Literature Collection

PURPOSE: Rural communities often have a high incidence of medical and behavioral health problems along with more limited access to care. This paper describes an innovative approach to providing integrated care in rural school-based health clinics in which graduate students serve as behavioral health interns. The purpose of this manuscript is 1) to describe a model for providing school-based integrated health services in a rural community and 2) to evaluate services provided by graduate interns embedded in school-based clinics. MATERIALS AND METHODS: Graduate interns completed a session checklist to track services provided in each session and collected data from participating students who received behavioral health services. Students completed the Outcome Rating Scale (ORS) after each session. Repeated measures MANOVAs were used to analyze the data for changes over time. RESULTS: Services provided most often by interns included assessment, engagement, positive reinforcement, coping skills, goal setting, and clinical intervention. The data suggest that students receiving at least three sessions improved over time on self-reported wellbeing. DISCUSSION: The results demonstrate the feasibility of providing integrated health care via school-based clinics that rely on graduate internships for behavioral health services. Challenges to implementing and sustaining school-based integrated health clinics are discussed. CONCLUSION: The ongoing challenges to meeting the medical and behavioral health needs of rural communities call for innovative approaches to providing integrated care. The clinics described here responded to these challenges through teamwork and strong university-community partnerships.

BACKGROUND: Contingency management (CM) is an effective yet underutilized behavioral intervention that uses rewards to improve outcomes in medication for opioid use disorder (MOUD) treatment. Prior implementation attempts have focused on specialized addiction clinics, using intensive daily treatment with methadone and high reward values (e.g. >$200 total). However, many people get MOUD from less specialized, more accessible, family medicine clinics. These clinics could also benefit from CM, yet present unique challenges for CM. Family medicine clinics typically use buprenorphine as their primary medication, which requires less intensive dosing schedules and thus provides fewer CM opportunities. They may also have lower institutional willingness to use high-value rewards. As an initial step in user-centered design of a low value reward (<$75 total) CM program for the family medicine context, we conducted qualitative interviews with patients and staff in the buprenorphine treatment program of a family medicine department. We gathered and analyzed qualitative data on CM knowledge, preferred program parameters, and implementation considerations. METHOD: Participants (N = 24) were buprenorphine treatment staff (n = 12) and patients (n = 12). Participants completed 30-50-minute semi-structured interviews, analyzed using rapid matrix analysis. RESULTS: Participants had little experience with CM, but generally viewed CM as acceptable, appropriate, and feasible. Interviewees coalesced around having staff who were not providers with prescription privileges conduct CM, consistent rather than escalating payments, and physical rewards delivered in-person. Potential challenges included medical record integration, demands on staff time, and confirmation of patients' goal completion. CONCLUSIONS: Patient and staff feedback was well-aligned, especially regarding rewards as an opportunity for staff-patient connection and the need for simplicity. Some consensus suggestions (e.g. non-escalating rewards) conflict with extant CM literature. Implications for implementation of CM in this setting are presented. These findings inform user-centered design and iteration of a CM program for this accessible, non-specialized family medicine setting.