Blueprint for Change: Ending Chronic
Homelessness for Persons with Serious
Mental Illnesses and Co-Occurring Substance Use Disorders

Chapter 4: Establish a Comprehensive, Integrated System of Care

People with serious mental illnesses and/or co-occurring substance use disorders who are homeless need multiple services, including housing, health care, mental health services, substance abuse treatment, income supports and entitlements, life skills training, education, and employment. These services typically are provided by multiple agencies in different systems, leaving individuals to coordinate their own care. They may receive duplicate services at multiple agencies or no services at all. This chapter examines both the need for a comprehensive, integrated service system, and the steps and strategies to achieve systems change.

Why Comprehensive, Integrated Services?

The concept of integrating human services to improve outcomes for individuals with multiple and complex needs is not new. For more than 30 years, active efforts to integrate human service systems have been called by such names as community integration, comprehensive services, community support systems, and a Continuum of Care (Dennis et al., 1999). In its 1992 report, Outcasts on Main Street, the Federal Task Force on Homelessness and Severe Mental Illness set as a goal for the Nation, "an integrated service system for homeless people with severe mental illness." Clearly, progress has been made, but much remains to be done.

Systems integration efforts have taken on special urgency in an era of increasing needs and limited resources. Contemporary systems integration efforts are driven by several important factors. The relaxation of some Federal program regulations—through block grants and special waivers, for example—creates opportunities to promote integrated services. In addition, some Federal/state programs, including Medicaid managed care and welfare reform, may prompt collaboration among diverse agencies in order to meet mandated financial objectives and client outcomes (NASMHPD and CMHS, 1999).

The Definition of Systems Integration

At its most basic, systems integration is designed to change service delivery for a defined population and involves fundamental changes in the way agencies share information, resources, and clients (Dennis et al., 1999). In particular, systems integration focuses on reducing barriers, coordinating and improving existing services, and developing new programs to improve the availability, quality, and comprehensiveness of services (Miller, 1996).

Systems integration efforts require the creation of formal relationships among agencies within and across systems. Systems integration cannot succeed without an emphasis on integrated services, as well (Agranoff, 1991; Cocozza et al., 2000).

The Creation of a Seamless System of Care

The ultimate goal of systems integration is to improve outcomes for people with serious mental illnesses or co-occurring disorders who are homeless. To do so requires creating a system of care that is seamless to the individuals being served. Indeed, full integration assumes a system-wide policy that makes "any door the right door" to receive needed treatment and services. This means that people with serious mental illnesses or co-occurring disorders who are homeless must be able to enter the service system through any service door, be assessed, and have access to the full range of comprehensive services and supports they want and need (Federal Task Force on Homelessness and Severe Mental Illness, 1992).

This approach challenges the ways in which systems with different funding streams, philosophies, and missions typically offer services. However, by responding collaboratively to address the multiple needs of people who are homeless, service systems benefit from a more efficient use of limited resources. Individuals benefit from client-centered services that place the burden of coordination on the systems that are serving them (NTAC, 2000).

Barriers to Integrating Services

Despite distinct advantages to both systems and clients, the barriers to integrating service systems are both broad and deep. As one observer notes, "While everybody is in favor of coordination, nobody wants to be coordinated." (Feldman, 1976).

Some specific system-level barriers to effective integration include:

• Well-established programs and a specialized work force;
• Interagency turf battles;
• Funding limitations;
• Lack of technology and resources to support information needs;
• Lack of available services;
• Size and complexity of the service system;
• Lack of political will and mechanisms to channel public support; and
• Legislative and political opposition.

(NASMHPD and CMHS, 1999; Yessian, 1995; Rochefort and Dill, 1994; Agranoff, 1991; Feldman, 1976)

The tools to address these barriers include the key strategies and mechanisms for systems integration highlighted below. Sometimes Federal or state regulatory, statutory, or budgetary requirements must be relaxed to make it easier for agencies to collaborate with one another. However, even small changes in the way agencies relate to one another can pave the way for greater cooperation on behalf of people with serious mental illnesses or co-occurring disorders who are homeless.

Key Systems Integration Strategies and Mechanisms

Successful systems integration is based on all the knowledge a community has at its disposal about the population to be served. In particular, research and experience have demonstrated that services for people with serious mental illnesses or co-occurring disorders who are homeless should be recovery-focused, culturally competent, flexible and individualized, and client-centered. Further, the full array of services that individuals need must be in place or must be created. This makes it essential that individuals with mental illnesses and substance use disorders who are homeless have access to all mainstream benefits and services for which they are eligible.

For instance, the importance of making a variety of safe, affordable housing options available cannot be overstated. Without housing, services and supports cannot be effective. Finally, individuals must be supported while making transitions among services (e.g., from transitional to permanent housing) or from an institution to the community.

Each of the specific steps outlined is critical to making systems change a reality. The strategies required to carry out each step will vary depending on the local needs, resources, and community priorities; however, strategies that have proven successful in other jurisdictions offer useful guidance (Foster et al., 1998; Hoge and Howenstine, 1997; Ridgely et al., 1998).

Develop the Infrastructure for Systems Change

Choose a Change Agent

A dedicated staff person brings energy and attention to the task of systems integration. This person should be capable of providing the leadership necessary to engage key stakeholders from all service sectors. Key leadership characteristics for such a person include "vision, entrepreneurship, political astuteness, a respect for diversity, and a talent for managing complexity." (Yessian, 1995). The systems integration coordinator must be highly respected and independent of the key collaborators to avoid the impression of favoritism or an imbalance of power.

Secure Adequate Resources

Money is a necessary, though not sufficient, ingredient of systems integration. Without flexible funding or regulatory relief, systems integrators begin in a weak position (Yessian, 1995). The next chapter includes an overview of strategies to support services for people with serious mental illnesses and/or co-occurring substance use disorders who are homeless.

Build a Coalition of Key Stakeholders

Building a coalition of key stakeholders is critical to the systems change process. This group must include individuals with the authority to commit their organizations and their resources to needed changes (Agranoff, 1991). Such groups may vary in size and composition, organizational structure and process, and missions and objectives (Cocozza et al., 2000). In general, however, coalition membership should be inclusive rather than exclusive and should involve consumers and recovering persons in an active role (Kaye and Wolfe, 1995). Other important stakeholders might include:

• Executive branch leaders from state and local governments (e.g., governors, mayors);
• Agency heads from state and local departments of housing, mental health, substance use, health, Medicaid, welfare/social services, education, homeless services, transportation, labor, criminal justice, etc.;
• Health, mental health, substance abuse treatment, and homeless assistance providers;
• Faith and community-based organizations;
• People who are homeless or formerly homeless;
• Consumers and recovering persons and their families;
• Members of the business community; and
• Advocacy groups.

HHS has sponsored a series of state-level Policy Academies designed to develop the infrastructure for systems change. The Academies create or reinforce relationships among key stakeholders in selected states (e.g., the governor’s office, state legislators, key program administrators, and stakeholders from the public and private sectors) who can work together to improve access to mainstream services for people who are homeless.

Nurture the Coalition and Continue to Form Partnerships

Relationships with key stakeholders must be nurtured to engage them fully in the process. Other important parties may be identified along the way and should be similarly engaged (NTAC, 2000). Once a coalition is established, members can begin to build relationships and develop a common language, define their mission, and create a structure for working together (Kaye and Wolff, 1995).

Building a coalition is a means to systems change but is not an end product. Collaborative planning is an ongoing process that involves building new relationships and securing commitment from all players to carry out a community’s plan to address homelessness. When forming new or re-evaluating old relationships, individuals must be aware of preconceived notions about the services and resources of other stakeholders and be open to understanding new or different perspectives. Engaging in active listening and focusing on ideas rather than people support honest expression of ideas and information sharing (HHS, HUD, and Interagency Council on the Homeless, 1999).

Engage in Strategic Planning

Developing a formal plan for action is a critical ingredient of the collaborative planning process (HHS, HUD, and Interagency Council on the Homeless, 1999; and HomeBase, 1999; HHS, undated). This is best accomplished by strategic planning, summarized in Table 4.1. Engaging in this process helps both delineate the parameters of the systems integration effort and set specific goals and objectives. Without such a plan, systems integration efforts have no direction, no means to evaluate their progress, and no basis on which to build trust (Dennis et al., 1999).

Define the Issue

Before a community can develop a plan to integrate care for people who are homeless, it must be clear about the services it currently offers and the existing gaps or unmet needs. Data that indicate where people are not being served or are underserved in the system, along with anecdotal examples that point to barriers or gaps in the system, should be discussed openly to help the group produce a shared definition of the problem (NTAC, 2000).

Such data may include "hard" data such as admissions and clinical encounter information from programs that serve people with serious mental illnesses or co-occurring disorders and people who are homeless. "Soft" information from key informant interviews and focus groups with system stakeholders also may be considered (NTAC, 2000).

Table 4.1. The Strategic Planning Process

Create a Shared Vision

When the group has identified the problem or problems it wants to address (e.g., lack of discharge planning for individuals with serious mental illnesses or co-occurring disorders leaving a hospital or jail), members can develop a shared vision or mission statement to create an integrated service system (National GAINS Center, 1999). When creating this vision, the group should not be constrained by the system’s current configuration or resources. Rather, the vision should represent the "preferred future," or what the system could look like if integration were achieved (NTAC, 1999). Ultimately, a vision statement should be simple, concise, and clear, and should immediately engage all parties (NTAC, 2000).

Develop a Plan

When the group has defined its mission, it should develop a formal plan that specifies recommendations for change. Such a plan documents the specific goals, objectives, and strategies to make the vision a reality. For example, the group may decide that it needs to implement formal discharge planning policies to keep people with serious mental illnesses or co-occurring disorders from becoming homeless when they leave a jail, a detoxification program, or a psychiatric hospital. The plan also should assign responsibilities for tasks and set timeframes for completion (Kaye and Wolff, 1995). Procedures to measure outcomes to ensure accountability should be built in, as well.

Implement the Plan

A number of mechanisms may be used to achieve a community’s specific goals, as highlighted in Table 4.2. These include co-location of services, pooled or joint funding, and streamlined application procedures. For example, a homeless services provider may station a case manager at the jail to help create discharge plans for people with serious mental illnesses and/or co-occurring substance use disorders who are at risk of homelessness.

Many of these strategies have been successful in promoting systems integration in other communities, including those involved in the ACCESS (Access to Community Care and Effective Services and Supports) demonstration program, administered by SAMHSA’s Center for Mental Health Services. Findings from the ACCESS program evaluation indicate that successful implementation depends, in part, on the specific strategies selected. Certain mechanisms, such as the use of interagency agreements, appear to be easier to implement. Others, including the development of interagency management information systems or the establishment of common eligibility criteria, require time and a well-functioning infrastructure to implement successfully (Cocozza et al., 2000).

Monitor Progress

Incremental improvements as well as long-term accomplishments can be highlighted by collecting and analyzing data (NTAC, 2000). For example, a community might measure the number of days homeless after leaving jail as an indicator of successful discharge planning efforts for people with serious mental illnesses or co-occurring disorders at-risk of homelessness. This information also can be used to make mid-course corrections in the implementation plan, as necessary.

Successful evaluation efforts require the establishment of guidelines for consistent data collection, performance standards, and reporting. Quality assurance can be linked to funding (e.g., written into contracts) as a means of ensuring compliance and promoting effective practices. Strategies for evaluating outcomes are described further in Chapter 7.

Seek Technical Assistance

The value of technical assistance at critical junctures is an important strategy in a successful systems change initiative. Communities sometimes need an outside facilitator to help with the strategic planning process or an evidence-based practice expert who can advise on implementing a specific service component (Pitcoff, 1997; Dennis et al., 1999). It also may be helpful to visit and talk with others who have already implemented a similar approach or system component in another community. Being able to identify specific technical assistance needs and to seek help early in the process can help communities avoid losing the momentum needed to achieve lasting change.

Table 4.2. Implementation Strategies

Participate in Community-Wide Planning Efforts

Systems change can’t happen in a vacuum. A number of local and statewide planning processes can bring key stakeholders to come together and create a plan for services. The needs of people with serious mental illnesses and/or co-occurring substance use disorders who are homeless must be represented in these plans. In addition, these groups may have valuable data and ideas to share, and their members may include some of the key players you need on your team.

For example, the Continuum of Care process is more than an application for HUD Homeless Assistance funds. According to HUD, a Continuum of Care plan is "a community plan to organize and deliver housing and services to meet the specific needs of people who are homeless as they move to stable housing and maximum self-sufficiency. It includes action steps to end homelessness and prevent a return to homelessness." (HUD, 1999).

Mental health and substance abuse services providers must participate in Continuum of Care planning to ensure that the needs of the individuals they serve are represented in requests for homeless assistance funds. Likewise the HUD Consolidated Plan, needed to access mainstream housing resources, is a strategy for holistic community planning. State and community Consolidated Plans are built on public participation. The volume, How to Be a "Player" in the Continuum of Care: Tools for the Mental Health Community, is an excellent resource in this regard (Technical Assistance Collaborative, 2000).

(Technical Assistance Collaborative, 2000).

Finally, in response to the Supreme Court’s 1999 decision in Olmstead versus L.C., most states have created task forces or commissions to develop plans to serve people with disabilities in less restrictive settings (GAO, 2000b). CMHS provides funds and technical assistance for statewide coalitions that are addressing barriers to full community integration for adults and children with mental illnesses. Because people with serious mental illnesses and/or co-occurring substance use disorders leaving institutions are at risk for homelessness, and those living precariously in the community are at risk for unnecessary hospitalization, key stakeholders in the mental health services, substance abuse treatment, and homeless service systems must be active players in developing statewide Olmstead plans.

Ensuring Adequate Resources

Devising a formal plan and getting the commitment of top-level leaders and key stakeholders are critical to any successful systems change effort. However, while necessary, they are not sufficient alone to make change a reality. Planning must be linked to adequate financial resources. Finding ways to leverage resources, make better use of mainstream resources, and pursue new sources of funding are essential. Improved coordination among existing funding sources also is necessary. The next chapter describes strategies to support housing and services for people with serious mental illnesses or co-occurring disorders who are homeless.

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