Behavioral health system a ‘weak chain’

Copyright © 2022 Albuquerque Journal

Part one of a two-day series

The behavioral health clinic in Clovis where Justin Nutt works is short five or six therapists at any given time. He said they’ve had the same therapist job openings since he started at the nonprofit three years ago.

Nutt, deputy executive director at Mental Health Resources Inc., said even behavioral health providers in big cities like Albuquerque and Las Cruces tell him they can’t hire enough people. And the issue isn’t easily fixed with money.

“If I have $100 million but I have eight therapists, it literally doesn’t matter that I have $100 million, because I can only provide so many services,” he said. “… What you end up with is the service vacuum.”

The hiring challenges Nutt and his counterparts across the state have been grappling with for years are but a piece of the very complicated puzzle that is New Mexico’s behavioral health system, which treats everything from substance use to depression and schizophrenia. And while the state actually ranks average to above-average when it comes to access to services, its behavioral health outcomes are among the worst in the nation – particularly for youth, according to a recent report from legislative analysts.

Local advocates and those who provide services, such as Nutt, blame those poor outcomes on the many hurdles they face in New Mexico, some deeply entrenched, which include a thinned workforce, inconsistent coordination of care, a complicated billing system and low Medicaid reimbursement.

Nutt compared the entire system to a weathered chain.

“I think sometimes it’s one of those that one link in the chain gets rusty and it weakens the entire chain type of situation,” he said. “That’s my understanding … mental health has been a very weak chain for a very long time simply because of resources in the state.”

JJ is on the wrong end of outcomes in the state.

Over the past several years she has bounced between hospitals, jail cells and homelessness as she battled a fentanyl habit, had a child and, at one point, suffered a gunshot wound. She is only 17 years old and started using hard drugs at age 10.

JJ said the system failed her repeatedly and other youths in recovery by often treating them like a criminal instead of someone who needed help.

“The reason why almost every one of us started using drugs was because we were dealing with our own (expletive) at home. And no one sat down to be like … ‘Hey, do you need some support?’… No one was there to lift us up,” she said. “That’s what hurts is the system automatically thinks, ‘Oh, they went and stole this, they’re a criminal.’ What if I had to steal it? What if I didn’t have money and I was hungry? There’s all these factors that come into play, not only for juveniles but even adults … And the second we do a crime, no one wants to bother to ask ‘Why?’”

New Mexico ranked second worst in the nation for youth suffering from a mental illness and among the worst six states for youth suffering from an addiction, according to an Aug. 18 Legislative Finance Committee report. The state was also ranked in the bottom 10 when it came to the general prevalence of mental illness among residents.

However, when it came to access to care, New Mexico was ranked more favorably – 20th in the nation, but analysts pointed out that most providers are along the Rio Grande corridor.

“The disparity between access and outcomes suggests the state should examine whether evidence-based programs and services are widespread, whether the quality of training mental health professionals is meeting the state’s needs and whether there are ways for the state to use its workforce more effectively,” the report states.

Marina Pina, a spokeswoman for the Human Services Department, said the more favorable ranking for access “in no way signals that the work is over to increase access to high quality care.” Pina also pointed out that there is a “significant lag” in the rankings, which were based on 2019 data.

She said the state is working toward a “more coordinated, easily accessible system” of behavioral health care with initiatives like the 988 Crisis Support Line and the Crisis Now system, which help with responding to “a wider array of urgent and crisis situations” while building out a coordinated crisis system that “is itself an easily remembered doorway to the behavioral health system of care.”

Pina said HSD is also bringing Certified Community Behavioral Health Clinics, or CCBHCs, to New Mexico in 2023, which she said “have a much more robust financing mechanism in exchange for a much more accessible suite of services.”

The rankings come two years after the LFC found the state was losing traction when it came to adults receiving continuous medicated treatment for major depression and providing follow-up services to those who had been discharged from a facility.

Between 2014 and 2020, according to the LFC, the state tripled spending on substance use treatment and increased service delivery by 85%. However, analysts said, in that same timeframe the alcohol-related death rate, drug overdose deaths and violent crime rose 49%, 43% and 30%, respectively.

New Mexico also has the highest alcohol-related death rate in the nation and the second highest drug overdose death rate in the nation, according to the most recent data from the Centers for Disease Control and Prevention and U.S. Department of Health & Human Services.

In their report, LFC analysts suggest the state, which is investing $930 million for this fiscal year to improve behavioral health outcomes, “should focus efforts on ensuring consistent care for youth and ensuring that this care is high quality and evidence based, while still expanding access.”

Inadequate prevention

Max Kauffman, an attorney with Disability Rights New Mexico, said part of the problem in the system is not being proactive enough before there is a crisis. From cases he has seen, there is an under-utilization of Medicaid-mandated early periodic screening, diagnostic and treatment of children under 21 years old.

Such screenings can detect warning signs of an impending crisis, underlying trauma or mental illness that, if unseen, can lead to exacerbated behavioral health problems down the road.

The LFC report found CYFD wasn’t putting the majority of funds toward proven programming and also hadn’t been spending as much as it could have.

A 2021 study found that CYFD’s Behavioral Health Program spent $7 million on “evidence-based, research-based, or a promising program” and $25 million that was not evidence-based or included overhead and other expenditures.

CYFD’s Behavioral Health Program also decreased spending by nearly $2 million between 2021 and 2022 despite a $4.6 million budget increase in that same period, according to the report.

Analysts said the Legislature in 2022 appropriated $20 million to the Human Services Department and CYFD to expand services, which could be used to cover training costs to ensure providers are certified to deliver evidence-based services.

A separate 2022 study found providers who receive state funding for a school-based health center, or SBHC, focused more on teen pregnancy and suicide and less on substance abuse. People reported that shortages and long wait lists for substance use programs were a “major problem” in responding to needs, according to the study.

The study notes that people reported that the state’s Medicaid certification requirements for SBHCs were “antiquated” and overly burdensome, posing barriers to provide services via telehealth or mobile vans – a “major need given the state’s rural and sparsely populated geography.”

Kauffman said for providers it can be a difficult system to navigate.

“I’ve heard this from providers that the billing process is onerous, it can be discouraging,” he said, adding that he’s been told it’s often “unclear what can be billed, and how and when.”

For example, he said, mobile crisis services can be billed to Medicaid but while there may not be a specific category for it, you can bill aspects of the service individually.

“So then it becomes very complicated … you have to put the pieces of the puzzle together … that would equate to mobile crisis services,” Kauffman said.

He said providers could use assistance to navigate those processes and handoffs between providers, from one treatment level to another, could be easier with a free flow of information. A universal release could benefit communities, where a client signs one document to authorize a number of entities to coordinate from there.

Kauffman said he believed all of these roadblocks are compounded in rural New Mexico, where communities lack the infrastructure to sustain a viable behavioral health system – which should include 24/7 crisis triage, detox for adults and youth, peer support, supportive housing and other services that would leave communities less reliant on emergency rooms to “solve the crisis.”

Kauffman said offering medication assisted treatment, or MAT, in prisons is crucial to “interrupt the cycle of re-incarceration that is linked to substance use.”

Carmelina Hart, spokeswoman for New Mexico Corrections Department, said no prisons in the state offer MAT for substance use, except in the case of pregnant inmates. She said the department is studying best practices and developing a pilot program to be implemented in 2023.

Kauffman said a large part moving forward is how the state will measure the quality of services as programs develop and funding increases.

“That’s a big piece to it, because you can have all of the services but if they’re poor quality, outcomes might not change,” he said.

Paying providers

Nutt, who works for the Clovis nonprofit, said a key to solving the state’s problem is attracting more therapists, particularly to rural areas. He said the current workforce is stretched thin due to lower salaries and high demand driven by above average rates of addiction and suicide.

According to HSD, the number of incoming behavioral health practitioners has waxed and waned since 2014. Some years will see up to 600 workers come into the field, others will see around 200.

In 2021, there were 5,895 in the state.

Some providers are doing better than others.

George Griego, a financial specialist who works on the outpatient side of the state-funded Behavioral Health Institute in Las Vegas, New Mexico, said he doesn’t have those issues. He said they are fully staffed, serve 700 clients and schedule at least two new intakes a day.

“The access is there,” Griego said. The institute also has an after-hours crisis line with a psychiatrist on call and clinics in Santa Rosa, Pecos and Mora.

“We’re always taking on clients. Unfortunately, we discharge the same amount as we intake because people don’t come to their appointments after a certain amount of time,” he said. Griego said another issue they face in northern New Mexico is a reluctance to ask for help, steeped in the culture.

“That’s always been kind of the issue,” Griego said.

For those in rural areas, the pay can’t compete with other states.

Nutt said therapists and other positions in the field here pay $20,000 less than places like Kansas and Texas, where he has worked. He said he knows several therapists who graduated in New Mexico and left to other states for more money.

“We have this massive amount of people, per capita, needing help and a relatively small number of providers, per capita, there to give the help, unfortunately,” Nutt said.

Nutt said his clinic serves up to 3,000 clients, 90% of them on Medicaid, from Harding, De Baca, Quay, Curry and Roosevelt counties. Some have to drive up to 70 miles to be seen.

He said the clinic only schedules out two days in advance and they open up the appointment book in the morning. He said within hours, the next 48 hours are often booked.

“That really speaks to how high the need is versus how high the access to a therapist is,” Nutt said.

He said it’s new patients who suffer the most.

Nutt said a new intake for them would be waiting until mid-October, but some private practices in the area aren’t taking new patients until January.

“I’m going to call you and I’m going to say, ‘Hey, man, I’m feeling a lot of depression, I lost my job, I lost my wife,’… And you’re going to tell me, ‘Well, January 14th we can get you in,’” he said. “That’s a really long wait for somebody who, right now, needs that help.”

Some still find the help they need.

JJ is now eight months sober and almost ready to leave Serenity Mesa, a youth recovery center perched on Albuquerque’s West Side. She said she recently had a craving, for the first time in months, and her “serenity sisters” at the center gave her a hug and told her not to give up.

JJ said she will miss them most.

But soon she will get an apartment, look for a job and take parenting classes to raise her 2-year-old boy. JJ said she is also getting her GED and wants to go into journalism and tell the stories of those going through what she has.

She said she is the most hopeful she’s felt in years.