Enhancing service system integration has long been an objective of policymakers, payers, and human service providers. As far back as the Model Cities Program of the 1960s processes that facilitate system integration have been thought to improve the capacity of systems to address the needs of individuals with multiple problems and have been widely believed to increase the accessibility, continuity and coordination of care (Morrissey et al. 1994; Provan & Milward 1995; Randolph et al 2002; Cocozza et al. 2000; Foster-Fishman et al. 2001; Provan & Milward 1995). Emphasis on implementation of evidence-based practices has been a growing and parallel trend in health care (Guyatt et al. 2004) and has been rigorously promoted in several recent policy summaries of literature on the treatment of mental illness (Drake et al. 2001; Torrey et al. 2001; DHHS 1999; New Freedom Commission on Mental Health 2003; SAMHSA 2003). It has been suggested that more integrated systems may also allow for more rapid dissemination of evidence-based practices, with greater model fidelity(2) (McKinney et al 1993; Goldman et al. 2001).
There is broad consensus that increasing the level of service system integration should lead to improved client outcomes. System integration can be defined broadly as the provision of services with high levels of coordination, communication, trust, and respect among service agencies so that they are better able to work together to achieve common objectives. While there is some supporting evidence from cross sectional data (Provan & Milward 1995; Rosenheck et al. 1998; Rosenheck, Morrisey, Lam, et al. 2001), two large prospective evaluations of system integration initiatives found that even when the levels of integration were increased there was no substantial improvement in treatment outcomes at the individual client level. One explanation for this finding may be that improved system integration may be necessary but not sufficient to improve client outcomes and that concomitant implementation of evidence-based clinical practices may also be necessary (Isett and Morrissey 2006; Goldman et al. 2001; Lehman et al. 1994).
In 1986, the Program on Chronic Mental Illness launched by the Robert Wood Johnson Foundation and the U.S. Department of Housing and Urban Development sought to evaluate whether more highly integrated systems of care were more effective in addressing needs of persons with severe mental illness (SMI). Results of this nine-site evaluation found that integration efforts were associated with measurable improvements in inter-agency collaboration and increased continuity of care (in part as a result of greater availability of case management services) but were not associated with improved client outcomes, such as symptoms, social relationships, and quality of life (Morrissey et al 1994; Lehman et al. 1994).
Similar results were reported from the 18-site evaluation of the Center for Mental Health Service's Access to Community Care and Effective Services and Supports (ACCESS) program. This five-year demonstration program, implemented in 1993, evaluated the impact of efforts to enhance system integration on outcomes of homeless persons with serious mental illness (Cocozza et al. 2000; Rosenheck et al. 2001) and represented a major improvement over the evaluation design of the Program on Chronic Mental Illness by including a matched sample of comparison sites that did not implement integration strategies. While intervention sites in ACCESS showed greater increases in measures of system integration than comparison sites (Morrissey et al. 2002), clients at these sites did not show greater improvement in housing or symptom outcomes (Rosenheck et al. 2002). However, correlational findings from the ACCESS evaluation showed that sites that had more integrated service systems, regardless of whether they were intervention or comparison sites, had superior 12 month housing outcomes at (Rosenheck et al. 1998) but that this relationship may have been mediated by the level of community social capital, an indicator of overall civic culture (Putnam 1994; 2000; Rosenheck et al. 2001) rather than by specific integration interventions (Rosenheck et al 2002).
In 2002 the federal government made a major commitment to address the problem of chronic homelessness (Sullivan 2002), which was defined in the CICH Notice of Funding Availability (NOFA) as, "an unaccompanied homeless individual with a disabling condition who has either been continuously homeless for a year or more OR has had at least four (4) episodes of homelessness in the past three (3) years." It was expected that by focusing on housing and service needs of this target population it would be possible to disrupt repetitive cycles of recurrent homelessness and free resources to meet the needs of the vast majority of people experiencing homelessness who, with limited assistance, can often exit homelessness relatively quickly (Interagency Council on Homelessness 2003).
A major service demonstration project that emerged from this effort is the Collaborative Initiative to Help End Chronic Homelessness (CICH), a $55 million in federal dollars effort ($35 million funding in 2003, with $20 million added in subsequent years) jointly funded by the Department of Housing and Urban Development, the Department of Veterans Affairs, and the Department of Health and Human Services. After a competitive Request for Applications, CICH awards were made to 11 jurisdictions to provide comprehensive assistance to chronically homeless persons, and to help them move from the streets and emergency shelters into stable housing.
CICH is the first national evaluation of client outcomes among chronically homeless individuals targeted to receive comprehensive housing and support services through a collaboration of HUD, HHS, & VA. Neither the Robert Wood Johnson Foundation Program on Chronic Mental Illness nor the ACCESS program targeted this particularly vulnerable and costly subgroup. Furthermore, no previous initiative focused on collaboration among the three federal agencies primarily responsible for assisting and providing care for homeless persons or emphasized both system integration and implementation of evidence-based practices.
In this report we present system-level observational evaluation data on the CICH program. We describe changes in performance measures over time, by agency type (i.e., lead, housing service provider, veteran service provider, etc) and across sites, as well as examine interrelationships among salient measures. CICH focused on improving outcomes for chronically homeless people by making funding available to provide five core services at each site: (1) permanent supportive housing, (2) mental health treatment, (3) substance abuse treatment, (4) primary health care, and (5) veteran health services. Services were to be provided through a local network of agencies, coordinated by a local "lead" agency that would oversee distribution of funds; facilitate joint planning and coordination across agencies; promote the use of evidence-based practices; and foster development of homeless management information systems. This evaluation was not designed to evaluate the causal impact of specific interventions but to present descriptive data on service system activities and characteristics, clinical service delivery, and client outcomes.
The CICH program represents an extension of efforts to integrate services for people experiencing homelessness fostered for many years by the Department of Housing and Urban Development's (HUD) Continuum of Care (COC) initiative. Since 1996, through its competitive application process for supportive housing programs, HUD has promoted the development of networks of agencies that together constitute a Continuum of Care. These networks are organized around the centralized distribution and coordination of federal funding to provide a comprehensive array of services for homeless Americans (Burt et al 2002). In addition to encouraging interagency collaboration, CICH took note of but did not mandate the development of "Housing First" service models, in which people experiencing homelessness are moved into permanent housing as quickly as possible, and once housed, are provided long-term support to facilitate access to services thereby preventing a return to homelessness (Tsemberis et al. 2000, 2004; Kowal 2006).
This report examines four questions reflecting central objectives of the CICH initiative at the service system level. First, to what degree is CICH associated with implementation of practices that encourage system integration; with improvements in coordination of service delivery and planning among participating agencies over time; and with increased trust and respect between providers? Second, was the initiative associated with changes in the type of housing provided at CICH sites, with the implementation of homeless information management systems, or with the availability of evidence-based mental health practices? Third, did some sites and some types of agencies show greater change in measures of system-wide performance than others? Lastly, to complement the focus on organizational integration we examine whether relationships specifically characterized by exchanges of funds are associated with greater levels of inter-agency integration, collaboration and trust, both cross-sectionally and over time.
While this report thus focuses on an examination of system-level activities in CICH, another report, "HUD/HHS/VA Collaborative Initiative to Help End Chronic Homelessness National Performance Outcomes Assessment Client Outcomes Report," will present data on service delivery and client outcomes in the CICH program and a third report will address the relationship of client outcomes and system integration.
"report.pdf" (pdf, 296.36Kb)