1. The University of Georgia CTN Membership and Innovation Adoption: Baseline Data from the UGA “Platform” Study NIDA Research Grant R01DA14482 Paul M. Roman, Principal Investigator Co-Investigators: JA Johnson, HK Knudsen, LJ Ducharme

2. The University of Georgia Setting the Context: The UGA “Platform” Study UGA’s study considers “best practices” in substance abuse treatment, including –Adoption of evidence-based treatment techniques –Attitudes of counselors toward innovative treatment techniques –“Best practices” in program management These data allow for comparison inside and outside the CTN Some analyses use the CTN as a platform for investigating substantive issues of interest

3. The University of Georgia Research Design: Onsite Interviews The primary unit of analysis is a “center” –Has own budget –Has own administrator –Baseline data collected from 240 “centers” within the CTN –Response rate = 95% This allows for comparison with data collected from non-CTN centers –363 publicly funded centers (response rate = 80%) –403 privately funded centers (response rate = 88%) Data collected via face-to-face interviews with administrators & clinical directors –Follow-up data collected via telephone at 6-month intervals to measure changes at the center

4. The University of Georgia Research Design: Additional Data Data were collected via mailback questionnaires with counselors at all participating centers –1,001 CTN-affiliated counselors (response rate = 61%) –1,207 counselors in publicly funded programs (response rate = 62%) –1,091 counselors in privately funded programs (response rate = 61%) Today’s presentation utilizes three data sources: –Baseline face-to-face interview data (collected 2003-2004) –6-month telephone follow-up data –Counselor questionnaire data

5. The University of Georgia Today’s Presentation Focus on three examples of analyses using both center-level and counselor-level data from CTN and non-CTN programs Adoption of buprenorphine and voucher- based motivational incentives Perceived acceptability of buprenorphine and voucher-based motivational incentives among counseling staff Clinical supervision as a “best practice” in program management

6. The University of Georgia Adoption of Buprenorphine and Voucher-Based Motivational Incentives: Exposure and “Trialability” in NIDA’s Clinical Trials Network

7. The University of Georgia Innovation Adoption and Inter-Organizational Relationships There is a major focus on technology transfer in substance abuse treatment centers, and on organizational characteristics that predict innovation. Involvement in research networks (like the CTN) is an important but under-studied area. Networks may increase exposure to innovations –Information flows via formal training and informal interactions The context of clinical trials offers the opportunity to try innovations for a limited period of time (Rogers’ concept of “trialability”)

8. The University of Georgia Research Questions NIDA’s CTN offers an important opportunity to examine if and how inter-organizational relationships promote innovation adoption –Focus on buprenorphine and voucher-based motivational incentives Are CTPs in the CTN protocols significantly more likely to adopt bup and/or vouchers? –Is “trialability” a predictor of adoption? Does membership in the CTN confer advantages to CTPs that are not involved in these protocols? –Is “exposure” a predictor of adoption?

9. The University of Georgia Methods Independent variables drawn from baseline face- to-face interviews –Compare 3 groups:  CTPs that participating in the relevant clinical trial  All other CTPs (not involved in the trial)  Non-CTN centers (N=766) –Control for revenue sources, profit status, accreditation, levels of care, size, staffing, and previous experience in clinical research Dependent variables drawn from 6-month telephone follow-up data –Current use of buprenorphine –Current use of voucher-based motivational incentives

10. The University of Georgia Adoption of Buprenorphine CTPs that participated in the buprenorphine trials were significantly more likely to have adopted buprenorphine than CTPs not in the trials and non- CTN centers

11. The University of Georgia Logistic Regression Model of Buprenorphine Adoption Controlling for other organizational factors: –CTPs in the buprenorphine protocols were 5.2 times more likely to use buprenorphine (at the 6-month follow-up) than non-CTN programs (p<.01) Other significant predictors, net of effects of CTN exposure: –Center offers detox services (O.R. = 3.59) –Center has a physician on staff or contract (O.R. = 3.94) –The percentage of primary opiate clients (O.R. = 1.009)

12. The University of Georgia Adoption of Voucher-Based Motivational Incentives These differences in adoption were not statistically significant

13. The University of Georgia Logistic Regression of Voucher-Based Motivational Incentives Net of other organizational factors, there were no significant differences between CTN trial participants, CTN members, and non-CTN centers Significant predictors of adoption (net of CTN exposure): –Centers that rely on public revenue sources were more likely to have adopted VB-MI (O.R. = 1.69) –For-profit centers were less likely to have adopted (O.R. =.59) –Accredited centers were less likely to adopt VB-MI (O.R. =.65) –Outpatient-only centers were less likely to have adopted (O.R. =.65)

14. The University of Georgia Discussion The ability to compare CTN vs. non-CTN centers provides a unique opportunity to examine a variety of factors that influence innovative behavior and the adoption of evidence-based practices at the organizational level. The longitudinal design of these studies will allow for observation of continued trends in adoption of these techniques. Future research is planned to examine the use of MET and motivational interviewing in CTN and non- CTN samples.

15. The University of Georgia The CTN and Counselors’ Attitudes Toward Innovations

16. The University of Georgia Why Study Counselor Attitudes? Although organizations make the decision to adopt innovations, staff members play important roles in the adoption process –Supportive attitudes may encourage decision-makers to adopt innovations –Supportive attitudes may increase the odds of successful implementation The attitudes of counselors towards treatment innovations have been understudied in health services research These analyses consider the “perceived acceptability” of buprenorphine and voucher-based motivational incentives among CTN and non-CTN counselors

17. The University of Georgia Key Research Questions Are there counselor-level differences in perceived acceptability based on CTN affiliation? If so, –Are these differences attenuated by counselor characteristics, such as educational attainment, certification, 12-step orientation, and personal recovery status? –Are these differences explained by differential levels of training and implementation related to the innovation?

18. The University of Georgia Counselor Samples Data drawn from: –193 counselors in privately funded CTPs –838 counselors in private centers outside the CTN –368 counselors in publicly funded CTPs –907 counselors in public centers outside the CTN CTN counselors in OTPs are excluded from these analyses due to lack of comparison group Separate models are estimated for the public and private sectors

19. The University of Georgia Measures Counselors asked, “To you as a treatment professional, how acceptable is the use of the following treatment techniques for substance abuse?” –1 = completely unacceptable –7 = very acceptable –Focus on buprenorphine and voucher-based motivational incentives Counselor characteristics: –Master’s-level degree –Certification in SATx –12-step orientation –Personally being in recovery Innovation-specific measures: –Extent that the center has provided specific training about the innovation (1 = no extent, 7 = very great extent) –Extent that the center has implemented the innovation (1 = never used, 7 = always used when clinically appropriate) Controls for age, gender, and race/ethnicity

20. The University of Georgia Findings: Buprenorphine In both the public and private sectors, CTN counselors perceived buprenorphine to be more acceptable than non-CTN counselors Controlling for counselor characteristics did not mediate this association Adding the measures of training and implementation reduced the difference to non-significant levels –Indicates that the CTN/non-CTN difference is a function of CTN counselors receiving more training and working in centers where buprenorphine has been implemented

21. The University of Georgia Findings: Voucher-Based Motivational Incentives In the private sector, CTN counselors perceived VB-MI to be more acceptable than non-CTN counselors –This difference persisted when counselor characteristics were added to the model –Controlling for training and implementation rendered the difference non-significant In the public sector, there was not a significant difference between CTN and non- CTN counselors in perceived acceptability of voucher-based motivational incentives

22. The University of Georgia Summary Data from counselors suggest that CTN counselors are more receptive towards buprenorphine and voucher-based motivational incentives These differences are not explained away by counselor characteristics Innovation-specific training and implementation accounted for the differences

23. The University of Georgia Best Practices in Program Management: Using the CTN as a Platform

24. The University of Georgia Program Management and Counselor Turnover Counselor turnover is widely regarded as a significant challenge for treatment centers –High turnover may disrupt the quality of service delivery and coordination of care –High turnover may be costly in terms of recruitment and training costs Data collected from other samples counselors suggests that turnover intention is predicted by management practices –Job autonomy reduces burnout and turnover intention  Autonomy—authority to make decisions about how to do one’s job –Organization justice reduces burnout and intention to quit  Distributive justice—fair distribution of rewards  Procedural justice—fair processes within the workplace

25. The University of Georgia Clinical Supervision: Is It a “Best Practice”? To date, there is little research on whether high- quality clinical supervision may reduce counselor turnover Such evidence might suggest that high-quality clinical supervision is a “best practice” in program management We used the CTN counselor sample as a “platform” to address this issue –Our interactions with CTPs prior to data collection suggested that clinical supervision was a key area of CTP interest –This sample is the first time we have examined the issue of clinical supervision

26. The University of Georgia Research Questions Is the perceived quality of clinical supervision associated with perceptions of: –Job autonomy, –Procedural justice, and –Distributive justice? Is clinical supervision directly associated with organizational commitment and emotional exhaustion? Is clinical supervision directly associated with intention to quit? What are the indirect associations between clinical supervision and turnover intention?

27. The University of Georgia Methods Data drawn from counselors employed in CTN- affiliated treatment programs (n = 1,001) Clinical supervision scale includes items about the quality work-related advice provided by the supervisor and the supervisor’s level of professional expertise Structural equation modeling was used to estimate the associations between clinical supervision and turnover intention –For clarity, we’ll present the model in sections

28. The University of Georgia Distributive Justice Job Autonomy Procedural JusticeClinical Supervision.42***.39***.55*** Clinical supervision is associated with perceptions of autonomy and justice

29. The University of Georgia Clinical Supervision Job Autonomy Procedural Justice Distributive Justice Organizational Commitment Emotional Exhaustion -.296*** -.123* -.235***.182***.239***.250***.176*** Clinical supervision is only directly associated with commitment R 2 =.31 R 2 =.63

30. The University of Georgia Clinical Supervision Job Autonomy Procedural Justice Distributive Justice Organizational Commitment Emotional Exhaustion Turnover Intention.27*** -.48*** Turnover intention is associated with commitment and emotional exhaustion R 2 =.60

31. The University of Georgia Summary of Results Clinical supervision was not directly associated with turnover intention, net of the other variables. It was indirectly associated with turnover intention via autonomy and justice and then commitment and emotional exhaustion. –Total effect of supervision on turnover intention = -.351 –Total effect of supervision on commitment =.543 –Total effect of supervision on emotional exhaustion = -.212 The model suggests that high-quality clinical supervision may be a “best practice” of program management

32. The University of Georgia Next steps…

33. The University of Georgia Upcoming CTN-Related Activities We are currently conducting the second wave of face-to-face interviews We plan to submit a renewal application to NIDA this summer Lillian Eby, professor of psychology at UGA, submitted a proposal to use “CTN as a platform” –Focuses on the relationship between clinical supervisors and counselors –Considers longitudinal implications of this relationship on counselor and supervisor turnover –25 CTPs provided letters of support –Project will start in Fall 2006

34. The University of Georgia The UGA team is grateful for the continued levels of high level of support shown by the CTPs. Thank you! Additional information can be found at http://www.uga.edu/ntcs