Behavioral Health Workforce Development in Washington State: Addition of a Behavioral Health Support Specialist

The significant shortage of mental health providers in the United States, combined with the increased demand for and limited access to care services, has led the White House and Bipartisan Policy Center to urge better preparation and expansion of the mental health workforce in the United States (1, 2). The two reports propose to expand access to services via behavioral health support specialists (BHSSs). BHSSs have the equivalent of at least a 4-year bachelor’s degree in the United States, complete a supervised clinical practicum, and will be credentialed in 2025 to deliver brief, supervised, and evidence-informed behavioral health treatments in Washington State.

The University of Washington (UW) is pioneering the development of a statewide BHSS educational program that has three primary aims: develop a competency framework and curricular resources to prepare BHSSs to offer brief evidence-informed treatment for depression and anxiety, cultivate opportunities for a robust clinical practicum experience, and collaborate with state policy makers in creating mechanisms for credentialing and billing services to Medicaid and third-party insurance for this new role in the behavioral health workforce. Because of variability in how BHSSs are defined, we note that in Washington State, this provider is situated between a nonspecialist and graduate-level mental health professional. This Open Forum presents a brief overview of the BHSS role and development of BHSS-related policies.

Rationale for a Bachelor’s-Level BHSS

Untreated depression and anxiety have an enormous negative effect on the health of individuals and families and also result in costs to the economy due to loss of work resulting from mental health–related impairment or disability (3). Underserved and marginalized communities often bear the brunt of untreated behavioral health needs. Primary care is the most common setting for depression diagnosis and treatment, and pharmacotherapy is often the first-line treatment despite patients’ preference for psychosocial interventions (4). One solution to increase access to psychosocial interventions is to equip a bachelor’s-level behavioral health workforce with the skills to deliver such interventions (5).

Preceding the development of bachelor’s-level credentialing in Washington State were global mental health initiatives that include task sharing (6). Leveraging communities and nontraditional providers (such as paraprofessionals, nonspecialists, and lay providers) to provide health care was pioneered in low- and middle-income countries and humanitarian settings, with robust evidence for the efficacy, effectiveness, and acceptability of these providers across many mental and general medical health conditions and different populations (7). Such strategies are readily translatable to U.S. contexts. Existing U.S. models include peer counselors, promotoras (e.g., patient liaisons, peer or family educators, and health advocates), and community health workers; however, treatment delivery is typically beyond the purview of these roles (8). Findings from previous studies (9, 10) indicate that patients accept care provided by a bachelor’s-level practitioner delivering brief, structured interventions for depression and anxiety. The employment of such practitioners within the United Kingdom’s talking therapies for depression and anxiety framework serves as proof of concept for preparing a BHSS to provide initial mental health care within a stepped care model (11). Positioning a BHSS in the context of stratified or stepped care means that low-acuity mental health needs are addressed by a trained practitioner such as the BHSS, whereas patients with more severe conditions may be served by a care team or a skilled specialist, with all team members practicing at the top of their license (12). Creating training programs to enable a bachelor’s-level workforce to competently deliver psychosocial intervention strategies is a priority for improving the quality of behavioral health care and reducing the long-term costs of untreated behavioral health conditions.

BHSS Clinical Training Program

The BHSS clinical training program emphasizes eight competency areas: health equity, helping relationships, cultural responsiveness, team-based care, screening and assessment, care planning and coordination, brief evidence-based interventions, and legal, ethical, and professional issues. The clinical training program was developed by following an initial feasibility study that included review of a BHSS job description and preliminary development and testing of a brief intervention for depression delivered by bachelor’s-level psychology students (6). Using a backward design (13), the BHSS project team produced a draft of competencies, along with required knowledge, skills, and attitudes, to frame the desired level of proficiency of BHSSs to begin clinical work. A second stage for developing a competency framework involved statewide focus groups with a convenience sample representing higher education, employers, payers, and policy groups that reviewed and provided feedback on the competency draft.

The BHSS clinical training program is designed to be integrated into an existing 4-year degree program in behavioral health care, psychology, social work, or closely related degree programs. Students enrolled in these programs may or may not have related mental or behavioral health experience but are expected to have completed prerequisite coursework in human development or theories of personality and in abnormal psychology or introduction to mental health care. The education program is fully described in the University of Washington Behavioral Health Support Specialist (BHSS) Clinical Training Program Implementation Guide (14). Currently, eight higher education programs across Washington State are in the process of conducting a self-study to assess alignment with the BHSS competencies and prepare curricular changes that help introduce applied skills. The duration of BHSS training is variable because of unique curricular designs within programs. On average, 45 quarter hours are dedicated to BHSS preparation. Competencies are assessed within the classroom and the practicum. For most programs, program integration into a baccalaureate degree means some modification to current learning outcomes and the addition of two to three courses focusing on screening and assessment, measurement-based care, brief evidence-based treatment for common behavioral health conditions, and enhanced learning on legal, ethical, and professional issues.

To crystallize learning as a bachelor’s-level provider, the BHSS clinical training program includes a minimum of 240 hours of practicum experience involving supervised direct care service. A practicum may be completed with appropriate supervision in an integrated care, specialty behavioral health, or other setting that provides behavioral health care to adults. A supervisor is defined as a person who is credentialed to provide assessment, diagnosis, and treatment of mental and behavioral health conditions in Washington State and who has supervisor training and education. BHSS supervisors will comply with existing state continuing education standards to be an approved clinical supervisor. The BHSS clinical training program will collaborate with state professional organizations to provide specific training for BHSS supervisors.

State Policy

A barrier to developing a bachelor’s-level workforce in Washington State has been insurance reimbursement to employers for services rendered by this workforce. To meet the demand to serve rural and underresourced regions of the state, potential BHSS employers must be able to bill state Medicaid services in addition to third-party payers to recover the cost of services provided by a BHSS. A 2019 sunrise review commissioned by the Washington State legislature (15) endorsed the viability of a bachelor’s-level provider to address the workforce shortage; however, the idea never gained traction.

With the official launch of the BHSS workforce project in July 2021, the project team determined that state policies needed to be developed to support service reimbursement. State Senator Yasmin Trudeau contacted the UW BHSS clinical training program to consult on a proposed bill designed to improve access to behavioral health services for integrated care and other settings. Senator Trudeau, with the support of colleagues, introduced Substitute Senate Bill (SSB) 5189 in the 2023 legislative session. On May 4, 2023, Washington State Governor Jay Inslee signed the bill into law to establish a BHSS certification in the state by January 1, 2025. The passage of this legislation has been one of the foundations to building the bachelor’s-level behavioral health workforce. The new law calls for higher-education programs offering the BHSS specialization to align with the UW BHSS clinical training program. Further, the Washington State Health Care Authority must ensure that BHSS services are covered under the state Medicaid program, and insurance carriers must provide their customers access to BHSS services according to network standards. Moreover, SSB 5189 requires approval of educational programs by the Washington State Department of Health and puts forth policies related to application, maintenance, and renewal of the BHSS credential. The department of health is currently leading rulemaking for SSB 5189 that will culminate in standards for credentialing of BHSSs.

Future Considerations

Initial criteria for demonstrating the impact and value of BHSSs to Washington State will include the number of students who are enrolled in and graduating from BHSS programs, the representative diversity of the credentialed providers, and the location and care settings where BHSSs are employed. Long-term criteria include examination of the populations served and patients’ responses to BHSS-administered interventions. We may be able to interrogate state Medicaid or other third-party insurer data that are related to symptom reduction or symptom escalation, as well as hours billed for treatment. Additionally, identifying how many BHSSs pursue advanced degrees will help assess success in building and diversifying the workforce pipeline to psychology, social work, mental health counseling, psychiatric nursing, psychiatry, and other mental and behavioral health disciplines.

The addition of a bachelor’s-level BHSS is one solution of many to addressing the gap in behavioral health access and the workforce shortage, with Washington State providing a pioneering case study. Complementary efforts to support peer specialists and community health workers as well as graduate-level specialist providers are all essential to stratifying services. A robust bachelor’s-level workforce is anticipated to increase access to evidence-informed treatment and psychosocial interventions for depression and anxiety. Such a workforce could help address these concerns and provide people with just the right level of care when they need it.