In one sense, of course, the question is moot. Credentials in health care do matter. They provide necessary proof that qualified professionals are engaged to deliver competent and effective services to consumers. Just as critical medical procedures such as surgery should be performed by licensed and certified surgeons, so should mental health and substance abuse treatment be delivered by those who have met professional standards of practice.
Generally speaking, these standards of practice are certified by a credentialing process based on three areas of competence: education, experience, and examination.
Appropriate degrees awarded by accredited educational institutions, sufficient and appropriate work experience under professional supervision, successful passing of uniform national or state licensing or certification examinations in a given field – all these approaches are used to determine whether an individual should be credentialed. In managed care, moreover, additional privileging may be granted by the plan based on the above considerations, plus an internal performance review.3
Regulators, payers and consumers (as well as professional disciplines themselves) all play a key role in ensuring accountability and quality of services by requiring credentials in service personnel. No one would argue against such a premise.
However, when applying this premise to screening and assessment in behavioral health, some existing paradigms bear a closer examination:
Only credentialed professionals can provide high-quality behavioral health screening and assessment.
Established as one of the tenets of mental health and substance abuse services, the intention of this paradigm is laudable, for it is based on the assumption that credentialed professionals can help ensure accountability and quality of screening and assessment.
But suppose we turn this paradigm on its head:
At the heart of this discussion lies the issue of how quality is to be perceived, defined, and measured. Credentials alone do not guarantee a high-quality outcome, but only permit it as a possibility. Other elements, such as active consumer participation or the specific content of screening and assessment can contribute as much, or even more, to the quality of screening and assessment. One national trend, for example, is that more and more screening and assessment instruments are standardized, and include consumers’ self-reporting as an integral part of information gathering.4
Credentialed professionals are essential to assist consumers during their initial contact with the service system.
One strong argument for using credentialed professionals in screening and assessment is to ensure that clinically capable and sensitive personnel are available at the front door to assist consumers in navigating the system. Undoubtedly, sensitivity to people in need, and particularly to people in crisis, is vital.
Yet consumers seldom go through a single door. Many come to the attention of the behavioral health care system through primary care physicians, schools, the juvenile justice system, law enforcement agencies, social services, civic groups, families, friends and other consumers. In fact, consumers sometimes feel more at ease speaking to other consumers about their service needs than to credentialed professionals. "Multiple doors" are even more of a reality for children than for adults. More often than not, the initial contact is a non-behavioral health care person or entity. To follow the letter of this paradigm, credentialed personnel would have to be available at all gates – clearly an expensive, unrealistic, and quite possibly unnecessary proposition.
Because assessment leads to provision of services, credentialed professionals are necessary during assessment to carry out service planning and interventions.
There is a clear place for credentialed professionals to perform assessment – in diagnostic evaluation (including psychosocial assessment) to assist service planning and intervention. Ideally, the same professional is engaged with the consumer throughout the process and is accountable for service outcomes. However, information gathering can sometimes be performed by others, as long as interpretation for evaluation rests with the credentialed professional. A recent study by the Center for Social Work Practice at Columbia University found that standardized screening and assessment information gathered by consumers and non-credentialed professionals can be used effectively by credentialed personnel in making sound assessment and service plans.5 Research studies comparing credentialed and non-credentialed personnel in screening and assessment are admittedly scanty, but should be pursued in the future.
One troubling phenomenon that has permeated public behavioral health systems is the repetitive assessments performed at each referral. It is not unusual for consumers to go through several providers and be assessed multiple times before service intervention even begins. Provider accountability is often cited as a primary reason for repeated assessment, and few providers feel comfortable accepting assessments performed by others. As a consequence, in addition to the constraint of relying on credentialed professionals to perform various service tasks, barriers to service – not to mention additional cost – are further created by repetitive assessments. Making assessment standardized, even though its interpretation would still be performed by credentialed professionals, would go a long way toward reducing the burden on all concerned, in addition to enhancing the ability to compare service outcomes across providers.
Rehabilitation and recovery are achievable, and should be the primary service goal.
Credentials are a process indicator, not an outcome indicator. Process indicators are often necessary, but they have limited roles in developing good outcome indicators.
There may be better and more cost-effective alternatives to Arizona’s requirement for Masters level certification for those carrying out initial behavioral health assessments.
Arizona’s current certification process takes longer than those in many other states, where provisional status and shorter review times are offered.
The screening function can be standardized and administered by non-credentialed personnel with appropriate in-service training.
Arizona’s Levels-of-Care system is recognized as one of the best in public behavioral health.
State rules and regulations ought to be reexamined every few years; what worked in the past may not work in the present or future.