The Louisiana Access to Recovery Project Final Evaluation Report Access to Recovery II: 2007-2010 Prepared for: Louisiana Department of Health and Hospitals (DHH) Office of Behavioral Health
Author: Laurel Mangrum, Ph.D Produced under a contract with the Office for Addictive Disorders, now known as the Office of Behavioral Health Gulf Coast Addiction Technology Transfer Center Phone 512 232 0616, Fax 512 232 0617
Executive Summary Background: The Access to Recovery (ATR) grant is part of a Presidential initiative to address clients difficulty in accessing substance abuse treatment and recovery support services. The purpose of the ATR project is to implement a service structure to achieve the following goals: Expand service capacity using grant funds to supplement (not supplant) current funding, including the recruitment of new treatment and recovery support providers in the service network. Ensure clients receive independent assessment for determining the appropriate levels and types of services needed. Provide clients genuine, free, independent choice among treatment and recovery support providers. Establish a wide network of community organizations and faith-based providers to ensure clients have at least one service provider choice among the array for which the client has no religious objection. Institute a voucher program that provides voucher monies directly to clients for independent purchase of all assessment, treatment, and recovery support services. On August 4, 2004, SAMHSA awarded the Louisiana Department of Health and Hospitals (DHH) Office for Addictive Disorders $22.8 million for three years to fund the Access to Recovery Program. Louisiana s Access to Recovery (LA-ATR) project was implemented on March 1, 2005 with a target number of clients to be served of 8,928. The LA-ATR is an electronic voucher program for substance abuse treatment and recovery support that was designed to expand services to pregnant women, women with dependent children, and adolescents. However, ATR vouchers are available to all Louisiana residents who meet the financial and substance abuse screening criteria. In September 2007, SAMHSA awarded the Louisiana Department of Health and Hospitals (DHH) Office for Addictive Disorders $13.4 million for three years to fund the Access to Recovery II Program. Louisiana s Access to Recovery II (LA-ATR II) was implemented on January 30, 2008 with a target number of clients to be served of 5,999. Priority target populations for LA-ATR II included those involved with the criminal justice system who were also identified as having an alcohol and/or drug abuse diagnosis and methamphetamine users. This report covers clients served and services delivered during LA-ATR II from February 1, 2008 through September 1, 2010.
Evaluation Results for ATR II I. Comparison of ATR Clients and Non-ATR Clients in Louisiana In an extensive analysis which integrated information about ATR clients with information within the total client database for substance abuse treatment in Louisiana, ATR clients were compared with the total population of clients in the state. This enabled an understanding of how ATR clients differed from other clients as well as the differences in outcomes from services received. It was found that ATR clients had characteristics which would normally place them at risk for poor clinical outcomes. Compared to non-atr clients, the ATR clients had greater severity on all Addiction Severity Index (ASI) composite scores which reflect problems in medical, employment, substance use, legal, family/social, and psychological areas of functioning. The ATR group had a more extensive record of previous substance abuse treatment and a greater rate of prior mental health treatment. ATR clients had a more extensive history of recent drug and alcohol use and were more likely to have used heroin, cocaine/crack, amphetamines, marijuana, ecstasy, and multiple substances than the non-atr group. ATR clients were also more likely than non-atr clients to be male, Black, and unemployed. However, in spite of admission characteristics which would lead to expectations of poor prognosis for the ATR group, their outcomes at the time of discharge were remarkably positive. Compared to the randomly selected non-atr comparison group, the ATR clients were significantly more likely to complete treatment than non-atr clients (65% vs. 49%). This is an important finding which was further explored in the second portion of the Evaluation Report. At the time of discharge, ATR clients were also more likely than other clients to be abstinent from drugs and to be employed. Non-ATR clients did have better outcomes in the areas of stable housing and involvement in self-help activities. II. Comparison of ATR Completers and Non-Completers Completion of treatment is an important variable in explaining treatment outcomes. Retention is recognized as a key predictor of other clinical outcomes. The premise is that one is not likely to benefit from treatment if he or she does not remain in treatment long enough to complete the needed course of services. The analysis confirmed that treatment completers had superior outcomes in all other areas, compared to non-completers. Accordingly, it is important to understand the factors associated with treatment completion or failure to complete. In terms of client characteristics at admission, non-completers had more problems and greater severity of problems. ATR completers received a greater number of service units and had higher service expenditures than non-completers. Thus greater retention was associated with receipt of more services and greater likelihood of enhanced outcomes. Conclusions The ATR II project was successful in enrolling high risk clients with severe substance abuse problems as well as other problems. In spite of the high-risk characteristics of enrollees, the clinical outcomes for these clients were remarkably high, and significantly higher than clients who were enrolled in non-atr substance abuse treatment services in the State during that time. One of the key predictors of successful outcomes in the ATR group was completion of treatment. This variable was highly associated with other successful outcomes. Although the highest risk ATR clients had lower treatment completion rates than other ATR clients, the overall ATR completion rates are significantly better than non-atr clients. These findings suggest that the range and extent of services available in ATR facilitate the enrollment and retention of high risk clients and that the enhanced outcomes observed in the program are closely associated with the enhanced rate of treatment completion.
TABLE OF CONTENTS ACCESS TO RECOVERY GRANT OBJECTIVES... - 1 - AWARD DETAILS... - 2 - SERVICE DELIVERY MODEL... - 2 - ALLOWABLE SERVICES... - 3 - Licensed Treatment Services...- 3 - Recovery Support Services...- 4 - CLIENT ELIGIBILITY... - 4 - PROVIDER NETWORK... - 4 - GENERAL DESCRIPTION... - 7 - FINANCIAL ELIGIBILITY... - 7 - CLINICAL ASSESSMENT... - 7 - PATIENT PLACEMENT DECISIONS (LEVEL OF CARE RECOMMENDATIONS)... - 8 - FACILITATING FREEDOM OF CHOICE... - 8 - ELECTRONIC TREATMENT VOUCHER... - 9 - VOUCHER PROCESSING AND PAYMENT... - 9 - ADDICTION TREATMENT OUTCOMES FOR ATR AND NON-ATR CLIENTS...- 10 - ATR VERSUS NON-ATR CLIENTS... - 11 - SUMMARY OF ADDICTION TREATMENT OUTCOMES FOR ATR AND NON-ATR CLIENTS... - 16 - PROGRAM OUTCOMES FOR ATR CLIENTS...- 17 - ATR PROGRAM COMPLETERS VERSUS NON-COMPLETERS... - 17 - SUMMARY OF ATR PROGRAM OUTCOMES... - 23 - SUMMARY OF ATR CLIENT OUTCOMES...- 24 -
LIST OF FIGURES Figure 1 Percentage of Clients Completing Addiction Treatment... - 12 - Figure 2 Percentage of ATR and Non-ATR Clients Abstinent for Past 30 Days... - 13 - Figure 3 Percentage of ATR and Non-ATR Clients Maintaining or Gaining... - 14 - Figure 4 Percentage of ATR and Non-ATR Clients Maintaining or Gaining Stable Housing at Discharge from Treatment... - 15 - Figure 5 Percentage of ATR and Non-ATR Clients Involved in Self-Help at Discharge from Treatment... - 16 - Figure 6 Percentage of ATR Completer and Non-Completer Clients Abstinent... - 18 - Figure 7 Percentage of ATR Completer and Non-Completer Clients Involved in Self-Help at Discharge from Treatment... - 19 - Figure 8 Percentage of ATR Completer and Non-Completer Clients Maintaining or Gaining Employment at Discharge from Treatment... - 20 - Figure 9 Percentage of ATR Completer and Non-Completer Clients Maintaining or Gaining Stable Housing at Discharge from Treatment... - 21 - Figure 10 Percentage of ATR Completer and Non-Completer Clients Arrested Past 30 Days at Discharge from Treatment.... - 22 - Figure 11 Mean Number of Days in Treatment for ATR Completers and Non-Completers... - 23 -
Section 1 Federal Grant Overview United States Department of Health and Human Services (HHS) Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT) Access to Recovery Grant Objectives The Access to Recovery (ATR) grant is part of a Presidential initiative to address clients difficulty in accessing substance abuse treatment and recovery support services. States receiving the ATR grant are awarded funds to implement a service structure with the following objectives: Expand service capacity by using grant funds to supplement (not supplant) current funding, including the recruitment of new treatment and recovery support providers in the service network. Ensure clients receive independent assessment for determining the appropriate levels and types of services needed. Provide clients genuine, free, independent choice among treatment and recovery support providers. Establish a wide network of community organizations and faith-based providers to ensure clients have at least one service provider choice among the array for which the client has no religious objection. Institute a voucher program that provides voucher monies directly to clients for independent purchase of all assessment, treatment, and recovery support services. In summary, ATR attempts to minimize barriers to treatment and recovery by engaging all available resources within the community to assist clients, including faith-based providers. The program seeks to empower clients with choice, so that clients can participate more fully in ensuring the services they receive best meet their individual needs. Access to Recovery provides resources to people seeking help with conquering drug and alcohol addiction, said Pamela S. Hyde, J.D., SAMHSA Administrator. Vouchers provide people access to treatment options that fit their needs and give them the flexibility to find the best path to recovery. Investing in treatment and recovery support not only saves lives, but every dollar invested in treatment and recovery services returns $7 in cost savings from social benefits such as reduced health costs, crime, and lost productivity. - 1 -
Section 2 Creating Access to Recovery Award Details In September 2007, SAMHSA awarded the Louisiana Department of Health and Hospitals (DHH) Office for Addictive Disorders $13.4 million for three years to fund the Access to Recovery II Program. Louisiana s Access to Recovery II (LA-ATR II) project was implemented on January 30, 2008 with a target number of clients to be served of 5,999. Service Delivery Model Public Sector (Includes schools, court, jails, public sector treatment providers, etc.) Screening & Referral Includes screening for financial, clinical & criminal factors Faith-Based Community Community Organizations Assessment For appropriate level of care placement and assignment of recovery support services Level of Care & RSS Determination Freedom of Choice Client chooses service providers for all clinical treatment and recovery support services Voucher Creation Initial level of care and recovery support services assigned Referral to Service Providers Assessing agency arranges referrals to chosen service providers Provision of Treatment and RSS Commences Care Coordination Throughout Lifetime of Voucher LA-ATR Voucher Terminates Six-months of service; Client Completes Treatment Plan Goals; or Client Discharged for Other Reasons - 2 -
As illustrated in the diagram above, clients may be identified through the public sector such as schools, court, jails, treatment providers, or through faith-based agencies and community organizations. After screening has been completed by one of the sources above and ATR eligibility is determined, the client is referred to a provider for an assessment. The client is asked to sign the appropriate ATR consent forms and authorizations for treatment before the comprehensive assessment is completed. The assessment provider determines the level of care for the client and assigns the appropriate recovery support services. The assessor is responsible for creating a treatment plan consistent with the needs identified in the assessment and the six problem dimensions of assessment used by the American Society of Addiction Medicine (ASAM). The client is given a list of clinical and recovery support service providers from which to choose services. Once the client signs the freedom of choice forms and selects service providers, a 180-day (sixmonth) voucher is created which may contain treatment and/or recovery support services. The assessor schedules an appointment and gives the client the date and time of his or her appointment. The ATR system also sends an e-mail to advise the facility administrator that a client has been referred to their facility. When the client presents for services, treatment begins using an individualized treatment plan that is created in collaboration with the client. The ATR system interfaces with the DHH Financial Systems to enable DHH to process payments for assessment, treatment, recovery support, and incentives to facilities. Payment requests are then collected by facility for payment on a monthly basis. Throughout client enrollment in ATR, a care coordinator is available at each treatment facility to ensure the client is properly linked to appropriate recovery support services and the next level of care. Allowable Services Screening and Assessment Services Client screening to determine immediate need(s) for substance abuse treatment and/or recovery support services using direct observation, screening tools and/or self-report. Clinical assessment utilizing the Addiction Severity Index (ASI) or Comprehensive Adolescent Screening Inventory (CASI) to determine appropriate client placement along the continuum of care. Licensed Treatment Services Intensive Outpatient Outpatient - 3 -
Recovery Support Services Care Coordination Transportation Safe and Sober Housing Spiritual/Pastoral Counseling Alcohol and Drug Free Social Activities Job Readiness ~ Education and Employment Life Skills Child Care Anger Management Family Education Services Recreational Therapy Client Eligibility The priority for ATRI funding is to expand services to pregnant women, women with dependent children, and adolescents.. Priority target populations for LA-ATR II included those involved with the criminal justice system who were also identified as having an alcohol and/or drug abuse diagnosis and methamphetamine users However, ATR vouchers are available to all Louisiana residents who meet the financial and substance abuse screening criteria. To be determined eligible for a comprehensive ATR assessment, the client must 1) have an annual income that is less than or equal to 200% of the Federal Poverty Level, and 2) demonstrate, either by observation or by screening responses, the need for a closer review of their alcohol and or drug use. Priority target populations for LA-ATR II included those involved with the criminal justice system who were also identified as having an alcohol and/or drug abuse diagnosis and methamphetamine users. Provider Network 99 providers participated in serving ATR II clients. 29 Faith-Based Organizations 70 Community-Based - 4 -
Number of ATR Providers by Region and Services Provided REGION # OF PROVIDERS SERVICES PROVIDED 1 ~ Greater New Orleans 2 ~ Greater Baton Rouge 3 ~ Southeast Louisiana 4 ~ Acadiana 5 ~ Southwest Louisiana 6 ~ Central Louisiana 7 ~ Northwest Louisiana 15 15 N/A 15 2 1 9 Treatment: Residential, Intensive Outpatient, Outpatient, and Social Detoxification Recovery Support: Care Coordination, Transportation, Safe & Sober Housing, Spiritual/Pastoral Counseling, Alcohol & Drug Free Social Activities, Job Readiness and Life Skills Treatment: Inpatient, Residential, Intensive Outpatient, Outpatient, and Social Detoxification Recovery Support: Care Coordination, Transportation, Safe & Sober Housing, Spiritual/Pastoral Counseling, Alcohol & Drug Free Social Activities, Job Readiness, Life Skills, and Youth Care Treatment: Inpatient, Intensive Outpatient, and Outpatient Recovery Support: Care Coordination, Transportation, Safe & Sober Housing, Spiritual/Pastoral Counseling, Alcohol & Drug Free Social Activities, Job Readiness, Life Skills and Youth Care Treatment: Inpatient, Residential, Intensive Outpatient, Outpatient, and Social Detoxification Recovery Support: Care Coordination, Transportation, Safe & Sober Housing, Spiritual/Pastoral Counseling, Alcohol & Drug Free Social Activities, Job Readiness, Life Skills, and Youth Care Treatment: Inpatient, Outpatient, and Medically Supported Detoxification Recovery Support: Care Coordination, Transportation, Spiritual/Pastoral Counseling, Alcohol & Drug Free Social Activities, Job Readiness, and Life Skills Treatment: Inpatient, Residential, Intensive Outpatient, Outpatient, Social Detoxification, and Medically Supported Detoxification Recovery Support: Care Coordination, Transportation, Safe & Sober Housing, Alcohol & Drug Free Activities, Job Readiness, and Life Skills Treatment: Inpatient, Residential, Intensive Outpatient, Outpatient, and Social Detoxification Recovery Support: Care Coordination, Transportation, Safe & Sober Housing, Spiritual/Pastoral Counseling, Alcohol & Drug Free Activities, Job Readiness, Life Skills, and Youth Care - 5 -
REGION # OF PROVIDERS SERVICES PROVIDED 8 ~ Northeast Louisiana 9 ~ Florida Parishes 10 ~ Jefferson Parish 24 11 7 Treatment: Inpatient, Residential, Intensive Outpatient, Outpatient, and Medically Supported Detoxification Recovery Support: Care Coordination, Transportation, Safe & Sober Housing, Spiritual/Pastoral Counseling, Alcohol & Drug Free Activities, Job Readiness, and Life Skills Treatment: Inpatient, Residential, Intensive Outpatient, Outpatient, and Social Detoxification Recovery Support: Care Coordination, Transportation, Safe & Sober Housing, Spiritual/Pastoral Counseling, Alcohol & Drug Free Activities, Job Readiness, Life Skills, and Youth Care Treatment: Intensive Outpatient and Outpatient Recovery Support: Care Coordination, Transportation, Safe & Sober Housing, Spiritual/Pastoral Counseling, Alcohol & Drug Free Activities, and Life Skills - 6 -
Section 3 Screening and Referral to ATR General Description Screening may occur in churches, faith-based or other community organizations, OAD clinical treatment offices, women s public health clinics, school-based health clinics, safe and drug free schools, juvenile drug court, the Office of Community Services, probation/parole offices, correctional facilities, or other entities. To be determined eligible for a comprehensive ATR assessment, the client must 1) have an annual income that is less than or equal to 200% of the Federal Poverty Level, and 2) demonstrate, either by observation or by screening responses, the need for a closer review of their alcohol and or drug use. Financial Eligibility The priority for ATR-I funding was to expand services to pregnant women, women with dependent children, and adolescents. Priority target populations for LA-ATR II included those involved with the criminal justice system who were also identified as having an alcohol and/or drug abuse diagnosis and methamphetamine users. However, ATR vouchers are available to all Louisiana residents who meet the financial and substance abuse screening criteria. Once a client s eligibility has been determined, it is valid through the duration of the six-month voucher. Providers may utilize the ATR system to assess and select the first level of care for the client who is ineligible for ATR. After clients are deemed eligible for ATR, they are asked to sign the OAD Notification of Patients Rights, Authorizations, the ATR Consent Form, and the HIPAA compliance consent document. After consent is collected, an assessment voucher is generated to authorize an ATR-approved assessor to provide a comprehensive assessment to the client. Clinical Assessment Stability and support in all life areas can be affected by substance use and abuse. To determine potential needs in these areas, clients meet with an ATR assessment provider for a comprehensive evaluation of their service needs. Demographic information and formal documentation of the client s referral source and financial eligibility are required to generate the assessment voucher. An assessment voucher must be generated before the assessing clinician can be paid for this service. The clinical assessments are conducted by a licensed clinician or counselor-in-training supervised by a licensed clinician in a face-to-face setting with the client. Responses to the assessments are entered into the computer with the client present, unless granted other permissions by ATR - 7 -
Administrative Staff. The clinician utilizes the Addiction Severity Index (ASI) if the client is an adult. If the client is under age 18, the Comprehensive Adolescent Severity Inventory (CASI) is used. ATR authorized assessment providers must have received OAD training and have developed proficiency in the administration of the Addiction Severity Index (ASI) and the Comprehensive Adolescent Severity Inventory (CASI), as appropriate. The ASI examines the medical status and needs, employment status, legal status, family and social relationships, and mental health status of the adult client. At the conclusion of the ASI, the clinician prints a copy of the problem list to assist in making an appropriate Level of Care recommendation, the assignment of Recovery Support Services, and Treatment Planning. The problem list is attached to the ASI narrative report. Both documents are signed by the clinician and placed in the client s paper case record. The CASI addresses health status, stressful life events, educational status, social networks and support, peer relationships, sexual behavior, family relationships, legal issues and mental health status of the adolescent client. The CASI narrative report is printed out, and the last page summarizing client needs is used to guide the appropriate Level of Care recommendation, the assignment of Recovery Support Services, and Treatment Planning. The electronic ATR system utilizes information from the comprehensive assessment to support clinicians in making Level of Care recommendations and in selecting Recovery Support Services and Treatment Interventions to meet the needs of their clients. Clients are issued an ATR treatment voucher if they are eligible. ATR provides a network version of both the ASI and the CASI. This greatly eases the reporting and paperwork burden, ultimately allowing clinicians to spend more time serving their clients. The e-atr system processes and tracks the clinical assessments and level of care recommendations. Assessors are assigned a login and password that enables them to use the web-based application to perform the assessment and to establish the client s appropriate level of care. Provider training on e-atr is supplied and technical support is available as needed. Patient Placement Decisions (Level of Care Recommendations) Upon completion of the assessment phase of the initial interview, or at any time a client is transitioning from one level of care to another, the assessor is required to make a patient placement decision utilizing the electronic ATR system. A patient placement decision (Level of Care Recommendation), is a recommendation to place an individual in the appropriate level of care without placing the individual at risk. The placement decision is generally based on a comprehensive assessment of the client s needs, client s demographics, and other client centered contextual factors. The recommendation is guided by uniform patient placement (UPPC) criteria, (e.g., American Society of Addiction Medicines (ASAM) Patient Placement Criteria), in conjunction with knowledge of available recovery support services (a.k.a., wrap around services) that are available. The Patient Placement Decision (a.k.a., Level of Care Recommendation) is accompanied by a clear and concise clinical justification. Facilitating Freedom of Choice ATR provides clients with freedom of choice forof treatment and recovery support service providers through each level of their continuum of care. The assessment provider explains and discusses the client s initial assigned level of care, answers questions and provides information to help the client select a caregiver provider. As clients move through their treatment levels, including recovery support, they continue to have freedom of choice in selecting providers. - 8 -
The e-atr system includes an up-to-date database of providers, classified as to areas of eligibility and expertise, levels of care, services offered, and other descriptors to assist clients in exercising free and informed choice. After the appropriate level of care for a particular client has been identified, the system generates a list of potential providers from which clients can choose. Once the client chooses a provider, the assessor schedules an appointment and gives the client the date and time of his or her appointment. The assessor then generates a 180-day voucher that may contain treatment and/or recovery support services. Electronic Treatment Voucher The assessment clinician generates an electronic treatment voucher after the client has selected providers. The treatment voucher is active for six months, and includes all approved treatment and recovery support services. Voucher Processing and Payment Vouchers are processed via the ATR system, subject to the following: The ATR System allows an assessor to create a treatment plan based on pre-defined levels of care and business rules regarding length of service and providers. Recovery Support and Care Coordination services can be provided at each level of care in the treatment plan. The ATR system sends an e-mail to advise the facility administrator that a client has been referred to their facility. The ATR System notifies providers and facility administrators of incoming clients, necessary reassessments, inactive clients and late voucher entries based on OAD-mandated timeframes. The ATR System interfaces with the DHH Financial Systems to enable DHH to process payments for assessments, treatments and incentives to facilities. Payment Requests are collected by facility for payment on a monthly basis. - 9 -
Section 4 ATR Evaluation Client Outcomes In this portion of the Evaluation Section, ATR client outcomes are examined from two perspectives. In the first section, client characteristics and addiction treatment outcomes for ATR participants are compared to a subset of clients who received state-funded addiction treatment during the same time period but did not receive ATR services. The second portion of the Evaluation Section examines ATR program outcomes by comparing client and service characteristics of successful and non-successful ATR program completers. Addiction Treatment Outcomes for ATR and Non-ATR Clients Non-ATR treatment providers are required to report client information in the Louisiana Addictive Disorders Data System (LADDS) and the Louisiana Addiction Services Information System (LASIS). LADDS is the mandatory data reporting system for Louisiana that collects client demographic, substance use, diagnoses, treatment services, and discharge status information for state-funded addiction treatment providers. LASIS is the required data reporting system that stores the Addiction Severity Index assessment data for state-funded providers, which measures substance use severity and client-reported levels of functioning in a variety of areas such as employment, legal issues, family/social status, medical concerns, and psychological health. ATR assessment providers are required to report client data for the Government Performance and Results Act (GPRA) as mandated by the federal government for grant management purposes. GPRA data include client descriptive data, services received, and status at discharge from the ATR program. The State of Louisiana created an enhanced GPRA data collection form that includes all ASI assessment items. To compare ATR and non-atr clients, comparable variables measuring client and treatment outcome characteristics were selected from LADDS, LASIS, and GPRA and were transformed into compatible variables to create a dataset that allowed for evaluation analyses between the two groups. GPRA data were available for 6,405 ATR clients who were admitted and discharged from services between February 1, 2008 and September 1, 2010. A comparison group of 6,405 non- ATR clients was generated through random selection of LADDS/LASIS clients who entered and were discharged from state-funded intensive and non-intensive outpatient treatment services during the same time period. The non-atr comparison group was created using the SAS statistical software random selection procedure to provide groups of equivalent size. - 10 -
ATR clients were compared to non-atr clients on demographic and social characteristics, addiction and mental health treatment history, ASI composite severity scores, substance use patterns, and treatment outcomes at discharge. Continuous variables were analyzed using t-tests for independent groups and categorical variables were assessed using X 2 tests. Cases with missing data were omitted from the analysis of that variable. Results of these analyses are reported in the following sections. Relevant tables are located in the Appendix of this report and referenced figures are placed in each respective section. ATR versus Non-ATR Clients Demographic and social characteristics of ATR and non-atr clients at admission to treatment are reported in Table 1. ATR clients were more likely to be male, Black, and unemployed, whereas non-atr clients were more often White, had higher incidence of arrest during the past 30 days, and had higher rates of stable housing. No group differences were found in average age, with both groups attaining a mean age of 34 years. The ATR group demonstrated greater severity on all ASI composite scores, indicating the ATR clients reported greater problems in the areas of medical, employment, substance use, legal, family/social, and psychological issues relative to the non-atr group. Group comparisons on addiction and mental health treatment history are reported in Table 2. ATR clients had a greater incidence of all addiction treatment types, including alcohol treatment, alcohol detox treatment, drug treatment, and drug detox treatment. Further, ATR clients had a higher number of previous treatments in all of these addiction treatment categories. In the area of previous mental health treatment, ATR clients had a higher incidence of mental health inpatient treatment, whereas the non-atr clients had a greater rate of mental health outpatient treatment. The ATR clients, however, had a higher number of previous treatments in both of these mental health treatment types relative to the non-atr clients. No group differences were found in the area of past mental health diagnoses. Past 30 day substance use patterns for the two groups are reported in Table 3. Primary substance use problem as rated by the clinician on the ASI indicated that the non-atr clients more often had alcohol problems, whereas the ATR group more often had primary problems with cocaine/crack and heroin/opiates. During the month prior to admission, ATR clients were more likely to use alcohol, any drugs, heroin, cocaine/crack, marijuana, ecstacy, polysubstances, and other drugs, whereas non-atr clients had higher use rates of sedatives and opiates other than heroin. Examination of frequency of past 30-day substance use indicated that ATR clients had greater days of use of alcohol, any drugs, cocaine/crack, amphetamines, marijuana, ecstacy, and polysubstances relative to the non-atr group. Figures 1 through 5 display discharge characteristics of the ATR and non-atr clients with significant group differences. The ATR group had significantly higher rates of treatment completion (Figure 1), past 30-day abstinence (Figure 2), and maintaining or gaining employment (Figure 3). By contrast, the non-atr group had higher rates of maintaining or gaining stable housing (Figure 4) and self-help involvement (Figure 5). No group differences were found in incidence of past 30- day arrest (3% arrest rate for both groups) or length of stay in treatment, with both groups averaging approximately 106 days in treatment. The types of services received by ATR and non-atr clients during the course of treatment are quite disparate between the two systems and data stored regarding units of service in the two datasets were not comparable, precluding direct comparisons of services received between the groups. For informational purposes, the types of services received by the ATR and non-atr clients are reported in Tables 4 and 5, respectively. - 11 -
Figure 1. Percentage of Clients Completing Addiction Treatment for ATR and Non-ATR Clients 70% 60% 65% X 2 (1) = 262.19 p <.0001 50% 49% 40% 30% 20% 10% 0% ATR Clients Non-ATR Clients ATR clients completed treatment at a higher rate than non-atr clients. - 12 -
Figure 2. Percentage of ATR and Non-ATR Clients Abstinent for Past 30 Days at Discharge from Treatment 100% 90% 80% 84% X 2 (1) = 550.52 p <.0001 70% 63% 60% 50% 40% 30% 20% 10% 0% ATR Clients Non-ATR Clients ATR clients had higher past month abstinence rates at discharge from treatment than non-atr clients. - 13 -
Figure 3. Percentage of ATR and Non-ATR Clients Maintaining or Gaining Employment at Discharge from Treatment 60% 50% 53% 49% X 2 (1) = 17.31 p <.0001 40% 30% 20% 10% 0% ATR Clients Non-ATR Clients ATR clients had a higher rate of maintaining or gaining employment at discharge from treatment than non-atr clients. - 14 -
Figure 4. Percentage of ATR and Non-ATR Clients Maintaining or Gaining Stable Housing at Discharge from Treatment 110% 100% 99% X 2 (1) = 808.06 p <.0001 90% 83% 80% 70% 60% 50% ATR Clients Non-ATR Clients Non-ATR clients had greater rates of maintaining or gaining stable housing at discharge from treatment than ATR clients. - 15 -
Figure 5. Percentage of ATR and Non-ATR Clients Involved in Self-Help at Discharge from Treatment 70% 60% 63% X 2 (1) = 187.37 p <.0001 50% 48% 40% 30% 20% 10% 0% ATR Clients Non-ATR Clients Non-ATR clients had higher rates of self-help involvement at discharge from treatment than ATR clients. Summary of Addiction Treatment Outcomes for ATR and Non-ATR Clients Overall, ATR clients demonstrated better substance abuse treatment outcomes relative to non- ATR clients. At discharge, ATR clients achieved greater rates of treatment completion, higher past month abstinence rates, and greater success in maintaining or gaining employment during the course of treatment despite having lower levels of employment at admission relative to non-atr clients. Analyses of client characteristics at admission indicated that the ATR group demonstrated greater severity in all seven of the ASI domains, including medical, employment, alcohol/drugs, legal, family/social, and psychological problems. Further, ATR clients had a greater history of addiction and mental health treatments and reported higher levels of substance use during the 30 days prior to treatment entry. These characteristics would normally be associated with expectations for poor clinical outcomes. In spite of the at-risk nature of these clients, the results suggest that participation in the ATR program may have enhanced client outcomes at discharge. Although direct comparisons between services received between the groups were not possible due to incompatible data, the additional recovery support services provided in the ATR program may have assisted these more severe clients in addressing multiple life issues and enhanced their ability to engage in treatment and achieve positive treatment outcomes. - 16 -
Program Outcomes for ATR Clients ATR assessment providers are required to report client data for the Government Performance and Results Act (GPRA) as mandated by the federal government for grant management purposes. GPRA data include client descriptive data, services received, and status at discharge from the ATR program. As stated previously, the State of Louisiana created an enhanced GPRA data collection form that includes all ASI assessment items. In this section, both GPRA and ASI data are used to compare ATR clients who were rated by the assessment providers as successful completers of the program are compared to those who did not complete the program successfully. GPRA and ASI data were available for 6,447 clients who entered and were discharged from the ATR program during the period of February, 1 2008 through September 1, 2010. ATR program completion groups were compared on demographic and social characteristics, addiction and mental health treatment history, ASI composite severity scores, substance use patterns, and treatment outcomes at discharge. Continuous variables were analyzed using t-tests for independent groups and categorical variables were assessed using X 2 tests. Cases with missing data were omitted from the analysis of that variable. Results of these analyses are reported in the following sections. Relevant tables are located in the Appendix of this report and referenced figures are placed in each respective section. ATR Program Completers versus Non-Completers Assessment providers rated 65% of the sample as successfully completing the ATR program, resulting in group sizes of 4,165 in the ATR completer group and 2,282 in the ATR non-completer group. Demographic and social characteristics at admission of ATR program completion groups are reported in Table 6. ATR completers were more likely to be male, Black, employed, and relatively older compared to ATR non-completers. No group differences were found in past 30-day incidence of arrest or rate of stable housing. The ATR non-completer group demonstrated greater severity on five of the seven ASI composite scores, including the medical, employment, drug use, family/social, and psychological domains. No group differences were found on the ASI alcohol use and legal composite scores. Group comparisons on addiction and mental health treatment history are reported in Table 7. ATR non-completers had a higher incidence of previous alcohol detox treatment, drug treatment, and drug detox treatment, but no group differences were found on previous alcohol treatment or in the number of previous treatments in all categories of treatment. In the area of previous mental health treatment, ATR non-completers had a higher incidence of both mental health inpatient and outpatient treatment, but the groups did not differ in the number of previous mental health treatments. The ATR non-completer group, however, had a higher rate of past mental health diagnoses compared to the ATR completer group. Past 30-day substance use patterns for the two groups are reported in Table 8. Primary substance use problem as rated by the clinician on the ASI indicated that the ATR completer clients more often had marijuana problems, whereas the ATR non-completer group more often had primary problems with heroin/opiates. During the month prior to admission, ATR non-completers were more likely to use any drugs, heroin, other opiates, cocaine/crack, and polysubstances relative to the ATR completer group. Examination of frequency of past 30-day substance use indicated that ATR non-completers had greater days of use of any drugs, but no group differences were found in frequency of use of the other categories of substances. - 17 -
Figures 6 through 11 display discharge characteristics of the ATR completers and non-completers with significant group differences. ATR completers had higher rates of past 30-day abstinence (Figure 6), self-help involvement (Figure 7), and maintaining or gaining employment (Figure 8) and stable housing (Figure 9). The ATR non-completer group had a higher incidence of past 30-day arrest relative to the completer group (Figure 10). Further, the ATR completer clients had significantly longer lengths of stay in treatment compared to the non-completer group (Figure 11). ATR service characteristics for completers and non-completers are reported in Table 9. ATR completers were more likely to receive alcohol and drug free activities, anger management, drug screening, family education, family session, halfway house, individual sessions, job readiness, life skills, intensive outpatient treatment, outpatient treatment, spiritual support groups, transitional housing, and transportation services compared to the ATR non-completers. No group differences were found in receipt of care coordination, child care, or recreational therapy. In addition, the ATR completer group received a greater number of service units and had higher expenditures in all service categories except family education and recreational therapy. Overall, the ATR completers received a greater number of ATR service types relative to non-completers. Figure 6. Percentage of ATR Completer and Non-Completer Clients Abstinent Past 30 Days at Discharge from Treatment 100% 90% 86% X 2 (1) = 41.69 p <.0001 80% 78% 70% 60% 50% 40% 30% 20% 10% 0% ATR Completers ATR Non-Completers ATR completers had higher rates of past 30-day abstinence at discharge from treatment compared to ATR non-completers. - 18 -
Figure 7. Percentage of ATR Completer and Non-Completer Clients Involved in Self-Help at Discharge from Treatment 60% 52% X 2 (1) = 204.77 p <.0001 50% 40% 30% 25% 20% 10% 0% ATR Completers ATR Non-Completers ATR completers had higher rates of involvement in self-help at discharge from treatment compared to ATR non-completers. - 19 -
Figure 8. Percentage of ATR Completer and Non-Completer Clients Maintaining or Gaining Employment at Discharge from Treatment 70% 60% 57% X 2 (1) = 84.19 p <.0001 50% 40% 38% 30% 20% 10% 0% ATR Completers ATR Non-Completers ATR completers had greater rates of maintaining or gaining employment at discharge from treatment compared to non-completers. - 20 -
Figure 9. Percentage of ATR Completer and Non-Completer Clients Maintaining or Gaining Stable Housing at Discharge from Treatment 100% 90% 86% X 2 (1) =106.45 p <.0001 80% 70% 72% 60% 50% 40% 30% 20% 10% 0% ATR Completers ATR Non-Completers ATR completers were more likely to maintain or gain stable housing at discharge from treatment relative to ATR non-completers. - 21 -
Figure 10. Percentage of ATR Completer and Non-Completer Clients Arrested Past 30 Days at Discharge from Treatment. 10% 9% 8% 8% X 2 (1) =113.84 p <.0001 7% 6% 5% 4% 3% 2% 2% 1% 0% ATR Completers ATR Non-Completers ATR non-completers had a higher incidence of past 30-day arrest at discharge compared to ATR completers. - 22 -
Figure 11. Mean Number of Days in Treatment for ATR Completers and Non- Completers 140 120 125 t (6401) = -40.58 p <.0001 100 80 74 60 40 20 0 ATR Completers ATR Non-Completers ATR completers had significantly longer lengths of stay in treatment compared to ATR non-completers. Summary of ATR Program Outcomes As would be predicted, ATR completer clients demonstrated better substance abuse treatment outcomes relative to non-completers. At discharge, ATR completers achieved greater rates of past 30-day abstinence, self-help involvement, success in maintaining or gaining employment and stable housing, and lower rates of past 30-day arrests. In addition, ATR completers had significantly longer stays in treatment compared to non-completers. Analyses of client characteristics at admission indicated that the ATR non-completer group demonstrated greater severity on five of the seven ASI domains, including medical, employment, drug use, family/social, and psychological problems. In addition, the ATR non-completer clients had a greater history of addiction and mental health treatments and reported higher use of the different substance use categories during the 30 days prior to admission, although the groups overall did not differ on frequency of use during that time period. Analyses of services received during the course of treatment revealed that the ATR completers received a wider array and greater units of services during the course of treatment. These results suggest that clients who entered the ATR program with greater levels of substance use and psychosocial problem severity were more difficult to retain - 23 -
in the program, resulting in lower levels of successful outcome at discharge. In addition, results indicate that greater retention in the program may allow for the receipt of a wider array and higher dosage of service types, which may enhance client outcomes at discharge from treatment. Summary of ATR Client Outcomes This section of the report considered ATR client outcomes from two viewpoints. First, treatment outcomes for ATR clients were examined relative to non-atr clients receiving state-funded addiction treatment services during the same time period. In these analyses, ATR clients achieved better outcomes in the areas of treatment completion, past month abstinence rates, and employment at discharge from treatment despite presenting with greater severity of substance use and psychosocial problems at admission to treatment compared to the non-atr clients. The analytical design for these comparisons was naturalistic, however, and did not include random assignment or a control group that would support causation in these findings. Further, existing services data between the two service systems precluded direct comparison of the types of services received by ATR and non-atr clients during the course of treatment. Analyses of ATR treatment completers and non-completers indicated that the non-completer clients presented with greater substance use and psychosocial problems at admission to treatment and had lower lengths of stay, suggesting that these clients were more difficult to retain in treatment. Those ATR clients that were retained longer in treatment were able to gain access to a wider array and amount of services, which may have enhanced their ability to complete treatment and achieve more successful outcomes at discharge. Collectively these results suggest that the ATR program may increase the ability of high severity clients to engage in treatment and to experience enhanced outcomes at discharge, given the results of the comparisons of ATR and non-atr clients. Analyses of the ATR completer and noncompleter clients, however, indicate that those presenting to the ATR program with greater severity may have more difficulty engaging in and being retained in treatment, resulting in less successful discharge outcomes. - 24 -
APPENDIX The following pages contain detailed tables of findings of the ATR II Evaluation analysis. Table 1. Demographic and Social Characteristics of ATR and Non-ATR Clients at Admission to Treatment Variable ATR (n=6,405) NON-ATR (n=6,405) df X 2 / t-value p Male 76% 70% 1 59.82.0001 Mean Age 34.3 34.4 12808-0.39 ns Race Black 53% 37% White 45% 60% Other 2% 3% 2 302.89.0001 Employment Employed 33% 42% Unemployed 67% 58% 1 98.92.0001 Living Situation Stable Housing 76% 99% Not in Stable Housing 24% 1% 1 1506.14.0001 Arrested Past 30 Days 9% 13% 1 34.66.0001 ASI Composite Scores Medical.16.14 12764 2.40.02 Employment.69.58 12783 20.42.0001 Alcohol.19.14 12782 11.75.0001 Drug.13.08 12782 22.87.0001 Legal.19.12 12771 24.95.0001 Family / Social.10.06 12776 15.58.0001 Psychological.20.13 12775 20.24.0001-25 -
Table 2. Addiction and Mental Health Treatment History of ATR and Non-ATR Clients Variable ATR (n=6,405) NON-ATR (n=6,405) df X 2 / t-value p Addiction Treatment Alcohol Treatment 27% 25% 1 7.64.01 Number of Alcohol Treatments 2.9 2.3 3282 4.49.0001 Alcohol Detox Treatment 38% 26% 1 54.99.0001 Number of Alcohol Detox Treatments 2.3 1.9 1127 2.29.03 Drug Treatment 46% 33% 1 192.19.0001 Number of Drug Treatments 2.7 2.2 5008 4.73.0001 Drug Detox Treatment 36% 27% 1 54.37.0001 Number of Drug Detox Treatments 2.2 1.6 1680 5.14.0001 Mental Health Treatment Inpatient Treatment 20% 17% 1 10.06.002 Number of Inpatient Treatments 3.2 2.6 2350 3.10.01 Outpatient Treatment 26% 29% 1 13.55.001 Number of Outpatient Treatments 5.3 3.0 3425 6.30.0001 History of Mental Health Diagnosis 26% 27% 1 2.06 ns - 26 -
Table 3. Past 30-Day Substance Use Patterns of ATR and Non-ATR Clients at Admission Variable ATR (n=6,405) NON- ATR (n=6,405) df X 2 / t-value p Primary Substance (Clinician Rating) Alcohol 14% 27% Alcohol and Drugs 21% 17% Marijuana 26% 27% Cocaine / Crack 17% 10% Heroin / Other Opiates 11% 7% Polydrug 8% 7% Other Drugs 3% 5% 6 443.95.0001 Substance Use Patterns Alcohol 51% 49% 1 5.03.03 Days of Use 9.6 8.2 6335 6.29.0001 Any Drugs 54% 26% 1 1021.89.0001 Days of Use 12.3 10.1 5104 5.14.0001 Heroin 5% 1% 1 236.82.0001 Days of Use 13.6 12.4 354 0.63 ns Other Opiates 7% 11% 1 52.49.0001 Days of Use 11.7 11.7 1110-0.08 ns Barbiturates 1% 1% 1 0.14 ns Days of Use 11.5 10.2 77 0.57 ns Sedatives 2% 8% 1 190.54.0001 Days of Use 10.4 10.0 648 0.33 ns Cocaine / Crack 21% 13% 1 114.79.0001 Days of Use 9.4 7.2 2153 5.50.0001 Amphetamines 3% 3% 1 3.18 ns Days of Use 9.1 6.6 370 2.72.01 Marijuana 33% 28% 1 33.65.0001 Days of Use 11.1 10.2 3898 2.78.01 Hallucinogens 0.4% 0.4% 1 0.44 ns Days of Use 7.8 5.7 49 1.04 ns Ecstacy / Club Drugs 3% 2% 1 7.04.01 Days of Use 4.9 3.5 262 2.02.05 Polysubstance 21% 15% 1 63.54.0001 Days of Use 10.2 8.8 2222 3.20.002 Other Drugs 7% 1% 1 283.01.0001 Days of Use 10.2 10.8 469-0.49 ns - 27 -