A rural health clinic’s journey to behavioral health integration

The need for behavioral health services in rural areas has never been greater, an issue compounded by lack of therapists. According to the Bureau of Health Workforce, 60.6% of Mental Health Professional Shortage Areas (MHPSAs) are in rural areas.¹ This correlates to data that show increased incidence of mental health-related conditions among the rural population. For example:

• Less than 20% of nonmetropolitan adults were treated for depression from a behavioral health care provider.²
• Rates of death by suicide among American Indians/Alaskan Natives, 54% of whom live in rural areas, are more than twice the national average.³
• The rate of rural men 75 and older who died by suicide was nearly three times higher than the national rate.⁴

Much of east-central Illinois is rural, including Piatt County, which is 94% cropland and pasture.⁵ Kirby Medical Center, a rural health clinic (RHC) that serves the county, is composed of three medical facilities:

1. Kirby Medical Group in Monticello, which opened in 2008;
2. Atwood Rural Health Clinic (in neighboring Douglas County), which opened in 1997 and moved into a new facility last October; and
3. Cerro Gordo Rural Health, which opened in 2016.

Kirby Medical Center’s behavioral health integration (BHI) journey started in 2016, thanks in part to one of the clinic’s internists. As an addiction specialist, the internist offered addiction counseling services and suboxone treatment. Prior to this, Kirby Medical Center had a contract with Piatt County Mental Health Center and worked with a private medical group in Champaign, 20 miles east of the Monticello clinic.

However, as Multisite Rural Health Clinic Director Sara Wells, MHA, MSN, RN, CRHCP, conveyed, this was not the best solution for the clinic’s patients. “When something happened at either of their primary practices, our patients weren’t the first priority,” she said. “It was at that point we realized that we really needed to have our own employed therapist here in our clinic.”

When Kirby Medical Center started its BHI program, there were no guidelines to help shape its structure as there are now with the Behavioral Health Integration Collaborative’s pilot program.⁶ Prior to that recent initiative by the American Medical Association (AMA) and other leading physician organizations, Wells said that networking was the only means of gaining insight into BHI.

“We belong to an accountable care organization (ACO) and have access to 22 other hospitals that have similar service lines, so I was able to ask questions and figure out what they were doing, what was working for them,” she said, adding that the Piatt County Mental Health Center provided insight as well. During the past seven years, Kirby Medical Center has been able to refine its BHI program through trial and error and eventually started getting reimbursed for its licensed clinical professional counselor (LCPC) services.

Although there was a demand for behavioral health services seven years ago, Wells said the pandemic helped drive a shift in diagnoses from general anxiety disorders to depression with anxiety, major depressive disorder, and post-traumatic stress disorder (PTSD). She added that the diagnosis of PTSD has increased significantly in the past few years. To help address this, two of the clinic’s therapists recently became certified (a third will become certified in mid-2024) in eye movement desensitization and reprocessing (EMDR) therapy, which is designed to help patients heal from trauma and painful life events through psychotherapy that help process those memories.

“In addition to these other diagnoses, the number of child and adolescent patients requesting services has grown,” Wells said, adding that it’s hard to determine if there’s a direct correlation with the pandemic.

Team structure and challenges

Currently, Kirby Medical Center has three full-time-equivalent (FTE) licensed clinical social workers (LCSWs) and one FTE licensed social worker (LSW), the latter of whom is working toward his supervision hours to sit for the LCSW exam. His goal is to become certified this July. The group also recently hired a part-time LSW, who is waiting for state approval to sit for the LCSW exam.

The FTE LSW serves as the clinic’s mental health services case manager and is a bridge between providers and therapists. “He provides patient introductions to the service line and does some intake for new patients,” Wells said. “He will then staff the patients according to their suspected diagnosis and modality needed and oversees the scheduling [done by registration staff] to make sure patients are coming back on the right cadence.”

Wells noted that communication between therapists and providers is mostly informal, but because they share the same space, individuals will occasionally get together for stand-up meetings. There are also quarterly all-staff meetings and monthly meetings for therapists and providers, during which they discuss patient care and incoming referrals.

While the primary advantage of RHC status is increased reimbursement rates for providing Medicare and Medicaid services, that’s not the case with behavioral healthcare. Documentation is not that different than at a private behavioral health practice; nevertheless, the clinic is only reimbursed for a few CPT® codes, which makes providing behavioral healthcare more difficult. “The limitations that CMS has placed on RHCs for mental health is a detriment to the communities we serve,” Wells said.

Despite reimbursement challenges, Wells noted that the clinic’s therapists “are always looking to add to their ‘toolbox.’” With the greater need for child and adolescent services, Wells added that the clinic is looking into play therapy certifications and similar services to reach more patients. “As the therapists add modalities and techniques, we are strengthening our BHI program to be able to treat more patients appropriately,” she said.

Hiring licensed clinical therapists has been one of the biggest challenges for Kirby Medical Center, Wells related. On one occasion, it took the clinic a year to fill an open LCSW position. Wells has found that it’s difficult to identify therapists who want to work with children or have an interest in geriatric patients. “This is a small area, and our pool is pretty shallow,” she said. “Additionally, we’ve found that LCSWs don’t really look for jobs in medical offices.”

If they do, Wells maintained that it’s been difficult to retain them because of the documentation challenges. “We had to build the necessary documentation as our charting system was tailored to the medical services side,” she said. “When we integrated behavioral health, we had to build templates and processes from scratch.” That said, the team is constantly striving to improve its documentation practices.

To help retain the clinic’s therapists, Wells said that flexibility has been key. She noted that the part-time LSW sees patients in the evenings and on Saturdays so that the FTE therapists don’t have to schedule patients outside standard clinic hours. This allows them more flexibility and a better work-life balance.

Even though Kirby Medical Center is getting the most from its therapists, the goal is to eventually hire a psychiatrist so that the clinic can offer more reimbursable services to its patients. An example is group therapy, for which the clinic can’t currently bill.

Another challenge Kirby Medical Center faced was accommodating behavioral health patients. In the Monticello clinic, two exam rooms were transformed into therapeutic spaces, and a third is scheduled to be remodeled in the coming months. Beyond cosmetic changes, such as removing blood pressure monitors from the walls, rooms were made more inviting. “Part of the renovation was that we added therapeutic spaces with floor space for play therapy, added soundproofing to the rooms, and added white noise speakers in the ceilings above the space,” Wells said.

When the additional clinics were built, rooms were designed with behavioral health patients in mind. According to Wells, the behavioral health rooms were built on the outside of the facilities so that patients had their own entrance and exit. “We tried to make the rooms as comfortable and inviting for the patients as possible, but we also considered how we could make them better and more comfortable for the therapists as well,” she said.

Training staff and engaging patients

When new therapists are hired, they are onboarded by senior therapists. Wells relayed that new hires always have some experience in the field and at minimum a basic understanding of what a visit and documentation need to look like.

Additionally, she said that Kirby Medical Center individualizes training to cater to each therapist’s background and needs. New hires typically start by sitting in on an experienced therapist’s appointments. The clinic also provides formal EHR training, with an EHR educator showing new hires how to effectively write a clinical note, along with how the visit should be coded. Finally, new therapists are introduced to the medical teams “So they have a space for warm handoffs or structuring plans of care for shared patients,” Wells said.

For Wells, a key component of training is ensuring that therapists are engaged. She noted that she does rounding with therapists once a month, and the therapists and case manager also meet each week to review schedules and staffing needs. Finally, the therapists and case manager meet each month with Wells.

“Our meetings are very transparent, which helps tremendously with engagement,” she said. “I share volumes, financials, and engage them in helping me with strategic planning.” She added that it’s during these meetings when important decisions are made for the group, including revamping their workspaces to make them more conducive to seeing patients and to pursue training and certifications that could benefit patients.

Incidentally, Wells expressed that engagement hasn’t been an issue with patients because there’s a huge demand for behavioral health services. “Once they know these services are available, they come,” Wells said, adding that Kirby Medical Center’s patients trust their providers when they make referrals, largely because providers and therapists practice in the same clinic and have developed a strong working relationship.

Wells pointed out that having a direct referral “where one of my physicians is right down the hallway, and she can say, ‘You know, I see [this therapist] every day at work. She’s wonderful with patients’” makes a big difference. In turn, providers can have face-to-face conversations with therapists to let them know why the patient has been referred and potential challenges in treating the patient.

Long-term sustainability and patient data collection

Reimbursement plays a big role in long-term sustainability, especially because Kirby Medical Center is limited in the services it can provide as an RHC. For example, the clinic can only be reimbursed for treatment by an LCSW or LCPC, which makes it difficult to meet the community’s needs. “If we have staff who aren’t certified but have the education and training to be able to provide services to patients, it’s not really a consideration when we’re thinking about reimbursement,” Wells conveyed.

Moreover, in Illinois, social workers need 3,000 supervised hours before they can become certified as an LCSW. “We can bill a few Medicaid payers for their services, and those are the patients the case manager is using toward his supervision hours,” Wells said, adding that the clinic has a waiting list of patients that the case manager can’t help with, putting an RHC like Kirby Medical Center at a disadvantage.

Wells contended that oftentimes students in a master’s of social work (MSW) program will graduate, and private behavioral health practices can employ them and “allow them to see patients and bill them while they’re getting their clinical hours.”

It’s also difficult, as Wells related, to attract new therapists to RHCs because many aren’t necessarily looking for positions in a clinic or hospital setting. To help address this, Kirby Medical Center offers internships for students at the University of Illinois, which has a rural health track in its MSW program, and hired its first intern from Bradley University, in Peoria, in May. Unfortunately, even if the clinic offers an intern a full-time position once they graduate, it’s difficult to convince them to accept because many would rather focus on individual therapy.

Kirby Medical Center is still in the data capturing phase of its BHI program and hasn’t yet established benchmarks. According to Wells, it hasn’t been easy to build up the clinic’s staffing levels, which has impeded the process of determining the type of information and data they should be capturing and measuring. “We’re doing PHQ-9s [Patient Health Questionnaire] as a baseline and then rechecks every three months with some of our patients with certain diagnoses,” she said of data the clinic has been focusing on.

As with many practices and clinics, Kirby Medical Center’s behavioral health integration was slowed by the pandemic, so Wells is optimistic that the group will now be able to focus on strategic planning and data collection. To that end, the clinic’s therapists are becoming trained in Internal Family Systems therapy. Together with the other therapy approaches in which they have been certified, the clinic’s therapists will be able to capture patient outcome data that will help enable patients to move from active therapy to maintenance, said Wells.

Notes:

1. Bureau of Health Workforce. “Designated health professional shortage areas statistics.” March 31, 2022. Available from: bit.ly/3LamBXl.
2. Borders TF. “Major depression, treatment receipt, and treatment sources among nonmetropolitan and metropolitan adults.” University of Kentucky Rural & Underserved Health Research Center. 2020. Available from: bit.ly/40IjKKO.
3. Dewees S, Marks B. Research note. First Nations Development Institute. 2017. Available from: bit.ly/3LvnyLi.
4. Hedegaard H, Curtin SC, Warner M. “Suicide mortality in the United States, 1999-2019.” National Center for Health Statistics Data Brief, No. 398. 2021. Available from: bit.ly/3AuBTRO.
5. Piatt County Facts. Available from: bit.ly/3HaECU8.
6. For more on this, see Green C. “Laying the foundation for behavioral health integration.” MGMA Connection. January 2023. Page 60. Available from: mgma.com/bhi-jan23.