Organizational implementation of evidence-based substance abuse treatment in racial and ethnic minority communities

Inter-organizational alignment and implementation outcomes in integrated mental healthcare for children and adolescents: a cross-sectional observational study

BACKGROUND

Integrated care involves care provided by a team of professionals, often in non-traditional settings. A common example worldwide is integrated school-based mental health (SBMH), which involves externally employed clinicians providing care at schools. Integrated mental healthcare can improve the accessibility and efficiency of evidence-based practices (EBPs) for vulnerable populations suffering from fragmented traditional care. However, integration can complicate EBP implementation due to overlapping organizational contexts, diminishing the public health impact. Emerging literature suggests that EBP implementation may benefit from the similarities in the implementation context factors between the different organizations in integrated care, which we termed inter-organizational alignment (IOA). This study quantitatively explored whether and how IOA in general and implementation context factors are associated with implementation outcomes in integrated SBMH.

METHODS

SBMH clinicians from community-based organizations (CBOs; nclinician = 27) and their proximal student-support school staff (nschool = 99) rated their schools and CBOs (clinician only) regarding general (organizational culture and molar climate) and implementation context factors (Implementation Climate and Leadership), and nine common implementation outcomes (e.g., treatment integrity, service access, acceptability). The levels of IOA were estimated by intra-class correlations (ICCs). We fitted multilevel models to estimate the standalone effects of context factors from CBOs and schools on implementation outcomes. We also estimated the 2-way interaction effects between CBO and school context factors (i.e., between-setting interdependence) on implementation outcomes.

RESULTS

The IOA in general context factors exceeded those of implementation context factors. The standalone effects of implementation context factors on most implementation outcomes were larger than those of general context factors. Similarly, implementation context factors between CBOs and schools showed larger 2-way interaction effects on implementation outcomes than general context factors.

CONCLUSIONS

This study preliminarily supported the importance of IOA in context factors for integrated SBMH. The findings shed light on how IOA in implementation and general context factors may be differentially associated with implementation outcomes across a broad array of integrated mental healthcare settings.

Inter-Organizational Alignment and Implementation Outcomes in Integrated Mental Healthcare for Children and Adolescents: A Cross-Sectional Observational Study

Background

Integrated care involves care provided by a team of professionals, often in non-traditional settings. A common example worldwide is integrated school-based mental health (SBMH), which involves externally employed clinicians providing care at schools. Integrated mental healthcare can improve the accessibility and efficiency of evidence-based practices (EBPs) for vulnerable populations suffering from fragmented traditional care. However, integration can complicate EBP implementation due to overlapping organizational contexts, diminishing the public health impact. Emerging literature suggests that EBP implementation may benefit from the similarities in the implementation context factors between the different organizations in integrated care, which we termed inter-organizational alignment (IOA). This study quantitatively explored whether and how IOAs in general and implementation context factors are associated with implementation outcomes in integrated SBMH.

Methods

SBMH clinicians from community-based organizations (CBOs; nclinician=27) and their proximal student-support school staff (nschool=99) rated their schools and CBOs (clinician only) regarding general (organizational culture and molar climate) and implementation context factors (Implementation Climate and Leadership), and nine common implementation outcomes (e.g., treatment integrity, service access, acceptability). The levels of IOA were estimated by intra-class correlations (ICCs). We fitted multilevel models to estimate the standalone effects of context factors from CBOs and schools on implementation outcomes. We also estimated the 2-way interaction effects between CBO and school context factors (i.e., between-setting interdependence) on implementation outcomes.

Results

The IOA in general context factors exceeded those of implementation context factors. The standalone effects of implementation context factors on most implementation outcomes were larger than those of general context factors. Similarly, implementation context factors between CBOs and schools showed larger 2-way interaction effects on implementation outcomes than general context factors.

Conclusions

This study preliminarily supported the importance of IOA in context factors for integrated SBMH. The findings shed light on how IOA in implementation and general context factors may be differentially associated with implementation outcomes across a broad array of integrated mental healthcare settings.

The relationship between first-level leadership and inner-context and implementation outcomes in behavioral health: a scoping review

BACKGROUND

First-level leadership is uniquely positioned to support evidence-based practice (EBP) implementation for behavioral health due to first-level leaders' access to and relationship with service providers. First-level leaders are individuals who directly supervise and manage frontline employees who do not manage others. However, first-level leadership is underrepresented in existing reviews of the impact of leadership on EBP implementation. This review describes the relationship between first-level leadership and implementation determinants and outcomes.

METHODS

A scoping review was performed to synthesize the literature on the relationship between first-level leadership and inner-context and implementation outcomes. A literature search was conducted in PubMed, Eric, PsycINFO, CINAHL, Scopus, and Web of Science. To be eligible, studies had to examine first-level leadership, be conducted in settings providing behavioral health services, and examine the relationship between first-level leadership and an implementation or inner-context outcome. Data extraction and synthesis were performed to describe study characteristics, leader-outcome relationships, and overlap in leadership frameworks.

RESULTS

Twenty-one records met our inclusion criteria. Studies primarily relied on observational designs and were often cross-sectional. Studies more often examined general leadership rather than leadership strategically focused on EBP implementation (i.e., strategic implementation leadership). Our findings suggest that several forms of first-level leadership are inconsistently related to a broad set of implementation determinants, with infrequent examination of specific implementation outcomes. The broad set of implementation determinants studied, limited number of replications, and inconsistent findings have resulted in sparse evidence for any specific leadership-outcome relationship. The greatest accumulation of evidence exists for general leadership's positive relationship with providers' EBP attitudes, most notably in the form of transformational leadership. This was followed by evidence for strategic implementation leadership facilitating general implementation. Our synthesis revealed moderate conceptual overlap of strategic implementation leadership behaviors described in the theory of implementation leadership and theory of middle managers' role in implementation.

CONCLUSIONS

Our findings suggest that first-level leadership may play an important role in shaping implementation determinants and outcomes, but consistent empirical support is sparse and confidence dampened by methodological issues. To advance the field, we need studies that adopt stronger methodological rigor, address the conceptual overlap in leadership frameworks, examine a broader set of implementation outcomes, and examine conditions under which leadership impacts implementation.

TRIAL REGISTRATION

This review was not registered.

Advancing theory on the multilevel role of leadership in the implementation of evidence-based health care practices

Background:

Top managers’ transformational leadership is associated with significant influence on subordinates. Yet little is known about the extent to which top managers’ transformational leadership influences middle managers’ implementation leadership and, ultimately, frontline staff delivery of evidence-based health care practices.

Purpose:

To test a multilevel leadership model examining the extent to which top managers’ transformational leadership, as mediated by implementation leadership of middle managers (i.e., those who supervise direct clinical services), affects staff attitudes toward evidence-based practices (EBPs) and their implementation.

Methodology/Approach:

We used data collected in 2013 from 427 employees in 112 addiction health services programs in Los Angeles County, California. We relied on hierarchical linear models with robust standard errors to analyze multilevel data, individuals nested in programs. We conducted two path models to estimate multilevel relationships with two EBPs: contingency management and medication-assisted treatment.

Results:

Findings partially supported our theory-driven multilevel leadership model. Specifically, results demonstrated that middle managers’ implementation leadership mediated the relationship between top managers’ transformational leadership and attitudes toward EBPs. At the same time, they showed the mediated relationship for delivery of contingency management treatment was only marginally significant (standardized indirect effect = .006, bootstrap p = .091). We did not find a mediation effect for medication-assisted treatment.

Discussion:

Findings advance leadership theory in health care, highlighting the importance of middle managers’ implementation leadership in transmitting the influence of top managers’ transformational leadership on staff attitudes toward EBPs. The full path model shows the extent to which transformational leadership may influence staff implementation of innovative practices as mediated through staff attitudes toward EBPs and middle managers’ implementation leadership.

Practice Implications:

Our findings have implications for developing a multilevel leadership approach to implementation in health care. Leadership development should build on different competencies based on managers' level but align managers' priorities on the same implementation goals.

Ensuring access to high-quality substance use disorder treatment for Medicaid enrollees: A qualitative study of diverse stakeholders' perspectives

BACKGROUND

Medicaid programs are vital to ensure low-income individuals have access to substance use disorder (SUD) treatment. However, shifts in Medicaid policies may alter coverage and SUD care for this population, who already face difficulties receiving high-quality SUD treatment. Using a policy implementation research approach, we sought to identify barriers and facilitators when transitioning from Medicaid fee-for-service to managed care plan structures and opportunities for improving SUD care in New York State (NYS).

METHOD

Study staff conducted semistructured, in-depth qualitative interviews (N = 40 total) with diverse stakeholders involved with different aspects of SUD treatment in NYS, including policy leaders (n = 13), clinicians (n = 12), Medicaid managed care plan administrators (n = 5), and patients (n = 10).

RESULTS

Findings from thematic analysis centered on three themes: 1) while transitions to managed care have benefited clinicians, certain policies affect patients' Medicaid enrollment and quality of care; 2) stakeholders perceived individuals with dual diagnoses, older adults, and linguistic minorities to be at higher risk for inadequate care; and 3) current quality metrics may not adequately capture treatment quality.

CONCLUSION

Policy changes should focus on promoting increased collaboration among stakeholders, expanding Medicaid coverage, and reducing stigma. Resources should be diverted to facilitate psychiatric care for patients with dual diagnoses and to build workforce capacity to adequately meet the needs of older adults and linguistic minorities. Opportunities for NYS Medicaid include adapting performance metrics to capture meaningful patient outcomes and link reimbursements to improvements in patients' quality of life.

Barriers and Facilitators to the Implementation of the Pathways to Comorbidity Care (PCC) Training Package for the Management of Comorbid Mental Disorders in Drug and Alcohol Settings

Background: We have previously reported that the Pathways to Comorbidity Care (PCC) training program for alcohol and other drug (AOD) clinicians improved identification of comorbidity, self-efficacy, and attitudes toward screening and monitoring of comorbidity. We aimed to identify barriers and facilitators of implementation of the PCC training program in drug and alcohol settings. Methods: The PCC training program was implemented across 6 matched sites in Australia as per (1), and 20 clinicians received training. PCC training included seminar presentations, workshops conducted by local "clinical champions," individual clinical supervision, and access to an online information portal. We examined barriers and facilitators of implementation according to the Consolidated Framework for Implementation Research. Results: Barriers included inner setting (e.g., allocated time for learning) and characteristics of individuals (e.g., resistance). Facilitators included intervention characteristics (e.g., credible sources), inner setting (e.g., leadership), and outer setting domains (e.g., patient needs). Clinical champions were identified as an important component of the implementation process. Conclusions: Barriers included limited specific allocated time for learning. A credible clinical supervisor, strong leadership engagement and an active clinical champion were found to be facilitators of the PCC training program.

"En la Lucha": Strategies to Improve HIV Care for Puerto Ricans with Opioids Use Disorders

BACKGROUND

Clínica Bienestar is a comprehensive HIV primary care clinic for Spanish-speaking Latinx with opioids use disorders (OUD). This article describes the barriers and trajectories to HIV viral suppression for Puerto Ricans with a transnational profile and dual diagnoses (HIV and OUD), and the strategies applied to increase retention in care.

METHODS

Case study methodology was used to select two patient life histories that illustrate the most common pathways to success in reducing HIV viral load to undetectable and achieving OUD long-term recovery.

RESULTS AND DISCUSSION

Patients' major challenges included: (1) Persistent migrating while seeking substance use treatment services with limited or no support from their sending and hosting communities; (2) Intersectional stigmas; (3) Untreated trauma; (4) Language and cultural barriers. Clínica Bienestar's service model included ten strategies to retain patients in care (e.g., Case management to identify cases with high social isolation), six emerged as central to addressing transnational challenges.

Attitudes Towards Evidence-Based Practice in Substance Use Treatment Programs Serving American Indian Native Communities

The objective of this paper was to compare attitudes towards evidence-based practice (EBP) of substance use disorder treatment (SUDT) center employees' serving American Indian and Alaskan Native (AIAN) populations to those serving non-AIAN populations. Survey data on the openness and divergence subscales of the Evidence-Based Practice Attitude Scale (EBPAS) were collected and analyzed. Independent samples T tests were performed to compare the two samples. For all comparisons, except the divergence subscale between counselors, the SUDT employees serving AIANs had significantly lower mean openness scores and higher mean divergence scores than those serving non-AIANs. This study suggests that employees of SUDT centers serving AIAN population hold less positive attitudes towards the adoption and use of EBP than non-AIAN.

The Temporal Relationship Between Medicaid Payment Acceptance and the Implementation of Medication-Assisted Drug Treatment

OBJECTIVE

To examine the temporal relationship of Medicaid funding on the implementation of evidence-based practices (EBPs) in outpatient substance use disorder (SUD) treatment.

METHODS

We examined data from 61 publicly funded SUD treatment programs in 2011 and 2013 using crossed-lagged regressions. We tested the impact of Medicaid payment acceptance on 2 measures of EBP implementation-contingency management treatment (CMT) and medication-assisted treatment (MAT).

RESULTS

Medicaid payment acceptance at wave 1 was not associated with implementation of CMT at wave 2 (standardized estimate = 0.170, SE = 0.208, P > .05). However, Medicaid payment acceptance at wave 1 was associated with implementation of MAT at wave 2 (standardized estimate = 0.880, SE = 0.047, P < .001).

CONCLUSIONS

Medicaid payment acceptance has a temporal relationship with the implementation of MAT in SUD treatment programs serving one of the largest racial/ethnic minority communities in the United States.

Organizational contextual features that influence the implementation of evidence-based practices across healthcare settings: a systematic integrative review

BACKGROUND

Organizational contextual features have been recognized as important determinants for implementing evidence-based practices across healthcare settings for over a decade. However, implementation scientists have not reached consensus on which features are most important for implementing evidence-based practices. The aims of this review were to identify the most commonly reported organizational contextual features that influence the implementation of evidence-based practices across healthcare settings, and to describe how these features affect implementation.

METHODS

An integrative review was undertaken following literature searches in CINAHL, MEDLINE, PsycINFO, EMBASE, Web of Science, and Cochrane databases from January 2005 to June 2017. English language, peer-reviewed empirical studies exploring organizational context in at least one implementation initiative within a healthcare setting were included. Quality appraisal of the included studies was performed using the Mixed Methods Appraisal Tool. Inductive content analysis informed data extraction and reduction.

RESULTS

The search generated 5152 citations. After removing duplicates and applying eligibility criteria, 36 journal articles were included. The majority (n = 20) of the study designs were qualitative, 11 were quantitative, and 5 used a mixed methods approach. Six main organizational contextual features (organizational culture; leadership; networks and communication; resources; evaluation, monitoring and feedback; and champions) were most commonly reported to influence implementation outcomes in the selected studies across a wide range of healthcare settings.

CONCLUSIONS

We identified six organizational contextual features that appear to be interrelated and work synergistically to influence the implementation of evidence-based practices within an organization. Organizational contextual features did not influence implementation efforts independently from other features. Rather, features were interrelated and often influenced each other in complex, dynamic ways to effect change. These features corresponded to the constructs in the Consolidated Framework for Implementation Research (CFIR), which supports the use of CFIR as a guiding framework for studies that explore the relationship between organizational context and implementation. Organizational culture was most commonly reported to affect implementation. Leadership exerted influence on the five other features, indicating it may be a moderator or mediator that enhances or impedes the implementation of evidence-based practices. Future research should focus on how organizational features interact to influence implementation effectiveness.

The impact of inter-organizational alignment (IOA) on implementation outcomes: evaluating unique and shared organizational influences in education sector mental health

BACKGROUND

Integrated healthcare delivered by work groups in nontraditional service settings is increasingly common, yet contemporary implementation frameworks typically assume a single organization-or organizational unit-within which system-level processes influence service quality and implementation success. Recent implementation frameworks predict that inter-organizational alignment (i.e., similarity in values, characteristics, activities related to implementation across organizations) may facilitate the implementation of evidence-based practices (EBP), but few studies have evaluated this premise. This study's aims examine the impact of overlapping organizational contexts by evaluating the implementation contexts of externally employed mental health clinicians working in schools-the most common integrated service delivery setting for children and adolescents. Aim 1 is to estimate the effects of unique intra-organizational implementation contexts and combined inter-organizational alignment on implementation outcomes. Aim 2 is to examine the underlying mechanisms through which inter-organizational alignment facilitates or hinders EBP implementation.

METHODS/DESIGN

This study will conduct sequential, exploratory mixed-methods research to evaluate the intra- and inter-organizational implementation contexts of schools and the external community-based organizations that most often employ school-based mental health clinicians, as they relate to mental health EBP implementation. Aim 1 will involve quantitative surveys with school-based, externally-employed mental health clinicians, their supervisors, and proximal school-employed staff (total n = 120 participants) to estimate the effects of each organization's general and implementation-specific organizational factors (e.g., climate, leadership) on implementation outcomes (fidelity, acceptability, appropriateness) and assess the moderating role of the degree of clinician embeddedness in the school setting. Aim 2 will explore the mechanisms through which inter-organizational alignment influences implementation outcomes by presenting the results of Aim 1 surveys to school-based clinicians (n = 30) and conducting semi-structured qualitative interviews. Qualitative data will be evaluated using an integrative inductive and deductive approach.

DISCUSSION

The study aims are expected to identify intra- and inter-organizational constructs that are most instrumental to EBP implementation success in school-based integrated care settings and illuminate mechanisms that may account for the influence of inter-organizational alignment. In addition to improving school-based mental health, these findings will spur future implementation science that considers the relationships across organizations and optimize the capacity of implementation science to guide practice in increasingly complex systems of care.

Advancing theory development: exploring the leadership-climate relationship as a mechanism of the implementation of cultural competence

BACKGROUND

Leadership style and specific organizational climates have emerged as critical mechanisms to implement targeted practices in organizations. Drawing from relevant theories, we propose that climate for implementation of cultural competence reflects how transformational leadership may enhance the organizational implementation of culturally responsive practices in health care organizations.

METHODS

Using multilevel data from 427 employees embedded in 112 addiction treatment programs collected in 2013, confirmatory factor analysis showed adequate fit statistics for our measure of climate for implementation of cultural competence (Cronbach's alpha = .88) and three outcomes: knowledge (Cronbach's alpha = .88), services (Cronbach's alpha = .86), and personnel (Cronbach's alpha = .86) practices.

RESULTS

Results from multilevel path analyses indicate a positive relationship between employee perceptions of transformational leadership and climate for implementation of cultural competence (standardized indirect effect = .057, bootstrap p < .001). We also found a positive indirect effect between transformational leadership and each of the culturally competent practices: knowledge (standardized indirect effect = .006, bootstrap p = .004), services (standardized indirect effect = .019, bootstrap p < .001), and personnel (standardized indirect effect = .014, bootstrap p = .005).

CONCLUSIONS

Findings contribute to implementation science. They build on leadership theory and offer evidence of the mediating role of climate in the implementation of cultural competence in addiction health service organizations.

Does the implementation of evidence-based and culturally competent practices reduce disparities in addiction treatment outcomes?

RATIONALE

Research is limited on the extent to which implementation of evidence-based and culturally responsive practices reduces outcome disparities in substance use disorder treatment. We examined the role of contingency management treatment (CMT), medication-assisted treatment (MAT), and culturally competent practices on Mexican Americans' rate of successful completion of treatment.

METHODS

We analyzed a concatenated dataset from 153 publicly funded substance use disorder treatment programs in Los Angeles County, California, in 2011 and 2013. These data were merged with data from 15,412 adult clients in both periods, of whom we selected only Mexican Americans (46.3%) and non-Latino Whites (53.7%). The outcome was successful treatment completion. The main independent variables were client demographics, drug use severity, mental health issues, and program license and professional accreditation.

RESULTS

Less than half of the programs highly implemented CMT, MAT, and culturally competent practices. CMT and cultural competence were not associated with successful treatment completion. However, Mexican Americans in programs with high degree of implementation of MAT had higher odds of successfully completing treatment compared to non-Latino Whites and programs with low MAT (OR=1.389; 95% CI=1.018, 1.897).

CONCLUSIONS

Findings highlight the role of MAT in reducing the disparity in treatment completion between Mexican Americans and non-Latino Whites. Implications for health policy and the dissemination of MAT are discussed.

Expected Impact of Health Care Reform on the Organization and Service Delivery of Publicly Funded Addiction Health Services

Little is known about how the Affordable Care Act (ACA) will be implemented in publicly funded addiction health services (AHS) organizations. Guided by a conceptual model of implementation of new practices in health care systems, this study relied on qualitative data collected in 2013 from 30 AHS clinical supervisors in Los Angeles County, California. Interviews were transcribed, coded, and analyzed using a constructivist grounded theory approach with ATLAS.ti software. Supervisors expected several potential effects of ACA implementation, including increased use of AHS services, shifts in the duration and intensity of AHS services, and workforce professionalization. However, supervisors were not prepared for actions to align their programs' strategic change plans with policy expectations. Findings point to the need for health care policy interventions to help treatment providers effectively respond to ACA principles of improving standards of care and reducing disparities.

Use of evidence-based interventions in child welfare: Do attitudes matter?

Implementation of evidence-based programs in progressed slowly, with the majority of services in child welfare settings lacking empirical evidence for effectiveness. In other settings, research has identified providers' attitudes about evidence-based practices (EBPs) as a potential barrier to adoption of EBPs. As little research has focused on the role of attitudes in influencing use after training in an EBP in child welfare, the potential for attitudes to impede implementation efforts in child welfare is unclear. This study addressed this question in a sample of 55 caseworkers and therapists randomly assigned to enhanced support to use an EBP following training or a training-only condition. Information on providers' use of the intervention after training and their attitudes about EBPs were measured for up to five time points. Results indicate that attitudes did not predict providers' use of the EBP, and attitudes did not change overall or in the enhanced condition that provided greater exposure to the intervention. Providers perceived of requirements to use a practice as more influential in their use than their openness to EBPs. However, those who were more open to EBPs were more likely to participate in implementation support after the training, suggesting that openness facilitates participation in activities that support use of a new intervention.

Providers' perspectives of factors influencing implementation of evidence-based treatments in a community mental health setting: A qualitative investigation of the training-practice gap

This study aims to elucidate relations between provider perceptions of aspects of the consolidated framework for implementation research (Damschroder et al., 2009) and provider attitudes toward the implementation of evidence-based treatments (EBTs) in an ethnically diverse community health setting. Guided by directed content analysis, we analyzed 28 semistructured interviews that were conducted with providers during the pre-implementation phase of a larger implementation study for cognitive processing therapy for posttraumatic stress disorder (Resick et al., 2008). Our findings extend the existing literature by also presenting provider-identified client-level factors that contribute to providers' positive and negative attitudes toward EBTs. Provider-identified client-level factors include the following: client motivation to engage in treatment, client openness to EBTs, support networks of family and friends, client use of community and government resources, the connection and relationship with their therapist, client treatment adherence, client immediate needs or crises, low literacy or illiteracy, low levels of education, client cognitive limitations, and misconceptions about therapy. These results highlight the relations between provider perceptions of their clients, provider engagement in EBT training, and subsequent adoption of EBTs. We present suggestions for future implementation research in this area. (PsycINFO Database Record

Identifying and ranking implicit leadership strategies to promote evidence-based practice implementation in addiction health services

Background

Despite a solid research base supporting evidence-based practices (EBPs) for addiction treatment such as contingency management and medication-assisted treatment, these services are rarely implemented and delivered in community-based addiction treatment programs in the USA. As a result, many clients do not benefit from the most current and efficacious treatments, resulting in reduced quality of care and compromised treatment outcomes. Previous research indicates that addiction program leaders play a key role in supporting EBP adoption and use. The present study expanded on this previous work to identify strategies that addiction treatment program leaders report using to implement new practices.

Methods

We relied on a staged and iterative mixed-methods approach to achieve the following four goals: (a) collect data using focus groups and semistructured interviews and conduct analyses to identify implicit managerial strategies for implementation, (b) use surveys to quantitatively rank strategy effectiveness, (c) determine how strategies fit with existing theories of organizational management and change, and (d) use a consensus group to corroborate and expand on the results of the previous three stages. Each goal corresponded to a methodological phase, which included data collection and analytic approaches to identify and evaluate leadership interventions that facilitate EBP implementation in community-based addiction treatment programs.

Results

Findings show that the top-ranked strategies involved the recruitment and selection of staff members receptive to change, offering support and requesting feedback during the implementation process, and offering in vivo and hands-on training. Most strategies corresponded to emergent implementation leadership approaches that also utilize principles of transformational and transactional leadership styles. Leadership behaviors represented orientations such as being proactive to respond to implementation needs, supportive to assist staff members during the uptake of new practices, knowledgeable to properly guide the implementation process, and perseverant to address ongoing barriers that are likely to stall implementation efforts.

Conclusions

These findings emphasize how leadership approaches are leveraged to facilitate the implementation and delivery of EBPs in publicly funded addiction treatment programs. Findings have implications for the content and structure of leadership interventions needed in community-based addiction treatment programs and the development of leadership interventions in these and other service settings.

Use of evidence-based treatments in substance abuse treatment programs serving American Indian and Alaska Native communities

BACKGROUND

Research and health surveillance activities continue to document the substantial disparities in the impacts of substance abuse on the health of American Indian and Alaska Native (AI/AN) people. While Evidence-Based Treatments (EBTs) hold substantial promise for improving treatment for AI/ANs with substance use problems (as they do for non-AI/ANs), anecdotal reports suggest that their use is limited. In this study, we examine the awareness of, attitudes toward, and use of EBTs in substance abuse treatment programs serving AI/AN communities.

METHODS

Data are drawn from the first national survey of tribal substance abuse treatment programs. Clinicians or clinical administrators from 192 programs completed the survey. Participants were queried about their awareness of, attitudes toward, and use of 9 psychosocial and 3 medication EBTs.

RESULTS

Cognitive Behavioral Therapy (82.2%), Motivational Interviewing (68.6%), and Relapse Prevention Therapy (66.8%) were the most commonly implemented psychosocial EBTs; medications for psychiatric comorbidity was the most commonly implemented medication treatment (43.2%). Greater EBT knowledge and use were associated with both program (e.g., funding) and staff (e.g., educational attainment) characteristics. Only two of the commonly implemented psychosocial EBTs (Motivational Interviewing and Relapse Prevention Therapy) were endorsed as culturally appropriate by a majority of programs that had implemented them (55.9% and 58.1%, respectively).

CONCLUSIONS

EBT knowledge and use is higher in substance abuse treatment programs serving AI/AN communities than has been previously estimated. However, many users of these EBTs continue to have concerns about their cultural appropriateness, which likely limits their further dissemination.

Paths to improving engagement among racial and ethnic minorities in addiction health services

Background

Members of racial and ethnic minority groups are most likely to experience limited access and poor engagement in addiction treatment. Research has been limited on the role of program capacity and delivery of comprehensive care in improving access and retention among minorities with drug abuse issues. The goal of this study was to examine the extent to which access and retention are enhanced when racial and ethnic minorities receive care from high-capacity addiction health services (AHS) programs and via coordination with mental health and receipt of HIV testing services.

Methods

This multilevel cross-sectional analysis involved data from 108 programs merged with client data from 2011 for 13,478 adults entering AHS. Multilevel negative binomial regression models were used to test interactions and indirect relationships between program capacity and days to enter treatment (wait time) and days in treatment (retention).

Results

Compared to low-capacity programs and non-Latino and non-African American clients, Latinos and African Americans served in high-capacity programs reported shorter wait times to admission, as hypothesized. African Americans also had longer treatment retention in high-capacity programs. Receipt of HIV testing and program coordination of mental health services played an indirect role in the relationship between program capacity and wait time.

Conclusions

Program capacity and coordinated services in AHS may reduce disparities in access to care. Implications for supporting low-capacity programs to eliminate the disparity gap in access to care are discussed.

Leadership and Licensure for Drug Treatment and the Implementation of Co-Occurring Disorder Treatment in Community Mental Health Centers

Using a random sample of 48 outpatient mental health programs in low-income and racial and ethnic minority communities, this study examined directorial leadership, drug treatment licensure, and implementation of evidence-based protocols and practices to address co-occurring mental health and substance abuse disorders (COD). Understanding of findings was enhanced with focus groups at six clinics. Most programs (81 %) offered COD treatment. Directorial leadership was positively associated with COD treatment (β = 0.253, p = 0.047, 95 % CI 0.003, 0.502) and COD supervision and training (β = 0.358, p = 0.002, 95 % CI 0.142, 0.575). Licensure was negatively associated with COD treatment (β = -0.235, p = 0.041, 95 % CI -0.460, -0.010) and COD supervision and training (β = -0.195, p = 0.049, 95 % CI -0.389, -0.001). Although lack of financial integration may limit the effect of licensing on COD treatment implementation, the response of leaders to regulation, funding, and human resources issues may encourage COD treatment practices. Implications for leadership interventions and policy are discussed in the context of health care reform.