Multiple Barriers Thwart Plans for MH Care in Rural Clinics

Rural primary care health clinics might serve as sites for mental health services, but very few offer that care, a situation unlikely to change without outside assistance, according to a report from the Maine Rural Health Research Center.

“It is clear that developing and offering mental health services is not an easy undertaking,” wrote health services researchers John Gale, M.S.,, Barbara Shaw, J.D., and David Hartley, Ph.D., of the Cutler Institute for Health and Social Policy in the Muskie School of Public Service at the University of Southern Maine; and Stephenie Loux, M.S., of the Department of Psychiatry at Beth Israel Deaconess Medical Center in Boston.

Only 6 percent of independent (clinic- or hospital-based) and 2 percent of provider-based rural health clinics offer mental health services using clinical social workers and/or doctoral-level psychologists, they estimated in a report published in May by the university's Maine Rural Health Research Center.

Such studies of the rural mental health work force are badly needed, said Deborah Altschul, Ph.D., an assistant professor of psychiatry and director of research at the Center for Rural and Community Mental Health at the University of New Mexico.

“It shows how little access to mental health services there are in many rural settings,” said Altschul in an interview.

Nearly 3,800 rural health clinics (RHCs) provide primary care services in rural, underserved areas. The clinics were established in 1977 by Congress to encourage provision of primary care services by channeling Medicare and Medicaid reimbursement for a mix of primary outpatient services, basic laboratory tests, and some emergency life-saving medical procedures. These clinics are usually the first, and often the only, source of mental health care in the areas they serve.

“Many are just small, one- or two-person practices, not lightweight versions of federally qualified health centers,” said Gale in an interview.

But integrating mental health services into this primary care setting is not easy, he said. The two fields may have different practice patterns, documentation requirements, and even clinical space needs.

Simply filling shortages of qualified staff by hiring another professional may not solve the problem at the community level, if it means cannibalizing another clinic or agency in the same area.

To get a better view of the role of rural health clinics in mental health care, Gale and colleagues looked at Medicare administrative datasets covering 2,466 clinics and found that only 62 out of 1,117 hospital-based RHCs and 28 out of 1,349 provider-based RHCs offered mental health services by doctoral-level psychologists or clinical social workers, either by employees or those on contract.

The reality behind even those numbers is hardly robust. RHCs using psychologists employed them only at an average of 0.4 full-time equivalents. They employed only 0.6 full-time-equivalent social workers.

From the 90 clinics of both types with mental health care personnel, they randomly selected 14 for semistructured interviews. While their numbers may seem small, the results “suggest a broad range of problems out there,” said Gale, who has collaborated with Hartley and others on previous studies of rural mental health.

The interviews with clinic personnel revealed several barriers to developing mental health services.

For one thing, both recruiting and retaining psychiatrists, psychologists, and clinical social workers are difficult because of poor compensation, professional isolation, lack of educational or career opportunities for family members, and difficulties in maintaining professional boundaries in a small community where everyone knows everyone else, said respondents.

As in other settings, administrative burdens and costs are increased by inconsistent third-party-payer reimbursement and credentialing policies, complex state-licensing laws, and tortuous managed care contracts.

Poor reimbursement rates by Medicaid and commercial insurers hurt clinics. Patient-related problems, such as cost shifting to patients by insurers, high no-show rates, and high rates of uninsurance create burdens too.

RHCs also lack what Gale calls “policy leverage,” the organizational and statutory muscle to develop mental health services. Federally qualified health centers, by contrast, are required to provide mental health services.

Also, some RHCs may be in communities with other mental health agencies or resources that serve specialized populations.

“For instance, an agency that handles only acute patients within a state system using Medicaid funding may not take uninsured or privately insured patients,” he said.

But there are important advantages to having mental health specialists in the same primary care clinics. When a patient needs mental health services, the primary care provider can walk the patient down the hall, either for immediate treatment or to secure a specific follow-up appointment.

“There's also better synergy between providers, who can hold case conferences or even less-formal discussions at the same site,” said Gale.

The few clinics that do offer mental health services often share one characteristic, according to the researchers: “a local champion who identifies the need for and undertakes the implementation of services”—typically a clinician or senior administrator.

Altschul has found a similar pattern in her work expanding cultural-competency and evidence-based practices in rural New Mexico.

“If there's no champion, it doesn't happen,” she said.

However, finding a champion to push for and support a program of mental health services might place too much faith in the appearance of one individual to solve the problem.

“I'm not sure what a systemic solution would be,” said Gale. “Perhaps expanding services could be achieved by identifying, targeting, and cultivating those individuals.”

A more concrete set of options might be collecting existing educational and technical resources into an “RHC mental health toolkit” to provide these small clinics with practical information on everything from evidence-based clinical practices and service models to mental health coding, billing, and reimbursement, he said.

The report was completed too early to reflect the influence of health reform legislation on RHCs, noted Altschul.

“Will primary care fold in mental health care or will numerous small agencies or practices continue as the norm?” she asked.

“The Provision of Mental Health Services by Rural Health Clinics” is posted at <http://muskie.usm.maine.edu/Publications/rural/WP43/Rural-Health-Clinics-Mental-Health-Services.pdf>.