Adopting a holistic view of clients in substance abuse treatment is especiallyimportant for any service provider making referrals to other providers or agencies.At the point of referral, there is both an opportunity to address a client's unmetneeds and a potential danger of losing the client. Collaboration is crucial forpreventing clients from "falling through the cracks" among independent andautonomous agencies. Effective collaboration is also the key to serving the clientin the broadest possible context, beyond the boundaries of the substance abusetreatment agency and provider.
This chapter explores the elements of integrated services using acommunity-collaborative model. This model is based on an agency's ability to makeeffective referrals within a network of numerous agencies, including vocationalservices, serving common clients. Only when these service providers are trulyinterconnected can they work together toward the common goal of successful clientoutcomes. The phrase authentically connected has been coined todescribe an integrated network in which agencies function as equal players with eachother and with the client to identify and address the complex interplay of needsthat is typical of clients with substance abuse disorders.
Collaboration as the Cornerstone of EffectiveReferral
When the many agencies that work with clients who have substance abuse disorderswork independently of each other, the result is that the client is subject tofragmented services, none of which might address the client as a whole person.One of the biggest challenges to any collaborative or network-based model occurswhen each of numerous agencies wants to use a different assessment tool togather the same information. At best, this produces a fragmented portrait of theclient; at worst, it creates frustration and confusion for the client, who maydrop out of treatment as a result.
A shared vision among potential collaborators facilitates strategies to achievecommon goals (Nelson et al., 1999).The biggest benefit of collaboration among health agencies is the improvedhealth of clients and therefore of the community. One study found that health isdependent on how people perceive the quality of their community. Leadership andvision among collaborative agencies can make a difference in the quality of acommunity health care system and in the cost-effectiveness of the care provided(Molinari et al., 1998).
Collaboration among agencies is the key to preventing fragmentation. In additionto reducing the likelihood of clients falling through the cracks betweendisparate and unconnected agencies, collaboration can foster a more holisticview of the client. Sometimes just a simple change of perspective can make thedifference between circ*mstances being viewed as "needs" and being viewed asassets. For example, a single parent who cannot find a babysitter on aparticular evening misses a treatment session. This client is then labeled"noncompliant" by one treatment provider, but another provider who focuses onchild care and parenting skills recognizes the client's adherence to herparental responsibility as a positive asset. With effective collaboration,service providers will learn to recognize these differing viewpoints throughtheir contact with professionals with expertise in different areas.
Another approach to prevent fragmentation is to designate one agency as theprimary contact both for the client and for the other agencies. The primaryagency provides a holistic assessment that accompanies the client throughout thereferral process. The assessment must be comprehensive enough to satisfy all theagencies and organizations participating in the client's care and might includemedical/psychiatric history and conditions, substance use patterns, workhistory, housing situation, physical/sexual abuse history, involvement in familyviolence and the criminal justice system, and other data about the client. Inaddition to decreasing paperwork and minimizing fragmentation, this processcould help to strengthen linkages and communication among various agenciesproviding different services.
Barriers toCollaboration
The traditional referral system from substance abuse treatment programs tooutside agencies can create obstacles to effective collaboration. Examplesof obstacles are designation of which agency has major responsibility for aclient, structural barriers driven by funding sources (e.g., payment to onlyone treatment agency), difficult-to-treat clients, and differing staffcredentials.
The issue of which agency "takes credit" for a client is a difficult questionarising from competition among different agencies, each of which has aninterest in maintaining a certain "head count" to ensure continued funding.This barrier highlights the need to change the way that agencies arecredited for their participation in a client's recovery. In many treatmentsystems, only one agency can receive credit for clients who are served byseveral service providers. It would be preferable to allow all participatingagencies to take credit for these clients. For example, this happens incommunities that have collaborative relationships based on shared outcomesnegotiated across agencies. These cross-agency outcomes can occur acrossservice systems (e.g., substance abuse treatment and social services) oracross provider networks (e.g., residential and outpatient providers).Outcomes are negotiated both across agencies and with funders of services.Funders play a critical role because they must "change the rules" that allowonly one agency to receive credit for a client. This change from arules-driven system to a results-based system encourages all participatingagencies to be recognized for their contribution to client outcomes. Also,it is important that each provider understand the role of the otherproviders so that it does not seem as if they are competing. Each providermust create an appropriate working relationship with the other providers sothe client can benefit from all.
Structural barriers may also be posed by program policies that are determinedby the program's primary funding source. Such policies may dictate, forexample, that clients cannot engage in concurrent activities, such asvocational training and treatment of substance abuse disorders. If the Stateor a managed care system does not allow clients to participate in concurrentservices, then collaboration efforts will be difficult, or even impossible.However, in some cases, this is simply a program philosophy and not a formalpolicy, and efforts should be made to change this mode of operation. Anothermajor barrier in the past has been confidentiality requirements. One answerto addressing this problem is joint training.
In the present system, there are no rewards for serving difficult-to-treatclients, and sometimes agencies set criteria under which only the clientswith the greatest potential for success are accepted. Incentives are neededfor programs to accept those clients who have the greatest problem severityor multiple needs. This is known as "case mix adjustment." The incentivesshould be based on three factors: (1) identification of difficult-to-treatclients based on analysis of differential outcomes and clients'characteristics, (2) analysis of the additional average costs of servingthese clients, and (3) provision of either explicit incentives for servingthese clients or a more equitable approach. A key element in a moreequitable approach is for funders to recognize that servingdifficult-to-treat clients is as valuable as serving clients with fewer riskfactors, even though success rates will be lower as a result. Referringdifficult-to-treat clients should be viewed not as a matter of "handing off"problematic clients, but rather as securing additional services to meetthese clients' needs.
Staff licensing can sometimes be a barrier to collaboration because it isdefined categorically. For example, sometimes the referring agency has apolicy requiring that the staff members of the receiving agency have thesame licenses and credentials as the referring agency's staff. In additionto requiring specific types of expertise, a referring agency sometimesrequires the staff members of the other agency to be "professionals" withadvanced degrees. The unfortunate consequence is that credentialingstandards, rather than transdisciplinary collaboration, often dictate theservices clients receive.
Finding PotentialCollaborators
Programs must look at their clients with the assumption that it is notfeasible or effective to provide everything that clients need "under oneroof." A more fruitful approach is to collaborate with other agencies on thebasis of client needs and overlapping client caseloads. This procedure iscalled data matching. Figure 5-1provides an example of this process.
Agencies and organizations that provide vocational training in collaborationwith substance abuse treatment programs can be divided into twolevels--agencies providing specific training for employment (Level 1), andagencies with resources and services needed by clients at the same time theyare receiving substance abuse treatment and employment rehabilitationservices (Level 2). Examples of Level 1 resources include
City-, county-, and State-operated vocational rehabilitation (VR)services
Public and private employment and job placement services
Public and private employers in the community
Vocational-technical colleges
Community colleges
Privately owned VR facilities
Criminal justice vocational training programs
Examples of Level 2 resources include
Economic Development Centers (One-Stop or Workforce DevelopmentCenters)
Shelters for survivors of domestic violence
Mental health agencies
Homeless shelters
Child welfare agencies
Child care services
Family services
Housing authorities
Evening adult education programs
Alternative education programs
Literacy programs
Adult basic education programs and general equivalency diploma(GED) programs
Young Men's Christian Associations (YMCAs), Young Women'sChristian Associations (YWCAs), Young Men's Hebrew Associations(YMHAs), and Young Women's Hebrew Associations (YWHAs)
Social service organizations
HIV/AIDS programs
Health and disability organizations
Independent living centers
Religious groups
Self-help meetings
Accessible meetings
Often, collaborating agencies must be educated about the nature of substanceabuse disorders, including the cycles of relapse and recovery. Alcohol anddrug counselors may also benefit from applying the relapsing and remittingmodel in areas other than substance abuse disorders. For example, clientsmay also "relapse" into and out of employment, medication management, orviolent situations. The failure of any one of these supports can then be atrigger for failure of any of the others. All collaborators,including those providing treatment for substance abuse disorders,should be aware that their efforts are likely to be ineffective unlessall the client's life areas are addressed. To that end,agencies must recognize the existence, roles, and importance of each otherin achieving their goals. It is preferable to have formal written agreementsthat outline the responsibilities of each agency.
Although the prison population has grown substantially in the last severalyears, vocational training programs for inmates are limited. The vocationaltraining programs that are available to incarcerated individuals will varyaccording to the setting of the incarceration, and treatment programs willneed to be in contact with penal institutions in order to find out whatparticular types of substance abuse treatment and vocational training areavailable (see Chapter 8 formore information about working with ex-offenders). Providers interested inmore information concerning the particular procedures and problems involvedin establishing service agreements with criminal justice agencies (includingprisons, detention centers, and community supervision agencies forex-offenders) should consult Chapters 1 to 4 in TIP 30, Continuityof Offender Treatment for Substance Use Disorders From Institution toCommunity (CSAT,1998d).
Figure 5-2 summarizes the stepsthat substance abuse treatment providers can take to establish anauthentically connected network with other agencies or to screen potentialcollaborators. The next section provides more detailed information aboutthis process.
Multidisciplinary Teams
In its conventional sense, a multidisciplinary team is composed of membersfrom different service areas (e.g., substance abuse treatment, vocationalrehabilitation, mental health). This method of service, which is more commonin programs that provide multiple services in-house, is just one way offunctioning in a multidisciplinary manner. In an authentically connectedreferral network, however, members of the multidisciplinary team providetheir services in different locations. Still, in an authentically connectednetwork, a multidisciplinary team approach can be fostered by regularlyscheduled case conferences.
In the authentically connected model, the agencies are interdependent. Theycross-train their staffs in concepts and methodologies from differentdisciplines and promote awareness of resources that each agency mightprovide. Instead of being dependent on certification, learning about otherdisciplines, and becoming recertified every few years, service providers aretaught how to learn on their own.
Careful consideration must be given to the formation of a multifocaltreatment team. One approach is to view the team as a pie divided intosections, with the team members proportionally reflecting the needs ofclients in areas such as coexisting mental disorders, job skills andemployment, and child custody and care. The community must be considered asa whole throughout the treatment and referral process, and all availableresources in the local geographic area should be considered to meet clientneeds. Multidisciplinary teams can be composed of credentialed specialistsas well as self-help and grassroots organizations. The more diverse theteam, the more likely that the client will be viewed holistically.
True collaboration is a higher order of referral than either cooperation orcoordination. Referral is a term that is used to mean manydifferent things. Whereas a traditional referral is unidirectional (e.g.,the client is sent for services to an outside agency), an authenticallyconnected referral network is multidirectional and incorporates the idealsof collaborative relationships, accountability, cultural competence,client-centered services, and holistic assessment.
Authentically Connected ReferralNetworks
Integrating Cultural Competence Into Treatment andReferral
People live in different environments, and service providers have aresponsibility to understand the contexts in which their clients operate.Client-focused treatment and referral must be based on an understanding ofthe family relationships, cultures, and communities of the clients. Culturecan be broadly defined as incorporating demographic variables (e.g., age,sex, family), status variables (e.g., socioeconomic, educational,vocational, disability), affiliations (formal and informal), andethnographic variables (e.g., nationality, religion, language, ethnicity).In many cases the client's belief system is intricately woven with culture,and providers must start where the client is and acknowledge the spiritualpart of the work. Substance abuse treatment programs should be open tofaith-based organizations in their communities, which can be valuablecollaborative partners.
Throughout this chapter, the expression cultural competencerefers to the capacity to view and understand individual clients withinthese contexts (Center for SubstanceAbuse Treatment [CSAT], 1999a). It is a core philosophy that mustbe integrated into and must guide the entire treatment and referral process.Too often, cultural competence is equated with the completion of a workshop,a multicultural staff, or proficiency in the language(s) spoken among theclient population served. However, diversity of staffing does not ensure thecultural competence of the treatment program. Cultural competence is notachieved solely by attending workshops or by having a diverse, multilingualstaff. When taken seriously, cultural competency is a continual learningprocess that is dynamic and is constantly expanded, refined, and defined bythe community being served.
Building an integrated service model based on community partners must beginfrom the clients' base, taking into account their values and building on thestrengths of their culture to create referrals that are appropriate andeffective for their particular needs. Issues of culture can begin during theintake and assessment process, when clients are asked about their ethnicidentification, their religion, and their participation in culturally basedactivities. Providers should feel comfortable discussing these issues withtheir clients and not make assumptions based on outward appearances, whetherthey are related to attire, complexion, or language. In programs workingwith highly diverse, multicultural populations, it may not be possible to beintimately familiar with all the details of each group's customs andculture. In any case, it is probably more important for providers to beaware of what they do not know and to have access to resources that canhelp, such as local community centers working in collaboration with theirprogram.
Moreover, a delicate balance is needed between a client's currentcirc*mstances and the historical and cultural issues that come into play.Some cultures may be relatively "closed" to nonparticipants. One mustsometimes maintain a presence for years until he is accepted as aparticipant or observer. Although outwardly some groups may seem moreapproachable, gaining the trust of any client takes time.
Client-Centered Versus Agency-Centered Treatmentand Referral
Substance abuse treatment that is both client-centered and client-focused ismore likely to improve the lives of clients. Collaboration among agenciesproviding requisite services is an initial step toward client-centered care.Referral can be a way for agencies to hold each other accountable forgetting results for clients. Referrals are necessary and appropriate whenthe substance abuse treatment program cannot provide special services neededby their clients. Some of the areas for which referrals may be neededinclude job readiness, job training, medical care, and ethnic/culturalexpertise.
If the rationale for integrated treatment is a successful outcome for theclient, there must be some way of measuring whether the referral issuccessful. From the referring provider's perspective, referral representsan act of faith, hope, and trust that the agency to which the client isreferred will be accountable and will share the goal of client success alongwith the referring agency. Referrals also represent an opportunity forchange, growth, and development. Far too often, however, a referral consistsmerely of handing a client a list of names and telephone numbers andassuming or hoping that the client will take the initiative to make thenecessary contacts.
Distinct from this traditional model is one in which collaborations arefostered and maintained among agencies providing services to clients withoverlapping needs, such as substance abuse treatment, employment, housing,education, and child care. In this context, the multidisciplinary teamapproach comes into play, but rather than coexisting under one roof, teammembers work within the various agencies engaged in collaboration. Referralsare negotiated among interlinked and interdependent agencies that sharemutual goals and outcomes. These authentic connections and shared outcomescan then serve as an agreed-upon basis for the involved agencies to measuretheir results instead of merely going through the motions of collaboration.Figure 5-3 lists thecharacteristics of authentically connected referral networks.
Elements of EffectiveReferrals
In general, an authentically connected referral network is composed of a setof defined relationships formed as clients' needs dictate, using soundprinciples of case management and building in flexibility and adaptabilityto meet the needs of individual clients (see also TIP 27,Comprehensive Case Management for Substance AbuseTreatment [CSAT,1998a]).
Although authentically connected referral networks share several featuressuch as those listed in Figure 5-3,this similarity does not constitute a mandate for all treatment programs toform identical referral networks. Rather, in order for such an authenticallyconnected network to be effective, each program must understand its ownmission as well as those of the other agencies.
Mechanism for informationdissemination
The authentically connected model calls for a communication mechanismthat allows the timely dissemination of information to all agencies andstakeholders. An authentically connected network also includescontinually updated information about available resources. For example,a network might use a Web site to post referral information, which canreadily be updated (see the "Inventory" section later in this chapterfor more information about electronic communication).
Focus on communitywideoutcomes
Focusing on communitywide outcomes allows community leaders and agencies,as well as clients, to set priorities based on client populations inindividual communities. Authentically connected referral networks alsoeducate the larger community about substance abuse in general. In sodoing, they encourage responsiveness on the part of the community andthe network as a whole, rather than from the agency only. The use of acommunity scorecard is one method to rate a community's responsivenessto treatment issues.
Vision-driven serviceprovision
Authentically connected referral networks are vision driven and haveclient needs as the primary focus of the agencies' existence. Theemphasis is on shared purpose while acknowledging the organizational"cultures" among collaborating agencies. In contrast, "rule-driven"systems are agency centered and tend to be focused on agencypolicies.
Provider credibility andconsistency
Mutual provider credibility and trust are at the core of the referralrelationship. In the absence of trust, even the most sophisticatedsystem will fail. Clients' trust must be built on the reliability of theprovider and the provider's ability to be a consistent, accessiblepresence for the client. To be otherwise is to risk reinforcing ahistory of repeated abandonment and disappointment. The need for trustspeaks to the credibility of providers and whether they are truly clientoriented or are merely protecting the status quo of the program.
A sense of uniformity and cooperation is fostered by effective referrals.In a well-coordinated referral system, providers have some sense ofbeing part of a systematic network rather than one of many disparate andindependent agencies. Clients and providers alike find it easier to workthrough a collaborative, uniform system.
Building an Authentically Connected ReferralNetwork
Fostering collaborative interagency relationships in the community is only onestep in the development of an authentically connected network. Once theparticipants in the network are identified and information about them gathered,the collaborating agencies can then begin to develop an interconnected servicesystem that reflects the needs of the local community. The next step is to forma focus group involving all the agencies. This group will develop a sharedvision of the services the community needs in regard to substance abusetreatment. Lastly, the collaborators can then determine which provider is bestequipped to offer which services; this step takes the form of resource mapping,which is discussed below.
Resource Mapping andInventory
Resource mapping
Resource mapping consists of gathering information about agencies andprograms in the community with which linkages can be made to providecollaborative services to clients. This mapping of available resourcesshould include the funding sources of these programs. In a collaborativeeffort, money can be pooled from the various funding streams and then"decategorized" so that it no longer drives the roles of serviceproviders. A proposal can be sent to Federal, State, and local fundingsources for approval of small demonstration projects or experimentalinitiatives. If these efforts are successful, this model might beaccepted on a more global level.
Inventory
Many agencies that are willing to make referrals find that they may notknow of all the resources and services available to meet their clients'needs. To fill in knowledge gaps, some communities maintain a databaseor inventory of available resources and geographically map them withcomputer software to facilitate the logistics of referrals. Such aninventory needs to include not only programs and agencies but alsocollaboratives. One way to make this information useful is to create adirectory that is updated periodically. This directory could be postedon the Internet and also include information on eligibility criteria andavailable slots. For substance abuse treatment providers, an inventoryof the full range of vocational opportunities available in thesurrounding area can be a useful resource. Another important source ofinformation is the State Occupational Information CoordinatingCommittees (SOICCs), which can provide labor market information.Computer technology can be a valuable resource for managing and updatinginformation and matching data across systems and agencies, within thelimits of confidentiality (see Chapter7 for discussion of confidentiality issues).
Organizational Alignment and CapacityBuilding
Organizational alignment means that a service provider's vision, structure,mission, and policies are all based on the same underlying philosophy. Allthe activities and services the organization provides must be evaluated todetermine the degree to which they contribute to client success. Having amechanism for measuring client outcomes is important; information systemsthat track referrals and fiscal responsibility play key roles in identifyingsuccessful referrals as well as troubleshooting for cases in which needswere not adequately met.
Capacity building is the process by which organizationalalignment is achieved; it involves elements such as program assessment andstaff development.
Program assessment
For substance abuse treatment programs, capacity building includeschanging the way in which assessment is viewed. At the client level,assessment involves determining a client's needs and assets and viewingthe individual within the concentric contexts of family, culture, andcommunity. At the agency level, assessment means evaluating thecollaborative network of service providers and determining how well theyare serving clients. This allows the collaborating agencies to betterunderstand their missions and how they overlap and support each other.There is a potential pitfall, however, that must be monitored. As anorganization begins to engage in capacity building, it will find thatit* initial costs may be higher than under the old method. Programs andfunders will need to be educated that in the short run, the newauthentically connected referral model will be more expensive, andcapacity building initially will incur more overhead costs. However,once the network is in place, it will maximize the use of funds byavoiding duplication of services and, most important, it will result inhigher client rehabilitation success rates.
Staff development
Cross-training initiatives are key to building the capacity to serveclients more directly and efficiently. Communication mechanisms must beestablished among collaborative agencies to provide and receive feedbackthat can be used to improve services. For example, in the SubstanceAbuse Treatment Initiative in Sacramento County, California, the entirestaff of the County Health and Human Services Department (about 1,500people) completed training in addiction and recovery. In addition, itshould be noted that alcohol and drug counselors should be cross-trainedin VR issues. The initiative was intended to ensure that staff membersconducting intake interviews in county health and human servicesagencies understood concepts related to substance abuse and were able toidentify individuals and intervene when appropriate. The Child WelfareLeague of America has published a book (Young et al., 1998) reviewing the lessonslearned from this and other projects across the fields of substanceabuse treatment and child welfare services. Several other Californiacounties and the State of Oklahoma have implemented cross-training basedon the curriculum developed by Sacramento County.
Capacity building also affects staff hiring, promotion, and compensationpractices, which must be geared toward enhancing client outcomes ratherthan based solely on an individual's credentials. Newly hired staffmembers should be informed that their responsibilities include becomingproficient in a sophisticated network of referral to and from otheragencies with which collaborations have been formed.
