Transcript Organizational Integration in the Delivery of Mental

Organizational Integration in
the Delivery of Mental Health
Services: Evidence-Based
Practice or Holy Grail
Robert Rosenheck MD
Professor of Psychiatry and Public Health,
Yale Medical School
Senior Associate in Mental Health Services
Research, VA New England MIRECC
Fragmentation of Mental Health
Services and Program Failure


The “fragmented service system” is a
universal nemesis in healthcare policy.
“Out of the contemporary debate comes one
point on which nearly all parties agree, the
need for improved coordination of services.
Underlying this consensus is widespread
recognition that… programs are fragmented,
incomplete and often inefficient. For this
reason, they have failed to respond to
the…problems of mentally ill persons in the
community.”
-- David Rochfort, 1992
Substance Abuse Treatment…


…patients with dual [substance abuse and
psychiatric] disorders tend to receive services
from one system and not from the other, and
they are often excluded from both because of
the complicating features of the second
disorder (Drake et al., 1998).
…medical care, even screening, is seldom
provided as part of substance abuse services
and are most often separate and largely
uncoordinated (Weisner et al., 2001).
President Bush: New Freedom
Commission on Mental Health

“The second obstacle to quality mental health
care [after stigma] is our fragmented mental
health service system. Mental health centers
and hospitals, homeless shelters, the justice
system, and all have contact with individuals
suffering from mental disorders…Many
Americans fall through the cracks of the
current system…And to make sure the cracks
are closed, I am honored to announce the
Freedom Commission on Mental Health.”
-April 29, 2002
New Freedom Commission on
Mental Health: Final Report
“…for too many Americans with mental
illnesses, the mental health services and
supports they need remain fragmented,
disconnected and often inadequate,
frustrating the opportunity for recovery.”
Michael F. Hogan PhD,
Chairman, President’s New Freedom
Commission on Mental Health
July 22, 2003
On the other hand…


The quest for coordination is “…the 20th
century equivalent of the medieval search of
the philosopher’s stone…”
“If we can only find the right formula for
coordination, we can reconcile the
irreconcilable, harmonize competing and
wholly divergent interests, overcome
irrationalities…and make hard … choices to
which no one will object.”
– Harold Seidman, 1986
Empirical Evidence?


Is there empirical evidence that fragmentation is:
 Extensive?
 Harmful to outcomes, morale, or leadership?
Two cross-sectional studies found clients in
communities with more centralized MH systems were
better served more satisfied (Beiser, ‘85; Milward and
Provan, ‘95)


One longitudinal study (ACCESS) found greater
interorganizational integration among homeless
service providers in 18 communities predicted better
housing outcomes after 1 year of case management
(but no better clinical outcomes) (Rosenheck et al., 1998)
That’s it (as far as I know)!
Nevertheless…
In spite of lack of evidence
of adverse effects of
fragmentation there have
been many efforts to correct
it by fostering “services
integration”.
What is integration?


Dictionary defines integration as
“making whole”.
Concept of “bringing together” allows
broader range of linkages from


making a single whole, to
improving communication.
Answer #1. Integration
interventions do not represent …




… novel biomedical treatments;
… novel psychotherapies or behavioral
therapies;
…interventions based on any model of
psychopathology.
…although they do represent major
investments of research and clinical
resources.
Answer #2.
They do represent…


Organizational interventions
Efforts to change in how groups and workers
in an organization:



1) are structured, and
2) interact,
…to improve organizational cooperation or
coordination to improve:


client access to services
client outcomes.
What can “organization” do?




Facilitate cooperation and coordination of
action between parties.
Prevents “free riding” – let others do the
work – the central problem of social life.
“Social capital reduces the cost of working
together: “transaction costs”.
BUT cooperation and coordination are only
useful IF there are unrealized synergies or
interdependencies.
Civic Culture/Social Capital


“Citizens in a civic community are active,
public spirited, equal...helpful, respectful, and
trustful towards one another, even when they
differ on matters of substance...”
“Social capital refers to features of social
organization, such as trust, norms, and
networks, that can improve the efficiency of
society by facilitating coordinated actions...”
-Robert Putnam, Making Democarcy Work,
1993
Social Capital

“Like other forms of capital, social capital is
productive, making possible the achievement
of certain ends that would not be attainable
in its absence... For example a group whose
members manifest truistworthiness will be
able to accomplish much more than a group
lacking trustworthiness.”

James Coleman, Foundations of Social
Theory, 1990
Examples

Interorganizational Integration




The “Big Three”: RWJ PCMI, Fort Bragg, ACCESS
HUD-VA joint initiative for homeless veterans
(1993-).
VA-SSA joint outreach initiative (1992-99).
Intraorganizational




Collaborative Care for Depression/Alcoholism
(Katon, Simon, Wells)
Integrated Mental Health/Medical Clinics (Druss et
al. 2001)
Assertive Community Treatment (Stein & Test)
ACT Augmentations (DDX, IPS– Drake et al.---)
ACCESS Demonstration for homeless
people with serious mental illness

Targeted for homeless people with mental
illness, a population with multiple service
needs:







Mental health services
Substance abuse services
Public support payments
Housing subsidies and support
Primary medical care
Employment assistance
Demonstration based on the assumption that
system fragmentation impeded access to
these services.
Hypothesized Causal Chain
Funds and
Implement
Improved
technical
More
Integration
access and
assistance
Integrated
Interventions
System
outcomes
ACCESS Demonstration: Study
Design




2 similar sites in each of 9 states = 18 sites
One site per state randomized to receive
$250,000/year to implement 12 integration
strategies, 2nd site to be control.
All 18 sites given $500,000 per year to
operate ACT team to serve 100 homeless
clients with serious mental illness each year.
Four annual cohorts recruited 100 clients
each: followed-up at 3, 12 months (n=7,200).
Twelve ACCESS “Systems
Integration” Interventions






Local interagency
coordinating body
State interagency
coordinating body
Co-location of services
Systems integration
coordinator position
Cross training
Interagency
agreements;
memoranda of
understanding






Pooled, joint funding
Uniform client
applications, eligibility
criteria, assessments
Interagency service
delivery team
Flexible funding
Use of special waivers
Consolidation of
programs/agencies
Implementation of Systems
Integration Strategies: Experimental
vs. Comparison Sites, Years 4 and 5.
5
4
Experimental Sites
Comparision Sites
3
2.6
2.19
2
0.88
1
0.48
0
Site Visit Year 4 (Wave 2, 1996)
Site Visit Year 5 (Wave 3, 1998)
Two kinds of integration
System-wide
Projectcentered
Changes in Integration:
Experimental vs. Control Sites
0.70
0.65
0.60
0.60
0.59
0.50
0.50
0.57
Project Integration
Experimental Sites
0.40
0.30
0.43
0.29
0.27
0.20
Comparison Sites
0.28
0.29
0.26
System Integration
0.10
0.00
Wave 1
Wave 2
Wave 3
Psychiatric Symptom Index*
OUTCOMES AS HYPOTHESIZED BY SYSTEMS
INTEGRATION ASSIGNMENT AND BY
COHORT:PSYCHIATRIC SYMPTOMS*
2
1
0
BL
3 Months
12 Months
Cohort
Int 1
Cont 2
Int 2
Cont 3
Int 3
Cont 4
Int 4
Cont 1
OUTCOMES AS HYPOTHESIZED BY SYSTEMS
INTEGRATION ASSIGNMENT AND BY COHORT: NOT
HOMELESS FOR 30 DAYS
Percent Not Homeless
70
60
50
40
30
20
10
0
BL
3 Months
12 Months
Cohort
Int 1
Cont 2
Int 2
Cont 3
Int 3
Cont 4
Int 4
Cont 1
Psychiatric Symptom Index*
OUTCOMES BY SYSTEMS INTEGRATION ASSIGNMENT
AND BY COHORT:PSYCHIATRIC SYMPTOMS*
2
1
0
BL
3 Months
12 Months
Cohort
Int 1
Cont 2
Int 2
Cont 3
Int 3
Cont 4
Int 4
Cont 1
OUTCOMES BY SYSTEMS INTEGRATION ASSIGNMENT
AND BY COHORT: NOT HOMELESS FOR 30 DAYS
Percent Not Homeless
50
40
30
20
10
0
BL
3 Months
12 Months
Cohort
Int 1
Cont 2
Int 2
Cont 3
Int 3
Cont 4
Int 4
Cont 1
Hypothesized Causal Chain:
Summary of Results
Funds and
Implement
Improved
technical
More
Integration
access and
assistance
Integrated
Interventions
System
outcomes
YES
YES
NO
% Not Homeless
One Thing We Learned: System
Integration and Housing Outcome*
60
40
20
r=.51
0
0.17
0.27
0.37
0.47
System Integration
*Housing data are adjusted
for differences in client
characteristics
Not Homeless
Linear (Not Homeless)
Figure 1. Model of The Achievement of
Independent Housing at 12 Months
.34c
Social Capital
Public Housing
Agency
.36d
.36a
.59d
.35d .93d .17d
Independent
Housing
System Integration
.41c
.47d
.08d
.31d .92d
Other Services
Housing
Affordability
BASELINE
.27b
.94d .97d
3 MONTHS
Unexplained
variance
12 MONTHS
Lesson Learned?
Integration can make a
difference in client outcomes!
 The ACCESS initiatives failed to
harness it to make a difference
in client outcomes.

What next?


Look for a theory.
What kind of theory?



Social Capital




Something social/organizational.
Something that fixes some problem!
Industrial capital=machines
Human capital=education
Social capital=authority, norms, trust
To take advantage of interdependencies


By improving coordination/cooperation
Lowering transaction costs.
Mental health examples that
“worked”

Interorganizational Integration



HUD-VA joint initiative for homeless veterans
(1993-).
SSA-VA joint outreach program (1992-99)
Intraorganizational



Collaborative Care for Depression (Caton, Simon,
Wells)
Integrated Mental Health/Medical Clinics (Druss et
al. 2001)
Assertive Community Treatment (Stein & Test)
Federal Interagency Collaboration
to Assist Homeless Veterans


In early 1990s Federal Interagency Council on the
Homeless sought to encourage interagency
collaborations.
Two VA projects:
 Social Security Administration (SSA)-VA outreach
to improve access to Social Security Benefits
 HUD-VA Supported Housing (HUD-VASH) to pair
VA case managers with HUD section-8 housing
subsidies.
HUD-VA Supported Housing




HUD set aside Section 8 housing vouchers
(50 per site) for homeless veterans.
Section 8 rental subsidy provides fair market
rent less 30% of veterans income.
VA funded 2 case managers/site for
maximum 25/1 case load.
RCT comparison of three groups at 4 sites:
 Case management + Voucher (N=182)
 Case management alone (N=90)
 Standard homeless support + referrals
(N=188)
Case Management (CM) Services
Delivered in First Three Months
CM+Voucher
Voucher by 3 Mos.
Helped Locate Apt.
Apts. CM Visited
CM met Landlord
Helped Furnish Apt.
Vet .Terminated
55%
44%
2.1
71%
37%
8%
CM Alone
2%
26%
0.6
45%
22%
17%
Control
1%
9%
0.0
0%
4%
53%
80
60
40
VASH exp. : N=182
Case mgt. N=88
Std. care: N=187
20
ye
ar
s
3
ye
ar
s
2
os
.
m
18
ye
ar
1
os
.
m
6
Ba
se
lin
e
ut
re
ac
h
0
O
% housed in past 60
Outcomes in the HUD-VA Supported Housing Program:
Percent Stably Housed (Apartment, Room, or House for 60 Days)
100
Outcomes in the HUD-VA Supported Housing Program:
Percentage of Days Homeless in Past 60 days
% days homeless in past 60
50
40
VASH exp. : N=182
Case mgt. N=88
Std. care: N=187
30
20
10
0
Baseline
6 mos.
1 year
18 mos.
2 years
3 years
SSA-VA Outreach


SSA Claims Representatives deployed to
VA sites to take claims at the time of
outreach contact and facilitate contact
with Disability Determination Specialists
who evaluate medical evidence.
VA staff facilitate gathering/generation
of medical evidence and help veteran
follow through on the process.
Observational Study Design


Compare application and award rates at
4 demonstration sites and at 24 control
sites.
Merge VA intake data with national SSA
files to identify application and award
rates.
SSA-VA Joint Outreach: Rates of Application
for Benefits (N=34,431)
Percent Applied
25
23
Intervention
20
18
15
19
14
12
10
10
8
7
8
7
10
9
10
11
12
7
5
0
Year 4
Year 3
Year 2
Year - Year + Year + Year + Year +
1
1
2
3
4
Cohort
Joint Outreach Sites
Comparison Sites
Percent Received Benefits
SSA-VA Joint Outreach: Rates of Award Among
Applicants (N=3,952)
80
60
58
55
69
71
61
61
67
55
75
68
68
60
65
57
59
58
40
Intervention
20
0
Year 4
Year 3
Year 2
Year - Year + Year + Year + Year +
1
1
2
3
4
Year Before/After Program Initiation
Joint Outreach Sites
Comparison Sites
Percent Received Benefits
SSA-VA Joint Outreach: Rates of Award Among
All Outreach Veterans (N=34,431)
15
13
Intervention
10
5
10
6
4
4
6
5
6
5
7
11
8
11
7
7
0
Year 4
Year 3
Year 2
Year - Year + Year + Year + Year +
1
1
2
3
4
Year Before/After Program Initiation
Joint Outreach Sites
Comparison Sites
Collaborative Care in Treatment
of Depression in Primary Care



Most depression is treated in primary care
setting by non-specialists and is of poor
quality
Katon, Von Korff, Simon et al., have
developed models of collaborative integration
of mental health and primary care treatment
of depression at Group Health Cooperative of
Puget Sound.
Four collaborative models developed by Katon
et al. (’95, ’96, ’99, ‘00) plus diffusion model
of Wells et al (2000).
Collaborative Model #1:
Katon et al. 1995





Research assistants screen all pts, identify
depressed and obtain consent
Pt. given booklet and video about depression
and structured questions for primary care MD
Primary care MD given ½ day didactic session
and monthly case conference and
consultation on treatment of depression.
Psychiatrist provide 2-4 direct visits,
prescription monitoring, and feedback to
primary care MD, esp. about premature
discharge
Primary care MD provides ongoing care
Collaborative Model #1:
Katon et al. 1995: Results



N=217
Greater adherence to medication regime for
90 days (76% vs. 50%, p<.01)
Greater subjective satisfaction




Overall quality of care (93% vs. 75%, p<.03)
With antidepressants (88% vs. 63%, p<.01)
More likely to show 50% improvement in
symptoms: (74% vs. 44%, p<.01)
Greater symptom improvement (p<.004)
Collaborative Model #4:
Simon et al. 2000


Patients identified by primary care MDs
Three conditions:




1. Usual care vs.
2. Computerized feedback to primary care MD
provided with recommendations based on
adherence to treatment algorithm vs.
3. Care management (15-20 minute telephone
calls at baseline, 8 and 16 weeks).
Results: #3> #1 = #2
Collaborative Models; What
doesn’t work)



One-time education from strangers.
Facilitated referral.
Computerized feedback to primary care
MD provided with recommendations
based on adherence to treatment
algorithm (Simon, 2000).
Conceptual
Conclusions (1)

Problem of fragmentation is not as well
demonstrated as commonly assumed
and should be demonstrated before
designing integrating interventions.
Conceptual Conclusions (2): Specify
unrealized interdependence



Unrealized interdependence allowing access
to resources should be specified in designing
integrative initiatives.
Specific interdependence must be mapped on
to organizational intervention.
Unrealized interdependencies are most likely
found between socially distant groups, e.g.
between mental health and housing agencies,
or police – rather than between mental health
and substance abuse agencies.
Conceptual Conclusion (3): Integration
efforts can be general or specific and can
be distal (higher level) or proximal (lower
level)
Distal
General
Specific
RWJ/ACCESS
HUD-VA
SSA-VA
Proximal
ACT
Collab Care
(Katon/Wells)
Conceptual Conclusion (4)

More specific and more proximal
interventions are more successful at
improving clinical outcomes.




Interventions are (can be) better targeted at those
who will benefit.
Interdependencies are better specified and can be
more explicitly mapped onto organization of
services.
But they rely on supportive frame works at
higher levels.
Effective interventions rely on feedback more
than programming due to high uncertainty.
Conceptual
Conclusions (5)


Integration need not involve structural
change if processes can be changed.
Resource enhancement seems to be
necessary in most cases – pure
integration is rarely effective.
Applications to Criminal Justice System
Mental Health System Integration





McGuire J et al Health status, service use, and costs among
veterans receiving outreach services in jails or community
settings. Psychiatric services 2003;54(2):201-207.
McGuire J and Rosenheck R. Criminal history as a prognostic
indicator in the treatment of homeless people with severe
mental illness. Psychiatric Services 2004;55(1):42-48.
Tejani N, Rosenheck, Tsai J, Kasprow W, McGuire JF. (under
review). Incarceration histories of homeless veterans and
progression through a supported housing process
Stephanie Hartwell et al Predictors of Accessing Substance
Abuse Services Among Individuals With Mental Disorders
Released From Correctional Custody. Journal of Dual Diagnosis
2013; 9: 11-22
From Prison to Work: Proposal for National Prisoner Re-Entry
Program. Bruce Western: 2008
Service Use Among Homeless Veterans
Contacted in LA Jail or in the Community:
Baseline (McGuire and Rosenheck, 2003)
(N=6,560)
Drug Abuse
Alcohol Abuse
Psychiatric Dx
Mood dx
Personal dx.
Schizophrenia
PTSD
Medical problems
LA Jail (N=1,676)
LA Street
62%
48%
50%
35%
21%
11%
5%
33%
39%
42%
22%
23%
13%
6%
6%
37%
Service Use Among Homeless Veterans Contacted in LA
Jail or in the Community: Service Use in Next Year
(McGuire and Rosenheck, 2003)
LA Jail (N=1,676)
Any VA Svces38%
MH OP
30%
MH IP
3%
Residential Tx 4%
Med Surg OP 29%
Med Surg IP
3%
Avge. VA Cost $5.503
LA Street (N=6,560)
84%
73%
6%
11%
60%
6%
$7,821
Outcomes of Homeless People with MH
Disorders (ACCESS: McGuire and
Rosenheck 2004
No Incar HX (1,195) < 6 Mos (N=2,007) >6 mos (N=1852)
Male
42%
59%
83%
Fam Inst.
4.4
5.2
6.2
Conduct sx
1.7
2.4
3.6
Diagnoses
Psych
80%
84%
87%
Drug
25%
37%
51%
Alc
26%
44%
57%
Schz
36%
35%
39%
Maj Dep
49%
48%
48%
Dual Dx
21%
36%
44%
Outcomes of Homeless People with MH
Disorders:Quarterly Mean Services Used @ 12
months (ACCESS: McGuire and Rosenheck 2004
No Incar HX (1,195) < 6 Mos (N=2,007) >6 mos (N=1852)
Empl
.15
Housing
3.39
Med Surg OP 4.1
Psych OP
8.5
SA OP
5.2
Health Costs $891
Criminal Justice $52
.15
2.21
4.2
7.6
7.3
$832
$99
.12
2.47
5.4
7.1
8.0
$790
$298
Outcomes of Homeless People with MH
Disorders:Quarterly Mean Outcome Scores@ 12
months (ACCESS: McGuire and Rosenheck 2004
No Incar HX (1,195) < 6 Mos (N=2,007) >6 mos (N=1852)
Days Homless
Reference
Days employed Reference
ASI Psych score Reference
ASI Alch score
Reference
ASI Drug score Reference
Days in Jail
Reference
+.53
.20
.06*
.007
.007
.576
+1.2
-.27
.07*
.008
.002
4.7***
ns
ns
ns
ns
Baseline Characteristics of Homeless Veterans
Admitted to HUD-VASH Housing Assistance
Program (Years 2008 - 2009)
mean ± SD or N (%)
Incarceration ≤ 1 yr
(Short
Incarceration
History N=6324)
mean ± SD or N
(%)
mean ± SD or N (%)
1594 (32.1%)
1259 (25.3%)
1461 (29.4%)
749 (15.1%)
826 (16.7%)
384 (7.7%)
555 (11.2%)
2424 (48.9%)
496 (10.1%)
2932 (58.8%)
3671 (73.4%)
1199 (24%)
828 (16.5%)
3632 (57.9%)
3054 (48.8%)
1815 (29%)
786 (12.6%)
1173 (18.8%)
638 (10.2%)
899 (14.5%)
3262 (52.3%)
635 (10.3%)
3845 (61.1%)
5432 (86.1%)
2755 (43.7%)
1494 (23.6%)
2002 (62.9%)
2201 (69%)
903 (28.5%)
298 (9.4%)
679 (21.5%)
397 (12.5%)
495 (15.6%)
1550 (49%)
261 (8.4%)
1848 (58.1%)
2915 (91%)
1520 (47.4%)
819 (25.5%)
Never Incarcerated
(No Incarceration
History N=5023)
Variable
Incarcerated > 1 yr
(Long Incarceration
History N=3210)
% difference
between
incarcerated
<1 yr and
never
incarcerated
% difference
between
incarcerated
>1 yr and
never
incarcerated
81%
93%
-1%
-16%
13%
32%
29%
7%
2%
4%
17%
82%
43%
96%
173%
-3%
-38%
29%
62%
39%
0%
-17%
-1%
24%
98%
55%
CLINICAL STATUS
Psychiatric Diagnoses
Alcohol Abuse/Dependency
Drug Abuse/Dependency
Any P.T.S.D.
P.T.S.D. From Combat
P.T.S.D. From Non-Combat Trauma
Schizophrenia Or Other Psychosis
Bipolar Disorder
Depressive Disorder
Other Psychiatric Disorder
Serious Psyc Prob
Psychiatric Or Substance Problem
Dual Diagnosis
Vet Inpt Of Res Tx When Admitted
Progression of Homeless Veterans through
the Housing Attainment Process
(Years 2008 - 2009)
Variable
Never
Incarcerated (No
Incarceration
History N=5023)
mean ± SD or N
(%)
Incarceration ≤ 1
yr
(Short
Incarceration
History N=6324)
mean ± SD or N
(%)
Incarcerated > 1
yr
(Long
Incarceration
History N=3210)
mean ± SD or N
(%)
% difference
between
incarcerated
<1 yr and
never
incarcerated
% difference
between
incarcerated
>1 yr and
never
incarcerated
-18%
-18%
-10%
-10%
-11%
-18%
-7%
-26%
-23%
4%
-8%
-15%
-11%
-9%
-6%
-7%
-11%
-2%
4%
257%
2%
-13%
PROGRESSION THROUGH HOUSING PROCESS (IN DAYS)
Admission To P.H.A. Visit
Admission To Voucher
Admission To First Look
Admission To Lease
Admission To Move In
P.H.A. To Voucher
Voucher To First Look
First Look To Lease
Lease To Move In
Successfully Housed
Housing Choice Scale
35.00 ± 62.58
54.29 ± 101.42
66.53 ± 77.31
104.92 ± 86.93
109.50 ± 90.44
20.98 ± 83.39
35.46 ± 59.55
55.17 ± 624.66
4.86 ± 14.41
2868 (57.1%)
0.48 ± 0.31
28.54 ± 50.76
44.77 ± 88.79
59.92 ± 70.04
94.75 ± 72.60
97.74 ± 73.74
17.13 ± 72.97
33.12 ± 56.23
40.64 ± 45.02
3.77 ± 12.48
3745 (59.2%)
0.44 ± 0.30
29.92 ± 55.04
48.15 ± 101.59
60.26 ± 68.03
98.17 ± 76.06
101.58 ± 78.64
18.66 ± 82.89
34.74 ± 55.37
57.22 ± 679.69
17.35 ± 590.80
1873 (58.3%)
0.42 ± 0.30
Hartwell et al 2013. Predictors of Accessing Substance
Abuse Services Among Individuals With Mental
Disorders Released From Correctional Custody. Journal
of Dual Diagnosis



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Patients discharged from criminal
justice system who used mental health
system.
69% had diagnosis of substance abuse
disorders
Within 24 months 61% used substance
abuse services.
Correlates: female, white, released
under correctional supervision
From Prison to Work: Proposal for
National Prisoner Re-Entry Program.
Bruce Western: 2008





Big three: Housing, Employment, Drug
Abuse Treatment
Personal Mentoring
Less harsh response to violations in
order to support reintegration
Fewer benefits restrictions
Data from demonstrations shows
modest reduction of recidivism:10-15%