Chapter 4

Facility Characteristics and Services

Facility Operation and Primary Focus
Type of Care Offered
Client Substance Abuse Problem and Co-occurring Mental Health Disorders
Facility Size
Facility Capacity and Utilization Rates
Services Provided
Clinical/Therapeutic Approaches
Programs or Groups for Specific Client Types
Services in Sign Language for the Hearing Impaired and in Languages Other than English
Detoxification Services
Client Outreach
Facility Licensing, Certification, or Accreditation
Facility Standard Operating Procedures
Payment Options
Facility Funding
Facilities with Opioid Treatment Programs (OTPs)

This chapter outlines key characteristics of facilities and programs in 2008.

Facility Operation and Primary Focus

Table 4.1. Facilities were asked to designate the type of entity responsible for the operation of the facility. They were also asked to designate the facility’s primary focus of activity.

Type of Care Offered

Table 4.2. Type of care offered was made up of three broad categories (outpatient, residential (non-hospital, and hospital inpatient), each with several subcategories. A facility could offer more than one type of care. The proportions of all facilities offering the different types of care were:³

Almost three quarters (74 percent) of private non-profit facilities provided outpatient care and more than one third (35 percent) provided residential (non-hospital) care. In contrast, 90 percent of private for-profit facilities provided outpatient care and 13 percent provided residential (non-hospital) care.

Client Substance Abuse Problem and Co-occurring Mental Health Disorders

Table 4.3. Facilities were asked to estimate the proportions of clients in treatment for both alcohol and drug abuse, for alcohol abuse only, and for drug abuse only. They were also asked to estimate the proportion of clients with diagnosed co-occurring substance abuse and mental health disorders.

• Almost all facilities (92 percent) had clients in treatment for both alcohol and drug abuse on March 31, 2008. Eighty percent had clients in treatment for drug abuse only and 78 percent had clients in treatment for alcohol abuse only.
• Most facilities (88 percent) also had clients in treatment with co-occurring substance abuse and mental health disorders on March 31, 2008.

Facility Size

Table 4.4. Facility size, i.e., the median number of clients in substance abuse treatment at a facility on March 31, 2008, was 41 clients.

• The median number of clients ranged from 40 in facilities operated by private non-profit organizations and by tribal governments to 58 in facilities operated by the Federal government.
• By facility focus of activity, the median ranged from 20 clients in facilities providing mental health services to 45 in those providing substance abuse treatment services.
• By type of care, the median number of clients in treatment on March 31, 2008, was:

Table 4.5. Facilities were grouped into five groups of approximately equal number, based on the total number of clients in treatment on March 31, 2008.

• Facilities operated by the Federal government were generally larger than facilities operated by other entities—33 percent had 120 clients or more in treatment on March 31, 2008, compared to 21 percent of all facilities.
• Facilities whose primary focus was the provision of mental health services tended to be smaller than facilities with other foci of activity—­40 percent had fewer than 15 clients in treatment on March 31, 2008, compared to 20 percent of all facilities.

Facility Capacity and Utilization Rates

Facilities were asked to report the number of residential (non-hospital) and hospital inpatient beds designated for substance abuse treatment. Utilization rates were calculated by dividing the number of residential (non-hospital) or hospital inpatient clients by the number of residential (non-hospital) or hospital inpatient designated beds. Because substance abuse treatment clients may also occupy non-designated beds, utilization rates could be more than 100 percent.

Table 4.6. Some 3,201 facilities reported having 112,004 residential (non-hospital) beds designated for substance abuse treatment on March 31, 2008. The utilization rate⁴ was 92 percent, and ranged from 88 percent in facilities operated by private for-profit organizations to 117 percent in facilities operated by the Federal government.

Table 4.7. Some 788 facilities reported having 11,668 hospital inpatient beds designated for substance abuse treatment on March 31, 2008. The utilization rate⁵ was 85 percent, and ranged from 79 percent in facilities operated by private non-profit agencies to 130 percent in facilities operated by tribal governments. By facility focus, utilization rates ranged from 80 percent in facilities providing substance abuse treatment services to 103 percent in facilities providing mental health services.

Tables 4.6 and 4.7 and Figure 8 show the distribution of facility-level utilization rates for residential (non-hospital) beds and for hospital inpatient beds. Facilities with residential (non-hospital) beds had generally higher utilization rates than facilities with hospital inpatient beds. Fifty-nine percent of facilities with residential (non-hospital) beds had utilization rates of 91 to 100 percent or more, while 39 percent of facilities with hospital inpatient beds had utilization rates in that range.

⁴ Residential (non-hospital) utilization rates are based on a subset of 3,032 facilities that reported for themselves alone and that reported numbers greater than zero for both designated beds and clients.
⁵ Hospital inpatient utilization rates are based on a subset of 502 facilities that reported for themselves alone and that reported numbers greater than zero for both designated beds and clients.

Services Provided

Tables 4.8 and 4.9. Facilities were asked about the types of services they provided. Services were grouped into the six broad categories shown below.

• Assessment and pre-treatment services were offered by 98 percent of all facilities.
  • Screening for substance abuse was provided by 92 percent of all facilities.
  • Comprehensive substance abuse assessment or diagnosis was provided by 89 percent of all facilities.
  • Screening for mental health disorders was provided by 62 percent of all facilities; rates were higher in facilities providing mental health services (94 percent), facilities providing a mix of substance abuse treatment and mental health services (91 percent), and facilities providing general health care (81 percent).
  • Comprehensive mental health assessment or diagnosis was provided 43 percent of all facilities; rates were higher in facilities providing mental health services (87 percent) and facilities providing a mix of substance abuse treatment and mental health services (77 percent).
  • Outreach to persons in the community who may need treatment was provided by 50 percent of all facilities, but by 83 percent of tribal government-operated facilities.
• Testing services were provided by 87 percent of all facilities.
  • Drug or alcohol urine screening was provided by 83 percent of all facilities.
  • Breathalyzer or other blood alcohol testing was provided by 58 percent of all facilities, but by 77 percent of Federal government-operated facilities.
  • Testing for each of TB, HIV, hepatitis B and C, and STDs was provided by between 20 and 34 percent of all facilities, but by 82 to 84 percent of facilities providing general health care.
• Counseling was provided by 99 percent of all facilities.
  • Individual counseling was provided by 96 percent of all facilities.
  • Group counseling was provided by 92 percent of all facilities.
  • Family counseling was provided by 72 percent of all facilities, but by 81 percent of facilities providing a mix of substance abuse treatment and mental health services.
• Transitional services were provided by 96 percent of all facilities.
  • Discharge planning was provided by 92 percent of all facilities.
  • Aftercare/continuing care was provided by 81 percent of all facilities.
• Pharmacotherapies were provided by 46 percent of all facilities; rates were higher in facilities providing general health care (83 percent) and by Federal government-operated facilities (82 percent).
  • Medications for psychiatric disorders were most frequently available—in 34 percent of all facilities and in 78 percent of facilities providing general health care.
• Ancillary services were provided by 99 percent of all facilities.
  • Substance abuse education was provided by 94 percent of all facilities.
  • Case management services were provided by 77 percent of all facilities.
  • Mental health services were provided by 56 percent of all facilities; rates were higher in facilities providing mental health services (97 percent), facilities providing a mix of substance abuse treatment and mental health services (93 percent), facilities providing general health care (84 percent), and Federal government-operated facilities (76 percent).

Clinical/Therapeutic Approaches

Table 4.10. Facilities were asked to indicate whether they used any of 12 specific clinical/therapeutic approaches.

• Two approaches were each used always or often by more than three-quarters of facilities:
  • Substance abuse counseling was used always or often by 96 percent of facilities.
  • Relapse prevention was used always or often by 88 percent of facilities.
• A number of approaches were used at least sometimes (always, often, or sometimes) by more than half of facilities:
  • Cognitive-behavioral therapy was used at least sometimes by 90 percent of facilities.
  • Motivational interviewing was used at least sometimes by 84 percent of facilities.
  • Anger management was used at least sometimes by 84 percent of facilities.
  • Brief intervention was used at least sometimes by 82 percent of facilities.
  • 12-step facilitation was used at least sometimes by 81 percent of facilities.
  • Trauma-related counseling was used at least sometimes by 65 percent of facilities.
  • Contingency management/motivational incentives was used at least sometimes by 61
    percent of facilities.
• Approaches that were used rarely or never, or were unfamiliar to the respondent, for more than half of all facilities were:
  • Rational emotive behavioral therapy was used rarely or never by 43 percent of facilities, and was unfamiliar to an additional 8 percent of facilities.
  • The matrix model was used rarely or never by 43 percent of facilities, and was unfamiliar to an additional 24 percent of facilities.
  • Community reinforcement plus vouchers was used rarely or never by 70 percent of facilities, and was unfamiliar to an additional 16 percent of facilities.

Programs or Groups for Specific Client Types

Table 4.11. Facilities were asked about the provision of treatment programs or groups specially designed for specific types of client. Overall, 82 percent of facilities offered at least one special program or group to serve a specific client type.

Services in Sign Language for the Hearing Impaired and in Languages Other than English

Table 4.12. Facilities were asked about the provision of substance abuse treatment services in sign language for the hearing impaired. They were also asked whether treatment was provided in languages other than English, whether this treatment was provided by a staff counselor or by an on-call interpreter, and in what languages staff counselors provided treatment.

• Substance abuse treatment services in sign language for the hearing impaired were offered in 28 percent of all facilities. Facilities operated by local and State governments were most likely to offer these services (43 and 40 percent, respectively). By primary focus of activity, facilities providing mental health services or a mix of substance abuse treatment and mental heath services (39 and 35 percent, respectively) were the most likely to offer sign language.
• Substance abuse treatment services in languages other than English were provided in 43 percent of all facilities, ranging from 20 percent of Federal government-operated facilities to 54 percent of local government-operated facilities.
• In 44 percent of facilities providing a language other than English, a staff counselor provided the service; another 21 percent of facilities used both a staff counselor and an on-call interpreter.
• Facilities with staff counselors most frequently provided services in Spanish (93 percent), although 23 percent provided other languages. American Indian/Alaska Native languages were provided by 3 percent of these facilities overall, but by 98 percent of those operated by tribal governments and by 92 percent of those operated by the Indian Health Service.

Detoxification Services

Table 4.13. Facilities that provided detoxification services were asked to indicate whether they detoxified clients from specified substances, and whether medication was routinely used during detoxification.

Client Outreach

Table 4.14. Facilities were asked whether they operated a hotline responding to substance abuse problems and whether they had a website providing information about their substance abuse treatment programs.

• A hotline responding to substance abuse problems was operated by 22 percent of facilities overall. Hotline operation ranged from 13 percent among Federal government-operated facilities to 35 percent among local government-operated facilities.
• Websites providing information about a facility’s substance abuse treatment programs were maintained by 69 percent of all facilities. Website availability ranged from 36 percent among tribal government-operated facilities to 78 percent among private non-profit facilities.

Facility Licensing, Certification, or Accreditation

Facilities were asked to report licensure, certification, or accreditation by specified agencies or organizations. These included the State substance abuse agency, State mental health department, State public health department or board of health, hospital licensing authority, the Joint Commission, CARF, NCQA, COA, and other State or local agency or organization.⁷

• Table 4.15. Overall, 95 percent of all facilities reported that they were licensed, certified, or accredited by one or more agencies or organizations. The proportions of facilities reporting the specified agencies or organizations were:

  State substance abuse agency State public health department/board of health State mental health department Hospital licensing authority Joint Commission CARF COA NCQA Another State or local agency or other organization

  82 percent 41 percent 34 percent 7 percent 21 percent 20 percent 5 percent 3 percent 12 percent

  
  
• Table 4.16. Facility licensing, certification, or accreditation was associated with the type of care offered.
  • The State substance abuse agency licensed, certified, or accredited 82 percent each of facilities offering outpatient treatment and residential (non-hospital) treatment, but only 56 percent of facilities offering hospital inpatient treatment.
  • The State mental health department licensed, certified, or accredited 46 percent of hospital inpatient facilities but only 36 percent of outpatient facilities and 26 percent of residential (non-hospital) facilities.
  • Facilities offering hospital inpatient treatment were more likely than facilities offering other types of care to report licensure, certification, or accreditation by the following

Facility Standard Operating Procedures

Table 4.17. Facilities were asked to indicate whether they followed specified practices as part of their standard operating procedure. Almost all the standard practices listed were used by 80 percent or more of all facilities.

• The proportions of facilities reporting use of the specified standard practices were:

Payment Options

Table 4.18. Facilities were asked to indicate whether they accepted specified payment or insurance options for substance abuse treatment. They were also asked about use of a sliding fee scale and whether they offered treatment at no charge to clients who could not pay.

• The proportions of all facilities reporting acceptance of specific payment options were:

• Facilities operated by Federal and tribal governments were least likely to accept cash or self-payment (39 and 42 percent, respectively). Private for-profit and Federal government-operated facilities were less likely to accept Medicare, Medicaid, and State-financed health insurance than were facilities operated by private non-profits and State and local governments.
• Acceptance of Access to Recovery vouchers was reported by 14 States. The proportion of facilities accepting Access to Recovery vouchers ranged from 11 percent in California to 62 percent in Idaho [Table 6.20].
• Use of a sliding fee scale was reported by 62 percent of all facilities, ranging from 15 percent of facilities operated by the Federal government to 82 percent of facilities operated by local governments.
• Treatment at no charge was offered by 52 percent of all facilities, ranging from 23 percent of private for-profit facilities to about 76 percent of facilities operated by Federal and State governments.

Facility Funding

Table 4.19. Facilities were asked about agreements or contracts with managed care organizations for the provision of substance abuse treatment services, and whether they received Federal, State, or local government funds or grants to support their substance abuse treatment programs.

• About half of all facilities (49 percent) reported that they had agreements or contracts with managed care organizations for the provision of substance abuse treatment services. In general, private non-profit and private for-profit organizations were more likely to have such agreements or contracts (52 and 50 percent, respectively) than were government-operated facilities (43 percent or less). Facilities that provided a mix of substance abuse treatment and mental heath services or provided mental health services were most likely to have agreements or contracts with managed care organizations (58 and 55 percent, respectively).
• Overall, 59 percent of facilities reported receiving government funds to support substance abuse treatment programs. The proportions were highest in facilities operated by local and State governments (86 and 82 percent, respectively). Seventy-three percent of programs operated by non-profit organizations reported receiving public funds compared to 21 percent of facilities operated by for-profit organizations.

Facilities with Opioid Treatment Programs (OTPs)

Opioid Treatment Programs (OTPs) are certified by SAMHSA to provide medication-assisted therapy in the treatment of opioid addiction. Currently, methadone and buprenorphine are the only opioid medications approved for the treatment of opioid addiction.

• Tables 2.3 and 3.2. Clients receiving methadone or buprenorphine in OTPs accounted for 24 percent of all clients in treatment on March 31, 2008, although OTPs were available in only 1,132 (8 percent) of all substance abuse treatment facilities.
• Tables 4.1 and 4.20. Private for-profit organizations operated 49 percent of OTPs, but operated only 29 percent of all substance abuse treatment facilities.
• Table 4.20. Of the 272,351 clients receiving medication-assisted opioid therapy in OTPs, 98 percent (268,071) received methadone. Of the 15,732 clients receiving buprenorphine, 73 percent received it in facilities that were not OTPs.
• More than half (52 percent) of clients receiving methadone were in private for-profit facilities compared to 38 percent of clients receiving buprenorphine. Most (92 percent) of clients receiving methadone were in facilities whose primary focus was the provision of substance abuse treatment services.
• Clients receiving buprenorphine were more likely than those receiving methadone to be in private non-profit facilities (46 vs. 38 percent) or in Federal government-operated facilities (9 percent vs. 1 percent).
• Facilities whose primary focus was the provision of substance abuse treatment services accounted for 59 percent of buprenorphine clients. Nearly one-third (32 percent) of buprenorphine clients were treated in facilities providing a mix of substance abuse treatment and mental health services.
• Table 4.21. Most facilities with OTPs offered outpatient treatment (92 percent). Eighty-nine percent offered outpatient methadone/buprenorphine maintenance and 47 percent offered detoxification.
• Table 4.22. OTPs were more likely than all facilities combined [Table 4.16] to be licensed, certified, or accredited by a State public health department or board of health (59 vs. 41 percent), by the Joint Commission (32 vs. 21 percent) or CARF (63 vs. 20 percent).

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