Missouri Department of Health Integrated Care for Individuals with HIV/AIDS, Mental Illness, and/or Substance Abuse Problems

Missouri Department of Health
Integrated Care for Individuals with HIV/AIDS, Mental Illness,
and/or Substance Abuse Problems

An Evaluation Report by The Measurement Group
The Measurement Group – PROTOTYPES
Evaluation and Dissemination Center

Interviews with Key Participant-Observers

Twelve key participant-observers involved with the Missouri Department of Health’s Integrated Care for Individuals with HIV/AIDS, Mental Illness, and/or Substance Abuse Problems project were interviewed over the telephone by The Measurement Group during a two-week period just as the project ended. The amount of time that the individuals interviewed had been involved with the project varied, with about half having been involved in the planning process from the very beginning and the other half having become involved more recently. Project staff interviewed included the current project coordinator, the Department of Health’s assistant bureau chief and direct supervisor of previous project coordinators, the regional service coordination supervisor for Kansas City, the regional quality services supervisor for St. Louis, the case management coordinator for St. Louis, the host case manager for five rural counties of Missouri, the rural site services coordinator, the mental health coordinator for St. Louis, the deputy director of the Department of Mental Health, and other service providers from mental health and substance abuse treatment agencies in Kennett and Poplar Bluff (rural areas), St. Louis, and Kansas City. Staff interviewed, who were selected from each of the three integrated care sites, gave their unique perspectives on the project based on their involvement with each site. This report summarizes the responses made during telephone interviews conducted with these individuals.

The Kansas City Model

The treatment model for the Kansas City site consisted of seven counties that were part of the Kansas City metropolitan area. The implementation model was developed by service providers and administrators at both the Missouri Department of Health and the Missouri Department of Mental Health. A 48-hour cross-training was provided over a four-month period (November 1995 through January 1996) to health, mental health, and substance abuse professionals. Upon completion of this training, the Kansas City site became operational in June 1996.

Through collaborative working relationships with local agencies, the project made services available at one site by state Department of Health (DOH) and other contracted case managers. Hence, the Kansas City model involved only one comprehensive mental health and substance abuse treatment facility, the Truman Medical Center-Behavioral Health (TMCBH). This agency, which was contracted by the Department of Mental Health, was selected to handle the needs of multi-diagnosed HIV/AIDS clients, thus providing medical care, mental health services, and substance abuse treatment. Kansas City Department of Health case managers referred clients to TMCBH when there were questions related to HIV/AIDS, substance abuse, or mental health. Clients’ needs were assessed and then they were enrolled into needed services at TMCBH. To ensure the provision of integrated, comprehensive services, open dialogue between the mental health and/or substance abuse counselor at TMCBH and the DOH case manager occurred on an ongoing basis. Such case conferencing and communication channels allowed for increased awareness of the inter-relationship between health, mental health, and/or substance abuse issues. In addition, open lines of communication ensured that services were not overlapped or counterproductive. The implementation model utilized for the Kansas City site is illustrated below.

Figure 1. The Kansas City Model.

Challenging Aspects of the Kansas City Model. According to staff interviewed who were involved with the Kansas City model, the implementation of this site proved somewhat challenging due to various issues. The following recommendations were made about how some of these issues could have been resolved.

Given that the contracted agencies sometimes had agendas somewhat different from the project’s agenda in terms of the services they would provide for clients, staff indicated the importance of clarifying the type of service model being utilized so as to minimize confusion.
The Kansas City model was originally designed to provide systematic and timely referrals to needed services for clients. Utilization of project services by the target population of multi-diagnosed individuals was lower than originally expected. Thus, staff interviewed indicated that it was vital to make numerous referrals to increase service utilization. Interview respondents also indicated that service utilization might have been low simply due to the fact that Kansas City is an area with many previously existing service agencies available for people with HIV/AIDS. Hence, assessments of a particular region were needed to determine whether there was an extreme need for such a service project in that area. Staff also stated the importance of selecting a site in which there are few or no stigmas associated with receiving services there that might create barriers for potential clients to accessing services.
Changes in financing through the Ryan White CARE Act resulted in unanticipated delays in the project’s planning process and initial start-up. This was out of the project’s control.

Successful Aspects of the Kansas City Model. In spite of encountering these obstacles, the Kansas City project site experienced several noteworthy successes.

Although time-intensive contract negotiations and planning committee meetings significantly delayed startup of the Kansas City project site, these delays allowed the project to use the experiences they learned to improve upon their implementation strategies in St. Louis and rural Missouri.
Staff were able to develop positive working relationships with other service agencies in Kansas City. These relationships were necessary for increasing opportunities for long-term collaborations and networking, linked and timely referrals, and education of local service providers, as well as for decreasing the duplication of services by different agencies.
The provision of cross-training was an important element of the project. As a result, Kansas City Department of Health case managers are now much more aware of mental health issues experienced by persons with HIV/AIDS and can, consequently, make better assessments and referrals for these services in the future.

"One of the key elements of this site was the collaboration among different types of local and state agencies in Kansas City, which helped to effectively link clients to needed care and to decrease duplication of services." – local substance abuse treatment coordinator

The St. Louis Model

This integrated care model involved six counties, which were chosen because they were part of the St. Louis metropolitan area and they were served by both the Department of Health and the Department of Mental Health in St. Louis. In contrast to the Kansas City model, St. Louis had three distinct service systems for health, mental health, and substance abuse. The goal of the St. Louis project site was to integrate these three systems so that clients would be able to access services in a coordinated manner. The model piloted in Kansas City was to be duplicated in St. Louis, followed by rural areas throughout the "Boot Heel" portion of Missouri. However, a traditional treatment team model was modified for St. Louis’ three service delivery systems.

Planning the implementation at the St. Louis site began in January 1996 with the formation of an advisory committee, which met to develop the model and plan cross-training. In September 1996, a two-day cross-training conference took place that brought together Department of Health case managers, mental health specialists, and other service providers from local agencies in St. Louis. After a lengthy planning process and numerous months of negotiating local contractual agreements, the project’s advisory (planning) committee finalized the model for St. Louis. Hence, the St. Louis site was operational by May 1997.

The St. Louis treatment team model consisted of two case review teams – the Integrated Care Review Team and the HIV/AIDS Consultation Team. In this system, Comprehensive Psychiatric Services (CPS), Alcohol and Drug Abuse (ADA), and/or HIV service coordinators attempted to access services for their clients. This was accomplished through a screener who prioritized the cases presented to him by these case managers to determine their eligibility for assessment by the Integrated Care Review Team. This review team then collaborated with the three service providers to provide feedback and to make recommendations on a treatment plan for their client. The Integrated Care Review Team referred the case to the HIV/AIDS Consultation Team, which scheduled all clinical or medical tests needed for that client. This cycle of information sharing and collaborative assessment of clients allowed for continual monitoring of client care and was an effective multidisciplinary team approach to servicing all the complex needs of clients. The St. Louis Integrated Care Review Team Model is illustrated below.

Figure 2. The St. Louis Model.

Challenging Aspects of the St. Louis Model. As expressed by the key participant-observers in St. Louis who were interviewed, the following proved challenging for project staff. Recommendations were made about how some of these issues could have been resolved.

Those interviewed stated that, to decrease staff burnout and subsequent staffing changes, caseloads needed to be small, with an ideal number of 15 cases (as opposed to the actual number of 75 clients). Limiting staff burnout also was important to move the project planning process along smoothly and expeditiously, and to eliminate confusion about the exact services being made available.
Project clients could not access their mental health services through the Department of Mental Health unless they had received an Axis I diagnosis. However, this criteria was too restrictive for St. Louis clients with HIV who had not received an Axis I diagnosis, yet had numerous mental health issues that needed to be addressed. Hence, there was a need for less stringent eligibility criteria.
To lessen the confusion experienced by contracted agencies with different agendas and, to establish common language among those agencies, interview participants felt that it would have been necessary to designate one agency as the sole source offering a wide array of integrated services. This would have been in contrast to the assortment of agencies providing different types of services.

Successful Aspects of the St. Louis Model. Staff interviewed indicated that the St. Louis project component was successful for numerous reasons.

The two-day staff training provided practical, hands-on experience to service providers in attendance. As expressed by the three St. Louis staff interviewed, this experience was one of the strongest project aspects. At the system level, the training was seen as extremely effective because, previously, many caregivers thought that communicating with other types of providers about clients they had in common was unnecessary. Furthermore, different types of providers did not understand the importance of other services. For example, some HIV case managers previously thought that providing mental health services was not as important as the provision of medical treatment. Hence, good working relationships were established as a result of the training. The training broadened providers’ minds to other issues (i.e., those handled by different types of providers) they needed to be aware of about their clients. In terms of infrastructure, there is now a great deal of information sharing between different service agencies and providers due to the training.
Service providers attending the training conference learned about complexities between therapies, and medical treatments for HIV/AIDS were addressed, as well as psychiatric medications, their interaction with other drugs, and their side effects. Ultimately, this helped them better serve their clients.
Two case review teams were established for this project site – the Integrated Care Review Team and the HIV/AIDS Consultation Team. The utilization of these two very different case review teams allowed for systematic and ongoing monitoring of client care and services received. Additionally, treatment plans were developed for each case presented to these two teams based on the collaborative input of service coordinators, mental health professionals, and medical care providers.
The provision of case management services to clients was not a time or labor intensive task. As expressed by interviewed staff, the referral/screening process was so simple because there were only a few forms that staff had to complete. Thus, staff could focus more on accessing services clients needed.
St. Louis had more local control over the project, which was perceived to be a key element of its success. Local control helped decrease the amount of time it took to create positive, long-term working relationships with different types of local service agencies and to easily identify the target population.
Before this project, St. Louis mental health did not offer substance abuse treatment programs.
Even though the project has ended, St. Louis staff will, on a voluntary basis, continue to conduct case conferences and training of local service providers. Hence, there was a need to utilize staff that is very dedicated to the project.

"One of the most useful aspects of this project site was the systematic follow-up that took place on the progress of clients assessed by the case review teams. Having this mechanism in place ensured that all of the clients’ complex issues were resolved efficiently." – state service coordination supervisor

The Rural (Southeast) Missouri Model

A treatment model for the rural project site was first presented in August 1996. Numerous planning meetings took place thereafter, and the rural advisory committee met with relevant community partners to begin developing this model in February 1997. Once the goals and objectives were established, all of the problems were worked out, the model was finalized, training was planned, and contract negotiations were completed, implementation of the rural site began in October 1997.

The model employed for this project site was designed to involve the demonstration of a "one-stop shop" system of care whereby HIV service coordination, mental health and addictions treatment services were available through one comprehensive mental health facility. One individual served as the "host case manager," who was responsible for receiving and making referrals for multi-diagnosed clients in the five rural counties targeted. Clients were referred into the system by area case managers when a potential client met the eligibility criteria (HIV/AIDS, Axis I or II diagnosis, and/or substance abuse issues). The host case manager also developed treatment plans in conjunction with the referring case managers and their clients, served as a services advocate for clients, and made mostly home visits to clients. An Assessment Team, comprised of a multidisciplinary group of professionals and rural advisory committee members, discussed difficult clients with the host case manager to determine a necessary plan of action for resolution. The rural case management model utilized is illustrated in Figure 3 on the next page.

Challenging Aspects of the Rural Model. As with the other two sites, staff involved in the rural component experienced some inevitable challenges to administering the project in Southeast Missouri. They gave the following recommendations about how these obstacles could have been overcome.

There were many stigmas associated with having HIV/AIDS and with treating those infected with the disease. These stigmas were escalated by rural service providers who, in the opinion of project staff interviewed, had limited accurate knowledge of HIV and the issues that those living with the disease deal with daily. This misinformation resulted in a lack of empathy and respect for individuals with HIV/AIDS, which in turn created additional barriers to care. Consequently, there was a need for ongoing training of rural service providers.
In order to attend advisory committee meetings on the rural model, staff working at this site had to travel anywhere from two to six hours (one-way) to Jefferson City, St. Louis, and/or Kansas City during the two-year planning process. Consequently, if the rural site had more local control over the project the key players involved in its implementation could have conducted planning meetings locally. This would have decreased the large amounts of time necessary for travel and might have ensured regular attendance by all individuals who needed to be involved in the site’s initial development and implementation.
Given the vast size of the rural "Boot Heel" region, transportation was projected to be the major barrier experienced by this site. Therefore, to decrease travel time that would have been required by clients to get to the host case manager and then to the referred service agency, the host case manager provided services in the clients’ homes. Since this was a very time intensive, yet essential, method of service delivery, the rural project needed to be operational for longer than one year.
High rates of turnover among staff and contracted providers made it difficult for clients given that, consequently, they were unable to receive care from the same provider for most service episodes. Therefore, it was essential to undertake efforts to decrease the occurrence of staffing changes.
Mostly in-home case management visits/services were provided to clients. The three rural staff interviewed considered this a very valuable project component since transportation was a major access barrier encountered by clients. Hence, there was an extreme need for provision of transportation to services among clients living in rural communities.

A support group for clients was created as a result of the project’s in-home case management service provision. This was an unexpected, yet valuable addition to the comprehensive service delivery model.

Staff was able to make more referrals because they established numerous good working relationships with service agencies throughout Southeast Missouri. As such, there was increased awareness in rural Missouri about the services available through the project.

Rural mental health providers are no longer afraid to treat HIV-positive patients because the project provided valuable training and education about this population and how providers can best meet their service needs.

Clients who were active at the end of the project were linked to other case managers in their areas so that they could still access needed services. Also, staff resolved all client crises before they transitioned them to other agencies so that none of their issues fell through the cracks.

Figure 3. The Rural Model.

Successful Aspects of the Rural Model. While the rural project site faced various obstacles, it also made several accomplishments in providing services to the target population.

"One of the key elements to starting the project in rural areas was that, in the first couple of months of the project’s startup, staff educated agencies in five rural counties on the site’s services, who’s eligible, how they access services, and how the project could assist them with their dually and triply diagnosed clients." – local host case manager