Can Limitation Mean Liberation? The Integrated Health Needs of a Rural

Community Rebekah A. Schiefer, MSW, LCSW, Instructor/Behavioral Health Consultant

Taylor D. Hartman, MA, Behavioral Health ConsultantJohn B Rugge, MD, Family Practice Physician

Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.

Session # A5a Redesign of Health Care Services and Structures Saturday October 17th, 2015

Faculty Disclosure

The presenters of this session• have NOT had any relevant financial relationships during

the past 12 months.

Learning Objectives

At the conclusion of this session, the participant will be able to: 1. Identify the barriers and ethical challenges facing behavioral

health clinicians in rural communities.

2. Describe at least three barriers to mental health access in rural communities and specific interventions that address these barriers

3. Understand various options for how to structure and provide meaningful behavioral health services in a rural community using a multi disciplinary approach

Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.

Presentation Outline

• Identify the barriers and ethical challenges facing behavioral health clinicians in rural communities

• Describe at least three barriers to mental health access in rural communities and specific interventions that address these barriers

• Understand various options for how to structure and provide meaningful behavioral health services in a rural community using a multi disciplinary approach

Understanding the Needs of a Rural Communities

• Rural residents have higher risk of– Both mental health and medical problems– Untreated mental health issues– Poverty– Unemployment– Increased isolation– Substance Use– Suicide

With these increased risk factors, rural clinicians are faced with multiple challenges in providing care to their patients.

Alford (2011), Badger, Ackerson, Buttell & Rand (1997), Chipp et al. (2011), Correll, Cantrell, & Dalton (2011), Hartley, Britain, & Sulzbacher (2002), Meadows, Valleley, Haack, Thorson, & Evans (2011), and Oakley, Moore, Burford, Fahrenwald, & Woodward (2005)

Rural Health Care Providers

Badger, Ackerson, Buttell & Rand (1997) Chipp et al. (2011), Correll, Cantrell, & Dalton (2011), Hartley, Britain, & Sulzbacher (2002), and Meadows, Valleley, Haack, Thorson, & Evans (2011)

• Rural areas have fewer mental health specialists resulting in reliance on PCP for mental health care

• PCPs have larger patient loads– Higher burn-out rates

Dilemmas in Rural Health Settings

• Overlapping relationships• Conflicting roles• Altered therapeutic boundaries• Multidisciplinary team issues• Limited options for primary care• Limited resources for consultation• Greater stress experienced by rural health

providers

(Roberts, Battaglia, & Epstein, 1999)

Ethical Considerations across Disciplines

• Privacy and confidentiality– Confidentiality in integrated system with EMR– Confidentiality concerns in small town– No regular office – Minimizing intrusions on privacy– Consultation vs. privacy – informed consent issue

• Competence– Boundaries of Competence vs. patient barriers– Emergency Services– Avoid Harm

APA. (2012). Ethical principles of psychologists and code of conduct: Including 2010 amendments. Retrieved from http://www.apa.org/ethics/code/i ndex.aspx

Ethical Considerations across Disciplines

• Multiple Relationships– Community Interaction

• Church• Grocery• Restaurants

– Conflict of Interest– 3rd Party request for services

• Parent referral• Employer referral• Church referral

– Informed Consent APA. (2012). Ethical principles of psychologists and code of conduct: Including 2010 amendments. Retrieved from http://www.apa.org/ethics/code/i ndex.aspx

Commonly asked questions with ethical considerations

• Can you see my son/daughter?• Can I bring my partner in?• What do you put in my note?• What if we see each other outside of clinic?• Do you talk to my doctor?• Don’t tell them I smoke medical marijuana.

Presentation Outline

• Identify the barriers and ethical challenges facing behavioral health clinicians in rural communities.

• Describe at least three barriers to mental health access in rural communities and specific interventions that address these barriers

• Understand various options for how to structure and provide meaningful behavioral health services in a rural community using a multi disciplinary approach.

Understanding Barriers to Care: Distance

Understanding Barriers to Care: Time

Understanding Barriers to Care: Money

• Higher percentage of people living below the poverty line.

• Gas prices

• Scarce employment opportunities

Understanding Barriers to Care: Privacy

• Multiple relationships

• Major stigma around seeking help because fear of lost privacy

Reviewing Barriers

• Transportation• Confidentiality• Beliefs about providers• Income and insurance• Undertreated depression or mental health

issue• Overburdened providers• Health Literacy

Chipp et al. (2011), Correll, Cantrell, & Dalton (2011), Meadows, Valleley, Haack, Thorson, & Evans (2011), and Oakley, Moore, Burford, Fahrenwald, & Woodward (2005)

Presentation Outline

• Identify the barriers and ethical challenges facing behavioral health clinicians in rural communities

• Describe at least three barriers to mental health access in rural communities and specific interventions that address these barriers

• Understand various options for how to structure and provide meaningful behavioral health services in a rural community using a multi disciplinary approach

Scappoose and Columbia County

US Census Bureau Statistics 2014 estimates

• Population of 49,459• 93.1% white, non-Hispanic• 4.9% speak language other than English at home• Primary industry is wood products, paper manufacturing,

construction and horticulture• About 89.6% of residents over age 25 have a high school diploma• About 18.1% of residents over age 25 have a Bachelor’s or higher• About 50% of county workforce commutes out of county for

work• Median household income $54,968• 13.6% of persons living below the poverty line

Healthcare Indicators

County Health Rankings and Roadmaps

• Chronic Disease: Ranked 21 out of 33 counties in the state for overall health, morbidity, and mortality

• Columbia County has two primary care clinics, one urgent care and no hospital.

• No methadone providers, Scappoose FM is the only provider of suboxone in the county (2 providers)

Oregon Health & Science UniversityFamily Medicine at Scappoose

• Approximately 9,000 patients• 2,500 monthly patient visits• 12% each month are new patients• More than half (55 percent) are patients with

Medicaid/Medicare• Primarily serve patients who live in Columbia

County- Some patients commuting from more rural counties

Oregon Health & Science UniversityFamily Medicine at Scappoose

• Patient age demographics:– Pediatrics (newborn through 18): 20%– 19-64 year olds: 61%; – 65 and older: 19%

Oregon Health & Science UniversityFamily Medicine at Scappoose

• Primary Care Providers– Physicians: 6– PA-C’s: 5– FNP’s: 2– 1 Sports Medicine Provider– 6 Family Medicine

Residents• Support staff: 47

• BH Providers– Psychiatrist: ½ day weekly

for consults– Behavioral Health

Consultants• LCSW .9 FTE• PsyD Students .5 FTE• MSW Student .3 FTE• Post Doc .9 FTE

Oregon Health & Science UniversityFamily Medicine at Scappoose

• Learners– Family Medicine residents daily who see their own

panel of patients– Second and third year medical students– First and second year Physician Assistant students– First and second year Nurse Practitioner students

Behavioral Health Team

• LCSW/BHC– Manages BH team and schedules, supervises MSW students– Warm h/o and care coordination– Some short and long term tx– Groups (Wellness and Parenting groups)– Residency teaching/precepting– Consultation

• Post Doc– Supervises PsyD candidates– Warm h/o and care coordination– Short and long term tx– Groups– Teaching and precepting– Evaluation projects– Consultation

Behavioral Health Team

• PsyD Candidates– Short and longer term Tx– Assessment for diagnosis and treatment planning– Warm hand-offs and care coordination– Consultation

• MSW Students– Short and long term Tx– Warm h/o and care coordination– Consultation– Groups

Behavioral Health Team

• Psychiatry– Weekly consults• Complex case• Diagnostic clarification• Chart review and med recommendations

– Providers can send msg directly– Most appts scheduled through BHC

Many Avenues to Care

1-2 Contacts•Warm Intro•Crisis•Psych Consult

3-6 contacts•Short Term Tx•Health/Behavior Visit•Testing

7+ Contacts

BH Touches

• Able to touch 6% of our total clinic visits in 2013-14. – This was prior to full time post doc or MSW students– Goal with increased FTE is at least 10%

• Average touches– 6.9 sessions for counseling patients– 1.3 touches same day or interim note visits

• Primary barriers to increased BH touch– Limited funding for greater FTE– No coverage early morning or late evening

Value of Behavioral Health Integration

• Warm hand-offs during moments in crisis• Less loss-to-follow-up• Joint planning for (and debriefing about) management of

complex patients• Pairing counseling sessions with primary care visits• Evaluation for more complex diagnostic questions without

referral to Portland• Management for those who would not make it to Portland• Management for those who would not go to ‘Mental Health’• Enhanced learning for practitioners and staff

Enablers of Behavioral Health Integration

• Departmental support• Use of PsyD students as inexpensive providers• Billing for LCSW visits• Post doc funding through county grant• MSW student through BH integration grant• … and hope that with Accountable Care

Organization, proactive use of Behavioral Health will reduce costs and improve clinic’s net reimbursement

Importance of saying “yes”

• Many models of BH integration• Several models discourage “therapy” as an option for patients• Limits of service in rural counties means need for flexible services• Evidence based treatment

– Need flexibility of sessions to see improvement– The choice is often between some or no treatment– Patients develop relationship at warm h/o, don’t want to talk to

another provider• Encouragement of family systems thinking

DISCUSSION TIME AND QUESTIONS

ReferencesAlford, N. B. (2011). Integrated care in rural settings. In G.M. Kapalka (Ed.), Pediatricians and pharmacologically trained

psychologists (67-94). NC: Carriage House Psychological Associates.Badger, L., Ackerson, B., Buttel, F., & Rand, E. (1997). The case for integration of social work psychosocial services into

rural primary care practice. The Journal of the National Association of Social Workers, 22 (1), 20-29.Chipp, C., Dewane, S., Brems, C., Johnson, M., Warner, T., & Roberts, L. (2011). “If only someone had told me…”: Lessons

from rural providers. The Journal of Rural Health, 27, 122-130. doi: 10.1111/j.1748-0361.2010.00314.xCorrell, J., Cantrell, P., & Dalton, W. (2011). Integration of behavioral health services in a primary care clinic serving rural

Appalachia: reflections on a clinical experience. Families, Systems & Health: The Journal Of Collaborative Family Healthcare, 29(4), 291-302. doi:10.1037/a0026303

Hartley, D., Britain, C., & Sulzbacher, S. (2002). Behavioral health: setting the rural health research agenda. The Journal Of Rural Health: Official Journal Of The American Rural Health Association And The National Rural Health Care Association, 18 Suppl 242-255.

Meadows, T., Valleley, R., Haack, M., Thorson, R., & Evans, J. (2011). Physician "costs" in providing behavioral health in primary care. Clinical Pediatrics, 50(5), 447-455.

Oakley, C., Moore, D., Burford, D., Fahrenwald, R., & Woodward, K. (2005). The Montana model: integrated primary care and behavioral health in a family practice residency program. The Journal Of Rural Health: Official Journal Of The American Rural Health Association And The National Rural Health Care Association, 21 (4), 351-354.

Roberts, L., Battaglia, J., Epstein, R. (1999). Frontier ethics: Mental health care needs and ethical dilemmas in rural communities. Psychiatric Services, 50(4), 497-503.

Polaha, J., Dalton, W. T., III, & Allen, S. (2011). The prevalence of psychosocial concerns in pediatric primary care serving rural children. Journal of Pediatric Psychology Special Edition in Rural Children’s Health, 36, 652 660.

Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!