by
Deborah L. Dennis, M.A.
Joseph J. Cocozza, Ph.D.
Henry J. Steadman, Ph.D.
Comprehensive systems of care to address the needs of homeless individuals have been called for by researchers and policymakers alike. This paper defines and differentiates systems and services integration, and examines specific strategies for each. A brief historical review of integration in other human services fields is provided. Findings from federal initiatives designed to encourage systems integration for people who are homeless are described and examples given. The paper concludes with suggestions for making systems integration work in practice and further recommendations for policy and research.
Nearly everyone writing on homelessness over the past decade or longer has called for comprehensive integrated systems of care to address the multiple and complex needs of people who become homeless (see for example, Wilkins, 1996; Interagency Council on the Homeless, 1994; U.S. Department of Housing and Urban Development, 1993; Federal Task Force on Homelessness and Severe Mental Illness, 1992; Martin, 1990; Levine, Lezak & Goldman, 1986). Many believed that the services that homeless people needed already existed. What was needed, they argued, was to reorganize the categoric and fragmented housing, health, and social welfare services available at the community level so that people’s needs could be addressed more holistically and more effectively.
As intensive attention was being paid to the problem of homelessness in the late 1980s, many communities found that some services simply did not exist (e.g., there were service gaps) or the demand for housing, shelter and services far outstripped the supply. Even where services existed, they found that those required by people who were homeless crossed systems – the public housing system, the private housing market, the mental health system, substance abuse system, primary health care system, the welfare or social service system, the criminal justice system, and private religious and other organizations. Each of these systems controlled access to any number of needed services and were often not integrated within a given system, let alone across different systems. Moreover, each system had its special purpose, sources of financing, particular eligibility requirements, geographic catchment area, and modes of operation.
Defining Services and Systems Integration
The goals of integration are to improve access to comprehensive services and continuity of care; to reduce service duplication, inefficiency, and costs; and to establish greater accountability (Randolph et al., 1997; Miller, 1996). Until recently, the terms services and systems integration have been used interchangeably. The lack of specificity between the two terms has lead to a good deal of imprecision and confusion for practitioners, policy makers, and evaluators alike. Over time, they have become increasingly distinct. Kahn and Kamerman (1992) distinguish between administrative level strategies that are aimed at changing service delivery for a defined population as a whole and case-oriented strategies designed to change service delivery for individual clients.
The first can be generally thought of as systems integration strategies and the second group fall into the services integration arena. The distinction is more than semantic. The strategies for each vary dramatically and so do the methods and measures for evaluating their impact.(1) The key strategies of each (see Figure 1) overlap with those listed in every major study of integration regardless of the field in which the initiative originated or target population (c.f., Kahn & Kamerman 1992; Cocozza, Steadman & Dennis 1997; Pitcoff 1998).
Figure 1
Strategies for Systems and Services Integration
Systems integration strategies
|
In services integration, services are coordinated, but relationships between agencies do not fundamentally change. Systems integration, by contrast, requires changes in the ways in which agencies interact with each other. There are fundamental changes in the ways in which agencies share information, resources, and clients. Such changes are difficult and time-consuming. Communities using similar strategies can vary greatly in the level of systems integration achieved. Konrad (1996) describes systems integration on a continuum ranging from information sharing and communication to cooperation and/or coordination to collaboration to integration.
Rog (1997) makes another useful distinction among three types of systems-level activities that are frequently found in efforts to integrate services and service systems:
What is often overlooked is that calls for systems integration are far from new (Yessian, 1995; Kahn & Kamerman, 1992; Agranoff, 1991; Yessian, 1991). Although the names change, the underlying concepts do not. Over the past 30 years, efforts to achieve systems integration have been variously called: community integration, comprehensive services, comprehensive planning, coordinated services, systems of care, community support services, and continuum of care—to name a few. In theory, if multiple service agencies were dealing with the same clientele in a case-by-case and uncoordinated fashion, then perhaps gains could be realized and costs reduced if each agency broadened its core service approach to involve coordination with other providers serving the same clients.
This was the impetus for efforts at the local, State, and Federal levels of government to reorganize human services and move them towards an integrated services configuration. Beginning with the Office of Economic Opportunity’s War on Poverty in the 1960s, community action agencies created the local-level capacity for case management which could cross system boundaries to link clients to needed services. The Model Cities legislation of 1966 called for demonstrations that would “overcome the local level service fragmentation in education, manpower, housing, health, mental health, public assistance, and poverty” (Kahn & Kamerman, 1992).
In the 1970s, the U.S. Department of Health, Education and Welfare moved to integrate its 500 programs. As a result, hundreds of demonstrations and state or local reorganizations were created through such initiatives as the Service Integration Target of Opportunities (SITO) program (Agranoff & Pattakos, 1979); the Partnership Program which created “umbrella” agencies for State and local human service bureaucracies (Yessian 1991); the Integrated Projects Funding System, designed to expedite joint funding from various categorical streams; and the Comprehensive Human Services Planning and Delivery System (CHSPDS) projects for systematic experiments with management reforms. These efforts were documented in publications written or collected by Project SHARE, a clearinghouse HEW created and funded to disseminate the results.(2)
Over the years, more services and systems integration initiatives followed in the fields of education, children’s mental health, employment and training, children’s and family services, and health. In each, services integration or coordination was championed as one of the basic strategies for promoting system change at the local level. Most of these efforts relied upon voluntary coordination strategies to promote resource sharing, joint planning, and continuity of care among otherwise autonomous service providers. The goal was to foster linkages (formal and informal interorganizational relationships) among the full range of agencies that were needed to create a comprehensive system of services for the target population in communities across the country.
Today, there is a resurgence of systems integration initiatives funded by public and private agencies in a variety of different fields. Federal programs that have systems integration as a key or primary goal, include: the Target Cities demonstration sponsored by the Center for Substance Abuse Treatment, the Departments of Labor and Education’s School To Work program, the Healthy Start program sponsored by the Health Resources and Services Administration, the federally-funded Empowerment Zones and Enterprise Communities, and the Children and Adolescent Service System Program sponsored by the Center for Mental Health Services. Private initiatives are even more numerous and include the Annie E. Casey Foundation’s seven-year Rebuilding Communities Initiative, the Edna McConnell Clark Foundation’s Neighborhood Partners Initiative, and the Ford Foundation’s Neighborhood and Family Initiative.
Most systems integration initiatives had some form of evaluation though it was often unsophisticated, underfunded, and planned after the fact. While many service integration initiatives have noted successful achievement in system-level goals, increased integration does not necessarily benefit the individuals receiving care (Provan, 1997; Talbott, 1995). Research teams which evaluated the Robert Wood Johnson Foundation’s Program on Chronic Mental Illness (Goldman, Morrissey & Ridgely, 1994), the Fort Bragg Demonstration of managed mental health services for children and adolescents (Bickman et al., 1997) and others have found little evidence that system-level interventions result in improved client outcomes.
Publication of these results has met with considerable debate. Many people in the research and public policy communities have taken these findings as evidence that the organization of services does not make a difference in service delivery and outcomes. Others believe that this judgement is premature and that it has been our inability to adequately measure the relationship between system changes and client outcomes that is responsible for inconclusive results. Still others believe that there is no reason to expect an overall measurable effect. As we will see, demonstrations that address homelessness offer perhaps the greatest opportunity to assess the extent to which client outcomes are related to systems-level interventions.
The literature on homelessness contains findings from four local efforts at systems integration. While these represent single case studies, they offer some insight into the promise and difficulties of systems integration for homeless persons. In Vancouver, B.C., providers from the mental health, alcohol/drug treatment, corrections, social and housing agencies created a “multi-service network” to more effectively serve persons with multiple problems who had been identified as consuming high levels of agency resources over long periods of time. Agencies reported increased communication via regularly scheduled, multi-agency case conferences and the development of a single individualized service plan (Buckley & Bigelow, 1992). This is a good example of services integration rather than system-level integration. A program in New Haven, CT, shows us how a clinical outreach team that is focused on services integration for individual clients can contribute to systems-level change as well (Rowe, Hoge, & Fisk, 1998).
Operating squarely in the arena of system-level integration, the City of St. Louis was among the first communities to formally attempt to stimulate systems integration for homeless services. As a result of a 1985 lawsuit requiring the City to provide shelter and services to help people exit homelessness, the City created a task force to plan a comprehensive system and used purchase of service agreements with local agencies to provide needed services. Johnson and Banerjee (1992) found that the system increased resources and institutionalized a coordinated system of care at the local level. Difficulties cited were the need for a more participatory strategic planning process, more attention to monitoring based on client outcomes, and a tendency toward stable relationships with a limited number of providers making it difficult for new, small, or innovative agencies to participate.
In a more recent example, a city-sponsored Task Force collaborated with a grass roots homeless coalition and a university to respond to homelessness in Long Beach, CA. Using a formal needs assessment process to identify needs and set priorities, conflict arose when the Task Force made its recommendations to the City. Some recommendations were reluctantly implemented and later sabotaged, others were ignored or actively refuted (Dowell & Farmer, 1997). What was clear was that City officials and business leaders were not participants in the process of developing the recommendations; they did not own the problem or the solution. The authors argue that the Long Beach experience points to the importance of linking local efforts with regional, state, and federal leadership on such complex issues as homelessness.
Over the past decade, federal agencies and private foundations have undertaken several initiatives designed to encourage localities to use systems integration as a mechanism to assist people who are homeless or at risk of homelessness. Findings from these initiatives are described below.
HUD/RWJF Program on Chronic Mental Illness
In 1986, the Robert Wood Johnson Foundation funded a five-year demonstration of systems integration for persons with serious mental illness, especially for those who were also homeless, in nine cities (Cohen & Somers, 1990). The U.S. Department of Housing and Urban Development also provided each site with 125 Section 8 housing certificates through the local public housing authority.
Findings from the evaluation of this program suggests that the cities were successful in developing central mental health authorities and that services and housing were expanded, but these changes alone were not sufficient to demonstrably improve the quality of life for individuals with severe mental illnesses (Goldman, Morrissey & Ridgely, 1994). This was largely due to an inadequate resource base for the services that the systems integration strategies were attempting to integrate (Goldman et al., 1992).
While the sites had been given the funds to integrate housing and support systems through a centralized authority, there were inadequate resources to augment already strapped case management services. In addition, the quality of the housing and the neighborhoods available to clients, even with Section 8 certificates, also contributed to the difficulty in producing improved client outcomes (Newman, 1994).
| Baltimore Mental Health Systems (BMHS), Baltimore's mental
health authority, was founded in 1987 as a condition of the city's receipt
of a $2.5 million grant from the Robert Wood Johnson Foundation. The foundation
required that a separate entity be created to improve the quality and quantity
of mental health services citywide.
To maximize housing opportunities for persons with serious mental illnesses in the city, BMHS, created a housing development and management subsidiary, Community Housing Associates (CHA). CHA coordinates its housing activities with BMHS to assure that mental health and other support services are available as needed by tenants. CHA also lends its expertise to other organizations seeking to develop housing for disabled persons in the Baltimore area. For example, CHA assisted seven local churches in their development of three group homes. Through formal partnerships with private investors, the Alliance for the Mentally Ill, and the Enterprise Foundation's Social Investment Corporation, CHA and BMHS have expanded the housing and services options available to persons with serious mental illnesses in Baltimore, many of whom were, or would have become, homeless if not for this project. |
Section 612 of the McKinney Homeless Assistance Act provided the authorization for two rounds of increasingly systems-change oriented demonstrations for homeless persons with serious mental illnesses. The orientation to systems-level change was a direct result of earlier work in the area of services integration by the Community Support Program.
Beginning in 1988, the first round of nine projects, administered by the National Institute of Mental Health, were required to provide, or arrange for, four essential services (outreach, case management, mental health treatment, and housing). In addition, they were required to conduct “administrative activities designed to link these services together” (Levine & Rog, 1990). These programs were among the first to attempt an evaluation of such comprehensive approaches. However, there was no cross-site evaluation and the individual level evaluations did not systematically assess the client-level impacts of these administrative (i.e., systems-level) activities (CMHS, 1994a).
A second round of five projects began in 1990. Building on the prior demonstration, and now administered by the Center for Mental Health Services, these projects were required to develop strong formal links between the community mental health, homeless services, and public housing systems in the targeted cities. Modeling the behavior expected at the local level, HUD and HHS developed a Memorandum of Understanding to jointly sponsor initiatives on behalf of homeless persons with serious mental illness and other disadvantaged populations. This agreement was then used by grantees (usually mental health centers) to forge formal agreements with their local public housing agencies to provide subsidized housing to study subjects. What began as a “system fix,” to use Rog’s (1997) conceptualization, in at least two sites (Boston and San Diego) evolved into systems change as the relationship between these two systems expanded and endured.
| In San Diego, the local mental health authority and two public housing agencies collaborated to test whether the combination of HUD Section 8 rental certificates and intensive case management would yield better client outcomes than any of three comparison groups. The collaboration between the PHAs and the mental health system was essential to the project design. The housing agencies revised their waiting lists to add a preference for project clients, agreed to consider applications from persons with histories of illegal drug use who are in treatment, and tailored the Section 8 orientation program to meet individual clients' needs. Support services are provided by the mental health agency. |
Systems-level activities were documented as part of each individual project’s process or implementation evaluation. In the San Diego project, which specifically examined the impact of these activities on housing outcomes, the results were dramatic. Those clients assigned to the group that received Section 8 certificates, a direct result of the newly created relationship between the housing authority and the mental health center, showed greater residential stability than those in the control condition (Hough et al., 1997; CMHS 1994b).
In 1988, the National Institute on Alcoholism and Alcohol Abuse (NIAAA) funded nine demonstration grants for alcohol and drug abuse treatment of homeless individuals in the first round of McKinney funding. Increased cooperation and formal linkages among alcohol treatment, drug treatment, housing and shelter providers, and other supportive services were required. Client-level outcome data from a subset of projects that used experimental or quasi-experimental evaluation designs were analyzed to estimate intervention effectiveness. Individuals in the experimental conditions were significantly more likely to report improvement than comparison clients in the majority of sites (Orwin et al., 1994).
The experiences in designing and implementing the first NIAAA demonstration program laid the groundwork for funding a second round of 14 projects designed to evaluate the effectiveness of comprehensive approaches (e.g., case management, treatment, housing and other support services) in reducing alcohol and other drug consumption and enhancing the residential and economic stability of project participants. In keeping with the intent of the RFA, systems-level activities and outcomes received relatively less emphasis. Nevertheless, several projects elected to make systems integration an integral part of their program and others found that they had to engage in systems-level activities in order to implement their interventions.
The projects experienced a number of systems-level barriers to implementation, including: (1) neighborhood resistance to project location, (2) conflicting interests with collaborating organizations, (3) budget cutbacks in multiple service areas, (4) difficulty accessing shelter and housing for program participants, and (5) the lack of technical assistance to help solve common problems as they arose (Orwin et al., 1995). The evaluation did not systematically address the impact of systems integration activities on program or client outcomes.
| At the time of the grant award, there were few services in Washington,
DC, for dually diagnosed homeless population were available in the surrounding
community. Community Connections set as its goal, the establishment of a
treatment system that would, at a minimum, tolerate dually diagnosed clients
and, as an ideal, design services specifically for this population. The program
reached out to receptive service agencies and provided basic education. Agency
staff were actively involved with the District's Center for Mental Health
Services (DC CMHS) and sat on a committee formed to examine this issue. They
addressed immediate service gaps by developing their own task forces and
topic-oriented groups for participants.
Although access remained a problem, the project made several significant gains, including: (1) collaborating with a clinic willing to provide physical and dental services to clients, (2) linking to an outreach program which served clients with HIV/AIDS, (3) negotiating with DC CMHS for housing subsidies, and (4) finding resources for pregnant women (Orwin et al., 1995). |
In 1991, the Social Security Administration (SSA) and the Veterans Administration (VA) began a two year demonstration of a joint initiative to increase the applications and awards for disability benefits (SSI and SSDI) among entitled homeless veterans.
| Four co-location projects were implemented at VA medical centers in New York City, Dallas, and Los Angeles. At each site, the VA designated a social worker to be responsible for (1) facilitating referrals for SSA benefits from VA clinical staff, (2) shepherding claims through the application process, and (3) helping to obtain medical records and other information required to support the application. Local SSA field offices co-located claims representatives with Health Care for the Homeless Veterans (HCHV) teams to increase understanding of the application process among VA staff and to initiate disability claims directly. Disability analysts were also designated to work directly with the HCHV teams. The Los Angeles site, the same two SSA staff members performed the tasks of both claims representative and the disability determination analyst. |
An evaluation of this effort found that access to disability benefits among homeless persons with mental illness were significantly improved by co-location of staff from an income support agency with clinical staff from a specialized mental health program (Rosenheck, Frisman, & Kasprow, 1999). Veterans at the intervention sites were almost twice as likely to apply for benefits and to receive awards as those in the comparison groups. Administration costs of this integration strategy ranged from $1,700 to $3,200 per award—a small price to pay when one considers that receipt of benefits is highly related to successful housing outcomes for homeless persons (Rosenheck, Frisman & Gallup, 1995).
In 1994, the Department of Housing and Urban Development fundamentally reorganized the process by which McKinney Homeless Assistance funds were awarded. HUD homeless programs (except for the Emergency Shelter Grant program) were consolidated into a single competitive grant. This change was made explicitly to encourage systems integration in communities throughout the country. The goal was to enable localities “to fashion a comprehensive system which addresses the needs of different homeless populations and which ensures that various elements of the system...are in balance “ (U.S. Department of Housing and Urban Development, 1994, p. 5).
In order for a community to apply for these funds, it must submit a Continuum of Care plan that demonstrates participation of a variety of community stakeholders, that defines a vision for combating homelessness, and that ensures a comprehensive system is under development for the delivery of outreach, transitional housing and services, and permanent housing. In addition, a Continuum of Care community must collectively decide its priorities for funding.
| In 1994 with more than 5,000 persons homeless on a given day and less than half as many shelter beds, Detroit's homeless service system was primarily focused on crisis-oriented emergency shelter. In response to the introduction of HUD's Continuum of Care, the Mayor convened a Task Force on Homelessness bringing together representatives from state and local government, non-profit service providers, advocates, religious organizations, private foundations, the business sector, and current and formerly homeless persons. Over nine months of intensive meetings, representatives of 46 key organizations crafted a Continuum of Care plan in its report, A Home for Every Detroiter. The report, which was accepted by the Mayor and the City Council, set goals and identified major gaps in the service delivery system. New service provider networks were organized to begin the collaborations necessary to implement the plan. In late 1995, the Detroit/Wayne County Homeless Action Network was formed uniting two separate coalitions that had focused on East and West Detroit. From a community where policy planners and service providers had worked in relative isolation, both public and private agencies have made the philosophical shift from a crisis-oriented shelter system to a more comprehensive array of outreach, assessment, and emergency, transitional and permanent housing and services (Fuchs & McAllister, 1996). |
The HUD reorganization of its McKinney programs is one of the largest systems integration initiatives in the homeless service system arena. It affects more than 500 communities nationwide. The Continuum of Care planning process and the McKinney annual application has fundamentally changed the way in which communities address homelessness. In some communities, providers and public officials are talking and planning together for the first time. In others, the process has become more difficult and more politically charged, especially for providers and consumers representing marginalized populations.
While there is no systematic evaluation of the implementation of this public policy, there are many examples of communities where the process appears to have moved things in the right direction (Fuchs & McAllister, 1996). However in many communities the level of McKinney funding available each year forces them to make hard choices between renewing existing projects and filling the gaps that have been identified in the Continuum of Care process.
Strategic planning is just one mechanism used by communities to assess housing and service gaps in the Continuum of Care. Another mechanism being explored in cities with large homeless populations is management information systems that provide the data necessary for good planning. Implementing such a system on a city or county-wide basis takes a great deal of time and commitment at all levels across many agencies. Providers, advocates, and government agencies that use such systems do so to help them more effectively organize the delivery of services to homeless persons. Of particular concern when implementing multi-agency management information systems is guarding the confidentiality of information on individuals in the system. It is important to know that by careful planning this issue can be, and has been, satisfactorily addressed by others (Soler & Peters, 1993).
| ANCHoR was developed by the University of Pennsylvania with funding from HUD and HHS specifically to help local providers and government agencies plan services for homeless persons. The system includes four information modules: outreach, assessment, residential services, and service planning. Tested in 16 cities nationwide, ANCHoR became available commercially in 1998. Three cities-Boston, Anchorage and Detroit-have adopted ANCHoR after participating in extensive testing and refinement of the system. In Detroit, 35 emergency shelters were scheduled to be on-line by Summer 1998. Transitional shelters were to be added shortly thereafter. |
In 1992, HUD made the first of what are now hundreds of grants in more than 345 communities to provide housing and support services to homeless persons with disabilities. The Shelter Plus Care (S&C) Program (funded under the Continuum of Care process described above) is designed to integrate housing and support services by requiring that each dollar of rental assistance provided by HUD is matched by an equal or greater dollar value of support services. Local S&C programs involve a partnership including the grantee agency, one or more housing providers and a network of support service providers.
An evaluation of the program (Fosburg et al., 1997) found significant improvements in the lives of program participants in terms of engagement in needed treatment; increased income and employment, and other support services; and reduced use of emergency room, inpatient care, and jails. Although one-third of residents left within one year of entering the program, 40 percent of residents at the end of the second year of the program had been housed for a year or more.
| The Shelter Plus Care program in Alameda County, California, represents a partnership of three key agencies: the Alameda County Housing and Community Development Program, the Alameda County Health Care Services Agency, and the Oakland Housing Authority. The three lead agencies administer the S&C program and work with 22 local housing or support service agencies to provide permanent housing with supports to formerly homeless persons with multiple disabilities, primarily alcohol or drug problems, mental illness, and/or AIDS. In addition to multi-system collaboration, the Alameda County S&C program also features a strong commitment to involving consumers in the development and operation of the program. For example, a committee comprised of a cross-section of providers and homeless or formerly homeless consumers advises the administrative team. In another example, several of the support service agencies in this collaborative effort are consumer-run organizations. Consumers of all kinds of related services - homeless, mental health, substance abuse, and AIDS services - provide case management, peer support, outreach and engagement and other services to homeless persons eligible for S&C (Fosburg, Locke, & Holin, 1994). |
HRSA’s Health Care for the Homeless Program
The Health Care for the Homeless (HCH) Program is administered by the Health Resources and Services Administration’s Bureau of Primary Care. Building on an earlier demonstration sponsored by the Robert Wood Johnson Foundation, 128 programs are funded nationwide to arrange for the delivery of health care, outreach, and case management to homeless individuals and families. Through formal subcontracts with 322 more community-based agencies and informal relationships with countless others, this program places a strong emphasis on advocacy for systems change, increased coordination of services across systems, and participation in multi-system coalitions where service delivery to homeless persons is the primary goal.
The Bureau supports these goals through technical assistance and information dissemination to grantees and other interested parties. In a study of HCH programs conducted in 1985, HCH programs were found to use a variety of strategies to reduce systems and organizational barriers to care for homeless persons (Cousineau, Wittenberg & Pollatsek, 1995). These strategies included collaboration with providers of housing and other support services, using mobile units to bring services to people, developing satellite clinics in shelters and soup kitchens, providing case management and outreach services, and advocacy with policy makers at all levels.
| The Health Care for the Homeless Network (HCHN) in Seattle, Washington, is a project of the Seattle-King County Department of Public Health. HCHN has created a continuum of health and social services for homeless people by combining direct services provided by public health staff and contracts with local hospitals, community health centers and other community- based organizations. The public health department provides such direct services as, TB outreach and directly-observed therapy, immunizations, communicable disease control, parent-child health, family planning, WIC, dental screening and referral, and health education for more than 70 area shelters. Contracted services include outreach, primary care, chemical dependency and mental health counseling, medical respite care, and assistance with enrollment and use of Medicaid managed care. As an HCHN contractor, Harborview Medical Center outreach workers and nurses provide triage, assessment, episodic care, referral and follow-up. Clients are enrolled in the Harborview system for outpatient and inpatient care. Those who need a place to recover upon release from the hospital are admitted to the HCH medical respite program and from there are discharged to emergency or transitional housing |
CMHS/CSAT’s Prevention of Homelessness Program.
An integrated service system may mean the difference between someone at-risk of homelessness who remains stably housed and one who repeatedly cycles into and out of homelessness. In 1997, after a one-year manualization phase, the Center for Mental Health Services (CMHS) and the Center for Substance Abuse Treatment (CSAT) began testing interventions designed to prevent homelessness among persons with serious mental illnesses and/or substance use disorders at eight sites (Rickards et al., in press).
The program focuses on three common pathways to homelessness: (1) housing loss; (2) diminished family support, and (3) misuse of financial resources. In order to demonstrate the prevention of homelessness, the target population formerly homeless or at risk for homelessness, is already engaged with the mental health and/or substance abuse treatment systems. In order to prevent homelessness, clients are linked by either a case manager or a community support specialist to services which cut across multiple systems. None of the eight sites are testing systems-level integration activities. The cross-site evaluation will focus, as do the interventions, on services-level impacts on client outcomes.
| Founded in 1992, Pathways to Housing was created to serve New York City's street-dwelling, mentally ill homeless population. The agency specifically seeks out persons who have been turned away from other housing programs because of active substance abuse, refusal to participate in psychiatric treatment, and/or histories of violence or incarceration. Key to the program's 85 percent success rate in keeping people in housing for one year or more is offering immediate access to scattered site housing coupled with intensive support provided by an assertive community treatment (ACT) team. With caseloads averaging about 10:1, ACT teams function as the services integrator for individual tenants linking or providing whatever the tenant needs or wants to achieve his or her long-term goals such as continuing education, job training, psychiatric and substance abuse treatment, and reconnecting with family or friends (Pathways to Housing, |
The CSH Health, Housing and Integrated Services Network
In 1996, the Corporation for Supported Housing began a demonstration project to develop a model managed care system for homeless adults with special needs in San Francisco and nearby Alameda County, California. The Health Housing and Integrated Services Network is a partnership that includes county health departments and public housing agencies in five counties and more than 20 non-profit organizations that provide residential and outpatient mental health and substance abuse treatment services, health care, social and vocational services, money management, peer support, affordable housing and employment opportunities for people who are homeless or at risk of homelessness, mentally ill, living with HIV/AIDS or other chronic health problems, or struggling with drug or alcohol problems.
The Network’s goal is not only to deliver integrated services, but to demonstrate a model for financing integrated services through the creation of a non-profit managed care provider system linked to supportive housing (Wilkins, 1996). The Network has begun to create and analyze the data necessary to establish appropriate reimbursement rates and funding mechanisms for this population and to document the cost effectiveness of housing-based service interventions as part of managed care systems. Support for this initiative is provided by the Robert Wood Johnson Foundation, the California Endowment, Rockefeller Foundation, the City of San Francisco, HUD, Medicaid reimbursements, and other public and private funders. The project is being evaluated by researchers at Vanderbilt University and others.
In 1990, the Robert Wood Johnson Foundation and the Department of Housing and Urban Development launched a five-year program in nine cities across the nation designed to restructure the systems of health, support services and housing for homeless families. Each site received approximately $600,000 over five years to facilitate systems of care for homeless families and to demonstrate a model of services-enriched housing for a group of families. A memorandum of understanding was developed with the local public housing authority which provided 150 HUD Section 8 certificates to each project. Case management was provided or arranged by the lead agency.
Evaluators of this initiative found that the projects tended to focus on temporary or small-scale “fixes” to improve service delivery for the families they were serving (Rog & Gutman 1997; Rog et al 1997). Systems changes C enduring reformulations in the structure of a system were rare. The one exception involved changes in the role of the public housing agency. Through their participation in the program, several housing agencies increased their awareness of the needs of homeless families and they became more active participants in developing supportive housing for this population. However, the role of the Foundation and HUD appear to have been key factors in facilitating this change.
| Situated within the Colorado Coalition for the Homeless, the Metro Denver Homeless Families Program is a collaboration of the City of Denver, two county governments, several public housing authorities and a large number of service providers, including the Health Care for the Homeless program. A 26-member Governance Council was streamlined and restructured over time into three independent committees - executive, operations, and policy and resources - which provide strong leadership. Project staff and the Governance Council set priorities and identified existing resources for housing and mental health and substance abuse treatment. The group expanded its resource base, staff and the services it provides with several major grants, including the Community Development Block Grant and HUD and HHS grants for rental assistance vouchers, transitional housing, housing location services, case management, homelessness prevention and children's services. They were also able to secure an eligibility worker from the Department of Social Services to work with families as they began to look for housing. By planning and collaborating at all levels, this group was able to create together what no agency had been able to build alone. (Rog, Hambrick, Holupka et al., 1994) |
The ACCESS (Access to Community Care and Effective Services and Supports) program, supported by SAMHSA’s Center for Mental Health Services, was established as a five-year demonstration program to develop integrated systems of care for homeless persons with mental illness in nine states. Using a quasi-experimental design, each of nine states identified two comparable sites, one of which was randomly assigned as the experimental site (the systems integration site) and the other one became the comparison site.
Both sites were provided funds to enhance services for the target population, particularly intensive outreach and case management services. Thus, their capacity for services integration was equalized. The experimental sites were provided with additional funding to support activities to improve systems integration. The core research question of the evaluation is whether higher levels of systems integration result in improvements in clients’ functioning, quality of life, and housing outcomes (Randolph et al., 1997; Randolph 1995).
| Overcoming a history of "homeless wars" among providers is not first on the list of accomplishments likely to be cited by the Wichita, Kansas, ACCESS program. They are much more likely to talk about providing stable housing, mental health treatment and other support services to hundreds of homeless persons with serious mental illnesses over the past five years. But they would be the first to admit that they couldn't have done the second without the first. Through community-wide strategic planning focused on homelessness more generally, COMCARE, the local mental health authority and the lead agency for the Wichita ACCESS program, was able to bring local business leaders, city and county agencies and local providers to the table to meet the needs of homeless people in Wichita, including persons with serious mental illnesses. They did it by adopting a variety of systems integration strategies, including: developing a local planning body that included city representatives, non-profit agencies, and business leaders; hiring a staff person to focus on systems integration activities; using a formal strategic planning process (repeatedly) to address problems that could not otherwise be resolved by a single provider; providing education and training for agency staff and lay persons; being willing to apportion federal, state, and local resources among providers in ways that were more rational than political; and delivering on promises to provide outreach and case management services responsive to the needs of clients and the community. |
The cross-site evaluation of the ACCESS program represents the most ambitious attempt to date to understand the mechanisms used by communities involved in a major demonstration focused on the integration of service delivery systems. It demonstrates that it is possible to move beyond a case study approach in examining systems integration strategies across multiple sites and that standardized measures can be meaningfully and reliably used. A number of descriptive and interim findings have been published thus far (Lam & Rosenheck 1997; Morrissey et al 1997; Rosenheck & Lam 1997a, b, & c; Rosenheck, Lam & Randolph 1997; Rosenheck et al, 1998). Preliminary findings specific to the implementation and impact of systems integration activities are reviewed in the next section.
Research on Systems Integration and Homelessness: The ACCESS Evaluation
Until recently, evaluations of integration initiatives have relied largely on observations of differences between client outcomes in the experimental and the control or comparison groups. But the mechanics of systems integration—what strategies were most effective, why communities using similar strategies have different outcomes, etc.—remained subject to speculation at best.
One of the most sophisticated and promising studies of systems integration is the evaluation of the ACCESS program. Preliminary findings from this study comparing client outcomes in the nine integration and nine comparison sites are have found greater access to housing for clients in the more integrated sites (Rosenheck, et al., 1998). The ACCESS evaluation is also looking at changes in systems integration over time as well as the strategies used by communities to achieve systems integration.
The nine ACCESS systems integration sites employed between six and ten of the systems integration strategies listed in Figure 1. Three strategies were used by all nine systems integration sites:
Based on a series of structured observations over a five-year period, these three strategies appear to be key factors in the level of integration achieved by the sites. Six other strategies were used by the majority of sites: the development of interagency management information systems, pooled funding arrangements, cross-training programs, interagency agreements, co-located services and state-level interagency coordinating bodies (Cocozza, Steadman & Dennis, in press).
It is important to note that targeted funding for systems integration was not, by itself, sufficient to ensure the successful development and implementation of system integration strategies. Given competing priorities (such as the need to recruit clients and provide services) and the lack of knowledge and experience about systems integration, it became evident during the first two years of the program that sites were having difficulty developing and implementing their systems integration strategies (Randolph et al., 1997). In response, a series of technical assistance efforts, sponsored by CMHS, were held for the systems integration sites. These were followed by on-going support and assistance to the sites. This assistance helped sites revise their strategic plans, clarify their objectives and strategies, reallocate staff and resources, and focus more directly on systems integration.
The strategies used by the sites remained relatively stable over the first four years of the program. Significant technical assistance was provided to the sites between their second and third years. Some of the changes, like the establishment of a staff position to coordinate systems integration activities at all sites, reflect this assistance. Changes that occurred between the third and fourth years include greater use of pooled funding and interagency MIS/client tracking systems and the first use by any site of strategies involving the consolidation of programs/agencies and the use of special waivers. These changes seem to reflect not only a further refinement of the sites’ overall plans for systems integration but also the result of activities that require both time and a well-functioning infrastructure (e.g., a coordinator and a coordinating body) to bring to fruition.
Although the comparison sites could not use grant funds to support systems integration, initiatives were sometimes underway within these communities that resulted in better systems integration. For example, in one comparison site a local elected official established a city-wide coordinating body on homelessness. In six of the nine comparison sites at least one initiative was occurring that paralleled the strategies being implemented in the systems integration sites. But systems integration activities were much more likely to be occurring at the systems integration sites than in the comparison sites. The one strategy found most often in the comparison sites was the existence of an interagency coordinating body – one of three strategies also occurring most frequently in the systems integration sites.
Although almost all experimental sites had made significant progress in implementing their systems integration strategies, no site had fully implemented all of their strategies by the fourth year of the program. Some strategies, such as developing an interagency client tracking system (or MIS) or the establishing a uniform application and eligibility criteria, have been more difficult to implement than others (e.g., establishing an interagency coordinating body, creating a systems integration coordinator position, and developing interagency agreements. In the four sites that chose to develop an interagency MIS, none had achieved even a moderate level of implementation by the end of the fourth year.
Making Systems Integration Work: Recommendations for Practice
There is a wealth of information and advice available to those who want to create systems change in their own localities. It ranges from syntheses of the possibilities and challenges of systems integration (c.f., Yessian, 1995; CMHS 1993; Kahn & Kamerman, 1992; Gardner, 1991; Agranoff, 1991) to guidebooks with detailed step-by-step instructions on how to implement specific aspects of systems integration (c.f., Marzke & Both 1994; U.S. Dept. of Health & Human Services 1985, undated; National Association of Area Agencies on Aging 1992; Bruner 1991; National Assembly of Voluntary Health & Social Welfare Organizations 1991; Homelessness Information Exchange 1987). Some of these are geared to formally developed projects with some funding to pursue systems integration, but, to varying degrees, these principles are relevant to more informal systems integration efforts.
· Leadership. Systems integration across multiple systems is time-consuming and difficult work requiring vision, initiative and capacity for follow-through. Without a paid staff person (or persons) whose time is dedicated to these activities, large-scale systems change is nearly impossible. The result is usually added responsibilities for already overburdened administrative staff. This finding has been reinforced by observations from other integration initiatives (Pitcoff 1998; Cocozza, Steadman & Dennis, in press).
Second, the person charged with systems integration must be someone with enough experience and at a level high enough to interact with and to engage decision-makers in other systems. Without the capacity to bring key players to the table and keep them there, there is little chance for real change. Third, study after study has identified leadership as an essential element in generating and sustaining collaborative efforts. Distinguishing features include vision, entrepreneurship, political astuteness, a respect for diversity and a talent for managing complexity (Yessian 1995). As one national evaluation team put it, “Strong leaders who instill a top-down commitment to collaboration, innovation from the bottom-up, a spirit of mutual trust and collaboration, and who have a vision for achieving broader system reform that transcends the needs of individual organizations” (Lewin-ICF and MDS Associates 1992).
Finally, for efforts that cut across multiple systems and categorical funding, some experts and researchers suggest that leadership be exerted by a central authority (Yessian 1995). This is especially important if the organizations involved do not have a history of working together well. But this is not an iron-clad rule. There are plenty of examples of an effective, trusted leader operating out of a single agency who has been able to effect multi-system, community change. The leadership qualities described above are personal more than institutional, and the people embodying them might be found at various points in a constellation of community agencies.
· Local Coordinating Body. Systems integration must involve key stakeholders who have the resources and/or the authority to create change. When addressing homelessness, this includes business leaders, public officials, non-profit service agencies, housing agencies, local police, as well as formerly homeless persons. Without broad-based community support for the level of effort and resources required to create an integrated service system, other needs are likely to take priority. Current or former service recipients should be involved in all stages of planning and implementation.
Efforts must be made to insure that staff from different agencies develop formal and informal communication networks, learn about and take advantage of each other’s areas of expertise, and develop a shared commitment to serving the target population in a comprehensive collaborative manner. More than one promising services integration effort has been disrupted by interagency conflicts, often based on long-held misunderstandings at the provider level. By establishing a forum that allows for personal relationships to develop among constituencies with competing or conflicting interests, the groundwork is laid for discussion of common goals.
· Strategic Planning With An Emphasis On Outcomes. “Failing to plan for a better system, is planning to fail” (Gardner, 1991). Without a clear sense of what communities offer and what they need to improve, service integration efforts have no direction, no means by which to evaluate their progress, and no basis on which to build the public’s, or anyone else’s, trust. Most of the nine systems integration sites in the ACCESS Program were floundering after a year of funding until they each undertook a formal strategic planning process in their communities (Randolph et al., 1997).
Often overlooked, but critically important, is identifying the specific types of measures that will be used to gauge success and making the commitment to collecting the necessary data on an on-going basis. Rather than documenting program outputs, such as the number of clients served or placements made, systems integration efforts are better served by pursuing client outcome measures such as the continuous quality improvement model that has been used widely in industry and health care (Yessian, 1995). Key elements of this model are:
· Flexible Funding/Adequate Resources/Fiscal Incentives. Systems integration projects must not only have a clear sense of direction, they must also have the means to get going. Without flexible funding or regulatory relief, systems integration efforts start in an extremely weak position. They find themselves almost entirely dependent on the responsiveness of specialized human service agencies that are focused on their own goals and processes and concerned about the insufficiency of their own resources.
With some discretionary funding or the authority to waive some existing rules, new possibilities arise. Although systems integration projects still depend on the participation of these agencies, the projects can now leverage the cooperation and resources of other agencies to stimulate action (Yessian, 1995). Sometimes new funding, from a Government or private source (as in the Robert Wood Johnson Foundation initiatives and the ACCESS Program) may also provide the stimulus for change (CMHS, 1993). Other initiatives are able to “piggy back” onto larger changes that create fiscal incentives for systems change, such as managed care and welfare reform.
· Focus on both Services and Systems Integration. Throughout this paper the emphasis has been on creating change through systems integration. But efforts that focus solely on the organizational-level without addressing the service delivery or client level are often “hollow, paper agreements” (Agranoff, 1991). Equally important are strategies that focus on the coordination of services to individual clients, such as intensive case management (see Figure 1).
During visits to the ACCESS integration sites, case managers cite the efforts of systems integrators for educating other providers, local business leaders, and public officials about the service needs of the population; for garnering new resources and opening doors to needed services; and for increasing the visibility of the program (and therefore the cooperation of other providers). But case managers were equally clear that “they can’t do it without us.” If the systems integrators could not back up promises to deliver high quality and timely services to clients, other providers would have been less likely to come to the table, and more importantly, to stay there.
· Long-Term Commitment. Old ways of doing business die hard. There may be some resistance at all organizational levels, and it will take time and effort to build a system that truly delivers integrated services. As with any new initiative, a trial period should be expected during which continuing reorganization and refinement of goals may occur (CMHS, 1993).
Given that most such efforts do not have dedicated funding for systems integration activities, it is important to remember that while large-scale systems change may be the goal, incremental change is more often than not the method by which most systems evolve. It needs to be recognized as an important interim goal in its own right (Yessian 1995).
· Need for Technical Assistance. In study after study of systems integration, the need for technical assistance arises as a key juncture in the program (c.f., Randolph et al., 1997; Rog & Guttman, 1997; Orwin, 1995; Cohen & Somers, 1990). Too often, that need is ignored because the programs do not recognize it in time, or they do not know specifically what they need or want from technical assistance, or the programs or funders wrongly assume that it is a luxury that they cannot afford.
Where technical assistance has been available to help communities “over the hump,” they are not only moved beyond an impasse, but they can be jump-started to a higher level of activity and renewed commitment. Having successfully worked through a difficult time together as a community becomes a bridge to help overcome future obstacles.
Technical assistance can take many forms. It may be having an outside facilitator come in to lead a strategic planning session, taking key stakeholders to visit a similar effort in another city, or offering training on a topic that the group is struggling with.
Successful systems integration requires a commitment by key decision-makers to an on-going planning process and the resources (financial and political) required to implement it. As the RWJF Program on Chronic Mental Illness so aptly demonstrated and as local experience with the Continuum of Care is beginning to suggest, commitment without adequate resources is not enough. Systems integration efforts cannot impact client outcomes if the resources to provide the services being integrated are not adequate to meet client needs. Because no single service system can meet the all the needs of homeless people, efforts at systems integration are essential to maximize the potential for individuals to reach a sustained level of self-sufficiency.
There are a number of ways in which federal and state policy could encourage systems integration at the local level.
In our effort to understand the relationship between systems integration and helping homeless people, there are a number of issues that warrant further research. Research needs to be conducted in the following areas:
Agranoff, R. (1991). Human Services Integration: Past and Present Challenges in Public Administration. Public Administration Review, 51(6): 533-542.
Agranoff, R. & Pattakos, A. (1979). Dimensions of Services Integration: Service Delivery, Program Linkages, Policy Management, and Organizational Structure. Washington, DC: Project SHARE, April.
Bickman, L., Summerfelt, W. & Noser, K. (1997). Comparative Outcomes of Emotionally Disturbed Children and Adolescents in a System of Services and Usual Care. Psychiatric Services, 48(12): 1543-1548.
Bruner, C. (1991). Thinking Collaboratively: Ten Questions and Answers to Help Policy Makers Improve Children's Services. Washington, DC: Education and Human Services Consortium.
Buckley, R. & Bigelow, D. A. (1992). Brief Report: The Multi-Service Network: Reaching the Unserved Multi-Problem Individual. Community Mental Health Journal 28(1): 43-50.
Center for Mental Health Services. (1993). Services Integration for Homeless Persons With Severe Mental Illnesses. Rockville, MD: Center for Mental Health Services.
Center for Mental Health Services. (1994a). Lessons Learned: A Final Look at the First-Round McKinney Service Demonstration Projects for Homeless Adults with Severe Mental Illnesses. Rockville, MD: Center for Mental Health Services.
Center for Mental Health Services. (1994b). Making a Difference: Interim Status Report of the McKinney Demonstration Program for Homeless Adults with Serious Mental Illness. Washington DC: Substance Abuse and Mental Health Services Administration (DHHS # [SMA] 94-3014).
Center for Mental Health Services. (1997). Process Evaluation of the ACCESS Demonstration Projects for Homeless Persons with Mental Illness: Third Year Implementation Case Studies. Rockville, MD: Center for Mental Health Services.
Cocozza, J., Steadman, H., Dennis, D. (1997). Implementing Systems Integration Strategies: Lessons from the ACCESS Program. (Unpublished paper).
Cohen, M. & Somers, S. (1990). Supported Housing: Insights from the Robert Wood Johnson Foundation Program on Chronic Mental Illness. Psychosocial Rehabilitation Journal 13(4): 43-50.
Corporation for Supportive Housing. (1996). Health, Housing and Integrated Services Network Managed Care Demonstration Project. Oakland, CA: Corporation for Supportive Housing.
Cousineau, M. R., Wittenberg, E. & Pollatsek, J. (1995). A Study of the Health Care for the Homeless Program: Final Report. Bethesda, MD: Bureau of Primary Care, Health Resources and Services Administration, Department of Health and Human Services.
Dowell, D. A. & Farmer, G. (1992). Community Response to Homelessness: Social Change and Constraint in Local Intervention. Journal of Community Psychology 20: 72-83.
Enterprise Foundation. (1995). Beyond Housing: Profiles of Low-Income, Service-Enriched Housing for Special Needs Populations. Columbia, MD: The Enterprise Foundation.
Farrow, F. & Bruner, C. (1993). Getting to the Bottom Line: State and Community Strategies for Financing Comprehensive Community Service Systems. New York, NY: National Center for Service Integration.
Federal Task Force on Homelessness and Mental Illness. (1992). Outcasts on Main Street: Report of the Federal Task Force on Homelessness and Severe Mental Illness. Washington, DC: Interagency Council on the Homeless.
Fosburg, L. B., Locke, G. P., Peck, L. & Finkel, M. (1997). National Evaluation of the Shelter Plus Care Program. Washington, DC: U. S. Department of Housing and Urban Development, October.
Fosburg, L., Locke, G. & Holin, M. (1994). Evaluation of the Shelter Plus Care Program: Interim Report, Volume II: Grantee Profiles. Washington, DC: U. S. Department of Housing and Urban Development.
Friedman, R. & Burns, B. (1996). The Evaluation of the Fort Bragg Demonstration Project: An Alternative Interpretation of the Findings. Journal of Mental Health Administration, 23: 128-136.
Fuchs, E. & McAllister, W. (1996). The Continuum of Care: A Report on the New Federal Policy to Address Homelessness. Washington, DC: U. S. Department of Housing and Urban Development, December.
Gardner, S. (1991). A Commentary. In P. B. Edelman & B. Radin. A. Serving Children and Families Effectively: How the Past Can Help Chart the Future. Washington, DC: Education and Human Services Consortium.
Goldman, H. H., Morrisey, J. P., & Ridgely, M. S. (1994). Evaluating the Robert Wood Johnson Foundation Program on Chronic Mental Illness. The Millbank Quarterly, 72(1): 37-47.
Goldman, H. H., Morrissey, J. P., Ridgely, M. S., Frank, R. G., Newman, S. J. & Kennedy, C. (1992). Lessons from the Program on Chronic Mental Illness. Health Affairs 11(3): 51-68.
Homelessness Information Exchange. (1987). Coalition Building to Address Homelessness: Guidelines/ Models/Accomplishments. Washington, DC: Homelessness Information Exchange.
Hough, R. L., Harmon, S., Tarke, H., et al. (1997). Supported Independent Housing: Implementation Issues and Solutions in the San Diego Project. In Breakey, W.R. & Thompson, J.W. (Eds.) Mentally Ill and Homeless: Special Programs for Special Needs, 95-118. Amsterdam: Harwood Academic Publishers.
Interagency Council on the Homeless. (1991). Initiatives for the Homeless: A Collection of Program Descriptions. Washington, DC: Interagency Council on the Homeless.
Interagency Council on the Homeless. (1994). Priority: Home! The Federal Plan to Break the Cycle of Homelessness. Washington, DC: U. S. Department of Housing and Urban Development HUD-1454-CPD.
Johnson, A. & Banerjee, M. (1992). Purchase of Service Contracts for the Homeless: The Development of a City-Wide Network. Journal of Applied Social Sciences 16(2): 129-141.
Kahn, A. & Kamerman, S. (1992). Integrating Services Integration: An Overview of Initiatives, Issues, and Possibilities. New York, NY: National Center for Children in Poverty.
Konrad, E.L. (1996). A Multidimensional Framework for Conceptualizing Human Services for Integration Initiatives. In New Directions for Evaluation, Jossey-Bass Publishers, No. 69.
Lam, J. A., & Rosenheck, R. (1997). Social Support and Service Use Among Homeless Persons with Serious Mental Illness. Rockville, MD: R.O.W. Sciences, Inc.
Levine, I. S. & Rog, D. J. (1990). Mental Health Services for Homeless Mentally Ill Persons: Federal Initiatives and Current Service Trends. American Psychologist 45(8): 963-968.
Levine, I. S., Lezak, A. D., & Goldman, H. H. (1986). Community Support Systems for the Homeless Mentally Ill. New Directions for Mental Health Services 30: 27-41.
Lewin-ICF and MDS Associates. (1992). Community Models of Coordination in Primary Care Programs: Final Report. Rockville, MD: Health Resources and Services Administration, July.
Martin, M .A. (1990). The Homeless Mentally Ill and Community-Based Care: Changing a Mindset. Community Mental Health Journal 26(5): 435-447.
Marzke, C. & Both, D. (1994). Getting Started: Planning a Comprehensive Services Initiative. New York, NY: National Center for Service Integration.
McMurray-Avila, M. (1997). Organizing Health Services for Homeless People. Nashville, TN: National Health Care for the Homeless Council.
Miller, E. (1996). The Evolution of Integration: Federal Efforts from the 1960s to Present Day. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.
Morrissey, J., Calloway, M., Johnsen, M. & Ullman, M. (1997). Service System Performance and Integration: A Baseline Profile of the ACCESS Demonstration Sites. Psychiatric Services, 48(3): 374-380.
National Assembly of National Voluntary Health and Social Welfare Organizations. (1991). The Community Collaboration Manual. Washington, DC: The National Assembly of Voluntary Health and Social Welfare Organizations.
National Association of Area Agencies on Aging. (1992). Handbook on Coalition Building. Washington, DC: Department of Health and Human Services.
Newman, S. J. (1994). The Housing and Neighborhood Conditions of Persons With Severe Mental Illness. Hospital and Community Psychiatry 45(4): 338-343.
Office of the Inspector General. (1991). Services Integration for Families and Children in Crisis. Washington, DC: U. S. Department of Health and Human Services.
Orwin, R. G., Goldman, H. H., Sonnefeld, L. J., Ridgely, M. S., Garrison-Mogren, R., & O’Neill, E. (1994). Alcohol and Drug Abuse Treatment of Homeless Individuals: Results From the NIAAA Community Demonstration Program. Journal of Health Care for the Poor and Underserved, 5(4): 326-352.
Orwin, R. G., Sonnefeld, L. J., Jacobs, M. L. et al. (1995). Cross-Site Synthesis of Intervention Designs and Implementation Analyses From the NIAAA Cooperative Agreement Program for Homeless Persons With Alcohol and Other Drug Problems. Presented at American Psychological Association Annual Meeting, August 15.
Pathways to Housing. History and mission. Flyer produced by Pathways to Housing, Inc., New York, NY (undated).
Pitcoff, W. (1998). Redefining Community Development Part II: Collaborating for Change. Shelterforce. 19(1), January/February.
Provan, K. G. (1997). Services Integration for Vulnerable Populations: Lessons From Community Mental Health. Family and Community Health 19(4): 19-30.
Randolph, F. L. (1995). Improving Service Systems through Systems Integration: The ACCESS Program. American Rehabilitation 21(1): 36-38.
Randolph, F., Blasinsky, M., Leginski, W., Parker, L. B., Goldman, H. H. (1997). Creating Integrated Service Systems for Homeless Persons with Mental Illness: The ACCESS Program. Psychiatric Services 48(3): 369-373.
Rickards, L. D., Leginski, W., Randolph, F., Oakley, D., Herrel, J. M., & Gallagher, C. (in press). Cooperative Agreements for CMHS/CSAT Collaborative Program to Prevent Homelessness: An Overview. Alcohol Treatment Quarterly.
Ridgely, M. S., Lambert, D., Goodman, A., Chichester, C., Ralph, R. (1998). Interagency Collaboration in Services for People With Co-Occurring Mental Illness and Substance Use Disorder. Psychiatric Services 49(2): 236-238.
Ridgely, M. S., Morrissey, J. P., Paulson, R. I., Goldman, H. H., Calloway, M. O. (1996). Characteristics and Activities of Case Managers in the RWJ Foundation Program on Chronic Mental Illness. Psychiatric Services 47(7): 737-743.
Rog, D. J. & Gutman, M. (1997). The Homeless Families Program: A Summary of Key Findings. In S. Isaacs & J. R. Knickman (Eds.), To Improve Health and Health Care, 1997: The Robert Wood Johnson Anthology. San Francisco: Jossey-Bass Publishers, 209-231.
Rog, D. J., Hambrick, R., Holupka, S., McCombs, K., Gilbert, A. & Brito, C. (1994). The Homeless Families Program: Interim Benchmarks. Report submitted to the Robert Wood Johnson Foundation, October.
Rog, D. J., Holupka, C. S., McCombs-Thirnton, K. L., Brito, M. C., Hambrick, R. (1996). Case Management in Practice: Lessons from the Evaluation of the RWJ/HUD Homeless Families Program. Journal of Prevention and Intervention in the Community 15(2): 67-82
Rosenheck, R. & Lam, J. A. (1997a). Client and Site Characteristics as Barriers to Service Use by Homeless Persons with Serious Mental Illness. Psychiatric Services 48(3): 387-390.
Rosenheck, R. & Lam, J. A. (1997b). Homeless Mentally Ill Clients’ and Providers’ Perceptions of Service Needs and Clients’ Use of Services. Psychiatric Services 48(3): 381-386.
Rosenheck, R. & Lam, J. A. (1997c). Individual and Community-Level Variation in Intensity and Diversity of Service Utilization by Homeless Persons with Serious Mental Illness. The Journal of Nervous and Mental Disease 185(10): 633-638.
Rosenheck, R., Frisman, L., & Gallup, P. (1995). Effectiveness and Cost of Specific Treatment Elements in a Program for Homeless Mentally Ill Veterans. Psychiatric Services 46: 1131-1139.
Rosenheck, R., Frisman, L., & Kasprow, W. (1998). Improving Access to Disability Benefits among Homeless Persons with Mental Illness: An Agency-Specific Approach to Services Integration. Paper prepared for publication.
Rosenheck, R., Lam, J., & Randolph, F. (1997). Impact of Representative Payees on Substance Use By Homeless Persons With Serious Mental Illness. Psychiatric Services 48(6): 800-806.
Rosenheck, R., Morrissey, J., Lam, J., Calloway, M., Johnsen, M., Goldman, G., Calsyn, R., Teague, G., Randolph, F., Blasinsky, M., & Fontana, A. (1998). Service System Integration, Access to Services and Housing Outcomes in a Program for Homeless People with Mental Illness. American Journal of Public Health 88(11): 1610-1615.
Rowe, M., Hoge, M., & Fisk, D. (1998). Services for Mental Ill Homeless Persons: Street-Level Integration. American Journal of Orthopsychiatry, 68(3): 490-496.
Soler, M. I. & Peters, C. M. (1993). Who Should Know What? Confidentiality and Information Sharing in Service Integration. New York, NY: National Center for Service Integration.
Talbott, J. A. (1995). Evaluating the Johnson Foundation Program on Chronic Mental Illness: An interview with Howard Goldman. Psychiatric Services 46(5): 501-503.
U. S. Department of Health and Human Services. (1985). Community Partnership Manual. Washington, DC: DHHS.
U. S. Department of Health and Human Services. (1994). Evaluation of HHS Services Integration Pilot Projects. Rockville, MD: Administration for Children and Families, HHS.
U. S. Department of Health and Human Services. (Undated). Strengthening Homeless Families: A Coalition-Building Guide. Washington, DC: HRSA, Administration for Children and Families.
U. S. Department of Housing and Urban Development. (1993). The D.C. Initiative: Working Together to Solve Homelessness. Washington, D.C.: HUD.
U. S. Department of Housing and Urban Development. (1994). Continuum of Care. Washington, DC: HUD, Office of Community Planning and Development, April.
Wilkins, C. (1996). Building a Model Managed Care System for Homeless Adults With Special Needs: The Health, Housing, and Integrated Services Network. Current Issues in Public Health 2: 39-46.
Yessian, M. R . (1991). Services Integration: A Twenty-Year Retrospective. Washington, DC: Department of Health and Human Services, Office of the Inspector General.
Yessian, M. R. (1995). Learning From Experience: Integrating Human Services. Public Welfare 34-42, Summer.
NOTES
(1) For the purpose of this paper, we will be examining the role of systems integration in addressing homelessness. Services integration in the form of case management is being addressed in a separate paper.
(2) Project SHARE operated from 1972-1990 and collected over 11,000 documents related to services integration. These materials are now housed at the National Center for Service Integration Information Clearinghouse, c/o National Center for Children in Poverty, 154 Haven Avenue, New York, NY, 10032, phone 212-927-8793.
Return to the Table of Contents, ASPE Home Page, or HHS Home Page.