Pathways to Recovery: Expanding Access to Integrated Care in Grayson County
The Project
Mount Rogers Community Services expanded comprehensive behavioral health and integrated primary care services in Grayson County, focusing on substance use disorders linked to trauma and poverty. Services were delivered through home visits, telehealth, and a rural clinic, using a no-wrong-door approach to ensure accessibility. A full-time Registered Nurse (RN) served as a client navigator and service coordinator, improving access to psychiatric care, care coordination, addiction treatment, and integrated primary care services.
Work Conducted:
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Expanded clinical capacity by hiring a full-time Registered Nurse.
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Increased service availability in Grayson County from part-time to 4-5 days per week.
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Enhanced telehealth accessibility through available equipment and trained staff, supporting behavioral health treatment access by October 31, 2025.
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Improved care coordination through RN-led navigation and integration of addiction treatment and primary care services.
Goals Achieved:
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Supported individuals in active addiction and long-term recovery.
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Increased patient engagement by reducing the no-show rate for appointments to below 25%.
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Improved treatment adherence through expanded services, coordinated care, and patient education.
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Measured success through patient outcomes, visit frequency, and retention rates.
Evidence from Across Appalachia
Substance Use in Rural Central Appalachia: Current Status and Treatment Considerations
Addressing Substance Use Disorder in Appalachia
Evaluation Summary Report
​With their project Pathways to Recovery, MRCS demonstrated how hiring and training a single RN could rapidly expand integrated behavioral health access in an underserved area. MRCS met all project goals described in their proposal, including the provision of comprehensive mental and behavioral health care for 76 patients in 142 discrete visits since June 2025. Of these, 39 of 48 patients experienced improved symptoms, and 48, all the members of this subsample, reported improved access to mental health services. Changes to the patient management protocol, combined with improved access to local services, were associated with strong appointment adherence, including a 3.84% no-show rate for RN visits and 10% overall, substantially outperforming common rural behavioral health attendance challenges and exceeding their goal of 25%. The supplemental award to expand peer wellness center activities resulted in services for 136 visitors over a three-month period. Wellness activities were implemented using the 5 Bridges to Wellness model, Bond, Fuel, Move, Rest, Give, and most visitors described feeling better and more supported following their visits. Food and nutrition programs were likewise expanded, with six new partnerships supporting interim food access and resource stability, including 110 food boxes from Feeding Southwest Virginia at no cost to the project or participants. The programs and services supported by this grant appeared sustainable in both the short term and long term. The RN position in Independence was expected to be supported with Medicaid funding from the increased patient cohort served at this clinic, ensuring the long-term sustainability of these services. With the evidence provided by this project, MRCS began establishing and refining permanent peer wellness centers at the Twin County Behavioral Health Campus in Galax, and campuses in Wythe and Smyth counties. Project-supported infrastructure such as shelving units and utensils to support the food pantries remained in use, and partnerships were expected to continue providing food boxes and other resources.