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Addressing Workforce Challenges in Serving Individuals with Co-Occurring MI/IDD

Individuals with mental illness (MI) co-occurring with intellectual/developmental disability (IDD) have complex needs and present clinical challenges to the professionals, programs, and systems. These individuals are among the most challenging, expensive, and intractable to work with. Although the situation has been improving, there are still many instances when the two relevant service delivery systems (behavioral health and developmental disabilities) deny services, believing that the appropriate provider of services should be found in the other service delivery system. Service providers and clinicians often feel poorly prepared to serve this challenging population, and as a result they may choose to not work with individuals who have these two co-occurring disorders.

NADD, whose mission over the past 30+ years has been “to advance mental wellness for persons with developmental disabilities through the promotion of excellence in mental health care,” has developed a series of initiatives aimed at raising the confidence and quality of the workforce providing services to individuals with MI/IDD. Divided between training and certifying competence, these initiatives are designed to result in improved quality of life for individuals receiving services, increased knowledge and competency for staff, as well as overall cost savings.

Training Component

NADD offers training by recognized experts in the field on all aspects of mental health concerns in individuals with intellectual/developmental disability. Our new training initiative centers on offering train-the-trainer sessions based on Mental Health Approaches to Intellectual/Developmental Disability: A Resource for Trainers by Robert J. Fletcher, Daniel Baker, Juanita St Croix, and Melissa Cheplic. A flash drive is included with this book, which has PowerPoint slides to facilitate offering trainings. Ten modules are covered in these trainings:

  • Module I: What Is a Dual Diagnosis?
  • Module II: Building on the Basics: Understanding Assessment Practices in Dual Diagnosis
  • Module III: Mental Health Evaluations: Mental Status Examinations (MSE)
  • Module IV: Signs and Symptoms of Mental Illness
  • Module V: From DM-ID to DM-ID-2
  • Module VI: Support Strategies
  • Module VII: Adaptive Therapy for People with IDD
  • Module VIII: Childhood and Adolescences
  • Module IX: Aging
  • Module X: Inter-Systems Collaboration

Learning objectives are included for each module and pre- and post-tests are included in an appendix, as well as in an accompanying work book: Trainee Workbook for Mental Health Approaches to Intellectual/Developmental Disability.

Accreditation and Certification

With the NADD Accreditation and Certification Programs, NADD, in association with the National Association of State Directors of Developmental Disability Services (NASDDDS), has established standards and benchmarks for services provided to individuals who have intellectual and developmental disabilities co-occurring with mental illness. The NADD Accreditation and Certification Programs were developed to raise their level of care, as well as to provide recognition to those programs and professionals offering quality care.

The NADD Accreditation and Certification Programs are composed of four interrelated programs: Accreditation for programs, Competency-Based Clinical Certification, Competency-Based Dual Diagnosis Specialist Certification, and Competency-Based Direct Support Professional Certification.

The NADD Accreditation Program

NADD developed the NADD Accreditation Program to improve the quality and effectiveness of services provided to individuals with a dual diagnosis through the development of competency-based professional standards and through promoting ongoing professional and program development.

A NADD Accreditation survey evaluates a program on the basis of eighteen competency modules:

  • Medication Reconciliation
  • Holistic Bio-Psycho-Social Approach
  • Database/Outcome measures
  • Protocols for Assessments
  • Treatment/Habilitation Plans
  • Basic Health Care
  • Interdisciplinary Team
  • Training / staff and family
  • Crisis Prevention and Intervention
  • Cultural Competency/Family Values
  • Trauma
  • Quality Assurance/Incident Management
  • Evidence-Based Treatment Practices
  • Ethics, Rights, Responsibilities
  • Interagency and Cross-Systems Collaborations
  • Long Term Living – Service Coordination
  • Advocacy and Rights Health Informatics (Technology)

(Note: Only the standards that are applicable to the program will be evaluated.)

One way that NADD Accreditation differs from almost all other accreditation programs is the inclusion of a consultation component. Through their expertise, NADD surveyors are not only able to identify areas that are in need of improvement, but they are also able to offer concrete suggestions about how to improve the program. The consultation component takes place on site during the course of the survey.

Competency-Based Clinical Certification Program

The NADD Competency-Based Clinical Certification was developed to improve the quality and effectiveness of services provided to individuals with a dual diagnosis through the development of competency-based professional standards and through promoting ongoing professional development. Certification attests to the clinician’s competency in providing services to individuals with a dual diagnosis.

NADD has identified five competency areas that applicants for Clinical Certification must demonstrate mastery of.

  • Positive Behavior Supports and Effective
  • Environment
  • Psychotherapy
  • Psychopharmacology
  • Assessment of Medical Conditions
  • Assessment

In order to be considered for Clinical Certification, an applicant must meet certain pre-requisites. They must be licensed to practice in a state or province or recognized as Applied Behavior Analyst, and they must have five years of experience in support of persons with intellectual disabilities and mental health issues. They are required to submit three letters of reference.

Applicants are required to submit a five-page work sample of a case that demonstrates clinical work with a person who has a dual diagnosis. The work sample should include formulation/conceptualization of clinical problem(s), format for therapy or intervention, landmark events or salient issues that arose during the course of treatment and how these were addressed within treatment, reflection on issues within therapy and/or ethical concerns and/or issues relevant to cultural competency, and how the clinical approach was informed by an understanding of intellectual disability or dual diagnosis.

The final aspect of the certification process is a telephone-based interview/exam. Prior to the interview, the applicant is presented with a case vignette approximately about which he or she will be asked to verbally offer his/her thoughts and reflections (i.e., provide a case formulation and treatment plan).

Clinicians who receive NADD Clinical Certification are entitled to use “NADD-CC” as a credential.

The NADD-CC is being recognized by a wider and wider variety of different entities as a unique specialty, and we anticipate broader recognition as time passes. Individual municipalities such as the City of Philadelphia recognize the NADD-CC, giving specific preference in a Request For Proposals. Some third-party payers, including managed care entities, recognize NADD-CC. Individual states, such as MN and NJ, recognize NADD-CC and are in the process of adopting NADD-CC into service qualifications and job class specifications.

Competency-Based Dual Diagnosis Specialist Certification

The NADD Competency-Based Dual Diagnosis Specialist Certification Program is designed for specialists in the field of dual diagnosis who deliver, manage, train and/or supervise services for persons with intellectual/developmental disabilities and mental health needs. Staff working in units of county, state or provincial government, QIDPs, RN’s, LPN’s, program directors, program supervisors, case/care managers, program specialists, supports coordinators, peer specialists, trainers, and others are examples of roles that can apply for this certification.

The specialist seeking certification is required to demonstrate mastery of the following six competency areas:

  1. Bio-psycho-social approach
  2. Application of emerging best practices
  3. Knowledge of therapeutic constructs
  4. Respectful and effective communication
  5. Knowledge of dual role service delivery & fiduciary responsibilities
  6. Ability to apply administrative critical thinking

Competency-Based Direct Support Professional Certification

In general, DSPs spend more time with the person with IDD/MI than any other professional. The competence of the DSP can make a big difference in the quality of life for people. DSPs are often the ones charged with supporting skill building. They help the person engage in recommended therapies on a day-to-day basis. This work requires an advanced level of skill and knowledge to do well. However, there is little available to guide DSPs and others in identifying the specific competencies a DSP should have for this work. As a result, many DSPs are under-qualified. Too often, they lack the support and training to do well. This lack of standards can make finding, hiring, training, and retaining qualified DSPs difficult. As a result, many people with IDD/MI do not have adequate daily support.

NADD identified five competency areas that the DSP applicant must demonstrate competency in:

  1. Assessment and Observation
  2. Behavior Support
  3. Crisis Prevention and Intervention
  4. Health and Wellness
  5. Community Collaboration and Teamwork

Synergy and Motivation

Several programs, recognizing the value of having qualified, certified personnel, reward employees who achieve certification through a financial bonus or increased pay. The CLOUD Project in South Carolina rewards certified DSPs with a bonus. The Behavioral Health Center of Nueces County, Texas, gives NADD-certified DSPs a raise. Certain Departments in the State of Ohio recognize NADD Clinical Certification as one of the certifications that entitle employees to increased remuneration.

One requirement of the NADD accreditation is that after the initial period of the accreditation the program is required to have 10% of their workforce, in various categories (clinical, dual diagnosis specialist, DSP) be NADD-certified. This will help insure the quality of the services and supports provided.

Those who complete the train-the-trainer model will have a higher level of knowledge and will have the tools and skills to train others concerning mental health aspects in persons with IDD. Those who complete a NADD competency-based certification program have demonstrated a high level of competency in their respective role. Programs that receive NADD accreditation have demonstrated that the treatments and supports they offer are of a high quality as measured by NADD standards. As a result of NADD trainings, certifications, and/or accreditation, it is expected that we will see improved outcomes for clients who use the services. Additionally, the anticipated outcome will include fewer hospitalizations; fewer emergency room visits and less needed for other crisis intervention services. This should significantly reduce costs.

Additional information is available on the NADD website, www.thenadd.org. Dr. Fletcher can be contacted by Email at rfletcher@thenadd.org or by phone at (845) 331-4336.

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