Solving for Clinical Recruitment & Retention

Every provider in the country is struggling with staffing - nurses, therapists, doctors, there’s a shortage. Providers are stuck in a cycle of paying higher and higher salaries, sign-on bonuses, and benefits, which is simply unsustainable. The average behavioral health provider is paying 30% more for its nursing staff than it did 2 years ago with only a commensurate 2-3% increase in reimbursements from payers. Many therapists have opted for providing online therapy in a private practice from home, so the ones willing to come into a brick and mortar location are also commanding higher salaries.

It’s become a game of who can pay the most in which nobody can afford to keep playing. It’s time to start thinking differently about recruitment and retention. There is always only one top payer in the country or in a region. The other 99% of providers aren’t paying the top salary tiers, yet those organizations have always done just fine. My point here is that pay is not the only tool in the recruitment toolbox. There are many ways to attract and retain talent and one of those tools is used by almost nobody in the field - ongoing staff development..?

I’m willing to bet this is your behavioral health hiring philosophy: “Hire therapists with credentials and then let them do what they think is best.”?

It's great that you trust your hires and give them autonomy, but it’s not actually what most of them want and it’s certainly no different than what everyone else is doing. Did you know that most undergrad and graduate programs do not teach therapists how to run groups? Yet groups are 90% of the therapy delivered in the average treatment program. Groups are intimidating and therapists can feel like they’re not making much progress with patients since there is so little engagement in the way the typical group is delivered in the field today.

Think back to your time at university. When you started your first job, did you really know what you were doing? Most of us thought we did, but looking back 10, 20, 30 years later, we laugh at how little we knew. Therapy is no different. A degree gives one a baseline level of knowledge, but nowhere near the experience and training needed to become a master of the craft.

Onboarding training cannot consist of just learning the EMR and a couple shadow sessions with some other therapist who also has never had any formal training on group delivery. Therapists want and need more.?

This need for training is becoming even more relevant as the field moves toward measurement-based care (MBC).?

This is part 2 of a 3 part series addressing the pain points of behavioral health.? Click here for Part 1: Measurement-based Care Is Coming. You Can Lead the Way or Fade Away, the Choice Is Yours

Options for outcomes tracking have flooded the market, so there are numerous options for organizations that aim to survive the changing, data-driven landscape.? MBC is the future; that is indisputable.? But, regardless of which software is determined to be the right fit for the organization, there will still be a hurdle ahead; what should they do with the data??

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Without staff properly trained in the delivery of EBPs, without compliance and auditing, what to do with the data will be a little more than a guessing game. If a patient isn't responding to a particular modality, is it because it wasn't right for the patient, or wasn't delivered appropriately? If a clinician receives the data, what guidance are they given on interpreting it or what to do next? Will they do anything at all, or will it be more "treatment as usual" or, as Dr. Carroll referred to it, "chat?"

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To solve this, we turn to training; training for staff on the effective delivery of EBPs; training for all levels on MBC and outcomes tracking software; training for supervisors on observational alignment, delivering feedback, and setting key performance indicators (KPIs). It might sound scary, at first, but it is the only way to ensure the best care is being provided for the patients that we have sworn to help.??

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Training comes with additional benefits, specifically relief to some industry-wide pressure. But, you get what you pay for; the idiom has never rang more true.?

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The market is saturated.? While the majority of providers are fueled by a true passion to serve patients and driven by staff who genuinely strive to save lives, at the end of the day, money talks, and it has a loud voice.

We have spoken to numerous providers, big and small, who see the writing on the wall; that evidence-based practices and measurement-based care is the future of behavioral health. Yet, when it is time to address the issue, hesitation consumes them.?

“There are so many free CEU opportunities online; we don’t need to pay for staff development” – CFO X

“I’ve been doing this for 40 years!? I know better” – Clinical Director Y

“Let’s wait to see what the landscape looks like next year” – CEO Z

Don’t invest, don’t evolve, don’t lead; or, do the opposite. Pull the trigger, invest in your people and business that saves lives, and relieve the pressure.

“Investing in our staff will save money by increasing efficiency and reducing turnover” - CFO A

“I am always interested in learning more if it means better care for our patients” - Clinical Director B?

“Not all trainings are created equal, and it is worth our time and investment to set our clinicians and patients up for success by ensuring they are trained and confident in delivering evidence-based practices” - CEO C?

Relieving the Pressure Through Adequate Training

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Burnout leads to turnover, and turnover leads to staffing issues, all of which are costly to an organization. According to The Center for American Progress, it costs about 20% of an employee's salary to replace them if they earn $75,000 a year or less. To put that in perspective, it takes, on average, $10,000 to replace a clinician making $50,000 a year; just one (Boushey & Glynn, 2012).?

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This direct cost is not the only cost, of course. What about other staff who get burned out when your facility is short-staffed or they have retrain yet another new staff member? What about patients that don’t feel cared for or can’t build relationships due to the turnover, or even new staff not delivering the quality of care that an experience staff member can? Does splitting the caseload of a vacant position overwhelm your staff and lead to more turnover?? Does it lead to understandable errors that impact patient progress and outcomes??

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“I don’t know”

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“Maybe not”

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“Probably”

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?“I hope not”

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Hope is not a strategy.

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Yang and Hayes describe burnout as a "psychological syndrome characterized by emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment. Due to the demands of treating people with psychological problems, burnout is prevalent among psychotherapists" (2020).?

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Yang and Hayes hit the nail on the head, but there is much to dissect within their multi-pronged assessment of clinical burnout. Working from the bottom up, training that allows clinicians to be more effective in their jobs, namely training on proper delivery of evidence-based practices, will help ensure that patients are making progress. The measured data provided to the clinician will prove it; the data is the accomplishment on paper.??

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Because proper auditing, which uses the collected data as a jumping-off point, involves observations, feedback, and follow-up, the whole process is personalized to the individual clinician. Depending on facility makeup, they will feel more connected to their clinical director, mentor, or auditor, whoever is responsible for the weekly, bi-weekly, or monthly check-ins.?

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While both of these improvements contribute to relieving emotional exhaustion, that is not all training and data collection will provide. Physical and emotional exhaustion are closely connected, and it's not uncommon for individuals to feel both if the work appears too much for one person to handle. Training and data collection allow clinicians to work smarter, not harder. Many outcomes tracking systems streamline the process for notes and other box-checking tasks that were once the clinician's responsibility to complete by hand. In addition, effective delivery of evidence-based practices will lower patient-resistant behaviors, an aspect of a mental health practitioner's job that can be emotionally draining.?

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If not addressed, burnout will lead to turnover, so it is vital to remember the role investing in staff training plays in reducing both. But, it goes beyond reductions alone; investing in staff training will produce gains. According to a 2018 U.K. L&D report, "Top-performing organizations are five times more likely to have learning cultures, suggesting a culture of learning is a key component of business success." According to Jack Welch, former chairman and CEO of General Electric, "An organization's ability to learn, and translate that learning into action rapidly, is the ultimate competitive advantage" (Findcourses.Co.UK, 2018). The report continues to describe the critical considerations organizations must make for an effective training and learning culture:?

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Research in the Field

For relevant and applicable data, we turn to the article, Training Therapists in Evidence-Based Practice: A Critical Review of Studies From a Systems-Contextual Perspective (2010).? According to research by Beidas and Kendall, “The quality of training provided to therapists refers to the availability of training for individuals interested in implementing an EBP, as well as the content and method of the training. The current “gold standard” of training in EBP includes a workshop, a manual, and clinical supervision (Sholomskas, Syracuse-Siewert, Rounsaville, Ball, & Nuro, 2005). The quality of training in EBP is likely to vary based on when therapists received their graduate training. Therapists trained before 1995 are unlikely to have had an emphasis on EBP, while those trained after 1995 have had varied exposure to EBP during training (Karekla, Lundgren, & Forsyth, 2004). A 1995 survey of training directors found that doctoral programs in clinical psychology covered about 50% of EBP (specifically—ESTs) and that most internships did not require competence in EBP (specifically—ESTs; Crits-Christoph, Frank, Chambless, Brody, & Karp, 1995). Similarly, a survey of 200 trainees in APA-accredited programs found that 32% had no coursework in EBP (specifically—ESTs) and over 65% had not read any of the major Task Force reports regarding EBP (specifically—ESTs). Those who had read the Task Force reports tended to be cognitive-behavioral in orientation (Karekla et al., 2004). These findings suggest that experienced therapists are not likely to have received training in EBP, and that newer therapists may have received training in some aspects of EBP.”

May have.? No consistency, no guarantee.?

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Beidas and Kendall continue, “Importantly in our view, the content and method (i.e., overall quality) of the training program is crucial to successful (implementation) …Training methods are an important vehicle through which change in therapist behavior may be achieved. Current training methods include passively delivered didactic lectures (e.g., the format of a continuing education workshop) despite findings that this type of instruction has limited effects on behavior change (El-Tannir, 2002). Active learning, an alternative to passive learning, is an interactive process that uses action and reflection.”

We agree.? Not all training is created equal.?

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Of course, an organization can encourage their clinicians to complete the required CEU hours on their own, free of charge.?

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Box checked. But, has anything improved???

Have the working conditions, the staff experience, the patient outcomes improved?? Probably not. If the course can be completed simply by signing on and, in many cases, turning the video off, (this is something we have witnessed well more than once) then any expectation for improvement associated with such a training should be thrown out the window.?

So, what should organizations focused on the future do when it comes to implementing training or any company wide initiative?

Work With Senior Leadership - Organizational buy-in is a critical component for success. Not only is this mirrored by Beidas and Kendall’s research, but it is intuitive.? A company's mission is crafted by leadership, and the mission drives motivation.? If your company is committed to deliver the best care possible for patients, ensuring staff are trained up on the delivery of EBPs and outcomes tracking will provide a return on investment both in terms of improved outcomes and a reduction in turnover.??

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Use Technology as an Enabler - Training on the use of outcomes tracking tools will streamline your organization's data collection process, reducing the workload on the clinician.?

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This is not an immediate fix.? Like any new skill, a bit of frontloading is involved.? Staff must be trained on new initiatives in a way that they feel comfortable, and this includes convincing them the new way is the best way.? Motivation is a key principle of learning; people don’t like being told what to do, especially if it means more perceived work for them.? The training and guided feedback should be delivered in a way that inspires and motivates, and this is not something you want to leave to chance.??

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Keep Employee Impact at the Heart of What You Do - The training an organization provides for its staff should allow them to execute their duties more efficiently and effectively. Training on the effective delivery of evidence-based practices will help lower patient-resistant behaviors, improve the therapeutic experience overall, and improve patient outcomes (Miller, 2014). The collected data will reflect this, increasing the sense of accomplishment and job satisfaction.??

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Push for Accountability on All Ends - It is not enough to simply train staff, on the delivery of evidence-based practices or otherwise, and simply call it a day. There needs to be follow-up and accountability in the form of observations and data tracking. This includes training managers on delivering feedback and handling difficult conversations; it will allow for the creation of personalized plans to help clinicians excel in their roles and best meet the needs of their patients.?

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Read that again.?

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Accountability is critical.? Just like outcomes data without assured evidence-based delivery, company-wide initiatives without implementation-checks become a guessing game; hope is not a strategy.

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Be Specific About the Impact You're Looking For and Then Measure It - The impact should deal with the pain points outlined in this article, and they will be tracked using the outcomes data.?

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This goes beyond patient data and includes clinical performance.? Understandably, some mental health practitioners will balk at the idea that key performance indicators might be introduced; wouldn’t anyone?? It is much easier to coast through without being compared to an agreed standard, but the reality is that payers care, patients and their families care, and clinicians focused on providing the best care… care.

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Make It Part of a Larger Cultural Transformation - This can include linking performance and results to promotion opportunities for interested staff and an overall shift from hoping for the best to evidence-based, measurement-validated, data-driven decision-making and care.??

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Investing in training shows staff that they are valued in the company and that you care about their development. Training and tools that lessen the burden on staff are keys to lowering burnout and turnover while enhancing your company's reputation for prospective new staff.??

Brighter Horizons?

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To all the clinicians dedicating your lives to helping others, thank you.? You deserve to be celebrated. We believe that you want to know with certainty that your patients are receiving care specifically tailored to their needs, but the only way to effectively track that is the data collection that supports and verifies your professional judgment. As much as we would like to believe we know what is going on in the patients’ heads, we can't. Without hard data, we cannot know with certainty how a program or person is performing and whether or not people are being left behind. Payers know this, and anyone who negotiates with them knows that proven methods that produce consistent results are the fastest way to coverage. If we want to help more people, we need to expand access to care, and the fastest way to do that is through the appropriate training combined with MBC.???

Talking to clinicians, clinical directors, and CEOs, they often admit a lack of consistency in delivery, which modality and approach varying wildly from one therapist to another.. Speaking of the delivery of group therapy in particular, one of the best EBP-delivered sessions we at The Institute have ever observed was at a Medicaid clinic, where one of the worst was a facility that charged over 10 thousand dollars a month.??

Here are some examples of the feedback we receive when running group therapy trainings.

“I was just thrown in; there was no training on this whatsoever.”

“We didn’t cover any of this in my graduate program.”

“I learned more about how to engage my patients in the last two hours with you than I did in the last 10 years at different facilities.”

“Groups are the killer of careers.”?

These are real quotes provided by clinicians on our feedback forms post training. Take some time to reflect on your own program and the training opportunities you offer for your valued staff. Is your mission statement reflected in your actions as an employer?

Training is required for evidenced-based delivery. The people who dedicate their lives to helping others are in short supply, and creating a business culture that shows investment in staff and commitment to patient outcomes shows your team that your mission is aligned with their values and career path.?

Are you committed to quality care? Can you prove it?? Prospective clinicians in the market want to know.

Cisco Systems, the number one ranked company to work for by Fortune Magazine has its own learning and development program.??

Disney University (The Walt Disney Company) provides ongoing training and development for their staff, including access to Harvard Business online courses.?

Walmat - 1 billion invested in staff development in 2022 alone.?

It isn’t a coincidence that the top performing organizations recognized in their field boast their commitment to staff development, as they should; they are proud to be the best, and they want to remain that way.??

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For behavioral health organizations to stand out as difference makers leading the way, onboarding progress and delivery standards must be established from within the organization. Senior leadership and the mission statement must align with the clinical staff’s motivation to break the cycle of intergenerational trauma, save lives, and do good; that will make your organization stand out as a leader, and it will be reflected in your Glassdoor rating.??

Measurement and training are the keys to continued growth and success; and you can’t have one without the other. Training provides the antidote to the poison pain points of the behavioral health space. Every thriving industry and organization uses data metrics and KPIs to track progress, inform decision-making, evaluate employee performance, set obtainable goals, ensure compliance, and provide quality product consistency. For a behavioral health organization to succeed in an ever-changing landscape, it must follow suit.?

Ready to move into the future of treatment and ensure the sustainability of your program? Contact us at [email protected]

Andrew Bordt is dedicated to helping clinicians develop the facilitation skills required to deliver evidence-based practices effectively, helping more patients recover and break the cycle of intergenerational trauma.???

The Institute for the Advancement of Group Therapy and ERP Health are joining forces to offer the only comprehensive measurement-based solution on the market.???

Are you considering becoming an industry leader??

Auditing and Optimization Package

Regular auditing and supervision of sessions is a critical component of any effective program. Most programs have regular supervision and group audits built into their SOPs, but the reality is that they are rarely implemented. The day to day of treating patients can be all consuming with supervision being the first thing to get dropped.

Additionally, measurement-based care is a new initiative in the fields of behavioral health and SUD, one that many clinicians are not only unfamiliar with, but also have some anxiety around. In order to continuously improve as an overall program as well as to help clinicians improve, patient outcomes tracking provides the backbone to continuous improvement and validation of program efficacy.

Comprehensive Supervision Implementation

The Institute has a robust process for implementing and facilitating regular session audits combined with feedback sessions in order to help counselors and therapists become the best they can be, ensuring sustained and continuing improvement for patient outcomes.

Our auditors are expertly trained in not just engaging and effective session delivery, but also in the art of effective feedback delivery. When it comes to the practice of therapeutic interventions, clinicians can, understandably, be very sensitive. If constructive feedback in particular is not presented correctly, clinicians will not be receptive and may even become resistant to coaching and development. This is why the team here at the Institute not only comes alongside your team during audits and feedback delivery, but actively coaches your team to be able to present feedback in a way that will be well received and, therefore, effective.

The Institute will:

• Provide audit forms if not already in place.
• In conjunction with the Clinical Director or Clinical Supervisor, communicate and implement a regular audit schedule for all clinicians at the facility.
• Conduct bi-weekly group audits and feedback sessions in conjunction with the Clinical Director, Supervisor, or relevant staff member (via remote live stream).
• Align on feedback and provide coaching related to feedback delivery to Clinical Directors, Supervisor, or relevant staff members (via remote live stream).
• Perform one onsite visit per year at minimum to provide feedback, maintain certifications, and deliver a refresher session if required.
• Train and support clinicians on the implementation of measurement-based care. MBC will be incorporated into all audit and feedback sessions. (If a robust, automated patient outcomes tracking system is not already in place, we partner with ERPHealth to setup and provide such a system).*
• Collaborate with Clinical Director or other relevant staff member to develop targeted trainings to clinical team based on observed gaps or areas for improvement.
• Handle all tracking and record keeping related to audits and supervision.
• Monthly reports to the executive team on sessions audited, areas for improvement, trainings conducted, and patient outcomes.
• Create dashboards and provide regular reporting to the executive team on both compliance and individual clinician's progress*
• In conjunction with patient outcomes data, provide analysis comparing individual and facility-level session delivery progress with patient outcomes gains.

* Optimization Package Only?

References:

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Beidas, R. S., & Kendall, P. C. (2010). Training Therapists in Evidence-Based Practice: A Critical Review of Studies From a Systems-Contextual Perspective. ?Clinical psychology : a publication of the Division of Clinical Psychology of the American Psychological Association, 17(1), 1–30. https://doi.org/10.1111/j.1468-2850.2009.01187.x

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Boushey, H., & Glynn, S. (2012).? There are significant business costs to replacing employees.? Center for american progress. ?https://www.americanprogress.org/wp-content/uploads/2012/11/CostofTurnover.pdf

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Carroll, K. (2012), Dissemination of evidence-based practices: how far we've come, and how much further we've got to go. Addiction, 107: 1031-1033. ?https://doi.org/10.1111/j.1360-0443.2011.03755.x

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Findcourses.co.uk (2018).? U.K. L&D Report: 2018.? retrieved from https://www.findcourses.co.uk/ld-report-2018

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Yang, Y., & Hayes, J. A. (2020). Causes and consequences of burnout among mental health professionals: A practice-oriented review of recent empirical literature. ?Psychotherapy, 57(3), 426–436. ?https://doi.org/10.1037/pst0000317

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