Perspectives from the Annapolis Coalition on the behavioral health workforce

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Behavioral Health Workforce Development
in the Age of Healthcare Reform Change is in
the Air 

• Perspectives from the Annapolis Coalition on the
  behavioral health workforce
• John A. Morris, Executive Director
• Navigating the new landscape
• Maryland addictions directors council
• Ocean city, md May 11, 2011

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It will be quite a ride
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Context for this presentation

• BEHAVIORAL HEALTH 1969 2011
• Trans- and de-institutionalization
• Major transition from state mental health
  authorities to Medicaid as the driver of services
  for people with mental illnesses (and
  increasingly for substance use conditions as
  well)
• Move from 12-step models of recovery to more
  professionalized models
• The rise of the consumer movement in MH
• Better But Not WellFrank Glied

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Better but not well

• Mental Health exceptionalism vs. mainstream
  integration
• Substance use treatment and prevention are a
  greater priority while these fields are changing
  paradigms to better address the often chronic
  nature of the illnesses and the need for more
  recovery focused care.
• Behavioral health moving closer to being a
  reality
• Now behavioral health/primary care integration
  (including bi-directional integration) is an
  accelerating reality

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Better but not well

• Historical Barriers to BH and SU integration to
  consider in developing unified workforce
• Etiology of nature of MH and SU and their
  treatment philosophies and techniques
• Practitioners from MH and SU have trained
  differently and often are unwilling or unprepared
  to treat MH, SU or COD
• Competition for scarce resources
• 
  - White/Davidson, 2006

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Better but not well

• BUT Individual, family recovery and community
  health and resilience are the common denominators
  the unifying principles of our work we cannot
  lose them!
• Each person must be the agent of his or her own
  recovery, each community must bolster its
  strengths.

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Behavioral health/primary care integration

• Do we really know what this will mean?
• Are providers in either sector really prepared?
• What are the dynamics likely to be?

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Agreed.

• There is a lot at stake.
• The history of behavioral health integration has
  some scary precedents
• Reduced access and benefits
• Inappropriate limits on visits and medications
• Dramatically under-priced reimbursement rates
• Narrow definitions of medical necessity that
  negatively impacted using natural supports and
  peers resistance to inclusion of substance use
  treatment in basic coverage
• Loss of recovery focus in care to medical
  management

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On the other hand.

• Data on mortality and morbidity for people
  diagnosed with major mental illnesses, including
  comorbid substance use disorders a scandal for
  our field
• Life expectancy reductions of 20 years cannot be
  allowed to continue

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The way forward Reasons for optimism

• Health care reformimproved potential for access
  for millions (ACA 2010)
• Behavioral health actually has something to bring
  to the table (more on this later)
• Co-occurring disorders are increasingly
  recognized as the norm not an anomaly
• The new buzz word in federal integration circles
  is bidirectional not a foregone conclusion
  that the mergers or integration will all be from
  behavioral health into primary care.

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Lessons from the rest of healthcare

• The history of how we arrived at the current
  general healthcare system is every bit as
  haphazard as ours.
• Atul Gawande, MD Health care development was
  path-dependent, following the paths of least
  resistance
• M.C. Escher might have envisioned this history
  thus

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Can we all say non-linear?
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Wisdom from rural behavioral health

• Behavioral health Exceptionalism never an issue
  in rural America
• Practical realities have always encouraged if
  not required collaboration, co-location,
  integrated approaches
• But what about the PEOPLE needed to make it all
  work?

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Workforce development

• For decades we have been using methods that dont
  work
• In the Annapolis Coalition Work, we refer to
  these as the
• PARADOXES OF WORKFORCE
• DEVELOPMENT IN BEHAVIORAL HEALTH

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THE PARADOXES OF WORKFORCE DEVELOPMENT

• Paradox 1 We train graduates of our
  professional programs for a world that no longer
  exists
• Paradox 2 Those who spend the most time with
  consumers receive the least training
• Paradox 3 Training programs persist in utilizing
  ineffective teaching strategiesin continuing
  education

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THE PARADOXES OF WORKFORCE DEVELOPMENT

• Paradox 4 We train only where willing crowds
  gather
• Paradox 5 Consumers and families receive little
  educational support and their lived experience
  doesnt inform the rest of the workforce
• Paradox 6 The diversity of the current
  workforce doesnt match the diversity of those
  served

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THE PARADOXES OF WORKFORCE DEVELOPMENT

• Paradox 8 We do not systematically retain or
  recruit staff
• Paradox 9 Once hired, little supervision or
  mentoring is provided
• Paradox 10 Career ladders and leadership
  development are haphazard
• Paradox 11 Service systems thwart the competent
  performance of individuals

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So whats to be done?What direction do we head
in?
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National Action Plan
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The planning process

• Two years 5,000 participants
• Federally funded
• Mental health addictions
• Treatment prevention
• Seeking to identify
• A core set of strategic goals objectives
• High priority ACTION items by stakeholder
• A planning resource
• Call to action

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The players

• SAMHSA
• The Annapolis Coalition
• Senior consultants
• Expert panels Advisory Groups (12)
• Reviews of existing recommendations
• Planning sessions in existing meetings
• Specially convened planning sessions
• Targeted requests and open calls for
  recommendations

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The seven major goals

• GOAL 1 Significantly expand the role of
  individuals in recovery, and their families when
  appropriate, to participate in, ultimately
  direct, or accept responsibility for their own
  care provide care and supports to others and
  educate the workforce.
• GOAL 2 Expand the role and capacity of
  communities to effectively identify their needs
  and promote behavioral health and wellness.

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The 7 major goals

• GOAL 3 Implement systematic recruitment and
  retention strategies at the federal, state, and
  local levels.
• GOAL 4 Increase the relevance, effectiveness,
  and accessibility of training and education.
• GOAL 5 Actively foster leadership development
  among all segments of the workforce.

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The 7 major goals

• GOAL 6 Enhance the infrastructure available to
  support and coordinate workforce development
• GOAL 7 Implement a national research and
  evaluation agenda on behavioral health workforce
  development

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GOAL 1 Its all about individuals and families

• Objectives
• Increased educational supports for them
• Shared-decision making with them
• Expand peer family support by them
• Greater employment as paid staff
• Formal engagement as educators of the workforce
• Healthcare reform cannot happen on the backs of
  M.D.s and Ph.D.s alone. Mike Flaherty,
  Executive Director IRETA

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Goal 2 Its all about communities

• Objectives
• Competency development with communities
• Competency development of the behavioral health
  workforce in community collaboration
• Strengthening connections between behavioral
  health organizations and their communities

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Goal 3 RETAIN and recruit

• Objectives
• Implement evaluate interventions
• Salary, benefits, financial incentives
• Non-financial incentives rewards
• Job characteristics
• Work environment
• Develop career ladders
• Grow your own workforce
• Cultural linguistic competence
• Public relations campaigns
• Too often our approach might be seen as

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TRAINING Relevance, effectiveness, accessibility.

• Objectives
• Competency development
• Curriculum development
• Evidence-based training methods
• Substantive training of direct care workers
• Technology-assisted instruction
• Addiction and co-occurring competencies in every
  staff member
• Systematic support to sustain newly acquired
  skills

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And are we perpetrating what we call

• RHETORIC INFORMED CARE?

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Nothing to it.

• We seek to provide person-centered, consumer-
  and family-driven, recovery and resilience
  oriented, strength-based, trauma-informed,
  gender-specific, age appropriate, developmentally
  relevant, community-based, co-occurring,
  time-limited, culturally and linguistically
  competent, transformational, health- and
  wellness-oriented, wrap-around, evidence-based
  care.

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• And now we are going to do that ALONG WITH
  providing primary healthcare.
• Did I mention we need to fasten our seatbelts.?

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Goal 5 Leadership development

• Objectives
• Identify leadership competencies tailored to
  behavioral health
• Competency-based curricula
• Succession planning
• Formal, continuous leadership development in all
  sectors beginning with supervision (or is it
  surveillance?)

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Goal 6 Infrastructure change

• Selected Objectives
• A workforce plan for every agency
• Data-driven CQI on workforce issues
• Strengthen HR training functions
• Improve the economic market for services
• Improve IT support for training, workforce
  support, tracking
• Decreased paperwork burden variable, redundant
  or purposeless reporting

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Goal 7 Research and technical assistance

• Objectives
• Federal and state inter-agency research
  collaboratives
• Technical assistance to field on evaluation of
  workforce practices

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Help is coming..!!!

• SAMHSA/HRSA Center for Integrated Health
  Solutions
• An important federal leadership partnership
• Led by the National Council for Community
  Behavioral Health
• Partners with broad workforce experience in
  behavioral health and primary care..across the
  life span
• Designed to provide practical, implementable
  solutions to the challenges of addressing the
  whole person

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Change in the real world.

• What role can we play in shaping the change?
• We have learned a lot about engaging healthcare
  consumers in self-care, peer-supports, and
  non-medical supports and recovery services. We
  need to build on this and bring more competent
  workers into our ranks at ALL levels.

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Change in the real world -2

• The Institute of Medicine has been pushing
  person-centered care for yearssubstantive
  convergence around the whole person.
• E-health and the Internet are arming healthcare
  consumers with vastly more knowledgebut its
  changing the behavior that improves health
  outcomes. New practitioners (e.g.
  interventionists) and practices (e.g. phone
  follow-up and outreach) are emerging.

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The change process

• Change always occurs in some real-world context
• Managing change is not an illusion, but it is
  also non-linear
• One mans theory of change

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Policy pinball.
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The message for us

• Be prepared for the
• Political dimensions
• Economic dimensions
• Practice dimensions
• Need to keep building measurable resiliency,
  wellness and recovery in the impending change.
• And there is even some helpful science an
  emerging body of literature on integration, and
  successful models, too.

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Some models to look at
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In closing

• The True North of healthcare reform has got to
  be improved health outcomes for real people in
  the real worldwhich means people who have
  multiple health conditions.
• There can be no health without behavioral health.
• Therefore we are positioned to provide leadership
  and context as we navigate the various paths
  that Gawande alerts us lie ahead.

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The Annapolis Coalition Motto

• I get up every morning determined to change the
  world AND to have one hell of a good time.
  Sometimes this makes planning the day difficult
• Adapted from E.B. WHite

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Thanks for listening, and
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Be in touch

• www.annapoliscoalition.org
• jmorris_at_tacinc.org