Paths and impacts in the progressive independence model: a homelessness and substance abuse intervention in Chicago.

In an attempt to reduce homelessness and substance abuse, Chicago graduates of short-term inpatient substance abuse programs who lacked domiciles were placed into one of three conditions: (1) a case management only intervention (n = 96), (2) a case management with supported housing intervention (n = 136), or (3) a control condition (n = 187) that allowed access to normal aftercare in the community. The two treatment interventions used a "progressive independence" approach, which focuses on simultaneously ameliorating tangible needs and clinical problems. Multivariate analyses suggest that subjects in both treatment interventions experienced lower levels of substance abuse and higher levels of residential stability than subjects in the control condition, as measured over the course of a year. Further analysis suggests that retention was improved by the focus on immediate tangible resources, substance abuse was reduced by both the support of outpatient substance abuse treatment and the promulgation of changes in coping styles, and residential stability was increased by both the focus on access to income maintenance benefits and help with location of housing.

The organization of substance abuse managed care.

Managed care came to dominate the delivery of substance abuse services during the 1990s. This paper uses literature and new data to describe and analyze the set of arrangements it implies. The description suggests that substance abuse managed care typically is "carved out" of the general health care plan and treatment is coordinated by a behavioral health managed care company that manages treatment access, length, type, and intensity. This administrative agent is provided financial incentives to keep costs low and otherwise faces such mandates as to ensure timely access to treatment and to deliver reports. A typical agent has some interest in improving the quality of decision-making, but has few incentives for controlling the treatment technology. In contrast, agents tend to control treatment providers through relatively rigid rules that substitute outpatient for inpatient care, regulate the length and intensity of services, provide limited social services, mandate accreditation, allow limited clinician discretion, administer an entire "network" of providers as an only slightly differentiated mass, and rarely shape the details of the treatment process. These patterns are analyzed in terms of transaction cost economics and institutional and resource dependency theories. In general, it is argued that managed care reflects an interest in controlling costs but also in ensuring access within an environment where there is uncertainty accompanying competing demands, varying conceptions of the client, and controversies over the efficacy of specific treatment technologies.

Service intensity and organizational attributes: a preliminary inquiry.

Service intensity can vary dramatically across the clients who are served within a psychosocial intervention. But studies of the determinants of intensity are disappointing, and examinations of its impacts on key client behaviors tend to be biased by unaccounted for reciprocal relations. The author argues that it may be useful to take into account organizational attributes. Service intensity may be more fully explained by attributes such as program life-cycles and learning routines, administrative reforms, worker attention spans, worker dispositions, and caseloads. Data from an intervention for adults with homeless experience and substance abuse problems (n = 136) support the author's argument. Results suggest that intervention leaders must become aware of and capable of manipulating the organizational context of treatment.

Homelessness and vulnerability among adults with and without alcohol problems.

While many works compare traits of homeless adults across levels of alcohol use, few specifically consider whether drinking status affects determinants of either homelessness or "vulnerability" to homelessness. This paper relies on a 1986 Chicago, Illinois sample (n = 535) to consider the potential contributions of resources, social network characteristics, disaffiliation, and mental health problems. Results suggest that resource problems may determine homelessness regardless of drinking status. But drinking-associated problems may raise the resource threshold for "vulnerability," reduce the protection afforded by social networks against both homelessness and "vulnerability," increase the deleterious impact of disaffiliation, and spur complicating mental health problems.