Rural Project Examples Addressing Integrated service delivery

Cross-Walk: Integrating Behavioral Health and Primary Care
Updated/reviewed October 2021

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.

Healthy Outcomes Integration Team
Updated/reviewed December 2019

Need: To provide integrated treatment planning and coordinated healthcare services to rural residents.
Intervention: The Healthy Outcomes Integration Team 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: Clients received coordinated care, substance abuse treatment, crisis services, and wellness planning. Many also improved their physical health outcomes.

Morrison County Accountable Community for Health
Updated/reviewed September 2021

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 40% reduction in the number of prescribed opioids, and the ACH was able to taper 684 patients off opioids completely.

Queen Anne's County Mobile Integrated Community Health (MICH) Program
Added February 2021

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 June 2019, the MICH program enrolled 233 patients and demonstrated a total savings of $3,393,908 in healthcare costs.

Family Wellness Warriors Initiative
Updated/reviewed November 2020

Need: Decrease rates of domestic violence, child sexual abuse, and child neglect for Alaska Native people in remote villages.
Intervention: An evidence-based model inclusive 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.

MORE Care
Updated/reviewed July 2020

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: MORE Care has led to increases in fluoride varnish administration, improvement in interprofessional communication, and patients' improved self-management of their daily oral health.

Optimal Health Behavioral Health Home Models
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.

Families Plus Comprehensive Health and Mentoring for Underserved Youth
Added March 2019

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

Fostering Futures in Menominee Nation
Updated/reviewed September 2018

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.

The Minnesota Integrative Behavioral Health Program
Added June 2018

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 engages representatives across all sectors in health integration between hospital, primary care, and community services.
Results: Strategy sessions have 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.

Rural Project Examples: Integrated service delivery