Integration is a multi-faceted, complex issue strewn with numerous hazards and challenges. Merriam-Webster offers several definitions of integration that are applicable to our discussion: "a combination and coordination of separate and diverse elements or units into a more complete or harmonious whole; a unification and mutual adjustment of diverse groups or elements into a relatively coordinated and harmonious society or culture with a consistent body of normative standards.".

Public systems of care can have a multitude of integration foci and a variety of scopes. Among the most common are service integration, systems integration, program integration, community integration, and data integration.

Integration is attractive as a resolution to the public services environment of cost containment and budget shortfalls because it produces a more coordinated, holistic approach to care planning and delivery. It can produce multi-disciplinary teams, integrated case management, centralized intake, continuity of care, and many other benefits. To respond to unwelcome limitations, public services systems can integrate to consolidate administrative functions, manage care initiatives, "braid" funding streams and break silos, increase fee-for-service arrangements in place of program funding, maximize purchasing power, and so on.

This noble objective cannot be accomplished without dramatic changes in system financing and administration. Regulatory guidelines and mandates instituted by funding institutions hinder enhancements in service management.

Human services organizations have been traditionally funded in a way that promotes their focus on specific consumer needs, in isolation from other needs and services. Numerous confidentiality regulations exacerbate this isolation. Furthermore, public systems have no real ability to use available community resources, especially those that are not financially quantifiable. In an environment where needs and promises to satisfy them grow much faster than funding, we only intensify the problem by excluding community supports from our formal planning efforts.

The October 2004 issue of Pennsylvania County News offers an overview of human services environments in the Commonwealth and discusses such subjects as the roles and responsibilities of county human services departments, funding, and administrative models. The fact that county-administered substance abuse services are under the Pennsylvania Department of Health with its funding streams and reporting guidelines, while Medicaid substance abuse services are under the Pennsylvania Department of Public Welfare attests to the difficulty of introducing coordinated care planning and delivery.

The State of Pennsylvania, because of its nature as a Commonwealth, can also illustrate the difficulties specific to the independent functioning of county administrative units. Different administrative models in local public welfare administration lead to multiple interpretations of regulations and reporting guidelines. The differences in interpretation are subtle but numerous, creating program offices with non-uniform services and operations.

In their honest but insufficiently coordinated attempts at integration, state and county authorities often interfere with one another. The state tends to integrate vertically, centralizing administrative efforts across certain geographical areas but within a specific program area (for example, services for the elderly). Counties tend to integrate horizontally across program areas by consolidating administrative and financial management functions. In this environment, the success of one party may provoke the failure of the other.

ACA believes that the community level of direct service delivery is the only appropriate target for service integration. Any level removed from the direct administration of care and case management functions would not be able to accurately account for clients’ needs. Consequently, we believe that the integration of administrative and fiscal management functions must be implemented at the same community level to create a foundation for coordinating clinical, program, and administrative efforts, as well as for identifying community resources and formally including them in service planning decisions. Most importantly, integrating these efforts at the community level would foster stakeholder participation and give community members a stronger feeling of responsibility for and ownership of public systems that they have the right to use.