Developing a Digital Web to Address Behavioral Health Disparities in Rural New York State

Background:

There is a behavioral health care crisis in rural America. The Substance Abuse & Mental Health Services Administration reports that 1 out of 5 residents of nonmetropolitan United States counties had some sort of mental illness. Meanwhile, more than 60% of rural Americans live in mental health professional shortage areas. Tragically, the economic decline that fuels despair and need for behavioral health care in many remote settings also reduces its availability. In upstate New York (NYS), our rural counties are among the hardest hit in these regards, following years of economic downturn and the outmigration of jobs. Over the last decade, the number of suicides in NYS increased by 32% (to over 1,700 per year). At the same time, rural cultural mores – including values on independence, caring for oneself and one’s own, and stigma around behavioral health – can create obstacles to seeking care.

Wicked Problem Description:

In rural Allegany County, we have a distinct wicked problem at this nexus of spiraling mental health need/suffering and a deep lack of access to resources including behavioral health care. 18.4% of the County’s population lives below the federal poverty level, and household income levels are among the lowest in the state. We are experiencing:

• Suicide rate at 14.7 per 100,000 – 8% above NYS overall
• Opioid overdose rate at 46.4 per 100,000 – 9% above NYS overall
• Alcohol-related motor vehicle injury & death rate at 11.9 per 100,000 – double NYS average
• Medicaid Potentially Preventable Emergency Visits for behavioral health symptoms rate at 48.4 per 100 – 7% above NYS overall

Extremely limited access to mental health services:

• Designated Federal Mental Health Provider Shortage Area
• Help seeking at small community hospital & behavioral health clinic
• Long wait times (up to 3 months) for outpatient care creates overutilization of emergency department and transfers out of community
• Many residents forgo care leading to unneeded suffering, premature institutional care, or early mortality or suicide
• Family caregivers try to take up the slack, too often with resulting economic hardship, loss of employment, and distress

Project Strategies:

We will address this wicked problem by leveraging the expertise of our team members and technology to create a “Digital Web” linking Allegany County community partners with behavioral health expertise. The Digital Web will engage all members of the community, reduce health disparities, and improve the quality of behavioral health care and support received by individuals, families and caregivers. Our community engagement plan will directly involve all parts of the community. We will equip community providers with the knowledge, skills, and comfort level to treat patients with complex behavioral health needs through the University of Rochester Project Extension for Community Healthcare Outcomes in General Psychiatry (ECHO® PSYCH). Using videoconferencing technology, this telementoring program will systematically connect our interdisciplinary team members and other University of Rochester psychiatric experts with community partners.

We will also offer community residents, families, and caregivers with greater access to behavioral health services by embedding a psychiatric assessment officer (PAO) into Jones Memorial Hospital, and providing expert consultation through telepsychiatry. The PAO will conduct psychiatric evaluations, collect patient reported outcomes, and provide brief crisis interventions. The PAO will also help facilitate a smooth transition of care across the community’s primary care network and social service organizations. For those community members that require a higher level of care, telepsychiatry will be provided by University of Rochester psychiatrists and psychiatric nurse practitioners. The telepsychiatry service will continue in Jones Memorial Hospital for the first year of the project with plans to expand the service into Allegany Rehabilitation Associates and primary care in years 2 and 3.

Outcomes:

Specific objectives of this project are to provide Allegany Rehabilitation Associates, Jones Memorial Hospital, and community primary care providers located in Allegany County with (1) capacity, knowledge and decision support, and, (2) the patients, families, and caregivers served by these providers with increased access to specialty behavioral health consultation services through a technology driven integrated care delivery system.

Timeline:

Engagement of Community Partners (0 to 6 months)

1. Elicit community engagement
2. Identify community stakeholders (i.e. housing, transportation, social services etc.)
3. Develop a community advisory board
4. Development of community policies and procedures

Adoption and Demonstration of the Digital Web (6 to 24 months)

1. Integration of patient reported outcomes into Jones Memorial Hospital and Allegany Rehabilitation Associates clinical workflows
2. Development of clinical dashboards
3. Establishment of ECHO® PSYCH program
4. Continuation of telepsychiatry in JMH

Expansion of the Digital Web (24 to 36 months)

1. Integration of patient reported outcomes into primary care
2. Development of clinical dashboards for primary care
3. Expansion of ECHO® PSYCH program into additional community organizations
4. Collection of quantitative and qualitative project impact data

Standardization and Dissemination of the Digital Web (30 to 36 months)

1. Draft final project report
2. Present findings to community advisory board
3. Disseminate the Digital Web framework through multiple modalities
4. Explore expansion of the Digital Web to other rural regions in NYS
5. Achieve sustainability

Partnerships:

The University of Rochester in collaboration with Allegany Rehabilitation Associates will lead the engagement of Allegany County community stakeholders. We already have a formal affiliation with Jones Memorial Hospital, and the Jones Memorial Hospital Primary Care Network. An advisory board of these key community stakeholders including acute care, primary care, long term care, transportation, and housing will be established to guide the development, implementation, and dissemination of the Digital Web on the community at large.

Evaluation Strategies:

We will conduct formative and summative evaluations using a mixed methods design to examine the impact of the Digital Web on the community. The evaluation has four primary aims:

1. To examine the extent to which the Digital Web impacts quality of care for the patient population presenting to Jones Memorial Hospital
2. To examine the extent to which the Digital Web impacts high cost health care utilization
3. To examine the extent to which the Digital Web impacts experience of care for individual patients through patient reported outcomes
4. To examine the extent to which the Digital Web impacts provider and clinician satisfaction working in the community