California Psychiatric Association Documents
Psychiatry in Rural California
Psychiatric problems, including serious mental illness, are no less frequent
in the rural areas of the state than they are in urban areas. The diagnosis
and treatment of these problems is provided by a broad range of clinicians
including psychiatrists, family practitioners, psychologists, clinical social
workers, psychiatric nurses, psychiatric technicians, family and marriage
counselors and community mental health workers. In small counties the majority
of this work is delivered by the community mental health system, some is
provided by the private sector and the remainder is provided in Indian Health
Programs, Probation and Parole departments or by Jail Psychiatric Services.
Over the past two years some have questioned whether there are adequate
numbers of Psychiatrists in California's rural areas. At least one group
has stated that several California counties have no psychiatric coverage
at all. Most would agree that all resources for the mentally ill in both
rural and urban areas are woefully underfunded. The accusation made, however,
appears to be specific to provision of service by psychiatrists and particularly
as to the availability of psychiatrists available to prescribe psychotropic
medication. Psychiatrists, of course, do more than just prescribe medication,
however, the presumption is that most of these other things can be performed
by other non-medical mental health practitioners.
It is the position of the California Psychiatric Association that psychiatric
treatment is no less a priority in rural California than it is in the urban
areas of the state. As a consequence the CPA has an undertaken a survey
of all California counties under 225,000 population, 1 most of which are
in rural areas, in an effort to ascertain whether there is adequate psychiatric
coverage provided within the constraints of the various county mental health
program budgets. It is important to distinguish between an adequate number
of funded psychiatric positions to serve the needs of any one county and
the ability of the county to fill the psychiatric position once funded.
There are currently no state or national standards as to what constitutes
optimal psychiatric staffing for a community mental health program. Goldman2
has devised a method for doing so utilizing the average active caseload
and average number of new intakes however this method is not currently being
utilized in California. It is certainly possible that some county programs
do not have an adequate number of funded psychiatric positions, however,
this is a different issue than being able to recruit psychiatrists for positions
that are already funded. The CPA survey therefore focuses on the latter
question and not the former. It remains for the various County Mental Health
Programs and Mental Health Advisory Boards to determine what represents
an optimal number of psychiatric positions for their respective counties.
The survey was carried out during the months of February and March 1996.
Inquiries were made relating to current psychiatric staffing and problems
that may have been encountered in recruiting psychiatrists. Respondents
included the medical directors of county programs, program chiefs, staff
psychiatrists and other administrative personnel. Other data resources included
the yellow pages of the phone books of the various locales and the California
Medical Association directory of physicians by specialty listed by county.
(See attachment A for summary data and attachment B for specific coverage
in each county).
Summary results:
Every California county with less than 225,000 population, with one
exception, has either a part time or full time psychiatrist or more. Alpine
county with a population of 1200 and only 14 active cases does not have
a funded psychiatric position in it's community mental health program. They
contract with a primary care physician one day a week for routine psychotropic
medication monitoring and send more complicated cases to a psychiatrist
in South Lake Tahoe about an hour away. There are no private psychiatrists
either practicing or living within Alpine county.
Every community Mental Health Program in counties with less than 225,
000 population, with one exception, ha* psychiatric coverage provided within
the constraints of the county's mental health budget. Merced county
currently has an unfilled position for which they are currently recruiting.
According to the medical director they have had problems in the past in
recruiting but do currently have two applicants whom they have interviewed
and they anticipate hiring one of these in the next two weeks.
Aside from those psychiatrists in private practice who are listed list in
the phone books of small counties there are a number of other psychiatrists
who either live or have offices in these counties. Some have full time
active practices to the point they have no need to list while others have
only small part time practices and work in other salaried positions such
as community mental health, probation or parole, corrections, or at Indian
Health clinics. In one case a psychiatrist works full time in a community
mental health program in the Sacramento area and on weekends commutes two
hundred miles north to maintain his small private practice.
One county, Colusa, had 12 applications for a part time position at the
time the county was recruiting in August/September of 1995.
Dr. Arnold Solis has "bundled" at least three counties and developed
a group of psychiatrists who cover Plumas, Glenn, and Lassen counties. As
the need for more psychiatric time expanded Dr. Solis recruited at a psychiatric
job fair in San Francisco sponsored by the Northern California Psychiatric
Society and received 14 applications from psychiatrists interested in
working in rural areas.
1 Napa county was not included due to the disproportionately high
number psychiatrists living in the county and working at Napa State Hospital.
2 Goldman, C.R., Faulkner, L.R., Breeding, K.A.: A Method for Estimating
Psychiatrist Staffing Needs in Community Mental Health Programs. Hospital
and Community Psychiatry 45: 333-337, 1994.
3 Unduplicated Clients Served and Number of Admissions to Local Mental
Health Programs, 1993-1994: Department of Mental Health, Performance Outcome
and Reporting, California Statistical Abstract 1995.
Three counties, Humboldt, Alpine and Merced, have Institutes for Mental
Diseases within their boundaries. All three utilize in-house psychiatrists
and indicated they have no difficulty in obtaining them.
Dr. Richard Dorsey, who pioneered Telepsychiatry in Riverside county for
use in an understaffed rural outpatient clinic, no longer uses it in this
setting because he now has sufficient "live" psychiatric coverage.
When he attempted to facilitate the use of Telepsychiatry by contacting
counties that were advertising for psychiatrists in the past six months
he was told by those counties that they had more than sufficient application
for their positions and that they had no need to implement this type of
approach. Dr. Dorsey continues to feel Telepsychiatry will be a very
useful resource in the future and is now using it fourteen hours a day in
a psychiatric emergency room Riverside County has recently opened in Indio.
He relates that both patients and the County Mental Health Advisory Board
have been very pleased with the new technology.
Some counties utilize Locum Tenens psychiatrists to fill positions that
have been recently vacated or newly funded while recruiting permanent physicians
to fill the position.
In talking with respondents they cited several factors in their ability
to psychiatrists to their areas.
At least three of the respondents were very pleased with their success
in recruiting psychiatrists through the Northern California Psychiatric
Society job fair.
One county, Placer, and Kingsview, which contracts for psychiatric coverage
for three rural counties, report establishing relationships with the psychiatric
residency programs at UCD in Sacramento and UCSF in Fresno respectively.
Dr. Peter Vanaucken, medical director in Placer County, and Mr. Larry Risinger,
CEO for Kingsview, report this relationship has very much facilitated recruitment
of young psychiatrists into their programs and as a consequence they experience
little difficulty in this regard.
Managed care has created an environment that many private practitioners
find intolerable. They are therefore opting to move into the public sector
and particularly into Community Mental Health Programs.
Several respondents noted that they have had applications from Los Angles
and from the Bay Area indicating an interest on the part of some to practice
in a more relaxed, rural setting.
Some counties, although unfortunately not all, incorporate the psychiatrist
into program planning, quality care activities, continuing medical education,
and provide the opportunity for a number of treatment responsibilities including
hospital and or correctional consultation, forensic evaluation, second opinions,
and in some cases opportunity for selected psychotherapeutic cases in addition
to the traditional medication monitoring role. It was the feeling of
some of the respondents that this solidifies the psychiatrist's commitment
to the program, they feel more of a partner and experience more job satisfaction
than if they merely prescribe medication.
The California Psychiatric Association stands ready to work with any
small, rural county in the event that they do have difficulty in recruiting
psychiatrists in the future.
CPA has in the past contributed free advertising in it's newsletters
for small rural counties that are recruiting psychiatrists and will continue
to do so in the future.
CPA District Branch newsletters will provide pro bono advertising to rural
counties within the District Branch boundaries which are attempting to recruit
psychiatrists.
CPA will review job descriptions or contracts and make suggestions as to
what might be modified to make a particular position more attractive in
small rural counties.
CPA, through it's Access to Care Task Force, will continue to monitor
the issue of recruitment to and availability of psychiatrists in rural areas
and explore issues of quality of care as they may relate to the problem
of access. Should recruiting of psychiatrists to county mental health programs
become a problem the Task Force will explore with the American Psychiatric
Association utilization of their APA Job Bank to help facilitate
recruitment to California.
CPA will continue to work with the CMA Task Force on Rural Mental Health
to assure that primary care physicians are provided timely and useful
information relating to the diagnosis and treatment of mental illness. For
a copy of Psychotropic Medications: Prescribing Guidelines for Primary
Care Physicians, call the California Psychiatric Association office
at 1 - (916) - 442 - 5196.
CPA is not unaware that the presence of psychiatrists in a county does not
necessarily equate with access. Some of the psychiatrists listed in the
phone book, or who are practicing but not listed, may not currently be taking
new patients. Caseloads fluctuate and are sometimes full. Some practitioners
take only limited numbers of MediCal patients. Managed Care complicates
the situation even more in that enrollees can see only those physicians
and psychiatrists who are on the panels of the managed care companies. CPA
will continue to support the concept of a "point of service" option
thus allowing the managed care enrollee to see the psychiatrist of their
choice so that access is not curtailed in areas where there is no panel
provider. By mid 1997, Fee for Service MediCal will be consolidated within
the local Community.
Mental Health Programs and will no longer be available in the private sector.
This should afford universal access to treatment for the seriously mentally
ill in all counties. It will, however, have to be monitored closely to assure
that there is active outreach for those who might not otherwise readily
seek out county mental health providers.
Appendix B
Psychiatrists by County, March 1996
This listing is available in the pamphlet, Psychiatry In Rural California.
To order please contact California Psychiatric Association
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