Rural ACT in Appalachia Challenges and Opportunities

1
Rural ACT in Appalachia- Challenges and
Opportunities

• Mindy Beam, LPC, PACT Team Leader, Mt. Rogers
  Community Services Board
• Tony Graham, M.D., Psychiatrist, PACT Team, Mt.
  Rogers Community Services Board

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Rural ACT in Appalachia

• Historical review of problems in rural mental
  health care delivery
• Challenges and review of rural ACT delivery
• Introduction to Appalachia region, demographics,
  history
• Overview of Virginia community mental health
  system/far southwest Virginia and Mt. Rogers PACT
  program

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Rural mental health challenges- National

• Guess when the following was stated in a report
  from the NIMH?
• Of more than 16000 psychiatristsonly 500 or
  three percent were in rural counties.
• In the four most rural states, the acceptable
  ratio of psychiatric beds per 1000 population is
  only one-tenth of that in the four most urban
  states.

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Rural Mental Health Challenges- National

• The lack of adequate mental health facilities
  often leads to inappropriate treatment of persons
  in need of psychiatric services.
• Alcoholics.and people who are confused and
  psychotic are frequently housed in local jails.

5
Rural Mental Health Challenges- National

• These quotations are from NIMH data from 1965
  cited in The Mental Health of Rural America
  from NIMH, 1973.

6
General challenges in rural mental health

• Poverty
• Lack of public transportation
• Lack of housing
• Lack of available jobs
• Large service area involves significant travel
  time-distance/geography must be considered
• Lack of mental health professionals
• Lack of private inpatient resources
• Stigma
• Primary health care shortage
• Lack of social networks

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Rural Mental Health Challenges- National

• Data from 2000- NIMH- 800 rural counties have
  high poverty rate
• Only 25 of people living in these rural counties
  qualify for Medicaid compared to 43 in urban
  areas.
• Women head 46 of rural households and of these,
  27 are living below the poverty level, compared
  to 9 of male headed rural families

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Rural Mental Health Challenges

• Inequitable distribution of mental health
  manpower psychiatrists, psychologists, licensed
  clinical social workers, case managers, licensed
  professional counselors
• Examples of how this maldistribution can be
  addressed- for example, National Health Service
  Corps, telemedicine, etc.

9
Recruitment of professionals

• Problems with recruitment and retention of mental
  health professionals..
• This has been particularly true with psychiatrists

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Recruitment obstacles

• Graham, M.A.- 1993- study of all NHSC
  psychiatrists regarding their placements/future
  plans
• Examined factors influencing the decisions of
  NHSC placed psychiatrists to stay or not to stay
  in primarily rural placements

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NHSC study

• 61.7 of NHSC psychiatrists surveyed did not
  plan to stay at their placement site beyond their
  service obligation- typically 3-4 years
• The most important discriminating factor in those
  who stayed from those who left was distance from
  their residency training site
• Psychiatrists who stayed were located an average
  of 267 miles from their residency program and
  those who left were located an average of 844
  miles from their residency program

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NHSC study

• Problems in rural areas most often cited by
  psychiatrists were lack of resources- staffing,
  inpatient beds, lack of community funding for
  mental health
• Isolation- both professional and social
• Lack of career opportunities for spouses-
  particularly for women psychiatrists placed in
  rural areas

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Methods to enhance recruitment and retention in
rural areas

• Medical school relationships- in Appalachian
  area- Quillen Dishner College of Medicine- East
  Tennessee State University is closest- new Edward
  Via College of Osteopathic Medicine opened three
  years ago in Blacksburg, Virginia.
• Scholarships in return for service in region
• Student and resident rotations in region
• Regional recruitment efforts- different
  professional opportunities
• Geographic salary differentials

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Retention- identifying characteristics

• Small town person
• Married with small children or hoping to have
  children in near future.
• Connection to region by family or education
• Willingness to seek out contacts outside region
  for professional sustenance
• Willingness to take on multiple roles within
  organization
• An interest in primary care and an interest in
  developing relationships with other physicians of
  the community.

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Retention- identifying characteristics

• Enjoys outdoor life and activities
• Wants to be involved in community affairs

16
Review of studies and published information
regarding rural ACT delivery in U.S.
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What does NAMI say about rural ACT?

• Team leader should try to be creative and hire
  staff living in various parts of the service area
• Decisions need to be made based on clinical needs
  rather than transportation needs
• Important to maintain fidelity to the model
• Think outside the box

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PACT in rural areas

• Lachance/Santos- South Carolina- much of the
  published work about PACT in rural areas
• 1995- Psychiatric Services- and in other
  publications- Santos identified differences
  between Urban/suburban ACT and Rural ACT

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Urban/Rural Differences in ACT
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Differences between urban and rural ACT

• Differences cited by Stein/Santos- staff
  mobility, accessibility, communications, health
  expectations, attitudes toward treatment, means
  of transportation and community resources.
• Focus on planning of routes, itinerary, master
  daily schedule, coordination of activities

21
Study of Critical Ingredients of Assertive
Community Treatment

• Study by McGrew, Pescosolido, Wright- based on
  1997 survey of 73 urban and rural teams.
• In this study, caseloads were reported as
  smaller than in other samples- mean of 57.3 in
  urban teams and 40.5 in rural teams.
• There were 27 critical ingredients identified
  with surveys of both urban and rural teams
• There was high agreement on the importance
  ratings between rural and urban teams

22
Study of Critical Ingredients in ACT- rural and
urban

• The top five critical ingredients whether you
  were an urban or rural team in this study were
  Presence of at least one fulltime nurse, team
  involvement in hospital admissions and hospital
  discharge, involvement of all team members in
  treatment planning, caseload of fewer than 100
  clients and daily team meetings.

23
Providing assertive community treatment for SMI
patients in a rural area

• Santos et.al.- 1993- Some modifications in the
  model for rural areas- 23 patients with chronic
  illness- 79 decrease in hospital days per year,
  64 percent decrease in number of admissions per
  year, 52 reduction in overall costs.

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Technical differences in fidelity- rural/urban

• NAMI PACT Model review
• Staff size- urban-10 FTE- minimum- rural-5-7
  minimum-
• At least 8 of the 10 FTE in urban models are
  mental health professionals vs. 3 of the 7 FTE in
  rural models
• Program size does not exceed 120 urban/80 rural

25
Student Poll at Ohio State University When you
think of Appalachia, what image comes to mind?

• Country bumpkin, toothless, friendly.
• Fast-food, welfare community.
• Bible-believing people, honest and trustworthy,
  hard-working.
• Hillbillies and people that are not real
  intelligent.
• Rundown shack, no food, kids with no food,
  newspaper on the walls to keep out the cold.

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OSU Poll continued

• Dueling banjos.
• They want a hand-out.
• Coal miners.
• Dirt roads, barefoot children, little shanty
  houses.
• Backwoods people, big satellite dishes in front
  of a shack.
• Trout stream with a junk refrigerator behind
  it.
• Insurance fraud, welfare fraud, baby factory,
  inter-marriage.

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Appalachia mental health facts

• Economically distressed counties have few
  hospital-affiliated providers of mental health
  and substance abuse treatment.
• 8 of distressed Appalachian counties have a
  provider offering hospital-affiliated substance
  abuse outpatient services.
• 20 of distressed counties have
  hospital-affiliated mental health services

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Mental health system in Virginia

• Centralized state department Department of
  Mental Health, Mental Retardation, and Substance
  Abuse Services
• Operates 16 facilities statewide directly
• Community services are provided by 40 local
  Community Services Boards

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What are Community Service Boards?

• Local government agencies created by the code of
  Virginia in 1968
• Some in Virginia are referred to as Behavioral
  Health Authority
• Charged with assuring the delivery of a
  community-based mental health, mental
  retardation, and substance abuse service to
  individuals with disabilities
• Officials are appointed by local governing bodies
  as board members and are responsible for services
  in their localities
• 1/3 of board members are family members or are
  consumers of services

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Virginia community mental health system

• Relatively underfunded overall for a number of
  years
• Particularly unbalanced in terms of ratio of
  facility funding compared to community services
  funding
• Under former Governor Mark Warner and continuing
  under Governor Tim Kaine, this has shifted with
  significant reinvestment in community based
  services.

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Far Southwestern Virginia planning region

• Includes our service area Wythe and Smyth
  counties
• Region accounts for slightly less than 8 of
  Virginia population yet 14 of identified SMI
  cases in Virginia.
• Highest state hospital utilization rate in
  Virginia SWVMHI in Marion

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Our PACT Team serves the following counties

• Wythe
• Smyth
• Neither of these counties have ever had a private
  psychiatric inpatient facility
• Located within Smyth County is a state hospital
• This state hospital has served as the primary
  source of inpatient treatment for individuals in
  our CSBs catchment areait also serves 5 other
  CSBs in a 16 county region

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Wythe County Statistics

• Population 26,511
• 47.6 male
• 52.4 female
• 94.9 white
• 4.2 black
• .3 Latino
• .1 native American
• .4 Asian

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Wythe County Statistics

• Per Capita Income 19,523
• Unemployment rate 4.1
• Considered In Transition due to recent economic
  growth and industries
• 13.9-19.64 of population considered in poverty
• Whole county considered to have shortage in
  mental health professionals

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Smyth County Statistics

• Population 32,692
• 47.9 male
• 52.1 female
• 96.8 white
• 2.2 black
• .5 Latino
• .1 Native American
• .3 Asian

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Smyth County Statistics

• Per capita income 18,360
• Unemployment rate 6.1
• Considered At-risk due to slowing of industry
• Different parts of county range from 31.1-39.29
  considered in poverty
• Whole county considered to have shortage of
  mental health professionals

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Stigma in Appalachia

• Very pervasive negative attitudes towards mental
  illness in Appalachia
• Poor educational level overall
• Not uncommon to see people who have been
  untreated for years due to family/cultural stigma
• Stigma of state hospital- the town of Marion is
  synonymous in the region with state hospital

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Cultural sensitivity

• In Appalachia, culture is independent, bordering
  on isolative, distrustful of authority/government,
  mountain people.
• Staff need to be sensitive to the limits and
  boundaries required by the culture
• Services provided in the home are often met with
  resistance

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Cultural sensitivity

• Example Client, a 55 year old man with long
  history of paranoid schizophrenia, poor
  medication compliance, recurrent admissions was
  referred and opened by PACT team
• He became more suspicious due to home visits and
  becoming aware of neighbors gossiping about those
  visits by those government vehicles- he
  ultimately insisted on returning to clinic based
  services due to worry about services being
  provided to him in his small community.
• However, this has only happened to us once!

43
Cultural sensitivity

• Understanding the mountain
• Client who lives on Whitetop Mountain, near Mt.
  Rogers, the highest part of Virginia
• Seasonal changes can involve being bound in by
  weather during winter for weeks at a time- coming
  off the mountain into town has its own
  purpose/meaning for client
• Think outside of the box!
• For exampleoutdoor activities fishing, hunting,
  hiking, rural farming- team members need to
  understand these areas.

44
True Story

• We had a staff person find homes for a consumers
  abandoned chickens. She moved them herself.

45
Employment issues in Appalachia

• Marked problems in both general employment-
  higher unemployment rates than in the rest of
  Virginia and U.S.
• Marked lack of supported employment
• Marked lack of supportive employers- stigma/lack
  of cultural sensitivity
• Requires a targeted, individualized approach to
  job support/employment support

46
Distance and geography obstacles

• Smyth and Wythe counties are primarily rural with
  both mountainous and farmland type terrains
• One interstate crosses both counties in a
  relatively central location
• Multiple tiny communities in both counties with
  two county seats- 8-10,000 people
• Secondary roads are limited- difficult to reach
  certain areas of both counties.

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Distance obstacles

• Cell phone limitations- tower placements and
  coverage is problematic in both counties
• Requires daily comprehensive planning and a
  detailed knowledge of every team members home and
  relationship to the routes necessary for client
  service delivery.

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Distance obstacles

• It is essential throughout the winter months to
  keep a close monitor of weather patterns and to
  determine early how best to attempt mountain
  deliveries.
• Usually will keep at least a week supply of
  medication if at all clinically possible as a
  backup during winter months.
• Four wheel drive vehicles are essential

49
Mileage Issues

• Our team drives approximately 178,400 miles per
  year
• 6 agency vehicles Average 26,112 miles per year,
  per vehicle (156,672 miles)
• Staff average of 180-200 miles per month on
  personal vehicles
• This does not take into account commute to work
  for numerous staff

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What does this mean?

• We figured this out.
• Each PACT staff is driving the equivalent of 6
  trips across the United States, coast to coast,
  each year!!!
• (And we are not at full capacity!)

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Housing in Appalachia

• Very limited both in type and location of
  suitable housing.
• Assisted living facilities- poor mixture of
  elderly and young chronically ill- poorly
  designed and poorly regulated
• Mental health system operates very few housing
  alternatives directly
• Only one shelter in Wythe and Smyth counties
  combined- very limited.

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Housing statistics Smyth, Wythe

• 4 of homes lack adequate plumbing, compared to
  0.7 in Virginia and 0.6 nationally
• 3.3 of homes lack adequate kitchens, compared to
  0.6 in Virginia and 0.7 nationally
• 13.75 of families live below poverty levels
• Median income is 30,037, compared with the
  national median income of 41,994
• 7.6 of families receive public assistance

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Housing statistics-Smyth and Wythe

• In 1990-2004, 72 of all new single family homes
  in Wythe County were manufactured homes, double
  the national average
• The median value of a home in the service area is
  70,283, compared to the Virginia average of
  125,400, and the national average of 119,600
• Virtually no supported living independent housing
  for individuals with serious mental illness in
  Smyth, Wythe counties.

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State facilities

• Mental Retardation facilities- five in number
• A Behavioral Rehab Center for mandatory paroled
  sex offenders
• One facility for children and adolescents
• One facility for geriatrics only
• Ten mental health facilities

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Virginia state facilities

• In the mid 1980s, Virginia decided to rebuild
  several mental health state hospitals
• Northern Virginia Mental Health Institute-Fairfax
• Southern Virginia Mental Health
  Institute-Danville
• Southwestern Virginia Mental Health Institute-
  Marion

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SWVMHI and Mt. Rogers CSB Facts

• This is significant due to earlier mentioned
  fact very limited access to private
  hospitalization
• SWVMHI is utilized in the same capacity as
  private facilitiesacute admissions, short-term
  stays

• FY 05 statistics
• Located within our catchment area
• Total bed days utilized 52,086 (for all 6 CSBs)
• Mt. Rogers CSB 12,180
• Total of admissions 1,336
• Mt. Rogers CSB admissions 343

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Information technology

• Important in all areas of health care service
  delivery but will be particularly critical in
  rural, geographically dispersed areas.
• Communications technology
• Electronic records
• Use of Internet technologies/videoconferencing

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Telemental health/telepsychiatry

• Telemedicine is defined by the Institute of
  medicine as the use of electronic information
  and communications technology to provide and
  support health care when distance separates the
  participants

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Telepsychiatry project Appal-Link

• In 1994, a consortium of the far southwestern
  Regional community services boards and SWVMHI
  received a federal outreach grant to seek to
  provide mental health services using interactive
  video.
• 2/14/1995- first telepsychiatry project in
  Virginia and one of only six in the nation at
  that time

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Telepsychiatry project

• Psychiatrists from SWVMHI provided aftercare
  psychiatric services/med management from the
  Institute via videoconference connection to
  discharged consumers at distant rural community
  service board locations

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Appal-Link project

• From 19942001 one of the most active
  telepsychiatry programs in the nation
• At its peak, in 1998 363 consumers were provided
  nearly 1200 clinical contacts by
  videoconferencing
• Ultimately, project declined in utilization
  primarily due to turnover in staff/personnel/resou
  rces/coordination of efforts.

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E-cet

• Agency is moving toward electronic record system
• How will this affect PACT team?
• Documentation required for PACT unique to model
  makes this a challenge
• PACT program and e-CET are mutually exclusive at
  this time, but maybe this gap can be bridged

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PDA Pilot

• We are currently piloting PDAsDell Axim 50vs
• PDAs provide mobile access to calendar,
  directions, medication lists, email, contact
  information
• We are piloting a remote Access database for the
  PDA

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Assertive Community Treatment in Virginia
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Assertive Community Treatment in Virginia

• Virginia until the mid 1990s was behind the curve
  in terms of PACT implementation
• Total teams in Virginia- 15 PACT teams and 4 ICT
  teams

66
PACT Census Growth
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State Hospital Bed Day Savings
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Overall PACT Success Rates FY04

• Living in stable housing and having few or no
  hospitalizations 75
• Living in stable private housing and having few
  or no hospitalizations 59
• Living in stable private housing, with few or no
  hospitalizations and no arrests 57
• Living in stable private housing, having few or
  no hospitalizations, no arrests and some
  employment experience 13

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Recovery Model Virginia DMHMRSAS

• Our vision is of a consumer-driven system of
  services and supports that promotes
  self-determination, empowerment, recovery,
  resilience, health, and the highest possible
  level of consumer participation in all aspects of
  community life including work, school, family and
  other meaningful relationships.

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Commissioner James S. Reinhard, M.D.

• I am convinced that our system will not be
  restructured appropriately until we fully
  understand, fully embrace, and fully implement
  the concepts of self-determination, empowerment
  and recovery. These concepts are just as
  important for providers, administrators, family
  members and advocates as they are for the people
  who receive services. Everyone needs to feel that
  there is unquestionable hope for improvement and
  that they are empowered to make meaningful
  changes.

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Mt. Rogers Community Services Board

• http//www.mtrogerscsb.com/