Digital, Retail Mental Health Services Are Straining Community-Based Behavioral Health Providers

Behavioral health services offered by digital health and retail companies have attracted many patients with lower-acuity mental health needs.

In turn, many community providers are seeing an influx of higher-acuity patients who need in-person services. This often means that community providers assign their clinicians a less balanced caseload, which some warn could lead to burnout.

And it’s not only patient acuity levels that are becoming less diversified. Many community providers are now seeing a higher number of Medicaid patients as well.


“I want to start off by saying greater access is always good,” Stacy DiStefano, CEO of Consulting for Human Services (CFS), told Behavioral Health Business. “But I think, as a behavioral health ecosystem, we have to acknowledge that we’re not adding new providers. We’re shifting resources from one clinic to another because there is a shortage of clinicians and behavioral health providers across the board.”

CFS is a behavioral health-focused consulting firm that works with nonprofit provider organizations, payers, state systems, tech vendors, and private equity firms.

Scores of digital behavioral health providers have launched over the past few years, bolstered by pandemic-era telehealth flexibilities and the general embrace of virtual care by the American public. Examples include companies such as Cerebral and Minded.


Meanwhile, CVS Health (NYSE: CVS), Walmart (NYSE: WMT) and Kroger (NYSE: KR) are just a few of the big retailers that have established in-house mental health programs or external partnerships.

CVS has been one of the more active retailers, just recently announcing that six of its Los Angeles-based MinuteClinic locations would staff licensed mental health professionals moving forward.

“This predates the pandemic,” Ashley Karpinski, executive director of behavioral health plus enterprise collaboration and care delivery at CVS Health, previously told BHB. “We’re really focused on how we bring mental health across our assets, including CVS MinuteClinics.”

Providers struggling with acuity creep

As DiStefano suggested, the emergence of digital and retail mental health services has boosted access nationwide. But much of that is for lower-acuity care, with more complex cases flowing toward traditional community-based providers.

If this trend continues, it could seriously impact community providers’ workloads, leading to burnout.

​​”Pre-pandemic, we were able to assign cases in a more balanced way, so that folks could have … maybe a third to a half of individuals on their caseload with a series of persistent mental illnesses, like schizophrenia, bipolar, paranoia,” Nicole Brown, chief operating officer of Chimes Holcomb, told BHB. “And now, I would say 90% of patients on their caseload have a serious and persistent mental illness.”

Founded in 2000 when Holcomb Behavioral Health Systems merged with Chimes Family Services, Chimes Holcomb cares for people with mental health conditions and substance use disorders, along with intellectual disabilities and other co-occurring disorders. It has over a dozen locations across Pennsylvania, New Jersey, Delaware and Maryland.

Burnout is already a significant issue in the behavioral health space. In fact, 90% of mental health workers have reported experiencing burnout, and 67% have reported experiencing moderate to severe burnout, according to a survey from the National Council for Mental Wellbeing and The Harris Poll.

At the same time, 7 in 10 providers report increased client severity since the pandemic began, according to the same poll.

“If you were an ER doctor and nurse, and you have all gunshot wounds and high-trauma victims every day, all day, that’s not sustainable,” DiStefano said. “If you don’t have the occasional sprained ankle and ear infection, you don’t get to catch your breath. And that’s what we’re seeing with all of our clients in the community space because of never-ending high acuity and not enough resources to attach to folks who need the social determinant piece.”

Many community health providers also provide case management services to their high-need patients. This means that clinicians are helping individuals link to a medical doctor, housing services or food resources.

Addressing social determinants of health issues can mean work and training for clinicians. At the same time, many providers in the retail and digital health space are focused more on therapy.

“I think the folks that come into the retail clinics, and somewhat the digital providers, aren’t on the verge of losing their housing, or aren’t food insecure, or those types of things,” DiStefano said.

But increased caseloads are just one of the reasons therapists and other clinicians are getting lured away from the community provider space. Community providers also have to compete with the higher salaries and better benefits packages some newcomers can offer.

“We ended up having to hire someone fresh out of school. We take two to three years to train them and provide the licensed supervision they need for them to get licensed,” Brown said. “And then because these private entities have … all the [resources], they can offer higher salaries and great incentive plans. So people go, so it’s a very expensive process for us to hire and train those staff for them to then leave.”

Longer waits at community health providers

The shortage of behavioral health providers and the increased resources needed to care for some higher-acuity patients can mean longer wait times for patients.

“Because we’re dealing with higher-acuity individuals, they’re with us on our caseload a lot longer,” Brown said. “So I would say, on average, they are with us for two to three years, compared to someone with lower needs. They may need a month to six months worth of sessions, and then they’re on their way. So you’re able to help more people faster, quicker. With serious and persistent illness, it’s a lifelong sort of chronic condition. That takes a lot more time.”

DiStefano noted that she had an outpatient provider client with a waitlist of 500 people. One of the major challenges organizations like this face is the Medicaid requirement to see a patient for a follow-up visit within seven days of intake.

“They can probably do an intake, but they don’t have the bandwidth,” DiStefano said. “They don’t have enough clinicians to see those folks ongoing. She said they could probably hire 10 [full-time] clinicians and fill them immediately.”

Providers accepting Medicaid are often disproportionately impacted by this trend. Additionally, Medicaid often has stricter regulations compared to commercial plans. But easing up on restrictions could help lighten the burden.

“We have this crisis point and shortage of clinicians,” DiStefano said. “[Maybe for now], we say instead of seven days, it’s 14 days – or some sort of relaxing to get people started.”

Better reimbursement could also help provide support for higher-acuity patients. It could also improve rates and conditions for clinicians, enticing them to stay in community health.

“I think a big part of this is the Medicaid fee schedule is just very, very poorly funded,” Brown said. “So if there was enhanced funding to the states for mental health, and drug and alcohol treatment,… that would be extremely beneficial because then we could put the money into paying staff more continuing enhanced training.”

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