Shawn Briley parks her car outside a convenience store and walks around to the back, where boxes of Doritos and Moon Pies get delivered. She meets Ed Robinson there about twice a week. They flip over milk crates to sit on, he lights a cigarette, and they start talking about what’s on his mind.
The gas station is her second stop on this early spring day. The first was an apartment tucked into the woods, to see a client who would have to walk a few miles in the snow to reach her office.
Briley is a licensed clinical social worker in rural Idaho. She has a master’s degree and about 20 clients, with an office in the first floor of St. Andrew’s Episcopal Church in McCall.
Unlike many mental health professionals, she makes house calls. Or gas station calls. Whatever works for her clients. It’s her way of solving one of the big hurdles in mental health access for rural Idahoans: getting to an appointment.
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Access to mental health treatment is critically important to rural Idaho. Not only are Idaho’s mountain and frontier communities short of psychiatrists, therapists and other mental health specialists, they tend to be poorer, uninsured or underinsured, and more isolated. Between 20 and 30 percent of people have no health insurance in the region where Briley works. Suicide rates are higher in rural areas than in urban cities.
About 28 percent of Idahoans live in rural areas. Not every one of those communities, though, has someone like Briley.
The first challenge is just showing up
For many Idahoans with a severe mental illness, driving an hour or two to get to a clinician’s office is not realistic.
Most of Briley’s clients are on Medicare and Medicaid. They subsist on Social Security checks. They’re lucky if they have a car and money for gas. And some mental illnesses make it hard to be on time for appointments or leave the house at all.
“People who have the ability to get here, who have some transportation to get here, this is great,” she said, sitting next to a fireplace in her office. “And probably 10 percent of the work I do happens here.”
Nearly 50 Idahoans responded to a Statesman survey this year that asked what makes it hard for them or their loved ones to get mental health treatment. Six said “transportation.” Twelve said “no local providers.”
The Idaho Behavioral Health Planning Council considers rural access to mental health care one of its top priorities.
“As we move into 2018, we remain grateful for the governor’s and state legislature’s commitment to improving behavioral health services in Idaho. However, several areas continue to present significant challenges,” including access to services and industry fragmentation, the council wrote in its fiscal year 2017 report to lawmakers. “... Although these challenges exist in all regions, rural communities face even greater barriers in accessing care.”
The council recommended “telehealth” — phone and videoconferencing — to help transcend those barriers.
Health systems like St. Luke’s and the VA are working to bring telehealth services to rural Idahoans who need mental health care. But for many reasons, those services aren’t a perfect option for everyone.
The local VA hospital also offers house calls, but only in the Treasure Valley — as far as Kuna and Caldwell.
“We see veterans in their homes, we transport them, we work on independent living skills, we try and keep them in the least restrictive environment possible despite chronic and persistent mental illness,” said Keri Barbero, manager for the Boise VA Medical Center’s Intensive Community Recovery Services program.
Can those who need the most help really handle their own care?
It was about three years ago that Robinson first stepped through Briley’s door. A judge had ordered him to start seeing Briley after run-ins with the law.
“When I met him, he was homeless, so this was a good space,” Briley said, “because we could heat up some food, he could get warm. Sometimes his boots would be sitting here (at the fireplace), we’d get him all dried up. And he even was sleeping in his truck outside the church at one point, and he kept a key (to) use the restroom.”
Robinson is a slender man in his mid-50s, with a beard and a laid-back charm. He is still basically homeless. But he’s stable. He has a bank account. When someone set his truck on fire, he called his auto insurer and filed a claim instead of just shrugging off the lost vehicle as another in a string of misfortunes. This spring, he was living in a camper at a friend’s property, where he was safe and had access to the comforts of home.
“I feel like an adult,” he said. “Doing my own grocery shopping, washing my own clothing, cooking my own food.”
Robinson has severe mental illness. (Actually, he’s been diagnosed with 10 such illnesses, but he thinks paranoid schizophrenia is his primary illness.)
Since seeing Briley, he’s gotten better at managing his illness and his life in general. She went with him to court hearings at first, and last year she accompanied him on a frightening trip to the emergency room at the St. Luke’s hospital in McCall. He’d gone off his medication.
“I was afraid to go (to the hospital), though, because I was afraid they would send me to one that keeps you longer than 30 days, because I was so bad,” he said.
Briley stayed with him that day and didn’t leave until a doctor got him a new prescription for the drug he’d previously been taking.
Robinson later told Briley it “just always seemed ridiculous” that people without reliable transportation, who might be afraid to leave home — those needing the most help to navigate life — should be expected to independently handle their mental health care.
Not enough help to go around
Briley started practicing 13 years ago, taking care of what she calls the “worried well” — people who make a good living and have private health insurance. But eventually, she found her calling: mental health provider on wheels. It’s something rural Idaho needs and doesn’t have, she says.
“I am at capacity,” Briley said. “And I am the only person that I know of that follows this model.”
Idaho is one of only three states — the others are Arizona and Wyoming — where every county is a federally designated mental health provider shortage area.
Using state licensing data, the Statesman found only 31 therapists, counselors and social workers in rural Valley and Adams counties, where Briley sees patients. More than 14,000 people live in those counties — an area roughly the size of Connecticut.
The state’s public health agency does fill in some gaps. The Idaho Department of Health and Welfare serves about 500 people statewide with ACT teams — the more commonly used name for “assertive community treatment.” Those teams go out to provide mental health care in the community, like Briley does.
Each team has a prescriber — such as a psychiatrist or a nurse practitioner — and a certain number of other mental health workers. It’s not uncommon for them to visit a patient every day, or for a patient to need ACT services for years.
Numerous studies have shown the ACT approach helps to keep people out of the hospital and is cost-effective.
But only people with certain severe disorders, like schizophrenia or bipolar disorder, qualify for ACT services in Idaho. And the department doesn’t have enough money to provide ACT for everyone who needs it, said Ross Edmunds, Division of Behavioral Health administrator. Funding has increased over the past several years, but so has the need, he said.
“It’s all about money,” he said.
The state has seen the benefit to house calls and is trying to encourage more private-practice health care workers to offer them. Health and Welfare asked its mental health contractor, Optum Idaho, to start paying extra for the kind of travel Briley does. Optum rolled out an extra $20 payment for in-home psychotherapy visits in March 2017.
Since then, Optum has seen a 35 percent increase in the number of rural Idahoans on Medicaid who get in-home therapy, and a similar increase in the number of rural therapists offering it.
It’s not cheap. The house calls cost an average of $38,000 a month, Optum says. But the company believes they “remove one barrier” to patients getting therapy “in the most effective setting” for them, said Georganne Benjamin, executive director of Optum Idaho.
“How do you convince someone from Boise to go up to Idaho City and regularly provide care? How is it financially viable for them to do that?” Edmunds said. “It’s pretty tough, right?”
Briley tried to hire additional providers since opening IdaCare Inc., her nonprofit agency, about two years ago. But she’s been thwarted by what she says is red tape. Most recently, Briley tried to hire a licensed professional counselor from Washington. She found it would take three months to get a newcomer approved for Medicaid — two or three times as long as it takes private insurance, she said.
And the different licensing rules in Idaho meant the Washington-based counselor had to take another college course before even starting the credentialing process, Briley said.
The counselor eventually sent her regrets.
“It was super frustrating,” Briley said.
The challenges of working on the road
Briley did recently hire someone to take on IdaCare clients at a senior living community in the Treasure Valley.
But in the McCall area, it’s just her and her car. She put 50,000 miles on it last year, shuttling between clients’ homes and the church.
Her office most days is the stretch of Highway 55 between Cascade and New Meadows. There’s no cubicle or photocopier, just views you find on postcards. The winter “office décor” is hoarfrost on the trees, steam rising from a lake, and snow-dusted mountains in the distance.
Briley’s actual office, in the church she attends, is cozy, too. Along with the fireplace, there’s living-room furniture. With snow and ice inches deep on the ground even in March, it feels like walking into a warm home.
But even with the low overhead — a free office — Briley says her profit margins are thin. She worries about her ability to keep the practice alive if budgets for public health insurance are cut even a little bit.
“I’m really concerned,” she said. “I can’t predict what’s going to happen down the road, but in my experience, the goal post moves in terms of legislation and what’s going to be available to pay for folks with Medicaid or Medicare.”
Why this approach to care matters
Briley is one of several mental health providers in rural Idaho who rely on the generosity of local churches and schools for their offices.
Central Idaho Counseling, owned by marriage and family therapist Eric Mikkelsen and staffed by 12 counselors, has a somewhat similar approach to Briley’s. Instead of going out to people’s homes, CIC has set up shop at schools in Garden Valley and Horseshoe Bend — offering mental health services to underserved rural school districts while also taking patients from the community.
“The people I see on a regular basis ... suffer with some of the most serious mental health issues,” Briley said. “It’s not people who are feeling down ... (they’re) really fragile folks. I see them multiple times a week.”
Why does that matter?
Robinson said the routine has helped him become a higher-functioning member of society. If Briley didn’t make the trek out to Cascade, he’d never make his appointments, he says.
Briley’s clients who have been hospitalized and institutionalized in the past seem to do better “when they’ve got somebody there with eyes on them, somebody who has regular contact,” she said. “The folks that I see have not been back in the hospital. ... That person you know you’re going to be seeing next Tuesday or is gonna be calling you or maybe dropping by and knocking on your door, I think there’s something to be said for that.”