Developing Regional Mental Health Priorities: Mixed-Methods Needs Assessment of Eight States in the Southeastern United States

State mental health agencies (SMHAs) offer a wide variety of services and programs to meet the mental health needs of the people in their states. Often, SMHAs work within their state’s geographic borders, with few opportunities to learn from and exchange information about effective initiatives with other states. The U.S. Department of Health and Human Services (HHS) has grouped states into 10 regions. The mental health activities of the Substance Abuse and Mental Health Services Administration (SAMHSA) within each region are coordinated by a regional administrator (1). These regional groupings provide an opportunity for SMHAs to collaborate and share best practices with other states in their region to promote capacity building and to disseminate evidence-based practices.

To provide mental health training and technical assistance and to facilitate dissemination and implementation of evidence-based practices, SAMHSA launched the Mental Health Technology Transfer Center (MHTTC) Network in 2018 (2). The network is composed of 10 regional centers (one for each HHS region), two national centers (a Hispanic and Latino center and an American Indian and Alaskan Native center), and a national coordinating office. The Southeast MHTTC serves the largest region, with eight states in HHS Region 4: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee. Region 4 is home to 20% of the U.S. population (3). Given the size and diversity of this region, we sought to better understand the structures, resources, strengths, and needs of our public mental health systems. Our goal was to identify common priorities across the southeastern states that could guide our center’s activities and promote cross-state interaction and collaboration throughout the region. In this column, we describe our process for identifying the mental health priority areas of the Southeast.

Needs Assessment Process

The purpose of the needs assessment was to examine Region 4’s demographic, clinical, and public mental health system characteristics; available mental health–related training; and the mental health priorities, initiatives, and needs of our states (4). We collected data through a mixed-methods approach that included document review, quantitative analysis of publicly available data, and stakeholder interviews. The Southeast MHTTC team contributing to the data collection and analysis included the evaluation director, two project coordinators, a data analyst, and two graduate students, who worked closely with the center’s director, deputy director, and training director. Data collection and analysis occurred from November 2018 through May 2019. For the document review, we gathered information about SMHAs and financing for mental health services from the websites of SMHAs and other state agencies as well as from publicly available reports and resources. We conducted targeted Internet searches to compile a list of available mental health–related training and resources in each state. To examine the location and characteristics of outpatient mental health facilities in the region, we analyzed data from the SAMHSA Treatment Locator Database (5) and the Health Resources and Service Administration’s Area Health Resources Files (6). We held a series of conversations with state mental health commissioners, and we conducted interviews with key SMHA leaders. In total, we spoke to 22 stakeholders (1–4 per state). The purpose of the key informant interviews was to gather in-depth information about the structure of the state mental health system; the SMHAs’ priorities, initiatives and programs, and areas of need; and the SMHAs’ preferences for technical assistance. We took detailed notes during each meeting, which were then analyzed for common themes.

We examined the findings from the three data sources to identify which topics were of importance to SMHAs, areas in which the SMHAs were working, and areas of need. We subsequently shared the identified regional priority areas with the eight-member Southeast MHTTC Advisory Board—composed of state mental health commissioners, chiefs of staff, and other state mental health leaders—for additional review and input. Advisory board members confirmed that the identified priorities aligned with their SMHAs’ aims and provided feedback that we incorporated into our report. We shared the final report with the advisory board and with other key stakeholders in the region.

Regional Characteristics

To gain a better understanding of HHS Region 4, we examined the characteristics of the region and the eight SMHAs to identify similarities and differences across states. The demographic profiles of the Region 4 states vary greatly in total population, racial and ethnic diversity, and percentage of the population living in rural areas. Compared with the United States overall, the southeastern states tend to have a larger proportion of the population living at or below the federal poverty level, as well as higher rates of people who are unemployed and uninsured (7). The percentages of people with a mental illness, substance use disorder, or suicidal ideation in the Region 4 states are generally comparable to those of the United States overall (8).

Across the region, the public mental health systems vary in organization, structure, financing, and services offered. A majority of SMHAs operate as independent state departments (Alabama, Georgia, Mississippi, South Carolina, and Tennessee), but some are housed under other state agencies (i.e., Health Department in Kentucky, Department of Human Services in Florida, and Department of Health and Human Services in North Carolina). Most SMHAs (except for those in North Carolina and South Carolina) are responsible for substance abuse services, and half provide services for individuals with intellectual and developmental disabilities (Alabama, Georgia, Kentucky, Mississippi). All of the SMHAs provide community-based mental health services and support as well as inpatient care in psychiatric hospitals. The SMHAs fund and administer community-based mental health services through one or more mechanisms, including direct provision of services, provision of funding but not operation of SMHA service provider organizations, and provision of funding to local authorities to oversee and manage service provision. According to SAMHSA data from 2014 (9), Region 4 states served approximately 1.3 million clients and expended $4.4 billion.

Like states across the country, Region 4 states experience shortages in the psychiatric workforce, particularly for adult and child psychiatrists, mental health counselors, social workers, and school psychologists (10). Similar to the United States overall, most counties in Region 4 (61%) are designated as complete mental health professional shortage areas, and 55% of counties in the region have fewer than one practicing psychiatrist per 100,000 residents. Across the Region 4 states, SMHAs, health care service providers, nonprofit organizations, and other organizations provide a variety of training opportunities for the mental health workforce and other professionals (4).

Regional Mental Health Priority Areas

Of the 24 topics that arose during the stakeholder interviews and the document review, we identified six regional priority areas: mental health workforce, school-based mental health, suicide prevention, peer workforce, criminal justice and mental health, and supported housing. These priority areas are being used to inform the training and technical assistance activities of the Southeast MHTTC. (A table summarizing the priority areas is available in the online supplement accompanying this column.)

Mental health workforce.

Shortages in the mental health workforce are challenging for all Region 4 SMHAs. States experience difficulties in filling behavioral health positions in community mental health clinics and in specialty sectors, including criminal justice and school-based mental health. States are looking to identify and implement effective strategies for recruitment, retention, and leadership development of the mental health workforce.

School-based mental health.

All of the states in the southeast region have initiatives to expand school-based mental health. SMHAs are working to identify and implement behavioral health assessments, develop the capacity of the school-based mental health workforce, and improve coordination between schools and mental health clinics. SMHAs have noted challenges in financing these efforts.

Suicide prevention.

Seven of the southeastern states have developed and are implementing state suicide prevention plans, and all have initiatives for crisis services (e.g., mobile crisis response teams and stabilization units). SMHAs discussed the need for expansion of services, focusing on priority populations, such as veterans, and reducing access to lethal means. Many states have incorporated suicide prevention strategies into their school-based mental health initiatives.

Peer workforce.

All our states have peer certification programs, and in all states except one, peer services are reimbursable through Medicaid. Enhancing peer services and further developing current peer programs were identified as priorities for more than half of the SMHAs. Two main needs related to peer services were identified. First, several states aim to further integrate their peer workforce into the behavioral health care system and specialty services, including hospitals, emergency rooms, and prisons, with the goals of facilitating care transitions and better supporting underserved populations. Second, SMHAs expressed a need to educate mental health providers and managers on the role and value of peer specialists and on how to best integrate peer specialists into their teams.

Criminal justice and mental health.

All of the SMHAs in the Southeast currently implement initiatives to address the mental health needs of individuals in the criminal justice system, including training for crisis intervention teams, prearrest diversion programs, and reintegration programs. Additional areas for development could include additional training for criminal justice professionals, strengthening of collaborations with state justice agencies, and expansion of services.

Supported housing.

All of the southeastern SMHAs implement supported housing initiatives, particularly permanent supported housing and transitional housing. Areas of need related to supported housing include financing, expansion of housing programs, and improved integration and coordination between supported housing and mental health services.

Conclusions and Lessons Learned

This needs assessment provided a valuable opportunity to understand the state mental health landscape not only in each of the eight southeastern states but also across the region as a whole. Our mixed-methods approach yielded key information from each data source about the region’s mental health initiatives, assets, and needs. Engagement of stakeholders, particularly the SMHA leaders, proved essential, both throughout the needs assessment process and as we continue to use the findings to inform the Southeast MHTTC’s activities.

Across Region 4, SMHAs implement a variety of initiatives and services to address the mental health needs of individuals in their states. However, each of the states experiences challenges, most of which are shared by other states (e.g., workforce shortages and financing). Through the needs assessment process, we identified six regional priority areas in which most or all states had current initiatives but also gaps between available services and the desired level of programming. Each state has key initiatives and assets that can serve as examples for other states in the region.

Identification of common priorities and challenges for SMHAs in the Southeast presents an opportunity for these states to converge on and discuss common topics and to facilitate shared learning. SMHAs could benefit from the opportunity to learn from each other, problem solve together, and consider ways to adapt new approaches to their states or leverage resources across states. In addition to allowing states to connect with each other, the Southeast MHTTC can coordinate opportunities for dialogue and training across the region. Group learning models, such as learning collaboratives, provide a framework for supporting discussion and sharing of information, organizational-level change, and implementation of evidence-based practices (11). The Southeast MHTTC has developed an array of strategies, including webinars, in-person training sessions, intensive coaching, and learning collaboratives, to address each of the priority areas identified in the needs assessment.

We identified several lessons from engaging in the needs assessment. This process demonstrated the value of using quantitative and qualitative data sources to identify regional strengths, challenges, and priorities. The information we obtained can be used in strategic planning to support the region. For example, the results can be used to facilitate shared learning across states and to engage state leaders, who may be especially interested to learn about examples from other states with similar challenges and constraints. Additionally, the priority areas identified can continue to inform the creation of training and programming targeted to regional needs. The needs assessment findings and mental health priority areas can serve as a foundation on which to foster collaborative engagement in the region.