RD454 - Substance Abuse Services Council Annual Report and Plan - December 31, 2009


Executive Summary:
Treatment and Prevention Programs for Older Adults

Following up on a report in last year’s Council report, the Department of Behavioral Health and Developmental Services (DBHDS; formerly the Department of Mental Health, Mental Retardation and Substance Abuse Services) identified evidence-based practices effective for treating and preventing substance abuse in older adults. This population is growing significantly: by 2030 it will constitute 20 percent of the U.S. population. This population is especially vulnerable to stigma that inhibits access to treatment, and continued substance abuse in older persons can also create barriers to receiving other needed supports and services.

Evidence-based programs and practices for this population include:

• Motivational Interviewing, which addresses ambivalent attitudes towards addressing substance abuse issues;

• Motivational Enhancement Therapy, which is an enhancement of Motivational Interviewing;

• Relapse Prevention Therapy, a behavioral control program that teaches individuals to anticipate challenging situations and practice proven successful responses before the challenges occur;

• Cognitive-Behavioral Therapy, which teaches the person to identify the chain of antecedent situations that trigger habitually occurring behaviors and likely consequences of those behaviors. Therapy focuses on changing the behaviors (substance using behaviors, in this case) so that more desirable outcomes will occur.

• Brief Interventions, an approach that uses a limited number of short counseling sessions to increase awareness about the deleterious effects of substance misuse and abuse.

• Screening, Brief Intervention, Referral and Treatment, an approach particularly endorsed by the federal Substance Abuse and Mental Health Services Administration, is being utilized in Florida as a targeted approach to working with older adults. Individuals who screen likely to be misusing or abusing are engaged in a brief intervention. If the brief intervention is not successful, the person is referred to specialty substance abuse treatment. SBIRT is an approach that may be offered by a variety of providers as it does not require extensive training and may be offered in a variety of settings.

Recommendations:

In order to meet the needs of Virginia’s older adults with substance use disorders, the Substance Abuse Services Council recommends the following:

1. The Office of Substance Abuse Services of the Department of Behavioral Health and Developmental Services (OSAS/DBHDS) shall:

(a) Continue research on issues related to the needs of Virginia’s older adults with substance use disorders;
(b) Investigate additional evidence-based programs and practices demonstrated to be effective with an older adult population;
(c) Disseminate these findings to the statewide professional community; and
(d) Implement training in evidence-based practices and programs to ensure appropriate workforce development and training to meet the current and projected needs of Virginia’s growing older adult population.

2. The Commonwealth’s 40 community services boards (CSBs) shall be encouraged, but not mandated, to use the techniques described in this report to develop evidence-based, age-specific model programs that are similar to the effective and efficient examples recommended by SAMHSA and implemented successfully by other states. To maximize scarce resources, it is important that CSBs focus on the characteristics and needs of the populations they are serving. Those CSBs serving proportionately larger numbers of older adults—CSBs in rural areas, for example—should focus appropriate resources on identifying and meeting the needs of the older adult population in their service areas.

Personnel costs (salary/benefits for program coordinators and counselors, and consultation fees for physicians and psychologists) would be the principal expense incurred by community services boards in implementing evidence-based model programs for older adults. Overhead costs (rent, utilities, insurance, etc.) would be included within each CSB’s budget. Medicare, which covers all citizens over 65, is a major resource for reimbursement. It covers treatment for substance-related disorders in both inpatient and outpatient settings. To qualify for reimbursement, CSBs should take steps to become certified as Medicare providers.

3. The Substance Abuse Services Council shall collaborate with all responsible and interested parties (Federal government, State government, local government partners, advocacy groups, foundations and other not-for-profit organizations, etc.) to seek public support and sufficient funding to provide and expand critical services for Virginia’s older adults.

Report of the Services Outcomes Work Group of the Substance Abuse Services Council

A report published by the Joint Legislative Audit and Review Commission (JLARC), Mitigating the Cost of Substance Abuse in the Commonwealth (2008) urged the Substance Abuse Services Council to:

(1) establish common measures capturing their clients’ outcomes after treatment,
(2) determine where to obtain outcomes information needed across agencies, and
(3) design a process to collect the information from other agencies on an ongoing basis. (p. 66)

In response, the Council chair appointed a work group that included Council member agencies that are engaged in the provision of treatment services or that collect data about the effects of treatment. These agencies include:

• Department of Behavioral Health and Developmental Services (DBHDS)
• Department of Corrections (DOC)
• Department of Criminal Justice Services (DCJS)
• Department of Juvenile Justice (DJJ)
• Department of Education (DOE)
• Commission on Virginia Alcohol Safety Action Program (VASAP)

The Governor’s Office on Substance Abuse Prevention, also a Council agency, was also invited to provide some insight into the role of prevention in the continuum of services. However, the efforts of the work group were primarily focused on treatment services.

The work group decided to utilize the National Outcomes Measures (NOMs) as the basic framework for outcomes data. The NOMs were established by the Substance Abuse and Mental Health Services Administration (SAMHSA) as the dataset required for compliance with the federal Substance Abuse Prevention and Treatment Block Grant, the largest single source of nonstate funding for treatment and prevention in the Commonwealth. These funds are distributed to the forty community services boards (CSBs), and the CSBs provide the data on persons served. Each executive branch agency, however, has its own data set and data infrastructure. A major task of the work group was to identify and describe these for each agency. Each agency identified whether or not it was able to provide the outcome measures identified in the NOMs.

The work group also identified barriers to addressing the goals identified by JLARC. These included operational issues about how data is collected and stored, lack of a coordinating agency or authority, and lack of dedicated resources to support these efforts. Mindful that SJR 318 was very interested in program effectiveness, the Council agreed to endorse the recommendations of the work group to:

• Recommend that Senate Joint Resolution Study 318 (The Study of Models and Strategies for the Prevention and Treatment of Substance Abuse in the Commonwealth) support continuing the SASC Services Outcomes Work group to:

- Develop NOMs, including agency ability to utilize and link existing systems that collect outcome data, even though each agency has already established its own system for creating the unique individual identifiers necessary to track individual outcomes.

- Support the development of measures of program effectiveness that take into account the life-long, chronic nature of substance use disorders. - Recommend that DBHDS, DJJ and DOC prioritize development of a “data warehouse,” infrastructure, in collaboration with the State Compensation Board (which collects information about jail inmates), that would store, manage and use commonly collected data about shared consumers/inmates/residents/ supervisees.

- Strengthen the legal authority of DBHDS to collect consumer data from CSBs.

- Explore ways to integrate prevention outcome data to provide another perspective on the impact of services on communities over time.

- Identify system gaps and barriers, and prioritize strategies to address them, including human resources, hardware and software necessary to build an information technology system that can support these goals, and provide cost estimates of implementing such a system.

To support these requests, the SASC also requests that SJR 318 strengthen the mandate of DBHDS to collect data from CSBs and provide seed funding, when available, to address some of the gaps and barriers to developing a systemic approach to program evaluation across agencies.