Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2025 Feb 1.
Published in final edited form as: J Integr Care (Brighton). 2023 Sep 22;32(1):31–44. doi: 10.1108/jica-08-2023-0061

Client perspectives on primary care integration in a rural-serving behavioral health center

Jeffersson Santos 1, Amanda Acevedo-Morales 2, Lillian Jones 3, Tara Bautista 4, Carolyn Camplain 5, Chesleigh N Keene 6, Julie Baldwin 7
PMCID: PMC10954248  NIHMSID: NIHMS1951332  PMID: 38516678

Abstract

Purpose:

Advancing behavioral health and primary care integration is a priority for helping clients overcome the complex health challenges impacting healthcare deserts like those in Arizona, United States of America (USA). This study aimed to explore the perspectives of people with a substance use disorder (SUD) on accessing integrated primary care (IPC) services in a rural-serving behavioral healthcare organization in Arizona.

Design/methodology/approach:

Clients from a behavioral health facility in Arizona (n = 10) diagnosed with SUDs who also accessed IPC participated in a 45-min semi-structured interview.

Findings:

The authors identified six overarching themes: (1) importance of IPC for clients being treated for SUDs, (2) client low level of awareness of IPC availability at the facility, (3) strategies to increase awareness of IPC availability at the behavioral health facility, (4) cultural practices providers should consider in care integration, (5) attitudes and perceptions about the experience of accessing IPC and (6) challenges to attending IPC appointments. The authors also identified subthemes for most of the main themes.

Originality/value:

This is the first study in rural Arizona to identify valuable insights into the experiences of people with SUDs accessing IPC, providing a foundation for future research in the region on care integration.

Keywords: healthcare delivery, primary care, mental health services, interdisciplinary health teams, addiction integrative care

1. Introduction

People diagnosed with substance use disorders (SUDs) experience a high risk for adverse physical health conditions linked to their substance use, such as hypertension and diabetes (Firth et al., 2019). Despite this elevated risk, people with SUDs may encounter multiple barriers to care, including limited transportation and lack of social support (Matsuzaki et al., 2018). People with SUDs, especially those from culturally diverse backgrounds, seeking medical care may also encounter discrimination, stigma and physical abuse via medical mistreatment (Meyerson et al., 2021). The complexities associated with substance use and limited healthcare access can contribute to increased mortality in individuals with SUDs, highlighting the need for integrated healthcare models addressing both physical health and SUD treatment (Lagisetty et al., 2017).

Integrated primary care (IPC) involves implementing primary care services such as routine check-ups, preventive measures and basic medical treatments within behavioral healthcare centers. In the IPC model, primary care and behavioral health providers collaborate to develop individualized care plans that meet clients’ mental and physical health needs (Maragakis et al., 2016). IPC primarily benefits clients already using behavioral health facilities and is associated with enhanced client satisfaction, improved physical health outcomes and adherence to substance use treatment (Dillard et al., 2010; Errichetti et al., 2020; Hwong et al., 2022; Katon et al., 2010; Mangurian et al., 2022). Despite the benefits associated with IPC, it is not widespread in the United States of America (USA), as only 26% of mental health care facilities currently offer IPC (Brown, 2019; SAMHSA, 2020). Because IPC is still a developing model of care in the USA, there is limited data on variation on urban-rural availability in the country (Brown, 2019). The most recent data regarding the availability of healthcare services in the USA indicates that rural regions experience greater unavailability of both behavioral health and primary care services compared to urban regions (Dobis and Todd, 2022).

Advancing IPC services is an urgent need in underserved USA states such as Arizona. While approximately 14% of USA citizens live in rural counties, 25% of Arizona citizens live in rural counties. Moreover, 40% of those individuals in rural Arizona live in federally designated health professional shortage areas, primarily lacking mental health and primary care providers (Arizona Department of Health Services, 2023). Arizona is also experiencing a substance use epidemic, primarily involving alcohol and opioids (Sanderson et al., 2017). Age-adjusted mortality rates due to chronic conditions related to SUDs, such as chronic liver disease, are also higher in rural Arizona when compared to national averages (Sanderson et al., 2017). Furthermore, multiple Arizona counties bear the highest proportions of residents living in poverty which contributes to the homelessness crisis across the state (Coconino County Health and Human Services, 2021). These compounding factors exacerbate the health crisis in Arizona, underscoring the potential benefits of advancing IPC in this state.

The Social Determinants of Health (SDH) framework acknowledges that non-medical factors can impact health outcomes (World Health Organization [WHO], 2023). SDHs can be classified into five main domains: economic stability, education access and quality, healthcare quality and access, neighborhood and built environment and social and community context (Healthy People 2030, 2023). The healthcare quality and access domain, particularly, highlights the people’s health can be influenced by having available healthcare services that provide high-quality, culturally-centered care within their communities (WHO, 2019). Within this context, IPC has the potential to address barriers to care and improve care quality for people with SUDs. Consequently, IPC can serve as a valuable tool to address the challenges associated with healthcare quality and access in rural Arizona. The SDHs within the healthcare access and quality domain identified in this study offered insight into opportunities to improve service utilization and advance care integration for a behavioral health facility offering IPC services in rural Arizona.

The limited availability of IPC services in the USA has resulted in a scarcity of research on such a model of care delivery in both research and real-world settings (Brown, 2019; McGinty et al., 2021; Ward and Druss, 2017). Understanding client perspectives is an important way to improve IPC services and ensure their needs are met (Gerolamo et al., 2016; Talley et al., 2019). However, little is known about the perspectives of clients on challenges and incentives to accessing IPC in underserved USA regions. Furthermore, it is also important to explore the social determinants of health associated with utilization of IPC services among underserved populations and what culturally-centered practices are needed to better serve them (Holden et al., 2014). Thus, this study aimed to understand the perspectives of people with SUDs accessing IPC services implemented in a community behavioral health care facility in Arizona.

2. Methods

2.1. Study setting

The study was conducted within a rural-serving community behavioral health center in Arizona. The state-licensed IPC services have been primarily offered by one primary care nurse practitioner (PCNP) since June 2021. The PCNP collaborates with the facility’s behavioral health providers to develop individualized care plans for clients. Offered IPC services include health assessments, physical examinations, referrals to specialized care, medication prescriptions and health education. IPC services are provided on weekdays during normal business hours. The facility has also attempted to recruit additional primary care providers but is encountering challenges due to the shortage of providers in rural Arizona.

2.2. Study design

This qualitative, community-based participatory study consisted of semi-structured interviews to explore the experiences of residential SUD treatment program clients accessing IPC. The study was designed in collaboration with the community health partner regarding their priorities. The community health partner identified IPC services as their target service for evaluation, with a goal of identifying how to improve service utilization and how best to integrate addiction treatment services with IPC services.

2.3. Study participants and data collection

We used purposive, non-randomized sampling to recruit participants for the study. Potential participants were recruited through fliers and researchers enrolled clients in person at the center. To be included in the study, clients had to (1) be 18 years of age or older, (2) experience an SUD and (3) be a SUD treatment client at the time of recruitment. Ten clients enrolled in the study. The research team conducted individual interviews with clients in person at the residential SUD treatment facility in a private office to safeguard privacy, confidentiality and safety. Participants received a $30 physical gift card as compensation. The interview guide is in box 1. The interviews were conducted until a thematic saturation was reached and informants no longer reported new information. This study was approved by the University’s Institutional Review Board. We obtained informed written consent from all study participants.

Box 1.

  1. Do you think receiving primary care is important for people with addiction? If yes, please explain why.

  2. Before being admitted to this facility, have you ever heard that you could get primary care at this facility? If yes, how did you learn about this service?

  3. In your opinion, what things could be done to improve or create awareness about the possibility of getting primary care at this facility?

  4. In your opinion, what cultural practices should providers consider in primary and addiction care integration?

  5. Tell me about your experience being seen by the primary care provider at this facility, how did this care/service make you feel?

  6. What challenges would you face in attending primary care appointments at this facility if you were not currently staying at this facility (e.g. coming from home, homeless shelter)?

Given that our community health partner is one of the few behavioral healthcare facilities in Arizona offering IPC and our small close-knit community, we have opted to protect participant confidentiality by not offering demographic data. However, we presented aggregated data to describe all clients (n = 578) who accessed IPC from June 2021 to March 2023, which encompassed age, race, housing situation (homeless vs no homeless), employment and type of health insurance (public vs private). This is the population from which our sample was recruited.

2.4. Analysis

The data were analyzed using applied thematic analysis techniques. The interviews were audio recorded and transcribed verbatim using Trint Software (trint.com 2022) and manually analyzed for themes and codes. The first three authors (JS, AA and LJ) reviewed interview transcripts and individually coded responses in line with the qualitative interview questions. The group met to review initial codes, reviewed content and codes when consensus was not achieved and collaborated to achieve the final coding schema using content analysis. Consensus decision-making was utilized to solve any differences in coding. Authors JB and CK mentored the research project, facilitated consensus on quotes not coded similarly by the first three authors and reviewed and approved the final coding themes. The themes we gathered represented determinants of health within the healthcare access and quality SDH domain. Data collection, transcription and analysis persisted until no novel or pertinent themes or concerns emerged.

3. Findings

The mean age of clients who accessed IPC was 44.5 (range = 14–89). The majority of clients were male (56.68%). Regarding the racial profile, most clients were white (76.75%), followed by Native Americans (16.26%) and other races (6.99%). Most clients were housed (88.40%), unemployed (75.46%) and had publicly funded health insurance (54.59%).

Six overarching themes emerged from the interviews: (1) the importance of IPC for clients receiving treatment for SUDs, (2) lack of awareness of IPC availability at the facility, (3) strategies to increase awareness of IPC availability at the facility, (4) cultural practice considerations in care integration for providers, (5) attitudes and perceptions about the experience accessing IPC and (6) challenges to attending IPC appointments.

3.1. Importance of providing access to IPC for clients receiving treatment for SUDs

3.1.1. Improved access to preventive care

Participants overwhelmingly identified IPC as a critical way to improve access to preventive physical health care. They discussed that people with SUDs often experience physical health conditions, making IPC essential for them to have access to regular physical health check-ups. The improved access to preventive care and regular check-ups enabled the diagnosis of physical health conditions associated with substance use.

“Without regular checkups and being told of what is going on with your body based on addiction, it could go one of two ways without education. One, you can keep using because you don’t know what is going on with yourself and you could further damage your body. But … by letting the patient know [about the physical health consequences associated with drug use], they could make better informed decisions. If I didn’t have anyone, you know, telling me, then I wouldn’t even worry one bit about my body. I would just continue to use and deteriorate myself further.”

“When I came here, I didn’t know my liver enzymes were really high or you know what I mean? Like, really, my liver was sick.”

Participants highlighted that clients in substance use treatment often neglect their self-care, including basic hygiene practices. They emphasized the importance of having access to IPC as it can facilitate the development of healthier habits and encourage individuals to prioritize their overall well-being.

“I think sometimes people who experience addiction don’t take care of themselves. I think self-care and even hygiene … so I think having primary care helps to get to that better habit of taking care of ourselves.”

The convenience associated with having behavioral health and IPC at the same location was also described as a factor that can facilitate access to preventive care and management of chronic physical health conditions.

“I live probably 5 minutes away from [the behavioral health care facility], so it’s very convenient. I was going to [another healthcare facility] for my non psych medicines … I have hypertension, so anything like that, like blood pressure medicine. Now I would be able to do all that at [the behavioral health care facility] with the psych medicine and blood pressure medicine or anything else other than psych medication.”

3.1.2. Facilitates adherence to SUD treatment

Participants reported that the care integration and the convenience associated with it was helpful in promoting adherence to SUD treatment.

“It’s important to be a part of integrated services just because they keep documentation that helps support my sobriety and keeps me up to health. And, you know, the services implemented actually really help.”

“I think it [IPC] just makes it a little bit easier for the client to just stay on medication. Sometimes it’s inconvenient [to access mental health and primary care in different healthcare facilities], especially with work and everything. It [IPC] makes it a little easier.”

3.2. Lack of awareness of IPC availability at the facility

Not being aware of the IPC services was often addressed by the community members. Most participants pointed out that they never heard of the behavioral health facility that offered IPC services.

“I knew this place existed, but I didn’t know the extent of the services until I, you know, did a search.”

3.3. Strategies to increase awareness of IPC availability at the facility

3.3.1. Increasing advertisement efforts

Increasing advertisement on social media and more traditional types of media, such as TV and radio, were often discussed as a strategy to improve client awareness of the IPC services.

“I think they need to expand their marketing department and post more informative news on social media, because social media is one definite way to reach everyone because everyone uses it.”

“Just maybe more billboards for more advertisements or maybe even like a little spot on the TV or radio station I think would help improve it that way. It’s always out there instead of just like a little pamphlet on a pin board.”

There is also a need to increase advertising efforts across the facility campuses. Many clients accessing smaller campuses may not be aware of the services available at the main campus due to a lack of advertisement. Expanding awareness through effective marketing strategies could help bridge this gap and ensure individuals are well-informed about the services provided.

“We have a [site] in [city B] too, which is connected here [city A]. If we knew about health care here [city A], we could probably get more people into the [IPC provider] more when they come do their medicine stuff. You know, they can do it all in one [site]or something … We go through there [site in city B] to come here [site in city A] for medicine and while we do meds, we can do appointments.”

3.3.2. Collaboration with court systems

Participants emphasized the necessity of enhancing collaboration between the behavioral health center and court systems to ensure that professionals within the court system can effectively inform clients about the available services at the center. Additionally, the participants discussed that clients referred to the facility through the court system often arrive without prior knowledge of the services they will be accessing.

“Lawyers and probation officers should have the information to share with some other clients, because a lot of people, a lot of drug addicts … Most people think of this place as just the plain rehab until they get here and know that there’s a lot more care.”

3.4. Cultural practices providers should consider in care integration

3.4.1. Being mindful and aware of cultural practices and beliefs

Participants discussed the need for providers to be mindful of the diverse cultural beliefs among clients accessing IPC at this behavioral health center.

“It’d be good if the doctors here knew people’s cultures and beliefs … The more knowledge the doctors know, I think the better.”

“Providers should consider things like the holiday season or birthdays and be mindful of the wording that they use.”

3.4.2. Religious beliefs

Keeping open and mindful discussions with clients about their religious beliefs was discussed as an important cultural practice that IPC providers need to consider. Participants highlighted that beliefs held by clients can sometimes conflict with certain aspects of healthcare, and it is important to be mindful of these contradictions as they can potentially hinder the provision of necessary healthcare services.

“Somebody may have a religious belief that may contradict some kind of health care … just being mindful that some of the other practices could contradict that person’s beliefs so interferes with health care.”

“I think that if the primary care provider discussed it with somebody who was knowledgeable and they came to an agreement, then I think that they can meet some middle ground to satisfy both parties. Some people do not believe in going to the hospital and they believe in traditional methods. And I think you need to explore all options.”

Some individuals mentioned the importance of cultural inclusivity going beyond religious practices to ensure clients feel safe and supported.

“We already get to go to church., You know, and then maybe somebody is not a Christian and maybe they need to practice their own cultural studies, you know?”

3.5. Attitudes and perceptions about the experience accessing IPC

All participants reported having a positive experience accessing IPC. The welcoming atmosphere, engaging conversations and attentive care were described as significant factors that improved client experience. The personalized care received at the facility was another factor that made clients feel comfortable accessing IPC.

“I felt very comfortable here. I was welcomed, talked to, and cared for. At my normal doctor, I am in and out.”

“They’ve been more than willing on listening to what my aches and pains or what problems I’m having, and they’ve been on top of it. In my eyes, I mean, getting the medicines that are needed or getting the cream I needed. So, I gave them a five star.”

The health education component offered during the IPC visits was identified as a contributing factor that enhanced the client experience. Participants reported that the health education provided a clearer comprehension of various health-related topics, such as understanding blood pressure. The participants expressed appreciation for the providers’ proactive approach in delivering informative health education, emphasizing how such a support differed significantly from their previous experiences elsewhere.

“They talked to me and she explained things to me that I didn’t know. I didn’t know what blood pressure meant, like one number over another number. They explained all that to me, and I like that they were there for me, not like the other places I’ve been to.”

3.6. Challenges to attending IPC appointments

3.6.1. Transportation-related problems

Although the facility offers transportation for clients to attend appointments, the lack of awareness of such services was highlighted in the interviews.

“[Arizona’s Medicaid System] covers transportation too as well, so I’m sure they would come to these appointments, even though [Arizona’s Medicaid System] covers transportation, I didn’t know that until recently.”

3.6.2. Operating hours

The IPC services operating hours were discussed as a problem that can make it difficult for clients to attend appointments.

“The hours that they’re of operation are, I believe, 8 to 5. And that’s generally unless somebody is working like a swing shift or even shift, I mean, that’s where most jobs are between those hours … So that does make it difficult for people that do have a full time job that is generally between those hours.”

3.6.3. Limited appointment reminders

Insufficient reminder calls were identified as a barrier to care. To address the issue of missed appointments, it was suggested to increase the number of reminder calls or develop additional reminder strategies.

“Well, what I struggle with would probably be like the over-the-phone appointments. Or maybe they can reach out a little more than just, you know, a phone call. And if you miss it, then, you know, because I missed a couple appointments like that before and it gets a little frustrating. I think trying to contact you a little more than one or two times.”

3.6.4. Healthcare avoidance

Feeling uncomfortable about seeking preventive care can act as a barrier to attending IPC appointments, which may lead individuals to prefer seeking care at the emergency department.

“For me personally, I just I’m not a doctor person, so I just make appointments and be lazy about it. I usually wait until I have to go to the E.R. [Emergency Room] or something because I don’t have a primary care doctor.”

4. Discussion

The results of this study suggest that clients within a rural behavioral healthcare center that utilized IPC reported greater access to preventive physical health care compared to their prior experiences accessing primary care. Providing access to regular check-ups is a fundamental aspect of IPC services because it can help monitor the impact of substance use on the body, detect potential complications early and facilitate timely interventions to prevent severe consequences (Samet et al., 2001). Participants noted that IPC services offered valuable health education, aiding in forming improved self-care routines and informed health choices. Health education is a critical component of preventive care and is an important element in the SUD recovery process (Rich et al., 2018). Health education equips people diagnosed with SUDs with knowledge about the risks associated with substance use on their bodies, empowering them to adopt safer practices and better comprehend the importance of seeking care when needed (Reddy et al., 2015). Rural areas in the USA face greater shortages in preventive care services compared to urban areas (Loftus et al., 2018). Individuals with SUDs already encounter healthcare access difficulties and residing in regions with limited preventive care options exacerbates these challenges (Meyerson et al., 2021). By providing access to preventive care in rural Arizona, IPC can help people with SUDs to improve their well-being, encourage healthier lifestyles and reduce the risk of long-term physical health consequences associated with substance use.

Furthermore, participants emphasized the convenience of having behavioral health and IPC at the same facility, which could encourage more individuals to seek out and receive necessary healthcare services. This is especially crucial for people with SUDs who often face barriers in accessing care in rural settings. Recognized as a significant SDH, convenient access to primary care not only promotes health-seeking behaviors among people with SUDs but also demonstrates potential to substantially decrease visits to hospital Emergency Departments (Pinchbeck, 2019). Care integration is associated with improved clients’ perceptions about their likelihood of following up on referrals, contributing to more comprehensive and effective healthcare utilization (Banfield et al., 2017).

Moreover, IPC was reported to be helpful in promoting adherence to SUD treatment and supporting the recovery process. The positive influence of care integration on SUD treatment has been reported by other studies (Beharie et al., 2022; Haddad et al., 2015). For instance, a randomized controlled trial conducted with 592 participants at a substance use treatment facility in California found that IPC was associated with higher abstinence averages and longer periods of abstinence (Weisner et al., 2001). The importance of supporting people with SUD in rural USA regions in their recovery journey cannot be overstated. A crucial factor linked to SUD treatment retention and successful recovery is the presence of a supportive environment in which clients perceive a high level of care (Perkins et al., 2016).

Participants discussed being unaware of IPC services at the behavioral health center in this study. The problem of widespread awareness of available healthcare resources is a major barrier to health equity in rural Arizona. The participants in this study also offered some suggestions to maximize community awareness of the IPC services available, identifying important strategies to improve utilization of IPC in rural Arizona. Suggested strategies included increasing advertising efforts on social media and on more traditional types of media, such as television and radio. Well-crafted and strategically deployed advertising presents rural healthcare facilities with the opportunity to significantly enhance their success in effectively connecting with existing and potential clients (Elrod and Fortenberry, 2020). Participants also identified that collaborations and partnerships with court systems and the criminal justice system as a whole would help improve awareness of the IPC services in rural Arizona. Many people struggling with SUDs encounter the criminal justice system; therefore, it is imperative that every level of the criminal justice system, including the courts and probation, provide useful information regarding the services in the community (Belenko et al., 2013). Advertising and providing information about the IPC services, not only to those who are referred to behavioral health centers through the criminal justice system but to everyone who might benefit, could allow more people with SUDs in rural regions to receive the care they need.

Participants emphasized the significance of being mindful of diverse cultural practices and religious beliefs as essential components of culturally-centered care, which providers must consider during care integration. Culturally-centered care fosters a safe and inclusive environment for diverse populations, facilitating healthcare access and contributing to the reduction of health disparities (Latif, 2020). As people with SUDs in rural settings face a number of barriers to care, especially those from underserved backgrounds, culturally-centered care integration can promote a greater degree of trust among clients, providers and other facility staff (Tucker et al., 2007). Supporting rural clients with SUDs involves addressing complex physical and emotional needs, overcoming mistrust and valuing diverse knowledge sources (medical, experiential and embodied expertise). To achieve this, it is essential to appreciate clients in their unique experiences and as central agents in their own care (Eaves et al., 2020). Future studies are needed to explore culturally-centered care practices for specific minority populations accessing IPC in rural settings, including Native Americans and people who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ).

In line with other studies that reported a positive healthcare experience when accessing integrated care services (Ede et al., 2015; Petts et al., 2022), our study evidenced a high perception of satisfaction in accessing IPC. Participants reported feeling comfortable accessing IPC at the facility due to providers being active listeners, addressing physical health concerns and providing a perception of individualized care. Client satisfaction is an important indicator of healthcare quality within the SDH framework and refers to how clients are traditionally regarded by providers (e.g. good clinical management practices) and how providers are perceived by community members (e.g. quality provider-client interactions) (WHO, 2023). Client satisfaction is crucial in the recovery journey of people with SUDs in rural settings because it promotes continuity of care. It also challenges stigma surrounding behavioral healthcare centers in rural settings as positive experiences and shared stories can shift perceptions, encouraging more people with SUDs to seek assistance without fear (Burgess et al., 2021). Further research should investigate the advantages and obstacles of integrating care in rural settings to enhance care quality from the providers’ viewpoint.

Transportation-related problems and operating hours were among the main barriers to attending IPC appointments reported by participants. Our results are similar to prior research examining barriers to SUD treatment in rural USA (Browne et al., 2016; Jackson and Shannon, 2012). A recent systematic review on rural-specific barriers to SUD treatment identified that travel burden is the most salient accessibility challenge (Lister et al., 2020). Although care integration has been found to be a strategy with the potential to overcome structural barriers to care among people with SUDs in rural settings, it is crucial to ensure flexible service provision, including evening and weekend hours or providing satellite or home-based services (Browne et al., 2016; Priester et al., 2016).

4.1. Implications for practice

The determinants of health identified in our study included literacy regarding the benefits of IPC, lack of awareness of available IPC services in rural Arizona, barriers to appointment attendance, needed culturally-centered care practices and positive client perception accessing IPC. These elements play a crucial role in the healthcare quality and access sphere within the SDH framework, which constituted the primary focus of our study. The SDHs identified in the current study need to be considered when implementing IPC in rural regions to ensure high-quality care and optimal utilization of the service. First, there is a need to raise awareness of new healthcare services across rural regions to ensure those who can benefit are aware of them (Sanderson et al., 2017). Second, it is important for people with SUDs to understand the benefits of IPC. Without this understanding, they might overlook the advantages and positive outcomes that IPC can bring. In turn, this lack of understanding might prevent people with SUDs from fully embracing and utilizing available IPC services, potentially hindering their overall well-being and treatment outcomes (Gleason et al., 2017). Third, missed appointments are a common problem across rural healthcare facilities serving people with SUDs. Although there are known factors for appointment missingness such as limited transportation, it is important to understand whether there are specific regional factors in rural regions contributing to appointment missingness (Sautter Errichetti et al., 2019). Finally, promoting culturally-centered IPC is crucial to better serve people with SUDs from culturally diverse backgrounds residing in rural regions (Holden et al., 2014). Advancing cultural sensitivity and tailoring care to meet clients’ beliefs can potentially lead to higher satisfaction with the healthcare experience. This patient-centered approach fosters a stronger sense of trust, which, in turn, can positively impact their willingness to engage more actively in their healthcare journey (Tucker et al., 2011; Santos et al., 2018).

4.2. Limitations and strengths

Our study has limitations. This is a cross-sectional study with a small sample size and findings were specific to a single behavioral health care facility in Arizona. However, this facility is one of the few behavioral health care facilities in the region offering IPC. Therefore, the findings may not be generalizable to other community behavioral health facilities with IPC services; however, they could be useful for future research on reverse integrated care in Arizona and other underserved USA regions. Additionally, due to the priority of protecting client identity, we did not evaluate demographic information of interview participants, thus contextual information related to client identity cannot be extracted.

5. Conclusions

This study underscores the importance of IPC in providing comprehensive services to people diagnosed with SUDs in underserved USA regions, such as rural Arizona. The findings from this line of research have widespread practical and healthcare implications. Emphasizing preventive care, health education and client-centered approaches, while addressing barriers to access, can lead to more comprehensive and effective healthcare utilization, ultimately supporting the recovery journey of individuals with SUDs. Recognizing the social determinants of health rooted in the experiences of people with SUDs accessing IPC in rural USA regions can help stakeholders to make informed decisions to improve access and quality of care. Future studies should assess the barriers and facilitators to IPC in other rural-based behavioral healthcare centers across Arizona to explore if there are patterns across sites.

Funding:

This work was funded by The NARBHA Institute. In addition, this work was funded by the National Institute on Drug Abuse (NIDA) Culturally Centered Addictions Research Training (C-CART) Program (No: 1R25DA053805) and the National Institute for Minority Health and Health Disparities (NIMHD) Southwest Health Equity Research Collaborative RCMI (No: U54MD012388).

Footnotes

Conflict of interest: The authors declare no conflicts of interest or financial benefits in conjunction with this study.

Contributor Information

Jeffersson Santos, Center for Health Equity Research, Northern Arizona University, Flagstaff, AZ.

Amanda Acevedo-Morales, Department of Clinical Psychology, Northern Arizona University, Flagstaff, AZ.

Lillian Jones, Department of Clinical Psychology, Northern Arizona University, Flagstaff, AZ.

Tara Bautista, Northern Arizona University, Flagstaff, AZ.

Carolyn Camplain, Department of Community and Population Health, Lehigh University, Bethlehem, PA.

Chesleigh N Keene, Northern Arizona University, Flagstaff, AZ.

Julie Baldwin, Center for Health Equity Research, Northern Arizona University, Flagstaff, AZ.

References

  1. Arizona Department of Health Services (ADHS) (2023), “ADHS initiatives are working to improve healthcare access in Arizona’s most rural communities”, available at: https://directorsblog.health.azdhs.gov/adhs-initiatives-are-working-to-improve-healthcare-access-in-arizonas-most-rural-communities/ (accessed 18 July 2023).
  2. Banfield M, Jowsey T, Parkinson A, Douglas KA and Dawda P (2017), “Experiencing integration: a qualitative pilot study of consumer and provider experiences of integrated primary health care in Australia”, BMC Family Practice, Vol. 18 No. 1, p. 2, doi: 10.1186/s12875-016-0575-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Beharie N, Kaplan-Dobbs M, Urmanche A, Paone D and Harocopos A (2022), “I didn’t feel like a number”: the impact of nurse care managers on the provision of buprenorphine treatment in primary care settings”, Journal of Substance Abuse Treatment, Vol. 132, 108633, doi: 10.1016/j.jsat.2021.108633. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Belenko S, Hiller M and Hamilton L (2013), “Treating substance use disorders in the criminal justice system”, Current Psychiatry Reports, Vol. 15 No. 11, p. 414, doi: 10.1007/s11920-013-0414-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Brown JD (2019), “Availability of integrated primary care services in community mental health care settings”, Psychiatric Services, 2019, Vol. 70 No. 6, pp. 499–502, available at: 10.1176/appi.ps.201800448 (accessed 27 January 2022). [DOI] [PubMed] [Google Scholar]
  6. Browne T, Priester MA, Clone S, Iachini A, DeHart D and Hock R (2016), “Barriers and facilitators to substance use treatment in the rural south: a qualitative study”, The Journal of Rural Health: Official Journal of the American Rural Health Association and the National Rural Health Care Association, Vol. 32 No. 1, pp. 92–101, doi: 10.1111/jrh.12129. [DOI] [PubMed] [Google Scholar]
  7. Burgess A, Bauer E, Gallagher S, Karstens B, Lavoie L, Ahrens K and O’Connor A (2021), “Experiences of stigma among individuals in recovery from opioid use disorder in a rural setting: a qualitative analysis”, Journal of Substance Abuse Treatment, Vol. 130, 108488, doi: 10.1016/j.jsat.2021.108488. [DOI] [PubMed] [Google Scholar]
  8. Coconino County Health and Human Services (2021), “Community needs assessment Coconino county”, Arizona, available at: https://www.coconino.az.gov/DocumentCenter/View/40704/Community-Needs-Assessment---FINAL-12320 (accessed 2 May 2023). [Google Scholar]
  9. Dillard D, Bincsik AK, Zebley C, Mongare K, Harrison J, Gerardi KE and Parcher DW (2010), “Integrated nested services: delaware’s experience treating minority substance abusers at risk for HIV or HIV positive”, Journal of Evidence-Based Social Work, Vol. 7 No. 1, pp. 130–143, doi: 10.1080/15433710903176021. [DOI] [PubMed] [Google Scholar]
  10. Dobis EA and Todd JE (2022), “Health care access among self-employed workers in nonmetropolitan counties”, Report prepared by the U.S. Department of Agriculture, available at: https://www.ers.usda.gov/webdocs/publications/103978/ap-099.pdf?v=7439.2 [Google Scholar]
  11. Eaves ER, Williamson HJ, Sanderson KC, Elwell K, Trotter RT and Baldwin JA (2020), “Integrating behavioral and primary health care in rural clinics: what does culture have to do with it?”, Journal of Health Care for the Poor and Underserved, Vol. 31 No. 1, pp. 201–217, doi: 10.1353/hpu.2020.0018. [DOI] [PubMed] [Google Scholar]
  12. Ede V, Okafor M, Kinuthia R, Belay Z, Tewolde T, Alema-Mensah E and Satcher D (2015), “An examination of perceptions in integrated care practice”, Community Mental Health Journal, Vol. 51 No. 8, pp. 949–961, doi: 10.1007/s10597-015-9837-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Elrod JK and Fortenberry JL Jr (2020), “Advertising in health and medicine: using mass media to communicate with patients”, BMC Health Services Research, Vol. 20 No. Suppl 1, p. 818, doi: 10.1186/s12913-020-05599-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Errichetti KS, Flynn A, Gaitan E, Ramirez MM, Baker M and Xuan Z (2020), “Randomized trial of reverse colocated integrated care on persons with severe, persistent mental illness in Southern Texas”, Journal of General Internal Medicine, Vol. 35, pp. 2035–2042, doi: 10.1007/s11606-020-05778-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Firth J, Siddiqi N, Koyanagi A, Siskind D, Rosenbaum S, Galletly C, Allan S, Caneo C, Carney R, Carvalho AF, Chatterton ML, Correll CU, Curtis J, Gaughran F, Heald A, Hoare E, Jackson SE, Kisely S, Lovell K, Maj M, McGorry PD, Mihalopoulos C, Myles H, O’Donoghue B, Pillinger T, Sarris J, Schuch FB, Shiers D, Smith L, Solmi M, Suetani S, Taylor J, Teasdale SB, Thornicroft G, Torous J, Usherwood T, Vancampfort D, Veronese N, Ward PB, Yung AR, Killackey E and Stubbs B (2019), “The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness”, The Lancet Psychiatry, Vol. 6 No. 8, pp. 675–712, doi: 10.1016/S2215-0366(19)30132-4. [DOI] [PubMed] [Google Scholar]
  16. Gerolamo AM, Kim JY, Brown JD, Schuster J and Kogan J (2016), “Implementation of a reverse colocation model: lessons from two community behavioral health agencies in rural Pennsylvania”, Journal of Behavioral Health Services Research, Vol. 43, pp. 443–458, doi: 10.1007/s11414-014-9423-x. [DOI] [PubMed] [Google Scholar]
  17. Gleason HA, Truong D, Biebel K, Hobart M and Kolodziej M (2017), “Perceived barriers to and facilitators of engagement in reverse integrated care”, The Journal of Behavioral Health Services and Research, Vol. 44, pp. 296–303, doi: 10.1007/s11414-016-9507-x. [DOI] [PubMed] [Google Scholar]
  18. Haddad MS, Zelenev A and Altice FL (2015), “Buprenorphine maintenance treatment retention improves nationally recommended preventive primary care screenings when integrated into urban federally qualified health centers”, Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 92 No. 1, pp. 193–213, doi: 10.1007/s11524-014-9924-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Healthy people 2030 (2023), “Social determinants of health”, available at: https://health.gov/healthypeople/priority-areas/social-determinants-health (accessed 20 August 2023).
  20. Holden K, McGregor B, Thandi P, Fresh E, Sheats K, Belton A, Mattox G and Satcher D (2014), “Toward culturally centered integrative care for addressing mental health disparities among ethnic minorities”, Psychological Services, Vol. 11 No. 4, pp. 357–368, doi: 10.1037/a0038122. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Hwong AR, Chagwedera DN, Thomas M, Niu G, Quan J, Vittinghoff E, Schillinger D, Newcomer JW, Gonzalez A, Essock S and Mangurian C (2022), “CRANIUM: a quasi-experimental study to improve metabolic screening and HIV testing in community mental health clinics compared to usual care”, BMC Psychiatry, Vol. 22 No. 1, p. 687, doi: 10.1186/s12888-022-04293-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Jackson A and Shannon L (2012), “Barriers to receiving substance abuse treatment among rural pregnant women in Kentucky”, Maternal and Child Health Journal, Vol. 16 No. 9, pp. 1762–1770, doi: 10.1007/s10995-011-0923-5. [DOI] [PubMed] [Google Scholar]
  23. Katon WJ, Lin EHB, Von Korff M, Ciechanowski P, Ludman EJ, Young B, Peterson D, Rutter CM, McGregor M and McCulloch D (2010), “Collaborative care for patients with depression and chronic illnesses”, New England Journal of Medicine, Vol. 363 No. 27, pp. 2611–2620, doi: 10.1056/nejmoa1003955. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Lagisetty PA, Maust D, Heisler M and Bohnert A (2017), “Physical and mental health comorbidities associated with primary care visits for substance use disorders”, Journal of Addiction Medicine, Vol. 11 No. 2, pp. 161–162, doi: 10.1097/ADM.0000000000000280. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Latif AS (2020), “The importance of understanding social and cultural norms in delivering quality health care-a personal experience commentary”, Tropical Medicine and Infectious Disease, Vol. 5 No. 1, p. 22, doi: 10.3390/tropicalmed5010022. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Lister JJ, Weaver A, Ellis JD, Himle JA and Ledgerwood DM (2020), “A systematic review of rural-specific barriers to medication treatment for opioid use disorder in the United States”, The American Journal of Drug and Alcohol Abuse, Vol. 46 No. 3, pp. 273–288, doi: 10.1080/00952990.2019.1694536. [DOI] [PubMed] [Google Scholar]
  27. Loftus J, Allen EM, Call KT and Everson-Rose SA (2018), “Rural-urban differences in access to preventive health care among publicly insured minnesotans”, The Journal of Rural Health : Official Journal of the American Rural Health Association and the National Rural Health Care Association, Vol. 34 No. Suppl 1, pp. s48–s55, doi: 10.1111/jrh.12235. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Mangurian C, Thomas MD, Mitsuishi F, Goldman LE, Niu G, Handley MA, Riano NS, Hwong A, Essock S, Dilley J, Newcomer JW and Schillinger D (2022), “Lessons learned from a new reverse-integration model to improve primary care screening in community mental health settings”, Psychiatric Services, Vol. 73 No. 8, pp. 942–945, doi: 10.1176/appi.ps.202100177. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Maragakis A, Siddharthan R, RachBeisel J and Snipes C (2016), “Creating a ‘reverse’ integrated primary and mental healthcare clinic for those with serious mental illness”, Primary Health Care Research and Development, Vol. 17 No. 5, pp. 421–427, doi: 10.1017/S1463423615000523. [DOI] [PubMed] [Google Scholar]
  30. Matsuzaki M, Vu QM, Gwadz M, Delaney JAC, Kuo I, Trejo MEP, Cunningham WE, Cunningham CO and Christopoulos K (2018), “Perceived access and barriers to care among illicit drug users and hazardous drinkers: findings from the Seek, Test, Treat, and Retain data harmonization initiative (STTR)”, BMC Public Health, Vol. 18 No. 1, p. 366, doi: 10.1186/s12889-018-5291-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. McGinty EE, Presskreischer R, Breslau J, Brown JD, Domino ME, Druss BG, Horvitz-Lennon M, Murphy KA, Pincus HA and Daumit GL (2021), “Improving physical health among people with serious mental illness: the role of the specialty mental health Sector”, Psychiatric Services, Vol. 72 No. 11, pp. 1301–1310, doi: 10.1176/appi.ps.202000768. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Meyerson BE, Russell DM, Kichler M, Atkin T, Fox G and Coles HB (2021), “I don’t even want to go to the doctor when I get sick now: healthcare experiences and discrimination reported by people who use drugs, Arizona 2019”, The International Journal on Drug Policy, Vol. 93, 103112, doi: 10.1016/j.drugpo.2021.103112. [DOI] [PubMed] [Google Scholar]
  33. Perkins KS, Tharp BE, Ramsey AT and Patterson Silver Wolf (Adelv Unegv), D. (2016), “Mapping the evidence to improve retention rates in addiction services”, Journal of Social Work Practice in the Addictions, Vol. 16 No. 3, pp. 233–251, doi: 10.1080/1533256x.2016.1200055. [DOI] [Google Scholar]
  34. Petts RA, Lewis RK, Brooks K, McGill S, Lovelady T, Galvez M and Davis E (2022), “Examining patient and provider experiences with integrated care at a community health clinic”, Journal of Behavioral Health Services and Research, Vol. 49, pp. 32–49, doi: 10.1007/s11414-021-09764-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Pinchbeck EW (2019), “Convenient primary care and emergency hospital utilisation”, Journal of Health Economics, Vol. 68, 102242, doi: 10.1016/j.jhealeco.2019.102242. [DOI] [PubMed] [Google Scholar]
  36. Priester MA, Browne T, Iachini A, Clone S, DeHart D and Seay KD (2016), “Treatment access barriers and disparities among individuals with co-occurring mental health and substance use disorders: an integrative literature review”, Journal of Substance Abuse Treatment, Vol. 61, pp. 47–59, doi: 10.1016/j.jsat.2015.09.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Reddy UK, Siyo RK, Ul Haque MA, Basavaraja H, Acharya BL and Divakar DD (2015), “Effectiveness of health education and behavioral intervention for tobacco de-addiction among degree students: a clinical trial”, Journal of International Society of Preventive and Community Dentistry, Vol. 5 No. Suppl 2, pp. S93–S100, doi: 10.4103/2231-0762.172949. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Rich KM, Bia J, Altice FL and Feinberg J (2018), “Integrated models of care for individuals with opioid use disorder: how do we Prevent HIV and HCV?”, Current HIV/AIDS Reports, Vol. 15 No. 3, pp. 266–275, doi: 10.1007/s11904-018-0396-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Samet JH, Friedmann P and Saitz R (2001), “Benefits of linking primary medical care and substance abuse services: patient, provider, and societal perspectives”, Archives of Internal Medicine, Vol. 161 No. 1, pp. 85–91, doi: 10.1001/archinte.161.1.85. [DOI] [PubMed] [Google Scholar]
  40. Sanderson K, Williamson HJ, Eaves E, Barger S, Hepp C, Elwell K, Camplain R, Winfree K, Trotter RT and Baldwin JA (2017), Advancing Wellbeing in Northern Arizona: A Regional Health Equity Assessment, Northern Arizona University, available at: https://nau.edu/wp-content/uploads/sites/160/2018/09/Wellbeing-in-Arizona_Final-9_22_17.pdf (accessed 22 March 2023). [Google Scholar]
  41. Santos J, Kameg B, Matthews E, Puskar K, Kane I and Mitchell A (2018), “Fetal alcohol spectrum disorders (FASD): promoting international awareness through ambassadors and collaboration”, International Journal of Nursing Student Scholarship, Vol. 5, pp. 1–8, ISSN 2291–6679. [Google Scholar]
  42. Sautter Errichetti K, Ramirez MM, Flynn A and Xuan Z (2019), “A reverse colocated integrated care model intervention among persons with severe persistent mental illness at the U.S.-Mexico border: a randomized controlled trial protocol”, Contemporary Clinical Trials Communications, Vol. 16, 100490, doi: 10.1016/j.conctc.2019.100490. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Substance Abuse and Mental Health Services Administration (2020), “National mental health services survey (N-MHSS): 2019”, Substance Abuse and Mental Health Services Administration, Rockville, MD, available at: https://www.samhsa.gov/data/sites/default/files/reports/rpt35336/2020_NMHSS_final.pdf (accessed 1 May 2023). [Google Scholar]
  44. Talley RM, Rolin SA, Trejo BN, Goldman ML, Alves-Bradford JE and Dixon LB (2019), “Perspectives of individuals with serious mental illness on a reverse-colocated care model: a qualitative study”, Psychiatric Services, Vol. 70 No. 9, pp. 793–800, doi: 10.1176/appi.ps.201800480. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Tucker CM, Herman KC, Ferdinand LA, Bailey TR, Lopez MT, Beato C, Adams D and Cooper LL (2007), “Providing patient-centered culturally sensitive health care: a formative model”, The Counseling Psychologist, Vol. 35 No. 5, pp. 679–705, doi: 10.1177/0011000007301689. [DOI] [Google Scholar]
  46. Tucker CM, Marsiske M, Rice KG, Nielson JJ and Herman K (2011), “Patient-centered culturally sensitive health care: model testing and refinement”, Health Psychology: Official Journal of the Division of Health Psychology, American Psychological Association, Vol. 30 No. 3, pp. 342–350, doi: 10.1037/a0022967. [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Ward MC and Druss BG (2017), “Reverse integration initiatives for individuals with serious mental illness”, Focus, Vol. 15 No. 3, pp. 271–278, doi: 10.1176/appi.focus.20170011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Weisner C, Mertens J, Parthasarathy S, Moore C and Lu Y (2001), “Integrating primary medical care with addiction treatment: a randomized controlled trial”, JAMA, Vol. 286 No. 14, pp. 1715–1723, doi: 10.1001/jama.286.14.1715. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. WHO (2023), “Client satisfaction”, available at: https://www.emro.who.int/child-health/health-systems/health-systems/Client-satisfaction.html (accessed 20 July 2023).
  50. World Health Organization (WHO) (2019), “Social determinants of health”, available at: https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1 (accessed 21 March 2023).

RESOURCES