N.H.'s Efforts to Improve Mental Health System Stymied by Low Pay, High Stress, and Licensing Logjams.
Five positions filled, about 15 more to go, before Manchester gets its mobile mental health unit up and running. Meanwhile, the July deadline for doing so has come and gone.
Jessica Lachance, the unit’s director, admits it’s been a struggle to attract applicants. And Manchester is far from alone in this dilemma.
Ken Norton of the National Alliance for Mental Illness in N.H. says there are widespread staffing shortages, resulting in long delays in care, often for people in crisis.
“It goes across the board, starting with direct care staff but on to clinicians and therapists, psychiatric nurses and nurse practitioners, psychiatrists, and peer specialists as well," Norton said on The Exchange this week. "It really goes beyond just the community mental health system… On the private side, as well, there’s lack of capacity; people are calling for appointments and unable to get seen.”
The mobile units, or rapid response teams, are designed to alleviate crowding in emergency rooms and help police safely resolve situations involving mental illness. Under a legal agreement, the state promised to launch these units to help improve mental health services. Concord opened its unit in July 2015. Nashua is aiming for July of next year.
But the search for qualified workers has many concerned and frustrated.
“Community mental health services have upwards of around 200 vacancies,” says Suellen Griffin, executive director of West Central Behavioral Health in Lebanon and president of the NH Community Behavioral Health Association. “These are primarily…the prescribers -- the psychiatrists, the advanced practice nurses. Those folks are really, really difficult to recruit and if we are able to recruit them, it’s really, really difficult to retain them.”
The pay, says Griffin, is a major problem, and is directly related to funding for community mental health systems, which are paid at 2006 Medicaid reimbursement rates. That funding shortfall, she suggests, comes down to a legislative decision.
“We’re in the red at a lot of the community mental health centers. So where is the flexibility to be able to give back to our workforce… It’s very frustrating for those of us who work in these agencies -- not being able to reward these people and give them compensation worth the work that they’re doing.”
Griffin said a student loan forgiveness program can help make up for salary shortfalls -- but the program allows for only three people per organization per year. “So we’d like to see that expanded,” she said.
Dr. Melissa Myers, medical director at Northern Human Services in Conway, says it can be especially hard to attract certain applicants to more rural areas. Myers is a psychiatrist.
“We don’t have an academic medical center in our immediate area and that’s something people coming fresh out of training are accustomed to having – the support of some specialists, of that kind of academic resource. So that can be somewhat scary.”
Myers said they’ve had a position open for ten months in their system – and still no qualified applicants. “We‘re moving people around to make sure that individuals throughout our region get the care they need. Things are getting worse.”
PRIMARY CARE DOCTORS STEPPING IN, SOMETIMES WITH UNEASE
Myers said she sometimes relies on primary care doctors to help with some of the more basic mental health cases.
Dr. Larry Schissel, primary care physician in New London, is on the receiving end of those calls in his region.
“One of biggest shortages that impact us is psychiatrists,” he says. “We generally can get people seen for counseling although those waiting periods can be lengthy. We deal with a lot of anxiety and depression.”
Schissel said he’s comfortable prescribing in some cases but not in cases involving severe illness and multiple medications. “Medicine for depression in very straightforward cases we handle that pretty well, but stronger meds for serious mental illness, those are medicines we don’t use that often and need help with.”
SOME HURDLES: LICENSING, BURNOUT
So what would it take to increase the pool of qualified mental health workers?
Ken Norton says licensing can be a major obstacle and he’d like to see reciprocity among states – so that a licensed professional from another state does not have to go through the lengthy licensing process in NH. Right now, that can dissuade people from pursuing jobs here.
“People come to us in a crisis and we become really valuable when people are in a crisis. We’re a lot less valuable when people don’t’ need us. So I think there has to be some better messaging around the fact that the work we do is consistently necessary and important.”
Several Exchange listeners brought up the issue of burnout. The stress involved in taking care of some of the more severe cases can end up affecting the mental health of caregivers.
Lachance said community mental health centers are particularly well equipped to help support their employees, with generous personal time off, as well as team support to help share the burden.
“Once we get people through door, we’ll be able to provide support and environment that will help our employees thrive,” she says.
For Lachance, the rewards of the job outweigh the stressors and low pay. Griffin agrees but says it shouldn’t be an either-or situation. “People do come into the profession because it’s meaningful. There is reward you get from helping people in these situations. So it’s a selling point but it’s not enough to bring in the number of people we need in the mental health system.”
ONE OF OUR LISTENERS WRITES:
In my experience as a former therapist in the New Hampshire Community Mental Health system financial pressures on Community Mental Health have lead to an increased pressure to manage mental health services and workers in a factory style. The expectation for therapists is to see clients in 45-55 minute blocks (depending on the type of billing) back to back. During the 5-10 minutes between sessions the therapist is expected to take 2 minutes to write the note for the session, and take 2 minutes to plan for your next session. If you are working with children this includes preparing any activities. With any extra time you are expected to do additional paperwork, return phone calls, and maybe have a bathroom break.
The problem with this is that when engaged in therapy with an emotional client you are focused on engaging with what the client needs, supporting them, guiding them, and challenging them at the same time. This uses a very different kind of thought and focus than writing a clinical document which requires a dispassionate, almost legalistic thought process. It can give the therapist a kind of intellectual whiplash to move from one to the other instantly. ….This is an awful lot of work, stress, and exhaustion for the 35,000-45,000 most Master's level therapists in community mental health receive annually.