RESEARCH WEEKLY: Mental health workforce shortages in Oregon

By Hope Parker

(July 19, 2023) As demand for mental health and substance use services rises, mental health staff shortages continue to increase. This is especially evident in Oregon’s public mental health and substance use treatment system, which ranks 49th out of the 50 states and the District of Columbia for unmet mental health and substance use needs according to a 2022 report from Mental Health America.  

Oregon’s public mental health system is comprised of a state inpatient psychiatric hospital and community mental health centers. While the state hospital tends to serve individuals involved in the criminal legal system, community mental health centers serve individuals with moderate to serious mental health conditions, many of whom are enrolled in Medicaid. This system serves some of the most vulnerable individuals in the state with the highest mental health and substance use related needs, so the stability and well-being of this workforce is particularly vital. 

A qualitative study, published last month in “Psychiatric Services,” asked mental health and substance use treatment providers, administrators, and policy experts in Oregon about the factors contributing to turnover and attrition in the public mental health treatment system to better understand their perspectives and the challenges they face in the clinical work environment.  

Methods 

Researchers recruited 24 individuals with experience working within Oregon’s public mental health and substance use treatment system. Most of the participants had experience working in clinical positions, including mental health therapists, addiction counselors, peer providers, and psychiatrists.  

Participants were given a 45-to-60-minute semi-structured interview where they were asked about their role within the healthcare system, wages, insurance reimbursement rates, billing processes, recruitment and retaining of staff, and barriers to career development. The interviews were then transcribed and reviewed by three researchers to look for themes between participants’ responses.   

Key Findings

When examining the results of the interviews, researchers found five key themes that contributed to the public mental health workforce crisis in Oregon: 

• Low wages

While the cost of education to become a mental health or substance use professional can be high, wages remain low, with few opportunities for career advancement. Participants reported inadequate benefits, little cost-of-living increases, and no differential pay for additional skills or services, such as language skills.

• Documentation burden

Documentation was reported to be an extremely time-consuming aspect of working in the public mental health and substance use treatment system, with several participants believing that public mental health providers are held to a higher standard than those in the rest of the medical care system. This documentation frequently takes away time for patient care and leads to burnout for providers.

• Poor administrative and physical Infrastructure

Insufficient funding to hire administrative support, such as human resources, administrative, and supervisory staff was reported by many participants, increasing the burden of those tasks onto the clinicians. Inadequate billing codes were an additional burden for public mental health and substance use providers. Some services provided by staff do not have appropriate Medicaid codes to reflect the scope or cost of their work. These state and organization-based limits on reimbursement are especially prominent for unlicensed providers, such as peer providers.

Others reported that their physical environments were in disrepair or that there was a lack of facilities altogether. The limited flexibility of funding was cited as one reason for this. Many funding sources are designated for delivering treatment and cannot be used to increase staff wages or improve the buildings.

• Lack of career development opportunities

Little career advancement opportunities into leadership and supervisory roles were a common complaint from participants. The lack of a well-defined career ladder left many individuals feeling as though public mental health or substance use treatment positions were not sustainable long-term career paths.

Additionally, participants reported that even completing job-related training was challenging, due to lack of funding, large caseloads, inadequate staffing, loss of billable hours, and trouble fitting it into their schedules.

• Chronically traumatic work environment

Many providers consistently work with high caseloads of patients that have severe and complex symptoms. When turnover is high, the remaining staff must often take on even higher caseloads. Some providers attributed the high and long-term severity of symptoms of patients to a lack of inpatient psychiatric beds, where patients could receive more intense services.

Adding to the chronic stress of these positions, providers reported being required to work far above their job responsibilities with no extra pay, such as supervising interns or translating documentation. Some providers even reported being asked to do more than one job at a time, which was especially prevalent in rural areas. This chronically stressful work environment is thought to contribute to worker burnout.

Implications

As the need for mental health and substance use services is increasing, it is more important than ever to take the steps necessary to create a stable public mental health workforce.

The researchers of this study concluded that most of the attrition problems in Oregon’s mental health and substance use treatment system can be traced back to chronic underfunding and a bias against mental health as a field of medicine. In over half of the states, Medicaid reimbursement rates are planned to rise in the next two years. However, the authors propose that these hikes may not be enough to retain staff.

Chronic stress, documentation burden, and a lack of career development also need to be improved along with expanding workforce capacity. This includes faster hiring processes, more paid time off for continuing education, more compensated supervisory roles, and leadership recognition of staff’s work, according to the authors.

While this study focused on Oregon, the authors note that it is likely that many of these problems are occurring in the public mental health and substance use treatment systems of other states, as many other states’ public mental health systems also rely on Medicaid for one of their primary sources of reimbursement.

Reference

Hallett, E. et al. (June 2023). Factors Influencing Turnover and Attrition in the Public Behavioral Health System Workforce: Qualitative Study. Psychiatric Services. 

 Hope Parker is a research assistant at Treatment Advocacy Center.