Robert Rosenheck MD Professor of Psychiatry and Public Health, Yale Medical School

1. 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

2. 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

3. 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).

4. 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

5. 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

6. 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

7. 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)!

8. Nevertheless… In spite of lack of evidence of adverse effects of fragmentation there have been many efforts to correct it by fostering “services integration”.

9. 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.

10. 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.

11. 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.

12. 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 IFthere are unrealized synergies or interdependencies.

13. 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

14. 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

15. 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.---)

16. 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.

17. Hypothesized Causal Chain Funds and technical assistance Implement Integration Interventions Improved access and outcomes More Integrated System

18. 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).

19. 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 Twelve ACCESS “Systems Integration” Interventions

20. Implementation of Systems Integration Strategies: Experimental vs. Comparison Sites, Years 4 and 5.

21. Two kinds of integration Project-centered System-wide

22. Changes in Integration: Experimental vs. Control Sites

23. OUTCOMES AS HYPOTHESIZED BY SYSTEMS INTEGRATION ASSIGNMENT AND BY COHORT:PSYCHIATRIC SYMPTOMS*

24. OUTCOMES AS HYPOTHESIZED BY SYSTEMS INTEGRATION ASSIGNMENT AND BY COHORT: NOT HOMELESS FOR 30 DAYS

25. OUTCOMES BY SYSTEMS INTEGRATION ASSIGNMENT AND BY COHORT:PSYCHIATRIC SYMPTOMS*

26. OUTCOMES BY SYSTEMS INTEGRATION ASSIGNMENT AND BY COHORT: NOT HOMELESS FOR 30 DAYS

27. Hypothesized Causal Chain: Summary of Results Funds and technical assistance Implement Integration Interventions Improved access and outcomes More Integrated System YES YES NO

28. One Thing We Learned: System Integration and Housing Outcome* r=.51 *Housing data are adjusted for differences in client characteristics

29. 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 .92d .31d Other Services .97d .94d .27b Unexplained variance Housing Affordability 3 MONTHS 12 MONTHS BASELINE

30. Lesson Learned? • Integration can make a difference in client outcomes! • The ACCESS initiatives failed to harness it to make a difference in client outcomes.

31. What next? • Look for a theory. • What kind of theory? • Something social/organizational. • Something that fixes some problem! • Social Capital • Industrial capital=machines • Human capital=education • Social capital=authority, norms, trust • To take advantage of interdependencies • By improving coordination/cooperation • Lowering transaction costs.

32. 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)

33. 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.

34. 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)

35. Case Management (CM) Services Delivered in First Three Months CM+Voucher CM Alone Control Voucher by 3 Mos. 55% 2% 1% Helped Locate Apt. 44% 26% 9% Apts. CM Visited 2.1 0.6 0.0 CM met Landlord 71% 45% 0% Helped Furnish Apt. 37% 22% 4% Vet .Terminated 8% 17% 53%

38. 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.

39. 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.

40. SSA-VA Joint Outreach: Rates of Application for Benefits (N=34,431) Intervention

41. SSA-VA Joint Outreach: Rates of Award Among Applicants (N=3,952) Intervention

42. SSA-VA Joint Outreach: Rates of Award Among All Outreach Veterans (N=34,431) Intervention

43. 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).

44. 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

45. 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)

46. 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

47. 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).

48. Conceptual Conclusions (1) • Problem of fragmentation is not as well demonstrated as commonly assumed and should be demonstrated before designing integrating interventions.

49. 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.

50. Conceptual Conclusion (3): Integration efforts can be general or specific and can be distal (higher level) or proximal (lower level) Distal Proximal General RWJ/ACCESS ACT Specific HUD-VA Collab Care SSA-VA (Katon/Wells)