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DATE: |
October 11, 2022 |
10 |
SUBJECT
Title
ADDRESSING THE BEHAVIORAL HEALTH WORKER SHORTAGE IN SAN DIEGO COUNTY (DISTRICTS: ALL)
Body
OVERVIEW
The County of San Diego (County) is facing a significant behavioral health worker shortage. Today, we lack 8,100 behavioral health workers to meet the current demand. By 2027, it is estimated we will need a total of 18,500 behavioral health workers. This forecast takes into consideration current workforce recruitment and retention projections and anticipated growth in demand. Our behavioral health workers serve some of our most vulnerable populations along the behavioral health continuum of care and range from peer support specialists to psychiatrists.
A recent report conducted by the San Diego Workforce Partnership, “Addressing San Diego’s Behavioral Health Worker Shortage” (Attachment A), commissioned by Chair Nathan Fletcher, discovered that San Diego regional behavioral health workers are paid less than their counterparts in most California counties, and are leaving the San Diego workforce. Although many behavioral health workers report they love their profession, many elements such as low compensation, burdensome documentation, inaccessible educational opportunities, and stress on the job are pushing workers out of the region and profession.
Given the heightened need for behavioral health workers to address the local substance use, mental health, and homelessness crisis, it is imperative the region implement policies to build and sustain the workforce. A year-long report by San Diego Workforce Partnership provides San Diego with an understanding of the worker shortage and outlines potential solutions for how to recruit, train, and retain behavioral health workers in the region. Today’s action recommends the County adopt solutions outlined in the report to address this crisis. We urge your support.
RECOMMENDATION(S)
CHAIR NATHAN FLETCHER AND SUPERVISOR LAWSON-REMER
Direct the Chief Administrative Officer (CAO) to advance a comprehensive strategy to address the regional behavioral health workforce shortage, including advancing the five key recommendations within the San Diego Workforce Partnership Report (Report), which shall include:
1. Receive the San Diego Workforce Partnership Report (Report), “Addressing San Diego’s Behavioral Health Worker Shortage” (Attachment A, on file with the Clerk of the Board).
2. Direct the CAO to include in the Board’s Legislative Program, Priority Issues, support for legislation that would address behavioral health worker recruitment, training, and retention. In addition, add to the Legislative Program, Guidelines, support for legislation that includes but is not limited to provisions to improve behavioral health workforce licensing and credentialing, supervision and training, higher education, and parity.
3. Direct the CAO to report back in 180 days with the feasibility and, if feasible, a plan to invest in competitive compensation for behavioral health workers by establishing competitive salaries for all behavioral health positions in the County region (County positions and contracted providers), as identified in the Report “Figure 11: Wage recommendations for 10 BH professionals,” such that compensation aligns with the median or higher cost-of-living adjusted wages for California Metropolitan Statistical Areas (MSAs). Implementation shall promote best practices and standards that ensure workers are paid and treated equally regardless of if they are County workers or contracted providers.
4. Direct the CAO to report back in 180 days with the feasibility and, if feasible, a plan to pursue administrative relief by implementing the “Opportunities” found in the Report in “Table A.5: Administrative Relief Issue Areas and Opportunities,” with the overarching goal to remove administrative barriers for those providing behavioral health services, and ultimately higher quality and more timely care provision. For those Opportunities that are deemed feasible, an implementation strategy should be developed, the feasible actions should be implemented, and the CAO should provide a progress report back to the Board every 120 days on the status of implementation.
5. Direct the CAO to report back in 180 days with the feasibility and, if feasible, a plan to establish regional behavioral health training centers of excellence, which are multiple-purpose sites that serve the public and develop core competencies in training and supervision programs, to establish partnerships with educational institutions, community-based organizations, health systems, workers, and the San Diego Workforce Partnership, to develop multi-agency partnerships at existing service sites.
6. Direct the CAO to report back in 180 days with a plan to build a regional behavioral health workforce training fund and identify Private Sector, County, State, and Federal resources that could be invested in the workforce training fund.
7. Direct the CAO to report back in 180 days with strategies to continue listening to workers during implementation of the aforementioned recommendations, planning, and progress reporting. The plan shall include regular surveys of workers to assess working conditions, updates to the community on the results of the survey, and the establishment of an advisory committee of stakeholders consisting of key healthcare, behavioral health professionals, service provider executives, and labor to help support these activities.
8. Direct the CAO to report back in 180 days with a plan to implement a regional master training agreement with San Diego area community colleges, colleges, and universities that provide practicum placements for future behavioral health professionals.
EQUITY IMPACT STATEMENT
We need a behavioral health workforce that reflects the diversity of the population it aims to serve and is culturally competent, linguistically diverse, and representative. Not only do we have a workforce shortage, but our workforce is not representative of our diverse communities. Survey respondents from the Report noted a need for more BIPOC clinicians who are generally underrepresented among licensed providers. Women are underrepresented among psychiatrists, yet make up most of the masters-trained providers. Cultural competency and humility are key components in most training programs, yet the workforce fails to represent the population it services either in language or cultural background. Today’s action, through investment in competitive compensation, training centers, and financial support for workers, are all essential for attracting the future workforce and retaining the one we currently have.
SUSTAINABILITY IMPACT STATEMENT
The proposed action to advance efforts to recruit, train, and retain the local behavioral health workforce will contribute to goals in the behavioral health continuum of care to provide services in the communities where people live and reduce the need to travel long distances to find a care provider. Increasing the behavioral health workforce could result in positive social and economic enhancements, contributing to the overall sustainability of the region by providing a large workforce that supports the most vulnerable of our community. Behavioral health workers provide many necessary services to our community that creates a healthier, stronger, and more resilient San Diego. Their dedication to the well-being of others provides positive social contributions to our communities, and therefore, positive social sustainability for our region.
FISCAL IMPACT
There is no fiscal impact associated with recommendations 1 and 2. There will be future fiscal impacts based on recommendations 3 through 8, as staff begins to explore feasibility of and advance overall recommendations from the San Diego Workforce Partnership (SDWP) Report. If recommendations are not feasible immediately, the report will outline rationale for barriers. The SDWP report referenced a cost of $128 million associated with a variety of projects through a regional training fund. Additionally, work associated with recommendation 6 could result in significant additional ongoing costs above and beyond the SDWP training fund scope, depending on how it is structured and implemented.
It is anticipated that initially some of the work would begin with funding from the $15 million of American Rescue Plan Act (ARPA) funds allocated for behavioral health renewable funds per Board action taken on August 30, 2022 (20). As different components are deemed feasible and ready to implement, staff will return to the Board for approval with specific fiscal impacts that will result from moving forward in recommended areas. Staff will identify any available funding sources including ARPA funds or other program revenue as available, including reprioritization of existing funding for Board consideration as needed. At this time, there will be no change in net General Fund cost and no additional staff years.
BUSINESS IMPACT STATEMENT
N/A
Details
ADVISORY BOARD STATEMENT
N/A
BACKGROUND
The County of San Diego (County), like many other regions, is experiencing a mental health and substance use crisis. To address a growing demand for services, a concurrent investment in both behavioral health facilities and the workforce is needed. On September 27, 2022 (23) the County approved a transformational item that outlined the significant gap in services across the continuum and presented a model for planning future investment in facilities by type. Although the County continues to make significant investments in the behavioral health continuum infrastructure, there is still a significant gap in the workforce available to provide services.
The County is facing a significant behavioral health worker shortage. Our behavioral health workers serve some of our most vulnerable populations along the behavioral health spectrum, and range from peer support specialists to psychiatrists. Today, we lack 8,100 behavioral health workers to meet the current demand - this means patients are not getting the care they need and cycling through ineffective solutions. By 2027 it is estimated we will need a total of 18,500 more behavioral health workers. When coupled with an aging population, the gap in our workforce will be that much more challenging to confront. This projected workforce gap takes into consideration current workforce recruitment and retention projections and anticipated growth in demand.
Recognizing these trends, Chair Nathan Fletcher convened the San Diego Behavioral Health Workforce Steering Committee, in partnership with the San Diego Workforce Partnership, in early 2020 to analyze the current shortage and to recommend solutions to the issue. The members of the steering committee met six times over a 12-month period and comprised experts in the field including representatives from universities, hospital groups, medical and health centers, behavioral health nonprofits, patient advocacy groups, County Behavioral Health Services, and the County Behavioral Health Advisory Board.
As a result of the convenings and Steering Committee meetings, supported by incoming San Diego Workforce Partnership Policy Committee Board Chair Supervisor Terra Lawson-Remer and continued work from Chair Nathan Fletcher, the San Diego Workforce Partnership produced a report, “Addressing San Diego’s Behavioral Health Worker Shortage” (Attachment A). The Report synthesized the results from a year-long research process, including 1,600 survey responses from behavioral health workers (representing about 10% of the current workforce). The Report identifies five key recommendations for how to address the worker shortage. The five key recommendations outline bold initiatives specific to San Diego: 1) invest in competitive compensation, 2) pursue administrative relief opportunities, 3) establish regional training hubs, 4) build a regional workforce training fund, and 5) continue listening to workers. In addition to these recommendations, the Report suggests legislative and administrative policy recommendations on licensing and credentialing, supervision and training, higher education, contracting, documentation, and reimbursement parity at the local, state and federal levels. The Report recommendations are described in greater detail below.
Invest in Competitive Compensation
Pay is the primary reason why people are leaving behavioral health professions. The Report notes that 55 percent of behavioral health workers interviewed were dissatisfied with their pay compared to 24 percent of U.S. workers overall. Furthermore, pay is a deterrent for those considering entering behavioral health professions when compared to other careers that may not require as much educational investment. If San Diego County is to attract and retain workers that can live in the region where they work, compensation must be a priority.
The Report shows that with higher pay individuals are less likely to leave their jobs. Survey responses emphasize the association between compensation and retention and indicate that workers who leave will leave for similar jobs but in a lower cost of living location or higher pay. Investment in competitive compensation for behavioral health workers refers to matching or exceeding median salaries when adjusting for cost-of-living. Among 33 other California Metropolitan Statistical Areas (MSAs), behavioral health occupations in San Diego fall below median salaries. See Table 1, Reproduction of Figure 11, Wage recommendations for 10 BH professionals. Social and human services assistants, which include peer support specialists, pay the lowest among comparison MSAs. Peer support specialists should be a key focus in addressing pay parity. With the passage of Senate Bill (SB) 803 (Sen. Jim Beall, 2020), certified peer support specialists now qualify for Medi-Cal reimbursement which opens new funding opportunities. Legislative advocacy around rate-setting structures and federal and state reimbursement is integral in the effort to address compensation and should be threaded with this recommendation.
Table 1. Reproduction of Figure 11, Wage recommendations for 10 BH professionals.
|
Occupation |
San Diego Percentile rank of 34 CA MSAs |
Average 2021 San Diego Wage |
Match median wage in highest- paying MSA |
Match median wage in 75th percentile MSA |
|
Social and Human Services Assistants (Includes Peer Support Specialists) |
1% |
$32,620 |
$73,340 |
$51,067 |
|
Psychiatrists |
4% |
$165,386 |
$383,773 |
$329,386 |
|
Psychiatric Aides |
11% |
$31,176 |
$66,957 |
$42,956 |
|
Community Health Workers |
12% |
$43,892 |
$73,882 |
$55,669 |
|
Marriage & Family Therapists |
12% |
$46,944 |
$98,632 |
$69,319 |
|
Mental Health and Substance Use Disorder Social Workers |
17% |
$56,216 |
$119,113 |
$93,362 |
|
Clinical, Counseling, and School Psychologists |
45% |
$103,811 |
$153,474 |
$140,097 |
|
SUD Counselors |
27% |
$45,590 |
$85,947 |
$63,837 |
|
Registered Nurses |
33% |
$112,222 |
$175,701 |
$138,380 |
|
Psychiatric Technicians |
48% |
$62,656 |
$96,016 |
$80,543 |
Today’s action will begin efforts to address compensation for behavioral health workers in the San Diego region both internally for County workers and through County contracts. Ensuring competitive compensation will promote staff retention, staff recruitment, and improve job satisfaction for Medi-Cal programs where there is high staff turnover and mental health clinicians are leaving for private practice. Staff turnover is detrimental to the people who rely on the County for behavioral health services. Trust developed between mental health providers and patients is integral to rehabilitation outcomes. When clinicians leave, it impacts their clients and dismantles the therapeutic alliance they have created.
Pay for workers is impacted by cost reimbursement and is a direct result of state and federal policies and contracting practices at the County level. On June 8, 2021 (11), the Board of Supervisors acted to strengthen the County’s service delivery and contracting policies with guidance from the Fiscal Subcommittee. Today’s action will build on this policy and the Framework for the Future to promote contracting policies that uplift all workers both in contracted agencies and among county staff. The dramatic shortage in behavioral health workers presents an environment where agencies are competing for the same employees. The recommendations today offer an opportunity to increase the pipeline of workers, reduce turnover, and support a robust behavioral health workforce for the region. With the implementation of the recommended actions, it will be imperative that contracts do not displace county employees or drive down public service investment.
To address compensation specifically, we propose a mechanism to support salary increases for behavioral health positions and build in market-rate adjustments such as cost of living adjustments. We need an additional 8,100 workers just to meet the current need which creates competition between agencies. The County of San Diego is a primary provider and payer for behavioral health services and has an opportunity to lead in addressing compensation for the region to keep workers here, support students who want to stay, and recruit new workers for the region, for both internal County positions and opportunities at contracted service providers.
Pursue Administrative Relief
The Report identifies 12 issue areas and 29 opportunities, Table A.5: “Administrative Relief Issue Areas and Opportunities” to address administrative relief as a mechanism for retaining workers. Administrative relief refers to lessening the documentation, paperwork, and administrative requirements of behavioral health worker jobs. These opportunities would create instant bandwidth within the existing workforce by prioritizing direct services in programs.
Among San Diego behavioral health workers surveyed, 39 percent were either dissatisfied or completely dissatisfied with the administrative burden of their work. This is the third most common reason why workers are leaving the profession ranking right below pay and stress on the job. The administrative burden was described in survey responses as “impossible,” “unsustainable,” and the audit process as “merciless,” “pathological,” “demoralizing” and “brutal.” Addressing administrative burden in the healthcare field is considered one of the most effective strategies for reducing burnout. Such a high level of dissatisfaction with administrative burden is of serious concern as the loss of any qualified, compassionate, and experienced behavioral health worker hampers our ability to respond to the regional behavioral health crisis.
While the State is potentially pursuing some administrative changes through the California Advancing and Innovating Medi-Cal (CalAIM) process, there are additional actions the County could take. The County can lessen the administrative burdens in County operational processes that are not required by State or Federal statutes, and negatively impact worker stress without demonstrated benefit to clients. Examples include duplicative documentation and redundant data entry due to separate electronic medical record systems. Chart review and auditing process are onerous both for contracted providers and staff within the Agency. Efficiencies should be explored in terms of technological solutions and reporting requirements with a focus on the triple aim of improving clinical care, promoting better outcomes, and reducing costs.
Additionally, administrative burdens for new and training behavioral health professionals is hampering their ability to enter the field. Most behavioral health occupations require hours in an internship, residency, or other on-the-job supervised clinical experience which are often performed at County contracted agencies. Agencies enter into service-learning agreements with colleges and universities and the student completes training and background screening before placement. Today’s recommendation asks the Department of Purchasing and Contracting and Behavioral Health Services to explore a master training agreement that would streamline the ability to place students with County contracted agencies expeditiously. If County contracts included an agreement with baseline training and screening processes for contracted providers who provide supervised clinical experiences it would allow for faster placements and more flexibility when changes are needed. Additionally, a master training agreement would streamline student placement onboarding and provide administrative relief for licensed clinicians providing supervision.
Ultimately, administrative burden takes time away from patient care, contributes to burnout, and increases the cost of providing services. The Report acknowledges that addressing administrative burdens is complex, systemic, and historical. We hope that Table A.5: “Administrative Relief Issue Areas and Opportunities” can be the first step in identifying opportunities for improvement both for improved County processes and in our Legislative Program.
Establish Regional Training Centers of Excellence
Regional behavioral health training centers of excellence (COE) are an opportunity to build a pipeline for in-demand behavioral health jobs. These multiple-purpose sites serve the public and develop core competencies in training and supervision programs that are needed to expand the region’s behavioral health workforce infrastructure. COEs would also provide technical assistance and operational support to other community-based organizations to establish their own training programs, and provide applied research opportunities for innovations in service delivery, training efficacy, and workforce optimization
Behavioral health training and education program coordinators identified the lack of quality training sites as one of the primary obstacles to increasing the number of students and graduates in their programs. Through COEs, future workers can be trained in real-world environments, supported through technical assistance, and can contribute to a culture of innovation. The Report recommends the County establish a partnership with educational institutions (mental health undergraduate programs, graduate programs, and community colleges), community-based organizations (CBOs) delivering behavioral health services, health systems, community colleges, and the San Diego Workforce Partnership, to develop multi-agency partnerships at existing service sites, like CBOs, that develop core competencies in integrated training and supervision program design, operations, behavioral health training financing, and public sector retention, all while providing much-needed services to the public. Workers should also be included in these partnerships.
Build Regional Behavioral Health Training Fund
A behavioral health workforce training fund would remove economic barriers that may prevent people from entering or advancing in the behavioral health workforce. The cost of living in San Diego coupled with the cost of education and training is an economic barrier for many. Working around the barrier of the cost of education can open up new pathways, and not only increase the pipeline for the behavioral health workforce, but can address systemic issues of economic inequity.
This Report estimates a $425 million investment is needed to expand the region's behavioral health worker talent recruitment, training, and education systems for the additional 18,500 workers needed over the next five years. The County has demonstrated a commitment to supporting this fund by allocating a portion of its remaining American Rescue Plan Act (ARPA) funds of $15 million towards this endeavor. However, the amount allocated by the Board is only a portion of the total funding that is needed. Continued investment, in coordination with community partners, is required to meet the goal of building out a regional behavioral health training fund.
The Report does not recommend the full amount of $425 million as the initial investment as it will take time for programs to scale. The recruitment, education, training, supervision, and placement needed, and public service incentive system infrastructure, is not yet in place to effectively manage the size of the total investment. Therefore, the Report recommends only an initial $128 million in investment from multiple entities to scale out the program and build the necessary infrastructure. The County should identify Private Sector, County, State, and Federal resources that could be invested into the workforce training fund.
Continue Listening to Workers
The final of the key five recommendations is a recommendation to continue listening to workers. Policy implementation should be informed by workers themselves and include representation from County-contracted providers’ workers, organized labor, and represented Behavioral Health Services staff. Behavioral health workers that responded to the survey clearly love the work but are still leaving the profession. If we address the workers’ identified needs, we can aim to increase recruitment, retention, and training. We must measure success through both quantitative measures and the voices of workers themselves.
To do this, the County should regularly survey workers, track trends and progress toward goals, and regularly report back to the local community of practice on findings and insights that can inform job quality investments for behavioral health workers. In addition to feedback from workers through surveys, an engaged advisory committee of stakeholders should be established consisting of key healthcare, behavioral health professionals, service provider executives, and organized labor to help support these activities.
Legislative and administrative policy recommendations
In addition to identifying key areas for improvement, the Report provides legislative and administrative policy recommendations. These policy recommendations cover licensing and credentialing, supervision and training, higher education, contracting, documentation, and reimbursement parity at the local, state, and federal levels. As with many things, this needs to be a partnership with state and federal partners to secure the policy changes needed. Therefore, advocacy for our behavioral health workforce through the County Legislative Program and Guidelines are necessary to fully address the barriers identified in the Report.
For example, many of the occupations profiled in this report require thousands of hours of internships, residencies, and other forms of on-the-job, supervised clinical experience in addition to education to sit for state licensure with the Board of Behavioral Sciences (BBS) or other licensure organizations. The state can reevaluate and ease requirements for various licensures or expand the scope of practice for various licenses. To attract new behavioral health workers to California, the State, through administrative changes or through legislation, can ease the burden of credentialing out-of-state and foreign behavioral health clinicians by streamlining and simplifying the approval process for respective boards.
Contracting, documentation, and parity can also be addressed by the State. As for administrative burden, the State and Federal government both have the purview to adopt policies regarding reporting and billing. The State sets documentation requirements local jurisdictions must adhere to. Although the State is going through a profound change in its processes through CalAIM, special attention should be given to various areas of improvement including the administrative burdens related to documentation identified in the Report. In addition, the State can alleviate issues of parity, documentation, and contracting by incorporating same-day billing for physical health and mental health appointments at Federally Qualified Health Centers and ensuring managed care plans are supporting behavioral health workers through proper reimbursement of services.
Today’s request is for the Board to receive the Report and to implement policies that will create the behavioral health workforce our region sorely needs. The County has a duty to provide services to the San Diego community and has a responsibility to help guide the local economy to keep the necessary workforce thriving. Implementing policies found in the Report can provide a pathway to begin addressing our current and future needs. We encourage you to support this board letter today.
LINKAGE TO THE COUNTY OF SAN DIEGO STRATEGIC PLAN
Today’s proposed actions support the Equity Strategic Initiative of the County of San Diego’s 2022- 2027 Strategic Plan by supporting opportunities to create a behavioral health workforce that serves our community.
Respectfully submitted,
CHAIR NATHAN FLETCHER TERRA LAWSON-REMER
Supervisor, District 4 Supervisor, District 3
ATTACHMENT(S)
Note: Due to the size of the attachments, the documents are available online through the Clerk of the Board's website at www.sandiegocounty.gov/content/sdc/cob/bosa.html.