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Unmet needs for comprehensive services in outpatient addiction treatment
Journal of Substance Abuse Treatment 30 (2006) 183 – 189
Unmet needs for comprehensive services in outpatient addiction treatment Janice L. Pringle, (Ph.D.)a,4, Nicholas P. Emptage, (M.A.)b, Robert L. Hubbard, (Ph.D.)c a
Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 449 Falk Clinic, Pittsburgh, PA 15213, USA b Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA c Institute for Community-Based Research, National Development and Research Institutes, Inc, Raleigh, NC, USA Received 22 March 2005; received in revised form 24 October 2005; accepted 23 November 2005
Abstract Many addiction treatment patients suffer from health and psychosocial problems in addition to substance misuse at the time of their treatment entry. Outpatient treatment programs have attempted to address these problems by providing or facilitating access to comprehensive health and social services. Nevertheless, previous research have suggested high levels of unmet needs for these services in the addiction treatment population. Using data from a large study on community-based outpatient addiction treatment, this article provides additional information on levels of unmet service needs and the relationship between need and receipt of services during treatment. Our results suggest extremely high levels of unmet needs for a wide variety of health and psychosocial services. Specifically, the data suggest that unmet service needs may be far more prevalent than previous estimates and that addiction treatment populations in rural areas may be particularly disadvantaged. D 2006 Elsevier Inc. All rights reserved. Keywords: Need; Outpatient; Psychosocial; Services; Unmet
1. Introduction Addiction treatment patients often suffer from secondary health and psychosocial problems at the time of their treatment entry. A large study on patients entering outpatient programs identified numerous co-occurring issues, including lifetime depression (53% of patients), violence issues (35%), prior mental health treatment (28%), unemployment and financial problems (41%), deficits in vocational skills (27%), unstable housing or homelessness (11%), and low educational achievement (an average education of 11 years), as well as substantial family problems, involvement in illegal activities, and limited social support (McLellan, Hagan, Meyers, Randall, & Durell, 1997). These problems are often closely related to patients’ alcohol or drug use behaviors and have been shown repeatedly to have significant negative impacts on treatment retention and subsequent outcomes (McLellan et al., 1994; Simpson, Joe, 4 Corresponding author. Tel.: +1 412 648 8560; fax: +1 412 648 9253. E-mail address: [email protected] (J.L. Pringle). 0740-5472/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jsat.2005.11.006
Fletcher, Hubbard, & Anglin, 1999). Drug use and alcohol use combined with psychiatric illness have been associated with higher health care costs (Westermeyer, Eames, & Nugent, 1998) and with violent behaviors leading to involvement with courts and jails (Ford, Snowden, & Walser, 1991). Analyses from the Drug Abuse Treatment Outcome Study (DATOS) found that, among cocaine-using patients across three modalities of treatment, those with the most severe problems (i.e., substance dependence or polysubstance use, psychiatric illness and social difficulties, criminal justice involvement, income and employment problems, and low social support) had the highest rates of relapse in the year after treatment (Simpson et al., 1999). Numerous studies examining family, marital, and employment issues among addiction treatment populations have found that such problems are associated with poor treatment outcomes (Hubbard et al., 1989; McLellan, Luborsky, O’Brien, Woody, & Druley, 1982; Moos, Finney, & Cronkite, 1990). Given the powerful negative impact of co-occurring problems shown by research and the additional evidence
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showing a sharp increase in the prevalence of such problems among those entering addiction treatment (Gerstein & Harwood, 1990; McLellan et al., 1997; Pickens & Fletcher, 1991), treatment providers have attempted to address health and psychosocial issues through provision of so-called wrap-around (or comprehensive) services. Larger treatment programs or those embedded within hospital systems are often able to offer medical or mental health services to patients onsite and may have ready access to other services via case management. In the case of more bdistalQ needs, however, such as housing, legal services, transportation, and vocational services, and in the case of smaller provider organizations, appropriate wrap-around services are frequently not available onsite and are typically accessed by referral to health care providers or social service organizations in the community (Ashery, 1992). Comprehensive service use is often not reimbursed as a component of patient care, and payment for these services is often complicated by institutional boundaries and separate state and federal funding sources that serve separate populations (Wrap-Around Services Impact Study [WASIS] Research Group, 2000). Research on the clinical impacts of comprehensive service provision to addiction treatment patients has generally found service provision to predict superior outcomes, although evidence to the contrary does exist (Fiorentine, 1998; McLellan et al., 1994). Several studies by McLellan et al. have found a positive relationship between enhanced access to psychosocial services during treatment and measures of treatment retention and outcome (McLellan, Arndt, Metzger, Woody, & O’Brien, 1993; McLellan et al., 1998). Hser, Polinsky, Maglione, and Anglin (1999) found superior outcomes and longer retention among patients who were matched to comprehensive services based on needs reported at treatment entry; meeting patients’ needs for vocational training, child care, housing, and transportation was shown to be especially beneficial. Most recently, the Center for Substance Abuse Treatment (CSAT) sponsored a large multisite evaluation of wraparound service provision in outpatient addiction treatment. This project, the WASIS, found that patient receipt of child care, basic needs services, educational training, family counseling, and medical and mental health services was associated with improvements in treatment retention and numerous indicators of posttreatment outcome (Pringle et al., 2002). Nevertheless, research suggests considerable unmet needs for these services. Analyses of patient-reported need and service provision across two national studies suggested that the number and variety of comprehensive services received by patients fell dramatically between 1979 and 1981 (during data collection for the Treatment Outcome Prospective Study) and between 1991 and 1993 (during data collection for the DATOS). At the earlier time point, the proportion of outpatients not receiving needed services was lower than 10% for every service category except for
employment and financial counseling (both roughly 20%). At the time of the DATOS, however, the proportion of patients reporting unmet needs in the former categories had risen to greater than 30% (with ~ 60% of those needing psychological and family counseling not receiving these services) whereas approximately 50% of patients needing employment and financial services also did not receive them (Etheridge, Craddock, Dunteman, & Hubbard, 1995). Significant decreases in service provision and substantial unmet needs for financial, mental health, vocational, and medical services were also found by D’Aunno and Vaughn (1995). In the CSAT National Treatment Improvement Evaluation Study (NTIES), half of those needing medical services or interpersonal skills training did not receive them whereas two thirds of those needing mental health treatment, family services, or parenting skills training did not receive them. Of the NTIES patients needing educational, vocational, or legal services, 76% – 89% did not receive them (Gerstein et al., 1997). More recent data have shown that provision of comprehensive services is very uncommon, particularly in outpatient programs, although patients in greater need may be more likely to receive medical, mental health, and family services (Asche & Harrison, 2002). In this study, we made use of the WASIS sample to examine the issue of unmet needs for comprehensive services in outpatient addiction treatment. In the WASIS, these services were defined as health care and social services that, in conjunction with addiction treatment, were intended to improve patient access to and retention in treatment and/or to comprehensively address the needs of patients during treatment. Given such a broad definition, 10 service types were included in the study. Moreover, the WASIS included multiple indicators of service need—an advance on previous research. In this article, we present descriptive statistics on the proportion of study patients needing and receiving each type of service during treatment.
2. Materials and methods 2.1. Study design and subject sample Data for this study came from the WASIS, which was sponsored by the CSAT. Between 1996 and 1999, this study collected data from patients in nine outpatient addiction treatment programs in western Pennsylvania. Given the population studied and the study aims, the WASIS used an observational prospective cohort design. We believed that the assignment of patients to service and no-service conditions would be prohibitively difficult from both logistical and ethical standpoints and would set up a scenario with poor external validity. Thus, this study observed a cohort of treatment patients prospectively through a specific episode of care.
J.L. Pringle et al. / Journal of Substance Abuse Treatment 30 (2006) 183–189
Assessments were conducted with participants shortly after their entry into treatment and at 3 months after their baseline assessment (results from the DATOS [refer to the work of Hubbard, Craddock, Flynn, Anderson, & Etheridge, 1997] suggested that this follow-up interval would characterize the period that study subjects spent in outpatient treatment with reasonable accuracy). Upon entering treatment at a participating program, patients meeting basic eligibility criteria (i.e., being between 18 and 65 years old and not having significant cognitive or psychiatric impairments) were given the option of participating voluntarily in the WASIS by their treatment counselor. Those who agreed to participate filled out a standard consent-to-contact form, which was then forwarded to a WASIS field interviewer, who made an appointment with each patient to conduct the baseline assessment. Patients who declined to participate were asked to fill up a brief form providing basic descriptive information. We estimated that 0.5% of adult patients were excluded from participation owing to cognitive or psychiatric conditions whereas approximately 19% of eligible subjects declined to participate, most often caused by their concerns about confidentiality or the time needed to complete assessments. Those who chose to participate completed informed consent documentation with the field interviewer before beginning the initial assessment. Participants also filled out locator forms to facilitate recontact for follow-up assessments. Participants received a $25 gift certificate for a local restaurant or market for each WASIS assessment they completed. All procedures were approved by the institutional review board of the St. Francis Medical Center (Pittsburgh, PA, USA). Additional details regarding the WASIS methodology are provided in the work of Pringle et al. (2002). The WASIS data collection instruments were based largely on those used in the DATOS (refer to the work of Flynn, Craddock, Hubbard, Anderson, & Etheridge, 1997) and the NTIES (refer to the work of Gerstein et al., 1997). The assessments used lengthy structured protocols and required approximately 90 minutes to complete. These assessments captured information on basic descriptive characteristics, alcohol and drug use, mental health status, history of mental health or addiction treatment, criminal activity and criminal justice status, socioeconomic status, health status and health care use, need for and receipt of psychosocial services, social support, and spirituality. Patient chart abstraction instruments similar to those used in the DATOS were used to verify information regarding the patients’ index treatment episodes. The WASIS also gathered program data from counselors and program directors using two self-report questionnaire forms that asked about characteristics of the study sites and changes in these characteristics during the study period. The study sites were nine outpatient addiction treatment programs located in urban and rural areas in western Pennsylvania. (Because of the small number of study sites, a crude definition of urban/rural status was used: the four
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programs [with 9 participating delivery units] located in the cities of Pittsburgh and Erie were designated as urban whereas the five programs [with 12 participating delivery units] located in smaller communities far from these cities were designated as rural.) These programs were publicly supported and served large numbers of Medicaid patients. In Pennsylvania, outpatient care is characterized by three distinct modalities: traditional outpatient treatment, intensive outpatient treatment, and partial hospitalization (for additional details as to the types of services implied by each level of care, refer to Pennsylvania Department of Health, 1999). Some WASIS sites offered only one of these modalities; others offered two or three of these. A total of 21 units of treatment (across all levels of outpatient care) across the nine programs participated in the WASIS. Three of the urban sites were able to provide all 10 wrap-around services, if not onsite then via referral; the fourth urban program provided all but transportation services onsite and all but medical services through referral. Among the rural programs, none was able to provide all services through referral networks, although two were able to provide all services onsite. No rural program was able to refer for medical services. Two of the rural programs provided no service onsite and had no information on referrals. There were 1,709 patients included in the WASIS baseline sample, with 1,003 patients followed up at the 3-month assessment. Of the baseline sample, 848 (49.6%) were from urban sites and 861 (50.4%) were from rural sites (incomplete data made it impossible to capture urban/rural distinctions at the service delivery unit level). After accounting for numerous contingencies, the follow-up rate at 3 months was 65%. The follow-up sample appears to be sufficiently representative of the baseline sample on variables closely related to addiction severity and service needs, including sociodemographic characteristics, employment, and criminal justice status (refer to the work of Pringle et al., 2002 for additional details). The WASIS subjects were primarily male (63.5%), aged between 30 and 39 years (43.5%), and of European or Caucasian descent (71.4%). Most had attended at least one grade of high school (74.8%) whereas 21.0% had attended school beyond the 12th grade. Approximately 64% (63.9%) were unemployed when they entered the index treatment episode. Approximately 57% (57.2%) reported being involved with the criminal justice system (e.g., probation, parole, trial pending, and recent arrest) at the baseline assessment. Approximately 40% (39.9%) had either one or two children. Most patients reported lifetime use of beer (91.6%), liquor (61.8%), and marijuana (81.0%). In addition, 47% reported lifetime use of cocaine and 46.2% reported lifetime use of crack. Approximately 59% (59.1%) reported that alcohol had precipitated their treatment entry whereas 30.3% indicated that crack use had precipitated theirs. Many WASIS patients (69.5%) reported prior treatment for addictions. Aside from a somewhat smaller proportion of African American subjects, the characteristics
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Table 1 Number and percentage of patients with self-reported and/or health care professional-indicated need for comprehensive services at initial assessment (N = 1,709) Patient
Advisory legal Basic needs Child care Educational Family Housing Medical Mental health Transportation Vocational
Professional
Patient + Professional
n
%
n
%
n
%
1,643 638 57 363 1,127 339 282 337 104 74
95.7 37.2 3.3 21.2 65.7 19.8 16.4 19.6 6.1 4.3
1 8 6 0 4 8 7 4 12 6
0.1 0.5 0.3 0.0 0.2 0.5 0.4 0.2 0.7 0.3
22 39 2 2 40 21 11 22 5 0
1.3 2.3 0.1 0.1 2.3 1.2 0.6 1.3 0.3 0.0
of the WASIS sample were comparable with those of the DATOS outpatients (Hubbard et al., 1997). 2.2. Measures Subjects were asked about recent (i.e., 30 days before entering treatment) receipt of comprehensive services at the baseline assessment. At follow-up, they were asked if they had received any of 10 wrap-around services between baseline and the follow-up interview. The services studied included the following: !
!
!
!
!
!
!
Advisory legal services–services addressing the need for legal representation in criminal or civil proceedings, advocacy before judges or probation/parole officers on treatment-related matters, or assistance in obtaining/enforcing restraining orders. Basic needs services–services addressing patients’ needs for food, clothing, and money for incidentals, utilities, or dire environmental needs (e.g., lack of windows and pest control). Child care services–care for patients’ dependent children while they attended addiction treatment or received other social or medical services. Educational services–assistance in obtaining new credentials or skills to enhance employability and/or psychosocial functioning. Family services–services for patients and family members addressing domestic violence, significant dysfunction, or medical/behavioral health issues among family members. Housing services–services addressing housing needs, including emergency shelter or temporary housing, placement in a permanent residence, or provision of first month’s rent. Medical services–onsite, clinic/hospital, or homebased services addressing medical needs, including primary, secondary, or tertiary medical care, not including diagnostic services.
!
! !
Mental health services–services addressing mental health needs unrelated to addiction, usually including provision of mental health treatment onsite, at a clinic/hospital, or at home. Transportation services–transportation to addiction treatment or social or medical services. Vocational services–services helping patients develop job skills and secure employment.
The baseline interview also captured needs for each cited type of comprehensive service. The WASIS assessed needs in three ways: First, patients were asked several items regarding whether they felt that they needed any of the said types of services in the past 30 days. Subjects were also asked whether a health care professional had recommended that they use any of the said types of services in this time interval. (A health care professional is defined as any clinical staff person in a medical, mental health, or addiction treatment organization.) Finally, items in the assessments allowed the WASIS to determine objectively whether a patient needed educational, housing, medical, mental health, transportation, or vocational services in the prior 30 days. (Because not all service needs were assessed objectively, these results are not discussed in detail.) 2.3. Data analysis We compiled basic descriptive information on selfreported and professionally indicated needs for each type of service at the baseline assessment and receipt of each type of service at the 3-month assessment. These provided unadjusted rates at which patients needed and received each type of service.
3. Results As depicted in Table 1, there was a significant variation in rates of comprehensive service needs, both across service types and between different indicators of needs. Nearly every patient in the WASIS reported a need for advisory legal services at baseline (95.7%), and a considerable number of patients reported a need for family (65.7%) and basic needs (37.2%) services. Approximately 20% of patients reported a need for educational, housing, medical, and mental health services; roughly 5% reported a need for other services. Very few patients reported that a professional had indicated that they needed any wrap-around service. In addition, few patients had both self-report and professionally reported needs for any type of service. The most striking data, however, are the rates of comprehensive service receipt reported at the 3-month assessment (see Table 2). In spite of very high levels of needs at least one of the services studied, rates of reported receipt were extremely low. For example, although more than 1,600 patients reported needing advisory legal services
J.L. Pringle et al. / Journal of Substance Abuse Treatment 30 (2006) 183–189 Table 2 Number and percentage of patients with reported receipt of comprehensive services at follow-up, overall and by self-reported/professional-indicated need at baseline
Advisory legal Basic needs Child care Educational Family Housing Medical Mental health Transportation Vocational
Three-month receipt (overall)a
Three-month Receipt (by baseline need)b
n (%)
Patient n (%)
Professional n (%)
Patient + professional n (%)
6 30 3 43 23 22 15 39 40 23
6 23 3 17 19 15 1 3 1 0
0 0 0 0 0 0 1 2 3 0
0 7 0 0 4 3 0 0 0 0
(0.6) (7.9) (7.1) (7.2) (3.2) (7.8) (2.6) (5.3) (6.7) (3.1)
(0.6) (6.6) (8.3) (7.7) (2.8) (7.8) (0.6) (1.5) (1.6) (0.0)
(0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (25.0) (50.0) (37.5) (0.0)
(0.0) (26.9) (0.0) (0.0) (17.4) (23.1) (0.0) (0.0) (0.0) (0.0)
a Percentages reported refer to the number of patients who received each service (of the number with any baseline indicator of need for the service). Subjects who reported a need at baseline but did not complete the follow-up assessment were excluded. b Percentages reported refer to the number of subjects in each need category who received each service (of the total number who reported the need indicator at baseline). Subjects who reported a need at baseline but did not complete the follow-up assessment were excluded.
at baseline, only 6 reported receiving them at 3 months. Similarly, although more than 1,000 patients were objectively determined to need transportation to treatment or other services (not shown), only 28 reported receiving transportation services at 3 months. Less than 8% of patients who needed any comprehensive service had received it by the 3-month follow-up. With the exception of child care, the same pattern was found for every other type of service studied in the WASIS: hundreds of patients reporting need for a service but less than 50 reporting subsequently receiving it. Although the numbers are extremely small, the proportions of patients who received services after a health care professional indicated that they needed them were noticeably higher than the corresponding proportions associated with self-reported need.
4. Discussion This article examined unmet needs for comprehensive services among WASIS subjects, a large sample of addiction treatment outpatients in western Pennsylvania. The goal of this article was to identify the rates at which specific types of wrap-around services were needed and received during treatment. This study made use of multiple indicators of comprehensive service needs and examined service receipt 3 months after the subjects’ treatment entry. The most striking pattern evidenced in the WASIS is that comprehensive service provision was extremely rare, regardless of service type, in spite of very high levels of reported needs for almost every service studied. As Table 2 shows,
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rates of receipt of needed services by the 3-month follow-up did not exceed 8% for any type of service. These rates are noticeably lower than those reported in similar studies, including those of Etheridge et al. (1995) and Gerstein et al. (1997). Although information from the project counselor and program director questionnaires did not provide clues as to the program characteristics accounting for these levels of unmet needs, there are many possible explanations for this. The WASIS’s ability to triangulate multiple reports of service needs may have led to a greater proportion of patients being identified with comprehensive service needs, which would make the proportion of patients with unmet needs appear higher. Second, it is possible that health care policies and cost containment practices in the WASIS region led to lower rates of wrap-around service provision, meaning that such effects would not be immediately noticeable in the two earlier studies, which featured national samples with presumably greater diversity in health policies and managed care penetration. Third, these rates of service receipt may reflect the organizational and geographical characteristics of the participating treatment programs; that is, none of the participating sites was affiliated with larger medical centers or health systems (and thus able to use the services provided or the community relationships cultivated by that organization), and more were located in rural areas with considerable distance between providers and lack of some services altogether (Etheridge, 2000). Moreover, subjects reported needing services for psychosocial troubles (i.e., advisory legal, basic needs, and family services) much more often than they reported needing health services (i.e., medical and mental health services). Relatively few patients reported a need for services thought to enable participation in treatment (i.e., child care and transportation). This suggests that addiction-related psychosocial problems may motivate many patients to enter treatment and provides additional support for comprehensive service provision insofar as the resolution of these psychosocial problems may also be critical to treatment retention. There were also interesting discrepancies between need indicators, as depicted in Table 1. Almost no patient reported that a health care professional had recommended any specific wrap-around service. Although this may have resulted from using a single-variable measure of professionally indicated need, it is nevertheless consistent with the findings of D’Aunno and Vaughn (1995) and Etheridge, Hubbard, Anderson, Craddock, and Flynn (1997), who have indicated that comprehensive service provision has decreased as treatment professionals have responded to declining resources for these services by focusing their work on core components of treatment. Although the unvalidated patient report is an imperfect proxy for professional determination of need and program staff may have identified far more needs than are suggested here, the poor patient recall of these assessments may mean that program staff did not adequately emphasize the importance of addressing psychosocial problems.
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The limitations of other large observational studies (e.g., subject attrition, missing data, and reliance on subject self-report) apply to the WASIS and should be considered in evaluating these results. The follow-up rates observed in this study, although lower than hoped for, are nonetheless comparable with those currently being achieved in other large survey efforts (Emptage, unpublished manuscript, 2005) and reflect the difficulty of conducting a community-based study on a population with significant psychosocial difficulties and unstable living arrangements. The rarity of service provision confounded our attempts to pursue multivariate analyses of subject characteristics associated with service receipt, the relationship between reported need and service provision, and the relationship between met need and subsequent functional improvement. How future research on the role of ancillary services in addiction treatment may address this problem is unclear; the results of this and other observational studies suggest that wrap-around service receipt is a relatively rare event in real world treatment, and recent research has shown that unforeseen methodological difficulties can occur when attempting to match patients to multidimensional treatments in an experimental design (Project MATCH Research Group, 1997; see Heather, 1999). Another important limitation of the WASIS was our inability to determine why patients failed to receive services. Clearly, if inadequate attention to patients’ needs at a treatment program, policies affecting their eligibility for particular services, or patients themselves are not following up referrals is responsible for unmet service needs, then different strategies at program and/or administrative levels would be warranted. Future studies should explore ways of assessing specific reasons for any unmet service need. Furthermore, the generalizability of these findings may be questionable. The WASIS sample included few patients of Asian or Latino descent, and the study did not evaluate comprehensive service provision in more intensive or specialized (i.e., methadone) treatment settings. Moreover, as the study focused on a single region, the urban/rural characteristics of the region and the policy issues affecting treatment there may render the findings less applicable to outpatient treatment elsewhere. Nonetheless, the extremely high levels of unmet needs for comprehensive psychosocial and health services among outpatient addiction treatment patients in the WASIS should be cause for concern in the treatment community, insofar as such unmet needs are associated with poorer posttreatment outcomes and lower levels of treatment satisfaction (McLellan et al., 1994, 1982; Simpson et al., 1999). Unmet comprehensive service needs are a product of barriers that exist at several levels of the addiction treatment system. Ethnographic work conducted by the WASIS identified issues at the policy, local service system, program, and patient levels that impeded access to needed services (Etheridge, 2000). Future research must explore the contributions of these barriers (alone and in concert) in
impeding access to services among diverse groups of outpatient treatment clients. The findings presented here echo those of other large studies that have shown significant declines in comprehensive service provision over time and high levels of unmet needs for these services in addiction treatment populations. The extreme difficulties that the WASIS patients appear to have experienced in accessing wrap-around services point to a serious discrepancy between need for and availability of these services to addiction treatment patients. Insofar as unmet needs for these services have been shown to impede the effectiveness of addiction treatment, it is important for treatment professionals and policymakers to explore innovations and reforms aimed at reducing these needs.
Acknowledgments The WASIS was supported by CSAT Grant TI11296-03 to the St. Francis Medical Center. We thank Valerie Balavage, Cynthia Holland, Lois Edmondston, and Levent Kirisci for their work on the WASIS data.
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Unmet needs for comprehensive services in outpatient addiction treatment Janice L. Pringle, (Ph.D.)a,4, Nicholas P. Emptage, (M.A.)b, Robert L. Hubbard, (Ph.D.)c a
Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 449 Falk Clinic, Pittsburgh, PA 15213, USA b Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA c Institute for Community-Based Research, National Development and Research Institutes, Inc, Raleigh, NC, USA Received 22 March 2005; received in revised form 24 October 2005; accepted 23 November 2005
Abstract Many addiction treatment patients suffer from health and psychosocial problems in addition to substance misuse at the time of their treatment entry. Outpatient treatment programs have attempted to address these problems by providing or facilitating access to comprehensive health and social services. Nevertheless, previous research have suggested high levels of unmet needs for these services in the addiction treatment population. Using data from a large study on community-based outpatient addiction treatment, this article provides additional information on levels of unmet service needs and the relationship between need and receipt of services during treatment. Our results suggest extremely high levels of unmet needs for a wide variety of health and psychosocial services. Specifically, the data suggest that unmet service needs may be far more prevalent than previous estimates and that addiction treatment populations in rural areas may be particularly disadvantaged. D 2006 Elsevier Inc. All rights reserved. Keywords: Need; Outpatient; Psychosocial; Services; Unmet
1. Introduction Addiction treatment patients often suffer from secondary health and psychosocial problems at the time of their treatment entry. A large study on patients entering outpatient programs identified numerous co-occurring issues, including lifetime depression (53% of patients), violence issues (35%), prior mental health treatment (28%), unemployment and financial problems (41%), deficits in vocational skills (27%), unstable housing or homelessness (11%), and low educational achievement (an average education of 11 years), as well as substantial family problems, involvement in illegal activities, and limited social support (McLellan, Hagan, Meyers, Randall, & Durell, 1997). These problems are often closely related to patients’ alcohol or drug use behaviors and have been shown repeatedly to have significant negative impacts on treatment retention and subsequent outcomes (McLellan et al., 1994; Simpson, Joe, 4 Corresponding author. Tel.: +1 412 648 8560; fax: +1 412 648 9253. E-mail address: [email protected] (J.L. Pringle). 0740-5472/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jsat.2005.11.006
Fletcher, Hubbard, & Anglin, 1999). Drug use and alcohol use combined with psychiatric illness have been associated with higher health care costs (Westermeyer, Eames, & Nugent, 1998) and with violent behaviors leading to involvement with courts and jails (Ford, Snowden, & Walser, 1991). Analyses from the Drug Abuse Treatment Outcome Study (DATOS) found that, among cocaine-using patients across three modalities of treatment, those with the most severe problems (i.e., substance dependence or polysubstance use, psychiatric illness and social difficulties, criminal justice involvement, income and employment problems, and low social support) had the highest rates of relapse in the year after treatment (Simpson et al., 1999). Numerous studies examining family, marital, and employment issues among addiction treatment populations have found that such problems are associated with poor treatment outcomes (Hubbard et al., 1989; McLellan, Luborsky, O’Brien, Woody, & Druley, 1982; Moos, Finney, & Cronkite, 1990). Given the powerful negative impact of co-occurring problems shown by research and the additional evidence
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showing a sharp increase in the prevalence of such problems among those entering addiction treatment (Gerstein & Harwood, 1990; McLellan et al., 1997; Pickens & Fletcher, 1991), treatment providers have attempted to address health and psychosocial issues through provision of so-called wrap-around (or comprehensive) services. Larger treatment programs or those embedded within hospital systems are often able to offer medical or mental health services to patients onsite and may have ready access to other services via case management. In the case of more bdistalQ needs, however, such as housing, legal services, transportation, and vocational services, and in the case of smaller provider organizations, appropriate wrap-around services are frequently not available onsite and are typically accessed by referral to health care providers or social service organizations in the community (Ashery, 1992). Comprehensive service use is often not reimbursed as a component of patient care, and payment for these services is often complicated by institutional boundaries and separate state and federal funding sources that serve separate populations (Wrap-Around Services Impact Study [WASIS] Research Group, 2000). Research on the clinical impacts of comprehensive service provision to addiction treatment patients has generally found service provision to predict superior outcomes, although evidence to the contrary does exist (Fiorentine, 1998; McLellan et al., 1994). Several studies by McLellan et al. have found a positive relationship between enhanced access to psychosocial services during treatment and measures of treatment retention and outcome (McLellan, Arndt, Metzger, Woody, & O’Brien, 1993; McLellan et al., 1998). Hser, Polinsky, Maglione, and Anglin (1999) found superior outcomes and longer retention among patients who were matched to comprehensive services based on needs reported at treatment entry; meeting patients’ needs for vocational training, child care, housing, and transportation was shown to be especially beneficial. Most recently, the Center for Substance Abuse Treatment (CSAT) sponsored a large multisite evaluation of wraparound service provision in outpatient addiction treatment. This project, the WASIS, found that patient receipt of child care, basic needs services, educational training, family counseling, and medical and mental health services was associated with improvements in treatment retention and numerous indicators of posttreatment outcome (Pringle et al., 2002). Nevertheless, research suggests considerable unmet needs for these services. Analyses of patient-reported need and service provision across two national studies suggested that the number and variety of comprehensive services received by patients fell dramatically between 1979 and 1981 (during data collection for the Treatment Outcome Prospective Study) and between 1991 and 1993 (during data collection for the DATOS). At the earlier time point, the proportion of outpatients not receiving needed services was lower than 10% for every service category except for
employment and financial counseling (both roughly 20%). At the time of the DATOS, however, the proportion of patients reporting unmet needs in the former categories had risen to greater than 30% (with ~ 60% of those needing psychological and family counseling not receiving these services) whereas approximately 50% of patients needing employment and financial services also did not receive them (Etheridge, Craddock, Dunteman, & Hubbard, 1995). Significant decreases in service provision and substantial unmet needs for financial, mental health, vocational, and medical services were also found by D’Aunno and Vaughn (1995). In the CSAT National Treatment Improvement Evaluation Study (NTIES), half of those needing medical services or interpersonal skills training did not receive them whereas two thirds of those needing mental health treatment, family services, or parenting skills training did not receive them. Of the NTIES patients needing educational, vocational, or legal services, 76% – 89% did not receive them (Gerstein et al., 1997). More recent data have shown that provision of comprehensive services is very uncommon, particularly in outpatient programs, although patients in greater need may be more likely to receive medical, mental health, and family services (Asche & Harrison, 2002). In this study, we made use of the WASIS sample to examine the issue of unmet needs for comprehensive services in outpatient addiction treatment. In the WASIS, these services were defined as health care and social services that, in conjunction with addiction treatment, were intended to improve patient access to and retention in treatment and/or to comprehensively address the needs of patients during treatment. Given such a broad definition, 10 service types were included in the study. Moreover, the WASIS included multiple indicators of service need—an advance on previous research. In this article, we present descriptive statistics on the proportion of study patients needing and receiving each type of service during treatment.
2. Materials and methods 2.1. Study design and subject sample Data for this study came from the WASIS, which was sponsored by the CSAT. Between 1996 and 1999, this study collected data from patients in nine outpatient addiction treatment programs in western Pennsylvania. Given the population studied and the study aims, the WASIS used an observational prospective cohort design. We believed that the assignment of patients to service and no-service conditions would be prohibitively difficult from both logistical and ethical standpoints and would set up a scenario with poor external validity. Thus, this study observed a cohort of treatment patients prospectively through a specific episode of care.
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Assessments were conducted with participants shortly after their entry into treatment and at 3 months after their baseline assessment (results from the DATOS [refer to the work of Hubbard, Craddock, Flynn, Anderson, & Etheridge, 1997] suggested that this follow-up interval would characterize the period that study subjects spent in outpatient treatment with reasonable accuracy). Upon entering treatment at a participating program, patients meeting basic eligibility criteria (i.e., being between 18 and 65 years old and not having significant cognitive or psychiatric impairments) were given the option of participating voluntarily in the WASIS by their treatment counselor. Those who agreed to participate filled out a standard consent-to-contact form, which was then forwarded to a WASIS field interviewer, who made an appointment with each patient to conduct the baseline assessment. Patients who declined to participate were asked to fill up a brief form providing basic descriptive information. We estimated that 0.5% of adult patients were excluded from participation owing to cognitive or psychiatric conditions whereas approximately 19% of eligible subjects declined to participate, most often caused by their concerns about confidentiality or the time needed to complete assessments. Those who chose to participate completed informed consent documentation with the field interviewer before beginning the initial assessment. Participants also filled out locator forms to facilitate recontact for follow-up assessments. Participants received a $25 gift certificate for a local restaurant or market for each WASIS assessment they completed. All procedures were approved by the institutional review board of the St. Francis Medical Center (Pittsburgh, PA, USA). Additional details regarding the WASIS methodology are provided in the work of Pringle et al. (2002). The WASIS data collection instruments were based largely on those used in the DATOS (refer to the work of Flynn, Craddock, Hubbard, Anderson, & Etheridge, 1997) and the NTIES (refer to the work of Gerstein et al., 1997). The assessments used lengthy structured protocols and required approximately 90 minutes to complete. These assessments captured information on basic descriptive characteristics, alcohol and drug use, mental health status, history of mental health or addiction treatment, criminal activity and criminal justice status, socioeconomic status, health status and health care use, need for and receipt of psychosocial services, social support, and spirituality. Patient chart abstraction instruments similar to those used in the DATOS were used to verify information regarding the patients’ index treatment episodes. The WASIS also gathered program data from counselors and program directors using two self-report questionnaire forms that asked about characteristics of the study sites and changes in these characteristics during the study period. The study sites were nine outpatient addiction treatment programs located in urban and rural areas in western Pennsylvania. (Because of the small number of study sites, a crude definition of urban/rural status was used: the four
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programs [with 9 participating delivery units] located in the cities of Pittsburgh and Erie were designated as urban whereas the five programs [with 12 participating delivery units] located in smaller communities far from these cities were designated as rural.) These programs were publicly supported and served large numbers of Medicaid patients. In Pennsylvania, outpatient care is characterized by three distinct modalities: traditional outpatient treatment, intensive outpatient treatment, and partial hospitalization (for additional details as to the types of services implied by each level of care, refer to Pennsylvania Department of Health, 1999). Some WASIS sites offered only one of these modalities; others offered two or three of these. A total of 21 units of treatment (across all levels of outpatient care) across the nine programs participated in the WASIS. Three of the urban sites were able to provide all 10 wrap-around services, if not onsite then via referral; the fourth urban program provided all but transportation services onsite and all but medical services through referral. Among the rural programs, none was able to provide all services through referral networks, although two were able to provide all services onsite. No rural program was able to refer for medical services. Two of the rural programs provided no service onsite and had no information on referrals. There were 1,709 patients included in the WASIS baseline sample, with 1,003 patients followed up at the 3-month assessment. Of the baseline sample, 848 (49.6%) were from urban sites and 861 (50.4%) were from rural sites (incomplete data made it impossible to capture urban/rural distinctions at the service delivery unit level). After accounting for numerous contingencies, the follow-up rate at 3 months was 65%. The follow-up sample appears to be sufficiently representative of the baseline sample on variables closely related to addiction severity and service needs, including sociodemographic characteristics, employment, and criminal justice status (refer to the work of Pringle et al., 2002 for additional details). The WASIS subjects were primarily male (63.5%), aged between 30 and 39 years (43.5%), and of European or Caucasian descent (71.4%). Most had attended at least one grade of high school (74.8%) whereas 21.0% had attended school beyond the 12th grade. Approximately 64% (63.9%) were unemployed when they entered the index treatment episode. Approximately 57% (57.2%) reported being involved with the criminal justice system (e.g., probation, parole, trial pending, and recent arrest) at the baseline assessment. Approximately 40% (39.9%) had either one or two children. Most patients reported lifetime use of beer (91.6%), liquor (61.8%), and marijuana (81.0%). In addition, 47% reported lifetime use of cocaine and 46.2% reported lifetime use of crack. Approximately 59% (59.1%) reported that alcohol had precipitated their treatment entry whereas 30.3% indicated that crack use had precipitated theirs. Many WASIS patients (69.5%) reported prior treatment for addictions. Aside from a somewhat smaller proportion of African American subjects, the characteristics
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Table 1 Number and percentage of patients with self-reported and/or health care professional-indicated need for comprehensive services at initial assessment (N = 1,709) Patient
Advisory legal Basic needs Child care Educational Family Housing Medical Mental health Transportation Vocational
Professional
Patient + Professional
n
%
n
%
n
%
1,643 638 57 363 1,127 339 282 337 104 74
95.7 37.2 3.3 21.2 65.7 19.8 16.4 19.6 6.1 4.3
1 8 6 0 4 8 7 4 12 6
0.1 0.5 0.3 0.0 0.2 0.5 0.4 0.2 0.7 0.3
22 39 2 2 40 21 11 22 5 0
1.3 2.3 0.1 0.1 2.3 1.2 0.6 1.3 0.3 0.0
of the WASIS sample were comparable with those of the DATOS outpatients (Hubbard et al., 1997). 2.2. Measures Subjects were asked about recent (i.e., 30 days before entering treatment) receipt of comprehensive services at the baseline assessment. At follow-up, they were asked if they had received any of 10 wrap-around services between baseline and the follow-up interview. The services studied included the following: !
!
!
!
!
!
!
Advisory legal services–services addressing the need for legal representation in criminal or civil proceedings, advocacy before judges or probation/parole officers on treatment-related matters, or assistance in obtaining/enforcing restraining orders. Basic needs services–services addressing patients’ needs for food, clothing, and money for incidentals, utilities, or dire environmental needs (e.g., lack of windows and pest control). Child care services–care for patients’ dependent children while they attended addiction treatment or received other social or medical services. Educational services–assistance in obtaining new credentials or skills to enhance employability and/or psychosocial functioning. Family services–services for patients and family members addressing domestic violence, significant dysfunction, or medical/behavioral health issues among family members. Housing services–services addressing housing needs, including emergency shelter or temporary housing, placement in a permanent residence, or provision of first month’s rent. Medical services–onsite, clinic/hospital, or homebased services addressing medical needs, including primary, secondary, or tertiary medical care, not including diagnostic services.
!
! !
Mental health services–services addressing mental health needs unrelated to addiction, usually including provision of mental health treatment onsite, at a clinic/hospital, or at home. Transportation services–transportation to addiction treatment or social or medical services. Vocational services–services helping patients develop job skills and secure employment.
The baseline interview also captured needs for each cited type of comprehensive service. The WASIS assessed needs in three ways: First, patients were asked several items regarding whether they felt that they needed any of the said types of services in the past 30 days. Subjects were also asked whether a health care professional had recommended that they use any of the said types of services in this time interval. (A health care professional is defined as any clinical staff person in a medical, mental health, or addiction treatment organization.) Finally, items in the assessments allowed the WASIS to determine objectively whether a patient needed educational, housing, medical, mental health, transportation, or vocational services in the prior 30 days. (Because not all service needs were assessed objectively, these results are not discussed in detail.) 2.3. Data analysis We compiled basic descriptive information on selfreported and professionally indicated needs for each type of service at the baseline assessment and receipt of each type of service at the 3-month assessment. These provided unadjusted rates at which patients needed and received each type of service.
3. Results As depicted in Table 1, there was a significant variation in rates of comprehensive service needs, both across service types and between different indicators of needs. Nearly every patient in the WASIS reported a need for advisory legal services at baseline (95.7%), and a considerable number of patients reported a need for family (65.7%) and basic needs (37.2%) services. Approximately 20% of patients reported a need for educational, housing, medical, and mental health services; roughly 5% reported a need for other services. Very few patients reported that a professional had indicated that they needed any wrap-around service. In addition, few patients had both self-report and professionally reported needs for any type of service. The most striking data, however, are the rates of comprehensive service receipt reported at the 3-month assessment (see Table 2). In spite of very high levels of needs at least one of the services studied, rates of reported receipt were extremely low. For example, although more than 1,600 patients reported needing advisory legal services
J.L. Pringle et al. / Journal of Substance Abuse Treatment 30 (2006) 183–189 Table 2 Number and percentage of patients with reported receipt of comprehensive services at follow-up, overall and by self-reported/professional-indicated need at baseline
Advisory legal Basic needs Child care Educational Family Housing Medical Mental health Transportation Vocational
Three-month receipt (overall)a
Three-month Receipt (by baseline need)b
n (%)
Patient n (%)
Professional n (%)
Patient + professional n (%)
6 30 3 43 23 22 15 39 40 23
6 23 3 17 19 15 1 3 1 0
0 0 0 0 0 0 1 2 3 0
0 7 0 0 4 3 0 0 0 0
(0.6) (7.9) (7.1) (7.2) (3.2) (7.8) (2.6) (5.3) (6.7) (3.1)
(0.6) (6.6) (8.3) (7.7) (2.8) (7.8) (0.6) (1.5) (1.6) (0.0)
(0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (25.0) (50.0) (37.5) (0.0)
(0.0) (26.9) (0.0) (0.0) (17.4) (23.1) (0.0) (0.0) (0.0) (0.0)
a Percentages reported refer to the number of patients who received each service (of the number with any baseline indicator of need for the service). Subjects who reported a need at baseline but did not complete the follow-up assessment were excluded. b Percentages reported refer to the number of subjects in each need category who received each service (of the total number who reported the need indicator at baseline). Subjects who reported a need at baseline but did not complete the follow-up assessment were excluded.
at baseline, only 6 reported receiving them at 3 months. Similarly, although more than 1,000 patients were objectively determined to need transportation to treatment or other services (not shown), only 28 reported receiving transportation services at 3 months. Less than 8% of patients who needed any comprehensive service had received it by the 3-month follow-up. With the exception of child care, the same pattern was found for every other type of service studied in the WASIS: hundreds of patients reporting need for a service but less than 50 reporting subsequently receiving it. Although the numbers are extremely small, the proportions of patients who received services after a health care professional indicated that they needed them were noticeably higher than the corresponding proportions associated with self-reported need.
4. Discussion This article examined unmet needs for comprehensive services among WASIS subjects, a large sample of addiction treatment outpatients in western Pennsylvania. The goal of this article was to identify the rates at which specific types of wrap-around services were needed and received during treatment. This study made use of multiple indicators of comprehensive service needs and examined service receipt 3 months after the subjects’ treatment entry. The most striking pattern evidenced in the WASIS is that comprehensive service provision was extremely rare, regardless of service type, in spite of very high levels of reported needs for almost every service studied. As Table 2 shows,
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rates of receipt of needed services by the 3-month follow-up did not exceed 8% for any type of service. These rates are noticeably lower than those reported in similar studies, including those of Etheridge et al. (1995) and Gerstein et al. (1997). Although information from the project counselor and program director questionnaires did not provide clues as to the program characteristics accounting for these levels of unmet needs, there are many possible explanations for this. The WASIS’s ability to triangulate multiple reports of service needs may have led to a greater proportion of patients being identified with comprehensive service needs, which would make the proportion of patients with unmet needs appear higher. Second, it is possible that health care policies and cost containment practices in the WASIS region led to lower rates of wrap-around service provision, meaning that such effects would not be immediately noticeable in the two earlier studies, which featured national samples with presumably greater diversity in health policies and managed care penetration. Third, these rates of service receipt may reflect the organizational and geographical characteristics of the participating treatment programs; that is, none of the participating sites was affiliated with larger medical centers or health systems (and thus able to use the services provided or the community relationships cultivated by that organization), and more were located in rural areas with considerable distance between providers and lack of some services altogether (Etheridge, 2000). Moreover, subjects reported needing services for psychosocial troubles (i.e., advisory legal, basic needs, and family services) much more often than they reported needing health services (i.e., medical and mental health services). Relatively few patients reported a need for services thought to enable participation in treatment (i.e., child care and transportation). This suggests that addiction-related psychosocial problems may motivate many patients to enter treatment and provides additional support for comprehensive service provision insofar as the resolution of these psychosocial problems may also be critical to treatment retention. There were also interesting discrepancies between need indicators, as depicted in Table 1. Almost no patient reported that a health care professional had recommended any specific wrap-around service. Although this may have resulted from using a single-variable measure of professionally indicated need, it is nevertheless consistent with the findings of D’Aunno and Vaughn (1995) and Etheridge, Hubbard, Anderson, Craddock, and Flynn (1997), who have indicated that comprehensive service provision has decreased as treatment professionals have responded to declining resources for these services by focusing their work on core components of treatment. Although the unvalidated patient report is an imperfect proxy for professional determination of need and program staff may have identified far more needs than are suggested here, the poor patient recall of these assessments may mean that program staff did not adequately emphasize the importance of addressing psychosocial problems.
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The limitations of other large observational studies (e.g., subject attrition, missing data, and reliance on subject self-report) apply to the WASIS and should be considered in evaluating these results. The follow-up rates observed in this study, although lower than hoped for, are nonetheless comparable with those currently being achieved in other large survey efforts (Emptage, unpublished manuscript, 2005) and reflect the difficulty of conducting a community-based study on a population with significant psychosocial difficulties and unstable living arrangements. The rarity of service provision confounded our attempts to pursue multivariate analyses of subject characteristics associated with service receipt, the relationship between reported need and service provision, and the relationship between met need and subsequent functional improvement. How future research on the role of ancillary services in addiction treatment may address this problem is unclear; the results of this and other observational studies suggest that wrap-around service receipt is a relatively rare event in real world treatment, and recent research has shown that unforeseen methodological difficulties can occur when attempting to match patients to multidimensional treatments in an experimental design (Project MATCH Research Group, 1997; see Heather, 1999). Another important limitation of the WASIS was our inability to determine why patients failed to receive services. Clearly, if inadequate attention to patients’ needs at a treatment program, policies affecting their eligibility for particular services, or patients themselves are not following up referrals is responsible for unmet service needs, then different strategies at program and/or administrative levels would be warranted. Future studies should explore ways of assessing specific reasons for any unmet service need. Furthermore, the generalizability of these findings may be questionable. The WASIS sample included few patients of Asian or Latino descent, and the study did not evaluate comprehensive service provision in more intensive or specialized (i.e., methadone) treatment settings. Moreover, as the study focused on a single region, the urban/rural characteristics of the region and the policy issues affecting treatment there may render the findings less applicable to outpatient treatment elsewhere. Nonetheless, the extremely high levels of unmet needs for comprehensive psychosocial and health services among outpatient addiction treatment patients in the WASIS should be cause for concern in the treatment community, insofar as such unmet needs are associated with poorer posttreatment outcomes and lower levels of treatment satisfaction (McLellan et al., 1994, 1982; Simpson et al., 1999). Unmet comprehensive service needs are a product of barriers that exist at several levels of the addiction treatment system. Ethnographic work conducted by the WASIS identified issues at the policy, local service system, program, and patient levels that impeded access to needed services (Etheridge, 2000). Future research must explore the contributions of these barriers (alone and in concert) in
impeding access to services among diverse groups of outpatient treatment clients. The findings presented here echo those of other large studies that have shown significant declines in comprehensive service provision over time and high levels of unmet needs for these services in addiction treatment populations. The extreme difficulties that the WASIS patients appear to have experienced in accessing wrap-around services point to a serious discrepancy between need for and availability of these services to addiction treatment patients. Insofar as unmet needs for these services have been shown to impede the effectiveness of addiction treatment, it is important for treatment professionals and policymakers to explore innovations and reforms aimed at reducing these needs.
Acknowledgments The WASIS was supported by CSAT Grant TI11296-03 to the St. Francis Medical Center. We thank Valerie Balavage, Cynthia Holland, Lois Edmondston, and Levent Kirisci for their work on the WASIS data.
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