Workforce Innovation and Opportunity Act: Additional DOL Actions Needed to Help States and Employers Address Substance Use Disorder

The Department of Health and Human Services declared the opioid crisis a public health emergency in October 2017. DOL has awarded grants to help address this crisis.

GAO was asked to examine how WIOA-funded programs are addressing the employment and training needs of those affected by SUD. This report examines (1) how workforce agencies in selected states are using WIOA funding to address employment and training needs, (2) challenges agencies face in addressing employment and training needs, and (3) how DOL is supporting communities affected by SUD. GAO interviewed officials in four of the 10 states that received DOL grants in the early award rounds (as of March 2019)—Maryland, New Hampshire, Ohio, and Washington—and two that did not—Alabama and Arizona; reviewed related documentation and relevant federal laws and regulations; and interviewed DOL officials and researchers, selected for their knowledge about these issues.

Workforce officials GAO interviewed in four of the 10 states receiving targeted Department of Labor (DOL) grants as of March 2019 said they were using Workforce Innovation and Opportunity Act (WIOA) funding to help meet the unique needs of those affected by substance use disorder (SUD). These officials, who said they had limited experience serving those affected by SUD, worked with required organizational partners and hired specialists to assist job seekers and to provide intensive job readiness services. However, these efforts are relatively new and outcomes are not yet known. Workforce officials GAO interviewed in two selected states without targeted grants said they had viewed SUD primarily as a public health issue, but had recently taken some steps to address it. For example, one state added a workforce subcommittee to an existing opioid task force.

State and local workforce officials in all six states identified a range of challenges they face in addressing the needs of SUD-affected job seekers. For example, criminal history or a lack of transportation may make it difficult for these job seekers to obtain and maintain employment. Officials said another challenge is finding employers who are willing to hire those in recovery. They stated that employers are concerned about the risks to their businesses, such as potential employee relapse and possible negative reaction from customers. Officials were seeking more information and assistance to help address such concerns.

DOL officials said they support SUD-affected communities mainly by providing information to states that apply for and receive targeted grants. However, officials in two selected states expressed uncertainty about DOL's expectations of states in serving the needs of SUD-affected job seekers and potential employers. Officials in another state said they were unclear on whether they could use non-targeted funds to continue targeted grant activities. GAO's review of related DOL guidance found that it does not provide specific information on expectations of states or the use of WIOA funds outside of targeted grants to address this issue. Further, while DOL has disseminated some information on serving job seekers with SUD (such as in quarterly calls with grant recipients), it does not plan to share information that grantees submit to the agency, such as lessons learned and successes, with all states. Doing so could help states meet the training and employment needs of those in recovery, and the needs of potential employers.

GAO recommends that DOL clarify (1) its expectations of state workforce agencies and (2) how WIOA funding can be used in addressing the needs of those affected by SUD and potential employers, and share information with all states on lessons learned and promising practices. DOL agreed with our recommendations.

Drug misuse—the use of illicit drugs and the misuse of prescription  drugs—has been a long-standing and persistent problem in the United  States. It represents a serious risk to public health and has resulted in  significant loss of life and effects to society and the economy, including  billions of dollars in costs. According to the Centers for Disease Control  and Prevention, over 716,000 people have died of a drug overdose since  2002, and in 2018 alone, over 67,000 people died as a result of a drug  overdose. Although the number of drug overdose deaths in 2018  decreased compared to 2017, drug misuse in the United States continues  to rise.

Opioid abuse is among the many types of drug misuse and abuse. An  estimated 10.2 million people misuse opioids at least once a year,  according to a 2018 Department of Health and Human Services (HHS)  survey. For some, this misuse becomes a substance use disorder  (SUD)—an illness resulting from the recurrent misuse of prescription or  illicit drugs, as well as non-prescription substances like alcohol. Past GAO  work, as well as other government and academic studies, have found that  SUD results in high costs for society and the economy. While SUD has  long been considered primarily a health care and law enforcement issue,  SUD has also affected costs associated with education, human services,  and the workforce, among others. Specifically, for workers and their  employers, SUD has been linked with lost productivity, absenteeism, and  unemployment.

In response to the prevalence of opioid misuse, HHS declared a public  health emergency in October 2017. The Department of Labor’s (DOL)  Employment and Training Administration (ETA) subsequently announced  two grants specifically to address the opioid crisis through the workforce  system—a network of federal, state, and local agencies that administer  and carry out an array of federal employment and training programs.  These grants, which were authorized under the Workforce Innovation and  Opportunity Act (WIOA), were available to states, tribes, and outlying  areas. DOL has awarded the grants in two phases; as of December 2019,  six states have been awarded National Health Emergency Dislocated  Worker Demonstration Grants (also known as Phase 1 grants) and one  tribe and 14 states have been awarded Disaster Recovery National  Dislocated Worker Grants (also known as Phase 2 grants).

You requested that we examine how WIOA-funded programs are  addressing the employment and career-specific education (or job training)  needs of communities and individuals affected by SUD. This report  examines (1) how selected state and local workforce agencies are using,  or planning to use, WIOA funds to provide training and employment  services to communities and individuals affected by SUD; (2) what  challenges workforce agencies face in addressing the needs of  individuals in recovery and their potential employers; and (3) how DOL is  supporting communities affected by SUD.

To address these objectives, we interviewed officials in six states,  including state and local workforce officials and their partners (for  example, community organizations or state departments of health). We  selected states—four that have received the grants to address the opioid  crisis through the workforce system and two that have not—with medium  to high rates of opioid use disorder based on an HHS survey, and varying  unemployment rates. These states represent four of the 10 states that  had received Phase 1 and Phase 2 grants as of March 2019. We also  reviewed selected grant applications and agreements for states that  received grants. Our findings cannot be generalized to all states and local  workforce agencies, but provide insights into the experiences of states in  addressing the needs of SUD-affected individuals and communities as  well as those of potential employers. See table 1 for more information on  our selected states.

To examine actions DOL has taken or planned to address communities’  employment and training needs related to SUD, we interviewed DOL  officials in headquarters and all six regional offices, and reviewed relevant  federal laws, regulations, and DOL documents, such as grant applications  and agreements, agency guidance, and reports. We also interviewed  individuals knowledgeable about strategies for addressing this issue  through the workforce system, including researchers and officials from  organizations that help design and implement these strategies such as  the Appalachian Regional Commission. We identified these researchers  and other groups through reviewing reports on employment and training  efforts in communities affected by SUD, and asking for recommendations  from officials in our selected states. We compared DOL’s actions to  relevant federal internal control standards on risk assessment and  communication.

We conducted this performance audit from January 2019 to May 2020 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

We previously reported that DOL is one of more than a dozen federal  agencies—known as National Drug Control Program agencies—that have  responsibilities for drug prevention, treatment, and law enforcement  activities. The Office of National Drug Control Policy (ONDCP) was  established in 1988 to, among other things, enhance national drug control  planning and coordination. As federal agencies engage in drug control  efforts, ONDCP is responsible for, among other things, overseeing and  coordinating the implementation of national drug control policy across the  federal government. These responsibilities include promulgating a  National Drug Control Strategy. In 2017 and 2018, ONDCP lacked a  statutorily-required National Drug Control Strategy, and we recently  reported that the 2019 National Drug Control Strategy did not fully comply  with the law. In December 2019, we recommended that ONDCP  develop and document key planning elements to help ONDCP structure  its ongoing efforts and to better position the agency to meet these  requirements for future iterations of the National Drug Control Strategy.  We also found that the 2019 strategy did not contain several pieces of  required information, such as quantifiable and measurable objectives, and  specific targets for long-term goals, or a description of a performance  measurement system. ONDCP subsequently issued the 2020 National  Drug Control Strategy on February 3, 2020. We reviewed this Strategy  and found that it made progress in addressing several statutory  requirements but fell short in meeting others. Furthermore, in our March  2019 High-Risk report, we named drug misuse as an emerging issue  requiring close attention. Based on our findings from a body of work  related to drug misuse—including 25 new GAO products issued since our  2019 High-Risk report—we have determined that this issue should be on  our High-Risk List.

DOL’s Phase 1 and Phase 2 grants, targeted to support efforts for  addressing the opioid crisis, are authorized by WIOA, which was enacted  in 2014 and emphasizes the alignment and integration of workforce  programs. ETA is responsible for some WIOA programs, which provide  education and other services to help job seekers obtain employment and  advance in the labor market, including job search assistance, career  counseling, and a variety of occupational skills such as classroom and  on-the-job training. In addition, WIOA emphasizes that employers are  also customers of the workforce system, and includes provisions that  involve them in helping the system provide the skilled workers they need.  WIOA requires states to submit plans to DOL every 4 years, and updates to these plans every 2 years, that outline the state’s workforce strategies  for core WIOA programs. The next state plans are due in 2020.

WIOA gives state and local officials the flexibility to develop and fund  services that meet the specific needs of their local communities and meet  WIOA goals of increasing employment, retention, and earnings to  promote economic self-sufficiency. To that end, WIOA core program  performance measures and targets include those related to job  attainment and retention; median earnings; and skill and credential  attainment. DOL officials told us that states generally use the same  WIOA performance measures for the Phase 1 and 2 grants as well. The  WIOA-funded workforce development system provides services through a  national network of approximately 2,400 American Job Centers (AJCs).  State and local entities deliver WIOA-funded employment and training  activities and coordinate with partner programs via the AJCs.

ETA’s Phase 1 and 2 grants are intended, in part, to serve dislocated  workers—adults whose jobs have been terminated, who have been laid- off, or who were self-employed. These grant funds are awarded to  states, tribal governments, or outlying areas that, in turn, may work with  local workforce boards to administer the grants. Grant recipients generally  have 2 years to expend their funds. See table 2 for more information  about these grants.

Both grants require that recipients partner with community organizations,  such as those in health care and justice systems, and with at least one  local workforce development board or AJC. While grants cannot be used  to pay the costs of in-patient drug treatment and in-patient rehabilitation  programs, grantees may use some funding to provide supportive services  to participants, such as assistance with child care.

States may be using other federal funds to address the workforce impacts  of the opioid crisis, including other WIOA-related funding. For example:

Ohio received $8 million in September 2018 from DOL’s Trade and  Economic Transition National Dislocated Worker Grant, which  provides training and career services to dislocated workers affected  by layoffs at one or more companies and are seeking reentry into the  workforce. The state targeted 16 counties in the state that officials  said had been hardest hit by the opioid crisis. State officials said they  plan to use this grant to provide services to anyone who meets the  criteria of a dislocated worker, and they felt the opioid crisis had a  strong enough economic effect for the state to use the grant for those  whose employment has been affected by the crisis.

DOL’s Women’s Bureau granted Maryland $650,000 in September  2018 to fund two projects providing job-seeking supports to women  affected by opioid use disorder.

Pennsylvania plans to use HHS funding to expand treatment capacity  for underserved populations through targeted workforce development,  according to its grant application.

Additionally, ETA has recently provided more funding opportunities to  support state and local workforce efforts to address the opioid epidemic.  In September 2019, ETA, in partnership with the Appalachian Regional  Commission and the Delta Regional Authority, announced the 23  grantees on the first round of funding under the Workforce Opportunity for  Rural Communities Initiative, which included a focus on serving  individuals impacted by the opioid epidemic. Five of the ten awards in the  Appalachian region committed to addressing opioid and other SUD  impacts as part of their projects. Also, in October 2019, ETA announced  another funding opportunity for $20 million in grants under the Substance  Use-Disorder Prevention that Promotes Opioid Recovery and Treatment  for Patients and Communities (SUPPORT) Act. The SUPPORT Act  directs DOL to conduct a pilot grant program to address the economic  and workforce effects associated with SUDs.

Beyond those recently funded, workforce efforts to address the opioid  crisis may need to continue for many years given the nature of SUD.  Research suggests that incentives for avoiding drug misuse, such as  obtaining and maintaining employment, can be highly effective in  promoting recovery from SUD. However, an estimated 40 to 60 percent of  people with SUD experience relapse, according to the National Institute  on Drug Abuse. As a result, people with SUD often need ongoing  support to reduce this risk.

States Used Targeted Grants to Tailor Assistance to Job Seekers in Recovery, but Results Are Not Yet Known

Workforce Agencies Relied on Partnerships to Enhance Services to Job Seekers in Recovery

Officials in the four selected states that received Phase 1 and Phase 2  DOL grants told us that the required partnerships with community  organizations were essential in their efforts to serve those affected by  SUD. These relationships fostered both knowledge sharing and  coordination, elements especially important to state officials with limited  experience serving this population. For example, in Ohio, state officials  said that input from community partners, such as substance use disorder  and mental health boards, helped them identify who could best provide  supportive services for job seekers in recovery.

We found workforce agencies in all four states receiving targeted DOL  grants worked to serve job seekers with the following partners:  Health care organizations. Workforce officials said they partner with  health care organizations to identify people in recovery from SUD who are  ready to look for employment. For example, New Hampshire state  officials described the state’s “hub-and-spoke” services system, where  health care entities such as hospitals refer people affected by SUD to  various services. The health care staff coordinate with local workforce  agency staff and notify them when an individual in recovery is ready for  employment and training services. Other states described similar  coordination of services. For example, a local workforce agency in  Washington is partnering with a nonprofit health care organization to  coordinate workforce development efforts with health and social services.

Justice organizations. Workforce agencies partnered with drug courts,  detention centers, and other facilities to address the employment  readiness and support needs of those in the juvenile and adult justice  systems who may have SUD. For example, in Washington, local  workforce agency officials told us that they provide training and education  services—including reentry workshops and work readiness services—for  their area’s juvenile justice facilities, where over 70 percent of the  population has a substance use disorder. In New Hampshire, state  workforce officials described a partner organization whose officials have  relationships with all of the drug courts in the state, and also sit on the  board of the drug court in one of the state’s largest counties. They said  that drug courts provide people an option to seek recovery services  instead of criminal charges, and the local workforce agency provides  employment services for people participating in drug courts.

Educational institutions. Partnerships with community colleges and  universities helped workforce agencies to provide employment training for  job seekers interested in participating in recovery services. In two of our  selected states, officials reported using funds to support the development  of peer recovery specialists. Such peer recovery specialists, according to  HHS, can bring the lived experience of recovery to assist others in  initiating and maintaining recovery. For example, in Ohio, the state  workforce agency partnered with a community college to help people to  become peer recovery specialists and licensed chemical dependency  counselors. Maryland provided Phase 1 Grant funds to a research-based  organization, housed on the campus of state university, which is  preparing peer recovery specialists. Furthermore, local workforce agency  officials in Ohio also told us that they worked with a university to put  together a master’s degree in social work for those with Licensed Social  Worker credentials or a bachelor’s degree.

Other organizations. Partnerships with community organizations and  housing commissions helped states address transportation and housing  needs through referrals and coordinated services. For example, local  workforce officials in Washington told us they work with partners through  subcontracts or memoranda of understanding to help job seekers with  childcare and housing so they can attain and retain employment. Also,  officials in New Hampshire told us that one state partner works with sober  living houses, which are group homes in which people in recovery can  live during and after treatment.

Several state workforce officials we interviewed noted that a key benefit  to the WIOA targeted-assistance grants was forging partnerships which  will have lasting impacts on how they conduct services in the workforce  system. For example, officials in New Hampshire noted that the state  plans to continue to leverage relationships with their partners after the  grant expires. Also, officials in Ohio said these partnerships put new  processes in place, including referral systems that will facilitate getting  people in recovery into the workforce system over the long term.

States not receiving targeted grants. Workforce officials in Alabama  and Arizona, the states we selected that did not receive targeted DOL  grants but are still experiencing high levels of opioid misuse in their  communities, stated that they were engaged in some newly formed  partnerships to address the workforce aspects of SUD. Alabama  workforce officials said they recently began participating in a statewide  opioid task force, including serving on the workforce subcommittee with  other state departments, such as the state Department of Commerce.  Arizona officials said that the state workforce agency partners with the  state Department of Corrections and has implemented second chance  centers, which offer services such as job training and onsite job fairs,  within three prisons. They noted that in one of these prisons, the majority  of women are incarcerated for drug-related offenses.

Workforce Agencies Used Funding to Provide Employment Services to Job Seekers in Recovery

Officials in the four selected states that received targeted DOL grants said  they used this funding to assist those in recovery from SUD to obtain  employment. While many of the services are also offered to other job  seekers, officials said grant-funded efforts involved intensive work with  SUD-recovering individuals, who may have inconsistent work histories or  long periods of unemployment.

New Hampshire state workforce officials reported providing individuals in  recovery with services, including job training, direct placement in a job, or  on-the-job training. As of January 2020, officials said the state had  enrolled 177 individuals into its program, including some who are  participating in on-the-job training (employment that is partially subsidized  by grant funds). Similarly, officials at a local workforce agency in  Washington told us that the agency aims to place 125 people affected by  SUD into transitional jobs as part of its grant-funded activities. These  subsidized jobs allow individuals to add experience to their resumes, as  well as gain an employment reference.

In Maryland, the state distributed part of its Phase 1 grant funds to local  workforce agencies in eight counties directly or indirectly affected by the  opioid crisis. These funds provide job seekers with employment, training,  and support services that help them prepare for, secure, and retain  employment, and advance along career pathways in high-demand  industries and occupations—including those related to SUD recovery,  such as counseling. Similarly, Ohio workforce officials told us they were  reintegrating individuals who are affected by opioid use into the workforce  by using some of their Trade and Economic Transition National  Dislocated Worker Grant funds to provide career services, guidance, and  counseling, along with support services.

Several officials noted that, while their agencies may use the same  process for those with SUD as those without to get individuals ready for  jobs, it is often a longer process when someone is in recovery or  otherwise affected by SUD. For example, officials from a local workforce  agency in Ohio told us that those in recovery from SUD often need more  services and support to work through barriers prior to job placement than  other clients without the disorder. Agency workforce staff are to follow up  with people in recovery to make sure they are still supported, even after  they have found employment or have enrolled in training—sometimes on  a weekly basis. Officials said that those in recovery may not have  previously had a job or attended post-secondary school before, and must  balance their recovery with these new responsibilities.

Similarly, state workforce officials in New Hampshire said that many in  recovery have not had the opportunity to build skills and confidence. The  New Hampshire Work Ready program is a 60-hour program offered  through the state’s community colleges that provides help in areas such  as how to dress for an interview and the workplace. This program, which  is available to all job seekers, also helps people decide what to disclose  regarding their personal history and helps them emphasize their  strengths. Officials characterized this program as especially helpful for  people with criminal backgrounds. In response to the needs of those in  recovery, they said the state has created a new “bridge” program to  prepare individuals to participate in the Work Ready program, which will  be implemented in recovery centers using targeted grant funds.

States not receiving targeted grants. Workforce officials in Alabama  and Arizona, states that did not receive targeted grants, said that state  efforts to address SUD, and more specifically opioid use disorder, were  largely focused on the health aspects of the issue. Alabama officials told  us that the state workforce agency was not originally part of the  Governor’s task force on opioid use disorder. The task force’s  recommendations were mostly health care related and addressed issues  such as provider practices. However, the task force has recently added a  workforce subcommittee with the goal of identifying strategies and  resources to provide in-demand career pathways for those affected by  SUD, and officials reported that they plan to apply for Phase 2 funding in  the future. Arizona state officials said that its workforce development  system provided support in communities, but noted that there is not a  coordinated strategy statewide. Arizona officials also emphasized that  they consider SUD primarily a public health issue, not a workforce issue;  they said that while employment is part of a spectrum of services, SUD is  an issue that is best addressed on the health side.

Agencies Also Funded Specialists and Are Piloting Workplace Programs

To assist those affected by SUD in finding employment, local workforce  agencies used their targeted grant funding to secure specialists. For  example, officials at two local workforce agencies in Ohio told us they had  hired or planned to hire new staff to work with the population affected by  SUD. One agency plans to hire case managers specializing in mental  health, who will team with AJC staff to help ensure clients in recovery get  the support they need to be successful. The other agency plans to hire  peer recovery specialists and job coaches to help those in recovery  develop soft skills. One local workforce agency in Washington also hired  peer recovery specialists, and is using them as case managers at an  AJC. Another agency in Washington is using Phase 1 grant funds to  employ four “navigators” to coordinate services to address the needs of  those in recovery. In addition, officials said they are in the process of  hiring a job developer to liaise between job seekers, navigators, and  employers, and help recruit employers who are willing to hire those in  recovery from SUD.

Additionally, communities are exploring different workplace programs to  support those in recovery. Officials in New Hampshire and Ohio reported  using their Phase 1 and Trade and Economic Transition National  Dislocated Worker Grant funds, respectively, to pilot recovery-friendly  workplace initiatives, which provide training and supports to employers to  help them better understand and work with individuals with SUD. Ohio  state officials told us that, in three pilot counties, the state will train  supervisors and managers and provide second-chance policies and  employee assistance programs. According to these officials, recovery- friendly workplaces encourage an environment where employers,  employees, and communities can collaborate to create positive change  and eliminate barriers for those affected by SUD. In New Hampshire,  employers may request that the state designate them as a recovery- friendly workplace. The New Hampshire workplace program will provide  an advisor who conducts an orientation with management and staff and  helps the employer publicize their participation in this effort so that their  employees will know of their commitment, and will know their workplace is  a safe place to disclose SUD. Employers in the program also agree to  complete certain activities, such as conducting training and making  connections with local recovery organizations. New Hampshire officials  said they had 220 employers participating in the program as of January  2020.

Workforce Efforts to Address Substance Use Disorder Are in Early Stages and Results Are Not Yet Known

State and local workforce officials said that their efforts to meet the needs  of job seekers and employers in communities affected by SUD are  relatively new. For example, officials in Ohio said that state efforts are still  very much in the preliminary planning stages of their broader  implementation goals. They said that, at this point, they are looking at  how to educate workforce agencies and staff about how to best address  the needs of this population.

State and local officials in our four selected states receiving targeted  Phase 1 and Phase 2 grants were not yet able to report outcomes.  Officials told us that it took time to organize and implement plans, causing  delays in beginning activities. Specifically, workforce officials stated that:  In Washington, officials said they received the notification for Phase 2  grant funding in March 2019. The state workforce agency finalized the  contract with the local workforce agency at the end of May 2019, and  began enrolling eligible job seekers in the late summer and early fall  of 2019.

In New Hampshire, it took the state six months to begin implementing  grant activities after receiving funding in July 2018, and officials  confirmed in January 2020 that they were still too early in addressing  the opioid crisis to have any outcomes.

In Maryland, officials originally planned to use funding to train peer  recovery specialists to work in the state’s AJCs. However, the state  Department of Health secured funding to train peer recovery  specialists, and they did not want to duplicate efforts. As a result, they  revised their plan to instead create an Opioid Workforce Innovation  Fund, which delayed grant activities by six months or more.

As of August 2019, Ohio officials said they were just starting to get the  local workforce areas on board and acclimated. They reported that  they had just completed training for the local workforce agencies on  the grant rules and activities, and launched a toolkit to help agencies  serve individuals with SUD.

Workforce Agencies Face Challenges Helping Individuals Affected by Substance Use Disorder Gain and Maintain Employment

Workforce Agencies Struggle to Support Job Seekers with a Range of Barriers to Employment

Workforce agency officials in all six of our selected states told us they  face challenges addressing the needs of job seekers affected by SUD, in  part due to their limited experience in serving this population. For  example,  Health issues. Officials in all six states said they continue to struggle with  ensuring job seekers receive necessary services due to lack of medical  treatment, mental health services, and recovery services and personnel,  especially in rural areas. For example, officials at a local workforce  agency in a rural area of Maryland said their area has no addiction  specialists, and many people in the area have to travel nearly 2 hours to  receive recovery treatment and counseling.

Involvement with the justice system. Individuals in recovery may be  more likely to have criminal records that complicate obtaining and  maintaining employment. Officials in New Hampshire told us that  employers might not hire people with a criminal history, and that  employers are allowed to ask about criminal history on a job application,  even if the individual is in long-term recovery. Appalachian Regional  Commission officials said that job seekers with a criminal record also  have especially limited employment options in their region because the  federal government and its contractors are large employers there, but  may not be able to hire someone with a felony conviction, which is an  issue for many individuals with SUD.

Transportation difficulties. Lack of reliable, affordable transportation  presents difficulties for many in recovery. For example, New Hampshire  officials told us many people with SUD have lost their license or have no  car, and few public transportation options are available in the state  outside of urban areas. Local workforce officials in a rural area of Ohio  said no reliable public transportation exists near them, and the limited taxi  service that exists is very expensive.

Housing difficulties. Individuals in recovery may not have access to  stable housing, making it difficult to focus on job training or employment.  Specifically, officials in Maryland, Ohio, and Washington cited  homelessness as an issue among those in recovery. Further, New  Hampshire officials said individuals who have a drug conviction may not  be eligible for government-subsidized housing. While homelessness can  be a result of a substance use-related history, local officials in New  Hampshire, Ohio, and Washington told us that there is also a lack of  affordable housing in their respective areas.

Workforce Agencies Face Difficulties Recruiting Employers

Workforce officials in all six selected states told us that they have had  difficulty finding employers who are willing to hire those in recovery. As a  result, workforce agencies risk not meeting WIOA performance targets  related to (1) job seekers’ obtaining and maintaining employment and (2)  effectiveness in serving employers. Workforce officials in all six states  cited employer concerns around relapses, safety and reliability, suitability,  and stigma.

Relapses. Officials from the Appalachian Regional Commission said this  was the most challenging aspect of SUD with respect to the workplace.  Officials from another organization that works with employees with SUD  also told us that employers may be reluctant to hire SUD-affected  individuals because state laws or claims related to lack of reasonable  accommodations under the Americans with Disabilities Act of 1990 can  make it difficult to terminate individuals with a known substance disorder  when they relapse. To address this, some employers put in place a zero- tolerance policy, automatically terminating an employee who tests  positive for drugs.

Safety/reliability. Workforce officials in Maryland said employers are  concerned that SUD-affected employees may bring drugs into their  workplaces or quit unexpectedly. New Hampshire officials told us that  employer liability is an issue as employers are worried about accidents.  They also told us employers are concerned about productivity loss due to  SUD and, in particular, an employee’s inability to work a regular schedule  because they or a family member is dealing with SUD. Ohio officials in  one local area told us that employers in white-collar jobs are less willing  to hire individuals in recovery because they are concerned about possible  theft, and that workforce officials have been working with businesses to  secure liability insurance.

Suitability. Some employers will not hire a person who is unable to pass  a drug test. This may present issues for individuals who take medication  as part of their recovery treatments. For example, Alabama officials told  us that a major reason that employers in their state did not hire job  applicants for vacant positions was because they could not pass initial  drug screenings. In addition, under U.S. Department of Transportation  regulations on workplace drug and alcohol testing, when an employee  performing safety-sensitive functions tests positive for drug use, they  must be removed from performing such functions and evaluated for  treatment options before returning to work. This includes those in  aviation, trucking and locomotive transit. Certain entities regulated by the  Nuclear Regulatory Commission are also required to administer drug and  alcohol testing. Workforce officials in Washington said that it is also  difficult for people with SUD to obtain the available jobs in their state in  the health care field and with federal agencies because these jobs  required drug testing.

Stigma. Employers may also be reluctant to hire those affected by SUD  because of its associated stigma. New Hampshire officials said that  employers are concerned about people’s perceptions and believe it would  hurt business if they declare themselves a recovery-friendly workplace.  For example, they told us about an employer who runs a high-end  restaurant in the state who expressed concern that customers may not  want an individual with SUD preparing their food. Washington officials  expressed similar concerns, saying that while some employers embrace  being a recovery-friendly employer, others do not publicize this because  they are unsure how it will be received by the public. Officials in Alabama  also noted the need for honesty and transparency about the stigma of  SUD and for employers who are willing to invest in their workers.

DOL Is in the Early Stages of Supporting State and Local Efforts through Information Sharing and Technical Assistance; Workforce Agencies Identified Additional Needs

Federal Partnerships Help DOL Identify Ways to Support State and Local Agencies Serving SUD- Affected Individuals

According to DOL officials, they have begun working with ONDCP and  other federal agencies to address the drug crisis. DOL officials noted that,  although the National Drug Control Strategy does not include explicit  goals and performance targets for DOL or employment and training- related efforts, DOL is using the strategy to guide its efforts in addressing  the opioid crisis. DOL officials said they have regular conversations with  ONDCP about how ETA can support the ONDCP strategy within its  current authority. For example, one DOL official told us she  communicates with ONDCP nearly every week. DOL officials also said  they attend meetings hosted by ONDCP which occur roughly every 6  weeks and include representatives from all of the agencies involved in the  National Drug Control Strategy. According to DOL officials, through these  meetings, they have learned about government-wide efforts to support  those affected by SUD, and have shared information about DOL’s own  efforts to address the opioid crisis.

DOL officials told us they communicate with other federal agencies  regarding the opioid crisis. For example, DOL officials said that HHS  provided a list of available grant funding to address the opioid crisis, and  DOL has sent this list to its regional offices to distribute to states. In  addition, ETA officials told us that two out of the six regional offices have  staff serving on regional opioid task forces, for example, with HHS.

DOL has also conducted several webinars with HHS on addressing  training and employment needs of individuals and communities affected  by SUD. Specifically, DOL officials described: a webinar in October 2018 discussing topics such as the rise in opioid  use and a screening and intervention technique; a webinar in May 2019 for program staff working directly with  participants in the workforce development programs located in states  in the mid-Atlantic region, which are among those with the highest  opioid-related deaths; and, a webinar with HHS, ONDCP, and other organizations in August 2019  on peer support recovery, including discussing how DOL grant funds  have been used to train SUD-affected individuals to become peer  recovery specialists.

Internally, DOL officials told us they began a DOL-wide opioid workgroup  in April 2019 to improve communication among units and strengthen  connections across the agency. According to DOL officials and meeting  agendas we reviewed, the workgroup meets about once a month, and  discusses what DOL is doing to address the opioid crisis and identify any  potential gaps in their efforts. They also invite speakers from external  organizations, such as ONDCP, the Centers for Disease Control and  Prevention, and the National Institute for Occupational Safety and Health.

DOL Provides Some Support for Targeted Opioid Grants Recipients, and Has Plans in Place for Oversight and Evaluation

ETA officials have provided technical assistance to states during the  Phase 1 and 2 grant application processes, such as by clarifying  allowable grant-funded activities and defining grant eligibility, and during  grant implementation. According to officials, ETA assigned Federal  Project Officers from one of its six DOL regional offices to work with each  state. Officials have also encouraged information sharing among  grantees. For example, officials said they hosted quarterly calls among  grantee states, where they discussed performance reporting, evaluation,  and use of the Federal Bonding Program, and have allowed time for peer- to-peer sharing of grant accomplishments and challenges. To  encourage peer-to-peer sharing and engagement, ETA also provided  grantees with a list of grantee contacts in all states that received Phase 1  or 2 grants. However, this technical assistance has been limited to those  receiving the targeted grants, and is not offered to all states, tribes, and  outlying areas that may be interested in conducting related work.

DOL officials are working to improve available information on addressing  the employment and training needs of those affected by SUD. According  to DOL officials, interested entities can access a DOL website called  WorkforceGPS with resources and materials on substance abuse,  including its effect on the workforce system, and case management  resources. DOL also contracted with a research organization to review  literature that examines what is known about workforce programs for  individuals with SUD. The research is meant to identify key themes and  findings related to successfully implementing the Phase 1 grants, such as  the role of mental health services in the lives of grant participants and  different employment-related interventions. DOL officials said that, as a  complementary piece to the literature review, the contractor was tasked  with developing a resource guide that identifies promising practices  across the public and private sectors, with a goal of providing up to date  information on tools, programs, websites from across the country to serve  as a resource for grantees who are planning and implementing their own  initiatives. Officials said that the contractor shared preliminary results from  its research activities with targeted grantees in October 2019. Based on  these results, DOL officials reported that there was a lack of evidence  about the relationship between opioid use disorder and employment.  Therefore, they said, the literature review covers a broader range of  information related to SUD in an effort to provide useful information. DOL  released the full results of the literature review and resource guide on its  website in March 2020.

Regarding oversight of grant activities, DOL plans to review grantee  performance through required state quarterly reports, which have only  recently begun to be submitted. DOL requires that these reports include  financial data and program performance information (such as  characteristics of, and services received by, participants, as well as  participant outcomes). These quarterly reports also contain a narrative  section where grantees can share information on project success stories,  upcoming grant activities, and promising approaches. The final quarterly  report for the grant must summarize the successes and/or challenges in  delivering services, as well as address the topics of sustainability,  replicability, and lessons learned. DOL officials said they do not have  plans to share information from the summaries in the quarterly reports  with other states. In addition, DOL officials told us that states generally  are to use the same performance measures for these grants as they do  for WIOA core programs. However, officials said they realize the SUD  population could have different challenges than the rest of the WIOA  population and, as a result, they are looking into developing new  performance measures to address these differences.

Regarding evaluation of grant activities, DOL has contracted with a  research organization to conduct a 3-year evaluation of Phase 1  activities. The evaluation is expected to end in September 2021, with a  final report to follow. DOL officials confirmed that there will be no interim  reports.

State and Local Workforce Agencies and Our Review Identified Areas for Further Assistance

Although some state and local workforce officials we interviewed were  aware of available technical assistance from DOL, they identified a need  for more information to help them address challenges in serving  communities affected by SUD, as discussed below. Furthermore, our  review of DOL documents and guidance such as the ETA  announcements to states of the targeted grants and the WIOA state plan  guidance, found that these documents did not fully address the questions  and concerns of state and local workforce officials. Federal internal  control standards regarding risk assessment state that management  should identify, analyze, and respond to risks related to achieving its  objectives such as WIOA’s goals of increasing employment and  retention. These standards also state that management should  communicate with its partners to help achieve its objectives. Better  communicating information could enhance DOL’s ability to respond to  these risks.

Specifically, state and local workforce officials and our review identified  three areas in which additional DOL actions could help officials address  the needs of job seekers in recovery and potential employers:  Clarity about expectations and use of funds. Officials in Arizona, Ohio,  and Washington said they would like clarification from DOL about its  expectations regarding the role of state and local workforce systems in preparing individuals in SUD recovery for employment, or in determining  the appropriate use of WIOA grant funds. Clarity around DOL’s  expectations for state workforce agencies could be helpful, as Arizona  officials emphasized that they consider SUD a public health issue, not a  workforce issue, and have viewed SUD as an issue that is best  addressed on the health side. Also, information on expectations and the  use of non-targeted WIOA grant funds is especially important as states  draft their 2020 WIOA state plans, which will set priorities for state  workforce agencies for the next 4 years. For example, officials from one  local area in Washington told us that they hoped to continue the grant  activities and partnerships past the end of the current targeted grant, but  they were unsure whether they could do this with non-targeted, WIOA  formula grant funding. Our review of the targeted grant announcements  found they did not contain information on whether this was an allowable  use of funds.

ETA issued guidance regarding the 2020 WIOA state plans in February  2020. However, our review of this guidance found that it does not provide  specific information about states’ roles in meeting the needs of job  seekers in recovery from SUD or their potential employers, or how non- targeted WIOA funding can be used to address those needs. DOL  officials acknowledged that the guidance does not include such  information, stating that the purpose of the guidance was to focus on the  procedures and instructions for states in submitting their state plans, and  not to provide specific suggestions on uses of WIOA funds or what  particular strategies states should pursue. Clarity on the role of states and  the use of WIOA funding would better position state workforce systems to  meet the training and employment needs of those affected by SUD and  their potential employers.

Better information sharing with all states. Officials from four of the six  selected states identified areas in which it would be useful for DOL to  enhance its information sharing. Specifically, officials in these states told  us that it would be useful for DOL to share information about lessons  learned and successful strategies in addressing the needs of job seekers  in recovery and potential employers with all states—whether or not they  received targeted grants. They said such information would be particularly  helpful given that many states are in the early stages of developing their  programs. Officials stated that information based on the experiences of  their peers would assist states in ensuring those in recovery are job ready  and in hiring and retaining these workers. For example, officials from  Arizona—a state without a targeted DOL grant—told us their communities  could benefit from learning about experiences of states or local areas that  are addressing the crisis within the workforce system, especially those  using an approach that offers wraparound services such as transportation  assistance. Additionally, officials from Ohio—a state with a targeted DOL  grant—said they would like to learn from more experienced state officials  who have been working for 6 months or a year within the workforce  system to address the opioid crisis.

Workforce officials stated that even if job seekers in recovery are trained  and job ready, workforce agencies face challenges in addressing  employers’ concerns about hiring these individuals. Workforce officials in  five of the six selected states said that information about incentives for  employers to hire individuals affected by SUD, and/or education for  employers about this population, would be helpful given that perceived  risks have led to difficulties with finding employers who are willing to hire  this population. In particular, given limitations of federally supported  incentive programs and the stigma associated with SUD, a dual  approach—education and incentives—may be needed. However, at this  point, most information on strategies to address employer concerns,  including leveraging pre-existing federal programs, is not widely  disseminated.

DOL officials stated that they recognize the challenges state and local  workforce agencies face in engaging employers in this area and are  exploring use of existing programs to incentivize the hiring of job seekers  with SUD. However, they acknowledged that to date, limited information  has been shared with the large network of state and local workforce  agencies. Thus far, DOL has been piloting and promoting one available  incentive, the Federal Bonding Program, which is designed to help reduce  employers’ risk by offering reimbursement for loss from illegal acts, such  as theft or embezzlement, for individuals with criminal records. DOL  officials have recognized that other existing incentive programs—targeted  to employers of other populations, such as low-income, and other  disadvantaged job seekers—may be helpful. They said that because the  populations eligible for these programs share similar characteristics as  those in recovery, they are exploring how to connect them to employers  who are willing to hire those in recovery. For example, the Work  Opportunity Tax Credit encourages employers to hire individuals from  certain targeted groups who have consistently high unemployment rates,  such as individuals with a felony record, by providing employers with a tax  credit as an incentive to hire and retain these workers.

However, state officials said, and our review confirmed, that these current  federal programs may not fully address employer concerns. Specifically,  bonds might not protect against other liabilities which may be of concern  to employers, such as accidents caused by an employee under the  influence of opioids. Furthermore, despite promoting awareness of these  programs, DOL officials recognized that these efforts alone may not  increase employer participation, particularly given the need to move  beyond the stigma associated with that condition. Officials in two states  told us that education is an important response in addressing employers’  concerns about the potential stigma associated with hiring individuals with  SUD. For example, New Hampshire has a pilot program on recovery- friendly workplaces to educate employers about reducing stigma  associated with SUD, as well as related human resource policies and  employee assistance programs. Also, Arizona officials stated that  workforce agencies need to understand the employer perspective and  engage, educate, and involve employers.

To date, DOL has been primarily communicating information about  emerging, workforce system-based strategies to serve job seekers and  employers affected by SUD with Phase 1 and 2 grantee states. As  previously noted, DOL has an existing mechanism—its WorkforceGPS  website—that could be used to share information more widely. Access to  information on promising practices and lessons learned can help  workforce agencies in all states learn about possible ways to address the  needs of job seekers affected by SUD and their potential employers.

More time to use grant funds. Officials in New Hampshire, Ohio, and  Washington said that a longer time window in which to use the DOL grant  funding would be helpful. For example, New Hampshire officials said the  length of time needed for intake and enrollment for clients with SUD is  longer than usual for a typical WIOA job seeker; therefore, more time to  use the Phase 1 grant funds could help them with the more intense  interventions. In addition, state workforce officials in Ohio told us it is  complicated and takes time to develop new partnerships and trust at the  local level, and to determine what the state and other partners can  provide. Similarly, Washington state officials said the limit on the time  allowed to use the Phase 1 and 2 grant funds has limited their ability to  enroll job seekers in recovery and implement their partnerships.  Specifically, state officials said that the delay in receiving funds means  they will not have the full 2 years for grant activities. To meet DOL’s  reporting deadlines, they will need to complete their activities earlier than  anticipated. ETA officials told us that they are considering extending the  Phase 1 and 2 grant periods for some states. In commenting on a draft of  this report, they also said that If these limitations prevent a state from  continuing its grant beyond a certain period of years, states can apply for  a new grant should it still meet the conditions for eligibility, such as if the  public health emergency declaration for the opioid crisis remains active.

In light of the persistent nature of the drug crisis and the complex set of  issues facing individuals on the path to recovery, workforce agencies are  likely to continue facing challenges in meeting the needs of this  population and their potential employers. As the agency responsible for  the nation’s workforce system, DOL can play an important role in serving  communities and individuals affected by SUD who are seeking  employment. However, state officials we interviewed expressed  uncertainty about what is expected of them or the specific allowable uses  of their non-targeted WIOA funds to address a crisis that has long been  considered primarily a health and law enforcement issue. Our work raises  concerns about how the workforce system continues to seek clearer  direction on the role of states and the use of non-targeted WIOA grant  funding in helping ensure the economic well-being of communities  affected by this public health emergency.

DOL’s current efforts are still in the early stages, and it will take time for  the agency to fully identify and disseminate effective, evidence-based  strategies. In the meantime, states are seeking the best information  currently available to help their workforce systems support job seekers  affected by SUD and their potential employers. DOL’s targeted grants  provide an opportunity for grantees and non-grantees alike to learn  states’ experiences in addressing the effects of the opioid crisis through  the workforce system, but information on the current approaches states  receiving targeted grants are using is not being shared beyond the  targeted grantee community. Sharing this information with all states could  better position workforce agencies to address the needs of job seekers  affected by SUD and help employers understand and address the  perceived risks of hiring job seekers in recovery. While the workforce  system may take time to fully build its capacity to work with these job  seekers and employers, opportunities exist to learn and make interim  progress towards this end.

We are making the following two recommendations to DOL:  The Assistant Secretary for Employment and Training should clarify  DOL’s expectations of the role of state workforce agencies in addressing  the employment and training needs of those affected by SUD and how  non-targeted WIOA funding can be used to assist job seekers and  employers. (Recommendation 1)

The Assistant Secretary for Employment and Training should share  information from targeted grantees with all state workforce agencies,  tribal governments, and outlying areas regarding lessons learned and  promising practices in addressing the needs of job seekers affected by  SUD and potential employers. (Recommendation 2)

We provided a draft of this report to DOL and HHS for review and  comment. In its formal comments, which are reproduced in appendix I,  DOL agreed with our recommendations. DOL also provided technical  comments, which we incorporated as appropriate. HHS did not have  comments.

In its response, DOL noted that throughout our report, we refer to SUD,  but that its targeted grants are limited to addressing SUD caused by  opioids. While our report focuses on SUD more broadly, many of the  efforts states and federal agencies are involved in focus on opioid use  disorder, as a result of HHS’s emergency declaration. DOL also stated  that it was in the process of announcing another round of grants in  partnership with the Delta Regional Authority and the Appalachian  Regional Commission, part of which will be available to address opioid or  other SUD. DOL also noted that grant-funding limitations, including the  availability of appropriated funds, make it difficult to address states’  concerns about not having enough time to spend their grant funds, and  suggested that states may consider applying for a new grant. We have  reflected this point of view in the final report.

In response to our first recommendation, DOL officials said they  anticipate providing information and technical assistance to help  workforce system grantees understand how they can address the impacts  of SUD on the workforce. ETA plans to issue guidance by the end of 2020  to share promising practices and describe how WIOA funds can be used  to support job seekers in recovery and employers.

In response to our second recommendation, DOL officials said ETA has  created resources that are available to all states based on its experience  administering some of the targeted grants. ETA officials cited the recently  published literature review and companion resource guide, and said they  also plan to share the evaluation of the Phase 1 grants widely when it is  available, including any resources or tools developed by states that were  awarded Phase 1 grants. In addition, ETA plans to host at least one  webinar to share additional promising practices from the targeted grants  that could be useful to local workforce boards around the country.

As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies to the appropriate  congressional committees, the Secretary of Labor, the Secretary of  Health and Human Services, and other interested parties. In addition, the  report will be available at no charge on the GAO website at  http://www.gao.gov.

If you or your staff have any questions about this report, please contact  me at (617) 788-0580 or nowickij@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. GAO staff who made key contributions to this report  are listed in appendix II.

Appendix I: Comments from the Department of Labor

In addition to the contact named above, Danielle Giese (Assistant  Director), Amy Sweet (Analyst-in-Charge), Linda Lootens Siegel, and  Anna Kallschmidt made key contributions to this report. Also contributing  to this report were Deborah Bland, Alex Galuten, Natalie Herzog, Tom  James, Bill Keller, Sheila R. McCoy, Corinna Nicolaou, Monica Savoy,  Almeta Spencer, Tonnye Connor-White, and Greg Whitney.

The Department of Labor has awarded grants to help states address the opioid crisis through training and employment services. State officials told us that job seekers who are in recovery may have additional challenges with finding employment, in part, due to employers’ concerns about potential criminal histories, relapse, and social stigma.

To help meet the training and employment needs of those in recovery and potential employers, state officials said they need

clearer expectations around their role in addressing the opioid crisis

more information on lessons learned and successful practices


Sexual Assault: Information on the Availability of Forensic Examiners

In 2016, about 323,000 individuals age 12 or older were reported victims of sexual assault, according to the Bureau of Justice Statistics. Studies have shown that exams performed by sexual assault forensic examiners—medical providers trained in collecting and preserving forensic evidence—may result in better physical and mental health care for victims, better evidence collection, and higher prosecution rates. Yet, concerns have been raised about the availability of such examiners. The Department of Justice administers grant programs that can be used by states and other eligible entities to train and fund examiners.

This statement summarizes GAO's findings from its March 2016 report ( GAO-16-334 ) describing (1) what was known in 2016 about the availability of sexual assault forensic examiners nationally and in selected states and (2) the challenges selected states faced in maintaining a supply of sexual assault forensic examiners. For that report, GAO reviewed literature on the availability of examiners and challenges training and retaining them. GAO also interviewed knowledgeable officials, including recipients of federal sexual assault examiner related grants and officials from sexual assault coalitions in six states (Colorado, Florida, Massachusetts, Nebraska, Oregon, and Wisconsin) selected to achieve variation in factors such as population and geographic location.

GAO's March 2016 report examining the availability of sexual assault forensic examiners found that only limited nationwide data existed on the availability of sexual assault forensic examiners—both the number of practicing examiners and health care facilities that had examiner programs. At the state level, GAO found that, in three of the six states it selected to review, grant administrators or officials from sexual assault coalitions were able to provide estimates of the number of practicing examiners and, in all six states, they were able to provide information on the estimated number of examiner program locations in their state. However, officials in all six selected states told GAO that the number of examiners available in their state did not meet the need for exams, especially in rural areas. For example, officials in Wisconsin explained that nearly half of all counties in the state did not have any sexual assault examiner programs available and officials in Nebraska told GAO that most counties in the state did not have examiner programs available. As a consequence, officials said victims may need to travel long distances to be examined by a trained examiner. In health care facilities where examiners were available, they were typically available in hospitals on an on-call basis, though the number available varied by facility and may not provide enough capacity to offer examiner coverage 24 hours, 7 days a week.

GAO's March 2016 report also found there were multiple challenges to maintaining a supply of examiners, according to its review of the literature and interviews with officials in the six selected states. These challenges include:

Limited availability of training . Officials in five of the six selected states reported that the limited availability of classroom, clinical, and continuing education training opportunities is a challenge to maintaining a supply of trained examiners. For example, officials told us that there is a need for qualified instructors to run training sessions.

Weak stakeholder support for examiners. Officials in five of the six selected states reported that obtaining support from stakeholders, such as hospitals, was a challenge. For example, hospitals may be reluctant to cover the costs of training examiners or pay for examiners to be on call.

Low examiner retention rates. The above-mentioned and other challenges, including the emotional and physical demands on examiners, contribute to low examiner retention rates. Officials in one of the selected states estimated that while the state trained 540 examiners over a two-year period, only 42 of those examiners were still practicing in the state at the end of those 2 years.

Officials described a variety of strategies they have employed that can help address these challenges, such as implementing web-based training courses, clinical practice labs, mentorship programs, and multidisciplinary teams that respond to cases of sexual assault.

I am pleased to be here today to discuss our work on the availability of  sexual assault forensic examiners. An estimated 323,450 individuals age  12 or older were victims of rape or other sexual assault in 2016,  according to the most recently available data from the Bureau of Justice  Statistics. When victims of sexual assault receive a medical forensic  examination, the exam may be provided by either a trained sexual assault  forensic examiner—that is, a medical provider who has received  specialized training in properly collecting and preserving forensic  evidence—or a medical provider who has not received such specialized  training. Studies have shown that exams performed by trained sexual  assault forensic examiners may result in shortened exam time, higher  quality health care delivered to victims, higher quality forensic evidence  collection, as well as better collaboration with the legal system and higher  prosecution rates. However, concerns have been raised about the  availability of examiners to meet victims’ needs for exams.

To help inform today’s discussion, my testimony will focus on findings  from our March 2016 report examining information on the training,  funding, and availability of sexual assault forensic examiners. In  particular, this statement will address:  1.  what was known about the availability of sexual assault forensic  examiners nationally and in selected states as of 2016, and  2.  the challenges selected states faced in maintaining a supply of sexual  assault forensic examiners.

For our March 2016 report, we conducted a literature review to identify  studies that measured the availability of sexual assault forensic  examiners, examined challenges to training and retaining examiners, and  strategies that could be used to address these challenges. We  interviewed experts, recipients of federal grants to train sexual assault  forensic examiners, and state sexual assault coalition officials in six  selected states about data on the availability of examiners or examiner programs; the extent to which examiner availability meets the need for  exams; challenges they experienced in training or retaining examiners;  and strategies that could be used to overcome these challenges. We  also interviewed officials from the International Association of Forensic  Nurses (IAFN) about these issues. Our March 2016 report includes a full  description of our scope and methodology. We conducted the work on  which this statement is based in accordance with generally accepted  government auditing standards. Those standards require that we plan  and perform the audit to obtain sufficient, appropriate evidence to provide  a reasonable basis for our findings and conclusions based on our audit  objectives. We believe that the evidence obtained provides a reasonable  basis for our findings and conclusions based on our audit objectives.

Victims of sexual assault may receive a sexual assault forensic  examination by a medical provider who may or may not be a trained  sexual assault forensic examiner. Medical providers assess victims’  clinical conditions; provide appropriate treatment and medical referrals;  and, given consent by the victim, collect forensic evidence through a  sexual assault forensic examination that may follow steps and use  supplies from a sexual assault evidence collection kit. Under its protocol  for sexual assault forensic examinations, the Department of Justice (DOJ)  recommends that medical providers collect a range of physical evidence.  In addition, sexual assault forensic exams typically include documenting  biological and physical findings such as cuts or bruises and a victim’s  medical forensic history, such as the time and nature of the assault. Once  the exam is complete, medical providers preserve the collected evidence,  which may include packaging, labeling, and sealing evidence collection  kits and storing kits in a secure location. Medical providers typically perform such exams only for acute cases of sexual assault, such as in  cases where the assault occurred within the previous 72 to 96 hours,  when the physical and biological evidence on a person’s body or clothes  is considered most viable.

DOJ, IAFN, and the American College of Emergency Physicians (ACEP)  recommend that sexual assault forensic exams be performed by specially  trained medical providers—known as sexual assault forensic examiners  (examiners). These examiners include physicians, physician assistants,  nurse practitioners, and other registered nurses who have been specially  educated and have completed clinical requirements to perform sexual  assault forensic exams. Sexual assault nurse examiners (SANE) —a  particular type of sexual assault forensic examiner—are registered  nurses, including nurse midwives and other advanced practice nurses,  who have received specialized education and have fulfilled clinical  requirements to perform sexual assault forensic exams. Examiner  programs have been created in hospital or non-hospital settings whereby  specially trained examiners are available to provide first-response care  and exams to sexual assault victims. DOJ, IAFN, and some states have  issued guidelines pertaining to the minimum level of training examiners  should receive in order to properly collect and preserve evidence, identify  victims’ medical and emotional health care needs, and provide counseling  and referrals for victims. These guidelines include recommendations of  objectives and topics that training programs should cover.

DOJ administers several grant programs that aim to, among other things,  improve response to and recovery from four broad categories of  victimization—domestic violence, sexual assault, dating violence, and  stalking. In our March 2016 report we describe three key grant programs  administered by DOJ’s Office on Violence Against Women that could be  used by grant recipients—including states or other eligible entities—to  fund or train sexual assault forensic examiners.

Nationwide Data on the Availability of Sexual Assault Forensic Examiners Are Limited; Officials in Selected States Reported a Need for Additional Examiners

In our March 2016 report examining the availability of sexual assault  forensic examiners, we found that only limited nationwide data exist on  the availability of sexual assault forensic examiners—that is, both the  number of practicing examiners and health care facilities that have  examiner programs. While IAFN reported that, as of September 2015,  there were 1,182 nurses with an active IAFN SANE certification in the  United States, such data do not represent all practicing examiners  nationwide. For example, the data do not account for examiners who  completed training through an IAFN or a state training program but never  became certified or were certified through another entity, such as a state  board of nursing. IAFN also collects data on examiner programs  nationwide—that is, data on hospitals, clinics, and other sites where  examiners practice. Such data provide an indication of the availability of  examiners, but the data are also limited. While 703 examiner programs  nationwide voluntarily reported to IAFN’s examiner program database, as  of September 2015, IAFN officials noted that the database is often not up  to date; and some health care settings where sexual assault forensic  exams are conducted, such as child advocacy centers, are not  represented. In addition, data collected on staffing characteristics of  examiner programs are often unavailable in the IAFN examiner program  database. For example, only about one-third of the examiner programs  reported on the number of examiners practicing in their program, and  about one-third reported on whether examiners were available on-site  versus on-call.

In three of the six selected states we reviewed in our March 2016 report,  grant administrators or officials from sexual assault coalitions were able to  provide estimates of the number of practicing examiners, and, in all six  states, they were able to provide information on the estimated number of  examiner program locations in their state. Of states that reported, the  number of practicing examiners and examiner programs varied by state.  (See table 1.) However, such data may also present an incomplete  picture of the availability of examiners. For example, only one of the six  selected states has a system in place to formally track the number and  location of examiners. Instead, officials generally reported on the  estimated number of examiners or examiner locations that were part of a  statewide examiner program or were identified through an ad hoc data  collection effort.

Although data are limited, grant administrators and sexual assault  coalition officials in all six selected states nevertheless told us that the  number of examiners available does not meet the need for exams within  their states. For example, coalition officials in Wisconsin told us that  nearly half of all counties in the state do not have any examiner programs  available, and coalition officials in Nebraska told us that most counties in  the state do not have examiner programs available. In addition, in four of  the six selected states—Colorado, Florida, Nebraska, and Wisconsin— state grant administrators and coalition officials told us that few or some  health care facilities in their state have examiners available. As a  consequence, officials said victims may need to travel long distances to  be examined by a trained examiner or be examined by a medical  professional without specialized training. While in the other two selected  states—Massachusetts and Oregon—state grant administrators and  coalition officials stated that some or most facilities have examiners  available, they noted that there is still a need for additional capacity to  reduce the burden on those examiners who are available, or to make  examiners available in a number of areas where examiners are currently  unavailable.

In health care facilities where examiners are available, they are typically  available through hospitals on an on-call basis, according to literature we  reviewed as well as all grant administrators and coalition officials we  interviewed for our report. In addition, among facilities that have  examiners available, the number of examiners available varies and may  not provide enough capacity for facilities to offer examiner coverage 24  hours, 7 days a week, according to state grant administrators and  coalition officials we interviewed. Nebraska coalition officials, for example,  told us that while one hospital in Omaha has a team of 26 examiners  available, other facilities in the state may have as few as three examiners  available. Further, officials from Florida and Colorado told us that there  are few facilities in their states able to offer full coverage with examiners  available 24 hours, 7 days a week.

Selected States Faced Challenges Training Examiners, Maintaining Stakeholder Support, and Retaining Examiners

In our March 2016 report, we found that maintaining a supply of trained  examiners that meets communities’ needs for exams is challenging for  multiple reasons, and that state officials have employed a variety of  strategies to address these challenges, as described below.

Limited availability of training. Officials in five of the six selected states  told us that the limited availability of classroom, clinical, or continuing  education training is a barrier to maintaining a supply of trained  examiners. Regarding classroom training, some officials told us that  training may only be offered once per year in their states. Additionally,  officials from both Florida and IAFN told us that there is a need for  qualified instructors to run training sessions. Experts and officials from  Colorado, Nebraska, and Oregon also told us that medical professionals  in rural areas may have difficulty completing the clinical training  necessary to become an examiner. Obtaining clinical experience, such as  performing exams under the supervision of a trained examiner, is a  particular challenge in rural areas where hospitals may treat only a few  sexual assault cases per year. One official in Nebraska told us that  trained examiners in rural areas might not feel competent to perform  exams due to the low number of cases they treat. A lack of continuing  education opportunities may also pose a challenge for examiners in  maintaining the skills necessary to perform exams. For example, the  National Sexual Violence Resource Center (NSVRC) reported that— based on common challenges identified through a survey of, and group  discussions among, examiner program coordinators—maintaining  competency may be difficult for nurses in rural areas due to a low volume  of patients presenting in need of exams and limited access to ongoing  and advanced training.

Officials told us they have been able to increase the availability of  examiner training through alternative training methods such as web- based training courses and simulated clinical training. For example,  officials in Colorado told us their state’s web-based examiner training  program has made training less expensive and has increased examiner  recruitment. Officials in Wisconsin told us they developed a clinical  training lab that allows examiners to gain hands-on experience by  performing elements of exams on experienced teaching assistants hired  for the purpose of training new examiners. Further, in 2014, a DOJ- funded evaluation of examiner training programs found that a web-based  training course may help increase the availability of trained examiners;  the study also found that implementing web-based training had benefits  such as decreasing the costs associated with attending in-person training,  expanding training opportunities to remote areas, and allowing examiners  to be trained by national experts.

Lack of technical assistance and other supportive resources.  Officials in four of the six selected states told us that the limited  availability of technical assistance and other supportive resources for  examiners poses a challenge to maintaining a supply of trained  examiners. For example, officials in Florida, Nebraska, Oregon, and  Wisconsin explained that, in general, there is a lack of mentorship  opportunities and leadership within the examiner community. Officials  also noted that the sustainability of examiner programs may be  threatened by a lack of internal capacity, such as not having a full-time,  paid examiner program coordinator available. Further, in its survey of and  group discussions with examiner program coordinators, NSVRC found  that examiners and examiner programs needed technical assistance and  support in the following areas: aspects of performing exams, training,  leadership development and policy issues, and examiner program  sustainability.

Officials we spoke to told us about strategies that can be used to increase  support for examiners and examiner programs, such as offering web- based technical assistance. For example, officials in Massachusetts told  us that, through their National Sexual Assault TeleNursing Center, trained  SANEs provide remote clinical guidance to two hospitals in the state that  do not have trained examiners available. In addition, officials from  Colorado told us an examiner program coordinator in an urban hospital in  the state provides volunteer on-call technical assistance and clinical  guidance to examiners in rural parts of the state, where those resources  are not otherwise available. Further, one study we reviewed found several  states were engaged in promising practices to increase support for  examiners, such as implementing state-wide mentorship programs,  developing regional examiner list-serves and online discussion boards,  creating formal leadership positions within the examiner community, and  requiring examiner program evaluations.

Weak stakeholder support for examiners. Officials in five of the six  selected states told us that limited stakeholder support for examiners and  examiner programs, such as from hospitals and law enforcement, is a  challenge to maintaining a supply of trained examiners. Some officials  told us that hospitals may be reluctant to support examiners and  examiner programs due to a low number of sexual assault cases treated  each year. One official told us that hospitals may be reluctant to send  nurses to examiner training, as it takes away from their regular shift  availability. Additionally, some hospitals do not pay examiners to be on  call. Officials in three states told us that hospitals typically either do not  pay examiners to be on call or pay on-call examiners significantly less  than other on-call medical professionals.

Apart from hospital support, officials in Colorado and Oregon explained  there is a need for more multidisciplinary support for examiners, such as  increased law enforcement, prosecutor, and first-responder  understanding of examiners’ role. The literature we reviewed also shows  that ambiguity around the role of the examiner in responding to sexual  assault may be a source of conflict between examiners and other  professionals. For example, examiners were found to have experienced  instances where victim advocates or law enforcement questioned  examiners’ medical decisions, speed of evidence collection, or asked  examiners to comment on the credibility of a victim’s case. One nationally  representative survey of examiner programs found that examiner program  coordinators felt ongoing education of community stakeholders on sexual  assault and examiner programs was needed due to the high turnover in  staff at relevant community institutions and agencies, such as law  enforcement officers, victim advocates, and prosecutors.

Through our interviews with officials, we learned of strategies selected  states have used to increase or mitigate limited stakeholder support for  examiners and examiner programs. For example, officials in Colorado,  Florida, Nebraska, Oregon, and Wisconsin told us that sexual assault  response teams have been developed in their states to help community  stakeholders to understand examiners’ role and better coordinate to meet  the medical and legal needs of sexual assault victims.

Low examiner retention rates. Officials in four of the six selected states  told us that low examiner retention rates can be an impediment to  maintaining a supply of trained examiners. In addition to the challenges of  limited training opportunities, technical assistance and other supportive  resources, and stakeholder support for examiners, the physically and  emotionally demanding nature of examiner work contributes to low  examiner retention rates. Further, studies have indicated that  dissatisfaction with compensation, long work hours, and lack of support,  among other things, may contribute to examiner burnout. Examiners  typically work on call in addition to their full time jobs as, for example,  emergency department nurses. Officials in Florida told us that examiners  may be on call for 6-hour, 12-hour, or even 24-hour shifts. Further, one  survey of examiner programs in Maryland found that examiners were  required to be on call for an average of 159 hours per month. Wisconsin  officials estimated that, although 540 SANEs were trained over a 2-year  period, only 42 (less than 8 percent) were still practicing in the state at the  end of those 2 years.

Chairman Harper, Ranking Member DeGette, and Members of the  Subcommittee, this concludes my prepared statement. I would be  pleased to respond to any questions that you may have at this time.

For further information about this statement, please contact A. Nicole  Clowers at (202) 512-7114 or clowersa@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this testimony. In addition to the contact named above,  key contributors to this statement were Kristi Peterson (Assistant  Director), Patricia Roy, Katherine Mack, Laurie Pachter, and Emily  Wilson.

This is a work of the U.S. government and is not subject to copyright protection in the  United States. The published product may be reproduced and distributed in its entirety  without further permission from GAO. However, because this work may contain  copyrighted images or other material, permission from the copyright holder may be  necessary if you wish to reproduce this material separately.

A government survey estimated that 323,450 people in the U.S. age 12 and up were victims of sexual assault in 2016.

Studies show that exams conducted by specially trained sexual assault forensic examiners may result in better physical and mental health care for victims and produce higher quality evidence.

This testimony discusses our earlier work assessing what is known about the availability of these examiners and the challenges to maintaining a supply of them in some areas. These include:

lack of support from hospitals or law enforcement

low retention rates due to the demanding work