October 28, 2024
CHDI's Jason Lang, PhD and Aleece Kelly, MPP recently collaborated with lead author, Michael Hoge, PhD as well as Manuel Paris, Jr., PsyD (both of the Annapolis Coalition on the Behavioral Health Workforce and Yale School of Medicine) to co-author a paper in the journal Psychiatric Services.
In their Open Forum piece, "State Policy Strategies for the Workforce Emergency in Behavioral Health," the authors highlight seven key policy strategies being used by states across the country to strengthen, grow, and diversify their behavioral health workforce. They also urge states to "seize this moment" of national attention on behavioral health to put these strategies in place.
As part of our ongoing series on how Connecticut can address the behavioral health workforce shortage, we're sharing a brief summary of the review here and highlighting what some of these policies might look like in Connecticut. Read the full article in Psychiatric Services here (may require institutional or library access).
The seven strategies highlighted by the authors include:
As we've discussed in the other posts in this series, low Medicaid reimbursement rates and insufficient grant funding for behavioral health services are major factors behind the current workforce shortage, particularly among the nonprofit community-based providers serving families with lower incomes. Many experienced clinicians have moved to private practice or left the field altogether in search of higher pay.
Many states have begun increasing reimbursement rates and/or grant funding to help providers improve staff compensation, recruitment, and retention (in fact, the authors note, a recent KFF survey revealed that nearly two-thirds of states have enacted fee-for-service Medicaid rate increases to attract or retain behavioral health providers). Maine, for example, raised rates for behavioral health services by 22% in 2023 and transformed its rate-setting system to ensure rates would keep up with inflation and the costs of providing care over time.
As CHDI's Jeff Vanderploeg, PhD discussed in a post earlier this year, this strategy should be a priority for Connecticut. A recent study of the state's Medicaid rates by the Department of Social Services (DSS) revealed that rates for behavioral health services are alarmingly low compared to similar states, averaging just 62% of those in similar states.
In addition, as Kelly pointed out in a blog post last spring, rate increases should be instituted across the entire spectrum of behavioral health services - including outpatient settings, intermediate levels of care, and more intensive inpatient and residential settings - because delays and shortages at any point on this continuum can affect all other levels of care. In past years, rate increases have often been done in a more piecemeal approach.
Learn more about the need to increase reimbursement rates in Connecticut in Recommendation 1 of the Strategic Plan.
Lang, Kelly, Hoge, and Paris note that several states have established permanent behavioral health workforce development centers to manage ongoing efforts to "build and sustain a workforce of sufficient size, diversity, and skill to meet current and future needs." These organizations are typically responsible for areas such as workforce assessment, strategic planning, funding, and overseeing the implementation and evaluation of workforce development initiatives.
The Behavioral Health Education Center of Nebraska (BHECN), established in 2009, was one example noted for its comprehensive workforce development initiatives in high schools, colleges, professional schools, residency programs, postdoctoral fellowships, and with community-based providers. Initiatives include education and training, expanding supervision opportunities for provisionally licensed clinicians, expanding telehealth in rural areas, and more. In a funding model that could be adopted by other states, the Center was able to leverage initial state funds to receive additional federal and private foundation grants to ensure long-term sustainability.
Connecticut established a similar center for the nursing workforce in 2013, but does not yet have one dedicated to behavioral health.
Learn more about the potential role and structure of a behavioral health workforce development center in Connecticut in the Strategic Plan released last year (see Recommendation 3).
As the authors write, "Effective workforce development requires a thorough, cross-agency, multi-stakeholder strategic plan that addresses initial training and education, licensing, recruitment, retention, and continued professional development." They cite Colorado's SB22-181 as a strong example of a legislatively mandated behavioral health workforce plan. It includes strategies to increase workforce diversity, expand the peer support workforce, expand credential portability, and reduce administrative burden on staff, among others.
In 2023, CHDI developed such a plan for Connecticut in partnership with the Children’s Behavioral Health Plan Implementation Advisory Board, funded by the State Department of Children and Families (DCF). While the plan is specific to the children's behavioral health workforce, its strategies and recommendations are applicable across the field. However, most of its recommendations have not yet been adopted or mandated by the state legislature. Read the strategic plan for Connecticut here.
"For the first time in generations, the workforce challenges in behavioral health have the focused attention of legislative and executive branch leaders in many states... States should seize this moment to learn from each other's policy decisions, strengthen their workforces, and share [the outcomes] with each other." - Hoge, Kelly, Paris, and Lang
To provide immediate, direct assistance to behavioral health agencies for staff recruitment and retention, some states have expanded grant funding and incentive payments. The funding is often targeted to agencies that primarily serve the uninsured or publicly insured (Medicaid/Medicare) and/or to increase workforce diversity. The authors cite Oregon's "workforce stability grant" program to boost employee compensation, recruitment, and retention as a strong example for other states to consider.
CHDI Director of Implementation Jack Lu, PhD, LCSW discussed how this strategy could work in Connecticut in his post on how Connecticut can retain its most experienced clinicians earlier this year. Find additional details in Recommendation 2 of the Strategic Plan.
The authors note that increasing funding for behavioral health education programs, internships, continuing education, and training in evidence-based practices can "increase the number of individuals entering the field, help workers maintain their licensure and certification, promote advancement, and increase effectiveness of the services that workers provide."
They cite Maryland as one example of a state that recently created a behavioral health workforce investment fund. In addition to providing additional funding for education and training, the Maryland fund must track and report on its outcomes, including diversity measures, to ensure the funds are being prioritized effectively and equitably where they are most needed.
CHDI's Kellie Randall, PhD and Katie Newkirk, PhD discussed some of the specific training needs of Connecticut's behavioral health workforce - and particularly for newer clinicians - in their recent blog post. Find additional details in Recommendation 5 of the Strategic Plan.
Many behavioral health clinicians and students entering the field - especially those from historically marginalized backgrounds or families with lower incomes - are facing increasing tuition and high levels of student loan debt.
Connecticut's CT Health Horizons program, of which CHDI is a partner, is cited in the article as a strong example of a state program providing tuition assistance for the state's social workers, nurses, and psychiatric nurse practitioners. Prioritizing bilingual students and students of color and those with current salaries below the state's living wage, the program offers $10,000 in tuition assistance per student.
In May 2024, the state also launched the Connecticut Student Loan Repayment Program, which offers up to $50,000 in student loan repayments for eligible healthcare providers - including behavioral health providers - who commit to practicing in underserved communities for at least two years. This initiative will especially benefit the clinicians working in nonprofit community-based clinics serving the state's highest-need families.
Recommendations 4 and 6 in the Strategic Plan describe these and other strategies to grow, diversify, and retain the behavioral health workforce.
Investing in the non-clinical direct support, peer support, and family advocacy members of the workforce is a smart strategy to expand access to services while strengthening and diversifying the behavioral health field, the authors say. They cite California as an example, highlighting that state's peer workforce investment grants designed to strengthen peer-run, nonprofit behavioral health agencies and increase recruitment of bilingual and BIPOC staff.
CHDI has promoted expanding the direct support, peer support, and family advocacy workforces in the children's behavioral health field specifically. The Children’s Behavioral Health Plan Implementation Advisory Board has recently endorsed a project to be led by CHDI, with funding from DCF, to develop recommendations and an accompanying action plan to expand family and youth peer supports within the children’s behavioral health workforce.
Learn more about possible strategies to expand the peer support and family advocacy workforces in Connecticut's behavioral health system in Recommendation 7 of the Strategic Plan and our 2023 Issue Brief. You can also learn more about the peer support and community health workforces in this 2024 report from the CT Health Foundation.
The article concludes with a call to action for states - and for the researchers and clinicians advocating on behalf of the behavioral health workforce and their clients.
"For the first time in generations," they write, "the workforce challenges in behavioral health have the focused attention of legislative and executive branch leaders in many states... States should seize this moment to learn from each other's policy decisions, strengthen their workforces, and share [the outcomes] with each other."
As the influx of pandemic-related federal funding to help states strengthen behavioral health services begins to wane - and with future political support for federal funding of human services up in the air - the authors urge state policymakers and advocates to act sooner rather than later.
"The opportunity is now," they write. "Time is of the essence."
Read the full article, including an online supplement highlighting 140+ additional state policy examples, in Psychiatric Services, Volume 75, Issue Number 9 (may require institutional or library access).
Strengthening the Behavioral Health Workforce for Children, Youth, and Families: A Strategic Plan for Connecticut (CHDI Report, November 2023)
Blog: "To Improve Access and Build Connecticut’s Behavioral Health Workforce, We Need to Talk About Reimbursement Rates." (Jeff Vanderploeg, PhD, CHDI Blog, 2024)
Blog: "Connecticut is Losing Our Most Experienced Community-Based Behavioral Health Providers. Here’s How We Can Keep Them." (Jack Lu, PhD, LCSW, CHDI Blog, 2024)
Blog: "Helping New Clinicians Navigate a Strained Behavioral Health System: A Recipe for Success." (Kellie Randall, Phd and Katie Newkirk, PhD, CHDI Blog, 2024)
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Jason Lang, PhD - Chief Program Officer jlang@chdi.org |
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Aleece Kelly, MPP - Senior Associate akelly@chdi.org |
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