How integrated are homelessness, mental health and drug and alcohol services in Australia?

Aims and objectives: The homelessness, drug and alcohol, and mental health service systems are separate service structures in Australia. They have their own unique funding and governance arrangements and work in separate domains. The homelessness service system fits largely within a community services support framework, while drug and alcohol, and mental health services are embedded within their respective health systems. Despite the fact that the homelessness, drug and alcohol, and mental health service systems are separate, they share many of the same clients and address similar problems among clients. Homelessness services, for example, provide support to clients who also have drug and alcohol, and mental health needs. Therefore, the homelessness, drug and alcohol, and mental health service systems interact. Service integration and effective working relationships between services across the homelessness, drug and alcohol, and mental health systems is, a priori, critical in achieving good outcomes for clients wherever they may be located. Service integration has become a point of policy focus in recent years. Despite the focus on systems and service integration in the present policy environment and among practitioners, there has been no study, as far as we are aware, of the integration of homelessness, drug and alcohol, and mental health services in Australia that also considers the perspective of clients. This study aims to fill this critical gap in the literature. The purpose of the present study is to increase our understanding of the extent and ways in which homelessness, drug and alcohol, and mental health services are working together to provide services to clients with particular emphasis on the needs of homeless people. The study also considers the barriers, costs and benefits of service integration and the perceived effectiveness of various integrated service delivery responses. It focuses at both the service level and at the level of the client and addresses the question as to client perceptions of the integration of services and the effectiveness of the services they are receiving. The study addresses six research questions. 1. What do we mean by the term 'service integration'? What models and typologies of 'service integration' have been advanced in the existing literature? 2. How do key policy and practice stakeholders in the homelessness, drug and alcohol, and mental health sectors in Australia define 'service integration' and its role in the delivery of services to clients? 3. What is the current structure and functioning of service integration in selected networks within the homelessness, drug and alcohol and mental health sectors? How does the practice of service integration in Australia compare with the existing models? 4. What do clients and the practitioners who work with them, tell us about clients' experiences of service integration and coordinated care within the homelessness, drug and alcohol, and mental health sectors? 5. What are the views of homelessness, drug and alcohol, and mental health services about the pros and cons of service integration and its overall effectiveness, particularly in relation to the delivery of services for homeless people? 6. In what ways can the findings of this study inform the development of policy with respect to service integration and the practice of integrated service delivery for homeless people? Research methodology: Our study is a cross-sectional, mixed methods study. It comprises three components: interviews with key stakeholders; case studies of specialist homelessness and health services; and, a multi-level survey (the Integration Survey) of specialist homelessness, drug and alcohol, and mental health services, the agencies they operate from and the clients they assist. The study was conducted across three capital cities: Perth, WA; Melbourne, VIC; and Sydney, NSW to ensure that findings were not specific to one particular jurisdictional setting. The structure of the health and community service systems is largely determined at the State/Territory level despite the significant role the Australian Government plays in funding these systems. As outlined in the study's Positioning Paper (Flatau et al. 2010), structural forces are an important driver of integration (Williams & Sullivan, 2009). Clients: The ultimate goal of a well-integrated service system is better client outcomes. It is common for clients to have a range of needs that require support from service providers from multiple systems or agencies. For example, clients presenting with homelessness and housing needs may also have drug and alcohol issues and/or require additional support with mental health issues. Likewise, clients of drug and alcohol and mental health services may have needs in relation to shelter and permanent housing. Clients from the three separate domains of service delivery: homelessness; drug and alcohol; and mental health services were asked to participate in the study in order to ascertain their experiences and attitudes toward service integration within the chosen geographical area. Key stakeholder interviews: Interviews were conducted with 25 key stakeholders at both the Commonwealth and state level holding prominent policy and practitioner positions in WA, Victoria and NSW across the homelessness, drug and alcohol, and mental health service systems. These interviews aimed to document: → The policy environment, including any whole-of-government approaches, at both the federal and state/territory levels in respect to the delivery of homelessness, drug and alcohol, and mental health. → Stakeholder perceptions of integration-what it means, how it can be operationalised and implemented, and the benefits and costs of integration. Case studies: Case studies were conducted in Melbourne, Perth and Sydney and aimed at developing an understanding of how integration is being implemented at the local level, focusing on responses that agencies themselves have developed to meet client need. Interviews were semi-structured and included the following discussion prompts: → Description of service/program and how it is linked into the broader organisational structure. → Target client group and definition of client success. → Integration mechanisms/strategies employed and the impact of these strategies on successful client outcomes. → Linkages and partnerships with external services/agencies. → Factors that facilitate and impede effective integration. → Funding sources and reporting requirements. The Integration Survey: The Integration Survey is a unique multi-level survey comprising an organisational or agency instrument, a service instrument and a client instrument. The Integration Survey covers all topic areas in the study with a particular emphasis on mapping the degree of integration that currently exists between agencies that provide homelessness, drug and alcohol, and mental health services within specified localities in Perth and Melbourne as well as gathering client-based data of relevance to the study. (We also attempted to implement the study in Sydney but faced a number of hurdles in doing so.) Measures used in the Integration Survey include a number developed in previous studies of integration such as the Partnership Self-Assessment Tool (Weiss et al. 2002) and the Integration of Human Services Measure (Browne et al. 2007) as well as others developed specifically for the present study. The area chosen to conduct the Integration Survey in Perth was from central Perth through to what is referred to as the South-East Corridor. This is an area of high concentration of clients of homelessness services (particularly inner Perth) but also of drug and alcohol, and mental health services. The Perth site was chosen as representing a typical area in which homelessness, drug and alcohol, and mental health services operate in Australia. It is also typical in that services work together, follow protocols of engagement that exist in relation to different service systems and exist in a policy and practice environment that seeks greater integration, but do not operate within a formal integrated network entity. The chosen Melbourne area was a more 'typical' suburban area of outer eastern Melbourne. This is an area of growing need but not an area of concentrated homelessness services. The area includes a large well-established single, multifunction agency, which developed as an integration response. Hence, the Melbourne site has a more structured network design. There is no sense in which the two regions, Perth and Melbourne, are comparable. Indeed, they represent intentionally quite different sites of analysis. Key research findings: A typology of integration: Integration involves 'joint working' in one form or another and this can range from loose collaborative arrangements around referral of clients and good communication between staff in different organisations to coordinated delivery of services and full integration where the resources of different organisational units are pooled in order to create a new organisation. Integration can be developed on a system-wide basis and be centrally funded and managed (system-level integration) or be generated at a service level involving the coordinated delivery of individual services within and/or across different sectors (service-level integration). It may also occur within agencies (vertical integration) or between agencies (horizontal integration) and involve a broad range of stakeholders including users, frontline providers, managers and policymakers. Ultimately, systemlevel integration and service integration is a means to the intermediate objective of greater client integration (a seamless service system as perceived by clients of services) and the final end of improved client outcomes.