New directions in substance abuse services: programmatic innovations in the Veterans Administration

An Economic Evaluation of Inpatient Residential Treatment Programs in the Department of Veterans Affairs

The Veterans Health Administration (VA) established psychosocial residential rehabilitation treatment programs (RTPs) to treat eligible veterans who have psychiatric and substance use disorders in a less intensive and more self-reliant inpatient setting. Fortytwo (25 percent) VA medical centers adopted RTPs in 1995. Panel regression models using data from 1993 through 1999 indicated that RTPs were associated with 8.6 and 24.4 percent decreases in the average cost per day for inpatient psychiatry and substance use care, respectively. During this time, VA transitioned much of the inpatient mental health care to ambulatory services. Yet medical centers with RTPs had smaller decreases in the number of inpatient patient days than those without RTPs. Because medical centers with RTPs provided more services, this offset the per diem savings, resulting in no significant differences in total costs between medical centers with and without RPTs.

Predictors of homeless veterans' irregular discharge status from a domiciliary care program

This study addresses the relationship of homeless veterans' discharge status from a domiciliary care program to biopsychosocial characteristics presented at admission into the program. Hypotheses were that younger age, less education, and substance abuse or psychiatric disorder would predict an irregular discharge. Research participants were 367 homeless male veterans who had been admitted to a domiciliary care program at the West Los Angeles Veterans Affairs Medical Center for treatment of medical, psychiatric, or substance disorders. Status of veterans' program discharge (regular or irregular) served as the outcome measure. Logistic regression analysis revealed that irregular discharge from the program was more likely among veterans who were black, who had poor employment histories, or who had problems with alcohol. Results are discussed in light of the need to maintain homeless veterans in treatment programs so that they can achieve maximum benefit from available programs.

Policy-relevant program evaluation in a national substance abuse treatment system

This article discusses recent trends in public and private substance abuse services and offers suggestions on how the evaluation of such services can inform clinical practice and policy making. This analysis focuses particularly on the Department of Veterans Affairs (VA), which operates the largest substance abuse treatment system in the United States. In recent years, there has been an erosion of services for substance abuse outside the VA. In contrast, due to increased funding from the U.S. Congress, the VA significantly expanded substance abuse treatment from 1990 to 1994. However, efforts to "reinvent" and downsize government initiated a reversal of this growth trend in 1994, and VA services may shrink further as the system becomes more decentralized and adopts managed care strategies from the private sector. Drawing from the VA Program Evaluation and Resource Center's (PERC) experience of evaluating the VA system and working with federal policy makers, this article presents examples and suggestions for making evaluations of substance abuse treatment systems more useful in policy discussions and in day-to-day clinical practice.

Access to substance abuse treatment for homeless women of reproductive age

Homeless women in the United States comprise a subpopulation at high risk for substance abuse, with rates of substance use disorder ranging from 16% to 67%. Despite the need for treatment that such high rates imply, relatively few substance-abusing homeless women avail themselves of formal treatment. The fact that they tend not to utilize formal treatment services is especially problematic among homeless women of reproductive age, who are not only themselves at risk of health-related problems but who place their fetuses and children in danger of multiple negative consequences. The imbalance between treatment need and treatment access suggests that homeless, substance-abusing women are facing severe barriers to care. Although identifying barriers to their treatment access is crucial if this imbalance is to be remedied, very little empirical research has been done in this area. This article presents an overview of current knowledge about barriers to substance abuse treatment for women generally and for homeless women specifically, and proposes a comprehensive empirical strategy for redressing the lack of information on homeless women's access to substance abuse treatment.