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When compared with urban areas, rural areas tend to have similar rates of mental illness. However, there tend to be a higher prevalence of catastrophic events in rural communities related to lack of accessibility and acceptability of mental health services. A quality of life survey completed in 2006 reported that 24.6% of those surveyed were unable to get the mental health services the needed within their respective communities. Resources for mental health services for Marshall County residents were provided outside of the county with travel distances up to 40 miles. In early 2007 there were 5 suicides within an 8 month period, individuals under the age of 30. During this same time period there were 2 violent deaths related to domestic violence. Within the WIC and Family Case Management programs for low income women, screening for post-partum depression began in 2006. Public Health Nurses were having difficulty finding accessible resources for new mothers scoring high on this screen. Law enforcement cited increased drug use and domestic violence as being significant issues within the county, while schools indicated that there were more children presenting with signs of depression as well increasing alcohol and drug use among children as young as middle school.
The Marshall County Health Department engaged with University of Illinois MPH students to complete a comprehensive community needs assessment utilizing the MAPP framework focusing on mental health needs. Two primary issues emerged: lack of available and accessible services and negative stigma toward mental illness, underscoring the importance and need of mental health services for this county. Findings of the assessment were presented to the Board of Health in December, 2007 and an ad hoc committee was formed to begin engaging community partners, build support and elicit feedback in addressing identified key issues. Initial focus groups were held in strategic areas within the county, surveys were conducted with key stakeholders and providers within the county. Input on mental health issues was sought from area churches and schools. A community-wide task force was established in the fall of 2008 to further discuss and plan for service delivery within the county to address identified unmet needs.
Members of the task force included community members, public health, mental health providers, schools, social service agencies, state employees, alcohol/drug abuse programs, medical providers and law enforcement. The overall goal was to bring mental health services into the county and link health centers, public health, mental health programs, emergency medical services and law enforcement in a comprehensive approach to mental wellness. Through a collaborative approach, the Marshall County Behavioral Health Task Force has established services including counseling, outreach and telepsychiatry 5 days per week based at the health department.
Innovation
Rural health departments often lack adequate resources to undertake comprehensive needs assessments. Through academic partnerships, Marshall County was able to utilize the MAPP framework to identify strategic issues related to mental health within the county. In 2004, the health department capitalized on this partnership to conduct a focused needs assessment for maternal child health. This strong academic partnership with the University of Illinois provided the manpower (graduate nursing students and MPH students) to complete a second comprehensive needs assessment focusing on mental health in 2007 and subsequently the development of the task force through the local health department leadership and commitment to address the strategic issues and formulate a logic model that would bring mental health services and awareness to the community.
Mental health services were provided previously within Marshall County, however lack of engagement by the community resulted in the loss of all services. A grass-roots effort to address this problem clearly was needed. Through information gathered at community meetings and encounters with service providers within the county it was determined that concrete data was needed to proceed. Engaging students in this comprehensive needs assessment supplemented limited resources and provided specific data and proposed interventions that prompted the Board of Health to take action, thus establishing the ad hoc committee to actively pursue a grass-roots effort to bring mental health issues to the forefront. It was determined that public health should take the lead and that the health department would become active members in the collaborative. The health department is considered a leading agency in the community as well as a "safe" place to obtain information and/or services. As with many rural communities, Marshall County residents are reluctant to talk about mental health issues and reluctant to seek services within their own community primarily related to the stigma of mental health problems. To this end, it was crucial that establishing service delivery would need to come from the people; in other words the task force had to be developed through focus groups and surveys to determine what the residents needed and what they would accept.
This project is unique in that the health department staff identified growing problems within the community and took the initiative to capitalize on academic partnerships to obtain comprehensive data to identify strategic issues and potential interventions. The needs assessment involved not only providers but residents of the county to obtain information. The collaborative task force included community members in an effort to develop trust and establish a service delivery system that would be accepted and utilized. In the fall of 2011, an additional academic partnership with the OSF Saint Francis School of Nursing provided undergraduate nursing students to study utilization patterns among providers in the community providing valuable information on strategies to increase knowledge and referrals to mental health services.
Primary Stakeholders
Stakeholders/Partners Role
As a result of the strong collaborative, North Central Behavioral Health Services was able to write and receive grant funding through the Illinois Department of Human Services in October, 2010. Entitled "Innovative Solutions for Rural Access", this special project provides mental health services for any resident of Marshall County, regardless of ability to pay. Services are provided through the health department in donated space and include counseling, outreach and telepsychiatry, Mental Health First Aid Training for first responders, provider webinars and in-school prevention programs.
LHD Role
The Marshall County Health Department has played a vital role in establishing the Behavioral Health Task Force and continues to be a driving force for the continued collaboration among community agencies. In the spring of 2009, the county board liaison brought the community collaborative to the attention of the County Board, requesting funding to sustain the task force. The County Board approved a line item for mental health totaling $5000 to be added to the health department budget for costs associated with the task force, such as copying, teleconferencing, a display board for community events, etc. This line item has continued with subsequent budgets.
The Marshall County Health Department has a long history of community involvement and commitment. There is strong support for public health activities by the County Board, businesses and providers within the community. While some interaction with the faith community had occurred in the past, the Behavioral Health Task Force has increased the participation of several clergy members. The Task Force is chaired by a member of the Board of Health and co-chaired by a retired Director of Nursing from the Health Department. All staff employed by the Health Department are residents of the county and participate in locally sponsored activities throughout the year. They are well-known and trusted among other residents of the county. Despite the fact that Peoria County Health Department provides a contractual administrative role, the Marshall County Health Department sought no assistance for this project from this much larger health department with considerable resources. The Health Department advocated for and received funds from the County Board to offset minor expenses related to the Task Force. Momentum to foster the collaborative task force and establish needed services was truly consumer driven. The Behavioral Health Task Force continues to meet on a monthly basis to share information and address unmet needs with strong public health representation.
Lessons Learned
While the Behavioral Health Task Force is now a strong, driving force within the community, as with any collaborative initially the most significant barrier was that of individual agency agendas and a lack of cohesiveness. This has resolved through facilitation and the development of a logic model that identifies the responsibilities of everyone contributing to the overall mental health and wellness among residents of Marshall County. Over time it became clear to those in the collaborative that achieving the goals could not be accomplished without a commitment to working together as opposed to working within the silos of their own service delivery system.
Implementation Strategy
The initial task in the overall process was to initiate the formal needs assessment utilizing the MAPP framework in response to the increased number of suicides and difficulty in securing mental health services for mental health issues within the county. The completed needs assessment prompted the formation of an ad hoc committee by the Marshall County Board of Health to take a closer look at identified strategic issues related to mental health and wellness. The ad hoc committee, comprised of a Board of Health member and health department staff, held four focus groups within the county to gain consumer input with the subsequent formation of the Marshall County Behavioral Health Task Force, focusing on a grass-roots effort to address identified issues. While initially the Task Force struggled with competing agendas, a logic model was developed six months after the initial meeting. The logic model provided a framework for the Task Force to set specific goals and focus the group on the overall outcome of bringing mental health services to the community. Input from members and the needs assessment provided needed data for North Central Behavioral Health Systems to write and receive funds through the Illinois Department of Human Services to establish service delivery. Recognizing that the delivery of services would not necessarily guarantee utilization, efforts turned to outreach and education. It was noted early on that mental health issues carried a stigma, especially within a rural community where seeking assistance within your own community often means that friends and neighbors can easily become aware. Considerable time has been dedicated to reducing the stigma by holding community forums, encouraging participation in the Task Force and distributing information throughout the community on mental health wellness. While these strategies continue, the focus of the Task Force has turned to maintaining service delivery through increasing utilization, thus a survey of providers was conducted with an additional survey of consumers to follow in the spring.
The only time frame set for achieving the tasks was that of beginning service delivery within a year of establishing the task force. Other tasks are ongoing and will continue in an effort to increase utilization to sustain services. With decreasing stigma and increasing awareness, utilization continues to increase. Focus must now turn to the identification of strategies to maintain an adequate third-party payment patient base that will continue to allow access for the small percentage of people who have no means of payment. In addition, the Mental Health First Aid trainings and school prevention programs, which are now provided free of charge through the Special Needs Project and SASS, are vital to the continuing success of achieving mental health wellness in the community. To this end, the Task Force will be setting new goals that will maintain these programs after 2013 when funding runs out.
Process & Outcome
The three primary objectives and performance measures for the Behavioral Health Task Force include:
Provide grass-root level efforts to improve and integrate access to mental health related services within the county Performance measures:
Provide and support delivery of advocacy and educational activities and programs concerning mental wellness and related issues Performance measures:
Disseminate information about the Marshall County Behavioral Health Task Force to provoke thinking and discussion about activities and potential unmet needs with the community Performance measures:
Please see individual objectives for specific information. Ongoing evaluation and results are published in local newspapers on a regular basis. While it is clear that the overall outcome objective of mental health service provision within the county has been met, it is also clear that work needs to continue to decrease stigma and continue cultivating a strong referral/utilization pattern for continued success. The Task Force remains committed to retaining services. The University of Illinois has been approached for an additional needs assessment to be conducted to determine further unmet needs and OSF nursing students will provide a formal survey/analysis of the community in the spring, 2012 to identify ongoing needs/concerns of community members.
Objective 1: Provide grass-root level efforts to improve and integrate access to mental health related services within the county The Special Project funds received by North Central Behavioral Health Systems has enabled service delivery for county residents at the Health Department regardless of ability to pay. Service delivery has increased from 3 days per week to 5. The current caseload is 112 individuals with 46% under the age of 17 and 37% between the ages of 18 and 44, significant numbers due to the suicide rate being more prevalent in those under the age of 30. Informal surveys of the clients receiving services have been favorable with respect to ease of access and affordability. In the fall of 2011, OSF Saint Francis School of Nursing senior nursing students conducted a utilization survey of key informants and providers within the county.
Significant results from this study include:
A referral protocol was developed by the students and distributed to all providers and key informants in addition to a magnet with specific phone numbers for easy reference. Additionally a referral informational sheet was developed for community members and distributed among businesses within the county. Monies identified by the County Board for the health department budget pertaining to the Behavioral Health Task Force were utilized for the expenses related to copying and magnet production.
Objective 2: Provide and support delivery of advocacy and educational activities and programs concerning mental wellness and related issues Since October, 2010, two Mental Health First Aid trainings have been held for first responders. These trainings were held at no cost to participants, again through the Special Projects grant. Post-test surveys of those participating in the Mental Health First Aid courses indicate that there is a substantial increase in the overall level of confidence in ability to respond appropriately to mental health emergencies. It is important to note that, as a rural county, the majority of first responders are volunteers and attended trainings on their own time. As this is a 12-week course, scheduling proved to be difficult. Community surveys have indicated that law enforcement personnel as well as clergy have expressed interest in trainings specific to their roles in mental health response. Additional trainings are being planned specifically targeting law enforcement and clergy, however scheduling remains a significant barrier. Evidence-based in-school programs have been provided in 2 schools within the county for the past several years. In the fall of 2011, an additional school has requested these programs. This is a significant achievement-this school has adamantly refused these programs and it was through many contact efforts made by task force members that this school district now is scheduling these programs.
Objective 3: Desseminate information about the Marshall County Behavioral Health Task Force to provoke thinking and discussion about activities and potential unmet needs within the community Task force members routinely participate in community events and provide information on services and activities. A resource guide was developed in 2010 and updated in 2011 which is provided at community events and businesses throughout the county. Local newspapers have donated space for articles relating to mental health wellness and for disseminating information related to Task Force meetings, trainings and other ongoing activities. Health department staff routinely participate in task force meetings and activities, actively promoting service options and information on mental health wellness. While the Task Force includes 4-5 community members on a regular basis, other participants are representing local businesses and organizations.
Partners in the Task Force collaborative continue to be committed to the practice as evidenced by strong representation at monthly meetings and ongoing communication. This group has been meeting for two years and has accomplished a great deal. In 2009, the Marshall County Health Department identified a need for increased space as demand for public health services has steadily increased. Specifically the staff and Board of Health have identified the need for larger areas where group activities can take place, such as health education, WIC nutrition classes, food safety classes and community meetings. In 2011, the Board of Health established a work group to look at these needs and develop an overall plan for building remodel or added space to accommodate them with specific attention to continuing donated space for mental health service provision, responding particularly to the need for establishing group sessions. The County Board is supportive of the Task Force and has provided monetary support each year to cover the modest costs incurred by the Task Force.
The Special Project funds allow for all services to be provided free of cost to any resident of Marshall County, regardless of ability to pay. Medicaid is the primary source of payment (78%), although some residents accessing services do have private insurance. Currently only 2% of those accessing services do not have a payment source. Sustainability is based on third party payers, Special Project Funds, County Board dollars and in-kind health department contribution of no-cost space. All of these variables have contributed to making the project successful. The task force continually evaluates the interaction of these variables to determine what needs to happen relative to this model if any of these variables/sources decline or change. This task force has been in existence since 2008 and membership remains strong, significant for the sustainability not only for the collaborative itself but commitment for continuing mental health services within the county.
Marshall County is located in the rural, northeastern part of Illinois. The population is approximately 13, 000 people with a racial distribution that is predominately white (98.5%). The median income is $41,000-$42,000 with about 6% of the population below the poverty line. Between 50-60% of the residents have private health insurance, 31% are covered by either Medicaid, Medicare or Supplemental insurance and over 8% have no insurance coverage. When looking at health resource availability in Marshall County it is important to note that Marshall County is a Medically Under-served Area as described by the Health Resources and Services Administration. Due to this, it is not surprising that the key informants, surveys, focus groups, and wind- shield surveys have found that there were few physical health care resources in the County, including the presence of a hospital. This is especially true with respect to mental health services-there were no mental health service providers in Marshall County in 2007. Sporadically over the years there have been mental health counseling and referral services in some towns within the county, however not on an ongoing, permanent basis. Noting a substantial increase in suicides (particularly among those under age 30) in 2006, an increase in drug use among the youth, increased domestic violence reports, untreated postpartum depression and other factors related to mental wellness with no easy access to primary, secondary or tertiary resources, a comprehensive needs assessment utilizing the MAPP framework was undertaken in 2007. The results of this assessment led to the development of a Behavioral Health Task Force that has been instrumental in obtaining funding and service provision beginning in October of 2010.
Through academic partnerships and a community-wide collaborative established and led by the Marshall County Health Department and Board of Health, the objectives for the project include:
The outcome of the work done by the Task Force has resulted in access for Marshall County residents to mental health counseling, outreach activities, telepsychiatry, training for first responders and in-school prevention activities that previously did not exist. Of particular note is the provision of services to the Medicaid population. Seventy-eight percent of those receiving services are Medicaid recipients. Through a special project grant (Illinois Department of Human Services)received by North Central Behavioral Health Services, 8% of those receiving services do not have insurance coverage and do not pay for services. In addition, this grant has allowed two evidence-based Mental Health First Aid Training sessions to be held free of charge to first responders and law enforcement personnel in the past year as well as webinars offered to providers and the community on mental health and interventions to improve response to an issue that previously had been haphazardly addressed. The efforts of the Task Force have resulted in schools registering for prevention curricula and a large group of children from the county schools attending the Teen Showcase in 2011, the first time any school children from Marshall County have attended. A resource guide has been developed and distributed throughout the county with updates completed during the summer of 2011. Goals for this project have been met and continue to evolve. The accomplishments would not have been possible without a strong community collaborative working together to achieve a unified approach to mental health services in a small rural county. The greatest lesson learned is that limited resources must be cohesive in the approach to developing a system in which access is available, acceptable and accessible for all.
