A: Mental health researchers and clinicians can serve as a needed resource by working in collaboration with primary care. Because patients present with both physical and mental needs, physicians often find themselves in the role of gatekeepers for mental health services (Bray & McDaniel, 1998). Due to a breakdown at some point in the referral process, however, few patients who are referred for these services ever receive them. Rural areas are particularly in need of combined primary care and behavioral health services because of the scarcity of mental health practitioners there.

Working together, physicians, researchers, and mental health clinicians can provide effective services for their clients. There are advantages for everyone involved in collaboration:

• physicians spend less time on mental health issues while learning more about behavioral issues that can effect their patients' health
• mental health practitioners more can easily coordinate and communicate with physicians, and provide continuity of care to their clients
• researchers can develop and evaluate prevention and intervention programs
• patients have easier access to the services they need, they are less dependent on physicians for mental health needs, and confidentiality is increased

A: The Munroe-Meyer Institute at the University of Nebraska (MMI) started developing primary care/behavioral health networks in 1997. Our Pediatric Behavioral Health Outreach Program now consists of 14 collaborative behavioral health clinics that serve children and their families in rural communities. Each site operates differently, but we have found that a setting with 3 pediatricians can refer enough to fill a full time mental health caseload. Our clinicians use empty examination rooms for their client visits, they help with administrative duties, and MMI pays part of the rent of the facilities.

A: An essential part of the collaborative equation is training and holding on to good providers. There's no point in developing a program that will fall apart after the research is finished. Originally, psychology faculty from the University of Nebraska traveled an average of about 100 miles one way to deliver services. Obviously, this was not feasible in the long run, so we began training pre-doctoral students. We have found that this procedure works very well.

After graduation, trainees are given postdoctoral fellowships, assigned to a rural site, and given responsibility for all clinic operations. Pre-docs are trained for 6 months; post-docs for 1 year at the primary care setting. They are supervised both by physicians and psychologists, then take part in co-therapy with their supervisors. When they are ready to provide care independently, they continue to work closely with their supervisors. They also learn about empirically-supported interventions. A little over half of the graduates from the training program work in rural settings, and 13 out of 14 of our sites are staffed by these graduates. (We also ensure that all clinicians at the sites are well-qualified; they can be master's level practitioners, post-docs, or assistant or associate professors).

To sustain the sense of community and collaboration, we schedule monthly videoconferencing using Polycom technology. All outreach sites have televideo capabilities through their local hospital systems and costs of the conferencing are covered by the Munroe-Meyer Institute. During these monthly meetings, we spend some time on administrative topics (billing, scheduling patients, etc.), provide updates on research projects, and discuss various clinical topics.

A: In order for this kind of program to be effective, we have found that mental health providers must live in the rural area that they serve. This not only eliminates long commutes and weather-related cancellation of appointments, but it fosters the sense that the providers are part of the community. Another advantage to rural placement is that it helps expand the program to other areas as people hear about it, and meet and talk with the clinicians. To encourage primary care settings to adopt this program, we also emphasize the many ways that mental health providers can help with administrative and clinical tasks, while requiring very little from the primary practice (generally a small space and minimal administrative assistance).

We've also learned that there are areas that are too remote to benefit from our program. We have two strategies for extending our reach to these places - we are currently training more students and trying to get them placed in these distant settings, and we are developing a telehealth clinic, which can provide care via teleconferencing to counties with populations of fewer than 6 people per square mile. We are also striving to develop individualized programs to address different community concerns. For example, one community is interested in helping learning disabled children, another needs services for their Hispanic clients, and a third has significant problems with teen pregnancy.

We also need to develop a comprehensive research infrastructure that can make use of the rich database that these clinics can provide. With an infrastructure in place to support research, people could more easily investigate mental health outcomes in primary care as well as the effectiveness of various collaborative models.