Factors Influencing Turnover and Attrition in the Public Behavioral Health System Workforce: Qualitative Study

Testing job wellbeing indicators among community behavioral health workers: Community-based participatory research

Many community behavioral health organizations (CBHOs) continue to struggle with their employees' reduced job wellbeing and job disengagement (i.e., turnover intentions, actual turnover). Understanding employees' job wellbeing priorities in their organizational contexts is essential to address the challenges, especially for workers in diverse work settings such as CBHOs. We used community-based participatory research (CBPR) strategies to develop and test job wellbeing indicators. The current study implemented 11 indicators with 168 people employed at a CBHO through initial and 6-month follow-up surveys. Positive endorsement of job wellbeing indicators differed based on employees' demographic (e.g., race, education, marital status) and job (e.g., exempt status, clinical positions) characteristics. Several indicators declined from the initial to the follow-up surveys (e.g., communication, job fairness, decision-making involvement, expectation alignment, supervisory support, career development opportunities). The change rates also varied by employee characteristics (e.g., work years, race, exempt status, full-time). The current study illustrates the utility of CBPR strategies to implement job wellbeing indicators based on employees' priorities and diverse job wellbeing experiences among employee subpopulations. Further, the developed indicators revealed job wellbeing heterogeneity by employee subpopulations within an organization that is often overlooked. Efforts to understand varying job wellbeing characteristics among diverse employees may eventually help develop organization-tailored interventions to improve job wellbeing and reduce turnover.

Trauma, Mental Health Workforce Shortages, and Health Equity: A Crisis in Public Health

The global mental health workforce is facing a severe crisis marked by burnout, secondary trauma, compassion fatigue, and workforce shortages, with disproportionate effects on marginalized communities. This paper introduces the Integrated Workforce Trauma and Resilience (IWTR) Model, a comprehensive framework to understand and address these interconnected challenges. This study employs a conceptual, documentary analysis approach to examine the challenges faced by mental health workers, particularly trauma, burnout, and workforce shortages. By synthesizing existing qualitative and quantitative studies, the research identifies recurring themes and provides recommendations for policy reform to improve workforce sustainability and equity. Using a thematic synthesis of 75 peer-reviewed articles, conceptual papers, and policy reports published between 2020 and 2025, alongside foundational theoretical works, the IWTR Model integrates five theoretical perspectives: trauma-informed care, Conservation of Resources Theory, Intersectionality Theory, the Job Demands-Resources Model, and Organizational Justice Theory. The analysis identifies three dimensions: the impact of trauma on mental health professionals, organizational and systemic factors influencing workforce retention, and strategies to build resilience through policy and education. The findings reveal how secondary trauma, burnout, and systemic inequities interact to undermine workforce stability and access to care. The IWTR Model emphasizes that individual-level interventions will be insufficient without addressing structural issues, such as workload inequities, lack of leadership diversity, and underfunding. This model offers a roadmap for systemic reforms to strengthen workforce resilience, improve retention, and advance global equity in mental health care systems.

State Policy Strategies to Promote the Recruitment and Retention of the Behavioral Health Workforce

Policy Points To address persistent gaps in behavioral health care access and availability, particularly for underresourced populations, state policymakers have implemented four core strategies to address the shortage of behavioral health providers serving the Medicaid population. In this paper, we describe each of these state policy strategies, discuss their potential workforce and service impacts, and highlight unanswered questions about their effectiveness and implementation. Altogether, our review of these policy strategies suggests that rigorous evaluation of these state policy strategies is needed along with broader transformations to the behavioral health system to sustainably grow and retain the workforce in the long term.

Reported Strategies by Medicaid Managed Care Organizations to Improve Access to Behavioral Health Services

Policy Points Despite the growing role of managed care organizations (MCOs) in financing and delivering behavioral health services in Medicaid, little is known about MCO strategies to overcome critical access barriers and the factors influencing these strategies. Through semistructured interviews of 27 administrators and executives across 19 local, regional, and national Medicaid MCOs, we describe a number of reported approaches to enhance behavioral health access: 1) contracting with core groups of Medicaid-focused behavioral health providers to provide a substantial share of care, and 2) targeted strategies to enhance the existing workforce through outreach, training, and workforce support programs; rate enhancements; telehealth and mobile unit care models; and high-touch case management. Findings highlight MCO perspectives on barriers and facilitators of access to behavioral health care, as well potential strategies that hold promise for other MCOs. Future research should evaluate the outcomes associated with these strategies and identify best practices that can be adapted across MCOs.

CONTEXT

Behavioral health access gaps are well documented in Medicaid, in which managed care now covers most enrollees, and for which there are typically fewer options for going out-of-network for care. Despite the growing role of managed care organizations (MCOs) in financing and delivering behavioral health services, little is known about MCO levers that can improve access to care.

METHODS

We interviewed 27 administrators and executives across 19 Medicaid MCO carriers with local, regional, or national operating presence to understand strategies to address behavioral health access barriers and the factors influencing these strategies. To achieve maximum heterogeneity, we employed iterative purposive sampling using a sampling matrix of plan and state characteristics. One-hour interviews were recorded, professionally transcribed, and analyzed using a coding scheme that was developed iteratively. Codes were bundled into major themes after iterative discussions, with analysis conducted at the MCO level.

FINDINGS

MCOs perceived acute access challenges for children and adolescents, rural geographies, and crisis and transitional services. To address these challenges, MCOs reported contracting with core groups of Medicaid-focused behavioral health providers, supplemented with targeted strategies to enhance the existing workforce. These strategies focused on enhancing provider retention and capacity through outreach, training, and workforce support programs; rate enhancements; telehealth and mobile unit care models; and high-touch case management to align members to appropriate providers or service levels. Strategies were influenced by state policy contexts, including by regional financing and organization of behavioral health services, rate setting procedures, and administrative and regulatory requirements.

CONCLUSIONS

As state Medicaid programs increasingly grapple with behavioral health access gaps, understanding MCO approaches and common challenges may help policymakers better align resources, incentives, and regulations centered on improving existing gaps in accessing behavioral health care. Future research should evaluate the outcomes associated with MCO perceptions and accompanying strategies and identify best practices that can be adapted across MCOs.

Medicaid managed care organizations' experiences with network adequacy

Access to behavioral health care continues to be a challenge in Medicaid, where most enrollees are restricted to networks of providers and facilities contracted with managed care organizations (MCOs). While state and federal regulations have sought to ensure access to care, little is known about how health plans perceive and respond to these network adequacy standards. We interviewed 27 administrators and executives across 19 local, regional, and national Medicaid MCOs to assess their behavioral health networks and perceived barriers and facilitators in these efforts. We purposively sampled MCOs for maximum heterogeneity, with early findings used to refine subsequent recruitment targets until thematic saturation. We used an iterative inductive coding approach with code discrepancies analyzed and reconciled until consensus was reached. Five major themes arose: existing regulations often failed to capture true access gaps; MCOs used supplementary approaches to monitor network adequacy; limited corrective actions were available; access measures were more meaningful when grounded in enrollee experiences; and provider directory accuracy was challenged by logistical barriers. In this first study to examine MCOs' experiences with network adequacy monitoring, our findings suggest key deficiencies with current regulations and opportunities to support MCOs more broadly as policymakers seek to strengthen network adequacy regulations.

Experiences of Telehealth Reimbursement Policies in Federally Qualified Health Centers

Importance

The impact of Medicaid telehealth reimbursement policies on staffing and patient-centered care in the safety net are largely unknown but critical to successful and equitable access to telehealth.

Objective

To identify and characterize federally qualified health center (FQHC) staff and leadership's perceptions of the benefits and drawbacks of Medicaid telehealth reimbursement policies.

Design, Setting, and Participants

This qualitative study used semistructured interviews conducted from April 2022 to January 2024 with snowballed sampled participants consisting of FQHC leadership, clinicians, and administrative staff in 6 FQHCs representing the 5 boroughs in New York, New York.

Main Outcomes and Measures

Participants described telehealth experiences, including factors impending or contributing to staff turnover, patient satisfaction, and financial sustainability within FQHCs. Thematic analysis was used to analyze the data.

Results

Of 56 interviews, 26 participants (46.4%) were part of the leadership team, 18 (32.1%) were clinical staff, 8 (14.3%) were program support staff, 7 (12.5%) were enabling services staff, 3 (5.4%) were site directors, and 3 (5.4%) were another staff category. Three overarching themes characterized staff and leadership understanding of the impact of Medicaid telehealth reimbursement policies on FQHCs: (1) Medicaid telehealth policy design was perceived to exacerbate a workforce shortage, particularly among mental health care practitioners; (2) patients ranged in preferences and ability to access telehealth while FQHCs struggled to attain resources for telehealth; and (3) FQHC leadership envisioned a productive hybrid model where telehealth complements on-site care. FQHC staff and leadership reported opportunities to improve compliance, no-shows, and workflows through telehealth, but improvements in funding policy, such as payment parity and more grants that can be used to address telehealth infrastructure (eg, Internet access, equipment, and literacy), are urgently needed.

Conclusions and Relevance

In this qualitative study, staff at FQHCs perceived the current telehealth Medicaid reimbursement policies in New York State as a factor that exacerbated inequities to accessing care, particularly for mental health needs. These findings indicate that although telehealth brings new opportunities to advance patient-centered care, there are serious challenges on the path toward equitable care because telehealth is not yet integrated into payment in a sustainable way.

Trends in retention and attrition in nine regulated health professions in Australia

Objective To identify factors associated with the retention and attrition of regulated health practitioners in Australia across nine health professions. Methods An online survey of practitioners and an analysis of 10years of Australian Health Practitioner Regulation Agency (Ahpra) registration data were carried out. Results Among surveyed health practitioners, 20,449 (79.4%) intended to stay, 1368 (5.3%) intended to leave, and 1759 (6.8%) were unsure. Most intending to leave planned to do so immediately or within 1-year (72.8%). Top reasons for leaving included mental burnout (32.9%), retirement (30.5%), feeling undervalued/unrecognised (28.5%), lack of professional satisfaction (27.9%), and work no longer being fulfilling (25.1%). Men, older practitioners, those working fewer than 20h per week, and non-self-employed practitioners were more likely to consider not renewing or to be unsure. Analysis of Ahpra registration data from 2014 to 2023 showed that the number of registered practitioners per 100,000 population increased by 29.6%, but the replacement rate showed notable fluctuations over the observed period. Females consistently exhibited higher replacement rates compared to males, with exits from the workforce highest in those aged under 35 pre-2020 and highest in those aged 35-60 post-2020. Conclusions Although the overall number of health practitioners increased from 2014 to 2023, replacement rates have been fluctuating, highlighting concerns about workforce stability, particularly among males, older practitioners, those working fewer or greater than full-time hours, and non-self-employed practitioners. Addressing intrinsic and workplace factors such as mental burnout, lack of recognition, and job satisfaction may improve retention.

Exploring the Issues Facing the Australian Community Mental Health Workforce: A National Mixed-Methods Study

The Commonwealth Psychosocial Support Program, funded by the Australian Government, offers psychosocial support to individuals with severe mental illness. Currently, little research has addressed the challenges confronting its workforce. This study aimed to assess whether recruitment, retention, and staff skills pose significant issues for the Commonwealth Psychosocial Support Program and to identify contributing factors. This study used a mixed-methods explanatory sequential design. 159 mental health support staff across Australia participated in an online survey. From this sample, 16 participated in a semi-structured interview. Survey data was analysed using descriptive statistics and chi-squared tests, while qualitative data was examined through deductive content analysis. 84%, 77% and 56% of staff agreed that recruitment, retention and the skill of staff are significant issues affecting the delivery of the Commonwealth Psychosocial Support Program, respectively. While no significant differences were found in staff characteristics for recruitment and retention concerns, geographical location showed notable disparities in perceptions of staff skill (χ²(4, N = 153) = 11.318, p = 0.023). Specifically, a higher proportion of rural or remote (68%) and regional (63%) staff identified staff skill as an issue compared to metropolitan counterparts (39%). Key factors contributing to poor recruitment included short-term contracts (77%), while burnout (74%) and job insecurity (72%) were indicated for poor retention. Inadequate skill was attributed to infrequent professional development (53%), insufficient on-the-job training (53%), limited mentoring and supervision (50%), and unclear role expectations (50%). Addressing these multifaceted issues is imperative for enhancing the effectiveness of community-based mental health services and ensuring sustained support for individuals with severe mental illness across diverse geographical locations.

Using Human Resources Data to Predict Turnover of Community Mental Health Employees: Prediction and Interpretation of Machine Learning Methods

This study used machine learning (ML) to predict mental health employees' turnover in the following 12 months using human resources data in a community mental health centre. The data contain 621 employees' information (e.g., demographics, job information and client information served by employees) hired between 2011 and 2021 (56.5% turned over during the study period). Six ML methods (i.e., logistic regression, elastic net, random forest [RF], gradient boosting machine [GBM], neural network and support vector machine) were used to predict turnover, along with graphical and statistical tools to interpret predictive relationship patterns and potential interactions. The result suggests that RF and GBM led to better prediction according to specificity, sensitivity and area under the curve (>0.8). The turnover predictors (e.g., past work years, work hours, wage, age, exempt status, educational degree, marital status and employee type) were identified, including those that may be unique to the mental health employee population (e.g., training hours and the proportion of clients with schizophrenia diagnosis). It also revealed nonlinear and nonmonotonic predictive relationships (e.g., wage and employee age), as well as interaction effects, such that past work years interact with other variables in turnover prediction. The study indicates that ML methods showed the predictability of mental health employee turnover using human resources data. The identified predictors and the nonlinear and interactive relationships shed light on developing new predictive models for turnover that warrant further investigations.

Embracing a different outlook: Strengths and goals of individuals currently in treatment for anorexia nervosa

PURPOSE

Developing personal goals beyond weight and shape, and promoting the agency to pursue those goals, could aid in treatment and recovery from anorexia nervosa (AN). This research explores the strengths, interests and goals of individuals currently receiving treatment for AN and evaluates how treatment services are supporting them to work towards personal goals across all areas of everyday life.

METHOD

A total of 58 community-dwelling adults currently receiving treatment for anorexia nervosa at any stage of recovery completed the Client Assessment of Strengths, Interests and Goals Self-Report (CASIG-SR). Participants reported their goals for accommodation, work and study, interpersonal relationships, recreational activities, spirituality, religion or life purpose, physical health and mental health, and the personal strengths and supports needed to achieve those goals. Concordance scores were calculated between importance of personal goals and level of support from current services regarding these goals.

RESULTS

Themes identified across goals, strengths and supports were Connection, Independence & Confidence, Meaning & Self: The Real Me, and Stability & Balance. Work and study goals and strengths were identified strongly. The key support needed was stability from the current treatment team to provide a stable base for change. Concordance scores indicate support provided for personal goals was less than the importance of the goal to the individual.

CONCLUSION

Results suggest goals for everyday living are critical to recovery in anorexia nervosa. Specific clinical considerations to increase motivation and hope are increased access to peer support, a focus on increasing positive affect, supporting safe exercise and promoting outdoor experiences and connection with nature.

LEVEL III

Evidence obtained from well-designed cohort or case-control analytic studies.

Barriers and Facilitators to Staff Recruitment and Retention for ACT Teams: Perspectives of Staff and Participants

The behavioral health workforce has been experiencing deepening problems with recruitment and retention, particularly in publicly funded settings serving individuals with serious mental illnesses. This quality improvement project gathered Assertive Community Treatment (ACT) participant (service user) and provider perspectives on workforce challenges. The authors conducted 8 interviews with ACT participants and 9 focus groups with ACT current staff, team leaders, and former staff. Interviewees discussed barriers to recruitment and retention, including inadequate compensation, work becoming more task-oriented during periods of short staffing, a lack of understanding of what ACT work entails, and elements of the team-based model of care; and facilitators of recruitment and retention, including other aspects of the team-based model of care, connections with colleagues and ACT participants, and flexibility. ACT participants had variable experiences regarding availability of their teams. Recommendations from focus groups and interviews include increasing flexibility, improving awareness of ACT work, optimizing team functioning, addressing staff wellness, and attending to risk. Findings include key insights that may help address the critical workforce shortages in public behavioral health settings.

Policy Recommendations for Coordinated and Sustainable Growth of the Behavioral Health Workforce

Policy Points Demand for behavioral health services outpaces the capacity of the existing workforce, and the unmet need for behavioral health services is expected to grow. This paper summarizes research and policy evidence demonstrating that the long-standing challenges that impede behavioral health workforce development and retention (i.e., low wages, high workloads, training gaps) are being replicated by growing efforts to expand the workforce through task-sharing delivery to nonspecialist behavioral health providers (e.g., peer specialists, promotores de salud). In this paper, we describe policy opportunities to sustain behavioral health workforce growth to meet demand while supporting fair wages, labor protections, and rigorous training.

Impact of U.S. Federal Loan Repayment Programs on the Behavioral Health Workforce: Scoping Review

OBJECTIVE

Federal loan repayment programs (LRPs) are one strategy to address the shortage of behavioral health providers. This scoping review aimed to identify and characterize the federal LRPs' impact on the U.S. behavioral health workforce.

METHODS

A scoping review was conducted in accordance with JBI (formerly known as the Joanna Briggs Institute) methodology for scoping reviews. The authors searched the Ovid MEDLINE, Web of Science, APA PsycInfo, EconLit, PAIS Index, and Embase databases, and gray literature was also reviewed. Two coders screened each article's abstract and full text and extracted study data. Findings were narratively synthesized and conceptually organized.

RESULTS

The full-text screening identified 17 articles that met eligibility criteria. Of these, eight were peer-reviewed studies, and all but one evaluated the National Health Service Corps (NHSC) LRP. Findings were conceptually organized into five categories: descriptive studies of NHSC behavioral health needs and the NHSC workforce (k=4); providers' perceptions of, and experiences with, the NHSC (k=2); associations between NHSC funding and the number of NHSC behavioral health providers (k=4); NHSC behavioral health workforce productivity and capacity (k=3); and federal LRP recruitment and retention (k=4).

CONCLUSIONS

The literature on federal LRPs and their impact on the behavioral health workforce is relatively limited. Although federal LRPs are an important and effective tool to address the behavioral health workforce shortage, additional federal policy strategies are needed to attract and retain behavioral health providers and to diversify the behavioral health workforce.

Why do Stayers Stay? Perceptions of White and Black Long-Term Employees in a Community Mental Health Center

Previous research has focused on factors influencing turnover of employees in the mental health workforce, yet little research has explored reasons why employees stay. To facilitate retaining a diverse mental health workforce, the current study aimed to elucidate factors that contributed to employees' tenure at a community mental health center (CHMC) as well as compare these perceptions between Black and White employees. Long-term employees (7 years or more) from one urban CMHC (n = 22) completed semi-structured stayer interviews. Using emergent thematic analysis, stayer interviews revealed four major themes for why they have stayed at the organization for 7 years or more: (1) work as a calling, (2) supportive relationships, (3) opportunities for growth or meaningful contribution, and (4) organization mission's alignment with personal attributes or values. Comparison between Black and White stayer narratives revealed differences in their perceptions with work as a calling and opportunities for growth and meaningful contribution. Guided by themes derived from stayer interviews, the current study discusses theoretical (e.g., job embeddedness theory, theory of racialized organizations, self-determination theory) and practical implications (e.g., supporting job autonomy, Black voices in leadership) in an effort to improve employee retention and address structural racism within a mental health organization.

Administrative Frictions and the Mental Health Workforce

This Viewpoint describes the administrative barriers experienced by mental health professionals and recommends strategies to address these barriers.

Using Collaborative Documentation to Support Person-Centered Care in Substance Use Settings

The delivery of person-centered care (PCC) is critical to promoting service engagement among individuals who use substances. Collaborative documentation (CD) is an emerging person-centered practice used in community mental health, but has not been evaluated in substance use settings. This qualitative study conducted focus groups with substance use treatment providers (n=22) in an outpatient clinic to examine the impact of CD on PCC and clinical quality. Rapid qualitative analysis methods were used to identify key themes. Participants reported that using CD reduced documentation time and helped build trust and better understand their clients. Using CD presented unique challenges and opportunities when used with mandated populations or those with complex symptoms. The importance of honoring clients' preference not to collaborate in care was a salient theme. Findings indicate that CD can promote PCC in substance use treatment. Targeted strategies to optimize CD for mandated and clinically complex populations are needed.