We examined whether the implementation of TOD policy in San Francisco was associated with enhanced access to drug treatment and found that TOD was associated with limited improvement. Citywide the number of applicants on the waiting list improved significantly. The length of time waiting for treatment did not change; however, among facilities that received TOD funding, waiting time significantly increased.
The decrease in applicants on the waiting list is congruent with other research. Earlier our group documented that admissions increased when TOD was implemented (6
). The finding of increased waiting time to enter treatment among TOD-funded facilities was unexpected. One possibility is that programs retained people in treatment longer, hence increasing the wait time for those seeking treatment. A study of admissions (7
) indicated TOD involved a shift away from short-term services, and increased access into longer-term care. Alternatively, facilities may have used TOD funds to launch new programs, starting wait lists before accepting patients. Our data cannot test these hypothesized explanations.
The study has limitations that can be explored in future research. Foremost is the quality of treatment access measurement. DATAR was developed as an administrative tool, not a research instrument. Interviews revealed inconsistencies in the way data were gathered. More frequent training and monitoring could improve the system. In addition, the access measure, as practiced in San Francisco, did not include individual client identifiers, so it is not possible to determine whether more people applied for treatment under the TOD policy. Also we emphasize that access is a broader topic than the number of patients in line for treatment or their waiting time. Equally important issues may include geographic, financial, and cultural access to services, which were not measured.
Finally, the 23-facility sample in the TOD analysis is small and could affect the stability of slope estimates related to the access measures. Because this was a community initiative, the sample size was fixed. However, the stability of the estimate is affected not only by the number of facilities, but also by the data points per facility, which involved multiple months of observation. The confidence interval for the finding of decreased mean number of days waited by those admitted to treatment, although based on data from only 23 facilities, does not encompass zero, reflecting good stability of the estimate derived.
Future research should develop more specific and reliable measures of treatment access, and program staff would benefit from continued training in these data systems. Progress in this area could improve federal efforts to monitor national waiting lists for drug abuse treatment. In community-based service systems, policy decisions seldom wait for research findings to guide them. As budgetary shortfalls mounted in San Francisco, and throughout the country during the early 2000s, San Francisco remained committed to TOD, and overall substance abuse treatment funding continued to increase during the years 2000–2001 and 2001–2002. Fiscal year 2002–2003 marked the first actual decrease in treatment funding in San Francisco. The TOD Planning Council still exists, yet the task has become managing budget reductions rather than planning to increase services. The concept of “Treatment on Demand” remains an ideal, which was partially implemented in San Francisco. Results of the current study indicate that TOD had a detectable, though not dramatic, impact on the accessibility of services.