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Co-occurring Capability and Collaborative Partnerships: Understanding the Service Linkages of Substance Abuse and Mental Health Programs Ron Claus, Ed Riedel, Mary E. Homan, and Steven Winton Missouri Institute of Mental Health, University of Missouri
Addiction Health Services Research Conference October 30, 2009
Collaboration and COD Capability
Fragmented service delivery systems present a substantial challenge for the treatment of persons with co-occurring substance use and mental health disorders. One solution focuses on improved linkage and collaboration between substance abuse, mental health and other service providers. Collaboration research has most often focused on business, government and nonprofits, or grant partners, with the aim that partnerships will remain after funding ceases. Collaborative partnerships have been viewed as a prerequisite for sustainability.
Potential Benefits of Collaboration
Client – faster access to more appropriate services, improved continuity of care, less likely to “fall through the cracks” in the service system Behavioral health staff – professional development, reduced role anxiety, greater sense of accomplishment and less role confusion Agency – provide needed services, shared resources, creative interventions, greater efficiency, enhanced communication and professional standing System – more effective service delivery, less fragmentation and duplication, improved cost effectiveness, improved ability to advocate and influence public policy
Tensions, Conflicts and Dilemmas of Collaboration
Behavioral health staff – communication, stigma, misconceptions about potential clients, professional knowledge and boundaries, trust, role ambiguity and clinical autonomy Agency – communication, incongruent values, missions, and cultures, work practice changes, practical considerations (client expectations, confidentiality, HIPAA) System – resources, agency competition, information systems, performance indicators, lack of effective interagency structures
Collaboration and COD Capability
Sociological and organizational studies suggest that network range and cohesion affect the efficiency of collaboration and information sharing. Network structure and tie strength can affect knowledge transfer, organizational change, innovation, and service delivery (Cross et al, 2009). There have been few systematic efforts to study organizational models that guide the delivery of integrated care for persons with co-occurring disorders. CJ-DATS findings (Taxman, Fletcher, Lehman, Wexler, and colleagues) Service linkages of SA agencies (Lee et al., 2006)
Stage Models of Collaboration
Stage models most often classify collaborative efforts along dimensions of increasing integration and increasing formalization of work processes Hogue’s (1993) taxonomy considers the purpose, structure, and process of collaboration. Level No Interaction Networking Cooperation Coordination Coalition Collaboration
Trait Co-existence Loosely defined roles Formal communication Some shared decisions Some shared resources Interdependent system
Study Context: The Missouri Foundation for Health’s Co-Occurring Disorders Priority Area 7
An initiative to support the implementation of evidence-based practices for co-occurring substance use and mental health disorders Publicly-funded treatment providers received support for system change: 14
programs awarded 3-year grants in Dec 2006 13 programs awarded 3-year grants in June 2007
Grantee programs are encouraged to initiate and develop collaborative partnerships.
Study Aims
Describe the network composition, size and tie strength of 27 community-based programs implementing evidence-based practices for cooccurring disorders Differences
between SA and MH programs?
Illustrate the use of a Collaboration Map Do programs with higher co-occurring capability report larger network size and stronger network ties?
Participating Programs 9
18 mental health programs and 9 substance abuse programs providing services to adults (“grantees”). Characteristic
Mean
SD
Range
Agency Age
27.7 years 8.7
4 – 41
Agency Annual Operating Expenses
$10.6M
$9.7M
$1.9 – 34.6M
Clients below Federal Poverty Level
77.4%
24.5%
19.6 - 100%
Most located in urban areas: Urban Core: 3 SA providers, 11 MH providers, 51.9% Large Town: 4 SA providers, 6 MH providers, 37.0% Small Town: 1 SA provider, 1 MH provider, 7.4% Isolated Small Census Tract: 1 SA provider, 3.7% Measuring Rurality: Rural-Urban Commuting Area Codes, USDA, 2007
Methods: Collaboration
Partners identified by each grantee Interview with each partner Agency
description (mission, services, size) Tie Strength with all network partners Barriers to collaboration with grantee Facilitators of collaboration with grantee
Level of Collaboration Survey (Frey et al., 2006) High
test-retest reliability (R ~ .8) Used to measure network changes among grant partners
Measure: Co-Occurring Capability 11
Dual Diagnosis Capability in Addiction Treatment (DDCAT) Index - McGovern, Matzkin, & Giard, 2007 Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) Index – Gotham et al., 2009 Semi-structured questions to elicit ratings on 35 items across 7 subscales:
Program Structure Program Milieu Clinical Process: Assessment Clinical Process: Treatment
Continuity of Care Staffing Training
Based on the American Society of Addiction Medicine’s Patient Placement Criteria (ASAM-PPC-2R)
Measure: Co-Occurring Capability 12
Programs received domain and global scores along a continuum:
Addiction Only or Mental Health Only Services (AOS/MHOS, 1)
Dual Diagnosis Capable (DDC, 3)
Programs that by choice or lack of resources cannot accommodate clients with co-occurring disorders, no matter how stable the illness and however well-functioning the client Programs that have a primary focus on one disorder but are capable of treating clients who have relatively stable diagnostic or sub-diagnostic co-occurring problems
Dual Diagnosis Enhanced (DDE, 5)
Programs that are designed to treat clients who have more disabling or unstable co-occurring disorders
Co-Occurring Capability DDE
5
4
DDC
Mean COD Capability = 2.65 Range = 1.57 – 3.60, SD = 0.53
3
2
AOS/ 1 MHOS
No differences: SA vs. MH programs or Urban vs. non-urban programs
Collaborative Partner Map Grantee
Average
Average
5
Number Of Links 4.2
Tie Strength of Collaboration 3.4
3.4
NAMI HIV/AIDS Service Organization
4
4
2.3
Drug and Alcohol treatment
4
3.5
HIV/AIDS Service Organization
4.3
3
Drug Court 5
4.5
2.3
Key Level 0 Level 1 Level 2 Level 3 Level 4 Level 5
None Networking Cooperation Coordination Coalition Collaboration
No line No line
Grantee Networks
Network Size On
average, 5.9 Partners (Mdn = 5, range = 0-14) Collaborators, on average, had “connections” with 81% (4.8/5.9) of the other network partners
Network Tie Strength Across
grantee networks, tie strength averaged 2.5 MH grantees described stronger connections (2.7, or approaching the Cooperation level) SA grantees described lower levels (2.2, or just above the Networking level)
Network Size and Composition MH grantees had slightly larger networks than did SA grantees (6.1 vs. 5.3; d = 0.26) # Partners by Service Type Substance Abuse Mental Health* Medical Criminal Justice* Other Social Service* *p < .05
SA Grantee 1.5 3.0 0.2 0.2 0.4
MH Grantee 1.4 0.9 0.5 1.4 1.9
COD Capability and Collaboration
Network size and COD Capability were moderately correlated (R = .37, p < .10) AOS/MHOS
programs averaged 5.3 partners, while DDC programs averaged 6.2 partners
Tie strength and COD Capability were not associated
Discussion
Collaborative networks at 27 programs working to develop integrated co-occurring services most often included 5 or 6 partners Grantees described connections to complementary COD services, the criminal justice system, and a variety of social service providers, but few grantees had connected with primary health partners. Mental health and substance abuse programs differed:
MH grantee networks were slightly larger than SA networks SA grantee networks included more MH partners MH grantee networks included more CJ partners
The larger size of MH grantee networks may reflect somewhat greater resources
Discussion
Partners most often interacted at the Networking or Cooperation levels of collaboration Tie Strength was not related to COD capability The
variety and number of resources for clients may be more important than collaborating at a high level Programs may develop stronger relations over the course of the three-year grant
Discussion
Agencies with higher COD capability had larger networks of collaborative partners. Does
higher co-occurring capability make a program a more desirable partner, or do stronger co-occurring programs get that way by developing broader partner networks? An alternate explanation recognizes that the quality of collaboration can be influenced by the intra-agency environment (Glisson, 1998). Turbulent, poorly led, and poorly resourced agencies have more difficulty in partnering.
Acknowledgements
Support for this presentation was provided by the Missouri Foundation for Health, a philanthropic organization whose vision is to improve the health of the people in the community it services.
Addiction Health Services Research Conference October 30, 2009
Collaboration and COD Capability
Fragmented service delivery systems present a substantial challenge for the treatment of persons with co-occurring substance use and mental health disorders. One solution focuses on improved linkage and collaboration between substance abuse, mental health and other service providers. Collaboration research has most often focused on business, government and nonprofits, or grant partners, with the aim that partnerships will remain after funding ceases. Collaborative partnerships have been viewed as a prerequisite for sustainability.
Potential Benefits of Collaboration
Client – faster access to more appropriate services, improved continuity of care, less likely to “fall through the cracks” in the service system Behavioral health staff – professional development, reduced role anxiety, greater sense of accomplishment and less role confusion Agency – provide needed services, shared resources, creative interventions, greater efficiency, enhanced communication and professional standing System – more effective service delivery, less fragmentation and duplication, improved cost effectiveness, improved ability to advocate and influence public policy
Tensions, Conflicts and Dilemmas of Collaboration
Behavioral health staff – communication, stigma, misconceptions about potential clients, professional knowledge and boundaries, trust, role ambiguity and clinical autonomy Agency – communication, incongruent values, missions, and cultures, work practice changes, practical considerations (client expectations, confidentiality, HIPAA) System – resources, agency competition, information systems, performance indicators, lack of effective interagency structures
Collaboration and COD Capability
Sociological and organizational studies suggest that network range and cohesion affect the efficiency of collaboration and information sharing. Network structure and tie strength can affect knowledge transfer, organizational change, innovation, and service delivery (Cross et al, 2009). There have been few systematic efforts to study organizational models that guide the delivery of integrated care for persons with co-occurring disorders. CJ-DATS findings (Taxman, Fletcher, Lehman, Wexler, and colleagues) Service linkages of SA agencies (Lee et al., 2006)
Stage Models of Collaboration
Stage models most often classify collaborative efforts along dimensions of increasing integration and increasing formalization of work processes Hogue’s (1993) taxonomy considers the purpose, structure, and process of collaboration. Level No Interaction Networking Cooperation Coordination Coalition Collaboration
Trait Co-existence Loosely defined roles Formal communication Some shared decisions Some shared resources Interdependent system
Study Context: The Missouri Foundation for Health’s Co-Occurring Disorders Priority Area 7
An initiative to support the implementation of evidence-based practices for co-occurring substance use and mental health disorders Publicly-funded treatment providers received support for system change: 14
programs awarded 3-year grants in Dec 2006 13 programs awarded 3-year grants in June 2007
Grantee programs are encouraged to initiate and develop collaborative partnerships.
Study Aims
Describe the network composition, size and tie strength of 27 community-based programs implementing evidence-based practices for cooccurring disorders Differences
between SA and MH programs?
Illustrate the use of a Collaboration Map Do programs with higher co-occurring capability report larger network size and stronger network ties?
Participating Programs 9
18 mental health programs and 9 substance abuse programs providing services to adults (“grantees”). Characteristic
Mean
SD
Range
Agency Age
27.7 years 8.7
4 – 41
Agency Annual Operating Expenses
$10.6M
$9.7M
$1.9 – 34.6M
Clients below Federal Poverty Level
77.4%
24.5%
19.6 - 100%
Most located in urban areas: Urban Core: 3 SA providers, 11 MH providers, 51.9% Large Town: 4 SA providers, 6 MH providers, 37.0% Small Town: 1 SA provider, 1 MH provider, 7.4% Isolated Small Census Tract: 1 SA provider, 3.7% Measuring Rurality: Rural-Urban Commuting Area Codes, USDA, 2007
Methods: Collaboration
Partners identified by each grantee Interview with each partner Agency
description (mission, services, size) Tie Strength with all network partners Barriers to collaboration with grantee Facilitators of collaboration with grantee
Level of Collaboration Survey (Frey et al., 2006) High
test-retest reliability (R ~ .8) Used to measure network changes among grant partners
Measure: Co-Occurring Capability 11
Dual Diagnosis Capability in Addiction Treatment (DDCAT) Index - McGovern, Matzkin, & Giard, 2007 Dual Diagnosis Capability in Mental Health Treatment (DDCMHT) Index – Gotham et al., 2009 Semi-structured questions to elicit ratings on 35 items across 7 subscales:
Program Structure Program Milieu Clinical Process: Assessment Clinical Process: Treatment
Continuity of Care Staffing Training
Based on the American Society of Addiction Medicine’s Patient Placement Criteria (ASAM-PPC-2R)
Measure: Co-Occurring Capability 12
Programs received domain and global scores along a continuum:
Addiction Only or Mental Health Only Services (AOS/MHOS, 1)
Dual Diagnosis Capable (DDC, 3)
Programs that by choice or lack of resources cannot accommodate clients with co-occurring disorders, no matter how stable the illness and however well-functioning the client Programs that have a primary focus on one disorder but are capable of treating clients who have relatively stable diagnostic or sub-diagnostic co-occurring problems
Dual Diagnosis Enhanced (DDE, 5)
Programs that are designed to treat clients who have more disabling or unstable co-occurring disorders
Co-Occurring Capability DDE
5
4
DDC
Mean COD Capability = 2.65 Range = 1.57 – 3.60, SD = 0.53
3
2
AOS/ 1 MHOS
No differences: SA vs. MH programs or Urban vs. non-urban programs
Collaborative Partner Map Grantee
Average
Average
5
Number Of Links 4.2
Tie Strength of Collaboration 3.4
3.4
NAMI HIV/AIDS Service Organization
4
4
2.3
Drug and Alcohol treatment
4
3.5
HIV/AIDS Service Organization
4.3
3
Drug Court 5
4.5
2.3
Key Level 0 Level 1 Level 2 Level 3 Level 4 Level 5
None Networking Cooperation Coordination Coalition Collaboration
No line No line
Grantee Networks
Network Size On
average, 5.9 Partners (Mdn = 5, range = 0-14) Collaborators, on average, had “connections” with 81% (4.8/5.9) of the other network partners
Network Tie Strength Across
grantee networks, tie strength averaged 2.5 MH grantees described stronger connections (2.7, or approaching the Cooperation level) SA grantees described lower levels (2.2, or just above the Networking level)
Network Size and Composition MH grantees had slightly larger networks than did SA grantees (6.1 vs. 5.3; d = 0.26) # Partners by Service Type Substance Abuse Mental Health* Medical Criminal Justice* Other Social Service* *p < .05
SA Grantee 1.5 3.0 0.2 0.2 0.4
MH Grantee 1.4 0.9 0.5 1.4 1.9
COD Capability and Collaboration
Network size and COD Capability were moderately correlated (R = .37, p < .10) AOS/MHOS
programs averaged 5.3 partners, while DDC programs averaged 6.2 partners
Tie strength and COD Capability were not associated
Discussion
Collaborative networks at 27 programs working to develop integrated co-occurring services most often included 5 or 6 partners Grantees described connections to complementary COD services, the criminal justice system, and a variety of social service providers, but few grantees had connected with primary health partners. Mental health and substance abuse programs differed:
MH grantee networks were slightly larger than SA networks SA grantee networks included more MH partners MH grantee networks included more CJ partners
The larger size of MH grantee networks may reflect somewhat greater resources
Discussion
Partners most often interacted at the Networking or Cooperation levels of collaboration Tie Strength was not related to COD capability The
variety and number of resources for clients may be more important than collaborating at a high level Programs may develop stronger relations over the course of the three-year grant
Discussion
Agencies with higher COD capability had larger networks of collaborative partners. Does
higher co-occurring capability make a program a more desirable partner, or do stronger co-occurring programs get that way by developing broader partner networks? An alternate explanation recognizes that the quality of collaboration can be influenced by the intra-agency environment (Glisson, 1998). Turbulent, poorly led, and poorly resourced agencies have more difficulty in partnering.
Acknowledgements
Support for this presentation was provided by the Missouri Foundation for Health, a philanthropic organization whose vision is to improve the health of the people in the community it services.
