COVID-19 placed a strain on Nebraska’s behavioral health system. In a 2021 poll by the University of Nebraska-Lincoln, 51% of metro-area Nebraskans and 40% of rural Nebraskans reported feeling the pandemic’s effect on their mental health. Nationally, the Centers for Disease Control and Prevention reported a 2.5% increase in unmet behavioral health needs in a matter of months as the pandemic took hold.
The crisis could not have hit at a worse time for Nebraska’s behavioral health workforce, which was already experiencing severe shortages. It led Gov. Pete Ricketts to loosen restrictions on out-of-state licensed practitioners, allowing them to offer telehealth services for 30 days past the duration of the COVID-related emergency declaration. That declaration ended in June 2021, but the story of Nebraska’s behavioral health workforce woes begins much earlier.
In 2004, the Nebraska Legislature passed LB 1083, a bill that de-institutionalized the state’s behavioral health system and expanded community-based health care. A 2008 report from the University of Nebraska Medical Center found that there was both a shortage and an unequal distribution of behavioral health care providers across the state. The report recommended the creation of a state health workforce center, which would collect and analyze workforce data to predict the state’s future health workforce needs and suggest policies to address them.
A year later, the Legislature passed LB 603, which created the Behavioral Health Education Center of Nebraska (BHECN for short, pronounced “beacon”). BHECN’s initial report to the Legislature in 2011 described a system in crisis: Professionals trained in Nebraska leaving the state after graduation, problems with basic clinical education, and training and licensure challenges.
BHECN’s efforts have largely been successful over the last decade; however, the shortage persists. The already increasing need for mental health care, compounded by the pandemic, has only exacerbated the problems Nebraskans face in finding services.
Nevertheless, the workforce has grown. Dr. Marley Doyle, BHECN’s director, said that’s unique from the rest of the nation.
“In most states, they’re seeing a plateau or decline … [Nebraska’s increase] is uncommon,” Doyle said.
The success, Doyle said, comes from a simple mantra: recruit, train and retain.
“We work very closely with the colleges and try to have as many mentorship and networking events as possible. Right now we’re developing an app that will match students with mentors, no matter where they’re located in the state. That helps with the recruitment side,” Doyle said.
Then there’s the training piece. Based at UNMC, BHECN provides scholarships and tuition aid for trainees, from residents to interns and everything in between. Doyle said a consortium of graduate behavioral health programs comes up with ideas for how to meet students’ needs. BHECN also provides free assistance for licensed providers that need to do continuing education to keep their licenses.
To address retention, BHECN funds studies on the barriers to working in Nebraska and how to make the state a more attractive place to work.
Between 2010 and 2020, the number of behavioral health providers in Nebraska has grown 38%. Doyle said that’s still not enough.
“That’s really an anomaly. We’re successful at recruiting people into the workforce, but it’s still not enough to meet the demand, particularly in rural areas,” Doyle said.
The Health Resources and Services Administration, a federal government agency, reports the U.S. has 14 psychiatrists per 100,000 residents. In urban Nebraska, there are 12; in rural, there are three. Even so, Doyle said the numbers don’t paint the full picture.
“They don’t really tell us anything about what type of practice that person has. Are they full-time or part-time? (Ambien) Are they using telehealth? … It’s really difficult to see if you have the types of services that you need,” Doyle said.
The number of psychologists and psychiatrists has remained relatively stagnant over the last decade. In 2010, Nebraska had 162 practicing psychiatrists. In 2020, that number hadn’t changed. The state added just 80 psychologists in the same time frame.
“It isn’t that surprising … Those are the two areas of our workforce that take the longest amount of time to train. They’re hard programs to get into. It takes a long time, it’s a big sacrifice and they’re very expensive. It takes 12 years to train a psychiatrist. There’s so many barriers … Even with the efforts we’ve made, we’re not necessarily going to see the full benefits of them for probably a decade or more,” Doyle said.
That raises the question: If the number of psychiatrists and psychologists in the state is so stagnant, where’s the growth among overall behavioral health care providers coming from?
That’s been concentrated largely in licensed independent mental health practitioners (LIMHPs). Consequently, the state has seen a drop in licensed mental health practitioners (LMHPs).
The key difference in the acronyms is the I. That stands for “independent,” meaning the practitioners can work independently without supervision. Once an LMHP accrues enough hours under supervision, they can become an independent practitioner.
Between 2010 and now, the number of LIMHPs has shot up by 163%. Doyle said the efforts of BHECN are easier to see there than elsewhere.
“LIMHPs get through their training a lot quicker … We’re seeing a jump in those areas where the training turns over faster,” Doyle said.
Doyle said the simultaneous growth and drop is a natural progression of LMHPs accruing enough supervised hours to establish an independent practice. The decline in LMHPs has largely plateaued in recent years, with minimal growth between 2018 and 2020.
Addressing provider supply, of course, is just one piece of the puzzle. Douglas County is preparing to invest $55 million into a mental health facility. In the months to come, The Reader will do a deep dive into how Omaha cares for its most mentally ill.
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