Minnesota has one of the best health care systems in the nation. But that’s not to say there isn’t room for improvement. For example, Minnesotans in Greater Minnesota who face challenges like a shortage of health care providers and long wait times for appointments likely have a different perspective Minnesota’s two-tier status than those in the metro area. The metro-rural health divide has been the topic of study and conversation for many of the state’s leaders.

Mental health care is another area where Minnesota could improve. Last summer, the Minnesota Hospital Association declared mental health “the most challenging crisis facing Minnesota.” Olmstead County Commissioner Sheila Kiscaden told Minnesota HealthBasics “Minnesota’s mental and behavioral health services are in crisis at every level.”

The Center for Rural Policy and Development, a think-tank based in Mankato and focused on issues pertinent to Greater Minnesota, recently examined how these areas for improvement overlap in a new study. Part one of the study follows, check back next week for the next installment.

Mental health services in Greater Minnesota

Limited resources are putting growing pressure on rural communities

By Marnie Werner, Research Director, Center for Rural Policy and Development

The mobile crisis and outreach teams of the Northern Pines Mental Health Center in Brainerd are busy. In 2016, they made 1,200 calls in the counties they cover—Aitkin, Cass, Crow Wing, Morrison, Todd and Wadena—and most of those calls were to emergency rooms at the counties’ seven local hospitals.

“That’s a lot,” says Northern Pine’s director, Glenn Anderson, more than Dakota County, which has more than double the population of Anderson’s six-county region, but Northern Pines has a good crisis response program, he says.

Other communities in Greater Minnesota aren’t as lucky. Mobile crisis teams are part of a continuum of care for people with mental illnesses called community-based services, and these services are vital to helping people manage their symptoms and recover from their mental illnesses. (Learn more about mobile crisis teams.)

As the name suggests, these services are offered through clinics and private offices in the community, where the person lives, rather than via an institution. Unfortunately, community services are inconsistent around the state, ranging from adequate to non-existent. No region is immune from a shortage in at least some services, forcing the people who need them to travel long distances or not access them at all.

Mental illness and how we as a society handle it is a sensitive subject. But even a quick look at the situation shows that lack of access to mental health care has real impacts. Without it, the seriously ill can find themselves debilitated, unemployed, homeless, in a revolving door of incarceration or worse. At the same time, first responders, hospitals, general practice doctors, families, teachers and employers are finding themselves increasingly on the front lines, confronting and trying to help those whose symptoms have gone out of control.

The fact is that we have a system that is incomplete, underfunded, woefully understaffed and unable to serve many of the people it is supposed to help, which in turn leads to higher costs for us all as we deal with the fallout in inappropriate ways.

“What we do have (in services) is pretty good, especially compared to other states,” says Sue Abderholden, director of the Minnesota branch of the National Alliance for Mental Illness, but those services aren’t consistently available or robust enough to meet demand.

The role of community services

There has been some improvement in recent years with increased funding, studies by two state task forces, some new innovative workforce programs and community efforts, but they have been mostly isolated fixes, according to those involved in mental health services.

From above, the mental health care system looks like a web of services covering the state, anchored by private, mostly nonprofit providers and a handful of state-operated facilities. The strands holding the web together are community-based adult mental health services, ranging from outpatient therapy to intensive residential treatment. (See here for definitions of the different community-based services.[1])

And these services are needed. It’s estimated that 20% of the population has some type of diagnosable mental illness, but only about half are receiving treatment. It’s also estimated that a large percentage of people in county jails (as much as 60%, says Abderholden) and people with substance abuse issues have mental illnesses that are likely diagnosable and treatable.

Until the 1970s, society addressed mental illness by housing people in institutions, or “mental hospitals.” At that time, the federal government began directing the closure of these institutions.

The plan was that instead of housing patients at large, distant, isolated facilities, people would instead be able to access the services they needed close to home through a network of community-based services.

Most Minnesotans with mental illnesses are much better off now than they were under the old system of large institutions, says Abderholden.[2]

The number of mentally ill patients in Minnesota’s state hospitals went from a peak of over 10,000 in the 1950s to less than 2,000 in 1980. By 2008 the state had closed all but two of its large hospitals, leaving only facilities at Anoka and St. Peter. Work started on community-based services in 1976, but in 1987, the Legislature put the responsibility for developing them on the Minnesota Department of Human Services and the counties.[3]

According to a report by the Office of the Legislative Auditor, though,[4] 30 years later, the web of services across the state still looks thin and inconsistent in many areas, with large gaps that the ill can easily fall through.

Spotty services in rural areas

In general, about 3% of the population has a “serious” mental illness and about 2% suffer from a “serious and persistent” mental illness. Ideally, a person would seek care (fig. 1) early on, when illnesses are the most treatable. But at whatever point individuals enter the “continuum of care,” they would receive a combination of treatment and services to help them move through the stages of recovery.

Mental health in greater MN fig 1

Fig. 1: Mental health continuum of care.

A 2015 report from the Minnesota Department of Human Services (DHS) shows the spottiness of services (fig. 2). Looking at their availability by adult mental health service region (formed to help counties by pooling resources for more efficient service—fig. 3), no one region meets demand for every service,[5] and almost all of them are lacking in at least one critical service.

mental health in greater MN fig 2

Fig. 2: Availability of community-based services (2015).

For instance, as of 2015, more than 50 counties had no permanent supportive housing for mentally ill adults, and nearly 40 had no adult assertive community treatment services.

mental health in greater mn fig 3

Fig. 3: Adult Mental Health Regions.

Region Northwest 8, the adult mental health service region serving the counties in the northwestern corner of the state, had a level of
access in 2015 that met demand for adult residential crisis services (a place where a person in crisis can safely stay overnight) and mobile crisis response teams, according to DHS. The region also had limited access to adult rehabilitative mental health services and adult intensive residential treatment services, but no access to adult permanent supportive housing services or assertive community treatment services, where health care professionals treat a person at home, making a hospital stay unnecessary. (Things may have changed since 2015.) Every region has similar gaps in services.

Services for children are even rarer. “In outstate, you have to start talking about the sparsity of providers, about how far away they are, how far parents have to drive, especially up north. The question then is how to make sure (children) and parents get there,” says Tom Delaney, supervisor of Interagency Partnerships in the Special Education division of the Minnesota Department of Education.

Minorities and immigrants face even larger barriers to services.

“Cultural communities are diverse—their faith, their values may be different from ours,” which can make these groups difficult to reach, says Louisa D’Altilia, senior director for Behavioral Health Services at Lutheran Social Service, which provides mental health counseling services around the state.

Minnesota needs to create diversity in its mental health system, but it’s slow to happen, D’Altilia says.