Disparities in Mental Health ServicesBetween Urban and Rural Communities

In Washington State

Anne Strode and John Roll

Methods

• Review of literature and data from national, state, and local sources

• Interviews with providers and consumers

2006 Estimated Washington State Population

Urban Rural Total

Eastern 900,400 5ll,700 1,412,100 (22%)

Western 4,342,900 620,600 4,963,500 (78%)

Total 5,243,300 (82%)

1,132,300 (18%)

6,375,600 (100%)

Source: Office of Management and Budget

Services Disparities • Ten percent of the average daily census of Eastern and

Western State Hospitals was composed of consumers from rural RSNs. Average length of stay was slightly less than nine days for both urban and rural consumers.

• Four percent of the average daily census for all community inpatient hospital stays for psychiatric care was composed of consumers from rural RSNs.

• There are four Children's Long-Term Inpatient Programs serving the most severely emotionally disturbed children in the State – all in urban areas of the State.

Services Disparities • Hospitalization rates for all mentally ill in isolated rural

areas were 7 per 1000 individuals, compared with 13 hospitalizations per 1000 individuals in the urban core.

• Treatment days (length of stay) in isolated rural areas were about 51 percent of the number of treatment days in the urban core areas.

• Hospitalization rates for severely mentally ill in rural areas were 34 percent (two versus six discharges per 1000 individuals) of those of urban core areas.

Services Disparities • Hospitalization rates for individuals with chemical

dependency in isolated rural areas were about 76 percent of those in urban core areas.

• Hospitalizations for those with co-occurring disorders (chemical dependency and mental illness) in isolated rural areas were about 67 percent of those from urban core areas).

• The average number of individual outpatient treatment hours was almost 6.6 hours less in rural areas and 8.4 less in rural Eastern Washington

Workforce Disparities • Urban areas have three times more psychiatrists per

100,000 population and more than 1.5 times non-psychiatrist mental health providers per 100,000 than rural areas.

• Twelve rural and zero urban counties had at least 40 percent unmet workforce needs.

General Barriers to Service • Lack of health care providers, specialty providers and

bi-lingual providers;

• Limited public and personal transportation and long distances to services;

• Limited funding for public mental health services;

• Strict Access to Care Standards;

• Insufficient inpatient bed capacity (crisis, evaluation and treatment, children's and adult's longer term beds);

• Lack of evidence based practices designed for rural areas;

• Over reliance on law enforcement.

Recommendations• Ensure there are adequate inpatient beds for adults and

children in rural Washington.

• Increase the number of community outpatient mental health providers in rural areas.

• Allow providers flexibility in implementing evidence-based practices.

• Allow rural providers transportation subsidies to reach isolated consumers.

• Expand education programs for rural mental health professionals. (also primary care physicians)

Recommendations• Support the efforts of statewide professional organizations

to provide interdisciplinary distant learning, telehealth and telemedicine opportunities.

• Support research and collaboration to develop new evidence-based practices specifically designed for rural areas.

• Continue support of early detection and prevention programs for infants, youth and adults.

• Develop ways to work with law enforcement (including criminal justice & prosecution systems) and local providers to treat mentally ill people without criminalizing them by providing more training within the adult and juvenile justice systems.

Recommendations• Explore a mechanism to allow rural counties access to

State-Only dollars to serve the working class poor when they are in need of mental health services, but unable to meet Access to Care eligibility criteria.

• Support housing and employment programs for mentally ill consumers in rural areas.

• Where practical, co-locate primary care and mental health treatment practitioners to provide a holistic approach to treatment.

• Study the implications of expanding prescriptive authority of providers of mental health services by assessing the experiences of other states’ and the U.S. military.