Demystifying substance use treatment implementation and service utilization in safety net settings
Crable, Erika Lynn
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Multiyear trends showing high rates of alcohol and opioid-related misuse as well as opioid-related deaths have renewed attention on both access to and the quality of substance use treatment. In response, diverse healthcare systems that care for the Medicaid population have begun implementing large-scale transformations including new services and provider training requirements. The Centers for Medicaid and Medicare Services has urged state Medicaid programs to use Sections 1115 waiver demonstrations as vehicles for substance use treatment delivery system transformation. For many states, undertaking the Section 1115 waiver demonstration means moving from very limited benefits to a full continuum of new services. States’ ability to achieve such transformations is unknown since demonstration processes are under-reported and considered implementation “black boxes”. Substance use treatment delivery changes are also occurring at the community level, where several hospitals systems have implemented new services to meet the needs of their patient population. However, the influence of these new care models on patient service utilization is unknown. In this dissertation, I use comparative case study design and qualitative content analysis to examine the pre-implementation decision-making processes that Medicaid policymakers in California, Virginia and West Virginia experienced when deciding to enhance their substance use treatment service delivery systems using Sections 1115 waivers. I qualitatively describe how broad sociocultural and local organizational factors influenced Medicaid agencies’ ability to expand access to treatment. I also present a taxonomy of implementation strategies used to translate Medicaid policy into clinical services available in the community. Finally, I present a latent transition analysis to reveal how the nature of substance use treatment services available to patients may influence their service utilization over time. This final quantitative analysis is set within the context of a safety net hospital that provides a comprehensive, low barrier access model for substance use treatment, and primarily serves Medicaid beneficiaries. Results of this dissertation illuminate processes and outcomes associated with pre-, mid-, and post-implementation activities targeting improvements in the delivery of substance use treatment services.