Chapter 12–Systems Coordination

Changing patterns in alcohol and other drug (AOD) involved individuals, patterns that may have developed over a lifetime, is a complex challenge. It is a challenge that calls for complex solutions. The effects of alcohol and other drug abuse on society as a whole are profound. AOD abuse creates a multitude of personal and financial burdens. The problem of AOD abuse absolutely defies a solution by an individual agency or program.

Forming a systemwide perspective is one of the first links to be constructed in any chain of solutions. Legislators, judicial officials, treatment personnel, and criminal justice professionals all have an impact on intervening with alcohol- and drug-involved persons. When tensions between agencies can be overcome, a "greater good" is achieved. Each professional within any system component has a job to do, but those responsibilities are still reconceived within a larger framework.

Although personnel from various system components may often have different, even opposing perspectives, the overriding goal is the same–to successfully intervene with AOD-abusing individuals. To achieve the most positive outcomes, communication and coordination are essential. When various agencies and sectors work together, much more is accomplished than if those same professionals acted alone, within a vacuum.

The Need for Coordination

Rates for both relapse and recidivism for AOD-involved offenders are high. AOD abuse is directly linked to criminal activity, in addition to illegal substance use, which is a crime in itself. Substance abuse may lead to income generating crimes to support an addiction, along with violent crimes which are an integral part of illegal drug trade.

Systems coordination is a necessary goal for effective intervention. As the National Institute of Corrections Task Force Report (1991) concluded, "Punishment alone is of questionable effectiveness, but treatment without strict expectations and consequences is also likely to be ineffective. Punishment and treatment should not be seen as alternatives, but as complementary."

Drug and alcohol addiction are chronic, relapsing disorders that require treatment. Research indicates that treatment can be effective in helping many alcohol- and drug-involved individuals decrease or overcome their dependency and also discontinue criminal activities. Studies affirm that treatment outcomes are improved with sufficient time spent in treatment. Such results indicate the long-term cost-effectiveness of treatment, as it impedes the financial drain created by AOD-involved individuals, as well as increases the ultimate responsibility and productivity of such persons within societal constructs. Treatment is most successful when there are comprehensive and continuing services; this collaborative approach can best be achieved through systems coordination. (See Figure 12-A for model.)

Coordination among systems is especially critical given the fact that treatment efforts are not, at this time, uniform and standardized. Lack of such standardization can lead to the duplication of effort and a reduction in maximum effectiveness of treatment if agencies and individuals do not communicate freely and collaborate. Coordination is the only means that treatment, health, and criminal justice agencies, as well as legislative and judicial personnel, have of ensuring effective service delivery.

The treatment system is complex. The mission of treatment agencies generally focuses on helping individuals effect positive change in their lives. Various treatment services may come under the auspices of the health care system; others are affiliated with mental health systems; still others function as independent, separate agencies. Funding sources, client referrals, staffing, facilities, and other aspects of treatment programs often vary markedly from agency to agency.

The criminal and juvenile justice systems (with which a high percentage of chemically dependent persons eventually have contact) are also complex, consisting of many agencies with specific and diverse purposes. The overall goals of the system are to protect the public and to rehabilitate offenders. In many cases, clients may be served by more than one agency within the criminal justice system; often, however, information is not shared among the agencies to facilitate the most comprehensive and effective interventions.

It is easy to understand why coordination of services among these two systems is difficult. The mission, funding, administration, personnel, and even clientele are often diverse, both within each of the systems and between them.

In a comparable manner, the judicial and legislative branches of government have different perspectives and goals. Members of each body represent the needs of their constituents, but they have very different avenues for carrying out their tasks. Both legislators and judges, however, are faced with difficult decisions related to alcohol and other drugs. The legislative and judicial branches of government are faced with the enormous human and fiscal costs of AOD abuse on a daily basis. It is necessary that legislators and judges collaborate and work together when dealing with this population. Improved communication and coordinated efforts will result in more effective outcomes than either entity could achieve separately.

Roles

Effective coordination combines the strengths of various systems. For example:

• Treatment/State AOD Directors–Treatment programs foster growth and development of patients toward drug-free lifestyles and improved personal functioning. Treatment staff are responsible for effective assessments, which is the first step in successfully intervening with AOD-involved persons. They are also responsible for developing effective case plans (in conjunction with medical staff/health agencies) which are part of the long-term process of intervention. State AOD Directors administer federal block grant funding and ensure that States comply with maintenance of effort requirements and necessary assurances. Without awareness of the need for this compliance, State policymakers run the risk of losing access to valuable funding.
• Public Health Agencies–Health agencies are involved in educating and assisting AOD-involved persons with the means for becoming drug free. They are also involved in providing primary health care and in educating AOD-involved individuals about the dangers of infectious diseases often spread through drug use. (For a complete treatment of this issue, see Chapter 7, Substance Abuse Related Infectious Diseases.)
• Legislatures–Legislators appropriate funds for the development and consideration of needed treatment programs and case management systems to support them. An understanding of treatment can also lead to the development of policies which have a great impact on the ability to provide services to AOD-involved persons.
• Judiciary–Judges mandate that offenders participate in treatment and primary health care to control the spread of infectious diseases. They also have the authority to enforce that participation, ensuring that individuals are motivated to stay in treatment. This is significant in that length of time spent in treatment is directly correlated with the ultimate success of a treatment plan.
• Criminal Justice–Criminal justice agencies can refer clients to treatment programs and provide sanctions which mandate that AOD-involved offenders remain in such programs.

In the final analysis, AOD-involved patients and the public are better served by systems which coordinate their efforts to provide a continuum of treatment services. Areas where this can be accomplished include, but are not limited to the areas noted in Table 12-A.

While these examples are not exhaustive, they provide illustrations of possible ways in which all systems–treatment, health, judicial, and legislative–can collaborate for the most effective service delivery for AOD-involved persons.

All systems and their key players have a role in systems coordination. Often, agency personnel develop informal means of collaboration, as one staff member becomes familiar with the programs and service providers in another agency. These staff members, and sometimes their agencies, may work very closely to meet the needs of mutual patients because of such voluntary efforts.

Sometimes agency administrators voluntarily enter into working relationships and cooperative agreements to address needs and issues they hold in common. Such interagency agreements help agencies concur on a joint purpose and serve to clarify tasks, roles, and responsibilities of each agency.

Legislative, judicial, health, and treatment personnel can develop communication channels to promote a better understanding of the needs and issues each system faces. Such collaboration may be informal, as through telephone calls and informal meetings; or they may be official, as with hearings, formal reports, and recommendations. In some instances, inter-systems coordination is facilitated through sophisticated Management Information Systems (MIS) case management procedures.

Challenges for Alcohol and Drug Abuse Treatment

Accumulated research on the effectiveness of treatment for alcohol and other drug abuse documents the efficacy of treatment strategies in alleviating substance abuse disorders and their related consequences. Successful treatment will have economic, health, and human benefits for individuals and society. For example, intravenous drug use is increasingly indicated as the route of transmission of the Human Immunodeficiency Virus (HIV), the causative agent of AIDS. Effective drug abuse treatment positively impacts the economic and health care burden of this major public health crisis. The cost, both financial and human, of placing children of substance abusing women in foster care could be significantly diminished through appropriate treatment for addicted women of childbearing age (Primm, 1992).

Although much is already known about substance abuse treatment, additional research is needed to increase and enhance treatment capabilities. Some identified areas for additional research include (Primm, 1992):

• improved pharmacologic agents for drug abuse treatment, including other chemical treatments to ease withdrawal, prevent craving, and block the effects of drugs;
• other ways that methadone can be used to help drug abusers (e.g., effectiveness in reducing risk of HIV transmission);
• new ways to keep drugs from entering the brain;
• improved nonpharmacologic treatment strategies;
• determination of the effects of drug abuse on the immune system, especially related to the efficiency of HIV transmission and to prevent asymptomatic HIV-infected intravenous drug users from progressing to symptomatic disease;
• discovery of exactly how HIV and other viral diseases are transmitted by intravenous drug users;
• exploration of the social and environmental pressures that stimulate renewed drug use among alcoholics and other drug-dependent persons after periods of abstinence and sobriety; and
• ways to improve retention in treatment.

Challenges for federal and State officials and the treatment community include the need to expand treatment capabilities and accessibility. Additional trained treatment personnel will be needed to accomplish this objective, and attention must be given to providing equitable salaries and reducing stress and burnout (Primm, 1992).

Drug abuse treatment also needs to be mainstreamed into the public health care delivery system and should become a part of hospital and clinic care. Treatment centers need to provide comprehensive, community-based service delivery systems in one location where clients receive a full range of medical, social, and psychological services. Not only are more and better organized services needed, but attention must be focused on matching patients with the most appropriate treatment modality for their needs (Primm, 1992). More information on patient-treatment matching is provided in Chapter 5.

Implementing Systems Coordination

There are at least five elements needed for effective systems coordination.

1. Planning groups
2. Communication
3. Teamwork
4. Conflict management
5. Evaluation

Planning Groups and Power Clusters

The first step in achieving systems coordination is an interactive planning process. Until the principal players in two or more systems come together to discuss their similarities and differences, collaboration cannot be accomplished. Planning groups should work toward assessing needs and resources, establishing mutual goals, and defining operating procedures.

The outcome of these groups should be a clearly articulated statement of the reasons for working cooperatively and the plan for doing so. The planning group may need to organize communication mechanisms and develop the parameters for effective working relationships. The planning group should also develop a strategy for evaluating the systems coordination efforts and making needed changes when indicated.

Dr. Daniel Ogden (1989) has discussed the formation of power clusters as the process by which many important policy shaping decisions are made. The "power cluster system" is an informal system of communication and decision making among people working in different areas revolving around the same issue. Ogden describes seven important patterns of behavior which drive the policy-making process.

1. Close personal and institutional ties develop among the participants in each cluster.
2. Participants rarely change power clusters.
3. People from all parts of each power cluster are driven by their own need to be effective and to become active participants in their power cluster communication network.
4. Policy decisions normally are made within each power cluster.
5. Each cluster has internal conflicts among competing interests.
6. Each power cluster develops its own internal, informal power structure.
7. The power clusters place great upward pressure on the budgets of federal, State, and even local governments.

Peggy Booth (in draft, 1993)) discusses the need for "finding allies" in developing successful methods for intervening with AOD-involved persons. Key players must communicate and must be committed if resistance is to be overcome. For example, in the criminal justice system, the leadership must communicate their commitment to a program to everyone involved in its implementation. Without this buy-in, programs run the risk of being undermined at any point in the continuum (Booth, in draft, 1993).

Communication and Information Sharing

The purposes of communication include sharing information, persuading others, clarifying and understanding, and decision making (Koehler and Sisco, 1981). Communications during the planning process and implementation of systems coordination efforts will serve all of these purposes. If communication is effective, coordination efforts are also likely to be effective. However, there are many barriers to effective communication. These may include (American Probation and Parole Association and National Association of State Alcohol and Drug Abuse Directors, 1992):

• misunderstanding respective roles;
• conflicting goals;
• confidentiality;
• control issues; and
• misconception of other professional perspectives.

These barriers are not insurmountable, however. In October 1989, the National Center for State Courts co-sponsored a conference called, "Legislative-Judicial Relations: Seeking a New Partnership." Conference participants discussed such issues as communication, cooperation in State governments, and intermediaries. Four attributes of successful communication between these two groups emerged over the course of the conference and can be generalized to many systems (Ridge, & Friesen, 1990):

• Familiarization with the roles, procedures, and organization of the other branch allows one branch to anticipate the effect of their actions on the other.
• Personal contact is important, because people are more likely to talk and listen to people they know.
• Permanence must be ensured by vesting responsibility for ongoing communication in an office or institution.
• Intermediaries can help communication when members of either branch feel they lack authorization to communicate.

Groups involved in collaborative efforts need to plan for effective communication. This may involve specifying mechanisms for communication, such as periodic meetings, reports, memoranda, and both formal and informal communication channels. Feedback is vital in communication loops. A process for periodic evaluation of communication is advisable.

Teamwork

In today's complex society, few tasks can be completed solely by one person or one agency. Forming alliances and sharing responsibilities are necessities. However, many people emphasize traditional values of independence and individuality. Sometimes personal values and preferences can be at odds with what is needed to accomplish the best outcomes for patients and the public.

The Center for Substance Abuse Treatment published a Criminal Justice Treatment Planning Chart (1993a) and a Juvenile Justice Treatment Planning Chart (1993b). These charts illustrate the numerous points in the criminal and juvenile justice systems where treatment and criminal/juvenile justice personnel may work as part of a team in providing services to AOD-involved individuals. There are many decision points in the criminal justice system where coordinated strategies for substance abuse assessment and treatment interventions may be applied–pre-trial, jail, trial, sentencing, probation, corrections, and parole. In the juvenile justice system, the decision points where coordinated strategies for alcohol and other drug abuse treatment interventions may be applied include intake, social investigation, fact-finding hearing, adjudication, disposition, and aftercare.

Understanding the critical substance abuse treatment components is essential to the development of comprehensive substance abuse treatment plans within the criminal/juvenile justice system. Likewise, an understanding of the flow of the case-management process, from arrest to release, is essential for coordination and linkages between and among the treatment, health, and criminal/ juvenile justice systems.

Conflict Management

Conflict is a fact of life. It is a natural mechanism, occurring on a daily basis. Conflict can be both constructive and destructive (Meyer, 1989). Constructive aspects of conflict include:

• opening issues to cooperative discussion;
• opportunity to solve a problem;
• improved understanding between individuals or groups;
• encouragement for people to grow;
• increased productivity;
• improved morale and self-esteem; and
• release of pent-up resentment, emotion, and anxiety.

Destructive aspects of conflict include:

• diversion of energy from important tasks and issues;
• barriers to cooperation, understanding, and action;
• decreased productivity;
• deepened differences;
• destroyed morale and self-esteem;
• nonproductive behavior like name calling; and
• prevention of healthy discussion of differences.

Appropriate conflict management strategies may depend on the situation and the context. Thomas (1976) has proposed five modes of handling conflict.

1. Competing. This involves pursuing one's own concerns at the other's expense–a win-lose approach. It is appropriate in emergencies, or when quick, decisive action is critical. It also is appropriate on issues that are vital to the welfare of the organization when one is sure s/he is right.
2. Accommodating. This strategy involves neglecting one's own concerns to satisfy the concerns of another. This is the opposite of competing and is a reversed win-lose approach. This is an appropriate strategy when one realizes one is wrong; when the issue is much more important to the other person; when maintaining good feelings is more important than the issue at hand; and when the other person is winning and continued resistance will damage one's cause.
3. Avoiding. In this approach, one pursues neither one's own concerns nor the other's. It is appropriate when an issue is not important enough to deal with; when the chances of satisfying one's concerns are very low; when a cooling off time is needed; and when time is needed to gather more information.
4. Collaborating. This style is the opposite of avoiding. Both parties work to find a solution that satisfies the concerns of both. It is appropriate when both sets of concerns are too important to be compromised; when the objective is to learn and grow; when commitment can be gained by including others' needs in a decision; and when bad feelings are interfering with a relationship.
5. Compromising. The objective of this style is to find a mutually acceptable solution that partially satisfies both parties. It is appropriate as a backup when collaboration or competition fail to arrive at a mutually acceptable solution, under time pressures, and when opponents with equal power are strongly committed to mutually exclusive goals.

Deep and Sussman (1990) offer 10 guidelines for resolving conflicts.

• Listen to the other person's assertions.
• Ask questions to clarify the other person's position.
• Don't get angry. Accept the person's right to disagree with you.
• Communicate your position clearly and thoroughly.
• Focus on issues and behaviors rather than on emotions and personalities.
• Discuss the present.
• Focus on the future.
• Take responsibility for your role in the conflict.
• Summarize apparent needs and desires of both parties. Be creative in exploring options and in finding an equitable solution.
• Keep the lines of communication open. Agree to talk about problems more openly in the future.

These strategies are important to keep in mind as they apply directly to the coordination of effort among the various individuals and agencies who deal with AOD-involved individuals. Conflict is a fact of life; learning to manage and resolve those conflicts is an important step in being able to work together to achieve a unified goal. In this case, the goal of effective service delivery to AOD-involved persons is well-served by a collaborative effort. Such an effort will inevitably be much smoother when all key players are familiar with the principles of conflict resolution. Evaluation

No program or task is complete without an evaluation. Evaluation of systems coordination should ask the questions:

• Is the process working effectively?
• Is it achieving the outcomes for which it was intended?

In order to evaluate the process and outcomes, a group must start with clear goals and objectives. These determine what is to be evaluated. Although it is usually considered last, evaluation should occur throughout collaborative efforts.

Evaluation mechanisms can be built into teamwork. When teams meet, a small amount of time should be set aside during the meeting to evaluate the team's efforts. If communication is open and conflict management techniques have been employed, participants should be able to express their thoughts and feelings about the group process and the outcomes of the team's efforts.

Evaluations can be both formal and informal. The type described in the preceding paragraph is an example of informal evaluation. More formal evaluation approaches may include descriptive summaries of program accomplishments and problems. These often are based on quantitative data that is easily compiled. For example, coordinated service systems might want to collect information about the number of clients served, the number of contact hours, the types of interventions (e.g., recidivism rates, employment rates, drug-free days).

Before and after studies take measures before the implementation of coordinated systems and again after they have been executed. For example, data could be compiled to look at the differences in waiting times for persons to enter treatment programs before and after development of working agreements between agencies. Indicators of effective feedback and communication between criminal/ juvenile justice systems and treatment personnel is another area that could be measured before and after development of collaborative relationships.

For effective evaluation of systems coordination efforts, several processes need to be instituted. These include collecting data that is indicative of the question to be answered. If possible, a management information system is helpful. However, manual collection of such data is feasible. Collected data must then be organized and analyzed to determine the effectiveness of coordinating efforts. Finally, it is important to disseminate the results of evaluation efforts and take action based on the findings. If evaluation efforts indicate that the goals of collaboration have not been achieved, new approaches may need to be developed and implemented.

Effective evaluation yields positive results. It provides concrete evidence about the incidence of substance abuse, the need for funding, and many other tangible and intangible factors. This information can then be utilized in the effort to obtain more funding or additional staff, for example.

Resource Development

The need for interventions with alcohol- and drug-involved persons far exceeds the resources for meeting the demand. One way in which systems coordination efforts can be beneficial is in obtaining and allocating these resources. Resources include funds, personnel, and information.

Funding

Funding frequently is cited as a pressing need in effective service delivery. Service systems often are stretched by increasing demands and decreasing funds. Funding also often determines the extent to which personnel, information, and other resources may be obtained.

Funding sources for alcohol and drug abuse interventions include federal, State, and local governments, and private sector funds. This section will contain a very brief overview of these funding options (Romig and Rasmussen, 1991).

Federal Funding

Grants. The following federal block grants transfer money to the States to purchase treatment services for AOD abusers:

• The newly configured State Block Grant for Prevention and Treatment of Substance Abuse (formerly the ADMS) Block Grants provide financial assistance to States and territories for substance abuse prevention, treatment, and rehabilitation programs and activities. It is administered by the Center for Substance Abuse Treatment.

Entitlement Programs. Federal income support and health care programs include services that can be used for substance abuse treatment and services. Oversight and administration for these programs is provided by the federal government.

• Medicaid is a joint program of federal and State governments. States have discretion to cover services such as alcohol and drug abuse treatment; services of State-licensed practitioners, such as psychologists, alcohol and drug counselors, and medical social workers; and outpatient alcohol and drug clinics.
• Medicare is public health insurance for persons age 65 and older and some disabled persons. Medicare benefits include payment for services related to alcohol and drug dependence and intoxication.
• Supplemental Security Income (SSI) provides income support to indigent, aged, blind, and disabled persons. If substance abuse is a significant factor in the eligibility of beneficiaries, the individual must agree to cooperate with a State-approved treatment plan.
• Social Security Disability Insurance (SSDI) provides income support for persons forced to retire because of a disability. A person cannot receive benefits solely because of a diagnosed substance abuse problem; there must be a concomitant physical or mental impairment.

Other Federal Programs. Various additional federal agencies and programs provide some funding related to substance abuse.

• CHAMPUS (Civilian Health and Medical Program of the Uniformed Services) provides health insurance coverage for military personnel and their dependents. Specific benefits include hospital care for detoxification, inpatient rehabilitation, and partial and outpatient care. This program is administered by the U.S. Armed Services.
• Drug-Free Schools and Communities Program, administered by the U.S. Department of Education, provides funds for anti-drug abuse education, prevention, early intervention, and rehabilitation referral programs.
• The Public and Indian Housing Drug Elimination Grant Program provides grants to public housing agencies to eliminate drug-related crime. It is administered under the U.S. Department of Housing and Urban Development.
• Drug Control and System Improvement Grant Program provides funds to carry out programs designed to enhance State and local drug control efforts and improve the functioning of the criminal justice system.
• Early and Periodic Screening, Diagnosis, and Treatment for Children Aged 21 and Under is a mandatory Medicaid benefit for all recipients under the age of 21. It was designed, in part, to address the needs of children who have manifested or who are at risk for mental health and substance abuse problems (Fox et al., 1993). This program is administered by Medicaid.

State and Local Funding

In some States and jurisdictions, State monies constitute the largest source of funds for substance abuse programs. State government sources of funds include:

• State general fund revenues;
• the State's portion of Medicaid funds designated for substance abuse services;
• taxes on products or services (e.g., alcoholic beverages, tobacco products, liquor licenses) designated for use by particular programs;
• seized assets derived from drug crimes used to support substance abuse treatment, prevention, and other services; and
• fines, fees, and assessments earmarked for substance abuse treatment.

Local sources of funds for substance abuse interventions may include:

• property tax revenues;
• sales taxes;
• local government fees for services; and
• court fines or assessments imposed on intoxicated drivers.

Private Sector Funding

Private sources of funding include the following:

• Insurance coverage includes AOD-related illness or trauma treated in a general hospital setting. Coverage for other services varies according to companies. States vary in the types and amounts of services that are mandated.
• Client fees are paid directly to service providers by the client. Some programs have sliding fee scales that adjust fees to the client's economic resources.
• Private foundations sometimes direct funds to specific program efforts. This funding often is time limited.
• Donations of cash and goods are received by some organizations from private companies or individuals.
• United Way and other charitable organizations may apportion funds to substance abuse treatment programs.

Personnel

Effective interventions hinge upon having sufficient qualified personnel. This applies to both the criminal/juvenile justice system and the treatment community. In both types of agencies staff resources are often stretched beyond their limits. Caseloads are high, and bureaucratic requirements for reports, records, and other tasks are often time-consuming.

Training is a vital aspect of preparing staff to provide quality treatment services. However, in times of diminishing resources, training is one of the first areas to be cut by agencies and States. Thus, personnel do not have resources for learning new techniques and renewing their knowledge and skills.

Treatment and criminal/juvenile justice personnel face inordinate stress in their daily jobs, and attrition rates are high. Without sufficient supplies of newly trained workers, treatment programs can be jeopardized.

It is important for legislators to examine the availability of training opportunities for current and new treatment and criminal/juvenile justice staff. State colleges and universities, State agency training departments, and private companies may be good resources for developing and providing important training opportunities.

Information

Access to information is vital in maintaining appropriate interventions for alcohol and drug- involved persons. Legislative and judicial officials need to receive up-to-date information on treatment approaches, funding sources, training programs, and other resources. Similarly, practitioners must be kept apprised of the latest information on drugs of abuse, their effects on individuals, and productive intervention strategies.

Research is important for generating new information. Although many research efforts are funded by the federal government, State and private foundations are also a source of research funds. Agency evaluations are important sources of information about effective and ineffective treatment approaches. All agencies receiving external funds should be required to have an evaluation component and use the information generated to improve their programs and inform the field.

Federal Oversight and Responsibilities

An understanding of the key federal agencies which oversee and have responsibility for working with AOD abuse on a national level is critical to any discussion of systems coordination.

The 1990 National Drug Control Strategy Report recommended the following policies and strategies (Primm, 1992, pp. 620-621):

• develop State service plans for the closer monitoring of the alcohol, drug abuse, and mental health block grant funds;
• increase the availability and quality of drug treatment services;
• improve and expand treatment services for the homeless, adolescents, the mentally ill, and people in public housing;
• improve and expand outreach and treatment services for pregnant women and drug-affected infants;
• expand treatment services in correctional institutions;
• enhance treatment research, including expanded data collection, medications development, and evaluation of current treatment methods;
• provide additional vocational counseling and aftercare for recovering addicts; and
• develop innovative approaches to drug treatment, including treatment campuses and special programs targeted for adolescents and pregnant women in conjunction with the Center for Substance Abuse Prevention.

The Center for Substance Abuse Treatment (CSAT) was created in 1990 as the Office for Treatment Improvement. CSAT's guiding philosophy is that:

addiction is a chronic, relapsing disorder and that treatment is most successful when providers offer comprehensive therapeutic services, combined with readily accessible post-treatment aftercare" (Primm, 1992, p. 621).

CSAT's position is that there is no one uniform treatment approach that will be effective with all persons. The appropriateness of a continuum of treatment and recovery services should be tailored according to such factors as the individual's gender, age, race, ethnicity, socioeconomic status, employment status, social status, life experience, and physiological and neurophysiological condition.

CSAT's vision for publicly funded addiction treatment and recovery services requires that the treatment and recovery infrastructure and individual community-based programs be empowered to:

• comprehensively assess the needs of individuals who request assistance;
• match individual needs with the interventions and recovery services that best suit their requirements, as well as the needs of their families and significant others;
• provide an appropriate array of specific treatment and recovery services along a sustained continuum of care for both the individual and his or her collaterals; and
• determine the outcome of specific treatment and recovery services

(CSAT, nd).

In order to help ensure that this empowerment occurs, CSAT collaborates with the Center for Substance Abuse Prevention and the Center for Mental Health Services in the Substance Abuse and Mental Health Services Administration (SAMHSA), the research institutes in the National Institutes of Health (NIH), the Centers for Disease Control, the Health Resources and Services Administration, the Indian Health Service, the Office of Minority Health, the U.S. Department of Labor, the Social Security Administration, the Health Care Financing Administration, and other agencies of the federal government; State and sub-State health and human service agencies; and the public treatment and recovery program network. A problem occupying the scope that substance abuse does in this country will require such a comprehensive, collaborative effort among federal, State, local, public, and private organizations.

In 1981, under the Omnibus Budget Reconciliation Act all community-based categorical funding was consolidated to provide alcohol, drug, and mental health services. The role of National Institute on Drug Abuse (NIDA) was changed to only conducting research and educational functions. This money was given to States to use for alcohol, drug, and mental health treatment. Few restrictions or accountability measures were required. Federal support actually declined in constant dollars under the block grant system in the early- to mid-1980s. Some federal conditions were added later, such as requiring a 35 percent minimum expenditure each for drug and alcohol treatment. Much of the federal data collection system about treatment was discontinued as a result of this change in policy (Institute of Medicine, 1990).

Block Grants

The 1986 Anti-Drug Abuse Act added the alcohol and drug abuse treatment and rehabilitation (ADTR) block grant in addition to other funding increases. This Act dictated that determination of the allocation of funds to each State would be based on a combination of the size of the population and documented estimation of the need for treatment. It also set aside 1 percent of block grant funds for collecting evaluation data, requiring States to develop and submit plans for use of block grant funds, and evaluation of the impact of the additional treatment funds. Despite this, the federal office did not have authority to approve plans and there was no accountability mechanism to determine whether the plan was followed (Institute of Medicine, 1990).

The 1988 Anti-Drug Abuse Act again increased federal appropriations and required that States allocate 20 percent of the substance abuse set aside for prevention activities, spend 20 percent of the total on women, and commit 10 percent of the drug portion to treating intravenous drug problems. In addition, Department of Health and Human Services (DHHS) was authorized to set aside 5 to 15 percent of the grant to collect data about treatment (Institute of Medicine, 1990).

Under the new reorganization law, the current alcohol, drug abuse, and mental health services block grants to the States are split into two separate block grants, one for mental health services and one for substance abuse services. The current block grant program is the Substance Abuse Prevention and Treatment (SAPT) block grant.

Block Grants Split

For FY 93, up to $1.5 billion is authorized for substance abuse, to be administered by the Center for Substance Abuse Treatment. Under the new formula, a State must:

• use at least 35 percent each for alcohol services and drug abuse services;
• use at least 20 percent for primary prevention services;
• spend an additional 5 percent in FY 93 to increase services for pregnant women and women with dependent children over the FY 92 level; and in FY 94, a 5 percent increase above the FY 93 funding for women;
• ensure that intravenous drug abusers receive drug treatment within 14 days of requesting it, or within 120 days if "interim services"–such as counseling and/or testing for HIV–are made available within 48 hours of the request for treatment;
• have a law on its books against the distribution or sale of tobacco products to minors under age 18; and
• require funded treatment programs to provide tuberculosis services or ensure that patients receive such service

(ADAMHA Reorganization Act of 1992).

Responsibility for administering the block grants has now been placed under the Center for Substance Abuse Treatment. This provides for more stringent monitoring of the funds to improve federal management and State accountability. One way in which CSAT has assumed this responsibility has been the State Systems Development Plan (SSDP). Its goal is to (Primm, 1992):

• assess State treatment demand and capacity;
• develop Statewide treatment improvement plans;
• provide on-site performance monitoring and targeted technical assistance; and
• create a national database of current State treatment information.

The SSDP program will assist States in finding the most effective means to utilize SAPT funds to provide treatment that is effective in reducing drug abuse. In developing guidelines, CSAT can ensure that State programs have common procedures and goals. In identifying weaknesses through technical performance reviews of State drug treatment activities, CSAT will be able to improve performance by providing technical assistance. In assisting States in conducting needs assessments, better data can be obtained on the incidence and prevalence of substance abuse. Additional information can also then be provided to the Department of Health and Human Services and federal policymakers on the delivery of drug treatment services. SSDP is critical in that it promotes accountability and allows for more effective sharing and dissemination of information.

State and Local Role

Working closely with the State Directors of Alcohol and Drug Treatment Services is also part of CSAT's approach to carrying out its responsibilities for the block grants. Each State has a designated office with a director to manage the block grant monies and other aspects of substance abuse treatment. The major responsibilities of these offices include:

• determining the proportion of the total grant that is appropriated to each type of treatment (alcohol, drug, mental health);
• allocating monies among programs and localities;
• maintaining or revising treatment protocols and other requirements;
• monitoring program performance;
• delivering technical assistance and training; and
• setting reimbursement rates.

To facilitate State efforts and coordination of treatment, CSAT has initiated several programs and products to accomplish its responsibilities.

• Technical assistance is provided, in part, through the Treatment Information Exchange, a series of conferences, on-site consultations, and documents to assist and coordinate State and local planning, financing, and management needs. In addition, manuals entitled Treatment Improvement Protocols (TIPs), will help States meet the standards of the latest treatment practices in various areas.
• Target Cities Program currently provides funds for demonstration projects in eight cities. The goal of these projects is to improve the delivery and quality of services, making them more attractive to those needing treatment. The projects are intended to serve as examples for other areas and programs.
• Critical populations are the focus of other CSAT initiatives because of their complex and varied needs. Among the groups targeted are: adolescents, racial and ethnic minorities, women of childbearing age and their children, people who are incarcerated, residents of public housing projects, homeless persons, rural populations, and those with a combination of drug addiction and alcohol addiction, physical health disorders, and mental health problems. Activities will include demonstration grants to: increase outreach; provide on-site primary medical and acute medical care; train staff; provide health education; offer life skills counseling, educational and vocational counseling, and enhanced aftercare; and provide psychological and psychiatric services.
• Improving linkages with agencies and organizations includes jointly sponsoring demonstration programs with other government agencies to integrate primary health care with substance abuse treatment programs. Linkage with medical, professional, and consumer organizations, designed to reduce the overlap of services and streamline referrals, will be initiated through a national coalition of primary health care and substance abuse health care systems to help Congress and the administration integrate and link these two health care groups. CSAT also will work with the National Association of State Alcohol and Drug Abuse Directors (NASADAD) and the Association of State and Territorial Health Officers (ASTHO) to coordinate and enhance better treatment for persons with HIV/ AIDS and other illnesses, including substance abuse and mental health.
• The Criminal Justice Linkages Project supports the Substance Abuse Prevention and Treatment Block Grant. It is a three-year project providing individualized technical assistance to 35 States in building coordinated State systems that link treatment, justice, and health agencies. Several prototypes of intersystems coordination between the courts and treatment field will be developed at diverse sites as part of this project.
• Treatment of offender populations provides funds for demonstration grants to provide treatment services to both adult and juvenile offenders. Included in CSAT's criminal justice programs are efforts to improve on-site drug treatment services in jails and prisons, expand procedures for diverting arrestees into treatment instead of incarceration, and coordinating all aspects of the criminal justice system related to drug treatment.

In its relatively short history the Center for Substance Abuse Treatment has positively focused efforts to improve and enhance treatment for substance abuse, particularly by working through the State Directors for Alcohol and Other Drug Treatment. It has attempted to enhance coordination and collaboration among all those concerned with improving substance abuse treatment. It has developed a model for comprehensive alcohol and other drug abuse treatment which is presented in Table 1-E, in Chapter 1. The components of this model are highlighted throughout this document, as various aspects of treatment are examined.

Conclusion

If interventions with alcohol- and drug-involved persons are to be successful, all systems and individuals involved must recognize the importance of the need for coordination, collaboration, and communication.

Primm (1992, p. 624) identifies the following areas in which treatment improvement or expansion is needed in the future:

• prenatal and postnatal care for infants of substance abusing mothers;
• day-care centers, educational and recreational facilities for children, as well as counseling for youths;
• a full mixture of services for women, including counseling, medical and psychological assistance, vocational training, education, and legal assistance;
• a full range of services geared to the specific needs of minorities (i.e., blacks, Hispanics, Native Americans and Asian Americans);
• services for the homeless, including medical and psychiatric help and vocational, educational, economic, and legal support;
• expanded services for the prison populations, including counseling, drug testing, vocational, and educational help;
• more HIV counseling and education to all members of society;
• more HIV health care, both in- and outpatient; and
• greater outreach and linkage connections with all groups involved in primary health care.

The needs and the agenda for the future, thus, are very clear. The coordination of efforts among all those with responsibility for service delivery, funding or other aspects of the problem is a key element in achieving these goals and a healthier, more productive nation.

Improved systems coordination can result in the most effective provision and delivery of services to AOD-involved individuals. It, therefore, needs to be a primary goal at the outset of any decision-making and policy-shaping process. When systems and agencies work together to deal with substance abusing individuals, there is an opportunity to effect societal change. "The common sense conclusions reached by legislators, high-ranking government bureaucrats, and influential public figures, without any special or technical knowledge of drug abuse, are likely to gain acceptance from other national social and political institutions" (Musto, 1987).

The long-term benefits of a coordinated approach have far-reaching implications. Such an approach provides all systems involved with an opportunity to achieve results in the most cost-effective manner possible; to reduce the spread of many diseases and infections associated with AOD abuse (e.g., HIV, STDs, TB); to reduce recidivism rates among AOD-involved offenders; and to effect positive human change among AOD-involved populations.

References

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Thomas, K. (1976). Conflict and conflict management. In E.M. Dunnett (Ed.), The handbook of industrial and organizational psychology. Chicago: Rand McNally.

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