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Home Grown Providers in Rural Integrated Care: The Web of Interconnectedness

Posted By Catherine Jones-Hazledine, Thursday, January 31, 2013
Updated: Monday, February 4, 2013
Rural blog series logo
Cate's blog is the
last post in a
month-long series
on integrated
care in rural settings.


Read the entire
series here.

 

Much has been written about the advantages of integrated or co-located behavioral health care in rural primary care settings. At this point, most in the field understand the practical benefits of this model, especially in our most rural and underserved areas. There is a growing understanding, as well, that there are many factors to consider in successfully implementing this model. Dr. Joe Evans and Dr. Rachel Valleley wrote very eloquently about some of these in a blog post earlier this month. And they would know. Over the years, they have worked to establish these services in many settings across our 99% rural, and 87% underserved state of Nebraska. I would like to think of myself as one of their success stories.

Almost 9 years ago now, after working with the Munroe-Meyer Institute Rural Outreach Program for two years as an intern, and obtaining my Ph.D. in Psychology, I made the decision to return to my own home area of the state. Dr. Joe Evans and Dr. Jodi Polaha were instrumental in helping make that happen. We originally established three integrated behavioral health clinics within primary care settings in small, isolated communities along Hwy 20 in the far northwestern corner of Nebraska. Our services were well received by the local family physicians and over the next few years the three clinics grew to five, and ultimately turned into a privately-owned network of clinics called Western Nebraska Behavioral Health.

Over these years, as well, we began to take on practicum students and interns from a small nearby college. These students were mostly Nebraska natives, many from the immediate area, who were training to receive a Master’s Degree in Community Counseling. Many of them ended up staying on with the clinic network after graduation, with the result that several of our clinicians, myself included, now find ourselves working in our home communities – a fact that has proven to add many layers to the collaborative care/integrative care model.


How many Master’s or
Ph.D. level clinicians
are dying to move to
Cody, Nebraska,
population 155?

One of the challenges of rural practice highlighted in another blog earlier this month (by Alysia Hoover-Thompson and Natasha Gouge) is the amount of turnover among those who decide to go into the area of rural integrated care. It is an unfortunate fact that many initial placements of clinicians into rural areas across the nation do not last much past the training phase or, as the authors indicated, the loan repayment phase. This obviously happens for many reasons: family obligations, spousal careers, health issues, financial concerns, lack of resources and support. One fact that contributes to the problem, I think, is that most of our training facilities for clinicians – especially doctoral level clinicians – exist in urban (or at least more urban) areas. As a result, individuals can be identified who express rural interest or commitment, but many of them are not actually from, or familiar with, truly rural settings. Even those who are from rural settings end up living for an extended period in the urban area to complete their training, and develop ties there that make it more difficult to jump out to a rural setting when the time comes.

Our real-life rural settings have many advantages: clean air, simplicity of life, wide-open spaces, good people. They also, however, have many peculiarities that make them challenging for those not accustomed to the lifestyle: lack of resources, lack of anonymity and privacy, distrust of outsiders, sometimes a slowness to open to new ideas, etc. Rural individuals exist in a web of interconnectedness that those from larger areas are often simply uncomfortable with. I once attended a meeting of psychologists at which a provider in a larger community was telling about the awkwardness of going to a home improvement store on a weekend, dressed casually and unshowered, only to run into a client. This was a rare event to hear about for many of the providers at the meeting, but our contingent was struck by surprise that it had only happened once to that provider. In our own rural area, it is the case that we rarely leave our homes without seeing a client or member of a client family

We see our clients outside of session more here because the population and communities are so small, and this issue would occur for us regardless of where we were from. Being originally from the area ourselves means that we are also more likely to know our clients or patients before they come to see us, or have some other level of connection to them. This web of connections is not limited to client connections, either.

Several years ago, I was contacted by a local woman who was in the process of getting her degree in community counseling (from the small local college I mentioned) and needed a practicum placement. I recalled that many years before that, when I was a middle school student and she was a precocious preschooler, our families had been next door neighbors. Further, her father (now retired) was my dentist, her older brother and my younger brother were very good friends in high school, her sister-in-law ran a local daycare that my children had attended as infants, and her nephews were in the same grade and school as my own children. None of these connections were close enough that it felt problematic to train the student, and few other options were available to her, and so she ultimately did a practicum placement, a pre-master’s internship, and an advanced training placement to accrue licensing hours within our clinic. Further, she continues on with us to this day - providing services in a clinic just blocks from where she used to run through my yard as a preschooler, pretending to be a horse. Having so many connections locally, she has no plans of living anywhere else. She is also well versed in the challenges of rural life, and very comfortable with that web of interconnectedness.

This clinician’s story is a common one in our clinic at this point, and it definitely raises issues to consider. It frequently occurs that our collaborating physicians refer a patient to us that one or more of our clinicians has some other connection (current or historical) to. This requires careful thought and supervision about the closeness of the connection, and any way in which it might be ethically problematic. A large number of our referrals end up being cases that, were we in an urban area, would be referred to another provider due to the additional connection. There is a fabulous model that we often refer to by Kitchener (1988) that helps us determine which connections are too close to be ethical for us to work with. This is an ongoing area of thoughtfulness in our work.

Some consider these multiple levels of connectedness to be a serious drawback in rural work. I remember hearing in graduate school the recommendation that if you were to work in a rural setting you should not live in the same community. Or, if you did live there, you should refrain from participating in local life (communities, organizations, etc). Being from a rural area myself, this struck me as silly. I remember thinking about most of my rural neighbors growing up, and realizing how they would perceive someone who kept themselves so distant from the community they meant to serve. Now, being in practice here for several years, I can tell you anecdotally that it is often the case that individuals come to see us BECAUSE we are known to them. There are many conservative rural residents who would be unlikely to seek "behavioral health” or "mental health” services (even at their physician’s recommendation) but who end up following through because the identified clinician is "Gene and Carol’s daughter” or was in their brother’s graduating class. We are a known, and therefore often a more trusted, quantity. Because they exist all the time within a closer web of connections, our rural clients are also just naturally more comfortable with the additional connections and casual interactions that occur outside of clinic.

Summarizing all of this thought, then, it seems that another key to the successful establishment of integrated behavioral health in rural settings involves greater recruitment of local individuals, as well as training of these individuals from the beginning within the rural settings they will eventually practice in. Not only does this seem likely to reduce turn-over and offer better preparation for real-life work scenarios, but it also provides additional job opportunities for rural individuals – thereby reducing the problems of de-population, unemployment and poverty in rural settings.

So positive have our experiences been of training locally raised clinicians, that we have recently taken things a step farther. Working with support from BHECN (the Behavioral Health Education Center of Nebraska) we have designed a program to help identify and mentor rural high school students in particularly isolated areas who have an interest in behavioral health careers. By catching them early in their education, we hope to help provide a pathway for them to access the training to eventually provide much-needed services in their home communities –spots that would have considerable difficulty drawing trained providers. How many Master’s or Ph.D. level clinicians, after all, are dying to move to Cody, Nebraska, population 155? It will be some time before we have available data to tell how successful this approach is, but we are excited to find out!

References:

Kitchener, K.S. (1988). Dual role relationships: What makes them so problematic? Journal of Counseling and Development, 67, 217 – 221.



Dr. Catherine Jones-Hazledine is a psychologist and the owner of Western Nebraska Behavioral Health, PC, a network of five integrated behavioral health clinics in rural western Nebraska which are affiliated sites with the University of Nebraska Medical Center’s Munroe-Meyer Institute Rural Outreach Program. She is also adjunct faculty with Chadron State College, in Chadron, Nebraska.

 


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Matthew P. Martin says...
Posted Tuesday, February 5, 2013
Terrific post. It seems that Dr. Jones-Hazledine has completely embraced the inevitable interconnectedness that comes from working in rural health care. And she is right that there is a lot of value in thoughtfully embracing such a situation. I group in a small town in Pennsylvania and received my health care from a husband and wife physician-team who were loved and respected by the entire community. That kind of relationship can become part of the healing power that we as health professionals can engender. I myself am very much attracted to the idea of working in a rural area, not only for the sake of raising a family in such a surrounding but also because of the satisfaction that can come from feeling so close to your patients. I wonder if the discomfort that behavioral health providers feel in rural care is not shared by patients, kind of like a one way street. Early training of psychotherapists in rural settings seems to be an excellent way to approach that discomfort. Keep up the good work!
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