Meeting the Behavioral Health Needs of Farm Families in Times of Economic Distress Prepared by the RUPRI Health Panel Andrew F. Coburn, PhD Alva O. Ferdinand, DrPH, JD Alana Knudson, PhD Jennifer P. Lundblad, PhD, MBA A. Clinton MacKinney, MD, MS Keith J. Mueller, PhD (Panel Chair) Timothy D. McBride, PhD Guest Authors Hannah Rochford, MPH Jocelyn Richgels, MPP February 2022 f°A%lN RURAL POLICY RESEARCH INSTITUTE ACKNOWLEDGEMENTS This report was supported through a cooperative agreement with the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), US Department of Health and Human Services (HHS), under cooperative agreement/grant #U18RH30805. The information, conclusions and opinions expressed in this report are those of the authors and no endorsement by FORHP, HRSA, or HHS is intended or should be inferred. KEY TERMS Behavioral Health While the accepted definition of 'behavioral health' continues to evolve, the dimensions emphasized here are mental health and substance use disorders. Behavioral health outcomes of interest include primary consequences of behavioral health, or mental health (e.g., depression and anxiety) and substance use disorders, as well as secondary consequences, including social and familial health challenges (e.g., marital/parental discord and intimate partner violence) and instances of acute bodily harm (e.g., suicide/self-harm, unintended injury, and overdose). Economic Distress Economic distress occurs when conditions affect the financial viability of a sector (here, the agriculture sector) ceases to function in a regular manner. It should be noted that economic distress is often interchanged with terms such as 'economic dislocation', 'economic disruption', and 'economic stress' in policy discourse. Farming Farming is defined by SIC-code 01-09 to include agriculture, fishing, and forestry. For the purposes of this work, agriculture includes establishments (e.g., farms, ranches, dairies, greenhouses, nurseries, orchards, hatcheries) primarily engaged in (1) the production of crops, plants, vines, or trees {excluding forestry operations), and the keeping, grazing, or feeding of livestock for the sale of livestock or livestock products (including serums), for livestock increase, or for value increase (including animal specialties); (2) operation of sod farms, cranberry bogs, and poultry hatcheries; in the production of mushrooms, bulbs, flower seeds, and vegetable seeds; and in the growing of hydroponic crops; and (3) establishments primarily engaged in supplying soil preparation services, crop services, landscape and horticultural services, veterinary and other animal services, and farm labor and management services. For the purposes of this work, fishing includes establishments primarily engaged in commercial fishing {including shellfish and marine products), in operating fish hatcheries and fish and game preserves, and in commercial hunting and trapping. For the purposes of this work, forestry includes establishments primarily engaged in the operation of timber tracts, tree farms, or forest nurseries; in the gathering of forest products; or in performing forestry services. Note, logging is a distinct manufacturing industry, one not inherent to forestry. A farmer or farm family is an individual or a household whose livelihood is fully or partially dependent on their engagement in one of the aforementioned sectors. Social Determinants of Health The Centers for Disease Control and Prevention defines social determinants of health as the conditions in which people live, learn, work, and play that affect an array of health and quality of life outcomes. Social determinants of health span dimensions of the place based framework: economic stability, education access and quality, healthcare access and guality, neighborhood and built environment factors, and social and community contexts. Social determinants of health include safe and affordable housing, access to education, public safety, availability of healthy foods, local emergency/health services, and environments free of life-threatening toxins. Meeting the Behavioral Health Needs of Farm Families in Times of Economic Distress Given recent global economic and climate trends, including those induced by the COVID-19 public health emergency, behavioral health consequences related to economic distress will likely continue as a public health concern for the foreseeable future. The RUPRI Health Panel offers guidance for specific Federal and State policy responses to address the behavioral health needs of rural farm families. community support that is protective against the consequences of economic hardship.2 Recent trade and COVID-19-related factors have increased the behavioral health challenges historically encountered by farmers during instances of economic distress. These challenges are exacerbated for farm families by limited affordable health insurance options and limited access to behavioral health services. Farm families' needs for behavioral health and support services are increasing as their ability to access and afford those services dwindles.*In addition to these access barriers, the perceived stigma associated with behavioral health challenges and the difficulty rural residents experience accessing behavioral health services without being recognized by other community member substantially limits rural individuals' willingness to seek help. As in most sectors and markets, economic fluctuations and periods of distress in farming cannot be eliminated. However, their effects on communities and individuals can be mitigated by improving access to behavioral health and other support services that have long been compromised by rural shortages of behavioral health treatment facilities and limited infrastructure for delivering other forms of needed support.'* A more in-depth discussion of (1) the relationships that market forces, farming community characteristics, and external circumstances have collectively with rural out comes, and (2) of the policy considerations offered in this brief can be found here. Policy & Programmatic Considerations Establishing and sustaining individual and community resiliency, while providing for the needed surge capacity to address periods of economic distress, could be priority goals of policy responses to the current behavioral health crisis in farming communities. Achieving these aims will require that policy responses be aligned with and respectful of the culture and values of farm families and communities. Public policies and programs, including grants, demonstrations, and direct payments, can help ensure that essential health care and social services are available and accessible to rural families in need. Support Community-Based Services to Improve Health Outcomes Rural community resources are insufficient to adequately address the behavioral health needs of farmers and farm families stressed by economic hardship.'* 1> Many of the unmet behavioral health needs among farm families are tied to social determinants of health (SDOH) and could be addressed by payment and delivery models that promote access to and coordination with community-based services. These approaches aim to support the development of systems and functionality to achieve better integration of services across health care (including behavioral health) and community-based organizations. Specific strategies for policy makers and community leaders include the following: (1) Leverage the resources of the Medicare and Medicaid payment systems and demonstrations to support coordinated care for families in distress. Medicare and Medicaid payment policies and demonstrations are already testing innovative contractual arrangements and payment approaches designed to enable stronger partnerships between health care and community- based organizations. For example, under managed care arrangements, Medicare and Medicaid programs are encouraging or requiring managed care organizations to incentivize health care providers to identify and address the SDOH and coordinate care with community-based organizations. Also, demonstrations are testing the use of global budgets" to support social services and address needs beyond clinical patient care. Similarly, revenue generated in shared-savings models could be directed to support community-based approaches to meet rural behavioral health needs. Payment policies under fee-for-service (cost-based and prospective payment) could be modified to include costs associated with SDOH services in health care organization cost reports. In Center for Medicare and Medicaid Innovation (CMMI) demonstration programs, Accountable Health Communities' could explicitly focus on behavioral health needs by encouraging relationships between health care providers and community organizations, including public health, faith-based institutions, Extension, schools, banks, veteran associations, veterinarians, and other community-based organizations that constitute a social support network for farmers and farm families.™ (2) Focus and align grant programs from multiple Federal agencies to address mental health and substance use disorders among farm families. Projects funded through grant programs (e.g., network outreach, and rural health communities opioid response program) of the Federal Office of Rural Health Policy (FORHP) have addressed multiple strategies for expanding and improving rural behavioral health care. Building on existing models, these programs could be used as vehicles to build community partnerships that provide multiple entry points for local behavioral health services. A special emphasis could include explicitly engaging community-based organizations that offer informal and formal counseling and other social and support services. Federal agencies, such as the Health Resources & Services Administration, the Substance Abuse and Mental Health Services Administration, and US Dept. of Agriculture (including its local Extension offices), could partner with philanthropic organizations to create new revenue streams for local communities that establish innovative and sustainable programs to meet the unique needs of farm families and agriculture-dependent communities. Resources may also be available from local hospitals using their designated community-benefit funds (required of non-profit hospitals). Federal agencies could leverage existing networks to extend their resources, including technical assistance, to community- based organizations. An example is the USDA Farm and Ranch Stress Assistance Network grant program, established to assist farmers and ranchers experiencing stress that could manifest issues in behavioral health. Expand Behavioral Health Services The existing rural health care infrastructure is inadequate to meet ongoing rural behavioral health needs, and has limited capacity to respond to surges in demand. Increased funding would help create appropriate rural community behavioral health system capacity. Additional considerations applicable to meeting the behavioral health service needs of farm families and communities in crisis were described in the Panel's report, Behavioral Health in Rural America: Challenges and Opportunities.t" Considerations of particular note include the following: (1) requiring local and state agencies/organizations involved with behavioral health services to assess gaps in services and service delivery systems contributing to unmet population needs; (2) providing technical assistance to local and state agencies/organizations involved with behavioral health services to plan and utilize sustainable regional systems of behavioral health * For more on the Pennsylvania model as an example of global budgets see the Pennsylvania Department of Health's website page overview of the Pennsylvania Rural Health Model: https://www.health.pa.gov/topics/Health-Innovation/Pages/Rural-Health.aspx . Accessed November 9, 2021. * For more on the Accountable Health Communities model, see the Center for Medicare & Medicaid Innovation website page description and early results: https://innovation.cms.gov/innovation-models/ahcm. Accessed January 17, 2021. 4 care; and (3) calling for states to invest in regional evidence-based prevention, treatment, harm reduction, and recovery programs. (3) Continue to integrate primary and behavioral care as the cornerstone of a high- performing rural health care system to provide initial treatment of mental health and substance abuse conditions triggered by economic stress in farm families. Recommendations made by the Behavioral Health Integration Task Force of the Bipartisan Policy Center' are particularly relevant to meeting the needs of farm families, given the scarcity of specialized behavioral health resources in rural communities. Specifically, pathways towards integration named by the task force that may benefit farm families in crisis include the following: (1) building financial incentives and accountability structures for integrated care delivery into established Medicaid Managed Care, Medicare Accountable Care Organizations, and Medicare Advantage plans' payment models; (2) extending Medicare coverage to additional types of behavioral health providers; (3) increasing scholarship opportunities and pipeline programs to diversify and broaden the behavioral health workforce; (4) increasing grant funding for providing primary care providers with the behavioral health expertise needed to treat mild to moderate conditions; and (5) creating a capitated, risk-adjusted payment model for primary care providers who deliver services to support mild to moderate behavioral health needs. These efforts would naturally build on the federal government's investment in behavioral health access via community health centers, loan repayment for addiction medicine specialists with the National Health Service Corps Substance Use Disorder Workforce Loan Repayment Program, and the Behavioral Health Workforce Education and Training program. (4) Expand the workforce to improve behavioral health services capacity to meet the needs of farm families. Existing programs within the Bureau of Health Workforce in the Health Resources & Services Administration could help supply behavioral health providers, including the National Health Services Corps and other scholarship and loan repayment programs. The J-1 visa program creates opportunities for community mental health professionals and prioritizes psychiatric professions and residency slots. State agencies could consider outreach and other strategies to get behavioral health resources to communities most affected by localized distress, such as shifting counselors to natural disaster areas. And finally, federal and state payment policies could reimburse for additional types of health providers, such as community health workers, recovery coaches, and community paramedics, to support the expansion of the nonclinical, social service workforce needed to address rural behavioral health needs in farming communities. (5) Increase telehealth services and repurpose available space to expand access to behavioral health services. As the Panel has previously recommended, current telehealth waivers established during the public health emergency, especially those applicable to tele- behavioral health care (including sites eligible for payment), could be made permanent in the Medicare program.?® Funding under the American Recovery Act of 2009 (P.L. 111-5) targets rural high-speed broadband connectivity, bolstering access to confidential tele-behavioral health care services and reducing the stigma of receiving behavioral health care. Additional federal and state investments could support the broadband infrastructure needed to assure all rural residents have convenient access to the high- speed connectivity needed to take full advantage of telehealth services. Mobile tele-behavioral health could be available for first-responders, including emergency medical services and law enforcement services, to support them when responding to challenging behavioral health situations. Crisis facilities (e.g., designated rooms/areas in health care facilities, schools, churches, or libraries) could be established in rural areas where no such facilities are currently available. (6) Expand private and public insurance coverage to improve access to essential behavioral health services. Policies (federal and state) that expand affordable insurance coverage could include behavioral health care benefits parity', which would improve affordability of services. Policies designed to improve affordable access include additional subsidies for purchasing insurance (while ensuring parity), incentives for employer-sponsored insurance to offer comprehensive and affordable coverage that includes behavioral health benefits, and outreach efforts to increase rural resident awareness of enhanced coverage benefits. A thorough study of State-based benefits for behavioral health and utilization by farm families during times of economic stress could inform policies in State Medicaid programs to address rural behavioral health needs. Conclusion While challenges associated with economic fluctuations and periods of distress in farming cannot be eliminated, their consequences can be mitigated by ensuring rural communities have access to sufficient social support and health care services. Leveraging policy and programmatic opportunities to achieve this aim prevents rural residents from managing behavioral health challenges they face during periods of economic distress with unhealthy coping behaviors. Preventable outcomes include opioid and alcohol misuse, mental health conditions, and violent acts towards self and others. Taking policy steps to support the resiliency of rural America through a robust community-based service infrastructure, and ensure rural communities can expand their behavioral health service delivery capacity in times of economic distress are necessary to meeting the behavioral health needs of farm families across the prevention continuum. Though sufficient support does not negate associated hardship, nor prevent the recurrence of economically challenging periods for farm families, it addresses the needs of those affected to minimize negative impact on their health and well- being. * 'Parity' requires insurers to provide the same level of insurance coverage and payment patients for behavioral health services as other categories of health services. 6 Endnotes 1 DHHS (NIOSH) Publication Number 92-105. U.S. Department of Health and Human Services, 1992:123-128. 2 Dertin, David L., "Agricultural Production Economics" (2012). Agricultural Economics Textbook Gallery. https://uknowledge.uky.edu/agecon_textbooks/1 3 |fft, J., Kuethe, T. H., & Morehart, M. (2013). Farm debt use by farms with crop insurance. Choices, 28(316-2016-7677). 4 Ortega, S. T., Johnson, D. R., Beeson, P. G., & Craft, B. J. (1994). The Farm Crisis and Mental Health: A Longitudinal Study of the 1980s Rural Sociology, 59(4), 598-619 5 Frank, C., Davis, C. G., & Elgar, F. J. (2014). Financial strain, social capital, and perceived health during economic recession: a longitudinal survey in rural Canada. Anxiety, Stress, & Coping, 27(4), 422-438. & Lasley P. Rural Economic and Social Trends. In: Conger R, Elder G. Families in Troubled Times: Adapting to Change in Rural America; New York: Aldine De Gruyter, 1994:57-78. 7 Mann, J. J., & Metts, A. V. (2017). The economy and suicide: an interaction of societal and intrapersonal risk factors. 8 Thu, K., Lasley, P., Whitten, P., Lewis, M., Donham, K. J., Zwerling, C., & Scarth, R. (1997). Stress as a risk factor for agricultural injuries: comparative data from the lowa Farm Family Health and Hazard Survey (1994) and the lowa Farm and Rural Life Poll (1989). Journal of Agromedicine, 4(3-4), 181-191. 9 Jurich, A. P., & Russell, C. S. (1987). Family therapy with rural families in a time of farm crisis. Family Relations, 364- 367. 1 Hoyt, D. R., O'Donnell, D., & Mack, K. Y. (1995). Psychological distress and size of place: The epidemiology of rural economic stress. Rural Sociology, 60(4), 707-720. 1 ibid 12 ibid 13 Gale J, Janis J, Coburn A, and Rochford H (2019 December) Behavioral Health in Rural America: Challenges and Opportunities. RUPRI Health Panel. Accessed May 27, 2021: https://rupri.org/wp-content/uploads/Behavioral-Health- in-Rural-America-Challenges-and- Opportunities.pdf 4 Hoyt, D. R., O'Donnell, D., & Mack, K. Y. (1995). Psychological distress and size of place: The epidemiology of rural economic stress. Rural Sociology, 60(4), 707-720. 15 Becot, F., Inwood, S., Bendixsen, C., & Henning-Smith, C. (2020). Health Care and Health Insurance Access for Farm Families in the United States during COVID-19: Essential Workers without Essential Resources?. Journal of agromedicine, 1-4. 16 Rural Response to Farmer Mental Health and Suicide Prevention Overview - Rural Health Information Hub. (2021, November 09). Retrieved from https://www.ruralhealthinfo.org/topics/farmer-mental-health 17 Gale J, Janis J, Coburn A, and Rochford H (2019 December) Behavioral Health in Rural America: Challenges and Opportunities. RUPRI Health Panel. Accessed May 27, 2021: https://rupri.org/wp-content/uploads/Behavioral-Health- in-Rural-America-Challenges-and- Opportunities.pdf 18 RUPRI Health Panel (2011) The High Performance Rural Health Care System of the Future. September 2. Accessed June 2, 2021: https://rupri.org/wp-content/uploads/High-Performance-Rural-HCS-of-the-Future-2011.pdf 19 Behavioral Health Integration Task Force, Bipartisan Policy Center (2021, March) Tackling America's Mental Health and Addiction Crisis Through Primary Care Integration. Accessed June 2, 2021: https://bipartisanpolicy.org/wp- content/uploads/2021/03/BPC_Behavioral-Health-Integration-report R02.pdf 20 RUPRI Health Panel (2020, October 9) The Evolving Landscape of National Telehealth Policies during a Public Health Emergency: Responsiveness to Rural Needs. Accessed March 28, 2021: https://rupri.org/wp-content/uploads/RUPRI- Telehealth-paper.pdf Suggested citation Coburn AF, Ferdinand AO, Knudson AD, Lundblad JP, MacKinney AC, Mueller KJ, McBride TD, Rochford H, Richgels, J. Meeting the Behavioral Health Needs of Farm Families in Times of Economic Distress, RUPRI Health Panel, February 2022.