Health Care in Rural Areas

Health care can be a challenge for many Americans, whether it pertains to cost or availability. Principals and administrators know that the physical and mental health of students play an important role in academic success. In rural areas, accessibility to health care can be a nearly insurmountable problem.

To find out how rural schools manage these barriers, we spoke with John Buckey, principal of Nantucket High School in Nantucket, MA; Hannah Nieskens, superintendent of Whitehall School District in Whitehall, MT; and Robyn Harris, principal of the Whaley School in Anchorage, AK. Principal Leadership’s senior editor, Christine Savicky, moderated the roundtable discussion.

Savicky: What are some of the major physical health problems that affect your students?

Buckey: We’re on an island, so we’re not only rural, we’re remote. We have students with asthma issues and allergies. With athletics, we see concussions, normal strains and sprains and breaks that student athletes experience, but then we have substance use—alcohol, marijuana—that’s on scale with what you would see in an urban environment but just fewer numbers.

Nieskens: I would add that, in our district, we have several kids with diabetes and seizure disorders. We have those students on 504 plans or IEPs as appropriate, depending on their level of need. We also see asthma, allergies, substance abuse, concussions, sprains, and strains.

Harris: I am in suburban Alaska—if that’s what you want to call it—in the largest district in Alaska, Anchorage School District. But I’m at an alternative school for students who exhibit profound behavior. For me, many of the health issues surround drug abuse and alcohol abuse. We have a great percentage of our students with fetal alcohol spectrum disorders that may include complications such as cognitive impairment.

Savicky: What kind of health care is available to you, and are those health care facilities sufficient for your students’ needs?

Buckey: We are fortunate. Just this spring—2019—a new $100 million hospital was completed here on the island. This hospital partners with one of the major hospitals in Boston, so I think we have adequate health care here. With technology, we’re able to provide specialized connections via medical conferencing. We have a very diverse population, so insurance for undocumented people who are living here becomes the obstacle to health care on Nantucket.

Nieskens: In Whitehall itself, we have a local clinic that does basic health care that’s open 8:00 a.m.–5:00 p.m., Monday through Friday. If we have a more serious health condition that requires an emergency room, trauma care, specialized care, or specialized doctors, the closest emergency room is 25 miles away—over the Continental Divide. In the winter, that [mountain] pass is really treacherous, so sometimes people choose to go the other direction on the interstate. That would be 60 miles to Bozeman to an emergency room. We have limited care in an emergency. For the common cold, we have the local clinic.

Harris: Because we are in a pretty large city here in Anchorage, we have two very large hospitals that are specialized in many different things—the heart institute and cancer institute—and our students are able to access that. We have several walk-in clinics located all over our expansive area, so students and parents are able to access that as well. Our students are fortunate to be able to utilize the income-based Denali Kid Care [insurance for low-income families provided by the Alaska Department of Health and Social Services]. They can access that on a regular basis. That’s what I see here within my school. Other parents have regular health insurance, but for those who don’t, they are able to access emergent care on a regular basis.

Savicky: What are some of the barriers to care you see that affect your students?

Buckey: I would say we have insurance and language barriers. Some of our providers are not bilingual. There are a number of languages spoken on the island. I think people who are undocumented are concerned about accessing health care or may not know how to access it, so I think that’s a barrier that we see. We also fly patients off the island when a health care need is beyond what we can do here at the local hospital. We have MedFlight that will land a helicopter and will fly people off the island to Boston for significant health issues. But being on an island in the middle of the ocean is a barrier.

Nieskens: Geography is our first barrier—access to care can be difficult. You have to have the resources to get to that care. If you’re a family in poverty, getting that 25 or 60 miles to the emergency room is a problem if you don’t have gas in your car. Also with regard to poverty, many of the social benefits offices are in those bigger cities that are 25 or 60 miles away. Even getting signed up to get additional resources for your family, such as Medicaid or the Healthy Montana Kids Plan [a child health insurance program in Montana for those who aren’t able to get insurance from their employers], just signing up for them can be difficult because they have to travel to those locations. Insurance limits are definitely a barrier, in particular with our mental health services. Many kids are undercovered in that area. They may have insurance, but their insurance only authorizes one therapy session per month or once every two weeks. That is simply not adequate to actually address the students’ issues. Those are probably our primary barriers.

Harris: I think in the larger scale of Alaska, we have a geographical barrier. But I also think our students who live in poverty and have to go through insurance red tape on a regular basis get tired and confused with the paperwork. Additionally, accessing mental health care is really difficult for our parents to understand. We do have a mental health trust that helps our students, as well as several agencies that work through that, but sometimes they are only able to have one counseling [session] per month—that’s the barrier.

Savicky: Are there mental health facilities in your area? Do students have access to those facilities?

Buckey: Yes, we do have mental health facilities on the island. There are two major providers in addition to a number of private practices. Our students have access to them, but I don’t think that they meet all of our needs. When I became principal here 12 years ago, we were on the heels of a suicide contagion on the island. Three young people had taken their own lives. So, we put a lot of focus on making sure that we are adequately staffed in the school. We have three full-time school counselors for a student population of 540. We have a social worker; we have a school psychologist and a full-time school nurse. We are sensitive to mental health needs. For me, it’s interesting that schools require students to have an annual physical and pay attention to physical health, but we don’t do any sort of mental health screenings for students. So, we see an increase—or at least I have in my career—in the number of students suffering from anxiety and depression.

Nieskens: There are three mental health facilities in our part of the state that actually serve children and offer acute psych care to kids. The closest one is 55 miles away, the next closest is 115 miles away, and the next is 170 miles away. The challenge is that these hospitals are serving a very large geographical area, so often their acute unit is full. We have to call around and see if they have a bed available to take our student. Sometimes, this can mean waiting for several days to weeks to get placement. In the meantime, locally, we’re trying to stabilize the situation and provide as much care as possible until they’re able to go to one of those facilities.

Harris: We have several facilities within the Anchorage Bowl. I oversee the educational portion. A few years ago, that was part of my umbrella as being the principal here at Whaley. I also oversaw what they called Special Schools. Ours are very overwhelmed. The facilities we have are very short-term, so if our students need long-term care, we need to send them to the Lower 48. That’s a big issue for us. Our short-term [care] is covered, again, but they are overwhelmed because of the number of beds that are available for our students. So, they are able to access it, but if they need some kind of longer-term treatment in the Lower 48, there’s so much red tape involved for the parents and the state that many hesitate to take this step.

Savicky: Is there a stigma in your area for the students who suffer from mental illness?

Buckey: I’m not so sure there’s a stigma, but I think that it’s similar to anywhere where people tend to focus on physical health issues at the expense of mental health issues. We try to decrease that stigma and make it OK to talk about mental health issues, but I think, in isolated areas where people are well known, people might tend to not want to seek mental health supports in a community where that mental health provider might see them at the grocery store or at a restaurant or at the movie theater—where in a larger community you could seek support services for mental health issues and not have those same challenges.

Nieskens: I think there’s a stigma in the sense that people want to be very private about their care and about the mental health issues they face. People aren’t very open, generally, with their challenges and the issues that they’re going through. Unfortunately, Montana has the highest suicide rate in the nation, and this is something that should be at the forefront of people’s minds. But really there is that stigma in the sense that it’s very “behind closed doors” and hush-hush. Beyond that, there’s also a misunderstanding about mental illness in that, particularly among children, people don’t discuss, “What is this child going through? What are they facing? What mental health issues do they have?” Students get labeled as “the troubled kid” or “the difficult kid” or “the problem kid” with no real attention to the cause.

Harris: I don’t believe that there is a stigma here in Alaska. I think that we have been working through mental health issues for a very long time. We also have a high suicide rate here, especially among our village areas. I know at my school, we are really focused on what we can do to help our families and our students in those areas of mental health, and we’ve connected with counselors at agencies who are able to come in. There’s a pilot program right now that my social worker created last year, giving our top-tier students the ability to talk with someone. But parents need to sign and agree to that. For some, I know that it’s difficult for our parents to admit these issues are happening with their child. But we are also working with the Distinguished School of Mental Health and Wellness, because we know how important it is for our students to be mentally healthy in order to move forward positively. We address this issue every single day, and I don’t believe there is a stigma here in our city because we do have a great focus on that piece.

Savicky: For your students with special needs, do they get the type of physical and mental health care that they require?

Buckey: I think they do, but given our remote location, students with significant special needs—who require care that we can’t provide—[are required] to be separated from their families, which is a challenge. They have to be placed in residential placements. So, a 14- or 15-year-old student with a profound disability can’t receive services here on the island; they become a residential student at a school off-island, and I don’t think that’s best for those students. We try to be creative in programming here and keep as many students on-island as we can because we don’t want to separate them from their families.

Nieskens: I would echo what John just said; kids receive the care that they can in our community. Their care really is commensurate with what we can offer, so, again, they’re having to travel long distances to get specialized care, but then, so are our non-special ed students. As far as kids with profound needs, for example, in Montana, we have a public school for the deaf and blind. It is a residential school with dormitories run by the state. That’s 120 miles from us. We do have a student placed there at this time, a high school student who is blind and who has been removed from their family, removed from our community. They don’t get to live in their home to attend these schools that have specialized care and services.

Harris: Considering 100 percent of my students are special education students, I would say that they are getting some of the physical and mental health care that they require. Unfortunately, I don’t, in many cases, feel like it is enough for our students. The counseling piece, especially, is lacking. They need more than just that once-a-month check-in. For our more profound [needs] students, I would have to agree with Hannah and John that we would need to send them away. We want to keep them here, but there are no facilities here that could take our students that are maybe nonverbal or combative. Families don’t want to part with their students, but sending them away is sometimes the only option they have at this point for those students.

Savicky: How does the lack of physical or mental health care affect your students academically?

Buckey: I do think it affects them academically because of time and money. For mental health care that we can’t provide on the island, or physical health care that we’re not able to address here, students and their families have to take a boat to the mainland. They go to Boston or another larger community in order to get the services that they need. That takes them out of the classroom and away from instruction, so I see the impact on our students in terms of loss of instructional time. There is also the financial impact to families who have to leave the island.

Nieskens: We have a lot of students who have excessive absences because they have to seek care and have to travel 120 miles or more, round trip, in order to receive that care. By the time they travel and have their appointment, they’ve missed an entire day of school. If they have weekly visits with a provider, they’re missing 20 percent of their education because they miss one full day per week. That creates huge gaps in their learning, which is frustrating for the student and for teachers alike. I would add that having untreated medical issues, whether they’re mental health issues or physical issues or just undertreated mental health or physical issues, creates challenges because the student isn’t ready to learn. They’re obviously experiencing issues related to their mental or physical health, which are barriers to them being ready to learn in the classroom.

Harris: We have short-term mental health facilities, and while they’re there, students are trying to work on that mental health, so the academic piece falls by the wayside. They don’t have as much academic time in the classroom. While our Anchorage School District supports all of these facilities and has teachers within these facilities, if the student is not ready to learn that morning, they do not come to the classroom. They are working with medical professionals and trying to get themselves healthy. For our high school students, the barrier arises in that they are not meeting the credit requirements for graduation. They are definitely getting their mental health under control; however, when they return to their neighborhood schools, they are behind in credits and need to make those up.

Savicky: What are your suggestions to improve access to care in rural communities?

Buckey: I think we need to recruit providers to come to the island. I think technology is certainly a piece that has helped us. As I said earlier, in terms of telemedicine, we make access to specialists available to people so they don’t have to leave. Housing ends up being an issue for us in terms of people being able to make Nantucket their home, so I think we need to have conversations about how to recruit doctors and mental health providers, clinicians to be here and to be able to make it financially. Nantucket is not an inexpensive place to live, but that doesn’t mean that these services aren’t needed. I think we have to have conversations about recruiting and retaining providers. We have a number of people who come to Nantucket and just can’t make it work because they’re not able to find affordable housing.

Nieskens: In Montana, we have something in place called the Comprehensive School and Community Treatment [CSCT] program which is school-based behavioral health services for children. It is a partnership between our Office of Public Instruction and the Children’s Mental Health Bureau at the Montana Department of Public Health and Human Services. The legislature has created a series of regulations that allow accredited public schools to contract with mental health centers to provide mental health services to children with emotional disturbances using Medicaid, in particular. Each school has a Medicaid provider number and can bill Medicaid for those services and bring providers to the school. There are about 5,000 students in Montana who get served in this way. The unique part of this is that it’s the school’s responsibility to initiate this service. If the school doesn’t, the students don’t get service, which creates an inequality between schools. Some schools have no CSCT, some schools have a really comprehensive CSCT program, and some schools are in the middle. It depends how much initiative the school district is taking.

There are even more remote locations than where I am where access is a huge barrier also. In my school, about 10 percent of our students receive in-school therapy. Some receive it daily; some receive it a couple times a week or once per week, depending on their need. We have partnered with six mental health organizations to bring in these services. Because these providers are not living in our community—they also have to travel 25 to 60 miles—we are able to bill Medicaid for travel and such so the providers are willing to come to our school. We provide them with offices on-site where they can meet with kids, and we’ve made it a priority among the staff that when these providers are here to meet with these students, they get pulled out of class.

We recognize that their mental health is as important as their instruction. Missing one period to receive therapy services on-site is certainly preferable to them missing an entire day. We’ve made it a priority to allow those kids to do that here on site. In addition, telehealth is just emerging in our state as a way to address our needs.

Harris: I think that our school in particular—and we have several outlier schools within our district that are also alternative schools—are connecting with our agencies and bringing counselors on site. Like Hannah said, it’s better for them to have those counseling sessions in school and miss maybe one period rather than an entire school day. I don’t have a large student population, but even then, we’re only able to serve the top 5 percent. That’s still not enough for me, because I know that 75 percent of my students need services. Not having enough providers to be able to do that is a barrier for us, but we are trying and moving forward to offer these types of services to our families so our students are able to get better. Luckily, my school is set right in the belly of an area that has three agencies around us, so we can connect families with them. We are trying to do more rapport building with families, so they understand the importance of students’ mental and physical health, and so they are able to access all of the opportunities around them. I think sometimes it’s just giving that knowledge to our families so that they better understand what they need to do for their children to help them to be more successful.

Savicky: Do you have any final thoughts about physical and mental health care in rural areas that you would like to share?

Buckey: I think that we need to be purposeful in making mental health as important as physical health. As I said at the beginning, we require students to have annual physicals, but we’re not doing anything for mental health in terms of an annual well-being check for students. I think access to care, increasing supports for students—we do programs for suicide prevention and awareness, substance abuse prevention and awareness—I think it was Robyn who said we need to make it available to our families. Having conversations about resources and making those clear and available to families is important in all areas.

Nieskens: I would just say that it’s important that we focus on, to the extent possible, closing the gaps in care, making care more accessible, utilizing technology to provide care or to access care. As a nation—and this applies to students who are not in rural areas also—in particular with mental health, most students are undercovered. Their insurance does not actually provide enough benefits for kids to seek the type of mental health care that they need in order to actually address the condition or the issues that they’re having. That needs to be improved significantly.

Harris: Continuing to get the word out there to our families is important. I go as often as possible to talk to other members of our district to connect our students and their families with our agencies. Telehealth is just new to us, too. Our staff members use that on a regular basis. It would be nice to see that expanded to our families. Because of privacy issues, if that would be something that could catch fire, it would be a perfect way for students to get some much-needed access.

Again, red tape, and I’m sure it’s all over the country, for our families to get that help that they need is overwhelming. I know for some families, they are turned down the first time, which sometimes is seemingly done on purpose, to see if they will go through the hassle of reapplying for the services they need. Sometimes our families give up. We try to push them forward. We have parent universities every other month to talk about specific areas for our students, and one of them is for the mental health piece. My nurse is there and available to answer questions, and we also have our agencies available to answer those questions as well. Education for all is part of the answer.