Service delivery and community: social capital, service systems integration, and outcomes among homeless persons with severe mental illness.

OBJECTIVES: This study evaluated the influence of features of community social environment and service system integration on service use, housing, and clinical outcomes among homeless people with serious mental illness. STUDY SETTING: A one-year observational outcome study was conducted of homeless people with serious mental illness at 18 sites. DATA SOURCES: Measures of community social environment (e.g., social capital) were based on local surveys and voting records. Housing affordability was assessed with housing survey data. Service system integration was assessed through interviews with key informants at each site to document interorganizational transactions. Standardized clinical measures were used to assess clinical and housing outcomes in face-to-face interviews. RESEARCH DESIGN: Structural equation modeling was used to determine the relationship between (1) characteristics of the social environment (social capital, housing affordability); (2) the level of integration of the service system for persons who are homeless in each community; (3) access to and use of services by individual clients; and (4) successful exit from homelessness or clinical improvement. PRINCIPAL FINDINGS: Social capital was associated with greater service systems integration, which was associated in turn with greater access to assistance from a public housing agency and to a greater probability of exiting from homelessness at 12 months. Housing affordability also predicted exit from homelessness. Neither environmental factors nor systems integration predicted outcomes for psychiatric problems, substance abuse, employment, physical health, or income support. CONCLUSION: Community social capital and service system integration are related through a series of direct and indirect pathways with better housing outcomes but not with superior clinical outcomes for homeless people with mental illness. Implications for designing improved service systems are discussed.

Characterization of rural mental health service systems.

This paper explores two mental health systems in rural North Carolina that provide services to people with severe mental disorders. Recent findings show rural people with mental disorders receive less mental health care than their urban counterparts. This study asks whether rural service systems differ from urban systems in the way that their services are coordinated and structured. A popular conception is that public mental health systems in the United States are uncoordinated with many services provided outside the mental health sector. Rural service providers are seen as even more dependent on nonspecialized mental health providers than their urban counterparts. While many rural service barriers are attributed to the rural environment, little is known about rural service systems and how their organization might contribute to or negate barriers to care. Social network methods were used in this study to compare two rural with four urban systems of care. Findings confirm that mental health systems fit the de facto hypothesis, but that rural systems differ in ways not anticipated by the hypothesis. Rather than being more dependent on nonmental health agencies, rural mental health agencies are more interdependent.

Overcoming service barriers for homeless persons with serious psychiatric disorders.

OBJECTIVE: To help homeless persons with comorbid psychiatric and substance use disorders gain access to community services, in 1993 the Center for Mental Health Services implemented the five-year Access to Community Care and Effective Services, or ACCESS program, in 15 cities. One aim of the program is to encourage collaboration between agencies serving the multiple needs of this population. This study examined the extent of linkages between agencies in the 15 demonstration cities. METHODS: One respondent from each of the 1,060 community-based programs in tie 15 cities rated the extent to which his or her agency was linked with each of the other agencies in the local community in 1994 and again in 1996. Overall, there were 20,801 potential pairwise linkages. Linkages were classified into four types: a mutual tie, in which both agencies send and receive clients; a unidirectional tie, in which one agency sends and the other receives; an attempted tie, in which one agency sends but the other agency does not confirm receiving; and an unattempted tie. RESULTS: In 1994 and 1996, of the 20,801 pairs of potential service linkages, about a third were in place, while the remaining two-thirds were absent. Overall, linkages showed a slight but significant increase between 1994 and 1996. More than half of the linkages changed in type, indicating fluid service systems. CONCLUSIONS: Linkages between community agencies serving homeless persons with comorbid psychiatric and substance use disorders are not extensive. However, they increased slightly under the first two years of the ACCESS program, and there are good reasons to anticipate greater improvements in the future.

Service system integration, access to services, and housing outcomes in a program for homeless persons with severe mental illness.

OBJECTIVES: This study evaluated the hypothesis that greater integration and coordination between agencies within service systems is associated with greater accessibility of services and improved client housing outcomes. METHODS: As part of the Access to Community Care and Effective Services and Supports program, data were obtained on baseline client characteristics, service use, and 3-month and 12-month outcomes from 1832 clients seen at 18 sites during the first year of program operation. Data on interorganizational relationships were obtained from structured interviews with key informants from relevant organizations in each community (n = 32-82 at each site). RESULTS: Complete follow-up data were obtained from 1340 clients (73%). After control for baseline characteristics, service system integration was associated with superior housing outcomes at 12 months, and this relationship was mediated through greater access to housing agencies. CONCLUSIONS: Service system integration is related to improved access to housing services and better housing outcomes among homeless people with mental illness.

An empirical assessment of rural community support networks for individuals with severe mental disorders.

The community support network has been well-established as a requirement for community treatment of individuals with severe mental disorders. This network generally consists of a multidisciplinary set of organizations that interrelate in some manner with individuals in the community. The question of coordination within this network has been much discussed; however little published research has empirically examined the types and extent of coordination among network organizations. In particular, little attention has been given to community support networks in rural communities. In each of seven rural counties, information was obtained on inter-actions among organizations in the community support network. These networks were analyzed to yield information on network density and centralization. Using measures of centrality, the most central organizations in each network were identified. Exchanges of information were the most common type of interaction among organizations in each network. Client referrals occurred less frequently, and sharing of resources was an even rarer phenomenon. Network analysis of community support networks provides an objective perspective on the structure of community support networks. An understanding of exchange among organizations within these networks is of value to administrators, clinicians, and planners interested in achieving greater effectiveness, as well as to patients, their families, and advocacy groups concerned with access and quality of care.

Involvement of the inferior vena cava by adrenal phaeochromocytoma--MRI findings.

Involvement of the inferior vena cava (IVC) by adrenal phaeochromocytoma is rare. Only angiographic and sonographic features have been described previously. We present a case with magnetic resonance demonstration of the IVC invasion.

Service system performance and integration: a baseline profile of the ACCESS demonstration sites. Access to Community Care and Effective Services and Supports.

OBJECTIVE: Networks of agencies at the 18 demonstration sites in the Access to Community Care and Effective Services and Supports (ACCESS) program for homeless persons with serious mental illness were surveyed to profile baseline levels of systems performance and integration as part of a longitudinal evaluation of systems change and client outcomes. METHODS: Interviews were conducted with a representative from each of 875 agencies in the 18 service networks. Information was obtained about the perceived performance of the service system and the extent of systems integration as measured by client referrals, funds exchanges, and information sharing between agencies. Measures consisted of two multi-item scales assessing the accessibility and coordination of services for the target population in each community and four indexes of interagency relationships. RESULTS: Services at baseline for homeless mentally ill persons at the program sites were rated as relatively inaccessible, and the coordination of services between agencies was rated as even more problematic. Interagency ties were largely based on client referrals and information exchanges, with very few instances of funding transfers in the form of contracts or grants. On average, at baseline agencies that had received an ACCESS grant were better connected to their local service network than were other agencies. CONCLUSIONS: Consistent with the premise of the ACCESS demonstration, services for persons who are homeless and mentally ill in urban America are fragmented and not very accessible. The longitudinal design of the evaluation will allow for an assessment of efforts to improve services and systems integration and of the effects of these improvements on client outcomes.

Evaluating performance and change in mental health systems serving children and youth: an interorganizational network approach.

Planning for the delivery of community mental health services has evolved from models of services within individual agencies to community-wide systems of care, but development of methodologies for assessing system performance has lagged behind. This article presents one approach to system-level assessment by viewing children's mental health systems as an interorganizational network. Data are presented on two county-based child mental health systems in North Carolina that participated in the Robert Wood Johnson Foundation Mental Health Services Program for Youth. Site-specific data on client referrals, fund exchanges, and information flows were collected at two time points (1991 and 1993) to measure the cohesiveness and concentration of the service system using network k-core analyses. In addition, stakeholder ratings of service adequacy, quality, availability, coordination, and overall demonstration project goal attainment were obtained at both time periods. Findings indicate that the rural system was outperforming the urban system at the time of the first survey, but the urban system caught up over the study interval. There was high agreement between the network and stakeholder ratings of system performance at both time periods. The method of data collection and analysis used in this study provides tools that can be used in a variety of settings to assess service system growth and development.

Rural mental health leaders' perceptions of stigma and community issues.

This paper provides a description of the attitudes of rural leaders toward mental health issues using data collected in two rural counties (one in Virginia and one in North Carolina). Study participants (N = 63) are individuals identified as leaders making a significant positive contribution to mental health issues in each county. While the counties were matched on a number of demographic characteristics, the counties had one difference believed important: one had a county mental health center located within the county boundary while the other had no in-county mental health center. The study found that rural leaders believed that other community members held attitudes toward mentally ill persons that were more discriminatory than their own. In addition, rural leaders expressed that mental health was a more important concern to them than it was to the community as a whole. Finally, the importance placed on issues of importance to the community and the resulting issue of priority of relevance varied in response to the occupation of respondents. The study presents an approach to understanding how occupational structures affect community issue priorities among rural leaders.

Characteristics and activities of case managers in the RWJ Foundation Program on chronic mental illness.

OBJECTIVE: Case management was seen as the major strategy for integrating mental health, housing, and social supports for clients in the Robert Wood Johnson Foundation Program on Chronic Mental Illness, a five-year multisite demonstration project designed to test the effects of reorganizing mental health systems in large urban areas. The authors assessed data on case management programs in the demonstration project to try to explain the lack of consistent improvement in clients' outcomes that was found in the national evaluation of the project. METHODS: Data on case management programs from five demonstration sites-Baltimore; Cincinnati; Columbus, Ohio; Denver; and Toledo, Ohio-were reviewed. Data sources included onsite interviews, documentary material, studies of case managers' contact with community agencies that were conducted in 1989 and 1991, and telephone interviews with coordinators of case management programs. RESULTS: The characteristics and activities of case managers changed little between 1989 and 1991. Case managers tended to become the principal service providers for their clients rather than coordinating service provision among multiple service providers. Case managers reported that their clients received few services from other agencies in the local community support system. CONCLUSIONS: Although lack of change in case managers' activities during the demonstration project may help explain clients' lack of improvement over time, case management by itself does not constitute comprehensive treatment. More attention must be paid to the development and refinement of community-based medical-psychiatric and psychosocial treatments with a proven track record of improving clients' level of symptoms and quality of life.

Local mental health authorities and service system change: evidence from the Robert Wood Johnson program on chronic mental illness.

The extent of change in the performance of local mental health authorities (LMHAs) and in the development of community support systems (CSSs) is assessed for nine demonstration cities that participated in the RWJF Program on Chronic Mental Illness and one comparison site. Parallel measures of LMHA and CSS performance were obtained from two data sources (key informant and interorganizational network surveys) conducted at each site at two times during the demonstration: 1989 and 1991. Findings indicate that the LMHAs were successfully implemented at most demonstration sites, but changes in the CSSs lagged behind LMHA performance levels. The amount of system change tended to be greater when estimated from network versus key informant data.