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Implementation Challenges

Rural services integration programs may experience implementation challenges or require mid-course corrections. Below are a few challenges that existing rural services integration programs have encountered. For additional information on challenges that rural programs may encounter, see Common Implementation Challenges in the Rural Community Health Toolkit.

Space

Some services integration programs require dedicated space to carry out program activities. In particular, co-location and one-stop shop models require partnering agencies to share the same office or facility. Startup costs for program planners can be substantial, especially if partnering agencies are required to break existing long-term leases. If program planners elect to co-locate single program staff from partnering organizations, they will also need to consider if these staff require a private office or meeting space in order to maintain the client's privacy.

Differences in Priorities

Services integration programs often require collaboration across different staff members, partners, agencies, organizations, and other stakeholders. Rural communities should clearly define the goals of the services integration program before implementation to ensure that all partners have the same priorities. In order to identify key priorities, rural communities could consider conducting a community needs assessment.

Legal Issues

Some federal and state laws restrict the sharing of patient or client information between different organizations. In particular, rural communities developing healthcare integration programs need to comply with health information privacy and security rules. Program leaders may need to establish business associate agreements with partnering organizations and develop confidentiality policies for program staff.

Another potential challenge, especially for models integrating the services of clinical providers, can be satisfying the various licensing requirements of clinical providers that are licensed by different governing bodies. This challenge can be mitigated by developing a single treatment protocol in collaboration with the clinical team at the outset of the program.

Reimbursement

Rural services integration programs have found that one of the greatest challenges they face is coordinating billing for different services provided by different partners. One rural services integration program found that it was helpful to begin the program by billing for services through individual provider streams (e.g., hospital, health center). As part of the project’s sustainability plan, this program has plans to develop a governing board to streamline billing through a single entity.

Confidentiality

Confidentiality can be especially critical for program staff who are working with victims of abuse, where disclosure of confidential information could put the safety of survivors and family members at risk. Programs that implement Co-location of Child and Family Services models should ensure that clients have a private space to speak with advocates in order to maintain confidentiality. Program staff also need to be trained on mandatory reporting laws, which vary from state to state.

Liability

A risk management plan may help to mitigate liability issues, such as medical malpractice claims, and identify staff training needs, such as safety training, within certain services integration programs.

Transportation

Transportation in rural communities is often limited, making it difficult for individuals to access health and human services. Barriers to reliable transportation include lack of public transit, costs (gas, insurance, vehicle, fare) and harsh weather conditions (icy roads, flooding). Long distances to healthcare services compound these barriers. Services integration programs can minimize the need for transportation by offering one-stop shops or co-locating several services in one facility in a centralized location in the community.

To address these barriers, some services integration may elect to provide transportation services for residents. The Giles Free Clinic, which co-locates behavioral, dental, and healthcare, helps operate G-REACH, a transportation program for non-emergency health services. Residents who meet eligibility requirements can request transport to the clinic.

Community health workers or services integration program staff may also be able to offer transportation assistance. PACE programs, such as the Senior CommUnity Care that serves rural Delta and Montrose counties in Colorado, offer transportation services. There are also locally-funded programs to address the needs of older adults such as Meals on Wheels, along with other assistance programs that can be found through the Administration for Community Living’s Eldercare Locator. This online, searchable directory helps individuals find public services for aging populations in their community.

In addition to providing transportation services, some organizations address transportation barriers by bringing services to individuals through mobile units. One example of this is The Washington State Department of Social and Health Services (DSHS), which allows individuals to apply for public benefits in a full-service Mobile Community Services Office (CSO). Rural residents can visit the Mobile CSO to apply for cash, food, and child care subsidy benefits, as well as certain Medicaid and Medicare programs.

Teleconferencing is another method used for overcoming transportation barriers. Healthcare providers can teleconference with individuals to address common health issues either in the home or in a nearby site such as a school.

Stigma

In small and rural communities, there may be social stigma associated with seeking health and human services. Rural services integration programs should carefully consider whether their programs reduce or increase stigma associated with seeking health and human services. One rural services integration program found that families were reluctant to seek early childhood intervention services because these services were located in the same complex as an adult day care center for individuals with behavioral and physical disabilities. This program decided to offer early childhood intervention services in a new location through a different partnership in order to increase participation. Services integration programs that may help to reduce stigma include the one-stop shop model, family resource centers, and school-linked services model.

Resources to Learn More

SAMHSA-HRSA Center for Integrated Health Solutions - Health Information Technology
Website
This website provides information about confidentiality as it relates to the implementation of health information technology in the integration of behavioral and primary care services.

Working Together, a Desk Guide: Domestic Violence Advocates Co-Located at DHS
Document
This desk guide has a section on survivor confidentiality in the context of co-located domestic violence services.
Organization(s): The Oregon Department of Human Services