Managerial capacity and adoption of culturally competent practices in outpatient substance abuse treatment organizations

Identifying the Heterogeneity in the Association between Workforce Diversity and Retention in Opioid Treatment among Black clients

Background

This study investigates the impact of workforce diversity, specifically staff identified as Black/African American, on retention in opioid use disorder (OUD) treatment, aiming to enhance patient outcomes. Employing a novel machine learning technique known as 'causal forest,' we explore heterogeneous treatment effects on retention.

Methods

We relied on four waves of the National Drug Abuse Treatment System Survey (NDATSS), a nationally representative longitudinal dataset of treatment programs. We analyzed OUD program data from the years 2000, 2005, 2014 and 2017 (n = 627). Employing the 'causal forest' method, we analyzed the heterogeneity in the relationship between workforce diversity and retention in OUD treatment. Interviews with program directors and clinical supervisors provided the data for this study.

Results

The results reveal diversity-related variations in the association with retention across 61 out of 627 OUD treatment programs (less than 10%). These programs, associated with positive impacts of workforce diversity, were more likely private-for-profit, newer, had lower percentages of Black and Latino clients, lower staff-to-client ratios, higher proportions of staff with graduate degrees, and lower percentages of unemployed clients.

Conclusions

While workforce diversity is crucial, our findings underscore that it alone is insufficient for improving retention in addiction health services research. Programs with characteristics typically linked to positive outcomes are better positioned to maximize the benefits of a diverse workforce in client retention. This research has implications for policy and program design, guiding decisions on resource allocation and workforce diversity to enhance retention rates among Black clients with OUDs.

Stability in a large drug treatment system: Examining the role of program size and performance on service discontinuation

Background

Little is known about the stability of public drug treatment in the United States to deliver services in an era of expansion of public insurance. Guided by organizational theories, we examined the role of program size, and performance (i.e., rates of treatment initiation and engagement) on discontinuing services in one of the largest treatment systems in the United States.

Methods

This study relied on multi-year (2006–2014) administrative data of 249,029 treatment admission episodes from 482 treatment programs in Los Angeles County, CA. We relied on survival regression analysis to identify associations between program size, treatment initiation (wait time) and engagement (retention and completion rates) and discontinuing services in any given year. We examined program differences between discontinued versus sustained services in pre- and post-expansion periods.

Results

Sixty-two percent of programs discontinued services at some point between 2006 and 2014. Program size and rates of treatment retention were negatively associated with risk of discontinuing services. Proportion of female clients was also negatively associated with risk of discontinuing services. Compared to residential programs, methadone programs were associated with reduced likelihood of discontinuing services. Two interactions were significant; program size and retention rates, as well as program size and completion rates were negatively associated with risk of discontinuing services.

Conclusions

Program size (large), type (methadone), performance (retention) and client population (women) were associated with stability in this drug treatment system. Because more than 70% of programs in this system are small, it is critical to support their capacity to sustain services to reduce existing disparities in access to care. We discuss the implications of these findings for system evaluation and for responding to public health crises.

La Cultura Cura: Latino Culture, Shared Experiences, and Recovery in Northern Californian Anexos

This article examines the anexo's use of Latino culture and shared experiences to promote recovery and its appeal to 1.5- and second-generation Latinos. Anexos are grassroots recovery groups with origins in Mexico that offer a residential Alcoholics Anonymous program in Latino communities. Data were gathered from a two-year (2014-2016) ethnographic study of anexos in Northern California and were analyzed thematically. Despite having access to publicly funded treatment, many 1.5- and second-generation Latinos accessed anexos based on cultural familiarity, shared experiences, and a desire to recuperate cultural practices lost during their substance use.

Grassroots interventions for alcohol use disorders in the Mexican immigrant community: A narrative literature review

This narrative literature review addresses grassroots interventions for alcohol use disorders as practiced in Mexican immigrant communities. These organic efforts are 24-hour AA groups, or anexos, fourth and fifth step AA groups, juramentos, and curanderismo. Literature was identified using PubMed and CINAHL and limited to works published from 2000 to 2018. In all, three publications on 24-hour groups were found, two on fourth and fifth step groups, four on juramentos, and one on curanderismo use. The review offers insight on their practices and concludes that the interventions' cultural resonance provides advantages over cultural competency AUDs programs developed in public health.

Drivers of continued implementation of cultural competence in substance use disorder treatment

The purpose of this study was to examine whether the key characteristics of organizational decision makers predicted continued implementation of five different practices that represent organizational cultural competence in one of the largest and most diverse substance use disorder (SUD) treatment systems in the United States. We analyzed data collected from SUD treatment programs at four-time points: 2011 (N = 115), 2013 (N = 111), 2015 (N = 106), and 2017 (N = 94). We conducted five mixed-effect linear regression models, one per each outcome to examine the extent to which program director's transformational leadership and ethnic background (Latino) predicted (1) knowledge of minority community needs; (2) development of resources and linkages to serve minorities; (3) reaching out to minority communities; (4) hiring and retention of staff members from minority backgrounds; and (5) development of policies and procedures to effectively respond to the service needs of minority patients. Results show that two of the five practices continued implementation at same degree (resources and linkages and policies and procedures), one practice increased degree of implementation (knowledge), while two practices reduced degree of implementation (staffing and outreach to communities) over the six-year period. Directorial leadership was positively associated with the continued implementation of all five practices. Latino directors were associated with an increase in knowledge of minority communities, but a decrease in resources and linkages and policies and procedures to serve minorities. On the other hand, interactions showed that leadership among Latino directors increased staffing over time and led to increases in resources and linkages and policies and procedures overtime. Overall, continued implementation of culturally responsive practices was uneven in the SUD treatment system studied. But program directors' transformational leadership and ethnic background played a critical role in increasing the implementation of key practices over time. Findings have implications for developing and testing culturally grounded leadership interventions for program directors to ensure the continued and increased implementation of practices that are necessary to improve standards of care in minority health.

Program Capacity to Deliver Prevention Services to Children of Adult Clients Receiving Substance Use Disorder Treatment

Children whose parents have a history of substance use are at elevated risk of developing substance use disorders (SUDs) and related debilitating behaviors. Although specialty treatment programs are uniquely positioned to deliver prevention care to children of adult clients, these programs may have limited capacity to implement prevention and early intervention care services, particularly in racial and ethnic minority communities. We merged data from program surveys and client records collected in 2015 to examine the extent to which program capacity factors are associated with the odds of delivering prevention and early intervention services for children of adult clients attending outpatient SUD treatment in low-income minority communities in Los Angeles County, California. Our analytic sample consisted of 16,712 clients embedded in 82 programs. Our results show that 85% of these programs reported delivering prevention care services, while 71% of programs delivered early intervention services. Programs with organizational climates supporting change and those that served a high number of clients annually were more likely to implement both prevention and early intervention practices. Programs accepting Medicaid payments and serving clients whose primary drug was marijuana were more than three times as likely to implement prevention services. Overall, our findings suggest both program- and client-level characteristics are associated with delivering preventive care offered to children of adult clients receiving SUD treatment in communities of color. As Medicaid has become a major payor of SUD treatment services and marijuana use has been legalized in California, findings identify capacity factors to deliver public health prevention interventions in one of the nation's largest public SUD treatment systems.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Identifying and reducing disparities in successful addiction treatment completion: testing the role of Medicaid payment acceptance

BACKGROUND

Medicaid has become the largest payer of substance use disorder treatment and may enhance access to quality care and reduce disparities. We tested whether treatment programs' acceptance of Medicaid payments was associated with reduced disparities between Mexican Americans and non-Latino Whites.

METHODS

We analyzed client and program data from 122 publicly funded treatment programs in 2010 and 112 programs in 2013. These data were merged with information regarding 15,412 adult clients from both periods, of whom we selected only Mexican Americans (n = 7130, 46.3%) and non-Latino Whites (n = 8282, 53.7%). We used multilevel logistic regression and variance decomposition to examine associations and underlying factors associated with Mexican American and White differences in treatment completion. Variables of interest included client demographics; drug use severity and mental health issues; and program license, accreditation, and acceptance of Medicaid payments.

RESULTS

Mexican Americans had lower odds of treatment completion (OR = 0.677; 95% CI = 0.534, 0.859) compared to non-Latino Whites. This disparity was explained in part by primary drug used, greater drug use severity, history of mental health disorders, and program acceptance of Medicaid payments. The interaction between Mexican Americans and acceptance of Medicaid was statistically significant (OR = 1.284; 95% CI = 1.008, 1.637).

CONCLUSIONS

Findings highlighted key program and client drivers of this disparity and the promising role of program acceptance of Medicaid payment to eliminate disparities in treatment completion among Mexican Americans. Implications for health policy during the Trump Administration are discussed.

Nurse-Environment Interactions in the Development of Cultural Competence

Studies on the development of cultural competence among healthcare providers tend to focus on the clinical encounter, with little attention paid to the environment. In this paper, results from a grounded theory study conducted with nurses and students to understand cultural competence development are presented; with a focus on findings that call particular attention to nurse-environment interactions. Two concurrent processes, as students and nurses develop cultural competence through interactions with their environment, were identified: "dealing with structural constraints" and "mobilizing social resources". These dynamic interactions between healthcare providers and the larger structures of healthcare systems raise critical questions about the power of healthcare providers to influence the structures that shape their practice. The intersection of nursing theory with social and critical theories is essential to gain a comprehensive understanding of cultural competence development and to transform healthcare providers' education in the service of social justice and health equity.

Program Capacity to Eliminate Outcome Disparities in Addiction Health Services

We evaluated program capacity factors associated with client outcomes in publicly funded substance abuse treatment organizations in one of the most populous and diverse regions of the United States. Using multilevel cross-sectional analyses of program data (n = 97) merged with client data from 2010 to 2011 for adults (n = 8,599), we examined the relationships between program capacity (leadership, readiness for change, and Medi-Cal payment acceptance) and client wait time and treatment duration. Acceptance of Medi-Cal was associated with shorter wait times, whereas organizational readiness for change was positively related to treatment duration. Staff attributes were negatively related to treatment duration. Overall, compared to low program capacity, high program capacity was negatively associated with wait time and positively related to treatment duration. In conclusion, program capacity, an organizational indicator of performance, plays a significant role in access to and duration of treatment. Implications for health care reform implementation in relation to expansion of public health insurance and capacity building to promote health equities are discussed.

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

We evaluated organizational factors associated with the implementation of contingency management treatment (CMT) and medication-assisted treatment (MAT) in substance abuse treatment (SAT) programs serving racial and ethnic minority communities. Analysis of cross-sectional data collected in 2010-2011 from a random sample of 148 publicly funded SAT programs showed that accepting private insurance was positively associated with CMT and MAT implementation, whereas larger programs were associated with greater implementation of MAT. Supervisorial openness to and expectations about implementing evidence-based practices (EBPs) and attributes for change were strongly associated with CMT, whereas the interactions between openness to EBPs and programs that accept private insurance and that are governed by parent organizations were positively associated with MAT. These external expectations and managerial attitudes supported the implementation of psychosocial and pharmacotherapy treatments in SAT. Implications for improving standards of care in minority communities are discussed.

Hepatitis C testing in substance use disorder treatment: the role of program managers in adoption of testing services

BACKGROUND

Health care organizations do not adopt best practices as often or quickly as they merit. This gap in the integration of best practices into routine practice remains a significant public health concern. The role of program managers in the adoption of best practices has seldom been investigated.

METHODS

We investigated the association between characteristics of program managers and the adoption of hepatitis C virus (HCV) testing services in opioid treatment programs (OTPs). Data came from the 2005 (n = 187) and 2011 (n = 196) National Drug Abuse Treatment System Survey (NDATSS). We used multivariate regression models to examine correlates of the adoption of HCV testing. We included covariates describing program manager characteristics, such as their race/ethnicity, education, and their sources of information about developments in the field of substance use disorder treatment. We also controlled for characteristics of OTPs and the client populations they serve.

RESULTS

Program managers were predominantly white and female. A large proportion of program managers had post-graduate education. Program managers expressed strong support for preventive services, but they reported making limited use of available sources of information about developments in the field of substance use disorder (SUD) treatment. The provision of any HCV testing (either on-site or off-site) in OTPs was positively associated with the extent to which a program manager was supportive of preventive services. Among OTPs offering any HCV testing to their clients, on-site HCV testing was more common among programs with an African American manager. It was also more common when program managers relied on a variety of information sources about developments in SUD treatment.

CONCLUSIONS

Various characteristics of program managers are associated with the adoption of HCV testing in OTPs. Promoting diversity among program managers, and increasing managers' access to information about developments in SUD treatment, may help foster the adoption of best practices.

Improving Coordination of Addiction Health Services Organizations with Mental Health and Public Health Services

In this mixed-method study, we examined coordination of mental health and public health services in addiction health services (AHS) in low-income racial and ethnic minority communities in 2011 and 2013. Data from surveys and semistructured interviews were used to evaluate the extent to which environmental and organizational characteristics influenced the likelihood of high coordination with mental health and public health providers among outpatient AHS programs. Coordination was defined and measured as the frequency of interorganizational contact among AHS programs and mental health and public health providers. The analytic sample consisted of 112 programs at time 1 (T1) and 122 programs at time 2 (T2), with 61 programs included in both periods of data collection. Forty-three percent of AHS programs reported high frequency of coordination with mental health providers at T1 compared to 66% at T2. Thirty-one percent of programs reported high frequency of coordination with public health services at T1 compared with 54% at T2. Programs with culturally responsive resources and community linkages were more likely to report high coordination with both services. Qualitative analysis highlighted the role of leadership in leveraging funding and developing creative solutions to deliver coordinated care. Overall, our findings suggest that AHS program funding, leadership, and cultural competence may be important drivers of program capacity to improve coordination with health service providers to serve minorities in an era of health care reform.

Predictors of language service availability in U.S. hospitals

BACKGROUND

Hispanics comprise 17% of the total U.S. population, surpassing African-Americans as the largest minority group. Linguistically, almost 60 million people speak a language other than English. This language diversity can create barriers and additional burden and risk when seeking health services. Patients with Limited English Proficiency (LEP) for example, have been shown to experience a disproportionate risk of poor health outcomes, making the provision of Language Services (LS) in healthcare facilities critical. Research on the determinants of LS adoption has focused more on overall cultural competence and internal managerial decision-making than on measuring LS adoption as a process outcome influenced by contextual or external factors. The current investigation examines the relationship between state policy, service area factors, and hospital characteristics on hospital LS adoption.

METHODS

We employ a cross-sectional analysis of survey data from a national sample of hospitals in the American Hospital Association (AHA) database for 2011 (N= 4876) to analyze hospital characteristics and outcomes, augmented with additional population data from the American Community Survey (ACS) to estimate language diversity in the hospital service area. Additional data from the National Health Law Program (NHeLP) facilitated the state level Medicaid reimbursement factor.

RESULTS

Only 64% of hospitals offered LS. Hospitals that adopted LS were more likely to be not-for-profit, in areas with higher than average language diversity, larger, and urban. Hospitals in above average language diverse counties had more than 2-fold greater odds of adopting LS than less language diverse areas [Adjusted Odds Ratio (AOR): 2.26, P< 0.01]. Further, hospitals with a strategic orientation toward diversity had nearly 2-fold greater odds of adopting LS (AOR: 1.90, P< 0.001).

CONCLUSION

Our findings support the importance of structural and contextual factors as they relate to healthcare delivery. Healthcare organizations must address the needs of the population they serve and align their efforts internally. Current financial incentives do not appear to influence adoption of LS, nor do Medicaid reimbursement funds, thus suggesting that further alignment of incentives. Organizational and system level factors have a place in disparities research and warrant further analysis; additional spatial methods could enhance our understanding of population factors critical to system-level health services research.

Perceptions of parental substance use disorders in cross-system collaboration among child welfare, alcohol and other drugs, and dependency court organizations

Cross-system collaboration among child welfare (CW), alcohol and other drugs (AOD), and court organizations shows promise in addressing the many needs of CW-involved families experiencing parental substance use disorders (SUDs). Research has suggested that differing perceptions of parents with SUDs among staff in these organizations may hinder the collaborative process. Using a sequential explanatory mixed-method approach, this study explored staff perceptions of parental SUDs among CW, AOD, and court organizations. Logistic regression analyses indicated that, compared to CW respondents, AOD respondents were: (a) less likely to believe that parents could provide effective parenting; (b) more likely to believe that abstinence should be a criterion for reunification; (c) more likely to agree that parents should receive jail time as a consequence for noncompliance with court orders; and (d) more likely to believe that parents could succeed in treatment. Thematic analyses of these focal areas identified two core themes (focus on the primary client and mandated time frames for permanency), as well as multiple subthemes, that provided a nuanced understanding of differing perceptions on these matters. Suggestions for the development of anticipatory cross-system training and practices and implications for policy evaluation are discussed.

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.

Gender disparities in utilization and outcome of comprehensive substance abuse treatment among racial/ethnic groups

This study examined gender differences within Black, Latino, and White subgroups in the utilization of comprehensive services and their relation to posttreatment substance use. Survey data were collected during the National Treatment Improvement Evaluation Study (NTIES), a prospective, longitudinal, multisite study of substance abuse treatment programs and their clients in the United States. The analytic sample consisted of 1,812 blacks (734 women and 1,078 men), 486 Latinos (147 women and 339 men), and 844 whites (147 women and 339 men) from 59 service delivery organizations. Results related to service utilization indicated that compared to men, women in all racial and ethnic groups needed and received more services targeted to their needs and reported more positive relations with service providers. Gender was a significant moderator of the relationship between service receipt and treatment outcomes for all racial and ethnic groups, but especially for the Latino subsample. Findings point to the need to consider race-specific gender differences in the development of culturally competent, comprehensive substance abuse treatment.

Disparities in Latino substance use, service use, and treatment: implications for culturally and evidence-based interventions under health care reform

BACKGROUND

The goal of this systematic literature review was to enhance understanding of substance use, service use, and treatment among Latino subgroups to improve access to care and treatment outcomes in an era of health care reform.

METHODS

The authors used 13 electronic databases and manually searched the literature from January 1, 1978, to May 30, 2013. One hundred (69%) of 145 primary research articles met the inclusion criteria. Two blinded, independent reviewers scored each article. Consensus discussions and a content expert reconciled discrepancies.

RESULTS

Current rates of alcohol and substance abuse among Latinos are comparable to or surpass other U.S. ethnic groups. Disparities in access and quality of care are evident between Latinos and other ethnic groups. As a heterogeneous group, Latinos vary by geographic region in terms of substance of choice and their cultural identity takes precedence over general ethnic identity as a likely determinant of substance abuse behaviors. There is growing research interest in systems influencing treatment access and adherence among racial/ethnic and gender minority groups. However, studies on Latinos' service use and immediate treatment outcomes have been both limited in number and inconsistent in findings.

CONCLUSIONS

This review identified human capital, quality of care, and access to culturally responsive care as key strategies to eliminate disparities in health and treatment quality. Implications are discussed, including the need for effectiveness studies on Latinos served by systems of care that, under health care reform, are seeking to maximize resources, improve outcomes, and reduce variation in quality of care.

Spanish language proficiency among providers and Latino clients' engagement in substance abuse treatment

Quality of care, such as provision of services in Spanish, is a common factor believed to improve treatment engagement among Spanish-speaking Latinos in health care. However, there is little evidence that Spanish language proficiency among providers increases treatment access and retention in publicly funded substance abuse treatment. We analyzed client and program data collected in 2010-2011 from publicly funded treatment programs in Los Angeles County, California. An analytic sample of 1903 Latino clients nested within 40 treatment programs located in minority communities was analyzed using multilevel negative binomial regressions on days to initiate and spent in treatment. As hypothesized, Spanish language proficiency was negatively associated with client wait time and positively associated with retention in treatment, after controlling for individual and program characteristics. The path analysis models showed that Spanish language proficiency played a mediating role between professional accreditation and client wait time and retention. These preliminary findings provide an evidentiary base for the role of providers' Spanish language proficiency and Latino engagement in treatment for a population at high risk of treatment dropout. Implications related to health care reform legislation, which seeks to enhance linguistically competent care, are discussed.

Organizational structure, leadership and readiness for change and the implementation of organizational cultural competence in addiction health services

Increasing representation of racial and ethnic minorities in the health care system and on-going concerns about existing health disparities have pressured addiction health services programs to enhance their cultural competence. This study examines the extent to which organizational factors, such as structure, leadership and readiness for change contribute to the implementation of community, policy and staffing domains representing organizational cultural competence. Analysis of a randomly selected sample of 122 organizations located in primarily Latino and African American communities showed that programs with public funding and Medicaid reimbursement were positively associated with implementing policies and procedures, while leadership was associated with staff having greater knowledge of minority communities and developing a diverse workforce. Moreover, program climate was positively associated with staff knowledge of communities and having supportive policies and procedures, while programs with graduate staff and parent organizations were negatively associated with knowledge of and involvement in these communities. By investing in funding, leadership skills and a strategic climate, addiction health services programs may develop greater understanding and responsiveness of the service needs of minority communities. Implications for future research and program planning in an era of health care reform in the United States are discussed.

How the states stack up: disparities in substance abuse outpatient treatment completion rates for minorities

BACKGROUND

This study was an exploratory investigation of state-level minority disparities in successfully completing outpatient treatment, a major objective for attending substance abuse treatment and a known process outcome measure.

METHOD

This was a retrospective analysis of state discharge and admission data from the 2006 to 2008 Treatment Episode Datasets-Discharge (TEDS-D). Data were included representing all discharges from outpatient substance abuse treatment centers across the United States. All first treatment episode clients with admission/discharge records meeting inclusion criteria who could be classified as White, Latino, or Black/African American were used (n=940,058).

RESULTS

States demonstrated racial and ethnic disparities in their crude and adjusted completion rates, which also varied considerably among the states. Minorities typically showed a disadvantage. A few states showed significantly higher completion rates for Blacks or Latinos.

CONCLUSIONS

Realistically, a variety of factors likely cause the state race/ethnic differences in successful completion rates. States should investigate their delivery systems to reduce completion disparities.

Disparities in completion of substance abuse treatment among Latino subgroups in Los Angeles County, CA

RATIONALE

A growing body of research has revealed disparities with respect to drug use patterns within Latino subgroups. However, the extent to which these potential disparities enable different Latino subgroups to respond favorably to treatment is unclear.

METHODS

This study analyzed a subset of multicross-sectional data (2006-2009) on Latinos collected from publicly funded facilities in Los Angeles County, CA (N=12,871). We used multilevel logistic regressions to examine individual and service-level factors associated with treatment completion among subgroups of first-time Latino treatment clients.

RESULTS

Univariate analysis showed that Cubans and Puerto Ricans were less likely to complete treatment than Mexicans and other Latinos. Cubans and Puerto Ricans entered treatment at an older age and with higher formal education than Mexicans, yet they were more likely to report mental health issues and use of cocaine and heroin as primary drugs of choice respectively. Multivariate analysis showed that age, having mental health issues, reporting high use of drugs at intake, and use of methamphetamines and marijuana were associated with decreased odds of completing treatment among all Latino subgroups. In contrast, age at first drug use, treatment duration, and referral monitoring by the criminal system increased the odds of completing treatment for all members.

CONCLUSION

These findings have implications for targeting interventions for members of different Latinos groups during their first treatment episode. Promising individual and service factors associated with treatment completion can inform the design of culturally specific recovery models that can be evaluated in small-scale randomized pilot studies.

Do cultural and linguistic competence matter in Latinos' completion of mandated substance abuse treatment?

BACKGROUND

Increasing evidence suggests that culturally and linguistically responsive programs may improve substance abuse treatment outcomes among Latinos. However, little is known about whether individual practices or culturally and linguistically responsive contexts support efforts by first-time Latino clients to successfully complete mandated treatment.

METHODS

We analyzed client and program data from publicly funded treatment programs contracted through the criminal justice system in California. A sample of 5,150 first-time Latino clients nested within 48 treatment programs was analyzed using multilevel logistic regressions.

RESULTS

Outpatient treatment, homelessness, and a high frequency of drug use at intake were associated with decreased odds of treatment completion among Latinos. Programs that routinely offered a culturally and linguistically responsive practice-namely, Spanish-language translation-were associated with increased odds of completion of mandated treatment.

CONCLUSIONS

These preliminary findings suggest that concrete practices such as offering Spanish translation improve treatment adherence within a population that is at high risk of treatment dropout.

Travel distance to outpatient substance use disorder treatment facilities for Spanish-speaking clients

BACKGROUND

Travel distance and English proficiency skills are widely recognized factors associated with service access and treatment engagement. As Latino populations represent one of the most rapidly growing populations in the United States, methods are needed to better understand availability of linguistically appropriate services in Latino communities. Given regional variability in the density of Latino communities, the current study examines treatment access as travel distance to outpatient substance use disorder treatment facilities in one of the largest and most rapidly changing Latino communities in the United States - Los Angeles County, CA.

METHODS

Data from the 2010 U.S. Census and the National Survey of Substance Abuse Treatment Services were analyzed using a geographic information system approach to determine the street-level distance between treatment facilities with services in Spanish and Latino communities throughout L.A. County. This study used an innovative approach that included network analysis and spatial autocorrelation to identify "hot spots," i.e. clusters of census tracts with high-density Latino populations that were relatively far from treatment services in Spanish.

RESULTS

The analysis identified several key hot spots with significantly large Latino populations and far street distances to the closest facility offering Spanish-language services. The average distance between these hot spots and the closest facilities was 2.74 miles (SD=0.38), compared to a county average of 2.28 miles (SD=2.60). In several key hot spots, the distance was greater than 3 miles.

CONCLUSION

Despite the growing presence of Latinos in L.A. County in 2010, constrained access to services in Spanish was found in geographic locations highly represented by Latinos. The distances identified in this study are almost triple the 1-mile threshold representing reduced access to treatment as determined by other studies. Geographic information systems represent an innovative and user-friendly approach for effectively and efficiently identifying areas with the greatest service needs. This approach can inform policies to increase the capacity of ethnic minority communities to develop linguistically responsive social services.

Workforce diversity in outpatient substance abuse treatment: the role of leaders' characteristics

Although the outpatient substance abuse treatment field has seen an increase in referrals of African American and Latino clients, there have been limited changes in the diversity of the workforce. This discordance may exacerbate treatment disparities experienced by these clients. Program leaders have significant influence to leverage resources to develop staff diversity. Analysis of panel data from 1995 to 2005 showed that the most significant predictors of diversity were the characteristics of leaders. In particular, programs with managers with racially and ethnically concordant backgrounds and their education level were positively related to the percentage of Latino and African American staff. A high percentage of African American staff was positively associated with managers' tenure, but inversely related to licensed directors. Diversification of the field has increased, yet efforts have not matched increases in client diversity. Implications for health care reform legislation seeking to improve cultural competence through diversification of the workforce are discussed.

Organizational characteristics that foster early adoption of cultural and linguistic competence in outpatient substance abuse treatment in the United States

Recent years have seen an increased interest in developing culturally and linguistically responsive systems of care in substance abuse treatment in the United States. This study examines the extent to which external and internal organizational pressures contributed to the degree of adoption of culturally and linguistically responsive practices in the nation's outpatient substance abuse treatment system early in the period of development of this system of care. Findings show that a higher degree of adoption of culturally competent practices was most likely in treatment programs with high dependence on external funding and regulation. Internally, programs with a larger number of professionals were associated with the lowest degree of adoption, while managers' cultural sensitivity contributed significantly to a high degree of adoption of these responsive practices. Considering the passage of recent legislation enforcing the use of cultural and linguistic competence in health care, implications of these baseline findings on early adoption patterns are discussed for future research and health care policy evaluation.

Cultural competence in outpatient substance abuse treatment: measurement and relationship to wait time and retention

BACKGROUND

Culturally competent practice is broadly acknowledged to be an important strategy to increase the quality of services for racial/ethnic minorities in substance abuse treatment. However, few empirically derived measures of organizational cultural competence exist, and relatively little is known about how these measures affect treatment outcomes.

METHOD

Using a nationally representative sample of outpatient substance abuse treatment (OSAT) programs, this study used item response theory to create two measures of cultural competence-organizational practices and managers' culturally sensitive beliefs-and examined their relationship to client wait time and retention using Poisson regression modeling.

RESULTS

The most common and precisely measured organizational practices reported by OSAT managers included matching providers and clients based on language/dialect; offering cross-cultural training; and fostering connections with community and faith-based organizations connected to racial and ethnic minority groups. The most culturally sensitive belief among OSAT managers was support for language/dialect matching for racial and ethnic minority clients. Results of regression modeling indicate that organizational practices were not related to either outcome. However, managers' culturally sensitive beliefs were negatively associated with average wait time (p<0.05), and positively associated with average retention (p<0.01).

CONCLUSIONS

Managers' culturally sensitive beliefs-considered to be influential for effective implementation of culturally competent practices-may be particularly relevant in influencing wait time and retention in OSAT organizations that treat Latinos and African American clients.

Availability of substance abuse treatment services in Spanish: a GIS analysis of Latino communities in Los Angeles County, California

Background

The percentage of Latino clients entering outpatient substance abuse treatment (OSAT) in the United States has increased significantly in the past 10 years. Evidence suggests that a lack of services in Spanish is a significant barrier to treatment access among Latinos.

Methods

Using a geographic information system (GIS) approach, data from the U.S. Census Bureau and the National Survey of Substance Abuse Treatment Services (N-SSATS) were analyzed to determine the geographic distance between OSAT facilities with services in Spanish and Latino communities throughout Los Angeles County, CA. Data from N-SSATS were also analyzed using logistic regression models to examine organizational characteristics and their association with offering services in Spanish. Our GIS methods are tested in their ability to provide baseline measures to inform future analysis comparing changes in demography and service infrastructure.

Results

GIS analysis revealed cold spots representing high-density Latino communities with extensive travel distance to facilities offering services in Spanish. The average linear distance between Latino communities and facilities offering Spanish-language services ranged from 2 to 6 miles, while the location of the cold spots pointed to a need for services in Spanish in a particular subregion of the county. Further, secondary data analysis revealed that, on average, being privately owned (OR = .23, 95% CI = 0.06-0.90) was associated with a lower likelihood of providing services in Spanish compared to public facilities. Additionally, a facility with a state license (OR = 2.08, 95% CI = 1.12-3.88) or a higher number of Medicaid recipients (OR = 2.98, 95% CI = 1.76-5.05) was twice as likely to offer services in Spanish.

Conclusion

Despite the significant presence of Latinos in L.A. County in 2000, low capacity was found in discrete Latino communities in terms of offering OSAT services in Spanish. Funding and regulation play a significant role in facilities' capacity to offer these services. Future studies should build from our multi-method approach to compare changes in population demography and system infrastructure and inform health care policy that seeks to improve providers' capacity to provide linguistically competent care.

Adoption and utilization of sexually transmitted infections testing in outpatient substance abuse treatment facilities serving high risk populations in the U.S

BACKGROUND

Although adoption and utilization of sexually transmitted infection (STI) testing is a cost effective public health intervention, it is inconsistently offered or referred out for by outpatient substance abuse treatment (OSAT) programs where at-risk racial/ethnic and sexual minorities receive services.

METHODS

We explored the organizational adoption and client utilization of STI testing using a nationally representative sample of OSAT facilities in the U.S. in 2005 (N=566). Data missing at random was imputed and the resulting database was analysed using multivariate Tobit and logistic regressions.

RESULTS

The analyses suggest that private non-profit facilities, which are the largest providers of OSAT treatment are less likely than public facilities to offer STI testing or to report adequate client utilization rates. Higher utilization was instead associated with professionally accredited facilities, and with facilities whose majority of clients were Latino/a, reported a history of treatment, stayed in treatment longer, or received case management.

CONCLUSION

While OSAT facilities are poised to be primary intervention points for diagnosis and treatment of STIs, only a segment of these facilities provide this preventive practice or manage to refer clients out. As such, U.S. health care policy should ensure the adoption and comprehensive utilization, particularly among high risk clients, of this cost-effective prevention strategy in OSAT admission protocols.