NECESSARY PARTNERSHIPS: A VIEW OF MENTAL

HEALTH AND SUBSTANCE ABUSE PROVIDER

NETWORKS IN RURAL AND URBAN MISSOURI

RON CLAUS, PHD

MICHAEL RENNER, MSW
EDWARD G. RIEDEL, LCSW
JJ RORICK, LCSW
MARY E. HOMAN, MA

BUILDING EQUITABLE PARTNERSHIPS

NOVEMBER 5-7, 2008
Where in the World is Missouri?
 Missouri Foundation for Health
Beginning

Nonprofit Blue Cross Blue

Shield of Missouri converts
to for-profit RightChoice

MFH created in 2000 to

receive Blue Cross Blue
Shield of Missouri nonprofit
assets
Who We Are
… Independent, nonprofit organization
… Not funded with state or federal monies
… Focus
† Grant making
† Health policy
… Goals
† Fill
gaps in health care services for the uninsured
and underinsure
† Identify and address unmet health care needs
 Mental Health & Substance Abuse
Funding Program

Co-Occurring Disorders—23 Agencies

† Integrating mental health and substance
abuse programs
† Focus on organizational change

† Technical assistance on implementation

† Evaluation
Technical Assistance
ZiaLogic
… Provided by Dr. Ken Minkoff and Dr. Christie Cline
… Help leverage resources & facilitate systems change statewide
… Assist grantees to become COD competent

MIMH
… Evaluate impact of all projects
… Conference calls to discuss process and findings
… Assist grantees with evaluation design, data collection, analysis, report writing.

MFH
… Organize grantee convenings
… Support Change Agent Cadre
… Conduct site visits
Potential Benefits of Collaboration
… Client – faster access to more appropriate services,
improved continuity of care, less likely to “fall through
the cracks” due to multiple problems like co-occurring
… Behavioral health staff – professional development,
reduced anxiety, greater sense of accomplishment and
less role confusion
… Agency – shared resources, creative interventions,
greater efficiency, enhanced communication
… System – more effective service delivery, less
fragmentation & duplication, improved cost
effectiveness, improved ability to advocate and
influence public policy
Challenges of Collaboration
… Behavioral health staff – stigma, misconceptions
about potential clients, professional knowledge and
boundaries, role ambiguity and clinical autonomy
… Agency – incongruent values, missions, and cultures,
practical (client expectations, confidentiality, HIPAA)
… System – resources, agency competition, lack of
effective interagency structures
Study Aims
… Describe the collaborative partnerships of 23
community-based agencies implementing evidence-
based practices for co-occurring disorders
† Differences between SA and MH agencies?
† Differences between urban and non-urban agencies?

… Report on barriers to collaboration identified by the

collaborators
… Examine the association between the co-occurring
capability of an agency and collaboration
Collaboration

Collaboration refers to a cooperative process of

exchange involving communication, planning, and action
of two or more entities working together towards a
shared goal.

† Communication, planning and action (Amir & Auslander,

2003)
† Cooperative (Frey, 2006)
† Individual, intra-agency and interagency communication
skills (Ferrara, 1996)
Levels of Collaboration

Coalition

Coordination

Cooperation

Networking

No Interaction
No interaction

… One agency has not heard of the other agency

Or

… The agency is familiar with the other’s services but

they do not interact
Networking

‰ Sharing information
‰ Creates dialogue and common understanding

… Communication is usually the primary link

… There are minimal decisions made together

Cooperation

… Limits duplication of services

… Communication link is advisory

… Facilitative leadership positions are forming

Coordination

… Share resources to address a common issue/ merge

resources to create something new.

… Links are formalized and roles are defined

… Communication is frequent and leadership is

autonomous but the focus is on a shared issue.
Coalition
… Share ideas and be willing to pull resources from
existing systems

… Develop a commitment for a minimum of 3 years

… Links are formal with written agreement

… Communication is common and prioritized

Missouri Foundation for Health’s
Co-Occurring Disorders Priority Area

… An initiative to support the implementation of

evidence-based practices for co-occurring substance
use and mental health disorders

… Publicly-funded treatment providers received

support for system change
† SA & MH providers in MO
† 10 programs awarded 3-year grants in Dec 2006

† 13 programs awarded 3-year grants in June 2007

Evaluation Process
… Partners identified by each grantee
… Brief (20-30 minute) phone interview with each
partner
† Agency description (mission, services, size)
† Collaboration Level with all network partners

† Barriers to collaboration with grantee

† Facilitators of collaboration with grantee

… Report to grantee
† Collaboration Map
Levels of Collaboration Survey
… Respondents were identified by the grantee’s
change agent
† All consented to be interview by evaluation staff
… Descriptions of levels of community linkage
provided in advance
… Respondents reported extent to which they
collaborated with each other partner, from
†0 = No interaction at all
† 5 = Collaboration

Frey et al., 2006

Perceived Barriers to Service Linkage

… Extent to which 18 specific financial and operational

conditions represented barriers to working with the
grantee
† Financial constraints (e.g., inadequate insurance
reimbursement, managed care restrictions, insufficient
funding)
† Operational challenges (e.g., caseload problems, long
waiting lists, transportation, hours of operation,
confidentiality)
† Relationship challenges (e.g., resource competition, mistrust,
different philosophies, client stigma)
† 5-point scale, “Not a problem” to “Very great problem”

Lee et al., 2006

 Grantee Co-Occurring Capability
… Dual Diagnosis Capability in Addiction Treatment
(DDCAT) scale - McGovern, Matzkin, & Giard, 2007

… Dual Diagnosis Capability in Mental Health

Treatment, parallel version for MH agencies – Gotham

… Semi-structured questions to elicit ratings on 35 items

across 7 subscales:
„ Program Structure ƒ Continuity of Care
„ Program Milieu ƒ Staffing
„ Clinical Process: Assessment ƒ Training
„ Clinical Process: Treatment
 Number of Sites
A

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2
4
6
8
10
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MH

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Co-Occurring Capability
MFH Grantees
… Urban Core – 54.5%
† Metropolitan area with > 50,000
† 10 MH providers, 2 SA providers
… Large Town – 36.4%
† Population10,000 – 49,000
† 6 MH providers, 3 SA providers
… Small Town – 4.5%
† Population range 2,500 – 9,999
† 1 SA provider
… Isolated Small Census Tract – 4.5%
† 1 MH provider

Measuring Rurality: Rural-Urban Commuting Area Codes, USDA, 2000

 Collaborative Partner Map
Grantee Average Average
5 3.4 Number Strength of 
NAMI Of Links Collaboration
HIV/AIDS 4.2 3.4
Service
Organization
4 3.5
4 2.3

Drug and
HIV/AIDS
Alcohol
treatment
Service Key
Organization
Level  0  None No line
4 4.3 3 2.3 Level  1  Networking No line
Level  2  Cooperation
Drug Level  3  Coordination
Court Level  4  Coalition
Level 5 Collaboration
5 4.5
Grantee Networks
… Network Size
† On average, 5.9 Partners (Mdn = 5)
† Wide range (0 – 14 collaborators)

† Each collaborator had “connections” with 81% of the

other network partners (4.8/5.9) on average
… Grantee or Location Differences?
† MH grantees had slightly larger networks than SA
grantees (6.1 vs. 5.3; d = 0.26)
† Urban and non-urban networks were similar in size
Network Composition
% Collaborative Partners by Service Provided

25% 24%
Substance Abuse
Mental Health
Medical
Criminal Justice
Other
19%
25%

7%
 Differences in Network Composition
Number of 
Partners by  Grantee Type
Grantee Type
Overall Substance Abuse Mental Health
Substance Abuse 1.4 1.5  1.4 

Mental Health * 1.5 3.0  0.9 

Medical 0.4 0.2  0.5

Criminal Justice * 1.1 0.2  1.4 

*p < .05
 Network Composition

Substance Abuse Grantees Mental Health Grantees

4%
4% 7%
Substance
28% Abuse 31% 23%
Mental
Health
Medical 15%
57%
Criminal 23% 8%
Justice
Other
Level of Collaboration

… On average, the average Level of Collaboration

across all the grantee networks was 2.5 (out of 5)
† MH grantees described stronger connections (2.7, or
approaching the Cooperation level)
† SA grantees described lower levels (2.2, or just above
the Networking level)*
† No differences were found between Urban and Non-
urban grantees

*p < .10
Barriers Perceived by Collaborators

Long waiting lists 2.6

Caseload problems 2.3

Transportation 2.3

Ability to pay out of pocket 2.2

Inadequate insurance 2

1 1.5 2 2.5 3 3.5 4 4.5 5

1 = “Not at all a problem”, 5 = “Extreme problem”
Do agencies with higher co-occurring
capability have more partners?
Number of Collaborative Partners

AOS or MH Only/Dual
6.2
Diagnosis Capable

Addiction/Mental Health
5.3
Only

0 5 10

Correlation between Number of Partners & Co-Occurring Capability

R = 0.37 (p < .10)
No Significant Correlation between Level of Collaboration & Co-Occurring Capability!
Discussion – Network Characteristics

… Collaborative networks at 23 grantee agencies

working to develop co-occurring services most often
included 5 or 6 partners
… Partners regularly included criminal justice agencies
and additional substance abuse and mental health
agencies
… Partners most often interacted at the Networking or
Cooperation levels of collaboration
… Findings are consistent with the limited literature on
other SA/MH networks
Discussion – Grantee Differences
… Mental Health and Substance Abuse Grantees differed:
† MH networks were slightly larger than SA networks
† MH networks included more CJ partners; SA networks
included more MH partners
† The level of collaboration was higher for MH grantee
networks
… May be due to prior work with partners by MH
grantees; may reflect the generally larger size and
greater resources of MH grantees
… No differences in network makeup for urban vs. non-
urban grantees
Discussion - Barriers
… Partners identified few and minor barriers to
collaboration
† Most common: Long waiting lists (slight to moderate);
caseload problems, transportation, and ability to pay
out of pocket for services (slight)
… Small differences between SA and MH grantees
… Small differences between urban and non-urban
grantees
Discussion – Co-Occurring Capability
… Agencies with higher COD capability had larger
networks of collaborative partners
† Developing more resources and discharge planning options
may lead to improved care for clients with COD (but
causality can’t be determined)
† Strong agencies may be effective at building partner
relationships and at developing specialized COD
programming
… Level of Collaboration was not related to COD
capability
† The variety and number of resources for clients may be
more important than working at the Coordination or
Coalition level of collaboration level
Building Partnerships: Practical Stuff

… How to identify partners

† Clinical Wisdom

† Assessing agency culture

† Data Driven
„ Needs Assessment of Consumers, Families, Community
Stakeholders.
„ Problem Identification
What Worked…
… Networking at existing community and coalition
meetings.
… Joint training
… Employee sharing
… Case consultation – Being a resource
… Behavior planning
… Getting it in writing
… Planned social events
… Clearly defining roles
What did not work. . .
… Assuming what the executive director promised was
going to happen- that they communicated the
partnership agreement to front line staff and got
buy-in.
… Assuming people would see a great opportunity like
we did.
… Assuming everyone had the same goals and
objectives we did.
… Putting partnerships at the bottom of the “to do
list”.
Getting started
… Piggy-back on existing relationships
… Consistency and follow through.
… Personal relationships - having a contact person
… Formalize relationships with agreements or MOUs
… Decide how disputes will be resolved
… Look for shared opportunities, grants, & presentations
that meet larger community needs
… Offer and accept invitations to cross-educate staff
… Identify shared goals and vision.
… Start with something that can be fixed easily.
 Acknowledgements
… Support for this presentation was provided by the
Missouri Foundation for Health, a philanthropic
organization whose vision is to improve the health
of the people in the community it services.

… Thanks to Kim Selig, Lisa Harper Chang, and Cathy

Williams for help with interviewing collaborative
partners