Behavioral Health Workforce: Quality Assurance Practices in Substance Abuse Treatment Facilities

National Survey of Substance Abuse Treatment Services

Short Report

July 11, 2017

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In Brief

In 2013, quality assurance practices related to the behavioral health workforce were common standard operating procedures in substance abuse treatment facilities. Although use of these practices differed little by facility characteristics, use did vary by U.S. state.
Almost all facilities (98.3 percent) monitored the continuing education requirements for professional staff.
Almost all facilities (95.5 percent) had regularly scheduled case review with a supervisor, and many facilities (73.5 percent) had regularly scheduled case review by an appointed quality review committee.
Nearly three-quarters of facilities (72.4 percent) used both types of case review practices (case review with a supervisor and case review by an appointed quality review committee); only 3.4 percent of facilities used neither type of case review practice.

Behavioral Health Workforce: Quality Assurance Practices in Substance Abuse Treatment Facilities

Authors

Laura J. Sherman, Ph.D., Sean E. Lynch, Ph.D., L.C.S.W., Catherine G. Greeno, Ph.D., and Elizabeth M. Hoeffel

introduction

Nationwide, there is concern about shortages, retention, and training in the behavioral health workforce.¹ Needs in both sectors of the behavioral health workforce (i.e., substance abuse and mental health) are similar; however, it has been noted that minimum requirements for substance abuse workers are lower than those for mental health workers.² Substantial reforms in the organization and delivery of care in the United States have created concerns that substance abuse workers may need support and supervision to keep pace with changing practices.^3,4 In the field of substance abuse treatment, some changes include a shift toward increased public financing, increased use of medication-assisted treatment, emphasis on evidence-based practices, use of peer support specialists, and changes in the profile of those needing services.^5,6,7 Many calls have been made to improve and strengthen the training, education, and supervision of the substance abuse treatment workforce.^1,8,9

Members of the behavioral health workforce benefit from continued training and clinical supervision to maintain high-quality services. In addition, these practices and other organizational factors may prevent staff from experiencing burnout^10,11and may assist in overcoming challenges in retention of qualified workers. For example, clinical supervision has been shown to serve as a protective factor in substance abuse treatment counselors' turnover, emotional exhaustion, and job satisfaction.¹² In the substance abuse treatment field, staff turnover has been found to be as high as 50 percent in some contexts, with average annual estimates around 32 percent for counselors.^13,14 Substance abuse treatment facilities can play a key role in supporting their workforce through training and supervision practices.

This issue of The CBHSQ Report focuses on quality assurance practices related to the behavioral health workforce that are used in substance abuse treatment facilities in the United States (a companion report on mental health treatment facilities is also available). These practices include continuing education requirements for professional staff, regularly scheduled case review with a supervisor, and case review by an appointed quality review committee. This report uses data from the National Survey of Substance Abuse Treatment Services (N-SSATS) to describe the number of substance abuse treatment facilities that use these quality assurance practices related to the behavioral health workforce as standard operating procedures. In addition, this report examines whether the use of these practices differs by facility characteristics and by state in the United States (including territories and the District of Columbia).

Data and Methods

N-SSATS, conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), is an annual survey of all known public and private substance abuse treatment facilities in the United States. N-SSATS is the only source of national and state-level data on the substance abuse services reported by both publicly and privately operated specialty substance abuse treatment facilities. N-SSATS is used to collect basic data on the number, location, and characteristics of specialty substance abuse treatment facilities and the people they serve throughout the 50 states, the District of Columbia, and other U.S. jurisdictions.¹⁵ N-SSATS is a point-prevalence survey that provides a picture of facilities' activities and gives an indication of the state of substance abuse treatment on a typical day but may not represent the full scope of practice in a given year.

The 2013 N-SSATS data used in this report are from the most recent available analytic data file with workforce information.¹⁶ Data come from 14,148 substance abuse treatment facilities. The facility response rate was 94.4 percent. This report examines use of three types of quality assurance practices: (1) requiring continuing education for staff, (2) regularly scheduled case review with a supervisor, and (3) case review by an appointed quality review committee. There was some missing data for each quality assurance practice; the numbers of facilities reporting data for each practice were 14,144, 14,147, and 14,140, respectively. There was also some missing data for facility characteristics (facility operation and type of care) and at the state level. The percentages described in this report were calculated using available data for each analysis presented, and the totals used to calculate the percentages are listed in the tables.

Because N-SSATS is considered a census of facilities and provides actual counts rather than estimates, statistical significance and confidence intervals are not applicable. The differences between percentages mentioned in this report were assessed using Cohen's h. The results described here have a Cohen's h effect size ≥0.20, which indicates that there were meaningful differences between the groups.¹⁷

Quality assurance practices in substance abuse treatment facilities

Figure 1. Substance abuse treatment facilities using workforce quality assurance practices as standard operating procedures: 2013

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey of Substance Abuse Treatment Services (N-SSATS), 2013.

In 2013, quality assurance practices related to the behavioral health workforce were common standard operating procedures in substance abuse treatment facilities (Figure 1). Specifically, 98.3 percent of substance abuse treatment facilities required continuing education for staff as a standard operating procedure; 95.5 percent of substance abuse treatment facilities used regularly scheduled case review with a supervisor as a standard operating procedure; and 73.5 percent of substance abuse treatment facilities used case review by an appointed quality review committee as a standard operating procedure.

In general, the percentages did not vary by facility characteristics (Table 1). Compared with the U.S. percentage overall, a lower percentage of facilities operated by tribal governments used case review by an appointed quality review committee as a standard operating procedure (60.4 vs. 73.5 percent), whereas a higher percentage of facilities operated by state governments used this practice (84.3 percent).

Table 1. Substance abuse treatment facilities using workforce quality assurance practices as standard operating procedures, by facility characteristics: 2013

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey of Substance Abuse Treatment Services (N-SSATS), 2013.

^{N/A = not applicable.}

^{1 Cohen's h was calculated by comparing the percentage of facilities in each facility operation with the overall U.S. percentage. Only comparisons in which Cohen's h was ≥0.20 are noted with an arrow indicating whether the percentage was higher or lower than the overall U.S. percentage.}

^{Note: Totals vary across quality assurance practices because of missing data.}

Case review patterns

The majority of substance abuse treatment facilities (72.4 percent) used both types of case review practices as standard operating procedures (regularly scheduled case review with a supervisor and case review by an appointed quality review committee; Figure 2). The next most common pattern (23.1 percent) was for facilities to use regularly scheduled case review with a supervisor as a standard operating procedure but not case review by an appointed quality review committee. The least common pattern (1.1 percent) was for facilities to use case review by an appointed quality review committee but not case review with a supervisor. The remaining 3.4 percent of facilities used neither case review practice as a standard operating procedure.

Figure 2. Substance abuse treatment facilities using regularly scheduled case review practices: percentages, 2013

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey of Substance Abuse Treatment Services (N-SSATS), 2013.

State Results

States varied in their use of the three quality assurance practices examined in this report (Table 2). Three states had higher percentages compared with the percentage for the United States overall for two of the three practices and were not different from the U.S. percentage for the other practice. The percentage of facilities that used regularly scheduled case review with a supervisor and case review by an appointed quality review committee as standard operating procedures was higher in Alabama and New York than in the United States overall. The percentage of facilities that required continuing education for staff and used case review by an appointed quality review committee as standard operating procedures was higher in Ohio than in the United States overall.

Table 2. Substance abuse treatment facilities using workforce quality assurance practices as standard operating procedures, by state: 2013

N/A = not applicable.¹Cohen's h > .20, state percentage compared to U.S. percentages. Arrow indicates whether percentage is higher or lower than U.S. Percentage.
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey of Substance Abuse Treatment Services (N-SSATS), 2013.

State Results (Continued)

Twelve states had a higher percentage of facilities compared with the percentage for the United States overall for one of the three practices and were not different from the U.S. percentages for the other two practices. Compared with the United States overall, Delaware, the District of Columbia, Mississippi, Montana, Vermont, and Wyoming had higher percentages of facilities that required continuing education as a standard operating procedure but did not differ otherwise. Alaska, Hawaii, and New Mexico had higher percentages of facilities that used regularly scheduled case review with a supervisor as a standard operating procedure but did not differ otherwise. Arkansas, South Carolina, and Tennessee had a higher percentage of facilities that used case review by an appointed quality review committee as a standard operating procedure but did not differ otherwise.

One state had lower percentages of facilities using two of the three practices than the percentage for the United States overall and was not different from the U.S. percentage for the other practice. The percentages of facilities using regularly scheduled case review with a supervisor and case review by an appointed quality review committee as standard operating procedures were lower in Kansas compared with the percentages in the United States overall.

Seven states had a lower percentage of facilities using one of the three practices as a standard operating procedure than the percentage for the United States overall but were not different from the U.S. percentages for the other two practices. Arizona, Colorado, Indiana, Virginia, Washington, and Wisconsin reported a lower percentage of facilities using case review by an appointed quality review committee than the U.S. percentage, whereas Michigan reported a lower percentage of facilities using regularly scheduled case review with a supervisor as a standard operating procedure than the U.S. percentage.

North Dakota showed mixed results. The percentage of facilities using regularly scheduled case review with a supervisor as a standard operating procedure was lower than the U.S. percentage overall, yet the percentage using case review by an appointed quality review committee was higher than in the United States overall.

Discussion

The 2013 N-SSATS data used in this report indicate that quality assurance practices related to the behavioral health workforce are common in substance abuse treatment facilities. Continuing education was the most commonly used practice, followed closely by regularly scheduled case review with a supervisor. Although case review by an appointed quality review committee was a less commonly used standard operating procedure than review with a supervisor or requiring continuing education, it was still common in facilities. Nearly three-quarters of facilities used both types of case review in their standard operating procedures.

Facilities can play a role in supporting the behavioral health workforce by including the practices outlined in this report in their standard operating procedures.^1,2 The best quality outcomes are likely to be produced when they go beyond the provision of basic continuing education and clinical supervision.^18,19 For example, continuing education that is interactive or tailored to individuals' practices and clinical supervisor expertise, especially in the areas of competencies and procedural knowledge, tends to yield better outcomes.^18,19,20 Furthermore, studies indicate that formal documentation and evaluation are important when supervision is conducted in groups,²¹ which has implications for case review by a quality review committee. Some practices may be more easily integrated into existing facility procedures, such as continuing education requirements for professional staff, compared with other practices that require greater time, resources, coordination, and funds (e.g., case review by a quality review committee). Online tools, video conferencing, and electronic health records might facilitate continuing education and case review for facilities in understaffed or under-resourced areas.²² Additional resources to support the behavioral health workforce can be found at https://www.samhsa.gov/workforce and http://www.integration.samhsa.gov/workforce/education-training.

Endnotes

1. Hoge, M. A., Morris, J. A., Stuart, G. W., Huey, L. Y., Bergeson, S., Flaherty, M. T., et al. (2009). A national action plan for workforce development in behavioral health. Psychiatric Services, 60(7), 883–887.
2. Kerwin, M. E., Walker-Smith, K., & Kirby, K. C. (2006). Comparative analysis of state requirements for the training of substance abuse and mental health couselors. Journal of Substance Abuse Treatment, 30(3), 173–181.
3. 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.
4. Cochran, G., Roll, J., Jackson, R., & Kennedy, J. (2014). Health care reform and the behavioral health workforce. Journal of Social Work Practice in the Addictions, 14(2), 127–140.
5. Bride, B., Kintzle, S., Abraham, A., & Roman, P. (2012). Counselor attitudes toward and use of evidence-based practices in private substance use disorder treatment centers: A comparison of social workers and non-social workers. Health & Social Work, 37(3), 135–145.
6. Glasner-Edwards, S., & Rawson, R. (2010). Evidence-based practices in addiction treatment: Review and recommendations for public policy. Health Policy, 97(2–3), 93–104.
7. Substance Abuse and Mental Health Services Administration. (2006). Addictions treatment workforce development: Report to Congress. Prepared for U.S. Department of Health and Human Services.
8. Wilkey, C., Lundgren, L., & Amodeo, M. (2013). Addiction training in social work schools: A nationwide analysis. Journal of Social Work Practice in the Addictions, 13(2), 192–210.
9. Lynch, S., Greeno, C., Teich, J., & Delany, P. (2016). Opportunities for social work under the Affordable Care Act: A call to action. Social Work in Health Care, 55, 651–674.
10. Broome, K. M., Knight, D. K., Edwards, J. R., & Flynn, P. M. (2009). Leadership, burnout, and job satisfaction in outpatient drug-free treatment programs. Journal of Substance Abuse Treatment, 37(2), 160–170.
11. Landrum, B., Knight, D. K., & Flynn, P. M. (2012). The impact of organizational stress and burnout on client engagement. Journal of Substance Abuse Treatment, 42(2), 222–230.
12. Knudsen, H. K., Ducharme, L. J., & Roman, P. M. (2008). Clinical supervision, emotional exhaustion, and turnover intention: A study of substance abuse treatment counselors in NIDA's Clinical Trials Network. Journal of Substance Abuse Treatment, 35(4), 387–395.
13. Eby, L. T., Burk, H., & Maher, C. P. (2010). How serious of a problem is staff turnover in substance abuse treatment? A longitudinal study of actual turnover. Journal of Substance Abuse Treatment, 39(3), 264–271.
14. Garner, B. R., Hunter, B. D., Modisette, K. C., Ihnes, P. C., & Godley, S. H. (2012). Treatment staff turnover in organizations implementing evidence-based practices: Turnover rates and their association with client outcomes. Journal of Substance Abuse Treatment, 42(2), 134–142.
15. The other U.S. jurisdictions include Guam, the Federated States of Micronesia, Palau, Puerto Rico, and the U.S. Virgin Islands.
16. Substance Abuse and Mental Health Services Administration. (2014). National Survey of Substance Abuse Treatment Services (N-SSATS): 2013: Data on substance abuse treatment facilities (HHS Publication No. SMA 14-4890, BHSIS Series S-73).
17. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2^nd ed.). Hillsdale, N.J.: Lawrence Erlbaum Associates.
18. Bloom, B. S. (2005). Effects of continuing medical education on improving physician clinical care and patient health: A review of systematic reviews. International Journal of Technology Assessment in Health Care, 21(3), 380–385.
19. Borders, L. D. (2014). Best practices in clinical supervision: Another step in delineating effective supervision practice. American Journal of Psychotherapy, 68(2), 151–162.
20. Cantillon, P., & Jones, R. (1999). Does continuing medical education in general practice make a difference? British Medical Journal (Clinical Research Edition), 318(7193), 1276–1279.
21. Kuipers, P., Pager, S., Bell, K., Hall, F., & Kendall, M. (2013). Do structured arrangements for multidisciplinary peer group supervision make a difference for allied health professional outcomes? Journal of Multidisciplinary Healthcare, 6, 391–397.
22. Weingardt, K. R., Cucciare, M. A., Bellotti, C., & Lai, W. P. (2009). A randomized trial comparing two models of web-based training in cognitive-behavioral therapy for substance abuse counselors. Journal of Substance Abuse Treatment, 37(3), 219–227.

Suggested Citation

Sherman, L. J., Lynch, S. E., Greeno, C. G. and Hoeffel, E. M. Behavioral health workforce: Quality assurance practices in substance abuse treatment facilities. The CBHSQ Report: July 11, 2017. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, MD.

Summary

Background: Nationwide, there is concern about challenges in the retention of the behavioral health workforce, which includes substance abuse treatment. Members of the substance abuse treatment workforce benefit from continued training and clinical supervision to maintain high-quality services and prevent emotional exhaustion, burnout, and turnover. Substance abuse treatment facilities can play a key role in supporting their workforce through training and supervision practices. Method: Data from the 2013 National Survey of Substance Abuse Treatment Services (N-SSATS) were used to examine the percentage of facilities that used quality assurance practices related to the behavioral health workforce and whether the percentage of facilities differed based on facility characteristics and by U.S. state (as evidenced by Cohen's h effect size ≥0.20). Results: Almost all facilities (98.3 percent) required continuing education for staff. Almost all facilities (95.5 percent) had regularly scheduled case review with a supervisor, and many facilities (73.5 percent) had case review by an appointed quality review committee; only 3.4 percent of facilities used neither type of case review practice. States differed in the use of quality assurance practices. Conclusion: Given that quality assurance practices related to the behavioral health workforce are common standard operating procedures in substance abuse treatment facilities, opportunities to enhance the quality of the practices should be supported.
Keywords: Behavioral health workforce, substance abuse treatment, continuing education, clinical supervision, case review, training

Author Information

CBHSQrequest@samhsa.hhs.gov

Keywords

Alabama, Alaska, All US States and Territories, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Federated States of Micronesia, Florida, Georgia, Guam, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Palau, Pennsylvania, Puerto Rico, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virgin Islands, Virginia, Washington, West Virginia, Wisconsin, Wyoming, Short Report, Substance Abuse Facility Data, 2013, Researchers, Workforce Development

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities.

The National Survey of Substance Abuse Treatment Services (N-SSATS) is an annual survey designed to collect information from facilities in the United States, both public and private, that provide substance abuse treatment. N-SSATS provides a mechanism for quantifying the dynamic character and composition of the United States substance abuse treatment delivery system. The objectives of N-SSATS are to collect multipurpose data that can be used to assist SAMHSA and State and local governments in assessing the nature and extent of services provided and in forecasting treatment resource requirements, to update SAMHSA's Inventory of Behavioral Health Services (I-BHS), to analyze general treatment services trends, and to generate the Substance Abuse Treatment facility Locator [http://findtreatment.samhsa.gov/].

The responsibility for N-SSATS is maintained by SAMHSA's Center for Behavioral Health Statistics and Quality (CBHSQ). N-SSATS collects three types of information from facilities: (1) characteristics of individual facilities such as services offered, types of treatment provided, and payment options; (2) client count information such as counts of clients served by service type and number of beds designated for treatment; and (3) general information such as licensure, certification, or accreditation, and facility website availability.

In 2013, N-SSATS collected information from 14,148 facilities from all 50 states, the District of Columbia, Puerto Rico, the Federated States of Micronesia, Guam, Palau, and the U.S. Virgin Islands. Information and data for this report are based on data reported to N-SSATS for the survey reference date March 29, 2013.

The N-SSATS Report is prepared by the Center for Behavioral Health Statistics and Quality (CBHSQ), SAMHSA, Synectics for Management Decisions, INC., Arlington, VA; and by RTI International in Research Triangle Park, NC.

Latest N-SSATS reports:
https://www.samhsa.gov/data/substance-abuse-facilities-data-nssats

Latest N-SSATS public use files and variable definitions:
http://datafiles.samhsa.gov

Other Substance abuse reports:
https://www.samhsa.gov/data