Barriers to Collaboration

The traditional referral system from substance abuse treatment programs to outside agencies can create obstacles to effective collaboration. Examples of obstacles are designation of which agency has major responsibility for a client, structural barriers driven by funding sources (e.g., payment to only one treatment agency), difficult-to-treat clients, and differing staff credentials.

The issue of which agency "takes credit" for a client is a difficult question arising from competition among different agencies, each of which has an interest in maintaining a certain "head count" to ensure continued funding. This barrier highlights the need to change the way that agencies are credited for their participation in a client's recovery. In many treatment systems, only one agency can receive credit for clients who are served by several service providers. It would be preferable to allow all participating agencies to take credit for these clients. For example, this happens in communities that have collaborative relationships based on shared outcomes negotiated across agencies. These cross-agency outcomes can occur across service systems (e.g., substance abuse treatment and social services) or across provider networks (e.g., residential and outpatient providers). Outcomes are negotiated both across agencies and with funders of services. Funders play a critical role because they must "change the rules" that allow only one agency to receive credit for a client. This change from a rules-driven system to a results-based system encourages all participating agencies to be recognized for their contribution to client outcomes. Also, it is important that each provider understand the role of the other providers so that it does not seem as if they are competing. Each provider must create an appropriate working relationship with the other providers so the client can benefit from all.

Structural barriers may also be posed by program policies that are determined by the program's primary funding source. Such policies may dictate, for example, that clients cannot engage in concurrent activities, such as vocational training and treatment of substance abuse disorders. If the State or a managed care system does not allow clients to participate in concurrent services, then collaboration efforts will be difficult, or even impossible. However, in some cases, this is simply a program philosophy and not a formal policy, and efforts should be made to change this mode of operation. Another major barrier in the past has been confidentiality requirements. One answer to addressing this problem is joint training.

In the present system, there are no rewards for serving difficult-to-treat clients, and sometimes agencies set criteria under which only the clients with the greatest potential for success are accepted. Incentives are needed for programs to accept those clients who have the greatest problem severity or multiple needs. This is known as "case mix adjustment." The incentives should be based on three factors: (1) identification of difficult-to-treat clients based on analysis of differential outcomes and clients' characteristics, (2) analysis of the additional average costs of serving these clients, and (3) provision of either explicit incentives for serving these clients or a more equitable approach. A key element in a more equitable approach is for funders to recognize that serving difficult-to-treat clients is as valuable as serving clients with fewer risk factors, even though success rates will be lower as a result. Referring difficult-to-treat clients should be viewed not as a matter of "handing off" problematic clients, but rather as securing additional services to meet these clients' needs.

Staff licensing can sometimes be a barrier to collaboration because it is defined categorically. For example, sometimes the referring agency has a policy requiring that the staff members of the receiving agency have the same licenses and credentials as the referring agency's staff. In addition to requiring specific types of expertise, a referring agency sometimes requires the staff members of the other agency to be "professionals" with advanced degrees. The unfortunate consequence is that credentialing standards, rather than transdisciplinary collaboration, often dictate the services clients receive.

Finding Potential Collaborators

Programs must look at their clients with the assumption that it is not feasible or effective to provide everything that clients need "under one roof." A more fruitful approach is to collaborate with other agencies on the basis of client needs and overlapping client caseloads. This procedure is called data matching. Figure 5-1 provides an example of this process.

Agencies and organizations that provide vocational training in collaboration with substance abuse treatment programs can be divided into two levels--agencies providing specific training for employment (Level 1), and agencies with resources and services needed by clients at the same time they are receiving substance abuse treatment and employment rehabilitation services (Level 2). Examples of Level 1 resources include

• City-, county-, and State-operated vocational rehabilitation (VR) services
• Public and private employment and job placement services
• Public and private employers in the community
• Vocational-technical colleges
• Community colleges
• Privately owned VR facilities
• Criminal justice vocational training programs

Examples of Level 2 resources include

• Economic Development Centers (One-Stop or Workforce Development Centers)
• Shelters for survivors of domestic violence
• Mental health agencies
• Homeless shelters
• Child welfare agencies
• Child care services
• Family services
• Housing authorities
• Evening adult education programs
• Alternative education programs
• Literacy programs
• Adult basic education programs and general equivalency diploma (GED) programs
• Young Men's Christian Associations (YMCAs), Young Women's Christian Associations (YWCAs), Young Men's Hebrew Associations (YMHAs), and Young Women's Hebrew Associations (YWHAs)
• Social service organizations
• HIV/AIDS programs
• Health and disability organizations
• Independent living centers
• Religious groups
• Self-help meetings
• Accessible meetings

Often, collaborating agencies must be educated about the nature of substance abuse disorders, including the cycles of relapse and recovery. Alcohol and drug counselors may also benefit from applying the relapsing and remitting model in areas other than substance abuse disorders. For example, clients may also "relapse" into and out of employment, medication management, or violent situations. The failure of any one of these supports can then be a trigger for failure of any of the others. All collaborators, including those providing treatment for substance abuse disorders, should be aware that their efforts are likely to be ineffective unless all the client's life areas are addressed. To that end, agencies must recognize the existence, roles, and importance of each other in achieving their goals. It is preferable to have formal written agreements that outline the responsibilities of each agency.

Although the prison population has grown substantially in the last several years, vocational training programs for inmates are limited. The vocational training programs that are available to incarcerated individuals will vary according to the setting of the incarceration, and treatment programs will need to be in contact with penal institutions in order to find out what particular types of substance abuse treatment and vocational training are available (see Chapter 8 for more information about working with ex-offenders). Providers interested in more information concerning the particular procedures and problems involved in establishing service agreements with criminal justice agencies (including prisons, detention centers, and community supervision agencies for ex-offenders) should consult Chapters 1 to 4 in TIP 30, Continuity of Offender Treatment for Substance Use Disorders From Institution to Community (CSAT, 1998d).

Figure 5-2 summarizes the steps that substance abuse treatment providers can take to establish an authentically connected network with other agencies or to screen potential collaborators. The next section provides more detailed information about this process.

Multidisciplinary Teams

In its conventional sense, a multidisciplinary team is composed of members from different service areas (e.g., substance abuse treatment, vocational rehabilitation, mental health). This method of service, which is more common in programs that provide multiple services in-house, is just one way of functioning in a multidisciplinary manner. In an authentically connected referral network, however, members of the multidisciplinary team provide their services in different locations. Still, in an authentically connected network, a multidisciplinary team approach can be fostered by regularly scheduled case conferences.

In the authentically connected model, the agencies are interdependent. They cross-train their staffs in concepts and methodologies from different disciplines and promote awareness of resources that each agency might provide. Instead of being dependent on certification, learning about other disciplines, and becoming recertified every few years, service providers are taught how to learn on their own.

Careful consideration must be given to the formation of a multifocal treatment team. One approach is to view the team as a pie divided into sections, with the team members proportionally reflecting the needs of clients in areas such as coexisting mental disorders, job skills and employment, and child custody and care. The community must be considered as a whole throughout the treatment and referral process, and all available resources in the local geographic area should be considered to meet client needs. Multidisciplinary teams can be composed of credentialed specialists as well as self-help and grassroots organizations. The more diverse the team, the more likely that the client will be viewed holistically.

True collaboration is a higher order of referral than either cooperation or coordination. Referral is a term that is used to mean many different things. Whereas a traditional referral is unidirectional (e.g., the client is sent for services to an outside agency), an authentically connected referral network is multidirectional and incorporates the ideals of collaborative relationships, accountability, cultural competence, client-centered services, and holistic assessment.

Integrating Cultural Competence Into Treatment and Referral

People live in different environments, and service providers have a responsibility to understand the contexts in which their clients operate. Client-focused treatment and referral must be based on an understanding of the family relationships, cultures, and communities of the clients. Culture can be broadly defined as incorporating demographic variables (e.g., age, sex, family), status variables (e.g., socioeconomic, educational, vocational, disability), affiliations (formal and informal), and ethnographic variables (e.g., nationality, religion, language, ethnicity). In many cases the client's belief system is intricately woven with culture, and providers must start where the client is and acknowledge the spiritual part of the work. Substance abuse treatment programs should be open to faith-based organizations in their communities, which can be valuable collaborative partners.

Throughout this chapter, the expression cultural competence refers to the capacity to view and understand individual clients within these contexts (Center for Substance Abuse Treatment [CSAT], 1999a). It is a core philosophy that must be integrated into and must guide the entire treatment and referral process. Too often, cultural competence is equated with the completion of a workshop, a multicultural staff, or proficiency in the language(s) spoken among the client population served. However, diversity of staffing does not ensure the cultural competence of the treatment program. Cultural competence is not achieved solely by attending workshops or by having a diverse, multilingual staff. When taken seriously, cultural competency is a continual learning process that is dynamic and is constantly expanded, refined, and defined by the community being served.

Building an integrated service model based on community partners must begin from the clients' base, taking into account their values and building on the strengths of their culture to create referrals that are appropriate and effective for their particular needs. Issues of culture can begin during the intake and assessment process, when clients are asked about their ethnic identification, their religion, and their participation in culturally based activities. Providers should feel comfortable discussing these issues with their clients and not make assumptions based on outward appearances, whether they are related to attire, complexion, or language. In programs working with highly diverse, multicultural populations, it may not be possible to be intimately familiar with all the details of each group's customs and culture. In any case, it is probably more important for providers to be aware of what they do not know and to have access to resources that can help, such as local community centers working in collaboration with their program.

Moreover, a delicate balance is needed between a client's current circumstances and the historical and cultural issues that come into play. Some cultures may be relatively "closed" to nonparticipants. One must sometimes maintain a presence for years until he is accepted as a participant or observer. Although outwardly some groups may seem more approachable, gaining the trust of any client takes time.

Client-Centered Versus Agency-Centered Treatment and Referral

Substance abuse treatment that is both client-centered and client-focused is more likely to improve the lives of clients. Collaboration among agencies providing requisite services is an initial step toward client-centered care. Referral can be a way for agencies to hold each other accountable for getting results for clients. Referrals are necessary and appropriate when the substance abuse treatment program cannot provide special services needed by their clients. Some of the areas for which referrals may be needed include job readiness, job training, medical care, and ethnic/cultural expertise.

If the rationale for integrated treatment is a successful outcome for the client, there must be some way of measuring whether the referral is successful. From the referring provider's perspective, referral represents an act of faith, hope, and trust that the agency to which the client is referred will be accountable and will share the goal of client success along with the referring agency. Referrals also represent an opportunity for change, growth, and development. Far too often, however, a referral consists merely of handing a client a list of names and telephone numbers and assuming or hoping that the client will take the initiative to make the necessary contacts.

Distinct from this traditional model is one in which collaborations are fostered and maintained among agencies providing services to clients with overlapping needs, such as substance abuse treatment, employment, housing, education, and child care. In this context, the multidisciplinary team approach comes into play, but rather than coexisting under one roof, team members work within the various agencies engaged in collaboration. Referrals are negotiated among interlinked and interdependent agencies that share mutual goals and outcomes. These authentic connections and shared outcomes can then serve as an agreed-upon basis for the involved agencies to measure their results instead of merely going through the motions of collaboration. Figure 5-3 lists the characteristics of authentically connected referral networks.

Elements of Effective Referrals

In general, an authentically connected referral network is composed of a set of defined relationships formed as clients' needs dictate, using sound principles of case management and building in flexibility and adaptability to meet the needs of individual clients (see also TIP 27, Comprehensive Case Management for Substance Abuse Treatment [CSAT, 1998a]).

Although authentically connected referral networks share several features such as those listed in Figure 5-3, this similarity does not constitute a mandate for all treatment programs to form identical referral networks. Rather, in order for such an authentically connected network to be effective, each program must understand its own mission as well as those of the other agencies.

Resource Mapping and Inventory

Organizational Alignment and Capacity Building

Organizational alignment means that a service provider's vision, structure, mission, and policies are all based on the same underlying philosophy. All the activities and services the organization provides must be evaluated to determine the degree to which they contribute to client success. Having a mechanism for measuring client outcomes is important; information systems that track referrals and fiscal responsibility play key roles in identifying successful referrals as well as troubleshooting for cases in which needs were not adequately met.

Capacity building is the process by which organizational alignment is achieved; it involves elements such as program assessment and staff development.