cover story two

Outstate Behavioral Health Care

Meeting the challenges and needs

By Thomas Otten, MA

Prior to the pandemic, the demand for mental health care far exceeded the supply, and now that equation has been made worse with one in every four job openings in the field unfilled. This situation is even worse in outstate areas where patients face unique barriers to seeking care. In small towns, not only is it more likely for everyone to know everyone else’s business, and such things to travel quickly, but the stigma—internal or external—of dealing with mental health concerns can be higher. Farmers, for example, have an ingrained can-do attitude of pulling themselves up by their boot straps, an admirable attitude but one that does not translate well, for example, to dealing with depression or anxiety disorder. As of mid 2022, nearly 30 farmers in America are dying by suicide every day, meaning they have one of the highest suicide rates of any occupational group. Though it may not help with climate change related drought or poor government policies, better access to mental health services would certainly help address this.

Simple mental health baseline data should be a part of every patient’s medical record.

The Zero Suicide Initiative, a national program with the goal of reducing suicides to zero through use of a set of tools—one of those being screening and assessment in clinics and emergency departments—is a program we have been using since 2016. The majority of suicides—75%—take place within 60 to 90 days after a medical encounter. This doesn’t assess any blame; it’s just a reality check for all of us, and it points to an opportunity for prevention. We won’t always catch it—in fact, research tells us that the decision to take one’s own life is usually made only a couple of hours earlier. But if we can spot a downward trend and encourage that person to take action, we might save a life.

Another element for concern relates to substance use disorder (SUD). Many people assume that large cities are havens for mind-altering drug use and alcohol abuse, however smaller communities have seen dramatic increases in opioid misuse and overdoses, and meth may be even more available there than in urban and suburban areas. What is not available are inpatient treatment beds, after care programs and certified counselors to help people understand and deal with these problems. While there are tools available to help start these kinds of programs, the infrastructure and staffing to accomplish this is rarely present. Some estimates suggest that as many as 50% of patients have SUD issues, no matter whatever other primary medical problem there might be. A basic mental heath patient in-take screening tool could help identify these concerns.



Increasing access to care

One recent positive development is the new 988 Lifeline. Going live on July, 16, 2022, this nationwide service follows NAMI’s standard of care and is billed as “a direct connection to compassionate accessible care.” Designed to strengthen and expand the National Suicide Prevention Hotline, this 24/7 service will serve and support anyone experiencing mental health-related distress. Funding for the program comes through the Substance Abuse and Mental Health Services Administration (SAMHSA). They envision a robust crisis care response system that will link callers across the country to community-based providers and resources that can deliver a full range of crisis care service. There are expected growing pains, as there were rolling out 911, but the hope is to help address the growing mental health crisis; this action is an example of the scope and serious nature of the challenges this presents.

Another area of emerging awareness, and crisis, involves pediatric mental health. It is now estimated that one in seven children aged 10-19 has some kind of mental illness with depression, anxiety or behavioral disorders leading the way. Almost 20% of U.S. high school students have given serious thought to suicide and almost 10% have actually tried to kill themselves. Evidence clearly shows a sharp increase in pediatric behavioral issues over the past 15 years, despite some calling it a hoax. Many factors for the increase can be cited, but there have also been many outstanding responses. Children require a different approach to treating behavioral health issues, and many medications for adults are not appropriate for developing brains.

One recent response that is proving beneficial is the development of the school-based health center and incorporating behavioral health services into these centers. It is an expansion on school nurses who may have to visit several schools each week and can work with a variety of community resources. As an example of this, our organization has been working for the past five years with school teachers in Brookings to help them understand ways they can assist students who may be facing behavioral health issues. We have recently expanded this outreach to include a middle school in Sioux Falls.

The growing creation of dedicated adolescent behavioral health inpatient treatment facilities, and dedicating sections of hospitals to this use, further illustrates the scope and importance of the issue. Children whose issues can be identified and treated early in life can minimize the development of chronic conditions later in life that can have serious adverse effects on their overall health.

People come from all over the country to study our model.

Dedicated facilities

Additionally, and importantly, the creation of new modern facilities addresses several issues. On a very basic level, these facilities build awareness around the serious nature of behavioral health treatment and foster acceptance replacing stigma. Depression is no different than high blood pressure or diabetes and should not be viewed as a weakness. Psychiatry was often confined to a broom closet at the back of the top floor of a hospital, a mistake leading to many downstream complications that are slowly being corrected. Our hospital, Avera Behavioral Health Hospital, was originally constructed in 2006 to serve all behavioral health care needs in our area; recently we added 60,000 square feet, which includes 24/7 behavioral health urgent care and youth addiction care services. We now have almost 150 inpatient beds and the facility is truly a world-class destination for mental health services. People come from all over the country to study our model, and we hope it will lead to similar advances in other markets.  

Perhaps we have proven the Field of Dreams maxim of “if you build it, they will come,” but that does not address the lack of behavioral health providers, especially in the outstate areas. There it becomes the de facto proxy of primary care providers to prescribe medications around whose benefits and uses they may have received minimal training. PAs, nurse practitioners, masters level social workers, psychologists and others are also called into service and must all work together with as much coordination as possible to address the workforce shortage crisis. There are phone counseling services available that can be accessed during a patient visit that can be very helpful.

Telemedicine applications to behavioral health have existed at Avera for 25 years, but that use was significantly increased during the pandemic. From the difficulties of the pandemic, it is important we use this as an opportunity to revolutionize the care of behavioral health patients. Developing the trust to make therapeutic progress can take time, but it is a pathway to care that is now more widely available. It should be explored and offered as an option, as it offers the flexibility to be incorporated into any clinical setting in a variety of ways. Most insurance continues to cover it, and while some patients simply do not have access to the internet or have limited literacy around computers and related technology, almost everyone can use a smart phone. The convenience of seeing a professional from their own home, or in the case of a farmer from their tractor, can have a significant appeal. In fact, research over the years has shown that some patients feel it is easier to build rapport with a therapist and to talk about difficult subjects via televideo instead of in person.

Addressing the future

Another challenge facing the delivery of behavioral health care is an increasingly diversified patient base. Different cultures perceive and respond to common diagnoses in different ways. In our practice, we see this most clearly in serving the Native American population. We provide specialized training to providers and support staff around how to best communicate around sensitive and complex issues. Oftentimes, when dealing with behavioral health concerns, listening is as important, or even more important, than offering a care plan. Part of diversity training is learning what to listen for. It is also important to understand that diversity goes beyond race and must also include age, economic status, people with disabilities and more. People from all of these groups may have behavioral health concerns and must be treated with equity and awareness of the unique challenges they may face.

As we move forward, solving the many challenges facing the delivery of behavioral health care will require building new partnerships. As an industry, this will mean new ways of involving and working with employers, communities, payers and state government. Each of these entities has a vested interest in everyone’s individual health and, as we have discussed, behavioral health is a big part of overall health. Each of these entities must be encouraged to continue their work in removing the stigma a person may feel around seeking help for behavioral health care concerns. Public and private partnerships are an incredibly effective way to help meet this challenge. We must all work together to raise awareness of what these concerns are and how they may be treated.

Thomas Otten, MA, is the behavioral health service line administrator for Avera Health, where for the past 22 years he has held positions relating to managing, improving and expanding behavioral health care within the hospital, university health center and the region.