Between the years of 2000 and 2020, suicide rates in rural areas increased by 46%, compared to 27% in urban areas. Rural residents are also 1.5 times more likely to seek emergency care for non-fatal self-harm than urban residents.
In areas outside of city limits, access to mental health care is limited, distance complicates response, there are fewer trained providers, and gaps in care coordination are common. Moreover, smaller, more interconnected communities tend to feel the heavier weight of stigma attached to mental health.
These factors combine to make crisis response in rural communities far more complex to navigate. This article will explore how certain rural communities around the country are adapting to these challenges and the opportunities for improvement in the future.
South Dakota and The Virtual Crisis Care (VCC) Program
Many rural communities recognize the large gap in mental health care but lack the infrastructure to provide the same resources that are more readily available in larger cities.
In 2020, South Dakota launched the Virtual Crisis Care (VCC) Program to address one of these gaps. Law enforcement and EMS often serve as the default responders to crisis calls in rural communities.
This places officers in a difficult position, requiring them to assess complex behavioral health situations and make critical decisions with little to no support. In many cases, they are also responsible for transporting individuals in crisis long distances to the nearest hospital.
With the VCC program, law enforcement officers who respond to mental and behavioral health crises can connect with a trained clinician virtually to assist with on-scene de-escalation and safety assessments, ultimately reducing unnecessary hospitalizations. Research has shown that 86% of individuals who have interacted with the VCC program through law enforcement response have remained safely at home.
This helps reduce traumatic experiences for individuals in crisis by avoiding unnecessary involuntary holds and hospitalizations, it keeps officers available and in service, while reducing costly and avoidable emergency department visits and inpatient stays.
Arizona’s Mobile Crisis Teams (MCTs)
With specialized resources being so limited, it’s important to adapt. One state’s rural communities are doing just that. The state of Arizona has identified a few unique solutions to address behavioral health crisis care gaps, particularly in rural regions. These solutions have led to national recognition of Arizona’s crisis system.
Mobile crisis teams (MCTs) across the state are equipped with GPS and tracked in real time, enabling them to be dispatched to crisis calls based on proximity rather than jurisdiction. Instead of being limited by city and/or county lines, the closest available team is sent to the call.
This shift in response alone makes a big difference in rural areas where distance is the largest barrier. Even with extensive geographic coverage, response times average 30 to 40 minutes statewide, including rural areas.
Some areas, such as Mohave County, have taken it a step further by placing these teams directly where the demand is highest. MCTs are often located with 911 dispatch centers, law enforcement agencies, jails, and tribal health centers. This approach has actually further decreased average response times. In these areas, response times are averaging closer to 25 minutes.
Additionally, Arizona’s system is supported by a braided funding model that combines Medicaid reimbursement, state funding, and federal grants. This model allows MCTs to stay operational regardless of time or call volume.
The MCTs are scheduled in blocks, similar to a “firehouse model,” to ensure there is always a team available, whether during peak, off-peak, and on-call hours. The funding model also supports a “no wrong door” approach to care, meaning that care is available regardless of an individual’s insurance status.
Oklahoma’s Certified Community Behavioral Health Clinics (CCBHCs)
One of the biggest challenges in crisis response comes after the crisis. Individuals may receive the care they need in the moment, but what comes next? The goal is to ensure that people have the follow-up services they need to help prevent future crises.
Oklahoma is working to close that gap by increasing access to crisis services in rural regions. They are doing this by expanding Certified Community Behavioral Health Clinics across the state. CCBHCs are designed to be a place where individuals can get the most help they need without having to navigate multiple disconnected systems. The CCBHC model requires the following three things:
- Crisis services must be available 24/7/365.
- Comprehensive behavioral health services must be available so that individuals can get the help they need in one place, instead of navigating care across multiple providers.
- Care coordination across behavioral and physical health, social needs, and any other services or systems they are involved in. As referenced in this Julota article, improving care coordination and communication ultimately leads to better overall outcomes.
The state initially certified just three of its Community Mental Health Centers (CMHCs) as CCBHCs. The success of the three original CCBHCs provided the support necessary to certify all 13 of Oklahoma’s CMHCs as CCBHCs.
These centers are also leveraging technology to help keep individuals living in rural communities connected to care. CCBHCs are giving tablets to individuals leaving crisis stabilization facilities.
These tablets provide access to a care team 24/7 and use a first-responder network that serves throughout the state, including rural areas. Research suggests that individuals who have received these devices are less likely to return to a crisis center or inpatient facility.
Michigan’s Upper Peninsula – Integrating Behavioral Health and Primary Care
Not all barriers to mental health care stem from distance, limited resources, or workforce shortages. Some barriers are far more personal, shaped by how individuals perceive mental health and whether they feel comfortable and safe enough to even ask for help in the first place. That barrier is stigma. But how do you address something as deeply rooted as stigma?
In Michigan’s Upper Peninsula, one approach has been to integrate behavioral health care directly into primary care settings. This way, care is already built into an individual’s visit.
When a resident of a rural community comes in for their routine check-up, providers can screen them for depression and substance use without it needing to be a whole new step. If additional support is needed, behavioral health clinicians are on-site to provide it right then and there.
This type of “warm handoff” helps to reduce some of the hesitation and makes the process feel a little more natural. Over time, this approach helps normalize and change perceptions of mental health care. In this model, mental health care becomes part of routine physical health care, and individuals are more likely to engage, follow through with their treatment, and stay connected to care.
This approach also helps address another big issue rural communities face: workforce shortages. Training primary care providers and integrating services help the system reach more people without relying solely on specialty providers.
Programs using this model have seen some promising results, including improvements in depression and substance use outcomes, increased patient engagement, and generally fewer barriers to follow-up care. When individuals are willing to engage earlier and in follow-up care, it ultimately helps to prevent a crisis before it happens.
Conclusion – Where to Go from Here
Crisis response in rural communities will never look the same as in larger cities. Distance, limited infrastructure, workforce shortages, and stigma will shape what is possible in the moment.
Rural communities around the country, however, are taking steps to address gaps in their crisis response systems. Some are using technology to bring clinicians to the scene, some are strategically placing MCTs in areas that improve crisis response times, and some are building systems that keep people connected to the appropriate resources during and after a crisis.
Some are seamlessly integrating mental and physical health to help reduce the stigma surrounding mental health care. All of these efforts are making an important difference in the lives of rural residents. There is still room to improve, though.
- Expanding reliable broadband access would strengthen telehealth and virtual response models in areas with connectivity barriers.
- Continuing to invest in workforce development, including training first responders and community-based roles, such as peer specialists with lived experiences, and teaching mental health first aid to individuals living in the community.
- Strengthening care coordination between services to ensure that no one falls through the cracks.
Efforts like the Rural Health Transformation Program (RHTP) are also helping to drive systemic change in how rural communities access and experience care. For those looking to explore the resources and initiatives available in their state, Julota’s RHTP hub offers state-tailored information to help communities understand what support is available and where growth opportunities may lie.
Ultimately, improving crisis response in rural communities comes down to building on what already exists and finding ways to make it work better, in the service of the community.
