Population Health and Health Policy

This paper summarizes the clinical skills and prescriptive authority of Advanced Practice Psychiatric Nurses, and investigates current trends in their geographic distribution to determine what their future role may be in addressing rural mental health needs.

Context: National data demonstrate that mental health visits to the emergency room (ER) comprise a small, but not inconsequential, proportion of all visits; however, we lack a rural picture this issue.

Purpose: This study investigates the use of Critical Access Hospital (CAH) ERs by patients with mental health problems to understand the role these facilities play in rural mental health needs, and the challenges they face.

Methods: We collected primary data through the combination of a telephone survey and ER visit logs. Our sampling frame was the universe of CAHs at the time the survey was fielded.

Key Findings: 43% of CAHs surveyed operate in communities with no mental health services, while 9.4% of all logged visits were by patients identified as having some type of mental health problem. The most common problems identified were substance abuse, anxiety and psychotic disorders. Only 32% of CAHs have access to onsite detoxification and 2% have inpatient psychiatric services, meaning that patients in need of these services typically must leave their communities to gain treatment.

Conclusions: The lack of community resources may impact CAHs ability to assist patients with mental health problems. Among those with a primary mental health condition 21% left the ER with no or unknown treatment, as did 51% of patients whose mental health condition was secondary to their emergent problem. Patients in need of detoxification or inpatient psychiatric services often must travel over an hour to obtain these services, potentially creating significant issues for themselves and their families

Released in June 2008, this study examines the distribution of substance abuse treatment services across the continuum of rural and urban counties, identifying the type and intensity of services provided. Using the 2004 National Survey of Substance Abuse Treatment Services linked to the 2003 Rural-Urban Continuum Codes, we found few substance abuse treatment facilities operating outside of urban and rural adjacent areas and limited availability of intensive services across rural areas. This situation is particularly striking for opioid treatment programs, which are nearly absent in rural areas. The narrow range of services available in rural areas may preclude an individualized treatment approach and long-term follow-up recommended by professional organizations and other experts. The greater proportion of rural-based facilities accepting public payers and providing discounted care may reflect higher rates of uninsurance and underinsurance.