Transcript Slide 1

Rural Urban Disparities in Mental
Health and Substance Abuse
Muskie School of Public Service
David Hartley, PhD
John Gale, MS
Maine Rural Health Research Center
University of Southern Maine
NOSORH Webinar
April 27, 2015
Muskie School of Public Service
Maine Rural Health Research Center
Goals for the Webinar
Disparities and Determinants of Population Health
Disparities in Prevalence, Access and Outcomes
Why is Behavioral Health Different?
Current and Perennial Issues:
Non-medical use of prescription drugs
Suicide
Stigma
A Few Promising Examples
Muskie School of Public Service
Maine Rural Health Research Center
What is a Disparity?
One population differs from another
differences in the overall rate of disease [or disability] incidence,
prevalence, morbidity, mortality or survival rates as compared to the health
status of the general population.
OR
significant differences in health outcomes or health care use between
socially distinct vulnerable and less vulnerable populations
Muskie School of Public Service
Maine Rural Health Research Center
What is Population Health?
Focus on interrelated factors that influence the health of a
population over the life course, identify systematic
variations in patterns of occurrence, and apply findings
to develop and implement policies and actions to improve
health and well-being of that population.
This definition acknowledges that disparity is a core
concept in thinking about population health.
Muskie School of Public Service
Maine Rural Health Research Center
Source: Singh and Siahpush, Widening Rural-Urban Disparities in Life Expectancy, U.S., 1969-2009.
American Journal of Preventive Medicine, 2014; 46(2):e19-e29.
Socio-economic determinants
Rural residents tend to be poorer than urban residents
Per capita income is $9,864 less for rural (2012)
21% of food stamp beneficiaries are rural (2014)
27% of rural children live in poverty (21% urban)
Rural residents’ educational attainment
16.6% have < high school education (13.9% urban)
17.6% have a Bachelor’s degree or higher (30.5% urban)
htthttp://www.ers.usda.gov/statefacts/US.HTM
Source: http://www.ers.usda.gov/data-products/state-fact-sheets/state-data.aspx#.VFpOS_nF91Y
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Muskie School of Public Service
Cutler Institute
Maine
Rural Health
for Health
Research
and Social
Center
Policy
Geographic Variations in Life Expectancy - Males
Muskie School of Public Service
Cutler Institute
Maine
Rural Health
for Health
Research
and Social
Center
Policy
Geographic Variations- Changes in Female Life Expectancy
Muskie
School of
of Public
Service
Muskie
School
Public
Service
Cutler
Health and
Social Policy
MaineInstitute
RuralforHealth
Research
Center
Top and Bottom Counties in
Life Expectancy
Females – top
six
Males – top six
Females –
bottom six
Males – bottom
six
Marin, CA
Fairfax, VA
Perry, KY
McDowell, WV
Montgomery, MD Gunnison, CO
McDowell, WV
Bolivar, MS
Collier, FL
Pitkin, CO
Tunica, MS
Perry, KY
Santa Clara, CA
Montgomery, MD Quitman, MS
Floyd, KY
Fairfax, VA
Marin, CA
Petersburg, VA
Tunica, MS
San Francisco,
CA
Douglas, CO
Sunflower, MS
Quitman, MS
Muskie
School of
of Public
Service
Muskie
School
Public
Service
Cutler
Health and
Social Policy
MaineInstitute
RuralforHealth
Research
Center
Socio-demographic
Challenges
URBAN
RURAL
230,825
24,389
% College Graduates
29.53
17.28
Poverty rate
12.92
16.44
Unemployment rate
4.71
4.40
% chronically poor
counties
4.22
16.57
% Counties w pop. loss
6.33
25.89
Average Population
Muskie School of Public Service
Maine Rural Health Research Center
Mental Health and Substance Abuse
Disparities
Muskie School of Public Service
Maine Rural Health Research Center
Disparities by the Numbers
Rural
Urban
Anxiety
18%
18%
Depression
9%
9%
Adult Binge Drinking
23.5%
22.1%
Teen Binge Drinking
12.2%
9.9%
Children with ADHD Dx
6.2%
5.1%
Children with MH Rx
8.0%
6.4%
27
17
Male Suicide per
100,000
Muskie School of Public Service
Maine Rural Health Research Center
Recent Analysis, MEPS (%)
Urban
Rural
Adjacent
Rural Not
Adjacent
Perceived MH
Fair/Poor
7.03
8.04
9.53
Presence of MH
Disorder (Kessler)
6.9
8.43
9.39
Depression
8.36
10.17
10.51
Muskie School of Public Service
Maine Rural Health Research Center
Regional Variations – Binge Drinking (12-20)
Muskie School of Public Service
Maine Rural Health Research Center
Non–Medical Use of Pain Relievers
Muskie School of Public Service
Maine Rural Health Research Center
Disparities Beget Disparities
Poverty
Poor Education
Unemployment
Substance Abuse
Domestic Violence
Teen Pregnancy
Crime
Adverse Childhood Experiences
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Maine Rural Health Research Center
Adverse Childhood Experiences
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Maine Rural Health Research Center
ACES increase risk for:
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Maine Rural Health Research Center
Current Project: Single Mothers’ Smoking
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Maine Rural Health Research Center
Disparities in Access
– Insurance
– Providers
– Stigma and Privacy
Rural health problem is often getting resources to
vulnerable sub-populations within a rural area
when the infrastructure is sparse and there is no
economy of scale.
Muskie School of Public Service
Maine Rural Health Research Center
Rural Behavioral Health Infrastructure
• Human Services involvement
– Homelessness
– Poverty
– Domestic violence
• Workforce Issues
– At least five different mental health professionals – differs
from one state to the next
– Different professions have different terminology, different
missions
Muskie School of Public Service
Maine Rural Health Research Center
Rural Behavioral Health Workforce
• 55% of US counties (all rural) have no psychiatrist,
psychologist or social worker.
• 75% of practicing psychiatrists report that they could
not schedule a patient, new or existing, with the next
two weeks.
• More than half of current psychiatrists are over 55 and
graduation rates in psychiatry are declining.
• Rural intervention and treatment often relies on law
enforcement, jail, and emergency rooms.
Muskie School of Public Service
Maine Rural Health Research Center
Behavioral Health Infrastructure
• Different venues
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Primary Care
Emergency Room
Schools
Corrections/jails
Welfare office
Workplace/EAP
• Different funding
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Block grants – funds targeted to specific populations
Medicaid is major funder
Disability – SSI – categorical funding
Parity
Muskie School of Public Service
Maine Rural Health Research Center
Disparities in Outcomes
Some Facts About Suicide
• 40,000 deaths each year in US, about 105 per day.
• Of ten leading causes of death, only suicide is
increasing.
• Half of all suicides have no prior suicide attempts.
• 45% of those dying by suicide saw their primary care
physician in the month before their death.
• 20% saw a mental health practitioner
Muskie School of Public Service
Maine Rural Health Research Center
Why are Rural Suicide Rates Higher?
Disparities in Access
Stigma
Culture
Access to Firearms
Disparities that beget Disparities
Muskie School of Public Service
Maine Rural Health Research Center
Promising Initiatives
• Telemental Health
• Flex Rural Veterans Health Access Program
• Rural Mental Health First Aid
• Integrating Behavioral Health and Primary Care
Services
Muskie School of Public Service
Maine Rural Health Research Center
Promising Initiatives
Telemental Health -- Challenges
• Limited scope of services
• Provider recruitment and retention
• Does not solve chronic shortages or economic
challenges of sustaining a mental health services
Telemental Health in Today’s Rural Health System
MeRHRC Brief July 2013
Muskie School of Public Service
Maine Rural Health Research Center
Promising Initiatives
Flex Rural Veterans Health Access Program
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Improve access and quality of mental health services
Coordinate care between rural providers and VA
Facilitate coordination between HHS and VA
Use of networks, telehealth and electronic records
Grantees in Alaska, Maine and Montana
Primary beneficiaries OEF and OIF veterans
Office of Rural Health Policy … HRSA
Muskie School of Public Service
Maine Rural Health Research Center
Promising InitiativesRural Mental Health First Aid
Training Program (National Council for Behavioral Health)
– Provide basic knowledge
– Reduce acute distress, then handoff to MH professionals
– Combat stigma
– 280,000 individuals trained by 5900 instructors
– Long term goal to enhance local infrastructure
Muskie School of Public Service
Maine Rural Health Research Center
Rural Mental Health First Aid -- Evaluation
“There’s still a lot of stigma…Some individuals that we serve [at our
mental health center] come in through the back door.”
“For lay folks, they need more practice asking, ‘Are you thinking about
killing yourself?’ and working with the answer they get.”
“She recognized some signs of …suicidal self-injury, and came to find
out that he was considering suicide, and …that he had a plan. The
signs …are subtle unless you know what you’re looking for…”
“There is no crisis team… As a rural person, what are you supposed
to do? Take the person into your house?”
‘We have no services here…What good is MHFA if we can’t get the
help?’”
Muskie School of Public Service
Maine Rural Health Research Center
Promising Initiatives
Rural Mental Health First Aid -- Challenges
• Handoff from lay to professional – but no infrastructure
• Reduces stigma among participants – but no clear
strategy for community impact
• Goal is to stimulate discussion about infrastructure but
no needs assessment or guide on how to initiate these
discussions.
• Biggest challenge is over-promising what MHFA can do
Muskie School of Public Service
Maine Rural Health Research Center
Other Rural Initiatives Targeting Stigma
• Sowing the Seeds of Hope
– 7 state initiative to reduce stigma barriers to seeking mental health
services by rural farm families
– Education, social marketing, direct service vouchers, training peer
and community outreach workers
• Lean on ME, Farmington, ME
– Community wide education program developed by local health
community coalition – funded by local foundation
– Community/social marketing, media coverage, education to clergy
and other key populations, mental health task force
Muskie School of Public Service
Maine Rural Health Research Center
Other Rural Initiatives Targeting Stigma
• Montana Warm Line
– Targets rural residents with limited access to services, limited
mobility, desire anonymity while seeking mental health support
– Phone/web-based prevention, health promotion, support, referrals
– Trained peer workers
• VA-Sponsored Rural Clergy Training Project
– 1 day workshop to train rural clergy to support veterans and
families – held regionally since 2009 with plans to continue
– Education on veteran’s issues, resources, and mental health
– Create a referral network for vets
Muskie School of Public Service
Maine Rural Health Research Center
Addressing Local Mental Health Disparities
• Collaborate with local partners
• Link strategies to identified community needs
– Conduct CHNA, develop priority strategies
• Target needed essential services to improve access
– Mental health, primary care
• Address needs of uninsured/vulnerable patients
– Integrate essential services to improve access, provide care
management, use financial assistance policies to reduce
financial barriers, provide MHFA to reduce stigma
Muskie School of Public Service
Maine Rural Health Research Center
Essentia Health St. Mary’s
• Collaborative Care Mgt of Depression in Primary Care
• Priority need identified in CHNA - initial funding with
grant from Office of Rural Health
• Depression care within primary care setting Screens
primary care patients using PHQ-9 by a team that
includes a behavioral health specialist, a psychiatric
nurse practitioner, and a care coordinator
• Coalition of EH-St. Mary’s and community mental
health professionals
• Community outreach and education
Muskie School of Public Service
Maine Rural Health Research Center
Wabash Valley Telehealth Network
• MH patients clogging EDs
• Hub & spoke model: CMHC provides crisis services to 6
CAHs using 24/7 access center (LCSW/LMH staff and
psychiatrist)
• Standardized protocols/algorithms used to assess patients
• CMHC prepares consultation report and disposition plan
• ED LOS reduced from 16-18 hours to 240 minutes
• Savings (lower ED LOS), fewer unnecessary hospital admits
• CAHs pay a consulting fee per encounter
Muskie School of Public Service
Maine Rural Health Research Center
Nor-Lea General Hospital
• Created Heritage Program for Senior Adults in 2003
• Provides outpatient mental health services using psychiatrist,
therapists, RN, and mental technicians
• Need identified through focus groups and hospital chaplains
• Initial assessment-measures of cognitive ability, home
environment, resources to develop master treatment plan
• Provides individual and/or family therapy and group therapy
• Van is available to transport clients for services
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Maine Rural Health Research Center
Regional Medical Center
• Developed 3 county continuum of mental health services in
response to a state de-institutionalization initiative
• Primary funding through Medicaid
• Outpatient counseling, crisis, supported community living,
children’s day treatment
• Medicaid funding cuts triggered re-organization
• Provides integrated behavioral services in two providerbased RHCs using licensed mental health counselors
• Serves children, adolescents, adults, seniors, and couples
Muskie School of Public Service
Maine Rural Health Research Center
MeRHRC
Examples of Rural Mental Health Studies
• Primary Care Settings – survey - 1998
• Community Mental Health Centers – case studies and site
visits - 2002
• Emergency Rooms – survey - 2005
• Jails - case studies – 2010
• Provision of Mental Health Services by Rural Health Clinics
• Kids Mental Health – 2010, 2011, 2013
• Mental Health First Aid - 2014