"Saving People's Lives": Access to Mental Health and Addiction Services in Rural Communities

00:00:00:09 - 00:00:21:21
Tom Haederle
Distance and lack of transportation. Obtaining a prescription and then paying for it. These are just some of the challenges that make accessing mental health and addiction services especially difficult in rural communities.

00:00:21:24 - 00:00:43:01
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. Access to quality care in rural communities often presents problems that defy easy solutions. Still, there are workarounds, as we learn in this podcast hosted by Rebecca Chickey, the AHA's senior director for clinical affairs and workforce.

00:00:43:04 - 00:01:06:17
Rebecca Chickey
Indeed, it's an honor to be here today with Brenda Romero. I have known her for over a decade now. She is a past member of AHA's Committee on Behavioral Health, our national advisory committee that helps us with our advocacy and policy, as well as resource work. And that's why Brenda is here today as a CEO of a small rural hospital in New Mexico.

00:01:06:19 - 00:01:31:21
Rebecca Chickey
She has a great deal of experience, some of which she's going to share with you here today about improving access to mental health and addiction services in a small rural community. So, Brenda, welcome. Thank you for sharing your time and expertise. My first question to you is, what are a couple of the biggest challenges to accessing behavioral health in a rural community?

00:01:31:25 - 00:01:37:09
Rebecca Chickey
For those many, many listeners who live in an urban, metropolitan area, help them understand.

00:01:37:11 - 00:02:09:20
Brenda Romero
The first issue is access to the care in that rural communities don't usually have taxis. Transportation is an issue. And for people who are suffering from this illness, they're usually couch surfing or living out in the streets. And so finding them and getting them to the care is usually the first issue that we encounter. And the second is getting them the medication. The cost

00:02:09:20 - 00:02:38:15
Brenda Romero
of the medication can be up to $500 a month. And getting them the prescriptions is one thing, but then getting them the medications is another. Usually people with that presentation don't have a payor source, and so then it would require somebody giving them that money and willing to support that every single month. In order to increase compliance with medication treatment

00:02:38:20 - 00:03:03:26
Brenda Romero
we have started using some medications, like Brixadi, that we can give in the ER or in our infusion center, and it'll last a whole month. And we're using that type of medication for pregnant women that present and that we're not sure if we're going to see again for some time. And so that's been helpful.

00:03:03:28 - 00:03:27:15
Rebecca Chickey
So I'm going to hit home with a couple of things that you said for people who live in Chicago or New York or even Nashville, Tennessee, where I lived for a number of years. The fact that there's not a taxi is really sort of like, what? And I suppose that same lack of transportation services, you don't have an abundance of Uber drivers or Lyft drivers in your community either, right?

00:03:27:16 - 00:03:53:11
Brenda Romero
No, it's not available. And when you're talking about where these patients need to come from, we are in Espanola and there's about, there's less than 10,000 people that actually live in the city. And then there's Rio Arriba county, and it can be 100 miles to one of the borders. So we're talking about they come from surrounding communities. So it's not like somebody can walk there.

00:03:53:13 - 00:03:55:13
Brenda Romero
They need to find a ride.

00:03:55:15 - 00:04:18:17
Rebecca Chickey
And so that means relying on family or friends who may or may not also have transportation services. So just that physical capability of getting to the hospital or the emergency room is a challenge that many of our listeners probably can't imagine, but I can. Having grown up in rural Alabama, when EMS tried to get to my father, they couldn't find the house because there was no GPS at that time.

00:04:18:19 - 00:04:49:26
Rebecca Chickey
The next thing that you mentioned is the cost of the medications. So that's not unique to mental health. There always seems to be an article in the news or a discussion somewhere about the cost of medications, but these medications are for our most fragile patient populations because they often, and please correct me if I'm wrong, but they often have physical comorbidities as a result of or perhaps one of the reasons that they may be self-medicating with substances.

00:04:50:03 - 00:04:56:29
Rebecca Chickey
So their physical health and their mental health are often fragile and being challenged. Is that an accurate statement?

00:04:57:01 - 00:04:58:09
Brenda Romero
Yes.

00:04:58:11 - 00:05:16:02
Rebecca Chickey
And so because of that, tell me why it's so important to be able to provide a medication that lasts for a month. Is that to know that you don't have to worry after that because of compliance issues, because the patients are actually going to, they don't have to worry about that then.

00:05:16:05 - 00:05:48:23
Brenda Romero
Yes, it's not only compliance, but it's actually getting the medication. And so usually they don't have a payor source so they don't have Medicaid. And if they have Medicare due to a disability, they usually haven't signed up for part D or any of the other parts that they need to get payment for the medications, for prescriptions. And so if they were to try to go get their medications and be compliant with that, most times they wouldn't even get the medications because they can't pay for them.

00:05:48:26 - 00:06:07:24
Brenda Romero
And if a family member is willing to start them on it, like pay for the first month, it's pretty hard to get somebody to commit to just continue to pay for that. In order to get them on Medicaid, they would have to then get all the paperwork in order to apply. And they can apply online.

00:06:07:24 - 00:06:28:24
Brenda Romero
But some of these older folks don't have the capacity to be able to do that. They don't have the phone. They don't have the experience with getting on a website and filling in all the information that they need. And some of that information that they might need is to upload a copy of the birth certificate, and they might not have the birth certificate.

00:06:28:26 - 00:06:37:12
Brenda Romero
So the barriers are huge for them. They can't get there. And so I think that...

00:06:37:15 - 00:06:40:28
Rebecca Chickey
So what's your solution? What have you been creating, what have you been innovating.

00:06:40:28 - 00:07:01:18
Brenda Romero
So what we've done is we've started the treatment in the emergency room and then following them up in the clinic. And if we can get them started on medication, then we can buy more time to work with peer counselors, to work with case managers to help them get what they need in place in order to continue the treatment.

00:07:01:21 - 00:07:29:00
Brenda Romero
We are also encouraging the homeless shelters to work with the homeless population and to get them to our E.R. if they can do that. Presbyterian Healthcare Services, organization I work for, is now also asking if our paramedics can start giving out some of the medication when they respond to a call, if the patient is willing to start the treatment at the time.

00:07:29:07 - 00:07:37:17
Brenda Romero
So we're trying to figure out how to get the medications to folks where we can, even if they can't afford to do it.

00:07:37:19 - 00:08:04:08
Rebecca Chickey
So it sounds like you're taking advantage of every opportunity where there's a touchpoint with a patient that has this need. Yes. That's phenomenal. It's, I think, a broader sense of patient-centered care. You're going to where the patients are and providing the services. So do you think this innovative idea is replicable? Can it be implemented by other organizations in a similar crisis situation?

00:08:04:08 - 00:08:11:23
Rebecca Chickey
I would say because the challenges that you described almost seem insurmountable. But do you think others could replicate it?

00:08:12:00 - 00:08:35:21
Brenda Romero
Yes. Also, keeping in mind that, especially at the beginning, they're not going to have a payor source, right? So we're going to have to start that and not be reimbursed for that. But it makes a huge difference, not only most importantly to that person's life. Right? Like, who wants to be suffering like that? And then it starts improving their participation in society

00:08:35:21 - 00:09:02:27
Brenda Romero
and with their family members. And in our area it's a very family-oriented area, and most people who don't have a place to live will have a place to live if they sober up. And so reuniting those patients with their families is just, it would be an amazing thing to do. And then their reentry into their communities would be another win for everybody, right?

00:09:03:00 - 00:09:25:08
Brenda Romero
And makes it a safer place for the patient and for the communities that they live in. And so I think it's very, very important. I think it's worth it to everybody. There's something in it for everyone. And I think that one way to start is to assess what the barriers are, what are the barriers that those patients in your community are experiencing.

00:09:25:08 - 00:09:37:07
Brenda Romero
Because as you said, bigger communities have transportation. They have other ways to get around. So the patients in their community might not have the same barriers that we have in ours.

00:09:37:14 - 00:09:59:26
Rebecca Chickey
Yeah. As you were describing the long-term impact of this, if an individual gets on a medication that helps them remain sober for a month, then that gives them hope, then they may be able to get traction to go back and live with their family. Then they may be able to get a job. And that is something that is priceless, right?

00:09:59:29 - 00:10:26:15
Rebecca Chickey
You can't really put a price on giving someone their humanity back. But at the same time, the reality is that often no margin, no mission. So I realized that this is a new innovative initiative that you undertake, and so you probably haven't, you don't have hard data on that. But I would assume that what you're hoping is that you're going to see fewer emergency room visits, which we all know are costly.

00:10:26:17 - 00:10:54:12
Rebecca Chickey
I assume that you're going to have less use of emergency services outside, sending someone out to rescue someone who is in a crisis from a substance use disorder. And perhaps even you will see a reduction long term in things like cirrhosis, in things like congestive heart failure, in wound care for individuals, depending upon what the substance is. Is that what you're hoping for in the long run?

00:10:54:15 - 00:11:21:19
Brenda Romero
Yes. But most importantly, saving people, saving people's lives, right? They are at risk of death every day, premature death every day. And there's a lot of violence that's, you know, associated with this diagnosis. And so not only the patient's life, but their family and friends and other community members walking around. I mean, it would improve all of that also.

00:11:21:21 - 00:11:33:08
Rebecca Chickey
So it's a population health approach, I agree. Thank you. So much, one, for the work that you're doing. Boots on the ground, making a difference in individuals' lives. And thank you for sharing that inspiration with us here today.

00:11:33:10 - 00:11:34:27
Brenda Romero
Thank you.

00:11:35:00 - 00:11:43:10
Tom Haederle
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