Mental health services are critical components of public health infrastructure that provide essential supports to people living with psychiatric disorders. In a typical year, about 20 percent of people will have a psychiatric disorder, and about 5 percent will experience serious psychological distress, indicating a potentially serious mental illness. Nationally, the use of mental health services is low; in a national survey conducted by the Substance Abuse and Mental Health Services Administration, only 66 percent of people with a serious mental illness had received mental health services in the past year (Substance Abuse and Mental Health Services Administration, 2020). Moreover, the use of care is not equitably distributed. In the United States as a whole and in New York City (NYC), non-Hispanic white individuals are more likely to use mental health services than non-Hispanic black or Hispanic individuals. Adding to these underlying challenges, the coronavirus disease 2019 (COVID-19) pandemic has disrupted established patterns of care.
To advance policy strategy for addressing gaps in the mental health services system, the NYC Mayor's Office of Community Mental Health and the Mayor's Office for Economic Opportunity contracted with the RAND Corporation to investigate the availability and accessibility of mental health services in NYC. City policymakers were particularly interested in the safety net of mental health treatment services for publicly insured and uninsured patients, many of whom have serious functional impairments as well as complex medical and social needs. The RAND research team used two complementary approaches to address these issues. First, the team conducted interviews with a broad group of professionals and patients in the mental health system to identify barriers to care and potential strategies for improving access and availability. The professionals included public-sector mental health providers, academic policy experts, and city policymakers. Second, the team investigated geographic variations in the availability of mental health services across the city by compiling and mapping data on the geographic locations and service characteristics of mental health treatment facilities in NYC.
Professionals’ Perspectives on the Availability of Mental Health Care
Two major themes related to barriers to expanding mental health services were identified from the interviews: workforce shortages and the integration of services. Workforce shortages were identified as a foundational issue; as one professional informant said, "I don't think we can talk about behavioral health without talking about workforce first." Informants noted that, although there are many mental health providers in NYC, some do not take Medicaid or other forms of insurance, which creates a workforce shortage that is specific to people who cannot pay out of pocket for their treatment. Shortages were identified as particularly acute for care for patients who do not speak English. Informants emphasized that, although the workforce shortage preceded the COVID-19 pandemic, it has been worsened by the increase in demand for services and a decrease in the number of providers.
Informants also highlighted challenges in integrating the diverse services needed by people with serious mental illness to live securely in the community. Informants focused on barriers that occur when patients are receiving services from multiple sources, such as homeless services and mental health care, or when they move from one setting to another, such as after discharge from jail. As one informant said, "We need more communication; it feels like we are very disjointed, and we need to figure out how to coordinate more. . . . Patients that jump around from one facility to another, we need to be able to communicate better for that."
Patient Perspectives on the Accessibility of Mental Health Care
Patients also reported challenges stemming from workforce shortages, such as long wait times for appointments and a lack of integration among providers. In addition, patients described barriers within their communities or families that prevented them from initiating care until they became adults, despite experiencing mental health problems from early adolescence. For others, initial contact with treatment was through a crisis that resulted in a psychiatric hospitalization. Patients described difficulties in finding information on how to seek services, difficulties with the process of navigating systems to access services, and problems connecting with a provider who they felt would understand them. During the pandemic, patients experienced more difficulties in finding care, which they attributed to exacerbated workforce issues. Some used telehealth to access services during the pandemic and felt that the quality of care was not as high as when they received care in person.
Mapping Mental Health Facilities
Mapping mental health facilities enables policymakers and other stakeholders to identify areas of the city that lack adequate mental health services for the local population. The RAND team sought to build a mapping tool that pulls information about mental health treatment facilities into a single data set and maps their locations and characteristics. The team combined three publicly accessible listings of mental health treatment facilities, resulting in a consolidated database of 1,724 facilities. The consolidated database was used to map mental health facilities across NYC neighborhoods, which were defined using Neighborhood Tabulation Areas (NTAs), a geographic unit commonly used by the NYC Department of City Planning. Information on the NTA populations, which was drawn from the U.S. Census Bureau and other data sources, was used to identify areas with needs for specific types of services.
The consolidated data set can be used to identify areas of the city with relatively low access to specific types of services. For example, the RAND team identified areas of the city where the number of facilities that accept Medicaid is low across multiple continuous NTAs, indicating a broad area with low geographic access to care for people who rely on Medicaid for their health insurance coverage. Notably, there are NTAs with no facilities in the Bronx, Queens, and Staten Island. Conversely, Manhattan and Brooklyn have no NTAs without at least one facility. Areas with groups of NTAs with few or no facilities are found in the northern and northeastern sections of the Bronx and in eastern sections of Queens. NTAs with high proportions of Medicaid-eligible populations and low numbers of treatment facilities are found in northern sections of the Bronx and southern sections of Brooklyn. We also used the data set to identify NTAs with high numbers of people who speak Spanish with low proficiency in English and low numbers of mental health treatment facilities that provide services in Spanish. Groups of NTAs meeting this description were found in Northern Queens, along the border of Brooklyn and Queens, and in the South Bronx.
Conclusions and Recommendations
The challenges that NYC faces in ensuring that all New Yorkers have access to mental health care are not unique. The challenges that were identified by providers—workforce shortages and a lack of integration of care—are long-standing national issues that have been at the forefront of policy discussions for many years. Similarly, the descriptions that our patient informants gave of their searches for care echo issues that have been voiced by people receiving public mental health services. All of these issues have been exacerbated during the pandemic.
Using the results of our qualitative interviews and our investigation of mental health treatment facility data, we offer the following recommendations:
- Focus on short- and long-term workforce issues: The city should support ongoing efforts to increase clinical training in mental health fields, expand the role of peers in providing services, and improve wages and benefits for workers in mental health facilities. However, the city should not expect hiring and retention of staff to fully address limits on the capacity of the service system. Additional strategies to improve capacity by increasing efficiency—such as the use of care managers to reduce no-shows to clinic appointments and to improve treatment follow-up, task-shifting (i.e., enabling care to be provided by nonclinical community-based service providers), and the deployment of technology, including telehealth and internet-based communication—should be considered. Different payment models can help achieve these goals.
- Continue developing a data system: The data compiled for this study provide an initial view of underserved areas in the city, but that view can be made more valuable to policymakers by integrating additional data, validating certain data elements, and updating facility data over time. The current data set is a foundation for the development of a system that can serve multiple functions for stakeholders inside and outside city government. In the future, additional data can be added to the system to enhance its value. The city should consider including additional variables from the Patient Characteristics Survey and the Community Health Survey, census data on the uninsured population, information on school-based mental health services, data that could be collected directly from facilities, and additional data from Medicaid, such as clinic financing reports.
- Develop a telehealth strategy: The role of telehealth in mental health care is in flux because of the pandemic, and policies that will shape this role after the pandemic are yet to be finalized. Our findings revealed both positive and negative aspects of telehealth for people receiving public mental health services. The technology has the potential to improve the capacity for care, but many are concerned about quality. The city can play a role in addressing quality-of-care issues by working with state regulatory agencies on quality assessment and disseminating evidence-based treatment models to clinics.
- Continue to develop clinical information systems: Providers in mental health clinics, other medical settings, and nonmedical social service settings are all interested in the ability to share information in making decisions about clinical care and identifying resources for their patients and clients. The city can work with partners in government and in the private nonprofit sector to improve information-sharing, which will enhance integration of care across the system. We recommend convening health systems and large community-based providers to create a long-term information system–development strategy.