Facilitators and barriers to interagency collaboration ...

Children and Youth Services Review 53 (2015) 176–184

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Children and Youth Services Review journal homepage: www.elsevier.com/locate/childyouth

Facilitators and barriers to interagency collaboration in mother–child residential substance abuse treatment programs A.L. Iachini ⁎, D.D. DeHart, J. McLeer, R. Hock, T. Browne, S. Clone College of Social Work, University of South Carolina, Columbia, SC 29208, United States

a r t i c l e

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Article history: Received 29 September 2014 Received in revised form 9 April 2015 Accepted 9 April 2015 Available online 17 April 2015 Keywords: Mother–child residential treatment Interagency collaboration Facilitators Barriers Substance abuse

a b s t r a c t Interagency collaboration is imperative to address the multiple and co-occurring needs of youth and families impacted by substance abuse. Mother–child residential treatment programs represent a unique program model where success often hinges on collaboration between substance abuse agencies and a range of other service providers. Little is known, however, about the facilitators and barriers to implementing these service programs. The purpose of this qualitative study was to uncover these program influences within six mother–child residential treatment programs in one southeastern state and identify whether there were differences in these influences based on the developmental stage of the collaborative. Interviews were conducted with 26 stakeholders from substance abuse agencies and their community partners. Field notes also were captured at each site. All qualitative data were analyzed using open, axial, and selective coding methods. Three overarching themes represented by both facilitators and barriers emerged, including 1) Clarity, Credibility, & Support for the Model (e.g., success stories, stakeholder support), 2) Continuity of Care across Agencies (e.g., interagency communication, disciplinary service silos), and 3) Knowledge and Processes for Collaborative Work (e.g., commitment to client population, need for training, sustainable practices). These influences on interagency collaboration were found to vary based on developmental stage of the collaborative. Implications and recommendations for child and family service practitioners, policymakers, and researchers are discussed relative to maximizing the positive impact of mother–child residential treatment programs for children and families. © 2015 Elsevier Ltd. All rights reserved.

1. Introduction Parental substance abuse is noted as a contributing factor in approximately one to two-thirds of cases in the child welfare system (Besinger, Garland, Litrownik, & Landsverk, 1999; Semidei, Radel, & Nolan, 2001; United States Department of Health and Human Services (USDHHS), 1999). Children living with parents that have substance use problems are at higher risk for maltreatment and abuse, and severity of child abuse and neglect tends to be worse when parents have substance abuse problems (Semidei et al., 2001). In addition, when children living in such situations enter the child welfare system, they often remain in the system longer with less chance of reunification with their family (Ryan, Marsh, Testa, & Louderman, 2006; USDHHS, 1999; United States Government Accounting Office, 1998). Thus, when parental substance abuse is unaddressed, detrimental consequences extend beyond the parents to affect children and families. Given the intersection of parental substance abuse with child maltreatment and child welfare involvement, as well as the broad-ranging impacts on the family, comprehensive and coordinated services are ⁎ Corresponding author at: 328 DeSaussure, College of Social Work, University of South Carolina, Columbia, SC 29208, United States. Tel.: +1 803 777 2373. E-mail address: [email protected] (A.L. Iachini).

http://dx.doi.org/10.1016/j.childyouth.2015.04.006 0190-7409/© 2015 Elsevier Ltd. All rights reserved.

needed to span across substance abuse treatment, child welfare, and other human service systems (Lee, Esaki, & Greene, 2009; Ryan et al., 2006; Semidei et al., 2001; USDHHS, 1999). Within the spectrum of such collaborative models (e.g., cross-agency referral, co-located offices), one family-centered model gaining increased attention is mother–child residential treatment. These programs provide in-patient substance abuse services for mothers, therapeutic services for children, and programming directed at supporting the family unit (Conners, Bradley, Whiteside-Mansell, & Crone, 2001; Killeen & Brady, 2000; Substance Abuse and Mental Health Services Administration, Office of Applied Studies, 2009). Models of mother–child residential treatment vary across locales (Child Welfare Information Gateway, 2014; Osterling & Austin, 2008), involving professionals from different disciplinary backgrounds (e.g., substance abuse treatment, child welfare, mental and physical health), engaging mothers and children through different methods (e.g., therapeutic childcare, parent–child interactive therapy), and operating under different administrative, funding, and policy parameters (e.g., as a single agency versus agency partnerships; utilizing state versus federal funding streams). Given these complexities, guiding literature and studies on implementation of these collaborative models are limited. This paper contributes to the knowledge of mother–child residential treatment programs. Specifically, we examine facilitators and barriers to

A.L. Iachini et al. / Children and Youth Services Review 53 (2015) 176–184

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interagency collaboration for mother–child residential treatment programs in one southeastern state and then explore whether these influences vary based on the developmental stage of the collaborative. First, we review extant literature on mother–child treatment, the importance of interagency collaboration to such treatment, theoretical frameworks on interagency collaboration, and facilitators and barriers to interagency collaboration. Next, we describe our qualitative needs assessment research conducted with six partnerships for mother–child residential treatment. Finally, we discuss implications of this research for child and family service practitioners, policymakers, and researchers, with specific recommendations for maximizing the positive impact of mother–child residential treatment for children and families served.

varying stages across the continuum of integration, ranging from cooperation (where there is differential power in agency decision-making) to coordination (where agencies work together and make some accompanying procedural and policy shifts to accommodate the other) to ultimately collaboration (Claiborne & Lawson, 2005; Tseng et al., 2011). Inter-agency collaboration is considered the ideal state of integration between agencies, where there is a joint pursuit of mutual goals that are encouraged and supported through policies and programs within each organization (Smith & Mogro-Wilson, 2008). However, achieving this level of integration is not a simple feat, and partners are likely to struggle along the way as they work through various stages of the continuum.

2. Background

2.3. Theoretical frameworks on inter-agency collaboration

2.1. Mother–child residential treatment programs for substance use

Several theoretical frameworks have been advanced to help identify and contextualize potential influences on inter-agency collaboration (Claiborne & Lawson, 2005; Reilly, 2001; Tseng et al., 2011). Common to all of these frameworks is an emphasis on the developmental stage of the collaborative and how developmental stage can serve as a critical progress marker to the identification of potential facilitators and barriers to progression into a subsequent stage. Reilly (2001) described these stages most succinctly, suggesting that inter-agency collaboration results through the following sequence of stages: identification of a need/problem, formation of the collaborative, implementation of a program/service via the collaborative, engagement/maintenance of the collaborative, and then ultimately resolution of the need and evolution of the collaborative itself. What might facilitate or hinder the progression of a collaborative, however, is proposed to differ by developmental stage (Reilly, 2001; Tseng et al., 2011). For example, processes to support interagency collaboration may be more important in the formation and implementation stages, whereas the effectiveness of the collaborative in achieving its goals may be more critical to the engagement/maintenance stage (Reilly, 2001). Thus, the nature of the challenges to inter-agency collaboration may be different depending on where these fall along the continuum of collaborative development. Thus, improving our understanding of influences upon interagency collaboration based on developmental stage can help shape the future development of inter-agency collaborative efforts around mother– child residential treatment programs.

Mother–child residential treatment programs for substance use support both mothers and their children in order to “reintegrate both mother and child back into the community” (Killeen & Brady, 2000, p. 24). These programs not only provide mothers with comprehensive substance abuse treatment, but also often allow children to reside with their mother in the treatment facility. Frequently, children have access to their own services and have treatment plans as well (Killeen & Brady, 2000). Given the larger movement toward family-centered treatment for women with substance use disorders (Werner, Young, Dennis, & Amatetti, 2007), many of these mother–child residential substance use treatment programs also offer other supportive services to mothers and their children through the development of collaborative partnerships with other service sectors (e.g., health, mental health, employment, education, housing). To date, mother–child residential treatment programs have demonstrated promising positive outcomes for both mother and child (Osterling & Austin, 2008). Conners et al. (2001) found that mothers who graduate from these programs tend to relapse less often and experience greater family cohesion than those who drop out of the programs. In addition, Killeen and Brady (2000) found that women who graduated from a mother–child residential treatment program experienced improved parental functioning compared to those who did not. Other positive outcomes include greater retention of mothers in treatment (Hughes et al., 1995; Metsch et al., 2001; Osterling & Austin, 2008) and better mental health outcomes for mothers (Wobie, Eyler, Conlon, Clarke, & Behnke, 1997). Mothers are also said to develop “enhanced coping skills and newfound knowledge about alternatives to physical punishment” (Carlson, 2006, p. 109). Accordingly, improved outcomes are noted for children in these programs, including decreased problems with internalizing and externalizing behaviors (Killeen & Brady, 2000). 2.2. The importance of inter-agency collaboration for mother–child residential treatment As mother–child residential treatment programs focus not only on promoting the mother's recovery, but also prioritize improving the child's developmental outcomes and strengthening the family unit, many of these programs cross the traditional boundaries of isolated programs being provided by substance abuse agencies alone. Child welfare agencies, mental health agencies, primary care providers, housing supports, and vocational rehabilitation agencies are often needed for a comprehensive continuum of care that supports the differing needs of mothers and their children (Werner et al., 2007). By design, then, the success of these mother–child residential treatment programs often hinges on inter-agency collaboration. Inter-agency collaboration has been defined as when there are “fully shared services among agencies and an increasing loss of autonomy of individual agencies replaced by collective policy-making” (Tseng, Liu, & Wang, 2011, p. 798). Partnerships between agencies can exist at

2.4. Facilitators and barriers to collaboration between substance abuse agencies and other service agencies In recent years, there has been increasing attention to inter-agency collaboration within child- and family-serving fields and sectors (e.g., education, child welfare, mental health, healthcare, juvenile justice; Anderson-Butcher & Ashton, 2004; Chuang & Lucio, 2011; Darlington, Feeney, & Rixon, 2005; Haight, Bidwell, Marshall, & Khatiwoda, 2014; Kingsnorth, Lacombe‐Duncan, Keilty, Bruce‐Barrett, & Cohen, 2015; Palinkas et al., 2014). For example, research has examined inter-agency collaboration between child welfare and mental health (Darlington et al., 2005), child welfare and juvenile justice (Haight et al., 2014), and child welfare, juvenile justice, and mental health agencies (Palinkas et al., 2014). Collaboration among schools, child welfare, mental health agencies, and other community organizations also has received attention (Anderson-Butcher & Ashton, 2004; Chuang & Lucio, 2011; Lee et al., 2012). Together, these studies have illuminated some critical influences on inter-agency collaboration among different child- and family-serving organizations. These include leadership (Kingsnorth et al., 2015; Palinkas et al., 2014), organizational processes (Darlington et al., 2005; Palinkas et al., 2014), and training or resource availability (Darlington et al., 2005; Haight et al., 2014). Stakeholder perceptions of trust, communication among partners, and profession/discipline-specific boundaries also have been noted to influence the extent of collaboration

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across these agency settings (Darlington et al., 2005; Kingsnorth et al., 2015). In the case of complex programs that require numerous agency partnerships, like Integrative Family and Systems Treatment (Lee et al., 2012) and other evidence-based programs (Palinkas et al., 2014), buy-in and belief that the program model will be effective also has been documented as a key influence on interagency collaboration. Within the field of substance abuse (Drabble, 2007, 2011; Lee et al., 2009), however, the studies on interagency collaboration have been more limited. Most studies focus on interagency collaboration between substance abuse and child welfare agencies (Lee et al., 2009; Drabble & Poole, 2011) or between substance abuse, child welfare agencies, and the court system (Drabble, 2011; Green, Rockhill, & Burns, 2008). Across these studies, documented facilitators to interagency collaboration have corroborated much of what has been found in the broader literature and include processes that support problem-solving (Drabble, 2011; Drabble & Poole, 2011); training and professional development offered across agencies (Drabble, 2011; Drabble & Poole, 2011; Green et al., 2008), leadership (Drabble & Poole, 2011), and the formation of solid, trusting relationships between individuals across agencies (Drabble, 2011; Drabble & Poole, 2011). In addition, Smith and Mogro-Wilson (2007, 2008) have conducted two quantitative studies on collaboration in the context of substance abuse treatment, and documented the importance of individual staff knowledge and skill around interagency collaboration, as well as staff perceptions of organizational policies to support collaboration, as critical for collaborative practice. Researchers also have begun to document barriers to collaboration involving substance abuse agencies. Differences in the focal population across agencies (i.e., the child versus the parent) and program staff members' competence in working with these populations can pose challenges (Drabble, 2011; Drabble & Poole, 2011; Green et al., 2008). Lack of communication between agencies, as well as resource constraints and funding challenges, also have been documented consistently as major setbacks for interagency collaborative efforts (Drabble, 2011; Drabble & Poole, 2011; Green et al., 2008). Individual-level influences such as staff resistance, negative staff perceptions of other agencies/partners, and poor communication across agencies have also emerged as notable barriers (Drabble, 2011; Drabble & Poole, 2011; Green et al., 2008). Together, these studies provide a foundation for understanding the potential facilitators and barriers to implementation of mother–child residential programs. Yet, these studies are limited in several ways. First, none of the studies to date have focused exclusively on mother– child residential treatment. Given the complexities inherent within this program model, the numerous partners they require to operate, and the long-term investment they require, we believe that inter-agency collaboration to implement these programs may be more difficult to achieve compared to collaboratives that require fewer partners or more limited time engagement. Our study is designed to further our understanding of this, particularly in relationship to uncovering whether there are shared facilitators and barriers to interagency collaboration regardless of agency setting or whether there might be unique influences on collaboration based on this program model. Moreover, no study to date has examined whether the influences on interagency collaboration differ by developmental stage, particularly in regard to mother–child residential treatment programs. Understanding the complexities of inter-agency collaboration in relation to developmental stages is critical, particularly as these findings can inform child and family service practitioners' attempts to foster collaboration across agencies and optimize the impact of these programs on the children and families served. 2.5. Study purpose Aiming to address the limitations of the existing research, three primary research questions guided our qualitative study: 1) What are the facilitators and barriers to interagency collaboration between substance abuse agencies and other agencies as they implement mother–child residential treatment programs? 2) Are these facilitators and barriers

similar or different to those identified in other empirical studies on interagency collaboration within substance abuse and other child- and family-serving organizations? 3) Do these identified influences on interagency collaboration within mother–child residential treatment programs differ based on the developmental stage of the collaborative? The answers to these research questions have important implications for the design, delivery, and enhancement of these services for children, youth, and families. 3. Methods 3.1. Sampling & data collection procedures All study procedures were reviewed and approved by a university human subjects review board. Researchers conducted stakeholder interviews and kept field notes during two-day site visits to six mother– child residential substance abuse treatment programs in a single southeastern state. All of the programs were in various stages of development and cultivation of interagency collaborative partnerships. We adopted the developmental stages articulated by Reilly (2001) as a way to classify the developmental stage of collaboration within each program. Two were in the formation stage, as they were focused on cultivating the agency partners needed to transition to this model of care. Three were in the implementation stage, already having started programmatic implementation. One program was in the engagement/maintenance phase, as they had been operating a residential treatment program for over twenty years and were focused on adding collaborative components such as housing and higher education. The six programs were selected because they were all part of a broader research initiative focused on enhancing services for addictions treatment and recovery support. During the site visits to each program, researchers conducted three to five individual or group interviews with persons identified as key stakeholders by staff at the substance abuse agency. Stakeholders could include board members, front-line staff, persons from partner agencies, or others. In addition to interviews, each investigator (i.e., authors) kept field notes about other aspects of the site visit, including group discussions and facility tours. 3.2. Interview participants Across these six programs, 26 stakeholders participated in 17 interviews (12 individual interviews and five group interviews). Eight interviewees were from substance abuse agencies, five were from child welfare agencies, and thirteen were from other service agencies (e.g., housing agency, vocational rehabilitation agency, and health agency). In terms of professional role, seven were board members, nine were staff, and 10 were directors/administrators. Of those who were interviewed, 58% were female. In terms of race/ethnicity, 77% reported as White, 19% reported as Black/African American and 4% reported as Other. The mean age of respondents was 49 years old. In terms of highest level of education, 65% reported to have a graduate degree or professional licensure, 27% reported to have an undergraduate degree, and 8% reported to have some college education. 3.3. Measures Interviews lasted between 30 min and 1 h. Interview prompts addressed a range of issues including the stakeholder's role relative to the mother–child treatment program, general impressions of the substance abuse agency, the purpose and activities related to implementation of the program, and strengths and challenges within the program experienced or anticipated to date. This manuscript focuses on interviewee responses to specific interview questions likely to tap into facilitators and barriers in interagency collaboration, including 1) What has excited you about the project so far? What are some current strengths of


the project? and 2) Do you have worries or concerns about the project? What challenges do you anticipate? 3.4. Data analysis All interviews were audio-recorded and transcribed verbatim. Seventeen qualitative interview transcripts, three sets of cross-site process notes with stakeholders knowledgeable about mother–child residential treatment, and six sets of program-specific researcher field notes were coded and analyzed using MaxQDA software (VERBI GmbH Berlin, Germany). First-cycle coding was performed by the second author using provisional codes derived from interview prompts, with additional open coding to further break down the data and provide analytic leads for exploration (Saldana, 2009). The first author then reviewed all transcripts to review application of codes, identify relevant passages that may have been missed, and tag discrepancies for discussion and refinement of codes. Second-cycle axial coding was then performed by the second author to differentiate and organize codes with particular attention to facilitators and barriers, and selective coding was used to identify the most salient codes as these related to practice and policy for mother–child residential treatment (Saldana, 2009). Throughout all aspects of this process, debriefing between both analysts was used to address discrepancies, clarify concepts, and refine codes based on consensus (Hill et al., 2005; Sandelowski & Barroso, 2003). 4. Findings Analysis of interview data revealed numerous facilitators and barriers to interagency collaboration between mother–child residential treatment programs and other social service agencies. We have organized these facilitators and barriers into three separate themes: 1) Knowledge and Processes for Collaborative Work, 2) Continuity of Care across Agencies, and 3) Clarity, Credibility, & Support for the Model. Each overarching theme is dimensional and thereby represented by both positive sub-themes (facilitators) and negative sub-themes (barriers) as described by the stakeholders who were interviewed. We provide examples of these sub-themes through excerpted quotations. Please note that quotations have been edited for clarity and to remove idiosyncratic speech patterns (e.g., “you know”). Because collaborative partnership arrangements varied across sites and only a few stakeholders were interviewed at each site, we have not provided demographic or professional affiliations of interviewees alongside each quote in an effort to protect the anonymity of respondents. We then report our findings related to how the identified influences to inter-agency collaboration may differ by developmental stage of the collaborative. 4.1. Knowledge and Processes for Collaborative Work The theme Knowledge and Processes for Collaborative Work captured 51% of coded segments and relates to knowledge of, and commitment to, the client population, training and skill-building for employees, and service/funding issues related to sustainability of programs. 4.1.1. Facilitators Facilitators (14% of quotes within this broader theme) included the sub-themes of knowledge and commitment to clients and training/ skill-building for employees. In relationship to the former, stakeholders would often describe their respect for individual collaborative partners as well as how well these partners meshed with the client population. She was familiar with [the agency] and how they operated in the state she came from. So, that was really a plus. And she would go out to the homes, and that was a bigger plus. So, she wasn't afraid to interact with these—our clients.

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Many stakeholders described commitment to serving families, and this helped partners in the collaboration find common ground. You have to deal with the entire family. You have to deal with the unit as a whole. So, that was part of what we anticipate. So, for me, I think one thing that comes from the [project] is simply this: we learn a better way to utilize the same resources to more effectively serve the clients that we want to serve. Stakeholders also described training and building skills of employees. For instance, one stakeholder described preparing workers to be in the “mindset” to begin to identify appropriate referrals for the program. Stakeholders described cross-training so that workers from different backgrounds would become familiar with the same terminology and concepts. One provider described training staff at all levels within the agency. Our staff are very friendly and welcoming to the clients that we serve. As soon as they walk in the front door, we even include our frontline staff in very important trainings—even sometimes clinical trainings. They were even included in some motivational interviewing training, and I was very impressed when I walked into that training and saw that. So we're teaching. We're teaching our administrative assistants some of those skills to utilize as soon as they see someone walk through the doors.

4.1.2. Barriers Knowledge and skill-building also figured prominently among barriers mentioned by stakeholders. Barriers (86% of the quotes represented within this broader theme) included subthemes of needing to develop new skills or processes and challenges around funding/sustainability. Stakeholders across the state and across disciplines expressed such challenges. In particular, agencies were sometimes frustrated with their own abilities or their partners' abilities to take on work with new populations. For instance, transitioning from working with children and youth who have been abused to working with mothers with substance abuse issues requires understanding of addictive processes, changes in facility protocols to accommodate adult rather than child developmental levels (e.g., use of cell phones), and different ways of staff relating to clients. One stakeholder described her agency's own struggles. We've met some challenges in doing this, more barriers than we really thought we might encounter when you're dealing with a different population than the population we deal with—which we have some recovering addicts in our program, but it's not just…that target population, which deals with a lot of additional barriers, not just the poverty barriers that our families deal with. Stakeholders also discussed that working with new populations often necessitated “re-branding” of the organization. I think the weakness to it is that historically again, you've served a certain populace, and there's a community perception and perspective that that's who you are. So, you have to redefine yourself. You have to have a public relations and a marketing component that will help to transition expectations and philosophies about what it is you do… So, telling that story in our community is somewhat of a challenge. You have to re-identify yourself. The barriers most frequently cited by stakeholders related to challenges around funding and sustainability, particularly in relation to trying to make existing policies around billing applicable to the collaborative effort. Billing and/or reimbursement for services became complicated by the variety of providers involved, whether providers were licensed for substance abuse treatment or for childcare, clientstaff ratios required for licensing, and eligibility restrictions for clients imposed by Medicaid, Title-IVE funding, Temporary Assistance for Needy Families (TANF) funding, or other state funding. Collaborators

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often faced challenges in patching together funding from a variety of these sources to make their programs sustainable. Our big thing is just, are we going to be able to sustain this? Are we gonna have time to get everything worked out? Stakeholders discussed logistical barriers associated with different funding and licensing issues. For instance, having a full facility presented problems if too many of the residents were children, in that child residents required higher staffing ratios and therefore more staff on shift. At one program, a stakeholder reflected on being overwhelmed by expenses for building modifications required for licensure. I had no idea—none whatsoever—the amount that I would have to do and that [another staff member] would have to do in order to get [agency] ready for this program. Not just structurally, material-wise. That was a big issue, as well. And they had already started working on updating the dorms and stuff. But money has been tight. So they would fix this, but not that. At multiple sites, a concern was that collaboration with struggling agencies would pose risk not only for those agencies, but for their collaborators. Like the old adage that “a chain is only as strong as its weakest link,” longstanding agencies were concerned that partnering with agencies-in-transition might siphon away crucial energy and resources, risking stability of all involved agencies. An inability to get an adequate number of qualified referrals needed for sustainability also was mentioned repeatedly by stakeholders across sites. Some stakeholders were hopeful. We need referrals. We need a pipeline of people. And so we certainly… From what we've heard from some of our sister programs around the state, they're not seeing the numbers that they maybe had originally anticipated. So obviously that's a real concern for us is hoping that we get the referrals we need. Others anticipated that some structural barriers might be overcome if agencies brought barriers to attention of legislators and state agency leaders. For example, state law does not allow persons with felony drug convictions to receive public benefits, such as Medicaid and TANF funds. Yet, these funds were part of those blended together to pay for room, board, and treatment for mothers and children in treatment. Foster placement would allow access to Title-IVE funds, but the placement must be voluntary. Such intricacies created challenges maneuvering fiscal management systems for the agencies involved. There's not a lack of referrals. There's a lack of qualified applicants. You know, qualified referrals. Being the criminal background check and people willing to sign voluntary placement. So she said they have had a slew of parents, and we have many, many parents that have addiction problems that we remove kids or the police remove kids, okay? So I don't think it's gonna be a lack of numbers, but I think it's going to be a lack of qualified applicants. Another layer of complexity is added given the nature of substance abuse treatment. A lot of people relapse… So, a lot of times people just have knee-jerk reactions… the reaction is jerk the child out or don't put the child in because of that one relapse. This mother's done good for a year, and she has a relapse just one time… How is that gonna affect this, the family in placing the child or not placing the child? 4.2. Continuity of Care across Agencies The theme Continuity of Care across Agencies captured 35% of coded segments and related to strategies for communication and coordination across agencies, disciplinary differences in styles and levels of

engagement in collaborative efforts, and resistance or conflict among partners or other stakeholders across agencies.

4.2.1. Facilitators Facilitators represented 31% of quotes within this theme. Subthemes included mapping out interagency protocols and memoranda of agreement, engaging key stakeholders early in the process, and pooling resources and expertise to maximize effectiveness. One provider described a philosophy for coordinating care. I think that we need to sit down and instead of talk about, “What you do, what you do, what you do,” we need to sit down and say “What do these families need to make them successful? What are the components that need to be there? Who's gonna do what?” And let the funding follow who's doing what and get out of this where you have to do this because you're the drug person [substance abuse agency], and you're the residential [care] person, and you're the [social service provider]… What does this family need, and let's support the family. And if we could do that and people could think that way, I think it could be amazing, the work we could do. Another provider emphasized the effort required to assure that stakeholders are fully engaged in the program itself. The process requires so much philosophical, territorial, procedural mending and changing and merging that… when you look at that from an internal process, to transition is not a matter of us just doing a name tweak, and us just sittin' over here, and we do what we do, and you do what you do, and this kind of thing. I think when you fuse these processes together and you get to the stage that we are, I think that's certainly an absolute strength. One stakeholder described using multiple steps to ensure that stakeholders were engaged early in the collaborative process. On the front end, we did bullets—this is what we would like for this to look like, and here's where we would go. And that actually ended up in the grant. And then [our partner] got the blessing from his folks, and I got the blessing from my folks. And input—so like I got my regional team leader to say here's what she would like, so then that kind of got me some buy-in. And then when we got further down… [our partner] came over and interviewed [co-located staff], like, “I think she would be a good fit for our team, because she is gonna spend most of her time in our office… We also had a very large group meeting… that included some state level folks, some regional folks, and our local folks… So I think that that gave them buy-in, also they were able to ask questions and have input into what they would want [the program] to look like, and how they thought that that could best work. Others described the benefit of joint decision-making. The other thing that excites me about this is the collaborative nature of what we do. That is, nobody's out there having to be a lone ranger about making a decision. Many stakeholders also described benefits of pooling expertise across disciplines. We certainly know [the] residential component very well. You know, that's what we've been doing successfully for years… We can bring in a partner that handles their counseling, their rehabilitation very well. And then obviously, [social services], that's what they do well. So, I mean it's a marriage of three organizations that do one thing very well. Pooling resources also went beyond sharing perspectives across disciplines to include sharing professional networks and volunteered services (e.g., clinical services, transportation), holding joint trainings,


sharing recreational equipment, and even sharing facilities and grounds (e.g., office space, residences). 4.2.2. Barriers Barriers to continuity of care represented 69% of quotes categorized within this broader theme. Sub-themes included getting trapped in disciplinary silos, failing to fully engage key stakeholders, and resistance and conflict among partners and other stakeholders. One stakeholder described typical silos that can exist between providers. Everything was sort of siloed… So, if you had a medical problem, there was that silo. If you had a drug problem, there was that silo. If you had a psychiatric mental illness, there was that silo. And our clients would get sent back and forth between [the substance abuse agency] and mental health. If they went to [substance abuse] the counselors would say, “My god, you're like hallucinating. We need to send you to mental health.” And then when they got to mental health, mental health would say, “But, I think you're using some substance, so I can't diagnose you. So, I'm gonna send you back to [the substance abuse agency].” This stakeholder said that providers historically began to work together with the realization that they had many clients in common. Still, as one stakeholder described, bridging systems across substance abuse agencies and other social service agencies came with certain barriers due to disciplinary differences. You go to one group, and they say alcoholism is a disease. And then you go to another group, and they say, “Hello, I'm so-and-so, and my drug of choice…” You know you would never say, “My cancer of choice is…” You kind of get a different framework everywhere you go. Competence of providers to work with clients outside of their original disciplinary expertise was also a major concern of stakeholders. This included concerns about providers understanding underlying causes of symptoms and behaviors, turf battles over clients, and differences in disciplinary norms on issues such as client autonomy and confidentiality. One stakeholder described how staff from another agency failed to view mothers and children as a family unit for treatment purposes. Another stakeholder described what began as a “territorial” relationship in which each agency did not trust the other to take care of “their” clients.

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haven't been as engaged as they were initially. So I don't know. We're havin' to pull them back in. Tryin' to reel them back in.

Of all the sub-themes within this broader theme, the most commonly mentioned barrier was resistance and conflict among stakeholders. Examples of this sub-theme included staff within agencies not respecting one another, staff resisting work with new populations, and community resistance to approval or funding of mother–child residential programs. Some of this resistance overlaps with and contributes to sub-themes identified in other areas. For instance, difficulty in getting referrals (discussed under Section 4.1) sometimes appeared to relate to attitudinal or motivational issues of individual workers. I have a one page referral sheet that… we ask [agency] to complete and fax to us along with a signed consent form so we can do the assessment and call them back and give them information. And I struggle getting that form from them. They don't want to fill it out because it's another sheet of paper.

Similarly, resistance around working with new populations appeared to sometimes stem from disciplinary turf wars (e.g., “our/your” clients), the need to learn new skills (discussed later), and individual resistance (e.g., preferring to work with children rather than adults). Agency workers and their partners sometimes reported struggling against resistance from boards and communities regarding the placement or funding of mother–child residential facilities. We had thought about coming in, and getting everybody on the area out here, and just sitting down, and explaining to them, “We've bought the land”—and that's all they heard. One of the guy calls us, when I met with him… about “all these drunks and the addicts and all this stuff y'all bringing.” Another stakeholder described resistance in a different community. The community is not necessarily as forgiving for addictive mothers. The story of a neglected or abandoned boy by his parents and wanting to help that individual child is a little bit different “sell” than a mother who they believe in some way—that they don't understand addictions and addiction-type things—believe you contribute to your own issues and concerns.

So you take care of your kiddies, and we'll take care of the moms. This stakeholder, however, was optimistic about the future. I finally feel like we're being honest with one another about struggles. And that we finally have turned the corner where we see that it's not “our moms, your kids.” It's “our families.” Some of the adversarial relationships and miscommunications across disciplines appeared to stem from a failure to fully engage key partners in the planning stages of the collaborative effort. For instance, some planning meetings focused on county-level staff but failed to include state-level policymakers to address some types of challenges (e.g., promoting cross-agency referrals). Having state-level decisionmakers present at the outset could have provided needed support for implementing system-wide protocol changes. Stakeholders also mentioned that the nature of mother–child residential treatment required a very intense and long-term commitment from all partners, and that they were unsure whether such a commitment would be maintained by all involved agencies. When [agency] opens a case, they have to stay involved for a year. So we were all thinkin', “Well this will be great. There would be someone who's workin' with mom for a full year. And after we close our case, they'll still be in there.” And they've kinda dropped out. Not dropped out, but they

4.3. Clarity, Credibility, & Support for the Model The theme Clarity, Credibility & Support for the Model captured 14% of coded segments and includes impressions about the effectiveness of the mother–child residential care model, the interviewee's comprehension for how components of the model fit together, and perceived stakeholder support or evidentiary support for the model. 4.3.1. Facilitators Facilitators represented 36% of the quotes within this broader theme. Sub-themes included examining feasibility of the program model, garnering staff and stakeholder (e.g., board, community) support for the model, and believing in success stories of mother–child residential models. For instance, one stakeholder described the meticulous planning of the organization in considering the model. Our board made the concerted decision to dissolve our current business model and to create this as a new business model. Not simply because of its ability to be more sustainable financially, but because it has more mission—drives what we want to do as a community provider. We serve a greater good… We had several meetings at the local level and state levels. We did all kinds of analysis and assessments to determine if, in fact, the model that we were in was salvageable. And so, I say that to

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say that to transition to this new model was not in haste nor was it a last ditch effort to do something. It was purposeful… Other stakeholders described their excitement in seeing clients and families have positive experiences with program participation, describing anticipated successful outcomes for existing clients or past success stories for clients in similar mother–child residential programs. As far as the family care center, I truly believe that there is a need for that service. I really do. And seeing the successes we've had makes you even more—you walk in and you see the little one over there that's what, 3 weeks old? I mean he was just so tiny. And to give him hope and his mom hope for a healthy relationship…

4.3.2. Barriers Barriers were represented by 63% of quotes categorized within this broader theme. Sub-themes included lack of familiarity with basic components of the program (e.g., roles of different providers, target populations for service) as well as uncertainty about the effectiveness of the model. I'm understanding a little bit more about the model, but I'm still not a hundred percent convinced that this is something that's going to be needed in every single county. Maybe something regionally? Another respondent felt that the length of the residential stay was insufficient to achieve the desired client-level outcomes. I don't see how this is gonna—to what extent we will really, really, really be successful. I think we're setting them up to fail. Because that's too much to do in too little an amount of time.

4.4. Examining influences on inter-agency collaboration by developmental stage Table 1 provides the percentage of quotes within each of the three theme areas according to the developmental stages of the programs represented in this study. Knowledge and Processes for Collaborative Work was discussed the most by stakeholders involved in programs in the implementation stages. Continuity of Care across Agencies was discussed most by stakeholders from the program in the engagement/ maintenance stage, but was also discussed quite comparably by stakeholders involved in programs in both the formation and implementation stages. The greatest percentage of quotes about Clarity, Credibility, & Support for the Model came from stakeholders involved in the program in the engagement/maintenance phase. 5. Discussion 5.1. Summary The purpose of this study was to explore influences on interagency collaboration between substance abuse agencies and other service agencies for the provision of mother–child residential treatment programs. Three overarching themes emerged that were represented by numerous facilitators and barriers to interagency collaboration.

Knowledge and Processes for Collaborative Work was the theme discussed most frequently and included subthemes pertaining to professionals' knowledge of and commitment to the client population, need for training and skill-building for professionals, and service or funding issues relating to sustainability of efforts. The second most frequent theme was Continuity of Care across Agencies, which was characterized by subthemes relating to coordination across agencies, addressing disciplinary difference, engaging stakeholders, and resistance or conflict among partners. Finally, the third most common theme was Clarity, Credibility, & Support for the Model. This included subthemes pertaining to effectiveness of the model, comprehension of the model, and perceived support for the model. We also sought to understand whether the facilitators and barriers to interagency collaboration around mother– child residential treatment programs were shared or unique compared to studies on interagency collaboration in other child- and family-service settings. Overall, the findings of this study suggest that many of the facilitators and barriers to interagency collaboration may not be unique to this program model (Drabble, 2011; Drabble & Poole, 2011; Green et al., 2008). Similar to other studies, we found that buy-in and belief that the program model will be effective (Lee et al., 2012; Palinkas et al., 2014) and commitment of individuals to their client population facilitated collaborative practice, whereas profession/disciplinespecific boundaries and conflict/resistance among staff challenged collaboration across agencies (Darlington et al., 2005; Drabble, 2011; Drabble & Poole, 2011; Green et al., 2008; Kingsnorth et al., 2015). An unexpected, yet important, finding of this study was that many of the facilitators and barriers appeared to be interconnected. For example, while commitment to a client population could act as a facilitator to collaboration, this same passion and devotion to a particular group of clients (e.g., women, children) could create resistance to working with new populations. The inter-related nature of facilitators and barriers to program implementation have been noted in studies of other youth service programs (Iachini, Beets, Ball, & Lohman, 2014), but this study is one of the first in the area of interagency collaboration and the field of substance use to illuminate how addressing one influence on collaboration may create a ripple effect in addressing others. One unique barrier to interagency collaboration with important implications for the design and implementation of mother–child residential treatment programs concerns current billing policies. We found that current billing policies were often at odds with the collaborative model of service provision, specifically service provision to both mothers and their children. For instance, certain types of family support services might fall under a “bundle” or episode-based payment that applies to one member of the family unit but not another; thus, a child's services may be covered by the bundle, but a mother's services may not. When the collaborative endeavor is intended to provide services to the family unit rather than individuals, this creates challenges for service providers. Further, eligibility restrictions of some funding streams created additional hurdles by excluding potential service recipients as qualified applicants. For instance, Temporary Assistance to Needy Families (TANF) may be denied to persons with felony drug convictions; yet TANF-eligibility may be required in order to receive certain other types of financial aid that was a planned stream of funding for these mother– child residential treatment programs. While funding is often identified as an influence on interagency collaboration, our study adds nuance to this area by identifying one key aspect of funding that may be important

Table 1 Percentage of quotes represented within each theme area according to developmental stage of the programs. Themes

Knowledge and Processes for Collaborative Work Continuity of Care across Agencies Clarity, Credibility & Support for the Model

Developmental stage of the programs Formation

Implementation

Engagement/Maintenance

50.0 34.7 15.2

53.5 35.7 10.8

30.7 41.0 28.2


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to consider when implementing mother–child residential treatment programs. Our study also adds to the existing research by examining whether influences to collaboration differ based on the developmental stage of the collaborative. Overall, our findings support the theoretical frameworks on interagency collaboration and influential factors advanced by others (Claiborne & Lawson, 2005; Reilly, 2001; Tseng et al., 2011). We found that developmental stage does appear related to greater identification of certain collaborative influences. For example, Knowledge and Processes for Collaborative Work were discussed most by stakeholders involved in programs in the formation and implementation stages. According to Reilly (2001), within these stages, structures and processes are critical for the collaborative to move toward more sustainable efforts via engagement/maintenance. In our study, we also found that Clarity, Credibility, & Support for the Model was discussed most by stakeholders who were involved in a program in the engagement/ maintenance phase. This finding was surprising but may make sense in the context of theory on interagency collaboration. Reilly (2001) suggests that stakeholders involved in programs that have been operating for some time often consider whether to remain involved and whether their collaborative efforts have been successful—thereby necessitating that they revisit and assess effectiveness of the program model. Future research should build from this work, as these findings provide preliminary evidence that the developmental stage of the collaborative has implications for the types of facilitators and barriers to specifically target at different developmental stages (Tseng et al., 2011).

buy-in and minimize resistance among key stakeholders influential in program delivery. It also may be important for organizational and program leaders to consider the developmental stage of the collaborative when making decisions about strategies to implement to foster interagency collaboration (Tseng et al., 2011). Engaging key partners, gaining buy-in, and addressing resistance would appear particularly important to address at the outset of implementing a new collaborative program. In contrast, discussions on the effectiveness of a program in achieving the goals of a collaborative may be important to undertake when the collaborative has already experienced some small “wins” or successes (Reilly, 2001). To continue to support substance abuse agencies and others in their efforts to maximize the impact of these programs on youth and families, continued research on interagency collaboration within these program contexts is needed. Future studies might delve further into organizational and individual-level influences on interagency collaboration and the extent to which these vary based on the stage of the collaborative (Tseng et al., 2011). In addition, quantitative studies may clarify how interventions addressing these facilitators and barriers influence changes in collaboration over time, as well as how these changes in collaboration ultimately impact outcomes for youth and families. This study contributes to this knowledge base through identifying key points for intervention to promote and enhance interagency collaboration across different developmental stages. Substance abuse and other human service organizations that serve children, youth, and families will greatly benefit from continued advancements in this line of inquiry.

5.2. Limitations

Acknowledgments

Several limitations to this study must be noted. The qualitative data for this study were collected at six mother–child residential treatment programs in a single southeastern state. As such, there may be limitations to the generalizability of findings. In addition, key stakeholders who participated in interviews were identified by the substance abuse agency at each site. This may increase likelihood of bias in responding, presumably toward stakeholders being more favorable toward the program being implemented. It is possible, however, that some agencies may have purposefully selected individuals with more diverse perspectives as a means of problem-solving around interagency collaboration. Finally, all six substance abuse agencies were in different stages of development of their mother–child residential treatment programs. While we believe this is a strength of the study as it allows for a comprehensive understanding of influences on interagency collaboration across varying stages of program development, future research is needed with larger sample sizes of agencies to examine more directly the developmental processes of facilitators and barriers in relationship to these service programs.

This project was supported by contract number #A201611015A with the South Carolina Department of Health and Human Services (SCDHHS). Points of view in this document are those of the authors and do not necessarily represent the official position or policies of SCDHHS. The authors also would like to acknowledge the numerous graduate research assistants who supported this study. Finally, we thank our colleagues who provided input on earlier drafts of this manuscript.

6. Conclusion and implications Interagency collaboration is imperative to address the multiple and co-occurring needs of youth and families impacted by substance abuse. While these efforts can be challenging, as evidenced by the barriers uncovered in this study, developing a greater understanding of the complexities of collaborative practice is critical. The findings of this study illuminate key targets for organizational and individual change within service programs (Smith & Mogro-Wilson, 2007). Through this study, we have uncovered three domains of influence. These all have the potential to strengthen or inhibit the collaborative service delivery of mother– child residential treatment programs. Organizational leaders and administrators of child and family service programs are encouraged to use the findings of this study as points for discussion in interagency collaborative team meetings. For example, each facilitator and barrier could be discussed relative to existing interagency efforts and used to guide refinement and enhancement of existing organization protocols and processes. Likewise, these conversations could help foster and enhance

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