H Iovatios i Rural Health System Developmet Maie s Behavioral Health Services Amada Burgess, MPPM Adrew Cobur, PhD Rapid chages i health care paymet ad delivery systems are drivig health care providers, payers, ad other stakeholders to cosider how the curret delivery system might evolve. This series of briefs profiles iovative rural health system trasformatio models ad strategies from Maie ad other parts of the Uited States. The aim is to assist rural commuities ad regios to proactively evisio ad develop strategies for trasformig rural health i the state. I preparig these briefs we cosulted experts, iterviewed key iformats, ad reviewed the professioal ad research literature to fid robust ad iovative models ad strategies that could be replicated i rural Maie. PROMISING STRATEGIES: Care Coordiatio ad Itegratio... 3 Telemetal Health Services... 6 Parterships with Law Eforcemet... 8 INTRODUCTION NOVEMBER 2016 Muskie School of Public Service Maie Rural Health Research Ceter This brief presets iovative approaches to the provisio of treatmet for metal ad/or substace use disorders which are referred to joitly i this brief as behavioral health disorders i rural areas. The Natioal Rural Health Associatio suggests implemetig multiproged programmatic ad policy approaches to icreasig access to behavioral health services that address the four As availability (workforce shortages), accessibility (kowledge of available services ad travel barriers), affordability (cost or services ad availability of health isurace), ad acceptability (stigma ad privacy cocers). 1 The four As highlight the primary barriers to accessig behavioral health services i a rural area, ad the examples icluded i this brief speak to these challeges. Muskie School of Public Service
Although the prevalece of metal disorders is similar i rural ad urba areas at the atioal level, 2 the experiece of livig with metal illess is differet i rural versus urba areas as evideced by higher suicide rates, 3 lower rates of use of office-based metal health services, 4 ad higher rates of prescriptio use i rural areas. 4,5 Both rural ad urba commuities are also strugglig to address the opioid abuse crisis. A atioal compariso of opioid abuse i rural versus urba areas foud that although prevalece of past year use of o-medical pai reliever ad heroi was slightly lower amog rural residets, the magitude of the differece was small. 6 Rural heroi users were less likely tha urba heroi users to have received treatmet for heroi use ad rural opioid users were more likely to be uisured, have poor health status, low educatioal attaimet, ad to have bee ivolved with law eforcemet compared with urba opioid users. 6 Behavioral Health i Maie The percetages of Maie residets who self-report livig with various behavioral health disorders 1 are similar to atioal averages. 7 However, the percetage of Maie adolescets aged 12-17 who report illicit drug use is higher tha the atioal average (11.1 percet vs. 9.2 percet). 7 Maie is oe of 14 states that had a statistically sigificat icrease i drug overdose deaths betwee 2013-2014 with the third largest percet icrease i deaths (27.3 percet) behid North Dakota ad New Hampshire. 8 The tred cotiued betwee 2014-2015, whe drug-iduced deaths i Maie icreased 31 percet from 208 to 272, with 58 percet of the deaths due to heroi or fetayl. 9 Although drug-iduced death rates are highest i urba Cumberlad, York, Adroscoggi, Keebec, ad Peobscot couties, drug-iduced deaths took place i every Maie couty i 2015. 9 Access to Care i Maie Despite the state s average to slightly above average rates of provisio of behavioral health services compared with the atio, accessig behavioral health services i Maie s rural commuities is hidered by shortages of behavioral health providers ad the scarcity of metal health ad substace use disorder treatmet facilities. Overall, Maie fares slightly better tha the atio overall regardig provisio of treatmet to idividuals with behavioral health disorders. The state has a higher percetage of adolescets with a major depressive episode receivig treatmet (47.7 percet) ad a higher percetage of adults with ay metal illess receivig treatmet (52.6 percet) compared with atioal averages for these measures. 7 Regardig substace use disorders, the percetages of Maiers with alcohol depedece ad illicit drug depedece receivig treatmet i 2009-2013 (8.6 percet ad 19 percet, respectively) are similar to atioal averages over the same time period. 7 Maie s behavioral health workforce is cocetrated i the state s urba areas. Although 41 percet of Maie residets live i urba Cumberlad, Peobscot, ad Adroscoggi couties, these couties are home to 70 percet of health care social workers ad 69 percet of metal health ad substace abuse social workers. 10 Federally desigated metal health professioal shortage areas are located i sectios of rural Aroostook, Piscataquis, Washigto, Somerset, ad Oxford couties, as well as urba Peobscot ad Cumberlad couties which speaks to the cocetratio of the behavioral health workforce i the cities of Bagor ad Portlad withi those couties. 11 Maie has fewer cliical, couselig, ad school psychologists per capita tha the atio overall ad early 70 percet of those psychologists are 50 or older. 10 1 Specifically, serious metal illess, illicit drug use, bige alcohol depedece, ad heavy alcohol use amog adults, as well as adolescets reportig bige alcohol use, a past year major depressive episode, ad thoughts of suicide. Maie s Behavioral Health Services 2
Maie s Behavioral Health Homes, a care coordiatio iitiative promoted by the Departmet of Health ad Huma Services, are located predomiatly i urba areas. 12 Additioally, Washigto ad Kox couties are the oly rural couties i the state with a methadoe cliic. 12 PROMISING STRATEGIES Care Coordiatio ad Itegratio What is care coordiatio ad itegratio? The icreased mortality ad morbidity amog idividuals with serious metal illess is largely due to prevetable, chroic coditios icludig diabetes, cardiovascular disease, ad ifectious disease. 13 Amog idividuals with serious metal illess, treatmet of cooccurrig health issues ofte happes i iappropriate ad expesive settigs like emergecy departmets rather tha through prevetive screeigs ad routie medical care. 14 The itegratio of physical ad behavioral health care ca take differet forms. Methods of itegratio iclude: uiversal screeig (primary health care providers scree for behavioral health eeds ad vice versa), the use of avigators to help those with behavioral health issues access medical care ad advocate for their eeds, co-locatio of behavioral ad physical health providers, ad care coordiatio iitiatives such as Health Homes a iitiative authorized by the Affordable Care Act that supports itegratio of primary, acute, behavioral health, ad log-term services ad supports for idividuals with chroic coditios who are covered by Medicaid. KEY FACT about care coordiatio ad itegratio i Maie: MaieCare, the state s Medicaid program, has udertake a behavioral health homes iitiative. A Behavioral Health Home Orgaizatio is a licesed commuity metal health provider that parters with oe or more medical Health Home practices to coordiate the physical ad behavioral health care of eligible adults ad childre. Both the metal ad physical health provider receive a per member, per moth paymet for Health Home services provided to erolled members. PROMISING STRATEGIES AND MODELS EXAMPLE: SBIRT (Screeig, Brief Itervetio, ad Referral to Treatmet) is a evidece-based, comprehesive, public health approach to the delivery of early itervetio ad treatmet services for idividuals with a substace use disorder ad those at-risk of developig a substace use disorder. The first compoet of SBIRT screeig etails a health care professioal screeig a patiet for risky substace use behaviors usig a stadardized screeig tool. Screeig ca occur i ay health care settig icludig primary care practices, studet health ceters, ad emergecy departmets. Stadardized screeig tools are used durig the first phase of SBIRT. The secod compoet of SBIRT is a brief itervetio a short coversatio betwee the health care provider ad patiet about ay risky behaviors beig exhibited by the patiet. The third compoet is a referral to appropriate treatmet for those i eed of additioal services. Maie s Behavioral Health Services 3
All Health Homes i Maie are required to have substace abuse screeig icorporated ito their practice but SBIRT is ot widely or cosistetly used i the health care system overall. Maie Quality Couts has developed a robust collectio of SBIRT resources ad tools for practices iterested i icorporatig SBIRT ito their work. I 2012, the Vermot Departmet of Health received a grat from the federal Substace Abuse ad Metal Health Services Admiistratio to trai practitioers i SBIRT. The Departmet traied 325 practitioers ad i the first two ad a half years of the program 34,000 Vermoters were screeed for substace misuse i a medical settig. Although grat fudig may be ecessary to support robust SBIRT traiig, SBIRT services are reimbursed by Medicare ad Maiecare (with a few restrictios o provider type ad locatio). EXAMPLE: Behavioral Health Services of the Sheadoah Valley Medical System (BHS) is a West Virgiia-based behavioral health program co-located withi a Federally Qualified Health Ceter (FQHC) that provides primary care services. Through co-locatig primary ad behavioral health care services BHS seeks to ehace care coordiatio ad reduce the stigma of metal health treatmet.. All patiets that receive primary care i the FQHC are screeed for behavioral health issues aually, ad all ew mothers receive post-partum screeig. Ay patiet that receives a score above the cut off o a screeig tool receives a o-the-spot behavioral health cosultatio with a member of the BHS staff. If the patiet eeds further treatmet the provider registers the patiet with BHS ad they are see for follow up i the same buildig. The providers i the FQHC ad BHS commuicate about patiets durig twice-weekly team meetigs ad through otes i patiet electroic medical records. Roughly half of patiets that are flagged for behavioral health cosultatio by their provider become regular BHS patiets. EXAMPLE: I 2013, the Vermot Departmet of Health s Divisio of Alcohol ad Drug Abuse Programs ad the Departmet of Vermot Health Access formally lauched the Care Alliace for Opiate Addictio (Hub ad Spoke) Iitiative a effort to itegrate Health Home services ad medicatio-assisted treatmet (MAT) for idividuals i Vermot s Medicaid populatio livig with opioid use disorder. The Hub ad Spoke model cosists of five Hubs across the state regioal specialty addictio treatmet ceters regulated as Opioid Treatmet Programs (OTPs) ad operated by commuity-based behavioral health agecies. The Hubs treat all participats i the iitiative receivig methadoe ad the cliically complex participats receivig bupreorphie. Previously, OTPs were exclusively methadoe providers, but uder the iitiative OTPs desigated at Hubs are also allowed to prescribe bupreorphie. I additio to MAT services, Hubs provide the six Health Home services (care maagemet, care coordiatio, health promotio, trasitioal care/follow up, patiet ad family support, ad referral to commuity ad social support services). Spokes are teams of health care professioals i practices that are led by physicias who prescribe bupreorphie ad are regulated as Office-Based Opioid Treatmet Programs (OBOT). Just as with Hubs, Spokes have health care professioals that provide Home Health services embedded ito their practice. Patiets receive treatmet at Hubs or Spokes depedig o their method of MAT ad the severity of their coditio. As the outcomes of idividuals receivig bupreorphie improve, their care is shifted from Hubs to Spokes. The ehaced staffig model for the provisio of Health Home services at Hubs cosists of approximately six FTE cliical staff for every 400 patiets i MAT. The ehaced staffig Maie s Behavioral Health Services 4
level for Spokes is oe FTE urse ad oe FTE licesed cliical case maager for every 100 patiets i MAT. Because most Spokes treat fewer tha 100 patiets, Spoke staff are shared across multiple practices. Paymets to Hubs ad Spokes are admiistered by the Departmet of Vermot Health Access ad because the Hubs ad Spokes provide services that are reimbursable uder Vermot s State Medicaid pla or Health Homes fudig build upo existig paymet structures. Hubs receive a mothly, budled paymet per patiet. Spoke physicias receive fee-for-service paymets from the state s Medicaid pla for the provisio of bupreorphie treatmet, while Spoke urses ad cliical case maagers providig Health Home services are paid based o the umber of uique patiets with a bupreorphie claim paid by Medicaid withi their health service area. Example: The Doweast Maie Substace Treatmet Network (Network), a group of stakeholders icludig health care providers, law eforcemet officials, oprofit agecy staff, hospital executives, ad govermet officials coveed by Healthy Acadia the Healthy Maie Partership servig Hacock ad Washigto couties is i the process of developig a regioal system of substace use disorder treatmet for opioid addictio. The Network s emergig Opioid Treatmet Hub ad Spoke model aims to coect idividuals with opioid use disorder to a etwork of local providers of MAT ad coordiate care for those idividuals. As desiged, after idividuals are iitiated i treatmet ad stabilized at a Treatmet Hub, they will be coected to Spokes of health care providers i the commuity for cotiued treatmet. The Hub will further coordiate care if eeded. The Hub is scheduled to ope i fall 2016. The Network is also developig regioal treatmet guidelies to create a more coordiated system for treatmet ad referrals i the regio, icludig a list of substace treatmet providers ad complemetary commuity resources i the Hacock Couty regio. I additio to grat fudig through Healthy Acadia, three area hospitals (Blue Hill Memorial Hospital, Maie Coast Memorial Hospital, ad Mout Desert Islad Hospital) will dedicate fudig to the Hub. Cosideratios for applicatio i Maie Ogoig fiacial ad techical support to physicia practices ad behavioral health orgaizatios will be eeded to support appropriate screeig ad to build ad sustai care coordiatio ad itegratio iitiatives. Co-locatio of physical ad behavioral health providers ca be difficult i rural areas ad i small practices; sharig of metal health specialists across practices withi geographic regios may be eeded to esure the fiacial feasibility of such arragemets. There is growig adoptio of evidece-based models for effective substace use disorder prevetio ad treatmet services i Maie ad elsewhere. Expasio of these models will require fiacial ad techical support. Maie s Behavioral Health Services 5
Additioal resources o itegrated physical ad behavioral health care: Maie Quality Couts SBIRT Resources: https://www.maiequalitycouts.org/page/2-1153/screeig-iformatio-for-practices America Psychiatric Associatio, Academy of Somatic Medicie. Dissemiatio of Itegrated Care withi Adult Primary Care Settigs: The Collaborative Care Model: http://www.itegratio.samhsa.gov/itegrated-care-models/apa-apm- Dissemiatio-Itegrated-Care-Report.pdf PROMISING STRATEGIES Telemetal Health Services What are Telemetal Healtlh Services? Telehealth ecompasses a umber of methods for disease diagosis, maagemet, ad patiet educatio icludig live video, remote patiet moitorig, ad Mobile Health (mhealth) techology. Telehealth services are a appealig health care delivery model for much of Maie due to the state s rural geography, iclemet weather, maldistributio of providers, ad iadequate ad/or costly trasportatio optios. Research has show that the applicatio of telehealth approaches to the treatmet of metal disorders, kow as telemetal health, has bee foud to be effective for diagosis ad assessmet across populatios ad care settigs. 15 KEY FACTS about telemetal health services i Maie: I a evaluatio coducted by the America Telemedicie Associatio (ATA), Maie received a composite score of A for telemedicie coverage ad reimbursemet stadards (oe of ie states i the coutry to receive a top score), due i part to the state s telemedicie parity law for Medicaid ad private isurace. 16 The orgaizatio gave Maie a composite score of B i regard to professioal licesure portability ad practice stadards for providers usig telemedicie. 17 Take together, the ATA s scores suggest a high level of legislative ad regulatory friedliess toward telehealth i Maie compared with other states. A April 2016 MaieCare rule chage removed the requiremet that providers obtai approval prior to usig telehealth techology to treat a patiet, makig provisio of telehealth services easier for providers. 18 PROMISING STRATEGIES AND MODELS EXAMPLE: Acadia Hospital (Acadia), a full-service psychiatric hospital located i Bagor, Maie, uses telepsychiatry to provide emergecy departmet cosults for a group of rural providers, icludig te critical access hospitals, withi a three hour radius of the hospital. Acadia has a 10-bed stabilizatio uit that is staffed with a psychiatrist 24 hours a day. The hospital has leveraged the fixed cost of havig a overight psychiatrist o staff through provisio of telepsychiatry cosults with remote, rural emergecy departmets. Acadia psychiatrists use two-way iteractive videocoferecig to brig themselves face-to-face with remote patiets for diagosis ad assessmet. A typical telepsychiatry cosult begis Maie s Behavioral Health Services 6
whe a emergecy departmet provider calls Acadia to request a psychiatric cosult for a patiet at their site. Preparatios for the psychiatry cosult iclude assemblig the ecessary teams at both the remote site ad Acadia, preparig the patiet for the cosult, ad testig the videocoferecig coectio. The care providers both those at the remote site ad at Acadia coferece to discuss the patiet s case both before ad after the psychiatrist at Acadia performs a patiet iterview via videocoferece. The objectives of the telepsychiatry cosults are to reduce the time it takes for patiets to receive appropriate care, provide expertise for risk maagemet, ad improve the patiet experiece ad provider satisfactio. For example, the telepsychiatry cosults allow psychiatric patiets who are delayed i the emergecy departmet for a exteded period of time due to a lack of available psychiatric beds at aother facility or high acuity that prevets trasfer to begi treatmet, icludig medicatio ad symptom maagemet, while i the emergecy departmet. A Acadia survey of telepsychiatry parter sites foud that a majority of providers at those remote sites report that the telepsychiatry service improved their kowledge of behavioral health ad icreased satisfactio treatig behavioral health patiets. 19 Patiets are geerally comfortable with the telepsychiatry service, with oly 1.2% of patiets refusig telecosults that have bee set up. 19 Acadia employs a Telecom Maager who troubleshoots techology issues. Acadia s videocoferecig hardware was purchased usig grats from the Health Resources ad Services Admiistratio ad the U.S. Departmet of Agriculture. The cost of services are covered through facility fees ad professioal fees reimbursed through isurace, as well as fiacial arragemets with parter facilities. EXAMPLE: The Oklahoma Departmet of Metal Health ad Substace Abuse Services developed a Statewide Telehealth Network the first of its kid to provide behavioral health services via videocoferece throughout the state. Telehealth services are provided to a etwork of 140 sites throughout rural Oklahoma icludig hospitals, cliics, commuity metal health ceters, ad state peitetiaries. The State cotracts with psychiatrists at hospitals to provide services through the telehealth etwork. Over 500 licesed providers are i the Network, ad over 30 hours of videocoferecig take place across the Network each day. The State estimates $190,000 i mothly savigs due to decreased travel time for providers ad icreased productivity. The Statewide Telehealth Network was origially grat fuded, but telehealth services are ow a lie item i the state budget. The State covers the salary of a State Coordiator who istalls telehealth systems ad promotes the Network. EXAMPLE: Project ECHO is a evidece-based iitiative led by the Uiversity of New Mexico (Uiversity) that uses telehealth techology to coect medical specialists at the Uiversity with primary care providers that serve rural ad/or uderserved commuities, thereby improvig cliical care ad decreasig the isolatio of providers i rural areas. The model was first rolled out i 2003 with a emphasis o the treatmet of hepatitis C, ad has sice expaded to other coditios icludig addictios ad psychiatry. Project ECHO s recet complex care iitiative targets Medicaid beeficiaries with behavioral health disorders ad other chroic coditios who were heavy utilizers of the health system. The Maie s Behavioral Health Services 7
five primary care teams takig part i the iitiative (each led by a urse practitioer or physicia assistat, ad icludig commuity health workers) are located at commuity primary care cliics throughout New Mexico. The primary care teams are supported by experts at the Uiversity (icludig a psychiatrist, ad a physicia ad couselor that specialize i addictio treatmet) durig two-hour bi-weekly videocofereces. Durig the videocofereces experts from the Uiversity give short presetatios o relevat topics ad offer recommedatios o challegig cases preseted by the care teams. Experts are also available over phoe ad email i-betwee videocofereces. I the first year of the program the umber of hospitalizatios amog participats decreased 27 percet; emergecy departmet visits decreased 32 percet; per member, per moth cost decreased; ad patiets reported better access to care ad better care experieces. 20 Cosideratios for applicatio i Maie Reliable delivery of telehealth ad telemetal health services to rural areas of the state depeds o the availability of broadbad iteret which is slowest i rural Piscataquis, Frakli, ad Somerset couties ad ot available i some rural areas of Maie. 21 Although Maie s telehealth reimbursemet policies make fiacially stable, o-grat fuded provisio of telehealth services possible, smaller provider orgaizatios will eed techical support to pla for ad implemet telemetal health services. Additioal resources o telemetal health services: Northeast Telehealth Resource Ceter: http://etrc.org/ Rural Health Iformatio Hub: https://www.ruralhealthifo.org/topics/ telehealth#challeges PROMISING STRATEGIES Parterships with Law Eforcemet The growig opioid crisis has ecessitated partership betwee law eforcemet ad local treatmet services i a effort to save the lives of idividuals with substace use disorder rather tha put them ito the crimial justice system. KEY FACTS about parterships with law eforcemet Maie is oe of 14 states that had statistically sigificat icreases i overdose deaths betwee 2013-2014.8 Maie had the third largest percet icrease i overdose deaths (27.3 percet) behid North Dakota ad New Hampshire. 8 From 2009-2015 per capita deaths due to heroi ad o-pharmaceutical Fetayl were highest i Cumberlad, Washigto, York, Adroscoggi, ad Keebec couties. 8 Maie s Behavioral Health Services 8
PROMISING STRATEGIES AND MODELS EXAMPLE: Operatio HOPE (the Heroi Opiate-Prevetio Effort) is a program ru through the Scarborough Police Departmet that works to get idividuals livig with substace use disorder ito treatmet. Whe a idividual comes ito the Scarborough Police Departmet requestig help with their substace use disorder they ca volutarily tur i drugs, eedles, ad other drug parapheralia without the risk of gettig arrested or charged with ay crimes. Idividuals are screeed by a police officer ad if they are foud eligible for the Operatio HOPE program, they are coected with a Agel a voluteer traied by the Portlad Recovery Commuity Ceter who coects Operatio HOPE participats to treatmet facilities. I the face of log wait times at the limited i-patiet treatmet facilities i Maie, Operatio HOPE has formed parterships with, ad set idividuals to, i-patiet treatmet facilities i other states icludig Arizoa, Califoria, ad Florida. Trasportatio to the treatmet facility is paid for by Operatio HOPE, ad program Agels egotiate scholarships ad other arragemets with ipatiet facilities for idividuals who do ot have isurace coverage. By mid-may 2016 eight moths after the project was lauched 150 idividuals had bee placed ito treatmet through Operatio HOPE. The participats came from 76 tows ad cities across 14 Maie couties. Operatio HOPE is modeled after a similar effort by the Gloucester Massachusetts Police Departmet called the Agel Iitiative. Fudig for Operatio HOPE is supported by a grat from the Maie State Departmet of Public Safety. A similar iitiative was recetly lauched by the Ellsworth Police Departmet i Hacock Couty. EXAMPLE: I 1996, the Portlad Police Departmet bega what came to be a atioally recogized behavioral health respose program that embeds metal health professioals i the Police Departmet. Staff members dedicated to the program iclude a full-time behavioral health coordiator who oversees the Departmet s co-respoder program ad facilitates crisis itervetio traiig for the Departmet s officers; a liaiso from a commuity-based metal health provider who acts as a full time co-respoder that assists officers as they iteract with idividuals havig a metal health crisis; ad iters from the Uiversity of Souther Maie Cliical Couselig Master s program who respod to behavioral health related calls with police officers, make referrals, ad coduct follow ups. Other program compoets iclude follow up with residets who have repeat behavioral health-related calls, ad attedace at Commuity Crisis Providers meetigs that brig together represetatives from commuity agecies who work together to address the cases of idividual residets who have iterfaced with the police departmet. The Portlad Police Departmet is ow replicatig their metal health respose to address substace abuse issues i the Portlad commuity. The Departmet s Law Eforcemet Addictio Advocacy Program (LEAAP) is staffed by a Substace Use Disorder Liaiso who respods to the site of overdoses, goes to the hospital to advocate for quality care ad follow up plas for idividuals who overdose, coects idividuals with behavioral health resources i Portlad, ad does proactive outreach with orgaizatios i Portlad, icludig homeless shelters. Mothly meetigs with case maagers ad providers are held to come up with solutios for idividuals who have overdosed ad iteracted with the LEAAP liaiso. Aother mothly meetig is focused o idividuals who are icarcerated. The program has bee well received by Portlad Police officers ad is fuded through drug forfeiture moey. Maie s Behavioral Health Services 9
Cosideratios for applicatio i Maie Commuity-level coversatios ad plaig have bee the startig poit for fosterig closer cooperatio betwee law eforcemet ad the behavioral health ad substace abuse treatmet commuities. Broader dissemiatio of models ad strategies for icreased cooperatio is eeded. Additioal resources o partership with law eforcemet: The Police Assisted Addictio ad Recovery Iitiative: http://paariusa.org/about-us/lotlittle-start-police-departmet-based-opiate-outreach-program/ Gloucester Police Departmet Agel Program : https://www.ruralhealthifo.org/ commuity-health/project-examples/903 REFERENCES 1. Wilso W, Bags A, Hattig T. The Future of Rural Behavioral Health. Natioal Rural Health Associatio; February 2015. 2. Breslau J, Marshall GN, Picus HA, Brow RA. Are Metal Disorders More Commo i Urba Tha Rural Areas of the Uited States? J Psychiatr Res. 2014;56:50-55. 3. Meit M, Kudso A, Gilbert T, et al. The 2014 Update of the Rural-Urba Chartbook. Rural Health Reform Policy Research Ceter; October 2014. 4. Ziller EC, Aderso NJ, Cobur AF. Access to Rural Metal Health Services: Service Use ad out-of-pocket Costs. J Rural Health. 2010;26(3):214-224. 5. Fortey JC, Harma JS, Xu S, Dog F. The Associatio betwee Rural Residece ad the Use, Type, ad Quality of Depressio Care. J Rural Health. 2010;26(3):205-213. 6. Leardso JD, Gale JA, Ziller EC. Rural Opioid Abuse: Prevalece ad User Characteristics. Portlad, ME: Uiversity of Souther Maie, Muskie School of Public Service, Maie Rural Health Research Ceter; February 2016. PB 63-1. 7. Substace Abuse ad Metal Health Services Admiistratio. Behavioral Health Baromter: Maie, 2014. Rockville, MD: Substace Abuse ad Metal Health Services Admiistratio;2015. 8. Rudd R, Aleshire N, Zibbell J, Gladde R. Icrease i Drug ad Opioid Overdose Deaths- Uited States, 200-2014. 2016. 9. Sorg M. Drug Deaths Jauary-December 2015 Statewide Brief Update. 2016. 10. Leparulo P. 2014 Health Occupatio Report. Maie Departmet of Labor, Ceter for Workforce Research ad Iformatio; April 15 2014. 11. MEGIS, Departmet of Health ad Huma Services. Federally Desigated Metal Health Professioal Shortage Areas. 2016. Maie s Behavioral Health Services 10
12. Kah-Troster S, Burgess A, Cobur A, et al. Maie Rural Health Profiles. Portlad, ME: Uiversity of Souther Maie, Muskie School of Public Service, Maie Rural Health Research Ceter; August 2016. 13. Mauer B. Morbidity ad Mortality i People with Serious Metal Illess. Alexadria, VA: Natioal Associatio of State Metal Health Program Directors Medical Directors Coucil; October 2006. 14. Hackma AL, Goldberg RW, Brow CH, et al. Use of Emergecy Departmet Services for Somatic Reasos by People with Serious Metal Illess. Psychiatr Serv. 2006;57(4):563-566. 15. Hilty DM, Ferrer DC, Parish MB, Johsto B, Callaha EJ, Yellowlees PM. The Effectiveess of Telemetal Health: A 2013 Review. Telemed J E Health. 2013;19(6):444-454. 16. Thomas L, Capistrat G. State Telemedicie Gaps Aalysis: Coverage ad Reimbursemet. America Telemedicie Associatio; Jauary 2016. 17. Thomas L, Capistrat G. State Telemedicie Gaps Aalysis: Physicia Practice Stadards ad Liscesure. America Telemedicie Associatio; Jauary 2016. 18. Nadeau S. Adopted Rules: 10-144, Chapter 101, Maiecare Beefits Maual, Chapter I, Sectio 4, Telehealth Services; 10-144, Chapter 101, Maiecare Beefits Maual, Chapter I, Sectio 1, Geeral Admiistrative Policies ad Procedures. I: MaieCare Services, ed2016. 19. Redmod R, Hoyt D. Telemetal Health i the Rural Emergecy Departmet. Natioal Associatio for Rural Metal Health Aual Coferece. Portlad, ME2016. 20. Hostetter M, Klei S, McCarthy D. Project Echo s Complex Care Iitiative: Buildig Capacity to Help Superutilizers i Uderserved Commuities. Commowealth Fud; August 2016. 21. Natioal Telecommuicatios ad Iformatio Admiistratio, Federal Commuicatios Commissio. Natioal Broadbad Map. 2014; http://www.broadbadmap.gov/. Accessed August 15, 2016. The authors would like to thak iterviewee Rick Redmod for takig the time to speak with us about his work. Suggested Citatio Burgess A, Cobur A. Iovatios i Rural Health System Developmet: Maie s Behavioral Health Services. Portlad, ME: Uiversity of Souther Maie, Muskie School of Public Service, Maie Rural Health Research Ceter; November 2016. Maie s Behavioral Health Services 11