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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
Introduction
The Missouri Department of Health, Bureau of HIV/AIDS Care was originally awarded a three-year grant in October 1994, which was extended for a fourth year, by the Special Projects of National Significance (SPNS) Program of the Health Resources and Services Administration (HRSA). Funding for the project ended September 30, 1998. As a means to learning about different project aspects, interviews were conducted with key staff actively involved in the project. This report describes the qualitative information obtained from these telephone interviews. It provides the perspectives of state department of health staff, HIV/AIDS service coordinators, mental health providers, and substance abuse treatment professionals – all of whom were part of what the project called its "SPNS network." The report briefly describes the characteristics of the three models and summarizes the challenges faced by the project as well as the successes. Lessons were learned about the program elements that, in retrospect, might have improved this project and that might be useful for other programs attempting to implement similar projects in the future.
The Missouri Department of Health project, entitled "Integrated Care for Individuals with HIV/AIDS, Mental Illness, and/or Substance Abuse Problems," was a demonstration designed to create, implement, and evaluate the effectiveness of coordinated, comprehensive systems of care through collaboration of the Missouri Department of Health and the Missouri Department of Mental Health. These two departments worked together to identify agencies interested in participating in an integrated system of care. The project’s HIV/AIDS service program was designed so that staff would work closely with state health departments and local community-based organizations.
The Missouri Department of Health project provided numerous services for persons with HIV/AIDS who had mental health and/or substance abuse issues. It was originally hypothesized that HIV/AIDS clients who were dually or triply diagnosed would have better medical, psychiatric, and/or substance abuse treatment outcomes if enrolled in a coordinated and integrated system of care, as opposed to parallel systems. Thus, the goals of the project were:
- to develop and evaluate the effectiveness of a coordinated system of care;
- to initiate collaboration between the Missouri Department of Health and the Missouri Department of Mental Health to create and implement a comprehensive integrated model of care, which consisted of both health and mental health services for multi-diagnosed individuals living with HIV/AIDS, mental illness, and/or substance abuse; and
- to establish advisory committees comprised of service providers from the three systems (HIV/AIDS, substance abuse, mental health) to identify and assess the training needs of their communities and the service needs of multi-diagnosed individuals residing there.
A primary aim of the project was to create an enhanced case management system, with the goal of simplifying the existing referral system for mental health and substance abuse treatment services throughout the state. The project provided cross-training to local service providers so they could make and accept appropriate referrals for multi-diagnosed individuals. In addition, coordinated comprehensive service models were established in three specific regions of the state.
Customized Regional Models.
To test the effectiveness of the basic model in urban and rural areas of the state of Missouri, three regions – Kansas City, St. Louis, and a rural Southeast or "Boot Heel" area – were selected for the implementation of the project. These areas were chosen to enhance the probability of the development of a broad range of models and philosophies that specifically addressed the needs, cultures, and delivery systems of the different regions. Although the models varied, each site’s target population consisted of HIV-positive individuals with mental health and/or substance abuse issues. Furthermore, each site provided cross-training for mental health service providers, substance abuse treatment professionals, and HIV service coordinators. The following is a brief description of the three models of care (each model is described in further detail later in this report):- In Kansas City, direct referrals were made to one comprehensive mental health and substance abuse treatment facility for automatic linkage of clients to needed HIV/AIDS, mental health, and substance abuse services. Department of Health (DOH) case managers referred clients to mental health and/or substance abuse counselors at this single agency. Then, there was open dialogue between the DOH case manager and the agency provider(s) about the client’s treatment plan.
- The St. Louis model provided Department of Health HIV case managers, Alcohol and Drug Abuse (ADA), and Comprehensive Psychiatric Services (CPS) providers with a resource to address the complex, overlapping needs of their multi-diagnosed HIV clients. Front-line case managers could refer these clients to a specialty case manager who did an initial assessment of client needs prior to referring the eligible case to the Integrated Care Review Team. This team of multidisciplinary professionals collaboratively reviewed the cases and developed comprehensive treatment plans. The treatment plans were then sent forward to the HIV Consultation Team, which assumed the responsibility of scheduling all necessary clinical tests and treatment.
- In rural Southeast Missouri, a "one-stop shop" model was developed to provide the region’s HIV case managers with a single mental health and substance abuse contact, or "host" case manager, to which they could refer their multi-diagnosed clients. The "host" case manager was responsible for evaluating the client’s mental health and/or substance abuse needs and referring the client accordingly to available services. The "host" case manager coordinated these services with the HIV case manager to ensure clients received the comprehensive services required to address their complex needs.
Cross-Training of Service Providers. Training different types of providers to increase their knowledge of and skills for serving individuals with HIV/AIDS who have mental health and/or substance abuse treatment issues is vital to establishing or making improvements in service delivery systems available to such multi-diagnosed populations. Recognizing the importance of service provider training, the Departments of Health and Mental Health collaborated on the development of cross-training curricula on service coordination for mental health providers, substance abuse professionals, and HIV case managers. A major component of the project was to cross-train case managers so that health professionals could heighten their ability to recognize clinical manifestations of substance abuse and mental illness, and so that mental health and addictions professionals would gain HIV clinical knowledge. Thus, the service providers working with the project were trained in the following areas:
- recognizing signs and symptoms of HIV/AIDS, mental illness, and substance abuse problems;
- clinical impressions and medical issues of multi-dimensional diagnoses; and
- the public mental health service delivery system to facilitate enhanced assessment ability and more appropriate referrals to mental health and substance abuse treatment agencies.
Feedback from Project Staff. Staff involved with the Missouri Department of Health Integrated Care for Individuals with HIV/AIDS, Mental Illness, and/or Substance Abuse Problems project had the unique ability to assess the strengths of this coordinated care project and the challenges faced by the project from a holistic, qualitative viewpoint. As such, The Measurement Group conducted interviews with project staff involved with each of the three customized models in the interest of gathering this important information.
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