Last week, we shared and introduction of the Center for Rural Policy and Development’s research on mental health care in Greater Minnesota. We continue this week with a look at the specific challenges that must be faced to improve care:

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 rural conundrum: An unsustainable business model

While the problem in urban areas is not enough services for the volume of people, in rural areas the issue is not enough services because of a lack of people.

“One of the biggest challenges is viability for providers,” says Eric Ratzmann, director of the Minnesota Association of County Social Service Administrators. Counties are responsible for ensuring services are available, especially to those who do not have insurance, but they are not required to provide the services themselves.

“It’s hard (for counties) to set up contracts with providers if there’s no one there to contract with—if the provider can’t develop a viable business model for that area,” says Ratzmann.

The six north central counties forming Region 5+ contract with Northern Pines, which is working on becoming a full-service provider for the region. “It’s a neat trick when you don’t have a big population center,” says Anderson.

And herein lies the problem at the core of providing services in Greater Minnesota.

Sparse populations, the stigma of mental illness, long distances between communities and the resulting transportation difficulties in rural areas all contribute to fewer people seeking treatment. Fewer patients mean fewer services provided and therefore fewer reimbursements from insurance companies and Medicaid, leading to less revenue overall and less money to provide a full array of services.

In 2014, Riverwood Centers, which operated five clinics in five east central Minnesota counties, closed abruptly after one of the counties opted not to renew its contract.[6] While the area had private mental health clinics, “Riverwood was more accessible, used sliding-scale fees and served the uninsured,” Minnesota Public Radio reported at the time. Counties had to scramble to find services for Riverwood’s 3,000 clients.

In the absence of services, clients either don’t get them or local hospitals become the catch-all in mental health care. “It’s the same problem when people without insurance get health care from an emergency room. They think it’s the only place they can go,” says Anderson.

“The most common source of mental health services in rural areas is the family physician,” says Mark Schoenbaum, director of the Minnesota Department of Health’s Office of Rural Health and Primary Care. “Lack of other mental health providers means the primary care physician and medical clinic are called on to treat most mental health cases. It creates workload issues, and many physicians feel they don’t have the expertise.”

As workforce shrinks, salaries grow

Nowhere does this revenue issue have a bigger impact than in the mental health workforce. A shortage of doctors, nurses and other staff has been developing in most health care fields for many years now, especially in rural areas. (See, for instance, The Coming Workforce Shortage and The Long-term Care Worker Shortage at

In mental health care, it is approaching a crisis. The situation is considered acute for psychiatrists, psychologists and advanced practice nurses (APRNs) in all of Minnesota except the Twin Cities and the state’s southeast corner.[7] Psychiatrists and APRNs are especially important because they are the only mental health professionals able to prescribe medication.

It’s not easy to pin down just how many psychiatrists are currently practicing in Minnesota. As of April 2017, the Board of Medical Practice recorded 631 licensed doctors with a Minnesota business address listing psychiatry as their first, second or third specialty (although this does not guarantee they are working as psychiatrists).

The number of psychiatrists specializing in child psychiatry and geriatric psychiatry is much smaller: only 139 licensed Minnesota psychiatrists listed child psychiatry as a specialty, while 21 listed geriatric psychiatry and 18 listed a specialty in addiction psychiatry.

The clock is ticking. Nearly half of the psychiatrists responding to a 2011 survey by the Minnesota Department of Health were 55 or over and most were planning to retire in fewer than ten years.[8] Also in 2011, there were only 303 licensed advanced practice psychiatric nurses, and 57% of them reported themselves as over age 55.

The Northwestern Mental Health Center in Crookston is recruiting and hiring constantly, says Shauna Reitmeier, the center’s director, and they’re having a difficult time affording salaries that are rising as the supply of professionals shrinks. Other expenses, like insurance, are going up, too, all while reimbursements from Medicaid and private insurers stay almost level.

For example: At Reitmeier’s clinic, psychiatrists’ services are effectively reimbursed 30 cents on the dollar, which means that for every one dollar the clinic spends on services delivered by a psychiatrist, the clinic receives 30 cents in reimbursement. Other services that are not performed by a psychiatrist are reimbursed at about 70 cents on the dollar. The clinic makes up the gap in both cases with grants and donations.

The reason for the difference? Psychiatrists are generally the highest paid individuals in the clinic, have the most years of training and are in a very specialized field, and yet the services they provide are reimbursed at a rate not much different from other staff members.

People who started out wanting to work for organizations like Lutheran Social Service are being lured away by higher salaries elsewhere, which is creating an issue, says LSS’s D’Altilia, when it comes to maintaining continuity of services.

The Minnesota Department of Employment and Economic Development’s Employment Outlook data projects that between 2014 and 2024, the size of Minnesota’s psychiatric workforce would need to grow by 18% above what it was in 2014 to meet expected demand. However, to also fill in vacancies left by people exiting the workforce, including due to retirement, the growth need increases to 44%.

Residency and clinical opportunities, where doctors, nurses, psychologists and social workers receive their required supervised practice training, play a crucial role in the supply of mental health professionals. In 2015, 2,445 students applied for the 1,353 available positions in U.S. psychiatric residency programs, and 1,339 of those positions (99%) were filled.[9]

Residencies are also important in that students have a tendency to stay near where they served their residency. Hospitals need some incentive to provide residencies and other supervised training opportunities, however, says Teri Fritsma at the Minnesota Department of Health. For mental health providers who are not doctors (e.g., psychologists, counselors or social workers), supervision is generally not a reimbursable activity. Therefore, time spent by them overseeing a student means less revenue coming into the facility.

Impact on the community

This shortage of services and the people who provide them is having a very real impact on law enforcement, ambulance services and local hospitals as they are increasingly asked to deal with people with untreated or difficult-to-manage mental health issues.

One tricky aspect of treating mental illness is that many people are undiagnosed, and it can be hard to detect building mental health issues, says Schoenbaum. By the time a person has come to the attention of the police, the severity may be higher than it would have been with early diagnosis and treatment.

While data recording just how many police encounters involve mentally ill persons is hard to find, there is data on drug use and alcoholism, which go hand in hand with mental illness, say both Schoenbaum and Anderson. The Minnesota Department of Public Safety announced a record amount of drugs seized in 2016.[10] In addition, the Centers for Disease Control reports that while Minnesota’s population grew by 13% between 1999 and 2015, suicides increased by 67%, alcohol-induced deaths by 97% and drug-induced deaths by 286%, from 169 to 653.[11]

Law enforcement on the front lines

The intensity of the symptoms a person experiences with untreated mental illness can rise and fall over time. When severity spikes enough, it becomes a crisis, which can be anything from a deep suicidal depression to a full-on psychotic episode, where the person is reacting to things only he or she sees or hears. These situations can be extremely dangerous for both the person and those around him, as news stories over the last few years have shown. In these cases, the first call is generally to the police.

Law enforcement agencies are spending a growing amount of money on training in peaceful de-escalation methods, but once that person is under control, officers must decide what to do with him. In most parts of the state, according to the Office of the Legislative Auditor, they are pretty much limited two options: jail or the local hospital.[12]

If a law enforcement officer, family member or anyone else believes a person presents a danger to himself and/or others, the officer can take that person to an approved facility to have a qualified health care professional determine if the person should be held 72 hours for further psychological evaluation. In rural areas with few mental health care facilities and fewer open at night, and since injuries can be involved, the community hospital’s emergency department is often the most expeditious place to take someone for immediate evaluation.

Ideally, the hospital would have a psychiatric unit with staff trained to handle people who are out of control physically and emotionally, so if the hold is approved, the person would be admitted there.

If the hold is approved and the hospital does not have psychiatric beds or none available, it then becomes the responsibility of the law enforcement agency and hospital staff to locate a facility that can hold the person for further evaluation and stabilization.

That’s how it’s supposed to work. “There are statutes, and then there’s the reality of how those statues actually impact people’s lives,” says Angela Youngerberg, Director of Business Operations for Blue Earth County Human Services.

mental health Greater MN fig.4

Fig. 4: How the issue of persons with mental illness in jails compares to other issues. An opinion survey of MN county sheriffs and human services directors.

The reality is that law enforcement agencies are spending an increasing amount of time and funding on transporting people, sometimes for hours across the state or out of state to a qualified facility with an opening.

In 2014, there were 1,249 available psychiatric beds in Minnesota (not including Anoka-Metro Regional Treatment Center); 530 of those beds were outside the Twin Cities metro area, with 28% located in Rochester and Duluth alone. Only six of the state’s 79 critical access hospitals had any psychiatric beds (60 beds in total).

The problem, of course, is not only a lack of physical beds but a lack of personnel. A certain number of staff, depending on training and qualifications, can handle only so many patients safely.

Bed availability and transportation are huge issues, says Schoenbaum. To transport an acute case safely, the local ambulance and EMTs are often pulled in, too, putting pressure on small communities and counties with small forces and few EMT personnel.

“Safe, qualified transport is usually the ambulance. With the shortage of beds, the ambulance and its patient can be hours away from an available bed,” Schoenbaum says.

The Minnesota Hospital Association and the Minnesota Department of Health maintain an online directory law enforcement and health care staff can use to search for available beds online instead of making numerous phone calls. But once an available bed is identified, it may be on the other side of the state or in North or South Dakota, and even if the facility has an opening, it is not required to take in a new patient.

The Legislative Auditor’s report draws the connection between community services and the psychiatric bed shortage: “A state with strong nonresidential mental health services (such as mobile crisis teams) might need fewer inpatient beds…”[13]

According to a 2015 Minnesota Hospital Association report, a large gap exists in services especially for individuals with mental illness combined with violent and aggressive symptoms because of the limited number of inpatient beds in community hospitals, a lack of access to state-operated facilities and few community providers willing or able to accept these clients.[14]

Patients with difficult symptoms pose major problems for local hospitals that are not staffed or equipped to handle them, especially smaller hospitals. “(H)ospitals have reported instances of closing beds to additional admissions because of security concerns stemming from one patient on the unit,” MHA reported. “This means that other individuals cannot be served and staff may be at higher risk of injury.”

The Office of the Legislative Auditor’s report states, “One community hospital administrator told us … he has experienced significant staff turnover due to the hospital’s inability to transfer aggressive patients out of the hospital.”[15]

If a person is too aggressive when brought to the hospital or if he becomes aggressive while there, he may find himself in jail.

Unintended consequences: the 48-hour rule

An effort was made in 2013 to reduce the growing number of individuals with mental illnesses ending up in county jails by passing “the 48-hour rule.” The results, though, have only brought the shortage of resources into sharper focus.

Under the 48-hour rule, a person in jail must be moved to a state-run treatment facility within 48 hours of being found incompetent to stand trial, not guilty, or the charges dismissed for reason of mental illness. As of August 2015, nearly 85% of people being moved under the rule were being moved because of incompetency to stand trial.[16]

The 48-hour rule gives these individuals priority placement at a facility, and because of capacity issues or restrictions at other state-run facilities, the Anoka-Metro Regional Treatment Center has become the default facility for 48-hour transfers.

The trouble is that community hospitals are trying to get their difficult patients into AMRTC at the same time. AMRTC takes people on civil commitment who don’t warrant the “mentally ill and dangerous” designation that would send them to the St. Peter Security Hospital, but who have some type of high need or acute disorder, says Blue Earth County’s Youngerberg.

And as the line of patients gets longer, AMRTC has been operating well below its 175-bed full capacity (110 beds in 2015) because of staff shortage. From 2013, when the 48-hour rule was enacted, to 2015, the median number of days a person had to wait—usually at a community hospital—to get into AMRTC went from 33 to 53.[17]

Once individuals at AMRTC receive treatment and no longer require its high level of care, they can be sent home, provided community services like assertive community treatment, supportive housing, and transportation are available there to support their recovery.

A lack of community services at home, however, means the individual is not allowed to leave AMRTC and thus continues to occupy a bed that could be used for someone who does need to be there. This situation accounted for 35 percent of the center’s patient days from January 2014 to mid-2015, according to the Legislative Auditor’s report.

These delays now cost counties. In 2015, the Legislature began requiring counties to pay for the full cost of a patient’s care at Anoka for every day after the person was determined to no longer need hospital-level care. In 2016, CBHHs were added to the list. For fiscal year 2017, county governments are projected to spend $24 million on “medically unnecessary” days at AMRTC and state community behavioral health hospitals, says Eric Ratzman, director of the Minnesota Association of County Social Service Administrators. That’s as much as $1,800 a day per patient. The money goes into the general fund, where originally it was not designated toward anything specific. In the 2017 legislative session, however, policy was changed to dedicate some of those funds toward grants aimed at developing community services.

Check back next week for the conclusion and recommendations.