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)
Counseling offered by Facilities

This chapter outlines key characteristics of facilities and programs in 2009.

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 4.2b. 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:¹¹

Almost three quarters (74 percent) of private non-profit facilities provided outpatient care and more than one third (34 percent) provided residential (non-hospital) care. In contrast, 92 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, 2009. Eighty-one percent had clients in treatment for drug abuse only, and 79 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, 2009.
  

Facility Size

Table 4.4. Facility size, that is, the median number of clients in substance abuse treatment at a facility on March 31, 2009, was 42 clients.

• The median number of clients ranged from 31 in facilities operated by tribal governments to 65 in facilities operated by the Federal government.
• The median number of clients ranged from 20 clients in facilities with a primary focus of mental health services to 45 in those with a primary focus of providing substance abuse treatment services.
• By type of care, the median number of clients in treatment on March 31, 2009, was:
  

Table 4.5. Facilities were sorted into five size groups based on the total number of clients in treatment on March 31, 2009. The smallest facilities were defined as having fewer than 15 clients and the largest as having 120 clients or more.

• Facilities operated by the Federal government were generally larger than facilities operated by other entities—37 percent had 120 clients or more in treatment on March 31, 2009, compared to 22 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—41 percent had fewer than 15 clients in treatment on March 31, 2009, compared to 19 percent of all facilities.

Facilities operated by the Federal government were generally larger than facilities operated by other entities—37 percent had 120 clients or more in treatment on March 31, 2009, compared to 22 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 3,248 facilities reported having 110,795 residential (non-hospital) beds designated for substance abuse treatment on March 31, 2009. The utilization rate¹² was 89 percent, and ranged from 82 percent in facilities operated by tribal government to 96 percent in facilities operated by the Federal government.

Table 4.7. Some 743 facilities reported having 12,829 hospital inpatient beds designated for substance abuse treatment on March 31, 2009. The utilization rate¹³ was 84 percent, and ranged from 75 percent in facilities operated by local governments to 113 percent in facilities operated by the Federal government. By facility focus, utilization rates ranged from 73 percent in facilities primarily focused on general health care to 289 percent in facilities focused on other types of services.

Tables 4.6 and 4.7 and Figure 7 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. Forty-eight percent of facilities with residential (non-hospital) beds had utilization rates of 91 to 100 percent, while 24 percent of facilities with hospital inpatient beds had utilization rates in that range.

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 93 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 primarily focused on mental health services (94 percent), facilities with a mixed focus of substance abuse treatment and mental health services (90 percent), and facilities primarily focused on general health care (85 percent).
  • Comprehensive mental health assessment or diagnosis was provided by 42 percent of all facilities; rates were higher in facilities primarily focused on mental health services (89 percent) and facilities with a mixed focus of substance abuse treatment and mental health services (76 percent).
  • Outreach to persons in the community who may need treatment was provided by 51 percent of all facilities but by 81 percent of tribal government-operated facilities.
  • Interim services for clients when immediate admission was not possible was provided by 40 percent of all facilities, but it was about 71 percent for Federal government 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 59 percent of all facilities but by 81 percent of Federal government-operated facilities.
  • Testing for each of TB, HIV, hepatitis B and C, and STDs was provided by between 19 and 34 percent of all facilities but by 80 to 84 percent of facilities providing general health care.
• Counseling was provided by 99 percent of all facilities.
  • Individual counseling was provided by 97 percent of all facilities.
  • Group counseling was provided by 93 percent of all facilities.
  • Family counseling was provided by 74 percent of all facilities but by 83 percent of facilities with a mixed focus 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 47 percent of all facilities; rates were higher in facilities primarily focused on general health care (83 percent) and by Federal government-operated facilities (83 percent also).
  • Medications for psychiatric disorders were most frequently available—in 34 percent of all facilities and in 77 percent of facilities primarily focused on general health care.
• Ancillary services were provided by 99 percent of all facilities.
  • Substance abuse education was provided by 95 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 with a primary focus of mental health services (98 percent), facilities providing a mixed focus of substance abuse treatment and mental health services (92 percent), and facilities with a primary focus of general health care (81 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 nearly all facilities:
  • Substance abuse counseling was used always or often by 96 percent of facilities.
  • Relapse prevention was used always or often by 87 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 91 percent of facilities.
  • Motivational interviewing was used at least sometimes by 85 percent of facilities.
  • Anger management was used at least sometimes by 83 percent of facilities.
  • Brief intervention was used at least sometimes by 80 percent of facilities.
  • 12-step facilitation was used at least sometimes by 79 percent of facilities.
  • Trauma-related counseling was used at least sometimes by 65 percent of facilities.
  • Contingency management/motivational incentives were used at least sometimes by 60 percent of facilities.
• Some approaches were used rarely or never, or were unfamiliar to the respondent, for more than half of all facilities:
  • Rational emotive behavioral therapy was used rarely or never by 43 percent of facilities, and it was unfamiliar to an additional 8 percent of facilities.
  • The matrix model was used rarely or never by 43 percent of facilities, and it was unfamiliar to an additional 20 percent of facilities.
  • Community reinforcement plus vouchers was used rarely or never by 72 percent of facilities, and it was unfamiliar to an additional 14 percent of facilities.
    

Programs or Groups for Specific Client Types

Table 4.11b. Facilities were asked about the provision of treatment programs or groups specially designed for specific types of client. Overall, 81 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 4.12b. Facilities were asked about the provision of substance abuse treatment services in sign language for the hearing impaired. They were also asked if treatment was provided in languages other than English, if 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 27 percent of all facilities. Facilities operated by local and State governments were most likely to offer these services (45 and 39 percent, respectively). Facilities with a primary focus of mental health services or a mixed focus of substance abuse treatment and mental heath services (39 and 33 percent, respectively) were the most likely to offer services in sign language.
• Substance abuse treatment services in languages other than English were provided in 43 percent of all facilities, ranging from 21 percent of Federal government-operated facilities to 52 percent of local government-operated facilities.
• In 46 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.
• Of those facilities where language services were provided by staff counselors, the most frequently provided services were in Spanish (94 percent of facilities), although 22 percent provided other languages. Services in American Indian/Alaska Native languages were provided by 3 percent of these facilities overall but by 89 percent of those operated by tribal governments and by 100 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

Tables 4.14 and 4.9. Facilities were asked whether they had a website providing information about their substance abuse treatment programs.

• Websites providing information about a facility’s substance abuse treatment programs were maintained by 73 percent of all facilities. Website availability ranged from 39 percent among tribal government-operated facilities to 81 percent among private non-profit facilities.
• Outreach to persons in the community who may need treatment was provided by 51 percent of all facilities but by 81 percent of tribal government-operated 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 department of health, hospital licensing authority, the Joint Commission, CARF, NCQA, COA, and other State or local agency or organization.¹⁵

Table 4.15b. 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:

Table 4.16b. 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 58 percent of facilities offering hospital inpatient treatment.
• The State mental health department licensed, certified, or accredited 46 percent of hospital inpatient facilities but only 37 percent of outpatient facilities and 25 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 4.17b. Facilities were asked to indicate whether they followed specified practices as part of their standard operating procedure. All the standard practices listed were used by two-thirds or more of all facilities.

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

Payment Options

Table 4.18b. Facilities were asked to indicate whether they accepted specified types of payment or insurance for substance abuse treatment. They were also asked about use of a sliding fee scale and if 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 45 percent, respectively). Private for-profit and Federal government-operated facilities were less likely to accept Medicare, Medicaid, or State-financed health insurance than were facilities operated by private non-profits and State or local governments.
• Acceptance of Access to Recovery vouchers was reported by 14 States. The proportion of facilities accepting Access to Recovery vouchers ranged from 9 percent in Florida to 52 percent in Idaho [Table 6.19]¹⁶.
• Use of a sliding fee scale was reported by 62 percent of all facilities, ranging from 16 percent of facilities operated by the Federal government to 83 percent of facilities operated by local governments.
• Treatment at no charge for persons who cannot afford to pay was offered by 52 percent of all facilities, ranging from 23 percent of private for-profit facilities to 83 percent of facilities operated bytribal governments.

Facility Funding

Table 4.19. Facilities were asked if they received Federal, State, or local government funds or grants to support their substance abuse treatment programs.

• Overall, 60 percent of facilities reported receiving government funds to support substance abuse treatment programs. The proportions were highest in facilities operated by local or tribal governments (both about 89 percent). Seventy-four percent of programs operated by non-profit organizations reported receiving public funds compared to 23 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, 3.2 and 4.20. Clients receiving methadone or buprenorphine in OTPs accounted for 24 percent of all clients in treatment on March 31, 2009, although OTPs were available in only 1,239 (9 percent) of all substance abuse treatment facilities.
• Tables 4.1 and 4.20. Private for-profit organizations operated 50 percent of OTPs but only 29 percent of all substance abuse treatment facilities.
• Table 4.20. Of the 290,316 clients receiving medication-assisted opioid therapy in OTPs, 98 percent (284,608) received methadone. Of the 24,173 clients receiving buprenorphine, 76 percent (18,465 clients) received it in facilities that were not OTPs.
  • More than half (54 percent) of clients receiving methadone were in private for-profit facilities compared to 34 percent of clients receiving buprenorphine. Most (93 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 (52 vs. 37 percent) or in Federal government-operated facilities (7 vs. 2 percent).
  • Facilities whose primary focus was the provision of substance abuse treatment services accounted for 52 percent of all buprenorphine clients. Thirty-nine percent of all buprenorphine clients were treated in facilities providing a mix of substance abuse treatment and mental health services.
• Table 4.21b. Most facilities with OTPs offered outpatient treatment (90 percent). Eighty-five percent offered outpatient methadone/buprenorphine maintenance and 49 percent offered detoxification.
• Table 4.22b. 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 (58 vs. 41 percent), the Joint Commission (33 vs. 20 percent), or CARF (61 vs. 22 percent).

Counseling offered by Facilities

Table 4.23. Individual counseling was the most frequently reported form of counseling, by 96 percent of facilities and marital/couples counseling was reported least frequently, by 48 percent of facilities.

⁹ Data for the Federal agencies specified in the survey (the Department of Veterans Affairs, the Department of Defense, the Indian Health Service, and other unspecified Federal agencies) are detailed in the tables.
¹⁰ Percentages do not sum to 100 Percent because of rounding.
¹¹ Facility percentages sum to more than 100 percent because a facility could provide more than one type of care.
¹² Residential (non-hospital) utilization rates are based on a subset of 3,100 facilities that reported for themselves alone and that reported numbers greater than zero for both designated beds and clients.
¹³ Hospital inpatient utilization rates are based on a subset of 499 facilities that reported for themselves alone and that reported numbers greater than zero for both designated beds and clients.
¹⁴ Facilities treating incarcerated persons only were excluded from this report; see Chapter 1.
¹⁵ Joint Commission: formerly JCAHO (Joint Commission on Accreditation of Healthcare Organizations); CARF: formerly Commission on Accreditation of Rehabilitation Facilities; NCQA: National Committee for Quality Assurance; and COA: Council on Accreditation.
¹⁶ Available only in AK, AZ, CA, CO, CT, DC, FL, HI, IA, ID, IL, IN, LA, MI, MO, MT, NJ, NM, OH, OK, RI, TN, TX, WA, WI, and WY. See table 6.19a for number of facilities accepting ATRs by State.

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