Rural Health Fractured: Sustaining Mental Health Resources in Rural Communities

Jeremiah Hodshire (Host): Welcome back to Real Health Today and our latest series, Rural Health Fractured. In this series, we’re discussing how rural health is being fractured in nearly every direction by the politicization of health and science, the decline of resources for rural communities. Deterioration of adequate insurance coverage, and so much more as we take a closer look at the fault lines in our healthcare system, our guest will provide a new perspective on how healthcare leaders can navigate these challenges and explore sustainable solutions.

Now, I am thrilled to be in the studio today with, for her first time on our podcast, it’s great to have you, a very special guest. Monica McConkey is an expert, a specialist, in rural mental health and founder of Eyes on the Horizon Consulting, which I am so excited to learn more about in just a few minutes. Monica, first of all, tell us a little bit about your role, regarding the work that you’re doing as the owner, and I would assume the operator, of Eyes on the Horizon Consulting and why did you choose the field?

Monica McConkey (Guest): Good question. It’s been a journey to get here. So, I grew up on a farm in rural northwest Minnesota. The closest known to us had 98 people. So, I know rural to the core. Same farm that my great grandparents and grandparents farmed. That’s really the starting point for rural. Grew up there, got degrees in psychology and counseling and then went to work. Really all 31 years of my career in rural communities. So, from, doing direct service, mental health work to being an administrator for, a variety of mental health programs, from inpatient psychiatric hospitalization to outpatient, kind of your general, program that is very accessible.

So that’s my history. In 2019, I had the opportunity to go into private practice and really focus in on mental health and agriculture. So, my work now, I do direct service work with farmers, ranchers and their family members, as well as lots of speaking and training around rural mental health topics with a specialization in mental health and agriculture. So that’s kind of where I’m at now. How I got here was a lot of open doors, a lot of closed doors. But definitely that rural thread has been with me through it all.

JH: So, Monica, in terms of the passion that it’s obvious that you have for rural, because we share that in common. Why don’t you give our listeners a little insight about you as a person, maybe an interesting fact. We like to humanize our guest. It’s like it’s not just someone that owns a company that’s talking about the services that they do, but humanize yourself to our listeners across the country. Maybe a fun fact, a notable item about yourself.

MM: Oh, I have a fun fact. I was 1987 Minnesota Milking Shorthorn Queen. We were in 4H, and we showed, a breed of cattle called Milking Shorthorns they’re a dairy breed of cattle. There are shorthorn beef cattle, but these were Milking Shorthorn dairy cattle. Through years of showing and connections, I got to wear the crown and the sash and hand out the ribbons and represent the organization.

JH: It’s really neat to know that we come from similar backgrounds as rural community members. We know what the farm life is like. We know what 4H is like going to the county fair to show animals. That is that is a way of life. Today across this country, that way of life is being threatened and it’s being threatened in many, many areas. As we look at social determinants of health and the challenges around access to care, whether it’s mental health services or physical health services, a lot of deserts that are happening across this country, and obviously you’re trying to fit a piece of this puzzle back together to try to bring sustainability to rural communities where mental health services are greatly needed.

So, I’m excited because today we’re going to be talking about mental health access. We’re going to be talking about access to mental healthcare in general, and how it applies to rural communities. I’m excited that Monica is here to share her perspective as a leader in rural mental health. We’ll talk about the service closures that we are all hearing about and even facing in our respective communities, how stigma affects care, and of course, what all of this has to do with rural health. So, why don’t you start by telling us, Monica, a little bit about Eyes on the Horizon Consulting? When it started, why it was formed, what is the mission today? What is the work that you’re doing?

MM: I really started building it, ten years ago, 2016. As we were getting more and more reports about farmer suicide deaths throughout the country. My mission, really through creating this organization, this business, was how do we reduce stigma and increase access to mental health services in our rural communities? And that has opened up a lot of really incredible doors for me to have conversations with people like you, who are also in that fight and adopt that mission for their organizations.

JH: So, the thought process for starting such a huge undertaking was to advocate, correct, and to be a voice.

MM: It was and it was really to expand knowledge and discussions around behavioral health in our communities. As you know, rural communities, there’s often a lot of stigma and the open communication around mental health does not happen and that, of course, leads to ongoing issues. So, really to have those conversations, engage people, support people, in whatever ways I’m capable.

JH: And is this a, not for profit? Are you a 501C3? Is this for profit?

MM: For profit.

JH: You consult; can you give us an example of who’s your main contact? When you go to a community, who are you working with?

MM: It varies. I have gone to communities and worked with public health. I have worked with agricultural organizations, from your local grain elevator, your co-ops, to extension. I do a lot of work with extension. The broader, State Department of Human Services, suicide prevention programing. The Department of Agriculture.

JH: You’re bringing teams together to try to find some solutions to these serious problems, and the problems though I think you would have to agree, always revolve around funding cuts and funding crisis. So, as you know, around this country, right now under the H.R.1, the big beautiful bill, it’s called, services in communities like Hillsdale and throughout this country, are going to be gutted, and those community services are community benefit services, whether it’s, OBGYN services, psych services, what we typically find is that hospitals, rural hospitals, when faced with budgetary constraints, will, look at their profit margins on certain programs and they have to make decisions. How long do we want to stay open? What programs are costing the community, the hospital? What is the revenue generation and what is the loss? And if it’s not a break even, is it a community benefit? If it’s community benefit, at what cost to the organization itself, but impact to the community.

And so oftentimes, on the chopping block, are mental health services, because in hospitals like mine where I have a ten-bed unit, it is not a revenue generator. In fact, it is a cost center. And so, what we have found that when rural hospitals or health systems themselves, experience financial challenges, the behavioral health unit is often the number one service that’s most likely closed, it’s at risk. And so, I want to ask you, why is this the case and what impact does it have on rural communities, when in fact a behavioral health service unit does close or services are divested?

MM: Good question. You touched on kind of the root of that. A couple things, reimbursement rates are lower in behavioral health, typically, when we look at medical services, also outcomes in behavioral health are tough to measure. They’re difficult to measure. How do we measure that someone is not as depressed, what’s the outcome? Are they being more productive at work? Are they parenting better? How do you measure that? And so, when we look at certain services tied to outcomes, that’s also tough for behavioral health because we have our scales, we have our screenings, we have tools we can use, but really different than being able to look at blood pressure, for example, or lab results or, it’s just a bit more abstract. So that, I feel like is a hindrance. If we could have really good outcomes and show impact, that would make a difference, but so much of the impact is prevention and early intervention, which is really hard to measure.

And then, overall, when you look at rural communities, behavioral health staff, it’s difficult to recruit and retain. They are often drawn to more urban settings, for a variety of reasons, but that adds to the burden of a healthcare system.

JH: It does, it really does. One of the challenges we face here is when you can’t recruit or retain talent, in those areas, the service line is also divested, and right now we’re really challenged with, at times, finding the workforce necessary to keep the beds filled that we need to fill in order to reach at least a break even so, many, many challenges in access. As we learn, the different states have different funding mechanisms for community mental health. Some CMHs are competitive in nature with for profit, or not for profit. Some are, strictly a division right of the state; the state covers a majority of it and has contracts with hospitals like mine. But all of that’s going to be interrupted very soon.

Under H.R.1 the reimbursement majority of this population that we find are Medicaid, populations in rural communities, because 70% of our payer mix is Medicaid and Medicare. So, let’s say that we can get through the funding crisis, which is going to be difficult, the next issue that we face, which is a broader issue, is something that we have fought for years, which is the stigma around receiving mental healthcare services or delivering those services, in communities and what I want to focus on is the work that you’ve done in agricultural communities, because I was alarmed, after doing some research, about the suicide rates, among our farmers. And I’m going, “why does that exist?” I mean, we’re being told that this is God’s country, it’s peaceful, it’s a land, you’re one in with nature, you own it and it’s your operation. But right now, I guess I’m going to ask the question about does the stigma around mental health make delivering that care a little more difficult, maybe, or challenging in agricultural communities, and tell us about the mindset toward mental health itself in the healthcare services often found in these communities.

MM: Yeah, huge barrier in rural because in rural we know that we are not anonymous. People know us, they know our families, they know where we live, they know what we do for a living. They often have known our parents and grandparents. So, when we are when we are struggling with a mental health issue, and there’s this stigma out there that drives people to remain quiet and not seek help, push it down; which, of course, that isolation exacerbates the condition.

In our rural communities, especially among the agricultural population, there is a lot of stoicism. They are a very self-reliant population because really, they’ve had to be over the years. No one’s come here to save us. We have to figure this out. We can’t afford to have people come in and solve our problems for us. So that has led to this belief that seeking help equates to weakness. Which of course we know it does not because if they had a chronic disease issue, I mean, sometimes it’s hard enough to get them into the doctor for medical care, but they’re much more receptive to seeking help for a physical medical issue than a mental health issue, because there’s this belief that I should be able to change it. I should be able to control it. Nobody else can fix it for me.

So, a lot of my work is around engaging people and understanding that you have no problem calling someone in to help with your livestock or your crops. Like if you’re noticing something’s not right and your livelihood is dependent upon it, you’re going to call that nutritionist, agronomist, veterinarian, soil health person, and you are going to work with them to find a solution. It’s no different than; I’m feeling stress, my relationships are falling apart, I find myself coping in ways that aren’t healthy, and I need those tools from someone who can guide me through what to do.

So, I find it helpful to have those conversations and really parallel that we are we are asking for help all the time in one form or another. And so, let’s really look at why is that different with mental health? I also feel like we are making gains in our rural communities because of conversations like this. You know, a lot of organizations are adopting the message that it’s okay to talk openly about mental health and suicide, especially ag-business types of organizations. I mean, we’re all talking about it. That makes stigma highly reduce.

JH: So currently, you know, resources that would be available in rural communities, though, are oftentimes on the chopping block. So, if someone was looking for those services, Monica, I mean, at the end of the day, let’s say I’m the rancher. I’m the farmer. Let’s talk about when should this intervention take place and I guess the second question that I would have for you is, where can that person go? Where would you recommend? So, if a rancher is listening today and saying, I’m really struggling, let’s give them some immediate direction and we’re going to talk to the industry in a minute. I want to talk to the patient right now, to the individual. What can we say to them today?

MM: Yeah, I would say even if you’re thinking about, should I call somebody or shouldn’t I; just do it. If you’re having the thought, just get ahold of somebody. Every state has something a little bit different. I’m in Minnesota. I’m legislatively funded to provide counseling services to farmers and ranchers. Costs them nothing, no insurance bill. It’s really remarkable. Other states have a voucher system, so every state does something a little bit different. One really great tool that you can look up is the, National Farm Bureau has created a lists and it’s called Farm State of Mind. And it is you can search by state, and they have collected, mental health resources from each state. Some are private practice counselors. Some are like extension programs. So that’s a place to start. Look at your state, on Farm Bureau, Farm State of Mind website and you can find providers. Another tool is through SAMHSA, the Substance Abuse Mental Health Services Administration.

JH: And we’re going to put these in the show notes.

MM: Perfect. So, SAMHSA has a provider locator for substance use for mental health, for both. You can go on, you can search in your location and it will show options. So, there are definitely tools out there to guide you to make the call. Many states also have helplines that you can call 24/7, 988 of course always available. The suicide crisis lifeline to call, text or chat with.

JH: So regardless if you feel there’s a barrier with insurance or costs, these programs come to you and there’ll be no charge to you in most states. Those resources are always free when you make the phone call. Don’t worry about, ability to pay at this time. Let’s get the services that you need right now. Talk to somebody.

JH: All right, let’s shift gears a little bit and talk about the industry, because right now there’s workforce shortages that we alluded to earlier. But healthcare professionals do not, at least in rural communities that I’ve experienced, do not seem to be gravitating towards rural America. It’s very difficult for me to find a psychiatrist today. In fact, I’m contracting with Tele-Psychiatry, because you can’t get anybody physically to come here. We’re also finding that individuals are not seeking, positions in therapy services. And, you know, we’re finding a decline, at least in rural communities that I serve. So, tell me what the industry is doing today. What are you seeing on a national basis? Is the industry looking up? Is it a challenge right now? What would you suggest to someone who wants to enter a career pathway of this?

MM: Definitely a challenge for all the reasons you talked about. Often are mental health providers are paid based on productivity. So, when you’re in a rural setting, that’s tough because you don’t have the population density to maybe support a practice. People have to travel long distances. Your cancellation rates are higher. All of that impacts people being drawn to rural. And of course we have higher, you mentioned this before, higher rates of medical assistance versus private insurance. So, the pay differential is great. There are, of course, the programs out there that will reimburse for working in an underserved area. So out of college, if you are looking at tuition reimbursement, there are definitely options out there to look at rural as a place to go.

Another thing, when I’m talking to, younger adults who are just getting started in their career, I really sell rural. The ability for you to become a champion in that community is great. Like you are going to be featured in the newspaper. You will probably be asked to speak at civic organizations. You are known entity in that community. So, your ability to build relationships and make an impact is felt very differently than in a bigger system in a larger metro area. Great place to raise kids. You know, the opportunities are living, cost of living is lower. Lots of opportunities that we in rural need to not be shy about selling. Let’s promote the goodness of being rural to our people.

JH: So, I had a healthcare professional reach out to me and I met with them and the question was, how do I build trust in this community? They were from a community at another county over. And that issue of trust really plays a big role in mental health services. So, what advice would you give to a practitioner, someone listening today that’s thinking, you know I want to go into a community but I need to build trust. How do they build that trust? Because one of the things that I suggested to this individual was, well, you can’t be in the shadows. You have to be upfront and present. So, what advice would you give to that person?

MM: Really, along those same lines, attend events, make yourself known, join, volunteer, join organizations. Find a church that fits you and your family. Really be out there and do a lot, a lot of listening. Like, tell me about this community. Tell me the history. Get to know the history of the community and be listening to the people. Get your name out there. Do the newspaper interviews, jump on the little local radio show. Because in rural, it is all about relationships. Another thing that’s important, I think, for rural mental health providers is assuring confidentiality.

So, if you’re a part of the community and this happens to me all the time, I’m meeting with people that sometimes I grew up with, or I grew up with their parents, or they’re a cousin because they don’t have the luxury of finding other providers. And so assuring confidentiality in rural is really an important aspect. So, you want to lead with that. Another thing too is to consider a co-located space, like, can you have an office in the clinic or in the chiropractor’s office or so that you are not the standalone mental health agency that people are going to know every vehicle that’s parked in front of you? And so how can you co-locate? Can you consider telehealth? I know that’s not an answer for everybody, right? Can you consider in-home work, going to the patient versus the patient coming to you? So, I think all of those we need to keep an open mind to when we’re talking about rural.

JH: All great ideas, great suggestions. And we need a talent pipeline that we need to build in this profession. And so, if you’re listening today, you know, reach out to your local colleges, speak with your local mental health professionals. You will find that many of them may even sponsor you, as we do, to become healthcare professionals. So, it’s a great opportunity.

JH: All right. We’re going to transition the conversation into our last major topic, which is really going to focus on what we would call the continuum of care. So currently right now, we’ve had silos and segments and mental health services we think are that’s relinquished to, Department of Health and Human Services. It’s a contract. But it’s more than that. We all have to own it. We can’t just say the hospital controls healthcare, for your physical health and that this organization, we have this continuum.

So, I want to ask you a question that communities are trying to figure out right now. We’ve we you said it early. Early prevention, early detection, early intervention. All those things can save lives, create good pathways for long, sustainable living. So how can we integrate mental health with other health and social services to work towards that full continuum that I just spoke about in these rural communities? Because there are so many. And maybe you’ll disagree, Monica, there’s so many silos. How do we break the silos? How do we how do we come together?

MM: Absolutely. There are silos. And some of the things that I’ve found to be helpful. I mean, any level of collaboration is helpful. And that’s really got to be the rule of thumb in rural. It’s got to be about collaborative effort, instead of anybody trying to do it on their own. So even things like common screening tools, can we all get on the same page that we’re doing the same type of screening tools, utilizing the same screening tools? Are we meeting collaboratively to share opportunities to apply for grant funding together as a community versus an organization. Are there referral pathways? So do we know what each other are doing, and do we know what would exclude someone from receiving that service. So really clear referral pathways.

And I think a big one too is how can we reduce barriers to sharing PHI? We’re not going to be all on the same electronic health record so what are some policies and procedures that can be in place community wide between providers, social services, healthcare, mental healthcare, that reduce that barrier and help us to really be able to communicate with each other so we’re treating the whole person. You know, there’s a lot of models out there. The collaborative care model, patient centered, medical home model, where there is colocation on different levels from being fully embedded to I’m just renting an office space here from you. And I think that’s rural. That’s key. That is absolutely key to providing really great holistic healthcare.

JH: Absolutely. Outreach, collaboration, communication. You’ll find that once that’s made, we all must work together. And we’re going to find an opportunity really to get that patient, the individual through the process quicker. It’s not going to be as cumbersome. And then the synergies that we’re going to have by doing that is because then you can refer them. You might identify that there is a physical barrier, and vice versa. And so great opportunity to collaborate. Much needed, especially in light of what we’re facing in the approaching months and years with the reduction of reimbursement to rural communities. Services like this may be going away.

And so, I would encourage our communities to look at new collaborative ways to engage with organizations like yours, with companies like yours, Monica, and have the conversation about how do we lead discussion groups, how do we find resources, since we have to cut out a certain segment of our service line? How do we replace those in these rural communities? I think there’s going to be a lot of challenges for our rural hospitals moving forward as it relates to mental health services.

JH: Let me ask you this. Do you have a success story, a favorite, like, you know, something you worked with a company maybe you worked with, a hospital, an organization, or even an individual story about where you realized, like, we’re really making a difference. Maybe it’s moved a metrics, something of that nature.

MM: I have a lot of them. I have a lot of really great examples of how people have come together in a collaborative model in rural communities to bring in knowledge of mental health. One, I think of very rural North Dakota. A small city said, we want you to come in and do both a suicide prevention training and just help us understand mental health. And we had had all county employees, from the road crew, to child protection, to the auditor. All that’s sitting there having this conversation.

JH: That had to feel also good.

MM: So good. Yeah. Other things that we’ve done is we have met with healthcare systems. So, Mayo in southern Minnesota, the system in St Cloud, Minnesota, center care and have really worked with them to make shared referral pathways really simple. So, they know our program, they know what we do. They know if there’s a farmer sitting in the office, they can call me either for consultation or for direct service.

So, it really comes down to communication. Even with our bigger systems. We’ve had some programs where we have the medical team go out to a farm to look at equipment. So, when somebody is coming in to the E.R. with trauma, they know exactly what happened. Like they can picture the auger, they know the grain bin. And, so it’s really this cross over of we’ve just got to be talking to each other. We’ve got to break down silos. We’ve got to know what the other does. One piece of, frustration for patients, is I got referred here, I went there and then they told me I didn’t qualify for services. And so, we’ve got to know what the exclusionary criteria is. So, collaborative meetings, constant communication, new programing needs to be built. There needs to be an education around that with other providers.

JH: In a follow up to that, Monica, do you do any advocacy work at your state or federal level to advocate for these types of services? And funding?

MM: Definitely at state level.

JH: How does that work for you and what would you suggest to your professionals out there listening, what they should do to advocate?

MM: Don’t be afraid to jump in. I go down it probably every other year, typically because we’re on a, we’re on two-year budget cycle in Minnesota. So, I go down and testify before the House or Senate and committees, finance committees and just talking about the in the gap in rural and the numbers that really reflect that gap. I mean, suicide rates in rural across the country are higher. As well as chronic disease. I mean, the numbers are there to support having the conversation. And so, don’t be afraid to reach out to your legislators individually and/or get involved in an organization to do some testifying. It’s it feels daunting when you’re thinking about it. But when you’re sitting there with those people, there they are people just like you are. And many of them are coming from these rural communities. They’re representing the rural communities. So, they really need to hear the voices of what the experience is.

JH: Absolutely great advice, great suggestion. Advocate, advocate, advocate. Because if you’re not at the table, we find that oftentimes we’re on the menu. And so, you’ve got to make sure that you are at the table having those discussions. You know, we could talk for a very long time. We’re going to put your contact information in the show notes. You will work with all individuals throughout the country, correct?

MM: Correct.

JH: You’re not just restricted to your state. And so, if you’re listening today and you want to learn more, you want to duplicate some type of services like this or be a powerhouse, like Monica is and her communities. Please feel free to reach out to her. Her information will be in the show notes.

JH: And before we conclude today, we always do a segment with our guest called Rural Health Recommendations. And you’ve been doing this now for quite some time, and you’re an expert in your field. You have, certainly, a depth of information and are very knowledgeable in the particular service area of mental health services, community engagement and those things. So, what we like to do is take the pieces of wisdom that you’ve learned over the years and give a recommendation to some of our new leaders who are listening to this podcast. It’s a tumultuous time right now. There are a lot of things going on federally, statewide, in their local community funding issues, reimbursement issues, labor force, tariffs, supply chain, the list goes on and on. And so, what sage advice, what piece of information would you give to a young aspiring leader, maybe someone who’s just at the crossroads today, who’s challenged by all of these pressures? What advice would you give today?

MM: You know, when we talk about rural it, it absolutely is all about collaboration and relationship building and out of the box thinking, to survive and to keep our services alive. And so, you can’t stay within the walls of your organization. Get out in the community, talk with other community leaders, talk with the natural helpers in your community. The ministers, the teachers, the people that the community goes to naturally and build relationships. How can we have those voices be a part of our services, meeting people where they are, its absolutely necessary.

JH: Great advice. Meet people where they are. That’s critically important. Don’t stay in the silos. Go outside, advocate, and reach out to your community to be engaged. Great advice Monica. It’s been great talking to you today. It’s been great to have you on the podcast. Would love to be able to interview in the future and see how your projects are moving along, if we could.

MM: Absolutely. Thanks for having me.