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Preliminary results of research published in the March issue of the Journal of Psychiatric Services show that services to homeless mentally ill people in several large metropolitan areas in the United States are often inaccessible and fragmented.
The findings reinforce the argument that improving services and creating an integrated system will increase access and therefore use. That is the goal of a five-year national demonstration program, Access to Community Care and Effective Services and Supports (ACCESS), initiated in 1993 by the Department of Health and Human Services.
"The ACCESS program encourages interaction and cooperation among community leaders and public and private-service providers to create a 'no wrong door' approach to services," stated Nelba Chavez, Ph.D., administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA).
The Center for Mental Health Services, which is a division of SAMHSA, established 18 ACCESS demonstration sites in 1994 to evaluate the effects of improved services and interagency coordination on homeless people with mental illness. The journal articles feature research on patients and community services at the initial stages of the ACCESS program.
The primary barriers to services identified by homeless mentally ill people in a large quantitative study were not knowing where to obtain services (32 percent); not affording services (30 percent); experiencing too much confusion, hassle, or wait to obtain services (27 percent); and having been previously denied a service (17 percent).
About 1,828 homeless mentally ill individuals completed assessments from May 1994 to May 1995, the first year of the ACCESS program. The participants were asked to identify three services they most wanted from a list of 17 services and state why they were not receiving them.
Using regression analysis, researchers found that the likelihood of encountering specific barriers and more barriers increased an average of 5 percent because of individual clinical and sociodemographic characteristics.
Participants were diagnosed with at least one psychiatric disorder. In order of frequency, the disorders were major depression, schizophrenia, personality disorder, anxiety disorder, and bipolar disorder. More than half the participants (57 percent) had comorbid substance abuse disorders.
Participants with psychotic symptoms and overt behavioral disturbances were more likely to report that obtaining services was too confusing or too much of a hassle or wait. Participants diagnosed with symptoms of depression were more likely to report not knowing where to get services and not being able to afford them.
Homeless mentally ill people in street or soup kitchens encountered more barriers to services. This finding underscores "the importance of sustaining outreach efforts to the most severely ill and underserved people, especially those in nontraditional sites of entry into service systems," state the authors.
Robert Rosenheck, M.D., principal investigator for the client-level evaluation team of ACCESS, told Psychiatric News that "this is the first quantitative study to find that program differences rather that solely patient differences explain the large variation in service use by homeless people with mental illness."
Rosenheck is a psychiatrist and director of the Northeast Program Evaluation Center at the Veterans Affairs Medical Center in West Haven, Conn.
He added that more qualitative research is needed to identify specific characteristics of program sites that would explain differences in service use.
Accessibility and coordination of services to the homeless mentally ill population at 18 ACCESS sites were rated as average to poor by program or agency directors at the start of the study. Poor accessibility was associated specifically with service locations and reasonableness of costs. Poor coordination ratings were highest in areas of joint planning among agencies and hospitals.
Interagency ties, considered a measure of system integration, were based largely on client referrals and information exchanges, with few instances of funding transfers in the form of contracts or grants, note the authors.
This is because most agencies have their own sources of funding and support. "In this environment, ACCESS grantee agencies face considerable challenges in creating incentives for agencies to collaborate inbuilding systems of care."
A representative from each of the 875 agencies at 18 sites was interviewed during 1994. The majority of respondents were agency or program directors or administrators. Agencies that provided the core services identified in the ACCESS initiative were more likely to be included. The core services are mental health care, substance abuse, housing, entitlements and income support, and primary health care.
The authors note that as more longitudinal data become available, causal relationships between systems performance and grantee linkages will be examined.
(Psychiatric News, April 4, 1997)