Rural Project Examples Addressing Integrated service delivery

Cross-Walk: Integrating Behavioral Health and Primary Care

Updated/reviewed May 2024

Need: To address and treat substance use disorder (SUD) 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 primary care patients were referred to a behavioral health specialist.

Updated/reviewed May 2025

Need: To connect patients to resources in order to reduce use of emergency services, emergency department visits, and hospital readmissions.
Intervention: Patients receive support (by in-person visit, phone call, or telehealth visit) from a paramedic, community health nurse, peer recovery specialist, and pharmacist.
Results: Between July 2016 and March 2024, the program made 1,098 patient contacts and continued to see a reduction in emergency department and inpatient visits and costs.

Updated/reviewed May 2023

Need: Out of 79 Critical Access Hospitals (CAHs) surveyed in Minnesota in 2015, behavioral health was the most frequently cited service requested.
Intervention: In response, Rural Health Innovations launched the Minnesota Integrative Behavioral Health Program. This initiative engaged representatives across all sectors in health integration between hospital, primary care, and community services.
Results: Strategy sessions resulted in the creation of resource directories to improve care coordination, evaluation measurements to document results, and an overall better understanding of integrative care challenges.

Updated/reviewed November 2020

Need: Decrease rates of domestic violence, child sexual abuse, and child neglect for people in remote tribal villages.
Intervention: An evidence-based model of traditional culture trains local communities on methods of prevention and treatment for domestic and interpersonal violence.
Results: Self-sustaining local system with improved family and spiritual well-being and decreased healthcare access needs.

Updated/reviewed December 2019

Need: A healthcare delivery model to improve health and well-being of Pennsylvania patients with serious mental illness in Pennsylvania, especially those in rural settings.
Intervention: County human service administrators, patients, families, a behavioral health provider network, and a nonprofit behavioral health managed care organization implemented 2 versions of a behavioral home health model focusing on a complete culture of wellness.
Results: These unique models significantly increased patient activation, engagement in both primary and specialty care, and improved client perception of their mental health status.

Added March 2019

Need: Pediatric behavioral health services in Delta County, Colorado.
Intervention: Multi-organizational and community-wide effort to increase healthcare access for children and to integrate behavioral health care into the area's primary care clinics.
Results: Sustainable increases in access to pediatric behavioral health services.