Opportunities and Challenges for Implementing Integrated Care Services in Primary Care: A Mixed Methods Study in Medically Underserved Communities of New Jersey

Background. People living in medically underserved communities (MUCs) face pronounced behavioral health burdens (e.g., substance use, mental health, physical health) and health care provider shortages. One way to address these issues is through delivery of behavioral health in primary care settings, or integrated care (IC). Limited research examines the implementation of IC programs in MUCs, with a scarcity of studies in New Jersey, a state with a high behavioral health burden. This mixed methods study, involving participants from three federally funded IC programs, integrating substance use and behavioral health services at 16 health centers serving MUCs in NJ, aims to: (1) identify challenges and opportunities in IC delivery; (2) compare IC program experiences of site leaders and trainees; and (3) describe practice and policy recommendations to improve, sustain, and expand the value of IC. Methods. Mixed methods data were collected and analyzed from participants (N=85) across four sources: quantitative (1) site leader (n=24) and (2) trainee (n=19) surveys using established measures; qualitative (3) site leader focus groups (n=33; 7 groups); (4) trainee in-depth interviews (n=9). Quantitative data were analyzed [Python 3.10.13] for descriptive statistics and site leader/trainee group differences (Cohen’s d effect sizes; small=0.20; medium=0.50; large=0.80). Qualitative data were analyzed [NVivo v.14] for emerging themes using cross-case thematic analysis. Mixed methods data were interpreted using triangulation. Findings. Survey data from site leaders revealed a medium/high level of IC readiness (Organization subscale item mean=2.75; Services subscale item mean=3.09; 4-point Likert). Trainee surveys indicated they ‘sometimes’ engaged in Essential IC activities (item mean=3.06; 5-point Likert) and ‘rarely’ engaged in Prohibited IC activities (item mean=2.27; 5-point Likert). Trainees demonstrated greater scores (than site leaders) (d>0.20) for most items regarding substance use stigma (5 of 7), negative opioid use disorder (OUD) attitudes/beliefs (6 of 9), and lower perceived effectiveness of medication treatment of OUD (2 of 3). Site leaders scored higher (d>0.20) on supportive attitudes about buprenorphine implementation (18 of 21) and concerns about infrastructure barriers for substance use service delivery (7 of 12). Qualitative findings revealed varying stages of IC readiness. Key themes for opportunities included service accessibility, warm handoffs, and interdepartmental teamwork. Sites with limited IC capacity relied on external referrals. Perceived challenges across sites included unclear expectations, limited resources, inflexible models, staffing, and inadequate supervision. Trainees prioritized interdisciplinary collaboration, team inclusion, and service accessibility, whereas site leaders emphasized the importance of clinician experience to alleviate the existing workload. Mixed methods triangulation highlighted that staffing and service barriers cut across methods and that site leaders and trainees have overlapping but unique perspectives. Conclusions. This study presents a novel regional analysis from three large-scale federally funded IC programs involving a wide-ranging group of clinical sites serving patients in NJ MUCs. Our findings suggest a need to tailor approaches to improve organizational readiness, expand support for resources and specialized training, and strengthen collaboration between trainees and site leaders. We recommend federal and state health departments, clinical directors, and academic researchers consider our findings to contribute to the development, sustainability, and expansion of IC programs.