With 717 square miles to call its own, Codington County, S.D., is home to a handful of lakes and 28,000 people. As in any rural county, government resources are stretched thin, which made the costly overcrowding at the county jail all the more frustrating.
Codington didn’t have an acute crime problem. Rather, the lack of mental health resources kept the same people cycling through county services: hospital emergency departments, social services and, eventually for many, the county jail.
What was happening in Codington County is typical of what is taking place in many rural counties -- and in urban ones as well. A significant portion of jail inmates are mentally ill. In Chicago’s Cook County, for instance, estimates run as high as 30 percent of jail inmates suffering from mental illness, much of it undiagnosed and untreated. But the problem is particularly acute in rural areas where access to mental health care -- be it clinics, primary care or specialty services -- is especially limited. “In a small, rural area you might not have access to a hospital, especially a hospital that has a behavioral health worker,” says Paul Mackie, president-elect of the National Rural Mental Health Association. “So law enforcement is the de facto response to mental health issues in rural areas.”
Even if there is access to care, there are cultural stigmas to mental illness that are particularly acute in rural areas and may keep people from seeking care. In a small community where everyone knows everyone, many don’t want their car seen in the parking lot of a behavioral health specialist.
Despite all of the obstacles, a movement toward changing the balance of access and care in rural regions is showing signs of life. It flickered in 2008 with a federal mental health parity law that required insurers to offer behavioral health services on par with primary care ones. But that rule has not been rigorously enforced. Now, spurred by aspects of the Affordable Care Act and by technology that can bring virtual care to those who need it, rural mental health experts see the new wave of innovation as a means of bringing much-needed help to counties. “We’ve just recently finished what I like to think of as chapter one in the story of mental health in rural America,” says Ron Manderscheid, executive director of the National Association of County Behavioral Health and Developmental Disability Directors, referring to the 2008 law. “I want to focus on chapter two, which is ever-evolving.”
To understand the evolving nature of chapter two, a little history of mental health disparity in general -- not just in rural areas -- is in order. It starts with a national reality: The majority of the American people don’t have access to a mental health-care specialist.
In 1963 when President John F. Kennedy signed the Community Mental Health Act, the effect of the law was to shift mental health care away from large, state-run mental institutions and place it in communities where the focus would be on prevention as well as treatment. But Congress never adequately funded the mental health services that were needed to support the law.
There was an assumption that existing services would take care of the people coming out of the hospitals. “But none of those people had insurance,” Manderscheid says. “Since the providers were mostly left on their own to be financially stable, it was never going to work.”
Meanwhile, mental health services were moving away from being a part of primary care and becoming more of a specialized service. Psychiatrists and psychologists tended to set up their practices where they trained, limiting access to therapeutic services to areas with universities. While access to mental health services was limited for a lot of the country, it was even more circumscribed in rural America.
That isn’t to say that there haven’t been rural-focused mental health community programs, especially in the past two decades. From 1999 to 2010, a behavioral health program called Sowing the Seeds of Hope served uninsured or underinsured farmers in the Midwest. From 2002 to 2004, the Iowa Rural Mental Health Initiative provided families with one-on-one mental health care that was culturally competent -- that is, the personnel providing the care were sensitive to rural needs.
But those programs came to an end, not because they weren’t effective, but for a reason that’s all too common. “Too often innovative and frontier model programs are lost after a grant expires or a reimbursement stream ends,” noted a 2006 report from the National Association of Rural Mental Health.
Ron Manderscheid is concerned that even with an increase of health workers in rural areas, it won't be enough to meet demand. (David Kidd)
In 2008, the Mental Health Parity Act promised that behavioral health services would now largely be covered by insurers. Even though state enforcement has had a checkered history, Manderscheid sees a bright side: “Mental health was able to get to the table in a way that had never been the case before.”
Today, in what is part of Manderscheid’s chapter two, money for programming is beginning to flow into mental health programs. The Obama administration has steadily been increasing the Substance Abuse and Mental Health Services Administration’s budget over the past couple of years. That agency provides much of the funding for mental health programs across the country, particularly for the opioid epidemic that has made significant incursions in rural areas.
In addition, the Affordable Care Act has been expanding the number of insured people, which improves access to care in places where services are available. At the same time, however, the mental health workforce has been shrinking and is distributed unevenly across the country. To meet that challenge, President Obama has pledged to increase the number of workers in the National Health Service Corps to 15,000 by 2020 from 9,200 in 2014. The corps sends health professionals to underserved areas for five years in exchange for repayment of education loans.
Even with more health workers in rural areas, Manderscheid fears there still won’t be enough to meet demand. Some rural areas are tackling the issue by upgrading resources already available to them. Most often that means training providers in primary care and community health clinics in the area. The emphasis on primary care is an overarching goal of the Affordable Care Act anyway, and many experts believe it to be the most efficient method of providing health services in rural areas. “The truth is, along the way, mental health has become over-medicalized,” says John Gale, a researcher at the Cutler Institute for Health and Social Policy at the University of Southern Maine. He notes that most of the general population will have to deal with behavioral health problems at some point in their lives. Progress in addressing their issues can be made by arming providers in the primary care setting with more and better mental health training.
This is an approach that Montana, which has the highest suicide rate in the country, is taking. The Billings Clinic, the largest health-care organization in the state, has been working with nurse practitioners to arm them with additional mental health training for the primary care setting. “As long as community health workers have more training, I think that’s a great substitute,” says Eric Arzubi, chair of the department of psychiatry at the Billings Clinic. “For mild to moderate anxiety or depression, that may be all you need. Then you can keep psychiatrists in the bigger towns for the more complex cases.”
The Billings Clinic has also teamed up with the Eastern Montana Telemedicine Network to expand care to the most remote reaches of the state. Telemedicine has proven to be a helpful tool. “In remote clinics, you might not even diagnose someone with a serious mental illness because you don’t know what to do with them,” Arzubi says. “Telemedicine can now help bridge that gap.”
The state allows patients and psychologists to establish care via telehealth as opposed to the rule in many states where patients have to establish care in-person first. That can be a roadblock for rural patients. While its program is still a work in progress, the American Telemedicine Association gave Montana a “B” for its clinical psychologist telemedicine practice.
Telemedicine has been around for about two decades, but in the past few years it has become more accepted as an effective alternative for those who don’t have in-person access to providers. Health-care experts are cautious not to label it as a total fix for rural health woes. Internet access in rural areas can be sparse, and some states have very stringent telehealth restrictions. “Telemedicine also assumes that there is a surplus of providers in urban areas with time on their hands,” Gale says. “That’s simply not the case.”
Back in Codington County, the jail population has eased down a bit in recent months, thanks in part to a program the county is using. Known as Stepping Up, it is an initiative that the National Association of Counties introduced in 2015.
Under Stepping Up, county officials are tasked with creating an action plan that spans departments and organizations. Codington County contracts with a community mental health center to go into the jail and identify people who might have a mental illness. From there, troubled inmates are placed in a case management program. It has been a breakthrough in Codington, where the only time an inmate could get mental help in the jail was when there was a crisis situation, according to Sarah Petersen, the county’s welfare director.
The program depends on cooperation between the welfare department and the justice and corrections systems. This care coordination requires officials from the affected departments to meet regularly in order to tackle best practices with low-risk jail populations. The idea is to prevent the ill inmates from reoffending and to find a way to allocate resources to serve those with more severe mental illnesses.
For counties that haven’t signed onto Stepping Up, Manderscheid says that it’s because there’s sometimes a lack of information sharing between county departments. “Many county behavioral health workers didn’t even know if their county jail was doing any sort of mental health screening,” he says.
Petersen, who signed the county up for the program, sees progress in the Codington County community since Stepping Up went into effect. “We have the exact same problems that any urban county has. We just have far fewer resources,” she says. “When you have your county sheriff and judge on board and working with you, it’s exciting. In a rural community, you have the benefits of just that: being a community.”