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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)
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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.