We suggest that integration of services into the primary care setting encourages interaction between professionals and enhances confidentiality and access for patients. We have little doubt that it will reduce nonproductive medical care utilization and eliminate duplication of effort by physicians and mental health professionals. We believe that social workers are especially suited to provide these psychosocial services because of their similar professional orientation to primary care’s emphasis on continuity of care and comprehensive health/mental health care. Although other health/mental health professionals are unquestionably qualified to provide psychosocial services, it is no small advantage that social workers also cost less than psychiatrists or psychologists and are already extensively located in rural areas.48 Social work has devoted considerable attention to training practitioners for rural mental health practice since the 1970s and currently plays a greater role in rural mental health hospital practice than any other mental health discipline.49
A proposed model
We propose a collaborative care model for integrating psychosocial services into rural primary care that has 3 essential features: (1) full on-site collaboration between physician and psychosocial care provider; (2) a psychosocial orientation to mental health assessment and treatment; and (3) a case-management model for psychosocial service delivery. These 3 components ensure that mental health services can be shaped to match the ecological context of rural primary care, patient preference for on-site treatment, physician time constraints, frequent negative rural attitudes toward psychiatric referral, concerns about privacy, symptom presentation focused on problems of living, and sparse community resources.
Full On-Site Collaboration
Successful integration of psychosocial services into primary care will require that the physician and psychosocial care provider establish a collaborative working partnership. Each physician/psychosocial care provider team will inevitably create its own style of partnership, according to the personality attributes of each professional and the particular structure and culture of the practice setting. This entails clearly defining (and redefining as the collaboration matures) treatment roles and areas of expertise while developing a unified team approach requiring open communication and coordination of treatment. For instance, some physicians will prefer to determine which of their patients are suitable for psychosocial treatment, while others may augment identification with mental health screening tools or provide for patient self-referral. We envision that the physician and the psychosocial care provider will need to consult each other during office hours. Spontaneous consultation can only occur, however, when both professionals work together on-site and are afforded the opportunity to develop the kind of complementary partnership that emerges naturally through close daily contact. Full collaboration between the psychosocial care provider and the physician also requires some investment of time in reviewing treatment together. The physician and the psychosocial care provider, therefore, would be expected to schedule regular meetings, and hold additional meetings as required, to discuss those patients whose cases are the most difficult. We recommend, in addition, that the psychosocial care provider write brief notes in patients’ medical records, compatible with the format used in the practice and sensitive to its setting. To assure patient confidentiality, more extensive progress notes could be filed separately and made available only to the physician and the psychosocial care provider.
Psychosocial Orientation
The mental health professional who collaborates with the rural primary care physician must be proficient both in diagnosing mental disorders and in psychosocial assessment and intervention. This specialist’s training must therefore include not only the standard classification of mental disorders, but also the more broadly defined psychosocial and ecological assessments that would identify those patients with major depression, for example, and also those patients whose subthreshold problems have psychosocial origins. A psychosocial orientation to mental health needs is essential to effectively treat rural primary care patients who typically present with multiple somatic complaints and problems in living. It best matches the patient’s own frame of reference and perception of need—more than half the battle in engaging rural patients in mental health treatment.31 The psychosocial orientation, in general, is less stigmatizing and more comprehensive in scope than specialized psychiatric care.
Case Management Model of Service Delivery
Case management—the “cornerstone in the delivery of contemporary human services”50 and “the dominant mode for serving the most vulnerable populations”51 —is an unusually flexible and successful model of service delivery, particularly where services are scarce and poorly integrated within a community.51-54 Case management provides for continuous boundary-spanning activities that create a better goodness of fit between people and their social environments. Problem-solving activities are pursued by both the patient and the psychosocial care provider outside their sessions, and may involve advocacy efforts to acquire public benefits, such as supplemental security income; Medicare and Medicaid; Women, Infants, and Children (WIC) supplements; or food stamps. Within this model of treatment, the psychosocial care provider can offer patients brief and effective psychological counseling, such as problem-solving treatment,9,55 as well as psychoeducational intervention, family treatment, and crisis intervention. For treatment of rural patients with depression, in particular, we recommend pairing psychosocial case management with brief models of problem-solving and task-oriented interventions empirically proven effective.9,55-57 This treatment model provides multiple arenas for psychosocial intervention—with the individual, the family, and the community—based on the patient’s self-identified needs, and combines psychological counseling with the acquisition of social supports that many rural residents lack.