Report State Strategies to Recruit and Retain the Behavioral Health Workforce

States often implement financial incentives, such as scholarships, loan forgiveness and repayment, and tax incentives to encourage new and existing providers to practice in underserved communities.

Scholarships, Loan Forgiveness and Loan Repayment

Financial aid is one strategy to incentivize providers to pursue a career in behavioral health, particularly in underserved communities.

Many scholarships and loan forgiveness or loan repayment programs, such as the National Health Service Corps, define a service obligation—or the number of years a provider must practice in a particular geographic area or facility type. Many states require a two- or three-year practice obligation for loan repayment programs, but some states—including California—extend practice obligations for up to five years. Providers tend to remain at their obligation sites beyond the required time period. Approximately 88% of clinicians participating in the NHSC in 2016 remained at their practice site at least one year after their obligation, and 43% intended to remain there for five or more years.

States may support scholarship and loan forgiveness or repayment programs through federal or state dollars. The federal State Loan Repayment Program allows states to create their own programs in compliance with federal requirements. At least 41 states, D.C. and the Northern Mariana Islands receive federal State Loan Repayment Program funding. The remaining nine states support their loan repayment programs through state funds.

States may also create additional programs, often through state funding or partnerships with private funding sources, to augment federal and state programs. For example:

• The Kansas Bridging Plan (2020) is funded by the University of Kansas Medical Center and provides up to $26,000 in loan forgiveness to primary care and psychiatry resident physicians who agree to a three-year service contract to work in rural areas.
• Minnesota (2021) created a Rural Physician Loan Forgiveness Program for family practice, obstetrics, gynecology, pediatrics, internal medicine and psychiatry physicians.

Tax Credits

Several states utilize tax credits, or a dollar-for-dollar reduction in income tax owed, to incentivize and reward health professionals practicing in rural and underserved communities. Many of these programs focus on primary and dental care providers but some states expanded their programs to include behavioral health professionals. For example:

• Utah (2017) extended tax credits for mental health providers, including psychiatrists or psychiatric mental health nurse practitioners and volunteer retired psychiatrists, who relocate to practice within the state. Providers receive tax credit certificates allowing them to claim a refundable tax credit of $10,000.
• Oregon (2021) allocated $60 million, including American Rescue Plan Act funds, to create financial incentives for Black, Indigenous, people of color, tribal and rural behavioral health providers. Incentives include sign-on and retention bonuses, tuition assistance and scholarships, loan forgiveness, housing assistance, child care and tax subsidies, grants for graduates to complete supervision and obtain licensure, and stipends for supervising clinicians.

States are also exploring ways to keep providers practicing within their borders through various retention activities. These may focus on provider burnout, or when health providers experience long-term stress marked by depersonalization or detached feelings, emotional exhaustion, moral injury or being unable to provide the correct kind of care, and a diminished sense of purpose or accomplishment. Provider burnout may result in poorer patient safety, lower patient satisfaction and providers leaving the workforce.

The COVID-19 pandemic heightened the severity of provider burnout and negatively impacted provider mental health, particularly among frontline professionals. More than three-quarters of psychiatrists—predominantly early-career and female providers—reported burnout in 2020, and 16% reported symptoms of major depression. While 13% of health care workers have received mental health services or medication specifically due to worry or stress related to COVID-19, nearly one in five said they thought they needed such services but did not receive them. Additional sources of provider burnout can include family responsibilities, time pressure, chaotic environments and lack of pace control.

Building Provider Resiliency

Many policymakers and employers are focusing on building resiliency within the health workforce, particularly among behavioral health providers and others on the front lines of providing care to patients and experiencing increasing demand for services.

While many strategies to build provider resiliency may occur at the organizational level, states have taken action to ensure the health of providers. Nearly every state has a program to serve the behavioral health needs of health professionals, but most are available only to specific provider types. Many of these programs existed prior to the pandemic but several have expanded their services or experienced increased demand amid COVID-19 pandemic. For example:

• Minnesota (2014) created its Health Professionals Service Program to promote early intervention, diagnosis and treatment for health professionals with illnesses, and to provide monitoring services as an alternative to board discipline. The program is overseen by the Health Professionals Services Program Committee to refer providers for evaluation, treatment and a written plan of continuing care. The program operates peer support networks for dentists, pharmacists, physicians and nurses who may practice in a behavioral health setting. Between July 1, 2020 and June 30, 2021, 414 health professionals were referred to the program. These referrals illustrated an increase in board referrals and a decrease in self-referrals.
• Florida (2020) contracts with private, nonprofit organizations, the Professionals Resource Network and the Intervention Project for Nurses to promote health professional wellness for a variety of provider types, including psychologists, marriage and family therapists, clinical social workers and mental health therapists. The Professionals Resource Network is often an alternative to the disciplinary process for health professionals experiencing difficulties and is funded by the Department of Health and the Department of Business and Professional Regulation. Participants are referred to treatment providers, monitoring groups, evaluators and drug monitoring programs for medical and therapeutic treatment.

The federal government has also taken steps to address the mental health of the health workforce in the wake of COVID-19. In 2021, the Department of Health and Human Services, through the Health Resources and Services Administration, awarded $103 million of American Rescue Plan Act funding  to improve the retention of health care workers and help respond to the nation’s critical staffing needs by reducing burnout and promoting mental health and wellness for the health care workforce. Funding is available for evidence-informed programs, practices and training, with a specific focus on providers in underserved and rural communities.

Mentoring Relationships

States are also exploring ways to foster connections between behavioral health professionals through mentorship programs. Mentoring relationships may include sponsoring, assigning challenging tasks, demonstrating trust and sharing knowledge across provider types. Research shows that mental health professionals in mentoring relationships were more satisfied with their jobs, and that mentoring relationships predicted career and personal development.

Project ECHO is one model for fostering mentoring relationships among health professionals, which was founded at the University of New Mexico in 2003. Since then, the federal ECHO Act of 2019 created grants and technical assistance to evaluate, develop and expand the use of virtual collaborative learning and capacity building models.

Several states have adopted Project ECHO to expand the reach of existing behavioral health professionals and provide mentorship opportunities to new behavioral health professionals and primary care providers operating in behavioral health professional shortage areas. For example:

• Indiana (2017, renewed 2018) received federal funding through the 21st Century Cures Act to establish Opioid Use Disorder TeleECHO Clinics. Three tracks exist for behavioral health providers: prescribers (including doctors, doctors of osteopathic medicine and nurse practitioners), therapists (psychologists, social workers and counselors) and other professionals (community health workers, peer recovery coaches and community advocates). Research on Indiana’s program found that knowledge about opioid use disorders increased and treatment was viewed as more practical after the ECHO series than before, but that external demands on time limited participation among ECHO for clinical providers.
• Minnesota’s Project ECHO program focuses on expanding capacity for treating opioid use disorder in primary care settings through tele-mentoring provided by interdisciplinary specialists to health care providers in rural or underserved areas. A 2021 study of the program found that providers who attended one or more sessions were more likely to prescribe buprenorphine to their patients, demonstrating that ECHOs can be part of a robust continuum of care. Minnesota (2021) also appropriated $200,000 in grant funding to the commissioner of human services to issue a competitive request for proposals for another opioid-focused Project ECHO program in 2022, 2023 and 2024.

Continuing Education

Professional development provides opportunities for health care professionals to upgrade skills, grow in their professional practice and continue to provide optimal, quality patient care. Educational support—such as release time for continuing education, educational leave and tuition reimbursement—can be a key retention strategy for health care professionals.

To ensure the safety of patients, state rules or regulations may require a certain number of continuing education hours for license renewal. Courses may focus on evidence-based practices intended to improve the quality and safety of care or other topics that improve patient outcomes. Although it is required for licensure, continued education may also provide a pathway for professional development and incentivize professionals to pursue long-term careers in behavioral health and health care.

Some states have begun requiring cultural competence training for behavioral health professionals, including the knowledge, understanding and skills for treating patients from culturally, linguistically and socio-economically diverse backgrounds. Research has found that cultural competence training can improve satisfaction for patients, including longer participation in mental health counseling, than patients whose providers did not complete training.

The federal Office of Minority Health offers cultural competence training resources and publishes the National Culturally and Linguistically Appropriate Services (CLAS) standards. CLAS standards are intended to reduce health care disparities by supporting individuals and health care organizations to implement culturally and linguistically appropriate services. As of May 2022, 10 states mandate and 12 states have proposed mandatory cultural competency training.

Some examples of mandatory cultural competency training include:

• New Jersey (2005) requires each college of medicine to include mandatory cultural competency instruction. Physicians licensed within the state are required to complete cultural competency training for re-licensure.
• Arizona (2020) requires all behavioral health licensees to report at least three hours of continuing education in behavioral health ethics or mental health law and cultural competency and diversity.