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Lin JS, Webber EM, Bean SI, Martin AM, Davies MC. Rapid evidence review: Policy actions for the integration of public health and health care in the United States. Front Public Health 2023; 11:1098431. [PMID: 37064661 PMCID: PMC10090415 DOI: 10.3389/fpubh.2023.1098431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/02/2023] [Indexed: 03/31/2023] Open
Abstract
ObjectiveTo identify policy actions that may improve the interface of public health and health care in the United States.MethodsA rapid review of publicly-available documents informing the integration of public health and health care, and case examples reporting objective measures of success, with abstraction of policy actions, related considerations, and outcomes.ResultsAcross 109 documents, there were a number of recurrent themes related to policy actions and considerations to facilitate integration during peace time and during public health emergencies. The themes could be grouped into the need for adequate and dedicated funding; mandates and shared governance for integration; joint leadership that has the authority/ability to mobilize shared assets; adequately staffed and skilled workforces in both sectors with mutual awareness of shared functions; shared health information systems with modernized data and IT capabilities for both data collection and dissemination of information; engagement with multiple stakeholders in the community to be maximally inclusive; and robust communication strategies and training across partners and with the public.ConclusionWhile the evidence does not support a hierarchy of policies on strengthening the interface of public health and health care, recurrent policy themes can inform where to focus efforts.
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Guerrero E, Amaro H, Kong Y, Khachikian T, Marsh JC. Gender disparities in opioid treatment progress in methadone versus counseling. Subst Abuse Treat Prev Policy 2021; 16:52. [PMID: 34162420 PMCID: PMC8220800 DOI: 10.1186/s13011-021-00389-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND In the United States, the high dropout rate (75%) in opioid use disorder (OUD) treatment among women and racial/ethnic minorities calls for understanding factors that contribute to making progress in treatment. Whereas counseling and medication for OUD (MOUD, e.g. methadone, buprenorphine, naltrexone) is considered the gold standard of care in substance use disorder (SUD) treatment, many individuals with OUD receive either counseling or methadone-only services. This study evaluates gender disparities in treatment plan progress in methadone- compared to counseling-based programs in one of the largest SUD treatment systems in the United States. METHODS Multi-year and multi-level (treatment program and client-level) data were analyzed using the Integrated Substance Abuse Treatment to Eliminate Disparities (iSATed) dataset collected in Los Angeles County, California. The sample consisted of 4 waves: 2011 (66 SUD programs, 1035 clients), 2013 (77 SUD programs, 3686 clients), 2015 (75 SUD programs, 4626 clients), and 2017 (69 SUD programs, 4106 clients). We conducted two multi-level negative binomial regressions, one per each outcome (1) making progress towards completing treatment plan, and (2) completing treatment plan. We included outpatient clients discharged on each of the years of the study (over 95% of all clients) and accounted for demographics, wave, homelessness and prior treatment episodes, as well as clients clustered within programs. RESULTS We detected gender differences in two treatment outcomes (progress and completion) considering two outpatient program service types (MOUD-methadone vs. counseling). Clients who received methadone vs. counseling had lower odds of completing their treatment plan (OR = 0.366; 95% CI = 0.163, 0.821). Female clients receiving methadone had lower odds of both making progress (OR = 0.668; 95% CI = 0.481, 0.929) and completing their treatment plan (OR = 0.666; 95% CI = 0.485, 0.916) compared to male clients and receiving counseling. Latina clients had lower odds of completing their treatment plan (OR = 0.617; 95% CI = 0.408, 0.934) compared with non-Latina clients. CONCLUSIONS Clients receiving methadone, the most common and highly effective MOUD in reducing opioid use, were less likely to make progress towards or complete their treatment plan than those receiving counseling. Women, and in particular those identified as Latinas, were least likely to benefit from methadone-based programs. These findings have implications for health policy and program design that consider the need for comprehensive and culturally responsive services in methadone-based programs to improve outpatient treatment outcomes among women.
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Affiliation(s)
- Erick Guerrero
- I-Lead Institute, Research to End Health Disparities Corp, 12300 Wilshire Blvd, Suite 210, Los Angeles, CA 90025 USA
| | - Hortensia Amaro
- Herbert Wertheim College of Medicine and Robert Stempel College of Public Health and Social Work, Florida International University, 11200 SW 8th ST, AHC4, Miami, Florida 33199 USA
| | - Yinfei Kong
- College of Business and Economics, California State University Fullerton, 800 N. State College Blvd, Fullerton, CA 92831 USA
| | - Tenie Khachikian
- Crown Family School of Social Work, Policy, and Practice, University of Chicago, 969 E. 60th Street, Chicago, IL 60637 USA
| | - Jeanne C. Marsh
- Crown Family School of Social Work, Policy, and Practice, University of Chicago, 969 E. 60th Street, Chicago, IL 60637 USA
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Guerrero EG, Khachikian T, Frimpong JA, Kong Y, Howard DL, Hunter S. Drivers of continued implementation of cultural competence in substance use disorder treatment. J Subst Abuse Treat 2019; 105:5-11. [PMID: 31443891 PMCID: PMC7532800 DOI: 10.1016/j.jsat.2019.07.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 07/19/2019] [Accepted: 07/19/2019] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Erick G Guerrero
- I-Lead Institute, Research to End Healthcare Disparities Corp, 150 Ocean Park Blvd, 418, Santa Monica, CA 90405, United States of America.
| | - Tenie Khachikian
- Psychological Science, University of California, 5200 North Lake Road Merced, CA 95343, United States of America.
| | - Jemima A Frimpong
- Johns Hopkins University, Carey Business School, 100 International Dr., Baltimore, MD 21202, United States of America.
| | - Yinfei Kong
- Mihaylo College of Business and Economics, California State University, Fullerton, CA 90089, United States of America
| | - Daniel L Howard
- Texas A&M University, Public Policy Research Institute, 4476 TAMU College Station, TX 77843-4476, United States of America.
| | - Sarah Hunter
- Rand Corporation, 1776 Main Street, Santa Monica, CA 90401, United States of America.
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Program Capacity to Deliver Prevention Services to Children of Adult Clients Receiving Substance Use Disorder Treatment. J Prim Prev 2019; 40:343-355. [PMID: 31093817 DOI: 10.1007/s10935-019-00551-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
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.
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Oldfield BJ, Muñoz N, Boshnack N, Leavitt R, McGovern MP, Villanueva M, Tetrault JM, Edelman EJ. "No more falling through the cracks": A qualitative study to inform measurement of integration of care of HIV and opioid use disorder. J Subst Abuse Treat 2019; 97:28-40. [PMID: 30577897 DOI: 10.1016/j.jsat.2018.11.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 11/06/2018] [Accepted: 11/19/2018] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Integration of HIV- and opioid use disorder (OUD)-related care is associated with improved patient outcomes. Our goal was to develop a novel instrument for measuring quality of integration of HIV and OUD-related care that would be applicable across diverse care settings. METHODS Grounded in community-based participatory research principles, we conducted a qualitative study from August through November 2017 to inform modification of the Behavioral Health Integration in Medical Care (BHIMC) instrument, a validated measure of quality of integration of behavioral health in primary care. We conducted semi-structured interviews of patients (n = 22), focus groups with clinical staff (n = 24), and semi-structured interviews of clinic leadership (n = 5) in two urban centers in Connecticut. RESULTS We identified three themes that characterize optimal integration of HIV- and OUD-related care: (1) importance of mitigating mismatches in resources and knowledge, particularly resources to address social risks and knowledge gaps about evidence-based treatments for OUD; (2) need for patient-centered policies and inter-organization communication, and (3) importance of meeting people where they are, geographically and at their stage of change. These themes highlighted aspects of integrated care for HIV and OUD not captured in the original BHIMC. CONCLUSIONS Patients, clinical staff, and organization leadership perceive that addressing social risks, communication across agencies, and meeting patients in their psychosocial and structural context are important for optimizing integration of HIV and OUD-related care. Our proposed, novel instrument is a step towards measuring and improving service delivery locally and nationally for this vulnerable population.
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Affiliation(s)
- Benjamin J Oldfield
- National Clinician Scholars Program, Yale School of Medicine, New Haven, CT, United States of America; Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States of America.
| | - Nicolas Muñoz
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | | | - Robert Leavitt
- AIDS Project New Haven, New Haven, CT, United States of America
| | - Mark P McGovern
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Merceditas Villanueva
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, United States of America
| | - Jeanette M Tetrault
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - E Jennifer Edelman
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, United States of America
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McClellan C, Flottemesch TJ, Ali MM, Jones J, Mutter R, Hohlbauch A, Whalen D, Nordstrom N. Behavioral Health's Integration Within a Care Network and Health Care Utilization. Health Serv Res 2018; 53:4543-4564. [PMID: 29845999 DOI: 10.1111/1475-6773.12983] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Examine how behavioral health (BH) integration affects health care costs, emergency department (ED) visits, and inpatient admissions. DATA SOURCES/STUDY SETTING Truven Health MarketScan Research Databases. STUDY DESIGN Social network analysis identified "care communities" (providers sharing a high number of patients) and measured BH integration in terms of how connected, or central, BH providers were to other providers in their community. Multivariable generalized linear models adjusting for age, sex, number of prescriptions, and Charlson comorbidity score were used to estimate the relationship between the centrality of BH providers and health care utilization of BH patients. DATA COLLECTION/EXTRACTION METHODS Used outpatient, inpatient, and pharmacy claims data from six Medicaid plans from 2011 to 2013 to identify study outcomes, comorbidities, providers, and health care encounters. PRINCIPAL FINDINGS Behavioral health centrality ranged from 0 (no BH providers) to 0.49. Relative to communities at the median BH centrality (0.06), in 2012, BH patients in communities at the 75th percentile of BH centrality (0.31) had 0.2 fewer admissions, 2.1 fewer all-cause ED visits, and accrued $1,947 fewer costs, on average. CONCLUSIONS Increased behavioral centrality was significantly associated with a reduced number of ED visits, less frequent inpatient admissions, and lower overall health care costs.
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Affiliation(s)
- Chandler McClellan
- Substance Abuse and Mental Health Services Administration (SAMSHA), Rockville, MD
| | | | - Mir M Ali
- Substance Abuse and Mental Health Services Administration (SAMSHA), Rockville, MD
| | | | - Ryan Mutter
- Substance Abuse and Mental Health Services Administration (SAMSHA), Rockville, MD
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Guerrero EG, Garner BR, Cook B, Kong Y. Does the implementation of evidence-based and culturally competent practices reduce disparities in addiction treatment outcomes? Addict Behav 2017; 73:119-123. [PMID: 28501676 DOI: 10.1016/j.addbeh.2017.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 04/13/2017] [Accepted: 05/08/2017] [Indexed: 10/19/2022]
Abstract
RATIONALE Research is limited on the extent to which implementation of evidence-based and culturally responsive practices reduces outcome disparities in substance use disorder treatment. We examined the role of contingency management treatment (CMT), medication-assisted treatment (MAT), and culturally competent practices on Mexican Americans' rate of successful completion of treatment. METHODS We analyzed a concatenated dataset from 153 publicly funded substance use disorder treatment programs in Los Angeles County, California, in 2011 and 2013. These data were merged with data from 15,412 adult clients in both periods, of whom we selected only Mexican Americans (46.3%) and non-Latino Whites (53.7%). The outcome was successful treatment completion. The main independent variables were client demographics, drug use severity, mental health issues, and program license and professional accreditation. RESULTS Less than half of the programs highly implemented CMT, MAT, and culturally competent practices. CMT and cultural competence were not associated with successful treatment completion. However, Mexican Americans in programs with high degree of implementation of MAT had higher odds of successfully completing treatment compared to non-Latino Whites and programs with low MAT (OR=1.389; 95% CI=1.018, 1.897). CONCLUSIONS Findings highlight the role of MAT in reducing the disparity in treatment completion between Mexican Americans and non-Latino Whites. Implications for health policy and the dissemination of MAT are discussed.
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Finlay AK, Ellerbe LS, Wong JJ, Timko C, Rubinsky AD, Gupta S, Bowe TR, Burden JL, Harris AHS. Barriers to and facilitators of pharmacotherapy for alcohol use disorder in VA residential treatment programs. J Subst Abuse Treat 2017; 77:38-43. [PMID: 28476269 PMCID: PMC5467688 DOI: 10.1016/j.jsat.2017.03.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 03/01/2017] [Accepted: 03/08/2017] [Indexed: 11/21/2022]
Abstract
Among US military veterans, alcohol use disorder (AUD) is prevalent and in severe cases patients need intensive AUD treatment beyond outpatient care. The Department of Veterans Affairs (VA) delivers intensive, highly structured addiction and psychosocial treatment through residential programs. Despite the evidence supporting pharmacotherapy among the effective treatments for AUD, receipt of these medications (e.g., naltrexone, acamprosate) among patients in residential treatment programs varies widely. In order to better understand this variation, the current study examined barriers and facilitators to use of pharmacotherapy for AUD among patients in VA residential treatment programs. Semi-structured qualitative interviews with residential program management and staff were conducted and the Consolidated Framework for Implementation Research was used to guide coding and analysis of interview transcripts. Barriers to use of pharmacotherapy for AUD included cultural norms or philosophy against prescribing, lack of access to willing prescribers, lack of interest from leadership, and perceived lack of patient interest or need. Facilitators included cultural norms of openness or active promotion of pharmacotherapy; education for patients, program staff and prescribers; having prescribers on staff, and care coordination within residential treatment and with other clinic settings in and outside VA. Developing and testing improvement strategies to increase care coordination and consistent support from leadership may also yield increases in the use of pharmacotherapy for AUD among residential patients.
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Affiliation(s)
- Andrea K Finlay
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA; National Center on Homelessness Among Veterans, Department of Veterans Affairs, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.
| | - Laura S Ellerbe
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.
| | - Jessie J Wong
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305, USA.
| | - Christine Timko
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305, USA.
| | - Anna D Rubinsky
- Kidney Health Research Collaborative, University of California, San Francisco and San Francisco VA Medical Center; 500 Parnassus Avenue, San Francisco, CA 94143, USA.
| | - Shalini Gupta
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.
| | - Thomas R Bowe
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.
| | - Jennifer L Burden
- Department of Veterans Affairs, Veterans Health Administration, 1970 Roanoke Blvd. (116A), Salem, VA 24153, USA.
| | - Alex H S Harris
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA; Department of Surgery, Stanford University School of Medicine, Alway Building, Room M121, 300 Pasteur Drive, Stanford, CA 94305, USA.
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Hunter SB, Schwartz RP, Friedmann PD. Introduction to the Special Issue on the Studies on the Implementation of Integrated Models of Alcohol, Tobacco, and/or Drug Use Interventions and Medical Care. J Subst Abuse Treat 2015; 60:1-5. [PMID: 26549295 DOI: 10.1016/j.jsat.2015.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
National efforts are underway to integrate medical care and behavioral health treatment. This special issue of the Journal of Substance Abuse Treatment presents 13 papers that examine the integration of substance use interventions and medical care. In this introduction, the guest editors first describe the need to examine the integration of substance use treatment into medical care settings. Next, an overview of the emerging field of implementation science and its applicability to substance use intervention integration is presented. Preview summaries of each of the articles included in this special issue are given. Articles include empirical studies of various integration models, study protocol papers that describe currently funded implementation research, and one review/commentary piece that discusses federal research priorities, integration support activities and remaining research gaps. These articles provide important information about how to guide future health system integration efforts to treat the millions of medical patients with substance use problems.
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