Preparing Social Work Students for Interprofessional Team Practice in Health-Care Settings

Abstract

Purpose:

This study presents the results of a workforce development initiative focused on preparing master’s-level social work students to work in interprofessional settings and integrated care. The study examines both trainees’ changes in interprofessional skills and attitudes as well as if there were differences in trainee experiences across race and gender.

Method:

Ninety-nine trainees participated in a training program and completed pre- and posttest measures on attitudes toward interdisciplinary teams and team skills. The team used multivariate analysis of variance (MANOVA) to examine the change in means and interaction effects.

Results:

Findings suggest that the training helps trainees acquire interdisciplinary team skills. However, results on attitudes toward interdisciplinary teams varied based on race and gender of the trainees.

Discussion:

Results suggest that there continue to be disparities in the training experiences of social work trainees around race and gender. Future research needs to continue to focus on this issue.

Keywords

interdisciplinary social work practice health-care teams interprofessional education

Social work has struggled with professional identity since its inception (Abramovitz, 1998; Soifer, 1999). Much of this arises from Flexner’s report (2001), in which he derided social work as less than a profession and questioned whether social workers had a role in the health-care field . Flexner’s intention may have been to strengthen the position of medicine as the preeminent profession in health care, but he may also have been simply responding to the positivist paradigm that pervaded medicine and eschewed the relational aspects of health care until relatively recently (Engel, 1992). Given the primacy of the “hard” sciences, social work has struggled with defining itself (Soydan, 2012) within the larger health-care context.

At the dawn of the 21st century, however, primary care is becoming increasingly understood as a person in environment (PIE) process. Health promotion and prevention require that contextual factors are understood and addressed (Interprofessional Education Collaborative Expert Panel, 2011). Diseases such as HIV and other global pandemics require collaborative teams of every type of worker in the health-care system (World Health Organization [WHO], 2010). Well-functioning interprofessional care teams optimize the depth and breadth of expertise to serve the client’s needs and are cost effective (Interprofessional Education Collaborative Expert Panel, 2011; McGregor, Mercer, & Harris, 2018; Nancarrow et al., 2013).

In recent years, health care has focused on environmental factors affecting health and wellness and what has been termed the “upstream determinants of health” (Jackson, 2017). Addressing these upstream determinants of health has led to the increasing recognition of social work as a valuable partner in health-care teams (Miller et al., 2017; Steketee, Ross, & Wachman, 2017). Social work is increasingly recognized as an important component in interprofessional care settings because of our expertise in addressing the social determinants of health (Jackson, 2017; McGregor et al., 2018; WHO, 2010). Prior research has demonstrated that failure to take into account all aspects of a person’s life and circumstances can have fatal consequences for patients (Engel, 1992). Prior research has also demonstrated that the inclusion of social workers in health-care teams often results in reduced costs (Steketee et al., 2017). Given these findings, it is not surprising that the use of social workers in health-care teams is increasing (Ashcroft, McMillan, Ambrose-Miller, McKee, & Brown, 2018; Miller et al., 2017; Williams, 2016). As interprofessional care teams become the norm in health care (McGregor et al., 2018; Miller et al., 2017; Nancarrow et al., 2013), teaching the skills to participate effectively and even lead interprofessional health-care teams will become increasingly necessary in social work education.

Interprofessional Education

Social work students will need to develop a strong professional identity, confidence in their skills, and areas of expertise that are relevant to interprofessional teamwork. If conflict between team members arises, it is often based on status or power rather than on professional expertise (Interprofessional Education Collaborative Expert Panel, 2011). Prior research has indicated that medical residents are less likely to value the team process and less likely to view team members across disciplines as equals compared to social work or nursing students (Leipzig et al., 2002).

Developing educational practices to teach students within a well-grounded framework in the social work professional identity will allow social workers to function more effectively and efficiently. Teaching the skills to participate effectively and lead interprofessional health-care teams will become increasingly necessary in social work education given the challenges in health-care graduates will face (Interprofessional Education Collaborative Expert Panel, 2011; WHO, 2010). Training in interprofessional care has been found to improve competence and cultural sensitivity in health-care organizations and to ultimately lead to improvements in the quality of services provided by such organizations (Morganti et al., 2014). In the study by Morganti and colleagues, training was most effective when it was intense, high in dosage, and included coaching elements.

Interprofessional education must teach social workers how to navigate interprofessional teams in health care in order to advocate for patients effectively and to raise issues that may not be apparent to other team members. Health is increasingly understood as holistic well-being rather than simply the absence of disease. In such a context, the role of social work takes heightened importance. Social work students must be adequately prepared with a strong professional identity and ability to advocate on health-care teams for the benefit of patient needs. Both social workers themselves and other professionals on the team must view the social worker as equal.

As we prepare social work students for an interprofessional workplace, we should keep in mind barriers to authority that social work students might face. First, there is the history of challenges to social work’s authority as a profession (Flexner, 2001). Second, there are demographic differences between social work students and other health professions students that may impact a student’s experience on an interdisciplinary team. The literature on race, gender, and power in the workplace indicates that it is generally more difficult for people of color to gain positions of authority in work environments (Elliott & Smith, 2004) and that the attempts of women and people of color to use authority effectively in the workplace are more frequently blocked through microaggressions (Weber & Messias, 2012). Nationally, nearly three quarters (73.3%) of medical students are White or Asian, and just under half are female (48.5%; Association of American Medical Colleges, 2018). In comparison, just over half of master of social work students are White or Asian (56.4%) and the majority are female (85.0%; Council on Social Work Education [CSWE], 2017). Thus, it is possible that our students are experiencing barriers to the interdisciplinary team process that are based on these demographic differences and not on their professional identities. In this study, we sought not only to examine the outcomes of a training program but also to examine whether the outcomes were different for participants across race and gender.

The Training Program

The authors present the results of an initiative funded by a Health Resources and Services Administration (HRSA) Behavioral Health Workforce, Education, and Training grant. This training program was conceptualized as having six foci: (1) transition-age youth, (2) violence prevention, (3) engagement with families, (4) interdisciplinary team practice, (5) integrated behavioral health, and (6) cultural and linguistic competency. The training program enhanced the master of social work (MSW) curriculum and the internship experience through the addition of six experiential-didactic sessions (one per focal area). Each trainee in the program was placed in a field internship that addressed the six focal areas and participated in the six experiential-didactic sessions in addition to the internship. Most of these trainings were one 8-hr day with the exception of the interdisciplinary team skills training which lasted two 8-hr days. The six sessions involved readings assigned prior to the session, agency visits and/or presentations on practice techniques, and skill development exercises. Each session was connected to an assignment that helped students apply the skills learned in each session. Agencies were chosen if they could demonstrate best practices in one or more of the six topical areas listed above.

The training sessions included professionals from across disciplines to promote the development of interprofessional collaboration and leadership skills necessary for effective participation in interprofessional teams. Assignments related to interprofessional education required that trainees conceptualize a case based on the interdisciplinary team process and through an integrated practice model. Training emphasized how primary care and behavioral health practitioners work together in interdisciplinary settings to promote wellness, reduce risk behaviors, and ensure that clients have holistic treatment across physical, mental, spiritual, and behavioral health.

The program was designed to enhance the competence of advanced year MSW students, hereafter referred to as trainees. The training program operates in a region where residents experience a significant number of risk factors related to mental health: High childhood poverty rates (44.3%; Delavega, 2013, 2017), high rates of single parenthood (Urban Child Institute, 2013), high rates of poor mental health days, high substance use rates, and high crime rates including homicide (Tennessee Department of Health, 2011). The area in which the project was implemented has been designated as medically underserved areas or federal primary care shortage areas for mental health (Tennessee Department of Health, 2011), highlighting the urgency for increasing the number of social work professionals with training in interprofessional education.

Trainees were assessed via assignments, competency evaluations, and a set of pre- and posttest measures around interdisciplinary team skills/attitudes and cultural and linguistic competency. The purpose of the present study was to assess outcomes around attitudes toward health-care teams and team skills. The research study also examined whether trainee experiences were different by race and gender. Specifically, the research questions were:

Will second-year MSW trainees who participate in a structured program experience improved attitudes toward working in health-care teams and trainees’ and improved skills for interdisciplinary team collaboration?

Do second-year MSW trainees experience training around interdisciplinary team practice differently by race or gender?

Method

A total of 99 trainees completed the program over a 3-year period (November 2014—December 2017). All trainees who participated in program also participated in the evaluation study. The study was reviewed and approved by the university’s institutional review board. Trainees completed the program in cohorts of approximately 16 (varied from 10 to 22 trainees per group). Trainees completed their experiential-didactic sessions over 6 months that overlapped with the 8 to 9 months that they were at field placement. At times, cohorts overlapped and completed the training sessions together. As part of the funded grant program, trainees received a US$10,000 stipend divided over 6 monthly payments. Stipends were docked if trainees missed a session, so attendance was close to 100% at every session. In a few emergency cases, a trainee missed a session and was assigned relevant make-up work by the training coordinator.

Most trainees were African American or Black (58.6%). All trainees reported their race in one of only two categories (Black and White), and these are the terms that will be used in the remainder of the paper. The most common age category was 25–29 (42.4%). The majority of the trainees were women (85.9%), which is typical in a social work program. Full demographics are found in Table 1.

Table 1.

Demographics.

	Total		White		Black
	N	%	N	%	N	%
Total	99	100.0	41	100.0	58	100.0
Program
Advanced standing	12	12.1	8	19.5	4	6.9
Full-time 60-hr Program	55	55.6	28	68.3	27	46.6
Extended 60-hr program	31	31.3	4	9.8	27	46.6
Missing	1	1.0	1	2.4
Gender
Male	14	14.1	7	17.1	7	12.1
Female	85	85.9	34	82.9	51	87.9
Age
Under 25	16	16.2	12	29.3	4	6.9
25–29	42	42.4	19	46.3	23	39.7
30–34	14	14.1	6	14.6	8	13.8
35–39	13	13.1	3	7.3	10	17.2
Over 40	14	14.1	1	2.4	13	22.4

Instruments

This study used two outcome variables, the Attitudes Toward Health Care Teams (ATHCTs) and the Team Skills Scale (TSS). These two scales were completed 2 times during the program, once prior to the first training session as a pretest and again at the end of the final training session for posttest (Dimitrov & Rumrill, 2003). The ATHCT (Heinemann, Schmitt, Farrell, & Brallier, 1999) used by HRSA participating researchers is a 21-item instrument on a 6-point Likert-type scale where 1 = strongly disagree and 6 = strongly agree. The ATHCT consists of two subscales, the 5-item Physician Centrality subscale and the 16-item Quality/Process subscale. The Physician Centrality subscales measures the degree to which the trainee believes that the physician is the central decision maker. The Process/Quality subscale measures the degree to which the trainee believes that interdisciplinary teamwork improves patient care. The ATHCT is used in conjunction with the TSS (Miller & Ishler, 2001). The TSS is a 17-item instrument on a 5-point Likert-type scale where 1 = poor and 5 = excellent. The TSS is a self-assessment measure designed to capture respondent’s perceived ability to carry out tasks and practices for optimal team functioning. The scores were reversed on negatively worded items where a higher score indicates a more desirable result; as a result, a higher score is better for every item.

Reliability analysis indicated strong internal consistency on the ATHCTs Scale at pretest (Chronbach α = .814) and posttest (Chronbach α = .884). The 5-item Physician Centrality subscale had moderate internal consistency at pretest (Chronbach α = .584) and acceptable internal consistency at posttest (Chronbach α = .706). The 16-item Quality/Process subscale had very strong internal consistency at pretest (Chronbach α = .864) and posttest (Chronbach α = .912). Finally, the 17-item TSS had very strong internal consistency at pretest (Chronbach α = .946) and posttest (Chronbach α = .950).

Data Analysis

IBM Statistical Package for the Social Sciences (SPSS) version 24 was used to analyze the data. Missing value analysis (MVA) was used to examine the patterns of missing data and estimate scores on the missing items. MVA uses the expectation-maximization algorithm to estimate missing values. Pretest data were missing for the first 18 trainees who participated in the program due to late adoption of these outcome measures. These pretest scores were estimated using MVA along with other scores that were randomly missing in the data set.

Univariate and bivariate analyses including correlations were conducted to assess the appropriateness of data for the purposes of analysis. Preliminary analyses were conducted on all variables to test for violations of assumptions. Analysis conducted included linearity (univariate analysis of variance—lack of fit p > .05; independence (Durbin–Watson, between 1.317 and 2.088); Kolmogorov–Smirnov (0.057, p = .200). Levene’s test was used to assess homoscedasticity (in most cases p > .05 except for change in quality/process and program, change in ATHCT Physician Centrality and gender, and change in ATHCT and program). No violations occurred with race. Normality was assessed with Kolmogorov–Smirnov, stem and leaf plots, and skewness and kurtosis. Based on these results, it was determined that no violations occurred. There were no outliers, as assessed by the examination of studentized residuals for values greater than ±3.

The research team decided to examine the data on ATHCTs in two ways. First, the team examined ATHCTs as one construct, and second, the team examined how students perceived roles on the team and the team process as separate constructs. Thus, the team conducted two repeated-measures MANOVAs. Results of Box’s M and Mauchly’s test of sphericity were nonsignificant for each MANOVA. The first MANOVA was performed with two independent between-subjects variables (race and gender) and two dependent variables (ATHCT and TSS). The second MANOVA used the same independent variables and included the TSS as a dependent variable; however, in the second MANOVA, the ATHCT was broken into the two subscales (Physician Centrality and Process/Quality). Wilks’s λ values are reported in Tables 2 and 3. In both MANOVA models, the team tested the two-way and three-way interaction effects between race, gender, and the dependent variables.

Table 2.

MANOVA 1: ATCHT and TSS.

	F	df	Significance	Partial η²
Multivariate tests within subjects
Levels	5.61	2, 94	.005	.107
Levels × Race	3.63	2, 94	.030	.072
Levels × Gender	.79	2, 94	.459	.016
Levels × Race × Gender	5.78	2, 94	.004	.109
Univariate tests within subjects
ATHCT	5.33	1	.023	.053
TSS	9.00	1	.003	.087
ATHCT × Race	7.02	1	.009	.069
TSS × Race	1.62	1	.206	.017
ATHCT × Gender	.11	1	.745	.001
TSS × Gender	1.59	1	.21	.016
ATHCT × Race × Gender	10.42	1	.002	.099
TSS × Race × Gender	.03	1	.865	>.001

Note. N = 99. ATCHT = Attitude Toward Health Care Teams Scale; TSS = Team Skills Scale.

Table 3.

Results of MANOVA 2: ATHCT Physician Centrality, ATHCT Process/Quality, and TSS.

	F	df	Significance	Partial η²
Multivariate Tests Within Subjects
Levels	3.94	3, 93	.011	.107
Levels × Race	4.88	3, 93	.004	.072
Levels × Gender	.56	3, 93	.642	.016
Levels × Race × Gender	3.98	3, 93	.010	.109
Univariate tests within subjects
Physician centrality	1.29	1	.258	.013
Process/quality	4.17	1	.044	.042
TSS	9.00	1	.003	.087
Physician Centrality × Race	11.28	1	.001	.106
Process/Quality × Race	1.95	1	.165	.020
TSS × Race	1.62	1	.206	.017
Physician Centrality × Gender	.022	1	.883	>.001
Process/quality × Gender	.08	1	.769	.001
TSS × Gender	1.59	1	.211	.016
Physician Cent. × Race × Gender	5.31	1	.023	.053
Process/Quality × Race × Gender	6.39	1	.013	.063
TSS × Race × Gender	.03	1	.865	>.001

Note. N = 99. ATCHT = Attitude Toward Health Care Teams Scale; TSS = Team Skills Scale.

Results

Preliminary bivariate analysis indicated that there were no differences in ATCHT overall scores or either of the subscale scores by race, gender, age, or income. Likewise, there were no differences in TSS scores by race, gender, age, or income.

Results of the MANOVA

Results of the first MANOVA are reported in Table 2. The researchers specifically examined the univariate tests for within-subject contrasts to observe change in each dependent variable and interaction effects. There were statistically significant main effects for both ATHCT, F(2, 94) = 5.33, p = .023, η² = .053, and TSS, F(2, 94) = 9.00, p = .003, η² = .087. Trainees had more positive ATHCTs and greater team skills at the end of training. The two-way interaction effect between ATHCT and race was significant, F(2, 94) = 7.02, p = .009, η² = .069, and the three-way interaction between ATHCT, race, and gender was also significant, F(2, 94) = 10.424, p = .002, η² = .099. Black trainees did not gain as much on the ATHCT during the training and specifically, and Black male trainees had lower ATHCT scores at posttest than at pretest. The two-way interaction between ATHCT and gender was nonsignificant. There were no significant interaction effects between TSS and race or gender. Full results of the ANOVA are reported in Table 2.

The results of the second MANOVA are reported in Table 3. The researchers used tests of within-subjects contrasts that examine for the change in each dependent variable and interaction effects. There were significantly significant main effects for the ATHCT Process/Quality subscale, F(3, 93) = 4.17, p = .044, η² = .042, and the TSS F(3, 93) = 9.00, p = .003, η² = .087. The main effect for ATHCT physician centrality was nonsignificant. There was a significant interaction effect by race for ATHCT physician centrality, F(3, 93) = 11.28, p = .001, η² = .106. Black trainees had lower scores on the Physician Centrality subscale at posttest. There was also a significant interaction effect by both race and gender on both the Physician Centrality subscale, F (3, 93) = 5.31, p = .023, η² = .053, and the Process/Quality subscale, F (3, 93) = 6.39, p = .013, η² = .063, of the ATHCT. White males made the most gains on both subscales, and Black males had lower scores at posttest on both subscales. White women had modest gains on both subscales. Finally, Black females had improved scores on process/quality, and their scores on physician centrality were virtually unchanged (see Table 3).

The means and standard deviations for the ATHCT, the ATHCT Physician Centrality subscale, the ATHCT Process/Quality subscale, and the TSS for both pretest and posttest are reported in Table 4. Given the significant interactions by race and gender, we also report the means and standard deviations separated by race and gender in Table 4.

Table 4.

Means and Standard Deviations by Race and Gender.

		ATHCT		ATHCT Physician Centrality		ATHCT Process/Quality		TSS
	n	Pre	Post	Pre	Post	Pre	Post	Pre	Post
	n	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)
Total	99	4.40 (.52)	4.60 (.63)	3.61 (0.80)	3.74 (0.97)	4.65 (.62)	4.86 (.69)	3.69 (.71)	4.00 (.68)
White	41	4.42 (.45)	4.64 (.64)	3.50 (0.80)	3.89 (0.99)	4.70 (.54)	4.87 (.68)	3.56 (.68)	4.00 (.70)
White male	7	4.49 (.43)	5.06 (.82)	3.67 (1.22)	4.51 (1.18)	4.74 (.64)	5.23 (.77)	3.97 (.62)	4.21 (.55)
White female	34	4.40 (.46)	4.39 (.59)	3.47 (0.71)	3.76 (0.92)	4.70 (.53)	4.80 (.65)	3.96 (.73)	4.01 (.70)
Black	58	4.39 (.43)	4.56 (.63)	3.68 (0.79)	3.64 (0.95)	4.61 (.67)	4.85 (.70)	3.78 (.71)	4.00 (.67)
Black male	7	4.41 (.45)	4.12 (.48)	4.29 (0.64)	3.68 (0.68)	4.45 (.45)	4.26 (.50)	3.88 (.55)	3.94 (.40)
Black female	51	4.39 (.59)	4.62 (.63)	3.60 (0.78)	3.63 (0.98)	4.63 (.70)	4.93 (.69)	3.77 (.74)	4.01 (.70)

Note. ATCHT = Attitude Toward Health Care Teams Scale; TSS = Team Skills Scale.

Discussion

All trainees reported gains in team skills. Examining the entire sample as a whole, there was a significant increase in ATCHT scores and specifically, ATCHT process/quality scores from pretest to posttest. However, when one examines the interaction effects by race and gender, meaningful differences may be found. Black trainees did not change their attitudes about physician centrality over the course of the training, but overall, Black trainees did report improved attitudes toward the process and quality of teams. Black male trainees did not change their attitudes about any aspect of health-care teamwork over the course of the training, although they did report improvements in their team skills. White males made the most gains in attitude toward health-care teams.

The results indicate that many trainees still held on to the idea of the physician as the undisputed leader in health-care teams. In the social work field, we need to teach more confidence in interdisciplinary team leadership. Given the results of our study, we particularly need to focus on building confidence for Black trainees. Many questions remain as to why Black trainees, and Black men in particular, did not show great gains in this area, but we discuss some possible explanations below.

As stated above, prior research has indicated that Black professionals and female professionals face micro-aggressions and challenges to authority in the workplace (Elliott & Smith, 2004; Harlow, 2003; Weber & Messias, 2012). The difficulties associated with power for people of color in the workplace could explain our findings. It is possible that Black trainees were more resistant to challenge the centrality of the physician in health care because Black people have to pay a much higher price for speaking up and attempting to gain authority in a workplace setting. It is also possible that Black trainees and female trainees did not experience as much authority and respect from coworkers on interdisciplinary teams during their year in field placement. That experience could result in them devaluing their role as social workers and over-valuing the role of the physicians. More research is needed to understand this finding.

There are several limitations to this study. The sample size was small, and there were only two racial groups among the participants. If the study had other racial groups, the results might have been different. Also, the study was nonrandomized and lacked a control group. As a result, it is impossible to determine causality. Additionally, the study was conducted only at one university in one region in the United States, and it was conducted only with social work students. A study at another location or with a different profession might lead to different findings. Finally, the training program was evaluated as a whole. We cannot say which aspects of the training curriculum were most closely associated with change in student scores. Future research could examine the training as separate components. Due to these limitations, the results must be interpreted with caution.

This study suggests some important avenues for future research. First, it would be interesting to study the ATHCT Scale with seasoned professional social workers in hospital or other health-care settings. Perhaps the confidence to stand up to a physician only comes through practice. The authors have heard many social workers in the field speak about “earning” the physicians’ respect through competence and correct actions and decisions. This is an interesting avenue for future research.

The significant differences found on the ATHCT Physician Centrality subscale pose a more interesting question—what causes Black trainees to continue to hold the same views on the primacy of physicians in health-care settings? Is there something inherent in race relations that afford physicians a much greater position in the hierarchy? Are there extraneous variables connected to race that are responsible for these results? If so, what are those? This is particularly interesting given that White trainees, and White males in particular, had the greatest gains in their confidence in leading interdisciplinary teams. It would be important to further investigate how social workers of color experience authority in the workplace and the impact of microaggressions from clients and colleagues.

Prior research has established that interdisciplinary teams are a critical component of best practices in health care (Bokhour, 2006; Nancarrow et al., 2013; Wittenberg-Lyles, Oliver, Demiris, & Regehr, 2010). Social workers, with their emphasis on the person and environment, are a critical component of those interdisciplinary teams (Day, 2012; Steketee et al., 2017; Williams, 2016). Increasing the competence and confidence of social work trainees for practice in interdisciplinary teams will permit the stronger presence and voice of social work in health-care settings. The U.S. population is increasingly diverse which demands a diverse workforce who is prepared to advocate for patient care (NASW, 2015).

This study has implications for educational policy in social work. Interprofessional education is rightfully being recognized as an important area of social work education. The CSWE Educational Policy and Accreditation Standards (2015) recognize “multidisciplinary theoretical frameworks” and “inter-professional collaboration” as critical elements of intervention with individuals, families, groups, organizations, and communities (p. 9). Yet it may be that social work programs should infuse more curriculum around interdisciplinary collaboration into their programs. Further research on the degree to which interdisciplinary practice is being infused into social work education is needed.

The article also has important implications for recent changes in health-care policy. For example on January 1, 2017, the Centers for Medicare and Medicaid Services began paying primary care clinicians separately for Collaborative Care that includes services from both a primary care physician and a behavioral health clinician (NIMH Press Office, 2016). Social workers, who are frequently the behavioral health providers on the team, need to be prepared to work collaboratively and share authority with physicians.

Challenging the primacy of the physician in health care will be difficult. However, training social workers as competent and confident professionals who are able to explain their perspective and serve as a bridge between disciplines will contribute to a more integrated and holistic practice of health care at all levels. This is why it is so important to reduce the perception of the physician as the undisputed leader in health-care settings.

Given the increasing recognition that the environment and upstream factors affect health and wellness and that the patient is not only a body but also a human person, social work has acquired rising importance in the delivery of health care. As a result, social workers are progressively more included in interprofessional teams. Social work education must acknowledge this new reality and prepare students for the needs of the world in which they will practice. The results of this study show that intensive training in interprofessional education is effective and relevant in social work.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was funded by a Health Resources and Services Administration (HRSA) Behavioral Health Workforce, Education and Training (BHWET) Program Grant #G02HP27984.

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