Psychiatric Residents And Fellows Fill Gaps In Rural Michigan Mental Health Care

According to CRC:

> An estimated 1.3 million Michigan residents have a mental health condition.
> Access to services is limited because of a shortage of mental health professionals across the state, especially rural areas.
> A number of reforms would improve the availability and affordability of mental health services to meet the gap in access.

https://www.modeldmedia.com/features/060623cmhfellows.aspx

Psychiatric residents and fellows fill gaps in rural Michigan mental health care
Joanne Bailey-Boorsma | June 13, 2023

For about the past year, Dr. Kellen Stilwell, a psychiatry fellow based at Grand Rapids’ Pine Rest Christian Mental Health Services, has been opening his computer and connecting with children in the North Country Community Mental Health (CMH) Cheboygan clinic through telepsychiatry.

“I know it is just over a Zoom, but it's been such a rich opportunity,” Stilwell says. “Even though we're not in the room, we still get to really connect, and I feel like I really bonded with these kids.”

The need for more mental health professionals is no secret — especially for children and adolescents. Even before the pandemic, the Citizens Research Council of Michigan had reported that about 38 percent of Michiganders (and 80 percent of those with substance use disorders) were not receiving the mental health care they needed. Psychiatric fellows and residents are helping meet that need. Medical school graduates typically take on fellowships after completing their residencies in a specific medical field.

Since the pandemic, Michigan’s rural areas have faced compounded challenges with a rise in mental health needs and a severe shortage of mental health professionals. Health Resources and Service Administration’s data shows that of Michigan’s 83 counties, 75 have at least a partial designation as a primary care health professional shortage area (HPSA). The American Academy of Child and Adolescent Psychiatry reports few to no child and adolescent psychiatrists for most of Michigan’s northern rural counties.

North Country CMH child psychiatrist and medical director Dr. Marit Vogel is familiar with these challenges in rural communities. She and nurse practitioner Susan McCloskey are the only two mental health professionals serving children and adolescents in Antrim, Charlevoix, Cheboygan, Emmet, Kalkaska, and Otsego counties, the six counties that North Country CMH serves.

Vogel notes that even before COVID, psychological and emotional trauma was becoming a bigger part of her practice. COVID added other stress factors such as long-term economic effects, the loss of loved ones, and the loss of development as children were not able to participate in school or activities.

For several years, Vogel has tried to get another child and adolescent psychiatrist for the area, but it never happened. Then Pine Rest officials reached out to her about expanding its Child and Adolescent Fellowship to include a rural rotation.

“They needed somebody to provide more training in child and adolescent psychiatry, and they especially were interested in somebody who could provide a rural setting so that the fellows would get some experience working with people in a non-urban setting,” Vogel says. “What we have in the way of services that are available and so on is different than in an urban setting.”

A rich learning experience that increases capacity

In July 2022, North County CMH added four fellows: Stilwell, Dr. Chad Percifield, Dr. Hannah Williams, and Dr. Mathew Koster. All are second-year child and adolescent doctors of psychiatry from the Pine Rest Psychiatric Residency and Fellowship Program. Every Friday, under the guidance of Vogel, the doctors meet with children and adolescents in North Country CMH’s Bellaire, Cheboygan, Gaylord and Petoskey offices.

“I think part of the work of learning medicine is to learn about systems of care, which kind of depends on where you are in the world,” Stilwell says, adding that the goal of a fellowship is to gain different kinds of experiences. “So the resources that I have in southwest Michigan are obviously the same that are available in northwest Michigan. The challenge and the learning points are how to navigate systems with these families and help get them effective care.”

Stilwell says if he had been required to learn the process on his own, it could have been intimidating but with the North Country CMH team, he felt he had developed a deeper understanding of the process for helping people in a rural setting.

“I think through our united efforts, we've been able to do really good things,” he says.

While no data on the impact of the program is yet available, Vogel concurs with Stilwell in that it has made a difference.

“Instead of one psychiatrist and one nurse practitioner seeing children, you've got four more people seeing children that morning,” Vogel says. “It’s like twice as much as what we could get done in the morning. Not twice as much, but more as it's having six people to see children, providing psychiatric evaluations and treatment. So yes it has increased access and made it easier to get children in faster.”

“50% of people will stay where they trained.”

Another Northern Michigan CMH, Northern Lakes Community Mental Health Authority is also partnering with Pine Rest to add a rural track to Pine Rest’s psychiatry residency. This program, which is in collaboration with Michigan State University, serves Crawford, Grand Traverse, Leelanau, Missaukee, and Rocommon counties. Northern Lakes CMH also partners with Munson Healthcare to create a Traverse City-based rural psychiatry program. Supervised by Dr. Scott Monteith, Northern Lakes CMH psychiatrist, and Dr. Neal Fellows, MSU College of Human Medicine, residents Dr. Stephen Murata and Dr. Cory Manoogian are in their third year of a four-year residence program. They are spending a year working with Northern Lakes CMH Cadillac and Traverse City Assertive Community Teams (ACT).

The program is part of the MIDOCs, a state-funded program that aims to recruit, train and retain providers with the goal of increasing access to care in rural and urban underserved communities in Michigan. Residents are recruited from four Michigan medical schools — MSUCHM, Central Michigan University College of Medicine, Wayne State University School of Medicine, and Western Michigan University Homer Stryker M.D. School of Medicine. After serving two years of full-time clinical practice at an approved service site the residents may receive up to $75,000 in student loan repayment.

The residents not not only provide increased capacity, but also help the sites they serve to engage in education and stay up-to-date. Monteith says that the long-term gain is making psychiatry residents aware of the opportunities in Michigan’s rural areas and encouraging them to stay in the community.

“We know, nationwide, that when people train somewhere, they're more likely to stay where they trained,” Monteith says. “In other words, about 50% of people will stay where they trained. But if you don't train them there, the odds of getting them there are almost nil.”

The student loan repayment incentive also greatly enhances the likelihood that the psychiatry resident is going to stay — to receive the repayment a resident has to serve in an underserved area.

Vogel also hopes that the rural rotation for Pine Rest’s Child and Adolescent Fellowship will make its fellows more aware of these rural Michigan opportunities because the need for general and child and adolescent psychiatrists will continue to grow.

Vogel concludes, “You can pay a lot of money to a search firm, but there's nothing like people knowing the area and knowing the setup and being aware of who they might be working with.”