There was a time in Carol Barnes’ life when the prospect of losing her car would have worsened her already severe anxiety and depression.
When she was struggling with her disorders during the mid-2000s, Barnes said, losing her only means of transportation would have meant losing access to her mental health providers.
“If you don’t already have anxiety, you will, because you worry about it,” said Barnes, who lives in Ponca City. “I finally had to make myself not worry about it and tell myself, God will have to take care of it, because I can’t keep on having this level of anxiety and not sleeping.”
Barnes isn’t alone.
Transportation is often one of the biggest barriers for those in rural areas seeking mental health or substance abuse treatment, according to rural mental-health workers interviewed by Oklahoma Watch.
Although health-care providers are exploring novel solutions to transportation issues, such as using iPads to consult with clients who can’t make it to the clinic, the problems could multiply as state budget cuts reduce existing services.
“Transportation is the most underrated, the most poorly addressed barrier for people getting the services they need,” said Mike Brose, chief executive officer of Mental Health Association Oklahoma.
“Every corner of the state of Oklahoma is theoretically covered by a community mental health center,” Brose said. “But that community mental health center may be 30, 40 or 50 miles away. For some of the families we’re talking about, that might as well be a million miles away.”
While both urban and rural areas in the state have transportation issues, the long distances involved in rural areas create a unique problem, Brose said.
The areas with people most in need of treatment often have the poorest access to transportation.
In seven of the 10 counties with the lowest rates of vehicle ownership, the majority of people live in rural areas, according to data from the U.S. Census Bureau.
Those counties are among the highest in poverty rates and indicators of mental illness or substance abuse, such as drug overdose and suicide rates, frequent mental distress, or clients seeking state-funded treatment, an analysis of data shows.
In Choctaw County, for example, 9 percent of households do not have a vehicle, and the county has the lowest median household income and highest poverty rate in the state.
The southeastern Oklahoma county also had the fourth-highest rate of fatal overdoses over the last two years, the second-highest percentage of people reporting frequent mental distress, and the 11th highest suicide rate over 10 years.
“Most people rely on a ride from friends, and that’s not the most dependable either, but that’s what I see a lot,” said Teresa Huggins, CEO of Stigler Health and Wellness Center, a federally qualified health center that offers mental health services in six southeastern counties.
Even if someone decides to walk to the clinic for an appointment, Huggins said, problems can arise.
“Imagine if you have to walk from Sonic (about a mile away) to here,” Huggins said. “You have to walk in the ditches along Highway 9. At least in the cities there are walkable paths, sidewalks, bike paths.”
Many people ordered by a court to participate in substance abuse treatment have suspended or revoked driver’s licenses, making getting to and from treatment difficult, said Kim Burns, a clinical social worker at Hugo’s Kiamichi Council on Alcoholism and Other Drug Abuse.
“It’s either ride a bicycle, walk or rely on a friend who does have a car,” Burns said. “Transportation is very poor here. Try supporting a habit and keeping food in the house – a car is a luxury item.”
The Carl Albert Community Mental Health Center in McAlester, which covers 10 counties in southeastern Oklahoma, has made efforts to ease transportation problems by consolidating appointments, sending mental-health teams to clients and transporting clients by van. But the barrier remains substantial, said Deborah Moran, executive director.
A ‘Good Workaround’
One man recently taken by ambulance from Atoka to a McAlester hospital was recommended for emergency detention at Carl Albert, Moran said. It was later determined that the man did not satisfy emergency detention criteria.
“Now he’s stuck,” Moran said. “He can’t get back home. He has no family, no resources.”
Eventually, Moran said, the man got home using a program called SoonerRide, which pays for some transportation access for those receiving Medicaid benefits.
“If somebody is responsible enough to utilize that system, it’s a good workaround if they’re Medicaid-eligible,” said Huggins, the Stigler health center CEO.
Because users must schedule a ride in advance and be at the pick-up location on time, “you have to follow through on your end, and oftentimes people with substance abuse issues are not as dependable on that,” Huggins said. “It’s not a fail-proof system.”
In fiscal 2015, SoonerRide transported more than 11,500 people and logged nearly 830,000 trips, according to the Oklahoma Health Care Authority.
However, state-imposed budget cuts have led to tighter limits on SoonerRide.
Josh Cantwell, adult services administrator at Grand Lake Mental Health Center, which has offices scattered across northeastern Oklahoma, said the cuts mean that fewer types of treatment now qualify for the service.
Because of this, Cantwell said, the center’s offices now try to schedule other non-qualifying services around clients’ qualifying appointments.
“What we try to do is tie services together,” Cantwell said. “When they need other core services besides that therapy appointment, we have to call and schedule that ride based on the therapy appointment.”
In 2014 Oklahoma’s rural public transit service traveled four times the number of miles traveled by urban systems, but transported only 41 percent as many passengers as urban systems, according to Federal Transit Administration data.
Unlike metro transit systems’ fixed-route bus services, rural systems usually have smaller vehicles that provide “demand response,” meaning customers must call to schedule a ride, according to the FTA data.
“In northeast Oklahoma, there aren’t any buses that come by every 15 minutes. That doesn’t exist,” said Grand Lake Mental Health Center CEO Charles Danley.
The cost to ride public transit in rural areas can vary widely, depending on time, location and distance. Those services often close at 5 p.m. and do not operate on weekends.
Sharon Arnett, a Ki Bois Area Transit Service dispatcher in Eufaula, said people often use the service to reach mental health clinics in town.
“The further out you go, the more it costs, and they can’t afford it,” Arnett said. “They might have a vehicle, but most of them don’t.”
The Poverty Problem
As a driver for the Ki Bois system in Eufaula, Leland Shanks encounters people almost daily in rural areas with mental illness or substance abuse issues who can’t afford transportation.
“From my experience, it’s usually because they don’t have the money,” Shanks said. “We get a lot of, ‘How far can I go?’ They’re checking the rate to see if they can even afford to go out that far.”
Some individuals seeking mental health treatment are unable to work because their reasoning and judgment is clouded. The cost of getting to and from appointments can be a problem for them, said Kim Hamilton, site director for CREOKS Behavioral Health Services’ clinic in Okmulgee.
“A lot of people we serve are indigent and don’t have gas money to get into the clinic,” Hamilton said.
When a client experiences an emotional or mental crisis, that leaves few options, she said.
“Typically we have to get law enforcement involved to transport them if it’s a crisis situation if they don’t have a way to get there or they’re being uncooperative,” Hamilton said.
In late 2014, CREOKS opened a crisis center in Sapulpa. Before, people experiencing mental health crises were transported around 60 miles to Wagoner Community Hospital or more than 100 miles to Griffin Memorial Hospital in Norman, Hamilton said.
“I’ve actually had clients say to me, ‘Well, I don’t have money to get to the hospital.’ So we have to find a way to get them there, because you can’t just let a person who is at risk not go,” Hamilton said.
Going the Distance
Because of the ethical and moral obligations to treat and care for clients, mental health workers and agencies have tried to come up with creative solutions to transportation problems.
Joy Sloan, CEO of Green Country Behavioral Health Services, which operates in Muskogee and McIntosh counties, said her workers often travel to clients’ homes to pick them up for appointments, though for safety reasons they must be regular clients.
In more remote rural areas, however, that’s not always an option, Sloan said.
“Eufaula is a whole different issue. It’s almost frontier,” Sloan said. “If you don’t have transportation or good transportation, you could be sitting somewhere for a long time waiting for help.”
Danley, the Grand Lake Mental Health CEO, said his organization has satellite offices in the more populated areas of the 5,000 square miles his agency covers. For the less populated areas, workers will often drive to clients who don’t have transportation.
“If it weren’t for us going where they’re at, they wouldn’t get any services. They would end up being incarcerated or hospitalized,” Danley said.
Phil Black, Tulsa County senior regional director of development for CREOKS, said traveling to a client’s residence is worth the time and effort if other transportation options are not available.
“A lot of case management and therapy work is done with the providers driving out to the apartments and homes,” Black said. “It eliminates the transportation problem for the client.”
CREOKS also uses a small fleet of vehicles to give clients in some areas a ride, but recent budget cuts by the state have made doing so more difficult, Black said.
Moran said she sometimes finds herself paying for clients’ transportation.
“Often, we are taking people home after services,” Moran said. “I’ve paid for transportation services from some of our local vans to help get people to their appointments.”
Grand Lake Mental Health Center has adopted a novel way to communicate with clients who have transportation issues, Danley said.
In January, the center began sending iPads home with some clients discharged from the organization’s intensive outpatient center, Danley said. This allows mental health workers to communicate with clients at home using the FaceTime computer application, he said.
“They can take an iPad home and they can call us 24 hours a day, seven days a week, until they’re stabilized,” Danley said.
So far, more than 200 clients have used the iPad services more than 1,200 times.
“We want people to be served in the same manner they would be served in a metropolitan area,” Danley said. “When you live in a rural area, you’ve either got to come up with creative ideas and put them to use, or just put up with being rural.”