MENTAL HEALTH SERVICES IN RURAL

COMMUNITIES: EXAMINE THE CHALLENGES AND

EFFECTIVENESS OF DELIVERING MENTAL HEALTH
CARE IN RURAL AREAS
A Dissertation
Submitted in a partial fulfilment of the requirement for the awarded of the
degree in

Master of Arts in Applied Psychology

Session – 2023-24

UNDER THE GUIDANCE OF:

Dr. Sarita Pathak

DEPARTMENT OF APPLIED PSYCHOLOGY
(DR. RAM MANOHAR LOHIA AWADH UNIVERSITY)
SUBMITTED BY: ARYAN SRIVASTAV
M.A IN APPLIED PSYCHOLOGY 4th SEMESTER
[Link]: 22010200010901
 CERTIFICATE

This is to certify that the work contained in the thesis entitled

“ Mental Health Services in Rural Communities: Examine the
challenges and effectiveness of delivering mental health care
in rural areas”, submitted by Aryan Srivastav for the award of
the degree of Applied Psychology to the Dr. Ram Manohar
Lohiya Awadh University, Ayodhya, is a record of bonafide
research works carried out by him under my direct supervision and
guidance.

I considered that the thesis has reached the standards and fulfilling
the requirements of the rules and regulations relating to the nature
of the degree. The contents embodied in the thesis have not been
submitted for the award of any other degree or diploma in this or
any other university.

Date:
Place: Ayodhya

[Link] Pathak
Department of Applied Psychology
 DECLARATION

I solemnly clear that the report “Mental Health Services

in Rural Communities: Examine the challenges and
effectiveness of delivering mental health care in rural
areas” has been prepared and completed by me under the
supervision and guidance of Professor “Dr. Sarita
Pathak” Department of Applied Psychology Dr. Ram
Manohar Lohiya Awadh University, Ayodhya. This report
has not previously been submitted to any other University,
College or Organization.
I hereby assured at the work I have submitted does not
infringe any existing copyrights.

ARYAN SRIVASTAV
[Link] – 22010200010901
M.A in Applied Psychology - (IV SEM)
 ACKNOWLEDGEMENT

Every work constitutes great deal of assistance and guidance from

the people concerned and this particular project is of no
exception.
Project of a nature is surely a result of tremendous support,
guidance, encouragement and help.
So here I have made some sincere effort to some of the eminent
person involved in making this project because without their
encouragement and support this report would have been non-
existent.
I wish to place on record my sincere gratitude my project guide
by Dr. Sarita Pathak I thank him for constructive help and
encouragement throughout the project. Without his support and
guidance taking this would not have been possible.
Also, wish to acknowledge enthuastic encouragement and
support extended to me by my family member.
I’m also thankful to my friend who provided me their constant
support and assistance.

ARYAN SRIVASTAV
[Link] – 22010200010901
M.A in Applied Psychology - (IV SEM)
INDEX
[Link] Particulars Sub-Topics Page. No

1 Introduction Defining 1-29

mental health
Rural Factors

Challenges and
opportunities

2 Program Modules Access to care 30-64

model
Avability
models
Affordability
model
Accessibility
model
Acceptability
model

3 Research & Data Rural health 65-72

Analysis partnership
Famlies plus

Healthcare
Care plans
JC Memorial
Hospital
Project Rural
Recovery
Training
Health System

4 Implementation Workforce 73-92

consideration
INDEX
Treatment
options
Stigma in rural
communities
Community
partnership
Transportation
Consideration
Population
consideration

5 Evaluation Questions & 93-97

Objectives
Measures &
Data collection
Tools

6 Funding & Sustanability 98-105

Sustanibility Planning
Sustanibility
Starategies
Fundings

7 Coclusion 106-109

8 Refrence 110-114
Introduction

The prevalence of mental health conditions is similar in urban and

rural areas across the Indian, but rural communities face unique
challenges accessing mental health screening, treatment, and
recovery services. This module provides an overview of mental
health and introduces some of the challenges and opportunities
unique to rural communities. It provides important background
information needed to implement a program to improve mental
health in a rural community.

In this module:
 Defining Mental Health
 Factors that Affect Mental Health in Rural Communities
 Challenges and Opportunities for Mental Health Services in
Rural Areas

1
Defining Mental Health

According to the World Health Organization, mental health is

defined as:
―…a state of well-being that enables people to cope with the stresses of life,
realize their abilities, learn well and work well, and contribute to their
community. It is an integral component of health and well-being that
underpins our individual and collective abilities to make decisions, build
relationships and shape the world we live in.‖

Mental health conditions comprise a broad umbrella of disorders.

These conditions can affect daily activities and relationships for
individuals and families involved. Common mental health
conditions include but are not limited to:

 Anxiety disorders (generalized anxiety disorder, panic disorder,

phobias)
 Mood disorders (depression, bipolar disorder)
 Psychotic disorders (schizophrenia)

According to the Substance Abuse and Mental Health Services

Administration (SAMHSA), mental health conditions are
considered serious mental illnesses (SMI) when they cause ―serious
functional impairment that substantially interferes with or limits
one or more major life activities.‖
Mental health conditions are affected by complex factors and are
associated with the following experiences and conditions:
2
  Substance use disorder
 Suicide
 Unemployment
 Homelessness
 Incarceration
 Deterioration of physical health

Long-term mental illness has also been associated with shorter

lifespan and increased co-occurrence of chronic diseases, such as
diabetes, obesity, epilepsy, cancer, and cardiovascular disease.

Factors that Affect Mental Health in Rural

Communities

In the India, approximately 1 out of 5 adults living in rural areas

experience mental illness. Although the prevalence of mental
illness and psychiatric disorders is similar in rural and urban areas,
people living in rural areas experience unique influencing factors
when it comes to managing their mental health.
The Indian Mental Wellness Association identifies many risk and
protective factors for mental health conditions. Protective factors
help promote positive mental health and make it less likely for
mental health conditions to emerge or become problematic. Risk
factors can make it more likely that individuals develop certain
mental health conditions.
These factors are especially important to consider when developing
and implementing programs. Understanding the influences of these
factors on community members will help determine each rural

3
community's specific needs for mental health services. Risk and
protective factors can be societal, community, inter-personal, or
individual characteristics.

 Societal
o Poverty
o Stigma
o Racism and discrimination
 Community
o Availability of community resources
o Housing instability
o Economic security
o Educational opportunities
 Interpersonal
o Adverse Childhood Experiences (ACEs) and other traumatic life
experiences
o Reliable support from peers and family members
o Parental involvement and supervision
o Family mental health and substance use
o Social isolation
 Individual
o Biological/genetic factors
o Chronic medical conditions
o Healthy diet and exercise
o Coping skills
At the societal level, lack of resources related to poverty and
limited educational opportunities are risk factors for developing
mental health conditions. Overall, rural populations have lower

4
median household incomes, levels of employment, and educational
attainment than the general population. Historical trauma may also
affect mental health conditions across generations of affected
groups, including tribal communities in rural areas.
At the community level, individuals living in rural areas are less
likely to have access to mental health services and treatment, such
as therapy and medication, due to a shortage of mental health
workforce professionals.

COVID-19 Pandemic
In evaluating risk and protective factors for mental health, it is
important to recognize the significant impact of the COVID-19
pandemic on health outcomes, including mental health, in the
INDIA. Research has linked the pandemic to increased rates of
anxiety and depression, substance use, drug and alcohol-related
deaths, and suicide deaths which have persisted after the end of the
public health emergency. These mental health concerns have been
exacerbated by other challenges that continue to affect rural
communities. For example, rural communities are particularly
vulnerable to changes in economic conditions, including the
pandemic's economic impact. Many rural residents dealing with
unemployment reported that the pandemic negatively affected
their mental health.
Additional factors that impacted mental health conditions during
and in the wake of the COVID-19 pandemic include:

 Workforce burnout
 Economic uncertainty
 Isolating public health precautions
 Concerns about serious illness

5
  Ongoing health impacts
 Loss of life

Challenges and Opportunities for Mental

Health Services in Rural Areas
Individuals who live in rural areas face unique challenges and
opportunities in receiving effective treatment for serious mental
illness and mental health conditions. To understand these barriers
and opportunities, the National Rural Health Association describes
a framework with four components of rural mental health —
accessibility, availability, affordability, and acceptability. The ―four
As‖ influence multiple aspects of rural mental healthcare and are
important to consider when developing rural mental health
programs.
This section describes rural barriers to and opportunities for mental
health services by the four As. Throughout the toolkit, the
framework is used to organize evidence-based models and
examples of rural mental health programs.

Access to Care
Access to care, or accessibility, refers to the ease with which one
can obtain mental health services within their community.
Transportation is a key factor that impacts access to mental
healthcare. There are several barriers to transportation in rural
areas. Rural community members are more likely than urban
residents to rely on personal vehicles for transportation, meaning

6
rural residents without cars are more isolated from treatment.
There are fewer mental health providers in rural areas, meaning
community members must travel farther to access mental health
services, and without access to transportation, care may be
inaccessible.
While transportation to care continues to be a barrier in rural
areas, several promising approaches could increase access to mental
health services. For example, investing in mobile clinics and
expanding telehealth services are two opportunities for addressing
challenges related to a lack of transportation.
To learn more about opportunities to improve access to rural
mental health services, explore Models to Improve Access to Care.

Availability
Availability refers to mental health services being available to
residents. Shortages of mental health professionals impact the
availability of mental health services in rural areas. According to
the Substance Abuse and Mental Health Services Administration
(SAMHSA), the mental health workforce is one of the fastest
growing in the country. However, mental health professional
shortages are greatest in rural and low-income areas compared to
more urban areas. These provider shortages may lead to long
waitlists for rural residents seeking necessary care.
In general, rural areas often lack specialty mental healthcare. Some
estimates suggest that nearly 70% of rural counties do not have a
psychiatrist. Without appropriate integration of mental health
services, primary care providers may not be equipped to provide
treatment for all mental health conditions.

7
Inadequate reimbursement rates for mental health services,
especially under Medicaid, create barriers to recruiting and
retaining providers in rural areas where Medicaid enrollment rates
are higher than urban areas. Non-clinical mental health providers
and Mental Health First Aid training offer opportunities for rural
communities to address this barrier.
To learn more about opportunities to improve the availability of
mental health services, see Models to Increase Availability.

Affordability
Affordability refers to the costs associated with receiving mental
healthcare, including increased costs and low reimbursement rates
for services in rural areas. In rural areas, one of the main barriers to
treatment is the cost of mental healthcare for patients. Some
insurance companies do not cover certain mental health services,
making these services too expensive for a patient to pay out of
pocket. In addition, rural residents are more likely than urban
residents to be uninsured.
Opportunities to improve the affordability of mental healthcare
services in rural communities include wraparound services,
community-based supports, and school-based social and emotional
supports.
To learn more about opportunities to improve affordability,
see Models to Increase Affordability.

8
Acceptability
Acceptability relates to the perceptions of the patient and
community associated with the need for mental health services.
Factors impacting acceptability include stigma, mental health
literacy, and culturally responsive care.

Stigma and Mental Health Literacy

Mental health stigma refers to the negative attitudes and prejudices
surrounding mental health issues, often resulting in discrimination
against individuals experiencing these conditions, which may deter
people from seeking needed mental healthcare. In small, rural
communities where everyone knows each other, residents may fear
judgment from their peers and worry about lack of confidentiality
among mental health professionals. Often, rural communities
foster a culture of self-reliance, which may make seeking help for a
mental health concern feel less acceptable.
Our identities and experiences can influence overall well-being
and perceptions of stigma surrounding mental health. For example,
experiences of discrimination and oppression based on gender,
race, class, and sexuality can affect individuals seeking mental
health support, often exacerbating stigma.
Increasing understanding and awareness of mental health through
mental health literacy can play a crucial role in reducing stigma
and promoting acceptance within communities. Addressing stigma
involves considering various factors such as social norms, resources
within communities, and cultural beliefs. For implementation
considerations related to reducing mental health stigma in rural
communities,
Rural areas in the Indias are racially and ethnically diverse. Race,
ethnicity, culture, language — along with multiple other
characteristics, like values and beliefs — may affect peoples'
9
conceptions of mental health and preferences for receiving
treatment. Patients may find treatment more acceptable if they
have access to a mental health provider with a shared lived
experience or understanding of their culture.
Therefore, it is particularly important for rural mental health
providers to work toward providing culturally responsive care and
embracing cultural humility. Training and education programs can
increase awareness of and respect for other cultures while giving
providers the opportunity to practice skills like communicating in a
culturally competent manner and integrating cultural
considerations into a patient's treatment plan.
Mental health organizations can support culturally responsive care
by:

 Implementing therapeutic models like trauma-focused cognitive

behavioral therapy
 Selecting culturally appropriate screening and assessment tools
 Establishing culturally responsive clinic environments, policies, and
procedures
 Recruiting and retaining a diverse workforce

According to the Results from the 2022 National Survey on Drug

Use and Health: Detailed Tables, approximately 7.7 million
nonmetropolitan adults reported having any mental illness (AMI)
in 2022, accounting for 23.0% of nonmetropolitan adults. In
addition, 1.9 million, or 5.7%, of adults in nonmetropolitan areas
reported having serious thoughts of suicide during the year.
While the prevalence of mental illness is similar between rural and
urban residents, the services available can be very different. Mental
healthcare needs are often not met in many rural communities

10
across the country because adequate services are not present.
Providing mental health services can be challenging in rural areas.
According to the National Rural Health Association, the following
factors are particular challenges to the provision of mental health
services in rural communities:

 Accessibility – Rural residents often travel long distances to receive

services, are less likely to be insured for mental health services, and
providers are less likely to recognize a mental illness.
 Availability – Chronic shortages of mental health professionals exist
and mental health providers are more likely to practice in urban
centers.
 Affordability – Some rural residents may not be able to afford the cost
of health insurance or the cost of out-of-pocket care if they lack health
insurance.
 Acceptability – Rural residents may be more susceptible to the stigma
of needing or receiving mental healthcare in small communities where
everyone knows each other and fewer choices of trained professionals
can lead to a lack of faith in confidentiality, as well as a reliance on the

The Mental Health in Rural Communities Toolkit features evidence-based

models, resources, and program examples for the successful development and
implementation of mental health programs to serve rural communities.

11
The Rural Suicide Prevention Toolkit highlights innovative, evidence-based
models and resources to develop and implement successful suicide
prevention programs in rural communities.

Frequently Asked Questions

 Where can I find mental health statistics for rural populations?
 What are the workforce challenges in providing rural mental health
services?
 What other challenges affect access and the provision of mental health
services in rural areas?
 What can a rural community or healthcare facility do to minimize the
challenges of accessing and providing mental health services in a rural
area?
 What are some of the benefits of integration of mental health services
into primary care in a rural community?
 Is there a resource for rural primary care providers and other
healthcare professionals that can connect patients to mental health
services and treatment?
 Where can rural veterans and rural healthcare providers assisting
veterans find information about mental health services in their rural
areas?
 What is the impact of suicide in rural INDIAN?
 How can our community take action to prevent suicides?
 What resources are available for suicide prevention efforts?
 How can our school take action to prevent suicides?

12
Where can I find mental health statistics for rural
populations?
On the national level, the Substance Abuse and Mental Health
Services Administration (SAMHSA) is the primary source of
information on behavioral health and provides an annual survey of
detailed data by geographic location on the prevalence of several
behavioral health measures in their annual National Survey on
Drug Use and Health.
Topics with data applicable to rural mental health include:

 Mental illness in the past year

 Co-occurring mental illness with substance use disorder
 Serious mental illness
 Mental health treatment/counseling
 Unmet mental health needs
 The incidence/prevalence of serious thoughts of suicide

The data for these topics are available by age, geographic

characteristics and socioeconomic characteristics. The geographic
characteristics are detailed by geographic region of the INDIA. and
county type. County type is divided into population data classes:

 Large metro – population of 1 million or more

 Small metro – population of 50,000 – 999,999
 Nonmetro – includes subcategories:
o Urbanized – population of 20,000 – 49,999 in urbanized areas
o Less urbanized – population of 2,500 – 19,999 in urbanized areas
o Completely rural – population of < 2,500 in urbanized areas
The Finding Statistics and Data Related to Rural Health provides
additional resources related to behavioral health data.

13
 What are the workforce challenges in providing
rural mental health services?
According to a 2018 study, one of the most significant challenges
preventing rural INDIANs from receiving care has been the
shortage of mental health professionals providing mental health
services in rural and frontier areas.
A 2022 series of reports from the WWAMI Rural Health Research
Center highlights the rural and urban breakdown of the behavioral

Rural (Nonmetro) Urban (Metro)

Counselors 87.7 131.2

Psychiatric Nurse Practitioners 3.4 4.8

Psychiatrists (2019) 3.5 13.0

Psychologists 15.8 39.5

Social Workers 57.7 96.4

Details number of practitioners per 100,000 population. Data from 2021 unless otherwise noted.

health workforce:
To further complicate the challenges of providing mental health
services, the most disadvantaged and under-resourced communities
are often those with the greatest need for mental healthcare
providers.
As of March 31, 2024, HRSA had designated 3,862 Mental Health
Professional Shortage Areas in rural areas. It is estimated that it

14
would take 1,682 practitioners to remove the designations. For the
most current figures, see HRSA's Designated HPSA Statistics.
This map identifies nonmetro Mental Health HPSAs based on April
2024 [Link] data:

15
The [Link] interactive map of Mental Health Professional
Shortage Areas (HPSA) identifies the total number and geographic
location of Mental Health HPSAs by state and county.

What other challenges affect access and the provision

of mental health services in rural areas?

Travel distance, lack of public transportation, and the lack of

health insurance covering mental health services are commonly
identified as challenges to accessing healthcare in rural areas.
Reimbursement issues and the social stigma associated with mental
health services are also identified as significant challenges that
affect access and the provision of mental health services in rural
areas.

Reimbursement
The reimbursement offered by payers such as Medicaid, Medicare,
and private insurers has a significant impact on the ability of rural
providers to offer mental health services. The
publication Encouraging Rural Health Clinics to Provide Mental
Health Services: What are the Options? notes that Rural Health
Clinics may be reluctant to start providing mental health services
when reimbursement rates are low. In addition, high no-show
rates among mental health clients and high numbers of uninsured
patients further exacerbate the issue of low reimbursement rates
paid by Medicaid and others.

16
Stigma
Nearly 1 in 5 adults in the INDIA. experiences a mental disorder
within any given year according to the National Alliance on
Mental Illness. Yet, the misconceptions, myths, and cultural stigma
associated with mental illness are significant barriers that keep
people with mental health disorders from seeking and receiving
treatment in rural areas. Factors that may influence rural residents
to avoid seeking care include such issues as:

 Lack of understanding and knowledge of mental illness, sometimes

even among healthcare staff
 Prejudice or stigma towards people with mental health disorders, often
based on fear and unease
 Secrecy about mental illness in the community and general hesitancy
to seek care
 Perception of a lack of confidentiality and privacy in small towns with
closely-tied social networks

While there are drawbacks to small communities when it comes to

mental health, there are positives as well. The close-knit nature of
rural communities can also mean that residents are more likely to
rally around each other and provide community support in times
of need. A strong external support group can help facilitate a
person's success in treatment and also help support the family's
efforts in attending to the care seeker.

17
What can a rural community or healthcare facility do
to minimize the challenges of accessing and providing
mental health services in a rural area?

There are several approaches that can be tried in rural

communities to minimize the challenges of providing mental
health services and expanding the mental health workforce. Some
of the most commonly cited practices to deal with workforce issues
include:

 Expanding the use of telemental health services

 Offering loan repayment programs and state tax waivers to recent
behavioral health professions graduates
 Providing clinical rotations in a rural setting to expose future health
care professionals to the qualities of working in rural areas
Providing mental health services via telehealth, sometimes referred
to as telemental health or telebehavioral health, has shown
promise in helping to alleviate the lack of mental health services in
rural areas.
The COVID-19 pandemic led to an increase in demand for mental
health services in rural areas that were already experiencing
significant provider shortages. Across the country, many mental
health services transitioned to telehealth, which has created both
opportunities and challenges for rural communities.
According to a 2021 report, 43% of rural adults who received
behavioral health treatment over the previous year said they used
telehealth at least once a month. Telehealth options allowed many
rural residents to maintain their treatment, and in some cases
improved the convenience of access to those services. However, in
some rural and remote areas lacking broadband access, video-based

18
telehealth was not feasible. On March 1, 2020, as a provision of the
CARES Act, CMS waived the video requirement and introduced a
range of flexibilities in Medicare's telehealth policy during the
Public Health Emergency, allowing telehealth to be conducted in
patients' homes via commercial video conferencing technologies
and audio-only sessions. The Calendar Year (CY) 2022 Medicare
Physician Fee Schedule Final Rule made permanent the ability to
bill Medicare for audio-only mental health and substance use
services provided to rural residents under certain conditions.
For additional information about telehealth services and associated
reimbursement issues, see the Telehealth and Health Information
Technology in Rural Healthcare topic guide.
Another approach to improving access and providing mental
health services is the School-Based Health Center (SBHC) model
for children in rural areas. SBHCs work with the school and
community to improve children's mental health by providing
onsite healthcare services delivered by an interdisciplinary team of
primary care and behavioral health clinicians. Services may range
from wellness exams to mental health services. SBHCs can screen
children for mental, behavioral, or developmental disorders
(MBDDs) including anxiety, depression, and attention-
deficit/hyperactivity disorder (ADHD). In addition, SBHCs can
provide customized care for children who may be at a higher risk
for MBDDs by monitoring medication and assisting in developing
Individualized Education Plans (IEPs).
In addition, education and awareness efforts targeted toward rural
residents have been used to increase familiarity and comfort with
mental health issues. An example of this is the Mental Health First
Aid public education program. This program helps rural residents
identify, understand (and thereby reduce the stigma), and respond
to signs of mental illnesses and substance use disorders.

19
What are some of the benefits of integration of
mental health services into primary care in a
rural community?

In recent years, health policy experts and healthcare providers

have begun to encourage closer integration of mental or behavioral
health and primary care services. It is assumed that integration will
increase access to mental healthcare services, particularly in rural
communities, as well as increase quality of care through enhanced
coordination of services. In rural areas, where behavioral health
workers and primary care providers are in short supply, integration
is vitally important. Integration of these services is an effective
strategy for maximizing the use of scarce rural healthcare resources
and improving the quality of care for both behavioral health and
primary care patients.
According to a 2010 Maine Rural Health Research Center report,
patients in rural areas who need mental health services typically
see their primary care provider first. Often it is the primary care
provider who initially diagnoses the need for mental health
services. In addition, a high percentage of mental healthcare for
rural patients is already provided by primary care providers, so
integrating the services of a mental healthcare provider into the
primary care setting can expand on what is already being done.
Efficiency of service and ease of use also create a level of
coordinated care and access that benefits both the patient and the
provider.
The integration, or even the co-location, of mental health services
with primary care services can also help to reduce or eliminate the

20
effects of the social stigma associated with mental illness in many
rural areas. Social stigma prevents many rural citizens from
obtaining needed services, but it is less of a deterrent when
behavioral health professionals see patients in primary care
settings. The integration of behavioral health and primary care
services also reduces the challenge of maintaining anonymity.
Rural patients may be reluctant to be seen in settings where their
privacy might be compromised but more willing to seek mental
healthcare from the more common and accepted primary care
clinic. Primary Care, Behavioral Health, Provider Colocation, and
Rurality discusses how co-location, although different from
integration, offers the potential of future collaboration with
primary care providers, as well as opportunities for care
coordination.
For additional information about integration of mental health
services into primary care, see The Future of Rural Behavioral
Health and A Guidebook of Professional Practices for Behavioral
Health and Primary Care Integration: Observations from
Exemplary Sites.
See Tri-Area Community Health Provides Community-Focused
Integrated Care in the Rural Monitor for a successful example of
integration in southwestern Virginia. In addition,
several promising examples of integrated service delivery are
available in our Rural Health Models and Innovations.

21
Is there a resource for rural primary care providers and
other healthcare professionals that can connect
patients to mental health services and treatment?
When there are few resources to provide direct mental health
services in a community, local healthcare professionals may need
to refer patients to facilities outside of the community. The
Substance Abuse and Mental Health Services Administration
(SAMHSA) maintains a Behavioral Health Treatment Services
Locator, which helps locate mental health services in your area,
and the National Directory of Mental Health Treatment Facilities
2023, an online listing of federal, state and local government, and
private facilities that provide mental health treatment services.

Where can rural veterans and rural healthcare

providers assisting veterans find information about
mental health services in their rural areas?
Rural healthcare providers and veterans can find information about
mental health services for veterans in their area by contacting
either their closest VA medical center or community-based
outpatient clinic (CBOC). To access contact information, go to
the VA Locations tool and choose a state to access a list of CBOCs,
VA Medical Centers, and Vet Centers. See the VA Mental Health
website for a broad overview of mental health programs available
to veterans.

22
What is the impact of suicide in rural INDIAN?

Suicide is a major public health concern across the INDIA.

According to Understanding the Impact of Suicide in Rural
INDIAN, suicide continues to be higher in rural counties and the
gap between rural and urban suicides has widened over time. A
2017 CDC report, Trends in Suicide by Level of Urbanization —
Indias, 1999–2015, discusses possible causes for the geographic
disparity: limited access to mental healthcare, social isolation, the
opioid overdose epidemic, and the economic recession. Included in
the report is this chart showing how the disparity has widened in
recent years:

Source:
Trends in Suicide by Level of Urbanization — Indias, 1999–2015, MMWR
(Morbidity and Mortality Weekly Report), 66(10), 270-273, 2017.

According to a 2020 report from the CDC, from 2000 to 2018, the
rural suicide rate increased by 48% while urban rates increased by

23
34%. In 2018, the suicide rate in rural counties was 19.4 deaths per
100,000 compared with urban counties at 13.4 deaths per 100,000.
The following table presents National Vital Statistics System
(NVSS) data for suicide deaths and death rates per 100,000 for
2013-2015.
Suicide Death Rates Per 100K — Indias, 2013–2015

Large
Characteristic metropolitan

County Urbanization 12.72

Sex

Male 20.20

Female 5.91

Race/Ethnicity

White, non-Hispanic 17.24

Black, non-Hispanic 6.56

INDIAN INDIAN/ Alaska Native, non-Hispanic 14.00

Asian/Pacific Islander, non-Hispanic 6.70

Hispanic 6.37

Source: Suicide Trends Among and Within Urbanization Levels by Sex, Race/Ethnicity, Age Group, and Mechanis
Surveillance Summaries, 66(18);1–16, 2017

24
Additional information regarding the impact of suicide in rural
communities can be found in Understanding the Impact of Suicide
in Rural INDIAN. This policy brief developed by the National
Advisory Committee on Rural Health and Human Services
(NACRHHS) also discusses prevention strategies available at the
state and national level and provides recommendations to the
INDIA. Department of Health and Human Services urging it ―to
focus more explicitly on emphasizing and including the rural
dimensions of suicide into their programs, research, and outreach
to address existing knowledge gaps and strengthen the evidence
base.‖

How can our community take action to prevent suicides?

The Suicide Prevention Resource Center (SPRC) is a premiere
source of information on the topic of suicide prevention. The
following resources and tools can be helpful to rural communities
working on suicide prevention efforts:

 Suicide Prevention Toolkit for Primary Care Practices – A toolkit that

contains information, resources, and tools to implement suicide
prevention practices in primary care, including rural settings.
 States and Territories – Find out what your state is doing to prevent
suicide. Includes state suicide prevention plans, state data, and how to
contact people involved in suicide prevention in your state.

You can also contact the Suicide Prevention Resource Center for
assistance. SPRC can connect you with people, organizations, and
resources in your rural community, state and nationally and
provide technical assistance and training on suicide prevention.
For more information on how to develop a suicide prevention
program, see the Rural Suicide Prevention Toolkit.

25
What resources are available for suicide
prevention efforts?

The INDIA. Department of Health and Human Services (HHS)

considers suicide a significant public health problem and is
involved in prevention activities. Several federal agencies
collaborate and direct necessary prevention resources, services, and
programs that are both public and private. Federal resources on
suicide prevention include:

 Suicide Prevention, Centers for Disease Control and Prevention

 Suicide Prevention, National Institutes of Health
 Preventing Suicide, Substance Abuse and Mental Health Services
Administration
 National Strategy for Suicide Prevention: Goals and Objectives for
Action, INDIA. Surgeon General
 Tribal Training and Technical Assistance Center, Substance Abuse and
Mental Health Services Administration

In addition to the resources provided by the federal government

and the Suicide Prevention Resource Center, these organizations
also provide additional suicide prevention information:

 INDIAN Association of Suicidology

202.237.2280
 INDIAN Foundation for Suicide Prevention
888.333.2377
 National Action Alliance for Suicide Prevention
202.572.3784

26
  National Institute of Mental Health – Suicide Prevention
866.615.6464
 988 Suicide and Crisis Lifeline
Contact by email for information and resources

How can our school take action to prevent

suicides?

According to the Centers for Disease Control and Prevention,

suicide is the second leading cause of death among youth aged 10
to 14 and third for youth aged 15 to 24 in INDIAN. Because of this,
rural schools can play an important role in preventing suicide
among rural youth by:

 Becoming involved with your state or community's suicide prevention

coalition to learn how to coordinate your school's efforts with state or
community efforts.
 Visiting SPRC's Customized Information pages
for Teachers and School Mental Health Providers to learn more about
how to respond to students and staff at risk for suicide.
 Implementing a school-based suicide prevention program, which
includes a comprehensive set of interventions, such as:
o Gatekeeper training
o Screening for mental health
o Health education curriculum that includes suicide prevention
and/or mental health
o Peer mentoring
o School-based mental health services
o Crisis response

27
 o Postvention
 Addressing postvention by creating a postvention plan for your school
with assistance from AFSP/SPRC's After a Suicide: A Toolkit for
Schools, Second Edition and for post-secondary students, Postvention:
A Guide for Response to Suicide on College Campuses.
 Offering a Mental Health First Aid training program in your rural
community for individuals to learn how to help people who are in a
crisis.

To review guidelines for school-based suicide prevention programs,

please refer to the University of South Florida's Youth Suicide
Prevention School-Based Guide. The guide also includes tips on
responding following a suicide or suicide attempt in the school
community. For more information on any of the items listed above,
please visit the SPRC Online Library or contact one of the SPRC
Prevention Specialists.
To explore school-based mental healthcare further, see:

 SAMHSA's Preventing Suicide: A Toolkit for High Schools for

assistance in developing a strategy to prevent suicide and promote
behavioral health.
 The National Association of School Psychologists webpage Preventing
Youth Suicide provides a variety of prevention resources for school
administrators, crisis teams, educators, and parents.
 A Rural Therapist and School Program Address Teen Mental Health,
a Rural Monitor feature on a rural school therapy program and
addressing teen mental health.

28
Module 2: Evidence-Based and Promising Mental
Health Program Models

This module introduces program models, which offer potential

strategies for addressing mental health in rural communities.
These models were identified based on research showing their
effectiveness and highlight a broad array of potential options for
addressing mental health in rural areas. To be responsive to
community needs, it may be necessary to implement more than
one model or combine aspects of multiple program models.
To learn how to identify and adapt interventions, see Developing a
Rural Community Health Program in the Rural Community Health
Toolkit.

In this module:
 Models to Improve Access to Care
 Models to Increase Availability
 Models to Expand Affordability
 Models to Enhance Acceptability

29
Models to Improve Access to Care for Mental
Health

Mental health access, or accessibility, refers to the ability to obtain

services for mental health conditions. Facilitating access can
involve different approaches for providing mental health services.
Barriers that affect access to mental health services include, for
example, limited availability of mental health providers
and challenges related to transportation.
This section describes four models to improve access to mental
health services in rural areas.

Models in this section:

 Primary Care Behavioral Health Integration Model
 Mobile Units Model
 Crisis Response Systems Model
o Mobile Crisis Teams
o Crisis Call and Text Lines
 Telehealth for Mental Health Services Model

30
Primary Care Behavioral Health Integration
Model

The primary care behavioral health integration model is an

approach that brings medical and mental health services together
into one setting. This model focuses on improving health and
overall quality of life through collaboration, holistic care, and
integration of services at multiple levels. Integration of services can
occur in multiple settings, including clinics, hospitals, and mobile
medical units.
The Substance Abuse and Mental Health Services Administration's
National Center for Integrated Health Solutions developed
a Standard Framework for Levels of Integrated Healthcare that
describes six levels of integration with primary care. The
framework follows a continuum within three categories —
coordinated, co-located, and integrated — with two levels in each
category. Level 1 is Minimal Collaboration, where mental health
and primary care providers work in separate buildings and have
infrequent communication, and Level 6 is Full Collaboration, in
which providers operate as one team and patients view the system
as one single entity.
Within the primary care behavioral health integration model,
evidence-based models for integrating care include:

 The Improving Mood-Promoting Access to Collaborative

Treatment (IMPACT) model, also known as the Collaborative Care
Model, is a collaborative approach that connects a depression care
manager (DCM), a primary care provider, and a psychiatrist. This team

31
 works together to create treatment plans and provide care for patients
with common mental health conditions such as depression. The
IMPACT model uses a stepped-care approach to provide the most
effective, yet least resource-intensive, treatment to meet the patient's
needs. Research has shown that patients receiving care through this
model experience significant improvement in mental health compared
to patients receiving traditional primary care.
 The expanded Screening, Brief Intervention, and Referral to
Treatment (SBIRT) model, or Behavioral Screening and Intervention
(BSI), is an evidence-based public health model that integrates mental
health screening, brief intervention, and referral to treatment into the
primary care setting. Although historically used by primary care
providers to deliver early intervention and treatment to people
with substance use disorders, SBIRT can also be used as a universal
screening tool for a wide range of behavioral health concerns.

Examples of Rural Programs that Integrate

Behavioral and Primary Care

 Cherokee Health Systems serves several rural communities in

Tennessee and is a national leader in primary care behavioral health
integration. Cherokee embeds behavioral health consultants, typically
psychologists or clinical social workers, in primary care teams.
Primary care providers screen all patients for mood disorders and
substance abuse and co-manage those who screen positive with
behavioral health consultants. The primary care and behavioral health
staff can also connect patients to a psychiatrist, often via telephone or
telehealth. All care team members are connected through shared
electronic health records. Cherokee Health Systems offers trainings for
program planners through their Integrated Care Training Academy.

32
  Due to the increased need for mental health services in Marquette
County, Michigan, the Upper Great Lakes (UGL) Family Health
Center introduced Cross-Walk, an integrated primary care and
behavioral health program. The program trains primary care staff, care
managers, and providers in motivational interviewing and behavioral
health screening methods. Together, they collaboratively design
behavioral health treatment plans. This model also involves
collaboration from dental care providers to ensure comprehensive
patient care.
 Rural Health Innovations (RHI) initiated the Minnesota Integrative
Behavioral Health Program to address the growing need for mental
health services in Critical Access Hospitals. This program facilitated
collaboration among healthcare providers, hospitals, and community
services through strategy sessions to discuss evidence-based practices
for successful behavioral health integration. This program emphasizes
community collaboration, education, and use of evaluation as part of
primary care behavioral health integration.

Implementation Considerations

The primary care behavioral health integration model can address

stigma associated with seeking mental health services. When
mental health professionals are located within the same facility as
primary care professionals, it becomes less apparent that patients
are seeking mental health treatment. Integrating behavioral care
helps maintain the patient's privacy and minimizes the potential
for negative judgment from community members, family, or
friends. Rural integrated clinics may consider how best to advertise
their services to explain that they provide both primary and
behavioral healthcare to all patients.

33
Rural and low-income areas experience significant workforce
shortages in mental healthcare, which is a barrier to accessing care.
Patient referrals to healthcare providers located outside of the
community can reduce the chances of follow-up and continuity of
care. By integrating mental health services into primary care
facilities, rural clinics can improve access to mental health services
that are integral to overall wellness. The primary care behavioral
health integration model can allow for a warm and sometimes
immediate handoff to mental health providers if they share the
same facility.
When implementing integrated care, programs should establish
infrastructure for health information exchange to support
communication among all providers involved in a patient's care.
For example, the Health Care Partners Foundation developed a
dual-provider assessment tool that enables both providers to assess
a patient's medical and mental health needs together and compiles
the results into one transition summary.
Staffing can be a significant challenge for rural clinics looking to
start a behavioral health integration program. Strategies for
addressing this barrier include working with behavioral health
students and having staff work at multiple practice locations. For
example, after starting its behavioral health integration
program, Kirby Medical Center created an internship program for
students at University of Illinois' Master of Social Work program to
alleviate sustainability and staffing concerns. The J.C. Blair
Memorial Hospital (now Penn Highlands Huntingdon) had limited
availability of clinical staff but remained committed to maintaining
access to care. Their integrated care staff respond to various
practice locations and offer social work and care coordination
support.
For more information on primary care behavioral health
integration, including considerations for implementation, visit
34
our Rural Services Integration Toolkit and the Integration of
Mental Health Services in Primary Care Settings page in our Rural
Prevention and Treatment of Substance Use Disorders Toolkit.

Program Clearinghouse Examples

 Families Plus
 J.C. Blair Memorial Hospital
 Lac qui Parle Behavioral Health Collaborative
 Project Rural Recovery
 Sinnissippi Centers, Inc.

Mobile Units Model

Rural programs can improve access to mental health services by

using mobile units or mobile clinics. Mobile units are vans or other
vehicles staffed with medical personnel and equipped to offer
onsite mental health services. Mental health mobile units often
have private rooms for counseling, harm reduction tools, and other
supplies like clothing and hygiene items.
Mental health mobile unit programs can provide a wide range of
services, such as crisis intervention, case management, individual
and family therapy, suicide prevention, patient education, peer
support, and medication management. Mental health mobile units
may also offer primary care services. Some may be equipped to
deliver telemedicine and telehealth-based services and treatments.

35
This model increases rural patients' access to mental health services
by allowing mental health providers to travel to patients, reducing
the need for patients to travel long distances to receive care.

Examples of Rural Mobile Unit Programs

 The Highway to Hope Project offers immediate psychiatric care to
adults and children in Charleston and Dorchester counties in South
Carolina. The mobile response clinic provides integrated mental health
and primary care services to people ages 3 and older, regardless of
insurance status or ability to pay. The mobile response clinic offers
acute care, primary care, mental health counseling, and psychiatric
services. The mobile unit is staffed by a care team of mental health
professionals and nurses.
 The University of Tennessee Health Science Center's College of
Nursing Mobile Health Unit (MHU) services Lake and Lauderdale
counties in rural Tennessee to improve access to care for residents in
need. The MHU offers a variety of services including integrated
primary and behavioral healthcare, chronic disease management, HIV
care, and prenatal care. In addition to improving access to care, the
program aims to enhance the nursing workforce and build their
capacity to better serve the unique needs of rural patients.
 RHA Health Services launched two mobile clinics to serve residents
from rural counties in eastern North Carolina. These mobile clinics
provide mental health and substance use disorder services to improve
access to behavioral healthcare in underserved, rural communities. In
the future, RHA Health Services seeks to expand its mobile clinic
services by offering medication for opioid use disorder, physical health
services, and vaccinations.

36
Implementation Considerations

Stigma can be a barrier to receiving mental healthcare in rural

communities. Rural mental health programs looking to implement
a mobile unit should consider integrating their services with
primary care and other health services. Several successful rural
mobile clinics focus on providing care for the whole person and
addressing all healthcare needs. Additionally, branding that overtly
displays mental health services may deter community members
from seeking services. Carefully designing the exterior of a mobile
unit and curating branding materials or wraps on units can help
reduce the fear of stigma or judgment.
Considerations for operating a mobile mental health unit differ
from those of a brick-and-mortar clinic. For example, mobile units
need to be located on flat surfaces. Parking on uneven surfaces can
be dangerous for mobile unit staff and community members.
Additionally, rural mental health programs may need to adjust
hours of operation and location during inclement weather. Staying
on top of mobile unit maintenance, such as emptying septic tanks
and fixing hydraulics, is another consideration for operating a
mobile mental health unit. Identifying and training staff to work
on a mobile unit and oversee maintenance may pose challenges in
rural communities with staffing shortages.
Offering telehealth services on mental health mobile units may
require expenses and equipment, including videoconferencing, Wi-
Fi, and other telehealth installation needs.
For more guidance on implementing a mobile unit program model,
see the Rural Services Integration Toolkit or the Rural Medication
for Opioid Use Disorder (MOUD) Toolkit.

37
Crisis Response Systems Model

Crisis response systems are organized structures, processes, and

services that seek to help address mental health crises quickly and
effectively while enabling individuals to remain in their
communities. Crisis response systems often aim to divert
individuals from avoidable interactions with the criminal justice
system.
The Substance Abuse and Mental Health Services Administration's
(SAMHSA) National Guidelines for Behavioral Health Crisis
Care identify three core elements of a crisis response system:

 Mobile crisis teams

 24/7 regional crisis call centers with crisis intervention capabilities
through phone, text, and chat support
 Crisis receiving and stabilization facilities that serve all people

In rural areas, mental health workforce shortages are a primary

barrier to crisis response, leaving most crisis response efforts in the
hands of law enforcement. This can lead to increased interactions
with the criminal justice system. Many rural communities are
implementing SAMHSA's Sequential Intercept Model to reduce
over reliance on law enforcement and the number of individuals
with a mental illness in jails. The Sequential Intercept Model
outlines several opportunities to divert individuals experiencing a
mental health crisis to community services. The Sequential
Intercept Model includes six intercept points:

 Intercept 0: Community services – Connect individuals with care

before a mental health crisis occurs.

38
  Intercept 1: Law enforcement – Establish mobile crisis teams and train
law enforcement officers in crisis response.
 Intercept 2: Initial detention/initial court hearings – Perform mental
health screenings and connect individuals to care services.
 Intercept 3: Jails/courts – Establish a mental health court and offer jail-
based mental health services.
 Intercept 4: Reentry – Develop treatment plans for reentry and
coordinate with community healthcare providers.
 Intercept 5: Community corrections – Maintain care on a consistent
and continuous basis.

Examples of Rural Crisis Response Programs

 The New River Valley Crisis Intervention Team program covers four
counties and one small city with 14 law enforcement agencies. This
program trains law enforcement officers to deescalate mental health
crises and established a crisis assessment center where officers can take
individuals in crisis for immediate evaluation and care instead of a law
enforcement facility.
 The Crisis Intervention Team (CIT) Academy is a crisis response
training serving various organizations in southwest Montana,
including the Sheriff's Office of Gallatin and Park County. The 40-
hour training equips emergency responders, detention staff, and others
with the skills needed to support individuals experiencing a mental
health crisis. The training covers topics such as suicide assessment,
substance use, mental illness, and strategies for intervention.

39
Implementation Considerations

Crisis response requires a systemic approach. The National

Guidelines for Behavioral Health Crisis Care offer best practices
programs should consider when implementing the three essential
components of a crisis response system — crisis call centers, mobile
crisis teams, and crisis stabilization services. However, these
guidelines can be difficult to implement in rural areas. To best
support individuals experiencing a mental health crisis, rural
mental health programs may consider using the Sequential
Intercept Model to identify new programs, policies, or practices
that are reasonable for implementation. Early intervention models
at Intercept 0 and Intercept 1 may be the most feasible solutions.
For example, rural mental health programs may consider
implementing co-location strategies where mental health providers
can share the same office space as law enforcement officials. This
enables mental health providers to provide pre-arrest services,
including screening and assessment, with the potential to prevent
incarceration.
It is important to tailor crisis response systems to address the
unique challenges in rural communities. Rural mental health
programs can enhance crisis response services by encouraging
partnerships between multiple jurisdictions and across large
geographic areas. Partnerships enable the sharing of information
and technological resources, such as tablets, laptops, phone lines,
and Wi-Fi which may be limited in rural areas. In addition, rural
mental health programs may consider training and certifying local
community members to respond to a mental health crisis, connect
the individuals experiencing a crisis to a mobile crisis team, and/or
transport the individual to the nearest crisis stabilization setting.

40
Implementing crisis response systems in rural areas can be costly.
Rural mental health programs may consider applying for funding
through the INDIAN Rescue Plan (ARP) Act. The Centers for
Medicare & Medicaid Services (CMS) issued guidance for state
officials about reimbursement for mobile crisis services and the full
crisis care continuum. Key factors rural mental health programs
may consider to qualify for CMS crisis response funding include
team structure, training, transportation policies, telehealth, and
post-crisis support. Rural mental health programs may consider
implementing a regional approach versus a county-focused
approach to crisis response. By taking a more regional approach to
crisis response, rural mental health programs can share resources
like personnel and technology, boosting the sustainability and
feasibility of crisis response services.

Mobile Crisis Teams

The Substance Abuse and Mental Health Services Administration's

(SAMHSA) National Guidelines for Behavioral Health Crisis
Care identifies mobile crisis teams (MCTs) as a core element of a
crisis response system. When dispatched to a crisis, an MCT can
de-escalate the crisis, administer medication (if necessary),
establish rapport with the person in need, and connect them to
appropriate treatment services.

41
MCTs typically consist of a nurse, social worker, and/or
psychiatrist. However, due to mental health workforce shortages, it
can be challenging to implement MCTs in rural areas. Rural mobile
crisis teams require a unique composition to accommodate for
workforce and financial limitations. For example, rural MCTs
typically adopt a co-responder model in which one member of the
team is a law enforcement officer. Alternatively, mobile crisis
teams can consist of two non-clinical, non-licensed
paraprofessional crisis intervention specialists, such as peer
specialists or community health workers. These teams are
supervised by a behavioral health provider and are trained to
conduct mental health assessments, crisis interventions, de-
escalation, suicide assessment and intervention, and follow-up.

Examples of Rural Mobile Crisis Programs

 In 2022, the Richmond Fire Department in Richmond, INDIANa
launched a mobile integrated health (MIH) program. The MIH team
collaborates with law enforcement, firefighters, EMS, or other first
responders in crisis response efforts. After a crisis, the MIH team
follows up with the individual in need to connect them to community
resources or treatment services. The MIH team also conducts outreach
to provide resources to those in need.
 South Dakota's Virtual Crisis Care program aims to enhance
collaboration between law enforcement and behavioral health
professionals during a mental health crisis using virtual technology.
When responding to a mental health crisis, law enforcement officers
can provide the individual in crisis with a tablet to perform a video
session with a crisis response team. The crisis response team then
performs a safety assessment and offers follow-up recommendations to
the person in need.
 In 2021, the Alabama Department of Health expanded the Alabama
Crisis System of Care to include Mobile Crisis Teams (MCTs). The goal
of this expansion was to improve access to crisis care for residents in
rural Alabama and reduce the burden on emergency departments and

42
 law enforcement. The MCTs provide a variety of crisis response
services including de-escalation, assessment, medical services
coordination, counseling, and peer support.

Implementation Considerations
Although national guidelines encourage less reliance on law
enforcement for crisis response, law enforcement officers are
typically the first to respond to a mental health crisis in rural
communities. To reduce the number of detained individuals with
serious mental illnesses, rural communities may consider training
law enforcement officers and jail staff in engaging, assessing, and
assisting individuals experiencing a mental health crisis.
In addition, rural mental health programs may consider training
and certifying peer support specialists, community health workers,
clergy, and other community members to become crisis responders
or part of a mobile crisis team. Crisis receiving and stabilization
facilities, another key component of a crisis response system, are
facilities that offer short-term care for people experiencing
behavioral health crises. Law enforcement officers can bring
individuals experiencing a mental health crisis to a crisis receiving
and stabilization facility instead of arresting them or taking them
to a psychiatric hospital. In rural areas, crisis receiving and
stabilization facilities often face challenges like limited resources
and staffing. Rural mental health programs may also consider
training non-clinical mental health providers in crisis response to
increase staffing at crisis receiving and stabilization facilities and
improve access to care in these facilities.
Telehealth can significantly support or reduce the need for mobile
crisis services. To better support crisis response, rural communities
may consider equipping mobile crisis team members with internet-
connected technology to connect individuals in crisis with a
behavioral health specialist. Other technological enhancements

43
such as live GPS tracking and coordination can ensure that the
nearest mobile crisis team is dispatched to an individual in need.
This technology can be costly and less feasible in rural
communities where there is limited broadband connectivity. To
offset costs and boost sustainability, rural mental health programs
may consider sharing technological resources such as tablets,
phone lines, and Wi-Fi.

Program Clearinghouse Examples

 Project Rural Recovery

Crisis Call and Text Lines

Crisis lines, also called mental health helplines, are another

essential component of a crisis response system. The 988 Suicide &
Crisis Lifeline, formally known as the National Suicide Prevention
Lifeline, is a 24/7 national crisis line that offers free support to
individuals experiencing a mental health crisis. Individuals can
call, text, or chat 988 to connect with trained crisis response
professionals who are able to provide support and resources.
To provide immediate access to mental health support for those in
need, rural programs can implement regional or statewide crisis
call lines or promote existing helplines in local healthcare facilities.
For more resources about talk and text lines, see our Rural Suicide
Prevention Toolkit.

Examples of Rural Crisis Call and Text Lines

 Native Crisis Line partners with Northwest Portland Area INDIAN
Health Board and the INDIAN Health Service to be responsive to the
44
 unique mental health needs of INDIAN INDIAN and Alaska Native
people. Individuals can text NATIVE to 741-741 to talk to a crisis
counselor.
 The Georgia Crisis and Access Line (GCAL) is an example of a state
call center that effectively handles rural cases. Available 24/7, GCAL
provides crisis intervention services via phone, dispatches mobile crisis
teams, and connects individuals to urgent services. Georgia residents
experiencing a mental health crisis have been encouraged to call
GCAL directly to ensure immediate and localized support.
 Be Well INDIANa is a 24/7 crisis helpline for residents across the state.
Residents are connected to a trained crisis counselor nearby.
 Nebraska's Rural Response Hotline, NY FarmNet, and South Dakota's
Farm and Rural Stress Hotline are free, confidential, and tailored
statewide initiatives that aim to address mental health challenges
among farmers and ranchers.

Implementation Considerations

The Substance Abuse and Mental Health Services Administration's

(SAMHSA) national guidelines for crisis call centers can be
challenging to implement in rural and under-resourced areas. Some
rural areas may have few mental health providers available to
answer crisis calls, leading to burnout. In addition, some rural
residents may be reluctant to call centralized call lines like 988 due
to beliefs that their concerns will not be understood by responders
in urban areas. To enhance emergency call capabilities, rural
mental health programs may consider partnering with other rural
communities to develop regional or state-wide crisis call lines. This
can ensure that callers receive immediate, localized support. Rural
mental health programs may also consider implementing peer lines

45
or warm lines where individuals with lived experience provide
emotional support to those experiencing a mental health crisis.
Rural mental health programs should consider applying the
implementation of 988 as a guide to ensure that local call centers
are evidence-based and culturally appropriate. Call centers should
be culturally relevant and meet the needs of all residents, including
deaf and hard of hearing populations, LGBTQ+ youth, and other
populations with unique considerations.

Telehealth for Mental Health Services

Model

Telehealth used to provide mental health services can sometimes

be referred to as telemental health or telebehavioral health.
Telehealth increases access to mental health services in rural areas
by providing a means for mental health professionals to reach
patients through technology. In a virtual environment, mental
health providers can offer instant services to their patients such as
evaluations and diagnoses, case consultations, treatments, and
medication management.
Benefits of the telehealth model include:

 Quick and easy referrals to a mental health provider

 Ability to offer services to people with disabilities who may not be
able to leave their homes

46
  Ability to provide services to people for whom travel time and costs
would limit their treatment options
 Reductions in mental health stigma because people can receive care
within their own homes

For more information on telehealth, including implementation

considerations for mental health programs, see our Telehealth
Toolkit and our Telehealth and Health Information Technology in
Rural Healthcare Topic Guide.

Examples of Rural Telehealth Programs Providing Mental

Health Services
 The Skills Training in Affective and Interpersonal Regulation (STAIR)
is a 10-week training for female veterans from rural areas with
military sexual trauma. It is a mental health program designed to
reduce PTSD and depression symptoms and increase emotional
regulation and social functioning. Program participants may
participate in the web-version of STAIR known as webSTAIR with
access to individual or group treatment via teleconferencing.

Implementation Considerations
To maximize the potential of the telehealth model, rural mental
health programs should evaluate the availability of
reliable broadband internet in their communities. Many rural
INDIANs, especially people living on tribal lands, lack access to
broadband internet.
Rural mental health programs should also be aware of patients'
needs for at-home treatment. This includes determining whether
patients have access to suitable devices (for example, a laptop,
phone, or tablet) for participating in telehealth services. Rural
programs may also want to assess the potential privacy risks
47
associated with using telehealth services, and recognize that
patients must have a private space at home to make the most of
their telemental health treatment.
Offering information technology (IT) training to staff can also
enhance the effectiveness of the telehealth model. Providers must
understand how to use telehealth software, applications, and
devices.
Medicaid reimbursement and licensure laws for telehealth vary by
state and may have certain stipulations for mental health services.

Program Clearinghouse Examples

 Health Care Partners Foundation

Non-Clinical Mental Health Workers

Model

Peer support workers are individuals who have experienced a

mental health or substance use condition and have been successful
in treatment. Peer support specialists can be trusted members of
the community and may have similar, shared experiences to the
individual seeking care. By connecting community members with
an individual who has lived experience with a mental health
condition, individuals may be more willing to engage in treatment
services. Family peer advocates and youth peer leaders are
additional examples of peer support models. For more information

48
on peer support programs for individuals with a substance use
disorder, see our Rural Prevention and Treatment of Substance Use
Disorders Toolkit.
Other non-clinical professionals who can help connect community
members to mental health services include:

 Behavioral health aides

 Community health workers
 Patient navigators

Non-clinical health worker positions are especially important to fill

in rural areas because the traditional mental health workforce is
smaller than in urban areas. Care from a non-traditional mental
health provider may be accessible immediately through a drop-in
service, unlike other clinical services. In addition, there may be less
discomfort associated with receiving help from an individual who
may not formally be considered a healthcare professional.
Mental health trainings for community members that can be
adapted for rural audiences include:

 COMET (Changing Our Mental and Emotional Trajectory) teaches

community members how to support a friend or neighbor who may be
struggling with their mental health while emphasizing rural cultural
values.
 QPR for Farmers and Farm Families teaches laypeople and
professionals to recognize and respond to mental health crises,
particularly in the agricultural community.

Examples of Rural Programs Using Non-Clinical Mental

Health Workers
 Libraries for Health, launched by Via Hope and the St. David's
Foundation, is a mental health program that collaborates with libraries
in rural Texas to enhance access to mental health services and address

49
 the mental health needs of residents. Libraries for Health also includes
a peer specialist training program. Built on a task shifting model, this
program aims to equip individuals with lived experience in mental
health, substance use, incarceration, and homelessness with the skills
to identify the mental health concerns of library patrons and provide
support.

Implementation Considerations
As peer support specialists emerge as leaders in the mental health
workforce, it becomes imperative for rural programs to set clear
standards in each area of work. The Substance Abuse and Mental
Health Services Administration (SAMHSA) identifies core
competencies for peer workers in behavioral health services. The
core competencies outline the knowledge, skills, and attitudes of a
successful peer support worker. They address provision of support
that is personalized and supports recovery; sharing of lived
experiences; connection to resources, services, supports, and
information; communication; collaboration with and support of
peers; and promotion of leadership, advocacy, growth, and
development. Rural programs can use the core competencies as a
guide for best practices and qualifications for peer support.
Rural programs looking to address mental health workforce
shortages should also consider task shifting. Task shifting, or task
sharing, is the process of sharing tasks between highly trained,
clinical healthcare providers and other professionals, such as peer
support specialists, allied healthcare professionals, or non-
traditional healthcare providers. Rural programs can implement
task shifting interventions by leveraging support from community
health workers. Our Community Health Workers Toolkit provides
information on implementing community health worker programs
in rural settings.

Program Clearinghouse Examples

50
  Arkansas Rural Health Partnership
 Families Plus
 Health Care Partners Foundation
 Sinnissippi Centers, Inc.

Mental Health First Aid Model

Mental Health First Aid (MHFA) is an evidence-based, early-

intervention education approach that trains community members
to assist someone experiencing a mental health crisis. MHFA has
several courses including MHFA for Rural Communities. This
intervention can increase the capacity for mental health crisis
intervention in rural communities for both the general public and
subpopulations with unique mental health needs.
MHFA is offered as an 8-hour training where participants learn
about recovery and resilience. The course covers topics such as risk
factors and warning signs for mental health conditions and
resources to help individuals experiencing a mental health
challenge. MHFA provides information on several mental health
conditions including depression, anxiety, and substance use
disorders.
Participants also learn about the MHFA action plan that can be
used to offer the best support to someone experiencing a mental
health challenge. Participants can test their knowledge of the

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MHFA action plan through role play, scenarios, and activities.
The MHFA action plan has five steps:

1. Assess for risk of suicide or harm

2. Listen nonjudgmentally
3. Give reassurance and information
4. Encourage appropriate professional help
5. Encourage self-help and other support strategies

MHFA is appropriate for a variety of audiences within rural

communities including, for example, teachers, military families,
nursing home staff, and farmers. In northwestern Oklahoma, one
educator leveraged her MHFA training to raise awareness
about depression and suicide risks among farmers. For more case
studies and success stories about MHFA in practice, see
the National Council for Mental Wellbeing's MHFA News &
Updates.

Implementation Considerations
It is important for rural programs to gain support for the
implementation of the MHFA program in the community. Offering
free classes to local leaders, law enforcement, and faith-based and
school organizations can help gain support and buy-in for the
program. Rural programs may also rally for legislative support for
improvement and investment in mental health programming.
When choosing MHFA instructors, rural programs should consider
identifying instructors that represent their community's
geographic and cultural makeup. Rural community members can
also undergo training and certification, including a rural
designation, to teach MHFA. To ensure accessibility of the course,
rural programs may want to consider placing bilingual MHFA
instructors in areas where more than one language is spoken.

52
Program Clearinghouse Examples
 Arkansas Rural Health Partnership
 Families Plus
 Lac qui Parle Behavioral Health Collaborative
 Sinnissippi Centers, Inc.
 Tanner Health System

Models to Expand Affordability for

Mental Health Services

Affordability of mental health services involves the costs associated

with receiving mental health services and attaining insurance that
covers those services. Some people who live in rural areas are
unable to afford the cost of health insurance or the cost of paying
for mental health services out-of-pocket. Affordable mental health
services help ensure rural communities can receive necessary care
to address their mental health needs.
This section describes two models to improve affordability in rural
communities.

Models in this section:

 Wraparound Services and Community-Based Supports for Mental
Health Model
 School-Based Social and Emotional Supports Model

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Wraparound Services and Community-Based
Supports for Mental Health Model

Some rural communities are using wraparound services and

community-based supports to deliver mental health services. This
is consistent with the Substance Abuse and Mental Health Services
Administration (SAMHSA) definition of recovery, which states
that recovery from mental health conditions happens in multiple
dimensions, including one's home and community. Mental health
wraparound services can include case management, counseling,
medical care and health services, family services, social work,
housing assistance, and dietitian assistance.
A popular community-based approach is the Clubhouse model,
which is based on the belief that every member has a safe and
respected space in the community. Social service organizations
who adopt the model can provide structure and meaning to an
individual living with a mental health condition. Those who
participate also have a chance to enhance their quality of life by
participating in social, occupational, and educational opportunities.
For an overview of wraparound services, see our Rural Services
Integration Toolkit. To learn about addressing social factors to
support substance use recovery, see our Rural Prevention and
Treatment of Substance Use Disorders Toolkit.

Examples of Rural Programs Offering Wraparound Services

and Community-Based Support for Mental Health
 The Pathways Vermont Housing First Program addresses the needs of
those experiencing homelessness by providing mental health and
substance use treatment. This community-based support program is
built around the Housing First model, which supports people

54
 experiencing homeless by providing housing, assistance, and other
basic necessities. The goal of the program is to help individuals
maintain housing, but the program offers a variety of other services,
including access to mental health services and computer training.
 The mission of the Rural Outreach Center (ROC) is to break the cycle
of rural poverty by supporting people toward self-sufficiency. These
wraparound services include counseling, play therapy, and care
coordination. ROC Counseling provides support through a team of
licensed mental health clinicians. Play therapy offers children with
mental health conditions, trauma, behavioral problems, and family
issues a way to help them grow, heal, and succeed.
 The Northern Lights Clubhouse uses the Clubhouse model to provide
social outlets for individuals with mental health conditions in rural
communities. Northern Lights Clubhouse is based in Ely, Minnesota. It
offers services including education and connection to community
resources, employment and academic support, holistic wellness
activities, and culinary and nutrition support.
 SAMHSA funds System of Care grants to provide wraparound services
for children and youth with serious emotional disturbances and their
families as part of the Comprehensive Community Mental Health
Services for Children and their Families Program. With their System
of Care grant, North Dakota is working to expand community-based
behavioral health services and supports for children with or at-risk for
mental health challenges.

Implementation Considerations
Providing wraparound services requires effective coordination and
sufficient resources to address mental health concerns. The ability
to offer wraparound services may be limited by the availability of
formal services in rural communities. Nonetheless, rural mental
health programs can provide individualized support for patients by
relying on and adapting community-based supports. In addition to
mental health professionals and other clinical providers, rural
mental health programs may engage other informal supports

55
including family members, teachers, mentors, and other
community volunteers, to assist in the provision of wraparound
services.
Building strong partnerships with local organizations, community
leaders, and healthcare providers is essential for effective
coordination and collaboration. When implementing wraparound
services and community-based supports, partners support access to
resources, community buy-in and trust, collaborative problem-
solving, and coordinated care.
Wraparound services and community-based supports for mental
health often aim to address a patient's social determinants of
health (SDOH). Rural mental health programs designed to address
SDOH may be disincentivized by a fee-for-service reimbursement
structure or only funded to focus on one social determinant. To
learn more about funding strategies for programs that address
SDOH, visit our Social Determinants of Health in Rural
Communities Toolkit.

Program Clearinghouse Examples

 Families Plus
 Health Care Partners Foundation

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School-Based Social and Emotional Supports
Model

Mental health conditions often begin in early childhood and can

impact long-term health and well-being. Children growing up in
rural communities may live in neighborhoods that lack access to
parks, libraries, and community centers. The lack of access to
certain amenities in rural communities can make it harder for
families to give their children opportunities to thrive and grow.
Schools serve as hubs in rural communities and can play an
essential role in addressing the mental health needs of students and
their families. In some areas, school-based mental health services
may be the only mental health services children are able to access.
Rural communities can create school-based social and emotional
support programs to promote positive mental health early in life
and serve as valuable prevention and early intervention for mental
health issues.
The National Center for Rural School Mental Health (NCRSMH)
helps rural schools address youth mental health concerns.
NCRSMH works with school districts to develop and assess a
comprehensive approach to advancing mental health through
prevention, identification, and intervention. The Center is
developing the Early Identification System for rural schools, which
includes online student report and teacher evaluation tools, an
online mental health training library, a dashboard system, and

57
tools to monitor effectiveness of interventions selected. NCRSMH
created a cost calculator tool to help calculate the cost of school
programs that support students' mental health.

Examples of Rural School-Based Social and Emotional

Support Programs
 Sources of Strength is an evidence-based program that addresses youth
mental health promotion and suicide prevention. The mission of
Sources of Strength is to prevent adverse outcomes by increasing
healthy coping, resiliency, help-seeking, well-being, and
belonging. Clintonville High School, in Clintonville, Wisconsin,
implemented the Sources of Strength program at their school. The
school's goal was to change the overall school climate around mental
health and wellness. The Clintonville Sources of Strength program has
51 active peer leaders in a school of 400 students. Clintonville credits
the success of the program to drawing upon student strengths,
providing guidance to students who take on leadership roles, and
being flexible so more students can participate with minimal stress.

Implementation Considerations
Rural schools are often not well-equipped to screen students for
mental health conditions due to limited resources and staff. Schools
should consider partnering with organizations and local clinics to
offer school-based mental health resources.
When implementing a school-based social and emotional support
program it is important to consider the need for trained
professional staff, funds to run the program, and a developed
curriculum. The Mental Health Technology Transfer Center
Network provides implementation tools for mental health
programs in rural schools.
Another important consideration for school-based services is
parental consent. Rural programs may need to design and

58
implement consent forms and procedures for obtaining parental
permission for students to obtain services in a school setting.

Program Clearinghouse Examples

 Families Plus
 Tanner Health System

Models to Enhance Acceptability of Mental

Health Services

Acceptability of mental health refers to a person's perception and

judgment of mental health services, including trust in healthcare
providers, perceptions of whether mental health services are
reasonable or necessary, and potential stigma associated with
seeking those services. People living in rural communities may
struggle with acceptability of mental health services due to lack of
anonymity and lack of care that acknowledges their values and
beliefs. When rural communities work to enhance acceptability,
and decrease stigma and negative perceptions around mental
health, they may increase the number of people who feel
comfortable accessing mental health services.
This section describes two models to enhance acceptability in rural
areas.

59
Models in this section:
 Public Education and Awareness Model
 Trauma-Informed Care Model

Public Education and Awareness Model

Public education can help raise awareness, improve understanding,

and support individuals at risk of or living with mental health
conditions. Public education is valuable for
reducing stigma associated with mental health conditions and
fostering a positive mental health environment. Educational
approaches to reducing stigma often begin with trainings that
deliver factual information about mental health. Effective trainings
use social contact with people with lived experience who can
personalize the information delivered. Trainings may be structured
as formal classes or informal conversations within the community.
Positive changes in the perception of mental health often start with
individuals; moves to families, workplaces, and schools; and ends
with community leaders who are then equipped to continue
community education efforts, including programs and events,
surrounding mental health.
Education and awareness efforts can improve mental health
literacy within the community. When people can comprehend

60
information about mental health, they are more likely to make
informed choices and seek support when needed. Improved mental
health literacy can also decrease the stigma around mental health,
making people feel more comfortable to reach out for help. Public
education and awareness efforts that focus on mental health
literacy can empower individuals to take positive steps toward
mental well-being, creating a community that values and supports
everyone's mental health journey.

Examples of Rural Public Education and Awareness

Programs for Mental Health
 I Got You: Healthy Life Choices for Teens (IGU) is an example of a
community mental health outreach program providing mental health
education to students in rural east central Mississippi. The goal of the
program is to decrease behavior-related office discipline referrals in
schools and provide general education about mental health and well-
being.
 Rural Minds aims to promote mental health in rural INDIAN. Rural
Minds is a resource for public education that offers a wide range of
programs and learning opportunities. Available learning opportunities
include webinars, FAQs, newsletters, fact sheets, and news relating to
rural mental health.
 Plumas Rural Services offers mental health and wellness trainings and
evidence-based certification courses, including Mental Health First
Aid, Applied Suicide Intervention Skills Training (ASIST), safeTALK
Suicide Alertness Training, and Connect the Dots on Mental Health.
Upon request, they also design workshops to meet specific workplace
or organizational needs such as Mental Health Awareness for court-
appointed special advocate (CASA) volunteers.

Implementation Considerations
Community figures and peers play an important role in supporting
public education and awareness for mental health. Rural

61
communities should consider implementing trainings for trusted
community figures, leaders, and peers that provide guidelines,
strategies, and approaches for handling discussions and responding
to people in a mental health crisis. Community figures, leaders, and
peers should be knowledgeable and can provide support and share
resources that make it easier for people to seek help. The Substance
Abuse and Mental Health Services Administration (SAMHSA)
provides resources for what community and faith leaders can do to
promote mental health awareness and education.
Our Rural Suicide Prevention Toolkit provides additional examples
and implementation considerations for mental health and suicide
prevention campaigns.

Program Clearinghouse Examples

 Arkansas Rural Health Partnership
 Lac qui Parle Behavioral Health Collaborative

Trauma-Informed Care Model

The Trauma-Informed Care (TIC) model is an approach that

accounts for a person's past experiences of trauma to ensure
provision of the appropriate and effective mental health services.
One of the goals of TIC is to make patients feel safe and welcomed
when receiving mental health treatment. It emphasizes creating a
safe and supportive environment where mental health

62
professionals can tailor their approaches to be sensitive, empathic,
and non-triggering. TIC seeks to:

 Prevent re-traumatization
 Integrate information about trauma into practices, procedures, and
policies
 Recognize the extensive impact of trauma and understand paths for
recovery

Using TIC can improve acceptability of mental health services by

recognizing and responding to the impact of trauma on individuals.
TIC uses six guiding principles to help patients feel safe, develop a
relationship with their provider, and achieve lasting mental health
support. The six guiding principles include:

 Safety
 Choice
 Collaboration
 Trustworthiness
 Empowerment
 Cultural, historical, and gender issues

TIC also promotes collaboration between individuals and their

provider, leading to more effective and respectful mental health
practices. Collaborative relationships reduce power differences and
increase shared decision-making between providers and patients.

Examples of Rural Trauma-Informed Care Programs

 The Alaska Veterans Telehealth and Biofeedback Services program
offers trauma-informed mental health services via telehealth in rural
communities. This program helps veterans address symptoms of
trauma, including stress, chronic pain, and sleeping issues. Patients
meet with trained counselors weekly for trauma-informed therapy.

63
 After participating in the program, participants were more willing to
pursue additional mental health treatment options.
 La Pine Community Health Center (CHC) is a Federally Qualified
Health Center with five clinic sites in rural areas of Central Oregon. La
Pine CHC serves approximately 7,500 individuals per year. In 2015, La
Pine CHC added trauma-informed care (TIC) as an approach for their
programming. Working in a health center with a priority on person-
centered care, the Chief Medical Officer recognized that many
patients have complex situations, including histories of trauma.
Integrating TIC helped staff better understand root causes associated
with many of their patients' social and physical health outcomes.
Using TIC has helped La Pine CHC understand how trauma affects
both staff and patient engagement with the clinics.

Implementation Considerations
Implementing a TIC approach involves changes at both the clinical
and organizational levels. The Implementation Resource Center
provides foundational steps to consider when adopting a TIC
approach. These include learning the basics of TIC, learning from
the experiences of others who have implemented TIC, and
accessing implementation resources. Rural organizations seeking to
implement TIC can take steps to do so gradually over time.
Policy efforts can also support the implementation of TIC
approaches. Additional considerations for policymakers include:

 Identify potential areas for cooperation to enhance adoption across

sectors and within systems
 Assess the impact and return on investment of TIC
 Promote the integration of TIC screening and treatment
 Advocate for the involvement of families and communities with
firsthand experiences to contribute to the development and
application of TIC policies

Program Clearinghouse Examples

64
  Project Rural Recovery
 Tanner Health System

Module 3: Program
Clearinghouse

The HRSA Federal Office of Rural Health Policy has funded

several programs in rural areas to implement mental health
programs as part of the 330A Outreach Authority program. This
program focuses on expanding access to healthcare services in rural
areas.
Examples of current 330A Outreach Authority grantees and other
organizations that have developed promising programs designed to
improve mental health in a rural community are provided below.
Evidence-based and promising service models for improving
mental health are available in Module 2.

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 Arkansas Rural Health Partnership (ARHP)
Synopsis: ARHP is a healthcare network comprising rural hospital
members, medical teaching institutions, and Federally Qualified
Health Centers. ARHP works to ensure access to quality and localized
healthcare throughout rural Arkansas. One of ARHP's focus areas is
behavioral health initiatives in which they support individuals
experiencing mental health and substance use disorders.
 Families Plus
Synopsis: This mental health specialty clinic began in 1998 and, after
receiving a federal grant in 2015, expanded its services while
partnering with other organizations. The goal of Families Plus is to
improve access to preventive healthcare, provide wraparound services,
and offer mental health treatment for children with complex needs.
 Health Care Partners (HCP) Foundation
Synopsis: The HCP Foundation is a nonprofit organization that aims to
improve the well-being of people who are incarcerated in jail systems
in Colorado. The HCP Foundation provides telemedicine,
telepsychiatry, and telecounseling for people who are incarcerated.
The use of telecounseling enables providers to address the root cause
of problems that often lead to incarceration.
 J.C. Blair Memorial Hospital (now Penn Highlands Huntingdon)
Synopsis: J.C. Blair Memorial Hospital, in partnership with J.C. Blair
Medical Services and UPMC Pinnacle, established a consortium of
clinical partners. This project integrates behavioral health services into
primary care clinics in rural Pennsylvania.
 Lac qui Parle Health Network (now River Valley Health Network)
Synopsis: This collaborative is working with three hospitals and clinics
and one behavioral health provider in southwestern Minnesota to
create an integration plan for behavioral health and primary care
services. One of the program goals is to implement a flow chart
providers can use to support patients experiencing mental health
conditions. The program is also working to establish care coordinator
positions to help patients manage their care plans.
 Project Rural Recovery
Synopsis: Project Rural Recovery offers integrated primary care,

66
 mental health, and substance use treatment services with four mobile
units in rural counties across Tennessee. The mobile units are staffed
and operated by dual certified nurse practitioners, a mental health
therapist, a medical assistant, and a case manager. This staffing model
may vary unit to unit dependent on need.
 Sinnissippi Centers, Inc.
Synopsis: This is a program consortium made up of agencies
collaborating to improve children's mental health. The consortium
uses the care coordination model and Parent Cafés (support groups) to
help children and their families access mental health services.
 Tanner Health System
Synopsis: Willowbrooke, a center within the Tanner Health System,
provides mental healthcare services to students through the local
school system by offering youth Mental Health First Aid trainings and
access to school counselors.

Arkansas Rural Health Partnership

 Grant Period: 2018 – 2021
 Program Representative Interviewed: Mellie Boagni Bridewell,
President, CEO & Founder, and Amanda Kuttenkuler, Vice President
of Programs
 Location: Lake Village, Arkansas
 Program Overview: Founded in 2008, the Arkansas Rural Health
Partnership (ARHP) is a nonprofit healthcare network comprising 18
rural hospital members, three medical teaching institutions, and two
Federally Qualified Health Centers (FQHCs) throughout rural
Arkansas. ARHP's vision is to ―advance the health and wellness of
rural residents, providers, and healthcare organizations through
dynamic collaboration, forward-thinking, and strategic leveraging.‖
ARHP's focus areas are rural health sustainability, health workforce
continuum, health-social initiatives, and behavioral health initiatives.

67
 ARHP's behavioral health initiatives support individuals experiencing
mental health and substance use disorders and strengthen the local
systems of care. The program's behavioral health initiatives include
Mental Health First Aid (MHFA) training; an opioid crisis information
video; Question, Persuade, and Refer (QPR) training; the South
Arkansas Behavioral Health Task Force; peer recovery specialists; and
Narcan training. ARHP uses community needs assessments to identify
the areas in need of mental health training. Before implementing the
MHFA training, ARHP conducted a thorough examination of existing
barriers related to mental health awareness and then identified
effective strategies for disseminating mental health information. This
proactive approach reflects ARHP's dedication to breaking down
obstacles and promoting a more inclusive and informed conversation
around mental health.

ARHP offers free MHFA training to community members, emergency

responders, healthcare workers, college students, and youth
throughout rural Arkansas. Seeing a growing need to engage with
youth in spaces where they feel most comfortable discussing mental
health, ARHP implemented MHFA trainings with teachers and
coaches. Recognizing the profound impact these mentors have on the
lives of young individuals, ARHP has actively sought to establish
connections within schools. In addition to schools, teachers, and
coaches, ARHP partners with the Arkansas Drug Task Force, hospital
CEOs, police, public health departments, judges, the Born This Way
Foundation, and peer recovery workers.

ARHP attributes the success of their MHFA trainings to understanding

community needs, building a dissemination platform, and finding
partners who will make an impact.

Models represented by this program:

 Non-Clinical Mental Health Workers Model
 Mental Health First Aid Model
 Public Education and Awareness Model

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Families Plus
 Grant Period: 2015-2018
 Program Representative Interviewed: Brenda K. Holland, Ph.D.,
Executive Director of Families Plus
 Location: Delta County, Colorado
 Program Overview: Families Plus consists of four agencies: a mental
health specialty clinic, a hospital network, a primary care facility, and
a safety net provider. Families Plus uses wraparound services to assist
children with complex needs from families with limited resources
using a collaborative approach. The program established the Families
Plus Mental Health Mentoring Model which uses motivational
interviewing to identify the patient's goals and needs, and then assigns
the child a mentoring family. The program's clinical staff also
offer cognitive behavioral therapy and trauma-focused cognitive
behavioral therapy.

Families Plus has been successful due to a variety of factors, including

the work of a volunteer consultant, Dr. John VanDenBerg. The
program's success can also be attributed to strong relationships with
various businesses and organizations in the Delta County area,
including Doughty Steel & Machine, Inc. and Delta United Methodist
Church. Families Plus has expanded their capacity to serve more
children, and they were the first group in the area to integrate
behavioral health into a medical clinic. The program also developed an
online training manual for the Families Plus Mental Health Mentoring
Model for mental health professionals and peer specialists.

69
Project Rural Recovery

 Program Representative Interviewed: Darren Layman, Program

Director, and Jessica Youngblom, Director of Strategic Initiatives,
Tennessee Department of Mental Health and Substance Abuse Services
 Location: Tennessee
 Program Overview: Project Rural Recovery has four mobile units that
bring integrated primary care, mental health, and substance use
services to 20 rural counties in Tennessee. The mobile units offer
walk-in services and scheduled appointments free of charge. The
mobile units are funded by grants from the Substance Abuse and
Mental Health Services Administration (SAMHSA) and the state
INDIAN Rescue Plan Act (ARPA) funds.

The mobile units are staffed by dual-certified nurse practitioners who

can provide both physical and mental health services, including onsite
counseling and referrals to treatment. In addition to the nurse
practitioner, each mobile unit is also staffed with a behavioral health
therapist, a medical assistant, and a case manager. Staff are trained to
use the following evidence-based tools and practices:

o Behavioral Health Integration (BHI)

o Screening, Brief Intervention, and Referral to Treatment
(SBIRT)
o Medication Assisted Treatment (MAT)
o Columbia-Suicide Severity Rating Scale (C-SSRS)
o Trauma-Informed Care (TIC)

To support the mobile units, Project Rural Recovery partners with

local health clinics, emergency medical services (EMS), courts, health
councils, homeless services providers, faith leaders, and pharmacies.

70
Project Rural Recovery assesses program outcomes by gathering
patient data at baseline and 6-month follow-up intervals. They track
metrics related to daily living activities, suicide and depression
screening, substance use and frequency, as well as multiple physical
health measures like blood pressure and A1C.

The program learned the following from their Year 3 evaluation:

o 1 in 5 clients had not seen a primary care physician in the last 5

years
o 1 in 3 clients said they would not have received any care if the
mobile clinic was not available
o 1 in 4 clients said it would have taken them over 30 minutes to
travel if it was not for the mobile unit
o 97% of clients said it took them less than 30 minutes to get to
the mobile clinic
o 70% of clients surveyed said they would have gone to the
emergency department if the mobile unit was not available

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Module 4: Implementation Strategies for
Rural Mental Health Programs

Each rural mental health program is unique, and there is no one-

size-fits-all implementation strategy. Successful programs identify
existing resources and best practices, and tailor them to address
their community's needs. This module identifies key concepts to
consider when implementing a program to improve mental health.
For a broad overview of rural program implementation,
see Implementing a Rural Community Health Program in the
Rural Community Health Toolkit.

In this module:
 Workforce Considerations for Rural Mental Health Programs
 Mental Health Treatment Options
 Mental Health Stigma in Rural Communities
 Community Partnerships for Rural Mental Health Programs
 Transportation for Rural Mental Health Programs
 Population Considerations when Implementing Rural Mental Health
Programs

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Workforce Considerations for Rural
Mental Health Programs

Having an adequate workforce is essential to delivering mental

health services in rural communities. Rural programs can ensure
access to quality services by having enough well-trained and
diverse healthcare providers and other staff. Recruitment and
retention are central to ensuring an adequate mental health
workforce.

Staffing
There are a variety of professional roles within a comprehensive
mental health system. These include primary care doctors, nurse
practitioners, psychologists, nurses, psychiatrists, counselors, and
social workers. Rural communities should include a variety of
professional roles within mental health programs, whenever
possible.
Rural programs should also consider developing a mental health
workforce that is representative of the demographics and cultures
in their community to help reduce disparities. This can help ensure
the provision of culturally competent care.
Many rural communities face a mental health workforce shortage.
Programs should consider nontraditional roles and engaging
community members when providing mental health support.
Community members may be trained in Mental Health First Aid so
they can provide informal support to other community members
struggling with mental health issues. Community members who
may provide more formal mental health services in rural areas
include peer support workers, community health workers, clergy
and other faith leaders, teachers and others in the school systems,
73
and police and other first responders. Community members are
also essential to addressing issues of social isolation and loneliness,
which are closely tied to mental health outcomes.

Recruitment and Retention

Recruitment and retention are essential to consider when
developing a quality rural mental health workforce. According to
the Substance Abuse and Mental Health Services Administration
(SAMHSA), the mental health workforce is growing due to
reimbursement changes and increases in demand for services.
Despite this growth, there is a shortage of mental health workers
and this severely impacts rural communities.
The following strategies can be used to help rural communities
with recruitment and retention of mental health professionals:

 Recruiting foreign healthcare professionals, including using the J-1

Visa Waiver for physicians
 Online job listings that can reach a broader network of providers
 Telehealth investments, which can improve access to mental health
services and help providers receive support from peers
 National Health Service Corps Loan Repayment Programs
o Federal programs
o State programs
 Pipeline/Pathway Programs, for example, Club Scrub
When establishing a rural workforce, burnout can significantly
affect retention. The mental health workforce often faces high
stress levels, lower salaries, understaffing, full caseloads, and high
student debt. SAMHSA created guidelines and tips for addressing
burnout at the organizational level for behavioral health providers.
Additionally, the National Rural Health Association
recommends policies that improve workforce reimbursement,

74
bolster wellness among mental health professionals, and support
Medicaid reimbursement for resident physicians.
For more on this topic, refer to our Recruitment and Retention for
Rural Health Facilities topic guide.

Workforce Training
Healthcare staff should be equipped with the necessary skills to
provide effective and efficient services to patients. In the field of
mental health, specific skills are essential for staff to provide proper
patient care. Trauma-informed care, Mental Health First Aid, and
cultural competence training are all examples of important
trainings for mental health providers. For more information on
trauma-informed care and Mental Health First Aid, see Module 2.
Cultural competency is an essential factor in addressing health
disparities. Providers who are culturally competent are aware of a
person's background, language, practices, and beliefs, which can
help them correctly diagnose and treat their patients. Cultural
competence is especially important in rural areas because patients
already experience numerous barriers to receiving care, including
stigma, distance to care, and mental health provider shortages.
Substance Abuse and Mental Health Services Administration
(SAMHSA) created a Treatment Improvement Protocol: Improving
Cultural Competence which includes a multidimensional model for
developing cultural competence. Becoming a culturally competent
healthcare organization may lead to significant improvements in
mental health services, by creating a more inclusive and accessible
environment, enhancing communication, and encouraging a better
understanding of cultural norms.

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Mental Health Treatment
Options
There are many different types of treatment options for people
with mental health conditions. No single treatment will work for
everyone. Before implementing a mental health program, rural
communities should consider the range of needs of residents,
determine which treatment options the program will offer, and
make a plan for service delivery that meets the unique needs of the
community. Mental health treatment typically includes a
combination of therapy and medication and may also incorporate
wellness approaches.

Therapy Options
There are many different types of therapy, including
psychotherapy and other therapies, that rural planners can
incorporate into a mental health program. However, because of
provider shortages in rural areas, programs may be unable to make
all options available.
Common types of psychotherapy include:

 Cognitive behavioral therapy (CBT) is a therapy strategy that explores

thoughts, feelings, and behaviors, with the goal of changing unhealthy
thinking and behavior patterns. Mental health providers trained in

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 CBT can empower patients with the tools to recognize and modify
unhelpful thoughts and behaviors.
 Interpersonal therapy (IPT) is a short-term form of therapy designed to
help patients recognize underlying interpersonal issues. These issues
can include unresolved grief, changes in social roles, and problems
relating to others. IPT can teach healthy ways of expressing emotions
and improving communication.
 Psychodynamic therapy is based on behavior and mental well-being
rooted in childhood and past experiences. It involves bringing
unconscious feeling to conscious awareness. The goal of this therapy is
to enhance self-awareness and change deep-seated patterns.
 Supportive therapy utilizes encouragement and guidance to help
patients develop their self-esteem, reduce anxiety, and strengthen
coping skills.

Other therapies rural programs may use in combination with

psychotherapy include:

 Creative arts therapy, which uses art, dance, music, and poetry to
express emotions.
o Art therapy incorporates art, creativity, and expression as
healing strategies for patients.
o Music therapy uses music as a tool for healing and processing
through music making, listening, singing, and dance.
 Animal-assisted therapy uses animals to help bring comfort to people
coping with trauma.
 Play therapy is a form of counseling that helps children identify and
talk about their emotions.

Medication Options
Prescription medications can help treat individuals with a mental
health condition. There are different types of prescription
medications available to treat mental health conditions, including
antidepressants, anti-anxiety medications, stimulants, and

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antipsychotics. Medication may come in various forms, including
pills, injections, or patches. Choosing the most appropriate
prescription should involve assessing the effectiveness, availability,
and affordability of the medication. Prescription medications
should only be taken when prescribed by a licensed medical
practitioner.
Many rural areas face barriers in accessing pharmacy services,
including transportation barriers and pharmacy closures. Some
barriers to pharmacy access may be overcome by using mail-order
or internet services to obtain medications. Another treatment
approach for overcoming barriers is using long-acting injectable
medications, which reduce the frequency of visits needed.
Workforce shortages may also make it difficult to access
psychiatrists and other professionals who can prescribe medication
and evaluate its usefulness for individual
patients. Telepsychiatry has been shown to be successful in
overcoming access to care barriers in rural areas.

Overall Wellness Options

Rural programs should prioritize wellness when treating mental

health conditions. Nutrition, exercise, stress management,
and tobacco cessation play a crucial role in achieving and
maintaining stability in individuals with a mental health condition.
Many people with mental health conditions experience co-

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occurring physical health problems and chronic conditions, such as
heart disease, cancer, stroke, and diabetes. The mental health
condition may precede the physical health problems, or vice versa.
Social prescribing is a way for primary care physicians to focus on
the well-being of the entire patient. Social prescribing is a formal
process in which primary care physicians connect patients, either
directly or indirectly, to non-medical interventions for alleviating
health concerns. These interventions may include activities to
improve well-being like art classes or walking groups.
When addressing overall wellness, nutrition can play a role in
mental health. Eating unhealthy foods, such as refined sugars, can
adversely affect brain functioning, including the regulation of
insulin and mood disorders like anxiety and depression. Promoting
intake of foods like fruits, vegetables, and foods rich in omega-3
fatty acids like seeds, nuts, and legumes, can help boost mental
health. To learn more about increasing access to healthy food in
rural areas, explore our Rural Hunger and Access to Healthy
Food topic guide.
Exercise is an essential part of wellness and should be considered
when implementing mental health programs in rural
areas. Exercise can lead to short-term relief and long-term
stabilization of mood disorders like depression and anxiety. In
some rural areas, there may be limited access to environments that
support physical activity, such as communities that lack recreation
centers. Rural communities can consider opportunities to integrate
exercise into mental health programs. This may be as simple as
incorporating daily walking routines.
Another lifestyle treatment option is mindfulness meditation,
which can take the form of still meditation or meditation through
movement, such as yoga. Research shows that yoga may help
relieve symptoms of anxiety and depression for some individuals.

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Mental Health Stigma in Rural
Communities

Mental health stigma is the fear or embarrassment experienced

when seeking out mental healthcare due to concerns about
negative perceptions from community members, family, providers,
and friends. In rural communities, stigma can prevent individuals
from seeking the help they need. In small, close-knit rural
communities, individuals experiencing a mental health condition
may delay receiving care due to the fear of feeling shame or
embarrassment if there are stigmatizing beliefs around mental
health in the community. In addition, rural communities
commonly foster a culture of self-reliance, which can increase
stigma related to seeking help for a mental health concern.
Due to the stigma associated with mental health conditions, people
often desire privacy and anonymity when seeking treatment.
Ensuring privacy can be particularly challenging in rural
communities due to the small population size and fewer locations
to receive care. For example, individuals may fear being seen
walking into a mental health clinic or may be reluctant to seek
help if local providers are friends or associates.
Rural mental health programs may consider addressing stigma by
offering services, like telehealth visits, that can reduce the
potential for stigma-related barriers to care by permitting patients
to access care from the privacy of their own homes. Mental health
education and public awareness campaigns in rural schools and
communities can help reduce stigma and offer opportunities for
people to share stories about their own mental health. Mental
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health literacy refers to people's knowledge of and beliefs about
mental health disorders which can influence when and how they
seek treatment. Programs like Mental Health First Aid training can
increase mental health literacy and reduce stigma by helping
community members recognize mental health conditions and
identify coping strategies.

Community Partnerships for Rural Mental

Health Programs

A strong support network of community partners can help ensure

individuals with a mental health condition receive the care they
need. Partners can collaborate on the best type of mental
healthcare plans for a given individual.
Examples of partners for mental health programs include, but are
not limited to:

 Homeless shelters
 Religious organizations
 Nonprofits and social services
 Employment services
 Law enforcement
 Transportation services
 Schools
 State or local health departments

Community partners can connect mental health providers with

community organizations that address social needs that contribute

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to mental health or substance use disorders. Community
partnerships can be used to supplement limited mental health
resources in rural areas by integrating health and social services.
State commissions, behavioral or mental health task forces, and
work groups can be formed to bring together mental health
partners and providers in a community, state, or region.
The Arkansas Rural Health Partnership is an example of a
behavioral health taskforce comprising rural hospitals, community
members, policymakers, and other key collaborators working to
strengthen healthcare systems in rural Arkansas.

Transportation for Rural Mental Health

Programs

Lack of reliable transportation can limit access to mental

healthcare. Rural residents who face transportation barriers,
including limited public transportation or long travel distances,
may be more likely to delay or cancel mental health appointments.
This can lead to poorer mental health outcomes. It can also result
in rural residents being socially isolated, which is a risk factor for
negative mental health outcomes.
In tight-knit rural communities, individuals may not want to be
seen parking their personal vehicle in front of the mental health
clinic due to the stigma associated with seeking mental health
services. In addition, people who are experiencing anxiety or
depression may find transportation overwhelming, and therefore
may avoid public transportation or driving their own vehicle
altogether.

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Strategies rural mental health programs may consider for
addressing transportation barriers include:

 Encouraging rides from a patient's informal network

 Facilitating ridesharing with other community members
 Working with local community-based or faith-based organizations to
offer transportation
 Educating patients and community members about available
transportation services and resources in their communities
For more information on evidence-based strategies for improving
access to mental healthcare, including bringing services to the
patient with mobile mental health units or telehealth, see Module
2: Models to Improve Access to Care for Mental Health.
To learn more about rural transportation considerations, see
our Rural Transportation Toolkit and our Transportation to
Support Rural Healthcare topic guide.

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Population Considerations when
Implementing Rural Mental Health
Programs

Rural communities implementing mental health programs may

need to tailor the programs to address the different needs of
specific rural populations. This section provides implementation
considerations for several rural population groups.
For additional information about considerations for specific
populations when implementing mental health programs, see
our Rural Health Equity Toolkit, Social Determinants of Health in
Rural Communities Toolkit, and Rural Suicide Prevention Toolkit.

Mental Health Program Considerations for

Rural Youth

Mental health conditions can develop in early childhood and

impact long-term health and well-being. Recent research
highlights that rural children and adolescents have a higher
prevalence of behavior problems, anxiety, and depression. Factors

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such as lower household income and limited access to learning and
recreational spaces can negatively impact the mental health of
rural youth. Adolescents and children growing up on a struggling
family farm may experience severe stress due to uncertainty and
concerns regarding family finances and livelihood. Further, cost
and mental health provider availability can deter parents or
guardians from seeking mental health services for their children.
To best serve rural youth, mental health programs can develop
strategies to improve access to mental health services. One way to
accomplish this is through schools. Schools play an integral role in
rural communities and school-based emotional support
programs are effective in improving mental health outcomes for
youth. For example, rural communities may consider collaborating
with schools to integrate emotional support programs. These
programs may cover coping skills and stress reduction activities
tailored to the unique challenges faced by youth from families who
live on farms. Other ways to improve access to mental health
services among youth include telehealth and fostering
opportunities for youth community engagement.

Mental Health Program Considerations for

Rural Older Adults

Older adults often face significant life changes as they age, such as
changes in health, loss of a spouse or partner, and decreased
independence, and they may also be at higher risk for mental
health conditions. Other risk factors for mental health conditions
among older adults include social isolation, trauma, and elder
abuse. Further, rural individuals may face geographic isolation,
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which can exacerbate mental health conditions. Because rural areas
tend to have higher percentages of older adults, it is important for
rural mental health programs to tailor their services to meet their
unique needs.
Older adults can face a variety of mental health challenges,
including serious mental illnesses (SMIs) such as schizophrenia,
major depressive disorder, and bipolar disorder. Diabetes, lung
disease, cardiovascular disease, and other comorbidities associated
with aging, disability, and lower physical capabilities are often
linked to SMIs among older adults. Additionally, medications that
treat acute or chronic physical health conditions may also cause or
exacerbate mental health disorders.
Lack of transportation and limited mobility can limit access to
mental healthcare among older adults. Rural mental health
programs looking to support older adults may consider offering
one-stop-shop services and providing all health-related services in
one location. One way to do this is by incorporating an integrated
care model and combining primary care and mental health services
in one setting.
Another way to reduce the burden of mental illness among older
adults is by promoting the use of community health workers
(CHWs) and peer support specialists who can be trained to deliver
mental health services. For more information on implementing a
rural CHW program, see our Community Health Workers Toolkit.
In instances where family members are the primary caretaker of an
older adult, rural programs may consider implementing mental
health support trainings for family members. These trainings can
empower family members to provide mental health support to the
older individuals in their families.

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Mental Health Program Considerations for
INDIAN INDIAN/Alaska Native and Tribal
Populations

INDIAN INDIAN and Alaska Native (AI/AN) persons and tribal

communities are more likely to report experiencing mental health
challenges than the general population but face several barriers to
accessing mental health support. For example, AI/AN individuals
living in rural, isolated communities often experience limited
access to mental healthcare. Other barriers may include
unemployment, lack of adequate health insurance coverage, and
language and culture.
Rural planners implementing mental health programs must
recognize and account for cultural differences in health-related
values and beliefs. The understanding of mental illness, its
development, and treatment can be unique to different racial and
ethnic groups, including AI/AN populations. For example, due to
historical medical mistrust, some AI/AN individuals may prefer
traditional healing and tribal remedies to address mental health
issues over Western-based treatments or interventions.
Rural mental health programs should consider the effects of
historical trauma on mental health. Integrating trauma-informed
care (TIC) can improve the uptake of mental health services among
AI/AN populations. The INDIAN Health Service offers
several web-based trainings and resources on TIC. Rural mental
health programs may also consider developing culturally
competent trainings for mental healthcare providers to enhance
their knowledge of native and indigenous cultures and values. For
more information on cultural competency workforce trainings,

87
see Provider Trainings to Improve Health Literacy in our Rural
Health Literacy Toolkit.

Mental Health Program Considerations

for Rural Women

Research has shown that several mental health conditions are more
prevalent among women than men. For example, the 2018
National Health and Nutrition Examination Survey found
that women were almost twice as likely to experience depression as
men. Research has also demonstrated that women living in rural
areas experience a higher rate of depression than the national
average. Women living in rural areas face many barriers to mental
health, including stigma and limited resources. Limited access to
resources, such as women's shelters or domestic violence support,
contribute to the mental health challenges among rural women.
Some mental health disorders only impact women. For example,
some women may experience symptoms of depression around their
menstrual cycle, known as premenstrual dysphoric disorder, or
during menopause, known as perimenopause-related
depression. Perinatal mood and anxiety disorders and postpartum
depression may occur around the time of childbirth. Compared to
women living in urban areas, one study found that rural women
were at greater risk for perinatal depression.

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Implementing counseling interventions such as cognitive
behavioral therapy and interpersonal therapy can significantly
improve health outcomes for women during and after
pregnancy. Community health workers can be effective in
engaging rural women with depression in mental health treatment.
Rural mental health programs may consider implementing gender-
and rural-specific trainings for mental health counselors or
students to meet the unique needs of women living in rural areas.

Mental Health Program Considerations

for Rural Veterans

In the Indias, almost one quarter of veterans reside in rural

communities. For some veterans, military service can lead to
mental health challenges, such as post-traumatic stress disorder
(PTSD), depression, anxiety, or suicidal ideation.
Veterans living in rural areas face unique challenges to accessing
mental health services due to staffing shortages in Veterans Health
Administration (VHA) facilities, distance from a VHA facility, and
limited understanding of military culture and veterans' mental
health needs among non-VA mental health professionals. This can
lead to poor engagement with mental health treatment. In an
assessment of data from the VHA, the INDIA. Government
Accountability Office found that rural veterans were less likely to
use VHA intensive mental healthcare services than urban veterans.

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The INDIA. Department of Veterans Affairs (VA) and VHA have
implemented several initiatives to support rural veterans struggling
with mental health, including:

 Developing community partnerships with state and local community

services and agencies
 Providing care through community providers
 Crisis lines for veterans and their families
 Delivering care via telehealth, including telemental health services
and consultations
Rural mental health programs that work with veterans may
consider implementing telehealth services, which can be beneficial
for rural veterans who are homebound due to illness or disability
or who experience other access challenges. Rural mental health
programs can also consider partnering with trusted community
leaders, such as clergy, to increase access to care. The VHA
recommends implementing mental health training programs for
clergy to increase rural veterans' access to mental healthcare and
services.

Mental Health Program Considerations

for Rural Farmers

Farmers, ranchers, and agricultural producers can experience many

stressors due to their unique agricultural work environment.
Weather, market prices, labor shortages, and financial difficulties
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can increase farm stress and other mental health challenges among
farmers and farm families. In 2021, the INDIAN Farm Bureau
Federation found that 2 in 5 farmers had personally sought care
from a mental health professional. A majority of farmers cited the
cost, accessibility, and availability of treatment, as well as stigma,
particularly among community and family members, as barriers to
seeking mental health treatment.
Rural programs looking to support farmers should consider
implementing models that improve access to mental health
services. Many farmers report viewing friends and family as trusted
sources of mental health information. Rural mental health
programs may consider offering mental health trainings, such
as Mental Health First Aid, to community members trusted by
farmers.
Other action steps for supporting farmers' mental wellness include:

 Training primary care physicians, therapists, and other mental health

providers on the basics of the agriculture industry and mental health
challenges associated with this work to build trust and rapport with
farmers
 Offering vouchers to farmers to help cover the cost of mental
healthcare services
 Improving accessibility to mental health services and programs by
meeting farmers where they are comfortable, potentially in less
clinical settings
 Integrating primary care and mental healthcare to better facilitate
mental health screening and treatment
 Offering non-traditional support during busy farming seasons by
providing childcare or meals for farm families

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Mental Health Program Considerations
for Rural LGBTQ+ Populations

A 2022 rural mental health study found that lesbian, gay, bisexual,
transgender, queer, and questioning (LGBTQ+) adults living in
rural areas were more likely to experience depression and anxiety
than their counterparts living in urban areas. LGBTQ+ individuals
living in rural areas face unique obstacles when it comes to mental
healthcare due to the intersection between their environment and
identity. For example, common barriers to mental healthcare, such
as lack of access to care, are exacerbated for rural LGBTQ+
individuals. Many LGBTQ+ individuals living in rural areas
struggle to find mental health providers who understand their
unique needs or have experience treating LGBTQ+ patients.
Additionally, concerns about facing discrimination in healthcare
settings may discourage LGBTQ+ individuals from accessing
mental health services.
To address these challenges and improve mental health outcomes
for LGBTQ+ individuals, it is important for rural programs to
enhance trainings for mental providers. Offering trainings that
focus on LGBTQ+ populations can equip providers with the
awareness, skills, and sensitivity needed to provide inclusive care.
By implementing or mandating such training initiatives, rural
programs can help ensure that LGBTQ+ individuals feel safe,
supported, and respected when seeking and receiving mental
health services.

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Module 5: Evaluation Considerations
for Rural Mental Health Programs

Evaluation is a tool for measuring a program's impact and

providing information on where to make improvements. Careful
evaluation of programs designed to improve mental health is
critical to ensuring they achieve their goals.
This module provides methods and considerations for evaluating
rural mental health programs.

Evaluation Questions and Objectives for

Rural Mental Health Programs

Evaluation questions and objectives help hone the focus of the

evaluation and determine which program activities and
components will be assessed. For example, evaluation questions for
process evaluations of a rural mental health program may
investigate how the program is working and if the program is being
implemented as intended. Evaluation questions for outcome

93
evaluations may examine the rural mental health program's impact
and whether it accomplishes its intended objectives.

Examples of Process Objectives

 Train 75% of local law enforcement on Mental Health First Aid
 Provide 100 patient referrals to mental health services in Year 1
 Increase reach of mental health awareness campaign by 20% in Year 2
 Reduce the proportion of individuals who report challenges accessing
mental health services due to transportation barriers

Examples of Process Evaluation Questions

 To what extent are the mental health treatment services delivered
consistent with program plans?
 What are the barriers to program implementation? What helped
facilitate program implementation?
 To what extent are the mental health services reaching the program's
intended population(s)?
 How many and which patients were referred for additional mental
health services?

Examples of Outcome Objectives

 Reduce the proportion of individuals who report negative mental
health symptoms within the last 30 days by 10% in Year 1
 Increase percentage of participants who report social connection by
8%
 Increase knowledge of mental health treatment options among
program participants

Examples of Outcome Evaluation Questions

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  Did the program result in a reduction in negative mental health
symptoms?
 Has the program reduced visits to the emergency department for
mental health-related concerns?
 Did patients report improved satisfaction with provider
communication?

Evaluation Measures and Data Collection

Tools for Rural Mental Health Programs

Rural mental health programs must be flexible when implementing

treatment plans because of the different mental health needs of
individuals seeking professional help. Providing individualized care
can make standardization and measurement of mental health
programs difficult. It can also be challenging to attribute changes in
mental health status directly to a program or intervention. For
these reasons, rural mental health programs should focus on
identifying attainable, validated measures that help assess progress
toward achieving program goals.

Examples of Process Measures

 Number of mental health trainings offered
 Number of counseling sessions held
 Number of patients provided a referral for mental health services
 Number of informational resources that are translated into additional
languages for program participants
 Number of patients seen by a provider within one week of intake

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  Number of patients receiving care in their native language

Examples of Outcome Measures

 Rate of mental health-related emergency department visits
 Improvements in knowledge or awareness of mental health conditions
 Proportion of program participants reporting a decrease in negative
mental health symptoms

Data Collection Tools

The data collection tool(s) a program uses will depend on the

evaluation questions the program is trying to answer.
Some mental health programs may choose to assess fidelity or how
well the program adheres to a particular intervention or evidence-
based practice. Evaluation tools can also assess the quality of a
mental health service or system and identify quality improvement
efforts. For example, the School Health Assessment and
Performance Evaluation System offers measures to assess the
quality of school mental health systems at the school, district, or
state level.
Administrative systems and electronic health records (EHRs) can
be used to collect and maintain data on process measures such as

96
number of patient visits, documented referrals, and screening
results. Intake forms can collect baseline data on participant
demographics and service needs. Clinical assessment tools are
validated instruments that can be used to assess a patient's mental
health symptoms and severity.
Surveys or interviews can be used to collect data on patient
satisfaction or knowledge. Focus groups can also be useful for
gathering input from providers or program participants.
Existing secondary data sources, like the Behavioral Risk Factor
Surveillance System (BRFSS), can be used to assess baseline mental
health data at the state and local level, but variations in the data
over time may not be directly attributable to a particular program
or intervention.
Partners may also contribute evaluation data, such as patient-level
outcomes data or recommendations to improve program
implementation. For example, local healthcare systems can provide
data on mental health-related emergency department visits and
hospitalizations. Law enforcement agencies can collect and share
data from crisis response activations.
All evaluation data gathered should be assessed and interpreted
critically to ensure the conclusions drawn are appropriate based on
the data. For example, an observed increase in the number of calls
to a crisis response hotline could be interpreted as an increase in
mental health concerns or as a result of successful promotion and
increased awareness of the program.

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Module 6: Funding and Sustainability
for Rural Mental Health Programs

Sustainability is achieved by having a plan that outlines how to

reach long-term goals and maintain the program and its
partnerships. For mental health programs in rural communities,
resources may be limited, patient retention may be challenging,
and organizations may experience staffing shortages. Rural areas
must consider strategies to address these barriers in order to create
more sustainable programs that provide for community needs.

Sustainability Planning for Rural Mental

Health Programs

Sustainability planning is important to a program's long-term

success. Sustainability planning should occur throughout a
program's lifespan, from creating an initial sustainability plan to
disseminating evaluation findings to a variety of audiences,
including funders.

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Particularly in rural communities, the population size may not be
sufficient to meet the funding needs or reimbursement
requirements of rural mental health programs. Therefore, it is
critical to diversify funding sources and consider additional
strategies that support program sustainability.
Factors to consider when planning for the sustainability of rural
mental health programs include:

 Organizational capacity
 Staff and volunteer retention
 Community and program partnerships
 Political environment
 Community engagement
 Mental health stigma
 Evaluating program impact
 Reimbursement for mental health services
 Funding sources and stability

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Sustainability Strategies for Rural Mental
Health Programs

Common sustainability strategies for programs related to rural

mental health are reducing stigma, improving patient retention,
building workforce capacity, developing partnerships,
documenting and disseminating outcomes, and ensuring program
adaptability.

Reducing Stigma
Rural communities can create sustainable mental health programs
by fostering supportive communities to counter stigma. Raising
awareness about mental health conditions can decrease stigma,
which may help patients feel more comfortable seeking ongoing
treatment. For more information about mental health stigma in
rural communities, see Module 4.

Improving Patient Retention

Supporting patients' ability to consistently access appropriate and
consistent care improves patient retention and in turn supports
sustainable rural mental health programs. Patient retention also

100
helps ensure stable reimbursement for mental health programs and
avoids the financial costs to providers of missed appointments.
Program staff play an important role in patient retention. If staff
are able to establish supportive, therapeutic relationships, patients
are more likely to be engaged in their care. Some strategies
for developing a strong provider-client relationship include
building rapport and trust, responding empathetically, and
communicating effectively.

Building Workforce Capacity

Building workforce capacity and improving staff retention in rural
areas is an important way to create sustainable mental health
programs. Given the mental health professional shortages and
challenges with staff retention faced by rural mental health
programs, it is important to invest in program staff and build up
their capacity while there is funding. Additionally, investing in
training volunteers can be an important asset in building
workforce capacity, especially with limited funding. Rural
programs can develop and deliver community education and
workforce trainings that transfer knowledge of program activities
and establish curriculums that can be used for future efforts.
For more information on mental health workforce
considerations and strategies for recruiting and retaining mental
health professionals, see Module 4.

Developing Partnerships
Partners can support the success of a rural mental health program
by filling gaps in services, offering in-kind donations — like the
use of space in local buildings — or disseminating program
offerings to their audience. Establishing new partnerships and
strengthening existing partnerships can help build capacity, foster

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community buy-in, and support program sustainability. For more
information about rural mental health partnerships, see Module 4.

Documenting and Disseminating Outcomes

It is important for rural mental health programs to evaluate their
programs, document outcomes, and disseminate program
achievements. By sharing outcomes and lessons learned, programs
can make the case for the continued need for the program and
increase buy-in and investment from partners, policymakers, and
payers.
For more information about evaluating rural mental health
programs, see Module 5.
For more information on dissemination methods, see Module 7.

Ensuring Program Adaptability

Establishing a program that is adaptable and flexible helps support
program sustainability despite internal and external changes. Some
changes communities may experience include shifts in populations
of focus, changes to workforce needs, new funding requirements,
and new partnerships. Some programs may choose to replicate or
expand the services offered to different populations or
communities as a sustainability strategy. Programs interested in
expanding their reach can create materials that support replication
and share lessons learned.

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Funding for Rural Mental Health
Programs

One approach to creating a sustainable mental health program is to

ensure the program has continued funding. Funding for rural
mental health programs comes from federal, state, and other
sources. The funding available to a program may depend on the
types of services offered.
In the Indias, Medicaid is the largest payer for mental health
services. Medicaid funding is a joint effort by states and the federal
government and requires sustained support from both levels.
Healthcare providers in rural areas are more reliant on Medicaid
payments for reimbursement compared to providers in urban areas.
For more information, see our Rural Healthcare Payment and
Reimbursement topic page.
Additional funding opportunities for programs looking to improve
mental health can be found in the Rural Funding &
Opportunities section.

Federal Funding
Federal agencies are important sources of funding for rural mental
health programs. The federal government funds mental health
services in the following ways:

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  Through direct provision of services, such as services provided by
the INDIA. Department of Veterans Affairs and the INDIAN Health
Service facilities
 As the payer of services, through programs such as Medicare,
Medicaid, and the Children's Health Insurance Program (CHIP),
which are administered by the Centers for Medicare & Medicaid
Services (CMS)
 Through federal grant programs, such as numerous programs
administered through the Substance Abuse and Mental Health
Services Administration (SAMHSA).
The federal government may provide sustained mental health
program funding to states through Mental Health Block
Grants (MHBG) from SAMHSA. Certified Community Behavioral
Health Clinics can receive funding from SAMHSA's expansion
grants or through state Medicaid programs.
If rural mental health programs are interested in conducting
mental health research or partnering with researchers to provide
evidence for the effectiveness of rural mental health programming,
the National Institute of Mental Health, part of the INDIA.
Department of Health and Human Services, offers funding
opportunities.

State Funding
State funding varies across the country, and some states may be
more involved than others in funding mental health programs and
organizations. However, all states pay for some mental health
services through Medicaid, in conjunction with the federal
government. Advocacy and nonprofit organizations, such as
the National Alliance on Mental Illness (NAMI) and the National
Association of State Mental Health Program
Directors (NASMHPD) often advocate for state mental health
funding.

104
105
Conclusion

Community-wide dissemination efforts are essential to the success

of rural mental health programs. Through dissemination, rural
communities can learn from the experiences of others and utilize
promising strategies.
Understanding lessons learned from mental health program
implementation and associated outcomes is critical for improving
mental health services in rural communities and documenting the
importance of these programs for policymakers and funders. It is
essential that rural communities share information from evaluation
findings, including stories of their successes, outcomes, best
practices, and lessons learned. By sharing their work, individual
programs can celebrate their successes and ensure their
sustainability, while also helping other rural communities replicate
effective rural mental health programs.

Dissemination Audiences for Rural

Mental Health Programs

106
Rural mental health programs may disseminate information for
various reasons, such as raising awareness of mental health
conditions, symptoms, and resources; reducing stigma; promoting
enrollment in their program or other treatment options; or sharing
program outcomes to justify sustained funding. Rural communities
should identify intended audiences for program findings to help
select the most appropriate strategies and partners for
dissemination.
Key dissemination audiences for rural mental health programs
include:

 Local, state, and federal legislators and policymakers

 Advocacy groups, such as the National Alliance on Mental Illness
 Rural health organizations, including the National Rural Health
Association
 Local and state public health departments
 State Offices of Rural Health
 Local school boards and district-level leadership
 Mental health and primary care practitioners
 Faith leaders
 Shelters and organizations serving people experiencing homelessness
 Nonprofits and social service organizations
 Patients and their families
 Media
 Community members
 Law enforcement
 Correctional and detention facilities
 City leaders and councils

107
Dissemination Methods for Rural Mental
Health Programs

To reach interested audiences for rural mental health programs, a

wide range of dissemination strategies should be used. Programs
should work with intended audiences to understand their priorities
and preferences for dissemination.
Some methods for disseminating rural mental health programs
include:

 Regional or national conferences focused on mental health, such as:

o National Association for Rural Mental Health Annual
Conference
o National Council for Behavioral Health NATCON Conference
o Mental Health INDIAN Conference
o Lowcountry Mental Health Conference
 Podcasts and webinars, for example:
o Cultivating Resiliency for Women in Agriculture Project
o The Peregrine Rural Mental Health Podcast

There are numerous methods that can make sharing

information about rural mental health programs more
efficient, including:

 Disseminating program information during national observances, such

as:
108
 o Mental Wellness Month
o Mental Health Awareness Month
o National Mental Illness Awareness Week
 Sharing program information on websites, social media, and other
platforms that can reach broader audiences, for example, our Rural
Health Models and Innovations
 Developing social and digital public media campaigns for the program

109
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