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Public Sector Treatment Outcomes:
A Changing Role for County/Local Authorities
— Robert C. Egnew, M.S.W., M.P.H., Past President, National Association of County Behavioral Health Directors,
Salinas, CA, and Director, Behavioral Health Division, Monterey County, CA, Health Department
Public policy decisions concerning managed care and welfare reform
have important implications for alcohol and other drug (AOD) delivery
systems operated by county and local authorities. Many county and local AOD
directors are anticipating and evaluating the impact of this reform for their
systems. In these new financial environments, there is a great need for
outcome measures to evaluate effectiveness and efficiency. One
of the key challenges that county directors face is how to define these
outcome measures.
What to Measure
Much re-evaluation of public-sector outcomes centers on the issue of
what to measure. Will such measures continue to focus solely on treatment
outcomes or will they encompass a broader range of performance
measures?
Historically, outcomes within public-sector AOD treatment systems
have focused on individual clinical successes. These individual
outcomes have been measured by rates of abstinence and/or rates of completed
treatment. In specific modalities, such as methadone maintenance
programs, arrest rates and other indicators have also been used as treatment
outcome indicators.
Traditionally, these treatment outcome measures have had a provider
focus; that is, they have measured the success of treatment for a particular
episode of care with a given provider. Based on these provider-specific
abstinence and completion rates, the conclusion generally drawn from this
particular set of treatment outcomes is that the longer an individual remains
in treatment, the greater the chance of recovery. However, this type of
out
come methodology does not address key questions. These questions
concern:
The effectiveness of any specific type of treatment
The appropriate duration of treatment
What frequency of services is most effective for a given set of clients
Treatment outcomes featuring abstinence and completion rates are
of limited usefulness. Because of this, local behavioral health authorities
have used these measures as only one part of their effort to evaluate
provider-specific programs.
The Changing Role of County Agencies
With the advent of both managed care and welfare reform, public-sector
AOD treatment systems are faced with the task of re-determining their public
mission. In the past, public-sector AOD services have suffered from the lack
of a concise or pragmatic mission. The field has long been plagued by
fundamental questions, such as:
Who is the public AOD system to serve?
How are these clients to be served?
What are the public policy objectives to be achieved?
The need to answer these public policy questions has been further
underscored by the move to managed care. Welfare reform simply intensifies
the need for answers.
Managed care and welfare reform present counties with a challenge
and an opportunity. Both these reform efforts have clearly defined the
target population that the public-sector AOD system is called upon to serve.
By focusing on Medicaid and welfare recipients, the public sector can begin
to define the number and types of persons who may utilize services.
Existing public-sector management information systems can make available
such data as the number, age, gender, ethnicity, aid code, and location
of eligible beneficiaries.
County public service systems can also evaluate what types of
programs and what levels of service capacity may need to exist in order to
provide care for specific target populations. Finally, welfare reform offers the
opportunity for the public sector to articulate a clear, concise, and pragmatic
mission that includes specific outcome objectives.
Broadening AOD Outcome Measures
Establishing a defined set of public objectives and a specific target
population both allows and compels county public-sector AOD authorities to
develop broader performance outcome measures that evaluate more
than abstinence and completed treatment episodes. Performance
outcomes need to become multidimensional to address key elements of
an individual's life beyond that person's chemical dependency issues.
The provision of public AOD services positively influences the utilization
and cost of a number of other publicly funded health, social service,
and criminal justice programs. It is, therefore, important that the county
AOD treatment system develop a shared responsibility with other agencies.
County and local AOD authorities need to develop horizontally integrated
service systems in cooperation with other public agencies. These
integrated service systems should incorporate a shared set of performance
outcome measures.
Because of managed care and welfare reform, public-sector AOD
providers and their integrated service systems need to develop performance
outcomes for broader problem measures. These measures should
incorporate such indicators as:
Employability/school participation
Incarceration rates
Use of out-of-home placements for youth
Utilization of emergency rooms and hospitalization
The number of drug-affected infants
Compliance with child welfare agreements
Welfare reform's emphasis on employment creates a new opportunity.
County AOD systems may now work collaboratively with local social
service departments to provide recovery services to clients who need these
treatment services to become employable.
Outcome measures for employability may include such indices as
obtaining and retaining a job, progress in school or vocational training, and, in the
case of youth, school attendance and academic achievement. These are
all objectives that need to be achieved if States and counties are to comply
with the work requirements of the Federal welfare reform legislation. To
reduce the utilization of costly emergency and hospital services, managed care
initiatives in either physical or behavioral health care require that AOD
services meet certain criteria, such as that they be provided on a timely basis, at
the right intensity, at the correct level of care, and for an appropriate duration
of time.
The New Systems-of-Care Approach
To achieve these outcomes and to implement new or expanded
public policy objectives effectively, public-sector AOD providers need to
provide a comprehensive spectrum of services for specific target populations.
This means that counties need to develop a systems-of-care approach. To
provide the full spectrum of both treatment and social support services needed
by individuals with severe addictive disorders, it is essential that AOD
services be coordinated with other health and social service agencies.
Systems of care require an interdependence among providers, so they
accomplish shared treatment goals and outcome measures. This
systems-of-care approach is significantly
different from the provider networks that have been established by most
public-sector AOD authorities. Existing provider networks typically consist of a
constellation of providers that operate independently. Improvements in
specific areas of client functioning require that treatment and service approaches
be coordinated among a variety of different programs and community
agencies. These programs include supported employment and
affordable, clean, and sober housing.
Linking Outcomes to Client Functioning
The future of AOD treatment outcomes is linked to improvements in
clients' functioning. The success of public-sector AOD clients is measured
by how well these clients are able to perform once they are in recovery.
Recovery in and of itself is only one ingredient in determining effectiveness.
The new test of effectiveness is whether clients are able to
capitalize on their recovery to achieve other life goals. As part of any
comprehensive AOD system of care, public-sector providers also have to incorporate
the teaching of appropriate adaptive skills.
Public-sector AOD delivery systems are evolving from their historic role
as a safety net into an emerging managed care environment. This shift
is creating an imperative to develop a broad range of valid and reliable
outcome measures. Such outcome measures should ensure that quality
services are accessible, efficiently delivered, and cost-effective.
These services also need to meet specific public policy objectives.
| Performance Measures For County Behavioral Health Systems |
County substance abuse agencies, like State agencies, face pressures to increase their performance evaluation.
The County Behavioral Health Performance Measures Project of the National Association of County Behavioral Health
Directors (NACBHD) responds to this need. The NACBHD, in conjunction with the Evaluation Center of the Human Services
Research Institute (HSRI), has developed a comprehensive set of performance measures intended to monitor and
improve quality for mental health and substance abuse systems.
This set of indicators is particularly relevant to service delivery at the county level. Performance measures are the
result of a roundtable meeting sponsored by the NACBHD. Behavioral health directors from 21 counties in 19 States
attended this meeting, representing all but one of the 20 States that have county-administered behavioral health systems.
Experts from a number of Federal agencies, including CSAT, participated in this roundtable. Each county participant selected
one domain to work on. For each domain, the groups identified three to five specific performance indicators, along with
associated measures. The group chose the following performance domains:
Access
Satisfaction of service recipients
Consumer outcomes
Intersystem outcomes
Utilization
For information about County Behavioral Health Performance Measures: Draft
Version, July 13, 1996, contact Lawrence Woocher at HSRI, phone 617-876-0426. In addition to the set of performance indicators, this document contains
summaries of indicators developed by 11 national and local organizations, as well as copies of 9 standard assessment
instruments.
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