Key Takeaways
- Workforce planning must account for the structural deficit caused by long training pipelines and annual turnover rates exceeding 30 percent in behavioral health roles.
Mental and behavioral health services are in higher demand than ever before. In the wake of the COVID-19 pandemic and the continuing acceleration of mental health awareness, both public and private entities have worked to expand services. Yet, across the nation, mental health organizations—ranging from large hospital systems to small outpatient clinics—have struggled mightily with staffing. Leaders cite burnout, funding constraints, policy restrictions, and administrative hurdles as factors contributing to the crisis.
However, as illustrated by experts working on the front lines, the reality of mental health staffing is not just about policy, pay, or job titles. It revolves around the complexities of human connection, long training pipelines, and the sheer stamina it takes to develop programs that both meet regulatory requirements and retain the essential humanity needed for truly effective care. These healthcare challenges and workforce challenges are at the heart of the current mental health crisis, with behavioral health workforce shortages becoming increasingly apparent. We spoke with Damir S. Utrzan, Ph.D., LMFT of Horowitz Healthto break down the challenges and their solutions.
Mental health needs are skyrocketing, while the workforce pipeline cannot keep up. The shortage of mental health professionals has reached critical levels, with many areas experiencing a severe mental health provider shortage. According to recent healthcare workforce statistics, the gap between demand and supply in the behavioral health workforce continues to widen. Burnout among nurses, social workers, therapists, and psychiatrists reached new heights during the pandemic, with many professionals working overtime to treat patients in increasingly high-acuity environments. The field already suffered from a limited supply: for instance, clinical doctoral programs (e.g., PhDs in psychology or related fields) graduate very small cohorts compared to other healthcare disciplines. It can take seven to twelve years for these practitioners to complete their education and clinical postdoctoral requirements. Meanwhile, demand grows steadily, and sometimes exponentially, as more individuals seek care.
Staff retention is also a major factor in the behavioral health workforce shortage. A national study by the National Council for Mental Wellbeing (formerly the National Council for Behavioral Health) found that mental health professionals have turnover rates between 30 and 40 percent annually—double the rate seen in other healthcare fields. This mass exodus compounds the strain on those who remain. In many mental health settings, such as Intensive Residential Treatment Services (IRTS) or acute inpatient psychiatric facilities, patient acuity is high and the care is complex. Staff members are exposed to emotionally taxing situations day after day, contributing to provider burnout and exacerbating the therapist shortage.
Compensation has historically not kept pace with the difficulty and importance of the work. Despite the specialized training needed, salaries and reimbursement rates have often remained stagnant or grown only modestly. The financial reality is that any mental health organization—large or small—needs revenue to cover expenses, but the reimbursement environment (particularly around Medicaid and Medicare) does not always match the complexity of mental healthcare. These healthcare workforce trends have led to a critical mental health care shortage across the country, highlighting the urgent need for comprehensive workforce development strategies in the behavioral health sector.
Given the coverage that mental health has received in recent years, one might assume legislation or policy is the main issue behind the workforce crisis. In reality, mental health policy issues are just one piece of the puzzle. Yes, state regulations play a huge role, particularly in licensing new facilities or expanding existing ones. For example, in Minnesota (as discussed by Damir S. Utrzan, Ph.D., LMFT, Chief Compliance and Strategic Development Officer at Horowitz Health), any new IRTS facility must navigate:
These steps can be time-consuming and expensive, representing significant regulatory barriers in the mental health field. Leaders must hire and train staff in anticipation of opening, yet the facility may not receive any reimbursements for months. While large health systems sometimes have the capital to weather this waiting period, smaller or newer organizations may find themselves in precarious financial positions. That said, the high-barrier licensing process can also act as a filter, discouraging groups whose primary focus is profit rather than true quality care. In other words, the strict licensure requirements mean that only the dedicated—those who understand the nuances of patient-centered mental health—are likely to see a new facility to its opening day. These mental health policies examples illustrate the complex landscape that providers must navigate, often facing significant administrative burdens in the process.
Staff shortages are not simply a matter of "not enough bodies." The behavioral health workforce requires individuals with advanced training and a deep capacity for empathy. Damir S. Utrzan, Ph.D., LMFT points out, the best outcomes in therapy and mental health care come not from the specific intervention or medication alone, but from the therapeutic relationship itself. Care is grounded in human connection, which means the right personality fit, combined with high-level clinical competencies, is essential.
Organizations that invest in staff training and ongoing professional development often reap the rewards in patient outcomes and employee satisfaction. For instance, new staff at IRTS facilities in Minnesota must fulfill state-mandated training requirements (often around 30 hours) before ever setting foot on the floor. On top of that, leading organizations provide:
This training can be expensive and time intensive. New hires sometimes struggle with the demands, and turnover is a risk if they feel overwhelmed. However, organizations that persist and embed a culture of support—where employees can ask for help, share cases, and receive mentorship—tend to see higher job satisfaction and better workforce retention. The synergy of collaborative support reduces burnout: employees feel they are part of something bigger, not just cogs in an operational wheel. This approach to workforce development is crucial for addressing the behavioral health workforce shortages and building a resilient mental health workforce. Additionally, promoting diversity in the behavioral health workforce is essential for providing culturally competent care and meeting the unique needs of diverse patient populations.
One might ask, "If mental health care is so crucial, and if demand is so high, shouldn't all these facilities be profitable and stable?" The short answer is: not necessarily. Even though the need is there, securing reliable funding streams can be complex. Many programs rely heavily on Medicaid reimbursements, and rates can vary drastically by state. Facilities offering specialized programs, such as co-occurring care (treating substance use disorders alongside mental health conditions) or neurocognitive rehabilitation (for patients with conditions like Korsakoff syndrome), often command a higher reimbursement rate due to the specialized staffing ratio. Still, the up-front investment is substantial and the timeline to become "cash flow positive" can extend over many months.
Horowitz Health, for example, opens IRTS facilities with a very high staff-to-client ratio—sometimes exceeding a two-to-one staff-to-patient ratio. For a 16-bed facility, over 20 staff members may be employed. This ratio includes cooks, administrators, clinicians, psychiatrists, and other support staff. While this structure is more expensive to maintain, it allows for truly comprehensive care that can lead to better patient outcomes and stronger relationships with local counties or referral sources.
Financial success in mental health—especially in higher-acuity settings—largely hinges on:
Understanding and navigating reimbursement rates is crucial for maintaining financial viability while providing quality care, especially in rural areas and underserved communities where the behavioral health workforce shortage is often more pronounced. Addressing financial barriers to training and exploring options for supervision cost relief can help alleviate some of the financial pressures faced by mental health organizations and professionals.
Perhaps the most vital takeaway from those working in the industry is that human connection remains the bedrock of effective mental health care. Whether in a telehealth environment or a 24/7 residential facility, the relationship between caregiver and patient—the trust, empathy, and mutual respect—plays a more significant role in outcomes than any single medication or evidence-based protocol. In an era of rapid technological growth, there is a temptation to rely on telehealth services or algorithms to triage patients. While these innovations can supplement care and expand reach, especially in rural areas and underserved communities, the on-site human element remains irreplaceable for individuals in crisis or living with severe mental illness.
Creating an environment conducive to healing requires staff who can connect with patients, especially when those patients are in the midst of a manic episode, severe depression, or a psychotic break. This connection cannot be "factory-assembled"; it thrives in facilities where staff feel supported, valued, and continuously trained. The ability to provide culturally competent care is also crucial, ensuring that diverse patient populations receive appropriate and effective treatment. Promoting diversity in the behavioral health workforce is essential for addressing the unique needs of various communities and improving overall mental health outcomes.
As the field evolves, primary care integration and tele-supervision are becoming increasingly important aspects of mental health care delivery. These approaches can help extend the reach of the behavioral health workforce and improve access to care, particularly in underserved areas. However, it's crucial to maintain the human element in these new models of care delivery.
For leaders looking to replicate successful mental health programs in their own geographic areas, there are a few key points to consider:
The realities of mental health staffing are far more complex than one might gather from headlines about "staffing shortages" or "policy gridlock." While it is true that national and state regulations can present hurdles, and that the pipeline of trained professionals is not keeping pace with rising demand, these challenges can be addressed through thoughtful planning, financial investment, and a deep organizational commitment to compassionate care.
Programs that successfully navigate these waters recognize that mental health care fundamentally revolves around relationships. They invest in recruiting, training, and retaining professionals who not only have the qualifications on paper but also the heart to connect meaningfully with patients. These organizations also form strategic partnerships with local counties, stay current with regulatory requirements, and balance financial realities with mission-driven principles.
In short, mental health staffing may look like a puzzle—consisting of policy constraints, reimbursement models, and workforce pipelines—but the essential piece that keeps everything together is the human element. As long as organizations remain dedicated to supporting their staff and fostering genuine connections between provider and patient, they can and do succeed in delivering the intensive, life-changing care that countless individuals desperately need. Addressing the behavioral health workforce shortages requires a multifaceted approach that combines policy changes, workforce development initiatives, and a commitment to improving access to care for all communities, including rural areas and underserved populations. By focusing on comprehensive workforce planning and addressing the root causes of behavioral health workforce shortages, we can work towards a more robust and effective mental health care system for all.
<p>it's not the intervention it's not the medication it's the human connection which often times is a source of suffering but then also the source of of healing hope and [Music] inspiration hello everyone this is Cole from the American Journal of healthcare strategy joined by a very very important leader today with uh you know many years of experience really tremendous amount of experience and it's in an area that we're really facing a crisis with continuously as a country uh Dr sson please introduce yourself and your current role great thank you for having me on Cole my name is Dr deir sson and I'm currently the chief compliance and strategic development officer at horwood health I have been with the organization for a little under two years but prior to that I worked as mental health manager at the Hazel and Betty Ford foundation in Center City Minnesota and before that in the direct care and treatment Administration within the Minnesota Department of Human Services you started back at Rockford according to LinkedIn with a bachelor in Psychology human development philosophy then you got your Masters at Northwestern in marriage and family counseling you got your doctorate your PhD at the University of Minnesota you did a post-doctoral fellowship and then of course you've been in the field many many years working with so many different organizations so you really are an expert in this space I I have to ask what has led you to horwood health especially in the role that you're in as Chief kind of compliance and strategic development officer that is a more business focused role than what you've done in terms of as a clinician so how does that that change and what Drew you to doing that absolutely and that's a great question and it highlights some of the underlying factors or considerations of around the topic that we're discussing today so when you're in a terminal master's degree or even a doctorate you're not trained uh or or taught around operations or or business right unless you maybe take an elective you're trained to be a clinician first and foremost at least in the The Master's level at the doctoral level you're trained as a research scientist uh in order to look and take apart uh logical arguments so you can design uh strong methodologies to execute research studies and so to some degree they are opposite sides of the the same Spectrum right whereas business leadership draws on different parts of the Continuum and so often we'll see uh clinicians who are great at delivering Psychotherapy or medicine if that's what they field is but not so good at transferring those skills to business operations and Leadership despite an underlying Factor being interpersonal relationships and and so when I finished my post-doctoral fellowship at the University of Minnesota I was looking for initially teaching opportunities right I was trained to be a clinical scholar and so I interviewed all across the country at medical schools at research universities but it didn't really align with my values at the time I couldn't really put words to it but it just didn't feel right and then an opportunity arose with the Minnesota Department of Human Services as a treatment director of an intensive residential treatment services facility so in Minnesota those facilities are licensed under the uniform uh standards mental health act or Uniform service standards act excuse me USS 245i and they provide a level of care that is just below the hospital in patients and it's designed to treat up to 16 clients for a range of 30 to 90 days by stabilizing their functioning uh returning them to uh you know a baseline whatever that may be for them that's individualized and person centered and then discharging them back into the community to prevent the revolving door of of rehospitalizations and I really enjoyed the ability and freedom to combine clinical practice scholarship and and Leadership so that was really unique and especially being uh governmental I got to see the policies procedures and and various aspects that go into operating a facility that program subsequently closed down and I went to the Hazel and Betty Ford Foundation where I oversaw the also licensed under 245i an outpatient mental health clinic with psychiatrist about 25 staff overall serving you know a campus of slightly over 300 clients wow and and that's where I you know I still maintain the clinical practice because under this law you have to be licensed as a mental health professional to be in set leadership position but I also worked with senior leadership to evaluate for example psychiatric acurity protocols and Implement measures for curbing uh referral so we can triage the most uh acute clients or patients if you will and thereby Marshal resources accordingly right what what you may experience as anxiety may not be the same as another person or as I would experience it and after that I got an opportunity to work with uh horwood health and what Drew me here was you know another evolution in my career if you will where uh Drew Horwitz president and chief executive officer was well known known in providing outpatient substance use disorder treatment and medically monitored detox or withdrawal management but because substance use disorders are mental health disorders and the dichotomy and separation is arbitrary to some degree he also wanted to expand into the mental health Continuum so you know over the past almost two years like I said uh I've worked with a team here to license three intensive residential treatment services facility one uh out patient mental health clinic and six outpatient substance uses or Improvement facilities W so that's your you've grown drastically then in terms of the amount of individuals that you're managing and the complexity of the situation I want to ask the the first place you mentioned that the program had shut down and that's one of the things that we're seeing across the country is consolidation but we're also seeing a lot of challenges and one of the things I brought to you when we had first spoke was that everyone I'm talking with is saying that it's a policy problem and you said that that might be true in different states it might be true in different circumstances but from your perspective yes the policy could be improved in some ways but there's this other aspect of things that maybe people aren't seeing in terms of efficiency management and then even greed in some ways where people especially VC uh need to kind of extract as much kind of resources they can to keep moving their portfolio forward I I want to ask when it comes to Staffing specifically because now you're overseeing a large amount of a large amount of staff um everyone is complaining about staff shortages are staff shortages due to education is it due to the the uh compensation the work environment why do you think everyone is complaining about staff shortages in behavioral and mental health you know the answer is all of the above the to some degree right and I don't know if you've ever heard of the term equifinality not that it just means that there's multiple ways of getting to the same end point yeah right and the reason I bring that up is because certainly since the pandemic there has been a shortage of mental health professionals independently licensed providers psychiatrists because of the burnout the exhaustion the long hours and the human body is unique and that we can adapt and and survive for a relatively long period of time in highly stressful situations but once our cortisol Rebels decrease and return to Baseline there's a sense of exhaustion and that's both physical and psychological the other part that you have and we're seeing that as a compounding effect of the rapid growth expansion and mergers which you know over the last year we've seen significantly more mergers than we have in the past four years combined and so if you look at even the facility that I'm in uh right now that that we're opening it's licensed for 16 beds has about 22 staff and I think four mental health professionals so it's a very high staff de client ratio given the intensity and it's four mental health professionals but putting that into context on average doctoral degrees are uh excuse me states with universities that have clinical doctoral programs award maybe 16 doctorates a year wow right so cohorts are between three to to six uh individuals and then it takes two plus years for Fellowship specialization and Licensing so it's a very prolonged and protracted process to some extent and the the need whether that be business or or clinical simply is outpacing the availability because you can't train cliss that quickly and so what we've seen in response is you know more hybrid or virtual uh opportunities but even then is then subsequently um faced with barriers and legislation policy in that you need to have waivers and different approvals to offer telea Health Services following expiration of the uh pandemic emergency exemptions but tellah Health doesn't work for all these these situations it doesn't work for the people that you are seeing you know at times it may like for Psychiatry for example we're fortunate enough to have a lot of psychiatric providers whether that be Physicians or uh nurse practitioners where if they're licensed in in the state which they are of course and working for our organization we can share resources across and offer a virtual presence right so let's say I have a provider at a facility in St Paul but there's a high need client or patient in Minneapolis we have waivers to provide P Health Services across licensed facilities but that is still within the context of a robust support system physically present on the site right psychotropic medications only work to a certain extent and there is a a large body of research showing that you know whenever you have severe mental illness there may be times where the psychopharmacological uh properties are rendered ineffective by by by the body that's concerning and so you you really can't be completely remote then you do have to have that physic so and so then that that breeds the question how are you in your organization able to function and do well and succeed in terms of Staffing what are the solutions that you have found to that problem where others have seemingly you know continued to struggle I I think and we talked about this before we started recording and in 2023 the National Council for mental health did a comprehensive study across the country looking at turnover rates across different disciplines and industries and and they found that mental health specifically has turnover rates between 30 and 40% annually compared to around 19 to 20% in healthcare overall so that is twice as high because the demand again is is outpacing the availability the other consideration is salaries have not maintained with the Demand right I always joke around with people saying that well you can't drive a Porche and AFF Ford budget right and and and there needs to be it's true yeah there needs to be a standardization and um Equalization if that's even of of of Revenue looking at you know comparing and contrasting what the facilities are billing what they're getting reimbursed versus what the uh value of the services provided as being one of the ways that I did it at previous organizations is implement the performance metrics so rvus or relative value units to ensure that uh providers are meeting targets but not using it in a punitive way using it as a measure to see where they are and how to assist and help them in um ensuring that they meet the targets and if they're unable to helping them remove barriers rather than Shifting the blame on them right a clinician can only do so much they're not necessarily able uh given all the other competing needs and and demands like documentation to recruit their own clients as well and so that's what we've kind of done here is really try to create an environment that is responsive but also invest a lot in uh training and ensuring that the facilities have operational capacity and infrastructure to handle the clients that they're serving um which is why our staffing ratios are so high there's not any single person responsible for delivering the Care at any single moment in time because because I I think when we had talked last time I was actually quite surprised at the Staffing ratios what were they uh when when we had spoken I think it was uh here we have actually 22 uh staff and 10 clients so it's a two staff for every client and that's uh licensed professionals unlicensed professionals books chefs um Physicians mental health professionals the treatment director is a licensed mental health professional the program director is a doctoral trained clinician and so there's a lot of distribution of responsibilities and expertise and so the facility that I'm sitting in now is the first of its kind where you know it's an S and there's many others in the state but that's going to treat cooccurring disorders with a neurocognitive impairment component so and and that was inspired by facilities historically admitting individuals for medically monitor withdrawal management or detox and you know they may have some cognitive impairments that the provider deems as a result of intoxication but once they complete the protocol it becomes clear that it's an organic disorder due to corov syndrome or wet brain well to that uh you're not really returning them to a baseline that would be mine or yours right you are rehabilitating them to some level of function Independence unlikely but then what would happen they wouldn't meet the level of care at a hospital because it's too high and they wouldn't be safe enough in a residential setting because they could get lost and I I think that's important because what some of the things that we're seeing is is that these these facilities that some of the the larger financial institutions are trying to start our there essentially are these like skilled nursing facilities or the facilities where the the ratios are much larger and the care is not as intensive but here's the question how are you know are you is your organization profitable and how is it able to actually make revenue and be sustainable because what we're seeing is even organizations with with tough Staffing with worse Staffing that have simpler less complex patients they're going out of business and and going away and the money's being invested elsewhere but when we spoke you said that that the organization was doing tremendously well and so I guess I'm wondering is how is that possible you know I think it's important to remember that any facility such as this one takes a while to be cash flow positive the last one took us you know six to8 months right so you have to have an upfront investment in in in the services that you're hoping to provide but by investing a lot in staff training and and I'm using it as a buzzword right we are meeting the statutory criteria for trading but then going above and beyond it to give you an example we are required by state law to train uh everyone in enhanced illness management and Recovery uh through the University of Minnesota so we have to do that period but then we have an internal protocol for integrated dual Disorders Treatment that we train everyone in we also train everyone in nonviolent conflict uh intervention with a trauma-informed component um we provide ongoing weekly uh clinical consultation across all of our sites where providers can come together and answer questions and and support each other and then we continuously use data driven practices to evaluate the clinical needs and the trends that are emerging across the sites in order to tailor interventions and training specifically to curb incidents and so it's a very irr iterative process of risk mitigation well I I wonder how during those six to eight months though are you doing all this risk mitigation and training as well even when you're not cash flow positive yeah so in in please for intensive Residential Treatment Services in Minnesota it's a it's a multi-step process right you have to get the permanence zoning then you have to get a supervised living facility license from the Department of Health then the Department of Human Services license then you have to go through uh Department of Human Services for rate setting which takes some time you have to demonstrate you know all the things that I've talked about and once that is finalized you are not billing for the interm period but once it's approved you're back billing okay so how and how much are we talking here is ending up being are we in the millions are we in the 100 thousands me is it a substantial amount it's in hundreds of thousands wow so this could be and then and how many this is a smaller facility compared to what some of the right yeah so these facilities intensive Residential Treatment Services can be licensed up to 16 te can't go above that because it's intensive um a lot are smaller the rate is publicly available information since it is uh you know most of the funding is through the centers of Medicaid and and Medicare I that would say over 90% of our clients in tenzo residential treatment services are through that mechanism and so to give you an example one of the sites is uh charging per DM something around 750 and then $50 for roomin board so it can be pretty substantial but you know there is an upfront investment when you think about it a substantial upfront investment for for that and I would argue to say that that although it's not you know formal in any sense or capacity also serves as a deterrent for individuals seeking to go into this business for the sole reason of making money now of course you want to be able to to have revenue and then reinvest and and continue expanding but that can't be the sole reason right there has to be you know kind of care for the community involved there because they need that intense level of care exactly especially for these types of facilities another factor in opening or requirement is a letter of support from the county in which the facility is going to be located because you're serving that population so every County that were in or have been in we do a demographic analysis of of uh clients patients uh demographic factors a gender sex overall prevalence rates of uh various disorders and then then design programming to meet the needs of that specific community and then have ongoing discussions and conversations with the county so you know that all feeds into a strategic approach to making a facility longterm sustainable and financially viable right the alternative is you open the facility if your sole motivation is revenue generation without looking at the underlying factors and then you know you're down the road you're surprised why there's no need I think that makes me ask the question though is that it is still profitable and does still generate Revenue even with those challenges and with that long-term sustainability kind of as as the approach I feel like we shouldn't be in as much of a crisis as we're in now right I feel like there shouldn't be people with you know in a manic episode or or in you know a sphere you know schizophrenic episode or and I've and you know my wife as my PO I interact with idual um a lot and so I know that my my sister-in-law for example had to be uh in one of the similar facilities for for a little bit um so I understand what it's like to be in the situations and I don't understand exactly why we're not able to provide care for people who are actually they need it they're seeking it out and they're being told to to you know there's no room or to wait or essentially things like that so why is that happening still despite profitability despite the possibility you know other than Staffing MH I mean several different factors as as I mentioned uh previously but you know what when we talk about it it sounds easy but the actual execution of the operational strategy is exhausting right you to to give you an example when we license one of these facilities we have to submit a policy and procedure manual to the Department of Human Services that meets various statutory criteria right like the program Abuse Prevention plan the length of those manuals is around pages and you're doing that for every facility now there are individuals out there who copy and paste right uh policy manuals but the Department of Human Services is a relatively small within that division so you can see similarities but if you're if you're designing programming and services that are uniquely tailored to the population you're serving which is you know a best practice it takes a lot of time and and that's just the the PO policy documentation beyond that you have you know the the trainings and outside of what I currently mentioned or previously mentioned you also need 30 hours of uh training on various uh requirements before you can even set foot into the facility oh wow okay it's that investment of time and well really time right and and mental effort you know I I think that it does serve as a good deterrent because unfortunately every field is prone to fraud waste and abuse I don't think that's unique to to mental health but if if if you are being asked to go through a complex process and are unable to do so it leaves me to wonder clinically whether you can handle then the needs of the individuals you will serve in the long term right because you know I may sit at a at a computer and look at numbers but those numbers are people and whatever intervention or directive I may give at the executive level doesn't only impact the staff that is directed to execute those but also the client the patient their family and and the members of the community and if we get too far removed from from that we tend to lose focus and become disconnected it's that agel Trope of uh senior leadership giving directives without fully understanding the cascading effects of of what that means if you could give and I I really appreciate your time and I'll just ask this one last question if you could give kind of one or two tips for individuals who really love the mission and then who are looking to do something similar in their own kind of geographic areas what are what are some of the tips that you would give leaders in this area you know the strongest predictor of a a positive therapeutic outcome is the relation ship uh it's not the intervention it's not the medication it's the human connection healing hope and inspiration and in a world where everything is moving very quickly and you know I'll be honest and that I I thrive in a world that's somewhat chaotic and and crisis oriented there are people like that um it's important to slow down and listen and and not just doing it to check the box right let's say I'm going through a document or I want to submit a a form and and I'm frazzled or distraught or or anxious if I take a step back and think about it it's a expectation that I'm imposing on myself and if I can remove myself from that expectation I can execute it more faithfully and and talking with other people so so so many times we live in a society in a world especially so after the pandemic right we're still not sure and Familiar of the social determinance of Health that resulted following a long period of of of isolation that we've grown accustomed to not picking up the phone calling asking you know networking if you will I I found in my business and uh almost every job that I've had it does come down to that as well the people whether it's colleagues our customers internal external it is the kind of the most vital aspect uh of kind of success I think and then it's also interesting to know that that flows down in in mental and Behavioral Health even at the clinical level so really great advice thank you so much for coming on uh deir I really do appreciate it I hope we can have you on again as well absolutely thank you for the opportunity call</p>
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