Service Integration Among Substance Abuse Treatment Programs in the United States
Integration of physical and behavioral health services is a principal aim of the Affordable Care Act (ACA), as it has the potential to expand service access, improve quality, and decrease health care costs by reducing need for acute medical services. The ACA promotes integration through a number of new intiatives, including accountable care organizations and patient-centered medical homes, that encourage physical and behavioral health service providers to integrate services. However, no studies have examined the current availability of co-located services—an important component of service integration—among substance abuse treatment (SAT) programs in the United States, or the characteristics and context of SAT programs that provide them. In response, the current study examines (1) the extent to which SAT in the United States is integrated with physical and mental health services, and (2) identifies characteristics of SAT programs that provide integrated services. Such information can be useful to policymakers and other stakeholders seeking to improve service integration within SAT programs.
Methods:
The study draws upon the 2011 National Survey of the Substance Abuse Treatment System (NSSATS), a survey administered annually to the population of 12,519 SAT programs in the U.S. (excluding solo practices). Descriptive comparisons were made using chi-square tests for categorical variables, and analysis of variance (ANOVA) for continuous variables. Multilevel logistic regression accounting for within-state effects was to used identify organizational factors (structure, resources, modality) associated with co-location of (1) physical health services and (2) mental health services within substance abuse treatment programs. Multiple imputation was used to specify values for missing data.
Results:
In 2011, 12.2% of SAT programs provided co-located physical health services, and 56.6% of SAT programs provided co-located mental health services. Adjusted odds of providing physical health services were positively associated with public and nonprofit ownership, urbanicity and insurance acceptance, and negatively associated with receipt of public grants, and provision of residential care. Adjusted odds of providing mental health services were positively associated with public and nonprofit ownership, insurance acceptance, and negatively associated with receipt of public grants, and provision of residential care.
Conclusions:
Co-location of physical and mental health services in SAT programs is limited, despite evidence demonstrating that individuals with substance use disorders achieve better health outcomes when co-occurring health problems are treated in tandem. SAT programs that offered co-located services were more likely to be public and non-profit programs that possess the technological and administrative sophistication to bill insurance providers—not surprisingly, because this is the way in which most physical and mental health services are financed. In contrast, SAT programs that relied primarily upon other public funds such as block grants were less likely to offer co-located services. The results highlight the need to address financial and technological infrastructure constraints of SAT programs, particularly within the context of ACA-related integration efforts. Moreover, availability of both services was greatest in outpatient, urban programs, suggesting the need to emphasize co-location and integration efforts in rural communities, and ensure appropriate linkages to physical and mental health services in residential care settings.