Innovations Showcase - Educational Models of Delivery Jeffrey Leichter, PhD, LP, MeritCare Clinic, Detroit Lakes, MN
Rural communities, including those in NW Minnesota are disproportionately underserved by mental health services. This, despite the prevalence of mental illness in rural communities which meets or exceeds that of urban communities. Rural communities have inordinately difficult tasks in recruiting and retaining mental health professionals due to several factors: Lack of training in the unique aspects of rural practice at the graduate or postgraduate level. Professional isolation, lack of cohesive mental health community, and stress of disconnected rural mental health providers. Lack of community resources to retain mental health providers. Lack of familiarity with the multidisciplinary crossover culture of mental health delivery in rural communities Need for generalist practice in a world of specialization. The Problem
The Problem: (Continued) Over the past 20 years, rural suicide rates have surpassed urban suicide rates (Fingerhut & Gunderson, 1995). Rural residents are more likely to be victims of violence than the urban population (SAMHSA, 1995). Alcohol and drug use is higher in rural residents than in urban or suburban residents, especially among rural youth (Columbia University, 2000). Depression threatens the health of rural residents (APA Public Policy Office, n.d.). An estimated 2/3 of rural residents with mental illness receive no care at all. Less than 10% of the 2200 rural hospitals across the nation offer mental health services. Further, 75% of federally designated Mental Health Professional Shortage Areas are rural (APA Public Policy Office). Transportation is a serious obstacle to obtaining and maintaining mental health services in rural communities (Bierman, 1997). Rural areas lack all forms of healthcare providers. But, the shortage of mental health professionals in rural areas outstrips that for medical or dental health. In the 3075 counties in the United States, 55% (all rural) have no practicing psychologist, psychiatrist, or social worker (Bureau of Primary Health Care, 1999). Most rural residents face triple jeopardy : They are poor, uninsured (20% of rural residents have no health insurance), and live in isolated areas.
Views from the Profession on The Problem At the same time, much more needs to be done, particularly with regard to problems associated with insufficient numbers of qualified mental health professionals in rural and frontier areas. The federal government has been the major force responsible for molding health professions education, partly through the sponsorship of innovative training practices and preparation of professionals for underserved areas. At the same time, mental health and substance abuse training have received considerably less support as compared to the traditional medical specialties Dunivin, D. (1994). Health professions education: The shaping of a discipline through federal funding. American Psychologist, 49, 868-878. Rural professionals often work in relative isolation and without many of the professional and personal amenities enjoyed in urban settings. Rural practitioners often lack professional peers to consult with on difficult cases and to share evening and weekend emergency coverage; frequently find appropriate continuing education programs inconvenient, inaccessible, or unaffordable; and often feel personally cut off from the cultural, educational, and recreational activities they grew accustomed to during their more urban and university based training years. Wagenfeld, M., Goldsmith, H., Stiles, D., Longest, J., & Manderscheid, R. (1988). Inpatient mental health services in non-metropolitan counties. Journal of Rural Community Psychology, 9, 13-18. The differences between rural and urban communities present another source of diversity in mental health services. People in rural America encounter numerous barriers to the receipt of effective services. Some barriers are geographic and some barriers are cultural insofar as rural America reflects a range of cultures and life styles that are distinct from urban life. Urban culture and its approach to delivering mental health services dominate mental health services. Beeson, P., Britain, C., Howell, M., Kirwan, D., & Sawyer, D. (1998). Rural mental health at the millenium. In Mandersheid, R. & Henderson, M. (Eds.). Mental Health United States, 1998. (DHHS Publication No. SMA 99-3285, 82-98. Washington, D.C: US Government Printing Office.
The Solution: Enhance the supply of rural mental health providers and their competencies: Recommendation #1: The mental health professions should actively encourage innovative training strategies (both in terms of didactic and experiential training) that are explicitly targeted at expanding the competencies required to practice effectively in rural settings. Recommendation #2: Training programs should make concerted efforts to recruit qualified applicants from rural areas who are more likely to practice in rural regions after graduation. Recommendation #3: Interdisciplinary collaboration can accomplish several goals with regard to enhancing the supply and effectiveness of mental health providers in rural areas and improving consumer access to these providers. Because interdisciplinary training makes such collaboration more likely to occur, the Work Group recommends several strategies to increase interdisciplinary training and service delivery opportunities. Recommendation #3A: Funding should be provided to increase the number of rural interdisciplinary practices, internships, and residency placements currently available. Recommendation #4: It is critically important to fund training of rural mental health service providers. Federal and state funds for training activities should be made available to both: (a) disciplinary based efforts to train individuals for rural mental health provider roles; and (b) efforts that view interdisciplinary training and collaboration as critical to providing services to rural and other at-risk populations. --Final Report of the Ad Hoc Rural Mental Health Provider Work Group The Center for Mental Health Services Substance Abuse and Mental Health Services Administration (SAMHSA) U.S. Department of Health and Human Services Rockville, MD October 1997
The Solution: Past and Current Attempts I. The practicum level: Pilot practicum conducted Summer 1994- Jackson, Wyoming. Michael Enright Ph.D., ABPP and colleagues. Based on APA curriculum from: Caring for the Rural Community. An interdisciplinary curriculum. 1995. American Psychological Association. In summary, this pilot project appears to have been a worthwhile and successful extension of the model curriculum, suggesting that continuation and expansion of this practicum represents a viable and effective means for training mental health professionals in a collaborative approach to mental health care in rural areas. Jeff Startzel, Psy.D. See also the Center for Rural Psychology (www.ruralpsych.org) practicum in rural Christian psychology- Illinois. II. The doctoral curriculum level: The Ph.D. program at the University of Nebraska-Lincoln developed a rural mental health specialty to train psychologists to work in rural settings. See: Hargrove, D. (1991). Training Ph.D. psychologists for rural service: A report from Nebraska. Community Mental Health Journal, 27 (4), 293-298. The program consisted of academic, clinical, and research components based on Boulder Model. Program now appears defunct, no longer on UNL website. III. The internship level: University of Florida Rural Psychology Program. See for description: Sears, S., Evans, G., and Perry, N. (1998). Innovations in training: The University of Florida Rural Psychology Program. Professional Psychology: Research and Practice, 29 (5), 504-507. Professional goals include: (a) acquisition of basic understanding about behavioral needs of rural populations; (b) to learn about benefits and obstacles associated with creating a satisfying rural practice; (c) to innovate and implement a full range of psychological services to rural communities. IV. **The post graduate level: Community Mental Health Consultants, Nevada, Missouri. 1 year postdoctoral fellowship in rural mental health. A practitioner-scientist model training program which seeks to prepare rural clinical psychologists for licensure, health facility practice, and to take a responsible position within the rural community as a community resource (see www.cmhconline.com/residency).
The Project: MCARPT 1. Simple beginnings: Conversations Summer 2002 with social work colleague BE CAREFUL WHAT YOU WISH FOR. 2. Contact with Office of Rural Health and Primary Care (ORHPC): Jill Zabel (www.health.state.mn.us/divs/chs/orh_home.htm) 3. Advised to apply for State of Minnesota Planning Grant 4. Presented idea of post-doctoral fellowship to local mental health and social service agencies. 5. Put together small team to write for ORHPC grant. Identified applicant agency (Becker County Children s Initiative), payee (Perham Hospital) and cooperating agencies. 6. It takes a community to raise a psychologist --Grant Objectives: The Minnesota Consortium for Advanced Rural Psychology Training will address the unique challenges of recruiting and retaining qualified mental health providers in rural Minnesota. The project proposes to initiate a consortium training program of multiple agencies within the project s catchment area to attract newly graduated doctoral level unlicensed psychologists who need to complete 1-2 years of postdoctoral supervised practice to be eligible to sit for licensure in the United States. These newly graduated practitioners will be trained for 2 years in the unique culture of rural practice through the integration of training experiences and cooperation of multiple agencies that make up the fabric of rural mental health practice. These agencies represent the spectrum of clinical experiences and challenges most often encountered by beginning mental health clinicians specific to rural practice. Exposure to training modules at each agency will shape the clinician to be sensitive to and able to integrate services with a variety of community resources.
The Participants: MeritCare Clinic Detroit Lakes: Primary care family medicine clinic with 14 multidisciplinary medical providers. MeritCare Clinic Perham: Primary care family medicine clinic with 6 multidisciplinary medical providers. Perham Hospital and Nursing Home: 29 bed acute care hospital attached to 102 bed skilled nursing facility Lutheran Social Services: Local office of statewide, non-profit, charitable social service agency offering outpatient and in-home mental health services in Becker County Glenmore Recovery Center: Outpatient chemical dependency satellite clinic. White Earth Health Services: Multidisciplinary Federal healthcare clinic, run by Indian Health Services, serving the White Earth Band of Ojibwe. Lakes Crisis and Resource Center: Local crisis center serving victims of domestic violence and other forms of trauma. Becker County Social Services: County social service agency providing a full spectrum of social, financial, protective, and support services to the residents of Becker County. Detroit Lakes School District (ISD #22): High school, middle school, and three elementary schools form the district. White Earth Tribal Mental Health: Tribal based mental health team that is designed to meet the needs of White Earth tribal members and their families who live on or near the reservation. Lakeland Mental Health Center: Community mental health center offering traditional outpatient mental health services along with day treatment, crisis intervention, and community support services.
Curriculum Writing Format Clinical Proficiency Set Clinical Proficiency Description Objectives: Trainee will demonstrate ability to: Suggested literature competencies: Suggested activities and rotations Objective documentation of competency
Challenges to Implementation Interagency Philosophical Differences (Can t we all just get along?) Augmenting and Enhancing vs. Supplanting Existing Services (I.E. No Slave Labor) Retaining Sufficient Supervisor Diversity and Numbers Securing Initial Start Up Funds and Seeking Sustainability Creating a Legal Consortium Entity Defining Agency vs. Consortium Roles and Responsibilities Building Infrastructure Community Logistics and Acceptance