Taking Action Summit: Challenges to Rural Behavioral Health Service Providers
Good afternoon everyone. Thank you for joining this session. Today's session is titled Challenges to Rural Behavioral Health Service Providers and my name is Patrick Such and it is my pleasure to be the facilitator for the session. I'd like to welcome all the participants that are joining us virtually and everyone sitting here in the session room.
And I would, before I introduce our speaker, I just want to remind everyone that there will be ample time for question and answer at the conclusion of the presentation. And we will field question both from the virtual platform as well as from people in the room. So if you've joined virtually, please use the chat to type in your questions and we'll alternate between the virtual platform and in person for questions. If for some reason we run out of time and we do not get to all of the questions, especially virtually, you are welcome to email the UR medicine recovery email address and the team will make sure that your question gets answered by someone.
We will ask everyone that is here in person that once the presentation's over, if you have a question to please go to the microphone that is set up here, even though we can hear you in this room. But for the virtual attendees to hear, we have to use the microphones. All right, so it is my pleasure to introduce our speaker for this session. Robert, we know as Bob Ross, I've had the pleasure of knowing Bob for several years now and actually worked together with him on the board of our State Association of Substance Use Disorder providers for several years and so since 2007.
So Bob is currently the president and CEO of St. Joseph's Addiction Treatment and Recovery Centers Since 2007, Bob Ross has been CEO of St. Joseph's in Saranac Lake, New York. Previously he was executive deputy director of the New York State Division of Alcoholism and Alcohol Abuse.
Those were the days when the alcohol office and the drug office were two separate offices. He served as the acting director for one year, was deputy director of the New York City Bureau of Alcoholism Services and for 22 years ran his own healthcare consulting firm with national and international clients. He has served on many boards and received numerous awards including the 2019 Charlie Devlin Award for Leadership and Advocacy, championing access to services for all people in need, particularly those living in rural communities and for an exemplary career in state government and in community settings for substance use services.
So it is very much my pleasure to hand this over to Bob Ross.
- Thank you Patrick. So thank you all for being here. Before I tell you a little bit about St. Joseph's, in the context of how this presentation got put together, I'd just be curious, show of hands, who in the room have responsibilities for actually direct services to individuals with substance abuse?
Oh, great. So St. Joseph's is located in the Adirondack Mountains. It's about as rural as you can get in New York state.
It's surrounded by 6 million square miles of the Adirondack Park. It is the largest area of that kind of rural nature, east of the Mississippi and was supported very extensively when it was getting started by Teddy Roosevelt who was a great conservationist and to the credit of many people who have been stewards of that responsibility since then, it is remarkably rural in a lot of wilderness and it's a great place to visit if you want, in either weeks of our summer. I would recommend it. So I serve, as Patrick said, with Patrick on the executive committee of our state association in New York of providers.
And we felt that this issue was sufficiently important that we have had for a number of years, a committee of the executive committee on rural issues. And toward the end of my comments, I'll describe some of the things that we've actually done as recommendations to go forward and make some improvements. But let me first start out by sharing with you what I think are some of the key challenges, none of which I think will surprise you. Access to services, diseconomy of scale, over representation of vulnerable populations, workforce shortages, and limitations in visibility and political significance on this issue.
The substance abuse issue as a whole fights for attention in resources and public understanding and visibility. And I think the rural area suffers even more because there's not as much clout in the media and politicians are not necessarily on a statewide basis as focused on some rural needs as they are on some of the urban needs. So what are some of the access to service limitations, limited behavioral health and substance use disorder services, availability in small communities surrounding low density, large geographic areas. So for example, in the north country where we are, there are 3,600 square miles in which there is no community larger than 7,000 people.
And there are only a few that are that big. So ruralness has a real meaning when you talk about that kind of consistency over large area. There are gaps in primary care services, which has an impact obviously on our behavioral health concerns because if people aren't getting primary care, there's a much greater likelihood that there also are deficient in behavioral health. I use that term sometimes interchangeably because we see so much mental health, substance abuse, crossover challenges, that it's a convenient term.
So I will be inconsistent and sometimes say behavioral health and sometimes say substance use disorder. Recruitment and retention of qualified professionals, not something that any of you are unfamiliar with and has gotten dramatically more problematic during the pandemic. There's one community that I was talking to one of my colleagues recently and she said that they have a waiting list that has multiplied by five times because they can't hire people. So although they actually have money to pay them, they can't find the people to hire.
So people can't get access to services in sufficient match to the need. Adequate, reliable, and affordable transportation. It is sometimes interesting to talk to colleagues of mine who work in urban areas, even upstate urban areas, doesn't have to be New York City, who have no understanding of what it means to have virtually no public transportation and who is more likely not to have access to a car than somebody who has lost that opportunity by virtue of a DWI? So getting people back and forth to services has become a real challenge.
One of the things that we've done in our agency is that we've used the small amount of money that we generate as a surplus agency wide and we have hired individuals and we've leased vehicles, so we actually provide transportation. But until last year we were never reimbursed for that. This year is the first year that we are actually getting some small amount of reimbursement, but it's a huge problem and it really affects not just the scheduling, it really affects how often people can get access to the treatment that they need. Imagine being somebody who has lost the ability to drive, has a job that it's not easy to get time off.
And because of the way in which at least in New York state things are organized, it's expected that they come two or three times a week to treatment. So 50 miles each way imposing somebody else to drive you, imposing on your boss to let you have that time free, major problem. Technology deficits we're all familiar with how much positive improvement there was during the period of COVID because there was a liberalizing of access to care as a result of telehealth and telephonic health. But what we found very quickly was that people didn't have access to the internet.
They didn't have enough minutes on their, on their smartphones. So many other agencies in rural areas wound up figuring out how to provide those services to give them minutes on their phones to give them access with creative ways to better communication for the internet. One of the interesting things that we found in during this period of increased ability to have access to telehealth was sometimes our counselors would be on the phone with one of our clients doing a telehealth meeting and client would say, "You know, I'm really not focused today because we don't have any food in the house."
And so we and others tried to figure out how to use access that we had to food, working with pantries, working with our own kitchen operations for our inpatient services. And we recognized very clearly that getting food was gonna be the first order of business and then we could potentially connect to the services that they needed for treatment. There are more uninsured people in rural areas, not a shocking comment, I'm sure all of you are aware of that. And stigma is a bigger issue, partially because sometimes stigma can make progress or the reduction of stigma can make progress where people were able to convene and individuals who are in the advocacy community are able to access meetings and opportunities when people are more spread out, those opportunities are just fewer.
So I think stigma's a problem everywhere, but I think it's a more acute problem in rural areas even than other areas. Diseconomy of scale, it sounds like kind of a term out of a economics book, but basically what we're talking about there, and I'll give it a very concrete example that we have in our communities in the northern part of New York state, there's a expectation that we can deliver outpatient services at a certain unit cost. So the state officials sometimes think that when you go north from New York City, the costs keep going down. Well, that's probably generally true that it's less expensive to run a program in Rochester than it is in Queens, New York.
But it's not necessarily true that if you go farther up toward the Canadian border, that it gets cheaper because we have eight clinics in our agency. They're all very, very small. But each individual clinic has to meet certain regulatory requirements for staffing, both direct care staff and administrative staff. So you don't have to be an economics genius to figure out if you're doing eight locations, you have eight rents, you have eight heating bills, and you don't necessarily have collectively the same cost per number of clients served.
So our eight clinics probably would amount to a medium size clinic, single medium size clinic in Rochester or Buffalo or Albany. But our costs are much higher per capita of individuals served because of the reasons that I just mentioned. So that diseconomy of scale is something that we have not yet been able to get our state officials to address. And I'll come back to a positive thing that we're moving in that direction, in a few minutes.
So rural primary care workforce shortages, again, not something that you're unfamiliar with, made more difficult As I said earlier, during the pandemic, all categories of healthcare professionals are more difficult to recruit and retain in rural areas. It's also a direct relationship. If you don't have enough staff, you don't have the ability to serve as many people, even if you have the money to pay for the staff that you can't find. The turnover of staff who leave to go get better paying jobs in other locations means that you have added costs because you have to retrain the staff.
And that's not an unexpensive thing to do. It's particularly a problem for medical staff. RNs are an endangered species in our area. I don't know what you're experiencing where you are, but that's just a really hard thing to fill.
And psychiatrists are even more so. We've tried to be creative in the latter category by sharing psychiatrists with other institutions, hospitals, other programs. So a part-time person in that category is better than nobody. And what we've found is that sometimes hospitals and other folks are very willing partners to work with us in that regard.
So what are the vulnerable populations that are more acute in rural areas? There's a higher percentage of people on opioids in rural areas, which we've all seen and Sam was very clear about some of the reasons for that in his presentation. Rural populations have higher rates of individuals needing behavior, health and substance use disorder services. It turned out that during the pandemic, we also had a dramatic increase, as all of you know in addiction.
Not just opioids but methamphetamines and other categories of substance abuse. There's been a challenge that we have found that there's an older population in many rural areas, including the one that I work in and live in. People who are older tend to have more healthcare needs, particularly if they have healthcare needs that are harder to address. As I said earlier, in terms of primary care.
The rural areas have higher percentages in many parts of the world, or many parts of the United States, excuse me, in of veterans. And veterans tend to have healthcare profiles that are more problematic. So if you have a higher concentration of veterans, you have bigger problems in terms of service needs. And then the other part, which is really not a population issue, but is a function of everything I've just described, is that financial stability with rural community services are more problematic 'cause they're smaller.
And being big doesn't guarantee that you're gonna have fiscal stability. Being small means you may have even greater challenges. So what are some recommendations? I mentioned earlier that in our case, there is a problem because of the fact that the in New York state, they have a upstate downstate distinction for regulations and for reimbursement rates for Medicaid.
Upstate downstate makes some logical sense. As I said earlier, it's a little bit more expensive to do things in New York City than in some upstate areas, but it is not necessarily more expensive to do things in Rochester, Syracuse, Buffalo than it is in urban areas, or excuse me, rural areas. If you're looking at that from the point of view of a unit cost. So one of the things that we've been doing recently, the committee that I mentioned earlier, that I serve as the co-chair on rural committee for our agency that represents providers of services in substance abuse and some mental health services.
We have teamed with Senator Harckham, Pete Harckham, who is the chair of the senate committee in New York state for addiction. And he and his staff have put together a legislation that would add a category of rural to upstate downstate. And that would mean that anytime the substance abuse agency or the mental health agency issue regulations or promulgate rates, they have to be for all three categories, not just upstate downstate. And that means that in some cases we wouldn't have to go through the time consuming and expensive process of getting waivers and those waivers occur so frequently, that it would just make a lot more sense to have legislation and guidance to not have to do it that way.
Another recommendation is that we need to expand rural workforce incentives so that we counter the notion of it being more difficult to get individuals hired and retained. And retention I think is sometimes underestimated as a problem. People talk about how hard it is to hire people, but we also don't wanna lose those really good people who have been with us for a long time that we've trained and who really wanna stay engaged because we can't meet their reasonable needs. Increased reimbursement rates for some reason in many rural areas, ourselves included, we find that the rates are unreasonably low and therefore we wind up having to figure out how to supplant the rates that we get paid for the services.
And that's not a very easy thing to do. We wanna see a preservation and expansion of the telehealth and telephonic behavioral health substance use disorder services that got started during COVID. And I think the federal government and some state governments are making efforts to make sure that those are continued. And we certainly think that that's a very valuable thing to do.
And the last point I would make, is we need to do a better job. And that's really on us in as rural providers to build coalitions. We need to reach out to local, state, and federal officials to get them engaged. We need to get the local media engaged in understanding what the consequences are in terms of reduced healthcare quality for individuals.
And we need to partner with other organizations and other coalitions that promote healthcare. One of the areas that I personally think is really undervalued is a concept of public health as opposed to the silos of the different categories of public health. We saw during COVID what the consequences are of not having really solid coordinated public health policy. And I think that that would help rural communities in all areas, but specifically including the area of behavioral health in rural areas.
So I guess I'd like to leave you with a visual somehow when we put together the slides. This one didn't get into the cut, but I'm sure all of you have a really good imagination. So imagine a Venn diagram with four circles. One is low resources, one is inadequate infrastructure, another is low density populations, and the fourth is a healthcare disparities on the high side.
So if you imagine those four circles, what's in the middle of those four circles in the Venn diagram, is basically what we're talking about and trying to be responsive to and be creative in our responses to it. So I wanna make sure that we have plenty of time for questions or comments. So I'm gonna turn it over to Patrick.
- All right, thank you Bob. So with that, we will open it up to questions.
- Or comments.
- Or comments. So if anyone in the room have a question, you can go to the microphone. And while you think about that, I have a couple questions here, Bob, that you mentioned early in your presentation about being able to provide, you know, you provided transportation, and now you are able to get reimbursed for it. Can you speak a little bit as to how you're getting reimbursed for that now?
- Sure. We found out that there is a process in New York State for Medicaid reimbursement for either bringing people to or from treatment services or bringing people to medical services that we don't provide primary care. It was a amazing process. There are four state agencies involved in getting approval.
They refused to meet with each other. We had to get a very high level person to intervene to get representatives of a sufficiently high level from all four to participate in a conference call. Following the conference call, we got letter from each of them and they all attended a different meeting than I was at 'cause they had total agreement during the meeting. And after the meeting there was a sense that they had a few more questions.
So it took 18 months and after that process we were told that we were gonna be able to be eligible for reimbursement, which was great. We then found out that once we started billing, there were a few other things that they did not tell us. One of those was that if you were bringing somebody from say, New York City, up to our facility our inpatient facility, in Saranac Lake, which we have representation throughout the year from 56 of the 62 counties in New York state, many of them are from downstate. The Medicaid reimbursement process for the Department of Health, they'd prefer to drive within their region.
So wouldn't it be a better idea if the individual who had agreed to come to St Joe's for treatment went somewhere locally? Well that would be ideal and if they had been able to do that, they wouldn't have contacted us in the first place. So the idea that you then start negotiating and saying, "Well, we'll provide treatment where the transportation will pay for it". That seems a little backwards.
And so we're in the middle of that fight at the moment. So it's not an easy process, but we think that we will be able to make the argument that the delay of people coming into services puts them at huge risk. And with all of the fentanyl that's now in all of the illicit drugs, that really basically puts (indistinct) lives at risk. So we expect to win that fight, but that one's not over quite yet.
But basically what we did is we did a lot of research to find out where there were pockets of reimbursement in New York. And it may vary from state to state and I think state's Medicaid programs would be my suggestion of where you can look in whichever state you're from.
- Thank you. And we have a question in the room.
- [Audience Member]
Yep, I don't, oh it does work okay.
- Thank you. Thank you Patrick and thank you Bob. The territory that I represent is a dozen or more counties in the Finger Lakes Southern Tier in Western New York. So it's very rural, not quite as rural as your area.
And we all know that the cards are stacked against people in that area because transportation, it doesn't even exist once you get out of the town centers, what little services there are, are in the towns and getting people in and out of those services is really challenging. Also, if we wanted to try and compensate for that through telehealth we deal with issues like broadband and availability. So we really are having a a hard time providing that. So what's happened over the last five years, as you know with DSRIP is we've started to collaborate our provider networks and get mental health, and medical, and social determine of health agencies working together collaboratively to outreach and provide services.
So I know how that's going in my territory. I'm just wondering up in the north country, in in the rural areas, what's happening up there in terms of getting providers to work together collaboratively to address the comprehensive needs of of patients?
- Great, great question. We were very fortunate in our part of the state in that the PPS during DSRIP which in our cases at Adirondack Health Institute, was much more receptive to working with community based behavioral health than were some of the other 24 DSRIP agencies. I think the Finger Lakes was also a pretty good area in that regard, but most parts of the state that wasn't the case. So now that there is, again, I'll do a little New York speak for a second.
There's something called an 1115 waiver to the federal government to try and keep, I think in our case it's somewhere over $10 billion in the state. I think the DSRIP was about 8.5 billion. So a little bit of an increase.
The structure though is very different. It's really not DSRIP 2.0, it's a different mechanism. That mechanism does two things that I think are potentially positive.
One is it talks about regional planning and there are gonna be nine regions as opposed to 25 PPSs. So that's more manageable. The second thing is that it specifically calls out a collaboration between hospitals and behavioral health community based organizations in a way that is more specific and more dramatic. There's a lot yet to be determined about how the mechanisms will work and who controls the money and who controls the evaluation.
But I think the answer that I would say is going forward, regional planning as opposed to a collection of individual agencies receiving money will have better opportunity in rural areas. And whether it's a mental health organization providing services under one agency jurisdiction and substance abuse under another and working with a primary care FQHC or a hospital, I think the expectation on the federal government's gonna be we're giving this $10 billion in order to do better regional, not just the planning part but the execution part. So it's a little early to tell exactly what it'll look like structurally, but I think in terms of concept, it's an improvement.
- All right. Have another question here and now I'll go back to the room. You mentioned workforce earlier in your presentation. Do you have any advice for organizations in rural communities on how they can better recruit and retain behavioral health providers?
- Again, New York, specific New York, the new governor and the new Oasis, which is our substance abuse agency commissioner, have made workforce very dramatically increased in their focus. There was additional money in the budget, which was just passed in April, and that makes it more possible for agencies to receive direct increases. Part of the problem though is those are not guaranteed over time. So it presents a real challenge for provider agencies.
Do you actually increase base pay or do you give bonuses? It's much better to give base pay increases if you can. But then you run into the potential problem that that lasts for a couple of years and then all of a sudden you've got a budget for personnel that isn't supported by increased rates. So part of what we're doing as a state association, is lobbying already for next year's budget that that not be made an individual year by year decision, but that it become part of the base increase that goes to agencies.
There's a big debate that we as individual agency and our association is involved in. Should federal money, which is coming into states in increasing amounts, should it be used only to increase new services or should some substantial amount of those dollars be used to shore up the base operations of existing agencies? To increase new agency categories while not shoring up the base, leaves the potential for a real disaster if you have new agencies that are funded and older agency, not older agency, older agency services that are not supported. So there's a lot of tension around how much of the new money that comes into the state from the feds should be used for new categories of services and how much should be used to shore up bases, which would allow for example increases in salaries.
- All right and we will take question in the room.
- [Audience Member]
And thank you for that last comment because that's something that we are doing this year is shoring up the base instead of trying to do anything new. But my question kind of touches on the last question, kind of the flip side of that. As opposed to hiring new, have you seen any areas, any job functions in the organization that might lend itself to outsourcing better than others do?
- Well, we individually at St. Joe's have looked at outsourcing and we have done some increase in that. We've also done something else, which I think is a little bit more creative, and our HR department is actually headed by an individual and her title is Chief Talent Officer. And in our organization she is of equal rank in the organization as the CFO.
She's called the CTO. And basically all decisions that we make include the three of us in a room together. So it's people and money, not just money that is at the table. And we've been doing that for about 12 years and we think it has made a difference.
So one of the creative areas that we're looking at is if we have really talented people, which we think we do, who are willing to take more responsibility. We're looking at expanding their role, giving them additional money to do a bigger role, giving them training and access to credentialing programs in areas that are pertinent to what they do. And then hiring assistance at a lower level to support them. And we've done that in a couple different departments and boy does that improve morale?
If somebody feels that you're investing in them because they've shown that they really want to learn and grow. So it's not a magic elixir, but it does provide an alternative way of saying if we need a certain capacity that we don't have, how do we grow that capacity, reward the individual who's doing that growth and provide some support at a assistance level so that they're not overwhelmed with too much work, but they can also grow. And the few places that we've done that, it's been very well received.
- All right, another question here. Bob can you share your thoughts around substance use disorder services embedded in primary care practices in rural communities?
- So that's a really great question because there are two different ways to do that. One way is to embed is the question suggests substance abuse in primary care. The other alternative way, which is the flip side of that, is to figure out how to get primary care services into substance abuse agencies. I will acknowledge and fully confess to a prejudice, and it's the latter.
And there's a very specific reason for that. The reason is that I think it is possible for substance abuse agencies to hire primary care individuals with skills and support and have them be able to treat the clients who they're already working with successfully. The opposite is not automatically true. It's not really an indictment of in any way of primary care agencies or the people who work for them.
It's just that we've tried both and have found that it works really nicely to get people who have primary care expertise bring them into agencies like a St. Joe's. And we're not the only ones who do it, and have better continuity of care for the clients. I know that there have been some successful alternatives in the first category, so it's not an absolute black or white situation, but I think for most agencies, that's the better way to go.
- All right. Checking the room here for any additional questions. All right, I have just one last question here. Can you speak to the role of telehealth in relieving the behavioral health provider shortages in rural areas?
Are there other models that should be either expanded or implemented using telehealth that could help with the behavioral health provider shortage?
- So let me expand that a little bit and say that we have found that mobile services and telehealth and telephonic health as a combination of how to supplement services with people coming to individual facilities, is it's a yes and, both and situation. I think there are very few circumstances in which there is a single way to do something. And if you do it that way and do it really well, you don't need to do anything else. So from my perspective, I would highly recommend that.
And it can be done in regions. It doesn't mean that every single agency has to do every single thing. So combining services or collaborating with an agency that provides mobile services if your agency doesn't, but that can serve the same population. We learned a ton about how to do telehealth more effectively.
We learned that there's a greater receptivity than some people thought. We learned that a lot of the restrictions were really unnecessary and actually harmful. And I think there's a big push. Rob Kent, who was here earlier and yesterday, talked very specifically about the fact that the federal government, ONDCP, is looking on how to make permanent some of the liberalization of regulations in that regard.
So I basically think it's figuring out how to do more of it, not figuring out how to leave out direct in person care, because I think that's an important ingredient. And what we've found is that individuals don't even necessarily as recipients of services, stick with one method and that's the preferred method. So what we've found is that people who had not had access to direct personal care because they couldn't, because the facilities were closed during the worst part of COVID. They've actually been enthusiastic about coming back, but they don't necessarily want to come back all the time.
And in rural areas, transportation issues, as we've already discussed are a real balance. So I think the sense is how do we meet clients where they're at by giving them the best support in rural areas? And my guess is that more often than not, that's a combination of different approaches.
- All right. Well thank you Bob for the presentation and discussion through the Q and A. Thanks to everyone who is here in the session, in person and who has been following on the virtual platform. This brings us to the end of this session, but I will share a little piece of information for you as you continue to enjoy the rest of the day and next session.
Stick around for dinner. I heard it's being catered by Dinosaur Barbecue. I don't even know whether I'm supposed to tell you that, but I'm telling you.
- I just had one quick- (applause) Thank you. I just had one quick comment that I wanted to share. I mentioned it, but I really would like to emphasize it. We have found that going to local rural press, newspapers, magazines, local radio, local TV, they really are looking for content about issues related to substance abuse.
And what we have found is if you go to them and say, "Oh, we're having an opening of a new facility or we're having an event", they will respond. But what they like even better is if you go to them and say, "We're not coming and asking you for something, we're offering. If you're doing an article about the fact that there's unfortunately been an increase of DWIs among kids after some event and there are two or three fatalities". And they're looking for context, they're looking to talk to an expert.
Because that relationship's already been built. It's really very valuable. And then when you go to them and say, "Hey, we're opening a new facility, could you get the coverage?" The relationship is very different.
So it's pretty inexpensive to do and they like it. And most of the local TV stations, for example, have crews in which you get one person coming out with the camera, the mic, and doing the story. And when you can give them information, they love it. So that would be my parting comment.
Robert A. Ross
President & CEO, St. Joseph’s Addiction Treatment & Recovery Centers