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acbhd-wet-needs-assessment-report-2024
Bright Research Group 1211 Preservation Park Way Oakland, CA 94612 www.brightresearchgroup.com ALAMEDA COUNTY BEHAVIORAL HEALTH DEPARTMENT WORKFORCE DEVELOPMENT EDUCATION AND TRAINING NEEDS ASSESSMENT REPORT WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 2 TABLE OF CONTENTS Executive Summary ...................................................................................................... 3 Introduction ................................................................................................................... 4 Methods ......................................................................................................................... 5 Key Findings: Workforce Capacity and Needs .......................................................... 7 Key Findings: Pipeline Programs and Preparation of a Diverse Workforce ........... 13 Key Findings: Training and Education Needs ........................................................... 17 Conclusion and Recommendations ......................................................................... 23 Appendices ................................................................................................................. 24 WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 3 EXECUTIVE SUMMARY The Alameda County Behavioral Health Department (ACBHD) engaged Bright Research Group (BRG) to conduct the Workforce Development Education and Training (WET) Needs Assessment to assess existing strategies, current gaps, and emerging needs of the ACBHD’s workforce. BRG utilized a mixed- methods approach comprised of focus groups with a total of 21 participants, as well as a survey with 85 respondents. The following key findings provide a snapshot of provider perspectives with respect to workforce, education and training needs: Workforce Capacity and Needs 1. Hiring and recruiting staff reflective of the client population is both a priority and a challenge for community-based providers. 2. There is a shortage of bilingual and racially diverse staff, especially clinicians. 3. Providers who participated in the needs assessment reported experiencing challenges in meeting the complex health and social needs of their clients, which can contribute to burnout. 4. Providers expressed support for the critical role that the family and peer workforce can play in meeting their clients’ needs and reported engagement efforts. Pipeline Programs and Preparation of a Diverse Workforce 1. Intern diversity does not align with the cultural and linguistic diversity of Alameda County’s client population. 2. Supervisors and former interns reported mixed levels of satisfaction and effectiveness with the intern program. 3. Providers who participated in the survey offered recommendations to strengthen and improve the ACBHD intern programs. Training and Education Needs 1. Providers have mixed feedback on current WET unit offerings. 2. Providers have an interest in a variety of training formats and delivery and offered recommendations to improve WET trainings. 3. Providers reported a strong demand for rigorous trainings that enable them to deliver culturally responsive services to Alameda County’s diverse client populations and specifically requested advanced clinical-skills training. 4. Providers feel most prepared to meet the needs of Latino/Hispanic communities but reported a need for training to engage clients across other ethnic and cultural backgrounds. 5. Providers expressed frustration with certain elements of the bureaucracy of the behavioral healthcare system and value up-to-date information. Given these findings, BRG offers the following recommendations: 1. Sustain marketing efforts to promote WET training and education offerings with community- based providers. 2. Continue to offer advanced-skills trainings in topics suggested by providers. 3. Routinely gather training feedback from providers and share format and delivery preferences with contracted trainers to integrate them into future offerings. 4. Sustain training offerings for certified peer specialists and other peer and family professionals to support the professional development of the peer and family workforce. 5. Recruit interns for licensed clinical and case-management roles to address provider-identified workforce gaps. 6. Sustain and develop new strategies to increase the applicant pool of interns so that they better reflect the cultural, linguistic, and ethnic diversity of clients. 7. Share workforce-capacity findings with human resources and systems of care across the ACBHD to adapt hiring and recruiting strategies to address identified needs. WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 4 INTRODUCTION The vision of the Alameda County Behavioral Health Department (ACBHD) is to ensure that its workforce is sufficient in size, diversity, and linguistic capacity to provide culturally responsive services and supports to clients and their families that center wellness, recovery, and resiliency. To achieve its mission, the Workforce Development Education and Training (WET) unit builds and expands the capacity of staff within the ACBHD and contracted community-based organizations (CBOs). The WET team supports the behavioral health workforce across Alameda County through the following strategies: • Behavioral Health Career Pipeline Programs • Retention and Financial Incentives • Internship and Psychiatry Residency Programs • Internship and Stipend Program • Training and Continuing Education The goal of the WET Needs Assessment is to assess the existing strategies, current gaps, and emerging needs of the ACBHD’s workforce. The WET unit engaged Bright Research Group (BRG) to conduct the assessment in 2024. This report documents the key findings and recommendations, which will be used to inform future WET unit programming and training offerings. LEGISLATIVE LANDSCAPE The evolving legislative landscape in California is significantly shaping the training and education needs of providers within the ACBHD network and influencing the work of the WET unit. Key legislative changes, such as the implementation of CARE Courts and the amendments to the 5150 hold criteria through Senate Bill 43 (SB 43), are demanding a higher level of expertise and specialization from behavioral health providers. CARE Courts allow for court-ordered treatment plans for individuals with severe untreated mental illnesses, necessitating specialized training for behavioral health workers to effectively engage in the legal processes and deliver integrated care.1 Additionally, SB 43 expands the definition of “gravely disabled” to include severe substance use disorders and incorporates telehealth assessments for 5150 holds. These changes require providers to be adept in new legal frameworks, telehealth technologies, and the comprehensive management of co-occurring mental health and substance use disorders, highlighting the need for robust evidence-based training programs.2 Moreover, the proposed changes under Proposition 1, which aim to redesign the Mental Health Services Act (MHSA), are set to require counties to redirect one-third of mental health dollars to housing interventions, potentially at the cost of broader behavioral health services.3 With 35% of MHSA funds now earmarked for behavioral health services and supports, and at least 51% of this allocation directed toward early intervention for individuals under 25, the resources available for workforce education and training will be significantly reduced.3 While the impact of Proposition 1’s recent passing is still being determined, county-level leaders across California have concerns about the possible changes in 1. California Lawmakers Approved CARE Court. What Comes Next?,” CalMatters 2. Bill Text—SB-402 Involuntary Commitment. (ca.gov) 3. “Understanding Proposition 1,” California Budget and Policy Center (calbudgetcenter.org) WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 5 prevention and early-intervention services, particularly for communities of color.4 Given that the majority of county mental health funding is allocated to community services and supports, counties anticipate that the re-allocation of funding to the state could result in the cancellation of CBO contracts, a reduction in county-level staff, and disruptions in prevention and early-intervention programs and services.3 METHODS BRG utilized a mixed-methods approach comprised of a provider survey, a CBO webinar, focus groups, interviews, and a review of background documents. Method Sample Size WET Provider Survey 85 CBO Provider Webinar and Focus Groups 15 SUD Provider Focus Group 6 Key Informant Interviews with WET Leadership 3 Review of Background Documents and Existing Data N/A WET PROVIDER SURVEY The WET provider survey was an online survey that asked providers to answer multiple-choice and open-ended questions about training needs and priorities, workforce capacity, experience with pipeline programs, and organizational characteristics. Researchers used a “convenience sample,” which is a non- probability sampling method used to gather input from a wide range of respondents. Convenience sampling does not guarantee a representative sample. The survey was distributed by the WET team to over 400 ACBHD staff providers and contracted CBO providers, who comprise over 80% of the ACBHD’s workforce. The survey was completed anonymously. Respondents were incentivized to complete the survey with a drawing for a $25 electronic gift card. To enter the drawing, respondents completed a separate form that was not linked to their original survey in order to maintain confidentiality. A total of 85 survey responses were collected, which represents a snapshot of provider perspectives regarding the workforce, education and training needs. There are over 3000 providers in the ACBHD network and results from the survey may not be representative of the general provider population. Most survey respondents described their workplace setting as a CBO (72%) or a community mental health / behavioral health agency (49%). All six of the ACBHD’s systems of care were represented across survey respondents. The organizational demographics of respondents are shown in Table 1 below. For workplace setting and system of care, respondents were able to select more than one option. Please see the appendix for additional respondent demographic data, as well as the complete survey instrument. 4. “Update: California Voters Narrowly Approve Prop. 1, Gavin Newsom’s Mental Health Overhaul,” CalMatters WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 6 Table 1. Organizational Characteristics of Survey Respondents PROVIDER FOCUS GROUPS BRG facilitated a CBO provider webinar to gain insights about general organizational-level workforce and training needs. The WET team recruited 15 providers to attend the webinar. Most participants (93%) described their workplace setting as a community-based organization and/or a community mental health / behavioral health agency. Webinar participants represented all six of the ACBHD’s systems of care, with the majority (60%) working in Child and Youth Services. A separate small-group conversation among SUD providers was held to gain deeper insight about SUD provider specific needs and challenges. The SUD leadership team recruited six SUD providers to attend the focus group. Most participants (50%) served in program management or leadership roles, including program manager and director. Half of the participants had worked at their organization for one to three years, and the other half had tenures of over six years. A thematic analysis of provider insights was conducted to determine trending themes from both focus groups. These themes were compared to themes across all data collection methods to identify key findings. N % Workplace Setting Community-Based Organizations 61 72% Community Mental Health / Behavioral Health Agencies 42 49% Hospital 6 7% School 5 6% Social Services Agency 5 6% Substance Use / Outpatient Setting Withdrawal Management 5 6% Peer Services 3 4% State and Regional Agency 3 4% Involuntary Treatment / Substance Use Disorder 1% 1% Organization Size More than 200 employees 28 33% 51–100 employees 24 28% 20–25 employees 17 20% Under 25 employees 8 9% 101–200 employees 8 9% System of Care Child and Youth Services 67 79% Adult and Older Adult Services 51 60% Substance Use 25 29% Acute and Crisis Services 20 24% Psychiatry and Nursing Services 19 22% Integrated Primary Care Services 15 18% Forensic Services 10 12% WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 7 KEY INFORMANT INTERVIEWS AND BACKGROUND-DOCUMENT REVIEW BRG reviewed the ACBHD and WET reports, presentations, and other background documents to better understand WET guiding priorities and the context and role of the WET team. The research team also conducted two interviews with Robert Farrow, ACBHD training officer, to better understand the WET unit’s role within the ACBHD. Additionally, BRG conducted one key informant interview with Dr. Karyn Tribble, ACBHD director, to learn more about WET priorities and alignment with broader ACBHD workforce goals. This WET Needs Assessment report documents key findings and recommendations to support the ACBHD in strategically addressing the current gaps and emerging needs of its workforce. KEY FINDINGS: WORKFORCE CAPACITY AND NEEDS The ACBHD aims to be intentional in its recruitment and retention efforts, given Alameda County’s diversity and ongoing labor challenges in the behavioral health sector. Through the needs assessment, the ACBHD wanted to understand the diversity of the workforce and the existing strategies to recruit and retain a diverse workforce. The WET unit contributes to preparing a diverse workforce through its Behavioral Health Career Pipeline and Internship Programs. Finding 1: Hiring and recruiting staff reflective of the client population is both a priority and a challenge for community-based providers. The retention of multilingual and diverse staff is a high-priority workforce need for CBO partners. Providers reported during the CBO provider webinar that they highly value the contributions of multilingual and diverse staff, emphasizing the importance of building a workforce that reflects the demographics of the client populations their organizations serve. More attractive compensation packages offered by government agencies, especially at the county level, draw high-quality staff away from CBOs and compound these issues. These providers also emphasized that the struggle to retain staff is particularly pronounced for SUD counselors, who receive less favorable compensation compared to their mental health counterparts. The bureaucratic duties of the job include substantial paperwork and strict audit protocols, which make these positions less desirable. “There is a large Middle Eastern population in our Newark location, and we have no staff to reflect that population.” WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 8 The challenge of hiring and recruiting staff who match the cultural and linguistic backgrounds of the populations served was also cited as a concern in the WET provider survey. Overall, most providers reported that their organizations retain staff well but face challenges with recruiting and hiring diverse staff. As seen in Figure 1, almost all providers reported some difficulty with filling open positions. Figure 1. Provider-Reported Difficulty in Filling Open Positions, N = 85 Source: 2024 WET Provider Survey In a budget-restrictive environment, employee retention is a high priority for the ACBHD’s leadership. Survey respondents did not report significant challenges with staff retention, as shown in Figure 2. Figure 2. Provider-Reported Effectiveness of Staff Retention, N = 85 Source: 2024 WET Provider Survey 35% 25% 35% 5% Very DifficultSomewhat Difficult Difficult Not Difficult at All 18% 42% 34% 6% Very well Well Somewhat well Not well at all WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 9 Providers who completed the survey noted the biggest challenges in recruiting and hiring. As seen in Figures 3 and 4, providers reported that licensed clinical roles were the most difficult positions to recruit and hire for. Figure 3. Percentage of Respondents Reporting Positions Most Challenging to Recruit For, N = 85 Source: 2024 WET Provider Survey Figure 4. Percentage of Respondents Reporting Positions Most Challenging to Hire For, N = 85 Source: 2024 WET Provider Survey Moreover, during the CBO provider webinar, the small group conversation among SUD provider, and in the provider survey, providers described the challenges in recruiting and retaining BIPOC clinicians, citing issues with noncompetitive salaries and benefits. Finding 2: There is a shortage in bilingual and racially diverse staff, especially clinicians. Providers spoke to the critical need for enhanced linguistic diversity and cultural competence within the workforce. Feedback from the CBO provider webinar, the provider survey, and the small group conversation among SUD providers surfaced a significant shortage of staff who can effectively serve 24% 24% 27% 35% Case Manager / Social Worker / Service… Child and Adolescent Psychiatrist Licensed Marriage and Family Therapist Licensed Clinical Social Worker 31% 33% 49% 53% Child and Adolescent Psychiatrist Case Manager/ Social Worker/ Service… Licensed Marriage and Family Therapist Licensed Clinical Social Worker “The lack of BIPOC clinicians is a significant issue, and we struggle to recruit and retain these essential staff members.” WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 10 specific community groups, such as the growing Middle Eastern population, and underscored the need for increased language capacity, particularly in Asian languages. Notably, over half of the survey respondents reported using languages other than English with their clients, with Spanish being the most common (58%), as seen in Figure 5. Respondents were able to select more than one language option, including “other.” Providers reported speaking “other,” including an Alaska Native Language, French, Ki’che’, Italian, Russian, Khmer, Tibetan, Nepali, Rwandan, Tigrinya, Korean, Japanese, and Punjabi. Figure 5. Percentage of Providers Reporting Speaking Languages with Clients Other than English, N = 85 Source: 2024 WET Provider Survey SUD providers further emphasized the impact of limited linguistic capacity on their ability to provide ethical and effective care. Providers noted that often the evidence-based models they are required to use do not have documentation available in many languages other than English. Providers stated that when they do translate documents, it is often a long and expensive process. “It makes me feel really uncomfortable signing clients up for things that they don’t understand.” “Not enough bilingual/bicultural mental health professionals to serve diverse underserved/unserved immigrant and refugee communities.” 6% 15% 8% 18% 58% 14% 6% Arabic Cantonese Farsi Mandarin Spanish Tagalog Vietnamese WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 11 Finding 3: Providers who participated in the needs assessment reported experiencing challenges in meeting the complex health and social needs of their clients, which can contribute to burnout. Some providers explained that a heavy workload and an inability to meet the complex and diverse needs of their client population lead to burnout and compromise the quality of care. Providers emphasized the complexity of their roles, which span therapy, case management, coordination, and coaching. In the provider survey, they pointed out the difficulties associated with serving populations affected by broader socioeconomic issues, such as poverty, housing, and food insecurity, and the lack of holistic services to meet these needs. Respondents highlighted the complex needs their clients are facing and the need for comprehensive wraparound services provided by a range of partners to address these needs. They spoke to gaps in the continuum of care, citing the need for dedicated translation/interpretation services for English-speaking clinicians and culturally and linguistically responsive substance use treatment. SUD providers noted that many clients on their caseloads were often living with co-occurring disorders and needed additional support to address their mental health needs. Finding 4: Providers expressed support for the critical role that the family and peer workforce can play in meeting their clients’ needs and reported engagement efforts. Providers expressed support for the ACBHD’s focus on expanding the family and peer workforce. The Office of Peer Support Services and the Office of Family Empowerment are primarily responsible for ACBHD’s peer initiatives, though the WET unit provides training for the peer and family workforce. Survey respondents reported that they are actively working to expand their family and peer workforce, with over half of the respondents reporting that they engage peers and families (54%) in work groups and advisory councils. Respondents were able to select more than one option for peer and family engagement. Figure 6 shows that provider organizations are utilizing a variety of methods to deepen their partnership with peers and family members. WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 12 Figure 6. Peer and Family Engagement in Organizations, N = 85 Source: 2024 WET Provider Survey Organizations are making progress with integrating peers and family members into their paid workforce. Overall, about 42% of providers reported that their organization had at least one designated peer or family-member position, as seen in Figure 7. Figure 7. Provider-Reported Number of Designated Family or Peer Positions at Organization, N = 85 Source: 2024 WET Provider Survey 28% 25%9% 8% 29% 0 positions 1–3 positions Not Sure 10 or more positions 4–6 positions 54% 31% 33% 31% 39% 41% 12% 19% 6% Involving consumers and family members in work groups, advisory councils, stakeholder meetings, planning, or policy groups Recruiting consumers and family members on boards and other leadership positions Meeting and/or job accommodations Priority preference given to applicants with lived experience Anti-stigma training for all staff Partnerships with consumer-run organizations Consumer or family member internship program None Other WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 13 Peers and family members working at provider organizations most commonly serve as family partners, advocates, peer recovery coaches, counselors, mentors, coordinators, and/or specialists, as shown in Figure 8. About 9% of survey respondents reported peers serving in other leadership or staff roles, including as program directors, program specialists, managers, and mental health specialists. Figure 8. Provider-Reported Roles for Peers and Family Members within Organizations, N = 85 Source: 2024 WET Provider Survey KEY FINDINGS: PIPELINE PROGRAMS AND PREPARATION OF A DIVERSE WORKFORCE To achieve the ACBHD’s vision for a workforce that is sufficient in size, the intern program currently prepares rising behavioral health professionals for future careers in the behavioral healthcare field. The mission of the ACBHD’s internship program is to provide training that optimizes student learning, leadership, and overall support and development. Finding 1: Intern diversity does not align with the cultural and linguistic diversity of Alameda County’s client population. ACBHD interns are not representative of the racial, ethnic, and linguistic backgrounds of the client population. As seen in Figure 9, there is the most incongruence in racial and ethnic diversity among African American / Black clients and interns. Figure 9. Racial/Ethnic Diversity of ACBHD Interns (N = 22) and Clients (N = 28,108), 2022–2023 Source: ACBHD Workforce Education, Training and Development Internship Program Data, Yellow Fin, 2023; Mental Health Services Demographic-Ethnicity Data, Yellow Fin, FY 2022–2023 55% 33% 17%12% 34% 9% Family partners or advocates Peer recovery coaches, counselors, mentors, coordinators, and/or specialists Receptionists or other clerical support staff Board members Not Sure Other 9% 32%36%23%18% 34% 12%22%22%10% Black or African American Asian White Hispanic/ Latino Other Interns Clients WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 14 A quantitative analysis of intern demographic data shows gaps in recruiting African American and Latino interns. From 2018 to 2023, ACBHD interns have become less racially and ethnically diverse, as seen in Table 2. While the percentage of Asian interns has doubled since 2018, the percentage of African American and Hispanic/Latino interns has decreased. Table 2. Racial/Ethnic Diversity of ACBHD Interns, 2018–2023 Year N Black or African American Asian White Hispanic/ Latino Other 2022–23 22 9% 32% 41% 0% 18% 2021–22 18 22% 11% 28% 28% 11% 2020–21 21 29% 24% 19% 19% 9% 2019–20 31 16% 23% 29% 32% 0% 2018–19 19 21% 16% 26% 37% 0% Source: ACBHD Workforce Education, Training and Development Internship Program Data, Yellow Fin, 2018–2023 The linguistic capacity of interns mostly reflects languages spoken among the ACBHD’s clients, as seen in Figure 10. There is a need for more interns who speak Farsi to meet emerging client language needs. Figure 10. Languages Spoken by ACBHD Interns (N = 22) and Clients (N = 28,108), 2022–20235 Source: ACBHD Workforce Education, Training and Development Internship Program Data, Yellow Fin, 2023, and Mental Health Services Demographic-Ethnicity Data, Yellow Fin, FY 2022–2023 The linguistic diversity of ACBHD interns has decreased over the last five years, as seen in Table 3. While the percentage of interns speaking Cantonese/Mandarin has increased since 2018, the percentage of interns speaking Vietnamese and other languages has decreased. 5. The bar chart includes only languages that were noted in both intern and client data. 64% 4%14%4%14%0% 81% 1%14%1%2%1% English Cantonese/ Mandarin Spanish Vietnamese Other Farsi Interns Clients WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 15 Table 3. Linguistic Diversity of ACBHD Interns, 2018–2023 Source: ACBHD Workforce Education, Training and Development Internship Program Data, Yellow Fin, 2018–2023 Finding 2: Supervisors and former interns reported mixed levels of satisfaction and effectiveness with the intern program. Almost two-thirds of survey respondents (62%) reported serving as an intern supervisor or host. Less than half of these respondents (47%) would recommend being a supervisor to a colleague, and 18% were unsatisfied with their experience and would not recommend it to others. In addition, 47% of providers reported the program as somewhat effective (32%) or not at all effective (15%) at preparing a diverse workforce, as seen in Figure 11. Figure 11. Provider-Reported Effectiveness of WET Pipeline Programs in Preparing a Diverse Workforce, N = 85 Source: 2024 WET Provider Survey The small number of survey respondents (13) who had experience as an ACBHD intern means that the survey feedback cannot be generalized across ACBHD’s workforce. While over half (7) of those who had participated would recommend the pipeline program to other students, almost one-fourth (3) would not recommend it. The majority of providers who responded were graduate-level interns in marriage and family therapy (4) and social work (4), as seen in Figure 12. Year N English Cantonese/ Mandarin Spanish Vietnamese Other 2022–23 22 64% 4% 14% 4% 14% 2021–22 18 55% 0% 28% 0% 17% 2020–21 21 52% 0% 24% 0% 19% 2019–20 31 55% 7% 29% 3% 3% 2018–19 19 42% 0% 21% 11% 21% 15% 32%44% 9% Somewhat Effective Effective Very Effective Not at All Effective WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 16 Figure 12. Provider-Reported Internship by Student Type, N = 13 Source: 2024 WET Provider Survey Finding 3: Providers who participated in the survey offered recommendations to strengthen and improve the ACBHD intern programs. A majority of survey respondents reported hosting a wide range of student interns, with graduate-level students in marriage and family therapy (59%) and social work (78%) comprising the largest proportion, as shown in Figure 13, which aligns with the ACBHD’s need for licensed clinical professionals. Figure 13. Provider-Reported Supervision by Student Intern Type, N = 53 Source: 2024 WET Provider Survey Qualitative-survey responses highlighted a need for interns with a range of levels of education, from associate to post-master level, to meet the needs of the communities they serve. Additionally, providers report a need for interns in roles ranging from SUD counselors to marriage and family therapists. They also recommended increasing opportunities for people with lived experience with behavioral health conditions and residents of Alameda County. Providers cited several structural barriers and challenges that make it difficult to find staff who are willing to take on the added responsibility of serving as an intern supervisor. They reported the following recommendations to improve the intern program: • Adequate compensation and stipends for intern recruitment and retention, especially when attempting to recruit multicultural and multilingual interns • More time and compensation for clinical supervisors • Expanded infrastructure and space for hosting interns 2 3 4 4 1 Community College Graduate Psychology Marriage and Family Therapy Social Work Undergraduate 15% 33% 11% 59% 6%2%9% 78% 20% Community College Graduate Psychology High School Marriage and Family Therapy Nursing Physician Assitant Psychiatry Social Work Undergraduate WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 17 • Additional professional development of interns as they advance in their careers, such as alumni networks and continued mentoring During the small-group conversation among SUD providers, providers mentioned similar intern needs and noted Merritt College’s Community Social Services / Substance Abuse (COSER) program as an effective SUD pipeline. They noted that incoming professionals still had a learning curve with the documentation requirements of their role, including writing case notes and client briefs. SUD providers also cited the need to support incoming COSER graduates with the development of soft skills. KEY FINDINGS: TRAINING AND EDUCATION NEEDS Through trainings to agency staff and licensed clinicians, the WET unit aims to strengthen the capacity of providers to deliver clinical services that can improve the lives of clients and their families. The Training Unit offers training opportunities for the ACBHD’s staff, contracted CBO staff, individual providers and other Alameda County agencies. The Training Unit hosts trainings facilitated by contracted trainers and also collaborates with the systems of care and other partners to offer continuing-education sponsorships and technical assistance. Through this collaboration, trainings can be tailored to meet the specific learning needs of staff from different systems of care. In FY 2021–2022, the Training Unit hosted 71 events and trained 2,469 people. The unit provides continuing education for the following licensed professions: • Clinical Social Worker • Marriage and Family Therapist • Professional Clinical Counselor • Education Psychologist • Psychologist • Registered Nurse • Vocational Nurse • Addiction Professional • Medical Doctor Through the needs assessment, the WET unit was looking to learn about current training gaps and how it could best address providers’ emerging skills and knowledge needs. Finding 1: Providers have mixed feedback on current WET unit offerings. Most respondents were unfamiliar with the WET trainings, but those providers who participated in WET offerings reported satisfactory experiences. It is possible that survey respondents did not know that the trainings they participated in were organized by the WET unit. Of providers who reported participating in WET education programs, a majority (63%) would recommend the programming to a peer. Similarly, of those who had participated in WET training programs, almost half would recommend it to a colleague (42%), but 29% would not, as seen in Figure 14. WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 18 Figure 14. Provider-Reported Likelihood to Recommend WET Education (N = 16) and Training (N = 38) to a Colleague Source: 2024 WET Provider Survey Most survey respondents reported accessing training and education opportunities outside of the ACBHD to support their professional development. Over half of the respondents seek trainings internally from their organization (79%) or other local training organizations (73%), as shown in Figure 15. Providers reported accessing training, education, and professional development through national organizations. They sought trainings from the Centers for Disease Control and Prevention; the National Alliance on Mental Illness; statewide agencies, including the California Alliance and Catalyst Center; and online sites. Figure 15. Provider-Reported Training and Education Resources, N = 85 Source: 2024 WET Provider Survey Finding 2: Providers have an interest in a variety of training formats and delivery and offered recommendations to improve WET trainings. Qualitive-survey responses and the small-group conversation among SUD providers, uncovered that providers prefer more interactive and dynamic training options. Providers shared diverse perspectives regarding their preferred training format, which included a mix of in-person sessions to prevent multitasking and enhance engagement, as well as virtual meetings for convenience. 79% 73% 17% 64% 33% 27% Your organization Other local training organizations Your certifying body Alameda County Behavioral Health Other county agencies/units Other 63% 42% Education Programs Training Programs WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 19 When asked about their training needs in the survey, providers expressed a desire for more robust mechanisms for feedback and evaluation of training programs. They suggested implementing evaluative measures to ensure that trainings are effective, relevant, and skill based. While some providers were unaware that the WET unit offered trainings with certification, others felt that the quality of the training could be improved. Other training recommendations offered by survey respondents, SUD providers, and CBO webinar participants are: • The need to accommodate various schedules by offering training at different times of the day was also emphasized • A desire to offer more input to the WET team around sharing resources and codeveloping training programs that meet CEU requirements • More efficient administrative procedures for accessing and participating in training programs. They noted that bureaucratic hurdles can delay or hinder their ability to attend necessary trainings • A preference for trainings that integrate real-world scenarios and case studies to practice applying knowledge • Content offered as a train-the-trainer model to allow attendees to share knowledge and skills with providers across their organization • A desire for trainings delivered by people with lived experience with behavioral health conditions • A desire to offer the general public trainings in essential life skills, such as financial literacy, community trauma, and self-advocacy. They noted that these trainings could enhance self- understanding, development, and people’s ability to effectively advocate within various systems “Staff like to go to trainings, but it’s more time required, and [there’s] lots they will have to catch up on. Already feel overwhelmed with day-to-day tasks.” “I would like to work in tandem with you to help develop a more cohesive network of trainings in the county (amongst CBOs and ACBH).” WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 20 Finding 3: Providers reported a strong demand for rigorous trainings that enable them to deliver culturally responsive services to Alameda County’s diverse client populations and specifically requested advanced clinical-skills training The training topics that providers felt they needed more training support in varied. As seen in Figure 16, providers reported the highest need for additional training in areas related to clients’ holistic needs and their own administrative duties. Figure 16. Percentage of Respondents Reporting Needing More Training Across Topics, N = 85 46% 47% 47% 49% 41% 44% 41% 46% 51% 52% 44% 42% 45% 42% 41% 46% Accessing ACBHD services Clinical supervision Conflict management Co-occuring disorders Crisis assessment and intervention Crisis management training Domestic violence Interdisciplinary teams Intergenerational teams and communication Knowledge and delivery of wellness, recovery, and resiliency services Managing aggressive behavior National Standards for Culturally and Linguistically Appropriate Services (CLAS) in health and health… Procurement overview Professional assault crisis training Skill building for new managers Working with families with complex issues WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 21 Source: WET Provider Survey Providers reported feeling well trained in areas related to service provision, such as clinical models, documentation, and collaborating with clients. Providers expressed a desire for trainings that increase their skills in implementing evidence-based practices and clinical skills. Some described current trainings as insufficiently advanced to strengthen clinical practices. During the CBO provider webinar, many providers reported that there is a significant demand within CBOs for high-quality evidence-based training that meets both the staff’s clinical needs and professional licensing requirements. Survey respondents also expressed interest in advanced training in specific therapeutic modalities and approaches, especially those that include certification. Overall, a majority of survey respondents (73%) reported that it was very important that trainings offer CEUs. There is also interest among providers in participating in training series or advanced-skills development. Some of the topic areas mentioned in qualitative responses about topics for advanced training include: • Family Therapy: Advanced training in family systems therapy and evidence-based practices for working with families • Suicide Prevention: In-depth training on assessing and managing suicidal ideation and behavior • Trauma-Informed Care: Comprehensive programs on understanding and treating trauma, including complex trauma and PTSD • Cognitive Behavioral Therapy (CBT): Advanced certification in CBT for various mental health conditions • Dialectical Behavior Therapy (DBT): Training and certification in DBT for treating borderline personality disorder and other conditions • Substance Use Disorders: Specialized training in treating co-occurring mental health and substance use disorders, including medication-assisted treatment (MAT) • Eating Disorders: Many providers indicated a need for specialized training on eating disorders, including early identification, treatment modalities, and ongoing support strategies • Cultural Competency: Programs that include cultural humility and practices for working with diverse populations, ensuring that providers can deliver equitable and effective care “A lot of the trainings have good titles, but they’re complete fluff. Clinicians are discouraged to take these trainings. I keep hearing ‘evidence based,’ but I don’t see evidence-based trainings.” WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 22 Finding 4: Providers feel most prepared to meet the needs of Latino/Hispanic communities but reported a need for training to engage clients across other ethnic and cultural backgrounds The majority of survey respondents did not cite the need for additional training to serve specific ethnic populations. Those who did cite a need reported the greatest need for training in order to support Native American / Indigenous People (25%), as shown in Figure 17. Figure 17. Provider-Reported Need for Training to Meet the Needs of Priority Populations Target Population N % Native American / Indigenous People 39 25% Asian American / Pacific Islander 31 19% Lesbian/Gay/Bisexual/Transgender//Questioning (LGBTQ+) 28 18% African American / Black 22 14% Transition-Aged Youth 23 14% Latino / Hispanic 14 9% Early-Childhood Mental Health 1 1% Asian American / Pacific Islander Family Support 1 1% Source: 2024 WET Provider Survey During the CBO provider webinar, providers expressed interest in training programs that strengthen their ability to engage clients of diverse cultural backgrounds and respond to the emerging needs of their clients. Similarly, survey respondents also noted the importance of culturally specific and inclusive training programs that address the unique needs of diverse populations, such as LGBTQ communities, immigrant families, Asian and Pacific Islander communities, Middle Eastern populations, African American communities, and children and youth. Finding 5: Providers expressed frustration with certain elements of the bureaucracy of the behavioral health care system and value up-to-date information. Providers explained that constant changes within the healthcare systems, especially new regulations and requirements, pose challenges and create barriers to care. Many respondents who were surveyed emphasized the need for timely information to help them stay compliant and effective in their roles. This includes access to training or briefings that cover new policy updates and regulatory changes. Many providers highlighted challenges in understanding and complying with various county-level policies and procedures. They mentioned that frequent changes to these requirements often lead to confusion and inefficiencies in service delivery. “The gaps in our team’s skills include lack of East Asian–language support for our clients, families, and community and of assessments and evaluations reflecting cultural factors related to the AAPI population.” WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 23 CONCLUSION AND RECOMMENDATIONS There are current workforce gaps in bilingual and racially diverse staff across community-based providers. Providers expressed challenges in the recruitment and hiring of staff who reflect the communities the ACBHD serves. Providers also cited clients’ needs for holistic supports and recognize the opportunity to leverage the peer and family workforce to meet client needs. Overall, there is a need for a pipeline of professionals who represent diverse cultural, linguistic, and professional-training backgrounds. There is also an opportunity to raise awareness of the ACBHD’s intern program among providers. Providers support interns as an effective means to grow the behavioral health workforce and meet emerging workforce gaps. Providers had varied experiences with current WET training offerings. Providers had keen insights about their emerging education needs. They expressed a desire for opportunities to give training feedback and offered suggestions for training topics, formats, and delivery methods. Given these findings, the resource-restrictive environment, and the WET unit’s scope of influence, BRG offers the following recommendations: 1. Sustain marketing efforts to promote WET training and education offerings with community- based providers 2. Continue to offer advanced-skills training in the following topics: • Understanding and assessing health conditions • Knowledge and delivery of “wellness, recovery, resiliency” services • Intergenerational teams and communication • Co-occurring disorders • Clinical supervision • Conflict management • Accessing ACBHD services • Interdisciplinary teams • Working with families with complex issues • Domestic violence 3. Routinely gather training feedback from providers and share format and delivery preferences with contracted trainers to integrate them into future offerings 4. Sustain training offerings for certified peer specialists and other peer and family professionals to support the professional development of the peer and family workforce 5. Recruit interns for the following roles to address provider-identified workforce gaps: • Licensed clinical social worker • Licensed marriage and family therapist • Case manager, social worker, and service coordinator • Child and adolescent psychiatrist 6. Sustain and develop new strategies to increase the applicant pool of interns so that they better reflect the cultural, linguistic, and ethnic diversity of clients, including the following: • Continue to collect intern demographic data • Offer a diversity stipend similar to peers (i.e., Multicultural Student Stipend Program) • Partner with minority-serving institutions for intern recruitment • Solicit ideas from other departments about how to give preference to interns who match the cultural, linguistic, and ethnic diversity of clients 7. Share workforce-capacity findings with human resources and systems of care across the ACBHD to adapt hiring and recruiting strategies to address identified needs WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 24 APPENDICES APPENDIX A. WET PROVIDER SURVEY INTRODUCTION As valued stakeholders to Alameda County Behavioral Health (ACBH), the Workforce, Education and Training (WET) team wants to hear from community-based providers and organizations across ACBH systems of care. Please take about 20 minutes to complete this survey. The WET team wants to hear from you about: • Your training and education needs • Your perspective on the diversity of the workforce • The effectiveness of pipeline programs to build the future workforce The WET team is currently conducting a needs assessment in partnership with an independent research firm, Bright Research Group. The WET team will use survey results to inform their workforce, education and training programming. Results will not be used to assess your organization nor affect future contracting with your organization. Answers are Confidential We want your honest feedback and there will be no consequence for your honesty. Although there are questions that ask you to share information about yourself and your organization, your answers will be kept confidential. If there’s a question you do not want to answer, you can skip it. TRAINING AND EDUCATION NEEDS 1. How important is it to you that trainings offer continuing education credits? o Very important o Important o Somewhat important o Not important at all 2. Where do go to meet your training and education needs? o Your organization o Other local training organizations o Your certifying body o Alameda County Behavioral Health o Other county agencies/units o Other_____________ 3. What feedback do you have for the WET team about your training needs? You can provide feedback on training topics, content, format, certification, availability, etc. [Open-ended/Short text] _________________________________________________________ WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 25 4. How would you like to collaborate with the WET team? [Open-ended/Short text] _________________________________________________________ 5. What are the gap(s) in your or your team’s skills or competencies? [Open-ended/Short text] _________________________________________________________ a. How can the WET team support you to address the gap(s)? ___________________________________________ FAMILARITY WITH WET AND EXPERIENCE ACCESSING PIPELINE NEEDS 6. Which WET unit program have you participated in? (Check all that apply) o Training Programs 1. [Skip logic based on selection] How likely are you to recommend a WET training program to a peer or colleague? 0 1 2 3 4 5 6 7 8 9 10 Not Likely Very Likely o Education Programs a. [[Skip logic based on selection] How likely are you to recommend a WET education program to a peer or colleague? 0 1 2 3 4 5 6 7 8 9 10 Not Likely Very Likely o Pipeline Programs (Programs that are specifically designed to develop our future workforce capacities, including internships, fellowships, and conferences for high school students that promote skill building and exposure to the various behavioral health-oriented careers.) 1. [Skip logic based on selection] How likely are you to recommend a WET training program to a peer or colleague? 0 1 2 3 4 5 6 7 8 9 10 Not Likely Very Likely o None of the above WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 26 7. What are your training needs in the following areas? Select those that apply. Training Area I could use more support to apply skills in this topic in my role I could use more training in this topic I feel well trained in this topic Advanced assessment, differential diagnosis and treatment planning Basic Cognitive Behavioral Therapy (CBT) Clinical Supervision Co-occurring disorders Compassion Fatigue Crisis Assessment and intervention (Danger to self, danger to others, grave disability) Cultural humility and responsiveness Documentation Domestic Violence Knowledge and delivery of “wellness, recovery, resiliency” services Managing aggressive behavior Motivational Interviewing Post-traumatic stress disorder Resource sharing between consumers and providers Trauma Assessment and Interventions Understanding and assessing health conditions Wellness Recovery Action Planning (WRAP) Working collaboratively with clients and families Working with families with complex issues Other__________________ WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 27 8. Were you a student intern with an ACBH contracted provider or system of care? Y/N 1. [Skip logic if Y to #7] What type of student intern were you? (Check all that apply) o Community College o Graduate Psychology o High School o Marriage and Family Therapy o Nursing o Physician Assistant o Psychiatry o Social Work o Undergraduate o Youth and Young Adults not enrolled in school 2. How likely are you to recommend this pipeline program to other students? 0 1 2 3 4 5 6 7 8 9 10 Not Likely Very Likely 9. Have you served as supervisor or host for student intern[s] at your organization? Y/N a. [Skip logic if Y to #8] What type of student intern[s] have you hosted? (Check all that apply) o Community College o Graduate Psychology o High School o Marriage and Family Therapy o Nursing o Physician Assistant o Psychiatry o Social Work o Undergraduate o Youth and Young Adults not enrolled in school b. How likely are you to recommend hosting a student intern to a colleague? 0 1 2 3 4 5 6 7 8 9 10 Not Likely Very Likely 10. In your opinion, how effective are the WET pipeline programs (programs that are specifically designed to develop our future workforce capacities, including internships, fellowships, and conferences for high school students that promote skill building and exposure to the various behavioral health-oriented careers) at preparing a diverse workforce? o Very effective o Effective o Somewhat effective o Not effective at all WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 28 11. What additional feedback do you have on how well the pipeline programs (programs that are specifically designed to develop our future workforce capacities, including internships, fellowships, and conferences for high school students that promote skill building and exposure to the various behavioral health-oriented careers) prepare a diverse workforce? [Open- ended/Short text] _________________________________________________________ 12. What level of internships are needed to address the needs of the communities you serve? [Open-ended/Short text] _________________________________________________________ 13. What infrastructure/staffing is needed to manage the interns at your organization effectively? [Open-ended/Short text] _________________________________________________________ PERSPECTIVE ON WORKFORCE SHORTAGES, CULTURAL COMPETNCE NEEDS AND FAMILY AND PEER WORKFORCE 14. When it comes to hiring in your organization, how difficult is it to fill open positions? o Very difficult o Difficult o Somewhat difficult o Not difficult at all 15. How well is your organization retaining staff? o Very well o Well o Somewhat well o Not well at all 16. How well is your organization recruiting staff that reflect the client population you serve? o Very well o Well o Somewhat well o Not well at all WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 29 17. Which three roles are the most challenging to hire, retain and recruit diverse staff for? (Select first, second, third for only three roles) 18. How well prepared do you feel to meet the needs of the following target populations? Target Population Need more training Somewhat Prepared Well Prepared N/A African American/Black Asian American/Pacific Islander Latinx/Hispanic Lesbian/Gay/ Bisexual/Transgender /Questioning (LGBTQ+) issues Native American/Indigenous People TAY- Transition Aged Youth Other: ______________________ 19. What language(s) other than English do you speak with clients? o Arabic o Cantonese o Farsi o Mandarin o Spanish Position/ Role Most Challenging to Hire Most Challenging to Retain Most Challenging to Recruit Diverse Staff N/A Case Manager/ Social Worker/ Service Coordinator Certified Peer Specialist Child and Adolescent Psychiatrist Designated Consumer/ Family Member Personnel Employment Services Staff Executive and Management Staff General Psychiatrist Housing Services Staff Licensed Clinical Social Worker Licensed Marriage and Family Therapist Mental Health Rehabilitation Counselor Psychiatric Mental Health Nurse Practitioner Substance Abuse Counselor Other______________ WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 30 o Tagalog o Vietnamese o Other: _______________ 20. What are the gap(s) in services for the communities you serve? [Open-ended/Short text] _________________________________________________________ a. How can the WET team support you to address the gap(s)? __________________________________________ 21. Which strategies does your organization use to engage and include peers and family members in service provision and/or practice and policy development? o Involving consumers and family members in workgroups, advisory councils, stakeholder meetings, planning or policy groups o Recruiting consumers and family members on boards and other leadership positions o Meeting and/or job accommodations o Priority preference given to applicants with lived experience o Anti-stigma training for all staff o Partnerships with consumer-run organizations o Consumer or family member internship program o None o Other: ___________________ 22. Does your organization hire certified peer specialists? o Yes o No o Not Sure 23. How many designated peer or family member positions are there at your organization? o 0 o 1-3 o 4-6 o 7-9 o 10 or more 24. What roles do peers and family members have within your organization? o Family partners or advocates o Peer recovery coaches, counselors, mentors, coordinators, and/or specialists o Receptionists or other clerical support staff o Board members o Other__________ WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 31 25. How interested are you in sharing information or developing public available trainings (for peers, family members, non-clinical staff and the general public) in the following areas? Select those that apply Not At All Interested Somewhat Interested Interested Very Interested Access to mental health services Family and/or consumer support Stress management 5150/5585 training Other: DEMOGRAPHICS 26. Please select the setting(s) that best represent your workplace. Select all that apply o Community Based Organizations o Community Mental Health/ Behavioral Health Agencies o Hospital o Involuntary Treatment/Substance Use Disorder o Peer Services o School o Social Services Agency o State& Regional Agency o Substance Use/ Outpatient Setting o Withdrawal Management 27. What is the size of your organization? o Under 25 employees o 25-50 employees o 51-100 employees o 101-200 employees o More than 200 employees 28. Which system of care does your organization work in? Select all that apply o Acute & Crisis Services o Adult & Older Adult Services o Child & Youth Services o Forensic Services o Integrated Primary Care Services o Psychiatry and Nursing Services o Substance Use WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 32 29. How long have you been at your organization? o Less than one year o 1-3 years o 4-6 years o 6-10 o Over 10 years 30. What is your highest level of education completed? o High school degree or GED equivalent o Associate’s degree o Bachelor’s degree o Master’s degree o Doctorate o Other: _______________ 31. What is your current role? o Case Manager/ Social Worker/ Service Coordinator o Child and Adolescent Psychiatrist o Designated Consumer/ Family Member Personnel o Employment Services Staff o Executive and Management Staff o General Psychiatrist o Housing Services Staff o Licensed Clinical Social Worker o Licensed Marriage and Family Therapist o Mental Health Rehabilitation Counselor o Psychiatric Mental Health Nurse Practitioner o Substance Abuse Counselor o Other______________ 32. How long have you been in your current position? o Less than one year o 1-3 years o 4-6 years o Over 6 years These questions are optional. Your answers are confidential. If you want to skip a question, just select prefer not to say. 33. What is your racial/ethnic identity (Select all that apply): o American Indian or Alaskan Native o Black/African American o East Asian o Latino/a/e o Middle Eastern or North African WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 33 o Native Hawaiian or Pacific Islander o South Asian o Southeast Asian o White o Other__________ o Prefer not to say 34. Please select the language(s) you speak (Select all that apply): o Arabic o Chinese o Farsi o Spanish o Tagalog o Vietnamese o Other: _______________ o Prefer not to say 35. What is your gender identity? o Female o Male o Gender non-binary o Genderqueer o Trans Female o Trans Male o Another gender identity: __________________ o Prefer not to say 36. Do you have a disability? o Yes o No o Prefer not to say 37. Which of the following lived experiences have you had? (Select all that apply) o Living with mental health challenges o Having a friend/family member living with mental health challenges o Living with a substance use disorder o Having a friend/family member living with a substance use disorder o Experiencing a significant traumatic event o Having a friend/family experience a significant traumatic event o Living in the foster care system o Having a friend/family member living in the foster care system o None of the above o Other:__________ o Prefer not to say WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 34 APPENDIX B. DEMOGRAPHICS OF WET PROVIDER SURVEY RESPONDENTS Race/Ethnicity American Indian or Alaskan Native 2 3% Black / African American 15 19% East Asian 6 8% Latino/Hispanic 15 19% Middle Eastern or North African 1 1% Native Hawaiian or Pacific Islander 2 3% South Asian 3 4% Southeast Asian 2 3% White 33 41% Other 4 5% Language Spoken Cantonese 1 1% English 54 74% Farsi 1 1% Mandarin 2 3% Spanish 15 21% Tagalog 2 3% Other 12 16% Educational Level High School Degree / GED 3 4% Some College 4 5% Associate Degree 14 17% Bachelor’s Degree 50 59% Master’s Degree 12 14% Doctorate 2 2% Gender Identity Female 66 83% Male 8 10% Gender Non-binary 1 1% Gender Queer 1 1% WET Needs Assessment Report COPYRIGHT © 2024 BRIGHT RESEARCH GROUP | 35 APPENDIX C. PROFESSIONAL TENURE OF WET PROVIDER SURVEY RESPONDENTS Organizational Tenure Less than 1 year 7 8% 1–3 years 19 22% 4–6 years 14 17% 6–10 years 16 19% Over 10 years 29 34% Current-Position Tenure Less than 1 year 13 15% 1–3 years 30 35% 4–6 years 16 19% Over 6 years 26 31%