1. The University of Georgia Variations in the Adoption of Management Practices Across Types of Substance Abuse Treatment Systems Paul M. Roman Hannah K. Knudsen

2. The University of Georgia General Theme The importance of the organizational framing of health services issues Tap into a massive research literature Reduce isolation and learn from other “industry” experience Generate novel applications of theoretical frameworks

3. The University of Georgia The American Substance Abuse Treatment System The national “system” that has evolved since the 1970s draws from diverse roots, such as: –Public substance abuse treatment facilities –State psychiatric hospitals –Community-based non-profit organizations that draw heavily on government block grants/contracts for funding –Private general hospitals and psychiatric hospitals –Entrepreneurial for-profit treatment programs

4. The University of Georgia A Typology of Addiction Treatment Centers Much of the literature views the system as a simple dichotomy: public (government-owned) vs. private (all others) By integrating information on: –Ownership (public vs. private) –Profit status (non-profit vs. for-profit) –Funding/revenue sources (government block grants/contracts vs. insurance/self-pay) A typology of treatment centers emerges: –Government-owned –Publicly funded non-profits –Privately funded non-profits –For-profit

5. The University of Georgia Applications of the Typology This four-category typology has substantive meaning in terms of service delivery –Differences in medication adoption by center type –Differences in availability of integrated care for co-occurring substance abuse & mental health conditions It is less clear if this typology is meaningful in characterizing the management of these different types of organizations –This presentation focuses on human resource management (HRM) practices and policies –We also consider whether HRM is associated with counselor turnover rates, a measure of organizational performance

6. The University of Georgia Human Resource Management Has generally been overlooked in SA health services research This neglect is found together with near-panic level concerns with “workforce” issues Within the SA policy field, “workforce” seems exclusively defined as labor market issues: –training –salaries –mobility –turnover

7. The University of Georgia Human Resource Management SA organizational HRM practices are: Significant Important Make a difference in “workforce” behavior

8. The University of Georgia Research Questions Are there differences in HRM practices & policies across the four types of centers? Which HRM practices are associated with counselor turnover?

9. The University of Georgia Sample Data from the National Treatment Center Study –Community-based addiction treatment centers –Must offer a minimum of outpatient care (as defined by ASAM) Two nationally representative samples –Publicly funded centers (n = 363): > 50% of revenues from government block grants/contracts  Response rate = 80% –Privately funded centers (n = 401): <50% of revenues from government block grants/contracts  Response rate = 88% Data collected via face-to-face interviews with administrators and/or clinical directors

10. The University of Georgia Key Measures Human resource management practices/policies in three broad categories: –Financial benefits –Employee well-being –Family-friendly practices/policies Counselor turnover as number of counselors that left in the past year

11. The University of Georgia Results: HRM Practices and Policies

12. The University of Georgia Average Counselor Salary The average counselor salary was $32,690 Gov-owned > public non-profit Private non-profit > public non-profit & gov- owned

13. The University of Georgia Universal Eligibility for Employee Benefits Administrators were asked if all counselors were eligible for employee benefits About 60.9% of centers reported that all counselors were eligible for benefits –For-profits less likely to have universal eligibility than government-owned & public non-profits

14. The University of Georgia Retirement Program Administrators were asked if the center makes financial contributions to a retirement program for its employees Although a clear majority of centers have a retirement program (75.7%), there are considerable differences by center type –For-profits less than all others –Public non-profits less likely to offer than government- owned & private non-profits

15. The University of Georgia Family Leave Policy Administrators were asked if the center had a family leave policy Family leave policies are nearly universal (89.4%) No differences by center type

16. The University of Georgia Child Care for Employees with Children Administrators were asked if the center offered childcare services to its employees with children About 20.4% of centers offer childcare, but this is largely driven by the significantly higher rate of childcare in private non-profits

17. The University of Georgia Elder Care for Employees with Aging Parents Administrators were asked if the center had an eldercare program This benefit is very rare (6.3%), but again, private non-profits are more likely to offer it than other types of centers

18. The University of Georgia Flextime Scheduling Administrators were asked employees had the option of a “flextime” work schedule The majority of centers (65.7%) offer flextime options No differences by center type

19. The University of Georgia Wellness Program for Employees Administrators were asked if the center offered a wellness program This is also a benefit that has been adopted by a majority of centers (58.1%) –Government-owned more likely to offer wellness than public non-profit & for-profit –Private non-profit more likely to offer than public non-profit & for-profit

20. The University of Georgia Employee Assistance Program (EAP) Administrators were asked if the center had an employee assistance program (EAP) The majority of centers have an EAP (62.1%), but availability varies widely across the four types of centers –For-profits less likely than government-owned & private non-profits –Public non-profits less likely than government-owned & private non-profits

21. The University of Georgia Summary The four-category typology revealed significant differences in HRM policies and practices Within the public sector, government-owned centers tended to be more advanced in HRM than publicly funded non-profits Privately funded non-profits tended to be ahead of other centers in family-friendly practices (e.g. childcare, eldercare) For-profit centers tended to lag behind the other types of centers in HRM

22. The University of Georgia Results: HRM Practices/Policies & Counselor Turnover

23. The University of Georgia Counselor Turnover in Addiction Treatment Centers There is growing concern about the high rates of counselor turnover –Some estimates range from 18% to 50% per year Health services researchers have been trying to identify organizational factors that reduce turnover No research on whether HRM practices/policies can reduce turnover

24. The University of Georgia Counselor Turnover Rates Across all centers, the average rate of turnover was 18.1% –Government-owned: 16.1% –Public non-profit: 23.9% –Private non-profit: 14.6% –For-profit: 14.4% Turnover in public non-profits significantly greater than both types of private centers –Trend for higher than government-owned (p=.08)

25. The University of Georgia Modeling Counselor Turnover There is substantial skew in the measure of turnover rate –35.0% of centers reported no counselor turnover in the past year –In small centers, turnover rates can look inflated We model the number of counselors who left in the past year, while controlling for the number employed –We use negative binomial regression because it is less sensitive to skewed data than OLS regression

26. The University of Georgia NBR Model of Counselor Turnover: Center Type Net of HRM, levels of care, and center accreditation, there was one significant difference in counselor turnover by center type –Compared to public non-profits, turnover was lower in private non-profits  Expected count of turnover 28.1% lower in private non- profits –Turnover in for-profits, relative to public non- profits, trended lower (p=.06)

27. The University of Georgia NBR Model of Counselor Turnover: HRM Practices & Policies Net of center type, levels of care, and center accreditation, three HRM measures were significant –Average counselor salary negatively associated with turnover  A standard deviation increase in salary (about $7,700) was associated with 11.8% decrease in expected count of turnover –Universal eligibility for employee benefits negatively associated with turnover  If all employees were eligible for benefits, the expected count of turnover was 22.3% lower –Presence of a childcare program reduced turnover  Expected count of turnover was 30.4% lower in centers with childcare –Trend of presence of a wellness program reducing turnover (p=.06)  Expected count of turnover 17.2% lower in centers with wellness program

28. The University of Georgia The authors gratefully acknowledge the support of research funding from the National Institute on Drug Abuse (R01- DA-14482 and R01-DA-13110). This presentation and other reports from the National Treatment Center Study are available at http://www.uga.edu/ntcs