Bridging the Behavioral Health Gap in Serious Illness Care: Challenges and Strategies for Workforce Development

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Available online at www.sciencedirect.com

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Special Issue Article

Bridging the Behavioral Health Gap in Serious Illness Care: Challenges and Strategies for Workforce Development Daniel Shalev, M.D.1, Mary Docherty, M.A., M.B.B.S.(Hons.), M.R.C.P., M.R.C.Psych.1, Brigitta Spaeth-Rublee, M.A., Nicole Khauli, M.P.H., Stephanie Cheung, M.D., Jon Levenson, M.D., Harold Alan Pincus, M.D. ARTICLE INFO

ABSTRACT

Article history: Received July, 1 2019 Revised August, 31 2019 Accepted September, 3 2019

Comorbidity with behavioral health conditions is highly prevalent among those experiencing serious medical illnesses and is associated with poor outcomes. Siloed provision of behavioral and physical healthcare has contributed to a workforce ill-equipped to address the often complex needs of these clinical populations. Trained specialist behavioral health providers are scarce and there are gaps in core behavioral health competencies among serious illness care providers. Core competency frameworks to close behavioral health training gaps in primary care exist, but these have not extended to some of the distinct skills and roles required in serious illness care settings. This paper seeks to address this issue by describing a common framework of training competencies across the full spectrum of clinical responsibility and behavioral health expertise for those working at the interface of behavioral health and serious illness care. The authors used a mixed-method approach to develop a model of behavioral health and serious illness care and to delineate seven core skill domains necessary for practitioners working at this interface. Existing opportunities for scaling-up the workforce as well as priority policy recommendation to address barriers to implementation are discussed. (Am J Geriatr Psychiatry 2019; &&:&&−&&)

Key Words: Behavioral health integrated care serious illness care palliative care psychiatric comorbidity workforce staff development

From the Columbia University Medical Center (DS, SC, JL, HAP), New York, NY; and the New York State Psychiatric Institute (DS, MD, BS-R, NK, HAP), New York, NY. Send correspondence and reprint requests to Harold Alan Pincus, M.D., Department of Psychiatry at Columbia University, New York State Psychiatric Institute, New York City, NY 10032. e-mail: [email protected] © 2019 Published by Elsevier Inc. on behalf of American Association for Geriatric Psychiatry. https://doi.org/10.1016/j.jagp.2019.09.003 1 Both the authors contributed equally to this work.

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ARTICLE IN PRESS Bridging the BH Gap in SIC

INTRODUCTION

T

here is a high prevalence of behavioral health (BH) comorbidity among individuals living with serious medical illnesses.1,2 In the context of historical silos in behavioral and physical healthcare in the United States (US), these comorbidities are poorly treated3 and associated with poor outcomes and high cost.4−6 The current workforce is ill-equipped to address the complex needs of individuals with comorbid serious illness and BH disorders.7 Specialist BH/serious illness care (SIC) providers are scarce, and there are gaps in core BH competencies among SIC providers.7 A number of sociocultural and demographic factors create urgency in redressing these gaps including an aging population, increasing chronic illness burdens, and ethical complexities at the intersection of SIC and BH, such as debates over medical assistance in dying. This paper presents an overview of the current challenges in workforce development at the BH/SIC interface and proposes recommendations to address them. We summarize the prevalence and consequences of BH/serious illness comorbidity, the scale of workforce gaps at this intersection, and current workforce barriers to delivery of integrated BH and SIC. We then present a common training framework of core BH/SIC clinical competencies. We argue that training alone will not be sufficient to close service gaps and accordingly, the training framework presented ties required competencies to the clinical functions needed to implement integrated BH/SIC. We conclude by reviewing existing opportunities to skill and scale-up the workforce and propose policy recommendations to address barriers to implementation. Our framework is derived from a model of BH/ SIC integration that builds upon existing work in primary care BH integration, palliative medicine, and geriatrics.7,8 Full details of the methodology are available in the corresponding paper presenting our BH/ SIC care model.8 In brief, both the model and subsequent competency framework presented here are based on a mixed-method study with four components. First, we conducted a systematic literature review surveying the prevalence of BH conditions in individuals with serious medical illness, clinical tools for BH care in SIC, and policy issues at the intersection of BH and SIC (full PRISMA table is available in

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Cheung et al. 2019).8 Second, we surveyed program leaders and academic experts across relevant disciplines (including for example, palliative care, psychiatry, geriatrics, and nursing) about best practices and barriers to implementation of BH/SIC components (55 responses of 113 surveys sent). Third, we subsequently conducted 23 semistructured interviews with selected experts working either programmatically or academically at the intersection of SIC and BH on the state of BH in SIC. And fourth, we convened an expert advisory panel to provide iterative feedback on the model and competencies.

SERIOUS ILLNESS AND BH COMORBIDITY Serious illness is defined as a health condition that carries a high risk of mortality and either negatively impacts a person’s daily function or quality of life or excessively strains their caregivers;9 examples include cancer, stroke, heart disease, chronic obstructive pulmonary disease, and end-stage renal disease. SIC involves the specialty and subspecialty care of such disorders on a spectrum that includes both disease-modifying and palliative care delivered across settings including outpatient, acute inpatient, home care, and care in other facilities (nursing homes, rehabilitation, and hospice units). A recent Commonwealth Fund survey of over 1,500 individuals living with serious illnesses and their caregivers found that approximately 62% of seriously ill individuals report feelings of anxiety, confusion, or helplessness; nearly half have emotional or psychological problems; and many struggle with loneliness.10 Among patients with serious illnesses, rates of depression and anxiety can exceed 50%.11,12 BH comorbidities beyond depression and anxiety, including trauma-related disorders and substance use disorders, are also significant.13,14 BH morbidities are associated with increased mortality among individuals with serious illnesses.3,11 Patients with serious mental illnesses, such as schizophrenia and bipolar disorder, fare especially poorly with increased chronic-illness mortality and decreased access to palliative care.15,16 Additionally, BH diagnoses are associated with increased hospitalization rates and SIC costs.17,18 For instance, the majority of Medicaid’s highest cost beneficiaries with disabilities have co-occurring behavioral and physical morbidities.19

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ARTICLE IN PRESS Shalev et al. While the etiology of disparities in outcomes for patients with comorbid BH and medical disorders is not fully understood, gaps in training among clinicians may manifest in lower quality treatment provision.20 Over past decades, several effective models to integrate BH into primary care have been developed (e. g., the Collaborative Care Model, Medicaid Health Home, Patient-Centered Medical Home.21−23 These have been tested and implementation strategies developed for general23,24 and specific populations including those with serious mental illnesses and/or substance use disorders,22,23 and in the geriatric population.25 Such models have influenced the provision of psychosocial care in certain serious illness settings, most notably in cancer care, but there remains a dearth of crossdiagnostic models for providing BH to individuals with serious illnesses across settings.26,27 Many of the barriers described for effective integration of BH into primary care including access, stigma, and lack of accountability for meeting the BH needs of patients apply to SIC settings.28,29 Workforce issues have been identified as key in meeting the BH needs of people living with serious illness.10 Competency frameworks have been proposed for integrated BH and primary care but these have not extended to the serious illness setting.30

WORKFORCE GAPS ACROSS THE INTERDISCIPLINARY TEAM The distinct clinical challenges presented by serious illness and BH comorbidity require tiers of specialization across BH and SIC providers. Interdisciplinary teams must provide holistic care addressing concurrent behavioral, physical, and social needs. Interdisciplinary team structure may vary according to demand, staff availability, and local service configurations. Teams must have the capacity to provide pharmacologic and psychosocial behavioral healthcare and appropriate medical care. There are current significant shortfalls in clinicians capable of crossing the divide between BH and SIC. Below, we focus particular attention on workforce gaps at the BH/SIC interface. BH Providers BH providers working at the interface of BH and SIC have varying degrees of medical training. Psychiatrists,

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psychiatric registered nurses and advanced practice nurses, and physician assistants working in psychiatry are all trained in the medical model, however, exposure to SIC may be limited. In particular, there are few mandates for SIC training in most education pathways.31,32 Lack of standardized curricula means that exposure to pertinent aspects of SIC such as advance care planning and pain management may not be guaranteed. However, BH experts with appropriate training can contribute skills in communicating with patients with mental illness or cognitive impairments, knowledge about how BH comorbidity may impact decision-making, and contribute to a team’s capacity to recognize counter-transferential reactions in the serious illness setting. Integration of BH expertise into SIC may increase recognized components of wisdom — and wise decision-making — including pro-social attitudes, reflectiveness, and tolerance of uncertainty.33 In order to gain SIC expertise, psychiatrists can pursue additional fellowships in geriatric psychiatry, consultation-liaison psychiatry (psychiatry in medically ill patients), or palliative medicine, all of which lead to subspecialty board eligibility. Nurse practitioners can complete dual-training programs, and like physician assistants, they may have opportunities for further postgraduate training toward the development of BH/SIC expertise through specialty certification programs.34 However, there are significant workforce capacity issues. First, only a relatively small proportion of the clinician workforce pursues BH expertise. In the past 20 years, the psychiatric workforce has increased by only 12% compared to a U.S. population increase of about 37%.35 There is particular scarcity of psychiatrists with special expertise in SIC with only 1,250 board-certified consultation-liaison psychiatrists, 1,505 geriatric psychiatrists, and under 100 palliative care psychiatrists.36 In addition, only approximately 3%−5% of the registered nurse workforce and 1.4% of the physician assistant workforce in the U.S. work in BH37 and only 3.8% of the 248,000 U.S. nurse practitioners are psychiatrically trained.38 Across all BH providers, capacity, and access issues are compounded by geographic disparities with unequal rural-urban distributions of clinicians.39 BH providers including psychologists and social workers may have access to additional training opportunities to improve their proficiency. Social workers are well-established members of palliative

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ARTICLE IN PRESS Bridging the BH Gap in SIC care teams but there are no reliable data on what proportion of the 600,000 plus social workers in the U.S. work in the SIC setting.40 There are limited opportunities for such exposure in early training,41 and palliative care social work core competencies have not been widely adopted for training purposes.42 Opportunities for postgraduate professional development do exist; the National Association of Social Workers and National Hospice and Palliative Care Organization offer specialty certificates for hospice and palliative care social workers contingent on additional supervision and continuing education modules in SIC.43 Clinical psychologists do not undergo medical training but can pursue training in health psychology, which deals with the intersection of behavioral and physical health. Although this training is not standardized nationally, there is an examination and board certification process through the American Board of Professional Psychology.44 There are no publicly available data on what proportion of the estimated 94,000 active clinical psychologists in the U.S. work in SIC settings,45 but approximately 3%−4% of psychologists focus on the care of older adults, an area of potential overlap.46 Despite the known benefits of clinical psychologists in the palliative care workforce, their role in this setting is not operationalized. There is increasing recognition of the need to look beyond conventional clinical roles and to optimize the range of perspectives and skills offered by other professions such as occupational therapists, case managers, chaplains, community health workers, and peer specialists. Data on the training and skillsets offered by these team members in BH/SIC is also lacking, and research needed to better characterize their contributions. For instance, chaplains may actively contribute to goals-of-care conversations and tend to interpersonal and familial relationships similarly to BH providers.47 A fundamental challenge in strategically increasing workforce capacity lies in the absence of census data both on core professions working at the BH/SIC interface but also in the emergent roles. Emerging paraprofessional occupations such as care coordinator, patient navigator, health coach, and community health worker are not included in the Standard Occupational Classification.48 Paraprofessionals may not receive formalized BH or SIC training but there are some models of relevant training.49 They could fulfill important functions in supporting longitudinal care management, caregiver support, self-management, and connection to social

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service organizations; but without appropriate documentation of these roles, workforce planning and development is seriously hindered. Overall BH providers, both with and without medical training, are tasked with working at the intersection of BH and SIC but current paradigms in training, certification or accreditation, and workforce data collection have not kept up with evolving clinical roles and responsibilities at this interface. SIC Providers Providers in specialty medical care such as geriatrics, oncology, cardiology, surgery, and neurology receive limited BH training. There are generally no BH milestones or experiential requirements for nonpsychiatric postgraduate medical training with the exception of neurology, which requires a brief psychiatry rotation.50 Nonphysician specialty care professionals including nurse practitioners and physician assistants, as well as registered nurses, also receive limited and uneven exposure to BH training.51−53 Palliative care providers may have more training in BH than other specialists. The Accreditation Council on Graduate Medical Education milestones for hospice and palliative medicine subspecialty training mandate proficiency in assessment and management of psychosocial distress.50 The American Academy of Hospice and Palliative Medicine also identifies a number of training competencies in diagnosis and management of neuropsychiatric disorders such as depression and delirium.54 Similarly, credentialing as a certified hospice nurse through the Hospice and Palliative Nurses Association requires knowledge of psychosocial aspects of SIC.55 Despite these requirements, few advanced palliative care training programs require physicians, nurse practitioners, physician assistants, or nurses to undergo practical BH experience with supervision by BH experts. Accreditation Council for Graduate Medical Education (ACGME) requirements for physician fellowship programs in hospice and palliative medicine do not require any formal BH clinical experiences.56

ADDRESSING WORKFORCE GAPS: A COMPETENCY FRAMEWORK Increased training of BH practitioners alone will not be sufficient to close workforce gaps. A workforce

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ARTICLE IN PRESS Shalev et al. strategy is required that addresses three core aspects of capacity building. First, in the context of changing clinical roles and responsibilities in the SIC setting to address BH needs, BH literacy must be considered a requirement for all SIC practitioners. Second, training and education responses need to target proficiency for new trainees and the existing workforce. Third, training must support the development of skills and competencies that align with the core clinical functions required to deliver integrated BH/SIC. We propose a common framework of training competencies within seven domains aimed at SIC workforce across the spectrum of clinical responsibility and BH expertise (Table 1). The framework was developed as part of a broader project conducted by the authors and supported by the Gordon and Betty Moore Foundation. A model of BH/SIC was developed using literature review, qualitative interviews, and an expert advisory panel as described in the introduction.7 It presents the building blocks required to develop and implement BH/SIC across conditions and care settings. Core clinical functions and structural supports to deliver these functions are described. Fundamental to implementing this model is the development of a workforce able to deliver these clinical functions. We delineate seven core skill domains necessary for practitioners working at the BH/SIC interface to implement high-yield diagnostic and therapeutic interventions, understand when to seek higher levels of care, and communicate across disciplines effectively. Within these domains, we have identified tiered BH/SIC skills; basic skills are those required by all staff who have clinical contact with patients in the SIC setting; intermediate skills are those required by clinicians involved in assessment and treatment of BH conditions; and advanced skills are those required by experts at the BH/SIC interface which include management of unusually challenging clinical situations and on teaching and leading teams. Domain 1: Communication, Teamwork, and Shared Decision-Making Training in culturally appropriate serious illness communication, including eliciting preferences from patients and families, and involving them as equal partners, is necessary to deliver person-centered care.57,58 Basic communication skills include use of appropriate communication styles; adaptations to

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account for cultural, linguistic, and other patient factors; and utilizing effective interprofessional communication. Intermediate skills include comfort with initiation of end of life discussions, eliciting goals of care, advance care planning.59,60 Advanced skills include adaptation of effective SIC communication for patients with BH/SIC comorbidities who may have altered cognition, affect regulation, communication ability, and other relevant domains. Other advanced communication and shared decision-making skills include understanding the impact of transference and counter-transference on medical decisionmaking; understanding the impact of comorbid BH disorders like depression, anxiety, and dementia on decision-making; and integrating BH plans within advance care planning (including in the setting of progressive cognitive impairment). The intermediate and advanced-tier skillset includes interprofessional communication leadership, the ability to foster effective, patient-centered communication across the BH/SIC divide through the use of a shared language across disciplines. Existing competency frameworks for effective interprofessional communication can support attainment of this competency.61 Domain 2: Case Finding, Screening, and Referral to Care Case finding, screening, and referral to care involve identifying and ensuring the care of individuals with BH needs in the SIC setting. While effective models of case-finding and referral have not yet been operationalized at the BH/SIC interface, BH integration models in other settings have addressed this function. Through initiatives such as screening and referral for alcohol and drug use disorders, a now substantial evidence base including effective implementation approaches has accumulated.62−64 Knowledge gained from these and other BH integration activities could serve as a starting point to inform the development of BH case finding, screening, and referral to care competencies within the SIC workforce. The tiered skills below are adapted from such information. At the basic level, all team members in contact with people with serious illness require knowledge of signs and symptoms of common BH conditions and the ability to communicate observations of potential BH comorbidity to other team members. Intermediate tier clinicians should be equipped to administer a brief

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ARTICLE IN PRESS Bridging the BH Gap in SIC TABLE 1. Key Clinical Team Competencies Demonstrating the Knowledge, Attitudes and Skills to Effectively Address Conditions Across the BH/SIC Continuum. Based on the Model of Care Presented in Cheung et al. 2019 Core Clinical Domain

Competency Basic Intermediate Advanced

Examples of Skills

Communication, teamwork and shared decision making

Communicate appropriately and respectfully around issues of advance care planning and decisionmaking.

 Use appropriate communication styles and approaches in response to culture, language, and need (e.g., sensory, perceptual or cognitive function)  Safeguard privacy and confidentiality.  Appreciate the roles, responsibilities and perspectives of all the care team and partners.  Recognize key interprofessional communication challenges at the interface of SIC and BH including advance care planning and medical decision-making.  Establish proactive and continuous communication about goals of care encompassing both physical and behavioral health.  Conduct advance care planning and end-of-life conversations with sensitivity including cultural and spiritual awareness.  Optimize methods such as interprofessional communication tools (e.g., SBAR) to aid efficient, timely and effective communication.  Operationalize and transmit communication, teamwork, and shared decision-making skills to other team members.  Train team members in conducting goals of care and advance care planning conversations goals of care and advance care planning conversations in the setting of comorbid BH and serious medical illness, including in the setting of serious mental illness.  Understand how reactions to and perceptions about patients with comorbid behavioral health issues may impact communication and advance care planning.  Account for differences in decision-making among patients with cognitive impairment, or with comorbid behavioral health disorders in communication and advance care planning.  Employ effective strategies for appropriately engaging patients with cognitive impairment and their families in decision-making.  Recognize common symptoms of BH conditions in the SIC setting (e.g., confusion in delirium) and of emergent BH symptoms in the SIC setting (e.g., suicidality).  Escalate recognition of BH issues to appropriate team members for further evaluation.  Administer and interpret brief standardized BH measures for depression, anxiety, substance use, cognitive impairment including scales adapted to serious illness conditions and/or care settings.  Delivering BH screening as part of a protocolled team approach that includes processes for screening, interpreting findings, and initiating referral.  Conduct in-depth behavioral health assessment tailored to the SIC setting.  Manage referrals in a seamless and timely manner, including sharing information with the patient, initiating, tracking and documenting referral outcomes.  Apply different communication modalities and techniques to ensure coordinated care, e.g., face to face discussions, teleconferencing, huddles, team meetings, written summaries, shared electronic care records and tracking through registries.

Effectively lead discussions on advanced care planning and medical decision-making.

Employ advanced communication techniques and train staff in appropriate communication strategies around decision-making and advance care planning.

Case finding, screening and referral to care

Be aware of symptoms of common BH conditions that necessitate further evaluation.

Conduct appropriate, operationalized, evidencebased BH screening and understand how to escalate care based on screening results.

Conduct in-depth BH evaluation. Facilitate and track referrals in response to evaluation findings.

Longitudinal care management and crisis management

Recognize that symptoms and needs associated with BH and serious illness vary and change over time. Apply communication skills and other strategies to prevent and/or prepare for crises.

(continued)

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ARTICLE IN PRESS Shalev et al. TABLE 1. (continued) Core Clinical Domain

Competency Basic Intermediate Advanced

Identify and triage BH/SIC crises across care settings.

Support longitudinal care needs by coordination and communication across settings and teams.

Integrated evidence-based and measurement-based care

Assist patients and families in the SIC setting to access evidence-based BH treatments, including psychopharmacological and psychosocial interventions. Directly provide evidence-based BH treatments, including psychopharmacological and psychosocial interventions, to patients with serious illnesses.

Directly deliver stepped, measurement-based BH care, including psychopharmacological and psychosocial interventions, to patients with serious illnesses.

Self-management support

Be familiar with the concepts of patient activation, engagement, and self-management. Supply appropriate patient-activation, engagement, and self-management materials to patients and families. Deploy evidence-based techniques to empower patients in self-management, engagement, and activation.

Examples of Skills  Develop shared crisis plans for both behavioral and physical health deterioration that address: advance care wishes; risk of interactions between serious illness and behavioral health symptomology on risks to health, self, to and from others (e.g., neglect, domestic violence, and financial exploitation); potential triggers to deterioration; preventative strategies.  Identify and manage crisis presentations including suicidality, agitation, delirium, and rapid deterioration of BH symptoms using evidence-based protocols.  Iterative goal-setting, advanced care planning and linkage to services that responds to the patient’s goals, preferences and intensity of need.  Proactive transitional care planning across settings including: access to medication and medication reconciliation, timely sharing of information across providers, patients and caregivers.  Effectively engage BH providers to ensure shared oversight of access and response to longer term treatment and recovery interventions for those with chronic BH conditions.  Support access to or deliver brief preventative or solution-focused SIC-adapted BH interventions, e.g., health promotion and wellness including complementary therapies, motivational enhancement, and problem-solving therapy.  Provide first line psychopharmacologic interventions for BH issues in the SIC context including depression, anxiety, and agitation.  Utilize alternative models of supervision and consultation including telepsychiatry to increase patient access to psychopharmacological interventions and medication assisted treatments for substance use.  Utilize measurement-based care approaches to optimize SIC/BH care provision, including SIC-specific BH measures.  Provide second-line and complex psychopharmacologic care at the intersection of BH and SIC, including for patients with SMI, absorption issues, and multidrug regiments with complex interactions.  Utilize sophisticated psychotherapies adapted to the SIC setting such as CBT modalities oriented toward coping with serious illness, and palliative care psychotherapies such as meaning-centered psychotherapy.  Approach patients with an empowering stance that facilitates activation, engagement, and selfmanagement.  Disseminate digital self-management tools and educational materials and train patients in their use.  Signpost to peer support, support groups, and other resources.  Deliver structured education on symptom management and self-care on BH/SIC to patients and families.  Utilize motivational interviewing, health coaching, and other psychosocial techniques to engage patients in self-management of BH/SIC health issues.  Adapt resources such as support groups to the BH/ SIC interface. (continued)

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ARTICLE IN PRESS Bridging the BH Gap in SIC TABLE 1. (continued) Core Clinical Domain

Caregiver support

Competency Basic Intermediate Advanced

Engage caregivers as shared partners in care.

Understand the consequences of caregiver strain. Identify signs of caregiver stress. Conduct caregiver needs assessments. Facilitate linkage of caregivers to appropriate support. Deliver targeted interventions to alleviate caregiver strain.

Responding to social determinants of health and linking to services

Appreciate the relevance of social determinants of health to health needs, engagement, and health outcomes. Provide basic information to patients and families about social services and community-based organizations. Conduct screening for socioeconomic risks. Connect patients and caregivers to appropriate services.

focused screening tool such as the Patient Health Questionnaire65 or specialty-specific global symptom burden scales like the Edmonton Symptom Assessment Scale, which includes depression and anxiety domains.66 Advanced tier training can build capacity to administer both brief screening and more in-depth assessment. Domain 3: Longitudinal Care and Crisis Management Effective care for BH/SIC comorbidity requires a combination of skills in longitudinal care management and the ability to identify and respond to acute crises. Longitudinal care management entails coordinating ongoing care through time and across settings. All team members require an awareness of the likelihood of changing BH needs over time and the raised risk of disengagement due to BH symptoms. All practitioners require the ability to use technologic (e.g., electronic patient registries) and team-based (e.g., team rounds) approaches to ensure continuous care

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Examples of Skills  Employ self-management support appropriately for patients and families of patients with dementia and other cognitive disorders.  Involve care givers as equal partners in the care team.  Communicate effectively in an empathetic and culturally appropriate manner with caregivers.  Recognize signs of caregiver stress.  Understand the compounding interaction of BH and SIC morbidity on caregiver burden.  Conduct caregiver needs assessments.  Connect caregivers to BH specialists when needed.  Deliver a range of informal and formal interventions for caregiver stress including support groups, education, and psychotherapy.  Deliver interventions for bereavement and/or prolonged grief.  Understand how social and cultural factors influence health behaviors, access to health care, and health outcomes.  Recognize local and national social services and community-based organizations that support social needs.  Facilitate referral to appropriate social services.  Use appropriate screening tools and techniques to evaluate patients’ socio-economic risks.  Understand innovations in identifying and addressing social determinants of health, such as, the Accountable Health Communities Model.  Collaborate on care planning with community-based partners.

across settings. Advanced tier clinicians should have the ability to proactively plan for care transitions, share information with providers across settings, and ensure patients are not lost to follow-up. Crisis management requires all team members to be aware of signs and symptoms of crisis presentations including suicidality, delirium, rapid emergence of or deterioration in BH symptomology, and complications from substance use including withdrawal. Additionally, all team members must have basic crisis plans in place for BH/SIC emergencies such as agitation or acute suicidality. For basic tier staff, such crisis planning may primarily entail appropriate de-escalation techniques. Intermediate and advance tier clinicians should be able to mount effective therapeutic responses to crises. Domain 4: Integrated Evidence-Based and Measurement-Based Behavioral Healthcare Training of non-BH clinicians in pharmacological treatment of common mental disorders and substance

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ARTICLE IN PRESS Shalev et al. use treatments can be facilitated and quality assured if implemented with systems for rapid access to BH experts. Upskilling existing SIC clinical workforce in first line psychosocial and preventative interventions (e.g., motivational interviewing, health promotion, brief manualized psychological treatments, or signposting to online therapy) can create capacity to target BH expertise at more serious or complex comorbidities. Basic tier provision of BH care in the SIC may involve effectively engaging BH providers to deliver such care, rather than direct care delivery. However, intermediate tier skills include integrating basic psychotherapeutic modalities and techniques (such as motivational enhancement, and problem-solving techniques) into the clinical encounter. Prescribing clinicians at the intermediate level should also have comfort with the provision of first-line psychopharmacologic therapies for common BH conditions in the SIC setting, such as depression, anxiety, and agitation. Finally, clinicians at the intermediate tier in this skill domain should have familiarity with alternative models of BH consultation and supervision for more complex cases including telepsychiatry and collaborative care.67 Advanced tier skills include the provision of sophisticated psychotherapeutic and psychopharmacologic therapies for complex BH/SIC comorbidity, as well as the utilization of measurement-based care approaches which include measurements at the intersection of BH/SIC. Domain 5: Self-Management Support Serious illness can cause psychosocial stressors including changes in role and perceived loss of autonomy. These stressors can contribute to the development of BH comorbidity. Self-management support entails promoting patient activation and enabling patients to build the skills and confidence needed to actively engage in their healthcare. All team members require an awareness of the psychosocial consequences of serious illness and the role of self-management techniques in ameliorating distress. Basic tier skills include assuming an empowering stance in the provision of care through encouragement and engagement of patients in their own care. Intermediate skills include appropriate dissemination of self-management tools and educational materials, and linkage to resources. Advanced skills include direct delivery of effective educational interventions, utilizing health

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coaching/motivational interview techniques, and adapting resources from other settings to the BH/SIC interface (for instance, leading a depression support group targeted toward individuals with comorbid depression and serious illness). Advanced-tier clinicians should also have an understanding about how to engage individuals living with neurocognitive disorders and their care-takers, in self-management support. Domain 6: Caregiver Support Serious illness can have far reaching effects on families including an increased risk of behavioral comorbidity in caregivers.68−70 There is a growing body of evidence-based interventions to alleviate caregiver stress71−73 and consensus that caregiver assessment should be embedded in SIC.74,75 Despite a growing recognition of the importance of caregiver support as a component of SIC, payment models often preclude the provision of BH services to caregivers within the context of the care receivers’ care. Basic tier caregiver support skills include appropriate involvement of and communication with caregivers in the team setting. Intermediate skills involve a more active approach to caregiver wellness, including understanding risk factors for caregiver morbidity, recognizing signs of caregiver distress, assessing caregiver needs, and referring caregivers to care. Advanced skills include the direct provision of psychosocial care to caregivers across a spectrum of needs inclusive of bereavement. Domain 7: Social Determinants of Health Patients with comorbid BH and serious illness frequently have complex social needs. There are multiple ways in which social factors influence health behaviors, access to care and ultimately, health outcomes.76 Methods to address socioeconomic factors influencing healthcare utilization have become an important focus in emerging integrated care models.77 Such methods should be patient- and family-centered and conducted in an operationalized manner that allows for assessment of patient strengths and needs.78 Of particular note are innovations emerging from new payment models and grant opportunities from the Centers for Medicare & Medicaid Services, such as the Accountable Health Communities Model which is predicated on the

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ARTICLE IN PRESS Bridging the BH Gap in SIC notion that systematic identification and amelioration of health-related social needs can decrease cost.79 In terms of competencies, at the basic level, clinicians should understand how social and cultural factors affect health. At the intermediate level, clinicians should additionally be familiar with local and national resources to support social needs and be able to connect patients and caregivers to such resources. At the advanced level, clinicians should have the ability to conduct sophisticated socio-economic assessments using tools such as Health Leads,80 to understand innovations in addressing social determinants of health such as the Accountable Health Communities model, and to effectively collaborate with community-based partners to improve patient care.

DISSEMINATING BH/SERIOUS ILLNESS TRAINING Preparing the workforce to meet the needs of the SIC/BH population will require a number of strategies. Traditionally, extending clinician skillsets occurred through either postgraduate training opportunities or continuing medical education.81,82 While postgraduate education may offer clinicians the opportunity to subspecialize and pursue additional board certification, it is often lengthy, onerous, and not feasible for clinicians already in the workforce. Continuing medical education provides less intensive, more flexible opportunities for practicing clinicians to extend, develop, or hone skills. However, working toward a shared basic skillset and tiers of competency requires new models of education. Such models should be flexible, easily disseminable, and applicable to clinicians across a range of backgrounds and disciplines. To that end, interprofessional education and electronic learning (e-learning) stand out as two particularly salient strategies for BH/SIC training. E-learning is a broad category referring to educational materials delivered electronically, ranging from traditional lectures accessed online, to more sophisticated interactive electronic modules. Utilizing adult learning principles, e-learning modules aimed at the BH/SIC interface would ideally integrate short, casebased modules with just 1−2 teaching points.80,81 Such curricula could support a tiered approach and be tailored to individual learners who have the option

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of selecting specific topics or modules in a “just in time” fashion based on patient care need.83 Such modules could also be integrated into clinician onboarding to ensure all team members have had a baseline of training to BH care in the SIC setting. The field of palliative care has already engaged robustly with e-learning initiatives, such as those provided by Center to Advance Palliative Care.84 Interprofessional education strategies, where two or more professions learn about, from and with each other to enable effective collaboration, is key in supporting team-based BH/SIC care.85−88 Interprofessional education can be used to increase the number of providers able to implement basic, high-yield interventions to address BH and SIC needs and can be delivered in a tiered manner. Delivery methods including simulation training, merging classes, and e-learning. Interprofessional education may also have a role in supporting changes in professional stigma toward mental illness.89 Interprofessional training underpins several established international approaches to improving BH literacy among the physical health workforce.90 Other techniques to spread and scale dissemination of skills and knowledge include “train the trainer” and clinical champion techniques.90,91 The Role of Health Information Technology Infrastructure in Building Capacity The feasibility and impact of these educational training approaches will be both contingent upon and potentially catalyzed by concurrent developments in technology. Telemedicine and developments in digital technology provide another strategy to build workforce capacity and increase access to BH care.92 Initiatives such as Project Echo have demonstrated efficacy in scaling up access to SUD expertise and there is a growing market in telemedicine to redress geographical disparities in access to BH expertise.93 In addition to enabling increased access to evidencebased interventions, these initiatives provide opportunity for supervision and education from BH experts to build SIC provider confidence and competency in BH assessment and treatment. Changes in health IT infrastructure can further support core workforce skills. Data regarding individuals’ medical, BH, and social needs are usually held in different systems preventing joined-up holistic care. Interprofessional SIC teams need a common, freely

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ARTICLE IN PRESS Shalev et al. accessible information base in the form of integrated, interoperable, cross-sector data, including electronic health records. Ready access to this information for all care providers through data sharing platforms can support greater continuity in care. Progress in the development of user-friendly tools that can capture core clinical data including BH screening and assessment, individuals’ level of functioning, cognition, frailty, symptom distress, advanced wishes, social needs and family caregivers’ capacity, and burden will improve feasibility of integrated care at the BH/ SIC interface. Obstacles to care such as data sharing privacy protections contained in HIPAA and 42 CFR Part 2 can be addressed through adaptable and secure data sharing agreements.94 Focusing training and technical assistance to support staff to use health information technologies is essential.

POLICY STRATEGIES TO ADDRESS BARRIERS TO IMPLEMENTATION The proposed framework to train an interdisciplinary tiered BH/SIC workforce must be linked to broader policy changes in funding and licensure. Current (fee-for-service) payment arrangements do not necessarily pay for services that address the behavioral and social needs of patients with serious illness and consequently greatly influence the type and range of services that can be provided. Novel valuebased payment models are designed to reward quality, safety, efficiency, and improve health outcomes, creating potential levers to invest in integrated services and providing flexibility to pay for staff that can provide these services. Two value-based payment models supporting integrated services are particularly relevant for this patient population. First, a model developed by the American Academy of Hospice and Palliative Medicine provides tiered monthly care management payments to support interdisciplinary palliative care teams.95 It is linked to a quality and cost accountability framework to ensure highquality, high-value care. The Advanced Care Model developed by The Coalition to Transform Advanced Care’s bridges medical and social services for Medicare beneficiaries with advanced chronic conditions in their last year of life.96 The model builds upon an individual’s changing needs in terms of health, function (i.e., cognitive impairment, dementia, mental

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illness, addiction, and trauma), and psychosocial status in light of disease severity and progression. Both payment models have been recommended to the Department of Health and Human Services Secretary as high priority for limited-scale testing. While none of these models addresses BH specifically, they allow for interdisciplinary teams which could provide a mechanism to have BH as a covered component under these payment models. Shifting toward value-based payment, however, will require the definition of value in BH and SIC to be operationalized and the necessary measurement and reporting infrastructure to be built. Innovation in strategies to task share, improve access to specialty care, or scale-up basic competencies are important but will be insufficient in addressing the BH/SIC workforce gaps. Ultimately, buy-in and support from certification and accrediting bodies across multiple disciplines, as well as state licensing bodies, will be necessary to address these critical workforce issues. The Institute of Medicine report The Mental Health and Substance Use Workforce for Older Adults97 includes a series of recommendations to establish accountability mechanisms across multiple agencies and organizations that address healthcare workforce development. Applying these recommendations to the BH/SIC interface can provide an avenue to help address workforce challenges in BH/SIC. The recommendations also suggest modification of standards, curriculum requirements, and credentialing procedures for professionals preparing to work in SIC settings. Organizations responsible for accreditation, certification, and professional examination, as well as state licensing boards should adopt these recommendations to enhance professional competence in BH for all levels of personnel that care for individuals with serious illnesses. The Department of Health and Human Services and its agencies including the Administration on Aging, Agency for Healthcare Research and Quality, Centers for Medicare & Medicaid Services, Health Resources and Services Administration, National Institute of Mental Health, National Institute on Drug Abuse, and Substance Abuse and Mental Health Services Administration, National Institute on Neurologic Disorders and Stroke, National Institute on Aging, and the Centers for Disease Control and Prevention should be expected to exercise leadership and assume overall responsibility for building BH capacity and

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ARTICLE IN PRESS Bridging the BH Gap in SIC facilitating deployment of a trained interdisciplinary workforce for individuals with BH/Serious illness.

CONCLUSION Current demographic and sociocultural challenges mean the importance of SIC will continue to increase yet there are significant gaps in workforce provision for integrated BH/SIC. The urgency of this issue is particularly revealed by current rapid changes in policies specific to the SIC interface. Medical assistance in dying is now legal in nine states and the District of Columbia and is the subject of extensive national debates. Development and application of such policies requires a sophisticated workforce fluent in both BH and SIC. Key challenges to meeting workforce needs at the intersection of BH/SIC include gaps in training, siloes of care, and lack of access to experts in the intersection of BH and SIC. While many of these challenges are longstanding and difficult to ameliorate, there are actionable interventions that may improve SIC delivery. We propose a tiered training framework to operationalize the skills that all staff working at this interface need to serve patients with comorbid BH/ SIC. A focus is placed on scaling up existing

competencies among all practitioners to deliver more integrated BH/SIC. While not exhaustive (for instance, a full discussion of training needs for the care of individuals with dementia), we present the competencies and skills most critical to delivering integrated BH/SIC. Facilitating the growth of a BH/SIC workforce equipped with these competencies requires both implementation strategies and policy changes. This includes application of technology and improvements in accreditation and certification requirements to close training gaps, leadership from government agencies and professional organizations and, refinement of value-based payment models that incentivize and reward clinical excellence in integrated BH/SIC. The authors thank The Gordon and Betty Moore Foundation for their generous support of the work leading to the development of the model referenced in this paper and the experts and program leaders that participated in the panels and interviews that contributed to the creation of the model. Disclosures: The authors confirm there are no disclosures to report. Funding: This study was funded by the Gordon and Betty Moore Foundation.

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