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Workforce Development: Core Competencies and the I ...
Presentation and Q&A
Presentation and Q&A
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I'd like to formally introduce our speaker, Dr. Jessica Monaghan-Pollard is the Director of the Office of Behavioral Health in the Maine Department of Health and Human Services. Previously, Dr. Pollard was Assistant Professor and Director of the Early Psychosis Program at Yale University School of Medicine. She has chaired the Mental Health Services Section of the American Public Health Association, and she earned her doctorate in clinical psychology at the University of Connecticut. She has founded multiple early psychosis programs, developed resources on workforce development for the National Association of State Mental Health Program Directors, NASHPD, a great SMI partner, and the Substance Abuse and Mental Health Services Administration, SAMHSA. On the next slide, we can see that she has no financial relationships, commercial interests, and no conflicts of interest to disclose. And we'd like to just, I'd like to just personally thank you so much for making the time to be here with us and for sharing your expertise with us. Turn the speaker, turn the platform over to you. Well, thank you for having me, and thanks everyone for joining, though I suppose it is the only session happening right now, but I'm sure you would have picked this one even if there had been competition. So what we're going to attempt to learn about today is an overview of the core competencies for coordinated specialty care, as well as some strategies for how to find staff for your programs, how to retain them, and then how to continue to support professional development for those staff. And because we'll also be talking about the likelihood of justice involvement for clients in our programs, we'll talk about opportunities for intervention within the criminal justice system, and also summarize what we know about disproportionate justice involvement among young people with psychosis, including racial and ethnic disparities within those groups. So just to orient it a different way to how we'll get through that information, we'll start with an overview of workforce development considerations for CSC, and with a particular focus on the core competencies, which refer to knowledge and skills, and particularly we'll focus on the criminal justice involvement as a competency that's important to coordinated specialty care workforce. And we'll end with a discussion about the overlay between race and ethnicity, criminal justice involvement, and coordinated specialty care competence, and save time as well for questions and answers. So why should we talk about workforce development? So we talk a lot about the services being delivered, and we also need to focus on who delivers them, and how we prepare that workforce to, in order to most effectively deliver the care, and also how to keep those staff invested in the work. This is important because we've gone from, at the time I started working in this area of the field, just a handful of programs in the U.S. to literally hundreds today. So a substantial growth of programs over the past two decades for which we need workforce. And I can say in my current role, I also see the challenges more broadly in the behavioral health workforce with respect to shortages among trained and qualified staff, as well as recruitment retention issues more broadly. So in the context of behavioral health, this is a challenge already in terms of workforce development. So we already have this set of concerns about achieving diversity that matches the population served, how people can become trained in evidence-based practices and maintain those skills through ongoing education and supervision. How do you include people in recovery and their family members in the workforce and in the treatment team? And so that's kind of, those are some of the points of the backdrop of the challenges of behavioral health workforce in the country. And then of course, CSC, we have a set of specialty skills and knowledge that we want to make sure our workforce have. And the field is far enough along now that we have some, while it's still an evolving field while we continue to learn more about the most effective treatments, there's pretty widespread, I think, agreement about general competencies that all CSC programs should have. Let's see. So we'll be reviewing not only the competencies themselves, but how we will look for and keep workforce in our CSC programs and how we might train, supervise, and continue to support their development. All right, so how, where did this information come from? Just to orient you to where some of these ideas are and to give proper credit. These are certainly not my ideas alone while I contributed to the guidance document that you have referenced on the bibliography slide. This is with input of diverse CSC programs from around the country at the time we established these guidelines. So we interviewed experts from these CSC programs, from both new programs and well-established programs, and also with respect to kind of setting. So private, public, academic, rural, urban, tried to, within a constrained sample size, have the most diverse representation of types of CSC programs and locations. The experts from these programs were interviewed, and then we transcribed the responses, identified themes and summarized them and got input from the experts who participated before we revised and published these guidelines. So they are available to you, the detailed issue brief, and so we can all just go on coffee break right now since you have this available in writing and just skip the rest of this talk. But since you're here anyway, I want to just highlight some of those competencies and some of the strategies, not go into great detail about them because I'll move into the discussion about criminal justice involvement as a particular area of competence that we didn't go into as much detail in those Workforce Development Guidelines. So I didn't cite this in the bibliography, but I do want to mention that there are also helpful resources, particularly about early psychosis and justice involvement. So you can find that at NASHBID's Early Psychosis Information for Providers page. So there's an information brief on first episode psychosis considerations for the criminal justice system, and we also put together a webinar partnering with the justice system to improve outcomes and coordinated specialty care on NASHBID's webinar section. So you can find additional resources about that topic there. Just make sure we're all on the same page. What are competencies typically refers to knowledge, skills, and attitudes. And one thing that was noted by a lot of the respondents is, while this might seem daunting if you look at all of the potential competencies, when you have a team-based approach that typifies coordinated specialty care, not all of the staff on the team have to have all of the competencies. It can be a complementary approach. So while there's agreement, I think that some of the knowledge and skills and attitudes should be universal to the team, that there are also specialized skills and knowledge to some of the particular roles on the team. So we'll talk a little bit more about that. And one could argue that many of the competencies that we're going to discuss are just good care, and that wouldn't be wrong. However, it's not the same thing as those competencies being widespread among the behavioral health workforce. So among the experts we spoke to, there was a real emphasis on how we need to focus and ensure that these high-quality competencies are part of CSC care delivery. And then some of them are unique to CSC, or at least somewhat unique to CSC. So assertive outreach and community engagement, for example. So outside of assertive community treatment, that is not necessarily a particular focus of other kinds of behavioral health programs. Ongoing differential diagnosis is relatively unique to CSC. Being developmentally responsive, working intensively with families, and taking a population health approach are some of the competencies that differentiate CSC from other types of programs. So thinking about what might be foundational knowledge that all of the members of the team should have, and a good kind of basis from which to operate. So it's particularly important with this age group that CSC staff be familiar with adolescents and transition-age youth, and know what's important to them developmentally, as well as what are some of the tasks of these developmental stages. So we know that young people in our programs are developing independent living skills. They're forming their adult identities. Thinking about and working on their career ambitions, romantic and other social relationships are all key aspects of this age range. So staff in our programs need to understand these developmental tasks, not just to assist clients in acquiring the skills that go along with them, and to do some psychotherapeutic work around those identity formations, but also being knowledgeable about typical development will help to recognize when something is going awry with respect to development that may be driven by psychosis, and that we also minimize the likelihood that staff are going to pathologize something that may just be part of typical developmental challenges. And we want to, this may seem obvious, but we want to remain current on the literature regarding the early stages of psychosis and its treatment. So instilling confidence in clients and families is part of that as well. So we want to be able to talk about outcomes, know what's effective, what characterizes the early stages of psychosis, so that we can know what to expect, what to look out for. And that can be reassuring to clients and families to convey that knowledge, as well as also just being good for making sure that our own approaches are most up-to-date and well-informed. So I had a somewhat humbling experience of a family I worked with, the father had a work schedule that made it difficult for him to come to our educational sessions. And so I met with him one-on-one and provided all this background on what is psychosis and the importance of early intervention. And I met with the wife, who is usually who I worked with, and asked her what feedback she had gotten, how did she think things had gone. And the feedback from the husband apparently was, well, I didn't really, I don't really necessarily understand a lot better, but she knows what she's talking about. And that wasn't exactly what I was going for. But I share that story just to say, of course, we want to make sure we are being thoughtful about how we deliver education, and that it's accessible to people. But also the other takeaway that I got from that was, he was conveying reassurance that his child was in a program with somebody who had expertise in that area, and that he found that comforting. So pros and cons to that reaction. And we also want to focus, especially when we start to talk about recruitment, about interpersonal abilities. Some of the skills and knowledge can be taught more easily than others. And some of these, you could argue, are innate characteristics that we really want to be paying attention to in recruitment, since they might not be as amenable to kind of trained approaches. So communication skills are incredibly important. Not just, as I mentioned, my own blender earlier about being able to convey complex information in ways that people can understand. But also being really sensitive and tactful, because this, we know, people still experience a lot of internalized stigma. People may not agree with the characterization of what's driving their experience. People may be anxious and paranoid and really pick up on nonverbal cues. And those are difficult conversations to navigate. So those communication skills are really important. And it's also important that staff are able to hold what might seem like contradictory perspectives and be able to engage in thinking that is much more flexible. And definitely, we're not looking for black and white thinkers here. So examples of that would be, we're, rightly so, conveying hope and optimism about the chance of success, while at the same time, making sure that we are aware of and clients are aware of the potential for recurrence of symptoms and that this is a high risk period. So being able to balance those perspectives. And I think this section of the guidelines could have been just flexibility, flexibility, flexibility, and talking to some of the program experts and thinking about my own experience in working in CSC. It's so important that people working in these programs be able to rapidly shift and that they understand the tasks may vary widely from day to day. And that they be flexible from clients, really, with clients in the ways that we approach the work. Engagement is an incredibly important part of this. So we have to be flexible about the ways we engage people. Meeting people in maybe unusual settings and maybe not focusing on things that seem typical for treatment. So clients in the early engagement phase, you might need to focus much more extensively on client interests and topics that seemingly have nothing to do with treatment in order to build that relationship. So you have to have that flexibility to not be stuck on your own agenda and not get into power struggles. And the comfort piece is really important. So being able to, through nonverbal and verbal communication cues, maintain poise when you might be faced with really intense emotions from the clients and families, when you might be hearing about content that seems very bizarre or unusual. Clients and families are very sensitive to the ways that the clinician reacts to those kinds of interactions. And so certainly, conveying comfort or the ability to convey comfort is really important. Getting yourself comfortable with psychosis and with those kinds of interactions. And then, of course, we're probably, no one needs to be convinced about the importance of being able to build alliance. And you know, it's not just enough to be able to work with clients in this way. We also have to understand what is our role within a team and to be able to operate in a team-based approach. That requires collaboration internally as well as externally. I mean, there's a reason why we call it coordinated specialty care. Taking this kind of holistic approach and being really thoughtful about how to support people in their functioning means that we're going to interact with lots of other systems. And in particular, as I mentioned, I want to talk about the criminal justice system. Because some staff in different educational backgrounds or different training experiences might have more familiarity with other kinds of treatment providers, other kinds of parts of the healthcare system, might have skills and expertise in working with schools. Maybe less so on the, maybe less so around the criminal justice system. So that's one area we'll focus on today. And then managing conflict. So that's a particular skill set. People, especially this age group anyway, the conflict between the clients and their family members, but also in particular when there may be disagreement about what needs to happen in order for things to get better between clients and families, between clinicians and clients. And so being able to take that person-centered approach, shared decision-making, and also de-escalation and conflict management, open communication, sense of calmness, all those are really important abilities. So another area of competence, of course, is screening and assessment. We work in, kind of inherent in working in early psychosis, there's diagnostic ambiguity and clinicians need to be able to have some patience and understand this is an iterative process, that some of the diagnostic questions we have are only going to be answered over time or with the passage of time. So it's not, of course, enough just to have expertise in psychosis, and even within that, an understanding of affective psychosis, what might be primary psychosis or substance-induced or secondary to medical condition. We obviously, of course, want to be familiar with the common comorbidities and rule-outs. So this is, you know, embracing that diagnostic uncertainty when people may feel very strongly that they want a definitive diagnosis or family members may feel that way. And so being able to communicate about why it's important to keep an open mind and that this is an ongoing process without creating a lack of or undermining confidence that the team has expertise in this area. And then there are a variety, of course, of interventions that, oh, skipped over a couple of these. So we want to talk about brief screenings and assessment of risk to self or others. So while, again, we're going to maintain that recovery-oriented approach and positivity and optimism, staff also have to be skilled at recognizing warning signs when might be, and those can be unique to or are unique to particular clients. What are early warning signs that somebody may be experiencing a return of active psychosis risk to self or others and how to do that thoughtfully and tactfully. And then it's helpful for teams to have either a neuropsychologist as part of the team or on consultation in order to get more comprehensive understanding of cognitive functioning. And then intervention, we want to make sure that clinicians are engaged in recovery-oriented practices that are appropriate for the phase of not just illness, but where somebody is in treatment. Early on, there's a strong focus on engagement. Later on, we may be moving more into spending a lot of time focused on supporting functioning. And again, it's about that flexibility of being able to adapt and change as the treatment progresses. There are a variety of evidence-based practices that there's pretty widespread agreement are part of core competency for CSE. So things like motivational interviewing, motivational enhancement therapy, cognitive behavioral therapy for psychosis, some of the family interventions, family focused therapy, behavioral family therapy, multifamily education and support. So, there are some evidence-based practices that are more detailed in the guidelines that you can see. We want to make sure clinicians have those skills and evidence-based practices and know how to implement evidence-based practices. So, knowing the skill set and also being able to flexibly adjust. And clinicians have to be very knowledgeable about their community resources, especially ones that that are age appropriate for our clients. And with respect to risk, not just screening for the risk, but knowing what to do when risk is present or when risk is suspected. So, being able to avoid inpatient hospitalization or involuntary hospitalization, I think, is a goal of many CSE programs and clients. We want to avoid that experience whenever possible. So, that means we have to be able to come up with alternative ways of managing a situation, such as stepping up the intensity of treatment, more immediate coping skill development, engaging families in that process. And if there is a time of heightened risk or crisis, we're, of course, reaching out actively trying to get the information and engaging in ways that are still remaining focused on as much as possible client choice and shared decision making. So, unique to prescribers, of course, not everybody on the team has to know all the details about medications and what those specific guidelines are. But a lot of the members of the team are, of course, going to be working with clients and with the prescriber around monitoring for side effects, making sure we keep those as minimal as possible. But then there are other things around, you know, this particular age group, this particular phase of illness, people may not have any prior experience with medication. It's particularly important to understand what's the meaning that somebody is making around the medication, understanding the reluctance and where that may be coming from and how to engage people more effectively with patient and motivational enhancement approaches, as well as taking into consideration the ways that clients and their families might think about medication. And this may be an area where we would argue this would be good for any behavioral health approach to monitor and measure outcomes. And though I think we can say that one of the things we can feel good about for coordinated specialty here in the early psychosis field is that we've put a particular emphasis on monitoring and measuring outcomes as a way of ensuring that besides training to fidelity, that the interventions that we're delivering continue to be effective, both at the individual level and the clinic level. So, and using technology to deliver services, you know, we developed these guidelines a few years ago and little did we know how important it was going to become to be tech savvy. It's developmentally appropriate to make use of different technologies and engaging with our population of clients. And of course, now more so as we have wide adaptation or wide pivot to telehealth. And, but even before the COVID-19 pandemic, we have CSCs that are trying to deliver care to rural areas. And it's not always possible to get everybody together in the same place. But beyond that, there are technologies that are really effective tools in terms of health monitoring, encouraging changes in health behaviors, and from an engagement standpoint and being developmentally appropriate. And that that's somewhat of a unique skill set for CSC workforce. So a very simple example is texting with clients is something that hadn't necessarily been as common or widespread when CSCs were developing engagement strategies, but have become I think really an essential part of client engagement for a lot of programs. I won't go into all of the details on the peer staff workforce competencies, but you can find some good resources on that. So on track New York peer specialist manual, as well as Neb Jones guidance manual for peer involvement and leadership in early intervention in psychosis services, from planning to peer support evaluation. And so, so I'll just touch. So sorry, that is a resource that you can also get on the NASHBD website. And to mention just briefly some of those core competencies, as I've been outlined. So thinking about peer staff as being particularly involved in outreach and engagement component of CSC. And so having those particular skill sets, strong emphasis on the relationship building, embracing creative narratives. So working with clients around those alternative or client specific ways of thinking about what may be explanatory for their experiences. Sometimes the peer serves as an advocate within the team and encourages shifting in team culture to be more client centered and to be more open minded and holistic about the ways of thinking about psychosis, as well as creating different kinds of support and wellness tools for clients. There are also some competencies specific to team managers or program managers that may be from an administrative standpoint, advocating for being kind of a buffer between the CSC and the organization in which they operate. So sometimes that's around things like the productivity expectations and making sure that they're not so high as to prevent teams from being able to be flexible in the ways that they deliver care, as one example. And some also argue that the team leader, the program manager might need to be the one who's most up to date on the latest information in the field as another example. So what is the utility of these competencies? How do you apply this information about them? So in a variety of different ways. So the competencies can inform the ways that you describe and describe the job that you're recruiting for. So putting some of that information right out there in order to potentially screen out people who might not be a good fit, but also attract people who may be really interested in using their skill sets. And of course, that can guide the way that you orient and train staff, and then both of the initial training and the on training professional. So these competencies. So yeah, of course, we want to use these competencies to develop our performance evaluation tools that we use with staff. So you can literally put them all in your performance evaluation and work with staff to identify what are the strength areas and then what are areas of professional growth or professional development needs and then outline what trainings or other resources might help people achieve those competencies and areas where they're challenged. Using the competencies as areas to focus on in supervision, and then of course, just ongoing topics for continuing education. So not just enough to read them and put them on the shelf, we want to put them into practice as well. See, all right. There we go. So I mentioned a little bit about the recruitment and how we want to think about using the competencies in the ways that we describe and advertise for the position. But some other strategies that can be used as part of the recruitment process include, well, in terms of thinking about who you're recruiting for, you want to think about the team as a whole. So what are the strengths and different professions that you already have on the team and what competencies are you complementing in terms of what you already have and what you might be recruiting for. And as much as possible, trying to recruit for characteristics that reflect the population being served, whether that be race, ethnicity, or other criteria. So when thinking about selection, of course, it's helpful if people have prior experience with Coordinated Specialty Care, and that is more likely now than it used to be. I had the pleasure over the course of my career in going from not really having any candidates early on who had prior experience in CFC to sometimes having multiple candidates who'd had training and experience in Coordinated Specialty Care. But that's not going to be true for all situations or all clinics, and we know there's just so far not enough to go around. But it can be helpful at least to try to find staff who have prior experience with psychosis, although that can be a double-edged sword you want to be thoughtful about. Sometimes people who've worked with chronic psychosis may have negative or stigmatizing attitudes that you have to look out for or have not as strong of a recovery orientation as we would like. It's helpful if staff have experience in delivering evidence-based practices so that they understand how to sometimes develop a structured intervention, but also be flexible in the way that they adapt it. And experience working with families can be particularly helpful. So, you know, sometimes we see what we heard a lot about in talking about this particular area is that there's a, you know, there's a training divide to some extent between the child adolescent trained folks and the adult trained folks. And so the child and adolescent side may be more comfortable working with families. They may be more developmentally knowledgeable or knowledgeable about development. They may have more understanding of how to work with school systems, but be less familiar potentially with psychosis because of the kind of typical age of onset. And of course, the delays in people getting into care have meant most of the experience with psychosis is on the adult side. And then conversely, of course, adult people working within adult systems might not have as much background or experience working with families, schools, and being developmentally sensitive. So those are just some things to keep in mind. So some of the strategies that you can use when recruiting are involving the whole team. So whether that's having the team do the interview, which maybe is a little daunting, at least meet with multiple members of the team, get different perspectives, particularly helpful if you can include a peer or person in recovery. I'm talking to the person about how they, what's their, what is their view on recovery? How have they dealt with similar situations, even if they haven't provided CSE before, how do they manage a crisis? How did they deal with someone who was actively symptomatic? And then you can role play different scenarios, talk about how they would manage it. Visiting a team meeting can be helpful so that the person gets a really good sense of what goes into this kind of team-based care. It's not for everybody. I mean, I think a lot of these things can be taught, but we also want to acknowledge tolerating risk isn't something that everybody is comfortable with. Tolerating uncertainty, ambiguity, knowing the level of coordination, while I think probably to most of us in this meeting, those are things that we really value and enjoy about our work experience, aren't necessarily something, there might be some people who really prefer to work highly independently without having to engage in that level of team-based approach. And maybe it goes without saying, but we really want people who are passionate about recovery and really like working with young people and like working with psychosis. This work can be, as we know, challenging. We want to make sure at the end of the day, of course, it's not going to be about salary and that this work could potentially lead to burnout due to the anxiety, the stress around managing risk, the sometimes discouraging elements about challenges around engagement. And we want to make sure that people are bringing their passion to that work in order to minimize the likelihood of turnover due to burnout. And just a quick note about estimating recruitment needs. There's more information in the guidance manual about this, but of course you can, you can look at the, the kind of catchment area, the, the size, the surrounding community that you're going to be serving. So defining how much based on census data and first episode incidence rates, how many clients you might have in your area. And of course, not necessarily going to be able to reach a hundred percent, although that would be the goal. There is an interactive tool, at least last time I checked on New York State's Office of Mental Health to estimate staffing needs. And you can set those aspirational goals about how much of the population you're going to be able to reach. But then there's some other guidance as well. Some, some programs start up slowly with a small staff and then grow as they hire additional workers as they get up to full census. And in the meantime, if staff are not fully engaged in the work, if this is a new program or if you're bringing on new staff without having a full caseload for them, those staff can be deployed in that outreach and engagement into the community. All right, so orienting, training, professional developments, an ongoing process may kind of state the obvious. You obviously need to have staff. You have, you have new staff that you have to train anytime you start a program. And sadly, people leave. So hopefully you have low retention, but even if, even if you retain all of your staff, your program may grow. And so you're going to need to bring on more people who you'll have to orient and train. And this is not a one and done kind of scenario that once you train people initially, you're not, that's not the end of it. It's an ongoing process of supervision, training, and reinforcing those skills. So in using multi methods to keep it stimulating, I'm not practicing what I preach here. I'm giving you a bunch of boring PowerPoint slides and talking at you in a less than interactive way. But of course, that's not how we would normally approach the ways that we train and encourage people's professional development. There are many, many different resources that are now available from role playing to interactive kinds of training sessions, manuals, and observation, lots of different methods. So we want to keep it multi methods to keep people interested and accommodate those different learning styles. And there are lots of different people who could deliver the intervention. It might be the program leadership, but it's also helpful to have more experienced or staff with emerging experience teach other staff in order to solidify their skills and gain a sense of mastery and also feel good about their work as another way of retaining staff. And then having those outside trainers or consultants can help bring in fresh knowledge and perspectives. So some of the different goals of the orientation and training process, we want to set expectations. So setting the expectation about collaboration, that this is the standard for coordinating specialty care, that we're going to always be learning setting. So exactly what I just said, that needs to be instilled as an expectation and staff as well that I feel wary on the occasion that I'm interviewing somebody for a position and they downplay the importance of supervision, or the need for continuing education. And so we want to talk about the importance of being self monitoring, being aware. And that we, because we're not always going to find people who have extensive CSE experience, that encouragement regarding existing skill sets. So one of the things that dawned on me early on when I was training people in early psychosis programs is people were hesitant about really great skills that they brought to the table, or they were feeling like they lacked very much at all competence in working with this population. So one of the key tasks from a supervisor or program leader is really about helping people see how their skills that they already have apply to this population, and how they already have really good skills and abilities that they can use. So ongoing strengths and needs assessments, both through observation. So some programs have setups where they either tape or can watch sessions or sit in on sessions, and then lots of other different approaches as well. So some variability in terms of when programs give hands on experience. So some train for a long time before hands on, some have clinicians start right away with seeing clients, and some do more of a shadowing approach. But in any case, our goals are really about monitoring performance and making sure that we don't see unhelpful attitudes, stigmatizing attitudes, pessimism, or non-recovery oriented kinds of thinking and approaches creep into the work. So professional development, I think that's another responsibility of program leadership is really to make sure that the time is protected and that ongoing learning is built into the workflow. So I'm going to pick up my pace a little bit here since we're running low on time. So lots of different resources, I mentioned some of them already, and thankfully, there are a lot of this, putting this presentation together was one indication that I'm starting to feel old when I was thinking, oh, back in my day, we hardly had any of these, you know, when I was starting out. But thankfully, now there are a lot of resources out there for training and ongoing learning. One just quick tip, programs do, some programs do offer incentives for participating in that ongoing training and learning, doesn't necessarily have to be pay or salary specific, although some do increase pay with levels of increased training and competence, could just be something as simple as a certificate or recognition. So I think in terms of content, it's important to know the background of the field. I think probably people are pretty familiar with these kinds of content areas, and a lot of them are touched on in the in the prior description of competency. So I'll skip over these. High quality supervision. Again, I think this is a specific, not necessarily specific to CSC, although it's extremely important, as emphasized by all the participants in this, and these guidelines being developed, strength based particular emphasis on being able to manage risk vicariously, being able to sit with the tension between being recovery oriented while at the same time really being mindful of risk. And then working with people around those elements of shared decision making, and procedural justice. So fairness, being heard, and how to incorporate that into the work while you're managing risk. So retention, a few of these I've touched on already, but I mean, of course, we want to retain staff for a variety of reasons. Those transitions between clinicians can represent increased risk. We know that turnover is a loss of an investment. So a lot of that happens on the recruitment and selection side that I've mentioned already, trying to get the best fit you can, making sure that there's an emphasis on self-care and support of staff. There's some divided opinion about whether or not salary has much of an effect, but there's certainly some other tips that programs can be aware of in thinking about retention. There's advantages to disadvantage and disadvantages to working with trainees. So some programs include them explicitly in the work and some do not. So we obviously want to make sure there's more workforce out there. So there is some motivation to include trainees, but of course, they do take up more supervision and training time. So people have to be thoughtful about whether or not their programs can accommodate that. I am going to skip ahead a bit more quickly. So just in thinking about trainees, selecting those, we definitely don't want this to be the first clinical experience that somebody has. So I just want to say that this isn't the, CSEs aren't the place to get basic clinical skills. So going into the focus on criminal justice, so why would we focus on criminal justice as an area of CSE confidence in particular? We know that symptoms of psychosis can lead to justice involvement because we see higher rates of prior arrest and incarceration when people come to our programs. We know there's much higher prevalence of psychosis and psychotic symptoms within correctional settings, and that this is a higher risk time in terms of violence compared to other phases of illness. Just to reiterate what people hopefully already know that still, we're not talking about this population as a whole having significantly high rates of violence, but this is an opportunity potentially for early detection and intervention. And arrest and incarceration can lengthen DUP, be associated with functional barriers or barriers to kind of functional things like housing and employment, as well as be associated with greater symptom severity in the long run. So it behooves coordinated specialty care programs to prioritize reducing incarceration. So that was sort of depressing talking about how much psychosis is, how much our clients might be likely to be involved in the justice system and how many people with psychosis are in those settings that we might not be engaged with or there aren't in the community where we might be able to engage with them more easily. So I'll spend just a second on some good news. We did find in our step, a randomized trial of specialized treatment early in psychosis compared to treatment as usual, that there was a positive effect of coordinated specialty care on judicial outcomes. So once adjusting for prior conviction, the clients in the step program were less likely to be convicted of a crime after they got to treatment. And pretty far out down the road, we had years worth of data and also less likely to be sentenced to jail. And there are other ways that people could be adjudicated like probation. And there was also a significant reduction of risk for those who had no prior criminal justice involvement. So less likely to commit a first crime if you were in the coordinated specialty care program. So those are really good outcomes. So what do clinicians need to know about justice involvement? So this is what's pretty widely regarded as a good model of thinking about the overlap between mental health and the criminal justice system that people refer to as the sequential intercept model. So the point of this really is that there are different steps along the way where the mental health system could, or mental health professionals could intervene as people come into contact with the criminal justice system. And this kind of lays out the ways that people flow through, may come into contact and flow through the criminal justice system from the point of contact with law enforcement, all the way from reentry, discharge from jail or prison, and sometimes back in and out depending on probation parole conditions. So if that seems complicated, I'll show you a different view, which is a more complex view of the sequential intercept model. So important for clinicians to become knowledgeable about this because the clients that you work with are going to navigate the system. And so if this looks complicated to you, imagine being a client or family member who's also struggling with symptoms of psychosis, trying to navigate the system. So it's incredibly important that staff and CSC programs know what the system looks like in your region so that you can help people navigate it appropriately, which can go a long way to reducing anxiety and providing support and reassurance. This is a more simplified way of looking at it. It's in a paper we wrote specifically about early psychosis and the sequential intercept model. I've referenced it here if you're interested in getting more detail about that. But the point is that there are, again, multiple points of contact. So when people first come into contact with the police, mobile crisis teams, clinicians on mobile crisis teams may be co-responding, or maybe areas have crisis intervention teams where the police are particularly trained in dealing with mental health crisis. And then we can also intervene after the point of arrest. So many communities have jail diversion programs, and it's important for CFCs to coordinate and build relationships with their local jail diversion program if one exists so that jail diversion clinicians are familiar with how to connect, know how to identify early warning signs of psychosis, and connect people to those resources. Specialty courts are another area where CFCs could develop those relationships and be a potential disposition. If somebody gets into a mental health court, CFC could be a potential treatment option. And then some programs could be encouraged to outreach to the incarceration setting. So once people are coming out, or before people are coming out, working on coordinating, getting somebody into specialty care post-release. A lot of our folks, a lot of potential CFC clients may already be in probation or parole, so developing those relationships and training those professionals in recognizing early warning signs and knowing how to make a referral to your program is certainly a really important part of early detection and a referral source. So this, I only have a few minutes left, I have poorly timed my presentation today. There are lots of different symptoms of psychosis that can lead to justice involvement. These are all drawn from real examples from our work in the STEP program about potential charges that people can incur related to psychosis symptoms. So sometimes, for example, when somebody has a persecutory or paranoid delusion, they may make a false report, and that can lead to a charge or anger lashing out spurred by delusion or agitation. So these generally tend to be relatively lower level crimes, like breach of peace or disturbing the peace. It's just part of good coordination, part of good specialty care, putting that coordination in there, and as I mentioned, reducing stress to help navigate the system. And maybe we'll have to go back to this during Q&A, but I want to make sure I touch on just the last couple of points here, which is that this is not at odds with CSC. So you can still engender client choice, you can still enact those elements of procedural justice to make sure that there's transparency and fairness in the process, that people feel heard, that there are very clear boundaries and people understand the roles. So the client has engaged, for example, in an agreement with the court system, you're not an enforcer there, you're simply supporting them in negotiating their agreement with the court system as one way to frame it. And lastly, I just want to mention that we know that transition age youth and particularly transition age youth of color are disproportionately overrepresented in the justice system. So much higher rates of BIPOC individuals being in jails and prisons, overrepresented particularly among youth. And that our clients experience the vicarious trauma of witnessing violent deaths at the hands of police that have been so pervasive across news and social media. And that, of course, has an effect on our clients. So if nothing else, although I think there are a lot of things we can do, we want to make absolutely certain that we're validating people's experiences rather than perpetuating the experiences of structural racism, and that we understand that there may be healthy and totally understandable cultural mistrust that we don't misinterpret as paranoia. And that we can't take for granted what it might mean to call 911 for families, for people of color, for clients and their families, for whom that may have a very different implication than a white clinician in a CSE program may otherwise appreciate. So there are added layers of risk and added layers of thoughtfulness and sensitivity that clinicians may need to be aware of. And with that, I am a little over time, so I will pause there and hopefully cover some of this in Q&A. We'll go ahead and start answering some of the questions that have been submitted. We got a lot of questions and a lot of really thoughtful comments as well in the Q&A, which we're happy to share with you later. And thank you all for posting in the chat. And thank you to Dr. Adelsheim. We pinned his post. He had linked to some NASMHPD resources that some of you were looking for related to evidence-based practices and CSCs. So those are in the chat thread as well. And we will start releasing the polling questions again. If you're a social worker or a psychologist, the polling questions will be released in the next few moments. Complete those under the poll tab to get credit. You have to complete all of them. I will tell you that we have to post the questions one at a time. So just make sure you come back and answer all those questions. And why don't we jump into the first question? So kind of early on in the presentation, we received a question about asking if there is any research regarding staff retention. And the writer noted that many CSC programs have both high needs to address and a heavy amount of documentation and reporting, and that there's a lot of staff that cycle through. And I'm wondering, have you seen, Dr. Pollard, practices that are clinics that have managed this better than others? What are some of the strategies people are using around staff retention and decreasing administrative burden that have been successful? Yeah, I think that is something that is a program leadership role as well to try to be that advocate for on behalf of the staff to try to find ways of reducing administrative burden. So advocating maybe within the institution that the CSC is a part of is a big program leadership role, trying to find ways of decreasing those kind of maybe duplicative paperwork. And also, I think it's a really important supervision note. So one of the things that we heard from people we talked about is this tendency for, if you're not careful, supervision can just be administratively driven, you know, is your paperwork done or your charts in order? And that's not, while some of that may need to happen, that we really want to make sure we're providing the right level of support and encouragement and ongoing professional development as ways to not just support staff, but hopefully retain them as well. So in terms of best practices, I mean, that is an area that people identified, making sure that administrative considerations weren't taking up too much supervision time. And that the program leadership took that responsibility for trying to as much as possible reduce those administrative burdens rather than kind of just pass them along to staff and not be aware of the potential burnout effect that has. But I think I heard a nugget in there, which is safe supervision for clinical supervision. Yeah, that sounds like a key take home that everyone here today could really be thinking about. I'm wondering if you could talk a little bit more about the assessment of competencies. This writer wrote, are there ways in which we can use competencies to determine clinical performance and adjust training and supervision accordingly? Yeah, I mean, I think, you know, one of the things that I've done is really just take the competencies and turn them into a performance evaluation tool and really get feedback, try to as much as possible get 360 feedback from not just the supervisor's perspective of how the staff is doing, but, you know, what are their colleagues observing? What are clients observing? What do support staff observe? And really using that as a basis of identifying kind of ongoing professional development needs. So whether there's a particular kind of tool for evaluating each component of competence, that I can't speak to succinctly. But I think just having an explicit focus as a part of performance evaluation, and I do think, you know, one of the recommendations, the practice guidelines around supervision was really about self-awareness and self-monitoring, strengths-based approach, self-awareness. So we don't want to just sort of come to staff and say, you know, these are the areas that you're struggling with. Of course, we want to engage people and being self-reflective as we do that evaluation process is another thing to keep in mind. We actually just had a question that came in that I think follows along really closely with that, that asked, could you describe what you mean by supervision? What would that look like for a CSC where there's a psychiatrist and or a psychologist? There may be very limited kind of doctorate level clinical staff. So can you talk a little bit about maybe what some of the different models of supervision might look like? Yeah, and that's a really good point. So some programs are really small and it doesn't necessarily need to always be supervision by the same discipline. Of course, that's great if programs have that kind of resource where discipline specific kind of guidance and supervision can be provided. But it really is about helping people reflect on their work, helping them tie the approach that they're taking with with particular clients to those principles that we talked about. So helping people reflect on what drove them to make this choice, what outcome are they trying to achieve? What principle or practice is it adhering to? So a lot of it is really just sort of Socratic questioning and helping structure the discussion in such a way that people are self-reflecting on the ways that they're approaching the work with clients. It doesn't necessarily have to be discipline specific. So when I talk about supervision, I don't mean, you know, just the components where you might need that in order to establish licensure, for example, where you get a certain number of hours. So as a psychologist, you've got to get supervision hours to to meet that goal. But I think it's really important for people to think of supervision as an ongoing part of the work, not just something you do when you're a trainee, but that all of us need help in taking different perspectives on our work. And I think it's not even just individual level supervision. We talk a lot about team-based supervision and and kind of that that shared experience in reflecting on kind of thinking through risk or thinking through approaches. So it's not even necessarily just the one-on-one part of supervision or one-on-one modality. Well, I think there's another really great pearl in there, which is that supervision comes in lots of flavors. It could be individual, it could be group, it could be cross-disciplinary, but it's important to build reflection and a practice. We have time for maybe one more question, last two minutes here. We had a question come in, several questions related to peers and particularly team composition. So this person writes, can you recommend a number of peers on a team relative to a number of other staff versus them being the only one on the team? You know, peers are a relatively newish concept, you know, increasingly popular across the entire mental health spectrum and medicine in general. But like, has the CSC world established best practices around what the right peer ratio might be in terms of team composition? That's a great question. I don't, if there is a set number or set ratio, I'm not aware of it. That doesn't mean it doesn't exist. I do know in general, the practice should be, you know, peers, just as said in the question, should not be the only peer. That can be isolating. It can cause kind of mission drift for the peer. It can, you know, in worst case scenario, lead to tokenism or lack of appreciation of the role. And so and helping people maintain that sense of identity as a peer professional is really important. Some CSCs are small and they, you know, in terms of the number of staff. So they may only have one person in each role, one, you know, social worker, one prescriber, one peer. So it may not be possible to have multiple peers. But what we what we could encourage as a practice is look for those opportunities within the broader context. So does the institution have other peers that we would be able to have the CSC peer get kind of group supervision or participate in professional development activities with the group of peers that may be part of their institution or in their community? So in Maine, for example, there are kind of statewide opportunities for peers to get together and engage in coreflection. So it doesn't just have to be within the CSC team that a peer could feel supported in their role and identity as a peer. Great insights. We so very much appreciate you taking the time to speak with us today and share your expertise and your experience. Really appreciate everything that you've done for for this conference and please accept my thanks and the thanks of all our audience members for for joining us today, Jessica. Really appreciate it. Thanks again for having me. Thank you.
Video Summary
Dr. Jessica Monaghan-Pollard, the Director of the Office of Behavioral Health in the Maine Department of Health and Human Services, gave a presentation on the core competencies for Coordinated Specialty Care (CSC) and strategies for workforce development in CSC programs. She emphasized the importance of focusing on who delivers the services and how to prepare the workforce to effectively deliver care. Dr. Monaghan-Pollard highlighted the challenges in the behavioral health workforce, including shortages among trained and qualified staff and recruitment and retention issues. She discussed the competencies for CSC, which include knowledge, skills, and attitudes, and the unique skills and knowledge required for working with clients with early psychosis. She also addressed the importance of workforce diversity and cultural sensitivity. Dr. Monaghan-Pollard spoke about the overlap between mental health and the criminal justice system and the opportunities for intervention within the criminal justice system. She emphasized the need to reduce incarceration for CSC clients and the importance of understanding the criminal justice system and its impact on clients. Finally, she discussed the disproportionate involvement of young people with psychosis, particularly those from racial and ethnic minority groups, in the justice system. Dr. Monaghan-Pollard provided recommendations for recruitment, training, supervision, and retention in CSC programs and highlighted the need for ongoing professional development and support for staff. She also highlighted the importance of self-awareness and self-monitoring in the delivery of CSC services and the need to address administrative burdens and documentation requirements to improve staff retention.
Keywords
Coordinated Specialty Care
workforce development
behavioral health
staff shortages
recruitment and retention
early psychosis
workforce diversity
mental health and criminal justice
reducing incarceration
young people with psychosis
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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