Breaking Point: Ohio's Behavioral Health Workforce Crisis
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In December 2021, The Ohio Council of Behavioral Health & Family Services Providers published “Breaking Point: Ohio’s Behavioral Health Workforce Crisis,” an in-depth report on the employee recruitment and retention challenges faced by mental health and addiction services provider organizations. Based on original research and first distributed to the public in mid-February 2022, “Breaking Point” outlines how front-line clinical and medical staff are proving difficult to find, easy to lose, and costly to replace. As the report explains, the consequences could be grave for many Ohioans in need.

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Questions about this report? Send an email to Training and Communications Director Erich Hiner at [email protected].

The Problem: Unprecedented Demand, Limited Workforce

Driven by stressors related to the COVID-19 pandemic and opioid overdose epidemic, demand for mental health and substance use disorder treatment is at an all-time high in Ohio. Data from the Ohio Department of Mental Health and Addiction Services show a 353% increase in demand for behavioral health treatment between 2013 and 2019. Demand rose sharply in 2020-21 and is anticipated to rise further by 2030.

Of responding behavioral health care organizations to a survey conducted by The Ohio Council, more than 70% said demand for adult and youth mental health services increased from August to October 2021 (see below). More than 60% noted higher demand for adult addiction services, and more than 57% reported higher demand for crisis services.

Bar graph showing increases in demand for behavioral health services.

As demand rises, patients wait longer for critical services. More than 60% of survey respondents reported longer wait times for adult and youth mental health services from August to October 2021, and more than 50% reported longer waits for adult substance use disorder (SUD) treatment (see below).

Bar graph showing increases in wait times for behavioral health services.

At the same time Ohioans’ need for treatment is rising, the behavioral health workforce is wearing thin. Ohio Council survey respondents report that front-line clinical and medical staff such as psychiatrists, therapists, and case managers are becoming harder to find in sufficient numbers to meet growing demand. When they can be found, front-line staff have become more likely to leave their jobs or to exit the field altogether. Once vacated, positions are staying open for longer, which widens the gap between treatment supply and demand.

More than 98% of survey respondents said recruitment was very or somewhat difficult between August and October 2021. More than 88% reported difficulty keeping staff. Roughly 77% reported higher turnover with many positions open for two to six months, and more than 10% reported clinical/medical vacancies lasting for more than a year. More than 70% said a lack of qualified applicants is an obstacle to recruitment and retention, suggesting that credentialing requirements may be limiting the number of potential recruits.Stacked bar chart showing obstacles to behavioral health professional recruitment and retention.


Download the Full "Breaking Point" Report.
Download the Executive Summary.

The Causes: Attrition, Stress, Insurance Issues, and Credentialing

Behavioral health workforce shortages have come about and worsened for several reasons. Natural attrition was an everyday reality in the field prior to the pandemic. Behavioral health care is often stressful with long, irregular hours and on-call requirements. In addition, community-based practice often requires practitioners to navigate emotionally taxing and high-risk situations. 

Pie chart showing professional incentives offered by various behavioral health providers to help with recruitment and retention of staff.

Pandemic stress has worsened these factors in recent years. As practitioners face longer hours and tough questions at home related to COVID-19, existing attrition issues have worsened. This has also been exacerbated by a lack of professional value. Many report feeling unrecognized as the critical health care workers they are. This feeds job stress, limits the workforce, and lengthens wait times for patients as a result.

Turnover is also due in part to an uncompetitive pricing market resulting from insufficient insurance coverage and reimbursement. While many private insurance companies cover behavioral health, many do not cover a full range of services for acute and chronic care or do not recognize all available licensed professionals. If an insurer does cover these essential services, it is likely at an inadequate rate. Ohio Medicaid, meanwhile, is limited to reimbursing for services at a rate that often falls below the actual cost of care. The gaps left by inadequate private-sector payments and coverage of services and providers have contributed to wage stagnation.

These trends are colliding at a time when many large, private employers are rolling out significant incentives to attract new workers. Most companies are not limited by the same reimbursement issues as behavioral health providers, which means providers often cannot adequately compete for workers despite creative retention efforts (see chart).

Lastly, recruits are being kept out of the system by excessive professional licensing and education requirements. State rules often require a person to have a master’s degree to hold behavioral health licensure, and earning potential is limited in the field below that level of education. As a result, the industry lacks a clear career ladder. More numerous and less costly points of entry and career growth paths are necessary to increase the workforce and meet demand.

Download the Full "Breaking Point" Report.
Download the Executive Summary.

The Solutions: Relief, Parity, Simplicity, and Administrative Reform

As more Ohioans require and seek behavioral health care, the workforce must be available to handle the rising demand and provide services to those in need. If the crisis remains unaddressed, Ohioans who need mental health and addiction services may go without them and, in some instances, need to escalate to crisis services to access care. The Ohio Council recommends the following to address the workforce shortage:

Short-Term: Targeted Relief & Infrastructure Development

  • Approve the remaining components of the plan from the Ohio Department of Medicaid for the use of American Rescue Plan Act funds for Home and Community Based Services Spending. This plan allocates desperately needed funding for immediate and short-term workforce recruitment and retention. It would help providers pay for badly needed sign-on and retention bonuses, expand current workforce through paid internships, provide scholarship opportunities, and enhance technology to increase efficiencies and reduce administrative burdens.
  • Provide funding opportunities for salary and cost-of-living incentives in high-demand jobs (e.g., community behavioral health centers) and high-need areas (e.g., rural areas).
  • Develop and expand state and local-level tuition reimbursement, student loan forgiveness/ repayment programs, training stipends, health insurance subsidies, housing stipends, child care subsidies, transportation stipends, and state tax credits to people entering and currently working in behavioral health organizations.
  • Provide financial resources and/or technical assistance opportunities to behavioral health providers to develop and implement local workforce development strategies and succession planning.
  • Develop and fund incumbent worker training programs, scholarships, internships, field placements, and residency positions in behavioral health organizations.
  • Create a statewide, centralized technical assistance center to market and support individuals in accessing and navigating federal and state student loan and tuition assistance programs.
  • Develop global public awareness campaigns to elevate the career opportunities and growth available in behavioral health professions, including outreach to middle and high schools.

Short-Term: Enforce Existing Parity Requirements

  • Increase education to individuals, families, providers, and employers about mental health and addiction insurance parity and increase oversight and enforcement of mental health parity among all insurance plans to increase coverage for behavioral health services.
  • Incentivize commercial insurance plans to provide direct reimbursement for all levels of licensure and certification among behavioral health professionals.

Short-Term: Remove Administrative Barriers

  • Reduce administrative barriers and expedite applications for licensed providers in good standing applying for Ohio licensure from out of state.
  • Create dedicated resources to compensate community-based behavioral health organizations that provide training for residents, students, and newly licensed behavioral health trainees in their field education and first two years of clinical practice to achieve advanced licensure.
  • Reduce burdens in documentation and service requirements related to treatment planning and align with standard medical care that integrates treatment planning into each session or note.

Mid-Term: Develop New Reimbursement & Licensure Models

  • Develop policies to implement and fund the Certified Community Behavioral Health Clinic (CCBHC) model supported by the U.S. Substance Abuse and Mental Health Services Administration. This would offer a prospective payment model and allow organizations to provide enhanced services and higher salaries.
  • Restructure and create community behavioral health reimbursement strategies to include alternative payment models that will support wages and benefits commensurate with education, experience, and levels of responsibility. These strategies must align with efforts to integrate traditional behavioral health workers as part of integrated bi-directional health care teams, assertive community treatment teams, non-clinical care settings, schools, etc.
  • Develop new reimbursement models that align incentives and risk sharing so providers can develop creative interventions and efficient practices to meet the needs of the population served.
  • Pending the availability of new, dedicated funding sources for home- and community-based services, identify targeted reimbursement adjustments that will augment access and reduce gaps in community-based behavioral health care.
  • Modernize state licensure requirements across all behavioral health professional disciplines to include certification and licensure options at all educational levels (i.e. associate’s, bachelor’s, master’s, and doctorate).

Long-Term: Strengthen the Workforce Pipeline

  • Identify opportunities to create innovative financing models for the recruitment of new workers, such as career impact bonds (CIBs). CIBs create education financing through public and private sector investments with an arrangement requiring students to pay back the cost of education overtime as a percentage of their wages.
  • Require education programs and accrediting bodies to prioritize establishing coursework that is reflective of current behavioral health practice. Such coursework should cover education and licensure requirements and practice in community-based settings while keeping pace with emerging evidence-based practices, quality improvement approaches, and models of care based on inter-professional teams.
  • Develop career ladders, including training programs, professional development, continuing education, and opportunities for licensure and certification at all levels of education across all professional disciplines.

Download the Full "Breaking Point" Report.
Download the Executive Summary.

Conclusion and Acknowledgments

The community behavioral health workforce is at its breaking point. The behavioral health workforce crisis was a growing cause for concern prior to 2020 and has only worsened since the pandemic began two years ago. The demand for employees across the economy has led to increased starting wages and improved benefit packages that are nearly impossible for non-profit organizations to compete with due to perceived lack of value of the work, challenging and unpredictable work settings and schedules, and insurance reimbursements that are static and do not keep pace with inflation or the cost of doing business.

In addition, administratively burdensome regulations and licensure make it difficult for behavioral health care providers to recruit and sustain an adequate workforce. As the demand for behavioral health services continues to increase, so does the need to recruit and retain qualified staff. The current shortage of skilled and highly trained workers requires immediate planning and action to ensure that Ohio can meet current demand, adapt to consistently growing behavioral health needs, sustain access to a full continuum of care, and provide quality services across the state. We must act now to build career pathways and a workforce pipeline that brings young and aspiring talent into these professions.

The Ohio Council of Behavioral Health & Family Services Providers would like to thank our member organizations that responded to our 2021 workforce survey. This report was made possible by the time and care taken by agency staff in providing reliable, recent employment data. We would also like to thank Ohio Governor Mike DeWine, RecoveryOhio, the Ohio Departments of Medicaid and Mental Health & Addiction Services, and other executive agencies for their ongoing efforts to improve access to mental health and substance use disorder treatment throughout the state.

Download the Full "Breaking Point" Report.
Download the Executive Summary.

Questions about this report? Send an email to Training and Communications Director Erich Hiner at [email protected].

 About The Ohio Council

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