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06-09-2024 | Original Paper

Understanding and Navigating the Unique Barriers Rural Primary Care Settings Face when Implementing Collaborative Care for Mental Health

Authors: Elizabeth J. Austin, Elsa S. Briggs, Angel Cheung, Erin LePoire, Brittany E. Blanchard, Amy M. Bauer, Morhaf Al Achkar, Diane M. Powers

Published in: Community Mental Health Journal | Issue 3/2025

Abstract

Rural primary care (RPC) clinics may face unique barriers to implementing the Collaborative Care Model (CoCM). We used mixed methods to explore RPC staff and practice facilitator (PF) perspectives on CoCM implementation. PFs reported on barriers and facilitators experienced after each monthly meeting with clinics (n = 459 surveys across 23 clinics). Data were analyzed descriptively and informed qualitative interviews with a purposive sample (n = 11) of clinic staff and PFs. Interviews were analyzed using Rapid Assessment Process and triangulated with quantitative data. The most prominent barriers experienced were: (1) the COVID-19 pandemic, (2) limited availability of site staff to participate in implementation activities, and (3) hiring of new CoCM staff. Qualitative data further characterized the ways these barriers uniquely influenced RPC settings and promising implementation strategies. RPC settings face unique challenges to CoCM implementation, but several promising implementation strategies – when tailored to RPC contexts - may help.

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About Collaborative Care—AIMS Center. (2024, January 30). https://aims.uw.edu/collaborative-care/

Albers, B., Metz, A., Burke, K., Bührmann, L., Bartley, L., Driessen, P., & Varsi, C. (2022). The mechanisms of implementation support—findings from a systematic integrative review. Research on Social Work Practice, 32(3), 259–280. https://doi.org/10.1177/10497315211042375CrossRef

Aldridge, W. A., Roppolo, R. H., Brown, J., Bumbarger, B. K., & Boothroyd, R. I. (2023). Mechanisms of change in external implementation support: A conceptual model and case examples to guide research and practice. Implementation Research and Practice, 4, 26334895231179761. https://doi.org/10.1177/26334895231179761CrossRefPubMedPubMedCentral

Aragonès, E., López-Cortacans, G., Cardoner, N., Tomé-Pires, C., Porta-Casteràs, D., Palao, D., & INDI·I Research Team. (2022). Barriers, facilitators, and proposals for improvement in the implementation of a collaborative care program for depression: A qualitative study of primary care physicians and nurses. BMC Health Services Research, 22(1), 446. https://doi.org/10.1186/s12913-022-07872-zCrossRefPubMedPubMedCentral

Archer, J., Bower, P., Gilbody, S., Lovell, K., Richards, D., Gask, L., Dickens, C., & Coventry, P. (2012). Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD006525.pub2CrossRefPubMedPubMedCentral

Austin, E. J., Briggs, E. S., Ferro, L., Barry, P., Heald, A., Curran, G. M., Saxon, A. J., Fortney, J., Ratzliff, A. D., & Williams, E. C. (2023a). Integrating routine screening for opioid use disorder into primary care settings: Experiences from a National Cohort of clinics. Journal of General Internal Medicine, 38(2), 332–340. https://doi.org/10.1007/s11606-022-07675-2CrossRefPubMed

Austin, E. J., Gojic, A. J., Bhatraju, E. P., Pierce, K. A., Pickering, E. I., Tung, E. L., Scott, J. D., Hansen, R. N., Glick, S. N., Stekler, J. D., Connolly, N. C., Villafuerte, S., McPadden, M., Deutsch, S., Ninburg, M., Kubiniec, R., Williams, E. C., & Tsui, J. I. (2023b). Barriers and facilitators to implementing a pharmacist, physician, and Patient Navigator-Collaborative Care Model (PPP-CCM) to treat hepatitis C among people who inject drugs. The International Journal on Drug Policy, 111, 103924. https://doi.org/10.1016/j.drugpo.2022.103924CrossRefPubMed

Beebe, J. (2001). Rapid assessment process: An introduction. AltaMira.

Bentham, W. D., Ratzliff, A., Harrison, D., Chan, Y. F., Vannoy, S., & Unützer, J. (2015). The experience of primary care providers with an integrated mental health care program in safety-net clinics. Family & Community Health, 38(2), 158–168. https://doi.org/10.1097/FCH.0000000000000067CrossRef

Bhatia, S., Landier, W., Paskett, E. D., Peters, K. B., Merrill, J. K., Phillips, J., & Osarogiagbon, R. U. (2022). Rural-urban disparities in Cancer outcomes: Opportunities for Future Research. Journal of the National Cancer Institute, 114(7), 940–952. https://doi.org/10.1093/jnci/djac030CrossRefPubMedPubMedCentral

Bowen, D. J., Powers, D. M., Russo, J., Arao, R., LePoire, E., Sutherland, E., & Ratzliff, A. D. H. (2020). Implementing collaborative care to reduce depression for rural native American/Alaska native people. BMC Health Services Research, 20(1), 34. https://doi.org/10.1186/s12913-019-4875-6CrossRefPubMedPubMedCentral

Coventry, P. A., Hudson, J. L., Kontopantelis, E., Archer, J., Richards, D. A., Gilbody, S., Lovell, K., Dickens, C., Gask, L., Waheed, W., & Bower, P. (2014). Characteristics of effective collaborative care for treatment of Depression: A systematic review and Meta-regression of 74 randomised controlled trials. PLOS ONE, 9(9), e108114. https://doi.org/10.1371/journal.pone.0108114CrossRefPubMedPubMedCentral

Craven, M. A., & Bland, R. (2006). Better practices in collaborative mental health care: An analysis of the evidence base. Canadian Journal of Psychiatry Revue Canadienne De Psychiatrie, 51(6 Suppl 1), 7S–72S.PubMed

Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4(1), 50. https://doi.org/10.1186/1748-5908-4-50CrossRefPubMedPubMedCentral

Franco, C. M., Lima, J. G., & Giovanella, L. (2021). Primary healthcare in rural areas: Access, organization, and health workforce in an integrative literature review. Cadernos De Saude Publica, 37(7), e00310520. https://doi.org/10.1590/0102-311X00310520CrossRefPubMed

Fraze, T. K., Lewis, V. A., Wood, A., Newton, H., & Colla, C. H. (2022). Configuration and delivery of primary care in rural and urban settings. Journal of General Internal Medicine, 37(12), 3045–3053. https://doi.org/10.1007/s11606-022-07472-xCrossRefPubMedPubMedCentral

Haack, S. A., Rehuher, D., Ghiasuddin, A., Kiyota, T., & Alik, T. P. (2022). Implementation of an adapted collaborative care model. Psychiatric Services (Washington D C), 73(10), 1186–1189. https://doi.org/10.1176/appi.ps.202100327CrossRefPubMed

Han, X., Chen, C., & Pittman, P. (2021). Use of Temporary Primary Care providers in federally qualified Health centers. The Journal of Rural Health: Official Journal of the American Rural Health Association and the National Rural Health Care Association, 37(1), 61–68. https://doi.org/10.1111/jrh.12424CrossRefPubMed

Harris, P. A., Taylor, R., Minor, B. L., Elliott, V., Fernandez, M., O’Neal, L., McLeod, L., Delacqua, G., Delacqua, F., Kirby, J., & Duda, S. N. (2019). The REDCap consortium: Building an international community of software platform partners. Journal of Biomedical Informatics, 95, 103208. https://doi.org/10.1016/j.jbi.2019.103208CrossRefPubMedPubMedCentral

Howland, M., Tennant, M., Bowen, D. J., Bauer, A. M., Fortney, J. C., Pyne, J. M., Shore, J., & Cerimele, J. M. (2021). Psychiatrist and psychologist experiences with Telehealth and Remote Collaborative Care in Primary Care: A qualitative study. The Journal of Rural Health: Official Journal of the American Rural Health Association and the National Rural Health Care Association, 37(4), 780–787. https://doi.org/10.1111/jrh.12523CrossRefPubMed

Katon, W., Von Korff, M., Lin, E., Walker, E., Simon, G. E., Bush, T., Robinson, P., & Russo, J. (1995). Collaborative management to achieve treatment guidelines. Impact on depression in primary care. Journal of the American Medical Association, 273(13), 1026–1031.CrossRefPubMed

Katon, W., Unützer, J., Wells, K., & Jones, L. (2010). Collaborative depression care: History, evolution and ways to enhance dissemination and sustainability. General Hospital Psychiatry, 32(5), 456–464. https://doi.org/10.1016/j.genhosppsych.2010.04.001CrossRefPubMed

Kilbourne, A. M., Irmiter, C., Capobianco, J., Reynolds, K., Milner, K., Barry, K., & Blow, F. C. (2008). Improving integrated general medical and mental health services in community-based practices. Administration and Policy in Mental Health, 35(5), 337–345. https://doi.org/10.1007/s10488-008-0177-8CrossRefPubMed

Kirchner, J. E., Ritchie, M. J., Pitcock, J. A., Parker, L. E., Curran, G. M., & Fortney, J. C. (2014). Outcomes of a partnered facilitation strategy to implement primary care-mental health. Journal of General Internal Medicine, 29(Suppl 4), 904–912. https://doi.org/10.1007/s11606-014-3027-2. Suppl 4.CrossRefPubMedPubMedCentral

Lewis, C. C., Boyd, M., Puspitasari, A., Navarro, E., Howard, J., Kassab, H., Hoffman, M., Scott, K., Lyon, A., Douglas, S., Simon, G., & Kroenke, K. (2019). Implementing measurement-based care in behavioral health: A review. JAMA Psychiatry, 76(3), 324. https://doi.org/10.1001/jamapsychiatry.2018.3329CrossRefPubMed

Lewis, C. C., Powell, B. J., Brewer, S. K., Nguyen, A. M., Schriger, S. H., Vejnoska, S. F., Walsh-Bailey, C., Aarons, G. A., Beidas, R. S., Lyon, A. R., Weiner, B., Williams, N., & Mittman, B. (2021). Advancing mechanisms of implementation to accelerate sustainable evidence-based practice integration: Protocol for generating a research agenda. British Medical Journal Open, 11(10), e053474. https://doi.org/10.1136/bmjopen-2021-053474CrossRef

McGINTY, B. (2023). The Future of Public Mental Health: Challenges and opportunities. The Milbank Quarterly, 101(S1), 532–551. https://doi.org/10.1111/1468-0009.12622CrossRefPubMedPubMedCentral

Moise, N., & Bauer, A. M. (2022). Current and future directions in the application of implementation science to accelerate the adoption of evidence-based practices in behavioral health. General Hospital Psychiatry, 77, 88–91. https://doi.org/10.1016/j.genhosppsych.2022.05.001CrossRefPubMed

Norfleet, K. R., Ratzliff, A. D. H., Chan, Y. F., Raney, L. E., & Unützer, J. (2016). The role of the Integrated Care Psychiatrist in Community settings: A Survey of psychiatrists’ perspectives. Psychiatric Services (Washington D C), 67(3), 346–349. https://doi.org/10.1176/appi.ps.201400592CrossRefPubMed

Palinkas, L. A., Horwitz, S. M., Green, C. A., Wisdom, J. P., Duan, N., & Hoagwood, K. (2015). Analysis in Mixed Method Implementation Research. Administration and Policy in Mental Health and Mental Health Services Research, 42(5), 533–544. https://doi.org/10.1007/s10488-013-0528-y. Purposeful Sampling for Qualitative Data Collection.

Powell, B. J., Waltz, T. J., Chinman, M. J., Damschroder, L. J., Smith, J. L., Matthieu, M. M., Proctor, E. K., & Kirchner, J. E. (2015). A refined compilation of implementation strategies: Results from the Expert recommendations for Implementing Change (ERIC) project. Implementation Science, 10(1), 21. https://doi.org/10.1186/s13012-015-0209-1CrossRefPubMedPubMedCentral

Powers, D. M., Bowen, D. J., Arao, R. F., Vredevoogd, M., Russo, J., Grover, T., & Unützer, J. (2020). Rural clinics implementing collaborative care for low-income patients can achieve comparable or better depression outcomes. Families Systems & Health: The Journal of Collaborative Family Healthcare, 38(3), 242–254. https://doi.org/10.1037/fsh0000522CrossRef

Proctor, E. K., Powell, B. J., & McMillen, J. C. (2013). Implementation strategies: Recommendations for specifying and reporting. Implementation Science: IS, 8, 139. https://doi.org/10.1186/1748-5908-8-139CrossRefPubMedPubMedCentral

Ratzliff, A. D., Unützer, J., Katon, W., & Stephens, K. A. (2016). Integrated care: Creating effective mental and primary health care teams. John Wiley & Sons, Inc.

Ratzliff, A., Phillips, K. E., Sugarman, J. R., Unützer, J., & Wagner, E. H. (2017). Practical Approaches for Achieving Integrated Behavioral Health Care in Primary Care settings. American Journal of Medical Quality: The Official Journal of the American College of Medical Quality, 32(2), 117–121. https://doi.org/10.1177/1062860615618783CrossRefPubMed

Rossom, R. C., Solberg, L. I., Magnan, S., Crain, A. L., Beck, A., Coleman, K. J., Katzelnick, D., Williams, M. D., Neely, C., Ohnsorg, K., Whitebird, R., Brandenfels, E., Pollock, B., Ferguson, R., Williams, S., & Unützer, J. (2017). Impact of a national collaborative care initiative for patients with depression and diabetes or cardiovascular disease. General Hospital Psychiatry, 44, 77–85. https://doi.org/10.1016/j.genhosppsych.2016.05.006CrossRefPubMed

Substance Abuse and Mental Health Services Administration (2020). Key substance use and mental health indicators in the United States: Results from the 2019 National Survey on Drug Use and Health (PEP20-07-01–001, NSDUH Series H-55). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/

Taylor, B., Henshall, C., Kenyon, S., Litchfield, I., & Greenfield, S. (2018). Can rapid approaches to qualitative analysis deliver timely, valid findings to clinical leaders? A mixed methods study comparing rapid and thematic analysis. British Medical Journal Open, 8(10), e019993. https://doi.org/10.1136/bmjopen-2017-019993CrossRef

Thota, A. B., Sipe, T. A., Byard, G. J., Zometa, C. S., Hahn, R. A., McKnight-Eily, L. R., Chapman, D. P., Abraido-Lanza, A. F., Pearson, J. L., Anderson, C. W., Gelenberg, A. J., Hennessy, K. D., Duffy, F. F., Vernon-Smiley, M. E., Nease, D. E., & Williams, S. P. (2012). Collaborative Care to improve the management of Depressive disorders: A community guide systematic review and Meta-analysis. American Journal of Preventive Medicine, 42(5), 525–538. https://doi.org/10.1016/j.amepre.2012.01.019CrossRefPubMed

Unützer, J., Katon, W., Callahan, C. M., Williams, J. W., Hunkeler, E., Harpole, L., Hoffing, M., Della Penna, R. D., Noël, P. H., Lin, E. H. B., Areán, P. A., Hegel, M. T., Tang, L., Belin, T. R., Oishi, S., & Langston, C. (2002). Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. Journal of the American Medical Association, 288(22), 2836–2845. https://doi.org/10.1001/jama.288.22.2836. IMPACT Investigators. Improving Mood-Promoting Access to Collaborative Treatment.CrossRefPubMed

Vindrola-Padros, C., & Johnson, G. A. (2020). Rapid Techniques in Qualitative Research: A critical review of the literature. Qualitative Health Research, 30(10), 1596–1604. https://doi.org/10.1177/1049732320921835CrossRefPubMed

Wagner, E. H., Glasgow, R. E., Davis, C., Bonomi, A. E., Provost, L., McCulloch, D., Carver, P., & Sixta, C. (2001). Quality improvement in chronic illness care: A collaborative approach. The Joint Commission Journal on Quality Improvement, 27(2), 63–80. https://doi.org/10.1016/s1070-3241(01)27007-2CrossRefPubMed

Waltz, T. J., Powell, B. J., Matthieu, M. M., Damschroder, L. J., Chinman, M. J., Smith, J. L., Proctor, E. K., & Kirchner, J. E. (2015). Use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importance: Results from the Expert recommendations for Implementing Change (ERIC) study. Implementation Science, 10(1), 109. https://doi.org/10.1186/s13012-015-0295-0CrossRefPubMedPubMedCentral

Title: Understanding and Navigating the Unique Barriers Rural Primary Care Settings Face when Implementing Collaborative Care for Mental Health
Authors: Elizabeth J. Austin
Elsa S. Briggs
Angel Cheung
Erin LePoire
Brittany E. Blanchard
Amy M. Bauer
Morhaf Al Achkar
Diane M. Powers
Publication date: 06-09-2024
Publisher: Springer US
Published in: Community Mental Health Journal / Issue 3/2025
Print ISSN: 0010-3853
Electronic ISSN: 1573-2789
DOI: https://doi.org/10.1007/s10597-024-01348-6

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Abstract

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The Role of Acculturative Stress on the Mental Health of Immigrant Youth: A Scoping Literature Review

“Because I Am a Female”: Stigma and Safety Perspectives from Racially/Ethnically Diverse Women with Serious Mental Illnesses

Exploring the Lived Experiences of Medication for Opioid use Disorder Treatment: A Qualitative Study among a Crowdsourced Convenience Sample

Addressing Hispanic Veterans that Live in Rural Area’s Needs to Improve Suicide Prevention Efforts

Virtual Service Delivery in Mental Health and Substance Use Care: A Systematic Review of Preference Elicitation Studies

Early Health Impacts of a Primary Care Consultation Model for People Served by Assertive Community Treatment teams