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Community Mental Health Center Staffing Patterns Alan I. Levenson, M.D. Shirley R. Reff, M.B.A. ABSTRACT: A survey of funded applications for federal staffing grants from 80 community mental health centers reveals that of 3,83o full-time positions projected by the centers, i,& 3 or 42% were listed as nonprofessional mental health personnel. The study was conducted to help the planners of new centers benefit from the projected staffing patterns of existing centers, and to gather information about the use of manpower and the types of personnel employed in the centers' variety of services. In many respects, each center is unique because it serves a distinct community. However, all share many features in common, including the use of a variety of personnel. Staffing needs for each of the five basic services and specialized services are analyzed by categories of centers and communities served. Federal funds now have been awarded to assist in the de- velopment of over 375 community mental health centers. In many respects each of these centers is unique, for each serves what is essentially a unique community. At the same time, however, these centers share many common features. One particularly important group of common features and experi- ences is that which relates to the development of center staffing patterns. The effective use of manpower is a critical ingredient in the success of any center. Accordingly, this review of projected staffing patterns in already funded centers is designed to help the developers of new centers to use the ex- perience of existing centers in planning their own programs and personnel structures. In addition, this review of common staffing features has been designed to provide information about the present and potential manpower needs of community mental health centers. During the period from June, i966, through June, 1968, a total of I56 com- munity mental health centers received staffing grants from the Federal Gov- ernment. The first year award to each center averaged $275,ooo, and the typi- cal center was identified with a catchment area of approximately ~55,ooo people. Dr. Levenson is Chairman, Department of Psychiatry, University of Arizona Medical School, Tucson, Arizona 8572~. Shirley Reff is statistician in the Program Analysis Section, Division of Mental Health Service Programs, National Institute of Mental Health, Chevy Chase, Maryland 2ooz 5. Community Mental Health Journal, Vol, 6 (2), 1970 118

Community mental health center staffing patterns

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Community Mental Health Center Staffing Patterns Alan I. Levenson, M.D.

Shirley R. Reff, M.B.A.

ABSTRACT: A survey of funded applications for federal staffing grants from 80 community mental health centers reveals that of 3,83o full-time positions projected by the centers, i ,& 3 or 42% were listed as nonprofessional mental health personnel. The study was conducted to help the planners of new centers benefit from the projected staffing patterns of existing centers, and to gather information about the use of manpower and the types of personnel employed in the centers' variety of services. In many respects, each center is unique because it serves a distinct community. However, all share many features in common, including the use of a variety of personnel. Staffing needs for each of the five basic services and specialized services are analyzed by categories of centers and communities served.

Federal funds now have been awarded to assist in the de- velopment of over 375 community mental health centers. In many respects each of these centers is unique, for each serves what is essentially a unique community. At the same time, however, these centers share many common features. One particularly important group of common features and experi- ences is that which relates to the development of center staffing patterns. The effective use of manpower is a critical ingredient in the success of any center. Accordingly, this review of projected staffing patterns in already funded centers is designed to help the developers of new centers to use the ex- perience of existing centers in planning their own programs and personnel structures. In addition, this review of common staffing features has been designed to provide information about the present and potential manpower needs of community mental health centers.

During the period from June, i 966 , through June, 1968, a total of I56 com- munity mental health centers received staffing grants from the Federal Gov- ernment. The first year award to each center averaged $275,ooo, and the typi- cal center was identified with a catchment area of approximately ~55,ooo people.

Dr. Levenson is Chairman, Department of Psychiatry, University of Arizona Medical School, Tucson, Arizona 8572~. Shirley Reff is statistician in the Program Analysis Section, Division of Mental Health Service Programs, National Institute of Mental Health, Chevy Chase, Maryland 2ooz 5.

Community Mental Health Journal, Vol, 6 (2), 1970

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Alan I. Levenson and Shirley R. Reff 119

EaGh center that is awarded a community mental health center staffing grant can anticipate Federal support for a period of 5I months. First year grants during fiscal years I966, I967, and I968 totaled just under $5o mil- lion. In addition to receiving this amount in first year awards, the x56 cen- ters will receive an additional $Ioo.2 million during the course of their 5~ months of support. The first year awards and continuations thus repre- sent a total of over $I5o million in Federal grants. This study focuses on data from 8o centers, which account for a Federal outlay of $26,874,0oo. This amount provides partiaI support over a 51-month period for 7,9o8 staff mem- bers in community mental health centers. The majority of these staff members works in the centers only part time, therefore, they represent the equivalent of 3,83o full-time positions.

Federal staffing funds have been used to support many different types of personnel. The four core mental health disciplines are well represented in the list of funded positions, but they are joined by many other staff categories. These latter categories include licensed practical nurses, aides, and atten- dants; rehabilitation personnel; professional health educators; community organizers; nonpsychiatric physicians; and a large number of indigenous nonprofessional personnel. Of the total of 3,83o full-time equivalent posi- tions (hereafter referred to as FTEs) that have been funded, 298 have been identified as positions for psychiatrists. Another 254 full-time positions were established for psychologists, approximately 545 full-time positions for social workers, and 679 for registered nurses, while an additional 836 positions were established for practical nurses, aides, and attendants.

It is clear from these figures that community mental health centers are re- lying heavily on the traditional categories of professional mental health personnel. At the same time, however, it must be pointed out that "r,6I 3 or 42~o of the full-time positions have been established for nonprofessional mental health workers. Most of these nonprofessional staff members are drawn from the catchment area served by the center, and they play a vitally important role in the center's programs, both in the center's clinical settings and in its extensions into the community.

Composite data describing the Federal Community Mental Health Centers Program as a whole is of value as an indicator of the total manpower needs of the Nation's community mental health centers. It seems even more im- portant, however, to consider the characteristic staffing patterns that have been developed in different types of community mental health centers. Cen- ters vary in many respects, but most significantly they vary in terms of the nature of the community being served and in terms of the center's own or- ganizational structure. Both types of variation have been used in preparing data for this paper.

A representative sample of funded community mental health centers was selected and categorized according to the nature of the catchment area served.

120 Community Mental Health Journal

Twenty-six of the centers in the sample serve an urban catchment area (de- fined as one located in a city of 5o,ooo or more inhabitants). Four of the cen- ters in the sample serve a suburban catchment area (defined as one located in a metropolitan area but outside the limits of a city with 5o,ooo or more inhabitants). Thirty-two centers in the sample serve a rural catchment area (defined as one including parts or all of one or more rural counties. A rural county is one in which more than 5o% of the population lived in commu- nities with less than 2,5oo inhabitants in I96o ).

Throughout this paper personnel data are presented in terms of FTEs. An FTE represents 4 ~ hours of staff time apportioned among one to eight staff members. For statistical purposes, the counting of FTEs is essential for mak- ing meaningful comparisons among centers.

COMMUNITY BASED CENTERS Staff Composition by Discipline The average urban center has a staff of lO4. 7 FTEs. This

personnel will cost the center an average of $813,7~ 4, In contrast to this typical urban center, the typical suburban center will be staffed with 41.8 FTEs at a cost of $347,638, and for the rural center there is a projected need for 44 staff members at a cost of $291,985 . As we look at the models for the three different community based centers, we find that the average cost per employee for rural centers is $6,636 compared with $7,772 in urban centers, and $8,3i 7 in the suburban setting. In the urban model there is a projected need for 9.5 full-time psychiatrists against 5.7 in the suburban center, while the projection in the rural centers is for only 2.2 psychiatrists. The rural cen- ters plan to pay the highest average salary for a full-time staff psychiatrist, namely, $22,o2o. The staff psychiatrist in the urban center will earn $2o,516 while his counterpart in the suburban center will earn $I8,o29 .

Looking at the three centers from another perspective, we find that in the urban centers 56.9% of the staff will be professionals who will receive 76.9% of the total salaries. In the suburban centers the proportion of profes- sional staff will be slightly higher--58.3%--and these professionals will re- ceive 77.8% of the total allotted salaries. In the rural center less than half of the staff- will be professional; however, this portion will receive 71.5% of total salaries.

Looking at the nonprofessional side, we see that in the urban centers the licensed practical nurses (LPNs), aides, and attendants will account for 21.6% of all staffing at a total cost of 11.4% of total salaries. The projection for this type of personnel in the suburban center is much lower with a pro- jection of 9.3% of total staff receiving only 2.9% of the salaries. In the rural setting these categories of nonprofessionals account for 33.2% of staffing with a salary cost of 17.8% of the total salary budget.

Alan I. Levenson and Shirley R. Reff 121

Staff Composition By Service At a cost of $243,57I, 39.9 FTEs will be used to man in-

patient services in urban centers. The cost of the inpatient service in the sub- urban centers is estimated at $97,9o4, and these staffing assignments will utilize 55.o FTEs. In the rural centers the inpatient service will use 2o. 5 FTEs at a cost of $99,625. Looking at the total staffing needs for inpatient service, it was found that the average person working on this inpatient service in an urban center will cost the center $6,o94 per annum; while in a suburban cen- ter, the average cost will be $6,526 compared with the low in the rural centers

of $4,859. Observing the staffing needs for an outpatient service in a rural center,

the estimated cost is $66,3o 9 with an average of 7.4 FTEs. The anticipated cost of an outpatient service in the suburban center will be $68,993 and will be manned by 6. 3 FTEs. The large urban center will use 52.8 FTEs at a cost of

$227,332. Observing the partial hospitalization service in the three types of com-

munity based centers, it appears that in the rural center there is a plan for 4.4 persons at a cost of $3o,992 with a high average cost per man of $7,o44. This is compared with the urban center that will use 55.6 persons at a cost of $2o5,943 to the center with an average cost'per man of $6,795. In the suburban center there is a projected need for 6.5 persons at a cost of $38,252 with a low average cost per man of $6,27o.

Reviewing the projections for emergency services, it can be seen that the typical urban center anticipates an assignment of 6. 4 FTEs to the emergency service at a total cost of $55,638. The typical suburban center anticipates the assignment of only 2. 4 FTEs at a total cost of $3o,845. The typical rural cen- ter anticipates the assignment of only 5.8 FTEs at a total cost of $54,499. The staffing costs per FTE for emergency service in the three types of centers are $8,o68 in the urban center, $52,852 in the typical suburban center, and $8,o55 in the typical rural center.

In consultation and education, as in the other basic services, the urban cen, ter model shows a higher projection, 9.5 FTEs, for personnel than do rural or suburban centers. The service will cost the center $96,768 or an average of $2o,586 per man. In the rural model there is a projected need for three per- sons at a cost of $3o,284, or at an average of $io,o65 per man. This cost per man is very similar to that in the large urban center. In the suburban center there is a projection of 2. 4 FTEs costing $22,766 or an average of $9,485 per man.

In the large urban setting, it is projected that 84.2 FTEs or 8o% of total staff will be assigned to providing the five essential services. This portion of staff will cost the urban center $624,852. The staff requirements for providing the basic services is much less in the rural and suburban centers, with a pro- jection Of 37.5 FTEs for rural and 32.2 FTEs for suburban.

122 Community Mental Health Journal

CENTERS CATEGORIZED BY ORGANIZATIONAL STRUCTURE Staff Composition By Discipline For this portion of the sample 46 centers based in general

hospitals, 26 centers based in state hospitals, and -rz based in teaching hos- pitals and/or medical schools were examined. The highest staffing projec- tions were in the teaching hospital centers. Such a center projects a need for 2o9.o FTEs at a cost of over $9oo,ooo per annum, with an average cost per employee of $8,387 . The state hospital center shows the next greatest projection, namely, 74.8 persons costing $549,625 or an average cost of $7,347 per man. The general hospital center shows the smallest projected staff, namely, 68.4 persons, costing $459,544, or an average cost of $6,728 per person a year. It is interesting to observe that in the general hospital the need for psychiatrists is projected at 4.8 FTEs, and in the teaching hospital, the need for psychiatrists is projected at 23.o FTEs. However, the salary for the psychiatrist in the general hospital is highest, $2o,582 per annum, con- trasted with $20,276 in the teaching hospital and only $I8,857 in the state hospital.

In the general hospital there is a projected need for 35.2 full-time profes- sionals or 5z~o of the entire staff, costing the general hospital based center $343,257, or 75% of its entire salary budget. In the state hospital there is a projected need for 39.8 full-time professionals or 53% of its entire staff at a cost of $4o2,539, or 73% of the salary allotment. In the teaching hospital center we see that the need for professional manpower jumps to 65 full-time persons, or 6o% of the staff needs, costing the center $722,382 or 79% of the entire staffing budget.

Although in the general hospital based center, the professional plays the dominant role in staffing, there is a projected need for ~9.4 LPNs, aides, and attendants, who will use ~5~o of the salary budget. In the state hospital, the projection is for ~9.6 nonprofessionals in the above personnel categories, also using only x5~ of the entire salary budget. In the teaching hospital center, this group plays a less important role than in the general or the state hospital centers. LPNs, aides and attendants will use only zo% of total salary funds and these 22 FTEs will represent 2o~o of the staff.

Staff Composition By Service Of the three organizational types of centers described, the

teaching hospital center displays a need for the largest number of staff to provide the five essential services. In the teaching hospital center there is a projected total staff of 89.3 full-time persons at a cost of $728,529 or at an average cost per man of $8,258. The average cost per man is quite similar in the general hospital and in the state hospital; however, the state hospital projects a staff of 62.0 FTEs compared with 47.5 FTEs in the general hospital. The data show that the teaching hospital center plans to utilize 82.o~o of its

Alan I. Levenson and Shirley R. Reff 123

staff in providing the five essential services. While the plan for utilization of staff in the state hospital center is very close to that of the average teaching center, the projection for staff allocated to provide the essential services in the general hospital center is much lower; namely, 69.5% of total staff.

It appears that of the five essential services the highest cost estimate per FTE will be for providing consultation and education. The teaching hospitals project an average of 24.6 FTEs to staff their consultation and education pro- gram costing $~56,546 at an average cost of $~o,7zz. The state hospital and the general hospital have Iow projections for staffing this service. The gen- eral hospital projects 3.6 FTEs costing $38,47 o at an average very close to that of the teaching hospital of $2o,686. The state hospitals have projected a need for 4.4 persons at a cost of $45,4o4, or at an average cost of $~o,3~ 9 per man.

The teaching hospital center will utilize ~t6.6 FTEs at a cost of $I65,o23 or an average cost per man of $9,94 ~ to staff an outpatient service. The state hospital projects the next highest number for an outpatient service at 9.z FTEs and at a cost of $8z,Sz4, or an average cost of $8,97 ~ per position. In the general hospital the outpatient staffing needs appear smaller--8.z persons at a cost of $77,97z; however, the average cost per person is higher--$9,5o 9.

Using the community mental health center model of delivering services to the mentally ill, the greatest manpower needs still appear to be in the inpatient service, as would be expected in the traditional pattern. In the teaching hospital there is a projection for 4o.8 FTEs costing $262,214, com- pared with the state hospital projection of 35.8 FTEs and a cost of $zo5,o24 for the inpatient service and the general hospital projection of z4. 4 FTEs at a cost of $23o,o25 for this service. The general hospital based center, with the lowest estimate of manpower, projects the lowest average cost per per- son at $5,3z8 as compared with the teaching hospital with an average cost of $6,4z6 a person.

The staffing of partial hospitalization services also shows variation among the three types of centers. The typical center in a general hospital projects 8. 3 FTEs for this service and a total budget of $56,544. The typical center based in a state hospital projects the assignment of 9.z FTEs at a total cost of $62,~53. The typical center based in a teaching hospital or a medical school projects z2.~ FTEs for this service at a total cost of $85,9o2. Average costs per man assigned to partial hospitalization service range from $6,72o in the state hospital affiliated center to $7,738 in the teaching hospital affiliated center.

COMMENT The data reported in this paper were drawn from staffing

projections prepared by community mental health centers which have now been awarded Federal funds. As a result, they provide a valuable guide for the planning of additional centers. The director of the new community men-

124 Community Mental Health Journal

tal health center is faced with many complex tasks, but certainly none is more critical than the development of his staff. Despite the fact that no two centers are identical, the experience of established centers can serve as a useful starting point for the new center director's own personnel planning. The value of this experience is particularly clear in regard to services which are to be newly developed in the community. The typical center is created through the affiliation of two or more existing agencies, but at least some of its services are newly developed. (Indeed, all the services to be funded with Federal staffing funds must be new.) Hence, the director of the center must look to existing centers elsewhere if he is to find practical guidelines for his own staffing pattern.

In one respect, however, the existing centers may not be able to provide appropriate models for the staffing of additional centers. The basic intent of the community mental health center is to develop preventive services in ad- dition to the traditional forms of diagnostic and treatment services. Of the five essential services required in each federally-funded center, four are direct treatment services. These, clearly, are the inpatient, outpatient, emergency, and partial hospitalization services. The fifth service, community consulta- tion and education, is the one required center service which is aimed at the primary prevention of mental illness and the promotion of mental health. What is quite evident from the data presented here, however, is that the typi- cal community mental health center has projected a very limited commitment to this consultation and education service.

In the typical urban center, for example, the consultation and education service utilizes only 9% of the total available manpower. On the other hand, the four direct services in this urban center utilize 72.5% of the manpower. In the typical suburban center, consultation and education utilizes only 5.7% of the manpower, while the four direct services utilize 71.o%. In the typical rural center, the figures are 6.8% and 77.6%, respectively.

The same relative proportions are seen in the manpower utilization pat- terns of the general hospital based and state hospital based community health centers. In the typical center developed in a general hospital, ,;.3% of the manpower is assigned to consultation and education, and 64.z% is assigned to the four direct services. In the typical center developed in a state hospital, the figures are 5.9% and 75.4%, respectively. It is only in the community mental health center which is based in a medical school or teaching hospital that we find an increased emphasis on preventive services. The typical com- munity mental health center in a teaching institution utilizes z3.4~o of its manpower for consultation and education, and it utilizes 58.6% of its man- power for the four required direct services.

Several factors may well be responsible for this limited emphasis on the preventive aspects of community mental health center programs. One is the relative newness of mental health consultation, at least in regard to its being based on a formally developed body of theory and practice. The second factor

Alan I. Levenson and Shirley R. Reff 125

--perhaps a corollary of the first--is the fact that there are very few psy- chiatrists and other mental health professionals who have been specifically trained to work as consultants. Still a third factor is an administrative one, namely the limited availability of funds for the support of mental health consultation activities. This has been especially true in regard to private funds.

Whatever the reasons may be, the effects are dear. Existing community mental health centers have planned to commit only very small portions of their manpower resources to consultation and education services. It can be anticipated, however, that greater emphasis will be given to these preventive services as more experience is gained with them. It seems reasonable to ex- pect that this experience will provide a basis for training additional person- nel in consultation techniques and also for developing reasonable fiscal mech- anisms for the support of consultation programs. Accordingly, it also seems reasonable to expect that as new community mental health centers are es- tablished, their staffing patterns will show a greater balance of direct and in- direct services than is found in the projections reported here.