There’s a map on the N.C. Department of Health and Human Services website that shades most of the state’s counties orange.
Buncombe County is one of the 91 counties the Office of Rural Health has designated as experiencing a behavioral health professional shortage. In fact, the 2022 departmental map designates all 16 counties of Western North Carolina as experiencing a shortage.
“We’ve had a shortage of pretty much all mental health workers for a long time — there aren’t enough psychiatrists, psychologists and master’s-level therapists to see all the people who need services,” says Dr. Steve Buie, Mountain Area Health Education Center psychiatry department chair and psychiatry residency program training director. He notes that Asheville and Waynesville both have some psychiatric services, but “if you get further west, there are no psychiatrists in those counties.” (Telehealth is an option for some behavioral health professionals, but not everyone provides it, and some patients prefer not to do their treatment virtually.)
MAHEC deemed as most needed child psychiatry and behavioral health professionals qualified to treat substance use disorder co-occuring with mental illness, Buie explains.
In 2020, the U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration awarded MAHEC a two-year, $4 million grant to become a certified behavioral health clinic. The clinic provides services for adults with serious mental illness, children with serious emotional disturbances, people with long-term and serious substance use disorders, who are also Medicaid beneficiaries. The clinic is dedicated to expanding “access to behavioral health and substance use services in our community because there is pretty great need here in western North Carolina,” explains Kristy Smith, clinical services director of MAHEC’s psychiatry department.
Over the past several years, MAHEC has sought to address the disparity through several new programs as well. “As so eloquently stated by others, there is no health without mental health,” Dr. Carrie Brown, chief medical officer for behavioral health and intellectual and developmental disability, tells Xpress in an email. “Partnering with the Mountain Area Health Education Center to help bring quality services to rural communities strengthens the state’s behavioral health support network so people can get the help they need closer to home.”
‘An imbalance between services’
Deficits in certain industries can sometimes be attributed to a so-called pipeline problem, meaning there are not enough workers undergoing training in the pipeline. In 2017, MAHEC established a psychiatry residency — building a pipeline, so to speak — as well as a rural psychiatry track for residents in April 2022, Buie explains.
(The medical program at University of North Carolina is affiliated with MAHEC through its UNC Health Sciences at MAHEC program and supports several programs. However, MAHEC recruits residents separately from UNC, Buie says.)
MAHEC’s psychiatry residency had the go-ahead from the Accreditation Council of Graduate Medical Education, Buie explains, which has “recognized there’s imbalance between services available in major metropolitan areas versus rural areas.” The governing body of medical residencies found that “people tend to stay in the area where they do their last training,” he says, and therefore, a new residency could put potential health care workers in the correct place.
The state began providing MAHEC funding for four, four-year psychiatry resident slots per year, Buie explains. It later increased to six residents per year. “Our hope is that over time, those folks will graduate and stay in the area to practice psychiatry and that’ll decrease the shortage that we have,” he explained.
MAHEC introduced a rural psychiatry track for residents, where residents work at the In-Patient Behavioral Health Hospital at Appalachian Behavioral Regional Health Center in Linville. “It’s a regular psychiatry residency, but it’s in a rural site,” explains Buie. Residents have to spend at least half their time in Linville, but they also will perform some rotations at MAHEC, since some of the training resources only are available closer to Asheville. For example, the residents must complete one month of training in in-patient addiction psychiatry at Julian F. Keith Alcohol and Drug Abuse Treatment Center in Black Mountain, and two months each of child and adolescent psychiatry and neurology.
(MAHEC also has a rural medicine fellowship, which is separate from the residencies. The rural medicine fellowship is available for residents in family medicine, psychiatry and OB-GYN, Buie explains. The residents’ training will be focused on their specific areas, but the fellowship adds training for residents planning to integrate their services into a rural community.)
Intensive outpatient and partial hospitalization programs
In addition to provider training, MAHEC introduced two programs to teach emotional skills and safety planning to behavioral health patients. The skills include “identifying your triggers in the environment and coping skills to use that are safe and healthy ways when you are at home or in the community,” Smith explains.
The two programs provide intensive work at the MAHEC clinic but the patient returns home each evening to practice the skills at home, she elaborates.
The intensive outpatient program started June 30 for adults age 18 and older. Intensive outpatient program patients have been treated for behavioral health previously “but weekly therapy and medication management have not been enough to support their improvement in symptoms and so they need something a little more intensive,” Smith says.
The intensive outpatient program is three to four months in group therapy and can include individual therapy or family therapy, if needed. It’s three hours a day, three days a week. MAHEC has four patients in the intensive outpatient program, Smith says, adding the goal is eight-10 patients.
Once the intensive outpatient program is off the ground, MAHEC will start a partial hospitalization program for patients who require even more treatment, says Buie. A partial hospitalization patient will receive four hours of therapy and skill building five days per week for two weeks before the patient “steps down” to the intensive outpatient program.
Addiction psychiatry fellowships
In April, MAHEC received accreditation for an addiction psychiatry fellowship, which is a one-year training. Dr. Stephen Wyatt, an addiction psychiatrist practicing in Charlotte, joined MAHEC as the fellowship director. The program will be the first of its kind in North Carolina.
In some cases, people have an addiction or a substance use disorder and a mental illness. So psychiatrists are trained to work with people who might have developed psychotic illnesses because of their substance use disorder or have bipolar disorder and are addicted to opiates or alcohol. An addiction psychiatrist can manage both. The fellows will begin training this month.
Since July 2020, MAHEC has operated an addiction medicine fellowship, which focuses on providing addiction treatment within its department of family medicine. Buie calls that fellowship “a training focused on teaching people who are not psychiatrists how to manage people with addiction.” The idea is that professionals in other specialties, whether it be anesthesiology or obstetrics and gynecology, can bring knowledge of addiction medicine to their care, he explains.
These many new programs, fellowships and residencies ideally should contribute to filling WNC’s pipeline.
It’s needed, says Buie, who has practiced psychiatry in WNC since 1987.
“During that time, I have worked in an environment where there just weren’t enough people to see the patients who were needed,” he tells Xpress. “You were always having to turn down people who needed care because there wasn’t enough time to see everybody.”
He would like to populate WNC with psychiatrists so people in need of behavioral health treatment don’t have “to drive two hours to see a doctor,” Buie says. The ultimate goal “is to be at a point where everyone who needs help has ready access to care.”