Session 5

Challenges Across Different Settings

Session 5 highlighted the complex and varied challenges faced by the behavioral health workforce across different settings. Several speakers emphasized the need for context-specific solutions that address the unique needs of each environment, whether that be cultural competence in Indigenous communities, services in local schools, or adequate resources for special populations or in rural areas. Speakers discussed a coordinated effort that includes state policy reforms, increased funding, and innovative approaches to workforce development and service delivery to address these challenges. See Box 6 for additional highlights.

RECRUITING AND RETAINING NATIVE AMERICAN CARE PROVIDERS IN BEHAVIORAL HEALTH SETTINGS

Laurelle Myhra, director of Mino Bimaadiziwin Wellness Clinic in Minnesota (owned and operated by the Red Lake Nation), highlighted her experience directing the clinic and focused on the challenges and strategies related to recruiting and retaining Native American care providers in behavioral health settings. She noted the importance of culturally competent care and the need for a workforce that reflects the communities it serves.

In describing the clinic, Myhra emphasized the integration of mental health and chemical health services.¹ The clinic offers a range of adult and pediatric mental health services, and (in collaboration with the nearby Native American Community Clinic) medication-assisted treatment and intensive

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¹ Chemical health services help adolescents and adults struggling with substance use. See https://www.redlakenation.org/chemical-health/ (accessed October 17, 2024).

outpatient treatment programs, which she said are critical in addressing the high rates of substance use disorders within Native American communities. In addition to health services, the clinic has 110 units of housing onsite, and for 24 of those, it provides targeted case management and housing support services. She said that these services are essential for addressing the SDOH that often contribute to poor health outcomes in Native American communities; the clinic helps to stabilize the lives of its patients, making it easier for them to engage in and benefit from behavioral health services.

Myhra began her discussion of workforce issues by describing the effort to increase the representation of Native American care providers at the Mino Bimaadiziwin Wellness Clinic. She shared that 82 percent of the providers and staff are Native American, a significant achievement given the historical and ongoing challenges in recruiting Native American professionals in the health care sector. She said that a key strategy was developing strong partnerships with local master’s programs. In addition, these partnerships create a pipeline for Native American students by offering practicums, where they gain experience as care coordinators and in case management roles. Myhra said that this dual approach provides practical experience and helps to secure employment for students after graduation. The clinic actively hires Native American staff in various roles, helping them advance into specialized positions within behavioral health, said Myhra. Additionally, they engage in community outreach to local undergraduates and faculty, inviting them to learn about the clinic. Myhra emphasized the importance of creating supportive environments that encourage professional growth and development among staff, which helps to retain them in the long term.

Myhra also addressed the challenges in retaining Native American care providers. She discussed the emotional and psychological toll on health care providers, especially those from Native American communities, which can lead to burnout and turnover if not adequately addressed. To mitigate these challenges, Myhra emphasized the need for cultural support for Native American health care providers, including spaces to connect with their heritage and receive peer support for the unique pressures of working within their own communities. Additionally, the clinic offers clinical supervision and support services that are sensitive to their cultural needs. Myhra also highlighted the need to address racial trauma in the workplace. She emphasized that understanding and addressing racial trauma is crucial for both health care providers and the clients they serve.

PSYCHIATRIC ADVANCED PRACTICE NURSES FOR SCHOOL-BASED MENTAL HEALTH SERVICES

Laura G. Leahy, a board-certified child, adolescent, and adult psychiatric and addictions APN and the founder of APN Solutions LLC, a private practice in Sewell, New Jersey, began by emphasizing that 50 percent of all long-term mental illness begins before the age of 14 (Lipari et al., 2016). She highlighted the alarming statistics regarding youth mental health: one in six children aged 6–17 has a diagnosable mental health condition,² and one in five children has seriously considered suicide, with one in 10 making a suicide attempt (CDC, 2022). These figures underscore the critical need for mental health services that are accessible and effective for children and adolescents. She noted that only about 20 percent of youth receive any kind of psychiatric treatment.³ About 42 percent of public schools offer mental health treatment (Schaeffer, 2022), but, again, that can be through a guidance counselor. Some may have a substance use counselor; others may have a licensed clinical social worker on staff.

Leahy then shared her experiences implementing school-based behavioral health services over the past 25 years. She has worked with a diverse range of school districts, from those serving migrant workers to wealthy communities, each with unique challenges. With a Psychiatric Advanced Practice Nurse’s consultation, the district to which she consults was able to maintain 25 students with autism spectrum disorder and behavior disabilities within the district, saving the district $1.7 million. Leahy also discussed the challenges associated with providing behavioral health services in school settings, including resource constraints, the lack of training and support for school staff, the lack of access to community-based treatment resources, and issues around scope of practice.

Her approach to school-based services includes providing bi-monthly consultations to a district serving 3,200 students, ranging from pre-K to 8th grade. Her model emphasizes multidisciplinary collaboration among school staff, students and families, administration, including guidance counselors, social workers, and special education teachers, to comprehensively address mental health needs. Leahy’s role involves performing psychiatric evaluations, making referral recommendations, consulting on complex cases, providing psychotropic medication management for children at risk of losing school placement, providing clinical guidance, and supporting staff in managing

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² See https://www.aafp.org/news/health-of-the-public/20190318childmentalillness.html (accessed October 14, 2024).

³ See https://www.cdc.gov/childrensmentalhealth/access.html (accessed September 30, 2024).

difficult behaviors and mental health crises. She also emphasizes the need to customize interventions to meet the specific needs of each school district. This involves understanding the unique demographics, cultural factors, and challenges of each community. Despite no formal studies documenting the effectiveness of the intervention, anecdotally, Leahy observed significantly reduced staff injuries and violence, school suspensions, and special education placement costs.

She concluded by encouraging other clinicians and policy makers to consider the school-based model utilizing Psychiatric Advanced Practice Nurses as a viable and effective way to address youth mental health needs. She emphasized that while the challenges are significant, the benefits of early, accessible mental health care in schools are far reaching and can have a lasting positive impact on individuals and communities.

ADDRESSING WORKFORCE CHALLENGES: PERSPECTIVE OF THE BIPARTISAN POLICY CENTER

Michele Gazda, associate director of Health Policy at the Bipartisan Policy Center (BPC), began by discussing the report Filling the Gaps in the Behavioral Health Workforce,⁴ which focuses on strengthening the nonclinical workforce. Because shortages are especially severe in rural and underserved areas, she argued that the nonclinical workforce—including peer support and recovery specialists, community health workers, and other paraprofessionals—could play a critical role in expanding access by supporting clinical providers and enhancing system capacity. She said the report also explored models of community-initiated care, empowering community members, such as educators and faith-based leaders, to serve as “community-based patient navigators” in behavioral health and prevention efforts.

However, she added that barriers such as inconsistent training standards, limited career advancement opportunities, and inadequate reimbursement structures hinder the effective engagement of the nonclinical workforce. She said BPC’s policy recommendations focused on federal levers to strengthen this workforce, and key strategies include the following:

1. Developing core competencies and shared certification criteria to guide states;
2. Creating pathways for Medicare and Medicaid coverage for nonclinical workers, including their classification as “auxiliary personnel” in the

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⁴ See https://bipartisanpolicy.org/report/filling-gaps-in-behavioral-health/ (accessed September 22, 2024).

2. 2024 Medicare physician fee schedule and a Standard Occupational Classification (SOC) category for peer specialists under the Bureau of Labor Statistics and;
3. Building pipeline programs to help interested nonclinical workers advance into licensed clinical roles, improving workforce diversity.

Gazda noted the importance of integrating behavioral health and primary care. She argued that integrated care models are crucial for improving coordination and care delivery, particularly for patients with complex needs. Successful implementation requires policy support, funding for program development, and incentives for care providers to adopt integrated care practices. She said BPC research suggests that policy support for integrated care models is crucial for successful implementation (BPC, 2021, 2023a, 2023b). This includes funding for development and expansion and incentives for health care providers to adopt them.

Under key proposals, Gazda emphasized that federal collaboration is key to maximizing sustainable funding. She highlighted “braiding” federal grants with Medicaid and SAMHSA funding and leveraging alternative payment models to support community-based care. This approach can help states secure more comprehensive and long-term funding. Finally, Gazda discussed strategies for rural areas. She advocated for training primary care providers to prescribe medications for opioid use disorder, particularly after the removal of the DEA waiver requirement. Additionally, she recommended using the collaborative care model (CCM) and care administered via telehealth to expand access to care. In rural and tribal areas, long-term telehealth access, “reverse integration” (allowing specialty clinics to provide primary care services), and expanded Medicaid coverage for eligible providers are additional critical strategies to improve service delivery and workforce capacity, she said.

WORKFORCE DEVELOPMENT STRATEGIES: STATE MENTAL HEALTH AUTHORITIES

Wendy Morris, senior behavioral health advisor at the National Association of State Mental Health Program Directors, focused on the challenges and strategies for addressing behavioral health workforce needs at the state level. She highlighted the association’s role in supporting state executives by facilitating learning and sharing opportunities. It has developed a workforce resource guide,⁵ updated last year, which compiles examples of state-level

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⁵ See https://www.nasmhpd.org/content/behavioral-health-workforce-resource-guide-0 (accessed September 25, 2024).

workforce development efforts. The guide was created using a framework from the NCSL to ensure consistent language among state officials and legislators when discussing workforce issues.

Morris outlined the complexities of managing workforce shortages, emphasizing the importance of leveraging existing resources and state leadership in driving systemic change. She pointed out that state mental health directors face common challenges, such as rigid regulations, job descriptions, pay structures, and procurement processes. However, each state also contends with unique factors, such as population density, political climate, and available funding, that influence workforce strategies. She identified several trends in state-level strategies:

• Developing new entry programs and incentives,
• Eliminating barriers to entering the field,
• Expanding peer support and adjunct roles,
• Increasing the use of technology,
• Improving wages and benefits,
• Creating supportive working environments, and
• Focusing on equity and diversity.

Morris also noted that some states are shifting the care paradigm upstream, focusing on prevention rather than just acute care. This public health perspective aims to intervene early in life, particularly for youth, to reduce future need for intensive services. Key initiatives include implementing federal and state parity laws,⁶ building 988 crisis response systems, expanding crisis stabilization programs, and promoting integrated care models, such as CCBHCs.

Regarding workforce development, she said some states are hiring professionals with expertise in workforce development, rather than relying solely on human resource departments. These specialists focus on developing strategic plans for initiatives such as revising job descriptions, building career pathways, establishing apprenticeship programs, and creating positive workplace cultures. States are also reimagining treatment teams, creating adjunct roles, such as navigators and liaisons, and involving families in care. Collaboration with community partners—such as primary care providers, emergency services, child welfare agencies, and the criminal justice system—was emphasized as essential for success. Morris stressed the importance of partnerships with higher education institutions for workforce development, including clinical

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⁶ State parity laws are laws that require insurance plans to provide the same level of coverage for mental health and substance use disorders as they do for other medical conditions. See https://store.samhsa.gov/sites/default/files/pep21-05-00-002.pdf (accessed October 17, 2024).

placements, internships, and scholarship programs. Universities can also assist with program evaluation and data systems.

She highlighted the growing role of technology and artificial intelligence (AI) in behavioral health care. While telehealth expanded rapidly during the COVID-19 pandemic, states still face challenges in workforce onboarding and training. AI tools, such as those for record review and trend analysis, are emerging but likely to be adopted more slowly in public systems than in the private sector. Morris offered key takeaways: prioritize and coordinate efforts, develop strategic plans, engage specialists in workforce issues, collect data, and ensure strategies are multifaceted. She emphasized the importance of cross-system collaborations and encouraged states to embrace upstream care models to positively change lives.

DISCUSSION

One participant asked panelists what “moves the needle” in terms of cultural sensitivity and cultural competency. Morris said there has been movement toward involving underserved communities as partners despite political pressure against diversity and inclusion efforts. Another participant noted the proliferation of new types of behavioral health care providers and asked about when disciplines might be interchangeable. Morris pointed out that the same skill sets may exist in different disciplines, despite assumed limitations related to licensure, education, and so on, and that one barrier to implementing evidence-based practices is that payers can be very prescriptive about reimbursement criteria—for example, requiring a full-time person of a particular discipline for billing and reimbursement of a service.