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General Models for Delivering Mental Health Services to the Seriously Mentally Ill in Frontier AreasLetter to the Field No. 8by 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. Table of Contents IntroductionThis is the second 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-an historically-underserved group living in a unique part of the United States. The first Letter dealt with the organization of services in five states with significant frontier populations. This Letter will look at some general models of service delivery and will also consider some of the implications of managed care. It is intended for a wide audience and is written in a non-technical and citation-light way. An extended, fully documented version, is available from the Frontier Mental Health Services Resource Network. As one might expect, providing services to this population presents formidable cultural, geographic and human resource problems. These difficulties notwithstanding, services to this important population are delivered. Some of these models have been adapted from urban or more populous rural areas, sometimes in a very imaginative and resourceful way. A planner in Idaho captured the essence of designing and delivering services in frontier areas in noting that "programs were born of necessity" (Sword, personal communication, 1997). One of the consequences of mental health policy in the last four decades has been the emptying of the state mental hospitals or the process of "deinstitutionalization" (Bachrach, 1977). A number of different research and service models for the treatment of SMI within communities as opposed to within a hospital were subsequently developed. Predictably, most have been urban in nature. However, some material has appeared that deals with its rural dimensions. The care of the SMI in frontier areas is a particular challenge. Here, resources that one would take for granted in urban or more populous rural areas may be nonexistent. In looking at service delivery to this population, the high levels of innovation and flexibility shown by providers is impressive. Combating few resources and long distances in innovative and flexible ways is a hallmark of the treatment modalities found in the frontier area programs described below. Programs in frontier areas can also take advantage of some of the unique features and strengths of the frontier, though often these features are under appreciated (Kane & Ennis, 1996). These assets include a higher tolerance for abnormal behavior among residents and the existence of natural systems of social support. While for many a negative feature of rural life is a lack of privacy (living in a "fishbowl"), for the mental patient, a strong sense of community and social ties can lend support to the patient. The lack of "therapeutic incognito" (Mazer, 1976) can also make it easier for the therapist to know the patient and his or her world. A number of approaches described below consider this. Multi-disciplinary TeamsA recurring theme in rural programs is the use of multi-disciplinary teams to compensate for a lack of mental health professionals. These programs take advantage of whatever resources are available within the community and then build upon them. Davis & Ziegler (1990) presented a Community Resource Team model that expanded the resources available to persons with severe mental illness living in rural communities in Wyoming. These communities had basic human services, but did not have the financial capacity nor the social commitment to develop a diverse network of services for the SMI population. The team was drawn from social services, mental health, nursing homes, hospitals, and vocational rehabilitation offices. A relatively new approach to the treatment of the SMI that also uses multi-disciplinary teams is Training in Community Living. Developed at the Mendota Mental Health Institute in Madison, WI and also known as assertive community treatment or ACT, it is an alternative to inpatient treatment and aftercare. It basically transposes the work of a multidisciplinary team from an inpatient to a community setting. Team members spend most of their time in the community providing direct treatment, rehabilitation, support, and educational services for a fixed caseload. Some data exist attesting to the cost-effectiveness of the ACT program. Though not a model created specifically for rural areas, it has been demonstrated and used there. Santos, et al. (1993) developed an ACT program for a rural population in South Carolina. Given the realities of service delivery in rural areas, the program differed in a number of respects from urban models, particularly in the availability of a treatment team, logistics of travel, use of formal and informal community support, and frequency of contact with family. The lack of residential and vocational opportunities in rural areas also required modification of program goals. These modifications notwithstanding, a measure of the program's success was a significant reduction in hospital utilization. This, in turn, resulted in a cost reduction of 52%. This approach has been adapted to frontier areas: ACT teams are in place in all of the service regions in Idaho (Idaho, 1997). The Community Support ModelThe community support model has also been used in frontier areas. Community Support as a therapeutic modality for the SMI was first described by Turner (1977). Several investigations have compared characteristics and outcomes for rural and urban SMI to determine if rural patients would be at a disadvantage in this model. One example, the Community Support Services (CSS) model, employs case managers for SMI patients. Baker & Intagliata (1984) evaluated several urban and rural CSS programs. They found that, while rural clients were more likely to reside in community residences or cooperative apartments, there were few differences between rural and nonrural SMIs in the medical, rehabilitative, and supportive services that were provided to them. Some services appeared even more readily available to rural clients, including competency and coping skills training. They concluded that the CSS model was appropriate for application in rural areas. Somers (1989) examined the relationship between geographic location and use of mental health services using data collected on 1,053 Community Support Program (CSP) clients. Results again did not support the assumption that rural residence had uniformly negative effects on service use. Husted, Wentler, & Bursell (1994) investigated the effectiveness of Prairie Community Waivered Services, a CSP serving five counties in rural western Minnesota. The lead persons in the program were paraprofessionals who resided in the communities in which they worked. They worked with clients in their homes and communities with backup from social workers and psychologists. Patients were given the option of choosing their own physician or psychiatrist or one who was under contract to the program. The physicians provided medication management. A crisis bed was provided by the program. The emphasis in the program was on flexibility of program plans for each client. In addition, support groups and social events were provided in the counties. The researchers reported a significant decrease in number of days hospitalized. An additional benefit reported was a greater acceptance of the mentally ill by the community. Jackson, Macias, & Farley (1993) reported the results of a CSP demonstration program in three sparsely populated rural areas in Utah, a state with a significant frontier population. Mental health center staff provided two kinds of help: money management and encouragement of daily social activity. Evaluation of the program by consumers was favorable. They reported that CMHC staff assisted them significantly in these areas, more so than either friends or family. In a related article, Macias, Kinney, Farley, Jackson, & Vos (1994) found that patients receiving a combination of case management and psychosocial rehabilitation, functioned at a higher level of competency and experienced lower levels of psychiatric symptomatology than those receiving only rehabilitation. Sullivan (1989) coined the term Program Without Walls to describe community support programs in rural areas. Central to this concept are the recruitment of community collaborators and the redesign of traditional community support programs to most effectively use available personnel for provision of necessary services to clients and their families. To minimize and overcome problems associated with lack of resources and great distances, a premium is placed on flexibility and innovation. Core services in traditional rural community support programs would normally deal with:
The Program Without Walls might go on to provide medication clinics on wheels, decentralized day programs and community collaborators. Potential sites for locally based programs would include churches and community halls. In the ideal scenario, case managers who are indigenous to the area would direct such efforts. Part of the goal would be to establish a culture in which the consumers begin to help each other. The case managers would strive to engage clients in activities that bolster self-esteem-volunteer work or regular employment. The Use of Paraprofessionals and Lay Care-GiversSeveral programs in frontier and rural areas build upon this theme of community collaborators and use paraprofessionals and lay care-givers as a way to extend services to the severely mentally ill. These programs attempt to identify and utilize all resources found within a community. One rurally developed model using this approach is the Rhinelander Model developed in Rhinelander, WI in the 1980s (Rhinelander Model Consultants, 1990). It served a small town and rural catchment area. The goal here was not to supplant or compensate for professional care, but to fill in the spaces between other services. Non-professional, supportive caregivers or citizen mental health workers provided the bulk of the service. These workers were supervised by more experienced non-professionals who, in turn, were under the aegis of agency professionals. Two basic services were supplied: companionship and monitoring. Supportive care workers worked weekly with two clients for five hours each. The developers emphasize that this went beyond togetherness. The model is strictly based on a theoretical perspective (Transactional Analysis) that guides interaction. The intent is to change client behaviors in a supportive and nonintrusive manner. Activities engaged in by workers with their clients varied from taking a walk to taking in a movie, from sewing to shopping, and from attending to chores to attending church. While all these divergent activities provided normalizing socialization opportunities for the SMI, the Rhinelander Model goes a significant step beyond by assuring that workers use these experiences to support their clients in developing increasing independence. Without that critical element, the Rhinelander Model would be little more than a low-cost escort service, but with it, it becomes a successful method of modifying [emphasis in original] the SMI's dependency and thereby reducing his or her reliance on excessive psychiatric hospitalizations (Rhinelander Model Consultants, 1990). Proponents of the model have argued that its effectiveness can be seen in a fifty percent reduction in mental hospitalization. The estimated annual per client cost in 1987 was estimated at $1,700, making it affordable. The relatively low level of professional involvement also suggests that it is feasible for frontier areas. It has not been widely adapted because of third-party reimbursement and certification requirements. Another barrier to adoption has been the requirements of its theoretical model. Having the community workers also provide crisis services, for example, would alter role relationships and may be inappropriate (Galli, personal communication, 1995). A frontier example of the use of non-professional care-givers is The Citizen Companion Program (CCP) in Idaho (Sword & Longden, 1989). CCP is a creative adaptation of several existing urban and rural models. It borrows elements from the Rhinelander Model, the COMPEER program developed in Rochester, NY, and a program sponsored by the Mental Health Association of Waukesha, WI. The CCP was initiated as a demonstration program in two rural sites in 1984. For strategic reasons, the demonstration was under the aegis of the Idaho Mental Health Association. After the success of the pilot phase, it became part of the formal service mix of the regional mental health programs. It was not, however, implemented in a uniform way. One measure of its flexibility is that it serves both child and adolescent patients, as well as adults. The CCP is designed to provide support and advocacy for persons with SMI thorough interaction with non-professional companions. This program enhances the work of professional case managers. The core of the program is its flexibility. The exact nature of the client/companion activities is determined by the needs of the client, but might include skills-building in activities of daily living, or advocacy with various entitlement programs. For younger clients, this might also involve locating child services. It is less theory-bound than the Rhinelander Model but-in common with that program-one of its goals is to provide normal role models for the SMI. The CCP is an interesting mix of public and philanthropic efforts. All service recipients must be clients of the Idaho Department of Health and Welfare, but services are provided by the Mental Health Association or other not-for-profit agencies. The CCP has a number of objectives, including:
In order to be eligible, adults must have a serious, persistent, mental disorder and be participating in a treatment program of the Idaho Department of Health and Welfare. In addition, the potential clients must be sufficiently motivated and physically capable of program participation and have sufficient self-care skills for independent or semi-independent living arrangements. The program is decentralized and operated out of the rural field offices of the mental health centers. Length of time of participation is determined by the therapist or case manager. One of the strengths of the program is its nominal cost. It was estimated that an on-site coordinator and three companions costs about $5,000/year. The program consists of four components:
The core of the program, however, is the citizen companions. The not-for-profit contracting agency recruits both the coordinator and companions. There are no formal educational requirements, but the prospective companions must display caring, responsibility, dependability, a willingness to learn, and a positive attitude toward the those with a mental disorder. Knowledge of the community and transportation are additional desiderata. Once hired, companions undergo a training program that covers psychiatric management, the availability of resources, and role relationships. There is also ongoing consultation, quarterly training, and monthly coordination meetings. An explicit decision was made to have paid companions and coordinators, rather than relying on volunteers. The companion is expected to provide 2-5 hours/week of service to a client as specified in the treatment plan. The Wellness/Clubhouse ModelAs a counterpoise to the medical model, the "wellness" model of psychosocial rehabilitation stresses the integration of the SMI into the community, providing a diverse set of meaningful activities, improving the individual's level of independent functioning, and enhancing self-worth and self-esteem through developing social skills and work habits. The service site is seen as a clubhouse, rather than a treatment center. The prototype of this approach was Fountain House, in New York City (Beard, 1976; Beard, Props, & Malamud, 1982). Pressing, Peterson, Barnes, & Riley (1983) describe the organization and development of a clubhouse program-Highlands Clubhouse-in a rural area of southwestern Virginia. A similar program -Cirrus House-operates under the aegis of the Panhandle Mental Health Center (MHC) in Scottsbluff, NE. The center serves a sparsely populated 11-county catchment area in Western Nebraska and serves 75 adults (Perkins, personal communication, 1995). A modified version of this approach is being employed in Idaho. Indeed, the state mental health plan notes: ".....Psychosocial Rehabilitation, sometimes known as psychiatric rehabilitation, has now become the treatment modality of choice [emphasis added], and enables services to be provided in the client's natural setting of home, work, and community. Ongoing training is taking place with both state staff and private providers to continually improve the practice of psychosocial rehabilitation (Idaho, 1997)." A program (Tele-N-Touch) in Appalachia uses the self-esteem enhancement goals of the clubhouse models to provide assurance to the rural elderly (Smith, 1989). Clubhouse members at Cumberland Mountain Community Services provide telephone reassurance to at-risk homebound elderly living in socially and geographically isolated areas of southwestern Virginia. Callers determine their immediate health and note any immediate needs. Back up by staff provides follow-up when immediate needs are identified. The help line afforded an opportunity for mutual benefit. The program was seen as consonant with the rural ethic of service to others in the community. While this project has not found any instances of a program of this sort in a frontier area, it's low cost and "low tech" approach suggest that it would be a feasible model for use in frontier areas. Other Frontier ModelsOther frontier models of note include the Badlands Human Services Center (HSC) and several grants programs in Alaska. The Badlands HSC serves a large, sparsely populated area. Care for the SMI is accomplished in some innovative ways. The largest community in the area-Dickinson-is the center for specialized services: 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. Direct services are provided by a psychiatric nurse who 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. Alaska 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. The service delivery system operated on three levels: village, region, and urban. A total of about 50 people and seven or eight facilities were involved (Group for the Advancement of Psychiatry, 1995). 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):
Soule (personal communication, 1995) described a program for delivering mental health services to Alaskan Natives living in remote villages. The intent of the initiative was to provide services that were responsive and sensitive to the unique needs of the target populations. Largely in response to direction from the Native community, significant changes were made to the way services were delivered, the nature of the services, and who provided the services. Except for the State Hospital, no direct services are provided. Grants are made to local entities to design and manage programs to address the problems of self-destructive behavior (including AODA) and suicide. The role of the state is to provide technical assistance and support, leaving the decisions about what will work for them to the 60 participating communities. Examples of local projects were: crisis response teams, teaching of traditional values and skills, teen centers, and preschool programs. A second program, the Rural Human Services Project, provides grants to local human service agencies to hire, train, and supervise indigenous providers. These grants are intended to reduce reliance on non-native professionals who ride circuit to the villages. The program also attempts to create service delivery models that are holistic and focused on the community as well as the individual and that respect and incorporate the values of both native and western cultures and approaches to prevention, treatment, and recovery. Treatment Modalities and the Evolving Healthcare SystemIf providing services to the SMI in frontier areas has traditionally been a problem, providing them in the evolving environment of the current healthcare system is even more of a challenge. 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. At this point, the discussion is largely theoretical. Planners and providers interviewed have generally noted that managed care has had little impact in their frontier areas. Private companies have shown little interest in these areas because of the low population base and poverty. In the following quote, Kane & Ennis (1996) discussed services for the seriously mentally ill in relation to healthcare reform, but their points have equal validity with respect to managed care, which is certainly one part of reform. They note (1996:447):
They outline four strategies for providing these services: linkages to primary care systems, use of ACT, use of lay caregivers and use of adult homes. The first strategy of integrating of the health and mental health service system is especially important in view of the higher risk of physical illness among the SMI. Over the years, repeated calls have been made for integrating mental health, primary care, and AODA services in rural areas as a means of improving access. Ozarin, Samuels, & Biedenkapp (1978), for example, evaluated the community health center/community mental health center linkage program and found it to be highly effective for providing mental health services. Indeed, this linkage between health and mental health systems is seen by some as an important element in a managed care system. A recent research study provides some useful contemporary insights (Maine Rural Health Research Center, 1996). The investigators conducted a national telephone survey of rural primary care providers who successfully linked with substance abuse or mental health services. The primary care providers included hospitals, community health centers, health departments, HMO and private practitioners. Of particular note, eight of the providers were in states with frontier populations: North and South Dakota, New Mexico, and Arizona. Four models of integration were employed, either singly or in combination:
Diversification is the closest form of integration: there is coordination of services within a single organization (primary care and mental health providers work for the same agency). With linkage, specialty mental health providers offer services at primary care sites through a formal, ongoing relationship. Referral, as the name suggests, involves primary care providers referring patients to off-site mental health providers. Finally, with enhancement, primary care providers receive training in order to improve their ability to treat mental health problems directly. Overall, these integration efforts have proven effective. Primary care providers often feel that they lack the knowledge to deal with the SMI and their orientation is to acute, rather than chronic care. Nonetheless, primary care providers are a crucial part of mental health and AODA care. Given the success of these linkages, a recommendation for architects of managed care would be to provide incentives for primary health care providers to link with mental health and AODA agencies. These incentives could include educational programs for providers as well as fiscal incentives for linkage. Kane and Ennis (1996) also feel that the large body of data supporting the efficacy of Assertive Community Treatment mandates its inclusion as a strategy in a reformed health system. They add a qualification (1996:448):
The nature of rural life suggests the third strategy: utilization of lay and informal caregivers. The use of these informal caregivers is not without some risk. Kane & Ennis (1996) caution:
The final element is adult homes, which can also be referred to as board and care homes, boarding houses, and congregate care facilities. These shelter arrangements house almost 40% of the SMI nationally. Kane & Ennis summarize the generally favorable literature on these homes. They provide a less restrictive environment and lower levels of stress than institutions and are better venues for maintaining independent living skills. In addition, they are much lower in cost than institutions and are perceived by residents as offering a higher quality of life. While no accurate data exist about the number in frontier areas, providers interviewed for this paper have noted that these homes exist in many communities in their areas. As part of its process of deinstitutionalization, New Mexico reported an increase in the number of such homes, many of them operated by former employees of the state hospital. The state hospital provided mental health, crisis intervention, and support services to these adult homes via a visiting psychiatrist and nurse team. Without careful controls on placements and the provision of adequate support services, however, these homes have proven problematic, as was the case in Colorado (Kane & Ennis, 1996). One of the impediments to creating a workable frontier model, using the above suggestions appears to be categorical funding. Designed to meet a certain need or designated population or to provide a certain modality, this approach severely limits the flexibility that is needed in resource-poor frontier areas. If, for example, funds are available to pay for adolescent inpatient treatment, then services are likely to be skewed in that direction. An alternative, community-based approach, may be more appropriate in a given case, but a lack of funds may preclude its use. Much has been said about the inappropriateness of the urban model of services-specialized, well-staffed and funded, with a geographically dense area of responsibility-for rural venues. This is even more true for the frontier. A frequent comment made by planners and providers in the interviews was the inability to afford the luxury of specialized caregivers. The frontier caregiver, even more than his or her counterpart in more populous rural areas, needs to be a versatile and flexible generalist. Fiscal constraints, a paucity of potential clients, and an absence of peer backup militate against specialty care. The generalist, by definition, needs to be concerned with a number of different approaches and to operate within a variety of milieus. This speaks to the issue of the need for flexibility. The need for a general, flexible orientation argues strongly against categorical funding of programs. A categorical program is directed toward a specific clientele and, often, prescribes a particular modality. This just does not work in frontier areas! Another concern of managed care plans, then, ought to be greater discretion on the part of planners and providers in allocating resources to meet local or individual needs. As noted, frontier mental health and AODA services are organized and delivered in several different ways. This reflects state differences in ideologies and fiscal arrangements. The richness of diversity, however, can be problematic in a call for linkage in a situation where, for example, the mental health agency is public, and the AODA agency is private, or where one state managed care plan includes AODA services and another specifically excludes them. What one can recommend is that a national organization such as the National Association of State Mental Health Program Directors assume a leadership position in advocating a more uniform policy. In sum, in keeping with the seriousness of the problem, a number of models of service delivery to the SMI have been developed or modified for rural areas. While all report success in reducing days in hospital and enhancing client autonomy, some of the "high tech" models that rely on high levels of professional input, would not appear appropriate for frontier areas. The first of these Letters ended with the observation that-in spite of formidable resource and geographic obstacles-a variety of core services for the SMI are provided in the five states with frontier populations examined. Reflecting the differences in the organization of state mental health systems, there was understandable diversity in approaches. This Letter has adopted a broader focus and looked at some of the models that have been developed or adapted for rural areas. In addition, the advent of managed care and other market-based reforms offers an opportunity to restructure the healthcare system and to integrate the various service delivery systems. ReferencesBachrach, L.L. (1977). Deinstitutionalization of mental health services in rural areas. Hospital and Community Psychiatry, 28, 669-672. Baker, F. & Intagliata, J. (1984). Rural community support services for the chronically mentally ill. Journal of Rural Community Psychology 5 (1), 3-14. Beard, J. (1976). Psychiatric rehabilitation at fountain house. In J. Meislin (ed.) Rehabilitation Medicine and Psychiatry. Springfield, IL: C.C. Thomas. Beard, J., Propst, R., & Malamud, T. (1982). The fountain house model of psychiatric rehabilitation. Psychosocial Rehabilitation Journal, 5, 47-53. Davis, L.F. & Ziegler, J.A. (1990). Working with people who are chronically mentally ill in rural areas: Developing a community resource team. Psychosocial Rehabilitation Journal, 13, 81-85. Group for the Advancement of Psychiatry (1995). Mental health in remote rural developing areas. Report No. 139. Washington, DC: American Psychiatric Press. Husted, J., Wentler, S.A., & Bursell, A. (1994). The effectiveness of community support programs for persistently mentally ill in rural areas. Community Mental Health Journal, 30, 594-600. Idaho, State of. (1997). Mental Health Plan for Adults and Children. Boise: Department of Health and Welfare. Kane, C.F., & Ennis, J.M. (1996). Health care reform and rural mental health: Severe mental illness. Community Mental Health Journal, 32, 445-462. Macias, C., Kinney, R., Farley, O.W., Jackson, R., & Vos, B.(1994). The role of case management within the community support system: Partnership with psychosocial rehabilitation. Community Mental Health Journal, 30, 323-339. Maine Rural Health Research Center (1996, February). Rural Models for Integrating Primary Care, Mental Health, and Substance Abuse Services. Portland: Center for Health Policy. Mazer, M. (1976). People and Predicaments. Cambridge, MA: Harvard University Press. Ozarin, L.D., Samuels, M.E. & Biedenkapp, J. (1978). Need for mental health services in federally funded rural primary health care systems. Public Health Reports 93 (4), 351-355. Pressing, K.O., Peterson, C.L., Barnes, J.K. & Riley, B.D. (1983). Growing wings: A psychosocial rehabilitation program for chronically mentally ill patients in a rural setting. Psychosocial Rehabilitation Journal, 6, 13-24. Rhinelander Model Consultants (1990). The Rhinelander model of community supportive care. Rural Community Mental Health Newsletter, 17, 7-8. Santos, A.B., Deci, P.A., Lachance, K.R., Dias, J.K., Sloop, T.B., Hiers, T.G., & Bevilacqua, J.J. (1993). Providing assertive community treatment for severely mentally ill in a rural area. Hospital and Community Psychiatry 44 (1) 34-39. Smith, H.A. (1989). Telephone reassurance to the elderly: Rural values in action. Community Mental Health Newsletter 16 (3), 10. Somers, I. (1989). Geographic location and mental health services utilization among the chronically mentally ill. Community Mental Health Journal 25 (2) 132-144. Sword, M. & Longden, G. (1989). The Idaho citizen companion program. Human Services in the Rural Environment, 12, 34-36. Sullivan, W.P. (1989). Community support programs in rural areas: Developing programs without walls. Human Services in the Rural Environment, 12, 19-2. Turner, J.C. (1977). Comprehensive community support systems for mentally disabled adults: A conceptual framework. Psychosocial Rehabilitation Journal, 1, 9-26.
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