Successful program maintenance when federal demonstration dollars stop: the ACCESS program for homeless mentally ill persons.

A major issue that has long dogged federal human services demonstration programs is the perception that when federal dollars end, the programs end-regardless of any proven successes. Access to Community Care and Effective Services and Supports (ACCESS) was a 5-year federal demonstration project to foster partnerships between service providers for homeless people with serious mental illness and co-occurring substance abuse disorders; and to identify effective, replicable systems integration strategies. After federal funding ended, research teams visited the ACCESS sites to determine which project elements remained and which strategies were used by the sites to continue ACCESS. This article describes ACCESS services and systems integration activities retained by the sites, new funding streams, and strategies used to obtain continued funding.

Overview of the ACCESS Program. Access to Community Care and Effective Services and Supports.

The authors provide an overview of the ACCESS program (Access to Community Care and Effective Services and Supports), which evaluated the integration of service systems and its impact on outcomes for homeless persons with severe mental illness. The ACCESS program provided funds and technical assistance to nine community sites to implement strategies for system change that would promote systems integration. These experimental sites, along with nine comparison sites, also received funds to support outreach and assertive community treatment for 100 clients a year for four years at each site. Data on the implementation of system change strategies were collected from 1994 to 1998 during annual visits to the sites. Data on changes in systems integration were obtained from interviews with key informants from relevant organizations in each community. Client outcome data were obtained at program entry and three and 12 months later from 7,055 program participants across the four annual client cohorts at all sites. Detailed findings from the ACCESS evaluation are presented in two accompanying articles, and overall conclusions are offered in a fourth article.

Lessons from the evaluation of the ACCESS program. Access to Community Care and Effective Services.

The authors summarize the main findings of the ACCESS (Access to Community Care and Effective Services) program and offer lessons for policy makers. Data from studies at the site level and the client level, which were presented in the two previous articles in this issue of Psychiatric Services, are summarized and synthesized with the authors' collective experience with the ACCESS program. The results of the evaluation suggest that although service systems integration can be improved, targeted efforts to implement strategies for integration do not produce better client outcomes. Efforts to integrate service systems can be supported by their effects on some organizational relationships within the mental health service system but not by their widespread effects across human services or their direct effects on clients.

Service systems integration and outcomes for mentally ill homeless persons in the ACCESS program. Access to Community Care and Effective Services and Supports.

OBJECTIVE: The authors evaluated the second of the two core questions around which the ACCESS (Access to Community Care and Effective Services and Supports) evaluation was designed: Does better integration of service systems improve the treatment outcomes of homeless persons with severe mental illness? METHODS: The ACCESS program provided technical support and about $250,000 a year for four years to nine sites to implement strategies to promote systems integration. These sites, along with nine comparison sites, also received funds to support outreach and assertive community treatment programs to assist 100 clients a year at each site. Outcome data were obtained at baseline and three and 12 months later from 7,055 clients across four annual cohorts at all sites. RESULTS: Clients at all sites demonstrated improvement in outcome measures. However, the clients at the experimental sites showed no greater improvement on measures of mental health or housing outcomes across the four cohorts than those at the comparison sites. More extensive implementation of systems integration strategies was unrelated to these outcomes. However, clients of sites that became more integrated, regardless of the degree of implementation or whether the sites were experimental sites or comparison sites, had progressively better housing outcomes. CONCLUSIONS: Interventions designed to increase the level of systems integration in the ACCESS demonstration did not result in better client outcomes.

Employment histories of homeless persons with mental illness.

This study examined the work histories of 7,228 homeless persons with mental illness who were enrolled into the multi-site Access to Community Care and Effective Services and Supports (ACCESS) research demonstration program. Multiple logistic regression analyses suggest that use of vocational services is significantly associated with increased likelihood of paid employment. The role of vocational rehabilitation services in removing persons from homelessness and improving their quality of life is discussed.