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THE INTEGRATION OF SERVICES OF A MEDICAL CLINIC AND A COMMUNITY MENTAL HEALTH CENTER IN A RURAL AREA a
Donald E. Maypole ACSW & William E. Wright MD
b
a
Assistant Professor and Coordinator, Social Work Program, College of Saint Teresa, Winons, MN 55987; and Doctoral Candidate, University of Minnesota b
Director, Community Medical Group, Mondovi, WI Published online: 26 Oct 2008.
To cite this article: Donald E. Maypole ACSW & William E. Wright MD (1979) THE INTEGRATION OF SERVICES OF A MEDICAL CLINIC AND A COMMUNITY MENTAL HEALTH CENTER IN A RURAL AREA, Social Work in Health Care, 4:3, 299-308, DOI: 10.1300/J010v04n03_05 To link to this article: http://dx.doi.org/10.1300/J010v04n03_05
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/ page/terms-and-conditions
THE INTEGRATION OF SERVICES O F A MEDICAL CLINIC AND A COMMUNITY MENTAL HEALTH CENTER IN A RURAL AREA
Downloaded by [University of Tennessee, Knoxville] at 15:57 30 December 2014
Donald E. Maypole. ACSW William E. Wright, MD
A B S T R A C T . This article describes the authors' use of open systems theory and exchange theory as a model for integrating the services to clients by the Community Medical Group (a private medical clinic) and the Mississippi River Human Services Center(a federally fundedpublic community mental health center.)As the directors of their twopmgrams, the authors specifically patterned the integiation of their services after the systems theory model of inputs, processing, and outputs. Expensive duplication of services was avoided and the two programs worked together to develop needed p m g m m s to serve the emotionally troubled, the alcohoVdrug abuser, and the developmentally disabled i n their service area.
One of the goals of the staff in community mental health programs, in addition to patient care, has been to integrate their s e ~ c e for s the emotionally troubled, the alcoholidrug abuser, and the developmentally disabled with those of other community programs, especially with primary health care providers. The contributions of family physicians, general hospitals, and nursing homes have been known for some time. However, this knowledge, itself, has not been sufficient, and in some areas the mental health and medical groups have adopted adversary positions. The purpose of this paper is to describe the integration of services of a rural community medical clinic and a community mental health center, by using concepts from exchange and open systems theories. This case study will illustrate both theoretical and practical considerations in providing integrated services to mentaly handicapped client groups.
Mr. Maypole is Assistant Professor and Coordinator. Social W o r k Program. College o f Saint Teresa. Winona. Minnesota 55987. and a doctoral candidate a t the University of Minnesota. Dr. W r i g h t is Director. Community Medical Group. Mondovi. Wisconsin. Sacinl Work in Hcolth Care. Vol. 1131, Spring 1979 O1979 by The Haworth Press. All rights reserved.
SOCIAL WORK I N HEALTH CARE
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THEORETICAL CONSIDERATIONS Systems theory regards the system a s a natural whole, with interdependent parts, that adapts to internal and external stresses to maintain an inner and outer equilibrium. Of the characteristics described by Katz and Kahn (1966)the present authors would emphasize the t h e e that relate to the production process: (a)input of resources (e.g., money, patients, staff, physical plant, equipmentisupplies, and information); (b) processing (i.e., the treatment of the patients' problems, in human services programs); and (c)output (i.e., rehabilitated patients). This specific framework was used in integrating the two agencies services. One of the major contributions of open systems theory to the field of organizational theory was its emphasis on the organization's relationships withits environment, especially certainelements in it. Dill (1958) labeled the primary elements in the organization's environment a s the "organization set." The or~anizationset is composed of the focal org&ation's suppliers (funders),regulatory bodies (e.g., Joint Commission of the Accreditation of Mosuitals). customersiclients. and competitors. The authors would modiiy &last category (competitors) to mean also the other related agencies in the human services area (which may or may not be competitors, depending on the pattern of interorganizational relationships). Other writers, such as Levinson and Astrachan (1974). have focused on the importance of boundaries between organizations. An explicit goal of the present authors was to minimize artificial boundaries between their staffs through exchanging resources. I t seems to the authors that joining exchange theory with open systerns theory is particularly appropriate in describing this case study. BPau (1967), writing on relationships between individuals and groups, stated that "social exchange, broadly defined, can be considered to underlie relations between R~OUDS - - as weU a s between individuals; both differentiation of power and peer group ties; conflicts between opposing forces a s well a s cooperation; both intimate attractions and connections between distant members of a community without social contacts" (p. 4). The exchange should be reciprocal agd should provide benefits to both parties. The units of exchange may be tangible (e.g., money) or intangible (e.g., praise or gratitude). Parties in the exchange are concerned about receiving the rewards dispensed by the other. Eevine and White (1961)used exchange theory to describe the relationships between work organizations. They defined exchange a s "any voluntary activity between two organizations which has consequences, actual or anticipated, for the realization of their respective goals or objectives" (p. 546). For an agency to achieve its own objec-
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Donald E. Maypole and William E. Wright
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tives, it has to possess or control three elements: clients, labor services, and resources other than labor. Since few agencies have all of their needed resources, they must exchange some of their resources with other agencies to attain their goals. To integrate their programs the present authors set up relationships linkages that would enhance the exchange of resources between their agencies (without a financial penalty to either party). BACKGROUND
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Mississippi River Human Services Center (MRHSC)
The initial program of the MRHSC was the implementation of three full-time outpatient service centers in the fall of 1968, one in each county seat. Preceding that, 5 years of community planning activities were necessary. The formation of the planning committee itself was a direct result of the 2-year (1963-1965)Comprehensive Mental Health and.Alcoholism Planning endeavor, which was federally funded as a part of the Kennedy-sponsored Community Mental Health Legislation. Before the outpatient service centers were developed, the only public mental healthialcoholism care was provided by the state hospital, which is 200 miles (321.8 km) away, and a custodial care county mental hospital (for chronic cases only). This latter facility was subsequently converted to a county nursing home in 1974. Private physicians also provided care to their patients. The Mississippi River Human Services Center is a federally funded community mental health center that serves the people in the three rural west central Wisconsin counties of Buffalo, Trempealeau, and Jackson. The three counties have a population of 53,000. scattered throughout 2,500 square miles (6,475 sq km),and are described as a "poverty area" in the state's mental health center plan. The MRHSC provides the community mental health center act's required elements of care for the emotionally troubled, the alcoholidrug abuser, and the developmentally disabled-outpatient treatment, 24-hour emergency services, consultation, and education-and operates halfway house for alcoholics, a sheltered workshop, and two day activity centers for developmentally disabled people. By "continuity of care" contracts, day treatment services for psychiatric and alcoholic patients are provided in a county nursing home, and acute inpatient psychiatric services and a 30-day alcoholic treatment program are provided a t Saint Francis Hospital (a regional medical facility)in Lacrosse. By individual contracts, the state-mandated and county boardappointed regional mental health, alcoholidrug abuse, and developmental disability board for the three counties provides for detoxifica-
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tion for alcohoUdrug abusers in four local community general hospitals for consenters, and at Saint Francis Hospital for nonconsenters. Letters of agreement have been negotiated to secure patient placements in the state mental health institutes, but because of local services only two such placements have been needed in the past 3 years. Before they MRHSC was developed, the annual admission rate to the state mental health institute was 68. The three full-time and three part-time outpatient service centers of the MRHSC are located so that no resident in the three counties lives more than 30 minutes away. No resident lives more than 30 minutes from a community general hospital. The furthest resident from Saint Francis Hospital would have to travel 1% hours. There is no public transportation, so the patients, families, sheriffs, police departments, and MRHSC staff provide transportation. Beginning in 1969, the MRHSC staff, especially the medical director (a psychiatrist), provided consultative services to family physicians, as well as to the staffs in the five local community general hospitals and a half-dozen nursing homes, on a demonstration project basis. This was done both on the telephone and by on-site visits. The medical director also joined the three-county medical society. Community Medical Group (CMG)
The Community Medical Group is a private medical practice located in Mondovi, Wisconsin (population 2,400),in northern Buffalo County at the western corner of the three-county catchment area. The group provides primary medical care to a large surrounding area and also provides medical coverage for a local hospital of 30 beds. I t operates two satellite clinics. The CMG provides medical coverage for five nursing homes in the area and also provides medical consultation to the staff of the MRHSC halfway Rouse for alcoholics, which is 2 miles (3.2 km) west of Mondovi. The CMG has a staff of one physician, two certified physicians' assistants, one registered nurse, and appropriate office and laboratory personnel. The CMG building also houses one of the part-time outpatient service centers of the Mississippi River Human Services Center, and the Western Wisconsin Dental Clinic, Hnc. The CMG's services are closely integrated with the MRHSC, nursing homes, and the local hospital to provide primary care to d patients in its service area including those patients who are emotionally troubled, alcoholics, drug abusers, or developmentally disabled. This integrated service has allowed, in a family practice setting, immediate care for all patients.
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JOINT DEVELOPMENT OF NEW PROGRAMS The staff of the CMG, soon after the founding of the MRHSC, found the services of the staff psychiatrist, the clinical psychologist, and psychiatric social workers to be valuable. As time passed, the two groups cooperated to develop new services in the area. Probably the most dramatic event was the development of an alcohol' drug abuse detoxification and treatment unit in the local general hospital. By securing the services of a full-time alcoholism counselor, the MRHSC was able to provide needed services to inpatients and outpatients to supplement the medical care of the CMG physicians and the nursing care of the general hospital nurses. After this joint program was developed there was a massive growth in Alcoholics Anonymous (three large AA meetings weekly held in the CMG building). This increasing interest to do something about the alcoholism problem contributed to the opening of the alcoholidrug abuse halfway house in the community and greatly increased the cooperation of providers of services (i.e., the local department of social services, public health nurse, local law enforcement officers, hospital, MRHSC and local physicians). These agencies increased their cooperation for client services not only in the alcoholidrug abuse field but also for the emotionally disturbed and the developmentally disabled. This was soon followed with a great deal of general public interest in the area, especially in the service organizations and local school systems. Both groups subsequently requested educational services, which were provided by MRHSC and CMG staff. INTEGRATED RESOURCES Programs Inpatient
The CMG physicians provide medical alcoholidrug abuse detoxification services at the Buffalo Memorial Hospital. The hospital and nursing home are located only 75 yards (68.6 m) from the CMG clinic building. The CMG physicians, as members of the threecounty medical society, endorsed the MRHSC's 1972 proposal that all five of the local community general hospitals provide detoxification services through the efforts of the physicians who have practicing privileges in each of the hospitals. A 1972 working agreement with the hospital integrated the MRHSC's services with those of the physicians and nursing staff, while the alcohol'drug abuser patient is hospitalized and for follow-up treatment. The MRHSC social workers and
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the alcoholism counselor for the county are in constant interaction with the physicians and nursing staff in their mutual work with alcoholics and their families. The 1972 working agreement committed the hospital to provide detoxification services to the community, to provide the number of beds appropriate to the need, and to involve the MRHSC staff in the treatment and predischarge planning. The MRHSC committed itself to provide its share of staff resources, to provide in-service training to the hospital staff, and to provide case and program consultation to the hospital staff. Saint Francis Hospital in Lacrosse is used for nonconsenters and medically complicated cases. The CMG physicians hospitalize patients for mild to moderate emotional problems a t the Buffalo Memorial Hospital and refer the more seriously disturbed patients to the MRHSC for admission to Saint Francis Hospital. Accordingly, emergency psychiatric cases needing hospitalization are referred on to Saint Francis Hospital only if they cannot be appropriately treated and managed in this community general hospital. The CMG physicians routinely involve the MRHSC staff in the psychiatric patients' treatment while they are hospitalized and in the predischarge planning and follow-up endeavors. Th e MRHSC social workers also provide case consultative assistance to the nursing home staff. In-service training has been provided to the general hospital and nursing home staffs. A t any given point in time, the MRHSC staff are involved with 15 to 20 patients in the hospital and nursing home. A 53-year-oldman was found to be extremely intoxicated after a house call by the physician. The information given by the family involved a 10-to 12-year history of drinking-worse over the past 3 months. At that time he was consuming over 1quart (1.11)of brandy daily. The individual was taken to Buffalo Memorial Hospital and was interviewed by the CMG physician, the MRHSC alcoholism counselor, and the satellite office social worker (an exceptionally capable worker who contributed much toward the success of this endeavor).The alcoholism counselor arranged for several visits from local AA members and his local clergyman while the patient was hospitalized. The man left the hospital after medical detoxification,continued with his counseling with the MRHSC alcoholism counselor, and has been off all alcoholic beverages for the last 18 months.
Outpatient The CMG physicians provide medical care to their psychiatric and alcoholidrug abuser patients and then involve the MRHSC staff (psychiatrist, psychologist, psychiatric social workers, alcoholism counselors, and occupational therapist), as deemed mutually appropriate. When a referral is received from the CMG physicians, the MRHSC social workers, a s the main case managers, present the
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case to the MRHSC "clinical committee," which is composed of the medical directoripsychiatrist, the psychologist, and other personnel, and then acts a s the liaison with the CMG physicians. Joint planning for evaluation, treatment, and entrance to any MRHSC program is worked out. A t any given point in time, the two groups are mutually involved in approximately 45 cases. A 30-year-old woman has been treated for a lengthy time with a multidisciplinary approach, for schizophrenic and alcoholism problems. The woman's last hospitalization for her mental healthialcoholism problems was over 18 months ago, and she has maintained her sobriety for 16 months. She is an active member of AA and is treated on a regular basis by the MRHSC satellite office social worker and by the CMG physician or physician's assistant. At the present time, to help her with her schizophrenic symptoms, she is receiving Prolixin injected every 14 days and has shown a good ajustment. 24-Hour Emergency Both the CMG physicians and the MRHSC staff are on call around the clock. Nonmedical emergencies are handled by the MRHSC. For psychiatric and alcoholidrug abuser cases involving hospitalization, if MRHSC staff were not previously involved, the CMG physicians will admit the patient to the general hospital and then inform the MRHSC staff. If the patient could not be adequately dealt with in the community general hospital, the MRHSC medical directori psychiatrist will admit the patient to the MRHBC-related psychiatric ward in Saint Francis Hospital, a t which she has practice privileges. Thusly, the problem of securing immediate hospitalization for someone who needs it is minimized. A 19-year-oldemotionally troubled woman attempted suicide with an overdose of drugs and was referred by the CMG physician to the MRHSC medical director who admitted her to Saint Francis.Hospita1. Following her return home from the psychiatric unit she was treated at frequent intervals'both by the CMG physician and the MRHSC social worker. The patient is doing well and plans on obtaining her high school diploma and attending vocational school. At the present time she receives no medication. AlcoholicRehabilitation House The MRHSC's halfway house for alcoholics is located 2 miles (3.2 km)west of Mondovi (the location of the CMG clinic and the Buffalo Memorial Hospital and Nursing Home). The CMG physicians played a decisive role in securing this particular house for the MRHSC, after the MRHSC staff had been unsuccessful elsewhere, due to neighbor and political resistance. By letter of agreement, the
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CMG physicians provide backup emergency medical services to the house residents. a s well a s make referrals. A 63-year-old man had been a chronic alcoholic for many years. For the past 3 years he had become a recluse. He was admitted to the Buffalo Memorial Hospital in July 1976 for detoxification, then transferred to the halfway house. While at the house he joined an AA group. He spent approximately 2 months at the halfway house. Since discharge he is still sober, is no longer a recluse, and is receiving follow-up care from CMG and MRHSC staff.
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Physical Plant
The MRHSC part-time satellite outpatient services center for Buffalo County is located in its own section of the ground floor of the CMG clinic building. Although the MRHSC pays all of the rent, staff members from the Buffalo County Social Services Department are permitted to use the offices 2 days per week. The MRHSC staff have unlimited access to the next-door CMG medical library. A t times, the MRHSC staff use the room for activity therapy and conferences. The CMG permits the local Alcoholics Anonymous group t o use the library for its meetings, without charge. Staff
The staffs of CMG and MRHSC are assigned to their respective agencies, but the colocation has been of salient irnportance for communication and integration of philosophies and activities. The CMG provides telephone receptionist support to the MRHSC staff, without charge. Biweekly, the MRHSC medical directoripsychiatrist, psychologist, alcoholism halfway house manager, day activity center manager, occupational therapist, sheltered workshop manager, and satellite office coordinator have a case review staff meeting for evaluation, planning, and coordination purposes. In between formal staff meetings the staff are in the office individually or are available by telephone. Funds
The CMG physicians and the MRHSC staff charge separately for their services to the patients. Both have separate record-keeping and billing systems. The MRHSC's systems are state mandated. The MRHSC board of directors has no type of purchase-ofservice contracts with the CMG; however, the regional mental health board does with the general hospital, for detoxification of alcoholidrug abusers.
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Equipment
There has been no exchange of any sort of equipment to date.
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Patients
The ready referral of patients, both ways, has been the linchpin of the effort to integrate the complementary and supportive services of both groups. For example, neither agency closes its case when a referral is made to the other. Mutual decisions are made on the appropriate referrals for both agencies and then jointly implemented. Generally, the CMG physicians will provide the medical care, and psychosocial-rehabilitative care is provided in the various MRHSC programs. Special attention is paid to mutual progress reports. Information
The steady flow of two-way communications is the vehicle that holds the integrated system together. Because of the colocation of the two facilities, most information is provided verbally. Although each facility has separate record-keeping systems and secures the patients' permission to share information, there are no redtape referral hurdles to cross. CONCLUSIONS Since no formal empirical endeavors were associated with the integration process, informal feedback has been the only evaluation tool available. An example of this feedback was a statement made by a pharmacist who is on the board of directors of the MRHSC. The retired Mondovi pharmacist, who has been associated with planning for and operating the MRHSC since 1963, stated: "The doctors in the area have been very good about referrals of patients and patients have received the best medical attention. This ideal situation has been brought about by the excellent cooperation of the doctors with the Human Services Center. I am very pleased with the progress of this association and hope to see it expand even more in the future." If one were to adopt "goal achievement" a s an indication of success, then the discussion in the text of the report would support the conclusion that the goal of integrated services was successfully achieved. Open systems and exchange theories, with their focus on interorganizational relationships, can be valuable aids to mental health and medical administrators, in meeting their mutual goals through integrating their services with those of other facilities. Open understandings be-
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tween agency staffs, systematically derived, should reduce the competition and conflict ~ossibilities.Com~etitiveand conflictual endeavors me wasteful of resburces and reduce the quantity and quality of care for people who need help. Because it appears (to the authors) that programs to combat the massive social and health problems in our communities may be dependent on static or dwindling resources, it behooves local program boards and staff to develop as close a working relationship with other human services providers as possible. As was evident in the project described in this article, this will entail a need for "good faith" in both parties. A bureaucratic defense of one's kingdom may appear to ensure stability in the short run, but it shows little regard for the welfare of the group the agencies were set up for-the clients. Social workers, with their education and experience in community service delivery systems, can provide the leadership to integrate theory (e.g.. open systems and exchange) with efforts to enhance the quality and quantity of interagency linkages. Fragmentation, duplication, and completely autonomously operating agencies may be luxuries that agency funders can no longer afford. The type of model of services developed in each community will depend on its social, cultural, political, financial, historical, and legal environmental contexts. The MRHSC, itself, could never have provided the full range of comprehensive medical services needed by the mental$ handicapped patient groups nor ensure accessibility-at reasonable costs-because this would have entailed duplication of the community care provided by the general practitioners. In this rural area, with its small population and scarce financial and staff resources, the CMG and MRHSC have integrated their programs to enhance the quality and quantity of care to the emotionally troubled, the alcoholidrug abuser, and the developmentally disabled. REFERENCES Blau. P.Exchange andpower in social life. New York: John Wiley & Sons. 1967. Dill, W. Environment as an influence on managerial autonomy. Adrninistmtiue Science Quarterly. 1958.2, pp. 409-433. Katz, D., & Kahn. R. The socialpsychology of organizations. New York: John Wiley & Snna 1qRR
Levine. S.. & White. P. Exchange as a conceptual framework for the study of interorganizational relationships. Adrninistmtiue Science Quarterly. 1961.5, pp. 583-601. Levinson, D.. &Astrachan. B. Organizational boundaries: Entry into the mental health center. Adrninistmtion in Mental Health. Summmer 1974, pp. 3-12.
Social Work in Health Care Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wshc20
THE INTEGRATION OF SERVICES OF A MEDICAL CLINIC AND A COMMUNITY MENTAL HEALTH CENTER IN A RURAL AREA a
Donald E. Maypole ACSW & William E. Wright MD
b
a
Assistant Professor and Coordinator, Social Work Program, College of Saint Teresa, Winons, MN 55987; and Doctoral Candidate, University of Minnesota b
Director, Community Medical Group, Mondovi, WI Published online: 26 Oct 2008.
To cite this article: Donald E. Maypole ACSW & William E. Wright MD (1979) THE INTEGRATION OF SERVICES OF A MEDICAL CLINIC AND A COMMUNITY MENTAL HEALTH CENTER IN A RURAL AREA, Social Work in Health Care, 4:3, 299-308, DOI: 10.1300/J010v04n03_05 To link to this article: http://dx.doi.org/10.1300/J010v04n03_05
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/ page/terms-and-conditions
THE INTEGRATION OF SERVICES O F A MEDICAL CLINIC AND A COMMUNITY MENTAL HEALTH CENTER IN A RURAL AREA
Downloaded by [University of Tennessee, Knoxville] at 15:57 30 December 2014
Donald E. Maypole. ACSW William E. Wright, MD
A B S T R A C T . This article describes the authors' use of open systems theory and exchange theory as a model for integrating the services to clients by the Community Medical Group (a private medical clinic) and the Mississippi River Human Services Center(a federally fundedpublic community mental health center.)As the directors of their twopmgrams, the authors specifically patterned the integiation of their services after the systems theory model of inputs, processing, and outputs. Expensive duplication of services was avoided and the two programs worked together to develop needed p m g m m s to serve the emotionally troubled, the alcohoVdrug abuser, and the developmentally disabled i n their service area.
One of the goals of the staff in community mental health programs, in addition to patient care, has been to integrate their s e ~ c e for s the emotionally troubled, the alcoholidrug abuser, and the developmentally disabled with those of other community programs, especially with primary health care providers. The contributions of family physicians, general hospitals, and nursing homes have been known for some time. However, this knowledge, itself, has not been sufficient, and in some areas the mental health and medical groups have adopted adversary positions. The purpose of this paper is to describe the integration of services of a rural community medical clinic and a community mental health center, by using concepts from exchange and open systems theories. This case study will illustrate both theoretical and practical considerations in providing integrated services to mentaly handicapped client groups.
Mr. Maypole is Assistant Professor and Coordinator. Social W o r k Program. College o f Saint Teresa. Winona. Minnesota 55987. and a doctoral candidate a t the University of Minnesota. Dr. W r i g h t is Director. Community Medical Group. Mondovi. Wisconsin. Sacinl Work in Hcolth Care. Vol. 1131, Spring 1979 O1979 by The Haworth Press. All rights reserved.
SOCIAL WORK I N HEALTH CARE
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THEORETICAL CONSIDERATIONS Systems theory regards the system a s a natural whole, with interdependent parts, that adapts to internal and external stresses to maintain an inner and outer equilibrium. Of the characteristics described by Katz and Kahn (1966)the present authors would emphasize the t h e e that relate to the production process: (a)input of resources (e.g., money, patients, staff, physical plant, equipmentisupplies, and information); (b) processing (i.e., the treatment of the patients' problems, in human services programs); and (c)output (i.e., rehabilitated patients). This specific framework was used in integrating the two agencies services. One of the major contributions of open systems theory to the field of organizational theory was its emphasis on the organization's relationships withits environment, especially certainelements in it. Dill (1958) labeled the primary elements in the organization's environment a s the "organization set." The or~anizationset is composed of the focal org&ation's suppliers (funders),regulatory bodies (e.g., Joint Commission of the Accreditation of Mosuitals). customersiclients. and competitors. The authors would modiiy &last category (competitors) to mean also the other related agencies in the human services area (which may or may not be competitors, depending on the pattern of interorganizational relationships). Other writers, such as Levinson and Astrachan (1974). have focused on the importance of boundaries between organizations. An explicit goal of the present authors was to minimize artificial boundaries between their staffs through exchanging resources. I t seems to the authors that joining exchange theory with open systerns theory is particularly appropriate in describing this case study. BPau (1967), writing on relationships between individuals and groups, stated that "social exchange, broadly defined, can be considered to underlie relations between R~OUDS - - as weU a s between individuals; both differentiation of power and peer group ties; conflicts between opposing forces a s well a s cooperation; both intimate attractions and connections between distant members of a community without social contacts" (p. 4). The exchange should be reciprocal agd should provide benefits to both parties. The units of exchange may be tangible (e.g., money) or intangible (e.g., praise or gratitude). Parties in the exchange are concerned about receiving the rewards dispensed by the other. Eevine and White (1961)used exchange theory to describe the relationships between work organizations. They defined exchange a s "any voluntary activity between two organizations which has consequences, actual or anticipated, for the realization of their respective goals or objectives" (p. 546). For an agency to achieve its own objec-
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Donald E. Maypole and William E. Wright
301
tives, it has to possess or control three elements: clients, labor services, and resources other than labor. Since few agencies have all of their needed resources, they must exchange some of their resources with other agencies to attain their goals. To integrate their programs the present authors set up relationships linkages that would enhance the exchange of resources between their agencies (without a financial penalty to either party). BACKGROUND
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Mississippi River Human Services Center (MRHSC)
The initial program of the MRHSC was the implementation of three full-time outpatient service centers in the fall of 1968, one in each county seat. Preceding that, 5 years of community planning activities were necessary. The formation of the planning committee itself was a direct result of the 2-year (1963-1965)Comprehensive Mental Health and.Alcoholism Planning endeavor, which was federally funded as a part of the Kennedy-sponsored Community Mental Health Legislation. Before the outpatient service centers were developed, the only public mental healthialcoholism care was provided by the state hospital, which is 200 miles (321.8 km) away, and a custodial care county mental hospital (for chronic cases only). This latter facility was subsequently converted to a county nursing home in 1974. Private physicians also provided care to their patients. The Mississippi River Human Services Center is a federally funded community mental health center that serves the people in the three rural west central Wisconsin counties of Buffalo, Trempealeau, and Jackson. The three counties have a population of 53,000. scattered throughout 2,500 square miles (6,475 sq km),and are described as a "poverty area" in the state's mental health center plan. The MRHSC provides the community mental health center act's required elements of care for the emotionally troubled, the alcoholidrug abuser, and the developmentally disabled-outpatient treatment, 24-hour emergency services, consultation, and education-and operates halfway house for alcoholics, a sheltered workshop, and two day activity centers for developmentally disabled people. By "continuity of care" contracts, day treatment services for psychiatric and alcoholic patients are provided in a county nursing home, and acute inpatient psychiatric services and a 30-day alcoholic treatment program are provided a t Saint Francis Hospital (a regional medical facility)in Lacrosse. By individual contracts, the state-mandated and county boardappointed regional mental health, alcoholidrug abuse, and developmental disability board for the three counties provides for detoxifica-
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tion for alcohoUdrug abusers in four local community general hospitals for consenters, and at Saint Francis Hospital for nonconsenters. Letters of agreement have been negotiated to secure patient placements in the state mental health institutes, but because of local services only two such placements have been needed in the past 3 years. Before they MRHSC was developed, the annual admission rate to the state mental health institute was 68. The three full-time and three part-time outpatient service centers of the MRHSC are located so that no resident in the three counties lives more than 30 minutes away. No resident lives more than 30 minutes from a community general hospital. The furthest resident from Saint Francis Hospital would have to travel 1% hours. There is no public transportation, so the patients, families, sheriffs, police departments, and MRHSC staff provide transportation. Beginning in 1969, the MRHSC staff, especially the medical director (a psychiatrist), provided consultative services to family physicians, as well as to the staffs in the five local community general hospitals and a half-dozen nursing homes, on a demonstration project basis. This was done both on the telephone and by on-site visits. The medical director also joined the three-county medical society. Community Medical Group (CMG)
The Community Medical Group is a private medical practice located in Mondovi, Wisconsin (population 2,400),in northern Buffalo County at the western corner of the three-county catchment area. The group provides primary medical care to a large surrounding area and also provides medical coverage for a local hospital of 30 beds. I t operates two satellite clinics. The CMG provides medical coverage for five nursing homes in the area and also provides medical consultation to the staff of the MRHSC halfway Rouse for alcoholics, which is 2 miles (3.2 km) west of Mondovi. The CMG has a staff of one physician, two certified physicians' assistants, one registered nurse, and appropriate office and laboratory personnel. The CMG building also houses one of the part-time outpatient service centers of the Mississippi River Human Services Center, and the Western Wisconsin Dental Clinic, Hnc. The CMG's services are closely integrated with the MRHSC, nursing homes, and the local hospital to provide primary care to d patients in its service area including those patients who are emotionally troubled, alcoholics, drug abusers, or developmentally disabled. This integrated service has allowed, in a family practice setting, immediate care for all patients.
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JOINT DEVELOPMENT OF NEW PROGRAMS The staff of the CMG, soon after the founding of the MRHSC, found the services of the staff psychiatrist, the clinical psychologist, and psychiatric social workers to be valuable. As time passed, the two groups cooperated to develop new services in the area. Probably the most dramatic event was the development of an alcohol' drug abuse detoxification and treatment unit in the local general hospital. By securing the services of a full-time alcoholism counselor, the MRHSC was able to provide needed services to inpatients and outpatients to supplement the medical care of the CMG physicians and the nursing care of the general hospital nurses. After this joint program was developed there was a massive growth in Alcoholics Anonymous (three large AA meetings weekly held in the CMG building). This increasing interest to do something about the alcoholism problem contributed to the opening of the alcoholidrug abuse halfway house in the community and greatly increased the cooperation of providers of services (i.e., the local department of social services, public health nurse, local law enforcement officers, hospital, MRHSC and local physicians). These agencies increased their cooperation for client services not only in the alcoholidrug abuse field but also for the emotionally disturbed and the developmentally disabled. This was soon followed with a great deal of general public interest in the area, especially in the service organizations and local school systems. Both groups subsequently requested educational services, which were provided by MRHSC and CMG staff. INTEGRATED RESOURCES Programs Inpatient
The CMG physicians provide medical alcoholidrug abuse detoxification services at the Buffalo Memorial Hospital. The hospital and nursing home are located only 75 yards (68.6 m) from the CMG clinic building. The CMG physicians, as members of the threecounty medical society, endorsed the MRHSC's 1972 proposal that all five of the local community general hospitals provide detoxification services through the efforts of the physicians who have practicing privileges in each of the hospitals. A 1972 working agreement with the hospital integrated the MRHSC's services with those of the physicians and nursing staff, while the alcohol'drug abuser patient is hospitalized and for follow-up treatment. The MRHSC social workers and
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the alcoholism counselor for the county are in constant interaction with the physicians and nursing staff in their mutual work with alcoholics and their families. The 1972 working agreement committed the hospital to provide detoxification services to the community, to provide the number of beds appropriate to the need, and to involve the MRHSC staff in the treatment and predischarge planning. The MRHSC committed itself to provide its share of staff resources, to provide in-service training to the hospital staff, and to provide case and program consultation to the hospital staff. Saint Francis Hospital in Lacrosse is used for nonconsenters and medically complicated cases. The CMG physicians hospitalize patients for mild to moderate emotional problems a t the Buffalo Memorial Hospital and refer the more seriously disturbed patients to the MRHSC for admission to Saint Francis Hospital. Accordingly, emergency psychiatric cases needing hospitalization are referred on to Saint Francis Hospital only if they cannot be appropriately treated and managed in this community general hospital. The CMG physicians routinely involve the MRHSC staff in the psychiatric patients' treatment while they are hospitalized and in the predischarge planning and follow-up endeavors. Th e MRHSC social workers also provide case consultative assistance to the nursing home staff. In-service training has been provided to the general hospital and nursing home staffs. A t any given point in time, the MRHSC staff are involved with 15 to 20 patients in the hospital and nursing home. A 53-year-oldman was found to be extremely intoxicated after a house call by the physician. The information given by the family involved a 10-to 12-year history of drinking-worse over the past 3 months. At that time he was consuming over 1quart (1.11)of brandy daily. The individual was taken to Buffalo Memorial Hospital and was interviewed by the CMG physician, the MRHSC alcoholism counselor, and the satellite office social worker (an exceptionally capable worker who contributed much toward the success of this endeavor).The alcoholism counselor arranged for several visits from local AA members and his local clergyman while the patient was hospitalized. The man left the hospital after medical detoxification,continued with his counseling with the MRHSC alcoholism counselor, and has been off all alcoholic beverages for the last 18 months.
Outpatient The CMG physicians provide medical care to their psychiatric and alcoholidrug abuser patients and then involve the MRHSC staff (psychiatrist, psychologist, psychiatric social workers, alcoholism counselors, and occupational therapist), as deemed mutually appropriate. When a referral is received from the CMG physicians, the MRHSC social workers, a s the main case managers, present the
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case to the MRHSC "clinical committee," which is composed of the medical directoripsychiatrist, the psychologist, and other personnel, and then acts a s the liaison with the CMG physicians. Joint planning for evaluation, treatment, and entrance to any MRHSC program is worked out. A t any given point in time, the two groups are mutually involved in approximately 45 cases. A 30-year-old woman has been treated for a lengthy time with a multidisciplinary approach, for schizophrenic and alcoholism problems. The woman's last hospitalization for her mental healthialcoholism problems was over 18 months ago, and she has maintained her sobriety for 16 months. She is an active member of AA and is treated on a regular basis by the MRHSC satellite office social worker and by the CMG physician or physician's assistant. At the present time, to help her with her schizophrenic symptoms, she is receiving Prolixin injected every 14 days and has shown a good ajustment. 24-Hour Emergency Both the CMG physicians and the MRHSC staff are on call around the clock. Nonmedical emergencies are handled by the MRHSC. For psychiatric and alcoholidrug abuser cases involving hospitalization, if MRHSC staff were not previously involved, the CMG physicians will admit the patient to the general hospital and then inform the MRHSC staff. If the patient could not be adequately dealt with in the community general hospital, the MRHSC medical directori psychiatrist will admit the patient to the MRHBC-related psychiatric ward in Saint Francis Hospital, a t which she has practice privileges. Thusly, the problem of securing immediate hospitalization for someone who needs it is minimized. A 19-year-oldemotionally troubled woman attempted suicide with an overdose of drugs and was referred by the CMG physician to the MRHSC medical director who admitted her to Saint Francis.Hospita1. Following her return home from the psychiatric unit she was treated at frequent intervals'both by the CMG physician and the MRHSC social worker. The patient is doing well and plans on obtaining her high school diploma and attending vocational school. At the present time she receives no medication. AlcoholicRehabilitation House The MRHSC's halfway house for alcoholics is located 2 miles (3.2 km)west of Mondovi (the location of the CMG clinic and the Buffalo Memorial Hospital and Nursing Home). The CMG physicians played a decisive role in securing this particular house for the MRHSC, after the MRHSC staff had been unsuccessful elsewhere, due to neighbor and political resistance. By letter of agreement, the
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CMG physicians provide backup emergency medical services to the house residents. a s well a s make referrals. A 63-year-old man had been a chronic alcoholic for many years. For the past 3 years he had become a recluse. He was admitted to the Buffalo Memorial Hospital in July 1976 for detoxification, then transferred to the halfway house. While at the house he joined an AA group. He spent approximately 2 months at the halfway house. Since discharge he is still sober, is no longer a recluse, and is receiving follow-up care from CMG and MRHSC staff.
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Physical Plant
The MRHSC part-time satellite outpatient services center for Buffalo County is located in its own section of the ground floor of the CMG clinic building. Although the MRHSC pays all of the rent, staff members from the Buffalo County Social Services Department are permitted to use the offices 2 days per week. The MRHSC staff have unlimited access to the next-door CMG medical library. A t times, the MRHSC staff use the room for activity therapy and conferences. The CMG permits the local Alcoholics Anonymous group t o use the library for its meetings, without charge. Staff
The staffs of CMG and MRHSC are assigned to their respective agencies, but the colocation has been of salient irnportance for communication and integration of philosophies and activities. The CMG provides telephone receptionist support to the MRHSC staff, without charge. Biweekly, the MRHSC medical directoripsychiatrist, psychologist, alcoholism halfway house manager, day activity center manager, occupational therapist, sheltered workshop manager, and satellite office coordinator have a case review staff meeting for evaluation, planning, and coordination purposes. In between formal staff meetings the staff are in the office individually or are available by telephone. Funds
The CMG physicians and the MRHSC staff charge separately for their services to the patients. Both have separate record-keeping and billing systems. The MRHSC's systems are state mandated. The MRHSC board of directors has no type of purchase-ofservice contracts with the CMG; however, the regional mental health board does with the general hospital, for detoxification of alcoholidrug abusers.
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Equipment
There has been no exchange of any sort of equipment to date.
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Patients
The ready referral of patients, both ways, has been the linchpin of the effort to integrate the complementary and supportive services of both groups. For example, neither agency closes its case when a referral is made to the other. Mutual decisions are made on the appropriate referrals for both agencies and then jointly implemented. Generally, the CMG physicians will provide the medical care, and psychosocial-rehabilitative care is provided in the various MRHSC programs. Special attention is paid to mutual progress reports. Information
The steady flow of two-way communications is the vehicle that holds the integrated system together. Because of the colocation of the two facilities, most information is provided verbally. Although each facility has separate record-keeping systems and secures the patients' permission to share information, there are no redtape referral hurdles to cross. CONCLUSIONS Since no formal empirical endeavors were associated with the integration process, informal feedback has been the only evaluation tool available. An example of this feedback was a statement made by a pharmacist who is on the board of directors of the MRHSC. The retired Mondovi pharmacist, who has been associated with planning for and operating the MRHSC since 1963, stated: "The doctors in the area have been very good about referrals of patients and patients have received the best medical attention. This ideal situation has been brought about by the excellent cooperation of the doctors with the Human Services Center. I am very pleased with the progress of this association and hope to see it expand even more in the future." If one were to adopt "goal achievement" a s an indication of success, then the discussion in the text of the report would support the conclusion that the goal of integrated services was successfully achieved. Open systems and exchange theories, with their focus on interorganizational relationships, can be valuable aids to mental health and medical administrators, in meeting their mutual goals through integrating their services with those of other facilities. Open understandings be-
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tween agency staffs, systematically derived, should reduce the competition and conflict ~ossibilities.Com~etitiveand conflictual endeavors me wasteful of resburces and reduce the quantity and quality of care for people who need help. Because it appears (to the authors) that programs to combat the massive social and health problems in our communities may be dependent on static or dwindling resources, it behooves local program boards and staff to develop as close a working relationship with other human services providers as possible. As was evident in the project described in this article, this will entail a need for "good faith" in both parties. A bureaucratic defense of one's kingdom may appear to ensure stability in the short run, but it shows little regard for the welfare of the group the agencies were set up for-the clients. Social workers, with their education and experience in community service delivery systems, can provide the leadership to integrate theory (e.g.. open systems and exchange) with efforts to enhance the quality and quantity of interagency linkages. Fragmentation, duplication, and completely autonomously operating agencies may be luxuries that agency funders can no longer afford. The type of model of services developed in each community will depend on its social, cultural, political, financial, historical, and legal environmental contexts. The MRHSC, itself, could never have provided the full range of comprehensive medical services needed by the mental$ handicapped patient groups nor ensure accessibility-at reasonable costs-because this would have entailed duplication of the community care provided by the general practitioners. In this rural area, with its small population and scarce financial and staff resources, the CMG and MRHSC have integrated their programs to enhance the quality and quantity of care to the emotionally troubled, the alcoholidrug abuser, and the developmentally disabled. REFERENCES Blau. P.Exchange andpower in social life. New York: John Wiley & Sons. 1967. Dill, W. Environment as an influence on managerial autonomy. Adrninistmtiue Science Quarterly. 1958.2, pp. 409-433. Katz, D., & Kahn. R. The socialpsychology of organizations. New York: John Wiley & Snna 1qRR
Levine. S.. & White. P. Exchange as a conceptual framework for the study of interorganizational relationships. Adrninistmtiue Science Quarterly. 1961.5, pp. 583-601. Levinson, D.. &Astrachan. B. Organizational boundaries: Entry into the mental health center. Adrninistmtion in Mental Health. Summmer 1974, pp. 3-12.
