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Limited care available for mental health patients in California's rural north

Fellowship Story Showcase

Limited care available for mental health patients in California's rural north

Picture of Alayna Shulman

This story, in the Record Searchlight, was produced as a project for the California Health Journalism Fellowship, a program of the USC Annenberg School for Communication and Journalism. Her reporting project examines the fragmented and overwhelmed mental health system in Shasta County and how its failings impact patients and public safety, and contribute to the problem of homelessness.

Other stories in this series include: 

Kimberly Davis plays dominoes with friends at a mental health support group, Circle of Friends, in Burney.
Record Searchlight
Saturday, August 29, 2015

Less than an hour east of Redding, Round Mountain feels like a world apart, a midpoint along Highway 299 as it rises through the pines from the valley floor.

Inside Hill Country Clinic, a woman with a T-shirt that reads “Caring is Healing” and a name tag that simply says “Lynn” is trying to give a tour. That would be Lynn Dorroh, the CEO of the clinic that is both Round Mountain’s largest employer and a perfect example of the growing struggle to care for the mentally ill in the rural North State.

Dorroh soon realizes she can’t show any of the rooms. They’re all occupied.

It’s just six weeks after the clinic hired its newest mental health staffers — three full-time licensed clinical social workers and a full-time case manager.

“And they’re full,” Dorroh says in near-disbelief. Already, the clinic is back to using its wait list.

This is the harsh reality of a system that is, a Record Searchlight analysis shows, one of the most overwhelmed in California.

The roster of mental health workers in the rural areas of the county is alarmingly small, officials say. And with too many people seeking help and few professionals to offer it, experts say the results are predictable: lengthy wait times, fragmented care and — in some cases — patients giving up hope of finding treatment altogether.

The newspaper’s analysis of federal Health and Human Services Agency data shows four of the eight California clinics most critically understaffed to deal with mental illness are in Shasta County. The agency’s data only includes clinics that, like Hill Country, qualify for extra federal funding — but they’re the exact ones primarily providing the care in the rural county.

Not everyone who needs help is willing and able to seek it, but the difference between supply and demand is stark.

“There are lots of reasons why people don’t access care, and some of those might improve if there was more care available,” said Dr. Candy Stockton, medical director of Shingletown Medical Center.

Simple as it sounds to hire more psychiatrists and other providers, the clinics face a daunting task in trying to recruit highly educated professionals primed for well-paying jobs to come to an isolated rural area where both the pay and cultural opportunities are relatively low.

“We work on this all the time,” said Doreen Bradshaw, executive director of The Health Alliance of Northern California, a coalition of area clinics. “It’s huge. Workforce is the biggest issue right now.”

And demand for the services in the rural county is only growing as the Affordable Care Act expands coverage and city dwellers who can’t get an appointment in town drive up to places like Hill Country.

In the meantime, experts say, the psychiatric care shortage is leaving diagnosis and treatment to general practitioners who aren’t specially trained — where they say it’s not uncommon for misdiagnoses to go on for years.

The imbalance between great need and little service has created a fragmented array of solutions.

Recruitment is, of course, a top priority. Also under discussion is telepsychiatry, although its use is controversial. In communities outside the North State, new models for emergency psychiatric care have sprung up.

Some people with mental illness have found the best way to fill the gaps is simply to help each other. In Burney, they call it a Circle of Friends.

“It’s not all doom and gloom,” Bradshaw said. “We just have to think creatively.”

THE SHORTAGE DEFINED

The U.S. Health and Human Services Agency scores all federally qualified health centers — and certain other kinds of clinics — based on how many doctors they have per capita and similar factors. Those health centers are the kind that get special reimbursement rates from the government because they treat patients in underserved areas regardless of their ability to pay, in addition to several other qualifying factors.

The ratings are on a need-based scale of 0 through 26, with a 26 score indicating the highest priority for hiring more mental health workers and a zero score meaning staffing levels are fine. The main scoring criteria is the number of mental health providers — usually psychiatrists — per capita. Any rate less than one psychiatrist for 30,000 residents is considered substandard.

Shortage scores don’t necessarily paint a picture of the entire network of care in an area, since practices that aren’t federally qualified health centers aren’t rated. But for remote areas where there are few private practices and nearly all the residents are low-income, the shortage ratings can turn out to be a fairly accurate picture of total care.

While Shasta County has four of the top eight need scores in California, the other four are spread across the map, with one each in Lake, Tulare, San Diego and Riverside counties.

What’s more, only two clinics anywhere in the state had ratings higher than those at Shasta’s neediest clinics, and they both scored 23, barely above Shasta’s highest ratings of 22.

The rated clinics in Shasta County — more than half of which are in very remote areas — almost all have scores of 21 or 22, with the lowest coming in at 19. Tabulated together, that makes for a higher average need than in any other California county, the paper’s analysis found.

“There is a very distinct shortage,” Stockton said. “It’s extremely well-below the ratio that we believe is adequate to provide all the care that’s needed.”

SOME PATIENTS JUST GIVE UP

While there isn’t a study or census that paints the full picture of how many people in the area have some type of mental health condition, clinic officials estimate the need is high.

Stockton said 30 to 40 percent of Shingletown’s 2,500 or so patients need treatment for some kind of behavioral health issue, while Dorroh said her clinic has about 900 patients with a serious mental illness.

Mountain Valleys Health Centers Chief Executive Officer Dave Jones estimated nearly 3,000 people who go to his clinics throughout far-eastern Shasta County and parts of Lassen County need mental health treatment.

The executives say actual need is even larger, because some who need treatment aren’t pursuing it — or start to, but give up when the wait time is over a month, in some cases.

“It reinforces people’s life experience, that there is no help available, so they just assume it isn’t,” Dorroh said.

Tammy Hebert, a Cassel resident who struggles with depression and post-traumatic stress disorder, said she knows some of those people. Getting treatment is scary, so if it’s not easy to come by, it’s easier to write it off, she said.

“If you’re really having a hard time, you’ve got to be seen then,” Hebert said. “If they’re asking for help right then, tomorrow they could change their minds if they can’t get in. That’s why it’s really important to get them in; right in.”

But getting right in usually isn’t possible when the ratio of people in need of care to people giving it is too far off.

“I have patients that we’ve been trying to get in to see a psychiatrist for 12 to 14 months,” Stockton said.

Rural areas face unique mental health challenges. Experts generally attribute poor social conditions — such as family substance abuse and poverty, both of which are prevalent — as strong contributing factors to mental illness.

Combine that with isolation, and it can be a recipe for depression.

“It’s really bad when you’re secluded,” said Sami Corona of Burney, who suffers from anxiety and bipolar disorder. “There’s nobody for miles, and you just feel all alone.”

Colleen Cambra, a licensed clinical social worker at Shingletown Medical Center, knows firsthand how desperate some people in the area are to get to even a therapy appointment, let alone see a psychiatrist for an acute mental episode.

Cambra has had clients tell her they hitchhiked to their appointments at the small federally qualified health center about a half-hour west of Redding. Another walked some five miles on winding Highway 44 to get there.

But “they wouldn’t have access to service at all if we weren’t here,” she said.

REDDING PATIENTS HEAD TO BURNEY

Another problem with the shortage is that more people are now eligible for care because of government health care expansion.

It may seem intuitive that rural residents would commute to the region’s largest city for care options, but local experts say the opposite is often true.

“It’s just inundated us with new clients coming down from the Redding area,” Dorroh said of the expansion.

Historically, about 30 percent of the clinic’s clients live in Redding, and the new Medicaid eligibility requirements have made that number swell, Dorroh said.

“So I get calls even from people in town who are privately insured saying, ‘I don’t know where to go,’” Dorroh said. “I say, ‘Try Chico.’”

GENERAL PRACTITIONERS PICK UP SLACK

Patients who don’t get an appointment with a psychiatrist often are still being seen and medicated — by their general practitioners.

Psychiatry, experts point out, is a specialized field with enormous complexities.

“It’s part of (a general physician’s) training, but it’s not a big part of their training,” Dorroh said. “It is very demanding and challenging for them. ... They’re having to work right up to the limit of their knowledge, all the time.”

Unsurprisingly, Stockton said, that can spell trouble.

“There’s this phenomenon ... information becomes true and established in a patient without actually being accurate. And that’s particularly true in psychiatry,” she said. “They just kind of accumulate diagnoses. There are many, many times when things become true in a patient’s record by method of repetition.” 

Being diagnosed incorrectly isn’t just a stumbling block toward getting the help a patient really needs. Stockton said in some cases, taking the wrong medication for a mental illness can actually make symptoms worse, such as taking anti-depressants when one really has bipolar disorder. That’s particularly dangerous if someone gets in to see a doctor only once or a few times, then doesn’t get the crucial ongoing monitoring needed for medications.

“Ten years later, you’re still on this medication that never benefited you,” she said. “It’s kind of scary to be a patient if you understand all the ways the medical system can go wrong.”

‘IT HAS TO BE ABOUT THE MISSION’

Despite the challenges, many still see recruitment as the most direct path to a better network of care.

Stockton, the Shingletown Medical Center director, knows that challenge from both sides.

When she completed her medical residency, she landed a job in a nice area with equally nice colleagues. The pay was good, and there were lots of cultural opportunities for Stockton and her family.

“And I hated my job,” she said.

Despite the on-paper appeal of working in an upscale community where the patients could easily afford her services, the job “was very unsatisfying,” Stockton recalled.

“I didn’t feel like what I was doing was important,” she said.

Then Stockton started researching federally qualified health centers online and discovered an opportunity in Shingletown. The owners of the clinic bought out her contract, “and I just absolutely fell in love with the work.”

It didn’t — and still doesn’t — offer much prestige, Stockton said. But it had one important advantage over her old job.

“It matters, right?” she said. “It can’t be something that you just come to, to get a paycheck. ... I didn’t want to live that lifestyle anymore.”

Years later, she’s the one hiring, and Stockton has done a lot of reflecting on how to do it — how she was convinced to relocate her family to a tiny town in the forest.

But she really didn’t need convincing, Stockton said, and that’s the key to finding more help — recruiting the right people.

“Because being a great doctor doesn’t mean you’re the right fit for a certain position,” she said. “It has to be about the mission, and if you’re trying to recruit for something else, you’re going to have difficulty with that.”

That’s something officials also have found at Bieber-based Mountain Valleys Health Centers, which has several clinics in far-eastern Shasta County.

“You have to be very honest,” Jones said. “Just initial calls with anyone I’m recruiting, the first thing I go into is how remote it is, and you really have to like the outdoors life. If you need to be close to a Nordstrom or something, it doesn’t work.”

Jones said it’s a lesson learned only recently — one husband-and-wife doctor team left the company after just a year, looking for more opportunities for their children, while other job candidates headed for the hills as soon as they showed up for an interview.

“They say, ‘We came into town the night before and my wife said, ‘No way,’” Jones said.

Then, sometimes, it works. Shingletown Medical Center hired its first-ever psychiatrist — part-time — in the spring.

“After you’ve done all that (recruitment),” Stockton said, “you have to get lucky.”

Indeed, finding those mission-based candidates is just not an easy thing to do, said Donnell Ewert, director of Shasta County Health and Human Services.

“These people have choices. The psychiatrists write their own ticket,” he said. “We wine them and dine them, and they say, ‘Well, you know, I’ve got this possibility in San Luis Obispo, I’ve got this possibility in Sacramento.’ And it’s like, how do we compete with San Luis Obispo?”

Still, the county is headhunting for a few new psychiatrists, and looking into a backup plan of recruiting foreign-born mental health professionals who can obtain work visas by coming here.

“We’re working hard to make things better,” he said. “It’s not really in our control, other than we’re doing our best to talk to possible providers that would be interested in opening facilities in the North State.”

A TECHNICAL FIX?

Some suggest that’s not enough, and technology has opened a new set of possibilities for a last-ditch effort to get residents the care they need. Hill Country has been relying on doctors from out of the area to do appointments via telepsychiatry, where patients never actually meet their doctors in person.

While it’s better than nothing, Dorroh said, it’s not her vision for the most effective care.

“It works well for some people, it doesn’t work at all for other people,” she said. “For both financial reasons and just logistical reasons, it’s hard to get the patients, the telemed psychiatrist and their ongoing primary care provider in the room at the same time. It’s not the highest quality of care, in my opinion. It’s being touted widely as the solution for rural mental health needs, and it absolutely is a piece of the solution. It’s better than nothing, but it’s not what I aspire to.”

Still, Bradshaw, of the Health Alliance of Northern California, said many of the clinics she works with have benefited from telepsychiatry.

Ewert also noted that it’s not preferable to in-person psychiatry, but still a good fallback for rural clinics.

“I don’t know if there are really advantages to it (over in-person appointments); it takes a lot of effort to arrange it,” he said. “But you do what you’ve got to do.”

‘THE CAVALRY ISN’T COMING’

It’s a late-spring evening in downtown Redding.

Dr. Scott Zeller, chief of psychiatric emergency services at San Leandro’s John George Psychiatric Hospital, stands at the foot of the Cascade Theatre’s stage, a growing crowd of people gathering around him to share stories or ask questions.

Sponsored by Shasta Regional Medical Center — itself inundated with would-be psychiatric facility patients who turn up in the emergency room out of desperation — Zeller had just finished a talk on a seemingly revolutionary idea he pioneered at John George — “psychiatric emergency facilities,” where people in an acute crisis can go at any hour of the day for immediate mental-health treatment.

He came prepared for a Shasta County crowd, knowing someone would argue that his idea could work in Alameda County, sure. Not here, though.

“It can work in Redding; It can work in Fairbanks, Alaska; It can work in downtown Manhattan, New York,” he told the crowd.

After all, Zeller said, it worked for Burke.

The nonprofit psychiatric emergency organization has multiple facilities throughout rural east Texas, a poor region well outside of FedEx’s delivery area and where the biggest cities have some 30,000 people. Houston is a good two hours away. Shreveport, Louisiana — population: 200,000 — is almost as far in the opposite direction.

Burke serves patients from 12 rural Texas counties and is funded in part by those counties themselves.

While Burke — previously known as The Burke Center — has been around some 40 years, it’s only been in the psychiatric emergency business since 2008, said Chief Executive Officer Susan Rushing.

It took a natural disaster for the 12 counties and Burke to start changing the system, Rushing said: Hurricanes Katrina and Rita ravaged the deep South, and refugees from Louisiana were crossing the border into Texas with nowhere able to take them.

“We were a disaster area, and so all of the emergency resources in our area were completely strained, and people were strained,” Rushing recalled. “The ER system just completely got overwhelmed, and that’s when we were mad at each other. Everybody was doing the best they could, but it was just completely broken. There were no empty beds anywhere in the state of Texas.”

Particularly in remote east Texas, people with mental health emergencies were showing up at hospitals — or in jail, Rushing said.

“We’re so rural ... there was no place for them to go. We didn’t have a resource for them,” she said. “And we basically just looked at each other and said, ‘The cavalry isn’t coming; We’ve got to work something out.’”

Burke and county officials started meeting and conducted a needs assessment to figure out just how bad the problem really was.

Eventually, a model started to emerge. The area needed a treatment center for people in acute mental distress that would help patients without locking them up, and free up law enforcement and hospital waiting rooms. Emergency psychiatry fit the bill, and Burke and the 12 counties agreed to jointly contribute funding for it, the state picking up the bulk of the bill.

Small, financially strapped areas should consider regionalizing services like they did in east Texas, Rushing said.

“What that means is, everybody doesn’t get everything,” she said. “But everybody gets something.”

They’re also able to keep costs down by relying solely on telemedicine for patients in acute distress and getting around the expensive requirements of running an actual hospital.

Another great thing about psychiatric emergency facilities, Rushing said, is that many people who show up in short-term crisis turn out not to need actual hospitalization and can eventually go free with a plan to simply return for regular case management.

But Ewert, the Shasta County Health and Human Services director, said it’s unlikely a system like that would work in Shasta County. He doesn’t believe the state would agree to pay for such a project, and he said the county doesn’t have enough money it can use on new endeavors to pay for most of it.

“Ultimately, it comes down to finances,” he said. “The state would not give us that money; They would say, ‘Oh, you have (Mental Health Services Act) and realignment (funds). Use that.’ ... I’m sure we could get something, But that wouldn’t win the day. We would need very significant funding from elsewhere.”

In Burke’s case, the bed-crisis was fortunately timed because the state was already undertaking an initiative to come up with solutions to such problems, Rushing said, and agreed to fund a large portion of it going forward.

RELYING ON A ‘CIRCLE OF FRIENDS’

Sitting around a card table in the main room of Hill Country’s mental-health support group in Burney, Circle of Friends, Kimberly Davis, 27, volunteers to draw a special face on one of the other attendee’s water bottle.

Davis has successfully managed her bipolar disorder with medication since 2012, she says. But her recovery hasn’t just been from a prescription. Along the way, she’s adopted two new “families” in addition to her relatives.

“It’s pretty much Circle family, church family, family-family,” she said. “We’ve been talking about changing the name to ‘Circle of Family.’ If you’re not there, expect a phone call. It really is this amazing group of people who come together. I can’t imagine my life without these people.”

Nearby, a poster on the wall of one of Circle’s rooms is covered in hand-drawn messages from members detailing what makes them grateful.

“Another day of life (heart symbol),” one large cursive message reads.

“I am thankful for you!!! Yes, you reading this right now! You rock!!!” another reads.

“I’m thankful I have a place to go when home is DARK and LONELY — Circle is bright and the people are loving and accepting,” one reads.

In an area where resources can be hard to come by, many turn to informal social groups such as Circle as a saving grace for their mental health.

“It’s about recovery and it’s about hope,” said Lynn Erickson, who manages Circle. “Some people are so distraught. The therapy, the medications, this — it’s all a piece.”

Inside another room, Hattie Montgomery surfs the Internet for job opportunities.

“It’s just a positive place to come,” she said. “And out here, that’s very few and far between.”

She comes with her aunt, who is deaf. Circle helps people with different types of problems, Montgomery explains.

There are other ways Circle helps people — many of them are driven to outside appointments and to and from sessions at Circle.

They have a literal circle, where people can share — or not share — what’s going on with them. There are field trips, all types of classes.

Montgomery looks through the window of the computer lab at Corona, who’s playing dominoes. She says she’s seen the change Circle has brought her life in the past few months.

“You just see a difference in her demeanor,” she said. “I can see it."

[Photograph by Andreas Fuhrmann.]

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