Roy M. Gabriel

Organization and Financing of Alcohol and Substance Abuse Programs for American Indians and Alaska Natives

OBJECTIVES Although American Indians and Alaska Natives have high rates of substance abuse, few data about treatment services for this population are available. We used national data from 1997-2002 to describe recent trends in organizational and financial arrangements. METHODS Using data from the Indian Health Service (IHS), the Substance Abuse and Mental Health Services Administration, the National Institute on Alcohol Abuse and Alcoholism, the Henry J. Kaiser Family Foundation, and the Census Bureau, we estimated the number of American Indians served by substance abuse treatment programs that apparently are unaffiliated with either the IHS or tribal governments. We compared expected and observed IHS expenditures. RESULTS Half of the American Indians and Alaska Natives treated for substance abuse were served by programs (chiefly in urban areas) apparently unaffiliated with the IHS or tribal governments. IHS substance abuse expenditures were roughly what we expected. Medicaid participation by tribal programs was not universal. CONCLUSIONS Many Native people with substance abuse problems are served by programs unaffiliated with the IHS. Medicaid may be key to expanding needed resources.

Outcomes for medicaid clients with substance abuse problems before and after managed care

Medicaid conversion from fee for service to managed care raised numerous questions about outcomes for substance abuse treatment clients. For example, managed care criticisms include concerns that clients will be undertreated (with too short and/or insufficiently intense services). Also of interest are potential variations in outcome for clients served by organizations with assorted financial arrangements such as for-profit status versus not-for-profit status. In addition, little information is available about the impact of state Medicaid managed care policies (including client eligibility) on treatment outcomes. Subjects of this project were Medicaid clients aged 18–64 years enrolled in the Oregon Health Plan during 1994 (before substance abuse treatment managed care, N=1751) or 1996–1997 (after managed care, N=14,813), who were admitted to outpatient non-methadone chemical dependency treatment services. Outcome measures were retention in treatment for 90 days or more, completion of a treatment program, abstinence at discharge, and readmission to treatment. With the exception of readmission, there were no notable differences in outcomes between the fee for service era clients versus those in capitated chemical dependency treatment. There were at most minor differences among various managed care systems (such as for-profit vs not-for-profit). However, duration of Medicaid eligibility was a powerful predictor of positive outcomes. Medicaid managed care does not appear to have had an adverse impact on outcomes for clients with substance abuse problems. On the other hand, state policies influencing Medicaid enrollment may have substantial impact on chemical dependency treatment outcomes.

Challenges Substance Abuse Treatment Agencies Faced in Adoption of Computer-Based Technology to Improve Assessment

The Oregon Practice Improvement Collaborative provided resources and technical assistance to help five Oregon drug treatment agencies adopt computer-based technology of their choice to support client progress in treatment. This manuscript describes agency processes related to that adoption of technology. Agencies chose computer programs to improve clinical outcomes, reduce staff burden, and respond to external pressures. Agencies used a combination of top-down and bottom-up approaches to involve staff in decision making. Agencies guided staff from current practice to a standardized paper-and-pencil tool, then from the paper-and-pencil tool to its electronic version. Staff experienced barriers in technology-related training, logistical challenges in integrating the technology, and sustaining the technology.

Relating Substance Abuse Counselor Background to the Provision of Clinical Tasks

Abstract This study examines the diverse academic and professional background characteristics of substance abuse treatment counselors, relating these characteristics to the work counselors are doing. Results indicate that while academic and professional background characteristics differentiate whether counselors perform certain clinical tasks or not, they do not differentiate the amount of time they spend doing them. In fact, regression analyses indicate that academic and professional background characteristics currently account for less than 10% of the total variability associated with how counselors spend their time. While meager, the best predictors of individual work tasks appear to be more contextual in nature. The fact that academic and professional background characteristics do not differentiate counselors in terms of time spent on specific clinical responsibilities raises some questions regarding the quality of client care. Results also indicate that the knowledge and skill sets needed for counselors to be effective may vary according to the treatment setting

Impact of Patient Placement Criteria on Substance Abuse Treatment Under the Oregon Health Plan

SUMMARY When Oregon shifted to managed care for Medicaid-funded substance abuse treatment, standardized patient placement and discharge criteria were rapidly implemented statewide. This prospective, naturalistic study examines the validity and impact of placement criteria with a sample of 240 adults presenting for treatment compared to a sample of 287 in Washington state, where implementation was phased in slowly. Baseline profile analysis suggested better differentiation between Level II and Level III clients for the Oregon sample and better implementation than with the Washington sample, presumably because Oregon clinicians received more training and had more experience with the criteria. A majority of the Oregon sample was placed in intensive outpatient programs, consistent with the recommended level of care. In this study, placement criteria showed good potential for changing treatment planning behavior, increasing individualization, and improving utilization of new levels of care.

The impact of managed care on publicly funded outpatient adolescent substance abuse treatment: service use and six-month outcomes in Oregon and Washington.

This study assessed the impact of managed care on publicly funded adolescent substance abuse treatment by comparing differences in service utilization and outcomes across prospective samples from two states: Oregon, which uses managed care practices in service financing and delivery, and Washington, which does not. One hundred and six adolescents from Washington and 94 from Oregon, who entered outpatient substance abuse treatment in 1998 and 1999, completed self-report surveys about their substance use before and after receiving treatment (follow-up rate = 75 percent). In addition, clinical chart reviews conducted at the 6-month follow-up assessed the type and amount of treatment these adolescents received during the study period. It was found that service utilization and treatment outcomes were comparable across the two state samples. The evidence presented here suggests that managed care is capable of delivering substance abuse treatment services of comparable quality to state-administered substance abuse treatment services.