Challenges to Developing Mental Health Policy

Identification of Issue

The lack of mental health care providers is an issue in our rural health community. Currently the patients located in the rural communities of Texas do not have easy access to mental health providers (counselors, therapists, psychiatrists, or mental health nurse practitioners). These communities depend heavily on law enforcement and emergency departments to deal with mental health patients that are in an acute crisis situation. Substantial increase of cost is incurred to families, criminal justice system, and society by the limited access to mental health services. The Public Policy Platform of the National Alliance on Mental Illness cites statistics such as:

• People with mental illness are at an increased risk for other illnesses such as diabetes, heart disease, cancer, respiratory diseases, AIDS, and Hepatitis C (National Alliance on Mental Illness, n.d.).
• People with mental illness die on an average of 25 years sooner (National Alliance on Mental Illness, n.d.).

The disparities continue to increase over time and certainly demands attention and funds. World Health Organization identifies depression as the leading cause of disability worldwide (World Health Organization. Depression fact sheet, n.d.). These individuals that are seeking assistance must currently do so in our primary care clinics. Those physicians that have not received proper training to treat mental illness are having to prescribe medications for these conditions, 65% of medications used to treat mental health disorders are prescribed by primary care physicians (Grazier, 2016). It is critical to good health and the best possible health outcomes are achieved when residents can access behavioral health services conveniently.

Context of the Issue & Political Feasibility

Health care centers that qualify and receive funding under section 330 of the Public Health Service Act are Federally Qualified Health Centers (FQHCs). These health centers eliminate many of the barriers that patients in rural areas have such as lack of insurance. They provide comprehensive services including primary care, dental care, and including mental health and substance abuse services. Behavioral health is seen in this primary care setting more than any other (Burke et al, 2013). Compared to other primary care clinics, the patients seen in FQHCs are typically below the national poverty level, uninsured, or covered by Medicaid (Burke et al, 2013). The National Survey on Drug Use and Health shows that these patients are more likely to have a behavioral health diagnosis. The current issue is lack of behavioral health providers in the FQHCs that are in rural areas. These patients lack the resources to travel to areas that provide behavioral health care.

The Affordable Care Act has provided many with coverage for behavioral health care, however the lack of providers is an issue. Healthcare reform increased the coverage for services, however how will we provide the caregivers to give the services. There are over 4,000 areas across the US containing 110,000,000 million people that have a shortage in mental health care providers. Texas ranks #50 with the least amount of providers per patients with mental health disorders (

http://www.mentalhealthamerica.net/issues/mental-health-america-access-care-data

).

Stakeholders, Network Evaluation, & Power Sources

The stakeholders for this issue include the underserved residents of Texas, ARPNs,

physicians, insurance companies, state and federal payer programs and professional healthcare

organizations. The stakeholders can be supporters and opponents for providing mental health providers in clinics that receive government funding in rural healthcare centers. Currently some public and private payers do not allow billing for a primary care visit and a behavioral health visit on the same day (Politico Staff, 2016)

.

This prevents patients from receiving care promptly when an issue is identified. The Office for Research on Disparities and Global Mental Health identifies the trends and gaps in the mental health areas and assists in setting goals for grants that could assist in funding a mental health care provider in the rural areas. The Office of Rural Mental Health Research is mandated by congress to coordinate research on mental health needs in the rural area. There are several influential organizations whose support is critical if this rural mental health mandate is to ever succeed. A few of the most prominent groups include the American Psychiatric Nurse Association, American Nurses Association, and National Alliance on Mental Health.

Necessary Resources

The rural areas are frequently not represented to any degree in the political arena. Whenever state governments are considering a budget cut, rural areas often lacks the concentrated political representation necessary to oppose the cuts (Reardon, 2010). To combat these tendencies, local and state representatives who are committed to funding rural mental health initiatives must come forward.

In addition to legislative support, there needs to be adequate clinical space allocated in a way that places the mental health provider in close proximity to the primary healthcare provider. Ideally, the location of this shared clinical space would be a private area, since the stigma of being a mental health patient might prevent patients from seeking mental healthcare. Transportation (or lack thereof) is also a very important issue when considering mental health patients living in rural areas.

Professional Values

It is a priority to address mental health care in the primary care setting by a mental health provider. Healthcare providers recognize the need for improved care for mental health patients. Addressing the mental health issues will decrease ER visits, decrease law enforcement intervention, and will decrease overall inpatient admissions with early identification and treatment. Screening for mental health issues takes place in the primary care setting and a patient should be immediately referred for treatment if needed. A positive finding on a screening for depression could prevent a suicide and this is the goal is early intervention and treatment. The funding is imperative to make this successful. American Psychiatric Nurse Association, American Nurses Association, and National Alliance on Mental Health are organizations that provide much support for the presence of a mental health care provider in rural areas.

Proposed Solutions

There is a need to have mental health providers at facilities in rural areas that provide primary care and receive government funding. Considering the lack of healthcare providers to treat those with mental health illnesses there are several proposed solutions to consider. Outpatient treatment must be readily accessible to individuals in their own community.

Providing psychotherapy is part of treatment regime for patients with mental health illness. Telemedicine is one strategy that rural health care centers are currently using. Although telemedicine for behavioral health has the disadvantage of the patient and provider not being in the same room, it can create enhanced feelings of safety, security and privacy for many patients.

The integration of mental health into primary care is one of the suggested solutions. This implementation has providers that are not specifically trained in mental health providing this care. This solution would ensure that patients get treatments needed to sustain long-term health outcomes. Primary care physicians are the most trusted providers for patients that are seeking treatment for mental health conditions. One of the limiting factors that prevent this from being entirely successful is that primary care providers is the lack of time with patients. The pace of a primary care setting is much quicker than that of behavioral health care settings. This is a disadvantage for the patient needing behavioral health intervention. One other disadvantage to this is that there is a shortage of not only mental health providers in rural areas but there is also a shortage of primary care physicians. There are approximately 68 primary care physicians per 100,000 people in rural areas (Khazan, 2014).

Another option to address the issue is to provide psychiatric advanced nurse practitioners in health care settings in rural communities. Statistics show that that as of May 2017 there was a 26% increase in the enrollment of PMH NP students since 2014-2015 (Delaney, 2017). PMH APNs provide a patient-centered approach that is important in addressing one’s mental health needs. These providers provide a holistic approach and have prescriptive authority to provide the necessary medications to treat their mental health issues. Treating mental health care patients by those specifically trained in mental health is the most reliable care for patients.

Comparison of Results for Proposed Solution versus Current Situation

Mental health care provider at primary care settings (proposed)	No mental health care provider at primary care settings (current)
Decrease in ER visits	Subpar interactions between primary care providers and patients
Decrease in psychiatric admissions	Missed opportunities for immediate psychiatric intervention
Decrease in healthcare costs	Primary care providers providing care for patients that the service is out of their specialty

References

• American Psychiatric Nurses Association, Position Statement on Whole Health Begins With Mental Health. Retrieved from
  
  http://www.apna.org/files/public/Whole-Health-Begins-With-Mental-Health-Position-Paper.pdf
  
• Delaney, K. (15 May 2017). Psychiatric Mental Health Nursing Advanced Practice Workforce: Capacity to Address Shortages of Mental Health Professionals.
  
  Psychiatry Online.
  
  Retrieved from
  
  https://doi-org.ezprozy.ttuhsc.edu/10.1176/appi.ps.201600405
  
• Goldsmith, Thomas (August 10, 2016).
  
  Congressional Mental-health Bill Meets Opposition from Advocates, Snags in Senate.
  
  Retrieved from
  
  https://www.northcarolinahealthnews.org/author/tommygoldsmith/
  
• Goodrich, D., Kilbourne, A., Nord, K., & Bauer, M., Mental Health Collaborative Care and Its Role in Primary Care Settings.
  
  Current Psychiatry Reports. 15
  
  (8). doi: 10.1007/s11920-013-0383-2.
• Grazier, K., Smiley, M., & Bondalapati, K. (2016). Overcoming Barriers to Integrating Behavioral Health and Primary Care Services.
  
  Journal of Primary Care & Community Health, 7
  
  (4), 242-248. doi: 10.1177/2150131916656455.
• Khazan, Olga (2014). Why Are There So Few Doctors in Rural America?
  
  The Atlantic.
  
  
  https://www.theatlantic.com/health/archive/2014/08/why-wont-doctors-move-to -rural-america/379291
  
• Masterson, L. (2018). The boons of-and barriers to- behavioral health integration.
  
  HealthcareDive.
  
  Retrieved from
  
  https://healthcaredive.com/news/behavioral-health-integration-care-settings/525347
  
• Mental Health America Fact Sheet 2015,
  
  Mental Health Facts, Stats, and Data,
  
  viewed October 31, 2018.
  
  https://mentalhealthamerica.net/issues/state-mental-health-america
  
• Politico Staff. (2016, June). Scope of practice: How can we expand access to care?
  
  Politico.
  
  Retrieved from
  
  https://www.politico.com/story/2016/06/scope-of-practice-health-care-224571
  
  .
• “Public Policy Platform of the National Alliance on Mental Illness, Revised Twelfth Edition”; National Alliance on Mental Illness; 2016, 25-29.
• Reardon, P. (2010). Mental Health Services are a Critical Rural Need.
  
  Journal of the Catholic Health Association of the United States.
  
  
  https://chausa.org/publications/health-progress/article/september-october-2010/when-there’s-no-place-to-turn
  
• Wakida, E., Akena, D., Okello, E., Kinengyere, A., Kamoga, R., Mindra, A., Obua, C., & Talib, Z. (2017). Barriers and facilitators to the integration of mental health services into primary health care: a systematic review protocol.
  
  Systematic Reviews 6
  
  (171). doi: 10.1186/s13643-017-0561-0.

Identification of Issue

The lack of mental health care providers is an issue in our rural health community. Currently the patients located in the rural communities of Texas do not have easy access to mental health providers (counselors, therapists, psychiatrists, or mental health nurse practitioners). These communities depend heavily on law enforcement and emergency departments to deal with mental health patients that are in an acute crisis situation. Substantial increase of cost is incurred to families, criminal justice system, and society by the limited access to mental health services. The Public Policy Platform of the National Alliance on Mental Illness cites statistics such as:

• People with mental illness are at an increased risk for other illnesses such as diabetes, heart disease, cancer, respiratory diseases, AIDS, and Hepatitis C (National Alliance on Mental Illness, n.d.).
• People with mental illness die on an average of 25 years sooner (National Alliance on Mental Illness, n.d.).

The disparities continue to increase over time and certainly demands attention and funds. World Health Organization identifies depression as the leading cause of disability worldwide (World Health Organization. Depression fact sheet, n.d.). These individuals that are seeking assistance must currently do so in our primary care clinics. Those physicians that have not received proper training to treat mental illness are having to prescribe medications for these conditions, 65% of medications used to treat mental health disorders are prescribed by primary care physicians (Grazier, 2016). It is critical to good health and the best possible health outcomes are achieved when residents can access behavioral health services conveniently.

Context of the Issue & Political Feasibility

Health care centers that qualify and receive funding under section 330 of the Public Health Service Act are Federally Qualified Health Centers (FQHCs). These health centers eliminate many of the barriers that patients in rural areas have such as lack of insurance. They provide comprehensive services including primary care, dental care, and including mental health and substance abuse services. Behavioral health is seen in this primary care setting more than any other (Burke et al, 2013). Compared to other primary care clinics, the patients seen in FQHCs are typically below the national poverty level, uninsured, or covered by Medicaid (Burke et al, 2013). The National Survey on Drug Use and Health shows that these patients are more likely to have a behavioral health diagnosis. The current issue is lack of behavioral health providers in the FQHCs that are in rural areas. These patients lack the resources to travel to areas that provide behavioral health care.

The Affordable Care Act has provided many with coverage for behavioral health care, however the lack of providers is an issue. Healthcare reform increased the coverage for services, however how will we provide the caregivers to give the services. There are over 4,000 areas across the US containing 110,000,000 million people that have a shortage in mental health care providers. Texas ranks #50 with the least amount of providers per patients with mental health disorders (

http://www.mentalhealthamerica.net/issues/mental-health-america-access-care-data

).

Stakeholders, Network Evaluation, & Power Sources

The stakeholders for this issue include the underserved residents of Texas, ARPNs,

physicians, insurance companies, state and federal payer programs and professional healthcare

organizations. The stakeholders can be supporters and opponents for providing mental health providers in clinics that receive government funding in rural healthcare centers. Currently some public and private payers do not allow billing for a primary care visit and a behavioral health visit on the same day (Politico Staff, 2016)

.

This prevents patients from receiving care promptly when an issue is identified. The Office for Research on Disparities and Global Mental Health identifies the trends and gaps in the mental health areas and assists in setting goals for grants that could assist in funding a mental health care provider in the rural areas. The Office of Rural Mental Health Research is mandated by congress to coordinate research on mental health needs in the rural area. There are several influential organizations whose support is critical if this rural mental health mandate is to ever succeed. A few of the most prominent groups include the American Psychiatric Nurse Association, American Nurses Association, and National Alliance on Mental Health.

Necessary Resources

The rural areas are frequently not represented to any degree in the political arena. Whenever state governments are considering a budget cut, rural areas often lacks the concentrated political representation necessary to oppose the cuts (Reardon, 2010). To combat these tendencies, local and state representatives who are committed to funding rural mental health initiatives must come forward.

In addition to legislative support, there needs to be adequate clinical space allocated in a way that places the mental health provider in close proximity to the primary healthcare provider. Ideally, the location of this shared clinical space would be a private area, since the stigma of being a mental health patient might prevent patients from seeking mental healthcare. Transportation (or lack thereof) is also a very important issue when considering mental health patients living in rural areas.

Professional Values

It is a priority to address mental health care in the primary care setting by a mental health provider. Healthcare providers recognize the need for improved care for mental health patients. Addressing the mental health issues will decrease ER visits, decrease law enforcement intervention, and will decrease overall inpatient admissions with early identification and treatment. Screening for mental health issues takes place in the primary care setting and a patient should be immediately referred for treatment if needed. A positive finding on a screening for depression could prevent a suicide and this is the goal is early intervention and treatment. The funding is imperative to make this successful. American Psychiatric Nurse Association, American Nurses Association, and National Alliance on Mental Health are organizations that provide much support for the presence of a mental health care provider in rural areas.

Proposed Solutions

There is a need to have mental health providers at facilities in rural areas that provide primary care and receive government funding. Considering the lack of healthcare providers to treat those with mental health illnesses there are several proposed solutions to consider. Outpatient treatment must be readily accessible to individuals in their own community.

Providing psychotherapy is part of treatment regime for patients with mental health illness. Telemedicine is one strategy that rural health care centers are currently using. Although telemedicine for behavioral health has the disadvantage of the patient and provider not being in the same room, it can create enhanced feelings of safety, security and privacy for many patients.

The integration of mental health into primary care is one of the suggested solutions. This implementation has providers that are not specifically trained in mental health providing this care. This solution would ensure that patients get treatments needed to sustain long-term health outcomes. Primary care physicians are the most trusted providers for patients that are seeking treatment for mental health conditions. One of the limiting factors that prevent this from being entirely successful is that primary care providers is the lack of time with patients. The pace of a primary care setting is much quicker than that of behavioral health care settings. This is a disadvantage for the patient needing behavioral health intervention. One other disadvantage to this is that there is a shortage of not only mental health providers in rural areas but there is also a shortage of primary care physicians. There are approximately 68 primary care physicians per 100,000 people in rural areas (Khazan, 2014).

Another option to address the issue is to provide psychiatric advanced nurse practitioners in health care settings in rural communities. Statistics show that that as of May 2017 there was a 26% increase in the enrollment of PMH NP students since 2014-2015 (Delaney, 2017). PMH APNs provide a patient-centered approach that is important in addressing one’s mental health needs. These providers provide a holistic approach and have prescriptive authority to provide the necessary medications to treat their mental health issues. Treating mental health care patients by those specifically trained in mental health is the most reliable care for patients.

Comparison of Results for Proposed Solution versus Current Situation

Mental health care provider at primary care settings (proposed)	No mental health care provider at primary care settings (current)
Decrease in ER visits	Subpar interactions between primary care providers and patients
Decrease in psychiatric admissions	Missed opportunities for immediate psychiatric intervention
Decrease in healthcare costs	Primary care providers providing care for patients that the service is out of their specialty

References

• American Psychiatric Nurses Association, Position Statement on Whole Health Begins With Mental Health. Retrieved from
  
  http://www.apna.org/files/public/Whole-Health-Begins-With-Mental-Health-Position-Paper.pdf
  
• Delaney, K. (15 May 2017). Psychiatric Mental Health Nursing Advanced Practice Workforce: Capacity to Address Shortages of Mental Health Professionals.
  
  Psychiatry Online.
  
  Retrieved from
  
  https://doi-org.ezprozy.ttuhsc.edu/10.1176/appi.ps.201600405
  
• Goldsmith, Thomas (August 10, 2016).
  
  Congressional Mental-health Bill Meets Opposition from Advocates, Snags in Senate.
  
  Retrieved from
  
  https://www.northcarolinahealthnews.org/author/tommygoldsmith/
  
• Goodrich, D., Kilbourne, A., Nord, K., & Bauer, M., Mental Health Collaborative Care and Its Role in Primary Care Settings.
  
  Current Psychiatry Reports. 15
  
  (8). doi: 10.1007/s11920-013-0383-2.
• Grazier, K., Smiley, M., & Bondalapati, K. (2016). Overcoming Barriers to Integrating Behavioral Health and Primary Care Services.
  
  Journal of Primary Care & Community Health, 7
  
  (4), 242-248. doi: 10.1177/2150131916656455.
• Khazan, Olga (2014). Why Are There So Few Doctors in Rural America?
  
  The Atlantic.
  
  
  https://www.theatlantic.com/health/archive/2014/08/why-wont-doctors-move-to -rural-america/379291
  
• Masterson, L. (2018). The boons of-and barriers to- behavioral health integration.
  
  HealthcareDive.
  
  Retrieved from
  
  https://healthcaredive.com/news/behavioral-health-integration-care-settings/525347
  
• Mental Health America Fact Sheet 2015,
  
  Mental Health Facts, Stats, and Data,
  
  viewed October 31, 2018.
  
  https://mentalhealthamerica.net/issues/state-mental-health-america
  
• Politico Staff. (2016, June). Scope of practice: How can we expand access to care?
  
  Politico.
  
  Retrieved from
  
  https://www.politico.com/story/2016/06/scope-of-practice-health-care-224571
  
  .
• “Public Policy Platform of the National Alliance on Mental Illness, Revised Twelfth Edition”; National Alliance on Mental Illness; 2016, 25-29.
• Reardon, P. (2010). Mental Health Services are a Critical Rural Need.
  
  Journal of the Catholic Health Association of the United States.
  
  
  https://chausa.org/publications/health-progress/article/september-october-2010/when-there’s-no-place-to-turn
  
• Wakida, E., Akena, D., Okello, E., Kinengyere, A., Kamoga, R., Mindra, A., Obua, C., & Talib, Z. (2017). Barriers and facilitators to the integration of mental health services into primary health care: a systematic review protocol.
  
  Systematic Reviews 6
  
  (171). doi: 10.1186/s13643-017-0561-0.