mc faul

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Rural Behavioral Health: A Glimpse into What is Working and What is to Come Virginia Rural Health Plan Access Council Summit December 7, 2011

Mimi McFaul, Psy.D. Associate Director WICHE Mental Health Program

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What do many Americans think of when they picture persons with mental health issues?

A homeless person on a city street

An out-of-control teenager in a large metropolitan school

A person on a locked hospital ward

Persons making poor choices

Someone else

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Few Americans Picture

A farmer or rancher with serious depression

The stress associated with changing rural economies

Someone driving 150+ miles to a clinic

A traveling psychiatrist

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The Cold, Hard Facts

More than 60% of rural Americans live in mental health professional shortage areas

More than 90% of all psychologists and psychiatrists, and 80% of MSWs, work exclusively in metropolitan areas

More than 65% of rural Americans get their mental health care from their primary care provider

The mental health crisis responder for most rural Americans is a law enforcement officer

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So What’s Different about Rural?

Not prevalence – rural/urban rates of mental disorders are pretty much the same.

Accessibility (getting there and paying)

Availability(someone there when you are)

Acceptability(choice, quality, knowledge)

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Some Common Rural BH Workforce Issues

Lack of sustained effort to prepare and deploy professionals for rural practice

Lack of systematic recruitment and retention of behavioral health workforce

Lack of communication between educational institutions and providers

Those who spend the most time with patients receive the least training

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How did it get this way?

Stigma/Discrimination

Lack of a rural plan

Lack of sustained effort to prepare and deploy professionals for rural practice

One size fits all planning and funding

Mental Health Care is “optional”

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What can we do?

Advocacy/Public Education

National Health Service Corps (NHSC) – Rural sites should become eligible sites – recruitment tool

Improve Primary Care/Mental Health Integration

Take rural into account – get a plan

Increase rural training placements

Grow Your Own

Train Natural Helpers (Mental Health First Aid)

Acknowledge rural innovation

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The Trend Toward Integration of Primary Care and Behavioral Health

It’s happening in an agency near you

How does this impact who we hire? How we train?

Many people seek care for mental health issues in primary care.

Primary care even more central in rural communities where BH workforce is limited.

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SAMHSA/HRSA Center for Integrated Health Solutions (CIHS)

http://www.integration.samhsa.gov/

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What are we doing to work on rural behavioral health access?

Suicide Prevention Toolkit for Rural Primary Care Providers

Rural Psychology Internship Consortia (Alaska, Hawaii…)

Integrated Care Projects

State-specific Consultation

Synthetic Estimation of Prevalence and Unmet Need

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How do we know what is working for rural

communities?

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Urban Testing Ground for EBPs

What is the rural applicabilty?

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Challenges and Opportunities

Challenges of implementing EBPs in rural due to smaller economies of scale

What is a realistic goal for rural?

Evidence-based practice vs. Practice-based evidence

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Many rural behavioral health programs…

Have always relied on creativity and working within their current resources

Have not been researched sufficiently to be considered EBPs for rural

Do not have evaluators (except if attached to a specific grant) to conduct ongoing research

Are fearful of what to do with data and how to use it in a meaningful way – we don’t need to measure everything!

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It always comes back to…FIDELITY

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Starting with the Community

What’s working in rural communities?

Promising Practice: Treatment programs or interventions designed for a particular population that have at least some data supporting their effectiveness in terms of client outcomes

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Why do this?

Recognition for model rural programs

Share best practices

Connect programs to researchers

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Inside the Boxing Ring: Approaching Heavyweight

Round One: 6 Programs

Round Two: 30 Programs

Round Three: 62 Programs

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Learning from Experience

Need clearly criteria for what defines a rural promising practice but…

Criteria also need specificity for particular program/population served

Need categories to “cluster programs”

The “will” is there but…

Programs need a road map for using evidence to demonstrate success and support program activities

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Rural Promising Practices Project

Nomination Process

Web-based Surveys

Phone Interviews to “drill down”

Categorization Scheme

Pruning Process

Top Tier Nominees

Site Visits

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Selected Questions

Type of “practice nominated”

Rationale/theory for practice

Indicators of success (decreasing symptoms, increasing staff retention)

% Rural

Staff Training/”Fidelity”

Manualized?

Evaluation Staff to collect data?

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32 of 50 States Represented!

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Categories

Adapting EBPs for Rural

Community education and outreach programs

Integrated care programs

Court teams

Crisis services programs

Hotline programs

Peer support programs

Programs serving special populations

Telemental health programs

Training programs

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Themes

Relevance to Rural

Impact on Rural

Sustainability and Expansion Capability

Capacity

Documentation of Program Information

Effectiveness

Community Engagement

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Highlighted Programs

One highlighted program for each theme

A few examples…

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Goal of Document

Highlight rural promising practices cohort across categories

Resource guide

Information Exchange

hrsa.gov/ruralhealth/pdf/ruralbehavioralmanual05312011.pdf

Future Directions…Dreaming

Rural “Oscars”

Website with interactive functionality

Connecting rural researchers to these programs

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Adapting and Adopting EBPs

Core clinical components

Hybrid models

Climbing up the evidence ladder

Rural-specific criteria

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ACA and Rural Behavioral Health??

More eligible for services (Medicaid) – heightens workforce issues

How do we incentivize people to be Medicaid providers?

State plans vary for Medicaid benefits for MH

How will our pre-service education, continuing education, and other training programs need to be adjusted to meet new workforce needs driven by integrating care?

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Questions?

Contact Information:

WICHE Mental Health Program

Mimi McFaul, Psy.D.

mmcfaul@wiche.edu