Applying for grants isn't easy. It is extremely competitive and takes skill in narrative writing, data collection and consortium building. Even if you have all those things going for you, an awesome grant application can still be denied based on some minor discrepancy.
I know because that's exactly what recently happened to our rural health addiction treatment program.
My talented wife, who has a background in business and health care administration, wrote a 65-page application for a federal addiction treatment development grant. She worked in collaboration with a state-sponsored grant-writing assistant who was on the phone with us as we uploaded every piece of data to the grant application website and beat the submission deadline just in the nick of time. We had the support of local health agencies and our state representatives, and we were told ours was one of the best applications they had seen.
To our great surprise, our application was ultimately rejected.
A slight discrepancy between CMS' rural health designation maps and those of the Health Resources and Services Administration cost us needed funding. Our facility has long been a rural health clinic according to CMS criteria, but we were outside the HRSA's specifications by about 100 feet.
This was a shocking and devastating blow because we were depending on this grant to grow our program, hire more staff and provide additional services.
We have since addressed this issue with HRSA, and the agency has promised to try to resolve the discrepancy with CMS. However, we will, unfortunately, have to wait until the next grant cycle and begin the process all over again.
Because of this setback, we decided to move forward and seek state certification under the Missouri Department of Mental Health, which we were told would make us eligible for state grants. Although we eventually succeeded by making a strong case that family physicians are more than equipped to provide behavioral health care, getting this certification turned out to be more difficult than expected.
The state surveyor informed us that we were an unusual case in that we are primary care-led, whereas addiction programs traditionally are behavioral health-based. Hence, DMH is the state credentialing body for such entities. We ultimately received a provisional certification with the caveat that we are expected to hire an addiction-trained counselor licensed as a licensed professional counselor, licensed clinical social worker or higher. This requirement was made despite the fact that we already utilize the local hospital's counseling staff. Although many addiction treatment centers around the country are adopting a medication-first model, one has to wonder if there is still a lingering bias toward behaviorally modeled programs.
The fact that many behavioral health programs are adding medical treatment components to their service repertoire makes them even more competitive candidates for grant selection. However, such programs cannot handle the wide breadth of the substance abuse crisis on their own. That's where primary care comes in. As family physicians, we know we are well trained and optimally positioned to bring top-notch medical and behavioral health care to our communities.
Unfortunately, the level of training and experience family physicians bring to behavioral health doesn't appear to be widely recognized by the public. Lalita Abhyankar, M.D., M.H.S., wrote in a recent post to this blog that unfounded comments from Lady Gaga about mental health and primary care can be harmful to patients, pointing out why -- and how -- the AAFP supports mental health care in the primary care setting.
As family physicians, we need to get the word out that we are often the first point of behavioral health care access for our patients. In fact, according to the AMA, there are more than 246,000 primary care physicians in the United States. AAFP data show that family physicians see an average of 83 patients per week across all settings. The percentages of primary care visits associated with mental/behavioral health are approximately 6% for children younger than 12 years and 31% for adults 75 and older, according to the CDC.
It is time for family physicians to lead the way in providing addiction care. The good news is that we are poised to do just that. On Aug. 1, the National Council for Behavioral Health Board of Directors announced its support of the bipartisan Mainstreaming Addiction Treatment Act, which would expand access to medication-assisted treatment, the "gold standard" of addiction treatment when prescribed in conjunction with regular counseling.
Ultimately, whether addressing substance use disorders or other public health issues, family physicians should be on the frontlines, leading the way in community resource development and organization. This takes networking among agencies and building coalitions. Once a need is identified, a community outreach initiative needs to be developed, and both internal and external funding streams can be sought.
Having the know-how to find appropriate grants and the skill to apply for them, or at least the resourcefulness to find someone who does, can be essential to the success and sustainability of your program. Don't be surprised if you face a negative bias as a physician seeking to obtain public funding for a program that has traditionally been within the purview of behavioral health organizations. We need to continue to get the word out that family physicians are community health change agents and that we play a critical role when it comes to providing access to high-quality preventive, behavioral and medicinal health care.
For example, while in residency, I was privileged to experience the benefits of an externally funded community health program. At Bronx-Lebanon Hospital, we had regular opportunities to work hand-in-hand with community health workers who acted as intermediaries between patients and the medical-social systems that served them. CHWs functioned as physician extenders, improving ambulatory care and augmenting preventive health by obtaining in-home vital signs and monitoring medication, as well as providing community education, patient advocacy and informal counseling. CHW programs like this are often funded through grants. Ours was through a partnership with 1199SEIU Training and Employment Funds. This is just one of the many examples of how family physicians can utilize external funds and community-based resources to improve primary care access and delivery.
There are many other community health funding opportunities, if you know where to look. For example, the AAFP Foundation offers grant opportunities. The National Center for Chronic Disease Prevention and Health Promotion also funds various grants. Other funding sources to check out include Grants.gov and GrantWatch.com.
Each state has its own funding programs for community-based health care initiatives. In Missouri, we have Community Partnerships, which helped fund a local community coalition, the Dallas County Live Well Alliance, through the Community Partnership of the Ozarks. This coalition helps us access small preventive health grants, carry out community health surveys and launch local initiatives for tobacco cessation, substance abuse prevention, obesity education and awareness of issues related to suicide and domestic violence.
There are multiple training venues and programs that can help FPs develop compelling grant proposals. The AAFP National Research Network offers family physicians opportunities to learn about and participate in research. The Family Medicine Discovers Rapid Cycle Scientific Discovery and Innovation initiative offers an annual scholars program. And the North American Primary Care Research Group is another place primary care researchers can learn about how to develop, write, implement and collaborate on grants.
When we publish the results of grant-funded mental health/primary care projects in peer-reviewed journals, it highlights both the grantee's work and the importance of family medicine in behavioral health. Family medicine is a research discipline, and we need to continue to tout the work of family physician researchers.
Ultimately, providing comprehensive patient care means identifying physical and psychosocial determinants of health and making sure patients have access to the treatments and services they need. Obtaining access to funding streams for public health initiatives and networking to develop a coalition of community-based resources can go a long way toward supporting optimal patient outcomes.
Kurt Bravata, M.D., is a family physician who practices primary care, geriatric medicine and addiction recovery in rural southwest Missouri.