The Behavioral Health Workforce: Ongoing Shortages & Innovative Solutions

Chronic Workforce Shortage Across the Provider Spectrum

Texas’s mental health and substance use workforce shortage is not a new challenge. In the last decade several state and federal legislative initiatives, agency reports, and advocacy efforts have offered recommendations for addressing workforce challenges across the various mental health disciplines. Texas continues to face critical shortages for the entire spectrum of providers, including psychiatrists, psychologists, professional counselors, clinical social workers, chemical dependency counselors, marriage and family counselors, advanced practice psychiatric nurses, peer support specialists, recovery coaches, certified family partners, and community health workers.1

Nearly the entire state remains designated as a mental health shortage area.2 Texans’ mental health needs have only grown, yet in 2023:

  • 170 of the 254 counties did not have any licensed psychiatrists,
  • 143 counties did not have any licensed psychologists,
  • 91 counties did not have any licensed clinical social workers,
  • 84 counties did not have any licensed chemical dependency counselors,
  • 29 counties did not have any licensed professional counselors, and
  • 163 counties did not have any Psychiatric-Mental Health Advanced Practice Registered Nurses (PMHAPRNs).3

Due to the ongoing crisis and need from every corner of the state, there was significant focus on this policy issue during the 88th legislative session. Legislation and budget changes were mostly focused retention efforts to maintain the current workforce in place. The most notable, successful legislative efforts include:

1. Loan Repayment Program for Mental Health Professionals

Bill NumberDescription
HB 2100 (Price/Schwertner)Extends eligibility criteria to any eligible professional working within a local mental health authorities/local behavioral health authority (LMHA/LBHA) or State Hospital.
SB 532 (West/Kuempel)Reduces the service requirement from 5 years to 3 years and extends eligibility criteria to any eligible professional working within a LMHA/LBHA or State Hospital.

*Amended to include language from HB 3631 (Lalani)
HB 1211 (Guillen/Zaffirini)Adds licensed specialists in school psychology to the list of eligible professionals.

2. Recruitment and Incentives

HB 400 (Klick/Kolkhorst)

  • Creates a psychiatric specialty innovation grant program to award incentive payments to increase the number of physicians who specialize in adult or pediatric psychiatric care.
  • Establishes a behavioral health innovation grant program to award incentive payments to institutions of higher education that administer innovative recruitment, training, and retention programs designed to increase the number of mental health professionals or professionals in related fields.

Note: funding was not included in the budget to fund the Behavioral Health Innovation Grant Program.

HB 1 – General Appropriations Bill 

Health and Human Services Commission (HHSC) Rider 52: Additional Mental Health Funding

HHSC Frontline Staff Salary Increases:

  • $134 million to State Hospitals
  • $202 to State Supported Living Centers (SSLCs)

HHSC Rider 23: Medicaid Provider Rate Increases – It is the intent of the Legislature that when Medicaid provider rates are increased as a result of a legislative appropriation, managed care organizations reimburse the full amount of the appropriated funds to providers, to the extent allowed by federal laws and regulations.

HHSC Rider 54: Local Authority Workforce Capacity – Directs HHSC to allocate $11,935,624 each fiscal year to LMHAs, LBHAs, and local intellectual and developmental disability authorities (LIDDAs) proportionally based on FY23 funding levels.

HHSC Rider 104: State Hospital Salary Funding – Appropriates $17,530,335 in GR each fiscal year to maintain funding for salary increases to address staffing challenges. If by December 1, 2023, HHSC is unable to hire enough staff to allow offline state hospital beds to be utilized, HHSC may instead allocate the funding to contract for additional competency restoration beds.

THECB (Texas Higher Education Coordination Board)

  • $28 million to Loan Repayment Program for Mental Health Professionals
  • $43 million to Workforce Expansion in the Texas Child Mental Health Care Consortium
  • $20.6 million to Child and Adolescent Psychiatry Fellowships in the Texas Child Mental Health Care Consortium

THECB Rider 57: Forensic Psychiatry Fellowship Program – Allocates $2.5 million each fiscal year to support the development or expansion, and administration of forensic psychiatry one-year fellowship training programs and to support the salaries and benefits of the training physicians.

THECB Rider #59 – Social Work Workforce Study – Directs the HECB to study and report on the state’s current social work workforce landscape and needs no later than November 1, 2024.

UT Tyler Rider #7: Mental Health Workforce Training for Underserved Areas – Allocates $6,730,000 in GR each fiscal year to support mental health workforce training programs in underserved areas including, but not limited to, Rusk and Terrell State Hospitals.

Creative Solutions to Expand the Workforce

Despite efforts in the 88th legislative session, we remain in a critical place with our workforce and must stay committed to recruit, retain, and incentivize Texans to stay in the mental health and substance use field. We need the entire spectrum of professionals, not just one type of provider. We also need providers of all backgrounds to meet the needs of our diverse state.

Having a diverse pool of providers to administer mental health and substance use care will benefit Texans of all backgrounds, allowing individuals to seek out the provider they most closely identify or share a language and background with. Social identification (i.e., sharing cultural groups such as race, religion, gender, personal activities, etc.) is a proven factor that further strengthens the therapeutic relationship between the individual and their therapist.4 A strong therapeutic alliance is the most robust indicator of therapeutic success rates.5 Therefore, a workforce that aligns with the many unique cultures within our state expands opportunities for all Texans to successfully address their mental health and substance use concerns.

Recognizing the need to proactively address the critical behavioral health workforce shortage in Texas, the Health and Human Services Commission (HHSC) created the Behavioral Health Workforce Workgroup in 2019, a multi-disciplinary group including state agency staff, non-profits, providers, and other stakeholders. The workgroup now functions as a subcommittee of the Statewide Behavioral Health Coordinating Council. In December 2020 the group released a comprehensive report “Strong Families, Supportive Communities: Moving our Behavioral Health Workforce Forward” that lays out a comprehensive set of recommendations that should be used as a blueprint for action.6

Stakeholders have dedicated time and energy to finding multi-disciplinary solutions to the workforce situation. Luckily, there are identified “short-term action items” from the Behavioral Health Workforce Workgroup:

  • Within plans regulated by Medicaid and the Texas Department of Insurance (TDI), ensure telehealth and telemedicine mental health and substance use condition services are reimbursed at the same rate as are in-person services; ensure all Medicaid-enrolled behavioral health professionals receive equal reimbursement for providing the same services.
  • Recommend the Texas Education Agency (TEA) take action to collaborate with local educational agencies (LEAs) to include behavioral health careers in career readiness programs, career days and career promotion activities to all grade levels.
  • Encourage collaboration between LEAs and individual hospital systems or clinics to encourage flexible volunteer and job shadowing opportunities for high school students interested in behavioral health careers.
  • Increase entry-level employment opportunities for high school and undergraduate students in behavioral health facilities.
  • Promote existing loan repayment programs available through the Texas Higher Education Coordinating Board (THECB) for graduates and current students preparing to enter the behavioral health workforce.
  • Create opportunities to expand access to integrated health care through provision of behavioral health services via telehealth and telemedicine.
  • Create and appoint a multi-disciplinary working group independent of any other advisory committee or working group to research and explore behavioral health professionals’ education, licensing, and scope of practice in Texas, including for advanced practice registered nurses (APRNs) and psychologists.
  • Re-examine Medicaid rates for behavioral health services and update (if possible based on available funding) to better reflect the cost of delivering services.7

Focus on Recovery: Peer Specialists, Recovery Coaches, and Certified Family Partners

Recovery is a primary goal for behavioral health care.8 The Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as the “process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential”.9 There are 10 guiding principles of recovery:

  • Hope
  • Person-driven
  • Many pathways
  • Holistic
  • Peer Support
  • Relational
  • Culture
  • Addresses Trauma
  • Strengths/Responsibility
  • Respect10

People with lived experience of mental health and substance use are the experts in their own care, which is why supporting peer support services should be a part of the workforce conversation. Thus, peer support services are a critical component of the Texas mental health and substance use workforce. The Texas Health and Human Services Commission (HHSC) continues to support recovery through the work of the Peer and Recovery Services Programs, Planning, and Policy unit, which was created to develop, support, and advance the peer workforce in Texas.11

Peer support is provided by individuals with lived experience of mental health and/or substance use conditions who are trained and certified. These individuals assist others achieve long-term recovery. Peer specialists offer emotional support, share knowledge, teach skills, provide practical assistance, and connect people with resources, opportunities, and communities of support.12

Peer specialists provide services at local mental and behavioral health authorities (LMHAs/LBHAs), peer-run service providers, state hospitals, substance use recovery community-based organizations, recovery organizations, emergency departments, treatment organizations, and more. Common tasks performed by peer specialists include:

  • Helping individuals self-advocate
  • Connecting people to resources and employment services
  • Goal setting
  • Facilitating support groups
  • Outreach and engagement
  • Face-to-face recovery coaching
  • Telephone peer support

2023 Peer Workforce Numbers:

  • Recovery support peer specialists (RSPS)- 827
  • RSPS – Intern – 26
  • Mental health peer specialist – 798
  • Peer specialist supervisor – 319
  • Certified family partner – 132
  • Re-entry peer specialist – 4913

Below are some key terms as defined in the Texas Administrative Code.

TermsDefinitions
Peer specialistA person who uses lived experience, in addition to skills learned in formal training, to deliver strengths-based, person-centered services to promote a recipient’s recovery and resiliency.
RecoveryA process of change through which a person:
– improves one’s health and wellness;
– lives a self-directed life;
– strives to reach one’s self-defined full potential; and
– participates in one’s personal community.
Person-centeredThe provision of services:
– directed by the recipient;
– aligned with the hopes, goals, and preferences of the recipient; and
– designed to build on the recipient’s interests and strengths.
Relationship-focusedRequires a peer specialist to deliver services through a relationship with the recipient that is respectful, trusting, empathetic, collaborative, and mutual.
Self-directed recoveryThe point at which an individual takes proactive steps to plan and implement the individual’s own recovery.
Source: Texas Health and Human Services Commission. (2023). Medicaid health services, peer specialist services, General Provisions, 1 Tex. Admin. Code §354.3003

Peer Certification

Individuals with lived experience of mental health and/or substance use conditions and family members of a child with a mental, emotional, or behavioral health challenge can be certified through PeerForce. PeerForce is a statewide coordination hub for the peer workforce created to support new individuals entering the career field to get certified and find employment.14 HHSC recognizes four Texas Peer Certifications through PeerForce:

  • Mental Health Peer Specialist (MHPS): a person who has lived experience of recovery with mental health challenges who is trained to support people with mental health challenges. They provide support by honoring the self-identification and self-determination of the people receiving peer services, without focusing on or using clinical language or diagnoses.15
  • Recovery Support Peer Specialist (RSPS): a person who has lived experience of recovery with substance use challenges who is trained to support people with substance use challenges. They recognize that there are multiple pathways of recovery, and support the people they serve to discover what pathway works best for them. They do not act as a sponsor or a guide, and they do not push people to embrace abstinence or the recovery pathway they chose.16
  • Certified Family Partner (CFP): a parent or guardian who has lived experience raising a child with mental, emotional, or behavioral health challenges and has at least one year of successfully navigating a child-serving system. They are trained to use this experience to help other parents/guardians for the purpose of educating, role modeling and providing hope related to the recovery process.17
  • Peer Specialist Supervisor (PSS): a person who supports and guides a peer specialists after they obtain their certification. A PSS will oversee peer specialists while they provide the necessary components of peer work, such as giving recovery-oriented peer services, skill-building, ethical problem solving, optimizing professional growth, and performing administrative duties.18

In addition to certification information, PeerForce offers a job board, financial aid opportunities, training calendars, and certification and career guidance for those interested or newly involved in the peer field.19

Research and Results

In the newly released article, “Unlocking the Potential of Recovery Community Organizations and Peer Recovery Support Services”, studies have found that peer supports:

  • Decreases morbidity and mortality rates
  • Increases life expectancy
  • Increases knowledge of a disease
  • Improves self-efficacy
  • Improves self-reported health status and self-care skills, including medication adherence
  • Reduces use of emergency services.20

Telehealth & Telemedicine

The COVID-19 pandemic rapidly changed the nation’s views and attitudes towards telehealth and telemedicine. Prior to the pandemic, both providers and the public mostly preferred to receive mental health and substance use services in-person compared to virtually. However, when the pandemic shut down in-person services, people quickly switched to virtual options in order to keep consistency and stability in their mental health and substance use care. Texas relaxed some telehealth and telemedicine rules in 2020 to allow providers the ability to switch to virtual care without penalty to their license or reimbursement rates. Further, Medicaid flexibilities allowed providers to offer care through audio-only telehealth and telemedicine, which had not previously been an option.

Passed during the 87th legislative session, HB 4 (Price/Buckingham) is an omnibus telehealth and telemedicine bill focusing mostly on Medicaid and Children’s Health Insurance Program (CHIP) plans.21 The comprehensive bill allows for telemedicine, telehealth, or other telecommunications services to be used by Medicaid recipients, CHIP enrollees, and other individuals receiving benefits under a public benefits program if cost- and clinically effective. Rules for HB 4 are still under review at HHSC.

There was far less attention on telehealth and telemedicine in the 88th legislative session. A few bills were filed to require private insurance plans to have payment parity for telehealth and telemedicine services with in-person services. The most successful bill, HB 1726 (Hernandez), did not ultimately pass despite successfully being voted out of the House Insurance committee.22 However, telehealth payment parity remains a priority for many mental health and substance use stakeholders.

Currently many providers have returned to offering in-person options, but virtual services remain popular for many people across the state. Stakeholders have noticed several reasons for this change in preference: no travel time to and from appointments, growing popularity of online therapy platforms nationwide, finding a provider that has a specialty in a therapy or service, bypassing long waitlists for services in a nearby area, and simply preferring the comfort of engaging in mental health or substance use services from home. Data shows that telehealth and telemedicine are here to stay.

References

  1. Statewide Behavioral Health Coordinating Council. (2022). Texas behavioral health workforce shortage snapshot. Texas Health and Human Services. https://mentalhealthtx.org/wp-content/uploads/2023/02/BH-WF-Shortage-Snapshot-Final_Jan-2023_1.17.23.pdf ↩︎
  2. Rural Health Information Hub. (2023). Health professional shortage areas: Mental health, by county, 2023. https://www.ruralhealthinfo.org/charts/7  ↩︎
  3. Texas Health and Human Services Commission. Personal communication regarding data from licensure files. Received on June 6, 2024.  ↩︎
  4. Cruwys, T., Lee et al. (2023). Therapists who foster social identification build stronger therapeutic working alliance and have better client outcomes. Comprehensive Psychiatry, 124, 152394–152394. https://doi.org/10.1016/j.comppsych.2023.152394 ↩︎
  5. Ibid. ↩︎
  6. Statewide Behavioral Health Coordinating Council. (December 2020). Strong families, supportive communities: Moving our behavioral health workforce forward. Texas Health and Human Services. https://mentalhealthtx.org/wp-content/uploads/2024/04/behavioral-health-workforce-workgroup-report-dec-2020.pdf  ↩︎
  7. Ibid.  ↩︎
  8. Substance Abuse and Mental Health Services Administration. (2014). Recovery: National and regional resources. https://www.samhsa.gov/sites/default/files/samhsa-recovery-5-6-14.pdf  ↩︎
  9. Substance Abuse and Mental Health Services Administration. (2012). SAMHSA’s working definition of recovery. https://store.samhsa.gov/sites/default/files/pep12-recdef.pdf  ↩︎
  10. Ibid. ↩︎
  11. Texas Health and Human Services Commission. (2023). Peer support services. https://www.hhs.texas.gov/providers/behavioral-health-services-providers/peer-support-services ↩︎
  12. Ibid. ↩︎
  13. Personal Communication. Health and Human Services Commission on January 3, 2024. [email] ↩︎
  14. PeerForce. (n.d.) PeerForce homepage. Retrieved on December 29, 2023 from https://peerforce.org/  ↩︎
  15. PeerForce. (n.d.) Mental Health Peer Specialist. Retrieved on December 29, 2023 from https://peerforce.org/mental-health-peer-specialist-mhps/  ↩︎
  16. PeerForce. (n.d.) Recovery Support Peer Specialist. Retrieved on December 29, 2023 from https://peerforce.org/recovery-support-peer-specialist-rsps/  ↩︎
  17. PeerForce. (n.d.) Certified Family Partner. Retrieved on December 29, 2023 from https://peerforce.org/certified-family-partner-cfp/  ↩︎
  18. PeerForce. (n.d.) Peer Specialist Supervisor. Retrieved on December 29, 2023 from https://peerforce.org/peer-support-supervisor-pss/  ↩︎
  19. PeerForce. (n.d.) PeerForce homepage. Retrieved on December 29, 2023 from https://peerforce.org/ ↩︎
  20. Peyson, R., Smith, K.D., and Castedo de Martell, S. (2022). Unlocking the potential of Recovery Community Organizations and Peer Recovery Support Services. Faces and Voices of Recovery. https://facesandvoicesofrecovery.org/wp-content/uploads/2023/06/FV_Position-Paper_Final-Accessibility_05-17-23.pdf  ↩︎
  21. https://capitol.texas.gov/BillLookup/history.aspx?LegSess=87R&Bill=HB4 ↩︎
  22. https://capitol.texas.gov/BillLookup/history.aspx?LegSess=88R&Bill=HB1726 ↩︎

Updated on December 16th, 2024



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