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Human Resource Issues in Rural Mental Health Services
Abstract
Human resource issues related to the provision of mental health care in rural areas under the proposed health care reform are addressed. Rural areas continue to utilize more non-specialty providers in the provision of mental health care. First, issues surrounding the training, recruitment, and retention of specialty mental health providers differ between urban and rural areas. Next, innovative strategies currently being used to attract and retain specialty providers to rural practice are presented. Finally, implications for expanding the knowledge base related to rural providers are explored.
... The rural characteristics of long distances and low population density might create challenges. Long travel distances can create transport challenges (2,8,47), and make it more difficult to handle crises (48) and perform outreach work (13,15,(49)(50)(51). This can be further complicated by challenging driving conditions (11,15) because heavy snowfall is common in Norway. ...
... Long travel distances can lead to time wastage (14), and increased costs (1,14). Sparsely populated areas can lead to fewer (1,4,47,52) and less specialized services (47), poorer access to professionals (2,4,6,16,47,(52)(53)(54)(55)(56)(57) and specialist expertise (4,12) as well as high staff turnover (54,56). Multidisciplinary teams can operate in rural areas (9,58), but care and treatment models are often developed for urban contexts (9,51,52). ...
... Long travel distances can lead to time wastage (14), and increased costs (1,14). Sparsely populated areas can lead to fewer (1,4,47,52) and less specialized services (47), poorer access to professionals (2,4,6,16,47,(52)(53)(54)(55)(56)(57) and specialist expertise (4,12) as well as high staff turnover (54,56). Multidisciplinary teams can operate in rural areas (9,58), but care and treatment models are often developed for urban contexts (9,51,52). ...
Background
Flexible assertive community treatment (FACT) is an innovative model for providing long-term treatment to people with severe mental illness. The model was developed in the Netherlands but is now used in other countries, including Norway, which has a geography different from the Netherlands, with many rural and remote areas. Implementation of innovations is context dependent. The FACT model's potential in rural and remote areas has not been studied. Therefore, we aimed to gain knowledge regarding the challenges and modifications of the model in rural and remote contexts and discuss how they can affect the model's potential in such areas. This knowledge can improve the understanding of how FACT or similar services can be adapted to function most optimally in such conditions. We sought to address the following questions: Which elements of the FACT model do team leaders of the rural FACT teams find particularly challenging due to the context, and what modifications have the teams made to the model?
Methods
Digital interviews were conducted with five team leaders from five rural FACT teams in different parts of Norway. They were selected using purposive sampling to include team leaders from some of the most rural teams in Norway. The interviews were analyzed using thematic text analysis.
Results
The following three themes described elements of the FACT model that were experienced particularly challenging in the rural and remote context: multidisciplinary shared caseload approach, intensive outreach and crisis management. The following eight themes described the modifications that the teams had made to the model: intermunicipal collaboration, context-adaptive planning, delegation of tasks to municipal services, part-time employment, different geographical locations of staff, use of digital tools, fewer FACT board meetings, and reduced caseload.
Conclusions
Rural and remote contexts challenge the FACT model's potential. However, modifications can be made, some of which can be considered innovative modifications that can increase the model's potential in such areas, while others might move the teams further away from the model.
... Long travel distances can create transport challenges [2,8,37] and make it more di cult to handle crises [38] and perform outreach work [13,15,[39][40][41]. This can be further complicated by challenging driving conditions [11,15] because heavy snowfall is common in Norway. ...
... Long travel distances can lead to time wastage [14] and increased costs [1,14]. Sparsely populated areas can lead to fewer [1,4,37,42] and less specialized services [37], poorer access to professionals [2,4,6,16,37,[42][43][44][45][46][47] and specialist expertise [4,12] as well as high staff turnover [44,46]. Multidisciplinary teams can operate in rural areas [9,48], but care and treatment models are often developed for urban contexts [9,41,42]. ...
... Long travel distances can lead to time wastage [14] and increased costs [1,14]. Sparsely populated areas can lead to fewer [1,4,37,42] and less specialized services [37], poorer access to professionals [2,4,6,16,37,[42][43][44][45][46][47] and specialist expertise [4,12] as well as high staff turnover [44,46]. Multidisciplinary teams can operate in rural areas [9,48], but care and treatment models are often developed for urban contexts [9,41,42]. ...
Background: Flexible assertive community treatment (FACT) is an innovative model for providing long-term treatment to people with severe mental illness. This model was developed in the Netherlands but is now used in other countries, including Norway, which has a complex and fragmented service system and geography different from the Netherlands, with many rural areas. Implementation of innovations is context-dependent. The FACT model’s potential in rural areas, such as those in Norway, has not been studied. Therefore, we aimed to gain knowledge regarding the challenges and modifications of the model in rural contexts and discuss how they can affect the model’s potential in such areas. This knowledge can improve the understanding of how FACT teams or similar services can be adapted to function most optimally in rural conditions. We sought to address the following questions: Which elements of the FACT model do team leaders of the rural FACT teams find particularly challenging due to the context, and what modifications have the teams made to the model?
Methods: Digital interviews were conducted with five team leaders from five rural FACT teams in different parts of Norway. They were selected using purposive sampling to include team leaders from some of the most rural teams in Norway. The interviews were analysed using thematic text analysis.
Results: The following three themes described the elements of the FACT model that were experienced as particularly challenging in the rural context: multidisciplinary shared caseload approach, intensive outreach and crisis management. The following eight themes described the modifications that the teams had made to the model: intermunicipal collaboration, context-adaptive planning, delegation of tasks to municipal services, part-time employment, different geographical locations of staff, use of digital tools, fewer FACT board meetings and reduced caseload.
Conclusions: Rural contexts appear to challenge the FACT model’s potential. However, modifications can be made, some of which can be considered innovative modifications that can increase the model’s potential in rural areas, while others might move the teams further away from the model. There appears to be a limit to the length of travel distances and sparsity of population for the FACT model to function.
... Merwin et al. [2] proposed two important strategies in addressing equitable distribution. These were the retention of current staff (i.e. ...
... The South African National Mental Health Plan [2] defines primary healthcare in accordance with the Alma Ata Declaration: 'essential health care made accessible at a cost a country can afford, with methods that are practical, scientifically sound and socially acceptable. ' The province could adopt the model implemented in Kenya, a lowmiddle-income country, for strengthening primary healthcare by the provision of training of staff in mental health. ...
p> Objectives. Part I of this research paper presented a needs and gap analysis for the management of schizophrenia, bipolar mood disorder and major depression for the Eastern Cape Province, South Africa. It identified deficits and inequitable distribution of human resources and beds in the province. In this article, Part II, the authors propose a plan for public sector mental health services to address the human resource needs in the poorer eastern regions of the province. The plan focuses on human resource training and development.
Methods. Evidence-based data on staff development in mental health from low-middle income countries were utilised to develop strategies to increase staff capacity to address unmet need. A financing model with a poverty index was developed to sustain a needs-based plan. Databases searched included Pubmed, Medline, Google and Google Scholar. The key words used included: mental health, mental health training, mental health resources, mental health in low-middle-income countries, mental health policy and plans, mental health needs- based planning, primary healthcare, primary mental healthcare, mental health financing. In addition the websites of the World Health Organization and the World Psychiatric Association were searched for similar resources.
Conclusions. It is feasible, with careful attention to planning and implementation of evidence-based tools, to improve public mental health service delivery in this province. Sustained political will and professional commitment will ensure successful delivery of mental health services in a resource-limited province.</p
... Using data from the National Comorbidity Survey conducted in 212 countries across the country with balanced rural and urban repre- sentation, Diala et al. (2004) found that alcohol and drug dependence in the workplace appears to be comparable across geographic regions. Even though rates of alcohol use and illicit drugs, as well as the related disability they cause, are roughly equivalent in rural and urban areas, behavioral health services in general are hard to access in rural areas compared to non-rural areas (Badger, 1999; Goldsmith, 1997; Hauenstein, 2006; Merwin, 1995; Muntaner, 1998). This disparity also exists for addiction treatment services (Bird, 2001; Booth et al., 2000; Fortney et al., 1995; Hagopian, 2000; Holzer et al., 1998; Institute of Medicine, 1990; Mick et al., 1993). ...
... Because of the lack of treatment availability. rural areas utilize more non-specialty providers in the provision of mental health care (Merwin et al., 1995 ). As an alternative, a high percentage of patients with addiction and other mental health problems may seek out their primary care physicians who may be ill-equipped to treat them effectively (Pollitt, 2000). ...
... Merwin et al. [2] proposed two important strategies in addressing equitable distribution. These were the retention of current staff (i.e. ...
... The South African National Mental Health Plan [2] defines primary healthcare in accordance with the Alma Ata Declaration: 'essential health care made accessible at a cost a country can afford, with methods that are practical, scientifically sound and socially acceptable. ' The province could adopt the model implemented in Kenya, a lowmiddle-income country, for strengthening primary healthcare by the provision of training of staff in mental health. ...
Objectives. Part I of this research paper presented a needs and gap analysis for the management of schizophrenia, bipolar mood disorder and major depression for the Eastern Cape Province, South Africa. It identified deficits and inequitable distribution of human resources and beds in the province. In this article, Part II, the authors propose a plan for public sector mental health services to address the human resource needs in the poorer eastern regions of the province. The plan focuses on human resource training and development. Methods. Evidence-based data on staff development in mental health from low-middle income countries were utilised to develop strategies to increase staff capacity to address unmet need. A financing model with a poverty index was developed to sustain a needs-based plan. Databases searched included Pubmed, Medline, Google and Google Scholar. The key words used included: mental health, mental health training, mental health resources, mental health in low-middle-income countries, mental health policy and plans, mental health needsbased planning, primary healthcare, primary mental healthcare, mental health financing. In addition the websites of the World Health Organization and the World Psychiatric Association were searched for similar resources. Conclusions. It is feasible, with careful attention to planning and implementation of evidence-based tools, to improve public mental health service delivery in this province. Sustained political will and professional commitment will ensure successful delivery of mental health services in a resource-limited province. © 2015, South African Medical Association. All rights reserved.
... Academic issues are also part of the problem in recruiting as mental health professionals are often poorly prepared to practise in isolated regions during their training. Most professionals are trained exclusively in urban centers, and their training does not include the needs and realities of practice in rural contexts (Gamm, 2004 ;Merwin, Goldsmith, & Manderscheid, 1995 ). ...
Most models of mental health services have been developed in urban centres, with large populations and many specialized resources. Rural and remote communities pose challenges to these models for reasons of geography, social structure and culture. In Canada and other countries, rural and remote communities include a high proportion of Indigenous peoples, with important cultural differences from the urban population. In this chapter, we discuss the role of cultural consultation in providing mental health services for remote and rural communities, with an emphasis on the mental health of Indigenous peoples in Canada. The authors have worked as psychiatric consultants to First Nations and Inuit communities in Northern Quebec and draw from this experience and the work of the CCS to outline key issues for cultural consultation in this setting. The major social determinants of health and contextual factors that are distinctive for remote communities and Indigenous populations are reviewed. Models of service discussed include: onsite delivery of mental health services through collaborative care models; itinerant consultants; telepsychiatry; and satellite services. Mental health services for Indigenous communities need to be provided in culturally appropriate ways, both through supporting the use of traditional healing approaches and ensuring that mainstream mental health services are culturally safe and competent.
School violence has emerged as a critical issue in the U.S. today. While the focus was traditionally on urban school and gangs, recent shootings in suburban and rural schools has brought attention to non-urban school settings. This is a study of a rural, multicultural state with a high at-risk youth population. New Mexico has the highest Hispanic population (38%) as well as a high American Indian representation (22 different tribes). Ranking high in youth violence, substance abuse, poverty, teen pregnancies, and with a significant school drop-out rate, a multicultural intervention effort was initiated to address this phenomenon. The program involves cutlural-centric approaches involving families, schools, and the juvenile justice system.
Health care has lagged behind most industries and businesses in its adoption of information and communication technologies (ICT). Many of the current information technologies and those to be deployed and developed over the next few years (e.g. electronic health records, telehealth applications, elearning technologies, social networking via Web 2.0) could be of benefit in health care delivery and improvement of the quality, efficiency and effectiveness of health care services. The uses of technology in human resources management (HRM) can help improve the medical care that health professionals provide to their patients. For instance, technology can be used to maximize communication, collaboration and support between health professionals separated by distance, as well as provide immediate and up-todate patient care information. ICT can also be used for distance training and education for those facing geographic isolation and provide a medium through which continued education can be maintained for both rural and urban health professionals. However, due to the differences in barriers to ICT use found for each group, such as computer illiteracy, geographic isolation or poor infrastructure, different steps need to be taken in order to ensure the successful implementation and use of information technologies in both urban and rural communities in developed and developing regions across the world.
The Deep South has seen a 36 percent increase in AIDS cases while the rest of the nation has seen a 2 percent decline. Many of the underlying reasons for the disease’s continued spread in the region—ignorance about HIV, reluctance to get tested, non-adherence to treatment protocols, resistance to behavioral changes—remain unaddressed by policymakers. In this extensively revised second edition, Kathryn Whetten and Brian Wells Pence present a rich discussion of twenty-five ethnographic life stories of people living with HIV in the South. Most importantly, they incorporate research from their recent quantitative study, “Coping with HIV/AIDS in the Southeast” (CHASE), which includes 611 HIV-positive patients from North Carolina, South Carolina, Georgia, Alabama, and Louisiana. This new edition continues to bring the participants’ voices to life while highlighting how the CHASE study confirmed many of the themes that originally emerged from the life histories. This is the first cohesive compilation of up–to–date evidence on the unique and difficult aspects of living with HIV in the Deep South. © 2013 by Kathryn Whetten and Brian Wells Pence. All rights reserved.
We describe characteristics of psychologist availability in rural, nonmetropolitan statistical areas in 1970 and 1981 to assess changes in distribution over time, using the listings in the
Directory of the American Psychological Association (1970 and 1981 editions). The number of rural psychologists increased 97% from 1970 to 1981, increasing significantly in all regions. The number of psychologists overall in rural areas may be an overestimate of actual availability because of the large percentage of rural psychologists living in the relatively few rural counties with schools providing graduate degrees in psychology. Rural distribution lags that in metropolitan areas in every region. The relevance of findings is noted with regard to recent changes in Medicare reimbursement, proposed Minimum Health Care legislation, mental health needs and demographics in rural areas, personnel shortages, and rural psychologists' roles. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
present comparable information on the size and characteristics of each of the four core [mental health] disciplines / psychiatry / psychology / social work / psychiatric nursing
addresses two types of human resources: clinically trained mental health personnel—active professionals who, because of recognized formal training and/or experience could perform direct clinical mental health care, whether or not they are doing so at present / clinically active mental health personnel—those professionals who are currently engaged in the provision of direct clinical mental health care
demographic and training characteristics / professional activities (PsycINFO Database Record (c) 2012 APA, all rights reserved)
• Building on a previous study, this report explores in more detail one aspect of the "de facto mental health services system," the treatment of mental disorders by nonpsychiatrist physicians in office-based practice. Data from the 1980 and 1981 National Ambulatory Medical Care surveys indicate that almost one half of all office visits to a physician resulting in a mental disorder diagnosis are to nonpsychiatrists, mostly in primary care. Nonpsychiatrists' mentally ill patients tend to be less seriously ill than patients of psychiatrists, and are more likely to come in with physical problems. They are also significantly more likely to be female, to be nonwhite, and to be elderly. Physicians treating these patients appear to be providing a different product than psychiatrists are, spending less time with patients, but using a wider range of diagnostic and therapeutic services during each office visit.
We describe characteristics of psychologist availability in rural, nonmetropolitan statistical areas in 1970 and 1981 to assess changes in distribution over time, using the listings in the Directory of the American Psychological Association (1970 and 1981 editions). The number of rural psychologists increased 97% from 1970 to 1981, increasing significantly in all regions. The number of psychologists overall in rural areas may be an overestimate of actual availability because of the large percentage of rural psychologists living in the relatively few rural counties with schools providing graduate degrees in psychology. Rural distribution lags that in metropolitan areas in every region. The relevance of findings is noted with regard to recent changes in Medicare reimbursement, proposed Minimum Health Care legislation, mental health needs and demographics in rural areas, personnel shortages, and rural psychologists' roles.
Examined the correlates of the distribution of psychiatrists, psychologists, and social workers across US counties using econometric and descriptive statistical methods. Results show that the majority of counties had either none or very few of the 3 mental health provider groups considered. The distribution of all 3 groups was significantly and positively associated with the availability of liberal mental health insurance benefits, the percentage of the population with some college education, and the percentage of the population between the ages of 20 and 64 yrs. (46 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
A classification of nonmetropolitan counties based on type of economy, socioeconomic level, and land use was applied to inpatient psychiatric services data of the National Institute of Mental Health. The scarce inpatient mental health services in nonmetropolitan areas were located mostly in nonfederal general hospitals in specialized-government and manufacturing-dependent counties. (KS)
Results of a survey of 177 members (mean age 39.7 yrs) of the North Carolina Chapter of the National Association of Social Workers show that social work practice between rural and urban settings did not differ significantly. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Identifies a process similar to cultural shock encountered when mental health professionals left urban settings for a rural New Hampshire community. Initial euphoria was followed by depression as workers endured loss of city resources and slow community acceptance. Colleagues experienced increased need for staff support in adjusting to professional isolation, lessened applicability of the urban psychoanalytically oriented therapy model, loss of therapist anonymity and formality, and loss of personal privacy and ability to exercise control over social contacts. Staff reaction produced greater openness and sharing which was both supportive and growth-producing. Public relations work with stress on consultation and education produced community receptivity to constructive change after an initial testing period. Effective communication and the ability to function independently are essential in working with the staff and community in rural areas. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
emphasize the concept of substitution in production and the opportunities for research associated with this way of thinking about mental health care provision systems
implications . . . for research and policy relevant to the supply, distribution, and reimbursement of mental health specialists are considered in some detail (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The paper describes the changes produced in the practice of dynamic psychotherapy when conducted within a circumscribed region. The authors discuss changes in anonymity, roles, and transference relationships for both therapist and patient. The paper demonstrates these effects on the therapist's professional training, his practice, and his family.