Journal of Rural Mental Health, Vol 49(4), Oct 2025, 344-353; doi:10.1037/rmh0000313
Individuals with serious mental illnesses living in rural areas experience challenges, including reduced access to providers, limited availability of specialty mental health care, lack of trained mental health providers and care coordination, and underutilization of available services. Driven by the identified needs of their community, a behavioral health care organization in rural Pennsylvania developed and implemented a community-based comprehensive approach to care for people with serious mental illness who are coming out of psychiatric hospitalization and at risk of being rehospitalized—the Community-Based Intensive Treatment program. The Community-Based Intensive Treatment is a high-intensity program in which a group of multidisciplinary mental and physical health staff provides services primarily in clients’ natural settings. The model is rooted in the foundations of harm reduction, critical-time intervention, integrated adult planning, and assertive community treatment. Most (82%) clients are seen within 24 hr of admission to the program, and the vast majority (95%) are seen within 1 week. To ensure effective communication, all providers serving each Community-Based Intensive Treatment participant have a weekly meeting, or “huddle,” where client issues are identified and addressed. This weekly huddle encourages provider accountability within care. Lessons learned that may generalize to other rural locations include the importance of identifying and working to ameliorate participants’ social determinants of health needs to lay the groundwork for recovery, investing in comprehensive and community-based services that can address common barriers to care in rural areas, and forming strategic community partnerships and focusing on evaluation to aid program expansion. (PsycInfo Database Record (c) 2025 APA, all rights reserved)