Claus, Renner & Riedel, Building Equitable Partnerships, November 2008

8/14/2019 Claus, Renner & Riedel, Building Equitable Partnerships, November 2008

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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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