1. Rural Behavioral Health: A
Glimpse into What is
Working and What is to
Come
Virginia Rural Health Plan
Access Council Summit
December 7, 2011
Mimi McFaul, Psy.D.
Associate Director
ALASKA ARIZONA CALIFORNIA COLORADO
WICHE Mental Health Program
HAWAII IDAHO MONTANA NEVADA NEW
MEXICO NORTH DAKOTA OREGON SOUTH
DAKOTA UTAH WASHINGTON WYOMING

2. What do many Americans think of when
they picture persons with mental health
issues?
 A homeless person on a city street
 An out-of-control teenager in a large
metropolitan school
 A person on a locked hospital ward
 Persons making poor choices
 Someone else
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

3. Few Americans Picture
 A farmer or rancher with serious
depression
 The stress associated with changing rural
economies
 Someone driving 150+ miles to a clinic
 A traveling psychiatrist
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

4. The Cold, Hard Facts
 More than 60% of rural Americans live in mental
health professional shortage areas
 More than 90% of all psychologists and
psychiatrists, and 80% of MSWs, work exclusively
in metropolitan areas
 More than 65% of rural Americans get their mental
health care from their primary care provider
 The mental health crisis responder for most rural
Americans is a law enforcement officer
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

5. So What’s Different about Rural?
 Not prevalence – rural/urban rates of
mental disorders are pretty much the same.
 Accessibility (getting there and paying)
 Availability(someone there when you are)
 Acceptability(choice, quality, knowledge)
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

6. Some Common Rural BH Workforce
Issues
 Lack of sustained effort to prepare and deploy
professionals for rural practice
 Lack of systematic recruitment and retention of
behavioral health workforce
 Lack of communication between educational
institutions and providers
 Those who spend the most time with patients
receive the least training
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

7. How did it get this way?
 Stigma/Discrimination
 Lack of a rural plan
 Lack of sustained effort to prepare and
deploy professionals for rural practice
 One size fits all planning and funding
 Mental Health Care is “optional”
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

8. What can we do?
 Advocacy/Public Education
 National Health Service Corps (NHSC) – Rural sites
should become eligible sites – recruitment tool
 Improve Primary Care/Mental Health Integration
 Take rural into account – get a plan
 Increase rural training placements
 Grow Your Own
 Train Natural Helpers (Mental Health First Aid)
 Acknowledge rural innovation
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

9. The Trend Toward Integration of
Primary Care and Behavioral Health
 It’s happening in an
agency near you
 How does this impact
who we hire? How we
train?
 Many people seek care
for mental health issues
in primary care.
 Primary care even more
central in rural
communities where BH
workforce is limited.
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

10. SAMHSA/HRSA Center for Integrated
Health Solutions (CIHS)
http://www.integration.samhsa.gov/
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

11. What are we doing to work on rural
behavioral health access?
 Suicide Prevention Toolkit for Rural
Primary Care Providers
 Rural Psychology Internship Consortia
(Alaska, Hawaii…)
 Integrated Care Projects
 State-specific Consultation
 Synthetic Estimation of Prevalence and
Unmet Need
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

12. How do we know what is
working for rural
communities?
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

13. Urban Testing Ground for EBPs
What is the rural applicabilty?
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

14. Challenges and Opportunities
 Challenges of implementing EBPs in
rural due to smaller economies of
scale
 What is a realistic goal for rural?
 Evidence-based practice vs. Practice-
based evidence
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

15. Many rural behavioral health
programs…
 Have always relied on creativity and working
within their current resources
 Have not been researched sufficiently to be
considered EBPs for rural
 Do not have evaluators (except if attached to
a specific grant) to conduct ongoing research
 Are fearful of what to do with data and how
to use it in a meaningful way – we don’t
need to measure everything!
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

16. It always comes back to…FIDELITY
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

17. Starting with the Community
 What’s working in rural communities?
 Promising Practice: Treatment programs or
interventions designed for a particular
population that have at least some data
supporting their effectiveness in terms of
client outcomes
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

18. Why do this?
 Recognition for model rural
programs
 Share best practices
 Connect programs to researchers
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

19. Inside the Boxing Ring: Approaching
Heavyweight
 Round One: 6
Programs
 Round Two: 30
Programs
 Round Three: 62
Programs
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

20. Learning from Experience
 Need clearly criteria for what defines a
rural promising practice but…
 Criteria also need specificity for
particular program/population served
 Need categories to “cluster programs”
 The “will” is there but…
 Programs need a road map for using
evidence to demonstrate success and
support program activities
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

21. Rural Promising Practices Project
 Nomination Process
 Web-based Surveys
 Phone Interviews to “drill
down”
 Categorization Scheme
 Pruning Process
 Top Tier Nominees
 Site Visits
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

22. Selected Questions
 Type of “practice nominated”
 Rationale/theory for practice
 Indicators of success (decreasing
symptoms, increasing staff retention)
 % Rural
 Staff Training/”Fidelity”
 Manualized?
 Evaluation Staff to collect data?
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

23. 32 of 50 States Represented!
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

24. Categories
 Adapting EBPs for Rural
 Community education and
outreach programs
 Integrated care programs
 Court teams
 Crisis services programs
 Hotline programs
 Peer support programs
 Programs serving special
populations
 Telemental health programs
 Training programs
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

25. Themes
 Relevance to Rural
 Impact on Rural
 Sustainability and Expansion Capability
 Capacity
 Documentation of Program Information
 Effectiveness
 Community Engagement
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

26. Highlighted Programs
 One highlighted program for each theme
 A few examples…
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

27. Goal of Document
 Highlight rural promising practices
cohort across categories
 Resource guide
 Information Exchange
hrsa.gov/ruralhealth/pdf/ruralbehavioralmanual05312011.pdf
 Future Directions…Dreaming
 Rural “Oscars”
 Website with interactive
functionality
 Connecting rural researchers to
these programs
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

28. Adapting and Adopting EBPs
 Core clinical
components
 Hybrid models
 Climbing up the
evidence ladder
 Rural-specific
criteria
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

29. ACA and Rural Behavioral Health??
 More eligible for services (Medicaid) – heightens
workforce issues
 How do we incentivize people to be Medicaid
providers?
 State plans vary for Medicaid benefits for MH
 How will our pre-service education, continuing
education, and other training programs need to be
adjusted to meet new workforce needs driven by
integrating care?
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING

30. Questions?
Contact Information:
WICHE Mental Health Program
Mimi McFaul, Psy.D.
mmcfaul@wiche.edu
ALASKA ARIZONA CALIFORNIA COLORADO HAWAII IDAHO MONTANA NEVADA
NEW MEXICO NORTH DAKOTA OREGON SOUTH DAKOTA UTAH WASHINGTON WYOMING