State Strategies to Recruit and Retain the Behavioral Health Workforce

5/20/2022

Two people holding hands

Introduction

Behavioral health conditions—including mental health and substance use disorders—are common in the United States. Nearly one in five American adults live with a mental illness, and one in 10 have had a drug misuse disorder. The COVID-19 pandemic has further exacerbated the prevalence of these conditions, with reported increases of anxiety or depressive disorders, overdose deaths and suicide attempts.

A shortage of behavioral health professionals, however, limits access to necessary services, particularly for residents of rural and underserved communities. About 37% of the U.S. population lives in an area with a shortage of psychologists, counselors and social workers, and nearly two-thirds of shortage areas are rural.

Who are behavioral health professionals?

Behavioral health care includes diagnosis, treatment and preventative services for mental health, substance use disorders, stress-linked physical symptoms and health behaviors. The behavioral health workforce is comprised of a variety of professionals, including:

Behavioral health professionals work in several settings, including prevention programs, community-based programs, inpatient treatment programs, primary care health delivery systems, emergency rooms, criminal justice systems, schools and higher education institutions.

States may consider various policy options to recruit and retain a behavioral health workforce to provide necessary services. This report highlights strategies organized into five categories:

CATEGORIES

STRATEGIES

Understanding workforce needs
  • Studying behavioral health trends
  • Statewide plans for behavioral health

Increasing the supply of professionals

  • Career pathways
  • Residencies
  • Emerging behavioral health providers
Expanding the reach of existing professionals
  • Telebehavioral health
  • Licensure for out-of-state providers
Addressing the distribution of professionals
  • Scholarships, loan forgiveness and loan repayment
  • Tax credits
Retaining professionals in the workforce
  • Building provider resiliency
  • Mentoring relationships
  • Continuing education

Understanding behavioral health workforce needs

State policymakers can first understand the behavioral health needs and workforce supply to explore solutions to ensure that residents receive necessary services.

The Health Resources and Services Administration projects that the supply of every behavioral health provider type will increase by 2030. Projections range from a 3% increase in addiction counselors to a 114% increase in social workers. Even so, demand for behavioral health services is projected to outpace the supply of providers. The relationship between demand for health services and the supply of providers is measured through a patient-to-provider ratio. A community is deemed a health professional shortage area in mental health if there are more than 30,000 residents for every provider. As of May 2022, there are 6,229 facilities, geographic areas and population groups designated as mental health professional shortage areas.

States including Colorado, Illinois, Maryland, Minnesota, Oregon, Pennsylvania, Texas and Washington recently enacted legislation to study behavioral health trends and develop plans to address workforce challenges. Examples include:

Illinois (2018) required the Behavioral Health Workforce Education Center Task Force to study psychiatry residencies, behavioral health internships and telehealth training in rural and underserved communities, as well as geographic and demographic trends. The Task Force recommended the creation of an Illinois Behavioral Health Workforce Education Center that would lead cross-agency and cross-sectoral statewide planning for the recruitment, education and retention of the behavioral health workforce. The Center was created by the Illinois General Assembly in 2021 to leverage workforce and behavioral health resources across the state.
Pennsylvania (2019) tasked the Joint State Government Commission to study provider shortages, projections, retention and strategies to address disparities in rural communities including telemedicine. The Commission recommended encouraging the use of integrated care models, using certified nurse practitioners and physician assistants, developing additional psychiatric residency positions, increasing tuition repayment programs, encouraging the recruitment of underserved students and expanding the use of telepsychiatry. Pennsylvania allocated $5 million in federal funding for loan repayment for behavioral health practitioners working in areas with high opioid use and workforce shortages.

Increasing the supply of behavioral health professionals

Several states have taken action to increase the overall supply of behavioral health professionals through partnerships with educational institutions and residency programs. These partnerships can encourage students and early career professionals to practice in rural and underserved communities.

CAREER PATHWAYS

Career pathways introduce students, from kindergarten through college, to health care careers through “a combination of education, training and other services that align with the skill needs of industries of the economy.” Research shows that career pathway participants are more likely to attain higher wages and to complete a training-related credentials than their peers.

States often pursue career pathways for professions in high demand and/or low supply, both of which apply to behavioral health care. While local and regional career pathway programs exist for health care professionals across the country, several Western states with many rural and frontier communities have created statewide career pathway programs in behavioral health to address workforce shortages.

Colorado (2015) developed career pathways for behavioral health—including counseling, therapy, social work, psychology, psychiatry and psychiatric nursing—in 2019-2020 through the My Colorado Journey platform. “My Colorado Journey” expands access to education and data to help students and job seekers find pathways to career and upskilling opportunities.
Washington (2019) created a work group to identify strategies to address behavioral health workforce shortages. Based on recommendations from the work group, Washington appropriated $1.5 million in 2021 to establish apprenticeship programs, compensate providers and apprentices, develop on-the-job training and provide incentives for providers in communities serving rural communities and communities of color.

RESIDENCIES

Exposure to clinical training in rural and underserved communities may increase the number of providers that practice there. Rural residency trainees are three times more likely to practice in rural communities than those who completed residencies in urban or suburban communities. This is especially true for students who lived in rural communities prior to medical school

The number of psychiatry residencies continue to increase annually, growing from 4.1% of all medical residencies in 2011 to 6.5% in 2021. Even so, at least five states did not offer a psychiatry residency as of 2020. Four of the five states (Alaska, Idaho, Montana and Wyoming) had the lowest count of psychiatrists and three (Alaska, Montana and Wyoming) had the highest suicide rates in the country. In response, universities and clinics in Idaho and Montana created residency programs in 2021 to increase access to behavioral health services. Residency program directors often cited the shortage of psychiatrists or subspecialists in their geographic area as the primary motivation for expanding psychiatry residencies.

Funding is often the primary barrier for expanding residency programs. New programs are predominantly funded by health facilities, the state, Medicare, Medicaid and the Department of Veterans Affairs.

Some states invest in psychiatry residencies or set requirements for residency programs to increase the supply of psychiatrists practicing in communities with the greatest demand for services. For example:

Iowa (2019) required psychiatry residency programs to provide rural rotations as an option for residents. The law also called for the University of Iowa to conduct a physician workforce study including workforce data, identified shortages, the number of residencies and recruitment and retention strategies.
New Jersey (2020) appropriated $4 million for 10 four-year psychiatry residencies focused on the treatment of lower income individuals, including those with serious mental illness and co-occurring mental health and substance misuse conditions. Residency programs must ensure physicians have rotations in a range of publicly funded and community-based health settings.

In addition to medical residencies for psychiatrists, many states are also implementing postgraduate training and fellowship programs for nurse practitioners, often referred to as “nurse practitioner residency programs.” While many postgraduate programs for nurse practitioners focus on increasing access to primary care, others for psychiatric mental health nurse practitioners focus on filling gaps in behavioral health care across the U.S.

EMERGING BEHAVIORAL HEALTH PROFESSIONALS

States also use various emerging professionals, with appropriate training and experience, to expand the capacity of existing behavioral health workforce. Two examples of behavioral health professionals becoming increasingly formalized in state statute are peer support specialists and addiction counselors.

Peer support specialists use their own lived experience with mental illness and/or addiction, plus skills learned in formal training, to provide behavioral health services, education, recovery support and connection to other services. Addiction counselors help people suffering from addiction to develop treatment goals, plans, skills and strategies necessary for recovery. Both professionals bolster the behavioral health workforce by providing a support network for individuals with mental or substance use disorders to ensure a successful pathway to recovery and wellbeing.

State strategies to professionalize peer support specialists and addiction counselors include credentialing and reimbursement.

  • Credentialing: To practice, health professionals must obtain a credential—either a license provided by the state or certificate provided by a third-party organization—indicating that they have reached a minimum acceptable level of training. Credentialing requirements vary across states.

Peer support specialists work in all 50 states and D.C. and credentialing varies across states. Credentialing for peer support specialists may be administered by a nonprofit entity, state agency or specific board.

Montana (2021) required the board of behavioral health to set professional, practice and ethical standards for behavioral health peer support specialists. Montana (2019) also allowed certain peer support services to qualify as medical assistance under the state Medicaid program.

Credentials for addiction counselors are offered by the International Certification and Reciprocity Consortium (IC&RC) and the Association for Addiction Professionals (NAADAC). Thirty states accept the IC&RC certification while 11 states accept the NAADAC certification; nine states accept both. States may modify credentialing requirements with each national credentialing body.

An individual can enter the field of addiction counseling by earning a certificate with a high school diploma or completing a behavioral health graduate degree with an addiction treatment focus.

United States map of States Requirements for Addiction Councselor Credentialing

A greater level of education may be substituted for practice requirements in some states. States with lower minimum degree requirements often require more practice hours.

New Mexico (2021) requires licensed alcohol and drug addiction counselors to complete either:

  • An associate’s degree and 3,000 hours of experience, or
  • A bachelor’s degree and 2,000 hours of experience.
  • Reimbursement: Low funding levels—such as insurance coverage for substance use disorder services—are cited as the largest disincentive to enter the behavioral health workforce. In many states, licensure serves as a facilitator for independent billing status, allowing emerging providers such as peer support specialists and addiction counselors to be directly reimbursed by Medicaid and commercial plans.

Medicaid is the largest funding source for peer support services since 2007 guidance from CMS authorized Medicaid reimbursement. As of 2019, at least 39 states allow Medicaid reimbursement for peer support services, with 23 states allowing reimbursement for services to individuals with addiction and/or mental disorders, 12 states for mental disorders only and four states for addiction only.

United States map of State Reimbursement of Peer Support Services

Most state Medicaid programs also reimburse for community and rehabilitative supports, crisis intervention, case management and care coordination, counseling services and screening, evaluation and assessment.

Hawaii reimburses peer support specialists for activities that promote socialization, recovery, wellness, self-advocacy, development of natural supports and maintenance of community skills for both mental health and addiction treatment.

Eleven states allow addiction counselors to enroll as independent billing providers. According to a 2020 study, federally qualified health centers that received Medicaid reimbursement for behavioral health services were five times more likely to offer addiction counseling and employ certified addiction counselors than those who did not.

Kentucky reimburses licensed clinical alcohol and drug counselor at 60% of the rate of a Kentucky-specific Medicare Physician Fee Schedule. Reimbursable services may include the diagnosis, prevention, treatment and amelioration of psychological problems, emotional conditions or mental conditions of individuals or groups.

Expanding the reach of existing behavioral health professionals

To ensure short-term access to behavioral health services, states may expand the reach of existing providers by increasing access to telebehavioral health, offering licensure for out-of-state providers and leveraging emerging professionals.

TELEBEHAVIORAL HEALTH

Telebehavioral health, or behavioral health services delivered via telehealth, is one strategy state policymakers use as they explore ways to address gaps and increase access to behavioral health services. Telehealth can be a cost-effective strategy to increase access, address workforce shortages and reach patients in rural and underserved areas. However, there may be limitations as well, including an inability to provide hands-on diagnoses and care and the potential security risks associated with personal health data transmitted electronically. In addition, rural communities often experience disparities in technology and broadband access that may limit the use of telehealth for rural patients.

The COVID-19 pandemic prompted the federal government and many states to expand access to telehealth coverage and services while protecting both patients and providers, and several of these states have made permanent the changes instituted during the public health emergency.

  • Settings: Telebehavioral health is delivered primarily in five settings: hospital care, integrated primary care, mobile health and direct-to-consumer services.

During the COVID-19 public health emergency, several states expanded their definitions of both originating site (where the patient is located) and distant site (where the provider is located). Expanding definitions can provide flexibility and remove barriers for providers delivering care and for patients receiving it. Some states added a specific location to the definition (such as a patient’s home, school or workplace or a certain health facility type), while others defined site more broadly to include wherever a patient or provider is located when services are delivered via telehealth.

Oklahoma (2021) expanded its definition of originating site to include (but not be restricted to) the patient’s home, workplace or school. Mississippi (2021) expanded its definition of originating and distant site to include federally qualified health centers and rural health centers. New York (2021) expanded its definition of originating site broadly to include anywhere the patient is located when services are delivered via telehealth.
  • Providers: States determine which types of health professionals may deliver health care services via telehealth. For the behavioral health workforce, this may include addiction counselors, peer support specialists, psychologists, psychiatric mental health nurses, social workers or other behavioral health professionals.

To expand access to telebehavioral health during the COVID-19 pandemic, many states examined the types of professionals authorized to provide services via telehealth within their state. For example:

Louisiana (2020) expanded the types of providers who can perform telepsychiatric evaluations to include psychiatric mental health nurses, if certain conditions, such as an examination over video conferencing, are met.

Maryland (2021) allowed alcohol and drug trainees to practice clinical drug and alcohol counseling without a license or certificate through telehealth while under supervision and completing certain experiential or course study requirements.

LICENSURE FOR OUT-OF-STATE PROVIDERS

States are responsible for several aspects of licensing health professionals and protecting patients within their borders. Health professionals providing services to patients located in other states must be licensed in both the state where the patient is receiving care as well as the state in which the provider is located. Obtaining a single-state license for multiple states can be time consuming and burdensome, as the processes and requirements for licensure may vary from state-to-state.

Many policymakers see streamlining licensing requirements as a way to remove barriers for the behavioral health workforce, mitigate workforce shortages and increase access in rural and underserved communities. In response to the COVID-19 pandemic, almost all states modified their licensure rules, requirements or processes to facilitate access to services provided via telehealth and authorize temporary in-person visits.

One of the most common strategies to facilitate telehealth across state lines is for a state to join an interstate licensure compact. Interstate compacts are a contract between two or more states to cooperate on regional or national matters, such as licensure standards for behavioral health providers. To join an interstate compact, states must enact specific legislation that allows providers that meet licensure standards and requirements to practice in participating states. Interstate compacts are administered by nongovernmental organizations, but all compact member states maintain their authority to monitor health care professionals practicing within their borders.

Two compacts currently exist for specific types of behavioral health providers:

United States map of types of behavioral health providers

States may also offer licensure by reciprocity or endorsement to out-of-state providers, allowing them to practice  in other states without obtaining new or additional licenses. Reciprocity is a formal agreement to license providers that hold an active license within another state. Endorsement is providing licensure to any provider that meets the state’s requirements. Behavioral health professionals may often provide services in person temporarily or provide care via telehealth.

Delaware (2019) offers reciprocity for out-of-state clinical social workers who have practiced for at least five of the past seven years or whose state license standards are substantially similar to Delaware’s, as determined by the Board of Social Work.

South Dakota (2020) offers licensure by endorsement for counselors and marriage and family therapists if they have been licensed in another state for at least three years and have taken one of the national examinations required for licensure.

Addressing the distribution of behavioral health professionals

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.

United States map of State Receiving Funding Through the State Loan Repayment Program

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.

Retaining behavioral health professionals in the workforce

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.

United States map of States with Mandatory Cultural Competence 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.

Conclusion

Legislators can play an important role in ensuring a state’s health, education and workforce policies meet the behavioral health needs of the state, including its rural and underserved communities. The policy options discussed in this report highlight only some of the innovative strategies that state legislators and stakeholders are employing to recruit, train and retain behavioral health professionals.

Additional NCSL Resources

This resource is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $767,749 with 100% funded by HRSA/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, HRSA, HHS or the U.S. Government.