California Substance Abuse Research Consortium (SARC) Meetings 2009

 Table of Contents

SARC Supplement No. 6

September  2010

Substance Abuse Research Consortium (SARC) Introduction: Moving Forward to Improve Addiction Treatment in California —Renée Zito

Editor’s Introduction: Improving the Addiction Treatment System in California through the Use of Data and Evidence-Based Practices – California Substance Abuse Research Consortium (SARC) Meetings, 2009 — Beth Rutkowski, M.P.H.; Richard Rawson, Ph.D. & Thomas Freese, Ph.D.

Improving the Accountability of California’s Public Substance Abuse Treatment System through the Implementation of Performance Models — Richard A. Rawson, Ph.D.; Rachel Gonzales, Ph.D.; Desirée Crèvecoeur-MacPhail, PhD.; Darren Urada, Ph.D.; Mary-Lynn Brecht, Ph.D.; Mady Chalk, Ph.D.; Jack Kemp, Ph.D.& Michael Cunningham, M.A.

Adoption of Motivational Interviewing and Motivational Enhancement Therapy Following Clinical Trials — Joseph Guydish, Ph.D.; Martha Jessup, R.N., Ph.D.; Barbara Tajima, M.Ed. & Sarah Turcotte Manser, M.A.

Adoption of Medications in Substance Abuse Treatment:  Priorities and Strategies of Single State Authorities —Traci Rieckmann, Ph.D.; Anne E. Kovas, M.P.H. & Beth A. Rutkowski, M.P.H.

Screening, Brief Intervention, and Referral to Treatment (SBIRT) Initiatives in California:

Notable Trends, Challenges, and Recommendations —Mehrnaz Davoudi, M.P.H. & Richard A. Rawson, Ph.D.

“I’ve been NIATxed”: Participants’ Experience with Process Improvement — Desirée Crèvecoeur-MacPhail, Ph.D.; Anne Bellows, M.S.W.; Beth A. Rutkowski, M.P.H.; Loretta Ransom, B.A.; Ana Ceci Myers, M.S & Richard A. Rawson, Ph.D.

Performance Improvement in Addiction Treatment: Efforts in California — Diane M. Herbeck, M.A.; Rachel Gonzales, Ph.D. & Richard A. Rawson, Ph.D.

Inside the Black Box: Measuring Addiction Treatment Services and Their Relation to Outcomes — Desirée Crèvecoeur-MacPhail, Ph.D.; Loretta Ransom, B.A.; Ana Ceci Myers, M.S.; Jeffrey J. Annon, M.A.; Nancy Diep, B.A.; Rachel Gonzales, Ph.D.; Richard A. Rawson, Ph.D.; John Viernes, Jr. M.A.; Wayne Sugita, M.P.A. & James Barger, M.D..

Indicated Prevention: Bridging the Gap, One Person at a Time — William W. Harris, B.S., C.A.D.C. II & Jan Ryan, M.A.

A Field Experiment in Capitated Payment Systems and Recovery Management:  The Women’s Recovery Association Pilot Study — Bryn King, M.S.W.; Stephen Kaplan & Thomas Hofstedt, Ph.D.

Chronic Care and Addictions Treatment: A Feasibility Study on the Implementation of

Posttreatment Continuing Recovery Monitoring — Mark Stanford, Ph.D. ; Kakoli Banerjee, Ph.D. & Robert Garner, B.A.

Closing the Gaps: The Impact of Inpatient Detoxification and Continuity of Care on Client Outcomes — Lucy K. Ford, L.C.S.W. & Patrick Zarate. 

COVER ART — Free Thinking by Rori Ranch Productions

Abstracts

Improving the Accountability of California’s Public Substance Abuse Treatment System through the Implementation of Performance Models — Richard A. Rawson, Ph.D.; Rachel Gonzales, Ph.D.; Desirée Crèvecoeur-MacPhail, PhD.; Darren Urada, Ph.D.; Mary-Lynn Brecht, Ph.D.; Mady Chalk, Ph.D.; Jack Kemp, Ph.D.& Michael Cunningham, M.A.

Abstract—Improving the care for individuals with substance use disorders is a national health policy priority. Like other parts of the health care system, the addiction field is under pressure for higher accountability—more efficient use of treatment resources, the delivery of quality services, and the production of positive client outcomes. This introductory article highlights the importance of the collection of articles being published in this special issue as they describe California’s efforts toward making the alcohol and drug (AOD) treatment system more accountable and effective. 

Keywords—accountability, performance standards, system improvement 

Adoption of Motivational Interviewing and Motivational Enhancement Therapy Following Clinical Trials — Joseph Guydish, Ph.D.; Martha Jessup, R.N., Ph.D.; Barbara Tajima, M.Ed. & Sarah Turcotte Manser, M.A.

Abstract—The National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) is designed to test drug abuse treatment interventions in multisite clinical trials and to support the translation of effective interventions into practice. In this study, qualitative methods were applied to examine adoption of motivational interviewing and motivational enhancement therapy (MI/MET) in five clinics where these interventions were tested. Participants were clinic staff (n = 17) who were interviewed about the MI/MET study, and about whether MI/MET was adopted after the study ended. Although clinics’ participation in a clinical trial includes many elements thought to be necessary for later adoption of the intervention, we found that there was “adoption” in one clinic, “partial adoption” in one clinic, “counselor adoption” in one clinic, and “no adoption” in two clinics. These findings highlight a distinction between adoption at the organizational and counselor levels, and suggest that a range of adoption outcomes may be observed in the field. Findings are relevant to clinical staff, program directors, administrators and policy makers concerned with improvement of drug abuse treatment systems through adoption of evidence-based practices.

Keywords—adoption, clinical trials, dissemination, drug abuse treatment, implementation

Adoption of Medications in Substance Abuse Treatment:  Priorities and Strategies of Single State Authorities —Traci Rieckmann, Ph.D.; Anne E. Kovas, M.P.H. & Beth A. Rutkowski, M.P.H.

Abstract—Research has confirmed the effectiveness of medications, when used in conjunction with ongoing counseling, to treat substance abuse disorders. This article describes a national, mixed-methods research project designed to investigate single state authorities’ (SSAs) perceptions of adoption of evidence-based practices in substance abuse treatment. Results are focused specifically on medication-assisted treatment, one of five evidence-based practices defined by the National Quality Forum. Medication-assisted treatment (MAT) is an important and effective part of comprehensive care options available to clients who are chronically ill with alcohol and other drug disorders. Despite mounting clinical evidence and increased availability, overall rates of implementation and sustained adoption of medications to treat addiction remain limited. The results illustrate that the SSA representatives who fund public treatment programs believe MAT is a priority and worthy of system-wide implementation. Current strategies utilized by SSAs to support the adoption of MAT are detailed, as are barriers to adoption and implementation.

Keywords—barriers to adoption, evidence-base practices, facilitative factors, medication-assisted treatment, National Quality Forum, single state authority (SSA)

Screening, Brief Intervention, and Referral to Treatment (SBIRT) Initiatives in California: Notable Trends, Challenges, and Recommendations —Mehrnaz Davoudi, M.P.H. & Richard A. Rawson, Ph.D.

Abstract—It is estimated that most substance users are not substance-dependent, yet they misuse alcohol and/or other drugs on a regular basis and are at risk in terms of health and further dependency. Screening, brief intervention, and referral to treatment (SBIRT) is an intervention model that identifies at-risk substance users and then provides them a patient-centered intervention. A review of selected SBIRT initiatives in California revealed a number of positive trends: the involvement of healthcare settings in substance use prevention; an increase in the number of providers trained in substance use screening; greater use of standardized screening tools; indications of reduced substance use by individuals receiving SBIRT; and the establishment of statewide policy initiatives. Despite these positive trends, SBIRT projects continue to face challenges related to leadership support, staff resources, integration into ongoing protocols, screening, client retention, client confidentiality, and data collection. To assist projects to overcome these challenges and to ensure future adoption and sustainability of SBIRT, state and local authorities can benefit from (a) promoting SBIRT among healthcare leaders, (b) identifying and sharing successful SBIRT “models,” (c) providing tailored trainings and ongoing technical assistance, (d) educating providers about patient confidentiality and reimbursement laws and regulations, and (e) creating benchmark measures and data collection protocols.

Keywords—early detection; policy; prevention; screening, brief intervention, and referral to treatment (SBIRT); substance use

“I’ve been NIATxed”: Participants’ Experience with Process Improvement — Desirée Crèvecoeur-MacPhail, Ph.D.; Anne Bellows, M.S.W.; Beth A. Rutkowski, M.P.H.; Loretta Ransom, B.A.; Ana Ceci Myers, M.S & Richard A. Rawson, Ph.D.

Abstract— Process improvement strategies provide industries with a method for improving outcomes and performance at a low cost and with minimal training. In Los Angeles County, two process improvement projects were implemented as a way to improve access to, and engagement and retention in, alcohol and other drug abuse treatment. A qualitative evaluation was completed after the Phase II pilot project to assess how the providers felt about the project, what worked, what did not work, what was learned, and the degree to which process improvements changed program operations.  Semistructured interviews were conducted with 33 individuals, representing every level of staff participation in the project. Overall, comments indicated a positive experience for staff, administrators, and clients. Providers noted the relative ease of implementation and how quickly changes resulted in impressive improvements. Challenging issues included resistant staff or a lack of additional resources to pay for the project; however, most noted that these issues were resolved. Interview participants also requested more training on data collection and a reduction in the frequency of the project conference calls. This study gives support to the idea of process improvement being a tool that dramatically improves services to consumers of addiction treatment services.
Key Words— process improvement, NIATx, change team, data collection, qualitative analysis, substance abuse

Performance Improvement in Addiction Treatment: Efforts in California — Diane M. Herbeck, M.A.; Rachel Gonzales, Ph.D. & Richard A. Rawson, Ph.D.

Abstract—This article examines performance data improvement efforts among alcohol and other drug (AOD) county and program stakeholders within California’s publicly-funded treatment system. County AOD system administrators from approximately two-thirds of California counties (N = 37) and a random sample of treatment program managers (N = 63) were surveyed about practices and priorities related to using performance data to improve service delivery. Survey results showed that over half (56.8%) of the county administrators reported using performance and/or outcome measures to guide decision-making about the treatment programs with which they contract. Measures of treatment engagement and retention were most frequently reported as high priorities for performance data collection. Treatment providers reported considerable variation with their use of performance measures to improve practices. Overall, findings from this study suggest that many programs and counties are taking steps toward adopting practices of performance measurement and management for treatment improvement, although they still require assistance and support in establishing, collecting, and using performance data.

Keywords—addiction treatment, performance measurement, system improvement

Inside the Black Box: Measuring Addiction Treatment Services and Their Relation to Outcomes — Desirée Crèvecoeur-MacPhail, Ph.D.; Loretta Ransom, B.A.; Ana Ceci Myers, M.S.; Jeffrey J. Annon, M.A.; Nancy Diep, B.A.; Rachel Gonzales, Ph.D.; Richard A. Rawson, Ph.D.; John Viernes, Jr. M.A.;  Wayne Sugita, M.P.A. & James Barger, M.D..

Abstract — The adoption of performance-based management has been under consideration by addiction treatment funding agencies, and, recently, many state and county agencies have developed performance-based measurement/management systems in an attempt to improve their treatment system.  This article describes one such effort in Los Angeles County, California.  The Performance-Based Pilot Project linked treatment encounters (counseling sessions, drug testing, case management, and methadone dosing) with client outcomes (abstinence or reduced drug use at discharge) and longer lengths of stay in treatment.   Eleven outpatient counseling programs and three narcotic treatment programs participated in the nine-month project.   Results indicated that for both outpatient counseling and narcotic treatment programs, more sessions attended in the first 30 days was associated with better client outcomes and longer lengths of stay.   Furthermore, in outpatient counseling programs, more group sessions during the first 30 days predicted abstinence or greater reductions in primary drug use; in narcotic treatment programs, more doses received during the first 30 days was correlated to longer treatment retention. This research implies that increasing the availability of counseling sessions for a client’’s first 30 days and engaging clients early is a promising area for program efforts to improve treatment outcomes and program performance.
Key Words —addiction treatment, evaluation, performance, performance and outcomes.

Indicated Prevention: Bridging the Gap, One Person at a Time — William W. Harris, B.S., C.A.D.C. II & Jan Ryan, M.A.

Abstract—In 2007, Riverside County, California, after identifying a gap between the substance abuse prevention and treatment services it offered to individuals, developed the Individual Prevention Services (IPS) program to fill that gap. Over the past two years, the IPS program has provided individualized prevention services on a one-on-one basis at all seven of the county’s substance abuse treatment clinics. The IPS program is provided to those individuals who are at highest risk for developing substance abuse related problems, i.e., those individuals who have some history of substance use/misuse, but have not yet reached a point where treatment is indicated. This unique “one person at a time” prevention service is provided at no cost to individuals in all age groups (from age 12 to senior citizens) and is based, in part, on a local student assistance model that offers over 20 years of proven results.

Keywords—brief intervention, Brief Risk Reduction Interview and Intervention Model (BRRIIM), Continuum of Services System Re-Engineering (COSSR) Task Force, indicated prevention, prevention service agreement

A Field Experiment in Capitated Payment Systems and Recovery Management: The Women’s Recovery Association Pilot Study — Bryn King, M.S.W.; Stephen Kaplan & Thomas Hofstedt, Ph.D.

Abstract—Against the backdrop of shifting perspectives regarding substance abuse policy, upcoming changes to the health care system, and progress toward parity for mental health and substance abuse treatment, an exploratory pilot study is being conducted in San Mateo County, California, to assess the potential of a capitated case rate combined with a recovery management approach in a community-based substance abuse treatment program for women. The rationale for developing the approach, planning, and implementation of the pilot project, the struggle of the agency to transform from episodic treatment to a chronic care model, and a case study that highlights organizational changes are discussed. Lessons learned and implications for the second year of the pilot project are also discussed.

Keywords—capitated payment, case rate approach, chronic care model, gender-specific treatment, recovery management, substance abuse treatment

Chronic Care and Addictions Treatment: A Feasibility Study on the Implementation of Posttreatment Continuing Recovery Monitoring — Mark Stanford, Ph.D. ; Kakoli Banerjee, Ph.D. & Robert Garner, B.A.

Abstract—In the treatment of drug addiction, as with other chronic conditions, the effects of treatment are significant but not long lasting after discharge unless continuing monitoring is provided. Efforts to help patients sustain positive treatment outcomes are generally directed to community support. Post-discharge checkups can help patients evaluate their behavior and recovery-related issues—similar to a person with diabetes reporting on blood sugar levels and diet and exercise patterns. The challenge for providers is to raise awareness of the importance of continuing recovery monitoring and the responsibility of the treatment program to build a more seamless continuum of care for patients who have completed a primary treatment episode. This article reviews a pilot project of the Department of Alcohol & Drug Services of Santa Clara County, California that tested the feasibility of implementing a continuing recovery monitoring (CRM) service using post-discharge telephone check-ups for volunteer patients (N = 32) who completed treatment. The aims of the study were to (a) develop a model for continuing recovery monitoring, (b) gather data on the model’s utility including identifying organizational and logistical challenges and, (c) describe several changes needed in the system of care to add CRM. The study showed that the model of continuing recovery monitoring is a feasible way to extend a system’s existing continuum of care.

Keywords—acute care model, chronic care, continuing recovery monitoring, coordinated care, system improvement model (SIM)

Closing the Gaps: The Impact of Inpatient Detoxification and Continuity of Care on Client Outcomes — Lucy K. Ford, L.C.S.W. & Patrick Zarate.

Abstract—Inpatient detoxification is a critical element of the continuum of care for chemically dependent individuals, especially for those unable to establish sobriety on an outpatient basis.  This study evaluated the impact of one such detoxification program on client outcomes during the year after detoxification. The program was a public/private partnership between Ventura County, California, and Tarzana Treatment Center in Los Angeles. Before admission, applicants agreed to enroll in treatment after detoxification. Clients were contacted at one month post-admission and quarterly thereafter for one year to collect data, corroborated by county records, on treatment and outcome variables. The sample included 117 consecutive admissions between July 2007 and June 2009. Detoxification completion rates and follow-up treatment enrollment rates were substantial: 85% of the sample completed detoxification; 71% enrolled in treatment afterward. Client outcomes were positive, particularly for those enrolled in follow-up treatment:  compared to clients not completing detoxification, and to client functioning in the year before admission, sobriety and employment rates increased, and rates of homelessness, arrests and days incarcerated decreased. The study concludes that public investment in inpatient detoxification services and aftercare is an effective means to decrease both individual and societal costs of addiction. 

Keywords—continuity of care, continuum of care, drug rehabilitation, inpatient drug detoxification, substance abuse treatment, treatment linkage, treatment outcomes