Behavioral Health in Rural America:
Challenges and Opportunities

Principal authors:

John Gale, MS

Jaclyn Janis, BSN, RN, MPH
Andrew Coburn, PhD
Hanna Rochford, MPH

Prepared by the
RUPRI Health Panel:

Keith J. Mueller, PhD

Alana Knudson, PhD

Jennifer P. Lundblad, PhD, MBA
A. Clinton MacKinney, MD, MS
Timothy D. McBride, PhD

ee
DECEMBER 2019

 

see

RURAL POLICY RESEARCH INSTITUTE
Acknowledgements

This report was supported by the Leona M. and Harry B. Helmsley Charitable Trust grant
number 2017PG-RHC006.

We would like to thank Paula Weigel, PhD, and Karen Pearson, MLIS, MA, for their research
and contributions to this document. We also thank Sue Nardie for helpful editing of this
document.
Table of Contents

INTRODUCTION ...... ee eeeeeeseseseeeesceseesesonessesesseceacesessessnesaseeecasesessessesascesonssssaesseseaeseesessseseseasens 1
I THE PREVALENCE OF BEHAVIORAL HEALTH DISORDERS AND THE RURAL
CONTEXT 00. ceeeeescscesecscencsersscnccesevssencsaessesceseversneseeseassnenevesenssevscassnesevenenesessassneneresenenesee? 1
IIT ACCESS TO BEHAVIORAL HEALTH SERVICES ..0... ec cec ces csesseeetessesessessenssseeeeees 7
Il DEVELOPING COMPREHENSIVE BEHAVIORAL HEALTH SERVICE SYSTEMS.. 11
IV POLICY OPTIONS TO ADRESS BEHAVIORAL HEALTH DISORDERS. ........... ee 19
TV CONCLUSION 0... ceesseeccesctseseneseeecseeeeaceserseeseseaeeeeeasesesseesaeeaeeeesasesesecssateaeesesaneseseeseese 23
REFERENCES 0000. eecscesecsceneececencesesevscenesevsncssesesevssenecessessnesevesenesessesaseneresceneersesssenerersrenees 24
Appendix A: Community Engagement and Collaboration Models ............ es seseseseeseseeeeeeeee 38
Appendix B: Mental Health and Substance Use Prevention Models...............::cssccsssresereeeseeees 41
Appendix C: Mental Health and Substance Use Treatment Models ....0........ ec eeseseseesesereeeeere 45

Appendix D: Recovery Program Models ...........:.scssscsesesseesesseseeeneneecsceeeseneerenenetsaseseseneerenenees 49
LIST OF ABBREVIATIONS AND ACRONYMS
American Indian/Alaska Native: AI/AN
Behavioral Health: BH

Behavioral Health Disorders: BHDs
Community Health Worker: CHW
Community Recovery Specialist: CRS
Critical Access Hospital: CAH

Human Immunodeficiency Virus: HIV
Hepatitis C Virus: Hep C

Medication Assisted Treatment: MAT
Mental Health: MH

Mental Health Conditions: MHCs
Opioid Use Disorders: OUDs

Substance Use: SU

Substance Use Disorders: SUDs

Veteran's Administration: VA
INTRODUCTION
Mental health conditions (MHCs) and substance use disorders (SUDs), collectively

referred to here as behavioral health disorders (BHDs), affect individuals from all sectors of
society. However, the prevalence of certain diagnoses and unmet treatment needs are not equally
distributed, with place of residence being one factor associated with these differences.! Although
overall prevalence rates for BHDs are similar across urban and rural areas, their prevalence
varies within specific sub-populations and/or across rural areas." Moreover, the rural context has
proven challenging for ensuring the availability of and access to BHD prevention, diagnosis,
treatment, and recovery services in rural areas. Given the increased health burden that already
exists in rural areas compared to urban areas,! attention to the patterns of BHDs and needs

among rural people is essential to improving the health of rural populations and communities.

This paper provides an overview of behavioral health (BH) in rural America. The goal is
to help rural leaders and providers understand the issues related to rural mental health (MH) and
substance use (SU) and give them resources and tools to develop targeted strategies to address
the unique needs of their communities. In the first section, we discuss the prevalence of BHDs in
rural populations generally and among certain high-risk population groups (e.g., veterans,
children). We then review what is known about rural access to BH services, focusing on the
challenges of providing prevention, treatment, and recovery services in rural areas. The third
section focuses on promising program and policy strategies that have been tested in rural
communities targeting improvements in rural BH systems. We conclude with a discussion of

opportunities for policy and system changes to improve rural BH systems and outcomes.

I THE PREVALENCE OF BEHAVIORAL HEALTH DISORDERS AND THE
RURAL CONTEXT

The framework for this paper is illustrated in Figure 1, which delineates key dimensions
that define the challenges of rural BH that will be discussed. The inner circle of the figure shows
the core factors related to addressing BH issues in rural areas: the prevalence of BHDs, access
to care, and social factors affecting both access and prevalence. Relevant social factors include
rural-urban geography, high-risk populations, socioeconomic conditions in rural areas, and rural
culture(s). Access to BH services in rural areas are a function of what has been termed, the "4As

and an S": accessibility, availability, acceptability, affordability, and stigma.* As a matter of
principle, this paper assumes that rural residents should have access to the same continuum of
services and care as urban people do, including prevention, treatment, and recovery. Prevention
strategies focus on reducing the onset of BHDs, mitigating the exacerbation of existing
conditions, and minimizing related harms. Treatment focuses on providing care for individuals
with BHDs, many of whom have co-occurring MH and SU issues. Treatment includes screening
for BHDs in primary care settings, integrating BH services into medical care settings, and
collaboration across providers and service systems to address the complex needs of individuals
with BHDs. Recovery interventions offer individuals with BHDs a "second chance" to live
healthy and productive lives by managing their conditions through education, peer support,
vocational training, housing, and other opportunities to break the cycles and patterns of behavior
that exacerbate their conditions. This paper discusses the effects of long-standing rural shortages
of specialty BH services, the rural challenges of long travel distances to obtain treatment, and the
impact of stigma and cultural/societal attitudes on efforts to ensure access to the full range of BH

services in rural areas.

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Figure 1: The Context for Understanding Rural Mental Health and Substance Use

 
   
    
    
     
   
  

Affordability

Acceptability

Prevalence

  

Access

Substance
Use

Social Factors

     
    
 

Geography Socioeconomics

High-Risk
Populations

The Prevalence of Rural Mental Health Conditions

Although the overall prevalence of MHCs is similar across rural and urban areas,' the
prevalence of some conditions, such as suicidality and depression, differ." For example, the
difference in suicide rates among rural and urban residents is particularly alarming: in 2013-
2015, the suicide rate was 55 percent higher in rural areas (19.7 per 100,000 population) than in
large urban areas (12.7 per 100,000 population).® Rural areas also experienced higher increases
in suicide rates over time. From 2001-2015, the rural suicide rate increased by 27 percent, from
15.5 to 19.7 per 100,000. By contrast, the large urban rate increased by 13 percent during this
same period, from 11.2 to 12.7 per 100,000.° The reasons for higher rates of suicide in rural areas
include limited access to MH services, high levels of SU, greater availability of firearms, and
reduced access to timely health care and emergency medical services."® There are also variations
within some rural sub-populations and communities in the rates of depression, suicidality,
disease burden, and mental distress, including among women, low-income children, veterans,
non-Hispanic blacks, and American Indian/Alaska Natives (AI/ANs).

3|Page
The downstream effects of untreated MHCs burden rural residents and communities
disproportionately. For individuals, these consequences include exacerbation of the symptoms
and severity of their illnesses as well as increased risk for SUDs (related to self-medication),
chronic diseases, suicidality, family erosion, homelessness, employment instability,
arrest/incarceration, and victimization." '! Societal costs include lost productivity and increased
demand on limited health and social services; hospitals, clinics, schools, courts, jails, and social
services strain to serve the needs of individuals who would be better served through appropriate

and timely BH treatment.":'°

Rural Substance Use Disorders

Rates of SUDs (which often co-occur with MHCs) also differ by rural-urban residence.
Alcohol is the most commonly used substance nationally, with higher use rates among rural 12 to
20 year old (37.8 percent) than their small and large metro area peers (35.3 and 34.3 percent,
respectively).!? Rural young people are also more likely than their urban peers to engage in risky
alcohol-related behaviors, including binge drinking (consuming five or more drinks within two
hours for men and four or more for women) and driving under the influence of alcohol.!*!°

Although the prevalence of illicit drug use is similar across rural and urban areas,'* many

rural areas and populations have disproportionately suffered from a growth in the use of opioids,
heroin, prescription medications, and methamphetamines (meth).!>'°'7-'8 Rural youth have 35
percent greater odds of having misused prescription opioids in the past year than their urban
peers.'? Although meth availability has received less attention recently, it has been rising
nationally since 2013 and is at an all-time high.'®!° Reports describe a resurgence in meth use in
rural communities in states such as Minnesota, Missouri, Ohio, Oregon, Pennsylvania, Texas,
and Wisconsin.!87°3! SU experts are increasingly calling meth our "second" drug epidemic and

point to alarming trends in its co-occurring consumption by opioid users."??*?

The consequences of greater opioid use in rural areas include increases in opioid-related
overdose deaths and increased exposure to human immunodeficiency virus (HIV) and hepatitis C
virus (HCV).*°7 The overdose death rate in rural areas surpassed that in urban areas in 2015; it
had previously been similar to or lower than the urban rate. Between 1999 and 2015, the
overdose death rate in rural areas increased by 325 percent.'* The surge in overdose deaths

involving meth, often in combination with opioids and other drugs, is of growing concern.?"°?

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Many SU experts are concerned that the high rates of injection drug use, the relative lack of HIV
surveillance resources, and the resistance to needle exchange programs also pose an ongoing and

growing risk to many rural communities.*°"!

Socioeconomic and Other Factors Contributing to Rural Behavioral Health Needs

Rural-urban BH disparities are closely linked to the socioeconomic characteristics of
rural and urban populations and communities. Rural areas have a higher proportion of families
living below the poverty level, more unemployment, and a greater percentage of residents who
have public insurance or are uninsured than do urban areas.*"*? These characteristics are all risk
factors for BHDs. Rural individuals also experience a greater sense of stigma, a higher sense of
isolation and hopelessness, lower education rates, and higher rates of chronic illnesses.
Addressing BH disparities that are so deeply rooted in socioeconomic stressors is a significant

challenge for rural health systems."+*°

Rural Subpopulations at High Risk for Behavioral Health Conditions

Rural disparities often disproportionately impact at-risk subpopulations who have their
own unique health and cultural needs that impact their willingness and/or ability to obtain the

services and support they need.

Rural Women: Rural women as a whole and pregnant women in particular are at greater risk for
BH issues than those living in urban communities.** Rural women exhibit twice the rates of
depressive symptoms of women in urban areas and are more likely to experience a range of
MHCs."' A study of rural and urban pregnant women entering a hospital-based detoxification
program highlighted significant differences in SU by geographic residence. Compared to urban
women, rural women in this study were almost six times more likely to report injection drug use,
eight times more likely to report illicit opiate use, and about three times more likely to report use

of multiple illicit substances in the past 30 days.**

Children and adolescents: Children and young adults living in rural areas have higher rates of
MHCs. For example, children ages 2-8 years in rural areas have a higher prevalence of mental,
behavioral, or developmental disabilities (18.6 percent) than do those in urban areas (15.2
percent).'? Rates of serious mental illness, adolescent major depressive episodes, serious

psychological distress, and suicide are higher in rural areas than in urban.' Additionally, children

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from low-income rural families experience higher rates of depression and other MHCs.°° Rural
youth are also more likely to use alcohol and meth than urban youth, with higher levels of use
reported by those living in more rural areas.*! Rural youth are also more likely to exhibit high
risk behaviors such as driving under the influence of alcohol and other drugs.*! Among people
who reported past-year opioid use, individuals living in rural areas are more likely to be under
age 20 than those living in urban areas. High school students living on farms had higher rates of
alcohol, smokeless tobacco, inhalant, and other illicit drug use than those living in towns."
Students living on farms were also exposed to a greater number of risk factors associated with
SU than were those living in rural towns, including higher levels of poverty, economic
uncertainty, geographic and social isolation, community norms favorable towards use of alcohol

and other substances, and a lower perceived risk of using alcohol and drugs. ~*

Veterans: There are 4.7 million veterans living in rural areas; 58 percent of rural veterans are
enrolled in the Veteran's Administration's (VA's) health care system compared to 37 percent of
urban veterans.** Although rural veterans have lower rates of MH issues than urban veterans,
they report a lower quality of life and greater disease burden.*+*> Veterans experience more
MHCs, SUDs, and post-traumatic stress disorders than the general population,~° and rural
veterans are at increased risk for additional stress related to MHCs.°"*? The receipt of MH
services differs for rural veterans compared to urban. The barriers to accessing care by rural
veterans include long travel distances, fewer specialty care options and local providers, and

transportation issues (including loss of license and limited public transportation).

Minority, Ethnic, American Indian, and Alaska Native Populations: Racial and ethnic
minorities in rural areas also face additional health disparities.°! In addition to having a higher
prevalence of self-reported fair or poor health (compared to non-Hispanic whites), non-Hispanic
blacks and AI/ANSs report higher rates of frequent mental distress.°' Suicide and alcohol use
disorders are particularly high among AI/ANs.*!? Differences in health care access compound
these disparities: fewer non-Hispanic blacks and Hispanics have insurance compared to non-
Hispanic whites, and more non-Hispanic blacks, Hispanics, and AI/ANs report not being able to

.61

see a physician because of cost.°' Many individuals also face cultural barriers that discourage

them from seeking care, including the lack of culturally sensitive providers.

6|Page
Older Adults: Older adults are disproportionately represented in rural populations, with 19
percent of the population aged 65 or older compared to 15 percent in urban areas.™ Rural older
adults experience higher rates of depression, suicidality, and alcohol misuse than do their urban
peers.© Although older adults in rural areas suffer from many of the same BH access issues as
other rural residents, they also struggle with their own unique issues, including transportation
(for those who can no longer drive), social isolation, and dramatic shortages of geriatric BH

specialists.

Individuals with Co-occurring Conditions: As noted, MHCs and SUDs are frequently co-
occurring. Close to nine million adults are estimated to have a diagnosis of a co-occurring
disorder (COD) (requiring a diagnosis of at least one MHC and one SUD that can both be
diagnosed independently). Although current data on the differences in the prevalence of CODs
across rural and urban areas are limited, past studies found that rural residents were more likely
to meet the diagnostic criteria for CODs and less likely to seek treatment for their conditions.®"
Despite recognition of the need for integrated care for CODs, evidence suggests MH and SU
treatment services are still siloed in rural areas, with MH services commonly available through
primary care settings while SU treatment services are provided through specialty treatment

settings.

Il ACCESS TO BEHAVIORAL HEALTH SERVICES
The high burden of BH diagnoses in rural areas requires a comprehensive, accessible

health care infrastructure that is often not available to rural populations. As noted earlier and in
Figure 1, barriers to BH care in rural areas have been summarized as "4As and an S":
accessibility, availability, acceptability, affordability, and stigma.' The barriers affect rural

communities in the following ways:

Accessibility: As an overriding value, rural people should have the same access to BH services
(e.g., emergency response, early identification and screening, diagnosis, treatment, and recovery)
as those living in urban areas. Given long-standing shortages of specialty BH providers, limited
specialty services, and long travel distances, achieving this goal will require creative policy
responses, such as regionalizing systems of BH care, encouraging the integration of BH and

acute care medical services, expanding use of telehealth, and using team-based care.

7|Page
Availability: The development of rural BH systems of care that ensure the accessibility of care is
predicated on the availability of an appropriately trained BH workforce. A recent study projects
general shortages through 2025 of psychiatrists; clinical, counseling, and school psychologists;
MH and SU social workers; school counselors; and marriage and family therapists." Advocates,
experts, and policymakers have long bemoaned the scarcity of psychiatrists and psychologists
serving rural areas. A study of MH shortage areas showed that rurality and per capita income
were the best predictors of MH workforce shortages. Increasing rurality was associated with an
increasing unmet need for MH providers."° The reasons for these shortfalls are complex and
include chronic underfunding of the BH safety net, historically low salary levels, high case-
loads, low reimbursement rates, and limited reimbursement for supporting services such as care
coordination, community BH workers, and peer recovery workers.'' Coupled with the ongoing
maldistribution of BH professionals that favors urban areas, these shortages suggest the need for
strategies to maximize the use of scarce clinical resources by expanding the workforce,
developing team-based care, using community BH workers and care managers, and developing

innovative ways to deliver care.

Prescribing capabilities for MATs are also limited in rural areas: about 60 percent of rural
counties in 2017 did not have a physician who could prescribe buprenorphine for opioid use
disorders (OUDs)." Rural Federally Qualified Health Centers are less likely to express interest
in expanding the availability of buprenorphine treatment compared to those in urban locations."
The limited BH treatment workforce and capacity in rural areas has meant that rural primary care

providers have become the front line for addressing BH problems in rural communities.

In addition to the burden on primary care resources, BH workforce and capacity problems
deeply affect other rural service providers, including the criminal justice system. Thirty-five jail
administrators, clinicians, and staff in Minnesota, Montana, Texas, and Vermont reported that 20
to 55 percent of jailed individuals in their facilities have a MHC and that their facilities have

inadequate resources to address their populations' needs."

Acceptability: Care must be provided in settings that are most likely to be used by rural
residents. This concept of acceptability is closely linked to stigma: the relative lack of anonymity
in rural communities discourages individuals from seeking care in specialty BH settings, such as

community MH centers or SU treatment facilities. Hence, BH services that are integrated into

8|Page
primary and acute care services and facilities are critical. At the same time, acceptability calls for
the delivery of culturally sensitive services. Rural BH treatment settings frequently rely on BH
generalists and primary care providers. Rural shortages of BH providers and the lack of
specialization for specific conditions limit choice for individuals seeking care. This lack of
choice may discourage the use of available services by rural individuals with unique cultural
and/or clinical needs, such as AI/ANs, veterans, victims of domestic violence, and individuals

with eating disorders.

Affordability: The ability to afford the cost of BH care is a significant factor related to its use.
Rural residents are more likely to be uninsured or underinsured, less likely to be insured through
an employer, and more likely to receive Medicaid than are urban residents.' While Medicaid
expansion under the Affordable Care Act has been particularly important for rural areas, where
residents have lower incomes and less access to affordable employer-sponsored coverage,
approximately two-thirds of the rural uninsured population live in states that did not expand
Medicaid.*? Among those covered by private insurance, rural residents are more likely than
urban residents to have a high deductible health plan and less likely to have an associated health
savings account.'> Increased cost sharing has been associated with forgoing necessary BH
treatment, and higher costs of services can result in a lower likelihood of accessing MH
services.'° At the same time, some BH providers may not participate in provider panels for
commercial health plans, which shifts a greater burden to those using their services. Finally,
some BH providers, such as opioid treatment programs, have typically operated as "cash only"

services, which further limits access to those services in rural areas.*°

Stigma: Stigma is a complex problem that is difficult to overcome in rural communities.
External societal misconceptions, stereotypes, and prejudices perpetuated by misinformation and
the popular media about people with BHDs reinforce feelings of shame, failure, low self-esteem,
and other issues experienced by people suffering from these problems."""* These stereotypes
create special problems in rural communities, where the relative lack of anonymity is a well-

documented barrier to care-seeking.""*

Facilities
The substantial burden of BHDs in rural areas is compounded by long-standing, chronic

shortages of specialty BH treatment services. Rural residents have limited access to acute BH

9|Page
treatment facilities. When they do have access, they frequently must travel farther than urban

residents to access care and typically have less choice when selecting services and providers.

A national shortage of psychiatric inpatient services extends to rural and frontier areas,
most of which have no inpatient psychiatric beds.®° Of the 595 psychiatric hospitals operating in
the United States, only 73 (12 percent) are located in rural areas.®! Among 1,054 short-term acute
care hospitals that operate prospective payment-exempt psychiatric units, 232 (22 percent) are
located in rural areas.®! Additionally, only 95 of 1,350 Critical Access Hospitals (CAHs) operate
distinct part psychiatric units.*" Rural areas also lack detoxification services; 82 percent of rural
residents live in a county with no detoxification service provider.*? About 80 percent of SU
treatment facilities are located in urban areas, and the number of inpatient or residential
treatment beds per capita was 27.9 per 100,000 population in rural areas compared to 42.8 per

100,000 in urban areas.*4

Telehealth is increasingly discussed as a tool for addressing the lack of rural BH
treatment services® and is more likely to be used for MH purposes in rural community-based
health centers than in urban health centers.®° While telehealth provides a viable strategy for
increasing access to BH treatment services, its adoption and utilization rates remain very low.
There are numerous barriers to widespread telehealth adoption, including the lack of specialty
psychiatric and addiction consultation resources in urban areas, reimbursement challenges, the
lack of high-speed internet capacity and/or access, cross-state professional licensing issues, and

challenges incorporating telehealth in primary care, hospital, and specialty care settings.*°
Rural-Urban Differences in the Use of Behavioral Health Services

Research suggests that the patterns of BH service use differ in rural and urban areas. For
example, compared to urban residents, rural residents are more likely to be prescribed a
psychotherapeutic medication for MH treatment and less likely to use office-based visits."° Rural
residents with MHCs are more likely to receive pharmacotherapy and less likely to receive
psychotherapy for depression.*' Rural residents who report their MH as fair or poor are less
likely to use MH services than urban residents with the same characteristics.** People living in
rural areas with a past-year diagnosis of anxiety, mood, impulse control, and SU disorders were
significantly less likely than their urban counterparts to receive treatment; additional underserved

groups include older adults, racial-ethnic minorities, low income individuals, and uninsured

10|Page
individuals.®' Rural residents using substances in Arkansas, Kentucky, and Ohio with high levels
of recent and lifetime use greatly underutilized treatment services." As discussed earlier, rural
veterans were less likely than urban veterans to receive psychotherapy and had 70 percent lower
odds of receiving any MH treatment, such as outpatient services and prescription

medications.?!*?

Given the limited formal BH services in rural areas, rural consumers are most likely to
access services through primary care providers (including Rural Health Clinics and Federally
Qualified Health Centers); general acute care hospital emergency, inpatient, and outpatient
settings; schools; the criminal justice system; and faith-based organizations. Travel distance to
services limits rural access to all services, including BH treatment. The longer the travel distance
to treatment facilities, the less likely an individual is to complete SU treatment.** The integration
of BH and general medical care is one solution to increasing access, especially for the significant
percentage of lower acuity BH care that can be addressed in primary care settings. Although the
integration of BH and primary care has substantial support among providers and policymakers, it
is not without challenges, including provider supply (both primary care and specialty BH
providers), reimbursement rates and other payment barriers, practice patterns, and the
development of effective and efficient approaches to integration, among others."* Additionally,
many primary care providers are not equipped to treat SUDs, as evidenced by the urban-rural

disparity in buprenorphine prescribing capacity."

Iii DEVELOPING COMPREHENSIVE BEHAVIORAL HEALTH SERVICE
SYSTEMS

Addressing the BH needs of rural residents is a complex undertaking that must reflect the
unique challenges facing rural communities. As reflected in Figure 1, the factors influencing the
prevalence of BHDs in rural America are a multifaceted mix of personal and environmental
characteristics as well as risk and protective factors. The obstacles to developing appropriate
strategies to reduce the onset of BHDs and moderate their impact (prevention), providing
services to those individuals with BHDs (treatment), and helping them to lead productive and
satisfying lives (recovery) are significant, chronic, and difficult to overcome. At the same time,
there are long-standing access barriers that make it difficult for rural residents to obtain the
services they need. These factors complicate the development of programs targeting BHDs in

rural areas and call for a coordinated community response engaging health care providers, local

11|Page
government, schools, business leaders, residents, faith-based communities, individuals suffering
from BH disorders, law enforcement, and other stakeholders to implement multipronged

strategies focused on prevention, treatment, and recovery."
Community Engagement

Community engagement is a critical strategy for engaging these diverse stakeholders in a
coordinated set of interventions to target the social and economic disparities that contribute to
BHDs, address the stigma that discourages individuals from seeking treatment, and develop an
infrastructure to implement critical prevention, treatment, and recovery programs.*?>-*8
Evidence from community engagement and coalition-building programs suggests that broad-

based coalitions can significantly improve BH services in local communities.?>??'

Project Vision provides an example of a community engagement process implemented in

a rural Vermont community.!°!

Appendix A provides a link to information on Project Vision as
well as other community engagement models that have been implemented in rural communities,
including Project Lazarus, Communities That Care, Drug Free Community Coalitions, and
SAMHSA's (Substance Abuse and Mental Health Services Administration's) Tribal Training

and Technical Assistance Center.

Project Vision, Rutland, Vermont: Rutland, a community located in rural southwestern
Vermont, has struggled with an influx of heroin due to its location on a major drug trafficking
route.!°!° In response, key stakeholders implemented a community collaboration and
engagement program known as Project Vision (Viable Initiatives & Solutions through
Involvement of Neighborhoods) in late 2012 based on a drug market intervention model to
reduce the supply of heroin in the community. Project Vision engages stakeholders through three
subcommittees: Building Great Neighborhoods; Substance Abuse, Prevention, and Treatment;
and Crime and Safety.! These stakeholders represented diverse sectors of the community
including housing, social services, media, law enforcement, health care, businesses and

employers, schools, government, consumers, and community leaders.

The initiative was developed in response to a US Department of Justice, Bureau of
Justice Assistance, grant program announcement. Although not selected for funding, the
stakeholders implemented their proposed structure with the voluntary engagement and in-kind

contributions of the Rutland City Police Department, local government, and a number of

12|Page
nontraditional partners. Their guiding principle is that SU, domestic violence, child abuse, MH,
crime, and quality of life in the community are interconnected and require an integrated
response. Project Vision has engaged more than 100 local, state, and federal stakeholders in its
work. Its website reports reductions in drug-related crimes, increases in treatment options, and
development of recovery programs.'®! This effort exemplifies what can be accomplished if key

stakeholders come together to identify and address local needs.
Prevention

As previously discussed, BHDs negatively impact a person's day-to-day functioning,
cause emotional suffering, and contribute to a diminished quality of life.**!°° They also have
significant negative social and economic impacts on communities through lost productivity and
increased homelessness and unemployment, and they place increased demands on health care,
academic, criminal justice, and social service systems. Evidence-based prevention strategies
provide a cost-effective way of addressing and minimizing the individual and societal costs of

BHDs 94,105-111

The implementation of evidence-based prevention strategies is not without challenges,
including stigma experienced by individuals with at-risk characteristics, infrastructure
limitations, limited access to a trained prevention workforce, funding and resource constraints,
and difficulty adapting prevention strategies to the unique needs of rural communities and
populations.**!" Prevention strategies should address the prevention needs of high-risk
populations and the general population. To be effective, prevention strategies must target
modifiable risk and protective factors identified in the community and must be adapted to the

unique characteristics of each rural community. !07-1!2,113.94

The following are broad examples of successful prevention strategies that rural

communities may consider:'4

e Laws, regulations, and community education to reduce harmful alcohol use;

e Laws and regulations to reduce access to lethal means of suicide;

e School-based social and emotional learning programs to prevent the onset of BHDs and
promote BH in children and adolescents;

e Community-based parenting programs, particularly during infancy and early childhood;

13|Page
e Training programs to help gatekeepers identify people with mental illness;
e Broad-based community-based coalitions; and/or

e Needle/syringe exchange programs.

As discussed below, the Fostering Futures project, implemented in rural areas of
Wisconsin, is an example of a prevention strategy.'!° Appendix B provides a link to information
on the Fostering Futures Projects as well as other innovative BH prevention models that have
been successfully implemented in rural communities, such as the 4P's Plus Pregnancy Support

Project, Madison Outreach and Services through Telehealth, and Keepin' it REAL Rural.

Fostering Futures Project: Tne Menominee Indian School District's and Menominee Tribal
Clinic's participation in Wisconsin's statewide Fostering Futures project focuses on building
resilience and mitigating the negative effects of adverse childhood experiences among tribal
children.!!> The clinic's staff and trauma-informed care coordinator facilitate trainings and other
strategies through the schools and community organizations. Children have access to a trauma
coach, safe zones/peace rooms, medication, and mood check-ins through the schools. General
education campaigns focus on culturally relevant reproductive health and support services; the
promotion of sobriety, positive parenting, strength-based language, and kindness; and trauma
issues for parents and families. Since the onset of the project, there has been an increase in BH
service utilization as well as decreases in school suspensions and expulsions, SU rates, and teen
births. There have also been increases in staff understanding of trauma issues, student health,

student resiliency levels, and graduation rates.
Treatment

Rural systems of BH care should provide rural residents with coordinated, evidence-
based services appropriate for their conditions and personal circumstances. Given the previously
discussed challenges facing rural systems of care, key strategies to improve access to BH
services include the integration of specialty BH and primary/general medical care services, the
development of regionalized systems of care through health systems or "hub-and-spoke" models,
the use of telehealth and other technologies to connect rural patients with specialty providers, or

some combination of the above.

The most common model of the integration of BH and primary/general medical care

services puts specialty MH providers, such as social workers, psychologists, or professional

14|Page
counselors, into primary care and acute care settings to address less complex MHCs such as
depression and anxiety. The models used to integrate these services have ranged from referral
agreements, shared space arrangements, contractual agreements with independent MH providers,
and employment arrangements in which the MH staff function as full team members employed
by the practice.!!®!"° Under these models of integration, primary care providers screen for BHDs
and prescribe necessary psychotropic medications, while the counselors and psychologists
provide individual counseling and psychotherapy. In more advanced integrated models, specialty
MH providers consult with the medical providers and staff on BH issues and remain available to
accept a "warm hand off" in which the medical providers introduce patients to specialty BH

providers during the course of their visits to facilitate patient engagement.

A more recent trend has involved the integration of MAT into primary/general medical
care settings.'*!,"* Barriers to the integration of BH and primary care/general medical services
include reimbursement issues, workforce shortages, stigma, and differences in treatment
cultures.!19:123.124 SAMHSA and the Health Resources and Services Administration have
collaborated on the Center for Integrated Health Solutions that provides resources and tools to

encourage the adoption of integrated medical and BH services.'""

Example of a Rural Integrated Service: Cherokee Health Systems serves rural communities in
Tennessee by embedding BH consultants, typically psychologists or clinical social workers, in
primary care teams.!"*-!7° The primary care providers screen all patients for BHDs and co-
manage those who screen positive with the BH consultants. Staff also have access to consultation
with a psychiatrist, often via telephone or telehealth. BH consultants serve as members of the
clinical care team. Coordination of care is facilitated through a shared electronic health record.
Cherokee has expanded its integrated service to include MAT and SU treatment. Cherokee's
integrated model has the following features: (1) shared care delivery functions across the entire
team, (2) guaranteed access to BH expertise throughout their system of care, (3) enhanced
communication and care coordination, (4) health management support, and (5) supported patient

engagement.

Regionalization of services supports the delivery of services through linkages between
local rural providers (who provide BH services for less complex patients) and specialty BH

providers (who provide consultative support and access to more intensive specialty services).

15|Page
The goal of regionalization is to build a system of care that is sustainable at each level of
delivery and avoid unnecessary competition for specialty services that require a larger population
base to be viable. Examples of regionalized models of behavioral care include larger
health/hospital systems with inpatient and other specialty BH services that provide consultative
support and access opportunities for patients served by their rural partners. An example of this

type of system is the Avera Health system serving states in the upper Midwest.!?'

A more recent example is the hub-and-spoke model used to support the provision of
medication-assisted treatment for OUDs in states such as Vermont, California, Washington State,
and West Virginia.'2°-!°? In the hub-and-spoke model, the spokes are the local service providers
waivered to prescribe buprenorphine for OUDs and the hubs are larger specialty providers
offering consultative support to the spokes as well as a referral source for patients with more

complex needs than can be addressed by the spoke providers.

Hub-and-Spoke Network Treatment Examples: Washington State and West Virginia have
implemented hub-and-spoke networks for MAT delivery to support treatment access for rural
persons with OUD. The program in West Virginia has established five hubs providing
consultative support to 13 spoke facilities. The treatment model is multidisciplinary and
combines group-based medication management with psychosocial therapy. The hubs lead
training and mentoring for teams providing MAT treatment at the 13 spokes.'" The hubs also
provide access to treatment for more complex patients. Washington State's program aids in
making opioid addiction medications more available by creating a "help network" in which the
hub facilities' staff provide consultative and specialty care services to support the spokes that
provide direct services, including MAT.'*!!3 The spokes may be housed within tribal medical

facilities, therapists' offices, primary care practices, drug courts, or emergency departments.

Tele-behavioral health provides a third option for expanding access to BH care in rural areas as
it allows effective care management, provides expanded access to services, and facilitates the
integration of primary/general medical and BH services.!**"!** Although the technology is readily
available, the implementation of tele-behavioral health services is complex and requires
providers to think differently about how they organize and deliver care. Barriers to the expanded
use of tele-behavioral health include coverage and reimbursement policies, cross-state

professional licensure issues, practice regulations, inadequate broadband access, workforce

16|Page
supply, issues related to the exchange and security of patient information, changes to
professional training and care delivery models, and hype (enthusiasm for the potential for
telehealth that exceeds practice realities and challenges).'39!*! Telehealth can be used to improve
access to and the delivery of the following BH services: evaluation and diagnosis; case
consultation; treatment; medication management; continuing care; and provider education.
Telehealth can be used to provide direct patient care services as well as care management, and
can facilitate peer recovery services. Despite the challenges of implementing tele-behavioral
health services, many successful programs are serving rural communities, including the
Wyoming Trauma Telehealth Treatment Clinic, the Madison Outreach and Services through
Telehealth (MOST) Network, and the Emergency Department Telepsychiatry Consultation

Program. !4?

Example of Tele-behavioral Health Services: The Wyoming Trauma Telehealth Treatment
Clinic serves survivors of domestic violence and sexual assault using telehealth to connect them
with psychology doctoral students.'*? The services are a partnership of the University of
Wyoming Psychology Department and the University of Wyoming Center for Rural Health
Research and Education funded by the State of Wyoming. Doctoral students who have been
trained in trauma intervention theory and techniques provide services under the supervision of
doctoral-level psychologists. The students gain valuable experience, while the patients receive

needed therapy at no cost.

Appendix C provides a link to information on these and other models of integrated care,
regionalized systems of care, and tele-behavioral health services that have been successfully
implemented in rural communities. Appendix C also provides links to resources and tools to

assist rural systems of care in adapting these models to their own unique needs.
Recovery

Recovery services are designed to help individuals suffering from MHCs or SUDs lead
healthy, productive, and fulfilling lives.!+!*° Both MHCs and SUDs are chronic, long-term
health conditions. Recovery for those suffering from either MHCs or SUDs is most appropriately
viewed as a process rather than an end state. Given that SUDs are chronic, relapsing conditions,
the definition of recovery for individuals with SUDs includes the ability to maintain a sober,

substance-free lifestyle. The following characteristics support recovery: good relationships,

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financial security, satisfying work, personal growth, the right living environment, developing
one's own cultural or spiritual perspectives, and developing resilience to possible adversity or

stress in the future.!*°

Support for recovery can be provided through self-help groups (e.g., Alcoholics
Anonymous, Recovery, Inc., Schizophrenics Anonymous), peer support programs, recovery
support services, Recovery Oriented Systems of Care (ROSC), and the development of recovery
centers. '47!*9 Recovery programs for individuals with MHCs can include club or social house
models and peer recovery programs. Regardless of an individual's condition, recovery in a rural
community can be more difficult given the stigma and relative lack of anonymity experienced by
those with MHCs and SUDs. That being said, recovery services are essential to allowing people
to get a "second chance" to reclaim their lives. Developing a supportive environment for
recovery begins with community education programs on the realities of BH and reinforcing the

understanding that individuals with MHCs and SUDs can recover and lead productive lives.

The Personal Helpers and Mentors (PHaMs) service, a nonclinical, community-based
Australian Government initiative designed to increase opportunities for recovery for people
affected by mental illness, is one example of an MH recovery program that has been successfully
implemented in rural areas.'*°-'>! The Vermont Recovery Network offers similar services for
substance users across the state of Vermont.*"'*? Peer recovery and support programs provide
another recovery model that is applicable to rural communities. These programs provide the
support of peer recovery coaches, individuals who have experienced issues with MHCs and/or
SUDs and are in recovery themselves, to support others struggling with these disorders.'*? Peer
recovery coaches are similar to community health workers (CHWs) with the exception of their
lived experience with their own BH issues. Peer recovery coaches can help clients complete
paperwork, provide transportation, and find community resources. Examples of a peer recovery
program implemented in rural communities include the Centra Wellness Network, the
Marquette Peer Recovery Drop-In Center,!*> and START - Sobriety Treatment and Recovery
Teams.'**!°7 Recovery services are important throughout the process of grappling with MHCs
and SUDs, including the contemplation phase (when individuals are deciding to seek treatment;
prior to, during, and following active treatment; and in later recovery stages.!°' Examples of

recovery models implemented in rural communities are described in Appendix D.

18|Page
Example of Peer Recovery Services: The Marquette Peer Recovery Drop-In Center provides
peer recovery support services, including peer mentoring and coaching, resource connecting,
facilitating recovery groups, and building a safe community for members. The Drop-In Center
serves multiple rural counties in Michigan's Upper Peninsula!*° by providing an environment
where people from the community who are living in recovery can work with people who are
currently receiving treatment for an SUD. These peer recovery specialists serve as a resource and
support system for others who are currently in treatment and who are living in recovery. They
also provide support to family members and others affected by SUDs. The Drop-In Center
provides peer mentoring or coaching, connection to recovery resources, recovery group
facilitation, and help making new friends and building healthy social networks through events

and pro-social activities.

IV POLICY OPTIONS TO ADRESS BEHAVIORAL HEALTH DISORDERS
As noted throughout this paper, the rural context has proven challenging for ensuring

rural access to comprehensive prevention, diagnosis, treatment, and long-term management
services for BH disorders. Yet, the opioid epidemic has brought a critical federal, state, and local
policy focus to the problem of SUDs with important advances in the availability and delivery of
SUD services across the prevention, treatment, and recovery continuum. The opioid epidemic
has also highlighted long-standing deficiencies in our rural BH system.

Increased policy attention, combined with the significant mobilization of local,
community resources (with needed federal and state policy and financial support), have produced
a number of promising strategies and approaches to expanding and improving services in rural
communities. As important as these program models are, success requires a comprehensive
strategy that engages citizens, consumers, health care providers, and community leaders, among
others, to design or choose the strategy that fits the community and to marshal available
resources. Federal and state policies and resources are critical to support the implementation of
these comprehensive strategies, especially in vulnerable rural communities.

This section discusses four broad areas where focused policies are needed to develop a
more comprehensive approach to combatting SUDs and improving MH in rural communities:

e Promote rural community engagement to support the design and implementation of local

and regional strategies;

19|Page
e Support the development of comprehensive local and regional MH and SU services;
e Reform regulatory and payment policies to expand coverage for BHDs and encourage the
development of comprehensive systems of care; and

e Expand the BH workforce and create incentives for rural practice. 81°!

The interrelationship of these priority areas is critical. For example, community
engagement is central to achieving the desired outcome of ensuring local and regional access to
prevention, treatment, and recovery services. But without a clear plan or strategy for building
regional systems of care, it is unlikely that most rural communities, however engaged they may
be, can be successful. Likewise, federal and state policies, combined with philanthropic resource
commitments, are needed to enable communities, providers, and others to build a better system
of care. And finally, the availability of an adequate workforce with the diverse skills needed to

support a comprehensive care system is essential.
Promote Rural Community Engagement

Communities provide the foundation to leverage local, state, and federal resources to
implement comprehensive strategies to reduce the onset and acuity of BHDs (prevention),
expand access to services to individuals with BHDs (treatment), and support individuals with
BHDs to live healthy and productive lives (recovery). Underlying each of these areas of activity
is the need to reinforce the understanding that BHDs are chronic conditions that can be
successfully managed and to reduce pervasive levels of stigma that marginalize individuals with
BHDs, discourage them from seeking treatment, and prevent them from reclaiming their lives.
Policy strategies to promote rural community engagement to address BH issues include the

following:

e Leverage existing and new federal and state incentives, technical assistance, and funding
to encourage collaborative community engagement to address social and economic
drivers of BHDs; combat stigma; undertake education programs; engage stakeholders;
rationalize use of scarce resources; develop prevention, treatment, and recovery services;

and connect to regional systems of care.

20|Page
Use state and local resources and organizations to disseminate information on successful
rural prevention, treatment, and recovery strategies and support the adaptation of these

programs to fit unique local needs.

Use state and local resources and organizations to support rural community education
aimed at reducing stigma, promoting awareness that BHDs are preventable and treatable,

and informing residents about existing BH resources.

Help local communities and regions explore alternative sources of support for local,
regional, and state efforts to improve BH services systems, including philanthropic and
foundation funding, hospital-community benefit resources, in-kind contributions, sharing
of resources, and the use of settlement funds that may result from suits against the

pharmaceutical industry.

Support Development of Local and Regional Behavioral Health Services

Demographic and economic characteristics of rural communities create barriers to the

development of sustainable specialty BH services. Creating a regional BH care network that

links integrated, local services with regional, specialty providers that can support local providers

and handle more complex cases represents one strategy for addressing these barriers. Examples

include the hub-and-spoke models used by Vermont, California, West Virginia, and other states

to support the use of medication-assisted treatment for OUDs; Colorado's statewide strategic

plan for the primary prevention of SU; and San Mateo County's Primary Prevention Framework

for SU and MH.!®!® Strategies to support the development of regional systems of care include

the following:

Require local and state BH agencies and organizations to assess local and regional gaps
in services, unmet needs, the adequacy of service systems, and available resources to
expand access to services.

Encourage and provide technical assistance to local, county, and state BH agencies to

plan and develop regional prevention, treatment, and recovery services.

Use existing federal and state programs to create incentives to develop regional systems

of BH care that minimize unproductive competition, conserve scarce resources, provide

21|Page
access to specialty services, support local service delivery, and develop a financially

sustainable service system.

e Encourage states to invest in regional evidence-based prevention, treatment, harm

reduction, and recovery programs.
Reform Behavioral Health Regulatory and Payment Policies

Current regulatory and payment policies reflect the view of MH and SU as separate,
specialty systems of care and fail to recognize that many BHDs are interrelated and can be
effectively treated in primary care and general medical settings. Current regulatory and payment
policies reflect this specialty bias and impede development of more rational and efficient BH
care systems. To better serve rural areas, regulatory and payment policy reform is needed to

expand coverage for BHDs and support innovative delivery system models by

e Encouraging the integration of BH and primary care/general medical services.

e Promoting the delivery of BH services by Federally Qualified Health Centers, Rural
Health Clinics, school-based clinics, and rural hospitals.

e Expanding the use of telehealth technology to facilitate access to treatment and recovery
services.

e Modernizing telehealth policies to expand the use of technology to improve prevention,
enhance access to care, and promote recovery.

e Funding the use of peer recovery workers.

e Supporting access to affordable health care coverage by improving the functioning of

state health insurance markets, reducing regulatory burdens, and expanding Medicaid.
Expand the Behavioral Health Workforce and Create Incentives for Rural Practice

Creative solutions are needed to address long-standing BH workforce shortages and the
maldistribution of specialty BH providers that favors urban communities. In addition, new
payment policies should support new types of BH providers such as peer support counselors and
recovery coaches. Traditional workforce recruitment and retention strategies remain important,
but they have been insufficient on their own to ameliorate these chronic rural workforce
challenges. Policy options to expand the rural BH workforce and incentivize rural practice

include the following:

22|Page
e Explore federal and state reimbursement and scope-of-practice regulations to expand the
pool of reimbursable providers.

e Revise Medicare reimbursement policies to cover an expanded array of behavioral
providers such as master's-trained counselors, marriage and family therapists, and peer
support counselors.

e Encourage the use of peer recovery and CHWs by creating training programs and
developing payment policies to encourage their integration into BH teams.

e Develop and fund more effective rural recruitment and pipeline programs.

e Expand scholarship and loan repayment options to encourage rural BH practice.

e Use technology to support supervision and collaboration among rural providers to reduce

isolation and burnout.

Vv CONCLUSION
In previous papers the RUPRI Health Panel has discussed the core elements of a high-

performing rural health system. BH care is a core element of this vision, especially in light of
key rural disparities in the prevalence of these conditions and the problems of availability and
access to preventive, treatment, and recovery services discussed here. As we have noted,
variations in the prevalence of specific BH conditions or SU in specific rural sub-populations
and/or communities deserve particular attention. The growing problem and concern over the
implications of rising injection drug use in rural areas and HIV and Hepatitis C rates 1n rural
populations illustrate this point. Likewise, the resurgence of meth use speaks to the importance

of a more comprehensive approach to SUDs in rural areas.

The shortcomings of the rural BH system are not new and have been discussed for many
years. It has taken the opioid epidemic, however, to draw attention to these limitations.
Mobilizing and organizing the limited health, SU, and MH capacity in rural areas has been
challenging, notwithstanding substantial new federal- and state-funded efforts devoted to the
problem. Nevertheless, states and communities are learning a lot about how to build effective
service systems to address the rural SUD epidemic. Federal and state governments, with the
collaboration of philanthropy and other private sector organizations, now have the opportunity to

build on this knowledge to support the development of more comprehensive BH systems of care.

23|Page
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