Systems Integration
Systems Integration
Overview PaPer Number 7
About COCE and COCE Overview Papers
The Co-Occurring Center for Excellence (COCE), funded through the Substance Abuse and Mental Health Services
Administration (SAMHSA), is a leading national resource for the field of co-occurring mental health and substance use
disorders (COD). COCE’s mission is threefold: (1) to receive and transmit advances in treatment for all levels of COD
severity, (2) to guide enhancements in the infrastructure and clinical capacities of service systems, and (3) to foster
the infusion and adoption of evidence- and consensus-based COD treatment and program innovations into clinical
practice. COCE consists of national and regional experts including COCE Senior Staff, Senior Fellows, Steering Council,
affiliated organizations (see inside back cover), and a network of more than 200 senior consultants, all of whom join
service recipients in shaping COCE’s mission, guiding principles, and approaches. COCE accomplishes its mission through
technical assistance and training, delivered through curriculums and other materials online, by telephone, and through
in-person consultation.
COCE Overview Papers are concise and easy-to-read introductions to state-of-the-art knowledge in COD. They are
anchored in current science, research, and practices. The intended audiences for these overview papers are mental
health and substance abuse administrators and policymakers at State and local levels, their counterparts in American
Indian tribes, clinical providers, other providers, and agencies and systems through which clients might enter the COD
treatment system. For a complete list of available overview papers, see the back cover.
For more information on COCE, including eligibility requirements and processes for receiving training or technical
assistance, direct your e-mail to coce@samhsa.hhs.gov, call (301) 951-3369, or visit COCE’s Web site at www.coce.
samhsa.gov.
Acknowledgments
Electronic Access and Copies of Publication
COCE Overview Papers are produced by The CDM Group, Inc.
Copies may be obtained free of charge from SAMHSA’s National
(CDM) under COCE Contract Number 270-2003-00004, Task
Clearinghouse for Alcohol and Drug Information (NCADI),
Order Number 270-2003-00004-0001 with the Substance
(800) 729-6686; TDD (for hearing impaired), (800) 487-4889,
Abuse and Mental Health Services Administration (SAMHSA),
or electronically through the following Internet World Wide Web
U.S. Department of Health and Human Services (DHHS). Jorielle
sites: www.ncadi.samhsa.gov or www.coce.samhsa.gov.
R. Brown, Ph.D., Center for Substance Abuse Treatment (CSAT),
serves as COCE’s Task Order Officer and Lawrence Rickards,
Public Domain Notice
Ph.D., Center for Mental Health Services (CMHS), serves as the
All materials appearing in COCE Overview Papers, except those
Alternate Task Order Officer. George Kanuck, COCE’s Task Order
taken directly from copyrighted sources, are in the public domain
Officer with CSAT from September 2003 through November
and may be reproduced or copied without permission from
2005, provided the initial Federal guidance and support for these
SAMHSA/CSAT/CMHS or the authors.
products.
Recommended Citation
COCE Overview Papers follow a rigorous development process,
Center for Substance Abuse Treatment. Systems Integration.
including peer review. They incorporate contributions from
COCE Overview Paper 7. DHHS Publication No. (SMA) 07-4295.
COCE Senior Staff, Senior Fellows, Consultants, and the CDM
Rockville, MD: Substance Abuse and Mental Health Services
production team. The development of this overview paper,
Administration, and Center for Mental Health Services, 2007.
Systems Integration, concluded in January 2006. Senior Staff
members Michael D. Klitzner, Ph.D., Fred C. Osher, M.D., and
Originating Offices
Rose M. Urban, LCSW, J.D., co-led the content and development
Co-Occurring and Homeless Activities Branch, Division of
process. Senior Fellow Kenneth Minkoff, M.D., made major
State and Community Assistance, Center for Substance Abuse
writing contributions. Other major contributions were made
Treatment, Substance Abuse and Mental Health Services
by Project Director Jill G. Hensley, M.A.; Senior Staff members
Administration, 1 Choke Cherry Road, Rockville, MD 20857.
Stanley Sacks, Ph.D., and Anthony J. Ernst, Ph.D.; and Senior
Fellows Barry S. Brown, M.S., Ph.D., Michael Kirby, Ph.D., David
Homeless Programs Branch, Division of Service and Systems
Mee-Lee, M.S., M.D., and Richard N. Rosenthal, M.A., M.D.
Improvement, Center for Mental Health Services, Substance
Editorial support was provided by CDM staff members J. Max
Abuse and Mental Health Services Administration, 1 Choke
Gilbert, Janet Humphrey, Michelle Myers, and Darlene Colbert.
Cherry Road, Rockville, MD 20857.
Disclaimer
Publication History
The contents of this overview paper do not necessarily reflect
COCE Overview Papers are revised as the need arises. For a
the views or policies of CSAT, CMHS, SAMHSA, or DHHS. The
summary of all changes made in each version, go to COCE’s
guidelines in this paper should not be considered substitutes for
Web site at coce.samhsa.gov/cod_resources/papers.htm. Printed
individualized client care and treatment decisions.
copies of this paper may not be as current as the versions posted
on the Web site.
DHHS Publication No. (SMA) 07-4295
Printed 2007.
EXECUTIVE SUMMARY
A growing body of research demonstrates that integrated services produce better outcomes for individuals with co-
occurring disorders (COD), particularly those with more serious or complex conditions. Systems integration supports the
provision of integrated services. In addition to distinguishing between systems integration and services integration, this
paper describes the organizational structures and processes that can promote or inhibit systems integration. The paper
encourages the use of creative thinking to obtain and effectively use funding and provides examples of successful initiatives
in systems integration at the local and State levels. Although evalu ation of the process of systems integration is stil in its
infancy, one measure of systems integration outcomes is discussed.
Systems integration involves the development of infrastructure within mental health and substance abuse systems that
supports the provision of integrated mental health and substance abuse services (integrated treatment within integrated
programs) to individuals with COD. Systems integration may include any or all of the following: integrated system planning
and implementation; continuous quality improvement; and mechanisms for addressing financing, regulations and policies,
program design and certification, interprogram collaboration and consultation, clinical “best practice” development, clini-
cian licensure, competency and training, information systems, data collection, and outcome evaluation.
The concept of systems integration for COD is relatively new and the research base supporting its effectiveness in improving
patient outcomes is limited. However, the theoretical appeal of systems integration is increasingly recognized, based in part
on the critical role systems play in shaping (or constraining) the activities of those who work in these systems.
TABLE 1: KEY DEFINITIONS
Systems of Care
Health and behavioral health systems (including those that address the needs of per-
sons with COD) are composed of the State and local governmental and private agencies,
organizations, and individuals who are collectively responsible for providing patient or
client care. The agencies, organizations, and individuals subsumed by a given system may
be defined as those who are currently involved in patient or client care for persons with
COD, but may also include those who are not currently involved but should be in order to
achieve optimal outcomes.
Integration
As used in this paper, integration refers to strategies for combining mental health and
substance abuse services and/or systems, as well as other health and social services to ad-
dress the needs of individuals with COD.
Services Integration
Any process by which mental health and substance abuse services are appropriately
integrated or combined at either the level of direct contact with the individual client with
COD or between providers or programs serving these individuals. Integrated services can
be provided by an individual clinician, a clinical team that assumes responsibility for pro-
viding integrated services to the client, or an organized program in which all clinicians or
teams provide appropriately integrated services to all clients.
Systems Integration
The process by which individual systems or collaborating systems organize themselves to
implement services integration to clients with COD and their families.
Funding: Flexible vs. Categorical funding is provided to an agency or organization to be used exclusively for
Categorical
services related to substance abuse or mental health and may carry other restrictions
related to target population, types of services, etc. Flexible funding provides some level of
discretion to recipients concerning the disorders, target population, or services for which
the funds may be used.
Funding: Blended
Blended or merged funding refers to a strategy by which an agency or organization pools
and Merged
resources or some portion of resources allocated for substance abuse and/or mental
health in order to meet the needs of persons with COD. Blending or merging may occur at
the level of the funding provider (e.g., a State), the funding recipients, or both.
Systems Integration
1
LITERATURE HIGHLIGHTS
assessment, and referral arrangements; and managed care
strategies. Despite these advances, the concepts related
Persons with COD are found in al service populations
to systems integration are still evolving, and the imple-
and settings. These clients will never be served adequately
mentation of these concepts in practice is not widespread.
by implementing a few programs in a system with scant
resources. Rather, COCE takes the position that
The literature on organizational development and the
implementation of innovative practices (see Fixsen et al.,
Co-occurring disorders are to be expected in all
2005 for a recent review) supports the theoretical appeal of
behavioral health settings, and system planning
systems integration. The well-documented role of organi-
must address the need to serve people with COD
zational structure and support in promoting and sustaining
in all policies, regulations, funding mechanisms,
practice changes clearly suggests that activities involving the
and programming. (See COCE Overview Paper 3,
integration of mental health and substance abuse systems
Overarching Principles To Address the Needs of
should increase the likelihood of integrated care for persons
Persons With Co-Occurring Disorders, p. 2; CSAT,
with COD. However, empirical support for systems integra-
2005).
tion is currently lacking. Formative evaluation of current
systems integration efforts (e.g., SAMHSA’s Co-Occurring
Systems integration is one important mechanism for
State Incentive Grants) may inform hypotheses to be tested
reaching this goal. It provides support to the programs
in future formal research.
and providers who are ultimately responsible for treating
persons with COD. As such, systems integration is a means
to an end (improved services and outcomes for persons
KEY QUESTIONS AND ANSWERS
with COD) rather than an end in and of itself. Former
1. What is meant by “integration” and “integrated”?
SAMHSA Administrator Charles Curie and his col eagues
(2005) note that meeting the needs of people with COD
The terms “integration” and “integrated” appear
requires a systemic approach “that addresses the chal enge
throughout the literature on COD: for example, systems
of organizing the entire infrastructure of the behavioral
integration, services integration, integrated care, integrated
health system.”
screening, integrated assessment, integrated treatment
plan, integrated interventions or treatment, integrated
Systems integration is the output of the various processes
models, integrated systems, integration continuum, and so
by which systems work individually and collaboratively to
on. The pervasiveness of “integration” and “integrated” in
develop structures or mechanisms to address individuals
the language of COD reflects the following factors:
with multiple needs. Integration can occur in systems of
any size (entire States, regions, counties, complex agencies,
• The awareness that the co-occurrence of these disorders
or individual programs) and in any population or funding
is not simply by chance and occurs frequently
stream (adults, elders, children, urban/rural, culturally
• An understanding that there is always a relationship
diverse populations, Medicaid, private payors, or State block
between the disorders that affects outcomes
grant funds) (Minkoff & Cline, 2004; Ridgely et al., 1998).
• The recognition that effective responses to persons
As noted by Minkoff and Cline (2004), the implementation
with either mental illness or substance use disorders are
of a complex multilayered systems integration model
compatible
requires an organized approach, incorporating principles
of strategic planning and continuous quality improvement
Therefore, integration is a logical strategy for unifying
in an incremental process. Al layers of the system (system,
approaches derived from independent efforts to
agency or program, clinical practice and policy, clinician
achieve positive outcomes with narrowly defined target
competency and training) and al components of the
populations.
system, regardless of the system’s size or complexity, must
interact.
COCE’s Overview Paper 3 (Overarching Principles To Address
the Needs of Persons With Co-Occurring Disorders; CSAT,
In order to guide systems integration efforts for COD,
2005) embeds these factors in the following principle:
Minkoff (1991, 2002) and Minkoff and Cline (2001a, b)
have developed the Comprehensive, Continuous Integrated
The interactive nature of COD requires each
System of Care (CCISC) model and its associated “Twelve-
disorder to be continually assessed and treatment
Step Program of Implementation” (Minkoff & Cline, 2004).
plans adjusted accordingly. It is a disservice to
Other examples of models that are intended to facilitate
the person with COD to emphasize attention to
the development of integrated systems of care are briefly
one disorder at the expense of the other. There is
described by Ridgely and col eagues (1998) and incorporate
always a relationship between the two disorders
comprehensive local planning; comprehensive screening,
that must be evaluated and managed (p. 4).
2
Systems Integration
The various types of integration listed above refer to
Figure 1. Systems Integration and Other Forms
different service components (e.g., screening, assessment,
of Integration
treatment planning, treatment provision) or levels of the
service system (e.g., individual practitioners, agencies,
local systems of care, States). The specifics of what is to
be integrated and the mechanisms by which integration
is accomplished will, of course, be different for different
service components and at different levels of care. However,
the goal of integration is always the same—identifying
and managing both disorders and the interaction between
them. Moreover, the objective of all forms of integration
is to support integrated treatment for the individual client.
Integration that does not result in changes in services at the
client level serves no useful purpose.
2. What is systems integration and how does it fit with
other kinds of integration?
Systems integration (see Table 1) is a process by which
individual systems (e.g., mental health) or collaborating
systems (e.g., mental health and substance abuse) organize
themselves to implement services integration to clients
with COD and their families. The goal of this process is to
work around the lack of integration in the system. These
promote the adoption of best practices for engaging clients
demonstration or pilot programs are then evaluated for
with COD in care and to provide for integrated screening,
dissemination potential. However, absent the infrastructure
integrated assessment, and integrated services and
supports provided by systems integration, isolated efforts at
interventions, in the service of producing the best possible
services integration may be limited in impact and difficult to
outcomes.
sustain.
Systems outside of substance abuse and mental health
3. Is systems integration the same thing as the creation
may also participate in systems integration efforts, as
of an integrated State mental health and substance
when persons with COD are recruited into treatment from
abuse department?
homeless shelters, emergency rooms, the criminal justice
No. Creation of an “integrated” State mental health and
system, and so on, or when COD treatment services are
substance abuse department is in no way synonymous with
located in homeless, healthcare, or correctional settings.
systems integration. Depending on the system, creation
of an integrated mental health and substance abuse
Systems integration initiatives range from the
department may provide a starting place for the organized
implementation of one or more of the strategies mentioned
integrated planning and implementation efforts that are
in Question 4 (see pages 3 and 4) to comprehensive
requisites for systems integration. Alternatively, such a
initiatives by which mental health and substance abuse
merger may create resistance within the existing systems
systems col aborate to create an overarching, integrated
that actual y impedes the operationalization of systems
vision of system design that addresses individuals with COD,
integration efforts.
as wel as those with a mental health or a substance use
disorder.
4. What types of organizational structure promote or
inhibit systems integration?
As shown in Figure 1, systems integration can facilitate
Systems integration is not dependent on any specific
services integration (integrated treatment and integrated
organizational structure. In general, systems integration
programs) in service of the overal goal of providing
is facilitated by organizational structures that support
integrated treatment to clients. Systems integration efforts
an integrated planning process and is complicated by
that are not ultimately designed specifical y and concretely
organizational structures that impede such processes (see
to support services integration are not likely to have a
Fixsen et al., 2005; Rogers, 2003). SAMHSA’s Co-Occurring
demonstrated impact on client outcome.
State Incentive Grants (COSIGs) have provided resources to
experiment with a variety of systems integration models.
Services integration can occur, at least to some degree, in
However, neither the models developed by the COSIGs or
the absence of systems integration. For example, individual
other systems integration models have been well researched.
practitioners or agencies may take it upon themselves to
Accordingly, science-based guidelines for implementation
provide integrated services to their clients. Systems can,
are not currently available, and systems integration should
and frequently do, fund “special” COD programs that
be undertaken with a clear organizational commitment
Systems Integration
3
to evaluating outcomes and impacts within a process of
Report on Improving the Quality of Health Care for Mental
continuous quality improvement.
and Substance-Use Conditions (2006) succinctly highlights
the existing phenomenon of adverse selection, in which
Former SAMHSA Administrator Charles Curie and his
powerful economic incentives exist to not serve individuals
colleagues (2005) describe seven organizational processes
with complicated clinical conditions. Because the person
that may support systems integration:
with COD is such an individual, these negative incentives
must be acknowledged and addressed. Systems integration
• Committed leadership: individuals or teams who have
can proceed under a variety of funding mechanisms. How-
the authority and vision to organize and sustain a com-
ever, a systems integration approach may require creative
plex change process.
thinking on the part of both funders and systems to iden-
• Integrated system planning and implementation: an or-
tify how various funding streams (including those that are
ganized structure or mechanism that creates a standard
categorical) can support integrated services. For example,
method for complex overarching strategic planning and
SAMHSA has provided States with explicit instructions that
stepwise strategic implementation.
both mental health and substance abuse block grant dol ars
could separately fund integrated services within the pro-
• Value-driven, evidence-based priorities: the articulation
grams those funds were already intended to support (SAM-
of a rationale to drive the change process based on data
HSA, 1999). SAMHSA’s 1997 State Incentive Grant for pre-
demonstrating poor outcomes for the target population
vention was the first cooperative agreement that promoted
and high costs, and the clinical and economic value of
blended/braided funding and infrastructure change at the
system transformation.
State agency. The overall success of the program led to the
• Shared vision and integrated philosophy: the develop-
development of the COSIGs mentioned in Question 4.
ment of a set of principles that encompasses validation
and recognition of the role of mental health systems,
Blended or merged funding streams may be a creative
programs, and approaches along with addiction systems,
technique to facilitate the development of specialized
programs, and approaches (e.g., the national consensus
programs, but reliance only on blended funding is both
Four Quadrant Model – See Overview Paper 1,
inefficient and likely to result in funding uncertainty and
Definitions and Terms Relating to Co-Occurring Disor-
confusion. Legitimate concerns may be raised about main-
ders; CSAT, 2006).
taining the integrity of addiction or mental health treat-
ment services when mental health and substance abuse
• Dissemination of evidence-based technology to define
dollars are merged into an “integrated” behavioral health
clinical practice and program design: the use of technol-
pool. To avoid these pitfalls, systems integration strategies
ogy transfer (including training and technical assistance),
often begin by supporting the integrity of existing funding
not as an end in itself, but as a vehicle to stimulate
streams while articulating the expectation that all funding
diverse changes in clinical practice throughout a complex
streams, whether flexible or categorical, should carry in-
delivery system, building on the burgeoning availability
structions for appropriate integration at the client level.
of evidence-based technology for a wide variety of prob-
lems and populations.
6. What are some real world examples of systems
integration initiatives?
• True partnership among all levels of the system: a criti-
cally important reliance on a continuous quality improve-
Many States and communities have shared with COCE their
ment model that uses a top-down, bottom-up, linked,
experiences related to systems integration as part of COCE’s
and empowered collaboration between every level of the
technical assistance and training activities. The following
system, including top administrators as well as frontline
example is a composite based on these experiences.
clinicians, consumers, and families, in organizing and
implementing the change process.
A Local Community Mental Health Clinic Integrates
To Improve COD Services
• Data-driven, incentivized, and interactive performance
improvement processes: using data connected to all as-
This local community mental health clinic (publicly funded)
pects of system performance to organize the incremen-
in a medium-sized county in the Midwest recognized the
tal implementation of complex change processes that
need to address COD within its existing client population
support systems integration within a continuous quality
but did not have funds to create a specialized co-occurring
improvement framework.
program. The mental health clinic subsequently hired cross-
trained clinicians with certifications or licenses in substance
5. Does systems integration rely on a specific funding
abuse treatment to address COD through a case manage-
model?
ment approach as a supplement to existing mental health
programs. The clinicians were tasked with implementing
No, but it does rely on both improving resource availability
COD therapy groups within the clinic, and existing mental
and using resources efficiently. The Institute of Medicine
4
Systems Integration
health staff rotated in as co-facilitators to develop their
Center for Substance Abuse Treatment. Overarching prin-
COD competencies. The clinic’s policies were modified to
ciples to address the needs of persons with co-occurring
support this approach by requiring integrated screenings,
disorders. COCE Overview Paper 3. Rockville, MD: Substance
integrated assessments if indicated through screening,
Abuse and Mental Health Services Administration, 2005.
and treatment through integrated case management. A
subsequent analysis of client outcomes revealed significant
Center for Substance Abuse Treatment. Definitions and
improvement in medication compliance and levels of absti-
Terms Relating to Co-Occurring Disorders. COCE Over-
nence for clients with COD.
view Paper 1. Rockvil e, MD: Substance Abuse and Mental
Health Services Administration, 2006.
7. What methodologies are available to evaluate sys-
Curie, C. G., Minkoff, K., Hutchings, G. P., & Cline, C. A.
tems integration, and how effective are they?
(2005). Strategic implementation of systems change for in-
Figure 1 makes clear that the ultimate outcome of systems
dividuals with mental health and substance use disorders.
integration (as well as all other types of integration
Journal of Dual Diagnosis 1 (4), 75–96.
related to COD) is improved outcomes for clients and their
Fixsen, D. L., Naoom, S. F., Blasé, K. A., Friedman, R. M., &
families. Methods for measuring these outcomes are well
Wallace, F. (2005). Implementation research: A synthesis of
documented.
the literature (FMHI Publication #231). Tampa, FL: Universi-
ty of South Florida, Louis de la Parte Florida Mental Health
However, methods for measuring and evaluating the
process
Institute, The National Implementation Research Network.
of systems integration are stil in their infancy.
Retrieved January 25, 2006, from http://nirn.fmhi.usf.edu/
Goldman and col eagues (2002) used a measure, based
resources/publications/Monograph/
on the number of integration strategies (e.g., coordinating
groups, co-location of services, pooled funding, cross-
Goldman, H. H., Morrissey, J. P., Rosenheck, R. A., Cocozza,
training), used by systems attempting to address COD
J., Blasinsky, M., & Randolph, F. (2002). Lessons from the
and homelessness. The CCISC Toolkit (Minkoff & Cline,
evaluation of the ACCESS program. Access to Community
2002) includes one, as yet unvalidated, measure of
Care and Effective Services. Psychiatric Services, 53 (8),
systems integration outcome (CO-FIT100). This measure
967–969. Retrieved March 23, 2005, from
of fidelity for the CCISC assesses implementation processes
http://ps.psychiatryonline.org/cgi/reprint/53/8/967
and achievement of welcoming, accessible, integrated,
continuous, and comprehensive services for individuals with
Institute of Medicine. (2006). Improving the quality of
COD throughout the system. This toolkit awaits further
health care for mental and substance-use conditions.
research support.
Washington, DC: National Academies Press.
Minkoff, K. (1991). Program components of a comprehen-
The General Organizational Index (GOI) (Center for Mental
sive integrated care system for serious mental y il patients
Health Services, 2005) has been used to measure an
with substance disorders. In K. Minkoff & R. E. Drake
organization’s operating characteristics associated with the
(Eds.), New directions for mental health services, No. 50
capacity to implement evidence-based practices, including
(pp.13–26). San Francisco: Jossey-Bass.
integrated approaches to COD. The GOI provides an
objective, structured method to evaluate the organizational
Minkoff, K. (2002). CCISC model: Comprehensive, continu-
processes associated with systems integration.
ous, integrated system of care model. Retrieved March 4,
2002, from http://www.kenminkoff.com/ccisc.html
FUTURE DIRECTIONS
Minkoff, K. & Cline, C. (2001a). COMPASS (Version 1.0):
The theoretical appeal of systems integration is undeniable.
Comorbidity program audit and self-survey for behavioral
However, there is a need for further evaluation of the
health services. (Co-occurring disorders services enhance-
impact of systems integration on the effectiveness and
ment toolkit - Tool number 5). Albuquerque, NM: ZiaLogic.
efficiency of care for persons with COD. There is also a need
to compare various organizational and reimbursement
Minkoff, K. & Cline, C. (2001b). New Mexico Co-occurring
models and approaches and to further explore methods for
disorders program competency assessment tool. Santa Fe,
overcoming barriers to systems integration.
NM: New Mexico Department of Health.
Minkoff, K. & Cline, C. A. (2002). CO-FIT100™ Version
CITATIONS
1.0: CCISC outcome fidelity and implementation tool. (Co-
Center for Mental Health Services. (2005). Evidence-based
occurring disorders services enhancement toolkit - Tool
practices: Shaping mental health services toward recovery.
number 10). Albuquerque, NM: ZiaLogic. Retrieved March
Retrieved February 9, 2005, from
23, 2005, from http://hpc.state.nm.us/ibhpc/
http://mentalhealth.samhsa.gov/cmhs/communitysupport/
138DOH_Best%20Practice-%20Co-
toolkits/cooccurring
Occurring%20DisordersB.pdf
Systems Integration
5
Minkoff, K. & Cline, C. A. (2004). Changing the world: The
Rogers, E. M. (2003). Diffusion of innovation (5th ed.).
design and implementation of comprehensive continuous,
New York: The Free Press, 2003.
integrated systems of care for individuals with co-occur-
ring disorders. Psychiatric Clinics of North America, 27 (4),
Substance Abuse and Mental Health Services Administra-
727–743.
tion. (1999). SAMHSA position statement on use of SAPT-
BG and CMHSBG funds to treat people with co-occurring
Ridgely, M. S., Goldman, H. H., & Willenbring, M. (1998).
disorders. Unpublished paper distributed at the State
Barriers to the care of persons with dual diagnoses: Orga-
Systems Development Program V conference, Orlando, FL.
nizational and financing issues. In R. E. Drake, C. Mercer-
McFadden, G. J. McHugo, K. T. Mueser, S. D. Rosenberg,
R. E. Clark, & M. F. Brunette (Eds.), Readings in dual
diagnosis. (pp. 399–414). Columbia, MD: International As-
sociation of Psychosocial Rehabilitation Services.
6
Systems Integration
COCE Senior Staff Members
The CDM Group, Inc.
National Development & Research Institutes, Inc.
Rose M. Urban, LCSW, J.D., Executive Project Director
Stanley Sacks, Ph.D.
Jill G. Hensley, M.A., Project Director
John Challis, B.A., B.S.W.
Anthony J. Ernst, Ph.D.
JoAnn Sacks, Ph.D.
Fred C. Osher, M.D.
Michael D. Klitzner, Ph.D.
National Opinion Research Center at the
Sheldon R. Weinberg, Ph.D.
University of Chicago
Debbie Tate, M.S.W., LCSW
Sam Schildhaus, Ph.D.
COCE National Steering Council
Richard K. Ries, M.D., Chair, Research Community
Andrew D. Hyman, J.D., National Association of State
Representative
Mental Health Program Directors
Richard N. Rosenthal, M.A., M.D., Co-Chair, Department
Denise Juliano-Bult, M.S.W., National Institute of
of Psychiatry, St. Luke’s Roosevelt Hospital Center;
Mental Health
American Academy of Addiction Psychiatry
Deborah McLean Leow, M.S., Northeast Center for
Ellen L. Bassuk, M.D., Homelessness Community
the Application of Prevention Technologies
Representative
Jennifer Michaels, M.D., National Council for
Pat Bridgman, M.A., CCDCIII-E, State Associations of
Community Behavioral Healthcare
Addiction Services
Lisa M. Najavits, Ph.D., Trauma/Violence Community
Michael Cartwright, B.A., Foundations Associates,
Representative
Consumer/Survivor/Recovery Community
Annelle B. Primm, M.D., M.P.H., Cultural/Racial/Ethnic
Representative
Populations Representative
Redonna K. Chandler, Ph.D., Ex-Officio Member,
Deidra Roach, M.D., Ex-Officio Member, National
National Institute on Drug Abuse
Institute on Alcohol Abuse and Alcoholism
Joseph J. Cocozza, Ph.D., Juvenile Justice Representative
Marcia Starbecker, R.N., M.S.N., CCI, Ex-Officio
Gail Daumit, M.D., Primary Care Community
Member, Health Resources and Services
Representative
Administration
Raymond Daw, M.A., Tribal/Rural Community
Sara Thompson, M.S.W., National Mental Health
Representative
Association
Lewis E. Gallant, Ph.D., National Association of State
Pamela Waters, M.Ed., Addiction Technology Transfer
Alcohol and Drug Abuse Directors
Center
Andrew L. Homer, Ph.D., Missouri Co-Occurring State
Mary R. Woods, RNC, LADAC, MSHS, National
Incentive Grant (COSIG)
Association of Alcohol and Drug Abuse Counselors
COCE Senior Fellows
Barry S. Brown, M.S., Ph.D., University of North
Stephanie Perry, M.D., Bureau of Alcohol and Drug
Carolina at Wilmington
Services, State of Tennessee
Carlo C. DiClemente, M.A., Ph.D., University of
Richard K. Ries, M.D., Dual Disorder Program,
Maryland, Baltimore County
Harborview Medical Center
Robert E. Drake, M.D., Ph.D., New Hampshire-
Linda Rosenberg, M.S.W., CSW, National Council for
Dartmouth Psychiatric Research Center
Community Behavioral Healthcare
Michael Kirby, Ph.D., Independent Consultant
Richard N. Rosenthal M.A., M.D., Department of
David Mee-Lee, M.S., M.D., DML Training and
Psychiatry, St. Luke’s Roosevelt Hospital Center
Consulting
Douglas M. Ziedonis, M.D., Ph.D., Division of
Kenneth Minkoff, M.D., ZiaLogic
Psychiatry, Robert Wood Johnson Medical School
Bert Pepper, M.S., M.D., Private Practice in Psychiatry
Joan E. Zweben, Ph.D., University of California -
San Francisco
Affiliated Organizations
Foundations Associates
Northwest Frontier Addiction Technology Transfer Center
National Addiction Technology Transfer Center
Pacific Southwest Addiction Technology Transfer Center
New England Research Institutes, Inc.
Policy Research Associates, Inc.
Northeast/IRETA Addiction Technology Transfer Center
The National Center on Family Homelessness
The George Washington University
COCE Overview Papers*
“Anchored in current science, research, and practices in the field of co-occurring disorders”
Paper 1: Definitions and Terms Relating to Co-Occurring Disorders
Paper 2: Screening, Assessment, and Treatment Planning for Persons With Co-Occurring Disorders
Paper 3: Overarching Principles To Address the Needs of Persons With Co-Occurring Disorders
Paper 4: Addressing Co-Occurring Disorders in Non-Traditional Service Settings
Paper 5: Understanding Evidence-Based Practices for Co-Occurring Disorders
Paper 6: Services Integration
Paper 7: Systems Integration
*Check the COCE Web site at www.coce.samhsa.gov for up-to-date information on the status of overview papers in
development.
For technical assistance:
visit www.coce.samhsa.gov, e-mail coce@samhsa.hhs.gov, or call (301) 951-3369
A project funded by the
Substance Abuse and Mental Health Services Administration’s
Center for Mental Health Services and Center for Substance Abuse Treatment
