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Frontier Mental Health Strategies: Integrating, Reaching Out, Building Up, And ConnectingLetter to the Field No. 6by Jack M. Geller, Ph.D., Marshfield Medical Research Foundation; Peter Beeson,
Ph.D, Prairie Wind Productions; Roy Rodenhiser, Ed.D., Rochester Institute of Technology Table of Contents IntroductionWhile a great deal of attention has been focused on rural mental health over the years,
virtually none of that attention has dealt specifically with "frontier mental
health." By "frontier mental health" we mean meeting the mental health
needs of persons living in areas with less than 6 (sometimes 7) persons per square mile.
Understanding and responding to the problems of availability and accessibility of mental
health services in frontier areas requires a different perspective from the traditional
"developmental model." The services and human resource literature in rural
mental health as well as the policy and programmatic initiatives of state and federal
government have had "development" as their primary focus (e.g., Wagenfeld,
Murray, Mohatt, & DeBruyn, 1994). In other words, to achieve equity (or perhaps
fairness) in the availability of mental health services in rural regions, emphasis has
been placed upon the development of mental health programs and services, and the
recruitment of mental health professionals to those areas. The appropriateness of such a
position, i.e., trying to make rural areas look more like urban areas, is questionable at
best when addressing the mental health needs of persons living in these remote and
isolated frontier areas. For the vast majority of frontier areas, the development of specialized mental health
services within the area is not economically feasible for either the private or public
sector. A low population base and corresponding weak economic base coupled with vast
distances and isolation mean that specialized mental health services will seldom be
locally available to frontier areas. For most persons living in frontier areas,
specialized mental health treatment is (and most likely will continue to be) available
from mental health professionals and programs that have their permanent central location
some place outside of (and often not readily accessible to) frontier areas. This means
that residents of frontier areas must either find services outside their community of
residence or not utilize needed mental health services. There are however, strategies that can be used to improve the access and availability
of mental health services to residents of frontier areas. Based on an examination of the
existing literature and observations, we have identified four global strategies for making
treatment resources more accessible and available to persons in frontier areas in need of
mental health services:
In this Letter to the Field, we explore each of these strategies, examining their sub-variations and the recorded experience of each, including their advantages and disadvantages. IntegratingIt has long been known that primary care physicians have been actively involved in the delivery of mental health services (Locke, Krantz, & Krammer, 1966; Locke & Gardner, 1969; Rosen, Locke, Goldberg, & Babigian, 1972; Lerner & Blackwell, 1975; Fink, 1977; Goldberg, Babigian, Locke, & Rosen, 1978; National Rural Health Association, 1992). Physicians that practice in rural and frontier areas tend to play an even larger role in mental health care provision. This is due, in part, to the relative scarcity of mental health and other health care professionals in these outlying areas of the country. Consequently, it is not surprising that a strategy increasingly used to bring mental health services to frontier areas is the integration of mental health and general medical services in a unified clinic structure. In a recent study of these integrated models in rural areas, Bird, Lambert and Hartley (1995) interviewed over 50 primary care provider organizations across the nation that successfully linked with mental health and substance abuse treatment services. Interestingly, over half of these integrated models were found in federally-funded community health centers (PL 330/329). The remainder were located in rural hospitals, health departments, rural health maintenance organizations (HMOs), and of course, rural private physician practices. In another report, Mohatt (1995) noted the advantages of linking primary care and mental health services in underserved areas. These include:
Disadvantages to integrated models seem to be few. However, sparsely populated areas that do not have established mental health services (i.e., counseling) or providers (i.e., psychiatrists, psychologists, and social workers) also tend to have fewer primary care physicians. Consequently, some frontier areas without established primary care clinics will obviously be unable to benefit from these integrated models. Reaching OutThe two primary vehicles for reaching out to persons in need have been the "circuit rider" and the "satellite clinic." From the early days on the frontier, the "circuit rider", whether a judge, preacher, or mental health professional, has been one of the cornerstone approaches to getting a scarce resource to rural and frontier communities. The circuit rider approach involves mental health professionals external to the area traveling to frontier communities, usually on some regular schedule (i.e., once a month or once a week). They may spend anywhere from a few hours to a few days seeing patients. Their work is commonly coordinated through local community institutions like churches, schools, other agencies or indigenous healers. The limited access provided by circuit riders is clearly better than nothing. However, it does present problems for continuity of care. Moreover, these types of service providers often have to conduct therapy in ad hoc environments that are at times problematic. Wagenfeld (personal communication, 1995) noted several instances of complaints by outreach workers regarding their inability to locate suitable space to work in remote communities. Ad hoc arrangements in beauty or barber shops, grocery stores, or on the street do not produce the most conducive environments for productive therapy. The satellite clinic is simply a more institutionalized version of the circuit rider. This model achieved prominence during the era of federal community mental health staffing grants. Through the Community Mental Health Centers Act (1963), federal funding greatly assisted in the development of these clinics in small, remote communities. The satellite clinic is usually a stable place (maybe a store front, church basement, or regular office) that is staffed by mental health professionals and support staff and open on some regular basis. In some cases, the satellite clinic is a full time operation and functions as a branch of a larger mental health program. In other cases the clinic is staffed by support personnel full time but by mental health professionals only part of the time. In frontier areas, the satellite clinic is more likely staffed by mental health professionals on some regular but not full time basis. However, satellite clinics in frontier areas are costly to operate with large overhead (office space, support staff) and rather low client volume. Further, since the changes in the federal government's funding obligation for community mental health centers in the early 1980s, there has been a steady reduction in the number of satellite clinics in operation. As the federal funds decreased, greater emphasis was placed on fee-for-service activities. Thus, given the high overhead and cost inefficiencies found in many of these clinics (especially those serving poor remote communities), many communities found them difficult to sustain. Lastly, while circuit riders and satellite clinics are reasonably suited to deal with the maintenance of long term mental health problems, emergent care is more difficult to address. Consequently, some clinics have established crisis intervention services, or "hot lines" through toll-free 800 services. These calls often are answered by staff at the "parent" clinic, or nearby facilities in other communities. Building UpOne of the often cited approaches to dealing with frontier mental health needs is to make frontier people and communities more self-reliant when it comes to responding to mental health problems. This takes several forms, including: use of natural helpers and local healers; use of paraprofessionals; use of local (non-mental health) professionals; public education; support groups and systems; and providing self-help resources. D'Augelli and Ehrlich (1982) and others have suggested that the shortage of professionals in rural areas leads to a greater potential for the use of indigenous workers to develop natural helping networks (Gottlieb, 1983; Kelley, Kelley, Gavron, and Rawlings, 1977). Hollister and his associates (Edgerton, 1983; Hollister, Edgerton, and Hunter, 1985) also believe that a rural model of service requires a shift away from direct treatment toward services that are supportive of individuals, their families, and the natural caregivers already present in the client's environment. Natural Helpers. The use of indigenous persons or natural helpers (those persons within the community people naturally turn to for help) in support roles in rural mental health programs is clearly of value. Clergy play a significant role as natural helpers in the lives of rural people and are often the only helping resource in rural areas. For decades, research has indicated that roughly 40% of persons seeking help for psychological distress prefer clergy over human service providers (Chalfant, et al., 1990). One reason for this may be the fact that a majority of people have personal contact with a church through family ties. Clergy then often become the first contact for services. In some rural communities, the police and sheriff play a major role as a social services agency. The mental health center often benefits from liaison work with law enforcement. Similarly, other community resources, such as churches or local medical practitioners, may add substantially to the effectiveness of mental health services. Treatment may be more effective if family and other informal support networks can be used in an individual's treatment plan (Loschen, 1986). The natural helper programs described by Timpson (1983) and Hollister, et al. (1985) usually involved collaboration between interagency personnel and indigenous workers. Paraprofessionals. The use of paraprofessionals to respond to local mental health needs has a long tradition (Richter, 1974; Walt, 1990; Indian Health Service [IHS], 1991). These local resources have been known, but long overlooked as members of the mental health care work force. Unfortunately, there is no single accepted definition of a community health worker or paraprofessional. Witmer, Seifer, Finocchio, Leslie, and O'Neil (1995) defined these workers as "community members who work almost exclusively in community settings and who serve as connectors between health care consumers and providers to promote health among groups that have traditionally lacked access to adequate care." Witmer, Seifer, Finocchio, Leslie and O'Neil (1995) noted that a recent national survey has identified community health worker programs operating in every state. The most extensive structure supporting these workers currently is the Indian Health Service (IHS). Since 1968, the IHS has hired local paraprofessionals as Community Health Representatives, or CHRs. CHRs serve as vital links between medical and mental health providers located in IHS-supported clinics and hospitals, and the Native American population they serve. Assistance with transportation, medication, appointment scheduling, and identification of problems are all part of the important role played by CHRs. Perhaps the most extensive use of paraprofessionals in frontier health care is the Alaska "Community Health Aide" program (IHS, 1991). These local workers are often found in remote villages and settlements with no other health providers. Consequently, the level of training they receive and the array of services they provide is extensive. Training includes basic emergency care, prenatal and well-baby check-ups, and patient education. More recently, Colorado has experimented with the development of "crisis homes" staffed with paraprofessionals as an approach to meeting rural crisis needs and as a way to avoid bringing rural persons in for treatment to state hospitals (Wackwitz & Wilson, 1992). Self-Help Resources. In a recent article, Ferguson (1996) discussed the revolution in consumer health informatics. In his discussion of the electronic self-help community, Ferguson noted that with a whole new generation of electronic tools, it is much easier for the average consumer to access accurate, reliable health-related information, where once only the most dedicated and diligent were able to succeed. Ferguson noted that while we think of our health care system as containing primary, secondary and tertiary resources today, tomorrow we will view the access to consumer health informatics as the fourth and biggest health resource of all: "... the ability of informed laypeople and experienced self-helpers to prevent and manage their own health care problems (1996, p. 36)." While not addressed directly, the implications for rural residents are considerable. This new field of informatics examines the development of computer and other telecommunications systems designed for use by lay-people. Interactive systems are already available to assist consumers in health promotion, and more importantly, self-management of existing health care problems. For example, the University of Wisconsin has developed software for use at home for people with diseases, such as AIDS, substance abuse, depression, and diabetes. Another example is the Therapeutic Learning Program that contains a "psychological spreadsheet" for people experiencing high stress life events. Resources like these that can be accessed from the home can have a significant impact in providing needed information resources for those in underserved areas. Today, a number of self-help organizations already have active on-line forums (e.g., Citizen Access Network of Maine, MADNESS network). The opportunities for rural residents to participate in electronic self-help groups and networks will only increase over time. Benefits and Disadvantages of Building Up. In assessing the benefits of lay-people, natural healers, paraprofessionals, and self-help groups in rural areas, clearly the greatest impact is in the area of increased access. For some (e.g., remote Alaska), indigenous workers are the sole link to health care information and the organized health care system. However, for most rural and frontier residents, these indigenous outreach workers augment the formal systems of care and are an important link to them. In addition to increasing access, lay outreach workers are cost effective as well by providing residents in remote locations with limited case management services and accurate information on the appropriate use of the health care system. A testament to this is in the state of Hawaii, where an HMO under a Medicaid contract uses community health workers to increase access to disease prevention services for Medicaid beneficiaries (Knobel, 1992). Computer-based resources may also prove to be cost effective. Preliminary studies suggest that the University of Wisconsin's software for home health workstations has reduced the medical bills for patients with AIDS by up to 30% (Ferguson, 1996). The obvious disadvantage to these indigenous and self-help resources lies in the limited training of those providing outreach services and the accuracy of information they deliver, both directly and electronically. The ability of such outreach workers or members of self-help groups to recognize when consumers need a referral to more formal systems of care are somewhat questionable. However, even recognizing these limitations, it would be hard to argue that consumers in remote areas would be better off without access to these indigenous resources. ConnectingTelemedicine is the practice of health care delivery, diagnosis, consultation, treatment, and transfer of medical data and education using telecommunications. The telecommunication technologies used can range from telephone and FAX to live interactive video. Today, many rural health experts view telemedicine as a critical tool for the direct care of rural patients and for the development of rural health systems. Primarily, telemedicine affords rural residents ready access to specialty care without the inconvenience of traveling to urban centers. One of the most common ways of connecting urban or rural mental health professionals to persons in frontier areas in need of treatment has been the "telephone hot line." This is often a toll free number staffed by mental health professionals or specially trained paraprofessionals. These hot lines are usually maintained by not-for-profit, consumer organizations (e.g., mental health associations; community-based programs, etc.) and allow rural residents entry into a service network 24 hours a day. Throughout the 1980s, these hot lines were highlighted in the literature, as they provided critical information, treatment and referral services to thousands of farm families during the "farm crisis". More recently this technology has become an important strategy of proprietary behavioral health systems and managed care providers for recruitment, crisis intervention and case management. Consequently, today it is commonplace to find these toll-free numbers in local telephone directories. One of the most comprehensive telecommunication projects today is called RODEO Net and is administered through the Eastern Oregon Human Services Consortium (Britain, 1995). This project utilizes multiple technologies in an effort to provide comprehensive services to residents of a 45,000 square mile area in eastern Oregon. Technologies utilized in the RODEO Net project include: two-way audio/one way video satellite services; fully interactive two-way video and audio digital satellite services; and a service area-wide computer network providing E-mail, bulletin boards, private conferencing, and Internet gateways. Behavioral health services provided over these technologies include crisis intervention and evaluation from the Eastern Oregon Psychiatric Center; pre-commitment legal hearings via interactive video; pre-admission and discharge planning via interactive video; and tele-consultation services from the Psychiatric Center, State Hospital, or University Health Science Center via interactive video. Britain (1995) notes that all three technologies are utilized for tele-education services for rural providers, as well as consumer and provider networking. However, it is important to note that there are several barriers to the future growth, development, and utilization of telecommunications services. First, and perhaps most important from the providers' perspective is the lack of reimbursement mechanisms in place for teleconsultation services. To date, few insurers (including the Health Care Financing Administration) have recognized teleconsultation as a reimbursable event. Consequently, most providers and proprietary systems are reluctant to make investments in these technologies without the ability to be reimbursed for services provided. Second, few empirical studies are available evaluating the strengths, weaknesses and effectiveness of telemedicine services. Most advocates in the field recognize that without a significant amount of scientific evidence, many providers will continue to shy away from this technology, and insurers will continue to view the technology as experimental. Finally, paradigmatic shifts will need to occur among providers in how they view the delivery of services to rural and remote consumers. Many health care providers, including those in behavioral health care, are skeptical that telecommunications technology is a significant advancement in the delivery of treatment services to patients with mental and emotional disorders. Consequently, without such paradigmatic shifts, telemedicine services will continue to be viewed as a technology unable to fulfill its potential. For a more in-depth treatment of telemental health, please see the Network's Letter to the Field No. 3. Managed CareNow that we have reviewed the four global strategies to improve access and availability to residents in frontier regions, we will review these strategies within the context of managed care. In an effort to improve service delivery and control the costs of mental health services, states have been initiating a variety of managed behavioral health care alternatives. Many managed care advocates (as well as state legislators) are embracing these changes, while many mental health advocates are fearful that it is all a pretext to simply cutting costs. We address two primary questions in this section: "Are these four global strategies congruent with the goals of managed care?" ; and "Will managed care organizations (MCOs) embrace or shun these strategies?" Medically-Integrated Clinics. In a managed care environment, it appears that medically-integrated clinics might fare quite well. As noted above, two of the obvious advantages of these integrated clinics are their low overhead and their integrated delivery system. These characteristics are usually quite attractive to managed care organizations. With both medical and behavioral health professionals working in an integrated delivery system, a MCO will have much lower marketing costs and need to expend fewer resources coordinating care between providers. Chris Jagmin, M.D., Vice President of Pacificare of the Southwest, noted in the Office of Rural Health Policy (ORHP) roundtable that MCOs spend a great deal of time working on the interface between providers. However, "when local providers are more integrated, the HMO can take less" (Office of Rural Health Policy [ORHP], 1995). Thus, in an integrated system, with MCOs finding efficiencies in coordinating care, they can take less of the premium and still make the same profit margin. The same argument can be made regarding the overall operating expenses of these integrated clinics versus situations where multiple providers maintain separate clinic facilities. With overhead expenses being shared by both medical and behavioral health professionals, the operating efficiencies realized are more attractive to a managed care organization. Further, it is assumed that MCOs are not interested in significant local infrastructure development, especially just to capture a small percentage of the rural market. However, some states, such as Washington are requiring MCOs to serve rural communities as a condition of doing business in their more metropolitan markets. Either of these conditions will lead MCOs to look for providers who already have a significant local market share and work aggressively to lower their costs. Again, local integrated clinics that have already brought together multiple providers and can document lower overhead costs could be attractive contractors for MCOs. In sum, it is assumed that managed care organizations are not aggressively entering the rural and frontier markets. However, as they slowly penetrate that market, they will seek contractors who already have a significant share of the market, keep costs low, and have reduced their expenses by coordinating care. Thus, low-cost, medically-integrated clinics may be net beneficiaries as MCOs continue to move into more rural markets. Satellite Clinics and Outreach Services. For many years community-based satellite clinics were the mainstay in the delivery of behavioral health services in small underserved areas. The expansion of these clinics was in part due to the 1963 Community Mental Health Centers Act, which required and helped states fund the provision of mental health services through community mental health centers. However, starting in 1981, the Omnibus Budget Reconciliation Act (OBRA, 1981) began shifting the responsibility to state mental health authorities. This initial shift resulted in a reduction in federal support for mental health services. Thus began an increasing emphasis on fee-for-service funding and a deterioration of the number of satellite clinics. Under a managed care environment, maintenance of these small, satellite clinics and outreach services may require a greater infrastructure investment than most health plans are willing to make. As Dr. Puskin noted in the ORHP roundtable on rural managed care, for a MCO "...to recoup its investment in developing rural infrastructure, .... it must have a significant share of the market and a strong network of providers. One way to achieve this ... would be to reach for broad rural markets encompassing a large number of providers (ORHP, 1995)." If this is true, it would suggest that more regionalized (or centralized) rural systems of care are more likely under a managed care scenario, than a scattering of small, relatively inefficient satellite clinics. With each satellite clinic having its own overhead costs and a rather small patient base, it is hard to imagine the benefits of such clinics to a MCO aggressively looking for efficiencies. Utilization of Indigenous Providers/Self-Help Resources. Unlike satellite clinics, the use of indigenous providers to augment and establish linkages to more formal systems of care requires much less infrastructure development and appears to be quite cost effective. In fact, Knobel (1992) reports the use of community health workers to provide health promotion/disease prevention services to Medicaid beneficiaries by the Kaiser Permanente HMO in Hawaii. Of course the obvious benefit in using indigenous providers in frontier areas is the increase in access. Without absorbing large infrastructure development costs, MCOs could significantly augment the delivery of services in underserved areas by training local community aides to provide limited services, information, and referral services to local consumers. In addition to health promotion/disease prevention information, indigenous workers can provide limited case management services, home-based services, transportation, and just as importantly, serve as an informed link between local consumers and the MCO. Much of the literature cited above documents the overall effectiveness (both in cost and outcome) of indigenous workers. Thus, faced with the alternatives of using indigenous workers, or utilizing a greater volume of resources to further develop local resources, it is reasonable to assume that many MCOs will look favorably on indigenous workers as a low cost method of maintaining service linkages in frontier communities. Support groups and self-help resources may also fare well in a primarily managed care environment. We do not at this time see a deterioration of support group activities as rural markets move more toward managed care. First, most of these self-help groups (e.g., Alcoholics Anonymous; National Alliance for the Mentally Ill) are currently outside of the formal reimbursement streams. Thus, changes in the financing and delivery systems should not greatly effect these "grass roots" activities. In fact, we may find MCOs supporting such activities, as they serve as locally-based prevention activities. Lastly, it appears that the field of consumer health informatics will continue to flourish as information science and technology continue to advance. Much of these resources are quite congruent with managed care's orientation toward data and consumer awareness. Further, many states have, or are in the process of developing Community Health Information Networks (CHIN). These networks often electronically link provider and consumer groups with state-based health information, as well as providing Internet gateway access. Consequently, in an effort to increase consumer involvement and education, we would speculate that this quickly emerging field will continue to flourish. In fact, we predict that many managed care organizations will actively participate in providing such information via these systems. Utilization of Telecommunication Services. Two of the major barriers to care for rural consumers, time and distance, are easily overcome through modern telecommunications technology. Modern telecommunications technology has the potential to significantly improve access in frontier areas that have traditionally been underserved. Even with the barriers cited earlier, we predict that as managed care continues to penetrate rural markets, the use of telecommunications will dramatically increase. We make this prediction based upon several factors. First, the use of telecommunications technology can be cost effective. As mentioned several times in this paper, managed care organizations are much more aggressive in finding cost efficiencies. The utilization of telecommunication technology, while expensive, is still considerably less costly than deploying human resources. Further, as with most technologies, as utilization increases, unit costs will decrease making it even more cost effective. Thus, over time, as MCOs cover more rural markets, the cost advantages of utilizing these technologies will increase. Second, as mentioned earlier, some states (e.g., Washington), require MCOs to cover rural areas as a condition to having access to their more profitable urban markets. While it is difficult to predict whether this type of policy will become a trend in other states, clearly telecommunications technology offers a MCO a cost effective method to meet this requirement. Third, in most states Medicaid benefits include the cost of transportation to access services not locally available to beneficiaries. More and more rural managed care plans also pay for patient travel to access urban providers (ORHP, 1995). Consequently, as more MCOs contract with states to serve Medicaid beneficiaries and serve more rural areas, the advantages to utilizing telecommunications technology to reduce these travel costs and improve cost effectiveness will become apparent. Summary. This section attempted to speculate on how the four identified global strategies to providing behavioral health services in our nation's most frontier and underserved areas will fare under a managed care environment. In exploring these issues, we predicted that three of the four approaches will likely continue under managed care, with only the maintenance and further development of satellite clinics and outreach services decreasing. Looking at these predictions from another viewpoint, one might conclude that, as is often the case, rural areas have already developed cost-effective methods of providing admittedly minimal services in a limited resource environment. Final ThoughtsThis paper has attempted to explore the strengths, weaknesses and utilization of four global strategies that are in place today to serve the mental health needs of frontier populations. However, a comprehensive approach to meeting the mental health needs of persons living in frontier areas should consider programs that employ all of these strategies. Unfortunately, there is a tendency in dealing with rural or other special populations to look for a single programmatic solution to problems of accessibility and availability. While some of these strategies may prove sufficient in and of themselves to address particular mental health problems, in most of the cases when we are dealing with diagnosable mental disorder, a single strategy will often prove inadequate. ReferencesBird, D.C., Lambert, D., & Hartley, D. (1995, October). Rural models for integrating primary care, mental health, and substance abuse treatment services (Working paper #5). Portland, ME: Maine Rural Health Research Center, Muskie Institute of Public Affairs. Britain, C.S. (1995). Telecommunications in rural mental health delivery: The RODEO NET project. In D.F. Mohatt & Kirwan, (Eds.), Meeting the challenge: Model programs in rural mental health. Washington, DC: Office of Rural Health Policy, U.S. Department of Health and Human Services. Chalfant, H.P., Heller, P.L., Roberts, A., Briones, D., Aguirre-Hochbaum, S., & Farr, W. (1990). The clergy as a resource for those encountering psychological distress. Review of Religious Research, 31, 305-315. D'Augelli, A.R., & Ehrlich, R.P. (1982). Evaluation of a community-based system for training natural helpers. II. Effects on informal helping activities. American Journal of Community Psychology, 10, 447-456. Edgerton, J.W. (1983). Models of service delivery. In A. W. Childs & G. B. Melton (Eds.), Rural Psychology (pp. 275-303). New York: Plenum. Ferguson, T. (1996, February). Consumer health infomatics: Turning the treatment pyramid upside down. Behavioral Healthcare Tomorrow, pp. 35-37. Fink, P.J. (1977). The relationship of psychiatry to primary care. American Journal of Psychiatry, 134(2):126-129. Goldberg, I.D., Babigian, H.M., Locke, B.Z., Rosen, B.M. (1978). Role of nonpsychiatrist physicians in the delivery of mental health services: Implications from three studies. Public Health Reports, 93:240-245. Gottlieb, B.H. (1983). Social support strategies: Guidelines for mental health practice. Beverly Hills, CA: Sage. Hollister, W.G., Edgerton, J.W., & Hunter, R.H. (1985). Alternative services in community mental health: Programs and processes. Chapel Hill, NC: University of North Carolina. Indian Health Service. (1991). Alaska Community Health Aide Program Description. Washington, DC: Author. Kelley, A. R., Kelley, P. L., Gavron, E. F., & Rawlings, E. I. (1977). Training helpers in rural mental health delivery. Social Work, 22(3), 229-232. Knobel, R.F. (1992, November). Medicaid and managed care with Kaiser Permanente in Hawaii. Paper presented at the Conference on Medi-Cal and Managed Care, Sacramento, CA. Lerner, R., & Blackwell, B. (1975). The GP as a psychiatric community resource. Community Mental Health Journal, 11(1):3-9. Locke, B.Z., & Gardner, E.A. (1969). Psychiatric disorders among patients of general practitioners and internists. Public Health Reports, 84(2):167-173. Locke, B.Z., Krantz, G., & Kramer, M. (1966). Psychiatric need and demand in a prepaid group practice program. American Journal of Public Health, 56:895-904. Loschen, E.L. (1986). The challenge of providing quality psychiatric services in a rural setting. Quality Review Bulletin, 12(11):276-379. Mohatt, D.F. (1995). Primary care and mental health service integration: The bay area service extension (BASE) project. In D.F. Mohatt & Kirwan, (Eds.), Meeting the challenge: Model programs in rural mental health. Washington, DC: Office of Rural Health Policy, U.S. Department of Health and Human Services. National Rural Health Association. (1992). Study of models to meet rural health care needs through mobilization of health professions education and services resources, (Volume I). Kansas City, MO: National Rural Health Association. Office of Rural Health Policy. (1995, November). Rural prescriptions for managed care: A roundtable. Washington, DC: Author. Omnibus Budget Reconciliation Act (OBRA), PL 97-35 (1981). Richter, R.W. (1974). The community health worker. American Journal of Public Health, 66 (2):273-277. Rosen, B., Locke, B.Z., Goldberg, I.D., & Babigian, H.M. (1972). Identification of emotional disturbance in patients seen in general medical clinics. Hospital and Community Psychiatry, 23:364-370. Timpson, J. (1983). An indigenous mental health program in remote northwestern Ontario: Development and training. Canada's Mental Health, 31(3), 2-10. Wackwitz, J.H., & Wilson, N.Z. (1992). The Colorado rural crisis study: Comparing methods for delivering rural crisis services. OutLook, 2(3), 21-23. Wagenfeld, M.O., Murray, J.D., Mohatt, D.F., & DeBruyn, J.C. (1994). Mental health and rural America: 1980-1993. Washington DC: Office of Rural Health Policy, Health Resources and Services Administration. Walt, G. (1990). Community health workers in national programmes: Just another pair of hands? Philadelphia, PA: Open University Press. Witmer, A., Seifer, S.A., Finocchio, L., Leslie, J., & O'Neil, E.H. (1995). Community health workers: Integral members of the health care work force. American Journal of Public Health, 85: 1055-1058.
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