The value of case management in the publicly funded substance abuse treatment system. The perspective of program directors, case managers and clients.

The many purposes of this article is to understand the role and value of case management from the perspective of program directors, case managers and clients. A survey of program directors from publicly funded substance abuse treatment programs in Boston was administered, and in-depth interviews with a sample of program directors, case managers, and clients were conducted. Case management allowed programs to serve more complex clients and increased time available for counselors to focus on the clinical needs of clients. From the perspective of case managers and clients, much of the value of case management came from educating clients about steps they could take to meet their needs and then supporting them in their efforts as they took these steps. Successful steps taken to deal with these needs helped lay the foundation necessary to confront the challenges of treatment. Program directors, case managers, and clients considered case management a valuable enhancement to substance abuse treatment.

HIV testing in substance abusers.

HIV testing among substance abusers in the United States is a significant public and individual health issue in need of further examination. We analyzed interview data gathered over 15 months in 1992 and 1993 from 2315 patients on presentation for addiction treatment to determine the frequency of and factors associated with previous HIV testing. Among this group of alcohol, heroin, and cocaine abusers, 53% (1231) reported previous HIV testing. Although in bivariate and multivariable analyses those with identifiable risk factors for HIV were more likely to have been tested, 27% of injection drug users, 38% with multiple sexual partners, and 39% of those with a history of a sexually transmitted disease (STD) had not been HIV tested. Other factors associated with previous HIV testing included having a primary care physician, the primary care physician's awareness of the patient's substance abuse problem, and having received prior addiction care. However, 38% of substance abusers who had previously received addiction treatment beyond detoxification had not been tested. Of those tested, 10% (n = 122) reported a positive test, and 7% (n = 81) had not received the test results. Of those with positive test results, 37% were not injection drug users. Promotion of HIV testing among alcohol and other drug abusers in both medical and substance abuse treatment settings should be a priority.

A community-wide infant mortality review: findings and implications.

The authors present the results of a community-wide infant mortality review, describe implications for the delivery of maternal and child health services, and discuss the value of such reviews in addressing local public health concerns. The review included an analysis of birth and death certificates and medical record data; maternal interviews; review of cases and development of recommendations by provider panels; and convening of community groups to develop strategies to improve the health and health care of women and infants. The review focused on 287 infant deaths during 1990-1993. More than half of all neonatal deaths were attributable to "previable" or "borderline viable" births. Sexually transmitted infections were the most frequently identified underlying risk, and smoking was the most frequently identified prenatal risk. Homelessness, physical and sexual abuse, and alcohol use were at least twice as likely among women whose babies died than among a high risk comparison group. Panelists identified fragmented health care over the course of women's reproductive lives as a predominant theme. The authors conclude that: (a) The focus of maternal and child health care should shift to a model of women's health care that addresses the chronicity of social and clinical risks. (b) Infant mortality reviews are a valuable tool for community education, systems review, and policy development and can be applied to other public health issues with local significance. (c) Expectations about the review process's ability to produce conclusions about causality or recommendations narrowly geared to reducing infant mortality rates need to be reframed. (d) The model will be strengthened by greater participation of families affected by infant death.

The functioning and well being of persons who seek treatment for drug and alcohol use.

We assessed the reliability of the Medical Outcomes Study Short Form Health Survey (SF-20) in a heterogeneous group of persons seeking drug and alcohol treatment. Patients (n = 2688) seeking detoxification and treatment at four intake sites for Addiction Treatment in Boston, Massachusetts, received all components of the SF-20 including physical, role, and social functioning; mental health; health perception and bodily pain. The primary drugs used were alcohol 38%, cocaine 38%, heroin 24%. Reliability coefficients for the MOS scales ranged from 0.70 to 0.92. Users of these three drugs had similar profiles among the health components. Sociodemographic characteristics in combination explained 2-7% of score variance. Alcohol and other drug use had little effect on physical or role function scores. Health perception and pain subscale scores were low. We conclude the MOS survey is a reliable measure of function and well being in this population. Like other chronic diseases, alcohol and drug use have powerful effects on quality of life.

Improving publicly funded substance abuse treatment: the value of case management.

OBJECTIVES: This study evaluated the impact of case management on client retention in treatment and short-term relapse for clients in the publicly funded substance abuse treatment system. METHODS: A retrospective cohort design was used to study clients discharged from the following four modalities in 1993 and 1994: short-term residential (3112 clients), long-term residential (2888 clients), outpatient (7431 clients), and residential detox (7776 clients). Logistic regression models were used to analyze the impact of case management after controlling for baseline characteristics. RESULTS: The odds that case-managed clients reached a length of stay previously identified as associated with more successful treatment were 1.6 (outpatient programs) to 3.6 (short-term residential programs) times higher than the odds for non-case-managed clients. With the exception of outpatient clients, the odds of case-managed clients' being admitted to detox within 90 days after discharge (suggesting relapse) were about two thirds those of non-case-managed clients. The odds of case-managed detox clients' transitioning to post-detox treatment (a good outcome) were 1.7 times higher than the odds for non-case-managed clients. CONCLUSIONS: Case management is a low-cost enhancement that improves short-term outcomes of substance abuse treatment programs.

Physician unawareness of serious substance abuse.

PURPOSE: To describe and assess the prevalence of perceived physician unawareness of serious substance abuse. PATIENTS AND METHODS: We report an observational study with validation of multivariable results of data collected by interview from persons presenting for addictions treatment in the public system who reported having a physician. RESULTS: Of 3,253 patients interviewed, 87% (2,843) responded to the question about having a physician. Of 1,440 patients who stated that they had physicians, 45% (651) reported that the physician who cared for them was unaware of their substance abuse. In multivariable logistic regressions adjusting for sociodemographics, health status, and substance abuse histories, the following patient characteristics were found to be independently associated with physician unawareness of substance abuse and were confirmed in a validation analysis (OR = Odds Ratio, CI = 95% Confidence Interval); no prior episodic medical illness (OR = 1.98, CI = 1.35-2.92), no health insurance (OR = 1.89, CI = 1.33-2.70), no prior mental health treatment (OR = 1.75, CI = 1.06-2.88), no chronic medical illness (OR = 1.69, CI = 1.18-2.40), no prior substance abuse treatment (OR 1.64, CI 1.17-2.31), and no prior detoxification (OR = 1.54, CI = 1.14-2.22). CONCLUSIONS: Forty-five percent of patients with substance abuse serious enough to prompt a presentation for treatment stated that the physician who cared for them was unaware of their substance abuse. Patients without health insurance, a history of medical illness, or prior substance abuse or mental health treatment were more likely to have reported physician unawareness. Even among substance abusing patients requesting addiction treatment, many perceive that their physicians do not recognize their substance abuse.

Conference report: community-based health promotion--state of the art and recommendations for the future.

The evaluators of the Henry J. Kaiser Family Foundation Community Health Promotion Grants Program in the West and the Foundation brought together 21 researchers, funders, and community organizers with a variety of perspectives on community-based health promotion to share what has been learned to date and how that knowledge should be applied in the future. The two-day conference was divided into three sessions, covering conceptual, implementation, and evaluation issues. Specific topics were selected by the organizers with input from participants. Two papers were presented in each session, followed by comments from discussants and a general discussion involving the entire group. The dominant theme of the conference was the relationship between communities and outside institutions, focusing on problems with the current state of relations and how they might be improved in the future. All viewed building partnerships between communities and institutions as a desirable goal; however, the challenges involved in building effective partnerships are considerable and require a substantial investment to make them work. Recommendations that emerged from the discussions included explicitly acknowledging the diverse interests of the parties in community-based programs at the earliest stages of program planning; making a concerted effort to bridge the cultural gaps that exist among the parties; structuring funding to allow enough lead time for partnerships to develop or using social reconnaissance to identify strong existing partnerships; and integrating the evaluation more closely into the process of program development.

The effect of anonymous vs. nonanonymous rating conditions on patient satisfaction and motivation ratings in a population of substance abuse patients.

Patient self-report in evaluations involving alcohol and other drug abuse has generally been found to be reliable and valid. However, little is known about the variables associated with greater or lesser degrees of reliability and validity. This study was conducted to determine how motivation and satisfaction ratings obtained under anonymous conditions would compare with ratings obtained under nonanonymous conditions. Over the course of 12 months, 1397 subjects in the Boston Target Cities Project were assigned to either confidential or fully anonymous data collection procedures in an interrupted time-series design. Anonymity had either no effect on ratings or accounted for < 1% of the variance. Satisfaction and motivation ratings obtained under confidential conditions are probably as reliable and valid as ratings obtained under fully anonymous conditions.

Length of stay as an outcome in an era of managed care. An empirical study.

Longer length of stay (LOS) in substance abuse treatment, a standard measure of treatment success, conflicts with pressures from managed care. To maintain LOS as an outcome, we identified, for four modalities, LOS categories such that program completion rates were relatively constant within category and differed among categories. We validated the cutoffs by showing that future utilization over a 2-year period by clients differed by category. Clients in the long-LOS category used the system in a way consistent with more successful treatment. Thus, rather than using increase in LOS as an outcome, one can use increase in the percentage of clients reaching the long-LOS category. Categories were developed and utilization analyzed for discharges from publicly funded Boston treatment programs between 1/92 and 12/94 from the following modalities: short-term residential (5,462 discharges), long-term residential (5,086 discharges), outpatient (13,656 discharges), and detox (19,965 discharges).

Implementing the Boston Healthy Start Initiative: a case study of community empowerment and public health.

This article examines the efforts on the part of a city health department, in partnership with a broad-based coalition of community-based, government, and social service agencies, to plan and implement, using principles of empowerment and community participation, a federally funded infant mortality reduction program. It examines the social and institutional dynamics of sharing power in an environment highly charged politically. Infant mortality in Boston is much more than a public health problem. It is the focal point of complex racial, political, and institutional factors. This case study illustrates how empowerment moves from rhetoric to reality and the challenge to both traditional public health practice and traditional community mobilization. The article describes the federal Healthy Start Initiative and its community participation mandate, the background on infant mortality in Boston, a case study of the development of the Healthy Start program from the perspective of community empowerment, and finally, the lessons learned in the first 2 years of the program. It describes the controversies encountered, some of the mistakes made, and the ways found that government must be reinvented if empowerment is to be a real public health tool.

Evaluating risk communication: narrative vs. technical presentations of information about radon.

This paper reports on an experiment to test the hypothesis that people respond better to risk communication that reflects more closely the conditions of their social and cultural lives. The experiment used the case of radon to determine whether technical or narrative forms of risk communication were more effective at drawing people's attention, imparting information, and modifying behavior. Two series of articles on radon were placed in the local newspapers of two Massachusetts communities. Homeowner attitudes, knowledge, and responses were monitored in baseline and follow-up telephone surveys. A third community was selected for comparison. The newspaper series were developed on the basis of previous research and six focus groups conducted with homeowners. The technical series presented authoritative, factual risk information, in the scientific style of the passive voice with generalized and impersonal language. The narrative series consisted of dramatized accounts of individuals making decisions about radon testing and mitigation, written in a more personal style. The findings from the focus groups confirm the results of previous studies, but the small size of the follow-up samples was a limiting factor in drawing definitive conclusions about the relative effectiveness of the two formats. The experiment demonstrates the difficulty of any risk communication effort on radon and underscores the need for good research design.(ABSTRACT TRUNCATED AT 250 WORDS)

Access to primary health care: developing state and local strategies for high risk groups.

Competition and a rapidly changing market place have dramatically altered the dynamics of primary health care delivery in urban areas across the US, focusing new attention on access to care for the indigent. Public and private sector policymakers in Boston, Massachusetts, addressed these issues by examining the health status, payer coverage and availability of providers of primary health care for individuals at risk. Strategies were targeted in the areas of health insurance, reimbursement, and provider organisations to improve access to services at the state and local level.

Case mix in end-stage renal disease. Differences between patients in hospital-based and free-standing treatment facilities.

This study examines the mix of cases in facilities for the treatment of end-stage renal disease in Michigan during the period January 1973 through September 1981. We compared 3135 patients treated in 29 hospital-based facilities with 307 patients treated in five proprietary, free-standing facilities. Patients were assigned to one of five severity groups on the basis of age, race, primary renal diagnosis, and accompanying conditions. The five severity groups were differentiated by the probability of death in the first year of treatment and the risk of death over the course of treatment. We then compared the distribution of patients in the five severity groups in hospital-based facilities with that in free-standing facilities. Hospital-based facilities had a higher percentage of patients in the higher-severity groups. When severity was measured by one-year survival, the difference was statistically significant. Sixty per cent of hospital-based patients were in the three highest severity groups, as compared with 50 per cent of patients in free-standing facilities. Within each severity group, hospital-based patients had a lower five-year survival rate than patients in free-standing facilities. Our findings suggest that the case mix in hospital-based facilities may include more severe cases than that in proprietary, free-standing facilities, but more data from more facilities will be needed before firm conclusions can be drawn. If the cost of providing services is related to case-mix severity, such data could have implications for federal reimbursement policies.

Protecting the reproductive health of workers: problems in science and public policy.

This paper first reviews the scientific problems involved in assessing the effects on reproductive health of toxic substances in the work environment. It then describes the current status of regulatory policies designed to control workers' exposures to toxins believed to affect reproduction. Finally, the paper discusses the relationship between scientific uncertainty and regulatory strategies. Because demonstrating reproductive health effects is extremely difficult, the assessment of the health risks of exposures, as well as of the economic costs of regulation, is probabilistic. Therefore, uncertainty is inherent in any regulatory decision in this area. And the case of reproductive risks is illustrative of the more general problem of protecting the health of workers within a context of scientific uncertainty, and within a highly charged political environment characterized by anti-regulatory sentiment and industries in economic decline.

KIE: The authors begin their discussion of current public policy on reproductive hazards in the workplace by reviewing the problems inherent in scientifically assessing the effects of toxic substances on reproductive health. They then describe present regulatory policy in this area, using the lead standard of 1978 as an example of a good standard whose effectiveness has been compromised by Reagan administration changes. Valentine and Plough recommend a regulatory approach which accommodates scientific uncertainty and recognizes the difficulty of determining costs and benefits, but conclude that such an approach is unlikely to be adopted because of a shift in the economic and political balance of power.

Social and contextual factors in the analysis of mortality in end-stage renal disease patients: implications for health policy.

A sample of medical records of decreased End-Stage Renal Disease (ESRD) patients was reviewed by a panel of experienced clinicians. The panel's determination of cause of death was compared to that reported for these patients in the Health Care Financing Administration Management Information System. There was concurrence in only 25 per cent of the cases. The difference is attributable to increased awareness of psychosocial and behavioral antecedent factors surrounding the occurrence of death.

Nursing home levels of care: problems and alternatives.

Providers and recipients of nursing home care under Medicaid are currently classified into two levels of care to facilitate appropriate placement, care, and reimbursement. The inherent imprecision of the two level system leads to problems of increased cost to Medicaid, lowered quality of care, and inadequate access to care for Medicaid recipients. However, a more refined system is likely to encounter difficulties in carrying out the functions performed by the broad two-level system, including assessment of residents, prescription of needed services, and implementation of service plans. The service type-service intensity classification proposed here can work in combination with a three-part reimbursement rate to encourage more accurate matching of resident needs, services, and Medicaid payment, while avoiding disruption of care.