their primary discipline) (NASMHPD and NASADAD, 2002). The congressionally mandated study also stated that with training and other supports, primary care settings can undertake diagnosis and treatment of these interrelated disorders (SAMHSA, undated). Alternatively, use of a systematic approach to referral to and consultation with a mental health specialist is often used in model programs for better care (Pincus et al., 2003).

Linking Mechanisms to Foster Collaborative Planning and Treatment

As discussed at the beginning of this chapter, the simple sharing of information, by itself, is insufficient to achieve care coordination. Care coordination is the result of collaboration, which exists when the sharing of information is accompanied by joint determination of treatment plans and goals for recovery, as well as the ongoing communication of changes in patient status and modification of treatment plans. Such collaboration requires structures and processes that enable, support, and promote it (IOM, 2004a).

Not surprisingly, available evidence indicates that referrals alone do not lead to collaboration or coordinated care (Friedmann et al., 2000a). Stronger approaches are needed to establish effective linkages among primary care, specialty mental health and substance-use treatment services, and other care systems that are involved in the delivery of M/SU treatment. These stronger linkage mechanisms vary in form and are theorized to exist along a continuum of efficacy. The extremes range from the ad hoc purchase of services from separate providers to on-site programs (see Figure 5-1) (D’Aunno, 1997; Friedmann et al., 2000a). Linkage mechanisms toward the right of the continuum are theorized to be stronger because they lower barriers or causes of “friction” (e.g., problems in identifying willing providers, clients’ personal disorganization, and lack of transportation16) that prevent patients from receiving services.

FIGURE 5-1 The continuum of linkage mechanisms.

SOURCE: Friedmann et al., 2000a. Reprinted, with permission, from Health Services Research, June 2000. Copyright 2000 by the Health Research and Educational Trust.

Approaches whose effectiveness in securing collaboration has some conceptual and/or empirical support include collocation and clinical integration of services, use of a shared patient record, case (or care) manage-


These are in addition to the problems in insurance coverage discussed in Chapter 3.

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