Using community surveys to inform the planning and implementation of environmental change strategies: participatory research in 12 Washington communities.

A number of studies have demonstrated the efficacy of environmental change strategies (ECS) in effecting community-level change on attitudes and behaviors related to underage drinking (Treno and Lee in Alcohol Res Health 26:35-40, 2002; Birckmayer et al. in J Drug Educ 34(2):121-153, 2004). Primary data collection to inform the design of these strategies, however, can be resource intensive and exceed the capacity of community stakeholders. This study describes the participatory planning and implementation of community-level surveys in 12 diverse communities in the state of Washington. These surveys were conducted through collaborations among community volunteers and evaluation experts assigned to each community. The surveys were driven by communities' prevention planning needs and interests; constructed from collections of existing, field-tested items and scales; implemented by community members; analyzed by evaluation staff; and used in the design of ECS by community-level leaders and prevention practitioners. The communities varied in the content of their surveys, in their sampling approaches and in their data collection methods. Although these surveys were not conducted using traditional rigorous population survey methodology, they were done within limited resources, and the participatory nature of these activities strengthened the communities' commitment to using their results in the planning of their environmental change strategies.

A mixed-method exploration of functioning in Safe Schools/Healthy Students partnerships.

This paper presents a mixed-method approach to measuring the functioning of Safe Schools/Healthy Students (SS/HS) Initiative partnerships. The SS/HS national evaluation team developed a survey to collect partners' perceptions of functioning within SS/HS partnerships. Average partnership functioning scores were used to rank each site from lowest to highest. Sites with the most favorable perceptions of partnership functioning were defined as having average scores in the top 10% (n=10) and sites with the least favorable perceptions of partnership functioning were defined as having average scores in the bottom 10% (n=10). Qualitative data for these 20 sites were inductively open coded for emergent themes and analyzed for patterns using grounded theory approach. Six themes emerged that distinguished sites reporting the most favorable and least favorable perceptions of partnership functioning: partner engagement, facilitators, barriers, shared decision making, partnership structure, and sustainability. Sites reporting the most favorable perceptions of partnership functioning effectively utilized collaboration processes that facilitate coalition building, such as shared decision making, effective communication, and developing a clearly defined structure. Qualitative themes from this analysis provide evidence of validity for the partnership functioning scale used and illustrate distinguishing features between sites with the most favorable and least favorable perceptions of partnership functioning.

Challenges substance abuse treatment agencies faced in adoption of computer-based technology to improve assessment.

The Oregon Practice Improvement Collaborative provided resources and technical assistance to help five Oregon drug treatment agencies adopt computer-based technology of their choice to support client progress in treatment. This manuscript describes agency processes related to that adoption of technology. Agencies chose computer programs to improve clinical outcomes, reduce staff burden, and respond to external pressures. Agencies used a combination of top-down and bottom-up approaches to involve staff in decision making. Agencies guided staff from current practice to a standardized paper-and-pencil tool, then from the paper-and-pencil tool to its electronic version. Staff experienced barriers in technology-related training, logistical challenges in integrating the technology, and sustaining the technology.

A population-based study on substance abuse treatment for adults with disabilities: access, utilization, and treatment outcomes.

AIMS: To examine potential disparities in access to substance abuse treatment services for Medicaid-eligible adults with disabilities, and compare utilization rates and outcomes in outpatient programs. DESIGN: Population-based multi-year cross-sectional study. SETTING: State-wide examination of substance-abuse treatment, particularly outpatient. PARTICIPANTS: Medicaid enrollees aged 18-64. MEASURES: Treatment access and utilization; outcome measures of retention, completion, readmission, and abstinence derived from state treatment and Medicaid databases. FINDINGS: Access and utilization rates for adults with disabilities were about half others' rates; treatment outcomes were generally equivalent across groups. CONCLUSIONS: Adults with disabilities are underutilizing substance abuse treatment, suggesting barriers to accessing treatment.

Prospective validation of substance abuse severity measures from administrative data.

BACKGROUND: Severity measures for clients in substance abuse treatment programs are becoming increasingly important as funders adopt payment systems linked to agency performance. Recently, two severity measures based on administrative data have been developed. This study validated these measures using prospective data. METHODS: Subjects were participants in the Drug Abuse Treatment Outcomes Study (adult or adolescent components) or the Substance Abuse and Mental Health Services Administration Medicaid Managed Behavioral Healthcare and Vulnerable Populations project (adult or adolescent chemical dependency components). Severity measures were calculated based on data obtained at entry into substance abuse treatment. The baseline severity measures were included along with age, gender, and race/ethnicity in logistic regression models predicting abstinence at follow-up for alcohol use, marijuana use, cocaine use, or heroin use. RESULTS: For adults, the severity measures were highly statistically significant (p<0.001) for all models in both data sets, indicating that adults with higher severity were more likely (and much more likely in many cases) to use alcohol, marijuana, cocaine, or heroin at the follow-up interview than were those with lower severity. For adolescents, the severity measure was highly statistically significant (p<0.001) for marijuana in both data sets and for alcohol in the Medicaid data set. CONCLUSIONS: Baseline severity measures were powerful predictors of abstinence at follow-up. These measures, derived from routinely available electronic records, appear to have noteworthy predictive validity. The severity indicators can be used for administrative purposes such as risk-adjustment when examining treatment agency performance.

Access barriers to substance abuse treatment for persons with disabilities: an exploratory study.

Research in substance abuse (SA) treatment has demonstrated that persons with disabilities (PWDs) are at substantially higher risk for SA than persons without disabilities. Despite their higher risk, PWDs access SA treatment at a much lower rate than persons without disabilities. Using the Behavioral Model for Vulnerable Populations as a research framework, we identified reasons for differences in access to SA treatment for Medicaid-eligible adults with disabilities in Oregon through a multiphase study. Analyses of demographic and referral source data, along with interviews with key state agency representatives, adults with disabilities, and treatment program personnel, helped identify barriers to SA treatment access. These barriers are reflected as attributes of PWDs, contextual variables that enable or impede access, recognition of the need for SA treatment, and characteristics of treatment services. The findings suggest needed policy and practice changes to increase access rates for PWDs. They provide direction for future research.

Organization and financing of alcohol and substance abuse programs for American Indians and Alaska Natives.

OBJECTIVES: Although American Indians and Alaska Natives have high rates of substance abuse, few data about treatment services for this population are available. We used national data from 1997-2002 to describe recent trends in organizational and financial arrangements. METHODS: Using data from the Indian Health Service (IHS), the Substance Abuse and Mental Health Services Administration, the National Institute on Alcohol Abuse and Alcoholism, the Henry J. Kaiser Family Foundation, and the Census Bureau, we estimated the number of American Indians served by substance abuse treatment programs that apparently are unaffiliated with either the IHS or tribal governments. We compared expected and observed IHS expenditures. RESULTS: Half of the American Indians and Alaska Natives treated for substance abuse were served by programs (chiefly in urban areas) apparently unaffiliated with the IHS or tribal governments. IHS substance abuse expenditures were roughly what we expected. Medicaid participation by tribal programs was not universal. CONCLUSIONS: Many Native people with substance abuse problems are served by programs unaffiliated with the IHS. Medicaid may be key to expanding needed resources.

Relating substance abuse counselor background to the provision of clinical tasks.

This study examines the diverse academic and professional background characteristics of substance abuse treatment counselors, relating these characteristics to the work counselors are doing. Results indicate that while academic and professional background characteristics differentiate whether counselors perform certain clinical tasks or not, they do not differentiate the amount of time they spend doing them. In fact, regression analyses indicate that academic and professional background characteristics currently account for less than 10% of the total variability associated with how counselors spend their time. While meager, the best predictors of individual work tasks appear to be more contextual in nature. The fact that academic and professional background characteristics do not differentiate counselors in terms of time spent on specific clinical responsibilities raises some questions regarding the quality of client care. Results also indicate that the knowledge and skill sets needed for counselors to be effective may vary according to the treatment setting.

Outcomes for medicaid clients with substance abuse problems before and after managed care.

Medicaid conversion from fee for service to managed care raised numerous questions about outcomes for substance abuse treatment clients. For example, managed care criticisms include concerns that clients will be undertreated (with too short and/or insufficiently intense services). Also of interest are potential variations in outcome for clients served by organizations with assorted financial arrangements such as for-profit status versus not-for-profit status. In addition, little information is available about the impact of state Medicaid managed care policies (including client eligibility) on treatment outcomes. Subjects of this project were Medicaid clients aged 18-64 years enrolled in the Oregon Health Plan during 1994 (before substance abuse treatment managed care, N = 1751) or 1996-1997 (after managed care, N = 14,813), who were admitted to outpatient non-methadone chemical dependency treatment services. Outcome measures were retention in treatment for 90 days or more, completion of a treatment program, abstinence at discharge, and readmission to treatment. With the exception of readmission, there were no notable differences in outcomes between the fee for service era clients versus those in capitated chemical dependency treatment. There were at most minor differences among various managed care systems (such as for-profit vs not-for-profit). However, duration of Medicaid eligibility was a powerful predictor of positive outcomes. Medicaid managed care does not appear to have had an adverse impact on outcomes for clients with substance abuse problems. On the other hand, state policies influencing Medicaid enrollment may have substantial impact on chemical dependency treatment outcomes.

The impact of managed care on publicly funded outpatient adolescent substance abuse treatment: service use and six-month outcomes in Oregon and Washington.

This study assessed the impact of managed care on publicly funded adolescent substance abuse treatment by comparing differences in service utilization and outcomes across prospective samples from two states: Oregon, which uses managed care practices in service financing and delivery, and Washington, which does not. One hundred and six adolescents from Washington and 94 from Oregon, who entered outpatient substance abuse treatment in 1998 and 1999, completed self-report surveys about their substance use before and after receiving treatment (follow-up rate = 75 percent). In addition, clinical chart reviews conducted at the 6-month follow-up assessed the type and amount of treatment these adolescents received during the study period. It was found that service utilization and treatment outcomes were comparable across the two state samples. The evidence presented here suggests that managed care is capable of delivering substance abuse treatment services of comparable quality to state-administered substance abuse treatment services.

Effect of managed care on access to mental health services among Medicaid enrollees receiving substance treatment.

OBJECTIVE: Mental health services are important to treatment retention and positive outcomes for many clients of substance abuse treatment programs. For these clients the implementation of managed care should provide for continued or increased access to mental health treatment, rather than decreased access because of short-term, cost-reduction objectives. This study assessed whether converting Medicaid from a fee-for-service program to a capitated, prepaid managed care program affected access to mental health services among clients who were treated for substance abuse. METHODS: Medicaid enrollees who were being treated for substance abuse in Oregon were interviewed before beginning treatment and after six months of service. One cohort (N=53) was interviewed one to six months before the implementation of managed care, a second (N=66) was interviewed two years after the implementation, and a third (N=49) was interviewed three to four years after the implementation. Logistic regression analyses were used to identify whether the implementation of managed care, the psychiatric need of the client, and other client characteristics affected the receipt of mental health services during the first six months of substance abuse treatment. RESULTS: Clients in all three cohorts had similar characteristics. The implementation of managed care did not affect whether clients received mental health services. A baseline interview score that was derived from items in the Addiction Severity Index psychiatric section was the only client characteristic that predicted receipt of mental health services. CONCLUSIONS: Although this study was a naturalistic experiment with many methodologic flaws, it provided a unique opportunity to observe whether the introduction of managed care changed access to mental health services among Medicaid enrollees who were being treated for substance abuse.

The toughest job you'll ever love: a Pacific Northwest Treatment Workforce Survey.

The training, recruitment, and retention of the most qualified professionals for the substance abuse treatment workforce is a crucial underlying strategy in the improvement of client care. Conducted in the year 2000, this survey of substance abuse treatment agency directors and clinical staff in the Pacific Northwest of the United States provides the first empirical estimates of issues surrounding these goals and points to the need for more aggressive strategies if a quality workforce is to be maintained and improved. Results of the survey indicate that there is an average of 25% turnover per year among treatment agency staff, and that the vast majority of this turnover is voluntary and stays within the treatment profession. Agency management and direct service staff differ in their perceptions of the recruitment and retention approaches currently in place in their agencies.

Oregon's transition to a managed care model for Medicaid-funded substance abuse treatment: steamrolling the glass menagerie.

The approval of a Health Care Financing Administration (now called Centers for Medicare and Medicaid Services) 1115 Medicaid waiver in Oregon allowed the state to design and implement an expanded publicly funded health care system, the Oregon Health Plan (OHP). Integral to OHP is the administration of physical and behavioral health services, including outpatient substance abuse treatment, through contracted managed care organizations. The two overarching changes to the outpatient substance abuse treatment system were expanded Medicaid eligibility and new operating procedures for the outpatient substance abuse treatment system. The authors used grounded theory to examine the effects of this transition on the treatment system, with an emphasis on the experiences of treatment providers.

Impact of patient placement criteria on substance abuse treatment under the Oregon Health Plan.

When Oregon shifted to managed care for Medicaid-funded substance abuse treatment, standardized patient placement and discharge criteria were rapidly implemented statewide. This prospective, naturalistic study examines the validity and impact of placement criteria with a sample of 240 adults presenting for treatment compared to a sample of 287 in Washington state, where implementation was phased in slowly. Baseline profile analysis suggested better differentiation between Level II and Level III clients for the Oregon sample and better implementation than with the Washington sample, presumably because Oregon clinicians received more training and had more experience with the criteria. A majority of the Oregon sample was placed in intensive outpatient programs, consistent with the recommended level of care. In this study, placement criteria showed good potential for changing treatment planning behavior, increasing individualization, and improving utilization of new levels of care.

Integration and its discontents: substance abuse treatment in the Oregon Health Plan.

With the creation of the Oregon Health Plan (OHP) in 1994, Oregon placed its Medicaid program under a managed care system. This paper examines the managed care practices of seven health plans serving OHP enrollees between 1996 and 1998. Results indicated that the original vision of integrating substance abuse treatment services with physical care for OHP enrollees evolved into a multilayered, carved-out approach. Factors working against integration included changes in the administration and management of the chemical dependency benefit, financial losses by health plans, and lack of training and incentives for physicians to refer clients to substance abuse treatment.

Reducing psychiatric hospital use of the rural poor through intensive transitional acute care.

A controlled study of the impact of brief, transitional acute care in reducing psychiatric treatment costs for people in rural areas is presented. Treatment emphasized home-based counseling and support, 24-hour rapid response, rural outreach, and intensive support management. The objective was to avert hospitalizations when possible, expedite discharge, and reduce likelihood of readmission, while maintaining comparable or superior clinical outcome. One-hundred eighty-two participants were randomly assigned to the experimental group or a routine care control group. Clinical and utilization data tracked at initial contact, 2 weeks, 6 months, and 12 months suggest substantially lower hospital utilization for the experimental group. Clinical outcomes were comparable between groups.