Overcoming Rural Service Delivery Barriers: Three Examples in Integrated Care Alysia Hoover-Thompson, Psy.D., Behavioral Health Provider, Stone Mountain Health Services Jodi Polaha, Ph.D., Associate Professor, Department of Psychology, East Tennessee State University Catherine Jones-Hazledine, Ph.D., Licensed Psychologist, Western Nebraska Behavioral Health Collaborative Family Healthcare Association 15 th Annual Conference October 10-12, 2013 Broomfield, Colorado U.S.A. Session # E4a Saturday, October 12, 2013

Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

Objectives Discuss barriers to growing a workforce in rural communities Identify strategies for developing a workforce in integrated rural practice Describe three programs successfully overcoming barriers

Stone Mountain Health Services Alysia Hoover-Thompson, Psy.D.

Background Stone Mountain Health Services is a Federally Qualified Health Center (FQHC) with 11 clinics Catchment area includes the three poorest and least healthy counties in the state of Virginia FQHCs must offer on-site, or access to, primary medical care, dental care and behavioral health care Must accept everyone, regardless of ability to pay

Problem Had 1 social worker serving as a Behavioral Health Consultant Hired additional social workers but had problems with retention due to rural location and fit into model of care

Solution “Grow your own” model Collaboration among: – Stone Mountain Health Services – Radford University (Master’s in Social Work, Master’s in Community Counseling and Counseling Psych PsyD) – East Tennessee State University (Clinical Psych PhD)

Solution This collaboration resulted in a unique arrangement with FQHC, 2 universities (in 2 different states) and 3 graduate programs Doctoral interns – 2 positions – Captured site for round 1, open for round 2 Social work interns – Placed based upon need

Implementation Rural Health Workforce Development Program – 20 grants awarded nationally Grant awarded in Fall 2010 ($600,000) 1st year: – Planning for implementation – Interviewed psychology doctoral students in January of 2011 and 2 nd round in March 1 slot for ETSU = filled 1 slot for RU = not needed, so went to 2 nd round of internship interviews

Implementation To meet internship training and supervision requirements, faculty members from ETSU (Dr. Jodi Polaha) and RU (Dr. Jim Werth) who are licensed psychologists spent 20 hours per week on site Social work interns supervised by existing LCSW Counselor Education component never came to fruition

Second Year of Implementation Hired both psychology interns and 2 of the 4 social work interns Hired an intern who had been offered one of the psychology internship slots, but declined offer to attend an APA-accredited site APPIC Accreditation Interviewed for (3 rd year): – 1 psychology intern from RU and 1 from ETSU – 3 social work interns

Third Year of Implementation Offered positions to both psychology interns – 1 accepted offer and 1 declined offer to accept a position closer to home Filled both psychology internship slots (1 from RU and 1 from ETSU) in 1 st round Hired an executive management-level director

Where We Are Today Director of Behavioral Health and Wellness Services 3 Clinical Psychologists and 3 Social Workers serving as Behavioral Health Providers 1 Post-Doc serving as a Behavioral Health Provider 1 Post-Doc serving as an Assessment Clinician 2 psychology and 2 social work interns Received 1 of 32 APA grants to fund accreditation

Southern Appalachian Telebehavioral Health Clinic Jodi Polaha, Ph.D. Associate Professor, Psychology HRSA: Office for the Advancement of Telehealth H2AIT16623

Telemental Health As Solution Provide care in novel contexts Decrease transportation Demonstrated effectiveness Increasingly affordable/accessible

Southern Appalachian Telebehavioral Health Clinic

Sneedville Wayne Co

Southern Appalachian Telebehavioral Health Clinic: August 2011 – September 2013 Total Patients:207  61.4% Warm Handoffs  38.6% Follow-up Average Number of Sessions: 1.69 (Range 1-11) Average Session Length: 30 Minutes (Range 10-75)

Annual Data: Mountain City Only

Satisfaction Survey ItemM (SD) N=12 I could see the psychologist clearly during the telemedicine visit.6 (.oo) I had no trouble hearing the psychologist when she spoke to me.5.92 (.28) I was able to speak freely with the psychologist and ask questions.5.75 (.62) The psychologist was able to ask me questions.5.75 (.62) The doctor seemed to understand my problem.5.92 (.29) I was comfortable with and understood what the psychologist told me about my complaint (.39) The camera or other equipment embarrassed me or made me feel uncomfortable. 2.9 (1.83) The telemedicine visit makes receiving care more accessible.5.67 (.65)

Satisfaction Survey ItemM (SD) N=12 I would prefer a telemedicine visit now rather than waiting for a face-to- face appointment with the same doctor (1.16) I would have traveled to another city to see a specialist if I had not used telemedicine 4.58 (2.02) Traveling to another hospital would have cut into my work/school or my child’s school time (1.93) Traveling would affect my wages for that time.3.83 (2.37) I would experience other inconveniences in traveling.5.00 (1.91) I would prefer a face-to-face visit with the specialist rather than a teleconsultation with a specialist (1.93) This telemedicine visit was as good as a face-to-face encounter.5.25 (.75) Overall, I am satisfied with telemedicine.5.67 (.49)

Training in Telemental/Telebehavioral Health Limited research Training facilitates use but most people don’t get it!  In a study of mental health professionals who used telemedicine 75% had not received any formal training (Simms, Gibson, & O’Donnell, 2011)  Those who did receive training were more comfortable with the equipment-particularly when they used the equipment at a higher frequency (Simms, Gibson, & O’Donnell, 2011) Nelson, Bui, and Sharp (2011) emphasizes three areas of competencies that trainees are expected to master during a rotations in the TeleHelp clinic at the University of Kansas.

Training in Telemental/Telebehavioral Health Developmental approach to training Addressing Technology Competency  ATA Telemental Health Standards and Practice Guidelines and Evidence Based Practice in Telemental Health (Available on the ATA website at d=3311) d=3311  Overview of technology  Overview of operations/procedures  Including emergency protocol  Interacting with clients over videoconferencing

Training in Telemental/Telebehavioral Health Addressing Clinical Competency  Similar to onsite  Emphasis on empirically supported treatment approaches  Supervision by Licensed Clinical Psychologist  Use of equipment to supervise on-site

Future Directions Focus groups to assess provider referral barriers Increased regional focus Future permanent positions Connections with other kinds of technology

F.A.R.M. C.A.M.P Frontier Area Rural Mental-Health Camp and Mentorship Program Western Nebraska Behavioral Health Catherine Jones-Hazledine, Ph.D.

Background WNBH is a clinic in the Panhandle area of Nebraska, one of the most rural and underserved areas in the state We have 5 (soon to be 6) satellite communities that we send providers to each week, over a 3,729 sq mile area Populations of these communities vary from: 877 to 8,500 (2011 Census) Started as Munroe-Meyer Institute clinics in 2004 and converted to private network (collaborating with UNMC in 2011)

Background Started with one provisionally licensed Psychologist in 2004, with supervision provided by telehealth to complete training. Began working early on with Chadron State College Community Counseling Program, taking practicum and internship students. Total of 10 M.A. students, and 2 PNP students have completed training Many stay on, with current clinicians including: 1 Psychologist, 1 LMHP, 5 PLMHP (2 pursuing doctorates, 3 nearing final licensure)

Challenges Area has traditionally been very underserved, due to: – isolated location – distance between communities – poverty and undersinsured nature of the population – Recruitment and retention difficult due to lack of resources, and shortage of jobs for spouses and family members – 8 hours from urban centers of the state

GOAL Expand recruitment and retention efforts within the rural setting to identify interested students in their high school career. It is hoped that recruitment from the setting will improve retention due to existing ties, and familiarity with the area. Idea came from working with students who had been mentored early with success. FARM CAMP

Solution FARM CAMP – Project idea originated within WNBH – Funded by the Behavioral Health Education Center of Nebraska – In cooperation with Chadron State College – A weeklong summer program for high school students interested in behavioral health careers

Project 6 communities in frontier area targeted Presentations on rural behavioral health careers given to students within those schools Interested students identified and provided with applications First group of 6 students identified: 9 th through completed 12 th grade. 5 females, 1 male Camp run June 20 – 26 in Rushville, NE

Project Introduction to basic behavioral health curriculum through college level class (with college credit from CSC) Introduction to rural providers in several disciplines of behavioral health College visit and on-campus behavioral health experience Assignment of mentor to follow them throughout the year

Outcome All six students completed the camp, and passed the college level class. Pre and Post tests reflect overall growth of knowledge about behavioral health topics. Anonymous camp evaluations indicate a high level of participant satisfaction with the experience, and intention to continue involvement. Second year will be in 2014, and will include opportunity for alumni participation.

Learning Assessment You have seen 3 unique programs that have successfully overcome rural service delivery barriers. What challenges have you experienced in rural service delivery? How might you use some of these ideas within your organization? Additional questions? Comments?

Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!