The Behavioral Health Workforce in Alaska: A Status Report

Transcription

1 The Behavioral Health Workforce in Alaska: A Status Report Prepared by the Western Interstate Commission for Higher Education (WICHE) Mental Health Program For: University of Alaska, Statewide Office of the Associate Vice President for Health March 2004

2 EXECUTIVE SUMMARY In largely rural states, such as Alaska, there have been historical difficulties in recruiting and retaining an effective behavioral health workforce. Additionally, the recent report of the President s New Freedom Commission on Mental Health described in detail the significant problems facing mental or behavioral health systems throughout the country, particularly in rural areas. These include critical gaps in accessibility to services, critical shortages in the availability of providers and programs, impaired acceptability of care due to urban-based models and strategies, and establishing mental health policy without consideration of its rural impact. The University of Alaska (UA) system convened a meeting of educators from disciplines spanning the behavioral health field to discuss how they can most effectively address workforce shortages, especially in rural areas. Despite a number of productive efforts in the UA system to develop an effective workforce that is trained in rural behavioral health, educators in Alaska see that more work needs to be done and are committed to formalizing workforce development activities that ensure the needs of Alaskans are met. In order to create a clear path toward achieving the development of an adequate and effective behavioral health workforce, UA educators, in collaboration with the Western Interstate Commission for Higher Education (WICHE) Mental Health Program, have been researching relevant issues facing Alaska. What follows is a summary of relevant concerns and data in several areas, including 1) the national context of rural behavioral health shortages, 2) Alaska workforce data, 3) occupational and population projections in Alaska, 4) trends in UA behavioral health programs regarding enrollment and degrees awarded, and 5) recommendations for developing the behavioral health workforce. National Issues for Rural Behavioral Health More than 60% of rural Americans live in mental health professional shortage areas. More than 90% of all psychologists and psychiatrists, and 80% of MSWs, work exclusively in metropolitan areas. More than 65% of rural Americans get mental health care from their primary care provider. Rural Americans enter care later in the course of their disorders, with more advanced symptoms, and require more intensive and expensive interventions. Rural Americans travel further to provide and receive services. Rural Americans are less likely to have insurance benefits for mental health care. Rural Americans are less likely to recognize mental illnesses, and understand their care options. 2

3 Specialty providers are highly unlikely to be available in rural areas. Comprehensive services are often not available. Few programs train professionals to work competently in rural places. Alaska Workforce Data Virtually the entire state is designated as a mental health professional shortage area, with most designations based on ratios of providers to population. In terms of actual numbers of professionals, Alaska ranks on average 9.8 among the 15 WICHE member states. The lowest rankings (14 th ) were for Clinical, Counseling, and School Psychologists, as well as Educational, Vocational, and School Counselors. Additionally, seven of the eleven (64%) behavioral health professional groups ranked between 10 th and 14 th in number of providers compared to other WICHE states. The vast majority of these providers are in the most densely populated areas. Alaska Occupational and Population Projections The Alaska Department of Labor and Workforce Development, Research and Analysis Section reports that Alaska employment is projected to increase 16.7%...between 2000 and On average, there will be a 47.3% increase in the need for behavioral health professionals. Mental health and substance abuse social workers are ranked 6 th among fastest growing occupations and are projected to have a 94.1% increase between 2000 and Professions with high projected percentage increases include medical and public health social workers (81.5%), mental health counselors (79.2%), and substance abuse and behavioral disorder counselors (76.2%). Alaska is one of the few WICHE states projected to have more people entering the workforce than leaving it by However, nearby lower 48 states are projected to have deficits in persons entering the workforce, which may require attracting workers from nearby states, including Alaska.\ In Alaska, for every th graders, only a little over 60% graduate from high school, about 28% enter college, and only 6% graduate within six years. All these numbers are lower than the national average and those from nearby states. Additionally, 52.1% of the occupational growth rate will require an Associate or Postsecondary Vocational Training and/or a Bachelor s or higher degree. 3

4 UA Behavioral Health Program Trends The UA system has 1,538 enrolled students who have declared their major in behavioral health programs. 307 students graduated from the UA system with behavioral health degrees in Enrollment in UA behavioral health programs has increased 8.2% since 1998, but degrees awarded decreased by 16.1%. However, the UA system s overall enrollment dropped in 1999 and 2000, including behavioral health programs, but has increased since that time. For instance, between 2001 and 2003, enrollment in behavioral health programs increased by 10.3% and degrees awarded increased 6.2%. Enrollment increased by 11.3% at UAA and 2.9% at UAF from 1998 to 2003 (UAF enrollment increased by 9% from ). These enrollments mirror the general trends of the UA system as a whole. Degree awards have remained relatively steady or have increased for the past several years after an initial decline in 1999 (e.g., UAF had a 41.2% decrease between 1998 and 2003, but this increased by 15.5% from 2001 to 2003). At UAA, two programs (Counseling and Guidance and General Psychology) have had increases in both enrollment and degrees awarded between 1998 and At UAF, the Social Work and Guidance and Counseling programs have had 44% and 36% increases in enrollment since Challenges and Barriers to Workforce Development Budgets that are set up to be competitive for scarce resources. A here today, gone tomorrow funding structure that makes it difficult to plan long range. The source of resources to support grow-your-own initiatives. The need to support students over a long period of time. State licensure and credentialing requirements have the effect of directing training, and billing and reimbursement are tied to licensure/credentialing. Brain drain of traditional age college students, resulting in a surplus of non-traditional students. 4

5 Behavioral Health Workforce Development Recommendations Based on the December 17 th, 2003 meeting regarding behavioral health workforce development in Alaska, educators in University of Alaska behavioral health programs recommend the following actions in the areas of collaboration, education, financing, and evaluation and research: Collaboration 1. Convene the first ever University of Alaska/Behavioral Health stakeholder discussion on workforce development. The workshop will be held in the spring of 2004, co-hosted by the State of Alaska Behavioral Health Division and the University of Alaska Associate Vice President for Health. It will include provider groups, policy boards, the Alaska Mental Health Trust, and urban and rural providers. The workshop will develop a behavioral health workforce vision and action plan. 2. Create collaborations to develop more rural-specific training and continuing education opportunities at all levels of competency. 3. Educate practitioners for changing roles; provide multidisciplinary training. 4. Explore how UA should respond to the integration of mental health and substance abuse disciplines. Education 1. Support innovative approaches using distance education to expand access to continuing education that enables rural persons to obtain professional training. 2. Improve access to higher education for underrepresented students. 3. Support the development of an articulated career pathway from paraprofessional through post-graduate training. Financing 1. Provide adequate funding to expand behavioral health professional training. 2. Offer financial incentives for graduates to return to or remain in Alaska to practice in rural and underserved areas. Evaluation and Research 1. Collect and analyze more data regarding articulation of coursework and training among UA behavioral health programs, as well as workforce needs. 2. Analyze factors that increase enrollments and declared majors, as well as factors that promote retention and degree completion. 5

6 TABLE OF CONTENTS Page Executive Summary... 2 Table of Contents... 6 I. Behavioral Health and Workforce in Alaska... 7 II. Workforce Shortages and Rural America... 8 National Workforce and Shortage Data WICHE Workforce Overview Alaska Workforce and Shortage Data Behavioral Health Disorder Data for Alaska Analysis of Alaska Occupational Forecast to Population Projections and Workforce III. University of Alaska Behavioral Health Programs Presentations University of Alaska Behavioral Health Program Data IV. Key Informant Interviews V. Group Discussion VI. Next Steps APPENDICES Appendix A: Designated Mental Health Professional Shortage Areas in Alaska Appendix B: Health Professional Shortage Area Criteria for Mental Health and Primary Care Appendix C: WICHE Member State Ranks for Behavioral Health Professionals Appendix D: Description of Current University of Alaska Programs in Behavioral Health Appendix E: Comments on Survey Questions Appendix F: Meeting Participants

7 Behavioral Healthcare and Workforce orce in Alaska In largely rural states, such as Alaska, there have been historical difficulties in recruiting and retaining an effective behavioral health workforce. Additionally, the recent report of the President s New Freedom Commission on Mental Health described in detail the significant problems facing mental or behavioral health systems throughout the country, particularly in rural areas. These include critical gaps in accessibility to services, critical shortages in the availability of providers and programs, impaired acceptability of care due to urban-based models or strategies and stigma, and establishing mental health policy without consideration of its rural impact, to name just a few. Significant projected changes in America s population over the next 20 years are a major focus of private and public entities, especially in the broad area of healthcare and, specifically, behavioral health. If population projections are accurate, more people will be leaving the workforce than entering it in many states, which will create competition among provider agencies for the most qualified individuals to fill the many positions likely to be open. Additionally, the problems of rural states in recruiting and retaining providers could very likely be compounded by the availability of higher paying jobs in more densely populated areas either within a state or in nearby states. Fortunately, Alaska has already taken up the call to train an effective and adequate behavioral health workforce to meet the needs of its citizens in the coming years. The call for western states to engage in formal efforts to develop a strong and able behavioral health workforce occurred in September, 2003, during a regional meeting in Reno, Nevada. The Reno Meeting was attended by top educators, providers, and legislators from western states, including representatives from Alaska. The meeting was facilitated by the Western Interstate Commission for Higher Education (WICHE) Mental Health Program, whose mission includes 1) assisting states in the improvement of systems of care for consumers and their families and 2) advancing the preparation of a qualified workforce in the West. Following this meeting, the University of Alaska (UA) system convened a meeting, facilitated by WICHE, of educators from disciplines spanning the behavioral health field to discuss how they can most effectively address workforce shortages, especially in rural areas. Behavioral health disciplines in the UA system (e.g., psychology, counseling, social work, nursing) already have a number of programs that provide specialized training in rural behavioral health, several of which provide training to persons living in the most remote and isolated communities to ensure quality care exists for those citizens. Furthermore, efforts to create a smooth articulation of coursework between different programs or from one level of training to the next is helping to facilitate interdisciplinary relationships and ensure that students training and experience are recognized and built upon. Despite these productive efforts, behavioral health educators in Alaska see that more work needs to be done and are committed to formalizing workforce development activities that ensure Alaska s residents needs are met. Thus, this report is designed to present a picture of the current state of Alaska s behavioral health workforce, including national and state-specific issues that 7

8 bear on developing an effective workforce. Specifically, this report will describe 1) behavioral health workforce shortages for rural Americans nationally and in Alaska, 2) Alaska s standing relative to 14 other WICHE states in their number of behavioral health professions, 3) data regarding the estimated prevalence of several disorders in Alaska, 4) the state s occupational forecast and population projections, 5) information regarding the University of Alaska s current or coming behavioral health training programs, including enrollment and degree award trends, 6) data collected prior to the meeting regarding attendees beliefs about aspects of workforce development, 7) group discussion of strengths and barriers to workforce development in Alaska, and 6) next steps to be taken to move the initiative forward. Workforce Shortages and Rural America President Bush s New Freedom Commission on Mental Health represents the first federal initiative to evaluate and reform America s mental health 1 system since the Carter Administration. The Commission s final report (see concluded that incremental reform of the mental health system is no longer a viable option; a fundamental transformation is needed. As indicated in the Vision Statement of the report: We envision a future when everyone with a mental illness will recover, a future when mental illnesses can be prevented or cured, a future when mental illnesses are detected early, and a future when everyone with a mental illness at any stage of life has access to effective treatment and supports essentials for living, working, learning, and participating fully in the community (p. 1). Moreover, the Commission s final report included a subcommittee report on unique problems in mental health care facing Americans living in rural or frontier regions. The committee identified several key issues with respect to mental health in rural America: 1. The federal government lacks a consistently applied definition of rural America. 2. There are critical gaps in accessibility to services. 3. There are critical shortages in the availability of providers and programs. 4. Acceptability of care is often impaired due to urban-based models and strategies. 5. A clearly defined plan to address long standing rural mental health disparities does not exist. 6. Mental health policy is routinely established without consideration of its rural impact. Rural America, as the map below indicates, covers the vast majority of geographical space in the country. However, rural is often defined and viewed by what it lacks, which is telling when considering behavioral health services. For example, consider these cold, hard facts related to rural areas in America: 1 Different states or federal agencies use different terms when referring to the range of problems and treatments that are held to have a biopsychosocial basis. Often, the terms mental health and substance abuse are used in a mutually exclusive manner and reflect the fact that many states have separate Divisions or Departments for each. However, Alaska recently combined these Divisions into a single Behavioral Health Division. Thus, use of the term behavioral health in this report is specific to Alaska, while mental health is the term used by some other referenced source of information. 8

9 More than 60% of rural Americans live in mental health professional shortage areas. More than 90% of all psychologists and psychiatrists, and 80% of MSWs, work exclusively in metropolitan areas. More than 65% of rural Americans get mental health care from their primary care provider. Finally, rural Americans enter care later in the course of their disorders, with more advanced symptoms, and require more intensive and expensive interventions. Map 1 Other facts of life regarding behavioral health services in rural America can be understood in terms of three general issues: accessibility, availability, and acceptability. Figure 1 below lists some of the major concerns related to these issues. However, a major issue concerns the availability of rural behavioral health professionals, which is dependent upon several interrelated factors. These include education, rural training opportunities, recruitment and retention activities, and continuing education and support. For instance, existing funding streams and training programs do not mandate a set of skills that lead toward rural competency (National Advisory Committee on Rural Health, 1994). Most specialty behavioral health (psychiatry and psychology) care is available locally only via itinerant providers (Wagenfeld et al., 1994). Furthermore, for rural persons with emergent behavioral health needs, law enforcement is often their emergency responder and transport out of the community for care (Larson et al., 1993). Many rural primary care sites are effectively staffed by physician extenders. However, difficulty in recruiting and retaining primary care physicians in rural communities is further complicated by the failure of the behavioral health field to develop a mid-level strategy for meeting the needs of rural people. Rural systems of care have been staffed by a de facto workforce strategy, which includes an array of non-doctoral level providers. There are no consistent standards or core competencies, and services are driven more by state scope of practice regulations and insurance reimbursement rules rather than science or competency (Bird et al., 1999; Ivey et al., 1998, Jerrell & Herring, 1983, Olson, 1983). In summary, rural America needs, but does not have, an 9

10 appropriate supply of competent, technically skilled professionals who have demonstrated knowledge and experience in rural/remote practice. Figure 1 Accessibility Problems in Rural Behavioral Healthcare Acceptability 1. Rural Americans travel further to provide and receive services. 2. Rural Americans are less likely to have insurance benefits for mental health care. 3. Rural Americans are less likely to recognize mental illnesses, and understand their care options. Availability 1. Rural areas suffer from chronic shortages of mental health professionals. 2. Specialty providers are highly unlikely to be available in rural areas. 3. Comprehensive services are often not available. 4. People in need often delay receiving care. 1. Few programs train professionals to work competently in rural places. 2. Care often is delivered by professionals without competence in rural culture or life. 3. Rural people often lack choice of providers. 4. Stigma. 5. Urban models are assumed to work for rural. National Workforce and Shortage Data Data regarding workforce shortages portrays a critical disparity in the availability of behavioral health professionals in rural areas. The National Advisory Committee on Rural Health (1993) noted that across the 3,075 counties in the United States, 55% had no practicing psychiatrists, psychologists, or social workers, and all of these counties were rural. Additionally, over 85% of 1,669 federally designated mental health professional shortage areas are rural (Bird et al., 2001; also see the map below). Multiple reports dating from the Eisenhower era Presidential Commission on Mental Health through today indicate that the problem is persistnet with little improvement (Bird et al., 1999; Flax et al., 1979; Larson et al., 1994; Murray & Keller, 1991). As indicated, few psychiatrists, psychologists, or clinical social workers practice in rural counties, and the ratio of these providers to the population worsens as rurality increases (Holzer et al., 2000). For instance, Holzer and colleagues studied the availability of health and mental halth providers by population density (see They found that only about 10% of frontier 2 counties had psychiatrists and less than 1% of very 2 The definition of frontier is based on that of the Frontier Mental Health Services Resource Network, which is a county with less than 7 persons per square mile (it is slightly altered to be 2 to 6.9 persons per square mile, to include the categorization very frontier ). 10

11 frontier 3 counties had any psychiatrists. These rates of psychiatrists per 100,000 people for frontier and very frontier counties are 1.3 and 0.1, respectively. Additionally, only 13.3% of very frontier counties had psychologists (13 per 100,000), although frontier counties had 43.1% (18.1 per 100,000). For very frontier counties, 18.5% had social workers (12.8 per 100,000), while 23.4% exist in frontier counties (9.1 per 100,000). Map2: Designated Mental Health Professional Shortage Areas: Nationally 4 Additionally, due to declining nursing school graduates, an aging workforce and general population, declines in wages, and alternative job opportunities, nursing shortages are expected to reach 20% by 2020 (Buerhaus et al., 2000). These workforce shortages are worse for specialty areas (e.g., children s behavioral health, older adult behavioral health), and are so great they are identified as a hole in the safety net in a recent report to the Secretary of the U.S. Department of Health and Human Services (National Advisory Committee on Rural Health, 2002). WICHE Workforce Overview The states composing the WICHE West are some of the most rural in the nation. Unless efforts are made to improve and expand the workforce, shortages that have existed will continue and intensify, particularly in behavioral health, for a number of reasons. First, there will be an increasing demand for services. America s population is aging, which brings with it greater potential for both physical and psychological problems. On the positive side, scientific and technological advances continue to proliferate and alternatives to institutional care are multiplying. However, the cost of these services, like all new products, will be initially high and it is not clear that the full demand for services will be met solely through these means. 3 Very Frontier is a county with 0 to 1.9 persons per square mile. 4 Health professional(s) shortage area means any of the following which the Secretary determines has a shortage of health professional(s): (1) An urban or rural area (which need not conform to the geographic boundaries of a political subdivision and which is a rational area for the delivery of health services); (2) a population group; or (3) a public or nonprofit private medical facility. A single county can have all three. For more information regarding the specific criteria for HPSA, see Appendix?? or go to Also see (primary care) or (mental health). 11

12 Furthermore, the regulatory and administrative environments are increasingly complex and involve continuing changes in healthcare financing. With these financial concerns come pressures to achieve high efficiency in all practice settings. As health care costs escalate, fewer people are choosing to enter or remain in health care and human service professions. Salaries and benefits are not competitive for many direct care occupations (e.g., residential and community behavioral health aides, psychiatric nurses, therapists, case managers, and others). Working conditions in healthcare are challenging and the healthcare workforce is aging. Many professionals view rural locations as too isolated and undesirable. Additionally, the cost of education is increasing and education in many rural areas is inaccessible. Alaska Workforce and Shortage Data According to the Census Bureau, Alaska has a land area of 571,951 square miles and a population of 634,892, which equals 1.1 persons per square mile. This clearly falls in under the very frontier category, and one would then expect low numbers of behavioral health professionals. As the map below indicates, virtually the entire state is designated as a mental health professional shortage area (which is also true for primary care; see Appendix A for current information on counties in Alaska with MHPSA designation). Map 3: Mental Health Professional Shortage Areas According to Alaska s Division of Occupational Licensing, the following data is current for the behavioral health disciplines regarding licensed professionals: Psychologists (151), Psychologist Associates (49), Marriage and Family Therapists (92), Licensed Professional Counselors (287), and BSW, MSW, LCSW Social Workers (399). Taken together, this equals 978 licensed behavioral health professionals. Another way to understand the current state of Alaska s behavioral health workforce is to compare the number of professionals within a given discipline to that of other states. The Bureau of Labor Statistics (BLS) maintains data for each state regarding 11 behavioral health disciplines, including Clinical, Counseling, and School Psychologists; Substance Abuse and Behavioral Disorder Counselors; Educational, Vocational, and School Counselors; Marriage and Family 12

13 Therapists; Mental Health Counselors; Child, Family, and School Social Workers; Medical and Public Health Social Workers; Mental Health and Substance Abuse Social Workers; Psychiatrists; Psychiatric Technicians; and Psychiatric Aides. As can be seen, some professionals are grouped together even though they may have some differences in professional focus or activities (e.g., Clinical, Counseling, and School Psychologists). Table 1 below presents BLS data for each of these disciplines in Alaska for 2002 (their most recent data), including the number of employed professionals, number of professionals per 100,000 persons in the state, as well as the ranking of a given profession among the 15 Western states that compose WICHE. The WICHE rankings regard both the number of professionals and number of professionals per 100,000 (see the tables in Appendix C for each state s rankings). In terms of actual numbers of professionals, Alaska on average ranks 9.8 among the 15 WICHE states. The best ranking (4 th ) is for Substance Abuse and Behavioral Disorder Counselors, while the lowest ranking (14 th ) was for Clinical, Counseling, and School Psychologists, as well as Educational, Vocational, and School Counselors. Additionally, seven of the eleven (64%) professional groups ranked between 10 th and 14 th in number of professionals. Table 1 Behavioral Health Occupations 2002 Occupation Title Employment Rank Among 15 WICHE States Per 100,000 Rank Among 15 WICHE States Clinical, Counseling, and School Psychologists th th Substance Abuse and Behavioral Disorder Counselors th st Educational, Vocational, and School Counselors th th Marriage and Family Therapists* 60 8 th th Mental Health Counselors* th th Child, Family, and School Social Workers th th Medical and Public Health Social Workers th rd Mental Health and Substance Abuse Social Workers th nd Psychiatrists* th th Psychiatric Technicians* 80 7 th th Psychiatric Aides* th th * Data were not available for all states. (source: When considering where behavioral health professionals rank among WICHE states in terms of the number of professionals per 100,000 persons, the numbers improve. For instance, on average, Alaska ranks 4.1 among WICHE states, with the best ranking (1 st ) again being for Substance 13

14 Abuse and Behavioral Disorder Counselors. Clinical, Counseling, and School Psychologists again have the lowest rank (6 th ), which they share with Psychiatric Technicians. Several caveats should be kept in mind when considering these rankings. First, these comparisons are among the 15 WICHE states and rankings might be different if looking at the whole country. Second, data was not available from BLS for given professions (e.g., Marriage and Family Therapists) in all states, which could also affect rankings. Finally, despite Alaska having fairly high rankings when considering the number of professionals per 100,000 persons, Map 4 below clearly indicates that the vast majority of the state has less than 1.0 persons per square mile and that there are very few densely populated areas. Map 4 Furthermore, Maps 5 and 6 show the distribution of mental health professionals and other health professionals, respectively, across the state. These maps were derived from a 1999 project called Ch'eghusten', a collaborative effort with the Fairbanks Native Association, Tanana Chiefs Conference, and UAF that came out of a three year Circles of Care strategic planning grant funded by the Substance and Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services. 14

15 Map 5: Derived from Ch'eghusten', a multi-year Circle of Care grant project funded by SAMHSA. M = Masters; B = Bachelors; P = Associate or Certificate Map 6: Derived from Ch'eghusten', a multi-year Circle of Care grant project funded by SAMHSA. 15

16 The distribution of mental health professionals indicates that there were only three psychiatrists and three doctoral-level psychologists in Fairbanks and none anywhere north of that line in One psychiatrist provided services to remote areas north of Anchorage on an itinerant basis. The distribution is similar for health professionals, although there are more of these personnel than mental health professionals. However, most of the medical services in remote areas are provided by persons with lower-level degrees (e.g., community health aide/practitioner). Additionally, there is a disparity in the ethnic makeup of degree-holding practitioners such that those with the highest degrees tend to be Caucasian while the majority of those with lower-level degrees are Alaska Natives. Finally, those with lower-level degrees and training are typically the ones who must deal with the most difficult crises in rural/remote areas. It should be noted that limited information exists on service level need at the regional and community level, and although these maps provide some estimate of where mental health professionals are distributed, it is likely that some of these numbers have changed between 1999 and today. However, the general point that there are limited numbers of professionals in most areas of Alaska still holds. Behavioral Health Disorder Data for Alaska As indicated earlier, virtually the entire state of Alaska is designated as a mental health professional shortage area, most of which is based on a single county population to provider ratio (see Appendix B for specific criteria). Thus, by definition, there is an unmet need of treatment for many persons with behavioral health disorders. Estimating the unmet need for treatment requires significant data sources, some or all of which may be available through a given state s mental or behavioral health division. For instance, Medicaid expenditures for both mental health and substance abuse treatment provide a partial but significant estimate of the number of persons being treated, which can then be compared to prevalence estimates of various disorders in a state s population. At present, data regarding the number of persons treated for behavioral health disorders in Alaska has not been gathered for this report. However, Table 2 below provides estimates of the prevalence of several disorders for counties in Alaska. The disorders are Schizophrenia, Substance Abuse and Dependence, and Affective Disorders. Schizophrenia was chosen to represent serious and persistent mental illness (SPMI), while the others were chosen because they subsume a fairly broad number of disorders in their respective categories. A link to the website where this data is available is presented under the table. Furthermore, the website offers data on more specific disorders and also divides data by age, race, sex, marital status, and several other variables. The prevalence estimates are based on the Epidemiologic Catchment Area Survey [U.S. MH Estimation Project (ECA & 1990 Census)]. Although 1990 census data formed the basis of the estimates, the percentage of cases in each of the three categories are presumed to have remained relatively stable until 2000, when the most recent census was conducted. Therefore, the percentages from the original study were applied to census data from 2000 for the counties listed to provide updated estimates. 16

17 As can be seen at the bottom of the table, Substance Abuse and Dependence have the highest number and percent of cases, followed by Affective Disorders then Schizophrenia. The average percent of cases of Schizophrenia is estimated to be 1%, with a range of.89% (Wrangell- Petersburg Census Area) to 1.8% (Northwest Arctic Borough). For Substance Abuse and Dependence, the average for all counties is estimated at 8%, with a range of 7.4% (Wrangell- Petersburg Census Area) to 11.2% (Aleutians West Census Area). Finally, Affective Disorders are estimated to be an average of 6%, with a range of 3.81% (Lake and Peninsula Borough) to 6.37% (Anchorage Borough). The total number of estimated cases for the state is 95,140 (15% of the population). Table 2: County Estimates for Adult Population in Alaska Extrapolated from 1990 Schizophrenia Substance Abuse & Dependence Affective Disorders County Population Cases % Cases % Cases % Aleutians East Borough 2, Aleutians West Census Area 5, Anchorage Borough 260,283 2, , , Bethel Census Area 16, , Bristol Bay Borough 1, Dillingham Census Area 4, Fairbanks North Star Borough 82, , , Haines Borough 2, Juneau Borough 30, , , Kenai Peninsula Borough 49, , , Ketchikan Gateway Borough 14, , Kodiak Island Borough 13, , Lake and Peninsula Borough 1, Matanuska-Susitna Borough 59, , , Nome Census Area 9, North Slope Borough 7, Northwest Arctic Borough 7, Prince of Wales-Outer Ketchikan Census Area 6, Sitka Borough 8, Skagway-Yakutat-Angoon Census Area 3, Southeast Fairbanks Census Area 6, Valdez-Cordova Census Area 10, Wade Hampton Census Area 7, Wrangell-Petersburg Census Area 6, Yukon-Koyukuk Census Area 6, Total 624,231 6,496 1% 51,073 8% 37,571 6% 17

18 There are several caveats to consider when looking at this data. First, since these are estimates of disorders based on county percentages from a 1990 study, it is possible that there is some variation due to population changes or other unaccounted for factors. Also, the categories of disorders obviously do not include all possible disorders and, therefore, one can assume that there is a somewhat higher percentage of persons with behavioral health disorders. Furthermore, this estimates are for the adult population and do not include children s disorders. However, to the extent that the data is a fairly reasonable picture of the number of adults needing treatment, future analyses can calculate unmet need based on prevalence estimates. Furthermore, such analyses will help to inform educators about where training efforts can or should be focused. Analysis of Alaska Occupational Forecast to 2010 The Alaska Department of Labor and Workforce Development, Research and Analysis Section have produced a document regarding the state s occupational forecast to the year Regarding the state overall, they write Alaska employment is projected to increase 16.7% from 302,255 to 352,693 between 2000 and These projected openings are the combined result of employment growth and net separations from the occupations and do not include jobs resulting from employee turnover. Additionally, they report that Although a significant amount of the occupational growth will be found in large size occupations, fast growing occupations are another source of employment opportunities for qualified applicants. Of the ten fastest-growing occupations with base year employment of 75 or more, nine are associated with health services or hospitals. The forecast need for health care workers in this projection period can be further established as 22 of the top 25 fastest growing occupations are health related occupations... It is expected as higher levels of education are attained, workers will experience higher earnings and lower unemployment rates. With this said, jobs will continue to be available for workers at all levels of educational attainment. Approximately 17 percent of the "new" jobs that is, jobs that will be created due to growth in the economy will require a bachelor's degree or above. Nearly 46 percent of new jobs during the projection period are expected to require some type of specialized or formal training ranging from medium term (one to 12 months) to an associate degree or postsecondary vocational training. About 17 percent of the new jobs, usually low-paying, will require less than one month's training and experience. Only about 12 percent of new jobs projected will require work experience. As can be seen in the graphs below, Mental Health and Substance Abuse Social Workers are ranked 6 th for fastest growing occupations and are projected to have a 94.1% increase between 2000 and 2010 (see Table 3 below). Additionally, 52.1% of the occupational growth rate will require an Associate or Postsecondary Vocational Training and/or a Bachelor s or higher degree. Table 3 below presents projections for behavioral health professionals from 2000 to On average, there will be a 47.3% increase in these professionals, with a range of 10.8% (psychiatric aides) to 94.1% (mental health and substance abuse social workers). Other disciplines with high projected percentage increases include medical and public health social workers (81.5%), mental health counselors (79.2%), and substance abuse and behavioral disorder counselors (76.2%). Thus, despite data that suggests there are substantial numbers of professionals already in these four particular occupations (at least compared to the 14 other WICHE states), there is a projected 18

19 need to increase the number of professionals in these disciplines to address the needs of Alaskans. Graph 1 Graph 2 19

20 Table 3 Employment Statewide Occupation % Change Clinical, Counseling & School Psychologists Substance Abuse & Behavioral Disorder Counselors Marriage & Family Therapists Mental Health & Substance Abuse Social Workers Child, Family & School Social Workers Medical & Public Health Social Workers Mental Health Counselors Educational, Vocational & School Counselors Psychology Teachers, Postsecondary Psychiatrists Psychiatric Technicians Psychiatric Aides Population Projections and Workforce In terms of population growth, Alaska, fortunately, is one of the few WICHE states (along with California, Hawaii, and New Mexico) projected to have more people entering the workforce than leaving it by 2025 (see Table 4 and Graph 3 below). However, the closest lower 48 states of Oregon, Washington, and Idaho are projected to have deficits in persons entering the workforce. This may motivate businesses and agencies in these states to attract potential workers from nearby states, including Alaska. In addition to the possibility that nearby states may draw off Alaska s workforce population, another complicating factor regards educational achievement. Graph 4 (below) compares students in Alaska with those from the states of Washington, Oregon, and Idaho, as well as the national average. For every th graders, only a little over 60% graduate from high school, about 28% enter college, and only 6% graduate within six years. All these numbers are lower than the national average and those from nearby states. Thus, Alaska has a relatively small pool of persons who go on to college and an even smaller pool that graduates within six years. Attracting the number of people from this group will be a significant challenge for educators. Table 4: Population Projections for Alaska, Idaho, Oregon, and Washington State Actual Pop. Ages (2000) Projected Pop. Ages (2025) % Change 2000 to 2025 Actual Pop. Ages 65+ (2000) Projected Pop. Ages 65+ (2025) % Change 2000 to (2025) Entering (+) vs Leaving (-) workforce by 2025 AK 400, , ,699 92, ,559 ID 779, , , , ,314 OR 2,136,696 2,387, ,177 1,054, ,140 WA 3,718,130 4,477, ,148 1,580, ,420 20

21 Graph 3 Projected Workforce Changes Population 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 Projected Pop. Ages (2025) Projected Pop. Ages 65+ (2025) 0-1,000,000 AK ID WA OR State Entering (+) vs Leaving (-) workforce by 2025 Graph 4 Student Pipeline Data (2000) 120 %of Students For every 100 Ninth Graders Graduate from High School Enter College Are Still Enrolled Their Sophomore Year Graduate within 150% Time 0 Alaska Washington Oregon State Idaho United States 21

22 The University of Alaska (UA) System has a number of behavioral health programs through their campuses at Anchorage (UAA) and Fairbanks (UAF). Additionally, distance education courses for some of the programs are offered at smaller campuses throughout the state, including frontier areas. UAA has programs in Clinical Psychology, Counseling and Guidance, Counseling Psychology, Developmental Disabilities, Disability Services, Human Services, Psychology (General), and Social Work. UAF offers programs in Community Health, Community Psychology, Guidance and Counseling, Human Services, Human Service Technology, Psychology, Rural Human Services, and Social Work. Presentations Representatives from behavioral health disciplines in the UA System were asked to briefly describe their respective programs and/or initiatives. Part of this process was aimed at increasing knowledge of important training activities across the University system, but also to identify areas of potential collaboration, overlap, articulation pathways, and, of course, the impact of training programs on behavioral health workforce development. The table below outlines key aspects of these programs (narrative descriptions are presented in Appendix D). Table 5 Program Degree Program Description Rural Human Services Program UAF College of Rural Alaska Human Services Program University of Alaska Behavioral Health Programs Certificate A.A.S. The curriculum combines indigenous values, personal growth, and entry-level skill training. Students are trained to perform entry level behavioral health work (counseling, referral, outreach, etc.). Upon completion, most graduates work in their own villages, tribal health corporations, or rural behavioral health centers. Credits are applicable to statewide substance abuse certification. Some graduates articulate into programs in other disciplines, e.g., human services and social work, with a few in psychology. Rural HSV program can be full or part-time, and courses are primarily via audioconferencing. Blended cohort model is offered, which involves month series of courses that couple with RHS credits to complete the AAS degree. Blended delivery model reflecting Best Practices of Adult Learning. One can also transfer in from other programs via articulation agreements between other UA programs and campuses. 22

23 UAA Psychology B.A., B.S. M.S. Upper level coursework (e.g., Best Practices in Mental Health, Field Experience in Psychology I & II) that emphasizes community service and prepares Baccalaureates to enter the job market. Center for Human Development: provides interdisciplinary pre-service preparation, continuing education, and community training. Learn as You Earn Leadership Institute Direct Service Workforce Training Initiative A scientist-practitioner model that emphasizes both research and clinical skills. Prepares students for professional practice in clinical psychology through skill development in psychotherapy, assessment, and research. The program has four tracks, which allows students to foster specialized interests or begin developing specialized skills. These four tracts are: Research, Clinical, Public Service, and Addictive Behavior. Conducted the 2002 Social Services Job Survey that evaluated the social service job market in Southcentral Alaska. UAF Psychology UAA Social Work B.A., B.S. M.A. Ph.D. (2006) B.S.W. (and honors track) M.S.W. Focus on providing breadth and depth in the science and profession of psychology with a commitment to honoring diversity and promoting human welfare. Developing a mechanism to allow HSV and RHS students to transition into the undergraduate program. Community psychology program designed to train practitioners for rural and cross-cultural settings who are capable of working with communities, groups, and individuals to create and sustain healthy communities. The program integrates community psychology and clinical counseling psychology perspectives, with all courses infused with a multicultural focus. The program is available on both a part-time and full-time basis, including the option of distance delivery via audio conferencing. Fulfilling need for doctoral-level psychologists who are equipped to meet the needs of Alaskans, particularly in rural Alaska, can serve as faculty members within the UA system, and who can conduct research on pressing issues in Alaska. The focus of the program will be clinical, community, and rural indigenous, and the projected start date is fall The educational purpose of the UAA BSW program is to prepare graduates for beginning professional social work practice; builds on a broad based liberal arts education; overall emphasis on client-centered problem solving. The Honors track is designed to prepare undergraduate students for leadership in social work practice. Graduating with honors results in automatic admission to MSW Program. The MSW Program has on-sight and distance delivered programs. Courses are offered in a mixed delivery plan students attend four days of on-sight intensive education at the beginning of the semester (one-third of class time), one-third is delivered via audio conference, and one-third is delivered via the Internet. Developing two Graduate Certificate Programs to meet the demand for advanced preparation in 1) social work management and 2) clinical practice. Current MSW students and MSW alumni will be eligible to apply for the certificate programs. 23

24 UAF Social Work UAA Gerontology Program B.A. Level 1 Level 2 Level 3 The overall goal is the provision of an applied, professional curriculum, containing a strong liberal arts foundation to prepare students for beginning social work practice with special emphasis in diverse cultural groups and rural populations. To be responsive to the needs of Alaska s rural communities and people, all students in the program are required to take the Alaska Native Studies class, Native Cultures of Alaska, and the Social Work course, Rural Social Work Practice. Administers two grants, the Title IV-E Child Welfare Training grant, which affords five students stipends and supervision at the child welfare office each year, and the Northern Region Geriatric Education Center grant, which provides education and training on elders in Fairbanks and throughout rural Alaska. The UAF Social Work Advisory Council is made up of representatives from social service agencies and students from both rural communities and Fairbanks, and annually administers a nationally standardized test to all students in the program on social work curriculum content areas. It is anticipated that many of these students will continue their education and pursue a masters degree in either the UAF Community Psychology program or the UAA Masters in Social Work program, both of which are offered through distance delivery. Utilizes a Career Ladder approach to training to be able to adequately respond to an increasing older population. Paraprofessional Training: Project focuses on developing a strategic plan, recruiting students, piloting credit and non-credit courses, and establishing a clearinghouse and lending library. Will Provide UA the tools to comprehensively address the critical shortage of direct service workers in the long-term care industry. Academic Education and Training: provide opportunities for education, training and research in the area of aging (undergraduate and graduate). Professional Training and Education: Mission is to advance access to quality health care for older Alaskans by promoting multicultural, interdisciplinary and discipline specific geriatric education for health professions faculty, health care providers, and current and aspiring health care professionals. The career ladder approach has been positive and mutually benefiting, as gerontology/geriatrics is multidisciplinary and interdisciplinary by nature of its content. Thus, these programs have a distinct advantage in that faculty and community professionals have a common base of understanding to begin with. A certificate of completion for paraprofessional training will be developed and available for both family caregivers and direct service care workers in the long-term care industry. A minor in gerontology already exists at UAA; however, we expect that this will be augmented with certificates for currently matriculating undergraduate and graduate students throughout the UA system. 24