The results of this study suggested most health center grantees needed additional capacity for providing onsite behavioral health services in 2010, and the current constraints are likely to be magnified as health centers expand to 40 million patients. This may be reflective of constraints in the behavioral health workforce in the U.S. in general. Shortages of providers, particularly psychiatrists, have been described, and the workforce is aging as fewer graduates are entering some behavioral health professions [31, 32]. The need for additional providers in rural and less affluent areas has also been well documented . There are currently no complete national data on practicing behavioral health providers, but Ellis et al estimated the mental health workforce was about 350,000 in 2009, with psychiatrists and advanced practice psychiatric nurses in shortest supply . State and federal programs designed to bring behavioral health professionals to medical underserved areas, such as the National Health Services Corps, play a vital role in connecting communities to these health care resources, but recruitment may be limited by insufficient supply. Our model estimated 6,992 additional mental health FTE were needed in health centers in 2010, which is less than 2 percent of the workforce of all providers.
A small number of vanguard health systems, including the Veterans Administration model of collaborative mental health-primary care at the White River Junction (WRJ) VA Medical Center, provide evidence to inform staffing. As of 2010, the White River Junction clinics employed one therapist, one psychiatrist, and twelve primary care physicians for every 14,000 primary care patients . Compared to our model, the WRJ clinics employed significantly fewer therapists per capita, but nearly the same ratio of psychiatrists.
Our estimates are shaped and limited by health centers’ current staffing patterns. Communities will need to account for their own local preferences, partnerships, and available resources when making staffing and delivery decisions. For instance, both urban and rural communities experience a high rate of psychiatrist vacancies, which likely will hinder recruitment . For these reasons, the total number of FTE needed to reach 40 million patients may be more informative than the number of FTE for each provider type.
It is also important to note primary care providers play a major role in screening, treating, and referring patients to appropriate behavioral health services. They are often the first point of contact for behavioral health needs, and they are responsible for most anti-depressants prescribed in the U.S. [35, 36]. Integrating behavioral health into primary care does not reduce the need for primary care providers, but redistributes some of that care as a team of providers shares responsibility for the whole patient.
Future staffing needs, particularly as more health centers move to fully integrate behavioral health services into primary care and adopt new patient empanelment processes, are difficult to predict because staffing models and the location of behavioral health service delivery are changing. Health centers across the nation are fully integrating behavioral health into routine primary care practices and transitioning into recognized Patient-Centered Medical Homes (PCMH). Accordingly, the use of interdisciplinary primary care teams along with more robust self-management support and patient education resources will influence how care is practiced. What is clear is the need to significantly increase the behavioral health workforce, as well as evolving their competencies and skills required to effectively function in an interdisciplinary primary care team.
There are several issues that must be addressed as we work toward filling the behavioral health workforce gaps in health centers:
Behavioral health provider supply: The overall supply of behavioral health providers in all professional categories will likely limit health centers’ ability to recruit providers.
Training and education: The majority of primary care and behavioral health providers were not trained to work together. Retraining providers to adapt to the professional culture of integrated behavioral health and primary care will be necessary to maximize the effectiveness of the model.
Financing for sustainability: Achieving financial sustainability to continue to support integration is paramount due to the historic separation of mental health funding from physical health funding. Funding for these services will need to be protected against reallocation to other pressing needs. This requires continued federal and state investment in health centers, including the availability of health center Expanded Medical Capacity grants for behavioral health services made available under federal health center funding.
Measurement and evaluation: Continuing to examine the impact of integrated services, both in health centers and other sites, will shape the more widespread adoption of this new model of healthcare across the system. Assessing clinical, operational and financial outcomes upon achieving the recommended staffing is also encouraged to determine what improvements in clinical outcomes and savings are seen in the system.
Several provisions of the ACA are aimed at mitigating the shortage of behavioral health providers in community based settings, through fostering care integration or training. In addition, a joint collaboration between the federal Substance Abuse and Mental Health Services Administration and HRSA has funded community-based partnerships that promote the integration of primary and behavioral health care.
First, the UDS data create some limitations. The UDS includes encounters and patients for services provided off-site (i.e., not through a health center-employed clinician) but paid for by the health center. We limited our utilization analysis to grantees with behavioral health staff onsite, but we may have overestimated the number of visits a health center provider can reasonably provide if some patients from those grantees also received services offsite. Furthermore, the UDS does not break out staffing categories beyond what is provided here.
Utilization data from the UDS were significantly skewed, with a small number of grantees reporting large numbers visits per provider and/or visits per behavioral health patient. Variations in disease severity, staffing models, and treatment modalities will influence the annual number of visits per patient and per clinician. It is likely that certain health centers treat a significant number of patients with SMI, which we excluded from this study. We used median values to estimate the number of providers needed, but the model could be run with other cut-points to account for differences in service use. It is likely an underestimation of actual need but absent data on what number of visits is adequate for this population, it is at least rooted in the experience of patients receiving care in these settings. We chose the median to estimate the midpoint of those experiences across all health centers with such services. It offers a measure of equity across FQHCs even if it doesn’t achieve adequacy. That is, it offers a measure of what workforce would be needed to achieve the same level of service across all health centers given the evidence-based prevalence of need for such care. This analysis also used only one year of data, though it was the most recent at the time. Changing staffing models may be apparent when exploring future or more years of UDS.
Second, we acknowledge that under broad insurance expansion, most uninsured patients will likely gain coverage through Medicaid, though many will also gain private insurance through the exchanges. Because our two categories of insurance represent applied benchmarks for assessing workforce needs, we recognize that our estimates under these insurance-based assumptions are relatively conservative.
Third, our estimates are still based on current staffing patterns in FQHC. Research has highlighted that health centers often experience staffing shortages and that they serve more patients per provider compared to other providers . It remains unclear whether the allocation of behavioral health positions would be made according to historic staffing patters or a new model. Further, estimates for staffing in general may be low given the presumption that by expanding behavioral health services, more patients may be retained over time in the FQHC.
Fourth, data from the NSDUH may likely underestimate need for behavioral health in FQHCs as it is based on general estimates from a national survey not necessarily reflective of the population seen in FQHCs.
Finally, because our study data sources were constrained to those age 12 and older, we likely underestimate behavioral health service needs for the full range of patients served in these settings and neglect specific counts of child behavioral health specialists.