Clinical Assessment and Substance Abuse Treatment: The Target Cities Experience

11. Lessons Learned from the National Target Cities Initiative to Improve Publicly Funded Substance Abuse Treatment Systems

C H A P T E R 11 Lessons Learned from the National Target Cities Initiative to Improve Publicly Funded Substance Abuse Treatment Systems Joseph Guydish, Richard C. Stephens, and Randolph D. Muck At the start of the Target Cities Program, the nation’s approach to substance abuse treatment suffered from several long-standing inadequacies : weak infrastructure, inconsistent quality of services, limited access to treatment, and inadequate service coordination and continuity. Authors of the previous chapters have illustrated those areas in which the Target Cities Program attempted to address those inadequacies. Some degree of success was achieved; however, in a project this large, diverse, and comprehensive, one might surmise that its goals would be reached only in part. The Activities and Goals of the Target Cities Program The Target Cities Program had an ambitious aim: to initiate and support changes in publicly funded substance abuse treatment systems in order to increase treatment access and improve treatment outcomes. CSAT prescribed activities that Target Cities should use to improve treatment systems and goals that these activities would support (U.S. Department of Health and Human Services [DHHS], 1990). As discussed in chapter 1, there were eight activities and four goals. Target Cities Required Activities As noted in chapter 1, CSAT did not require that all components of the proposed system be new. Specifically, the service system 179 components already existing in an applicant’s metropolitan area could combine with the proposed system enhancements needed to result in a system that had the following characteristics: 1. ABILITY TO ASSESS STAFF TRAINING REQUIREMENTS, IMPLEMENTATION OF CONTINUING EDUCATION TO MEET THESE REQUIREMENTS, AND EVALUATION OF THESE TRAINING EFFORTS. In general, assessment of Target Cities training initiatives was not included in multisite evaluation efforts. This does not mean that training did not occur, but that it was not the focus of multisite evaluation efforts. One single-site process evaluation reported that Target Cities conducted these activities, and that the trainings were well received by the treatment community (Woods, Tajima, Guydish, Chan, & Ponath, 1996). Other single-site reports, not published in the professional literature, may be available locally. 2. DESIGN AND IMPLEMENT CENTRALIZED INTAKE, ASSESSMENT, AND REFERRAL FACILITIES. In addition to implementing a Centralized Intake Unit, CSAT specified that CIU procedures should incorporate (a) a standardized assessment including physical examination, infectious disease screening, psychosocial assessment, and psychological evaluation when needed, (b) a protocol for matching participants with services, and (c) a system for tracking participants across programs. The second wave of Target Cities either enhanced or implemented CIUs, and the process of implementing CIUs and adjusting CIU designs to local needs has been described for several cities (e.g., Barron et al., 1999; Guydish, Woods, Tajima, & Frazier, 1999; Stephens, Kaye, & Chen, 1999; Scott, Muck, & Foss, 2000). In fact, it may be that implementing some sort of CIU in a number of large metropolitan treatment systems was the most successful part of the Target Cities Program. Claus and Dailey (see chap. 3) report descriptive characteristics for those participants, both across and within each of a subset of eight Target Cities sites, who received the CIU intervention (N=43,624). While this multisite sample is not representative of any participating site, it is one of the largest national samples of substance-abusing persons presenting for treatment. The sample was broadly diverse on a number of characteristics including demographics, alcohol and other drug use patterns, mental health, and employment and treatment history . Chapter 3 offers a view of the broad reach of the Target Cities Program, in terms of the number of participating sites and the diversity of participants seeking treatment across sites. Using cluster analysis for a random sample of the multisite Target Cities participants, Foss, Barron, and Arfken (see chap. 4) identi180 Joseph Guydish et al. fied seven ways in which problems and service needs clustered. The resulting clusters profiled service populations having higher problems in selected areas at baseline—for example, those with higher problem severity in medical, alcohol, and psychiatric areas (Cluster 1). While all seven service need profiles were present in all sites, the proportion of persons in each service need cluster varied by site, reflecting different patterns of service needs in different sites. The diversity of the clusters supports the underlying assumption of the Target Cities Program that participants with different needs have to be matched to the programs that address those needs. Arfken, Klein, Agius, and di Menza (see chap. 7), using a...