In some rural towns, it's not unusual for just about everyone to know your name—and the car you drive.
As a result, a rural resident's means of transportation can actually play a big role in mental health. The act of parking near a mental health professional's office is a conspicuous act in rural settings, so much so that many residents would rather forgo needed care than have neighbors know that they're seeking help, industry experts say. Combine that with the fact that few mental health specialists are available in most rural areas, and a climate is created in which mental health issues often go untreated.
“There are a lot of people who are suffering and have a range of behavioral health concerns and don't access care,” says Parinda Khatri, director of integrated care at Cherokee Health Systems, a Knoxville, Tenn.-based operator of federally qualified health centers with a strong rural presence.
But there is increasing interest among rural providers to get past those two problems by using primary care as the conduit for providing mental healthcare, an approach that has been successful at improving outcomes and saving money in urban regions if reimbursement issues can be worked out or avoided.
“We reduce the stigma of seeing a behavioral health provider” if the care is provided in the more welcoming environment of primary care, Khatri says.
One of the latest efforts is a federally backed project to provide mental healthcare for depression among lower-income older adults in the rural areas of Washington state, Wyoming, Alaska, Montana and Idaho, a region known as WWAMI. The project was awarded $2 million in seed money for a two-year grant in August by the federal Social Innovation Fund, and may get an additional $1 million for its third year of operation. That will be matched by the recipient of the grant, the John A. Hartford Foundation, which will seek matching funds from the regions where the projects are implemented, bringing total funding to an expected $11 million.
Healthcare providers offering mental healthcare integrated into primary care include Cherokee Health, which has offered integrative care in mental health and other areas for years, and Minnesota's Depression Improvement Across Minnesota, Offering a New Direction program, known as Diamond, which was launched in March 2008 using the same model underlying the WWAMI project.
That model, called Improving Mood-Promoting Access to Collaborative Treatment, or IMPACT, was developed by Dr. Jurgen Unutzer, director of the Advancing Integrated Mental Health Solutions Center, or AIMS, at the University of Washington, Seattle, and professor and vice chairman of the school's department of psychiatry and behavioral sciences.
Unutzer led a 2001 study showing that the approach reduced symptoms of depression by half or more for 45% of the patients undergoing the treatment, compared with those receiving more typical mental healthcare separate from primary care. In addition, the researchers found that over time, the approach saved money. One 2008 study in the American Journal of Managed Care found that IMPACT patients incurred mean total healthcare costs of $29,422 over a four-year period, while patients not participating in IMPACT incurred mean costs of $32,785, a difference of more than $3,300.
“When you integrate, it works,” says Benjamin Miller, director of the Office of Integrated Healthcare Research and Policy in the department of family medicine at the University of Colorado School of Medicine. He's also director of information and policy at the Collaborative Care Research Network. More research is needed to know why it works, but it does have a positive effect on care, Miller says.
IMPACT's particular form of integrated mental healthcare calls for three clinicians—a frontline care manager, a primary-care physician and a consulting psychiatrist—to collaborate in providing mental healthcare within a primary-care setting. The care manager, who receives training and might be a nurse, psychologist or social worker, works with the physician to create a care plan. The care manager also performs education, coaches the patient and, most importantly, monitors the patient for treatment response.
“We are very big on a concept called measurement-based care, or treatment to target,” Unutzer says. The initial plan is given 10 to 12 weeks to work, and if it doesn't work, the consulting psychiatrist is brought in to change it.
Unutzer says the IMPACT model may work especially well in the areas targeted by the WWAMI grant, where fewer mental-health professionals practice and large sections of the states are classified as rural.
“There's an access problem,” he says, with the targeted areas containing only one medical school, at the University of Washington.
An area the AIMS Center would like to study further is the question of whether the approach can reduce healthcare costs in rural regions, as it does in urban areas, Unutzer says.
“Providing good care in a rural setting often is more expensive because you don't have the economies of scale,” he says. It's possible that telemedicine will play a larger role in the project, he says. Telemedicine can save money by allowing a specialist mental health provider to confer with a patient without traveling to the patient or having the specialist reside in the area.
Cherokee Health has had success offering a primary-care integrated mental health approach to rural residents using telemedicine, Khatri says. “Our director of psychiatry hasn't seen a patient face to face in, I'm thinking, five or six years,” Khatri says. Telepsychiatry is practiced with the assistance of a local psychiatric nurse in seven of Cherokee's clinics, she says.
Other mental health providers are interested in adopting primary-care integrated approaches. “As a model of care, this is really exciting,” says Katherine Davis, program director for Vitality for Life, a senior mental health wellness program at 23-bed Carson Valley Medical Center, Gardnerville, Nev.
The IMPACT approach, in reducing the fear that seniors have in accessing mental healthcare, could solve a difficult problem with depressed rural seniors, who often feel isolated and alone, Davis says. “They're starting to feel like life has no purpose anymore,” she says.
Dr. Neil Korsen, medical director for the behavioral health integration program at seven-hospital MaineHealth system, Portland, says the system is working toward implementing a form of the IMPACT model, but has hit a stumbling block. MaineHealth serves rural areas as well as Portland, the state's largest city.
“We've not been able to keep that psychiatrist role going because nobody pays for it,” Korsen says. “It's a problem with our payment system” that might be alleviated by the industry's broader move to implementing accountable care, he says. In the meantime, MaineHealth executives will continue to find a way that works, he says.
The Diamond program in Minnesota, which has the backing of not-for-profit insurers in the state, is in its fourth year and is offered by more than 60 clinics and has activated roughly 10,000 patients into the program, says Jim Trevis, a spokesman for the Institute for Clinical Systems Improvement, the Bloomington, Minn., not-for-profit that runs Diamond. The ICSI finds clinics willing to implement the program and then the participating insurers agree to reimburse for the costs, Trevis says.
After six months, of all patients entering the program, two-fifths had at least a 50% reduction in the severity of their depression and almost one-third were no longer depressed.
Officials for Medicare and Medicaid are showing interest. In June, the CMS awarded $18 million over three years to an ICSI-led group that includes the Mayo Clinic and Kaiser Permanente to create a model that expands on the Diamond approach to treat patients with depression and either diabetes or cardiovascular disease, or all three.
The Hartford Foundation, based in New York, wouldn't mind getting similar or better results with the project in WWAMI, given the success IMPACT has had in Minnesota and elsewhere, says Chris Langston, program director for the foundation. “We're pretty confident it's going to work, but if it were 100% confidence, it would be a lot less interesting.”