Montana Program Effectively Addressing ‘Frontier Trifecta’ of Barriers to Care

Collaborative care can be a highly effective approach to mental health care delivery in rural areas with a large proportion of underserved, underrepresented patients. In this month’s column, we hear from primary care provider David Mark, M.D., whose team has modified collaborative care to best address the “frontier trifecta” of barriers to care—lack of transportation, shortages of health care professionals, and stigma. —Jürgen Unützer, M.D., M.P.H.

In late July 2019, one of the reservation communities within our service area in the eastern Montana frontier declared a state of emergency over a mounting suicide crisis and a spike in overdose deaths. The Fort Belknap Indian Community Council issued the declaration in the hopes of garnering attention and resources to combat the epidemic.

In an effort to improve the behavioral health of this community—where resources are limited—we have integrated an assessment of our patients’ social determinants of health into our collaborative care model. The approach helps pinpoint and address each patient’s unique barriers to health care to help improve patient outcomes. Examples of social determinants of health include income, education level, food security, housing, language barriers, discrimination, unemployment, living in the presence of abuse, access to transportation, and health insurance.

The literature confirms that the state of mental health in Montana is rather bleak. According to the 2017 Behavioral Risk Factor Surveillance Survey, 1 in 5 Montana adults reported ever having a depressive disorder, and nearly 1 in 3 reported having at least one poor mental health day in the last month. Also, the rates of binge drinking and heavy drinking in Montana are far higher than national rates. Among Montana youth, more than 1 in 4 high school students reported symptoms consistent with depression in the last year.

The consequences of these behavioral health concerns can be devastating. The adult suicide rate in Montana is consistently twice that of the U.S. rate. In fact, in 2017, Montana had the highest rate of suicide of any U.S. state, 29.6 per 100,000 versus 14 per 100,000 nationally.

As noted by our colleagues in Fort Belknap, racial disparities are prevalent across our region. The highest rate of suicide statewide is among American Indians/Alaska Natives (AI/AN; 35.5 per 100,000 versus 28.1 per 100,000 for whites), even though they constitute only 6% of the state’s population. Among youth, the disparity is even more striking: The suicide rate is five times higher among AI/AN youth than the rate among whites (42.8 per 100,000 versus 8.0 per 100,000, respectively).

Underdiagnosis of mental health issues certainly contributes to the suicide epidemic in Montana; only 40% of people who died by suicide in the state had been diagnosed with a mental illness at the time of death.

Mirroring our sparsely populated landscape, the available resources to respond effectively to the crisis are limited. The eastern third of the state—where the population density is 1.83 people per square mile—has been a mental health professional shortage area for decades, according to the Health Resources and Services Administration. Current demographic trends don’t forecast a change to that status in the near future.

In the face of these myriad challenges, our federally qualified health center has found that the IMPACT model of collaborative care—extended to address a wide range of behavioral health disorders—is a highly effective approach to care delivery. Judicious mixing of virtual and in-person visits by licensed behavioral health professionals within our network of clinical sites expands the reach of our personnel without sacrificing the core elements of the collaborative care model. The IMPACT model is largely synonymous with collaborative care. The terms originate from the IMPACT study, the first large, randomized, controlled trial of treatment for depression. The IMPACT study demonstrated that collaborative care more than doubled the effectiveness of depression treatment for older adults in primary care settings.

In addition, we have integrated an “upstreamist” element into our approach: universal screening of patients for mental and substance use disorders coupled with deployment of a risk assessment tool to better understand our patients’ social determinants of health. This tool, the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE), standardizes patient risk assessment and provides a process for identifying social determinants of health as well as a collection of resources to act on those determinants.

Additionally, for patients struggling with what we call the “frontier trifecta” of barriers to care—lack of transportation, shortage of health care professionals, and mental health stigma—the inclusion of resource support specialists in the collaborative care team is an important modification. These specialists complement the work of behavioral health care managers and provide an efficient means of addressing the items identified in the PRAPARE screening assessment.

Adding a robust focus on the social determinants of health to a model of collaborative care provides a powerful tool to leverage finite resources across the large and sparsely populated geography in eastern Montana with the hope of delivering measurable improvements in behavioral health outcomes for our communities. ■