O3226: Expanding Rural Access to Child Abuse Expertise in Colorado: An Analysis of CARE Network Strengths and Challenges

Background: There are over 100,000 referrals made for child maltreatment concerns annually in Colorado, many of which occur within 51 rural counties. Board-certified child abuse pediatricians (CAPs) are only available at Colorado’s urban centers. Most rural cases are managed locally, with social services and law enforcement relying on trusted community providers for medical and behavioral health assessment. The Child Abuse Response and Evaluation (CARE) Network is a state-funded program connecting CAP experts with local medical/behavioral health providers and providing support through education, mentorship, case review, behavioral health resources, administrative support, and reimbursement. Since its inception in 2019, the network has substantially expanded access. However, despite high program satisfaction and training effectiveness, many rural counties have low CARE Network utilization rates.

Methods: This qualitative study explores the multidisciplinary dynamics of child abuse assessments in rural and urban counties in Colorado. CARE Network referrals since program inception were characterized, identifying the two most and three least active counties. These counties were targeted for qualitative investigation with 23 semi-structured interviews conducted with stakeholders across all disciplines (law enforcement (n=6), social services (n=6), child advocacy centers (n=5), and medical/behavioral CARE Network providers (n=6)). Interview domains included CARE Network experiences, implementation factors, barriers and facilitators to program usage, and suggestions for improvement. Interviews were recorded, transcribed, and de-identified. ATLAS.Ti Version 25.0.01 was utilized for coding. A codebook was derived from the interview guide, and any disagreements on coding schema were resolved by consensus. Two data analysts established inter-rater reliability by double-coding 10% of the transcripts to demonstrate a simple percent agreement of >80%. The remaining transcripts were coded by individual analysts. Three analysts reviewed the coded data and extracted themes.

Results: Thematic analysis identified several challenges impacting CARE Network effectiveness: 1) relatively low child abuse case volumes in rural counties lead to inconsistencies in case management and reliance on community providers who may not have CARE Network training; 2) fragmented coordination between small law enforcement and child welfare agencies makes it difficult to identify the proper CARE Network provider; 3) limited resources and geographic isolation create barriers to best practices, including language services and mental health support; 4) rural counties experience disproportionate disparities in immigration, insurance, transportation, and socioeconomic status, requiring cultural sensitivity for equitable investigations, and 5) staffing turnover and outreach challenges limit our ability to establish the long-term CARE Network relationships that rural counties need.

Conclusion: This study outlines high-yield areas of intervention to increase CARE Network referrals and effectiveness. They highlight the logistical, communication, cultural, and contextual reasons why a multidisciplinary response is challenging, especially in rural areas. These findings inform the next study phase, where we will bring this information to community stakeholders to derive locally applicable solutions.