A public health approach to the challenges of rural mental health service integration.

Abstract

Discussions of the delivery of mental health care in rural areas tend to focus on system-level issues, including parity, historic barriers between physical and mental health systems, the growing role of managed care, the traditional separation of funding streams, and the shortage of qualified mental health providers willing to practice in rural areas. Although these public policy issues deserve attention, they are not particularly amenable to local solutions. In these system-level discussions, the needs of rural consumers and providers are often overlooked, and attention is diverted from the development of local-level solutions to the problems of rural mental health delivery systems.In this chapter, we suggest an alternative perspective, that of the public health model, to inform the discussion of delivering mental health services in rural areas. Within the context of the public health model, we take a broad view of mental health services that includes both a mental health orientation and a mental illness orientation. We describe the de facto rural mental health system, discuss the populations served by the existing systems and their service needs, identify access issues and barriers for these populations, and provide a series of tools with which stakeholders can begin to analyze their local delivery system. By doing so, stakeholders will develop a context for understanding how the various components of the system fit together. These tools will enable stakeholders to identify the multiple points of access within their community, to categorize those access points according to a logical framework, and to identify the clinical roles and functions of the various providers, agencies, and organizations that constitute their local mental health system. Within this context, we suggest opportunities to improve and integrate existing components of local mental health delivery systems in rural areas to better meet the needs of the people served by them. Elements of the Public Health ApproachPublic health focuses on the diagnosis, treatment, and etiology of disease; epidemiological surveillance of the health of the population at large; health pro-

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