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Avoiding the Oncoming Train Wreck

By Joel Miller posted 09-17-2015 16:39


The Need to Increase the Behavioral Health Care Workforce Under Heath Care Reform

There has been a widely recognized workforce shortage in the field of behavioral health for several years. It involves both specialty-level providers in mental health and addiction services as well as primary care providers who frequently are needed to respond to the physical health needs of persons with behavioral health conditions.

According to the Health Resources and Services Administration (HRSA), in 2013, 77 million Americans live in areas that are not adequately served by substance abuse or mental health professionals, the majority of which are rural and remote. This shortage could enter a crisis phase as the practical implications of behavioral health parity and the changing health care landscape take hold over the coming months and years. There is an urgent need to plan for the increased demand in behavioral health services, both in primary care settings as well as in specialty clinic environments. Priority should be given to programs that educate students in team-based approaches to care, including the patient-centered medical home.

The Role of the Behavioral Health Sector Is Changing Rapidly

The need for behavioral health services within primary care settings will be in much higher demand. Effective workforce development strategies must address the following challenges:

  • Education from appropriately accredited programs;
  • Recruitment and retention;
  • Accessibility, relevance, and effectiveness of training;
  • Staff competency in integrated care, communication with medical professionals and ability to work as part of multidisciplinary treatment teams, evidence-based practices, and recovery-oriented approaches, and substance abuse training, attitudes and skills in prevention and treatment of persons with mental and substance use conditions;
  • Leadership development; and
  • Workforce roles for persons in recovery and family members.

Advancements in technology such as telemental health offer great promise. In addition to bringing greater access to general and specialty behavioral health services in underserved areas (which will experience even greater challenges in the coming years), technological advances such as telemedicine and telemental health facilitate the ability to provide real-time access to culturally competent providers of services to highly diverse communities.

Technology also dramatically increases efficiency for the workforce, allowing for greater productivity, and can offer additional part and full-time employment opportunities for providers who wish to work from home or while traveling. An emphasis on, and strong commitment to, the use of technology must be a cornerstone to addressing this rapidly growing workforce shortage. Alternatives to face-to-face interaction, i.e., telemental health, must be optimized, which requires funding to facilitate further development of technological advancements as well as adequate reimbursement for provision of such services. Moreover, there is also a training need here regarding the effective and ethical use of telemental health.

Next Steps for Clinical Mental Health Counselors (CMHCs)

Specialized Training

Without changes in the workforce, the field will have difficulty meeting the increased demand for specialty mental health services. There are known shortage areas for behavioral health practitioners, and these are likely to correlate with locations of the newly insured. There is a gap between the typical current competencies of CMHCs and those needed to practice in integrated care models. Thus there may not be sufficient numbers of trained individuals who can meet the demand for mental health care to be appropriately embedded in integrated models. All physicians, especially those in primary care, need a stronger focus on mental health training. Clinical mental health counseling education programs would best serve their communities by preparing practitioners who are trained in the following areas: Multidisciplinary treatment teams, communication with medical professionals and ability to speak their common language.

One Professional Standard

Curriculum, accreditation standards, new Continuing Medical Education (CME) trainings and collaboration with primary care practitioners are needed to meet newly insured patient needs as well as provide for new care delivery models. The future workforce should be directed toward CACREP programs. If the current workforce is not from CACREP program, they should become certified via specialty exams through the NBCC (i.e., NCMHCE) and established transitional periods. Curriculum and accreditation standards should be developed for all residents on the core competence and skill sets needed for integrated medical and behavioral health care. Practice management modules, like CME, should be developed in the following areas like teaching primary care providers about identifying and screening for mental illnesses and substance use disorders, and using health information technology.

Roles and Skills Needed by Individual CMHCs

Clinical mental health counselors will be ideally situated to provide Behavioral Medical Interventions based on their expanded training and implementation of AMHCA’s Clinical Standards. They will then need to promote themselves in the following settings:

  • Patient Centered Medical Homes (PCMH’s) and Affordable Care Organizations(ACO’s)
  • General Medical Practices: Family Practice & Internal Medicine
  • ClinicsRehabilitation In-patient and out-patient Centers
  • General and Specialized Hospitals
  • Senior Citizen’s Independent housing, Assisted Living & Nursing Homes

Basic knowledge needed by CMHCs about key health behaviors and physical health indicators (normal, risk and disease level blood chemistry measures ) routinely assessed & addressed in an integrated system of care, including:

  • body mass index
  • blood pressure
  • glucose levels
  • lipid levels
  • smoking effect on respiration (e.g., carbon monoxide levels)
  • exercise habits
  • nutritional habits
  • substance use frequency (where applicable)
  • alcohol use (where applicable)
  • subjective report of physical discomfort, pain or general complaints

CMHC skills & knowledge needed to effectively function on an integrated health team and new workforce include: Medical Literacy; Consultation Liaison skills with medical problems; Population Screening; Chronic Disease Management; Working within the fast-paced, action-oriented ecology of primary care.