Abstract
This article describes the experience and outcomes of the National Institute on Drug Abuse–funded Criminal Justice Drug Abuse Treatment Studies 2 Improving Best Practices in Assessment and Case Planning for Offenders protocol in the state of New Jersey. The protocol was designed to test the effectiveness of an Organizational Process Improvement Intervention in improving four assessment and case planning domains for drug-involved offenders in correctional settings transferring to community treatment based agencies. This article describes the protocol and the change team model process through which correctional and community agency staff collaborated to improve assessment and case planning for offenders with substance abuse problems. The primary goal of these collaborative efforts was to link information across stages of the treatment continuum to improve service coordination. Data taken from qualitative interviews with agency participants are used to illustrate the common themes that emerged relating to the intervention process, barriers to implementing developed goals, and facilitative factors that contributed to successes. The findings from the current study provide indication that organizational process improvement strategies can be implemented within a correctional setting to reduce interorganizational barriers and to facilitate improvements in the continuum of care involved in the treatment of offenders with histories of substance abuse.
Introduction
Substance abuse treatment programming within the field of corrections is a complex, and often multiagency process that begins when an individual is first processed into the correctional system and continues through the individual’s period of incarceration and their release into the community under correctional supervision. Ideally, the assessment, case planning, and service referral processes would be interconnected, with agencies engaging in ongoing communication and collaboration to ensure a seamless “continuum of care” for individuals in need of substance abuse services, thus ensuring the highest potential for successful outcomes. However, in reality, this treatment continuum is often a fragmented path as a result of limited resources, communication barriers, and underdeveloped interagency relationships, resulting in repeated assessments, poor delivery and receipt of information between agencies, and less-than-ideal progression of treatment services for the clients.
In response to this need for greater service coordination between prison-based treatment programs and community treatment providers, The National Institute on Drug Abuse (NIDA) initiated a multisite national cooperative study in 2008 called the Criminal Justice Drug Abuse Treatment Studies 2 (CJ-DATS2). This research cooperative was tasked with the goal of identifying and improving common intra- and interorganizational barriers to the implementation of evidence-based practices (EBPs) delivered to offenders in prison and community-correctional settings (Ducharme, Chandler, & Wiley, 2013). One of the primary areas of need identified by NIDA and the CJ-DATS2 cooperative was to evaluate and target for improvement gaps in the correctional system involving the assessment and case planning process of offenders in need of substance abuse treatment.
The overall purpose also included improving service coordination between prison-based treatment programs and community treatment providers. 1 The CJ-DATS2 cooperative developed a protocol specifically aimed at interagency collaboration and communication using an Organizational Process Improvement Intervention (OPII). This protocol was a multisite 2 cluster randomized design. For each site, a state correctional agency was partnered with a research center that could facilitate and evaluate the intervention’s process and outcomes. Findings presented in this article come from the partnership between the Center for Drug and Alcohol Studies (CDAS) at the University of Delaware and the New Jersey Department of Corrections (NJDOC).
This intervention utilized the development of local change teams (LCTs) consisting of staff and supervisors from correctional and community-based agencies that are involved in the treatment continuum. These LCTs were to implement a process improvement strategy addressing potential gaps/needs in four assessment and case planning domains: (a) measurement and instrumentation, (b) integration with case plan, (c) conveyance and utility, and (d) service activation. For each site, the LCT was required to develop a 12-month improvement strategy that consisted of four phases: Needs Assessment, Process Improvement Planning, Implementation, and Follow-Up/Sustainability. The goal of the Implementation Phase was to carry-out process improvement goals identified and targeted for change during the Needs Assessment and Process Improvement Phases with the Follow-Up/Sustainability Phase directed at how to best maintain these changes beyond the 12-month intervention process. In terms of evaluation, the overall goal of the intervention was to determine whether the LCT process could influence the improvement in one or more of the four assessment- and case planning domains. This was done by examining the successful completion of intervention objectives, a review of offender case plans, and through quantitative surveys and qualitative interviews administered to LCT members, their supervisors, and clinical line-staff associated with this treatment process. The current article focuses on the responses from qualitative interviews of LCT members and the research center facilitator.
This article describes some of the characteristics of the NJDOC and the treatment of offenders with problems of substance abuse, key issues relating to the treatment continuum between prison-based and community aftercare services, processes regarding the assessment and case planning of these offenders, an overview of the intervention process and LCT goals and accomplishments, as well as other key findings associated with the CJ-DATS2 study as it occurred in New Jersey. In addition, this article touches on some of the issues pertaining to the sustainability of implementation efforts beyond duration of the initial intervention.
Background of Clinical Assessment Process in Criminal Justice Settings
Screening and assessment are important processes within a correctional setting when it comes to determining which inmates are in need of substance abuse treatment (Shafer et al., 2014). It is vital, therefore, that valid and reliable measurement and instrumentation are used when screening these inmates and that appropriate treatment services are linked to an inmate’s treatment needs. Despite the wide availability of several valid and reliable screening instruments (e.g., Addiction Severity Index, Global Appraisal of Individual Needs, Level of Severity Inventory-Revised), there is little known regarding how widely implemented these instruments are within the correctional field, or how successful implementation of these instruments could be used to increase treatment effectiveness (Peters & Wexler, 2005). Proper implementation of these assessment instruments not only serves to identify the characteristics associated with an inmate’s substance abuse issues but also helps to increase the efficient use of scarce treatment resources by treating only those who exhibit a true need. In spite of the importance of proper assessment and screening, one recent study suggests that only around 58% of all prisons, jails, and community corrections agencies use a standardized assessment instrument (Taxman, Crospey, Yount, & Wexler, 2007).
Many inmates, once released from prison, receive additional aftercare services. Although traditionally considered a part of the postrelease transition to the community, there is typically little guidance and coordination of assessment and treatment services between the correctional and community treatment agencies. These deficiencies include areas such as the processes of assessment, service planning, and service delivery for offenders (Belenko & Peugh, 2005; Taxman, Cropsey, Young, & Wexler, 2007; Taxman, Perdoni, & Harrison, 2007). Advancements in the assessment process for offender’s transitioning to the community would help to improve access to scarce resources, better tailoring of an offender’s treatment needs to services, and ultimately to increase the effectiveness of substance abuse treatment services in reducing relapse and recidivism. Furthermore, these more effective assessment processes could help improve service coordination between correctional and treatment agencies (Grella & Greenwell, 2007; Pelissier et al., 2000).
Substance Abuse Treatment of Inmates in the NJDOC
Like many other states, the NJDOC is faced with the problem of substance abuse and addiction among the inmate population. As of 2013, the total number of inmates was just over 23,000. This number includes both inmates currently held within a prison setting as well as those who have been released under supervision into the community (i.e., halfway houses). While approximately 20% of all Department of Corrections inmates have been committed for a narcotics law violation (e.g., possession, sale, and distribution), the number in need of substance abuse treatment is likely much higher.
The structure of substance abuse treatment of the inmate in the NJDOC system represents a “continuum of care” model focusing on the staged recovery of offenders (see Figure 1). The first step of this process begins at the Central Reception and Assignment Facility (CRAF) where initial screening is done with each inmate to determine the potential need for substance abuse treatment. The NJDOC currently contracts 1,376 therapeutic community (TC) beds in eight different programs, located in six different correctional facilities throughout the state. Those individuals identified with a substance abuse problem generally begin their treatment in one of these prison-based TCs. In terms of community aftercare, offenders begin this transition when they are released to a Community Assessment and Treatment Center (CATC) where their need for community-based aftercare is evaluated. If further treatment is required, inmates are released to one of the state-licensed Residential Community Release Programs (RCRPs; for example, halfway houses) that specialize in intensive substance use disorder treatment.
NJDOC drug treatment continuum.
The responsibility for overseeing this treatment process (i.e., prison-based to community aftercare) is shared between the Office of Substance Abuse Programming and Addiction Services (hereafter referred to as the “Office of Addiction Services” for brevity) and the Office of Community Programs—both of which are subunits of NJDOC. The Office of Addiction Services is charged with screening all NJDOC jurisdictional offenders for level and severity of addiction and making appropriate referrals. Staff members are specifically trained to conduct assessments and carry-out screening interviews at CRAF and other intake facilities. The mission of Office of Community Programs is to prepare offenders to reenter society as productive citizens and to reduce the likelihood that they will relapse. To that end, the office contracts with private, not-for-profit agencies and provides oversight of these contracts.
Assessment and Case Planning in New Jersey
Throughout the continuum of care, there are multiple points of assessment, case planning, and service coordination, with the ultimate goal of creating a seamless transition between the stages of treatment for the inmate. Inmates are assessed for problems of substance abuse at various stages throughout the duration of their correctional supervision. As mentioned in the preceding section, the first stage occurs during intake at CRAF where staff from Office of Addiction Services administers an initial screening. This information is used to identify which inmates are eligible for in-prison TC treatment—those so identified are transferred to prison facilities which offer these programs. Within 12 months of release from prison, inmates who were identified during intake as having a substance abuse problem are referred from the general prison population to one of the in-prison TCs for additional screening and admission. Those admitted to the TCs are eventually released after a period of 9 to 12 months of treatment to a CATC. Within a period of 2 to 3 months, the CATC administers measurement and assessment instruments to determine what types of community-based aftercare services are warranted. Those offenders in need of additional aftercare services for substance abuse are then moved to one of the halfway houses which specialize in this type of treatment.
In terms of case planning, inmates who enter a prison-based TC will receive a Master Treatment Plan which specifies the types of services and treatment needs rated in terms of priority. This treatment plan is created using information collected from the assessment and measurement instruments administered to inmates, a review of the offender’s case file, and through consultation with inmates by clinical staff. Similarly, the CATC that receives an inmate upon discharge from the in-prison TC (and before entering community supervision; for example, halfway houses) develops a Master Treatment Plan (which will be utilized by the halfway houses). This treatment plan is based on background treatment assessment and treatment progress reports from the in-prison TC, additional assessments completed at the CATC, and through an interview with the offender by the clinical staff. Upon discharge to a halfway house, the Master Treatment Plan developed by the CATC is forwarded to Office of Community Programs along with other important documentation.
With regard to service coordination (i.e., information about treatment shared across treatment providers involved in the continuum of care), Office of Community Programs is chiefly responsible for collecting this information and organizing it into a treatment file kept for each offender. Once this information is collected, the Office of Community Programs transfers a copy of the file to the agency involved in the next subsequent stage of treatment. The primary purpose of sharing this information across treatment sites relates to the idea of a continuum of care model and the view that substance abuse treatment is a staged progression of recovery.
The Current Study
As mentioned in the introduction, the CJ-DATS2 project was initiated by NIDA for the purposes of evaluating and targeting for improvement gaps in the correctional system involving the assessment and case planning process of offenders in need of substance abuse treatment. This was an organizational-level implementation study, meaning that the primary focus was to improve both intra- and interorganizational practices in the delivery of these services involving inmates transferring between prison-based and community treatment. There were nine research centers paired each with a state-level criminal justice system. The focus of the current paper is the University of Delaware’s CDAS and their partnership with NJDOC and the subunit of this organization maintaining a large responsibility for substance abuse treatment in the state—The Office of Addiction Services. Other agencies also participating in New Jersey were selected prisons, each of the treatment agencies involved in the continuum of care, the Office of Community Programs, the New Jersey State Parole Board, and the New Jersey Intensive Supervision Program. New Jersey was selected as CDAS’ partner site because of Department of Corrections’ strong support of a research-based continuum of care approach to address offender addiction issues.
While a short description of the OPII and the CJ-DATS2 study design is discussed here, please refer to a published protocol by Shafer et al. (2014) for more detail. The design of the OPII was drawn from Proctor’s model of implementation research that differentiates between intervention strategies, implementation strategies, and three levels of outcomes (implementation, services, and client; Proctor et al., 2009). Within this model, it is believed that implementation strategies can be aimed at five levels of the service delivery environment (individual providers, supervisory practices, group learning, organization, and systems environments) and can occur individually or in conjunction. In line with the Proctor model, the EBP targeted within this study was improvement of assessment and case planning procedures, and the implementation strategy was an approach employing a LCT. Guided by a facilitator, the LCT proceeded through a systematic process improvement protocol with the aim of bringing about improvements in assessment and case planning within correctional settings.
Method
LCTs
The CJ-DATS2 project in New Jersey utilized two separate LCTs, consisting of 8 to 12 active members per team (periodically, members would leave due to changes in employment and therefore replacement members would be recruited). Each of these LCTs included criminal justice and treatment agencies involved in prison-based TCs and RCRPs affiliated with two state correctional institutions. The individuals appointed to serve on the LCTs included individuals with a direct responsibility for the assessment, case planning, transitioning, and community-based treatment planning functions for reentering offenders, as well as individuals in managerial and/or supervisory roles associated with these tasks. The duties of the LCT members included (a) working with the Facilitator and Researcher to complete a Needs Assessment Report during the first phase of the intervention; (b) assuming primary responsibility for using the results of the Needs Assessment to develop the Process Improvement Plan; (c) assuming primary responsibility for implementing the Process Improvement Plan; (d) communicating regularly with the LCT facilitator, researchers, and other stakeholders regarding the progress of the LCT; and (e) working with the facilitator and researchers to prepare progress reports throughout the intervention.
Data Collection
During the course of the intervention, there were extensive data collection efforts to track the progress of the change teams, identify strengths and barriers, as well as to assess whether the goals developed by the change teams were addressing the needs of the staff members at the various agencies involved in the project. Data were collected through the use of surveys, case file evaluations, and qualitative interviews conducted at various points throughout the study beginning at baseline through the end of the follow-up phase. Participants included the change team members, supervisors of these change team members at their respective agencies, as well as agency staff such as counselors and unit supervisors. While the protocol involved the formation of two change teams (whose intervention start times were staggered, defining one team the “early start site” and the other as the “late start site”), the change teams goals, experiences with the intervention process, successes, and barriers were highly similar. In addition, both change teams had members who served on each of the change teams, which may have also contributed to the similarity between the two teams in their process and outcomes. The only notable difference between the teams is the fact that one of the change teams had preexisting relationships among the agencies and personnel involved due to collaboration on a separate, but similar project. Due to these similarities and member overlap between the teams, the two change teams will be discussed together when reporting on the findings from the intervention process and outcomes. The current article focuses on the findings from the qualitative interviews conducted with LCT members, their supervisors, and the research center facilitator.
Qualitative Interviews
In addition to the surveys and the case file evaluations, qualitative interviews were conducted at the end of the Process Improvement Planning and Implementation phases, and at the end of the Follow-Up phase. At each data collection point, interviews were conducted with four of the change team members (with at least one of those four being the change team leader) from each site, as well as the facilitator for the change teams. In addition, treatment directors and two staff were also asked to complete interviews at the end of the implementation stage for a total of 24 interviews across the change teams and data collection points (It should be noted that one change team did not complete the follow-up phase, and therefore members were not interviewed from that team at that particular data collection point). The interviews were structured and consisted of a set of questions intended to assess the participants’ experience and perception of the change team goals, the process of working together to achieve the goals, and to identify the strengths and limitations of the change team and their collaborative efforts. Interviews lasted approximated 15 to 25 min in length and were audio-recorded and later transcribed and coded for common themes.
Data Analysis
All data collected from surveys and the case file evaluations were entered into both separate and merged databases using SPSS statistical software. Due to the low number of responses for most surveys (particularly those administered to change team member supervisors and agency staff), inferential analyses are not appropriate. Therefore, the findings reported in the current article are taken from the qualitative data that were collected and analyzed. Qualitative interviews were transcribed by trained graduate and undergraduate students into word document files which were later uploaded to qualitative analysis software for coding purposes. One member of the research team was responsible for analyzing and coding the transcribed interviews. This individual had substantial prior experience with qualitative analysis including the use of qualitative software and the development and use of coding frames for analysis. An initial sample of five interviews (representing both change teams and each of the three data collection points in which interviews were conducted) were analyzed to develop an initial coding frame that was then used to analyze and code the remaining 19 interviews. While only one member of the research team engaged in the coding process, other members of the team were consulted regarding the coding frame that was developed and feedback was used to further refine the codes used prior coding the remaining transcribed interviews. Quotes from particular interviews were selected to present in the results section due to their representativeness of larger patterns or themes that were found across interviews, as well as their illustrative and articulate descriptions of those themes. In other words, the quotes were not selected randomly from all the available coded transcription segments, but were purposefully chosen because they were the most representative and illustrative of the common themes found in the qualitative analysis. Some of the quotes selected have been edited to enhance readability, and as such, expressions such as “um,” “uh,” and “you know,” and redundant wording have been removed. In addition, quotes are only identified by whether the comments were made by a change team member or the change team facilitator. This is done to maintain confidentiality and protect the identities of specific agencies and agency staff.
Results
The presentation of results from this study is divided into two separate categories: (a) evidence of completion by LCTs with reference to stated goals and objectives and (b) evaluation of the overall impact of the OPII on change team members and their respective agencies. Dividing results into these two broad categories provides perspective on both the utility of change teams in a correctional setting as well as the substantive responses of individuals involved in this process. In terms of the former, results will be presented in general terms as not to compromise the integrity of the actual working processes within the respective agencies.
Summary of Goals, Objectives, and Evidence of Completion
Both change teams developed between three and six goals with multiple action items within each of the broader goals. The type and complexity of goals ranged from relatively simple changes requiring only minor policy redirectives to changes requiring much more involvement and action by LCT members and their respective agencies. As a requirement of the intervention, the change teams’ goals addressed shortcomings in the continuum of care for substance abuse within the four domains of (a) measurement and instrumentation, (b) integration with case plan, (c) conveyance and utility, and (d) service activation. They were not required to develop goals that address all four of the domains, and as such, the change teams’ goals largely targeted the domains of “conveyance and utility” and “measurement and instrumentation.” The largest area of concern identified by both changes teams during the process improvement planning phase was the exchange of information and communication within and across agencies involved in the continuum of care. As a result, all of the goals developed by the change team address some aspect of information sharing, whether it is access or delivery of particular assessment instruments or reports, or the development of strategies for cross-agency communication and apprising staff of the functions of each of the agencies that precede and follow their particular agency within the continuum of care. Table 1 lists the change team goals developed during the Process Improvement Planning phase as a result of the Needs Assessment phase used to identify particular gaps within the NJDOC continuum of care. Table 1 also indicates which of the four domains each goal addresses as well as the final implementation status of the goal. Progress toward the implementation of these goals was measured through the survey responses collected during the implementation and follow-up phases, evidence of changes (or lack thereof) related to LCT goals found in the review of case files, and responses provided during the qualitative interviews where respondents were directly asked to what extent each of the team’s goals were implemented.
List of LCT Goals Developed During Process Improvement Planning Phase.
Note. LCT = local change team; TC = therapeutic community.
Of these eight goals developed by the change team, only three were fully implemented (Goals 1, 6, and 7), with partial implementation of four goals (Goals 2, 3, 5, and 7), and one goal (Goals 4) that was unable to be started due to its reliance on the completion of Goals 1 through 3, only one of which was fully implemented. Factors involved in the success and limitations of goal completion were the focus of participant interviews which are discussed in the next section.
Success of the intervention
While only three of the eight goals developed by the change teams were considered fully implemented, four other goals achieved partial implementation, resulting in substantial efforts to improve agency collaboration and address gaps within the continuum of care. First, change teams made arrangements and carried out focus groups and training sessions to provide participating agencies and staff information about each agency’s role in the stages of recovery and how assessment may be used to identify which stage of the recovery process an offender is in. In addition, change team members developed an in-service training video that provided information about each agency’s role in the stages of recovery. The change teams thought that this video could be shown to new staff to educate them on their particular role within the continuum of care as well as inform them about the sources of information they receive from agencies earlier in the continuum and what information they need to provide to the later stage agencies. These activities required a great deal of communication and information sharing between agencies at a level not achieved prior to participation in this intervention (with the exception of those who had preexisting relationships due to their involvement in a residential treatment system). The value of these activities was described by interviewees during the planning and implementation phases of the intervention. As one LCT member stated,
You know, just for me- and for my facility, I think it’s been a very positive process. In the way that I got to sit down with members of each part of the process from start to finish that a resident goes through, or an inmate goes through. So it has been beneficial because it has sparked ideas in me ’cause I can say? “okay, well that’s done at step three in the process.” So I can kind of use that information on my end and, and pass it onto the next step after they use my facility. So, it has been good to kind of get everybody together and really discuss what works and what doesn’t work . . . So the honesty of the change team members once we got to know each other and understood the process I think the communication between us all really, at least for me, sparked a lot of talk as to this might work better for our process. (Change team member)
Again, the benefits to the individual change team member as well as their respective agency were recurring themes that emerged in the interviews. Another change team member had a similar perception of the information-sharing process:
It was useful to know where my clients are coming from. Sure, I know they’re coming from the assessment center, but before they get to the assessment center . . . and that was very useful for me to know. In that sense it was very informative for me and I think I am able to also keep my staff better [informed] about this is what our [clients] have gone through although there are some forms that never make it to us from the point of entry into the prison system. But the fact that we know, I know them better some of the processes helps me understand, it helps me understand where they are or how far they’ve come and then that also helps in their treatment. (Change team member)
Beyond the value of agency staff communication with one another and solving problems together, the LCT members also produced actual changes in agency processes that enhanced information sharing between agencies. The completion of Goals 6 and 8 resulted in important assessment and treatment information being shared with in-agency staff as well as the Parole Board to provide the Board with the necessary information to make better-informed supervision decisions. In sum, the change team members were able to use the intervention to not only increase interagency (and intraagency) communication but also to implement agency-level change in information sharing.
Barriers to implementation
While the majority of the change team goals were either fully or partially implemented, several barriers prevented successful completion of all goals. These barriers are largely related to constraints on time, technological resources, and the relationship among agencies that tend to promote competition rather than collaboration. Each of these factors was identified by multiple change team members as well as the change team facilitator as preventing the full implementation of the developed goals. The implementation phase of the intervention was only 6 months long, and while this may have been enough time to accomplish very specific goals such as granting agency staff access to particular assessment information, other goals were incredibly ambitious within such a small window. The change team facilitator acknowledged time as being a primary factor in why some of the goals were not achieved:
My thought from seeing what I have observed is the goals of CJ-DATS have been very important but also very complex to create a kind of unified system. I think it’s somewhat unrealistic to think that it’s possible to do within a 6-month time frame. So my suggestion would be to—that more time is needed to—accomplish these objectives. (Change team facilitator)
Practical constraints on access to technology and information-sharing capabilities between agencies also limited the ability to complete particular goals. Change team members discussed that there were policy restrictions on who could access information as well as incompatibilities in technology between agencies. Therefore, training videos could not be kept and maintained on any agency server because it would be extremely difficult to allow other agencies access to that server to view the training materials. There were also concerns that training materials would not be maintained over time due to staff turnover and therefore once the member in charge of maintaining the information left, there would need to be a structure in place to appoint and train someone else to take their place.
For example, if [someone] sent information that I needed to- required information and- to update it, I can only do it at my desk computer. I’m very seldom at my desk computer so without having a system that would be universal- or where you could access from any internet website. You know—that just has some files in it—then I think over the long haul, they—we kind of got to the point to where some—if a member didn’t send the information back then it didn’t get updated. (Change team member)
As a result of these technological barriers, any goals that required a central database or online access or dissemination of materials were almost impossible to achieve. Some team members stated that they wish they had identified these types of barriers (technology-based limitations) during the earlier phases of the intervention because they may have selected different goals to pursue or revised the goals in a way that alleviated the reliance on technology.
Finally, the competitive relationship among several of the agencies was identified by several change team members as a barrier to goal implementation. The treatment continuum in New Jersey involves a number of correctional agencies and treatment providers working in collaboration toward reducing relapse and recidivism of offenders reentering the community. Within this context, there are often competing interests and priorities within and between these organizations. These competing interests include issues of public safety versus client needs, differences in how assessment and treatment is evaluated and implemented, issues of budgeting and offender placement, and preexisting agreements between correctional and treatment agencies and NJDOC. Certain agencies participating in the intervention were direct competitors with one another for clients and change team members from those agencies stated (and other change team members observed) that this resulted in a sometimes uncomfortable dynamic at change team meetings and influenced the identification of goals as well as the implementation of those goals. As one change team member noted:
I think it’s rewarding. But I also think that it’s—for me, uncomfortable at times, just because of—I know what our intent is to try to come up with a more universal system for all of our agencies and to work together as a team and ensure information. But I think it’s been really uncomfortable because we’re working with [Agency A] and [Agency B] are probably the biggest competitors to one another. I think and I guess from like an executive management we know that, but as far as the team was concerned, we kind of didn’t, discuss that information, but I think it prevented some of the progress from taking place because I was always on the defensive about what type of information—what I was willing to share with them. (Change team member)
These tensions were also observed by the research center facilitator who was working with the change teams:
The one thing that I probably have learned the most from the experience is how complicated and how complex it is to work within a system that encompasses many agencies, both within DOC as well as multiple competing vendors. The idea of creating a seamless continuum of care for individuals within the DOC system is complex when you have to navigate all of the different agencies and their cultures and their resistance to change and as well as resistance to others such as competing vendor interests. (Change team facilitator)
These statements highlight the ongoing conflict that some change team members felt. While they appreciated the opportunity the intervention provided in allowing agencies to come together to develop and implement goals related to improving the continuum of care for clients with substance abuse issues, they also recognized the reality of their abilities to effectively bring about organizational change. The intervention was very time constrained which limited the ability to fully implement more ambitious goals, agencies had to work with limited technology with accessibility restrictions, and change team members had to resolve (if able) the dissonance of wanting to collaborate with other agencies while still recognizing the competitive nature of their agencies’ relationships to one another.
Overall Impact of the Intervention and Sustainability
In addition to improving the assessment and case planning process, the intervention was also designed to help increase communication and sense of partnership between organizations involved in the continuum of treatment between in-prison and community-based aftercare. The chances for implemented changes to be sustained after the intervention was complete would require ongoing communication and partnership between the agencies and motivated staff (likely former change team members) and supportive management to continue to incorporate the changes made into the broader organizational structure and culture. Many of the goals developed by the LCTs required the support of management within the agencies they worked for. Furthermore, these managers were critical to the intervention in terms of allowing the LCT members representing their agencies the time needed to participate in this project, providing encouragement and support to their efforts, supplying vital resources (e.g., space to meet, access to facilities and treatment staff, etc.), and embracing the overall purpose of the intervention.
It was anticipated that success of the intervention, and the goals carried forth after the intervention was complete, would rest on the attitudes and efforts of LCT members. LCT members who were committed to the goals of the project are more likely to exert the requisite efforts needed to sustain the changes made to bring about long-term organizational changes. Several change team members addressed this issue when asked whether they believed their accomplishments could be sustained over time.
I think that the goal is the process improvement and the-went from the planning to the implementing and now the, the sustaining and we’ve kind of all invested enough in that whole process that right now there’s a momentum to keep it going and I think that’s-I think everybody, I haven’t seen anybody say-really don’t think we’ve met what we wanted to do and don’t think we’re there. We may not be 100% but we’re where we should be in terms of moving. (Change team member) I mean the strong support of the DOC combined with the individuals that make up the change team, their invested interest in the project, and [there is] almost a comradery among the group. Good working alliances have really kept this thing moving forward. (Change team facilitator)
Other change team members acknowledged that while they did not know whether the collaborative efforts of the change team would continue, they did feel that their own participation and experience in the intervention will influence their work within their own agency.
I believe we’ll keep our—what’s the word—like basically spark the individual people at each facility to be more proactive, as a basis to make further improvements at their own facility. I don’t really know how you would work that. I mean, I can just say that on my end, the stuff that’s come out of the change team has given me different ideas to improve my process. (Change team member)
Based on the comments made by the change team members and the facilitator, there is a general optimism that the efforts and products that resulted from the intervention will be sustained and incorporated into long-term organizational change. However, this will be dependent on the ongoing motivation of the change team members to continue to keep pathways of communication open between agencies as well as management support with the agencies to incorporate the changes made by the change team into organizational policy and practice.
Discussion
The current study examined the effectiveness of implementing an OPII specifically aimed at interagency collaboration and communication between prison-based and community-correctional substance abuse treatment providers involved in the treatment of offenders within the NJDOC. The overall goal of this intervention was to utilize LCTs consisting of clinical and administrative staff from the NJ Department of Corrections and treatment agencies involved in this continuum of care (prison- to community-based care) to improve the use of EBPs focused on four major domains: (a) measurement and instrumentation, (b) integration with case plan, (c) conveyance and utility, and (d) service activation. The findings from this study provide important insight into the processes and challenges of implementing inter- and intraorganizational change in the field of substance abuse treatment within a correctional setting.
For the current article, qualitative data were used to analyze the implementation of the OPII. LCTs were charged with the task of identifying gaps within the continuum of care between prison- and community-based care and to devise and implement strategies for improvement. The primary areas of need identified by the LCTs centered on improving service coordination between agencies, sharing of resources and client information, and training staff. While not all of the goals targeted for improvement were realized, the LCTs were successful in beginning the process of change and reducing or eliminating some of the organizational barriers that diminish the overall quality of care offenders receive. Specifically, they were able to create a training video that will be used to educate clinical and other treatment staff from the various agencies on the continuum of care model and how each phase of this process is interconnected and the importance of information sharing.
In addition to designing and creating a training video, the LCTs were also able to complete other goals and to partially implement others. Overall, the majority of these goals centered on improving service coordination across treatment providers, developing ways of sharing information (e.g., intake screening information and assessment tools), and providing a more accurate way of tracking the offenders progress as they transition across the stages of recovery. While they were unable to fully implement the goal, one of the LCTs was able to create and pilot test a tool that would incorporate all of the aforementioned needs. Given a wider time frame for implementation (more than 6 months), many of the uncompleted tasks may have been achieved.
While the purpose of the OPII was designed to implement effective organizational change, the overall experience of the LCT members who participated in this experience is worth mentioning. By in large, most of those who were involved in this process found the structure and direction of the OPII to be helpful in moving their respective organizations, as well as the system, in a positive direction. Furthermore, they embraced the opportunity to get together with others within their system of care and to share what they do and learn from others about their agencies’ roles. This is particularly important in terms of understanding the continuum of care, from the perspective of their organization’s role in this pathway, within the broader context of the overall treatment process.
The OPII was model after Proctor et al.’s (2009) conceptual framework for conducting implementation research. The hope of the current study was to assess the impact of each of the three interrelated outcomes described within this conceptual framework—implementation, service, and client outcomes. While the implementation of the current intervention achieved a modicum amount of success, the latter two outcomes (service and client) were outside the measurable context of the current study. Responses to interviews by LCT members support the premise proposed by Proctor et al. (2009) that successful implementation requires consideration as to whether innovation is compatible with the organization considering it. There was a great deal of energy and support among LCT members for creating a seamless continuum of care focused around information sharing. The biggest impediments to the realization of this goal were concerns over feasibility, fidelity, and sustainability. For example, there was a great deal of disagreement and discussion on how to effectively implement a system measuring stages of recovery (feasibility) and to make this consistent across sites (fidelity).
Limitations
Although the findings from this study are important, careful consideration of the limitations is warranted. Given the selective nature and representation of LCTs (e.g., 10-12 participants in each), the findings represent a small cross-section of the wider treatment continuum in New Jersey. Furthermore, quantitative analysis was extremely limited due to the small number of respondents for each survey, thus preventing any inferential analyses, and the qualitative interviews were representative of a small subset of each LCT. While this limitation has important implications for the generalizability of the findings, the positive findings do suggest that structured interventions can be implemented with some effectiveness in a correctional setting. In addition, the members who were selected for participation in these LCTs were identified because of their mid- to high-level rank within their respective organizations and their ability to influence change within them. Given their status within these organizations, their experience and impressions with the intervention may also reflect the organization’s attitudes and willingness to change on a system-wide level. Furthermore, the wider CJ-DATS2 collaborative involved seven other research centers partnering with their respective state agencies—many of whom were very similar in structure to the system in place in New Jersey. Implementation goals from LCTs at other sites corresponded with an overarching concern over system integration. Given these shared concerns and needs, findings from this study could suggest generalizability beyond the state of New Jersey.
As mentioned in the introduction, the primary purpose of this intervention was to facilitate organizational change around four primary domains associated with evidence-based principles inherent to substance abuse treatment for offenders (e.g., measurement and instrumentation). Findings from the current study are limited to LCT and agency-level outcomes. Although it is implied that key organizational change around the four process-based domains would translate into improved client-level outcomes, it was not possible to address these outcomes given the design and time constraints surrounding the current study.
Conclusion
Despite the limitations of the current study, the findings provide indication that organizational process improvement strategies can be implemented within a correctional setting to reduce interorganizational barriers and to facilitative improvements in the continuum of care involved in the treatment of offenders with issues of substance abuse. The findings from this study illustrate the importance of information sharing and communication both within and across agencies. For there to be a continuum of care, there needs to be a smooth transition of information from one agency to the next so that treatment staff (and clients) do not have to constantly repeat assessments, allowing treatment to be streamlined and delivered more effectively. A continuum that is fractured due to lack of communication results in “silos” of care, each seemingly independent from another, leading to incomplete and fragmented delivery of treatment.
The agencies involved in the current study recognized that existing communication practices were limited due to the nature of the relationships among one another as often-times competing vendors. However, those directly involved in the LCTs found that creating spaces for regularly occurring, ongoing communication lead agencies to develop stronger, cooperative relationships with one another. Instead of merely being competing vendors, they began to see themselves as complimentary agencies that each play an important role in the treatment continuum and that by coming to the table together and discussing their concerns and needs, they could work together to develop goals that not only benefitted their respective agencies and staff through more efficient information sharing but benefitted also the clients as they move through the continuum. While specific goals may not have been fully actualized, the creation of open lines of communication across agencies was recognized as an incredibly valuable first step in an ongoing collaborative relationship for improving treatment practices and programming. Change team members were inspired and motivated to continue to communicate with another and see what other goals and objectives they could achieve. Process improvement strategies, such as the one studied, increase the quality of communication between key stakeholders within this system of treatment, encourage collaborative efforts in terms of improving best practices, and create a universal sense of purpose across respective agencies.
Footnotes
Acknowledgements
The authors gratefully acknowledge the collaborative contributions by NIDA; the Coordinating Center, AMAR International, Inc.; and the Research Centers participating in CJ-DATS. The Research Centers include the following: Arizona State University and Maricopa County Adult Probation (U01DA025307); University of Connecticut and the Connecticut Department of Correction (U01DA016194); University of Delaware and the New Jersey Department of Corrections (U01DA016230); Friends Research Institute and the Maryland Department of Public Safety Correctional Services’ Division of Parole and Probation (U01DA025233); University of Kentucky and the Kentucky Department of Corrections (U01DA016205); National Development and Research Institutes, Inc., and the Colorado Department of Corrections (U01DA016200); University of Rhode Island, Rhode Island Hospital and the Rhode Island Department of Corrections (U01DA016191); Texas Christian University and the Illinois Department of Corrections (U01DA016190); Temple University and the Pennsylvania Department of Corrections (U01DA025284); and the University of California at Los Angeles and the Washington State Department of Corrections (U01DA016211).
Authors’ Note
The views and opinions expressed in this report are those of the authors and should not be construed to represent the views of National Institute on Drug Abuse (NIDA) nor any of the sponsoring organizations, agencies, Criminal Justice Drug Abuse Treatment Studies 2 (CJ-DATS) partner sites, or the U.S. government.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is funded under a cooperative agreement from the U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse (NIH/NIDA), with support from the Substance Abuse and Mental Health Services Administration (SAMHSA), the Bureau of Justice Assistance (U01DA0162), and U.S. Department of Justice.