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Identifying the Heterogeneity in the Association between Workforce Diversity and Retention in Opioid Treatment among Black clients. RESEARCH SQUARE 2024:rs.3.rs-3932153. [PMID: 38405811 PMCID: PMC10889050 DOI: 10.21203/rs.3.rs-3932153/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
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.
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Innovation in the Delivery of Behavioral Health Services. Annu Rev Public Health 2023; 45. [PMID: 37871139 DOI: 10.1146/annurev-publhealth-071521-024027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Several factors motivate the need for innovation to improve the delivery of behavioral health services, including increased rates of mental health and substance use disorders, limited access to services, inconsistent use of evidence-based practices, and persistent racial and ethnic disparities. This narrative review identifies promising innovations that address these challenges, assesses empirical evidence for the effectiveness of these innovations and the extent to which they have been adopted and implemented, and suggests next steps for research. We review five categories of innovations: organizational models, including a range of novel locations for providing services and new ways of organizing services within and across sites; information and communication technologies; workforce; treatment technologies; and policy and regulatory changes. We conclude by discussing the need to strengthen and accelerate the contributions of implementation science to close the gap between the launch of innovative behavioral health services and their widespread use. Expected final online publication date for the Annual Review of Public Health, Volume 45 is April 2024. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Abstract
This JAMA Forum argues that hospitals and health systems should not take the lead in programs to address social determinants of health and provides examples and reasons why.
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Variation in Risk-Standardized Acute Admission Rates Among Patients With Heart Failure in Accountable Care Organizations: Implications for Quality Measurement. J Am Heart Assoc 2023; 12:e029758. [PMID: 37345796 PMCID: PMC10356066 DOI: 10.1161/jaha.122.029758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/10/2023] [Indexed: 06/23/2023]
Abstract
Background Accountable care organizations (ACOs) aim to improve health care quality and reduce costs, including among patients with heart failure (HF). However, variation across ACOs in admission rates for patients with HF and associated factors are not well described. Methods and Results We identified Medicare fee-for-service beneficiaries with HF who were assigned to a Medicare Shared Savings Program ACO in 2017 and survived ≥30 days into 2018. We calculated risk-standardized acute admission rates across ACOs, assigned ACOs to 1 of 3 performance categories, and examined associations between ACO characteristics and performance categories. Among 1 232 222 beneficiaries with HF, 283 795 (mean age, 81 years; 54% women; 86% White; 78% urban) were assigned to 1 of 467 Medicare Shared Savings Program ACOs. Across ACOs, the median risk-standardized acute admission rate was 87 admissions per 100 people, ranging from 61 (minimum) to 109 (maximum) admissions per 100 beneficiaries. Compared to the overall average, 13% of ACOs performed better on risk-standardized acute admission rates, 72% were no different, and 14% performed worse. Most ACOs with better performance had fewer Black beneficiaries and were not hospital affiliated. Most ACOs that performed worse than average were large, located in the Northeast, had a hospital affiliation, and had a lower proportion of primary care providers. Conclusions Admissions are common among beneficiaries with HF in ACOs, and there is variation in risk-standardized acute admission rates across ACOs. ACO performance was associated with certain ACO characteristics. Future studies should attempt to elucidate the relationship between ACO structure and characteristics and admission risk.
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Predicting and responding to change: Perceived environmental uncertainty among substance use disorder treatment programs. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 145:208947. [PMID: 36880916 DOI: 10.1016/j.josat.2022.208947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 10/03/2022] [Accepted: 11/29/2022] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Substance use disorder (SUD) treatment programs offering addiction health services (AHS) must be prepared to adapt to change in their operating environment. These environmental uncertainties may have implications for service delivery, and ultimately patient outcomes. To adapt to a multitude of environmental uncertainties, treatment programs must be prepared to predict and respond to change. Yet, research on treatment programs preparedness for change is sparse. We examined reported difficulties in predicting and responding to changes in the AHS system, and factors associated with these outcomes. METHODS Cross-sectional surveys of SUD treatment programs in the United States in 2014 and 2017. We used linear and ordered logistic regression to examine associations between key independent variables (e.g., program, staff, and client characteristics) and four outcomes, (1) reported difficulties in predicting change, (2) predicting effect of change on organization, (3) responding to change, and (4) predicting changes to make to respond to environmental uncertainties. Data were collected through telephone surveys. RESULTS The proportion of SUD treatment programs reporting difficulty predicting and responding to changes in the AHS system decreased from 2014 to 2017. However, a considerable proportion still reported difficulty in 2017. We identified that different organizational characteristics are associated with their reported ability to predict or respond to environmental uncertainty. Findings show that predicting change is significantly associated with program characteristics only, while predicting effect of change on organizations is associated with program and staff characteristics. Deciding how to respond to change is associated with program, staff, and client characteristics, while predicting changes to make to respond is associated with staff characteristics only. CONCLUSIONS Although treatment programs reported decreased difficulty predicting and responding to changes, our findings identify program characteristics and attributes that could better position programs with the foresight to more effectively predict and respond to uncertainties. Given resource constraints at multiple levels in treatment programs, this knowledge might help identify and optimize aspects of programs to intervene upon to enhance their adaptability to change. These efforts may positively influences processes or care delivery, and ultimately translate into improvements in patient outcomes.
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Primary Care Nurse Practitioner Work Environments and Hospitalizations and ED Use Among Chronically Ill Medicare Beneficiaries. Med Care 2022; 60:496-503. [PMID: 35679173 PMCID: PMC9202077 DOI: 10.1097/mlr.0000000000001731] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Nurse practitioners (NPs) play a critical role in delivering primary care, particularly to chronically ill elderly. Yet, many NPs practice in poor work environments which may affect patient outcomes. OBJECTIVE We investigated the relationship between NP work environments in primary care practices and hospitalizations and emergency department (ED) use among chronically ill elderly. RESEARCH DESIGN We used a cross-sectional design to collect survey data from NPs about their practices. The survey data were merged with Medicare claims data. SUBJECTS In total, 979 primary care practices employing NPs and delivering care to chronically ill Medicare beneficiaries (n=452,931) from 6 US states were included. MEASURES NPs completed the Nurse Practitioner-Primary Care Organizational Climate Questionnaire-a valid and reliable measure for work environment. Data on hospitalizations and ED use was obtained from Medicare claims. We used Cox regression models to estimate risk ratios. RESULTS After controlling for covariates, we found statistically significant associations between practice-level NP work environment and 3 outcomes: Ambulatory Care Sensitive (ACS) ED visits, all-cause ED visits, and all-cause hospitalizations. With a 1-unit increase in the work environment score, the risk of an ACS-ED visit decreased by 4.4% [risk ratio (RR)=0.956; 99% confidence interval (CI): 0.918-0.995; P=0.004], an ED visit by 3.5% (RR=0.965; 99% CI: 0.933-0.997; P=0.005), and a hospitalization by 4.0% (RR=0.960;99% CI: 0.928-0.993; P=0.002). There was no relationship between NP work environment and ACS hospitalizations. CONCLUSION Favorable NP work environments are associated with lower hospital and ED utilization. Practice managers should focus on NP work environments in quality improvement strategies.
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Critical issues in alliances between management partners and accountable care organizations. Health Care Manage Rev 2021; 46:237-247. [PMID: 36800403 DOI: 10.1097/hmr.0000000000000263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite widespread engagement of accountable care organizations (ACOs) with management partners, little empirical evidence on these alliances exists to inform policymakers or payers. Management partners may be providing a valuable service in facilitating the transition to population health management. Alternately, in some cases, partners may be receiving high fees relative to the value of services provided. PURPOSE The aim of this study was to use qualitative data to identify motivations for and critical issues in alliances between ACOs and management partners. METHODOLOGY/APPROACH We used qualitative data collected from seven ACOs (193 semistructured interviews and observational data from 12 site visits) to characterize the alliances between management partners and providers in ACOs. RESULTS We found that ACOs sought partners to provide financing, technical expertise, and risk bearing. Tensions in partnerships arose around resources (e.g., delivery on promised resources), control (e.g., who holds decision making authority), and values (e.g., commitment to safety net mission). Some partnerships persisted, whereas others dissolved. We found that there are two different underlying models of ACO-management partner alliances in our sample: (1) short-term partnerships aimed at organizational learning and (2) long-term partnerships based on complementarity. CONCLUSION Our results demonstrate how ACO alliances with management partners have unfolded as a kind of natural experiment in value-based payment reform. We expect that there is wide variation in quality, expertise, and delivery by management partners. Now multiple years into many of these alliances, we may address their value, strengths, and weaknesses from the perspective of providers as well as policy makers and payers. PRACTICE IMPLICATIONS Accountable care organization providers must determine whether a management partner is the best solution to the challenges they face and, if so, which alliance model to pursue. Policymakers and payers should consider short- and long-term implications of ACO-management partner alliances, including considering changing the regulatory environment.
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Patient-centered care's relationship with substance use disorder treatment utilization. J Subst Abuse Treat 2020; 118:108125. [PMID: 32972650 PMCID: PMC7528396 DOI: 10.1016/j.jsat.2020.108125] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 07/29/2020] [Accepted: 08/25/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Calls for more patient-centered care are growing in the substance use disorder (SUD) treatment field. However, evidence is sparse regarding whether patient-centered care improves access to, or utilization of, effective treatment services. METHODS Using nationally representative survey data from SUD treatment clinics in the United States, we examine the association between patient-centered clinical care and the utilization of six services: methadone, buprenorphine, behavioral treatment, routine medical care, HIV testing, and suicide prevention counseling. We measured clinics' practice of and emphasis on patient-centered care with two variables: (1) whether the clinic regularly invites patients into clinical decision-making processes, and (2) whether supervisors believe in patient-centered healthcare and shared decision-making practices within their clinics. RESULTS In 2017, only 23% of SUD treatment clinics regularly invited patients into care decision-making meetings when their cases were discussed. A composite variable captured clinical supervisors' own experience with and expectations for patient-clinician interaction within their clinics (Cronbach's alpha = 0.79). Results from regression models that controlled for several organizational and environmental factors show that patient-centered care was independently associated with greater utilization of four of six evidence-based services. CONCLUSIONS A minority of SUD clinics practice patient-centered healthcare in the United States. Given the connection to evidence-based services, increasing participatory mechanisms in SUD treatment service provision can facilitate patients' access to appropriate and evidence-based services.
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Stability in a large drug treatment system: Examining the role of program size and performance on service discontinuation. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 86:102948. [PMID: 32977185 PMCID: PMC7508010 DOI: 10.1016/j.drugpo.2020.102948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 08/31/2020] [Accepted: 09/02/2020] [Indexed: 12/02/2022]
Abstract
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.
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The relationship of Medicaid expansion to psychiatric comorbidity care within substance use disorder treatment programs. J Subst Abuse Treat 2019; 105:44-50. [PMID: 31443890 DOI: 10.1016/j.jsat.2019.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 05/31/2019] [Accepted: 07/22/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Co-occurring mental health disorders are common among substance use disorder (SUD) patients. Medicaid expansion aimed to reduce barriers to SUD and mental health care and thereby improve treatment outcomes. METHODS We estimated change in the proportion of United States SUD treatment sites offering treatment for psychiatric comorbidities following Medicaid expansion as part of implementation of the Affordable Care Act (ACA) in 2014. Using panel data from the 2013-2014, n = 660, and 2016-2017, n = 638, waves of the National Drug Abuse Treatment System Survey (NDATSS), we estimated change in the proportion of sites offering antidepressant medication, other psychiatric medication, behavioral treatment, or any combination thereof for treatment of mental health comorbidities (i.e., beyond services focused on SUD). We modeled the impact of Medicaid expansion as an interaction between year and date of Medicaid expansion. We constructed a mixed-effects linear regression model for each outcome, with the interaction variable as the main exposure, site as a random effect, and site's average duration of treatment, proportion of clients with psychiatric comorbidities, average caseload per treatment prescribing-clinician on staff, type of facility and geographic region as covariates, to estimate a difference-in-differences (D-I-D) equation. RESULTS The adjusted D-I-D analysis indicated that the proportion of SUD treatment sites offering antidepressants for psychiatric treatment increased 10% (95% CI 1%, 18%) in the Medicaid expansion sites compared to non-expansion sites. The D-I-D for other psychiatric medications was also 10% (95% 1%, 19%). No significant changes were observed in behavioral treatment or the combination measure. The strongest association between Medicaid expansion and offering medication for mental health comorbidities was the 34% increase observed for residential treatment settings (95% CI 10%, 59%). CONCLUSION Availability of psychiatric medication treatment in SUD treatment settings increased following Medicaid expansion, particularly in residential SUD facilities. This policy change has facilitated integrated treatment for the substantial share of SUD treatment patients with mental health comorbidities, with the greatest benefit for patients receiving SUD treatment in residential programs.
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Abstract
Accountable care organizations (ACOs) are often discussed and promoted as driven by physicians, hospitals, and other health care providers. However, because of the flexible nature of ACO contracts, management organizations may also become partners in ACOs. We used data from 2013-15 on 276 ACOs from the National Survey of Accountable Care Organizations to understand the prevalence of nonprovider management partners' involvement in ACOs, the services these partners provide, and the structure of ACOs that have such partners. We found that 37 percent of ACOs reported having a management partner, and two-thirds of these ACOs reported that the partner shared in the financial risks or rewards. Among ACOs with partners, 94 percent had data services provided by the partner, 87 percent received administrative services, 68 percent received educational services, and 66 percent received care coordination services. Half received all four of these services from their partner. ACOs with partners were more heavily primary care than other ACOs. ACOs with and without partners had similar performance on costs and quality in Medicare ACO programs. Our findings suggest that management partners play a central role in many ACOs, perhaps supplying smaller and physician-run ACOs with services or expertise perceived as necessary for ACO success.
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Trust, Money, and Power: Life Cycle Dynamics in Alliances Between Management Partners and Accountable Care Organizations. Milbank Q 2019; 96:755-781. [PMID: 30537369 DOI: 10.1111/1468-0009.12356] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Policy Points Accountable care organizations (ACOs) form alliances with management partners to access financial, technical, and managerial support. Alliances between ACOs and management partners are subject to destabilizing tension around decision-making authority, distribution of shared savings, and conflicting goals and values. Management partners may serve either as trainers, ultimately breaking off from the ACO, or as central drivers of the ACO. Management partner participation in ACOs is currently unregulated, and management partners may receive a significant portion (in some cases, majority) of shared savings. CONTEXT Accountable care organizations (ACOs) are a prominent payment and delivery model. Though ACOs are often described as groups of health care providers, nearly 4 in 10 ACOs partner with a management company for services such as financial investment, contracting, data analytics, and care management, according to recent research. However, we know little about how and why these partnerships form. This article aims to understand the reasons providers seek partners, the nature of these relationships, and factors critical to the success or failure of these alliances. METHODS We used qualitative data collected longitudinally from 2012 to 2017 at 2 ACOs to understand relationships between management partners and ACO providers. The data include 115 semistructured interviews and observational data from 7 site visits. Two coders applied 48 codes to the data. We reviewed coded data for emergent themes in the context of alliance life cycle theory. FINDINGS Qualitative data revealed that management partners brought specific skills and services and also gave providers confidence in pursuing an ACO. Over time, tension between providers and management partners arose around decision-making authority, distribution of shared savings, and conflicting goals and values. We observed 2 outcomes of partnerships: cemented partnerships and dissolution. Key factors distinguishing alliance outcome in these 2 cases include degree of trust between organizations in the alliance; approach to conflict resolution; distribution of power in the alliance; skills and confidence acquired by the ACO over the life of the alliance; continuity of management partner delivery on promised resources; and proportion of savings going to the management partner. CONCLUSIONS The diverging paths for ACOs with management partners suggest 2 different roles that management partners may play in ACO development. In some cases, management partners may serve as trainers, with the partnership dissolving once the ACO gains skills and confidence to work alone. In other cases, the management partner is a central driver of the ACO and unlikely to break off.
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Evidence-based treatment for opioid use disorders: A national study of methadone dose levels, 2011-2017. J Subst Abuse Treat 2019; 96:18-22. [PMID: 30466543 PMCID: PMC6258192 DOI: 10.1016/j.jsat.2018.10.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 10/12/2018] [Accepted: 10/15/2018] [Indexed: 10/28/2022]
Abstract
The nation's methadone maintenance treatment (MMT) programs play a central role in addressing the current opioid epidemic. Considerable evidence documents the treatment effectiveness of MMT and, in turn, the importance of adequate dosing to MMT's effectiveness. Yet, as recently as 2011, 41% of patients received doses below the level of 80 mg/day. Using survey data from a nationally representative sample of MMT programs in 2011 and 2017, we examine (1) the extent to which the nation's MMT programs are meeting evidence-based standards for methadone dose level and (2) characteristics of MMT programs that are associated with variation in performance. Our results show that 43% of MMT patients receive <80 mg/day in 2017, and 23% of methadone maintenance patients receive daily doses below 60 mg. Results from multivariate regression analysis of the 2017 survey data show that private for-profit and public organizations significantly under-dosed patients compared to private nonprofit providers. Under-dosing also was more common in programs that serve high proportions of African-American patients. These results are concerning because MMT remains the medication of choice for vulnerable patients with the most severe opioid use disorders, and for-profit providers treat a growing proportion of MMT patients.
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Abstract
OBJECTIVE As the United States grapples with an opioid epidemic, expanding access to effective treatment for opioid use disorder is a major public health priority. Identifying effective policy tools that can be used to expand access to care is critically important. This article examines the relationship between state-targeted funding and technical assistance and adoption of three medications for treating opioid use disorder: oral naltrexone, injectable naltrexone, and buprenorphine. METHODS This study draws from the 2013-2014 wave of the National Drug Abuse Treatment System Survey, a nationally representative, longitudinal study of substance use disorder treatment programs. The sample includes data from 695 treatment programs (85.5% response rate) and representatives from single-state agencies in 49 states and Washington, D.C. (98% response rate). Logistic regression was used to examine the relationships of single-state agency targeted funding and technical assistance to availability of opioid use disorder medications among treatment programs. RESULTS State-targeted funding was associated with increased program-level adoption of oral naltrexone (adjusted odds ratio [AOR]=3.14, 95% confidence interval [CI]=1.49-6.60, p=.004) and buprenorphine (AOR=2.47, 95% CI=1.31-4.67, p=.006). Buprenorphine adoption was also correlated with state technical assistance to support medication provision (AOR=1.18, 95% CI=1.00-1.39, p=.049). CONCLUSIONS State-targeted funding for medications may be a viable policy lever for increasing access to opioid use disorder medications. Given the historically low rates of opioid use disorder medication adoption in treatment programs, single-state agency targeted funding is a potentially important tool to reduce mortality and morbidity associated with opioid disorders and misuse.
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Factors That Distinguish High-Performing Accountable Care Organizations in the Medicare Shared Savings Program. Health Serv Res 2016; 53:120-137. [PMID: 28024312 DOI: 10.1111/1475-6773.12642] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To identify factors that promote the effective performance of accountable care organizations (ACOs) in the Medicare Shared Savings Program. DATA SOURCES/STUDY SETTING Data come from a convenience sample of 16 Medicare Shared Savings ACOs that were organized around large physician groups. We use claims data from the Center for Medicaid and Medicare Services and data from 60 interviews at three high-performing and three low-performing ACOs. STUDY DESIGN Explanatory sequential design, using qualitative data to account for patterns observed in quantitative assessment of ACO performance. DATA COLLECTION METHODS A total of 16 ACOs were first rank-ordered on measures of cost and quality of care; we then selected three high and three low performers for site visits; interview data were content-analyzed. PRINCIPAL FINDINGS Results identify several factors that distinguish high- from low-performing ACOs: (1) collaboration with hospitals; (2) effective physician group practice prior to ACO engagement; (3) trusted, long-standing physician leaders focused on improving performance; (4) sophisticated use of information systems; (5) effective feedback to physicians; and (6) embedded care coordinators. CONCLUSIONS Shorter interventions can improve ACO performance-use of embedded care coordinators and local, regional health information systems; timely feedback of performance data. However, longer term interventions are needed to promote physician-hospital collaboration and skills of physician leaders. CMS and other stakeholders need realistic timelines for ACO performance.
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The Role of Program Directors in Treatment Practices: The Case of Methadone Dose Patterns in U.S. Outpatient Opioid Agonist Treatment Programs. Health Serv Res 2016; 52:1881-1907. [PMID: 27618580 DOI: 10.1111/1475-6773.12558] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE To describe changes in characteristics of directors of outpatient opioid agonist treatment (OAT) programs, and to examine the association between directors' characteristics and low methadone dosage. DATA SOURCE Repeated cross-sectional surveys of OAT programs in the United States from 1995 to 2011. STUDY DESIGN We used generalized linear regression models to examine associations between directors' characteristics and methadone dose, adjusting for program and patient factors. DATA COLLECTION Data were collected through telephone surveys of program directors. PRINCIPAL FINDINGS The proportion of OAT programs with an African American director declined over time, from 29 percent in 1995 to 16 percent in 2011. The median percentage of patients in each program receiving <60 mg/day declined significantly, from 48.5 percent in 1995 to 29 percent in 2005 and 23 percent in 2011. Programs with an African American director were significantly more likely to provide low methadone doses than other programs. This association was even stronger in programs with an African American director who served populations with higher percentages of African American patients. CONCLUSIONS Demographic characteristics of OAT program directors (e.g., their race) may play a key role in explaining variations in methadone dosage across programs and patients. Further research should investigate the causal pathways through which directors' characteristics affect treatment practices. This may lead to new, multifaceted managerial interventions to improve patient outcomes.
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Spillover effects of HIV testing policies: changes in HIV testing guidelines and HCV testing practices in drug treatment programs in the United States. BMC Public Health 2016; 16:666. [PMID: 27473519 PMCID: PMC4966765 DOI: 10.1186/s12889-016-3322-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 07/19/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To examine the extent to which state adoption of the Centers for Disease Control and Prevention (CDC) 2006 revisions to adult and adolescent HIV testing guidelines is associated with availability of other important prevention and medical services. We hypothesized that in states where the pretest counseling requirement for HIV testing was dropped from state legislation, substance use disorder treatment programs would have higher availability of HCV testing services than in states that had maintained this requirement. METHODS We analyzed a nationally representative sample of 383 opioid treatment programs from the 2005 and 2011 National Drug Abuse Treatment System Survey (NDATSS). Data were collected from program directors and clinical supervisors through telephone surveys. Multivariate logistic regression models were used to measure associations between state adoption of CDC recommended guidelines for HIV pretest counseling and availability of HCV testing services. RESULTS The effects of HIV testing legislative changes on HCV testing practices varied by type of opioid treatment program. In states that had removed the requirement for HIV pretest counseling, buprenorphine-only programs were more likely to offer HCV testing to their patients. The positive spillover effect of HIV pretest counseling policies, however, did not extend to methadone programs and did not translate into increased availability of on-site HCV testing in either program type. CONCLUSIONS Our findings highlight potential positive spillover effects of HIV testing policies on HCV testing practices. They also suggest that maximizing the benefits of HIV policies may require other initiatives, including resources and programmatic efforts that support systematic integration with other services and effective implementation.
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On-site bundled rapid HIV/HCV testing in substance use disorder treatment programs: study protocol for a hybrid design randomized controlled trial. Trials 2016; 17:117. [PMID: 26936623 PMCID: PMC4776446 DOI: 10.1186/s13063-016-1225-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 02/10/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND More than 1.2 million people in the United States are living with human immunodeficiency virus (HIV), and 3.2 million are living with hepatitis C virus (HCV). An estimated 25 % of persons living with HIV also have HCV. It is therefore of great public health importance to ensure the prompt diagnosis of both HIV and HCV in populations that have the highest prevalence of both infections, including individuals with substance use disorders (SUD). METHODS/DESIGN In this theory-driven, efficacy-effectiveness-implementation hybrid study, we will develop and test an on-site bundled rapid HIV/HCV testing intervention for SUD treatment programs. Its aim is to increase the receipt of HIV and HCV test results among SUD treatment patients. Using a rigorous process involving patients, providers, and program managers, we will incorporate rapid HCV testing into evidence-based HIV testing and linkage to care interventions. We will then test, in a randomized controlled trial, the extent to which this bundled rapid HIV/HCV testing approach increases receipt of HIV and HCV test results. Lastly, we will conduct formative research to understand the barriers to, and facilitators of, the adoption, implementation, and sustainability of the bundled rapid testing strategy in SUD treatment programs. DISCUSSION Novel approaches that effectively integrate on-site rapid HIV and rapid HCV testing are needed to address both the HIV and HCV epidemics. If feasible and efficacious, bundled rapid HIV/HCV testing may offer a scalable, potentially cost-effective approach to testing high-risk populations, such as patients of SUD treatment programs. It may ultimately lead to improved linkage to care and progress through the HIV and HCV care and treatment cascades. TRIAL REGISTRATION ClinicalTrials.gov: NCT02355080 . (30 January 2015).
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Implementation of comprehensive services as a mediator and race and ethnicity as a moderator of access and retention in addiction health services. Addict Sci Clin Pract 2015. [PMCID: PMC4347468 DOI: 10.1186/1940-0640-10-s1-a18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Paths to improving engagement among racial and ethnic minorities in addiction health services. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2015; 10:40. [PMID: 26503509 PMCID: PMC4624163 DOI: 10.1186/s13011-015-0036-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 10/15/2015] [Indexed: 11/21/2022]
Abstract
Background Members of racial and ethnic minority groups are most likely to experience limited access and poor engagement in addiction treatment. Research has been limited on the role of program capacity and delivery of comprehensive care in improving access and retention among minorities with drug abuse issues. The goal of this study was to examine the extent to which access and retention are enhanced when racial and ethnic minorities receive care from high-capacity addiction health services (AHS) programs and via coordination with mental health and receipt of HIV testing services. Methods This multilevel cross-sectional analysis involved data from 108 programs merged with client data from 2011 for 13,478 adults entering AHS. Multilevel negative binomial regression models were used to test interactions and indirect relationships between program capacity and days to enter treatment (wait time) and days in treatment (retention). Results Compared to low-capacity programs and non-Latino and non-African American clients, Latinos and African Americans served in high-capacity programs reported shorter wait times to admission, as hypothesized. African Americans also had longer treatment retention in high-capacity programs. Receipt of HIV testing and program coordination of mental health services played an indirect role in the relationship between program capacity and wait time. Conclusions Program capacity and coordinated services in AHS may reduce disparities in access to care. Implications for supporting low-capacity programs to eliminate the disparity gap in access to care are discussed.
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Integration of Substance Abuse Treatment Organizations into Accountable Care Organizations: Results from a National Survey. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2015; 40:797-819. [PMID: 26124307 PMCID: PMC4704856 DOI: 10.1215/03616878-3150062] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
To meet their aims of managing population health to improve the quality and cost of health care in the United States, accountable care organizations (ACOs) will need to focus on coordinating care for individuals with substance abuse disorders. The prevalence of these disorders is high, and these individuals often suffer from comorbid chronic medical and social conditions. This article examines the extent to which the nation's fourteen thousand specialty substance abuse treatment (SAT) organizations, which have a daily census of more than 1 million patients, are contracting with ACOs across the country; we also examine factors associated with SAT organization involvement with ACOs. We draw on data from a recent (2014) nationally representative survey of executive directors and clinical supervisors from 635 SAT organizations. Results show that only 15 percent of these organizations had signed contracts with ACOs. Results from multivariate analyses show that directors' perceptions of market competition, organizational ownership, and geographic location are significantly related to SAT involvement with ACOs. We discuss implications for integrating the SAT specialty system with the mainstream health care system.
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Evidence-based treatment for opioid disorders: a 23-year national study of methadone dose levels. J Subst Abuse Treat 2014; 47:245-50. [PMID: 25012549 PMCID: PMC4139092 DOI: 10.1016/j.jsat.2014.06.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 06/02/2014] [Accepted: 06/03/2014] [Indexed: 10/25/2022]
Abstract
Effective treatment for patients with opioid use problems is as critical as ever given the upsurge in heroin and prescription opioid abuse. Yet, results from prior studies show that the majority of methadone maintenance treatment (MMT) programs in the US have not provided dose levels that meet evidence-based standards. Thus, this paper examines the extent to which US MMT programs have made changes in the past 23 years to provide adequate methadone doses; we also identify factors associated with variation in program performance. Program directors and clinical supervisors of nationally-representative methadone treatment programs were surveyed in 1988 (n=172), 1990 (n=140), 1995 (n=116), 2000 (n=150), 2005 (n=146), and 2011 (n=140). Results show that the proportion of patients who received doses below 60 mg/day-the minimum recommended-declined from 79.5 to 22.8% in a 23-year span. Results from random effects models show that programs that serve a higher proportion of African-American or Hispanic patients were more likely to report low-dose care. Programs with Joint Commission accreditation were more likely to provide higher doses, as were a program that serves a higher proportion of unemployed and older patients. Efforts to improve methadone treatment practices have made substantial progress, but 23% of patients across the nation are still receiving doses that are too low to be effective.
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Determinants of the availability of hepatitis C testing services in opioid treatment programs: results from a national study. Am J Public Health 2014; 104:e75-82. [PMID: 24825236 DOI: 10.2105/ajph.2013.301827] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES We examined trends and organizational-level correlates of the availability of HCV testing in opioid treatment programs. METHODS We used generalized ordered logit models to examine associations between organizational characteristics of 383 opioid treatment programs from the 2005 and 2011 National Drug Abuse Treatment System Survey and HCV testing availability. RESULTS Between 2005 and 2011, the proportion of opioid treatment programs offering HCV testing increased but largely because of increases in off-site referrals rather than on-site testing. HCV testing availability was higher in opioid treatment programs affiliated with a hospital and those receiving federal funds. Opioid treatment programs providing both methadone and buprenorphine were more likely to offer any HCV testing, whereas opioid treatment programs providing only buprenorphine treatment were less likely to offer on-site testing. HCV testing availability was associated with more favorable staff-to-client ratios. CONCLUSIONS The increasing use of off-site referrals for HCV testing in opioid treatment programs likely limits opportunities for case finding, prevention, and treatment. Declines in federal funding for opioid treatment programs may be a key determinant of the availability of HCV testing in opioid treatment programs.
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HIV testing in the nation's opioid treatment programs, 2005-2011: the role of state regulations. Health Serv Res 2013; 49:230-48. [PMID: 23855724 DOI: 10.1111/1475-6773.12094] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2013] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE To identify the extent to which clients in a national sample of opioid treatment programs (OTPs) received HIV testing in 2005 and 2011; to examine relationships between state laws for informed consent and pretest counseling and rates of HIV testing among OTP clients. DATA SOURCE Data were collected from a nationally representative sample of OTPs in 2005 (n = 171) and 2011 (n = 200). STUDY DESIGN Random-effects logit and interval regression analyses were used to examine changes in HIV testing rates and the relationship of state laws to HIV testing among OTPs. DATA COLLECTION Data on OTP provision of HIV testing were collected in phone surveys from OTP managers; data also were collected on state laws for HIV testing. PRINCIPAL FINDINGS The percentage of OTPs offering HIV testing decreased significantly from 93 percent in 2005 to 64 percent in 2011. Similarly, the percentage of clients tested decreased from an average of 41 percent in 2005 to 17 percent in 2011. OTPs located in states whose laws do not require pretest counseling and that use opt-out consent were more likely to provide HIV testing and to test higher percentages of clients. CONCLUSIONS The results show the need to increase HIV testing among OTP clients; the results also underscore the beneficial possibilities of dropping pretest counseling as a requirement for HIV testing and of using the opt-out approach to informed consent for testing.
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A multi-level model of factors associated with HIV testing in US opioid Treatment programs. J Subst Abuse Treat 2012. [DOI: 10.1016/j.jsat.2012.08.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The productivity and cost-efficiency of models for involving nurse practitioners in primary care: a perspective from queueing analysis. Health Serv Res 2012; 47:594-613. [PMID: 22092009 PMCID: PMC3419879 DOI: 10.1111/j.1475-6773.2011.01343.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To develop simple stylized models for evaluating the productivity and cost-efficiencies of different practice models to involve nurse practitioners (NPs) in primary care, and in particular to generate insights on what affects the performance of these models and how. DATA SOURCES AND STUDY DESIGN The productivity of a practice model is defined as the maximum number of patients that can be accounted for by the model under a given timeliness-to-care requirement; cost-efficiency is measured by the corresponding annual cost per patient in that model. Appropriate queueing analysis is conducted to generate formulas and values for these two performance measures. Model parameters for the analysis are extracted from the previous literature and survey reports. Sensitivity analysis is conducted to investigate the model performance under different scenarios and to verify the robustness of findings. PRINCIPAL FINDINGS Employing an NP, whose salary is usually lower than a primary care physician, may not be cost-efficient, in particular when the NP's capacity is underutilized. Besides provider service rates, workload allocation among providers is one of the most important determinants for the cost-efficiency of a practice model involving NPs. Capacity pooling among providers could be a helpful strategy to improve efficiency in care delivery. CONCLUSIONS The productivity and cost-efficiency of a practice model depend heavily on how providers organize their work and a variety of other factors related to the practice environment. Queueing theory provides useful tools to take into account these factors in making strategic decisions on staffing and panel size selection for a practice model.
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HIV testing and counseling in the nation's outpatient substance abuse treatment system, 1995-2005. J Subst Abuse Treat 2010; 38:307-16. [PMID: 20171038 DOI: 10.1016/j.jsat.2009.12.004] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Revised: 11/02/2009] [Accepted: 12/31/2009] [Indexed: 11/16/2022]
Abstract
This article examines the extent to which U.S. outpatient substance abuse treatment (OSAT) facilities provide HIV counseling and testing (C&T) to clients between 1995 and 2005. We also examine organizational and client characteristics associated with OSAT facilities' provision of HIV C&T. Data were collected from a nationally representative sample of outpatient treatment facilities in 1995 (n = 618), 2000 (n = 571), and 2005 (n = 566). Results show that in 1995, 26.8% of OSAT clients received HIV C & T; by 2005, this proportion had increased, but only to 28.8%. Further, results from random-effects interval regression analysis show that C&T is especially widespread in public and nonprofit facilities, in methadone facilities, and in units that serve injection drug users and commercial sex workers. HIV C&T was also more widespread in units that employed formal intake protocols. Despite widespread efforts to increase HIV C&T services in OSAT care, only a small and stable minority of clients receive these services. Adoption of formal intake procedures may provide one vehicle to increase provision of C&T services.
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Abstract
OBJECTIVE To examine the extent to which U.S. methadone maintenance facilities meet established standards for minimum dosages, 1988-2005. DATA SOURCE Data were collected from a nationally representative sample of outpatient treatment facilities in 1988 (n=172), 1990 (n=140), 1995 (n=116), 2000 (n=150), and 2005 (n=146). STUDY DESIGN Random-effects multiple regression analysis was used to examine unit characteristics associated with below recommended doses. DATA COLLECTION Data regarding the proportion of patients who received maintenance dosages of <40, 60, and 80 mg/day were collected from unit directors and clinical supervisors. PRINCIPAL FINDINGS Forty-four percent of patients receive doses of at least 80 mg/day--the threshold identified as recommended practice in recent work. Thirty-four percent of patients receive doses below 60 mg/day, while 17 percent receive doses below 40 mg/day. Units that serve a high proportion of African American or Latino clients were more likely to report low-dose care. Units managed by individuals who strongly favor abstinence models (e.g., Narcotics Anonymous) were more likely to provide low-dose care. CONCLUSIONS One-third of methadone facilities provide doses below recommended levels. Managerial attitudes about abstinence and their relationship to low doses underscore the contested role of methadone in treatment of opiate disorders.
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The role of organization and management in substance abuse treatment: Review and roadmap. J Subst Abuse Treat 2006; 31:221-33. [PMID: 16996385 DOI: 10.1016/j.jsat.2006.06.016] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2006] [Accepted: 06/15/2006] [Indexed: 11/20/2022]
Abstract
To develop an understanding as to why there exists a seemingly wide gap between research and practice in the field of substance abuse treatment and, more important, to understand how this gap can be closed, researchers have focused their attention on the role of organizational and management factors in the delivery of treatment services. This article's overarching goal is to stimulate research and interventions that focus on these factors so as to improve the standards and outcomes of care in substance abuse treatment. Part 1 introduces the key assumptions and perspectives that guide organization and management research. Part 2 selectively reviews empirical studies that examine relationships between treatment programs' use of research-based treatment practices and organization and management factors. The article concludes with a discussion of the next important steps for research and policy.
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Outpatient substance abuse treatment and HIV prevention: an update. J Subst Abuse Treat 2006; 30:39-47. [PMID: 16377451 DOI: 10.1016/j.jsat.2005.09.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2004] [Revised: 09/21/2005] [Accepted: 09/27/2005] [Indexed: 10/25/2022]
Abstract
Testing and counseling, along with community outreach, have been identified as valuable in the prevention of human immunodeficiency virus (HIV) and other blood-borne diseases. This article assesses the extent to which outpatient substance abuse treatment (OSAT) programs provide such services. Longitudinal data for 1988-2000 were analyzed from the National Drug Abuse Treatment System Survey (NDATSS). Random-effects regression was used to examine factors associated with the provision of prevention services. HIV testing, which had became more common between 1990 and 1995, continued to proliferate between 1995 and 2000. The proportion of units that provide HIV testing and counseling increased from 66% to 86%. The proportion of units that provide HIV community outreach increased significantly before 1995 but then slightly decreased from 77% to 73% between 1995 and 2000. In conclusion, HIV testing and counseling widely proliferated in OSAT care. However, OSAT units remain less likely to offer HIV community outreach services.
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Gender differences in the impact of comprehensive services in substance abuse treatment. J Subst Abuse Treat 2004; 27:289-300. [PMID: 15610830 DOI: 10.1016/j.jsat.2004.08.004] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2003] [Revised: 03/15/2004] [Accepted: 08/12/2004] [Indexed: 10/26/2022]
Abstract
This study examines the impact of comprehensive services on treatment outcomes for women and men. The study uses data collected from 1992 to 1997 for the National Treatment Improvement Evaluation Study, a prospective, cohort study of substance abuse treatment programs and their clients. The analytic sample consists of 3,142 clients (1,123 women and 2,019 men) from 59 treatment facilities. The results show that substance abuse treatment benefits both women and men. Further, both women and men benefit from comprehensive services provided as part of substance abuse treatment: specifically, the receipt of educational, housing and income support services is related to reduced post-treatment substance abuse for both women and men. Gender differences are revealed by the fact that, overall, greater proportions of women receive services and, when individual, service, and treatment organizational characteristics are controlled, women show greater reductions in post-treatment substance use. Further, women and men differ in their responsiveness to organizational characteristics: the availability of on-site services and the frequency of counseling significantly predict reduced post-treatment substance use for men but not for women.
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Abstract
CONTEXT Results from several studies conducted in the early 1990s showed that the majority of US methadone maintenance programs did not use treatment practices that met established standards for the care of heroin users. Effective treatment for heroin users is critical given the upsurge in heroin use and the continued role of injection drug use in the human immunodeficiency virus and hepatitis C epidemics. OBJECTIVES To examine the extent to which US methadone maintenance treatment programs have made changes in the past 12 years to provide adequate methadone doses and to identify factors associated with variation in program performance. DESIGN, SETTING, AND PARTICIPANTS Program directors and clinical supervisors of nationally representative methadone treatment programs that varied by ownership (for-profit, public, or private not-for-profit) and setting (eg, free-standing, hospital-based) were surveyed in 1988 (n = 172), 1990 (n = 140), 1995 (n = 116), and 2000 (n = 150). MAIN OUTCOME MEASURES Percentage of patients in each treatment program receiving methadone dosages of less than 40, 60, and 80 mg/d. RESULTS The percentage of patients receiving methadone dosage levels less than the recommended 60 mg/d has decreased from 79.5% in 1988 to 35.5% in 2000. Results also show that programs with a greater percentage of African American patients are especially likely to dispense low dosages, while programs with Joint Commission on Accreditation of Healthcare Organizations accreditation are more likely to provide adequate methadone doses. CONCLUSIONS Efforts to improve methadone treatment practices appear to be making progress, but many patients are still receiving substandard care.
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The organization of service delivery. Overview. RECENT DEVELOPMENTS IN ALCOHOLISM : AN OFFICIAL PUBLICATION OF THE AMERICAN MEDICAL SOCIETY ON ALCOHOLISM, THE RESEARCH SOCIETY ON ALCOHOLISM, AND THE NATIONAL COUNCIL ON ALCOHOLISM 2002; 15:3-7. [PMID: 11449749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
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The organization of substance abuse managed care. RECENT DEVELOPMENTS IN ALCOHOLISM : AN OFFICIAL PUBLICATION OF THE AMERICAN MEDICAL SOCIETY ON ALCOHOLISM, THE RESEARCH SOCIETY ON ALCOHOLISM, AND THE NATIONAL COUNCIL ON ALCOHOLISM 2002; 15:27-49. [PMID: 11449746 DOI: 10.1007/978-0-306-47193-3_3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
Managed care came to dominate the delivery of substance abuse services during the 1990s. This paper uses literature and new data to describe and analyze the set of arrangements it implies. The description suggests that substance abuse managed care typically is "carved out" of the general health care plan and treatment is coordinated by a behavioral health managed care company that manages treatment access, length, type, and intensity. This administrative agent is provided financial incentives to keep costs low and otherwise faces such mandates as to ensure timely access to treatment and to deliver reports. A typical agent has some interest in improving the quality of decision-making, but has few incentives for controlling the treatment technology. In contrast, agents tend to control treatment providers through relatively rigid rules that substitute outpatient for inpatient care, regulate the length and intensity of services, provide limited social services, mandate accreditation, allow limited clinician discretion, administer an entire "network" of providers as an only slightly differentiated mass, and rarely shape the details of the treatment process. These patterns are analyzed in terms of transaction cost economics and institutional and resource dependency theories. In general, it is argued that managed care reflects an interest in controlling costs but also in ensuring access within an environment where there is uncertainty accompanying competing demands, varying conceptions of the client, and controversies over the efficacy of specific treatment technologies.
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Managing the care of health and the cure of disease: arguments for the importance of integration. Health Care Manage Rev 2001; 26:85-7; discussion 89-90. [PMID: 11233357 DOI: 10.1097/00004010-200101000-00008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The financial performance of hospitals belonging to health networks and systems. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2001; 37:234-52. [PMID: 11111282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
The U.S. health industry is experiencing substantial restructuring through ownership consolidation and development of new forms of interorganizational relationships. Using an established taxonomy of health networks and systems, this paper develops and tests four hypotheses related to hospital financial performance. Consistent with our predictions, we find that hospitals in health systems that had unified ownership generally had better financial performance than hospitals in contractually based health networks. Among health network hospitals, those belonging to highly centralized networks had better financial performance than those belonging to more decentralized networks. However, health system hospitals in moderately centralized systems performed better than those in highly centralized systems. Finally, hospitals in networks or systems with little differentiation or centralization experienced the poorest financial performance. These results are consistent with resource dependence, transaction cost economics, and institutional theories of organizational behavior, and provide a conceptual and empirical baseline for future research.
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Changes in methadone treatment practices: results from a panel study, 1988-1995. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 1999; 25:681-99. [PMID: 10548442 DOI: 10.1081/ada-100101886] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Results from several studies conducted in the late 1980s and early 1990s showed that the majority of the nation's methadone treatment units did not use effective treatment practices. Since then, however, many efforts have been made to improve critical treatment practices. This paper examines the extent to which key methadone treatment practices (dose levels, treatment duration, client influence in dose decisions) changed from 1988 to 1995 in a panel sample of methadone maintenance units. We also examine factors that may account for variation in methadone treatment practices. We use panel data from a national random sample of 172 units in 1988 (82% response rate), 140 units in 1990 (87% response rate), and 116 units in 1995 (89% response rate). Unit directors and clinical supervisors provided phone survey data on clients influence on doses, upper limits on doses, average dose levels, unit emphasis on decreasing doses, time when clients are encouraged to detoxify, and average length of treatment. Results from random effects regression analyses indicate that treatment practices concerning methadone dose levels, client influence in dose decisions, and treatment duration improved significantly between 1988 and 1995. Several characteristics of clients (race, age) and treatment units (staff, ownership, geographic location) are associated with the use of less-effective treatment practices. Efforts to improve treatment practices appear to be making progress and certainly need to be continued.
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An institutional analysis of HIV prevention efforts by the nation's outpatient drug abuse treatment units. JOURNAL OF HEALTH AND SOCIAL BEHAVIOR 1999; 40:175-192. [PMID: 10467763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Drawing from an institutional-theory perspective on innovations in organizations, this paper examines the use of human immunodeficiency virus (HIV) prevention practices by the nation's outpatient substance abuse treatment units during a critical period from 1988 to 1995. An institutional perspective argues that organizations adopt new practices not only for technical reasons, but also because external actors actively promote or model the use of particular practices. We examine the extent to which treatment units use several practices to prevent HIV infection among their clients and among drug-users not in treatment. Results from random-effects regression analyses of national survey data show that treatment units significantly increased their use of HIV prevention practices from 1988 to 1995. Further, the results show that treatment units' use of prevention practices was related to clients' risk for HIV infection, unit resources available to support these practices, and organizational support for the practices. Implications are discussed for an institutional view of organizational innovation as well as for research on HIV prevention.
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Decision making, goal consensus, and effectiveness in university hospitals. HOSPITAL & HEALTH SERVICES ADMINISTRATION 1999; 36:505-23. [PMID: 10160787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
This article examines changes in the influence of several key actors (state and university officials, board members, and hospital and medical school administrators) in management and policy decisions for university hospitals (UHs). We propose that the decreasing influence of external actors in UH decision making and the increasing influence of UH and medical school actors as well as UH-medical school goal consensus will be related to higher levels of UH performance. Data are drawn from a national sample of 52 UHs that participated in a study of UH decision making in 1981 and 1985. Results indicate that state and university actors lost influence in UH policy decisions between 1981 and 1985, while actors internal to academic health centers (AHCs) gained influence in such decisions. The data indicate a similar trend, although not as strong, regarding influence in UH management decisions. Results from regression analyses indicate that decreasing levels of external influence on UH decision making are related to UH effectiveness, but increasing levels of AHC influence and goal consensus have weak or inconsistent relationships with UH effectiveness. Implications for improving the performance of UHs are discussed.
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Business as usual? Changes in health care's workforce and organization of work. HOSPITAL & HEALTH SERVICES ADMINISTRATION 1999; 41:3-18. [PMID: 10154620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Major changes are occurring in the health care workforce and organization of work. Such changes include, for example, a shift in workforce composition from specialists to generalists in medical care, as well as a shift from autonomous work performance to work performed in teams. This article provides a survey of such major changes. It identifies patterns of change and examines their causes. Further, we raise questions about the implications of these changes for practice and research in the health care field.
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Commentary 1. Health Serv Manage Res 1998. [DOI: 10.1177/095148489801100107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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An organizational analysis of service patterns in outpatient drug abuse treatment units. JOURNAL OF SUBSTANCE ABUSE 1995; 7:27-42. [PMID: 7655310 DOI: 10.1016/0899-3289(95)90304-6] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The effectiveness of drug abuse treatment depends in part on meeting clients' medical and social needs related to drug abuse. Yet, we know little about the type and amount of medical and social services that clients receive in outpatient drug abuse treatment units. This article addresses this issue, drawing from conceptual perspectives in organizational theory and using data from a national random sample of 481 outpatient treatment units that participated in a phone survey in both 1988 and 1990. We examine the extent to which clients in these units receive: physical (medical) and mental health care; special treatment for multiple drug abuse; and employment, financial, and legal counseling. Results from a multivariate analysis of variance (MANOVA) indicate that there was a significant decrease from 1988 to 1990 in all services we examined. Regression analyses were conducted to identify organizational and client characteristics related to these decreases. Results show that changes in both client characteristics and key organizational factors (e.g., resources, staffing) are significantly related to decreases in the services clients receive. Implications for meeting the medical and social service needs of drug abuse clients are discussed.
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The financial performance of diversified hospital subsidiaries. Health Serv Res 1993; 27:741-63. [PMID: 8428811 PMCID: PMC1069911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Despite its proliferation, we know relatively little about the impact of hospital restructuring to offer new services. This exploratory study examines the relationship between types of services offered and financial performance among separately incorporated subsidiaries of acute care hospitals. We draw data from the subsidiaries of all hospital firms operating in one state (Virginia) that requires reporting by all such firms. Results from multiple regression analyses of 1987 data indicate that units that existed longer, produced health care or related products, or were nonprofit subsidiaries of nonprofit firms tended to be more profitable than the other subsidiaries.
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Variations in methadone treatment practices. Results from a national study. JAMA 1992; 267:253-8. [PMID: 1727522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To examine the extent to which outpatient methadone maintenance treatment units are engaging in treatment practices that previous research indicates are ineffective (eg, inadequate dose levels); to examine factors that may be related to variation in methadone treatment practices. DESIGN Survey of unit directors and clinical supervisors. SETTING The study includes units that vary in terms of ownership (public, private for-profit, or private not-for-profit) and setting (eg, hospital-based, mental health center-based, or free-standing facility). PARTICIPANTS A national random sample of 172 units participated, for an 82% response rate; the data were weighted to ensure that they were nationally representative. MAIN OUTCOME MEASURES Clients' awareness of and influence on doses; units' use of take-home dosages; upper limits on doses; average dose levels; unit emphasis on decreasing dosages; time when clients are encouraged to detoxify; average length of treatment. RESULTS The data indicate that many units have treatment practices such as low average dose levels that are not effective according to the majority of previous studies. Units with higher average dose levels have longer average lengths of time in treatment. CONCLUSIONS Steps should be taken to monitor and, if necessary, change the treatment practices of methadone units that are providing inadequate dose levels with little client input.
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Isomorphism and external support in conflicting institutional environments: a study of drug abuse treatment units. ACADEMY OF MANAGEMENT JOURNAL. ACADEMY OF MANAGEMENT 1991; 34:636-661. [PMID: 10128668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Using institutional theory, we developed predictions about organizational units that moved from an environment making consistent demands to one making conflicting demands. Many community mental health centers have diversified into drug abuse treatment. The units providing those services face conflicting demands from the traditional mental health sector and the new drug abuse treatment sector about which clients to serve, how to assess their problems, and who should provide treatment. We propose that in response to such demands these units will adopt apparently conflicting practices. Also, isomorphism with the traditional sector will be positively associated with external support from parent mental health centers and other actors in the mental health sector. Results generally support those predictions.
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