Journal of Substance Abuse Treatment xxx (2014) xxx–xxx

Contents lists available at ScienceDirect

Journal of Substance Abuse Treatment

Perceptions of behavioral health care among veterans with substance use disorders: Results from a national evaluation of mental health services in the Veterans Health Administration Daniel M. Blonigen, Ph.D. a,⁎, Leena Bui, B.A. a, Alex H.S. Harris, Ph.D. b, Kimberly A. Hepner, Ph.D. c, Daniel R. Kivlahan, Ph.D. d a

Center for Innovation to Implementation, VA Palo Alto Health Care System VA Substance Use Disorder Quality Enhancement Research Initiative, VA Palo Alto Health Care System c RAND Corporation d Mental Health Services, Veterans Health Administration, Department of Psychiatry and Behavioral Sciences, University of Washington b

a r t i c l e

i n f o

Article history: Received 2 October 2013 Received in revised form 23 January 2014 Accepted 24 March 2014 Available online xxxx Keywords: Substance use disorders Perceptions of behavioral health care Recovery orientation Veterans Health Administration

a b s t r a c t Understanding patients' perceptions of care is essential for health care systems. We examined predictors of perceptions of behavioral health care (satisfaction with care, helpfulness of care, and perceived improvement) among veterans with substance use disorders (SUD; n = 1,581) who participated in a phone survey as part of a national evaluation of mental health services in the U.S. Veterans Health Administration. In multivariate analyses, SUD specialty care utilization and higher mental health functioning were associated positively with all perceptions of care, and comorbid schizophrenia, bipolar, and PTSD were associated positively with multiple perceptions of care. Perceived helpfulness of care was associated with receipt of SUD specialty care in the prior 12 months (adjusted OR = 1.77, p b .001). Controlling for patient characteristics, satisfaction with care exhibited strong associations with perceptions of staff as supportive and empathic, whereas perceived improvement was strongly linked to the perception that staff helped patients develop goals beyond symptom management. Survey responses that account for variation in SUD patients' perceptions of care could inform and guide quality improvement efforts with this population. Published by Elsevier Inc.

1. Introduction Understanding patients' perceptions of the care they receive is essential information for all health care systems. By enabling comparisons across providers, services, and facilities, such information can help identify gaps in quality of care provided by a system and stimulate improvements in services (Black, 2013). Across a range of medical and mental health conditions, patient perceptions of care have been linked to patterns of health care utilization (Fenton, Jerant, Bertakis, & Franks, 2012), as well as a number of health care outcomes–e.g., treatment adherence, health status, health-related quality of life (Fremont et al., 2001; Guldvog, 1999; Jha, Orav, Zheng, & Epstein, 2008). Identifying factors that account for variation in perceptions of care may therefore be critical to quality improvement efforts (Davies et al., 2008), as well as for detecting disparities across different patient populations (Hatzenbuehler, Keyes, Narrow, Grant, & Hasin, 2008; Keyes et al., 2008). The Veterans Health Administration (VHA) is the largest provider of mental health services in the United States (Watkins, Pincus, Paddock, et al., 2011), and veterans with substance use disorders ⁎ Corresponding author at: Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025. Tel.: +1 650 493 5000x27828; fax: +1 650 617 2736. E-mail address: [email protected] (D.M. Blonigen).

(SUD)–particularly those with a comorbid mental health condition– account for a disproportionate share of VHA healthcare utilization and costs (Humphreys, Wagner, & Gage, 2011; Watkins, Pincus, Paddock, et al., 2011; Yu, Wagner, Chen, & Barnett, 2003). In 2006, the VHA commissioned a comprehensive evaluation of its mental health and substance use treatment system (Watkins, Pincus, Smith, et al., 2011). This evaluation included a client survey to obtain data regarding veterans' perceptions of behavioral health care (i.e., counseling or treatment for substance use and/or other mental health problems) they received in the VHA in fiscal years (FYs) 2007 and 2008. The current study focused on the cohort of patients with SUDs who completed the client survey and investigated perceptions of behavioral health care in this population. In particular, we sought to elucidate the factors (e.g., patient characteristics, SUD specialty care utilization, aspects of staff recovery orientation) that account for variation in perceptions of care among VHA patients with SUDs. Such information could help to target quality improvement efforts in the VHA with this highly prevalent and costly patient population. 1.1. Perceptions of care among patients with SUDs In the aforementioned survey, multiple, distinct domains of perceptions of care were assessed. The present study focused on the

http://dx.doi.org/10.1016/j.jsat.2014.03.005 0740-5472/Published by Elsevier Inc.

Please cite this article as: Blonigen, D.M., et al., Perceptions of behavioral health care among veterans with substance use disorders: Results from a national evaluation of mental he..., Journal of Substance Abuse Treatment (2014), http://dx.doi.org/10.1016/j.jsat.2014.03.005

2

D.M. Blonigen et al. / Journal of Substance Abuse Treatment xxx (2014) xxx–xxx

following perceptions of care: satisfaction with care, helpfulness of care, and perceived improvement. Patient satisfaction is a global index of quality of care, which has been linked to better clinical outcomes in some studies (Holcomb, Parker, Leong, Thiele, & Higdon, 1998; Kane, Maciejewski, & Finch, 1997), but not in others (Fenton et al., 2012). Helpfulness of care is the perception of the extent to which care received led to improvements in functioning. Ratings of perceived improvement correspond to the perception that the care provided led to improved functioning in a number of specific areas (e.g., dealing with daily problems, social situations; problems and symptoms; ability to accomplish things). Among SUD patients, prior research has reported links between positive patient perceptions of care and better outcomes (e.g., Boden & Moos, 2013; Long, Williams, Midgley, & Hollin, 2000). However, it has also been observed that SUD patients, relative to non-SUD patients, are less likely to perceive their health care experiences positively (Burnett-Zeigler, Zivin, Ilgen, Islam, & Bohnert, 2011). For example, Hepner et al. (2014) found that, among mental health patients, those with an SUD diagnosis reported lower ratings on satisfaction with care than those without this diagnosis. While such findings support the need for further quality improvement efforts with this large segment of the VHA mental health population, additional information is needed to guide these efforts. Specifically, what factors contribute to variation in these perceptions of care within this patient population? 1.2. Staff recovery orientation Staff recovery orientation is a key dimension of health care quality (Eisen et al., 2011; Institute of Medicine, 2001; Kupfer & Bond, 2012). It comprises a range of patient-centered practices (e.g., involving patients and their families in the treatment planning process; identifying other life goals of patients; introducing patients to role models/mentors; expressing high expectations for a patient's recovery). In general, recovery-oriented practices have been linked to higher ratings of satisfaction and perceived helpfulness of care (e.g., Harth, Germann, & Jester, 2008; Mueser et al., 2006), and improvements in physical and mental health functioning (Mueser et al., 2006; Stewart et al., 2000). Conversely, in a study by Cooper et al. (2013), a patient-centered care model (relative to standard care) was associated with higher ratings of helpfulness of care, but not improvements in clinical outcomes. Recovery orientation has also been highlighted as an important aspect of care for the treatment of SUDs and comorbid mental health conditions (Davidson & White, 2007; Gagne, White, & Anthony, 2007; Humphreys & McLellan, 2011). However, recovery orientation is multifaceted. Accordingly, a notable gap in the research literature on patients with SUDs is which aspects of recovery orientation are most strongly linked to various perceptions of care in this population. At present, the evidence supports a number of different recovery elements, including facilitating patient goal setting (Gates, 1991), providing empathy and encouragement (McKellar, Kelly, Harris, & Moos, 2006; Resnick & Griffiths, 2011), and involving significant others in treatment planning (Kidorf et al., 2005). Elucidating which aspects of recovery orientation are most salient in terms of predicting SUD patients' perceptions of care will help target quality improvement efforts on the aspects of treatment that matter most to patients.

perceptions of care in this cohort; (3) estimate the amount of variability in perceptions of care across VHA facilities; and (4) examine which aspects of staff recovery orientation are uniquely linked to perceptions of care among VHA patients with SUDs. 2. Materials and methods 2.1. Participants 2.1.1. Study population The data for this study were collected as part of a national program evaluation of mental health services in the VHA (Watkins, Pincus, Smith, et al., 2011). The sample consisted of veterans who were identified from VHA healthcare utilization records as having at least one inpatient episode or two outpatient encounters in any setting during FY 2007, one of which was for one of four mental health diagnoses – i.e., schizophrenia, bipolar disorder, posttraumatic stress disorder (PTSD), and major depressive disorder (MDD). Patients were also required to have any additional VHA encounters for one of these diagnoses in FY 2008 to reflect continuing engagement in VHA care. These diagnoses were targeted because they account for a disproportionate share of healthcare utilization and costs among mental health patients in the VHA. Patients were assigned to only one of these mental health cohorts based on the modal frequency of appearance of 38 ICD-9-CM diagnostic codes in the veteran's VHA medical utilization files. Any ties in frequency were resolved by using the following rank order: schizophrenia, bipolar disorder, PTSD, or MDD. In addition, patients with SUD diagnoses were identified as a separate cohort, and patients with comorbid substance use and mental health disorders were assigned to the SUD cohort plus one of the mental health cohorts. The target sample of the present investigation is the SUD cohort, which comprises five separate subgroups: SUD only; comorbid schizophrenia (SUD-schizophrenia); comorbid bipolar disorder (SUD-bipolar); comorbid PTSD (SUD-PTSD); and comorbid MDD (SUD-MDD). 2.1.2. Sampling plan A random sample of 9,619 patients was selected from the target population of veterans with mental health disorders and SUDs to ensure that the sample contained sufficient numbers of veterans by geographic region (i.e., Veteran Integrated Service Networks; VISN) and diagnostic cohort. First, the sample was stratified by VISN and the four mental health diagnostic cohorts (schizophrenia, bipolar disorder, PTSD, MDD), with approximately 100 veterans per VISN and diagnostic cohort stratum. Second, the sample was further stratified within each diagnostic cohort and VISN stratum to match the prevalence of comorbid SUDs in the population represented by each stratum. Third, an additional random sample of veterans with SUDs was selected to obtain a sample of the SUD diagnostic cohort (for further details, see Watkins, Pincus, Smith, et al., 2011). Sampled veterans were contacted to evaluate their perceptions of care and current functioning using a client survey. The survey was administered to 6,190 patients (67% response rate for all veteran patients in the study who were contacted; 62% response rate for patients in the SUD cohort). The present analyses focus on the 1,581 patients from the SUD cohort who (a) completed the client survey and (b) reported receiving behavioral health care from the VHA in the past 12 months. Sample sizes across the SUD subgroups are as follows: SUD only (n = 391); SUD-schizophrenia (n = 263); SUD-bipolar (n = 380); SUD-PTSD (n = 280); SUD-MDD (n = 267).

1.3. The present study With a focus on VHA patients with SUDs, the current study used survey data from a national program evaluation of VHA mental health services to examine multiple domains of perceptions of behavioral health care. Our specific aims were as follows: (1) obtain nationallevel estimates of perceptions of behavioral health care in the SUD cohort; (2) identify the patient characteristics associated with

2.1.3. Survey procedures The survey was administered to patients between November 2008 and August 2009. Patients were sent a study brochure a week prior to being contacted by phone. Interviewers made a maximum of 15 call attempts to complete the interview. Interviews included a complete description of the study and verbal informed consent. Interviews lasted approximately half an hour, and participants received a $10

Please cite this article as: Blonigen, D.M., et al., Perceptions of behavioral health care among veterans with substance use disorders: Results from a national evaluation of mental he..., Journal of Substance Abuse Treatment (2014), http://dx.doi.org/10.1016/j.jsat.2014.03.005

D.M. Blonigen et al. / Journal of Substance Abuse Treatment xxx (2014) xxx–xxx

check. All procedures were approved by the RAND Human Subjects Protection Committee. 2.2. Measures At the outset of the survey, participants were asked if they received counseling or treatment for mental health or substance use problems in the past 12 months, using an item that was adapted from the Experience of Care and Outcomes (ECHO) survey (Daniels, Shaul, Greenberg, & Cleary, 2004). Participants who endorsed receiving behavioral health care were asked additional survey items across a variety of domains related to functioning and patient perceptions in regards to the past 12 months. Although all of the sampled patients had received behavioral health care of some kind, only 31.5% of the SUD cohort had received SUD-specific treatment in the 12 months prior to the survey. 2.2.1. Sociodemographics Patient characteristics were measured from both the client survey and VHA administrative records. Specifically, race/ethnicity, educational level, marital status, household income (past 12 months), and employment status were measured via the survey. Data on age, gender, and service connection status (i.e., whether or not the veteran received compensation for a mental or physical health condition that was incurred or aggravated during active duty) were obtained from administrative records. 2.2.2. Functioning Functional status was assessed using the Veterans RAND 12 Item Health Survey (Iqbal et al., 2007). This measure creates two composite scores reflecting mental health and physical health functioning, which were independent of one another in the present sample (r = .04, p = .118). The composite scores were standardized using a t-score transformation (mean of 50 and a standard deviation of 10). The scores are norm-based vis à vis the distribution of scores in the 1990 US population and are unadjusted for age and gender. 2.2.3. SUD specialty care utilization SUD specialty care utilization in the 12 months prior to completion of the client survey was defined as an encounter with an SUD diagnosis resulting from treatment received in a residential or outpatient SUD treatment program, as determined by outpatient clinic stop codes or residential bed section codes recorded in VHA administrative data (Harris, Reeder, Ellerbe, & Bowe, 2010). 2.2.4. Staff recovery orientation Patient perceptions of the staff recovery orientation were assessed using seven items drawn from the recovery self-assessment (O'Connell, Tondora, Croog, Evans, & Davidson, 2005). Response options for each item were reported on a 4-point scale (1 = “strongly disagree,” 2 = “disagree,” 3 = “agree,” 4 = “strongly agree”). The items inquired as to whether the veteran perceived that staff (a) expressed high expectations for the patient's recovery (M = 3.3, SD = 0.78); (b) believed the patient could make their own life choices (M = 3.2, SD = 0.77); (c) listened to and respected the patient's decisions (M = 3.2, SD = 0.79); (d) asked about the patient's interests (M = 2.9, SD = 0.88); (e) helped the patient develop life goals beyond symptom management (e.g., employment, education, physical fitness, connecting with family and friends, hobbies) (M = 2.9, SD = 0.86); (f) helped the patient to include other important people in treatment planning (M = 3.0, SD = 0.84); and (g) introduced the patient to role models or mentors (M = 2.6, SD = 0.91). Consistent with prior work (Watkins, Pincus, Smith, et al., 2011), these items may be dichotomized (i.e., 1 = “strongly agree”). 2.2.5. Perceptions of VHA behavioral health care Veterans' overall satisfaction with their VHA counseling or treatment was assessed using a single item from the ECHO survey, which asked the veterans to rate their behavioral health care from 0 to 10 (0 = “worst

3

counseling or treatment possible,” 10 = “best counseling or treatment possible”) (median = 8.0, SD = 2.42). Consistent with prior work (Watkins, Pincus, Smith, et al., 2011), this item may be dichotomized (i.e., 1 = “9 or 10”). Using another item from the ECHO survey, veterans were asked how much they perceived the counseling or treatment they received in the last 12 months to be helpful, with responses rated on a 4point scale (0 = “not at all,” 1 = “a little,” 2 = “somewhat,” and 3 = “a lot”) (M = 2.1, SD = 0.97). Consistent with prior work (Watkins, Pincus, Smith, et al., 2011), this item was dichotomized when included in all analyses (1 = “somewhat” or “a lot”). Participants' perceived improvement in their functioning, compared to the prior 12 months, was assessed using four items from the ECHO survey, which were rated on a 5-point scale (1 = “much worse,” 2 = “a little worse,” 3 = “about the same,” 4 = “a little better,” 5 = “much better”). The items asked about participants' improvement in (a) ability to deal with daily problems (M = 3.4, SD = 1.15); (b) ability to deal with social situations (M = 3.3, SD = 1.14); (c) ability to accomplish things they want to do (M = 3.1, SD = 1.19); and (d) problems or symptoms (M = 3.2, SD = 1.18). Items were highly intercorrelated (average r = .66; range = .64–.69) and were summed to create an improvement composite (Daniels et al., 2004). Consistent with prior work (Watkins, Pincus, Smith, et al., 2011), these items may also be dichotomized (i.e., 1 = “a little or much better”). 2.3. Statistical analyses To begin, we generated national estimates of study variables by calculating percentages and means for patient characteristics (sociodemographics, functioning, diagnostic subcohort), SUD specialty care utilization, staff recovery orientation, and perceptions of VHA behavioral health care. All estimates were weighted to reflect the population of VHA patients with an SUD diagnosis – i.e., a sampling weight was used to adjust for the stratified sampling design (Cochran, 1977), and a non-response weight reflecting the inverse probability of each sampled veteran from the SUD cohort completing the survey was derived using logistic regression of an indicator of survey completion on veteran characteristics (Little, 1986). The weight used in the descriptive analyses is the product of the sampling and nonresponse weights. Next, we analyzed patient ratings on perceptions of care (satisfaction with care; helpfulness of care; and perceived improvement) in the following manner. First, we examined which patient characteristics were associated with these perceptions using linear and logistic regression models. Second, we examined the distribution of scores on the three perception of care variables across a sampling of VHA facilities. Specifically, the average patient ratings on these variables were calculated for facilities with at least 15 or more survey respondents (median = 20), which yielded a total of 39 facilities. This cutoff was selected to ensure an adequate sampling of facilities across geographic regions. Third, we examined which aspects of staff recovery orientation are independently linked to satisfaction with care, helpfulness of care, and perceived improvement via multivariate linear and logistic regressions models. All regression models were performed in SAS 9.2 (PROC SURVEYREG and PROC SURVEYLOGISTIC), and all analyses accounted for clustering of participants within facilities. Scores for satisfaction with care were negatively skewed (−1.16). However, when transforming this variable to increase normality the results were virtually identical to the results using the raw scores, thus; we present the latter findings. 3. Results 3.1. National estimates of patient characteristics, SUD specialty care utilization, and staff recovery orientation among VHA patients with SUDs Weighted estimates of patient characteristics and SUD specialty care utilization for the population of VHA patients with SUDs are presented in Table 1. The sample consisted primarily of Caucasian men in their mid-fifties, the majority of whom reported their highest

Please cite this article as: Blonigen, D.M., et al., Perceptions of behavioral health care among veterans with substance use disorders: Results from a national evaluation of mental he..., Journal of Substance Abuse Treatment (2014), http://dx.doi.org/10.1016/j.jsat.2014.03.005

4

D.M. Blonigen et al. / Journal of Substance Abuse Treatment xxx (2014) xxx–xxx

Table 1 National estimates of patient characteristics and substance use disorder (SUD) specialty care utilization among SUD patients in the Veterans Health Administration. Variable

Age (mean) Gender – male (%) Race/Ethnicity (%) Caucasian Hispanic African American Other1 Education level (%) Did not complete high school High school graduate or GED Some college College graduate or beyond Marital status (%) Married or cohabitating Household income – past 12 months (%) $15,000 or less $15,001–$30,000 $30,001–$60,000 More than $60,000 Employment status (%) Employed Unemployed Out of the workforce2 Service connected3 (%) Functioning4 (means) Mental health composite Physical health composite Diagnostic subcohort (%) SUD only SUD-schizophrenia SUD-bipolar SUD-PTSD SUD-MDD SUD specialty care utilization – past 12 months (%) Any care Outpatient Residential

aspects of staff recovery orientation ranged from 17% (introduced patient to role models and mentors) to 42% (encouraged hope and high expectations).

Total SUD cohort (N = 1581) Weighted % or mean

SE of % or mean

54.7 94.8

0.34 0.59

56.7 8.0 27.0 8.3

2.16 1.33 2.07 0.92

7.0 38.4 34.3 20.3

0.81 1.59 1.56 1.23

29.7

1.38

47.6 28.7 18.5 5.3

1.56 1.33 1.19 0.67

17.5 10.0 72.5 42.6

1.31 0.91 1.43 1.53

36.8 35.1

0.44 0.46

36.6 9.5 9.3 31.7 12.9

1.30 0.59 0.52 1.62 0.82

31.5 31.0 3.9

1.56 1.58 0.59

Notes. Data on age, gender, service connection status, diagnostic subcohort, and SUD specialty care utilization were obtained from VHA administrative records. All other data were obtained via the client survey. 1 Race (“Other”) includes Asian, Native Hawaiian/Other Pacific Islander, American Indian/Alaskan Native, multiracial, none of these races, and refused/don’t know. 2 Out of the workforce includes unable to work/disabled (n = 884), retired (n = 245), unemployed and not looking for work (n = 25), student (n = 12), and homemaker (n = 2). 3 Service connected = receiving compensation for a mental or physical health condition that was incurred or aggravated during active duty. 4 Mental health and physical health composite scores are T-scores (higher = better functioning). PTSD = posttraumatic stress disorder; MDD = major depressive disorder.

education level as a high school diploma or GED, were unmarried, out of the workforce, had an annual income of $15,000 or less, and were not service connected. The mental and physical health functioning composites scores were both approximately 1.5 standard deviations lower than the general US population, with slightly poorer functioning reported in regards to physical health. The majority of participants from the SUD cohort had a comorbid mental health diagnosis. Per the administrative data, approximately 1/3 of the sample received some form of SUD specialty care in the past 12 months, the majority of whom received care on an outpatient basis. These rates are consistent with prior analyses of VHA administrative data (cf. Dalton, Oliva, Harris, & Trafton, 2012; Harris & Bowe, 2008; Oliva, Dalton, Harris, & Trafton, 2011). Estimates of patients' perceptions of staff recovery orientation are given in Table 2. Rates of endorsing “strongly agree” on specific

3.2. National estimates of perceptions of behavioral health care among VHA patients with SUDs In terms of perceptions of care, 36% of the sample rated their satisfaction with care as a 9 or 10. Regarding helpfulness, 72% of participants reported that they were helped ‘somewhat’ or ‘a lot’ by the care they received. Most participants did not report improvements in specific areas of functioning. Specifically, 46%, 40%, 37%, and 37% of the sample reported at least ‘a little’ improvement in dealing with daily problems, dealing with social situations, problems or symptoms, and ability to accomplish things, respectively. However, the majority of participants (61%) reported at least ‘a little’ improvement in at least one of these areas.

3.3. Predictors of perceptions of behavioral health care among VHA patients with SUDs Table 3 shows the results of a series of multivariate regression models examining associations between patient characteristics and SUD specialty care utilization with perceptions of behavioral health care. The proportion of variance accounted for by the predictors in these models was modest for satisfaction and helpfulness of care (R 2 = .09 for both), but was substantial for the improvement composite (R2 = .42). In terms of general trends, higher mental health functioning and utilization of SUD specialty care were associated positively with all outcomes after adjustment for other variables, as was physical health functioning (with the exception of helpfulness of care). To better gauge the incremental effect of SUD specialty care utilization on each of the perception of care variables, supplementary analyses were conducted to examine the increase in R2 when entering SUD specialty care utilization into the models. For satisfaction with care, helpfulness of care, and the improvement composite, the ΔR2 were .005, .015, and .003, respectively (all ps b .01). In terms of specific trends, the following was observed: higher ratings of satisfaction with care were associated with older age and comorbid schizophrenia, bipolar, and MDD (relative to SUD only); patients with SUD and comorbid schizophrenia, bipolar, and PTSD perceived their care as more helpful than those with SUD alone; and higher scores on the improvement composite were associated with younger age, being African American (relative to Caucasian), and comorbid PTSD (relative to SUD only).

Table 2 National estimates of perceptions of staff recovery orientation among SUD patients in the Veterans Health Administration (VHA). Staff recovery orientation (% ‘strongly agree’)

Encouraged hope and high expectations Believed patient could make own choices Listened to and respected patients' decisions about care Asked about patient interests Helped patient develop/plan for life goals beyond symptom management Helped patient to include others in treatment planning Introduced patient to role models and mentors

Total SUD cohort (N = 1581) Weighted %

SE of %

41.5 33.1 39.2

1.32 1.48 1.35

26.2 26.2

1.34 1.36

28.9

1.31

17.1

1.15

Please cite this article as: Blonigen, D.M., et al., Perceptions of behavioral health care among veterans with substance use disorders: Results from a national evaluation of mental he..., Journal of Substance Abuse Treatment (2014), http://dx.doi.org/10.1016/j.jsat.2014.03.005

D.M. Blonigen et al. / Journal of Substance Abuse Treatment xxx (2014) xxx–xxx

5

Table 3 Patient characteristics and substance use disorder (SUD) specialty care utilization in the prediction of perceptions of Veterans Health Administration behavioral health care. Predictor variable

Satisfaction with care (R2 = 0.09) Βs (SEs)

ORs (CIs)

Βs (SEs)

Age Gender (1 = male) Race/Ethnicity Caucasian (referent) Hispanic African American Other Education level Marital status (1 = married/cohabitating) Household income – past 12 months Employment status Employed (referent) Unemployed Out of the workforce Service connected (1 = yes) Functioning Mental health composite Physical health composite Diagnostic subcohort SUD only (referent) SUD-schizophrenia SUD-bipolar SUD-PTSD SUD-MDD SUD specialty care utilization – past 12 months

0.02 (0.01)⁎⁎ −0.29 (0.24)

1.00 (0.99, 1.02) 0.83 (0.52, 1.33)

−0.02 (0.01)⁎ −0.41 (0.34)

– 0.07 (0.22) 0.14 (0.14) −0.04 (0.23) −0.10 (0.07) 0.19 (0.14) −0.04 (0.08)

– 1.38 (0.83, 0.93 (0.69, 1.18 (0.69, 1.12 (0.97, 1.11 (0.84, 0.97 (0.83,

2.32) 1.27) 2.01) 1.29) 1.47) 1.13)

– 0.49 (0.32) 0.50 (0.21)⁎ 0.37 (0.26) −0.08 (0.09) 0.03 (0.18) −0.03 (0.10)

– 0.09 (0.25) 0.15 (0.21) 0.09 (0.15)

– 0.97 (0.57, 1.65) 0.95 (0.61, 1.47) 0.90 (0.70, 1.15)

– 0.44 (0.32) 0.35 (0.30) −0.38 (0.21)

0.05 (0.01)⁎⁎⁎ 0.02 (0.01)⁎⁎⁎

1.04 (1.03, 1.05)⁎⁎⁎ 1.00 (0.99, 1.01)

0.17 (0.01)⁎⁎⁎ 0.08 (0.01)⁎⁎⁎

– 0.50 0.49 0.29 0.44 0.38

– 1.64 (1.09, 1.70 (1.20, 1.55 (1.02, 1.35 (0.95, 1.77 (1.38,

– 0.47 0.43 0.56 0.14 0.52

(0.20)⁎ (0.18)⁎⁎ (0.19) (0.22)⁎ (0.12)⁎⁎

Helpfulness of care (R2 = 0.09)

2.46)⁎ 2.41)⁎⁎ 2.33)⁎ 1.90) 2.25)⁎⁎⁎

Improvement composite (R2 = 0.42)

(0.26) (0.24) (0.26)⁎ (0.25) (0.17)⁎⁎

Notes. Ns = 1448–1477. For each outcome, all covariates were entered together in multivariate regression models. Responses to satisfaction with care were rated on a 0–10 scale. Helpfulness of care (1 = “somewhat” or “a lot”). Bs = unstandardized betas. SEs = Standard Errors. ORs = odds ratios. CIs = Confidence Intervals. PTSD = posttraumatic stress disorder. MDD = major depressive disorder. For each model, variable inflation factors were acceptable (i.e., ≤1.42). ⁎ p b .05. ⁎⁎ p b .01. ⁎⁎⁎ p b .001.

3.4. Facility-level variation in perceptions of behavioral health care among VHA patients with SUDs The histograms shown in Fig. 1 illustrate the distribution of scores and 95% confidence intervals for satisfaction with care (panel A), helpfulness of care (panel B), and the improvement composite (panel C) across 39 VHA facilities. To facilitate interpretation of the magnitude of the differences across facilities, scores on the improvement composite were plotted on a z-score metric. Substantial facilitylevel variation was observed for all outcomes: satisfaction with care ratings ranged from 5.9 to 8.6 (on a 0–10 scale); the percentage of those who rated helpfulness of care as ‘somewhat’ or ‘a lot’ ranged from 33% to 94%; and improvement composite z-scores ranged from − 0.85 to 0.67 SDs. The number of participants across these sites (median = 20; range = 15–42) precluded further analyses of facility-level predictors of these outcomes. 3.5. Staff recovery orientation as predictors of perceptions of behavioral health care among VHA patients with SUDs Table 4 provides the results of three hierarchical regression models examining which of the seven staff recovery orientation items is associated with perceptions of care. In step 1, we adjusted for patient characteristics (sociodemographics, functioning, diagnostic cohort) and utilization of SUD specialty care. In step 2, the individual recovery orientation items were entered simultaneously. For all models, the addition of the recovery items in step 2 was associated with a significant increase in R 2 (ps b .001). Several aspects of staff recovery orientation were associated with satisfaction of care and helpfulness of care–perceptions of care for which patient characteristics and SUD specialty care utilization accounted for only a modest proportion of variance. In particular, higher satisfaction with care exhibited strong associations with the perception that staff listened to and respected

patients' decisions about care and encouraged hope and high expectations, whereas helpfulness of care exhibited a strong association with the perception that staff included others in treatment planning. In the context of larger associations with patient characteristics and SUD specialty care utilization (R 2 = .42), the only staff recovery orientation item that was a significant, incremental predictor of the improvement composite was the perception that staff helped patients develop and plan for life goals beyond symptom management.

4. Discussion The present study used survey data and administrative records from a national evaluation of VHA mental health services to understand perceptions of behavioral health care in patients with SUDs. Specifically, we examined multiple, distinct domains of perceptions of care and sought to identify factors that account for variation in these perceptions in this patient population. SUD specialty care utilization and higher functioning (particularly mental health) were uniformly and robustly associated with higher ratings on all perception of care variables. In addition, comorbid mental health conditions of schizophrenia, bipolar, and PTSD (but not MDD) were associated positively with multiple perceptions of care, which suggests that these dual-diagnosis patients may be more likely than SUD-only patients to perceive their care positively. A number of specific associations were also observed between patient characteristics and various perceptions of care, which can inform case-mix adjustment schemes in future work comparing the quality of care for SUD patients across health care facilities. For example, higher ratings of satisfaction were associated with older age, and higher ratings of perceived improvement were linked to younger age, and being African American.

Please cite this article as: Blonigen, D.M., et al., Perceptions of behavioral health care among veterans with substance use disorders: Results from a national evaluation of mental he..., Journal of Substance Abuse Treatment (2014), http://dx.doi.org/10.1016/j.jsat.2014.03.005

6

D.M. Blonigen et al. / Journal of Substance Abuse Treatment xxx (2014) xxx–xxx

A

Satisfaction with care (0 to 10)

10 9 8 7 6 5 4 3

B

Facilities Helpfulness of care (% rating "somewhat" or "a lot")

120 100 80 60 40 20 0

C

Facilities Improvement composite (z-scores)

1.5 1 0.5 0 -0.5 -1 -1.5 -2

Facilities

Fig. 1. Distribution of scores and 95% confidence intervals for perceptions of behavioral health care across 39 Veterans Health Administration facilities (median n = 20 patients per facility; range = 15–42).

In terms of identifying quality of care gaps and stimulating improvements in services, the patient ratings for staff recovery orientation and perceptions of care highlight the challenges for the VHA in improving the overall quality of care provided to patients with SUDs. For example, the majority of participants provided ratings of less than ‘strongly agree’ on all aspects of staff recovery orientation, suggesting a general need for quality improvement efforts to enhance patient-centered practices among VHA providers who frequently work with SUD patients. Further, despite the fact that patient perceptions were somewhat more favorable in terms of helpfulness of care and perceived improvement in functioning, there was substantial variation in each of the perception of care outcomes across VHA facilities. The small sample sizes limited our ability to identify facility-level predictors of this variation; however, from a quality improvement standpoint, the observed distributions underscore the importance of future work to identify facility-level predictors of this variation (especially given that patient characteristics accounted for a small proportion of the variance in most outcomes), and implement programs to increase the quality of care for SUD patients at low-performing sites. Examples of the latter might include de-implementation of confrontational approaches that have been linked to poorer outcomes and perceptions of care among SUD patients (Moyers & Miller, 2013). These implications notwithstanding, caution should be taken in interpreting the facility-level findings, given that (a) we were only able to select 39 VHA facilities, and (b) the median number of participants per facility (20) was modest and limits the ability to detect significant differences across facilities. A notable set of findings in the present study was our analysis of specific staff recovery orientation items and their incremental contribution to the prediction of perceptions of care after controlling for patient characteristics and utilization of SUD specialty care. Specifically, patients' overall satisfaction with care was accounted for primarily by a supportive and empathic staff orientation (e.g., encouraging hope; listening to and showing respect for patients' decisions), whereas the perception that care led to improvements in functioning was accounted for exclusively by the perception that staff helped patients to develop and pursue individually-defined life goals such as employment and education (O'Connell et al., 2005). The extent to which other staff recovery items could predict perceived improvement may have been constrained, given the large amount of variance in this outcome that was already predicted by patient characteristics and SUD specialty care utilization. Nonetheless, these findings suggest that there is potential value in targeting specific aspects of recovery orientation in the assessment and implementation of such services with patients with SUDs. For example, consistent with the

Table 4 Aspects of staff recovery orientation in the prediction of perceptions of Veterans Health Administration behavioral health care, adjusting for patient characteristics and substance use disorder (SUD) specialty care utilization in the past 12 months. Predictor variable

Step 1: Patient characteristics and SUD specialty care utilization Step 2: Staff recovery orientation Encouraged hope and high expectations Believed patient could make own choices Listened to and respected patients' decisions about care Asked about patient interests Helped patient develop/plan for life goals beyond symptom management Helped patient to include others in treatment planning Introduced patient to role models and mentors

Satisfaction with care

Helpfulness of care

Improvement composite

Βs (SEs)

R2

ORs (CIs)

R2

Βs (SEs)

R2

– – 0.68 0.08 0.76 0.19 0.30 0.28 0.11

.09 .47

– – 1.25 (0.99, 1.56) 1.25⁎ (1.01, 1.55) 1.39⁎⁎ (1.12, 1.73) 0.98 (0.78, 1.22) 1.39⁎ (1.08, 1.79) 1.58⁎⁎⁎ (1.23, 2.03) 1.01 (0.83, 1.24)

.09 .27

– – 0.21 0.04 0.20 0.02 0.55 0.24 0.00

.42 .47

(0.10)⁎⁎⁎ (0.09) (0.09)⁎⁎⁎ (0.08)⁎ (0.10)⁎⁎ (0.09)⁎⁎ (0.05)⁎

(0.14) (0.14) (0.17) (0.13) (0.17)⁎⁎⁎ (0.15) (0.11)

Notes. Ns = 1318–1581. † Patient characteristics = sociodemographics; functioning; diagnostic subcohort. Staff recovery items were entered together at Step 2. Responses to satisfaction with care were rated on a 0–10 scale. Helpfulness of care (1 = “somewhat” or “a lot”). Bs = unstandardized betas. SEs = Standard Errors. ORs = odds ratios. CIs = Confidence Intervals. For each model, variable inflation factors were acceptable (i.e., ≤2.43). ⁎ p b .05. ⁎⁎ p b .01. ⁎⁎⁎ p b .001.

Please cite this article as: Blonigen, D.M., et al., Perceptions of behavioral health care among veterans with substance use disorders: Results from a national evaluation of mental he..., Journal of Substance Abuse Treatment (2014), http://dx.doi.org/10.1016/j.jsat.2014.03.005

D.M. Blonigen et al. / Journal of Substance Abuse Treatment xxx (2014) xxx–xxx

literature on therapeutic alliance and SUD treatment (Crits-Christoph et al., 2009; Ilgen, McKellar, Moos, & Finney, 2006), initiation in SUD treatment and other types of behavioral health care may be maximized by a therapeutic approach that emphasizes instilling hope, optimism, and high expectations, whereas improved functioning post-treatment may require efforts to help people develop valued social roles and other meaningful activities (e.g., hobbies, education, physical fitness). Importantly, these two approaches represent distinct principles in the recovery orientation literature (Davidson, O’Connell, Sells, & Staeheli, 2003; O'Connell et al., 2005). Efforts to operationalize these principles into standards and practices that are both measureable and can be implemented into the care for veterans with SUDs are specific quality improvement efforts suggested by the present findings, which may greatly enhance the overall quality of care provided to these patients (Gagne et al., 2007; Sheedy & Whitter, 2009). Further, these principles may serve as a framework for augmenting brief interventions for the large number veterans with harmful substance use who are seen in nonSUD and non-mental health settings such as primary care where patient motivation for SUD specialty care is likely lower and providers have limited time and training to address these issues (Bradley et al., 2002; Tracy, Trafton, Weingardt, Aton, & Humphreys, 2007). 4.1. Limitations and future directions Some limitations of the present work should be acknowledged. First, diagnoses of SUDs and other mental health disorders were based on administrative records and were limited to categorical information. Although a detailed protocol was employed in the national program evaluation to assign participants to diagnostic cohorts, future evaluations of this kind may benefit from standardized protocols to better gauge the reliability of the diagnoses (e.g., Hasin et al., 2006), as well assessments tools that can quantify severity and chronicity of symptoms so as to provide a more refined dimensional assessment of patients' diagnostic status (e.g., McLellan et al., 1992). Further, the sample selection method precluded estimation of the degree of diagnostic overlap across the mental health cohorts defined as mutually exclusive within the overall SUD sample. Second, our use of self-reports, although advantageous in being able to ascertain detailed information on patient perceptions of care, has its own set of limitations, which in this context may have included retrospective recall biases. Third, perceptions of care were not assessed in reference to SUD specialty care per se, but rather “behavioral health care” more generally (i.e., counseling or treatment for substance use and/or other mental health problems). However, framing the questions in this manner is better aligned with the VHA's recent efforts to integrate mental health and SUD services into team-based care (Department of Veterans Affairs, 2008). In summary, the current findings used the recent national program evaluation of VHA mental health services to provide an examination of perceptions of behavioral health care among VHA patients with SUDs. The findings extend prior work (Hepner et al., 2014) by identifying predictors of perceptions of care in this population, and highlight specific aspects of patient characteristics, receipt of SUD specialty care, and staff recovery orientation that are uniquely linked to these perceptions, which should be investigated further in future work to improve treatment quality and engagement in care. Acknowledgments This research was supported by the Veterans Affairs' Substance Use Disorder Quality Enhancement Research Initiative (SUDQ-LIP 1206). Daniel M. Blonigen was supported by a Career Development Award-2 from the VA Office of Research and Development (Clinical Science Research & Development). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veteran Affairs.

7

References Black, N. (2013). Patient reported outcome measures could help transform healthcare. BMJ, 346(7896), http://dx.doi.org/10.1136/bmj.f167. Boden, M. T., & Moos, R. (2013). Predictors of substance use disorder treatment outcomes among patients with psychotic disorders. Schizophrenia Research, 146, 28–33, http://dx.doi.org/10.1016/j.bbr.2011.03.031. Bradley, K. A., Epler, A. J., Bush, K. R., Sporleder, J. L., Dunn, C. W., Cochran, N. E., et al. (2002). Alcohol-related discussions during general medicine appointments of patients who screen positive for at-risk drinking. Journal of General Internal Medicine, 17, 315–326. Burnett-Zeigler, I., Zivin, K., Ilgen, M. A., Islam, K., & Bohnert, A. S. (2011). Perceptions of quality of health care among veterans with psychiatric disorders. Psychiatric Services, 62, 1054–1059, http://dx.doi.org/10.1176/appi.ps.62.9.1054. Cochran, W. (1977). Sampling techniques (3rd ed.). New York, NY: John Wiley & Sons. Cooper, L. A., Ghods Dinoso, B. K., Ford, D. E., Roter, D. L., Primm, A. B., Larson, S. M., et al. (2013). Comparative effectiveness of standard versus patient-centered collaborative care interventions for depression among African Americans in primary care settings: The BRIDGE study. Health Services Research, 48, 150–174. Crits-Christoph, P., Gallop, R., Temes, C. M., Woody, G., Ball, S. A., Martino, S., et al. (2009). The alliance in motivational enhancement therapy and counseling as usual for substance use problems. Journal of Consulting and Clinical Psychology, 77, 1125–1135, http://dx.doi.org/10.1037/a0017045. Dalton, A., Oliva, E., Harris, A., & Trafton, J. (2012). Health services for VA patients with substance use disorders: Comparison of utilization in fiscal years 2011, 2010, and 2002. Palo Alto, CA: Program Evaluation and Resource Center. Daniels, A. S., Shaul, J. A., Greenberg, P., & Cleary, P. D. (2004). The experience of care and health outcomes survey (ECHO): A consumer survey to collect ratings of behavioral health care treatment, outcomes and plans. In M. E. Maruish (Ed.), The use of psychological testing for treatment planning and outcomes assessment. Instruments for adults, 3. (pp. 839–864). . Fairfax, VA: Lawrence Erlbaum Associates. Davidson, L., O’Connell, M. J., Sells, D., & Staeheli, M. (2003). Is there an outside to mental illness? In L. Davidson (Ed.), Living outside mental illness: Qualitative studies of recovery in schizophrenia (pp. 31–60). New York, NY: New York University Press. Davidson, L., & White, W. (2007). The concept of recovery as an organizing principle for integrating mental health and addiction services. Journal of Behavioral Health Services and Research, 34(2), 109–120. Davies, E., Shaller, D., Edgman-Levitan, S., Safran, D. G., Oftedahl, G., Sakowski, J., et al. (2008). Evaluating the use of a modified CAHPS survey to support improvements in patient-centred care: Lessons from a quality improvement collaborative. Health Expectations, 11(2), 160–176, http://dx.doi.org/10.1111/j.1369-7625.2007.00483.x. Department of Veterans Affairs (2008). Uniform Mental Health Services in VA Medical Centers and Clinics. Washington, DC: Veterans Health Administration. Eisen, S. V., Bottonari, K. A., Glickman, M. E., Spiro, A., III, Schultz, M. R., Herz, L., et al. (2011). The incremental value of self-reported mental health measures in predicting functional outcomes of veterans. The Journal of Behavioral Health Services & Research, 38(2), 170–190, http://dx.doi.org/10.1007/s11414-010-9216-9. Fenton, J. J., Jerant, A. F., Bertakis, K. D., & Franks, P. (2012). The cost of satisfaction: A national study of patient satisfaction, health care utilization, expenditures, and mortality. Archives of Internal Medicine, 172(5), 405–411, http://dx.doi.org/10. 1001/archinternmed.2011.1662. Fremont, A. M., Cleary, P. D., Hargraves, J. L., Rowe, R. M., Jacobsen, N. B., & Ayanian, J. Z. (2001). Patient-centered processes of care and long-term outcomes of myocardial infarction. Journal of General Internal Medicine, 16(12), 800–808, http://dx.doi.org/ 10.1111/j.1525-1497.2001.10102.x. Gagne, C., White, W., & Anthony, W. A. (2007). Recovery: A common vision for the fields of mental health and addictions. Psychiatric Rehabilitation Journal, 31(1), 32–37. Gates, M. F. (1991). Transcultural comparison of hospital and hospice as caring environments for dying patients. Journal of Transcultural Nursing, 2(2), 3–15, http:// dx.doi.org/10.1177/104365969100200202. Guldvog, B. (1999). Can patient satisfaction improve health among patients with angina pectoris? International Journal for Quality in Health Care, 11(3), 233–240. Harris, A. H. S., & Bowe, T. (2008). Predictors of initiation and engagement in VA substance use disorder (SUD) treatment. Psychological Services, 5(3), 228–238, http://dx.doi.org/10.1037/1541-1559.5.3.228. Harris, A. H., Reeder, R. N., Ellerbe, L., & Bowe, T. (2010). Are VHA administrative location codes valid indicators of specialty substance use disorder treatment? Journal of Rehabilitation Research and Development, 47(8), 699–708. Harth, A., Germann, G., & Jester (2008). Evaluting the effectiveness of a patient-oriented hand rehabilitation programme. The Journal of Hand Surgery, 33, 771–778. Hasin, D., Samet, S., Nunes, E., Meydan, J., Matseoane, K., & Waxman, R. (2006). Diagnosis of comorbid psychiatric disorders in substance users assessed with the psychiatric research interview for substance and mental disorders for DSM-IV. American Journal of Psychiatry, 163, 689–696. Hatzenbuehler, M., Keyes, K., Narrow, W., Grant, B., & Hasin, D. (2008). Racial/ethnic disparities in service utilization for individuals with co-occurring mental health and substance use disorders in the general population: Results from the national epidemiologic survey on alcohol and related conditions. Journal of Clinical Psychiatry, 69(7), 1112–1121. Hepner, K. A., Paddock, S. M., Watkins, K. E., Soloman, J., Blonigen, D. M., & Pincus, H. (2014). Perceptions of behavioral health care among veterans: Results from a national survey. Psychiatric Services, http://dx.doi.org/10.1176/appi.ps.201200385. Holcomb, W. R., Parker, J. C., Leong, G. B., Thiele, J., & Higdon, J. (1998). Customer satisfaction and self-reported treatment outcomes among psychiatric inpatients. Psychiatric Services, 49(7), 929–934. Humphreys, K., & McLellan, A. T. (2011). A policy-oriented review of strategies for improving the outcomes of services for substance use disorder patients. Addiction, 106(12), 2058–2066, http://dx.doi.org/10.1111/j.1360-0443.2011.03464.x.

Please cite this article as: Blonigen, D.M., et al., Perceptions of behavioral health care among veterans with substance use disorders: Results from a national evaluation of mental he..., Journal of Substance Abuse Treatment (2014), http://dx.doi.org/10.1016/j.jsat.2014.03.005

8

D.M. Blonigen et al. / Journal of Substance Abuse Treatment xxx (2014) xxx–xxx

Humphreys, K., Wagner, T. H., & Gage, M. (2011). If substance use disorder treatment more than offsets its costs, why don’t more medical centers want to provide it? A budget impact analysis in the Veterans Health Administration. Journal of Substance Abuse Treatment, 41, 243–251, http://dx.doi.org/10.1016/j.jsat.2011.04.006. Ilgen, M. A., McKellar, J., Moos, R., & Finney, J. W. (2006). Therapeutic alliance and the relationship between motivation and treatment outcomes in patients with alcohol use disorder. Journal of Substance Abuse Treatment, 31, 157–162. Institute of Medicine (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press. Iqbal, S. U., Rogers, W., Selim, A., Qian, S., Lee, A., Ren, X. S., et al. (2007). The veterans rand 12 item health survey (VR-12): What it is and how it is used. Bedford, MA: Center for Health Quality, Outcomes and Economic Research (CHQOERs) Veterans Administration Medical Center, Center for the Assessment of Pharmaceutical Practices (CAPP) Boston University School of Public Health. Jha, A. K., Orav, E. J., Zheng, J., & Epstein, A. M. (2008). Patients' perception of hospital care in the United States. New England Journal of Medicine, 359, 1921–1931, http:// dx.doi.org/10.1056/NEJMsa0804116. Kane, R. L., Maciejewski, M., & Finch, M. (1997). The relationship of patient satisfaction with care and clinical outcomes. Medical Care, 35(7), 714–730. Keyes, K. M., Hatzenbuehler, M. L., Alberti, P., Narrow, W. E., Grant, B. F., & Hasin, D. S. (2008). Service utilization differences for Axis I psychiatric and substance use disorders between white and black adults. Psychiatric Services, 59, 893–901, http:// dx.doi.org/10.1176/appi.ps.59.8.893. Kidorf, M., Disney, E., King, V., Kolodner, K., Beilenson, P., & Brooner, R. K. (2005). Challenges in motivating treatment enrollment in community syringe exchange participants. Journal of Urban Health, 82, 456–467. Kupfer, J. M., & Bond, E. U. (2012). Patient satisfaction and patient-centered care: Necessary but not equal. Journal of the American Medical Association, 308, 139–140, http://dx.doi.org/10.1001/jama.2012.7381. Little, R. J. A. (1986). Survey nonresponse adjustments for estimates of means. International Statistical Review, 54, 139–157. Long, C. G., Williams, M., Midgley, M., & Hollin, C. R. (2000). Within-program factors as predictors of drinking outcome following cognitive-behavioral treatment. Addictive Behaviors, 25, 573–578. McKellar, J., Kelly, J., Harris, A., & Moos, R. (2006). Pretreatment and during treatment risk factors for dropout among patients with substance use disorders. Addictive Behaviors, 31(3), 450–460.

McLellan, A. T., Kushner, H., Metzger, D., Peters, R., Smith, I., Grissom, G., et al. (1992). The fifth edition of the Addiciton Severity Index. Journal of Substance Abuse Treatment, 9(3), 199–213. Moyers, T. B., & Miller, W. R. (2013). Is low therapist empathy toxic? Psychology of Addictive Behaviors, 27, 878–884. Mueser, K. T., Meyer, P. S., Penn, D. L., Clancy, R., Clancy, D. M., & Salyers, M. P. (2006). The illness management and recovery program: Rationale, development, and preliminary findings. Schizophrenia Bulletin, 32, S32–S43. O'Connell, M., Tondora, J., Croog, G., Evans, A., & Davidson, L. (2005). From rhetoric to routine: Assessing perceptions of recovery-oriented practices in a state mental health and addiction system. Psychiatric Rehabilitation Journal, 28(4), 378–386. Oliva, E., Dalton, A., Harris, A. H., & Trafton, J. A. (2011). Health services for VA patients with substance use disorders: Comparison of utilization in fiscal years 2010, 2009, and 2002. Menlo Park, CA: Department of Veterans Affairs PERC. Resnick, S. M., & Griffiths, M. D. (2011). Service quality in alcohol treatment: A research note. International Journal of Health Care Quality Assurance, 24(2), 149–163. Sheedy, C. K., & Whitter, M. (2009). Guiding principles and elements of recovery-oriented systems of care: What do we know from the research? (HHS Publication No. (SMA) 09– 4439). Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration. Stewart, M., Brown, J. B., Donner, A., McWhinney, I. R., Oates, J., Weston, W. W., et al. (2000). The impact of patient-centered care on outcomes. The Journal of Family Practice, 49, 796–804. Tracy, S. W., Trafton, J. A., Weingardt, K. R., Aton, E. G., & Humphreys, K. (2007). How are substance use disorders addressed in VA psychiatric and primary care settings? Results of a national survey. Psychiatric Services, 58, 266–269. Watkins, K. E., Pincus, H. A., Paddock, S., Smith, B., Woodroffe, A., Farmer, C., et al. (2011). Care for veterans with mental and substance use disorders: Good performance, but room to improve on many measures. Health Affairs, 30, 2194–2203, http://dx.doi.org/10.1377/hlthaff.2011.0509. Watkins, K. E., Pincus, H. A., Smith, B., Paddock, S. M., Mannle, T. E., Woodroofe, A., et al. (2011). Veterans Health Administration Mental Health Program Evaluation: Capstone report. : RAND (TR-956). Yu, W., Wagner, T. H., Chen, S., & Barnett, P. G. (2003). Average cost of VA rehabilitation, mental health, and long-term hospital stays. Medical Care Research and Review, 60 (3 Suppl), 40S–53S, http://dx.doi.org/10.1177/1077558703256724.

Please cite this article as: Blonigen, D.M., et al., Perceptions of behavioral health care among veterans with substance use disorders: Results from a national evaluation of mental he..., Journal of Substance Abuse Treatment (2014), http://dx.doi.org/10.1016/j.jsat.2014.03.005