States are increasingly engaging in efforts to address behavioral health workforce shortages. Relatively low wages and high caseloads, elevated stress and burnout levels, and an aging workforce have contributed to these persistent shortages, which have been exacerbated by the COVID-19 pandemic.
While the pandemic eroded behavioral health workforce capacity, the social and economic impact of the pandemic precipitated increased rates of substance use, stress, and suicidal ideation. Moreover, the pandemic also laid bare existing behavioral health disparities for Black and Indigenous People of Color (BIPOC): a 2020 CDC mental health survey showed that 48% of non-Hispanic Black Americans and 46% of Hispanic/Latino Americans experienced adverse behavioral health symptoms, indicating higher levels of mental health distress than their white counterparts. Both groups also reported higher rates of using substances to cope with stress; drug overdose fatalities are currently rising at faster rates among Black and Latinx populations. For example, a recent report reviewing overdose fatality data in Philadelphia showed that during the first few months preceding and into the pandemic, fatal overdoses decreased 7.3% among white individuals, but increased 5.9% among Latinx individuals and 40.3% among Black individuals.
To address these disparities, state policymakers are exploring opportunities to improve behavioral health outcomes among BIPOC communities, and to address the systemic factors that foster disparities, including the lack of diversity among providers. A behavioral health workforce that more closely aligns to the community it serves may alleviate some of these factors, as working alliances have been shown to be stronger when clinicians and clients are of the same ethnic background. Building on existing work to expand behavioral health workforce capacity, states are focusing on policies that foster equity and inclusion in recruitment and retention efforts, looking to increase workforce capacity and workforce diversity at all levels.
This brief explores existing state strategies that target increasing engagement of BIPOC across the workforce. NASHP is including lessons learned from states that have implemented programs and policies to address disparities in behavioral health workforce in particular, as well as strategies for workforce diversity more generally that may be applicable for behavioral health workforce.
What Does America's Health Care Workforce Look Like?
BIPOC practitioners are underrepresented among states’ SUD workforce: data from the Association of American Medical Colleges (AAMC) indicate that over 56% of active physicians are White, while 17.1% identify as Asian, 5.8% identify as Hispanic, and 5% identify as Black, and recent data indicates that racial diversity among medical students is decreasing. A HRSA Bureau of Health Workforce analysis from 2017 indicated an even greater differential among advanced practice nurses (APN) and physician assistants (PA): 84% of APNs and nearly 73% of PAs identify as white. The same analysis indicates that among dedicated behavioral health workforces, 83.5% of psychologists are white, as are 60.6% of social workers and 64.6% of counselors. The majority of BIPOC providers in the health care workforce, including behavioral health, are employed in non-licensed, lower-paying, lower-level positions that lack standardized career ladders for professional advancement.
Summary Take-Aways of State Strategies
- Engage BIPOC communities through planning and outreach. Consider opportunities to directly involve BIPOC stakeholders and staff in the building of diversity and equity initiatives, and develop meaningful outreach to diverse communities in recruitment activities.
- Use data to understand behavioral health workforce needs. Using provider licensure and certification information, states can collect and maintain demographic and geographic data to illuminate workforce gaps and opportunities for development.
- Build diversity, equity, and inclusion into state workforce planning. State Workforce Innovation Opportunity Act plans offer policymakers opportunities to integrate diversity initiatives across agencies and programs that support workforce development.
- Align across state agencies and branches. Engaging all relevant agencies under centralized state leadership to make connections that reduce duplication and maximize resources that support diversity and equity initiatives.
- Prioritize behavioral health in recruitment and retention of the health care workforce. As states implement initiatives to address health care workforce shortages, dedicating efforts specifically to the engagement of BIPOC within the behavioral health workforce helps to focus resources and policies for the particular needs of behavioral health services.
- Create a more culturally inclusive workplace for BIPOC professionals. Recognizing and responding to the lived experiences of BIPOC in behavioral health workplaces can help state policymakers address the retention issues within the field, and elevates BIPOC in environments in which client-provider relationships are essential.
- Leverage new and emerging funding opportunities to invest in diverse workforce. Recent funding options through both federal initiatives and potential legal settlements offer states a unique opportunity to consider using non-workforce specific dollars to address behavioral health workforce needs.
Engage BIPOC Communities through Planning and Outreach
Meaningful and elevated stakeholder engagement is an essential starting point for building diversity within a state behavioral health workforce.
Include BIPOC communities in program development. States can create formal structures to ensure that the needs and interests of communities of color are reflected in workforce planning. Minnesota‘s Cultural and Ethnic Communities Leadership Council was established by the state legislature to serve as an advisory group to the state’s human services commission, providing guidance on initiatives to implement culturally and linguistically appropriate services to reduce disparities. The Council’s membership is required to be composed of 15 to 25 individuals appointed “in consultation with county, tribal, cultural, and ethnic communities.” The 2020 report from the Council outlines policy and programmatic projects and achievements, including both an internal state agency workforce diversity outreach initiative with Historically Black Colleges and Universities (HBCU) and similar work within community agencies to improve workforce diversity. Hawaii‘s Workforce Development Board, a required component of state’s Workforce Innovation and Opportunity Act (WIOA) plan, must include representation from community-based Native Hawaiian organizations, and the Native Hawaiian Education Council serves as an educational partner in delivering job readiness services.
Outreach to current behavioral health workforce. A small behavioral health workforce retention survey performed with BIPOC providers by the University of Michigan Behavioral Health Workforce Center illuminated the factors that pose barriers to retention. Among survey respondents, 55% reported that they felt their opportunities for advancement are limited, though 35% expressed interest in leadership roles and 78% reported feeling qualified for leadership. Discrimination in the workplace — especially in terms of advancement and promotion — was experienced or witnessed by 28%, and among those, 66% attributed that to race or sexual orientation. These kinds of data can help state policymakers better understand challenges for recruitment and retention of BIPOC providers in behavioral health settings, and identify policy strategies that foster diversity, reduce discriminatory practices, and provide opportunities for advancement. Recognizing that opportunities for advancement within behavioral health settings help to retain talented staff, states can consider including diversity efforts in existing leadership programs, like Virginia Department of Behavioral Health and Developmental Services’ (DBHDS) SystemLEAD program that provides leadership training to applicants from both state agency and local clinical behavioral health staff.
Outreach to students and pre-licensed workforce. In 2010, Nebraska enacted legislation that created the Behavioral Health Education Center of Nebraska (BHECN) — supported by state general funds — to coordinate efforts to develop the statess behavioral health workforce across institutions of higher education. Operated out of the University of Nebraska Medical Center, BHECN tracks and responds to emerging trends and gaps in the behavioral health workforce and provides the legislature with biannual reports that include workforce data analysis. BHCEN has created paid leadership opportunities for students of color in the form of a student advisory board, with the intent of harnessing diverse student input to better understand the needs of emerging behavioral health providers in the state.
Use Data to Understand Behavioral Health Workforce Needs
Robust demographic data helps policymakers understand changes to diversity in the workforce over time, indicating how well recruitment activities are working and where opportunities for recruitment may remain. However, accessing demographic data for both professionals and the populations they serve can be challenging.
Mandate provider reporting. Several states collect demographic data as part of provider licensure renewal processes. Washington State requires physicians and physician assistants to provide information about their practices upon license renewal, including demographic information. As a part of this process, the Washington Medical Commission develops survey questions and aggregates licensee responses, publishing an annual Physician Demographic Census Aggregate Report. Notably, Washington’s report also includes responses regarding how many opioid patients a physician is actively seeing and how pain management services and/or referrals are provided. Indiana partners with the Bowen Center for Health Workforce Research and Policy, which collects, maintains, and reports on health workforce data across disciplines. The state passed a law in 2018 requiring behavioral health licensees to provide practice and demographic information upon licensure renewal beginning with the 2020 renewal cycle. In 2021, the Center published a Behavioral Health Workforce Brief detailing the information captured, and outlines the racial makeup of various specialties, analyzing diversity trends. The report indicates that diversity is increasing among all behavioral health specialties, but most significantly among addictions counselors, who, at over 20% non-White, represent the most racially diverse behavioral health workforce in the state.
Build Diversity, Equity, and Inclusion into State Workforce Planning
State departments of labor, in collaboration with other state agencies, administer federal WIOA funds that support a range of employment-related efforts. Under WIOA, states develop plans for workforce initiatives across economic sectors, including physical and behavioral health care. These plans outline the state vision and key goals, the policy and resource components within the state to support the plan, and the specific efforts that the state will undertake to achieve an overall workforce vision. States can use WIOA plans to target specific initiatives and programs that focus on engagement and recruitment in BIPOC and other underserved communities.
Include culturally competent, community-specific services. Employment preparation programs in state WIOA plans can be tailored to specific communities and populations. Hawaii‘s state plan includes development services targeted to both adult and youth Native Hawaiians. These services involve targeted outreach at Native Hawaiian community events, individual assessments and employment plans, and use of both Hawaiian and English language resources. The state plan also identifies the use of a curricular tool — Ka La Hiki Ola (Dawning of a New Day) to provide culturally relevant job readiness and employment prep that integrates the socio-political context of Native Hawaiian history and culture as a framework for learning job skills.
Address the disproportionate impact of corrections involvement on BIPOC communities. WIOA plans provide another tool for states to address the disparate impact that corrections involvement has on communities of color and reentry into the job market. Recent federal data indicates that Black men are 5.8 times more likely to be incarcerated in state and federal prison than are White men, and given this disparity, programs and policies can be targeted to re-entering individuals to ensure that employment is prioritized. To this end, states can engage their departments of corrections in WIOA planning and programs. For example, in Michigan, the state’s Department of Labor and Economic Opportunity funds the Fidelity Bonding Program, which enables employers to bond employees for the first six months of employment free of charge, helping qualified job seekers with criminal convictions or histories of SUD overcome initial employer concerns about hiring.
Mitigate trauma and social determinants that impede job readiness and success. States can leverage existing programs and build a range of employment supports into their WIOA plans. Wisconsin‘s WIOA plan provides trauma-informed care training to career counselors and other staff working in local job centers, recognizing that addressing the factors that cause and foster trauma can support success on the path to employment. California’s plan notes that services and supports can be individualized and may include resources such as subsidized childcare and dependent care, transportation vouchers, substance use disorder treatment, and housing supports.
Align across State Agencies and Branches
Developing a diverse and robust behavioral health workforce crosses state agencies and state boards: Medicaid, behavioral health, higher education, labor departments, and licensing and accreditation boards can be key to these workgroups, as are stakeholders and community leaders. Such workgroups are increasingly considering equity and diversity in their recommendations and reports, recognizing the disparity between the demographics of patient populations and the workforce that provides services.
Engage leadership. Given the cross-sector nature of workforce generally, and the specific needs of a diverse behavioral health workforce, governor-level leadership can be instrumental in making sure that these issues garner the multi-agency support needed to effect change. Governor Inslee in Washington tasked that state’s Workforce Board with developing a Behavioral Health Workforce Assessment. Among other recommendations, the report and updated 2020 recommendations focus on the role of background checks in behavioral health employment as having an inequitable impact on welcoming BIPOC providers to the field. In Illinois, Governor Pritzker appointed a Workforce Innovation Board that includes a Taskforce on Equity specifically charged with reducing inequities across the state’s workforce programs.
Leverage budget opportunities. State budgets offer a path to encourage coordination among state agencies who are critical to behavioral health workforce development and to better understand how states can remove barriers to care for BIPOC communities. The 2020 Massachusetts budget included a $250,000 appropriation for the state’s department of higher education to work in consultation with the department of mental health to develop a pilot in support of “culturally, ethnically, and linguistically diverse behavioral health workforce” development. The agency will draft a report on this work following the conclusion of the pilot, to include recommendations for state policy actions to increase diversity among the behavioral health work force. Further, the legislature made a $1.8 million appropriation for a psychiatric nurse practitioner fellowship pilot program to recruit and retain these clinicians at community health centers. Within the appropriation language, the legislature requires the state’s public health agency to work with the department of mental health to provide a report on culturally competent behavioral health service availability — including a review of the specific barriers to care for underserved communities. The report will further detail how closely current providers culturally and linguistically reflect the communities they serve.
Build workforce diversity into cross-systems planning. The 2020 West Virginia Behavioral Health Workforce Development Plan, a product of a state-university partnership funded through the federal State Opioid Response (SOR) grant, places specific emphasis on SUD treatment workforce, and highlights the need to engage equity and diversity leaders in behavioral health workforce development. Rhode Island’s Overdose Prevention and Intervention Task Force has set goals for the state to acknowledge the role structural racism plays in preventing BIPOC communities from accessing treatment for SUD. The Task Force recently revised the state strategic plan to include Meeting, Engaging, and Serving Diverse Communities among its core principles. Adding this new core principle creates a lens for Rhode Island to consider how current and future efforts to address the opioid crisis will impact communities of color, and how policymakers might take action to better address disparities in access to care and treatment.
Prioritize Behavioral Health in Recruitment and Retention of the Health Care Workforce
The process of developing a representative and diverse SUD workforce starts well before licensure, often by engaging students as early as middle school or high school. Institutions of higher education play an important role in these recruitment efforts, and states can support them through funding and partnerships across public universities and other state agencies. State efforts to increase diversity among licensed providers can take the form of university partnerships to develop medical career pipelines. Community colleges also provide educational programs for counselors and other non-licensed staff, and these programs can offer a lower-barrier entry into behavioral health careers without formal licensure.
Tailor educational pipeline programs to support underrepresented communities. States can support the emerging behavioral health workforce through targeted programs that provide tailored supports to help the provider community more closely reflect the communities they serve. The University of Fairbanks in Alaska offers a remote learning option for a social work bachelor’s program that supports students in remote/rural Native Alaskan villages. This approach grows the pool of eligible applicants for future behavioral health careers while allowing students to remain in the communities in which they live and work. This program specifically offers rural students access to university instructors but also to other remote learners and Alaska Native Elders as part of their educational experience. New Mexico is working toward a more representative professional health workforce through educational outreach and training efforts for both licensed and non-licensed professionals, including community health workers (CHW). The University of New Mexico Health Sciences Center collaborates with the University of New Mexico Office for Community Health Academy, Central New Mexico Community College, and Health Leadership High School, a local charter school focused on exposing low-income students of color to the health care field, to pilot the Community Health Worker Pilot Apprenticeship Program. This program dually accredits high school students, who graduate with a high school diploma and a certificate as a CHW — a job they can turn into a career or use as a steppingstone to a different role along a health career ladder. New Mexico is one of the few states with a minority-majority population — 48% of the state’s population identifies as Hispanic or Latinx, 10.5% is American Indian/Alaska Native, 2.6% is Black or African American, and 1.7% as Asian. Engaging local students early in their careers, retaining young professionals from underserved communities as they enter the health workforce, and educating up existing workforce necessarily diversifies New Mexico’s behavioral health workforce and ensures that existing capacity meets increasing demand for services.
Provide financial incentives. Oregon enacted HB2949 in the 2021 legislative session, which requires the Oregon Health Authority (OHA) to provide sweeping incentives and assistance to recruit and retain BIPOC, tribal, and rural behavioral health providers and to encourage providers to practice in underserved areas. The law follows OHA’s 2019 analysis of the behavioral health workforce that demonstrated both provider shortages and maldistributions of behavioral health providers across geography, practice settings, provider types, and demographics, which informed their Behavioral Health Workforce Recruitment and Retention Recommendations. The law also allocates $60M in funding, including federal American Rescue Plan Act funds, for an extensive list of financial incentives including sign on and retention bonuses, tuition assistance and scholarships for undergraduate and graduate students, loan forgiveness, housing assistance, childcare and tax subsidies, grants for graduated students to complete supervision to obtain licensure and bonuses and stipends for supervising clinicians, and more.
Build diversity into state contracting and Medicaid payment strategies. States can leverage contracts and other tools to require providers and health care organizations to implement recruitment and retention practices targeted at diversifying the SUD workforce. The New York State Office of Mental Health’s Office of Diversity and Inclusion works within the State Operated system to incorporate workplace diversity and inclusion strategies. Additionally, New York has incorporated the National Culturally and Linguistically Appropriate Services (CLAS) standards and equity requirements into all requests for proposals (RFPs) to access state funding. By tying state funding to these initiatives, New York has required community-based organizations and contractors to review and utilize workforce demographic data to inform specific diversity recruitment activities. The Oregon legislature recently enacted a law that allows the Oregon Health Authority (OHA) to amend their Medicaid demonstration project to direct coordinated care organizations (CCOs) to spend up to three percent of their global budgets to improve health equity. CCOs must spend these funds on creating a culturally and linguistically competent workforce, supporting staff based in underserved communities, and investing in behavioral health. OHA will track outcomes and make them publicly available. States can also consider innovative options to include diversity components for individuals with behavioral health needs in Medicaid managed care contracts.
Create a More Culturally Inclusive Workplace for BIPOC Professionals
States, health care organizations, and professional associations are increasingly requiring cultural competency and implicit bias training for employees, as such training has the potential to improve the quality of care provided to diverse populations and ensure better health outcomes for communities of color. Providing cultural competence training to healthcare providers has been found to improve sensitivity to language barriers and the importance of the patients story, in addition to boosting patient satisfaction.
Consider continuing education requirements. Licensing boards and professional organizations play a critical role in increasing the diversity and cultural competency of the SUD workforce. These boards can also uphold continuing education requirements that address diversity and bias training for providers. Oregon‘s health regulatory boards, for example, all have regulatory authority to require cultural competence training for licensed providers. Professional organizations, like the American Society of Addiction Medicine’s (ASAM), recommend reviewing continuing medical education (CME) and training requirements to ensure that they include trauma-informed care and competency around structural racism to better serve racially marginalized individuals.
Several states require cultural competency continuing education (CE) for social workers, who provide behavioral health assessments, treatment and therapy, and case management services. Notably, Rhode Island requires three hours on “cross cultural practice to include alleviation of oppression” for each renewal. Arizona, Alaska, Illinois, Mississippi, New Mexico, and the District of Columbia also require cultural competency CE training for social workers. Many states also allow free, online CLAS courses through federal Health and Human Services (HHS) to count as credit for ongoing and continuing education requirements for various behavioral health/SUD practitioners.
Require culturally competent supervision for peers. All states require peers to complete a period of supervision, usually by a licensed or certified provider, prior to certification. In 2017, the Oregon Health Authority reviewed peer supervisor standards, which state certified peers and peer supervisors then used to develop Oregon’s Substance Use Disorder Peer Supervision Competencies. These competencies require supervisors to help peers develop an understanding and respect of traumatic ‘experiences, oppression, institutional, and judicial bibias experienced by vulnerable populations” and the role trauma plays in substance use. Oregon’s Peer Supervision Competencies also include a Peer Employee Competency Evaluation Form, which evaluates peers’ ability to “recognize and respond to the traumatic experiences of vulnerable populations.” In the absence of a diverse peer supervisor population that could provide more effective mentorship to diverse peers, it is especially important for supervisors to be trained in competency and trauma-informed care when working with BIPOC peers.
Recent research from the Foundation for Opioid Response Efforts (FORE) examines the particular roles that peers play in SUD care, as well as the challenges of this work. While peers are uniquely qualified to work with individuals in SUD treatment based on shared lived experience – and self-report a sense of purpose and drive in this work – they also expressed that a lack of clear career ladders, lack of longevity/job security, and low pay pose barriers to remaining in these roles. Further, peers reported that because training generally is not population-specific and encourages “meeting people where they are,” their work with individuals is not usually informed by specific diversity or ethnically oriented frameworks, which suggests an opportunity for states to develop further training and education.
Looking Ahead: Leverage New/Emerging Funding Opportunities to Invest in Diverse Workforce
New, one-time federal investments in behavioral health create opportunities for states to fund workforce diversity initiatives. The American Rescue Plan Act of 2021 (ARPA) included funding for states not only through increases in Substance Abuse Prevention and Treatment block grants (SABG), but specific provisions to support workforce development. Among several behavioral health workforce supports included in the bill, ARPA authorizes $100 million for behavioral health workforce and education training for educational institutions through the Public Health Service Act and establishes a 10% increase in federal matching funds for state Medicaid home and community-based services (HCBS). This match, which is available to states for one calendar year through March 2022, is being used by states to support HCBS workforce development through increased reimbursement rates and specialty pay in order to recruit and retain behavioral health staff, as well as for trainings and other equity initiatives. Importantly, as one-time funding, this presents states with opportunities for recruitment and retention initiatives in the short term; states can build on these development opportunities as they consider how to develop longer-term, sustainable approaches to workforce diversity.
Further, recent legal settlements reached between state attorneys general and opioid pharmaceutical companies totaling $26 billion (a $21 billion distributor settlement agreement to be paid out over eighteen years and a separate $5 billion Janssen settlement agreement to be paid out over nine years) may also provide states with new, flexible funds to address systemic needs for SUD care. With many other legal cases pending, the potential for additional funding also remains. Many states are setting these dollars aside in dedicated funds to be administered year over year by newly established authorities. These settlement dollars offer states opportunities to consider infrastructure investments, including efforts to develop, recruit and retain the SUD workforce.
