWET 2017-2022):
– Five BHWET awards to Illinois Universities – Granted to Social Work, Psychology, Counseling, Psychiatric NP, Psychiatry
(also para professional track for community colleges)– Internships in rural or underserved areas (HPSA) – Longitudinal field placements (6+ months) – Interprofessional Education (IPE) before & during field placement– Integrated Behavioral Health & Primary Care training sites – Evaluation, data tracking & RCQI
Illinois Behavioral Health Workforce Education Learning & Leadership (BHWELL)
HRSA Grant M01HP31357-01-00, 2017-2021
To date: • 59 BHWELL Scholars (expect 116 over 4 yrs)• 60 BHWELL-approved agencies in 30 counties (*)
• FQHCs, RHC, CAH, CMHC, IDOC, VA, PH… • MSW program includes 2 new courses in IC • Interprofessional Ed (IPE) on campus, during field • IC seminar during 2-sem FT field placement• IC certificate earned at graduation • $10,000 stipend to each student
BHWELL Training Site Eligibility• Required:
– Approved MSW field placement – Rural or Underserved (HPSA shortage area) – Organizational support for Integrated Behavioral Health (IBH) &
Primary Care – Interprofessional team-based care
• Preferred:– Level 3 or above on IBH+PC integration– Interprofessional training readiness– Part of a healthcare system – Long-term partnership
Partners:
Training Strategies 1. Train to expand BH workforce via targeted degree programs
– counselors, clinical social workers, psychologists, psychiatrists, and psych NPs – HRSA BHWET grants, SUD grants’
2. Train students to meet current needs and shortages in IL – HRSA grants train specifically for rural/underserved, IC, IPE, SUD/SBIRT – Incentivize IL BH degree programs to enhance curricula to prepare students to meet IL needs
3. Train professionals to strengthen existing BH workforce – CEU, CME training in best practices, EBPs, new care delivery models
4. Statewide coordination and support of all of the above– Build capacity within and across sectors– Train students and professionals together for seamless capacity building – Train to add support staff such as peer recovery specialists into workflow, teams – Consider state-wide coordination to training and implementing new delivery models
HRSA Example: Integrated Care (IC)
• IC is… “The care patients experience as a result of a team of PC & BH clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population.” (www.integration.samhsa.gov)
• Primary care and Behavioral health services are integrated ; usually co-located but not necessarily
Levels of Collaboration/Integration
Source: www.integration.samhsa.gov
Levels 1 & 2 Levels 3 & 4 Levels 5 & 6
Integrated Behavioral Health in Primary Care
https://www.integration.samhsa.gov
• 75% psychotropic meds prescribed by PCPs, often without benefit of BH provider/team
• Common BH concerns in PC– Adults: depression, anxiety, SUD, stress, PTSD– Children: anxiety, ADHD, behavior problems– Common comorbidities: dep+DM, anxiety+asthma,
sleep+pain, etc. – PC issues won’t resolve if comorbid BH issues ignored
• IC Solution: Integration of BH & PC
Does it work? EBP• Collaborative Care Model (adapted from Wagner’s chronic illness care model)
– Strongest evidence to date– More than 38 RCTS over past 25 years – Population health approach
• Key Components– Care management (patient education, monitoring, coordination)– BH screening, solution-focused and brief treatment, , psychoeducation, groups– Evaluate and change course until patient outcome targets are met– Data-driven: track diagnoses, BH comorbidities, outcomes, to improve pop health– Stepped care, use providers to the top of their license – Use technology to improve access and outcomes
• Outcomes improve, QOL improves, waiting lists for psych consults diminish, follow-up on referrals increases from 15% to 40-60%. Plus, patients prefer it.
Ell et al, Diabetes Care. 2010; 33(4): 706-713. Mastellos et al, Int J Integr Care. 2014; 14:e015. www.improvingchroniccare.org
SBIRT• Screening, brief intervention, and referral to
treatment (SBIRT)– Used in widely in medical and BH settings– Can be applied to SUD, dep, anxiety, etc.– Assess BH issue & level of risk to step response:
• Low risk: raise awareness, increase motivation • Mod risk: provide brief tx (CBT, meds) if pt seeking help• High risk: Refer pt to specialty care as needed
http://sbirt.samhsa.gov/
IC is Trending: Federal Agencies Promoting IC
• HRSA: Health Resources & Services Administration• SAMHSA: Substance Abuse & Mental Health Services
Administration• AHRQ: Agency on Healthcare Research and Quality • CMS: Centers for Medicare and Medicaid Services• VA: US Department of Veterans Affairs• IHS: Indian Health Service • NIH/NIMH, NIDA, NIAAA: National Institutes of Health
www.integration.samhsa.gov/
Training Strategies 1. Train to expand BH workforce via targeted degree programs
– counselors, clinical social workers, psychologists, psychiatrists, and psych NPs – HRSA BHWET grants, SUD grants’
2. Train students for specific areas of practice and EBP models – Curricula – SAMHSA grants, SBIRT– HRSA grants for integrated care, interprofessional, trauma-informed care
3. On-going professional training to strengthen existing BH workforce – CEU, CME training in best practices, EBPs, new care delivery models– Often individually driven, fragmented training, doesn’t improve delivery systems– Barriers (especially in rural): Access, affordability, acceptability of change
4. Statewide coordination and support of all of the above– Build capacity within and across sectors– Train students and professionals together for seamless capacity building – Train to add support staff such as peer recovery specialists into workflow, teams – Consider state-wide coordination to training and implementing new delivery models
Can we forge a new path forward?
IL BH Workforce Dev & Training Center?1. Train to expand BH workforce via targeted degree programs
– counselors, clinical social workers, psychologists, psychiatrists, and psych NPs – HRSA BHWET grants, SUD grants’
2. Train students for specific areas of practice and EBP models – Curricula – SAMHSA grants, SBIRT– HRSA grants for integrated care, interprofessional, trauma-informed care
3. Train professionals to strengthen existing BH workforce – CEU, CME training in best practices, EBPs, new care delivery models
4. Statewide coordination and/or support of all of the above?– Statewide center for BH workforce development with regional training hubs– Build capacity within and across BH, health, human services, and higher ed sectors– Train students and professionals together for seamless capacity building – Learn how to incorporate MH staff such as peer recovery specialists into workflow– Coalition building, collaboration toward common BH goals – State-wide coordination to train and implement EBP modalities & new delivery models, e.g.,
• BHECN model https://www.unmc.edu/bhecn/• MA Child Psychiatry Access Project https://www.mcpap.com/
Discussion Questions• What are pros and cons of statewide coordination of BH workforce training through a
Center? • How could technology be used to promote training goals? • How could individuals affected (clients, patients, providers) have input? • In what ways could a BH Workforce Center help attract, train, and retain a skilled BH
workforce ready to work where needed, in EBP modalities most needed? • How can Illinois help incentivize and support recruiting talented young adults from
underserved communities into BH careers and who will want to return to work in these high need communities?
• What criteria should determine where a Center is located? …where regional training hubs are located? What are pros/cons of centralized v. distributed center functions?
• Beyond tax dollars, what stakeholders may be interested in supporting a center? • What structural or “design” elements for a Center or regional training hubs might
help foster cooperation and trust between and across institutions of higher education, community entities, and healthcare systems, toward common BH infrastructure and workforce goals for our state?
Website: http://socialwork.illinois.edu/bhwell/
Join our mailing list www.socialwork.Illinois.edu/BHWELL
Grant #M01HP31357
Extra slides
• Annapolis Coalition. (2007). An action plan for behavioral health workforce development: A framework for discussion. Prepared for SAMHSA. Retrieved from http://annapoliscoalition.org/wp-content/uploads/2013/11/action-plan-full-report.pdf
• Bradley, E. H., Curry, L. A., & Devers, K. J. (2007). Qualitative data analysis for health services research: developing taxonomy, themes, and theory. Health services research, 42(4), 1758-1772. • Cameron, A., Lart, R., Bostock, L., & Coomber, C. (2014). Factors that promote and hinder joint and integrated working between health and social care services: A review of research literature.
Health & social care in the community, 22(3), 225-233. • Carpenter-Song, E., & Snell-Rood, C. (2016). The changing context of rural America: A call to examine the impact of social change on mental health and mental health care. Psychiatric Services,
68, 503-506 (e-pub ahead of print). https://doi.org/10.1176/appi.ps.201600024 • Centers for Disease Control and Prevention [CDC], (2017a). Trends in suicide by level of urbanization: United States, 1999–2015, Morbidity and Mortality Weekly Report [MMWR], 66(10), 270-
273. • Centers for Disease Control and Prevention [CDC]. (2017b). Differences in health care, family, and community factors associated with mental, behavioral, and developmental disorders among
children aged 2–8 years in rural and urban areas- United States, 2011–2012. MMWR, 66(8):1-11. • Glasser, M., Hunsaker, M., Sweet, M. K., MacDowell, M., & Meurer, M. M. (2008). A comprehensive medical education program response to rural primary care needs. Academic Medicine, 83(10),
952. • Health Resources and Services Administration [HRSA]. (2016). Mental health professional shortage areas: Interactive data maps for Illinois. Retrieved from
https://datawarehouse.hrsa.gov/Tools/MapToolQuick.aspx?mapName=HPSAMH • Horevitz, E., & Manoleas, P. (2013). Professional competencies and training needs of professional social workers in integrated behavioral health in primary care. Social Work in Health Care, 52,
752–787 • Interprofessional Education Collaborative. (2016). Core competencies for interprofessional collaborative practice: 2016 update. Washington, DC: Interprofessional Education Collaborative.
Available at https://nebula.wsimg.com/2f68a39520b03336b41038c370497473?AccessKeyId=DC06780E69ED19E2B3A5&disposition=0&alloworigin=1 • King, G., Orchard, C., Khalili, H., & Avery, L. (2016). Refinement of the Interprofessional Socialization and Valuing Scale (ISVS-21) and development of 9-item equivalent versions. JCEHP,
36(3):171-177. • Kirkpatrick, D., & Kirkpatrick, J. (2005). Transferring learning to behavior: Using the four levels to improve performance. San Francisco, CA: Berrett-Koehler. • MacDowell, M., Glasser, M., & Hunsaker, M. (2013). A decade of rural physician workforce outcomes for the Rockford Rural Medical Education (RMED) Program, University of Illinois. Academic
Medicine, 88(12), 1941-1947. • Mann, C. C., Golden, J. H., Cronk, N. J., Gale, J. K., Hogan, T., & Washington, K. T. (2016). Social workers as behavioral health consultants in the primary care clinic. Health & Social Work, 27. • Mechanic, D. (2014). More people than ever before are receiving behavioral health care in the United States, but gaps and challenges remain. Health Affairs, 33, 1416–1424.
http://dx.doi.org/10.1377/hlthaff.2014.0504 • O'Neil, H. F., Wainess, R., & Baker, E. L. (2005). Classification of learning outcomes: Evidence from the computer games literature. The Curriculum Journal, 16(4), 455-474. • Praslova, L. (2010). Adaptation of Kirkpatrick’s four level model of training criteria to assessment of learning outcomes and program evaluation in higher education. Educational Assessment,
Evaluation and Accountability, 22(3), 215-225. • Rishel, C. W., & Hartnett, H. P. (2015). Preparing MSW students to provide mental and behavioral health services to military personnel, veterans, and their families in rural settings. Journal of
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References
Source: https://healthpolicy.usc.edu/wp-content/uploads/2018/07/IL-Facts-and-Figures.pdf
Rural Behavioral Health Needs• Like U.S. overall, 1 in 5 people in rural and non-metro areas
experience MH problems (SAMSHA, 2015)
– Rural communities - higher rates of depression & suicide than non-rural area: 17.6 vs. 10.3 suicide deaths per 100,000 in rural vs. urban counties (CDC, 2017a)
– High rates of untreated SUDs– High level of unmet BH needs among rural children and
adolescents (CDC, 2017b)
• 41% with unmet BH needs in US report they couldn’t afford care(National Survey on Drug Use and Health, 2016)
Heath B, Wise Romero P, and Reynolds K. A Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, D.C.SAMHSA-HRSA Center for Integrated Health Solutions. March 2013
Six Levels of Collaboration/Integration
What is the BH Consultant (BHC)?
• Licensed BH provider/trainee (e.g., LCSW, Psychologist, LCPC)• Screens and responds to psychological problems, e.g., dep &
anxiety; and social problems, e.g., SUD, food insecurity, IPV• SBIRT (screening, brief intervention, referral to treatment)• Motivational Interviewing• Recognizes psychosocial aspects of acute and chronic physical
illnesses and conditions• Assesses and addresses barriers to health: stress, non-adherence,
health beliefs and behaviors, relationships, social support • Team oriented
SAMHSA/HRSA Tools for IC• Framework for Levels of IC
https://www.integration.samhsa.gov/resource/standard-framework-for-levels-of-integrated-healthcare
• Assessment tools https://www.integration.samhsa.gov/operations-administration/assessment-tools
• Four Quadrant model https://www.integration.samhsa.gov/resource/four-quadrant-model
• Lexicon for BH and PC integration (AHRQ, 2013) https://www.integration.samhsa.gov/integrated-care-models/Lexicon.pdf
• Quick Start Guide to IC https://www.integration.samhsa.gov/resource/quick-start-guide-to-behavioral-health-integration
• Core competencies for IBH and PC https://www.integration.samhsa.gov/workforce/Integration_Competencies_Final.pdf
• Billing and financial worksheets and webinars by state https://www.integration.samhsa.gov/financing/billing-tools
• Lessons learned https://www.integration.samhsa.gov/about-us/esolutions-newsletter/e-solutions-sept-2014