The staff workplace and the quality and outcome of substance abuse treatment.

Abstract: A comprehensive assessment of organizational functioning and readiness for change (ORC) was developed based on a conceptual model and previous findings on transferring research to practice. It focuses on motivation and personality attributes of program leaders and staff, institutional resources, and organizational climate as an important first step in understanding organizational factors related to implementing new technologies into a program. This article describes the rationale and structure of the ORC and shows it has acceptable psychometric properties. Results of surveys of over 500 treatment personnel from more than 100 treatment units support its construct validity on the basis of agreement between management and staff on several ORC dimensions, relationships between staff organizational climate dimensions and patient engagement in treatment, and associations of agency resources and climate with organizational stability. Overall, these results indicate the ORC can contribute to the study of organizational change and technology transfer by identifying functional barriers involved.

Abstract: Enhancing the functioning of parents, teachers, juvenile justice authorities, and other health and mental heal professionals who direct children and adolescents to services is a major mental health services concern. The Gateway Provider Model is an elaborated testable subset of the Network-Episode Model (NEM; B. A. Pescosolido & C. A. Boyer, 1999) that synthesizes it with Decision (D. H. Gustafson, et al., 1999) and organizational theory (C. Glisson, 2002; C. Glisson & L. James, 1992, 2002). The Gateway Provider Model focuses on central influences that affect youth’s access to treatment, i.e., the individual who first identifies a problem and sends a youth to treatment (the “gateway provider”); and the need those individuals have for information on youth problems and relevant potential resources. Preliminary studies by the authors and other applicable studies (D. Carise & O. Gurel, 2003) show that providers’ perception of need, and their knowledge of resources, and their environment are related to the decision to offer or refer to services, supporting key aspects of the Model.

Abstract: Background: Accumulating evidence indicates that addiction and psychiatric treatment programs that actively promote self-help group involvement can reduce their patients' health care costs in the first year after treatment, but such initially impressive effects may wane over time. This paper examines whether the positive clinical outcomes and reduced health care costs evident 1 year after treatment among substance-dependent patients who were strongly encouraged to attend 12-step self-help groups were sustained at 2-year follow-up. Methods: A 2-year quasi-experimental analysis of matched samples of male substance-dependent patients who were treated in either 12-step–based (n=887 patients) or cognitive-behavioral (CB, n=887 patients) treatment programs. The 12-step–based programs placed substantially more emphasis on 12-step concepts, had more staff members “in recovery,” had a more spiritually oriented treatment environment, and promoted self-help group involvement much more extensively than did the CB programs. The 2-year follow-up assessed patients' substance use, psychiatric functioning, self-help group affiliation, and mental health care utilization and costs. Results: As had been the case in the 1-year follow-up of this sample, the only difference in clinical outcomes was a substantially higher abstinence rate among patients treated in 12-step (49.5%) versus CB (37.0%) programs. Twelve-step treatment patients had 50 to 100% higher scores on indices of 12-step self-help group involvement than did patients from CB programs. In contrast, patients from CB programs relied significantly more on outpatient and inpatient mental health services, leading to 30% lower costs in the 12-step treatment programs. This was smaller than the difference in cost identified at 1 year, but still significant ($2,440 per patient, p=0.01). Conclusions: Promoting self-help group involvement appears to improve posttreatment outcomes while reducing the costs of continuing care. Even cost offsets that somewhat diminish over the long term can yield substantial savings. Actively promoting self-help group involvement may therefore be a useful clinical practice for helping addicted patients recover in a time of constrained fiscal resources.

Abstract: To consider key issues in understanding effective treatment and recovery, the author reviews selected principles and unresolved puzzles about the context of addictive disorders and the structure, process, and outcome of treatment. The principles focus on the process of problem resolution, the duration and continuity of care, treatment provided by specialist versus nonspecialist providers, alliance and the goals and structure of treatment, characteristics of effective interventions, and the outcome of treatment versus remaining untreated. The unresolved puzzles involve how to conceptualize service episodes and treatment careers, connections between the theory and process of treatment, effective patient–treatment matching strategies, integration of treatment and self-help, and the development of unified models to encompass life context factors and treatment within a common framework. There has been an expanding cornucopia of research on addictive behaviors in the past 30 years. We have formulated conceptual models, measured key constructs, examined salient theoretical issues, and made substantial progress in understanding the ebb and flow of addictive disorders. An integrated biopsychosocial orientation and a theoretical paradigm of evaluation research have supplanted earlier adherence to an oversimplified biomedical model and reliance on a restrictive methodological approach to treatment evaluation. And yet, in an ironic way, more remains to be done than before, in part because of our increased knowledge and in part because of new clinical perspectives and treatment procedures and the evolving social context in which we ply our trade. Here, I set out seven principles that exemplify advances in our effort to understand the processes involved in effective treatment and recovery. I then describe some unresolved puzzles and important questions for future research. Principles: What We Know or Think We Know

Abstract: An 18-item version of the Client Satisfaction Questionnaire (CSQ-18) was included in an experimental study of the effects of pretherapy orientation on psychotherapy outcome. The psychometric properties of the CSQ-18 in this study were compared with earlier findings. In addition, the correlations of the CSQ-18 with service utilization and psychotherapy outcome measures were examined. Results indicated that the CSQ-18 had high internal consistency (coefficient alpha = .91) and was substantially correlated with remainer-terminator status (rs = .61) and with number of therapy sessions attended in one month (r = .54). The CSQ-18 was also correlated with change in client-reported symptoms (r = -.35), indicating that greater satisfaction was associated with greater symptom reduction. Results also demonstrated that a subset of items from the scale (the CSQ-8) performed as well as the CSQ-18 and often better. The excellent performance of the CSQ-8, coupled with its brevity, suggests that it may be especially useful as a brief global measure of client satisfaction.

Abstract: Subjects (A' = 970) representing five stages of smoking cessation (precontemplation, contemplation,action, maintenance, and relapse) were given a 65-item test measuring 10 basic processes of change.Subjects recorded the last time they quit smoking, their current use, the frequency of occurrence,and the degree of item helpfulness. A 40-item questionnaire provided highly reliable measures of 10processes of change, labeled (a)consciousness raising, (b) dramatic relief, (c) self-liberation, (d)socialliberation, (e) counterconditioning, (f) stimulus control, (g) self-reevaluation, (h) environmental re-evaluation, (i) reinforcement management, and (j) helping relationship. In a confirmatory analysis,770 subjects were assessed 6 months later. The analysis both confirmed the 10-process model andrevealed two secondary factors, Experiential and Behavioral, which were composed of 5 processeseach and reflected hou. individuals in particular stages use more lhan I process at a time. The trans-theoretical model of change and available external validity evidence are reviewed.

Abstract: A significant portion of health care resources are spent in intensive care units with, historically, up to two-fold variation in risk-adjusted mortality. Technological, demographic, and social forces are likely to lead to an increased volume of intensive care in the future. Thus, it is important to identify ways of more efficiently managing intensive care units and reducing the variation in patient outcomes. Based on data collected from 17,440 patients across 42 ICUs, the present study examines the factors associated with risk-adjusted mortality, risk-adjusted average length of stay, nurse turnover, evaluated technical quality of care, and evaluated ability to meet family member needs. Using the Apache III methodology for risk-adjustment, findings reveal that: 1) technological availability is significantly associated with lower risk-adjusted mortality (beta = -.42); 2) diagnostic diversity is significantly associated with greater risk-adjusted mortality (beta = .46); and 3) caregiver interaction comprising the culture, leadership, coordination, communication, and conflict management abilities of the unit is significantly associated with lower risk-adjusted length of stay (beta = .34), lower nurse turnover (beta = -.36), higher evaluated technical quality of care (beta = .81), and greater evaluated ability to meet family member needs (beta = .74). Furthermore, units with greater technological availability are significantly more likely to be associated with hospitals that are more profitable, involved in teaching activities, and have unit leaders actively participating in hospital-wide quality improvement activities. The findings hold a number of important managerial and policy implications regarding technological adoption, specialization, and the quality of interaction among ICU team members. They suggest intervention "leverage points" for care givers, managers, and external policy makers in efforts to continuously improve the outcomes of intensive care.

Abstract: Objective This study examines the relationships among organizational culture, quality improvement processes and selected outcomes for a sample of up to 61 U. S. hospitals. Data sources and study setting Primary data were collected from 61 U. S. hospitals (located primarily in the midwest and the west) on measures related to continuous quality improvement/total quality management (CQI/TQM), organizational culture, implementation approaches, and degree of quality improvement implementation based on the Baldrige Award criteria. These data were combined with independently collected data on perceived impact and objective measures of clinical efficiency (i.e., charges and length of stay) for six clinical conditions. Study design The study involved cross-sectional examination of the named relationships. Data collection/extraction methods Reliable and valid scales for the organizational culture and quality improvement implementation measures were developed based on responses from over 7,000 individuals across the 61 hospitals with an overall completion rate of 72 percent. Independent data on perceived impact were collected from a national survey and independent data on clinical efficiency from a companion study of managed care. Principal findings A participative, flexible, risk-taking organizational culture was significantly related to quality improvement implementation. Quality improvement implementation, in turn, was positively associated with greater perceived patient outcomes and human resource development. Larger-size hospitals experienced lower clinical efficiency with regard to higher charges and higher length of stay, due in part to having more bureaucratic and hierarchical cultures that serve as a barrier to quality improvement implementation. Conclusions What really matters is whether or not a hospital has a culture that supports quality improvement work and an approach that encourages flexible implementation. Larger-size hospitals face more difficult challenges in this regard.

Abstract: PART I. A SYSTEMS EVALUATION OF ALCOHOLISM TREATMENT: Evaluating and improving alcoholism treatment programs Objectives, methods, and assessment of treatment implementation Short-term outcome and patient prognosis The process and effects of treatment Gender and marital status in treatment and outcome PART II. EXTRATREATMENT FACTORS AND THE RECOVERY PROCESS: Life stressors, social resources, and coping responses Context, coping, and treatment outcome The process of recovery and relapse PART III. ALCOHOLISM AND THE FAMILY: Spouses of alcoholic partners Children of alcoholic parents PART IV. PRACTICAL APPLICATIONS: Improving treatment, work, and family settings Implications for treatment and program evaluation Index.