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NECESSARY PARTNERSHIPS: A VIEW OF MENTAL
HEALTH AND SUBSTANCE ABUSE PROVIDER
NETWORKS IN RURAL AND URBAN MISSOURI
RON CLAUS, PHD
MICHAEL RENNER, MSW
EDWARD G. RIEDEL, LCSWJJ RORICK, LCSW
MARY E. HOMAN, MA
BUILDING EQUITABLE PARTNERSHIPSNOVEMBER 5-7, 2008
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Where in the World is Missouri?
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Missouri Foundation for Health
Beginning
Nonprofit Blue Cross Blue
Shield of Missouri converts
to for-profit RightChoice
MFH created in 2000 to
receive Blue Cross Blue
Shield of Missouri nonprofitassets
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Who We Are
Independent, nonprofit organization
Not funded with state or federal monies FocusGrant making
Health policy Goals Fill gaps in health care services for the uninsured
and underinsure Identify and address unmet health care needs
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Mental Health & Substance Abuse
Funding Program
Co-Occurring Disorders23 Agencies
Integrating mental health and substanceabuse programs
Focus on organizational changeTechnical assistance on implementation
Evaluation
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Technical Assistance
ZiaLogic
Provided by Dr. Ken Minkoff and Dr. Christie Cline
Help leverage resources & facilitate systems change statewide Assist grantees to become COD competent
MIMH
Evaluate impact of all projects
Conference calls to discuss process and findings
Assist grantees with evaluation design, data collection, analysis, report writing.
MFH
Organize grantee convenings
Support Change Agent Cadre
Conduct site visits
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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 due to multiple problems like co-occurring Behavioral health staff professional development,
reduced anxiety, greater sense of accomplishment and
less role confusion Agency shared resources, creative interventions,
greater efficiency, enhanced communication
System more effective service delivery, lessfragmentation & duplication, improved costeffectiveness, improved ability to advocate andinfluence public policy
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Challenges of Collaboration
Behavioral health staff stigma, misconceptions
about potential clients, professional knowledge andboundaries, role ambiguity and clinical autonomy
Agency incongruent values, missions, and cultures,
practical (client expectations, confidentiality, HIPAA)
System resources, agency competition, lack of
effective interagency structures
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Study Aims
Describe the collaborative partnerships of 23
community-based agencies implementing evidence-based practices for co-occurring disorders
Differences between SA and MH agencies?
Differences between urban and non-urban agencies?
Report on barriers to collaboration identified by the
collaborators Examine the association between the co-occurring
capability of an agency and collaboration
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Collaboration
Collaboration refers to a cooperative process ofexchange involving communication, planning, and actionof two or more entities working together towards ashared goal.
Communication, planning and action (Amir & Auslander,2003)
Cooperative (Frey, 2006)
Individual, intra-agency and interagency communicationskills (Ferrara, 1996)
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Levels of Collaboration
No Interaction
Networking
Cooperation
Coordination
Coalition
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No interaction
One agency has not heard of the other agency
Or
The agency is familiar with the others services but
they do not interact
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Networking
Sharing information Creates dialogue and common understanding
Communication is usually the primary link
There are minimal decisions made together
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Cooperation
Limits duplication of services
Communication link is advisory
Facilitative leadership positions are forming
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Coordination
Share resources to address a common issue/ mergeresources to create something new.
Links are formalized and roles are defined
Communication is frequent and leadership isautonomous but the focus is on a shared issue.
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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 receivedsupport for system change
SA & MH providers in MO
10 programs awarded 3-year grants in Dec 2006
13 programs awarded 3-year grants in June 2007
Missouri Foundation for Healths
Co-Occurring Disorders Priority Area
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Evaluation Process
Partners identified by each grantee
Brief (20-30 minute) phone interview with eachpartner
Agency description (mission, services, size)
Collaboration Level with all network partners
Barriers to collaboration with grantee
Facilitators of collaboration with grantee Report to grantee
Collaboration Map
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Levels of Collaboration Survey
Respondents were identified by the grantees
change agent All consented to be interview by evaluation staff
Descriptions of levels of community linkage
provided in advance
Respondents reported extent to which they
collaborated with each other partner, from 0 = No interaction at all
5 = Collaboration
Frey et al., 2006
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Perceived Barriers to Service Linkage
Extent to which 18 specific financial and operationalconditions represented barriers to working with thegrantee Financial constraints (e.g., inadequate insurance
reimbursement, managed care restrictions, insufficient
funding) Operational challenges (e.g., caseload problems, long
waiting lists, transportation, hours of operation,
confidentiality) Relationship challenges (e.g., resource competition, mistrust,
different philosophies, client stigma)
5-point scale, Not a problem to Very great problem
Lee et al., 2006
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Grantee Co-Occurring Capability
Dual Diagnosis Capability in Addiction Treatment
(DDCAT) scale - McGovern, Matzkin, & Giard, 2007
Dual Diagnosis Capability in Mental Health
Treatment, parallel version for MH agencies Gotham
Semi-structured questions to elicit ratings on 35 items
across 7 subscales:
Continuity of Care
Staffing
Training
Program Structure
Program Milieu
Clinical Process: Assessment
Clinical Process: Treatment
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Co-Occurring Capability
0
2
4
6
8
10
A
OS/MH
Only
Only/
Capable
COD
Capable
Capable/En
hanced
COD
Enha
nced
Numbe
rofSites SA
MH
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MFH Grantees
Urban Core 54.5% Metropolitan area with > 50,000
10 MH providers, 2 SA providers
Large Town 36.4% Population10,000 49,000
6 MH providers, 3 SA providers Small Town 4.5% Population range 2,500 9,999
1 SA provider Isolated Small Census Tract 4.5% 1 MH provider
Measuring Rurality: Rural-Urban Commuting Area Codes, USDA, 2000
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Average Average
Number 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 andAlcohol
treatment
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)Wide range (0 14 collaborators)
Each collaborator had connections with 81% of the
other network partners (4.8/5.9) on average
Grantee or Location Differences?
MH grantees had slightly larger networks than SAgrantees (6.1 vs. 5.3; d= 0.26)
Urban and non-urban networks were similar in size
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Network Composition
24%
25%
7%
19%
25%
% Collaborative Partners by Service Provided
Substance Abuse
Mental HealthMedical
Criminal Justice
Other
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Differences in Network Composition
NumberofPartners
by
GranteeType Grantee
Type
Overall SubstanceAbuse MentalHealthSubstance
Abuse 1.4 1.5
1.4
MentalHealth* 1.5 3.0 0.9Medical 0.4 0.2 0.5CriminalJustice* 1.1 0.2 1.4
*p < .05
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23%
15%
8%23%
31%
Network Composition
Substance Abuse Grantees Mental Health Grantees
28%
57%
4%
4%
7%SubstanceAbuseMentalHealthMedical
CriminalJustice
Other
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Level of Collaboration
On average, the average Level of Collaborationacross all the grantee networks was 2.5 (out of 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)*
No differences were found between Urban and Non-
urban grantees
*p < .10
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Barriers Perceived by Collaborators
2
2.2
2.3
2.3
2.6
1 1.5 2 2.5 3 3.5 4 4.5 5
Inadequate insurance
Ability to pay out of pocket
Transportation
Caseload problems
Long waiting lists
1 = Not at all a problem, 5 = Extreme problem
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Do agencies with higher co-occurring
capability have more partners?
5.3
6.2
0 5 10
Addiction/Mental HealthOnly
AOS or MH Only/DualDiagnosis Capable
Number of Collaborative Partners
Correlation between Number of Partners & Co-Occurring Capability
R = 0.37 (p < .10)
No Significant Correlation between Level of Collaboration & Co-Occurring Capability!
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Discussion Grantee Differences
Mental Health and Substance Abuse Grantees differed:
MH networks were slightly larger than SA networks
MH networks included more CJ partners; SA networksincluded more MH partners
The level of collaboration was higher for MH grantee
networks
May be due to prior work with partners by MHgrantees; may reflect the generally larger size and
greater resources of MH grantees No differences in network makeup for urban vs. non-
urban grantees
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Discussion - Barriers
Partners identified few and minor barriers to
collaborationMost common: Long waiting lists (slight to moderate);
caseload problems, transportation, and ability to pay
out of pocket for services (slight) Small differences between SA and MH grantees
Small differences between urban and non-urban
grantees
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Discussion Co-Occurring Capability
Agencies with higher COD capability had largernetworks of collaborative partners Developing more resources and discharge planning options
may lead to improved care for clients with COD (butcausality cant be determined)
Strong agencies may be effective at building partnerrelationships and at developing specialized CODprogramming
Level of Collaboration was not related to COD
capability The variety and number of resources for clients may be
more important than working at the Coordination orCoalition level of collaboration level
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Building Partnerships: Practical Stuff
How to identify partners
Clinical Wisdom
Assessing agency culture
Data Driven
Needs Assessment of Consumers, Families, Community
Stakeholders.
Problem Identification
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What Worked
Networking at existing community and coalitionmeetings.
Joint training
Employee sharing
Case consultation Being a resource Behavior planning
Getting it in writing
Planned social events
Clearly defining roles
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What did not work. . .
Assuming what the executive director promised wasgoing to happen- that they communicated thepartnership agreement to front line staff and gotbuy-in.
Assuming people would see a great opportunity likewe did.
Assuming everyone had the same goals and
objectives we did. Putting partnerships at the bottom of the to do
list.
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Getting started
Piggy-back on existing relationships
Consistency and follow through.
Personal relationships - having a contact person
Formalize relationships with agreements or MOUs
Decide how disputes will be resolved
Look for shared opportunities, grants, & presentationsthat meet larger community needs
Offer and accept invitations to cross-educate staff
Identify shared goals and vision.
Start with something that can be fixed easily.
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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.
Thanks to Kim Selig, Lisa Harper Chang, and Cathy
Williams for help with interviewing collaborativepartners
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