The International Journal of Psychosocial Rehabilitation

 Evaluation of Integrated Treatment Outcomes at Places for People

 
 
Melissa A. Hensley, MSW, MHA
Group Home Director Places for People, Inc.

 
4232 West Pine Boulevard St. Louis, MO 63108 USA
314-531-9450 (Office) 314-531-4733 (FAX)
  melissah0610@aol.com  


 Citation:
Hensley, M.A. (2004)  Evaluation of integrated treatment outcomes at places
for people. International Journal of Psychosocial Rehabilitation. 8,  141-149.



 
Acknowledgements
The author wishes to acknowledge the assistance of Scott Bayliff, M.S.Ed., and Richard Holmes, Ph.D. in data collection.  She also wishes to thank Suzanne Austin Boren, M.H.A. for her help with data analysis.


Abstract
The problem of co-occurring mental health and substance use disorders is one of the most intractable challenges facing mental health treatment systems.  Individuals with dual diagnosis have lower levels of functioning and poorer life outcomes in a broad range of areas.  Treatment providers have gone from parallel and sequential forms of treatment to an integrated model.  Places for People, Inc., a mental health agency in St. Louis, implemented an integrated treatment program in 2001.  This study examines outcomes of this program.
Demographic and outcomes data were collected on a sample of 31 clients.  Three of the 6 outcome measures were found to have statistical significance:  Global Assessment of Functioning score, substance abuse/dual hospitalization rate, and housing status.  Participation in the integrated treatment program is associated with some positive change in life outcomes.  Though it is not possible to say for certain whether these gains were caused by the program, the results are nonetheless encouraging.  


Introduction
The problem of patients who are dually diagnosed with substance use disorders and severe mental illness is one of the most persistent challenges in the mental health field.  Individuals with dual diagnoses consume more treatment resources (Drake, et. al., 1996), have more frequent hospitalizations, have more trouble caring for themselves, and exhibit more disruptive behaviors in the community than individuals with a diagnosis of only serious mental illness (Drake & Wallach, 1989).

Dual diagnosis is also more common than was once thought.  Thirty-seven percent of those who abuse alcohol and 53 percent of those who abuse drugs also meet diagnostic criteria for at least one severe mental illness (NMHA, 2003).

For decades, the standard of treatment for dual diagnosis was parallel treatment.  The dually diagnosed person would receive separate substance abuse services and mental health services, often from two separate agencies, and would be responsible him/herself for integrating the services and information received from each (Drake, et. al., 1996).  The other common scenario was sequential treatment, in which the person with the dual diagnosis would be treated by one service system, and then discharged to be treated by the other system, with no communication or interplay between the mental health and substance abuse agencies (Mueser, et. al., 2003).  More and more, however, the standard of care has become integrated treatment, whereby substance abuse and mental health services are delivered under the same roof, by the same clinicians, as one package of services (Drake, McHugo, et. al., 1998).  Reviews have been conducted on the effectiveness of integrated treatment, and the consensus seems to be that integrated treatment is more effective than parallel or sequential treatment for individuals with dual diagnosis (Drake, Mercer-McFadden, et. al., 1998).  

Despite the fact that integrated treatment seems to be the method of choice for intervention with dually-diagnosed individuals, according to the Substance Abuse and Mental Health Services Administration (SAMHSA), there is still lacking a strong evidence base for which kinds of integrated interventions work the best (SAMHSA, 2003).  Case management, group therapy, and individualized motivational techniques all show promise (Drake, McHugo, et. al., 1998; Ridgely & Jerrell, 1996).  Also of interest are blends of these methodologies.  More research is needed in order to understand which programs and combinations of programs lead to improved outcomes with this population.

Through this study, the author hopes to add to the evidence base regarding effective interventions for clients with co-occurring disorders.  
This purpose will be carried out through the following objectives:

1.    To describe the integrated treatment program at Places for People, Inc.

2.    To analyze demographic and outcomes data from 31 client charts and the Places for People management outcomes database.

3.    To learn from this analysis whether the Places for People integrated treatment program is associated with improved outcomes.


Places for People, Inc. is a small mental health agency located in the Central West End neighborhood of St. Louis, Missouri.  The agency was founded in the early 1970s in response to the de-institutionalization of many people with mental illness who had spent much of their lives in state hospitals (Places for People, 2003a).  In the 1990s, the population served by the agency began to shift to include more people with mental illness who were younger and who were often homeless (Places for People, 2003b).  The integrated treatment program at Places for People, Inc. was started in the fall of 2001.  Agency leaders recognized that the problem of co-occurring disorders was becoming more and more prevalent, and in early 2001, the position of Integrated Treatment Specialist was created.  An MSW-degreed staff person from within the agency was hired to fill the position, and the program developed under his leadership.

Integrated treatment at Places for People consists of several different components.  One is intensive case management.  Places for People operates five continuous treatment teams, all of which serve homeless and dually-diagnosed individuals.  One clinical team, the HOME team, specializes in outreach and engagement with clients who are homeless or in unstable housing situations.  All clinical teams have received training in harm reduction (Marlatt, 1998) and motivational interviewing (Miller & Rollnick, 2002).  The integrated treatment specialist consults with members of each continuous treatment team to help assess what kinds of interventions might be most helpful to particular clients.

Another aspect of the integrated treatment program consists of group interventions.  Groups for dually-diagnosed clients meet seven days a week at Places for People.  Five days a week, the integrated treatment specialist coordinates the groups, which include Double Trouble, Dual Recovery Anonymous, cognitive-behavioral therapy, and “persuasion” (Mueser, et. al., 2003) groups.  On the weekends, the integrated treatment groups are peer-led.

The program also provides social support.  Several times a week, following their group meeting, members of the integrated treatment program go to a neighborhood coffeehouse to play pool and air hockey, drink coffee, and support one another.  Places for People has budgeted funds to pay for the first beverage of the day for every participant.
Places for People also offers payeeship services, nursing services, and a psychosocial rehabilitation program to all of its clients.  A “damp” housing development (Mueser, et. al., 2003) is under construction .

Harm reduction is an essential theme in all of Places for People’s services.  The integrated treatment program aims first to reduce the negative consequences created by substance use behaviors, and then works with each individual to develop the motivation to change those behaviors (Marlatt, 1998; DiClemente, 2003).

Six outcome measures of the integrated treatment program will be examined:  Global Assessment of Functioning scores; psychiatric hospitalizations; substance abuse/dual hospitalizations; medical hospitalizations; housing status; and arrest rates.
The hypotheses that are being tested are as follows:

•    Global Assessment of Functioning (American Psychiatric Association, 2000) scores will increase from the year before program implementation to the year after its implementation.  This is because reduced substance use and stabilization of psychiatric symptoms will lead to gains in levels of functioning.

•    Psychiatric hospitalizations will decrease from the year before to the year after because involvement in treatment will help to mitigate psychiatric symptoms.

•    Substance abuse/dual hospitalizations will increase as more clients enter the action stage of readiness to change (DiClemente, 2003).

•    Medical hospitalizations will decrease as clients gain greater medical stability.

•    Fewer clients will be homeless or housed in hotels during the second year examined when compared to the first year examined.

•    There will be fewer arrests in the second year than in the first year, as clients reduce their substance use and therefore become less likely to commit crimes

This study has limitations that restrict the ability of its results to be generalized to other programs and settings.  First of all, the sample size (N=31) is very small, making the results less dependable.  In order to obtain consistency in the time period studied, it was necessary to include only clients who began the dual diagnosis program in November, 2001.  The integrated treatment program has actually enrolled over 80 clients during the past two years.

In the sample of dually-diagnosed clients whose records were reviewed for this study, less than one-fourth of the subjects were women.  This makes generalizing the results of this study to the experience of women with co-occurring disorders difficult.
Another limitation is that detailed demographic data for Places for People’s clientele as a whole is unavailable at this time, making it difficult to know whether the differences between the integrated treatment sample and the entire agency’s population are statistically significant.

In addition, it is, of course, impossible to say for certain whether the improvements and setbacks noted in this study are caused by the clients’ enrollment in integrated treatment, or whether these events should be attributed to some other aspect of their lives or involvement with Places for People.
Materials and Methods
Data for this study were obtained from the Management Outcomes database and from the clients’ medical records at Places for People, Inc.  The sample was selected from the roster of Places for People clients who have participated in intensive case management since November, 2000 or before, and who began the integrated treatment program in November, 2001.  This yielded a sample size of 31.  Each subject in the sample possessed a diagnosis of severe and persistent mental illness as defined by the Missouri Department of Mental Health as well as a diagnosis of substance abuse or dependence.

The author was granted a waiver of informed consent by the University of Missouri-Columbia Health Sciences Institutional Review Board for the clients in this study on the condition that the names of study participants not be available to her.  Therefore, in December, 2003, the Medical Records Manager and the Clinical Director of Places for People extracted the data from the client charts and the Management Outcomes database and created a spreadsheet of client information, assigning a number to each client in the sample.  The following descriptive information was collected:  age, gender, and ethnicity of each client.  Information about the sample of dual diagnosis clients was compared to demographic information reported in the Fiscal Year 2002 Management Report of Places for People (Places for People, 2002).

Six different outcome measures were collected.  These were Global Assessment of Functioning (GAF) scores; number of psychiatric, substance abuse/dual diagnosis, and medical hospitalizations; housing status; and number of arrests.  GAF scores and housing status were assessed for November, 2001 and November, 2002.  Hospital admissions and arrest rates were measured for the period from November, 2000 to October, 2001 and from November, 2001 to October, 2002.  In this way, outcomes for the year prior to the start of the integrated treatment program could be compared to outcomes for the first year of the program’s operation.  Selected outcomes were chosen largely because these pieces of information were readily available in client charts and the Management Outcomes database.  An outcome related to reduction in substance use was not chosen because Places for People does not put initial emphasis on this outcome.  The harm reduction approach that Places for People uses makes improvement in housing status and GAF, plus reduction in arrests and hospitalizations, more important than reduction in overall use of substances.  

Data for this study were analyzed using SPSS 9.0 for Windows.  In analyzing the outcomes data, paired-samples t-tests were performed.
Approval from the Health Sciences Institutional Review Board of the University of Missouri-Columbia was granted on September 15, 2003.  A waiver of HIPAA authorizations was granted on July 15, 2003.  This protocol was found to be of minimal risk to the research subjects.  The author of this paper is employed by Places for People but works in its residential program rather than in the integrated treatment program.

Results

The following demographic information was collected about the 31 clients in the sample:  age, gender, and ethnicity.  The results are as follows:
Age

•    The oldest client in the sample was 56 years old.
•    The youngest client was 30 years old.
•    The average age was 42 years.
•    The standard deviation was 6.94.


The Fiscal Year 2002 management report of Places for People states that the average age of its clients is 47, with an age range of 20 to 83 (Places for People, 2002).  Clients in dual diagnosis treatment were somewhat younger than the clients of the agency in general.
Gender

•    24 clients were male. (70.8%)
•    7 clients were female. (29.2%)
•    Males outnumbered females by more than 3 to 1.

Places for People as a whole had 45.7% female African-American and European-American clients and 53.5% male African-American and European-American clients in fiscal year 2002 (Places for People, 2002).
Ethnicity

•    18 clients were African-American. (58.1%)
•    13 clients were European-American. (41.9%)

This reflects a higher percentage of African-American clients than in the agency as a whole.  According to the Fiscal Year 2002 management report of Places for People, 42.9% of the agency’s clients were African-American, and 56.4% were European-American (Places for People, 2002).


Outcome Measures
Summary of Outcome Measures
The tables below provide a summary of information regarding the six outcome measures.  Measures that represent a point in time are in Table 1, and measures that tallied occurrences over a period of time are in Table 2.

Table 1:  Outcome Measures
Outcome Mean, 11/01 Standard Deviation, 11/01 Mean, 11/02 Standard Deviation, 11/02  p value
Global Assessment of Functioning 41.06 7.34 43.71 6.30 .048
Housing .23 (23% of the sample was homeless in 11/01) n/a .00 (No clients in the sample were homeless in 11/02) n/a .006

Table 2:  Outcome Measures, Continued
Outcome Mean, 11/00-10/01 Standard Deviation, 11/00-10/01 Mean, 11/01-10/02 Standard Deviation, 11/01-10/02 p value
Psychiatric admissions .81 1.60 2.06 5.18 .166
Substance abuse/dual admissions 2.16 .3.09 .71 1.07 .011
Medical admissions .32 1.45 .01 .40 .415
Arrests .29 .59 .29 .82 1.000
 

Global Assessment of Functioning
Global Assessment of Functioning scores were examined twice, once in November, 2001, when the integrated treatment program began; and again in November, 2002, after the program had been operational for a year.  

It was found that the difference in GAF scores from November 2001 to November 2002 was statistically significant (p=0.048).  The range for both time periods was 25, with the highest score being 55 and the lowest 30.  The highest and lowest scores did not change, but those in the middle of the range were slightly higher.  It is interesting to note that the average GAF score during both periods represented a level of functioning so impaired as to necessitate inpatient treatment in many cases (Dziegielewski, 2002).  This sample did experience quite a few psychiatric and dual-diagnosis hospitalizations, but it is surprising, perhaps, that there were not more.


Housing Status

Housing status for the 31 clients in the sample was compared from November, 2001 to November, 2002.  Clients were divided into two groups:  those who were homeless or living in a hotel; and those who were living independently, with family/friends, or in a residential care facility.
   Seven clients were homeless or living in a hotel in 11/01.
•    There were no clients in 11/02 who were homeless or living in a hotel.
•    This difference is statistically significant (p=.006).


Psychiatric Admissions

Inpatient admissions were tallied for the twelve months before the integrated treatment program began, and for the twelve months after the program’s inception.  The mean number of psychiatric hospitalizations per client for the period of 11/00 to 10/01 was 0.81.  The mean for the period of 11/01 to 10/02 was 2.06 hospitalizations per client.


This is a startling increase from one year to the next; however, it is not statistically significant (p=0.166).  Part of the increase from one year to the next can be attributed to one particular client who had 27 psychiatric inpatient admissions from 11/01-10/02.  The largest number of psychiatric hospitalizations that any one client had in the previous time period was eight.

Substance Abuse/Dual Hospitalizations
Substance abuse and dual hospitalizations were counted for the same time period as psychiatric hospitalizations:  November 2000 to October 2001; and November 2001 to October 2002.  The mean number of hospitalizations during the first time period was 2.16 per client; during the second time period, this number had decreased to 0.71.  The decrease in substance abuse/dual inpatient hospitalizations from one year to the next was found to be statistically significant (p=.011).  Broderick (personal communication, December 20, 2003) has commented that substance abuse/dual hospitalizations may have decreased because clients were no longer needing to escape their situation or hide from someone to whom they owed money.


Medical Hospitalizations

Inpatient medical admissions were also counted for the year before the integrated treatment began and for the first year of the program’s operation.  There were very few medical hospitalizations among the 31 clients, making data analysis difficult.  The total number of medical admissions from 11/00-10/01 was ten; from 11/01-10/02, the number was three.  Analysis of the data showed that although there was a decrease in medical admissions, the difference was not statistically significant (p=.415).

Arrests
Data on arrests were collected from November 2000 to October 2001 and from November 2001 to October 2002.  There were a small number of occurrences of arrests during both time periods.
•    Seven clients were arrested from 11/00-10/01 for a total of nine arrests.
•    Five clients were arrested from 11/01-10/02 for a total of ten arrests.
•    This difference is not statistically significant (p=1.000).
•    The standard deviation for the first time period was 0.59; for the second period it was .82.

Discussion
Summary
A review of the literature on dual diagnosis treatment shows that integrated treatment programs are favored over parallel and sequential treatment modalities (Drake, Mercer-McFadden, et. al., 1998).  The Places for People program contains several elements of programs that have been shown to be successful (Mueser, et. al., 2003).  These include intensive case management, outpatient group interventions, and social support.
This project revealed that participation in Places for People, Inc.’s integrated treatment program is associated with several changes in client outcomes.  Global Assessment of Functioning scores increased significantly, as was hypothesized.  Housing status improved significantly, as none of the 31 participants were homeless or in a hotel at the end of the program’s first year.  And, opposite of what was hypothesized, substance abuse/dual diagnosis hospitalizations decreased significantly.

There were several outcomes that were not associated with significant change.  Psychiatric hospitalizations increased from the year before the program’s genesis to the first year of its implementation.  The arrest rate stayed the same from one year to the next, and though medical hospitalizations decreased from one period to the next, the difference was not significant.

Conclusions
The Places for People integrated treatment program appears to be associated with some positive changes for its participants.  The program participants show a great deal of affection toward the Integrated Treatment Specialist, and according to the Integrated Treatment Specialist, the clients find their participation enjoyable and beneficial (A. J. Nave, personal communication, December 30, 2003).  Though it cannot be said that the integrated treatment program caused these positive changes, the association is important.  As change in dually-diagnosed clients must be measured in years rather than months or days, the program should continue, striving to increase its fidelity with the evidence-based integrated treatment model, and collecting more and better outcome and demographic data (Mueser, et. al., 2003).

The Places for People integrated treatment program has made a promising beginning.  More rigorous data collection, continued collaboration with other community organizations, and continued emphasis on harm reduction should help the program continue to grow and help more individuals with co-occurring disorders.


References

American Psychiatric Association (2000).  Diagnostic and statistical manual of mental disorders (4th ed., text rev.) Washington, DC:  American Psychiatric Press.

DiClemente, C. (2003).  Addiction and change:  How addictions develop and addicted people recover.  New York:  The Guilford Press.

Drake, R. E., McHugo, G. J., Clark, R. E., Teague, G. B., Xie, H., Miles, K., & Ackerson, T. (1998).  Assertive community treatment for patients with co-occurring severe mental illness and substance use disorder:  A clinical trial.  American Journal of Orthopsychiatry, 68(2), 201-215.

Drake, R. E., Mercer-McFadden, C., Mueser, K. T., McHugo, G. J., & Bond, G. R. (1998).  Review of integrated mental health and substance abuse treatment for patients with dual disorders.   Schizophrenia Bulletin, 24(4), 589-608.

Drake, R. E., Mueser, K. T., Clark, R. E., & Wallach, M. A. (1996).  The course, treatment, and outcome of substance disorder in persons with severe mental illness.  American Journal of Orthopsychiatry, 66(1), 42-51.

Drake, R. E., & Wallach, M. A. (1989).  Substance abuse among the chronically mentally ill. (1989, October).  Hospital and Community Psychiatry, 40(10), 1041-1046.

Dziegielewski, S. F. (2002).  DSM-IV-TR in action.  New York:  John Wiley & Sons, Inc.

Marlatt, G. A. (1998).  Basic principles and strategies of harm reduction.  In G. A. Marlatt, ed., Harm reduction:  Pragmatic strategies for managing high risk behaviors. New York:  The Guilford Press.

Miller, W. R., & Rollnick, S. (2002).  Motivational interviewing (2nd ed.):  Preparing people for change.  New York:  The Guilford Press.

Mueser, K. T., Noordsy, D. L., Drake, R. E., & Fox, L. (2003).  Integrated treatment for dual disorders: A guide to effective practice.  New York:  The Guilford Press.

National Mental Health Association (2003).  Substance abuse—Dual diagnosis fact sheet.  Retrieved December 28, 2003 from http://www.nmha.org/infoctr/factsheets/03.cfm

Places for People, Inc. (2002).  FY02 management report.  St. Louis:  Places for People, Inc.

Places for People, Inc. (2003).  About Places for People:  History.  Retrieved January 6, 2004 from http://www.placesforpeople.org/history.htm

Places for People, Inc. (2003).  Welcome to Places for People:  A message from the executive director.  Retrieved January 6, 2004 from http://www.placesforpeople.org/

Ridgely, M. S., & Jerrell, J. M. (1996, December).  Analysis of three interventions for substance abuse treatment of severely mentally ill people.  Community Mental Health Journal, 32(6), 561-572.

Substance Abuse and Mental Health Services Administration (2002).  Report to Congress on the prevention and treatment of co-occurring substance abuse disorders and mental disorders.  Retrieved December 21, 2002 from http://www.samhsa.gov/reports/congress2002/


1“Damp” housing refers to an apartment building or other housing development in which the use of alcohol or other drugs is tolerated.  Illicit drugs are not allowed on the premises, but tenants who use substances are not automatically evicted, as is the case with many housing programs offered by mental health and substance abuse agencies (Mueser et. al., 2003).


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