Rural ACT in Appalachia- Challenges and Opportunities: 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


Rural ACT in Appalachia: 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


Rural mental health challenges- National: Rural mental health challenges- National Guess when the following was stated in a report from the NIMH? “Of more than 16000 psychiatrists…only 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.”


Rural Mental Health Challenges- National: 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.”


Rural Mental Health Challenges- National: Rural Mental Health Challenges- National These quotations are from NIMH data from 1965 cited in “The Mental Health of Rural America” from NIMH, 1973.


General challenges in rural mental health: 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


Rural Mental Health Challenges- National: 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


Rural Mental Health Challenges: 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.


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


Recruitment obstacles: 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


NHSC study: 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


NHSC study: 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


Methods to enhance recruitment and retention in rural areas: 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


Retention- identifying characteristics: 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.


Retention- identifying characteristics: Retention- identifying characteristics Enjoys outdoor life and activities Wants to be involved in community affairs


Review of studies and published information regarding rural ACT delivery in U.S.: Review of studies and published information regarding rural ACT delivery in U.S.


What does NAMI say about rural ACT? : 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”


PACT in rural areas : 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


Urban/Rural Differences in ACT: Urban/Rural Differences in ACT


Differences between urban and rural ACT: 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


Study of Critical Ingredients of Assertive Community Treatment: 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


Study of Critical Ingredients in ACT- rural and urban: 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.


Providing assertive community treatment for SMI patients in a rural area: 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.


Technical differences in fidelity- rural/urban: 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


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


OSU Poll continued:: 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.”


Appalachia mental health facts:: 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


Mental health system in Virginia: 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


What are Community Service Boards?: 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


Virginia community mental health system: 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.


Far Southwestern Virginia planning region: 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


Our PACT Team serves the following counties:: 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 CSB’s catchment area—it also serves 5 other CSB’s in a 16 county region


Wythe County Statistics: 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


Wythe County Statistics…: 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


Smyth County Statistics: 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


Smyth County Statistics…: 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


Stigma in Appalachia: 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


Cultural sensitivity: 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


Cultural sensitivity: 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!


Cultural sensitivity: 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 example…outdoor activities: fishing, hunting, hiking, rural farming- team members need to understand these areas.


True Story:: True Story: We had a staff person find homes for a consumer’s abandoned chickens. She moved them herself….


Employment issues in Appalachia: 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


Distance and geography obstacles: 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.


Distance obstacles: 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.


Distance obstacles: 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


Mileage Issues: 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


What does this mean?: 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!)


Housing in Appalachia: 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.


Housing statistics: Smyth, Wythe: 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


Housing statistics-Smyth and Wythe: 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.


State facilities: 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


Virginia state facilities: 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


SWVMHI and Mt. Rogers CSB Facts: 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 facilities—acute admissions, short-term stays FY ’05 statistics Located within our catchment area Total bed days utilized: 52,086 (for all 6 CSB’s) Mt. Rogers CSB: 12,180 Total # of admissions: 1,336 Mt. Rogers CSB admissions: 343


Information technology: 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


Telemental health/telepsychiatry : 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”


Telepsychiatry project: Appal-Link: 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


Telepsychiatry project: 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


Appal-Link project: Appal-Link project From 1994—2001: 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/resources/coordination of efforts.


E-cet: 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


PDA Pilot: PDA Pilot We are currently piloting PDA’s—Dell Axim 50v’s PDA’s provide mobile access to calendar, directions, medication lists, email, contact information We are piloting a remote Access database for the PDA


Assertive Community Treatment in Virginia: Assertive Community Treatment in Virginia


Assertive Community Treatment in Virginia: 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


PACT Census Growth: PACT Census Growth


State Hospital Bed Day Savings: State Hospital Bed Day Savings


Overall PACT Success Rates FY04: 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%


Recovery Model: Virginia DMHMRSAS: 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.”


Commissioner James S. Reinhard, M.D.: 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.”


Mt. Rogers Community Services Board: Mt. Rogers Community Services Board http://www.mtrogerscsb.com/