One of the essential and most challenging tasks facing the change agent promoting an integrated response to persons with co-occurring disorders is identifying necessary resources. Without funding, programming and supports to implement new concepts, even the most articulate strategic plan becomes no more than an exercise in frustration.
Because money is always tight in every system, the change agent is likely to be told that no funds are available for systems integration activities. However, before accepting this response, it is important to step back for a moment and consider the many systems that serve public clients.
Large amounts of money are spent on a broard array of activities by various systems, yet very little of this money is spent in the most efficient, effective and integrated fashion. Many systems provide specific, ongoing services to clients with complex and challenging problems, but the outcomes often are not as favorable as they might be if the services were integrated and well coordinated. Current clinical research indicates that persons with co-occurring mental health and substance abuse disorders do not improve significantly when treated in sequential or parallel fashion by two treatment systems. Thus we are spending large amounts of limited public funds on services that do not provide the most effective treatments.
Identifying the complete array of existing resources requires conducting an inventory of programs and services across all systems that serve clients with multiple problems. Although this can be a time consuming and challenging activity, knowledge of allocated resources in your system is highly relevant and important. Systems to include in this inventory are:
- mental health services,
- substance abuse and chemical dependency services,
- subsidized and supported housing programs,
- local and statewide entitlement programs (e.g., general assistance, welfare),
- local police jurisdictions (e.g., city police, county sheriff),
- local court systems (e.g., judicial and probation services), and
- local correctional systems (e.g., jails, community corrections and other alternative sanctions).
As a result of system fragmentation and a lack of coordination and integration, the level of resources and funding available to serve multiple-problem clients may be surprisingly high—even staggering. There may be more money spent than any single system knows about.
Each system perceives that it is underfunded—given the scope of the tasks each system is expected to accomplish—and this may be the case. Yet when the resources are tallied across multiple systems, it may become clear that with so much funding, measurable client outcomes should be reflecting more consistently positive treatment outcomes.
The task of collecting information about current resource allocations may meet with substantial resistance. Unless the process occurs in an open and collegial fashion, participants may experience a perceived threat when one system examines and questions how money is spent in another system.
Systems may feel their decisions about resource allocations are being chal- lenged. It is important to carefully determine what are reasonable and unreasonable levels of resistance.
Target Duplication
Where feasible, the inventory of resources should identify where funding, time and effort from multiple systems (or within one system) are spent on the creation of parallel or duplicate programs or services. Challenging the existence of services that appear to be inefficient or duplicative must be done with care and great diplomacy. It is imperative to frame questions in a manner that invites informative responses.
Remain open to the possibility that duplication of services may be a valuable component of the system. A system offering multiple portals of entry may actually help to advance the goal of “No Wrong Door” if it creates opportunities for clients to select a doorway best suited to their geographical location or their clinical conditions. Other forms of duplication may be less defensible and more readily challenged.
For example, many jurisdictions maintain separate 24-hour crisis and help lines for both mental health/suicide calls and drug/alcohol information. These programs are an artifact of traditional funding silos and organizational structures. Individuals who answer the phones in these types of programs usually indicate that a significant proportion of callers present issues that are relevant to both the mental health and substance abuse systems, suggesting the presence of co-occurring disorders.
Maintaining expenses associated with two separate and distinct programs is a duplication of services and a waste of resources. An integrated crisis telephone service with the professional capacity to address the full spectrum of mental health, substance abuse and co-occurring disorders will provide better care and save money at the same time.
Identify Ineffective Practices
Change agents should be prepared to examine existing programs and question local services and systems that may not meet best practice standards. To do so, they need to become familiar with the growing body of literature and research that demonstrates the effectiveness of integrated mental health, substance abuse and other services for persons with co-occurring disorders and with promising practices and models of integrated services that are being developed, tested and implemented around the country.
For example, in King County, Wash., a careful analysis of data on services collected by the state found that in a recent 12-month period, more than 1,300 individuals received simultaneous services in both the mental health and substance abuse systems. The services provided to these individuals were among the most expensive the system had to offer—including inpatient psychiatric hospitalization, residential treatment, detoxification and intensive case management. At the time the data were collected, few of the services incorporated the principles or practices of an integrated approach to co-occurring disorders. Although specific outcomes for these individuals could not be tracked with the county’s existing data system, national research confirmed local providers concerns. Without integrated care, these individuals would not show much improvement. The price tag for serving these 1,300 individuals exceeded $4.2 million annually. Local elected officials and appointed policy makers agreed on the need for a more effective, integrated system of care.
It is the responsibility of the change agent to challenge poor and ineffective practices. Using solid data to make the case, mediocre programming not meeting desired outcomes can be effectively channeled in a more integrated direction.
Locate Unexpended Resources
Not all funding for integrated programming needs to come from existing services, even if these services are not operating with maximium efficiency and effectiveness. The savvy change agent identifies unspent funds in each system. Every system has them, even though they are called by different names in different contexts. In most public systems, there often are unspent funds at the end of each fiscal year.
Avoid initial concern that these unexpended resources are given the “one-time money” label. If the system generates “one-time money” every year, then these resources constitute an ongoing funding stream. If “one-time money” is used to generate programming that clearly demonstrates improved outcomes for those clients who need services, programming will be continued,
and more stable, ongoing funding streams
will be identified.
Locating funds requires the change agent to become a systems sleuth. Many creative system managers are careful to shield these resources in order to fund specific projects or backfill revenue shortfalls.
In a fee-for-service system, money may accrue as a result of underutilization. In managed care environments that capitate or case rate services (rather than use a fee-for-service modality), money accrues when payments exceed expenses incurred in providing care. These accruals may be labeled as “fund balance” and kept either at the system level or in provider agency coffers.
Large, well-managed systems can develop fund balances that run well into seven or eight figures. When these savings are not returned to general fund pools or distributed as profit to the shareholders of private managed care organizations, they can be reinvested to help meet the needs of individuals for whom the managed care paradigms are not as successful. These groups may include homeless persons, clients involved in the criminal justice system and those with co-occurring mental health and substance abuse disorders. These unspent funds can be a valuable resource to the change agent.
Target Non-Cash Resources
Not all resources of interest to the change agent are financial. With enhanced coordination or modest modification, existing services or
programs often become part of an inte-integrated approach to complex problems. It may be easier, both organizationally and politically, to request that funders and providers utilize existing parts of collaborative efforts rather than radically reallocate resources and rearrange services.
Not all resources of interest to the change agent are financial.
With enhanced coordination or modest modification,
exisitng services or programs often can become part of
an integrated approach to complex problems.
Transforming existing programming helps to acknowledge and validate efforts made by dedicated stakeholders. This strategy can be successful with capital resources, services that support them, and existing organizational structures and programs. The following examples will help to illustrate this point:
Shelter Beds
Although it may be difficult to raise the funds required to expand shelter capacity for persons with co-occurring disorders, policies for the use of existing shelter beds can be reviewed. Beds can be prioritized and modified to serve the most severely compromised individuals who are homeless and struggle with multiple problems.
Modest capital improvements can provide the renovations necessary for sheltering more severely disabled individuals. Training for shelter staff can be developed to better equip them with the required skills for working with these challenging populations.
Transitional and Permanent Housing
Effective advocacy with local housing authorities and the organizations that manage housing subsidy programs, such as Shelter Plus Care and Section 8, can help ensure that persons with co-occurring disorders gain access to housing and the services and supports needed to sustain safe housing. Housing authority officials are more likely to place persons with serious mental illness in existing units if there are effective linkages and agreements between housing authorities and mental health and substance abuse services providers that offer on-site consultation and case management services.
Crisis Response Services
Following a model developed in Memphis, Tenn., and later replicated throughout the nation, local police departments can be encouraged to create Crisis Intervention Teams (CIT). In CIT programs, training is provided to seasoned law enforcement officers to enhance skills related to persons manifesting the symptoms of mental illness and substance abuse.
Local 911 operators can request that CIT trained officers be dispatched to calls involving behavioral health crises. Where successfully implemented, these teams have proven invaluable. They serve a pre-booking diversion function and help prevent the arrest and jailing of individuals who could be charged with nonviolent misdemeanors. These teams have also benefited the police by training officers to de-escalate potentially dangerous situations.
Generate Integrated Pilot Project
Once the change agent has developed a clear sense of the resources currently present across multiple systems, he or she can begin to conceptualize the details of pilot projects and integrated programming.
Proposing blended resources will be essential at this point in the process. One-time money, in-kind services, and existing capital facilities and programs can be assembled to create integrated, systemic responses to identified needs.
Blended funding also stimulates a sense of shared ownership in specific projects. If multiple systems make an investment in an integrated activity, stakeholders will develop interest in ensuring that the effort is successful. These integrated efforts create a natural synergy through creating a service or project no one system could afford on its own.
In King County, a Crisis Triage Unit (CTU) was developed as a component of the system’s “No Wrong Door” vision. The CTU was conceptualized as a place where any person experiencing a behavioral health crisis could come, 24 hours a day, 7 days a week, for integrated assessment, stabilization services and linkage to community-based supports to address ongoing needs.
Although system stakeholders supported the CTU, its estimated price tag—in excess of $2.4 million annually—made the unit seem more a fantasy than a possibility. The CTU cost far more than any single system could afford. Yet an examination of available system resources that could be blended into the CTU model identified components of the initiative for marketing to a variety of funders and stakeholders.
The county hospital provided space to house the Crisis Triage Unit as well as psychiatric services and staff supports. The county mental health, substance abuse and correctional systems provided additional staff supports for the CTU, “back door” discharge planners linked to community-based treatment services and fast-track access to next day appointments, detoxification and residential treatment services.
The state developmental disabilities system provided staff supports to enhance treatment and discharge planning for persons with developmental disabilities. The city of Seattle provided shelter beds that were converted into a secure respite unit for persons without stable housing who were being discharged from the CTU.
Together these six systems were able to blend both dollars and in-kind resources to facilitate mobilization of the Crisis Triage Unit. Today, the unit serves more than 600 individuals each month. The collective resources of these six systems continue to provide the foundation for the CTU. The synergy that resulted from the project has been far greater than any one system could have anticipated.
The Crisis Triage Unit has become the focal point for both hospital and jail diversions, and it may help both the treatment and criminal justice systems realize significant cost savings through reductions in the rates of hospitalization and incarceration. Although resources dedicated to the unit have been threatened by funding cuts, the fact that all six systems have ownership in the project has helped to ensure that crucial resources supporting the Crisis Triage Unit continue to be leveraged from multiple systems.
With a strategic planning process in place and a clear sense of the resources present across multiple systems, the change agent is in a unique position to mobilize activities that have the potential to move these systems toward their collective vision of fully integrated services.
This material was prepared by David M. Wertheimer, M.S.W., M. Div.,
Service and Systems Integration
Administrator for the King County, Wash., Department of Community and Human Services. For additional
information on this topic, contact him at davidmwertheimer@aol.com or at (206)726-0102.
