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Mountain Plains ATTC States Serves Six States

Susan Mickelson
Mountain Plains ATTC 

The Mountain Plains ATTC was established on September 30, 2017, in a partnership between the University of North Dakota (UND) and the University of Nevada, Reno’s (UNR) Center for the Application of Substance Abuse Technologies (CASAT). This collaboration combines the extensive experience of UND and CASAT team members in working with frontier/rural and tribal populations, knowledge of region-specific health disparities and culture, and proficiency in developing and implementing innovative training and intensive technical assistance (TA) in treating and providing recovery support services for individuals and families with substance use disorders (SUDs) that reflect the Region’s needs.   

Thomasine HeitkampCo-Directors of the Mountain Plains ATTC are Thomasine Heitkamp and Nancy Roget. Ms. Heitkamp is a UND professor in the College of Nursing and Professional Disciplines. She is a Licensed Independent Clinical Social Worker (LICSW) in North Dakota with more than 30 years of experience in addressing the training and TA needs of child welfare, addiction, and mental health treatment providers. Her academic focus has been on increasing access to workforce through the use of technology, and her leadership capabilities include workforce education in rural and tribal communities. As a result, she brings a host of proficiency, including her academic work as a scholar, educator, trainer, and administrator of numerous grant-funded research and training projects. Her recent administrative work includes Chair of Graduate Nursing and Associate Provost at UND.



Nancy RogetNancy Roget, MS, MFT, LADC has served as CASAT Executive Director since 2006 and oversees a staff of more than 50 individuals as part of a grant/contract funded center at the University of Nevada Reno (UNR). She worked as an instructor, grant writer, curriculum developer, and principal investigator/project director of numerous federal and state grants/contracts and is a contributing author to several industry publications. Ms. Roget’s tenure at CASAT totals 24 years and she was one of the original faculty members of the first round of the ATTCs back in 1993. Along with colleagues, she assisted in the development of the 18-credit and 12- credit academic programs in Addiction Treatment Services. In 2002, she led the efforts to put all the minor courses online to expand access to students residing in rural areas as part of workforce development efforts. Currently, the minor/graduate programs instruct more than 1,000 students per semester and represent the largest minor program on the UNR campus. Ms. Roget was the Executive Director for two adolescent/young adult substance use disorders (SUDs) treatment programs for more than 15 years before coming to UNR. Ms. Roget has spent 39 years in the SUD treatment and recovery field.

The catchment area for Mountain Plains training/TA events is HHS Region 8 (Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming). Region 8 is vast, with some areas designated as frontier, defined by low population density (fewer than six persons per square mile in at least 50% of a state’s counties) and residents located more than 60 miles/60 minutes from the nearest market center; and rural, which has a population density between 6.1 and 99.9 persons per square mile. “Frontier/rural areas are characterized by small population centers that cannot readily support healthcare services such as SUD treatment, which is available in more densely populated centers,” noted Heitkamp. “In four of the six Region 8 states, the largest urban areas have populations less than 200,000.” Those cities include Sioux Falls, SD (153,440); Fargo, ND (105,549); Billings, MT (105,845); and Cheyenne, WY (59,466).

“Frontier/rural areas are characterized by small population centers that cannot readily support healthcare services such as SUD treatment, which is available in more densely populated centers,” noted Heitkamp. “In four of the six Region 8 states, the largest urban areas have populations less than 200,000.”

Due to its rural/frontier nature, Region 8 struggles with limited access to additional services and faces challenges with transportation and protecting client privacy.  According to Roget, rural residents experience significant health disparities. “People living in frontier/rural areas (roughly 20% of the U.S. population) compared to urban residents are less likely to have health insurance; typically have lower incomes; experience higher levels of depression, domestic violence, and child abuse; and experience more behavioral health risk factors such as sedentary lifestyle and smoking,” noted Roget. “Hence, the focus of Mountain Plains ATTC is on providing training/TA services that are accessible, evidence-based, and reflect the issues related to service delivery in rural and remote areas.”

Additional alarming trends in the region include the rates of depression and suicide, which are higher than the national average in all six states, placing them in the top 12 (Wyoming, Montana, and Utah are in the top 5) for suicide. The highest rates of suicide are among whites (15.1%) and American Indians (12.6%). Recent CDC data indicates that North Dakota saw the most significant increase in rates of suicide with an escalation of 57.69% from 1999 to 2016. Other states in Region 8 also witnessed a dramatic increase in suicides:  Colorado – 34.1%; Montana – 38%; Wyoming – 39%; South Dakota – 44.5%; and Utah - 46.5%.

Health Disparities and Limited Access to MAT

Health disparities significantly affect American Indians, which comprise up to 9% of the Region 8 population. “Mortality rates are higher from chronic liver disease and cirrhosis, unintentional injuries, diabetes mellitus, assault, homicide, and intentional self-harm/suicide,” explained Heitkamp. “People residing in frontier/rural areas may have similar prevalence rates of drug and alcohol disorders as those in urban areas; however, their mortality rates and risks for suicide are higher and alcohol/drug problems more severe.”

Culture is another complex and dynamic concept integrating the racial/ethnic or linguistic groups’ thoughts, communications, actions, customs, beliefs, values, and characteristics, according to the Co-Directors.  The racial/ethnic population in Region 8 shows little diversity, with 88%-93% white residents; however, Mountain Plains ATTC staff members strive to acknowledge the importance of matching the culture and languages of the client, provider, and organization when planning and implementing SUD-related training/TA activities. Services that are culturally and linguistically competent not only take into consideration past and current discrimination and social injustices, but also the population’s standards.

MAT is limited in frontier/rural areas for the more than 21 million people residing in counties without waivered physicians to prescribe buprenorphine. In Region 8, access is limited to a waivered physician. “There is essentially a corridor from the US-Canadian border to the Oklahoma-New Mexico border with inadequate access to MAT providers,” Heitkamp points out. As a result, treatment/recovery support providers must understand the sociocultural factors affecting substance abuse/recovery patterns related to these differences within frontier/rural and tribal community cultures.

Advisory Board Represents the Region

 “Our goal is to ensure culturally congruent and competent treatment/recovery support services,” Roget noted. Mountain Plains staff members apply existing knowledge related to cultural competence best practices and work with Advisory Board/Workgroup members to ensure development and dissemination of training/TA activities, curricula, and materials that honor and address diversity.

Mountain Plains ATTC created an advisory board that equitably represents the region and includes members from recovery community organizations; tribal colleges; medication assisted care providers; treatment provider associations; rural and tribal behavioral health treatment providers; representatives from each state office that manages the SUD prevention/treatment/ and recovery support funding; researchers; faculty from social work, nursing and addiction programs; and policy makers. This group met for the first time in December 2017 to assist with initial training/TA activities and provide input for development of a regional training/TA needs assessment. “The first advisory board meeting was a great success,” stated Heitkamp. “It helped solidify our proposed goals and objectives and our work plan for Year #1.” Details of the first meeting are available in Summary of Advisory Board Discussion.

Three Themes for Training and Technical Assistance

Three general themes for training/TA needs were identified by advisory board members, including: 1) integrated care; 2) evidence-based practices; and 3) technology-based services. During the past nine months, the Mountain Plains ATTC developed and distributed a needs assessment survey instrument completed by Region 8 providers to determine training and technical assistance needs for SUD treatment and recovery services within the region. Individual state input was also secured from the SSAs prior to distribution. Survey results will be available soon and posted on the Mountain Plains website.

Workforce development is a significant issue in Region 8 as the number of behavioral health providers is currently inadequate for the population, which qualifies each state as a Mental Health Professional Shortage Area. SUD treatment/recovery services in frontier/rural areas are at times difficult to sustain, which then reduces availability. This may be due to high delivery costs, workforce shortages and, in some cases, public opposition to drug/alcohol treatment programs. A recent study on the number of behavioral health practitioners in rural counties found that 24% had no counselors, 35% had no social workers, and 61% had no psychologists. The lack of racial/ethnic diversity also impacts the Region’s tribal communities. With 31 federally-recognized tribes, the American Indian population in four of the six states (Montana, North Dakota, South Dakota, and Wyoming) is higher than any other ethnic group. According to Heitkamp, “Developing and sustaining a culturally-informed treatment/recovery workforce is crucial.”

Currently the Mountain Plains ATTC is busy creating well-designed and user-friendly online learning systems and research-based learning activities (e.g., webinars, self-paced courses, skill practice exercises), as well as increasing access to regional, national, and international experts through videoconferencing platforms which provide web-based learning that matches or in many cases exceeds traditional in-person learning activities. Specifically, the Mountain Plains staff have developed a web-based sequenced learning model called Enhanced Professional Learning series (EPLs) that uses cutting edge technologies and instructional/ consultation activities to increase knowledge, build skills, and change practice through the adoption of EBPs and promising practices by clinicians and peer support specialists, especially those in rural areas.

Collaborative Training Offerings

Dozens of collaborative training offerings have been provided by Mountain Plains ATTC throughout the six-state region, including ECHO sessions and EPLs on subjects ranging from ASAM criteria to SBIRT. A review of one-year objectives indicates that the Mountain Plains is on track to meet its projected targets. A training video is in the last stages of production which features Tami DeCoteau, an expert on trauma-informed care and historical trauma, being interviewed by Co-Director Heitkamp. The video will be housed on the Mountain Plains website when complete.

"We feel blessed with our teams and look forward to serving our region focusing on workforce development, promoting the adoption and implementation of evidence-based practices; and making sure that all behavioral health professionals understand the four "A”s and "S" (accessibility, accountability, acceptability, affordability, and stigma) and how they impact behavioral health service delivery in rural areas." 
Mountain Plains ATTC Co-Directors, Nancy Roget and Thomasine Heitkamp

Recently, Mountain Plains has partnered with Mid-America ATTC, serving Region 7, to offer Family-Centered Behavioral Health Support for Pregnant and Postpartum Women. This program features the unique perspectives of leaders in the pregnant/postpartum women’s treatment and recovery field. Through policy, research, and practice lenses, the leaders share how the field has broadened its scope to begin serving the entire family. Interviewees discuss the historical evolution toward family-centered care and next steps to improving care for families.  

The Mountain Plains ATTC staff includes a talented array of faculty, project managers, evaluators, media and graphic designers, webinar/online learning coordinators and assistants to complete the goals and objectives of the project. Expertise includes: provision of MAT services in a FQHC setting; perinatal issues; SBIRT; service delivery in rural/frontier areas; child welfare; digital health technologies; conducting webinars and online learning events; website development and marketing.

Roget and Heitkamp noted, “We feel blessed with our teams and look forward to serving our region focusing on workforce development, promoting the adoption and implementation of evidence-based practices; and making sure that all behavioral health professionals understand the four ‘As’ and ‘S’ (accessibility, accountability, acceptability, affordability and stigma; Green Stewart, 2018) and how service delivery in rural areas is impacted.”