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–Patricia Harrison, Ph.D., Administrative Planning Director, Chemical Dependency Program Division, Minnesota Department of Human Services

Accompanying health care reform efforts is a new emphasis on outcomes-based accountability. Single State Agencies have a key role with respect to ensuring the highest quality of AOD treatment and the best outcomes for the lowest possible cost. To deliver the requisite level of account- ability, State agencies will need to consider setting up statewide outcomes monitoring systems for their substance abuse treat- ment providers. A successful outcomes monitoring system offers a number of advantages. It will be able to:

• Help States, treatment programs, and policymakers to determine the effectiveness of certain types of treatment for different types of patients

• Improve program performance by using outcomes data to identify weaknesses or gaps in services, and provide feedback to enhance system performance

• Document cost-effectiveness and minimize inefficiencies and unnecessary expenditures in treatment program

• Help improve allocation of resources

• Provide justification to support funding requests, especially the use of public dollars and the necessity of including treatment in a basic health care benefits package

• Assist managed care systems by providing data on treatment outcomes

Empirical data derived from a State outcomes monitoring system can be used to develop or refine patient placement, continued stay, and discharge criteria, so that patients can be provided the services most likely to produce successful out- comes. Improvement in treatment outcomes for clients is the ultimate purpose of an outcomes monitoring system.

Limited resources will dictate the scope and capabilities of any system. AOD resources are shrinking in many areas while demands placed upon them are increasing. As time goes on, more is expected of State agencies and providers. In this climate, outcomes monitoring may be seen as just one more added burden. Without a distinct and visible payoff, enthusiasm for the undertaking is likely to be lacking.

CSAT's New Outcomes-Based TIP

The Center for Substance Abuse Treatment (CSAT) is now developing a new Treatment Improvement Protocol (TIP) that addresses the importance of outcomes monitoring systems at the State level. This new guide will enhance the States' abilities to fulfill their increasing roles and responsibilities in monitoring treatment outcomes.

The TIP recognizes that differences among States will influence both the process and the design of an outcomes monitoring system. States are diverse in terms of the populations they serve and:

• In the prevalence of alcohol and specific drug use disorders

• In the rates of injection drug use, HIV, and tuberculosis among the AOD-using populations

• In their mix of rural and urban communities

• In their poverty rates

• In language differences and the racial/ ethnic composition of the populace

• In the extent to which cultural factors influence substance use patterns and attitudes toward treatment.

States also vary in terms of how programs currently operate and how they are funded, as well as in their variety of treatment philosophies, programs, and services in operation. Finally, there are vast differences among States in terms of their financial resources and the burdens placed upon them, as well as their current management information system capacities and how much needs to be accomplished before an outcomes monitoring system can be implemented. Whereas some States have already designed and put into practice statewide data collection systems that include a follow-up component, others have yet to begin the planning process.

Two general principles guided the selection of outcomes that are recommended by the TIP for inclusion in a State outcomes monitoring system. These principles are:

• Treatment outcomes must be measured in terms of each individual patient's improvement along a con- tinuum rather than against some pre- determined arbitrary success measure.

• Treatment outcomes measures need to be multidimensional, addressing AOD use as well as the areas in which AOD use has had an impact on patients' lives, such as general health, social and occupational functioning, and legal involvements.

The most useful outcomes measures will have broad public and political appeal, such as cost savings that follow successful treatment or evidence of reduced harm to society.

Primary Goal: Measuring the Total System

While individual program evaluation is usually assumed to be the primary goal of an outcomes monitoring system (OMS), the OMS can be designed to measure the system as a whole–to address specific policy-relevant questions without providing ratings for individual programs. In fact, there are considerable obstacles to using an OMS to measure individual program performance. To conduct valid comparisons of treatment programs in terms of treatment outcomes, program samples must be sufficiently large to ensure that observed differences are statistically significant. Even when outcome differences are significant, the poorer outcomes may be attributable to patient differences at admission.

In contrast, focusing on the aggregated data set from all programs can address a variety of broad questions about the correlates of successful outcomes and the best use of available resources. If data are included on patient characteristics, treatment services, and outcomes, then outcomes can be compared for groups of patients with similar characteristics who receive different services, or who receive services different in intensity or duration.

Pooling data from a diversity of patients and treatment models and services will ultimately enhance the ability to determine what kinds of service and level of service are most likely to benefit which patients. The emphasis shifts to treatment components (or service packages) rather than treatment programs. Analysis targets the set of services that comprise treatment rather than the individual treatment program.

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