Community Ment Health J DOI 10.1007/s10597-014-9798-4


Workforce Development Innovations with Direct Care Workers: Better Jobs, Better Services, Better Business Wayne F. Dailey • John A. Morris Michael A. Hoge

Received: 17 February 2014 / Accepted: 6 December 2014 Ó Springer Science+Business Media New York 2014

Abstract This study describes findings from a national search to identify innovative workforce practices designed to improve the lives of direct care workers serving individuals with mental health and substance use conditions, while simultaneously improving client care, and the business vitality of the employer. The search process, conducted by The Annapolis Coalition on the Behavioral Health Workforce, resulted in the selection of five programs to receive the Pacesetter Award from among 51 nominations received. Awardees understood the value of investing in direct care workers, who constitute an essential, but often overlooked, group within the behavioral health workforce. A review of these innovations yielded six cross-cutting principles that should inform future workforce efforts (a) supporting educational and career development (b) increasing wages and benefits (c) creating workforce development partnerships (d) using evidencebased practices to train staff and assess service fidelity (e) strengthening supervision and (f) employing people in recovery in direct care roles. Keywords Workforce innovation  Workforce development  Direct care worker

W. F. Dailey (&)  M. A. Hoge Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT 06511, USA e-mail: [email protected] J. A. Morris  M. A. Hoge The Annapolis Coalition on the Behavioral Health Workforce, 1001 Barton Street, Columbia, SC 29203, USA

Introduction There is broad consensus that a workforce crisis exists in the treatment of mental health and substance use conditions (Substance Abuse and Mental Health Services Administration [SAMHSA] 2013; Ryan et al. 2012; Hoge et al. 2009). The crisis is characterized by difficulties that include (a) recruiting and retaining staff (b) training them effectively (c) developing supervisors, managers, and leaders and (d) expanding the caregiving role of primary healthcare providers, persons in recovery, and family members within the behavioral health workforce (Hoge et al. 2013; Morris and Stuart 2002). The challenges are projected to become even more daunting with the expansion of insurance coverage under the Affordable Care Act (Beronio et al. 2013). Traditional workforce development approaches focus on graduate degreed professionals. However, there is ample evidence that direct care workers, who have little or no preservice education for their positions, comprise a major segment of the behavioral health workforce, estimated at over 200,000 in number (Hoge et al. 2007). Known by different names, such as direct service workers, direct support professionals, paraprofessionals or technicians, they tend to receive low wages and benefits and minimal on-the-job training. The competencies required for these positions tend to be poorly defined and stigma is associated with having such jobs. Since there are few career pathways or advancement opportunities, rates of turnover tend to be high (The Lewin Group 2008). One strategy for addressing quality concerns in behavioral health has been to identify and broadly disseminate innovations (Schoenwald and Hoagwood 2001; Schoenwald et al. 2012). This approach has been adopted by the Center for Medicare and Medicaid Innovations


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( The strategy has also been applied directly to workforce development issues for more than 10 years by The Annapolis Coalition on the Behavioral Health Workforce, which is a nonprofit organization dedicated to improving the quality of life of individuals and communities by strengthening the effectiveness of those who work to prevent, treat, and support recovery from mental health and substance use conditions (www.annapo Over the past decade, the Coalition has conducted five previous national searches for innovative workforce practices in behavioral health and has disseminated the findings throughout the field via social media, conference presentations and publications (Hoge et al. 2004; O’Connell et al. 2004). This article reports on the findings of the sixth national search for innovation, which was unique in two ways. First, the search was funded by The Hitachi Foundation and driven by its interest in identifying and promoting practices that create better jobs for workers, while simultaneously producing better services for consumers and better business, defined as the improved financial health of the service organization. Second, this search centered exclusively on innovations with direct care workers, driven by The Annapolis Coalition’s interest in highlighting the needs of this important workforce sector and by The Hitachi Foundation’s priority of improving the lives of ‘‘low-wealth’’ individuals and the communities in which they reside ( The article describes the methods for this national search and the findings, including brief summaries of the five National Award Winners. It concludes with a discussion of the crosscutting themes and lessons learned from these innovative practices with direct care workers.

Nominations provided an overview of the initiative, eligibility and judging criteria, and announced that organizations selected to receive the Behavioral Health Pacesetter Award in Support of Direct Care Workers would have information on their innovation broadly disseminated by The Hitachi Foundation and The Annapolis Coalition. This article is part of that dissemination effort. Participants Eligible programs included community-based services run by private nonprofit and for-profit agencies, state and county-operated or funded agencies, Federally Qualified Health Care Centers, Indian or tribal community health services, recovery community and recovery support organizations, and faith-based organizations. Review Process The Annapolis Coalition assembled a project team of senior staff who conducted an initial screening of nominations to determine whether eligibility requirements were met. Each eligible application was then fully reviewed by a panel of judges selected by the Coalition. The panel was comprised of behavioral health workforce experts chosen to ensure diversity of expertise with respect to prevention, and treatment and recovery from mental health and substance use disorders across the life span. Each judge used eight criteria to assess eligible programs. These slightly overlapping criteria were derived from two sources: Criteria Adapted from The Hitachi Foundation Priorities 1.

Methods Study Design In order to identify workforce innovations that benefited low-wage, direct care staff who generally do not hold a professional license or certification, the Coalition developed a Call for Nominations that was distributed electronically throughout the United States. It was sent to (a) behavioral health service providers (b) federal, state, and county-level government agencies (c) scientific and professional organizations (d) academic institutions (e) evidence-based practice developers (f) family, peer and recovery advocacy groups (g) legal rights organizations and (h) children’s mental health specialists. Simultaneously, the federal Substance Abuse and Mental Health Services Administration (SAMHSA) distributed the announcement to over 50,000 recipients using its ‘‘enetwork’’ system. Several large provider associations also distributed it to their members. The Call for




Positive employer/business impact—improved the strength and vitality of the behavioral health organization as a business entity. Positive employee impact—improved work life, skill levels, and career advancement among direct care workers. Positive client impact—improved mental health or substance use treatment and recovery outcomes or promoted healthy living.

Criteria Adapted from the Harvard Innovations in American Government Awards1 4.


Significance—addressed a workforce development issue that has potential to cause important and widespread change.

Available at and used in previous Annapolis Coalition searches for innovation.

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5. 6. 7. 8.

Effectiveness—had documented positive impact on the host organization, employees and clients. Novelty—used non-traditional concepts, methods or technologies, deviating from ‘‘business as usual.’’ Durability—evidenced stability and adaptability in the face of changing conditions. Transferability—showed potential to be successfully replicated.

The judges were provided with a semi-structured form for evaluating each program on these criteria and then each used that information to identify programs for possible recognition. The project team assembled the recommendations from all judges to create a consensus-based list of semifinalists. A senior member of the project team then site visited all of these programs to vet the nominated innovation in person through interviews with staff and a review of documentation. Collected information was assembled into written case studies for each semifinalist, which was presented to the Board of Directors of The Annapolis Coalition for review and selection of the awardees. The Hitachi Foundation staff reviewed project documents and provided input at multiple stages during this process. All authors of this study certify responsibility for its content and attest that no known conflicts of interest exist related to its publication.

Results Among 51 applications submitted, 38 met eligibility requirements and were distributed to thirteen judges, each of whom examined nine or ten applications. Each application had at least two reviewers, M = 3.2. Following completion of site visits and case studies on the seven most promising programs, five programs where selected as award winners. The five recipients and their innovations are described below. Family Services of Western Pennsylvania This agency is a provider of behavioral health care serving greater Pittsburg. Internal reviews led agency leadership to conclude that its case managers were ill prepared to assist clients with complex needs. Meanwhile, county officials, planning to close the local state hospital, recognized similar problems in other agencies. Using the Family Services agency as a laboratory for workforce improvements, a multiagency partnership was established to re-engineer all eleven case management programs in the county. The partnership involved close collaboration between Family Services, the University of Pittsburg, county government, the county Medicaid managed care agency, and a

community coalition comprised of consumers, family members and advocates. These parties agreed to add trained mentors and regularly scheduled supervision at the agencies and establish university-based training in jobrelated competencies and evidence-based practices. Case management was renamed ‘‘service coordination.’’ Career ladders were established linked to salary increments, resulting in an average increase in minimum salary of 8.5 % for newly hired service coordinators. Within a 2-year period, turnover among service coordinators improved, as evidenced by the fact that those employed at the agency \12-months decreased from 25 % of all service coordinators to 20.3 %. Those employed \18-months fell from 34.2 to 28.1 %. Average tenure of service coordination supervisors increased from 79.8 to 83.4 months. Agency managers also reported improved care quality and reduced recruitment and training costs. The county increased reimbursement rates helping these reengineered programs gradually improve profitability. Stanley Street Treatment and Resources (SSTAR) Located in Fall River, SSTAR grew from a small addictions treatment provider to a multiservice agency serving Massachusetts and Rhode Island. Historically, SSTAR had trouble hiring qualified staff members who were credentialed to provide reimbursable services. This undermined the agency’s financial health and potential growth. SSTAR found a solution when, supported by a Jobs to Careers grant, it partnered with a private training consultant and a local community college to offer SSTAR’s entry-level staff college courses at the agency with credits usable toward addiction counselor certification. Within 5 years, 22 staff achieved addiction counselor certification enabling reimbursement of their services. With more revenue SSTAR was able to increase ambulatory care staff salaries 17 % during a 4-year period just prior to this study. During onsite interviews staff reported improved selfesteem due to their career advancement and greater loyalty to the agency. By enhancing its complement of certified staff SSTAR also was able to keep pace with increasingly stringent state regulatory requirements, successfully competed for federal grants, and implemented several new evidence-based practices. Hartford Dispensary In the early 1980s, Hartford Dispensary was forced by competition from local hospitals to discontinue providing general medical services after a century of serving indigent Connecticut residents. In response to the growing crisis of heroin abuse, it reopened as a methadone treatment clinic. But its struggles continued because it had hired people in


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recovery from addictions whom, while eager to help, lacked training and failed to meet emerging service reimbursement and accreditation standards. New management concluded that to survive the agency needed to invest in its direct care workers. It established supportive weekly supervision in which individualized educational goals were set and monitored. A professional development program was established which added three paid professional leave days and covered up to $1,000 per employee annually for approved educational expenses. Two-thirds of staff participated. A local community college was enlisted to provide classes at an agency treatment facility to prepare staff for counselor certification. Salary adjustments gave Hartford Dispensary a recruitment edge over competitors and merit bonuses and other benefits were added. In the 8 years preceding this study, staff turnover averaged 16.3 %, which is below average for this healthcare sector (Hoge et al. 2013). In 2010, comparative data revealed the Dispensary’s 93.7 % patient satisfaction rate was second highest among six opioid treatment providers in Connecticut. Satisfied patients had increased treatment duration and greater probability of remaining opioid free. Additionally, the agency became involved in applied research, studies of evidence-based practices, and actively participated in the National Drug Abuse Treatment Clinical Trials Network, all of which seemed to energize direct care staff by their own self-report. Borinquen Health Care Center Located in Miami, Borinquen Health Care Center was battling an HIV epidemic in the city’s poorest neighborhoods. However, for many years its HIV testing outreach efforts met with marginal success. The breakthrough came when Borinquen realized it had to address the role of drug addiction in the transmission of blood-borne diseases. The Center concluded that to assist city residents from diverse cultural backgrounds, many of whom were homeless and distrusted public authorities, it needed to hire street-savvy, bilingual behavioral health staff and train them in an evidence-based method of client engagement. Borinquen created the Substance Abuse Targeted Outreach and Pretreatment Program (STOPP), which utilized Comprehensive Risk Counseling and Services (CRCS), a manualized approach to risk-reduction for people with complex needs. CRCS has well defined fidelity measures and requires intensive staff training and highly supportive ongoing supervision. Concurrently, Borinquen established flexible work schedules for employees pursuing educational goals, and awarded its behavioral health staff an average $1,170 for educational expenses in the year preceding the Pacesetter case study. A five-year program evaluation that followed more than


1,000 clients revealed improvement on all client-reported outcome measures from intake to completion. Abstinence from drugs/alcohol for past 30 days, no arrests in past 30 days, and being employed or in school revealed statistical significant improvement, p \ 0.001.2 While not statistically significant, the trend showed positive impact for reducing behavioral or social consequences from (a) substance use (b) having a stable place to stay and (c) improved social connectedness. Collaboration with Borinquen’s medical programs resulted in better integration of primary care services, improved outcomes for STOPP clients, and more effective use of the Center’s finite healthcare resources. Thresholds This agency serves more people with severe mental illnesses than any other private nonprofit organization in Illinois. For years, Thresholds conducted onsite classroom training to enhance the skills of its direct care staff, 67 % of whom held a bachelor’s degree or less. Some agency managers questioned the efficacy of this classroom training method and struggled to find coverage for workers attending classes. But it was outside forces that set the stage for internal change. In 2006, Illinois began converting from state grants for public mental health care to feefor-service reimbursement. Since employees in classrooms were unavailable to generate billable care the agency began reexamining its training approach. The new payment system also prompted Thresholds to establish individual productivity requirements, which upset many staff. To meet these challenges, Thresholds began the use of embedded consultants to educate and coach staff. These were skilled trainers, chosen from within the agency, who worked with team supervisors and direct care staff in community settings. They taught evidence-based practices, such as Integrated Dual Disorders Treatment (IDDT), observing many clinical encounters in situ to shape worker skills, while workers provided billable services. In supportive supervision sessions, embedded consultants and supervisors engaged direct care staff in discussions about how to enhance care quality and meet productivity requirements while simultaneously achieving the worker’s educational goals, which would increase eligibility for promotion. The agency also implemented cash incentives tied to productivity. Each month during the first year, an average 28 % of direct care staff received these bonuses, increasing their monthly income an average $117. Additionally, clients were receiving better services as IDDT fidelity data revealed improved performance scores from baseline to 6 and 12-month follow-up. 2

Welch’s T Test for unequal variances at intake and completion.

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A major question confronted by leaders of direct care organizations is how to support workforce innovations in the face of ongoing funding challenges. Findings in this study suggest that investing in workforce enhancements serves to activate a ‘‘Workforce Enhancement Cycle’’ producing results needed to make the cycle self-sustaining. This model is shown in Fig. 1. Examining the five innovative programs as a group reveals some important crosscutting themes that are common to all or most of the programs and seems to create momentum that propels the workforce enhancement cycle. These themes deserve consideration in future efforts to strengthen the direct care workforce in behavioral health.

Discussion There are inherent limitations in efforts to identify workforce innovations. Data evaluating their impact is typically scarce and controlled comparisons with usual workforce practices are virtually never conducted. It is difficult to compare innovations quantitatively, thus judgments of merit rely heavily on qualitative information and informed expert opinion. While recognizing those limitations, this study attempted to maximize the structure in the search process by issuing a broad call for nominations using explicit eligibility criteria, engaging a large panel of judges with diverse expertise, adopting explicit selection criteria, and conducting site visits to verify claims made in the nomination process. In the behavioral health field there are few publications that highlight novel efforts with direct care workers. Yet the process described here yielded five compelling cases in which a focus on these workers led to better jobs, better services, and better business. More detailed case studies and contact information for these agencies can be accessed at ?portfolio=behavioral-health-pacesetter-award. The leaders responsible for these innovations have agreed to respond to questions from other agencies regarding implementation.

Fig. 1 Workforce enhancement cycle

Supporting Educational and Career Development All award winners demonstrated a conscious, active determination not just to train, but to support educational and career growth for their direct care workers—a group traditionally overlooked in staff development and training priorities. Examples from these case studies include (a) creating career ladders for these staff within an agency (b) bringing courses onsite that linked to eligibility for credentialing and (c) providing time off for professional development.

Workforce Enhancement Cycle Return on Investment in Workers Direct Care Worker


Employer Agency

Increased competency-based training, supervision, mentoring, and professional development

Improved continuity of caregiver (related to decreased staff turnover)

Increased service volume (related to retention in treatment and appointments kept)

More professional certifications and academic credits

Improved treatment associated with use of EBPs

Increased revenue

Increased opportunities for job advancement

Improved satisfaction, retention in treatment, and appointments kept

Improved program stability and strengthened community partnerships

Improved wages and benefits

Improved clinical and rehabilitation outcomes

Reduced costs associated with staff recruitment and turnoverrelated orientation and training

Increased worker satisfaction, productivity, and retention

Improved recovery

Improved financial stability and ability to re-invest in the direct care workforce


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Increasing Wages and Benefits There was recognition by these agencies that compensation matters. Through various mechanisms they offered increased wages, incentives tied to productivity or revenue generation, and funding for professional development. It is striking that some of the agencies decided to address their financial problems by investing scarce resources in their direct care workers. Creating Partnerships All of the agencies highlighted in this initiative recognized the need to collaborate with others in order to achieve their workforce objectives. To address needs that were beyond their capabilities, such as training, evaluation, and building career ladders, they partnered with community colleges, universities, county governments, and advocacy organizations. Using Evidence-Based Practices These innovative programs adopted evidence-based practices. This gave them well-developed, documented, and effective interventions as the basis for training direct care workers. Fidelity measures allowed them to assess staff adherence to these practices. Strengthening Supervision Each of the Pacesetter Award winning programs emphasized the critical role of supervision in achieving program goals. Attention was paid to ensuring that personnel and structures were in place to provide effective support, coaching, and mentoring of direct care workers. Employing People in Recovery Many of those employed as direct care workers were people in recovery from mental illness or addiction, bringing unique skills to these roles. By implication, each agency’s efforts to improve the lives of its direct care workers also served the dual purpose of improving the lives of people in recovery.

Conclusion Throughout history, direct care workers have been central to the workforce in the mental health and substance use disorders fields, typically spending more time with consumers and families than other types of providers. While long neglected in terms of compensation, career advancement opportunities, and professional development, the


innovations identified through this national search suggest that strengthening their work lives can also benefit the people they serve and the organizations in which they are employed. As healthcare reform dramatically increases the number of Americans who will have access to mental health and substance use disorders treatment, it becomes all the more urgent to focus efforts on strengthening the competencies of these workers and their role in meeting the nation’s healthcare needs. Acknowledgments This work was supported by a contract from The Hitachi Foundation. The authors thank Tom Strong and Mark Popovich for their important contributions to this study.

References Beronio, K., Po, R., Skopec, L., & Glied, S. (2013). Affordable Care Act expands mental health and substance use disorder benefits and federal parity protections for 62 million Americans. ASPE Issue Brief. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, 2013. Retrieved February 13, 2014, from reports/2013/mental/rb_mental.cfm. Hoge, M. A., Huey, L. Y., & O’Connell, M. J. (2004). Best practices in behavioral health workforce education and training. Administration and Policy in Mental Health, 32(2), 91–106. Hoge, M. A., Morris, J. A., Daniels, A. S., Stuart, G. W., Huey, L. Y., & Adams, N. (2007). An action plan for behavioral health workforce development: A framework for discussion. Substance Abuse and Mental Health Services Administration Publication No. 280-02-0302. Rockville, MD, U.S. Department of Health and Human Services. Hoge, M. A., Morris, J. A., Stuart, G. W., Huey, L. Y., Bergeson, S., Flaherty, M. T., et al. (2009). A national action plan on workforce development in behavioral health. Psychiatric Services, 60(7), 883–887. doi:10.1176/ Hoge, M. A., Stuart, G. W., Morris, J. A., Flaherty, M. T., Paris, M., & Goplerud, P. (2013). Mental health and addiction workforce development: Federal leadership is needed to address the growing workforce crisis. Health Affairs, 32(11), 2005–2012. doi:10.1377/hlthaff.2013.0541. Morris, J. A., & Stuart, G. W. (2002). Training and education needs of consumers, families, and front-line staff in behavioral health practice. Administration and Policy in Mental Health, 29(4–5), 377–402. O’Connell, M. J., Morris, J. A., & Hoge, M. A. (2004). Innovation in behavioral health workforce education. Administration and Policy in Mental Health, 32(2), 131–165. Ryan, O., Murphy, D., & Krom, L. (2012). Vital signs: taking the pulse of the addiction treatment profession: a national report— version 1. Addiction Technology Transfer Center National Office in residence at the University of Missouri–Kansas City. Retrived February 13, 2014 from documents/VitalSignsReport.pdf. Schoenwald, S. K., & Hoagwood, K. (2001). Effectiveness, transportability, and dissemination of interventions: What matters when. Psychiatric Services, 52(9), 1190–1197. doi:10.1176/appi. ps.52.9.1190. Schoenwald, S. K., McHugh, R. K., & Barlow, D. H. (2012). The science of dissemination and implementation. In R. K. McHugh & D. H. Barlow (Eds.), Dissemination and implementation of

Community Ment Health J evidence-based psychological interventions (pp. 16–42). New York, NY: Oxford University Press. Substance Abuse and Mental Health Services Administration. (2013). Report to Congress on the nation’s substance abuse and mental health workforce issues. Retrieved February 13, 2014 from PEP13-RTC-BHWORK.pdf.

The Lewin Group. (2008). A synthesis of direct service workforce demographics and challenges across intellectual/developmental disabilities, aging, physical disabilities, and behavioral health. (Contract #TLG05-034-2967). Falls Church, VA. Commissioned by the Centers for Medicare and Medicaid Services.


Workforce Development Innovations with Direct Care Workers: Better Jobs, Better Services, Better Business.

This study describes findings from a national search to identify innovative workforce practices designed to improve the lives of direct care workers s...
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