The effect of individual, program, and neighborhood variables on continuity of treatment among dually diagnosed individuals

Characterization of multilevel influences of mental health care transitions: a comparative case study analysis

PURPOSE

Mental health care transitions are increasingly prioritized given their potential to optimize care delivery and patient outcomes, especially those focused on the transition from inpatient to outpatient mental health care. However, limited efforts to date characterize such mental health transition practices, especially those spanning multiple service setting contexts. Examination of key influences of inpatient to outpatient mental health care transitions across care contexts is needed to inform ongoing and future efforts to improve mental health care transitions. The current work aims to characterize multilevel influences of mental health care transitions across three United States-based mental health system contexts.

METHODS

A comparative multiple case study design was used to characterize transition practices within the literature examining children's, non-VA adult, and VA adult service contexts. Andersen's (1995) Behavioral Health Service Use Model was applied to identify and characterize relevant distinct and common domains of focus in care transitions across systems.

RESULTS

Several key influences to mental health care transitions were identified spanning the environmental, individual, and health behavior domains, including: community capacity or availability, cross-system or agency collaboration, provider training and experience related to mental health care transitions, client care experience and expectations, and client clinical characteristics or complexity.

CONCLUSIONS

Synthesis illustrated several common factors across system contexts as well as unique factors for further consideration. Our findings inform key considerations and recommendations for ongoing and future efforts aiming to plan, expand, and better support mental health care transitions. These include timely information sharing, enhanced care coordination and cross setting and provider communication, continued provider/client education, and appropriate tailoring of services to improve mental health care transitions.

Barriers for homeless with dual diagnosis: lessons learned from intensive mobile psychosocial assertive community treatment program

Purpose

Dual diagnosis is a term that describes the co-occurrence of mental health disorders or illness and substance use or abuse disorders. Because this co-occurrence results in multiple diseases, layers of treatment are often needed to successfully create positive change in the individual. The purpose of this study is to explore factors of treatment that could facilitate improvements in functionality and quality of life for those with a dual diagnosis.

Design/methodology/approach

A secondary data analysis, using both quantitative and qualitative data, was completed. Secondary analysis is an empirical exercise that applies the same basic research principles as studies using primary data and has steps to be followed, including the evaluative and procedural steps commonly associated with secondary data analysis. Documentation data from the intensive mobile psychosocial assertive community treatment program was gathered for this analysis; this program was used because of the intensive and community-based services provided to patients with a dual diagnosis.

Findings

The major findings from this secondary analysis suggested that significant barriers included “denial” (e.g. evasion, suspension or avoidance of internal awareness) of diagnoses, complicated treatment and other barriers related to housing. Ultimately, these findings provided greater insight into potential effective treatment interventions for people living with a dual diagnosis.

Originality/value

This study adds to the growing body of literature showing that patient-centered care allows for more effective treatment and ultimately, improved health outcomes.

Are Rural Opioid Treatment Program (OTP) Facilities Associated with Lower Deaths?

Objectives: Rural areas have been particularly affected by the opioid epidemic in the U.S., with treatment options being scarce. This study focuses on opioid treatment programs (OTPs), which combine counseling services and opioid-related medication provision. In the South census region (comprised of 16 states and D.C.), 156 urban counties and 27 rural counties contained OTPs as of 2013. We examine whether their presence is associated with lower opioid-related death rates during 2014-2016. Methods: Coarsened exact matching (CEM) is used to match treated and untreated counties on demographic characteristics and opioid-related deaths from 2011 to 2013. Two treatments are considered: (1) if a county had an OTP in 2013; and (2) if an OTP existed in a neighboring county in 2013. The matched samples are then used in weighted least square regression models, with propensity score matching serving as a robustness check. Rural and urban counties are analyzed separately to determine if the impact of OTPs differs between these areas. Results: Results show that the presence of an OTP mostly has no statistical association with the rate of (or change in) future opioid deaths, in either rural or urban counties. Proximity to a neighboring county OTP displays a similar lack of association. Conclusions: The findings suggest that OTPs are not associated with fewer opioid-related deaths in the South over the near term, regardless of rural or urban location. These results could be attributed to outside factors that hinder this relationship. Continued assessment of varied approaches to the rural opioid crisis is encouraged.

Community social deprivation and availability of substance use treatment and mutual aid recovery groups

Background

The spatial distribution of substance use services impacts their use, with greater access to services associated with more positive outcomes. Findings from availability of primary healthcare indicate service shortages exist in areas characterized by social deprivation. This study investigated whether community social deprivation was associated with a lack of availability of substance use treatment or mutual aid recovery support services.

Methods

This is an ecological analysis investigating the availability of substance use services at a community level in the state of New Hampshire. Several public data sources were combined to represent community social deprivation and availability of substance treatment of mutual aid recovery support groups. Principal components analysis and negative binomial regression were used to test the relationship between community structure and the availability of substance use services.

Results

Community social deprivation was characterized by high rates of poverty, no access to motor vehicles, renter-occupied housing, less than a high school degree, and nonemployment. Communities high in measures of social deprivation were associated with increased availability of both substance use treatment and recovery support services.

Conclusions

Contrary to findings in access to primary healthcare services, social disadvantage was positively related to availability for both types of substance use services. This relationship may reflect the stigma associated with substance use where services associated with stigmatized conditions locate in areas with the least resistance to their presence or be a function of affordability of space. Future research could investigate the relationship between access to services and individual client outcomes.

HIV risk and the association with accessibility coverage to medical facilities and socioeconomic status among heroin users in Kaohsiung, Taiwan (2011-2015): A GIS approach

Illegal drug use has caused considerable health and social costs. Access to medical treatment has been one of the most cost-effective interventions to reduce problematic drug use. Accessibility to treatment, which can be analyzed by the spatial approach such as geographic information system (GIS), has thus been utilized as a measure of the proportion of population that reaches appropriate health services. In this study, the association of accessibility coverage to medical facilities and socioeconomic status with human immunodeficiency virus (HIV) risk for heroin users was evaluated by GIS analysis in Kaohsiung, Taiwan. Data of 7890 heroin users were collected from 2011 to 2015 and categorized into five risk groups according to their income and distance to treatment settings. The results of this GIS-based analysis show that the areas with over 50% accessibility coverage rate had less amounts of HIV cases with statistical significance. Inconvenient access to medical facilities could result in poor treatment outcomes such as higher HIV incidences. Therefore, in order to effectively reduce HIV incidences among the heroin users, the accessibility coverage and locations of medical treatment facilities should meet the needs of drug users. It is also advised that the formulation of policies associated with illegal drug use problems should be evidence-based and geographical indicators could serve for this purpose from either prevention or intervention perspective.

Disparities in the Treatment of Substance Use Disorders: Does Where You Live Matter?

This study focused on (1) whether disparities in timely receipt of substance use services can be explained in part by the characteristics of the community in which the clients reside and (2) whether the effect of community characteristics on timely receipt of services was similar across racial/ethnic groups. The sample was composed of adults receiving publicly funded outpatient treatment in Washington State. Treatment data were linked to data from the US census. The outcome studied was "Initiation and Engagement" in treatment (IET), a measure noting timely receipt of services at the beginning of treatment. Community characteristics studied included community level economic disadvantage and concentration of American Indian, Latino, and Black residents in the community. Black and American Indian clients were less likely to initiate or engage in treatment compared to non-Latino white clients, and American Indian clients living in economically disadvantaged communities were at even greater risk of not initiating treatment. Community economic disadvantage and racial/ethnic makeup of the community were associated with treatment initiation, but not engagement, although they did not entirely explain the disparities found in IET.

Individual and Environmental Determinants of Provider Continuity Among Urban Older Adults With Heart Failure: A Retrospective Cohort Study

Objective: Continuity in patient–provider relationships is important to providing high-quality care for older adults with chronic conditions. We investigated individual and environmental determinants of provider continuity for office-based physician visits among urban older adults with heart failure. Method: We linked Medicare claims with data on neighborhood characteristics for a retrospective cohort of community-dwelling Medicare beneficiaries with heart failure in New York City (N = 50,475). Results: Mean continuity using the Bice–Boxerman index was 0.33 (SD = 0.22) (possible range of 0 [no continuity] to 1 [perfect continuity]). Multivariable regression indicated that provider continuity was higher among older, female, and dually eligible beneficiaries. Those with more chronic conditions had higher continuity, controlling for number of medical specialties seen. Continuity was lower for beneficiaries in neighborhoods with high median income and high primary care density. Conclusion: Individual and environmental predictors of provider continuity among urban older adults with heart failure could help to identify those at risk of care fragmentation.

Treatment outcome disparities for opioid users: Are there racial and ethnic differences in treatment completion across large US metropolitan areas?

BACKGROUND

The present study examined racial/ethnic disparities in initial treatment episode completion for adult clients reporting opioids as their primary problem substance in large US metropolitan areas.

METHODS

Data were extracted from the 2013 TEDS-D dataset (Treatment Episode Dataset-Discharge) for the 42 largest US metropolitan statistical areas (MSAs). Fixed effects logistic regression controlling for MSA was used to estimate the effect of race/ethnicity on the likelihood of treatment completion. The model was repeated for each individual MSA in a stratified design to compare the geographic variation in racial/ethnic disparities, controlling for gender, age, education, employment, living arrangement, treatment setting, medication-assisted treatment, referral source, route of administration, and number of substances used at admission.

RESULTS

Only 28% of clients completed treatment, and the results from the fixed effects model indicate that blacks and Hispanics are less likely to complete treatment compared to whites. However, the stratified analysis of individual MSAs found only three of the 42 MSAs had racial/ethnic disparities in treatment completion, with the New York City (NYC) MSA largely responsible for the disparities in the combined sample. Supplementary analyses suggest that there are greater differences between whites and minority clients in the NYC MSA vs. other cities on characteristics associated with treatment completion (e.g., residential treatment setting).

CONCLUSION

This study underscores the need for improving treatment retention for all opioid using clients in large metropolitan areas in the US, particularly for minority clients in those localities where disparities exist, and for better understanding the geographic context for treatment outcomes.

Residential and outpatient treatment completion for substance use disorders in the U.S.: Moderation analysis by demographics and drug of choice

BACKGROUND

This study investigates the impact of residential versus outpatient treatment setting on treatment completion, and how this impact might vary by demographic characteristics and drug of choice, using a national sample of publicly funded substance abuse programs in the United States.

METHODS

This is a retrospective analysis using data extracted from the 2011 Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Episode Data Set (TEDS-D). A total of 318,924 cases were analyzed using logistic regression, fixed-effects logistic regression, and moderated fixed-effects logistic regression.

RESULTS

Residential programs reported a 65% completion rate compared to 52% for outpatient settings. After controlling for other confounding factors, clients in residential treatment were nearly three times as likely as clients in outpatient treatment to complete treatment. The effect of residential treatment on treatment completion was not significantly moderated by gender, but it was for age, drug of choice, and race/ethnicity. Residential compared to outpatient treatment increased the likelihood of completion to a greater degree for older clients, Whites, and opioid abusers, as compared to younger clients, non-Whites, and alcohol and other substance users, respectively.

CONCLUSION

We speculate that for opioid abusers, as compared to abusers of other drugs, residential treatment settings provide greater protection from environmental and social triggers that may lead to relapse and non-completion of treatment. Greater use of residential treatment should be explored for opioid users in particular.

Risky Substance Use Environments and Addiction: A New Frontier for Environmental Justice Research

Substance use disorders are widely recognized as one of the most pressing global public health problems, and recent research indicates that environmental factors, including access and exposure to substances of abuse, neighborhood disadvantage and disorder, and environmental barriers to treatment, influence substance use behaviors. Racial and socioeconomic inequities in the factors that create risky substance use environments may engender disparities in rates of substance use disorders and treatment outcomes. Environmental justice researchers, with substantial experience in addressing racial and ethnic inequities in environmental risk from technological and other hazards, should consider similar inequities in risky substance use environments as an environmental justice issue. Research should aim at illustrating where, why, and how such inequities in risky substance use environments occur, the implications of such inequities for disparities in substance use disorders and treatment outcomes, and the implications for tobacco, alcohol, and drug policies and prevention and treatment programs.

Modeling the impact of place on individual methadone treatment outcomes in a national longitudinal cohort study

BACKGROUND

Little has been published on the effect of geography on methadone treatment outcomes.

OBJECTIVE

To measure the effect of place on longitudinal outcomes Methods: From 2003 to 2006, 215 clients were recruited to a cohort study of methadone treatment. Participants had their address and clinic geocoded. Treatment outcomes were measured at intake, at one and three years posttreatment using the Maudsley Addiction Profile instrument. Spider diagrams and buffer rings were used to visually map clinics and clients. Regression models were used to measure the effect of place.

RESULTS

Client's accommodation and social and criminal problems in the region had a medium to large effect on heroin use. Analysis of buffer rings revealed that clients located within a 10-km radius of a major clinic demonstrated poorer outcomes in terms of heroin use. Conclusion/Importance: Findings illustrated the relevance of geography on drug treatment outcomes and the planning of services.

Continuity of Care in Dual Diagnosis Treatment: Definitions, Applications, and Implications

OBJECTIVE

The goal of this work is to review the current literature on continuity of care in the treatment of people with dual diagnosis. In particular, this review set out to clarify how continuity of care has been defined, applied, and assessed in treatment and to enhance its application in both research and clinical practice.

METHODS

To identify articles for review, the term "continuity" and combinations of "substance" and "treatment" were searched in electronic databases. The search was restricted to quantitative articles published in English after 1980. Papers were required to discuss "continuity" in treatment samples that included a proportion of patients with a dual diagnosis.

RESULTS

A total of 18 non-randomized studies met the inclusion criteria. Analysis revealed six core types of continuity in this treatment context: continuity of relationship with provider(s), continuity across services, continuity through transfer, continuity as regularity and intensity of care, continuity as responsive to changing patient need, and successful linkage of the patient. Patient age, ethnicity, medical status, living status, and the type of mental health and/or substance use disorder influenced the continuity of care experienced in treatment. Some evidence suggested that achieving continuity of care was associated with positive patient and treatment-related outcomes.

CONCLUSIONS

This review summarizes how continuity of care has been understood, applied, and assessed in the literature to date. Findings provide a platform for future researchers and service providers to implement and evaluate continuity of care in a consistent manner and to determine its significance in the treatment of people with a dual diagnosis.

Spatial accessibility of drug treatment facilities and the effects on locus of control, drug use, and service use among heroin-injecting Mexican American men

BACKGROUND

This study explores the spatial accessibility of outpatient drug treatment facilities and the potential relationship with drug use-related outcomes among Mexican American heroin users.

METHODS

Secondary data on 219 current and former heroin-injecting Mexican American men aged 45 and older were drawn from a research study in Houston, Texas. We used geographic information systems (GIS) to derive two spatial accessibility measures: distance from one's place of residence to the closest drug treatment facility (in minutes); and the number of facilities within a 10-minute driving distance from one's place of residence. Exploratory logistic regression analyses examined the association between the spatial accessibility of drug treatment facilities and several drug use-related outcomes: internal locus of control (LOC); perceived chances and worries of injecting in the next six months; treatment utilization; and location of last heroin purchase.

RESULTS

Participants with greater spatial access to treatment programs were more likely to report a higher chance of injecting in the near future. However, while current heroin users were more worried about injecting in the next six months, greater spatial access to treatment programs seemed to have a buffering effect. Finally, those who lived closer to a treatment programs were more likely to have last purchased heroin inside the neighborhood versus outside the neighborhood. Spatial accessibility was not associated with internal LOC or treatment utilization.

CONCLUSION

The findings showed that the presence of outpatient treatment facilities-particularly services in Spanish-may influence perceived risk of future heroin use and purchasing behaviors among Mexican American men. Implications for future spatially-informed drug use research and the planning of culturally and linguistically responsive drug treatment programs are discussed.

Geospatial technology and the "exposome": new perspectives on addiction

Addiction represents one of the greatest public health problems facing the United States. Advances in addiction research have focused on the neurobiology of this disease. We discuss potential new breakthroughs in understanding the other side of gene-environment interactions-the environmental context or "exposome" of addiction. Such research has recently been made possible by advances in geospatial technologies together with new mobile and sensor computing platforms. These advances have fostered interdisciplinary collaborations focusing on the intersection of environment and behavior in addiction research. Although issues of privacy protection for study participants remain, these advances could potentially improve our understanding of initiation of drug use and relapse and help develop innovative technology-based interventions to improve treatment and continuing care services.

PREDICTING RECIDIVISM FOR RELEASED STATE PRISON OFFENDERS: Examining the Influence of Individual and Neighborhood Characteristics and Spatial Contagion on the Likelihood of Reincarceration

We examined the influence of individual and neighborhood characteristics and spatial contagion in predicting reincarceration on a sample of 5,354 released Pennsylvania state prisoners. Independent variables included demographic characteristics, offense type, drug involvement, various neighborhood variables (e.g., concentrated disadvantage, residential mobility), and spatial contagion (i.e., proximity to others who become reincarcerated). Using geographic information systems (GIS) and logistic regression modeling, our results showed that the likelihood of reincarceration was increased with male gender, drug involvement, offense type, and living in areas with high rates of recidivism. Older offenders and those convicted of violent or drug offenses were less likely to be reincarcerated. For violent offenders, drug involvement, age, and spatial contagion were particular risk factors for reincarceration. None of the neighborhood environment variables were associated with increased risk of reincarceration. Reentry programs need to particularly address substance abuse issues of ex-offenders as well as take into consideration their residential locations.

Qualitative GIS and the Visualization of Narrative Activity Space Data

Qualitative activity space data, i.e. qualitative data associated with the routine locations and activities of individuals, are recognized as increasingly useful by researchers in the social and health sciences for investigating the influence of environment on human behavior. However, there has been little research on techniques for exploring qualitative activity space data. This research illustrates the theoretical principles of combining qualitative and quantitative data and methodologies within the context of GIS, using visualization as the means of inquiry. Through the use of a prototype implementation of a visualization system for qualitative activity space data, and its application in a case study of urban youth, we show how these theoretical methodological principles are realized in applied research. The visualization system uses a variety of visual variables to simultaneously depict multiple qualitative and quantitative attributes of individuals' activity spaces. The visualization is applied to explore the activity spaces of a sample of urban youth participating in a study on the geographic and social contexts of adolescent substance use. Examples demonstrate how the visualization may be used to explore individual activity spaces to generate hypotheses, investigate statistical outliers, and explore activity space patterns among subject subgroups.

Needs of persons with serious mental illness following discharge from inpatient treatment: patient and family views

Patients with serious mental illnesses often struggle with persistent symptoms that interfere with daily functioning in the community. The first days and weeks following inpatient treatment for an acute episode may be a critical time for patients to connect with the recommended community follow-up. Residual symptoms may interfere with their ability to access and benefit from these services to meet their needs. A descriptive study was conducted to explore perceptions of patients and families of patients' needs, functioning, coping and social support in the first 4 weeks after inpatient treatment. Results suggested that these patients had residual symptoms after discharge that interfered with functioning despite the availability of follow-up services. Patients identified unmet needs related to their illness. Family members identified concerns related to the lack of improvement in their ill relatives over time. Patients expressed satisfaction with care and felt supported by their families. Both patients and families seemed to lack a thorough understanding of goals for follow-up care.

Addiction research ethics and the Belmont principles: do drug users have a different moral voice?

This study used semi-structured interviews and content analysis to examine moral principles that street drug users apply to three hypothetical addiction research ethical dilemmas. Participants (n = 90) were ethnically diverse, economically disadvantaged drug users recruited in New York City in 2009 . Participants applied a wide range of contextually sensitive moral precepts, including respect, beneficence, justice, relationality, professional obligations, rules, and pragmatic self-interest. Limitations and implications for future research and the responsible conduct of addiction research are discussed.