What Will it Take?
Recently a colleague sent me a link to a presentation I gave at the 31st Annual Rosalynn Carter Symposium that was focused on the behavioral health workforce. In this talk entitled, The Behavioral Health Workforce: Evolution, Transformation or Revolution, I did not recount the multifaceted nature of the problem, nor its historical roots, nor the overwhelming data we have documenting the crisis. I did suggest that neither “evolution” nor “transformation” have served our field well as limited progress has been made on the issue for the past couple of decades. Rather, I proposed we needed “revolutionary” tactics and strategies focused on four areas: 1) settings, 2) providers, 3) practice, and 4) education. (The talk can be accessed at https://youtu.be/WYqcWUKZBwg).
Settings. I observed that our clinical settings have traditionally included hospitals and clinics. But those settings are not where people work, play and live. If we really want to meet the needs of our population, we must consider providing behavioral health services in schools, community centers, churches, and even retail stores. The recent pandemic has increased our use of telehealth care moving our practice into the home, and that benefit will hopefully only grow in the days ahead.
Providers. My second challenge was to rethink who we include when we talk about our workforce. CMS reports behavioral health providers to be psychiatrists, psychologists, social workers, counselors and marriage and family therapists. But their definition is based on which providers get direct reimbursement for their services. And so, I asked where are the 18,000 advanced practice nurses, the 82,000 nurses working in mental health facilities, the peers and consumers, families, friends and lay community workers? Other countries around the world expand their concept of the workforce and document the effectiveness of their work. They engage in task-sharing and task-shifting, while our providers too often demonstrate task-retention and task-withholding thus limiting the ability of others outside their group from practicing to the full extent of their training and skill set. Thus, I recommended that we allow for the full scope of practice and reimbursement for all licensed/credentialed clinicians, and that we expand our view of who can provide care to include peers, lay community workers, nurses and primary care providers.
Practice. I then asked us to reevaluate our practice or our focus of care suggesting that we move beyond only emphasizing medications and incorporate more psychosocial interventions that are evidence-based. I also proposed new functions to expand the reach of our current behavioral providers, suggesting that they spend a considerable amount of their time providing consultation, training of generalist providers, education to patients and families, supervision of generalist providers and quality assurance activities. Our practice would also be improved if we all used standardized, universal, simplified screening tools that would allow us to triage patients based on symptom severity, and type and intensity of service needed.
Education. My final suggestion was that we need to reconsider what and how we are teaching. Mental Health First Aid should be required for all health care students just as we teach CPR. Screening, triaging and referring should be taught as the “6th vital sign”. Brief interventions such as SBIRT, and elements of suicide prevention, crisis de-escalation and even basic CBT should be required competencies for all health care providers. Along the way we need to take down specialty and disciplinary silos, focus on task-sharing and delegation, utilize technology for anytime, anywhere lifelong learning, and work with accreditors and regulators to remove barriers to making these changes.
The revolutionary list is indeed long and ambitious but all the items on it can be done. Which brings me to the question of, “What will it take?” It has been over five years since my presentation, and we have made minimal progress on most of these issues. We have the ideas; we have the capacity to change; we have the critical crisis. What is holding us back?
Gail W. Stuart PhD, RN, FAAN
Annapolis Coalition on the Behavioral Health Workforce
Dean Emerita, College of Nursing
Medical University of South Carolina