Promising Practices: Workforce

Methodology: This practice utilizes affiliations with academic institutions (universities, community colleges, vocational schools) and federal programs (like the Teaching Health Center Graduate Medical Education and National Health Service Corps) to build a robust pathway of trained healthcare professionals, directly addressing staff recruitment and retention challenges by providing students with clinical experience and a defined route to employment in health centers.

To replicate this practice, health centers should implement the following steps:

1. Establish Foundational Academic Partnerships:
◦ Form affiliations with academic institutions, including universities and community colleges, for various disciplines (e.g., Family Medicine, Dental, Behavioral Health).
◦ Develop formal Memorandums of Understanding (MOU) to define the partnership, and proactively address initial challenges related to health center staff time, student supervision, liability, and insurance coverage.
◦ Explore in-house residency programs and pilot programs, such as the Teaching Health Center Graduate Medical Education (THCGME) initiative, to establish accredited, community-based training.

2. Implement Staffing and Program Infrastructure:
◦ Appoint dedicated Lead Staff to manage student programs within each department.
◦ Utilize federal and state programs, such as the National Health Service Corps (NHSC) Loan Repayment and Scholarship programs, to attract eligible practitioners across various disciplines (e.g., Physicians, PAs, NPs, Dentists, LCSWs).
◦ Explore immigration options for foreign physicians, such as the J-1 Waiver (Conrad Waiver) and H-1B visas, especially since affiliations with institutions of higher education may qualify for H-1B cap exemption.

3. Conduct Strategic HR Efforts to Recruit from the Student Pool:
◦ Provide Orientation for students to promote the organization and opportunities for employment post-graduation.
◦ Facilitate Recommendations from Lead Staff for job candidates.
◦ Maximize recruitment success by extending Offers of Employment to students selected prior to graduation.

4. Ensure Successful Post-Recruitment Retention and Onboarding:
◦ Develop a comprehensive Talent Management Program that includes recruitment, orientation, training, evaluation, and career counseling for retention and advancement.
◦ Appoint Mentor Providers for new hires who originated from the student pool.
◦ Develop Onboarding Training and a Supervision Schedule, ensure assignment to a Care Team, and provide constant evaluation and feedback.

Methodology: This practice involves the Board taking a strategic role in evaluating and overseeing the complex, multi-year process of transforming the health center into a Teaching Health Center (THC), ensuring that all necessary financial, human capital, and partnership requirements are strategically managed to address provider shortages and patient access barriers.

To replicate this practice, the Health Center Board should implement the following steps:

1. Use Strategic Planning to Assess Organizational Fit (Tip 1): Dedicate time during the strategic planning process to decide if becoming a Teaching Health Center is the right solution for the health center’s workforce needs.
◦ Review existing data regarding provider burnout, patient access barriers, and workforce shortages.
◦ Review data on provider retention rates and local/statewide workforce numbers, as well as needs assessment data.
◦ Ask the CEO high-level questions regarding staff capacity, workload, and necessary management and oversight.

2. Evaluate Required Human Capital and Financial Investments (Tip 2): Consider the large staffing and financial investments needed for the multi-year process.
◦ Review preliminary numbers regarding staffing needs, time allocations, budgetary impacts, and the cost of the accreditation process and ramp-up period.
◦ Leverage community connections and foundation partnerships to identify specific sources of financial support.

3. Establish Necessary Community Partnerships (Tip 3): Determine if the health center has a plan to build new community partnerships or deepen existing ones to meet the requirement of providing residents with experience in specialty services.
◦ Proactively leverage existing relationships and include board members in reaching out to key community leaders, which can provide leverage in negotiating partnership agreements.

4. Build Board and Staff Infrastructure for Oversight (Tip 4): Determine the necessary staff committees and board structure to support the extensive compliance required for the process.
◦ Decide which standing board committee (e.g., Clinical and Quality Board Committee) will manage the ongoing oversight and compliance of the THC program.
◦ Build board education and updates from the CEO and CMO into monthly board agendas and the annual work plan calendar.

Methodology: This practice provides health centers with a systematic process and tools for recruiting, hiring, and integrating licensed Dental Therapists (DTs) into the care team, ensuring compliance with a state's scope of practice, supervision, and documentation requirements, thereby filling oral health workforce gaps and increasing access for communities with additional needs. It uses standardized documents such as a sample job description, request for privileges, and a template for the Written Practice Agreement (WPA).

To replicate this practice, health centers should implement the following steps:
1. Prepare Policy and Review State Requirements: Review the state's Dental Therapy scope of practice and supervision model. Review and check for needed Policy & Procedure Manual changes, specifically regarding dental program policies, the organizational chart, and the unique supervision/authorization process required for DTs.
2. Develop Recruitment Documents and Compensation: Prepare a clear, articulated job description (using the sample provided in the manual) and a DT privileging form (using the sample provided). Develop a competitive wage and compensation package, which may include a sign-on bonus, moving expenses, or a service term agreement if recruiting from another state.
3. Ensure Operational and Clinical Readiness: Ensure the health center has the appropriate space (typically 1-2 chairs), instruments, staff (typically 1-2 assistants), and overall capacity to support the DT. Ensure a sufficient patient base and procedure mix to maintain a full schedule for the DT.
4. Recruit, Onboard, and Educate Staff: Utilize support from organizations for distributing job postings. After interviewing and hiring, introduce the DT to the entire staff, allowing time for questions and answers, and ensure the DT feels welcomed and accepted by the team. Prepare all dental staff and providers by educating them on the DT role, their scope of practice, and how workflows may change.
5. Establish the Written Practice Agreement (WPA) and Supervision: Complete the credentialing process (e.g., CHAMPS enrollment, Medicaid Health Plans) and have the DT complete the privileging form. The supervising dentist must collaborate with the DT to draft the Written Practice Agreement (WPA), which must be signed by both parties and is valid for three years. The WPA must include details on:
◦ The services, procedures, practice settings, and limitations authorized for the DT.
◦ A quality assurance plan for monitoring care, including patient record review, referral follow-up, and chart review.
◦ Protocols for managing medical emergencies and administering/dispensing medications.
6. Provide Mentorship and Communication: Appoint a committed mentor for the DT and encourage daily huddles. Ensure the DT always has a means to communicate with their supervising dentist as needed during care provision. The supervising dentist must be available on a regularly scheduled basis for consultation and review of records.

Methodology: This practice enables healthcare providers to effectively implement a team-based Patient-Centered Medical Home (PCMH) diabetes care management program. The strategy involves using team-based care, patient registries, and risk stratification to align interventions and improve clinical outcomes.

To replicate this practice, an organization should follow these eleven steps for starting a diabetes care management program:
1. Identify a Population Health Tool: Identify a population health tool or an electronic medical record system to generate a panel of individuals with diabetes.
2. Identify a Risk Stratification Process: Define a process to identify risk levels (low, medium/rising, and high) for the diabetes patient panel. Risk stratification should categorize patients based on claims data, chronic conditions, utilization, adherence to treatment plans, and mental health status.
3. Define the Care Team: Define the care team, which may include a Primary Care Provider, Care Manager, Pharmacist, Diabetes Educator, Registered Dietitian Nutritionist, Community Health Worker (CHW), Endocrinologist, and Mental Health professional.
4. Determine Care Team Processes: Determine the care team’s processes and interface, utilizing team-based strategies such as providing structured care according to evidence-based clinical guidelines and engaging in goal setting with patients.
5. Identify Partners: Identify specialists and community partners to refer patients.
6. Determine KPIs and Measurement Processes: Determine Key Performance Indicators (KPIs) and processes for measuring the program, including assessment based on structure, process, and outcome measures (such as HEDIS or UDS measures).
7. Communicate Launch Plan: Communicate the launch plan to staff and patients.
8. Begin Enrolling Patients: Begin enrolling patients into the care management program and conduct outreach to the panel based on the risk level care team process.
◦ High-Risk Patients: Require the most intense intervention and need frequent care management outreach (e.g., once a month). These patients may have HbA1c >9% or multiple risk factors.
◦ Rising/Medium-Risk Patients: The model of care focuses on managing risk factors; care management reduces progression to high risk and overall costs. Outreach should occur every 6–8 weeks.
◦ Low-Risk Patients: The care model aims to keep the patient engaged and can be managed remotely, requiring outreach every three months.
9. Complete Assessments and Care Planning: Complete assessments and care planning in accordance with guidance from NCQA and ADA, and organizational policies.
10. Discharge Patients: Discharge patients from the care management program once goals are met or the patient disengages.
11. Evaluate the Program: Evaluate the program at the frequency and based on previously identified KPIs and measurement processes.

Methodology: This practice guides health centers in developing a comprehensive workforce development strategy focused on creating and clearly communicating career paths, thereby reducing high rates of burnout and turnover (nearly half of mental health workers consider leaving due to workforce shortages) by offering consistent opportunities for professional growth and advancement.

To replicate this practice, health centers should implement the following steps:
1. Integrate Career Pathways into the Comprehensive Workforce Plan: Identify career paths as a key area of the retention strategy within the overall Comprehensive Workforce Plan. Recognize that staff are more likely to stay with the organization if professional growth and advancement opportunities are available and accessible.
2. Determine and Disclose Career Paths: Define and disclose specific skills- and competency-based career paths to employees. Structure these paths to include typical growth stages for mental health providers, such as progression from Student/Resident to Non-Licensed Independent Practitioner (LIP) Provider, to LIP, and potentially to Clinical Supervisor, Admin Supervisor, or a Broader Agency Role.
3. Define Skill Requirements and Training Resources: Determine the necessary skills and competencies required to achieve various roles or career stages within the health center. Identify professional development, continuing education, and mentorship resources available for staff to gain those required skills.
4. Implement Targeted Skill-Building Strategies: Utilize various skill-building methods, including Upskilling (developing deeper expertise in a current role), Cross-Skilling (gaining skills in a lateral role), and Reskilling (training for a completely new role), to invest in the professional growth of employees.
5. Communicate and Evaluate Development Plans: Clearly and consistently communicate career path information and resources to all employees. Invest in career ladders that train employees for the successful achievement of leadership positions, and plan for a Formal Development Plan Evaluation to track progress.
6. Support Retention with Organizational Benefits: Supplement career pathways with other vital retention strategies, such as offering increased compensation, support for continuing education and student loan repayment, flexible/variable work schedules, and operating as a wellness-focused organization. Ensure the Mental Health Department receives the same level of support as other clinical departments.

Methodology: This practice guides health centers in establishing a structured, paid administrative fellowship program, typically lasting one year, which involves intense mentorship from executive-level preceptors and a rotational model to expose master’s-level postgraduates to key health center operations, governance, and strategy, ultimately developing new executives and retaining talent.

To replicate this practice, the health center should implement the following steps:

1. Determine Program Structure and Length (Questions 2 & 4): Decide whether to offer a general or specialized fellowship and determine the duration (one year is recommended to start, beginning in June or July and concluding the following May or June).
◦ If starting a two-year fellowship, be aware it requires double the preceptor, project/rotational lead, and financial support.

2. Establish Fellowship Model and Rotations (Question 5): Use a rotational model to structure the fellowship, embedding the fellow in various service lines (e.g., Operations, HR, Finance, IT, Marketing) and practice sites to work on local projects, rather than relying solely on a project list model.
◦ The fellow should be exposed to numerous departments, including Clinical Service Lines, Finance, HR, IT, and Quality/Process Improvement.

3. Appoint Preceptor and Rotational Leads (Questions 6 & 7): Select a member of the executive suite (CEO, COO, CFO) to serve as the Preceptor, who must have sufficient time, desire, and leadership standing to mentor the fellow.
◦ Identify energetic, committed leaders from departments like Clinical Chiefs, CIO, or General Counsel to serve as Rotational Leads, as the fellow will spend the majority of their time under their direction.

4. Ensure Comprehensive Access and Support (Question 1): Grant the fellow access to senior leadership meetings, board meetings, business plan development, and practice acquisition discussions so they can witness the inner workings of the community health center.
◦ Compensate the fellow based on a medical resident’s salary (median income reported in 2016 was about $56,600) and provide full benefits.
◦ Budget for stipends like reimbursement for one healthcare conference per year.

5. Utilize Centralized Application and Onboarding: Require candidates (recent Master's graduates, preferably from a CAHME institution) to submit materials via the Centralized Application Service for Administrative Fellowships (NAFCAS) portal.
◦ Onboard the fellow by creating a structured first month’s calendar that includes site visits, orientation sessions, system access, and setting up one-on-one meetings with all relevant leaders.
6. Manage Post-Fellowship Transition (Question 9): Make no promise of a position post-fellowship, but highly recommend requiring the fellow to interview for any open internal roles to ensure the position fills a true agency need.
◦ Support the fellow in their job search, utilizing a job search tracking sheet and holding candid conversations about job fit and resume editing, typically beginning in January.

Methodology: This practice guides Federally Qualified Health Centers (FQHCs) and other eligible facilities to utilize the VA MISSION Act Section 403 GME Pilot Program to expand community-based training opportunities for medical residents, which is designed to increase the primary care workforce in rural and communities with additional needs through two structured reimbursement models, Model A (existing programs) and Model B (new programs).

To replicate this practice, FQHCs and other covered facilities should implement the following steps:

1. Determine the Model and Identify Partners: Decide whether to participate via Model A or Model B and identify necessary partners.
◦ Model A (Existing Programs): Partner with an existing ACGME-accredited GME Sponsoring Institution (e.g., a university or hospital) to allow their residents to rotate at the FQHC or covered facility. The VA Office of Academic Affiliations (OAA) issues Requests for Proposals (RFPs) for Model A, and the sponsoring institutions apply to OAA.
◦ Model B (New Programs): The covered facility (e.g., FQHC) serves as the GME sponsor, attains provisional accreditation status, and starts a new residency program.

2. Align Program Goals with Workforce Needs: Ensure the program addresses the need for providers in surrounding areas, as priority is given to facilities located in a Health Professional Shortage Area or rural/remote areas.

3. Establish Financial and Operational Structure: Understand the reimbursement mechanism offered by the VA for the pilot.
◦ Model A: The VA reimburses the GME sponsor for the resident's salary and benefits for time spent rotating at the covered facility.
◦ Model B: The VA reimburses the covered facility for the resident's salary and benefits, as well as the startup costs for the new GME program, including curriculum development, accreditation costs, faculty salaries, and recruitment.

4. Engage VA Leadership and Faculty: Proactively engage VA leadership, including the local Designated Education Officer (DEO), to foster partnerships and collaborate on developing curriculum and resident experiences, such as offering specialty rotations (e.g., Dermatology, Surgery) and Veteran-Centered instruction.
5. Utilize Data Reporting for Monitoring: Be prepared for comprehensive data reporting required by the MISSION 403 program, including the number of residents, medical specialties, program costs, clinical appointments for Veterans, and the number of residents hired by the VA.

Methodology: This practice guides a health center in establishing a structured student and/or postgraduate clinical psychology residency program to staff clinical roles, increase client access, and provide professional development opportunities for existing staff.

To replicate this practice, a health center should follow a phased process covering strategic planning, resource assessment, recruitment, and program operation:

1. Strategic Planning and Resource Assessment.
◦ Determine the key drivers for launching the behavioral health training program (e.g., meeting the behavioral health needs of clients trained in an integrated care model, benefits to the health center, benefits to the trainee).
◦ Identify the specific training requirements based on discipline and level (e.g., practicum, internship, residency).
◦ Assess necessary resources, including physical space, human capital, and financial needs.
◦ Secure essential organizational buy-in from the board, leadership, and clinicians.
◦ Develop a financial and strategic plan, considering direct/indirect costs, long-term Return on Investment (ROI), and potential partners.

2. Program Structure and Competency Definition.
◦ Define professional competencies specific to the health center setting, such as integrated care, telebehavioral health, and OUD/SUD care.
◦ Establish the core training program elements, including clinical exposure (e.g., integrated care settings, school-based health centers, shelters) and specific requirements for direct clinical care (e.g., minimum 900 visits/year).
◦ Implement didactic seminar types, such as training on treating chronic health conditions, multicultural considerations, and conducting group treatment.
◦ Ensure required supervision meets state licensing standards (e.g., 2 hours individual, 1 hour group) and incorporates Quality Improvement (QI) training and participation in QI initiatives.

3. Recruitment and Implementation Timeline.
◦ Develop a comprehensive recruitment strategy, including building relationships with local programs, maintaining a website presence, attending academic placement fairs, and leveraging professional networks (such as APPIC for Postdocs).
◦ Implement the program according to a schedule (often following the academic year), starting with orientation and setting individual and group training goals.
◦ Trainees begin seeing clients using a ramp-up approach, starting with intakes and warm-handoffs.
◦ Conduct formal evaluations (e.g., first written evaluation in December) and structured feedback sessions or surveys (e.g., in February).
◦ Use the second half of the year for advanced activities, such as residents leading didactic seminars and participating in interviews for the next cohort, leading to hiring discussions for permanent roles.

Methodology: This practice enables a health center to establish a formal, 12-month postgraduate training program for NPs and PAs, which is structured around a full-time employment model featuring clinical training, specialty rotations, and dedicated education in core areas like integrated care and Quality Improvement, with the goal of producing highly skilled clinicians and future health center leaders. The process is typically guided and validated by seeking accreditation, which ensures adherence to rigorous educational and clinical practice standards.

To replicate this practice, health centers should implement the following steps:

1. Determine Program Structure and Goals: Define the program structure, recognizing that it should address the shortage of expert providers, reduce attrition due to burnout, and support the development of confidence and mastery in the health center setting.
◦ Structure the program as a 12-month full-time employment model.
◦ Allocate program time for 80% clinical-based training and 20% education.

2. Design the Training Components: Ensure the curriculum includes core elements of a high-performance model of care, training to clinical complexity, and full integration at the organization.
◦ Include Precepted Continuity Clinics (40% of time) where residents develop and manage a patient panel with an expert preceptor.
◦ Include Specialty Rotations (20% of time) and Mentored Clinics (20% of time) focused on critical primary care skills and efficiency.
◦ Integrate Quality Improvement Training, including collecting and reviewing data, and leadership development.

3. Develop a Recruitment and Marketing Plan: Create a recruitment strategy to increase the selection of candidates and coordinate with the HR team around hiring processes.
◦ Collaborate with local academic institutions, schools of nursing, and organizational alumni networks.
◦ Implement a rolling application process to accommodate varying graduate timelines.
◦ Utilize communications and marketing efforts, such as press releases, a dedicated webpage, and presentations to academic institutions.

4. Pursue Program Accreditation: Anchor program development by seeking formal accreditation, which provides external validation of the program's rigor and quality.
◦ Follow the established accreditation timeline, including completing a Self-Study (internal program evaluation) and a subsequent on-site visit by peer evaluators.
◦ Adhere to the consortium standards that drive excellence in program design, such as standards relating to Curriculum, Evaluation, Administration, and Staff.

Methodology: This practice enables a Community Health Center (CHC) to leverage academic partnerships with educational institutions (such as dental, hygiene, or assistant schools) to create structured service learning experiences, serving as an effective recruitment strategy, offering professional development to existing staff, and increasing patient access to oral healthcare services.

To replicate this practice, a CHC should follow a comprehensive planning checklist and address key implementation considerations:

1. Assess Organizational Readiness (Step 1 of Planning Checklist):
◦ Determine the CHC's benefits and challenges for pursuing an academic partnership.
◦ Secure commitment from CHC leadership and other departments to devote necessary resources.
◦ Assess the level of interest of the existing dental team in serving as enthusiastic teachers and mentors.
◦ Evaluate physical capacity, noting that a clinical site should ideally have a minimum of three operatories to host a dental student, dental hygiene student, or dental resident.
◦ Ensure the capacity of team members, including dental assistants, to support learners and understand that front desk staff may require training for specific scheduling needs.

2. Establish Partnership and Define Structure (Steps 2 and 3 of Planning Checklist):
◦ Contact other CHCs with existing academic partnerships to learn from their direct experiences.
◦ Contact an academic institution, residency, or training program, prepared to discuss necessary considerations.
◦ Define the specific education model, such as Pre-doctoral Student Rotations, Post-Doctoral Residency Training, or Dental Hygiene/Assistant Program Collaborations.
◦ Align the curriculum with academic institution requirements, ensuring the CHC can support the types of procedures and patient demographics needed for the learner to achieve competency.
◦ Determine the appropriate length and frequency of rotation, ensuring continuity of care (e.g., 6–12 months for Post-Doctoral Dental Residents).

3. Formalize Expectations and Communication:
◦ Develop a Memorandum of Understanding (MOU) to establish clear expectations between the CHC and the academic institution.
◦ The MOU should outline financial terms, responsibility for liability insurance for learners, requirements for privileging and credentialing, and expectations for supervision.
◦ Prior to the service learning experience, schedule a meeting between the CHC supervising faculty and the learner to share the learner's existing skill set and describe the day-to-day operations of the CHC.
◦ Maintain continuous, effective communication between the academic institution and the CHC, and hold daily huddles with the learner to review the schedule and patient cases.

4. Manage Financials and Data:
◦ Do not pursue an academic partnership solely with the goal of increasing revenue; aim for revenue neutrality, recognizing that supervisor productivity may decrease due to time spent mentoring.
◦ Negotiate a financial arrangement that determines who covers salaries and how revenue generated by the learner is shared (e.g., the CHC retains revenue and provides a stipend, or the academic institution covers the resident's salary).
◦ Collect accurate productivity data before initiating academic partnerships and continue to track this data after implementation to quantitatively measure the impact of hosting learners.

5. Develop Faculty and Maintain Workflow:
◦ Ensure that CHC oral health professionals selected as supervising faculty complete all required faculty development, including training on mentoring techniques and evaluation standardization.
◦ Adjust the schedule, if necessary, for dental and dental hygiene students who may require longer appointments to accommodate their skill level.

Methodology: This practice enables a health center to retain talented behavioral health (BH) staff and build internal management capacity by creating structured career pathways and providing dedicated leadership training and mentorship.

To replicate this practice, an organization should focus on developing structures that promote and prepare current BH practitioners for leadership roles:

1. Assess Agency Needs and Staff Skills.
◦ Determine the specific roles the agency needs to accomplish its goals.
◦ Identify staff skills and interests to see where they can exercise their expertise.
◦ Identify what scaffolding is in place to support career development.

2. Establish Career Pathways and Promotion Structure.
◦ Develop pathways for current BH practitioners to become leaders, such as a progression from Therapist to Lead/Senior Therapist to Program Manager.
◦ Implement Horizontal Job Promotion to show the organization values career growth and rewards effort. Horizontal promotion involves increasing the title and pay with little to no change in responsibilities (e.g., Therapist to Lead Therapist).

3. Develop and Utilize Leadership Training.
◦ Create a leadership training manual or curriculum.
◦ Leverage existing resources, such as an EAP Provider or the Google Project Management Professional Certificate.
◦ Utilize BH staff's existing graduate-level training, which often includes clinical skills, systems understanding, research and data analysis, and teaching skills, for broader agency leadership roles.

4. Build Opportunities and Identify Leaders.
◦ Identify emerging leaders starting at recruitment, hiring, and onboarding.
◦ Encourage movement along career pathways.
◦ Provide mentorship focused on specific tasks and projects.
◦ Ensure annual appraisals include stretch goals that go beyond documentation and productivity.
◦ Secure funding sources such as grants and foundations to support these efforts.

Methodology: This practice enables a health center to define, staff, manage the clinical workflow, and measure the effectiveness and financial sustainability of an Integrated Behavioral Health (IBH) program in primary care.

To replicate this practice, an organization should execute a phased approach focused on structure, workforce, workflow, and long-term sustainability:

1. Define the Integrated Behavioral Health Model (Groundwork).
◦ Determine the organization's current landscape of IBH integration along the continuum of care, selecting the appropriate level of collaboration (Level 1 Minimal to Level 6 Full Collaboration).
◦ Adopt the five core IBH principles: ensuring patient-centric care, defining clear goals/measures (treatment to focus on), using evidence-based behavioral treatments, conducting efficient team care, and establishing population-based care.
◦ Identify the core integrated care team members, including Primary Care Physicians/NPs/PAs, Behavioral Health Clinicians (Psychologists, Social Workers), and Allied Health Professionals (Community Health Workers).

2. Implement Targeted Recruitment and Onboarding Strategies.
◦ Create job descriptions that accurately reflect the IBH role and responsibilities, aligning them with IBH core competencies (e.g., systems-oriented practice, collaboration, and quality improvement).
◦ Use specific recruitment methods, such as alumni boards of local educational institutions that train IBH clinicians or conferences promoting integrated care.
◦ Utilize unique interview questions that assess characteristics like flexibility, growth mindset, and willingness to take an active role in clinic-wide quality improvement efforts.
◦ Develop a comprehensive onboarding checklist that ensures the new IBH clinician is embedded in primary care and that systems are updated (e.g., updating consent language to include behavioral health as part of medical consent).

3. Establish Efficient Clinical Workflows.
◦ Implement universal screening for the entire patient population annually (e.g., PHQ-9, GAD7, Substance Use).
◦ Structure the IBH clinician’s day to include pre-visit planning and rotating huddles with the care teams.
◦ Ensure warm hand-offs for every patient with a positive IBH screen.
◦ Adopt short-term, evidence-based treatment models typically ranging from 6–8 visits per care episode.
◦ Schedule appointments efficiently (e.g., 30-minute visits, targeting 9–11 visits per day) using an open-access schedule that allows for same-day appointments.

4. Measure Success and Ensure Sustainability.
◦ Establish a Year 1 Sustainability Plan covering operational, clinical, cultural, and financial actions (e.g., setting workflows, training primary care teams, monitoring early financial performance).
◦ Define key outcome metrics (e.g., PHQ-9 improvement, access rates) and use Quality Improvement (QI) measures, such as Plan-Do-Study-Act (PDSA) cycles, to drive improvement.
◦ Measure integration success over time using validated tools across organizational (e.g., MeHAF Site Self-Assessment Evaluation Tool) and clinician domains (e.g., Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ)).
◦ Ensure all roles able to bill are billing from the outset while ramping up, and secure buy-in from payers for reimbursement models (e.g., grants, FFS, PPS, or bundled payments).

Methodology: This practice enables a health center to build local employment capacity and address dental assistant (DA) shortages by implementing a formal, structured, on-the-job DA training program.

To replicate this practice, a health center should follow a phased process to assess readiness, secure resources, and design a customized training program:

1. Evaluate Need and Organizational Readiness.
◦ Determine the local and internal need for DAs, noting that 74% of dental leaders have reported a DA shortage.
◦ Research local and state regulations regarding DA, Infection Prevention and Control (IPC), radiology, and certification requirements.
◦ Assess the health center’s overall capacity, including physical space (e.g., operatories), financial resources (e.g., ability to sustain the program while ramping up), and workforce (willing and supportive team).

2. Engage Stakeholders and Establish Leadership.
◦ Secure essential organizational buy-in from key stakeholders, including the CEO, Human Resources director, and, critically, existing dental assistants and the dental team.
◦ Select program implementation leaders, often dental directors or office managers, who are passionate about teaching or program management.

3. Develop Budget and Funding Strategy.
◦ Create an initial budget outlining one-time startup costs (which can range from $2,000 to $169,000) and an operating budget for ongoing costs.
◦ Identify funding sources, which typically include the organization-wide or dental department budget, and allocate funds for equipment, teaching materials, and certification classes (like radiology or infection control).

4. Design Curriculum and Training Structure.
◦ Define the program's frequency, length (most interviewed programs are four to six weeks), scope, and size.
◦ Design the curriculum to align with state regulations, covering didactic content (e.g., terminology, anatomy) and clinical components (e.g., IPC, radiology, EDR training, and procedures).
◦ Identify trainers, noting that they are often existing DAs, and ensure they are equipped with the resources they need to teach trainees.
5. Implement Recruitment, Competency Assessment, and Retention.
◦ Establish trainee requirements (e.g., 18 years old or older, high school diploma/GED).
◦ Implement recruitment strategies, including internal recruitment (existing staff) and external outreach (community postings, patient base).
◦ Develop competency assessments using checklists, quizzes, exams, or by embedding the training into regular clinic competency procedures, such as 30-60-90-day reviews.
◦ Develop a retention strategy, such as establishing career ladders to provide upward mobility, offering competitive salaries/benefits, or using employment contract clauses.
6. Evaluate and Refine the Program.
◦ Evaluate the program by documenting the recruitment rate (trainees hired/total trainees) and retention rate (trainees remaining/total trainees).
◦ Collect feedback via satisfaction surveys from trainees and trainers.
◦ Use ongoing communication and feedback to continually re-evaluate and refine the program.