Filling Behavioral Health Gaps in Rural Communities

The article is part of a partnership between the Commonwealth Fund and the Bassett Research Institute in Cooperstown, N.Y., to explore innovative approaches to the health care challenges facing rural communities across the United States.

Introduction

In 2016, just months after taking charge of Dayton General Hospital, a 25-bed critical access hospital in the southeastern corner of Washington State, Shane A. McGuire came upon a nurse who was tossing referrals from outlying hospitals into a trash can. “It’s just someone wanting to unload their patients on us,” he recalls her saying.

As CEO, McGuire was intrigued. The hospital — part of the Columbia County Health System (Columbia), which also operates two rural health clinics and a nursing home in a county with roughly 4,700 people — had an average daily census of just 1.7 patients and the staff to care for far more.

McGuire learned the hospital received one to two requests like this each day from discharge planners at hospitals across the state, all wanting to know if Dayton General could take on patients who needed skilled nursing care but were hard to place. Some were homeless, many had mental health or substance use issues, and nearly all were covered by Medicaid, one of the lowest payers in the state. Without a place to go, these patients often remain in hospitals, filling beds that are needed during COVID surges, heat waves, and other emergencies.

Like other critical access hospitals, Dayton General was in a position to help because it can dedicate some of its beds as “swing beds” for people needing rehabilitation. In rural communities, swing beds are often used for patients recovering from surgeries or those who require infused antibiotics to treat infections. Across the United States, the capacity of critical access hospitals often goes untapped. The median average daily census for a critical access hospital was 2.2 patients in 2020, according to data from the Flex Monitoring Team, a consortium of rural health research centers. The census for swing beds was even lower that year at 1.5 patients per day.

As McGuire and his staff began thinking through what it would take to honor these requests, he was also hearing about a pressing need for mental health services in his local community. Columbia’s rural health clinics had recently begun screening for depression as part of a patient-centered medical home program. A full third of patients were screening positive for clinical depression and “we weren’t doing anything about it,” McGuire says.

Part of the problem was that there were no psychiatrists in the county and the issues clinicians were seeing were not easy to address, even for the clinics’ newly hired social worker. “We were getting in a room with people who had experienced just horrific childhood events, some had posttraumatic stress disorder, and there was nowhere to refer them,” McGuire says. This workforce shortage is pervasive in rural counties: nearly two-thirds lack psychiatrists and nearly half lack psychologists.

Leveraging Rural Hospitals’ Strengths to Help Patients with Complex Needs

To build a continuum of behavioral health services, McGuire partnered with the University of Washington’s Advancing Integrated Mental Health Solutions Center (AIMS Center) in Seattle in 2017. The AIMS Center promotes the integration of physical and behavioral health services through its Collaborative Care model, which enables specialists to offer guidance to primary care and hospital-based providers as they manage behavioral health conditions. Two of its psychiatrists agreed to provide consultations to providers in Columbia’s rural health clinics, as well as its hospital and nursing home, and offer telehealth visits with patients as needed.

With this support in place, McGuire and his staff began making the rounds of vendor fairs at hospitals across the state. Their pitch — that Dayton General could provide acute care or skilled nursing services to patients at high risk of readmission — resonated with discharge planners who saw patients, particularly those with substance use issues, cycle in and out of hospitals and emergency departments. “They are tired of the revolving door. They want to see some intervention for these folks as well,” McGuire says.

As hospitals across the state took them up on the offer, Dayton General’s average daily census increased to 14 patients. Of those using its swing beds, nearly 60 percent have substance use disorders, including problems with methamphetamine, alcohol, and opioids. Many come from outside the community, putting distance between them and the environment or relationships that contributed to their substance use. “If you’re from Aberdeen, more than 350 miles away, the person who supplies you with drugs is not going to run to Dayton,” McGuire says.

Addressing Physical and Behavioral Health Issues

Patients in the swing bed program can be in the hospital for 30 days or more, giving providers time to offer treatment that patients might have difficulty finding elsewhere or might otherwise refuse.

Dayton General providers have curbside consults with University of Washington psychiatrists to talk through medication options for patients experiencing delirium or strategies for caring for those struggling with the limitations that a catastrophic injury brings, says Sara Ragsdale, D.O., a hospitalist at Dayton General. They can also arrange for patients to meet with Thomas Soeprono, M.D., a University of Washington psychiatrist who keeps time open on his schedule for telemedicine visits. He typically spends an hour with a patient and enters his recommendations for medication and follow-up care directly into Dayton’s electronic record system. “I try to create a robust plan that goes beyond just medication recommendations to address the psychosocial issues that are playing a role,” says Soeprono.

Ragsdale remembers referring one patient who was having “nearly violent” interactions with staff, throwing objects around the room. He was resistant to taking medication until he had an appointment with Soeprono. Once treated for anxiety and depression, “he was a completely different person,” she says. Over the course of his stay, he began making career plans and even got engaged to his significant other. “He invited us all to the wedding,” Ragsdale says.

For patients with substance use disorders, providers prescribe medications and make connections to outpatient care. McGuire estimates that between 10 percent and 20 percent of the patients with substance use disorders have stayed in long-term treatment. Not all are receptive to offers of help, but staff have long memories of the successes, including a patient who qualified for heart valve transplant after getting sober. “She’s been an amazing source of inspiration,” McGuire says.

Staff try to use challenges, like the time a patient ordered alcohol-based mouthwash via Amazon, as teaching moments. “We see them as a catalyst to have that critical conversation, to say, ‘Is this really what you want for yourself?’” says McGuire. “It’s not meant to be punitive. We say, ‘we know how hard this battle is and we’re coming with you, not at you.’”

Integrating Behavioral Health Services into Primary Care

Columbia’s partnership with the AIMS Center also helped the rural health clinics offer behavioral health services, though these have been hard to sustain given the difficulty of recruiting licensed clinical social workers to rural areas. When the program launched in 2018, the rural clinics had two social workers on staff who met with an AIMS Center psychiatrist once a week via video conference to discuss new patients and those not making expected improvements. The social workers also began offering counseling, including specialized treatment for posttraumatic stress disorder.

The psychiatrist saw the clinics’ patients remotely as needed and added assessments and treatment recommendations into a shared medical record. This approach ameliorated some of the behavioral health issues that drove emergency department use — including anxiety and domestic violence — and also relieved provider burnout, says Dawn Meicher, A.R.N.P., Columbia’s population health provider champion. "The providers saw it was working and the patients saw it was working,” she says.

After the two social workers moved out of the area last year, it has been difficult to hire others. Columbia eventually recruited someone with a master’s degree in social work, who has been meeting with AIMS Center psychiatrists and seeing some patients. But she’s unable to bill for her services: in rural health clinics, only psychiatrists, psychologists, and licensed clinical social workers can do so.

Lessons for Other Rural Providers

While there are similar “hub-and-spoke” approaches connecting specialists in academic medical centers to providers in rural communities, the partnership between Columbia County Health System and University of Washington appears to be unique in that it supports a comprehensive suite of inpatient, outpatient, and rehabilitative behavioral health services.

The model has proven beneficial for both urban and rural communities: Columbia helps larger hospitals find places to send patients who need long-term support and, in turn, gains access to specialty behavioral health care for patients in its community. Columbia recoups most of what it pays for the AIMS Center program (around $132,000 per year for a designated number of psychiatric consultations) through the cost-based payment system for critical access hospitals and rural health clinics. This is significantly less than the cost of hiring a full-time psychiatrist. The health system covers the remainder with shared savings it receives as an accountable care organization and from grant funds.

Along with expanding access to specialty behavioral health services, the partnership benefits the broader community. As the hospital’s census and revenue have increased, Columbia has reduced its dependence on property tax levies to sustain its operations.

Columbia’s experience offers lessons for other rural providers.

Recognize and leverage the strengths of your institution.

Columbia has taken a key challenge of rural health care — low volume of patients — and turned it into an asset.

According to Onora Lien, executive director of Northwest Healthcare Response Network — a coalition of Washington State providers working together to prepare for emergencies — many of the state’s hospitals struggle to find places to discharge patients who have complex medical and social needs. “At any given time, 10 percent to 20 percent of hospital beds are being filled by patients who medically are cleared for discharge and don't belong there,” she says. This makes it harder for hospitals to prepare for surges of patients during emergencies, like the heat waves the region has experienced.

By taking on some of these patients — and giving them the time and attention to address some of their physical and behavioral health conditions — rural hospitals can use their swing bed capacity to fill a critical gap in the continuum of behavioral health services.

Find opportunities to build the skills and confidence of your workforce.

Having more patients, and ones with more complex needs, has helped keep Dayton General’s staff busy and challenged, McGuire says. “They are happy because they’re taking care of people and getting better at their craft. When one of my local people come here, they are getting the top-level skill they can have,” he says.

Building behavioral health services in rural communities will require a more stable workforce.

Rural hospitals already struggling to hire and retain behavioral health providers, as well as those facing nursing shortages, may not be willing to take on the added challenge of caring for patients with complex needs, even if doing so increases revenue.

Recognizing this, the Health Resources and Service Administration, which helps set policy for federally qualified health centers and rural health clinics, has taken steps to expand the behavioral health workforce in rural communities through training and technical assistance programs. It recently launched a grant program for rural providers interested in delivering substance use disorder treatment. In addition, the Centers for Medicare and Medicaid Services may soon allow marriage and family therapists and licensed professional counselors to bill Medicare for behavioral health services, a move that would make it vastly easier for rural providers to meet local needs.