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provides increased access to whole-person care and recovery services via Porter Starke Services (PSS) and LifeSpring Health Systems (LSHS) in Indiana.
February 2017

EVALUATION OF THE INDIANA MEDICATION ASSISTED TREATMENT PROGRAM (IMAP): 2ND FORMATIVE REPORT

SUBMITTED TO THE INDIANA FAMILY AND SOCIAL SERVICES ADMINISTRATION-DIVISION OF MENTAL HEALTH AND ADDICTION (DMHA)

INDIANA UNIVERSITY RICHARD M. FAIRBANKS SCHOOL OF PUBLIC HEALTH CENTER FOR HEALTH POLICY

Dennis Watson, PhD Brad Ray, PhD Johanne Eliacin, PhD, HSPP Joanna Jackson, MSN, RN Lisa Robison, MPH

ACKNOWLEDGEMENT This work is supported by the Substance Abuse and Mental Health Services Agency (SAMHSA) Award #1H79TI026149. We would like to thank the staff at Porter Starke Services and LifeSpring Health Services for collecting data that contributed to this report. We would also like to thank Stephanie Mann at the IU Fairbanks School of Public Health for editing this report.

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EXECUTIVE SUMMARY This is the second biannual evaluation report for the Indiana Medication Assisted Treatment Project (IMAP), which began in February 2016. IMAP aims to decreases barriers between providers and individuals with opioid use disorder living in Porter, Starke, and Scott counties through a partnership between the Indiana Division of Mental Health and Addiction and Porter Starke Services (PSS) and Life Spring Health Services (LSHS). In this formative report, we discuss quantitative results and qualitative findings related to client and staff data collected between February 2016 and January 2017. Quantitative results demonstrate the client population served at both sites is highly similar in terms of sociodemographic characteristics. However, clients at LSHS were statistically more likely to indicate they were on parole and have higher levels of self-reported psychological or emotional problems at program intake, while PSS clients were more likely to have indicated they had used illegal drugs (including opioids) or injected drugs within the past 30 days. Regarding outcomes at their 6-month follow-up interviews, clients overall were significantly more likely to report employment and higher incomes, had improved self-reported physical and mental health, and reported significantly less drug use. We also found those with lower levels of social support at program intake were more likely to be discharged from programming at 6-month follow-up. Qualitative-interviews clients demonstrate they have highly positive opinions of the program. Discussions also suggest the program is helping to improve clients’ social support and internal motivation, which is likely leading to improvements in the outcomes discussed above. Clients also discussed employment and childcare as barriers to full service engagement and shared their anxiety over what they will do when they are no longer receiving IMAP services. LSHS clients discussed long wait times for starting MAT, while interviews with LSHS staff indicated they had and were continuing to make improvements to shorten this process. The sustainability assessment demonstrated funding stability and partnerships with stakeholders to be primary barriers for both PSS and LSHS. Additionally, lack of internal and external support for the IMAP program was a recognized barrier at PSS, while strategic communications with the public and stakeholders was demonstrated to be a top concern of LSHS. Overall, formative evaluation results indicate the IMAP program has been largely successful in its first year. However, barriers to sustainability will need to be addressed in order to ensure the program’s existence beyond the initial funding mechanism’s support. We provide the following list of recommendations for both programs based on our results: (1) (2) (3) (4)

Assess social support at program entry and consider social isolation in treatment planning. Investigate ways to better accommodate client work and child care needs. Select one or two of the top sustainability barriers identified in this report to tackle. Work with the evaluation team to disseminate evaluation findings in an effort to improve external relationships.

We also provide some program specific findings for PSS and LSHS at the end of the report, as well as representing our findings from our previous formative report.

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INTRODUCTION This is the second biannual evaluation report for the Indiana Medication Assisted Treatment Project (IMAP), which is led by the Indiana Division of Mental Health and Addiction (DMHA) and funded by the Substance Abuse and Mental Health Treatment Administration (SAMHSA). Medication assisted treatment (MAT) refers to the use of medications in combination with counseling and behavioral therapy for the treatment of substance use disorders. IMAP aims to decreases barriers between providers and individuals in rural communities in need of opioid addiction treatment. The project provides increased access to whole-person care and recovery services via Porter Starke Services (PSS) and LifeSpring Health Systems (LSHS) in Indiana. PSS is a community health center and opioid treatment provider in northern Indiana. Their IMAP program is targeting rural residents of Porter, Starke, and LaPorte Counties who fall below the poverty line and experience challenges accessing MAT, as it is not currently covered by Medicaid. Methadone1 is the primary MAT treatment at PSS, with patients being moved to Suboxone2 if it is deemed clinically appropriate at later stages of treatment. PSS clients are also encouraged to engage in a continuum of services for mental health and addiction needs. IMAP services are fully covered upon initial enrollment; however, clients are slowly shifted to covering the full cost of treatment over time. One other important aspect of the program is that it offers assistance in the form of gas cards to clients for whom transportation is a barrier to treatment. PSS admitted its first IMAP client on February 8, 2016. LSHS is a community mental health center in southern Indiana. Their IMAP program targets residents of Scott County (a rural community with high levels of poverty) who experience opioid addiction, have been diagnosed with or are at risk for HIV/Hepatitis C, and/or have significant barriers accessing MAT. LSHS offers Suboxone as the primary form of MAT treatment; however, they can refer clients to methadone treatment offered by an external provider. Clients at LSHS are required (rather than encouraged) to attend both group and individual counseling sessions as a condition of treatment. LSHS admitted its first IMAP client on April 13, 2016. In this formative report, we discuss quantitative results and qualitative findings related to client and staff data collected between February 2016 and January 2017. We also present findings from a sustainability assessment conducted in November of 2017.

EVALUATION APPROACH We are employing a simultaneous mixed method evaluation design that utilizes both quantitative and qualitative data to develop a more complete picture of program implementation and performance than any one approach is likely to foster alone.3 Our primary questions for the evaluation include: Process questions: (1) How are clients experiencing IMAP?

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Methadone is a synthetic opioid analgesic drug that is used in MAT as a form of opioid substitution due to its long-lasting effects. 2 Suboxone is a combination of Buprenorphine (an opioid partial agonist) and naloxone (an opioid antagonist that block the body from feeling the effects of opioids), which is used in MAT because it prevents withdraw without allowing the patient to feel the full opioid effect, thus making it more difficult to abuse than other forms of MAT. 3 Creswell, J. W., & Plano Clark, V. L. (2011). Designing and conducting mixed methods research. Thousand Oaks, CA: Sage.

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(2) How is IMAP impacting client recovery? (3) What facilitators and barriers to implementation and sustainability are experienced by PSS and LSHS? (4) How are the programs addressing possible diversion of medications used in MAT treatment? Outcome questions: (5) What is the effect of IMAP on client outcomes? (6) What individual factors (e.g., race, gender, ethnicity, sexual orientation, etc.) are associated with specific outcomes? (7) What outcomes are sustained over time? As this is a formative report, we are only able to begin answering these questions. The evaluators collect quantitative data for IMAP using the Government Performance Results Act (GPRA) tool and a supplemental survey instrument to measure additional recovery-related outcomes.4 The GPRA is completed with all clients, and it is administered through an interview conducted by a staff member. The supplemental instrument is completed with approximately every other client who enters the program at each location using a self-report questionnaire completed immediately after the GPRA interview. Both instruments are delivered over the Research Electronic Data Capture (REDCap) system,5 which collects data through an online portal and immediately delivers it to a secure server where evaluators can access it. Data are collected at intake, 6 months, 12 months, and discharge. We also plan to collect 3-month post-discharge data from a subset of clients to measure sustainability of the program’s effects. The selection of instruments for the supplemental survey is guided by a theory of change, which represents the evaluator’s understanding of how the IMAP program works to improve clients’ lives. The theory of change, represented in Figure 1, proposes MAT treatment will increase clients’ recovery capital (i.e., internal and external resources necessary for a person to be successful in substance abuse recovery such as social support and treatment motivation). Improvements in recovery capital should then lead to a higher sense of self-efficacy as participants feel they are ready to change and have the resources to accomplish their goals. Greater self-efficacy will then result in improved recovery outcomes such as reduced substance use, improved quality of life, employment, housing, etc. Finally, the theory recognizes that relapse is a reality of the recovery process that can occur to anyone. However, the development of strong recovery capital before relapse can serve as a foundation to get clients back on track with their recovery as soon as possible.

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https://www.samhsa.gov/grants/gpra-measurement-tools/csat-gpra Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G. (2009). Research Electronic Data Capture (REDCap) - A metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), 377-3981. 5

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Qualitative data are being collected through semi-structured interviews with clients and staff, as well as through notes taken during regular meetings with staff6 and SAMHSA in-person site visits. The theory of change also guided our initial development of qualitative interview questions. However, as happens regularly in qualitative research, these questions have changed and evolved based on our developing knowledge of the program, our need to understand reasons behind preliminary quantitative results, and requests for specific information from DMHA and SAMHSA. Finally, we collected sustainability data from staff using the structured Program Sustainability Assessment Tool7 and open-ended interviews.

QUANTITATIVE RESULTS For the quantitative analysis, we examined GPRA and additional self-report survey data from February 8, 2016 through January 15, 2017 for both programs. Given that we did not have any clients who completed a full year of the program at the time of this report, we focus only on intake and 6-month data. Because we have a large sample size for the GPRA data at baseline (N=260), we focused on comparisons between the two locations. However, when looking at changes over time, we can only examine those with baseline and 6-month follow-up GPRA—which is only 65 cases. Therefore, we combined the locations in our analysis. Similarly, with the self-report data, there were 123 clients with baseline data so we compare locations, but when looking at changes over time there are only 35 cases and so we again combined the location in our analysis. In our analysis of the data we report on notable differences but pay particular attention to those findings that are statistically significant. When comparing locations, we conducted chi-square tests for categorical measures and independent t-test for continuous measures, and to look at significant changes over time we used paired t-tests.

CLIENT SOCIODEMOGRAPHIC CHARACTERISTICS As of January 15, 2017, there are a total of 260 clients who provided baseline GPRA data; 178 of these clients are from PSS and 82 are from LSHS. Table 1 displays the sociodemographic information of these clients. An important finding to note is that there were no statistically significant differences among the sociodemographic characteristics displayed in Table 1. That is, clients receiving MAT treatment are relatively similar at both locations. Table 1 shows clients at both sites had an average age of mid-30s, were slightly more likely to be female (54%), and were overwhelmingly White (94%). In terms of education nearly three-quarters (72%) have a high school degree or higher, though over half (62%) were unemployed at baseline and less than one-quarter (23%) had any income from wages. There were similar rates of clients who owned or rented a home (46%) as those who lived with someone else (47%); though at LSHS 12% of clients were homeless or incarcerated in the 30 days prior to baseline compared to 5% at PSS. Finally, nearly three-quarters (74%) of the clients have children and 5% served in the Armed Forces.

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DMHA and the evaluators conduct one conference call with each provider separately and one with both providers together on a monthly basis. 7 Calhoun, A., Mainor, A., Moreland-Russell, S., Maier, R. C., Brossart, L., & Luke, D. A. (2014). Using the Program Sustainability Assessment Tool to assess and plan for sustainability. Preventing Chronic Disease: Public Health Research, Practice, and Policy, 11.

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Table 1: Sociodemographic Characteristics by Location LifeSpring N=82

Porter Starke N=178

Total N=260

Age (average)

37.3

35.5

36.1

Sex Female Male

62% 38%

51% 49%

54% 46%

Race/Ethnicity White Non-White

95% 5%

94% 6%

94% 6%

Education Less than HS HS/GED More than HS

27% 44% 29%

28% 43% 29%

28% 43% 29%

Employment Employed Unemployed Disabled Retired/Other

20% 54% 21% 6%

16% 65% 12% 7%

17% 62% 15% 7%

Living Arrangement Own/Rent Home Someone Else's Home Homeless/Incarcerated

45% 43% 12%

46% 49% 5%

46% 47% 7%

Any Income from Wages (Yes)

23%

23%

23%

Any Children

78%

72%

74%

Armed Forces (Yes)

6%

4%

5%

CRIMINAL HISTORY AND SUBSTANCE USE Next we examined the criminal history and substance use characteristics of clients. Table 2 looks at the baseline measures for these areas across location. While more of the LSHS clients were involved in the criminal justice system at baseline than PSS (23% and 14% respectively), the differences were not significant. However, LSHS clients were significantly more likely be on criminal justice supervision (i.e., probation/parole) than PSS (32% and 17% respectively, p< .01). There were no differences in alcohol use at baseline between the locations. Yet, as Table 2 shows, PSS clients were significantly more likely to report illegal drug use (79% vs. 50%, p