Factors that Influence Co-production among Student Interns, Consumers, and Providers of Social and Public Health Services: Implications for Interprofessional Collaboration and Training.

Providers of public health and social services ("providers") develop and deliver services by engaging in interprofessional collaboration (IPC), from seeking external advice to making referrals and linkages to various social and public health services. Providers collaborate with consumers of social and public health services ("consumers") and student interns (e.g., social work, public health) to explore, determine, and deliver relevant services through a process referred to as co-production. Both IPC and co-production are widespread strategies with the potential to improve service accessibility and quality. However, the intersection of co-production and IPC remains understudied. This study examines factors that influence co-production in IPC among service providers, consumers, and student interns. We used cross-sectional survey data from an NIMH-funded study, including 379 providers in 36 HIV-service organizations in New York City. We examined the relationships between providers' perspectives on co-production in IPC and multiple provider- and organization-level variables using random-effects logistic regression. Most respondents said that consumers and students in their agency participate in IPC on the issues that concern them. Providers who perceive greater flexibility in the IPC process were more likely to agree that their organizations' providers co-produced IPC. Organizational service offerings (i.e., multilingual services, a comprehensive range of services), job positions, and full-time employment status were strong predictors of co-production. Our findings indicate that intentional and inclusive models of flexible IPC are needed. Fostering co-production in the HIV service field requires more institutional support and incentives for organizations, providers, and student interns. Implications for research and practice are discussed.

Community engagement in dissemination and implementation models: A narrative review.

Background: Responding to the growing demand for scientific understanding of adoption and uptake of evidence-based interventions (EBIs), numerous dissemination and implementation ("D&I") models have been proposed in the extant literature. This review aimed to identify community-specific constructs with the potential to help researchers engage community partners in D&I studies or deploy EBIs. Methods: We identified 74 D&I models targeting community-level changes. We built on Tabak et al.'s narrative review that identified 51 D&I models published up to 2012 and identified 23 D&I models published between 2012 and 2020 from the Health Research & Practice website (16 models) and PubMed database (7 models). Three coders independently examined all 74 models looking for community-specific engagement constructs. Results: We identified five community engagement constructs: (1) Communication, (2) Partnership Exchange, (3) Community Capacity Building, (4) Leadership, and (5) Collaboration. Of the 74 models, 20% reflected all five constructs; 32%, four; 22%, three; 20%, two; and 5%, only one. Few models with strong community content have been introduced since 2009. Conclusion: This article bridges the community-engaged and D&I research literature by identifying community engagement constructs reflected in existing D&I models, targeting community-level changes. Implications for future research and practice are discussed. Plain language summary: Responding to the growing demand for scientific understanding of adoption and uptake of evidence-based interventions (EBIs), numerous dissemination and implementation ("D&I") models have been proposed. This review aimed to identify community-specific constructs with the potential to help researchers engage community partners in D&I studies or deploy EBIs. We identified 74 D&I models targeting community-level changes, published between 2012 and 2020. Three coders independently examined all 74 models looking for community-specific engagement constructs. We identified five community engagement constructs: (1) Communication, (2) Partnership Exchange, (3) Community Capacity Building, (4) Leadership, and (5) Collaboration. Of the 74 models, 20% reflected all five constructs; 32%, four; 22%, three; 20%, two; and 5%, only one. This article identified community engagement constructs reflected in existing D&I models targeting community-level changes. Implications for future research and practice are discussed.

Patient-centered care's relationship with substance use disorder treatment utilization.

BACKGROUND: Calls for more patient-centered care are growing in the substance use disorder (SUD) treatment field. However, evidence is sparse regarding whether patient-centered care improves access to, or utilization of, effective treatment services. METHODS: Using nationally representative survey data from SUD treatment clinics in the United States, we examine the association between patient-centered clinical care and the utilization of six services: methadone, buprenorphine, behavioral treatment, routine medical care, HIV testing, and suicide prevention counseling. We measured clinics' practice of and emphasis on patient-centered care with two variables: (1) whether the clinic regularly invites patients into clinical decision-making processes, and (2) whether supervisors believe in patient-centered healthcare and shared decision-making practices within their clinics. RESULTS: In 2017, only 23% of SUD treatment clinics regularly invited patients into care decision-making meetings when their cases were discussed. A composite variable captured clinical supervisors' own experience with and expectations for patient-clinician interaction within their clinics (Cronbach's alpha = 0.79). Results from regression models that controlled for several organizational and environmental factors show that patient-centered care was independently associated with greater utilization of four of six evidence-based services. CONCLUSIONS: A minority of SUD clinics practice patient-centered healthcare in the United States. Given the connection to evidence-based services, increasing participatory mechanisms in SUD treatment service provision can facilitate patients' access to appropriate and evidence-based services.

Correlates of Patient-Centered Care Practices at U.S. Substance Use Disorder Clinics.

OBJECTIVE: Substance use disorder treatment professionals are paying increased attention to implementing patient-centered care. Understanding environmental and organizational factors associated with clinicians' efforts to engage patients in clinical decision-making processes is essential for bringing patient-centered care to the addictions field. This study examined factors associated with patient-centered care practices in substance use disorder treatment. METHODS: Data were from the 2017 National Drug Abuse Treatment System Survey, a nationally representative survey of U.S substance use disorder treatment clinics (outpatient nonopioid treatment programs, outpatient opioid treatment programs, inpatient clinics, and residential clinics). Multivariate regression analyses examined whether clinics invited patients into clinical decision-making processes and whether clinical supervisors supported and believed in patient-centered care practices. RESULTS: Of the 657 substance use disorder clinics included in the analysis, about 23% invited patients to participate in clinical decision-making processes. Clinicians were more likely to engage patients in decision-making processes when working in residential clinics (compared with outpatient nonopioid treatment programs) or in clinics serving a smaller proportion of patients with alcohol or opioid use disorder. Clinical supervisors were more likely to value patient-centered care practices if the organization's administrative director perceived less regional competition or relied on professional information sources to understand developments in the substance use disorder treatment field. Clinicians' tendency to engage patients in decision-making processes was positively associated with clinical supervisors' emphasis on patient-centered care. CONCLUSIONS: A minority of U.S. substance use disorder clinics invited patients into clinical decision-making processes. Therefore, patient-centered care may be unavailable to certain vulnerable patient groups.

Representative Bureaucracy Through Staff With Lived Experience: Peer Coproduction in the Field of Substance Use Disorder Treatment.

This study extends the representative bureaucracy literature by theorizing and empirically testing how staff sharing lived experience with service users can serve as user representatives in service provision processes (i.e., the peer coproduction mechanism). Using survey data from a representative sample of substance use disorder treatment clinics in the United States, we explore factors associated with descriptive representation (the presence of staff with firsthand experience of a substance use disorder in both frontline treatment and senior positions) and directors' perceptions of recovering staff's potential to serve as user representatives in individual care and organizational decision-making processes. Recovering staff accounted for a third of the field's workforce, but the majority of the clinics did not employ them in senior staff positions. Regression results suggest that organizational leaders' recognition of recovering staff's unique representation capacities may facilitate greater descriptive representation and grant meaningful organizational decision-making authority to recovering staff. Multiple research and practice implications are discussed.

Coproduction in the Treatment of Substance Use Disorder and Its Relationship to Clinics' Service Output Patterns.

Health, social, and human service providers seek diverse ways to engage service users in the service production process. This approach to engagement with users is known as "coproduction." In addition to conventional user-provider coproduction (i.e., patient-centered care), providers attending to stigmatized and marginalized groups may hire staff who share life experiences with user groups. These providers are known as "user representatives," and their service provision is known as "peer coproduction." Using nationally representative data from substance use disorder treatment clinics in the United States, I investigate how clinics' use of patient-centered care and peer coproduction mechanisms is associated with organizational service availability and utilization patterns. Results demonstrate the potential and limitations of the two coproduction mechanisms in substance use disorder treatment. This study is a critical examination of working conditions and the impact of user-engagement mechanisms and calls for a more empowered work environment in human service organizations.

A client-centered relational framework on barriers to the integration of HIV and substance use services: a systematic review.

BACKGROUND: Given the close connection between human immunodeficiency virus (HIV) infection and substance use disorder (SUD), access to integrated HIV and SUD services is critical for individuals experiencing both challenges and their biopsychosocial conditions. METHOD: Adopting an integrative method, this systematic review included 23 empirical studies published between 2000 and 2018. Articles investigated providers' and clients' perspectives on barriers to accessing integrated HIV and SUD services in various service settings (e.g., HIV primary care, SUD treatment, pharmacy). RESULTS: Using a client-centered relational framework, we identified barriers in three relational domains with "the client" as the focus of each: client-provider, client-organization, and client-system. The review shows that (1) barriers to HIV and SUD services do not exist in isolation, but in the dynamics within and across three relational domains; (2) service providers and clients often have different perceptions about what constitutes a barrier and the origin of such barriers; and (3) interprofessional and interorganizational collaborations are crucial for integrating HIV and SUD services. CONCLUSION: This review points out the limitations of the conventional paradigm grouping barriers to service integration into isolated domains (client, provider, organization, or system). Reforms in service arrangements and provider training are recommended to address barriers to integrated services.

Evidence-based treatment for opioid use disorders: A national study of methadone dose levels, 2011-2017.

The nation's methadone maintenance treatment (MMT) programs play a central role in addressing the current opioid epidemic. Considerable evidence documents the treatment effectiveness of MMT and, in turn, the importance of adequate dosing to MMT's effectiveness. Yet, as recently as 2011, 41% of patients received doses below the level of 80 mg/day. Using survey data from a nationally representative sample of MMT programs in 2011 and 2017, we examine (1) the extent to which the nation's MMT programs are meeting evidence-based standards for methadone dose level and (2) characteristics of MMT programs that are associated with variation in performance. Our results show that 43% of MMT patients receive <80 mg/day in 2017, and 23% of methadone maintenance patients receive daily doses below 60 mg. Results from multivariate regression analysis of the 2017 survey data show that private for-profit and public organizations significantly under-dosed patients compared to private nonprofit providers. Under-dosing also was more common in programs that serve high proportions of African-American patients. These results are concerning because MMT remains the medication of choice for vulnerable patients with the most severe opioid use disorders, and for-profit providers treat a growing proportion of MMT patients.

Medicaid retrenchment politics: fragmented or unified?

Medicaid has grown substantially over time; indeed, more than half of all Americans have some connection to the program. Considering that Medicaid retrenchment is the centerpiece of recent proposals to repeal and replace the Patient Protection and Affordable Care Act, we ask: How will the American public react to massive reductions in Medicaid funding? Using a nationally representative survey, our study investigates whether adults with elderly parents who have used long-term care services and supports (LTSS), compared to other constituency groups, (1) perceive the Medicaid program as more important, (2) are more knowledgeable about program benefits, and (3) are more likely to oppose Medicaid funding cuts. Results show that people with any connection to the Medicaid program are more likely to view the program as important than those with no connection. However, when it comes to understanding specific Medicaid benefits and protecting Medicaid against retrenchment, adults with elderly parents who have used LTSS are significantly more knowledgeable and more likely to favor protection, compared both to other connected groups and the nonconnected. These findings suggest that Medicaid retrenchment politics could be characterized by fragmentation and infighting among constituency groups, unless significant mobilizing work is done to create a broad-based Medicaid coalition.

The Politics of Medicaid: Most Americans Are Connected to the Program, Support Its Expansion, and Do Not View It as Stigmatizing.

Policy Points: More than half of Americans are connected to the Medicaid program-either through their own coverage or that of a family member or close friend-and are significantly more likely to view Medicaid as important and to support increases in spending, even among conservatives. This finding helps explain why Affordable Care Act repeal efforts faced (and will continue to face) strong public backlash. Policymakers should be aware that although renaming programs within Medicaid may have increased enrollment take-up, this destigmatization effort might have also increased program confusion and reduced support for Medicaid even among enrollees who say the program is important to them. CONTEXT: Since the 1980s, Medicaid enrollment has expanded so dramatically that by 2015 two-thirds of Americans had some connection to the program in which either they themselves, a family member, or a close friend is currently or was previously enrolled. METHODS: Utilizing a nationally representative survey-the Kaiser Family Foundation Poll: Medicare and Medicaid at 50 (n = 1,849)-and employing ordinal and logistic regression analyses, our study examines 3 questions: (1) are individuals with a connection to Medicaid more likely to view the program as important, (2) are they more likely to support an increase in Medicaid spending, and (3) are they more likely to support adoption of the Medicaid expansion offered under the Affordable Care Act? For each of these questions we examine whether partisanship and views of stigma also impact support for Medicaid and, if so, whether these factors overwhelm the impact of connection to the program. FINDINGS: Controlling for the strong effect of partisanship, people with any connection to the Medicaid program are more likely to view the program as important than those with no connection. However, when it comes to increasing spending or expanding the program, the type of connection to the program matters. In particular, adults with current and previous Medicaid coverage and those with a family member or close friend with Medicaid coverage are more likely to support increases in spending and the Medicaid expansion; but, those connected to Medicaid only through coverage of a child are no more likely to support Medicaid than those with no connection. CONCLUSIONS: Future research should probe more deeply into whether people with different types of connection to Medicaid view the program differently, and, if so, how and why. Moreover, future research should also explore whether state-level attempts to destigmatize Medicaid by renaming the program also serves to reduce knowledge and support for Medicaid.

The Racial Divide in State Medicaid Expansions.

This study considers five important questions related to the role of race in state-level public support for the Medicaid expansion: (1) whether public support for the Medicaid expansion varies across the American states; (2) whether public support is positively related to state adoption; (3) whether this support is racialized; (4) whether, if racialized, there is evidence of more state responsiveness to white support than to nonwhite (black and/or Latino) support; and (5) does the size of the nonwhite population matter more when white support is relatively low? Our findings suggest that while public support for the Medicaid expansion is high at the state level, especially in comparison to public support for the ACA, there are important variations across the states. Although overall public support is positively related to state adoption, we find that public support for the Medicaid expansion is racialized in two ways. First, there are large differences in support levels by race; and second, state adoption decisions are positively related to white opinion and do not respond to nonwhite support levels. Most importantly, there is evidence that when the size of the black population increases and white support levels are relatively low, the state is significantly less likely to expand the Medicaid program. Our discussion highlights the democratic deficits and racial bias at the state level around this important coverage policy.