FEDERALLY­FUNDED "FRONTIER RURAL" TECHNICAL ASSISTANCE CENTER IS DEVELOPING RURAL MENTAL HEALTH SERVICE REVIEWS AND POLICY­RELEVANT PAPERS

Published in the Newsletter of Division 18 (Psychologists in Public Service), American Psychological Association -- Volume 22, Number 1 (Spring issue), 1997, pp. 1,7-9.

In the Article:

The Frontier Mental Health Services Resource Network
The Nature of the "Frontier" and Its Many Faces
Initial Findings on Estimating Frontier­Rural Area Needs for MH/SA Services
Early Thoughts Regarding Frontier­Area MH/SA Caregivers
Current Reflections on Frontier­Area "Managed Care" MH/SA Services

The Frontier Mental Health Services Resource Network

For the past two years, a multi­person "network" of mental health, substance abuse, and health experts funded by the U.S. Center for Mental Health Services (CMHS) has been developing policy­related papers on key aspects of mental health services for isolated rural or frontier areas of the United States. Centered at the University of Denver in Colorado, in the heart of western frontier rural country, the Frontier Mental Health Services Resource Network operates as a decentralized consortium of researchers, educators, and service agency personnel from primarily western states that have concentrations of frontier counties. Its basic mission is to examine available information relevant to meeting the mental health/substance abuse (MH/SA) service needs of people living in rural frontier counties, and to disseminate the findings to as many interested parties as possible.

Defining "isolated rural/frontier" as non­metropolitan U.S. counties having less than 7 residents per square mile (the vast majority of which lie west of the 98^th meridian), the Network's members have been reviewing published and "fugitive" literature in order to produce policy­relevant "syntheses of knowledge" on key topics and issues. These include:

• Surveillance of need and demand for MH/SA services in frontier rural areas;
• Surveillance of availability and accessibility of services in these areas;
• Determination of specialty and general­medical interventions appropriate to frontier areas, including services aimed at four special sub­populations (severely and persistently mentally ill persons, children/adolescents, elderly persons, and persons abusing substances);
• Determination of strategies that will permit identification of the outcomes and costs of frontier­area services;
• Determination and evaluation of organization(s) of service systems, including problems of and prospects for managed care in MH/SA services for these areas;
• Identification of issues involved in specifying, recruiting, training, and retaining MH/SA providers, including frontier­area professionals, "mid­level" practitioners, and indigenous helpers; and
• Identification and evaluation of integrated communication systems and telemental health applications that would permit "networking" between service system consumers, caregivers, backup professionals, and administrators who lack adequate geographic access to one another.

A major focus of the Network is helping caregivers to meet the needs of persons with severe and persistent mental illness, making information available that will facilitate provision of the requisite services. Emphasis is being placed on services for crisis and emergency situations. The service needs of an even larger frontier­area population-those with less severe (though possibly long­term) and less disabling mental disorders and dysfunctions-are also being addressed. Such persons are often treated solely by medical­sector "primary caregivers", because mental health specialists are so seldom available in frontier areas. The Network also seeks to identify strategies that can be used to link in­the­field caregivers with expertise or resources on alcohol and drug abuse problems that frequently accompany mental health crises and long­standing dysfunction in daily living.

A major thrust of the knowledge synthesis efforts will involve review of current electronic communication technology that may facilitate the delivery of MH services in frontier rural areas, and determination of its costs and potential benefits. Computer networks, telephone conferencing and "hotlines", and videoconferencing (using either satellite or ground­based linkages) are among the communications tools that are being reviewed and evaluated.

The Network's primary information dissemination strategies involve newsletters, workshops at professional meetings or conferences that include providers and consumers from frontier areas, and telephone consultations to individual callers. Electronic dissemination in the form of a public­oriented home page on the World Wide Web is also being used. In addition, the Network has established electronic intercommunication linkages among all its paper­drafters and most of its 10­member Advisory Committee (using extended telephone conferences and computer E-mail networks) to foster sharing of what experience is available in these matters.

The range of expertise represented by Network members is quite broad. Included are a MH/SA epidemiologist (James Ciarlo), a MH services researcher (Jack Wackwitz), an annotator of published literature on rural mental health topics (Morton Wagenfeld), a senior state­level MH official (Dennis Mohatt), a rural medical services research center director (Jack Geller), a finance and services cost­effectiveness expert (James Sorensen), an administrator with experience in work­force issues (Frank McGuirk), a geographer consultant (Douglas Clark), two managed­care consultants (Andrew Keller, Marjorie Ross), an expert in the design and use of telecommunications in rural medicine (Walter LaMendola), and an experienced scientific-publications editor (Pearlanne Zelarney). Additional administrative support and close linkage to top­level MH/SA officials from frontier states is provided by staff of the Mental Health Program based at the Western Interstate Commission on Higher Education in Boulder, CO.

The Network is just beginning to move into its second stage of knowledge acquisition, involving much closer connections with frontier­area residents, MH/SA service consumers, and with medical/MH caregivers working in isolated rural settings. The topics listed above will be reviewed in intensive discussion and study groups, each formed to provide first­hand and experience­based input for incorporation into the knowledge syntheses already developed. While these work groups cannot replace extensive, formal surveys as research tools for confirming the many ideas and/or hypotheses generated by the paper writers, we do expect them to provide a rich source of in­depth information about frontier­area needs, available services and caregivers, and other "systems" issues which are not now be found in published or unpublished literature.

The Nature of the "Frontier" and Its Many Faces

A major effort has gone into explicating the demographic and social characteristics of frontier areas, their resident and visitor populations, the impact of long travel distances between residents' homes and medical/MH/SA service sites or commercial centers, and the differences between these frontier counties and other types of rural, suburban, and urban areas. The Network's second Letter to the Field describes the project's findings on these issues (beginning with the initial population­density criterion). It also strongly recommends against the too­frequently­used definition of a "rural" area as being any county termed "non­metropolitan" by the U.S. Census Bureau. It also describes several additional area typologies that promise to be more precise and useful in understanding MH services problems in frontier areas, and in considering MH/SA services policies and funding decisions important to residents of these isolated areas.

At a recent workshop, Network member Zelarney illustrated the great variability in social and economic characteristics that exist among western counties and communities designated as "frontier". She contrasted three types of frontier counties from different states, detailing the different pressures and challenges faced by these areas. One was Colorado's Costilla county, a poor, farming­dependent area with a high percentage of Hispanics (many monolingual). Significantly, and unlike many other frontier counties, Costilla has a MH clinic that provides a fairly extensive range of services, including outreach to a number of quite remote areas. In contrast to Costilla, North Dakota's Dunn county is characterized by a declining predominantly white population with a high concentration of aged persons. Its residents are also not as poor as Costilla's. But Dunn County has no MH services, except those that might be available from a local medical clinic. Again in sharp contrast with both Costilla and Dunn Counties, Montana's Lincoln county consists largely of a national forest area, and has a sizable population (17,000). Although long, harsh winters add to the stresses experienced by residents, this scenic area is growing substantially. Its economy is linked to mining and logging industries that tend to experience booms and busts. Compared to the other counties, Lincoln's population is younger and better­educated. Further, this county has multiple doctors and MH counseling services available.

Each of these county types has unique MH/SA problems and issues. High poverty is associated with high rates of severe and persistent MH disabilities; hence, Costilla must continue to devote much of its MH resources to planning for and servicing this multiple­needs population. Psychiatric medication for its severely affected consumers is critical, and Spanish­speaking caregivers (including indigenous outreach workers) are key components in providing culturally appropriate services. In sharp contrast, Dunn County is considerably worse off. It badly needs at least one or two MH specialty caregiver staff to provide consultation to medical staff who now must handle all of the county's MH/SA cases. These MH caregivers could also then provide crisis, emergency, and longer­term counseling for those cases which require expertise not normally possessed by general­medical personnel. In a still different treatment situation, Lincoln county must contend with the difficult problems generated in a "boom­town" atmosphere-transience and rootlessness, cultural "clashes" between long­time residents and newcomers and consequent feelings of isolation, anger, and depression, and also greater­than­usual substance abuse problems and perhaps violence as well. While basic MH resources may be adequate at present, continued growth will demand more MH/SA specialty­trained caregivers than are usually found in frontier counties.

Initial Findings on Estimating Frontier­Rural Area Needs for MH/SA Services

A new statistical "social­indicator" model for estimating the need for mental health/substance abuse services in rural geographic areas, particularly those which have a low population density and are remote from sizable metropolitan areas, is being intensively studied by Network member Ciarlo. It employs three decennial census­based variables-percentage of the population in poverty, per cent of single males, and per cent of people residing in rural parts of nonmetropolitan and metropolitan areas. An earlier model employing the first two variables had been shown to accurately predict several categories of need for MH/SA services (including DSM­III diagnosable disorders) as assessed in 4,745 household interviews known collectively as the Colorado Social Health Survey. Incorporation of the "per cent rural" variable has improved the model's accuracy still further. Unexpectedly, but quite convincingly, the model predicted somewhat lower need for mental health services in Colorado's highly rural areas. However, this positive factor is more than offset by a negative one-the much lower availability of MH/SA services in such areas. Further, it must be recognized that statistical models do not necessarily provide good estimates for every frontier area. For example, one of two frontier areas surveyed had the second­highest MH need prevalence in the state, while the other one had need prevalence rates similar to Colorado's statewide averages. Still, this statistical model performs far better than either random variations in prevalence rates or using "standard" uniform need prevalence estimates for all Colorado areas. Generalizability of the new model to other western state rural and frontier areas is currently being explored.

Early Thoughts Regarding Frontier­Area MH/SA Caregivers

Both consumers and MH providers in frontier areas are likely to experience "isolation" problems that are linked to low population density and/or small community populations, according to Network member McGuirk. For starters, everyone in small communities is likely to know everyone else; consequently, the well­known "stigma" associated with mental illness (especially apparent in many rural areas where independence and coping ability are highly valued) tends to reduce help­seeking among potential consumers for their MH problems. In addition, the low frequencies of severe mental disorders (sometimes less than 1% of the population) precludes funding of "on­site" personnel with adequate specialized training for handling a particular illness or disability-the critical mass for supporting professional service for it simply does not exist. For consumers, this also means a lack of "peers" who are dealing with similar problems, further strengthening their sense of isolation and "difference". Next, the absence of appropriately trained local caregivers forces the referral of consumers to specialty MH caregivers or facilities distant from their local communities, requiring them to travel far from their homes-and sometimes interrupting their ability to remain in their home area. The potential option of consumers being able to access needed MH/SA services via electronic communications is not yet a realistic one; few such frontier­area "telemental health" applications are in place.

For MH/SA providers, the lack of professional or urban­acculturated peers with whom one can associate has often been cited as a reason that it is difficult to recruit and retain MH/SA providers in frontier areas. Again, the low frequency of certain disorders or disabilities, coupled with extremely small populations at risk, means that many MH professionals cannot make a living in a frontier area unless they travel extensively to serve different locales separated by long distances.

As a partial answer to the problems associated with low population density and small communities, the Network suggests exploring the possibility of training of a locally­based "broker" who could recognize, adequately "diagnose" needs for different types of wide range of MH/SA services, and then link up a potential consumer with the required service resources (including those outside the local area).

Current Reflections on Frontier­Area "Managed Care" MH/SA Services

Managed care systems for either MH/SA services or general­medical services are still rare in frontier areas. Again, this is at least partly because frontier populations are very low density and scattered, and consequently may not easily support service systems that appear to need centralized administrative control and concentration in central locations (usually large towns or cities). In addition, since caregivers aren't widely available in these areas, there is no "abundant supply" of providers that will allow managed care organizations (MCOs) to easily sign up practitioners who desire to have a steady source of referrals for service. Nonetheless, MCOs may be coming to frontier rural areas, either because a large local employer (possibly governmental) wishes to contract for MH/SA care for its frontier/rural employees, or because a state government wishes to contract with a MCO in hopes of reducing its outlays for publicly supported MH/SA services (such as those under Medicaid).

Some Network members remain highly skeptical of the likelihood that any for­profit MCO would increase levels of medical or MH/SA services in any area it serves, let alone rural and frontier areas. However, according to Network members Keller, Ross, and Ciarlo, it may still be in best interests of many frontier rural counties to seek inclusion in a MCO service system if it is part of a larger one (regional, state) that may be more attractive to an MCO. With appropriate legislative support, a state (with its unusually great fiscal "clout") may be able to use an MCO's desire to serve a state's urban populations as a wedge to obtain more balanced and adequate services for its rural-and particularly its frontier-areas as well. The reasonableness of this is now being evaluated. However, we already believe this possibility should be evaluated by MH/SA administrators of any state deciding to implement a MCO­type service system for its residents, since it may represent a rare opportunity to increase the availability of rural and frontier­area MH/SA health services from their currently low levels.

Other cautions are also relevant here. States should seek a MCO service delivery plan that does not allow centralization of all services into a few urban locations distant from the state's frontier counties. This may mean that states must be prepared to offer greater cost reimbursement for MH/SA services delivered in its outlying areas. It is also imperative that states require that a MCO implement a performance measurement data system that can track rural and frontier care delivery separately. This will permit them to monitor the adequacy with which the MCO is serving their frontier and other outlying rural areas.

Further reader inquiries about the Network are welcome; it can be reached at:

Mental Health Program
Western Interstate Commission on Higher Education
P.O. Box 9752
Boulder, CO 80301
(303) 541-0225
FAX: (303) 541­0291

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Frontier Mental Health Resource Network
Please send comments and suggestions on this home page to Dennis F. Mohatt at dmohatt@wiche.edu
http://www.wiche.edu/MentalHealth/Frontier/frontier.asp