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For nearly a decade, behavioral health providers in Minnesota have pushed to increase access and reduce wait times for substance use disorder treatment for low-income residents.
To do this, state officials have reworked a system that has been in place for more than 30 years—one that requires low-income people seeking treatment sometimes to wait more than a month to receive state-funded care.
Policymakers’ solution, called Direct Access, was implemented last summer, promising rapid assessments and care for people seeking treatment.
But because of pre-existing loopholes in the state’s behavioral health care system — such as those limiting care options in other states — that promise of immediate treatment is not reaching some residents of rural Minnesota.
Providers say shortages are a matter of life and death.
The need for behavioral health treatment in rural communities nationwide has been exacerbated by the ongoing flood of fentanyl in rural areas. Providers say an increase in need coupled with a rural workforce shortage has hampered rollout of the new Minnesota system because it hinges on the availability of licensed alcohol and drug counselors, which are in short supply in rural Minnesota.
Direct access was Minnesota’s way of joining in what other states have done for some time: letting treatment seekers choose their providers.
Previously, Minnesotans seeking publicly funded treatment had to wait for officials in their county to approve their application and refer them to a provider. But the change also highlighted pre-existing challenges For the treatment of substance use disorder in rural areas nationwide.
In many states, rural areas suffer from a shortage of behavioral health providers. This deficit persists even though, compared to more densely populated places, rural areas have more people living in poverty and more people who are potentially uninsured or uninsured—both risk factors for substance use disorders.
“We realize that it may not be feasible to have specialists everywhere,” he said. Tim McBrideLouis, a professor at Washington University in St. Louis and a health staff member of the Institute for Rural Policy Research. “But if you don’t have that local provider, it’s not good for the patient.”
Providers in Minnesota say a shortage of local practitioners in rural areas means systemic changes made months ago aren’t working for many patients.
At Riverwood, a treatment center in Otsego overlooking the Mississippi River, nearly 50 inpatient beds are empty because the facility is not fully equipped. To fill those beds, he said, the facility would need to hire at least 10 consultants Tim Walshchief of behavioral health at NorthStar Regional, which operates Riverwood.
Of the 90 patients in inpatient and residential care in Riverwood, Walsh said, about 90% are funded through direct access or Medicaid, and at least half of the program’s patients are from rural areas.
Staffing shortages have forced the facility to redirect people seeking treatment, but Walsh said the center has no way of knowing if people have been accepted to another provider.
“If they are not with us, we know they are in danger of dying,” Walsh said. “It’s what keeps us up at night.”
Sadie Brockmire, a licensed alcohol and drug counselor in rural Kanabec County, about an hour’s drive north of Minneapolis, is loath to turn away potential direct access patients. Its women’s treatment center, Recovering Hope, is one of only five providers in the state offering family therapy. The facility has an on-site daycare for children under the age of 5.
Broekemeier, who is also president of Recovering Hope, said the facility is trying to avoid turning people away. “And we make a family for them.”
The facility is licensed for 108 beds but does not usually use that many. He was not available on the last Thursday afternoon when the mother arrived to seek treatment with her child.
“But our team went and took some beds from the shed,” Broekemeier said. “We will not expel them.”
However, women sometimes end up on the facility’s waiting list.
Prior to direct access, low-income Minnesotans were assessed by officials in the county where they lived to determine if they were eligible for publicly funded addiction treatment. Within direct access, people can instead go directly to a provider to be evaluated by a licensed counselor and receive care immediately, if they qualify.
To find their nearest provider, people looking for treatment can visit the state-run search engine FastTrackerMN or the Federal Administration on Drug Abuse and Mental Health Services treatment specific.
Most of the state’s licensed counselors are located in or near the Twin Cities, resulting in a population-to-counselor ratio three times greater in rural areas of the state than in urban areas. Before direct access was launched, the Minnesota Association of Chemical Recovery and Health Resources, MARRCH, a group of addiction treatment professionals, said the requirement that assessments be conducted by counselors, and not other treatment personnel, would exacerbate the disparity created by counselor shortages in rural areas. .
That wasn’t news to state officials who, in anticipation of challenges, instituted a nearly two-year transition period, during which direct access and the former county’s evaluation process took place simultaneously.
“Since this is a change from a process that has been going on for nearly 40 years, we realized that people may need time to make the change.” Jennifer SatherDirector of Substance Use Disorder Services at the Minnesota Department of Human Services. “We realized with this transition that time would be required to ensure that qualified personnel were in place to do these documents.”
That transition period ran from October 2020 to June 2022.
Sather also said the state embarked on direct access despite a workforce shortage because it expected only an incremental increase in requests to assess patients’ behavioral health concerns.
But the roll-out has not been smooth, particularly in places where the shortage of advisers is acute.
Thirty-six of Minnesota’s 87 counties have five or fewer counselors based in them. Twelve have no licensed advisors whatsoever. Each of the 36 rural counties.
He said these disparities with counselors particularly hinder the experience of direct access for people imprisoned in rural areas Marty PaulsonCEO of the Turnabout Project, which operates several treatment centers.
“They may have to wait five to 10 days to get an assessment because there are not enough counsellors to do that,” she said.
Recent expansions in telehealth have allowed counselors to conduct virtual assessments, but such communication does not eliminate the “treatment desert,” in which residents have to drive for hours to receive residential or outpatient care, he said. Amy DiloChairman of the Marsh Board of Governors.
She said telehealth was not “a panacea, of course, to correct some of the disparities”.
The Range Mental Health Center in the Mesabi Iron Range faced similar recruitment challenges. its Director of Substance Use Disorders Services, Dave ArchambaultIt operates both inpatient and outpatient programs, with a staff of three consultants.
Archambault said direct access is a good idea but “it doesn’t always work for us here, just because of the staff. So if someone walks off the street, we may not have the staff to provide that service right away.”
The state implemented direct access in part to shorten wait times for treatment, which were sometimes weeks under the county-led system. At the time, the state’s Department of Human Services mandated that counties complete the evaluation within 20 days of a person’s request for an appointment and provide results no more than 10 days later. Under direct access, providers are supposed to complete assessments within three days, fulfilling the policy’s promise that those in need have “immediate access to care.”
Archambault appointed a fourth chancellor earlier this year, so he expects direct access to the center will be faster going forward.