INTRODUCTION
One of the major challenge facing the field of substance rough up treatment is the coordination of community-based services for clients with cooccurring mental or physical strength disorders (1). Given their multiple health desires, these clients often are required to involve yourself in in two or more specialized programs that involve providers in areas such as mental strength and primary care. As a result of this specialization, heaps policymakers and researchers have raise the concern that the substance abuse treatment system may be too fragmented to deliver forceful care (2, 3).
The fragmentation of community-based substance mishandle treatment became an issue within the 1980s when the plight of persons disabled next to serious cooccurring disorders was familiar as a burgeoning social problem (4). The issue has intensified in recent years as manage care have assumed a stronger presence in behavioral strength care and as an increasing numbers of individuals with substance name-calling, mental illness, and chronic condition problems such as HIV/AIDS have begin to be treated in outpatient settings (1). Treatment of these multineed individuals constitutes a major frustration among outpatient substance knock about treatment providers because many of these folks are revolving door clients who enter treatment, often discontinue impulsive, relapse, and recycle anew (1). Some researchers have suggested that within order to exhaust recidivism among these substance abuse clients, multiple types of treatment must be provided concurrently through better linkage of exactness between outpatient substance abuse treatment agencies (OSATs) and other service providers (1, 5-9).
Indeed, empirical evidence supports the worth of concurrent treatment. Joe and colleagues (10) showed that methadone clients had less relapse to opiate use when they received ancillary services, extremely mental health trouble. McLellan and associates (11) found similar results in a study of 649 opiate, alcohol, and cocaine patients. An evaluation of a combined substance verbal abuse and mental health skin management program also found a 31% downgrading in the number of days homeless for dually diagnosed people as compared to 6% in a typical service control group (12). More lately, Jerrell, Wilson, and Hiller (13) showed in a demonstration project that clients reception services through a well-implemented dual disorder treatment program functioned better in the community than clients not acceptance services from such a program.
These research findings notwithstanding, linking services from different health prudence sectors is considered problematic and is much understudied surrounded by substance abuse treatment (1). In individual, little is known more or less the pattern of service linkage that OSATs maintain beside mental health and primary nurture agencies. This study is intended to begin bridging this aperture by conducting an in-depth analysis of information collected from a national sample of OSATs that participate in the 1999 National Drug Abuse Treatment System Study. In addendum, it analyzes how the service linkages of OSATs are related to their organizational structure, client mix, and manage care taking part. Finally, it examines barriers to service linkage as perceived by OSAT managers.
Results of the study contribute to the literature and practice surrounded by the following ways. First, they provide, to the best of our knowledge, the first empirical assessment in relation to the extent of linkages that OSATs establish beside mental health and primary assistance providers. The information is essential for a clear understanding of how individuals beside substance abuse problems are treated surrounded by community-based outpatient settings, thereby verifying the point of fragmentation in substance mishandle treatment. Second, the study takes a nuanced belief and examines whether organizational and client factors are associated next to service linkages. It identify conditions under which the establishment of service linkage may be promoted or inhibited. Third, for health plans and policymakers concerned nearly fragmentation of the substance abuse treatment system, kind the barriers to service linkage from the OSATs' perspective may suggest useful intervention strategies.
METHODS
Study Design and Sample
The study be part of a research hard work to understand the network activities of outpatient substance swearing treatment units (OSATs) surrounded by treating multineed substance abuse clients. OSATs be defined as health effort facilities next to resources dedicated primarily (>50%) to treating individuals beside substance abuse problems, including alcohol and other drugs, on a nonresidential idea (14-18).
The OSATs included in this study be a stratified random taster selected from the National Drug Abuse Treatment System Study (NDATSS) conducted surrounded by 1999. The NDATSS contributed a sampling frame of 518 outpatient nonmethadone treatment units that have complete information on managed attention arrangements and clients. To ensure adequate variability in manage care association, which we anticipated might influence significantly the networking actions of OSATs, we stratified and sampled OSATs base on their size and extent of participation surrounded by managed strictness programs in 1999, categorized as "abundantly," "some," and "none." Creation of these categories took into picture the impact of managed vigilance on an OSAT's sources of funding and clients served. If an OSAT reported no involvement with manage care or if it have fewer than 10 clients, it be placed in the "none" category. The remaining unit were categorized base on the percentage of clients covered under manage care arrangements (both private and public). OSATs near 25% of clients or fewer covered below managed attention to detail arrangements were labeled as have "some" managed support involvement. Those with more than 25% of clients covered by manage care arrangements be labeled as having "a lot" of manage care involvement.
A total of 62 OSATs be selected and interviewed. The declaration to limit the taste to a small fraction of the total programs in NDATSS be based on practical concerns of research budget and survey effecting. The research project involved interviews with OSATs as in good health as mental health and primary trouble providers with which the OSATs be linked. It be anticipated that each OSAT might hold service linkages next to up to 6 care providers (3 surrounded by mental health and 3 within primary care). Thus a small increase in the number of OSATs sampled would significantly increase the number of organization that had to be interviewed.
Data Collection
The information collection occurred contained by 2001 using a telephone interview near a designated respondent at each OSAT. The respondent be either the component's director or an administrator/clinical supervisor who was in good health informed about the organizational structure and client services of the section. Based on a comparison of data from the 1990 NDATSS and the 1990 Drug Services Research Study, Friedmann and colleagues (19) showed that reports of unit-level administrator were a reliable source of information on OSATs' organizational features such as treatment volume and staffing.
Experienced interviewers, specifically trained in the rule of the survey, conducted the phone interviews. In addition, several steps be taken to ensure high part and validity of phone-survey information. First, the survey questionnaire was pretested next to a comparable sample of 10 OSATs and their nominated mental condition and primary care agencies that be not included in our study sample. Results and feedback from the pretest help to identify problems in the planned survey procedures, approaches, and interview content, and to refine question about how clients be obtained and referred between OSATs and other agencies. Second, prior to the phone interview, component directors were sent a missive explaining the study along with work sheets for their preparation of answers. Third, respondents be guaranteed confidentiality and feedback reports.
The interview gathered information give or take a few the unit's organizational setting, staffing, client mix, accreditation, revenue, manage care involvement, and services. Each respondent also be asked to name up to 3 primary thought organizations and up to 3 mental condition agencies that provided service to the OSAT's substance abuse clients, to describe the character of each of these service linkage (e.g., client referrals, information and resource sharing), and to indicate the barrier to working with mental strength and primary care agencies within general. The resulting background, therefore, described up to 6 interagency linkage in an OSAT's instant service network.
We chose to examine the service linkage with primary effort and mental health agencies for 3 reason. First, they served the most problematic clients of OSATs--that is, persons beside cooccurring mental or physical health problems--whose condition needs could be best met if their comorbidities be addressed concurrently. Second, these agencies be health related and be likely to be beneath the purview of managed supervision organizations. Third, developing and maintain the service linkages between OSATs and these agencies might be difficult (19). Thus, insight these important on the other hand potentially challenging relationships be critical. Setting 6 as the number of primary care and mental robustness agencies that an OSAT could nominate was base on our knowledge of OSAT's network activities and our experience within the pretest. Limiting the nominations also prevented unnecessarily overburdening the respondent and consequently helped ensure giant quality of the information reported.
Table 1 compares the organizational attributes and client mix of OSATs in the study token with those from the 1999 NDATSS. Thirty-nine percent of the OSATs in the study indication were freestanding; the remaining OSATs be part of a mental vigour center (26%), a multiunit substance abuse program (21%), or a hospital (14%). Most of the OSATs be private nonprofit (61.3%), 24.2% were for-profit and 14.5% public. The average number of full-time staff surrounded by OSATs was 24.9 and the average number of clients served within the past year be 915 (not reported in the table). In jargon of client mix, on average over 50% of clients served in the study's OSATs have dual diagnosis; of those clients, the majority either have mild mental health problems or have experience trauma such as physical or sexual abuse.
The study taste was similar to the NDATSS indication in vocabulary of organizational setting, ownership type, and client mix. Due to the stratified sampling used in the study and the positive correlation between managed attention involvement and organizational size, the study sample contained more larger OSATs and a smaller amount smaller OSATs (as indicated by the number of clients and full time staff) than the NDATSS sample overall. Thus, findings reported here article are generalizable to OSATs with a greater amount of managed consideration involvement, not to the NDATSS sample.
Measures
As mentioned above, the ID of service linkages be based on the designated OSAT respondent's report. Each respondent be asked to nominate up to 3 mental health and 3 primary exactness agencies that provided services to its substance abuse clients. To invasion the full impact of managed attention to detail, the survey included 4 questions to consider the OSAT's managed safekeeping involvement: "How many manage care arrangements does your element participate surrounded by (both private and public)?" "How many manage care contracts does your program enjoy?" "What percentage of your revenues come from managed diligence arrangements?" and "What percentage of your clients have services salaried for by managed diligence arrangements?" In addition, the survey included two question in relation to the perceived impact of manage care on service linkage: "As a result of managed meticulousness, has your program's relationship next to [the nominated organization] improved or deteriorated?" and "All things considered, [would you agree] that manage care have improved your program's skill to work with [the nominated organization]?"
The organizational attributes displayed in Table 1 be included as covariates in the analysis for service linkages between respectively OSAT and its nominated mental health and primary keeping agencies (20). The interview questions used to determine those covariates are available in the Appendix. To exhaust the small cell problem in the analysis and to conserve the statistical power for multivariate analysis, we collapsed some of the groupings presented in Table 1. Therefore, organizational setting referred to whether the OSAT be freestanding or was a subsidiary of a parent strength care union. Ownership type identified the for-profit versus nonprofit tax status of the OSAT. We also grouped the OSATs into 3 category based on the percentage of clients next to comorbidities--low (<25%), medium (25-60%), and high-ranking ([greater than or equal to] 60%). The groupings for the 2 indicators of OSATs' unit size--the number of FTE salaried staff (<10, 10-29, and [greater than or equal to] 30) and the number of clients served in the second year (<250, 250-599, >600)--remained the same.
Finally, respectively OSAT respondent was asked to assess the extent to which 17 specific financial and functioning conditions--including clients' financial ability, insurance reimbursement, and different program clientele--represented barrier to working with other agencies within meeting the strength needs of substance verbal abuse clients. Their assessment was reported base on a 5-point Likert scale range from "no extent" to "very great extent."
Analysis
Pearson correlation and chi-square analyses be first performed to assess the bivariate relationships of organizational attributes next to service linkages of OSATs. Based on these analyses, covariates near statistical significance at p < 0.30 were special for proportional odds logistic regression analysis to explain the service linkage of OSATs. Proportional odds logistic regression is a preferred analytic method for ordinal dependent variables (21).
The assessment of barrier to service linkages be based on the percentage of OSATs reporting that a specific condition be at least to some extent (including "some extent," "great extent," and "exceptionally great extent") a barrier to working beside other agencies in serving substance foul language clients.
RESULTS
OSAT Service Linkages
In general, a predetermined extent of service linkages be found in the study taste (Table 2). The average number of ties between OSATs and primary care and mental form agencies was 3.3. The majority of OSATs (59.7%) have 3 or fewer ties; OSATs beside 6 ties represented a distinct minority (6.5%).
The extent of service linkages diverse by type of external agencies. Results showed that OSATs had more links to mental form agencies than to primary care providers; this is possibly due to the certainty that among substance abuse clients treated within OSATs, cooccurring mental health problems (42%) and trauma experience (34%) be more common than physical form problems (14%), including pregnancy (Table 2).
Organizational Covariates of OSAT Service Linkages
OSATs varied surrounded by their organizational arrangements and client mix. We examined whether organization type, ownership, size and clients' health inevitability were associated beside the OSAT's linkages beside mental health and primary effort agencies. Results based on the chi-square analysis are presented contained by Table 3. (The chi-square results should be interpreted with forewarning because some of the cells own a small number of observations--i.e., an expected count of smaller quantity than 5). With the exception of percentage of clients with comorbidities, none of the organizational variables be correlated with total linkage or linkages near mental health or primary assistance providers.
The percentage of clients with comorbidities displayed a statistically significant correlation next to mental health linkage (Z2 = 10.92,p = 0.03). The result suggests a linear and positive relationship between the 2 variables; the number of ties that an OSAT had beside mental health agencies increased along next to the percentage of OSAT clients with comorbidities.
The impact of manage care on OSAT service linkage was assessed using both aim and subjective measures. First, OSATs' managed nurture involvement (based on the number of managed safekeeping arrangements, percentage of revenues from managed guardianship, and percentage of clients covered by managed watchfulness programs) was correlated next to the number of service linkages beside mental health and primary carefulness agencies. As Table 4 shows, none of the correlations was statistically significant, suggesting that manage care involvement be unrelated to the extent of OSATs' linkages next to external agencies.
Further, the designated respondent was asked whether he or she perceived any progress in the OSAT's service linkage in former times year as a result of managed assistance involvement. Results showed that the majority of OSATs (57.4%) perceived no change and that the percentage of OSATs detecting a refusal influence of managed strictness on their service linkages (26.2%) be higher than that of OSATs perceiving a positive impact of manage care (16.4%) (Table 5). Interestingly, a significant proportion of OSAT respondents (52.4%) disagreed or strongly disagreed that manage care have improved their service linkage with mental strength or primary care agencies, 32.8% perceived no difference, and one and only 14.7% experienced an improvement as a result of manage care involvement.
Finally, 3 proportional likelihood logistic regression models--one each for the total number of service linkage, the number of mental health linkage, and the number of primary care linkages--were run beside covariates that were correlated near any of the 3 service linkage variables at p<0.30 in the bivariate analysis. The covariates included number of managed supervision arrangements, percentage of clients covered by managed fastidiousness, freestanding (vs. subsidiary) organizational type, and percentage of clients with comorbidities.
As Table 6 shows, 3 covariates be significantly associated with the total number of service linkage in OSATs at p < 0.10. The coefficients for the number of manage care arrangements and percentage of clients next to comorbidities were positive, whereas the coefficient for percentage of clients covered by manage care be negative. One covariate-percentage of clients next to comorbidities--was significantly and positively related to the number of mental health linkage (p < 0.01), confirming the chi-square result in Table 3. For the number of primary care linkage, only one covariate--percentage of clients covered by manage care--was statistically significant (p < 0.05) and the coefficient was negative.
Perceived Barriers to Service Linkages
To assess problems associated near the creation and maintenance of service linkage between OSATs and external service providers, the designated respondents were asked to rate a detail of potential barriers to working beside other agencies in jamboree the health desires of substance abuse clients.
As Table 7 indicates, the cited reason were similar for mental condition and primary care agencies. However, several issues seem to be more problematic for mental health linkage: "client's ability to wages out of pocket," "client stigma," "caseload problems," "long waiting list," "insufficient staff," "insufficient discretionary funding," "mistrust," and "resource competition." It is interesting to entry that the 2 most frequently cited barriers to service linkages--"client's fitness to pay out of pocket" and "deficient insurance reimbursement"--were related to clients' financial ability to gain needed services. Managed care restrictions be considered to be a barrier to service linkage for about 60% of OSATs included in the study taster.
DISCUSSION
Fragmentation of the substance abuse treatment system is perceived to be a key problem in treatment for folks with cooccurring substance knock about, mental and physical disorders. A suggested solution is improvement of service linkage of OSATs with primary precision and mental health agencies (20). To know the extent of service linkages surrounded by OSATs and to identify correlates of and barriers to such linkage, we conducted an analysis of information collected from a sample of 62 OSATs. Results suggested a mosaic outlook of the substance abuse treatment system near either impossible or good word about the extent of service linkage depending on one's perspective.
The bad word was that we might still hold a long way to budge if linking OSATs with other vigour care providers be considered a solution to the reorganization of substance abuse treatment. The analysis indicated that a majority of OSATs have 3 or fewer linkage with any mental health or primary perfectionism agencies, suggesting that treatment of substance abuse might be fragmented as various researchers and policymakers had assumed. Also, the expertise of OSATs to work with other programs appeared to be fixed by managed consideration, which has have an increasingly strong presence in the behavioral health transfer system. While the multivariate analysis suggested mixed results associated with manage care involvement (depending on the estimate of managed watchfulness involvement and the type of service linkages examined), the majority of the designated respondents of OSATs disagreed (some strongly) that manage care have improved their service linkage. Moreover, a significant proportion of respondents cited managed attention to detail restrictions as a barrier to their collaboration near mental health and primary aid agencies in treating substance invective clients.
There was obedient news, however, essentially in that OSATs appeared to own adjusted their pattern of service linkages to the wants of substance abuse clients. Mental strength problems were more prevalent than physical illnesses among the clients treated at the OSATs surrounded by the study sample. Correspondingly, OSATs also have more service linkages next to mental health agencies than near primary care providers. Furthermore, the multivariate analysis showed that within OSATs with a difficult percentage of comorbid clients, a greater number of service linkages near mental health providers be established. Together, these findings suggested that OSATs might be responsive to client health requirements in service design, irrespective of the idiosyncrasy of their organizational structure and the degree of their manage care involvement.
Two other findings are outstanding. First, interviews with OSAT respondents indicated that of adjectives the reasons cited, clients' financial problems, including lacking insurance coverage, represented the most significant barrier to linkage with, and client referral to, mental health and primary thinking agencies. As proposals have be considered to move toward the parity of behavioral strength services with medical trouble in the design of robustness insurance benefits, it would be interesting to see if the proposed change would own any positive impact on interagency linkages and service integration in substance maltreat treatment. Second, a significant proportion of OSATs also cited organizational capacity and financial issues (e.g., caseload problems, long waiting list, insufficient staff, and insufficient discretionary funding) as limitations to linkages beside mental health and primary vigilance providers. With diminishing government funding during the current monetary downturn, the situation may be exacerbated, further fragmentizing health service confinement for individuals with substance assault problems.
This study represents an initial step toward a systematic examination of service linkage in OSATs surrounded by relation to their organizational attributes and managed attention involvement. There are several ways to extent this research effort. First, within addition to the extent of service linkage, there are other ways to takeover OSATs' interagency networking actions, for example, the degree of coordination, horizontal of trust, and amount of resources invested in the collaborative relationship. Questions also could be raised as to whether the most critical outcome is not the number of OSAT ties to other providers but the proportion of individuals reception needed primary care and mental vigour services. A few well-organized service linkage may serve clients as effectively as, or more effectively than, several linkages, outstandingly if the clients' health wants are relatively homogeneous. Alternatively, one could argue that multiple service linkages are mandatory because they allow on OSAT to identify appropriate referrals for finicky subgroups of substance abuse clients. Which of these arguments applies to substance ill-treat treatment is an empirical question that could be address in adjectives research.
It is important to transcribe that the extent of service linkages reported surrounded by this article was assessed from the vantage point of the OSAT. The existence and efficiency of the service linkages would necessitate to be corroborated by the OSAT's service partners. Arguably, it is with the sole purpose the mutually positive and intense relationships that contribute to effective service provision to multineed clients.
Location in a hospital, a mental health center, or a multi-substance harm program might introduce additional ebb and flow in how OSATs connect with external service providers. It might eat up the necessity for service linkages because of the resources and systematic support from the parent organization that allows onsite service integration in the OSAT. Alternatively, it might facilitate service linkage by mitigating the managed strictness burden or financial constraints on the OSAT. The small sample size contained by the study limited the statistical power to detect significant differences between these groupings, but this is clearly an big avenue for further research.
Managed care is not a monolith, however (15-17, 22); it might affect OSATs' service linkage in ways that are more complex than observed within this study. A research question worth investigating is whether and how the complexity and diversity of manage care's oversight mechanism may influence OSATs' decision to provide mental and physical form services either on-site or through collaboration near external service providers. Many of the OSAT respondents interviewed perceived a negative impact of manage care on service linkage. If the presence of managed fastidiousness in behavioral robustness services continues to grow and if the oversight mechanisms of manage care organization become more stringent, collaboration between OSATs and other health consideration providers is likely to be hampered. If equal changes simultaneously diminish OSATs' resources to provide services onsite, the access to care and treatment outcomes of substance misuse clients may be adversely affected. Further pains to clarify these relationships would enhance our understanding of the organizational constraints that service providers struggle next to in treating multineed substance harm clients.
Finally, OSATs' decision to collaborate next to other service providers may be contingent upon conditions in their organizational environments, such as the availability of mental health and primary nurture providers in the local flea market. Such environmental constraints need to be taken into explanation in directive to design feasible policy interventions to modernize substance abuse treatment, especially contained by nonmetropolitan and rural areas.
APPENDIX
Interview Questions Regarding Organizational and Client Attributes Organizational Setting
(1) What statement best describes your program?
a. This program is free standing. It is not part of a parent management that provides other types of services.
b. This program is part of a parent concern that primarily provides services other than substance treat roughly treatment.
c. This program is part of a parent running that primarily provides substance abuse treatment.
(2) If your program is module of a parent organization, is that parent managing a
a. hospital?
b. mental health center?
c. multi-program substance maltreat organization?
Ownership Type
What is the rates status of your program?
a. Public
b. Private, non-profit
c. For-profit
Unit Size
(1) How many full-time or full-time equivalent salaried staff, including consultants, are employed by your program?
(2) How many clients did your program serve within the past year?
Client Mix
What percentage of the clients that you enjoy admitted to your program enjoy been identified beside the following characteristics ...
a. both substance abuse and severe mental condition problems such as psychoses, schizophrenia, or severe depression?
b. both substance abuse and mild or moderate mental condition problems?
c. severe mental health problems such as psychoses, schizophrenia, or severe depression?
d. mild or moderate mental robustness problems?
e. substance abuse problems with the sole purpose?
f. HIV positive or have AIDS?
g. other severe medical problems?
h. pregnant woman?
i. hold experienced trauma such as physical or sexual abuse?
j. out of work and claiming benefit?
k. homeless?
l. involved in the criminal justice system?
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