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.

Successful systems integration strategies: the access program for persons who are homeless and mentally ill.

In 1993, the Access to Community Care and Effective Services and Supports (ACCESS) federal demonstration program was initiated. Using a quasi-experimental design, the 5-year demonstration program sought to assess the impact of integrated systems of care on outcomes for homeless persons with mental illness. The authors report on which integration strategies were chosen and how their implementation is quantified. Data collected primarily through annual site visits revealed that only two strategies were used by all nine systems. The systems integration strategies employed remained relatively stable over the 5 years. Successful implementation appears to be related to the strategies selected.

Case management models for persons who are homeless and mentally ill: the ACCESS demonstration project. Access to Community Care and Effective Services and Supports.

Persons who are homeless and mentally ill present unique challenges to service providers and human service systems. In vivo case management approaches such as assertive community treatment (ACT) have shown promise in engaging this population. This paper explores case management models employed within the ACCESS program, a five year, 18-site demonstration program enriching services for homeless persons with serious mental illness. We describe the implementation of case management with ACCESS programs and determine the extent of variation across sites using a measure of fidelity to ACT. While programs reported using four models, much similarity was found among programs on multiple dimensions.

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.

Creating integrated service systems for homeless persons with mental illness: the ACCESS Program. Access to Community Care and Effective Services and Supports.

The Access to Community Care and Effective Services and Supports (ACCESS) demonstration program was initiated in 1993 by the U.S. Department of Health and Human Services as part of a national agenda to end homelessness among persons with serious mental illness. Demonstration projects have been established in nine states to develop integrated systems of care for this population. This paper provides an overview of the ACCESS program and presents definitions of services integration and systems integration. Evaluating the effectiveness of integration strategies is a critical aspect of the program. The authors describe the evaluation design and the integration strategies being evaluated and summarize findings from a formative evaluation of the project's first two years. The evaluation revealed several problems that were addressed by providing technical assistance to the states. States were helped to articulate a broader mission of addressing system-level barriers, develop an expanded plan, strengthen the authority of interagency councils, involve leaders at the state and agency levels, and develop joint funding strategies.

Screening for risk factors for adolescent alcohol and drug use.

While alcohol and drug abuse are widely prevalent among adolescents, screening for drug and alcohol use, abuse, and risk factors is not a routine practice in primary care pediatrics. This article presents data from a pilot investigation of an instrument for in-office screening of alcohol and drug use and abuse problems. A 42-item questionnaire was administered to two patient populations: 97 youths from a drug abuse treatment program and 206 youths from a private pediatric practice. The questionnaire successfully discriminated between the two samples and appears capable of discriminating drug and alcohol risk within the samples. This research suggests that a simple paper-and-pencil questionnaire can successfully discriminate the degree of risk of substance abuse in adolescent patient populations and that such an instrument can be successfully integrated into the routine activities of pediatric practice.