Determinants and Outcomes of Efforts to Engage Human Service Users in Care Decisions: The Case of Substance Use Disorder Treatment Centers in the United States

Background and Purpose: Human service organizations (HSOs) provide essential social and health services in the contemporary welfare state. Despite the significance reliance, lay users have limited opportunities to participate in and influence service design and implementation processes, potentially undermining organizational responsiveness to local conditions and preferences. Thus, HSOs are increasingly asked to engage service users in care decisions, or to co-produce social services. Unfortunately, social work scholars have very little systemic understanding of the conditions required for organizations to co-produce services, especially in highly professionalized organizations serving stigmatized groups.

Looking closely substance use disorder (SUD) organizations, this study investigates (1) which organizational factors influence whether SUD clinics co-produce services with patients, and (2) how co-production efforts impact treatment units’ service offerings and utilization patterns. The SUD field employs two mechanisms to ensure patients’ meaningful opportunities to provide voice in their care. First, the ACA not only created market incentives for clinics to learn patients’ preferences, but also mandated clinics to conduct patient-centered quality assessment and report the result. Thus, SUD clinicians are motivated to legitimatize their operations and practices by incorporating the medical field’s norm of “patient-centered care”, an analog of co-production. Second, I theorize that SUD clinics use staff with addiction histories as an alternative co-production venue. Staff with lived experience can channel patients’ preferences and “best interest” by leveraging their dual identity as formal staff and previous service user.

Methods: I use the National Drug Abuse Treatment System Survey—a nationally representative longitudinal split-panel survey of approximately 700 SUD treatment facilities in the U.S to answer my research questions. I measure co-production adoption in two ways: whether SUD units regularly invited patients to clinical decision-making process and the proportion of staff with lived experience. I first predicted SUD clinics’ adoption of co-production mechanisms, then assessed the association between coproduction and SUD clinics’ availability and utilization of clinical and supportive services.

Results: Findings show that 75% of treatment centers implemented at least one co-production mechanism in 2014. Compared with public SUD treatment units, nonprofit clinics were less likely to invite patients in clinical decision-making process. For-profit clinics hired more staff with lived experience than nonprofit or public units. Other factors predicted SUD clinics’ adoption of co-production mechanisms as well, including greater public insurance income, greater medical professionalization, and endorsement of 12-step recovery model. Co-producing mechanisms were associated with availability and utilization of services facilitating patients’ long-term recovery—such as family therapy, housing assistance and aftercare services.

Conclusions and Implications: Considering the growing demand to collaborate with users and provide services that are more responsive across the HSO field, this project has multiple implications for human service sectors stakeholders, such as which types of organizations may need additional support in implementing co-production practices. In addition to offering importance evidence of co-production using nationally representative data, this paper demonstrates how staff with lived experience can facilitate co-production with highly marginalized groups by leveraging their experiential knowledge and bridging professionals and users—a rarely discussed political role.