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Practice Directorate Office of Rural Health APA Rural Health Initiative 1999 Year in Review Executive Summary
The rural initiative of the American Psychological Association encompasses the work of the APA Committee on Rural Health and the efforts of the APA Office of Rural Health working with partners at the state and federal level. The objective of the initiative is to help insure that the behavioral health care needs of Rural and Frontier Americans are met. During 1999 the APA Rural Health Initiative achieved significant progress in advancing its mission in the following areas:
In future years the APA Rural Health Initiative will assist the Association in addressing areas such as the following in order to insure that the highest quality behavioral health care is available to all rural and frontier citizens:
The American Psychological Association has identified rural health as a priority. Through the establishment of the Office of Rural Health and the Committee on Rural Health, the APA has committed resources to addressing the behavioral health care needs of individuals residing in rural and frontier areas where behavioral health care providers and services are in short supply. Members of the APA Committee on Rural Health and staff members of the APA Office of Rural Health, working in conjunction with state psychological associations, federal and state agencies, national organizations with an interest in rural populations, and the U.S. Congress and state legislatures, continue working to advance the cause of improved behavioral health care for rural Americans. The Committee on Rural Health, working in conjunction with the Committee for the Advancement of Professional Practice, recognizes that rural America offers opportunity for innovation and creativity in the delivery of behavioral health care services. Several current areas of emphasis characterize the work of the Committee. The application of technology to the expansion of psychological practice is seen in the Committee’s work in the telehealth arena. The importance of collaborative care relationships as psychologists team with other health care providers to improve services to rural residents is being highlighted in the Committee’s upcoming handbook on providing behavioral health care to rural residents. Expansion of the roles of psychologists in rural and frontier areas by advocating for prescriptive authority for psychologists is also an important part of the Committee’s agenda. Working to improve the legislative/advocacy skills of psychologists and state psychological associations is another avenue for involving psychologists in those decision-making processes, which directly impact the practice of our profession. The Committee has also worked to address the needs of special groups of rural residents as was demonstrated by the Rural Women’s Work Group’s study of the behavioral health care need of rural women. And, in the near future, the Committee will begin to address the needs of persons with serious mental illness and the types of delivery systems needed to meet those needs in rural communities. Katherine C. Nordal, Ph.D. James G. Hill
This is a report of the Rural Health Initiative of the American Psychological Association (APA). It identifies activities undertaken in 1999 by the APA Committee on Rural Health and efforts in support of the initiative by the APA Office of Rural Health, which is staffed and resourced by the APA Practice Directorate. In addition, the report contains a brief history and background for the initiative, information on the Committee and Office of Rural Health, and a description of possible future activities. This first report on the APA Rural Health Initiative takes the place of the APA Rural Health Bulletin, a newsletter that has been previously published. It will be repeated in future years and will serve as a record of the many activities undertaken by the American Psychological Association to support and provide quality health care for rural and frontier Americans. At its June 1992 meeting, the APA Board of Directors created an APA Rural Health Task Force to deal with issues related to the behavioral health care needs of rural residents. The Task Force worked for four years with the APA Office of Rural Health and the Practice Directorate to accomplish a number of projects that facilitated the work of psychologists in meeting the behavioral health care needs of rural Americans. The accomplishments included developing innovative models of practice, an interdisciplinary training curriculum for the delivery of behavioral health care to rural areas, opening of federal rural programs to psychology, and the use of telehealth technology by psychologists to deliver psychological care to their rural patients. In August 1996, the APA Council of Representatives, the governing body of the Association, approved a proposal to make the Task Force a Continuing Committee of the Association. The Council approved the following mission: The mission of the Committee on Rural Health shall be to address the full breadth of issues affecting the health of citizens living in rural and frontier America. The Committee will study and attempt to ameliorate health and mental health problems that may yield to the special knowledge and competence of psychologists. The Committee will identify and develop programs to meet the needs of residents of these areas. Linkages of psychologists with other health providers in these areas will be promoted to enhance the assessment and treatment of health problems with a behavioral component.@ The Committee on Rural Health (CRH) reports to the APA Board of Directors and the APA Council of Representatives through the APA Committee for the Advancement of Professional Practice (CAPP). The 1999 CAPP liaison to the Committee on Rural Health is Robert Resnick, Ph.D. Membership of the APA Committee on Rural Health
APA Office of Rural Health Staff Roster and Functions
The Office of Rural Health is responsible for the expansion of practice opportunities for psychologists to provide behavioral health care in rural areas through the administration of projects in the areas of practice, education, science, and the public interest. It provides staff support to the meetings and convention program of the APA Committee on Rural Health and insures close coordination of the work of the CRH with CAPP. In addition to supporting the work of the CRH, the Office of Rural Health performs liaison and advisory roles with government agencies such as the Office of Rural Health Policy, the National Institute of Mental Health, the National Health Service Corps, the Bureau of Health Professions, and the State Offices of Rural Health. It also performs the same roles with professional organizations such as the National Rural Health Association, the American Academy of Family Physicians, and the Capitol Area Rural Health Roundtable. The office is also responsible for developing and maintaining a website, RuralPSYCH that serves as a resource center for rural behavioral health care for providers, purchasers, and consumers of behavioral health care in rural and frontier areas. The site provides information on policy, practice, and training on rural behavioral health care. Psychologists can use this website to communicate with each other and access expert information resources in tertiary care centers, government agencies, and academic institutions. The website, RuralPSYCH, contains a button that visitors can click on and Join the Initiative by answering a brief questionnaire. This enables psychologists and others interested in the APA Rural Health Initiative to become part of a database maintained by the APA Office of Rural Health for the purpose of information dissemination and project development. The database is used as the basis for distribution of this report. During 1999, the APA Rural Initiative achieved significant progress in advancing its mission. Highlights of this progress are described below. Readers interested in additional information on the projects described should contact the APA Office of Rural Health by calling 202.336.5896 or sending an email note to Rural Health Advocacy in support of the APA Health Policy Agenda with particular reference to rural and frontier populations From its inception, the Committee on Rural Health has devoted one meeting day each year to advocate with members of Congress and their staffs to advance the APA Health Policy Agenda. At their meeting in March 1999, members of the CRH visited congressional offices and advocated for the Norwood/Dingell "Patient’s Bill of Rights". Study and Analysis of Managed Care in Rural Areas A member of the APA Committee on Rural Health, Doug Wear, Ph.D., has worked with the Office of Managed Care in the Practice Directorate to gain an understanding of the determinants for the spread of Managed Health Care to rural and frontier areas and to analyze the consequences for rural behavioral health. He presented his findings at the 1999 Conference of the National Rural Health Association in San Diego, CA in May and at the 1999 APA Convention in Boston, MA in August. His presentation addressed:
Study and Analysis of the Application of Telecommunications Technologies to Rural Health Two members of the APA Committee on Rural Health, Antoinette Anker, Ph.D. and Beth Hudnall Stamm, Ph.D., have taken lead roles in various efforts by the APA to explore the development of policy for the association that would aid and guide psychologists in the use of this new modality in such areas as licensure, confidentiality, reimbursement, etc. Although these modalities have the potential to alleviate the shortage of behavioral health care services in rural areas, the application of this innovation must be accomplished in an ethical and effective manner that provides better, not Avirtual@ behavioral health care to rural populations. Development of the Rural Women’s Work Group Report Members Pamela Mulder, Ph.D., Pam Thurman, Ph.D. and Sylvia Shellenberger, Ph.D. have served on a ARural Women=s Work Group@ (RWWG) that has developed a report on AThe Behavioral Health Care Needs of Rural Women@. Other members of the RWWG include Mary Beth Kenkel, Ph.D., Madonna Constantine, Ph.D., Delia Saldana, Ph.D., and Regina Striegel, Psy.D. Presentations on the report have been made at the 1999 meetings of the National Rural Health Association and the American Psychological Association. The report presents a survey of the current literature related to physical and mental health concerns of the 30 percent of American woman who are rural and frontier residents. Its major findings are that they are a large population representing diverse cultural, ethnic, and economic backgrounds, but there is a dearth of research concerning their behavioral health needs. The research that has been reported is specific to very limited regions, or, when larger samples are employed, demographic information including age, ethnicity, and cultural background are not provided. Despite their diversity, rural women share experiences and have common challenges, including isolation, distance from major metropolitan centers, geographic barriers, inclement weather, poverty, substandard housing, and limited opportunities for employment. Social and educational resources are lacking. There are fewer trained professionals to provide services, little or no public transportation, and, in many instances, minimal communication systems. The cultural attitudes in rural communities frequently exhibit preferences for self-reliance, distrust of strangers, stigmatization of persons with mental and certain physical illnesses, acceptance of self-perceived poor health, and patriarchal traditionalism. These attitudes are expressed within an environment of dense social relationships and strong kinship ties, resulting in a lack of anonymity, compromised confidentiality, and questionable provider objectivity. Economically, rural women earn lower incomes and are less educated than their urban counterparts. The vast majority of the most impoverished U.S. counties are rural. More than half the substandard housing in the U.S. is found in rural counties. Women who work outside the home frequently face a "second work shift" of the traditional homemaker’s duties and, in many cases, a "third shift" related to farm chores. There are usually fewer child care options available for rural working mothers. The available employment in rural areas is frequently very labor intensive, favoring male over female workers. Socially, rural women are more likely than urban women to be married, to care for extended families, and to have children earlier in life. A greater proportion of rural births is to teenage mothers, and rural women are less likely to have abortions. Fertility rates are higher in rural areas and fetal, infant, and maternal mortality rates are disproportionately higher. Elderly women are disproportionately represented in rural communities. Rural residents suffer higher incidences of chronic illness, experience greater disability and morbidity related to diabetes, cancer, hypertension, heart disease, stroke, and lung disease. They are more likely to be involved in an injury-producing accident due to the more dangerous rural environment (e.g., farm equipment). Rural women are at risk for exposure to toxic agricultural chemicals, resulting in higher incidences of non-Hodgkins lymphoma, leukemia, multiple myeloma, and cancers of the breast, ovary, lung, bladder, and cervix. Rural women are more likely to smoke, even during pregnancy, and to be obese. They are likely to exercise less or to utilize preventive services. They frequently seek help at a late stage in their illness and seriously underestimate the risk of such conditions as AIDS. Rural women are at great risk for depression and stress-related disorders, although these are less likely to be diagnosed by rural practitioners. Rural women also have higher rates of alcohol abuse and dependence than urban women and are more likely to report bouts of heavy drinking. Young rural women who commit suicide are more likely to employ firearms. Rural spouse abuse and the incidence of completed rape are more prevalent in rural than in urban areas. The isolation, anonymity, and lack of support services common to many patriarchal rural communities limit the alternatives available to victims of violence. Not only are the needs of this silently suffering population easily ignored, there are limited resources and few professionals to address the problems that are identified. There are few medical specialists outside of family practice. The Center for Mental Health Services reports that fifty five percent of U.S. counties are not served by a psychologist, psychiatrist, or social worker and all of these counties are rural/frontier. Rural women are unlikely to have health insurance and there is great reliance on Medicare and Medicaid. Poor funding of behavioral health care has resulted in understaffing, the use of less well-trained providers, and limited options for continuing education and professional consultation. After presenting these findings, the report ends with recommendations for psychologists, physicians, other health care providers, professional organizations, and policy makers. The report also includes vignettes, which present examples of community oriented interventions and strategies, which have been successful in many rural regions. Among the most important recommendations are those that identify the need for interdisciplinary cooperation, specialized training for rural practice, the use of innovative technologies to increase the availability of services and specialists, involvement of indigenous paraprofessionals, preparation of culturally competent providers, and political activism focused on identifying and meeting the behavioral health care needs of this large, diverse, and often overlooked population. Interdisciplinary Collaboration for the Delivery of Rural Health Care The APA Committee on Rural Health has undertaken the development of Behavioral Healthcare in Rural and Frontier Areas: An Interdisciplinary Handbook. This volume, to be published by APA Books, will be the continuation and expansion of an effort begun in 1995. Then a curriculum, Caring for the Rural Community: An Interdisciplinary Curriculum, was developed by the Committee on Rural Health and the Office of Rural Health. CRH member Beth Stamm, Ph.D. is serving as the general editor and many of the other CRH members are writing chapters. The handbook will incorporate the following features:
The chapters will be organized into the following four sections:
Target date for publication of the Handbook is late 2000. Rural Health Networking Networking opportunities (e.g., collaboration on policy development, advocacy to support mutual interests, and rural health program development) have been pursued with the National Rural Health Association (NRHA) and the National Organization of State Offices of Rural Health (NOSORH). State Psychological Associations have been encouraged to network with State Rural Health Associations and State government Offices of Rural Health. The CRH and Office of Rural Health staff members will participate in the 2000 NRHA meeting in New Orleans. They will be presenting on various behavioral health subjects and developing a plenary session on "Rural Adolescent Male Violence" that will feature the materials developed in the Practice Directorate’s anti-violence initiative such as the brochure titled "Warning Signs" developed through collaboration by the APA with MTV. National Health Service Corps Loan Repayment The staff of the Office of Rural Health has worked closely with the APA Public Policy Office to promote participation by psychologists in the Loan Repayment Program of the National Health Service Corps. This program makes behavioral health care delivered by psychologists in primary care settings available to residents of Mental Health Professional Shortage Areas (MHPSA’s). Over 70 percent of MHPSA=s are in rural areas (the others are in the inner city). During 1997, 13 psychologists were recipients of NHSC Loan Repayment. In 1998, this number grew to 35. The number for 1999 is not yet available. NRHA Policy Paper on Rural Mental Health Services The staff of the Office of Rural Health has worked with the membership of the NRHA to develop a Policy Paper on Rural Mental Health Services (it is an attachment to this report). The paper was reviewed and endorsed by the Rural Health Policy Board, the governing body of the National Rural Health Association, and this policy paper with its recommendations become NRHA policy. Prescriptive Authority Rural residents are chronically underserved for health services, and knowledgeable providers to prescribe psychotropic medication are particularly scarce in rural and frontier America. Older people are disproportionately represented in rural populations and their medication needs are greater than younger populations. For these reasons the APA Rural Initiative is an important part of the quest for prescriptive authority for psychologists. The APA Committee on Rural Health has identified prescriptive authority as one of its priority issues. [As part of this effort, the CRH is developing a proposal for a symposium at the 2000 APA Convention on the topic, "Strategies for Obtaining Prescriptive Authority in Rural States."] ?? ask Katherine!!! Advocacy in the New Millennium The CRH proposes to develop an advocacy effort in conjunction with the 2000 APA Convention to advance the APA Health Policy Agenda with the U.S. Congress with particular reference to the Rural and Women’s Caucuses in the House and Senate. The effort will focus on issues current at that time and will feature the Report of the Rural Women’s Work Group and the APA Rural Interdisciplinary Handbook. Promotion of Graduate Training with a Rural Emphasis |
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