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Behavioral health access for Alaskans: big challenges are geography, availability, workforce, and cost.

Alaska's vast expanses, rugged terrain, and rural communities are often considered one of its highlights. But when it comes to delivering behavioral health services, the state's geography is one of many challenges. Kate Burkhart, the executive director of the state's mental health board, says geography, availability, workforce, and cost are among the big challenges to delivering behavioral health services across the state.

Demand for services is high, and it's linked to other high statistics: domestic violence and sexual assault are prevalent; suicide, substance abuse, and other mental health conditions are also more common in Alaska than many other states.

Alaskans are also more likely to receive mental health services than residents of other states, according to data provided by the state of Alaska. And the number of men and women served by the state's Division of Behavioral Health increased each year from 2009 through 2013.

Integration Helps

Step by step, providers across the state are reaching Alaskans.

Integration of mental health treatment and substance abuse treatment has helped both fields over the past decade and represents the biggest change.

"Recognizing that the majority of clients who experience mental health disorders also experience a substance use disorder [and vice versa], and that the fields share effective health promotion and prevention practices, has allowed the fields to align more closely to serve the whole person," Burkhart writes in an email. "This work provides the foundation for further integrating behavioral health and primary care--so that we truly provide whole person health."

But challenges remain: availability of treatment chief among them. Burkhart says Alaska's substance abuse treatment providers--particularly the two in-state methadone programs--usually operate at full capacity with long waiting lists. That's especially problematic because ideally, treatment needs to be provided when a person is ready for it.

"To be confronted with a wait of months, weeks, or even just days can result in a lost opportunity to get treatment to a person in need," she says.

Far-Flung Locales

Geography is also an issue. Alaska's treatment and recovery resources are concentrated in the Anchorage area, according to Burkhart, with some services available in Fairbanks, Juneau, and rural hubs. For Alaskans in even more remote locations, community health aides and behavioral health aides can provide day-to-day care, visiting itinerant counselors offer less frequent services, and telehealth augments those offerings.

Few communities have residential substance abuse treatment or inpatient mental health treatment, so some individuals only have access to lower levels of care, and community health centers funded by the state must prioritize treatment, so not everyone is always able to access it, Burkhart says.

Even communities as large as Fairbanks and Juneau don't have enough psychiatrists, so care isn't always easy to schedule.

For the services that are mostly only available in Anchorage--like acute psychiatric care and medically-monitored detox--patients must choose between travel or forgoing care.

"This means that Alaskans seeking higher levels of treatment must usually travel, whether by road, air, boat/ferry, or a combination of these, to get care," she says. "Weather delays can exacerbate already emergent situations. People seeking treatment often have to leave home--their jobs, families, and support networks--to get treatment."

Other services, like serious eating disorders, some developmental/sensory disorders, and certain serious behavioral health and mental health disorders can require leaving the state entirely for treatment.

Geography and availability of treatment contribute to a problem for Alaskans who want or need to access care. Those aren't the only challenges, though.

Understaffed Industry

The industry is understaffed, which means providers aren't always available. And care in Alaska can be expensively, sometimes prohibitively so. Even when a patient has Medicaid or insurance, they can't necessarily afford the services they need.

Burkhart says Medicaid expansion will help change the access dilemma for some Alaskans.

"We anticipate that the demand for all levels of substance abuse treatment services will grow significantly as newly eligible adults enroll in Medicaid," Burkhart says. "These clients are also expected to have significant primary care and mental healthcare needs, given the high incidence of co-morbidities with chronic alcoholism and addiction."

According to Burkhart, the state expects to see newly enrolled adults with mild to moderate conditions also seeking out counseling and therapy services, but they may still face constraints in doing so, particularly when there aren't enough providers to care for everyone.

Network of Providers

But for all the challenge's the state offers, there's a vast network of providers trying to serve Alaskans; from the newly opened Chris Kyle Patriots Hospital in Anchorage that is part of North Star Behavioral Health to long-standing programs operated by regional providers.

The Chris Kyle Patriots Hospital opened in July and serves veterans needing mental health services. Alaska has a large population of veterans, and many of the same issues with Veterans Administration healthcare that have cropped up elsewhere in the country exist in Alaska, leading to a gap between needs and services. For the most part, the Chris Kyle Patriots Hospital is focused on post-traumatic stress disorder and short-term needs.

Southcentral Foundation, Cook Inlet Region, Inc.'s biggest nonprofit, provides varying levels of service and support to Alaska Native and American Indian people living in Anchorage, the Matanuska-Susitna Borough, fifty-five rural communities, statewide, and outside of Alaska, according to it's website. The foundation jointly owns both the Alaska Native Medical Center hospital and Anchorage Native Primary Care Center outpatient clinic with the Alaska Native Tribal Health Consortium, which provide the varying levels of service and support. The foundation has also taken a more integrated approach to care over the past decade. The Nuka System of Care is a relationship-based system that integrates medical, dental, behavioral, traditional, and healthcare support services, according to the organization. In addition to primary behavioral healthcare services, Southcentral Foundation uses several approaches to care, including learning circles and residential and nonresidential recovery programs.

Denaa Yeets'is a program designed to provide specialized support to Alaska Native and American Indian adults who are at risk for suicide. It tries to help participants develop an increased sense of self-worth, cultural identity, and desire to live. The Family Wellness Warriors Initiative is focused on addressing problems related to domestic violence, abuse, and neglect. According to the organization, its purpose is to equip organizations and individuals to effectively address the spiritual, emotional, mental, and physical effects of domestic violence, abuse, and neglect.

Regional Providers

Outside of Anchorage, many regional providers have a track record of providing care.

In the Yukon-Kuskokwim region, the Yukon-Kuskokwim Health Corporation is a main provider. The health corporation provides a range of services in western Alaska, from in-patient psychiatric treatment, residential treatment, and emergency youth services to collaboration on treatment court and home visits focused on strong families.

The state Department of Corrections also runs a sex offender treatment program called the YK Delta Sex Offender program that boasts low rates of recidivism for those who successfully complete the program. Through that program, convicted offenders receive help with their re-entrance into society, including working with village councils to be re-accepted.

In the northernmost part of the state, the North Slope Borough is a partner in providing behavioral health services, one of few municipal governments that has taken on that role. The boroughs services include counseling through the Integrated Behavioral Health program and a day program for adults impacted by severe and persistent mental illness. The borough also collaborates on a group home.

A couple thousand miles away, the South-East Alaska Regional Health Consortium also delivers services through a wide range of methods. A primary behavioral healthcare clinic is located in Sitka, and other providers are based in Juneau, and patients in additional communities are reached via telehealth. Some residential programs are also available in Sitka, such as Raven's Way, an adolescent substance abuse treatment program. That program combines facets of traditional substance abuse recovery with adventure-therapy and Native cultural activities.

Many hubs and rural communities have similar offerings. But added up, providers and those in the know say there still just isn't enough.

More Services Needed

No one can move the mountains, and few would want to make Alaska's far-flung places closer together. Burkhart says more services could help make access easier.

Statewide, she says there's a need for more residential substance abuse treatment, more methadone programs, and medication-assisted treatment for alcohol and narcotic addictions. Aftercare and recovery programs are also needed throughout Alaska. As the state's population ages, she says there's also a growing demand for geriatric psychiatry capacity. Certain communities have particular needs--for instance, there's not enough acute psychiatric care in the Matanuska-Susitna region.

There's also a need for the supports that make accessing care a little more feasible, Burkhart says. "Supportive housing and community transportation services [so that people can get to treatment, work, school, and other services] are critical to people's recovery."

Freelance writer Molly Dischner writes from Dillingham.
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Title Annotation:SPECIAL SECTION: Healthcare
Comment:Behavioral health access for Alaskans: big challenges are geography, availability, workforce, and cost.(SPECIAL SECTION: Healthcare)
Author:Dischner, Molly
Publication:Alaska Business Monthly
Geographic Code:1U9AK
Date:Dec 1, 2015
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