The following program description provides a brief introduction to treatment services we are currently evaluating as part of the Modified Assertive Community Treatment program in Memphis Tennessee:
The project combines evidence-based core principles of Assertive Community Team (ACT) (Phillips, 2001), integrated treatment (Drake et al., 2001), and Essential Service System Components for ending chronic homelessness (SAMHSA, 2003) for individuals affected by co-occurring conditions; those whom state and local needs assessments determine as most desperately needing housing, yet for whom less than 10% of state providers deliver focused services or housing. The model incorporates the many complex social, cultural and financial barriers affecting the over-representation of African American residents in this target population and in a region so economically depressed, it is characterized as “the Third World on the Mississippi River” (where over 40% of African American households have median incomes below poverty level). Foundations Associates, the recipient agency, is the only integrated treatment provider in the community, and our partners and supporters are poised to implement recommendations stemming from both city-wide and statewide initiatives supporting that: Homelessness, is not the problem. It is a symptom of underlying problems (Memphis Blueprint, 2002). Our objective is to incorporate interagency strategies that not only coordinate existing services but also use resources differently to improve the range and types of available services for our homeless Memphians affected by co-occurring conditions.
With a culture rich in valuing extended families and faith based supports, our over-burdened communities and families are increasingly unable to tolerate the added dependency and behaviors related to co-occurring conditions on already overwhelmed resources. The human and financial toll of homelessness for people with SMI and/or co-occurring disorders is incalculable. Equipped with cost-effective solutions that work and the will to implement them, states, communities, and providers can begin the difficult but necessary work of systems change to the benefit of persons with SMI and co-occurring disorders (SAMHSA, 2003).
On any given night in Memphis/Shelby County, approximately 2,000 people are literally homeless [i.e., residing in emergency shelters, transitional housing for homeless people, or on the streets] (Memphis Blueprint, 2002). A 2001 study indicated that more than 7,000 unduplicated people who were literally homeless during that year received shelter, housing, and/or services and another 9,058 requested, but did not access, emergency shelter or transitional housing in Memphis (Memphis Blueprint, 2002). This does not include countless residents who are not literally homeless but reside in unstable settings (e.g., co-habitating, or inappropriate or substandard living conditions).
In an effort to address this pressing community crisis, the Mayors of Shelby County and Memphis combined to form a Joint Task Force on Homelessness, with the objective of developing a comprehensive Community Blueprint as a community-centered plan for reducing homelessness. Through a series of surveys, focus groups, and other efforts, the Mayors’ Task Force determined that two of the three major homeless subgroups were comprised of people with SA conditions and persons with serious mental illness (SMI) and/or dual diagnoses. That report aptly stated that, Homelessness, therefore, is not the problem. It is a symptom of underlying problems.
Our objective is to include the community in a community health initiative that seeks to bring culturally competent MH and SA treatment together with housing assistance, vocational support and assertive linkage to primary health care, HIV/AIDS CBOs, and other support and treatment services. Our project model will engage a range of culturally diverse partnerships, faith based members, and other community supports comprised of predominantly African American staffing patterns, including agencies with indigenous memberships and staff to provide urban ACT services to 135 predominantly African American individuals meeting criteria for homelessness: those who lack a fixed, regular, adequate nighttime residence (including those whose primary nighttime residence is a supervised public or private shelter designed to provide temporary living accommodations; a time limited/non-permanent transitional housing arrangement for individuals engaged in MH/SA treatment or a public or private facility not designed for, or ordinarily used as, a regular sleeping accommodation, and; doubled-up – a residential status that places the individual at imminent risk to become homeless) along with co-occurring diagnoses of substance abuse or dependence and severe mental illness (schizophrenia, schizoaffective disorder, bipolar disorder, major depression, or anxiety). Services will be provided for adults ages 18 and above. Given our experience with this target population and our community roots, we anticipate that approximately 80-90% of participants will be African-American, and approximately 25% will be female. The most commonly used substances will include crack/cocaine, alcohol, and marijuana, while schizophrenia, bipolar disorder, and major depression will account for most of the psychiatric diagnoses.
A comprehensive statewide study of homelessness conducted in Tennessee by THDA identified people with co-occurring conditions to be the most desperate in need of housing, finding greater than 1/3 inappropriately housed (including homeless and sheltered status), with less than 10% of state providers delivering focused services or housing assistance for people affected by co-occurring conditions (THDA, 2000). This is supported by national data that people with co-occurring SA/MH conditions are almost universally refused admission or are discharged prematurely from both MH and A&D service systems; therefore much more vulnerable to homelessness (Ridgely, Goldman & Willenbring, 1990). Homelessness is often a consequence of prolonged SA, MI, social dysfunction, and a treatment system which lacks the flexibility to serve individuals with multifaceted clinical and social needs (Bachrach, 1987). This has not changed with the revolution of managed care. In a longitudinal study of hospital aftercare, Drake and Wallach (1989) found that A&D use was strongly correlated with homelessness, and over half of the dually diagnosed subgroup experienced homelessness within six months after hospital discharge. Recent social pressures, including welfare reform, are putting increased strain on this at-risk population. Of the homeless, our residents with co-occurring disorders are at elevated risk for co-morbidities due to the presence of multiple disruptive, frequently interactive impairments (Drake et al., 2001; Drake, Osher, & Wallach, 1991).
Co-occurrence impacts extended family and supports, also increasing the likelihood of homelessness due to the direct negative effects of SA/MI on social support networks, finances, and ability to maintain stable housing (Belcher, 1989; Benda & Datallo, 1988; Lamb & Lamb, 1990). NIAAA estimates that 40%-50% of the homeless suffers from serious alcohol problems, while 23%-37% have problems with other drugs, and a significant portion also experiences a concomitant mental illness (1992). More recent research estimates prevalence rates for co-occurrence as high as 50%, constituting the largest and most problematic homeless subgroup and placing unique demands on overburdened MH health and A&D treatment systems (DeLeon et al, 1999). The National Council on Disability 2000 report estimates 1/3 of homeless individuals suffer from SMI, and Drake (1991) identifies dual diagnosis as a key predictor of homelessness, with more than 1/2 of individuals with co-occurring disorders reporting homelessness with the previous 6-months.
Once homeless, it is even less likely that the individual affected by co-occurring conditions will access services within existing SA/MH treatment systems (Fischer, 1990). Traditional models of care rarely provide the services most needed, including assertive outreach, a range of intensity/duration, and housing (McGlynn et al., 1993; Morse et al., 1992). While Tennessee data reports 30%-40% of the homeless population as having SMI (point estimates ranging from 6,566 to 14,000 – THDA, 2000) findings also show that co-occurring conditions among the homeless is under-identified – a consequence of failure to receive the range of needed services along with failure of our state system to even gather prevalence/incidence data about co-occurrence.
Foundations offers field-tested services for providing integrated treatment, and we have demonstrated our ability to successfully implement, with fidelity, projects meeting quality and timeliness guidelines with individuals affected by co-occurring conditions – including those with long histories of homelessness.
The project proposes an evidence-based model of integrated treatment and services that combines practices in the CMHS-toolkit, Implementing Dual Diagnosis Services for Clients with Severe Mental Illness (Drake et al, 2001) within a CMHS-toolkit recommendation for an integrated team platform. In keeping with recommendation from the Federal Task Force on Homelessness and Severe Mental Illness, Outcasts on Main Street (Blueprint, SAMHSA, 2003), these provide a national strategy and comprehensive framework for addressing homelessness among people with complex MI and SA diagnoses, particularly through integrated systems of treatment, housing, and support – which include key elements such as outreach, case management, and a range of housing options – which ‘has withstood the test of time and rigorous evaluation, not only for people with serious mental illnesses but also for those with ‘co-occurring mental illnesses and substance use disorders.’ SAMHSA’s collaborative demonstration projects confirm that integrated treatment of co-occurring disorders reduces A&D use, homelessness, and the severity of MH symptoms (CMHS and CSAT, 2000). We will combine our interventions with the ten principles of Assertive Community Treatment in the Toolkit, Moving Assertive Community Treatment Into Standard Practice (Phillips et al, 2001), with variations described below.
- Caseloads: In determining sustainability options through local and state funding, we propose a model that is more consistent with funding structures, but with smaller ratios (1:15) and more intensive services.
- Services provided through external resources: External resources will be necessary to provide wide-ranging service needs not always available in-house. For example, hospital admissions screenings must be provided by a single point of entry as mandated under state law. When appropriate, our treatment team will leverage existing relationships and partnerships with external agencies, continue to build working relationships, and accompanying clients to offsite services in order to coordinate service delivery and to increase accessibility of needed services.
- Emphasis on building trusting relationships and reduced burden on the client: Toolkit research on ACT teams documents studies of client perceptions of ACT models, where ACT teams were perceived to be coercive, most especially when involving recent substance abuse, arrests, hospitalizations, and more severe symptoms also citing an earlier study that one in ten participants believed the treatment was too coercive (Philips et al, 2001; Neale and Rosenheck, 2000; McGrew et al, 1996). Perceptions of coercion and reluctance towards healthcare providers that have historically failed to provide appropriate treatment services for this population can render a team approach overwhelming and ineffective. Therefore, outreach and engagement efforts are facilitated by 1-2 members to build trusting relationships, counter mistrust, and mitigate, as appropriate, the frequency of contacts so as not to overwhelm participants.
- Integrated Training Curriculum: While much can be accomplished through changes in staffing patterns, caseloads, services, etc., truly integrated treatment cannot succeed without staff buy-in to integration. Perhaps the most important concern is for the clinical team to provide consistent messages to the consumer and, when the team fails in this regard (as is often the case in traditional, segmented, SA and MH treatment systems), the consumer is left to determine his or her course to recovery. To ensure a continuous integrated focus we will train initially and annually via application of Integrated Training Curriculum (ITC, a one week integrated training with pre-post measures) including foci on integrated treatment, motivational interviewing, readiness to change model, dual diagnosis, and ACT interventions. In addition, we will apply the Mueser Integration Fidelity Scale [Mueser, 2003]at 90 days and no less than annually thereafter (retaining the option for quarterly administration if indicated).
- Continuum of Care: Participants may receive additional services through other in-house programs, as appropriate, while remaining engaged and linked to the ACT team in order to maintain seamless care.
- Staff Specialization: The availability of specialists within a multidisciplinary team provides an effective model for peer-education and exchange of knowledge. These specialist team members also ensure appropriate care and treatment for multiple and complicated needs addressing specialty issues such as housing, vocational rehabilitation, outreach, psychiatry, and nursing.
Treatment services combine essential evidence-based elements of Integrated Treatment (Drake et al., 2001), ACT (Phillips et al., 2001), and Service System Components (SAMHSA Blueprint, 2003) for engaging people who are homeless with co-occurring substance use and mental health disorders.