The final report will focus on the research questions that call for recommendations, drawing upon input from the TAG and issues identified in the reviews of literature and needs assessments reports described above. Specifically, these questions are:
What data and methods most effectively gauge treatment needs and current gaps?
What questions should be answered in conducting these needs assessments?
How does ASAM Levels of Care relate to capacity needs (both in workforce and setting)?
How can best staffing practices, telehealth policies and peer supports be incorporated into needs assessments?
What are the key pieces of missing data that would improve these needs assessments, including one-time data collection efforts and potential federal efforts?
How can needs assessment methods be validated?
How can needs assessment approaches be made more uniform while remaining adaptable to local conditions and stakeholder priorities?
How can assessments become more effective at promoting organizational and system change to address, rather than simply identify, system gaps?
Here we provide some background information based on the environmental scan for more detailed discussion on specific recommendations to be provided in the Final Report.
Data and Methods for Gauging Treatment Needs and Gaps
Although the review of methodology literature describes a variety of methods and types of data for assessing treatment needs of varying complexity, most of the needs assessment reports reviewed, with a few exceptions, use relatively simple approaches, combining quantitative data from secondary sources such as national surveys and local administrative data with qualitative information obtained from stakeholders. Some considerations for recommendations are: development and use of more systematic methods for combining qualitative and quantitative information (data triangulation), federal action to address current gaps in data sources, and better methods for measuring clinical significance in addition to diagnosis.
Questions that Should be Answered in Needs Assessments
Some of the recommendations in this area should address the questions of how to define and measure continuity and continuum of care, what are the specific types of services required by different subgroups defined by severity, chronicity etc., how to identify redundant and ineffective services, how to incorporate measurement of assets with measurement of needs.
Relation of ASAM Levels of Care to Capacity Needs
The review of needs assessment reports identified very few that drew upon the ASAM Criteria as a framework. The final report, with input from the TAG, will provide a detailed discussion about how ASAM Criteria may be incorporated in needs assessment as a formulation for the "what should be" conditions.
Incorporating Best Staffing Practices, Telehealth Policies and Peer Supports into Needs Assessments
While information on these topics was relatively sparse in the needs assessments we reviewed, there were some examples that would serve as recommendations for the field. The question of peer supports requires further investigation. Only four of the reports indicated that they included peers in their assessment of workforce categories. It may be that this is a question of nomenclature, however, as a considerable portion of the SUD treatment workforce are persons in recovery. The final report will include these as well as other recommendations suggested by the TAG and other sources such as the research and policy literature.
Supplying Key Pieces of Missing Data
The description of commonly utilized federal data sources in the previous section identifies a number of limitations for purposes of SUD needs assessment. Members of the TAG have expertise in this area, which the final report will draw upon to recommend options for addressing these gaps.
Validating Needs Assessment Methods
While validation of tools for needs assessment at the individual level is commonplace, there was virtually no mention of validation in the reviewed needs assessment reports. However, several articles in the methodology literature, including some by members of the TAG, do report on methods of validation, which will be included in the final report.
Approaches for Making Needs Assessments More Uniform
Because SUD treatment systems vary extensively from one locale to another, locally conducted needs assessments have the advantage of being attuned to the issues and characteristics unique to the region. A drawback of the variability in design, methods and quality, however, is that it limits the possibility of another potential use of these reports for some form of "meta-assessment" to investigate regional variations and consistencies of SUD treatment systems. The review of needs assessment reports, especially those in the federally mandated category, as well as the methodology literature review suggested possibilities for this purpose.
One strategy that would aid in making SUD treatment needs assessments more uniform and also support improvements in quality would be to emulate the many federal, state, and private organization guidelines and tools that are available for conducting CHNAs and CHAs. At the federal level the CDC provides the web-based CHI (CHI) Navigator, which provides tools for conducting CHNAs, with an emphasis on promoting collaboration among various types of organizations such as health care systems, public health agencies, and community-based organizations. A number of state public health agencies have developed guides for local agencies to develop CHAs for purposes of accreditation by the Public Health Accreditation Board (PHAB). For example, the Iowa Department of Public Health provides an online guide with detailed information for each of the steps in developing a CHA keyed to the requirements of the PHAB.
A private non-profit organization, Community Commons, has developed a free web-based platform "designed to assist hospitals (with particular attention to critical access and other smaller facilities), non-profit organizations, state and local health departments, financial institutions, and other organizations seeking to better understand the needs and assets of their communities, and to collaborate to make measurable improvements in community health and well-being."
Tools modeled on these examples but designed specifically for SUD treatment, with options to accommodate local variations, would be an important contribution the enhancing uniformity. Tools of this kind could also serve to enhance the quality of needs assessments by establishing quality criteria and offering guidance on methodology.
Another promising approach for enhancing uniformity as well as quality is the research-based methodology of CAST, a tool designed to provide practitioners and policy makers with guidelines on the number of programs, practitioners, and interventions that are needed in the local substance abuse treatment system (Green, et al., 2016). This methodology is described in more detail in the review of SUD needs assessment methodology literature.
Increasing the Effectiveness of Needs Assessment in Promoting Organizational and System Change
This topic primarily concerns the recommendations and prioritization component of needs assessment, the extent and quality of which varied considerably among the reviewed needs assessment reports. The final report will draw upon best practices from the reports to provide recommendations for enhancing this function. Additionally, there are several recent reports on the potential, as yet largely unrealized, of leveraging the information from CHNAs and CHA for system change, for example Bender (2017), which we will summarize for recommendations.
Overall, we found that the SUD-specific assessments that we reviewed share certain features such as mixed methods of data collection (surveys, key informant interviews, focus groups, services utilization data, etc.) but with considerable variability in the scope and level of detail that is provided.
Recommendation priorities, feasibility, and strategies: As discussed in the introductory section on needs assessment methodology, a key function of a needs assessment is to serve as a guide for decision making and/or priority-setting. A comprehensive needs assessment, therefore, will go beyond documenting gaps in a treatment system or unmet needs in a population, but will additionally provide at least guidance on ways in which needs and gaps may be addressed, and--optimally--information about the feasibility, challenges, costs, and opportunities for implementing recommendations. Appendix D, which presents our quality assessments, indicates that only about half of those reviewed provide this key function.
Resources/assets/strengths: As emphasized in the more recent literature on needs assessment methodology, documentation is an important component for serving the function of planning and priority-setting--not only documentation of system gaps and limitations but also of strengths on which to build. This was addressed by only a handful of the reports we reviewed (n=7).
Levels of care: One of the questions in our review was about reporting on levels of care, including whether ASAM Criteria were employed. We found that ASAM Criteria were used only in a few cases, and that generally there was a great deal inconsistency about how levels of care were specified. Few of the reports asked the direct question, "What is the capacity of different levels of care in the system?"
System redundancy/efficiency: None of the reports that we reviewed measured the extent to which there was redundancy, underutilized capacity, and inefficient service delivery that might provide opportunities for system reform without additional resource demands.
Some important aspects of treatment capacity were addressed by only a few of the needs assessments. These included peer involvement, the functions of law enforcement, estimates of changes in demand resulting from system reforms, treatment completion/adherence as an aspect of utilization, and the extent of EBPs.
The most likely reasons for many of these omissions are limitations in currently available data, which will be addressed in the final report.
It is evident from our review that SUD treatment presents some unique challenges for needs assessment, mainly in the considerable variability in how SUD treatment systems are structured and in the relative lack of uniformity in defining aspects of systems (such as workforce designations, service categories, provider types and levels of care) compared to health care and even mental health. A framework to address these challenges, known as CAST, developed by Green et al. (2016) is now being tested in several sites. It will be interesting to see how this approach will be disseminated and the extent to which it influences SUD treatment needs assessment.