Last year, staffing shortages at the Alabama Department of Mental Health caused a temporary halt in admissions at one of three remaining state hospitals that provide long-term mental health care.
A unit at another hospital was closed because of a lack of staff, ADMH Commissioner Kim Boswell recently told Alabama Daily News.
Staffing, Boswell said, is the department’s biggest challenge.
“Our ability to build out the crisis system of care is absolutely contingent on our ability to be able to recruit,” Boswell said about the ongoing effort to place crisis centers around the state.
Outside the hospitals, where community based providers use ADMH funding to deliver mental health, intellectual disability and substance addiction services to thousands of Alabamians, a staffing shortage that existed prior to the COVID-19 pandemic has only worsened.
According to the Alabama Council for Behavioral Healthcare, an association of public and nonprofit providers, its members had about 740 staff vacancies in the fall of 2020. In January of this year, they had 1,142 vacancies.
The shortages within ADMH’s structure include entry level staff who don’t need specific training to provide direct care to patients as well as clinical staff with medical training.
Pay is a significant part of the problem, said Holly Caraway McCorkle, executive director of the council. On average, a therapist with a master’s degree starts at about $40,000, she said. That’s about $3,000 less than a public school teacher with a bachelor’s degree.
“We are losing people to school systems,” Caraway McCorkle said. “We cannot continue to pay at this level and meet the demands of the community.”
Boswell told ADN the hospital staffing situation has improved since the department was approved to raise pay for entry level, direct care positions by $2 an hour to almost $14 to $16 an-hour, depending on the shift.
While those employees aren’t providing the clinical health care, they are doing the day-to-day care necessary to support treatments.
“And they’re the individuals who spend the most time with our patients,” Boswell said. “That’s the group we have the biggest challenge getting and keeping.”
On Wednesday, Boswell requested from lawmakers a $41.4 million funding increase in fiscal year 2024, much of which would be dedicated to increasing pay for staff at community providers.
“One of the most important things we’d like to do is align wages across settings,” Boswell told lawmakers during a State House budget hearing in advance of the legislative session.
Several legislators on Wednesday shared stories about trying to help constituents in crisis.
“Absolutely, we need more beds,” Boswell said in response to a story about a young man with mental health needs who has been in and out of jail because care can’t be found.
Rep. Pebblin Warren, D-Tuskegee, told Boswell she needed to be aggressive in her request to lawmakers.
“I want (the Legislature) to understand this is a crisis,” Warren said.
The department is trying a variety of approaches to retain and grow its workforce.
Last summer, the department hired a staffing agency to help with what Boswell hoped was a short-term need. That contract will now run through April or May, she said.
For the current fiscal year, Gov. Kay Ivey and lawmakers allocated a record $193.1 million to ADMH. Both Boswell and Caraway McCorkle said they’re grateful for the renewed focus and funding on mental health services following agency budget cuts more than a decade ago.
One of the major burdens for providers now is uncompensated care, the cost of caring for those who are uninsured and under insured. It totals about $41 million for mental health services, $8 million of which for substance abuse each year, Boswell said. She would like the state to pay for more of that care in fiscal 2024.
“In essence, our community mental health centers are required to serve anyone without regard for ability to pay,” Boswell said. “If we could cover that uncompensated care, our community mental health centers could offer wages that are at least competitive in the market.”
Teena McGuinness, a professor emerita at the University of Alabama Birmingham’s School of Nursing and member of the Alabama National Alliance on Mental Illness, said more than ever, mental health conditions are highly treatable. However, the scarcity of workers, McGuinness said, will continue unless Alabama builds its pipeline.
McGuinness and NAMI also advocate for Medicaid expansion. Alabama is one of a few states that never expanded Medicaid coverage for low-income earners under the federal Affordable Care Act.
“We need to take advantage (of expansion),” she said. “It’s the poor people and the people with mental illness who suffer the most.”
Another way to expand care, McGuinness said, is to expand the scope of practice for psychiatric nurse practitioners. She said Alabama is losing the nurses to the 26 states that allow them to do more.
“We cannot continue in this way,” McGuinness said. “When there is a lack of mental health access, people die.”
Boswell Wednesday also detailed efforts to serve more people in need, including expanded telehealth options for youth services.
Meanwhile, there is a need for in-patient psychiatric space for youths in Madison and Lee counties.
Boswell said about 800 youths per year are sent out of the Huntsville area if they need in-patient care. Meanwhile, Children’s Hospital in Birmingham is overwhelmed by the need for in-patient care.
“A lot of what you’re beginning to see now is a building out of a system for kids that looks like the work that we’ve been doing for adults because there’s a crisis going on there,” Boswell said.