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Sean Fadale, FACHE 
President and CEO, Nathan Littauer Hospital and Nursing Home 
Gloversville, N.Y. 
Chair, AHA Rural Health Services Committee

From the beginning of my health care career through the present day, there has been one constant challenge that my organizations have had to deal with: access to consistent and quality behavioral health services. The bulk of my work in health care has been in rural areas and the lack of access to behavioral health services has negatively impacted three major areas of need:  

• Lack of step-down levels of care from inpatient units
• Decreased volumes and challenges throughout (especially in emergency departments)
• Lack of integration of behavioral health services

Thankfully, AHA has champions like Jill Howard, who has spent her career providing organizations with solutions and initiatives that can help us mitigate our challenges.  

Jill Howard, RN  
Senior Consultant, Sheppard Pratt Solutions
Towson, Md.
Chair, AHA Committee on Behavioral Health

Improving the continuum of care in behavioral health involves ensuring that patients receive seamless, coordinated and comprehensive care across different stages and settings. This is especially important in rural markets, where access is often the most challenging.  Below are approaches that I have leveraged to enhance that continuum:

• Integrate care models that incorporate behavioral health care services into primary care settings. This helps to improve access and facilitate communication and coordination between primary care providers and behavioral health specialists.
• Coordinate care through the employment of care managers who perform roles such as tracking patient progress and ensuring that follow-up appointments are kept. This can help bridge gaps in communication among providers.
• Leverage telehealth services that increase access to behavioral health care.
• Develop Partial Hospitalization Programs (PHP) and Intensive Outpatient Programs (IOP). These can be financially viable options in behavioral health care and are often greatly needed. Without the option of step-down services, inpatient length of stay can be driven up due to provider concerns surrounding safe discharge options. In addition, the lack of adequate step-down services can result in an increase in readmission rates.
• Advocate for increased funding for behavioral health services to improve access and quality of care.  
• Collaborate with community mental health agencies and local providers.

Improving behavioral health care access, volume, and ED throughput requires strategic planning, efficient processes and leveraging technology. There are several approaches to achieve this:

• Implement uniform processes such as standardized admission algorithm and criteria​; metrics for response times to referrals; referral and deflection logging; and a designated MD or RN accountable for admission deflections.  
• Implement a system for capturing system referrals to decrease outmigration. ​
• Add ED crisis assessment staff and case managers to include potential billing for assessments; this can also be achieved virtually.
• Ensure provider and staff productivity and staff-to-patient ratios are in line with industry standards. Review inpatient admission and exclusionary criteria for opportunities to increase access and to include monitoring of adherence to set criteria and deflection tracking.
• Leverage telehealth to expand access to behavioral health services.

All of the above can improve access to care for individuals living in rural areas. In taking even one of these steps, hospitals and health systems can move towards the ultimate goal: To provide the best of physical and mental health care for everyone, regardless of where they live.