The Mental Health Workforce Crisis

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Good afternoon. I'm Kathryn Santoro, Director of Programming at the National Institute for Health Care Management Foundation.

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Thank you for joining us today for this important discussion on the Behavioral Health Workforce Shortage and Strategies to improve access and quality of mental health care.

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You will have the opportunity to submit text questions to today's presenters by typing your questions into the questions pane of the control panel. You may send in your questions at any time during the presentation. We will collect these and address them during the Q and A session at the end of today's presentation.

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Today's webinar is being recorded, and we will share a recording in the coming weeks.

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OK, Almost half of Americans live in an area with a shortage of mental health professionals, and the demographics of the mental health workforce are not representative of the population and communities they serve.

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There is also a lack of culturally appropriate care, and it is difficult to find providers of more specialized care.

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Before we hear from our prestigious panel of experts today, on this topic, I want to thank NIHCM President and CEO, Nancy Chockley, and the NIHCM team, who helped to convene today's event.

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You can find biographical information for our speakers, along with today's agenda and copies of their slides on our website.

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We also invite you to join the conversation on Twitter using the hashtag Mental Health Workforce.

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I am now pleased to introduce our first speakers, Cleese Erickson, and Randall Done.

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Cleese and Randall work at the fitzhugh Molan Institute for Health Workforce Equity at the George Washington University.

1:52

We're so honored to have them with us today, Cleese and Randall.

1:59

Thank you for the opportunity to present, hey, I was really excited, too, Be invited to be a part of this panel and talk about Behavioral Health workforce shortages.

2:08

This is a topic that's near and dear to so many hearts as we're just coming out of a major trauma nationally with a pandemic.

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And all of the other behavioral health workforce crises that we're facing in terms of, you know, what we've learned about health disparities and racial inequities, and that was on top of an existing need under supply of behavioral health services prior to the pandemic.

2:34

So we're hoping that we can share some of the data that we've put together with you, which was put together and part funded by SAMHSA. The substance is a grant that we got to build a unique database on the behavioral health workforce.

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Next slide.

2:52

They provided us with $3 million of funding over the past over three years to develop a database.

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And of course all the findings that we're going to present today, including some of the work from Randall does not necessarily reflect SAMHSA, or, or HHS's, is, I think, an important set of information to make available to you today.

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Next slide.

3:16

When we released the data that we put together, we also had a companion blog post to go out and Health Affairs pointing out that the data that we've put together paints a pretty stark picture.

3:28

We are a, We had few a shortage of providers in the past, and now we're able to put together a unique database that really shows down to the county level.

3:41

This apply to providers across the nation, but it shows some serious gaps is presented in just a moment. Next slide.

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I want to spend just a minute on how we built this database, because this was not something sitting around that we just took advantage of. two that had already put this information together.

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We had to spend a lot of work, was a labor of love, to a creative experience, to use prescription data, to identify the prescribers of behavioral health, medications Psychotropics, and medications for opioid use disorder.

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And through that, we're able to identify not only specialists, psychiatric and addiction medicine specialists that are prescribing these medications but also the primary care physicians, MPs, and TAs and other specialists, including emergency medicine physicians and ..., among others.

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That prescribe a significant amount of behavioral health medications in their country.

4:37

Separately, we compiled state licensure data for the following progressions Here: psychologists, clinical social workers, professional counselors, a marriage and family therapist, by contacting all 50 states, and all of their licensure boards.

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And I want to spend a special shout shout out to those that make their data available on the website, to download, and, particularly, if they include information like data on race slash ethnicity, which Tennessee does, or other information about provider demographics.

5:07

So, we pulled this data together, next slide, and we're able to identify one point if I want to point out that this was really important because when we released the Health Affairs blogpost we got a lot of media attention about this. And one of the Quotable quotes that came out of that was that this data just didn't exist before.

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It's really kind of shocking to think that despite all the behavioral health needs, we didn't have data on our workforce, particularly for counselors and therapists.

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Next slide.

5:37

So, we know it does exist, and we've found that there are one point three million individual providers that we can identify, mapped down to the location, including almost 700,000 behavioral health specialists, that includes psychiatric and addictions, specialists, psychologists, and counselors, and therapists.

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Then, as I mentioned earlier, we can also bring into, into visibility the primary care physicians and advanced practice providers, which are almost 450,000 in total, who are a big part of this workforce.

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And, in fact, prescribe twice as many or half of the behavioral health medications that collectively in the country, compared to psychiatric and addiction specialists.

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Next slide.

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But we can do so much more with this data, and people that go down to the county level, as I'm about to display on the math will go live, which is always a little risky when you're pulling these things up online.

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But you can see my screen here, shows a map of the United States. And what we're looking at right now is psychiatric and addiction medicine specialist.

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And you'll note that there are a lot of counties that are shown in white here, and that's because they don't have any behavioral, psychiatric, or addiction medicine specialists, that's half the counties in the US.

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But, as I mentioned before, we can show primary care providers, and how they help fill in gaps, as well as advanced practice providers, and you can see the ratios change over time.

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And you're able to mouse over any county and see the number of providers. And in this case, I'm going to go to Harris County, where I went to high school, and this is Houston, and you can see there are about 5133 prescribers of behavioral health medications in Harris County.

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And that number is going to change over time as we go through the tool a little bit.

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So if you just focused on those, they accept Medicaid, and now go to Harris County, you see this is now the number has dropped to 3500.

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We can also, because of the database that we've developed, um, show those that are prescribing serious mental illness And then again, you go to ... County and the number drops now to 648.

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So anyone can go on this tool, I believe a link has been posted in the chat for you, and you can click and access the data and find out how the supply of providers varies in your county or state.

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But, it's also the data that we've put together.

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And I'm gonna get rid of all the providers now and start showing what psychologists, and you'll see, that we get the same sort of distribution for psychologists as we do for psychiatrists. There are a lot of counties that don't have a psychologist.

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But, when you add in counselors and therapists to get a different picture, but, still, there are counties that don't have any providers, available, and you can go into this tool and see how things change for me to get rid of psychologists again, and show that there's a variety of providers.

8:37

You look and see that the county that California's got a pretty robust supply providers when you look in the poll, and that's because they have a lot of marriage and family therapist.

8:47

When you look at their licensed professional counselors supply, that changes and they in Nevada really have very few.

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This, I think, is an important part of understanding the workforce because, at a time, when we need all hands on deck to treat behavioral health workforce crisis, we need to states have a lot of room to be able to cover and reimburse for Medicaid through Medicaid.

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For example, whether they covered licensed professional counselors or marriage and family therapist, and half the states don't don't reimburse for those services. And that's a missed opportunity to bring into play the possible workforce for you.

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And when we talk with providers, employers of behavioral health providers, licensed clinical social workers and professional counselors, are the ones that are most in demand and the hardest to recruit.

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They're now offering retention, bonuses, and recruitment.

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And retention bonuses in particular were not something that were available, but also increasing salaries to be more competitive with telehealth opportunities that also don't have as much paperwork.

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And we also need to think about scope of practice limitations, too.

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Because in half the states, they don't have lots of these, these counseling and therapist professions are sometimes not able to diagnose or service, or they're limited, what's building Medicaid. So there's a lot of flexibility in that could be introduced to increase the supply of providers through policy changes, that nature.

10:20

So now I'm going to, and one last point, I wanted to make me go back to psychiatrist.

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And primary care providers, and where they're coming into play, is that you can see in states and in areas where counties, where maybe there's more primary care providers, they are offering service.

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That you can offer project echo type models to support those primary care providers and make sure that they are connected to experts that can make them more comfortable, inexperienced in training. And then, in areas where you don't have any providers at all.

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You can bring in it and focus more on building up broadband services and telehealth access.

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And that's communities to make sure they have access to, of course.

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I'm going to come back to the slide deck now and talk a little bit about our findings around peer support workforce.

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Because while the data that I presented to you is a major leap forward, it is missing data, on peer support providers, community health workers, and others.

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So, we not only need to continue to maintain data like I just showed you, but invest in building the data on these vital members of the team as well.

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Through other means, through our SAMHSA grant, we were able to use job postings, and change in demand for peer support, job postings, time to document a 17 fold increase in demand for peer support providers, and we were able to do analysis on this to look at what might be behind those.

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The growth and we had hypothesize next slide that the demand would be associated with with Medicaid reimbursement for peer support providers.

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But, in fact, we found the opposite that it was not, although Medicaid expansion was and so states have a lot of room to be able to improve.

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Next slide, showing up to be able to bring, increase their use of peer support providers, potentially, through greater reimbursement from Medicaid, beneficiaries and peer support.

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We found that only 200, 6000 beneficiaries in 20 19, same time as parents, we did this analysis, we're had services paid for by Medicaid, and that's after 43 states have gone through this state plan amendment process. And other methods to be able to to enable peer support services to be billed to Medicaid is just not being taken up to the extent that we.

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So that's another opportunity for states to increase the workforce, because this, this workforce, with lived experience is an important avenue for helping people with serious mental illness and substance abuse use disorder addressed their needs.

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Next slide.

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This is my last slide before I turn it over to Randall to take on some more. But the point I wanna make here is that we need to continue to invest in data and liberate. And no one needs to think, like, to talk that much about data, but it can be so valuable.

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We're documenting gaps in care and services and really informing understanding our workforce.

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And this is data from the State of Tennessee on Counselors and Therapists.

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And on the left-hand side, you can see that the variation in supply of providers, the same data I showed before, I'm at the county level for 2021.

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Then, on the right, it's the same map, but now counties, where there are no black counselors and therapists have been grayed out.

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And you can see that's over half the counties in the state of Tennessee.

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And when you take into account the recent study that the AMC put together with HRSA that showed that counties that had more, a higher ratio of black physicians had greater life expectancy for black populate the black population area.

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And also, if we could do more work and have data like this available to do research, we could probably show the same thing for counselors therapists.

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So in the meantime, I'm going to turn it over to Randle, who's gonna really go into great detail about some of the studies that need undertaken.

14:17

Cleese, so I'd like to spend a little bit of time talking about the redlining study that we conducted with our team.

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So it's really just one example of the questions that we can ask with the database that our team has built.

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For those of you who are not familiar, redlining was a practice of categorizing wealthier neighborhoods with predominantly white populations as low financial risk, and that was color coded with green while designating neighborhoods with black and immigrant populations as high financial risk with the highest financial risk being color coded as red.

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Previous research has found that residents living in formerly ratlines areas were at high risk for later cancer diagnosis, higher risk of pre-term birth, and other birth outcomes, relevant to the current study for mental health.

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When he saw that there is some evidence that residents and formerly red line areas have poor mental health, we wondered if there were behavioral health workers in those areas that would be able to meet those needs. Next slide, please.

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To answer that question, we examined two cities, Richmond, Virginia, and brainstorming North Carolina to understand how behavioral health providers were distributed across different areas at both cities.

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When we compare these green ... areas, and, as a reminder, those were categorized with the lowest risk to the red line areas, highest financial risk in both cities.

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We found that, rather than areas were associated with, lower, per one thousand population counts of psychologists, counselors, and therapists.

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And those red line areas also had a current day, higher percentage of black residents and higher deprivation scores.

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When we looked at psychiatrist in Greensboro, we also found that red line areas had lower counts of psychiatric specialists.

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But when we looked at that same pattern, that same analysis in Richmond, we saw that red line areas did not have significantly different psychiatric specialists count per one thousand.

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And so the QR code that's on this slide, links to our paper that was published last year.

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Next slide, please.

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So these findings suggest that the has these historical policies like redlining that are embedded with racism are still associated with present day access to care and health outcomes.

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These findings are consistent with recent research that redlining has led to increased racial segregation and continued disinvestment, and is associated with health inequities.

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We would really like to expand this analysis to see if these findings remain true for other formerly red lines.

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Slide, please.

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So now I would like to talk a little bit about strengthening pathways to behavioral health workforce And Q&A. You can go to the next.

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And some of our recent work that's not yet published, but we hope to publish soon.

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We found that black women are actually pretty well represented in both the student population and the work force, or counseling, marriage, and family therapists, and social work professions.

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We also found that black women were under represented in the psychology and school psychology work force, and with the stats that Catherine sure shared earlier, that I'm sure it comes as a surprise to no one.

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When we examined the student population, we did see that there were many black women, students in the pathway to becoming behavioral health professionals. And so, we do expect an increase in the behavioral health workforce.

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You'll see in the bottom left quadrant, and, similar to other professions, we found that black men under represented are all professions in both the workforce and the student population.

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And so, what I'd like to say, lastly, on this slide, is most of the current National diversity statistics focus on the psychologist workforce for the psychiatrist's workforce.

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But we know that's only a portion of all behavioral health professions.

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A few caveats about this work, and the workforce data that we share is based on self reported occupation from the American Community Survey Survey, so we cannot confirm whether respondents are actively licensed or saint clinically.

18:48

I understand that we really do need a publicly available database, just like Lisa was saying, of behavioral health providers, and their racial and other demographic measures that are important.

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There are some databases that exist like this for the physicians, including the American Medical Association asked your file, and so they're able to know a lot better about the number of providers where they are located and minor, and Rachel on demographic characteristics of their provider population.

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Next slide, please.

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So, one way that we've been talking about at our institute and Sandbar work to strengthen the pathway to the behavioral health professions is to leverage the talent that exists within communities.

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We think that we can do this, particularly by engaging community college students.

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The community college student population is racially and ethnically diverse. And community college students have a greater interest in returning to their home communities to practice after finishing health professions Training.

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Slide, please.

20:03

So we've seen that medical schools have found some success with partnering with communities to increase the diversity of their student population and train locally invested health professionals.

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The QR code on this page links to a paper that I recently co-authored with some colleagues at UC Davis at regarding revolutionizing admissions practices to train at work, a more diverse workforce.

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And so this paper talks about practices that health professions institutions are currently putting into place, and something that you might want to try at your institution, too.

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In regard to policy levels, strategies, we really do need more federal dollars that are going to training behavioral health professionals in the US.

20:48

one specific way that we could do that would be to continue to expand the Minority Fellowship Program by SAMHSA and currently spends about 200 fellows, but imagine if it was funding a lot more.

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I also would like to note that loan forgiveness and repayment would go a long way in helping the future and current workforce of mental and behavioral health.

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Next slide, please.

21:16

Now, to wrap up, I'd like to talk a little bit about supporting the current behavioral health workforce.

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Next slide.

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So, these are just a few headlines from, pretty much the last six months.

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Though, you're seeing a shortage of mental health care professionals in Texas, you're seeing a similar thing in California, and that hiring alone isn't going to solve the healthcare worker shortage, especially for behavioral health workers.

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It's also important to note that certain populations, including therapists that identify as black, Indigenous, and people, of color ARR and equitably, These things are and equitably experienced by providers from those groups.

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Next slide, please.

22:09

So, how can we begin to tackle what is this, a very huge and complex issue?

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I think the first thing that organizations can do is listen to the concerns and needs of behavioral health workers and co design strategies to alleviate the factors that are causing work distress.

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Many times, administrators don't really understand what life is like on the front lines or how certain operational decisions will affect day-to-day clinical practice.

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Providing opportunities for behavioral health professionals to voice their needs and concerns without fear is crucial to being able to address the issue of burnout.

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Last fall, SAMHSA released a resource that's a QR Code it on this slide about what organizations can do to address burnout among their behavioral health workers.

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For individuals, we've seen a lot of behavioral health workers building coalitions because they've learned that there's a lot of strength in numbers.

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And so we've seen a huge uptick in health workers organizing not just in behavioral health patient, but among other health professions as well, including physicians.

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Recently, a mental health clinicians at Kaiser Permanente facilities in California were able to negotiate a deal where they got additional hours to perform indirect patient care.

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So that I include patient calls and e-mails, tailoring treatment plans, or making referrals to social service agency, They were also able to negotiate more therapists, labor management committees, so that they have more of a say in the decisions that are made at their organization.

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It's also important to note that mental health professionals are helping people cope with some of the most stressful moments of their lives and we know that that takes a toll.

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So it's important to employ some of the strategies that mental health professionals teach others and that organizations provide time and space to do just that.

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On this point, I particularly think about mental health professionals who are just entering the field, and may not know how that's to take care of themselves while caring for others.

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In terms of different policies, strategies, we know that reimbursement rates are an issue and that they're unequal between physical health care and mental health care, and lastly, on the slide, I would really like to just talk about reducing barriers to practicing across state lines. And so, I live in the DC, Maryland, Virginia area. I live in Virginia. I work in DC, and that's the case for many in different areas around here.

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But now, that psychologists and in DC, Maryland and Virginia are all part of PSYPACT.

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They're able to apply to practice across state lines, and so it opens up my choice of provider in this area.

25:06

And the last thing I would like to note is that there's a similar contact coming. Starting for counseling in 20 24.

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Next slide, please.

25:17

And so, we would just like to thank you all for your time and place and I have put our contact information on the slide and links to the chapters and there's also one in the chat.

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And I'm happy to pass it on to the next presenter.

25:31

Thank you so much, Randall, and please for giving us that overview of the tracker and sharing a lot of important resources and strategies to improve diversity in the workforce.

25:44

Next, we will hear from Angela Weeks, Director of the National Center for Youth with Diverse Sexual Orientation, Gender, Identity, and Expression. We're so grateful she is with us today to share her perspective and expertise. Angela?

26:02

Yes, thank you for having me. I'm really glad to be here today.

26:08

And I will go ahead and jump into my slides the next slide.

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I'll be talking about LGBTQ populations. Our center focuses on LGBTQ people across the lifespan.

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And so I will talk a little bit about some of the unique experiences that LGBT LGBTQ people have that will require some special considerations for behavioral health care.

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Next slide.

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This is our Center of Excellence on LGBTQ plus Behavioral Health Equity. This is funded by SAMHSA, and I'll talk a little bit at the end of the presentation about some of the resources we have that we can share with you. Next slide.

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So if you haven't already worked with this population very closely, it's important to know that the population experiences unique vulnerabilities directly related to hostility violence and rejecting behaviors, specifically because of their sexual orientation, gender identity, or gender expression.

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And I'll talk a little bit about those on the next slide.

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So risk factors with this population are a lack of family acceptance and support. And in some cases, the LGBTQ person might lose their family entirely or be sort of forced out of their community. If they're living in a space, that's very anti LGBTQ, they may feel pressure, or even a need to move to another location, and so there's a lot of loss that comes with that.

27:42

High rates of bullying, harassment, and violence with this population are still very problematic. Bullying is LGBTQ related bullying is the number one bullying, you know, sort of topic or bucket, that young people experience. And in fact, over 90% of high school students report that they hear anti LGBTQ students stop at school on the regular.

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And then, as far as violence and harassment, it's prevalent.

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one example is that black trans women, or, really, trans women of color, are one of the most targeted groups in the US for hate crimes.

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There's also a lack of visible possibility models. So in other words, who, around me is LGBTQ that's living a healthy, open life?

28:28

So there's a lack of those models around lack of social programs, limited access to affirming care.

28:35

There's a lot of stigma, of course, associated with LGBTQ identity is that impact daily life, There's internalized biases as a result of all of these experiences, economic hardship, due to discrimination, which could be, you know, an ability to access affirming workplaces. It could be being fired because of an LGBTQ identity, and still in the United States, there are a lot of states that don't offer protections for people who identify as LGBTQ from workplace harassment, or even losing your job or housing. And then there's historical trauma and anti LGBTQ legislation to consider, as well.

29:12

So if you're serving older LGBTQ adults, they've lived through a time where LGBTQ identities were criminalized, where they were not able to build families and even discouraged from being around children, they were not able to marry. In many cases, lost lots of family lost brands, and entire communities to the aids epidemic, which was an epidemic. No one was rushing to help with, until it started affecting straight and ... populations. And so there's a lot of historical trauma there that impacts, even now, the mental health of LGBTQ older adults.

29:46

And right now, as we see a really huge uptake of anti LGBTQ legislation across the country, and there have been somewhere around 400 bills that have either been proposed debated.

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Some of them have passed.

30:00

that national debate about LGBTQ rights is also very stressful on the population.

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And so all of this leads to high rates of isolation, depression, anxiety, minority stress, and other mental health outcomes.

30:13

Next slide, there are protective factors, Easy access to affirming care is one of them, high self-esteem.

30:22

So, if there are programs or therapeutic practices that can help build self-esteem, learning, and applying coping skills, there are several therapeutic programs that do that, supportive family. And this could be family of choice, teachers, mentors, connection to other LGBTQ people, having positive role models, or even if that person is able to be a role model themselves.

30:43

Hope of transitioning to one's affirmed, gender, supportive communities, which includes supportive churches, schools, places of employment, and positive reactions when someone comes out or discloses their identity. Next slide.

31:00

There are gaps in behavioral health care.

31:03

There's a gap of affirming and competent providers. So I wish I had a map, you know, as shown by earlier, presenters, that would show how many LGBTQ competent and affirming providers are across the country. It's very few, and some, there are many counties that don't have anyone, In some cases, someone would have to travel hours to get to a provider. That is affirming of an LGBTQ identity and usually, it's concentrated in like the metropolitan area of the state.

31:31

There is a incredible lack of tailored programming and services, so all of those risk factors I just mentioned, you know, call for some tailored and culturally specific programming for the population that discusses the coming out process loss of family loss of community.

31:47

And there's really virtually, uh, hardly anything out there. There's a handful of programs that have been developed, but very few behavioral health providers have actually taken those programs and implemented them in their practices.

32:01

There's also hardly any intentional work with families of LGBTQ people.

32:05

And so oftentimes, LGBTQ people are told to, you know, cut off their families.

32:11

if they're not being accepting, move to a different town. Move to the big city, or find a chosen family. But little behavioral health work is actually done with the families of LGBTQ people to try to help get them to move along to a place of more acceptance and love.

32:26

And there are programs for that too. They're just not adopted very often by the behavioral health provider agencies.

32:33

There's also a lack of consistently collected health data for the population.

32:38

And I would be remiss if I didn't mention again that, you know, anti LGBTQ environments increase the risk of negative health outcomes for this population.

32:46

And as we see anti LGBTQ legislation being continuously proposed, it also makes it increasingly more difficult for LGBTQ people, particularly trans people to feel safe, disclosing their identities and needs to their providers. Next slide.

33:04

There's a couple of lessons that we've learned and evaluating several work belle's Workforce development initiatives. one is that training is a necessary first step, but it can't. It can't be the last step. It can't be the only step.

33:17

We've learned that if you have a training, you will most likely lose any gains you made around attitudes and behaviors about 3 to 6 months after the training. So there's a short window after training, where you want to get in, and you want to provide a coaching and reflective supervision and follow up content to help people retain the information and, and apply it to practice settings. So, training can't be the only thing.

33:43

As I said, consistent coaching and reflective supervision really, are what it's going to take to help people change their behaviors towards this population.

33:51

We've also learned through evaluation that virtual live training has a similar impact as in person training, which is great news for those who love virtual trainings. Self paced e-learning that people do on their own, also have gains across all areas that we've measured, though not as many gains as the live training, either virtually or in person.

34:12

Then many providers avoid conversations about LGBTQ identity because they're worried that they're gonna make a mistake, or that they're gonna feel they're gonna, it's gonna feel awkward to have these conversations. And so we've really learned the only way to overcome this is to practice. And so people need opportunities to practice through coaching or role plays to really get beyond that fear.

34:30

Next slide.

34:34

We also evaluated some Virtual groups, and if you want more information on on virtual groups for this population, have included two links in the slide.

34:42

But, what we found was that virtual clinical groups had similar outcomes to the in person clinical groups. which is great news.

34:49

We also found out this was only possible because of the pandemic, but we were able to compare in person and virtual of the of the same programs. And we found that there were higher retention among members, both families and LGBTQ, young people.

35:06

Also, being virtual enabled, the group members to use a different name or a photo to protect their own privacy. So if they were worried about someone finding out that they were LGBTQ, that just increased their access to be able to participate in virtual sessions, and then the program reach really extended into rural communities, which we hadn't been able to reach before. So those were some of the benefits of our virtual work.

35:30

Next slide.

35:33

And I just wanna give a shout out to some of the resources that are available to everyone here on the call. Our Center of Excellence provides free access to experts, updated resources. We have rapid technical assistance.

35:45

If you were to request TA, loads of free professional development in the form of live sessions, recorded sessions, and also self paced e-learning. And we offer provide opportunities for peer-to-peer learning, and you can get all of that through the Center of Excellence site. Next slide.

36:03

We also have a national ... center, which is a clearinghouse and repository of hundreds of resources across the country. And so there's really a lot to check out there. And then if you don't know where to look or where to get resources, you can always contact us, and we can connect you.

36:17

So that concludes my part of the presentation. And I'm going to pass it on to the next presenter.

36:26

Thank you so much, Angela, for sharing all that information and resources for how we can support behavioral health for LGBTQ individuals. Next, we will hear from doctor Caitlin Kenny Wash Senior Director of Policy and Research at the Blue Cross Blue Shield of Massachusetts Foundation. We're so honored to have doctor Kenny wash with us today.

36:52

Thanks so much. Thanks for the opportunity to be with all of you today as part of today's webinar. It's wonderful to be with so many leaders from organizations that are doing such thoughtful and meaningful impactful work in the behavioral health space. Next slide, please.

37:08

Next slide, please.

37:11

I had planned to talk through the agenda quickly, but I'm going to ask you to skip over again just in the interest of time. Thank you. Next slide, please. Before I launch, and I just want to tell you a little bit about the Foundation, our mission is to ensure equitable access to health care for all those in Massachusetts who are economically, racially, culturally, or socially marginalized. The way we do our work is really through two arms. I think of it as sort of our grantmaking arm where we provide grants to both support programmatic interventions, support, advocacy in advance of our mission, and also to provide general operating support in our other arm of work, our policy, and research arm. Our aim is to develop non partisan, objective educational materials, as well as analytic pieces with policy, suggestions all, intended to advance our mission. Next slide, please.

38:04

We organize our work really, in three key focus areas, which are depicted here. These three focus areas are coverage and care, paid rural health, which is the focus of my comments today.

38:19

And the report that I will really be focusing in on as well as structural racism and racial inequities in health, this latter 1 is 1 that we recently added in 2020. And while it is a separate focus area, we really try to embed a racial equity lens in all the work we do across all of our focus areas. Next slide, please.

38:39

So, highlighted on this slide.

38:41

Next slide, please.

38:44

I'll keep going just in the interest of time.

38:47

Highlighted here is just a sampling of work we have done that has reinforced, both from consumer perspectives and provider perspectives, that a primary reason people can't get behavioral health services when they need them is our behavioral health workforce crisis. And notably, these data also suggests that the need for services, and the challenges in accessing a provider who is considered a good fit, is more pronounced among adults who are from marginalized communities. That is, those who are in groups other than non hispanic white, and those who identify as LGBTQ individuals, very much in line with the comments and the data shared by my prior panel, by my co panelists.

39:27

In addition.

39:31

There is good news. The good news in Mass sorry, it's just a little disgruntled thrown off by the change in slides on the good news front in Massachusetts and in many other states. There's been a groundswell of movement towards behavioral health reform. on the both the policy and the funding fronts. Reform can't succeed without funding and not just funding, but sustainable funding depict it. Here are many of the state initiatives or financial resources that were aimed at, or available to, support behavioral health services or behavioral health workforce in Massachusetts. I won't go through all of them. But the American Rescue Plan Act was a significant source of funding, dedicating over $400 million to the state's behavioral health system. In Massachusetts, our State Medicaid program, known as MassHealth, included two provisions in its 1115 waiver extension, dedicated to investment, or repayment programs for the behavioral health workforce. Next slide, please.

40:32

At the same time, one of the challenges we frequently heard is that those initiatives are not co-ordinated or organized according to a strategic approach for addressing the behavioral health workforce issues over the long term. It is within that backdrop that we commissioned the report that I'll focus on today. We conducted this work in collaboration with ...

40:52

Health, intended to fill what we perceived as a gap in laying out a comprehensive strategy to address these problems and take advantage of opportunities in a co-ordinated way. Our project really had a multi-pronged approach. We included interviews with national and state experts in behavioral health, in workforce development, and or in diversity, equity, and inclusion.

41:14

We conducted a lit review of organizations with expertise that have prioritized work in this area, Conducted an inventory of behavioral health programs in Massachusetts and across the country. And where evidence existed, documented, what we knew about the efficacy of those particular programs. We've finally completed with a set of recommendations informed by these activities. I won't go through this in detail right now, just given time. But I do want to point to the fact that we used this framework, which was published in Health Affairs article, really, to guide the development of our interview guide. And the Organization of Bar Recommendations. That is to say, when you think about the behavioral health workforce, and not only expanding the behavioral health workforce, but also promoting retention through resiliency and it, and diversifying it, you really need to think about policies in each of these four quadrants: production, distribution, resilience, and maximizing potential. And, well, I won't categorize each of the recommendations that I'll discuss.

42:17

It was a key goal of ours to make sure that we were thinking through all of these key pillars as we developed recommendations. Next slide, please?

42:28

Aye, on this slide, are seven key recommendations that were developed as part of our report. If you can go to the next slide again, please. Thank you. I won't, in the interest of time, go deep on all seven of these recommendations. What I will do is go deep on Recommendations 1, 2, and four, but I do want to make sure I take a minute to address the remaining Recommendations 3, 5, 6, and seven. Despite the Federal Mental Health Parity and Addiction Act, we know that insurance reimbursement rates are often low for covered behavioral health services.

43:06

As compared to physical health services, a 2017 melanin study found that commercial, insurers in Massachusetts provided reimbursement rates for primary Care office visits that were almost 60% higher than reimbursement for comparable behavioral health office visits. We know that these disparities and reimbursement rates have cascading impacts that impact our behavioral health workforce. We routinely heard in this work and other work. That pay is a critical factor determining many deterring, many people from entering the field, or prompting shifts and sites of care provider's practice. That is in places where there are higher reimbursement rates, there are opportunities for greater salaries. This often has deleterious impact on community based organizations that might work and more marginalized communities, and we also recommended a multi-pronged strategy to dramatically expand the paraprofessional workforce. Paraprofessional workforce, as you can see here, is one that I'm representative of peers, community health workers, recovery specialists, and we think this workforce is critical to advancing health equity. I'm echoing some of the comments of Police in Randolph.

44:14

These individuals belong to the community they serve serve. They're able to identify and share experience with clients, with respect to race, ethnicity, culture, and language. And we really need to be more ardent in developing policy solutions that support financial stability for these roles and that enhance the pathways for career in these spaces.

44:35

Again, echoing a theme from one of my earlier panelists, we need to create a system of social supports for all members of the behavioral workforce. And this includes things that Randle mentioned around ensuring that we're supporting employees, providing service at providing behavioral health service with vicarious trauma, providing them the opportunity to prioritize self care, given what we know about burnout.

45:00

And lastly, while the recommendations was to fund an in-depth evaluation of the impact of telehealth on the behavioral health workforce, prior to March 2020, we know that less than 1% of behavioral health services were delivered by Telehealth. By August 2021, more than a third of behavioral health services were delivered by Telehealth. As Angela described, there are definitive benefits associated with telehealth. in addition to some of the ones she mentioned, we also know that telehealth expanded access for people who live in rural communities.

45:35

At the same time, we have heard of some adverse repercussions associated with the growth of telehealth particular. We understand that telehealth has created an opportunity for the development of private companies, which might offer enhanced salaries and or better work-life balance for behavioral health providers, all good things for staff and for employees. But oftentimes one unintended consequence of this has been a loss of behavioral health workforce in other settings and often in settings where there are already exacerbated shortages for behavioral health providers. Next slide, please.

46:14

I'm going to jump in now to a bit more of a detailed review of some of the other recommendations. The first one being conducting a baseline workforce needs assessment. We have multiple views into the problem.

46:27

Behavioral health workforce crisis, but we really need a comprehensive understanding of the current state to identify gaps and build the pathway out. I won't go through all of the recommendations pursuant to what we should include in this Behavioral Health Workforce needs assessment. I will point to the fact that there are examples from the field, including from my colleagues at the Mullen Institute around ways to kickstart this work. So, it is doable. But it really needs to be a multi-disciplinary working group of individuals across health and human service agencies, the Department of Education, the Executive Office of Labor and Workforce Development. As well as inclusive of people with lived experience from marginalized communities, to make sure that we have a sense of the prevalence and their risk of behavioral health conditions, and some of the challenges that have been experienced, as well as an opportunity to leverage existing data sources and grow upon them as well.

47:25

As was mentioned, we do have some data.

47:28

However, much of that data, blacks, for example, providers who might not be licensed professionals, we don't have a great deal of data on the peer workforce. And we also don't have a systematic way of collecting race, ethnicity, language, gender identity, other information. That's really critical, as we think about meeting the needs of our community writ large, and also specifically, communities that may have been marginalized. Next slide, please.

47:58

Armed with information from a comprehensive needs assessment and mindful of the initiatives that might be at play, both from a federal perspective and a state perspective. The next recommendation is to develop and fund. Again, fund a 10 year strategy for growing the behavioral health workforce. There are really three critical ways in which we're thinking about this strategy. And, again, some of these echo comments of my prior panelists, You know, we really need to minimize barriers, financial barriers to entry, and we'll go into the data. But there is specific data that's available from 20 20 nationally, indicating that people entering social work programs enter with significant burden of debt.

48:38

And that burden of debt is greater for individuals who are Black and for individuals who are White and greater for individuals who identify as Hispanic as compared to individuals who don't identify as Hispanic. If we want to diversify our workforce, we need to address these issues generally, and, specifically, in thinking about inequities facing communities of color. We recommend in our report that the state worked with colleges and universities to develop scholarship opportunities as opposed to, you know, loan repayment or grant programs, but scholarship opportunities that mitigate sort of the entry level barrier to following in the Behavioral Health Workforce tract.

49:16

We also think we really need to think about encouraging interest in this field. There's some really interesting examples of across the country. For example, in Montana, their AAC offers a heads-up behavioral health camp to expose high school students to careers in behavioral health And other ideas for sort of garnering this interest.

49:35

And exposure might be offering training to students in mental health first aid, training on suicide, or training on anti bullying as initial programs to generate exposure, awareness, and identify people who might otherwise be interested in this field and not know much about it. Lastly, we need to continue to monitor strategies to address them, all distribution of providers. And, when I say e-mail distribution of providers, I mean it comprehensive, like, not just geographically, but also in terms of provider type, in terms of providers that are, you know, working full-time in terms of thinking about the representation of providers by race, ethnicity, language, cultural affinity.

50:17

So, really thinking about a comprehensive strategy that last over the long term be enduring and be updated in the context of what other federal and state policies are emerging. And next slide, please.

50:34

Our last recommendation is to establish a behavioral health workforce center. A behavioral health workforce center could be responsible for all of the prior recommendations. But the really, the goal here is to have a centralized systematize entity that's responsible permanently for moving forward with the behavioral health strategy to serve as the central hub that can be mindful of taking note of evaluating behavioral health interventions that are proving effective or not as a mechanism to continue to share best practices to serve as a resource. You know, as funders, as policymakers seek to deploy new policies or investments as an entity that can provide guidance on those interventions that have been proven as the most effective.

51:26

And also to similarly provide on the ground TA for organizations seeking to implement behavioral health interventions or practices. Next slide, please.

51:39

So many of the recommendations that I summarized and, again, ended so quickly in an effort to try and keep some time here, are ones that will need to be implemented over the long term. So what do we do in the short term? You know what, where do we go from here? The Foundation has recently implemented a grant program that we're calling Advancing Community Driven Mental Health. This grant program is on that leverages, the problem management pluss model instituted by the World Health Organization, largely an under resourced countries.

52:11

And it's a really a program that intends to equip, lay non clinical people with basic skills, to help their community members manage everyday stress adversity, and to equip them with strategies to address those challenges.

52:29

That the benefit that we see in the short-term is creating a community work force that looks like the community serve, that is therefore approachable, That speaks their language, and that is armed with skills to help individuals mitigate some of the mental health or behavioral health mental health challenges that they may be experiencing. Ideally, this helps to reduce potential acute behavioral health conditions and mitigate, you know, pressure on the behavioral health care system, providers who might need to be available for, you know, more acute behavioral health or mental health conditions. So, with that, I'm gonna wrap it up to leave at least a little time, and thank you again for the opportunity to speak with you.

53:16

Thank you, doctor ..., for sharing all your work at Massachusetts to grow diversity and capacity of the workforce. We'd like to use our remaining time to engage in a Q and A session.

53:28

You can submit your questions in the Q and A tab, I'll ask our panelists to come off mute and back on video and we had several questions come in about telehealth, a few of our speakers.

53:43

Shauna, could you talk about how the increase in telehealth you said just contributing to burnout as well as well as how it can continue to help address workforce shortages?

54:00

I can, I can start. We had done a lot of interviews with employers, the behavioral health specialist, for the ones that typically employed served Medicaid beneficiaries.

54:12

And one of the things that they're pointing out was a real challenge is that they are actually losing some of their workforce to go off and provide telehealth services.

54:21

And so, while that's expanding access to telehealth for some populations, it's coming at the expense of Medicaid beneficiaries, and creating concerns about burnout and and inadequacy of the workforce or the Medicaid population specifically, because those organizations just can't compete with the salaries and the lifestyle that's offered through the telephone.

54:44

So the providers who aren't going to offer dental health may actually have better work-life balance and the ones who are engaging in activities.

54:58

I can speak a little on that point, too.

55:02

I think there's also a difference between, let's say, for-profit organizations like Talk Space that are employing behavioral health workers and ARR.

55:14

They are significantly underpaid compared to other providers, and so in that same vein, they are working more to trying to see more clients. And so I think that's something that we just kind of need to be on the lookout for.

55:35

I would also add, I think many of these comments surfaced in my presentation, but a benefit that we've seen from Telehealth is forcing some of our rural community based organizations. They've been able to really use Telehealth as a means to do a consult with other providers that can offer expert expertise, expert insight on the ground in a way that may not have previously been available in Massachusetts. And so, again, those are some of our, you know, community based organizations that might be serving some Medicaid enrollees or others, and this has facilitated a mechanism to bring in that expert consultation.

56:16

Great, that's actually a great segue into the next topic area. We had a few questions. I know, Randall, you mentioned fellowships as one strategy. Are there other effective strategies for recruiting mental health professionals to rural areas?

56:38

That's a good question. And I can't speak specifically to rural areas with some of the work that we've done.

56:47

I do think that it kind of reminds me of what we're just talking about around telehealth as a potential to like expand access. But, I think, beyond that, like more globally, we're like, we need to think about expanding broadband access, because I think that's something that's super important. And, of course, that's not, you know, housed within the healthcare system.

57:13

But if we could expand broadband access, that would allow behavioral health providers to reach rural areas.

57:24

I can add on to that, too.

57:26

I was involved in a study that was funded by HRSA that looked at, it's a telehealth on a different format, is telehealth vacation. So people who are completing their social work programs, online programs, and those graduates were more likely to work in rural areas after they completed their training and professional training.

57:44

So, investing more in creating training opportunities, that can happen online, I think is a big component.

57:50

Then also, the National Health Service Corps is just a huge draw, an increased funding that's gone into the National Service Corps over time, A lot of it has been focused on the mental health workforce, and you can see that they're really going into underserved communities.

58:08

Hmm, Question for Angela Weev, we've heard a lot of data today, but also talks about a need for more data. This question is about, if the data is not there, how how do we get a better understanding of the mental health needs and the LGBT community, and then how can we measure, if we're meeting that need to have any advice?

58:32

Yeah, I would suggest that if you're not already collecting the data, that you take a look at some of the resources out there that can help get you started. So, there's some checklists to measure readiness, to give you some ideas about how you could collect the information and safe and competent ways, there's even scripts and forms that you can borrow offline. And, so, you can go to the websites, I mentioned earlier, to get access to those. But there's, everyone has to start somewhere. So, if you're not already doing that, there's plenty out there that you can lean on.

59:05

You, we have a lot of great questions here, but we are at the end of our time, so we will share those with the speakers, especially those that are some specific to their organizations and resources.

59:18

So, I want to thank our excellent panelists, speakers for being with us and sharing all this great work. Thank you to our audience for joining our discussion. Your feedback is important to us. Please take a moment to complete a brief survey that will open on your screen after the event.

59:37

Please also stay tuned, and we'll be coming out with an infographic on the mental health workforce, and we also have a webinar coming up on May 10th on children's health. And that will also touch on children's mental health. I know there are a few questions on that that we didn't get to today, but thank you all again, so much for joining us today.