Puerto Rico Substance Abuse Needs Assessment Program. Treatment Capacity Survey Final Results

Transcription

1 Puerto Rico Substance Abuse Needs Assessment Program Treatment Capacity Survey Final Results Mental Health and Anti Addiction Services Administration Commonwealth of Puerto Rico

2 Hon. Pedro A. Rosselló Governor, Commonwealth of Puerto Rico Hon. Carmen Feliciano viuda de Melecio Secretary, Puerto Rico Department of Health José A. Acevedo, Ph. D. Administrator, Mental Health and Anti Addiction Services Administration Investigators: Irene Meléndez, Ed.D. Héctor Manuel Colón, M.A. Rafaela Robles, Ed. D. Juan Reyes Pulliza, M.S. This study was conducted for the Center for Substance Abuse Treatment, SAMHSA, USDHHS, under Contract

3 TABLE OF CONTENTS Page I. Introduction... 1 II. Main Findings... 2 III. Organization of this Report and Use of Terminology... 3 IV. Results...5 V. Methods and Procedures VI. List of Participating Treatment Providers VII. Interview Protocol... 26

4 LIST OF TABLES, GRAPHS AND MAPS Page TABLE I-A: Number of substance abuse treatment provider organizations and treatment units by type of provider organization...5 TABLE I-B: Substance abuse treatment units by type of provider organization and service phase/modality...6 TABLE I-C: Number of substance abuse treatment units by type of setting...7 GRAPH I-A: Year of first operation of currently operating substance abuse treatment units...8 TABLE II-A: Mean and total number of FTE personnel employed in direct service in substance abuse treatment units by type of provider and occupational category...9 TABLE III-A: Availability, utilization, and 30-day capacity utilization of alcohol and drug treatment services by service phase/modality...10 TABLE III-B: Availability, utilization, and capacity utilization of alcohol and drug treatment services by type of service provider...11 TABLE III-C: Number of substance abuse treatment units, total treatment capacity, and capacity per 1,000 population by Municipality...12 MAP III-A: Substance abuse treatment availability by Municipalities...16 TABLE IV-A: Substance abuse services offered at treatment units by type of provider17 TABLE V-A: Waiting lists at substance abuse treatment units by type of service provider...19 TABLE V-B: Percent of substance abuse treatment units that require special conditions/documents at time of admission by type of provider...20 TABLE V-C: Percent of substance abuse treatment units that discharge patients for special reasons by type of provider... 21

5 I. Introduction Substance abuse is widely considered Puerto Rico's most compelling socio-medical problem. Since the first public discussions during the early 1960s, the substance abuse problem has grown in the public opinion and among policy makers to be considered the single most pressing problem not only in sheer magnitude but, more so, in its social, economic, and public health consequences. The crime and AIDS epidemics, endemic school drop-out, family disruption, domestic violence, and child abuse are all assumed to be highly associated to substance abuse in Puerto Rico. The high level of public concern over substance abuse has been consistently accompanied by a growing allocation of resources to drug treatment and prevention programs. However, the types of data required to develop policy and assess the effectiveness of programs have been, for the most part, lacking. More recently, Puerto Rico has embarked in an ambitious project to reform its public health care system, which historically has been completely state-operated, and to transform it into privately owned and operated managed care regional systems. The need of substance abuse services, the types of services which are available and their demand, the patterns of service utilization, its costs and the results that can be expected, are largely unknown. This report is part of a family of studies aimed at assessing the need for alcohol and drug treatment services in the population of the island of Puerto Rico. The family of studies has been designed to provide a comprehensive profile of the need, unmet need and demand for substance abuse treatment services, as well as the capacity of the existing treatment system and the gaps between need and availability of services island wide. To date, three studies have been conducted: A household survey of approximately 5,000 individuals constitutes the principal study. This survey estimates prevalence rates of substance abuse/dependence and the need of treatment services in the general adult and adolescent population. The household survey combines an area probability sample of households with a computer assisted telephone interview. The sampling strategy has been designed to increase the number of individuals in need in the sample. The second study uses existing indicator data series to develop synthetic estimates of need at the level of Municipality. The indicator data series have been collected and used to classify the Municipalities into high, medium, and low drug problem intensity Municipalities. This classification constituted the stratification criteria for the household survey. As part of the second study, multiple capture estimation techniques will be applied to the state treatment admission data to estimate cocaine and heroin users, and injection drug users. Lastly, a treatment capacity survey comprises the third study. This survey is intended to provide information about the service capacity of the alcohol and drug treatment service providers operating in Puerto Rico, as well as an estimate of the level of utilization of such capacity. The results of the treatment capacity study, coupled to the results of the other studies, can be used to detect the gaps in service availability. This report contains the results of the treatment capacity survey. The treatment capacity survey was conducted between February and July of For this survey, an inventory of all known alcohol and drug treatment providers operating in Puerto Rico during 1997 Page 1

6 was compiled. The inventory of providers included all the public and private providers registered with the Mental Health and Anti Addiction Services Administration. The inventory also included all the providers under contracts with the behavioral health care organizations (BHCOs) managing the regional mental health carve outs of the Puerto Rico Health Reform Insurance Plan. Treatment services offered within correctional facilities were not included in this survey. A total of 49 providers were listed. Of these, 46 (93.9%) participated in the survey. The 46 providers that participated in the survey operated a total of 175 separate treatment units. Each of the 175 treatment units was surveyed separately and they constitute the units of analysis of this survey. The information obtained from each treatment unit included the types of services offered, the number of patients served during the past month, and the maximum number of patients that the unit could serve in a single month. The survey questionnaire also ascertained the staff profile, and the admission and discharge criteria. II. Main Findings Availability, utilization, and capacity utilization of alcohol and drug treatment services in Puerto Rico, Service Phase/Modality Detoxification Number of Units Providing Each Type of Service Maximum Number of Patients That Can Be Served on a Given Month Patients With a Primary Alcohol Condition Served Past Month Patients With a Primary Drug Condition Served Past Month Percent Capacity Utilization Inpatient 68 3, , Outpatient 17 3, , Treatment /Recovery Inpatient 117 5, , Day Treatment , Outpatient 12 5,129 1,303 3, Maintenance 2 6 2, , Any Modality ,870 3,740 14, Also referred to as partial hospitalization or intensive outpatient 2 Refers to Methadone Maintenance Programs The table above shows the main results of the treatment capacity survey. The table shows the survey estimates of the availability of alcohol and drug treatment services, the total patient population served on a single month by type of primary condition (i.e., alcohol or drugs) and type of modality, and the percent of the total capacity utilized. The total 30-day capacity was estimated at 20,870 treatment slots; 7,164 (34.3%) for Page 2

7 detoxification, 11,071 (53.0%) for treatment and rehabilitation, and 2,635 (12.6%) for methadone maintenance. Of the total available treatment slots, 3,740 (17.9%) were being used to serve patients with a primary alcohol condition, and 14,209 (68.1%) to serve patients with a primary drug condition. The estimate of overall capacity utilization indicates that the treatment services available during the survey period were being used close to their maximum capacity, 86.0%. Two types of service modality day treatment and methadone maintenance were being offered at a rate above their capacity, 198.6% and 120.6%, respectively. The only type of modality that showed room for any significant increase in utilization was inpatient detoxification, used at 50.0% of its capacity. Nevertheless, the overall capacity utilization of all treatment/recovery services was 88.4%. Thus, the rather low rate of use of the available inpatient detoxification services could be the result of difficulties in making available treatment slots to patients completing the detoxification phase. III. Organization of this Report and Use of Terminology The full results of the treatment capacity survey are presented in Section IV. The results have been organized into five series of tables. The series correspond to i) organizational description of the treatment units, ii) staff profiles, iii) availability and utilization of service phase/modalities, iv) types of services offered to patients, v) and admission and discharge process and criteria. A description of the methods and procedures used to conduct the treatment capacity survey are detailed in Section V. Section VI lists the provider organizations that participated in the survey. A copy of the interview protocol can be found in Section VII. Table notes briefly describe the operationalization of the measures. A fuller description of each measure follows: Series I Provider Organizations and Treatment Units. Provider organizations refers to the legal owners of the alcohol and drug treatment units. Provider organizations were classified into state agencies, private not-for-profit lay organizations, private faith-based organizations, and private for-profit organizations. Provider organizations offering services exclusively to inmates of correctional facilities were not included in this survey. Professionals offering substance abuse services from private offices were also excluded from the survey. A service unit refers to a single physical facility where patients were treated, irrespective of the number of modalities offered in the facility. Series II FTE Staff. Respondents were asked to report the number of staff at each service unit in terms of Full-Time Equivalent (FTE) staff persons for each occupational category. For example, half-time personnel were to be counted as 0.50 FTEs, professionals offering services one day a week were to be counted as 0.20 FTEs. Series III Service Phase/Modality and Capacity. Service phase or modality refers to the therapeutic goal of a treatment plan: detoxification, treatment and recovery, or maintenance. In Puerto Rico, only methadone was used among the maintenance Page 3

8 programs surveyed. Capacity was operationally defined as the maximum number of patients that the service unit could treat during a period of 30 days. The survey instrument asked respondents to calculate the 30-day capacity of the service unit. Series IV Services Offered. Refers to the types of medical, psychological/psychiatric, counseling, and case management services available at the service unit. Ancillary services such as child care, legal assistance, and transportation were also included. Series V Admission and Discharge Process and Criteria. This series includes information on waiting lists, admission hours, and admission requirements. This series also includes information on the criteria used by the service unit to discharge patients before completion of the treatment plan. Page 4

9 IV. Results TABLE I-A Number of substance abuse treatment provider organizations and treatment units by type of provider organization, Puerto Rico, Type of Provider Organization Public Number of Provider Organization Number of Services Units Percent State Agencies Private NFP 1 Lay NFP 1 Faith-Based FP Total Not-For-Profit 2 For-Profit Page 5

10 TABLE I-B Substance abuse treatment units by type of provider organization and service phase/modality, Puerto Rico, Detoxification Public State Agencies NFP 1 Lay Private NFP 1 Faith- Based FP 2 n % n % n % n % Inpatient Outpatient Treatment /Recovery Inpatient Day Treatment Outpatient Maintenance Not-For-Profit 2 For-Profit 3 Also referred to as partial hospitalization or intensive outpatient 4 Refers to Methadone Maintenance Programs Page 6

11 TABLE I-C Number of substance abuse treatment units by type of setting, Puerto Rico, Type of Setting Number of Services Units Percent General Hospital Psychiatric Hospital Community Mental Health Center Hospice for AIDS Patients School Free-Standing Community Treatment Program Total Page 7

12 GRAPH I-A Year of first operation of currently operating substance abuse treatment units 1, Puerto Rico, Number Years 1 Missing information on 20 treatment units. Page 8

13 TABLE II-A Mean and total number of FTE 1 personnel employed in direct service in substance abuse treatment units by type of provider and occupational category, Puerto Rico, Type of Provider Public Private All Units State Agencies NFP 2 Lay NFP 2 Faith-Based FP 3 Occupational Category Mean 4 Total Mean 4 Total Mean 4 Total Mean 4 Total Mean 4 Total Licensed physicians Registered nurses Other licensed medical staff Licensed psychologists Licensed social workers Accredited substance abuse counselors Other accredited counselors Peer counselors , Other unaccredited counselors Ministers, priests, nuns Teachers Probation/parole officers Other criminal justice personnel Interns, residents, students Other personnel All Categories , , Full time equivalents, 2 Not-For-Profit, 3 For-Profit, 4 Mean FTEs per unit, 5 Includes psychiatrists, 6 Refers to recovering substance abusers

14 TABLE III-A Availability, utilization, and 30-day capacity utilization of alcohol and drug treatment services by service phase/modality, Puerto Rico, Service Phase/Modality Detoxification Number of Units Providing Each Type of Service Maximum Number of Patients That Can Be Served on a Given Month Patients With a Primary Alcohol Condition Served Past Month Patients With a Primary Drug Condition Served Past Month Percent 30-Day Capacity Utilization Inpatient 68 3, , Outpatient 17 3, , Treatment /Recovery Inpatient 117 5, , Day Treatment , Outpatient 12 5,129 1,303 3, Maintenance 2 6 2, , Any Modality ,870 3,740 14, Also referred to as partial hospitalization or intensive outpatient 2 Refers to Methadone Maintenance Programs Page 10

15 TABLE III-B Availability, utilization, and capacity utilization of alcohol and drug treatment services by type of service provider, Puerto Rico, Service Provider Public Number of Treatment Units Maximum Number of Patients That Can Be Served on a Given Month Patients With a Primary Alcohol Condition Served Past Month Patients With a Primary Drug Condition Served Past Month Percent 30-Day Capacity Utilization State Agencies 32 12,433 2,936 9, Private NFP 1 Lay 84 3, , NFP 1 Faith- Based 44 2, , FP , All Providers ,870 3,740 14, Not-For-Profit 2 For-Profit Page 11

16 TABLE III-C Number of substance abuse treatment units, total treatment capacity, and capacity per 1,000 population by Municipality, Puerto Rico, Municipality Number of Treatment Units 30-Day Capacity Population Years Old 30-Day Capacity per 1,000 pop. Adjuntas , Aguada , Aguadilla 4 2,653 38, Aguas Buenas , Aibonito , Añasco , Arecibo , Arroyo , Barceloneta , Barranquitas , Bayamón 11 1, , Cabo Rojo , Caguas 8 1,144 87, Camuy , Canóvanas , Carolina , Cataño , Cayey , Ceiba , Ciales , Cidra 2 1,470 22, Coamo , Comerío , Corozal , Page 12

17 Culebra TABLE III-C (Continued) Number of substance abuse treatment units, total treatment capacity and capacity per 1,000 pop. by Municipality, Puerto Rico, Municipality Number of Treatment Units 30-Day Capacity Population Years Old 30-Day Capacity per 1,000 pop. Dorado , Fajardo , Florida 0 0 5, Guánica , Guayama , Guayanilla , Guaynabo , Gurabo , Hatillo , Hormigueros , Humacao , Isabela , Jayuya 0 0 9, Juana Díaz , Juncos , Lajas , Lares , Las Marías , Las Piedras , Loiza , Luquillo , Manatí , Maricao 0 0 3, Page 13

18 Maunabo 0 0 7, Mayagüez 9 1,442 66, TABLE III-C (Continued) Number of substance abuse treatment units, total treatment capacity and capacity per 1,000 pop. by Municipality, Puerto Rico, Municipality Number of Treatment Units 30-Day Capacity Population Years Old 30-Day Capacity per 1,000 pop. Moca , Morovis , Naguabo , Naranjito , Orocovis , Patillas , Peñuelas , Ponce 11 1, , Quebradillas , Rincón 0 0 7, Rio Grande , Sabana Grande , Salinas , San Germán , San Juan 33 6, , San Lorenzo , San Sebastián , Santa Isabel , Toa Alta , Toa Baja , Trujillo Alto , Utuado , Page 14

19 Vega Alta , Vega Baja , Vieques 0 0 5, TABLE III-C (Continued) Number of substance abuse treatment units, total treatment capacity and capacity per 1,000 pop. by Municipality, Puerto Rico, Municipality Number of Treatment Units 30-Day Capacity Population Years Old 30-Day Capacity per 1,000 pop. Villalba , Yabucoa , Yauco , Island Wide ,870 2,247, Page 15

20 [Map goes here] MAP III-A

21 TABLE IV-A Substance abuse services offered at treatment units by type of provider, Puerto Rico, Public Private All Units State Agencies NFP 1 Lay NFP 1 Faith- Based FP 2 Type of Service Number Percent Number Percent Number Percent Number Percent Number Percent Substance Abuse Treatment Individual substance abuse counseling Group substance abuse counseling Family counseling Self-help group meetings Other counseling Acupuncture Case management services Referrals to outside services Medical Treatment Medical substance abuse services Prenatal care Testing for HIV Testing for Tuberculosis Testing for sexually transmitted diseases Treatment of Tuberculosis Treatment of sexually transmitted diseases Treatment of HIV/AIDS

22 Other medical services TABLE IV-A (Continued) Substance abuse services offered at treatment units by type of provider, Puerto Rico, Public Private All Units State Agencies NFP 1 Lay NFP 1 Faith- Based FP 2 Type of Service Number Percent Number Percent Number Percent Number Percent Number Percent Other Services Educational/vocational services Health education Family planning Legal Assistance Child care Neo natal care Transportation Not-For-Profit 2 For-Profit

23 TABLE V-A Waiting lists at substance abuse treatment units by type of service provider, Puerto Rico, Service Provider Public Number of Treatment Units With Waiting Lists Percent of Treatment Units With Waiting Lists Mean Number of Patients in Waiting Lists Per Treatment Unit Total Number of Patients in Waiting Lists Mean Number of Days in Waiting List Before Admission State Agencies , Private NFP 1 Lay NFP 1 Faith- Based FP All Providers , Not-For-Profit 2 For-Profit Page 19

24 TABLE V-B Percent of substance abuse treatment units that require special conditions/documents at time of admission by type of provider, Puerto Rico, Public Private All Providers Admission Requirements State Agencies NFP 1 Lay NFP 1 Faith-Based FP 2 Drug free at time of admission Alcohol free at time of admission Payment of admission fee Official ID with photograph In possession of a Police certificate Absence of previous convictions No severe mental health condition No severe physical handicap Not pregnant at time of admission In possession of health insurance Negative STD tests Negative Tuberculin tests Negative HIV tests Negative other communicable diseases In possession of a social security number Proof of a relative in charge Permanent residence Personal hygiene products Not-For-Profit 2 For-Profit

25 TABLE V-C Percent of substance abuse treatment units that discharge patients for special reasons by type of provider, Puerto Rico, Public Private All Providers State Agencies NFP 1 Lay NFP 1 Faith-Based FP 2 Failure to pay for services Used up plan coverage Failure to comply with appointments Failure to comply with referrals Abusive language Aggressive behavior Use of alcohol Use of drugs Use of cigarettes Not-For-Profit 2 For-Profit

26 V. Methods and Procedures Sampling and Unit of Analysis The treatment capacity study was a cross-sectional survey of all substance abuse treatment units in Puerto Rico. A treatment unit was defined as a single physical facility from where alcohol and/or drug treatment services were offered. An inventory of all the existing treatment units was developed in two stages. In a first stage, a listing of all provider organizations was developed. Excluded from the study were provider organizations that provided services exclusively to correctional inmates (e.g., Division of Correctional health of the Puerto Rico Department of Health), and professionals in solo practice. A listing of treatment providers was compiled from two sources. The Licensing Division of the Mental Health and Anti Addiction Services Administration has legal authority to license and monitor non hospital-based substance abuse treatment programs. All the treatment providers with active licenses from the Licensing Division were included in the study. The inventory of providers also included the providers under contracts with the behavioral health care organizations (BHCOs) managing the regional mental health carve outs of the Puerto Rico Health Reform Insurance Plan. A total of 49 providers were listed. In a second stage, provider organizations were contacted by phone to develop an inventory of treatment units. Of the 49 providers identified in the first stage, 46 (93.9%) participated in the study (see list in Section VI), and from these a total of 175 separate treatment units were identified. Each of the 175 treatment units was surveyed separately and they constitute the units of analysis of this survey. Data Collection A self-administered questionnaire was mailed to the Director of each treatment unit. The questionnaire was mailed together with a letter of the Administrator of the Mental Health and Anti Addiction Services Administration, stating the purposes of the study and guaranteeing the confidentiality of the information to be provided. The questionnaires were mailed during January of A copy of the mailed questionnaire is included in Section VII below. The questionnaire was designed to take approximately one hour to complete. The questionnaire ascertained information about the parent organization and the treatment unit. Information about the parent organization included type of organization (i.e., public, private not-for-profit, for-profit) and year of establishment. Information about the treatment unit included: Clinical environment (e.g., hospital-based, free-standing) Year of first operation Treatment modalities offered at the unit Patient population served at each modality during the past 30 day period Maximum number of patients that the unit could serve at each modality in a 30- day period Number and occupational category of the personnel in direct service in the unit at the time of questionnaire Page 22

27 Waiting lists Special admission and discharge procedures Unit directors were followed up on the phone to clarify questions and to ensure a prompt response. Upon completion of the questionnaire, the study personnel picked up the questionnaire on site. At that time, the filled questionnaire was reviewed by the study personnel to make sure the information was complete. Data Management and Quality Control The filled questionnaires were reviewed again to detect inconsistencies in the responses. Unit directors were contacted to resolve inconsistencies or incongruencies and the questionnaire was edited. Questionnaire information was entered into computer disk and double-keyed to validate the data entry process. Data Analysis Data analysis consisted of calculations of percents, means, and sums. Standard errors were not calculated because the study was not based on a sample, but on the universe of treatment units identified. Corrections for non-response were not made since only three of 49 provider organizations did not participate. To calculate the rate of 30-day capacity per population, population estimates per municipality were derived from the Puerto Rico Planning Office and they represent 1995 Census-based population estimates. SPSS version 8 was used for all data analysis. Page 23

28 VI. List of Participating Treatment Providers Participating Provider Type and Name Treatment Units PUBLIC, STATE AGENCIES Administración De Correcciones 1 Administración de Servicios de Salud Mental y Contra la Adicción 31 PRIVATE, NOT-FOR-PROFIT LAY El Arca Hogar Para Mujeres, Inc. 1 Hogares Crea, Inc. 82 Proyecto Oasis De Amor, Inc. 1 PRIVATE, NOT-FOR-PROFIT FAITH-BASED CARDA De Puerto Rico, Inc. 1 Casa De Restauracion, Inc. 1 Casa La Providencia 1 Centro De Ayuda Y Prevencion Casa Joven Del Caribe, Inc. 1 Centro De Refugio Para El Joven, Inc. 1 Centro Renacer, Inc. 2 Fundación El Ave Maria 1 Hogar Camino A La Salvación 1 Hogar Del Buen Pastor, Inc. 1 Hogar Dios Es Nuestro Refugio 1 Hogar El Alfarero, Inc. 1 Hogar El Buen Samaritano, Inc. 2 Hogar El Camino, Inc. 1 Hogar J.E.S.U.S. Inc. 1 Hogar Juvenil Emmanuel, Inc. 1 Hogar Monte Sión 1 Hogar Nueva Vida 3 Hogar Nuevo Pacto, Inc. 1 Hogar Piedra Viva, Inc. 1 continues Page 24