In January, Behavioral Healthcare Executive surveyed its audience on industry-specific workforce issues. More than 600 treatment center professionals responded, and results indicate that clinical staffing remains the top workforce challenge not just to ensure quality of care but also to allow for future program growth.

The most surprising finding was that almost half of the audience with some knowledge of the business’s growth say that their organization at some point has abandoned service expansion plans because of concerns about finding the right clinical staff. It’s an issue that speaks to both the quantity and the quality of the available workforce in local areas.

When characterizing the various types of staff in comparison to current needs, respondents clearly sense there’s an inadequate supply of clinical employees. About 60% say their clinical departments are understaffed, and only 38.1% say such staffing is adequate.

“It doesn’t surprise me,” says Jeffrey Quamme, executive director of the Connecticut Certification Board. “Clinical staff is the hardest to recruit.”

By contrast, only 29.3% of respondents say their administrative departments are understaffed. When looking at only the treatment center organizations that include marketing departments—more than half—about a third of those respondents indicate that they could use more marketing staff.

Greatest need

It’s clear that treatment professionals with clinical education and experience represent the greatest human resource need. In fact, an overwhelming majority (81.5%) of respondents say as much. 

Angela J. Beck, PhD, MPH, professor and assistant dean for the University of Michigan School of Public Health and director of its Behavioral Health Workforce Research Center, says the BHE findings are consistent with national studies that estimate the workforce shortage. For example, in a November 2016 report, the Health Resources and Services Administration estimates that by 2025, the United States will experience a shortage of 250,000 workers in the field.

“We’re not expecting a huge influx of behavioral health workers,” Beck says. “But that doesn’t mean we should give up on pipeline programs.”

What the field does have going for it in terms of recruitment is the personal investment of its many workers who have experienced mental health and addiction treatment themselves and feel a calling to give back, improve the system and share their fellowship of recovery.

“This work is tremendously missional, and it’s work in which people have a lot of passion for helping others,” says Dawne Carlson, vice president of human resources for Hazelden Betty Ford Foundation. “And because it is such deeply felt work, it can sometimes feel heavy.”

Carlson says those who care for patients and clients can get burned out easily, and that’s why the turnover rates can be rather high in comparison to other health specialties. Self-care is imperative, she says.

More than 28% of the BHE survey respondents indicate that their clinical staff turnover rates are higher than industry average.

“I don’t have statistics on clinical staff turnover in behavioral health, but anecdotally, we know it’s pretty high,” says Beck. “This is a field in which burnout is high, compensation is comparatively low, and there’s still some stigma attached to working in mental health and addictions. That three-quarters of your respondents are reporting turnover at the industry average or more than industry average would be concerning.”

Solutions for the future

About half of survey respondents say their organization offers tuition reimbursement or similar education benefits. Such perks can help retain workers while also increasing clinical competencies. Additionally, nearly 17% believe that student loan forgiveness or academic scholarships would be the best solution to help attract more workers to the behavioral health field—second only to strategies that would increase workers’ pay.

In terms of solutions, Carlson says Hazelden Betty Ford offers a graduate school program that helps create a direct link from education to active clinical work at its facilities. Talent can be replenished close to home, and new openings can be filled by the graduating students who are already familiar with the organization.

While 66% of survey respondents say improved wages for experienced and entry level workers are the top solutions, experts fully agree that good pay certainly doesn’t hurt.

“It’s important that we seek to pay competitively—that’s one of our solutions,” Carlson says. “That said, in every clinical aspect, we don’t necessarily lead the pay scale, but it’s important if you want good clinicians that you help them grow and continue to learn.”

She believes good leadership also makes a difference in retaining employees. More workers leave their jobs because they don’t care for the managers than those who leave because they don’t care for the job itself, she says.

Quamme says the rise in private, for-profit treatment centers has caused a noticeable shift of workers away from the traditional not-for-profit agency setting. Part of the attraction is likely higher pay.

“The industry does have a hard time keeping people,” he says. “Workers will jump for that one job with that $1 dollar per hour more.”

Of the survey respondents with some knowledge on the subject, more than half report that their organization has seen a staff reduction at some point in the past two years attributed to financial strains. Even with its long established programs, Hazelden Betty Ford has had to cut staff in the past, according to Carlson.

 “Healthcare as an industry is in such a state of change continuously, it’s challenging to be able to set the right levels of staff and be able to provide excellent care when margins are reducing,” Carlson says.

Policy enhances service

While some solutions can be implemented at the organization level, broader strategies might be needed to extend the reach of the workforce. For example, Beck says clinical professionals could have more impact right now if policies were in place to allow them to leverage all of their practice skills.

“It’s an area where legislators can get involved to address capacity issues in their states by ensuring the workforce they have is working up to the full scope of their practice,” she says. “It’s an issue of how you best utilize the staff you have.”

For example, a nurse might be limited by state restrictions, causing a physician’s time to get tied up in delivering services that the nurse otherwise is trained for and capable of providing.

Additionally, telehealth has been held up as a tool that could extend the workforce. Digital visits could solve some access issues, connecting more patients with behavioral health services, especially in rural areas. However, barriers to adoption—such as licensing requirements when patients and providers aren’t located in the same state—continue to drag down telehealth’s progress.

Beck says telehealth providers need to know who they can treat and where, taking licensing and reciprocity into account. Meanwhile, providers that are philosophically open to the idea of conducting telehealth visits might decide against it if they’re already overbooked with office visits.

“And there are still the questions about alleviating perceptions about the quality of care with telehealth: Can you treat someone as sufficiently as with in-person care?” says Beck.

According to Quamme, clinical competency has evolved in behavioral health. While its origin might be one of fellowship or spiritual support, system pressures today increasingly call for evidence-based practice that has the science to back up its efficacy. However, there’s room for both, he says.

“I’d like to see the field put certification in higher esteem because we are the ones who guarantee competence, as opposed to permission to practice,” says Quamme. “I think they go hand-in-hand.”

In the future, as the healthcare system at large seeks greater integration, clinicians might also find themselves on large care teams. And how the teams are comprised matters, according to Beck. Sometimes it’s difficult to ensure that behavioral health professionals are equitably included in a team-based care provision—and equitably reimbursed.

Not all numbers add up to 100% due to rounding.

“I don’t know” and “N/A” responses were excluded from data calculations. Total respondents ranged from 605 to 721.