December 2018, Volume XXXII, No 9

special focus: rural Health

Rural Health Innovations

An integrative behavioral health program

iving with a mental illness in rural Minnesota is more challenging than one might anticipate. Lack of local behavioral health providers, limited access to tele-psychiatry and inpatient psychiatric beds, and new or unknown community awareness of support services, all contribute toward a health system that fails for many patients with mental illness. However, there are some critical access hospitals across Minnesota that are engaging their communities to address these challenges and provide whole-person care through the integration of behavioral health.

A common scenario

FConsider this series of developments, all too common in rural areas. When Matt, a 39-year-old male, is seen crawling around on the ground with a knife below his neighbor’s windows and screaming in agitation and fear, the sheriff gets called. The sheriff knows Matt. She has brought him to the local critical access hospital emergency department (ED) many times, as Matt suffers with severe psychosis. When Matt experiences a mental health crisis, he is often a danger to himself and a perceived danger to others.

The community has limited behavioral health providers, so Matt is brought once again to the ED. In this hospital, tele-psychiatry options are no longer available to ED staff, as the remote provider got burned out and opted into early retirement. Naturally, it is also late Friday night, so any possibility of connecting with the psychiatrist two counties over must wait until Monday morning. Meanwhile, Matt becomes increasingly agitated due to the lack of care and support he needs at that moment. The ED is unequipped to provide for these unique needs, and Matt’s family members grow increasingly concerned, because they have seen a cycle of lengthy ED visits that have not resulted in a sustainable improvement in the quality of life of their loved one.

The local ED puts Matt on a 72-hour commitment hold and identifies that he could benefit from psychiatric stabilization in an acute inpatient facility. However, bed space is exceptionally limited across the state—and even into the Dakotas—due to state budget cuts and closings of inpatient psychiatric facilities. In fact, nine out of ten rural ED physicians report that individuals experiencing a mental health crisis are being held in the ED, sometimes up to weeks at a time, until an inpatient bed becomes available. Nurses struggle for hours going through the highly coveted list of inpatient facilities that may have space available and are willing to accept Matt, who has a criminal record and multiple comorbidities. While Matt waits to be transferred out of town, his symptoms escalate because he’s afraid.

To continue to ignore the impact that mental health plays on one’s physical health is faulty.

When an inpatient psychiatric bed is eventually secured, the ED, as it often does, coordinates with local law enforcement to transport him. This is humiliating for Matt, as it reinforces the stigma of mental illness. It’s also costly for law enforcement, and takes an officer off of local patrol for hours, affecting the community. Matt is dropped off for inpatient psychiatric care, alone and scared, because his family doesn’t have reliable transportation, the funds to get to the inpatient facility, or the time off from work to offer emotional support. Matt, who is in crisis, feels increasingly isolated and disconnected.

After his psychiatric medications are stabilized, Matt is released and tries to return to life as normal…until another trigger occurs that becomes too unbearable to deal with and a new crisis ensues, perpetuating the pattern of cyclical care through the ED.

Finding answers

Unfortunately, this scenario plays out daily across rural Minnesota. One remedy is for hospitals and their communities to rally together to minimize the unintended gaps in care and begin providing whole-person care that integrates behavioral health. That’s the vision for 13 Critical Access Hospitals (CAHs) and their communities across Minnesota who are participating in Rural Health Innovations (RHI)’s Integrative Behavioral Health Program.

RHI is a subsidiary of the National Rural Health Resource Center, a nonprofit organization designed to build and sustain health care in rural communities across the country. CAHs cited access to mental health care as their top health concern, according to a statewide analysis of Community Health Assessment Findings conducted by the Minnesota Department of Health (MDH). In response to inquiries from that department’s Office of Rural Health and Primary Care, RHI designed a program using a Performance Excellence Framework—one that has yielded substantial success to date, according to Alyssa Meller, chief operating officer at RHI.

This Performance Excellence Framework—a systemic approach for managing the integration of behavioral health—includes essential organizational and operational components. One essential organizational component is engaging buy-in of the program from leadership at all levels throughout the organization. It is imperative for CAHs to address the mental and behavioral health needs of individuals in the transition towards population health and value.

“To continue to ignore the impact that mental health plays on one’s physical health is faulty, dangerous, and leads to poor quality health outcomes,” said Meller. Operationally, it is essential to unite key community stakeholders, including schools, law enforcement, clergy, public health, city and county leaders, business owners, and others under a Community Collaborative to establish a strategic plan and action steps for coordinating care and improving the quality of life for individuals experiencing a mental or behavioral health crisis. “When rural communities come together around a common cause, we see change happen,” said Meller.

RHI guides a community strategic planning process that helps prepare all parties to respond to or prevent behavioral health crises. Participants learn about the various strengths, services, and resources available throughout the community that they could coordinate, transition, or refer patients to. Community members are often surprised to learn about all of the local resources or services that haven’t been tapped into yet, despite each of these communities being rural. “Many people tend to problem-solve independently,” said Meller, “but when we get together in these Community Collaborative events, people begin to recognize that working together saves time and effort.”

Begin providing whole-person care that integrates behavioral health.


Community members quickly identify the value of integrating behavioral health and working together. One specific example: LifeCare Medical Center’s outpatient Behavioral Health Department hired a clinical social worker to serve as a roving therapist, providing behavioral health and care coordination for individuals who are incarcerated. Some of these patients had been transferred from the correctional facility to the ED for mental or behavioral health crises, creating a costly concern and burden for all involved. By treating incarcerated patients onsite, the local hospital has seen these transfers drop to almost zero.

The cost savings generated by the roving therapist’s involvement grabbed the attention of county corrections officials, county commissioners, and the county justice department. The staff at Roseau’s LifeCare Medical Center’s ED has also recognized that their partnership with law enforcement, clergy, and other key community stakeholders, such as the Crisis Response Team, helps to provide higher quality care and to reduce the overall number of transfers to inpatient psychiatric facilities. This focus on coordination and preventive support reduces crisis situations, improves the quality of life for the patient, offers cost savings from more expensive and duplicative treatment, and starts to break the cyclical pattern of ED use and uncoordinated care. “There is a paradigm shift in thinking when community members start to see the value proposition of working together, both from a fiscal perspective as well as a quality of life perspective,” says Meller.

One of the common themes throughout RHI’s participating Community Collaboratives’ strategic plans is to educate the community on eliminating the stigma associated with mental illness and offering community education on where to go for support when a crisis arises. Therefore, RHI’s next venture is aimed toward partnering Community Collaboratives with local artists to help change the conversation and perspective on mental illness and to support mentally healthy communities.

Extending the model

For organizations or communities that are looking to integrate behavioral health into their programming, a systemic approach is needed that engages leadership at all levels and gains the support and actions of the community. No monetary funds were provided to the CAHs and the Community Collaboratives participating in RHI’s Integrative Behavioral Health Program, as the value proposition for each participant needed to be self-identified to promote sustainability. When a community works together under a common goal, the outcomes will be much greater. For more information on the Performance Excellence Framework or RHI’s Integrative Behavioral Health Program, contact Alyssa Meller at

Kami Norland, MA, ATR, community program manager at the National Rural Health Resource Center, provides education and facilitation to rural communities on community engagement for improved health and wellness. 


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Kami Norland, MA, ATR, community program manager at the National Rural Health Resource Center, provides education and facilitation to rural communities on community engagement for improved health and wellness.