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Focus on Rural Health

University of North Dakota Sets Example in Rural Behavioral Health

By Jena Pierce on

Each year, more than 20% of adults experience a behavioral health disorder in the U.S. The percentage of adults experiencing a behavioral health disorder in rural communities is even higher. The reasons for the high percentages, and solutions to try and combat the behavioral health issues, were shared during a meeting of the National Conference of State Legislatures (NCSL) last June.

Shawnda Schroeder, PhD, former principal investigator for the Mountain Plains Mental Health Technology Transfer Center (MHTTC) at the Center for Rural Health housed within the University of North Dakota School of Medicine & Health Sciences (UND SMHS), and Dr. Andrew McLean, clinical professor and chair of the Psychiatry and Behavioral Science Department at UND SMHS, presented research findings during the virtual meeting.

National Conference of State Legislatures

University of North Dakota Sets Example in Rural Behavioral Health - Focus article photos NCSL hosted the meeting to highlight state policy options for legislators aiming to increase access to rural behavioral health services. NCSL is a bipartisan organization that represents legislatures in the states, territories, and commonwealths of the U.S. Its mission is to advance the effectiveness, independence, and integrity of legislatures and to foster interstate cooperation and facilitate the exchange of information among legislatures.

Judy Lee is a North Dakota state senator from the 13th District. She has served in the state Senate since 1995 with focus areas on health and human services.

"Educational offerings through NCSL are regularly provided," Lee said. "There are webinars offered and also a national summit at which there are excellent national speakers and panelists. I always learn something good to bring back to North Dakota when I attend. The purpose of NCSL is for legislators to gather and share what works and what does not work at home, to hear presentations on multiple topics, and to provide many educational opportunities to staff members from each state."

"It leads to better policy in other states," Lee continued, "because we can always contact NCSL staff members or other legislators whom we have met and who had shared their programs."

This was an excellent opportunity to share with state-level decision makers the barriers that exist to accessing behavioral healthcare among rural residents.

"This was an excellent opportunity," Schroeder said, "to share with state-level decision makers the barriers that exist to accessing behavioral healthcare among rural residents. These are the conversations that can lead to strong, data-driven policy decisions that truly support the advancement of behavioral healthcare delivery in rural areas."

Assistance From Mountain Plains MHTTC

Mountain Plains MHTTC Originally, a request was made to the Substance Abuse and Mental Health Services Administration (SAMHSA) to speak to mental health in rural areas. SAMHSA is the funder for MHTTCs. The SAMHSA regional administrator contacted was unable to attend the meeting and deferred the request to Schroeder, who asked McLean to join her.

Both have worked with the Behavioral Health Bridge, a website focused on mental health. Schroeder has spent a decade focused on rural health, and McLean has clinical/integration of care/telehealth expertise.

"They were interested in policy, data showing the needs," said McLean. "Being able to present broad data was useful, looking at ways legislators can make changes to strengthen mental health, including enhancing resources, as well as trying to get more providers, and how to do things more efficiently."

Rural Needs

There are unmet needs for care in rural areas.

  • Among the 51.5 million adults age 18 or older with a mental illness in 2019, 26% (or 13.3 million people) perceived an unmet need for mental health services in the past year.
  • Among the 13.1 million adults aged 18 or older with a serious mental illness in 2019, 47% (or 6.2 million people) perceived an unmet need for mental health services in the past year.

Rural Barriers

Rural barriers to mental health services can be attributed to three areas:

  • Availability
  • Accessibility
  • Acceptability

Availability speaks to the low levels of mental health professionals working in counties that were more rural and had lower income levels. Workforce shortages are an issue across the country, but especially in large rural areas.

Accessibility refers to rural residents who may have limited access to mental healthcare. This may be due to cost of services, insurance coverage, and lower behavioral health awareness that allows mental health concerns to go unrecognized and/or untreated. In addition, the remote nature of living rural may require residents to travel long distances to receive services.

"Accessibility really is unique for rural areas," said Schroeder. "Issues around transportation go beyond needing to drive long distances to access the provider, but individuals who may be diagnosed with mental illness requiring a prescription may also need to frequently travel to the pharmacy. It can take a while to find the right dose and this may require several visits to the pharmacy which requires reliable transportation and time away from work and home."

Acceptability indicates how rural residents are often facing self-stigma, fear, or embarrassment when considering reaching out for mental healthcare. Persons living in rural areas may also struggle to recognize the signs of various mental health issues which can serve as barrier.

"A small community has to be more creative," McLean said, "in terms of who their champions are, who is able to step in. What expertise do you have locally, how to build on those strengths, and looking at what training needs are necessary for rural communities can go a long way to improving care."

Solutions Exist

Schroeder and McLean shared possible solutions states may want to explore. Ideas such as working with state licensing boards, scope of practice changes, current workforce adjustments, loan forgiveness, and telebehavioral health issues are areas where states have some latitude to find solutions that will work best for their residents.

"One of the barriers for states has been the rules," said McLean, "in terms of education and degree. These requirements vary from state to state, so one group in a state who is able to practice, see clients/patients, and be licensed, might not be able to in another state. That can be a significant barrier based on what the requirements are that licensing groups have. This can be managed by legislative change. We have gone through this process during every legislative session in North Dakota. If the associations and licensure groups aren't willing to make those changes that are reasonable, legislators are able to come in and say this is how we are going to do this differently. Reminding the legislatures that they have the power and authority to not only to work with those boards, but also make changes if changes aren't coming."

McLean continued, "There are ideas in terms of some of the loan-forgiveness programs, access, and wanting to 'grow your own.' There are public/private agreements that can be put into place to attract people to go into these areas. There are state loan- and national loan-forgiveness programs, but there isn't consistency. One of the things that has happened has been, for example, with the National Health Service Corps. There was a disincentive in terms of doing telebehavioral health because a provider had to be within a certain number of miles to get credit for the loan forgiveness. It would be great to have those people living in the communities, and that is the idea, but the next best thing is to be able to provide service to those communities. This is an example of loan-forgiveness rules that can be changed."

One of McLean's areas of focus has been working to assist rural practitioners with identifying and managing the care of individuals with mental health needs who may not rise to the level of needing to see a psychiatrist.

"Some of the collaborative care is simply doing things more efficiently. And spreading the wealth of experience and information."

He shared that one of the dilemmas when referring people automatically to see a mental health practitioner is that often the default is to send the patient to psychiatry. But that can cause a bottleneck of people who really need to see psychiatry. When a provider has someone to turn to and consult with, often there are resources within the clinic that can help the patient.

"Some of the collaborative care is simply doing things more efficiently. And spreading the wealth of experience and information," he said.

Tribes and Reservations

North Dakota, along with many other states that have Native American reservations within their borders, has an additional barrier to mental healthcare access. Schroeder shares, "Indigenous peoples are going to be presented with a dual disparity of both likely living rural and also lacking equitable and culturally responsive access to mental health services."

"One of the things our department has done," said McLean, "with the healthcare workforce initiative dollars is to increase our psychiatry residency numbers and focus on not only telepsychiatry training for those residents, but have them go out to those locations at least monthly. Part of that includes Tribal communities. There is a focus on getting to those communities."

Policy Changes

Policy changes through state governments do make a difference on behavioral health. Whether it be to allocate additional funding to expand the number of practitioners and trainees, and also to find innovative ways to incorporate loan forgiveness and incentivize people to go into behavioral health fields. Strengthening the workforce in addiction, social work, therapy, nursing, and medicine, can improve the barriers to receiving quality mental healthcare.

"These are areas in which legislators can make a difference," said McLean. "They can also change the scope of practice. One of the ways that has happened in North Dakota, was with physician assistants and nurse practitioners. In North Dakota and many other states, the nurse practitioners are considered licensed independent practitioners who don't require a collaborative agreement with physicians. Physician assistants still required that oversight by physicians."

"The legislature and licensing board agreed," McLean continued, "that they have many of the skills needed and allowed them to have a greater scope of practice so they can now prescribe medications they weren't previously allowed to prescribe, or practice in different ways. Removing some of those barriers, in a safe manner, is one of the ways legislators can instill change."

National recognition

The presentation was well received and several state legislators who were unable to attend have reached out to Schroeder asking questions and for the slide set.

"It was an honor for North Dakota and for Dr. McLean and Dr. Schroeder to be invited to present" said Lee, "and they did a wonderful job!"

Schroeder explained what is meant for North Dakota to be seen in front of a national audience.

We recognize the issues and concerns, and we can be innovative with some of the solutions.

"SAMHSA has a lot of respect for the work we are doing in North Dakota and at UND. They see the reach we have in rural, nationally, and see us as an expert in rural mental health," she said. "We recognize the issues and concerns, and we can be innovative with some of the solutions. It was an opportunity for us to say let's make some changes and see what we can do and be an example for other states with large rural and tribal populations."


Footnote: As of August 23, 2021, Dr. Shawnda Schroeder left CRH and is an assistant professor in the Department of Indigenous Health at UND SMHS. The Mountain Plains MHTTC will be moving to the UND College of Education and Human Development.

Jena Pierce Jena Pierce

is the Communications Manager at the Center for Rural Health at the University of North Dakota School of Medicine & Health Sciences in Grand Forks.