Rural Project Examples Addressing Integrated service delivery

Healthy Outcomes Integration Team
Updated/reviewed November 2018

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.

Cross-Walk: Integrating Behavioral Health and Primary Care
Updated/reviewed October 2018

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 primary care patients were referred to a behavioral health specialist.

Physical and Behavioral Health Integrated Care Project
Updated/reviewed October 2018

Need: To provide unified and seamless access to primary care to adult patients in Pennsylvania's rural Clearfield and Jefferson counties 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.

TeleTEAM Care for Diabetes Program
Updated/reviewed November 2018

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 provided 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 showed decreases in blood sugar, as well as in weight, depression, and diabetes-related distress.

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.

Morrison County Accountable Community for Health
Updated/reviewed August 2018

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.

MORE Care
Updated/reviewed July 2018

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.

Optimal Health Behavioral Health Home Models
Added July 2018

Need: A healthcare delivery model to improve health and well-being of 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.

Behavioral Health Home Plus Program
Updated/reviewed June 2018

Need: A facility that offers both behavioral and primary healthcare services for the ease of patients in Northwestern Pennsylvania.
Intervention: The Behavioral Health Home Plus Program provides coordinated care for patients having primary care and behavioral health needs.
Results: Dickinson Center, Inc. has seen a decrease in hospital stays, emergency department visits, diabetes, and depression in patients enrolled in the Behavioral Health Home Plus Program.

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