This study documents disparities between urban (metropolitan) and rural (micropolitan and non-core) MHSAs in mental health workforce capacity (Institute of Medicine, 2005
; Wang et al., 2005
; Hauenstein & Peddada, 2007
; Ellis et al., 2009
; Konrad et al., 2009
; Thomas et al., 2009
). This study also illuminates important variations in the kinds of disparities found within non-core areas, micropolitan MHSAs and micropolitan MHSAs with Native American populations. For instance, there is virtually no PFMHA workforce to provide local mental health services to low-income adults with SMI in noncore areas. These areas continue to depend on PFMHAs in nearby micropolitan MHSAs for services.
Disparities in workforce capacity between micropolitan MHSAs were notable. Policy and program development efforts to lessen disparities must not rely on the assumption that workforce capacity is the same across non-metropolitan service areas. This study identified three tiers of MHSAs between which workforce capacity varied as much or more than between micropolitan and metropolitan MHSAs. PFMHAs in these tiers must be regarded independently in terms of workforce strengths and weaknesses.
The first tier of micropolitan MHSAs possesses workforce capacities that approach and sometimes exceed those of metropolitan MHSAs in terms of low-income adults with SMI per PFMHA provider FTE. These MHSAs can therefore be considered a principal resource for improving the quality of mental health care for micropolitan and non-core service areas.
An important reason for heightened workforce capacity in first tier micropolitan MHSAs may be that three of four are home to universities with training programs for behavioral health professionals. The fourth first tier MHSA also benefits from solid connections to higher education. This suggests the importance of developing close linkages with training programs.
The second tier micropolitan MHSAs reported low-income adults with SMI to PFMHSA provider FTE ratios from 61:1 to 274:1 and strong capacity in terms of independent and supervised therapists and case managers. The ratio of low-income adults with SMI to case manager FTE was lower than for metropolitan MHSAs in two micropolitan MHSAs, moderately higher in two others and extremely high in one. The potential caseloads of psychiatrist, psychiatric nurse, paraprofessional and substance abuse counselor FTEs were extremely high.
The two micropolitan MHSAs with higher numbers of Native American residents (Gallup and Farmington) have the greatest challenges in terms of total workforce capacity among the six second tier MHSAs. These disparities are likely the result of a combination of higher than average prevalence of SMI in the low-income adult population, extreme poverty, small and isolated rural environments in which it is difficult to provide and support services, special needs related to delivering culturally appropriate mental health care and the organizational complexities of service delivery in tribal communities.
The third tier of micropolitan MHSAs has little or no workforce capacity. Two of the five MHSAs in this category report no FTEs for any type of provider. While there is some capacity in terms of psychiatrists and therapists in PFMHAs, the numbers of potential clients per FTE are overwhelming, and substance abuse counselor FTEs are limited. These disparities can be traced to the relatively isolated, small and low-income status of MHSAs in this tier. Thus, planning is clearly needed.
Implications for Reducing Disparities in Workforce Capacity to Serve Adults with SMI
Although the number of FTEs in first tier micropolitan PFMHAs is insufficient to ensure state of the art care for low-income adults with SMI, the numbers are at least comparable to those in metropolitan MHSAs in the state. The most notable exceptions were found in the ratio of low-income adults with SMI to psychiatrist FTE in Roswell and the general lack of psychiatric nurse and substance abuse counselor FTEs across the four MHSAs. Importantly, parity in the ratio of low-income adults with SMI to provider FTE is not necessarily an indicator of the quality of care across MHSAs. For example, the actual number of psychiatrist FTEs in PFMHAs in micropolitan MHSAs remains very small compared to the concentration of psychiatrists in the Albuquerque MHSA. Psychiatrists in micropolitan MHSAs are forced to be “psychiatric generalists” who treat a wide range of disorders, while those in metropolitan MHSAs can specialize. Lack of time and resources can compromise the psychiatric generalist's ability to stay current with the latest evidence-based diagnostic and treatment models emerging in relation to specific types of mental health problems. Lessening disparities in the quality of psychiatric care will require intense efforts to increase the range of psychiatric expertise available in micropolitan and other rural areas. Similarities in therapist caseloads in first tier micropolitan MHSAs and metropolitan MHSAs may disguise significant disparities in quality of care. Subsequent analyses showed that the ratio of therapists requiring supervision to independent therapists was significantly higher in micropolitan than metropolitan MHSAs. Additionally, therapists in micropolitan areas incur greater expense and labor burden than their urban peers to deliver care to the same number of adults due to the distances they must travel.
The core of the second tier MHSA workforce largely consists of FTE independent and supervised therapists (72.2), case managers (26.3) and paraprofessionals (22.6). Disparities in psychiatrist FTEs (12.3) and psychiatric nurse FTEs (4.3) relative to low-income adults with SMI needing service were acute. These disparities limit workforce capacity to accurately diagnose complex conditions, deliver suitable treatments, and provide medication management. Substance abuse counselor FTEs (16.5) were also low in relation to the number of low-income adults with SMI.
There is little likelihood of quickly increasing the size of the workforce in second and third tier MHSAs. Efforts to reduce such disparities by federal and state governments over the last 30 years have been largely unsuccessful. The research literature documents that it is incredibly difficult to recruit and keep mental health professionals in rural areas for a number of reasons—lower salaries, professional isolation, difficulties finding work for spouses, limited social outlets and educational opportunities for one's children, the discomfort of transitioning from urban training environments to rural life, and an insufficient population base to support services (Wagenfeld et al., 1994
; Merwin et al., 1995; Institute of Medicine, 2005
; Meyer et al., 2005
Decreasing disparities in quality of care between the first tier micropolitan and metropolitan MHSAs is more likely to be achieved by enhancing training and support for the existing core of therapists and non-specialty providers. Decreasing disparities in availability and quality of care in PFMHAs in second and third tier micropolitan MHSAs will be more difficult. Improvement may require greater enhancement of the extant workforce of case managers, independent and supervised therapists, paraprofessionals, and other non-specialty providers, and increasing collaboration between organizations in first tier micropolitan and metropolitan MHSAs to provide direct services. Disparities in the number of substance abuse counselors in micropolitan PFMHAs is particularly acute, limiting the provision of appropriate services for comorbid mental health and substance abuse conditions. These and other disparities may be partially addressed through national health care reform, as micropolitan PFMHAs will be required to provide a full range of behavioral health services. Supplementing the rural workforce with resources from metropolitan MHSAs via telebehavioral health and web-based technologies will also help facilitate direct service, consultation and collaboration. These technologies lend themselves to interactive distance learning and continuing education opportunities (Institute of Medicine, 2005
; Kriechman, Salvador, & Adelsheim, 2010
). Finally, evidencebased practice implementation for comorbid conditions may be facilitated through intensive training, coaching and supervision by remote technical assistance centers and performance assessment teams (Bond et al., 2008
; Bruns et al., 2008
Facilitating coordination of services in rural areas is also important (Institute of Medicine, 2005
). Mechanisms include: clinical homes (Smith & Sederer, 2009
); integrated service agency models (Chandler et al., 1996
); wraparound models for adults (Walker & Bruns, 2006
); intensive case management (Meuser et al., 1998
); cross training (Fleury & Mercier, 2002
); and co-location of mental health and primary care (Badger, Robinson, & Farley, 1999
). Other recommendations capitalize on de-facto rural systems of care to augment available workforce (broad networks of mental health, social, educational, health, vocational, religious, peer-support, self-help and other community services and supports) (Fox, Merwin, & Blank, 1995). With continuous education and performance improvement programs stressing identification of disorders, referral and treatment, local communities can assist in upgrading delivery systems for low-income adults with SMI (Fried et al., 1998
; Gale & Deprez, 2003
; Meyer et al., 2005
In terms of mental health care system design, this study also suggests that it is extremely important to develop mechanisms to encourage coordination of care across local and regional MHSAs. Mechanisms might include statewide organization of micropolitan and non-core MHSAs around the kinds of relatively high capacity centers found in the first tier of micropolitan MHSAs that have direct access to pipelines of academic training for providers and the provision of incentives for local PFMHAs to extend services and support to lower service capacity MHSAs in their geographic region. Equally important is finding mechanisms to encourage high capacity metropolitan PFMHAs to provide services and support for first tier micropolitan service centers. Resources to support these mechanisms have been limited and the evidence base for their effectiveness is mixed. Several demand support from urban specialty centers that are themselves under-resourced. However, any improvement in the quality of the core micropolitan PFMHA workforce will likely depend on the deployment and evaluation of such mechanisms.