The Opportunity for Systems Transformation: Community Health Workers and Peer Coaches for Reducing Mental Health Inequities

Margarita Alegria & Lauren Cohen

Even after 30 years of acknowledging racial and ethnic mental health service disparities, the Agency for Healthcare Research and Quality continues to report that racial/ethnic minorities have less access to mental health services, are more likely to use emergency departments for care, and are increasingly likely to obtain poor quality services.¹ Deprived access to mental healthcare not only contributes to inadequate recovery among these minority groups² but also erodes the social fabric of society by leading to lack of social mobility, parental incarceration, unstable employment, and many other social ills.³ What seems surprising is that we now know many of the barriers for improving the system of mental healthcare but remain stagnant with the same system that creates and perpetuates them. Here we discuss the potential for community health workers and peer coaches as solutions to the lack of available mental health workforce, fragmentation in the integration and communication between behavioral health and primary care, and lack of access to quality mental healthcare. We call for improvements in mental health policy with a focus on supporting the paraprofessional workforce.

Mental Health Policy

In recent years, mental health equity has emerged as a priority in the national policy agenda (as highlighted in the 2020 Healthy People Leading Health Indicator Report), but the investment in behavioral health and addiction services continues to be misaligned with this goal. A report from the National Alliance of Mental Illness documented a $400 million cut in the Substance Abuse and Mental Health Services Administration’s budget allocated to support mental health and addiction services, resulting in defunding of health workforce education services.⁴ This further constricts the workforce trained to serve racial and ethnic minorities, as many still confront a workforce that is not proficient to offer culturally and linguistically competent services. Consequently, we fail to retain consumers in care,⁵ and patients drop out of care without receiving enough psychotherapy or counseling to be effective or enough information to offer them choices in their treatment. In fact, racial/ethnic service disparities are evident across the continuum of mental healthcare, pointing towards Blacks and Latinos initiating less care and reporting less adequate care than whites.⁶ Growing evidence demonstrates the importance of linguistic and cultural competency in obtaining quality care by establishing positive patient-provider interactions in the clinical visit.⁷ Also of importance is having a similar lived experience to prevent providers from forming stereotypes and prejudice when offering mental healthcare.^8,9

Even with the advances of the Affordable Care Act¹⁰ and Medicaid expansions, racial and ethnic minorities represent more than 50% of the uninsured population.¹¹ Today over 10.3% of all adults with a mental illness remain uninsured.¹² Medicaid expansions at the state level have demonstrated increases in the number of low-income individuals receiving care,¹³ but many still encounter a shortage of providers. Currently, most psychiatrists do not accept Medicaid due to low reimbursement rates14¹⁴ and insurmountable paperwork to get paid.¹⁵ So, if we do not have the mental health workforce, or the workforce is not efficiently trained to serve ethnic/racial minorities, what can we do?

The assumption that primary care providers will fill this gap by integrating mental health services into their healthcare visits seems unrealistic.^16,17 For the most part, this assumption has been proven mistaken.¹⁸ We have a workforce of primary care providers overwhelmed with electronic medical record systems, with more illness information to address in an 8-minute visit than ever before.¹⁹ Even for those with good intentions and integrated teams (those that combine primary care providers and staff with behavioral health staff), there is the need to grapple with an overflow of information, coordination of care across team members, and building trust across team members to generate effective integrated care.

Paraprofessional Workforce Could be the Answer

At the community level, employing a diverse workforce of community health workers (CHWs) may enhance trust-building with the community members, as well as empower CHWs as stakeholders promoting positive mental healthcare in their communities. Paraprofessionals, often referred to as CHWs or promotores, have the unique leverage to bridge the gap between the patient and their interactions with mental health and primary care providers.²⁰ By engaging in the role of case management, follow-up, and referrals, they partner with the patient, becoming their ally and advocate in mental healthcare. As vital components of mental health services, peer supports and CHWs are essential in reducing stigma and social exclusion by empowering service users and giving them a voice.²¹ CHWs can often aid in reaching vulnerable and disengaged populations that lack care. Research has found CHW services to be more accessible than clinical providers for those living with mental illness.²² The availability and integration of mental health services into communities has been shown to promote adherence to treatment, increasing the likelihood of positive clinical outcomes.²³

Since the employment of CHWs is relatively new in the field, there are several obstacles that this workforce faces. Due to the variability of the position, they may have undefined roles as members of interdisciplinary healthcare delivery teams, which can create difficulties for receiving funding to support their work.²⁴ Also, in the current healthcare system, there is a lack of reimbursement policies to pay for work administered by CHWs, which can have ripple effects on recruitment and retention of CHWs.²⁵ Although Medicaid is widely utilized across the country, it does not reimburse services provided by CHWs in some states. At its core, there is also a lack of standardized training and credentialing for CHWs that creates problems in terms of reciprocity and consistency in care.²⁴ Ensuring the participation and integration of community health workers into mental healthcare will only be achieved if policies surrounding them become more comprehensive. States can begin by implementing guidelines supporting and protecting CHWs, establishing sustainable funding mechanisms, and developing standards for training and certificates. With these advancements in place, the paraprofessional workforce would be better protected and enabled to meet the behavioral needs of diverse populations.

Conclusion

Persistent disparities in mental healthcare are a public health crisis that needs to be addressed to ensure positive health outcomes for all. The current system of mental healthcare is fragmented, underfunded, and does not meet the needs of racial/ethnic minorities. Community health workers and peer support could fill vital roles in racial/ethnic minority communities, yet are faced with obstacles to their continued success. Only through policy level change can barriers to equitable behavioral healthcare services be dismantled and fuel our hope to achieve mental health equity.

About the Authors

Margarita Alegria, PhD

As Chief of the Disparities Research Unit at Massachusetts General Hospital, Margarita Alegria, PhD is a leading expert in the field of healthcare inequity. Currently, she leads an NIH-funded research project titled Mechanisms Underlying Racial/Ethnic Disparities in Mental Disorders and is a psychiatry professor at Harvard Medical School.

Lauren Cohen, BA

Lauren Cohen, BA is currently a Project Coordinator at the Disparities Research Unit at Massachusetts General Hospital. She holds a BA in Psychology & Health: Science, Society, and Policy from Brandeis University.

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