| This study articulates two approaches to the integration
of psychiatric and substance abuse services, one involving an integrated
team model and the other a collaborative relationship between agencies.
It applies this conceptualization to a sample of dually diagnosed
homeless people who participated in the ACCESS demonstration (N=1,074)
and were followed for 12 months. A survey of ACCESS case managers
was conducted to obtain information on: (i) the proportion of clients
who received substance abuse services directly from ACCESS case management
teams, and the proportion who received services from other agencies;
and (ii) the perceived quality of the relationship (i.e. communication,
cooperation and trust) between providers -- both within the same teams
and between agencies. Significant associations are observed between
perceptions of communication, cooperation and greater levels clinical
service use. The proportion of clients treated entirely within a single
team, however, was associated with poorer housing and psychiatric
outcomes.
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Background: There is great concern about fragmentation of mental
health service delivery, especially for dually diagnosed homeless people,
and apprehension that such fragmentation adversely affects service access
and outcomes.
Aims of the Study: This study first seeks to articulate two alternative
approaches to the integration of psychiatric and substance abuse services,
one involving an integrated team model and the other a collaborative relationship
between agencies. It then applies this conceptualization to a sample of
dually diagnosed homeless people who participated in the ACCESS demonstration.
Methods: Longitudinal outcome data were obtained through interviews
at baseline, 3 months, and 12 months with homeless clients with a dual
diagnosis (N = 1074) who received ACT-like case management services through
the ACCESS demonstration. A survey of ACCESS case managers was conducted
to obtain information on: (i) the proportion of clients who received substance
abuse services directly from ACCESS case management teams, and the proportion
who received services from other agencies; and (ii) the perceived quality
of the relationship (i.e. communication, cooperation and trust) between
providers -- both within the same teams and between agencies. Hierarchical
linear modeling was then used to examine the relationship of these two
factors to service use and outcome with mixed-model regression analysis.
Results: Significant (p<.05) and positive relationships were
observed in 4 of the 20 analyses of the association of service use and
measures of communication, cooperation, and trust (either intrateam or
inter-agency) while none were significant and negative. At 12 months,
receipt of a higher proportion of services from agencies other than the
ACCESS team was associated with fewer days homeless, and greater reduction
of psychiatric symptoms, contradicting the hypothesis that integrated
team care is more effective than interagency collaborations.
Discussion and Limitations: This study broadens the conceptual
framework for addressing service system fragmentation by considering both
single team integration and interagency coordination, and by considering
both program structure and the quality of relationships between providers.
Data from a multi-site outcome study demonstrated suggestive associations
between perceptions of communication, cooperation and measures of clinical
service use. However, the proportion of clients treated entirely within
a single team was associated with poorer housing and psychiatric outcomes.
These empirical results must be regarded as illustrative rather than conclusive
because of the use of a non-experimental study design, imperfections in
the available measures, and the incomplete sampling of case managers.
Implications for Health Policy: This study suggests that fragmentation
of services for dually diagnosed clients may be reduced by improving the
interactions within and between agencies providing these services. While
primary emphasis has been placed on developing integrated teams, interagency
approaches should not be prematurely excluded.
Implications for Future Research: Research on approaches to reducing
system fragmentation have focused on either global efforts to integrate
numerous agencies in a community or highly focused efforts to develop
specialized teams. Future research should also focus on the possibility
of fostering constructive relationships between selected pairs or subsets
of agencies. Research in this area will also benefit from the further
development measures of team integration and of both intra-team and inter-agency
communication, collaboration, and trust.
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