This week we have a guest blog post from Carlos Herndon who is a Certified Application Counselor at the Bullhook Community Health Center, Inc. in Havre, Montana. In this two-part series, which will conclude next week, he addresses the challenges that exist in rural areas as it relates to the treatment of substance abuse with some additional parallels to finding treatment for people with disabilities.
The Mayberry Illusion
Mayberry was the name of the small rural town on the Andy Griffith Show. A town where crime was low and the only person who struggled with abuse was Otis the lovable town drunk. Many Americans believe this is the picture of rural life. Serene, peaceful, and far removed from the problems of city life. This led to little research or strategy development into the challenges faced by rural communities. The reality of rural life is far different from the idealized perception. Montana where 80% of the state is still officially classified as Frontier with less than 5 people per square mile provides a good sample of rural life in America. Despite its population being scattered mainly among towns of less than 5,000 people its substance use issues loom large today and for the future. Rural populations have higher rates of alcohol, meth amphetamine, and prescription drug abuse than city populations but far fewer treatment options, providers, and resources available to help overcome these issues. Montana has a substance/alcohol abuse rate nearly 1.5 times the national average. For Montana’s youth drug/alcohol use begins on average at age 13. In my service area in north central Montana 30% of high-school youth will graduate already having or being at risk for a substance/alcohol addiction. Recognizing this allows us to develop effective strategies to overcome these challenges. We will focus on the solutions we have used to overcome the challenges and to develop successful treatment programs. In this post we will focus on distance while in a future post, we will address age and independence. Addiction Counselors across the region noted these were the 3 most common challenges that they faced: Distance patients had to travel for services, the young age at which Montanans begin using alcohol and drugs and the Independence of individuals that prevents them from seeking help and are universal issues common in rural areas.
In rural areas patients often have to travel long distances for care or treatment. This challenge is greater for those seeking substance treatment and those with disabilities due to the lower number of specialists offering treatment services. Many of those seeking help already have transportation challenges to overcome. For many who are on the margin of financial stability personal transportation is unreliable for long distance travel or simply nonexistent. Others may have lost their mode of transportation or their right to drive through the courts. For those with disabilities (13.1% of Montanans under age 64 and 27% of those over age 64) the challenges and degree of difficulty is multiplied exponentially. Many require care provided by specialists. Most specialists are based almost exclusively in the larger cities or far too often located out of state. Within my service area the minimum distance to visit a specialist for adult care located in Great Falls means a round trip of 250+ miles and in many cases the specialists only have offices in Billings a 500 mile round trip. Montana has few pediatric specialists available and most families have to make trips to Seattle or Denver for care. While some public transportation is available to Great Falls the service is limited and no public transportation is available to Billings. In winter, especially, many are forced to delay or forego even necessary care simply because safe reliable transportation is unavailable. Only 43% of those with mental disabilities and 59% of those with physical disabilities in rural areas receive treatment.
The main causes for between 40-57% of those with disabilities not receiving consistent treatment were cited as 1) Lack of providers, 2) lack of transportation and 3) poverty and income disparities. These 3 factors link together creating serious disadvantages. The remoteness of rural areas, lack of services, and earning potential means they attract fewer providers which causes persons in need of treatment to travel farther which because of higher poverty levels and lower wages places an almost insurmountable burden on them. The Successful treatment programs have found they must do 3 things. 1) They must make transportation means available to those seeking treatment. 2) They must make themselves and their services available in diverse locations. 3) Pool resources bringing multiple providers together to offer a variety of service. A strategy used by several treatment centers in Montana was to partner with the Opportunity Link programs ran through the local area Human Resource Development Council. The Opportunity Link program was already running its own fleet of shuttle buses to remote communities to provide transportation for students and workers to provide access to education and employment opportunities and are linked in with the tribal transportation programs shuttle designed to provide tribal members with access to services. They worked to expand the program grants to add routes that included health care providers. This allowed patients needing treatment who lived far away, did not have transportation, or could not drive in winter conditions to have reliable year round transportation. This led to significant increases in patients completing their treatment programs and corresponding decreases in missed appointments, incompletion of treatment programs, and relapses. The second key to overcoming the distance challenge was to become more available in multiple locations especially those without transportation opportunities. They worked with community leaders in the smaller more remote towns to find available locations they could use as satellite offices or clinics where they could do individual and group treatment once a week or as needed. They saw an increase in patients utilizing their services and chances to improve their relation with community leaders and residents of remoter communities who were impressed by their willingness to devote the time, effort, and resources to come out and serve their community. Third, organizations began to partner together to pool providers and offer more services and treatments especially those that were working in more remote areas.
Next week, we will look at the other two challenges of age and independence.