For thousands of Georgia residents, Highland Rivers Health isn’t just their first option for substance abuse treatment services. In some cases, it is their only option.
“We are like public health departments, but for behavioral health,” Highland Rivers Community Relations Director Michael Mullet described the agency. “We work with people who otherwise would not have access to these services and we do a lot — a lot — of stuff.”
That includes a wide range of services, spanning from residential treatment to intensive outpatient to community-based supports.
“People come to our clinic for five days a week for several hours to start with,” he said. “We have two residential treatment centers, one for women in Rome and one for men in Jasper. Then there’s the community-based services — it’s really a continuum, because our crisis units also work with people in need of acute detox.”
Designated as a community service board (CSB) by the Georgia Department of Behavioral Health and Developmental Disabilities, Highland Rivers serves about a dozen counties throughout northwest Georgia, including Bartow County.
The agency serves about 16,000 people annually. In the 2019 fiscal year, Mullet said Highland Rivers served about 1,900 people with substance use diagnoses — and more than 5,500 with dual mental health and substance use disorder diagnoses.
“Are the mental health issues because of the drug use, or is the drug use a response to the mental health issues?” said Highland Rivers Health Director of Addictive Disease Ansley Silvers. “Everything that we do here is utilizing evidence-based practices, so we try to treat all aspects of an individual, so that we’re able to address those co-occurring disorders.”
Tammy Floyd, a regional manager for Highland Rivers’ Substance Abuse Intensive Outpatient Program, said it’s rare to encounter an individual seeking treatment for just one substance use disorder. Rather, she said it’s far more common to see someone seeking treatment for both alcohol and methamphetamine use, for example, or perhaps simultaneous opioids and benzodiazepine abuse.
For the last two years, Silvers said that trend has certainly increased.
“It’s really no longer just one drug of choice,” she said. “Addiction’s always been in our communities, been in our families, been in our neighborhoods, but with the issue of opioids really taking the spotlight, I think it’s kind of piqued interest and raised some awareness into the risks associated with it. Because we’re seeing more deaths associated with opioid use.”
Cartersville resident Nikki Kemp is the program manager of Highland Rivers’ Mosaic Place, a recovery community and resource center in Cedartown.
“It’s always been a problem here,” she said. “My parents used here, at one point I used here. With the opioid overdoses and stuff, now people are seeing that it’s here.”
Kemp started using methamphetamine when she was 14. In recovery for the last seven years, she ultimately went through six different Highland Rivers programs.
“Each time, I got what I needed, it’s just that when I got back out into the community, I was going right back to the same environment that I was already in,” she recounted, “so there really wasn’t a resolution for that.”
The scope of Bartow’s substance use epidemic, Silvers said, is larger than many may realize — or want to realize. Making matters worse, she said, is that many individuals with substance use disorders refuse to seek treatment due to social stigmas.
“When we’re working with crises or addiction, then we’re dealing with a true illness that sometimes stays hidden from the community’s eye or appears as anything other than someone needing help,” she said. “When we walk into a doctor’s office because we’re sick, we don’t necessarily think about how someone’s going to judge us for that. When people walk in to seek treatment for addiction, they don’t need to fear that, either.”
As for the types of evidence-based treatments employed by Highland Rivers, Silvers listed a litany of programs and modalities: motivational interviewing, cognitive behavioral therapy, trauma-focused therapies like Seeking Safety and the Matrix model for stimulant abuse, among many others.
The programs, she said, tend to be about six months long and include post-treatment wraparound services.
“We also offer addictive disease support services where a person in long-term recovery is able to go and work with them out in the community on establishing a healthy support system, helping them find employment, safe and stable housing, reunification with their children,” she said.
Kemp said the Mosaic Place certainly qualifies as another wraparound service source.
“We have a multitude of community supports in different aspects,” she said. “We have church that comes a few days a week, we have employers that we can call and say ‘Hey, we have this person who needs a job,’ … it takes the whole community coming together and supporting not only the people in recovery, but also the people who provide the treatment and the services.”
The agency also provides youth-focused services, such as the State-funded APEX Project.
“We have a therapist in the schools that works with school teachers, staff and administrators to identify kids at risk for behavioral health, whether that’s mental health problems or substance abuse,” Mullet said. “That has been a tremendously successful program, school staff loves it. And you know, kids are at school for so long and they spend most of their time there. And they don’t check their problems at the door.”
Highland Rivers Health CEO Melanie Dallas said the agency has contracted with at least two counties to provide in-jail behavioral services.
“That’s been really critical,” she said. “Because we’re able to connect with folks during their incarceration, engage and develop relationships so that follow-up following incarceration is much more likely — we would love to expand that, and we’ve talked to several counties about that.”
Dallas said program expansion opportunities are limited, however, due to a lack of funding and workforce. In fact, she said there is a lack of specialized care providers not just throughout the agency, but throughout the entire northwest Georgia region.
Then there’s the legislative restrictions.
“We’ve got about 227 policies of oversight that we’re trying to say ‘Is there anyway we can maybe reduce that?’” she said.
THE INSURANCE QUESTION
While many people think that CSB services are reserved for those who simply “can’t afford” treatment, Dallas said Highland Rivers’ client base is far more narrow.
“To qualify for Medicaid is right around 50% of the Federal Poverty Line [FPL], and our services are closer to 200%, so there’s kind of a big gap there,” she said. “The State funds us a considerable amount of our budget, but those dollars are specific to individuals who have severe or persistent mental illness who have quite involved substance use issues and also, who are probably more at the 200% [threshold] of poverty.”
With those restrictions in mind, Dallas said the individuals that can be served by Highland Rivers programs constitute a small percentage of Bartow County’s 100,000-plus population.
“The numbers that we would serve are literally only a portion of those with substance abuse or mental illness, based on need and meeting some of those financial qualifications,” she said.
Dallas estimates that about 80%-90% of the individuals her agency works with qualify for either State-funded services or have Medicaid or Medicare. If a provider isn’t Medicare-credentialed, she said the agency refers service-seekers to other options in Cherokee, Floyd or Whitfield.
In many circumstances, the problem isn’t that individuals don’t have insurance. Rather, it’s that their plans don’t provide coverage for effective substance abuse or mental health treatments — this, despite federal laws being on the books since 1996 requiring health insurance and group health plans to implement equivalent dollar limits on both medical and mental health benefits.
Yet even after the passage of laws like the Mental Health Parity and Addiction Equity Act in 2008, Dallas said that “true parity” simply does not exist.
“Folks with insurance have co-pays and deductibles that can sometimes be really high and may be difficult to afford, but it is against federal law for us to [not] actually collect those and that can make treatment cost-prohibitive for folks who actually have insurance,” she said. “That’s probably one of the tougher gaps that I think that we see right now, those who are underinsured, to try to address mental health and substance abuse.”
Silvers said it’s not uncommon to see insurance dictating the kind of treatment one may receive. “And when you’re dealing with mental health and addiction, this didn’t occur overnight,” she said. “So this is not going to be a very quick fix.”
Mullet echoed those sentiments.
“Regardless of whether you’re insured or not insured, or your socioeconomic status or the problems that you have, there can be barriers to accessing treatment,” he said. “Probably without some mandated parity, we’re always going to run through this, where some people who need services are not going to be able to get them in the time that they need … if your insurance pays for five visits with a counselor, that might not be enough.”
While there have been federal conversations on the issue of mental health parity in insurance coverage, Dallas said she hasn’t seen the needle move very much over the last few years.
“We have a system, financially, that’s sort of built on failure,” she said. “We have some long-term programs that are very, very successful, but to qualify for those programs you have to have lost almost everything — you pretty much have to be unemployed, you have to be near homelessness, you have to be financially insolvent or even destitute and have a significant substance use issue.”
And that still may not be enough to guarantee an individual receives services immediately.
“Even when you do sort of reach that level, we have a men’s program that we opened five years ago,” she said, “and it has had a waiting list from the day it opened for services.”
Dallas said she does not expect Georgia’s 1115 and 1332 Medicaid waivers to have much of an impact when it comes to expanding substance abuse treatment access throughout the state.
Indeed, she said she anticipates as little as 50,000 additional Georgians qualifying for Medicaid coverage under the waivers.
“There’s a work requirement in that, so that is a way for us to increase some of the folks who will have an opportunity to have Medicaid,'" she said, “but it won’t make a dent in where I think the need is.”
Under Gov. Brian Kemp's administration, however, Dallas said she does expect to see some forward movement on substance abuse and mental health treatment issues. She brought up the recently formed Behavioral Health Reform and Innovation Commission — a State committee comprised of legislators, judges and law enforcement officials, among other stakeholders — tasked with addressing subject such as “the impact behavioral health issues have on the court system” and “whether there is sufficient access to behavioral health services and supports and the role of payers in such access.”
“I do think that under this administration, the Department of Community Health will be making some other considerations around other types of expansion,” Dallas said. “Or expanding that population, once they can see the impact.”
Mullet said he believes raising public awareness is the first step in obtaining adequate substance abuse treatment funding.
“I think there is some recognition that there ought to be parity, and I think you will see that change going forward because there still continues to be a lot of stigma around mental illness and addictive disease,” he said. “People are being more open about having experienced mental health challenges, about living with addiction and living in recovery — especially with younger people, a growing recognition that these illnesses affect a lot of people, and they always have.”
From a financial standpoint, Mullet said it simply makes sense for the State to address substance abuse interventions as early as possible.
“Prevention is less expensive than treatment, treatment is less expensive than incarceration,” he said. “We need ways to access treatment before it’s a consequence of probation or incarceration or court-mandated … there’s already a lot of money and resources being taken up to punish that person rather than have a primary treatment.”
While agencies like Highland Rivers could certainly benefit from more resources, Mullet said community partnerships are also needed.
“We are always ready to partner with community agencies that need help, that need a place to refer individuals,” he said. “And in terms of this insured/non-insured, this-that-and-the-other thing, you know what? Make the referral to us, and we can take it from there, or we can partner with you.”
BARRIERS TO TREATMENT
As for referral sources, Silvers said law enforcement, the judicial system, crisis centers and Division of Family and Children Services (DFCS) are all quite common. But the most commonly utilized today, she said, appears to be emergency rooms.
Not only is it the first point of contact for substance abuse treatment, she said it’s often the most critical.
“We tell people going into treatment and getting treatment is hard, it’s one of the hardest things you’ll do in your life,” she said. “Even in the establishment of recovery support centers within our own agency, [that] kind of bleeds into and supports the treatment aspect of the diseases that we’re treating so that there is an all-inclusiveness about it and a warm hand-off, so that when treatment has been completed, those other relationships and supports have already been established.”
One obstacle Floyd said she encounters are misunderstandings between agencies and community partners.
“I think a lot of what I see is the entities such as DFCS and probation, the officers and things, lack that knowledge and education of recovery and what treatment is about,” she said. “We do a lot of trying to educate, give them information, things like that … it’s like ‘Oh, they’ll never change, recovery and treatment’s not going to make a difference,’ those types of things. So it’s lack of knowledge of what real recovery is about.”
Community partnerships, Dallas said, are essential in promoting long-term recovery.
“We can be effective with somebody in treatment, we can give them all the skills they need,” she said. “But if they don’t have a house, if they can’t seek employment, if they’ve got a record of something that’s related to their substance abuse, then it’s hard for them to sustain recovery.”
In fact, she said she believes a lack of such supports may be the single biggest barrier to effective substance abuse treatment.
“When we start to look at folks with substance abuse issues that are very involved, we’re not just talking about treatment as being what’s needed to get them sort of into leading a life of recovery,” she said. “We need a community response, and when we start to look at individuals who are challenged in this way — homelessness, housing options, employment options, being able to address diversions through the court systems ... later in the process, they are actually employable.”
Mullet agreed, stating that supportive housing and supportive employment initiatives can serve as critical components of long-term recovery.
“There’s a lot of other community linkages that our peers and therapists and case managers can link people with,” he added.
Silvers likened residential treatment programs to chemotherapy. By that point, she said those seeking treatment are in the third and fourth stages of their illnesses.
“It’s not alway necessary to wait until somebody is that sick before you offer services,” she said. “We need to be able to work together and identify issues before you lose everything.”
And in some cases, she acknowledged that opportunities "to get better" simply aren't afforded.
“I’ve had to bury friends of my children,” she said. “They weren’t in Stage III or IV of an illness, but they were teenagers with an inquisitive brain testing drugs and what they were curious about. And it killed them.”
Silvers said the power of stigma cannot be discounted as a barrier to treatment.
“Sometimes, it’s not a one-and-done, it’s an investment, and a lot of times we have to meet someone where they are,” she said. “Not everybody comes in willing to throw everything on the ground and go ‘Make me better.’ They want to hold onto some kind of control, be it healthy or not, but through the treatment and recovery process, they start realizing what they actually do have access to.”
Simply letting people know where to locate assistance, Floyd said, is a step in the right direction for Bartow.
“I think it’s about getting information out into the community, where they can look for services or they can look for help,” she said. “Educating the community of where the resources are — someone at the E.R. could hand someone a list or brochure or something that says ‘This is where you can go to get help.’”
Kemp recounted falling into the “vicious cycle” of substance abuse over and over prior to going into Highland Rivers’ Women’s Outreach residential program.
A big piece of her recovery, she said, was receiving trauma-informed care.
“There, I was taught how to be OK with not being OK, and how to get life skills that I knew nothing about,” she said. “I learned what responsibility was and how to put one foot in front of the other and actually walk.”
To make headway on Bartow’s substance abuse crisis, Kemp said the local community has to come together and support recovery efforts — something Silvers said she definitely agrees with.
“You never know when it’s going to impact you personally,” she said. “It’s important to know what communities need to support someone to seek treatment or to seek recovery.”
Especially important, Silvers added, is the need to reach out to children, adolescents and teens.
“We need to invest in our communities and we need to invest in our youth,” she said, “because they’re the ones that are going to take care of us one day and keep things rolling.”
Community Torn is a five-week series exploring the many ways substance abuse impacts Bartow, with an emphasis on the voices of those most impacted by the community's drug crisis. Using a multidisciplinary approach encompassing public policy specialists, health care providers, law enforcement officials and judicial system representatives, the series seeks to demonstrate the true toll of substance dependency throughout the county.