HARVARD UNIVERSITY

Ernst Mayr Library

of the Museum of

Comparative Zoology

MCZ

I (ppaRi

NOV

% 2006

Journal of the

VOLUME 86

Number*#

December, 2000

l-W

CIENCE

ISSN 0043-0439

Issued Quarterly

at Washington, DC

library

1

lUUJ

CONTENTS

Articles:

HARVARD

A Word from the Editorial Staff . . i

James A. Ciarlo, Pearlanne T. Zelarney, “Focusing on “Frontier”: Isolated

Rural America” . 1

Charles E. Holzer III, Harold F. Goldsmith, James A. Ciarlo, “The

Availability of Health and Mental Health Providers by Population Density” . 25

Dennis F. Mohatt, “Access To Mental Health Services in Frontier America” . 35

Charles E. Holzer III, James A. Ciarlo, “Mental Health Service Utilization

in Rural and Non-Rural Areas” . 49

Morton O. Wagenfeld, “General Models for Delivering Mental Health

Services to Seriously Mentally Ill Persons in Frontier Areas” . 59

Morton O. Wagenfeld, “Organization and Delivery of Mental Health

Services to Adolescents and Children with Persistent and Serious Mental

Illness in Frontier Areas” . 81

Sheila Cooper, Morton O. Wagenfeld, “Delivering Mental Health Services

to Children and Adolescents with Serious Mental Illness in Frontier Areas:

Parent and Provider Views” . 89

Courtenay M. Harding, Mary Van Pelt, James A. Ciarlo, “Problems Faced

by Consumers of Mental Health Services Out in a Frontier Community” . 99

James W. Stockdill, James A. Ciarlo, “Aging, Mental Illness, and the

Frontier” . 107

Jack M. Geller, Peter Beeson, Roy Rodenhiser, “Frontier Mental Health Strategies:

Integrating, Reaching Out, Building Up, and Connecting” . 117

Jack M. Geller, Kyle J. Muus, “The Role of Rural Primary Care Physicians

in the Provision of Mental Health Services” . 131

James E. Sorensen, “Cost Dynamics of Frontier Mental Health Services” . 143

James E. Sorensen, “Client Outcomes and Costs in Frontier Mental Health

Organizations” . 159

James E. Sorensen, “Effective Management Strategies for Frontier Mental

Health Organizations” . 179

Walter F. LaMendola, “Telemental Health Services In US Frontier Areas” . 189

Walter F. LaMendola, “Telemental Health Services in Frontier Areas:

Provider and Consumer Perspectives” . 197

Andrew Keller, “Managed Behavioral Health Care on the Frontier” . 205

1999 Membership List . 219

^asiljington gUabemp of Sciences;

Founded in 1898

EXECUTIVE COMMITTEE

President

Allen Barwick

President Elect

Jerry Gibbon

Secretary

Clifford Lanham

Treasurer

Frank R. Haig

Past President

Rex Klopfenstein

Vice President, Membership Affairs

Robert Katz

Vice President, Administrative Affairs

Dianne Pickar

Vice President, Junior Academy Affairs

Vacant

Vice President, Affiliate Affairs

Peg Kay

Board of Managers

John H. Proctor

Eric Rickard

Norman Doctor

Jerry Chandler

Janet Reid

Thomas E. Smith

REPRESENTATIVES FROM

AFFILIATED SOCIETIES

Delegates are listed on inside rear cover

of each Journal.

ACADEMY OFFICE

Washington Academy of Sciences

Room 8 1 1

1200 New York Ave., N. W.

Washington, DC 20005

Phone (202)326-8975

FAX (202) 289-4950

Email was@aaas.org

Web http://www.washacadsci.org

EDITORIAL BOARD

Editors:

Marilyn R. London

Thomas E. Smith

The Journal

This Journal , the official organ of the Washing¬

ton Academy of Sciences, publishes original

scientific research, critical reviews, historical

articles, proceedings of scholarly meetings of

its affiliated societies, reports of the Academy,

and other items of interest to Academy mem¬

bers. The Journal appears four times a year

(March, June, September and December). The

December issue contains a directory of the cur¬

rent membership of the Academy.

Subscription Rates

Memberships, fellows, and life members in good

standing receive the Journal without charge.

Subscriptions are available on a calendar year

basis, payable in advance. Payment must be

made in U.S. currency at the following rates:

U.S. and Canada . $25.00

Other Countries . 30.00

Single copies, when available . 10.00

Claims for Missing Issues

Claims will not be allowed if received more

than 60 days after the day of mailing plus time

normally required for postal delivery and

claim. No claims will be allowed because of

failure to notify the Academy of a change of

address.

Notification of Change of Address

Address changes should be sent promptly to the

Academy Office. Such notification should

show both old and new addresses and zip

codes.

POSTMASTER: Send address changes to

Washington Academy of Sciences, Room 811,

1200 New York Ave., N.W., Washington, DC

20005.

Journal of the Washington Academy of Sciences (ISSN 0043-0439)

Published by the Washington Academy of Sciences, (202) 326-8975.

A Word from the Editorial Staff

This volume consists of 17 articles on the subject of Mental Health on the Frontier,

organized by Fellow and Past WAS President Dr. Ronald W. Manderscheid and his

colleagues. These articles address a real and growing need in our society, and we hope

that our readers will find the information both interesting and useful.

This publication represents the entirety of Volume 86. Our next publication, Vol¬

ume 87, will also come out as a single issue instead of four individual issues. JWAS

will then be back on schedule for the year 200 1 , but we may continue to experiment

with the number of issues per volume.

The editorial staff is still seeking WAS Fellows who wish to participate in the pub¬

lication of the Journal by reviewing manuscripts in their fields. The Journal receives

scores of manuscripts each year, and they all require peer reviewers. Please contact the

Journal (by mail), indicating your interest and specifying your area of expertise.

New Guidelines for Contributors are being developed, and these will appear both in

the Journal and on the WAS Web site, http://www.washacadsci.org. Please visit the site

for up-to-date information on Academy activities and projects.

On behalf of the Board of Managers and all members of the Academy, we thank

each of the contributors to the journal for their continued interest and their patience.

Marilyn R. London

Thomas E. Smith

.

Mental Health on the Frontier

Edited by

Ronald W. Manderscheid, Ph.D.

US Center for Mental Health Services

Harold E Goldsmith, Ph.D.

US Center for Mental Health Services (Retired)

James A. Ciarlo, Ph.D.

Pearlanne T. Zelamey, M.S.

University of Colorado

Peter G. Beeson, Ph.D.

National Association of Rural Mental Health

Marilyn J. Henderson, M.P.A.

US Center for Mental Health Services

in

Mental Health on the Frontier

Outline

Section A. What is the Frontier?

Ciarlo and Zelamey, Focusing on “Frontier”: Isolated Rural America

Section B. Mental Health Service Availability and Access

Holzer et al., The Availability of Health and Mental Health Providers by

Population Density

Mohatt, Access to Mental Health Services in Frontier America

Holzer and Ciarlo, Mental Health Service Utilization in Rural and Non-Rural

Areas

Section C. Care of Special Populations

Wagenfeld, General Models for Delivering Mental Health Services to

Seriously Mentally Persons in Frontier Areas

Wagenfeld, Organization and Delivery of Mental Health Services to

Adolescents and Children with Persistent and Serious Mental Illness in

Frontier Areas

Cooper and Wagenfeld, Delivering Mental Health Services to Children and

Adolescents with Serious Mental Illness in Frontier Areas: Parent and

Provider Views

Section D. Special Concerns and Approaches

Harding et al., Problems Faced by Consumers of Mental Health Services Out

in a Frontier Community

Stockdill and Ciarlo, Aging, Mental Illness and the Frontier

Geller et al., Frontier Mental Health Strategies: Integrating, Reaching Out,

Building Up, and Connecting

Geller and Muus, The Role of Rural Primary Care Physicians in the

Provision of Mental Health Services

Section E. Cost and Outcome of Care

Sorensen, Cost Dynamics of Frontier Mental Health Services

Sorensen, Client Outcomes and Costs in Frontier Mental Health

Organizations

Sorensen, Effective Management Strategies for Frontier Mental Health

Organizations

Section F. Future Strategies

LaMendola, Telemental Health Services in US Frontier Areas

LaMendola, Telemental Health Services in Frontier Areas: Provider and

Consumer Perspectives

Keller, Managed Behavioral Health Care on the Frontier

vi

Mental Health on the Frontier

Introduction

Although the frontier areas of the United States still hold considerable interest and

promise, they also have special problems not shared by other segments of the popula¬

tion. One of these areas is the delivery of mental health services. In the early 1990s, the

US Center for Mental Health Services funded a Technical Assistance Center for Fron¬

tier Mental Health Services to identify problems in mental health service delivery on

the frontier, to prepare needed technical assistance documents, and to offer technical

assistance. The manuscripts included in the present edition of the Journal of the Wash¬

ington Academy of Sciences were prepared as part of that endeavor.

The manuscripts are organized into six Sections to help the reader think through the

problems associated with delivering mental health services on the frontier. Section A

can help the reader understand the “frontier” and its characteristics; Section B exam¬

ines the questions of service availability and accessibility on the frontier; Section C

discusses service delivery to two key populations— adults with serious mental illness

and children and adolescents with serious emotional disturbance; Section D analyzes

several broad-based topics from the point of view of the frontier— consumer involve¬

ment; aging; service integration, and the role of the primary care physician; Section E

provides tools to determine the cost and outcome of care; and Section F examines

telemedicine and managed behavioral health care as two potential future strategies.

We hope that readers will find this compilation or articles useful in addressing men¬

tal health problems on the frontier. For more than 100 years, the Washington Academy

of Sciences has demonstrated the importance of turning research into practice. This

volume of the Journal is intended to continue that grand tradition.

Readers can provide any comments to the Senior Editor, Dr. Ronald W.

Manderscheid, by contacting him on e-mail at rmanders@samhsa.gov.

The Editors

Vll

List of Contributors

Peter G. Beeson, Ph.D., Administrator

| Strategic Management Services

Nebraska Health and Human Services

P.O. Box 95026

Lincoln, NE 68509

| Phone: (402) 471-7781 FAX: (402) 471-7783

pete .beeson @hhss .state .ne .us

; www.narmh.org; www.hhs.state.ne.us

James A. Ciarlo, Ph.D.

Director

Former Director Frontier Mental Health Resource

Network

Columbine Hall East, Room 1 15

j University of Denver

: University Park

| Denver, CO 80208

j Phone: (303) 871-3099 Home: (303) 499-0124

j jciarlo@du.edu

Sheila Cooper, MA

University of New Mexico Psychiatry

Department

! Chairman’s Advisory Committee

P.O. Box 312

Alcaida,NM 87511-0312

| Phone:(505) 852-2034

I Sheilac@roadrunner.com

j Jack M. Geller, Ph.D., President

Center for Rural Policy and Development

! MSU 138, P.O. Box 8400

Minnesota State University, Mankato

Mankato, MN 56002-8400

| Phone: (507) 389-2599 FAX: (507) 389-2813

jack.geller@Mankato.msus.edu

Harold F. Goldsmith, Ph.D.

Consultant: Applied Demography

5006 Russett Road

Rockville, MD 20853

Phone: (301) 460-0734 FAX: (301) 443-7926

1033476.754@cs.com

Courtenay M. Harding, Ph.D.

Senior Program Director

Mental Health Program

Western Interstate Commission for Higher

Education (WICHE)

P.O. Box 9752

Boulder, CO 80301-9752

charding@ wiche .edu

Charles E. Holzer III, Ph.D., Professor

Department of Psychiatry, Rm 5.202 RSH

The University of Texas Medical Branch

301 University Boulevard

Galveston, TX 77555-0189

Phone: (409) 747-8362 FAX: (409) 747-8364

cholzer @ utmb .edu

Andrew B. Keller, Ph.D.

Assistant Deputy Director

Mental Health Corporation of Denver

4141 E. Dickerson Place

Denver, CO 80222-6060

Phone: (303) 757-7227

akeller@dimensional.com

Walter F. LaMendola, Ph.D.,

Telecommunications Consultant

4098 Field Drive

WheatRidge, CO 80033-4358

Phone: (303) 940-0095 FAX: (303) 457-3061

walter@ lamenola .com

Also

Director of Technology

Graduate School of Social Work

University of Denver

University Park

Denver, CO 80208

waiter @ cyberdyne sy stems .com

IX

Dennis F. Mohatt, MA

Vice President of Development

AB Solute Integrated Solutions

2500 West Cardwell Road

Lincoln, NE 68523

Phone: (402) 420-7332 FAX: (402) 420-7342

dennis .mohatt @ absfirst .com

Roy Rodenhiser, Ed.D.

Professor of Social Work

Rochester Institute of Technology

Rochester, NY 14623

James E. Sorensen, Ph.D.

Professor

School of Accountancy

University of Denver

University Park

Denver, CO 80208

James W. Stockdill, MA

Director

Office of Public Policy Studies

Mental Health Program

Western Interstate Commission for Higher

Education

P.O. Box 9752

Boulder, CO 80301-9752

Phone: (303) 530-4671

Mary Van Pelt, M.H.W.

Outreach Worker

San Luis Valley Mental Health Center

1015 4th St.

Alamosa, CO 81101

Phone: (719) 589-3671 FAX: (719) 589-9136

Morton O. Wagenfeld, Ph.D.

Professor

Department of Sociology

Western Michigan University

Kalamazoo, MI 49008

Phone: (616) 387-5292

wagenfeld@wmich.edu

Pearlanne Zelamey

Former Research Associate, Frontier Mental

Health Resource Network

Department of Psychology

University of Denver

University Park

Denver, CO 80208

Phone: (303) 455-2840 (home number)

pzelame@du.edu (Pearlanne Zelamey)

x

Journal of the Washington Academy of Sciences,

Volume 86, Number 3, 1-24, December 2000

V

Focusing on “Frontier”:

Isolated Rural America

James A. Ciarlo, Ph.D. and Pearlanne T. Zelarney, M.S.

Abstract

Under a contract from the Center for Mental Health Services of the Federal Substance

Abuse and Mental Health Service Administration, the Frontier Mental Health Services Re¬

source Network (FMHSRN) was created in 1994 to gather, analyze and disseminate infor¬

mation about the need and demand for and availability of behavioral health services in

“isolated rural areas.” Providing any type of human services to this rural population pre¬

sents formidable geographic, cultural, and human resource problems. As an initial step in

explicating the behavioral health problems of frontier areas, this paper uses existing litera¬

ture to distinguish frontier rural areas from other types of ‘rural’ areas and thereby provides

the basis for understanding the special problems of isolated rural areas.

Introduction

The Frontier Mental Health Services Resource Network, under a contract with the

Center for Mental Health Services of the Substance Abuse and Mental Health Services

Administration, was created to gather, analyze and disseminate information about men¬

tal health and substance abuse needs and services in “isolated rural areas” in the US.

The papers^ presented in this special issue of the Journal of the Washington Academy of

Sciences identify some of the technical assistance information about frontier behavioral

health problems and their solutions provided by this contract. As an initial step in expli¬

cating these problems of frontier areas, this paper uses existing literature to distinguish

frontier rural areas from other types of ‘rural’ areas and thereby provides the basis for

understanding the special problems of isolated rural areas. This paper presents com¬

mon and unique physical, socio-demographic, and economic characteristics of rural

and frontier rural areas.

Defining Rural Areas

In the existing literature, rural areas share the common characteristics of compara¬

tively few people living in the area, limited access to large cities (and sometimes even

to smaller towns), and considerable traveling distances to “market areas” for either

work or everyday-living activities (see Ciarlo et al., 1996; Zelarney and Ciarlo, 1999).

Often rural areas are conceptualized as a continuum from more rural (frontier) to less

rural to urban and operationally identified using the following factors (Hewitt, 1989):

2

JAMES A. CIARLO, PEARLANNE T. ZELARNEY

Proximity to a central place

Community size

Population density st

Total population i i

Economic/Socioeconomic factors

Over the years, public agencies and researchers have used combinations of these 1

factors to define “rural” and designate geographic areas as “rural.” I

The particular definitions discussed below have been selected largely from the dif- !

ferent ways mental health-oriented researchers and writers have defined “rural” in their 0

work. It in no way purports to be a definitive review. Instead, our focus is to bring j 11

greater clarity to the mental health-oriented tasks that comprised the mission of this *(

Frontier Mental Health Services Resource Network.

The Nonmetropolitan County as “Rural.” The Federal Office of Budget Man- 0

agement (OMB) distinguishes metropolitan areas from nonmetropolitan areas. f(

Nonmetropolitan areas are frequently considered by medical and mental health writers b

as “rural .” These designations are based on the concept of living either within or outside Sl

the “labor market” area of a large central place , typically a large city. Specifically,

except in New England, OMB defines labor market areas, called Metropolitan Areas c

(MAs)1 , as counties that contains a city with more than 50,000 residents or a Census 1

Bureau defined urbanized area (a built-up area) of 50,000 residents and a total popula- c

tion of at least 100,000 (central areas) and counties that are socially and economically If

integrated with the central areas. Commuting to work is used to index social and eco- 1

nomic integration . In New England , minor civil divisions are used as the building blocks •<

for metropolitan areas. All counties not classified as metropolitan are designated si

nonmetropolitan (nonmetro) (Bureau of the Census, 1990; GAO, 1993). An extremely

large number of counties throughout the US are “rural” based on this nonmetro classi¬

fication (see Fig. 1). sl

Figure 1 . Metro and Nonmetro Counties, 1990

FOCUSING ON “FRONTIER”: ISOLATED RURAL AMERICA

3

|

If we consider just the total number of persons living in these nonmetro counties, some of the

j midwestem and southern large-population states (e.g., Illinois, Pennsylvania, Texas, and Alabama) have

the largest nonmetro populations. However, if one considers the proportion of nonmetro residents in a

state, the states with the highest percentages of nonmetro residents tend to be those more commonly thought

of as “rural”— for example, Maine, Montana, Iowa, Arizona, and Alaska (see Ciarlo et al., 1996).

An important reason why many health and mental health-oriented data sets use the

nonmetro definition to designate rural is because a great deal of important health-re¬

lated and economic data are collected in the US by county. So-called “rural” data can

thus be obtained, and compared with data for “urban” areas, by simply dividing any set

of counties into these metro/nonmetro categories. Federal and state agencies are often

required by statute to use metropolitan area and nonmetropolitan designations for “al¬

locating program funds, setting program standards, and implementing other aspects of

their programs” (OMB, 1998). Such political mandates, as well as the easy availability

of these nonmetro and metro county designations, have made this an often-used scheme

for labeling some counties as “rural” and others as not. Noteworthy, this is a fairly

broad characterization that treats small, often densely populated eastern counties the

same as large counties in the west with more variable population densities.

Rural Areas by Census Definition. A definition that can be used for not only

counties but also smaller (e.g., census tracts) and larger (e.g., regions, states) geographic

areas is the Census Bureau’s definition of rural. This definition is based on the con¬

cepts of place size and population density. Urban areas include the built-up areas around

large cities (the urbanized area) and places of 2,500 or more persons. “Urbanized”

areas include a large city and the surrounding densely settled regions with a total popu¬

lation of 50,000 or more persons and generally a density of greater than 1000 persons/

sq.mi. Again, rural is defined by exclusion; all areas not designated as urban are con¬

sidered “rural” (Bureau of the Census, 1990; GAO, 1993).

It is worth noting, again, that states with large total populations also tend to be the

states with the largest “rural” populations by this definition (e.g., New York, California,

Pennsylvania, Illinois). When considering the ratio of rural to total population, how¬

ever, those states with more than half their population living in “rural” areas are again

those commonly spoken of as rural— Maine, West Virginia, Alabama, and the two Da¬

kotas. Notice that Alaska’s population is less than 50% rural, reflecting the concentra¬

tion of its people into its coastal cities and towns (see Ciarlo et al., 1996 for map).

Overlap of Metro/Nonmetro and Rural/Urban Definitions. While both the Cen¬

sus and the OMB definitions lead to an estimate of a “rural” US population of around

25%, the areas defined can be quite different. Many people living in nonmetropolitan

| “rural” counties may actually live in urban areas (towns and cities with 2,500-50,000

people) according to the census definition. Conversely, within an MA and its associ-

I ated metro counties, there are many rural areas where most or all residents live outside

the densely populated urbanized area or towns of larger than 2,500 population. This

4

JAMES A. CIARLO, PEARLANNE T. ZELARNEY

situation occurs more commonly in the West, where counties are generally larger. The

boundaries of these large counties are less likely to match up with urban and suburban

developments, thus creating pockets of rural living within metro counties. Hence, when

the county is used as the geographic unit in question, accurate designation of an area as

“rural” is more difficult in the West than in other regions of the US.

Emphasizing this, some metropolitan counties are so large that one cannot assume

that all residents have easy geographical access to the central areas of the MA. Thus,

even though the most populous part of a large metro county may be metropolitan in

character (socially and economically integrated with central areas), other parts are clearly

not integrated. Recognition of the situation has resulted in a reevaluation of the use of

counties as the basic building block of metropolitan areas. (Goldsmith et al., 1993;

Cromartie and Swanson, 1997). Accordingly, as part of the preparation for the 2000

Census, the OMB is currently conducting a full review of the concepts and standards

surrounding the metropolitan designation with the intent of revising them. First, under

consideration is changing the geographic “building block” from the county to a subcounty

level, which should allow finer specification of areas as metro or nonmetro (see the

section below on Use of Census Tracts in Definitions for more on the implications of

this change). Second, the OMB has recently presented four new criteria approaches for

public comment. One approach uses population density rather than the traditional iden¬

tification of a core area and its commuting relationships with surrounding areas. The

other three approaches continue to use commuting as a criteria, but leave out various

other criteria used currently to include outlying areas as part of a metropolitan area

(OMB, 1998).

Alternative (non-binary) Typologies of “Rural”

As mentioned earlier, rural areas in the US, including “frontier” areas, are widely

diverse and vary along a continuum from most urban-like to most isolated rural. Re¬

searchers have found the preceding simplistic definitions do not always adequately

describe or differentiate the diversity. Therefore, further classification schemes or

typologies have been proposed which use more factors and categories to define rural

areas. Several of these are noted below.

Defining the Continuum: There are two scales sponsored by the USDA that '

operationalize a rural-urban continuum. These are the Economic Research Services

(ERS) Rural-Urban Continuum Code and the Urban Influence Code. These codes are

useful because they go beyond a simple metro/nonmetro or census rural-urban dichotomy j

and array counties along a continuum from the most isolated rural counties (counties

with limited access to services of generally available in towns and cities) to the most

FOCUSING ON “FRONTIER”: ISOLATED RURAL AMERICA

5

urban and metropolitan counties (counties with easy access to the services of big cities.

The codes for these classifications are presented below (see Buttler and Beale, 1994;

Ghelfi and Parker, 1996).

ERS Rural-Urban Classification

Metro counties(MSAs)

0. Central counties of MS As of 1 million or more persons

1 . Fringe counties of MS As of 1 million or more persons

2. Counties in MS As of 250,000 to 1 million adjacent to metro areas

3. Counties in MS As of fewer than 250,000 persons

Nonmetro

4. Urban population of 20,000 or more persons adjacent to a metro area

5. Urban population of 20,000 or more persons not adjacent to a metro area

6. Urban population of 2,500 to 19,999 persons adjacent to a metro area

7. Urban population of 2,500 to 19,999 persons not adjacent to a metro area

8. Urban population of less than 2,500 persons adjacent to a metro area

9. Urban population of less than 2,500 persons not adjacent to a metro area

The Urban Influence Categories

Metro counties (MSAs)

1 . Counties in MSAs of 1 million population or more

2. Counties in MSAs with fewer than 1 million residents

Nonmetro

3. Counties that are adjacent to large metro areas and have a city of 10,000 or more

4. Counties that are adjacent to large metro areas and do not have a city of at least

10,000

5. Counties that are adjacent to small metro areas and have a city of 10,000 or more

6. Counties that are adjacent to small metro areas and do not have a city of at least

10,000

1 7. Counties that are not adjacent to a metro area and have a city of 10,000 or more

: 8. Counties that are not adjacent to a metro area and have a city of 2,500 to 9,999

9. Counties that are not adjacent to a metro area and do not have a city of at least

1 2,500

6

JAMES A. CIARLO, PEARLANNE T. ZELARNEY

It should be noted that not only do these continua clearly separate metropolitan |

counties from nonmetropolitan counties, but for nonmetropolitan counties distinguish |

predominately urban from predominately rural counties and counties adjacent to met¬

ropolitan areas from those that are not. To be classified as an adjacent nonmetro county,

two percent of the labor force of the county must commute to the adjacent metropolitan

county. These continua assume that the larger the population, particularly the urban

population, or the presence of a city of 10,000 or more persons, the more likely the

county is to have a market that provides a range of goods and services and conse- i

quently is more urbanized. It is also assumed that if nonmetropolitan counties are adja¬

cent to metropolitan counties they are more likely to have access to the good and ser¬

vices that are available in the central areas of the metropolitan county (see Holzer et al.,

1998). t

ERS County Typology. The Economic Research Service (ERS) of the US Depart- (

ment of Agriculture (USDA) has developed a classification of nonmetropolitan areas $

based on type of economy and socioeconomic characteristics of the population (Bender s

et al., 1985). Eleven (11) types of nonmetropolitan counties, six “economic” and five t

“policy,” are defined. The developers argued that the classification provides a useful j

perspective for policy analyses and “reflects the extremely diverse economic and social c

structure of rural America” (Cook and Mizer, 1994).

The six distinct, mutually exclusive types of counties identified based on economy

were: farming-dependent, government-dependent, manufacturing-dependent, mining-

dependent, services-dependent and non-specialized. This typology scheme also classi¬

fies nonmetro counties by five policy criteria; retirement-destination, Federal lands,

persistent poverty, commuting, and transfers-dependent (Cook and Mizer, 1994). When

using this classification of nonmetro areas, one normally characterizes areas according

to both economic and policy classifications. d

What is Frontier America Like?

Frontier Rural. The type of rural area of primary interest to this project is that

designated as “isolated” or “frontier.” Frontier areas have usually been defined exclu¬

sively by low population density , most often fewer than 6 (sometimes 7) persons per ?

square mile (Popper, 1986; NRHA, 1994; GAO, 1993). The consequences of this more ■

restricted definition of rural are striking. Applied to US counties, an upper limit of 6 f

persons per square mile reduces the number of rural counties by the nonmetro defini¬

tion from 2,357 using 1980 census data to roughly 400 frontier rural counties (Popper,

1986; Hewitt, 1989; NRHA, 1994) —a reduction of 83% in the list of nonmetro coun¬

ties. This restriction to only low-density frontier rural areas removes from discussion

many nonmetropolitan “rural” counties having sizable towns or small cities. However, j.

FOCUSING ON “FRONTIER”: ISOLATED RURAL AMERICA

7

using density alone as a defining factor can also be deceiving, especially in large west¬

ern counties. An extremely large county land mass may mask the existence of higher

density urban populations by unrepresentatively low county- wide density figures.

In contrast to the nonmetropolitan (OMB) and rural (Census) definitions, essen¬

tially all frontier counties are in western states (including Alaska), lying West of a north-

south line (approximately the 98th meridian) running from the middle of North Dakota

through the middle of Texas (see Ciarlo et al., 1996). They are characterized by consid¬

erable distances from central places (cities) and consequently by poor access to market

areas with a wide range and volume of goods and services. Such isolation is character¬

istic of frontier areas.

Reflecting this isolation, the frontier constitutes less than 1 percent of the popula¬

tion, but a prodigious forty-five percent of the total US land mass (Popper, 1986). As

one might expect, providing any type of human services to this rural population pre¬

sents formidable geographic, cultural, and human resource problems Isolation is con¬

sidered to be its greatest defining characteristic. This isolation often results in long

trips, both inside and outside the county and state, for basic needs. Duncan (1993), a

journalist, suggested that these residents differ in kind, not just degree from urban and

other residents:

People in these regions have always had to adapt to weather and terrain, but the

counties of the contemporary frontier have made a further adaptation — to

their unique paucity of people. Healthcare, education, religion, politics, law

and order, transportation, communication, sense of community, sense of self,

even the act of finding a mate — virtually every human institution and activity

demonstrates the impact of few people and long miles.

Breshears (1993) has deftly encapsulated the meaning of frontier and how it is

different:

Frontier is an attitude. The last frontier; frontier spirit; independence; low tol¬

erance of systems, especially governmental systems; Indian nations and tribal

lands; a “boys will be boys” attitude; and wide open spaces. Many things we

often associate with “frontier” are all often true in the frontier states.

Fragile Economy. It has been discussed elsewhere (e.g., Wagenfeld et al., 1994)

that rural areas in general tend to be economically unstable and that this may have an

impact on the mental health of its residents. This is even more true for the frontier.

There is little manufacturing; the major sources of income are tourism, ranching, farm¬

ing, logging, and mineral extraction.

Economic downturns have begun earlier in frontier areas than in the rest of the

country. For much of the Plains, the Great Depression began over a decade earlier. By

1925, Montana had experienced 214 bank failures and the average value of ranch land

had dropped by half. During the Depression, the proportion of farm families on relief

was highest in many of these states. The infamous Dust Bowl, the result of misguided

8

JAMES A. CIARLO, PEARLANNE T. ZELARNEY

agricultural policies, came to the Plains earlier than the rest of the Midwest. The more

recent farm crisis of the 1980s was also felt more acutely in this area. Many of these

points can also be made about the petroleum industry. The single industrial base of

these areas makes earning a consistent living more difficult, and one of the conse¬

quences is frequent migration (NRHA, 1994).

If the industrial base is depressed or collapses, an inevitable chain reaction occurs.

Businesses dependent on these industries experience reverses, public services shrink or

disappear, and the quality of life suffers (Popper and Popper, 1987). In addition, dis¬

tance from metropolitan centers and low population density have made frontier areas

attractive for practice bombing ranges, missile sites, and nuclear waste dumps. In their

zeal for economic stability, communities have actively sought these more questionable

opportunities (Norris, 1993).

New Work in Defining Frontier

A simple binary definition of frontier rural areas, such as designating counties with

less than seven persons per square mile as frontier counties and all other as not, belies

the diversity of these areas. Thus, as with rural areas, a number of more complex fron¬

tier typologies have also been developed to overcome the limitations of such simplistic

dichotomous definition. They tend to use combinations of population parameters and

other parameters such as total population, percent rural, distance and/or time from

central areas as well as density, economics, poverty, commuting, and county infrastruc¬

ture. Some of these typologies are discussed below.

States with Frontier Populations. This project has developed a scheme to iden¬

tify and then rank states with frontier populations. This designation is based on two

defining variables — total population of a state’s frontier counties (those with less

than 7 persons/sq.mi.), and the percentage of frontier-county residents within a state.

There are 26 states with frontier counties (See Table 1). These states have as few as one

county to as many as 62 frontier counties. This scheme breaks these 26 states into four

groupings or categories based on the two variables. Category I includes those states

with more than 15% of their population in frontier counties or with a total frontier

population of greater than 250,000. Six western states fit into this category. Category

II includes states with 5 to 14% of their population in frontier counties or with a total

frontier population of greater than 150,000. Several states are included in this category

because they have a large frontier population, even though in relation to the state’s total

population it is only a small percentage (e.g., Texas). Even some of the higher-popula¬

tion western states have substantial numbers of frontier counties within their borders;

for example, about half (32) of Colorado’s 63 counties had seven or fewer persons per

square mile in 1990. For less populous states like North Dakota and Wyoming, the

proportion of frontier counties is even higher. Categories III and IV include more east¬

ern and higher-population states with few frontier residents.

FOCUSING ON “FRONTIER”: ISOLATED RURAL AMERICA

9

Table 1 . States with Frontier Populations

10

JAMES A. CIARLO, PEARLANNE T. ZELARNEY

Rural Composite Index. In an attempt to better define rural areas, and particu¬

larly the most isolated or “frontier” rural counties, this project also created a new rural-

urban continuum by expanding upon the previously described “density” definition of

rural. To the population density (persons per square mile) criterion, we added the Cen¬

sus definition of “rural” and another standard population measure— county population

size— to create a thirteen-category classification or “index” of rurality versus urbanicity.

It was postulated that a combination of these three parameters— population density,

raw population size, and residence outside a town of 2,500 or more— came closer to

describing rurality than most, if not all, single-criterion definitions. Thus, this classifi¬

cation scheme assumes that if a county has a very small population, a high degree of

dispersion among its residents, and a high percentage of “rural” non-town residents

according to the Census definition, the county is extremely rural in nature. At the other

end of the continuum, counties with very large populations, with residents living ex¬

tremely close to each other, and with most living within towns or cities of at least 2,500

persons, must be quite urban in nature.

The continuum from most rural to most urban counties was generated using com¬

posite index scores. The population values were all from the 1990 Census, and the

county was the geographic unit used (although other geographic units would also be

appropriate for the continuum). Each county population variable was divided into five

categories. These individual categories were assigned a number from 1 to 5, where 1

was the least populous, least dense, or most “rural” (see Table 2). A county’s Rural

Composite Index Score was simply the sum of the three individual variable scores.

Hence, each county scored over a range of 3 to 1 5 , where 3 would be the most rural and

15 the most urban. For instance, in 1990, Costilla County in Colorado had a population

of less than 10,000 (Score = 1), a density of 2.6 (Score = 2), and was 100% “rural” in

Census terms (Score =1). Its Rural Composite Index Score was therefore 4. The 13-

point continuum produced was then again split into five categories primarily for easy

viewing on plotted maps, (see Zelamey and Ciarlo, 1999 for maps).

It should be noted that the 98th meridian (or “anhydrous line”) shows up as an

apparent eastern border to less populated areas. Counties from the most rural category

can be found primarily in the West where counties tend to have the most land and the

fewest people. This lowest category of the continuum (scores of 3-5) also closely

mirrors the designation of frontier counties based simply on density (in this project,

less than 7 per square mile). However, it may be more useful (and certainly less arbi¬

trary) to have frontier areas designated by the broader continuum that includes popula¬

tion size and residential location, rather than using a simple binary classification based

solely on density. Furthermore, in contrast to the previously described rural defini¬

tions, this continuum-based classification designates the most isolated rural areas (fron¬

tier) within the full spectrum of rural and urban counties. It also has the advantage of

being simple to understand and easy to apply. With sub-county unit data sets, it could

FOCUSING ON “FRONTIER”: ISOLATED RURAL AMERICA

11

also easily be applied to smaller geographic units, where one would expect greater

specificity and differentiation of highly rural areas than can be generated by county-

level data.

Table 2. Variables Used in Rural Composite Index Scores

* All values are from the 1990 Census.

Frontier Education Center Definition. The Frontier Education Center, in con¬

junction with the Office of Rural Health Policy, conducted a consensus-development

project to generate a widely acceptable definition of frontier that again also goes be¬

yond the use of density as a single definer. They felt that the definition must allow for

extremes of distance and isolation and in some way reflect the major problem of infra¬

structure development in frontier communities. They began by limiting the population

density to less than 20 persons per square mile. Both the Frontier Education Center and

12

JAMES A. CIARLO, PEARLANNE T. ZELARNEY

the Frontier Mental Health Services Resource Network have noted that this loosening c

of the density does not make a significant difference in counties and areas identified, c

The counties delineated are still found primarily in western states and make up less than $

4% of the US population. The Center went on to limit the counties to those that in ■

addition to being less than 20 persons/sq.mi. were also located at least 60 miles and/or i

60 minutes from the nearest market center. The Center developed a multi-classification

matrix with a 0-to- 105 -point scale that can be used as a tool to determine frontier status f

for individual areas (see Table 3). On this scale a given area, such as a county, must 2

have a minimum of 50 points to be designated as frontier. £

I

Steps Toward Development of a Sociodemographic Typology of Rural Coun- f

ties. While most categorization schemes to denote differences in “rurality” involve the

use of primarily geographic variables (such as metropolitan/ nonmetropolitan area types,

Table 3. Frontier Education Center Frontier Matrix

adjacency to cities, population size and/or density, etc.), few if any employ personal

characteristics of area residents or their social environments as defining variables. An

exception to this is Goldsmith, Holzer, Woodbury, and Ciarlo’s (1999) recent use of

grade of membership (GOM) analysis of sociodemographic variables to derive “pure

types” of rural and non-rural areas intended to better depict the nature and character of

rural residents. Such a typology may often be more helpful than geographically-based *

categories of “rurality” in planning mental health and substance abuse services for these 1

residents. For example, it could be important to know the socioeconomic statuses, age

FOCUSING ON “FRONTIER”: ISOLATED RURAL AMERICA

13

characteristics, and ethnic backgrounds of a rural area’s residents before trying to re¬

cruit mental health personnel to staff a planned public facility to provide mental health

services. Steps toward such a sociodemographics-based descriptive typology for both

rural and urban areas have been made by Goldsmith et al. as part of FMHSRN’s efforts

to improve the quantity and quality of mental health services in the western rural US.

“Grade of Membership” analysis or GOM is a multivariate statistical classification

procedure applied to a set of variables that generates “pure types” (or clusters of vari¬

ables) with distinct characteristics. It was used to analyze a data set consisting of 75

economic, social, and health variables using 1980 decennial Census data and other

government statistics for the 3,064 counties in the coterminous United States. The

principal types of variables covered are listed in Table 4.

Table 4. Types of Variables Used in GOM Analysis

Social rank (including economic, occupational and educational status)

Household and family composition

Housing characteristics

Mobility

Journey to work characteristics

Ethnicity

Local economic activities

Tax structure

Expenditure for police and fire service

The GOM analysis led to 27 pure types of counties, each of which would possess

specific patterns of demographic, economic, social, and health characteristics. Once

the pure types were defined, Goldsmith et al. then selected out for further attention

those pure types with high concentrations of “isolated rural” or “frontier” counties as

defined by very low population density. Nine of the pure types had greater-than-aver-

age percentages of counties with less than 7 persons per square mile (FMHSRN’s working

definition for “frontier” counties), or between 7 and 15 persons per square mile (often

termed “frontier-like” and usually found near or adjacent to “frontier” counties). Table

5 lists the nine pure types, along with their population-density characteristics.

Note that Pure Type 2 consists almost entirely (91%) of sparsely populated coun¬

ties, while the remaining eight types have lower percentages of such “frontier” areas

(49% or less). Nonetheless, all nine types are important to studies or analyses of ex¬

tremely rural or “isolated” rural areas because they have greater-than-average percent¬

ages of these “low density counties”— that is, all are comprised of at least 25% sparsely

populated or less densely settled counties. Further, they are of particular interest since

they include 7 1 % of all such “frontier” and “frontier-like” counties in the coterminous

United States.

14

JAMES A. CIARLO, PEARLANNE T. ZELARNEY

Table 5. Percentage Distributions of Designated Pure Types by Density in Order of Proportion of

Low Density Counties

Pure Type 1 counties are concentrated in the short-grass prairie states of the west¬

ern US (Iowa, Kansas, Minnesota, Nebraska, North Dakota and South Dakota), even

though a few (about 9%) fall outside this locale. Also found in this region of the US are

the counties of Pure Type 2, concentrated in the states of Kansas, Nebraska, Texas,

Colorado, and Montana. For the rest of the pure types, the counties were found in a

wide variety of US regions. Maps of locations of the pure types are not shown here

because of space limitations; however, pure-type location maps can be seen in the

HREF=”http://www.du.edu/frontier-mh/letterl 8.html”, entitled Low Density Counties

with Different Types of Sociodemographic , Economic, and Health/Mental Health Char¬

acteristics , or viewed on the FMHSRN’s Internet website (www.du.edu/frontier-mh/)

under that same heading.

These nine pure-type (PT) sets of counties tend to share certain sociodemographic,

economic, and health-related characteristics. Most counties have a small population

(less than 45,000 persons). Their residents typically have a moderate educational sta-

FOCUSING ON “FRONTIER”: ISOLATED RURAL AMERICA

15

tus, but are economically mixed. They consistently work within their county of resi¬

dence or at home. They are predominately white, but pockets of higher concentrations

of Hispanic persons do exist. These counties also share a high percentage of husband-

wife households, although PT 10 is an exception with a high percentage of elderly

people living alone. Finally, and not surprisingly, these counties all have low numbers

of physicians per 1000 persons, and moderate to low numbers of (medical) inpatient

days. Somewhat contrary to expectations, only those residents in PT 1 and PT 2 have a

high percentage of employment in resource-dependent industries (such as mining and

logging).

Denoting the diversity of Frontier Areas

In HREF=”http://www.du.edu/frontier-mh/letter 18.html” , Goldsmith et al. (1999)

described four “frontier-like” clusters of counties with distinct characteristics along

with their locations in the United States (Pure Types 2, 1,5 and 10). The FMHSRN’s

advisory committee, as well as many newspaper and magazine articles, informally con¬

firms the existence of these community types. To emphasize the diversity of frontier

areas, this paper will use these four GOM-derived portraits of frontier communities as a

backdrop for a discussion of issues important in frontier areas, including the economy,

population growth, poverty, land use, and mental health services in frontier areas.

Western Farming, Ranching, and Mining Communities (Pure Type 2 coun¬

ties). As noted, these communities are scattered throughout the west from the eastern

edges of the coastal states to the Great Plains, but particularly in the states of Kansas,

Nebraska, Texas, Colorado and Montana. Goldsmith et al. (1999) describe these coun¬

ties as:

The population in these counties was very small (<15,000) and stable. The average person living in a

PT2 county would be a white, high school graduate, most likely married, with a high to a very high per

capita income who works in his/her county of residence, commutes less than 10 minutes to work and lives

j in an older home (built prior to 1951), which may be modular (10% or more) or rented (20 to 40%). Males

are employed full-time, while women, if seeking work, are likely to be employed. Often, employment was

| in resource dependent industries (40% or more of the labor force) such as agriculture. Employment in

service or manufacturing industries is likely to be very low (less than 10% of labor force).

Mining, lumber, and other extractive industries are increasingly limited in these

areas in the western US, often leading to increased unemployment (Murray and Keller,

1986; Wilkinson, 1982). This can be even more true for frontier areas such as Pure Type

2 where the economy is often resource-based and less diversified. The major sources of

[ income in these areas are farming, ranching, logging, and mineral extraction; there is

little manufacturing. Each of these industries fosters significantly different cultures.

Interacting as a mental health professional with a farmer in North Dakota will be sig¬

nificantly different than with a miner in Nevada.

16

JAMES A. CIARLO, PEARLANNE T. ZELARNEY

Mining played a large role historically in the settlement of frontier areas. By its

very nature, mining activities create boom and bust cycles, from the discovery of the

mineral to the closing of the mine when the cost of extracting the mineral becomes

prohibitive. Mining communities therefore are often temporary in nature and experi¬

ence extreme instances of boom and bust. For example, in Las Animas County in

Colorado as late as the 1950s, 40 coal mines operated, employing thousands, and driv¬

ing a thriving economy. In 1996, the last operating coal mine closed, ending an era and

bringing a decline in county population from 42,000 in 1950 to approximately 13,000

(Foster, 1996).

Ranching in frontier areas also has a long and colorful history. Arid and vast, these

areas are ideal for cattle and buffalo. Jackson County, a frontier area in northern Colo¬

rado, now struggles with a ranching based economy. Located in the vast mountain

basin of North Park, land-use restrictions limiting logging and mining have meant job

loss and a stagnant economy. Almost two-thirds of the million-plus acres of the county

are publicly owned. Most of the remaining land is held by large privately owned ranches.

Ranching as a way of life is becoming precarious for smaller ranches. To survive, some

ranching families have turned to tourism and outfitting in an uneasy compromise (Gar¬

ner, 1995).

The single industrial base often found in these and other frontier areas makes earn¬

ing a consistent living more difficult, and one of the consequences is frequent migration

and shrinking communities (National Rural Health Association, 1994). If the industrial

base is depressed or collapses in these areas, an inevitable chain reaction occurs. Busi¬

nesses dependent on these industries experience reverses, public services shrink or dis¬

appear, and the quality of life suffers (Popper and Popper, 1987). It can be catastrophic

when the only industry in a county declines dramatically. The town of Walden is one

such example. This town in northern Colorado relied heavily on the lumber industry.

When the main lumber mill closed down in 1994, 100 people in the town of 900 resi¬

dents lost their jobs and Walden lost a $3.5 million annual payroll. Luckily ranching

and farming, the other industries in the area, have done better recently and the town is

now getting a big boost from tourism and recreation. However the economy is still

fragile and town leaders are trying to bring in light industry to provide year-round jobs

and greater security (Kelly, 1997).

As these more traditional industries falter, frontier areas such as those in Pure Type

2 as well as other frontier areas are turning more and more to tourism to answer eco¬

nomic woes, especially in the scenic wilderness areas in the west. This new industry

creates large transitory populations who often overload the existing mental health ser¬

vices in the area. The economic base of one frontier state —Nevada — is heavily

dependent on gambling-based tourism. This, of course, has implications for health,

mental health, and substance abuse services. Obviously, these areas attract many tran¬

sients, who may experience crises with substance abuse and mental illness. The gam-

FOCUSING ON “FRONTIER”: ISOLATED RURAL AMERICA

17

bling lifestyle of these places also has an impact on the health and well-being of perma¬

nent residents. In their zeal for economic stability, some communities have also ac¬

tively sought more questionable opportunities (Popper, 1986; Norris, 1993). Distance

from metropolitan centers and low population density have made frontier areas attrac¬

tive for practice bombing ranges, missile sites, and nuclear waste dumps.

Some of the more scenic frontier counties have recently experienced a resettle¬

ment. So-called “urban-refugees” have come looking for a better way of life in these

frontier areas. These new settlers tend to hold service jobs in teaching, medicine, law,

business and technology. This obviously changes the mix of the economy. For in¬

stance, in Montrose County Colorado, the percent of mining dependent jobs went from

17% in 1979 to only 1% in 1993 (Frazier, 1996).

Northern Great Plains Farming Communities (Pure Type 1 counties). In the

Great Plains, once popularly known as the Great American Desert (Stolzenburg, 1996),

the frontier areas are unique. The GOM analysis cited above shows that these commu¬

nities are made up of mainly white, married couples with children who have lived in the

same community for at least 5 years. They own their own homes and the husband tends

to work in a resource-dependent industry, such as farming. Persons in the labor force

tend to work in their country of residence (less than a ten-minute commute to work).

The populations in these counties are very small, generally less that 15,000 persons.

Many of these areas were developed during the westward expansion in the mid- to

late- 1800s. Homesteaders settled here with great anticipation of personal success and

the promise of significant population growth. Many of these rural communities did

experience population growth through the 1930s, and only over the past 50-60 years

have they experienced dramatic population declines. Consequently, many of the early

settlers migrated to the Great Plains not as an escape from urban life, but rather, to

found and build great communities of the future. Unfortunately, the combination of the

! absence of adequate water, the technical revolution in agriculture (the green revolu-

| tion), the development of modem transportation and communications, and the onset of

World War II led to a mass exodus, or mral-to-urban migration. As a result, many rural

I counties that would not have met the density criteria for “frontier” in the 1950s meet

those criteria today. In fact, the number of frontier counties continues to grow in the

Great Plains as the population decreases.

The decline in population in the frontier areas of the Great Plains is not characteris¬

tic of all counties or all decades. The populations in rural areas have been said to be

both increasing dramatically and decreasing alarmingly, depending on the specific area

and the decade described. The 1970s were an era of growth in nonmetro rural areas.

Population tended to decline in the 1980s and now in the 1990s the trend seems to be

repeating that of the 70s (Nucci and Long, 1995). This population growth in the 90s is

i widespread in nonmetro counties (Johnson and Beale, 1994; Nucci and Long, 1995).

The increase may be due to the net inflow of migrants — particularly seniors, but is

18

JAMES A. CIARLO, PEARLANNE T. ZELARNEY

probably also due to suburbanization. Nonmetro counties adjacent to metro counties or «

suburban areas seem to be growing the fastest. Growth has also been seen consis- ' l

tently in recreation-centered counties, supporting the net inflow supposition and the a

idea of a “rural renaissance.” There is believed to be a preference by Americans to live 1)

in smaller places to avoid the crime and congestion of urban areas (Nucci and Long, p

1995). For instance, in the 1990s over 1 million Californians have moved to other • ?

western states, presumably to avoid crime and to find a simpler lifestyle. This increase j

in population in nonmetro areas may also be due to a shift in the nation’s economy from il

manufacturing to more service-oriented industries (Nucci and Long, 1995).

This growth in nonmetro and frontier areas is not, however, universal. At the other a

end of the spectrum, rural to urban migration continues as a consistent theme in some

frontier areas, particularly in the Great Plains (Jenkins, 1991 ; Wilkinson, 1982). Growth o

was much less prevalent in nonmetro counties in the Great Plains and West Texas and in i

farming- and mining-dependent counties (Johnson and Beale, 1994). Nonmetro coun- a

ties with the lowest population densities (frontier counties) also showed the least growth ft

(Johnson and Beale, 1994). Population declined in large portions of the Great Plains »

during the 1980s, creating new ghost towns and apprehension in remaining residents, re

Increased farm productivity in farming areas has lead to fewer workers, larger farms la

and therefore lower population densities. The number of counties with less than two k

persons/sq.mi. grew from 143 to 150 during the 1980s, another indication of the loss in 1(

population and the growing number of extremely sparsely-populated frontier areas, fc

There are some indications that this trend may be slowing in the 1990s. For example, in re

North Dakota where approximately three-fourths of the state is in the Great Plains, 89% ; k

of its counties declined in population from 1980 to 1990. In Census estimates from

1990-95, however, only 81% of the counties declined in population. But the Great ire

Plains states, such as South Dakota, North Dakota, Nebraska and Kansas, still have m

very slight population changes in comparison to the rest of the frontier states. These I

four states had an average percentage of growth of 1 .9, compared with 5.6 for the US k

and 10.2 for all frontier states (Census, 1996). to

Low Density Counties with Hispanic Frontier Communities (Pure Type 5 coun- 15

ties). While almost all frontier areas in the United States are composed primarily of Ik

white residents, there are significant populations of Hispanics in certain areas of the (

southwest (mainly in Texas, New Mexico, and southern Colorado). Settled earlier than

most other frontier areas, these areas still include communities of mostly Spanish-speak- . |

ers. Goldsmith et al. describe these counties as follows: I

Unlike PT2 or PT1 counties, the populations of PT5 counties generally include; ij

some Hispanic persons (at least 5% of county populations and often 20% or more). An fo

average resident of a PT5 county would be white (generally, 80 to 90% of county popu- |

lations), married and living with his/her spouse and their children, often, in a town.

Mothers with children are not likely to be employed (generally, less than 50%). He/she i i

FOCUSING ON “FRONTIER”: ISOLATED RURAL AMERICA

19

i

would work within the county and have a commuting time of less than ten minutes.

Household income would be low and there is a good chance the family would be living

at or below poverty level (15 to 30% of PT5 county populations, have incomes at or

below the poverty level). He/she might not have completed high school (30 to 70% of

persons 18 and over in PT5 counties, complete high school). If male, he would be

working in a low occupational status job (generally, 40 to 45% of the male labor force);

if female, chances are that she would be working in a high status job. The likelihood

that the average resident would be employed in resource dependent industries is gener¬

ally between 20 and 40% of the labor force. The likelihood of employment in manufac¬

turing industries, however, is very low (less than 10% of labor force).

Poverty is often an issue for these small communities, much more so than in the

other frontier types. The recent changes brought on by welfare reform are expected to

have devastating effects on these extremely rural communities. Costilla County in south¬

ern Colorado is one example. This frontier county is extremely poor; 16.5% of its

residents are unemployed and 34.8% receive food stamps (as opposed to 5.9% state¬

wide). The new welfare reform laws call for the county to move 30% of adult welfare

recipients into jobs, however, there are no jobs in Costilla county. In fact, a local mine

laid off 68 people in 1997. Neighboring counties have some job openings, but most are

seasonal or part-time and there is not public transportation to these areas (Callahan,

1997; Crowder, 1998). The fear is that working age adults in poor families may be

forced to leave their homes and go to more urban areas, such as Denver, for work. The

result of this would be a county with mainly elderly residents taking care of the children

left behind.

It should be noted that poverty is not a defining characteristic for all frontier coun-

t ties. The frontier tends to be a land of extremes and this is true for its poverty levels as

: well. The two counties in the US with the lowest and the highest poverty rates found by

: the 1990 Census are both designated frontier (Shannon, SD — highest; Loving, TX —

i lowest). The West, however, does have the highest regional poverty rate (15.4%) in the

country. Two of the only three states in which poverty rates increased from 1994 and

• 1996 are western states - Arizona and Montana. New Mexico, home to many Hispanic

f frontier communities, had the highest state poverty rate— 24.0%— for 1994 to 1996

e (Census, 1997).

n Declining Retirement Communities (Pure Type 10). These small communities

can be found mainly in the Great Plains. The average age is high and the death rate is

quite high in these communities. However, these areas are not prospering retirement

e destinations as can be found in Arizona, California, and Florida. These were once

n thriving farming communities, but because of the incredible increases in farm size due

i- to farm efficiencies, there are not enough jobs for younger people to stay. Here the

i. concerns of aging citizens and disappearing communities are paramount. Goldsmith et

le al. (1999) describe these counties as follows:

20

JAMES A. CIARLO, PEARLANNE T. ZELARNEY

An average person in a PT10 county would live in a county with a small population j

(15,000 or less) that is characterized by concentrations of elderly persons (median age

of county residents is 54 or greater), few children, low economic status and residence in

older (built prior to 195 1) stand-alone home (90% or more of the dwelling units). While

not as high as PT2 or PT1 counties, persons in PT10 counties generally work in their

county of residence. Many of the residence of these counties, particularly the elderly,

either live alone or with non-related adults and receive social security payments. Em¬

ployment in resource dependent industries, like agriculture, is often high (30 to 40% of

the labor force) but below that of PT2 or PT 1 counties.

Frontier areas, particularly PT10 counties, are often economically dependent on

agriculture. The land and climate, however, make farming extremely challenging. Farm¬

ing-dependent areas in the Great Plains have experienced many cycles of boom and

bust since their settlement in the late 1800s. After the Homestead Act of 1862 lured

settlers, creating a boom, the financial panic and drought of 1890 caused a bust in

which many residents left. In the early 1900s homesteaders were again encouraged to

settle and it was during this era that the Great Plains experienced its highest population

levels. Drought and the Dust Bowl in the 1930s reduced the population again. In the ^

1970s, federal subsidies, an export boom, and gas and oil discoveries brought new (

prosperity, only to usher in an oil bust and farm crisis in the 1980s. Parts of the Great ]

Plains today are again struggling with drought conditions. Coupled to these boom and !

bust trends, farming as a whole has become more efficient. Increased farm productivity a

has lead to the need for fewer workers and larger farms. This has also has led to declin¬

ing populations in the farming counties of the frontier. s

A trend in the Great Plains frontier areas, such as PT 10 counties, is an increasingly ^

older average age of its residents. US News and World Report (1995, July 17) carried f

a story on the economic decline and depopulation of the ranching area of the Sand Hills

in Nebraska. With the outmigration of younger persons, the population is becoming

increasingly elderly. In some counties this chronic outmigration of younger persons of

childbearing age has resulted in deaths outnumbering births (Nucci and Long, 1995).

One resident, aged 67, noted: [f

i 1

The area has turned elderly. I put up the mail and I know how many get Social Security checks, and

that’s most of them. Our kids got a good education and they took a good work ethic with them when they

left— none of them are slackers. But there’s nothing here to hold the young ones. The opportunities are

better somewhere else. What it means is that Paul and I are the ‘young couple’ in the church and at the |

Library Society, and that’s so sad. ,

FOCUSING ON “FRONTIER”: ISOLATED RURAL AMERICA

21

The Future of the Frontier

A vigorous debate has emerged in recent years about the meaning of the frontier

and its future (Duncan, 1993; Popper, 1986; Popper and Popper, 1987). On the one

hand, its history and resources make it a vital part of our heritage and future. On the

other hand, it has been said that the Plains— as a result of the “largest, longest-running

agricultural and environmental miscalculation in American history”, may “become al¬

most totally depopulated” (Popper and Popper, 1987:12). In addition, as the US be¬

comes more densely populated and urban, these isolated rural areas are increasingly

seen as important for preservation and protection. A sense of immediacy is added with

the incursions into traditionally rural areas by more urban development. In Colorado

alone it was estimated that 250 acres per day are converted from farmland, ranchland

and open space to housing and other more urban developments (Foster, 1996).

At the same time that Frank Popper was rediscovering frontier areas, he was also

speculating about their future (Popper and Popper, 1987). In a controversial hypoth¬

esis, he predicted that the population would continue to decline in the Great Plains until

large portions became completely uninhabited. He feels these areas should revert to

pristine short grass prairie and become a vast wildlife preserve — home to large herds

of buffalo. The area that would be created has been dubbed the “Buffalo Commons.”

To current residents of these frontier counties, this idea is abhorrent.

Yet Dayton Duncan (1993) in his noteworthy book Miles from Nowhere suggested

another view of the future of the frontier. After his yearlong travel in the American

frontier he remained optimistic about its survival. He maintains frontier counties will

stabilize at their “irreducible minimum,” which he estimates at around 2 persons/sq.mi.

At this density, small towns always have “hairdressers and video rental stores,” in his

view apparently the two businesses essential for survival.

Frontier residents themselves often see their countryside as the “affordable new

frontier” with new opportunities for progress. They view themselves as “pioneers” and

feel that other more urban dwellers will follow their lead. This has begun to happen in

limited areas as urban “refugees” move to frontier areas and start new businesses using

technology. Examples can be found in Lincoln County, Montana where an orthopedic

surgeon settled and created an informatics company (Kootenet, 1996); and in Colorado

d where old ghost towns are being resettled (Lipsher, 1997).

e Ironically, these lands that nobody wanted 50 to 100 years ago are now the targets

e of great debate over how to protect them. As a Denver newspaper put it— “What hap¬

pens to what many consider the last and best acres of truly wild land?” (Ryckman,

1996). This debate seems to be heating up as the rest of the nation becomes more urban

and densely populated. Environmental groups are racing to preserve federal lands within

the frontier as wilderness areas. Others are working toward the establishment of Na¬

tional Monuments and National Parks, which increases tourism in these areas and there¬

fore stimulates the economy. Wilderness area designations are supported much more

22

JAMES A. CIARLO, PEARLANNE T. ZELARNEY

by those who either live in urban areas within the state now or have done so in the past

(Bradsher, 1997; Ryckman, 1996). Ironically, environmental groups and rural resi¬

dents alike oppose the establishment of National Parks, fearing the overuse by tourists

(Ryckman, 1996). Even in the less traditionally scenic Great Plains, efforts are afoot to

preserve and protect isolated areas. The Nature Conservancy is one organization that

has begun a national effort, called the Great Plains Project, to save North American

grasslands (Stolzenburg, 1996).

The view of frontier areas as valuable and worthy of preservation is often in direct

opposition to their resident’s dreams of economic prosperity. Frontier residents fear

that this preservation trend will limit economic opportunity and change land use that

has existed for a hundred years. At the forefront of this battle are the federal govern¬

ment, environmental groups and frontier residents. They are squaring off over grazing,

water and mineral rights. This conflict has spawned a political movement variously

described as the “county rights movement,” “county supremacy movement,” or the

“private property rights movement.” These movements maintain counties have author- 1

ity over the federal lands within their borders and have sometimes led to violent actions

against federal offices and agents (Larson, 1995). (

Implications of Behavioral Health Services

Frontier areas are a particularly interesting and often forgotten type of rural area.

c

They are notably distinct from other types of rural and nonmetro areas because of their

location in the West and their extreme isolation. In fact, their isolation and distance c

from services define them. Their western nature lends to their picturesque, but also c

extremely rugged, character. This harshness and a lack of abundant water make every¬

day living on the frontier a challenge. Their future has always been in question, and 1

never more so than now with the pressures from their more urban neighbors.

Frontier areas are not at all homogenous, however. They differ in climate, econo- c,

mies, population trends, and certainly in culture. All of their common and unique char- f,

acteristics must be taken into account when discussing mental health service provision

to their residents. Funding agencies, Congress and rural advocates need to understand

frontier areas’ commonalties to adequately understand their residents’ needs. Individual f]l

practitioners, managed care organizations, and state authorities must understand theiri

diverse natures when providing treatment and creating service provision models. These

areas cannot be arbitrarily lumped with other rural areas, and certainly not with urban .

or metro areas when considering health and mental health services issues. Frontier!

areas deserve to be understood and accounted for in the new health and mental health!1 Cl

care arena on their own terms and in consideration of their special uniqueness and value

Go

to all US citizens.

FOCUSING ON “FRONTIER”: ISOLATED RURAL AMERICA

23

References

Bachrach, L.L. (1977). Deinstitutionalization of mental health services in rural areas. Hospital and Community

Psychiatry, 28(9):669-672.

| Bender, L.D., Green, B.L., Hady, T.F., Kuehn, J.A., Nelson, J.K., Perkinson, L.B. and Ross, P.J. (1985, Septem¬

ber). The diverse social and economic structure of nonmetropolitan America. Washington, DC: Economic

Research Service, USDA, Rural Development Research Report #49.

I Berry, B. and Davis, A.E. (1978). Community mental health ideology: A problematic model for rural areas.

American Journal of Orthopsychiatry, 48(4):673-679.

Blouch, R.G. (1982). Rural people. In L.R. Snowden (Ed.), Reaching the Underserved: Mental Health Needs of

Neglected Populations (pp. 75-94). Beverly Hills, CA: Sage Publications, Inc.

Breshears, E. (1993, June). AOD and AIDS in the Frontier States. Paper presented at the meeting of the National

Council of State Legislators, Snowbird, UT.

Bureau of the Census (1990). 1990 Census of population and housing: summary population and housing char¬

acteristics, Colorado (1990 CPH-1-7). Washington, DC: US Government Printing Office.

Butler, M. and Beale C. (1994). Rural-Urban Continuum Codes for Metropolitan and Nonmetropolitan Coun¬

ties, 1993. US Department of Agriculture, Economic Research Services, Staff report No. AGWS. 9425.

Ciarlo J.A. and Tweed D.L. (1992). Exploring rural Colorado’s need for mental health services: Some prelimi¬

nary findings. Outlook (publication of the National Association, of State Mental Health Program Directors

Research Institute), 2(3):29-3 1 .

Ciarlo, C.A., Wackwitz, J.H., Wagenfeld, M.O., Mohatt, D.F. and Zalamey, P.T. (1996). Frontier Mental Health

Service Resource Network Letter to the Field No. 2. Denver, CO: Department of Psychology, University of

Denver.

Cook, P.J. and MizerK.L. (1994, December). The Revised ERS County Typology: An Overview. Rural Economy

Division, Economic Research Service, US Department of Agriculture. Rural Development Research Report

89.

Cordes, S.M. (1990). Come on in, the water’s just fine. Academic Medicine: Journal of the Association of Ameri¬

can Medical Colleges, 65(Supplement 3):S1-S9.

Cowan, S.C. (1979). The rural poor and mental health. Human Services in the Rural Environment, 1(2): 10-18.

I Coward, R.T., De Weaver, K.L., Schmidt, F.E. and Jackson, R.W. (1983). Distinctive features of rural environ¬

ments: A frame of reference for mental health practice. International Journal of Mental Health, 12(l-2):3-24.

j Cromartie, J.B. and Swanson, L.L. (1997). Census tracts more precisely define rural populations and areas.

Rural Development Perspectives, 1 1(3):3 1-39.

I Duncan, D. (1993). Miles from Nowhere. New York: Penguin Books.

I Fitchen, J.M. (1981). Poverty in rural America: A case study. Boulder, CO: Westview Press.

Fitchen, J.M. (1986). When rural communities collapse: Implications for mental health. Rural Community Men-

j tal Health Newsletter, 13(2):5-9.

, Fitchen, J.M. (1990). Poverty as context for old age in rural America, Journal of Rural Community Psychology,

1 1 1(1):3 1-50.

1 Fitchen, J.M. (1991). Endangered spaces, enduring places: Change, identity, and survival in rural America.

r Boulder, CO: Westview Press.

, Flax, J.W., Wagenfeld, M.O., Ivens, R.E. and Weiss, R.J. (1979). Mental Health and Rural America: An Over¬

view and Annotated Bibliography. Rockville, MD: National Institute of Mental Health.

GAO (1993, April). Rural Development: Profile of Rural Areas. Fact Sheet for Congressional Requesters, Wash-

r ington, DC: United States General Accounting Office, April 1993.

(l Ghelfi, L.M. and Parker, T. (1995). A new county-level measure of urban influence. Paper presented at the annual

meeting of the Rural Sociological Society, Pentagon City, VA, August 13-20.

Goldsmith, H.F., Holzer III, C.E., Woodbury, M.A. and Ciarlo, J.A. (1999). Frontier Like Counties with Different

Types of Sociodemographic, Economic and Health/Mental Health Characteristics. Frontier Mental Health

Service Resource Network Letter to the Field No. 18. Denver, CO: Department of Psychology, University of

Denver.

24

JAMES A. CIARLO, PEARLANNE T. ZELARNEY

Goldsmith, H.F., D.S. Puskin and D.J. Stiles. 1993. Improving the Operational Definitional of “Rural Areas” for

Federal Programs. Rockville, MD: Federal Office of Rural health Policy.

Harrington, M. (1962). The Other America . New York: Penguin Books.

Hewitt, M (1989, July): Defining “Rural” Areas: Impact on Health Care Policy and Research. Washington, DC:

Health Program, Office of Technology Assessment, Congress of the United States.

Holzer III, C.E., H.F. Goldsmith and C.A. Ciarlo. 1998a. “Effects of rural-urban county type on the availability of

health and mental health care providers.” In Mental Health , United States, 1998, R.W. Manderscheid and M.J.

Henderson (Eds.). Publication DHHS No. (SMA)99-3285. Washington, DC: US Government Printing Office,

pp. 204-213.

Kenkel, M.B. (1986). Stress-coping-support in rural communities: A model for primary prevention. American

Journal of Community Psychology, 14(5):457-478.

Melton, G.B. (1983). Ruralness as a psychological concept. In A.W. Childs and G.B. Melton (Eds.). Rural psy¬

chology. pp. 1-14. New York: Plenum.

Norris, K. (1993). Dakota: A spiritual geography. New York: Ticknor and Fields.

NRHA (1994, September). Health Care in Frontier America: A Time for Change. Washington, DC: Office of

Rural Health Policy, Health Resources and Services Administration, Public Health Service, US Department of

Health and Human Services.

O’Hare, W. and Curry-White, B. (1992). The rural underclass: Examination of multiple -problem families in

rural and urban settings. Washington, DC: Population Reference Bureau.

Popper, D.E. and Popper, F. (1987). The great plains: From dust to dust. Planning, 53(12): 12-18.

Popper, F. (1986). The strange case of the contemporary American frontier. Yale Review, Autumn: 101-121 .

Porter, K.H. (1989, April). Poverty in rural America: A national overview. Washington, DC: Center on Budget

and Public Priorities.

Turner, F.J. (1993). History, Frontier, and Section. Three Essays by Frederick Jackson Turner. Albuquerque:

University of New Mexico Press.

Wackwitz, J. (1994, April). Defining the Continuum. Paper presented at the Mental Health Services for Rural

Colorado meeting, Durango, CO.

Wagenfeld, M.O. (1994, July). Mental Health and substance abuse in underserved rural areas: Models of effec¬

tive service delivery. Helsinki, Finland: Federation for International Cooperation of Health Systems and Ser¬

vices Research Centers.

Wagenfeld, M.O. and Wagenfeld, J.K. (1981). Values, culture, and the delivery of mental health services in rural

areas. In M.O. Wagenfeld (Ed.), Perspectives on rural mental health. New Directions for Mental Health Ser¬

vices Series, No. 9. San Francisco, CA: Jossey-Bass.

Webb, W.P. (1952). The Great Frontier. Boston: Houghton Mifflin.

Zelamey, P.T. and Ciarlo, J.A. Defining and Describing Frontier Areas in the United States: An Update (1999).

Frontier Mental Health Service Resource Network Letter to the Field No. 22. Denver, CO: Department of

Psychology, University of Denver.

E

Notes

1 Metropolitan areas are further classified into free-standing Metropolitan Statistical Areas (MS As) or Consoli- ®

dated (multiple) Metropolitan Statistical Areas (CMS As) based on their location with respect to other MAs. ||

Journal of the Washington Academy of Sciences,

Volume 86, Number 3, 25-33, December 2000

The Availability of Health and

Mental Health Providers

by Population Density

Charles E. Holzer III, Ph.D., Harold F. Goldsmith, Ph.D. and

James A. Ciarlo, Ph.D.

Abstract

This paper explores the local availability of mental health service providers in different

types rural areas. Emphasis is place upon the services available to frontier and isolated rural

areas. Because persons with mental health problems may use a wide variety of social, medi¬

cal and psychological providers depending on their degree of functional deficit, providers

in both the general medical and the specialty mental health sectors are evaluated. This per¬

mits the determination of the extent to which both of these services are locally available in

high density urban areas as well as frontier and isolated rural areas. The types of providers

examined are psychiatrists, child psychiatrists, family practice physicians, all physicians,

psychologists and social workers. The analysis demonstrates that mental health service pro¬

viders tend to be concentrated in the densely settled counties, counties that are likely to be

highly urbanized and in metropolitan areas. This is particularly true for psychiatrists and

child psychiatrists and to a lesser extent psychologists and social workers. Such providers,

however, are not likely to be found in frontier and isolated rural counties. While most coun¬

ties, including frontier and isolated rural counties are likely to have physicians, including

family practice physicians; there are many of these low density counties that do not have the

services of physicians available.

Introduction

Based on population density, this paper examines the local availability of mental

health service providers for those living in rural areas and those living in areas desig¬

nated as frontier due to their extremely low population per square mile. Our initial

assumption, which is largely bom out in the following analysis, is that persons living in

frontier and isolated rural areas have fewer mental health service providers available to

them either through the general medical sector or through specialty mental health sec¬

tors than persons living in more urbanized areas. In addressing this question we define

availability of mental health services as the presence and the number of those psychiat¬

ric and/or psychological providers of services that traditionally address the needs of

those with various types of behavioral health problems or disorders.

Earlier studies clearly demonstrate that services provided by specialty organiza¬

tions increase as one goes from low density isolated rural areas to the most urbanized

high density counties, no empirical demonstration has shown that this relationship holds

26 CHARLES A. HOLZER III, HAROLD F. GOLDSMITH, JAMES A. CIARLO

for both general medical and specialty providers of mental health services (Goldsmith

et al., 1997; Holzer, Goldsmith and Ciarlo, 1998). Since services needs are likely to be

similar at all population density (urbanization) levels (Wagenfeld et al., 1994), under¬

standing differences in availability is essential for effective program planning. Also,

because persons with mental problems may use a wide variety of social, medical and

psychological providers depending on their degree of functional deficit, providers in

both the general medical and the specialty mental health sectors play major roles in

providing care for behavioral health problems. The extent to which these services are

both locally available reflects the extent to which the residents of an areas have choices

among professional service providers.

Sources of Data

Area Resource File. A primary source of data for addressing the availability of

services is the Area Resource File (ARF) of the Department of Health and Human

Services, Bureau of Health Professions, Office of Research and Planning (Quality Re¬

source System, 1996). Most of the data included in the file is drawn from governmental

agencies such as the National Center for Health Statistics and the US Census, or from

private agencies such as the American Medical Association (AMA), and the American

Hospital Association (AHA). They collect data either from administrative records of

the agencies or from surveys of hospitals or other facilities.

Public Use Microdata 5 % Sample (PUMS) - 1990. Because the Area Resource

File focuses primarily on professionals in specified health settings, it contains only

minimal data on psychologists and social workers. In order to gather additional infor¬

mation on these professions, we conducted analyses of data from the Public Use

Microdata 5% Sample (PUMS) of the 1990 US Census. This contains a sample of

approximately 5% of the US population, particularly those who filled out the Census

long form questionnaire — the form that contains detailed information about respon¬

dents and their families. Because the PUMS is a sample of individual records, confi¬

dentiality is protected by limiting geographic identification to areas corresponding to

about 100,000 persons. For purposes of the present analyses we aggregated sub-county

areas up to the county level, and for areas containing multiple (small) counties we

allocated the record data to the counties contained within it, proportionally by county

population, and then adjusted the marginals of tables to match available published Cen¬

sus tabulations (STF files). This procedure is described elsewhere, but has the effect of

approximating the county information in a manner that should not be unduly biased in

subsequent tabulations (see Holzer et al., 1998).

THE AVAILABILITY OF HEALTH AND MENTAL HEALTH PROVIDERS

27

Definitions of Rural and Frontier

Our primary measure of the urban-rural dimension is population density. This is

the number of persons residing in a county divided by its land area. We have adopted

the Frontier Mental Health Services Resource Network’s definition of “frontier” as

counties with less than 7 persons per square mile (see Ciarlo et al., 1998). To provide a

continuum, we have further divided this density category into “very frontier” (0 to 1 .9

persons per square mile) and “frontier” (2.0 to 6.9). All frontier and very frontier coun¬

ties are nonmetropolitan (having limited access to the daily market areas of big cities,

cities with 50,000 or more persons) and are predominately rural (having no urban place

of 2,500 or more persons represent 64.4 and 81.4 percent of these counties, respec¬

tively) (see Holzer and Goldsmith, 1998).

Analyses Based on the 1996 Area Resource File

The Area Resource File provides counts for a number of different types of health

and mental health providers by the setting in which they practice. Rather than attempt¬

ing to present too many subtypes, we have selected for presentation a few of the major

types of providers. These include psychiatrists, child psychiatrists, psychologists, so¬

cial workers, family practice physicians, and all physicians.

For each of the selected provider types we have presented the availability of the

provider by population per square mile categories. In each figure the legend identifies

the population density category and the number of counties in that density category.

For each variable the percentage of counties with any providers in the category is given.

This is important because it shows that many counties have no service providers of the

particular type. Also present in each figure is the number of providers or units of ser¬

vice per 100,000 persons living in the designated county area. Thus one can see when

there are not only fewer providers, but also fewer providers relative to the size of the

population.

Availability of Psychiatrists. Figure 1 presents the availability of psychiatrists for

each population density category. This variable is reported from the AMA survey of

medical specialists, and does not include those employed by the federal government.

The county for the psychiatrists in this source appears to correspond to the office loca¬

tion rather than his/her residence. In the lowest density category, from 0 to 1.9 persons

per square mile, there are 129 counties that are designated “very frontier.” In the next

category, with densities from 2.0 up to 7.0 persons per square mile, there are 296 coun¬

ties identified as “frontier.” The first data set presents the percentage of those counties

identified as having any non-federal psychiatrists, regardless of type of activity. Less

than 1 percent of the very frontier counties had any psychiatrists, and only about 10%

of the frontier counties had any psychiatrists. This contrasts sharply with 30.6% for

counties with more than 15 persons/sq. mi., and with 91% for counties with over 100

28 CHARLES A. HOLZER III, HAROLD F. GOLDSMITH, JAMES A. CIARLO

persons/sq. mi. The next data set presents the number of psychiatrists per 100,000

populations. This figure takes into account the smaller population of the frontier coun¬

ties. Even as a rate of psychiatrists per 100,000 population, the availability of psychia¬

trists in frontier counties is almost nonexistent and much lower (0.1/100,000 and 1.3/

100,000 respectively) than the 10.5/100,000 found for the most densely settled coun¬

ties.

Availability of Child Psychiatrists. Figure 1 also presents the availability of child

psychiatrists in 1994, which are not federal employees, as obtained from the AMA

Physician Master File by density category. This figure shows that child psychiatrists

are not present in any of the lowest density counties and are found in only 0.7 percent

(i.e., only two) of the remaining frontier counties. Less than 10% of the counties with

7 through 99.9 persons per square mile have any child psychiatrists. Only in the coun¬

ties with over 100 persons per square mile does the percentage with even one child

psychiatrist rise to 58.1%. Similarly the availability of child psychiatrists by rate in¬

creases with population density, but then only to an average of 1.5 per 100,000 persons

for the densest areas. The maximums in a few areas are much higher, but those are

primarily in counties with major medical schools.

Figure 1 . Availability of Psychiatrists and Child Psychiatrists in 1994 by Population Density

□ 0 - 1.9 (very frontier, 129 counties)

□ 2 - 6.9 (frontier, 296 counties)

0 7 - 9.9 (126 counties)

H 10 - 14.9 (163 counties)

■ 15 - 99.9 (1625 counties)

■ 100+ (742 counties)

Availability of Family Practice Physicians. According to the de facto model

(Regier et al., 1978), as much as half of mental health care may be obtained in the

general medical sector. Much of this care will be from physicians in family or general

primary care practices. We have included family practice physicians to identify the

availability of physicians who could provide mental health care in the absence of men¬

tal health specialists. It should also be noted that many family practice physicians

obtain additional training in psychiatry, not only as a general requirement of their resi¬

dencies, but because of interest in mental health in family settings. Figure 2 presents

Percent with Rate of Percent with Rate of Child

any Psychiatrists/ any Child Psychiatrists/

Psychiatrists 100,000 Psychiatrists 100,000

THE AVAILABILITY OF HEALTH AND MENTAL HEALTH PROVIDERS

29

the 1994 distributions for MDs in non-federal family practice, as obtained from the

AMA Physician Master File by population density. Of the counties with the lowest

density, 0-1.9 persons per square mile, only 33.3% have MDs in family practice. Note¬

worthy, this reflects an average of only 0.7 per county. With a rate of 14.3 family

practice physicians per 100,000 persons, an average practice size would be nearly 7,000

if patients were not accessing other forms of care. Clearly, a medical practice this large

would not allow a great deal of time for providing mental health services.

For the counties with densities of 2.0-6.9 persons per square mile (frontier), the

availability of family practice physicians increases to 68.9 percent, or an average of two

per county. The availability of family practice physicians per 100,000 population is

25.8. This is not only a substantial increase from the very frontier counties, but is

actually higher than for any of the more densely settled areas. This finding may indi¬

cate that while it takes a minimum population density to maintain a practice, the family

practitioner is a common form of medicine in frontier areas. Additionally, as will be

noted later, after our examination of psychologists and social workers, the family prac¬

titioner is also the most common medical practitioner who is likely to provide mental

health services.

Availability of All Physicians. In order to address the question of whether the

reduced availability of specialty mental health providers or family practice providers is

part of a general pattern of availability of physicians, we have included figures on the

distribution of all MDs engaged in patient care. Figure 2 also presents the availability

of all physicians engaged in patient care by population density. This variable includes

all MDs who are active and providing patient care, including office-based, hospital

residents, clinical fellows, and hospital-based full-time staff. It excludes those prima¬

rily involved in administration, teaching, or research. It was drawn from the AMA

Physician Master File for 1994.

Figure 2. MDs in Family Practice or any Practice in 1994 by Population Density

□ 0 - 1.9 (very frontier, 129 counties)

□ 2 - 6.9 (frontier, 296 counties)

□ 7-9.9 (126 counties)

□ 10 - 14.9 (163 counties)

H 15 - 99.9 (1625 counties)

■ 100+ (742 counties)

Percent with any Rate of Family Percent with any Rate of MDs in

Family Practice Practice MDs in Patient Patient

MDs MDs/ 100,000 Care Care/100,000

30 CHARLES A. HOLZER III, HAROLD F. GOLDSMITH, JAMES A. CIARLO

Even when all types of physicians are considered, less than half of the very frontier

counties have any physicians, although this jumps to over 85% for even the frontier i

counties. The rate per 100,000 is 30.7 for the very frontier counties. The range is 53.4 l

to 68.7 per 100,000 for all the intermediate categories, and then jumps to 179.8 per i

100,000 for the highest density counties/cities. Clearly, physicians are concentrated in 1

the cities. Moreover, in comparison with psychiatrists and child psychiatrists, it is clear i

that in the more densely populated areas, there is more opportunity for choice of a

mental health provider who is in the specialty sector or the medical sector.

Analyses Based on the 1990 US Census PUMS Data

Rationale. In preliminary work, we examined the distribution of psychologists.

We discovered during this work, however, that the available counts in ARF are limited

to psychologists working full- or part-time in hospitals, whether short- or long-term

facilities. The numbers of psychologists identified by that means was extremely low,

with only a small proportion of counties having any psychologists identified at all.

Even in metropolitan central cities, only 66% had even one psychologist. Although this

pattern could be consistent with psychologists being in individual or group private prac- j

tice outside hospitals, or working in nonhospital-based health care settings, it appeared

to greatly understate the availability of psychologists. In order to obtain a more com¬

plete picture of the distribution of psychologists, we examined the US Census Public

Use Microdata Sample for 1990. We were able to identify psychologists, social work¬

ers, and clergy as potential sources of mental health care, but these titles are non-spe¬

cific and do not identify function. Because many with these occupational titles are

engaged in work totally unrelated to mental health, we placed two additional restric¬

tions on the persons to be tabulated. First, we limited the count to persons with at least

a master’s degree. This is the usual level at which one can engage in independent

mental health practice, although there is variability in state statutes regulating private

practice. Second, we limited the count to persons who are identified as working in any

kind of health-related industry, including offices and clinics of physicians, health prac¬

titioners, hospitals, nursing and personal care facilities, health services not otherwise

classified, residential care facilities, and miscellaneous professional and related ser¬

vices. We think that this would include psychologists in private practice. This reduced

the numbers of M.A. or higher psychologists by about 30-40% from their total and

M.A. level social workers by 60-70%.

Availability of Psychologists. Figure 3 presents the number of M.A. or greater

psychologists working in health-related settings by population per square mile. Be¬

cause these figures are based on 1990 rather than 1993 data, the distribution of counties

by population per square mile is slightly different. In the areas with less than 2 persons

per square mile, only 13.3% of counties have psychologists in health care settings,

although that percentage would increase to nearly 3 1 . 1 % if all settings were included.

!

C

c

I

P

e

ti

C

a,

F

H

](

«

5(

«

I

1

1C

11

15

ifii

il

K

THE AVAILABILITY OF HEALTH AND MENTAL HEALTH PROVIDERS

31

The difference might be influenced by psychologists working primarily in schools who

may have both mental health and educational roles. For population densities of 2.0

through 6.9, about 43.1% of counties have psychologists in health care settings. This

increases gradually and then jumps to 79.5% for high density counties. In a parallel

way, the number of psychologists per 100,000 population is lowest (13.0 per 100,000)

in the least densely populated counties and is greatest in the densest counties (28.9 per

100,000).

Availability of social workers. Figure 3 also presents the population density dis¬

tributions of social workers with master’s degrees or greater who work in health-related

settings. Only 18.5 percent of counties with less than 2 people per square mile had

social workers of this type, and only 23.4 percent of the remaining frontier counties had

comparable social workers. In contrast, 73.2 percent of the most densely populated

counties have social workers at this level. As a population rate, the low density counties

had about 12.8 social workers of this type per 100,000 population, as compared to 23.6

per 100,000 for the high density counties. The rates for the intermediate counties were

even lower than for the frontier counties. For reference, social workers in health set¬

tings represented about a third of all social workers with comparable education levels.

Other settings in which social workers are found include schools and social service

agencies without a health focus.

Figure 3. MA+ Psychologists and Social Workers in Health Settings in 1990 by Population Density

□ 0 - 1.9 (very frontier, 135 counties)

□ 2 - 6.9 (frontier, 299 counties)

□ 7 - 9.9 (126 counties)

□ 10 -14.9 (167 counties)

■ 15 -99.9 (1659 counties)

■ 100+ (935 counties)

Percent with

any

Psychologists

Rate of

Psychologists

per 100,000

Percent with

any Social

Workers

Rate of Social

Workers per

100,000

Implications for Behavioral Health Services Behavioral Health Services

This paper explored the availability of mental health services providers in counties

with different levels of population density using the 1996 Area Resource File and the

1990 Public Use Microdata Sample. Emphasis was placed upon the availability of pro¬

viders in frontier and vary frontier counties. The primary concern was to determine

whether the access to providers in both the general and specialty mental health sectors

were significantly lower these types of “isolated rural counties” as compared to more

32 CHARLES A. HOLZER III, HAROLD F. GOLDSMITH, JAMES A. CIARLO

highly urbanized counties. The extent to which such services are not available to the

residents of “isolated rural areas,” residents have only limited choices with respect to

locally based professional mental health services. Using a density classification to dif¬

ferentiate counties with respect to their frontier status, we examined the distributions of

types of providers, including psychiatrists, child psychiatrists, family practitioners, all

physicians, psychologists and social workers. Not unexpectedly, the overall finding

was that mental health service providers tend to be concentrated in the most densely

settled counties — counties that likely to be either metropolitan counties or

nonmetropolitan counties with large cities. This is particularly true for psychiatrists

and child psychiatrists, and to a lesser extent, for psychologists and social workers.

Such providers are not likely to be found in the frontier or very frontier counties. While

physician family practitioners as well as all physicians are likely to be found in the

majority of frontier and very frontier counties, there are still many of these counties that

have no physicians available who might provide mental health services in the absence

of specialty mental health care providers.

It is clear from the analyses presented, specialty mental health service provider are

not available in many frontier and very frontier areas. This means that if mental health

services are to be provide to these areas, they will have to be provided by locally based

primary care providers in the areas that have such providers or, in areas that do not have

primary care providers, through strategies such as telemental health that make the spe¬

cialty provider who reside in densely settle areas accessible.

Limitations

Clearly, the Area Resource File has limited current information about types of spe¬

cialty mental health services. The distribution of psychiatrists may be a rough surro¬

gate for that distribution, but it can only do so minimally due to the large proportion of

mental heath services offered by psychologists, counselors, and other mental health

workers. A second limitation of the present analyses is that the providers of services are

identified by the county in which they are located rather than differentiating the coun¬

ties that they serve. The ARF identifies contiguous counties but provides no means of

allocating services identified to neighboring populations. A third limitation is that it

does not take into account the ability or willingness of rural residents to access services

beyond their county of residence. Finally, access to services, even when present, can be

limited by economic, social, and psychological barriers to access.

THE AVAILABILITY OF HEALTH AND MENTAL HEALTH PROVIDERS

33

References

Bergstrom, D.A. (1982). Collaborating with natural helpers for delivery of rural mental health services. Journal

of Rural Community Psychology, 3:5-26.

Hargrove, D.S. and Breazeale, R.L., (1993). Psychologists and rural services: Addressing a new agenda. Profes¬

sional Psychology: Research and Practice, 24:319-324.

Hill, C.E. and Fraser, G.J. (1995). Local knowledge and rural mental health reform. Community Mental Health

Journal, 31:553-568.

Holzer III, C.E. and Goldsmith, H.F. (1998) The Availability of Health and Mental Health Providers by Popula¬

tion Density and Urban-rural County Type. An unpublished Frontier Mental Health Service Resources Net¬

work Knowledge Syntheses Paper. Denver. Department of Psychology, University of Denver.

Merwin, E.I., Goldsmith, H.F. and Manderscheid, R.W., (1995). Human resource issues in rural mental health

services. Community Mental Health Journal, 3 1 :525-537.

Quality Resource Systems, Inc. (1996, February). Area Resource File [CD-ROM]. Bureau of Health Profes¬

sions, Office of Research and Planning.

Regier, D.A., Goldberg, I.D. and Taube, C.A. (1978) The de facto US mental health services system: a public

health perspective. Archives of General Psychiatry, 35:685-693.

Regier, D.A., Narrow, W.E., Rae, D.S., Manderscheid, R.W., Locke, B.Z. and Goodwin, F.K. (1993). The de

facto US mental and addictive disorders service system. Epidemiologic catchment area prospective 1-year

prevalence rates of disorders and services. Archives of General Psychiatry, 50:85-94.

US Census of Population and Housing (1992). 1990, Public Use Microdata Samples, United States [Technical

Documentation prepared by the Bureau of the Census]. Washington, DC: Author.

■

Journal of the Washington Academy of Sciences,

Volume 86, Number 3, 35^47, December 2000

Access To Mental Health Services

In Frontier America

Dennis F. Mohatt, M.A.

Abstract

This paper reviews and evaluates the access, the potential and actual entry of a given popu¬

lation group, to mental health services in frontier areas of the United States. The paper takes

into account that the combination of the shortage of providers and limited array of services,

coupled with a thin layer of third party payors, creates a fragile continuum of care for rural

residents, especially those residing in remote frontier areas, these conditions exacerbate the

problems of providing access to appropriate and effective mental health care. Several case

studies are presented to illustrate the nature of the problem and potential solutions to the

problems. The importance of Medicaid and the emergence of managed care in frontier areas

are also considered.

Introduction

While comprehensive healthcare reform at the federal level now appears unlikely,

the healthcare marketplace is nonetheless changing rapidly. The traditional American

healthcare system of independent providers being reimbursed by patients and indem¬

nity insurers on a fee-for-service basis is rapidly yielding to myriad new payment and

delivery systems, multi-provider networks, and innovative private and public efforts to

manage the care of beneficiaries. This shift toward what is most often called managed

care has been a clear trend in the marketplace for the past decade, and has currently

shown a rapid acceleration of pace (US Congress, Office of Technology Assessment

[USC-OTA], 1995). The trend is especially evident in the public sector, where 42 states

have received approval from the federal Health Care Financing Administration (HCFA)

for various managed care approaches to Medicaid (WAMI Rural Health Research Cen¬

ter [WAMI], 1994).

The rural implications of this trend have not been empirically established, due to a

lack of rural-specific managed care experience and the rapid evolution of managed care

strategies. Rural issues that may impact the development of managed care have how¬

ever, been clearly illuminated in recent years. Limited access to and availability of

appropriate mental health care for rural residents are just two examples. These issues

take on new meaning and are even more dramatic in isolated “frontier” areas of the

United States. Murray (1990) testified at a regional field hearing on rural mental health

that “we are beyond needing to argue that there are rural human resource shortages or

that rural practice is unique and presents a special set of demands on professionals;

36

DENNIS F. MOHATT

solutions to these problems need to be provided.” This is particularly true in our evolv- I

ing efforts to reform the healthcare system through the imposition of managed care b

strategies, and imposed funding growth ceilings for federal spending in Medicare and n

Medicaid. j si

Some are already concerned that managed care efforts, instead of providing for it

more affordable and accessible services, will further limit already sparse mental health is

services in rural frontier areas (T. Perkins, personal communication, 1995; J. Fowler, ' ft

personal communication, 1995; K. Quint, personal communication, 1995). While oth¬

ers (Korczyk, 1994) believe managed care may actually be more effective than the P

current system in enhancing health care access for rural populations, they also feel it ti

will be less effective in reducing the cost of care to rural populations. Korczyk believes j pi

rural residents will probably have greater access to primary care under managed care, ai

but will need to utilize urban resources for more specialized care at a greater cost, ici

Serrato and Brown (1992) suggest, from their review of the Medicare system, that rural tr

areas are typically underserved and not a source of high cost. As a result, they believe, m

emphasis can be placed upon increasing access in rural areas, rather than on controlling id

costs. Clearly the need is critical to better understand the impact of such dramatic tii

system change on accessibility and availability of services in behavioral health systems

serving remote frontier populations. Pi

Aday and Anderson (1974) assert that “access may be defined as those dimensions Q

which describe the potential and actual entry of a given population group to the health k

care delivery system.” In reviewing existing literature, three spheres of access seem to oi

impact individuals seeking health and/or mental health services. The special issues of et

rural frontier environments impact all three spheres. The first sphere is financial access ca

to care, how the care for an individual in need is funded. The second sphere is physical tic

access to care, not to be confused with availability, which relates to how a person di- as

rectly links with the caregiver. The third sphere is psychological access, which is the pe

actual acceptability of the caregiver, treatment setting, and modality of care to the con- al,

sumer. As access is explored in this paper, all three spheres will be examined. Finally,

availability of services appears to be impacted by the complex interactions of the distri- (si

bution of professionals and agencies, the comprehensiveness of a continuum of ser- dri

vices, and the choice of public and private service delivery systems. i ft

I If

Current Access to Mental Health Care in Frontier and Rural Area

Cif

Se:

Over one-fourth of the population of the United States reside in non-metropolitan

areas, and nearly all states have distinct rural populations. These rural Americans expe¬

rience incidence and prevalence rates of mental illnesses and substance abuse which

are equal to or greater than their urban counterparts (Wagenfeld, Murray, Mohatt and

DeBruyn, 1994). They also suffer from chronic shortages of mental health providers

and services which significantly impact the organization and delivery of behavioral

lil

fol

tc

Ser

k

ACCESS TO MENTAL HEALTH SERVICES IN FRONTIER AMERICA

37

healthcare. Rural and frontier residents are less likely than their urban counterparts to

have access to inpatient mental health services. One study indicates that in isolated,

rural counties inpatient psychiatric services are almost nonexistent (Wagenfeld, Gold¬

smith, Stiles and Manderscheid, 1988). While the data does not look specifically at

inpatient resources in frontier areas, it appears evident that persons residing in these

isolated, low population areas will be least likely to find psychiatric inpatient resources

within their community hospitals.

Over sixty percent of rural areas have been designated as federal Mental Health

Professional Shortage Areas (USC-OTA, 1990), and many of these are frontier coun¬

ties. The public mental health system is often the only provider in rural areas and

primarily serve persons with serious mental illnesses (Wagenfeld et al., 1994). Frontier

areas are often served only by itinerant providers or regionalized systems requiring

considerable travel to access most services. As a result, isolated rural residents must

travel for substantially longer distances to access a mental health provider, and are

much more likely to see a mental health provider with less advanced training than their

urban peers (Schurman, Kramer and Mitchell, 1985; K. Quint, personal communica¬

tion, 1995).

Rural areas are also less likely to offer a full array of behavioral health services (T.

Perkins, personal communication, 1995; J. Fowler, personal communication, 1995; K.

Quint, personal communication, 1995). For example, while 95% of urban counties

have psychiatric inpatient services, only 13% of rural counties have such services, and

outpatient services are available in twice as many urban as rural hospitals (Wagenfeld

et al., 1988). Frontier settings, with small and widely dispersed populations, often

cannot support the economies of scale necessary to maintain specialty services. Addi¬

tionally, supportive resources such as public transportation, housing, and vocational

assistance, which are vital for promoting independence in persons with serious and

persistent mental illnesses, are often limited or unavailable in rural areas (Wagenfeld et

al., 1994).

In sparsely populated frontier areas such as those found in the larger western states

(such as Nevada, Arizona, Utah, New Mexico), consumers may have to travel hun¬

dreds of miles for mental health care (J. Fowler, personal communication, 1995; K.

Quint, personal communication, 1995). An example of distance as a barrier to treat¬

ment was given by a physician’s assistant, Mary, who sought care for depression pre¬

cipitated by the tragic death of her only child. Mary was working in an Indian Health

I Service (IHS) hospital on the Rosebud Reservation in South Dakota. Her son was

1 killed in a tragic car accident on the way home from a basketball game. In the weeks

following his death, Mary became increasingly depressed and pondered suicide. Al-

1 though a range of care was available in Rosebud’s IHS hospital, specialty mental health

h services were unavailable. As a federal employee, Mary’s health care was reimbursed

s through the Federal Employee Health Plan (FEHP); however its nearest approved pro-

38

DENNIS F. MOHATT

vider for mental health care was in Rapid City, 150 miles northwest of Rosebud. When

Mary finally sought care, it required her to drive over four hours twice weekly to re¬

ceive outpatient care. While Mary had the resources and transportation to seek this

care, for many persons the time and travel required to access care would prove an

insurmountable barrier.

Catchment areas can also complicate access to services for rural residents. These

service area designations for public mental health providers are often the artifacts or

remnants of the Community Mental Health Centers (CMHC) Act (US Congress, 1963

as amended). This act initially guided federal efforts to develop community based

comprehensive treatment options across the nation. Although the CMHC Act lapsed in

the early 1980s, replaced by the Mental Health Block Grant (OBRA 1981), many rural

catchment areas endure based upon the acceptable practices of the Act. As a result, the

delivery system for public mental health maintains its ties to county and state policy

and revenue streams, which serve as the conduit for public oversight and revenue. While

useful for public accountability for disbursement and revenue accounting, and imple¬

mentation of mental health public policy by the states, these catchment areas often have

little if anything to do with the reality of how persons seek services, which is more

likely to relate to their patterns of trade or commerce.

An example of this was clearly illuminated by a consumer from the panhandle

region of Nebraska. The panhandle region is in northwest Nebraska, and is a typical

western frontier area. The consumer routinely travels 120 miles (one-way) to Chey¬

enne, Wyoming for everything from groceries to healthcare. Cheyenne is the center of

trade and commerce for the region. However, since her son, who has a serious and

persistent mental disorder and receives public assistance due to this disability, receives

his mental health care from the public sector, he must use a Nebraska provider. This

requires regular trips of 90 miles (one-way) in the opposite direction and clearly out¬

side the routine patterns of trade/commerce for the family. Since the community where

the mental health care is available in Nebraska lacks the services and products routinely

accessed in Cheyenne, the family is forced to make extra trips, incur extra expenses,

and often delay or postpone care due to access barriers (e.g., weather, cost of travel,

time). The consumer relays, “...the solution to this issue for me would be to shop where

I want for the services that best suit me and my family.”

While the previous example relates to a more complex issue of interstate public

policy and cooperation, the same problem also arises within state boundaries. A family

living in a frontier county in northcentral Montana faces similar difficulties due to county

borders. Their child needed specialized treatment as a result of Serious Emotional

Disturbance (SED). Although the child attended school across the county-line in a

small town (pop. 3,500), only 25 miles from their ranch, the public mental health agency,

which they were required to utilize for care five days per week, was 60 miles in the

opposite direction. Since the provider catchment areas were organized via multi-county

designations, and received county funds, the family would have to seek the approval

for payment of services received outside the area.

ACCESS TO MENTAL HEALTH SERVICES IN FRONTIER AMERICA

39

Rural areas also have disproportionate populations of uninsured and underinsured.

As a result of a large percentage of rural persons being employed in small business or

self-employed, they are more likely to be uninsured or have only “catastrophic” insur¬

ance coverage, which lack behavioral health benefits. Only one-fourth of the rural poor

qualify for Medicaid, compared to 43% of the poor in urban areas (US Senate, 1988).

The combination of professional shortage and limited array of services, coupled

with a thin layer of third party payors, creates a fragile continuum of care for rural

residents, especially those residing in remote frontier areas. These conditions have tra¬

ditionally resulted in: 1) rural persons going without appropriate care; 2) rural persons

accessing less than timely care, resulting in increased cost and duration of care; 3) rural

persons being treated at higher (and more costly) levels of care; and 4) rural persons

receiving care at a greater distance from their home and work, resulting in loss of com¬

munity ties and difficulty in reintegration (Beeson and Mohatt, 1993). Effective health

care systems, such as managed care strategies, must address each of these issues to

ensure both cost containment and access to quality service in frontier areas. Collec¬

tively, these issues make up a “check-list” of potential challenges to the planning, imple¬

mentation, management, delivery, and evaluation of mental healthcare in rural and fron¬

tier settings. These include:

• Wide Dispersion of Population

• Geographically Vast Areas

• Few Inpatient Psychiatric Resources

• Chronic Shortages of Health and Mental Health Professionals

• Lower Per Capita Participation in Health Insurance

• Lower Per Capita Participation in Medicaid

• Limited Array of Health and Mental Health Services

• Dependence Upon Public Subsidy for Mental Health Systems

• Limited Supportive Services (Housing, Transportation, Vocational)

• Low Penetration of Commercial Managed Care

• Limited Consumer Advocacy

• Limited Self-Help Resources

• Stigma

• Lack of Anonymity

Two Frontier Area Examples

Rural advocates and researchers stress the need to carefully develop our view of

rural America. Rural America is not homogenous. The frontier environment is equally

diverse, with Kewauna County, Michigan being vastly different from Apache County,

Arizona. This diversity has specific impact upon access and availability of services,

iand the strategies shaped to address them.

40

DENNIS F. MOHATT

Apache County in northeastern Arizona stretches over 350 miles along the New

Mexico border north/south from the Utah border, and is the longest county in the United

States. Its more than 60,000 residents are widely dispersed across 1 1,21 1 square miles.

The geography includes high mountains, the fertile Little Colorado river valley, and

high desert. The nearest large metro areas are Flagstaff, Tucson, and Phoenix in Ari¬

zona, and Albuquerque in New Mexico, each of which are many hours away by car.

The area is not served by commercial airlines or public transportation (except for lim¬

ited specialized transportation for senior citizens). The county population is predomi¬

nately Native American, with the northern one-third of the county dominated by the

Navajo Nation. The county is also home to a small Zuni reservation and a portion of the

Whiteriver Apache Reservation. The remaining quarter of the population is Caucasian

or Hispanic.

Reservation residents have access to mental health services operated by either the

tribes, Indian Health Service, or sometimes both, as well as community mental health i

programs funded by other public and private sources off-reservation. The non-reserva- '

tion residents are primarily served by a community mental health program and a mini- £

mal number of private providers who serve the area on an itinerant basis out of Phoe¬

nix. Any inpatient psychiatric treatment must be accessed in a distant metro area. f

While patterns of trade and commerce in this area cross county, state, and tribal

boundaries, access to outpatient mental health care is primarily limited to defined ser- a

vice areas. As a result, the issues relating to access to and availability of mental health I

care are complicated and complex; involving multiple funding streams, policies and p

procedures, governmental and agency boundaries/responsibilities, patterns of trade and j ti

commerce, and last, real cultural diversity relating to mental healthcare and help-seek- it

ing behavior. it

For example, it is not uncommon for a non-Indian residing on the reservation to x

experience a mental health crisis requiring involuntary admission to the State Hospital

in Phoenix. Often they enter the mental health emergency services system through the

intervention of law enforcement. They are on the Reservation, a region larger than

some states, however outside the jurisdiction of either the Navajo Department of Public

Safety or Tribal Court System. Although the Tribal Police may be the initial point of

contact, they must call in either an Arizona state law enforcement officer or county

deputy sheriff, who will then transport the person (under emergency protective cus¬

tody) to a secure facility (i.e., jail or hospital emergency room) for emergency mental

health evaluation and, if appropriate, the filing of a petition for involuntary treatment

with the Superior Court. This would likely occur in the county-seat, St. Johns, which

may be anywhere from 1 to 3 hours from the person’s residence on the Reservation.

Following their discharge from an involuntary hospitalization, it would be highly

unlikely for them to receive aftercare services from the off-reservation mental health I

program due to the vast travel distances involved. The Indian Health Service and Na- I m

vajo Nation operate mental health programs on the Reservation, however the non-In- i

dian Reservation resident cannot access care from these systems.

ACCESS TO MENTAL HEALTH SERVICES IN FRONTIER AMERICA

41

Kewauna County in Michigan is at the very tip of the long finger-like Upper Pen¬

insula reaching out into Lake Superior. An area which is now dependent upon the trade

generated by tourism, it formerly was a center of mining and timber industry. It is one

of the few frontier counties east of the Mississippi, sharing primarily its low population

density with its western frontier peers. The residents of the county do not face the

diversity of jurisdictions or complexity of service delivery responsibilities as those in

Apache County.

Instead residents face simple isolation, compounded by winters where snowfall can

exceed 250 inches. The nearest outpatient mental health services are available prima-

i rily through the community mental health provider, an official multi-county authority.

The bulk of the continuum of care is located in Houghton, at least an hour long drive

away. The nearest inpatient psychiatric services are in Marquette, MI, requiring at least

a three hour drive. The population is simply too small and dispersed to support a full

array of community-based services in a cost-effective manner. However, unlike many

western frontier areas, a full continuum of services is available within an hour’s drive

and in a location which is a part of resident’s routine pattern of trade/commerce.

These two counties, one in the southwest and the other in the northcentral US, are

representative of the ends of the “frontier spectrum”, and between them rests frontier

America. Accessibility and availability to mental health services are strongly associ¬

ated with the specifics of the particular place, its culture, and myriad other factors.

Although the county in Michigan’s Upper Peninsula is as isolated as many frontier

places, the fact that Michigan ranks second in per capita expenditures for public mental

health (National Association for State Mental Health Program Directors, 1995) makes

it much more likely for these frontier residents to have access to a full array of services

in relatively close proximity. In Nebraska, which ranks forty-ninth, frontier resident’s

access and availability is impacted by both isolation and public policy.

“Rural areas are often neglected in health care planning because it

is easier and more economical to rely on existing urban models ,

than to gather new information and to plan systems specifically suited

for rural communities”

-Jeffrey Human,

former Director,

Federal Office of Rural Health Policy

;

Medicaid and The Emergence of Managed Care

Currently more than 33 million Americans receive their health insurance through

i Medicaid. The cost of Medicaid has increased over 400% since 1980 and it absorbs an

average of 16% of state budgets (WAMI, 1994). Congressional efforts to balance the

42

DENNIS F. MOHATT

national budget have seen the emergence of managed care as a strategy (along with

spending ceilings) for controlling the cost of Medicaid. Frontier and rural areas are

likely to be disproportionately impacted by such strategies, since they have proportion¬

ately greater populations of Medicaid and Medicare beneficiaries. The need to control

cost is obvious, and managed care is being embraced as the vehicle to drive cost con¬

tainment. While the motive for the move to managed care is clearly cost containment,

it is unclear how this marketplace shift will impact rural and frontier behavioral healthcare

where the challenges are more closely related to access and availability than cost con¬

tainment.

Regardless of the changes which evolve, the focus in rural areas remains trying to

address the same underlying problem always faced in relation to health care: how to

keep local, financially accessible, good-quality care available to rural populations less

able to pay and less efficient for providers to serve (because of low population density)

than their urban counterparts. When not considered in the move to managed care

through the waiver process, the rural issues previously discussed can pose serious bar¬

riers to consumer access.

For example, a current 1915b waiver for a Medicaid managed care program for

mental health and substance abuse in a western state contains standards for pre-treat¬

ment assessment and supervision of care that may create significant barriers to con¬

sumer access to treatment. These standards, which are part of the waiver, require a pre¬

treatment assessment of all recipients prior to the provision of outpatient care (i.e.,

psychotherapy, day treatment) by a psychosocial intake-diagnostic process. These new

standards require the mental status portion (inclusive of the diagnosis) to be completed

by either a physician or licensed doctoral level psychologist. Furthermore, the standard

requires monthly supervision by a physician or psychologist of all cases where treat¬

ment is provided by other mental health providers (e.g., social workers, counselors,

psychiatric nurses) including a verbal discussion/case presentation. The supervising

professional is also required to have face-to-face contact with the consumer at six-

month intervals. Obviously the intent of such standards, albeit influenced by the politi¬

cal process, is to ensure quality of care. However, considering that much of the west is

rural and has serious shortages of health and mental health professionals (especially

physicians and doctoral level psychologists), these standards could seriously impede

consumer access to treatment resources currently available primarily via mid-level prac¬

titioners.

“Rural health networks have the potential to play a key role in the

development of coordinated systems of care in rural areas under

virtually every health care reform scenario ”

-Ira Moscovice and

Jon Christianson

ACCESS TO MENTAL HEALTH SERVICES IN FRONTIER AMERICA

43

Health Care Reform: Issues for Rural Areas

Provider and System Integration

The development of horizontally or vertically integrated provider networks has

become a well established industry response to managed care across the country. It has

been frequently adopted in rural and underserved areas as a popular mechanism for

rural provider response to both access and availability issues. The objective of managed

care is clear: the achievement of cost containment via utilization management. Man¬

agement of utilization can best be achieved through systematic protocols for access,

level, and duration of care, which are directly related to the measurement of outcomes.

Clearly the predominant system of public behavioral health care in the United States

does not operate in such an environment. Instead, persons traditionally served by the

public system often go without appropriate care; access care later than desirable result¬

ing in increased cost and duration of care; are often treated at higher (and more costly)

levels of care; and receive care which is not integrated with their physical healthcare.

Integrated networks seek to achieve the objectives of managed care through collabora¬

tion among providers.

So what exactly is an integrated network? Conrad and Dowling (1990) define it as

“...an arrangement whereby a health care organization (or closely related group of orga¬

nizations) offers a broad range of patient care and support services operated in a func¬

tionally unified manner.” When organizations agree to form a network to provide ser¬

vices, the concept of autonomy for those individual organizations diminishes. Figure 1

outlines the progression from autonomy to integration which occurs through the forma¬

tion of a provider network (Rosenberg, 1994).

Figure 1 . Types of Provider Network Integration

Governance Structure -

Decision Making & Policy —

Administrative & Service Delivery

Goal Identification & Assessment

Reprinted by permission of the author.

44

DENNIS F. MOHATT

All provider organizations consist of four functional levels, which are represented

in Figure 1 :

• Governance Structure

• Decision Making and Policy

• Administrative and Service Delivery

• Goal Identification and Assessment

In most public mental health organizations this translates into:

• Board of Directors

• Executive Director - Management

• Staff - Service Delivery

• Needs assessment and program planning

Developmental Aspects of Network Formation

The process depicted in Figure 1 is indicative of a developmental process which

occurs over time as providers move from independent and autonomous operation to

collaboration. Each stage of development requires ever increasing interdependence,

and the cornerstone of such interdependence is trust. As with any group, such trust is

dependent upon the partners’ capacity to adopt a shared vision for mission and values,

and their ability to resolve internal and external conflict. Furthermore, in establishing a

network it is far more important to address issues of “process” rather than structure.

How it works, how it is integrated, and how it communicates is more important initially

than its size, shape, function, and structure (Rappaport, 1977). Unless such process

issues are examined, accepted, and implemented any structural integration is doomed

to failure.

For some frontier areas, the establishment of integrated service networks could

provide a solution for enhancing access and availability. However the very culture of

frontier/rural society demands a developmental process sensitive to their desire for lo¬

cal control and flexibility. In addition, networking in rural and frontier areas is not

without its own special problems. The limited number of providers and basic rural/

frontier demographics mean that if local providers form an integrated service network,

the result may be a monopoly (McKay, 1995), raising serious anti-trust issues. A dis¬

cussion of two possible types of integration, vertical and horizontal, for frontier areas |

follows.

ACCESS TO MENTAL HEALTH SERVICES IN FRONTIER AMERICA

45

Vertical Integration

Vertical integration approaches to managed care seek to network a group of rural

healthcare providers, at various levels of primary care and behavioral health, to form an

integrated service network (Casey, Wellever and Moscovice, 1994). They seek to de¬

velop, via cooperation, a coordinated, consumer focused, seamless continuum of care

designed to improve access and availability through efficiencies gained by the elimina¬

tion of redundant services or systems.

A model rural, vertically integrated system is the Laurel Health System in north¬

eastern Pennsylvania. Laurel was founded in 1989 with the merger of five not-for-

profit organizations: 1) Laurel Management Services, 2) Laurel Realty, 3) Soldiers and

Sailors Memorial Hospital (SSMH), 4) Soldiers and Sailors Memorial Volunteers, and

5) North Penn Comprehensive Health Services (North Penn). This network spans the

human service gamut inclusive of primary care, nursing homes, senior housing, ambu¬

lance service, and hospital.

The continuum of care is focused in Laurel’s two major service anchors, SSMH

and North Penn. The merger linked a primary and tertiary health care system serving a

balanced public/private payor mix, with a community health and mental health system

which was heavily government subsidized (six federally qualified rural health centers

and the community mental health program). To accomplish the merger, both major

organizations were forced to, and succeeded in, overcoming a history of rivalry dating

back to 1972.

Today, Laurel is moving forward in its partnership. In its move toward managed

care, Laurel has turned its planning focus toward the development of a health mainte¬

nance or preferred provider organization (HMO/PPO) option for the local insurance

marketplace. Laurel is seen as a model integrated rural health delivery system, suc¬

cessful in its mission to provide the community a seamless system of care inclusive of

both traditional health and mental health services.

Horizontal Integration

The horizontally integrated network brings “same type” providers together to achieve

the advantages of economies of scale, and to position organizations to eliminate admin¬

istrative duplication. Access is enhanced through the redirection of resources formally

utilized in redundant, primarily administrative, functions.

A recent example of such a horizontal integration is the 1994 formation of

Northpointe Behavioral Healthcare Systems in Michigan’s sparsely populated Upper

Peninsula. It was formed as a proactive response to the evolving managed care envi¬

ronment in public sector mental health. Northpointe was established through the con¬

solidation of two community mental health programs serving three rural counties. The

46

DENNIS F. MOHATT

consolidation allowed the CMHCs to centralize executive administration, management

information, fiscal management, and human resources for the new entity which em- i

ploys more than 300 people and serves more than 3,500 consumers annually. |

Neither CMHC alone would have possessed the capital to effectively build the '

management and information infrastructure necessary for a managed care operation, t

The efficiencies gained through the consolidation have allowed Northpointe to invest (

its combined capital in managed care readiness efforts. The new entity employs cen- (

tralized intake and utilization review, coupled with an evolving clinical outcome and i

consumer satisfaction assessment system. Northpointe utilized a portion of Michigan s

law, known as the Urban Cooperation Act, which allows elements of local government

to consolidate to more effectively meet public needs (previously used primarily to form

airport and solid waste authorities). This act allows Northpointe to establish for-profit

and not-for-profit subsidiaries, and provides the participating county governments le¬

gal separation from Northpointe related risk. j

c

Implication for Behavioral Health Services

c

Rural areas present a unique environment for the creation of state-of-the-art behav- j

ioral health care systems, such as managed care. The managed care movement seeks to k

contain costs through effective and efficient clinical management, however, it is un¬

clear how such a system will impact and address the problems of serious underservice

in rural frontier America. While health care in urban settings is characterized by com- M

petition, health care in remote rural areas will likely take on aspects of cooperation due

to a limited number of providers. The formation of both vertically and horizontally N

integrated networks has become a common response to managed care in rural health R

care settings.

Despite some existing cooperation, integration, which rests upon an ability for col- h

laboration and cooperation, faces many challenges in the rural environment. Historic

relationships between providers may often exclude collaboration. Geographic realities $£

of many frontier regions, where the population is widely dispersed and the service con¬

tinuum extremely limited, may mean they simply do not have the resource base to Sc

effectively meet the demands of a managed care approach. Finally, integration poses ^

risks to provider autonomy. Through collaboration the partners must agree to share

authority, accountability, risk, as well as benefit or loss. In a managed care environ- I

ment, it is essential to ensure beneficiaries are linked with both the most appropriate

level of care and provider of care. For an integrated network to succeed, the partners

must be capable of addressing myriad issues arising out of such shared responsibility i

for utilization and outcome. As with any group process, the key to success as a cohe- j

H 1

sive group will be the member’s ability to resolve conflict.

ACCESS TO MENTAL HEALTH SERVICES IN FRONTIER AMERICA

47

The bottom-line has remained constant for decades; Rural and frontier populations

are underserved by the health care system in general, and the mental health system in

particular. Accessibility and availability are impacted directly by the costs associated

with providing a comprehensive continuum of quality care to dispersed population ar¬

eas. Additionally, the disparity between rural and urban populations in relation to rates

of insurance, high-risk populations, and infrastructure makes the enhancement of ac¬

cess and availability especially challenging. Finally, the ability to effectively address

access and availability is a complex process which must involve the entire health care

system and community.

References

Aday, L. and Anderson, R. (1974). A framework for the study of access to medical care. Health Services

Research, 9:208-220.

Beeson, R G. and Mohatt, D. F. (1993). Rural mental health and national healthcare reform. Arlington, VA:

National Association of State Mental Health Program Directors.

Casey, M., Wellever, A. and Moscovice, I. (1994). Public policy issues and rural health network development

(Working Paper Series). Minneapolis, MN: University of Minnesota Rural Health Research Center..

Conrad, D. and Dowling, W. (1990). Vertical integration in health services: Theory and management implica¬

tions. Health Care Management Review, 15:9-22.

Korczyk, S.M. (1994). Making managed health care work in rural America (A report from the Office of Rural

Health Policy). Rockville, MD: HRSA, PHS, DHHS.

McKay, D.G. (1995, February 15-17). Anti-trust issues in developing IDSs in rural areas. Presentation at the

National Health Lawyers Association conference on Anti-trust in the Healthcare Field, Bangor, ME.

Murray, J.D. (1990, April 12). Written testimony submitted to the regional field hearing on mental illness in rural

America. Rural Community Mental Health Newsletter (National Association for Rural Mental Health), 17.

National Association of State Mental Health Program Directors (NASMHPD) (1995). Per capita expenditures

of States for mental health services. Washington, DC: NASMHPD.

Rappaport, J. (1977). Community Psychology: Values, Research, and Action. New York: Holt, Rinehart, and

Winston.

Rosenberg, S. (1994). The role of States and communities in building viable health care delivery systems: An

overview of the healthcare delivery situation in rural communities. In Conference proceedings: Implementing

health care reform in rural America: State and community roles. Iowa City, IA: The University of Iowa.

Serrato, C. and Brown, R. (1992). Why do so few HMOs offer Medicare risk plans in rural areas? (Report).

Baltimore, MD: Office of Research Development, HRSA, PHS, DHHS

Schurman, R. A., Kramer, R. D. and Mitchell, J. B. (1985). The hidden mental health network. Archives of

General Psychiatry, 42, 89-94.

US Congress, Office of Technology Assessment. (1995). Impact of health reform on rural areas: Lessons from

the states. Washington, DC: Author.

US Senate. (1988). Report of the Special Committee on Aging. Washington, DC: US Government Printing

Office.

Wagenfeld, M. O., Goldsmith, H. F., Stiles, D. and Manderscheid, R. W. (Eds.). (1988). Inpatient mental health

services in metropolitan and non-metropolitan counties. Journal of Rural Community Psychology, 9.

Wagenfeld, M. O., Murray, J. D., Mohatt, D. F. and DeBruyn, J. (Eds.). (1994). Mental health and rural America:

An overview and annotated bibliography 1978-1993. Washington, DC: US Government Printing Office

WAMI Rural Health Research Center. (1994, Winter). Medicaid managed care coming to rural America. Rural

Health News, 1:1.

48

Journal of the Washington Academy of Sciences,

Volume 86, Number 3,49-57, December 2000

Mental Health Service Utilization in

Rural and Non-Rural Areas

Charles E. Holzer III, Ph.D. and James A. Ciarlo, Ph.D.

Abstract

This paper uses data from the 1989 Mental Health Supplement to the National Health Inter¬

view Survey (NHIS) to determine the mental health utilization patterns, including type of

provider utilized and met and unmet needs, for the residents of different types of urban-

rural areas with behavioral health problems. A four fold classification of residence is

utilized— within metropolitan areas respondents are classified as residing in or not in a

central city and within nonmetropolitan areas respondents are classified as residing on a

farm or hot on a farm. The highest rate of mental disorder are reported for central cities of

metropolitan areas. Nonmetropolitan nonfarm areas have prevalence level nearly equal to

those of central cities. The noncentral-city metropolitan areas and nonmetropolitan farm

areas show a much lower prevalence of disorder. Generally, unmet need for mental health

services (persons with a disorder but not using services) is higher in nonmetropolitan areas

than metropolitan areas. Further, within nonmetropolitan areas, farm areas have higher lev¬

els than nonfarm areas and, within metropolitan areas, noncentral-cities have higher levels

than central cities.

Introduction

The often-limited availability of mental health services to residents of rural America

j has been an issue of importance to those residents, to states with large rural popula¬

tions, and to the federal government (Human and Wasem, 1991). A closely related

issue is that of utilization of such services by rural persons needing mental health (MH)

services — that is, to what degree are these people willing and able to use what services

i may be available in their area? This paper discusses MH service utilization in terms of

a four fold urban-rural typology, and points to some potentially important implications

for governments hoping to provide greater assistance with mental and emotional prob¬

lems than has been typical in the past.

Recent epidemiologic surveys have established that, on the whole, the need for MH

services is only slightly less prevalent for Americans living in rural areas than it is for

| urban or suburban residents. For example, a national survey by Kessler et al. (1994)

found that the prevalence rate of any formally diagnosable mental disorder was only

1 .1 times higher in major metropolitan areas than in rural (i.e., nonmetropolitan) areas.

Also, Ciarlo and Tweed (1992) found that while relatively isolated “rural non-towns” in

Colorado had somewhat lower prevalence of need for services (diagnoses and every-

50

CHARLES E. HOLZER III, JAMES A. CIARLO

day dysfunction) than urbanized areas, the more populous rural “towns” (that is, urban

areas of at least 2,500 people) had very nearly the same need prevalence as major cities

in that state. In sharp contrast, however, there is considerable evidence that the avail¬

ability of services for mental disorders is substantially lower in rural areas than in urban

ones — and especially so in the lowest-density, more isolated rural areas often termed

“frontier” (Goldsmith, Wagenfeld, Manderscheid and Stiles, 1996; Holzer, Goldsmith

and Ciarlo, 1998). Hence, it is important to learn whether this relative scarcity of MH

services in rural areas may reduce the number and proportion of needy residents able to

access and receive or “utilize” MH services. The purpose of this paper is to examine

the extent to which there may be differential utilization of available services in rural

and non-rural areas, through reanalysis of the 1989 Mental Health Supplement to the

National Health Interview Survey (NHIS) (National Center for Health Statistics, 1993).

Use of the Mental Health Supplement of the NHIS provides both advantages arid

disadvantages for the present purpose. Its greatest strengths are its large sample size (n

= 84,572) and national sampling frame. It provides enough nonmetropolitan respon¬

dents for accomplishing meaningful analysis of at least part of the “rural” component

of MH service usage (i.e., rural towns). Further, the data are relatively recent (1989)

compared to survey data from the Epidemiologic Catchment Area Study (ECA) (Rob¬

ins and Regier (1991), which was conducted between 1980 and 1983. The data are not

much older than those of the National Comorbidity Survey (NCS) by Kessler, et al. |

(1994), which was conducted between 1990 and 1992. One disadvantage of this NHIS f

Supplement is that it assessed mental disorders by a simple self-report or informant

report of whether a disorder is present. Unlike the ECA and NCS, it does not employ a

formal diagnostic questionnaire and thus reports lower prevalence rates. It has been '

speculated that this is because respondents are unable or unwilling to identify illnesses

without the extended probing of a structured diagnostic instrument, or without the feed- 1

back and labeling received in treatment of mental disorders. On the other hand, the «

Supplement asks simple direct questions about the use of MH services that are roughly si

equivalent to those asked in the ECA and NCS. The relationship between prevalence i

and utilization will be explored further below.

Defining A “Urban-Rural” Typology

As noted in this paper a four fold urban-rural typology is utilized. First metropoli- r{ ;

tan areas, the daily labor market of big cities, are distinguished from nonmetropolitan ;;

areas (areas outside the daily labor market of big cities). Within a metropolitan area, :

central cities (densely settled urban areas) are distinguished from areas outside central t

cities (usually less densely settled than central cities) and within nonmetropolitan ar- .

eas, residence on a farm is distinguished from residence that is not on a farm ( nonfarm

residence) (see Zelamey and Ciarlo, 1999). |,

MENTAL HEALTH SERVICE UTILIZATION

51

Comparative Prevalence of Disorders in Rural and Urban Areas

The ECA project has reported some limited “rural/urban” comparisons for a num-

i ber of disorders, employing the common non-metropolitan vs. metropolitan county

I definitions of these terms. The urban lifetime prevalence for any disorder is 34%,

which is only slightly higher than 32% for rural areas (Robins and Regier, 1991), and

for the past one-year prevalence the comparison is 21% vs. 20%. It should be noted

that the ECA had relatively small rural samples, primarily in North Carolina and Mis¬

souri, which were compared to cities such as New Haven, Baltimore, St. Louis, and Los

Angeles. In the NCS study, which was based on a national sample, comparisons were

made that differentiated major urban, other urban, and rural, with the latter being equiva¬

lent to nonmetropolitan. These comparisons showed only slightly higher prevalence of

several disorders for the major metropolitan and other urban as compared to rural areas,

but none of the comparisons was significant. The prevalence rate of any formally

diagnosable mental disorder was only 1 . 1 times higher in major metropolitan areas than

in rural (i.e., nonmetropolitan) areas, which was not statistically significant.

In considering these small differences in ECA and NCS prevalence rates surveyed

across areas, one might expect there to be at most a small differential between urban

and rural utilization of services. However, both the ECA and the NCS reported rates of

services utilization which were far smaller than the reported disorder prevalence rates.

Hence, for the NHIS with its sharply lower prevalence rates, any utilization rates are

expected to be still smaller.

Methods

The NHIS is a large national survey of a variety of health conditions initiated in

1957 and conducted continuously since that time by the US Bureau of the Census,

under specifications from the National Center for Health Statistics. The sampling de¬

sign is closely linked to the Current Population Surveys of the US Census and consists

of a multistage sampling design of the noninstitutionalized civilian population of the

US. The sampling design is intended to result in approximately 49,000 housing units

and 132,000 persons per year.

The core questions of the NHIS survey include basic health and demographic items,

which are asked of a person in a household or of a household informant about each

i eligible member of the household. These items include disability days, physician vis-

■ its, acute and chronic conditions, limitations of activity, and hospitalizations. In addi-

i tion, representative subsamples of households are asked to respond to questions on

il special health topics, and in 1989 mental health was one of those topics. The MH

(• questions included items asking whether specific disorders were present, and whether

m particular types of MH services were used and when. Interviews were completed with

96 percent of all eligible households.

52

CHARLES E. HOLZER III, JAMES A. CIARLO

The identification of mental disorders in the 1989 mental health supplement was

based on the question: “During the past 12 months did this [person] have [...any of

the...] following mental and/or emotional disorders?” The listed items included: schizo¬

phrenia, paranoid or delusional disorder, manic episodes, manic depression, major de¬

pression, personality disorder, senility, alcohol abuse, drug abuse, and/or mental retar¬

dation. Then the respondent/informant is asked whether this person “had any other

mental disorder” and “what the other disorder is called.” Finally, a summary “mental

disorder reported” was coded which includes the mental disorders and senility. Sub¬

stance abuse or mental retardation were coded separately.

Utilization of services was identified by the question “When [this person] last saw

a mental health professional about [any] disorder(s).” The answers were coded into the

categories: less than two weeks, less than one month, less than three months, less than

one year, less than five years, five years or more, and never. Those with no known

mental disorder received a blank code.

Results

Table 1 presents the distribution of the sample and the population estimates by the

urban-rural categorization. The sample column is the number of persons who responded

or who had informant provided information. The population is the weighted population

estimate based on the sample, and the percentages are calculated on the weighted popu¬

lation estimates.

Table 1 . Distribution Of Adult Sample And Population By Urban-Rural Categories

* The population figures and percentages are based on population weights (NWTFA).

Table 2 presents the number and percentage of specific disorders reported by re¬

spondents or household informants broken down by the type of urban-rural residence.

It is immediately apparent that the rates presented for mental disorders are substantially

lower than those presented in epidemiologic surveys based on diagnostic interviews,

and by an order of magnitude or more (for example, the rates for the EC A or the NCS

noted above were 21%-urban and 20%-rural).

MENTAL HEALTH SERVICE UTILIZATION

53

Table 2. Typology Of Mental Disorders Reported By Urban-Rural Categories

Table 3 presents a typology of reported utilization of MH services by persons with a

mental disorder, excluding substance abuse and mental retardation. The four levels are

persons with no reported mental disorder; disorder but no use of services; past use; and use

in the last 12 months (current utilization). Percentages are weighted for the adult popu¬

lation. As can be seen, reported current utilization is highest for those in central cities

(1.22%), followed by 1.06% for nonfarm, 0.92% for noncentral-city areas, and 0.91%

for farm areas. Rates of utilization in the past are quite low, and are again lowest for the

farm (0. 16%) and noncentral-city metropolitan areas (0.25%). Combining past and current

utilization yields rates of lifetime utilization not much higher than for the last year.

Table 3. Utilization Typology For MH Services By Urban-Rural Categories

54

CHARLES E. HOLZER III, JAMES A. CIARLO

Table 4 presents utilization in the last 12 months as a percentage of persons with a

disorder reported for the same time period. Those with no reported utilization but a

current disorder can be considered cases of unmet need for services. Those in the

central cities reported the highest utilization relative to disorder, with 59.75% reporting

current use. Noncentral-city, metropolitan area residents reported the next highest level

of utilization —56.45%. The nonfarm areas were next with 55.43% utilization, and the

farm areas had the lowest utilization (52.53%) and the highest unmet need (47.47%).

Table 4. Unmet Need For MH Services By Urban-Rural Categories

Table 5 presents the type of mental health professional last seen by persons who

received specialty mental health services. In each of the urban-rural areas the mental

health professional identified is predominantly a psychiatrist. Psychologists are listed

as a distant second, which is unexpected given the role of psychologists in mental health

facilities and the broad definition of psychologist used in this study. Only 14 persons

reported contact with a doctoral level psychologist. Social workers and nurses are

rarely identified as the last MH contact. The larger number of “other mental health

workers” is exclusive of the categories designated above, but may reflect the work of

case workers or specialists whose formal designation is unknown. Only a few

nonpsychiatrist physicians were identified, most likely because the question used the

term “mental health professional.”

Table 5. Type Of MH Professional Last Seen By Urban-Rural Categories

MENTAL HEALTH SERVICE UTILIZATION

55

Discussion

Results from the above analyses are largely consistent with our expectations re¬

garding urban-rural differences, given the initial finding that the reported prevalence of

MH disorders is sharply lower than in standard mental health epidemiologic surveys

such as the EC A, NCS, and CSHS. Our expectation was that urban-rural differences in

the prevalence of mental disorder would be relatively small, paralleling other surveys.

The present analyses show a somewhat lower reported prevalence in nonmetropolitan

areas, but the large sample size of the present survey makes it clear that a simple “ur¬

ban-rural” classification is inadequate to characterize the differences found. The high¬

est rates of Any Mental Disorder are reported in the central cities of metropolitan areas;

however, the noncentral-city metropolitan areas show a much lower prevalence of dis¬

order-lower even than the nonmetropolitan farm areas. Further, the nonmetropolitan

nonfarm areas show higher prevalence than farm areas, and very nearly reach the level

of central cities. Interestingly, this same pattern of disorder prevalence was found in

Colorado subareas (Ciarlo and Tweed, 1992), where the non-central city metropolitan

areas were labeled “exurban,” and the nonmetropolitan nonfarm areas were called “ru¬

ral towns.” Finding the same patterning of prevalence of MH service needs on a na¬

tional-scale survey thus makes it clear that the debate over urban-rural differences must

move beyond the use of a simple urban-rural dichotomy. While it is unfortunate that

the present data set does not include the greater levels of differentiation afforded by the

identification of “frontier” areas or the use of the USDA rural-urban typology (Butler

and Beale, 1994), it does indicate clearly that greater refinement in our classifications

are essential.

An important issue is the lower prevalence rates generated from the present survey

in comparison to the estimates generated by the diagnostic surveys of the ECA and

NCS. The most likely explanation for these differences is the simple self-report of

“disorder” used in the NHIS, which inquires about the disorders in terms of their labels

or names. In contrast, the diagnostic surveys ask about patterns of symptoms found in

DSM-III or IV diagnostic systems, and subsequently identify all disorders matching the

presenting symptomatology (some or all of which disorders may not have been identi¬

fied by the respondents, their families, or their doctors). The latter is a far more sensi¬

tive diagnostic approach than simple self-report of disorders, because even persons who

have psychiatric symptoms may not recognize them as such, and/or may not have the

knowledge necessary to identify and label them as disorder. Further, knowledge of

mental illness and the elements of making a self-diagnosis vary widely throughout US

culture, with some expectations that younger, better educated, and more cosmopolitan

persons are more likely to have the knowledge base to do so than persons who grew up

in a less psychologically-oriented culture. Such cultural differences are likely to be

related to the urban-rural categorization, but not necessarily in a tidy manner.

56

CHARLES E. HOLZER III, JAMES A. CIARLO

The NHIS Mental Health Supplement also addresses issues of service utilization,

with some clear urban-rural differences. Again, however, we note that the reported

rates of services utilization are much lower than reported in the EC A and NCS surveys.

This is perhaps to be expected, given the greater focus on mental health issues in the

latter surveys; it certainly raises the issue of how important it is to establish a specifi¬

cally mental health symptoms/problems context when performing interviews related to

use of MH services.

We have also considered the question of whether extensive use of “household infor¬

mants” in the NHIS survey would make a difference; such differences were observed

when informant interviews were conducted in the ECA project. In the present study,

analysis of informant responses regarding another household member showed lower

rates of reported disorder and service utilization than did self-reports. The overall rate

of disorder for completely self-reported information is 2.33%, for partial self-report

2.21% and for a proxy interview 1.81%. Similarly, the reported utilization rate for

complete self-report is 1.15%, for partial self-report it is 1.05%, and for proxy inter¬

views it is 0.80%. This may have significantly lowered over- all results, as about one-

third of the data come from proxy interviews.

Notwithstanding these concerns, we do see trends for lower MH services utiliza¬

tion in the nonmetropolitan areas as compared to metropolitan central cities, though

again the nonmetropolitan nonfarm areas are fairly close to the latter. This appears to

be true both as a percentage of the total population and as a percentage of only those

persons in need. And again it is apparent that utilization rates are lower in the noncentral-

city metropolitan areas than in the nonfarm nonmetropolitan areas. Finally, farm areas

show the lowest levels of utilization in both absolute and relative terms. However, the

tiny number of westem-US. farm areas included (51) make this conclusion hard to

generalize to “frontier”-area farms, the vast majority of which lie west of the 100th

meridian (which runs from North Dakota to Texas).

It was surprising that the highest rates of MH service utilization were reported for

psychiatrists, followed by psychologists of all levels and unspecified mental health

workers. This pattern was unexpected because the staffing of most mental health facili¬

ties is weighted in favor of nonpsychiatrists. Further, we know that much of the care

nationally for mental health problems is provided in primary care settings, yet

nonpsychiatrist MDs were barely represented in the provider list (perhaps because the

utilization questions asked when a person “last saw a mental health professional”).

This may also be partly because many persons treated in primary-care settings do not

receive psychiatric diagnostic labels, even if they receive psychoactive medications;

hence, such utilization may have gone unreported in this survey.

In conclusion, we must note that the expected pattern of lower rates of utilization in

nonmetropolitan areas was confirmed by this survey, despite the unexpectedly low rates

of disorder and utilization reported. Finally, it should also be noted that ongoing changes

in the entire health care system, especially the advent of managed mental health care (or

MENTAL HEALTH SERVICE UTILIZATION

57

“managed behavioral health care” as it is often termed), are likely to have brought about

changes in the provision and utilization of such services over the decade since these

data were collected.

Reader inquiries are welcome!

For further information contact:

Mary Obata

Network Administrative Assistant

Frontier Mental Health Services Resource Network

Mental Health Program

Western Interstate Commission for Higher Education

P.O. Box 9752

Boulder, CO 80301-9752

(303) 541-0261

FAX: (303)541-0291

References

Butler, M. A. and Beale, C.L. (1994) Rural-urban continuum codes for metro and nonmetro counties, 1993.

Washington, DC: US Department of Agriculture, Economic Research Service.

Ciarlo, J. A. and Tweed D.L. (1992). Exploring rural Colorado’s need for mental health services: Some prelimi¬

nary findings. Outlook , 2(3): 29-31 .

Ciarlo, J.A., Wackwitz, J.H., M.O. Wagenfeld and Mohatt, D.F. (1996). Focusing on “frontier” : Isolated rural

America (Letter to the Field No. 2). Denver, CO: Frontier Mental Health Services Resource Network.

Goldsmith, H.F., Wagenfeld, M.O., Manderscheid, R.W. and Stiles, D.J. (1996). Geographical distribution of

organized mental health services (Chapter 8). In Mental Health, United States, 1996 (pp. 154-167). Rockville,

MD: US Department of Health and Human Services.

Hines, F.L., Brown, D.L. and Zimmer, J.M. (1975). Social and Economic Characteristics of the Population in

Metro and Nonmetro Counties. 1970 (Report #AER-272). Washington, DC: Economic Research Service, US

Department of Agriculture.

Holzer, C.E. Ill, Mohatt, D.F., Goldsmith, H.F. and Ciarlo, J. (in press). The Availability of Health and Mental

Health Providers by Urban-Rural County Type. In Mental Health, United States, 1998. Rockville, MD: US

Department of Health and Human Services.

Human, J. and Wasem, C. (1991). Rural mental health in America. American Psychologist, 46(3), 323-339.

Kessler, R.C., McGonagle, K.A.,Zhao, S., Nelson, C.B., Hughs, M., Eshleman, S., Wittchen, H.U. and Kendler,

K.S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States.

Archives of General Psychiatry, 51,8.

National Center for Health Statistics. (1993). 1989 National Health Interview Survey (CD-ROM). Washington,

DC: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and

Prevention.

Robins, L.N. and Regier, D.A. (Eds.). (1991) Psychiatric disorders in America: The Epidemiologic Catchment

Area Study. New York: The Free Press.

Zelamey, P. and Ciarlo, J. (1999). Defining and describing frontier areas in the United States: An update (Letter

to the Field #21). Denver, CO: Frontier Mental Health Services Resource Network.

58

a

Journal of the Washington Academy of Sciences,

Volume 86, Number 3, 59-79, December 2000

General Models for Delivering Mental

Health Services to Seriously Mentally Ill

Persons in Frontier Areas1

Morton O. Wagenfeld, Ph.D.

Abstract

This paper deals with the delivery of services serious and persistent mental illness (SMI) in

scarcely populated frontier areas— an historically underserved group living in primarily in

the western part of the United States. The paper provides information on some of the gen¬

eral models of service delivery that are available as well as the implication of these models

for managed behavioral health care. The models discussed include multi-disciplinary team

models, community support models, models that utilize paraprofessionals and lay care¬

givers, and wellness/clubhouse models. Some of the models have been adapted from urban

or more populous rural areas, sometime in very imaginative and resourceful ways.

Introduction

At the extreme rural end of the rural-urban continuum there are 394 frontier coun¬

ties (counties with less than 7 persons per square mile) in 27 states. They are protected

! from large-scale settlement by harsh climate, difficult terrain, lack of water, distance

! from metropolitan areas , lack of exploitable resources , and federal land policies . These

areas also contain a high proportion of persons living in poverty and have a limited

local tax base. Most human services are provided through state and federal programs.

I Low population densities make it impractical to deliver many labor- and resource-in¬

tensive programs. In addition, of course, these areas also chronically lack trained staff.

As one might expect, providing services to this frontier population presents formidable

cultural, geographic and human resource problems. These difficulties notwithstanding,

services to this important population are delivered, often in imaginative and resourceful

ways. This paper deals with the delivery of services to persons with serious and persis¬

tent mental illness (SMI) these sparsely populated areas. Specifically, this paper

sketches some general models of service delivery, consider some of the implications of

managed care and indicate where detailed information about the models can be found.

To illustrate how states with frontier population provide services to SMI, the organiza¬

tion of services in five states with significant frontier population is presented in Appen¬

dix A.

60

MORTON O. WAGENFELD

One of the consequences of mental health policy in the last four decades has been

the emptying of the state mental hospitals or the process of “deinstitutionalization”

(Bachrach, 1977). A number of different research and service models for the treatment

of SMI within communities as opposed to within a hospital were subsequently devel¬

oped. Predictably, most have been urban in nature. However, some material has ap¬

peared that deals with its rural dimensions. The care of the SMI in frontier areas is a

particular challenge. Here, resources that one would take for granted in urban or more

populous rural areas may be nonexistent. In looking at service delivery to this popula¬

tion, the high levels of innovation and flexibility shown by providers is impressive.

Combating few resources and long distances in innovative and flexible ways is a hall¬

mark of the treatment modalities found in the frontier area programs described below.

Programs in frontier areas can also take advantage of some of the unique features

and strengths of the frontier, though often these features are under appreciated (Kane

and Ennis, 1996). These assets include a higher tolerance for abnormal behavior among

residents and the existence of natural systems of social support. While for many a

negative feature of rural life is a lack of privacy (living in a “fishbowl”), for the mental

patient, a strong sense of community and social ties can lend support to the patient. The

lack of “therapeutic incognito” (Mazer, 1976) can also make it easier for the therapist to

know the patient and his or her world. A number of approaches described below con¬

sider this.

Multi-disciplinary Teams

A recurring theme in rural programs is the use of multi-disciplinary teams to com¬

pensate for a lack of mental health professionals. These programs take advantage of

whatever resources are available within the community and then build upon them. Davis

and Ziegler (1990) presented a Community Resource Team model that expanded the

resources available to persons with severe mental illness living in rural communities in

Wyoming. These communities had basic human services, but did not have the financial

capacity nor the social commitment to develop a diverse network of services for the

SMI population. The team was drawn from social services, mental health, nursing

homes, hospitals, and vocational rehabilitation offices.

A relatively new approach to the treatment of the SMI that also uses multi-disci¬

plinary teams is Training in Community Living. Developed at the Mendota Mental

Health Institute in Madison, WI and also known as assertive community treatment or

ACT, it is an alternative to inpatient treatment and aftercare. It basically transposes the

work of a multidisciplinary team from an inpatient to a community setting. Team mem¬

bers spend most of their time in the community providing direct treatment, rehabilita-

GENERAL MODELS FOR DELIVERING MENTAL HEALTH SERVICES

61

tion, support, and educational services for a fixed caseload. Some data exist attesting to

the cost-effectiveness of the ACT program. Though not a model created specifically

for rural areas, it has been demonstrated and used there.

Santos et al. (1993) developed an ACT program for a rural population in South

Carolina. Given the realities of service delivery in rural areas, the program differed in

a number of respects from urban models, particularly in the availability of a treatment

team, logistics of travel, use of formal and informal community support, and frequency

of contact with family. The lack of residential and vocational opportunities in rural

areas also required modification of program goals. These modifications notwithstand¬

ing, a measure of the program’s success was a significant reduction in hospital utiliza¬

tion. This, in turn, resulted in a cost reduction of 52%. This approach has been adapted

to frontier areas: ACT teams are in place in all of the service regions in Idaho (Idaho,

1997).

The Community Support Model

The community support model has also been used in frontier areas. Community

Support as a therapeutic modality for the SMI was first described by Turner (1977).

Several investigations have compared characteristics and outcomes for rural and urban

SMI to determine if rural patients would be at a disadvantage in this model.

One example, the Community Support Services (CSS) model, employs case man¬

agers for SMI patients. Baker and Intagliata (1984) evaluated several urban and rural

CSS programs. They found that, while rural clients were more likely to reside in com¬

munity residences or cooperative apartments, there were few differences between rural

and nonrural SMIs in the medical, rehabilitative, and supportive services that were

provided to them. Some services appeared even more readily available to rural clients,

including competency and coping skills training. They concluded that the CSS model

was appropriate for application in rural areas. Somers (1989) examined the relation¬

ship between geographic location and use of mental health services using data collected

on 1 ,053 Community Support Program (CSP) clients. Results again did not support the

assumption that rural residence had uniformly negative effects on service use.

Husted, Wentler and Bursell (1994) investigated the effectiveness of Prairie Com¬

munity Waivered Services, a CSP serving five counties in rural western Minnesota.

The lead persons in the program were paraprofessionals who resided in the communi¬

ties in which they worked. They worked with clients in their homes and communities

with backup from social workers and psychologists. Patients were given the option of

choosing their own physician or psychiatrist or one who was under contract to the

program. The physicians provided medication management. A crisis bed was provided

by the program. The emphasis in the program was on flexibility of program plans for

each client. In addition, support groups and social events were provided in the coun-

62

MORTON O. WAGENFELD

ties. The researchers reported a significant decrease in number of days hospitalized.

An additional benefit reported was a greater acceptance of the mentally ill by the com¬

munity.

Jackson, Macias and Farley (1993) reported the results of a CSP demonstration

program in three sparsely populated rural areas in Utah, a state with a significant fron¬

tier population. Mental health center staff provided two kinds of help: money manage¬

ment and encouragement of daily social activity. Evaluation of the program by con¬

sumers was favorable. They reported that CMHC staff assisted them significantly in

these areas, more so than either friends or family. In a related article, Macias, Kinney,

Farley, Jackson and Vos (1994) found that patients receiving a combination of case

management and psychosocial rehabilitation, functioned at a higher level of compe¬

tency and experienced lower levels of psychiatric symptomatology than those receiv¬

ing only rehabilitation.

Sullivan (1989) coined the term Program Without Walls to describe community

support programs in rural areas. Central to this concept are the recruitment of commu¬

nity collaborators and the redesign of traditional community support programs to most

effectively use available personnel for provision of necessary services to clients and

their families. To minimize and overcome problems associated with lack of resources

and great distances, a premium is placed on flexibility and innovation. Core services in

traditional rural community support programs would normally deal with:

• medication monitoring and maintenance

• case management

• leisure time and recreational opportunities

• family support.

The Program Without Walls might go on to provide medication clinics on wheels,

decentralized day programs and community collaborators. Potential sites for locally

based programs would include churches and community halls. In the ideal scenario,

case managers who are indigenous to the area would direct such efforts. Part of the

goal would be to establish a culture in which the consumers begin to help each other.

The case managers would strive to engage clients in activities that bolster self-esteem—

volunteer work or regular employment.

The Use of Paraprofessionals and Lay Care-Givers

Several programs in frontier and rural areas build upon this theme of community

collaborators and use paraprofessionals and lay care-givers as a way to extend services

to the severely mentally ill. These programs attempt to identify and utilize all resources

found within a community. One rurally developed model using this approach is the

Rhinelander Model developed in Rhinelander, WI in the 1980s (Rhinelander Model

Consultants, 1990). It served a small town and rural catchment area. The goal here was

GENERAL MODELS FOR DELIVERING MENTAL HEALTH SERVICES

63

not to supplant or compensate for professional care, but to fill in the spaces between

other services. Non-professional, supportive caregivers or citizen mental health work¬

ers provided the bulk of the service. These workers were supervised by more experi¬

enced non-professionals who, in turn, were under the aegis of agency professionals.

Two basic services were supplied: companionship and monitoring. Supportive care

workers worked weekly with two clients for five hours each. The developers empha¬

size that this went beyond togetherness. The model is strictly based on a theoretical

perspective (Transactional Analysis) that guides interaction. The intent is to change

client behaviors in a supportive and nonintrusive manner.

Activities engaged in by workers with their clients varied from taking a walk to

taking in a movie, from sewing to shopping, and from attending to chores to attending

church. While all these divergent activities provided normalizing socialization opportuni¬

ties for the SMI, the Rhinelander Model goes a significant step beyond by assuring that

workers use these experiences to support their clients in developing increasing inde¬

pendence. Without that critical element, the Rhinelander Model would be little more

than a low-cost escort service, but with it, it becomes a successful method of modifying

[emphasis in original] the SMI’s dependency and thereby reducing his or her reliance

on excessive psychiatric hospitalizations (Rhinelander Model Consultants, 1990).

Proponents of the model have argued that its effectiveness can be seen in a fifty

percent reduction in mental hospitalization. The estimated annual per client cost in

1987 was estimated at $1 ,700, making it affordable. The relatively low level of profes¬

sional involvement also suggests that it is feasible for frontier areas. It has not been

widely adapted because of third-party reimbursement and certification requirements.

Another barrier to adoption has been the requirements of its theoretical model. Having

the community workers also provide crisis services, for example, would alter role rela¬

tionships and may be inappropriate (Galli, personal communication, 1995).

A frontier example of the use of non-professional care-givers is The Citizen Com¬

panion Program (CCP) in Idaho (Sword and Longden, 1989). CCP is a creative adap¬

tation of several existing urban and rural models. It borrows elements from the

Rhinelander Model, the COMPEER program developed in Rochester, NY, and a pro¬

gram sponsored by the Mental Health Association of Waukesha, WI. The CCP was

initiated as a demonstration program in two rural sites in 1984. For strategic reasons,

the demonstration was under the aegis of the Idaho Mental Health Association. After

the success of the pilot phase, it became part of the formal service mix of the regional

mental health programs. It was not, however, implemented in a uniform way. One

measure of its flexibility is that it serves both child and adolescent patients, as well as

adults.

The CCP is designed to provide support and advocacy for persons with SMI thor¬

ough interaction with non-professional companions. This program enhances the work

of professional case managers. The core of the program is its flexibility. The exact

64

MORTON O. WAGENFELD

nature of the client/companion activities is determined by the needs of the client, but

might include skills-building in activities of daily living, or advocacy with various en¬

titlement programs. For younger clients, this might also involve locating child ser¬

vices. It is less theory-bound than the Rhinelander Model but— in common with that

program — one of its goals is to provide normal role models for the SMI.

The CCP is an interesting mix of public and philanthropic efforts. All service re¬

cipients must be clients of the Idaho Department of Health and Welfare, but services are

provided by the Mental Health Association or other not-for-profit agencies. The CCP

has a number of objectives, including:

• sustain persons with a history of SMI in a community setting and enhance their

level of functioning,

• increase community tenure and delay or reduce the need for hospitalization,

• enhance client quality of life,

• improve access to needed services,

• provide role models for a trusting and responsible relationship,

• enhance the capabilities of professional case managers,

• reduce the stigma of mental disorder,

• enhance community collaborative efforts to provide services to adults and chil¬

dren and adolescents,

• assist families in caring for the client.

In order to be eligible, adults must have a serious, persistent, mental disorder and

be participating in a treatment program of the Idaho Department of Health and Welfare.

In addition, the potential clients must be sufficiently motivated and physically capable

of program participation and have sufficient self-care skills for independent or semi¬

independent living arrangements.

The program is decentralized and operated out of the rural field offices of the men¬

tal health centers. Length of time of participation is determined by the therapist or case

manager. One of the strengths of the program is its nominal cost. It was estimated that

an on-site coordinator and three companions costs about $5 ,000/year. The program

consists of four components:

• clinical services provided by the local mental health center,

• program administration,

• companion services,

• technical assistance by State Mental Health Program staff

The core of the program, however, is the citizen companions. The not-for-profit

contracting agency recruits both the coordinator and companions. There are no formal

educational requirements, but the prospective companions must display caring, respon¬

sibility, dependability, a willingness to learn, and a positive attitude toward the those

with a mental disorder. Knowledge of the community and transportation are additional

desiderata. Once hired, companions undergo a training program that covers psychiatric

GENERAL MODELS FOR DELIVERING MENTAL HEALTH SERVICES

65

management, the availability of resources, and role relationships. There is also ongo¬

ing consultation, quarterly training, and monthly coordination meetings. An explicit

decision was made to have paid companions and coordinators, rather than relying on

volunteers. The companion is expected to provide 2-5 hours/week of service to a client

as specified in the treatment plan.

The Wellness/Clubhouse Model

As a counterpoise to the medical model, the “wellness” model of psychosocial

rehabilitation stresses the integration of the SMI into the community, providing a di¬

verse set of meaningful activities, improving the individual’s level of independent func¬

tioning, and enhancing self-worth and self-esteem through developing social skills and

work habits. The service site is seen as a clubhouse, rather than a treatment center. The

prototype of this approach was Fountain House, in New York City (Beard, 1976; Beard,

Propst and Malamud, 1982). Pressing, Peterson, Barnes and Riley (1983) describe the

organization and development of a clubhouse program— Highlands Clubhouse— in a

rural area of southwestern Virginia. A similar program —Cirrus House— operates un¬

der the aegis of the Panhandle Mental Health Center (MHC) in Scottsbluff, NE. The

center serves a sparsely populated 1 1 -county catchment area in Western Nebraska and

serves 75 adults (Perkins, personal communication, 1995). A modified version of this

approach is being employed in Idaho. Indeed, the state mental health plan notes: “ . Psy¬

chosocial Rehabilitation, sometimes known as psychiatric rehabilitation, has now be¬

come the treatment modality of choice [emphasis added], and enables services to be

provided in the client’s natural setting of home, work, and community. Ongoing train¬

ing is taking place with both state staff and private providers to continually improve the

practice of psychosocial rehabilitation (Idaho, 1997).”

A program (Tele-N-Touch) in Appalachia uses the self-esteem enhancement goals

of the clubhouse models to provide assurance to the rural elderly (Smith, 1989). Club¬

house members at Cumberland Mountain Community Services provide telephone reas¬

surance to at-risk homebound elderly living in socially and geographically isolated ar¬

eas of southwestern Virginia. Callers determine their immediate health and note any

immediate needs. Back up by staff provides follow-up when immediate needs are iden¬

tified. The help line afforded an opportunity for mutual benefit. The program was seen

as consonant with the rural ethic of service to others in the community. While this

project has not found any instances of a program of this sort in a frontier area, it’s low

cost and “low tech” approach suggest that it would be a feasible model for use in fron¬

tier areas.

66

MORTON O. WAGENFELD

Other Frontier Models

Other frontier models of note include the Badlands Human Services Center (HSC)

and several grants programs in Alaska. The Badlands HSC serves a large, sparsely

populated area. Care for the SMI is accomplished in some innovative ways. The larg¬

est community in the area— Dickinson— is the center for specialized services: a psy¬

chosocial center, a supported employment program, and a social club.

On the other hand, there is significant decentralization. Virtually every small com¬

munity in the region has a long term care facility. Direct services are provided by a

psychiatric nurse who travels to remote sites to work with patients and to develop treat¬

ment plans with family and local caregivers. Regular outreach is provided to commu¬

nities more than 80 miles round-trip from Dickinson. Local primary care physicians

provide medication monitoring through formal agreements with the HSC. This pro¬

vides an impetus for cooperation with the outreach workers.

Alaska represents a unique set of problems in the delivery of care for the SMI. The

authors of the GAP volume describe the complexities of caring for a single person with

SMI. The service delivery system operated on three levels: village, region, and urban.

A total of about 50 people and seven or eight facilities were involved (Group for the

Advancement of Psychiatry, 1995). In a situation like this, how does one achieve con¬

tinuity of care, so that immediate and long-term needs are met? In the case of this

patient (identified as Dog Bone):

... a village response team was eventually assembled, using the health aide [an

indigenous paraprofessional] , the VPSO [village public safety officer] , and a local min¬

ister. A regional master’s-level person was identified for backup. This person in turn

kept in telephone contact with the psychiatrist in the urban center. The village team,

after some initial hesitation, went to the village council to discuss the situation with the

village leaders. They were able to get Dog Bone to go to a family physician at the

regional general hospital for a checkup. He was medicated ... and returned to the village

where he is somewhat improved. The village health aide dispenses his medication and

checks for side effects and then calls the family physician in the regional town to get

advice on any changes in his condition. Brief training for the local village team and the

master’s-level backup person was provided by teleconference with the psychiatrist (GAP,

1995).

i

f

Ii

Pi

m

01

in

A

k

Pi

tit

vii

eq

11

lei

me

Kf

lei

mr

Soule (personal communication, 1995) described a program for delivering mental!

health services to Alaskan Natives living in remote villages. The intent of the initiative

was to provide services that were responsive and sensitive to the unique needs of the

target populations. Largely in response to direction from the Native community, sig¬

nificant changes were made to the way services were delivered, the nature of the ser¬

vices, and who provided the services. Except for the State Hospital, no direct services

are provided. Grants are made to local entities to design and manage programs to

address the problems of self-destructive behavior (including AODA) and suicide. The

S|$

I

t

call

in

i

GENERAL MODELS FOR DELIVERING MENTAL HEALTH SERVICES

67

role of the state is to provide technical assistance and support, leaving the decisions

about what will work for them to the 60 participating communities. Examples of local

projects were: crisis response teams, teaching of traditional values and skills, teen cen¬

ters, and preschool programs. A second program, the Rural Human Services Project,

provides grants to local human service agencies to hire, train, and supervise indigenous

providers. These grants are intended to reduce reliance on non-native professionals

who ride circuit to the villages. The program also attempts to create service delivery

models that are holistic and focused on the community as well as the individual and that

respect and incorporate the values of both native and western cultures and approaches

to prevention, treatment, and recovery.

Implications for Behavioral Health Services: Evolving Healthcare System

If providing services to the SMI in frontier areas has traditionally been a problem,

providing them in the evolving environment of the current healthcare system is even

more of a challenge. Without doubt, managed care as a way of funding health and

mental health service is the salient issue in the field today. The implications of this for

rural and frontier mental health and AODA services have only recently been explored.

At this point, the discussion is largely theoretical. Planners and providers interviewed

have generally noted that managed care has had little impact in their frontier areas.

Private companies have shown little interest in these areas because of the low popula¬

tion base and poverty. In the following quote, Kane and Ennis (1996) discussed ser¬

vices for the seriously mentally ill in relation to healthcare reform, but their points have

equal validity with respect to managed care, which is certainly one part of reform.

They note (1996:447):

The constellation of impairments and deficits of the seriously mentally ill chal¬

lenge mental health service systems, both urban and rural. However, rural environ¬

ments have consistently been identified as having limited capabilities to comprehen¬

sively care for the serious mentally ill. Health care reform, in attempting to address the

needs of the severely mentally ill, must ensure that the capacities for rural mental

L health care are further developed to enhance the delivery of comprehensive care to the

rural living seriously mentally ill.

They outline four strategies for providing these services: linkages to primary care

systems, use of ACT, use of lay caregivers and use of adult homes. The first strategy of

integrating of the health and mental health service system is especially important in

16 i

view of the higher risk of physical illness among the SMI. Over the years, repeated

: calls have been made for integrating mental health, primary care, and AODA services

r in rural areas as a means of improving access. Ozarin, Samuels and Biedenkapp (1978),

68

MORTON O. WAGENFELD

for example, evaluated the community health center/community mental health center

linkage program and found it to be highly effective for providing mental health ser¬

vices.

Indeed, this linkage between health and mental health systems is seen by some as

an important element in a managed care system. A recent research study provides some

useful contemporary insights (Maine Rural Health Research Center, 1996). The inves¬

tigators conducted a national telephone survey of rural primary care providers who

successfully linked with substance abuse or mental health services. The primary care

providers included hospitals, community health centers, health departments, HMO and I

private practitioners. Of particular note, eight of the providers were in states with fron¬

tier populations: North and South Dakota, New Mexico, and Arizona. Four models of I

integration were employed, either singly or in combination:

• diversification

• linkage

• referral

• enhancement

Diversification is the closest form of integration: there is coordination of services

within a single organization (primary care and mental health providers work for the

same agency). With linkage , specialty mental health providers offer services at pri¬

mary care sites through a formal, ongoing relationship. Referral , as the name suggests,

involves primary care providers referring patients to off-site mental health providers.

Finally, with Enhancement primary care providers receive training in order to improve

their ability to treat mental health problems directly.

Overall, these integration efforts have proven effective. Primary care providers

often feel that they lack the knowledge to deal with the SMI and their orientation is to

acute, rather than chronic care. Nonetheless, primary care providers are a crucial part

of mental health and AO DA care. Given the success of these linkages, a recommenda¬

tion for architects of managed care would be to provide incentives for primary health

care providers to link with mental health and AO DA agencies. These incentives could

include educational programs for providers as well as fiscal incentives for linkage.

Kane and Ennis (1996) also feel that the large body of data supporting the efficacy

of Assertive Community Treatment mandates its inclusion as a strategy in a reformed

health system. They add a qualification (1996:448):

Assertive community treatment programs have the potential to significantly im¬

prove the care of the rural seriously mentally ill. However, those factors which pres¬

ently impede the provision of mental health services in rural areas, will also need to be

addressed in implementing rural PACT programs (1996;455).

The nature of rural life suggests the third strategy: utilization of lay and informal

caregivers. The use of these informal caregivers is not without some risk. Kane andl

Ennis (1996) caution:

£2

Of

f

if

cb

i

of

li

i

ot

li

t

i

bo

to

be

pe:

at

k

prt

via

Jes

flei

ava

if

spe.

GENERAL MODELS FOR DELIVERING MENTAL HEALTH SERVICES

69

Use of and reliance upon lay caregivers as an adjunct to more formal systems of

care have a number of issues which must be addressed to insure optimal utility. The

informality of natural support systems establishes an opportunity for lapses in practices

of confidentiality. Individual, family and community boundaries may be blurred in a

paradoxical environment which seeks to both protect the privacy of an individual and

offer a caring supportive ‘neighborhood.’ Professional ethics standards adopted by psy¬

chiatrists, psychologists, social workers, and nurses are all at risk when these profes¬

sionals embrace lay caregivers as a part of the service system. The absence of standards

of ethics in relation to confidentiality among lay caregivers leaves practice violations

without sanction... While lay caregivers offer resource enhancement to the care of the

mentally ill and offer mental health professionals an understanding of local custom ...

one cannot forget that, generally, lay caregivers have not received training in the care of

the mentally ill. The imposition of formality to a system which is inherently informal

places mental health providers, consumers and their supports at risk for relying on a de

facto delivery system that cannot provide essential skilled services.

The final element is adult homes, which can also be referred to as board and care

homes, boarding houses, and congregate care facilities. These shelter arrangements

house almost 40% of the SMI nationally. Kane and Ennis summarize the generally

favorable literature on these homes. They provide a less restrictive environment and

lower levels of stress than institutions and are better venues for maintaining indepen¬

dent living skills. In addition, they are much lower in cost than institutions and are

perceived by residents as offering a higher quality of life. While no accurate data exist

about the number in frontier areas, providers interviewed for this paper have noted that

these homes exist in many communities in their areas. As part of its process of

deinstitutionalization, New Mexico reported an increase in the number of such homes,

many of them operated by former employees of the state hospital. The state hospital

provided mental health, crisis intervention, and support services to these adult homes

via a visiting psychiatrist and nurse team. Without careful controls on placements and

the provision of adequate support services, however, these homes have proven prob¬

lematic, as was the case in Colorado (Kane and Ennis, 1996).

One of the impediments to creating a workable frontier model, using the above

suggestions appears to be categorical funding. Designed to meet a certain need or

designated population or to provide a certain modality, this approach severely limits the

flexibility that is needed in resource-poor frontier areas. If, for example, funds are

available to pay for adolescent inpatient treatment, then services are likely to be skewed

in that direction. An alternative, community-based approach, may be more appropriate

in a given case, but a lack of funds may preclude its use.

mal Much has been said about the inappropriateness of the urban model of services —

and specialized, well-staffed and funded, with a geographically dense area of responsibil-

j ity — for rural venues. This is even more true for the frontier. A frequent comment

70

MORTON O. WAGENFELD

made by planners and providers in the interviews was the inability to afford the luxury

of specialized caregivers. The frontier caregiver, even more than his or her counterpart

in more populous rural areas, needs to be a versatile and flexible generalist. Fiscal

constraints, a paucity of potential clients, and an absence of peer backup militate against

specialty care. The generalist, by definition, needs to be concerned with a number of

different approaches and to operate within a variety of milieus. This speaks to the issue

of the need for flexibility . The need for a general, flexible orientation argues strongly

against categorical funding of programs. A categorical program is directed toward a

specific clientele and, often, prescribes a particular modality. This just does not work in

frontier areas! Another concern of managed care plans, then, ought to be greater dis¬

cretion on the part of planners and providers in allocating resources to meet local or

individual needs.

As noted, frontier mental health and AODA services are organized and delivered in

several different ways. This reflects state differences in ideologies and fiscal arrange¬

ments. The richness of diversity, however, can be problematic in a call for linkage in a

situation where, for example, the mental health agency is public, and the AODA agency

is private, or where one state managed care plan includes AODA services and another

specifically excludes them. What one can recommend is that a national organization

such as the National Association of State Mental Health Program Directors assume a

leadership position in advocating a more uniform policy.

In sum, in keeping with the seriousness of the problem, a number of models of

service delivery to the SMI have been developed or modified for rural areas. While all

report success in reducing days in hospital and enhancing client autonomy, some of the

“high tech” models that rely on high levels of professional input, would not appear

appropriate for frontier areas. The first of these Letters ended with the observation

that— in spite of formidable resource and geographic obstacles— a variety of core ser¬

vices for the SMI are provided in the five states with frontier populations examined.

Reflecting the differences in the organization of state mental health systems, there was

understandable diversity in approaches. This Letter has adopted a broader focus and

looked at some of the models that have been developed or adapted for rural areas. In

addition, the advent of managed care and other market-based reforms offers an oppor¬

tunity to restructure the healthcare system and to integrate the various service delivery

systems.

Beai

ci

Dav

Hu*

le

Mali

Kani

I

Mac

ct

3(

Mail

H

Maz

Ozai

Pres:

111

III

ni

Santi

' K

Smit

.N,

Somi

Ci

Swoi

ra

Sul

h

Tumi

Ira

Ap

to I

Evi

References

Bachrach, L.L. (1977). Deinstitutionalization of mental health services in rural areas. Hospital and Community

Psychiatry, 28:669-672.

Baker, F. and Intagliata, J. (1984). Rural community support services for the chronically mentally ill. Journal of

Rural Community Psychology, 5(1 ):3- 14.

Beard, J. (1976). Psychiatric rehabilitation at fountain house. In J. Meislin (ed.) Rehabilitation Medicine and

Psychiatry. Springfield, IL: C.C. Thomas.

Iiitr

unde

sigm

and i

GENERAL MODELS FOR DELIVERING MENTAL HEALTH SERVICES

71

Beard, J., Propst, R. and Malamud, T. (1982). The fountain house model of psychiatric rehabilitation. Psychoso¬

cial Rehabilitation Journal, 5:47-53.

Davis, L.F. and Ziegler, J.A. (1990). Working with people who are chronically mentally ill in rural areas: Devel-

1 oping a community resource team. Psychosocial Rehabilitation Journal , 13:81 -85 .

t Group for the Advancement of Psychiatry (1995). Mental health in remote rural developing areas. Report No.

j> 139. Washington, DC: American Psychiatric Press.

Husted, J., Wentler, S.A. and Bursell, A. (1994). The effectiveness of community support programs for persis¬

tently mentally ill in rural areas. Community Mental Health Journal , 30:594-600.

i Idaho, State of. (1997). Mental Health Plan for Adults and Children. Boise: Department of Health and Welfare.

1 Kane, C.F. and Ennis, J.M. (1996). Health care reform and rural mental health: Severe mental illness. Community

^ Mental Health Journal , 32:445-462.

Macias, C., Kinney, R., Farley, O.W., Jackson, R. and Vos, B.(1994). The role of case management within the

community support system: Partnership with psychosocial rehabilitation. Community Mental Health Journal ,

r 30:323-339.

Maine Rural Health Research Center (1996, February). Rural Models for Integrating Primary Care, Mental

Health, and Substance Abuse Services. Portland: Center for Health Policy.

Mazer, M. (1976). People and Predicaments. Cambridge, MA: Harvard University Press.

Ozarin, L.D., Samuels, M.E. and Biedenkapp, J. (1978). Need for mental health services in federally funded

a rural primary health care systems. Public Health Reports, 93(4):35 1-355.

j Pressing, K.O., Peterson, C.L., Barnes, J.K. and Riley, B.D. (1983). Growing wings: A psychosocial rehabilita¬

tion program for chronically mentally ill patients in a rural setting. Psychosocial Rehabilitation Journal, 6: 1 3-

:r 24.

II Rhinelander Model Consultants (1990). The Rhinelander model of community supportive care. Rural Commu-

a j nity Mental Health Newsletter, 17:7-8.

i Santos, A.B., Deci, P.A., Lachance, K.R., Dias, J.K. , Sloop, T.B., Hiers, T.G. and Bevilacqua, J.J. (1993). Provid¬

ing-assertive community treatment for severely mentally ill in a rural area. Hospital and Community Psychia-

lf try, 44(1): 34-39.

11 Smith, H.A. (1989). Telephone reassurance to the elderly: Rural values in action. Community Mental Health

Newsletter, 16 (3): 10.

,e j

Somers, I. (1989). Geographic location and mental health services utilization among the chronically mentally ill.

11 Community Mental Health Journal, 25(2): 132-144.

n Sword, M. and Longden, G. (1989). The Idaho citizen companion program. Human Services in the Rural Envi-

j ronment, 12:34-36.

, Sullivan, W.P. (1989). Community support programs in rural areas: Developing programs without walls. Human

■*' Services in the Rural Environment, 12: 19-2

IS Turner, J.C. (1977). Comprehensive community support systems for mentally disabled adults: A conceptual

id framework. Psychosocial Rehabilitation Journal, 1:9-26.

Ill

( Appendix A. Delivering Mental Health Services

' to the Seriously Mentally Ill in Frontier Areas:

Evidence from Five States2

Introduction

itf j ;

Frontier areas are a unique part of the United States and are also historically

V kmderserved. This Appendix will look at the organization of services in five states with

significant frontier populations. A planner in Idaho captured the essence of designing

land delivering services in frontier areas when noting that “programs were born of ne¬

cessity” (Sword, personal communication, 1997).

72

MORTON O. WAGENFELD

Without doubt, managed care as a way of funding health and mental health service

is the salient issue in the field today. The implications of this for rural and frontier

mental health and AO DA services have only recently been explored. If providing ser¬

vices to the SMI in frontier areas has traditionally been a problem, providing them in

the new environment of a changing healthcare system is even more of a challenge. At

this time, the discussion is largely theoretical. Planners and providers interviewed have

generally noted that managed care has made little impact in their frontier areas. Private

companies have shown little interest in these areas because of the low population base

and poverty.

While frontier areas share some common obstacles to service delivery, they also

display great diversity. This diversity is reflected in the variety of organizational mod¬

els for the delivery of mental health and AODA services at the state level. States with

frontier populations tend to vary both in ideologies and fiscal arrangements. For ex¬

ample, in Idaho and North Dakota, mental health and AODA services are part of a

single agency. In Nevada, they are housed in separate agencies at both the state and

community level. At the local level, these services may be delivered by a single entity

or delivered separately. In yet another approach, Idaho has an umbrella state agency

that is responsible for mental health and AODA services. At the local level, treatment

for mental disorders is provided by state-run agencies, while delivery of AODA ser¬

vices is carried out by private, not-for-profit agencies under contract to the state. This

can be even further subdivided: a private, not-for-profit organization contracts with the

state to provide case management for the SMI (Sword, personal communication, 1997).

This paper will now consider services to the SMI by sketching the delivery systems in

five states: North Dakota, Idaho, Arizona, Montana, and Alaska.

H

I

c

D

lo

se

so

North Dakota yt

North Dakota provides a good example of frontier issues. A quarter of its popula-

tion resides in frontier areas. It has received recognition for the organization of its se

mental health system and it is the only state with a 24-hour 800-number Help-Line. ita'

This Help-Line, which is run by the state mental health association, provides referral

and brief emergency counseling (Armstrong, personal communication, 1997). In 1972, h

the state was divided into eight regions under the Department of Human Services for C)1

the provision of mental health services. Each of the eight regional Human Services ^

Centers is autonomous and is charged with providing care for both adults and children/

adolescents. In theory, each is required to provide a full range of services. As one 11

might expect, this is often not the case in practice. Table 1 presents the six broad areas !e

of service provided.

to

GENERAL MODELS FOR DELIVERING MENTAL HEALTH SERVICES

73

Table 1.

crisis stabilization and resolution, admis¬

sion/intake, information/referral, short-term

inpatient, crisis residential beds, state

hospital liaison, inpatient discharge planning

evaluation, medication administration,

medication monitoring, and treatment

evaluation, therapy, consultation and techni¬

cal assistance

individual, group, and family therapy

meeting the needs of the SMI — provides a

variety of modalities under case manage¬

ment, community residential, partial care/

day treatment, psychosocial rehabilitation

centers, supported employment, and com¬

munity supportive care

a variety of outpatient, residential, supervi¬

sory, and consultation activities

One of the eight regional service centers, the Badlands Human Services Center, in

Dickinson, ND provides a good example of local delivery of services to the SMI. It is

n located in a very sparsely populated area of southwestern North Dakota. The center

serves an eight county area covering 41,000 square miles. Excluding the 17,000 per¬

sons residing in Dickinson, the population density is quite low: 1 .5 persons/square mile.

The area has been experiencing severe declines in population, with an outmigration of

younger persons. Higher-risk groups tend to remain behind, and a “silting up” effect

.. has occurred, with a rise in prevalence of disorder. This is seen in the high demand for

ts services: 320 cases of SMI, along with 320 clients with developmental disorder or men-

, tal retardation. As one might expect in an area as sparsely populated as the Badlands,

jl vast distances and a lack of transportation are major impediments to service delivery.

i In addition, the widely recognized problem of lack of specialized treatment staff also

J exists here. Of necessity, the generalist model prevails (Fry, personal communication,

5 1997).

ul [ St. Joseph’s Hospital in Dickinson provides inpatient services. The state hospital,

ie in Jamestown, is 200 miles east, but state policy discourages anything other than emer-

as gency or involuntary admissions. Few private therapists practice in the area. There are

83.5 FTE staff, and an additional 20 who work on contract. In addition to the statewide

hotline run by the Mental Health Association mentioned above, there are specialized

hot lines for the Badlands Human Services region. There are a number of inter-agency

agreements to facilitate coordination of services. In anticipation of managed care, the

Regional Intervention

Medical

Psychological

Acute Treatment

Extended Care

Children and Family Treatment

74

MORTON O. WAGENFELD

HSC is attempting to obtain accreditation from the Council on Accreditation of Reha- a

bilitation facilities (CARF). In addition, a new model of mental health delivery (“New ! o

Company”) is in the process of being developed. This will combine the best elements l

of both public and private care in preparation for a move to managed care.

Badlands Human Services Center provides care for the SMI in some innovative tl

ways. Specialized services are provided in Dickinson, the largest community in the o

area. Services include a psychosocial center, a supported employment program, and a j p

social club. On the other hand, there is significant decentralization. Virtually every i;

small community in the region has a long term care facility. A psychiatric nurse pro- si

vides direct services. This nurse travels to remote sites to work with patients and to

develop treatment plans with family and local caregivers. Regular outreach is provided

to communities more than 80 miles round-trip from Dickinson. Local primary care

physicians provide medication monitoring through formal agreements with the HSC.

This provides an impetus for cooperation with the outreach workers.

Idaho

In Idaho, mental health services are part of an umbrella human services agency— V(

the Department of Health and Welfare. This department fulfills such diverse functions e,

as veterans services, environmental quality, welfare, family and community services, jj

and information systems. Mental health services fall under the Division of Family and j

Community Services. The organization of services in Idaho, while funded at a very low v

level, has been viewed as a model for rural states (Sargeant, personal communication, ^

1997).

The state is divided into seven human services regions. State community mental c]

health centers in all seven regions deliver mental health services. Inpatient services are ai

provided in two state hospitals — one in the north in Orofino with 60 adult beds, and n

the other in the South in Blackfoot with 90 adult beds. With virtually no psychiatric V|

beds in community hospitals and almost no free-standing private psychiatric hospitals, t]:

state policy, unlike in North Dakota, does not discourage inpatient admissions to the ^

state hospitals. ai

Recently, the regional mental health centers were transformed into Regional Men- C(

tal Health Authorities (RMHAs) with increased responsibility for system development |

and planning, and coordination of public and private service delivery. These RMHAs a

are also charged with the responsibility of developing opportunities for the privatization i,,

of services. For example, contracting agencies now deliver AODA services. In addi- |

tion, the RMHAs have used Medicaid’s Rehabilitation Option to support the move

toward privatization of services. The Medicaid program has traditionally required that

mental health services be provided in medical settings. In frontier areas, the lack of

these facilities has been a major service delivery problem. Recently, Medicaid has

GENERAL MODELS FOR DELIVERING MENTAL HEALTH SERVICES

75

adopted the Rehabilitation Option that allows non-medical services to be delivered in

community settings. This option introduces a welcome note of flexibility into pro¬

gramming.

Priority for the public sector delivery of core adult mental health services is to

those, age 18 and older, with a severe chronic mental disorder that interferes with one

or more areas of functioning. Short-term treatment is accorded to those with acute

problems not falling into the above criteria and who are at risk of psychiatric hospital¬

ization. Similar to the array of services in North Dakota, core adult mental health

services broadly provided by each of the regional centers include:

• screening for eligibility for services

• targeted case management

• crisis intervention

• psychosocial rehabilitation

• assertive community treatment

• psychiatric services

• short-term mental health intervention

Targeted Case Management includes psychosocial assessment, treatment plan de¬

velopment, monitoring and coordination of service delivery, linkage with services, cli¬

ent advocacy, and direct assistance with symptom management. Crisis Intervention

includes an array of both agency- and community-based services. Psychosocial Reha¬

bilitation encompasses a variety of outcome-oriented services that includes both indi¬

vidual and group rehabilitation, pharmacological management, nursing services, skills

development, housing, and supported employment.

Assertive Community Treatment is part of the repertoire of adult services and in¬

cludes assistance with symptom management, medication management, 24-hour crisis

availability, financial monitoring, and assistance in vocational reintegration. Psychiat¬

ric Services are an essential element in any program for the SMI. In Idaho, these in¬

volve evaluation, prescribing and monitoring of medications, consultation and educa¬

tion, and psychiatric nursing. The final service element is Short-Term Mental Health

Intervention. Here, services are provided to those without a SMI who are in distress

and at-risk of hospitalization. This includes short-term therapy, medication, referral to

community agencies, and designated examinations (Idaho, 1997). In conjunction with

the Department of Housing and Urban Development, Idaho has instituted Shelter Plus,

a sheltered housing program for the SMI. Dual diagnosis services (for persons with

both SMI and AODA problems) are provided at the State Hospital North and in three of

the seven regions.

76

MORTON O. WAGENFELD

Arizona

Arizona delivers services through a managed care system. It is organized around

five non-profit Regional Behavioral Health Authorities (RHBAs). The major features

of the Arizona approach are:

• a statewide behavioral health carve out to the Health Department

• agreements between the state Medicaid and mental health programs

• integration of mental health and AODA services

• combining of Medicaid and non-Medicaid funding streams

• capitated Medicaid for acute care

• capitated Medicaid for behavioral health

• non-profit Regional Behavioral Health Authorities

• open competitive bidding for authorities

• consent decree for the SMI population

The RBHA has several functions:

• provider network development

• contracting with providers

• prior authorization

• case management

• monitoring of performance

• quality management

• human resources

• needs assessment and community planning

• grievances and appeals

Some data exist on the accomplishments of the Northern Arizona RBHA. By shar¬

ing risks and incentives with providers, there has been a reduction in utilization of

inpatient and residential services, an increase in the use of wraparound services, in¬

creased incentives for providers to work with schools and the juvenile justice system, a

reduction in paperwork though elimination of prior authorization for outpatient ser¬

vices, and a reduction in RBHA authority administrative costs. It has also enabled

providers to improve their financial situation, establish standards of performance and

reward positive performance, all the while maintaining and improving quality. Miller

(personal communication, 1996) suggested that managed care has had a greater impact

on services for children and adolescents than on the SMI population.

Montana

In Montana, public mental health services are under the aegis of the Addictive and

Mental Disorders Division of the Department of Public Health and Human Services

(DPHHS). Until recently they were delivered primarily through five regional Commu-

V GENERAL MODELS FOR DELIVERING MENTAL HEALTH SERVICES

77

nity Mental Health Centers (CMHCs). Montana also operates two inpatient facilities:

j | the Montana State Hospital and Montana Mental Health Nursing Care Center. As the

s J name suggests, the latter is a residential care facility for those with mental disorders

who require nursing home level care. In the last year, Montana instituted a state- wide

managed mental health care system called the Mental Health Access Plan (MHAP).

This program is to provide all necessary and appropriate publicly funded mental health

care through a managed care organization on a prepaid, risk basis.

Montana began the process by issuing Request for Proposals (RFP) for managed

care organizations (MCOs) to implement the Mental Health Access Plan. The approach

was seen as unique:

...the MHAP represents a significantly different approach to providing mental health

care from that seen under traditional Medicaid and other health insurance programs or

even other managed care programs. Montana’s Mental Health Access Plan, if adminis¬

tered by a competent and experienced MCO which is dedicated to the program’s suc¬

cess, will establish a comprehensive and coordinated system of care which integrates

all public funding sources to provide treatment of a uniform quality and continuity that

we believe will be unprecedented in the nation’s public health system (Montana, 1996).

The RFP required that specific attention be paid to several groups of persons and

levels of service:

• the SMI

• homeless mentally ill

• individuals eligible for Medicaid and Medicare

• elderly

• Native Americans

• secondary prevention

I • jail inmates

1 1 • clients of the juvenile justice system

It is interesting that, unlike Arizona, which integrates AODA and mental health

a services in its system, persons with a sole diagnosis of an AODA disorder or mental

retardation are specifically excluded from the RFP.

d

Alaska

Alaska, the ultimate frontier, represents a special case of mental health service de¬

livery that dwarfs even those of the most remote areas of the continental US — the

“lower 48.” With population densities approaching 0 in some areas, it goes beyond

frontier and can be considered wilderness. The Group for the Advancement of Psychia¬

try (GAP, 1995) has written about the problems of providing mental health services

j under extreme conditions of isolation, harsh climate, long distances, different languages

. and sub-cultures , and resource deficits . In many ways , they view the situation in Alaska

as analogous to a developing country.

78

MORTON O. WAGENFELD

More than 200 communities, many with populations of less than 800 persons,

are scattered through out the state. Only about 19 communities are accessible by road;

the rest can only be reached by plane, boat, snowmobile, or dog sled. Distances are

staggering: a person requiring mental hospitalization and living on of one of the outer

Aleutian Islands would have to be flown a distance equivalent to that from Boston to

Los Angeles. Because so much travel is by air and both the patient and an escort need

to be transported and lodged, cost per unit of service is formidable. To cite a “simple”

case:

...the costs of doing an assessment included a 30-minute round-trip charter flight

from the village to the regional hub town, at $90 for the patient and another $90 for the

escort. The 3-hour trip to the urban center was another $450 round trip for the patient as

well as $450 for the escort. Because of plane connections, the escort had to stay

overnight in the city, entailing food and lodging costs. Hotel costs for professionals

traveling to the regional hub centers from the city were $125 per night. In the village,

itinerants who stay overnight would probably sleep in a sleeping bag on the floor of the

health clinic, at a cost of $20 (GAP, 1995).

These time and cost factors are important because they obviously become part of a

proposed treatment response. Additionally, the “ownership” of a problem is an issue in

frontier areas where there are often overlapping spheres of responsibility. These can

cause jurisdictional disputes. Then, there is the issue of empowerment and how to

avoid over-dependence on scarce professional resources.

Virtually all mental health services are public sector in Alaska, organized in a three-

level hierarchical fashion. Front-line services are delivered at the village level by para-

professionals (community health or mental health aides), who are generally indigenous

to the village and who have little formal education. Being native to the villages where

they practice, they share the values of their clients. Even the standard clinical reference

book, the Physicians Desk Reference (PDR) has been adapted for village use. The

Village Drug Reference is designed to be used with telephone backup from regional

primary care physicians.

At the next level are the small regional hospitals (12-15 beds) that provide basic

emergency inpatient services. Primary care physicians and mid-level mental health

practitioners are found here. Also likely to be found here would be a regional jail.

Tertiary-care mental health facilities are found in the urban areas (with populations of

40,000 - 200,000).

Alaska, then, represents a unique set of problems in the delivery of care for the

SMI. The authors of the GAP volume describe the complexities of caring for a single

person with SMI. This person received services from all three levels: village, region,

and urban. A total of about 50 people and seven or eight facilities were involved. In a

situation like this, how does one achieve continuity of care, so that immediate and long¬

term needs are met? In the case of this patient (identified as Dog Bone):

GENERAL MODELS FOR DELIVERING MENTAL HEALTH SERVICES

79

...a village response team was eventually assembled, using the health aide [an in¬

digenous paraprofessional] , the VPSO [village public safety officer], and a local minis¬

ter. A regional master’s-level person was identified for backup. This person in turn

kept in telephone contact with the psychiatrist in the urban center. The village team,

after some initial hesitation, went to the village council to discuss the situation with the

village leaders. They were able to get Dog Bone to go to a family physician at the

regional general hospital for a checkup. He was medicated. . .and returned to the village

where he is somewhat improved. The village health aide dispenses his medication and

checks for side effects and then calls the family physician in the regional town to get

advice on any changes in his condition. Brief training for the local village team and the

master’s-level backup person was provided by teleconference with the psychiatrist.

In sum, this overview illustrates the diversity of mental health systems in states

with frontier populations. A common feature to all, however, is the fact that services to

the SMI are provided— often under extreme circumstances of distance, inhospitable

climate, and chronic shortages of professional staff.

References

Group for the Advancement of Psychiatry. (1995). Mental health in remote rural developing areas (Report No.

139). Washington, DC: American Psychiatric Press.

Idaho, State of (1997). Mental health plan for adults and children. Boise, ID: Department of Health and Welfare.

Montana, State of (1996, August). Request for proposals for managed mental health care. Helena, MT: Purchas¬

ing Bureau, Department of Administration.

Notes

1 This letter owes much to the generous assistance of a number of planners and practitioners: Myrt Armstrong,

John Fowler, Mark Friedman, Joseph Fry, Michael Galli, Maurice Miller, Tom Perkins, Roy Sargeant, Susan

Soule, Marilyn Sword, and Beth Stamm. My thanks to them.

This letter owes much to the generous assistance of a number of planners and practitioners: Myrt Armstrong,

John Fowler, Mark Friedman, Joseph Fry, Michael Galli, Maurice Miller, Tom Perkins, Roy Sargeant, Susan

Soule, Marilyn Sword, and Beth Stamm. My thanks to them.

80

V Journal of the Washington Academy of Sciences,

a Volume 86, Number 3, 81-88, December 2000

Organization and Delivery of

Mental Health Services to Adolescents and

Children with Persistent and

Serious Mental Illness in Frontier Areas1

Morton O. Wagenfeld, Ph.D.

Abstract

This paper sketched out a number of models of organizational structures that are being

used or can be used to the delivery of behavioral health services to children and adoles¬

cents in frontier areas— a historically underserved group living primarily in the western

part of the United States. It is based on published and unpublished literature as well as

interviews with mental health planners and providers. Nearly all the models identified were

rural models, but they are applicable for frontier or remote areas. Three general principles

can help guide us in the presentation:

• do the models make use of existing informal and community support systems?

• can the models be run without specialized staff?

• can the models be done in a decentralized manner?

Using these principles, most of the models described in this paper are modifiable for fron¬

tier areas. The salience accorded services to children in various frontier programs speaks

well for the concern for the well-being of this vital part of our society.

Introduction

This paper is one of a series (see Wagenfeld, 2000) dealing with different aspects

of delivery of mental health services to persons in sparsely-populated frontier areas.

This paper deals with the organization and delivery of services to children and adoles¬

cents with serious mental illness (SMI). It is based on published and unpublished lit¬

erature, and interviews with planners and providers. A companion paper (Cooper and

Wagenfeld, 2000) will complete the picture by presenting the highlights of two study

groups— one for providers, and the other for parents held in a frontier area.

Models of Service Delivery

Children and adolescents are an important part of any community as a resource for

the future. Attention to their problems of mental disorder, the abuse of alcohol and

other drugs (AO DA), and developmental disability should, therefore, be a priority. A

number of papers and interviews with planners and providers have highlighted numer-

82

MORTON O. WAGENFELD

ous impediments to service delivery for this group, as well as delivery models. To

begin with, an important impediment is the problem of cases crossing systems when i

they involve minors (e.g., school, juvenile justice, welfare, etc.). Often, and this is by

no means unique to child and adolescent services, there is a lack of coordination be¬

tween systems and a lack of information sharing.

Providers view categorical funding of services, in itself, as a possible barrier, inas¬

much as it limits flexibility. In other words, if moneys are available for inpatient or

institutional services, that, rather than the needs of the child may drive treatment plans.

As a result, these approaches may not necessarily tap into available and local informal i

systems, particularly, the families of the children or community value systems.

A number of authors have considered the general problems of service delivery to

rural children and adolescents. Kelleher, Taylor and Rickert (1992) note that there are

four barriers unique to rural areas:

• transportation

• communication

• laws

• attitudes

In addition, there is the well-documented problem of recruiting and retaining quali¬

fied providers. Like other aspects of frontier mental health services, the lack of child

and adolescent specialists is a significant problem. In North Dakota, specialty mental

health services decline as one moves west from the population centers at the eastern

edge of the state. It is not unusual for a family to have to travel more than 100 miles one

way to see a child psychiatrist. The response of rural providers has generally been to

rely on federal and state dollars and focus on noncategorical and preventive services.

The use of paraprofessionals and natural helper systems has helped to provide needed I

services in a resource-poor environment.

Petti and Leviton (1986) developed some policy guidelines for serving rural youth.

They proposed that a practical option is developing personnel trained to function as

extenders of service delivery by certified child psychiatrists and psychologists. Petti

developed and evaluated a specific consultative model in a rural area of western Penn¬

sylvania (Petti, Comely and McIntyre, 1993). Sheldon-Keller, Koch, Watts and Leaf

(in press) feel that mental health and social services for mral children and adolescents

should address four areas:

• placement options (from most to least restrictive)

• treatment options (psychotherapy, pharmacotherapy, rehabilitation, etc.)

• treatment modalities (individual, family, group)

• service delivery locations (e.g., schools, mental health centers).

A new approach that overcomes many of the mral impediments is what has been

termed “wraparound services”. Here, services are needs-based (as defined by an as¬

sessment), flexible, individualized, and “wrapped around” the family. The service plan

can use both formal and informal local resources. Wraparound services are flexible,

MENTAL HEALTH SERVICES TO ADOLESCENTS AND CHILDREN

83

To

en

by

>e-

is-

or

as.

lal

ire

ili-

:m

me

to

es,

led

ith.

as

etti

an-

eaf

nts

een

as-

dan

capitalize on local support systems, and involve the family in planning. Such flexibil¬

ity and reliance on local resources make it ideal for frontier communities. Arizona,

North Dakota, and Idaho are three states providing these types of services to frontier

populations.

Linkage with school systems is particularly important for working with children

and adolescents. Consultation can be provided to the schools through special education

districts and the human services or mental health centers. A problem here is a low level

of recognition of mental health problems or issues in schools. School personnel tend

not to be trained in the assessment of these problems (Ronnigen and Sweet, personal

communication, 1997).

A number of specific models of delivery will be discussed in the following sections

for mental disorder, alcohol and other drugs of abuse, and developmental disability.

The programs highlighted here are all from rural areas in ten states and one region

(Appalachia). Some of these were from states with significant frontier populations

(e.g., Alaska, Idaho, North Dakota, Wyoming), while others were from less isolated

rural areas (e.g., Florida, Michigan, New York, North Carolina, Wisconsin, Virginia).

Understanding where the models were developed and have been practiced is important

in assessing the applicability of these programs to the special needs of the frontier.

Mental Disorder. Several models for delivering services to children and adoles¬

cents in rural and frontier areas with SMI have been reported. The Family Living Model

was developed in a rural area of central Oregon as an alternative to traditional residen¬

tial care. It focuses on reducing costs, maintaining the child (aged 3-12) in his or her

local culture, using community resources, and forming a network of support for the

children. The principal program element is day treatment, with a supplementary plan

enabling one to three children to be placed with residential Family Living parents. The

children usually return to their own homes on weekends. This often avoids placement

in a more traditional residential setting. The model is based on the Teaching Family

Model of Boys Town, Nebraska (Tovey, 1983).

Schools are an obvious venue for the prevention and detection of mental illness.

Several school-based prevention models have been developed. A structured 8- week

program to target all 1 1-to 13-year-old youths in an 11 -county rural school district in

Florida had three goals:

• develop an inexpensive rural primary prevention program that could be easily

maintained and replicated

• promote activities that address the correlates of youth at risk

• provide a positive recreational and group experience for the participants (Rich¬

mond and Peeples, 1984).

ble,

84

MORTON O. WAGENFELD

In a rural area of New York State, a consortium of school-based programs for early

detection and prevention of school adjustment problems was established. The program

expanded the reach of early services to young children and stimulated communication,

interaction, and support among professionals in participating districts (Farie, Cowen

and Smith, 1986).

Another school-based program, one that would likely be suitable for remote or

frontier areas, was developed in southeastern Washington. The area was almost totally

without services. No state or county social or health agencies, not even a satellite

center, were located in any of the towns. A program of helping skills intervention was

developed in five schools. With the coordination of a mental health worker, outreach

personnel from county agencies talked to the students. They focused on enhancing

self-concept, increasing sensitivity and response to other people and their situations,

problem solving, and the knowledge and skills to seek assistance appropriately. Re¬

sults indicate that the program was successful in increasing support among students and

promoting cooperation between schools and county agencies (Mooney and Eggleston,

1986).

The increase of suicide in younger populations has forced communities to develop

prevention and intervention programs. One such program in rural Maryland, Lifelines , j

utilized a systems approach to the development of a community-based suicide preven¬

tion program. The model employed three levels: awareness, intervention, and post¬

intervention. Because it is not a resource-intensive program, it appears feasible for

isolated rural areas (Gray and Cannon, 1987).

A model developed specifically for a frontier area (in Idaho) was the Citizen Com¬

panion Program (Sword and Longden, 1989). It has proven useful for adults with SMI.

A version for children and adolescents— The Children’s Companion Program— was

subsequently put in place. Adults serve as companions in school or at home. It is

currently referred to as Youth Trackers and is even more popular than the original adult

program (Sword, personal communication, 1997). To be eligible for Youth Trackers,

children or adolescents, in addition to a diagnosis of a severe mental disorder, must:

• reside in intensive inpatient or residential facilities but could benefit from a less

restrictive environment, or

• currently reside in the community, but have a history of hospitalization or are at

risk for further hospitalization, or

• be at risk for out-of-home placement because of their disorder, or

• be under commitment due to criminal conduct, child protection requirements, or

are at risk of injuring themselves or others (Idaho, 1997).

Child abuse and neglect programs are badly needed in rural areas, but their imple¬

mentation faces a number of barriers. Sefcik and Ormsby (1978) review some of these

problems:

in

sei

i

sis

vei

Pi!

fol

k

trei

liar

Edr

eral

Diei

lirbi

nira

iet\

lice

iloti

tisi

MENTAL HEALTH SERVICES TO ADOLESCENTS AND CHILDREN

85

• rural community attitudes

• lack of awareness of and education about the incidence and impact of child

abuse/neglect and its spin-off problems (truancy, juvenile delinquency, crime)

• small town conservatism

• perceived threat to parental rights and family privacy

• fear of becoming involved through reporting

• lack of knowledge regarding the law and reporting procedures

• small town politics and power structures

• geographic scattering

• scarce or inaccessible resources.

Project Children is a rural child abuse/neglect program serving a five-county area

in south-central Indiana. The purpose of this program is twofold. First, to develop a

service network in which the various agencies’ roles and relationships are clear. Sec¬

ond, to provide the best system for helping families by avoiding overlapping functions

and ensuring that essential services are available in the community. The program con¬

sists of a hospital child protection team, parent aides, community education, and pre¬

vention efforts. The hospital child protection team uses a physician, a Department of

Public Welfare worker, and a psychologist and/or psychiatric social worker. The initial

focus of prevention efforts was on two identified needs:

• a child care facility that would serve children 0-6 years of age, and

• a parenthood course as part of a junior and senior high school curriculum.

Alcohol and Other Drugs of Abuse. In recent years there has been great concern

about the AO DA problems of children and adolescents. A number of prevention and

treatment models have been developed specifically for rural areas or adapted from ur¬

ban models. AO DA prevention programming can be a special challenge in rural areas.

Edwards, Egbert-Ed wards, D’Anda and Perez (1988) provided a good overview of sev¬

eral special considerations. As in most areas involving professional resource deploy¬

ment, the staff members working in prevention activities have often been trained in

urban settings. It is important to provide these professionals with orientation to the

rural environment.

The Upper Peninsula Teen Leadership Program (UPTLP) in Michigan involved

networking to provide quality substance abuse prevention and early intervention ser¬

vices to high school students (Lindenberger, 1994). The program was based on peer

leadership to prevent substance abuse by strengthening resiliency factors. One of the

developers noted: “It promotes the concept that prevention is not something that we can

do to our teens, but something that we must do with them, as partners.”

se The New Holstein Student Assistance Program was developed in a rural area of

Wisconsin and was designed to serve students in grades K-12. In addition to students

and school staff, the program involved parents and the community-at-large. The pro-

86

MORTON O. WAGENFELD

gram offered identification, assistance, referral, and support services for students with

problems related to the use of alcohol or other drugs. Three kinds of support groups

were available: use/abuse groups, concerned persons groups, and aftercare groups. The

program was seen as an alternative to strict disciplinary codes that too often resulted in

dropouts, expulsions, and the loss of educational opportunities (Wieser, 1988).

In any discussion of delivery of services to remote populations, Alaska — the ulti¬

mate frontier — needs to be mentioned. The Group for the Advancement of Psychiatry

(GAP, 1995) published a book on delivering mental health services to remote popula¬

tions in this state. Illustratively, providing treatment services to an adolescent girl liv¬

ing in an alcoholic family in a remote village was problematic. Little help could be

offered, even by the itinerant regional workers. In this case, the psychiatrist attempted

to help her by periodic, brief telephone calls and letters, supplemented by contacts with

regional providers. Many mental health professionals in these situations must choose

between providing sub-optimal clinical services or expending effort to develop local

capacity.

Many professionals are opting for the latter. A major effort is underway in Alaska

to develop village capacity to deal with alcoholic families. Paraprofessional village

counseling positions have been developed, as well as regional teen substance abuse

outreach and aftercare coordinators. As noted (GAP, 1995:120):

. . .Specialized training, including creation of curricula and training manuals, uni¬

versity-based efforts to get certification systems in place, and statewide regional work¬

shops, is being developed to give village paraprofessionals and regional backup teams

the skills they need to work with adolescents and their families. Difficult problems that

in urban [and populous rural] locations would be handled by subspecialists will in

remote rural areas be dealt with by paraprofessionals and mid-level staff [emphasis

added] .

Developmentally Disabled. A group not at all well served in rural areas are chil¬

dren with developmental disabilities. Federal legislation mandating educational and

preschool services for all developmentally disabled children places additional pressure

on local resources.

When services to these children are to be delivered in “mainstream” settings, there

are particular concerns that need to be addressed. Gerber and Semmel (1983) describe

two technical assistance systems— Virginia’s Technical Assistance Centers (TACs), and

California’s Special Education Resource Network (SERN)— that illustrate important

issues in providing comprehensive special education services to preschool children ini

rural areas. The obstacles to delivery of these services share a number of the same

problems as rural service delivery in general. They include recruitment and retention

of staff, higher per-capita costs, and difficulty in achieving economies of scale.

MENTAL HEALTH SERVICES TO ADOLESCENTS AND CHILDREN

87

Both TACs and SERN utilize a mix of core staff and paid consultants that over¬

comes the limitations of both center-based and home-based delivery systems. In es¬

sence, a resource center “travels” to where the primary service provider is located. The

arrangement allows for adaptation, adjustable funding arrangements, and data-based

responsiveness to clients and their requests. They also assert that the effectiveness of

these models might be enhanced by some of the advances in telecommunications and

microcomputer technology: e.g., computer-assisted self-instructional modules; video¬

tape and disc storage and retrieval systems; closed-circuit or microwave transmission

of lectures, workshops, and demonstrations; and remote monitoring and evaluation sys¬

tems.2

A model of family-centered, community-based case management for families with

developmentally-disabled children was developed in Appalachia. The goal was the

empowerment of parents as caretakers and planners for their children. Master’s level

social work case managers staffed the program (Fiene and Taylor, 1991). In a rural area

of North Carolina a program of peer support ( Parents Supporting Parents) was devel¬

oped for parents of children with developmental disabilities. Support was given either

face-to-face or over the phone. The program provided training in basic listening skills

and the availability of community resources. The program was inexpensive to develop

and, therefore might be applicable in a wide variety of areas (Scott, 1989).

Implications for Behavioral Health Services

, This paper sketched out a number of models for the delivery of services to children

J and adolescents in frontier areas. Nearly all were rural models, but are they applicable

J for frontier or remote areas? Three general principles can help guide us in this decision:

• do they make use of existing informal and community support systems?

• can they be run without specialized staff?

j • can they be done in a decentralized manner?

j Using these principles, most of the models described in this paper are modifiable

for frontier areas. The salience accorded services to children in various frontier pro-

J grams speaks well for the concern for the well-being of this vital part of our society.

^ References

1 Edwards, E.D., Egbert-Edwards, M., D’Anda, T. and Perez, E. (1988). Prevention of substance abuse in rural

fll communities . Report to the OSAP Conference Cluster. Rockville, MD: Office of Substance Abuse Prevention.

e Farie, A.M., Cowen, E.L. and Smith, M. (1986). The development and implementation of a rural consortium

program to provide early, preventive school mental health services. Community Mental Health Journal , 22(2):94-

4 103.

! Fiene, J.I. and Taylor, P.A. (1991). Serving rural families of developmentally disabled children: A case manage¬

ment model. Social Work, 36(4):323-327.

I Gerber, M.M. and Semmel,M.I. (1983). Models for delivery of technical assistance for rural special education of

preschool handicapped children. International Journal of Mental Health, 12:144-158.

88

MORTON O. WAGENFELD

Gray, J.B. and Cannon, G. (1987). A model of suicide prevention and intervention in rural areas. Rural Special j

Education Quarterly, 10(1): 17-25.

Group for the Advancement of Psychiatry. (1995). Mental health in remote rural developing areas (Report No.

139). Washington, DC: American Psychiatric Press.

Idaho, State of. (1997). Mental health plan for adults and children. Boise: Department of Health and Welfare.

Kelleher, K.J., Taylor, J.L. and Rickert, V.I. (1992). Mental health services for rural children and adolescents.

Clinical Psychology Review, 12:841-852.

Lindenberger, D. (1994). The Upper Peninsula teen leadership program: Marquette- Alger Intermediate School i

District. In Rural issues in alcohol and other drug abuse treatment (Technical Assistance Publication Series

#10. DHHS Publication No. (SM A) 94-2063, pp. 1 1-24). Rockville, MD: Substance Abuse and Mental Health !

Services Administration, Center for Substance Abuse Treatment.

Mooney, K.C. and Eggleston, M. (1986). Implementation and evaluation of a helping skills intervention in five

rural schools [Special Issue: Prevention and promotion]. Journal of Rural Community Psychology, 7(2):27-

36.

Petti, T. A., Comely, P.J. and McIntyre, A. (1993). A consultative study as a catalyst for improving mental health

services for rural adolescents. Hospital and Community Psychiatry, 44(3):262-265.

Petti, T.A. and Leviton, L.C. (1986). Re-thinking rural mental health services for children and adolescents. Jour¬

nal of Public Health Policy, 7(2):58-77.

Richmond, J. and Peeples, D. (1984). Rural drug abuse prevention: A structured program for middle schools.

Journal of Counseling and Development, 63(2): 1 13-1 14.

Scott, S. (1989). Use and training of peer counselors. Rural Community Mental Health Newsletter, 16(1):9.

Sefcik, T.R. and Ormsby, N.J. (1978). Establishing a rural child abuse/neglect treatment program. Child Welfare,

57(3): 1 87-195 .

Sheldon-Keller, A.E.R., Koch, J., Watts, A.C. and Leaf, P.J. (in press). The provision of services for mral youth

with serious emotional and behavioral problems: Virginia’s comprehensive services act. Community Mental

Health Journal.

Sword, M. and Longden, G. (1989). The Idaho Citizen Companion Program. Human Services in the Rural

Environment, 12(4):34-36.

Tovey, R. (1983). The family living model: Five-day treatment in a mral environment. Child Welfare, 62(5):445-

449.

Wieser, J. (1988). New Holstein student assistance program. Student Assistance Journal, l(l):23-26.

1

Notes

1 I am indebted to my colleague, Sheila Cooper, for her helpful comments and for organizing the two study *

groups.

2 By eliminating or minimizing the barriers of access to specialized care and distance to services, telecommuni¬

cations have become an increasingly important way of delivering mental health services in frontier areas. A 0

paper on this topic is available (see LaMendola, 2000) from the Frontier Mental Health Services Resource j

Network

Journal of the Washington Academy of Sciences,

Volume 86, Number 3, 89-98, December 2000

Delivering Mental Health Services to

Children and Adolescents with

Serious Mental Illness in Frontier Areas:

Parent and Provider Views1

Sheila Cooper and Morton O. Wagenfeld, Ph.D.

Abstract

This paper builds on an earlier paper that provide an evaluation of the types of services

available to adolescents and children with serious mental health disorders who reside in

sparsely-populated frontier areas (see Wagenfeld this issue). Specifically, this paper pro¬

vides local evaluations of the adequacy of services typically available to adolescents and

children in frontiers areas. In 1998, the Frontier Mental Health Service Resources Network

1 1 (see Ciarlo, 2000) invited mental health professionals and parents of adolescents and chil-

I dren receiving care for mental health problems and who were residents of four contiguous

frontier counties in a western state to participate in two separate focus groups that evaluated

I local availability and access to appropriate mental health services. This paper summarizes

the results of these focus groups

-

Introduction

Adolescents and children are our link to the future, so attending to their health and

I mental health needs is a vital investment and should be accorded a high priority. A

previous paper described some of the models of service delivery to this group in sparsely-

n populated frontier areas — a historically-underserved group living in a special and

! unique part of the United States. Some of these approaches were adaptations of urban

A or more populous rural models; others were developed specifically for frontier areas.

e This Letter builds on the earlier one by providing input from both service providers and

parents of children with serious mental disorders— those closest to the problem.

There are 394 frontier counties (equal to or less than six persons/square mile) in 27

states primarily in the western part of the United States. These areas are at the extreme

end of a rural/urban continuum. As a group, frontier America constitutes less than one

percent of the population, but forty-five percent of the land mass. While the frontier of

historic imagination no longer exists, it does live on, protected from large-scale settle¬

ment by harsh climate, difficult terrain, lack of water, distance from metropolitan areas,

lack of exploitable resources, and federal land policies. These areas contain a high

proportion of persons living in poverty, and have a limited local tax base. Federal and

90

SHEILA COOPER, MORTON O. WAGENFELD

state programs provide most human services. Low population densities make it im¬

practical to deliver labor- and resource-intensive programs. In addition, of course, there

is the chronic problem of hiring and retaining a qualified staff.

A Snapshot of the Focus Group Site

In 1998, the Frontier Mental Health Services Resource Network (see Ciarlo, 2000)

invited mental health professionals and parents of children and adolescents receiving

care for mental health problems from four contiguous frontier counties to participate in

two separate focus groups. Although each of the counties met the frontier criterion of

low population density, their diversity was profound. Two of the counties are among

the least populous in the state or nation, with 1990 population densities of 0.4 and 1.7

persons per square mile. The only community mental health center is located in the

community where the focus group was held (which we will refer to as Central Place).

The service area for the community mental health center totals 19,783 square miles,

making transportation and driving distances a major issue for both professionals and

clients. One of the counties— which has a geographic area of 6,928 square miles— is

larger than the states of Delaware and Rhode Island combined. All four counties are

quite impoverished; the percentage of families below the federally designated poverty

level ranged from 18% to 25%. Per capita income in these counties was below state

and national levels. Federal lands constituted as much as 63% of the land area of one of

the counties and 50% of another. Major industries vary from mining to ranching.

The four counties are all federally-designated health professional shortage areas.

The only psychiatrist is located in the same county as the community mental health

center. There is no in-patient psychiatric care for children and adolescents in these

counties. The nearest such facility is 1 15 miles from the Central Place and much fur¬

ther for most of the service area. Only one county has a public sector primary care

provider. In 1995, the most recent data available, suicide rates for all age groups in two

of the counties exceeded the state average of 2.4 deaths per 100. The national preva¬

lence figure is 1 .3. From 1993 to 1995 the average suicide rates per 100,000 population

in this state for males age 15-24 was 37.7; the national rate was 23.4. For females in

this age group the national and state suicide rates were 3.7 and 7.3, respectively. The

effects of distance, poverty, underfunding and lack of services are likely reflected in

these figures. Births to teen single mothers did not exceed the state average in any of

the studied counties, but the state rate exceeds the national figure.

Providers and Parents

The groups were held on a Saturday at a local university. To encourage open dis¬

cussion, two separate sessions were held; one for providers and another for parents.

Each group lasted for about two hours. The sessions were audio-taped, and major

SERVICES TO CHILDREN: PARENT AND PROVIDER VIEWS

91

points put on a flip chart. A set of questions was prepared in advance and individual

questions are included below in italics. The format of this Letter is to aggregate the

responses to the questions. In some instances, side comments did not easily fit into a

question, but are included wherever possible.

Providers. The providers in this group were from the mental health agency that

served the four-county catchment area (CA). Most of them were enthusiastic partici¬

pants and, at times, it was difficult to keep up with the flow of responses. The agency

has 1.5 FTE psychiatrists. A little over 6 therapists serve the two major population

centers. The caseload for the case managers was 25-30; for the more intensive program

Assertive Community Treatment (ACT) it was 12. For a few families, the modality

was intensive home-based care.

What is the first thing that comes to mind when I mention mental health ser¬

vices for children and adolescents in frontier areas?

They cited three related problems as most significant: lack of transportation, long

I waiting lists, and— as one staffer put it— “the kids were desperately underserved .” In

! situations where there is conflict in the biological family or the parents are unable or

unwilling to care for the child, foster care is frequently employed. Not enough foster

parents were available in the area. There were no mental health inpatient services for

children and adolescents within a reasonable distance. From some parts of the CA, it was

necessary to drive over 150 miles to receive this service. In addition to distance, the

roads were typical of frontier areas in this part of the country: narrow and mountainous.

In your opinion, what do you think are the major mental health problems for

children and adolescents in this area?

The participants listed eight mental health problems:

• substance abuse

• suicide

• child abuse

• incest (particularly in two counties)

• depression

• domestic violence

• homelessness

• developmental disabilities

Several side comments dealt with shortages. It is well known that rural areas suffer

from extreme shortages of health and human services. Problems in frontier areas are

even more extreme. Staff —often with less than optimal levels of education— need to

travel long distances to reach clients. One clinician summed it up well by noting:

92

SHEILA COOPER, MORTON O. WAGENFELD

“We’re it!.” In addition, they felt their salaries were much lower than in other areas.

One participant noted, “I could make double what I make here. But why? I don’t want

to. I like it here.”

If a young person has an emotional problem around here, how does one go about

getting help? To whom do you turn? (Probe for “formal” and “informal” caregivers:

e.g., specialty sector, primary care sector, ministers, public health nurses, county

agents, family, neighbors, etc. In areas with large Hispanic or Native- American

populations, probe specifically for alternative healers (e.g., Curanderas, shamans)).

One could receive help directly through: walk-ins at the clinic, making an appoint¬

ment, calling a 24-hour crisis 800-number, or from a mobile crisis unit. Adults, but not

children, can go to the emergency room at the local hospital. In addition to direct client

contacts, they received a large number of referrals from a variety of sources: members

of the clergy, shelters, school counselors, and primary care physicians. Indeed, the

latter group was the major source of referrals.

Participants volunteered a number of responses for alternative sources of care:

• ministers and churches

• primary care physicians

• family and neighbors. (The group felt that this was a particularly important

resource and that people were deeply involved.)

• these providers referred clients to curanderas when appropriate. (One therapist

noted that these healers “...help them (patients) help themselves .”)

• public health nurses

• child protective services

• juvenile probation

• domestic violence shelter

• jail

• peer support programs (includes mentoring, mediation, and teen court)

• Big Brother/Big Sister

• private therapists who deal in alternative or complementary approaches (e.g.,

Reiki massage therapy, Healing Touch)

Particular mention needs to be made of school counselors. They are an obvious

source of case-finding and first-line treatment. In general, feeling toward them was

positive, particularly in view of the fact that they were overwhelmed; one district did

not even have any. The linkage was essentially one-way: referrals to the mental health

center for drug and alcohol screenings. As one participant noted: “They look to us for

resources. We’re their resource, they’re not our resource. They’re the one who send us

the clients, but they’re not a resource. We don’t refer back . to [them].”

SERVICES TO CHILDREN: PARENT AND PROVIDER VIEWS

93

The providers did not see the state hospital— seven hours away— as accessible or

helpful since it does not provide care for children and adolescents. Finally, it is worth

noting that one important source of care that was mentioned as being absent in the area

was detoxification. The nearest service was about 1 15 miles from Central Place.

A related issue in resources is the availability of psychotropic medications. These

drugs often spell the difference between remaining in the community or being hospital¬

ized. Because of widespread poverty and the lack of health insurance, obtaining these

medications is quite difficult. The mental health center will provide one year of medi¬

cations while the client qualifies for benefits. Another source of these drugs is dona¬

tions from pharmaceutical companies.

How well do agency staff understand the particular emotional problems of

young people around here?

As we noted in the section on the demographics of the CA, the four counties are

dissimilar in their ethnicity, culture and values. This creates problems for providers.

They noted the difficulty in being accepted by clients, along with the statement, “They

want us when they need us.” It’s interesting that staff felt the lack of acceptance was

most evident in the least populous and most remote counties. Staff felt that more bilin¬

gual therapists were needed, but that cultural competency was not a problem. They

noted that the staff is half Hispanic and half Anglo, just as the counties themselves are.

In addition all of the employees have participated in workshops on multiculturalism and

many have taken a multiculturalism counseling class at a local, small public university.

A major health care issue nationally is managed care. By that, I mean organi¬

zations like HMOs that attempt to control utilization and cost of health and men¬

tal health services. Has it had any impact in this area?

Responses to this question were, in general, a mixture of frustration and anger. One

respondent referred to it as “mangled care.” Some jokes were made about managed

care (MC) and one respondent said that they laughed so that they wouldn’t cry.

A Medicaid MC was introduced in one county and was scheduled to be instituted in

the other three in early summer, 1998. The center was part of a Behavioral Health

Organization of 12 members. Among the problems cited were:

• less money

• increased bureaucracy

• confusing and contradictory requirements

• mandating intake assessments in what they consider to be an unreasonably short

time

• unethical nature of MC — making large profits at the expense of client services

• poorer quality of care for persons with a serious mental disorders

94

SHEILA COOPER, MORTON O. WAGENFELD

To elaborate on some of these points, there was a great deal of discussion about

alleged cost savings. When the state was directly funding services, the center could

expect to spend about 80% on clients. With the introduction of an additional echelon,

the amount available has declined to 50 or 60%. As a consequence, one therapist noted

that clients were “deeply suffering.” The limitation on number of visits goes against the

chronic nature of schizophrenia, bipolar disorder, borderline personality disorder, and

major depression with psychotic features. While patients need intensive care at the

beginning of treatment, once stabilized, they could be seen monthly.

Let’s say that we could put together, from the ground up, a mental health

program for an area like this. The program would be designed to serve all persons

in need of services. What would be the ideal program for you?

Not surprisingly, there were plenty of responses to this question. The providers

offered 31 suggestions on various aspects of an ideal system. Eliminating redundancy,

they were:

• funding for expansion of services and for • centralized computers with links

increased staff and staff salaries to the Internet

• a nicer facility • less paperwork, standardized

• day care for both clients and staff

forms

• improved communications

• a housing assistance program

• employment services

• detoxification services

system

• increased client accessibility

• family-based system

• more wilderness or experiential

• a training center

• inpatient facilities for children

programs

• sex education for clients

• a system to assist teenagers and

adolescents become used to the

“real world” through part-time

• safe home for teenagers

• group homes

jobs, job skills training

• preventive services

• skills-based education

(parenting, goal setting,

anger management,

job preparation.

• better transportation

problem solving)

• a focus on substance abuse

prevention

SERVICES TO CHILDREN: PARENT AND PROVIDER VIEWS

95

Parents. The participants in the group were a mixture of one-and two-parent house¬

holds, both Anglo and Hispanic. Their children had a number of serious mental disorders.

What is the first thing that conies to mind when I mention mental health ser¬

vices for children and adolescents in frontier areas?

Here, the participants volunteered a variety of answers, stressing problems of money,

geography, and access to and quality of services:

• having to drive so far

• trouble with agencies

• suicidal children

• agencies are hard to deal with

• anger at the lack of agency responsiveness. One parent asked plaintively: “Why

wasn’t there help?”

• a lack of money to pay for services

• a too-easy willingness of providers to hospitalize their children without

finding out the nature of the problem

• confidentiality was a major concern. Too many persons with no need to know

were privy to the problems of the children.

• labeling. Related to confidentiality, parents expressed concern that their other

children, as well as they, would be stigmatized and isolated, making the situation

worse.

• lack of understanding by the community

• a need for family advocacy

• lack of communication between clinicians and parents. It was often seen as

difficult for parents to understand what was wrong with their child. Information

came out in bits and pieces, but they [parents] were required to act, even with

incomplete knowledge.

• an over-reliance on pharmacology, often given at inappropriate doses and a lack

of supportive services to help the children understand the nature of their problems

• the need for individualized treatment

• long distances to hospitalization that were financially draining

• a generalized and diffuse view that no help was available

• the need for more staff to serve outlying areas

If a young person has an emotional problem around here, how does one go

about getting help? Who do you turn to?

The parents listed the following options:

• Make a lot of long-distance calls.

• Mental health center

96

SHEILA COOPER, MORTON O. WAGENFELD

• Pediatrician

• Primary care physician (This was qualified by the feeling that the physicians

were not familiar with the full range of psychotropic medications.)

• Clergy

Although not a direct response to the question, they continued to voice anger to¬

ward the system: for example, “I can’t get help,” “Nobody cares,” “They just say it, but

it’s not there.” Long waiting lists were also cited.

How helpful are all these mental health services? Are people satisfied? Which 1

would you rate most helpful? The least?

For some of the participants, response to the question on satisfaction was short and |

emphatic: “Zero.” Others— mainly residing in or near Central City— expressed more •

satisfaction. It is interesting that the most vocally negative were from one of the more

remote counties. The residents of this county were also those the staff saw as least

accepting of services.

Participants cited two services as most helpful: counseling and medication. They j

further noted that more dependable and reliable choices were needed in counseling.

Counseling services needed to be “sensitive” and “good.” Additional concerns were: I

lack of transportation and insurance coverage. fi

is

How well do agency staff understand the particular emotional problems of d

young people around here? i

Although we did not ask this question specifically, the answers to some of the other te

questions displayed a pervasive feeling of dissatisfaction. Again, those living in the to

more remote areas were more vocal about staff’s lack of understanding. A particular \[

target of ire were psychiatrists. They were viewed as thinking that they knew the prob- to

lems of the child better than the parents. Additionally, parents felt that they had to |

implement treatment plans that they did not fully understand and that the doctors would i %

unilaterally change medications or put the child on a vacation from the medications. ;;

Let’s say that we could put together, from the ground up, a mental health

program for an area like this. The program would be designed to serve all persons

in need of services. What would be the ideal program for you?

fft

We were surprised at the flurry of responses to this question. They very eloquently fa

listed over 16 suggestions: - a

• affordable • reasonable distance to affordable jj$

services ' ie<

• more trained and educated people -

dependable

SERVICES TO CHILDREN: PARENT AND PROVIDER VIEWS

97

• reliable

• 800-number

• people who care, listen, and try to help,

not thinking that they know more than

you do

• affordable medications

• knowledgeable people

• transportation

preventive services

public education about mental illness

to avoid stigmatization

extended peer and parent support

groups to enhance coping skills

an outdoor weekend for parents and

children

educational material about day-to-

day coping with the problems of

living with a child with a

mental disorder.

public policy to encourage more

mental health professionals to work

in frontier areas (This was starred

on the chart!)

Implications for Behavioral Health Services. It is appropriate to end this paper

by noting points of the implication of the focus groups for the provision of services in

frontier areas While the parents and providers expressed problems in different terms, it

is also clear that both were in agreement on a substantial number of points. They in¬

clude geographic barriers, deficiencies in services, pressing need for services, long

waiting lists, need for more staff, and advanced training for staff.

The areas in which parents and providers disagreed were what one might broadly

' term “communication.” The literature on client/provider differences as an impediment

to the effective delivery of mental health services is voluminous (e.g., Frank and Frank,

' 1991; Snowden, 1982; Wagenfeld and Wagenfeld, 1981). Differences in the tendency

to define a problem in mental health terms, in willingness to seek help, and in expecta-

i tions of outcome have been shown to be influenced by socioeconomic status, gender,

l race, and ethnicity. In their classic work, Frank and Frank (1991) said that a shared

; assumptive world was necessary for therapeutic success.

In response to the question of how well agency staff understand the emotional prob-

i lems of young people, providers commented on the difficulty of being accepted by

5 clients, along with an assertion that the clients wanted help in a selective way. While

acknowledging the need for more bilingual therapists, they did not feel that cultural

| competency was a problem. The parents, on the other hand, expressed strong negative

{\ feelings towards the providers. They said they wanted knowledgeable people who

care, listen, and try to help, without thinking that they know more than you do. This

discrepancy in viewpoints may be the result of the lack of a shared assumptive world as

| described by Frank and Frank. Much work remains to be done to reduce this barrier to

access.

98

SHEILA COOPER, MORTON O. WAGENFELD

References

Frank, J. D., and Frank, J. B (1991). Persuasion and healing (3rd ed.). Baltimore: Johns Hopkins University

Press.

Snowden, L.R. (Ed.) (1982). Reaching the Underserved . Beverly Hills: Sage Publishers.

Wagenfeld , M .O . , and Wagenfeld , J .K . ( 1 98 1 ) . Values , culture , and the delivery of mental health services in rural

areas. In M.O. Wagenfeld (Ed.), Perspectives on rural mental health. ( New Directions for Mental Health Ser¬

vices Series, No. 9). San Francisco, CA: Jossey-Bass.

Notes

Prepared under contract for the Frontier Mental Health Services Resource Network. This Letter owes much to

the generous assistance of a number of parents and practitioners. A pledge of anonymity, however, precludes

our identifying them. We are, nonetheless, grateful to them

Journal of the Washington Academy of Sciences,

Volume 86, Number 3, 99-106, December 2000

Problems Faced By Consumers Of

Mental Health Services Out In A

Frontier Community

Courtenay M. Harding, Ph.D., Mary Van Pelt, BA, MHW and

Janies A. Ciarlo, Ph.D.

Abstract

While there is considerable information about how consumers of mental health services in

rural areas cope with stigma, feelings of isolation, lack of relevant services, and the trauma

of having a mental illness, little is known about such issues for consumers who live in

frontier areas. Also little is known for frontier consumers about the role of work, the impor¬

tance of hope, self-control of psychotic mechanisms, and emerging recovery paradigms.

Bases on a focus group of nine consumers, two of which were case managers in a frontier

areas of a western state, information about these problems in frontier areas are explicated.

In addition, problems related to distances, lack of transportation, lack of caregiver choice,

overlapping roles in the community, lack of any anonymity, lack of peer consumer groups,

and scarcity of work opportunities in frontier areas are explored.

Introduction

Most people think that the frontier is somewhere up in Alaska. In reality, however, 1%

of the US population lives in 45% of the total US landmass (Popper, 1986). In our western

frontier areas with less than 7 people per square mile (Ciarlo, Wackwitz, Wagenfeld, Mohatt

and Zelamey, 1996), . . healthcare, education, religion, politics, law and order, transporta¬

tion, communication, sense of community, sense of self, even the act of finding a mate—

virtually every human institution and activity demonstrates the impact of a few people and

long miles.” (Duncan, 1993). To compound all of these problems with serious and persis¬

tent mental illness is nearly unthinkable. Yet frontier is home to only a slightly smaller

proportion of residents having a wide variety of mental health problems and service needs

than are urban areas; and even worse, it is approximately equal to urban areas in proportion

of population with the more severe, dysfunction-linked disorders (Ciarlo, 1999). Add pov¬

erty, chronic provider shortages, a disproportional number of uninsured, and huge distances

and it is a sheer wonder that anyone finds treatment in the frontier (Beeson and Mohatt,

1993; GAO, 1993; Geller, 1998).

Both the formal and fugitive literature now abounds with articles by consumers of

mental health services about coping with stigma, feelings of isolation, lack of relevant ser¬

vices, and the trauma of having a serious mental illness. Also to be considered are the

100 COURTENAY M. HARDING, MARY VAN PELT, JAMES A. CIARLO

emerging recovery paradigm, the role of work, the importance of hope, and self-control of

psychotic mechanisms (e.g., Deegan, 1994; Leete, 1988; Lovejoy, 1982; Unzicker, 1989).

However, there is little known literature from frontier consumers on such issues or even

about how to receive services there. In addition, more needs to be known about living with

the compounding problems of frontier life (distances , lack of transportation, lack of caregiver j

choice, overlapping roles in the community, lack of any anonymity, lack of peer consumer

groups, and scarcity of work opportunities).

Profile of the Service Area

To talk about these problems and gather more information, a focus group was held with (

seven clients and two case managers (both of whom were also consumers) in a frontier area

of a Western state. The case managers used two vans and drove a total of 346 miles round .

trip to bring these consumers to a centralized town. The town had a population of 800 and ^

was located in a county of 3,190 people. This was a farming and ranching county with a f

large mountain range nearby and only 2.6 people per square mile. Hispanics numbered j

79% and had a long, illustrious history of Spanish occupation prior to US statehood. The

nearest mental health center and small general hospital with a psychiatric bed was 42 miles g

away from the community in which the focus group was held, and the closest state hospital ‘

was 120 miles. The mental health center had served the area since 1972 and had entered

into a partnership 3 years ago with one of the nation’s largest managed care organizations.

The town, where the meeting was held, had a small medical clinic, three restaurants, and a

small historical museum. Main Street was five blocks long. The meeting was conducted in

a building that used to be a small convent adjacent to the church, but was now converted to

a small, pleasant, church-run bed and breakfast inn (B & B). ,

Description of the Focus Group

The consumers all had serious and persistent mental illnesses such as bipolar disorder,

schizophrenia, and major depressions. Some participants also suffered from combinations

of substance abuse, other medical diagnoses, and personality disorders. Altogether, there

were 2 males and 9 females contributing to the discussion with an average age of 40 years.

The session was held in the living room of the B & B . It was such an amiable atmo¬

sphere that the participants wished out loud that they could meet at the B & B for their

weekly group meetings as well. (The group did reserve the room for their weekly meetings

for the next several months.) With the participant’s permission, the entire afternoon was

audio- taped. Questions had been prepared in advance of the meeting and a flip chart was

available, but little used. The focus group facilitators were clinicians familiar and comfort¬

able with persons suffering from serious and persistent mental illness. A spontaneous con¬

nection with early arrivals was made out on the porch before the meeting started while the

focus group facilitators were eating lunch. Some participants were dropped off earlier thar

others due to the transportation challenges. The facilitators offered part of their lunches

PROBLEMS FACED BY CONSUMERS

101

purchased at the local market minutes before. This simple act led to many conversations

and a relaxation of all parties before the start of the “official” meeting. It soon became clear

that focus group members knew one another and had participated in weekly groups, to¬

gether, on a regular basis. This fortuitous circumstance permitted the group to get down to

the business of the meeting more rapidly and to speak more freely. They had much to

contribute on each question and demonstrated impressive and considerable humor about

themselves, their predicaments, and their lives. They particularly enjoyed being paid con-

; sultants to the “big city folks.”

Questions and Discussion

The group was asked a specific set of questions approved in advance by the Center for

Mental Health Services/S AMHS A, which was the funding agent for this project of the

Frontier Mental Health Services Resource Network. However, the discussion was far-

ranging and interactive. Meeting participants sometimes jumped back to a previous topic in

their efforts to share more information and to make certain that their out-of-town visitors

really understood their situations. An overview of the project was given as well as the

ground rules for the process. Included in this presentation was a description of what was

1 meant by a “frontier area.”

1

1. Based upon your own experience or experience of others, what is it like for

1 you to live in such a frontier area?

i

The participants spoke about how pleasant the area was with beautiful scenery,

which was “serene”, and how warm the weather was compared to northern parts of the

state. “It’s real peaceful and you don’t have to worry about somebody breaking into

your house or at least not as much.”

r| However, the discussion went almost immediately to the huge distances which people

is had to travel to meet their needs and how much they had to depend on others for transporta-

re tion. “You make sure that, when you go to town, you get all your prescriptions for the

$ month because I go into town once a month.” Further, the distances caused feelings of

3- isolation and depression. If they had a telephone they used it a lot. However, “If you need

:ii help at 3 am, you gotta wait! It is not like you have a neighbor right outside your door like

^ in the city.” The mental health center did have a 24-hour emergency crisis clinician on call.

as

2. What is it like to live in the frontier with the addition of coping with your

illness?

ill'

Some respondents spoke poignantly about the fact that even though the distances

iao w^re large, everyone seemed to know everyone else and their business. “Everyone

es [knows that you have this problem.” Some remarked that it was harder to make friends.

102 COURTENAY M. HARDING, MARY VAN PELT, JAMES A. CIARLO

In fact, one person said “I think, for awhile, I tried to just totally withdraw from society and

people and to not interact with anybody, but that didn’t work for me. So now I am selective

in who I talk to and what I share with them. Most of my friendships or acquaintances are

people that are just kind of on the surface.” When asked if that was lonesome, the reply was

that it was “safe.” A second consumer spoke about her sheep dog who seems to make

bridges between her and others. Another person said “I wouldn’t live anywhere else be¬

cause I think it’s also helped me to sort through my problems in a way too, on my own

because the mental health people aren’t always there when you are isolated in a smaller

community. . .you just don’t have these people to rely on all the time.”

3. How does living in a frontier area affect your ability to get to and obtain

services for your problems?

Having a family or friends with a car was perceived as very helpful to get needed

services. However, the mental health center also provided case manager van drivers

who logged a phenomenal yearly mileage. Consumers seem to spend more time in the

van than in treatment. Sometimes people only got a ride one way and had to figure out

how to get back home. Some consumers said, “they have their route and if you live

outside their route. . .that can really be a problem.” (It should be noted that this person

lived 17 miles outside the route.) The staff members said that coordinating their own

staff meetings with those for consumer groups posed a very difficult strategic problem

with transportation.

4. What kinds of services are available to you?

When discussing their entry into services, some had been using them for so long

they had forgotten where the referral had been generated. Some said the state hospital,

some mentioned family members, while others used the telephone book for a self-refer¬

ral. Some complained that the phone books they had were old ones and the emergency

number they dialed got them, ironically, Community Corrections. This service had

provided emergency call answering services until 3 years ago.

Some participants spoke about the small frontier staff of the mental health center

and the large job they had. Indeed, some meetings at other sites had to be discontinued,

as well as outings to do fun things. Other groups focused on activities of daily living

(balancing a checkbook, cooking, etc). There was some discussion about being spoon¬

fed and that consumers might take more responsibility, themselves, and with helping

one another. Other participants spoke about many other people, whom they knew and

who could use services, but were not connected to any care.

To counter these comments, another participant said that she thought that small was

beautiful. . . “because everybody knows everybody and you get to be kind of friends and

you miss somebody when they’re not there. . .and. . .you try to keep track of those. . .or

PROBLEMS FACED BY CONSUMERS

103

they call each other at home even.” Others spoke about the stability of the group “so

that you don’t have to explain yourself all over again” Yet others related that this

stability could have negative side effects, such as unfavorable feedback to ideas which

would then not be broached again. Yet everyone agreed that someone who listens well

was the best treatment. . . “just being there to listen and be.”

5. What kinds of services are not available which you would recommend as

important to frontier residents?

A consumer wanted a computer to be connected to the Internet but also needed

lessons on how to use it. Others said they got free ones from the local school or a raffle

but no one knew how to use them.

Staff turnover was cited as a substantial problem but the focus group facilitators

noted that this is also a problem for urban staff. A lady said, “I find it really hard for me

to have to keep dealing with somebody different.” Another consumer said, “I was tired

of saying the same story over and over so I don’t say it no more.” One of the focus

group facilitators suggested that a videotape be made so that a new clinician could see

it and then the consumer would not have to retell his or her story over and over. The

group liked the idea but they were certain that the new case manager would still not

take the time or have the time to see it. On the other hand, those workers who stay can

also be a problem because “even if the personalities clash... you’re going to have to

stick with the same person... and you hope that that’s the one that’s going to move on!

(animated with group laughter).” The group talked about the multiple roles people play

in small communities. Clinicians are also neighbors, relatives, shoppers in the grocery

store, and churchgoers. One described the difficulty with her brother who is employed

in the same agency where she was being treated. “It’s changed our relationship.” Her

case manager said that this same brother was her own supervisor on the same case, an

awkward situation that made her uncomfortable.

When asked what would keep counselors around, the group thought that more pay,

hiring indigenous workers with families in the area, time to read the records so patients

would not have to repeat their histories, more staff, and being native to the culture of the

place would be advantageous. The focus group members also liked having bi-lingual

clinicians.

When asked if there were other organizations (e.g., church, grocery stores. Rotary

Club, etc.) which might be helpful, one answer was the history museum. They said it

gave them roots and linkages to the community. Further, the town had a shrine built at

the top of a nearby bluff. Many participants said that it symbolized their faith or spiri¬

tuality, which could be supportive to them. Alcoholics Anonymous and Narcotics Anony¬

mous meetings were also available but at considerable distance. The local 4H organiza¬

tion was also mentioned as a truly rural group. There were senior citizen groups used

by other consumers and the library was also mentioned as a resource.

104 COURTENAY M. HARDING, MARY VAN PELT, JAMES A. CIARLO

A discussion ensued about substance use and abuse out in the frontier. Cocaine,

inhalants, acid, marijuana, crack cocaine, and methamphetamine were all listed. “You’d

be surprised how big it is!” When asked how easy it was to find a dealer, laughter

erupted in the group and we were told of a dealer who even printed his own business

cards! Another consumer chimed in: “My therapist showed up at one of my AA meet¬

ings so I quit the meetings.”

When asked about the interface with the sheriff’s department, the response was: “It

took them 6 _ hours to respond.” 91 1 was not even available in this frontier. One of the

consumers spoke about a serious attempt at overdosing on antipsychotics, but when she

called, the counselor said: “Make yourself throw-up and I’ll call back in an hour.” One

participant noted that to get oneself into the hospital you “act real crazy and the cops

come and get you.” This behavior, however, is not unique to the frontier. There also

appeared to be a problem between the police and emergency workers from the mental

health center because of a lack of collaboration.

Residential services/options seemed to be very sparse with a very long waiting list.

Homeless services existed only in the town where the community mental health center

was located.

Vocational rehabilitation, work training, supported work, transitional work programs,

and individual placement services, appear to be nonexistent.

There was much confusion about all the rules and complexities around SSI, SSDI,

Medicaid, and Medicare. Most consumers living on entitlements felt they had to figure

out how to obtain the entitlements by themselves. A few were helped to obtain SSI

or SSDI by the state hospital or the community mental health center physician,

who evaluated them for only 15 minutes. Some of the consumers were surprised at

being told they might be eligible for entitlements, because they were working and

living independently.

6. What “types” of caregivers do you think could best provide services in the

frontier?

The answers were: “indigenous people, religious people, a nonjudgmental person,

an experienced person, a helping person, a listening person, someone who can stop

being serious and have some fun.”

7. How can services be improved?

When asked what would be helpful in the frontier, the responses were: “home vis¬

its, someone willing to travel miles and miles, willing to work with families, someone

I have something in common with, someone who understands the social and economic

problems here.”

PROBLEMS FACED BY CONSUMERS

105

8. Are there any consumer-led or sponsored services in this county?

They did not know of any consumer-led services, other than the two van drivers

who also provided support and education to the consumers.

Other Comments and Discussion

In looking over the transcript, we found that this group of consumers did not know

about a wide variety of work options/programs. For instance, many participants did not

know how to get entitlements, how to set up consumer- run enterprises, how to be em¬

powered to ask for programs they needed, how to get their clinicians to pay attention to

milder but annoying side effects of medication, or how to be more assertive and ask for

a different clinician if there was not a match.

Despite the perceived natural beauty of their surroundings, these people were con¬

sumers with serious and persistent mental illnesses who also suffered from poverty and

extreme isolation. They relied upon whatever services a distant community mental

health center could manage and “the kindness of strangers.” Their treatment was mini¬

mal compared to standard maintenance and stabilization models found across the US

and did not come close to rehabilitation or Program for Assertive Community Treat¬

ment (PACT) models being offered in other parts of the country in service “pockets of

excellence.” The community mental health center only provided one weekly support

group, medication reviews as needed, and two consumer/case managers in an agency

van to provide transportation. Their personal resilience and persistence, in the face of

life on the frontier with all of its challenges, were truly remarkable.

Implications for Behavioral Health Services

It is difficult to live in the frontier. It is even more difficult to live in the frontier

with a severe mental illness. It is more difficult yet to have mental illness and medical

co-morbidity or co-occurring disorders and live in a frontier area. Transportation is the

number one problem to overcome. The distances to centers and hospitals, pharmacies

and the basic necessities are large barriers to service and life.

The sheer distance, scarcity of resources, few services, and a staff spread too thin

and often unavailable when needed makes it a wonder that treatment occurs at all.

Minimal supports are provided to the few people connected to the system but many

people still fall through the cracks. Acquisition of entitlements is still a hit or miss

affair. Consumers make linkages to any existing organization such as the library, post

office, history museum, market, church, 4H, and senior citizen’s group for support and

feelings of belonging to a community.

106 COURTENAY M. HARDING, MARY VAN PELT, JAMES A. CIARLO

The few staff working out there are devoted but overworked, often transient, and

sometimes not culturally competent. They have found it as difficult as their clients to

have multiple roles to play in the community in which they live. The treatment options

are very limited (case management and a weekly group or two, and many long trips to

and from the distant center for medication evaluations of their clients). Other options,

such as crisis and nearby inpatient care, vocational and other rehabilitation strategies,

are non-existent.

Persons with mental illness living in the frontier have a small voice but very large

needs. They include speedier crisis response, psychosocial and vocational rehabilita¬

tion, a range of housing and employment options, access to medical and dental care,

eye glasses, hearing tests, cognitive retraining and therapy, and timely lab work and

side effects evaluations. Finally, they need someone with whom to share their deepest

fears and hopes in order to reclaim their lives.

References

Beeson, P. and Mohatt, D. (1993). Rural mental health and national healthcare reform. Paper presented at the

National Association of State Mental Health Program Directors, Arlington, VA.

Ciarlo J.A. (1999). Assessing need for mental health services in frontier America (Letter to the Field No. 22).

Denver, CO: Frontier Mental Health Services Resource Network, University of Denver.

Ciarlo, J.A., Wackwitz, J.H., Wagenfeld, M.O., Mohatt, D.F. and Zelamey, P.T. (1996). Focusing on “frontier”:

Isolated rural America (Letter to the Field No. 2). Denver, CO: Frontier Mental Health Services Resource

Network, University of Denver.

Deegan, PE. (1988). Recovery: The lived experience of rehabilitation. Psychosocial Rehabilitation Journal,

1 1(4): 11-19. Reprinted with revisions in W.A. Anthony and L. Spaniol (Eds.) (1994). Readings in Psychiatric

Rehabilitation. Boston, MA: Boston University Center for Psychaitric Rehabilitation, pp. 149-162.

GAO. (1993, April). Rural Development: Profile of Rural Areas (Fact Sheet for Congressional Requesters).

Washington, DC: United States General Accounting Office.

Geller, J.M. (1998). The role of rural primary care providers in the provision of mental health services: Voices

from the plains (Letter to the Field No. 10). Denver, CO: Frontier Mental Health Services Resource Network,

University of Denver.

Leete, E. (1989). How I manage and perceive my illness. Schizophrenia Bulletin, 15(2): 197-200.

Lovejoy, M. (1982). Expectations and the recovery process. Schizophrenia Bulletin, 9 (4):604-609.

Popper, F. (1986). The strange case of the American frontier. Yale Review, Autumn: 101- 121.

Unzicker, R. (1989) On my own: A personal journey through madness and re-emergence. Psychosocial Reha¬

bilitation Journal, 13(l):71-77.

Journal of the Washington Academy of Sciences,

Volume 86, Number 3, 107-1 15, December 2000

Aging, Mental Illness, and the Frontier

James W. Stockdill, M.A. and James A. Ciarlo, Ph.D.

Abstract

This paper reports on the findings from an eight-person study group meeting held in 1998 in

a frontier rural community to discuss the mental health needs of older adults. The group

consisted of five older (over 64) adult mental health service consumers and three family

members of the older adult consumers. The study group members indicated that older per¬

sons have difficulty receiving appropriate and responsive health and mental health services

because of stigma, vast distances, lack of transportation, limited finances, lack of commu¬

nity education about geriatric mental illness and delayed diagnosis and treatment. Delayed

diagnosis and treatment the elderly can mean that subsequent disability is more severe,

requiring more expensive and restrictive long-term care, often in combination with chronic

health problems.

Introduction

The Frontier Mental Health Services Resource Network (FMHSRN), under a con-

i tract with the Center for Mental Health Services (CMHS) of the Substance Abuse and

Mental Health Services Administration (SAMHSA), was created to gather, analyze and

disseminate information about mental health needs and services in “frontier” areas.

These isolated rural areas, defined for purposes of this contract as having fewer than 7

persons per square mile, are almost all located in the western states and Alaska. Eleven

western states have substantial areas considered to be “frontier” (Ciarlo, Wackwitz,

Wagenfeld, Mohatt and Zelamey, 1996). This paper reports on the findings from a

study group meeting held in a frontier rural area to discuss the mental health service

needs of the older adult population.

A National Association of State Mental Health Program Directors Task Force on

Mental Health and Aging recently declared that “the elderly remain the most underserved

and inappropriately served population in mental health services” (Wilson, Kazieczko

| and Kast, 1997). This problem is exacerbated in rural and frontier areas, where vast

distances, mountainous terrain, poverty, and inadequate human resources serve as se¬

vere barriers to access for rural and frontier residents.

Several major concerns must be considered in examining the quality of care for

older persons with serious mental illness living in frontier rural areas: 1) older adults

have difficulty in accessing health and mental health services because of stigma, vast

distances, lack of transportation, limited finances, and a lack of community education

about geriatric mental illness; 2) delayed diagnosis and treatment means subsequent

108

JAMES W. STOCKDILL, JAMES A. CIARLO

disability is more severe, requiring more expensive and restrictive long-term care; 3)01der

persons frequently have serious mental illness in combination with chronic health prob¬

lems; and 4) support and coping skills needed to deal with life stresses caused by social, , f

economic, and housing conditions are critical. To confirm and further examine these 1

concerns, the FMHSRN invited older adult mental health consumers and family mem¬

bers, from two contiguous western-state counties, to participate in a study group to ■

discuss mental health problems, service availability, and service access issues.

i f

Profile of the Service Area

The two counties selected are served by the same mental health center, located in ^

the larger of the two counties. The larger county had an estimated population of 12,000

in 1995 with 10% of its population over 65 years of age. This older age group is il

increasing. Its largest minority groups were Hispanic at 5% of the county population

and Native Americans at 0.9 % in 1990. This larger county is a frontier-like rural

county with a population density of 8.9 persons per square mile. Approximately 12% i

of the population are estimated to be below the poverty line. The smaller, neighboring l

county had an estimated population of 2,600 in 1995 with 19% of the population esti¬

mated to be over 65 years of age. The smaller county has a smaller minority popula¬

tion, with 3% Native Americans and 1 .4% Hispanics in 1990. The smaller county is a

“frontier” county with a population density of 0.9 people per square mile. Approxi¬

mately 17% of its population are estimated to be below the poverty line (U.S. Census, 1

1990). The two counties have a combined population density of approximately 3.7

persons per square mile.

The mental health center operates two satellite locations, one in the contiguous

county and one in the larger county. The larger county has two senior centers; the

smaller county has one. The directors of the senior centers in both counties, and the a

director of the mental health center, which serves both counties, put a high priority on a

improving the mental health care of older adults. The two counties need to work to¬

gether on mental health and health services in order to maximize their resources as they

have a small population in a huge area.

>

'

Description of the Study Group

The eight-person study group consisted of five older adult mental health service

consumers and three family members of older adults with mental health problems. One

of the consumers also had a seriously mentally ill family member whom she sometimes

cares for. At least four of the consumers also had serious medical problems or physical

disability problems. One of the consumers was dually diagnosed with alcoholism and

mental illness. All of the consumers were women, while two of the three family mem¬

bers were men.

AGING, MENTAL ILLNESS, AND THE FRONTIER

109

:r ! The group met at a senior center on a weekday afternoon in the fall of 1998. The

1 session lasted for close to three hours and was audio taped. Questions had been pre-

1, pared in advance, and the major group responses were summarized on a flip chart,

e However, the group bonded very well and some of the most interesting points made

i- were generated by the group interaction and were not necessarily in response to any one

o question. The group seemed to enjoy the interaction and some clearly felt that the

opportunity to share experiences with their peers and these two FMHSRN strangers

from out of town was therapeutic in itself.

.n

i0

is

in

al

l

«

i-

a-

a

s,

.7

JS

le

)n

o-

*

ce

net

es

:al

m

n

Questions and Discussion

The sequence of questions posed by the group facilitator will be used to highlight

the major findings:

1. Based on your own experience or the experience of others, what are the

main things you think we should know about what it is like for an older person

living in an isolated or frontier area here in this state?

Surprisingly, at least to the facilitator, the major response to this question dealt with

the weather. Immediate reference was made to the winter “gloom” in this state. The

“cloudy gray days affect elder moods.” The weather was also mentioned in terms of the

long distances that sometimes have to be traveled on slippery winter roads in order to

obtain services and/or meet basic needs such as buying groceries. However, the major

emphasis was placed on the feeling of being shut-in in the wintertime.

2. In your opinion, how does living in a frontier or rural area in this state

affect your ability to get to and obtain services for a mental health or substance

abuse problem?

Again, in response to this more specific question, they cited the long distances that

sometime must be traveled to get services and the winter weather that affects the driv¬

ing conditions. However, the major issue presented was the shortage of mental health

specialists. One participant noted: “we have physicians, not mental health specialists.”

No psychiatrists are actually located in the service area. The point was made, and

reemphasized several times, that the general practitioners in their area are not well

trained to provide mental health services and, in addition, there are no geriatric medical

specialists. It was brought out that, as a result, many older persons are not adequately

or accurately diagnosed, and because of the lack of qualified providers, older adult

consumers get medications only (maintenance approach), with little counseling, psy¬

chotherapy, or other interpersonal mental health care. One of the participants indicated

110

JAMES W. STOCKDILL, JAMES A. CIARLO

that older adults get “over-treated for medical problems and under-treated for mental

health problems.” However, it was pointed out that there were some “good counselors

available through the mental health center that had been helpful to some of the partici¬

pants of the study group. The professional level of training of these counselors was not

known. It was indicated by another participant that “you must go a long way for real

therapy” — that is to the nearest large town, from 45 to over 100 miles away, depending

on your location in the service area.

Two examples illustrated the effect a combination of a lack of mental health spe¬

cialists and the long distances to larger communities where they might be available can

have. One family traveled over 250 miles (one way), to another state, to get specialized

mental health treatment for their older adult family member. In another case, when a

well-liked family care doctor moved to a larger town outside the county, his satisfied

consumers had to travel longer distances to continue to receive services from him.

3. What types of mental health services for elderly persons can be found in

your county?

Consensus was reached among the group that the following services were available

within the two-county area:

• Counseling services from the mental health center and satellites

• Prescriptions for psychiatric medications (generally provided by general practi¬

tioners) 1 1

• An Alcoholism Anonymous group in at least one of the satellites

• Primary health care

• Transportation - Senior centers provide buses in the towns where the centers are t

located and the State hospital provides buses for hospitalized patients to and from t

the state hospital, which is located over 300 miles away.

The study group developed the following list of services that are not available within

the two counties:

• Psychiatric inpatient beds

• Psychiatric emergency services

• Special outreach to the elderly (identification and engagement of older adults

with symptoms of mental illness)

• Day care for the elderly s

• Home-based services for mental health and substance abuse consumers i

• Individual psychotherapy and group therapy

• Respite care for family caretakers

AGING, MENTAL ILLNESS, AND THE FRONTIER

111

I The lack of inpatient beds and emergency services seemed to be of particular con¬

cern to both the mental health consumers and family members. The lack of quick

access to inpatient or emergency assistance usually meant an exacerbation of the ill-

t ness. Members of the study group indicated that the lack of emergency service on

1 weekends was particularly problematic because of the difficulty in getting transporta-

: tion to the nearest psychiatric emergency services (again, located in a town, 45 to 100

miles away).

i 4. Of the services that are not available in the service area, which would you

1 ! recommend as being the most important for elderly residents to have available?

1 The majority of the study group expressed their belief that local access to psychiat¬

ric inpatient beds and emergency services were of the highest priority. Also important

to the group were the availability of special home-based services for mental health and

l substance abuse consumers and respite care to assist family caretakers. There was also

an interest in learning more about Medicare coverage for specialized day treatment for

the elderly. Group members believed that most of these services were available in a

; town of with a population of about 50,000 in an adjacent county — but they were

neither accessible nor affordable.

5. What types of rural or frontier-area caregivers do you think can (or would)

provide the services that are most important to an older adult consumer?

The group seemed resigned to the reality that the numbers and types of mental

health specialists will not change any time soon. However, they did discuss the possi-

i bility that psychiatrist time might be provided by traveling psychiatrists from larger

communities on specified days (the “circuit rider” approach). Still, what they expressed

most strongly was a need for more education on mental health and substance abuse

n treatment for the primary care doctors and their support staff. One participant also

discussed the possibility of more extensive use of psychiatric nurse practitioners to

meet the needs of older adults. Trained, affordable, home mental health care workers

was also given as a priority.

|

6. How do most elderly persons pay for mental health and substance abuse

services in the two counties — does Medicare cover most needed services? Are

many persons eligible for Medicaid? Have these resources been available to you?

Medicare covered most mental health and substance abuse costs of the members of

our study group and they paid out of pocket for what Medicare did not cover. Their big

concern was that they did not always understand how Medicare worked. As one par-

112

JAMES W. STOCKDILL, JAMES A. CIARLO

ticipant put it— “If you know all of the little hoops and loops that you have to go through

you come out all right— if not, you can get stung for extra costs.” They expressed

concern that there was no coverage of psychiatric or general medical medications under

Medicare. Their highest priority was getting the Medicare and Medicaid bureaucratic

policies and regulations simplified and standardized to the point where they could un¬

derstand them, and medications that were at least partially and consistently reimbursed.

They were also concerned that Medicare supplemental insurance policies were not af¬

fordable, and that many of the elderly may someday have to spend or give away their

assets to be eligible for basic Medicaid coverage.

7. Are there any problems in accessing medical services that an elderly person

might need — do you receive general medical care, dental care, eye exams/glasses,

hearing aids that might be needed? How far do you have to go for these services?

There was general satisfaction with access to general medical care. In some cases,

where medical specialists were required, they had to travel outside the service area to a

larger community in an adjoining county (45 to 100 miles away). At least two of the

study group members also traveled outside the service area to see their general practi¬

tioners because of their preference for a particular individual. Two participants ex¬

pressed the feeling, however, that they had had general practitioners who were “embar¬

rassed” to have them in their office for medical treatment because the doctor knew that

they also had a mental health and/or substance abuse problem. One person traveled

outside the service area for general medical services because of this stigma issue.

8. How satisfied are you with whatever mental health and substance abuse

services you have received? And, in your opinion, how can services for older per¬

sons with mental illness be improved? What would you like to see changed?

The group indicated general satisfaction with the counseling services provided by

the mental health center. These counseling services were sometimes recommended by

their primary care doctors. They were also generally positive about their primary health

care services including dental care and optometry. They insightfully observed, how¬

ever, that there was a great need for mental health specialists and for education of pri¬

mary caregivers in order to “treat the whole person” (this point got particularly strong

emphasis in relation to older adults with substance abuse problems). They were very

positive about the services provided by the senior centers. There was general consensus

around one participant’s comment that “the Senior Center is the touch point for the

elderly.”

AGING, MENTAL ILLNESS, AND THE FRONTIER

113

The following changes or improvements were cited as priorities, along with filling

1 the gaps in services:

[

'

r

i

a

e

We need a central clearinghouse of services and providers. We need to know

what is available — where and when. (The assumption was that this would

include the service area and the surrounding area.)

We need educational activities about mental illness in older adults for consumers

themselves, their family members, the general community, and most of all for the

primary care givers.

In substance abuse services, the elderly are in groups with the young people. We

need a separate group for the elderly. (They recognized that this was not always

feasible because of the small number of clients in a frontier area.)

More use of “alternative medicine” could be helpful for older persons. There

was specific reference to natural foods and herbs.

We need more consumer group meetings (like this one) to talk about needs and

priorities. The primary care doctors need them as well.

9. Are there any consumer-operated or consumer-sponsored services in the

service area at the present time? Should they be encouraged?

it Interestingly, they could not think of any and did not seem to understand the

d concept.

Other Comments and Discussion

ie

r. In response to some specific sub-questions throughout the meeting it seemed clear

that the group had little or no knowledge of the following mental health related topics:

,y • They did not seem to know about the Alliance for the Mentally 111 (AMI) family

organization at the national, state or local level,

ll • They seemed to believe that protection and advocacy services were only avail-

v. able for the developmental^ disabled population and the physically disabled.

!;• They did not seem to have much understanding of psychiatric rehabilitation

| concepts or programs.

,-v • Only one member of the group (a family member) seemed to have any knowl-

us edge of telecommunications and the potential it might have for mental health

he ; education and treatment activities.

There were miscellaneous important thoughts expressed throughout the meeting

that seemed to define the human condition:

114

JAMES W. STOCKDILL, JAMES A. CIARLO

• The spiritual side of life is very important for recovering from or living with i

mental illness — “you must have God in your life.” t

• Suicide feelings are a reality — “My attitude is dark sometimes.” f

• Perhaps feeling problems of isolation from family, the group resonated to one

person’s observation that “The Japanese still keep their old people at home — t

when did we get away from that in this country?” i [

• Younger adults have children to take care of — “so they must be seen as a higher r

priority for services than us older adults.” 1 1

Despite the tenor of these comments, the group appeared to bond very well to each r

other, and individual members used humor throughout. Laughter was quite prevalent, n

suggesting that their sense of humor also helps them survive and cope with their prob¬

lems on a daily basis. n

: II

Implications for Behavioral Health Services

It was clear that the highest immediate priority of this study group of older adult

consumers and family members from a frontier area was improved communication and

education about geriatric mental illness. This improved communication is needed be¬

tween consumers, family members, mental health center staff, primary health care pro- Cl

viders, senior center staff and advocates for the elderly. Education about geriatric

mental illness must be directed at the general community and the groups listed above,

with an emphasis on primary health care providers. Technical assistance and education Hi

about the financing of mental health services for the elderly is also a high priority.

It is interesting to note that the high priority for improving the mental health educa¬

tion of primary health care providers is consistent with the findings of a previous %

FMHSRN study group that dealt with primary care providers and mental health ser¬

vices. Geller (1998) reported that “the literature suggests and the focus group con¬

firms, these providers (primary caregivers) do the best they can, they often feel uncer¬

tain and less than fully prepared to serve the mental health needs of their patients.”

Indeed, one of the physician participants from this earlier study group is reported as

saying, ‘And I think that, just speaking freely, I don’t think I’m adequately trained to do I

a lot of what Ido’. And, more to the subject of this paper, another primary care provider

is quoted: ‘I have a pretty clear idea of how far I can go with a depressed patient. . . .but

the place I really get stuck all the time is with geriatrics.” It seems clear from this

earlier report that the primary caregivers in rural and frontier areas themselves feel the

need for mental health treatment education and technical assistance.

AGING, MENTAL ILLNESS, AND THE FRONTIER

115

There are indications that the federally funded Geriatric Education Centers Pro¬

gram is a promising resource for providing mental health education and training activi¬

ties to primary care providers, consumers, family members, and other stakeholders in

frontier areas. In an earlier Frontier Network knowledge-synthesis paper, Wagenfeld

(1998) reported on a collaborative geriatric education center in Iowa. He indicated

that, “the Iowa Geriatric Education Center (IGEC) provides training and education pro¬

grams for primary care physicians, public health nurses, social service workers, and

related caregivers in service delivery models for the elderly.” A similar model should

be developed for frontier areas. Perhaps the increased utilization of telemental health

technology, in combination with the geriatric education center model, will be the an¬

swer to improving the quality of mental health services for older adults living in remote

rural and frontier areas.

Advocacy for the growing percentage of older adults in rural areas is very much

needed. It is hoped that increased communication among stakeholders, and the imple¬

mentation of new educational activities concerning mental illness and substance abuse,

will facilitate the availability and/or accessibility of inpatient services, emergency ser¬

vices, and home-based care for older adults in frontier areas.

References

Ciarlo, J.A., Wackwitz, J.H., Wagenfeld, M.O. and Mohatt, D.F. (1996). Focusing on “frontier”: isolated rural

America (Letter to the Field No 2). Denver, CO: Frontier Mental Health Services Resource Network.

Geller, J.M. (1998). The role of rural primary care providers in the provision of mental health services: Voices

from the Plains (Letter to the Field No. 10). Denver, CO: Frontier Mental Health Services Resource Network.

US Bureau of the Census. (1997, December). Estimates of the population of counties by age, sex, and race/

! Hispanic origin: 1990-1996. Washington, DC: Author.

Wagenfeld, M.O. (1998). Mental health services in frontier areas: Models of service delivery and special

populations (Knowledge Synthesis Paper). Denver, CO: Frontier Mental Health Services Network.

Wilson, R., Kazieczko, I. and Kast, B. (1997, December) Memorandum re Task Force recommendations and

work plan (Task Force, Older Persons Division). Alexandria, VA: National Association of State Mental

Health Program Directors.

'

Journal of the Washington Academy of Sciences,

Volume 86, Number 3, 1 17-129, December 2000

Frontier Mental Health Strategies:

Integrating, Reaching Out,

Building Up, and Connecting

Jack M. Geller, Ph.D., Peter Beeson, Ph.D., and Roy Rodenhiser, Ed.D.

Abstract

To achieve equity in the local availability of mental health services rural and frontier re¬

gions, emphasis has often been placed upon the development of mental health programs

and services and the recruitment of mental health professional to these areas. Given the low

population base and corresponding weak economic base coupled with vast distances and

isolation, it is unlikely that specialized mental health services will seldom be locally avail¬

able to frontier areas. There are, however, strategies that can be used to improve the access

and availability of mental health services. This paper discusses a number of these strategies.

Specifically, these include integration of medical and mental health resources (integration),

sending mental health professional from external treatment resources out to provide local

services to residents of frontier areas (reaching out), using the external treatment resources

to build up local service capacity (building up) and connecting frontier areas to external

treatment resources via telecommunication and other vehicles (connecting).

! Introduction

While a great deal of attention has been focused on rural mental health over the

years, virtually none of that attention has dealt specifically with “frontier mental health.”

By “frontier mental health” we mean meeting the mental health needs of persons living

in areas with less than 6 (sometimes 7) persons per square mile. Understanding and

responding to the problems of availability and accessibility of mental health services in

frontier areas requires a different perspective from the traditional “developmental model.”

The services and human resource literature in rural mental health as well as the policy

and programmatic initiatives of state and federal government have had “development”

as their primary focus (e.g., Wagenfeld, Murray, Mohatt and DeBruyn, 1994). In other

words, to achieve equity (or perhaps fairness) in the availability of mental health ser¬

vices in rural regions, emphasis has been placed upon the development of mental health

programs and services, and the recruitment of mental health professionals to those ar¬

eas. The appropriateness of such a position, i.e., trying to make rural areas look more

like urban areas, is questionable at best when addressing the mental health needs of

persons living in these remote and isolated frontier areas.

118

JACK M. GELLER, PETER BEESON, ROY RODENHISER

For the vast majority of frontier areas, the development of specialized mental health

services within the area is not economically feasible for either the private or public

sector. A low population base and corresponding weak economic base coupled with

vast distances and isolation mean that specialized mental health services will seldom be

locally available to frontier areas. For most persons living in frontier areas, specialized

mental health treatment is (and most likely will continue to be) available from mental

health professionals and programs that have their permanent central location some place

outside of (and often not readily accessible to) frontier areas. This means that residents

of frontier areas must either find services outside their community of residence or not

utilize needed mental health services.

There are however, strategies that can be used to improve the access and availabil¬

ity of mental health services to residents of frontier areas. Based on an examination of

the existing literature and observations, we have identified four global strategies for

making treatment resources more accessible and available to persons in frontier areas

in need of mental health services:

Integrating integration of medical and mental health resources

Reaching Out sending mental health professionals from external treatment re¬

sources out to provide services to residents of frontier areas in their

own or nearby communities

Building Up using the external treatment resource to build up local capacity to

respond to local frontier community treatment needs

Connecting connecting frontier areas to external treatment resources via telecom¬

munications or other vehicles

In this paper , we explore each of these strategies, examining their sub- variations

and the recorded experience of each, including their advantages and disadvantages.

tl

Integrating

It has long been known that primary care physicians have been actively involved in :

the delivery of mental health services (Locke, Krantz and Krammer, 1966; Locke and i

Gardner, 1969; Rosen, Locke, Goldberg and Babigian, 1972; Lerner and Blackwell, ®

1975; Fink, 1977; Goldberg, Babigian, Locke and Rosen, 1978; National Rural Health ici

Association, 1992). Physicians that practice in rural and frontier areas tend to play an

even larger role in mental health care provision. This is due, in part, to the relative

scarcity of mental health and other health care professionals in these outlying areas of

FRONTIER MENTAL HEALTH STRATEGIES

119

the country. Consequently, it is not surprising that a strategy increasingly used to bring

mental health services to frontier areas is the integration of mental health and general

medical services in a unified clinic structure.

In a recent study of these integrated models in rural areas, Bird, Lambert and Hartley

(1995) interviewed over 50 primary care provider organizations across the nation that

successfully linked with mental health and substance abuse treatment services. Inter¬

estingly, over half of these integrated models were found in federally-funded commu¬

nity health centers (PL 330/329). The remainder were located in rural hospitals, health

departments, rural health maintenance organizations (HMOs), and of course, rural pri¬

vate physician practices.

In another report, Mohatt (1995) noted the advantages of linking primary care and

mental health services in underserved areas. These include:

• The enhancement of real and perceived levels of patient confidentiality.

• A decrease in patients’ feelings of being stigmatized when visiting an integrated

clinic as compared to a free-standing mental health facility.

• Enhancement of referrals from physicians to mental health professionals.

• An increase in early identification of persons with mental disorders.

• An increase in interaction between medical and mental health professionals,

leading to reductions in feelings of professional isolation.

• Increased clinic economic viability, as operating costs are reduced through the

sharing overhead expenses.

Disadvantages to integrated models seem to be few. However, sparsely populated

areas that do not have established mental health services (i.e., counseling) or providers

(i.e., psychiatrists, psychologists, and social workers) also tend to have fewer primary

care physicians. Consequently, some frontier areas without established primary care

clinics will obviously be unable to benefit from these integrated models.

Reaching Out

The two primary vehicles for reaching out to persons in need have been the “circuit

rider” and the “satellite clinic.” From the early days on the frontier, the “circuit rider”,

whether a judge, preacher, or mental health professional, has been one of the corner¬

stone approaches to getting a scarce resource to rural and frontier communities. The

i circuit rider approach involves mental health professionals external to the area travel-

j ing to frontier communities, usually on some regular schedule (i.e., once a month or

once a week). They may spend anywhere from a few hours to a few days seeing pa-

| tients. Their work is commonly coordinated through local community institutions like

n churches, schools, other agencies or indigenous healers,

e •

120

JACK M. GELLER, PETER BEESON, ROY RODENHISER

The limited access provided by circuit riders is clearly better than nothing. How¬

ever, it does present problems for continuity of care. Moreover, these types of service

providers often have to conduct therapy in ad hoc environments that are at times prob¬

lematic. Wagenfeld (personal communication, 1995) noted several instances of com¬

plaints by outreach workers regarding their inability to locate suitable space to work in

remote communities. Ad hoc arrangements in beauty or barber shops, grocery stores,

or on the street do not produce the most conducive environments for productive therapy.

The satellite clinic is simply a more institutionalized version of the circuit rider.

This model achieved prominence during the era of federal community mental health

staffing grants. Through the Community Mental Health Centers Act (1963), federal

funding greatly assisted in the development of these clinics in small, remote communi- j

ties. The satellite clinic is usually a stable place (maybe a store front, church basement,

or regular office) that is staffed by mental health professionals and support staff and

open on some regular basis. In some cases, the satellite clinic is a full time operation

and functions as a branch of a larger mental health program. In other cases the clinic is

staffed by support personnel full time but by mental health professionals only part of

the time. In frontier areas, the satellite clinic is more likely staffed by mental health

professionals on some regular but not full time basis.

However, satellite clinics in frontier areas are costly to operate with large overhead

(office space, support staff) and rather low client volume. Further, since the changes in

the federal government’s funding obligation for community mental health centers in

the early 1980s, there has been a steady reduction in the number of satellite clinics in

operation. As the federal funds decreased, greater emphasis was placed on fee-for-

service activities. Thus, given the high overhead and cost inefficiencies found in many

of these clinics (especially those serving poor remote communities), many communi¬

ties found them difficult to sustain.

Lastly, while circuit riders and satellite clinics are reasonably suited to deal with the

maintenance of long term mental health problems, emergent care is more difficult to

address. Consequently, some clinics have established crisis intervention services, or

“hot lines” through toll-free 800 services. These calls often are answered by staff at the

“parent” clinic, or nearby facilities in other communities.

Building Up

One of the often cited approaches to dealing with frontier mental health needs is to

make frontier people and communities more self-reliant when it comes to responding to

mental health problems. This takes several forms, including: use of natural helpers and

local healers; use of paraprofessionals; use of local (non-mental health) professionals;

public education; support groups and systems; and providing self-help resources.

D’Augelli and Ehrlich (1982) and others have suggested that the shortage of profes-

FRONTIER MENTAL HEALTH STRATEGIES

121

sionals in rural areas leads to a greater potential for the use of indigenous workers to

i develop natural helping networks (Gottlieb, 1983; Kelley, Kelley, Gauron and Rawlings,

1977). Hollister and his associates (Edgerton, 1983; Hollister, Edgerton and Hunter,

1985) also believe that a rural model of service requires a shift away from direct treat¬

ment toward services that are supportive of individuals, their families, and the natural

caregivers already present in the client’s environment.

Natural Helpers. The use of indigenous persons or natural helpers (those persons

within the community people naturally turn to for help) in support roles in rural mental

health programs is clearly of value. Clergy play a significant role as natural helpers in

the lives of rural people and are often the only helping resource in rural areas. For

decades, research has indicated that roughly 40% of persons seeking help for psycho¬

logical distress prefer clergy over human service providers (Chalfant et al., 1990). One

reason for this may be the fact that a majority of people have personal contact with a

church through family ties. Clergy then often become the first contact for services.

In some rural communities, the police and sheriff play a major role as a social

services agency. The mental health center often benefits from liaison work with law

enforcement. Similarly, other community resources, such as churches or local medical

practitioners, may add substantially to the effectiveness of mental health services. Treat¬

ment may be more effective if family and other informal support networks can be used

1 1 in an individual’s treatment plan (Loschen, 1986). The natural helper programs de-

i scribed by Timpson (1983) and Hollister et al. (1985) usually involved collaboration

i between interagency personnel and indigenous workers.

Paraprofessionals. The use of paraprofessionals to respond to local mental health

j needs has a long tradition (Richter, 1974; Walt, 1990; Indian Health Service [IHS],

1991). These local resources have been known, but long overlooked as members of the

mental health care work force. Unfortunately, there is no single accepted definition of

; | a community health worker or paraprofessional . Witmer, Seifer, Finocchio , Leslie and

) O’Neil (1995) defined these workers as “community members who work almost exclu-

i sively in community settings and who serve as connectors between health care consum-

i ers and providers to promote health among groups that have traditionally lacked access

to adequate care.” Witmer, Seifer, Finocchio, Leslie and O’Neil (1995) noted that a

| recent national survey has identified community health worker programs operating in

every state.

The most extensive structure supporting these workers currently is the Indian Health

Service (IHS). Since 1968, the IHS has hired local paraprofessionals as Community

o1 Health Representatives, or CHRs. CHRs serve as vital links between medical and men-

d tal health providers located in IHS-supported clinics and hospitals, and the Native

q American population they serve. Assistance with transportation, medication, appoint-

s- 1 ment scheduling, and identification of problems are all part of the important role played

rj by CHRs.

122

JACK M. GELLER, PETER BEESON, ROY RODENHISER

Perhaps the most extensive use of paraprofessionals in frontier health care is the

Alaska “Community Health Aide” program (IHS, 1991). These local workers are often

found in remote villages and settlements with no other health providers. Consequently,

the level of training they receive and the array of services they provide is extensive.

Training includes basic emergency care, prenatal and well-baby check-ups, and patient

education. More recently, Colorado has experimented with the development of “crisis

homes” staffed with paraprofessionals as an approach to meeting rural crisis needs and

as a way to avoid bringing rural persons in for treatment to state hospitals (Wackwitz

and Wilson, 1992).

Self-Help Resources. In a recent article, Ferguson (1996) discussed the revolution

in consumer health informatics. In his discussion of the electronic self-help commu¬

nity, Ferguson noted that with a whole new generation of electronic tools, it is much

easier for the average consumer to access accurate, reliable health-related information,

where once only the most dedicated and diligent were able to succeed. Ferguson noted

that while we think of our health care system as containing primary, secondary and

tertiary resources today, tomorrow we will view the access to consumer health informatics

as the fourth and biggest health resource of all: “... the ability of informed laypeople

and experienced self-helpers to prevent and manage their own health care problems

(1996, p. 36).” While not addressed directly, the implications for rural residents are

considerable.

This new field of informatics examines the development of computer and other

telecommunications systems designed for use by lay-people. Interactive systems are

already available to assist consumers in health promotion, and more importantly, self¬

management of existing health care problems. For example, the University of Wiscon¬

sin has developed software for use at home for people with diseases, such as AIDS,

substance abuse, depression, and diabetes. Another example is the Therapeutic Learn¬

ing Program that contains a “psychological spreadsheet” for people experiencing high

stress life events. Resources like these that can be accessed from the home can have a

significant impact in providing needed information resources for those in underserved

areas. Today, a number of self-help organizations already have active on-line forums

(e.g., Citizen Access Network of Maine, MADNESS network). The opportunities for

rural residents to participate in electronic self-help groups and networks will only in¬

crease over time.

Benefits and Disadvantages of Building Up. In assessing the benefits of lay-

people, natural healers, paraprofessionals, and self-help groups in rural areas, clearly

the greatest impact is in the area of increased access. For some (e.g., remote Alaska),

indigenous workers are the sole link to health care information and the organized health

care system. However, for most rural and frontier residents, these indigenous outreach

workers augment the formal systems of care and are an important link to them.

FRONTIER MENTAL HEALTH STRATEGIES

123

\

In addition to increasing access, lay outreach workers are cost effective as well by

I providing residents in remote locations with limited case management services and

accurate information on the appropriate use of the health care system. A testament to

this is in the state of Hawaii, where an HMO under a Medicaid contract uses commu¬

nity health workers to increase access to disease prevention services for Medicaid ben¬

eficiaries (Knobel, 1992). Computer-based resources may also prove to be cost effec¬

tive. Preliminary studies suggest that the University of Wisconsin’s software for home

health workstations has reduced the medical bills for patients with AIDS by up to 30%

(Ferguson, 1996).

The obvious disadvantage to these indigenous and self-help resources lies in the

limited training of those providing outreach services and the accuracy of information

they deliver, both directly and electronically. The ability of such outreach workers or

members of self-help groups to recognize when consumers need a referral to more

formal systems of care are somewhat questionable. However, even recognizing these

limitations, it would be hard to argue that consumers in remote areas would be better off

j without access to these indigenous resources.

Connecting

Telemedicine is the practice of health care delivery, diagnosis, consultation, treat¬

ment, and transfer of medical data and education using telecommunications. The tele¬

communication technologies used can range from telephone and FAX to live interac-

I tive video. Today, many rural health experts view telemedicine as a critical tool for the

| direct care of rural patients and for the development of rural health systems. Primarily,

| telemedicine affords rural residents ready access to specialty care without the inconve¬

nience of traveling to urban centers.

One of the most common ways of connecting urban or rural mental health profes¬

sionals to persons in frontier areas in need of treatment has been the “telephone hot

line.” This is often a toll free number staffed by mental health professionals or spe¬

cially trained paraprofessionals. These hot lines are usually maintained by not-for-

profit, consumer organizations (e.g., mental health associations; community-based pro¬

grams, etc.) and allow rural residents entry into a service network 24 hours a day.

Throughout the 1980s, these hot lines were highlighted in the literature, as they pro¬

vided critical information, treatment and referral services to thousands of farm families

during the “farm crisis.” More recently this technology has become an important strat¬

egy of proprietary behavioral health systems and managed care providers for recruit¬

ment, crisis intervention and case management. Consequently, today it is common¬

place to find these toll-free numbers in local telephone directories.

124

JACK M. GELLER, PETER BEESON, ROY RODENHISER

One of the most comprehensive telecommunication projects today is called RO¬

DEO Net and is administered through the Eastern Oregon Human Services Consortium

(Britain, 1995). This project utilizes multiple technologies in an effort to provide com¬

prehensive services to residents of a 45,000 square mile area in eastern Oregon. Tech¬

nologies utilized in the RODEO Net project include: two-way audio/one way video

satellite services; fully interactive two-way video and audio digital satellite services;

and a service area- wide computer network providing E-mail, bulletin boards, private

conferencing, and Internet gateways. Behavioral health services provided over these

technologies include crisis intervention and evaluation from the Eastern Oregon Psy¬

chiatric Center; pre-commitment legal hearings via interactive video; pre-admission

and discharge planning via interactive video; and tele-consultation services from the

Psychiatric Center, State Hospital, or University Health Science Center via interactive

video. Britain (1995) notes that all three technologies are utilized for tele-education

services for rural providers, as well as consumer and provider networking.

However, it is important to note that there are several barriers to the future growth,

development, and utilization of telecommunications services. First, and perhaps most

important from the providers’ perspective is the lack of reimbursement mechanisms in

place for teleconsultation services. To date, few insurers (including the Health Care ,

Financing Administration) have recognized teleconsultation as a reimbursable event.

Consequently, most providers and proprietary systems are reluctant to make invest- I

ments in these technologies without the ability to be reimbursed for services provided.

Second, few empirical studies are available evaluating the strengths, weaknesses

and effectiveness of telemedicine services. Most advocates in the field recognize that

without a significant amount of scientific evidence, many providers will continue to

shy away from this technology, and insurers will continue to view the technology as

experimental.

Finally, paradigmatic shifts will need to occur among providers in how they view

the delivery of services to rural and remote consumers. Many health care providers,

including those in behavioral health care, are skeptical that telecommunications tech¬

nology is a significant advancement in the delivery of treatment services to patients

with mental and emotional disorders. Consequently, without such paradigmatic shifts,

telemedicine services will continue to be viewed as a technology unable to fulfill its

potential. For a more in-depth treatment of telemental health, see LaMendola (this

issue).

Managed Care

Now that we have reviewed the four global strategies to improve access and avail¬

ability to residents in frontier regions, we will review these strategies within the context

of managed care. In an effort to improve service delivery and control the costs of

1

FRONTIER MENTAL HEALTH STRATEGIES 125

mental health services, states have been initiating a variety of managed behavioral health

care alternatives. Many managed care advocates (as well as state legislators) are em¬

bracing these changes, while many mental health advocates are fearful that it is all a

pretext to simply cutting costs. We address two primary questions in this section: “Are

these four global strategies congruent with the goals of managed care?” ; and “Will

managed care organizations (MCOs) embrace or shun these strategies?”

Medically-Integrated Clinics. In a managed care environment, it appears that

medically-integrated clinics might fare quite well. As noted above, two of the obvious

advantages of these integrated clinics are their low overhead and their integrated deliv¬

ery system. These characteristics are usually quite attractive to managed care organiza¬

tions. With both medical and behavioral health professionals working in an integrated

delivery system, a MCO will have much lower marketing costs and need to expend

fewer resources coordinating care between providers.

Chris Jagmin, MD, Vice President of PacifiCare of the Southwest, noted in the Of¬

fice of Rural Health Policy (ORHP) roundtable that MCOs spend a great deal of time

working on the interface between providers. However, “when local providers are more

integrated, the HMO can take less” (Office of Rural Health Policy [ORHP], 1995).

Thus, in an integrated system, with MCOs finding efficiencies in coordinating care,

they can take less of the premium and still make the same profit margin. The same

argument can be made regarding the overall operating expenses of these integrated

clinics versus situations where multiple providers maintain separate clinic facilities.

With overhead expenses being shared by both medical and behavioral health profes¬

sionals, the operating efficiencies realized are more attractive to a managed care orga¬

nization.

Further, it is assumed that MCOs are not interested in significant local infrastruc¬

ture development, especially just to capture a small percentage of the rural market.

However, some states, such as Washington are requiring MCOs to serve rural commu¬

nities as a condition of doing business in their more metropolitan markets. Either of

these conditions will lead MCOs to look for providers who already have a significant

local market share and work aggressively to lower their costs. Again, local integrated

clinics that have already brought together multiple providers and can document lower

overhead costs could be attractive contractors for MCOs.

In sum, it is assumed that managed care organizations are not aggressively entering

the rural and frontier markets. However, as they slowly penetrate that market, they will

seek contractors who already have a significant share of the market, keep costs low, and

have reduced their expenses by coordinating care. Thus, low-cost, medically-integrated

clinics may be net beneficiaries as MCOs continue to move into more rural markets.

Satellite Clinics and Outreach Services. For many years community-based satel¬

lite clinics were the mainstay in the delivery of behavioral health services in small

underserved areas. The expansion of these clinics was in part due to the 1963 Commu-

126

JACK M. GELLER, PETER BEESON, ROY RODENHISER

nity Mental Health Centers Act, which required and helped states fund the provision of

mental health services through community mental health centers. However, starting in

1981, the Omnibus Budget Reconciliation Act (OBRA, 1981) began shifting the re¬

sponsibility to state mental health authorities. This initial shift resulted in a reduction in

federal support for mental health services. Thus began an increasing emphasis on fee-

for-service funding and a deterioration of the number of satellite clinics.

Under a managed care environment, maintenance of these small, satellite clinics

and outreach services may require a greater infrastructure investment than most health

plans are willing to make. As Dr. Puskin noted in the ORHP roundtable on rural man¬

aged care, for a MCO “...to recoup its investment in developing rural infrastructure, ....

it must have a significant share of the market and a strong network of providers. One

way to achieve this ... would be to reach for broad rural markets encompassing a large

number of providers (ORHP, 1995).” If this is true, it would suggest that more region¬

alized (or centralized) rural systems of care are more likely under a managed care sce¬

nario, than a scattering of small, relatively inefficient satellite clinics. With each satel¬

lite clinic having its own overhead costs and a rather small patient base, it is hard to

imagine the benefits of such clinics to a MCO aggressively looking for efficiencies.

Utilization of Indigenous Providers/Seif-Help Resources. Unlike satellite clin¬

ics, the use of indigenous providers to augment and establish linkages to more formal

systems of care requires much less infrastructure development and appears to be quite

cost effective. In fact, Knobel (1992) reports the use of community health workers to

provide health promotion/disease prevention services to Medicaid beneficiaries by the

Kaiser Permanente HMO in Hawaii.

Of course the obvious benefit in using indigenous providers in frontier areas is the

increase in access. Without absorbing large infrastructure development costs, MCOs

could significantly augment the delivery of services in underserved areas by training

local community aides to provide limited services, information, and referral services to

local consumers. In addition to health promotion/disease prevention information, in¬

digenous workers can provide limited case management services, home-based services,

transportation, and just as importantly, serve as an informed link between local con¬

sumers and the MCO. Much of the literature cited above documents the overall effec¬

tiveness (both in cost and outcome) of indigenous workers. Thus, faced with the alter¬

natives of using indigenous workers, or utilizing a greater volume of resources to fur¬

ther develop local resources, it is reasonable to assume that many MCOs will look

favorably on indigenous workers as a low cost method of maintaining service linkages

in frontier communities.

Support groups and self-help resources may also fare well in a primarily managed

care environment. We do not at this time see a deterioration of support group activities

as rural markets move more toward managed care. First, most of these self-help groups

(e.g., Alcoholics Anonymous; National Alliance for the Mentally Ill) are currently out-

FRONTIER MENTAL HEALTH STRATEGIES

127

side of the formal reimbursement streams. Thus, changes in the financing and delivery

i systems should not greatly effect these “grass roots” activities. In fact, we may find

MCOs supporting such activities, as they serve as locally-based prevention activities,

i Lastly, it appears that the field of consumer health informatics will continue to

flourish as information science and technology continue to advance. Much of these

resources are quite congruent with managed care’s orientation toward data and con-

> sumer awareness. Further, many states have, or are in the process of developing Com-

i munity Health Information Networks (CHIN). These networks often electronically

link provider and consumer groups with state-based health information, as well as pro¬

viding Internet gateway access. Consequently, in an effort to increase consumer in¬

volvement and education, we would speculate that this quickly emerging field will

continue to flourish. In fact, we predict that many managed care organizations will

actively participate in providing such information via these systems.

Utilization of Telecommunication Services. Two of the major barriers to care for

rural consumers, time and distance, are easily overcome through modem telecommuni-

) cations technology. Modem telecommunications technology has the potential to sig¬

nificantly improve access in frontier areas that have traditionally been underserved.

■ Even with the barriers cited earlier, we predict that as managed care continues to pen-

il etrate rural markets, the use of telecommunications will dramatically increase. We

e | make this prediction based upon several factors.

o First, the use of telecommunications technology can be cost effective. As men-

e tioned several times in this paper, managed care organizations are much more aggres¬

sive in finding cost efficiencies. The utilization of telecommunication technology, while

e I expensive, is still considerably less costly than deploying human resources. Further, as

s with most technologies, as utilization increases, unit costs will decrease making it even

g| more cost effective. Thus, over time, as MCOs cover more rural markets, the cost

o I advantages of utilizing these technologies will increase.

i- Second , as mentioned earlier, some states (e .g . , Washington) , require MCOs to cover

s, ! rural areas as a condition to having access to their more profitable urban markets. While

i- j it is difficult to predict whether this type of policy will become a trend in other states,

> clearly telecommunications technology offers a MCO a cost effective method to meet

r- this requirement.

r* | Third, in most states Medicaid benefits include the cost of transportation to access

ik services not locally available to beneficiaries. More and more rural managed care plans

;s also pay for patient travel to access urban providers (ORHP, 1995). Consequently, as

more MCOs contract with states to serve Medicaid beneficiaries and serve more rural

;d | areas, the advantages to utilizing telecommunications technology to reduce these travel

costs and improve cost effectiveness will become apparent,

ps

it-

128

JACK M. GELLER, PETER BEESON, ROY RODENHISER

Summary. This section attempted to speculate on how the four identified global

strategies to providing behavioral health services in our nation’s most frontier and

underserved areas will fare under a managed care environment. In exploring these

issues, we predicted that three of the four approaches will likely continue under man¬

aged care, with only the maintenance and further development of satellite clinics and

outreach services decreasing. Looking .at these predictions from another viewpoint,

one might conclude that, as is often the case, rural areas have already developed cost-

effective methods of providing admittedly minimal services in a limited resource envi¬

ronment.

Implications for Behavioral Health Services

This paper has attempted to explore the strengths, weaknesses and utilization of I

four global strategies that are in place today to serve the mental health needs of frontier

populations. However, a comprehensive approach to meeting the mental health needs

of persons living in frontier areas should consider programs that employ all of these

strategies. Unfortunately, there is a tendency in dealing with rural or other special

populations to look for a single programmatic solution to problems of accessibility and

availability. While some of these strategies may prove sufficient in and of themselves

to address particular mental health problems, in most of the cases when we are dealing

with diagnosable mental disorder, a single strategy will often prove inadequate.

References

Bird, D.C., Lambert, D. and Hartley, D. (1995, October). Rural models for integrating primary care, mental

health, and substance abuse treatment services (Working paper #5). Portland, ME: Maine Rural Health

Research Center, Muskie Institute of Public Affairs.

Britain, C.S. (1995). Telecommunications in rural mental health delivery: The RODEO NET project. In D.F.

Mohatt and Kirwan, (Eds.), Meeting the challenge: Model programs in rural mental health. Washington, DC:

Office of Rural Health Policy, US Department of Health and Human Services.

Chalfant, H.P., Heller, P.L., Roberts, A., Briones, D., Aguirre-Hochbaum, S. and Farr, W. (1990). The clergy as a

resource for those encountering psychological distress. Review of Religious Research , 31:305-315.

D’Augelli, A.R. and Ehrlich, R.P. (1982). Evaluation of a community-based system for training natural helpers.

II. Effects on informal helping activities. American Journal of Community Psychology, 10:447-456.

Edgerton, J.W. (1983). Models of service delivery. In A.W. Childs and G.B. Melton (Eds.), Rural Psychology

(pp. 275-303). New York: Plenum.

Ferguson, T. (1996). Consumer health informatics: Turning the treatment pyramid upside down. Behavioral

Healthcare Tomorrow, February:35-37.

Fink, P.J. (1977). The relationship of psychiatry to primary care. American Journal of Psychiatry, 134(2): 126-

129.

Goldberg, I.D., Babigian, H.M., Locke, B.Z. and Rosen, B.M. (1978). Role of nonpsychiatrist physicians in the

delivery of mental health services: Implications from three studies. Public Health Reports, 93(3):240-245.

Gottlieb, B.H. (1983). Social support strategies: Guidelines for mental health practice. Beverly Hills, CA: Sage.

Hollister, W.G., Edgerton, J.W. and Hunter, R.H. (1985). Alternative services in community mental health: Pro¬

grams and processes. Chapel Hill, NC: University of North Carolina.

FRONTIER MENTAL HEALTH STRATEGIES

129

Indian Health Service (1991). Alaska Community Health Aide Program Description. Washington, DC: Author.

Kelley, A. R., Kelley, P. L., Gavron, E. F. and Rawlings, E. I. (1977). Training helpers in rural mental health

delivery. Social Work, 22(3):229-232.

Knobel, R.F. (1992, November). Medicaid and managed care with Kaiser Permanente in Hawaii. Paper pre¬

sented at the Conference on Medi-Cal and Managed Care, Sacramento, CA.

Lemer, R. and Blackwell, B. (1975). The GP as a psychiatric community resource. Community Mental Health

Journal, ll(l):3-9.

Locke, B.Z. and Gardner, E.A. (1969). Psychiatric disorders among patients of general practitioners and inter¬

nists. Public Health Reports, 84(2): 167-173.

Locke, B.Z., Krantz, G. and Kramer, M. (1966). Psychiatric need and demand in a prepaid group practice pro¬

gram. American Journal of Public Health, 56:895-904.

Loschen, E.L. (1986). The challenge of providing quality psychiatric services in a rural setting. Quality Review

Bulletin, 12(ll):276-379.

Mohatt, D.F. (1995). Primary care and mental health service integration: The bay area service extension (BASE)

project. In D.F. Mohatt and Kirwan, (Eds.), Meeting the challenge: Model programs in rural mental health.

Washington, DC: Office of Rural Health Policy, US Department of Health and Human Services.

National Rural Health Association. (1992). Study of models to meet rural health care needs through mobilization

of health professions education and services resources, (Volume I). Kansas City, MO: National Rural Health

Association.

Office of Rural Health Policy. (1995, November). Rural prescriptions for managed care: A roundtable. Wash¬

ington, DC: Author.

Omnibus Budget Reconciliation Act (OBRA), PL 97-35 (1981).

Richter, R.W. (1974). The community health worker. American Journal of Public Health, 66 (2):273-277.

Rosen, B., Locke, B.Z., Goldberg, I.D. and Babigian, H.M. (1972). Identification of emotional disturbance in

patients seen in general medical clinics. Hospital and Community Psychiatry, 23:364-370.

Timpson, J. (1983). An indigenous mental health program in remote northwestern Ontario: Development and

training. Canada’s Mental Health, 3 1(3):2- 10.

Wackwitz, J.H. and Wilson, N.Z. (1992). The Colorado rural crisis study: Comparing methods for delivering

rural crisis services. OutLook, 2(3):21-23.

Wagenfeld, M.O., Murray, J.D., Mohatt, D.F. and DeBruyn, J.C. (1994 ). Mental health and rural America: 1980-

1993. Washington DC: Office of Rural Health Policy, Health Resources and Services Administration.

Walt, G. (1990). Community health workers in national programmes: Just another pair of hands? Philadelphia,

PA: Open University Press.

Witmer, A., Seifer, S.A., Finocchio, L., Leslie, J. and O’Neil, E.H. (1995). Community health workers: Integral

members of the health care work force. American Journal of Public Health, 85:1055-1058.

130

\ Journal of the Washington Academy of Sciences,

J Volume 86, Number 3,131-142, December 2000

The Role of Rural Primary Care Physicians

in the Provision of Mental Health Services

Jack M. Geller, Ph.D. and Kyle J. Muus, Ph.D.

Abstract

Frontier areas of the United States tend to have fewer mental health providers and impatient

facilities, and low utilization of traditional mental health services due to lack of anonymity

in treatment, stigma and denial of mental problems, clashes between treatment and tradi¬

tional rural values such as independence and privacy, and rural poverty. These conditions

contribute to a scenario where much of the burden of mental health care is placed on pri¬

mary care physicians. This paper provides an analysis of the role of the primary care physi¬

cian in the provision of mental health services in rural and frontier regions of the country.

Introduction

Frontier rural areas suffer from a lack of mental health providers and inpatient

psychiatric services (Goldsmith, Wagenf eld, Manderscheid, Stiles and Longest, 1989;

Wagenfeld, Goldsmith, Stiles, Longest and Manderscheid, 1990; Goldsmith et al., 1994).

A variety of reasons have been offered as to why mental health service delivery is

impaired in rural and frontier areas. In frontier areas, community mental health centers

cover vast service areas and the resultant distance from provider to consumer can im¬

pede mental health service provision (Prue, Keane, Cornell and Foy, 1979; Nease, 1993;

Sullivan, Jackson and Spritzer, 1996). The ability to operate economically viable men¬

tal health services in frontier areas is hindered by low population density (Comey, 1968;

Bachrach, 1983; Loschen, 1986), higher per-unit costs (Gertz, Meider and Pluckhan,

1975; Loschen, 1986) and greater reliance on governmental and other outside funding

I sources (Bachrach, 1983).

It is also generally believed that rural residents tend to under-utilize the mental

health services that are available (Bachrach, 1985; Watts, Scheffler and Jewell, 1986;

Nease, 1993; Rost, Smith and Taylor, 1993). Some rural residents will not seek or

utilize mental health care because of a lack of anonymity in treatment, the stigma asso¬

ciated with treatment, and clashes between treatment and traditional rural values such

as independence and privacy (Jeffrey and Reeve, 1978; Solomon, Hiesberger and Winer,

1981; Meyer, 1990; Rost et al., 1993). Denial of mental illness by the individual or

family also impedes service utilization and can result in the future need for much more

extensive care and decreased likelihood of a positive response to treatment (Berry and

Davis, 1978; Loschen, 1986). Rural poverty is another, often overlooked factor affect-

132

JACK M. GELLER, KYLE J. MUUS

ing under-utilization of mental health services . For instance , the economic downturn in if

the 1 980s left farmers and other rural residents with fewer resources to be able to afford ci

adequate health insurance coverage or the out of pocket costs of such care. Compound- J

ing the problem, this rural recession decreased employment opportunities in rural com- la

munities and raised stress levels among residents (Meyer, 1990; National Rural Health I1

Association, 1992; Nease, 1993).

The combination of fewer mental health providers and inpatient facilities, and low e

utilization of traditional mental health services due to social factors and rural poverty ii

all point to a scenario where much of the burden of mental health care provision is k

placed on primary care physicians. i

I f

Generalist Physicians as Sources of Mental Health Care

Almost 20 years ago, Regier, Goldberg and Taube (1978), in response to the 1977 [1;

President’s Commission on Mental Health, used epidemiological methods to estimate

the number of persons in the US who had a mental disorder, as well as the sector of the i

health care system where they sought treatment. They reported that approximately m(

21% of those estimated to have a mental disorder in 1975 sought care from the specialty Bl

mental health sector (approximately 7 million). However, over 60 percent of the total lc

persons affected by mental disorders (estimated at over 19 million) sought treatment in

a primary care setting. In a follow-up study in 1993 using Epidemiologic Catchment , ^

Area study data, Regier et al. found that approximately 40% (9 million) of those who |a

sought care for a mental disorder in 1980 received care from the specialty mental health

sector, and 43% (10 million) received care from the general medical health system. K

Similarly, a 1984 report found that non-psychiatrist physicians provided 48% of the : a

patient visits resulting in the diagnosis of a mental disorder, and primary care physicians ^

(i.e., general practitioners; family physicians; and general internists) accounted for 77% of nro

these diagnoses (US Department of Health and Human Services [DHHS], 1984). The tarj

DHHS also found that 28% of primary care visits were for psychological problems, and ^

anxiety /nervousness accounted for 11% of the reasons people give to visit a physician. for

More recent studies of this nature have purported that generalist physicians provide up to r

60% of the mental health services received by a population (Regier, Boyd and Burke, 1988; lfea

US Congress, 1990). Many other studies have also documented the important role of pri¬

mary care physicians in mental health care provision (Locke and Gardner, 1969; Rosen,

Locke, Goldberg and Babigian, 1972; Lemer and Blackwell, 1975; Fink, 1977; Goldberg, h

Babigian, Locke and Rosen, 1978; Regier, Burke, Manderscheid and Bums, 1985; Schurman,

Kramer and Mitchell, 1985; National Rural Health Association, 1992). bin

The use of generalist physicians holds true for rural residents as well. They also tend to

utilize general medical resources for mental ailments more frequently than area mental ^

health centers (Fehr and Tyler, 1987) and actually prefer such primary care givers in the ^

treatment of such problems (Flaskerud and Kviz, 1982). Ordway (1976) found that mral f0(

THE ROLE OF RURAL PRIMARY CARE PHYSICIANS

133

residents tended to first think of receiving mental health treatment from primary care physi¬

cians and preferred consultation from a psychiatrist only in the case of serious mental disor¬

der. Equally important, other studies have also found that rural persons afflicted with men¬

tal disorder prefer to initially consult a primary care physician (Blackwell and Goldberg,

1968; Goldberg and Blackwell, 1970; Lemer and Blackwell, 1975).

Johnson (1995) recently explored this preference for seeking help from a primary

care physician in a statewide study of help seeking behavior among residents of Ne¬

braska. In that analysis, respondents were asked who they would turn to first in seeking

help for a mental health problem. Not surprisingly, a family physician was reported

more frequently than any other category of provider (40.9%), followed distantly by a

private psychiatrist (16.2%) and a minister (13.9%). Johnson also explored variations

in help seeking behavior by residential location. Using Beale codes, Johnson found an

even greater propensity for the most rural residents to seek help from a family physi¬

cian (43% in the most isolated rural areas as opposed to 37% in urban areas).

Johnson’s analysis suggests that primary care physicians are the primary choice of

all residents when seeking help for a mental disorder, and that rural residents are even

more likely to seek help from a family physician than urban residents. Surprisingly,

and of some interest, is that less than one respondent in ten (7%) reported that they

* would first seek help from a community mental health center. This preference for the

1 family physician can continue even after a person receives treatment from mental health

1 providers. Lemer and Blackwell (1975) surveyed 100 psychiatric inpatients and found

3 that 38% planned to have their family physician assist in aftercare.

1 ! Physicians that practice in rural and frontier areas tend to play an even larger role in

mental health care provision due, in part, to the relative scarcity of mental health and

e other health care professionals in these outlying areas of the country. Unfortunately,

s sparsely populated areas without established mental health services (i.e., counseling) or

'* providers (i.e., psychologists, social workers) also tend to have relatively few primary

e care physicians to act as substitutes. Nonmetro and frontier areas possess far less phy-

^ sician coverage than more urbanized areas even after controlling for population size.

1 For example, Frenzen (1994) found that in 1988, the ratio of primary care physicians

10 per 100,000 persons for remote mral areas was 38.2; for the more inclusive nonmetro

ft areas it was 51 .3. In comparison, metro areas had a ratio of 95.9.

>

n,

0 Treatment Patterns

&

ui If primary care physicians are providing a majority of the care for mental illness in

frontier areas, how well are they providing it? Much has been written about how primary

to pare physicians treat and manage patients presenting symptoms of mental disorder, and

tal now this differs from treatment provided by mental health professionals (e.g., psychiatrists

he and psychologists). Several studies have documented the drug-dispensing behavior and use

ralpf other treatments among non-psychiatrist physicians. One study (DHHS, 1984) found

134

JACK M. GELLER, KYLE J. MUUS

that non-psychiatrists appeared to substitute drugs for time as their mental health-related

office visits lasted half as long as those of psychiatrists and were twice as likely to result in

a drug prescription. Gardiner, Peterson, and Hall (1974) also found that generalist physi¬

cians placed heavy reliance on the use of psychotropic drugs and favored their use as the

sole treatment for the majority of their patients with mental disorders. In fact, these physi¬

cians have been found to favor such drug treatment in many patient visits even when no

mental diagnosis is officially rendered (Jencks, 1985).

Not only do generalist physicians seem to use psychotropic drugs in treatment more

frequently, there is also evidence of inappropriate use of drug therapy among these

physicians. Fauman (1980) found that 59.2% of 72 surveyed general hospital physi¬

cians who prescribed tricyclic antidepressants did not dispense sufficient doses to their

patients. In addition, 61.5% of 112 respondents were found to have inappropriately

used tricyclic treatment for such conditions as chronic pain, insomnia, enuresis, agita¬

tion, and anxiety.

Although there is an abundance of information that points to the generalist physi¬

cians’ higher propensity to use drug therapy, some studies have also documented their

use of counseling in concert with prescription drugs and have even found counseling to

be the most common treatment for mental disorders in the general practice setting. In

one study of primary care physicians, it was found that 31% of patients with emotional

disorders were provided with supportive therapy, 14% were given prescription drugs,

and 35% were given a combination of these treatments (Rosen et al., 1972). Yet an¬

other study revealed that a combination of drugs, advice, and reassurance was the most

common method of mental health treatment among a group of family practice physi¬

cians (Orleans, George, Houpt and Brodie, 1985).

Somewhat contrary to previous findings, Andersen and Harthorn (1989) found that

primary care physicians did recognize the presence of mental disorder essentially as

well as mental health professionals (e.g., psychiatrists, psychologists). However, these

physicians were less accurate in their diagnoses of affective, anxiety, somatic, and per¬

sonality disorders. Generalist physicians were most accurate (81%) in recognizing

organic disorders and least accurate (14%) in identifying personality disorders. Only

about one-half of the physicians correctly identified anxiety (49%), somatic (49%), and

affective (47%) disorders (Andersen and Harthorn, 1989).

In one of the more recent and rural studies, Rost, Williams, Wherry and Smith (1995)

examined the relationship between process and outcome for patients with major depression

in 21 rural primary care practices in Arkansas. After screening over 600 patients, 47 meet¬

ing DSM-III-R criteria for major depression were recruited into the study. Findings from

the study are significant: only 24 percent of the cases meeting the diagnosis criteria were

found to have “depression” noted in the patient’s medical record at the initial visit. Al¬

though 63 percent of those diagnosed received pharmacologic treatment, only 29 percent

received a sufficient dosage for a long enough period of time to meet the AHCPR clinical

practice guidelines. Further, while it was inconsistently noted in the record, it appeared that

THE ROLE OF RURAL PRIMARY CARE PHYSICIANS

135

few patients received psychotherapy from a mental health professional. Most importantly,

only one-third (32%) of the patients followed were in remission after 5 months (a rate of

less than half that found in other practice settings).

Rost, Humphrey and Kelleher (1994) examined the barriers rural primary care phy¬

sicians face in the treatment of patients with depression. In that study, the lack of

physician time and the inability of rural patients to recognize their problem were found

to be the most often reported barriers. Other barriers such as the unavailability of

mental health specialists and the inability of the patients to afford specialty care were

also reported at somewhat lesser percentages.

In sum, the literature appears to be mixed regarding the appropriateness of general¬

ist physicians’ handling of mentally ill patients. This uncertainty raises questions con¬

cerning the extent of their mental health training and the degree to which they are pre¬

pared to adequately manage such patients. Both of these issues will now be addressed

by examining the literature of the past 20 years in these areas.

Mental Health Training and Primary Care Physicians

Although primary care physicians provide a significant volume of mental health

services, their training in mental health diagnosis and treatment appears to be limited.

The time allotted to clinical psychiatric clerkships has gradually declined in most medi¬

cal schools (Callen and Davis, 1978). In fact, the six- week clerkship in psychiatry for

all third-year students is the briefest among the five standard third-year clinical rounds,

and course work in behavioral sciences amounts to about 5% of the medical school in-

class curriculum (US Congress, 1990).

In addition, it appears that students have little direct contact with psychiatrists dur¬

ing this training. Jones, Badger, Parlour and Coggins (1982) studied family practice

residency programs and found that training was typically provided by part-time or vol¬

unteer faculty and that less than 5% of faculty members were full-time psychiatrists.

Strain, Pincus, Houpt, Gise and Taintor (1987) also noted a general under-utilization of

psychiatrists in medical school-based mental health training. In some cases, programs

were found to bypass psychiatry departments entirely to hire less expensive nonmedi¬

cal behavioral scientists to teach mental health content. Pincus, Strain, Houpt and Gise

(1983) concluded that some family medicine programs don’t adequately train students

to carefully diagnose and treat psychiatric disorders. This lack of training can also be

found in internal medicine, the major US primary care field. For board certification in

internal medicine there is no required test for competence in patient interviewing or

psychiatric diagnosis (Fogel, 1993). Similarly, Pincus et al. (1983) found that little

attention was given to psychosocial concerns in most internal medicine programs.

Several articles have addressed how generalist physicians themselves feel about

their preparation in the provision of mental health care. In an early study, Castelnuovo-

Tedesco (1967) polled a group of recent medical school graduates and found that one-

136

JACK M. GELLER, KYLE J. MUUS

third said their graduate training in psychiatry was indifferent or poor and one-half felt

they had not learned enough psychiatry for their current general practice. Further, re¬

spondents felt psychiatry was one of the worst-taught subjects among their medical

school experiences (Castelnuovo-Tedesco, 1967). Werkman, Mallory and Harris (1976)

found that family physicians rated marital discord and alcoholism as the most common

psychiatric matters, and many felt they needed additional training to adequately man¬

age these patients. Fisher, Fowler and Fabrega (1973) found that the majority of family

physicians under study felt they needed and desired additional postgraduate training in

psychiatry to better serve their patients. Similarly, Cassata and Kirkman-Liff (1981)

report that a group of family physicians they studied, in response to increasing demand

for mental health care provision in their practices, expressed an interest in taking addi¬

tional continuing education courses in psychiatry covering such topics as individual/

marital/parental counseling and psychopharmacology. Finally, about one-third of polled

US family physicians indicated a need for further training in treating emotional and

psychiatric disorders (Orleans et al., 1985).

What subjects are important for someone who will set up a rural, primary care

practice? Johnson and Snibbe (1975) studied a group of psychiatrists, psychologists

and nonpsychiatrist physicians and determined the most important psychiatric topics

for their practices. Topics included: interviewing, suicide evaluation, psychopharma- i

cology, chronically ill or dying patients, psychophysiologic disorders, psychiatric re- :

ferral, the doctor-patient relationship, drug and alcohol abuse, differential diagnosis, i

and sexual problems. Callen and Davis (1978) conducted a similar study using only i

rural primary care physicians and found that this group deemed many of the same top- i

ics to be the most pertinent to their practice. This rural list also included treatment of f

depression, psychosomatic disorders, and geriatric psychiatry. (

A number of articles have concluded that non-psychiatrist or primary care physi- t

cians are, by and large, inadequately prepared to recognize, refer, or treat mental disor- a

ders (Feldman, 1978; Pincus et al., 1983; Jones, Badger, Ficken, Leeper and Anderson, (

1988; Zimmerman and Wienckowski, 1991; Barrett, 1991; National Rural Health As¬

sociation, 1992). Other possible reasons for this drawback, aside from inadequate training j p

in psychiatry/psychology, included heavy patient load and time constraints on patient ft

visits, expectations of authority and peers, medical school selection process, and stu- i

dents’ experiences in medical school (Feldman, 1978; Orleans et al., 1985; Fogel, 1993). (I

Referral Patterns

Some research has also alluded to generalist physicians’ referral behavior and its q

appropriateness. Although there is no reason to suppose that every patient presenting tfl

symptoms of mental disorder in a primary health care setting should see a psychiatrist, j

it is commonly believed (at least by psychiatrists) that the proportion referred is too ! ,,

small. L

THE ROLE OF RURAL PRIMARY CARE PHYSICIANS

137

it

Kessel (1960) was one of the first to look at this issue and found that only 10% of

patients in general practice considered suitable for referral were actually referred to a

psychiatrist. Twenty-four years later, the US Department of Health and Human Ser¬

vices (1984) found that primary care physicians referred mental health patients to men¬

tal health professionals of any kind in only 5% of the episodes. Others have found that

primary care physicians referred patients with psychiatric diagnoses at rates of 17-30%

(Shapiro and Fink, 1963; Locke, Krantz and Kramer, 1966; Fink, Goldensohn, Shapiro

and Daily, 1967; Orleans et al., 1985).

The type of disorder present appears to influence referral patterns. Andersen and

Harthom (1989) found that both primary care physicians and mental health profession¬

als (i.e., psychologists) favored psychiatric referral over on-site treatment for most mental

disorders, but physicians favored treatment in primary care settings for certain anxiety

and somatic disorders. Hull (1979), surveying a group of nonpsychiatrist physicians,

found that most tended to refer psychosis cases to psychiatrists but preferred to treat

alcoholic and neurotic cases themselves. In a similar vein, Fauman (1983) found that

among polled internists, more than one-half said they normally forgo referral and prefer

to treat depression, anxiety, and psychosomatic and organic brain disorders themselves.

Research has also been conducted on other factors associated with the likelihood of

referral. Patient characteristics such as being male, higher socioeconomic status, younger

age and presence of a psychiatric label have been found to be positively correlated with

referral rate (Shepherd, Cooper, Brown and Kalton, 1966; Wilkinson, 1989; Farmer

and Griffiths, 1992). Physicians with longer practice tenure and positive feelings to¬

ward psychiatrists tended to refer more frequently (Shortell and Daniels, 1974; Gardiner

et al., 1974; Wilkinson, 1989; Ozbayrak and Coskun, 1993). Also, attributes of the

disorder, specifically issues of its type, severity and chronicity, and inadequate response

to physician treatment have been found to be positively related to referral (Shepherd et

al., 1966; Fink et al., 1967; Fink, Shapiro, Goldensohn and Daily, 1969; Hopkins and

Cooper, 1969; Wilkinson, 1989; Andersen and Harthom, 1989).

Mezey and Kellett (1971) found the most common reasons why nonpsychiatrist

physicians did not refer patients to psychiatrists were the patients’ dislike for such re¬

ferral, physician concerns about labeling the patient, and feeling that the treatment of

neurotic patients was every physician’s responsibility. Steinberg, Torem and Saravay

(1980) found that physician opposition to consultation was involved in more than 50%

of non-referred cases. Specifically, physicians felt that there was either no psychiatric

problem or that psychiatry could not help the patient. Less frequently cited was physi¬

cians’ feeling that the patient might become upset with such suggestions of referral.

Orleans et al. (1985) also found, while studying a group of family physicians, that they

tended to treat most psychiatric disorders themselves. Most felt, however, that this care

was incomplete due to patient opposition, time restrictions, limited third-party payment

for mental health care, lack of coordination between primary and mental health care

providers, and inadequate psychosocial training.

138

JACK M. GELLER, KYLE J. MUUS

Implications for Behavioral Health Services

As populations in frontier areas continue to dwindle, it will probably become less and

less feasible to recruit additional local mental health specialists (psychiatrists, psycholo¬

gists, psychiatric nurses, and psychiatric social workers) to these regions. Nurses, social

workers, and occasionally family therapists or ministers with some mental health training

are currently working in rural and frontier areas, but primary care physicians are still the

most numerous service provider in these areas (Holzer, Mohatt, Goldsmith and Nguyen,

1997). Thus, in the immediate future, rural as well as frontier mental health services are

most likely to continue to be in the hands of primary care physicians. Therefore, a premium

must be placed not on rural recruitment of psychiatric care givers, but on developing rural

networks of care between primary care providers, mental health professionals, and

nonphysician providers. It will also be necessary to improve medical and continuing medi¬

cal education to better inform primary care physicians on mental health care issues. Inter¬

estingly, that was the exactly what Regier et al. ( 1978) concluded almost 20 years ago when

they wrote, “Hence, there is a need for both further integration of the general health and

mental health care sectors and for a greater attention to an appropriate division of responsi¬

bility that will maximize the availability and appropriateness of services for persons with

mental disorder.” (Regier et al., 1978:693).

There have been some innovative approaches to educating primary care providers

on mental health issues. For example, the National Institute on Mental Health (NIMH)

provides programs that teach primary care physicians how to recognize and treat men¬

tal conditions. The Depression Awareness, Recognition, and Treatment (DART) Pro¬

gram was developed in 1988 to educate primary care physicians and other health pro¬

fessionals around the country about the signs of and treatment for depressive disorders

(Meyer, 1990; Hunter and Windle, 1991). In addition, the NIMH provides funding for

various forms of mental health-related continuing education programs.

One of the most effective tools available to rural primary care physicians, however,

appears to be the development and dissemination of the AHCPR Clinical Practice Guide¬

lines for Depression in Primary Care (1993). In a small, but significant study, Rost et

al. (1995) reported that depressed patients who received treatment in concordance with

the guidelines were significantly more likely to be in remission after 5 months, than

patients who received pharmacologic treatment, but not in concordance with the guide¬

lines. Further, since that study, computer assisted versions of the guidelines have been

developed, and are currently being tested.

Further efforts must also be made to explore ways in which primary care providers

can successfully link with mental health care providers to improve efficiency and qual¬

ity of care. Strides should be made in developing alternative means to strengthen the

linkages between primary care physicians in frontier and rural areas and urban-based

mental health specialists. One successful strategy to link primary care providers with

mental health providers is the integration of practices in rural medical clinics (Bird et

THE ROLE OF RURAL PRIMARY CARE PHYSICIANS

139

al., 1995). Probably the most successful models of this type are the federally-funded

Community Health Centers. These centers, many of which are located in rural areas,

are required under federal law to offer a wide range of services to patients, including

mental health services. Consequently, it is not uncommon to find patients requiring

medical, mental health, or dental services sitting side-by-side in the waiting rooms of

these centers. In addition, Bird et al. (1995) found that similar rural models in the

private sector exist, although the majority are still in the public sector.

Another area that holds considerable promise is telemedicine. The use of two-way

interactive video is slowly becoming an important bridge between rural primary care physi¬

cians and urban specialists and sub-specialists. Similar connectivity between rural physi¬

cians and urban based mental health specialists could considerably improve access to ur¬

ban-based consultation. This would allow rural primary care physicians to consult about

the diagnosis and treatment of various mental afflictions they encounter in the course of

their practice. Just as important is the hope that as these linkages develop, and mental health

and primary care providers establish stronger ties, that referral rates among primary care

physicians will increase, to the benefit of both providers and patients.

The success of these emerging networks and training initiatives is likely to be di¬

rectly linked to the ability of rural residents to access quality mental health services.

Such networks will utilize local primary care providers (both physician and nonphysician)

as the local point of contact, but offer the patient access to an expansive array of more

urban-based professional mental health resources. The establishment of such emerging

networks is critical, if rural mental health care is not to be synonymous with substan¬

dard mental health care.

References

Andersen, S.M. and Harthom, B.H. (1989). The recognition, diagnosis, and treatment of mental disorders by

primary care physicians. Medical Care, 27:869-885.

Bachrach, L.L. (1983). Psychiatric services in rural areas: A sociological overview. Hospital and Community

Psychiatry , 34 : 2 1 5 -226 .

Bachrach, L.L. (1985). A Sociological Perspective. In L.R. Jones and R.R. Parlour (Eds.), Psychiatric services

for underserved rural populations. New York, NY: Brunner/Mazel.

Barrett, J.E. (1991). Practice-based mental health research in primary care: Directions for the 1990s. In M.L.

Grady (Ed.), Primary care research: Theory and methods. Rockville, MD: US Department of Health and

Human Services.

Berry, B. and Davis, A.E. (1978). Community mental health ideology: A problematic model for rural areas.

American Journal of Orthopsychiatry , 48:673-679.

Bird, D.C., Lambert, D. and Hartley, D. (1995, October). Rural models for integrating primary care, mental

health, and substance abuse treatment services (Working paper #5). Portland, ME: Maine Rural Health

Research Center, Muskie Institute of Public Affairs.

Blackwell, B. and Goldberg, D. (1968). Psychiatric interviews in general practice. British Medical Journal, 4:99-

101.

Callen, K.E. and Davis, D. (1978). What medical students should know about psychiatry: The results of a survey

of rural health practitioners. American Journal of Psychiatry , 135:243-254.

140

JACK M. GELLER, KYLE J. MUUS

Cassata, D.M. and Kirkman-Liff, B.L. (1981). Mental health activities of family physicians. Journal of Family

Practice, 12:683-692.

Castelnuovo-Tedesco, P. (1967). How much psychiatry are medical students really learning? Archives of General

Psychiatry, 16:668-675.

Comey, R.T. (1968). Community psychiatry: Some special factors in providing comprehensive mental health

care in the nonurban setting. Psychosomatics , 9:140-144.

Farmer, A. and Griffiths, H. (1992). Labelling and illness in primary care: Comparing factors influencing general

practitioners’ and psychiatrists’ decisions regarding patient referral to mental illness services. Psychological

Medicine, 22:717-723.

Fauman, M.A. (1980). Tricyclic antidepressant prescription by general hospital physicians. American Journal of \

Psychiatry, 137:490-491.

Fauman, M.A. (1983). Psychiatric components of medical and surgical practice, II: Referral and treatment of

psychiatric disorders. American Journal of Psychiatry , 140:760-763.

Fehr, A. and Tyler, J.D. (1987). Public awareness of mental health services in rural communities. Journal of

Rural Community Psychology, 8(l):36-40.

Feldman, A. (1978). The family practitioner as psychiatrist. American Journal of Psychiatry , 134(2) .126- 129.

Fink, P.J. (1977). The relationship of psychiatry to primary care. American Journal of Psychiatry , 134(2): 126-

129.

Fink, R., Goldensohn, S., Shapiro, S. and Daily, E.F. (1967). Treatment of patients diagnosed by family doctors

as having emotional problems. American Journal of Public Health, 57:1550-1564.

Fink, R., Shapiro, S., Goldensohn, S. and Daily, E.F. (1969). The “filter-down” process to psychotherapy in a I 1

group practice medical care program. American Journal of Public Health, 59:245-260.

Fisher, J.V., Fowler, H. and Fabrega, H. (1973). Family physicians want more postgraduate psychiatric training. i

Patient Care, 7:54-57.

Flaskerud, J.H. and Kviz, F.J. (1982). Resources rural consumers indicate they would use for mental health 1

problems. Community Mental Health Journal, 1 8(2): 107- 1 19.

Fogel, B. (1993). Mental health services and outcome-driven health care. American Journal of Public Health, I

83:319-321.

Frenzen, P.D. (1991). The increasing supply of physicians in US urban and rural areas, 1975 to 1988. American

Journal of Public Health, 81:1141-1147. 1

Gardiner, A.Q., Peterson, J. and Hall, D.J. (1974). A survey of general practitioners’ referrals to a psychiatric (

outpatient service. British Journal of Psychiatry , 124:536-541 .

Gertz, B., Meider, J. and Pluckhan, M.L. (1975). A survey of rural community mental needs and resources. (

Hospital Community Psychiatry, 26:816-819.

Goldberg, D.P. and Blackwell, B. (1970). Psychiatric illness in general practice: A detailed study using a new (

method of case identification. British Medical Journal, 2:439-443.

Goldberg, I.D., Babigian, H.M., Locke, B.Z. and Rosen, B.M. (1978). Role of nonpsychiatrist physicians in the f

delivery of mental health services: Implications from three studies. Public Health Reports, 93:240-245.

Goldsmith, H.F., Wagenfeld, M.O., Manderscheid, R.W., Stiles, D. and Longest, J.W. (1989). Geographical P

distribution of mental health organizations that provide inpatient psychiatric services. Unpublished manu¬

script. 5

Goldsmith, H.F., Wagenfeld, M.O., Manderscheid, R.W., Stiles, D.J., Windle, C. and Witkin, M.J. (1994). The

ecology of mental health facilities in metropolitan and nonmetropolitan counties. In R.W. Manderscheid and ^

M.A. Sonnenschein (Eds.), Mental Health, United States, 1994. Rockville, MD: US Department of Health and

Human Services.

t

Holzer, C.E., Mohatt, D.F., Goldsmith, H.F. and Nguyen, H.T. (1997). Accessibility and availability of mental

health/ substance abuse service care in frontier rural areas. Paper presented at the 23rd Annual Meeting of the

National Association for Rural Mental Health, Grand Forks, ND.

Hopkins, P. and Cooper, B. (1969). Psychiatric referral from a general practice. British Journal of Psychiatry,

115:1163-1174. | Rl

Hull, J. (1979). Psychiatric referrals in general practice. Archives of General Psychiatry, 36:406-408.

Hunter, M. and Windle, C. (1991). NIMH support of rural mental health. American Psychologist, 46(3):240-3.

THE ROLE OF RURAL PRIMARY CARE PHYSICIANS

141

Jeffrey, M.J. and Reeve, R.E. (1978). Community mental health services in rural areas: Some practical issues.

Community Mental Health Journal , 14(l):54-62.

Jencks, S.F. (1985). Recognition of mental distress and diagnosis of mental disorder in primary care. Journal of

the American Medical Association, 253: 1903-1907.

Johnson, P. (1995). Unpublished analysis of population preference for mental health providers among urban and

rural Nebraskans. Lincoln, NE: Department of Sociology, University of Nebraska.

Johnson, W. and Snibbe, J. (1975). The selection of a psychiatric curriculum for medical students: Results of a

survey. American Journal of Psychiatry , 132:513-516.

Jones, L.R., Badger, L.W., Ficken, R.P., Leeper, J.D. and Anderson, R.L. (1988). Mental health training of pri¬

mary care physicians: An outcome study. International Journal of Psychiatry in Medicine, 1 8(2): 107-121 .

Jones, L.R., Badger, L.W., Parlour, R.R. and Coggins, D.R. (1982). Mental health training in family practice

residency programs. Journal of Family Practice, 15:329-335.

Kessel, W.I.N. (1960). Psychiatric morbidity in a London general practice. British Journal of Preventive Social

Medicine, 14:16.

Lemer, R. and Blackwell, B. (1975). The GP as a psychiatric community resource. Community Mental Health

Journal, ll(l):3-9.

Locke, B.Z. and Gardner, E.A. (1969). Psychiatric disorders among patients of general practitioners and inter¬

nists. Public Health Reports, 84(2): 167-173.

Locke, B.Z., Krantz, G. and Kramer, M. (1966). Psychiatric need and demand in a prepaid group practice pro¬

gram. American Journal of Public Health, 56:895-904.

Loschen, E.L. (1986). The challenge of providing quality psychiatric services in a rural setting. Quality Review

Bulletin, 12:276-379.

Meyer, H. (1990). Rural America: Surmounting the obstacles to mental health care. Minnesota Medicine, 73(8):24-

31.

Mezey, A.G. and Kellett, J.M. (1971). Reasons against referral to the psychiatrist. Postgraduate Medical Jour¬

nal, 47:315-319.

National Rural Health Association. (1992). Study of models to meet rural health care needs through mobilization

of health professions education and services resources (Volume I). Kansas City, MO: National Rural Health

j Association.

Nease, D.E. (1993). Mental health issues in rural settings. Kansas Medicine, September: 246-248.

lOrdway, J.A. (1976). Transference in a fishbowl: A survey of rural psychoanalysis. Comprehensive Psychiatry,

j 17:209-216.

Orleans, C.T., George, L.K., Houpt, J.L. and Brodie, H.K.H. (1985). How primary physicians treat psychiatric

disorders: A national survey of family practitioners. American Journal of Psychiatry, 142(l):52-57.

Ozbayrak, K.R. and Coskun, A. (1993). Attitudes of pediatricians toward psychiatric consultations. General

Hospital Psychiatry , 15:334-338.

Pincus, H.A., Strain, J.J., Houpt, J.L. and Gise, L.H. (1983). Models of mental health training in primary care.

Journal of the American Medical Association, 249:3065-3068.

Prue, D.M., Keane, T.M., Cornell, J.E. and Foy, D.W. (1979). An analysis of distance variables that affect after¬

care attendance. Community Mental Health Journal, 15: 149-154.

Regier, D.A., Boyd, J.H. and Burke, J.D. (1988). One-month prevalence of mental disorders in the United States.

Archives of General Psychiatry, 45:977-986.

jRegier, D.A., Burke, J.D., Manderscheid, R.W. and Burns, B.J. (1985). The chronically ill in primary care. Psy¬

chological Medicine, 15:265-273.

iRegier, D. A., Goldberg, I.D. andTaube,C.A. (1978). The de facto US mental health services system. Archives of

General Psychiatry, 35:685-693.

Regier, D.A., Narrow, W.E., Rae, D.S., Manderscheid, R.W., Lock, B.Z. and Goodwin, F.K. (1993). The de facto

, US Mental addictive disorder service system. Archives of General Psychiatry, 50:85-94.

Rosen, B., Locke, B.Z., Goldberg, I.D. and Babigian, H.M. (1972). Identification of emotional disturbance in

j patients seen in general medical clinics. Hospital and Community Psychiatry, 23:364-370.

142

JACK M. GELLER, KYLE J. MUUS

Rost, K., Humphrey, J. and Kelleher, K. (1994). Physician management preferences and barriers to care for rural

patients with depression. Archives of Family Medicine, 3:409-414.

Rost, K., Smith, G.R. and Taylor, J.L. (1993). Rural-urban differences in stigma and the use of care for depressive

disorders. Journal of Rural Health, 9(l):57-62.

Rost, K., Williams, C., Wherry, J. and Smith G.R. (1995). The process and outcomes of care for major depression

in rural family practice settings. Journal of Rural Health, 1 1:1 14-120.

Schurman, R.A., Kramer, P.D. and Mitchell, J.B. (1985). The hidden mental health network: Treatment of mental

illness by nonpsychiatrist physicians. Archives of General Psychiatry, 42:89-94.

Shapiro, S. and Fink, R. (1963). Methodological considerations in studying patterns of medical care related to

mental illness. Milbank Memorial Fund Quarterly, 41:371-399.

Shepherd, M., Cooper, B., Brown, A.C. and Kalton, G.W. (1966). Psychiatric illness in general practice. Lon¬

don: Oxford University Press.

Shortell, S.M. and Daniels, R.S. (1974). Referral relationships between internists and psychiatrists for fee-for-

service practice: An empirical examination. Medical Care, 12:229-240.

Solomon, G., Hiesberger, J. and Winer, J.L. (1981). Confidentiality issues in rural community health. Journal of

Rural Community Psychiatry, 2: 17-3 1 .

Steinberg, H., Torem, M. and Saravay, S.M. (1980). An analysis of physician resistance to psychiatric consulta¬

tions. Archives of General Psychiatry, 37:1007-1012.

Strain, J.J., Pincus, H.A., Houpt, J.L., Gise, L.H. and Taintor, Z. (1985). Models of mental health training for

primary care physicians. Psychosomatic Medicine, 47(2):95-l 10.

Sullivan, G., Jackson, C.A. and Spritzer, K.L. (1996). Characteristics and service use of seriously mentally ill 1

persons living in rural areas. Psychiatric Services, 47(4): 57-61 .

US Congress, Office of Technology Assessment. (1990). Health care in rural America (OTA-H-1 13). Washing¬

ton, DC: US Congress.

US Department of Health and Human Services, Office of Data Analysis and Management. (1984). The hidden

mental health network: Provision of mental health services by non-psychiatrist physicians. Rockville, MD:

Department of Health and Human Services.

Wagenfeld, M.O., Goldsmith, H.F., Stiles, D., Longest, J. and Manderscheid, R.W. (1990). Inpatient mental

health services in nonmetropolitan counties. Unpublished manuscript.

Watts, C., Scheffler, R. and Jewell, N. (1986). Demand for outpatient mental health services in a heavily insured I

population: The case of Blue Cross and Blue Shield Association’s federal employees health benefits program.

Health Services Research, 21:267-289.

Werkman, S.L., Mallory, L. and Harris, J. (1976). The common psychiatric problems in family practice. Psycho¬

somatic s ,17:119-122.

Wilkinson, G. (1989). Referrals from general practitioners to psychiatrists and paramedical mental health profes- •

sionals. British Journal of Psychiatry, 154:72-76.

Zimmerman, M.A. and Wienckowski, L.A. (1991). Revisiting health and mental health linkages: A policy whose

time has come. ..again. Journal of Public Health Policy, 12(4):5 10-524.

Journal of the Washington Academy of Sciences,

Volume 86, Number 3, 143-158, December 2000

Cost Dynamics of Frontier

Mental Health Services

James E. Sorensen, Ph.D., CPA

Abstract

New emphasis is being placed on the cost of providing mental health services to frontier

communities. In part this reflects the growing importance of managed behavioral health

care organizations in both rural and urban areas and their emphasis on cost containment and

in part the growing importance of mental health as part of total health care. These trends

result in demands for more organized and efficient services in rural and frontier areas. The

ultimate goal is to provide mental health care equal to or better than in the past for less cost

with more accountability. Coping with these condition in a frontier mental health setting

requires both efficiency and effectiveness. Efficiency is the accomplishment of objectives

at a minimum cost, while effectiveness measures how well objectives are achieved. This

paper provides information on how key tools of cost analysis can aid managers of frontier

mental health programs to obtain both effectiveness and efficiency in a developing man¬

aged care environment.

Introduction

Mental health programs in frontier areas of the United States face many challenges,

i Frontier areas suffer from a lack of health-care resources (any resources present are

J often underfunded and understaffed) and an absence of integrated health-care systems.

Funding methods are changing as Medicaid expenditures grow and federal funds to

i states and local governments are concurrently cut. New service systems are developing

with a shift from provider-centered to client-centered services. Pressures are increas¬

ing for assessment of client and program outcomes and effectiveness. Demands are

also increasing for more organized and efficient services, all resulting in a thrust toward

managed care (Broskowski, 1991; Feldman, 1992; Wagenfeld, Murray, Mohatt and

DeBruyn, 1994; Van Hook and Ford, 1995; Minden and Hassol, 1996; Manderscheid

and Henderson, 1997; “Study Finds Mental Health Spending,” 1998).

Managed care is now an omnipresent pressure in health care (American Managed

Care and Review Association [AMCRA], 1995). State mental health authorities

(SMHAs) are reporting widespread current (or intended) use of managed care opera¬

tions or contracts and the use of Medicaid funds to finance managed care (Sherman,

Zahniser and Smukler, 1995). While some states with large frontier populations show

low penetration of managed care, states with somewhat smaller frontier populations

show higher utilization of managed care (AMCRA, 1995). In mental health services.

144

JAMES E. SORENSEN

managed care seeks to reduce or eliminate unnecessary services, reduce the costs of

care and maintain or increase effectiveness. The aim is to improve client outcomes,

control costs, and decrease system fragmentation. The ultimate goal is mental health

care equal to or better than in the past for less cost and with more accountability. How¬

ever, managed care is not without its critics or problems. Managed behavioral health

care in its various forms appears to reduce costs and improve access, but the effect on

quality has not been conclusively demonstrated (Minden and Hassol, 1996). Reduction

of costs in public sector managed behavioral health care programs also remains incon¬

clusive (Minden and Hassol, 1996).

As mental health services increase as a part of total health services (Broskowski,

1991), new emphasis is placed on costs and outcomes of these services (Mirin and

Namerow, 1991). Managing care requires careful documentation of the costs of ser¬

vices and of clinical outcomes. Strategies to monitor and assess treatment plans and

outcomes take many forms ranging from preadmission reviews, continuing treatment

authorizations, concurrent review, screens (often computerized), to performance out¬

come measures (Austin, Blum and Murtaza, 1995). This documentation of cost and

outcome can be used, in addition, to respond to consumer and management concerns.

Consumers (including clients, employers and payers) are beginning to demand account¬

ability for the consumption of resources and the client outcomes in mental health pro¬

grams. Good managers of mental health programs need to know how well their

program and their clients are doing. Information systems (IS) to meet these needs

should focus on systematic cost reports, indicators to assess clinical outcomes, and

analyses of costs and outcomes to evaluate cost-effectiveness. Today’s complex mental

health environment gives neither easy nor clear-cut guidelines for these information

requirements.

Coping with these constraints and opportunities in a frontier mental health setting

requires both efficiency and effectiveness. Efficiency is the accomplishment of objec¬

tives at a minimum cost, while effectiveness measures how well objectives are achieved.

This Letter focuses on how the key tools of cost analysis can aid the manager of frontier

mental health programs in the developing managed care environment. Subsequent Let¬

ters to the Field will cover the topics of linking costs and client outcomes and choosing |

cost-effective management strategies.

Cost Analysis and Reporting

Managers of frontier mental health organizations are expected to acquire and use

resources to create effective mental health services at minimum cost. Cost containment

is also a primary motivation for today’s health care reform (Freeman and Trabin, 1994).

Sound cost management requires an understanding of cost behavior, cost distinctions

for planning and control, and unit-of-service costs (Sorensen, Hanbery and Kucic, 1983).

COST DYNAMICS OF FRONTIER MENTAL HEALTH SERVICES

145

Unit cost information will be increasingly important in the era of managed mental health

care (McFarland, Smith, Bigelow and Mofidi, 1995; Zelman, McCue and Millikan,

1998).

Cost behavior — in total. Management accounting examines cost behavior in

relation to volume of activity. As volume of activity varies, a cost may increase pro¬

portionally to volume (a variable cost), may not change as volume changes (a fixed

cost) or may change in stepwise fashion (a step-variable cost) as volume changes. Some

costs may contain both variable and fixed components and are called “mixed costs.”

The left column of Figure 1 portrays the graphical behavior of these total costs. Copy¬

ing costs, for example, may vary directly with the number of copies (e.g., a variable

cost), while annual lease payments may remain constant (e.g., a fixed cost) regard¬

less of client volume. The number of administrative assistants may increase as the

volume of activity (e.g., number of contracts) changes. This cost behaves in a stair-step

fashion (e.g., step- variable cost), since each assistant can handle up to a certain number

of contracts before another assistant is required. Utilities like heat and light may be

mixed costs if there is a minimum (fixed) charge regardless of the level of service

and a variable component depending of how much gas or electricity was used beyond

the minimum.

Cost behavior — per unit. These cost categories, however, take on different be¬

haviors when expressed on a per unit basis. Variable costs on a per unit basis are

assumed to be constant. For instance, the first copy costs the same as each subsequent

copy. Fixed costs, on the other hand vary inversely with volume. For example, the

constant monthly rent is divided by a varying number depending on the volume; lower

volumes create higher unit costs while higher volumes create lower unit costs. The

I step- variable and mixed costs tend to vary inversely with volume since they have a

mixture of variable and fixed costs (e.g., the variable costs are constant per unit while

the fixed costs vary per unit depending on the volume, thus leading to a decreasing cost

per unit as volume increases). The right column of Figure 1 portrays the graphical

behavior of these unit costs.

Short-run behavior of cost and volume changes deserves a special comment. If a

step-variable cost is increased, the cost of the first few units of service after the new

cost step is added may be higher than the former unit cost. As volume increases, how¬

ever, the unit cost drops and is expected eventually (as economic return-to-scale emerges)

jto be lower than the unit cost before the new cost is added. For example, assume the

following:

A cost of $ 1 0,000 divided by the volume of 1 ,000 units of service equals

a $10 unit cost ($10,000 / 1,000 = $10). If $5,000 is added for a new

cost of $ 1 5,000 and the expected new volume at full operation is 2,000

units of service, the final cost per unit will be $7.50 ($ 1 5,000 / 2,000 =

$7.50). As the operational volume adjusts upward, however, the early

146

JAMES E. SORENSEN

periods may show a volume greater than the original 1,000, but less

than the expected level of 2,000 (say, 1 ,200 units). In this case, the unit

cost is $12.50 ($15,000 / 1,200 = $12.50) and that is higher than the

original unit cost of $10. If these costs and volumes are graphed, the

display shows a jagged cost curve with little spikes where you add the

new cost. When the scale of the graph is reduced (such as in Figure 1),

the curve appears to be smooth.

Cost distinctions for planning and control. Fixed costs can be either committed

or discretionary. Committed fixed costs are fundamental (e.g., property taxes, bond

interest payments, key personnel) and reflect long-run capacity needs. Typically these

costs are not responsive to short run variations in activity. Discretionary fixed costs, on

the other hand, are periodic costs influenced by management decisions (e.g., scheduled

maintenance, staff training, professional travel). They often bear little relationship to

volume of activity. In times of hardship, discretionary fixed costs are subject to reduc¬

tion, although long-term effects can be negative.

Variable costs are either engineered or discretionary. Engineered costs represent a

defined cost to produce a given service or product (e.g., cost of a psychologist to per¬

form testing). Shifts in engineered costs change the resulting service or product (e.g.,

moving from a Ph.D. to a Masters level psychologist). Discretionary variable costs

represent managerial choices that may be altered without a fundamental effect on the

service or product (e.g., switching from a brand name drug to a generic type).

When management is looking for short-term cost reductions, discretionary variable

and discretionary fixed costs become prime targets. Often these costs are subject to

reduction without immediate adverse effects, but, some, if postponed indefinitely, will

produce adverse effects (e.g., training or maintenance).

Unit-of-service costs for rate-setting, contracts and performance evaluation.

Unit-of-service costs serve several essential purposes:

• Rate-setting and cost estimating for varied contract negotiations. Contracts

should be based on the cost of services. As capitation contracting spreads, the

capitation rate should be a function of the aggregated costs derived by the unit-

of-service costs times estimated utilization for a package of services proposed for

a targeted population. Unit-of-service costs (especially budgeted or projected

ones) are fundamental financial tools as a provider assumes risk in meeting the

needs of a covered population with a predetermined rate per participant.

• Highlighting inappropriate rates charged or productivity problems. The cost per

unit of service is a powerful summary of resource consumption and level of

activity for a period of time (e.g., annual cost per hour of individual outpatient

service). When dividing the costs by the units of service there may be, for

example, excessive costs (in the numerator) or poor productivity (in the denomi¬

nator) that could produce unacceptable unit costs.

sit

is

pn

It

i

COST DYNAMICS OF FRONTIER MENTAL HEALTH SERVICES

147

• Maintaining financial control. By comparing budgeted unit costs to actual unit

costs managers possess a straight-forward, yet potent and understandable key

performance indicator. Comparison of actual results to the budget is the under¬

pinning of financial control. The ideal ratio would be 1.0 (actual cost divided by

budgeted cost = 1.0). If the actual cost exceeds the budget, the ratio is greater

than 1.0. For instance, if the actual cost is $150,000 and the budgeted cost is

$100,000, then the ratio is $150,000/$ 100,000 or 1.5 or 150% of the budget. If

the actual cost is $90,000 and the budget is $100,000 the ratio is .9 or 90% of

budget ($90,000/$ 100,000 =.9 = 90%). Both favorable and unfavorable vari¬

ances should be investigated. While over-spending may be problematic, under¬

spending may be masking a failure to make needed expenditures (e.g., routine

maintenance).

• Benchmarking against the unit costs of outstanding organizations. A provider

organization can move to superior performance by measuring its performance

against the best-in-class providers, determining how the best-in-class achieves its

cost levels and then using the information to set targets, strategies and implemen¬

tation.

• Performing cost-outcome and cost-effectiveness reviews. The resources con¬

sumed for a particular target group may be estimated with the unit-of-service

costs along with levels of service (viz., unit-of-service cost x number of units

received = resources consumed). Estimated costs can be linked to the target

group outcomes to produce a cost-outcome analysis. Comparisons of cost-

outcomes enable program managers (and funders) to select the most cost-effec¬

tive services or programs.

Unit-of-service cost procedures. Costs are associated with some activity, event,

situation, product, or service — in short, with some cost objective. If the cost objective

is the unit cost of services (or cost-per-unit), competent cost- finding requires ten (10)

procedures (Vermont Department of Mental Health, 1988).

ten Cost-Finding Procedures

Procedure Description

1 . Identify and document the organizational units and the services (or programs) of

each unit of the organization.

2. Assign the direct salary and wage cost to each organizational unit and to each

service (or program).

3. Determine the cost of fringe benefits (e.g., social security, vacation, insurance,

education leaves) and assign (estimated) fringe benefits to each organizational

unit and to each service (or program).

148

JAMES E. SORENSEN

Figure 1 . Cost Behavior

COST:

VARIABLE

Total

Per Unit

Constant

Volume

FIXED

Varies Inversely

With Volume

STEP-

VARIABLE

Varies Inversely

With Volume

MIXED

Total Cost

Volume Volume

Average Total

Cost Per Unit

at Varying Volumes

Depending on MIX

of Variable, Fixed

and Semivariable Costs

COST DYNAMICS OF FRONTIER MENTAL HEALTH SERVICES

149

4. Assign other direct and traceable expenses to each organizational unit and to each

service (or program).

5. Assign indirect operating expenses by organizational unit and service (or pro¬

gram).

6. Estimate and assign the value of donated services, supplies and facilities (e.g.,

essential volunteers’ services or “in kind” expenses) to each organizational unit

and to each service (or program).

7. Assign the costs of administrative and support units to other organizational units

and to services (or programs).

8. Determine the most feasible basis for unitizing the services provided by the

organization.

9. Identify the actual (or estimated, if prospective) annual (or some other period)

amount of service for each service (or program).

10. Compute the unit cost rate for each service (or program) (step 7 divided by

step 9).

Table 1 summarizes these 10 cost-finding procedures required to pro¬

duce unit costs for services. Each procedure is linked to an illustrative

example in Figure 2. Procedure 1 identifies the organizational units

and services as one administrative (and other support) services and two

mental health services (A and B) in this hypothetical example. Costs

are assigned to each service using procedures 2 through 6.1 Costs are

totaled for administration ($60,000) and for the two services (A =

$300,000 and B = $200,000). Procedure 7 assigns the administration

costs of $60,000 based on the relative cost of each service program

(A= $300,000, B= $200,000) to the total organization costs less the

assigned costs ($560,000 less $60,000 = $500,000). A is assigned

$36,000 ($300,000/$500,000 or 60% of $60,000) and B is assigned

$24,000 ($200,000/$500,000 or 40% of $60,000). Total program costs

are $336,000 for A ($300,000 + $36,000) and $224,000 for B ($200,000

+ 24,000). Procedure 8 defines the units of service and procedure 9

inserts actual (or estimated) levels of service (A = 6720 and B = 3200).

Procedure 10 computes the cost of per unit of service for A at $50

($336,000/6720) and $70 for B ($224,000/3200).

Activity-based costing suggests costs should be assigned to cost pools and then to

specific services. This two-stage allocation procedure can result in improved cost as¬

signments. For instance, the costs of an information system (e.g., IS personnel, com¬

puter, processing costs) may be collected in a cost pool and then assigned to organiza-

150

JAMES E. SORENSEN

tional units based on use (e.g., number of transactions or hours of usage). Administra¬

tive costs may also be collected in a cost pool and assigned to other organizational units

based on the number of full time equivalent (FTE) personnel (e.g., two half-time per¬

sons equal one FTE) employed in each unit (e.g., if a unit had 1 FTE out of a total of 10

FTE in the organization, the unit’s assignment would be 10%).

An illustration of unit costing with typical services. Typical frontier organiza¬

tions offer five to seven services. Versions of these services along with illustrative

definitions include:

• Residential - usually a non-hospital, 24 hour care with varying levels of support

for room, board and supervision; in some cases, a single category or varied

combinations of support are separate services (i.e., living support).

• Partial or day-treatment - contact may be of varying lengths, but activities are

generally programmatically linked. A long partial-day, for example, may be

more than four (4) hours but less than 24 while a short partial-day as another

service may be two (2) hours, but less than (4) hours.

• Group - therapeutic contact with more than one client up to a predetermined time

(i.e., up to including two (2) hours).

• Individual - services may be apportioned on time (e.g., brief = up to and includ¬

ing 30 minutes or conventional = more than 30 minutes, up to and including two

(2) hours) or the character of the service (e.g., early intervention).

• Case management - activities that focus on the deployment of the service plan

(defined comprehensively to include the mental health treatment plan and plans

of other care providers to meet the needs of the client).

• Other mental health services - a variety of other mental health services found

in frontier centers. Illustrative services are inpatient (a 24 hour day in a

facility licensed as a hospital by the State in or near the community, but are not

state operated mental health institute days), vocational, senior support, and

prevention.

Appendix A contains an extended example adapted from an actual frontier mental

health organization. It illustrates the foregoing procedures using seven services found

typically in frontier service delivery organizations and it offers a guide for the frontier

mental manager embarking on an (or evaluating a current) unit-of-service costing

system.Use as a key performance indicator in financial management. Managing men¬

tal health organizations with key performance indicators, including unit costs, is ex¬

panded by Sorensen, Zelman, Hanbery and Kucic (1987) to 25 measures covering the

mixes of revenues, clients, staff and services. When unit cost performance indicators

are computed as budgetary estimates and then compared to actual achievements, the

comparison (of budgeted to actual cost per unit of service) can be used to maintain

financial control of services and programs. Apparent performance deficiencies (Sherman,

1986) of a service or program indicator may be a function of:

COST DYNAMICS OF FRONTIER MENTAL HEALTH SERVICES

151

1. Problems with the systems that generate, aggregate and report the data used to

calculate the index — data deficiencies

2. Problems with the reliability or validity of the index — psychometric deficiencies

3. Problems with the standard used — inappropriate standards

4. Problems with the operation of the entity whose performance is being mea¬

sured — numerator and/of denominator issues.

If an entity is not performing up to standards, managerial attention may focus on

unit costs where the numerator is cost and denominator is units of service. Numerator

issues may include excessive professional, support, operating or overhead costs. De¬

nominator issues may include time devoted to indirect services, time used in adminis¬

trative activity, time lost in poor time management, excessive leave time, poor produc¬

tivity requirements, and excessive staff turnover.

More refined unit service costs. The Substance Abuse and Mental Health Ser¬

vices Administration (S AMHS A) has sponsored research (Capital Consulting Corpora¬

tion, 1993) to produced more refined unit service costs. These unit service costs disag¬

gregate the earlier analyses into more specific component costs based on activity based

cost (ABC) methods. The approach identifies the activities of the service path in more

detail. The following service events are identified and applied to measure program cost

profiles (Capital Consulting Corporation, personal communication, 1996):

Initial assessment, medical examination, psychosocial evaluation, in¬

dividual counseling, group counseling, medical and diagnostic services

(with HIV testing and counseling identified separated), housing, clini¬

cal case management, networking and outreach, client transportation,

child care services, client education and staff education.

A traditional step-down allocation assigns depreciation, rent and interest, adminis-

; trative, and other support services to the client-oriented services. An illustrative appli-

: cation of these newer methods is found in Anderson, Bowland, Cartwright and Bassin

j (1996, in press) applied to substance abuse treatment program costs. The expanded

1 level of analysis requires a more sophisticated cost accounting and statistical informa-

I tion system than is found usually in frontier mental health organizations.

r Costs not discussed. A comprehensive concept of costs includes the use of re-

I I sources, loss of resources and money transfers (Kamper- Jorgensen, 1976). Theforego-

■ ing analysis bears only on the resources used to provide direct mental health care by a

specified organization . Left out are direct services received from other providers

e (e.g., state hospital inpatient stays, social services), private costs of clients (e.g., trans-

Lportation to receive mental health services, family burden), loss of resources (e.g.,

e time-off from work or illness episode [loss of earnings and labor productivity], perma-

n nent disability [capitalized losses of earnings and labor productivity], destroyed private

J

152

JAMES E. SORENSEN

or public property [via accidents]), and money transfers (e.g., governmental benefits or

pensions and personal income taxes paid). Sharfstein and Clark (1978), however, chal¬

lenge public money transfers as “costs.”

Money transfers such as public aid, disability pension pay, disability insurance re¬

ceipts or other cash payments do not use up resources, but only transfer title to re¬

sources from one group to another. The expanded version of costs is more likely to be

accounted for in controlled cost-effectiveness or cost-benefit research studies.

Role of the Independent Public Accountant (Auditor). In most states with fron¬

tier service areas, the independent public accountant (usually a Certified Public Ac¬

countant or CPA), is required to examine and report on the financial statements of the

mental health organization(s). Audits by a CPA requires * adherence to the American

Institute of Certified Public Accountants (AICPA) Audits of Providers of Health Care

Services (1994), referred to as the Health Care Audit Guide , or the AICPA Audits of

Not-for-Profit Organizations (1996), referred to as the Not-for-Profit Audit Guide. The

Health Care Audit Guide applies to 1) investor-owned businesses, 2) not-for-profit en¬

terprises with no ownership interest and are essentially self-sustaining from fees or 3) a

governmental entity. The Not-for-Profit Audit Guide may be appropriate for a non¬

governmental Voluntary Health and Welfare Organization (VHWO) if a not-for-profit

organization provides services to individuals, but derives its revenues primarily from

voluntary contributions. The not-for-profit status implies 1) contributions are a signifi¬

cant source of resources and the resource providers do not expect any meaningful pecu¬

niary returns, 2) operating purposes other than profits, and 3) an absence of a business

type ownership. A mental health organization that derives a majority of its support

from public grants and donations (rather than fee for services, capitated care contracts

or other health care payment arrangements) may use the audit guide for Guide for Not-

for-Profit Organizations.

If an organization qualifies as a non-governmental VHWO, then a Statement of

Functional Expenses is required (along with the Balance Sheet, the Statement of Ac¬

tivities, and the Statement of Cash Flows). The Statement of Functional Expenses

assigns costs to program services and supporting services of the organization. When

these costs by service are related to the units of service provided, unit costs can be

derived.

Alert funding agencies (e.g., State Department of Mental Health) will add addi¬

tional reporting requirements for the auditor to review and evaluate the statistical infor¬

mation system and to express an opinion on the units of service and/or clients service in

relation to the basic financial statements taken as a whole and the related costs per unit

of service. Typically the independent auditor is involved in detecting undisclosed li¬

abilities. A major liability could arise because of inaccurate reporting on costs and

services to one or more funding agencies. Because of a need to identify undisclosed

liabilities as part of the audit, the independent auditor must review both the accounting

a

{

i

c

n

o

S

t(

a,

ai

*

Ii

el

to

COST DYNAMICS OF FRONTIER MENTAL HEALTH SERVICES

153

and statistical systems related to unit costs, thus nominal costs are incurred usually by

expanding the reporting requirements to unit-of-service costs. By adding the indepen¬

dent auditor's opinion to the unit costs, however, the power and credibility of the unit

costs are increased enormously. Now the unit costs are appropriate for contracting,

reimbursement, internal financial management and as an input to cost-outcome and

cost-effectiveness analyses.

For Colorado mental health service providers funded by the Department of Human

Services — Mental Health Services, as an example — the independent auditor is required

to review the expenses assigned to services and the accumulation of units of service

and is required to express an opinion on the service unit costs (see “Chapter 5: Auditing

and Financial Reporting Guidelines” in the 1997 Accounting and Auditing Guidelines ,

Mental Health Services, Colorado Department of Human Services.)

Implications for Behavioral Health Care

In this paper key tools of cost analysis were provided so as to facilitate efficient and

effective management of frontier mental health programs. The implications of these

tools for behavioral health can be summarized as follows:

• Managers of frontier mental health organizations are expected to find and use

resources to create effective mental health services at a minimum cost.

• Frontier mental health programs face several challenges including managed care.

Managed mental health care seeks to reduce or eliminate unnecessary services,

reduce the costs of care, maintain or increase effectiveness and provide services

satisfying to the customer. The effort is to decrease system fragmentation,

improve client outcomes, control costs and please customers. Managed care

reflects the emerging Continuous Quality Improvement (CQI) focus by providing

“. . . the right care . . . delivered] to the right patients at the right time in the

right way” (Freeman and Trabin, 1994).

• Sound cost management requires an understanding of cost behavior, cost distinc¬

tions for planning and control and unit-of-service costs. Unit-of-service costs are

a key performance indicator in effective financial management.

• Funding agencies should require the independent public accountant (auditor) to

include the assignment of expenses to services, the accumulation of units of

service and the unit-of-service cost as part of the audit opinion to enhance the

credibility of unit costs in financial management, contract negotiations and

accountability, and cost-outcome (and cost-effectiveness) analyses.

• Comparing the costs and outcomes of optional services enables cost-effective

choices among services and programs.

• To survive realistically in an unsettled environment, frontier mental health

programs need to document costs, clinical outcomes and client satisfaction.

154

JAMES E. SORENSEN

APPENDIX A

Schedule of Unit Costs Example

The Schedule of Unit Costs (Figure A.l) follows the 10 procedures outlined in

Table 1 and Figure 2.

Procedure 1:

Identify and document the

organizational units and the

services of each unit of the

organization

Procedure 2: Assign the

direct salary and wage cost to

each organizational unit and

to each service (or program).

Procedure 3: Determine the

cost of fringe benefits (e.g.,

social security, vacation,

insurance, education leaves)

and assign (estimated) fringe

benefits to each organizational

unit and to each service ( or

program).

Procedure 4: Assign other

direct and traceable expenses

to each organizational unit

and to each service ( or

program).

Procedure 5: Assign indirect

operating expenses by organi¬

zational unit and service ( or

program).

Nine categories of costs were identified and listed in

the column headings, including administrative and

other support services, seven mental health services

and non-mental health services.

The analysis for Procedure 2 and 3 starts with a

Schedule of Time Allocation (Figure A.2). Using time

reported in each major service, this schedule deter¬

mines the compensation cost allocations for the seven

services offered by the frontier mental health center.

The cost data from Figure A.2 are imported into the

Schedule of Unit Costs (see line 1 of Figure A. 1).

Costs for direct and indirect operating expenses are

extracted from the accounting general ledger system

for all of the services including administration and non¬

mental health services (See lines 2 and 3 of Figure

A.l).

COST DYNAMICS OF FRONTIER MENTAL HEALTH SERVICES

155

Procedure 6: Estimate and

assign the value of donated

services, supplies and facilities

(e.g., essential volunteers'

services or “ in kind ” ex¬

penses) to each organizational

unit and to each service ( or

program).

Procedure 7: Assign the costs

of administrative and support

units to other organizational

units and to services (or

programs).

There are no donated services, supplies or facilities in

this mental health center.

The administrative and support unit costs of $195,000

are assigned proportionally to each of the seven

services and non-mental health services based on the

ratio of the individual service ’s cost to the total organi¬

zational costs less the administrative costs. For

example, the cost of residential service of $30,000 (line

4 in Figure A.l) divided by the total costs of the organi¬

zation (i.e., $899,500 - $195,000 = $704,500) equals

an assignment ratio of .042583. Multiplying the total

administrative costs by this assignment ratio gives an

assigned administrative cost of $8304. In terms of a

formula:

Admin $ x [Service $ before Admin $ / (Total costs - Admin $) ] =

Assigned Admin $

$195,000 x $30,000 / ($899,500-$! 95,000) =$8,304

or

Admin $ x (Assignment Ratio) = Assigned Admin $

$195,000 x .042583 =$8,304.

In other words, for every dollar of cost incurred by the

residential service, slightly over $0,045 (or 4 and _

cents) are assigned for administration. The remaining

services are computed in a similar fashion until the

$195,000 is assigned to all services including non¬

mental health services (See line 5 of Figure A.l).

156

JAMES E. SORENSEN

Procedure 8: Determine the

most feasible basis for unitizing

the services provided by the

organization.

Procedure 9: Identify the actual

(or estimated, if prospective)

annual (or some other period )

amount of service for each type of

service (or program).

Procedure 10: Compute the unit

cost rate for each service (or

program) (step 7 divided by step

9).

The seven mental health services are defined by

the state contract and the units of service are

computed from a time analysis of staff working

in each service. Because the agency uses a log

system, both staff time and client unit of services

data are captured. Staff time spent in each

service is used to assign compensation costs to

each service (Procedure 1) and the total units of

service from the Schedule of Time Allocation

(Figure A.2) is carried forward to fine 7 of the

Schedule of Unit Costs (Figure A. 1). Units of

service could also be gathered from other

sources, e.g., service rendered documents.

The unit cost rates are computed on line 8 of the

Schedule of Unit Costs (line 6 divided by fine 7

on Figure A. 1).

The remaining lines on Figure A. 1 are adjustments made to comply with state regu¬

lations and reporting requirements. Line 9 subtracts donated resources (since they are

not allowed by the state) to compute a net reimbursable rate on line 10. Since there are

Figure A. 1 . Schedule of Unit Costs

FRONTIER MENTAL HEALTH

Schedule of Unit Costs

for year ended 19B

# EXPENSES

TOTAL Administration

COSTS and other Residential Partial Day Individual Group

support

Case Non-Mental

Brief Management Vocational Health

1 Compensation (see time allocation)

2 Other direct and traceable

3 Indirect

4 TOTAL $ 899,500 $ 195,000 $ 30,000 $ 21,500 $ 275,000 $ 71,000 $ 67,000 $ 72,000 $ 28,000 $ 140,000

5 Assignment of administration $ (195,000) $ 8,304 $ 5,951 $ 76,118 $ 19,652 $ 18,545 $ 19,929 $ 7,750 $ 38,751

6 TOTAL PROGRAM $ 899,500 $0 $ 38,304 $ 27,451 $ 351,118 $ 90,652 $ 85,545 $ 91,929 $ 35,750 $ 178,751

COSTS _

7 UNITS of SERVICE (see time allocation) I 672 422 438 2590 1426 3ZB

COST DYNAMICS OF FRONTIER MENTAL HEALTH SERVICES

157

no donated resources in this example, the adjustments are all zero amounts. Line 1 1

identifies the unit cost rate from the prior fiscal year and computes a dollar change (line

12) and a percentage change from the prior year (line 13). Lines 12 and 13 are used to

track the changes in unit costs to assess the increasing (or decreasing) direction and to

test the reasonableness of rate changes from the prior year.

Figure A.2. Schedule of Time Allocation

FRONTIER MENTAL HEALTH

Schedule of Time Allocation

for year ended 19B

Case

Employee MH $ Residential: Partial Day: Individual: Group: Brief: Management: Vocational

io"# Allocated Units Hrs n% Allocation Units Hrs n% Allocation Units Hrs n% Allocation Units Firs n% Allocation Units Hrs n% Allocation Units Firs n% Allocation Units Hrs n% Allocation

231 $ 30,000 0 0 0 $ 0

258 $ 24,000 0 0 0 $ 0

356 $ 16,000 0 0 0 $ - 24

461 $ 16,000 672 600 0.5 $ 8,000 0

- detail omitted —

0 6% $ 1,800 500 550 6% $ 1,800 200

0 0% $ • 400 400 50% $ 11,925 400

75 8% $ 1,304 770 720 78% $ 12,522 165

0 0 $ - 0 0 0 $ 0

70 6% $ 1,800 150 50 6% $ 1,800

260 32% $ 7,752 140 45 6% $ 1,342

20 2% $ 348 50 25 3% $ 435

0 0% $ - 0 0 0% $

- detail omitted -

250 70 6% $ 1,800 10 10 1% $ 400

400 100 12% $ 2,981 0 0 0% $

100 70 8% $ 1,217 10 10 1% $ 174

0 0 0% $ - 0 0 0% $

589 $ 12,000 0 0 0 $ 0 0 0% $ - 180 195 43% $ 5,143 160 100 22% $ 2,637 50 ## 22% $ 2,637 240 60 13% $ 1,582 0 0 0% $

•Totals forwarded to Schedule of Unit Costs: see shaded cells)

References

American Institute of Certified Public Accountants. (1994). Audits of providers of health care services. New

York: Author.

American Institute of Certified Public Accountants. (1996). Audits of not-for-profit organizations. New York:

Author.

American Managed Care and Review Association. (1995). 1994-95 managed health care overview. Washing¬

ton, DC: AMCRA Foundation.

Anderson, D.A., Bowland, B.J., Cartwright, W.S. and Bassin, G. (1995). Drug abuse treatment costs: Findings

from a new methodology. Research Triangle Park, NC: Research Triangle Institute, Center for Economics

Research.

Anderson, D.A., Bowland, B.J., Cartwright, W.S. and Bassin, G. (in press). Service level costing of drug abuse

treatment. Journal of Substance Abuse Treatment.

Austin, M.J., Blum, S.R. and Murtaza, N. (1995). Local-state government relations and the development of

public sector managed mental health care systems. In M.J. Austin and S.R. Blum (Eds.), Public sector plan¬

ning for managed mental health care. Administration and Policy in Mental Health , 22(3):203-215.

Broskowski, A. (1991). Current mental health care environment: Why managed care is necessary. Professional

Psychology: Research and Practice, 22:6-14.

Capital Consulting Corporation. (1993). Uniform system of accounting and cost reporting for substance abuse

treatment providers (SAMHSA contract number 271-91-8327). Fairfax, VA: Author.

Colorado Department of Human Services, Office of Health and Rehabilitation Services, Mental Health Services.

(1997). Accounting and auditing guideline. Denver, CO: Author.

Feldman, S. (1992). Managed mental health services. Springfield, IL: Charles C. Thomas.

Freeman, M. and Trabin, T. (1994). Managed behavioral healthcare: History, models, key issues, and future

course. Rockville, MD: U.S. Center for Mental Health Services, Substance Abuse and Mental Health Services

Administration.

Kamper-Jorgensen, J. (1976). Cost-benefit analysis in mental health services. Copenhagen: World Health Orga¬

nization.

158

JAMES E. SORENSEN

Manderscheid, RW and Henderson, MJ (1997). Federal and state legislative and program directions for managed

care. In E.J. Mullen and J.L. Magnabosco (Eds.), Outcomes measurement in the human services : Cross¬

cutting issues and methods. Washington, DC: NASW Press.

McFarland, B.H., Smith, J.C., Bigelow, D.A. and Mofidi, A. (1995). Administration and Policy in Mental Health,

23:27-42.

Minden, S. and Hassol, A. (1996). Final review of available information on managed behavioral health care.

Rockville, MD: Center for Mental Health Services.

Mirin, S.M. and Namerow, M.J. (1991). Why study treatment outcome? Hospital and Community Psychiatry,

42:1007-1013.

Sharfstein, S. and Clark, H.W. (1978). Economics and the chronic mental patient. Schizophrenia Bulletin, 4:399-

414.

Sherman, P.S. (1986). Uses of performance measurement systems. In C. Windle, J.H. Jacobs and P.S. Sherman

(Eds.), Mental health program performance measurement (DHHR Pub No. (ADM) 86-1441). Washington,

DC: National Institute of Mental Health.

Sherman, P.S., Zahniser, J. and Smukler, M. (1995). S.M.H.A.’s managed care practices. Evergreen, CO: re¬

sources for human service managers, inc.

Sorensen, J.E., Hanbery, G.W. and Kucic, A.R. (1983). Accounting and budgeting for mental health organiza¬

tions. Washington, DC: US Government Printing Office.

Sorensen, J.E., Zelman, W., Hanbery, G.W. and Kucic, A.R. (1987). Managing mental health organizations with

25 key performance indicators. Evaluation and Program Planning, 10:239-246.

Study finds mental health spending cut in half over last decade. (1998, May 7). Wall Street Journal.

Van Hook, M.P. and Ford, M. (1995). Linking mental and primary health care in rural areas. Administration and

Policy in Mental Health, 22:633-641.

Vermont Department of Mental Health. (1988). Mental health/mental retardation guidelines: Services, account¬

ing, auditing, key performance indicators. Montpelier, VT: Agency of Human Services.

Wagenfeld, M.O., Murray, J.D., Mohatt, D.F. and DeBruyn, J.C. (1994). Mental health and rural America:

1980-1993 An overview and annotated bibliography (NIH Publication No. 94-3500). Washington, DC: Office

of Rural Health Policy (HRS A) and Office of Rural Mental Health Research (NIMH).

Zelman, W., McCue, M. and Millikan, A. (1998). Financial management of health care organizations: an intro¬

duction to fundamental tools, concepts and applications. Malden, MA: Blackwell Publishers, Inc.

Notes

Donated supplies (or materials), services and facilities require additional discussion. If the organization is

using the American Institute of Certified Public Accountants (AICPA) Health Care Audit Guide, supplies are

recorded at fair market value and reported as non-operating gains (or other operating revenues if material in

amount). Under the same Guide, professional services may be recorded at fair market value and reported as

non-operating gains (or other revenues) if the services are significant and would be performed by salaried

personnel (if not for the volunteer), are subject to the usual employer-employee relationship, and are subject to

an objective valuation. The fair market value of donated facilities (e.g., rent-free building) is recognized when

placed in service. If a fixed asset is donated, then the timing of revenue and gain recognition is a function of

either unrestricted use by the governing board or use by donor- specified restricted purposes. Unrestricted

revenues and gains are recognized on an accrual basis while assets restricted for specified purposes are real¬

ized in the period they are used for the restricted purpose. If the organization is reporting as a non-government

Voluntary Health and Welfare Organization (VHWO), then guidance comes from the Financial Accounting

Standards Board, Statement of Financial Accounting Standards No. 116, “Accounting for Contributions Re¬

ceived and Contributions Made,” (June 1993). The fair market value of significant donated materials or

facilities or other assets used is reported as a contribution when received and as an expense when used or sold.

Donated services are reported as contributions and expenses (or assets) if the service (1) created or enhanced a

nonfinancial asset or (2) required specialized skills (e.g., accounting, medicine, pluming) provided by indi¬

viduals with those skills and would have to be purchased typically if the services were not donated. These

strict criteria preclude most volunteer services, for example in assisting staff work with agency clients

Journal of the Washington Academy of Sciences,

Volume 86, Number 3, 159-177, December 2000

Client Outcomes and Costs in Frontier

Mental Health Organizations

James E. Sorensen, Ph.D., CPA

Abstract

Managers of mental health organizations that serve frontier areas residents are expected to

acquire and manage resources to create effective and efficient mental health services. To do

this managers must document costs, outcomes and client satisfaction at a minimum to sur¬

vive the assault of managed care. As part two of a three-part series on frontier mental

health that includes (1) analyzing cost dynamics, (2) linking costs and client outcomes, and

(3) choosing cost-effective management strategies, this report builds a framework outlining

the role of costs and outcomes in cost-outcome and cost-effectiveness analyses. This paper

explores issues related to outcomes (to be linked with costs) and how cost-outcomes and

cost-effectiveness may be used as a management strategy in the operating frontier mental

health programs.

Introduction

Managers of mental health organizations that serve frontier area residents are ex¬

pected to acquire and manage resources to create effective and efficient mental health

services. Efficient cost management requires understanding cost behavior, applying

cost distinctions for planning and control, computing unit-of-service costs, using unit-

cost data in contracting and financial management and adding credibility to the unit-of-

service costs by including the opinion of an independent auditor. But the fast emerging

managed care environment requires more than just efficient cost management. Man¬

aged behavioral health care seeks to reduce or eliminate unnecessary services, reduce

and control the costs of care, and maintain or increase outcomes and effectiveness.

As costs are reduced, concerns surface about compromised quality of care or, more

specifically, poor clinical outcomes and meager client satisfaction. Knowing about

client outcomes with services can help identify costs to be enhanced, diminished or

reengineered. Outcome measures such as client functioning or symptomatic psycho¬

logical distress or quality of life appropriate for the age and client type should be con¬

sidered. Client satisfaction should also be measured. While not a measure of client

functioning, assessing client satisfaction is a key measure of program performance and

may be as important as treatment outcome. Standardized methods provide the ideal

160

JAMES E. SORENSEN

assessment approach for both outcome and client satisfaction. Comparing the costs

and outcomes of two or more services enables managers (and policy makers) to make

cost-effective choices among services and programs.

Frontier mental health programs must document costs, outcomes, and client satis¬

faction at a minimum to survive the assault of managed care. As part two of a three-

part series on frontier mental health that includes (1) analyzing cost dynamics, (2) link¬

ing costs and client outcomes, and (3) choosing cost-effective management strategies,

this report builds a framework outlining the role of costs and outcomes in cost-outcome

and cost-effectiveness analyses. This paper explores issues related to outcomes (to be

linked with costs) and how cost-outcomes and cost-effectiveness may be used as a

management strategy in operating frontier mental health programs.

Acquiring A Comprehensive View Of Mental Health Services

With the stimulus of widespread implementation of managed care, various healthcare

organizations are focusing on a comprehensive framework of analysis using broad

spheres of activity (or influence) called domains (MHSIP, 1996; ACMHA, 1997;

NASMHPD Research Institute, 1997 and 1998). While the list varies across organiza¬

tions, the domains generally include the four listed in the MHSIP Consumer-Oriented

Mental Health Report Card (1996):

• access — is a full range of needed services quickly and readily obtainable?

• appropriateness — do appropriate services address a consumer’s individual

strengths and weakness, cultural context, service preferences and recovery goals?

• outcomes — do services for individuals with emotional and behavioral disorders

have an effect on their well-being, life circumstances, and capacity for self¬

management and recovery?

• prevention — do preventive activities reduce the incidence of mental disorders by

(1) early identification of risk factors or precursor signs and symptoms of disor¬

ders and (2) increasing social supports and coping skills for those at risk?

An analysis of each domain can produce a robust set of categories and questions.

The MHSIP analysis of the domains focused heavily on the customer perspective. What

is the customers’ perception of access, appropriateness, and outcomes? Besides the

customer viewpoint, a mental health manager may want additional measures. For ex¬

ample, access includes continuity of care, integration of physical and behavioral health

care, use of hospitalization, success at engaging specific target populations (or penetra¬

tion rates) and assessments of waiting time. The other domains expand in the same

way. A suggested expansion is shown in Table 1 . Many of the questions surrounding a

domain are pervasive and may emerge at a service or program level or, perhaps, at a

county or state level. When a frontier service provider tries to select from the bewilder¬

ing number of interesting and relevant questions, s/he is compelled to make choices

CLIENT OUTCOMES AND COSTS IN FRONTIER MENTAL HEALTH

161

+2 o

I |

1 g

i s

u g

Vh

% Q

<d

»■ .o

cd >

g L

a <u

<3 ro

O-

1 o

* <

T3 cd

I s

a, °

£-1

B 3

cd cr

o 0)

Oh -d

8.1

CO CD

•9 3

cd Qh

& d

£ o

8 ©

co c

CD (D

d -T3

2 -s

.2 £

Oh O

O

& K

g 2

£h2

CD C

SO

M

2 s

CO ?d

^ E

o cd

CD (D

-d -O

(D

d d

o cd

TO CO

d <u

2 ^

<+H

d

O

'3

d

E

a>

Dd

«* C

o S

c/3 O

d 2

<D T3

d3 d

o cd

£ x V.

o

.2 |

cd co

*-' <d

CD 43

d3 ^

^ cd

• 2 cd

l^cE

£ CO

g e

O, 5

CO ts

cd

g ^

£ id

2 fcJ

g <2

3 2

£ 2

cd cd

§ ®

g £

^ £

to d

o d

u u

o -d

-d ~

■TO (D

.2 £

o xs 3

• to <D ^

CO > -To

•2 £ £

•d CD o

q co d

Td U cd

^ TO &

h_. d d

d a

.2^2

Oh ^ ."S

g ±3

(L>

O !d d

CD C CO

GO O O

cd d £

■TO <H_ C+H

g O °

O « O

g '■£

Oh C

O CD o

TO Oh -to

cd cd cd cd ^ cd

#J2 C/5 C/3 C/3 C/3 C/3 <Z) C/3

£ £

to M fC) d- (O vo

to cs to fn d- in

g .2

cd td o

S

o o rd ^

£ g * |

c|| g

^ 2

o 3

DO

T3

d

cd

"cd

o

‘3

>v

2 -f 8

Ho

CD

d

-d

<D

l-i

o

d

CD

£

>>

o

’Hh

£

<D

cu .+3

0 2 X cu

o o

O u

Oh** 2

4ro 3 g

0 Oh £

§ &•§

•to cd -to co

2 § fc o

Sb J2 g >

2 o o iro

S S CD

£ ^ &H

8 .g

8 °

CD > 2

d to >

d cd d

g d o

*‘e| I f >

d ’rt

O D

2 -to

.£ ^ -TO C-l— I TO CD TO

§3 “ ^'o c O

“ m2c2 5 H.

„ - £ * -s J e

to c, dO-TO^cj 3 >,

UdHUHEhjcyc^c/ion

to- (N m toh vo t^-

cd

‘C

Oh

O

to (n m d- 'O i — ooov

Oh

<

^ ^ ^ ^ 5

TOTO^ffl't'n'Of'OOOV toH

O. d

.2 °

Cd 2

£ "d

c2 g

Interventions designed to reduce the risk of developing 2. What is the percentage of enrollees participating in preventive programs?

mental disorder

162 JAMES E. SORENSEN

because of limited resources such as time and money. This paper suggests several

questions may be more important than others given sparse resources. Two are promi¬

nent: service costs and client outcomes.

As mental health services increase as a part of total health services (Broskowski,

1991), new emphasis is placed on costs and outcomes (Mirin and Namerow, 1991).

Managing care requires careful documentation of the costs of services and of clinical

outcomes. Strategies to monitor and assess treatment plans and outcomes take many

forms ranging from preadmission reviews, continuing treatment authorizations, con¬

current review, screens (often computerized), to performance outcome measures (Aus¬

tin, Blum and Murtaza, 1995). This documentation of cost and outcome can be used, in

addition, to respond to consumer and management concerns. Now consumers (includ¬

ing clients, employers and payers) are beginning to demand accountability for the con¬

sumption of resources and the client outcomes in mental health programs. Good man¬

agers of mental health programs need to know how well their program and their clients

are doing. Information systems (IS) to meet this need should focus on systematic cost

reports, indicators to assess clinical outcomes, and analyses of costs and outcomes to

evaluate cost-effectiveness. Comparing the costs and outcomes of optional services

enables cost-effective choices among services and programs. Today’s complex mental

health environment gives neither easy nor clear-cut guidelines for these information

requirements.

Because the analysis of costs is pursed in a separate Letter to the Field, (No. 12,

“Cost Dynamics of Frontier Mental Health Services”), this paper will focus on issues of

measuring outcomes and linking to cost. Regardless of the programmatic or service

strategy taken, assessing the costs and outcomes is a vital first step in managing for

cost-effective mental health.

Outcomes

Concern for client outcomes was embedded in the traditional mental health pro¬

gram evaluation literature (Attkisson, Hargreaves, Horowitz and Sorensen, 1978; Ciarlo,

Brown, Edwards, Kiresuk and Newman, 1986). Today it is part of a larger quality

movement in health care known as Continuous Quality Improvement (or CQI). In the

corporate sector the movement is often called Total Quality Management (or TQM) and

is associated with improvements in employee morale and productivity, customer satis¬

faction, and financial viability (General Accounting Office, 1991; Ernst and Young,

1992). The CQI movement complements managed care as both focus on client out¬

comes. CQI in managed care calls for providing “. . . the right care . . . delivered] to

the right patients at the right time in the right way” (Freeman and Trabin, 1994). A

significant feature of this quality movement in health care is the reemergence of a con¬

cern for the client and how s/he feels about and responds to health care encounters.

CLIENT OUTCOMES AND COSTS IN FRONTIER MENTAL HEALTH

163

Shem (1994, p. 23), described the linkage between CQI and outcomes by observing

CQI focuses on a recipient and outcomes orientation with an emphasis on understand¬

ing how program processes are related to desired outcomes.” The application of CQI in

mental health, unlike health care, is in an early developmental stage (Rago and Reid,

1991; Evans, Faulkner and Hodo, 1992; Sluyter and Barnett, 1995). As purchasers and

providers press prices and costs downward, consumer concern about compromised qual¬

ity of care surface. Outcome management and practice guidelines programs may be

able to deliver consistent and high quality care by reducing practice pattern variation

(Freeman and Trabin, 1994).

Research on Outcomes. Outcome can be defined in many ways (Ware, 1997;

i Bergin and Garfield, 1993; Massey, 1991; Newman, 1980). The McGuirk, Zahniser,

Bartsch and Engleby (1994) study, using varying stakeholders, found a general prefer¬

ence for skilled coping, safety, and symptom reduction as measures of outcome. Ranked

closely behind were customer involvement and social functioning. All six were ranked

higher than customer satisfaction as an outcome by both consumers and providers.

Program implementation and demonstration projects offer additional examples of out¬

come measures. New Mexico (Callahan and Shaening, 1994) has outcome measures

focusing on living arrangements, work and related activity, quality of life, and client

satisfaction. Oregon (Wachal, 1994) adult community outcomes concentrate on hous¬

ing, financial supports, daily activities, employment, overall treatment satisfaction and

| level of functioning. A Unified Services Program (USP) in Pittsburgh, PA (Gould,

1994:63) uses scales covering “. . . symptomatology, levels of functioning, multiple

measures of quality of life, substance abuse and treatment participation.” Andrews,

Peters and Teesson (1994), in Australia’s search for mental health outcome measures,

conclude with a set dealing with symptoms, functioning, quality of life, burden and

satisfaction.

State-level Indicators. The National Association of State Mental Health Program

Directors (NASMHPD) Research Institute is currently preparing an inventory of man¬

aged care performance indicators including outcome measures for state mental health

programs (Mazade, 1997; NASMHPD Research Institute, 1997). The database should

reflect service structures, levels of resources available, processes and outcomes used in

developing and monitoring managed care contracts. In a five state feasibility study on

state mental health agency performance measures, the NASMHPD Research Institute

(1998) examined the feasibility and comparability of state performance indicators on

• outcomes (e.g., improvement of functioning, reduction in symptoms)

• consumer evaluation of care (e.g., outcome, access, appropriateness)

• consumer status (e.g., % employed, % living independently)

• community services (e.g., % contacted within 7 days of hospital discharge, %

receiving case management).

164

JAMES E. SORENSEN

In this study a frontier mental health organization could be responsive to state re¬

quirements for performance information if it obtained outcome and consumer evalua¬

tion of care data and was able to extract consumer status (e.g., % employed) and com¬

munity services information (% receiving case management) from internal sources such

as the client record.

Classifying Outcome Measures. Ciarlo et al. (1986) consolidated knowledge about

outcome measures for mental health clients. The authors suggest a useful three-dimen¬

sional taxonomy:

• Assessment approach (individualized, partially standardized and standardized

methodology)

• Functional area/domain assessed (individual/self, family/interpersonal, and

community functioning)

• Respondent (client, collateral, therapist, and other)

Client satisfaction with services is differentiated from client outcome evaluation

because . . the former measures do not normally address any specified area of client

functioning” (Ciarlo et al., 1986:1). In the new thrust of managed care and CQI, how¬

ever, the satisfaction of the client or an organization (e.g., Medicaid, an employer or a

managed care vendor) may be as important as treatment outcome (Ware, Snyder, Wright

and Davies, 1983). Competitive advantage accrues to providers who learn about and

respond to customer needs. The challenge is to . . design an assessment program that

provides useful, reliable, and valid data in an easy-to-use and cost-effective manner”

(Plante, Couchman and Diaz, 1995:265). Quality for rural areas may be meaningfully

addressed through a combination of clinical outcomes and client satisfaction (Bird,

Lambert and Hartley, 1995).

Recommendations. Most frontier mental health programs should focus on out¬

come measures such as

• client functioning or symptomatic psychological distress or quality of life that are

appropriate for the age (adult, adolescent, or child) and type (e.g., inpatient or

outpatient, severely and persistently mentally ill, alcohol or other drug abuser) of

patient, and

• satisfaction of the client.

Standardized methods provide the ideal assessment approach (Ciarlo et al., 1986).

Well-standardized measures are needed to maximize the reliability (the extent to which

the measure is reproducible) and sensitivity (the extent to which true changes in func¬

tional status can be detected). McLellan and Durell (1996) argue that standardized

measures permit comparison conditions. Results from a single evaluation can be mea¬

sured against results from a larger data base of comparable patients samples and treat¬

ment conditions. Without comparisons, outcome data from a single treatment or pro¬

gram cannot be interpreted scientifically (McLellan and Durell, 1996). While conver-

CLIENT OUTCOMES AND COSTS IN FRONTIER MENTAL HEALTH

165

gence between multiple respondents creates more valid measures, often client and thera¬

pist evaluations alone provide adequate and useful assessments, especially when stan¬

dardized measures are employed.

The key ingredients are assessment of client outcomes and client satisfaction. The

outcome reports can document program performance for managers, clients, and payers.

Satisfaction data can help spot areas where the process can be improved (Nguyen,

Attkisson and Stegner, 1983). Recent news reports, for example, reveal an HMO re¬

sponding to client dissatisfaction with appointment processes (Graham, 1995). Now

the HMO offers the same or next-day appointments instead of a delayed visit. Anyone

who calls and asks for an appointment that day will get one. “Our approach to a mem¬

ber who called before was, ‘are you sure you want to be seen (by a medical provider)?’

Now it’s ‘when do you want to be seen?’” This important change in the service would

not have happened without client/customer satisfaction reports.

Client satisfaction information, however, may not be enough. Summaries of satis¬

faction may not pinpoint what might be wrong with the health care system. By the time

the information works its way back to front-line managers and providers, it may be too

general to be helpful. A client satisfaction survey may also not help front-line profes¬

sionals to provide better service or to solve problems that cross departmental or service

boundaries. Front-line personnel often need the results of root-cause analysis (Reichheld,

1996). Focus groups, as an example, that converge on dissatisfied customers and those

who defect from the system can be rich sources of information about needed adjust¬

ments in the health care delivery system — adjustments that may not be clearly revealed

in satisfaction surveys.

Criteria for Selecting Outcome Measures. Several authors identify the criteria1

for selecting outcome measures (Attkisson et al., 1978; Ciarlo et al., 1986; Ciarlo, 1982;

Mirin and Namerow, 1991; Vermillion and Pfeiffer, 1993; Burlingame, Lambert,

Reisnger, Neff and Mosier, 1995; Sherman and Kaufmann, 1995; Mulkem, Leff, Green

and Newman, 1995):

• The measure should meet minimal psychometric standards including reliability,

validity, sensitivity, nonreactivity to situations, and minimization of respondent

bias. If a measure does not have known reliability or validity, then its use is

discouraged. This requirement eliminates most individualized (or homemade)

instruments. Internal consistency reliability (coefficient alpha) estimates should

be at .80 or above and test-retest should exceed .70. Validity coefficients should

be at least .50 and are preferred at .75 or above.

• The measure should be suitable for the population under care. In managed care

settings, nearly 75% of all patients present adjustment problems, affective

(anxiety or depression) problems and/or problems with daily living (Ludden and

Mandell, 1993). Mental health measures should tap symptomatic and psychoso¬

cial functions of the client (Russo et al., 1996).

166

JAMES E. SORENSEN

• The measure should be easy to use, score and interpret. While some mental

health literature on outcomes suggests multiple instruments (Waskow and Parloff,

1974), practice seems to follow a more simple approach (Lambert and Hill,

1993). Simple methodology and procedures insure uniformity (Ciarlo et al.,

1986). To guarantee outcome assessments are integrated into mental health

practice, brief and understandable instruments can report client status simply and

objectively. If a measure is used frequently and addresses key dimensions of

presenting problems and/or relates to treatment goals, then it becomes an easy

addition to the clinical record. It can also reduce the effort spent on progress

notes.

• The measure should be relatively low cost. If many clients are to be assessed

regularly, then expensive instruments will present prohibitive demands on limited

resources. Impossible requests for time and money are likely to result in no

evaluation at all.

• The measure should be useful in clinical service functions and for evaluation

purposes. The measure should be useful in planning treatment, measuring its

impact and predicting outcome (American Psychiatric Association, 1994). The

measures should reflect meaningful change. Some scales mix broad improve¬

ments in symptomatic and functional areas. Others attempt to separate symptom

distress, interpersonal relations, and social role performance (Lambert, Lunnen

and Umpress, 1994). Sometimes a measure is not used for clinical decisions

about individualized client changes, but it is helpful in assessing how groups of

clients perform. This aggregated analysis can be powerful in assessing program

effectiveness and in documenting client progress to clients, clinicians, program

managers, payers and legislative or regulative groups.

While only exploratory solutions are offered on what are good outcome measure¬

ments, frontier mental health programs must carefully select from available measures

to survive the descending mantle of managed care enveloping all health care programs.

The struggle is to balance sound research methods with the demands of a fast-paced

market-driven business (Freeman and Trabin, 1994). Ciarlo (1996) suggests outcome

for managed mental health care in frontier rural areas should focus on one (or more) of

the following types of outcome assessment for

• adults using general measures such as global assessment of functioning (GAF), a

role functioning scale (RFS) or a composite score from a symptom check-list

(SCL-90-R or BSI) or a combination of behavior and symptom identification

scale (BASIS-32) or the MOS 36-item short-form health survey (SF-36)

• children and adolescents using a behavioral and symptom checklist oriented to

younger clients (Children Behavioral Checklist or CBCL) since adult scales are

usually inappropriate or ineffective for children and adolescents.

CLIENT OUTCOMES AND COSTS IN FRONTIER MENTAL HEALTH

167

• seriously and persistently mentally ill (SPMI)2 people focusing on the lower end

of the functioning continuum relative to meeting basic needs, securing self-

support via employment, and avoiding inappropriate and/or violent behavior.

• alcohol and other substance abuse identifying the special impairment arising

from alcohol and drug abuse.

Table 2, Selected Program or Service Outcome Measures, reviews 12 measures

including a client satisfaction scale. The measures, which tend to be inexpensive, are

assessed for reliability, validity and the ability to produce an overall score that can be

linked to costs. Samples of the instruments can be obtained from the authors, sponsors

or through the Health and Psychosocial Instruments (HAPI) database3 . Key work of

the primary authors or sponsors is included in the references. In an independent and

separate research effort, Sederer and Dickey (1996) concurrently review 10 of the 12

suggested measures.

Costs, Outcomes, and Effectiveness

With increased accountability, service providers of all sizes are being asked to dem¬

onstrate their effectiveness with outcome data. Outcome data can provide valuable

information for accountability and for the improvement of clinical services and pro¬

grams (Newman and Sorensen, 1985). Demonstrating effectiveness by itself, however,

is usually insufficient. In managed care settings, effectiveness must be linked with

costs.

Callahan (1994) suggests outcomes provide a method for evaluating the cost-effec¬

tiveness of services. Her approach involves outcomes, effectiveness and cost-effec¬

tiveness as evidenced by the questions for varying stakeholders:

Client

Mental Health Staff

Program Manager

How does my progress and length of service

compare to the progress made by other persons with

similar characteristics?

Have my symptoms improved (or changed)

as reflected by a valid scale or assessment tool?

How does the progress of this person compare to the

progress of my other clients with similar

characteristics?

Have the client’s symptoms improved as reflected by

a valid scale or assessment tool?

What was the rate of effectiveness for each type

of service and treatment alternative?

168

JAMES E. SORENSEN

How many clients were served? At what cost?

How does our program compare to others with

similar services?

Policy Maker

What types of service utilization patterns have the

best (most effective) outcomes for specific types

of clients?

Are these outcomes being achieved in the

most cost effective manner?

The client and mental health staff questions use outcomes (or comparative out¬

comes) to assess effectiveness4 . The client is asking, ‘Am I getting better?” as a mea¬

sure of progress or effectiveness while the clinician asks, “Are my clients improving,

especially when compared to a relevant comparison group?” When the program man¬

ager and policy maker frame their questions, they are asking comparative cost-outcome

or cost-effectiveness questions. “How do my costs and outcomes compare to other

programs?” and “Are the outcomes most cost-effective” requires comparing costs and

outcomes to assess cost-effectiveness5 .

Cost-Outcome and Cost-Effectiveness. Cost-outcome assessment (tying cost to

clinical outcome) is one key to building viable cost-effectiveness analyses for program

evaluation and accountability (Newman and Sorensen, 1985). Figure 1 identifies the

major financial, statistical and evaluation tasks required for cost-outcome and cost-

effectiveness analysis.

Starting with total costs of a (public) mental health organization, costs are refined

to the per unit cost of service. Statistical data on professional staff activities are re¬

quired to assign personnel costs, while information about services (e.g., units of ser¬

vice) is necessary to unitize program and service costs. With unitized costs of service

and accumulated services received by specific target groups, total costs for an episode

of care may be computed. Evaluation tasks then involve the selection of a target group,

preintervention assessment, and careful non-experimental assignment of clients to var¬

ied treatments or services. Random assignment is ideal, but practical constraints argue

for quasi-experimental procedures which try to equate for problem severity and other

key characteristics of clients. After postintervention measurements, outcomes are as¬

sessed. Then costs are related to outcomes for the final cost-outcome report. If cost

outcomes are calculated on more than one service and comparatively analyzed, cost-

effectiveness can be assessed for optional approaches for specific target groups (Thornton

et al., 1990).

Illustrative example of cost-outcome and cost-effectiveness. As measures of

human service accountability and program management, cost-outcome and cost-effec¬

tiveness are interrelated. Cost-outcome analysis finds the programmatic resources con-

CLIENT OUTCOMES AND COSTS IN FRONTIER MENTAL HEALTH

169

Figure 1. Overview of Major Tasks in Cost-Outcome and Cost-Effectiveness Studies in Human Service

Organizations

Identify Total Costs of

Specific Programs

Trace Professional Staff

Resources into Programs

and Services

Assign Clients to

Program/Services

Randomly or by Matched

Comparison

Identify Total Costs of

Specific Services

Administer Pre-

Intervention Measurement

Determine per Unit Cost of

Services

Accumulate Total Units of

Service Rendered

Administer Post-

Intervention Measurement

Accumulate Total Costs

for Client Episode of

Service

Accumulate Units of

Service Received by

Specific Clients or Client

Subgroups

Assess Outcome

SOURCE: Sorensen, Hanbery and

Kucic, 1983

Compare Cost

Outcomes Among

Programs to Assess

Relative Cost

Effectiveness

170

JAMES E. SORENSEN

sumed to achieve a change in a relative measure of client outcome (e.g., functioning).

Cost-effectiveness analysis compares beneficial program outcomes to the cost of pro¬

grams (or modalities or techniques) to identify the most effective programs. The fol¬

lowing example illustrates the basic steps. The outcome measure used in the illustra¬

tion identifies the major criteria for client performance (Figure 2) and the scale metrics

(Figure 3). The scale is a global assessment of the four criteria scaled into nine levels of

measurement (Endicott, Spitzer, Fleiss and Cohen, 1976). Levels 1 to 4 are considered

dysfunctional while levels 5 to 9 are deemed functional. Figure 4 is a basic cost-out¬

come matrix using only the dysfunctional-functional level of functioning. Level of

functioning is assessed at the start and end of a time period for a specific target group of

clients. Combining the two rows and two columns results in four-cells:

cell A start: dysfunctional ( 1 -4 ratings)

cell B: start: dysfunctional (1-4 ratings)

cell C: start: functional (5-9 ratings)

cell D: start: functional (5-9 ratings)

end: dysfunctional (1-4 ratings)

end: functional (5-9 ratings)

end: dysfunctional (1-4 ratings)

end: functional (5-9 ratings)

Figure 2. Major Criteria for Performance

■ Personal self-care (adjust to age level)

■ Social functioning (adjust to age level)

■ Vocation and/or educational functioning

- Working adults

- Homemakers and/or parents and/or elderly

■ Evidence of emotional stability and stress

tolerance

Figure 3. Develop Scale Metrics

■ Level 1: Dysfunctional in all four areas

■ Level 2: Not working; intolerable; minimal self care, requires restrictive

setting

■ Level 3: Not working; strain on others; movement in community restricted

■ Level 4: Probably not working, but may if in protective setting; can care

for self; can interact but avoid stressful situations

■ Level 5: Working or schooling, but low stability and stress tolerance;

barely able to hold on and needs therapeutic intervention

■ Level 6: Vocational/educational stabilized because of direct therapeutic

intervention; symptoms noticeable to client and others

■ Level 7: Vocational/educational functioning acceptable; therapy needed

■ Level 8: Functioning well in all areas; may need periodic services (e.g.,

med check)

■ Level 9: Functioning well in all area and no contact with Behavioral Health

Services is recommended

CLIENT OUTCOMES AND COSTS IN FRONTIER MENTAL HEALTH

171

Figure 4. Cost-Outcome Matrix (basic)

n = xxxx

Next, for the clients in each cell, the services received and related unit-of-service

costs are multiplied and summed and statistics such as the mean (x-bar) and standard

deviation (sd) are computed for each cell. Of special concern is cell C since moving

from functional to dysfunctional may suggest clinical risk. Cell A is of interest since

the clients have not moved from a dysfunctional status and often represent high con¬

sumption of expensive services. Cell B is of interest since the clients moved from a

dysfunctional to a functional level and this change may prompt questions about the type

and cost of services used. Finally cell D may deserve a review to assess resource con¬

sumption by clients who started and ended the review period as functional.

Figure 5 is an expanded matrix of costs and outcomes using all nine points of the

scale developed in Figure 3. Individuals starting and ending at the same level are on the

! diagonal while those showing improvement are above the diagonal and those showing

1 Figure 5. Cost-Outcome Matrix (expanded)

>< Level of Functioning as of March 31, 19xx

1 2 3 4 5 ‘J'SHmm 7 8 9

172

JAMES E. SORENSEN

regression are below the diagonal. Means and standard deviations are computed for

each cell. Client change and costs are aggregated by improvement, maintenance, and

regression (as shown conceptually in Figure 6) and illustrated with sample values in

Figure 6. Cost-Outcome Matrix (summary)

Figure 7. Client outcome (e.g., improvement, maintenance or regression) and the re¬

sources used to achieve the outcome are linked in Figure 7. Note in the illustration that

40% are improved (with 19% of the resources), 50% are maintained (by consuming

71% of the resources) and 10% regressed (while receiving 10% of the resources).

Figure 7. Cost-Outcome Matrix (table)

CLIENT OUTCOMES AND COSTS IN FRONTIER MENTAL HEALTH

173

In cost-outcome analysis, there is no way to document whether change during ser¬

vice is actually caused by the intervention or is simply concurrent with it. Gathering

comparative cost-outcomes on optional services (e.g., A vs. B) may separate the effects

of service strategy and cost differences. Potential intervening variables, such as history,

selection bias, practice effects, maturation and other factors unrelated to the service can

be controlled by random assignment to alternative services or by less desirable quasi-

experimental methods such as matched comparisons. The purpose of the analysis is to

reach conclusions about the relative cost and effectiveness of the services. Figure 8

reviews the logical relationships and choice points about two services (A and B). Seven

of the choice points are self-explanatory (e.g., A is as effective and A costs less, there¬

fore choose A) while the cells with question marks (?) are not clear conclusions (e.g., A

is less effective and A costs less).

Figure 8. Cost-Effectiveness Matrix

Effect of Capitation. Cost-effective care with limited resources can be reinforced

by capitation (Lehman, 1987). The Monroe-Livingston demonstration project, as an

illustration, evaluated capitated funding of mental health care in contrast to fee-for-

service in a seriously mentally ill population. After a two-year follow-up, Cole, Reed,

Babigian, Brown and Fray (1994) found patients in the capitation had fewer hospital

j inpatients days than the fee-for-service group, while both groups were similar in their

functioning and level of symptoms. This report evaluated effectiveness using outcomes.

Reed, Hennessy, Mitchell and Babigian (1994) evaluated total costs and benefits in the

same demonstration and concluded, “. . . capitation funding can promote care of seri¬

ously mentally ill persons in community settings at lower overall costs.” This report

then linked costs to outcomes to assess cost-effectiveness.

174

JAMES E. SORENSEN

Implications for Behavioral Health Services

With respect to behavioral health services, frontier mental health programs need to

document costs and outcomes at a minimum. Armed with cost and outcome data, a

cost-outcome report is possible. Medicaid (and Medicare) purchasing authorities, state

mental health authorities, managed care vendors, HMOs and business coalitions are

likely to respond positively to cost-outcome information. Cost-outcome can also con¬

tinuously assess, plan and improve services. Where comparative cost-outcome infor¬

mation is available, cost-effectiveness reports may be possible, but in frontier mental

health environments these opportunities may be limited.

Cost-effectiveness as a strategy for the design and deployment of frontier mental

health services is reflected in several applications reviewed or proposed. In some in¬

stances, highly acceptable approaches (in theory) must by tempered by the realities

faced in deployment (in practice.)

References

American College of Mental Health Administration (ACMHA). (1997). Santa Fe Summit, 1997. Columbia, SC:

Author

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Wash¬

ington, DC: Author.

Andrews, G., Peters, L. and Teesson, M. (1994). The measurement of consumer outcome in mental health: A

report to the National Health Information Strategy Committee. Sydney, Australia: Clinical Research Unit for

Anxiety Disorders.

Attkisson, C.C., Hargreaves, W.A., Hororwitz, M.J. and Sorensen, J.E. (1978). Evaluation of human service

programs. New York: Academic Press.

Austin, M.J., Blum, S.R. and Murtaza, N. (1995). Local-state government relations and the development of

public sector managed mental health care systems. Administration and Policy in Mental Health, 22:203-215.

Bergin, A. and Garfield, S. (Eds.). (1993). Handbook of psychotherapy and behavior change (4th ed.). New

York: Wiley.

Bigelow, D.A., McFarland, B.H. and Olson, M.M. (1991). Quality of life of community mental health program

clients: Validating a measure. Community Mental Health Journal, 27:43-55.

Bird, D.C., Lambert, D. and Hartley, D. (1995). Rural models for integrating primary care, mental health and

substance abuse treatment services. Portland, ME: Maine Rural Health Research Center.

Bohmstedt, G.W. (1983). Measurement. In PH. Rossi, J.D. Wright and A.B. Anderson (Eds.), Handbook of

survey research. San Diego: Academic Press, Inc.

Broskowski, A. (1991). Current mental health care environment: Why managed care is necessary. Professional

Psychology: Research and Practice, 22:6-14.

Burlingame, G.M., Lambert, M.J., Reisnger, C.W., Neff, W.M. and Mosier, J. (1995). Pragmatics of tracking

mental health outcomes in a managed care setting. The Journal of Mental Health Administration, 22:226-236.

Callahan, J. and Shaening, M.A. (1994). Mental health in the 90’s: A New Mexico initiative. In F.D. McGuirk,

A.M. Sanchez and D.D. Evans (Eds.), Outcomes issues in a managed care environment. Boulder, CO: West¬

ern Interstate Commission for Higher Education.

Callahan, N.M. (1994). The role of outcomes in managed mental health care. In F.D. McGuirk, A.M. Sanchez

and D.D. Evans (Eds.), Outcomes issues in a managed care environment. Boulder, CO: Western Interstate

Commission for Higher Education.

Ciarlo, J.A. (1982). Accountability revisited: The arrival of client outcome evaluation. Evaluation and Program

Planning, 5:31-26.

CLIENT OUTCOMES AND COSTS IN FRONTIER MENTAL HEALTH

175

Ciarlo, J.A. (1996, August 26-28). Remarks on outcome evaluation of mental health services in frontier rural

areas. Presented at WICHE Mental Health Program’s 11th Annual Decision Support Conference, Reno, NV.

Ciarlo, J.A., Brown, T.R., Edwards, D.W., Kiresuk, T.J. and Newman, F.L. (1986). Assessing mental health

treatment outcome measurement techniques (DHHS Pub. No. (ADM)86-1301). Washington, DC: Superinten¬

dent of Documents., US Government Printing Office.

Cole, R.E., Reed, S.K., Babigian, H.M., Brown, S.W. and Fray, J. (1994). A mental health capitation program: I.

patient outcomes. Hospital and Community Psychiatry, 45: 1090-1096.

Derogatis, L.R. (1977). SCL-90R: Administration, scoring and procedures manual-I for the ( revised ) version.

Maryland: Johns Hopkins University.

Derogatis, L.R. and Clearly, PA. (1977). Confirmation of the dimensional structure of the SCL-90: A study in

construct validation. Journal of Clinical Psychology, 33:981-989.

Drake, R.E., Osher, F.C. and Wallach, M.A. (1989). Alcohol use and abuse in schizophrenia: A prospective

community study. Journal of Nervous and Mental Disease, 177:408-414.

Eisen, S.V., Dill, D.L. and Grob, M.C. (1994). Reliability and validity of a brief patient-report instrument for

psychiatric outcome evaluation. Hospital and Community Psychiatry, 45:242-247.

Endicott, J., Spitzer, R.L., Fleiss, J.L. and Cohen, J. (1976). The global assessment scale: A procedure for mea¬

suring overall severity of psychiatric disturbance. Archives of General Psychiatry, 33:766-771.

Ernst and Young. (1992). International Quality Study. New York: The American Quality Foundation.

Evans, O.M., Faulkner, L.R. and Hodo, G.L. (1992). A quality improvement process for state mental health

systems. Hospital and Community Psychiatry, 42:465-474.

Feldman, S. (1992). Managed mental health services. Springfield, IL: Charles C. Thomas.

Freeman, M. and Trabin, T. (1994). Managed behavioral healthcare: History, models, key issues, and future

course. Rockville, MD: US Center for Mental Health Services, Substance Abuse and Mental Health Services

Administration.

General Accounting Office. (1991). US companies improve performance through quality efforts. Gaithersburg,

MD: Author.

Goodman, S.H., Sewell, D.R., Cooley, E.L. and Leavitt, N. (1993). Assessing levels of adaptive functioning: The

role function scale. Community Mental Health Journal, 29: 1 1 9- 1 3 1 .

Gould, E.K. (1994). Decision support and service outcomes in a managed care environment. In F.D. McGuirk,

A.M. Sanchez and D.D. Evans (Eds.), Outcomes issues in a managed care environment. Boulder, CO: Western

Interstate Commission for Higher Education.

Graham, J. (1995, August 6). Kaiser tries more consumer-friendly ways. The Denver Post, pp. 1G, 15G.

Hodges, K. (1994). Child and adolescent functional assessment scale. Unpublished manuscript.

Lambert, M.J. and Hill, C.E. (1993). Assessing psychotherapy outcomes and processes. In A. Bergin and S.

Garfield (Eds.), Handbook of psychotherapy and behavior change (4th ed.). New York: Wiley.

Lambert, M.J., Lunnen, K. and Umpress, V. (1994). Manual for the outcome questionnaire. Salt Lake City, UT:

Behavioral Health Care Efficacy.

Larsen, D.L., Attkisson, C.C., Hargreaves, W.A. and Nguyen, T.D. (1979). Assessment of client/patient satisfac¬

tion: Development of a general scale. Evaluation and Program Planning, 2:197-207.

Lehman, A.F. (1987). Capitation payment and mental health care: A review of the opportunities and risks.

Hospital and Community Psychiatry, 38:31-38.

Lehman, A.F. (1988). A quality of life interview for the chronically mentally ill. Evaluation and Program Plan¬

ning, 11:51-62.

Lehman, A.F. (1997). Evaluating quality of life for persons with severe mental illness. Cambridge, MA: Evalu¬

ation Center at HSRI.

Ludden, J. and Mandell, L. (1993). Quality planning for mental health. The Journal of Mental Health Adminis¬

tration, 20:72-78.

Massey, O.T. (Ed.) (1991). Level of functioning. The Journal of Mental Health Administration, 18:77-134.

Mazade, N.A. (1997). Interassociation project on performance measures and client outcome indicators. Admin¬

istration and Policy in Mental Health, 24:257-259.

176

JAMES E. SORENSEN

McGuirk, F.D., Zahniser, J.H., Bartsch, D. and Engleby, C. (1994). Capturing outcome values: priorities of key

stakeholders. In F.D. McGuirk, A.M. Sanchez and D.D. Evans (Eds.), Outcomes issues in a managed care

environment. Boulder, CO: Western Interstate Commission for Higher Education.

McLellan, A.T. and Durell, J. (1996). Outcome evaluation in psychiatric and substance treatments: Concepts,

rationale, and methods. In L.I. Sederer and B. Dickey (Eds.), Outcomes assessment in clinical practice. Bal¬

timore: Williams and Wilkins.

McPheeters, H.L. (1984). Statewide mental health outcome evaluation: A perspective of two southern states.

Community Mental Health Journal, 20:44-55.

MHSIP Task Force on a Consumer-Oriented Mental Health Report Card. (1996). The MHSIP consumer-ori¬

ented mental health report card. Rockville, MD: Center for Mental Health Services, Substance Abuse and

Mental Health Services Administration.

Mirin, S.M. and Namerow, M.J. (1991). Why study treatment outcome? Hospital and Community Psychiatry,

42:1007-1013.

Mulkem, V., Leff, S., Green, R. and Newman, F. (1995). Performance indicators for a consumer-oriented mental

health report card: Literature review and analysis. In Stakeholder perspectives on mental health performance

indicators. Cambridge, MA: The Evaluation Center at HSRI.

National Association of State Mental Health Program Directors (NASMHPD) Research Institute. (1997). Man¬

aged care performance indicators and outcome measures. Manuscript in preparation.

National Association of State Mental Health Program Directors (NASMHDP) Research Institute. (1998). Five

state feasibility study on state mental health agency performance measures (Draft Executive Summary). Alex¬

andria, VA: Author.

Newman, F.L. (1980). Global scales: Strengths, uses and problems of global scales as an evaluation instrument.

Evaluation and Program Planning, 3:257-268.

Newman, F.L. and Sorensen, J.E. (1985). Integrated clinical and fiscal management in mental health. Norwood,

NJ: Ablex Publishing Corporation.

Nguyen, T.D., Attkisson, C.C. and Stegner, B.L. (1983). Assessment of patient satisfaction: Development and

refinement of a service evaluation questionnaire. Evaluation and Program Planning, 6:299-313.

Plante, T.G., Couchman, C.E. and Diaz, A.R. (1995). Measuring treatment outcome and client satisfaction

among children and families. The Journal of Mental Health Administration, 22:261-269.

Rago, W.V. and Reid, W.H. (1991). Total quality management strategies in mental health systems. The Journal

of Mental Health Administration, 18:253-262.

Reed, S.K., Hennessy, K.D., Mitchell, O.S. and Babigian, H.M. (1994). A mental health capitation program: II.

Cost-benefit analysis. Hospital and Community Psychiatry, 45:1097-1103.

Ross, D.C. and Klein, D.F. (1979). A comparison analysis of covariance and the ( technique as applied to illus¬

trative psychopharmacological data. Journal of Psychiatric Research, 15:67-75.

Reichheld, F.F. (1996). Learning from customer defections. Harvard Business Review, March- April:57-69.

Russo, J., Roy-Byme, P, Jaffe, C., Ries, R., Dagadakis, C., Dwyer-O’ Conner, C. and Reeder, D. (1996). The

relationship of patient-administered outcome assessments to quality of life and physician ratings: Validity of

the BASIS-32. The Journal of Mental Health Administration, 24:200-214.

Sederer, L.I. and Dickey, B. (Eds.). (1996). Outcomes assessment in clinical practice. Baltimore: Williams and

Wilkins.

Sherman, P. and Kaufmann C. (1995). A compilation of the literature on what consumers want from mental

health services. In Stakeholder perspectives on mental health performance indicators. Cambridge, MA: The

Evaluation Center at HSRI.

Shem, D.L. (1994). System change and the maturation of mental health outcome measurement. In F.D. McGuirk,

A.M. Sanchez and D.D. Evans (Eds.), Outcomes issues in a managed care environment. Boulder, CO: West¬

ern Interstate Commission for Higher Education.

Sluyter, G.V. and Barnett, J.E. (1995). Application of total quality management to mental health: A benchmark

case study. The Journal of Mental Health Administration, 22:278-285.

Sorensen, J.E., Hanbery, G.W., and Kucic, A.R. (1983). Accounting and budgeting for mental health organiza¬

tions. Washington, DC: US Government Printing Office.

CLIENT OUTCOMES AND COSTS IN FRONTIER MENTAL HEALTH

177

Thornton, P.H., Goldman, H.H., Stegner, B.L., Sorensen, J.E., Rappaport, M. and Attkisson, C.C. (1990). As¬

sessing the costs and outcomes together: Cost effectiveness of two systems of acute psychiatric care. Evalu¬

ation and Program Planning, 13:23 1 -24 1 .

Vermillion, J. and Pfeiffer, S. (1993). Treatment outcome and continuous quality improvement: Two aspects of

program evaluation. Psychiatric Hospital, 24:9-14.

Wachal, M. (1994). The Oregon health plan: managing by outcomes. In F.D. McGuirk, A.M. Sanchez and D.D.

Evans (Eds.), Outcomes issues in a managed care environment. Boulder, CO: Western Interstate Commission

for Higher Education.

Ware, J.E. (1997). Health care outcomes from the patient’s point of view. In E.J. Mullen and J.L. Magnabosco

(Eds.), Outcomes measurement in the human services: Cross-cutting issues and methods (pp. 44-67). Wash¬

ington, DC: NASW Press.

Ware, J.E., Kosinski, M. and Keller, S.D. (1994). SF-36 physical and mental health summary scales: A user's

manual. Boston: The Health Institute, New England Medical Center.

Ware, J.E., Snyder, M.K., Wright, W.R. and Davies, A.R. (1983). Defining and measuring patient satisfaction

with medical care. Evaluation and Program Planning, 6:247-263.

Waskow, I.E. and Parloff, M.B. (Eds.). (1974). Psychotherapy change measures (DHEW Pub. No. (ADM)74-

120). Washington, DC: Superintendent, of Documents, US Government Printing Office.

Notes

1 For an advanced discussion of measurement, measurement error, reliability and validity, the reader is referred

to Bohmstedt, G.W. (1983). Measurement. In P.H. Rossi, J.D. Wright, and A. B. Anderson (Eds.), Handbook

of Survey Research. San Diego: Academic Press, Inc.

2 Measures under consideration include the Quality of Life Interview (QOLI) and other scales contained in A

Lehman, Evaluating Quality of Life for Persons with Severe Mental Illness, Evaluation Center @ HSRI, Cam¬

bridge, MA. The QOLI, with eight (8) life domains, is not easily connected to costs since the scales are not

additive and there is no overall summary score. Costs might be associated with primary program goals such as

social contacts or family/social relations (e.g., an objective measure such as frequency of social contacts or a

subjective measure such as satisfaction with family or social relations), but the linkage of costs to the QOLI is

ill defined. The paper by Bigelow, McFarland, and Olson (1991) is also useful.

3 For information contact Behavioral Measurement Database Services, PO Box 1 10287, Pittsburgh, PA 15232-

0787; telephone 412.687.6850 or fax 412.687.5213.

4 Statistical assessment of outcomes can be a complex issue. Simple gain scores (viz., time 1 - time 2) are

subject to much deserved criticism. If pre- and post-scores are correlated at reasonable levels (e.g., .3 to .4)

and are linear, then analysis of co-variance (ANCOVA) with time 1 as the covariate may be explored. The

results have to be interpreted with caution, however, since those with higher initial scores can be expected to

improve at a higher rate than those with lower scores. By relating the actual gain to a potential gain and

analyzing the percentages with ANCOVA is somewhat more defensible. The analysis uses the form: Time 2-

Time 1/ Ideal -Time 1= %. ANCOVA is problematic in any event. First, the statistical assumption that the

treatment and the covariate do not interact systematically is not met since entry levels of a mental health

condition (e.g., depression) and treatment approaches do have a systematic interaction. Second, since the

interaction of treatment and entry level is of concern along with the main effect of treatment, any statistical

control procedure to partition or subtract out information typically used in clinical decision-making should be

viewed with caution. Analysis of variance with repeated measures poses similar problems.

5 Most parametric statistical analyses pose problems in comparing the effectiveness of two approaches to men¬

tal health treatment. The ( (Theta) technique (with a x2 statistic) can analyze two outcome matrices by compar¬

ing the two approaches against an ideal matrix. The test is sensitive to the magnitude of differences in treat¬

ment effects and represents a measure of the differences in patterns of client outcomes for two treatments at

measured levels of intake functioning . . . relative to a hypothesized pattern of outcomes. See Newman and

Sorensen (1985) and Ross and Klein (1979). Other approaches include structural equations that are beyond

the scope of this paper

178

Journal of the Washington Academy of Sciences,

Volume 86, Number 3, 179-187, December 2000

Effective Management Strategies for

Frontier Mental Health Organizations

James E. Sorensen, Ph.D., CPA

Abstract

This report focuses on how integrated primary and mental health services should aid the

manager of frontier mental health programs in the developing managed care environment

by increasing effectiveness. Also discussed are how the integration actually works, how

to improve the reintegration of the client into the community, and how to increase the

yields from limited resources. In addition to literature reviews, this paper reports the results

of several focus groups conducted by the Frontier Mental Health Services Resource

Network with mental health executives. The focus group attendees were able to provide

“on the scene” perspective and to document many of the operating examples described in

this paper.

Introduction

Managers of mental health organizations need to acquire and use resources to cre¬

ate effective and efficient mental health services. The fast emerging managed care

environment now requires even more than just efficient cost management. Managed

behavioral health care seeks to reduce or eliminate unnecessary services, reduce and

control the costs of care, and maintain or increase outcomes and effectiveness. Serving

frontier areas offers a greater challenge because of limited resources. This Letter is the

third installment of a three-part series on cost, outcomes, and effective management

strategies for frontier mental health organizations. This report focuses on how inte¬

grated primary and mental health services should aid the manager of frontier mental

health programs in the developing managed care environment by increasing effective¬

ness. Also discussed will be how the integration actually works, how to improve the

reintegration of the client into the community, and how to increase the yields from

limited resources. In addition to literature reviews, this paper reports the results of

several focus groups conducted by the Frontier Mental Health Services Resource Net¬

work with mental health executives. The focus group attendees were able to provide

“on the scene” perspective and to document many of the operating examples described

in this paper1 .

Integration of Caregivers. Rural primary care providers have strong incentives

and significant opportunities to form linkages with mental health providers. They in¬

clude large and diverse caseloads, severe time constraints, changing mental health treat-

180

JAMES E. SORENSEN

ment modalities and medications, fluid Medicare and Medicaid reimbursement, and

vertically integrated health networks (Lambert, Bird, Hartley, and Genova, 1996). While

arguments for the integration of services emerged during the 1970’s (Borus et al., 1985)

and 1980’s (Goldman, Bums and Burke, 1980), the development of health care net¬

works and managed care has stimulated renewed interest in integration (Zimmerman

and Wienckowski, 1991 ; Mechanic, 1994).

What can happen when primary and mental health care are integrated? When cli¬

ents access comprehensive health services that include mental health care, the demand

for medical and surgical services may decrease as much as 72 percent (Mumford,

Shlesinger, Glass, Patrick and Cuerdon, 1984). Because this reduction in demand sig¬

nificantly reduces net medical costs, the result is labeled the medical cost offset effect.

These dramatic savings in medical and surgical services costs could finance cost reduc¬

tions and expanded services for all health care. Another major implication is integrated

treatment through teamwork. The integrated team of both health and behavioral health

care providers can not only reduce the cost of health care, but also improve its effective¬

ness (Sloan and Chmel, 1991). This integrated approach is especially appealing in

frontier mental health environments where resources are nearly always limited. Alii- 1

ances and collaborations between health care and behavioral health care providers can

restore physical and psychological health and also establish healthy habits in their cli¬

ents. Frontier mental health leaders should be encouraged to take the initiative in inte¬

grating behavioral health with other health care to develop world-class health care.

Medical Cost Offset Effect. Table 1 offers a practical way to see how medical

cost-offset works. Total health care expenditures are assumed to be $100 million with

90% for medical care, 6% for behavioral care and 4% for other types of health care.

The model examines the introduction of behavioral health care over a five year time

period. All health care costs are assumed to increase at 10% over the prior year (includ¬

ing inflation) and new additional behavioral health care costs are added yearly at 5%

over the prior year to accommodate increased behavioral health services. The medical

cost-offset is assumed to have a first year reduction of 20% and graduated increases up

to 50% by the end of the fourth year and subsequent years. The offset percentages are

estimates derived from the cost-offset literature (Mumford et al., 1984; Holder and

Blose, 1987).

Integration of services reduces the combined costs of medical and behavioral care

dramatically. In the first year, the cost reduction in Table 1 is almost 19% (20/106 =

18.9%) while in year five the cost reduction is 46% (72/157 = 46%). In each year the

combined medical and behavioral costs are reduced until year five when the costs in

total begin to rise. (See Figure 1.) Even after five years, the total combined costs in

year 5 ($85 million) are still lower than the year one combined costs before offset ($106

million) by 20% ($ 1 06-$85/$ 1 06 = 20%). During years four and five, the percentage

distribution between medical and behavioral costs begins to stabilize at 86% and 14%,

MANAGEMENT STRATEGIES FOR FRONTIER MENTAL HEALTH

181

respectively, as shown in Figure 2. The results, while illustrative, provide a powerful

insight into how behavioral health care introduced before medical health care can im¬

prove the total cost picture. The cost-offset percentages can be lowered (or increased),

but the patterns are generally similar. When people have access to comprehensive

mental health services, the demand for medical and surgical services decreases. The

alliance between mental health and primary care can become a strategic one for sur¬

vival and success as both areas face limited resources and pressure for quality out¬

comes.

Current arguments against requiring insurance coverage for mental illness to be in

parity with coverage for other illnesses (Pear, 1996) seem not to take into account the

cost-offset research (Suinn, 1996). If funding comprehensive mental health services

can reduce total health care costs, there should be an eagerness to fund mental health

services. Efforts to limit the funding of mental health services will only increase total

health care costs not decrease them.

The resources in behavioral health are often inadequate and one way to argue for an

! increase in resources is to show its impact on other health care systems through the

medical cost offset. However, some mental health administrators suggest that while

savings from offsets to physical health may accrue to society; integration often leads to

unfavorable outcomes for mental health. The end result can be a reduction in the costs

of other health care systems, but not an increase in behavioral health resources. The

fear of losing resources is part of the choice to carve-out mental health and alcohol and

other drugs of abuse services rather than integrating behavioral health into an HMO

managed care system. As one mental health executive explains: “The choice to carve-

out behavioral health stems, in part, from the experience that behavioral health suffers

when it is included in a physical health HMO. HMOs may serve the mildly ill

adequately, but those who have traditionally been the purview of the state mental health

agency tend to get the worst care. It is a matter of time before the client goes from the

HMO to the mental health center. The clients exhaust their benefits with the HMO, get

transferred to the public system, and there is no symptom change from the time they

entered the HMO until they came to the public system. HMOs do not know how to

deal with serious and persistent mental illness, but they know how to deal with mild

depression.”

Carve-in models may work better if you retain a specialization (e.g., mental health,

substance abuse). A subcontract with a specialty program (as opposed to a total carve-

out) is another possible option for integrating physical health and mental health.

Outsourcing the mental health component (which is a small piece of the general health

care costs) can reduce threats to both medical/surgical and mental health professionals.

Co-location offers yet another possible solution for physical and behavioral health care

integration. In a building in a Midwestern state, a new health care clinic occupied one

, wing, behavioral health occupied the other, and space in the middle was used by both.

182

JAMES E. SORENSEN

Table 1 . Simulation of Behavioral Health Cost-Offset on Total Health Care Costs

(millions)

Model Assumptions:

Number of time periods 5

% of overall health care increase (including inflation) 10%

% of new behavioral care costs (over prior year) 5%

% of overall health care decrease related to cost-offset:

1st year -20%

2nd year -30%

3rd year -40%

4th year and thereafter -50%

Dynamic Cost Estimation: Medical and Behavioral only

Model Results:

Year 1 Year 2 Year 3 Year 4 Year 5

MANAGEMENT STRATEGIES FOR FRONTIER MENTAL HEALTH

183

Figure 1 . Simulation of Behavioral Health Cost-Offset on Combined Health Care Costs

Medical Health

Behavioral Health

Total-before offset

Cost-Offset

Total-after offset

Figure 2. Simulation of Behavioral Health Cost-Offset on Combined Health Care Costs:

% Allocation Between Medical and Behavioral Costs

1 2 3 4 5

TIME

■ Behavioral Health

■ Revised Medical

184

JAMES E. SORENSEN

“It was beneficial to combine these two functions in a rural community and it helped to

de-stigmatize the behavioral health part,” observed a mental health executive who vis¬

ited the center’s open-house ceremony.

Other Integration Options. Some states are now pushing integration, collabora¬

tion and partnerships between mental health systems and other human services organi¬

zations such as social services, child welfare, but not physical health. Co-locations ,

joint sites, joint assessments and joint treatment plans are examples of this new col¬

laboration. “Co-location in child welfare can place mental health assessment staff and

child welfare personnel can do front-end assessments as opposed to a referral three or

six months later when the child is being reviewed for an out-of-home placement,” noted

another seasoned administrator.

Front-end partnerships can achieve cost-offsets and cost savings while maintaining

the specialization of both the mental health professional and the partner professionals.

Out- stationing mental health professionals in the emergency rooms in hospitals can

integrate the behavioral health care and physical medical care. Psychiatric nurses in the

city jail performing pre- arraignment screenings can divert individuals into the mental

health system as opposed to the correctional system. Counselors stationed at the desk

of social services in high schools solves the problem of contacting potential clients. “If

they are unlikely to come to you, then you go to them,” commented one provider. “Fre¬

quently the first warning signs of a child with severe emotional disturbance appears in

the schools. By getting the clinician [at school] instead of downstream, they can front-

end services and avoid later and more costly services” he concluded. Mental health can

join with other public agencies in site visits to migrant populations. “It is easy for

mental health to tag along with the other services that are being done and are more

acceptable than mental health,” stated one focus group member.

Some examples that work include using existing facilities, with minor changes and

using night staff as necessary — not necessarily 24 hours. Mental health and mental

retardation in one program shared after-hours location and staff, where mental health

was using someone else’s building and a staff person paid for by two different agencies.

In another example, a large nursing home is now used for brain injury cases while one

of the houses is a children’s unit with 24 hour staff on campus.

Unfortunately, existing programs and staff are often resistant to integration. In one

Rocky Mountain state, counties were given the opportunity by the state legislature to

restructure at the local level. As one executive summarized the effort: “We were going

to combine all of our behavioral health or all of our human services under a single

service authority. We were going to combine the health department and human ser¬

vices. However, nearly all of the counties came back with the decision to keep all of the

organizations the same as they were! The most dramatic change was using a common

database and computer screen. Bureaucratic inertia overwhelms change ! ”

MANAGEMENT STRATEGIES FOR FRONTIER MENTAL HEALTH

185

Reintegration of the Client into the Community. Focus group members offered

On the other hand, there may be greater community acceptance for mental health con¬

sumers in frontier areas. The different professionals know each other in these areas and

are better able to negotiate the best options for the client through integration of ser¬

vices. As an example, when one client in a rural area would take off his clothes and

direct traffic on main street, the chief of police would call the director of the mental

health center and say “Harold’s at it again!” The director would bring clothing and take

Harold back to his group home. If someone did the same thing in a large city, the

director of mental health would not get the call! While the options may be fewer, the

opportunity for integration is greater in a rural environment.

Even with excellent support from health and mental health professionals, clients

are often unable to live independently without a support network. Clients want therapy

from their therapists, but are also often tired of being told what to do by therapists and

advocates. Consumers supporting consumers is a growing movement. It behooves the

mental health system to locate customers where they can help each other.

All of these efforts to reintegrate clients into the community can be part of “wrap¬

around” services. These services are often hard to understand and can be defined many

ways. As one executive commented, “It is a form of customization and generally goes

beyond case management or outreach to include special needs. You are purchasing

special services for a special person. Often the goal is to stabilize the client. Maybe it

is hiring a buddy to go to school with the kid for three weeks to help them integrate or

to enroll them in a soccer league or rent a phone for their home. The classic case

example is the state hospital patient, for example, a female who begins to decompen¬

sate when she starts discharge planning. In contrast to the clean environment with

regular meals and friendly people, her ‘back home’ involves an alcoholic husband and

filthy house filled with roaches. Clearly she needed other special services.”

Information Management. Managed care is data-driven in real-time; it is not

retrospective. “It has to be current and enable you to forecast so you change directions

quickly,” concluded one executive. “You have to know on Wednesday how many indi¬

viduals you have in patient beds on Wednesday. You need a system that generates

reports automatically. You a need a daily ‘flash report’ on available capacity and time

spent in service.” For example managers need information on:

• Alternative Treatment Units (ATU) — available capacity, where, how many, and

when?

• Residential facilities — independent and support — available capacity, where, how

many, and when?

• Outpatient — number of units of service provided yesterday and week-to-date,

available capacity?

186

JAMES E. SORENSEN

Estimating Out-of-System Costs. Managers also need to know the prospective

liability for out-of-system services based on the number of service authorized for people

in your service plan. Costs can vary significantly. One executive gave the following

scenario: “If you referred 17 people to out-of-network providers and authorized 170

units of service, and if you know based on experience that 53% of the authorized ser¬

vices are consumed and at an estimated $65 per unit, you have a current estimate of

your cost and liability of almost $5,900 (170 units x.53 conversion x $65 estimated cost

= $ 5,856.50 potential cost and liability). You must follow-up to see if the 53% is true.

In mental health, it is more likely to be 90% and the cost and liability would be almost

$10,000 (170 x .90 x $65 = $9,945).”

Later a more complete report on actual results (e.g., rolling averages) can be pro¬

vided to make sure there is clear understanding of what did happen. Budgeted vs.

actual unit costs can identify cost or units of service problems early in the process. “If

you have to wait for the annual report, that is too late,” observed one administrator.

Staffing Options. If you contract with staff on a piece-work basis, one financial

specialist felt “you ...rent instead of buying to own. When you hire, you’ve adopted

staff to raise them instead of contracting with them. If you hire on a piece-work basis,

you have converted a fix cost into a variable one.”

Implications for Behavioral Health Services. Being efficient and effective in

frontier areas with limited resources is a challenge. This paper focused on a number of

areas that are important for the delivery of behavioral health services in frontier areas.

Specifically, the paper, the third installment of a three-part series on cost, outcome, and

effective management strategies for frontier mental health organizations, provide in¬

formation on (1). how integrated primary and mental health services should aid the

manager of frontier mental health programs in the developing managed care environ¬

ment by increasing effectiveness, (2). how the integration actually works, (3). how to

improve the reintegration of the client into the community, and (4). how to increase the

yields from limited resources. In addition, the results of several focus groups con¬

ducted by the Frontier Mental Health Services Resource Network with mental health

executives were reported. The paper indicated that while integrating primary and be¬

havioral health care may be an ideal solution, the more likely response is an integration

with other human services (e.g., welfare), and using shared facilities or staff and joint

activities. Low-cost client reintegration approaches, “flash-reports” on availability of

resources, and contracting for delivered units of service are other likely responses.

References

Borus, J.F., Olendzki, M.C., Kessler, L., Bums, B.J., Brandt, U., Broverman, C.A. and Henderson, P.R. (1985).

The “offset effect” of mental health treatment on ambulatory medical care utilization and charges: Month-by¬

month and grouped-month analyses of a five year study. Archives of General Psychiatry , 42:573-580.

Goldman, H.H., Bums, B.J. and Burke, J.D. (1980). Integrating primary health care and mental health services:

A preliminary report. Public Health Reports, 95:535-539.

MANAGEMENT STRATEGIES FOR FRONTIER MENTAL HEALTH

187

Holder, H.D. and Blose, J.O. (1987). Changes in health care costs and utilization associated with mental health

treatment. Hospital and Community Psychiatry , 38:1070-1075.

Lambert, D., Bird, D.C., Hartley, D. and Genova, N. (1996). Integrating primary care and mental health ser¬

vices: Current practices in rural areas. Kansas City, MO: National Rural Health Association.

Mechanic, D. (1994). Integrating mental health into a general health care system. Hospital and Community

Psychiatry, 45:893-897.

Mumford, E., Shlesinger, H.J., Glass, G.V., Patrick, C. and Cuerdon, T. (1984). A new look at evidence about

reduced cost of medical utilization following mental health treatment. American Journal of Psychiatry, 41:1 145-

1158.

Pear, R. (1996, May 2). Wider mental health policies seen as feasible requirement. New York Times, pp. Al,

All.

Sloan, N.D. and Chmel, M. (1991). The quality revolution and health care: A primer for purchasers and provid¬

ers. Milwaukee, WI: American Society for Quality Control, ASQC Quality Press.

Suinn, R.M . (1996). The case for psychological services in primary health care: medical costs offset. CPA

Bulletin (Colorado Psychological Association), May: 8.

Zimmerman, M.A. and Wienckowski, L.A. (1991). Revisiting health and mental health linkages: A policy

whose time has come... again. Journal of Public Health Policy, 12(4):5 10-524.

Notes

1 A special note of appreciation to the mental health executives who participated in the focus groups. Because

of our confidentiality agreement, we are not permitted to cite individual contributions

188

-

Journal of the Washington Academy of Sciences,

Volume 86, Number 3, 189-196, December 2000

Telemental Health Services In

US Frontier Areas

Walter F. LaMendola, Ph.D.

Abstract

This paper provides information about the status of “telemental health,” the use of telecom¬

munication technologies to assist in the delivery of mental health services and related ac¬

tivities, in frontier or isolated rural areas. Specifically, the paper provides information about

the availability and type of services currently provided in frontier areas as well as the prob¬

lems that need to be solved if additional services are to be provided to consumers and their

families and communication enhanced among service providers. The telemental health ser¬

vices provided include, but are not limited to, prevention, diagnosis, consultation, outreach,

case management, education treatment and the transfer of mental health data for use in the

provision of services to specific clients.

Introduction

The Frontier Mental Health Services Resource Network, under a contract with the

Center for Mental Health Services of the Substance Abuse and Mental Health Services

Administration, was created to gather, analyze, and disseminate information about mental

health needs and services in “isolated rural areas” in the United States— often called

frontier areas (see Ciarlo et al., 1998). These areas, found predominately in the western

part of the United States, often struggle to provide appropriate mental health services

that are accessible to those in need. This paper looks at telecommunication applica¬

tions— called “telemental health services”— that may be used to support and enhance

communication among mental health providers, administrators, and consumers in fron¬

tier rural areas.

The application of telecommunication technologies in health systems has been de¬

fined in a number of ways, using terms such as “telemedicine” and “telehealth.” Little

agreement exists about the meaning of these terms (GAO, 1997). Whatever term is

used, however, the common dynamic is always the use of telecommunications as a

medium. Telehealth has been used to include the broadest meanings of health— such as

community health education or the administration of health services. Telemedicine is

usually used to refer to “medical” or “clinical care” events. In specialized areas the

notion of telemedicine is advanced by adding “tele” as a prefix to the specialization,

such as in “telepsychiatry” or “teleradiology.” We have followed that convention here;

the term telemental health services is meant to connote all mental health services whose

190

WALTER F. LAMENDOLA

delivery is assisted by telecommunications technologies, including telepsychiatry. In¬

deed, mental health services include an array of related social, medical, counseling, and

case management services needed by persons suffering acute to severe and sometimes

persistent disabilities. Such services could include, but are not limited to, prevention,

diagnosis, consultation, outreach, case management, education, and treatment. It also

includes the transfer of mental health data for use in the provision of services to specific

clients— a service array consistent with what Mechanic (1996) has termed the “key

considerations” for managed care in mental health. The telecommunication technolo¬

gies used to provide these telemental health services can range from telephone and fax

to live interactive video.

The Emergence of Telemental Health Services in Rural and Frontier Areas

A true count of the number of rural and frontier telemental health programs in the

United States is a moving target. Estimates have ranged anywhere from 6 to 50 pro¬

grams. One conclusion, however, is consistent— the number and visibility of telemental

health services in rural and frontier areas is small. The Joint Working Group on

Telemedicine (JWGT) provides a picture of telemental health service activity in the US

through reports on the Federal Telemedicine Gateway. They list 28 projects that pro¬

vide mental health services, of which 6 are located in states with significant frontier

populations— Alaska, Colorado, Kansas, Montana, Nebraska, and South Dakota (JWGT,

1997). In two specific surveys of telemental health applications, Telemedicine Today

(Allen and Allen, 1994) and the Office of Rural Mental Health Research (LaBella,

1995) found few telemental health projects— 7 and 20 respectively. A more recent

study by Abt Associates (1997) found 159 non-federal rural hospitals and other provid¬

ers actively using telemedicine; 31% of which reported the use of telepsychiatry. This

was the fifth largest group of reported specialty use. This may be an under-representa¬

tion of telemental health activities. The 18 respondents most likely to be in frontier

areas probably reported what the study called telepsychiatry. Though the published

study did not define telepsychiatry, it was presumably understood as a service in which

at least one participant was a psychiatrist— the list of specialties in the study actually

excluded psychology and social work, and listed “substance abuse” as a separate spe¬

cialty. If these other groups were included, presumably the occurrences of telemental

health services would increase. In fact, the Mid-Nebraska Telemedicine Network re¬

ported 209 individual mental health consults last year— the largest single specialty use

and 40% of the total use. The current on-line Telemedicine Information Exchange

(TIE) database lists 33 programs under telepsychiatry and 17 programs under mental

health (Telemedicine Research Center, 1997). This also may be an underestimate. For

example, the Department of Veteran Affairs uses the listing to indicate that there are a

number of VA hospitals that offer telemental health services. They list these separately

at their own web site.

TELEMENTAL HEALTH SERVICES IN US FRONTIER AREAS

191

The Abt (1997) study went on to estimate that nearly 30% of all rural US hospitals

would have telemedicine applications in place in 1996. Interestingly, the survey found

the greatest penetration of telemedicine (23% of the reporting hospitals) in the Rocky

Mountain area— an area with large numbers of frontier residents. In contrast, however,

the JWTG (1997) lists only two states with significant frontier populations, Texas (with

6 projects, ranked 9th) and Colorado (5 projects, ranked 10th), among the ten states with

the highest number of telemedicine projects. The Abt survey also found that the small¬

est hospitals were generally more likely to have telemedicine services. Though it would

be sensible to deduce that this phenomena was driven by the hospitals having the high¬

est need for access to specialists, frontier telemedicine programs also constituted 62%

of those whom both received and delivered services.

Frontier and Rural Telemental Health Programs

This project identified 30 telemental health programs operating in frontier or rural

areas. The services they report providing are organized in Table 1 into four broad

categories: education, consultation, therapy, and administration. Education services

reported included continuing education and training. Consultative services were made

up of medication reviews, assessments, psychiatric supervision and case review, and

involuntary commitment appraisals. Also included were varieties of case conferences

and supervision between psychiatrists, primary care providers, mental health profes¬

sionals, and other allied health personnel. The range of administrative services in¬

cluded meetings, record sharing, information transfer, and utilization review. Ninety-

three percent of the identified sites offered consultative services, 70% offered educa¬

tion services, 43% offered administrative services, and 17% offered therapy services.

Only 2 (7%) offered all four services. Ten (33%) offered three services and 10 (33%)

others offered two services. The remaining 8 (27%) offered one service. Three sites

reported performing court evaluations. Three sites plan to do discharge monitoring and

three plan to do substance abuse counseling.

Almost all of the sites identified are using interactive technologies that involve

video conferencing or television. Equipment and telecommunication requirements for

these interactive technologies are generally among the most expensive arrangements

available today. A majority of the sites are also using “store and forward” technologies.

This is less expensive as it does not demand live interaction. Two of the sites list

telephone based technologies. These are the least expensive telecommunications tech¬

nologies. There is a relationship between the type of services offered and the technol¬

ogy in use. For example, live therapy where participants see each other in real time

requires different equipment than a therapeutic telephone conversation. Unfortunately,

minimum requirements matching equipment to problem to service to outcome do not

exist. Indeed, the fundamental question of whether telemental health services increase

192

WALTER F. LAMENDOLA

access and/or improve outcomes for under-served populations has not been sufficiently

studied. Nevertheless, the telemental health service innovation is underway in rural

and frontier areas.

A robust example of telemental health services in a frontier area today is the RO¬

DEO Net (Rural Options for Development and Educational Opportunities Network).

In 1991, the Eastern Oregon Human Services Consortium was awarded a three-year

grant of approximately $700,000 by the Rural Health Outreach Grant Program of the

Office of Rural Health Policy (Health Resources and Services Administration) to dem¬

onstrate an innovative model of mental health care in a rural area. The mission of

RODEO Net was to pioneer advances in the delivery of human services by connecting

people using appropriate communication technologies. RODEO Net uses three ED-

Net networks created by the State of Oregon in 1989. Network 1 provides live, interac¬

tive, one-way video and two-way audio services to 45 “receive” sites in eastern Or¬

egon. Network 2 provides two-way video, audio, and data services using digitally

compressed video technology in 10 studios. Network 3, COMPASS, is a local “dial¬

up” computer data network that provides a variety of information services. These in¬

clude user-friendly access to local, national, and international databases and the Internet;

government and academic libraries; bulletin boards; electronic mail; and computer¬

conferencing services.

RODEO Net currently uses all three networks to train mental health providers in

eastern Oregon. For example, both professional and paraprofessional staff, who work

with children and adolescents with severe emotional disturbances, participate in a cer¬

tificate program to upgrade staff qualifications. Individual training is also provided. In

addition to training, RODEO Net also provides crisis response. Using Network 2,

personnel access the on-call psychiatrist at the Eastern Oregon Psychiatric Center in

Pendleton to help deal with persons suffering extreme emotional or behavioral turmoil.

Such a response system often saves the time and money required to transport an indi¬

vidual and keeps that person in the community. RODEO Net provides clinics for medi¬

cation management and case consultations on an ongoing or as needed basis, reducing

the number of admissions to acute care facilities. Interviews for pre-admission, pre¬

discharge, and transfers are now accomplished via Network 2, and pre-commitment

and psychiatric review board hearings are conducted using interactive TV. The project

also plans to work with consumer groups to help them create their own computer net¬

working conferences within the COMPASS system (Britain, 1996; Telemedicine Re¬

search Center, 1997; Witherspoon, Johnstone and Wasem, 1993).

Analysis of RODEO Net and the 29 other frontier and rural programs listed in

Table 1 suggests that schools of medicine and hospitals are the primary promoters of

frontier and rural telemental health services. Sixteen of the programs are sponsored by

hospitals; seven by schools of medicine. Four have been developed by some form of

managed care entity. The type of sponsoring organization appears to have important

TELEMENTAL HEALTH SERVICES IN US FRONTIER AREAS

193

consequences for the type of telemental health activities undertaken. All of the hospi¬

tal-sponsored programs were interested in consultative services. The programs spon¬

sored by schools of medicine were interested in educational uses. All of the managed

care sponsored programs were interested in administrative applications. Unlike the

hospitals and schools of medicine, the four programs developed by the managed care

entities did not use federal funds and had systems that tended to use technologies that

were not based on full, two-way interactive video. RODEO Net seems to be the only

program of the 30 identified evolving from a non-medical, human service perspective,

which may explain its broad applications.

It is important to recognize that without the involvement of the federal government

it is likely there would be very little public sector provision of telemental health ser¬

vices in frontier areas. Twenty-three of the thirty programs highlighted received money

from federal sources. It is highly probable that hospitals would develop such services

even without federal funds, but they would most likely be “filler” or “add-ons” to the

provision of other telemedicine services. Developing and enlarging a revenue stream

for these services will be the paramount preoccupation for those who invest in these

services for the next five years. Further, while the Internet holds special promise as a

quickly proliferating, locally available and relatively inexpensive network for inter¬

connectivity, none of the projects report using the potentially more cost-effective Internet

service providers as intermediary telecommunication providers in their networks.

Cost and Access Problems

After careful examination of the literature and existing telemental health services,

it appears that telecommunication services in rural and frontier areas in the United

States are severely disadvantaged. Not only are expertise lean and prices high in rural

areas, but in many cases service connections are unavailable. For example, it would

seem that the telephone could be used to support many mental health services. Indeed

it often is in urban areas. Unfortunately, some rural and frontier areas still have rela¬

tively low telephone penetration. In fact, a number of rural and frontier areas have no

911 service, which may indicate a lack of digital switches essential for advanced tele-

j communication services. Further, because of a lack of appropriate switches, in some

parts of frontier Colorado it has been cheaper to call Chicago than Denver. Stated

differently, geographic distance from mental health services is not the only prevailing

determinant of cost; instead, it is the framework of telephone companies serving the

local area and their connection to the long distance carriage system. Basically, unlike

: urban areas— where prices are falling rapidly, in rural and frontier areas the price of

telecommunications continues to be high. Equally important, as a consequence of di-

f vestiture by major telephone companies, some observers expect the costs to rise under

1 1 the new telecommunications policies. US West, the regional Bell Operating Company

194

WALTER F. LAMENDOLA

i

with the highest amount of frontier territory, has already divested itself of $1 .1 billion i

dollars worth of rural service lines because they are “high cost” and “unprofitable.”

However, the intent of the new Universal Fund set up by the Federal Communications

Commission (FCC) implementation of the E-rate under the Telecommunications Act of

1996 is to reduce overall telecommunication costs for qualifying non-profit rural

healthcare providers.

Each of the programs listed in Table 1 uses some combination of audio and video

systems at all participating sites. The cost for on-site equipment at each location can

range from $30,000 to $150,000 (a subsequent Letter to the Field will include a de¬

tailed discussions of these costs). These sites are then physically connected to eachi

other by different levels of service provided by telephone companies. The costs for

connecting lines vary due to individual circumstances and bargaining power. Costs are

also related to carrying capacity and sometimes to the distance to a switching device

capable of moving the signal on to the next connection. Carrying capacity is directly

related to the speed of transmission. Though costs are changing, generally the faster

the transmission time the higher the costs. If a user is interested in seeing the other

person’s movements and talking interactively, higher transmission rates are required so

that images look natural and movements are relatively smooth. A cost effective solu¬

tion used by the Southwest Montana Telepsychiatry Network is achieved by combining

pairs of switched 56k or ISDN (Integrated Services Digital Network) lines (N. Cobble,

personal communication, June 18 1997).

At the moment, telemental health service development is strongly related to the

ability to see and talk to the consumer as though the service provider was there. One

can expect that telemental health service providers will also prefer high quality audio

and specialized camera capabilities, such as zoom and pan. This is because service

providers will want to use the technology at first to replicate— as much as possible—

the manner in which they do their work today. To mimic face to face interactions, they

will want as many technological tools as possible to replicate that context, which will

require the highest line types available today. This can make telemental health services

a natural complement to hospital-based teleradiology services that use high bandwidth

and can support interactive video. Rare but important use in telemental health services

is being made of technologies that do not require anything more than a telephone con¬

nection. Additionally, new, less demanding devices are now available.

One example of costs and line connections in frontier counties can be found in the

Telemedicine Alliance of Healthcare Organizations (TAHO) project of the Office of

Rural Health Policy. Six telephone companies needed to be involved in the beginning

phase of this project because of significant engineering and cost of service issues. The

first service bids ranged from $18,000 to $29,000 a month for two urban and six fron¬

tier participating sites. After a substantial vendor identification and negotiation process,

TAHO was able to reduce their service costs considerably. The service connection

TELEMENTAL HEALTH SERVICES IN US FRONTIER AREAS

195

il

8

f

ll

0

n

h

costs, after installation costs and equipment purchases, were about $7543 per month in

1995. In contrast, the monthly service connection costs of an identical system con¬

tained entirely in the Denver metro area would be $805.26 a month or roughly 10% of

the fee charged in the rural areas. A discussion of the specific costs of each of the

telemental health sites identified by the Office of Rural Mental Health Research is con¬

tained in their report (LaBella, 1995). Further, each site listed on the TIE exchange

gives information about funding and technology in use (Telemedicine Research Center,

1997). In all cases, collaboration was an important key to cost effectively linking com¬

puter networks and interactive sites with one another.

ir

e

y

:r

o

l-

«

e,

le

io

:e

-y

in

es :

th

es |

n- !

he I

of|

ng

he

iii-

Implications for Behavioral Health Services

Mental health services delivered using telecommunications technologies, or

telemental health services, are not yet common in most frontier rural areas. Those

programs that do exist are primarily supported by federal money and the services pro¬

vided tend to vary depending on the sponsoring organization. Programs are now plac¬

ing a high priority on the development of revenue streams beyond federal funding. At

the same time prices for rural telecommunication services continue to be high in rural

areas and in many cases service connections are unavailable. Even with these avail¬

ability and cost problems, frontier areas will probably have a much higher adoption rate

of telemental health services in the future than other types of rural areas because of a

greater lack of local providers. There already seems to be a higher concentration in the

largely frontier Rocky Mountain area. In addition, rural areas where managed care ap¬

proaches are in place or are emerging are likely to be subjected to telemental health

services as a matter of course. Managed care providers often see telemental health

services as a competitive advantage to consolidate provider resources, to review the

work of local providers, or to provide cost-effective expert consultation.

Currently, telemental health service development is strongly related to the ability to

see and talk to the consumer as though the service provider was there. The technology

is being used at first to replicate— as much as possible— the face to face manner in

which service providers work today. This is why current telemental health services

frequently use high bandwidth that can support interactive video. Universal access and

adequate service to support interactive, mixed video, audio, and text messaging for

rural and frontier areas constitute the fundamental telecommunications considerations

in developing rural and frontier telemental health services. From a mental health ser¬

vice system point of view, consumer access— particularly for underserved populations,

provider use, and service outcome are more fundamental considerations for telemental

health service development.

196

WALTER F. LAMENDOLA

References

Allen, D. and Allen A. (1994). Telemental health services today. Telemedicine Today , 2(2):2, 12-15, 24.

Abt Associates. (1997). Exploratory evaluation of rural applications of telemedicine [On-line]. Office of Rural

Health Policy. Available: ftp://158.72.84 .9/ftp/finalabt.pdf

Britain, C.S. (1996). Making the connection in rural mental health. Behavioral Healthcare Tomorrow, August: 67-

69.

GAO Report. (1997, February 14). Telemedicine: Federal strategy is needed to guide investments (Publication

No. NSIAD/HEHS-97-67) Washington, DC: US Government Printing Office.

Joint Working Group on Telemedicine. (1997). Reports 5 and 6 [On-line] . Federal Telemedicine Gateway. Avail¬

able: http://206.156.10.7/gateway/

LaBella, S. (1995, October). A compendium of telecommunications projects with mental health applications.

Washington, DC: ORMHR, NIMH, NIH.

Mechanic, D. (1996). Key policy considerations for mental health in the managed care era. In Mental Health,

United States, 1996, (CMHS, SAMHSA, HHS Publication No. (SMA) 96-3098) Washington, DC: US

Government Printing Office.

Telemedicine Research Center. (1997). Telemedicine Information Exchange [On-line]. Available: http://

tie.telemed.org

Witherspoon, J.P., Johnstone, S.M. and Wasem C.J. (1993). Rural telehealth: Telemedicine, distance education

and informatics for rural health care. Boulder, CO: WICHE Publications.

Additional Suggested Readings

Joint Working Group on Telemedicine. (1997, January 31). Telemedicine report to Congress, Washington, DC:

NTIA, Department of Commerce.

Kansas Telemedicine Policy Group. (1993, November). Telemedicine: Assessing the Kansas environment (Vols.

1-4). Kansas: Author.

McCarthy, J. (1995). Colorado health care telecommunications (monograph). Denver: Colorado Rural Health

Telecommunications Coalition.

Mecklenberg, S. and Green, L. (1995). Progress report for the Office of Rural Health Policy. Ft. Morgan, CO:

High Plains Rural Health Network.

National Rural Health Association. (1994, September). Health care in frontier America: A time for change.

Rockville, MD: Office of Rural Health Policy.

Office of Rural Health Policy. (1994). Reaching rural. Rockville, MD: Author.

Puskin, D. (1992). Telecommunications in rural America: Extended clinical computing by hospital computer

networks. Annals of the New York Academy of Sciences, 670:67-75.

Schoech, R. and Kelley Smith, K. (1995). Use of electronic networking for the enhancement of mental health

services. Behavioral Healthcare Tomorrow, 4(l):23-29.

Journal of the Washington Academy of Sciences,

Volume 86, Number 3, 197-203, December 2000

Telemental Health Services in

Frontier Areas: Provider and

Consumer Perspectives

Walter F. LaMendola, Ph.D.

Abstract

The provision of mental health services to frontier, sparsely populated rural areas, is made

difficult by the long distances between providers and consumers. However, advances in

telecommunication technologies, specifically telemental health, are beginning to provide

options for dealing the distance and isolation challenges of frontier areas. Base on two

focus groups conducted in frontier areas, this paper provides information about the experi¬

ences of non-medical mental health providers and the experiences of consumers with

telemental health services.

Introduction

Isolated rural or frontier areas, areas generally found in the western part of the

United States, often struggle to provide mental health services and related activities to

persons with severe and sometimes persistent mental disabilities because such persons

often live far from the population centers where an array of mental health services

might be offered. However, with advances in telemental health technologies, mental

health services and related activities whose delivery is assisted by telecommunication

technologies, these remote areas may have a mechanism to deal with their distance and

isolation challenges. The paper “Telemental Health Services in US Frontier Areas”

(LaMendola, 2000) defines and describes the current situation in the provision of

telemental health in frontier areas. The technologies in use range from telephone and

fax to live interactive video. The services provided include, but are not limited to,

prevention, diagnosis, consultation, outreach, case management, education and treat¬

ment, as well as transfer of mental health data for use in the provision of services to

specific clients. Little of the information , however, directly reports the experiences of

non-medical mental health services providers or the experience of consumers of

telemental mental health services (TMHS). This paper reports the results of two

focus groups conducted by the Frontier Mental Health Services Resource Network in

the fall of 1997 — one with TMHS service providers. It is the first to provide such

information.

198

WALTER F. LAMENDOLA

Focus Group Site and Composition. The site of the focus groups was a small,

remote Community Mental Health Center in a frontier area of the western United States.

The Center was a participant in a federal rural health project that connected them — via

ISDN lines supporting interactive video — to other rural health settings, hospitals in

urban areas, and the state hospital mental health unit. The service provider focus group

consisted of eight staff members. Providers’ backgrounds ranged from a bachelor de¬

gree with experience to a licensed psychologist. The experience of the service provider

group members with TMHS ranged from a high of two years to a low of one month.

The consumer focus group consisted of nine consumers who had volunteered to

participate. They all were a part of the caseload of a psychiatrist located in an urban

area over one hundred miles from the Community Mental Health Center. All had expe¬

rience with the use of TMHS and all were in active treatment. The consumer with the

least amount of experience with TMHS had participated in six TMHS sessions. Each

consumer reported a major psychiatric diagnosis and one was also physically disabled.

Two of the consumers reported that they had received only medication reviews in

TMHS sessions. Six consumers reported on-going, periodic treatment in TMHS ses¬

sions, and one consumer related an intensive, crisis oriented psychotherapeutic TMHS

intervention.

The Typical TMHS Service Episode. TMHS services involving consumers were

usually instituted after an initial face to face visit with the psychiatrist. The sole excep¬

tion in the focus group was a consumer who was receiving crisis intervention and had

not yet met with the psychiatrist face to face. For these sessions, the psychiatrist went

to a broadcast booth located in a nearby hospital. Consumers — usually accompanied

by their local service provider — went to a multi-purpose room in the mental health

center that was set up like an old style classroom. The room was large enough to hold

public meetings. In the room, the consumer sat at a table on which there was an operator’s

panel and a microphone. He or she faced a set of two large monitors that looked like

TV sets, one of which had a camera on top of it. When the session was initiated, one

monitor would display the remote site and the second monitor would display the pic¬

ture being captured at the local site. In other words, the consumer would see himself or

herself on one of the monitor displays. Functions of the site’s interactive video — such

as pan, zoom, and switching off displays — could be controlled using an operator’s

panel. The panels are small, the controls easy to use, and they were located near the

participant so that they could control a session without moving from their seat. After a

few experiences where consumers had specifically asked to control the environment,

the psychiatrist routinely gave each consumer instructions that enabled them to use the

operator panel during the session. Consumers describe the interactive video setup as

“being on TV,” and this seemed to be a good, shorthand manner of describing TMHS

sessions for everyone. Because they could place the event in such a familiar landscape

as television, very little about the technology of these sessions seemed remarkable to

TELEMENTAL HEALTH SERVICES: PROVIDER AND CONSUMER

199

II,

s.

la

in

‘P

e-

er

either the service providers or consumers. Session length was the same as session

length face to face. Consumers initiated some of the sessions; however, these were not

usually treatment events. Instead, they consisted of consumers visiting with family or

relatives, who were, for example, residential patients at the State hospital. TMHS ser¬

vices involving service providers, but with no consumers, consisted of education, case

supervision, and case management. Sessions were sometimes conducted ad hoc, or

were evoked by consumer needs, but usually they were pre-scheduled.

to

in

e-

le

:h

d.

in

is-

IS

le

P-

ad

int

ed

Ith

)ld

r’s

ke

ne

ic-

or

ich

r’s

he

ra

nt,

the

as

BS

ipe

:t0

Evaluation of TMHS: Positive Reactions

Satisfaction. Service providers expressed a high level of satisfaction with the sys¬

tem and mentioned a number of uses and potential uses that the system could accom¬

modate. One person commented that the system broke through much of the isolation

that they felt as professionals in a remote community and enabled them to communi¬

cate regularly with professionals in other places. Satisfaction of the service providers

also seemed to come from the improved continuity of service that they described. For

example, a number of the providers commented that they now could participate in dis¬

charge planning and have a good sense of the consumer and other members of the case

management team. Others mentioned the opportunity to talk with peers and experts at

other sites as a source of satisfaction and improved service.

Consumers were quite satisfied with the TMHS services they had received. They

expressed the opinion that the services were good and may not have been otherwise

available. As one consumer said; “The TV provides access to timely treatment and

actually gives me what I think is more quality direct contact with my therapist.” Con¬

sumers felt satisfied with the arrangement of having their local service provider present.

They felt this allowed the local service provider to participate in their treatment and

provide insights that they sometimes didn’t have or that they might have been unable to

express during the session. Service providers reported that they sometimes left the

room if the consumer needed either privacy or confidentiality. One service provider

was more forceful in describing their participation, saying that they would “...deter¬

mine the situation as to whether or not I need to be there.”

A Needed Service Capacity. Service providers felt that TMHS availability kept

everyone in communication in a manner that was different than the telephone. Perhaps

this was due to the fact that interactive video meant that everyone needed to be in place

at a scheduled time for the event. This most certainly decreased “telephone tag” and

increased timeliness. In that manner, they felt that TMHS saved time and discouraged

fragmentation of treatment. They also talked about the personal contact TMHS af¬

forded them. By personal contact, they meant the increased sense of presence over

telephone contact provided by the combined visual and auditory medium.

200

WALTER F. LAMENDOLA

Through out the focus group session, consumers emphasized that TMHS helped

them cope with problems of daily living. They explained that TMHS provided them

access to a psychiatrist or provider, or to family and community, particularly when

travel condition were difficult (including weather, poor roads, availability of transpor¬

tation and long time consuming distances) and when quick access to services was re¬

quired — such as during a crisis situation. Stated differently, because of TMHS, a

consumer was not concerned about problems of access due to geography, particularly

when they were acutely ill. Further, they felt they had more direct contact with their

provider when TMHS was a part of existing mental health services.

Evaluation of TMHS: Problems and Concerns

Personal contact. Some consumers reported that they did not like TMHS at first,

but that after they used them they judged them much more favorably. There was con¬

sensus among the consumers that TMHS was much more personal than telephone con¬

tact, but not as personal as a face-to-face meeting with their provider. Consumers felt

that more attention to “business” and less to socialization characterized TMHS ses¬

sions. One consumer pointed out that “some of the fun is gone.” They also indicated

that they would still like to see their psychiatrist in person from time to time, even if

they saw them regularly via TMHS .

Service providers pointed out that TMHS need to be viewed as part of a set of

services. They expressed the opinion that TMHS allows service providers to augment

or supplement services, but they do not replace face to face services. Service providers

reported that consumers who did not have face to face contact with the distant provider

seemed to do less well than those who had at least one such session.

Confidentiality and Privacy. Both service providers and consumers expressed

some reservation about the ability of TMHS to protect confidentiality. No specific

examples of non-confidential behavior were cited, but consumers noted that techni¬

cians and other non-professional people were involved in the provision of TMHS ser¬

vices.

Consumers felt that providing TMHS at home may violate privacy rather than sup¬

port it. They also felt that such services might distress family members, particularly

children, who are not ready to accept the fact that a close family member has a mental

illness. They noted that having the services at home might preclude the presence of the

local therapist, a condition that focus group members felt facilitated effective commu¬

nication. Further, participants noted that availability of at home services might over¬

load the provider.

Paying for services. Participants of both groups emphasized that because insur¬

ance companies are not always willing to pay for TMHS, they have serious concerns

about how their TMHS will be funded. A federal grant initially paid for TMHS at this

site; unfortunately, the grant has been completed. Medicare and Medicaid generally

TELEMENTAL HEALTH SERVICES: PROVIDER AND CONSUMER

201

pay when other insurance pays, and need to be encouraged to pay for TMHS . Medicare/

Medicaid do not always pay for TMHS. One consumer reported that they had to obtain

a court order so that their insurance company would pay for TMHS provided to them.

Computer Access. Most of the consumers had access to personal computers, but

not to Internet services. A few mentioned that they used the Internet in the local library.

Consumers related the provision of TMHS services to the spread in access to networked

computers, but, as a group, they had no opinion about where this might lead in terms of

access to support groups, educational information, or other types of computer mediated

mental health services.

Scheduling the use of TMHS was the major disadvantage expressed by service

providers. Providers also gave diverse reports about the capability of their computing

environment. Five of them had computers at home and two of them reported Internet

access on those computers. The Center had Internet access, but only two of the service

providers had used it. One service provider commented that “...we probably had the

net work... because everyone had a computer on their desk... but, I mean, I could do

virtually everything except word processing stuff... faster with a pen.”

TV Appearance. One consumer expressed a strong dislike for seeing “ myself on

TV,” and “didn’t appreciate seeing how bad I looked.” This consumer felt much better

when able to use the operator’s panel to turn off the monitor display whenever they

were talking.

Service providers reported that the TV appearance was “intimidating, if they are

having paranoid delusions.” They felt this was a special group that needed more assis¬

tance for TMHS to be used successfully. They also reported that consumers seem to get

confused by the time delay in the voices and expected it to work “just like TV.”

Research

When asked about research topics, consumers and service providers indicated that

an investigation of the range of mental health services that could be provided though

TMHS should be explored. Both groups were interested in 1) identifying the correct

mix of face to face and TMHS; 2) understanding the interaction between control of the

TMHS environment and consumer mental illness; 3) investigating the phenomena of

having both the therapist and psychiatrist present with the consumer at TMHS sessions;

and 4) exploring the effects of having TMHS services available at home.

Tell Your Government

Funding. The consumer group asked a simple question: why would the federal

government underwrite such a needed service and then withdraw the funding? Recog¬

nizing the importance of finding funds for TMHS, service providers suggested that

funds should be transferred from activities that they considered to have low priority

202

WALTER F. LAMENDOLA

areas (such as administration) to activities they considered to have high priority (such

as provision of TMHS to isolated rural areas). In particular, they were concerned about

rural communities that have limited access to mental health services.

Outreach. Focus group participants recommended that awareness of both the po¬

tential availability and effectiveness TMHS services should be encouraged. They felt

that many potential users are unaware that TMHS exist and are useful. They felt the

government needs to initiate outreach campaigns. They speculated that such campaigns

would facilitate community support for TMHS .

Congress. Focus group participants felt that congress should support keeping TMHS

in small isolated communities. Their rationale is that TMHS is a reasonable way of

providing essential services to isolated rural persons, particularly those who do not

have easily geographic access to providers.

Implications for Behavioral Health Services

When asked what the major benefit of TMHS was, service providers answered that

it saved time and money. They thought that a second major benefit was the role TMHS

played in what they termed prevention. By prevention they meant the increased ability

to provide continuity of care and immediate response to problems. Consumers also felt

more secure in their home community knowing that TMHS was available.

Service providers and consumers were remarkably similar in their positive atti¬

tudes towards and high level of satisfaction with TMHS. Both groups reported that

TMHS increased access and decreased isolation. Both reported that the technology

afforded them a different level and type of personal contact that was not previously

available. Consumers particularly noted that they felt TMHS supported timely inter¬

vention, increased attachment to community and family, and feelings of security in

regard to the availability of expert help. Service providers felt that TMHS discouraged

fragmentation of treatment, kept people in communication, saved time, and supported

more personal contact.

The environment in which the services took place was important to both consumers

and service providers. Consumers wanted the psychiatrist to appear in the same office

that was used for face to face sessions — not a broadcast room. They disliked the room

used locally and wanted one smaller, more comfortable and congenial. Based on com¬

ments from focus group participants, providers should generally expect a period of

consumer adjustment to the TMHS. Thus, when first exposed to TMHS, some of the

consumers did not like the service. After exposure to THMS, consumers began to ex¬

press much more positive opinions.

Consumers noted that they were nervous the first time they experienced TMHS,

“not knowing what to expect.” Based on the consumer comments it appears that some

type of initial training should be considered before a patient is exposed to TMHS. Con¬

sumers did not like being passive in sessions — i.e., seated in a large room and subse-

TELEMENTAL HEALTH SERVICES: PROVIDER AND CONSUMER

203

quently exposed to the provider on the screen. Also, for at least one consumer, lack of

control over the situation was distressing. Clearly there is a need to provide orientation

and training to both service providers and consumers.

There is no need to present telemental health services as experimental or innova¬

tive. Most consumers like the idea of being on TV, and those who did not expressed

comfort when they were able to control the environment. While service provider resis¬

tance has been a concern nationally, none of these service providers expressed resis¬

tance. The use of an initial face to face session seems to be good practice, and certainly

intermittent face to face contact appears to increase the consumer’s expression of satis¬

faction with treatment.

Finally, the issue underlined by the conversations in the focus groups is the devel¬

opment of an understanding of the personal and supportive uses of the technology.

Both groups personalized the uses of the technology; for example, service providers

felt less isolated and more effective in continuity of care, while consumers felt more

attached and comfortable that help could be provided when it was needed. Both groups

reported supportive uses. For example, one of the unplanned uses of the technology

was its use to allow visitation by family members. It is a sign of the strength of the

project that this type of use was permitted. It is also a good example of how unantici¬

pated uses of technology are often the most powerful. Still, many unanticipated effects

are not as positive and need to be reported, investigated and noted as well. For ex¬

ample, it seems clear that certain types of consumers will not tolerate a TV monitor that

pictures them. Fortunately, in this case they were given control of the monitor and

could remove their own video images if they wished. In developing a knowledge base

about TMHS , we would do well to consider the positive and negative effects of the use

of the technology reported by consumers and service providers here; they stand on the

frontier of what we now know and understand about TMHS .

204

Journal of the Washington Academy of Sciences,

Volume 86, Number 3, 205-217, December 2000

Managed Behavioral Health Care

on the Frontier1

Andrew Keller, Ph.D.

Abstract

In its second decade of the development of the behavioral health industry, managed care for

mental health has come to many frontier regions and soon may come to others. While fron¬

tier residents in private health plans may soon come under managed care due in part to the

growth managed care companies, most health care in frontier areas is government funded.

Consequently this paper focuses largely on the impact of managed care on public payers

such as Medicaid. The potential problems such as the decrease in quality in the interest of

decreased costs and the damage to publicly funded safety net of services in rural and fron¬

tier areas as well as the benefits such as providing an extensive specialist referral network,

telemedicine resources and continuity of care, are reviewed and evaluated. The context of

managed care in frontier areas is also explicated.

General Overview

As the behavioral health care industry enters the second decade of the development

of care management strategies, managed care for mental health has come to many fron¬

tier regions and may soon come to others. It has already come to Medicaid and other

public sector recipients in rural and frontier areas of Arizona, Colorado, Montana, New

Mexico, Oregon, Utah and Washington. Despite some arguments to the contrary, it

seems likely that the residents of these states will soon be joined by many others whose

behavioral health care benefits will be managed.

Those frontier residents in private health plans may also come under managed care

due to increasing enrollment in health maintenance organizations (HMOs) and other

managed plans, as well as continued market growth for companies managing behav¬

ioral health. However, since most health care in frontier areas is government funded,

this letter will largely focus on the impact of managed care on public payers such as

Medicaid. While many of the principles will be applicable to private and other govern¬

ment payers such as Medicare and CHAMPUS, the impact of Medicaid managed care

on public systems will be the central focus.

Managed care raises many concerns, including the potential for decreased quality

in the interest of decreased costs and damage to the publicly funded safety net of ser¬

vices in rural and frontier communities. Beeson (1994) has described several concerns

given the increased incentives to control costs, including: neglect of vulnerable popu-

206

ANDREW KELLER

lations, cost-shifting or “dumping” of high need/cost people from managed to unmanaged

systems (e.g., state hospitals, corrections systems), denials of appropriate care, limited

access to care, decreased funds overall, a decline in resources for mental health and

substance abuse treatment in particular, risks inherent in the privatization of public

services (e.g., private systems historically under- serving persons with severe and per¬

sistent mental illness, the potential loss of gains in consumer and family involvement),

and decreased influence of local communities. Mental health consumers have echoed

many of these same concerns. In response to these and other concerns, pressure is

building at a federal level and in many states to increase government regulation of

managed care plans

Despite increasing public sentiment against managed care, there are still compel¬

ling factors arguing for increased care management in frontier areas, particularly for the

public sector. First, mental health care costs have risen dramatically, even exceeding

the rate for general health expenditures. For example, Medicaid mental health costs in

Colorado rose over 80% from 1990 to 1995. Despite these tremendous cost increases,

traditional funding approaches (including fee-for- service insurance and prior initiatives

by federal and state governments through community mental health centers and state

hospitals) have failed to adequately serve frontier and rural areas. The rising tide of

mental health care financing has yet to reach rural, let alone frontier, America.

Yet frontier areas tend to be unattractive markets for managed care development.

By definition they have small populations that tend to be scattered rather than clustered.

There are few providers among whom to foster competitive markets. Finally, there is

little room is left for cost-cutting given that health care is more expensive to deliver in

frontier areas and reimbursement is already significantly below urban rates. Neverthe¬

less, a recent analysis of managed care trends in rural areas argues for increased pros¬

pects for managed care expansion.

System Design Considerations in Frontier Areas

Risk Assignment. When designing care management approaches for frontier ar¬

eas, policy-makers must look at the full array of financing approaches available to them

and the incentives that they create. On the one extreme are fee-for-service arrange¬

ments, in which the payer bears all financial risk. The more services provided, the

more the payer must spend, regardless of how many services are eventually provided or

their outcome. This creates an incentive for providers to provide as many services as

possible (the more services provided, the more income generated) and a situation in

which payers face essentially unlimited liability for increases in the cost of care. These

two factors strongly motivate payers to move to managed care.

On the other extreme is capitation. Capitated health plans achieve their savings

and increased accountability largely by transferring the risk of the cost of care from

payers (e.g., federal and state government agencies in the case of public plans, insur-

MANAGED BEHAVIORAL HEALTH CARE ON THE FRONTIER

207

ance companies or self-insured corporations in the case of private plans) to providers

(e.g., networks of independent practitioners, community mental health centers, regional

governmental entities, managed behavioral health care organizations, etc.). In a capitated

health plan, a provider agrees to provide all the health care services required by a speci¬

fied population in return for a pre-set amount of dollars. If the costs of care are less than

the pre-set amount, the provider makes a profit; if the costs exceed the pre-set amount,

the provider incurs a loss.

Between these two extremes are a variety of intermediary strategies that offer pay¬

ers options for managing care short of full capitation, including:

• Case-rate capitation, in which payers provide a set dollar amount for each

category of client treated. This approach transfers to the provider the risk of the

cost of treating each case, but retains for the payer the risk for how many cases

will be treated. The first phase of managed behavioral health care in Arizona

utilized this approach.

• Partial capitation, in which some services are capitated (either fully or through

a case-rate) and some are not. Most public managed mental health care ap¬

proaches are partial capitation approaches (Montana is the only current excep¬

tion), generally due to the retention of traditional funding for state hospitals and

indigent care. This allows a payer to put only part of a system of care under

increased financial risk.

• Managed fee-for-service, in which, although a fee is still paid for each specific

covered service rendered, providers are not free to perform as many services or

charge as much for each service as they choose. Fee schedules are used to limit

the amount charged for each service. Utilization management strategies such as

prior authorization for treatment and concurrent utilization review help control

the number of reimbursable services provided.

It is important to keep in mind that a single managed behavioral health care system

may employ several of these strategies. For example, a state may award a capitated

contract for the entire Medicaid mental health plan to a single managed care organiza¬

tion, but retain traditional funding for its state hospital. The managed care organization

may in turn employ managed fee-for-service arrangements (e.g., fee schedules, prior

authorization for treatment, and concurrent review) with the providers with whom they

sub-contract and perhaps even a case-rate for certain sub-populations (e.g., persons

with severe and persistent mental illness).

Integrated vs. Carved Out Approaches. Medicaid managed mental health care

developments have primarily centered on full and partial capitation. Here, an impor¬

tant debate has taken place between those advocating that mental health funds be inte¬

grated with funds for primary care and those advocating that they be kept separate.

Often referred to as the choice between an integrated versus a carved out model, the

208

ANDREW KELLER

debate seems to have ended up largely in favor of carved out models for the present.

Integrated plans, while perhaps the ultimate goal of many, nevertheless pose significant s

risks for behavioral care. Mental health care tends to be overlooked, underutilized, and

poorly managed when part of an overall, primary care oriented health plan. In addition,

primary care physicians tend to under-diagnose mental health disorders.

Many are now viewing carved out mental health plans as a developmental step

toward increased integration. Carved out plans allow for the development and refine¬

ment of care delivery and management systems specifically tailored to the realities of

mental health care provision. If integrated delivery systems are developed that coordi¬

nate all health care beneath a single funding, administrative and clinical umbrella, today’s

carve outs may become the robust mental health components of these systems. For

frontier areas, the question of carve out or integration may be of less interest. Specialty

care, including mental health care, is of little concern in areas that are lucky to have any

health care capacity at all. Yet, whether mental health care will diminish in importance

or evolve into a stronger component of the overall health care picture may depend upon

the outcome of the integration/carve out discussion.

Frontier Considerations. Once these larger, structural questions have been ad¬

dressed, the realities of frontier care delivery systems must be kept in mind as managed

care comes to frontier areas. First, health care is more expensive to deliver in frontier

areas. Rates in frontier and rural areas may not offer as much room for cost-cutting

given their historically lower reimbursement, especially for inpatient care. However,

costs can still be controlled through better aligned incentives. For example, an early

finding in Iowa’s and Colorado’s Medicaid capitation pilots has been decreased costs

and increased access. Many reason that these seemingly contradictory results have

been achieved by increasing access to outpatient and other less costly interventions that

save money by decreasing the need for more costly emergency and inpatient care. In¬

patient savings have fueled the system, not through fewer episodes but rather through

shorter lengths of stay.

In serving frontier areas, it will be important that urban models are not uncritically

applied. For example, hospital savings typically achieved in urban areas may not be

realistic in the frontier where outpatient supports and inpatient alternatives are often not

available. Specifically, the use of hospital step-downs may not be possible if a con¬

sumer has to commute two hours each way to the hospital in order to transition from

24-hour care to partial care.

Another unique challenge in the frontier is that of access to services. Geographic

distance and the expense incurred in overcoming it, a shortage of providers, and atti¬

tudes that stigmatize the seeking of mental health care already pose a barrier to service

utilization. This causes many frontier advocates to fear managed care as yet one more

impediment to adequate health care. While managed care can increase access, it will be

important for payers to ensure that this is the case for frontier people as well as the plan

MANAGED BEHAVIORAL HEALTH CARE ON THE FRONTIER

209

1

as a whole. Given that frontier residents often comprise only a small minority of recipi¬

ents in a plan, access standards governing the plan must ensure, as they should with any

minority group, that the impact upon frontier members is examined separately from the

overall population average. Otherwise, differential impacts on frontier residents and

their communities may be missed.

In fact, managed care in less populous areas may be less focused upon reducing

costs and more concerned with improving access to more efficient models of care.

While most describe managed care as cost-focused, it can also be viewed as increasing

accountability for value from the health care that is purchased. In densely populated

areas, value has been increased by holding care providers accountable for cost-efficient

services. In these areas, an over- abundance of care providers, both individuals and

! institutions, chasing fewer and fewer health dollars results in competition to increase

efficiency and reduce costs.

The situation is reversed in rural and particularly frontier areas. Here, there are too

i few providers and too few services provided. In such a context, increased value and

accountability to sound health care cuts the other way, calling for increased access to

appropriate services. One study of managed primary health care has found that physi-

1 1 cian availability was the key to successful initiatives. This suggests that mental health

r care provider availability could be essential to effective managed behavioral health

! care in rural areas. Some have even argued that Medicaid managed care will create new

; incentives for providers to come into rural and frontier areas. Although one should not

i assume that managed care will necessarily lead to increased access to care in frontier

s areas, managed care does offer the opportunity for payers to revisit the value realized

; for what they do spend on health care in frontier areas.

t In addition to the number and type of health care providers within a reasonable

• commute, other factors influence the quality of access within a health system. One

i must also keep in mind that managed care approaches organize the system of care.

Currently, the focus of care managers has shifted away from simple cost-cutting to

v more efficient system design through integration across similar and diverse types of

e health care providers. System organization is another factor to consider when evaluat-

it ing the access afforded by a health plan. For example, driving 75 miles to access a

physician tied into an extensive specialist referral network, telemedicine resources, and

n other amenities of a managed health plan might afford access to better care overall than

driving 25 miles to a solo physician.

c j Nevertheless, the fear remains that geographic centralization will pose a threat to

i- access in frontier areas. However, the risk seems to be less that managed care plans will

e remove frontier providers already on the scene than that plans will fail to improve

e < access for frontier residents that must already rely on providers located far away. While

e increased inaccessibility through geographic centralization is a threat in managed plans,

,n the situation can also be viewed as an opportunity to use evolving geographic distance-

210

ANDREW KELLER

to-care standards to require plans to improve distance-to-care in frontier areas. Never¬

theless, payers must take care that unscrupulous plans not use distance barriers — ei¬

ther preexisting or newly imposed — to lower frontier utilization.

Controlling the Quantity of Care: From Managing Utilization to

Managing Care

Most discussions of managed care center on decreasing the costs of care, usually

by decreasing the quantity of services provided. For a good overview of managed care

techniques and approaches, see Mindon and Hassol (1996); and for the application of

these techniques to child and adolescent services, see Lourie, Howe and Roebuck (1996).

It is important to remember, however, that care management strategies evolve over

time. Behavioral health care has only been managed at the longest for just over a

decade in a few markets. Therefore, to gauge the possible direction of this evolution it

may be helpful to consider the evolution of care management approaches for primary

health care, which have had significantly more time to develop.

The management of primary health care can be described as having moved through

four stages: unmanaged, early management focused upon costs, horizontal integration,

and vertical integration. The table on the next page presents each of these stages, de¬

scribing their care delivery system structure, financial implications, and impact on pay¬

ers, providers and consumers.

While many markets are still dominated by early managed care approaches, hori¬

zontal integration is increasing in many markets and more mature markets are begin¬

ning to experiment with vertical integration. With the advent of vertically integrated

delivery systems, many have proposed an as-yet untested hope that the management of

care toward improved consumer outcomes will usurp crass utilization management,

allowing savings to be achieved instead through improved care.

The implication of these developments for behavioral health is the possibility that

managed care can offer more than decreased costs and strict utilization controls. As

managed care moves into new areas such as frontier mental health, it will be important

to remember that strict utilization management is not the only option available. As

noted earlier, frontier areas may find it easier to realize increased value for mental

health dollars through enhanced access and care coordination rather than simply through

decreased rates and shorter inpatient stays. This level of development is more in keep¬

ing with stage four integrated delivery system development rather than more primitive

cost controls. Perhaps the question most pertinent to rural and frontier residents is

whether managed care will ultimately focus upon restricted care or improved access to

coordinated and comprehensive services.

MANAGED BEHAVIORAL HEALTH CARE ON THE FRONTIER 211

it

is Improved Quality Through Increased Accountability

While the effort to measure the impact of mental health care has reemerged at lev-

els that rival even the hey-day of community mental health in the 1970s, research has

yet to shed much light upon the concerns raised by managed care. Managed delivery

^ systems may bring opportunities such as improved quality of care, increased organiza-

P' tion and coordination within systems of care, more integrated care (primary and mental

/e Ihealth), and renewed attention to the outcomes of care. Case study research has shown

■ that managed care for general health care has worked well in some rural and frontier

10 areas, in particular making health care more affordable. Although the study found man¬

aged care’s effect upon the quality of care difficult to determine, it reasoned that re¬

aligned provider incentives and increased accountability could very well increase qual¬

ity. Also, studies have found “positive potential” in managed care principles compat-

212

ANDREW KELLER

ible with the development of comprehensive systems of care, especially for children

and adolescents. While it seems clear that managed behavioral health care has effec¬

tively reduced costs across the board and even improved access in some areas; access

has decreased in some locales. Overall, findings regarding the effect of managed be¬

havioral care on quality and the relative strengths of different models of managed care

remain inconclusive.

One should not be fooled into thinking, however, that the major, or in many cases

even a primary, motivation for proponents of managed care is improved quality. Cur¬

rently, there are no accepted standardized measures of quality and plans compete pri¬

marily on the basis of price. However, the opportunity exists to change this balance.

Improved tracking systems and more flexible computer databases offer the potential of

increased accountability not simply for cost but also for quality. In particular, this is an

opportunity that must not be lost for persons in frontier areas and others who currently

receive a disproportionately low share of the behavioral health care dollar. It may be a

unique chance to hold health plans accountable for the care they provide in the frontier.

A host of performance indicator and outcome measurement approaches are cur¬

rently emerging from development into more widespread practice. Performance indica¬

tors seem to be gaining wider use than outcome measures, as consensus seems to have

been more easily reached about the hallmarks of effective performance as opposed to

the measurement of the overarching outcome goals that they seek to achieve. The

primary measures are summarized below:

Standardized measures such as these could help frontier health care advocates first

identify the differences in service delivery that currently exist for frontier residents and

second use the standards over time to hold plans accountable for rectifying these differ¬

ences. Measures that can help define these differences more clearly could help draw

attention to the needs in these locales.

This underscores a key guideline that should govern performance measurement in

frontier areas. Specifically, behavioral health plans should analyze utilization and other

performance patterns by separating the data for frontier areas from data for more popu¬

lated areas. Ensuring that sub-populations within plans are examined separately for

differential experiences has been put forward in standards for the care of other minority

groups. Others have specifically suggested the separate measurement for frontier resi¬

dents of data pertaining to satisfaction, service utilization, access and grievances. Fail¬

ure to analyze data from frontier areas separately can lead to various mistaken interpre¬

tations. For example, if satisfaction overall is 90%, it may wash out higher rates of

dissatisfaction in frontier areas overlooked unless disaggregated.

Challenges for Providers

Managed care developments bring many changes for the mental health care pro¬

vider. These can be grouped into system level and individual practitioner challenges.

MANAGED BEHAVIORAL HEALTH CARE ON THE FRONTIER

213

,v

System Level Challenges. Foremost among the system challenges facing care

providers in frontier areas are credentialing difficulties. This includes the lack of ad¬

equate policies defining just who counts as a mental health professional in managed

health care plans, as well as the appropriate uses for those providers who are counted.

Managed care plans generally develop credentialing guidelines defining which profes¬

sionals can be reimbursed by the plan (i.e., which providers can be members of the

provider network) and which cannot (i.e., the remaining providers). By restricting the

available pool of providers to those that meet the plan’s guidelines (which are generally

more restrictive than state guidelines for holding a license as a mental health profes¬

sional), credentialing standards pose the risk of compounding mental health workforce

shortages when applied to frontier areas.

The argument that frontier areas and other special needs groups should be excepted

from credentialing standards has generally been rejected, perhaps for the better given

the concern that frontier areas not be relegated to second-class status. Strategies to

respond to this in rural plans include the development of specific reimbursable roles for

mid-level providers, more flexible reimbursement for mid-level providers, and compe-

214

ANDREW KELLER

tency-based credentialing procedures. One positive approach has been to grant a grace

period to providers that fall below minimum requirements, allowing a period of time in

which providers can bring themselves up to par. An alternative approach that might

better serve those frontier providers for whom no amount of time would be enough to

pass muster would be for health plans to develop alternative credentialing standards.

Such standards have already been put forward for mental health providers in other

specialized niches such as rehabilitation workers or Washington State’s standards for

Minority Mental Health Specialists.

Individual Practitioner Challenges. Managed care also changes the work life of

the individual practitioner. Advantages for rural physicians include development or

preservation of their market share and assistance from managed care organizations in

complying with non-clinical requirements. Other advantages include the enhanced back¬

up provided by the resources of an organized system of care, including referrals,

informatics, technology, and managed relationships with other facilities, as well as in¬

creased efforts to expand telephonic and other telemedicine capacities as managed care

organizations seek to augment the capacity of individual providers.

Disadvantages include loss of control over certain aspects of clinical practice and

the feeling of cultural difference from the managed care organization, especially if it is

located in an urban location far from the frontier practice. Other challenges include

concerns about job security, declines in income, changes in professional identity in¬

cluding loss of status and autonomy, and financial conflicts of interest. Most mental

health providers have experienced a loss of autonomy, especially through frequent treat¬

ment plan reviews and frugal authorizations, often even for outpatient care. However,

plans are increasingly moving away from costly utilization management strategies and

toward network management techniques that more closely align the care practices of

individual practitioners with the care models of the health plan. This allows, in some

cases, for the delegation of outpatient care management responsibility to the individual

provider.

In negotiating these new challenges, providers need to avoid several pitfalls often

found in managed care contracts. Among the most notorious are gag clauses that seek

either to prevent clinicians from disclosing to their clients their financial arrangements

with the managed care organization or in some cases from recommending services that

the plan does not cover. Related to this and similarly problematic are contracting ar¬

rangements that allow the dismissal of clinicians without cause or without appeal to a

neutral clinical authority.

Also problematic are the use of incentives that create conflicts with patient care

such as bonuses for low utilization or at-risk arrangements that reward clinicians for

providing less care. It should be kept in mind, however, that all financing arrangements

create financial incentives of some sort for clinicians. Fee-for-service arrangements

created the incentive to over-utilize. This fact was not missed by many consumer advo-

MANAGED BEHAVIORAL HEALTH CARE ON THE FRONTIER

215

cates who see the move away from fee-for-service reimbursement as a way to decrease

the use of restrictive interventions such as involuntary hospitalization. It might be pointed

out that the necessity for clinicians to put the needs of their clients over their own

1 financial self-interest is a long-standing concern in the fields of medicine and mental

health. No matter what the financing arrangement, clinicians should continue to seek

support through peer- and self-imposed ethical standards. However, the more egre¬

gious managed care practices that reward clinicians for decreased care should be sim¬

ply avoided.

Also worthy of scrutiny is the bias in most if not all managed care settings toward

brief psychotherapy and an accompanying move away from long-term, psychoanalyti-

i cally- or insight-oriented psychotherapy. Psychotherapy in managed care plans in¬

creasingly amounts to little more than brief, focused and supportive psychotherapy,

behavioral and cognitive-behavioral therapy, and greater reliance on medication. Such

moves seem to be due less to research findings than to the financing practices of the

: managed care plan. Clinicians would be wise to balance managed care pressures to¬

ward briefer treatment with research findings and their own clinical experience,

i The role of the frontier mental health provider is also likely to change. It has long

$ been argued that the answer to the shortage of professionals in rural and frontier areas

e rests in the redesign of the delivery system, not simply in attempts to attract more indi¬

vidual workers. Delivery system reforms such as service integration (between primary

il | and mental health care) have been suggested as the key to the long-term effectiveness

of managed care in general and in rural areas in particular, given the shortage of mental

f, health providers in such areas. It is likely that such strategies will also be needed in

d frontier areas.

if

Implications for Behavioral Health Services

This paper has demonstrated that managed care has important consequences for the

n provision of mental health care in frontier areas. Thus, as managed care increasingly

1 1 moves toward risk-shifting strategies such as capitation, frontier stakeholders must be

tj i careful not to allow such risks to be shifted to the consumer through excessively re¬

al duced care expenditures. Toward this end, the table below presents some key recom-

r. tmendations for the major stakeholder groups in frontier areas:

3

State Mental Health Authorities in Frontier States

re • Design Requests for Proposals (RFPs - the documents specifying the require-

0[ ments for public mental health care purchases) with frontier areas in mind. Do

K not simply look at the state as a whole; remember that there are special popula-

lK tions within the state that merit special consideration.

216

ANDREW KELLER

• Learn to write good contracts. States in general and mental health departments in

particular have formerly not had to write contracts governing such large expendi¬

tures for such softly defined products.

• Begin to use risk corridors and other strategies to ensure that plans do not unduly

profit and that providers do not take on so much risk as to endanger the public

mental health safety net. Given the difficulty in separating profit and administra¬

tive costs, some states have moved to setting limits for combined profit and

administrative expense, creating the twin benefits of limited profit and minimized

administrative expenses.

• Ensure a market for frontier health care by pooling funding for frontier areas with

that for more populated locales. This will create a population base large enough

and inclusive enough of traditional delivery system excesses in urban and subur¬

ban areas so as to motivate managed care organizations to come into frontier

areas.

Advocates for Frontier Health Care

• Advocate for frontier-sensitive RFPs, sound contracting, risk corridors, limits to

profit and administrative expenses and the pooling of funding for frontier areas

with more populated suburban and urban areas so that your state governments

will be more likely to do the right thing.

• Demand the development of quality standards and advocate for their standardiza¬

tion and application to frontier populations. Also advocate for their relevancy to

frontier concerns such as geographic access.

• Support the effective use of these standards by insisting that payers monitor them

separately for frontier beneficiaries and hold plans accountable for any deficien¬

cies.

• Advocate for increased use of outcomes in contracting and provider selection.

The most important thing is what health care systems accomplish for the people

they serve.

Frontier Providers

• Start planning for managed care now, as the “hope” that rural and frontier areas

will remain a safe-haven from managed care practices is fast eroding. Knowl¬

edge of managed care itself is an important first step.

• Diversify and specialize. The more things that you do well and the better you do

them, the more competitive you will be in a managed care market.

• Move into management roles. Why not have care managed by clinicians sensitive

to frontier concerns?

MANAGED BEHAVIORAL HEALTH CARE ON THE FRONTIER

217

• Move toward more efficient models of care. Brief treatments and time-efficient

models may not respond to all mental health needs, but they are fast emerging as

necessary components of contemporary clinical practice.

• Organize for economies of scale and increased leverage within managed systems

of care. Providers should also consider integration across professional bound¬

aries.

• Organize for advocacy through local organizations and the National Association

for Rural Mental Health.

• Beware of problematic clauses in managed care contracts and feel free to seek

legal advice before signing.

Mental Health Consumers

• Influence the design of managed behavioral health care systems through local

and national organizations.

• Advocate for increased emphasis on self-help as a cost-effective way to provide

care.

• Expect less restrictive service alternatives and use new grievance and complaint

procedures and the incentives tied to them to demand less restrictive care alterna¬

tives.

• Be wary of less service and vigilant for the risk that too few services be provided.

As with overly restrictive services, the primary means for avoiding under-service

are grievance and complaint processes.

References

Beeson, P.G. (1994). Rural mental health in an era of reform: A key issues focus group meeting. Rockville, MD:

Center for Mental Health Services and National Association of Rural Mental Health.

Lourie, I.S., Howe, S.W. and Roebuck, L.L. (1996). Lessons learned from two behavioral managed care ap¬

proaches with special implications for children, adolescents, and their families . Rockville, MD: Center for

Mental Health Services.

Mindon, S. and Hassol, A. (May, 1996). Final review of available information on managed behavioral health

care. Rockville, MD: Center for Mental Health Services.

Notes

1 This Letter to the Field draws upon the work of many other authors and researchers not referenced here. A

more comprehensive treatment of this material with citations is available from the Frontier Mental Health

Services Resource Network.

218

1999 Membership Directory

DR. SUHEIL F. ABDULNUR 5715 GLENWOOD ROAD,BETHESDA, MD 20817

DR. P.H. ABELSON 4244 50th STREET NW, WASHINGTON, DC 20016

DR. LEWIS F. AFFRONTI 108 WATERVIEW CIRCLE, FOREST, VA 24551

DR. J. FRANCES ALLEN RR1 BOX 9,ROXBURY, NY 12474

DR. PHILIP ANDERSON DEPARTMENT OF PHYSICS, PRINCETON, NJ 08544

MR. CASPER J. ARONSON 3401 OBERON STREET, KENSINGTON, MD 20895

MR. COLLINS ARSEM 10821 ADMIRALS WAY, POTOMAC, MD 20854

MR. PAUL T. ARVESON 6902 BREEZEWOOD TERRACE, ROCKVILLE, MD 20852

DR. RAVSHAN I. ATAULLAKHANOV SEVERODVINSKAJA 13, 1-262, 129224 MOSCOW RUSSIA

DR. R. CLIFTON BAILEY 6507 DIVINE STREET, MCLEAN, VA 22101-4620

DR. LEONARD BAKER 2301 JEFFERSON DAVIS HWY, ARLINGTON, VA 22202-3821

DR. VLADIMER BAKHUTASHVILI 9-36 GAMSAKHURDIA STREET, TBILISI 380015 REPUBLIC OF

GEORGIA

MR. LARRY L. BARBOUR PEQUEST VALLEY FARM, 585 TOWNSBURY ROAD, GREAT MEADOWS, NJ

07838

DR. CHARLES I. BARTFELD 6007 KIRBY ROAD, BETHESDA, MD 20817

DR. W. ALLEN BARWICK 13620 MAIDSTONE LANE, POTOMAC, MD 20854-1008

DR. VICTOR R. BASILI A.V. WILLIAMS BUILDING, COLLEGE PARK, MD 20742

MR. ANDREW I. BATAVIA 2845 PRAIRIE AVENUE, MIAMI BEACH, FL 33140

DR. LOUIS A. BEACH 1200 WAYNEWOOD BLVD., ALEXANDRIA, VA 22308-1842

DR. WALTER R. BEAM 4804 WELLINGTON FARMS DRIVE, CHESTER, VA 2383 1

DR. EDWIN D. BECKER BLDG. 5, RM. 124, NAT. INSTITUTES OF HEALTH, BETHESDA, MD 20892

DR. ROBERT B. BECKMANN 10218 DEMOCRACY LANE, POTOMAC, MD 20854

MR. IVAN BEKEY 4624 QUARTER CHARGE DRIVE, ANNANDALE, VA 22003

DR. MAURICE BENDER 1684 152nd AVE NE APT 103, BELLEVUE, WA 98007-4278

DR. WILLIAM M. BENESCH 4444 LINNEAN AVENUE, NW, WASHINGTON, DC 20008

DR. CHESTER R. BENJAMIN 315 TIMBERWOOD AVENUE, SILVER SPRING, MD 20901

MR. JOHN A. BENNETT 5400 VANTAGE POINT RD #P1 1, COLUMBIA, MD 21044

DR. OTTO BERGMANN 1039 SOUTH 19TH ST., ARLINGTON, VA 22202-161 1

DR. HAROLD BERKSON 12001 WHIPPOORWILL LANE, ROCKVILLE, MD 20852

MR. BERNARD BERNSTEIN 7420 WESTLAKE TERRACE, APT 608, BETHESDA, MD 20817

MR. JESSE F. BERRY 2601 OAKENSHIELD DRIVE, ROCKVILLE, MD 20854

MR. GARY L. BINGE 13919 LORD FAIRFAX PLACE, UPPER MARLBORO, MD 20772

DR. SAMUEL J. BIONDO 10144 NIGHTINGALE ST., GAITHERSBURG, MD 20882

MS. PATRICIA M. BITTNER 12780 FLAT MEADOW LANE, OAKHILL, VA 20171-2249

DR. CHARLES A BLANK 255 MASSACHUSETTS AVENUE APT 607, BOSTON, MA 021 15

DR. ROBERT F. BLUNT 541 1 MOORLAND LANE, BETHESDA, MD 20814-13335

! DR. JEAN K. BOEK 501 1 LOWELL ST. NW, WASHINGTON, DC 20016

DR. MARILYN SUE BOGNER 9322 FRIARS ROAD, BETHESDA, MD 20817-2308

DR. TOM BOTTEGAL ARTHUR D. LITTLE, WASHINGTON, DC 20024

MR. WENDELL J. BOYD 6307 BALFOUR DRIVE, HYATTSVILLE, MD 20782

MS. SARA L. BRADSHAW 5405 DUKE, #312, ALEXANDRIA, VA 22304

DR. EMANUEL L. BRANCATO 7370 HALLMARK ROAD, CLARKSVILLE, MD 21029

DR. ANDREW F. BRIMMER 4400 MacARTHUR BLVD., NW, WASHINGTON, DC 20007

S MR. ROBERT D. BRISKMAN 61 VALERIAN COURT, NORTH BETHESDA, MD 20852

220

DR. ELISE A.B. BROWN 6811 NESBITT PLACE, MCLEAN, VA 22101-2133

MR. MILTON M. BRYAN 3322 NORTH GLEBE RD„ ARLINGTON, VA 22207-4235

DR. FELIX A. BUOT CODE 6862, WASHINGTON, DC 20375

MR. EDMUND M. BURAS, JR. 824 BURNT MILLS AVENUE, SILVER SPRING, MD 20901-1492

MR. EDGAR JOHN BURNS 3718 THORNAPPLE STREET, CHEVY CHASE, MD 20815

MR. DONALD O. BUTTERMORE 34 WEST BERKELEY ST, UNIONTOWN, PA 15401-4241

MR. LOWELL E. CAMPBELL 14000 POND VIEW ROAD, SILVER SPRING, MD 20905

MR. FRANCIS J. CAMPBELL 2412 CREST STREET, ALEXANDRIA, VA 22302

MR. WILLIAM M. CARPENTER SRI INTERNATIONAL, ARLINGTON, VA 22209

DR. DANIEL B. CARR 9930 RAND DRIVE, BURKE, VA 22015

DR. WILLIAM R. CARROLL 4802 BROAD BROOK DRIVE, BETHESDA, MD 20814-3906

DR. VINTON G. CERF 3614 CAMELOT DRIVE, ANNADALE, VA 22003

MR. MATTHEW J. CERRONI

DR. RANDALL M. CHAMBERS 2704 WINSTEAD CIRCLE, WICHITA, KS 67226

MR. JERRY CHANDLER 837 CANAL DRIVE, MCLEAN, VA 22102-1407

DR. SATHISH CHANDRAN 42, SOLOK BATU UNJUR 3, SELANGOR D.E. MALAYSIA

DR. ALPHONSE CHAPANIS 5 HAMPSHIRE WOODS CT, TOWSON, MD 21204-4304

DR. HARVEY R. CHAPLIN, JR 1221 WEST LEIGH DRIVE, CHARLOTTESVILLE, VA 22901

DR. FENNER A. CHASE, JR. 6 LELAND COURT, CHEVY CHASE, MD 20815

DR. DAVID ARTHUR CHERNIN DAVIS SQUARE, SOMERVILLE, MA 02144

DR. CURTIS G. CHEZEM 3378 WISTERIA STREET, EUGENE, OR 97404-5930

DR. ESTHER NAGN-LING CHOW 7420 BRICKYARD ROAD, POTOMAC, MD 20854

DR. GALE W. CLEVEN 205 RIVER PLACE, LANDER, WY 82520

DR. THOMAS LYTTON CLINE 13708 SHERWOOD FOREST DRIVE, SILVER SPRING, MD 20904

DR. GIDEON MARIUS CLORE LAB OF CHEMICAL PHYSICS, BETHESDA, MD 20892

MR. JOSEPH F. COATES PRES., COATES & JARRETT, INC., WASHINGTON, DC 20008

DR. TIMOTHY P. COFFEY NAVAL RESEARCH LABORATORY, CODE 1001, WASHINGTON, DC 20375-5000

DR. MICHAEL P. COHEN 555 NEW JERSEY AVENUE, NW, WASHINGTON, DC 20208-5654

DR. RITA R. COLWELL DIRECTOR, NATL SCIENCE FOUNDATION, ARLINGTON, VA 22230

DR. JAMES COMAS NIST/ATP, GAITHERSBURG, MD 20899-4720

DR. WILLIAM J. CONDELL, JR. 4511 GRETNA STREET, BETHESDA, MD 20814

MR. EDWARD McD. CONNELLY 1 1915 CHEVIOT DR., HERNDON, VA 22070

DR. KENNETH W. COOPER 4497 PICACHO DRIVE, RIVERSIDE, CA 92507-4873

DR. LEON N. COOPER DIRECTOR, INSTITUTE FOR BRAIN AND NEURAL SYSTEMS, PROVIDENCE, RI

02912

MRS. EDITH L.R. CORLISS 2955 ALBEMARLE STREET, NW, WASHINGTON, DC 20008-2135

MR. JOHN J.F. CORRIGAN 1 1768 OWENS GLEN WAY, NORTH POTOMAC, MD 20878

MR. LOUIS COSTRELL 15115 INTERLACHEN DRIVE, APT 621, SILVER SPRING, MD 20906-5641

DR. CAROLYN E. COUSIN 1903 ROXBURY COURT, ADELPHI, MD 20783

DR. KEITH WARREN CRAWFORD 2806 FT. BAKER DR. S.E., WASHINGTON, DC 20020

DR. CYRUS R. CREVELING 4516 AMHERST LANE, BETHESDA, MD 20814

DR. JOHN K. CRUM 1155 16TH STREET, NW, WASHINGTON, DC 20036

REV. C. L. CURRIE, S.J. PRES., ASSN OF JESUIT COLLEGES & UNIVERSITIES, WASHINGTON, DC 20036

DR. DONALD P. D’ AMATO MITRETEK SYSTEMS, INC., McLEAN, VA 22102

DR. JOHN WILLIAM DALY CHIEF, LABORATORY OF BIOORGANIC CHEMISTRY, BETHESDA, MD 20892

DR. ROBERT E. DAVIS 1793 ROCHESTER STREET, CROFTON, MD 21 1 14

DR. ROLAND DE WIT 11812 TIFTON DRIVE, ROCKVILLE, MD 20854-3538

DR. GEORGE E. DEAL 6800 FLEETWOOD ROAD, MCLEAN, VA 22101

DR. ROBERT L. DEDRICK 1633 WARNER AVENUE, McLEAN, VA 22101

CDR. HAL P. DEMUTH 118 WOLFE STREET, WINCHESTER, VA 22601

DR. RICHARD D. DESLATTES, JR 610 ASTER BLVD., ROCKVILLE, MD 20850

DR. STANLEY DEUTSCH 7109 LAVEROCK LANE, BETHESDA, MD 20817

MR. NORMAN DOCTOR 6 TEGNER COURT, ROCKVILLE, MD 20850

COL THOMAS W. DOEPPNER 9000 BELVOIR WOODS, PKWY, FORT BELVOIR, VA 22060-2706

MRS. JOHANNA B. DONALDSON 3020 NORTH EDISON STREET, ARLINGTON, VA 22207

MS. EVA G. DONALDSON 3941 AMES ST NE, WASHINGTON, DC 20019

DR. MILDRED DONLON 8525 THORNDEN TERRACE, BETHESDA, MD 20817

221

DR. ROBERT J. DOOLING 13615 STRAW BALE LANE, GAITHERSBURG, MD 20878-3994

DR. SATYA D. DUBEY 7712 GROTON ROAD, WEST BETHESDA, MD 20817

DR. DICK DUFFEY CHEM-NUCLEAR ENGINEERING DEPT., UNIVERSITY OF MARYLAND, COLLEGE

PARK, MD 20742

DR. JAMES A. DUKE 8210 MURPHY ROAD, FULTON, MD 20759

DR. RAYNOR L. DUNCOMBE 1804 VANCE CIRCLE, AUSTIN, TX 78701

MR. JOHN E. DUPONT P.O. BOX 358, NEWTOWN SQUARE, PA 19073

DR. ARJAN DURRESI 925 CITY PARK AVENUE, COLUMBUS, OH 43206

DR. STANLEY EVAN EDINGER 5901 MONTROSE ROAD, APT #1400 SOUTH, ROCKVILLE, MD 20852

MR. NORMAN W. EDMUND 407 NE 3rd AVENUE, FT. LAUDERDALE, FL 33301

DR. GRAEME EISENHOFFER 5803 WILMETT ROAD, BETHESDA, MD 20817

DR. MILTON PHILIP EISNER 1565 HANE STREET, MCLEAN, VA 22101-4439

DR. HASSAN EL KHADEM DEPT. OF CHEMISTRY, WASHINGTON, DC 20016-8014

DR. BURTON Y. ENDO 1010 JIGGER COURT, ANNAPOLIS, MD 21401-6886

MR. WILLIAM JOHN ENTLEY 5707 PAMELA DRIVE, CENTREVILLE, VA 22020

MR. PAUL C. ETTER 16609 BETHAYRES ROAD, ROCKVILLE, MD 20855-2043

DR. ROBERT F. FARMER C/O AKZO NOBEL CHEMICAL, 300 S. RIVERSIDE PLAZA, CHICAGO, IL 60606

MR. JOSEPH A. FAULKNER 2 BAY DRIVE, LEWES, DE 19958

DR. WILLIAM R. FAUST 1665 HEATHER LANE, HUNTINGTON, MD 20639-4108

DR. ROBERT E. FAY 6621 10TH ST B-l, ALEXANDRIA, VA 22307

JON D. FAYE 4004 QUEENSBURY ROAD, HYATTSVILLE, MD 20782-3049

DR. S. NORMAN FEINGOLD 1801 EAST JEFFERSON ST., ROCKVILLE, MD 20852-4057

DR. RICHARD A. FERRELL 661 1 WELLS PARKWAY, UNIVERSITY PARK, MD 20782

DR. ROBERT FINKELSTEIN 11424 PALATINE DRIVE, POTOMAC, MD 20854-1451

DR. JOEL L. FISHER 4033 OLLEY LANE, FAIRFAX, VA 22032

DR. DAVID R. FLINN 2826 SHAWN LEIGH DR., VIENNA, VA 22181

DR. NANCY FLOURNOY 4712 YUMA STREET, NW, WASHINGTON, DC, 20016-2048

MR. HERBERT H. FOCKLER 10710 LORAIN AVENUE, SILVER SPRING, MD 20901

DR. SAMUEL N. FONER 1 1500 SUMMIT WEST BLVD NO. 15B, TEMPLE TERRACE, FL 33617

DR. RICHARD H. FOOTE HC 75 BOX 166 L.O.W., LOCUST GROVE, VA 22508

DR. ALPHONSE F. FORZIATI 2235 OLD HAMILTON PLACE, GAINESVILLE, GA 30507-6900

DR. JUDE E. FRANKLIN 7616 CARTERET ROAD, BETHESDA, MD 20817-2021

DR. ERNEST R. FREEMAN 5357 STRATHMORE AVENUE, KENSINGTON, MD 20895-1 160

DR. MOSHE FRIEDMAN 4511 YUMA STREET, NW, WASHINGTON, DC 20016

DR. GEORGE T. FURUKAWA 1712 EVELYN DRIVE, ROCKVILLE, MD 20852

DR. WILLIAM W. GAGE 10 TRAFALGAR ST, ROCHESTER, NY 14619-1222

DR. DAVID GARVIN 18700 WALKER’S CHOICE RD, NO. 807, MONTGOMERY VILLAGE, MD 20886-0560

DR. SYLVESTER JAMES GATES PHYSICS DEPT - RM 4125, COLLEGE PARK, MD 20742-41 1 1

DR. GUILLERMO C. GAUNAURD 4807 MACON ROAD, ROCKVILLE, MD 20852-2348

DR. KATHARINE B. GEBBIE, DIRECTOR, PHYSICS LABORATORY, NATIONAL INSTITUTE OF

STANDARDS AND TECHNOLOGY, 100 BUREAU DRIVE, MS 8400, GAITHERSBURG, MD 20899-8400

MS. LAURIE GEORGE 11306 BENT CREEK TERRACE, GERMANTOWN, MD 20876

DR. ABOLGHASSEM GHAFFARI 7532 ROYAL DOMINION DRIVE, WEST BETHESDA, MD 20817

MR. JOROME GIBBON 311 PENNSYLVANIA AVENUE, FALLS CHURCH, VA 22046

DR. HAROLD GLASER 1902 BERRYMAN STREET, BERKELEY, CA 94709-1919

MR. JOHN GLAZE 658 E ST., S.E., WASHINGTON, DC 20003

PROF ROLFE E. GLOVER III 7006 FOREST HILL DR, HYATTSVILLE, MD 20782

MR. ALBERT G. GLUCKMAN 1 1235 OAKLEAF DRIVE, NO. 1619, SILVER SPRING, MD 20901-1305

DR. ROBERT L. GLUCKSTERN 801 DROHOMER PLACE, BALTIMORE, MD 21210

DR. JAMES F. GOFF 3405 - 34TH PLACE, N.W., WASHINGTON, DC 20016

MS. ELAINE KALSTEIN GOLDBERG 719 HARRINGTON ROAD, ROCKVILLE, MD 20852

DR. A. MORGAN GOLDEN 9110 DRAKE PLACE, COLLEGE PARK, MD 20740

DR. CALVIN GOLUMBIC 6000 HIGHBORO DRIVE, BETHESDA, MD 20817

DR. JANE GOODALL THE JANE GOODALL INSTITUTE, SILVER SPRING, MD 20911-4890

| MR. ROBERT J. GOODE 2402 KEGWOOD LANE, BOWIE, MD 20715

DR. RUTH E. GORDON 9405 QUILL PLACE, MONTGOMERY VILLAGE, MD 20879

RICHARD G. GOULD TELECOMMUNICATIONS SYSTEMS, WASHINGTON, DC 20036-4646

222

DR. WILLIAM R. GRAVER SAIC, 2-3-1, MCLEAN, VA 22012

MR. M. L. GREENOUGH GREENOUGH DATA ASSOC., 616 ASTER BLVD., ROCKVILLE, MD 20850

DR. VICTOR M. GRISHKEVICH VISHNEVSKY INST. OF SURGERY, 1 13093 MOSCOW RUSSIA

DR. ANGELA M. GRONENBORN 5503 LAMBETH ROAD, BETHESDA, MD 20814

PROF. VLADIMIR V. GRUBNIK ODESSA CENTER FOR LASER MEDICINE, ODESSA UKRAINE

THE HONORABLE GILBERT GUDE 5411 DUVALL DRIVE, BETHESDA, MD 20816-1871

DR. VICTORIA C. GUERRERO 10627 PATTERNBOND TERRACE, SILVER SPRING, MD 20902

DR. PRADEEP KUMAR GUPTA 8301 ARLINGTON BLVD. #405, FAIRFAX, VA 22182

DR. PAUL-GEORG GUTERMUTH LM WINGERT 28, GERMANY

DR. HARVEY HACK OCEAN SYSTEMS, ANNAPOLIS, MD 21404

DR. EDWARD HACSKAYLO 7949 N SENDERO UNO, TUCSON, AZ 85704-2066

DR. EDWARD O. HAENNI 7907 GLENBROOK ROAD, BETHESDA, MD 20814-2403

MR. GEORGE H. HAGN 4208 SLEEPY HOLLOW ROAD, ANNADALE, VA 22003-2046

REV. FRANK R. HAIG, SJ LOYOLA COLLEGE, BALTIMORE, MD 21210

MR. KENNETH A. HAINES 900 N. TAYLOR ST. #1231, ARLINGTON, VA 22203-1855

DR. WALTER J. HAMER 407 RUSSELL AVENUE, #305, GAITHERSBURG, MD 20877-2890

DR. RUDOLPH A. HANEL 3881 BRIDLE PASS, ANN ARBOR, MI 48108-2264

MR. WILLIAM E. HANFORD, JR. 5613 OVERLEA ROAD, BETHESDA, MD 20816

MR. JAMES W. HARR 180 STRAWBERRY LANE, CENTREVILLE, MD 21617

DR. JANET W. HARTLEY 3513 IDAHO AVENUE, NW, WASHINGTON, DC 20016-3151

MS. MICHELLE HARVEY 734 15TH ST., NW - SUITE 420, WASHINGTON, DC 20005

DR. CARYL P. HASKINS 1545 18TH ST., N.W., SUITE 810, WASHINGTON, DC 20036

DR. GEORG H. HASS 7728 LEE AVENUE, ALEXANDRIA, VA 22308-1003

DR. HERBERT HAUPTMAN THE MEDICAL FOUNDATION OF BUFFALO, 73 HIGH STREET, BUFFALO, NY

14203-1196

MRS. ELIZABETH D. HAYNES 4149 25TH STREET, NORTH, ARLINGTON, VA 22207-3964

DR. GEORGE HELZ WATER RESOURCES RESEARCH, COLLEGE PARK, MD 20742

MR. ROBERT L. HERB ST 4109 WYNNWOOD DRIVE, ANNADALE, VA 22003

MR. FRANCIS L. HERMACH 2850 AQUARIUS AVENUE, SILVER SPRING, MD 20906

DR. W. RONALD HEYER AMPHIBIAN AND REPTILE, M.S. 162 SMITHSONIAN, WASHINGTON, DC 20560

DR. EUTHYMIA D. HIBBS 7302 DURBIN TERRACE, BETHESDA, MD 20817

MR. LAHLOU HICHAM 94 RUE ALLAL BEN ABDELLAH, CASABLANCA MOROCCO

DR. BRUCE F. HILL NO FORWARDING ADDRESS

DR. WALTER J. HILLABRANT 1927 38TH STREET, NW, WASHINGTON, DC 20007

MR. JOSEPH HILSENRATH 9603 BRUNETT AVENUE, SILVER SPRING, MD 20901-3232

DR. ROBERT B. HOBBS 9707 OLD GEORGETOWN ROAD, BETHESDA, MD 20814

DR. J. TERRELL HOFFELD 1 1307 ASHLEY DRIVE, ROCKVILLE, MD 20852-2403

DR. JOHN D. HOFFMAN 6121 MAIDEN LANE, BETHESDA, MD 20817

GARY M. HOLAHAN 10000 TENBROOK DRIVE, SILVER SPRING, MD 20901

DR. ARIEL HOLLINSHEAD 3637 VAN NESS STREET, NW, WASHINGTON, DC 20008-3130

DR. JOHN G. HONIG 7701 GLENMORE SPRING WAY, BETHESDA, MD 20817

MR. LARRY A. HOOVER 1541 STABLEVIEW DRIVE, GASTONIA, NC 28056-1658

DR. JOHN HORNSTEIN 10123 HEREFORD PLACE, SILVER SPRING, MD 20901

DR. IRWIN HORNSTEIN 5920 BRYN MAWR ROAD, COLLEGE PARK, MD 20740

DR. EMANUEL HOROWITZ 14100 NORTHGATE DRIVE, SILVER SPRING, MD 20906

DR. COLIN M. HUDSON 143 S. WILDFLOWER RD„ ASHEVILLE, NC 28804

DR. JAMES E. HUHEEY SOURWOOD MOUNTAIN SCIENTIFIC, LENOIR CITY, TN 37771

DR. RUSSELL HULSE PLASMA PHYSICS LABORATORY, PRINCETON, NJ 08543

MS. LANI S. HUMMEL 1709 SO. BRADDOCK AVENUE, PITTSBURGH, PA 15218

DR. BURTON G. HURDLE 6222 BERKLEY ROAD, ALEXANDRIA, VA 22307

DR. WOODLAND HURTT 1 1403 EASTOOD COURT, HAGERSTOWN, ND 21742

MR. GEORGE L. HUTTON 1086 CONTINENTAL AVENUE, MELBOURNE, FL 32940

DR. JO- ANNE A. JACKSON 14711 MYER TERRACE, ROCKVILLE, MD 20853

DR. MARILYN E. JACOX 10203 KINDLY COURT, MONTGOMERY VILLAGE, MD 20886-3946

DR. ARTHUR S. JENSEN CHAPEL GATE 1 104, OAK CREST, PARKVIEW, MD 21234-9022

DR. ROBERT W. JERNIGAN 14805 CLAVEL STREET, ROCKVILLE, MD 20853

DR. DANIEL P. JOHNSON 3610 RANDOLPH RD, APT 305, CHARLOTTE, NC 2821 1

223

DR. PHYLLIS T. JOHNSON 4721 EAST HARBOR DRIVE, FRIDAY HARBOR, WA 98250

DR. EDGAR M. JOHNSON 5315 RENAISSANCE COURT, BURKE, VA 22015

MR. ALLEN B. JOHNSTON 31 S. ABERDEEN STREET, ARLINGTON, VA 22204

DR. DANIEL B. JONES 3422 IBIS DRIVE, ORLANDO, FL 32803

DR. HOWARD S. JONES, JR. 3001 VEAZEY TERRACE, NW, APT 1310, WASHINGTON, DC 20008

DR. SHUNG-CHANG JONG AMER. TYPE CULTURE COLLECTION, 10801 UNIVERSITY BLVD.,

MANASSAS, VA 201 10-2209

DR. GARY BLAKE JORDAN 13392 FALLENLEAF ROAD, POWAY, CA 92064

DR. ROMAN DE VICENTE JORDANA BATALLA DE G ARELLANO, 15, MADRID SPAIN

DR. ROBERT E. KAHN 909 LYNTON PLACE, McLEAN, VA 22102

DR. HANS E. KAISER 433 SOUTHWEST DRIVE, SILVER SPRING, MD 20901

DR. PEDRO R. KANOF 1669 32ND STREET, N.W., WASHINGTON, DC 20007

DR. C.A. KAPETANAKOS 4431 MACARTHUR BLVD, WASHINGTON, DC 20007

DR. ARTHUR A. KARELIN VISHNEVSKY INST. OF SURGERY, MOSCOW 113811 RUSSIA

DR. SHERMAN KARP 10205 COUNSELMAN ROAD, POTOMAC, MD 20854-5023

DR. ROBERT KATZ 3 BETHESDA METRO CENTER, BETHESDA, MD 20814

MS. PEG KAY VERTECH INC., CHANTILLY, VA 20153

DR. LARRY KEEFER 7016 RIVER ROAD, BETHESDA, MD 20817

DR. HARRY R. KEISER 2367 S. QUEEN STREET, ARLINGTON, VA 22202-1550

DR. BERNHARD E. KEISER 2046 CARRHILL ROAD, VIENNA, VA 22181

DR. RAKHIM M. KHAITOV INSTITUTE OF IMMUNOLOGY, MOSCOW, 1 15478 RUSSIA, CIS

DR. NODAR KIPSHIDZE 9 ANJAPARIDZE STREET, TIBLISI 380079 REPUBLIC OF GEORGIA

DR. KENNETH L. KIRK NATIONAL INSTITUTES OF HEALTH, BETHESDA, MD 20892

: DR. JOSEPH H. KIRKBRIDE, JR. 1001 DEVERE DRIVE, SILVER SPRING, MD 20903

DR. CYRUS KLINGSBERG 1318 DEERFIELD DRIVE, STATE COLLEGE, PA 16803

MR. REX C. KLOPFENSTEIN 4224 WORCESTER DR., FAIRFAX, VA 22032-1140

MR. ROBERT KOGLER NOT AT THIS ADDRESS (1/8/99)

DR. SAMUEL KOTZ, 617 KENBROOK DRIVE SILVER SPRING, MD 20902

DR. VLADIMIR A. KOUZMINOV VIA ALDO MORO 72, VENICE ITALY

DR. STEPHEN KROP 960 OLD CUTLER ROAD, VIRGINIA BEACH, VA 23454

DR. JEROME KRUGER 619 WARFIELD DRIVE, ROCKVILLE, MD 20850

MRS. MARYLIN KRUPSAW 346 OAK HARBOUR DRIVE, JUNO BEACH, FL 33408

DR. WILLIAM JOHN LACY 9573 MANASSAS FORGE DR., MANASSAS, VA 201 1 1-2583

MR. CLIFFORD E. LANHAM P.O. BOX 2303, KENSINGTON, MD 20891

MR. MICHAEL J. LAVINE 9992 MARSHALL POND ROAD, BURKE, VA 22015

DR. ROGER H. LAWSON 10613 STEAMBOAT LANDING, COLUMBIA, MD 21044

DR. LAWRENCE M. LEIBOWITZ 3903 LARO COURT, FAIRFAX, VA 22031

MR. ALAN L. LEINER 850 WEBSTER STREET, APT 635, PALO ALTO, CA 94301-2837

DR. PETER P. LEJINS COLLEGE HEIGHTS ESTATES, 7114 EVERSFIELD DRIVE, HYATTSVILLE, MD

20782-1049

DR. PAUL LEWIS LENTZ 5 ORANGE COURT, GREENBELT, MD 20770

DR. E. NEIL LEWIS MOLECULAR BIOLOGY SECTION, BETHESDA, MD 20892

DR. DAVID C. LEWIS 609 SIDELING COURT, VIENNA, VA 22180

DR. HERBERT L. LEY, JR 4816 CAMELOT STREET, ROCKVILLE, MD 20853

MR. LOUIS F. LIBELO 9413 BULLS RUN PARKWAY, BETHESDA, MD 20817

DR. JULIUS LIEBLEIN 5901 MONTROSE RD. APT. S800, ROCKVILLE, MD 20852-4751

MR. ROY P. LINDQUIST, P.E. SUITE 1575, 1300 PENNSYLVANIA AVE., NW, WASHINGTON, DC 20229

MR. LEE LING 1608 BELVOIR DRIVE, LOS ALTOS, CA 94024

DR. CONRAD B. LINK 407 RUSSELL AVENUE, #813, GAITHERSBURG, MD 20877

DR. MORLEY LIPSETT 1529 WHITES AILS DRIVE, BOWEN ISLAND, BC VON 1G0 CANADA

DR. J. DAVID LOCKARD CELL BIOLOGY AND, COLLEGE PARK, MD 20742

MS. MARILYN LONDON 4890 BATTERY LANE, APT. 121, BETHESDA, MD 20814

MRS. BETTY JANE LONG 416 RI VERB END ROAD, FORT WASHINGTON, MD 20744-5539

MR. TOM H. W. LOOMIS 1 1502 ALLVIEW DR., BELTS VILLE, MD 20705

DR. THOMAS E. LOVEJOY SMITHSONION INSTITUTE, WASHINGTON, DC 20560

; DR. HANS J. LUGT 10317 CROWN POINT COURT, POTOMAC, MD 20854

DR. ROBERT J. LUTZ 17620 SHAMROCK DRIVE, OLNEY, MD 20832

224

MR. HARRY B. LYON 7722 NORTHDOWN ROAD, ALEXANDRIA, VA 22308-1329

DR. JOHN W. LYONS 7430 WOODVILLE ROAD, MT. AIRY, MD 21771

DR. ROBERT P. MADDEN 12730 KNOLL ROAD, MT. AIRY, MD 21771

ACAD. IGOR M. MAKAROV CHIEF SCIENTIFIC SECRETARY, GSP1 MOSCOW, V-71 RUSSIA CIS

DR. THOMAS B. MALONE 20856 WATERBEACH PL, STERLING, VA 20165-7407

DR. RONALD W. MANDERSCHEID 10837 ADMIRALS WAY, POTOMAC, MD 20854-1232

MS. TONI MARE’CHAUX PO. BOX 23188, WASHINGTON, DC 20026-3188

DR. TIMOTHY P. MARGULIES U.S. EPA, WASHINGTON, DC 20460

DR. CHARLES R. MARTIN 10125 GRAVIER COURT, MONTGOMERY VILLAGE, MD 20886

DR. EDWARD J. MARTIN, PE. 7721 DEW WOOD DRIVE, DERWOOD, MD 20855

DR. KEVIN B. MARVEL AMERICAN ASTRONOMICAL SOCIETY, WASHINGTON, DC 20009

DR. HENRY LEA MASON 3440 S JEFFERSON ST #823, FALLS CHURCH, VA 22041-3127

PROF. SAMUEL P MASSIE DEPARTMENT OF CHEMISTRY, ANNAPOLIS, MD 21400

DR. THOMAS A. MAZZUCHI OPERATIONS RESEARCH DEPT., FAIRFAX, VA 22032

MR. GORDON W. McBRIDE PO. BOX 151505, CHEVY CHASE, MD 20825-1505

DR. JAMES R. McNESBY 13308 VALLEY DRIVE, ROCKVILLE, MD 20850

MR. BUFORD K. MEADE 20510 FALCONS LANDLING CIR, STERLING, VA 20165-7596

MR. THOMAS W. MEARS 2809 HATHAWAY TERRACE, WHEATON, MD 20906-3756

MS. RUTH MELLEN 6338 EDGEMOOR LANE, ALEXANDRIA, VA 22312-1528

DR. ALLEN J. MELMED 732 TIFFANY COURT, GAITHERSBURG, MD 20878

DR. TAY KIANG MENG 82 1C UPPER EAST COAST ROAD, SINGAPORE 466613

DR. ROBERT E. MENZER 161 1 ALLISON STREET, NW, WASHINGTON, DC 2001 1-4213

DR. GARY S. MESSINA 4201 CATHEDRAL AVENUE, NW, WASHINGTON, DC 20016

MRS. CARLA G. MESSINA 9800 MARQUETTE DRIVE, BETHESDA, MD 20817

DR. LANCE A. MILLER 7403 BUFFALO AVENUE, TAKOMA PARK, MD 20912

MR. RAYMOND D. MINTZ OFFICE OF INF & TECH, WASHINGTON, DC 20229

MR. GARY MITCHELL 3018 ASHBURTON MANOR DR., OAK HILL, VA 20171

DR. DON MITTLEMAN 5200 BRITTNY DR. S, ST. PETERSBURG, FL 33715-1538

MR. TOM MOFFAT NIST, GAITHERSBURG, MD 20899

CONGRESSWOMAN C. MORELLA OFFICE OF REPRES. MORELLA, WASHINGTON, DC 20515

DR. J. ANTHONY MORRIS 23E RIDGE ROAD, GREENBELT, MD 20770

DR. ALAN MORRIS, PE. 5817 PLAINVIEW ROAD, BETHESDA, MD 20817

F. K. MOSTOFI, M.D. 7001 GEORGIA STREET, CHEVY CHASE, MD 20815

DR. RAYMOND D. MOUNTAIN 5 MONUMENT COURT, ROCKVILLE, MD 20850

DR. MICHAEL J. MUMMA 210 GLEN OBAN DRIVE, ARNOLD, MD 21012

DR. WALLACE P. MURDOCH 65 MAGAW AVENUE, CARLISLE, PA 17013-7618

DR. CHARLES R. NAESER 6654 VAN WINKLE DRIVE, FALLS CHURCH, VA 22044

DR. ARVIN K.N. NANDEDKAR DEPT. OF BIO-CHEMISTRY, WASHINGTON, DC 20059

MRS. EVELYN S. NEF 2726 N STREET, N.W., WASHINGTON, DC 20007

DR. ARKADI NEKRASOV BLDG. 1, 420 FLAT, 121351 MOSCOW RUSSIA CIS

DR. WERNER G. NEUBAUER 8410 WESTFAIR CIRCLE, NORTH, GERMANTOWN, TN 38139-3275

DR. MORRIS NEWMAN 1050 LAS ALTURAS ROAD, SANTA BARBARA, CA 93103

DR. TERRELL L. NOFFSINGER 125 ECHO VALLEY ROAD, AUBURN, KY 42206

MR. KARL H. NORRIS 11204 MONTGOMERY ROAD, BELTS VILLE, MD 20705

DR. JOHN J. O’ HARE 108 RUTLAND BLVD, WEST PALM BEACH, FL 33405-5057

DR. JOHN A. O’KEEFE WESTFORD AT ALL SAINTS #301, SIOUX FALLS, SD 57104

MS. E. MARILYN OBERLE 58 PARKLAWN ROAD, WEST ROXBURY, MA 02132

DR. PW. OGILVIE 1227 FRANKLIN STREET, NE, WASHINGTON, DC 20017

MR. LEE OHRINGER 5014 RODMAN ROAD, BETHESDA, MD 20816

DR. HIDEO OKABE 6700 OLD STAGE ROAD, ROCKVILLE, MD 20852

DR. V. SUSIE F. OLIPHANT 910 LURAY PLACE, HYATTS VILLE, MD 20783

DR. FRED ORDWAY 5205 ELSMERE AVENUE, BETHESDA, MD 20814-5732

DR. HANS J. OSER 8810 QUIET STREAM COURT, POTOMAC, MD 20854-4231

ACAD. YURI S. OSIPOV PRESIDENT, GSP1 MOSCOW, V-71 RUSSIA CIS

MR. WILLIAM ALLEN OSTAFF 10208 DRUMM AVENUE, KENSINGTON, MD 20895-3731

DR. GRACE OSTENSO 2871 AUDUBON TERRACE NW, WASHINGTON, DC 2008-2309

DR. HENRY MCILVAINE PARSONS HumRRO, 66 CANAL CENTER PLAZA, ALEXANDRIA, VA 22314

225

DR. D. G. PATEL 1 1403 CROWNWOOD LANE, ROCKVILLE, MD 20850

DR. ELVIRA L. PAZ 172 COOK HILL ROAD, WALLINGFORD, CT 06492

DR. THEODORE P. PERROS 500 23RD STR. NW B-606, WASHINGTON, DC 20037

MR. RAY PETERSEN 5828 BLACKHAWK DRIVE, FOREST HEIGHTS, MD 20745

ACAD. REM V. PETROV VICE PRESIDENT, GSP1 MOSCOW, V-71 RUSSIA CIS

DR. RAYMOND L. PICKHOLTZ 3613 GLENBROOK ROAD, FAIRFAX, VA 22031-3210

DR. GEORGE F. PIEPER 3155 ROLLING ROAD, EDGEWATER, MD 21037

MR. ALAN O. PLAIT 8550 PARK SHORE LANE, SARASOTA, FL 34238-3316

DR. HARVEY R. POLLARD DEPARTMENT OF ANATOMY AND CELL BIOLOGY, USUHS, BETHESDA, MD

20814

DR. JULIUS S. PRINCE 7103 PINEHURST PARKWAY, CHEVY CHASE, MD 20815-3144

DR. DIANNE K. PRINZ 1704 MASON HILL DRIVE, ALEXANDRIA, VA 22307

DR. JOHN H. PROCTOR 308 EAST STREET, N.E., VIENNA, VA 22180

DR. C. NICHOLAS PRYOR 3715 PROSPERITY AVENUE, FAIRFAX, VA 22031

DR. ROBERT H. PURCELL 17517 WHITE GROUNDS ROAD, BOYDS, MD 20841

MR. THOMAS N. PYKE, JR 4887 N. 35TH ROAD, ARLINGTON, VA 22207

MR. RODERICK S. QUIROZ 4520 YUMA STREET, N.W., WASHINGTON, DC 20016

MR. CHARLES A. RADER 1101 PACA DRIVE, EDGEWATER, MD 21037

DR. GEORGE T. RADO 818 CARRIE COURT, MCLEAN, VA 22101

A.K. RAJAGOPAL CODE 6860.1, WASHINGTON, DC 20375

DR. VIL Z. RAKHMANKULOV INSTIT. FOR SYSTEMS ANALYSIS, MOSCOW 117312 RUSSIA CIS

DR. JOSEPH EDWARD RALL 3947 BALTIMORE STREET, KENSINGTON, MD 20895

DR. DAVID E. RAMAKER 6943 ESSEX AVENUE, SPRINGFIELD, VA 22150

DR. MAYNARD J. RAMSAY 3806 VISER COURT, BOWIE, MD 20715

DR. NORMAN F. RAMSEY LYMAN PHYSICS LABORATORY, CAMBRIDGE, MA 02138

DR. APPAJOSULA S. RAO 8312 BEECH TREE ROAD, BETHESDA, MD 20817

DR. JIM RASEKH USDA/FSIS/OPPDE RM405, 300 12TH STREET, NW, WASHINGTON, DC 20250

DR. ROBERT L. RAUSCH P. O. BOX 85447, UNIVERSITY STATION, SEATTLE, WA 98145-1447

MR. CHARLES RAVITSKY 1505 DREXEL STREET, TAKOMA PARK, MD 20912

PROF. EDWARD F. REDISH 6820 WINTERBERRY LANE, BETHESDA, MD 20817

DR. JANET W. REID SMITHSONIAN INSTITUTION, WASHINGTON, DC 20560-0163

MR. ALVIN REINER 1 1243 BYBEE STREET, SILVER SPRING, MD 20902

DR. JAMES J. RHYNE 2704 WESTBROOK WAY, COLUMBIA, MO 65203

DR. SUE ANN RICE 6728 FERN LANE, ANNANDALE, VA 22003

MR. ERIC C. RICKARD SRI INTERNATIONAL, ARLINGTON, VA 22209-211 1

DR. RICHARD RICKER 16549 SIOUX LANE, GAITHERSBURG, MD 20878

DR. ROBERT WILLIAM RIDKY 622-A NORTH TAZEWELL ST, ARLINGTON, VA 22203

DR. GORDON K. RIEL NSWC CD 682, BETHESDA, MD 20817-5700

MR. ALFRED J. ROACH AMER. BIOGENETIC SCIENCES, INC., COPIAGUE, NY 1 1726

DR. MARY LOUISE ROBBINS LAUREL HOUSE, IF, SUGINAMI-KU 167-0051, TOKYO JAPAN

DR. SUSAN ROBERTS OCEAN STUDIES BOARD, HA-470, WASHINGTON, DC 20418

DR. A. F. ROBERTSON 4228 BUTTERWORTH PLACE N.W., WASHINGTON, DC 20016

DR. MICHAEL HILL ROBINSON 2729 ORDWAY ST. NW - UNIT 5, WASHINGTON, DC 20008

DR. KENNETH C. ROGERS 6202 PERTHSHIRE COURT, BETHESDA, MD 20817-3348

DR. NINA M. ROSCHER 10400 HUNTER RIDGE DRIVE, OAKTON, VA 22124-1616

DR. WILLIAM K. ROSE 10916 PICASSO LANE, POTOMAC, MD 20854

DR. DAVID ROSENBLATT 2939 VAN NESS STREET, N.W., APT 702, WASHINGTON, DC 20008

DR. JOAN R. ROSENBLATT 2939 VAN NESS STREET. N.W., APT 702, WASHINGTON, DC 20008

DR. AZRIEL ROSENFELD 847 LOXFORD TERRACE, SILVER SPRING, MD 20901

PROF. PETER H. ROSSI 34 STAGECOACH ROAD, AMHERST, MA 01002

DR. RICHARD B. ROTHMAN 8508 CARLYNN DRIVE, BETHESDA, MD 20817

I COL. JOHN E. ROTHROCK (RET) 6100 WESTCHESTER PARK DR., COLLEGE PARK, MD 20740

MR. ISRAEL ROTKIN 11504 REGNID DR, WHEATON, MD 20902

DR. G. RUSTAMOV CASPIAN HOSPITAL, BAKU 370065 AZERBAIJAN

DR. EMILE RUTNER 34 COLUMBIA AVENUE, TAKOMA PARK, MD 20912

DR. ADNAN A. SAAD 8647 OAK CHASE CIRCLE, FAIRFAX STATION, VA 22039

DR. ALBERT W. SAENZ 6338 OLD TOWN COURT, ALEXANDRIA, VA 22307

226

MR. THOMAS T. SAMARAS 1 1487 MADERA ROSA WAY, SAN DIEGO, CA 92124

DR. VICTOR J. SANK 5 BUNKER COURT, ROCKVILLE, MD 20854-5507

MR. FREDERICK RICHARD SAPP MOVED, LEFT NO ADDRESS

MR. CARTER BUZZ SAVAGE 2730 UNIVERSITY BLVD., WHEATON, MD 20902

MR. THORNDIKE SAVILLE, JR 5601 ALB I A ROAD, BETHESDA, MD 20816-3304

DR. JAMES M. SCHALK 7 OAKLAND DRIVE, PATCHOGUE, NY 11772

MR. MILTON S. SCHECHTER 10909 HANNES CT„ SILVER SPRING, MD 20901

DR. ALBERT I. SCHINDLER 6615 SULKY LANE, ROCKVILLE, MD 20852

MR. NEAL F. SCHMEIDLER OMNI ENGR & TECHNOLOGY, INC, McLEAN, VA 22102

DR. CLAUDE H. SCHMIDT 1827 NORTH 3RD STREET, FARGO, ND 58102-2335

DR. MARIAN M. SCHNEPFE POTOMAC TOWERS, APT. 640, 2001 N. ADAMS STREET, ARLINGTON, VA

22201

DR. JAMES F. SCHOOLEY 13700 DARNESTOWN ROAD, GAITHERSBURG, MD 20878

STEPHEN A. SCHROFFEL 1 129 PARK STREET, N.E., WASHINGTON, DC 20002-6317

DR. WARREN W. SCHULTZ 4056 CADLE CREEK ROAD, EDGEWATER, MD 21037-4514

MR. TED SCHUTZBANK CHILDREN’S HOSPITAL, WASHINGTON, DC 20210

DR. DAVID B. SCOTT 761 ALLIANCE DR. #437, VIRGINIA BEACH, VA 23454

MR. BOURDON F. SCRIBNER 7210 RIVER CRESCENT DRIVE, ANNAPOLIS, MD 21401-7727

DR. MARC M. SEBRECHTS 7014 EXETER ROAD, BETHESDA, MD 20814

DR. FREDERICK SEITZ ROCKEFELLER UNIVERSITY, 1230 YORK AVENUE, NEW YORK, NY 10021

MRS. ELAINE G. SHAFRIN 800 4TH ST SW, NO. N702, WASHINGTON, DC 20024

MR. GUSTAVE SHAPIRO 3704 MUNSEY STREET, SILVER SPRING, MD 20906

DR. STEFAN SHRIER 624A SOUTH PITT ST., ALEXANDRIA, VA 22314-4138

DR. W. SHROPSHIRE, JR OMEGA LABORATORY, P.O. BOX 189, CABIN JOHN, MD 20818-0189

DR. ART SIEBENS 3900 CONNECTICUT AVE., NW, #101F, WASHINGTON, DC 20008

DR. DAVID M. SILVER APPLIED PHYSICS LABORATORY, 11100 JOHNS HOPKINS ROAD, LAUREL, MD

20723-6099

DR. BARRY G. SILVERMAN GEORGE WASHINGTON UNIVERSITY, WASHINGTON, DC 20052

DR. ROBERT SIMHA DEPT. MACROMOLECULAR SCI., CLEVELAND, OH 44106-7202

DR. MICHAEL M. SIMPSON 4602 DUNCAN DRIVE, ANNANDALE, VA 22003-4610

DR. LEWIS SLACK 2104 TADLEY DRIVE, CHAPEL HILL, NC 27514-2109

MS. JANET SLOVIN USDA CLIMATE STESS LAB, BELTSVILLE, MD 20705-2350

DR. THOMAS E. SMITH DEPT OF BIOCHEMISTRY & MOLECULAR BIOLOGY, COLLEGE OF MEDICINE,

HOWARD UNIVERSITY, WASHINGTON, DC 20059

MS. MARCIA S. SMITH SCIENCE POLICY RESEARCH DIV., WASHINGTON, DC 20540-7490

MR. REGINALD C. SMITH 7731 TAUXEMONT ROAD, ALEXANDRIA, VA 22308

MR. EDWARD L. SMITH 18475 HAVN CT., NE, POULSBO, WA 98370-7668

MR. BLANCHARD D. SMITH, JR 2509 RYEGATE LANE, ALEXANDRIA, VA 22308

MR. DAVID L. SODERBERG 403 WEST SIDE DR. APT. 102, GAITHERSBURG, MD 20878

DR. RICHARD M. SOLAND SEAS, GEORGE WASHINGTON UNIV., WASHINGTON, DC 20052

DR. HELMUT SOMMER 9502 HOLLINS COURT, BETHESDA, MD 20817

DR. ROBERT J. SOUSA 168 WENDELL ROAD, SHUTESBURY, MA 01072

DR. MARK SPANO NAVAL SURFACE WARFARE CENTER, WEST BETHESDA, MD 20817-5700

DR. WILLIAM J. SPARGO 9610 CEDAR LANE, BETHESDA, MD 20814

MR. JAMES E. SPATES 8609 IRVINGTON AVENUE, BETHESDA, MD 20817

DR. A.F. SPILHAUS, JR 10900 PICASSO LANE, POTOMAC, MD 20854

BRIAN R. STANTON 12150 ISLAND VIEW CIRCLE, GERMANTOWN, MD 20874

MS. IRENE A. STEGUN 62 LEIGHTON AVENUE, YONKERS, NY 10705

DR. KURT H. STERN 103 GRANT AVENUE, TAKOMA PARK, MD 20912-4636

DR. LOUIS J. STIEF CODE 690 N.A.S.A., GODDARD SPACE FLIGHT CENTER, GREENBELT, MD 20771

DR. ROBERT D. STIEHLER 3234 QUESADA STREET, N.W., WASHINGTON, DC 20015-1663

DR. MANYA B. STOETZEL SYST. ENTOMOLOGY LAB, RM 100 BLDG. 046, BARC-WEST USDA,

BELTSVILLE, MD 20705

DR. SIMON W. STRAUSS 4506 CEDELL PLACE, CAMP SPRINGS, MD 20748

GEORGE STUART

DR. JOSEPH SUCHER 6200 WESTCHESTER PARK DR., COLLEGE PARK, MD 20740

DR. ROBERT W. SWEZEY 17203 CLARKS RIDGE ROAD, LEESBURG, VA 20176

227

DR. ALAN O. SYKES 304 MASHIE DRIVE, VIENNA, VA 22180

DR. HERBERT TABOR NIDDK, LBP, BLDG 8, RM 223, BETHESDA, MD 20892

DR. JUAN TAMARGO GUZMAN EL BUENO 100, 3 A, 28003 MADRID SPAIN

DR. ICHIJI TASAKI 5604 ALTA VISTA ROAD, BETHESDA, MD 20817

MR. DOUGLAS R. TATE CAROLINA MEADOWS VILLA #257, CHAPEL HILL, NC 27514-8526

ALBERT N. TAVKHELIDZE, ScD 52, RUSTAVELI AVE, 30008, TBLISI REPUBLIC OF GEORGIA

DR. DUANE TAYLOR 8300 CORPORATE DRIVE, LANDOVER, MD 20785

MR. WILLIAM B. TAYLOR, PE. 4001 BELLE RIVE TERRACE, ALEXANDRIA, VA 22309

MR. MAURICE J. TERM AN 616 POPLAR DRIVE, FALLS CHURCH, VA 22046

DR. F. CHRISTIAN THOMPSON 6611 GREEN GLEN CT, ALEXANDRIA, VA 22315-5518

DR. JOHN S. TOLL WASHINGTON COLLEGE & U. OF MD, BETHESDA, MD 20817

DR. PAUL F. TORRENCE NIDDK, LAC, BLDG 8, RM B2A-02, BETHESDA, MD 20892

DR. CHARLES H. TOWNES DEPARTMENT OF PHYSICS, BERKELEY, CA 94720-7300

DR. CHARLES E. TOWNSEND 3529 TILDEN STREET, NW, WASHINGTON, DC 20008-3194

MRS. MARJORIE R. TOWNSEND 3529 TILDEN STREET, NW, WASHINGTON, DC 20008-3194

DR. LEWIS R. TOWNSEND 8906 LIBERTY LANE, POTOMAC, MD 20854

DR. JAMES H. TURNER 4927 FALCON BLVD, PORT ST. JOHN, FL 32927-3030

DR. PAUL E. TYLER 1023 ROCKY POINT CT. N.E., ALBUQUERQUE, NM 87123-1944

DR. DOUGLAS H. UBELAKER DEPT. OF ANTHROPOLOGY, WASHINGTON, DC 20560

DR. HERBERT UBERALL 5101 RIVER RD, APT 1417, BETHESDA, MD 20816

DR. J.E. UHLANER 4258 BONAVITA DRIVE, ENCINO, CA 91436

MS. MARIANNE P. VAISHNAV P.O. BOX 2129, GAITHERSBURG, MD 20879

DR. HAROLD P. VAN COTT 8300 STILL SPRING COURT, BETHESDA, MD 20817

DR. TOM VAN FLANDEM META RESEARCH, P.O. BOX 15186, CHEVY CHASE, MD 20825-5186

DR. ANDREW VAN TUYL 1000 W. NOLCREST DRIVE, SILVER SPRING, MD 20903

DR. PETER F. VARADI 4620 NORTH PARK AVENUE, APT 1606W, CHEVY CHASE, MD 20815

DR. DANIEL J. VAVRICK 500 GREENBRIER CT - APT 204, FREDRICKSBURG, VA 22401

DR. FLETCHER P. VEITCH, JR P.O. BOX 513, LEXINGTON PARK, MD 20653

DR. VALERY F. VENDA DEPT. OF MECH & INDUS ENGR, WINNIPEG, MANITOBA CANADA R3T 5V6

DR. ARTHUR VON HIPPLE 265 GLEN ROAD, WESTON, MA 02193

MR. A. JAMES WAGNER 7568 CLOUD COURT, SPRINGFIELD, VA 22153

DR. THOMAS A. WALDMANN 3910 RICKOVER ROAD, SILVER SPRING, MD 20902

DR. ISABEL WALLS NATL FOOD PROCESSORS ASSOC, WASHINGTON, DC 20005

DR. RONALD W. WAYNANT 13101 CLAXTON DRIVE, LAUREL, MD 20708

DR. RALPH E. WEBB 21-P RIDGE ROAD, GREENBELT, MD 20770

DR. EDWARD J. WEGMAN 157 SCIENCE - TECHNOLOGY II, FAIRFAX, VA 22030

DR. JOHN WEINER 8401 RHODE ISLAND AVENUE, COLLEGE PARK, MD 20740

DR. ARM AND B. WEISS 6516 TRUMAN LANE, FALLS CHURCH, VA 22043

DR. ISSAC WELT 1 17 N. EDGEWOOD ST., ARLINGTON, VA 22201-1102

DR. GLEN W. WENSCH 413 S. RISING ROAD, CHAMPAIGN, IL 61822-9708

DR. WILLIAM P. WERGIN 10108 TOWHEE AVENUE, ADELPHI, MD 20783

MR. MICHAEL W. WERTH 14 GRAFTON STREET, CHEVY CHASE, MD 20815

LCDR JAMES T. WESTWOOD, USN (Ret) 5608-34 WILLOUGHBY, CENTREVILLE, VA 20120

DR. HOWARD J. WHITE, JR 466 HERON PT, CHESTERTOWN, MD 21620-1681

DR. WOLFGANG L. WIESE 8229 STONE TRAIL DRIVE, BETHESDA, MD 20817

DR. PETER F. WIGGINS 1016 HARBOR DRIVE, ANNAPOLIS, MD 21403

DR. HAROLD WILLIAMS 818 RICHMOND AVENUE, SILVER SPRING, MD 20910

DR. DAVID WILLIAMS GEORGETOWN UNIV. MED. CTR., WASHINGTON, DC 20007

DR. RAYMOND M. WILMOTTE 2512 QUE STREET, NW, WASHINGTON, DC 20007

MR. WILLIAM K. WILSON 1401 KURTZ ROAD, MCLEAN, VA 22101

WILLIAM W. WINTERS 6825 CAPRI PLACE, BETHESDA, MD 20817-4209

DR. RUTH G. WITTLER 2103 RIVER CRESCENT DR., ANNAPOLIS, MD 21401-7271

DR. ELLIS L. YOCHELSON 12303 STAFFORD LANE, BOWIE, MD 20715

DR. HATTEN S. YODER, JR GEOPHYSICAL LABORATORY, 5251 BROAD BRANCH RD., N.W.,

WASHINGTON, DC 20015-1305

MR. CHARLES E. YOUMAN 4419 N. 18TH STREET, ARLINGTON, VA 22207

MR. CHARLES YOUNG 6808 ROLLING ROAD, SPRINGFIELD, VA 22152

NOTES

'

NOTES

.

NOTES

DELEGATES TO THE WASHINGTON ACADEMY OF SCIENCES,

REPRESENTING THE LOCAL AFFILIATED SOCIETIES

Acoustical Society of America . Tim Margulies

Intemational/American Association of Dental Research . J. Terrell Hoffeld

American Association of Physics Teachers . Frank R. Haig

! American Ceramic Society . Laurie George

American Fisheries Society . Ramona Schreiber

American Institute of Aeronautics and Astronautics . Reginald C. Smith

American Institute of Mining, Metallurgy and Exploration . Michael Greeley

American Meteorological Society . VACANT

American Nuclear Society . Charles Young

American Phytopathological Society . Kenneth L. Deahl

American Society for Microbiology . VACANT

i American Society of Civil Engineers . John N. Hummel

American Society of Mechanical Engineers . Daniel J. Vavrick

i American Society of Plant Physiology . VACANT

j Anthropological Society of Washington . Marilyn R. London

ASM International . Toni Marechaux

I Association for American Women in Science (AWIS) . Susan Roberts

Association for Computing Machinery . Margaret Williams

Association for Science, Technology, and Innovation . Clifford Lanham

Biological Society of Washington . VACANT

Botanical Society of Washington . VACANT

Chemical Society of Washington . Elise Ann B. Brown

District of Columbia Institute of Chemists . VACANT

District of Columbia Psychology Association . David Williams

Eastern Sociological Society . Ronald W. Mandersheid

! Electrochemical Society . VACANT

Entomological Society of Washington . F. Christian Thompson

Geological Society of Washington . Bob Schneider

j Historical Society of Washington, DC . Phillip Ogilvie

Human Factors and Ergonomics Society . Jack Leveson

Institute of Electrical and Electronics Engineers . Rex C. Klopfenstein

Institute of Electrical and Electronics Engineers . Jerome Gibbon

Institute of Food Technologists . Isabel Walls

Institute of Industrial Engineers . Neal Schmeidler

Instrument Society of America . John I. Peterson

Mathematical Association of America . Sharon K. Hauge

Medical Society of the District of Columbia . Duane Taylor

National Capital Astronomers . Andrew Seacord

National Geographic Society . VACANT

Optical Society of America . VACANT

Pest Science Society of Washington . VACANT

Philosophical Society of Washington . James Goff

Society for General Systems Research . VACANT

Society of Experimental Biology and Medicine (SEBM) . C. R. Creveling

i Society of American Foresters . Michelle Harvey

Society of American Military Engineers . VACANT

Society of Manufacturing Engineers . Jean Boyce

Washington History of Science Club . Albert G. Gluckman

Technology Transfer Society . Clifford Lanham

Washington Evolutionary Systems Society . Jerry L. R. Chandler

Washington Operations Research/Management Science Council . John G.Honig

Washington Paint Technical Group . Robert Kogler

Washington Society of Engineers . Alvin Reiner

Washington Statistical Society . Michael P. Cohen

World Future Society . Dianne Pickar

Washington Academy of Sciences

Room 811

1200 New York Ave.,N.W.

Washington, DC 20005

Return Postage Guaranteed