Measuring collaboration and integration activities in criminal justice and substance abuse treatment agencies

Cascade of care for substance use and mental health disorders for justice-involved populations

INTRODUCTION

Justice-involved populations have dramatically higher rates of substance use disorders (SUD) and mental health disorders (MHD) compared to the general population. Despite high rates of SUD and MHD, treatment for this population is often limited and not evidence-based. The cascade of care model estimates drop-offs in the continuum of care from screening to identification of need, referral, care initiation, care engagement, and care completion. Recently, healthcare providers have utilized the cascade of care to improve the continuity of care for people with SUD and MHD in justice settings. The purpose of the current study is to 1) identify typologies that explain the proportion of new intakes that pass through each level of the cascade of care for SUD and MHD, and 2) describe agency-level factors that predict typology assignments and agency ability to assess client flow through the levels of the care cascade.

METHOD

Using Latent Class Analysis, we classify 791 agencies serving justice-involved individuals into typologies according to utilization of each stage in the mental health and substance cascades of care. Then, we examined county and agency characteristics that affect three stages of the cascade process: identification of need for behavioral health services, referrals to appropriate services, and treatment initiation. We build on previous work by exploring these patterns for both SUD and MHD treatment.

RESULTS

The study identified four SUD/MHD treatment patterns: Low Access, SUD-Focused, High Need-High Access, and Lower Need-High Access classes. Factors influencing typology alignment include location, specialized staff availability, warm hand-off coordination, Medicaid reimbursement, and performance measure tracking. Thirty-nine percent (39 %) of agencies could not be classified because they were unable to report their rate of care along the cascade measures.

CONCLUSION

Focusing on factors influencing typology assignment can help counties in assessing service delivery, identifying barriers, and targeting areas for improvements in policies and practices, potentially facilitating long-term changes and overall improvement in the care of individuals with mental health and substance use disorders. Identification of these factors and typologies can improve mental health treatment and access in counties and agencies with large resource barriers or limited attention to mental health treatment.

Inequities in Mental Health Services: A 16-Year Longitudinal Study of Youth in the Justice System

OBJECTIVE

To examine: (1) if youth who have mental health disorders receive needed services after they leave detention-and as they age; and (2) inequities in service use, focusing on demographic characteristics and type of disorder.

METHOD

We used data from the Northwestern Juvenile Project, a longitudinal study of 1,829 youth randomly sampled from detention in Chicago, Illinois in 1995. Participants were re-interviewed up to 13 times through 2015. Interviewers assessed disorders using structured diagnostic interviews and assessed service use using the Child and Adolescent Service Assessment and the Services Assessment for Children and Adolescents.

RESULTS

Less than 20% of youth who needed services received them, up to median age 32 years. Female participants with any disorder had nearly twice the odds of receiving services compared with male participants (OR: 1.82; 95% CI: 1.41, 2.35). Compared with Black participants with any disorder, non-Hispanic White and Hispanic participants had 2.14 (95% CI: 1.57, 2.90) and 1.50 (95% CI: 1.04, 2.15) times the odds of receiving services. People with a disorder were more likely to receive services during childhood (< age 18) than during adulthood (OR: 2.29; 95% CI: 1.32, 3.95). Disorder mattered: participants with an internalizing disorder had 2.26 times and 2.43 times the odds of receiving services compared with those with a substance use disorder (respectively, 95% CI: 1.26, 4.04; 95% CI: 1.49, 3.97).

CONCLUSION

Few youth who need services receive them as they age; inequities persist over time. We must implement evidence-based strategies to reduce barriers to services.

Using structured implementation interventions to improve referral to substance use treatment among justice-involved youth: Findings from a multisite cluster randomized trial

INTRODUCTION

Youth involved in the justice system have high rates of alcohol and other drug use, but limited treatment engagement. JJ-TRIALS tested implementation activities with community supervision (CS) and behavioral health (BH) agencies to improve screening, identification of substance use service need, referral, and treatment initiation and engagement, guided by the BH Services Cascade and EPIS frameworks. This paper summarizes intervention impacts on referrals to treatment among youth on CS.

METHODS

This multisite cluster-randomized trial involved 18 matched pairs of sites in 36 counties in seven states randomly assigned to core or enhanced conditions after implementing the core intervention at all sites for six months. Enhanced sites received external facilitation for local change team activities to reduce unmet treatment needs; Core sites were encouraged to form interagency workgroups. The dependent variable was percentage referred to treatment among youth in need (N = 14,012). Two-level Bayesian regression assessed factors predicting referral across all sites and time periods. Generalized linear mixed models using logit transformation tested two hypotheses: (H1) referrals will increase from baseline to the experimental period, (H2) referral increases will be larger in enhanced sites than in core sites.

RESULTS

Although the intervention significantly increased referral, condition did not significantly predict referral across all time periods. Youth who tested drug positive, had an alcohol/other drug-related or felony charge, were placed in secure detention or assigned more intensive supervision, or who were White were more likely to be referred. H1 (p < .05) and H2 (p < .0001) were both significant in the hypothesized direction. Interaction analyses comparing site pair differences showed that findings were not consistent across sites.

CONCLUSIONS

The percentage of youth referred to treatment increased compared with baseline overall, and enhanced sites showed larger increases in referrals over time. However, variations in effects suggest that site-level differences were important. Researchers should carry out mixed methods studies to further understand reasons for the inconsistent findings within randomized site pairs, and how to further improve treatment referrals across CS and BH systems. Findings also highlight that even when CS agencies work collaboratively with BH providers to improve referrals, most justice-involved youth who need SU services are not referred.

Impacts of COVID-19 at the intersection of substance use disorder treatment and criminal justice systems: findings from three states

BACKGROUND

Individuals with substance use disorders (SUD), particularly opioid use disorder (OUD), who are criminal justice-involved are a particularly vulnerable population that has been adversely affected by COVID-19 due to impacts of the pandemic on both the criminal justice and treatment systems. The manuscript presents qualitative data and findings exploring issues related to SUD/OUD treatment among individuals involved in the justice system and the impacts of COVID-19 on these service systems. Qualitative data were collected separately by teams from three different research hubs/sites in Illinois, Indiana, and Kentucky; at each hub, data were collected from justice system personnel (n = 17) and community-level SUD/OUD providers (n = 21). Codes from two hubs were reviewed and merged to develop the cross-hub coding list. The combined codes were used deductively to analyze the third hub's data, and higher-level themes were then developed across all the hubs' data.

RESULTS

Themes reflected the justice and treatment systems' responses to COVID-19, the intersection of systems and COVID-19's impact on providing OUD treatment for such individuals, and the use of telehealth and telejustice.

CONCLUSIONS

Results highlight that despite rapid adaptations made by systems during the pandemic, additional work is needed to better support individuals with OUD who are involved in the justice system. Such work can inform longer-term public health crisis planning to improve community OUD treatment access and linkage for those who are criminal justice-involved.

Exploring Norwegian prison frontline workers' perceptions of inter professional collaboration - a pilot study

PURPOSE

Interprofessional collaboration is necessary for handling the complex psychosocial needs of prisoners. This collaboration must be addressed to avoid high recidivism rates and the human and societal costs linked to them. Challenges are exacerbated by a linear approach to handling prisoners' problems, silo working between welfare agencies and professional boundaries between frontline workers. There are few adequate theoretical frameworks and tools to address these challenges in the prison context. The purpose of this study is to explore the perceptions that frontline staff working in Norwegian prison facilities have regarding interprofessional collaboration in providing mental health services for prisoners.

DESIGN/METHODOLOGY/APPROACH

This study had a non-experimental, cross-sectional design to explore perceptions of interprofessional collaboration in a prison context. Descriptive and multifactorial analyses (exploratory factor analysis and confirmatory factor analysis) were used to explore the data.

FINDINGS

The analysis showed that three factors, communication, organizational culture and domain, explained 95% of the variance. Results are discussed using relational coordination, as well as the conceptual PINCOM model, as a theoretical framework.

ORIGINALITY/VALUE

Few studies explicitly explore collaboration between professionals in mental health and prison services despite its being a prerequisite to achieving sufficient services for prisoners. To our knowledge, this current study is one of the first in Norway to explore collaboration in a prison context by analysing quantitative data and focusing on frontline workers perception of the phenomenon.

Bridging juvenile justice and behavioral health systems: development of a clinical pathways approach to connect youth at risk for suicidal behavior to care

BACKGROUND

Justice-involved youth have high rates of suicidal behavior and co-morbid psychiatric disorders, yet low rates of service use. Implementation efforts aimed at supporting cross-agency linkage protocols may be useful components of interventions promoting behavioral healthcare service access for youths on probation. The purpose of this study was to develop clear referral Pathways for three suicide risk classifications of youth, across 10 counties in a single state through a community-academic partnership in New York state, a strategic planning process between county Probation departments and community Behavioral Health.

RESULTS

We sought to clarify service destinations for youth in three classes of risk for suicidal behavior: Class I (Crisis, Imminent Risk); Class II (Crisis, Non-Imminent Risk); and Class III (Non-Crisis but in Need of Service). Prior to Pathway Meetings, there was a low degree of agreement between Probation and Behavioral Health leadership for the appropriate service destination for youths in crisis, whether at imminent risk (Class I: 57.8% overlap) or at lower than imminent risk (Class II: 45.6% overlap). Options for referral destinations for Classes I and II decreased significantly (indicating greater overlap) as a result of Pathway Meetings [(Class I: from 2.5 to 1.1 (t₍₉₎ = 3.28, p < 0.01); Class II: from 2.8 to 1.3 (t₍₉₎ = 4.025, p < 0.003)]. Pathway Meetings allowed Behavioral Health and Juvenile Justice systems to make joint decisions regarding referral pathways, resulting in innovative solutions, such as the use of mobile crisis.

CONCLUSIONS

The community-academic partnership served to bring internal (Juvenile Justice) and external (Behavioral Health) contexts together to successfully generate agreed upon Pathways to care for youths demonstrating risk for suicidal behavior. Bridging Behavioral Health and Juvenile Justice systems together to agree to referral Pathways for each risk class can increase appropriate service use.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03586895 . Registered 21 June 2018, https://register.clinicaltrials.gov/prs/app/template/EditRecord.vm?epmode=Edit&listmode=Edit&uid=U0003B7I&ts=4&sid=S00080NN&cx=-n4kinh.

Good Lives Model: Importance of Interagency Collaboration in Preventing Violent Recidivism

Violence is a complex and multifaceted problem requiring a holistic and individualized response. The Good Lives Model (GLM) suggests violence occurs when an individual experiences internal and external obstacles in the pursuit of universal human needs (termed primary goods). With a twin focus, GLM-consistent interventions aim to promote attainment of primary goods, whilst simultaneously reducing risk of reoffending. This is achieved by improving an individuals’ internal (i.e., skills and abilities) and external capacities (i.e., opportunities, environments, and resources). This paper proposes that collaborations between different agencies (e.g., psychological services, criminal justice systems, social services, education, community organizations, and healthcare) can support the attainment of primary goods through the provision of specialized skills and resources. Recommendations for ensuring interagency collaborations are effective are outlined, including embedding a project lead, regular interagency meetings and training, establishing information sharing procedures, and defining the role each agency plays in client care.

Core Correctional Practices in Community Supervision: An Evaluation of a Policy Mandate to Increase Probation Officer Use of Skills

Community supervision officer training programs aim to translate core correctional practices into routine practice. These training programs emphasize skill-building designed to shift supervision strategies from law enforcement/compliance-oriented to a focus on promoting and supporting behavior change. Despite evidence of their effectiveness, research finds trained officers use newly learned skills infrequently. The current study examined the impact of a policy, implemented post-training, designed to encourage trained officers to use skills emphasized by the Staff Training Aimed at Reducing Rearrest (STARR) training program more frequently. The current study examined the effectiveness of this policy on the frequency and type of skills used by officers in their interactions with individuals on their caseload. Analyses suggested the policy mandate was effective in increasing skill use, however officers still used trained skills in less than half of their interactions. Implications and considerations for increasing the use of skills are discussed.

The Missing Link(age): Multilevel Contributors to Service Uptake Failure Among Youths on Community Justice Supervision

OBJECTIVES

Youths in the juvenile justice system often do not access needed behavioral health services. The behavioral health services cascade model was used to examine rates of substance use screening, identification of substance use treatment needs, and referral to and initiation of treatment among youths undergoing juvenile justice system intake and to identify when treatment access is most challenged. Characteristics associated with identification of behavioral health needs and linkage to community services were also examined.

METHODS

Data were drawn from administrative records of 33 community justice agencies in seven states participating in Juvenile Justice-Translational Research on Interventions for Adolescents in the Legal System, funded by the National Institute on Drug Abuse (N=8,307 youths). Contributions of youth, staff, agency, and county characteristics to identification of behavioral health needs and linkage to community services were examined.

RESULTS

More than 70% (5,942 of 8,307) of youths were screened for substance use problems, and more than half needed treatment. Among those in need, only about one-fifth were referred to treatment, and among those referred, 67.5% initiated treatment. Overall, <10% of youths with identified needs initiated services. Multivariable multilevel regression analyses revealed several contributors to service-related outcomes, with youths' level of supervision being among the strongest predictors of treatment referral.

CONCLUSIONS

Community justice agencies appear to follow an approach that focuses identification and linkage practices on concerns other than youths' behavioral health needs, although such needs contribute to reoffending. Local agencies should coordinate efforts to support interagency communication in the referral and cross-system linkage process.

Critical Factors Influencing Interorganizational Relationships Between Juvenile Probation and Behavioral Health Agencies

Although interorganizational relationships (IORs) are essential to the effective delivery of human services, very little research has examined relationships between juvenile justice agencies and behavioral health providers, and few studies have identified the most critical organizational and individual-level characteristics influencing IORs. Across 36 sites, juvenile probation officials (n = 458) and community behavioral health providers (n = 91) were surveyed about characteristics of their agencies, themselves, and IORs with each other. Generalized Linear Mixed Models were used to analyze the data. The strongest predictors included Perceived Organizational Support and individual Adaptability. Implications for research, theory and practice are discussed.

Stepped-wedge randomized controlled trial of a novel opioid court to improve identification of need and linkage to medications for opioid use disorder treatment for court-involved adults

In response to the opioid crisis in New York State (NYS), the Unified Court System developed a new treatment court model-the opioid intervention court-designed around 10 Essential Elements of practice to address the flaws of existing drug courts in handling those with opioid addiction via broader inclusion criteria, rapid screening, and linkage to medications to treat opioid use disorder (MOUD). The new court model is now being rolled out statewide yet, given the innovation of the opioid court, the exact barriers to implementation in different counties with a range of resources are largely unknown. We describe a study protocol for the development and efficacy-test of a new implementation intervention (Opioid Court REACH; Research on Evidence-Based Approaches to Court Health) that will allow the opioid court, as framed by the 10 Essential Elements, to be scaled-up across 10 counties in NYS. Using a cluster-randomized stepped-wedge type-2 hybrid effectiveness-implementation design, we will test: (a) the implementation impact of Opioid Court REACH in improving implementation outcomes along the opioid cascade of care (screening, referral, treatment enrollment, MOUD initiation), and (b) the clinical and cost effectiveness of Opioid Court REACH in improving public health (treatment retention/court graduation) and public safety (recidivism) outcomes. Opioid Court REACH has the potential to improve management of individuals with opioid addiction in the court system via widespread scale-up of the opioid court model across the U.S., should this study find it to be effective.

"Built on Respect and Good Honest Communication:" A Study of Partnerships Between Mental Health Providers and Community Corrections

The prevailing approach to managing persons with criminal histories involves community supervision professionals like probation and parole officers partnering with other mental health providers to address clients' needs. The relationships between individual professionals are seldom researched, though, and the current study aims to address this deficit in the empirical literature. This study utilized interviews about professionals' perceptions of their work experiences, analyzed open-endedly to identify major themes. Mental health providers' themes included appreciation and process of collaboration, individual characteristics and roles, characteristics of collaboration, elements of interprofessional relationships, and involvement of the courts. Community supervision professionals discussed issues pertaining to appreciation and process of collaboration, individual characteristics and roles, when conflict occurs, and the lack of basic knowledge about other professionals. Second, these partnerships were examined in light of interprofessional healthcare competencies. Themes identified here resembled healthcare values and ethics competencies and roles and responsibilities competencies; healthcare competencies regarding interprofessional communication and teamwork showed partial congruence with the current themes. Overall, interprofessional collaboration is valued. This research highlights the strengths of this type of interprofessional collaboration and offers suggestions for improving the efficacy of collaboration.

Assessing factors associated with discharge from opioid agonist therapy due to incarceration in the United States

The following study investigates factors associated with discharge from OAT due to incarceration in a sample of 64,331 discharges in the United States. Multinomial regression investigated the association between demographic factors, prior arrest, referral source (i.e criminal justice agency) intravenous drug use, types of drug used, length of prior treatment and discharge due to incarceration compared to completing treatment or discharge due to other reasons. African Americans, Latinx, and Native Americans were at greater risk of discharge due to incarceration compared to whites. Referral to OAT from criminal justice agencies and self-referral was associated with increased risk of discharge from OAT due to incarceration compared to referral from a health care provider. Substance use of heroin, benzodiazepines, synthetic opioids, cocaine and non-prescription use of methadone were associated with discharge due to incarceration. Risk of discharge due to incarceration was higher for patients who reported intravenous drug use and who reported a co-morbid psychiatric problem. These findings enrich a nascent body of literature on mechanisms associated with attrition from OAT due to incarceration and emphasize the need for programs to divert people with OUD from incarceration to increase engagement and retention in OAT.

A randomized controlled trial of buprenorphine for probationers and parolees: Bridging the gap into treatment

BACKGROUND

Buprenorphine can be effective in a variety of community substance use treatment settings outside of methadone programs, including outpatient programs and medical practices. In these settings, it has been found to be effective in reducing opioid use and retaining patients in treatment. Despite its effectiveness and safety, it is rarely provided to individuals with opioid use disorders in probation and parole settings.

METHODS

Male and female individuals under probation or parole supervision (N = 320) with histories of opioid use disorder will be enrolled in this randomized controlled trial. Participants will be randomized to one of two study arms: Buprenorphine Bridge Treatment (BBT): Participants will begin buprenorphine using the MedicaSafe dispensing device immediately after an on-site intake at a community supervision office and continue such treatment until they are transitioned to a community program; or Treatment as Usual (TAU): Participants will receive a referral to buprenorphine pharmacotherapy treatment in the community. Treatment outcomes will be: (a) illicit opioid oral saliva drug test results; and (b) treatment adherence (i. entered community based treatment; ii. number of days receiving opioid treatment).

RESULTS

We describe the background and rationale for the study, its aims, hypotheses, and study design.

CONCLUSIONS

If shown to increase compliance rates with conditions of probation and parole, buprenorphine treatment co-located at community supervision field offices could have a major impact on delivery of buprenorphine treatment to the criminal justice population. The public health impact of the proposed study would be widespread because this intervention could be implemented throughout areas of the US.

Collaboration: A Mechanism of Drug Court Model Adherence

Drug courts solve problems, namely, reducing drug use and recidivism. The current research attempts to answer the question of how to ensure program fidelity and therefore optimize the efficacy of drug courts. Justice professionals and scholars have recognized that there are multiple internal and external threats that could undermine the drug court operation. At this point, the mechanism(s) by which threaten factors affect drug court program fidelity has been neither theoretically modeled nor empirically tested. In the present study, using a national sample and the Structural Regression Analysis (SRA), we found collaboration and judicial decision making are the most important factors for maintaining drug court program fidelity. This is because collaboration and judicial decision making can mediate the threats and challenges from many quarters, including the lack of information sharing and evaluation, treatment, operational support, and community and political support.

An evaluation of welfare and child welfare system integration on rates of child maltreatment in Colorado

Policies that improve the socioeconomic conditions of families have been identified as one of the most promising strategies to prevent child maltreatment, particularly neglect. In this study, we examined the impact of integrated Temporary Assistance for Needy Families (TANF) and child welfare (CW) systems on child maltreatment-related hospitalizations and Child Protective Services investigations and substantiations in nine counties in Colorado from 1996 to 2014. Regression analyses showed TANF-CW integration was associated with subsequent year, but not second-year, increases rates of substantiated child maltreatment overall and neglect specifically (that is, there was no longer a difference in the rate two years after the change in integration). Neither unemployment nor the one- or two-year lagged effect of integration were significant for investigations or child maltreatment-related hospitalizations. Increased opportunities to interact with a family in crisis using an integrated case management model may help explain these findings. Implications for future research are discussed.

Patterns of Substance Use and Arrest Histories Among Hospitalized HIV Drug Users: A Latent Class Analysis

Using baseline data from the NIDA Clinical Trials Network 0049 study (Project HOPE), we performed latent class analyses (LCA) to identify discrete classes, or clusters, of people living with HIV (PLWH) based on their past year substance use behaviors and lifetime arrest history. We also performed multinomial logistic regressions to identify key characteristics associated with class membership. We identified 5 classes of substance users (minimal drug users, cocaine users, substantial cocaine/hazardous alcohol users, problem polysubstance users, substantial cocaine/heroin users) and 3 classes of arrest history (minimal arrests, non-drug arrests, drug-related arrests). While several demographic variables such as age and being Black or Hispanic were associated with class membership for some of the latent classes, participation in substance use treatment was the only covariate that was significantly associated with membership in all classes in both substance use and arrest history LCA models. Our analyses reveal complex patterns of behaviors among substance using PLWH and suggest that HIV intervention strategies may need to take into consideration such nuanced differences to better inform future studies and program implementation.

Organizational Factors and Probation Officer Use of Evidence-Based Practices: A Multilevel Examination

Growing evidence pointing to the ineffectiveness of control-oriented supervision practices has led to an emphasis on evidence-based practices (EBPs), or practices that are empirically tied to recidivism reduction. Research on EBPs in probation highlights the importance of case management-oriented supervision and provision of proactive, appropriate program referrals. Despite research support, challenges exist regarding implementing EBPs in real-world practice. Utilizing survey data from 813 adult probation officers across 43 agencies, the current study examined variation in use of case management and proactive referral practices. Findings highlight the important role organizational commitment plays in supporting implementation efforts. Implications suggest a need for probation agencies to promote and sustain staff commitment to their agency before embarking on significant reform efforts.

Using Goal Achievement Training in juvenile justice settings to improve substance use services for youth on community supervision

BACKGROUND

The link between substance use and involvement in the juvenile justice system has been well established. Justice-involved youth tend to have higher rates of drug use than their non-offending peers. At the same time, continued use can contribute to an elevated risk of recidivism, which leads to further, and oftentimes more serious, involvement with the juvenile justice system. Because of these high rates of use, the juvenile justice system is well positioned to help identify youth with substance use problems and connect them to treatment. However, research has found that only about 60% of juvenile probation agencies screen all youth for substance involvement, and even fewer provide comprehensive assessment or help youth enroll in substance use treatment.

METHOD

This paper describes an integrated training curriculum that was developed to help juvenile justice agencies improve their continuum of care for youth probationers with substance use problems. Goal Achievement Training (GAT) provides a platform for continuous quality improvement via two sessions delivered onsite to small groups of staff from juvenile justice and behavioral health agencies. In the first session, participants are taught to identify goals and goal steps for addressing identified areas of unmet need (i.e., screening, assessment, and linkage to treatment services). In the second session, participants learn principles and strategies of data-driven decision-making for achieving these goals. This paper highlights GAT as a model for the effective implementation of cost-efficient training strategies designed to increase self-directed quality improvement activities that can be applied to any performance domain within juvenile justice settings. Efforts to monitor implementation fidelity of GAT within the specific context of the juvenile justice settings are highlighted.

DISCUSSION

Challenges to setting the stage for process improvement generally, as well as specific hurdles within juvenile justice settings are discussed, as are next steps in disseminating findings regarding the fidelity to and effectiveness of GAT in this unique context.

TRIAL REGISTRATION

Clinical Trials Registration number - NCT02672150 .

Indicators and Measurement Tools for Health Systems Integration: A Knowledge Synthesis

Background:

Despite far reaching support for integrated care, conceptualizing and measuring integrated care remains challenging. This knowledge synthesis aimed to identify indicator domains and tools to measure progress towards integrated care.

Methods:

We used an established framework and a Delphi survey with integration experts to identify relevant measurement domains. For each domain, we searched and reviewed the literature for relevant tools.

Findings:

From 7,133 abstracts, we retrieved 114 unique tools. We found many quality tools to measure care coordination, patient engagement and team effectiveness/performance. In contrast, there were few tools in the domains of performance measurement and information systems, alignment of organizational goals and resource allocation. The search yielded 12 tools that measure overall integration or three or more indicator domains.

Discussion:

Our findings highlight a continued gap in tools to measure foundational components that support integrated care. In the absence of such targeted tools, “overall integration” tools may be useful for a broad assessment of the overall state of a system.

Conclusions:

Continued progress towards integrated care depends on our ability to evaluate the success of strategies across different levels and context. This study has identified 114 tools that measure integrated care across 16 domains, supporting efforts towards a unified measurement framework.

Substance abuse and batterer programmes in California, USA: factors associated with treatment outcomes

The association between substance abuse and intimate partner violence is quite robust. A promising area to improve treatment for the dual problems of substance abuse and violence perpetration is the identification of client characteristics and organisational and programme factors as predictors of health outcomes. Therefore, we examined associations of client, organisational and programme factors with outcomes in community health settings. Directors of 241 substance use disorder programmes (SUDPs) and 235 batterer intervention programmes (BIPs) reported outcomes of programme completion and substance use and violence perpetration rates at discharge; data collection and processing were completed in 2012. SUDPs having more female, non-white, younger, uneducated, unemployed and lower income clients reported lower completion rates. In SUDPs, private, for-profit programmes reported higher completion rates than public or private, non-profit programmes. SUDPs with lower proportions of their budgets from government sources, and higher proportions from client fees, reported better outcomes. Larger SUDPs had poorer programme completion and higher substance use rates. Completion rates in SUDPs were higher when clients could obtain substance- and violence-related help at one location, and programmes integrated violence-prevention contracting into care. In BIPs, few client, organisational and programme factors were associated with outcomes, but the significant factors associated with programme completion were consistent with those for SUDPs. Publicly owned and larger programmes, and SUDPs lacking staff to integrate violence-related treatment, may be at risk of poorer client outcomes, but could learn from programmes that perform well to yield better outcomes.

Indicators and measurement tools for health system integration: a knowledge synthesis protocol

BACKGROUND

Health system integration is a key component of health system reform with the goal of improving outcomes for patients, providers, and the health system. Although health systems continue to strive for better integration, current delivery of health services continues to be fragmented. A key gap in the literature is the lack of information on what successful integration looks like and how to measure achievement towards an integrated system. This multi-site study protocol builds on a prior knowledge synthesis completed by two of the primary investigators which identified 10 key principles that collectively support health system integration. The aim is to answer two research questions: What are appropriate indicators for each of the 10 key integration principles developed in our previous knowledge synthesis and what measurement tools are used to measure these indicators? To enhance generalizability of the findings, a partnership between Canada and Brazil was created as health system integration is a priority in both countries and they share similar contexts.

METHODS/DESIGN

This knowledge synthesis will follow an iterative scoping review process with emerging information from knowledge-user engagement leading to the refinement of research questions and study selection. This paper describes the methods for each phase of the study. Research questions were developed with stakeholder input. Indicator identification and prioritization will utilize a modified Delphi method and patient/user focus groups. Based on priority indicators, a search of the literature will be completed and studies screened for inclusion. Quality appraisal of relevant studies will be completed prior to data extraction. Results will be used to develop recommendations and key messages to be presented through integrated and end-of-grant knowledge translation strategies with researchers and knowledge-users from the three jurisdictions.

DISCUSSION

This project will directly benefit policy and decision-makers by providing an easy accessible set of indicators and tools to measure health system integration across different contexts and cultures. Being able to evaluate the success of integration strategies and initiatives will lead to better health system design and improved health outcomes for patients.

Effects of a strategy to improve offender assessment practices: Staff perceptions of implementation outcomes

BACKGROUND

This implementation study examined the impact of an organizational process improvement intervention (OPII) on a continuum of evidence based practices related to assessment and community reentry of drug-involved offenders: Measurement/Instrumentation, Case Plan Integration, Conveyance/Utility, and Service Activation/Delivery.

METHODS

To assess implementation outcomes (staff perceptions of evidence-based assessment practices), a survey was administered to correctional and treatment staff (n=1509) at 21 sites randomly assigned to an Early- or Delayed-Start condition. Hierarchical linear models with repeated measures were used to examine changes in evidence-based assessment practices over time, and organizational characteristics were examined as covariates to control for differences across the 21 research sites.

RESULTS

Results demonstrated significant intervention and sustainability effects for three of the four assessment domains examined, although stronger effects were obtained for intra- than inter-agency outcomes. No significant effects were found for Conveyance/Utility.

CONCLUSIONS

Implementation interventions such as the OPII represent an important tool to enhance the use of evidence-based assessment practices in large and diverse correctional systems. Intra-agency assessment activities that were more directly under the control of correctional agencies were implemented most effectively. Activities in domains that required cross-systems collaboration were not as successfully implemented, although longer follow-up periods might afford detection of stronger effects.

Intersectoral collaboration for physical activity in Korean Healthy Cities

Intersectoral collaboration (ISC) is important in the health field because the complexity of determinants of health makes it difficult for one institution to resolve all health issues. Promotion of physical activity can especially benefit from a multi-sectoral approach. Despite so much emphasis on its importance in both primary health and health promotion, ISC has been underachieved in the field. This study aimed to examine the characteristics and level of ISC among physical activity programs in Healthy Cities as compared to non-Healthy Cities. I conducted a postal survey where 24 people from Healthy Cities and 72 people from non-Healthy Cities participated. The survey included questions to measure the level of ISC as well as to determine ISC partners and activities. Among the entire 393 physical activity programs, 336 (85.5%) had some kind of collaboration with one or more partners. The percentage having one or more partners was greater in Healthy Cities than in non-Healthy Cities. However, there were no statistical differences between the two groups in terms of the level of ISC within a municipal organization. Collaboration activities of the other departments were mostly supportive, such as providing a venue, recruiting participants and publicizing, and other kinds of administrative support. To strengthen ISC in Korean Healthy Cities, various actions including providing a legal basis, specific and substantive supports, financial incentives, and organizational recognitions will be helpful as well as the development of partnerships with other departments in urban planning, transport, urban design, and communication.

The effect of a local change team intervention on staff attitudes towards HIV service delivery in correctional settings: a randomized trial

The National Criminal Justice Drug Abuse Treatment Studies research program conducted cluster randomized trials to test an organizational process improvement strategy for implementing evidence-based improvements in HIV services for preventing, detecting, and/or treating HIV for individuals under correctional supervision. Nine research centers conducted cluster randomized trials in which one correctional facility used a modified Network for Improvement of Addiction Treatment (NIATx) change team approach to implementing improved HIV services and the other facility used their own approach to implement the improved HIV services. This paper examines whether the intervention increased the perceived value of HIV services among staff of correctional and community HIV organizations. Baseline and follow-up measures of the perceived acceptability, feasibility, and organizational support for implementing HIV service improvements were collected from correctional, medical, and community HIV treatment staff. Results indicated that the perceived acceptability and feasibility of implementing HIV services improved among staff in the facilities using the modified NIATx change team approach as compared to staff in the comparison facilities.

Design and methods of a double blind randomized placebo-controlled trial of extended-release naltrexone for HIV-infected, opioid dependent prisoners and jail detainees who are transitioning to the community

BACKGROUND

People with opioid dependence and HIV are concentrated within criminal justice settings (CJS). Upon release, however, drug relapse is common and contributes to poor HIV treatment outcomes, increased HIV transmission risk, reincarceration and mortality. Extended-release naltrexone (XR-NTX) is an evidence-based treatment for opioid dependence, yet is not routinely available for CJS populations.

METHODS

A randomized, double-blind, placebo-controlled trial of XR-NTX for HIV-infected inmates transitioning from correctional to community settings is underway to assess its impact on HIV and opioid-relapse outcomes.

RESULTS

We describe the methods and early acceptability of this trial. In addition we provide protocol details to safely administer XR-NTX near community release and describe logistical implementation issues identified. Study acceptability was modest, with 132 (66%) persons who consented to participate from 199 total referrals. Overall, 79% of the participants had previously received opioid agonist treatment before this incarceration. Thus far, 65 (49%) of those agreeing to participate in the trial have initiated XR-NTX or placebo. Of the 134 referred patients who ultimately did not receive a first injection, the main reasons included a preference for an alternative opioid agonist treatment (37%), being ineligible (32%), not yet released (10%), and lost upon release before receiving their injection (14%).

CONCLUSIONS

Study findings should provide high internal validity about HIV and opioid treatment outcomes for HIV-infected prisoners transitioning to the community. The large number of patients who ultimately did not receive the study medication may raise external validity concerns due to XR-NTX acceptability and interest in opioid agonist treatments.

CLINICAL TRIAL NUMBER

NCT01246401.

Organizational capacity for service integration in community-based addiction health services

OBJECTIVES

We examined factors associated with readiness to coordinate mental health, public health, and HIV testing among community-based addiction health services programs.

METHODS

We analyzed client and program data collected in 2011 from publicly funded addiction health services treatment programs in Los Angeles County, California. We analyzed a sample of 14 379 clients nested in 104 programs by using logistic regressions examining odds of service coordination with mental health and public health providers. We conducted a separate analysis to examine the percentage of clients receiving HIV testing in each program.

RESULTS

Motivational readiness and organizational climate for change were associated with higher odds of coordination with mental health and public health services. Programs with professional accreditation had higher odds of coordinating with mental health services, whereas programs receiving public funding and methadone and residential programs (compared with outpatient) had a higher percentage of clients receiving coordinated HIV testing.

CONCLUSIONS

These findings provide an evidentiary base for the role of motivational readiness, organizational climate, and external regulation and funding in improving the capacity of addiction health services programs to develop integrated care.

Posttreatment drug use abstinence: does the majority program clientele matter?

The current study examines differences in organizational characteristics and client posttreatment drug use abstinence in residential substance abuse treatment programs serving clients with high or low levels of legal coercion to participate in treatment. The findings show that low legal coercion programs have higher counselor caseloads (Z = 59, p < .05) than high coercion programs. Although the results showed that programs with a large proportion of African American clients (β = 14.26, p < .0001) and high legal coercion programs (β = 19.99, p < .05) predicted longer abstinence posttreatment, the final models suggest organizational factors are the key predictors of client posttreatment abstinence.

Implementation of contingency management in probation agencies using a case controlled longitudinal design: a PDSA study protocol

Background

Moving evidence-based practices (EBPs) from clinical research settings to real world work environments is challenging. Grounded in the work of Proctor and colleagues on “bench-trench” partnerships, quality improvement studies use a bench (academic)-trench (practitioner) model that incorporates “practice knowledge” while building a feedback process throughout the various change phases (Social Work Research, 27, 67-69). Yet, few implementation studies give adequate attention to longitudinal collection of key organizational and individual level-information.

Method/Design

The Justice Steps (JSTEPS) project uses a PDSA (Plan-Do-Study-Act) quasi-experimental design that combines active and engaged researcher and practitioner learning collaborations about EBP adoption and implementation. The academic researchers and practitioners (Federal probation and judicial staff) work together to implement contingency management (CM) into routine practice. Each site participates in two learning collaborative meetings, receives six feedback reports, and accesses telephone consultation on the design and implementation of the CM procedure. The study protocol allows examination of the implementation of CM over 24 months in five settings. Each setting proceeds based on the sites’ own pace of adopting CM. This study uses a case controlled pre-post design to measure individual level data and a pre-post design for staff level outcomes. The outcomes of interest are reduced substance use and increased time on probation. The project data collection includes individual-level client data and organizational and staff data to assess the implementation of the CM in five probation agencies through three periods: inception, implementation and sustainability. Qualitative methods include observations and interviews combined with data gathering during learning sessions. Individual level client data includes attendance, status at required events, and arrests.

Discussion

This project contributes to the current understanding of how contextual factors affect implementation decisions. The protocol allows each site to develop their own tailored CM protocol and a process for implementing CM, compatible with the local socio-political environment. Feedback loops are important for fostering attention to CM implementation issues.

Electronic supplementary material

The online version of this article (doi:10.1186/2194-7899-1-7) contains supplementary material, which is available to authorized users.

Implementing drug abuse treatment services in criminal justice settings: Introduction to the CJ-DATS study protocol series

BACKGROUND

Despite a growing pipeline of effective clinical treatments, there remains a persistent research-to-practice gap in drug abuse services. Delivery of effective treatment services is especially lacking in the U.S. criminal justice system, where half of all incarcerated persons meet the need for drug abuse or dependence, yet few receive needed care. Structural, financial, philosophical and other barriers slow the pace of adoption of available evidence-based practices. These challenges led to the development of a multi-site cooperative research endeavor known as the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS), funded by the National Institute on Drug Abuse (NIDA). CJ-DATS engages university-based research teams, criminal justice agencies, and community-based treatment providers in implementation research studies to test strategies for enhancing treatment service delivery to offender populations.

METHODS

This Introduction reviews the mission of NIDA, the structure and goals of the CJ-DATS cooperative, and the implementation studies being conducted by the participating organizations. The component Study Protocols in this article collection are then described.

DISCUSSION

CJ-DATS applies implementation science perspectives and methods to address a vexing problem - the need to link offender populations with effective treatment for drug abuse, HIV, and other related conditions for which they are at high risk. Applying these principles to the U.S. criminal justice system is an innovative extension of lessons that have been learned in mainstream healthcare settings. This collection is offered as both an introduction to NIDA's work in this area, as well as a window onto the challenges of conducting health services research in settings in which improving public health is not the organization's core mission.

Prison, a missing target to address issues related to drug detoxification and rehabilitation: Nepalese experiences

PURPOSE

Drug use has numerous consequences on health, the economy, culture and the peace and security of families and communities. Drug users often engage in various criminal activities, including drug dealing, to sustain their drug use. Under Nepalese law, consumption, possession and sale of drugs are illegal, which increases the risk of incarceration for drug users.

DESIGN/METHODOLOGY/APPROACH

Using a phenomenological/qualitative approach, the paper explores how various activities can lead to the arrest of drug users, how they cope without taking drugs in custody and prison and how they plan abstinence after release.

FINDINGS

Participants engaged in various categories of criminal activity, including stealing, looting, etc. Most of the drug users were in custody and prison at least once. Drug use relapses led the participants to re-engage in criminal activities including drug dealing. Parents were often overburdened by their sons and daughter's drug use and were worried about their repeated relapses. Finally, some parents negotiated with their sons and daughters to keep them in prison where they would be able to stay without taking drugs and their involvement in crimes and conflicts would decrease.

ORIGINALITY/VALUE

Keeping substance abusers in prison does not appear to be an effective strategy, as many participants relapse after release from prison. However, a prison-based educational and health promotion strategy would be beneficial for drug users to develop knowledge and skills on staying drug-free. However, to date, no effort has been made to provide such services to drug users and develop their coping strategy after release.

Policies and practices in the delivery of HIV services in correctional agencies and facilities: results from a multisite survey

HIV risk is disproportionately high among incarcerated individuals. Corrections agencies have been slow to implement evidence-based guidelines and interventions for HIV prevention, testing, and treatment. The emerging field of implementation science focuses on organizational interventions to facilitate adoption and implementation of evidence-based practices. A survey of correctional agency partners from the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) revealed that HIV policies and practices in prevention, detection, and medical care varied widely, with some corrections agencies and facilities closely matching national guidelines and/or implementing evidence-based interventions. Others, principally attributed to limited resources, had numerous gaps in delivery of best HIV service practices. A brief overview is provided of a new CJ-DATS cooperative research protocol, informed by the survey findings, to test an organization-level intervention to reduce HIV service delivery gaps in corrections.

Staff Perspectives on Juvenile Drug Court Operations: A Multi-Site Qualitative Study

Substance use is pervasive among youth, particularly among those involved in the juvenile justice system. Juvenile drug courts (JDCs) are a promising approach for delinquent youth with substance abuse issues. However, research regarding JDCs has shown inconsistent effects, and little is known about the specific components associated with positive outcomes. The current study examines data from interviews of JDC judges and team member focus groups in six JDCs from two contiguous southeastern states to identify stakeholders' perceptions about what places youth at risk for involvement in JDC and the factors that may contribute to successful outcomes. In addition, we examine these stakeholders' perceptions of the strengths and challenges facing their JDCs. Our findings highlight the importance of parents and specific strategies implemented by JDCs in influencing the outcomes of youth in JDCs and the importance of interagency collaboration and access to treatment and community resources for the overall success of JDCs.

Addressing substance abuse and violence in substance use disorder treatment and batterer intervention programs

BACKGROUND

Substance use disorders and perpetration of intimate partner violence (IPV) are interrelated, major public health problems.

METHODS

We surveyed directors of a sample of substance use disorder treatment programs (SUDPs; N=241) and batterer intervention programs (BIPs; N=235) in California (70% response rate) to examine the extent to which SUDPs address IPV, and BIPs address substance abuse.

RESULTS

Generally, SUDPs were not addressing co-occurring IPV perpetration in a formal and comprehensive way. Few had a policy requiring assessment of potential clients, or monitoring of admitted clients, for violence perpetration; almost one-quarter did not admit potential clients who had perpetrated IPV, and only 20% had a component or track to address violence. About one-third suspended or terminated clients engaging in violence. The most common barriers to SUDPs providing IPV services were that violence prevention was not part of the program's mission, staff lacked training in violence, and the lack of reimbursement mechanisms for such services. In contrast, BIPs tended to address substance abuse in a more formal and comprehensive way; e.g., one-half had a policy requiring potential clients to be assessed, two-thirds required monitoring of substance abuse among admitted clients, and almost one-half had a component or track to address substance abuse. SUDPs had clients with fewer resources (marriage, employment, income, housing), and more severe problems (both alcohol and drug use disorders, dual substance use and other mental health disorders, HIV + status). We found little evidence that services are centralized for individuals with both substance abuse and violence problems, even though most SUDP and BIP directors agreed that help for both problems should be obtained simultaneously in separate programs.

CONCLUSIONS

SUDPs may have difficulty addressing violence because they have a clientele with relatively few resources and more complex psychological and medical needs. However, policy change can modify barriers to treatment integration and service linkage, such as reimbursement restrictions and lack of staff training.

Gender differences in prison-based drug treatment participation

Prisons inmates have high rates of substance abuse and associated social and health problems, and a concomitant high need for drug treatment while incarcerated. Female inmates have an even greater treatment need, yet most inmates do not participate in treatment while incarcerated. Using data from a nationally representative sample of prison inmates, this article examines the impact of gender on prison treatment participation and gender differences in the factors associated with clinical treatment participation. Females were significantly more likely to participate in prison drug treatment than males, controlling for other factors. For both males and females, severity of drug problems predicted participation in treatment. For males but not females, race was associated with prison treatment participation, and among those with drug abuse or dependence, females with co-occurring mental health problems were more likely to participate in treatment. Implications for prison assessment and treatment policies, and future research, are discussed.

The landscape of services for drug users in Yogyakarta, Indonesia

INTRODUCTION AND AIMS

Drug use has increased rapidly in Indonesia since the late 1990s. The formal drug treatment sector has grown within the bounds of available government funding; however, there is also a substantial informal sector which provides a range of services for current and former users. While information regarding the former is available from the provincial and national governments, there are few sources that detail the latter. The aim of the current study, therefore, is to document the drug treatment services in one Indonesian city, Yogyakarta.

DESIGN AND METHODS

This qualitative study utilised nine key informant interviews with drug treatment workers from nine government and non-government treatment services. Transcripts were analysed thematically.

RESULTS

There exists a patchwork of enthusiastic yet under-resourced non-government services that complement the government rehabilitation and withdrawal programs in Yogyakarta. The focus of most such services is on abstinence (including several faith-based residential rehabilitation programs); however, some harm reduction programs have emerged in recent years. Under-utilisation is a feature of many non-government services, and all respondents acknowledged a significant gap in service coordination.

DISCUSSION AND CONCLUSIONS

Yogyakarta has a drug treatment sector in which most major treatment types are represented, and there appears to be potential for growth within many organisations. Nevertheless, the number and reach of the services are limited by a lack of resources and collaboration, and there are substantial cultural barriers to improving inter-organisational coordination. This study suggests that Yogyakarta and greater Indonesia may benefit from greater service coordination facilitated by local government.

Adding positive reinforcement in justice settings: acceptability and feasibility

Although contingency management (CM) approaches are among the most promising methods for initiating drug abstinence (S. T. Higgins, S. M. Alessi, & R. L. Dantona, 2002; S. T. Higgins, S. H. Heil, & J. P. Lussier, 2004), adoption and implementation of CM protocols into treatment programs are both challenging and infrequent. In criminal justice agencies, where roughly 70% of clients report substance abuse issues (F. S. Taxman, K. L. Cropsey, D. W. Young, & H. Wexler, 2007), CM interventions are virtually nonexistent. The Justice Steps (JSTEPS) study uses a longitudinal, mixed-method design to examine the implementation of a CM-based protocol in five justice settings. This article presents qualitative data collected during Phase 1 of the JSTEPS project regarding the acceptability and feasibility of CM in these justice settings. The study finds a level of acceptability (find CM tolerable) and feasibility (find CM suitable) within justice agencies, but with some challenges. These challenges are reflected in the following: (a) incorporating too many desired target behaviors into CM models; (b) facing intraorganizational challenges when designing CM systems; and (c) emphasizing sanctions over rewards despite the evidence-base for positive reinforcers. These findings have implications for advancing the dissemination, adoption, and implementation of evidence-based treatments (and CM in particular) in criminal justice settings.

Understanding the importance of organizational and system variables on addiction treatment services within criminal justice settings

NIDA's Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) is the primary vehicle for testing emerging treatment interventions and fostering adoption of evidence-based therapies in criminal justice settings. The papers in this issue of Drug and Alcohol Dependence use data from the CJ-DATS National Criminal Justice Treatment Practice Survey to explore the influence of organizational and system variables on access to addiction treatment and the types of services available within correctional settings. This essay provides context for the papers in this issue of Drug and Alcohol Dependence. Systems and organizational interventions that improve the delivery and quality of drug abuse treatment services are described and the potential to apply systems change thinking to addiction treatment services available in the criminal justice system is discussed. Each paper is described briefly. CJ-DATS is evolving to support research at the organizational and systems level that facilitates the implementation and sustainability of research-supported treatments and business practices in criminal justice settings.

Availability and capacity of substance abuse programs in correctional settings: A classification and regression tree analysis

OBJECTIVE TO BE ADDRESSED: The purpose of this study was to investigate the structural and organizational factors that contribute to the availability and increased capacity for substance abuse treatment programs in correctional settings. We used classification and regression tree statistical procedures to identify how multi-level data can explain the variability in availability and capacity of substance abuse treatment programs in jails and probation/parole offices.

METHODS

The data for this study combined the National Criminal Justice Treatment Practices (NCJTP) Survey and the 2000 Census. The NCJTP survey was a nationally representative sample of correctional administrators for jails and probation/parole agencies. The sample size included 295 substance abuse treatment programs that were classified according to the intensity of their services: high, medium, and low. The independent variables included jurisdictional-level structural variables, attributes of the correctional administrators, and program and service delivery characteristics of the correctional agency.

RESULTS

The two most important variables in predicting the availability of all three types of services were stronger working relationships with other organizations and the adoption of a standardized substance abuse screening tool by correctional agencies. For high and medium intensive programs, the capacity increased when an organizational learning strategy was used by administrators and the organization used a substance abuse screening tool. Implications on advancing treatment practices in correctional settings are discussed, including further work to test theories on how to better understand access to intensive treatment services. This study presents the first phase of understanding capacity-related issues regarding treatment programs offered in correctional settings.

Organizational-level correlates of the provision of detoxification services and medication-based treatments for substance abuse in correctional institutions

In recent years, there has been an increased examination of organizational-level innovation adoption in substance abuse treatment organizations. However, the majority of these studies have focused on community-based treatment centers. One understudied area of the substance abuse treatment system is correctional institutions. This study uses the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) cooperative's National Criminal Justice Treatment Practices (NCJTP) survey to examine the adoption of detoxification services and pharmacotherapies for the treatment of substance abuse across a nationally representative sample of correctional institutions (n=198). There were significant differences between jails and prisons in the percentage of organizations offering detoxification services and medications. Specifically, detoxification services were offered by 5% of prisons and 34% of jails; and, medications were offered by 6% of prisons and 32% of jails. Binary logistic regression models were used to examine the associations between these services and organizational characteristics, including context, resources, previously introduced practices, culture, and systems integration. Variables measuring organizational context and previously introduced practices were significant correlates of the provision of both detoxification services and medications. Multivariate results indicated that the differences between jails and prisons remained significant after controlling for other organizational factors. Although the adoption of detoxification services and pharmacotherapies may be a controversial topic for correctional institutions, these services have the potential to improve offender well-being and reduce public health risks associated with substance abuse.

Filling service gaps: Providing intensive treatment services for offenders

Consistent with the few studies that have previously examined treatment prevalence and access in the adult and juvenile justice systems, the recent National Criminal Justice Treatment Practices (NCJTP) survey indicated that there is a particular need to expand intensive treatment modalities for offenders in both institutional and community corrections settings. Applying multilevel modeling techniques to NCJTP survey data, this study explores conditions and factors that may underlie the wide variation among states in the provision of intensive treatment for offenders. Results indicate that states' overall rates of substance abuse and dependence, funding resources, and the state governor's political party affiliation were significantly associated with intensive treatment provision. Numerous factors that have been implicated in recent studies of evidence-based practice adoption, including state agency executives' views regarding rehabilitation, agency culture and climate, and other state-level measures (e.g., household income, crime rates, expenditures on treatment for the general population) were not associated with treatment provision. Future research should examine further variations in offenders' service needs, the role of legislators' political affiliations, and how other factors may interact with administrator characteristics in the adoption and expansion of intensive treatment services for offenders.

Organizational context, systems change, and adopting treatment delivery systems in the criminal justice system

The correctional system does not include service provision as a primary goal, even though individuals in prison, jail, and on probation/parole have large unmet substance abuse treatment needs. In response to mandates in the U.S. Constitution for basic health care, services are provided for incarcerated offenders, but generally do not include substance abuse treatment. The system does little to extend any type of health care service to individuals in community settings. This leaves the majority of offenders (6 million under community supervision in the U.S.) basically unattended, even with substance abuse disorders that are four times greater than the general public. The challenge of adapting the correctional system to be part of an integrated service provision system - working in conjunction with the public and private community-based service delivery sector - has intrigued researchers and policy makers over the last two decades. A series of articles using data from the National Criminal Justice Treatment Practices survey have examined factors that influence the adoption of a myriad of substance abuse treatment services for offender populations in various settings. These articles explore the factors that affect adoption and implementation, and provide guidance on issues relevant to organizational change and a dual mission of correctional agencies to advance public safety and public health. This special issue of Drug and Alcohol Dependence is devoted to understanding organizational constructs and factors to improve health outcomes for offenders.

Competing values among criminal justice administrators: The importance of substance abuse treatment

This study applied latent class analysis (LCA) to examine heterogeneity in criminal justice administrators' attitudes toward the importance of substance abuse treatment relative to other programs and services commonly offered in criminal justice settings. The study used data collected from wardens, probation and/or parole administrators, and other justice administrators as part of the National Criminal Justice Treatment Practices survey (NCJTP), and includes both adult criminal and juvenile justice samples. Results of the LCA suggested that administrators fell into four different latent classes: (1) those who place a high importance on substance abuse treatment relative to other programs and services, (2) those who place equal importance on substance abuse treatment and other programs and services, (3) those who value other programs and services moderately more than substance abuse treatment, and (4) those who value other programs and services much more than substance abuse treatment. Latent class membership was in turn associated with the extent to which evidence-based substance abuse treatment practices were being used in the facilities, the region of the country in which the administrator worked, and attitudes toward rehabilitating drug-using offenders. The findings have implications for future research focused on the impact that administrators' attitudes have on service provision as well as the effectiveness of knowledge dissemination and diffusion models.