For nearly a decade, behavioral health providers in Minnesota pushed to increase access and reduce wait times for substance use disorder treatment for low-income residents.
To do so, state officials reworked a system in place for more than 30 years — one that required low-income people seeking treatment to sometimes wait more than a month to receive state-funded care.
Policymakers’ solution, called Direct Access, was implemented last summer, promising to provide quick evaluations and care for people who ask for treatment.
But because of preexisting gaps in the state’s behavioral health care system — like those that limit options for care in other states — that promise of immediate treatment isn’t reaching some rural Minnesotans.
Providers say the shortcoming is a matter of life or death.
The need for behavioral health treatment in rural communities nationwide has been exacerbated by the ongoing flood of fentanyl into rural areas. Providers say the surge in need combined with rural workforce shortages have impeded the rollout of Minnesota’s new system because it hinges on the availability of licensed alcohol and drug counselors, who are in short supply in rural Minnesota.
Direct Access was Minnesota’s way of getting on board with what other states have done for some time: allowing treatment-seekers to choose their providers.
Previously, Minnesotans seeking publicly financed treatment had to wait for officials in their county to approve their request and refer them to a provider. But the change has also highlighted the preexisting challenges of treating substance use disorder in rural areas nationwide.
Across many states, rural areas are riddled with behavioral health provider shortages. Those deficits persist even though, compared with more densely populated places, rural areas have more people living in poverty and more people likely to be uninsured or underinsured — both risk factors for substance use disorders.
“We recognize that it’s probably not feasible for specialists to be everywhere,” said Tim McBride, a professor at Washington University in St. Louis and a member of the Rural Policy Research Institute Health Panel. “But if you don’t have that local provider, that is not good for the patient.”
Providers in Minnesota say the lack of local practitioners in rural regions means the systemic changes instituted months ago aren’t benefiting many patients.
At Riverwood, a treatment center overlooking the Mississippi River, nearly 50 inpatient beds are empty because the facility isn’t fully staffed. To fill those beds, the facility would need to hire at least 10 counselors, said Tim Walsh, chief of behavioral health at NorthStar Regional, which operates Riverwood.
Of the 90 patients in Riverwood’s inpatient and residential outpatient care, Walsh said, about 90% are funded through Direct Access or Medicaid, and at least half of the program’s patients are from rural areas.
The staffing shortage has forced the facility to redirect people seeking treatment, but Walsh said the center has no way of knowing whether the people were admitted to another provider.
“If they’re not with us, we know that they’re at risk of death,” Walsh said. “That is what keeps us up at night.”
Sadie Broekemeier, a licensed alcohol and drug counselor in rural Kanabec County, about an hour’s drive north of Minneapolis, hates turning away prospective Direct Access patients. Her women’s treatment center, Recovering Hope, is one of only five providers in the state that offer family residential treatment. The facility has an on-site day care for children younger than 5.
Broekemeier, who is also Recovering Hope’s president, said the facility tries to avoid turning people away. “And we create beds for them.”
The facility is licensed for 108 beds but doesn’t typically use that many. It didn’t have any available on a recent Thursday afternoon when a mother arrived, seeking treatment with her child.
“But our team went and got some beds out of the shed,” Broekemeier said. “We weren’t going to send them away.”
Even so, women sometimes end up on the facility’s waitlist.
Before Direct Access, Minnesotans with low incomes were assessed by officials in the county where they lived to determine whether they were eligible for publicly funded addiction treatment. Under Direct Access, people can instead go directly to a provider to be assessed by a licensed counselor and receive care immediately, if they’re eligible.
To find their nearest provider, people seeking treatment can visit the state-run search engine FastTrackerMN or the federal Substance Abuse and Mental Health Services Administration’s treatment locator.
Most of the state’s licensed counselors are in or near the Twin Cities, resulting in a population-to-counselor ratio three times as large in rural areas of the state as in urban areas. Ahead of the Direct Access launch, the Minnesota Association of Resources for Recovery and Chemical Health, MARRCH, a group of addiction treatment professionals, said the requirement that assessments be conducted by counselors, not other treatment workers, would worsen the disparity created by the counselor shortage 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 assessment process ran at the same time.
“Since this is a change from an almost 40-year process, we understood that people may need time to make the shift,” said Jennifer Sather, director of substance use disorder services at the Minnesota Department of Human Services. “We recognized with that transition that time would be needed to ensure that there were qualified individuals to do those documents.”
That transition period ran from October 2020 to June 2022.
Sather also said the state proceeded with Direct Access despite workforce shortages because it anticipated only an incremental increase in requests for assessment of patients’ behavioral health concerns.
But the rollout hasn’t been smooth, especially in places where counselor shortages are acute.
Thirty-six of Minnesota’s 87 counties have five or fewer counselors based in them. Twelve have no counselors licensed to them at all. Each of the 36 counties is rural.
Those counselor disparities especially hinder the Direct Access experience for people incarcerated in rural areas, said Marti Paulson, CEO of Project Turnabout, which operates several treatment centers.
“They may have to wait five to 10 days to get an assessment because there’s not enough counselors to do them,” she said.
Recent expansions in telehealth have allowed counselors to conduct assessments virtually, but such outreach doesn’t eliminate “treatment deserts,” whose residents must drive hours to receive residential or outpatient care, said Amy Dellwo, president of MARRCH’s board of governors.
Telehealth has not been a “panacea of course-correcting some of the disparities,” she said.
The Range Mental Health Center in the Mesabi Iron Range has faced similar staffing challenges. Its director of substance use disorder services, Dave Archambault, runs both inpatient and outpatient programs, with a staff of three counselors.
Archambault said Direct Access is a good idea but “doesn’t always work for us here, just due to staff. So if someone does walk in off the street, we might not have the staff to provide that service right away.”
The state implemented Direct Access in part to shorten wait times for treatment, which under the county-driven system were sometimes weeks. Back then, the state Department of Human Services mandated that counties complete an assessment within 20 days of a person’s request for an appointment and provide the results no more than 10 days later. Under Direct Access, providers are supposed to complete assessments within three days, to fulfill the policy’s promise that those in need have “access to care immediately.”
Archambault hired a fourth counselor earlier this year, so he predicts Direct Access intake will be quicker for the center from now on.
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