Need: Improved behavioral health care offerings for a community after losing 5 senior-aged men to suicide.
Intervention: A Critical Access Hospital in Yoakum, Texas, created a community-based program focusing on inpatient and outpatient behavioral health care for area residents age 50 and older.
Results: A financially-sustainable behavioral health care delivery model demonstrating positive impacts on physical health conditions, healthcare service utilization, and high patient satisfaction rates.
Yoakum Community Hospital, a 25-bed Critical Access
Hospital (CAH) located in
Yoakum, Texas, was determined to offer quality
behavioral health services in the aftermath of 5
senior-aged men's suicides in a period of 2 years. With
this as their primary goal, the Yoakum team created an
inpatient and outpatient behavioral health care continuum
Someone experiencing depression
may not realize their illness. Without treatment symptoms
often worsen. Understanding that depression and other
behavioral health conditions are
treatable for all age groups, including the geriatric
population, the Yoakum team used information provided by
the Substance Abuse and Mental Health Services
Administration (SAMHSA) to help build their program.
Their program includes
trauma-informed care, an approach
inclusive of both physical and emotional events that
impact a patient's well-being.
As predicted by other similar evidenced-based models, the
Yoakum approach for patients age 50 and older has high
patient satisfaction rates. By including care management,
the model helps transition patients seamlessly from
inpatient care to outpatient care and includes an
outpatient-generated referral process. It has
demonstrated positive impact on acute hospitalizations
and readmission rates, chronic physical health
conditions, and improved other community health and
wellness indicators in addition to impacting suicide
rates. Outpatient care utilization rates have also
Important to the model is the specific community-based
approach involving both inpatient and outpatient care
coordination. Medical/surgical hospital standard
admission process includes depression screening. A
positive finding triggers referral information provided
to the patient and the patient's local primary care
provider. For more acute inpatient behavioral health
needs, psychiatric specialty consultation is provided by
a contract psychiatrist. In addition to contract
psychiatric care that is available by phone, acute
inpatient behavioral health needs are also met by on-site
visits if needed.
The model also integrates with the community's primary
care providers. This coordination within the local
community allows patients to stay in a
culturally-familiar environment with their families
nearby, a key to providing this type of comprehensive
behavioral health care.
This care model necessitates that all medical/surgical
hospital nurses be trained in the assessment and
treatment basics of acute behavioral health conditions.
Several of the hospital's registered nurses are certified
instructors who train all new staff.
Outpatient care includes coordination with primary care
teams. The program's specific outpatient staffing needs
include the on-site licensed clinical social workers and
a contract psychiatrist who comes weekly.
In addition to delivering positive patient outcomes, the
program has proved financially sustainable and
revenue-generating. No outside funding sources support
the program. The payment model is based on Medicare,
Medicaid, and commercial insurance reimbursement.
Psychiatry services are arranged by providing a
consulting fee for directorship and psychiatric patient
care services billed independently. Assistance is also
available for patients without traditional insurance
The Yoakum model demonstrates that despite limited
resources, this comprehensive care can be provided in a
rural community. Its leaders said it's important to
understand that the current program was built around the
failures of an original inpatient model that did not meet
their initial goals. With significant re-tooling of the
original inpatient model, the current model puts focus on
the outpatient arm that uses evidence-based group
The Yoakum team was invited to present their model at the
2018 annual meeting of the American Academy of Geriatric
A psychiatrist provides weekly on-site visits,
provides certification/recertification of patient care
plans, and leads multidisciplinary team meetings
Licensed Clinical Social Workers (LCSWs)
Certified instructors for
inpatient training on:
Actual use of trauma-informed
Secure training/caring for the combative patient
Acute Memory Impairment
Caregiver Burnout and Stress
Mild Cognitive Decline
Unfounded Fears and Anxiety
When needed, psychiatric consultation and follow-up
Medication therapy if needed
Psychotherapy, better known as "talk therapy," in
group and individual settings
Decreased admission/readmission rates, improved blood
pressure and glucose control, weight loss and other
physical outcome measures in addition to improved quality
of life measures.
Informal qualitative assessments
demonstrate that stigma around treatment for behavioral
health conditions in the Yoakum community is very low.
Patient perspectives of the New Horizons program can be
seen in this video:
Transition process from a vendor's inpatient model to
a re-tooled program focusing on outpatient care.
Finding the "right fit" between contracted specialty
psychiatry services and community need.
Implementing universal use of depression screens in
the outpatient medical community.
Resource limitations that don't allow for formal data
collection required for academic publication of the
Expect a low initial referral rate to improve after
hospital staff see the long-term impact of formal
treatment for identified coexisting behavioral health
conditions; for example, shorter acute admissions and
Expect low initial referral rates by primary care
providers until treatment results prove the program's
worth by outcomes seen with providers' most challenging
patients. Similar to the results seen with hospital
staff, providers became supporters of the program when
they saw evidence of improved physical health due to
behavioral health treatment along with fewer outpatient
and inpatient visits.
Recognize that though inpatient treatment is a
necessary offering, outpatient care is the setting which
brings most sustained improvement for behavioral health
Recognize a staffing priority for an outpatient LCSW
which will further assist in a "grow-your-own" strategy.
Because 3,000 LCSW-supervised clinical hours are required
for a Licensed Master Social Worker to become an LCSW, a
LCSW can help train additional staff.
Administrators and clinicians suggest that an
important aspect of their program is the potential for
successful replication. They see the program as adaptable
by other rural communities with similar resource
limitations who serve an ever-growing geriatric
population whose behavioral health conditions impact
their physical chronic conditions.
Please contact the models and innovations contact directly for the most complete and current information
about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The
programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural
community should consider whether a particular project or approach is a good match for their community’s
needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep
in mind that changes to the program design may impact results.