Organizational Capacity for Service Integration in Community-Based Addiction Health Services

摘要

Objectives. We examined factors associated with readiness to coordinate mental health, public health, and HIV testing among community-based addiction health services programs. Methods. We analyzed client and program data collected in 2011 from publicly funded addiction health services treatment programs in Los Angeles County, California. We analyzed a sample of 14?379 clients nested in 104 programs by using logistic regressions examining odds of service coordination with mental health and public health providers. We conducted a separate analysis to examine the percentage of clients receiving HIV testing in each program. Results. Motivational readiness and organizational climate for change were associated with higher odds of coordination with mental health and public health services. Programs with professional accreditation had higher odds of coordinating with mental health services, whereas programs receiving public funding and methadone and residential programs (compared with outpatient) had a higher percentage of clients receiving coordinated HIV testing. Conclusions. These findings provide an evidentiary base for the role of motivational readiness, organizational climate, and external regulation and funding in improving the capacity of addiction health services programs to develop integrated care. Providers of addiction health services (AHS) face an unprecedented challenge to implement integrated care services to respond to the complex health care conditions of racial- and ethnic-minority populations entering addiction treatment. 1–3 Increased access to integrated addiction, mental health, and medical care has been associated with reduced health care costs and positive health outcomes among minority populations. 4–8 Yet AHS providers face significant barriers to integrating or collaborating with mental health or medical care providers to address the needs of clients with co-occurring problems. 6–11 Because the Affordable Care Act promotes delivery of community-based integrated care for vulnerable populations, outpatient AHS located in low-income and ethnic-minority communities are poised to become significant intervention points for the diagnosis and treatment of sexually transmitted infections and other mental health and physical conditions if they integrate services. 12–14 In our study, we examined the organizational capacity (funding, regulation, readiness for change, and leadership) of community-based AHS to coordinate mental health, public health, and HIV-testing services in low-income, urban, and ethnic-minority communities in Los Angeles County, California. Despite significant efforts to increase service coordination and integration in health care settings during the past 50 years, there is limited and inconsistent evidence regarding the most effective approaches to implementing integrated practices. 15 Service integration refers to the effective coordination of specific services to holistically respond to the health care needs of individuals. 16 The extant literature has revealed multiple system and organizational barriers to integration, including the bureaucratic process of service delivery, professional and philosophical differences among providers, and inadequate resources. 10,17 More specifically, effective coordination is generally affected by limited funding and infrastructure for communication among providers to establish effective coordination of services across agencies 18 and build necessary partnerships. 19–21 Because more than 44% of clients entering AHS report dual substance use and mental health or physical disorders, 9 providers have made ongoing efforts to coordinate care. 22–26 Yet, besides entering service agreements across agencies, providers with fewer resources (e.g., limited time for training, access to computer terminals, or supervision) struggle to invest in coordination practices, such as dual-diagnosis training and medical staffing, as well as clinical processes to effectively diagnose, treat, or triage mental, physical, 27,28 and HIV-related conditions. 29–31 Extensive research has shown that public funding increases safety-net services (child care, job readiness, and other ancillary and social services) and HIV preventive care among AHS providers, 30,32–36 and state-licensed and professionally accredited facilities are more likely to test for HIV/AIDS. 33,37,38 However, little is known about how these external funding and regulatory factors, in combination with internal program factors, enable program staff to coordinate with mental health, public health, and HIV-prevention programs to ensure integrated care. To examine the capacity of AHS programs to integrate care in the addictions system, which is generally characterized by unstable funding, passive leadership, high staff turnover, 32,39,40 and limited technical resources to conduct complex clinical operations and support effective decision-making, 41 we relied on Shortell’s 42 conceptual model of organizational c