Vibrant ONE Mapping the Mental Health & Substance Use System of Care

Northern Counties Health Care

In partnership with Northern Counties Health Care and the Vibrant ONE Accountable Health Community, MDR conducted a comprehensive qualitative research initiative to map the behavioral health system in Vermont’s Northeast Kingdom (NEK). The project aimed to understand how consumers and providers experience the mental health and substance use care system, identify barriers to access, and develop actionable recommendations to improve service delivery and coordination. 

Project Objectives 

The primary goals of the project were to: 

  • Construct two journey maps that illustrate how behavioral health services are accessed in the NEK. 
  • Identify pain points and barriers in the system from both consumer and stakeholder perspectives. 
  • Recommend improvements to crisis response, intake and referral processes, and data collection protocols. 
  • Propose a universal screening and intake model to streamline access and improve coordination. 

Methodology 

MDR conducted five online focus groups and 19 in-depth interviews between March and April 2023. Participants included consumers with lived experience in the NEK behavioral health system and stakeholders such as primary care providers, care managers, and substance use treatment professionals. 

Recruitment was conducted via online screeners and community outreach led by Vibrant ONE. Consumers received compensation for their participation. All sessions were facilitated via Zoom or Microsoft Teams and transcribed for thematic analysis. MDR developed separate discussion guides for consumers and stakeholders, covering topics such as service navigation, provider relationships, barriers to care, and ideas for system improvement. 

Deliverables 

MDR synthesized the qualitative data into two detailed journey maps—one from the consumer perspective and one from the provider/system perspective. These maps visually depict the pathways individuals take through the behavioral health system, including entry points, decision-making junctures, and common obstacles. 

In addition to the maps, MDR produced a comprehensive recommendations report outlining strategies to improve access, coordination, and equity in the NEK behavioral health system. Recommendations included: 

  • Increasing provider capacity and diversity. 
  • Enhancing provider training and communication practices. 
  • Expanding telehealth and remote care options. 
  • Creating centralized information systems and real-time waitlist databases. 
  • Integrating consumers into decision-making processes and reducing stigma through peer support and education. 

This project used in-depth qualitative research to create dual consumer- and provider-focused journey maps and actionable recommendations that reveal barriers, streamline access, and improve coordination within the Northeast Kingdom’s behavioral health system.