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News and Notes   |    
SAMHSA Report Documents Workforce Crisis, Offers Goals and a Blueprint for Improvement
Psychiatric Services 2007; doi: 10.1176/appi.ps.58.5.725
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"It is difficult to overstate the magnitude of the workforce crisis in behavioral health. … [T]here is substantial and alarming evidence that the current workforce lacks adequate support to function effectively and is largely unable to deliver care of proven effectiveness in partnership with the people who need services. There is equally compelling evidence of an anemic pipeline of new recruits to meet the complex behavioral health needs of the growing and increasingly diverse population in this country. … Urgent attention to this crisis is essential."

So begins a report documenting the results of a multiyear process to assess problems in the U.S. behavioral health workforce and develop a shared agenda for improving it. Because neither states nor associations routinely collect information by use of a standardized data set, the report's authors were challenged to assemble a unified picture of the workforce.

The best available estimates indicate that there were slightly more than a half million clinically trained and active mental health professionals in 2002. Psychiatry has remained static in terms of growth, psychology has doubled in size over the past 25 years, and social work has increased by 20% in the past 15 years. Increases in the number of psychiatric nurses with graduate-level preparation largely have been offset by nurses leaving the active workforce and by sharp reductions in the number of graduate nursing students.

The report notes a critical lack of diversity. Most professionals are non-Hispanic whites, often exceeding 90% of discipline composition. For most disciplines, substantially more than half of professionals are over the age of 50, raising serious concerns about whether the pipeline of young professionals will be adequate.

Compounding these concerns are problems with geographic distribution. More than 85% of the 1,669 federally designated mental health shortage areas are rural. Half of U.S. counties do not have a single mental health professional.

In addition to professionals are 145,000 workforce members who have a bachelor's degree or less. This group too seldom receives systematic training and support, the report notes, even though it accounts for up to 40% of the workforce in many public-sector service settings.

The workforce that is specifically trained to provide substance abuse services is small in comparison to the identified need. An estimated 67,000 licensed and unlicensed counselors provide substance abuse treatment and related services. An additional 40,000 professionals are licensed or credentialed to provide such care. The substance abuse workforce is primarily female, older, and white. From 70% to 90% of treatment personnel are Caucasian, and 70% of new counselors are female. The average age of staff is mid-40s to early 50s. Thus staff frequently differ from their predominantly young, male, and minority clientele.

The report also examines system-level factors that strongly influence whether behavioral health needs are met. Throughout the multiyear planning process participants repeatedly expressed concerns that the health care environment is "toxic" to adults in recovery, to youths, and to their families. Workforce members described their low morale and low levels of commitment because of low pay, the absence of career ladders, excessive workloads, tenuous job security, a lack of supervision, and an inability to influence their organization or system.

To address workforce issues, agencies tend to do what is affordable rather than what is effective, according to the report. The most glaring example is the provision of single-session, didactic in-service trainings, despite clear evidence of their ineffectiveness in changing practices.

To address the workforce crisis, the Substance Abuse and Mental Health Services Administration (SAMHSA) commissioned the Annapolis Coalition on the Behavioral Health Workforce (www.annapoliscoalition.org) to develop a national action plan. The Coalition is a not-for-profit organization focused on improving workforce development. Since 2000 it has functioned as a neutral convener of individuals, groups, and organizations that recruit, train, employ, license, and receive services from the workforce. The report is the result of an iterative process to which more than 5,000 individuals contributed. The draft report was vetted through a national conference held by SAMHSA in July 2006 with more than 200 participants from all sectors.

The planning process identified seven core, cross-cutting goals and objectives (see box on page 725). For each goal, several objectives and numerous specific action steps are detailed in a 37-page appendix. For example, an objective for goal 4 is to launch a national initiative to ensure that every member of the workforce develops basic competencies in assessment and treatment of substance use disorders and co-occurring disorders. The first action step is to incorporate these competencies into all competency models, preservice and continuing education curricula, accreditation standards, and certification and licensure requirements. The report calls for the creation of a special commission to identify barriers, create strategies to overcome them, and report annually on progress and outcomes.

Strategic goals for behavioral workforce development

Broadening the concept of workforce

Goal 1: Significantly expand the role of individuals in recovery, and their families when appropriate, to participate in, ultimately direct, or accept responsibility for their own care; provide care and supports to others; and educate the workforce

Goal 2: Expand the role and capacity of communities to effectively identify their needs and promote behavioral health and wellness

Strengthening the workforce

Goal 3: Implement systematic recruitment and retention strategies at the federal, state, and local levels

Goal 4: Increase the relevance, effectiveness, and accessibility of training and education

Goal 5: Actively foster leadership development among all segments of the workforce

Structures to support the workforce

Goal 6: Enhance the infrastructure available to support and coordinate workforce development efforts

Goal 7: Implement a national research and evaluation agenda on behavioral health workforce development

Because the focus of the planning process was on cross-cutting goals, detailed strategic plans for specific sectors or populations were not developed. However, several panels examined nine areas, and their summaries are included in a 105-page section, "Focused Topics." The nine topics are children and their families, adult consumers and families, cultural competency and disparities, older adults, rural health care, school-based mental health, substance abuse prevention, substance abuse treatment, and workforce financing.

The report, entitled An Action Plan for Behavioral Workforce Development, is available online at www.samhsa.gov/matrix2/matrixworkforce.aspx.

Almost one-fourth of all admissions to U.S. community hospitals in 2004 for patients age 18 and older—7.6 million of nearly 32 million hospitalizations—involved depression, bipolar disorder, schizophrenia, and other mental disorders or substance use disorders, according to a new report by the Agency for Healthcare Research and Quality (AHRQ). The report presents the first documentation of the full impact of mental health and substance use disorders on U.S. community hospitals.

According to the report, about 1.9 million of the 7.6 million stays (6% of all community hospital stays by adults) were for patients who were hospitalized primarily because of a mental health or substance use problem. In the other 5.7 million stays (18% of adult stays), patients were admitted for another condition, but they also were diagnosed as having a mental health or substance use disorder. Patients who had both a mental health and a substance use disorder accounted for one million of the 7.6 million stays.

The top five behavioral health diagnoses seen in community hospitals were mood disorders, substance-related disorders, delirium-dementia, anxiety disorders, and schizophrenia. One of every ten adult hospital stays included a diagnosis of a mood disorder (more than 3.3 million stays). One of every 14 stays included a substance-related disorder (2.3 million stays), and one of every 20 was related to delirium-dementia (1.7 million stays). Nearly two-thirds of the costs for the 7.6 million hospitalizations were billed to the government: Medicare covered nearly half, and 18% were billed to Medicaid. Roughly 8% of the patients were uninsured. Private insurers were billed for the balance.

Adults with any mental health or substance use diagnosis (principal or secondary) stayed in the hospital longer than adults without such diagnoses (5.8 versus 4.5 days). The difference was even more pronounced for adults who had only a behavioral health diagnosis—they stayed in the hospital an average of eight days. Stays involving any behavioral health diagnosis were less resource intensive. The mean cost per stay was $7,800, compared with $8,900 for stays that involved other conditions. Costs per hospital day were also lower—$1,600 compared with $2,300.

The 55-page report, Care of Adults With Mental Health and Substance Abuse, presents data on nonfederal, short-term (or acute care) general and specialty hospitals and does not include specialty psychiatric or substance abuse treatment facilities. The report, which is based on 2004 data from AHRQ's Healthcare Cost and Utilization Project Nationwide Inpatient Sample, is available on the AHRQ Web site at www.ahrq.gov/data/hcup/factbk10/.

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