The planning process for the Missouri Department of Health Integrated Care for Individuals with HIV/AIDS, Mental Illness, and/or Substance Abuse Problems project began in October 1994, and consisted of numerous advisory (planning) committee meetings, timely contract negotiations, and service provider cross-trainings. Advisory committees of medical providers, case managers, and mental health and substance abuse treatment staff were developed, which met on several occasions to discuss implementation of the project’s three service sites. The committee designated Kansas City as the region most appropriate to pilot the project model since it had shown the greatest level of interest in multiple diagnosis and interagency collaboration. Consequently, the first region of Missouri to implement a project site was Kansas City (began in June 1996), followed by St. Louis (May 1997), and then rural Southeast Missouri (October 1997). Although these three models were designed to deliver services in different ways, each aimed to integrate and coordinate the system of care through collaborative working relationships with state and local service agencies in their respective regions.

Based on the unique experiences of service providers and staff working with the Missouri Department of Health project, various cross-cutting themes among the three sites were discovered and numerous lessons were learned about conducting such a statewide project, which are briefly discussed below. In addition, the twelve staff members interviewed made several recommendations about how, in retrospect, the project could have been improved if certain aspects were done differently. These lessons learned and subsequent recommendations will most likely prove useful to other programs attempting to administer similar projects in the future.

Cross-cutting Themes Among the Three Project Models. In interviewing key individuals actively involved with the Missouri Department of Health project, numerous themes emerged that were common across the three project sites. Some of those cross-cutting themes are described below.

• As a result of the cross-training conferences provided in the three regions, the different types of service providers employed learned about the importance of one another’s roles (e.g., the necessity for offering mental health services to people with HIV/AIDS). They were also able to learn about the different services various types of staff would be providing to clients. Additionally, project staff gained information on current treatment options for their target populations.

• At the very beginning of the project planning process, there was little or no communication among the service providers who were supposed to be collaborating to provide comprehensive care to clients. However, as the result of the trainings provided, there was an increase in interactions and communication, an increase in collaborations among the providers involved, and clear ideas were developed for establishing long-term working relationships.
• Negotiating and finalizing contractual agreements with local service agencies proved to be a more timely process than was originally expected. However, this was an uncontrollable obstacle.

• The project experienced a high rate of staff turnover. Thus, a large proportion of service providers who received cross-training initially, and those on the advisory planning committees, were no longer staff members by the time the first site (Kansas City) was implementated in June 1996.

Replication of the Three Models. Given that the Missouri Department of Health was a demonstration project, those interviewed were asked about the possibility of replication of the three project models. The majority responded that the St. Louis model made the most achievements and, therefore, would be the best model for future replication and/or follow-up. Additionally, this model provides concrete examples of the detailed processes necessary to implement similar projects in one specific locale as opposed to throughout an entire state.

The key participant-observers interviewed attributed the following to the success and subsequent perceived replicability of the St. Louis model.

• The cross-training provided in St. Louis was considered excellent by the majority of participants interviewed because it put different types of providers together in the same room to educate them and to help them build long-term working relationships. Consequently, this site improved collaboration on service provision among providers who, before the project, were competing due to turf issues and funding constraints, and who were not interacting to provide a wide array of linked comprehensive services.
• St. Louis’ vast referral network and staff’s ability to access a wider array of services for clients was an invaluable project asset.
• The two very different case review teams – Integrated Care Review Team and HIV/AIDS Consultation Team – working together to make decisions and recommendations regarding clients in order to develop multidisciplinary treatment plans was a vital project element. As a result, staff were better able to continually address and follow-up on all client issues and needs.
• Moreover, each of the twelve individuals interviewed felt that St. Louis was the most replicable model because it had more local control. Having local control, as opposed to being run strictly by the state, was a key element to this site’s success.

Lessons Learned and Recommendations Made by Staff Interviewed. In reviewing the project retrospectively, the staff interviewed indicated the valuable lessons learned about this project and about implementing such a statewide, state-run project in general. In an effort to supply other integrated care coordination programs with information about the valuable lessons they learned, several recommendations were made by the key participant-observers interviewed.

• One of the most valuable lessons that staff learned and expressed in their interviews was the importance of having more local control over the project. Ten of the twelve key participant-observers interviewed felt that local control would have allowed for more time available for services provision (i.e., project sites operational longer). They believed that local providers are more aware of the key players who need to be involved in the planning process, contract negotiations, and start-up. They also were aware of the unique needs of the target population in their respective regions. However, some interviewed staff felt that, regardless of whether such a project is run locally or by the state, problems will be encountered, such as with contract negotiations and implementation planning.

• Focusing such a state-run program on only one city with one distinct model decreases constraints resulting from trying to implement the project in the three areas before the grant’s funding ends. It also permits greater service provision in the same amount of time.
• For projects with multiple service sites, there is a need for communication between each to ensure that staff at one site knows what staff at the other sites are doing, what kinds of dilemmas they encounter, and how those issues are resolved. This type of information sharing allows staff to learn from one another based on their unique experiences.
• An orientation packet will enable a project to run more smoothly and will help eliminate staff confusion about the project in general and the specific services it makes available. The packet should consist of the original grant, clear descriptions of the overall project goals and objectives, enrollment eligibility/criteria, a local resources manual for each region, and a menu of services to be provided.

• It is extremely important to limit staff turnover as much as possible. Frequent staffing changes can result in confusion about project details and how its goals and objectives are to be accomplished. Efforts need to be undertaken to ensure stable staffing and to ensure that all new staff receives descriptive training about the project.
• Since treatment options and available medications change so rapidly with HIV/AIDS, project staff and all collaborating agencies need to be updated through ongoing training that is offered at least once a year. Additionally, a detailed, written training curriculum needs to be developed so that systematic trainings of service providers and staff are conducted regularly and efficiently.