Rural Urban Disparities in Mental Health and Substance

Rural Urban Disparities in Mental Health and Substance Abuse Muskie School of Public Service David Hartley, Ph. D 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): e 19 -e 29.

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#. VFp. OS_n. F 91 Y 8

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 Public Service Muskie School Public Service Cutler Health and Social Policy Maine. Institute Ruralfor. Health Research Center Top and Bottom Counties in Life Expectancy Females – top six Males – top six Females – bottom six Marin, CA Fairfax, VA Perry, KY Mc. Dowell, WV Montgomery, MD Gunnison, CO Mc. Dowell, 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 Public Service Muskie School Public Service Cutler Health and Social Policy Maine. Institute Ruralfor. Health 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% 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

Muskie School of Public Service Maine Rural Health Research Center Adverse Childhood Experiences

Muskie School of Public Service Maine Rural Health Research Center ACES increase risk for:

Muskie School of Public Service Maine Rural Health Research Center Current Project: Single Mothers’ Smoking

Muskie School of Public Service 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 – – – Primary Care Emergency Room Schools Corrections/jails Welfare office Workplace/EAP • Different funding – – 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 Me. RHRC Brief July 2013

Muskie School of Public Service Maine Rural Health Research Center Promising Initiatives Flex Rural Veterans Health Access Program • • 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 Initiatives. Rural 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

Muskie School of Public Service 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 Me. RHRC 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