Despite progress in recent years, mental healthcare remains out of reach for many Americans. According to findings by Mental Health America (MHA), more than half of adults — 54.7% — with a mental illness are not receiving healthcare. About 42% of adults with a mental illness reported that they did not receive treatment because they couldn't afford it.
Moreover, there are significant disparities between healthcare in rural areas versus in urban and suburban regions, and these disparities are even more stark when it comes to mental healthcare. According to MHA, 65% of rural counties do not have a psychiatrist and 81% of rural counties do not have a psychiatric nurse practitioner — who, like a psychiatrist, can prescribe medication. Two-thirds of areas with a shortage of mental health professionals are rural. And while telemedicine can be a way to bridge this geographic isolation, many rural Americans lack access to broadband. The CDC also reports that suicide rates have been consistently higher in rural areas than in urban areas over the past two decades, with suicide rates increasing by a startling 46% in non-metro areas compared to 27.4% in metro areas.
One funder on the case is the Leona M. and Harry B. Helmsley Charitable Trust, which counts rural health as one of its focus areas. For years, Helmsley has made investments to support access to quality healthcare across the rural upper Midwest — North Dakota, South Dakota, Nebraska, Wyoming, Minnesota, Iowa, Montana — and now in Nevada, as well. It's looking to add more regions in the near future. To date, Helmsley has awarded almost $700 million in grants through its Rural Healthcare Program, $42 million of which has gone to expanding access to mental healthcare in the places where it funds.
"Mental health issues are a newer area. We knew it was an area we needed to go into early on, but there wasn't a magic silver bullet… But now, we've found some levers to actually pull and give tools to first responders and also to do some unique things to limit the overcrowding in emergency rooms," said Walter Panzirer, a trustee on the Helmsley Charitable Trust’s board. Panzirer is a grandson of Leona Helmsley and has worked as a first responder in California and South Dakota.
"I worked in an urban center and in a rural area as a paramedic and first responder, and I saw glaring differences going into hospitals in urban centers [versus] rural centers. I saw different, older diagnostic equipment being used in rural areas," Panzirer said.
Here are a few of the ways Helmsley is addressing that disparity with funding for methods and technologies that can help rural responders deliver better-quality mental healthcare.
Investments in telemedicine
Law enforcement officials are often called when someone is experiencing a mental health crisis, but these encounters often end poorly. According to a report from the Treatment Advocacy Center, people with untreated mental illnesses are 16 times more likely to die during an encounter with a law enforcement official than other civilians.
Helmsley is looking to change that in the places it works via support for the Virtual Crisis Care initiative. The program provides law enforcement agencies with training and tablets to connect people undergoing mental health crises with response teams that can help de-escalate the situation and provide immediate psychiatric telehealth care. The iPads are wired into the Avel system, a third party vendor with a team of mental health workers, including psychologists and nurses.
"In the real-world situation, the deputy sheriff gets called out to someone… having a mental health crisis or breakdown. They stabilize the patient in a safe area, and give them the option to talk to a licensed mental health counselor," Panzirer said.
After the mental healthcare team assesses the patient, they make recommendations for next steps, which may include a 24-hour hold if the patient is deemed a threat to themselves or others, an in-patient care setting, or referral to outpatient care, among other responses. The team lines up the next steps and helps the patient receive further diagnostics.
Virtual Crisis Care began as a pilot project in 2020 in South Dakota funded by Helmsley. The pilot was successful and the program has now expanded — including via funding from the state — to equip 23 county sheriff's offices, police departments in 10 cities, and probation officers in two judicial circuits, all in South Dakota. According to a Crime and Justice Institute study, a full 8 out of every 10 people who received treatment via the Virtual Crisis Care were diverted from involuntary hospitalizations or jail.
"They're eliminating 80% of the people who do not need to be on a mental health hold and be transported sometimes four to six hours across the state just to be turned away within an hour and be sent back home," Panzirer said. He added that the program has reduced the number of calls about "frequent fliers" by more than 50%. "It's something that's working. It's getting these people into the mental healthcare system… so they're not reaching a crisis point all over again," Panzirer said.
It’s a good example of one of philanthropy’s strengths: backing an idea or program that then serves as a model for wider publicly funded implementation. Last year, Helmsley followed up on its success in South Dakota with a $3.8 million grant to Nevada's Department of Health and Human Services to launch a Virtual Crisis Care program in that state. "We're trying to use telemedicine because in rural America, telemedicine is the only way to level the playing field," Panzirer said. "It's hard to get that specialty care in urban centers, let alone in rural areas."
Helmsley has also provided funding for Emergency Psychiatry Assessment, Treatment, and Healing (EmPATH) Units in Montana, Minnesota and Nebraska. These are 23-hour units that provide immediate access to a psychiatrist so that patients experiencing mental health crises can begin treatment in a safe and supportive setting.
These units prevent unnecessary hospital admissions, which reduces overcrowding in emergency rooms. It is estimated that between 12% to 15% of all emergency room visits are related to substance abuse or mental health crises. While some ERs can provide care, most do not have the necessary resources or expertise to efficiently treat these patients.
Panzirer said Helmsley is seeing better outcomes as more people are able to access community services and continue to receive them at a higher rate than they would have if they were given a referral sheet with information. “It’s a coordinated effort and not just, ‘Here, call these numbers,’” Panzirer said.
Separately from its support of EmPATH units, Helmsley has also helped launch a first-of-its-kind 24/7 Behavioral Health Center at the Avera Behavioral Health Hospital in Sioux Falls, South Dakota. There, patients with a mental health crisis can receive urgent care and undergo a full evaluation by nurses and assessment counselors to determine the next steps for treatment. Like EmPATH units, the behavioral health center can help reduce urgent care and emergency room visits for patients who need specialized care.
An underfunded area
Mental healthcare was already an issue in rural America prior to the pandemic, but according to Panzirer, COVID was the breaking point that fast-tracked the mental health crisis in rural areas.
In a recent op-ed published in Grantmakers in Health, Panzirer called on philanthropy to step up its response by increasing its investments in "the historically neglected area of behavioral health."
"We face an all-hands-on-deck moment to address current needs," Panzirer wrote. "Philanthropy can often act more nimbly than local, state or federal governments, and we are in a fortunate position to help transform care in communities with novel solutions that respond to expressed needs.”
In my conversation with him, Panzirer noted that mental health issues are not relegated to one specific geographic region or demographic. "[It's] truly across the board in every social and economic area of America, from the very rich to the very poor. It knows no bounds. It's across everyone. But this is something so important to cover and so important to highlight to help lower the stigma and encourage people who are… not feeling well mentally, to really encourage them to seek help.”