Journal of Evidence-Informed Social Work
ISSN: 2376-1407 (Print) 2376-1415 (Online) Journal homepage: http://www.tandfonline.com/loi/webs21
Improving Service Utilization for Parents with Substance Abuse Problems: Experimenting with Recovery Coaches in Child Welfare Sam Choi To cite this article: Sam Choi (2015): Improving Service Utilization for Parents with Substance Abuse Problems: Experimenting with Recovery Coaches in Child Welfare, Journal of EvidenceInformed Social Work, DOI: 10.1080/15433714.2013.858090 To link to this article: http://dx.doi.org/10.1080/15433714.2013.858090
Published online: 11 Apr 2015.
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Journal of Evidence-Informed Social Work, 00:1–9, 2015 Copyright q Taylor & Francis Group, LLC ISSN: 2376-1407 print/2376-1415 online DOI: 10.1080/15433714.2013.858090
Improving Service Utilization for Parents with Substance Abuse Problems: Experimenting with Recovery Coaches in Child Welfare
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Sam Choi College of Social Work, University of Tennessee, Nashville, Tennessee, USA
Substance abusers often face substantial systematic and personal barriers to receiving required substance abuse treatment services as well as other services; hence, various linkage mechanisms have been proposed for drug abuse treatment programs to overcome such barriers. Although there is a growing interest in the use of case management with a substance abuse background, its effectiveness in child welfare has yet to be explored. In this study the author attempts to investigate the effectiveness of case management in service utilization by systematically evaluating the five-year Alcohol and Other Drug Abuse (AODA) waiver demonstration project with Recovery Coaches in Illinois. A classic experimental design with a control group was used. Random assignment occurs at the agency level. Parents in the experimental group (N ¼ 1562) received recovery coaches in addition to traditional child welfare services while parents in the control group (N ¼ 598) only received traditional child welfare services. Bivariate and multivariate analyses (Ordinary Last Square regressions) were used. Compared to parents in the control group, parents in the experimental group were more likely to utilize substance abuse treatment. The results suggest that gender, education level, employment status, and the number of service needs were significantly associated with service utilization. Controlling other factors, recovery coaches improved overall service utilization. Because the outcome of child welfare often depends on the improvement of risks or resolution, it is important for parents to utilize the needed services. Future studies need to address what aspects of recovery coaches facilitate the services utilization. Keywords: Parents with substance abuse problems, child welfare, case management, service utilization
Substance abusers often face substantial systematic and personal barriers to receiving required substance abuse treatment services as well as other services; hence, various linkage mechanisms have been proposed for drug abuse treatment programs to overcome such barriers (Friedmann, Lemon, Stein, Etheridge, & D’Aunno, 2001). Methods of improving client linkages include: on-site service delivery, external arrangements of variable formality, case management, and transportation assistance (Zlotnick, Kronstadt, & Klee, 1999). Case management was developed as a response and a means of assisting individuals and families in dealing with an “increasingly complex society and correspondingly complex human service system” (Weil & Karls, 1985, p.3). As a result, case management has become a popular way to coordinate and allocate services in substance abuse treatment service fields, agencies, and interventions. Although there is a growing interest in the use of case management with a substance abuse background, its effectiveness in child welfare has yet to be explored. In this study the author attempts to investigate the effectiveness of case management in
Address correspondence to Sam Choi, College of Social Work, University of Tennessee-Knoxville, 193 E. Polk Ave., Nashville, TN 38210, USA. E-mail: [email protected]
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service utilization by systematically evaluating the five year Alcohol and Other Drug Abuse (AODA) waiver demonstration project conducted in Illinois between 2000 and 2005. Case management in the AODA project is handled by persons who are called “Recovery Coaches.” The recovery coach model is an intensive case management model designed to increase the access of clients to substance abuse services, to improve child welfare services, and to increase rates of family reunification. Although the expertise of recovery coaches is in substance abuse, recovery coaches engage in a variety of activities including comprehensive clinical assessments, advocacy, service planning, outreach, and case management. The recovery coach model also uses an interdisciplinary team model for its case management process. Recovery coaches regularly maintain contact with the AODA treatment agency and provide a comprehensive report to caseworkers regarding parents’ progress in AODA and other areas. Therefore, caseworkers incorporate the permanency recommendation to the court. The initial evaluation of the AODA project indicated that recovery coaches improved parents’ timely access to their first treatment, time to reunification, and family reunification (Ryan, Marsh, Testa, & Louderman, 2006). Specifically, parents who received recovery coaches accessed substance abuse services and achieve family reunification more quickly. Yet no published studies from this larger AODA demonstration project focus on the relationship between recovery coaches and overall service utilization. In this current study, I focus on two specific questions: (1) do recovery coaches improve overall service utilization for parents with substance abuse problems in child welfare?, and (2) to what extent are recovery coaches related to service utilization for parents with substance abuse problems in child welfare?
METHOD Sample and Procedures I used a subset of data from the Illinois Title IV-E AODA waiver demonstration (see Ryan et al., 2006; Marsh, Ryan, Choi, & Testa, 2006 for a detailed description of the AODA study design and methods). The AODA waiver features an interorganizational collaboration between the Department of Alcoholism and Substance Abuse (DASA) and the Illinois Department of Children and Family Services (IDCFS). Participants in the AODA demonstration wavier are parents whose children entered foster care on or after April 28, 2000, in Cook County, Illinois. Parents were referred to the Juvenile Court Assessment Project (JCAP) immediately following the temporary custody hearing or at any time within 90 days subsequent to the hearing. If parents were identified as having a substance abuse problem and assigned to a demonstration group, they received substance abuse services plus the services of a recovery coach. Recovery coaches assisted caregivers with obtaining needed treatment services and in negotiating departmental and judicial requirements associated with drug recovery and concurrent permanency planning. As of December 31, 2008, the AODA demonstration group is comprised of 1,720 caregivers and 2,249 children. I limited samples enrolled in the AODA project to between July 1, 2000 and June 30, 2008 because Treatment Record and Continuing Care System (TRACCS) data1 was not implemented until February, 2000 and the TRACCS data are only available up to June 30, 2008. The sample is also limited to parents who had at least one TRACSS CW forms. Thus, the participants for this current study include 1,562 parents in the experimental group and 598 parents in the control group. The average number of TRACCS CW forms was 8 and the modal number of TRACCS CW forms was 7. About 25% of parents had less than 4 forms and 31% parents had more than 10 forms. Only 5.9% of parents had only one form. The sample for the current study included 1,523 mothers and 637 fathers. The average age of parents was 32. About 80% were African American, 13% were Caucasian, and the remaining were Hispanic.
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Data In this study I utilize multiple data sources, including intake assessment data, and substance abuse treatment and service data.
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JCAP data. JCAP data are intake substance abuse assessment data, containing a wide variety of information, such as mothers’ demographic information, drug patterns and prior history of treatment, mental and physical symptoms, violence history, and levels of dependency on primary drugs. TRACCS. TRACSS data provide information on caregivers’ status of substance abuse treatment. TRACCS forms are collected from three sources: caseworkers, AODA treatment providers, and recovery coaches. One form covers a 3 month period, containing information on parents’ living situations, parent – child relationships, DCFS service plans, and clients’ needs and services. This study only uses TRACCS CW forms that are collected from caseworkers. Variables Measures of Mothers’ Demographic Characteristics Demographic information. Demographic information includes age, race/ethnicity, number of children, education, male partners in the AODA project, had living problems that interfered with a drug free life style, had health insurances, no sources of income, marital status, Substance Exposed Infants (SEI) history, and prior mental health treatment history. Measures of Recovery Coach Recovery coach. The recovery coach model is a type of case management with expertise in substance abuse. Recovery coaches are involved with various types of activities including clinical assessment, advocacy, service planning, outreach, and case management2. Recovery coaches were provided to parents in the experimental group only. This variable indicates whether clients received recovery coaches or not. Dependent Variable Measures of service utilization. Measures of service utilization are taken from TRACCS quarterly report by caseworkers. Caseworkers identify co-occurring problems and service needs to their knowledge only and indicate whether a mother received services at given reporting period. Service utilization. The sum of frequency of service receipts was used as a proxy for service utilization. In each quarter, caseworkers identify the different types of service needs (yes or no) in the area of legal service, housing, transportation, education, job training, parenting, family counseling, domestic violence counseling, child care, mental health services, and substance abuse treatment. Once a need was identified in each area, caseworkers report whether one received services to meet the identified needs. When there was no service provided, it was coded 0. The frequency of service receipts codes are: 1—received once in a quarter; 2—received once a month; 3—received more than once a month but less than once a week; 4—received once a week; 5—received up to six times a week; and 6—received daily. To get the proxy of service utilization, the frequency of service receipts in each service area were summed up.
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Methods of Analysis In order to address the research questions, various statistical analysis methods were used. Descriptive analyses were conducted, and bivariate analysis was used to examine the relationship between recovery coaches and service utilization. I then constructed the multiple regressions.
RESULTS
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Descriptive Statistics The sample for the current study included 1,523 mothers and 637 fathers who enrolled in AODA project between July 1, 2000 and June 30, 2004. Parents’ characteristics are displayed in the first column of Table 1. Parents in this study reported limited resources. At intake, about 32% of parents TABLE 1 Descriptive Statistics of Parents
Variables Age Total number of service needs
Gender Female Male Race/Ethnicity African American Caucasian Hispanic Less than high school education—Yes No Employment** Unemployment Employment Marital status Never married Married Divorced/separated Other Partner in AODA project—Yes No No health insurance—Yes No Income Salary Public income program Disability Other No income **p , .05.
Total Sample (N ¼ 2160) Mean
Experimental G (N ¼ 1562) Mean (SD)
Control G (N ¼ 598) Mean (SD)
32.5 1.68 N (%)
32.6 6.39 (2.55) N (% within each group)
32.4 6.34 (2.47) N (% within each group)
1523 (70.5) 637 (29.5)
1098 (70.3) 464 (29.7)
425 (71.1) 173 (28.9)
1720 (79.6) 280 (13.0) 161 (7.5) 1211 (56.1) 949 (43.9)
1226 (78.5) 210 (13.4) 126 (8.1) 877 (56.1) 685 (43.9)
494 (82.6) 70 (11.7) 35 (5.9) 334 (55.9) 264 (44.1)
1794 (83.1) 366 (16.9)
1278 (81.8) 284 (18.2)
516 (86.3) 82 (13.7)
1626 (75.3) 221 (10.2) 287 (13.3) 26 (1.2) 473 (22.2) 1681 (77.8) 1366 (63.2) 794 (36.8)
1177 (75.4) 171 (10.9) 200 (12.8) 12 (2.0) 347 (22.2) 1215 (77.8) 963 (61.7) 599 (38.3)
449 (75.1) 50 (8.4) 87 (14.5) 14 (1.0) 132 (22.1) 466 (77.9) 403 (67.4) 195 (32.6)
333 (15.4) 691 (32.0) 107 (5.0) 47 (2.2) 1019 (47.2)
249 (15.9) 520 (33.3) 89 (5.7) 34 (2.2) 702 (44.9)
84 (14.0) 171 (28.6) 18 (3.0) 13 (2.2) 317 (53.0)
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were participating in public income support programs and approximately 47.2% of parents reported no income sources. More than half of parents did not have any health insurance (63.2%). Not surprisingly, about 83.1% of mothers were currently unemployed and 56.1% of parents had less than a high school education. A random assignment was successful in creating homogeneity between the experimental and the control group. Two groups were equivalent in over 100 variables that were assessed at intake. Differences were found only in employment status that is expectable differences based on chance alone. Parents in the control group had a higher rate of unemployment than those in the experimental group (81.8% vs. 86.3%). A wide range of service needs were identified by caseworkers, and the rate of service needs among parents with substance abuse was generally high. For example, service needs for parenting skills and substance abuse were 88.9% and 87.2% respectively. Approximately 68% of parents had transportation needs. Service needs in housing (59%), job training (58.4%), education (49.1%), and child care (20.3%) reflected the limited resources available. Interpersonal difficulties were also recognized as an issue and there was a high rate of service needs in family counseling (64.6 %) and domestic violence counseling (35.3%). Additionally, service needs in mental health treatment (51.6 %) was high. Descriptive statistics for the type of service needs are displayed in the first column of Table 2. Service Utilization The mean of services received for study participants were 33.77 in all 11 service types as displayed in the first two columns of Table 2. The findings indicated that the service utilization rates varied depending on the areas of service. Regarding service type, service utilization was highest in substance abuse treatment (mean ¼ 8.64), followed by transportation (mean ¼ 7.12), parenting training (mean ¼ 3.62), mental health services (mean ¼ 2.92) domestic violence counseling (mean ¼ 1.59), and job training (mean ¼ 1.21). The service utilization was relatively low in childcare (men ¼ 1.17), housing (mean ¼ 1.08), legal services (mean ¼ 1.08), education (mean ¼ 1.18), and job training (mean ¼ 1.43). TABLE 2 Effects of Recovery Coaches on Service Utilization by Service Type Service Utilization by Intensity Total Sample
Total Number of Services Received By Service Type Legal* Transportation Housing* Education Job training Parenting Family counseling Domestic violence** Childcare* Mental health AODA* *p , .1, **p , .05.
N (%)
Mean (SD)
Experimental Group Mean (SD)
Control Group Mean (SD)
2160 (100) Service Needed 654 (19.4) 1465 (68.0) 903 (59.0) 800 (49.1) 934 (58.4) 1294 (88.9) 1087 (64.6) 346 (35.3) 298 (20.3) 588 (51.6) 1276 (87.2)
33.77 (23.01)
32.75 (45.95)
32.76 (48.11)
1.08 (3.35) 7.12 (11.35) 1.08 (3.69) 1.18 (4.48) 1.21 (4.11) 3.62 (6.02) 2.37 (6.20) 1.59 (4.96) 1.17 (5.19) 2.92 (6.99) 8.64 (12.63)
.99 (2.91) 7.23 (11.54) 1.67 (4.83) 1.24 (4.77) 1.13 (4.06) 3.55 (5.95) 2.48 (6.32) 1.42 (4.20) 1.11 (4.77) 2.97 (7.15) 8.93 (13.00)
1.33 (4.29) 6.85 (10.83) 2.14 (5.87) 1.04 (3.61) 1.41 (4.24) 3.78 (6.19) 2.09 (5.86) 2.04 (6.53) 1.32 (6.16) 2.80 (6.57) 7.89 (11.59)
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The Effects of Recovery Coaches on Service Utilization Bivariate analysis was conducted to determine the relationship between recovery coaches and service utilization using independent t-tests. The last two columns of Table 2 display the results of bivariate analysis. Overall, service utilization was not higher for parents in the experimental group compared to parents in the control group (35.75 vs. 35.76). I also investigated service utilization by service type. Parents in the experimental group received significantly more services in area of AODA compared to parents in the control group. Although not significant, parents in the experimental group received more services in transportation, education, family counseling, and mental health counseling. On the other hand, parents in the control group received significantly more services in areas of legal service, housing, domestic violence, and childcare services than parents in the experimental group. The multiple regressions—Ordinary Least Square (OLS)—were conducted to investigate the effectiveness of recovery coaches in improving service utilization for parents with substance abuse problems in child welfare. The final model is displayed in the Table 3. The direction and size of the coefficient indicated that recovery coaches significantly improved the service utilization for parents with substance abuse problems in child welfare (b ¼ 3.232, p , .01). The total number of service needs was significantly associated with service utilization. Parents with more service needs received more intensive services than parents with less service needs. Several parents’ demographics including education level, employment status, and gender were also related to the service utilization. Compared to fathers, mothers were more likely to receive services. Regarding the education level, parents with less than a high school education were more likely to receive services. Compared to parents with employment, unemployed parents were less likely to receive services.
DISCUSSION Case management has been considered an important service enhancement for clients in social services (Zlotnick et al., 1999). There is growing interest in the use of additional case management with a substance abuse background because of the complex nature of substance abuse problems and the overwhelming burden of caseloads involving substance abuse problems (Maluccio & Ainsworth, 2003; Young, Gardner, & Dennis, 1998). The effects of case management on service TABLE 3 Effects of Recovery Coaches on Service Utilization (OSL) Final Model Variable Constant African American Latino No health insurance Less than high school**** Unemployed* Never married Female**** Total number of service needs**** Recovery coaches* *p , .1, ****p , .001.
b
SD
BETA
215.466 3.926 22.184 2.255 8.844 24.295 21.506 7.920 1.374 3.232
3.886 2.411 3.655 1.705 1.624 2.298 2.815 1.953 .039 1.775
.034 2.012 .023 .094 2.035 2.030 .078 .610 .031
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utilization in prior literature in the field of substance abuse have been inconsistent. Some studies support the effectiveness of case management in service utilizations in the substance abuse field (McLellan et al., 1998, McLellan et al., 1999; Shwartz, Baker, Mulvey, & Plough, 1997; Siegal et al., 1996). Other studies, however, have demonstrated little or no effects of case management on service delivery (Friedmann, D’Aunno, Jin, & Alexander, 2000; Friedmann, Hendrickson, Gerstein, & Zhang. 2003). The findings in this study support the effectiveness of recovery coaches in service utilizations, especially in an area of substance abuse treatment utilization. Yet the relationship between recovery coaches and service utilization is not clear. Bivariate analysis indicated that overall service utilization between two groups were identical. Two groups were different when investigating the type of service receipts. Compared to the control group, parents with recovery coaches had significantly higher service utilization in AODA services. On the other hand, parents in the control group had higher service utilization in legal, housing, domestic counseling, and childcare services compared to parents in the experimental group. The results from the multivariate analysis, controlling parents’ demographics, and total number of services needs, parents in the experimental group were more likely to utilize services compared to parents in the control group. A failure to find a clear relation between recovery coaches and service utilizations might be due to several factors. First, it was the caseworkers’ primary responsibility to assess service need as well as plan services and deliver services, rather than recovery coaches. Second, it is possible that there were isolated efforts of caseworkers to facilitate service utilization, instead of expected close collaboration and information sharing between caseworkers and recovery coaches. Finally, recovery coaches may not focus on overall service utilization but focus more on substance abuse treatment. Like other case management, recovery coaches performed multiple tasks but their expertise is in substance abuse. Thus it is possible that the findings of this study were highly dependent on the recovery coaches’ focus of activities. The current study contributes to our understanding of service utilization of recovery coaches for parents with substance abuse problems in child welfare, yet, it is important to recognize the limitations of the study. First, as for the measurement of service needs and receipts, the service needs and receipts were limited solely to observations of caseworkers. Data in this study do not reflect the perspectives of parents nor the recovery coaches on service needs or service receipts. Accordingly, information on clients’ needs and services received depends on caseworkers’ knowledge. Second, a measure of service utilization does not reflect the actual number of service receipts. The sum of frequency of service receipts was used as a proxy for the intensity of service utilization. Prior evaluation research indicated that the use of recovery coaches improve the likelihood of timely access to treatment, time to reunification, and family reunification (Marsh et al., 2006; Ryan et al., 2006). The results of this study also indicated that recovery coaches improved treatment utilization. Yet we know little about what aspects of recovery coaches accounted for these successes in child welfare. As in other types of case management strategies, recovery coaches performed multiple tasks, yet this study could not obtain information regarding the focus of recovery coaches’ activities between recovery coaches and parents with substance abuse problems in child welfare. Future studies should explicitly examine what aspects of case management may relate to service utilization and other important child welfare outcomes. Finally, the recovery coach models also use an interdisciplinary team model for its case management process with multiple entities in child welfare including caseworkers, AODA treatment providers, and judges. Prior literature consistently pointed out that collaboration in child welfare has proven difficult to put into practice (Garmston & Wellman, 1999; Halett & Birchall, 1992). Garmston and Wellman (1999) state that collaboration is a complex phenomenon, which entails a joining of perspectives, energies, talents, philosophies, and resources that transcend common conversations and simple problem solving, Additionally, according to Gray (1989), obstacles to collaboration may be more difficult to overcome when conflict is rooted in basic ideological
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differences. Conflict among different professionals in child welfare is inherent because the origin, expertise, goals, and focuses of each professional differ (Kopels, Carter-Black, & Portner, 2002). While the needs of collaboration are apparent in child welfare, our knowledge in inter-agency collaboration is limited. Accordingly, future work is needed to explore how diverse views, expertise, and recourses pull together to solve increasingly complex substance abuse problems and how recovery coaches contribute to form partnerships with other social service systems.
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CONCLUSIONS The purpose of the author in this study is to investigate the efficacy of use of recovery coaches in increasing service utilization. The results of this study suggest that the use of recovery coaches is associated with the intensity of service utilization among parents with substance abuse treatment. With regards to specific services, recovery coaches significantly improved higher rates of substance abuse treatment utilization. The findings from this current study provides empirical evidence of the effectiveness of recovery coaches in promoting service utilization among parents with substance abuse treatment in child welfare. Future studies should investigate what aspects of case management may relate to service utilization in child welfare. ACKNOWLEDGMENTS This research was completed with support from the Illinois Department of Children and Family Services and the Children and Family Research Center at University of Illinois at UrbanaChampaign.
NOTES 1 2
Service log data that collected quarterly by caseworkers, recovery coaches, and AODA service providers. Recovery coaches help ensure that the DCFS service plan, the AODA agency’s treatment plan and other requirements are coordinated. In addition, recovery coaches conduct independent clinical assessment not only for substance abuse but also a wide range of services needs (clinical assessment) and then prioritize plans (service planning). To achieve successful, recovery coaches provide continual and aggressive outreach efforts including home visiting (outreach) for parents to access to services and re-engage parents in treatment when necessary (case management). Recovery coaches also identify other resources and help them to obtain it (advocacy).
REFERENCES Friedmann, P., D’Aunno, T., Jin, L., & Alexander, J. (2000). Medical and psychosocial services in drug abuse treatment: Do stronger linkages promote client utilization? Health Services Research, 35, 443–465. Friedmann, P., Hendrickson, J., Gerstein, D., & Zhang, Z. (2003). Designated case managers as facilitators of medical and psychological service delivery in addiction treatment programs. Journal of Behavioral Health Services & Research, 31, 86 –97. Friedmann, P., Lemon, S., Stein, M., Etheridge, R., & D’Aunno, T. (2001). Linkage to medical services in the drug abuse treatment outcome study. Medical Care, 39, 284–295. Garmston, R. J., & Wellman, B. M. (1999). The adoptive school: A sourcebook for developing collaborative groups. Norwood, MA: Christopher-Gordon. Gray, B. (1989). Collaborating: Finding common ground for multiparty problems. San Francisco, CA: Jossey-Bass. Hallett, C., & Birchall, E. (1992). Coordination and child protection: A review of the literature. Edinburgh: HMSO.
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Kopels, S., Carter-Black, J., & Poetner, J. (2002). Reducing conflict between child welfare communities. Journal of Health and Social Policy, 15, 117–129. Maluccio, A., & Ainsworth, F. (2003). Drug use by parents: A challenge for family reunification practice. Children and Youth Services Review, 25, 511– 533. Marsh, J. C., Ryan, J., Choi, S., & Testa, M. (2006). Integrated service for families with multiple problems: Obstacles to family reunification. Children and Youth Services Review, 28, 1074–1087. McLellan, A. T., Hagan, T., Levine, M., Meyers, K., Gould, R., Bencivengo, . . . Jaffe, J. (1999). Does clinical case management improve outpatient addiction treatment? Drug and Alcohol Dependence, 55, 91–103. McLellan, A. T., Hagan, T., Meyers, K., Levine, M., Gould, F., Bencivengo, J., & Durell, J. (1998). Improved outcomes following service enhancements in public substance abuse treatment programs. Addiction, 93, 1489–1499. Ryan, J., Marsh, J., Testa, M., & Louderman, R. (2006). Integrating substance abuse treatment and child welfare services: Findings from the Illinois AODA Waiver Demonstration. Journal of Social Work Research, 30, 95–107. Shwartz, M., Baker, G., Mulvey, K., & Plough, A. (1997). Improving publicly funded substance abuse treatment: The value of case management. American Journal of Public Health, 87, 1659–1664. Siegal, H. A., Risher, J. H., Rapp, R., Kelliher, C., Wagner, J., O’Brien, W., & Cole, P. (1996). Enhancing substance abuse treatment with case management: Its impact on employment. Journal of Substance Abuse Treatment, 13, 93–98. Weil, M., & Karls, J. M. (1985). Historical origins and recent developments. In M. Weil & J. M. Karls (Eds.), Case management in human service practice (pp. 1–28). San Francisco, CA: Jossey-Bass, Inc.. Young, N. K., Gardner, S. L., & Dennis, K. (1998). Responding to alcohol and other drug problems in child welfare: Weaving together practice and policy. Washington, DC: CWLA. Zlotnick, C., Kronstadt, D., & Klee, L. (1999). Essential case management services for young children in foster care. Community Mental Health Journal, 35, 421–430.
ISSN: 2376-1407 (Print) 2376-1415 (Online) Journal homepage: http://www.tandfonline.com/loi/webs21
Improving Service Utilization for Parents with Substance Abuse Problems: Experimenting with Recovery Coaches in Child Welfare Sam Choi To cite this article: Sam Choi (2015): Improving Service Utilization for Parents with Substance Abuse Problems: Experimenting with Recovery Coaches in Child Welfare, Journal of EvidenceInformed Social Work, DOI: 10.1080/15433714.2013.858090 To link to this article: http://dx.doi.org/10.1080/15433714.2013.858090
Published online: 11 Apr 2015.
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Article views: 10
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=webs21 Download by: [University of Otago]
Date: 12 November 2015, At: 00:25
Journal of Evidence-Informed Social Work, 00:1–9, 2015 Copyright q Taylor & Francis Group, LLC ISSN: 2376-1407 print/2376-1415 online DOI: 10.1080/15433714.2013.858090
Improving Service Utilization for Parents with Substance Abuse Problems: Experimenting with Recovery Coaches in Child Welfare
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Sam Choi College of Social Work, University of Tennessee, Nashville, Tennessee, USA
Substance abusers often face substantial systematic and personal barriers to receiving required substance abuse treatment services as well as other services; hence, various linkage mechanisms have been proposed for drug abuse treatment programs to overcome such barriers. Although there is a growing interest in the use of case management with a substance abuse background, its effectiveness in child welfare has yet to be explored. In this study the author attempts to investigate the effectiveness of case management in service utilization by systematically evaluating the five-year Alcohol and Other Drug Abuse (AODA) waiver demonstration project with Recovery Coaches in Illinois. A classic experimental design with a control group was used. Random assignment occurs at the agency level. Parents in the experimental group (N ¼ 1562) received recovery coaches in addition to traditional child welfare services while parents in the control group (N ¼ 598) only received traditional child welfare services. Bivariate and multivariate analyses (Ordinary Last Square regressions) were used. Compared to parents in the control group, parents in the experimental group were more likely to utilize substance abuse treatment. The results suggest that gender, education level, employment status, and the number of service needs were significantly associated with service utilization. Controlling other factors, recovery coaches improved overall service utilization. Because the outcome of child welfare often depends on the improvement of risks or resolution, it is important for parents to utilize the needed services. Future studies need to address what aspects of recovery coaches facilitate the services utilization. Keywords: Parents with substance abuse problems, child welfare, case management, service utilization
Substance abusers often face substantial systematic and personal barriers to receiving required substance abuse treatment services as well as other services; hence, various linkage mechanisms have been proposed for drug abuse treatment programs to overcome such barriers (Friedmann, Lemon, Stein, Etheridge, & D’Aunno, 2001). Methods of improving client linkages include: on-site service delivery, external arrangements of variable formality, case management, and transportation assistance (Zlotnick, Kronstadt, & Klee, 1999). Case management was developed as a response and a means of assisting individuals and families in dealing with an “increasingly complex society and correspondingly complex human service system” (Weil & Karls, 1985, p.3). As a result, case management has become a popular way to coordinate and allocate services in substance abuse treatment service fields, agencies, and interventions. Although there is a growing interest in the use of case management with a substance abuse background, its effectiveness in child welfare has yet to be explored. In this study the author attempts to investigate the effectiveness of case management in
Address correspondence to Sam Choi, College of Social Work, University of Tennessee-Knoxville, 193 E. Polk Ave., Nashville, TN 38210, USA. E-mail: [email protected]
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service utilization by systematically evaluating the five year Alcohol and Other Drug Abuse (AODA) waiver demonstration project conducted in Illinois between 2000 and 2005. Case management in the AODA project is handled by persons who are called “Recovery Coaches.” The recovery coach model is an intensive case management model designed to increase the access of clients to substance abuse services, to improve child welfare services, and to increase rates of family reunification. Although the expertise of recovery coaches is in substance abuse, recovery coaches engage in a variety of activities including comprehensive clinical assessments, advocacy, service planning, outreach, and case management. The recovery coach model also uses an interdisciplinary team model for its case management process. Recovery coaches regularly maintain contact with the AODA treatment agency and provide a comprehensive report to caseworkers regarding parents’ progress in AODA and other areas. Therefore, caseworkers incorporate the permanency recommendation to the court. The initial evaluation of the AODA project indicated that recovery coaches improved parents’ timely access to their first treatment, time to reunification, and family reunification (Ryan, Marsh, Testa, & Louderman, 2006). Specifically, parents who received recovery coaches accessed substance abuse services and achieve family reunification more quickly. Yet no published studies from this larger AODA demonstration project focus on the relationship between recovery coaches and overall service utilization. In this current study, I focus on two specific questions: (1) do recovery coaches improve overall service utilization for parents with substance abuse problems in child welfare?, and (2) to what extent are recovery coaches related to service utilization for parents with substance abuse problems in child welfare?
METHOD Sample and Procedures I used a subset of data from the Illinois Title IV-E AODA waiver demonstration (see Ryan et al., 2006; Marsh, Ryan, Choi, & Testa, 2006 for a detailed description of the AODA study design and methods). The AODA waiver features an interorganizational collaboration between the Department of Alcoholism and Substance Abuse (DASA) and the Illinois Department of Children and Family Services (IDCFS). Participants in the AODA demonstration wavier are parents whose children entered foster care on or after April 28, 2000, in Cook County, Illinois. Parents were referred to the Juvenile Court Assessment Project (JCAP) immediately following the temporary custody hearing or at any time within 90 days subsequent to the hearing. If parents were identified as having a substance abuse problem and assigned to a demonstration group, they received substance abuse services plus the services of a recovery coach. Recovery coaches assisted caregivers with obtaining needed treatment services and in negotiating departmental and judicial requirements associated with drug recovery and concurrent permanency planning. As of December 31, 2008, the AODA demonstration group is comprised of 1,720 caregivers and 2,249 children. I limited samples enrolled in the AODA project to between July 1, 2000 and June 30, 2008 because Treatment Record and Continuing Care System (TRACCS) data1 was not implemented until February, 2000 and the TRACCS data are only available up to June 30, 2008. The sample is also limited to parents who had at least one TRACSS CW forms. Thus, the participants for this current study include 1,562 parents in the experimental group and 598 parents in the control group. The average number of TRACCS CW forms was 8 and the modal number of TRACCS CW forms was 7. About 25% of parents had less than 4 forms and 31% parents had more than 10 forms. Only 5.9% of parents had only one form. The sample for the current study included 1,523 mothers and 637 fathers. The average age of parents was 32. About 80% were African American, 13% were Caucasian, and the remaining were Hispanic.
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Data In this study I utilize multiple data sources, including intake assessment data, and substance abuse treatment and service data.
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JCAP data. JCAP data are intake substance abuse assessment data, containing a wide variety of information, such as mothers’ demographic information, drug patterns and prior history of treatment, mental and physical symptoms, violence history, and levels of dependency on primary drugs. TRACCS. TRACSS data provide information on caregivers’ status of substance abuse treatment. TRACCS forms are collected from three sources: caseworkers, AODA treatment providers, and recovery coaches. One form covers a 3 month period, containing information on parents’ living situations, parent – child relationships, DCFS service plans, and clients’ needs and services. This study only uses TRACCS CW forms that are collected from caseworkers. Variables Measures of Mothers’ Demographic Characteristics Demographic information. Demographic information includes age, race/ethnicity, number of children, education, male partners in the AODA project, had living problems that interfered with a drug free life style, had health insurances, no sources of income, marital status, Substance Exposed Infants (SEI) history, and prior mental health treatment history. Measures of Recovery Coach Recovery coach. The recovery coach model is a type of case management with expertise in substance abuse. Recovery coaches are involved with various types of activities including clinical assessment, advocacy, service planning, outreach, and case management2. Recovery coaches were provided to parents in the experimental group only. This variable indicates whether clients received recovery coaches or not. Dependent Variable Measures of service utilization. Measures of service utilization are taken from TRACCS quarterly report by caseworkers. Caseworkers identify co-occurring problems and service needs to their knowledge only and indicate whether a mother received services at given reporting period. Service utilization. The sum of frequency of service receipts was used as a proxy for service utilization. In each quarter, caseworkers identify the different types of service needs (yes or no) in the area of legal service, housing, transportation, education, job training, parenting, family counseling, domestic violence counseling, child care, mental health services, and substance abuse treatment. Once a need was identified in each area, caseworkers report whether one received services to meet the identified needs. When there was no service provided, it was coded 0. The frequency of service receipts codes are: 1—received once in a quarter; 2—received once a month; 3—received more than once a month but less than once a week; 4—received once a week; 5—received up to six times a week; and 6—received daily. To get the proxy of service utilization, the frequency of service receipts in each service area were summed up.
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Methods of Analysis In order to address the research questions, various statistical analysis methods were used. Descriptive analyses were conducted, and bivariate analysis was used to examine the relationship between recovery coaches and service utilization. I then constructed the multiple regressions.
RESULTS
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Descriptive Statistics The sample for the current study included 1,523 mothers and 637 fathers who enrolled in AODA project between July 1, 2000 and June 30, 2004. Parents’ characteristics are displayed in the first column of Table 1. Parents in this study reported limited resources. At intake, about 32% of parents TABLE 1 Descriptive Statistics of Parents
Variables Age Total number of service needs
Gender Female Male Race/Ethnicity African American Caucasian Hispanic Less than high school education—Yes No Employment** Unemployment Employment Marital status Never married Married Divorced/separated Other Partner in AODA project—Yes No No health insurance—Yes No Income Salary Public income program Disability Other No income **p , .05.
Total Sample (N ¼ 2160) Mean
Experimental G (N ¼ 1562) Mean (SD)
Control G (N ¼ 598) Mean (SD)
32.5 1.68 N (%)
32.6 6.39 (2.55) N (% within each group)
32.4 6.34 (2.47) N (% within each group)
1523 (70.5) 637 (29.5)
1098 (70.3) 464 (29.7)
425 (71.1) 173 (28.9)
1720 (79.6) 280 (13.0) 161 (7.5) 1211 (56.1) 949 (43.9)
1226 (78.5) 210 (13.4) 126 (8.1) 877 (56.1) 685 (43.9)
494 (82.6) 70 (11.7) 35 (5.9) 334 (55.9) 264 (44.1)
1794 (83.1) 366 (16.9)
1278 (81.8) 284 (18.2)
516 (86.3) 82 (13.7)
1626 (75.3) 221 (10.2) 287 (13.3) 26 (1.2) 473 (22.2) 1681 (77.8) 1366 (63.2) 794 (36.8)
1177 (75.4) 171 (10.9) 200 (12.8) 12 (2.0) 347 (22.2) 1215 (77.8) 963 (61.7) 599 (38.3)
449 (75.1) 50 (8.4) 87 (14.5) 14 (1.0) 132 (22.1) 466 (77.9) 403 (67.4) 195 (32.6)
333 (15.4) 691 (32.0) 107 (5.0) 47 (2.2) 1019 (47.2)
249 (15.9) 520 (33.3) 89 (5.7) 34 (2.2) 702 (44.9)
84 (14.0) 171 (28.6) 18 (3.0) 13 (2.2) 317 (53.0)
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were participating in public income support programs and approximately 47.2% of parents reported no income sources. More than half of parents did not have any health insurance (63.2%). Not surprisingly, about 83.1% of mothers were currently unemployed and 56.1% of parents had less than a high school education. A random assignment was successful in creating homogeneity between the experimental and the control group. Two groups were equivalent in over 100 variables that were assessed at intake. Differences were found only in employment status that is expectable differences based on chance alone. Parents in the control group had a higher rate of unemployment than those in the experimental group (81.8% vs. 86.3%). A wide range of service needs were identified by caseworkers, and the rate of service needs among parents with substance abuse was generally high. For example, service needs for parenting skills and substance abuse were 88.9% and 87.2% respectively. Approximately 68% of parents had transportation needs. Service needs in housing (59%), job training (58.4%), education (49.1%), and child care (20.3%) reflected the limited resources available. Interpersonal difficulties were also recognized as an issue and there was a high rate of service needs in family counseling (64.6 %) and domestic violence counseling (35.3%). Additionally, service needs in mental health treatment (51.6 %) was high. Descriptive statistics for the type of service needs are displayed in the first column of Table 2. Service Utilization The mean of services received for study participants were 33.77 in all 11 service types as displayed in the first two columns of Table 2. The findings indicated that the service utilization rates varied depending on the areas of service. Regarding service type, service utilization was highest in substance abuse treatment (mean ¼ 8.64), followed by transportation (mean ¼ 7.12), parenting training (mean ¼ 3.62), mental health services (mean ¼ 2.92) domestic violence counseling (mean ¼ 1.59), and job training (mean ¼ 1.21). The service utilization was relatively low in childcare (men ¼ 1.17), housing (mean ¼ 1.08), legal services (mean ¼ 1.08), education (mean ¼ 1.18), and job training (mean ¼ 1.43). TABLE 2 Effects of Recovery Coaches on Service Utilization by Service Type Service Utilization by Intensity Total Sample
Total Number of Services Received By Service Type Legal* Transportation Housing* Education Job training Parenting Family counseling Domestic violence** Childcare* Mental health AODA* *p , .1, **p , .05.
N (%)
Mean (SD)
Experimental Group Mean (SD)
Control Group Mean (SD)
2160 (100) Service Needed 654 (19.4) 1465 (68.0) 903 (59.0) 800 (49.1) 934 (58.4) 1294 (88.9) 1087 (64.6) 346 (35.3) 298 (20.3) 588 (51.6) 1276 (87.2)
33.77 (23.01)
32.75 (45.95)
32.76 (48.11)
1.08 (3.35) 7.12 (11.35) 1.08 (3.69) 1.18 (4.48) 1.21 (4.11) 3.62 (6.02) 2.37 (6.20) 1.59 (4.96) 1.17 (5.19) 2.92 (6.99) 8.64 (12.63)
.99 (2.91) 7.23 (11.54) 1.67 (4.83) 1.24 (4.77) 1.13 (4.06) 3.55 (5.95) 2.48 (6.32) 1.42 (4.20) 1.11 (4.77) 2.97 (7.15) 8.93 (13.00)
1.33 (4.29) 6.85 (10.83) 2.14 (5.87) 1.04 (3.61) 1.41 (4.24) 3.78 (6.19) 2.09 (5.86) 2.04 (6.53) 1.32 (6.16) 2.80 (6.57) 7.89 (11.59)
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The Effects of Recovery Coaches on Service Utilization Bivariate analysis was conducted to determine the relationship between recovery coaches and service utilization using independent t-tests. The last two columns of Table 2 display the results of bivariate analysis. Overall, service utilization was not higher for parents in the experimental group compared to parents in the control group (35.75 vs. 35.76). I also investigated service utilization by service type. Parents in the experimental group received significantly more services in area of AODA compared to parents in the control group. Although not significant, parents in the experimental group received more services in transportation, education, family counseling, and mental health counseling. On the other hand, parents in the control group received significantly more services in areas of legal service, housing, domestic violence, and childcare services than parents in the experimental group. The multiple regressions—Ordinary Least Square (OLS)—were conducted to investigate the effectiveness of recovery coaches in improving service utilization for parents with substance abuse problems in child welfare. The final model is displayed in the Table 3. The direction and size of the coefficient indicated that recovery coaches significantly improved the service utilization for parents with substance abuse problems in child welfare (b ¼ 3.232, p , .01). The total number of service needs was significantly associated with service utilization. Parents with more service needs received more intensive services than parents with less service needs. Several parents’ demographics including education level, employment status, and gender were also related to the service utilization. Compared to fathers, mothers were more likely to receive services. Regarding the education level, parents with less than a high school education were more likely to receive services. Compared to parents with employment, unemployed parents were less likely to receive services.
DISCUSSION Case management has been considered an important service enhancement for clients in social services (Zlotnick et al., 1999). There is growing interest in the use of additional case management with a substance abuse background because of the complex nature of substance abuse problems and the overwhelming burden of caseloads involving substance abuse problems (Maluccio & Ainsworth, 2003; Young, Gardner, & Dennis, 1998). The effects of case management on service TABLE 3 Effects of Recovery Coaches on Service Utilization (OSL) Final Model Variable Constant African American Latino No health insurance Less than high school**** Unemployed* Never married Female**** Total number of service needs**** Recovery coaches* *p , .1, ****p , .001.
b
SD
BETA
215.466 3.926 22.184 2.255 8.844 24.295 21.506 7.920 1.374 3.232
3.886 2.411 3.655 1.705 1.624 2.298 2.815 1.953 .039 1.775
.034 2.012 .023 .094 2.035 2.030 .078 .610 .031
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utilization in prior literature in the field of substance abuse have been inconsistent. Some studies support the effectiveness of case management in service utilizations in the substance abuse field (McLellan et al., 1998, McLellan et al., 1999; Shwartz, Baker, Mulvey, & Plough, 1997; Siegal et al., 1996). Other studies, however, have demonstrated little or no effects of case management on service delivery (Friedmann, D’Aunno, Jin, & Alexander, 2000; Friedmann, Hendrickson, Gerstein, & Zhang. 2003). The findings in this study support the effectiveness of recovery coaches in service utilizations, especially in an area of substance abuse treatment utilization. Yet the relationship between recovery coaches and service utilization is not clear. Bivariate analysis indicated that overall service utilization between two groups were identical. Two groups were different when investigating the type of service receipts. Compared to the control group, parents with recovery coaches had significantly higher service utilization in AODA services. On the other hand, parents in the control group had higher service utilization in legal, housing, domestic counseling, and childcare services compared to parents in the experimental group. The results from the multivariate analysis, controlling parents’ demographics, and total number of services needs, parents in the experimental group were more likely to utilize services compared to parents in the control group. A failure to find a clear relation between recovery coaches and service utilizations might be due to several factors. First, it was the caseworkers’ primary responsibility to assess service need as well as plan services and deliver services, rather than recovery coaches. Second, it is possible that there were isolated efforts of caseworkers to facilitate service utilization, instead of expected close collaboration and information sharing between caseworkers and recovery coaches. Finally, recovery coaches may not focus on overall service utilization but focus more on substance abuse treatment. Like other case management, recovery coaches performed multiple tasks but their expertise is in substance abuse. Thus it is possible that the findings of this study were highly dependent on the recovery coaches’ focus of activities. The current study contributes to our understanding of service utilization of recovery coaches for parents with substance abuse problems in child welfare, yet, it is important to recognize the limitations of the study. First, as for the measurement of service needs and receipts, the service needs and receipts were limited solely to observations of caseworkers. Data in this study do not reflect the perspectives of parents nor the recovery coaches on service needs or service receipts. Accordingly, information on clients’ needs and services received depends on caseworkers’ knowledge. Second, a measure of service utilization does not reflect the actual number of service receipts. The sum of frequency of service receipts was used as a proxy for the intensity of service utilization. Prior evaluation research indicated that the use of recovery coaches improve the likelihood of timely access to treatment, time to reunification, and family reunification (Marsh et al., 2006; Ryan et al., 2006). The results of this study also indicated that recovery coaches improved treatment utilization. Yet we know little about what aspects of recovery coaches accounted for these successes in child welfare. As in other types of case management strategies, recovery coaches performed multiple tasks, yet this study could not obtain information regarding the focus of recovery coaches’ activities between recovery coaches and parents with substance abuse problems in child welfare. Future studies should explicitly examine what aspects of case management may relate to service utilization and other important child welfare outcomes. Finally, the recovery coach models also use an interdisciplinary team model for its case management process with multiple entities in child welfare including caseworkers, AODA treatment providers, and judges. Prior literature consistently pointed out that collaboration in child welfare has proven difficult to put into practice (Garmston & Wellman, 1999; Halett & Birchall, 1992). Garmston and Wellman (1999) state that collaboration is a complex phenomenon, which entails a joining of perspectives, energies, talents, philosophies, and resources that transcend common conversations and simple problem solving, Additionally, according to Gray (1989), obstacles to collaboration may be more difficult to overcome when conflict is rooted in basic ideological
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differences. Conflict among different professionals in child welfare is inherent because the origin, expertise, goals, and focuses of each professional differ (Kopels, Carter-Black, & Portner, 2002). While the needs of collaboration are apparent in child welfare, our knowledge in inter-agency collaboration is limited. Accordingly, future work is needed to explore how diverse views, expertise, and recourses pull together to solve increasingly complex substance abuse problems and how recovery coaches contribute to form partnerships with other social service systems.
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CONCLUSIONS The purpose of the author in this study is to investigate the efficacy of use of recovery coaches in increasing service utilization. The results of this study suggest that the use of recovery coaches is associated with the intensity of service utilization among parents with substance abuse treatment. With regards to specific services, recovery coaches significantly improved higher rates of substance abuse treatment utilization. The findings from this current study provides empirical evidence of the effectiveness of recovery coaches in promoting service utilization among parents with substance abuse treatment in child welfare. Future studies should investigate what aspects of case management may relate to service utilization in child welfare. ACKNOWLEDGMENTS This research was completed with support from the Illinois Department of Children and Family Services and the Children and Family Research Center at University of Illinois at UrbanaChampaign.
NOTES 1 2
Service log data that collected quarterly by caseworkers, recovery coaches, and AODA service providers. Recovery coaches help ensure that the DCFS service plan, the AODA agency’s treatment plan and other requirements are coordinated. In addition, recovery coaches conduct independent clinical assessment not only for substance abuse but also a wide range of services needs (clinical assessment) and then prioritize plans (service planning). To achieve successful, recovery coaches provide continual and aggressive outreach efforts including home visiting (outreach) for parents to access to services and re-engage parents in treatment when necessary (case management). Recovery coaches also identify other resources and help them to obtain it (advocacy).
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Kopels, S., Carter-Black, J., & Poetner, J. (2002). Reducing conflict between child welfare communities. Journal of Health and Social Policy, 15, 117–129. Maluccio, A., & Ainsworth, F. (2003). Drug use by parents: A challenge for family reunification practice. Children and Youth Services Review, 25, 511– 533. Marsh, J. C., Ryan, J., Choi, S., & Testa, M. (2006). Integrated service for families with multiple problems: Obstacles to family reunification. Children and Youth Services Review, 28, 1074–1087. McLellan, A. T., Hagan, T., Levine, M., Meyers, K., Gould, R., Bencivengo, . . . Jaffe, J. (1999). Does clinical case management improve outpatient addiction treatment? Drug and Alcohol Dependence, 55, 91–103. McLellan, A. T., Hagan, T., Meyers, K., Levine, M., Gould, F., Bencivengo, J., & Durell, J. (1998). Improved outcomes following service enhancements in public substance abuse treatment programs. Addiction, 93, 1489–1499. Ryan, J., Marsh, J., Testa, M., & Louderman, R. (2006). Integrating substance abuse treatment and child welfare services: Findings from the Illinois AODA Waiver Demonstration. Journal of Social Work Research, 30, 95–107. Shwartz, M., Baker, G., Mulvey, K., & Plough, A. (1997). Improving publicly funded substance abuse treatment: The value of case management. American Journal of Public Health, 87, 1659–1664. Siegal, H. A., Risher, J. H., Rapp, R., Kelliher, C., Wagner, J., O’Brien, W., & Cole, P. (1996). Enhancing substance abuse treatment with case management: Its impact on employment. Journal of Substance Abuse Treatment, 13, 93–98. Weil, M., & Karls, J. M. (1985). Historical origins and recent developments. In M. Weil & J. M. Karls (Eds.), Case management in human service practice (pp. 1–28). San Francisco, CA: Jossey-Bass, Inc.. Young, N. K., Gardner, S. L., & Dennis, K. (1998). Responding to alcohol and other drug problems in child welfare: Weaving together practice and policy. Washington, DC: CWLA. Zlotnick, C., Kronstadt, D., & Klee, L. (1999). Essential case management services for young children in foster care. Community Mental Health Journal, 35, 421–430.
