Chapter 9 - Successful Service Programs

Outcome evaluation should be applicable to the particular population being served, but as a general rule, client progress in the following areas should be tracked.

physical health mental health career/employment success family stability social support solution or avoidance of criminal justice problems

Surveys

Data collection tool used to gather direct information about problems and community attitudes.

In the case of substance abuse programming, these trends make themselves felt most directly through three current movements:

the emphasis on accountability for achievement of outcomes, the continued dominance of managed care, and the use of placement criteria.

Among instruments with a long history of use for this purpose are the following:

* Behavior Rating Scale—social, employment, economic, legal, drinking * Alcohol Dependence Scale * Addiction Severity Index * Health and Daily Living Form * Timeline Follow-Back Assessment Method

Two types of evaluations

Accomplishment of these distinct purposes requires two types of evaluation. Process evaluation assesses the agency's activities to determine whether programs are operating in accordance with plans and expectations. Outcome evaluation attempts to verify the impact of services by measuring the degree to which clients have changed as a result of the program's interventions. A useful evaluation plan must contain elements of each.

Managed care models have changed over time (Center for Substance Abuse Treatment, 1995b).

1. The first generation of managed care focused on reducing costs by restricting access to services through such means as overly rigid utilization review, limited benefits, and large co-payments. 2. The second-generation managed care organizations (MCOs) manage benefits. They focus on the development of provider networks, selective contracting, increased treatment planning, and a less rigid utilization review process. 3. Third-generation MCOs focus on managing the care of enrollees by emphasizing treatment planning and carrying out more active management of clients through the course of their treatment(s). This involves enhancing the breadth and seamlessness of the continuum of care and actively using the least restrictive treatment settings that are clinically appropriate. 4. A fourth generation—now being aspired to—is for MCOs to manage by outcomes. This model seeks to focus on the outcomes of treatment and allows great provider auto

The report generated by this collaboration identified a set of concepts and principles that capture the complexity of outcome evaluation. The principles include:

1. The multiple, often overlapping reasons for conducting outcome evaluation should be recognized, as should the often differing motivations of various parties who have interest in outcomes data. 2. Outcome evaluation should be meaningful. 3. Evaluation studies of the process of treatment or the outcomes of treatment should specify a number of different domains. 4. Parameters being evaluated should be measurable and comparable. 5. Addiction treatment outcome measures should be as consistent as possible with outcome measures utilized in generally accepted public health research and health care delivery research. 6. Abstinence should not be the only variable considered in evaluating the effectiveness of a treatment intervention for a substance-related disorder. 7. Treatment outcome studies should take into account that persons with addictive disorders are not a uniform population. 8. Outcome evaluations should creatively apply the available capabilities and recognize the limitations of currently existing data sets and methodologies. 9. Outcome studies in addiction treatment must comply with ethical standards for treatment services research.

Today's human service organizations tend to be larger, more complex, and subject to greater external controls than has been true in the past. Some agencies cope with these realities by implementing more bureaucratic controls. At the same time, however, an important counter-trend can be seen. Across the helping professions, services to consumers are increasingly characterized by

1. a focus on client empowerment; 2. an emphasis on clients' strengths, rather than their deficits; 3. a recognition that service providers should carry out advocacy on behalf of clients who belong to oppressed or marginalized groups; and 4. a philosophy oriented to social justice.

An agency or program must continually try to adapt to trends that might have been difficult to foresee. In recent years, the context within which human service organizations exist has been so radically altered that it often feels completely unfamiliar to experienced practitioners. Current trends include:

1. an emphasis on accountability for achievement of outcomes is replacing the traditional focus on provider-controlled methods and services 2. privatization, contracting, and other forms of cost savings are replacing customary funding mechanisms 3. a replacement of autonomous practice with an insistence on interagency collaboration, including coalitions between public- and private-sector organizations 4. a replacement of the long-established routine of screening clients to determine whether they "fit" the program's methods with the expectation that programs will tailor services to individuals' assessed needs 5. a replacement of the time-honored bureaucratic skills that formerly kept programs afloat with marketing, public relations, and entrepreneurship

Effective programming depends on a step-by-step planning process that includes the following basic components:

1. assessing needs 2. identifying desired outcomes 3. generating alternative methods for reaching goals and selecting among these alternatives 4. devising implementation and evaluation plans budgeting 5. These steps make up a generic planning process that is appropriate for activities of such varied scope as developing an agency-wide strategy, planning for changes in an existing program, or devising a treatment plan for an individual client.

In response to the Patient Protection and Affordable Care Act of 2010, the Substance Abuse and Mental Health Services Administration (2014) created the National Behavioral Health Quality Framework. The framework consists of 6 goals:

1. evidenced-based practices; 2. person-centered care; 3. coordinated care; 4. healthy living for communities; 5. reduction of adverse events; and 6. affordable/accessible care.

Among the new federal provisions to expand and train the addiction and mental health workforce are the following (Substance Abuse and Mental Health Services Administration, April, 2011):

1. grants to recruit and train community health workers from racially and ethnically diverse communities; 2. loan assistance to professionals who serve in medically under-served areas; 3. establishment of the National Healthcare Workforce Commission, which includes mental health treatment as a priority; and 4. support for model cultural competence training members of the workforce.

Process evaluation becomes simplified when information about clients, communities, and services are maintained. Among the types of information needed are:

1. information related to the community, such as demographic information, data on social and economic characteristics, identification of underserved populations, and listings of external services and resources 2. information concerning individual clients, groups of clients, and the client population as a whole, including such data as presenting problem, history, type of service received, length of service, socioeconomic and family characteristics, employment, and even measurements of satisfaction and service outcome 3. service information, including types of service provided by units within the agency, number of clients served, number of admissions and discharges in a given period, and specification of service-related activities 4. staff information, including time spent in varying activities, number of clients served, volume of services, and differences among separate programs within the agency 5. resource allocation information, including total costs, costs for specific types of services, and data needed for financial reporting

Hoffman, Green, Ford, Wisdom, & Gustafson (2012) identified five improvements for substance abuse services: "

1. understand and involve the customer, 2. fix key problems, 3. pick a powerful change leader, 4. get ideas from outside the organization, and 5. use rapid cycle testing."

multivariate

A conceptualization that involves different variables of drug and alcohol problems to bring a change in focus concerning outcome evaluation.

implementation plan

A plan which includes the questions on the specific tasks, the personnel needed to carry out these tasks, reasonable targets for completion of tasks and resources needed to meet the targets.

needs assessment

A planning activity designed to discover the gaps between what is desirable for a community or potential client population and what currently exists.

Managed Behavioral Health Care Organizations (MBHOs)

A professional company that specializes in the provision of addiction and mental health care.

Managed care

A system designed to control the quality and cost of health care.

The Mental Health Parity and Addiction Equity Act of 2008

An act passed in 2008 which requires equity in coverage for physical and mental health conditions, including addictions.

health maintenance organizations (HMOs)

An organization that charges a set amount per person and provides a variety of health services to members of the group being covered.

The 2008 Mental Health Parity and Addiction Equity Act provides the following:

Equal benefits: Means that benefits coverage for mental health and substance use treatments must be at least equal to that coverage provided for physical health services. Equal limits: All of the financial requirements and treatment limitations applied to mental health and substance use benefits may be no more restrictive than for physical health benefits. Equal cost-sharing: The new law prohibits the use of higher patient cost-sharing (deductibles, co-payments, maximum-out-of-pocket costs) for mental health and substance use benefits than for physical benefits... (American Psychological Association, 2008, p. 2).

Open forums

Meetings where community members get a chance to speak out about their needs and priorities.

Outcome evaluation

Information about the effectiveness of treatment interventions needed for decision making, whether the decisions at hand concern the development of a program or the design of an individual treatment plan.

health information technology (HIT)

It enables providers to render care more efficiently by eliminating the use of paper-based records and reducing the duplication of diagnostic tests.

Process evaluation

It involves collecting and analyzing information that can verify whether planned services have been delivered consistently to the appropriate number and types of clients.

The ASAM Patient Placement Criteria—criteria developed by the American Society of Addiction Medicine—have attained very widespread use in addiction treatment. The ASAM criteria identify several levels of service, including the following:

Level 0.5:Early Intervention Level I:Outpatient Services Level II:Intensive Outpatient/Partial Hospitalization Level III:Residential/Inpatient Services Level IV:Medically Managed Intensive Inpatient Service

agency surveys

Local agencies that help in the development of realistic plans.

Key informants

People who are known to be well informed about a given issue or about local opinions on a variety of topics.

Social indicators

Quantitative measures of characteristics that might correlate with service needs.

Affordable Care Act of 2010

The health care act that brought the opportunities for treatment to people who had not had access to care in the past.

multicultural competence

The ability of the therapist to adapt counseling strategies to the individual characteristics of the client, including but not limited to disability, gender, sexual orientation, developmental level, culture, ethnicity, age, and health status.

One fact about the Mental Health Parity and Addiction Equity Act has been widely misunderstood.

The act required that treatment for physical health and mental health/addictions be equitable. There was, however, no requirement that a third-party payer provide mental health or addictions treatment as part of any plan.

electronic health records

The medical records of patients digitally stored on a computerized database.

Each service that has withstood this final test should now be the subject of an implementation plan. The questions to be asked at this point include:

What specific tasks need to be carried out? What personnel do we need to carry out these tasks? What are the reasonable target dates for completing each task? What resources do we need in order to meet our targets?

multidimensional treatment

Treatment that is based on the least intrusive possible alternative, given for any special health, safety, and support needs the clients have.

In this example, the objectives for the first four months of the program's first year might include:

identifying all appropriate services in the community within three months establishing facilities and equipment to provide referral services within two months employing and training a referral and administrative staff within two months completing an operational program within three months establishing liaison with all referral agencies within four months