Bringing it All Together: Integrating Services to Address Homelessness
DOI:
https://doi.org/10.11575/sppp.v12i0.43279Abstract
Homeless-serving systems are striving for greater impact and efficiency amidst austerity. Those with lived experience, governments, funders, and service providers have consistently and increasingly called for enhanced integration across services, organizations, systems, processes and policies as a means of maximizing existing resources. Here, the discourse of integration refers to ways of working better together across diverse internal and external organizational boundaries. At the heart of these efforts lies the assumption that integration is the desired state, an ideal that will result in improved outcomes at individual and population levels.
As actors actively engaged in homeless-serving system planning work, we draw from on-the-ground experiences in Calgary, Alberta to consider how a nuanced understanding of integration can shape the evolution of a systems planning response to homelessness. Our practical experience working in the homeless-serving system on diverse integration initiatives has prompted us to reconsider the evidence and critically probe the implicit link between systems integration efforts and improved individual and population outcomes. In some instances, we have experienced how integration efforts can result in the addition of new layers of complexity to the issue they were created to resolve in the first place. In other cases, integration efforts delivered marginal benefits given the amount of resources used as inputs into planning and implementation. Of course, there are also examples where integration spurs positive impacts at the system and target population levels.
Rather than declaring a course of action, this paper is intended to spur discussion. We are posing questions we continue to grapple with at a praxis level, which may resonate with fellow policy makers, system planner organizations, service providers and researchers. We want to go beyond conventional wisdom to probe the merits of integration as a de facto answer to complex social issues by asking:
- What exactly is integration?
- When and how is integration appropriate?
- What are the pitfalls of integration and how do we manage risks?
Findings suggest that while ventures to enhance integration remain important, they are not and cannot be the panacea to social challenges, including homelessness. If integration is an appropriate response, we must understand what makes it work, what environment it thrives in, and what success looks like. We maintain that no matter how system integration is implemented or delivered, a central focus on the person served must be maintained, rather than systems themselves.
References
Backer, T. E., Howard, E. A., Moran, G. E. 2007. “The role of effective discharge planning in preventing homelessness”. The Journal of Primary Prevention, 28(3-4): 229-243.
Baron, M., Erlenbusch, B., Moran, C. F., O’Connor, K., Rice, K., Rodriguez, J. 2008. “Best Practices Manual for Discharge Planning: Mental Health & Substance Abuse Facilities, Hospitals, Foster Care, Prisons and Jails”. Available from http://homelesshub.ca/resource/best-practices-manual-discharge-planning-mental-health-substance-abuse-facilities-hospitals
Barr H. 1999. “Prisons and Jails: Hospitals of Last Resort. The Need for Diversion and Discharge Planning for Incarcerated People with Mental Illness in New York”. New York: Correctional Association of New York and Urban Justice Center.
Boardman, J. B. 2006. “Health Access and Integration for Adults With Serious and Persistent Mental Illness”. Families, Systems, & Health, 24(1): 3-18.
Browne, G., Kingston, D., Grdisa, V., & Markle-Reid, M. 2007. “Conceptualization and measurement of integrated human service networks for evaluation”. International Journal of Integrated Care, Oct.-Dec., e51.
Burt, M., Pollock, D., Sosland, A., Mikelson, K., Drapa, E., Greenwait, K., and Sharkey, P. 2002. “Evaluation of continuums of care for homeless people” U.S. Department of Housing and Urban Development Office of Policy Development and Research.
Calgary Homeless Foundation. 2015. “Calgary’s Updated Plan to End Homelessness: People First in Housing First”. Available from
http://www.ihearthomeyyc.com/content/uploads/Update_to_Calgary_Plan_March_4.pdf
Calgary Homeless Foundation. 2017a. “Data That Makes a Difference”. 2nd Annual Canadian Homelessness Data Sharing Initiative. Available from http://calgaryhomeless.com/content/uploads/Data-Sharing-Minutes-May-18-Final-Version-12jun2017.pdf
Calgary Homelessness Foundation. 2014. “The Cost Benefits of Housing First”. Available from http://calgaryhomeless.com/wp-content/uploads/2014/06/The-CostBenefits-of-Housing-First.pdf.
Calgary Homeless Foundation. 2017b. “I am Home: Calgary Homeless Foundation 2017 Report on Progress”. Available from http://calgaryhomeless.com/content/uploads/CHF-2017-Annual-Report_WEB.pdf
Calgary Homeless Foundation. 2018. “Calgary’s 10 Year Plan to End Homelessness enters its final year”. Available from http://newsroom.calgaryhomeless.com/press-releases/calgarys-10-year-plan-to-end-homelessness-enters-its-final-year-gnw_2033199_001
Centre for Health Economics. 2014. “Financial mechanisms for integrating funds for health and social care: an evidence review”. University of York, Economics of Social and Health Care Research Unit. Available from: www.york.ac.uk
Christ, W. R., and Hayden, S. L. 1989. “Discharge Planning Strategies for Acutely Homeless Inpatients”. Social Work in Health Care, 14(1): 33-45.
Conly, C. 1999. “Coordinating Community Services for Mentally Ill Offenders: Maryland’s Community Criminal Justice Treatment Program”. American Jails, 13(1): 9-114.
GGI Consultants (2015). “Evaluation of the NAVNET Initiative”. Prepared for: The NAVNET Steering Committee. Available from from http://navnetnl.ca/wp-content/uploads/2013/09/NAVNET-Evaluation-Summary-Report-July-3-2013.pdf
Cornes, M., Manthorpe, J., Hennessy, C., Anderson, S., Clark, M., Scanlon, C. 2014. “Not just a talking shop: practitioner perspectives on how communities of practice work to improve outcomes for people experiencing multiple exclusion homelessness”. Journal of Interprofessional Care, 28(6): 541-546.
Corbett, T. and Noyes, J. 2008. Human Services Systems Integration: A Conceptual Framework. Paper prepared for the Annual Meeting of the Association for Public Policy Analysis and Management, Washington, DC, November 8–10, 2007.
Culhane D.P., Metreaux S., Hadley T. 2002. LDI Issue Brief. Feb; 7(5):1-4.
Culhane D.P. 2008. “The cost of homelessness: a perspective from the United States”. Eur J Homelessness 2(1):97–114
Eberle M., Kraus D., Pomeroy S., et al. 2001. The cost of homelessness in British Columbia [Internet] In: Office of Housing and Construction Standards, editor. Ministry of Natural Gas Development and Responsible for Housing of British Columbia. Homelessness—causes and effects reports. 1−5. Victoria (BC): Office of Housing and Construction Standards.
Erick G. Guerrero, B. H., and Suzanne L. Wenzel. (2014). Service Integration to Reduce Homelessness in Los Angeles County: Multiple Stakeholder Perspectives. Human Service Organizations: Management, Leadership & Governance, 38, 44-54.
Evans, T., Neale, K., Buultjens, J., & Davies, T. (2011). Service integration in a regional homelessness service system. Available from http://socialfutures.org.au/wp-content/uploads/2015/11/Service-Integration-in-a-Regional-Homelessness-Service-system-Nov-2011.pdf
Fisher, M.P., and Elnitsky, C. (2012). Health and Social Services Integration: A Review of Concepts and Models. Social Work in Public Health, 27, 441-468.
Flatau P, Conroy E, Thielking M, Clear A, Hall S, Bauskis A, et al. How integrated are homelessness, mental health and drug and alcohol services in Australia? Melbourne: Australian Housing and Urban Research Institute, 2013.
Gaetz, Scott, Gulliver 2013. 3.1 Calgary, Alberta: Calgary Homeless Foundation. Housing First in Canada: Supporting Communities to End Homelessness. Canadian Observatory on Homelessness
Gladwell M. 2006. “Million-dollar Murray: why problems like homelessness may be easier to solve than to manage”. New York (NY): The New Yorker; Feb 13, p. 96
Gold, J. and Dragicevic, N. 2013. Integration Imperative. The Mowat Centre. Available from https://mowatcentre.ca/the-integration-imperative/
Gordon, A. J., Montlack, M. L., Freyder, P., Johnson, D., Bui, T., Williams, J., and Aim-High Team. 2007. “The Allegheny Initiative for Mental Health Integration for the Homeless: Integrating Heterogeneous Health Services for Homeless Persons”. American Journal of Public Health 97(3): 401-405.
Grdisa, V. 2009. Conceptualizing & Measuring Integration: Tools & Resources for System Leaders. Available from http://www.nhlc-cnls.ca/assets/grdisa%20presentation.pdf
Greenberg, G., & Rosenheck, R. 2010. “An Evaluation of an Initiative to Improve Coordination and Service Delivery of Homeless Services Networks”. The Journal of Behavioral Health Services & Research 37(2): 184-196.
Hambrick, R., and Rog, D. 2000. “The Pursuit of Coordination: The Organizational Dimension in the Response to Homelessness”. Policy Studies Journal 28(2): 353-364.
Harrison, M. L., Moore, K. A., Young, M. S., Flink, D., & Ochshorn, E. (2008). “Implementing the Comprehensive, Continuous, Integrated System of Care Model for Individuals with Co-Occurring Disorders: Preliminary Findings from a Residential Facility Serving Homeless Individuals”. Journal of Dual Diagnosis 4(3): 238-259.
HC Health Committee. 2014. “Managing the care of people with long-term conditions”. Second Report of Session 2014-15, HC 401, July 2014.
Hulchanski, D. Campsie, P., Chau, S., Hwang S. and Paradis, E. 2009. “Finding Home: Policy Options for Addressing Homelessness in Canada”. Toronto: Canadian Homelessness Research Network Press.
Kania, J., and Kramer, M. 2011. “Collective Impact”. Stanford Social Innovation Review. Available from: http://www.ssireview.org/articles/entry/collective_impact
Kertesz, S. G., Posner, M. A., O., Connell, J. J., Swain, S., Mullins, A. N., Shwartz, M., & Ash, A. S. 2009. “Post-Hospital Medical Respite Care and Hospital Readmission of Homeless Persons”. Journal of Prevention & Intervention in the Community 37(2): 129-142.
Kodner, D. L., and Spreeuwenberg, C. 2002. “Integrated care: Meaning, logic, applications, and implications–a discussion paper”. International Journal of Integrated Care, (2).
KPMG. 2013. The Integration Imperative: reshaping the delivery of human and social services. Available from https://assets.kpmg.com/content/dam/kpmg/nz/pdf/October/integration-imperative-kpmg-nz.pdf
Konrad, E. 1996. “A multidimensional framework for conceptualising human services integration initiatives”. New Directions for Evaluation (69): 5-19.
Local Government Association. 2013. “Integrated Care evidence review”. Available at: www.local.gov.uk
Ly, A., and Latimer, E. 2015. “Housing First impact on costs and associated cost offsets: A review of the literature”. Canadian Journal of Psychiatry 60(11): 475-487.
Lynn, J and Stachowiak, S. 2017. “The Collective Impact Research Study: What is all this really going to mean, anyway?” Available from http://sparkpolicy.com/2019-2/
Mares, A., Greenberg, G., and Rosenheck, R. 2008. Client-level Measures of Services Integration Among Chronically Homeless Adults. Community Mental Health Journal, (44) 367-376.
Mays, G.P., Scutchfield, F.D., Bhandari, M.W., Smith, S.A. 2010. “Understanding the organization of public health delivery systems: an empirical typology”. Milbank Q. 88(1): 81-111.
Mental Health Commission. 2011. Turning the Key: Assessing Housing and Related Supports for Persons Living with Mental Health Problems and Illness (Ottawa: Mental Health Commission of Canada). Available from https://www.mentalhealthcommission.ca/sites/default/files/PrimaryCare_Turning_the_Key_Full_ENG_0_1.pdfsites/default/files/PrimaryCare_Turning_the_Key_Full_ENG_0_1.pdf
Morrissey, J.P., Calloway, M.O., Thakur, N., Cocozza, J., Steadman, H.J., Dennis, D.; ACCESS National Evaluation Team. 2002. “Integration of Service Systems for Homeless Persons With Serious Mental Illness Through the ACCESS Program”. Psychiatric Services 53(8): 949-957.
Morse, A. 2017. “Health and social care integration”. Report by the Comptroller and Auditor General Department of Health, Department for Communities and Local Government and NHS England. Available from https://www.nao.org.uk/wp-content/uploads/2017/02/Health-and-social-care-integration.pdf
Moss, J. E., Flower, C. L., Houghton, L. M., Moss, D. L., Nielsen, D. A., & Taylor, D. M. 2002. “A multidisciplinary Care Coordination Team improves emergency department discharge planning practice”. The Medical Journal of Australia 177(8): 435-439.
National Audit Office. 2017. Health and social care integration. Press release. https://www.nao.org.uk/report/health-and-social-care-integration/
Nelson, G., Sylvestre, J., Aubry, T., et al. 2007. “Housing choice and control, housing quality, and control over professional support as contributors to the subjective quality of life and community adaptation of people with severe mental illness”. Adm Pol Ment Health 34(2): 89–100
Nuffield Trust. 2013. Evaluating integrated and community-based care: How do we know what works?
Preskill, H, Parkhurst, M, Splansky Juster, J. 2014. “Learning and Evaluation in the Collective Impact Context”. Guide to evaluating collective impact. Available from: https://collectiveimpactforum.org/sites/default/files/Guide%20to%20Evaluating%20CI%2001.pdf
RAND Europe, Ernst and Young LLP, National Evaluation of the Department of Health’s Integrated Care Pilots, March 2012.
Randolph F, 1995, ‘Improving service systems through systems integration: the ACCESS Program (Access to Community Care and Effective Services)’, in American Rehabilitation, 21(1):36
Richter RSM. 2008. Report on the cost of homelessness in the city of Calgary. Calgary (AB): Calgary Homeless Foundation.
Rowe, M., Hoge, M. A. and Fisk, D. 1998. Services for Mentally Ill Homeless Persons: Street -Level Integration. American Joumal of Orthopsychiatry 68(3): 490-496.
Smelson, D.A., Zaykowski, H., Guevermont, N., Siegfriedt, J., Sawh, L., Modzelewski, D., Tsemberis, S., Kane, V. 2016. Integrating Permanent Supportive Housing and Co-Occurring Disorders Treatment for Individuals Who Are Homeless. J Dual Diagn. 2016 Apr-Jun;12(2):193-201.
Sun, A. P. 2012. “Helping Homeless Individuals with Co-occurring Disorders: The Four Components”. Social Work 57(1): 23-37.
Turner, A. 2014. Beyond Housing First: Essential elements of a system-planning approach to ending homelessness. The School of Public Policy, 7(30), 1-24.
Turner, A. 2016. Calgary Case Management Group Evaluation – Technical Report. Calgary Homeless Foundation.
Turner, A., Albanese, T. and Pakeman, K. 2017. “Discerning ‘Functional and Absolute Zero’: Defining and Measuring an End to Homelessness in Canada”. SPP Research Paper 10(2). Available at: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2957845
Wright, O. 2016. “Ten Places where Collective Impact gets it Wrong”. Collaboration for Impact. Available from http://www.collaborationforimpact.com/ten-places-where-collective-impact-gets-it-wrong/
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