Rural individuals with depression face substantial barriers to care, seldom receive evidence-based treatment, and experience poor outcomes. Collaborative care has been documented to improve outcomes in large urban Primary Care (PC) clinics. Implementing collaborative care in small rural practices presents a unique challenge because it is not feasible to employ on-site multidisciplinary care teams dedicated to depression treatment. No published studies have documented the effectiveness of collaborative care in small rural PC clinics. In fact, one recent collaborative care effectiveness study conducted in both rural and urban practices found that outcomes were significantly improved in urban clinics, but not rural clinics. Results from our current VA study demonstrate that telemedicine-based collaborative care is effective in small rural PC clinics. Telemedicine-based collaborative care was provided to rural clinics by an off-site depression care team using telephones, emails, interactive video, and a shared electronic medical record. A critical question for the field is whether it is more effective for small rural clinics to provide collaborative care services on-site (practice-based collaborative care model) or to contract with an off-site care team that specializes in providing collaborative care to multiple clinics from a centralized location using telemedicine technologies (telemedicine-based model). We propose to compare the effectiveness/cost-effectiveness of telemedicine-based collaborative care to practice-based collaborative care in six Community Health Center (CHC) systems in rural Arkansas. In 2003, 890 federally-funded CHCs served over 12 million poor, ethnically diverse patients living in medically underserved areas. CHCs are in the process of re-engineering clinics to provide practice-based collaborative care as a part of the Health Disparities Collaboratives. The proposed research has the potential to have a major public health impact because the results should be generalizable to the hundreds of rural CHCs across the country. CHCs represent one of the largest and fasting growing PC systems in the nation, and thus results should be applicable to a large number of providers and patients across the nation. In addition, CHCs serve predominantly low income minority populations living in medically underserved areas. This population is at high risk for experiencing health disparities and thus, interventions targeting this population have the potential to have a major impact. ? ? ?
