Episode 7: Bridging the Mental Health Gap in Rural Indiana

Transcript

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Denny Spinner:
This is Denny Spinner from the Indiana University Center for Rural Engagement. Welcome to Our Indiana: Stories from Rural Hoosiers, recording today from the St John's Catholic Church Center in Loogootee. We are with Jodi Routson, the director of Deaconess Outpatient Behavioral Health Services at Memorial Hospital and Health Care Center; Jon Agley, associate professor at the IU School of Public Health in Bloomington; and Amy Todd, a registered nurse and program management specialist at the IU School of Public Health in Bloomington.

Welcome to the podcast, you all. And we're going to have a really interesting topic as those of us with us today have been collaborating and are instrumental in working in rural Indiana to provide telehealth interventions for those struggling with mental health, which is something that's pretty a very topical discussion right now. So Jodi, let's start with you tell us about your work at Memorial Hospital and Healthcare Center and how it relates to our discussion today.

Jodi Routson:
Well, I've been at Memorial Hospital and Healthcare Center a number of years and had the pleasure of kind of working all over our service line as a licensed clinical social worker. And what we have found and continue to find, as you know, the demand for mental health services sometimes far exceeds the capacity of our providers, and especially more so in rural areas, that people who are living and working in rural Indiana find difficulty in accessing those services.

And so because Memorial Hospital has primary care clinics in some of our outlying counties—Martin County, specifically, we have two primary care clinics—we decided to join in this collaborative effort to see how we can provide those mental health services to those persons living and working in in rural Indiana. And so as a result, we have embedded some mental health services within those locations and opened up access to telehealth for patients who need to see a therapist and a psychiatric medication prescriber by means of a psychiatric nurse practitioner. And so we have developed a program in which we can get patients more immediate access to those services.

Initially, we wanted to really look at those patients who are in need of crisis or emergency services, because the closest emergency room is, you know, 20 to 30 minutes away, and we see very high volumes of patients with mental health crises there. But allowing more immediate access through a channel of telehealth and through a channel of a primary care provider that people already have relationships with has really allowed patients to access services that very likely they wouldn't have been able to before.

Denny Spinner:
So Jon, on the IU side of things, what brought you into this picture? How did you become aware of this? How did IU start collaborating in this situation where this issue was being addressed by the university?

Jon Agley:
Yeah, so I think the interesting thing about this project is that, many times at a university, academic faculty will sit and think, Well, we have a project, and we want to find a community to do it with us. And that's not what happened here. Instead, the community said, We have a real need, and we want to find someone at the university to help us structure a plan and obtain grant funding and address this need. So it wasn't me or anyone else at IU going to the community and saying, Hey, we want your partnership. It was actually the community, particularly Amy, coming to us and saying, We have identified a need in our community, and we think we know how to address this need, but we could use some of the specific expertise that you have at IU.

And through the use of that expertise, we put in an initial grant to a federal organization called HRSA, and that was funded in 2020, and that was the launching point for the project that is currently ongoing. And so I think the way I would describe our partnership is that each member of the team and each unit within the team—so not only individuals, but also Memorial Hospital and the faith community nurses and IU—brings specific expertise that's complementary.

So Jodi and her team have a tremendous representation throughout all these rural communities. They have a presence in these communities. They have access to primary care offices where they can network with the care providers. And they have social workers and nurses who can provide expert care from the position of being in the community, even though it's through telehealth. And the faith community nurses kind of can function as boots on the ground, you know, understanding, taking the temperature to the community. And then what IU does is, we do statistics, we do analyses, we develop workflows and send them to Jodi to vet. And now we're at a point where they develop workflows, and we're just like, Yeah, that looks great.

Denny Spinner:
And the key to part of this—you know, if I’ve got to write a commercial or an intro on what the Center for Rural Engagement is about, you just described what that is like, and having that connection. Because so many of our rural communities—I was in Huntingburg as a mayor before I worked with the CRE, and just having a front door to IU was difficult. So you were able to find that door that connected you to a project that not only is academically very stimulating, but also is a learning experience for the students that are part of this as well.

Jon Agley:
Right. And I think that's the key, is that it's not a perspective that “IU knows everything.” It's a perspective that “This is truly a partnership, and everyone brings their specific expertise.” It's more like a construction team, where you have an electrician and a plumber and a drywall guy, you know, and everyone comes together and does their part. And so, yeah, I think that's why, in my opinion, this project has functioned very well, is because it really is highly collaborative.

Denny Spinner:
Amy, you kind of found the door. You're here in Loogootee. You heard the need. Tell us about how you connected that, what FaithNet is about, and how did that connect those resources together?

Amy Todd:
Sure. As a faith community nurse, we intentionally care for the mind, body, and spirit. And that's not just to the individual, that's also to the community. And as a representative of St John's Catholic Church, I was able to start attending some meetings in the community, and I was hearing a lot about mental health needs. Additionally, we had some individuals who were coming into my office and were really needing some support, some conversations about stressors they were dealing with. And as I started to see more and more first hand and started to connect some of the resources we had available, whether it was IU or through Memorial Hospital, we just really wanted to look at what we can do and how we could help beyond.

Originally, we wanted to see how faith community nurses could really be those boots on the ground and be a connection. Because a lot of what I was hearing from individuals was about a wait time. You know, if they needed help, it was six to eight months. And here in Loogootee, sometimes that meant 75 miles away. And people were really having a lot of stress related to that. So I started thinking, what is some type of non-traditional way that we could get people help? Some of the information I was hearing, there was a lot of stigma around mental health, whether it was in the family unit itself or within the community, but then also some of those resources—like I know that congregations have support groups, chaplains are within congregations and pastors, but some people didn't feel comfortable going into that.

So I started thinking about how people go into a primary care setting for a weight check, maybe for an allergy shot. Why couldn't they go in there and be seen for mental health? And honestly, as a faith community nurse and tending to the community, I assessed the community. And Memorial Hospital had been very invested in our community. They had two clinics in our community, in our county, with primary care providers and nurse practitioners, and it just seemed like this was the route we needed to go.

I had the blessing of meeting Dr. Priscilla Barnes at one of those meetings, who was doing community health improvement plans. So I mentioned to Dr. Barnes, I said, I think we need to work together on something. And she connected me with Dr. Agley, and then we connected with Memorial, and it all worked out.

Denny Spinner:
So Jodi, when this idea started percolating, and you started hearing about how this was going to happen, what excited you about this collaboration from the view of Memorial Hospital extending their services? What was exciting about this kind of relationship being possible?

Jodi Routson:
Yeah, I think that we at Memorial are always trying to reach those needs that are unmet, right? But it's also very difficult, just given financial limitations of health care, and reimbursement specific to mental health is extremely poor. And you see lots of agencies and lots of lots of hospital systems actually eliminating those services because the reimbursement is so poor. And so I won't get on my soapbox related to that, but for Memorial Hospital, it was very exciting to be able to partner with funding possibility through this grant program. Without that, we would have not been able to expand services and reach people in more rural communities just because of the reality of financial limitations in healthcare.

And so this really allowed us to kind of launch an entirely new aspect of the service line in being able to meet people where they are, look at it through the telehealth lens. Because in mental health, telehealth has proven to be very successful, you know, through the pandemic and through isolation, and continues to be, to the point that it's actually changing payer models for that, because telehealth in general in the mental health space has been so successful. And so this collaboration just really allowed us to develop new services, new processes that we can very easily embed, then, into many of our other clinics.

And so it was hugely beneficial in helping us to reach people that we hadn't been able to reach for, and also deter them from coming to the emergency room for those services because we were able to get more immediate access to care. And so eliminating those wait times, eliminating the drive time of 75 miles was super important and super exciting to us.

Denny Spinner:
And so, Jon, as you looked at this from the university's perspective, Amy talked about a stigma of rural areas with addressing mental health. What did you learn from that, more about the rural areas and rural living, that was exciting for you to be a part of that?

Jon Agley:
Yeah, I think one of the biggest things in my mind is the kind of what's called the digital divide or the digital disconnect, which is the idea that, you know, I'm very used to Zoom at this point, for example. And for an older patient who may be asked to use Zoom for the first time for a telehealth encounter, that's a pretty big step. And I think I didn't appreciate fully how big of a step that was until we had people saying, I really need help, but I don't need help so badly that I can learn this at the same time.

And that was that was very eye-opening to me, that, as a so called Xennial who grew up in the analog world and then has migrated to digital, to really understand the degree to which someone might not be comfortable with digital technology. But that having been said, I want to emphasize how unique this opportunity is in this community. So imagine what Amy and Jodi said, where you have someone who has a 75-minute drive and a six- to eight-month wait if they identify that they have a need for mental health care.

And imagine instead, if the doctor could say—and you don't have to imagine that, this is what's happening—but imagine, conceptually, if the doctor instead says, You know what? That sounds really hard. I have a colleague who I'd like you to meet with. And then they can give them a tablet, and their first 30-minute psychiatric encounter can occur then.

I mean, think of the difference. You're eliminating windshield time, and you're eliminating three quarters of a year of a wait. So if a problem is acute, or if there's an emergency being precipitated, this program is really remarkable in how differently it enables Memorial to address that need.

Denny Spinner:
Right. So as you look at this, I mean, we're having some success. There are real stories to tell where this is happening. So share with me a little bit, maybe, some ideas of what a difference is being made right now. What's the future look like in this? What doors are open now that didn't exist before this collaboration? Amy, you want to start?

Amy Todd:
Sure. First, I want to address the value that IU has brought into us. Dr. Agley with prevention insights, he's been able to really look at the data. We've been able to expand on things. We've learned more about how social determinants of health are really propelling the mental health issue in our community. And I think Dr. Agley, on his first data sweep, learned that one or two people had ever been diagnosed with a mental health disorder. And so that was, to me, even in this community, really telling about how much need was being unmet.

So just working together and making this an evolving collaboration has really helped us. We have the social workers there who do the triage, and we learn, Okay, well, now we need to adapt. We need to include. We need to bring this in. And Memorial has been really great about informing us to make sure that we're addressing all those needs. Because sometimes it is a matter of, maybe they do have an acute anxiety issue, but what is the root cause? Can the root cause be addressed beyond or before needing that long-term care intervention? Maybe it's a matter of, how do they pay for their food and their medicine at the same time? And we can just connect them with resources.

And I think one of the ways that we're seeing this in the future—Jodi and Dr. Agley can expand on this—is we do have a second grant. So we have expanded, and we are going for another five years and expanding to additional counties.

Jodi Routson:
What we found through this initial five years was that, most definitely the social work resource, the therapy resource, and the medication resource—all having access to those things really does positively impact the patient.

And so we want to be able to individualize the program to whatever patients may need when they present. And so the next phase of this project will allow us to continue those services, and by hiring a full-time more bachelor's level patient coordinator position, that really is going to help those individuals with those social determinant of health needs, and what aren't they accessing? What resources do we need to get them connected with, and really looking at that availability to help support somebody through the struggles and the mental health issues that they're having.

But then we are going to take this program and replicate it in our other rural communities, and so over the course of the next five years, we will see this program expand into the other service areas of Memorial Hospital and Healthcare Center that are designated as rural In nature, and be able to replicate that and allow those patients more immediate access to the social work and mental health services that they're in need of by means of telehealth.

Jon Agley:
Yeah, and I want to piggyback on that. So these are not only rural counties. The reason these counties were identified is that there are areas where Memorial is working right now, but they are federally designated health provider shortage areas. So these are areas where not only are there many patients who may not necessarily be aware of the specific help they need, they have never gone through any kind of diagnostic procedure, or they've never really had that discussion.

There are also counties where, in many cases, if a resident identified that they wanted this help, they wouldn't necessarily have the ability to get it without leaving the county. And so that's one of the other pieces of this, is the telehealth aspect in particular enables a limited number of what we call FTEs—full time equivalencies—to spread across many, many more counties than they could if people had to drive every day. So if you had to have a social worker, a psychiatric nurse practitioner, and a licensed clinician drive to each county every day, you would need to hire like 15 people. And in this case, we can hire three.

And then, by using strategic assets with telehealth, we actually have the ability to cover this very broad area and reduce this provider shortage by leveraging that technology. That's something that we, again, going back to the idea of taking for granted, I think it's worth that initial discomfort of pushing the technology out into the communities. Because first of all, what we've observed in patients is that over time, they do become more comfortable with the technology, especially once they know that the person on the other end of the phone is just a county over. It's not like they're calling another state or anything like that.

And then the second thing is, I think the patients themselves also come to appreciate the convenience, and this is something we've heard in informal testimonials from patients is they'll say something like, I was a little skeptical of this, but honestly, the fact that I can go to the grocery store and then go back home and have my appointment is really helpful.

And so it's not only a benefit to the clinicians and the efficiency of the effort, it's a benefit to the patients.

Denny Spinner:
Right. Lessons learned, I guess, as we're going into a second phase of this—what are you taking away from this first effort that's really going to enhance what happens next for all the communities that you serve? And I'll just leave it open to whoever wants to answer first.

Jon Agley:
I can, yeah. So I think there's a couple of things, one of which is something that Amy said earlier, which is what we've identified through the data in our first project. For example, these are the numbers I know off the top of my head in our first 68 patients, which was the first six months of operation. So this has been a couple years. Now, 46 of those people who were referred to the program ended up meeting for a diagnostic visit with one of the providers, either a psychiatric nurse or a licensed social worker. And of those, 46 all had one or more new diagnoses related to mental health. And then in their medical records, there was only one or two people who had any preexisting diagnosis.

So what that is suggesting to us is that there truly is evidence of a large volume of unmet need. Now in our first grant, we were focused on emergency care, and so the metrics that we used and the plans that we provided to the primary care offices were focused on identifying and preventing these more serious mental health concerns from manifesting or precipitating a visit to the emergency room.

Now, especially given the unmet need that we've observed, we're broadening that out. And so basically, we're saying anyone who has a real concern of any kind related to mental health or psychiatry or behavioral health is now eligible to participate in this program. So it's a real broadening out from our initial focus on emergency needs to a focus on any needs.

Jodi Routson:
And then I think I'd like to add to that I don't know that I recognize the impact that this program would have on satisfaction for our providers in offices of the primary care nature. So their nurses, their physicians, their nurse practitioners, really have been the advocates for this program. And in recognizing their own limitations of not being that behavioral health expert, but having a colleague to refer to immediately, really has allowed them some stress alleviation, of not feeling like they're out here in these rural communities practicing independently and not having access to services.

And so my hope is that through the next phase of this program, we can provide some satisfaction to those providers as well in offering more immediate help for the patients that they serve, because it's very difficult and challenging to work in healthcare. And so anything that we can do, not only to support patients, but to support providers who will then want to stay in these areas and work and help their communities thrive from a health perspective, is very important too.

Amy Todd:
Yeah, and I think for the future, I've already seen a reduction in stigma in the community. People are talking more about when they need help, when they need a provider, and I think the trust is being built. So I'd like to see more and more conversations going forward, and I think that will happen.

And I do want to also add, circling back to one of the other questions—I think it's good to see that people are not spending so much money on an emergency room visit that could be helped here. You know, we're in a rural community where resources are limited. We have a lot of barriers and challenges, and so I think it's great to be able to see people live their best life and to get the help they need to continue to live that best life.

Denny Spinner:
So as we go into this next phase, how do you see this work that you're doing—from what we've learned and where we're going—how do you see this impacting rural communities and their ability to access services like this?

Jodi Routson:
Yeah, so as Memorial has become part of the Deaconess Health System, I've had the honor and privilege of doing some work in Evansville. And so a program like this, and knowing that we can embed mental health services within primary care offices, but not take up physical space and do it by means of telehealth, is something that I'm super excited that other communities could grab on to this concept and touch those other rural communities, not only in southern Indiana, but even in other states, to be honest. You know, Southern Illinois is very sparse and very rural.

And so to know that we kind of have led the way with a program that has been very successful, has been very supported and very wanted within primary care clinics, I think other communities and other entities are really able to look at programming like this that could be easily replicated to reach those rural areas.

Jon Agley:
And Jodi, one thing that that you sparked in my mind when you said that—and it dovetails with what you talked about with providers and supporting providers—there's a statistic that I like to quote very often, which is that if every doctor asked every screening question that's recommended for best practice at every visit, their entire day would be spent asking screening questions. And so there's a temptation to say, well, we've identified this new thing. Can you just do a little more?

And this program actually kind of goes in the opposite direction. Because if you imagine you're a physician, you have 15 to 20 minutes scheduled for a primary concern, and then a patient has maybe some mental health concerns that come up in the visit, and that visit ends up taking 45 minutes. Well, now your day is shifted, other patients have delayed visits, and there's this cascading effect. And rather than adding to provider burden, what this program does is it essentially says you can do your part, and then when you get to a part where you feel like you have less expertise and there's a real need, there's an expert at your fingertips who can step in to the plate for you.

And then so it not only provides more precision, focused care to the patient, it actually helps the provider’s workload feel more manageable. And that's feedback that we've gotten from some of the providers involved in this project. So I think there'll be interest in other counties and areas as they learn about this program, because it's not one more thing to do. It's actually a means of reducing stress and provider load.

Denny Spinner:
And this meets the goals of what your FaithNet is all about, Amy. Is that right? I mean this is right in line with everything you're wanting to do.

Amy Todd:
Yeah, absolutely. And you know, from a community member aspect or standpoint, I knew the first round we wanted to include—yes, it was Martin County, but we wanted to make sure it was people who lived here, worked here, played here, learned here, and prayed here. Because Martin County has a lot of individuals in the surrounding counties that come and do one of those five things.

So this enabled us to not just reach Martin County but some of our surrounding counties, and now we can see the benefit of even going broader. Because I know all these counties that are service areas, they have the same five things. They have people who work, live, play, pray, and learn there as well.

Denny Spinner:
Well, guys, I really want to thank you for your insights on this very important work that's going on. And thank you to Jodi and Jon and Amy for joining us on this discussion. And thank you to our listeners for tuning in for another episode of Our Indiana: Stories from Rural Hoosiers.

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