Rural Areas – Sometimes It’s the Distance, Not the Journey

Providing services to children and families has always been a challenging and complex problem. Through agencies, these services are often contracted to local providers. Distance, travel, and method of transportation have always been a further complicating factor, especially in rural areas.  As an Indiana governor suggested – “identify a problem, fix a problem, don’t embrace it.”

Transportation, distance, and travel time

In most jurisdictions, transportation to and from activities, such as court ordered visitation, drug/alcohol counseling, or medical or drug screening/assessment, is a challenging requirement. Many providers indicate that “no-shows” are the most frequent problem they have in managing the budgets and scheduling. Often, this is due to notification challenges or even failure of notification; most likely, however, it is due to transportation, regardless of the distance.

In fact, no-shows for assessment, treatment, or counseling significantly impact treatment success and satisfactory closure. In urban/suburban communities, public mass transportation or even paying mileage reimbursement can solve the issues of timely participation. 

Distance and time significantly impact availability for a counselor/therapist to provide services to a financially acceptable number of clients.  It could be argued, however, that the rural community referrals for services are not as numerous as those in an urban/suburban setting. That is not the case, but it may merely be a matter of perception or degree. Drugs, for instance, have been prominent in urban/suburban setting for years but there is now a reality of the increase use of methamphetamines, heroin, or prescription drugs in rural communities as well. All of this is not to ignore the issues of physical or sexual abuse and child neglect in all communities.


Service delivery in rural, frontier communities

Regardless of the circumstances, there are particular issues that need to be addressed in rural communities – in some jurisdictions identified as “frontier” communities – including:

  1. Understanding the problem. Rural communities may have abuse and neglect, domestic violence, drug and alcohol use/abuse, mental health and other issues affecting children and families – just not as concentrated by numbers. Identifying and understanding the nature and extent of those issues is an important part in providing services. Agencies can take a significant first step by working with mental health centers, health departments, schools, law enforcement, courts, and others having databases to identify and quantify particular issues.

  2. Service provision. After identification, a solution must be found. Typically, these will be contracted to a not for profit agency or provided in conjunction with the health department, community mental health center, clinic, etc. The agency can identify a provider willing and able to provide services of a particular nature with a distance and quantity factor considered. The agency should be prepared to offer services that are consistent with the current models including trauma-informed care, evidence-based practice, etc.

  3. Contract procurement. The next step is to contract for the services by procurement, particularly for isolated or distant areas. While the current practice is moving away from fee for services on an hourly/daily basis to other forms such as blended rates, braided rates, or pay for performance, the procurement process must take into consideration alternative forms of service provision. The process must also allow creative management and experimentation for service provision. A contract for rural communities therefore cannot be “cookie-cutter” contracts without addressing the particular challenges that rural communities present.

  4. Travel/transportation. The procurement process and contract arrangements must be made in a way that compensates for travel, by either the provider or the client. In most circumstances where the client has access to transportation, consideration should be given to paying mileage or some other form of compensation. This may also be done by authorizing the client to provide or arrange transportation with a friend or relative. In regards to provider travel, it is not acceptable to ask a highly qualified therapist/counselor to travel one hour each way for a single 50-minute session. This is where quantity (or numbers of clients) start to impact contract procurement and also why having an expanded database to determine need is critical. It may be worthwhile for one therapist/counselor to travel one hour each way if he/she provides services at one location for multiple clients. All of this requires significant review and evaluation and certainty of service need in a general rural geographic area.

  5. Distance therapy.  Consideration should also be given for the use of current technologies to allow counseling therapy to be conducted using technology. With much of today’s technology meeting the requirements under HIPAA and other confidentiality requirements, agencies are starting to use technologies to provide certain services to more remote clients.  All of this can be done while complying with all requirements under HIPAA and other confidentiality requirements. Mitch Roob’s organization, Healthcare Anywhere, has been doing just that for health services, including initial assessment of harm or injury. They have now found that a more accepted use of the current technology is for human/social services and not medical or health. Many clients are personally using computers, tablets, laptops and smart phones for their daily activities and communication – Face Time, Skype, go to meetings, and others. The above-mentioned system not only provides time scheduling, certainty of use including notification, documentation of services for billing purposes, opportunity for notes to be taken and shared, visual clarity and sense of connection, but also appears to be accepted readily by children for individual counseling.  For those without the current technology meeting the requirements for acceptable standards of distance therapy, the technology is, in all probability, available at a clinic, office, hospital, or other potentially secure environment through which arrangements can be made to conduct the contracted services.

Rural or frontier communities present additional challenges and nuances for service delivery. However, that does not mean that these communities should go untreated, nor does it mean that there are no programs available to address the increasingly difficult challenges. Leadership has the responsibility of ensuring that identifiable needs are met and successfully addressed. Rural communities, their children and families, deserve the very best that an agency has to offer.