Mental Health Providers in Rural and Isolated Areas

Inside This Issue:

• Acknowledgments
• Executive Summary
• Enhance the Supply of Rural Mental Health Providers and Their Competencies
• Improve Access of Rural Residents to Mental Health Providers and Services
• Final Report: Rural Mental Health Provider Work Group
• Enhancing the Supply and Effectiveness of Mental Health Service Providers
• Improving Access to Mental Health Services in Rural Areas
• Conclusion

Acknowledgments

This Rural Mental Health Provider Work Group Report, which is based on two meetings of an Ad Hoc Rural Mental Health Provider Work Group, was made possible through the assistance of and contributions from many individuals representing the Federal government, State and local governments, professional and consumer organizations--far more than we can acknowledge by name here.

We are especially grateful to the following persons for the initial planning of the meeting: Charles Windle, Ph.D., the late Acting Associate Director, Office of Rural Mental Health Research, National Institute of Mental Health (NIMH); Cathy Wasem, M.N., R.N., Senior Program Analyst/Mental Health, Office of Rural Health Policy, Health Resources and Services Administration (HRSA); Carol Bush, R.N., Ph.D., Acting Chief, Human Resource Planning and Development Branch, Division of State and Community Systems Development, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration (SAMHSA); and Jacqueline Sheridan, Chief, Alternative Delivery Organization Branch, the Centers for Medicare and Medicaid Services (CMS).

We are deeply indebted to the distinguished group of rural mental health and substance abuse researchers, administrators, clinicians, academicians and consumers who provided the expertise upon which the meeting and this report is based. We are particularly grateful to the following participants for their role as presenters: Dennis Mohatt, past President, National Association for Rural Mental Health, Wood River, Illinois; Jacqueline Sheridan, Chief, Alternative Delivery Organizations Branch, the Centers for Medicare and Medicaid Services, Baltimore, Maryland; David Worgo, Health Insurance Specialist, Medicaid Bureau, the Centers for Medicare and Medicaid Services, Baltimore, Maryland; and Colleen Conway Welch, Ph.D., Professor and Dean, School of Nursing, Vanderbilt University, Nashville, Tennessee.

Executive Summary

A series of recent reports have continued to underscore the lack of parity between urban and rural residents in accessing appropriate mental health and substance abuse services (e.g., Beeson, 1994; National Advisory Committee on Rural Health, 1992, 1993; National Public Forum, 1993; National Association of State Mental Health Program Directors, 1993a, 1993b; U.S. General Accounting Office, 1990). Federal policy-makers have responded to these disparities to some degree; for example, there is now an Office of Rural Mental Health Research in the National Institute of Mental Health, along with an Office of Rural Health Policy in the Health Resources and Services Administration. These programs have been responsible for developing special opportunities for research and services, including the Rural Outreach Demonstration Grant Program, the Rural Health Research Center Grant Program, the Rural Health Outreach Grant Program, the Rural Interdisciplinary Training for Health Care for Rural Areas Grant Program, and the Center for Support of Mental Health Services in Isolated Rural Areas (DeLeon, Wakefield, Schultz, Williams, & VandenBos, 1989; Human & Wasem, 1991; Hutner & Windle, 1991). Such efforts, albeit modest in size, are welcome responses and merit increased support.

At the same time, much more needs to be done, particularly with regard to problems associated with insufficient numbers of qualified mental health professionals and the barriers impeding access to providers who currently serve residents 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, 1994).

In another attempt to address these problems, the Rural Mental Health Provider Work Group was convened in Fall 1994 by the Center for Mental Health Services at the request of the Secretary of the Department of Health and Human Services. After examining the available evidence concerning the status of rural mental health services, the group was unanimous in concluding that serious inequities in accessing mental health and substance abuse services remain. Similar to the conclusions reached by the National Advisory Committee on Rural Health (1993), the group determined that several of these disparities can be traced to the grossly insufficient supply of qualified professionals in rural areas. A set of recommendations were developed in the following two areas: (1) needed strategies for enhancing the supply of providers who are prepared for practice in rural settings; and (2) efforts that would improve access to qualified mental health professionals currently working in rural areas.

The following recommendations overlap with several of those previously proposed by other groups (e.g., Larson, Beeson, & Mohatt, 1993; National Advisory Council on Rural Health, 1992, 1993; National Association of State Mental Health Program Directors, 1993). As such, the results of the Rural Mental Health Provider Work Group should be interpreted as a relatively independent confirmation of the seriousness of the problem and the types of strategies that must be implemented in order to improve the system of health, mental health, and substance care for rural Americans -- a group whose special needs can no longer be overlooked in health care policy debates. Listed below is the series of steps that the Work Group recommends be undertaken.

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 locations 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 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.

Recommendation 6: Funders, administrators, and providers of mental health services should encourage training and service delivery models that respect, and include natural helpers and traditional healers found in rural cultures as one way to maximize available resources.

Recommendation 7: Training programs and credentialling bodies should identify which of their current practices create barriers to the training of rural providers and the delivery of mental health services in rural settings and work toward removing these impediments.

Recommendation 8: Statutory and regulatory mechanisms are needed that allow for the approval of mental health providers to deliver and be reimbursed for the full range of services for which they have the appropriate skills and competencies.

Recommendation 9: Mental health and substance abuse services must be incorporated as an essential component of primary health care if effective delivery of services to rural residents is to be achieved. Achieving full integration can be accomplished in several ways as noted in the following recommendations.

Recommendation 10: Federal and State policy-makers should support efforts aimed at increasing collaboration among the various professions on rural mental health and substance abuse issues.

Recommendation 11: Creative applications of information technology (e.g., telecommunications) that are directed at reducing barriers to accessing mental health services in rural areas and sound evaluations of their effectiveness should be promoted.

Final Report:
Rural Mental Health Provider Work Group

Background and Purpose of the Work Group

Health care in the United States is currently under considerable scrutiny. Although comprehensive health reform legislation has yet to be enacted by Congress, ambitious initiatives already have been launched by many States. These efforts have been at least partly prompted by the need to halt spiraling health care costs and redress glaring inequities in the accessibility of services. The extent to which Federal and State reforms are expected, however, to actually improve access is far from certain, and nowhere is the issue of parity more salient than with regard to mental health and substance abuse services. For example, across the State Medicaid programs, coverage for these types of services -- a key factor in accessibility -- ranges from extensive to none (Frank, Sullivan, & DeLeon, 1994).

The extent to which reform initiatives will improve the accessibility and availability of mental health and substance abuse services to rural Americans is even more unclear. Because rural residents have long experienced difficulty in accessing adequate health care, this uncertainty is particularly troubling. Nearly 21% of Americans live in non-metropolitan areas (Statistical Abstract of the United States, 1993). However, compared to their urban counterparts, rural areas have more serious shortages of appropriately trained professionals, service delivery alternatives are fewer, the array of support services is extremely limited, and the opportunities to acquire affordable health insurance that includes mental health and substance abuse benefits are limited (e.g., DeLeon, Wakefield, Schultz, Williams, & VandenBos, 1989; Rowland & Lyons, 1989; Wagenfeld, Goldsmith, Stiles, Longest, & Manderscheid, 1988). Additional barriers to accessing services also exist, such as increased costs associated with transportation and communication in sparsely populated areas and the perceived stigma surrounding the treatment of mental health disorders among some subgroups.

Nearly thirty years ago, these service inequities were brought to the attention of policy-makers (United States Department of Health, Education, and Welfare, 1969) and were reiterated ten years later by the President's Commission on Mental Health (1978). Since the early 1980s, such stressors as the farm crisis, the outmigration of population, industry, and resources from rural areas, rising unemployment and poverty, and a shrinking tax base have contributed to the increased numbers of rural Americans "at risk" for mental health and substance abuse problems (e.g., Ortega, Johnson, Beeson, & Craft, 1994). In fact, the assembled research evidence suggests that the prevalence and pattern of certain psychiatric disorders may be even higher in rural as compared to urban populations (Kessler et al., 1994), and that for those problems typically linked to urban environments (e.g., drug abuse), the gap between urban and rural may be shrinking (U.S. General Accounting Office, 1990; Wagenfeld, Murray, Mohatt, & DeBruyn, 1994).

In response to a request from the Secretary of the Department of Health and Human Services, the Center for Mental Health Services (CMHS) convened a work group to examine the delivery of rural mental health services by non-physician providers.; As part of this broad charge, recommendations were to be made in four areas:

• The identification of proven and/or promising models for increasing the pool of qualified rural mental health professionals and for delivering appropriate and effective mental health services to residents of rural areas;
• The evaluation of current standards and criteria for the delivery and reimbursement of mental health services and the credentialling of mental health professionals in terms of how they promote or hinder the provision of quality mental health care to rural populations;
• The need for educational strategies that promote the acceptance of non-physician mental health providers by rural communities and consumers/survivors; and
• How education and training efforts can be improved to increase the supply and capabilities of mental health professionals who serve rural populations, especially in terms of strengthening interdisciplinary cooperation and collaboration among providers.

To accomplish these tasks, the membership of the Ad Hoc Rural Mental Health Provider Work Group included representatives from the major constituencies concerned with these human resource-related issues: Federal and State agencies responsible for overseeing health care policies and programs in rural areas; Federal sponsors of research and training in rural mental health services; professional organizations and academic institutions involved in the education and credentialling of rural mental health providers; and mental health consumers/survivors living in rural areas. Two meetings were held in late 1994, and their agendas included both small- and large-group discussions, along with formal presentations by experts in the field.

After reviewing the evidence related to the current status of rural mental health services, the group concluded that basic inequities in accessing mental health and substance abuse services between urban and rural areas persist. Furthermore, redressing these inequities requires more than simple replication of urban service delivery systems due to the unique characteristics of rural residents and their communities. Similar to the conclusion reached by the National Advisory Committee on Rural Health (1993), the group determined that several of these disparities can be traced to the grossly insufficient supply of qualified professionals in rural areas. A set of recommendations were developed in the following two areas: (1) needed strategies for enhancing the supply of providers who are prepared for practice in rural settings; and (2) efforts that would improve access to qualified mental health professionals currently working in rural areas.

A key factor responsible for the limited availability of mental health and substance abuse services in rural areas involves the insufficient number of qualified providers. This shortage has been repeatedly identified as a major problem (e.g., Larson, Beeson, & Mohatt, 1994; Murray & Keller, 1991; National Advisory Committee on Rural Health, 1992, 1993; National Association of State Mental Health Program Directors, 1993; Rost, Williams, Wherry, & Smith, 1995; Wagenfeld, Murray, Mohatt, & DeBruyn, 1994). Furthermore, this shortage applies not only to qualified professionals with the particular skills necessary to practice in rural settings (i.e., the generalist approach) but also to the needed expertise for working with specific target populations such as children and adolescents (Kelleher, Taylor, & Rickert, 1992), the elderly (Teri, 1993), and the dually diagnosed (Osher et al., 1994).

The available data on the distribution of providers between urban and rural settings illustrate the striking disparities. Across the 3,075 counties in the United States, 55% have no practicing psychiatrists, psychologists, and social workers, and all of these counties are rural (National Advisory Committee on Rural Health, 1993). In general, members of the core mental health professions remain concentrated in urban settings; for example, in 1986, about 94% of all psychiatrists and 90% of psychiatric and mental health nurses with graduate degrees were in metropolitan areas (Health Resources and Services Administration, 1992).

The insufficient supply of mental health providers results in several problems associated with not only recruiting but also retaining qualified professionals. As Wagenfeld, Murray, Mohatt, & DeBruyn (1994) cogently summarized:

The quality of services is affected in other ways. Having too few professionals typically results in high caseloads and the assignment of additional responsibilities (e.g., administrative tasks), which reduces the time available for services and interagency coordination and contributes to the fragmentation that already exists among substance abuse, mental health, and primary health care providers.

Given this state of affairs, the Work Group believed that efforts to reduce the serious shortage of trained providers are critical to improving the availability and quality of mental health services in rural areas. Multiple strategies are needed, including those aimed at: (a) increasing the number of mental health service professionals through improved disciplinary and interdisciplinary training provided by academic and service settings; and (b) improving the competencies and support/enabling resources for assisting rural mental health practitioners to deliver appropriate services. As past experience has shown, efforts directed at addressing provider shortages that rely on simply producing more professionals are insufficient by themselves, given the problems associated with attracting and retaining qualified providers in underserved areas (e.g., non-competitive salaries, professional isolation, and frustration with the lack of service resources) and the existing barriers that work against cross-disciplinary collaboration and cooperation in delivering appropriate care (e.g., regulatory constraints on reimbursement and professional ethnocentrism).

The available knowledge about professional training models and the delivery of mental health services in rural areas clearly indicates a mismatch between the two in at least two ways. First, while there is ample evidence that effective rural mental health professionals must be generalists (e.g., Murray & Keller, 1991), the trend of training programs and credentialling bodies has been toward increasing specialization. Second, previous research and experience demonstrate that the characteristics and needs of rural mental health services and the community contexts in which they operate are sufficiently distinct from those in urban settings to justify targeted attention (Wagenfeld, Murray, Mohatt, & DeBruyn, 1994). At the same time, the models guiding most mental health training programs are grounded in the needs, service delivery systems, and resources typically found in urban settings. This is true for even those specialties that stress the importance of understanding community contexts in designing, implementing, and evaluating mental health services, e.g., community psychiatry and psychology (Heyman & VandenBos, 1989).

Consequently, more focused attention must be paid to developing innovative training strategies that are better tailored to preparing individuals to address the specific mental health and substance abuse service needs of rural settings. The Work Group viewed the interdisciplinary curricula recently developed for students in psychology, nursing, and social work (American Psychological Association, the Office of Rural Health, 1995) and the collaborative training model implemented at the University of Hawaii's School of Social Work as positive steps in this direction. However, the heterogeneity of rural areas and their target populations require considerably more work in this area. A variety of creative training mechanisms targeted at different components and stages of the educational process are needed; these include both the didactic and experiential ingredients of formal degree programs (i.e., required and elective course work, clinical practica, and internships), advanced (postgraduate) study, and continuing education strategies.

Previous efforts to train individuals for specific populations or careers have met with mixed success in terms of producing individuals who devote significant portions of their careers to the targeted areas in which they were trained (e.g., Neligh et al., 1991; Santos et al., 1994). This is no less true for rural mental health services delivery (e.g., Hargrove, 1991; Petti et al., 1987). However, some factors have been identified that increase the probability of producing professionals who migrate and practice in rural areas. One involves demonstrated commitment to working in a rural setting at the time of application to a degree program. An indicator of such commitment is previous residence in a rural area (e.g., Breazeale, 1991; Dunbar, 1982; Hargrove, 1991). As such, training programs interested in preparing mental health professionals to practice in rural settings should have as one of their recruitment goals the attraction of qualified applicants from rural settings.

Providing health care increasingly requires interdisciplinary collaboration and cooperation (e.g., Larson, Beeson, & Mohatt, 1993; Wagenfeld, Murray, Mohatt, & DeBruyn, 1994). Because individuals often suffer from multiple problems, particularly ones that involve physical, mental health, and/or substance abuse diagnoses, appropriate quality care requires the combined efforts of several professionals, each with expertise in specific areas. In addition, the advent of managed care carries with it the "organizational reality" that providers in these settings must work effectively as a team in treatment planning, delivery, and review if quality care is to be ensured.

In rural settings, interdisciplinary teamwork and collaboration are often even more critical for several reasons. For example, in sparsely populated areas, health and mental health services are often provided at a single site, prompting the need for routine consultation among providers (American Psychological Association, Office of Rural Health, 1995). The responsibility of Community Mental Health Centers (CMHCs) and other State agencies to treat people with serious mental illness, and adolescents with serious emotional disturbances also requires the involvement and coordination of multiple providers. Furthermore, collaboration in rural areas frequently extends to non-health care professionals such as clergy, teachers, judges, police officers, and paraprofessionals (Heyman & VandenBos, 1989; Reed, 1992).

In addition to promoting the delivery of quality care, interdisciplinary collaboration can be instrumental in reducing professional isolation, stress, and burnout and thus support the retention of providers. As a result of working in teams, individuals begin to understand where their skills and those of their colleagues in other professions overlap and are distinct; they also may acquire additional expertise from their colleagues and thus expand their competencies (e.g., Carty & Day, 1993). Not only do these outcomes facilitate quality care, but such collegial interaction can help to alleviate feelings of professional isolation in rural settings. Another benefit is the reduction of stress associated with being the only psychiatric nurse, psychologist, or social worker in an area and thus always "being on call;" by better understanding where competencies overlap and learning additional skills, arranging for emergency coverage may be less difficult.

However, such collaboration is not common. As Mohatt and Sharer-Mohatt (1990) observed with regard to the delivery of services to a single client, "the scenario of a school counselor treating a school-related behavior problem, a community mental health center involved in outpatient counseling, a court worker dealing with abuse issues, and a social service worker managing family-related issues, all with little collaboration or integration, is the rule not the exception in rural United States." Furthermore, learning to work with individuals in other professions requires certain skills, some of which can be developed through educational programs (e.g., Bhatura, Fuller, & Unruh, 1994). At the same time, many of these capabilities are not a standard component of mental health professional training programs. These programs, for the most part, are disciplinary-based and located in one department within a specific college or school, and the typical organization of universities and colleges is not one which promotes cross-departmental interaction, let alone program development. The increasing trend toward specialization in each of the professions, requiring additional and lengthier training in already packed curriculums, also does not increase the willingness of faculty to add additional components directed at acquiring such skills.

As such, the Work Group has the following specific recommendations with regard to interdisciplinary training:

Few didactic materials are available that address the skills needed for effective interdisciplinary collaboration. A recent exception to this is the interdisciplinary curricula developed by a team of psychologists, social workers, and nurses and sponsored by the American Psychological Association's Office of Rural Health (1995). More such efforts are needed.

In addition, however, a critical ingredient to preparing individuals for rural mental health practice and attracting them to work in rural areas is on-site involvement in rural practice settings. These placements also benefit both faculty in the academic training programs and staff in the service organizations. For example, professors responsible for supervising students may become better sensitized to the research questions and teaching needs specific to rural mental health (Hargrove, 1991); the mental health service programs may gain access to university-based expertise in consultation, program assessment, and other areas. As such, building on the efforts of such individuals as Bridges (1994), Petti et al., (1987), Boust (1991), and others, opportunities for practica, internship, and residency placements should be increased in all the core mental health professions.

Of the current Federally-funded mechanisms that exist, there are at least two programs that could be expanded so as to increase the number of such clinical opportunities. One involves the Area Health Education Centers (AHECs), which are often used as training sites for the provision of rural health care (Zimmerman & Wienckowski, 1991). The second concerns the National Health Service Corps (Larson, Beeson, & Mohatt, 1993). Both of these do incorporate selected mental health professions as part of their training target populations, but existing resources are quite limited, with the majority of attention directed at the medical specialties.

AHECs have played an important role in health care education, training, prevention, and services delivery (e.g., Bridges, 1994; Fowkes, Campeau, & Wilson, 1991; Wagenfeld, Murray, Mohatt, & DeBruyn, 1994). Unfortunately, they have a considerably more varied track record with regard to serving the mental health and substance abuse needs of rural residents, and their distribution is skewed toward rural areas with certain characteristics (Beeson, 1993). Nevertheless, because of their inclusion of multiple disciplines, they represent one promising mechanism for acquiring the interdisciplinary team-oriented skills needed to function in rural practice settings.

In order for these settings to achieve this goal, the geographic distribution of AHECS needs to be made more equitable. Developing the capacity of these organizations cannot stop at increasing their numbers. Rather, it is critical that mental health and substance abuse services be integrated into their overall health care mission. One way to increase the probability of this occurrence is to incorporate the integration of health, mental health, and substance abuse services into the review criteria used to make funding decisions about individual applications.

This recommendation is not new. Similar conclusions have been reached by several blue-ribbon groups charged with identifying strategies for rectifying the inequities in accessing adequate health care faced by rural residents (e.g., National Advisory Committee on Rural Health, 1993; National Association of State Mental Health Program Directors, 1993). At the same time, Federal and State response to such advice has waivered. Some opportunities have been created; for example, Congress established the Rural Interdisciplinary Training for Health Care for Rural Areas Grant Program, which awards a small number of grants to develop and implement interdisciplinary approaches to training rural health care professionals (DeLeon, Wakefield, Schultz, Williams, & VandenBos, 1989). However, a more comprehensive effort is needed with regard to mental health and substance abuse training programs. In addition to strategies that are designed to modify initial training efforts so as to facilitate rural mental health practice, organized programs should be involved in retraining mental health providers who are practicing in urban areas but who are interested in pursuing rural practice opportunities (Merwin, Goldsmith, & Manderscheid, 1995).

Given the recent fiscal constraints facing academic institutions, it would be naive to expect that programs have sufficient resources at their disposal to make such innovations independently. Interdisciplinary training is neither easy nor inexpensive to implement. Without Federal guidance and support in terms of encouraging and supporting innovations for a reasonable period, it is unlikely that any of the prior recommendations can be implemented at a level that would have a demonstrable impact on increasing the supply of providers. As shown by the outcomes of previous federally-sponsored training efforts geared at other underserved populations (e.g., people with serious mental illness and ethnic minorities), such Federal investments are valuable in terms of producing professionals who work with such populations after graduation (Center for Mental Health Services, 1993).

The valuable role of consumers/survivors in improving the mental health service delivery system is widely acknowledged, particularly with regard to people with serious mental illness (Larson, Beeson, & Mohatt, 1993). At the same time, less attention has been given to the role of the rural consumer/survivor (Wagenfeld, Murray, Mohatt, & DeBruyn, 1994). Because involving consumers/survivors in rural settings may present unique challenges not found in urban environments (e.g., the problems created by geographic distance among individuals and confidentiality concerns), there is the need to develop models and evaluate them for their effectiveness with rural populations.

Although small, there is a growing body of evidence that suggests the value of nonprofessional mental health providers. For example, Hollister, Edgerton, and Hunter (1985) examined the relative effectiveness of such alternative forms of service, and their findings point to the need for training more paraprofessionals who are competent to deliver specific services in rural communities. Nonprofessional mental health providers and traditional healers have value in rural cultures. The traditional healers are individuals acknowledged and respected by the rural community as having knowledge, authority, power and training to relieve people of the physical and emotional problems within rural cultural beliefs.

The role of paraprofessionals and self-help groups may be increasing as health care reform initiatives are implemented by the States. For example, in a study of the effects of shifting the responsibility for State hospital services to community mental health centers ("bed buy-back"), evidence suggested that the reductions observed in State hospital admissions may have resulted in mental illness more often treated in the community (Cuffel, Wait, & Head, 1994). Exactly how the community took on this responsibility is unclear, but one strategy may have been to involve paraprofessionals and natural helpers more effectively in the treatment process. Although a much better understanding of how to effectively integrate the formal and informal systems of care is needed, it is important for the future development of culturally relevant care (Fox, Merwin, & Blank, 1995).

How best to utilize these resources is less clear, however. Consequently, those organizations responsible for mental health services and training should foster the use of research findings to identify effective formal and informal systems of care, the implementation of promising strategies and the assessment of their impact on client and service delivery system outcomes.

The supply and utilization of qualified mental health providers are affected by the standards developed and enforced by professional credentialling bodies in licensing and/or certifying mental health professionals and accrediting training programs. The former often are used by third-party payers in the development of their regulations governing which professionals can deliver and be reimbursed for which services. Such limitations on the scope of practice place rural mental health organizations in a special predicament. As compared to their urban counterparts, rural agencies are more likely to rely on mid-level practitioners whose involvement must be approved and supervised by a physician or doctoral-level provider. The shortages of physicians, psychiatrists, and licensed doctoral providers, along with the requirement that the supervision be carried out "on site," creates difficulties in meeting these requirements and thus providing the appropriate services.

Training programs and their accrediting bodies have practices that work against accessing competent practitioners. Training and licensing have become increasingly specialized, and more "generalist" capabilities and interdisciplinary teamwork skills are not viewed as integral program components. Furthermore, rigid requirements for full-time participation in both training programs and clinical internships may be prohibitive for mid-level rural practitioners in rural settings who seek to acquire additional training on a part-time basis.

The current situation may present a "window of opportunity" for such bodies to seriously revisit the appropriateness of their practices and incorporate the needs of rural communities in their decisions. First, there is increasing recognition by training programs (and their students) that their graduates will be working in managed care settings, where team decision-making, trust, and risk-taking are desirable attributes. As such, interdisciplinary practica and internships may be more frequently viewed as valuable and appropriate. Second, current accreditation practices have been criticized for being too onerous, restrictive, and inhibiting innovative training efforts; in fact, the controversy has helped lead to the dissolution of the Council on Postsecondary Accreditation (COPA) and threatened withdrawal of participating universities. This situation may be conducive to change and the incorporation of interdisciplinary training requirements into revised accreditation standards easier to achieve than originally expected.

Whereas increasing the supply and utilization of appropriately trained personnel works toward enhancing the availability of mental health services, it also is necessary to address needed improvements in accessing these services. Currently, significant barriers exist in rural areas as suggested by studies indicating that contact with mental health services was lowest in rural areas (e.g., Cohen & Hesselbart, 1993; Lambert & Aggar, 1994) and that the volume of services is markedly lower (Goldsmith et al., 1994). Although the set of factors responsible for this are complex, they include the geographic distance that separates consumers from providers in sparsely populated areas, the lack of mass transportation, and the infrastructure of the agencies themselves that fund, deliver, and/or credential mental health providers. Moreover, the Federal, State, and local resources for funding services have dropped sharply and continue to decline. The next set of recommendations address strategies aimed at reducing barriers to services.

Exacerbating the shortage of mental health providers in rural settings are the constraints on delivery and reimbursement of services imposed by the major third-party payers of services. For rural areas where the public sector is the major services provider, these requirements typically are attached to Medicaid and Medicare. Although most Federal and State regulations allow or mandate the reimbursement of licensed psychologists, licensed clinical social workers, and licensed psychiatric nurses for services, the most latitude and authority is awarded to physicians. Furthermore, Medicaid requires both approval and/or supervision by physicians for all care, including mental health services delivered by these other professionals. In many cases, there are either no available or interested physicians, including psychiatrists, to carry out these prescribed roles.

The current practice of vesting legal responsibility and accountability solely in physicians often places undue restrictions on the delivery of appropriate and timely mental health services in rural settings. First, there is a shortage of physicians in rural areas, resulting in difficulties experienced in securing approval or supervision for care under Medicaid. Second, the decision as to the professionals who should make which treatment decisions must be guided by which individuals possess the appropriate expertise. As previously stated, the necessary knowledge about mental health and substance abuse problems is highly variable among primary care physicians. The result is that clients' needs are often not appropriately identified and the necessary mental health services ordered. Furthermore, even when other professionals are utilized, the use of physicians as gatekeepers may contribute to parallel rather than coordinated treatment planning and delivery (e.g., multi- versus interdisciplinary services).

Statutory restrictions on who can provide mental health care also have been viewed as generating barriers. Examples are often cited where practitioners with the appropriate training are prohibited from independently providing specific services and being reimbursed for their professional care. Regulations on who can and cannot provide which services (e.g., hospital and prescription privileges) vary across service settings, States, and funding sources. For example, in many hospitals, admission and discharge can only be performed by a physician; however, some community hospitals require the approval of a psychologist before the patient can be discharged, provided the admitting diagnosis involved a psychiatric disorder. Variation among States is also found with regard to the services that psychologists and nurse specialists can approve (e.g., the use of restraints). Additional regulatory barriers have been introduced by managed care, including the limiting of reimbursement to selected individual providers and reductions in the number of disciplines designated as approved providers.

Removing barriers will require a complex set of strategies. The use of mid-level providers (e.g., nurse practitioners and providers with master's degrees in psychology) has been recommended as one approach to increasing access to appropriate care in the health arena (e.g., Campion, Helms, & Barrand, 1993; National Advisory Committee on Rural Health, 1992). At the same time, decisions as to which tasks these individuals can perform (with or without supervision) and receive reimbursement has been an issue generating much controversy among the various professions. It is important that this provider-service specification be developed for several reasons. First, it is unlikely that the core professions as currently defined (e.g., psychiatry, psychiatric nursing, psychology, and social work) can produce sufficient numbers of professionals for rural practice or that rural settings have sufficient resources to attract these individuals (e.g., Hargrove, 1991). Furthermore, in some States, licensed providers other than physicians have been allowed to provide services (e.g., admission to a hospital), resulting in more available care. Finally, it is believed by some that "guild interests" have intruded into these regulatory and credentialling decisions. Given that general relationships have been found among graduate training, therapist experience, and therapy outcome (e.g., Stein & Lambert, 1995), research targeted at deriving actual empirically-based delineations of provider-service specifications for guiding future policy decisions is needed.

A more ambitious and longer-term strategy involves the need to identify ways to enhance the sharing of resources, collaborative decision-making, and joint risk-taking among providers. For example, strategies that would allow more flexibility in the assignment of responsibility for treatment planning and decisions would do much in improving the match between client problems and needed services. The possibility that treatment responsibility and accountability could be shared by a team of providers rather than a single person (i.e., the physician) should be evaluated. Although not a formal recommendation, the Work Group concurs with the recommendation offered by the National Advisory Council on Rural Health (1992) that the feasibility of alternative legal arrangements that can promote flexibility and improved treatment decision-making in rural settings with extreme shortages of mental health personnel should be assessed.

The integration of mental health and substance abuse services is critical to providing quality primary health care. This has been repeatedly stressed (e.g., National Association of State Mental Health Program Directors, 1993; Wagenfeld, Murray, Mohatt, & DeBruyn, 1994). One primary reason is that the shortage of mental health professionals, specific specialty settings, and so forth further limit the cooperation and collaboration among providers (Wagenfeld, Murray, Mohatt, & DeBruyn, 1994).

The need to integrate mental health and substance abuse care with medical care has been the focus of previous recommendations for improving rural health care (e.g., Larson, Beeson, & Mohatt, 1993; National Advisory Committee on Rural Health, 1993). However, this is not the case in many Federal health-related grant programs, e.g., Community and Migrant Health Centers and AHECS (Beeson, 1993). Instead, their focus is on the delivery of primary medical care -- an emphasis that is problematic inasmuch as prior research indicates that mental illness, severe emotional disturbances, and substance abuse disorders often go undetected and, when detected, are poorly managed by physicians.

Availability of mental health and substance abuse services could be enhanced by capitalizing on the resources already allocated to these existing grant programs. One strategy would be to require that grantees have service delivery configurations that make specialty mental health care both more available and more closely linked to general medical care. Such interconnecting of services, often provided "under one roof," would increase the access to these services and also help in the earlier diagnosis of mental health and substance abuse problems.

In discussions of health care reforms, one frequently mentioned option for organizing services in rural areas is the establishment of health networks. In terms of mental health and substance abuse services, the likely success of implementing such strategies remains questionable (e.g., Beeson, 1993; Kronick, Goodman, Wennberg, & Wagner, 1993). Given that such initiatives will go forward, it is important that their membership include mental health and substance abuse providers and that incentives be developed to facilitate such linkages. Otherwise, access to these services will not be improved in those rural areas where specialty services, technology, and provider willingness to participate are limited (Christianson & Moscovice, 1993). A similar argument can be made for including mental health and substance abuse practitioners on the provider panels established and administered by managed care organizations.

Available Federal monies for health service programs are often targeted at underserved populations (i.e., target populations who suffer from shortages of appropriate professionals and services). The current criteria used for awarding such grants (e.g., demonstration programs) typically rely on such indicators as the percentages who are living in poverty and/or who are ethnic minorities (Beeson, 1993). Such criteria discriminate against many rural and frontier areas that also face serious service gaps and deficiencies but do not have high rates of poverty or minority residents. If these Federal programs are designed to improve the availability of services for underserved populations, the criteria for funding decisions should be expanded so that rural areas experiencing serious difficulties in meeting the mental health needs of their residents can be competitive (Beeson, 1993; National Association for Rural Mental Health, September 1994). Furthermore, research efforts directed at better identifying the levels of unmet mental health treatment needs should be encouraged.

One way of maximizing the use of already limited service dollars and professional staff is to encourage consultation and collaboration between primary health care providers and mental health professionals. There are several ways to do this such as using liaison arrangements to assist primary care physicians in managing patients with chronic mental illnesses (e.g., Mechanic, 1990), attaching mental health specialty services to health care service delivery organizations, the use of short-term "swing-bed" capacity to increase collaboration between rural hospitals and local mental health providers (Larson, Beeson, & Mohatt, 1993), to name a few. Interdisciplinary training should also help to promote such collaborative behaviors (see Bray & Rogers, 1995, for a specific example in a rural setting). The benefits are clear -- e.g., more cost-effective treatment can be delivered through the combination of appropriate care and reduced overhead costs. There is the added advantage that availability and accessibility are both enhanced (the professional peer support that results can improve retention of providers).

Increasing interdisciplinary collaboration in service provision requires an understanding of both the common and unique skills of the individual mental health professions. A clear demarcation of these similarities and differences is still lacking, however, and it is unlikely that without Federal encouragement and guidance, a single profession will have the resources (or motivation) to initiate such cross-disciplinary examination. CMHS can be instrumental in stimulating such efforts and possesses the leadership to involve representatives from the major constituencies and work with State and local bodies to sponsor similar efforts that are tailored to specific needs or subpopulations. As a first step, CMHS should provide funding for the major mental health disciplines to continue and expand cross-professional efforts aimed at increasing collaboration on rural mental health and substance abuse issues. This should include assembling representatives from the specific groups interested in rural mental health within the professional societies and other leadership to identify the specific competencies required for service delivery in rural settings.

Current information technology advances hold the strong potential for benefiting rural and frontier areas in many ways. The appropriate use of telecommunications can be valuable in several ways. First, it can work to decrease the professional isolation experienced by rural mental health providers who are separated by long distances and may be the only provider in an area. Second, access to appropriate continuing education is also possible. Sponsorship of efforts to create telecommunication networks and computer technology applications in rural areas has been recommended frequently (Larson, Beeson, & Mohatt, 1993; National Advisory Committee on Rural Health, 1993; National Association of State Mental Health Program Directors, 1993). Some progress has been made in this area; for example, a grant awarded by the Office of Rural Health Policy is supporting the development of telecommunications technologies in Oregon to provide continuing education, college coursework, and communication linkages between rural providers and urban specialists. A resource center for behavioral health care on the World Wide Web (RuralPSYCH) is also being developed by the American Psychological Association. However, these are fairly isolated efforts. More comprehensive efforts are needed to support such demonstration projects and assessment of their success and adaptation by other rural settings.

During an era of tremendous change in the health care system, the mental health needs of rural citizens are of special concern. Policy makers are re-evaluating strategies to: (1) enhance the supply of providers who are prepared for practice in rural settings and (2) improve access to qualified providers currently working in rural areas. If our system of health care is to effectively serve rural communities, care consideration will be needed for the unique aspects of rural service delivery and training providers for practice in rural and isolated areas. The recommendations in the report provide substantive material for consideration.

Substance Abuse and Mental Health Services Administration
Center for Mental Health Services
Ad Hoc Rural Mental Health Provider Work Group

Dr. Peter G. Beeson
Director of Planning
Nebraska Department of Public Institutions
Lincoln, Nebraska

Ms. Cathy Britain
Project Manger
RODEO NET
Eastern Oregon Human Services Consortium
La Grande, Oregon

Mr. Bruce D. Emery
Special Projects Manager
National Association of State Mental Health Program Directors
Alexandria, Virginia

Dr. Michael Enright
Chair, Rural Health Task Force
American Psychological Association
Jackson Hole, Wyoming

Ms. Barbara Garcia
Executive Director
Salud Para la Gente
Watsonville, California

Ms. Karen Gautney
American Association for Marriage and Family Therapy
Washington, DC

Mr. James G. Hill
Director, Office of Rural Health
American Psychological Association
Washington, DC

Ms. Vivian Jackson
Director, Office of Policy and Practice
National Association of Social Workers
Washington, DC

Dr. Peter Keller
Chairman
Department of Psychology
Mansfield University
Mansfield, Pennsylvania

Dr. Oscar Kurren
Professor, School of Social Work
University of Hawaii at Manoa
Honolulu, Hawaii

Dr. Arthur L. McDonald
President
Dull Knife Memorial College
Lame Deer, Montana

Dr. Clair Martin
Dean and Professor
School of Nursing
University of Colorado Health Science Center
Denver, Colorado

Dr. Beth Merwin
Associate Professor
School of Nursing
Virginia Commonwealth University
Richmond, Virginia

Mr. Dennis Mohatt
President
National Association for Rural Mental Health
Wood River, Illinois

Dr. Georgine Pion
Research Associate Professor
Psychology and Human Development
Vanderbilt University
Nashville, Tennessee

Dr. Janet A. Rodgers
Dean
Philip Y. Hahn School of Nursing
University of San Diego
San Diego, California

Mr. Thomas Stanitis
National Rural Alcohol and Drug Abuse Network
Johnson, Bassin, & Shaw, Inc.
Silver Spring, Maryland

Dr. Colleen Conway Welch
Professor and Dean
School of Nursing
Vanderbilt University
Nashville, Tennessee

Federal Representatives

Dr. Bernard S. Arons
Director
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
Rockville, Maryland

Dr. Marcia Brand
Allied & Associated Health Branch
Division of Associated, Dental, & Public Health Professions
Health Resources and Services Administration
Rockville, Maryland

Mr. Armand Checker
Office of Rural Mental Health Research
National Institute of Mental Health
Rockville, Maryland

Dr. Harold Goldsmith
Survey and Analysis Branch
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
Rockville, Maryland

Ms. Sandie Johnson
Center for Substance Abuse Prevention
Substance Abuse and Mental Health Services Administration
Rockville, Maryland

Ms. Glenda Koby
Office of Rural Health Policy
Health Resources and Services Administration
Rockville, Maryland

Dr. Harriet G. McCombs
Prevention, Program Development, & Special Populations Branch
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
Rockville, Maryland
Dr. George McCoy
Mental Health Program
Indian Health Service
Rockville, Maryland

Mr. James E. Pittman
Director, Division of Program Development, Special Populations & Projects
Center for Mental Health Services
Substance Abuse and Mental Health Administration
Rockville, Maryland

Mr. Robert T. Van Hook
Secretary for Planning and Evaluation
Department of Health and Human Services
Washington, DC

Dr. Paul Wohlford
Human Resource Planning and Development Branch
Center for Mental Health Services
Substance Abuse and Mental Health Administration
Rockville, Maryland

Mr. David Worgo
Medicaid Bureau
the Centers for Medicare and Medicaid Services
Baltimore, Maryland

SMA98-3166