States' investment in recovery support services: An exploratory analysis.

INTRODUCTION: Recovery support services (RSS), while not yet precisely defined, nevertheless have a longstanding role in managing chronic illnesses including substance use disorders (SUDs). This exploratory study is the first to identify the amounts of money that states invest from Substance Abuse and Mental Health Services Administration (SAMHSA) Block Grants; SAMHSA discretionary grant and state-appropriated sources; the types of organizations from which RSS are purchased; and the non-financial supports states provide for RSS. METHODS: The study is a mixed method exploratory analysis, based on three data sources: content analysis of all 51 (Washington, D.C. included) Substance Abuse Block Grant (SABG) state applications; in-depth interviews with a purposive sample of ten states and one territory; and a structured electronic survey sent to all SABG recipients. Forty states and 2 territories returned a total of 42 questionnaires from 56 possible states and territories (75%). Thirty-two of the responding states provided complete FY2022 financial data. RESULTS: States reporting financial data spent $412 million from SABG, SAMHSA discretionary grants, and state appropriations for RSS. An estimate based on extrapolating regionally grouped per capita spending averages to non-responding state populations projected $775 million spent from these sources for all states. The study also calculated per capita and SUD prevalent population expenditures from these sources for each state. States purchase services from recovery community organizations and SUD treatment organizations in equal proportions, as well as from statewide recovery support organizations, educational institutions, hospitals, community health centers, and justice system organizations. Purchased services are not uniformly defined, but include community centers, peer staff, housing, and other support services. States provide non-financial support in forms that include technical assistance, community engagement, practice guidelines, and regulatory frameworks. CONCLUSIONS: This first report of states' investments establishes a baseline to serve as a reference point for future analysis of these expenditures, as well as a foundation to which other sources of RSS funding such as Medicaid and other state and federal (e.g. HRSA, CDC, DOJ) dollars may be added. Uniform definitions for RSS will be necessary to support future reporting, accountability, and research. Finally, newly formed peer-based provider organizations need particular attention in order to be sustainable.

Facing the future of substance use disorders treatment in Vietnam - A case study for international development and cooperation.

Vietnam made progress transitioning from a criminal justice to a health treatment response for substance use disorders (SUD) in recent years. This case study describes the evolution of Vietnam's SUD treatment system from 2005 to 2020 to understand and learn from the phases of its development. The case study is based on data from a predesigned interview guide for 47 respondents, literature and policy desk review and direct experience of the authors. Vietnam saw remarkable growth of opioid use disorder (OUD) treatment from 2005 when methadone was unavailable, to 2020 with 335 methadone clinics in all 63 provinces serving more than 52,200 patients. The growth in OUD treatment accounts for much of Vietnam's success managing its HIV epidemic for which injection drug use was a major vector. An unintended consequence, however, focused only on OUD as a strategy to address HIV and was unable to address multiple substances. Most elements of a modern evidence and community-based SUD treatment system exist in Vietnam; however, they are siloed and influenced by multiple government administrative jurisdictions. Faced with rising amphetamine and persistent alcohol use, the path ahead for Vietnam involves a choice between a reliance on compulsory rehabilitation centers or a plan to broaden the scope of substances and treatments, and further integrate with Vietnam's commune-based primary health system.

Specifying and Pilot Testing Quality Measures for the American Society of Addiction Medicine's Standards of Care.

OBJECTIVES: In 2013, the American Society of Addiction Medicine (ASAM) approved its Standards of Care for the Addiction Specialist Physician. Subsequently, an ASAM Performance Measures Panel identified and prioritized the standards to be operationalized into performance measures. The goal of this study is to describe the process of operationalizing 3 of these standards into quality measures, and to present the initial measure specifications and results of pilot testing these measures in a large health care system. By presenting the process rather than just the end results, we hope to shed light on the measure development process to educate, and also to stimulate debate about the decisions that were made. METHODS: Each measure was decomposed into major concepts. Then each concept was operationalized using commonly available administrative data sources. Alternative specifications examined and sensitivity analyses were conducted to inform decisions that balanced accuracy, clinical nuance, and simplicity. Using data from the US Veterans Health Administration (VHA), overall performance and variation in performance across 119 VHA facilities were calculated. RESULTS: Three measures were operationalized and pilot tested: pharmacotherapy for alcohol use disorder, pharmacotherapy for opioid use disorder, and timely follow-up after medically managed withdrawal (aka detoxification). Each measure was calculable with available data, and showed ample room for improvement (no ceiling effects) and wide facility-level variability. CONCLUSIONS: Next steps include conducting feasibility and pilot testing in other health care systems and other contexts such as standalone addiction treatment programs, and also to study the specification and predictive validity of these measures.

Sustaining enrollment in health insurance for vulnerable populations: lessons from Massachusetts.

OBJECTIVE: Since 2008 Massachusetts has had universal health insurance with an individual mandate. As a result, only about 3% of the population is uninsured. However, patients who use behavioral health services are uninsured at much higher rates. This 2011 study sought to understand reasons for the discrepancy and identify approaches to reduce disenrollment and sustain coverage. METHODS: The qualitative study was based on structured interviews and focus groups. Structured interviews were conducted with 15 policy makers, consumer advocates, and chief executive officers of provider organizations, and three focus groups were held with 33 patient volunteers. RESULTS: The interviews and focus groups identified several disenrollment opportunities, all of which contribute to "churn" (the process by which disenrolled persons who remain eligible are reenrolled in the same or a different plan): missing and incomplete documentation, acute and chronic conditions and long-term disabilities that interfere with a patient's ability to respond to program communications, and lack of awareness among beneficiaries of the consequences of changes that trigger termination and the need to transfer to another program. Although safeguards are built into the system to avoid some disenrollments, the policies and procedures that drive the system are built on a default assumption of ineligibility or disenrollment until the individual establishes eligibility and completes requirements. Practices that can sustain enrollment include real-time Web-based prepopulated enrollment and redetermination processes, redetermination flexibility for designated chronic illnesses, and standardized performance metrics for churn and associated costs. CONCLUSIONS: Changes in the information system infrastructure and in outreach, enrollment, disenrollment, and reenrollment procedures can improve continuity and retention of health insurance coverage.

Examining access to addiction treatment: scheduling processes and barriers.

This paper reports on the phone scheduling systems that patients encounter when seeking addiction treatment. Researchers made a series of 28 monthly calls to 192 addiction treatment clinics to inquire about the clinics' first available appointment for an assessment. Each month, the date of each clinic's first available appointment and the date the appointment was made were recorded. During a 4-month baseline data collection period, the average waiting time from contact with the clinic to the first available appointment was 7.2 days. Clinics engaged in a 15-month quality improvement intervention in which average waiting time was reduced to 5.8 days. During the course of the study, researchers noted difficulty in contacting clinics and began recording the date of each additional attempt required to secure an appointment. On average, 0.47 callbacks were required to establish contact with clinics and schedule an appointment. Based on these findings, aspects of quality in phone scheduling processes are discussed. Most people with addiction seek help by calling a local addiction treatment clinic, and the reception they get matters. The results highlight variation in access to addiction treatment and suggest opportunities to improve phone scheduling processes.

Development of a Multilevel Framework to Increase Use of Targeted Evidence-Based Practices in Addiction Treatment Clinics.

Implementing specific evidence-based practices (EBPs) across a set of addiction treatment providers have been a persistent challenge. In the Advancing Recovery(AR) demonstration project, single state agencies, the entities that distribute federal funds for substance use disorder prevention and treatment services, worked in partnership with providers to increase the use of EBPs in the treatment of addiction. The project supported two cohorts of six 2-year awards. Field observations from the first year of implementation guided development of a multilevel framework (the Advancing Recovery Framework). Government entities and other payers can use the framework as a guide for implementing evidence-based clinical practices within treatment networks. The Advancing Recover Framework calls for a combination of policy and organizational changes at both the payer (government agency) and provider levels. Using the Advancing Recovery Framework, 11 of the 12 AR payer/provider partnerships increased use of clinical EPBs. This article identifies key payer policy changes applied during different phases of EBP program implementation. The public health benefit of the demonstration project was broader use of medication-assisted therapy and continuing care in addiction treatment services.

Massachusetts's experience suggests coverage alone is insufficient to increase addiction disorders treatment.

The Affordable Care Act is aimed at extending health insurance to more than thirty million Americans, including many with untreated substance use disorders. Will those who need addiction treatment receive it once they have insurance? To answer that question, we examined the experience of Massachusetts, which implemented its own universal insurance law in 2007. As did the Affordable Care Act, the Massachusetts reform incorporated substance abuse services into the essential benefits to be provided all residents. Prior to the law's enactment, the state estimated that a half-million residents needed substance abuse treatment. Our mixed-methods exploratory study thus asked whether expanded coverage in Massachusetts led to increased addiction treatment, as indicated by admissions, services, or revenues. In fact, we observed relatively stable use of treatment services two years before and two years after the state enacted its universal health care law. Among other factors, our study noted that the percentage of uninsured patients with substance abuse issues remains relatively high--and that when patients did become insured, requirements for copayments on their care deterred treatment. Our analysis suggests that expanded coverage alone is insufficient to increase treatment use. Changes in eligibility, services, financing, system design, and policy may also be required.

The readiness of addiction treatment agencies for health care reform.

The Patient Protection and Affordable Care Act (PPACA) aims to provide affordable health insurance and expanded health care coverage for some 32 million Americans. The PPACA makes provisions for using technology, evidence-based treatments, and integrated, patient-centered care to modernize the delivery of health care services. These changes are designed to ensure effectiveness, efficiency, and cost-savings within the health care system.To gauge the addiction treatment field's readiness for health reform, the authors developed a Health Reform Readiness Index (HRRI) survey for addiction treatment agencies. Addiction treatment administrators and providers from around the United States completed the survey located on the http://www.niatx.net website. Respondents self-assessed their agencies based on 13 conditions pertinent to health reform readiness, and received a confidential score and instant feedback.On a scale of "Needs to Begin," "Early Stages," "On the Way," and "Advanced," the mean scores for respondents (n = 276) ranked in the Early Stages of health reform preparation for 11 of 13 conditions. Of greater concern was that organizations with budgets of < $5 million (n = 193) were less likely than those with budgets > $5 million to have information technology (patient records, patient health technology, and administrative information technology), evidence-based treatments, quality management systems, a continuum of care, or a board of directors informed about PPACA.The findings of the HRRI indicate that the addiction field, and in particular smaller organizations, have much to do to prepare for a future environment that has greater expectations for information technology use, a credentialed workforce, accountability for patient care, and an integrated continuum of care.

Advancing recovery: implementing evidence-based treatment for substance use disorders at the systems level.

OBJECTIVE: A multisite evaluation examined the process and outcomes of Advancing Recovery, a Robert Wood Johnson Foundation initiative to overcome barriers to implementing evidence-based treatments within alcohol and drug treatment systems. METHOD: We report findings from a 3-year, mixed-method study of how treatment systems promoted two evidence-based practices: medication-assisted treatment and continuing care management. We compared outcomes and implementation strategies across 12 state/county agencies responsible for alcohol and drug treatment and their selected treatment centers. Each partnership received 2 years of financial and technical support to increase adoption of evidence-based treatments. RESULTS: Partnerships flexibly applied the Advancing Recovery model to promote the adoption of evidence-based treatments. Most sites achieved a measurable increase in the numbers of patients served with evidence-based practices, up from a baseline of virtually no use. Rates of adopting medication-based treatments were higher than those for continuing care management. Partnerships used a menu of top-down and bottom-up strategies that varied in specifics across sites but shared a general process of incremental testing and piecemeal adaptation. CONCLUSIONS: Supported partnerships between providers and policymakers can achieve wider adoption of evidence-based treatment practices. Systems change unfolds through a trial-and-error process of adaptation and political learning that is unique to each treatment system. This leads to considerable state and local variation in implementation strategies and outcomes.

Advancing performance measures for use of medications in substance abuse treatment.

Performance measures have the potential to drive high-quality health care. However, technical and policy challenges exist in developing and implementing measures to assess substance use disorder (SUD) pharmacotherapy. Of critical importance in advancing performance measures for use of SUD pharmacotherapy is the recognition that different measurement approaches may be needed in the public and private sectors and will be determined by the availability of different data collection and monitoring systems. In 2009, the Washington Circle convened a panel of nationally recognized insurers, purchasers, providers, policy makers, and researchers to address this topic. The charge of the panel was to identify opportunities and challenges in advancing use of SUD pharmacotherapy performance measures across a range of systems. This article summarizes those findings by identifying a number of critical themes related to advancing SUD pharmacotherapy performance measures, highlighting examples from the field, and recommending actions for policy makers.

Improving care for the treatment of alcohol and drug disorders.

The Network for the Improvement of Addiction Treatment (NIATx) teaches alcohol and drug treatment programs to apply process improvement strategies and make organizational changes that improve quality of care. Participating programs reduce days to admission, increase retention in care, and spread the application of process improvement within their treatment centers. More generally, NIATx provides a framework for addressing the Institute of Medicine's six dimensions of quality care (i.e., safe, effective, patient-centered, efficient, timely, and equitable) in treatments for alcohol, drug, and mental health disorders. NIATx and its extensions illustrate how the behavioral health field can respond to the demand for higher quality treatment services.

Making "stone soup": improvements in clinic access and retention in addiction treatment.

BACKGROUND: The Network for Improvement of Addiction Treatment (NIATx) provides 39 treatment organizations with collaborative learning opportunities and technical support to reduce waiting time between the first request for service and the first treatment session, reduce the number of patients who do not keep an appointment (no-shows), increase the number of people admitted to treatment, and increase continuation from the first through the fourth treatment session. ACADIA'S STORY-TREATMENT ON DEMAND: Given capacity constraints, only 25% of the clients scheduled for outpatient care at Acadia Hospital (Bangor, Maine) showed up for their assessment appointments, and only 19% made it into treatment. A variety of changes were introduced, including increasing staff availability to provide clients with assessments immediately on arrival (at 7:30 A.M.), establishing a clinician pool to handle client overflow, and allowing for same-day admission to intensive outpatient or chemical dependency services. These process improvements reduced the time from first contact to the first treatment session from 4.1 to 1.3 days (68%), reduced client no-shows, and increased continuation in treatment and transfers across levels of care. DISCUSSION: The successes experienced by organizations in the NIATx initiative should be useful for implementing change in other fields of service delivery.

The Network for the Improvement of Addiction Treatment (NIATx): enhancing access and retention.

The Network for the Improvement of Addiction Treatment (NIATx) teaches participating treatment centers to use process improvement strategies. A cross-site evaluation monitored impacts on days between first contact and first treatment and percent of patients who started treatment and completed two, three and four units of care (i.e., one outpatient session, 1 day of intensive outpatient care, and 1 week of residential treatment). The analysis included 13 agencies that began participation in August 2003, submitted 10-15 months of data, and attempted improvements in outpatient (n=7), intensive outpatient (n=4) or residential treatment services (n=4) (two agencies provided data for two levels of care). Days to treatment declined 37% (from 19.6 to 12.4 days) across levels of care; the change was significant overall and for outpatient and intensive outpatient services. Significant overall improvement in retention in care was observed for the second unit of care (72-85%; 18% increase) and the third unit of care (62-73%; 17% increase); when level of care was assessed, a significant gain was found only for intensive outpatient services. Small incremental changes in treatment processes can lead to significant reductions in days to treatment and consistent gains in retention.

Automating addiction treatment: enhancing the human experience and creating a fix for the future.

The country's system of providing treatment for people struggling with addiction requires a fundamental overhaul. To address these daunting problems, a group of experts from outside the addiction field met in an intensive retreat and envisioned a new future for addiction treatment that would use the latest available technology. Retreat leaders employed creative techniques to help free up thinking beyond incremental improvement ideas. Current and former addicts or alcoholics and family members also attended the retreat to provide the panelists with a real-world understanding of their lives. Through this process, the panelists generated eight idea categories that visualized future treatments for addiction using technology. They were: (1) Integrated System and Record; (2) Monitoring/Treatment; (3) Virtual Experiences; (4) Treatment Access and "One Stop Shop"; (5) Networks; (6) Tailored Media Campaigns; (7) Diagnostic Tools; and (8) Help for Family. Two stories illustrate how these ideas could help a heroin addict and an alcoholic. The sponsors plan another meeting to bring these visionary concepts closer to real application.