The Multi-Systems Impact of Barriers to Behavioral Health Services in Rural Communities

Background: Multiple studies have identified barriers to behavioral health services in rural communities, but few have explored the multi-system impact of these barriers in rural, resource-poor settings. The Rural Initiative, a federal health policy designed to expand access to behavioral health services in rural communities, suggests telemedicine, enhanced medical staff training, and a single-service-system entry point as strategies for rural communities to address behavioral health needs. While these strategies may increase screening and referral, they are insufficient to mitigate barriers to behavioral health treatment in rural communities. The aim of this research is to explore how barriers to behavioral health services impact service systems in rural communities.

Methods: Focus groups were conducted with key stakeholders, including community medical partners, staff, interns, and clients at county behavioral health service providers in three rural communities in a southeastern state. Qualitative content analysis was conducted on focus group transcripts. Interpretation of transcripts was driven by themes that emerged from the data. These themes were compared across cases and describe how barriers to behavioral health services impact multiple service systems in rural communities.

Results: Overall, stakeholders and clients expressed a need for a holistic approach to service provision in rural areas. Clients shared that basic needs such as food, daycare, housing, and medical care take precedence over behavioral health treatment and medication self-management. Given the lack of public transportation in rural areas, clients indicated case management services that assist with obtaining basic needs, as a treatment component would increase likelihood of treatment attendance. Second, an absence of technology infrastructure and antiquated software and hardware act as a barrier to interagency communication, leading to the duplication of services and paperwork redundancy that may deter clients from engaging in services and decrease practitioner availability for clients. Third, all groups indicated that despite high need; there are limited choice and availability of behavioral health services. In particular, intensive inpatient services for individuals without insurance are plagued by extensive waiting lists lasting up to a year. Inadequate workforce development and recruitment incentives for behavioral health professionals to practice in rural areas may result in staff shortages that limit availability of services. This can force local and/or geographically adjacent services systems to compensate for the burden created by unmet need.  Finally, limited service availability and access to basic needs may result in high utilization of emergency services. Individuals suffering from substance abuse, mental health issues, or both, frequently create high-cost, high-need, super-utilizers of emergency services who consume a disproportionate amount of community resources. 

Conclusions & Implications: Findings suggest that an important consideration for behavioral health social workers implementing interventions in rural communities is the development of community infrastructure that improves agency resources and supports participation in services. This includes the development of technology infrastructure and integrated treatment options that provide wrap-around, co-located services to vulnerable rural clients. This approach might ensure progression through the continuum-of-care, increase treatment retention and engagement, and decrease non-therapeutic service demands on area service systems including hospitals, jails, and emergency medical services.