Moving mental health care out of the office

The U.S. is experiencing shortages of mental health services in a range of locations and service delivery contexts. Just over one in five people in the U.S. reported having a mental health condition in 2021, and of those, about half received any services for those conditions. For some groups of people, including youth and people of color with certain mental health conditions, rates of receiving services are lower than for other groups. The poorest communities in the U.S. have the lowest rates of availability of mental health providers. The gap between apparent need for mental health services and receipt of them is longstanding, and takes on urgency, as rates of reported mental health conditions, as well as suicide rates, have increased. These gaps impose significant human and societal costs.

As part of efforts to expand access to mental health care, some policymakers have proposed engaging more people in mental health care services outside of traditional, office-based health care settings. For example, in last year’s Bipartisan Safer Communities Act, Congress established policies and grants to advance provision of Medicaid-covered health and behavioral health services in schools, building on previous grant investments through the Department of Health and Human Services (HHS) and Department of Education (ED) to expand mental health services in schools. Last year, the Administration also proposed to integrate mental health expertise into social service and early childhood programs.

The goal of these policies is to expand access, reduce unmet need for mental health services, and address maldistribution of mental health providers. They aim to “meet people where they are” by reducing barriers people face accessing services and making them available in the settings people prefer. Barriers include geographic limits on available providers, travel costs, and challenges scheduling appointments during typical provider office hours. They are also intended to diminish stigma that can be associated with mental health care (which can deter people from seeking services when they need them), expand culturally competent service provision, and increase person-centeredness. Some proposals are developed with a recognition that notable groups of people, including people of color, obtain services at lower rates than do others, and that some longstanding approaches to providing mental health services are not adequately meeting the needs of those groups. These approaches can be an alternative to telemedicine to establish immediate, in-person connections, or to serve in place of telemedicine in places where telemedicine is not available or preferred. Policies to advance mental health services outside of health care settings are not new. Grant programs that the Substance Abuse and Mental Health Services Administration (SAMHSA) administers, as well as Medicaid home and community-based services programs, have long supported such services. But policy proposals to promote services outside of traditional office-based settings are receiving increased attention now.

Policymakers face several challenges with respect to expanding access to mental health services outside of traditional health care settings. Efforts to expand access outside of traditional health care settings can encompass a range of goals and approaches, from broad approaches that seek to augment services provided in traditional health care settings to efforts to serve as an access point or conduit to treatment. This makes it difficult for policymakers to match specific interventions with specific policy or system goals. In addition, there is limited evidence on the impact of some of these policy interventions on the people who receive them, including whether they connect people to needed services. This makes it difficult for policymakers to assess the likely impact of policy or funding changes. A third challenge is that some interventions have been well-researched, resulting in solid evidence of their impact on people, but these interventions are not yet widely available. To help address these policy challenges, this paper a) describes some mental health interventions that are provided outside of traditional, office-based health care settings and available evidence of their impact, and b) proposes policies to advance access to these interventions, including in some cases policies to develop a stronger evidence base. These policy options are aimed at federal policymakers; some are also relevant to state and local policymakers.

Read the full white paper here.

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