EDITOR’S NOTE: This investigation is part of the ongoing “On Edge” series about Colorado’s mental health by the Colorado News Collaborative, a nonprofit that unites more than 160 communities and news outlets like Sentinel Colorado to 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 many Coloradans.
If 60 licensed clinicians walked into the Aurora Mental Health Center tomorrow for a job, organization leadership says they could hire all of them and deploy more staff across the system, which is increasingly stretched thin as the pandemic wears on locals and decreased stigma has more people looking for help.
This week, there are 107 job openings on the center’s website, the vast majority of which are clinical in nature. Like other mental health organizations across the state and country, Aurora Mental Health leaders say a staffing shortage is amid their biggest problems in providing care to a growing clientele.
“If we really wanted to expand our touch, we would probably add another 30 clinical positions, and probably another five to seven psychiatrists or advanced nurse prescribers,” said Aurora Mental Health CEO Kelly Phillips-Henry. “So 40 (positions) above what our wish list and what we have budgeted.”
In 2020, AuMHC documented 21,105 calls from people who weren’t current clients. This fiscal year, that number grew to 22,499, which translates to about 433 calls per week. Of those, the center estimates 56% of people were initially served in immediate access programs and 44% in programs working on an advanced appointment basis.
The pandemic has significantly increased workload for staff, Phillips-Henry said. And the cases staff are seeing are much sicker.
“I’ve been in behavioral health for about 30 years… And I remember sitting around tables when we talked about strategic planning and visioning, and our biggest goal was to decrease the stigma of mental health. Guess what, folks, we’re not talking about that anymore. That is a huge win,” she said. “Unfortunately, it comes on the heels of the pandemic, which is causing a lot of grief and a lot of pain and a lot of really hard times for many people in our community.
“And so, I think as we are seeing people reach out for more help, and we are certainly seeing celebrities, sports stars, Prince Harry, everybody, talk about ‘it’s OK to ask for help.’ People finally are because they’re hurting, and we’re beginning to normalize how common mental health struggles are. I think the most unfortunate part about this is when it’s falling in the middle of the pandemic, when we are seeing massive workforce shortages in every industry, but certainly in ours.”
Phillips-Henry said staffing priorities focus on retaining the ability for anyone to walk into a designated intake center and talk to someone during business hours. Cases deemed in crisis are referred up. Others are reviewed and triaged. She said the average wait now to see a provider for a problem that is not deemed critical is about two weeks.
In February 2020, just before the pandemic gripped Colorado, AuMHC counted 370 staff members who provided services to clients. Last month, that number had dropped to 315, even as demand has increased.
Difficult jobs are difficult to fill across the state
The problem isn’t just one in Aurora, but all of Colorado’s 17 regional community mental health centers. They 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 Aurora Center says it has held off on hiring some of its administrative positions to save money.
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.
READ THE FIRST INSTALLMENT OF ON EDGE: Mental healthcare safety net failing in Aurora, across Colorado
“Many for-profit, on-line therapy start-ups are heavily recruiting clinicians in our area. They offer fully remote work, higher salaries, and less administrative burden,” AuMHC spokesperson Lori McKenzie said. “We are offering many clinicians hybrid work, but our primary mission is to meet the needs of our clients and our community, and many clients want to be seen face-to-face. In addition, we operate many programs that require staff to be on site full time.”
In Aurora, a therapist’s annual salary ranges from $42,000 to $60,000, according to job listings.
The need in Aurora also often looks much different than other places. A diverse city where nearly one-fifth of residents are foreign-born requires a diverse staff. Phillips-Henry noted that 35 different languages are spoken by clinicians and there are positions specifically for immigrant and refugee communities. The need for the city’s homeless population is also growing.
On the other side of the metroplex, 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, Kiara Kuenzler, president and CEO of the Jefferson Center, which has offices in Lakewood, Wheat Ridge, Evergreen, Conifer and Black Hawk.
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.
Aurora Mental Health Center, employee tenure
| AuMHC Position | Average tenure at the Center, in years |
|---|---|
| Licensed Psychologist | 10.36 |
| Licensed Therapist | 4.12 |
| MD DO Psychiatrist | 7.03 |
| Nurse Practitioner RN AP | 2.81 |
| Unlicensed Psychologist | 0.67 |
| Unlicensed Therapist | 1.76 |
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 turnover rate among community center counselors and social workers statewide 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.
In Aurora, the turnover rate for fiscal year 2020 was 38.58%. For fiscal year 2021, year to date turnover is 12.28% so far.
Low pay and low expectations for change
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.”
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.
If you’re experiencing a mental health crisis, call the Colorado Crisis hotline at 1-844-493-TALK(8255). There is no wrong reason to reach out.
A task force working on recommendations about how best to spend the windfall and help create a new Behavioral Health Administration has keyed in on the workforce shortage.
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.
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.
“We’ve got to think about loan repayment and tuition assistance,” Phillips-Henry said of attracting new workers in Colorado. “We’ve got to go upstream on how we think about the generations to come of how you find an interest in this industry.”
Eagle Valley Behavioral Health 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.
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.
Aurora Mental Health Center Staffing
| Position at AuMHC | Current Number |
|---|---|
| All payrolled employees | 572 |
| Licensed Psychologist | 11 |
| Licensed Therapist | 65 |
| MD DO Psychiatrist | 13 |
| Nurse Practitioner RN AP | 9 |
| Unlicensed Psychologist | 2 |
| Unlicensed Therapist | 72 |
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.
Besides student loan forgiveness and new graduate programs, Kuenzler, of Jefferson Center, 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.
Solvista CEO Brian Turner said his mental health center in Salida 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 demand for more supply
Requests for behavioral health care have 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.”
If you’re experiencing a mental health crisis, call the Colorado Crisis hotline at 1-844-493-TALK(8255). There is no wrong reason to reach out.
