ORIGINAL ARTICLE

Perspectives of Behavioral Health Clinicians in a Rural Integrated Primary Care/Mental Health Program Dallas Williams, BS;1,2 Jessica Eckstrom, BS;1,2 Marc Avery, MD;2,1 & Jurgen Unutzer, MD, MPH2,1 ¨ ¨ 1 Medical Student Research Training Program, University of Washington School of Medicine, Seattle, Washington 2 Advancing Integrated Mental Health Solutions (AIMS) Center, Division of Integrated Care and Public Health, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington

Disclosures: The Community Health Plan of Washington (CHPW) administers the program being studied by this project and contracts with the AIMS Center at the University of Washington School of Medicine, which provides technical assistance, training, and psychiatric clinical consultation. Both organizations provided support for the study in the form of office space and logistical assistance. Their involvement represents an inherent potential conflict of interest. Extensive measures were taken to prevent impacts on the data. Specifically, study protocols, materials, data collection, data interpretation, and manuscript writing were designed and performed by persons with no previous association to or investment in CHPW or the AIMS Center. Funding: Medical Student Research Training Program, University of Washington School of Medicine, with support from the AIMS Center and the CHPW. Acknowledgments: The authors would like to acknowledge the helpful staff and support provided by the AIMS Center and the CHPW. For further information, contact: Dallas Williams, BS, 1959 NE Pacific St, Box 356340, Seattle, WA 98195-6560; e-mail: [email protected]. doi: 10.1111/jrh.12114

Abstract Purpose: This study compares the perspectives of rural and urban mental health clinicians working in various Washington State Community Health Centers that have implemented an integrated primary care/mental health program. Methods: We conducted a Web-based survey of mental health clinicians (n = 71) who work in an integrated primary care/mental health program (“the program”) in 1 of 150 safety net primary care clinics in Washington State. Most participating clinics are Federally Qualified Health Centers or Rural Health Clinics. Pooled survey results from clinicians working in rural settings were compared to those working in urban settings. Semistructured interviews were conducted with a subset (n = 32) of survey respondents. Comments made during these interviews were analyzed for themes. Findings: In the survey phase, both rural and urban clinicians generally agreed that the program benefitted their patients. Rural respondents were particularly appreciative of the flexibility that the program offered when planning care. Not surprisingly, social service limitations (such as housing or transportation services) were more often mentioned as program limitations. Rural clinicians were more likely to note a lack of awareness of program resources among other medical providers on the team. Conclusions: Clinicians working in rural primary care clinics value the availability and flexibility of an integrated primary care/mental health program as an option for providing mental health care for their patients. Clinicians working in rural settings could benefit from additional training and program implementation support to best meet the needs of their patients.

Key words access to care, integrated care, mental health, primary care, rural.

More people in America receive mental health care from their primary care provider than from a mental health specialist.1 However, few patients actually receive adequate mental health care.2,3 Confounding the problem, two-thirds of primary care physicians (PCPs) report difficulty accessing appropriate mental health services for their patients.4 Access to mental health services and mental health specialists are even more limited in rural areas. More than 85% of the federally designated mental

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health professional shortage areas are rural,5 and 90% of rural hospital CEOs report a shortage of mental health care professionals in their service areas.6 To address this need, integrated systems of care such as the IMPACT Model of Care7 have been tested in primary care settings nationwide. In these integrated models, a behavioral health care manager supervised by a psychiatrist and a primary care provider offers education, care management, behavioral interventions, and support of

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psychiatric medication management through ongoing visits. There is now considerable evidence showing these models to be significantly more effective in improving mental health outcomes than the traditional model.8-14 While integrated models of care have been extensively studied in urban areas, implementation in rural areas is less well understood and very little research has been done to analyze how applicable these models are in rural areas. This study is a systematic evaluation of behavioral health clinician (“care coordinator”) perceptions of an integrated mental health care program implemented across Washington State, with additional attention paid to challenges faced in rural or frontier clinics. The location of participating clinics across Washington State varies tremendously, from dense urban areas in King County to isolated rural or frontier communities. This provides an opportunity to evaluate the variation in implementation in urban and rural settings with an established, effective evidenced-based collaborative care program. It is important to better understand the adjustments that rural care coordinators are making in the implementation of the program and to evaluate whether this truly is an effective option for rural areas. A systematic evaluation of rural adaptations may help identify best practices and ways to better support those communities and other rural or frontier communities seeking to implement collaborative care. The aim of this study is to inform researchers and people working within collaborative care about ways to further improve and advance the implementation of integrated health in rural areas.

Methods Setting The Mental Health Integration Program in Washington State is based on the IMPACT model of care7 and is one of the largest reported implementations of integrated care for common mental health problems. This program, administered by the Community Health Plan of Washington (CHPW), delivers behavioral health care via a team that consists of a primary care provider, a behavioral health specialist (“care coordinator”), and a consulting psychiatrist. In this model, appropriate patients are identified by the primary care provider or via structured depression and anxiety screening tools (such as the patient health questionnaire9 ). A care coordinator then contacts the client and offers mental health counseling, care coordination, and other services as clinically indicated. The care and clinical outcomes are tracked using an electronic caseload registry (described elsewhere).15 The care coordinator also consults regularly with a psychiatrist who

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provides caseload consultation and medication reviews as indicated. To date, the program has provided mental health care to over 35,000 publicly funded patients since 2008 in over 150 primary care clinics and community health centers across Washington. The study was conducted in 2 phases. The first phase consisted of an online anonymous survey of care coordinators in the program working in federally qualified primary care health centers and other community primary care health care settings across Washington State. The initial survey was followed by an optional semistructured telephone interview for participants that agreed to be contacted. This study was conducted in collaboration with the Advancing Integrated Mental Health Solutions Center in the Department of Psychiatry and Behavioral Sciences at the University of Washington and the CHPW. CHPW is a nonprofit organization responsible for implementing and managing the program as well as providing training and resources to care coordinators. Study protocols were approved by the Institutional Review Board of the University of Washington.

Sample Population We aimed the survey toward all care coordinators (n = 125), urban and rural, working in primary care clinics across Washington State. Care coordinators are trained professionals certified or licensed in the state of Washington to provide behavioral health services. Most possess a master’s degree or higher. Many also have backgrounds in nursing, psychology, social work, or counseling and all receive additional training from the CHPW. Training consists of Web-based and in-person training sessions on mental illnesses, various therapeutic intervention skills, medications, and collaborative care. Typical services and interventions provided by care coordinators include medication education, teaching coping skills, cognitive behavioral therapy, assistance in accessing social services, and appointment reminders and follow-up. Due to the anonymous nature of the survey, the specific characteristics of survey participants remain unknown. Care coordinators were recruited via e-mail. Participants were excluded from analysis if they did not work directly with at least 1 primary care clinic, or if they did not have regular clinical contact with patients enrolled in the program at the time of the study. Sixty-four of the 118 eligible care coordinators completed the survey (54%). Twenty-seven of those (42% of survey participants) completed the interview. Of the 64 care coordinators who completed the survey, 45 indicated that they work in urban or suburban settings (urban group) and 19 indicated they work in rural or frontier settings (rural group). Of the 27 who completed the interview, 20

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indicated they work in an urban setting, whereas 7 worked in a rural or frontier setting. No defining population parameters were given for determining the type of community in which care coordinators work; it was left up to the participants to designate whether they worked in an urban, suburban, rural, or frontier area.

Study Procedures The survey was programmed, administered, and managed online using an online survey reporting tool. All responses in the survey phase were anonymous. At the end of the survey, respondents had the option of being contacted for a follow-up interview, at which point participant name and e-mail address were collected. The survey questions (Table 1) regarded advantages and disadvantages of the program as well as adaptations required to implement the program in rural areas. Survey questions included both structured queries using a Likert scale as well as the ability to provide detailed free-text explanations or clarifications of their responses. Respondents who agreed to personal contact during the anonymous survey were contacted by e-mail to schedule an interview. Two researchers on the research team conducted all interviews over 15 days. Interviews were conducted following an interview guide in which participants were asked a standardized series of openended questions, some of which were designed to follow up on findings from the survey results. Questions related to their perceptions of the program, trainings, and psychiatric consultations; level of support care coordinators receive; whether they perceived any issues with the program or in working with primary care providers; their opinions related to the care coordinator role and its unique features; and for rural care coordinators, the challenges and effects of application of the program to a rural setting. All interviews were recorded, partially transcribed, and later reviewed with potential themes extracted as described below.

Data Analysis Survey data were pooled and responses were given numerical codes in order from 1 to 5 for “Strongly Disagree” to “Strongly Agree.” Results were then analyzed using standard statistical methods to find mean, median, mode, and SD of responses to each question for each group. Mean responses to questions asked to both urban and rural groups were compared between groups in a 2-tailed t test for statistical significance at P < .05. The follow-up interviews were analyzed qualitatively. Following an interview, the interviewer listened to the recording, partially transcribed the interview, and

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documented all relevant views expressed by the participant as potential themes. Periodically, the other interviewer separately analyzed a subset of recorded interviews conducted by the primary interviewer. Resulting themes from both analyses were then compared for completeness and accuracy. Fourteen of the 31 interviews (45% of the interviews) were double-analyzed this way and the 2 interviewers were found to be consistent in determining thematic results. Interviewers met regularly to debrief about interviews, discuss preliminary findings, modify interview techniques to maintain standardization, and monitor saturation of common themes. All potential themes were systematically categorized and grouped with similar themes as they were gathered. Through this process, themes consistent among many participants became apparent. Partial transcriptions and interview notes were reviewed throughout the process of theme categorization and grouping to ensure completeness and accuracy of final themes. The prevalence of each theme was determined by the percent of participants who expressed views consistent with that theme. Themes were compared between urban and rural groups based on the percent of care coordinators from each group who mentioned a specific theme. Given the relatively low number of interview participants and the qualitative nature of theme extraction and categorization, statistical methods were not used to determine the significance of the comparison.

Results Structured Survey Data Overall, surveyed urban and rural care coordinators viewed the program positively (Table 1). Over 75% of the participants responded “agree” or “strongly agree” regarding the advantages of the program (“It helps my patients have a better overall care experience,” “It improves patient satisfaction,” and “It helps my patients achieve better clinical outcomes overall”). The average response to the latter of these questions was different between rural and urban groups (P = .0225), with the urban group agreeing more on average than the rural group. The majority of respondents (59%) disagreed that “the program omits important elements of patient care needs.” Responses were neutral to “the program requires a lot of extra work that is neither helpful nor necessary.” Care coordinators working in rural settings generally agreed with the following statements: 1. “Our rural or frontier setting has required us to substantially modify the care model to meet patient needs” (58%).

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Table 1 Number of Respondents in Rural and Urban Groups, Survey Questions, and Mean Survey Responses for Each Question for Rural and Urban Groupsa

Number of Respondents Survey Question Advantages of the MHIP Collaborative Care Program It helps my patients have a better overall care experience It helps my patients achieve better clinical outcomes overall It improves patient satisfaction Disadvantages of the MHIP Collaborative Care Program It omits important elements of patient care needs It requires a lot of extra work that is neither helpful nor necessary Adaptations to the Collaborative Care Model in Rural/Frontier Settings. Our rural or frontier setting has . . . required us to substantially modify the care model to meet the needs of our patients made it more difficult to recruit and maintain qualified clinical staff made it more difficult to obtain appropriate clinical supervision made it more difficult to obtain necessary continuing education made it more difficult to access the necessary computer, telephone, and other technology made it more difficult to access appropriate offices or clinical space to see patients made it more difficult to provide outreach to patients who live far away from my workplace

Rural (% Total)

Urban (% Total)

19 (29.7) Rural Mean (SD) 4.05 (1.026) 3.89 (0.875)∗ 3.68 (0.820)

45 (70.3) Urban Mean (SD) 4.44 (0.586) 4.36 (0.645)∗ 4.11 (0.804)

2.89 (0.994)∗ 3.11 (1.243) Rural Mean (SD) 3.84 (0.958) 3.32 (1.108) 3.37 (1.342) 3.00 (1.202) 2.26 (1.046) 2.79 (1.228) 3.79 (1.228)

2.27 (1.009)∗ 2.69 (1.083)



P < .05. Each survey answer choice was given a corresponding number: strongly disagree = 1, disagree = 2, neutral = 3, agree = 4, strongly agree = 5 for statistical evaluation. The mean values were compared between groups in a 2-tailed t test for statistical significance at P < .05. a

2. “Our rural or frontier setting has made it more difficult to provide outreach to patients who live far away from my workplace” (53%). We received generally neutral or evenly dispersed responsesi from care coordinators working in rural settings in regard to: 1. “Our rural or frontier setting has made it more difficult to recruit and maintain qualified clinical staff” (mean 3.32). 2. “Our rural or frontier setting has made it more difficult to obtain appropriate clinical supervision” (mean 3.37). 3. “Our rural or frontier setting has made it more difficult to obtain necessary continuing education” (mean 3.00). 4. “Our rural or frontier setting has made it more difficult to access appropriate offices or clinical space to see patients” (mean 2.79). Finally, rural care coordinators generally disagreed (68%) to “Our rural or frontier setting has made it more difficult to access the necessary computer, telephone, or other technology,” indicating that rural care providers do not report a technology deficit as the primary limitation in working in a rural integrated care setting. In addition to the survey data, several themes and representative quotes were identified from the interviews with care coordinators (Table 2). Themes brought up by

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rural and urban participants were both positive and negative, and many were shared equally between the groups. Participants from both groups were very appreciative of the psychiatric consultations, with 93% of participants saying the psychiatric consults are a valuable source of professional education and/or support. Several also said the PCPs they work with find the psychiatric consultations valuable for improved patient care. Both groups felt the program generally helped care coordinators improve patient care, a sentiment expressed by 81% of participants. Sixty-three percent of all participants expressed positive feelings about their role as a care coordinator, sharing feelings of satisfaction in supporting patients and recognizing that their work is important. Rural participants were more likely to express confusion about their responsibilities in the clinic, with 86% relating difficulties in understanding the care coordinator role or working with providers who are unfamiliar with care coordinators. They said they often provide education about their purpose on the team and can feel isolated. Only 40% of urban participants shared these challenges. Eighty-six percent of rural participants also said they are challenged by very busy schedules, with many responsibilities and limited time, and 57% said they have responsibilities in their clinics in addition to being a care coordinator, which can be difficult to balance. Seventy-one percent of rural participants felt the trainings were helpful in expanding knowledge on psychiatric problems and treatments, use of the computer registry,

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Table 2 Themes Identified Most Commonly by Rural Care Coordinators, Urban Care Coordinators, and Shared Equally by Both Groups With Representative Quotes Themes identified more commonly by rural care coordinators (CCs; % of rural CCs)

Scarcity of community resources is a major barrier to patient care. (100%) “Without the resources to meet basic needs, the depression anxiety cycle escalates because of situational stressors . . . Medication is not going to change that problem.” Clinic staff and providers lack a clear understanding of the CC role, so CCs often provide education about their purpose on the team and can feel isolated. CCs question whether medical care managing should be as much of their role as it is, and would appreciate further clarity on the extent of their responsibilities and place in the team. (86%) “I don’t feel like any of the providers even know about the program.” CCs work hard to budget time between many responsibilities both within and outside of the program. They have limited time for trainings. (86%) “When you’re integrating health care with mental care, it gets busy. We don’t individually bill for psychological services or visits, so the productivity has to stay high to make this sustainable . . . they have to utilize us at a fairly intensive level.” CCs modify the program to fit patients’ needs and their rural environment. CCs may provide significant case management as needed for struggling patients and/or travel to see patients in distant areas or lacking transportation. (71%) “I go from clinic to clinic to try to make myself available as much as I can to the distant population.”

Themes shared equally by both urban and rural CCs (% of all CCs)

CCs greatly appreciate the consulting psychiatrists because they provide support, clinical advice, and education. (91%) Many say PCPs also greatly appreciate the psychiatric consultation and the caseload registry helps facilitate their collaboration. “I think the [psychiatric consultations] are invaluable and many times [the PCPs] would like to wait to prescribe for their patient until they get a psychiatric recommendation.” The program helps CCs improve care for patients by providing trainings, increasing collaboration among providers, increasing patient access to mental health services, and facilitating high-quality and efficient patient improvements. (81%) “There are a lot of coexisting physical and mental issues, and so it’s very helpful to be able to treat the whole person in a team context . . . I think it is a powerful approach.” CCs feel their work is important and enjoyable and feel supported by their clinics and CHPW. (63%) “I take a lot of pride in the work that I do and making sure my clients are taken care of.”

Themes identified more commonly by urban CCs (% of urban CCs)

The program creates extra work for CCs and is limited by its focus on brief interventions. (60%) “It’s kind of the cliff note variation of therapy.” Trainings do not account for the variety of background knowledge among CCs. (40%) “I’m a licensed psychologist, so many of the trainings aren’t as useful for me.”

and clinical skills. All of the rural care coordinators mentioned scarcity of community resources as a major barrier to their patients’ care. Of those, 71% said they modified the program to fit the needs of their specific patients and

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location. They also said the program was flexible enough to allow them to alter their focus with each patient to better address patient priorities for care. Common examples include providing case management for struggling

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patients and traveling to see distant patients or those lacking transportation. They appreciated this flexibility and felt it improved patient care, particularly in the face of limited resources. In contrast to rural participants, only 10% of urban care coordinators mentioned scarcity of resources as a barrier to their effectiveness. They also expressed less confusion or negative feelings about their role, fewer difficulties in collaborating with PCPs, and were less likely than their rural counterparts to express a sense of being overwhelmed by numerous responsibilities and tight scheduling. Urban participants were slightly more likely to report that they felt the program was beneficial for their patients and encouraged better collaboration among providers. Fifty percent of urban participants found the trainings helpful but 40% said they did not find the trainings helpful in expanding knowledge and improving patient care. In comparison, none of the rural participants said they did not find the trainings helpful. Some urban participants said the trainings were too basic for their existing knowledge and skills. Others said they found the trainings helpful at first and thought they may benefit from additional or more advanced trainings in topics such as clinical psychology. Sixty percent of urban care coordinators mentioned limitations of the program. Many felt it was difficult to utilize the program to its full potential due to clinics not following the model, low provider cooperation, and lack of organization or coordination among participating providers and staff. Some felt limited by brief clinic visits and the focus on brief interventions rather than in-depth therapy sessions.

Discussion The data from the survey suggest that care coordinators appreciate this program and feel it benefits their patients. However, rural care coordinators more commonly reported a need to adapt the program model in order to meet their patients’ needs. They also were more likely to experience difficulty reaching out to distantly located patients. While responses to other potentially challenging aspects of rural implementation varied among care coordinators, access to technology was not a major challenge. Few other studies have examined implementation of integrated care in rural areas. One recent qualitative study exploring a reverse integration of medical care into 2 community behavioral health agencies found the staff to have similar opinions to those described by the themes in this study, such as difficulty building collaborative relationships with primary care providers, discomfort providing medical management, and difficulty establishing new procedures and communication protocols.15 Another

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recent qualitative study investigated challenges to care integration in rural areas and found barriers such as limited access to specialists, difficulty communicating with external providers, and payment models with limited support for care integration, with rurality compounding these challenges.16 Themes identified from the interviews were roughly consistent with the survey data but offer additional details. Overall, care coordinators appear to appreciate the value of the program’s trainings, believe the program facilitates collaboration among providers and increases access to mental health services for appropriate patients. The psychiatric consults are a valuable resource for PCPs, patient care, and care coordinator education and support. Importantly, many care coordinators see the benefit they bring to their patients, say their work is rewarding, and feel supported by their employer and clinics. Notably, rural care coordinators appear to face many more systemic challenges in implementing integrated care than were noted by urban care coordinators. Urban care coordinators said they felt limited by the brief scope of the program, which can be contextualized by considering they are more often part of a larger multidisciplinary team in patient care. Given their specialized mental health role within the team, it is understandable that urban care coordinators would want to be able to provide more long-term and in-depth interventions for patients in their area of expertise, rather than brief interventions or spending more time on medication management and documentation. This can be contrasted to rural care coordinators, who appear to function in a much broader role in patient care, likely because of the relatively smaller team size and fewer professionals found in rural areas. Thus, the rural care coordinators have less focus on mental health alone. The other theme more commonly seen in the urban group referred to trainings being redundant with previous knowledge or not advancing enough to accommodate the ever-increasing clinical skills and knowledge gained through experience as a care coordinator. This speaks to the variety of care coordinator backgrounds and points to an accessible area of potential improvement. Addressing issues raised by the urban group could take the form of providing more advanced online trainings with brief descriptions of the contents of each training. This would allow care coordinators to efficiently pursue the trainings most appropriate to advancing their knowledge and skill sets. They could access trainings when they need them and be allotted the time in their schedules to complete them. This would empower care coordinators to pursue their needed level of training and would likely improve patient care. For the issue of limited scope, it could be addressed by allowing more focus on

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chronic mental health care and longer therapy sessions for those whose schedules can accommodate them. However, these changes will likely not be possible for most care coordinators without more systemic changes to the program. Two themes more common in the rural group illuminate aspects that could be further explored and considered in program development to improve integrated mental health care in rural areas. The first theme is recognition of the flexibility within the program. Rural care coordinators expressed an appreciation for this flexibility, because it allows them to make adjustments to the care they provide to best help their patients given their clinical circumstances and the specific needs of each patient. They described the ability to adapt the focus of the program to meet their patients’ needs (for example, helping the patient with meeting basic needs, helping the patient with coordinating medical care, or providing mental health counseling). In sparsely populated rural or frontier areas, it was often necessary for the care coordinator to travel to see patients in a more convenient location due to transportation limitations. The relative lack of community resources and infrastructure in rural areas (such as financial, housing, and transportation resources) poses a challenge for care coordinators working with patients in rural and frontier areas. The second theme is difficulty in care coordinator integration into the rural clinic environment. Interviewees were concerned that staff and providers at some rural clinics struggle with educating clinic providers and staff of the purpose and role of the care coordinator. Working with peers who do not understand the care coordinator role and having no peers with whom to problem solve or commiserate about work-related difficulties has left some care coordinators feeling understandably isolated. Addressing the challenges presented by these 2 rural themes could begin immediately and continue to develop. Seeking experienced and independent mental health providers comfortable working with little to no direct mentoring or on-site supervision could help prevent challenges posed by uncertainty and isolation. In addition, some care coordinators were not prepared to work with underserved populations, and the program may be more successful if rural care coordinators are interested and prepared to work with safety-net populations. In the longer term, it appears that care coordinators in rural areas would benefit from additional resources for addressing patients’ nonmental health needs and more assistance with introduction to new clinics. Resources for addressing additional patient needs could take the form of supplementary training for rural care coordinators on basic medical care management and case management

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or, where possible, additional or increased social worker involvement with struggling patients. Successful implementation in new rural clinics may be assisted by a requirement that clinic staff and medical providers undergo a mandatory brief introduction and training about the program and specifically how to work with care coordinators. This introduction could be done by the care coordinators themselves or, for more consistency, assisted or administered by CHPW.

Conclusion Our study supports the hypothesis that an integrated primary care and behavioral health program can be successful in rural settings, but adaptation to the program structure may be necessary as compared to similar programs implemented in urban settings. Particular challenges that were identified by care coordinators working in rural settings include: specialized outreach to patients, need for program flexibility for some patients, need for careful program implementation, and specialized ongoing program support and training.

Endnote i Means derived using 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree.

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This study compares the perspectives of rural and urban mental health clinicians working in various Washington State Community Health Centers that hav...
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