Community Health Centers Play a Critical Role in Delivering Essential Behavioral Health Services

Ron Manderscheid, PhD

Adjunct Professor

Johns Hopkins University

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University of Southern California

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Community health centers are an essential part of the health safety net in the United States. Last year, they served almost 1 in 10 people across the Nation, or a total of 32.5 million individuals. They also are a critical component of the overall behavioral health system. The largest number of diagnosis-based visits to community health centers is for mental health conditions, followed by obesity, hypertension, and substance use.

In 2022, more than 36 million visits were for mental health or substance use conditions, up more than 39 percent since 2018. Today, more than three-quarters of all community health centers screen automatically for behavioral health conditions. About 88 percent offer short-term mental health counseling; 70 percent offer this type of care on a long-term basis; 66 percent offer substance use disorder treatment; and 62 percent offer medication assisted treatment.

The population served by community health centers consists principally of children and adults who are poor, marginalized, and excluded. Recent statistics support this observation: 20 million are poor; 17 million are people of color; 15 million are insured through Medicaid or the Children’s Health Insurance Program (CHIP); and 6 million are uninsured.

Under Section 330A of the Public Health Service Act, the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services operates an annual program of grants for community health centers. Currently, HRSA funds 1,383 federally qualified health centers (FQHCs), which operate 17,566 actual service sites. There are an additional 149 FQHC look alikes with equivalent services, which operate 591 local service sites. However, these look alikes do not receive HRSA grant funding.

FQHCs are community-based organizations located in both urban and rural areas. They provide comprehensive?primary care and preventive care both in-person and virtually, including health, oral, and mental health/substance use services to people of all ages, regardless of their ability to pay or?their health insurance status.?FQHCs are known by several different names: Community Health Centers, Migrant Health Centers, Homeless Health Centers, and 330 Funded Clinics. They are automatically designated as?health professional shortage facilities because they operate in places and with populations that do not have access to an adequate supply of health and behavioral health professionals. In recent years, more FQHCs also have operated service sites in schools. In 2022, 950 thousand clients were served in these school-based settings.

About 73 percent of FQHCs indicated that it was difficult or very difficult to connect their Medicaid and uninsured clients with specialty care. Further, 54 percent reported a similar problem for their Medicare clients, and 41 percent, for their privately insured clients.

FQHCs employ about 5,000 full-time equivalent behavioral health professionals. Their numbers have grown from 5.7 percent of FQHC staff in 2018, to about 6.6 percent in 2020. And, like primary care physicians themselves, behavioral health professionals are in short supply in FQHCs. The percent of FQHCs that reported behavioral health on-site staff shortages in their largest site grew from 70 percent in 2018 to 77 percent in 2024; and the percent that viewed this as a major or minor challenge grew from 63 to 70 percent in the same period. Further, the percentage that reported an inadequate supply of behavioral health professionals in the surrounding community grew from 86 to 91 percent during this same interval. Similarly, 70 percent reported shortages of primary care physicians, and 49 percent reported advanced practitioner shortages.

What implications can we draw about the relationship between FQHCs and the behavioral health field?

Clearly, most important is the fact that FQHCs serve populations with behavioral health conditions who are most in need. Because of their low economic and social status, these individuals are more likely also to have low health status, as reflected in severe behavioral health conditions and comorbid chronic physical conditions, such as hypertension, diabetes, and heart disease. Thus, FQHCs are a primary resource as the first line of integrated behavioral health and health services for the poorest communities in the United States.

There are several action implications for the behavioral health field. First, any planning done for behavioral health care services in the future must include discussion with and consideration of the contributions currently made by FQHCs. Second, local specialty behavioral health provider entities, including state, county, and city programs, must undertake efforts to develop working collaborations and partnerships with their local FQHCs.

Another equally important fact is that the current behavioral health workforce crisis in specialty settings also extends to FQHCs. And, as the number of people with behavioral health conditions served by FQHCs continues to grow over time, so too will the severity of their behavioral health workforce crisis.

This has action implications for the behavioral health field. First, as the behavioral health field begins to address the workforce crisis in specialty settings, FQHCs and their state and national associations must be included in these deliberations and become part of any proposed solutions. Second, with appropriate training, other staff who already work in FQHCs, such as community health workers and physician assistants, can become excellent resources for assisting in the delivery of behavioral health services in those settings.

More than three decades ago, we described the “de facto” mental health service delivery system as comprised of four sectors—specialty, health, social, and self-care services. As shown clearly above, FQHCs are an extremely vital component of the health sector for these services, which now also include substance use care. Very important work remains for us to develop a strong ongoing relationship with these centers and to undertake steps to support their essential behavioral health mission.

? 2024 RW Manderscheid