Access to Integrated Care in Substance Abuse Treatment: Travel Distance From Low Income and Diverse Communities

Background/Purpose: The high prevalence of mental health issues in clients attending substance abuse treatment (SAT) has pressured treatment providers to develop integrated substance abuse and mental health care. However, access to integrated care is limited to certain communities. Racial and ethnic minority and low income communities may not have the same access to needed integrated care in large urban areas. As health care reform will expand health insurance for low income individuals and seek to reduce health disparities among minorities, it is necessary to understand the geographic access to integrated care in minority and low income communities. Drawing from system change theories, we examined geographic and organizational factors associated with implementation of integrated care among SAT providers in Los Angeles County, California.

Methods: The National Survey of Substance Abuse Treatment Services (N-SSATS) data from 2009 were analyzed using logistic regression models to examine association between organizational factors and offering integration of mental health services among SAT programs. In addition, we relied on geographic information systems (GIS) to conduct geographic analysis of travel distance. "Service areas” were calculated for each of the facilities (n=402 total; 104 offering integrated services), which represented the surrounding area within a 10-minute drive. Spatial autocorrelation analyses were used to derive hotspots (or clusters) of census tracts with similarly high concentrations of Latino, African American, Asian, and low-income households. Access to integrated care was reflected by the extent of “hotspot coverage” of each facility, i.e. the proportion of its service area that overlapped with each type of hotspot.

Results:  The GIS analysis suggested that ethnic and low income communities have limited access to facilities offering integrated care. The regression analysis showed the facilities whose service areas overlapped more with the Latino hotspots were less likely than other communities to offer integrated care (OR = 0.28, 95% CI = 0.12-0.70). The GIS maps show Latino hotspots (East L.A.) with limited availability of integrated services. Further, the logistic regressions showed that facility characteristics, such as clients with co-occurring disorders (OR = 1.02, 95% CI = 1.01-1.03) and offering psychiatric medication were associated with higher odds of offering integrated care (OR = 4.67, 95% CI = 2.38-9.14). In turn, facilities offering more ancillary services (OR = 0.81, 95% CI = 0.68- 0.95) and located in hospitals (OR= 0.19, 95% CI = 0.04-0.87) were less likely than facilities with fewer services and located in outpatient facilities to offer integrated care.

Conclusions/Implications: Despite the significant pressure to enhance access to integrated services, low income and ethnic minority communities are disadvantaged to have geographic proximity to this type of care. Indicators of program capacity were found negatively associated with offering integrated care. Future studies should build from our preliminary approach to understand the barriers and disincentives to implement mental health services in SAT system infrastructure. This finding can inform the implementation of healthcare reform and parity legislation that seeks to enhance access to integrated care for low income and ethnically diverse vulnerable populations.