1. The University of Georgia Adoption of Innovative Treatment Techniques in Public and Private Substance Abuse Programs Hannah K. Knudsen, Ph.D. Paul M. Roman, Ph.D. Meredith Huey, M.A. Center for Research on Behavioral Health and Human Services Delivery American Public Health Association, November 2004

2. The University of Georgia The “Research to Practice” Gap There is ongoing concern in the substance abuse treatment field that the pace of innovation adoption is slow A growing literature is beginning to examine the organizational predictors of innovation adoption in these healthcare settings Key gaps in the research literature include: –Comparisons of public & private treatment facilities –Applications of broader organizational theory in this context –Consideration of both aggregate innovativeness as well as the processes underlying the adoption of specific innovations

3. The University of Georgia Organizational Research on Innovation Adoption In the larger literature, most research focuses on individual innovations –Substance abuse treatment literature follows this pattern— adoption of specific techniques, attitudes toward a given innovation, technology transfer within an organization Rogers’ concept of “organizational compatibility” is useful in understanding the adoption of particular innovations –There needs to be a “fit” between the characteristics of a given innovation and the organization’s culture & structural resources The emphasis on individual innovations complicates the development of general theory about innovation adoption

4. The University of Georgia Aggregate Innovation Some organizational theorists have called for research on aggregate measures of innovativeness –Such a measure usually involves an additive count of the number of innovations adopted The goal of such research is to identify the broader organizational & managerial processes that increase an organization’s propensity to adopt innovations It allows for the development of theory that addresses the variation in innovation adoption

5. The University of Georgia Aggregate Innovation and Absorptive Capacity Cohen & Levinthal (1990) define “absorptive capacity” as the extent to which an organization can procure, process, & assimilate information Three organizational behaviors that indicate greater absorptive capacity: –The employment of a professional workforce –Environmental scanning (the use of external sources of information, e.g. journals, professional development) –Collection of satisfaction data from organizational “buyers” and suppliers” (i.e. gathering information about unmet needs that could be addressed with innovations)

6. The University of Georgia Absorptive Capacity: Applications in Substance Abuse Treatment Organizations Absorptive capacity may be a key organizational resource that can support the adoption of innovations To date, absorptive capacity and aggregate innovation has only been examined in private treatment organizations (Knudsen & Roman, 2004) –It is unclear if the utility of this construct generalizes to the public sector It is less clear if absorptive capacity will also have applicability to specific treatment innovations

7. The University of Georgia Research Questions Is there variation in aggregate innovation across government-owned, public non-profits, private non- profits, and for-profits? Does absorptive capacity predict aggregate innovation in a sample of public & private treatment facilities? Is absorptive capacity associated with the adoption of specific innovations? –Buprenorphine –Naltrexone –Motivational incentives/vouchers (a.k.a. contingency management)

8. The University of Georgia Methods Nationally representative samples of publicly funded and private funded substance abuse treatment facilities (n = 746) Dependent variables –Aggregate Innovation: sum of 14 techniques (4 medications and 9 psycho-social techniques)  Mean = 4.60 (SD = 2.69) –Buprenorphine Adoption: dichotomous measure of center currently uses vs. does not use  10.0% have adopted –Naltrexone Adoption: dichotomous measure of center currently uses vs. does not use  30.4% have adopted –Motivational Incentives Adoption: dichotomous measure of center currently uses vs. does not use  25.4% have adopted

9. The University of Georgia Methods (continued) Absorptive Capacity Workforce professionalism –% Master’s-level counselors –% counselors in recovery –Physician resources (doctors on payroll, contract doctors, no doctors as reference category) Environmental Scanning: additive index of five items of use of external information sources Collection of Satisfaction Data: sum of two items measuring data collected from referral sources & third party payers

10. The University of Georgia Methods (continued) Organizational Characteristics –Center type: government-owned, publicly funded non-profit, for-profit, privately funded non-profit (reference category) –Size: natural log-transformed number of employees –Age: natural log-transformed years –Rural location: center in non-MSA county vs. center in MSA county –Levels of care: inpatient-only, mixed inpatient & outpatient, outpatient-only (reference category)

11. The University of Georgia Negative Binomial Regression: Aggregate Innovation % Change in Expected Count % Change in Expected Count Government-Owned-21.6%NS Publicly Funded Non-Profit-25.0%-12.3% For-Profit-13.7%NS Size-----NS Age-----NS Rural-----NS Inpatient-only-----14.2% Mixed IP & OP-----24.4% % Master’s Counselors-----0.2% % Recovering Counselors-----NS Doctor On-Staff-----38.6% Contract Physician-----25.8% Environmental Scanning-----9.5% Collection of Satisfaction Data-----8.3%

12. The University of Georgia Logistic Regression: Buprenorphine Adoption Odds Ratio Government-Owned.113.155 Publicly Funded Non-Profit.224.385 For-ProfitNS Size-----NS Age-----NS Rural-----NS Inpatient-only-----NS Mixed IP & OP-----2.306 % Master’s Counselors-----NS % Recovering Counselors-----NS Doctor On-Staff-----3.497 Contract Physician-----NS Environmental Scanning-----NS Collection of Satisfaction Data-----1.681

13. The University of Georgia Logistic Regression: Naltrexone Adoption Odds Ratio Government-Owned.301.405 Publicly Funded Non-Profit.219.332 For-ProfitNS Size-----NS Age-----NS Rural-----NS Inpatient-only-----NS Mixed IP & OP-----1.951 % Master’s Counselors-----1.009 % Recovering Counselors-----NS Doctor On-Staff-----2.048 Contract Physician-----NS Environmental Scanning-----1.270 Collection of Satisfaction Data-----1.260 (p=.06)

14. The University of Georgia Logistic Regression: Motivational Incentives Adoption Odds Ratio Government-Owned1.9131.822 Publicly Funded Non-Profit2.2512.439 For-Profit.501 (p=.052).449 Size-----NS Age-----.695 Rural-----NS Inpatient-only-----NS Mixed IP & OP-----NS % Master’s Counselors-----NS % Recovering Counselors-----NS Doctor On-Staff-----NS Contract Physician-----NS Environmental Scanning-----NS Collection of Satisfaction Data-----NS

15. The University of Georgia Summary: Innovation & Center Type Innovation adoption varied by center type Privately funded non-profits scored highest in aggregate innovation, while publicly funded non- profits were the lowest –These differences largely mediated by absorptive capacity & organizational characteristics Private sector more likely to adopt buprenorphine & naltrexone than public sector Public sector more likely to adopt motivational incentives –These differences persisted after controlling for absorptive capacity & organizational characteristics

16. The University of Georgia Summary: Absorptive Capacity Measures of absorptive capacity worked well in the model of aggregate innovation –Workforce professionalism, environmental scanning, and collection of satisfaction data all significantly associated with aggregate innovation, net of organizational characteristics Absorptive capacity less useful in predicting adoption of specific innovations –Modest support for buprenorphine, clearer support for naltrexone, and no support for motivational incentives Models of organizational compatibility—that look at “fit” between innovation’s characteristics and the organization’s culture/structure—may be more predictive of the adoption of specific innovations

17. The University of Georgia Acknowledgements This research was supported by the National Institute on Drug Abuse (R01-DA-13110 and R01-DA-14482). More information about the National Treatment Center Study can be found online at http://www.uga.edu/ntcs