Remarks by
A. Kathryn Power, M.Ed.
Director

Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services

34th Meeting
SAMHSA National Advisory Council
Panel on Rural & Frontier Workforce Issues

December 11, 2003
Washington, DC

As you know, I currently live in the fine State of Rhode Island. One of the State's claims to fame is that it had the highest population density of all American States from 1900 to 1960. (Because of this density, it stills ranks very high in mental health and substance abuse issues after Washington, DC.) Even with that urban profile, however, the population of Rhode Island today remains 8 percent rural. I mention this fact because it demonstrates that rural America stretches from sea to shining sea. As Wesley [Clark] indicated, nearly 60 million Americans live in rural and frontier areas. Each of these individuals faces a range of life challenges and deserves the same quality of mental health care as our urban citizens.

The President's New Freedom Commission on Mental Health emphasized this point by highlighting rural mental health care under its goal to eliminate health care disparities. Recommendation 3.2 in Achieving the Promise is "to improve access to quality care in rural and geographically remote areas." Responding to this challenge means that we must find solutions to the mental health care workforce issues that are creating provider shortages in the majority of rural areas. More than 30 million Americans are currently living in federally designated mental health professional shortage areas.

Meeting the needs of our rural and frontier citizens means understanding the unique characteristics of this population's problems and how these social, economic, geographic, and delivery constraints affect workforce issues. What do we know about rural Americans and the unique challenges of serving them?

The number of rural Americans has remained relatively stable for the past 30 years, but the face of the rural population is changing. Many growing rural counties are becoming more ethnically and racially diverse. Many immigrants, especially Hispanic and Asian immigrants, are increasingly settling in the rural U.S. Consequently, workforce issues for rural areas involve not only adequate access to quality care, but also to culturally competent care.

In addition, rural populations have a higher proportion of older adult residents than urban areas. This is significant for two reasons. A high proportion of older persons means that rural health care systems are increasingly dependent on Medicare as a primary funding source. If Medicare is reformed to eliminate disparities between physical and mental health care, if it is expanded to cover more services, the demand for mental health care services will increase. This will place even more pressure on an already inadequate supply of service providers.

In addition, although an estimated 15 to 25 percent of older adults suffer from mental disorders, only 2 to 4 percent of practice time by rural mental health care professionals is spent with older clients. This indicates a severe disparity between treatment need and treatment provision by available providers.

Women and children in rural areas also have recognized, but unmet, service needs. Rural women, for example, have an estimated rate of depression that is twice that of the female population in general. Researchers also report that some behavioral problems, such as youth aggression, suicide, and substance abuse, may be more common in rural areas. The workforce implication of these data is that local health care providers, particularly primary care providers, need cross-training in screening patients for these problems.

Adequacy of mental health care, when provided by non-mental health specialists, presents another workforce issue. In many rural counties, primary care physicians are the only health professionals providing mental health services. These physicians may have had no cross-training in mental health or they may have insufficient skills in offering mental health care.

Equally troubling, their training may not have prepared them to screen for mental illnesses and co-occurring disorders and make referrals. This lack of appropriate care raises the specter of having the criminal justice system fill the breach as the primary treatment system for persons with serious mental illnesses and addictive disorders.

Primary care physicians also may be ill-equipped to dispel the stigma frequently associated with mental health care. Although stigma is a national problem, it is particularly pronounced in rural areas where there is a lack of anonymity. As a result, some primary care physicians in rural communities deliberately under-diagnose mental illnesses because of stigma and the uncertainty that their patients will accept their diagnosis.

And, of course, the geographic isolation of rural and frontier areas creates workforce issues. One issue is recruiting and retaining an adequate number of mental health care providers in remote areas. Another issue is how geography limits the providers' ability to provide services. The size of rural service areas is frequently large, and residents may live hundreds of miles from the nearest town clinic. As a result, it is almost impossible for available providers to adequately address the mental health needs of people within an area. Complicating this issue is the scarcity of public transportation that could enable rural and frontier residents without reliable transportation to reach services. Furthermore, the additional time and cost involved in providing services to geographically remote areas contributes to workforce issues.

There is also a host of other factors affecting the provision of mental health care in rural and frontier areas. These include insurance barriers, fragmented government funding, and government decisionmaking based primarily on cost-effectiveness criteria.

Clearly, there are several complex workforce issues related to improving access to quality care in rural and frontier areas. On the other hand, recognizing and understanding the bases of these issues raises the very real hope that they can be directly addressed and remedied.

What are we doing within the Center for Mental Health Services and the Substance Abuse and Mental Health Services Administration (SAMHSA) to help resolve rural mental health care workforce issues? SAMHSA is very much a part of the Department of Health and Human Services "One Department, Serving Rural America" initiative. Secretary Tommy Thompson has elevated rural health care as a priority. Just recently, we drafted a SAMHSA rural health action plan, which was developed by a national committee of providers, consumers, and others. The recommendations in this report align with those proposed by the President's Mental Health Commission.

We are taking direct action to address workforce issues in rural and frontier areas. One of the most pressing issues is the mental health care provider shortage. Among rural counties with populations between 2,500 and 20,000 residents, nearly three-fourths lack a psychiatrist. Ninety-five percent lack a child psychiatrist. Only about 50 percent have a psychologist and only 42 percent have a social worker with an advanced degree. Even fewer of these professionals practice in counties with fewer than 2,500 residents.

To confront this situation, the President's Mental Health Commission recommended that SAMHSA and the Health Resources and Services Administration (HRSA) collaborate on training efforts that will expand the capacity and competence of the rural mental health care workforce. I'm proud to say that the two agencies have entered into a collaborative agreement to do just that. Through a memorandum of understanding, SAMHSA and HRSA are about to pilot cross-training of primary health professionals for mental health and substance abuse in community health centers in rural Western States.

We are very excited about the potential of this pilot program. Very often, primary care physicians or physician assistants are the only health care providers for rural and frontier areas. If we can train them in how to screen for mental illnesses, co-occurring disorders, or behavioral problems as part of practicing basic health care, than we have made a giant step toward getting proper care for persons with these problems.

We are also emphasizing community capacity-building across our programs because this is one way to expand the number of persons involved in providing mental health care. Persons living within rural and frontier communities depend on each other for help, support, and to pitch in and take responsibility for whatever needs doing. Their ability to take many roles, their sense of community, and their make-do attitude are strengths that we can build on in expanding the mental health workforce.

In addition, community capacity-building presents an opportunity for us to target resources at known problems, such as the growing suicide rate among American Indians and other native groups. At present, Native Americans have the highest rate of suicide among all ethnic groups as well as the highest rate of suicide by adolescents and young adults.

Our Alaska Suicide Prevention Program illustrates how we are building mental health care capacity within a community by expanding the number of service providers trained to address suicide. The suicide rate for Alaska during the past 10 years has been approximately double that of the U.S. Our Alaska Suicide Prevention Program addresses this tragedy by providing gatekeeper training to community groups that are well positioned to intervene with individuals at risk for suicide. Gatekeepers being trained in this pilot study are health care providers, law enforcement officials, and religious and lay clergy.

Also, as I mentioned earlier, youth aggression, suicide, and substance abuse may be more common in rural areas. Through our interagency Safe Schools/Healthy Students program, we are stimulating local partnerships that promote the healthy development of children, foster their resilience in the face of adversity, and prevent youth violence. As of this date, we have funded 44 grants to schools in rural areas.

We also fund Sowing the Seeds of Hope, a collaborative community-based effort to provide behavioral health care supports to agricultural families in seven predominately rural States. This program focuses on bringing the community together to promote accessible services for underserved and at-risk populations affected by rural stress.

I want to talk for just a few minutes about telehealth, which is goal 6 of Achieving the Promise. The Mental Health Commission described telehealth as one of the most promising ways to improve specialty mental health care in rural areas. Telehealth is using electronic technology to provide long-distance health care, patient and provider education, public health, and health administration.

Widespread use of telehealth faces some barriers, including availability. Less than half of local health departments have continuous high speed Internet access. This access may be especially limited in rural areas, where the infrastructure needed to support technology may not exist and the cost of providing it remains extremely high.

On the other hand, we cannot afford to overlook its potential advantages. Imagine the health care possibilities of being able to link rural primary care providers in consultation with urban mental health care specialists! Imagine the potential to decrease stigma and increase treatment by linking individuals with providers who speak their own language or reflect their own culture!

Progress in recognizing the potential of telehealth is being made. For example, several years ago, the Northern Arizona Regional Behavioral Health Authority began developing a telemedicine system designed to deliver mental health care throughout 62,000 miles of northern Arizona. In a 5-year period, the system delivered more than 7,900 telehealth services via videoconferencing. In addition to direct provider-patient psychiatric services, the Behavioral Health Authority uses this system to deliver regular training, case consultation, and other services to its 15 sites.

SAMHSA is collaborating with several other Federal agencies to identify how we can extend the advantages of telehealth to rural areas. Just last week, the interagency work group on telehealth—of which SAMHSA is a member—focused its attention on the Federal Communication Commission's new order affecting rural health care providers. Under this new ruling, additional health care providers will be eligible for a 25 percent discount on Internet access costs. Our part may be to encourage rural providers to take advantage of this under-utilized program.

We can certainly look for opportunities to alert providers in rural and frontier areas to available Federal resources. For example, we can encourage appropriate Federal and State organizations to include links on their Web sites to HRSA's Rural Assistance Center. This Center is an online clearinghouse for information about available HHS programs, funding, and research supporting quality health care in rural areas.

I have devoted a fair amount of time to describing the barriers we face in resolving workforce issues in rural and frontier America. The significance of these barriers is underscored by the fact that the percentage of rural areas underserved in mental health care remains at 60 percent. This is roughly the same percent of underserved areas as an Eisenhower commission on rural mental health care found in the mid-1950s.

Despite our progress, we still need to see beyond these barriers to better solutions. I believe that we can. I believe that we have the combined talent, ingenuity, and commitment to find new solutions to old problems.

Robert Collier, publisher and author, said that "vision reaches beyond the thing that is, into the conception of what can be." The Mental Health Commission has offered us a vision of what can be in Achieving the Promise—a vision in which every aspect of the Commission's report can, and should be, applied to improving mental health care in rural America. It is now up to us to move that vision forward.

Each of us has several roles in this effort—to listen, to learn, to share ideas, to act. We cannot transform mental health care in America unless, and until, access to quality mental health care extends from our cities to our frontiers. I look forward to working with you in making these connections so that we will improve the lives of all individuals with serious mental illnesses. Thank you.

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