Building the Plane as We Fly: Considerations for Scaling Out Coordinated Specialty Care for Early Psychosis in the Rural United States.

Coordinated Specialty Care (CSC) programs for early psychosis (EP) have expanded rapidly in the United States (US) in recent years due to evidence supporting early intervention and subsequent federal funding. The majority of CSC programs are located in major urban and surrounding suburban areas, although many states are expanding or planning to expand CSC services to rural and remote areas. Despite ongoing implementation efforts, little is known about effective implementation of CSC in rural and remote communities. The present article uses the "scale out" model as a guiding framework to consider how CSC can be implemented in rural areas and describes considerations relevant to infrastructure for rural CSC: defining rurality, priority population, workforce, financing, telehealth, strengths of rural communities, culture and social determinants of health. We then discuss two overarching challenges of: a) integrating alternative bottom-up, community partnership approaches, such as community-based participatory research (CBPR), into the scale out model and b) using the scale out model for an implementation effort that is already underway. We argue that successful rural CSC implementation will involve integrating the scale out model with rigorous CBPR to incorporate theory with real-world needs and learn in real-time from ongoing implementation efforts.