Frontier Mental Health Services Resource Network

by Morton O. Wagenfeld, Ph.D., Department of Sociology, Western Michigan University

This letter owes much to the generous assistance of a number of planners and practitioners: Myrt Armstrong, John Fowler, Mark Friedman, Joseph Fry, Michael Galli, Maurice Miller, Tom Perkins, Roy Sargeant, Susan Soule, Marilyn Sword, and Beth Stamm. My thanks to them.

Introduction

This is the first of two Letters to the Field dealing with the delivery of services to persons with serious and persistent mental illness (SMI) in sparsely populated frontier areas. Frontier areas are a unique part of the United States and are also historically underserved. This Letter will look at the organization of services in five states with significant frontier populations. The second Letter will discuss a number of general models of service delivery. Both will consider the implications of managed care in delivering mental health services to the SMI. This Letter is intended for a wide audience and is written in a non-technical, reader-friendly and citation-light way. An extended, fully documented version, is available from the Frontier Mental Health Services Resource Network.

At the extreme rural end of the rural-urban continuum there are 394 frontier counties in 27 states. They are protected from large-scale settlement by harsh climate, difficult terrain, lack of water, distance from metropolitan areas, lack of exploitable resources, and federal land policies. These areas also contain a high proportion of persons living in poverty and have a limited local tax base. Most human services are provided through state and federal programs. Low population densities make it impractical to deliver many labor- and resource-intensive programs. In addition, of course, these areas also chronically lack trained staff. As one might expect, providing services to this frontier population presents formidable cultural, geographic and human resource problems. These difficulties notwithstanding, services to this important population are delivered, often in imaginative and resourceful ways. A planner in Idaho captured the essence of designing and delivering services in frontier areas when noting that "programs were born of necessity" (Sword, personal communication, 1997).

Without doubt, managed care as a way of funding health and mental health service is the salient issue in the field today. The implications of this for rural and frontier mental health and AODA services have only recently been explored. If providing services to the SMI in frontier areas has traditionally been a problem, providing them in the new environment of a changing healthcare system is even more of a challenge. At this time, the discussion is largely theoretical. Planners and providers interviewed have generally noted that managed care has made little impact in their frontier areas. Private companies have shown little interest in these areas because of the low population base and poverty.

While frontier areas share some common obstacles to service delivery, they also display great diversity. This diversity is reflected in the variety of organizational models for the delivery of mental health and AODA services at the state level. States with frontier populations tend to vary both in ideologies and fiscal arrangements. For example, in Idaho and North Dakota, mental health and AODA services are part of a single agency. In Nevada, they are housed in separate agencies at both the state and community level. At the local level, these services may be delivered by a single entity or delivered separately. In yet another approach, Idaho has an umbrella state agency that is responsible for mental health and AODA services. At the local level, treatment for mental disorders is provided by state-run agencies, while delivery of AODA services is carried out by private, not-for-profit agencies under contract to the state. This can be even further subdivided: a private, not-for-profit organization contracts with the state to provide case management for the SMI (Sword, personal communication, 1997). This paper will now consider services to the SMI by sketching the delivery systems in five states: North Dakota, Idaho, Arizona, Montana, and Alaska.

North Dakota

North Dakota provides a good example of frontier issues. A quarter of its population resides in frontier areas. It has received recognition for the organization of its mental health system and it is the only state with a 24-hour 800-number Help-Line. This Help-Line, which is run by the state mental health association, provides referral and brief emergency counseling (Armstrong, personal communication, 1997). In 1972, the state was divided into eight regions under the Department of Human Services for the provision of mental health services. Each of the eight regional Human Services Centers is autonomous and is charged with providing care for both adults and children/adolescents. In theory, each is required to provide a full range of services. As one might expect, this is often not the case in practice. Table 1 presents the six broad areas of service provided.

Table 1.
Regional Intervention	crisis stabilization and resolution, admission/intake, information/referral, short-term inpatient, crisis residential beds, state hospital liaison, inpatient discharge planning
Medical	evaluation, medication administration, medication monitoring, and treatment
Psychological	evaluation, therapy, consultation and technical assistance
Acute Treatment	individual, group, and family therapy
Extended Care	meeting the needs of the SMI -- provides a variety of modalities under case management, community residential, partial care/day treatment, psychosocial rehabilitation centers, supported employment, and community supportive care
Children and Family Treatment	a variety of outpatient, residential, supervisory, and consultation activities

One of the eight regional service centers, the Badlands Human Services Center, in Dickinson, ND provides a good example of local delivery of services to the SMI. It is located in a very sparsely populated area of southwestern North Dakota. The center serves an eight county area covering 41,000 square miles. Excluding the 17,000 persons residing in Dickinson, the population density is quite low: 1.5 persons/square mile. The area has been experiencing severe declines in population, with an outmigration of younger persons. Higher-risk groups tend to remain behind, and a "silting up" effect has occurred, with a rise in prevalence of disorder. This is seen in the high demand for services: 320 cases of SMI, along with 320 clients with developmental disorder or mental retardation. As one might expect in an area as sparsely populated as the Badlands, vast distances and a lack of transportation are major impediments to service delivery. In addition, the widely recognized problem of lack of specialized treatment staff also exists here. Of necessity, the generalist model prevails (Fry, personal communication, 1997).

St. Joseph's Hospital in Dickinson provides inpatient services. The state hospital, in Jamestown, is 200 miles east, but state policy discourages anything other than emergency or involuntary admissions. Few private therapists practice in the area. There are 83.5 FTE staff, and an additional 20 who work on contract. In addition to the statewide hotline run by the Mental Health Association mentioned above, there are specialized hot lines for the Badlands Human Services region. There are a number of inter-agency agreements to facilitate coordination of services. In anticipation of managed care, the HSC is attempting to obtain accreditation from the Council on Accreditation of Rehabilitation facilities (CARF). In addition, a new model of mental health delivery ("New Company") is in the process of being developed. This will combine the best elements of both public and private care in preparation for a move to managed care.

Badlands Human Services Center provides care for the SMI in some innovative ways. Specialized services are provided in Dickinson, the largest community in the area. Services include a psychosocial center, a supported employment program, and a social club. On the other hand, there is significant decentralization. Virtually every small community in the region has a long term care facility. A psychiatric nurse provides direct services. This nurse travels to remote sites to work with patients and to develop treatment plans with family and local caregivers. Regular outreach is provided to communities more than 80 miles round-trip from Dickinson. Local primary care physicians provide medication monitoring through formal agreements with the HSC. This provides an impetus for cooperation with the outreach workers.

Idaho

In Idaho, mental health services are part of an umbrella human services agency -- the Department of Health and Welfare. This department fulfills such diverse functions as veterans services, environmental quality, welfare, family and community services, and information systems. Mental health services fall under the Division of Family and Community Services. The organization of services in Idaho, while funded at a very low level, has been viewed as a model for rural states (Sargeant, personal communication, 1997).

The state is divided into seven human services regions. State community mental health centers in all seven regions deliver mental health services. Inpatient services are provided in two state hospitals -- one in the north in Orofino with 60 adult beds, and the other in the South in Blackfoot with 90 adult beds. With virtually no psychiatric beds in community hospitals and almost no free-standing private psychiatric hospitals, state policy, unlike in North Dakota, does not discourage inpatient admissions to the state hospitals.

Recently, the regional mental health centers were transformed into Regional Mental Health Authorities (RMHAs) with increased responsibility for system development and planning, and coordination of public and private service delivery. These RMHAs are also charged with the responsibility of developing opportunities for the privatization of services. For example, contracting agencies now deliver AODA services. In addition, the RMHAs have used Medicaid's Rehabilitation Option to support the move toward privatization of services. The Medicaid program has traditionally required that mental health services be provided in medical settings. In frontier areas, the lack of these facilities has been a major service delivery problem. Recently, Medicaid has adopted the Rehabilitation Option that allows non-medical services to be delivered in community settings. This option introduces a welcome note of flexibility into programming.

Priority for the public sector delivery of core adult mental health services is to those, age 18 and older, with a severe chronic mental disorder that interferes with one or more areas of functioning. Short-term treatment is accorded to those with acute problems not falling into the above criteria and who are at risk of psychiatric hospitalization. Similar to the array of services in North Dakota, core adult mental health services broadly provided by each of the regional centers include:

Targeted Case Management includes psychosocial assessment, treatment plan development, monitoring and coordination of service delivery, linkage with services, client advocacy, and direct assistance with symptom management. Crisis Intervention includes an array of both agency- and community-based services. Psychosocial Rehabilitation encompasses a variety of outcome-oriented services that includes both individual and group rehabilitation, pharmacological management, nursing services, skills development, housing, and supported employment.

Assertive Community Treatment is part of the repertoire of adult services and includes assistance with symptom management, medication management, 24-hour crisis availability, financial monitoring, and assistance in vocational reintegration. Psychiatric Services are an essential element in any program for the SMI. In Idaho, these involve evaluation, prescribing and monitoring of medications, consultation and education, and psychiatric nursing. The final service element is Short-Term Mental Health Intervention. Here, services are provided to those without a SMI who are in distress and at-risk of hospitalization. This includes short-term therapy, medication, referral to community agencies, and designated examinations (Idaho, 1997). In conjunction with the Department of Housing and Urban Development, Idaho has instituted Shelter Plus, a sheltered housing program for the SMI. Dual diagnosis services (for persons with both SMI and AODA problems) are provided at the State Hospital North and in three of the seven regions.

Arizona

Arizona delivers services through a managed care system. It is organized around five non-profit Regional Behavioral Health Authorities (RHBAs). The major features of the Arizona approach are:

Some data exist on the accomplishments of the Northern Arizona RBHA. By sharing risks and incentives with providers, there has been a reduction in utilization of inpatient and residential services, an increase in the use of wraparound services, increased incentives for providers to work with schools and the juvenile justice system, a reduction in paperwork though elimination of prior authorization for outpatient services, and a reduction in RBHA authority administrative costs. It has also enabled providers to improve their financial situation, establish standards of performance and reward positive performance, all the while maintaining and improving quality. Miller (personal communication, 1996) suggested that managed care has had a greater impact on services for children and adolescents than on the SMI population.

Montana

In Montana, public mental health services are under the aegis of the Addictive and Mental Disorders Division of the Department of Public Health and Human Services (DPHHS). Until recently they were delivered primarily through five regional Community Mental Health Centers (CMHCs). Montana also operates two inpatient facilities: the Montana State Hospital and Montana Mental Health Nursing Care Center. As the name suggests, the latter is a residential care facility for those with mental disorders who require nursing home level care. In the last year, Montana instituted a state-wide managed mental health care system called the Mental Health Access Plan (MHAP). This program is to provide all necessary and appropriate publicly funded mental health care through a managed care organization on a prepaid, risk basis.

Montana began the process by issuing Request for Proposals (RFP) for managed care organizations (MCOs) to implement the Mental Health Access Plan. The approach was seen as unique:

The RFP required that specific attention be paid to several groups of persons and levels of service:

It is interesting that, unlike Arizona, which integrates AODA and mental health services in its system, persons with a sole diagnosis of an AODA disorder or mental retardation are specifically excluded from the RFP.

Alaska

Alaska, the ultimate frontier, represents a special case of mental health service delivery that dwarfs even those of the most remote areas of the continental US -- the "lower 48." With population densities approaching 0 in some areas, it goes beyond frontier and can be considered wilderness. The Group for the Advancement of Psychiatry (GAP, 1995) has written about the problems of providing mental health services under extreme conditions of isolation, harsh climate, long distances, different languages and sub-cultures, and resource deficits. In many ways, they view the situation in Alaska as analogous to a developing country.

More than 200 communities, many with populations of less than 800 persons, are scattered through out the state. Only about 19 communities are accessible by road; the rest can only be reached by plane, boat, snowmobile, or dog sled. Distances are staggering: a person requiring mental hospitalization and living on of one of the outer Aleutian Islands would have to be flown a distance equivalent to that from Boston to Los Angeles. Because so much travel is by air and both the patient and an escort need to be transported and lodged, cost per unit of service is formidable. To cite a "simple" case:

These time and cost factors are important because they obviously become part of a proposed treatment response. Additionally, the "ownership" of a problem is an issue in frontier areas where there are often overlapping spheres of responsibility. These can cause jurisdictional disputes. Then, there is the issue of empowerment and how to avoid over-dependence on scarce professional resources.

Virtually all mental health services are public sector in Alaska, organized in a three-level hierarchical fashion. Front-line services are delivered at the village level by paraprofessionals (community health or mental health aides), who are generally indigenous to the village and who have little formal education. Being native to the villages where they practice, they share the values of their clients. Even the standard clinical reference book, the Physicians Desk Reference (PDR) has been adapted for village use. The Village Drug Reference is designed to be used with telephone backup from regional primary care physicians.

At the next level are the small regional hospitals (12-15 beds) that provide basic emergency inpatient services. Primary care physicians and mid-level mental health practitioners are found here. Also likely to be found here would be a regional jail. Tertiary-care mental health facilities are found in the urban areas (with populations of 40,000 - 200,000).

Alaska, then, represents a unique set of problems in the delivery of care for the SMI. The authors of the GAP volume describe the complexities of caring for a single person with SMI. This person received services from all three levels: village, region, and urban. A total of about 50 people and seven or eight facilities were involved. In a situation like this, how does one achieve continuity of care, so that immediate and long-term needs are met? In the case of this patient (identified as Dog Bone):

In sum, this overview illustrates the diversity of mental health systems in states with frontier populations. A common feature to all, however, is the fact that services to the SMI are provided-often under extreme circumstances of distance, inhospitable climate, and chronic shortages of professional staff.

References

Group for the Advancement of Psychiatry. (1995). Mental health in remote rural developing areas (Report No. 139). Washington, DC: American Psychiatric Press.

Idaho, State of. (1997). Mental health plan for adults and children. Boise, ID: Department of Health and Welfare.

Montana, State of. (1996, August). Request for proposals for managed mental health care. Helena: Purchasing Bureau, Department of Administration.

Delivering Mental Health Services to the Seriously Mentally Ill in Frontier Areas: Evidence from Five States