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Rural Project Examples: Integrated service delivery

Promising Examples

funded by the Federal Office of Rural Health Policy Healthy Outcomes Integration Team
Updated/reviewed November 2017
  • Need: To provide integrated treatment planning and coordinated healthcare services to rural residents.
  • Intervention: This program was designed to treat adults who have a serious mental health condition and those who have, or are at risk of developing, chronic health conditions.
  • Results: Thus far, 84 clients have received integrated health and mental health services.
funded by the Federal Office of Rural Health Policy Physical and Behavioral Health Integrated Care Project
Updated/reviewed October 2017
  • Need: To provide unified and seamless access to primary physical care to adult patients in Clearfield and Jefferson counties in Pennsylvania who have been diagnosed with Serious and Persistent Mental Illness.
  • Intervention: A “one-stop shop” of healthcare services addressed the physical and behavioral health and medication needs of adults in the region.
  • Results: Results indicated better behavioral and physical health outcomes for participants, as well as increased adherence to medications.
funded by the Federal Office of Rural Health Policy Cross-Walk: Integrating Behavioral Health and Primary Care
Updated/reviewed October 2016
  • Need: To address and treat substance abuse and depression in the Upper Great Lakes region.
  • Intervention: Cross-Walk, a program that integrates behavioral healthcare into primary care services, was developed in Michigan's Marquette County.
  • Results: The collaborative efforts strengthened care management services in local healthcare facilities as 344 patients were referred to a behavioral health specialist.

Other Project Examples

TeleTEAM Care for Diabetes Program
Updated/reviewed October 2017
  • Need: The rate of diabetes and diabetes mortality in North Carolina is higher than in many other states, but is even higher in the eastern part of the state.
  • Intervention: TeleTEAM provides integrated care for patients with diabetes during regular primary care visits, using telehealth to connect them with off-site behavioral therapists, dietitians, clinical pharmacists, and a medical diabetologist.
  • Results: Patients who have received care from TeleTEAM providers have shown decreases in blood sugar, as well as in weight, depression, and diabetes-related distress.
Fostering Futures in Menominee Nation
Updated/reviewed September 2017
  • Need: Since the late 1800’s, trauma caused by historic events have greatly affected the way of life for Menominee Indians living on the Menominee Reservation. Economic, socioeconomic, behavioral health, and physical health issues have risen and are causing direct implications for Menominee youth.
  • Intervention: Through Fostering Futures, clinic, school, and Head Start/Early Head Start staff are trained in administering trauma-informed care and building resilience among children.
  • Results: Behavioral health visits at the Menominee Tribal Clinic have increased, school suspension rates have decreased, and graduation rates have improved from 60% to 85% since 2008.
Morrison County Accountable Community for Health
Added August 2017
  • Need: To combat prescription drug misuse in rural Morrison County, Minnesota.
  • Intervention: The Morrison County ACH brings together primary care, social services, law enforcement, and other partners to make sure that patients receive treatment and support.
  • Results: One pharmacy saw a 20% reduction in the number of prescribed opioids, and the ACH was able to taper 127 patients off opioids completely.
funded by the Health Resources Services Administration MORE Care
Added June 2017
  • Need: To improve rural residents' oral healthcare.
  • Intervention: MORE Care creates interprofessional oral health networks to 1) better integrate oral health into primary healthcare and 2) coordinate oral health between primary and dental healthcare.
  • Results: Operating in 3 states, MORE Care has led to increases in fluoride varnish administration, improvement in interprofessional communication, and patients' improved self-management of their daily oral health.
Total HEALTH
Added April 2016
  • Need: A facility that offers both behavioral and primary healthcare services for the ease of patients in Northwestern Pennsylvania.
  • Intervention: A pilot project was launched at one behavioral health facility that added a primary care and pharmaceutical component to provide a one-stop shop for patients.
  • Results: Patients have become more willing to follow through with treatment plans and attend appointments. Partnering healthcare facilities have also experienced positive medical outcomes of enrolled patients.
Recovery-Oriented System of Care (ROSOC)
Updated/reviewed January 2016
  • Need: To serve adults in Mendocino County, California with chronic substance use disorders, mental health diagnoses, and/or complex medical conditions who frequently utilize emergency departments and jail services.
  • Intervention: A safety net organization was formed that works with medical providers and law enforcement to reduce the high cost of caring for frequent utilizers through intensive care coordination activities.
  • Results: Greater overall stability in the lives of clients, with less utilization of low-efficacy, crisis-oriented services, hospitalizations, and incarcerations.