This investigation is part of the ongoing “On Edge” series about Colorado’s mental health by the Colorado News Collaborative, the nonprofit that unites more than 160 communities and news outlets ensure quality news for all Coloradans. The series title reflects a state that has the nation’s highest rate of adult mental illness and lowest access to care, and the fact that state government is on the edge of either turning around its behavioral health care system or simply reorganizing a bureaucracy that is failing too many Coloradans.
By Jennifer Brown, The Colorado Sun
In the spring of 2020, the community mental health center that serves Jefferson, Gilpin and Clear Creek counties had a completely manageable number of job openings — 11 therapists, counselors and other clinicians.
But as the coronavirus pandemic gripped Colorado, the vacancies started to climb, first into the teens and then the 30s and then to 50 by the end of 2020. Just as the Jefferson Center was growing alarmed, the pace of the resignations picked up even more. By March, a year into the pandemic, the community mental health center was down 105 workers, about one-fifth of its clinical workforce.
The center has only started to catch up from the hit it has taken in the nation’s “great resignation.”
“We had 75 and 90 and then 102 and 105, and we’re back to about 90,” said Kiara Kuenzler, president and CEO of the Jefferson Center, which has offices in Lakewood, Wheat Ridge, Evergreen, Conifer and Black Hawk.
The workforce shortage extends beyond Jefferson Center to all of Colorado’s 17 regional community mental health centers — the safety net for people without insurance, on Medicaid or who can’t afford to pay for private treatment. The centers combined have 1,092 job vacancies, according to data collected by the centers’ trade group. That includes 233 administrative jobs and 859 openings for clinical workers, or 16.4% of the total clinicians.
The dire shortage means therapists at the centers are overburdened with patients, that people are waiting weeks or even months for appointments, if they get one at all, and that in the midst of a mental health crisis brought on by the isolation and stress of coronavirus, the centers are seeing thousands fewer patients now than they were before the pandemic began.
Some in the industry consider it a reckoning. After decades of low pay, the centers have become a training ground for inexperienced mental health workers, and now many of those workers have either burned out or moved on to better-paying jobs where the patients have simpler diagnoses rather than layers of illness, trauma and addiction. In Colorado, they’re walking away from community mental health clinics to work in hospital systems that are expanding their behavioral health networks, or they’re signing on with telehealth startups where not only is the pay better but they can work from anywhere in front of a computer screen.
The 90 help-wanted postings at Jefferson Center are not a wish list or a new goal based on a growing community need for behavioral health care. They represent the clinicians who’ve quit in the past year and a half, Kuenzler said.
Case managers with a bachelor’s degree start out as low as $37,698 at Jefferson Center, working their way to a mid-level salary of $43,369. A mid-level licensed counselor with a master’s degree earns $63,242 and a mid-level clinical psychologist with a doctorate is paid $84,862.
That’s far below what any of those professionals could earn working for a hospital network or one of the private-equity backed telehealth companies that have ramped up services during the past two years. Switching jobs often means an automatic $20,000 jump in pay.
Kuenzler has heard all the reasons over and over during exit interviews throughout the last year.
The workers are tired, worn out by trying to help folks with a complex set of issues that might involve criminal justice and homelessness and child welfare. They’re tired of the paperwork, required by state and federal government insurance programs, that sometimes takes just as much time as they spend with the patient. Why take on the most complex cases, the ones in which resolution is often elusive, when there are other opportunities in mental health care? It’s now much easier to work from home, spend more time working with patients and less on paperwork, and earn bigger salaries.
“It’s just really hard work,” said Kuenzler, a licensed psychologist. “During the pandemic, when everything is hard, if there is an opportunity for your work to be a little less hard, then people are choosing that. They’re taking stock in what’s important and what they value.”
Consider the staffing shortage in human terms. Each clinician at Jefferson Center typically sees about 150 patients in the course of a year. With 90 of them gone, that’s about 13,500 patients who didn’t get an appointment, Kuenzler said. “It has a huge impact on our ability to serve our community.”
The center served about 34,000 people each in 2018 and 2019. Last year, that dropped to about 28,000, partly because of the staffing crisis and partly because of the logistics of the pandemic. While emergency crisis centers remained open, many counseling appointments moved online. Jefferson Center set up “telehealth kiosks” in various spots — including libraries and homeless shelters — where people could log into an appointment using a laptop.
Now, clinicians have outpatient caseloads reaching 100, an unhealthy shift from pre-pandemic times when the center considered 75-80 the upper reaches of the limit.
“We can’t just keep piling onto our clinicians,” Kuenzler said. “We don’t turn people away. What that means is sometimes people have to wait too long between appointments, and they are not able to have as much choice.”
Instead of getting an appointment with a psychologist or a therapist, a patient might instead get a phone call from an outreach worker.
The turnover rate among community center counselors and social workers was 30% in 2021, nearly double the rate of other mental health workers, according to the trade organization, called the Colorado Behavioral Healthcare Council. The council blames the problem on decades of inadequate rate increases from the state Medicaid system, and is asking the legislature next year for a 5% boost.
The reimbursement rates the state pays to individual clinicians in private practice are far lower even than those paid to mental health centers. Centers, however, say they need higher reimbursement rates than therapists in private practice in order to cover the costs of operating 24/7 crisis services, case management and community education courses.
Since 2000, community mental health provider rates have lost 30.1% of their spending power compared with inflation, and salaries have lagged 27.8% behind state employees, the council said. The mental health centers cannot keep up, the council said, “especially at a time when Colorado communities expect more services by the providers whose mission it is to serve all Coloradans, regardless of their ability to pay.”
Workforce shortage is connected to low pay, high-cost housing
In 2019, when Eagle Valley Behavioral Health opened the first community mental health center in Colorado in 40 years, the goal was to hire 100 clinicians.
Two realizations have hit Casey Wolfington, senior director of community behavioral health, since she helped set that goal: 100 more clinicians in the Vail area isn’t enough, and, some days, it feels like it will be impossible to find even that many.
Two years after opening, the mental health center has managed to hire 50 clinicians, including several school-based counselors, therapists who work next to doctors inside Colorado Mountain Medical clinics, and four psychiatrists — two enticed to the mountains from Denver and two from out of state.
People apply because they’re pumped about being part of the progress in Eagle Valley, the only community in Colorado that has competing safety-net mental health centers. Eagle Valley Behavioral Health was started with a $60 million investment from Vail Health, the local nonprofit hospital, because the decades-old mental health center, Mind Springs Health, was failing to keep up with the community’s mental health crisis. The new center takes private insurance, Medicare and Medicaid, and has a fund, named after a 13-year-old girl who died by suicide, that pays for therapy for people who can’t afford it.
But the job interviews with potential new hires often stall. “They are so excited … and then they look for a place to rent or a place to buy,” Wolfington said. “They change their mind. Or they pause their mind.”
In the meantime, Eagle Valley can’t help all the people asking for appointments.
The pressure for counseling services is so high in part because there are no in-patient mental health services in the region. The closest residential care is in Denver or Grand Junction, a drive along Interstate 70 regularly blocked by wildfire, snowstorms and rockslides. By April, Eagle Valley Behavioral Health is hoping it will have approval from the county to break ground on its own short-term inpatient facility, with 28-beds for adults and adolescents.
For now, the mental health center keeps openings in the schedule every day in case people need immediate help and can’t wait weeks for an appointment. “There are more people showing up for help than we can schedule,” Wolfington said.
Colorado has $450 million to fix the system, but not without workers
Colorado policymakers have what many have called a “once-in-a-generation opportunity” to improve the behavioral health care system in the form of $450 million in federal coronavirus relief aid that Gov. Jared Polis has tagged for mental health.
But no amount of money will fix a broken system unless there are enough workers, which is why a task force responsible for recommending ways to spend the money has focused much of its time on the workforce crisis.
A real-life example is coming up in Salida, where the local community mental health center is building the area’s first 24/7 crisis intervention center. Right now, the counties of Fremont, Chaffee, Lake, Custer and beyond have no crisis stabilization center for people experiencing mental health or addiction emergencies. Across rural Colorado, people in mental health crisis are held in jail when no treatment bed is available.
The new unit is on target to open in the spring, but here’s the problem: it will need 28 full-time employees to run it. And Solvista Health, the local mental health center, is already trying to fill 16 vacancies for clinicians.
“Detox work is hard. Acute treatment is hard,” Solvista CEO Brian Turner said. “Supporting people 24/7, that is very difficult work and it pays very poorly, generally.”
Despite the worker shortage, Solvista — unlike other community mental health centers in the state — managed to increase its patients last year, by about 300 people. The mental health center, which spends 83% of its budget on salaries and benefits, pays about $60,000 annually for a licensed clinical professional with a master’s degree, and about $41,000 for a peer counselor — people who are in recovery but don’t have professional degrees.
At Southeast Health Group, the community mental health center for Lamar, La Junta and Rocky Ford, current job postings include multiple therapists, youth therapists and peer specialists. The pay listed in the peer specialist job posting starts at minimum wage: $12.32-$14.69 per hour.
And the Mental Health Center of Denver, which has had an easier time filling vacancies and already pays more than other centers across the state, announced an “unprecedented” raise for its staff last week. All staff will earn no less than $24.04 per hour, or $50,000 per year for a full-time employee. The adjustment means that all the center’s jobs will reach the 60th percentile in the behavioral health market.
The Denver center, with multiple locations in the city, spends 66% of its budget on salaries and benefits. The center has 160 job openings, and in nearby Aurora, the Aurora Mental Center has 78 vacant positions, or 18% of its staff.
A task force working on recommendations about how best to spend the $450 million and help create a new Behavioral Health Administration has keyed in on the workforce shortage. Wolfington, from Eagle Valley Behavioral Health and a task force subcommittee member, said she was optimistic about the state’s potential plans.
One idea is a student loan repayment program in which federal coronavirus aid would pay off a chunk of a mental health clinician’s college debt each year they stayed on the job. Eagle Valley already has such a program, and the loan payments continue as long as the worker stays in the community — even if they switch jobs but stay in mental health.
Other ideas include funding for scholarships so that clinicians can easily seek master’s and doctoral degrees.
Growing the pipeline could include programs that allow people to get advanced degrees without moving to a city with a major university, either through online programs or partnerships with smaller, far-flung campuses. The University of Denver, for example, offers a master’s degree in social work through Colorado Mountain College in Glenwood Springs. Wolfington is advocating for the state to offer universities some of the coronavirus relief money to set up similar programs statewide.
Right now, behavioral health centers and companies are fighting over the same workers, she said. “We’re often just shifting them around the state,” she said. “There is not one part of the state that’s like, ‘We’re perfect! We’re swimming in providers!’”
The task force in particular wants to find ways to recruit first-generation college students, graduates of rural high schools, first-generation immigrants and students who are Black, indigenous or Spanish-speaking.
Kuenzler, with the Jefferson Center, predicts that even with the new incentives, it will take at least five or 10 years to increase the behavioral health provider pipeline. Besides student loan forgiveness and new graduate programs, she wants to see Colorado policymakers decrease the administrative burden for providers who have complained for years that they must produce duplicative paperwork required by federal and state law.
Turner, at Solvista, said his mental health center was required to submit 139 reports last year to seven state agencies that regulate the industry, including the state Medicaid department, the state Office of Behavioral Health and the Colorado Department of Public Health and Environment. That was one report or audit every 2½ days.
Also, mental health providers, at community mental health clinics and beyond, want a boost in rate payments. Some state officials, however, have argued against using the federal aid to increase rates because the money is a one-time allotment meant to create systemic change, an argument that makes sense to providers even as they say they are desperate for a raise.
“I think the money will fly by,” Turner said. “We need to make sure that what already exists out there is sustainable before we go invent a whole bunch of new things that will not be sustainable once the money goes away.”
The workforce shortage extends, too, to independent counselors in private practice. More than 2.5 million Coloradans — nearly 40% of the population — live in an area with a shortage of behavioral health workers, according to the state Department of Health Care Policy and Financing.
Independent clinicians have offered up a solution of their own. A trade group representing therapists in private or small-group practices is pushing for a change in law that would allow them to more easily take on interns under an apprenticeship model. Right now, hundreds of providers are blocked from doing so by the rules of the agency that processes their Medicaid claims.
COVID “turned a problem into a crisis”
The demand for behavioral health care has skyrocketed during the pandemic, resulting in overflowing emergency departments at hospitals, including Children’s Hospital Colorado, and even longer waits than usual to see a therapist, and way longer, still, to see a psychiatrist. Youth mental-health emergency room visits jumped by 70%, and calls to the statewide crisis hotline rose by nearly 40%.
To fill the gap, hospitals are expanding mental health programs — and hiring workers away from community mental health clinics.
UCHealth, for one, is in the midst of a $150 million push that includes expanding “tele-psych” and “tele-social work,” and embedding psychologists and social workers inside its network of primary care clinics. The hospital system has hired about 100 behavioral health workers in the last couple of years and now has 68 vacancies for social workers, counselors, psychologists and other mental health workers.
The hospital’s midpoint salary for a clinical social worker, at $76,814, is about $27,000 more annually than the average pay of a social worker or counselor at a Colorado community mental health center, according to the centers’ trade group.
Companies including BetterHelp, advertising “therapy from your couch,” and Denver-based Sondermind are scooping up therapists from community centers, too. Sondermind patients can use private insurance and book a virtual or in-person appointment within minutes on the company’s website, which boasts results in six sessions or less. Sondermind declined an interview request and did not answer questions about how many Colorado-based clinicians it employs or its average starting salary.
The good news is that people — more than ever before — are seeking therapy, likely a result of decades of work to destigmatize mental health care. But concerns about an insufficient workforce circling for the last 20 years are now at perfect-storm levels, said Chuck Ingoglia, president and CEO of the National Council for Mental Wellbeing in Washington, D.C.
“It does seem like COVID has turned something that had been a problem into a crisis,” he said. “Everybody I talk to says that their biggest problem right now is finding staff. There is all this money and they want to expand programs, but people are struggling to keep up with current staffing challenges.”
The lure of “wearing gym shorts all day” while counseling people via computer is strong, particularly for clinicians who’ve grown weary helping people with the layers of complex mental health and addiction struggles that community mental health center clients often have, Ingoglia said. The behavioral health workforce was affected more severely than some industries because the field has been dominated by women, who were more likely to quit their jobs during the pandemic, he said.
Vincent Atchity, president of the advocacy group Mental Health Colorado, said the gritty work of community mental health care got even tougher during the pandemic. So much of it is “driven by the instability of life,” intractable problems including a lack of housing, unemployment, and family issues that continue for generations. The “burnout factor” is intense, even in normal times.
“There is a different level of satisfaction in the work when you don’t solve somebody’s problem,” he said. “You see them over and over and over again and you don’t have that sensation of cure or remedy. People’s distress is hard to solve.”
Atchity doesn’t want Colorado to put the federal dollars into a system that’s broken, and is hopeful that policymakers will instead find ways to fix it, as well as increase the value of workers willing to help those who need it most. One obvious fix is integration. Despite talking for decades about combining mental and physical health care in this country, it hasn’t yet happened.
“The industry is so slow to realize how foolish they are,” he said. “Why is it the Mental Health Center of Denver? Why not just be The Health Center of Denver? You can get a mole checked or see a psychiatrist.
“It’s a darn shame to pour money into that system.”