# Presentation: 134399

## Current Challenges and Issues Facing the Addiction Treatment Workforce

**Melanie Whitter**
**Ohio Association of Alcohol **
**    ****and Drug Abuse Counselors Conference**
**Abt Associates Inc.**
**October 7, 2004**

## Order of Presentation

- CSAT efforts to address workforce issues (environmental scan, meetings with stakeholders)
- Contextual conditions of the workforce
- Major challenges and cross-cutting issues
- Key themes to assist the workforce

**Notes:**
I’ll talk some about how workforce development is a priority issues for CSAT and what they have done to address this issues
-scan provides background or context to understand the issues

## State of the Workforce

- Addiction treatment is only as good as the workforce that delivers it
- Good treatment is dependent on the *quantity* and *quality* of the workforce --
- 	a sufficient number of individuals adequately trained to provide care

**Notes:**
Good tx is dependent on the quantity and quality

## State of the Workforce

- Instability in the workforce inhibits

- Day-to-day operations
- Quality improvement
- Workforce expansion

**Notes:**
Instability in the workforce inhibits improvements in the quality of services and challenges the field to develop and implement a national plan for workforce development

## CSAT Efforts to Address Workforce Development Issues

## History of CSAT Efforts

- In 1999, CSAT reviewed workforce issues through the Workforce Issues Panel of the National Treatment Plan (now Partners for Recovery)
- Panel recommendations:
- Create national platform within SAMHSA
- Develop and strengthen infrastructure to attract, support and maintain competent and
- 	diverse workforce
- Improve workforce competency through education and training

**Notes:**
Not clear on the conxn btwn the Panel and NTP?? 
And what is the relevance of presenting the recommendations??

## Current Efforts of CSAT 

- Develop a national workforce strategy
- Environmental scan conducted in 2003
- Nine stakeholder meetings held in 2004
- Strategy in development

**Notes:**
understanding these issues is crucial to development of effective workforce recommendations for the future. So conducted e-scan and met with ....

## Environmental Scan

- Document and highlight demographic and system conditions
- Examine existing workforce related documents and published articles
- 	(Focused on the last 5 years)

**Notes:**
Too many words on this slide – need to omit once content of slide is understood/approved

## Meetings with Stakeholders

- To identify the most pressing workforce development issues
- To solicit recommendations for SAMHSA and their DHHS partners in developing  a national strategy
- 120 individuals provided input

**Notes:**
Meetings with stakeholders I

## Meetings with Stakeholders

- The nine meetings were:
- Key Leaders
- Professional Associations
- Colleges and Universities
- Federal Agencies
- Clinical Supervisors
- Human Resource Managers
- Recovery Support Personnel
- 2 Regional meetings with State Directors, providers, ATTCs)

## Meetings with Stakeholders (cont’d)

- Attendees in these meetings represented

- Psychiatrists
- Researchers
- Social Workers
- Treatment Providers
- Others

- Certification Boards
- Faith-based Providers
- Marriage and Family Therapists
- Nurses
- Physicians
- Professional Trade Associations

## Contextual Conditions of the Addictions Treatment Workforce

**Notes:**
As a result of e-scan and nine meetings

## Composition of the Workforce

- In 1996-97, substance abuse treatment workforce
- 132,000 full-time staff
- 45,000 part-time
- 22,300 contract staff (SAMHSA 2003, Landis 2002)
- Medical staff
- 17% full-time staff
- 31% part-time
- 47% contract staff (SAMHSA 2003)

## Composition of the Workforce

- Most programs did not have full time medical staff
- Only 54% had part-time physician on staff
- Outside of methadone programs, fewer than 15% employed a nurse (McLellan et al 2002)

## Demographics of the Clinical Workforce

**More than 67,000 practitioners provide addiction treatment **(Harwood, 1998)

**Gender**
- 	- Females comprised 50-70% of clinical workforce
- 	- 70% of new counselors are female (NAADAC study)
**Age**
- 	- Average age of clinical staff (mid 40s to 50 years)
- 	- 75% of workforce over 40
**Race and Ethnicity**
- 	- 70-90% of workforce is White
- 	- Private agencies have fewer minority staff than
- 	  public agencies

**Notes:**
Mangers more likely to be males and male directors significantly more likely to be 51-60, majority of female directors tend to be under  50. 

On race, many studies didn’t even spend much time breaking down race since there were so few minorities.

*The discrepancies between gender, age and race of the workforce when compared to clients may have implications for retaining and engaging clients in tx: pts avg age 25-44; only 60% non-hispanic white, and 70% male admissions

## Source: Kaplan, 2003; TEDS, 2000

## Demographics of the Workforce

**Education Level**

- 60-80% of direct service staff had a bachelor’s degree and
- 50% had a master’s degree
- 	(Kaplan, 2003)
- Treatment staff have degrees in many areas (few have academic courses or degrees in addiction treatment)

**Notes:**
Education level-Counselors had degrees in other types of counseling, social work, psychology. Of the schools that are listed by NAADAC only 55% on the community college level; 32% at graduate level and 13% at bachelors

Certification- studies reported findings from a low of 45% to a high of 79% (NAADAC). However,we need to look at public vs. private and type of facility. Outpatient drug-freehad highest number of certified counselors.

Need a comprehensive survey as data varied widely; Workforce does not resemble the client population with is younger, male and more diverse

## System Issues

- Changing patient population
- Utilization of medications
- Application of evidence-based practices
- Performance and outcome measures requirements
- Capacity pressures

## Major Challenges and Cross-cutting Issues of the Addiction Treatment Workforce

**Notes:**
These systemic and demographic conditions set the stage for the challenges and cross-cutting issues currently facing the workforce; 

## Major Challenges of the Workforce

- Recruitment
- Retention
- Competency

**Notes:**
While the challenges are complex and overlapping, they can be presented in three primary areas with other issues that related to all three areas. These major challenges also have significant implications for the quality of care

## Recruitment

- Estimates are that close to 5,000 new counselors are needed annually for net staff replacement and growth (Lewin 1994)
- Most people enter the field in mid-30s and often as a second career
- 84% of staff and directors said low salaries are #1 reason for recruitment problems (RMC 2003; RMC 2003a; OASAS 2002)

## Recruitment (cont’d)

- Reasons for entering the field were:
-  Work is challenging
-  Want to help others
-  Concerned about substance abuse
-  Person or a family member has had
-   	 substance abuse problem  (NAADAC 2003)

## Retention

- Turnover rates above national average of 11% ranging from 18.5 - 33% a year (McLellan & Johnson, et al 2002)
- Most turnover is voluntary
- People move from one agency to another
- 63% of staff have worked in the field six years or more but 68% have been in their jobs less than 5 years (Harwood 2002)

**Notes:**
Low salaries and job turnover cost $$$. It would be cheaper in the long run to increase salaries

## Retention

- Strategies for improving retention include:
- 		- Increasing salaries
- 		- Reducing paperwork and
- 		- Creating more opportunities for personal 	  growth and advancement

## Competency

- “...a measurable human capability that is required for effective performance...”
- “...comprised of knowledge, a single skill or ability, a personal characteristic, or a cluster of two or more of these...”
- “...are the building blocks of work performance...”
- -- Marrelli et al

**Notes:**
Training, education and credentialing standards help define a profession and ensure ongoing competency

## Competency

- Education
- Standards
- Training

## Competency

- Variation in educational programs (curricula, degree programs)
- 442 addiction studies programs at various degree levels
- 18% at graduate level
- 13% at undergraduate level
- 69% at associates level (Taleff, 2003)
- No national academic accreditation process
- No national core competency standards

## Competency

- Training
- Use of evidence-based practices
- Outcome measurement
- New medications
- Addiction treatment (primary health care, allied health professions)

## Competency

- <footer>

***Competency***

**Source: IOM 1997**

## Cross-Cutting Issues

- Stigma
- Noncompetitive compensation

**Notes:**
The list that follows is not exhaustive and none of these issues exist in isolation, for they all impact each other.  Ultimately, each issue affects the recruitment and retention of qualified professionals in the addictions treatment field and the need for advanced training and credentialing/improved competency

## Stigma

- Negative consequences of stigma associated with addiction
- Difficulty in recruitment and retention
- Addiction professionals considered lower status than other professionals
- Reluctance to enter the field
- Contributes to noncompetitive salaries
- Misconceptions about treatment, and the qualifications of a clinician

## Compensation 

- Low Salaries
- In 2002, average salaries in low $30,000s
- Majority of counselors (61%) earned between $15,000 and $34,000
- Majority of agency directors (68%) had salaries ranging from $40,000 - $75,000
- Factors associated with higher salaries: graduate degrees, certification, and years in the field

## Compensation

- Inadequate health care coverage among professional staff
- 30% had no medical coverage
- 40% no dental coverage
- 55% not covered for substance use or mental health services	(*Counselor, 2004)*

**Notes:**
Relapse and wellness impact retention

## Key Themes to Assist the Workforce

## Key Themes

**Support training for clinical and recovery support supervisors**
**Investigate loan forgiveness and repayment programs**
**Develop career paths and establish national core competencies**
**Develop leadership and management initiatives**
**Provide support related to relapse in the workforce**
**Provide education on addiction treatment within other disciplines**