Recruiting the Next Generation of Behavioral Health Professionals

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Tom Haederle
The shortage of health care workers in America is not news, but the shortage of behavioral health care professionals is especially acute. And that's even truer in rural areas. As one expert says, If you thought it was bad before the pandemic, we've got a new definition of dire over the past two and a half years. But the scarcity of qualified professionals hasn't stopped some rural care providers from recruiting, training and retaining behavioral health specialists with some success.

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Tom Haederle
Welcome to Community Cornerstones: Conversations with Rural Hospitals in America. A new series from the American Hospital Association. I'm Tom Haederle with AHA Communications. The state of Iowa didn't have a reputation as a magnet for psychiatrists or other mental health professionals just starting out on their careers. But in recent years, Iowa has chosen to fund the expansion of psychiatric residency programs, now numbering about 20 across the state.

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Tom Haederle
Iowa is investing in the training and retention of future psychiatrists who want to be change agents and who are passionate about working with underserved populations. Hear how it's all working out in this podcast discussion.

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Rebecca Chickey
Hi, this is Rebecca Chickey, senior director of behavioral health services for the American Hospital Association. And it's my honor today to be joined by Dr. Jodi Tate, who is the clinical professor, as well as vice chair for education and director of the Intellectual Disabilities and Mental Illness Program at the University of Iowa Health Care in Iowa City, Iowa.

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Rebecca Chickey
Jodi, thank you for being here with us today. I had the honor, since I'm at the AHA Health Care Rural Leadership Conference, being on a work session where you spoke about improving behavioral health workforce and services in a rural state. I have to tell you, the room was packed because if we thought the shortage of behavioral health workers prior to COVID was dire, we got a new definition of dire in the last two and a half years.

00;02;06;27 - 00;02;24;05
Rebecca Chickey
So for the benefit of the listeners and those who aren't here at the Rural Leadership Conference, could you describe for me, can you tell me about how you have expanded the psychiatric residency programs, particularly in the rural parts of Iowa?

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Jodi Tate
Well, thank you very much for having me. And we are very lucky in the state of Iowa that our government has been extremely supportive in expanding our residency program into rural parts of the state. And in 2019, our governor allocated funds to expand our residency program. And Dr. Shay Jorgensen, who was a resident when this was all going down, has taken on the lead and has developed a rural psychiatry track from our in our residency program.

00;03;01;08 - 00;03;32;24
Jodi Tate
And she graduated from the University of Iowa and moved to Mason City. She grew up in rural Iowa, and her dream was to return to rural Iowa. But she wanted to have a connection with academic medicine and expand psychiatry throughout the state. So she has been a trailblazer in making that happen. And this is the third year where she has two residents per year in the psychiatry residency program.

00;03;33;14 - 00;04;04;02
Jodi Tate
And so that's going amazingly well. She is also single handedly developing substance use treatments and treatments in rural Iowa with her connections. And so we she's gotten that off the ground. And then our state last year provided more funding to expand our residency training program even further, funding for up to 12 additional residents per year, which is huge.

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Jodi Tate
Right now we have nine per year, phenomenal. And so I was in a different position when this funding came down and I was very excited about the possibilities of changing psychiatry across the state of Iowa and improving services to underserved populations wherever they are. And I went to medical school in a rural state and spent time in rural areas and had that experience as well.

00;04;31;18 - 00;05;02;19
Jodi Tate
So I'm trying to figure out how to expand our residency program even further, which is challenging because part of the state appropriation bill that funds this new addition mandates that the residents spend time in locations that are in rural Iowa. It's a mandate. And many of these specific locations where they mandate that we have to be ... there isn't the capacity, there aren't physicians or there's not the capacity of the current physicians to have residents.

00;05;02;22 - 00;05;23;23
Jodi Tate
So they have the capacity to teach the residents. So we wouldn't be able to receive ACGME accreditation to expand our residency training program. So we're having to be really creative about how we go about doing that. And the thing that I have learned through this process in meeting with folks at these institutions is everyone is passionate about this.

00;05;23;23 - 00;06;04;01
Jodi Tate
Everybody wants to improve psychiatric care, but there's just a limited resource. So what we've decided to do is to develop a public psychiatry fellowship program in Iowa, and there are about 20 public psychiatry fellowship programs across the state, and most of these are in urban areas. So not sure how it's going to go in a rural area, but I'm very hopeful that it will be successful. The way that the Public Psychiatry Fellowship works in with expanding the residency is that these fellows will have graduated residency program already so they can practice independently and they can supervise residents.

00;06;04;18 - 00;06;55;23
Jodi Tate
The fellowship gives them extra training and exposure to learning more about our health care system, learning more about being a change agent, about social determinants of health and our hope is that we recruit psychiatrists to do this fellowship that are really passionate about underserved populations and who will be future change agents in improving our health care system. And these fellows would spend time at these sites that are mandated for our residents to be, and then we'd slowly create a culture of education and excitement in these rural areas, which in turn would allow us to have residents there, which hopefully would in turn, the residents would stay there and they would be physicians there in rural

00;06;55;23 - 00;07;01;14
Jodi Tate
Iowa. So that was a very long answer to your question, but it is a long process.

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Rebecca Chickey
No, that was excellent. But for perhaps some of our non-health care listeners, could you describe or articulate what ACT is as well as a ACGME.

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Jodi Tate
ACT: Assertive Community Treatment. Dr. Williams talked about that at our talk earlier today. So it is a treatment for individuals with chronic severe mental illness that live in the community, that have multiple hospitalizations, interactions with the legal system, lots of complications. So essentially, it's a it's an inpatient team that goes out in the community and takes care of patients in the community.

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Jodi Tate
Evidence based treatment that shows to improve outcomes for people with serious mental illness, including schizophrenia.

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Rebecca Chickey
And I think it's also been proven to reduce the number of readmissions and the number of visits to emergency rooms and all of that, as well as be able to meet the patient where they are in their own home.

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Jodi Tate
We do not need any more evidence that ACT works. It works. You know, the challenges in rural areas. And Dr. Williams talked eloquently about that. And Dr. Jorgensen actually has started an ACT program in rural Iowa. And she has you know, she's running the rural track that we talked about earlier, expanding the psych residency program. So she's exposing residents, psych residents to the ACT program.

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Rebecca Chickey
Yeah. Gotcha. Yeah. Can you go back and and tell me a little bit about the psych residency sort of structure? There's four years to the program, is that correct? I'm hoping I'm going to get this right for ACGME: the American College of Graduate Medical Education, correct? Right. Yeah. So before you can even go on this journey, you have to go through a process where you get their blessing.

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Rebecca Chickey
And it's not a one stop process, is it? So, you know, just at a high level, you don't have to give us each step. But what did you have to go through in order to be able to move this program forward? And then how is it structured? Because if you are in rural areas, you know, how are they connecting back to, you know, sort of the mega metro centers, you know?

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Rebecca Chickey
So how is that structured? Two questions.

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Jodi Tate
So Dr. Jorgensen did that already for the rural track. So we have two additional residents right now. And to get ASCGME accreditation, essentially you have to meet a whole bunch of requirements about space, about faculty, about time, about learning. And it's not easy. And Dr. Jorgensen accomplished that, got the accreditation for that. And it's a long process, so it can take up to a year to get all that done.

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Rebecca Chickey
It's just good for the listeners to hear, you know, and know what's realistic. Yes. It's not going to be a fix in six weeks.

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Jodi Tate
No, this is a very long process. Okay. Yeah. And the ACG acknowledges an understands that we as a state, as a country, need to do better in educating our physicians in rural America. And they've created a think tank for rural and medically underserved populations to try to determine how they can help states develop programs and reach ACGME accreditation and given all the strict requirements.

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Jodi Tate
But that is just started. So they're just trying to figure that out now.

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Rebecca Chickey
Gotcha. So what about the structure of the residency program? You said that is underway and I think you have had six residents go through so far or are in the process of going through? What's the first year, second or third year, fourth year look like for them?

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Jodi Tate
Yes. So, again, this is Dr. Jorgensen's area and this is all her developing this. So there so I hope I'm going to get this right. But their first year they do a primary care rotation in rural Iowa. And then their second year, they have three months of electives that are all in rural areas. And then their third year they have a telesite clinic to a rural area. And then their fourth year they can do any of those electives that I just mentioned.

00;11;03;29 - 00;11;26;03
Jodi Tate
And she is currently working with other parts of the state to expand and rural locations for residents. So that's our current state. Our future state will be to develop our residency program even further and there will be a lot of collaboration between Dr. Jorgensen's program and what we decide to do in the future with expanding throughout the state.

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Rebecca Chickey
Well, and also through the fellowships that you're just now establishing in terms of what does this look like and feel like in rural America? Right, Right. So thank you for being on what I often call the bleeding edge of innovation. So it's not always comfortable and but but often, you know, thank heavens for the Wright brothers who were the first people to go up in that plane.

00;11;48;25 - 00;12;08;26
Rebecca Chickey
Right. You're the first person to try to do this in rural America through the fellowships. So you've mentioned a couple of times that the government of Iowa has been incredibly supportive. And you even mentioned that the governor, I think, had put forward a we can do better than this for individuals with mental illness and substance use disorders in our state.

00;12;09;05 - 00;12;13;24
Rebecca Chickey
Its really it's been the state legislature to some degree that's been driving this?

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Jodi Tate
It has. It's been the state legislature that's been driving it. So they advocated strongly for it. It was the number one priority for for folks, and they made it happen. So it came from them. So the academic world can't claim any pats on the back for that one.

00;12;32;08 - 00;12;49;22
Rebecca Chickey
Well, you had to be ready to catch the ball when they threw it to you, right? Yeah, right. You know, I think you get a little street cred there. The other thing I was wondering, I think in the breakout session I heard you say that for the new 12 slots that the state is actually funding $100,000 per residency slot.

00;12;49;22 - 00;13;15;09
Rebecca Chickey
Is that correct? Yep. So just to give the listeners that sense, that may not cover all of the cost of a residency, but it certainly covers a significant part of it. So just know that your state legislature should be in contact with the Iowa State Legislature to be inspired for helping us get more health care workers. In terms of the key success elements,

00;13;15;22 - 00;13;39;26
Rebecca Chickey
based on your experience with the psych residency program under Dr. Jorgensen's leadership and passion for this and now looking at the psychiatric fellowship programs which will once achieved, have dual role, they'll have that fellowship and also will be, you know, at the same time as they go through the fellowship, are able to oversee the residency slots. What do you think are some of the key success elements that got this off the ground?

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Rebecca Chickey
Certainly Dr. Jorgensen deserves a bright star, but were there other elements in addition to that?

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Jodi Tate
Well, I think willing is to collaborate and communicate across different organizations. It always comes down to communication and collaboration. So I have met a lot of new people during this adventure and finding out that we all share something in common and that's trying to improve health, mental health care to Iowans. And so I think willingness to collaborate, willingness to communicate, willingness to think big, but then also realize, okay, well, this is our big end dream, but what are the steps we have to get to do that?

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Jodi Tate
And is it going to be perfect starting out? Probably not. But let's just go and let's try it. So I think collaboration and communication and willingness to to try and to think and then willingness to actually make it happen and put the hard work in to make it happen.

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Rebecca Chickey
And I thought I heard in there the ability to pivot. Yes. In case it's not going to be exactly going in the direction that you dreamed of initially. Okay.

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Jodi Tate
Right. Who knows where this will end up, But we've got to start trying to figure it out. Yeah.

00;14;55;18 - 00;15;17;24
Rebecca Chickey
So let me ask you this two last questions. One, if you had to pick the biggest barrier that you overcame or went around or underneath, what would that be? Something for people to learn from your lessons, your own experience, so they can see the barrier is there and perhaps prepare better for it?

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Jodi Tate
Well, I wish Dr. Jorgensen was up here because she's actually gotten over all those hurdles and her program is off the ground. And I'm just in the early stages of doing this next phase. But but I would say that the biggest hurdle so far has been getting everybody together here to talk, to have a similar vision, even though that vision may be not exactly clear, but at least something that everyone can agree on.

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Jodi Tate
And I think we're still working on that. But I think having something that the group can agree on is where we need to go. So I would say I'm in the middle stages of that.

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Rebecca Chickey
But you're building the foundation for the collaboration.

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Jodi Tate
Thank you.

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Rebecca Chickey
Yes, that sounds like. Right. Yeah. And that's not easy work because it means relationships, right?

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Jodi Tate
It's all about building relationships. Yeah.

00;16;08;16 - 00;16;35;01
Rebecca Chickey
And learning the things about the other organizations that you didn't know were struggles or challenges. And they for you. Yeah. All right. So we are going to wrap this up. Are there a couple of things that you want to leave the listeners with that might inspire them to say, Hey, I'm going to start talking to my state representative and see if we can get something off the ground or I'm going to talk to my local academic medical center, something to inspire them as we close this out.

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Jodi Tate
Yeah, I think at least for some of us that have been in the mental health system for a long time, it's hard sometimes not to think there's so many problems that we can't overcome. But I think that we have to keep optimism and keep some idealism that, you know, I've lost some of that. But to keep it that, you know, that we can fix this or we could please try to fix this.

00;16;59;09 - 00;17;18;22
Jodi Tate
And there is hope. And if we work together and we get the right type of people together that are passionate about mental health care and are passionate about making changes, then it can happen. So never give up hope and always keep trying.

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Rebecca Chickey
That's exceptional. And I do believe that the Generation Z and all of those the millennials, they are going to demand.

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Jodi Tate
Good.

00;17;29;20 - 00;17;42;11
Rebecca Chickey
Treatment for their entire for their whole self, right? Just like the surgeon general said, you know, there is no complete good health without good mental health. So hopefully we have a lot of champions coming behind you and I.

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Jodi Tate
Yes. So we need them. We need them.

00;17;44;12 - 00;17;50;12
Rebecca Chickey
Keep the optimism going. And thank you so much, Dr. Tate. This has been a joy and thank you for the work you're doing.

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Jodi Tate
Thank you.