Access to mental health care in rural Missouri is improving.
Improvement had been slow but began to pick up the pace about two years ago with the introduction of Certified Community Behavioral Health Clinics (CCBHC).
The federal government created the program two years ago, according to Brent McGinty, president and chief executive officer of the Missouri Coalition of Community Behavioral Healthcare.
“We’ve known for many, many years that there’s been an access problem for mental health care across the United States and particularly in rural parts of the country and the state,” McGinty said. “That has slowly begun to change in Missouri.”
Federal authorities created the CCBHC program to begin dealing with the shortage of mental health services offered in rural communities. The clinics are required to provide mental health crisis services, screenings and assessments, patient-centered treatment planning, outpatient mental health and substance use services, primary care screenings, case management, psychiatric rehabilitation services, peer and family support, and intensive community-based mental health care for veterans and members of the Armed Forces.
The project has improved access to care, McGinty said.
“It changes how providers are paid, and it changes how providers offer their business,” he said. “It’s the biggest change in behavioral health care in generations.”
Instead of paying providers for each face-to-face visit with patients, which encourages multiple visits, the program pays for a continuum of care through the course of the day. Providers are paid the same whether they are seeing patients or not. The program allows providers to have staff available for when they are needed.
Taking clinics to patients
There are currently 113 CCBHCs operating in 21 states, according to the National Council for Behavioral Health. That includes 66 clinics in the eight states chosen for the original Medicaid demonstration program — Missouri, Minnesota, Nevada, New Jersey, New York, Oklahoma, Oregon and Pennsylvania.
Missouri has the highest number of clinics of the states in the program with 15 and the highest number of access points (clinical sites) with 200.
Data shows, in the first two years, the number of patients receiving medication-assisted treatment in the program has increased 83 percent.
The number of patients served increased by about 20 percent, from 122,425 to 146,530. Program organizers credit the improvement with having someone immediately available to assist when people experiencing a crisis arrives at emergency rooms.
The CCBHC’s Emergency Room Enhancement Project puts the providers on site, or on call, within hospital departments. It is aimed at keeping someone who often shows up in emergency rooms from taking up resources. They may be given a card after the crisis and directed to make an appointment with a mental health care provider weeks in the future, according to Dorn Schuffman, the project lead for CCBHC. They were unlikely to show up for the appointments, whether the need has gone away or not.
“We’ve gone to same-day access,” Schuffman said. “The time to see a mental health professional has dropped immensely — from weeks to same-day.”
Friendly faces
Staff divert people who have nowhere else to go and are arriving at expensive emergency rooms to the program’s mental health provider.
“We can put a warm, friendly face — and someone who has been trained — in the emergency room and say, ‘Hey, let’s talk about this and find a plan to get you care that’s better,’” McGinty said. “Tied to that, a critical thing we are all learning is the importance of people with lived experiences in our system.”
He explained someone who has an overdose and ends up in the emergency room may not be receptive to law enforcement trying to talk to them. But they may listen to a peer who says, “Don’t feel hopeless; I’m two years without use.”
Through the CCBHC program, school-based services increased 81 percent. During the 2018-19 school year at Joplin Middle School, the school identified 300 students with suicidal ideations, self-harm, depression, emotional distress and other behaviors. Staff referred 230 of those to CCBHC for mental health services. No suicides occurred during the school year, according to the CCBHC data.
In the first two years of the program, the program reduced hospital and ER visits more than 23 percent.
And law enforcement referred 38,277 people to CCBHC for care.
Partnerships with health care providers and law enforcement are crucial to success of the clinics, McGinty said.
Crisis Intervention
The program would like to get 25 percent of rural county and city law enforcement officers trained as Crisis Intervention Team members, he said. Team members have the tools to de-escalate crises and help patients get the care they need.
Jason Klaus, a detective with the Perry County Sheriff’s Office (about an hour south of St. Louis), is the Missouri CIT state coordinator. The sheriff’s office allows him to spend 90 percent of his time acting for CCBHC.
Crisis intervention team members receive 40 hours of intervention training. They continue with monthly meetings, Klaus said.
CIT members are not mental health providers, but they are oftentimes the first people on scenes with intervention training.
“The historic response of locking somebody up in a jail doesn’t solve anything. And waiting for hours and hours in an emergency room doesn’t help anything,” he said. “We’re trained to do an assessment and get them on to the next level of care.”