Claus.ahsr 2009.Collaborative Partnerships and COD Capability

8/14/2019 Claus.ahsr 2009.Collaborative Partnerships and COD Capability

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Co-occurring Capability and Collaborative

Partnerships:

Understanding the Service Linkages of

Substance Abuse and Mental HealthPrograms

Ron Claus, Ed Riedel, Mary E. Homan, and Steven Winton

Missouri Institute of Mental Health, University of Missouri

Addiction Health Services Research ConferenceOctober 30, 2009


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Collaboration and COD Capability

Fragmented service delivery systems present asubstantial challenge for the treatment of persons withco-occurring substance use and mental health disorders.

One solution focuses on improved linkage andcollaboration between substance abuse, mental healthand other service providers.

Collaboration research has most often focused onbusiness, government and nonprofits, or grant partners,with the aim that partnerships will remain after fundingceases. Collaborative partnerships have been viewedas a prerequisite for sustainability.


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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, improvedability to advocate and influence public policy


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Tensions, Conflicts and Dilemmas of

Collaboration Behavioral health staff communication, stigma,

misconceptions about potential clients, professionalknowledge and boundaries, trust, role ambiguity andclinical autonomy

Agency communication, incongruent values, missions,and cultures, work practice changes, practicalconsiderations (client expectations, confidentiality,HIPAA)

System resources, agency competition, informationsystems, performance indicators, lack of effectiveinteragency structures


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Collaboration and COD Capability

Sociological and organizational studies suggest thatnetwork 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 ofintegrated 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)


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Stage Models of Collaboration

Stage models most often classify collaborative

efforts along dimensions of increasing integrationand increasing formalization of work processes

Hogues (1993) taxonomy considers the purpose,

structure, and process of collaboration.

Level Trait

No Interaction Co-existence

Networking Loosely defined roles

Cooperation Formal communication

Coordination Some shared decisions

Coalition Some shared resourcesCollaboration Interdependent system


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An initiative to support the implementation of

evidence-based practices for co-occurring substanceuse 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 Context: The Missouri Foundation for

Healths Co-Occurring Disorders Priority Area7


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Study Aims

Describe the network composition, size and tie

strength of 27 community-based programsimplementing evidence-based practices for co-

occurring disorders

Differences between SA and MH programs?

Illustrate the use of a Collaboration Map

Do programs with higher co-occurring capabilityreport larger network size and stronger network

ties?


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Participating Programs

Characteristic Mean SD Range

Agency Age 27.7 years 8.7 4 41

Agency Annual Operating Expenses $10.6M $9.7M $1.9 34.6MClients below Federal Poverty Level 77.4% 24.5% 19.6 - 100%

9

18 mental health programs and 9 substance abuse programs

providing services to adults (grantees).

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


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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 grantpartners


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Measure: Co-Occurring Capability

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 itemsacross 7 subscales:

Continuity of Care

Staffing

Training

Program Structure

Program Milieu

Clinical Process: Assessment

Clinical Process: Treatment

Based on the American Society of Addiction Medicines Patient Placement Criteria

(ASAM-PPC-2R)

11


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Measure: Co-Occurring Capability

Programs received domain and global scores along a

continuum: Addiction Only or Mental Health Only Services (AOS/MHOS, 1)

Programs that by choice or lack of resources cannot accommodate

clients with co-occurring disorders, no matter how stable the illness andhowever well-functioning the client

Dual Diagnosis Capable (DDC, 3) Programs that have a primary focus on one disorder but are capable of

treating clients who have relatively stable diagnostic or sub-diagnosticco-occurring problems

Dual Diagnosis Enhanced (DDE, 5) Programs that are designed to treat clients who have more disabling or

unstable co-occurring disorders

12


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Co-Occurring Capability

1

2

3

4

5DDE

DDC

AOS/

MHOS

No differences: SA vs. MH programs or

Urban vs. non-urban programs

Mean COD Capability = 2.65

Range = 1.57 3.60, SD = 0.53


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Average Average

Number Tie StrengthofOf

Links Collaboration

4.2 3.4

Key

Level 0 None NolineLevel 1 Networking NolineLevel 2 CooperationLevel 3 CoordinationLevel 4 CoalitionLevel 5 Collaboration

Grantee

5 3.4

NAMI

4 3.5

HIV/AIDSService

Organization

4 2.3

Drug andAlcoholtreatment

4 4.3

HIV/AIDSService

Organization

3 2.3

Drug

Court

5 4.5

Collaborative Partner Map


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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)


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Network Size and Composition

# Partners by Service Type SA Grantee MH Grantee

Substance Abuse 1.5 1.4

Mental Health* 3.0 0.9

Medical 0.2 0.5

Criminal Justice* 0.2 1.4Other Social Service* 0.4 1.9

MH grantees had slightly larger networks than did SA

grantees (6.1 vs. 5.3; d= 0.26)

*p < .05


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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


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Discussion

Collaborative networks at 27 programs working to developintegrated 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 socialservice 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 reflectsomewhat greater resources


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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


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Discussion

Agencies with higher COD capability had largernetworks of collaborative partners.

Does higher co-occurring capability make a program amore desirable partner, or do stronger co-occurringprograms get that way by developing broader partnernetworks?

An alternate explanation recognizes that the quality ofcollaboration can be influenced by the intra-agency

environment (Glisson, 1998). Turbulent, poorly led, andpoorly resourced agencies have more difficulty inpartnering.


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Acknowledgements

Support for this presentation was provided by the

Missouri Foundation for Health, a philanthropicorganization whose vision is to improve the health

of the people in the community it services.

Documents

Claus.ahsr 2009.Collaborative Partnerships and COD Capability