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IIR 95-011 – HSR&D Study

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IIR 95-011
Matching, Outcomes and Costs in Substance Abuse/Psychiatric Treatment
Christine Timko PhD
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: October 1997 - August 2001

BACKGROUND/RATIONALE:
This project’s goal is to improve the quality of care and reduce treatment costs for veterans with substance abuse and psychiatric problems.

OBJECTIVE(S):
This project is evaluating a patient-treatment matching strategy to improve residential treatment for substance abuse patients with psychiatric disorders. Its immediate objective is to examine whether the matching strategy results in more effective and cost-effective treatment in VA programs. We hypothesize that patients with severe clinical problems will have better outcomes when they are matched to service-intensive programs; patients with moderate problems will have better outcomes when they are matched to programs having a lower intensity of services. For both patient groups, community treatment should prove to be more cost-effective than hospital treatment.

METHODS:
The project utilized a stratified randomized design. We paired each of three VA hospital programs that treat dual diagnosis patients and are high on intensity with a nearby high-intensity community residential facility (CRF) that contracts with the VA. We also paired four VA hospital and four CRFs that are low on intensity. Veterans who applied for substance abuse treatment at VA facilities were randomly assigned to either the VA hospital or CRF. Patient assessments have been conducted at intake (N=230), discharge, and a 4-month follow-up. Primary outcomes are patients’ severity of substance abuse and psychiatric problems. Secondary outcomes are patients’ functional status and their VA and non-VA health care utilization and its costs.

FINDINGS/RESULTS:
Recent findings concern the first step of the project, involving nationwide surveys of VA mental health treatment programs. We compared psychiatric and substance abuse acute care programs, within both inpatient and residential modalities of care, on organization and staffing, clinical management practices and policies, and services and activities. Fully 412 (95% of those eligible) VA programs were surveyed. Some 40 percent to 50 percent of patients in psychiatric and substance abuse programs, in both inpatient and residential venues of care, had dual diagnoses. Although psychiatric programs had a sicker patient population, they provided fewer services, including basic components of integrated programs, than substance abuse programs did. There is a strong emphasis on the use of clinical practice guidelines, performance monitoring, and obtaining client satisfaction and outcome data in mental health programs. We suggest how psychiatric programs might better meet the needs of acutely ill and dually diagnosed patients.

IMPACT:
The matching strategy, if supported, can be used by decision-makers to enhance the therapeutic effectiveness and reduce the treatment costs of VA substance abuse and psychiatric services. It will be useful to system planners for identifying patient and system needs that can be addressed by new program initiatives and training approaches to ensure that the system includes the full range of treatment alternatives to which patients may be optimally matched. Substance abuse and psychiatric program managers will also find the matching strategy useful for clarifying and improving their program’s capacity to successfully treat substance abuse patients with psychiatric disorders. Individual case managers can use the matching treatment model to assess the capacity of components of their own system to meet the needs of individual clients.

PUBLICATIONS:

Journal Articles

  1. Chen S, Barnett PG, Sempel JM, Timko C. Outcomes and costs of matching the intensity of dual-diagnosis treatment to patients' symptom severity. Journal of substance abuse treatment. 2006 Jul 1; 31(1):95-105.
  2. Timko C, Sempel JM. Short-term outcomes of matching dual diagnosis patients' symptom severity to treatment intensity. Journal of substance abuse treatment. 2004 Apr 1; 26(3):209-18.
  3. Timko C, Sempel JM. Intensity of acute services, self-help attendance and one-year outcomes among dual diagnosis patients. Journal of Studies On Alcohol. 2004 Mar 1; 65(2):274-82.
  4. Timko C, Sempel JM, Moos RH. Models of standard and intensive outpatient care in substance abuse and psychiatric treatment. Administration and policy in mental health. 2003 May 1; 30(5):417-36.
  5. Timko C, Lesar M, Calvi NJ, Moos RH. Trends in acute mental health care: comparing psychiatric and substance abuse treatment programs. The journal of behavioral health services & research. 2003 Apr 1; 30(2):145-60.
  6. Timko C, Yu K, Moos RH. Demand characteristics of residential substance abuse treatment programs. Journal of substance abuse. 2000 Oct 1; 12(4):387-403.
  7. Timko C, Lesar M, Engelbrekt M, Moos RH. Changes in services and structure in community residential treatment facilities for substance abuse patients. Psychiatric services (Washington, D.C.). 2000 Apr 1; 51(4):494-8.
Book Chapters

  1. Timko C, Moos R. Trends in acute care for substance use in psychiatric patients. In: Directions in Addiction Treatment and Prevention. 8 ed. Long Island City, NY: The Hatherleigh Company, Ltd.; 2004. 63-73 p.
  2. Timko C, Moos R. Measuring the therapeutic environment. In: Campling P, Davies S, Farquharson G, editors. From Toxic Institutions to Therapeutic Environments: Residential Settings in Mental Health Services. United Kingdom: Gaskell Press, Royal College of Psychiatrists; 2004. Chapter 14. 143-156 p.
  3. Timko C, Moos RH, Finney JW. Models of matching patients and treatment programs. In: Craik K, Price R, Walsh WB, editors. New directions in person-environment psychology. Hillsdale, NJ: Erlbaum; 2000.
Conference Presentations

  1. Timko C, Sempel J, Moos RH. Models of Standard and Intensive Outpatient Care in Substance Abuse and Psychiatric Treatment. Paper presented at: VA HSR&D National Meeting; 2002 Feb 1; Washington, DC.
  2. Timko C. Person-environment psychology and mental health. Paper presented at: American Psychological Association Annual Convention; 2001 Aug 1; San Francisco, CA.
  3. Timko C, Moos R. Breaking into the black box of therapeutic communities: Studying organizational and treatment practices. Paper presented at: National Institute on Drug Abuse Annual Conference; 2000 Aug 1; San Francisco, CA.
  4. Timko C, Moos R, Finney J. Person-environment matching in substance abuse and psychiatric treatment. Paper presented at: American Psychological Association Annual Convention; 2000 Aug 1; Washington, DC.
  5. Timko C, Yu K, Moos RH. Demand characteristics of residential substance abuse treatment programs. Paper presented at: VA HSR&D National Meeting; 2000 Mar 22; Washington, DC.


DRA: Mental, Cognitive and Behavioral Disorders, Substance Abuse and Addiction, Health Systems
DRE: Epidemiology, Technology Development and Assessment
Keywords: Dual diagnosis – substance abuse and mental health, Patient outcomes
MeSH Terms: Diagnosis, Dual