Improving service systems through systems integration: the ACCESS Program.

In 1990, the Federal Task Force on Homelessness and Severe Mental Illness--with representatives from the Departments of Health and Human Services, Housing and Urban Development, Labor, Education, Veterans Affairs, and Agriculture--was convened to develop a national agenda to end homelessness among people with serious mental illness. In 1992, their findings and recommendations were published in Outcasts on Main Street. Report of the Federal Task Force on Homelessness and Severe Mental Illness.(1) The Task Force acknowledged that many of the services that homeless people with serious mental illness require are inadequately financed and in short supply. In addition, services are provided by various public and private agencies, many with their own area of specialty, financing sources, eligibility requirements, geographic target, and procedures for operating. To obtain access to services, people who are homeless and seriously mentally ill have to overcome enormous barriers created by these complicated and fragmented bureaucracies. For this reason, they are likely to fall between the cracks and receive fewer services than other special-need populations.

About one-third of single adults who are homeless have serious mental illnesses. While they are a diverse group, they share certain characteristics that contribute to their becoming and remaining homeless. They tend to be poor, unemployed, uneducated, members of racial and ethnic minorities, have few or tenuous social ties, and have frequent contact with the criminal justice system. More than half have cooccurring alcohol or substance abuse disorders.

In an effort to help these people to move from the streets into permanent housing and receive all of the services and supports they need to keep that housing and live a fulfilling life, the task force recommended a national demonstration program that would identify innovative approaches to developing integrated systems for insuring that comprehensive services are available, accessible, appropriate, and accountable for homeless people with serious mental illness.

The ACCESS Program

The ACCESS (Access to Community Care and Effective Services and Supports) Program, a 5-year demonstration program administered by the Homeless Programs Branch of the Center for Mental Health Services (CMHS), was initiated by CMHS in response to this recommendation. The long-term goal of the ACCESS Program is to foster enduring partnerships that will improve the integration of existing federal, state, local, and voluntary service systems to homeless people with serious mental illness, particularly those with cooccurring alcohol or other substance abuse disorders. The more immediate goal is to identify promising approaches to systems integration and to evaluate their effectiveness in providing services to this population. In September 1993, nine states were awarded approximately $17 million in cooperative agreement grants for 18 communities to test systems reform strategies that encourage cooperation among different levels of government and voluntary organizations to eliminate service fragmentation. Similar amounts were awarded to these states in September 1994, and comparable levels of funding are expected through 1998.

The states and localities receiving funds are: Bridgeport and New Haven, Connecticut; two communities in Chicago; Sedgwick and Shawnee counties in Kansas; St. Louis and Kansas City, Missouri; Mecklenburg and Wake counties in North Carolina; two communities in Philadelphia; Austin and Fort Worth, Texas; Richmond and Hampton/Newport News, Virginia; and two communities in Seattle, Washington.

The two communities in each state were matched on selected demographic and economic variables. To test the effectiveness of different integration strategies, CMHS randomly assigned the two communities within each state to either an integration or a comparison condition. Both communities within each state receive similar levels of service funds to provide assertive outreach and case management. In addition, the integration community receives additional funds to demonstrate different integration strategies. An important component of the ACCESS Program is a national evaluation which is comparing the integration and comparison communities within each state and across all nine states. The system-level evaluation will identify the different systems integration approaches, document how they are implemented, and measure their impact on system capacity and system barriers. The client-level evaluation will determine whether systems integration efforts result in improved service delivery; improvements in mental health and health status, rehabilitation, quality of life; and permanent exit from homelessness.

Systems Integration vs. Services Integration

The concept of systems integration is often confused with the concept of services integration. The goal of services integration is to maximize an individual's use of existing resources in order to help that person achieve improved functioning, greater independence, and enhanced quality of life. Case management is an example of a services integration strategy. The case manager helps clients obtain mental health and substance abuse treatments, benefits and entitlements, rehabilitation and health services, dental care, housing, and transportation. In contrast, systems integration refers to establishing linkages with agencies within a system and across multiple systems to facilitate the provision of services to individuals at the local level. Systems integration focuses on reducing barriers, coordinating and improving existing services, and developing new programs to improve the availability, quality, and comprehensiveness of services.

Examples of Systems Integration Strategies

A variety of innovative strategies is being tested across the nine states, with each integration community demon-strating a combination of these strategies. Multi-agency task forces are being established at the systems level by many of the integration communities to promote alliances among the participating agencies, identify barriers to service delivery, and develop strategies to address these barriers. Some of the strategies include developing uniform assessment, referral, and eligibility processes and creating shared electronic client and resource databases. Other strategies include staff training about the services provided by other agencies (i.e., cross-training), cooperative agreements for sharing or coordinating resources, and collaborative proposals to various funding sources to create new resources.

Several integration communities are creating one-stop shopping models. These are multiservice centers where health-care, mental health and substance abuse treatment, housing assistance, rehabilitation services, vocational training, and entitlements are provided in one location. These centers are usually situated in low-demand settings where homeless persons can also find relief from the streets and get a meal and shower.

A managed care approach to service delivery is being tested in one community in which homeless people with serious mental illness will be able to choose among a network of affiliated service providers. Contracts and interagency agreements are being developed with many service providers to provide a comprehensive range of services, including substance abuse treatment, mental health services, health-care, family support services, and a drop-in center.

Anticipated Changes

A major goal of the ACCESS Program is to create "any door" access. If communities are successful in creating integrated service systems, any homeless person with serious mental illness should be able to contact an agency, within or outside of the mental health system, be assessed, and obtain a full complement of services and supports. To accomplish this will require major changes in the way agencies currently operate and interact with one another. All public and private agencies that provide mental health and substance abuse treatment, health-care, housing assistance, rehabilitation, and income supports and entitlements will have to share in the responsibility of providing services to people who are homeless and have serious mental illness. Interdepartmental collaborations will be necessary to develop common goals, share resources, and reduce service barriers. Also, there will need to be authorities designated at the local or state level to provide coordinated leadership for systems integration activities and be held accountable for the results.

Although it will take a number of years to complete this demonstration program, positive results are already occurring. Relationships are being forged with agencies that historically have underserved or ignored this population. In addition, barriers to service delivery are being identified and solutions for overcoming these barriers are being implemented. An evaluation report will be published annually to provide a timely summary of results to date.

Note

(1.)Copies of this report are available from the Center for Mental Health Services, Office of Consumer, Family and Public Information, 5600 Fishers Lane, Room 15-99, Rockville, MD 20857.