Clinical Assessment and Substance Abuse Treatment: The Target Cities Experience

5. The Target Cities Participants: From Centralized Intake to Treatment Entry

C H A P T E R 5 The Target Cities Participants: From Centralized Intake to Treatment Entry Ronald E. Claus, Nancy Barron, and Kimberly A. Pascual An individual’s access to substance abuse treatment can be influenced at multiple points in any particular treatment system. To gain entry to treatment, an individual must typically identify a provider, contact that provider for an appointment, attend and complete a pretreatment assessment, obtain a referral and a starting date for treatment, and, finally, begin attending treatment in a specific modality at a specific level of care. Each step of this process offers opportunities to improve system capabilities and to decrease roadblocks to treatment entry. Centralized intake as operationalized in the Target Cities Program was intended to both expedite treatment entry and ensure that participants entered appropriate treatment. The central intake concept has been implemented in a variety of locations and ways since the 1970s (Scott, Muck, & Foss, 2000). Research that evaluates CIUs and their effects on access and on individual and treatment system outcomes, however, is limited and conflicting. Wickizer et al. (1994) reported positive effects of a CIU on treatment outcomes for participants in the Washington State Substance Abuse Monitoring System, while Rohrer et al. (1996) reported negative findings in a central assessment and referral unit in Iowa. Differences in the structure and function of the CIUs in these two studies likely contributed to the divergent findings that were observed. Cautioning against a prevalent tendency to speak of central intake as a single model, Scott et al. emphasized the different ways in which Target Cities sites acted to centralize access to treatment. Each city offered its own context to introduce this intervention, described by 73 factors such as the number of access points, use of management information systems (MIS) technology, and matching and referral practices . The study of treatment access often attempts to identify predictors of pretreatment or early treatment dropout by focusing on client characteristics rather than on treatment system or environmental factors. This body of research has delivered contradictory findings (cf. Stark, 1992) and generally identified participant characteristics (such as sociodemographics) that are not subject to manipulation. Of the few studies that have reported on system factors and pretreatment dropout, most have focused on time to treatment entry. Festinger , Lamb, Kountz, Kirby, and Marlowe (1995) and Stasiewicz and Stalker (1999) found that fewer days between initial phone contact and scheduled intake appointment led to higher treatment show rates. Intervention at the system, rather than the participant, level may generate more practical solutions for treatment providers. For instance, Morrissey, Calloway, Johnson, & Ullman (1997) conceived of clients’ entry into treatment as a measure of the strength of the organizational ties among service system elements and, therefore, a measure of system integration. Despite the promise of improved access offered by centralized intake , at the outset of the Target Cities Program questions were nonetheless raised about its potential negative impact. Some argued that a single entry point was simply a barrier to treatment. Holding a pretreatment assessment at a place different from the treatment location might actually increase the time to treatment entry. Others voiced concern that an added step for persons seeking assessment would lead to increased dropout rather than increased access. This chapter summarizes treatment access findings for the Target Cities sites. Multiple-Site Findings Findings regarding access to treatment across the Target Cities sites are explored with data from database 2c and database 2e (Leahy, Stephens, Huff, & Kaye, chap. 2 in this volume). These databases contain initial referral and treatment information on a sample of participants who were followed for 6 to 12 months. Only those participants who were assessed at a CIU are discussed. Sample size varied by site: Chicago, n = 1,445; Cleveland, n = 1,242; Dallas, n = 430; Portland, n = 838; St. Louis, n = 310; San Francisco, n = 464. For these individuals, referral mode was characterized as drug-free, methadone 74 Ronald E. Claus et al. maintenance, therapeutic community, or other; level of care was defined as standard or intensive outpatient, short-term or long-term residential , or other; and referral environment was characterized as jail-based, community-based, hospital-based, or other. For participants who entered a program, the treatment mode, level of care, and environment were similarly described. Finally, time to treatment entry was calculated as the number of days between the date of CIU assessment and the date of entry into treatment. A series...