Iowa’s Mental Healthcare Workforce Shortage
If we build it, they will come.
Every time there’s another horrific mass shooting, or devastating local news story about a teen suicide, we hear the same chorus about how people need better mental healthcare. Like, if the person had only gotten mental health treatment, this might not have happened.
Okay, but let me ask this:
Any chance you’ve tried to make an appointment with an Iowa psychiatrist lately?
Or tried to get a loved one experiencing an acute mental health crisis admitted to a mental health facility?
If you have, then you’ve likely been scheduled out weeks, sometimes even months, or put on a double-digit waiting list for a bed in a psychiatric facility, and possibly at a facility hours away from your home that’s struggling to cover work shifts for the patients already there.
According to an APA 2022 COVID-19 Practitioner Impact Survey, 60% of psychologists reported they had no openings for new patients, and more than 40% were carrying waiting lists of 10 or more patients.
Here in Iowa, our state is currently in what can only be described as a mental healthcare workforce drought.
The 2022 State of Mental Health in America Report—compiled with data collected from the federal government agencies SAMHSA, the CDC, and DoE—ranked Iowa 50th in the nation for adults with any mental illness reporting unmet needs, 45th in the nation for mental health workforce availability, 47th for number of psychiatrists per resident, and our continued crowning glory of 51st in the nation for psychiatric beds per resident.
More than half of Iowa counties have no licensed psychiatrist practicing within their county lines.
NAMI Iowa’s second legislative priority will attempt to address this workforce drought with a multi-pronged approach:
Incentives
In recent years, Iowa has created a few incentives to start addressing the mental healthcare workforce shortage, like the Mental Health Professional Loan Repayment Program established to increase the number of non-prescribing mental health practitioners serving high-need communities in Iowa. It also provides loan repayment benefits for up to five consecutive years of full-time service, and can be adjusted for part-time service.
Last May, Polk County launched a $1.8M mental health workforce investment from the county’s ARPA funds to go towards up to $20,000 in loan payments for 90 new mental health professionals. To be eligible, therapists must commit to work for 5 years at a Polk County community-based mental health provider, have a master’s degree, and student loan debt.
But these two incentives aren’t going to be enough to end the drought. According to data collected by the KFF, “gaps in access to certain providers, especially psychiatrists, are an ongoing challenge in Medicaid and often in the broader health system due to overall provider shortages . . . . Lower Medicaid payment rates (relative to other payers) as well as disparities in pay between physical and mental health providers could limit participation in Medicaid and further exacerbate existing workforce shortages.”
And Iowa government officials are well aware of this problem as seen here in the September 21, 2023 MHDS Commission Meeting report:
The Commission discussed its executive summary to HHS and the members’ thoughts on Medicaid Managed Care over the previous year. During their deliberations, the Commission has heard of several concerns from stakeholders that remain similar to the concerns reported in 2022. The Commission is disappointed to note and deeply concerned that we have not seen significant progress in the following areas even though they have been brought up for multiple years, and strongly urges HHS and MCOs to increase efforts to address the following:
· Lack of reimbursement to mental health and substance use disorder treatment providers for multiple clinical services provided on the same day, which results in barriers to individuals’ access to services
· Lack of consistency and easy access for translation services across MCOs.
· Delayed and partial payments to providers
· Delayed and/or reduced authorization for long term supports and services
· Concern regarding burdensome administrative requirements for Integrated Health Homes
· Peer support and recovery peer support services are undervalued and, as a result underfunded
· Increased administrative burdens and costs for providers particularly for keeping claims alive to receive payment
· Understaffed mental health providers and substance use disorder treatment services workforce due to rates that have not been adjusted to reflect changes in costs for years for some services. (The Commission recognizes legislation was passed to increase rates for direct support professionals and appreciates those efforts by the Legislature.)
· Increased oversight during times of MCO contract transition is needed to ensure continuity of care, and funding of services and supports.
· Increased development of quality services, including evidenced based and promising practices, is needed for all population groups including children
· Increased community capacity to serve individuals with the most complex and serious needs
· Delayed eligibility updates for individuals post incarceration on Medicaid’s Eligibility and Verification Information System (ELVS) line has resulted in large recoupments for providers due to receiving inaccurate eligibility information
· Need to assure that behavioral health services are reimbursed on par with other health services in accordance with parity law
· Procedural and financial barriers to providing integrated care
Their words, not mine.
Medical Residencies and Professional Development Programs
Medical residencies are something the Iowa legislature has done in the past, where the University of Iowa Hospitals and Clinics expanded their Psychiatric Residency Program by providing for up to 12 additional residency positions for each class of residents, and provided financial support for residency positions that were in excess of the federal residency cap established by the federal Balanced Budget Act of 1997. Residents were required to complete a portion of their psychiatric training at one of the State institutions, but could also complete additional accreditation-required clinical experiences not available at the State institutions through clinical rotations at the University of Iowa Hospitals and Clinics or its affiliates across the State.
In 2019, Grandview University launched a Master’s in Clinical Mental Health Counseling program designed to prepare students for direct entry into the practice of counseling and counseling-related fields. Last year, 100% of Grand View students passed the state Clinical Mental Health Counseling licensing exam. And, Grandview students are eligible for the Polk County loan repayment program mentioned above.
The idea is that programs like these ultimately brings new practicing psychiatrists and other professionals into the system and who hopefully stay in Iowa.
Again, more programs like these are a no-brainer.
Elevation of Peer Support Models
One majorly underutilized resource in Iowa is the use of peer support in the mental healthcare workforce. Peer support workers are people who have been successful in the recovery process of their illness who help others experiencing similar situations. Through shared understanding, respect, and mutual empowerment, peer support workers help people become and stay engaged in the recovery process and reduce the likelihood of relapse. Peer support services can effectively extend the reach of treatment beyond the clinical setting into the everyday environment of those seeking a successful, sustained recovery process.
Iowa DHHS recently awarded a contract to the University of Iowa to provide comprehensive training for Iowa’s Peer workforce. The project provides training for Peer Support Specialists, Family Peer Support Specialists, and Peer Recovery Coaches to grow the workforce and organizations that employ peers.
It’s this type of model that Iowa needs to expand throughout the state, particularly in our rural areas that have been hit by the mental healthcare workforce drought the hardest.
We can’t address the mental healthcare crisis until we build a system to grow our mental healthcare workforce.
This is a lot of data and numbers and links and acronyms, but they’re all saying the same thing:
We can’t address the mental healthcare crisis until we build a system to grow our mental healthcare workforce.
It isn’t a vision in a cornfield and a leap of faith. It’s a stark reality. ~
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I have so much to say here. I don’t know where to begin...
I have been in the Iowa Mental healthcare system for roughly 15 years, both as a patient, and as an inaugural Peer Support Specialist, receiving my initial training through the ABBE Center in Cedar Rapids, where I also reside.
I was diagnosed on 2009 with initially Depression, Anxiety, PTSD, and was suicidal. I also learned I had a personality disorder. I was sent to live at County Home Road for 18 months.
I credit the programming at County Home road for saving my life. Had I not learned that I had triggers and medication and meals provided daily I don’t think I would be alive today.
I worked hard, taking advantage of every class, even exercise group, which was not my favorite thing because I also have severe Fibromyalgia. At the end of 18 months, I my house had been sold, my assets liquidated and I was now on Medicaid.
I was resident I the Abbe Center’s Transitional Living housing program, which consists of a few apartments, including one staff office dedicated apartment. After 18 months there I moved into a condominium on my own. Staff paid community visits for several visits for years. I was doing well.
I took a job at the ABBE Center at their daily drop in club, Club 520, and afternoon community group with activities for anyone with a diagnosed mental illness in Linn County. It was an enjoyable job. I also took Saturdays to go over to the Transitional Living apartments and held a group every week. It was very enriching for all of us. I still miss some residents, especially those who passed away.
I was tapped for the initial group of IHH workers. I loved meeting with the clients. It was the numerous ill-timed meetings and inability to find company transportation that killed the job for me. There were 12 of us, each having to meet in person at least once a month with our 30 clients, for one hour (not including transportation time), and four cars. Often cars were not there. We had so many meetings that I couldn’t get my thoughts together. It was too stressful so I resigned.
All of this time up to present day, I have been extremely fortunate to have the same astute ABBE psychiatrist. I haven’t any idea how he manages such a huge caseload. In fact I’ve watch in these past five or six years, the number of ABBE psychiatrists dwindle down to two older men. I don’t see anyone else coming into their program and I’m perplexed as to what would happen if one were no longer able to see clients. That did happen for a while this fall.
My only backup was to make sure that I have my new ARNP has a psychiatric background, because over the past few years my mental health received a more devastating diagnosis is of Schizoaffective Disorder. This diagnosis makes more sense. And my mind has definitely degraded. I only drive familiar places in good days, so I don’t get lost.
I have to work harder these days to remember how to even remember how to type some of these words. I feel that what I have to say is important so I’m trying hard.
I moved into an assisted living facility and frankly, they’re not doing much for me. In fact, there are quite a few things that are wrong, but if you’re under 65 years of age your options appear to be nil. There is no correct place for me and at-home services failed me repeatedly. I couldn’t take it anymore. I trained people so often that it was if I was doing the work and they were paid. It only made my psychosis worse. I was in terrible pain all of the time too.
I would estimate that 60 percent of the residents where I live have some form of a mental illness. Having had some training, spending time with, and being a person with mental illness, I have a pretty good grasp on situations. Staff is usually clueless. They don’t understand these residents at all, especially those with dementia. There is a complete bypass for even communicating and understanding some people that have lived here. It saddens me.