Keynote Panel:
Perspectives on the Behavioral Health Workforce

Howard H. Goldman, professor of psychiatry, University of Maryland School of Medicine, moderated the keynote panel focusing on the critical issues facing the behavioral health workforce. Goldman emphasized the multifaceted challenges confronting the field, particularly in the context of workforce development and retention and the implementation of evidence-based practices. As he introduced the panelists, he pointed out that the decision to use a panel format instead of a traditional keynote speech was intentional and designed to reflect the interdisciplinary nature of the challenges and bring together experts from different sectors to provide a comprehensive overview.

Angela Beck, vice president of health equity and engagement at ChenMed, provided an analysis of the behavioral health workforce, focusing on its current state, challenges, and areas for improvement. She began by offering a broad definition of the workforce, which includes a wide range of occupations involved in preventing and treating mental health conditions and substance use disorders. This workforce, according to Beck, encompasses not only core licensed professionals, such as psychiatrists, psychologists, and social workers, but also peer support specialists, community health workers, case managers, and other essential service providers.

Beck highlighted the significant challenges faced by this workforce, emphasizing the issues of shortage and maldistribution. She noted that as of 2023, 169 million people were living in areas designated as mental health professional shortage areas by the Health Resources and Services Administration (HRSA, 2023). The shortage is acute not only among core licensed professionals but also within other segments of the workforce important to behavioral

health care delivery. She said that one of the most pressing issues is the need for a better understanding and documentation of the workforce’s full composition. Research has largely focused on the core licensed occupations, leaving significant gaps in data and knowledge about other vital segments, such as peer specialists and community health workers. This incomplete information hampers efforts to address shortages and maldistribution effectively, she said.

Beck emphasized the maldistribution of the workforce as a critical barrier to care access, particularly in underserved areas where the need for behavioral health services is greatest. She underscored that the estimated need for 300,000 additional workers over the next 15 years (HRSA, 2024b) does not even account for unmet needs, which disproportionately affect people of color, individuals with lower socioeconomic status, and historically underserved populations. She said that the fragmentation within the field and its siloed relationship with the broader health care system exacerbates the challenges of workforce capacity and hinders integration of behavioral health into primary care and other health care settings. Overcoming these silos is essential for developing a more cohesive and effective workforce that can meet the complex needs of patients across different care settings, she said.

Beck expressed optimism about the increased attention and emphasis in recent years on behavioral health and the associated workforce. She observed that the conversation is shifting from convincing payers and policy makers of the importance of a robust workforce to discussing practical solutions for addressing the workforce shortage. She called for systemic reforms that focus on both expanding and better distributing the workforce, ensuring that all segments are equipped to meet the challenges of the evolving health care landscape.

Alex Briscoe, principal at California Children’s Trust, provided an overview of how the evolving health care landscape influences the behavioral health care workforce and discussed innovative strategies to enhance its capabilities and service delivery. Briscoe highlighted Medicaid’s central role in behavioral health services, pointing out that it is the largest payer for mental health care services (CMS, n.d.). He detailed the shift over the last 2 decades toward a managed care model, which has fundamentally changed the regulatory and operational framework within which services operate. This shift, he argued, presents both opportunities and challenges, especially in how workforce requirements and service delivery models are structured.

Briscoe then discussed the transformative impact of the COVID-19 pandemic on behavioral health service delivery, notably the rapid adoption of telehealth. He explained how emergency measures during the pandemic led to a significant shift from face-to-face to technology-enabled services. This shift, while necessary, exposed and sometimes widened gaps in regulatory frameworks, particularly around network adequacy and the timeliness of care

standards. He noted that these changes have made traditional regulatory measures somewhat outdated, necessitating a reevaluation of how these services are delivered and regulated.

He also discussed the misalignment between the behavioral health workforce and the actual needs of the communities it serves. He pointed out the demographic mismatch in many areas where the majority of Medicaid recipients are people of color, but the licensed workforce is predominantly White. Briscoe emphasized the importance of diversifying the workforce to provide culturally congruent care, which has been shown to improve patient outcomes. He provided examples of how states, particularly California, are using Medicaid to innovate and expand the types of reimbursable care providers within this sphere. He detailed the creation of new types of behavioral health care providers, such as community health workers, peer counselors, and wellness coaches, all aimed at expanding access and making the workforce more reflective of the communities it serves. These changes, he argued, are crucial for democratizing the delivery of behavioral health care services and addressing systemic inequities.

Vincent Guilamo-Ramos, executive director of the Institute for Policy Solutions and director of the center for Latino adolescent and family health at the Johns Hopkins School of Nursing, focused on addressing health equity and the social determinants of health (SDOH) within the behavioral health workforce. He highlighted the persistent inequities in health care, emphasizing the need for systemic changes to improve outcomes for marginalized communities.

Guilamo-Ramos began by underscoring the significant U.S. health disparities, particularly affecting racially and ethnically minoritized groups. He referenced a 2024 report that revisited findings from the 2003 report on unequal treatment (IOM, 2003). The new report highlighted that despite some advancements, substantial inequities remain, largely due to structural and systemic barriers that continue to disadvantage minority communities (NASEM, 2024b).

A major focus of his remarks was on SDOH, which include housing, education, and employment, and how these influence health outcomes. Guilamo-Ramos pointed out that SDOH are often overlooked in policy and practice but are crucial for understanding and addressing health disparities. He argued for a health care model that integrates social care, focusing on not just clinical interventions but also improving the conditions that contribute to health disparities.

Guilamo-Ramos called for health policies that are not only responsive but also proactive in addressing the needs of marginalized populations. He emphasized the importance of implementing and scaling evidence-based strategies that have been shown to reduce disparities but have not been adopted broadly or integrated effectively into health care systems.

A final point of Guilamo-Ramos’s presentation was the need for a culturally competent workforce. He stressed the importance of training health professionals to be aware of and sensitive to patients’ cultural and social backgrounds, which is essential for effective communication, diagnosis, and treatment. This includes expanding the workforce with health care providers from underrepresented groups, who can bring beneficial perspectives and experiences to their practice.

Eduardo Vega, executive director of the Palliance Institute for Peer Support and Lived Expertise and CEO of Humannovations, began by sharing his own experience and the unique insights and empathy that individuals with lived experience bring to this workforce. He said that personal experiences with behavioral health issues provide a profound understanding of the patient journey, which can enhance the therapeutic relationship and improve care outcomes. Vega highlighted the growing recognition of peer support roles in behavioral health services.

Despite evidence of its benefits, Vega pointed out several barriers to the full integration of individuals with lived experience into the behavioral health workforce. These include stigma, both within health care settings and broader society, and regulatory and educational hurdles that make it difficult for peer support workers to gain recognition and advancement in their roles. He called for changes in training and certification processes to make them more inclusive and accessible to individuals with nontraditional backgrounds.

Vega emphasized the importance of shifting from a purely clinical model of mental health care to a community-based model that prioritizes prevention and early intervention. He argued that approaches that incorporate peer support are more effective in reaching underserved populations and addressing the root causes of issues before situations escalate into crises.

Sergio Aguilar-Gaxiola, professor of clinical internal medicine at the University of California, Davis, and founding director of the Center for Reducing Health Disparities, focused on the challenges facing the behavioral health workforce in rural areas and the potential of technological innovations to address them. He began by highlighting the significant barriers to care access in rural areas, especially for immigrants and farmworkers. He noted that rural populations often face a severe shortage of behavioral health professionals, leading to significant unmet needs. This shortage is compounded by factors such as geographic isolation, limited transportation options, and a lack of culturally and linguistically appropriate services, which contribute to the higher prevalence of untreated mental health conditions and substance use disorders in rural compared to urban communities.

To address these challenges, Aguilar-Gaxiola emphasized the importance of changing the prevailing mode of behavioral health service delivery from “waiting” to “seeking.” He advocated for an innovative approach that lever-

ages technology to expand access to care using digital health navigators who engage with individuals in their communities—where they live, work, and congregate—to provide preventive health services and screenings, including for depression. Funded by HRSA, his Digital Health Equity Project¹ has implemented this model over the last 2 years in migrant housing centers and Federally Qualified Health Centers (FQHCs), representing a complete shift from traditional, clinic-based care to a more proactive, community-oriented approach. Aguilar-Gaxiola highlighted the efficacy of this model in providing care to underserved populations by integrating preventive health services with mental health screenings. He also pointed out the role of telehealth in reducing barriers to care, noting that telebehavioral health services can overcome geographic and logistical challenges, making it easier for rural populations to access care.

DISCUSSION

Goldman asked about nontraditional workers (e.g., doulas, promotores de salud,² community health workers, peer counselors, cultural brokers) and whether the current conceptions about differentiated functions for various qualified health professionals (psychiatrists, psychologists, social workers, nurses, etc.) make sense for a changing behavioral health landscape. Aguilar-Gaxiola noted a need to adjust to the realities of the current demand for services and said that changes are already underway, giving the example of licensed professionals providing services in rural areas. Beck concurred that the focus should be on how various members of the workforce can bring skills that complement each other to optimize capacity. She emphasized the importance of focusing less on workforce composition by category and more on collective skills and ensuring that regulatory and payment models allow for efficient operation. Briscoe warned against a false choice of engaging traditional or nontraditional workers—recommending a focus on models of integrated teams with “extenders” and licensed clinicians. Vega supported the role of those with lived experience for their unique contributions, especially in reaching individuals who might be reluctant to engage with traditional health care providers.

The keynote panelists highlighted the complexity of the challenges facing the workforce and noted different approaches that include workforce develop-

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¹ See https://health.ucdavis.edu/crhd/projects/digital-health-equity (accessed September 15, 2024).

² Promotores de salud (health promoters) are community members who serve as liaisons between their communities and health care providers. See https://visionycompromiso.org/who-we-are/who-are-promotores/ (accessed September 16, 2024).

ment, policy reform, integration of care, and a commitment to health equity. Highlights from this panel can be found in Box 1. The insights from the panel set the stage for further discussions throughout the workshop, focusing on opportunities to develop actionable strategies to build and sustain a robust workforce capable of meeting the behavioral health care needs of the broad population in the United States in the 21st century.