Lessons learned from implementing integrated mental health and substance use services in frontline addiction treatment facilities
An estimated 8.2 million adults in the United States live with co-occurring mental health and substance use disorders. Although this combination is very common and benefits of treatment services that target both conditions simultaneously by the same provider (i.e., integrated care) has been well-established, gaps in access to integrated care persist. This study examined the effectiveness of implementing integrated services into frontline addiction treatment organizations.
WHAT PROBLEM DOES THIS STUDY ADDRESS?
Despite the frequent co-occurrence between substance use disorders and other mental health concerns, many frontline addiction treatment facilities do not provide integrated care where the same provider, or team of providers, simultaneously addresses both concerns. Treatment administrators and clinical policy makers have engaged in sustained efforts to increase access to integrated treatment services. However, barriers to delivery of integrated care persist. Implementation science may serve to address this gap in treatment access. The goal of implementation research is to identify processes and factors related to successful, sustained development of evidence-based practices, programs, and policies. Given the need to enhance access to care for individuals with co-occurring disorders, implementation research can help us understand how well programs are incorporating evidence-based strategies into their treatment program. Ultimately, by modifying their approach to care in clinically useful ways, these programs are increasing the availability of quality care sensitive to the needs of individuals with co-occurring disorders. In this study, authors used a well-documented implementation strategy – the Network for the Improvement of Addiction Treatment (NIATx; a multi-faceted implementation strategy that combines process improvement with principles from industrial engineering) – to install and potentially sustain integrated treatment services for individuals with co-occurring disorders.
HOW WAS THIS STUDY CONDUCTED?
Study authors randomized outpatient treatment programs in Washington State to receive either the NIATx strategy initially (i.e., active training group) or one year later (i.e., the waitlist services as usual group), comparing how groups changed on programmatic measures of quality co-occurring disorder treatment over the course of one year. At the end of year one, the NIATx group transitioned into the sustainment phase, while the waitlist group began utilizing NIATx strategies.
Data were obtained during independent site visits conducted by trained evaluators at baseline and one-year follow up. Site visits included brief group and individual interviews with many program leaders, staff, and patients, as well as document reviews. The evaluators did not know to which group programs were assigned (i.e., blind to study group). Study participants were 49 community addiction treatment agencies across the State of Washington. Eligibility criteria included: outpatient and/or intensive outpatient services; tax-exempt status; government status or at least 50% publicly funded (e.g., block grants, Medicare, Medicaid); and no prior enrollment in NIATx research studies.
The authors hypothesized that organizations in the active NIATx study arm would demonstrate greater gains in integrated service capacity compared to the waitlist group. Outcomes were analyzed in two ways. In the first, the authors compared the active NIATx group to the waitlist control group, whether or not they adhered to the NIATx implementation strategy, as long as data from at least one of the two assessments/time periods were available (i.e., intent-to-treat analysis). In the second, the study compared active NIATx to the waitlist group, but only for NIATx assigned organizations that fully adhered to the NIATx protocol (i.e., per-protocol analysis). To be considered fully adherent, an agency had to complete all NIATx related activities and spend an average or higher amount of time in training activities.
Authors identified three classes of adolescent alcohol use.
To assess gains in integrated services capacity, the authors used the Dual Diagnosis in Addiction Treatment (DDCAT) Index collected by independent evaluators during onsite visits. The DDCAT is a widely used comprehensive instrument to evaluate integrated services capacity at the organizational level across seven dimensions that assess policy, clinical practices and workforce domains. The DDCAT consists of 35 benchmark items across the seven dimensions which are: 1) Program Structure; 2) Program Milieu; 3) Clinical Process: Assessment; 4) Clinical Process: Treatment; 5) Continuity of Care; 6) Staffing; and 7) Training. It also provides a total score reflective of all seven dimensions.
The NIATx implementation strategy included a coach led site visit, individual site coaching calls, group coaching calls, and learning sessions. For a typical program, their coach made contact approximately two weeks after an initial assessment visit where baseline DDCAT scores were obtained. That call was followed up with a site visit planning call two weeks later. Typically, the site visit occurred a month after the site visit planning call, but the actual timing was dependent on program staff member availability. The first cohort-wide learning session occurred in October/November which was after the site visit for all but three programs. After the site visit, individual coaching calls occurred approximately every 40 days, but the actual number of calls varied by program. Two group coaching calls occurred in February and May. The NIATx implementation concluded at the end of June after a wrap-up learning session.
WHAT DID THIS STUDY FIND?
Organizations varied widely in their capacity to implement the NIATx strategy. Importantly, 52% of NIATx assigned organizations (13 of 25) did not adequately adhere to the implementation protocol.
Both the NIATx and waitlist arms showed improvements from baseline to one-year post active implementation in their overall integrated services capacity.
At baseline, organizations in the active NIATx condition arm had higher Dual Diagnosis in Addiction Treatment Index (DDCAT; degree of competency in treating patients with co-occurring disorders, the study’s primary outcome) total and dimension scores compared to waitlist. Both study arms showed improvements over time in the DDCAT total score and in all the seven dimensions scores. However, the two study arms were generally not different in their rate of change, except in the program milieu dimension, in which organizations in the NIATx strategy arm showed significantly greater improvement as compared to the waitlist. Program Milieu reflects how receptive and welcoming to persons with co‑occurring disorders an organization’s culture is (e.g., staff, physical environment).
When only examining change in organizations that fully adhered to the NIATx, there was an improvement in overall integrated services capacity in the NIATx arm compared to the waitlist.
Only 48% of organizations assigned to the NIATx arm had full adherence. The remaining organizations had partial or no adherence to NIATx, limiting their potential for growth. For this reason, another set of analyses were conducted with only organizations with sufficient adherence (i.e., per-protocol analyses). Here the study found that the NIATx arm demonstrated more improvement in their overall capacity for integrated services as well as in program milieu and continuity of care (i.e., addressing the long-term treatment needs of those with co-occurring disorders).
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
These results suggest that front-line addiction treatment providers are able to make meaningful changes to their practice in order to better accommodate the needs of individuals with co-occurring disorders. The finding that both study arms improved over the year may indicate that the audit and feedback alone (which were also provided to both the active NIATx and the waitlist control group) were useful to initiate important and significant changes in both study arms.
The findings also suggest that NIATx may be effective in implementing integrated services for persons with co-occurring substance use and mental health disorders if a program is adherent to the protocol. However, the differences between groups in the per-protocol analyses were modest. The groups were already different at baseline, so it’s possible this limited the amount of improvement they could make (i.e., ceiling effect) potentially leading to an unfair comparison.
Additionally, Washington state had a mandate for integrated care and programs volunteered to be in this study which could have led to a bias in motivation to improve their services with the changing landscape.
It is important to note that improvement in integrated services capacity does not equal improvement in patient outcomes. Additional research is needed to determine if that is the case. Historically, federally funded clinical trials networks (e.g., NIDA) have struggled to produce better outcomes with the implementation of empirically-support treatments when compared to services as usual under rigorous evaluation conditions. For now, all we know is that programs can improve their approach which has potential to impact consumers.
- A relatively small sample size of programs (N=50) – as was the case in this study – can mean that randomization does not always adequately even out comparison groups on important confounding variables. This was the case in this study. Baseline differences between the groups were not eliminated by randomization meaning that other variables could have influenced outcomes beyond whether programs received the NIATx help or not. Scores on the outcome measure also were quite high at the beginning of the study, thus there was a possible ceiling effect whereby there was little room to show improvement or uncover differential improvement.
- The per-protocol did not use an empirically informed threshold for what makes a program adherent to the training.
- Washington state had a mandate for integrated care and programs volunteered to be in the study which could have led to a self-selection bias in factors such as motivation and existing eagerness to improve their services with the changing landscape. This makes generalization of the findings to other programs difficult.
- Evaluators were not only from the same state as the organizations, they worked for a state organization that helped determine clinical policies and guidelines, which could have impacted programs’ ability to speak freely about the challenges they were facing.
- For individuals and families seeking recovery: Both the active NIATx and waitlist groups showed improvements from baseline to one-year post active implementation in their overall integrated services capacity. However, the two study arms were generally not different in their rate of change, except in how receptive and welcoming to persons with co‑occurring disorders an organization’s culture is. Despite the frequent co-occurrence between substance use disorders and other mental health concerns, many frontline addiction treatment facilities do not provide integrated care. Thus, if you are a person (or supporting a person) interested in recovery who has co-occurring needs please choose your provider wisely. With new state mandates for integrated services, programs are working to provide integrated services for individuals with co-occurring disorders but have done so to varying degrees. Looking for a provider is an important decision. Ask program staff directly about the services they have to offer for co-occurring disorders to see how well equipped they are to meet you or your family’s needs before deciding on a program, if you have more than one choice. Please see our guide to identifying quality addiction treatment for some helpful tips.
- For treatment professionals and treatment systems: Both the active NIATx and waitlist groups showed improvements from baseline to one-year post active implementation in their overall integrated services capacity. However, the two study arms were generally not different in their rate of change, except in how receptive and welcoming to persons with co‑occurring disorders an organization’s culture is. Despite the frequent co-occurrence between substance use disorders and other mental health concerns, many frontline addiction treatment facilities do not provide integrated care. There are a series of complicated reasons for this and many barriers remain. However, results suggest that simply getting assessment and feedback about your facility’s capacity for integrated services is a good place to start. Having the most comprehensive care possible is essential to addressing the many needs of those seeking recovery.
- For scientists: The results of this paper suggest that the NIATx implementation strategy may be effective in improving integrated care capacity for the most training-adherent programs. Replication of this work is needed. Future work should include comprehensive assessment of factors that impact protocol adherence and ways to best support organizations as they attempt to implement new evidence-based practices. Despite less than ideal results, the authors provide an elegant model for future studies seeking to evaluate the effectiveness of a clinical training. Also, importantly, additional research is needed to determine if improvement in integrated service capacity leads to actual ultimate improvement in patients’ outcomes.
- For policy makers: The impetus for this study was a state-wide mandate for integrated services. The results of this paper suggest that the NIATx implementation strategy may be effective in improving integrated care capacity for the most training-adherent programs. The results also suggest that simply getting assessment and feedback about your facility’s capacity for integrated services can have a positive impact and may be as good place to start. Policy makers should investigate if the existing laws in their state address the issue of integrated services for those with co-occurring substance use disorders and other mental health concerns. If not, perhaps this is the time to consider amending these policies. Also, policy makers should consider investing in implementation science in this area.
Assefa, M. T., Ford, J. H., Osborne, E., McIlvaine, A., King, A., Campbell, K., Jo, B., & McGovern, M. P. (2019). Implementing integrated services in routine behavioral health care: primary outcomes from a cluster randomized controlled trial. BMC health services research, 19(1), 749. doi: 10.1186/s12913-019-4624-x