Substance abuse problems are a major source of dysfunction and reduced quality of life, and have high economic, medical, family, and social costs (Donnermeyer, 1997
; Mark, Woody, Juday, & Kleber, 2001
; Office of National Drug Control Policy, 2004
; Rosenheck & Kosten, 2001
; Substance Abuse and Mental Health Services Administration [SAMHSA], 2004). Despite these negative consequences, in 2005 only about 2.3 million of an estimated 23.2 million Americans with substance-related problems received some form of treatment, and many who sought help were unable to obtain treatment (SAMHSA, 2006
). In addition, only about 51% of those who enter care complete treatment (SAMHSA, 2002
). These findings show that substance-related problems remain under-addressed in our health care system, and that significant barriers exist for those who need care.
Such systemic problems suggest that major changes are needed to improve access and delivery of substance abuse treatment, yet poor treatment results have often been blamed on patients with little attention paid to the way care is organized or delivered, or the extent to which available care meets patient needs (Broome, Simpson, & Joe, 1999
). Recently, more attention has been focused on treatment facilities, their ability to engage and retain clients in treatment for prescribed lengths of time, and their ability to provide appropriate therapeutic services (Simpson, Joe, Rowan-Szal, & Greener, 1997
). Moreover, McLellan, Carise, and Kleber (2003)
have questioned whether the addictions service infrastructure, in its current form, can support adequate provision of high quality care.
In addition, a host of treatment access and other difficulties are compounded by problematic “business processes” that negatively affect individuals seeking care (Ebener & Kilmer, 2001
). Further, these problems are exacerbated by regulatory requirements that add additional barriers through increased paperwork, assessment requirements, and financial screening (Martin, 2005
; Soman, Brindis, & Dunn-Malhotra, 1996
). Together, these barriers can hinder initial intake assessments, delay entry into treatment, and lead to missed treatment opportunities (Farabee, Leukefeld, & Hays, 1998
; Hser, Maglione, Polinsky, & Anglin, 1998
To address these problems, the Robert Wood Johnson Foundation (RWJF) and the Center for Substance Abuse Treatment (CSAT) created a nationwide effort to identify and address barriers to access and retention in addiction treatment. The RWJF Paths to Recovery
initiative and CSAT Strengthening Treatment Access and Retention (STAR)
program formed a nationwide learning collaborative called the Network for the Improvement of Addiction Treatment (NIATx) (Capoccia, Cotter, Gustafson, Cassidy, Ford, Madden, Owens, Farnum, McCarty, & Molfenter, 2007
). NIATx provides collaborative learning opportunities and technical support to agencies so they can improve treatment access and retention. NIATx's central tenets are that patient-level outcomes are directly and indirectly affected by agency practices and policies, and by organizational influences (Heinrich & Fournier, 2005
), and that process improvement can make organizational systems more consumer friendly, improving outcomes.
Substance abuse treatment agencies seeking participation in the RWJF Paths to Recovery program submitted six-page letters of intent that are the focus of the work presented here. As part of the application process, and as an introduction to process improvement, Paths to Recovery applicants were given instructions for completing an admissions “walk-through” exercise and asked to describe their agency's strengths and weaknesses in their letter of intent, basing their answers on the “walk-through” findings.
Walk-throughs are typically conducted by an employee of an organization, assuming the role of a prospective client and interacting with the organization as would a client. Such walk-throughs enable organizations to better understand their clients' points of view; can uncover assumptions, inconsistencies, and limitations of systems; and can generate ideas for improving organizational processes (Gustafson, 2004
). Such patient-centered approaches have increasingly been called for to improve the quality of medical care (Institute of Medicine, 2001
This paper examines agency and process information submitted as part of the first round of Paths to Recovery letters of intent, focusing on use of patient-centered walk-through exercises and describing potential barriers to treatment identified in the context of these exercises. Based on this work, we describe the organizational processes agencies identified as having the potential to impede access to care or affect treatment continuation.