Strained Infrastructure

Staff shortages. The number of substance use treatment staff continues to be insufficient to meet the needs of individuals seeking treatment. Key issues contributing to this shortage include:
• Lack of qualified applicants. Substance use treatment organizations encounter insufficient number of applicants who meet minimum qualifications for open positions; ^[6]
• Retirement. Over half of individuals working in the substance use treatment field are over the age of 45 years. Vital Signs surveys show 60 percent of clinical directors are over the age of 50 and 46 percent of direct care staff are over the age of 45; ^[7]
• Low salaries. Inadequate compensation packages can act as a deterrent in attracting new individuals to the field as shown in many studies (e.g., Johnson, Knudsen, & Roman, 2002; Annapolis Coalition on Behavioral Health, 2007; Kaplan, 2003; SAMHSA, 2006). ^[8] In addition, as healthcare reform brings new payers into an integrated health care system, it becomes even more important to reimburse substance use treatment practitioners on an equal level with other healthcare professionals; ^[9]
• Few incentives. Financial barriers prevent many SUD treatment facilities from offering competitive salaries and benefit packages (e.g., retirement plans, group health care, sick/vacation pay, educational assistance), which is critical to recruit the best candidates to jobs within the SUD treatment field.
• Structural issues. The amount of paperwork and heavy caseload of direct care staff are cited as barriers to successful recruitment. Vital Signs found 30 percent of licensed counselors had 30 or more clients.
1. High turnover. Many substance use treatment facilitates are in a constant state of recruitment with an average staff turnover rate is 18.5 percent. ^[10] The greatest need is retaining direct care staff; however, as the substance use treatment field changes and new EBP protocols emerge some treatment staff would rather leave the field than face being retrained in new EBPs. ^[11] Other issues that need to be addressed in order to increase retention rates include: ^[12]
   • provide paid vacation time,
   • provide paid sick time,
   • allow for program input,
   • offer group health insurance,
   • provide ongoing training (i.e., direct care staff, management),
   • cultivate a supportive facility culture,
   • provide better management and supervision,
   • reduce paperwork burden,
   • assign smaller caseloads,
   • offer promotion opportunities and higher salaries,
   • create healthy work/life balance,
   • offer paid educational assistance, and
   • offer retirement plans.
2. High workloads. Staff shortages contribute to higher workloads. Vital Signs found the majority of program directors (54%) and about a third of clinical supervisors (32%) do not have clients, while licensed counselors (30%) can have caseloads of 30 clients or more. ^[13] Implementing work/life balance strategies (e.g., flexible work hours, onsite daycare, free or low cost exercise programs) are becoming more common in other businesses and similar strategies could help the substance use field retain staff. ^[14]
3. No defined career paths. Although the substance use field is moving toward a more credentialed, licensed, and professional workforce, there continues to be no uniform educational standards or enough professional development and advancement opportunities that incorporate core competencies and provide credibility to the field. Well-defined career paths can support retention efforts by helping individuals progress into leadership positions. In addition, greater uniformity in credentials, licenses, and educational degrees is important for the field as it becomes more integrated and standardized policies are needed for the workforce to be recognized by new payers coming into the system such as Medicaid and private insurance. ^[15] Several recommendations to address this problem include:
   • Encourage workforce to continue to earn degrees in higher education and professional credentials;
   • Provide leadership training (executive/clinical directors) especially in how to provide constructive feedback, how to establish a positive work environment, and how to provide regular, ongoing support for clinical supervision that help clinicians adopt skill-based learning and stay in their jobs; and
   • Provide on-going licensing and credentialing opportunities for substance use workforce especially in areas of measurement and data analysis, health behavior models, options for treatment, HIT, specific treatment modalities, and treatment plan development.
   • Peer support: As the field moves towards greater credentials and degrees, it is important to note that people in recovery providing peer support services are important in establishing a person-centered, recovery-oriented treatment environment as they can offer understanding of the disease, the culture, and how to exchange and interchange with clients coming in the system. However, they may not necessarily have or desire degrees in social work, and it is important to find tiers of advanced education and training. ^[16]
4. Stigma. Substance use treatment field continues to struggle to be recognized as providing vital health care services for a life-threatening chronic disease. Substance use disorders are still not considered a legitimate healthcare issue by many and have not been integrated into mainstream healthcare; therefore, individuals who may be interested in a career in healthcare do not tend to investigate careers in substance use treatment. Negative perceptions and misunderstanding of substance use treatment are detrimental to recruitment and retention efforts within the field, thus strategies are needed to recognize the value of the substance use field to the overall health of the population. ^[17]
5. Lack of resources and insufficient funding. Many substance use providers lack infrastructure to prioritize training, provide regular salary increases, make technology improvements, or implement evidence-based practices. Staff most commonly need training in EBPs and behavioral management of clients; however, many facilities experienced barriers in providing staff training and professional development mainly due to tight budgets and time needed to send staff for training. ^[18] Training staff in EBP implementation is increasingly important because it is linked with how providers are paid in the changing healthcare system ushered in through healthcare reform. ^[19]
6. Lack of diversity. There is a rising need for substance use practitioners to reflect the diversity of the client’s served in terms of age, ethnicity, and sexual orientation. Lack of diversity persists in the substance use treatment workforce with discrepancies in gender (51% - 59% female), age (60% age 50+ years), and race (85% white) compared to clients. ^[20] There also is a lack of treatment providers with military affiliations, recovery experiences, or different sexual orientation. In addition, professionals’ licenses and credentials continue to come mainly from social work. ^[21]
7. New Technology. There is a need for substance use treatment professionals to increase their technological competence. Vital Signs found almost one third of clinical directors are only somewhat proficient in web-based technologies, and almost half of substance use treatment facilities do not have an electronic health record system in place. ^[22] The field needs to embrace HIT and support its implementation in order to survive in the more integrated healthcare system emerging through healthcare reform where compensation for services increasingly come from health insurance companies and Medicare who use EHRs. Barriers to EHR implementation include amount of capital needed to install a system (80%), costs to maintain EHR system (45%), and lack of technical staff to implement and maintain a system (33%). ^[23]
8. Health Care Reform. As healthcare reform changes the reimbursement structure for substance use treatment services, advocates for the field should consider mounting a concerted effort to ensure substance use treatment practitioners are reimbursed on an equal level with other healthcare professionals. ^[24] It is expected other healthcare providers will begin offering substance use treatment services such as primary care and emergency room practitioners who will need to have the capacity to provide some types of substance use treatment. In addition, mental health professionals need to become more familiar with treating substance use disorders specifically and not solely in patients with co-occurring disorders. ^[25] Despite these changes, there will remain a need for specialized substance use treatment providers. ^[26]
    

• Report to Congress on the Nation’s Substance Abuse and Mental Health Workforce Issues – 2013: This is a report that provides an overview of the facts and issues affecting the behavioral health workforce, including workforce demographic data.
• Vital Signs: Taking the Pulse of the Addiction Treatment Profession – 2012: This report provides an overview of the characteristics and development needs of the substance use disorders treatment workforce.
• Core Competencies for Integrated Behavioral Health and Primary Care – 2014: Workforce development is essential to integrated care. Resources are organized in six categories that capture the essential components of this unique labor force. In addition, the Core Competencies for Integrated Behavioral Health and Primary Care are accessible to outline the particular integrated care competencies vital to that area of development. _[27]
• Provider- and practice-level competencies for integrated behavioral health in primary care: a literature review – 2015: This resource highlights a comprehensive set of competencies, practices, providers, and staff required to advance integration efforts and provide comprehensive care to improve patient outcomes. Competencies are organized into Provider and Staff Competencies and Practice-Level Competencies. _[28]
• Workforce Issues Related to: Physical and Behavioral Healthcare Integration Specifically Substance Use Disorders and Primary Care – 2011: This document was developed for the joint ONDCP/SAMHSA/HRSA meeting August 10th, 2011, for discussion of practice strategies, related workforce, training and education issues regarding the integration of services for Primary Care and Substance Use Disorders. _[29]
• Workforce Capacity for Reducing Rural Disparities in Public Mental Health Services for Adults with Severe Mental Illness – 2011: This is study was published in the Journal of Rural Mental Health (Jan. 13, 2012) and examined workforce capacity in publicly-funded mental health agencies in rural mental health service areas (MHSAs). Overall, workforce capacity in rural MHSAs varied greatly, with some areas’ workforce capacity similar to metropolitan areas, while others have little to no capacity. The study asserts better leverage of rural MHSA’s core workforce would lead to more comprehensive, higher quality services, noting current core workforce lacks high levels of training in specialty care or adequate access to support from urban areas. It also calls for future efforts to establish sustainable mechanisms for ongoing training, education, and support for the core workforce in rural areas and for de facto rural systems of care in general. Case to Care trainings expand the traditional case manager role from helping consumers with serious mental illness establish a life in recovery to a broader role of assisting them to learn to manage chronic physical illness. _[30]
• Peer-Delivered Wellness Recovery Services: From Evidence to Widespread Implementation – 2011: This report discusses the growing body of evidence suggesting that peer-provided, recovery-oriented mental health services produce outcomes as good as and, in some cases superior to, services from non-peer professionals. The editorial asserts that as evidence continues to mount, the stage has been set for a coordinated, national peer workforce development and maintenance initiative. _[31]
• Health Worker Shortages and Global Justice – 2011: This report points to a shortage of about 4 million health workers needed to deliver essential health services. It references the World Health Organization’s assertion that health workforce shortages have replaced system financing as ""the most serious obstacle"" to realizing the right to health within countries. _[32]

• SAMHSA: Workforce: SAMHSA works with federal and other partners to increase the supply of trained and culturally aware professionals to address the nation’s behavioral health needs.
• 3000 Health IT Graduates for Hire: The Community College Consortia to Educate Health IT Professionals Program funds community colleges to train mid-career healthcare or IT professionals on HIT. The program aims to create a skilled workforce that can implement electronic healthcare systems and connects provider organizations with graduates to hire.
• The Collaborative Mental Health Care Pedialink: This course helps primary care clinicians identify referral sources to help expand their role in behavioral healthcare. After the course, primary care clinicians are able to identify needs that require emergency specialist care, determinate other clinical circumstances that require specialty mental health or substance abuse services, and describe methods for making effective referrals to mental health or substance abuse specialists.
• Health Care Workforce: Future Supply vs. Demand: This is an Alliance for Health Reform policy brief that estimates the nation will need 10 to 12 million new and replacement direct care workers in 10 years. It explores options for growing the workforce, including options within the Affordable Care Act.
• SAMHSA’s Scopes of Practice and Career Ladder for Substance Use Disorder Counselors: This resource guides states in developing scopes of practice (e.g., rules, regulations, and boundaries) and career ladders for counselors working with people with substance use disorders. It includes a full range of responsibility and practices, from entry level to supervisory.
• Patient Centered Primary Care Collaborative: This is a coalition of over 900 members from major employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, clinicians, and others that works to develop and advance the patient-centered medical home.
• Promoting Healthy Behaviors in Primary Care Research Networks: This is a national program that tested the use of evidence-based models and innovative tools in primary care to counsel patients to change unhealthy behaviors. Prescription for Health funded 22 practice-based research networks.
• HealthTeamWorks: This resource focuses on continuous quality improvement using a systems approach to optimize (1) the care team and their role in the care delivery; (2) health information technology; (3) patient engagement via effective self-management; and (4) the creation of learning communities.
• SAMHSA: Federal Collaboration: SAMHSA and the Health Resources and Services Administration (HRSA) are working to address integration of behavioral health in primary care settings. A number of these joint workforce efforts develop models that support integration, technical assistance, and training.
• Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice –2015: This resource provides guidelines to enhance competencies of substance use treatment counselors. Discusses patient assessment and screening, treatment planning, referral, service coordination, counseling, family and community education, and cultural competency.
• An Action Plan for Behavioral Health Workforce Development: a Framework for Discussion: This report was prepared for SAMHSA by The Annapolis Coalition on the Behavioral Health Workforce (Cincinnati, Ohio) in 2007. This strategic planning process was designed to examine current weaknesses in efforts to develop and sustain a strong workforce in behavioral health; develop a vision for a future workforce that is compassionate, effective, and efficient; and identify practical strategies that can be implemented to achieve that vision.
• Knowledge Application Program (KAP): KAP collects knowledge about best treatment practices for substance use and promotes it in a way to ensure widespread application in the field.