Although Mental Health Residential Rehabilitation Treatment Programs (MH RRTPs) are resource-intensive, they continue to be a vital part of the Veterans Affairs (VA) mental health system. These programs serve "Veterans with mental illnesses or addictive disorders who require additional structure and support to address multiple and severe psychosocial deficits, including homelessness and unemployment" (VHA HANDBOOK 1162.02). While MH RRTPs have unique treatment cultures and practices, recent factors (e.g., endorsement of the MH RRTP Handbook) have put significant pressure on programs to implement common core standards and practices, manage costs, and improve outcomes. Most recently, a 2011 follow-up report by the VA Office of the Inspector General (OIG) found significant progress in MH RRTP Handbook implementation but noted persistent gaps in services.
The VA Substance Use Disorder (SUD) Quality Enhancement Research Initiative (QUERI) seeks to improve the quality of intensive SUD treatment and related care transitions, particularly within Substance Abuse Residential Rehabilitation Treatment Programs (SARRTPs), one type of MH RRTP. Although prior research studies and program evaluations have highlighted important clinical variability among the VA's SARRTPs, there are no reliable and valid metrics that might be used to monitor residential SUD treatment program structures, processes and outcomes, as well as to identify targets for quality improvement.
This study aims to: (a) develop and conduct initial validation of SARRTP-specific metrics that capture critical aspects of SARRTP access, pre-admission engagement, within-treatment processes, and post-discharge follow-up, and (b) obtain information about the structure and treatment processes of SARRTPs that cannot be gleaned from administrative data.
New metrics for residential SUD treatment program processes and practices were developed using fiscal year 2012 (FY12) administrative data and the following sources: (a) Mental Health Information System (MHIS) metrics, (b) processes of care emphasized in program evaluation reports (e.g., OIG), but not implemented in MHIS, and (c) other processes and outcomes prioritized by our operational partners in VA Office of Mental Health Services (OMHS) and Office of Mental Health Operations (OMHO). Next, the project team identified the study population of 97 VA residential SUD treatment programs (63 SUD RRTPs; 34 RRTPs with a SUD track) using data from the Northeast Program Evaluation Center (NEPEC).
Data calculated from the new metrics were then linked to results from the VA Program Evaluation and Resource Center's FY12 Drug and Alcohol Program Survey (DAPS) and NEPEC's MH RRTP Annual Survey for FY12 to create individualized program profile reports. Each report summarized the program's data on key metrics (e.g., wait time) and showed how the data compared to the national average for similar VA residential SUD treatment programs. The research team reviewed each report in order to highlight metrics in which the program was a high or low performer compared to the national average. This information was then used to tailor specific questions in the interview protocol.
Points of contact (typically program managers or directors) from the 97 identified programs were extracted from the DAPS and NEPEC databases. These potential participants were invited to participate in a telephone interview to discuss their program from pre-admission processes to follow-up care. To facilitate the interview, participants were asked to send relevant program materials (e.g., weekly programming schedule). Interviews were conducted via an online Microsoft Lync meeting so that participants could answer questions while simultaneously viewing their program's data. At the end of the interview, participants were asked to recommend front-line staff from their program who might be interested in participating in the study.
A total of 59 interviews were conducted, representing 63 participants from 44 unique treatment programs (35 SUD RRTPs and 9 RRTPs with a SUD track; facility-level response rate of 45%). There were four joint interviews (i.e., two program staff interviewed together). The interviewees were from 17 of the 21 VISNs having at least one residential SUD treatment program. Four participants declined to be audio-taped.
Preliminary observations indicate that the new metrics could be extremely useful in monitoring residential SUD treatment processes and practices. Data calculated from the new metrics were generally perceived as accurate and participants expressed interest in seeing regular updates, as well as a summary of best practices. Some key facilitators of high-value residential SUD care appear to be engagement while waiting, diverse programming, and solid aftercare planning. Some key challenges include meeting patient needs with existing staffing and addressing the diverse needs of a complex patient population. When discrepancies in the data were noted, participants described qualifying factors such as wait time influenced by patient preference or the detoxification post discharge metric not including treatment from non-VA providers.
These previously unavailable metric data combined with the findings from the interviews will enable us to describe the VA residential SUD landscape well enough to reveal points for immediate operational action and high-value targets for quality improvement. Data from the new metrics, especially when linked to data from the DAPS and NEPEC MH RRTP Annual Survey, will be valuable in future discussions with residential SUD treatment program leaders, our VA OMHS and OMHO partners, and VA QUERI researchers. Furthermore, these metrics will act as baseline data and outcome measures for future implementation evaluation and research.
None at this time.
Substance Abuse and Addiction