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Temple University Department of Criminal Justice Improving the Quality of Drug Treatment in Community Corrections: Lessons from Technology Transfer Models.

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Presentation on theme: "Temple University Department of Criminal Justice Improving the Quality of Drug Treatment in Community Corrections: Lessons from Technology Transfer Models."— Presentation transcript:

1 Temple University Department of Criminal Justice Improving the Quality of Drug Treatment in Community Corrections: Lessons from Technology Transfer Models Steven Belenko, Ph.D. Temple University Philadelphia, PA, USA Presented at: 2011 International Conference Crime Prevention and Offender Rehabilitation – Prospects and Challenges Hong Kong, China May 28,

2 Temple University Department of Criminal Justice Acknowledgments Supported in part by: National Institute on Drug Abuse Grant U01-DA025284, Pennsylvania Research Center at Temple University (part of the Criminal Justice Drug Abuse Treatment Studies cooperative) (S. Belenko, principal investigator) National Institute of Corrections, Cooperative Agreement 06PEI06GJN8, Technology Transfer of Evidence-based Practice in Substance Abuse Treatment in Community Corrections Settings (S. Belenko, principal investigator) 2

3 Temple University Department of Criminal Justice Overview of Presentation Need to implement, expand, and sustain evidence-based drug treatment in community corrections Defining and understanding technology transfer and implementation Stages and components of implementation Improving treatment implementation 3

4 Temple University Department of Criminal Justice BACKGROUND

5 Temple University Department of Criminal Justice Substance Abuse and Treatment Needs among Offenders Majority of 14 million arrests test positive for drugs (NIJ, 2004) 1.7 million arrests for drug law violations (82.5% for possession) > 4.3 million U.S. adults on probation (Glaze & Bonczar, 2009) 37% have a substance abuse disorder (NSDUH, 2008) 1.4 million state inmates, 785,000 jail inmates (Sabol & Couture, 2008), 826,000 on parole (Glaze & Bonczar, 2009) 53% estimated to meet criteria for drug dependence or abuse (Mumola & Karberg, 2006) 5

6 Temple University Department of Criminal Justice Drug Use among Offenders  Offenders have higher rates of psycho-social disorders than general population  Substance Use  Mental Health and Physical Health  Educational Deficiencies  CJ Populations: 4 Times Greater SA Disorders NSDUH 2007

7 Temple University Department of Criminal Justice Behavioral Health Disorders by Offense Type 7 NO PROBLEMS DRUG ABUSE/ DEPEND ONLY MENTAL HEALTH DISORDER ONLY DRUG ABUSE/ DEPENDENCE & MENTAL HEALTH DISORDER TOTAL INMATE POPULATION 29.6%22.0%17.8%30.6% OFFENSE TYPE* VIOLENT 32.9%18.8%21.0%27.3% DRUG 26.1%28.5%11.7%33.7% NON- VIOLENT, NON-DRUG 26.3%22.9%16.7%34.1% *p <. 001

8 Temple University Department of Criminal Justice Drug-Involved Offenders are not like All Drug Abusers  Different set of treatment needs  Substance abuse treatment for offenders should address both substance abuse and criminal risk factors.  The CJ experience may have a negative impact on readiness and motivation to change  Community corrections agencies—probation, parole, pretrial—should be partners with treatment agencies  Correctional agencies are now pursuing EBPs which should open the doors to expand treatment GMU

9 Temple University Department of Criminal Justice Offenders Have Limited Access to Effective Addiction Treatment  Only 24% of state, 8% of jail inmates receive any drug “treatment;” only 10% receive clinical treatment (Belenko & Peugh, 2005)  25% of probationers with histories of drug use receive treatment (Mumola, 1998)  Drug courts serve <10% of eligible population (Belenko et al., 2011)  Prison TC beds are limited; most released inmates don’t enter aftercare (Wexler et al., 1999; Prendergast et al., 2005; Inciardi et al., 2004)  Supervision, security, and control are overriding functions of institutional and community supervision (Taxman et al., 2003)  Medications treatment is not generally accepted in CJS (Friedmann et al., 2011)

10 Temple University Department of Criminal Justice Education Outpatient Intensive OPT Residential Criminal Thinking No Use 30% User 19% Abuse 20% Addict 31% (2.5 M) Projected Treatment Needs for Adult Offenders Belenko & Peugh, 2005; Taxman, et al., 2007 Estimates based on severity of substance use disorders and effects of drug use Half of women offenders may need residential services; one-third of males (Belenko & Peugh, 2005)

11 Temple University Department of Criminal Justice Over Half of CJ Facilities Offer Any Type of Service (% Facilities)

12 Temple University Department of Criminal Justice But…Few Offenders Participate, and the Services are Inconsistent with Need

13 Temple University Department of Criminal Justice Unlikely to Reduce Recidivism  Too few offenders exposed to treatment ◄ Less than 11% can receive tx a year; on any given day, ~7.6% are in treatment  Treatment is inconsistent with needs

14 Temple University Department of Criminal Justice Treatment Received Since Admission by Disorder 14 NO PROBLEM DRUG ABUSE/ DEPENDENCE ONLY MENTAL HEALTH DISORDER ONLY DRUG ABUSE/ DEPENDENCE & MENTAL HEALTH DISORDER SUBSTANCE TX ONLY 19.6%37.4%17.2%30.2% MENTAL HEALTH TX ONLY 6.0%5.9%19.6%16.4% SUBSTANCE AND MENTAL HEALTH TX 2.3%5.6%6.9%14.1% NO TX 72.2%51.2%56.2%39.4% *p <. 05 **p <.01 *** p <.001

15 Temple University Department of Criminal Justice Expanding Treatment Participation Benefits Public Safety and Public Health 15 Strong link between drug use and crime Reduced recidivism and relapse, increased social productivity Positive effects on health risk behaviors Economic benefits Fewer technical violations Evidence-based, well-implemented treatment needed

16 Temple University Department of Criminal Justice Public Health Impact Perspective Population Impact = [Effect Size] * [Rate of Treatment Utilization] Tucker & Roth (2006), Coeira (2003)

17 Temple University Department of Criminal Justice Potential Criminal Justice System Linkage Points Police Prosecutors Defense Attorneys Courts (judges) Pretrial Services Agencies Probation Jail Prison Parole

18 Temple University Department of Criminal Justice EVIDENCE-BASED TREATMENT INTERVENTIONS

19 Temple University Department of Criminal Justice Effective Substance Abuse Treatment for Offenders 19 Chronic vs. acute care model Standardized assessment and services should address co- occurring disorders and dynamic risk factors Continuing, adaptive care from institution to community Target criminogenic risk factors, criminal thinking Monitoring and accountability, with clinical integrity Efficient and appropriate information exchange Use evidence-based treatment practices (Cognitive behavioral therapy, Motivational Enhancement Therapy, family-focused, relapse prevention skills)

20 Temple University Department of Criminal Justice What Works for Offenders?  TREATMENT  Skill building, recovery models, rather than traditional alcohol/educational and outpatient programs  Dosage (length of treatment) is important through stages: motivate, change, reinforce  COMPLIANCE MANAGEMENT: Rewards & Incentives  WORKING ALLIANCE: Rapport, Relationship GMU

21 Temple University Department of Criminal Justice The Quest for EBPs  Evidence-based practices are specified programs and services, based on research, that reduce criminal behavior and drug use  BUT, significant gaps exist between best practices identified by research and their implementation in routine care (Institute of Medicine, 2006). Are community correctional agencies ready for research- based programs? **National Institute of Corrections evidence-based practices initiatives** GMU

22 Temple University Department of Criminal Justice Why EBPs are important…. Opponents Proponents  Effect sizes (~ 10%) are too small to have an huge impact  Punitive policy change like length of incarceration or probation will have greater impact  Goal is to prevent crime and reduce recidivism  Deterrence is more important  Politicians do not support treatment interventions  EBPs are a formula for success: no gains from pure punishment  EBPs can help to professionalize corrections  Effects are small because..  POOR IMPLEMENTATION  Existing structures serve a small % of target population  Corrections should be part of the service system to improve outcomes  Human rights GMU

23 Temple University Department of Criminal Justice Model: Risk-Need-Responsivity Model in Assigning Treatment Model: Risk-Need-Responsivity Model in Assigning Treatment Services SUD High RiskMedium RiskLow Risk DependentResidential/ Drug Court IOP/ Drug Court IOP AbuserIOPOutpatient None Correctional Program Minimal Substance Abuse Screener Risk Screening Tool Assessment Appropriate programming Diagnosis

24 Temple University Department of Criminal Justice Use of Standardized Substance Abuse Assessment Tool

25 Temple University Department of Criminal Justice Treatment Practices in the Field % Administrators Reporting Availability in Facility Taxman, Perdoni & Harrison, 2007; Young, Dembo, & Henderson, 2007

26 Temple University Department of Criminal Justice Factors Affecting Access to Effective Treatment Lack of incentives for offender to participate Poor match between offender needs and treatment services Supervision, security, and control are overriding functions of community supervision (Taxman et al., 2003) Funding restrictions Inadequate treatment infrastructure Disincentives for treatment providers to accept offender clients Paperwork Supervision requirements 26

27 Temple University Department of Criminal Justice Advancing Practices for Drug-Involved Offenders  Integrate criminal justice and treatment agencies processes  Focus on moderate to high risk offenders  Ensure that programs are sufficient duration –6 months  Use of medication assisted treatments  Use external supports and partnerships to alter correctional agency culture (create learning environments)

28 Temple University Department of Criminal Justice IMPLEMENTATION ISSUES

29 Temple University Department of Criminal Justice Technology Transfer Challenges  Dissemination of model program information is insufficient  Training ≠ implementation fidelity or sustainability (Bero et al., 1998; Taxman et al., 2004)  Implementation science and organizational change principles not always incorporated  Overcoming treatment and CJ staff resistance to change (Miller et al., 2006, Simpson, 2002)  Innovation diffusion and technology transfer can be slow, multistage processes (IOM, 2001; Liddle et al., 2002; Roman & Johnson, 2002; Simpson, 2002)  Weak treatment infrastructure (McLellan et al., 2003) 29

30 Temple University Department of Criminal Justice Technology Transfer Challenges  Lack of EBP “fit” to organization/staff values, experience, and daily activities (Liddle et al., 2002; Simpson, 2002)  Public health/public safety disconnect  Emphasis heavily weighted toward social control and public safety  Treatment providers are not “at the table”  Offender needs are not considered  Legal, economic, structural, organizational impediments (e.g. supervision & reporting requirements, security issues, lack of CJ staff “buy-in”)  Resource constraints and competing priorities can limit uptake of EBP (Backer, 1996; Simpson, 2002)  Lack of “absorptive capacity” (Knudsen et al., 2007) 30

31 Temple University Department of Criminal Justice Dissemination vs. Implementation Dissemination: distribution of information about an evidence-based practice or program to a specific target audience manuals web-based program summaries trainings conferences Examples: NREPP, CDC, OJJDP Blueprints, Campbell Not effective for changing practice Implementation: Strategies to introduce and sustain evidence-based interventions into practice in specific settings 31

32 Temple University Department of Criminal Justice Moving to Effective Implementation 32 Successful technology transfer of evidence-based treatment into practice settings requires effective implementation Slow process with a number of stages Most EBPs are not well-implemented Replication beyond the research setting poses many challenges Training by itself is largely ineffective for achieving full EBP implementation and sustained change

33 Temple University Department of Criminal Justice Phases of Program Implementation Exploration/adoption Installation Initial Implementation Full Implementation Innovation Sustainability 33 SOURCE: Fixsen et al. (2005), National Implementation Research Network

34 Temple University Department of Criminal Justice Implementation Phases, Activities, and Outcomes 34 Exploration Perceived need for change, choose EBP Meet and exchange info, needs assessment, garner support Installation Prepare to implement, obtain funding, train staff Staff meetings held, manuals prepared Initial Implementation Modify org culture, monitor fidelity, overcome barriers Additional training, stakeholder meetings, progress reports Full Implementation EBP integrated into daily practice, policies in place, monitor fidelity Staff meet clinical criteria, referrals made routinely Innovation Adapt to changes in environment, monitoring Fidelity maintained, program modified Sustainability Maintain external support, replace staff, funding EBP maintained over time, fidelity

35 Temple University Department of Criminal Justice IMPLEMENTATION COMPONENTS

36 Temple University Department of Criminal Justice Multilevel factors may affect implementation and client change in CJ settings:  External/Environmental  Organizational/System  Staff  Client

37 Temple University Department of Criminal Justice Factors Influencing Implementation External Influences Funding availability Legal structure Political support Availability of skilled workforce and effective treatment Public safety concerns Community readiness Interagency communication and support structure 37 SOURCES: Aarons (2006), Fixsen et al. (2005), Glasgow & Emmons (2007)

38 Temple University Department of Criminal Justice Factors Influencing Implementation Organizational Influences Organization culture for innovation Organizational structure Organizational readiness to change Administrative/management support Competing priorities Organizational resources Mission alignment (public safety vs. public health) Information technology (monitoring services and outcomes, data management) Treatment infrastructure to support change 38 SOURCES: Aarons (2006), Fixsen et al. (2005), Glasgow & Emmons (2007)

39 Temple University Department of Criminal Justice Factors Influencing Implementation Staff Influences Skills level, acceptability of EBP Incentive structure for change Competing priorities, caseloads Perceived support of supervisors and leadership Attitudes toward EBP Rehabilitative vs. punitive focus Goal alignment 39 SOURCES: Aarons (2006), Fixsen et al. (2005), Glasgow & Emmons (2007), Taxman (2003)

40 Temple University Department of Criminal Justice A Multi-Level Model of Implementation Research 40 SOURCE: Proctor et al., (2009), Adm Policy Ment Health, 36:24–34.

41 Temple University Department of Criminal Justice Implementation Model 41 Implementation needs to occur at multiple levels: System Organization Staff Client Interactions among these levels Outcomes need to be measured at multiple levels Implementation domains Service outcomes Client outcomes

42 Temple University Department of Criminal Justice Implementation Outcome Examples 42 Implementation phase Penetration – staff training and involvement in EBP, selection bias, targeting Fidelity to the EBP Organizational climate and culture change Staff uptake of EBP (knowledge, skills, perceived utility, satisfaction)

43 Temple University Department of Criminal Justice 43

44 Temple University Department of Criminal Justice 44

45 Temple University Department of Criminal Justice IMPLEMENTATION STRATEGIES

46 Temple University Department of Criminal Justice Technology Transfer Models RE-AIM Availability-Responsiveness-Continuity (ARC) Plan-Do-Study-Act QUERI model (Veterans Administration) Network for Improvement of Addiction Treatment (NIATx) 46

47 Temple University Department of Criminal Justice 47 Plan-Do-Study-Act

48 Temple University Department of Criminal Justice Local Change Team Strategy – the NIATx Model Process improvement by creating local change teams Focus on discrete, achievable performance measures treatment retention reduce waiting time for admission reduce no-shows to treatment Executive sponsor: org head authorizes staff and resources Change leader: senior staff invested in improvements, facilitates plans Change team: staff critical to local implementation 48

49 Temple University Department of Criminal Justice NIATx Model (cont’d)  Identify short term performance goals and strategies  Rapid Cycle Testing to monitor performance goals  Develop consensus plan to resolve problem, achieve change  Test new procedures and modify if needed  Develop sustainability plan 49

50 Temple University Department of Criminal Justice Performance Monitoring and Outcomes  Need standardized performance measures that can inform decision making  Program operations need to be rigorously described so they can be replicated with fidelity  Provide quicker and more regular performance feedback  Simplify outcome measures for policy makers and practitioners

51 Temple University Department of Criminal Justice IMPLEMENTATION CHALLENGES

52 Temple University Department of Criminal Justice Advances in Changing Community Correction Cultures  Correctional cultures need to embrace behavioral management techniques of engagement, clear expectations, and rewards/consequences  Change the role of probation/parole and correctional officers from security to facilitator of change  Use evidence-based practices  Shown to reduce recidivism and technical violations  Creates culture of accountability  Alters role of officer to be a facilitator of change/behavioral manager

53 Temple University Department of Criminal Justice Competing Values: Importance of SUD Treatment to other CJ Services

54 Temple University Department of Criminal Justice Qualities of Leaders 1. Community Setting 2 Administrator:  Human Services  Increased Knowledge of EBPs  Supports Rehabilitation  Pursue Reforms from Clinical Perspective 3. State Executive Support (even for county) Organizational Culture & Climate Learning Performance Emphasis Quality Treatment State Support* Training Resources Secure Physical Facilities Internal Support Training Resources What Matters in Adoption of EBPS? Overview of NCJTP Findings Network Connections Integration

55 Temple University Department of Criminal Justice General Challenges  Public Health versus Public Safety  Improve communication, establish common values  Public safety issues are paramount  Alignment: can’t have successful implementation without organizational and systems change. Need to invest in organizational change to sustain EBP  Standardized implementation and outcome measures that are useful to inform rational decision making  Resources to support organizational change and infrastructure improvement to facilitate effective implementation

56 Temple University Department of Criminal Justice  Infrastructure and service system problems make it difficult to implement EBP  Affect fidelity  Fidelity vs. adaptation: Need to adapt interventions to the real world and local conditions  Regular performance outcome monitoring  Workforce issues, line staff resistance, training and attitudes, staff development  Incentives may be needed to encourage staff to implement and sustain EBP Practice Challenges

57 Temple University Department of Criminal Justice  Implementation research is a new field  Complexity of different levels and systems and perspectives  Conceptual models to incorporate multi-level factors influencing implementation and outcomes  Need better implementation and process measures; social context, systems, org & staff capabilities, workload  How can we increase adoption of EBPs? Research Challenges and Opportunities

58 Temple University Department of Criminal Justice Research Questions  How to design implementation research studies: RCT vs. case studies, multiple baseline studies, etc.  Should include organizational and implementation measures  What are the impacts of different models of technology transfer?  What are the most effective components?  What are the key factors that increase sustainability?

59 Temple University Department of Criminal Justice 59 Conceptual Model for Evidence Based Interagency Implementation

60 Temple University Department of Criminal Justice Moving Toward a Public Health Framework for Offender Change  Public Health Mission  Community corrections as a service provider  Corrections is part of network of providers to improve the health and well-being of the offender Policy decisions should be informed by: 1) how can science inform the practice? 2) what actions needed to empower the offender to become a contributing member of society? 3) answers to these questions will reduce the RISKS associated with the offender’s behavior, which is a goal of public health.

61 Temple University Department of Criminal Justice Summary The community corrections environment offers both opportunities and challenges for expanding use of EBP Implementation Science can help conceptualize the challenges of moving evidence-based drug treatment from research to practice The implementation process must be planned and organized Successful and sustained implementation can be difficult Several frameworks and strategies offer promise 61

62 Temple University Department of Criminal Justice Summary (cont’d) Need to consider multi-level influences on implementation Full implementation is best achieved with local stakeholder involvement and change leaders Inter-agency and inter-organizational collaboration and communication Staged process improvement strategies with achievable and measurable objectives can stimulate organizational and staff change and support for EBP Engagement of line staff and line supervisors Integrate public health and public safety and build partnerships 62

63 Temple University Department of Criminal Justice Contact Information: Steven Belenko, Ph.D. Department of Criminal Justice Temple University Philadelphia, Pennsylvania USA


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