Demand for behavioral healthcare in the United States is greater than ever, taxing the already strained capacity of the broad range of professionals who provide prevention, treatment, and recovery services for mental health and substance use disorders.
How can the behavioral health workforce be optimized to meet this increased demand for the care it provides? Angela Beck, Ph.D., M.P.H., director of the Behavioral Health Workforce Research Center at the U-M School of Public Health (SPH), and Clinical Assistant Professor of Health Behavior and Health Education, SPH, studies issues related to access, reimbursement, and capacity of the behavioral health workforce in the United States, work that is informing key workforce development and planning efforts.
Why is it a particularly important time to be studying this workforce?
Between mental health and substance use parity laws and ACA Medicaid expansion, the demand for behavioral health services has risen significantly in recent years, exacerbating what was already a shortage situation due to both insufficient numbers and uneven distribution of behavioral health providers. This workforce, which includes a broad range of professionals from psychiatrists to social workers to peer recovery specialists, provides critical services to support the mental and emotional well-being of millions in this country.
We don't see evidence of a magic answer to these supply and demand challenges – there's no influx of workers coming in to the field that we can predict at this point – so we've got to turn our attention to how we can monitor better, how we can project better, and how we can use the workforce and resources we have more effectively. To remedy some of the access issues that pervade behavioral health care, effective workforce planning and policymaking demands timely and usable data about the workforce that provides these services, and that’s what our center aims to provide.
What are the issues your center is looking at?
One of the most policy-relevant issues is around scopes of practice for behavioral health professionals, in other words what licensing and other regulatory boards are permitting their providers to do state-by-state. This gets into questions about whether various professionals are able to practice to the full extent of their training, which providers can be directly reimbursed and for what services, and how those scopes of practice can either be a facilitator or a barrier to service delivery models like team-based care.
As an example, nurse practitioners may get waivered to provide medication-assisted treatment for opioid use disorder, but if their state’s scope of practice restricts them from performing all of those duties independently, the policy is effectively limiting capacity despite the great need and demand for this service.
Scope of practice is really important when thinking about workforce capacity and leveraging resources to more effectively meet demand for services. One resource we’ve developed is a comprehensive data visualization tool that displays state-by-state characteristics of the behavioral health workforce. We know there's variability across states and across professions, and understanding those patterns is an essential starting point to consider what that means for service delivery and patient outcomes.
How is your research trying to address the challenges posed by the opioid epidemic?
This is a public health emergency that has certainly increased demands on an already overtaxed and unevenly distributed workforce. We’re working to better characterize behavioral workforce shortages and maldistribution to help policymakers at the state and federal levels determine how to allocate resources in a way that can maximize their response to the epidemic. Part of that is putting more emphasis on understanding which workers across the disciplines are trained to address components of opioid use disorder. While a lot of the attention has been on the important role of prescribers, we also need a better understanding of the other various members of a care team who are needed to coalesce to effectively solve this problem.
How would you characterize recent trends in the behavioral health workforce?
Overall, we continue to see a downward trend in absolute numbers of professionals, although we do see some specific disciplines starting to gain, for example psychiatric nurses. I would say the biggest change over the last ten years or so is a more intentional integration of peer support workers and community health workers to provide services to clients, and we’re seeing an increasing movement toward credentialing and evidence of reimbursement for these professionals too. Going forward the peer workforce will become an increasingly important component of the care team and the behavioral health workforce at large.
Why is broadening access about more than increasing numbers of providers?
It's not just the absolute numbers but where professionals are located and trying to figure out how we can address needs in those areas that simply don't have a behavioral specialist that's accessible at all. We find that, similar to other healthcare fields, professionals who train in rural areas tend to stay and practice in rural areas, so we need to figure out how to get more education and training resources in those places. We’re engaged in a national qualitative study with the Center for Health & Research Transformation that's looking at the elements of recruitment and retention packages that states are using to pull behavioral health providers into those areas of poor distribution with the aim of developing a best practice toolkit around a rural health workforce strategy for behavioral health.
Recruitment and retention in this field are generally pretty tough; it’s lower paying than many of the other healthcare professions, and there’s a fair amount of burnout and even stigma attached to working in this field. Addressing some of those root causes of workforce shortages and maldistribution in behavioral health means that we need to be thinking more about the ‘quadruple aim’ in healthcare that includes a focus on worker satisfaction and well-being of the workers themselves.
What’s the potential role for telehealth in behavioral health service delivery?
Like many other fields exploring telehealth’s potential, behavioral healthcare is trying to answer questions about regulation, oversight, and reimbursement, and particularly finding a balance between spreading access meaningfully but ensuring quality of care. As one example, we’re conducting a study to better understand telehealth’s role in potentially expanding access to medication-assisted treatment for opioid use disorder. In those areas that have few behavioral health workers, primary care workers are your behavioral health workers, and not trained in the specialty to fully provide all of the services. So, how do you continue to leverage the good work of the primary care providers, but provide enough support that they're not having to be the sole source of care for some pretty complex cases? What role can telehealth play in that?