F. Part Six: Treatment Provider Servicesand Perspectives 2(Volume Three)
1. Program Phases
Duration of Each Phase
Like their judicial counterparts, treatmentproviders responding to the survey indicated that their drug courts generallyconsist of three phases. As noted in Section A ("Judicial Perspectives")In some instances, a fourth phase of the program has been instituted consistingprimarily of aftercare- related services.
Services Provided in Each Phase
Detox, stabilization, counseling, drug educationand therapy are commonly provided during phases I and II and, in some instances,throughout the program. Other services relating to personal and educationaldevelopment, job skills, employment services are frequently provided duringphases II and III, after participants have responded to initial detox andstabilization. Housing, family, and medical services are frequently availablethroughout the program. Approximately 40% of the reporting programs offeracupuncture services.
Criteria Used to Move Participantsamong Program Phases
Almost all of the programs rely upon urinalysisresults and participant attendance at treatment sessions. Most also lookto the length of time a participant has been participating in the drug courtand the degree to which he or she has fulfilled program conditions, suchas payment of fees, obtaining employment, etc., which are considered tobe indicia of the individual's assumption of personal responsibility forhis/her life.
Criteria Used to Decrease/Increasethe Intensity and Length of Treatment Services
Treatment professionals recommend decreasesand/or increases in the intensity and length of treatment services basedon criteria similar to that used to make recommendations regarding the movementof participants among phases: urinalysis results, attendance at treatmentsessions; and length of participation time in the program.
2. Providers of Drug Court Treatment and Related Services
| Agencies Performing Drug Court Substance AbuseScreening, Assessment, Case Management, and Treatment and RehabilitationServices | ||||
| Substance Abuse Screening | Assessment of Treatment Needs | Case Management | Treatment & Rehabilitation Services | |
| Drug Court Staff | 35% | 26% | 31% | 10% |
| Pretrial Services Agency | 22% | 6% | 11% | 3% |
| Probation | 31% | 21% | 29% | 14% |
| TASC | 18% | 17% | 11% | 7% |
| Local Public Health Agency | 17% | 19% | -- | -- |
| Private Treatment Organization | 32% | 51% | 54% | 54% |
| Local Alcohol & Drug Agency | 38% | -- | -- | 18% |
| Drug Courts Using More than One of the aboveAgencies for These Services | 38% | 38% | 69% | -- |
Substance Abuse Screening
Drug Courts are using a number of agencies toperform substance abuse screening of eligible drug court participants. Amongthe reporting jurisdictions, substance abuse screening is performed by thefollowing agencies, with 38% of these drug courts using more than one agencyfor substance abuse screening:
· Drug Court Staff - 35%
· Private treatment organization - 32%
· Pretrial Services Agency - 22%
· Probation Department - 31%
· TASC program - 18%
· Local public health agency - 17%
· Drug Courts Using More than one agency for substance abuse screening - 38%
Several programs also use the screening servicesprovided by local alcohol and drug agencies.
Assessment of Treatment Needs
Assessment of the treatment needs of drug courtparticipants in the reporting drug courts is generally performed by thefollowing agencies, with some drug courts utilizing two or more agenciesin the assessment process:
· Private treatment organization - 51%
· Drug Court Staff - 26%
· Pretrial Services Agency - 6%
· Probation Department - 21%
· Local public health agency - 19%
· TASC program - 17%
· Local Alcohol and Drug Agency - 6%
· Drug Courts Using More than one agency for treatment assessment - 38%
Case Management
Drug courts are using a number of differentagencies to provide client case management for drug court participants.Case management functions are being performed by the following agenciesin the reporting jurisdictions, with many jurisdictions utilizing multipleagencies to perform client case management:
· Private treatment organization - 54%
· Drug Court staff - 31%
· Probation department - 29%
· Pretrial service agency - 11%
· TASC program - 11%
· Local public health agency - 11%
· Drug Courts using more than one of the above to perform case management - 69%
Treatment and Rehabilitation Services
Treatment and rehabilitation services are providedby the following agencies to participants in the responding drug courts:
· Private treatment organization - 67%
· Local public health agency - 18%
· Probation Department - 14%
· Drug Court staff - 10%
· TASC program - 7%
· Pretrial Services Agency - 3%
Nineteen (26%) of the reporting programs usetwo agencies to provide treatment and rehabilitation services and six percentuse three agencies. Most drug courts that use private providers for treatmentservices use one primary provider with some using several additional providersto address special participant needs. A few programs utilize a large numberof providers (Brooklyn uses 80 providers whose services are paid with Medicaidfunds) but the use of a large number of providers presents special issues,including those relating to coordination, supervision, and maintenance ofquality standards.
3. Screening, Assessment and Case Management
Use of a Standard AssessmentInstrument to Diagnose Addictive Disorders
Approximately 75% of the treatment professionalsresponding indicate that a standard assessment instrument is used. (Seealso Section A10 above)
Assessment of Special Needs
The assessment process of most programs is designedto identify special needs presented by the drug court population. For mostprograms, these include identifying participants who: are dually diagnosed;present evidence of HIV/AIDS infection, sexually transmitted disease, tuberculosis,hepatitis or other physical problems; have learning disabilities; employmentand/or housing needs; and may be victims of domestic or other violence.
Criteria Used to Screen for TreatmentProgram Eligibility
The major goal of the drug court screening(as opposed to the assessment) process is to assure that individualsaccepted for the drug court do, in fact, present significant substance abuseproblems to warrant the application of drug court treatment and rehabilitationservices. Most programs rely upon participants' history of drug useand self-reporting at the time of screening, with 60% also relying uponurinalysis results.
4. Effect of Mental Disorders on Program Eligibility
Most programs appear to be accommodating individuals with mental disorderswho are otherwise eligible for the drug court program by providing themspecial services. Approximately 10% of the reporting programs disqualifyparticipants who present psychoses.
5. Timeframe for Determining Eligibility for Treatment Following Determinationof Drug Court Eligibility
Once an individual has met the justice system criteria for drug court eligibility,the reporting programs indicate that determination of treatment programeligibility appears to occur promptly in most programs. The reported timeframes are as follows:
· automatically 33%
· within 24 hours 33%
· within one to three days 18%
· within three days to one week 16%
6. Client Treatment Plans
All but four of the reporting programs indicate the use of individualizedclient treatment plans for drug court participants. Approximately 40% ofthe programs update these plans every 30 days; 10% update them every 60days; and the remaining programs update them every 90 days. Approximatelyhalf of the programs automatically provide copies of these plans to thecourt; the others provide them only upon request.
7. Client Case Management
Agency Performing Client CaseManagement
As noted above, a variety of agencies are performingcase management functions for drug court participants, with private treatmentorganizations, drug court staff, and probation agency officials the mostfrequently cited. Over two thirds of the responding programs use more thanone agency to provide case management services.
Case Management Functions Performed
Case management functions being performed fordrug court participants in the reporting programs include:
· referral for ancillary rehabilitation - 90%
· client supervision - 89%
· client orientation - 88%
· appearing at court status hearings - 86%
· substance abuse screening and assessment - 85%
· urine monitoring - 83%
· client supervision - 89%
· treatment plan development - 83%· preparing court reports - 82%
· presenting court reports - 78%
· off-site counseling - 72%
· data entry/data base management - 69%
· referral to dedicated treatment service providers - 68%
· on-site counseling - 65%
· treatment program visiting and monitoring - 60%
· referral to non-dedicated treatment providers - 56%
8. Drug Court Treatment and RehabilitationServices
The degree to which the types of treatment services listed below are availablefor all clients in the reporting drug courts was reported as follows:
· relapse prevention 72%
· availability of treatment in jail 56%
· outpatient counselingup to 3 hours/week 55%
3 or more hours/week 45%· outpatient therapy/up to 3 hours/week 24%
· intensive therapy/3 or more hours/week 21%
· acupuncture 21%
· residential treatmentup to 30 days 3%
30-60 days 3%
61-90 days 1%
over 90 days 1%
9. Addressing Mental Health Needs
Percentage of Drug Court Participantswith Major Mental Disorder
Respondents were asked to indicate the percentageof drug court participants with the following mental disorders: depression;bipolar disorders; anxiety disorders; psychosis. Sixty percent of the reportingprograms indicated the prevalence of individuals with these problems. Anadditional 14% indicated that no data was available on this topic.
Specialized Treatment ServicesProvided for Persons with Mental Disorders
(1) Specialized services provided
Fifty-eight percent of the responding drug court treatment providers indicatedthey have the capability to provide specialized treatment services to drugcourt participants with mental health needs. A number of programs have specialcomponents or referral arrangements to address the needs of dually diagnosedparticipants.
(2) Staff serving as liaison/case managers for participants with mentalhealth needs
Fifty-four percent of the responding treatment have the capability of providingstaff to serve as liaison and/or case managers for participants with mentalhealth needs who are receiving treatment services from specialized agencies.
(3) Affiliations with mental health agencies to provide services for programparticipants with mental disorders
Seventy-two percent of the responding treatment programs indicated theyhad developed special affiliations with mental health agencies to providespecial services for program participants with mental disorders.
10. Capability to Refer Participant to Inpatient Treatment
Few drug courts maintain the capability for referring individuals to inpatienttreatment for more than thirty days. The following is a summary of the capabilitiesof the responding treatment providers to refer individuals for inpatientservices:
Programs Which Can Provide Some Residential Services
· for up to 30 days
for all participants - 6%
for most participants - 4%
for some participants - 53%
for very few participants - 23%
for no participants - 14%
· for 31 to 60 daysfor all participants - 3%
for most participants - 4%
for some participants - 26%
for very few participants - 19%
for no participants - 34%
· for 61-90 days
for all participants - 1%
for most participants - 2%
for some participants - 13%
for very few participants - 22%
for no participants - 62%
· for over 90 days
for all participants - 1%
for most participants - 0
for some participants - 8%
for very few participants - 28%
for no participants - 63%
11. Medications Permitted
Prescription Medications (including anti-depressants)
Only one program (Pasadena) prohibits prescription medications; two programs(Newark and Philadelphia) indicated that the issue of whether to permittheir use has not yet been raised. The remaining programs permit participantsto take medications that are prescribed by physicians.
Use of Pharmacotherapeutic Interventions
Fourteen of the reporting programs have specific policies prohibitingthe use of any pharmacological interventions, such as methadone, naltrexone,and antabuse. An additional 18% indicate that the issue as to whether topermit these interventions has not yet been raised. Those programs thatpermit pharmacological interventions usually limit these to specific interventionssuch as antabuse, naltrexone, or require that the individuals withdraw fromtheir usage upon program admission.
12. Use of Alcohol by Drug Court Participants
Over 75% of the reporting programs prohibit the use of alcohol by drugcourt participants and an additional 15% strongly discourage its use. Only10% of the responding treatment providers appear to have no articulatedpolicy against the use of alcohol by drug court participants.
13. Adjuncts to Treatment Used
Reporting programs use a variety of adjuncts to support the treatmentservices provided. The following are the most frequently noted:
· relapse prevention - 96%
· cognitive restructuring - 60%
· 12-step programs
on premises - 46%
off premises - 88%
· community mentors - 42%
· acupuncture - 40%
14. Child-care Services for Participants While Attending Treatment Sessions
Approximately 20% of the reporting programs provide child care servicesfor participants while attending treatment sessions. Approximately one thirdof the reporting programs permit participants to bring children to the treatmentsessions. In some instances, only participants who are pregnant or postpartumare permitted to bring their children to the treatment sessions.
15. Urine Testing
Drugs For Which Tests Are Conducted
Responding treatment providers indicated thatthe following drugs were tested for initially:
marijuana (90%)
crack/cocaine (89%)
methamphetamine (76%)
alcohol (58%)
barbiturates (56%)
PCP (44%)
LSD/Hallucinogens (22%)
Routinedrug testing practices are reported as:
marijuana (92%)
crack/cocaine (88%)
methamphetamine (71%)
alcohol (60%)
barbiturates (43%)
PCP (35%)
LSD/Hallucinogens (15%)
Eight programs also test for benzodiazopenes.
Costs Per Test/Drug Screen
Costs per drug screen are between $1- 3 foralmost 40% of the programs, $3-5 for 8%, and $5-7 for 11% of the programs.Approximately 34% of the reporting programs are spending in excess of $7for each drug screen. Five programs (7%) did not have cost information.
Agency Performing Urinalysis
The reporting drug court treatment programsare using a variety of agencies to perform urinalysis for drug court participants.The following is a summary of the information reported:
· Private Treatment Agency - 38%
· Probation Department - 22%
· Local Health Department - 15%
· TASC Program - 14%
· Pretrial Services Agency - 9%
· Local Corrections Agency - 2%
Approximately one-quarter of the reporting programs use two or more differentagencies to perform urinalysis.
Timeframe and Method for ReportingDrug Test Results to Court
(1) Time frame
Over 40% of the reporting drug court treatmentprograms can provide urinalysis reports to the drug court judge within 24hours, with 30% of the reporting programs able to provide reports within1-2 hours.
(2) Method for Reporting Results to Court
Most programs provide written urinalysis reportsto the drug court judge, frequently accompanied by oral reporting in court.Approximately 20% of the programs report the capability of electronicallytransmitting the urinalysis report; approximately one-third also fax thereport.
Maintaining Urinalysis Integrity
(1) Detecting Waterloading
Approximately 45% of the reporting programsindicate an awareness of potential waterloading by drug court defendantsin an effort to skew urinalysis results. An additional 15% indicate theyare not aware of a problem in this area; the remaining 40% indicate waterloadingis not a concern. Most programs, even those which did not cite waterloadingas a concern, appear to have in place methods to detect such adulteration.
(2) Detecting Other Adulteration
Fifty-three percent of the reporting programsnote a concern regarding other adulteration or urine samples, although noneindicated that adulteration was common. Most of these programs have establishedprocedures and policies to address adulteration, including use of temperaturegauges, random "surprise" observations, and strict policies fordealing with individuals involved with urine tampering.
Judicial Response to Positive Urines
The drug court judges for all of the reportingprograms have established responses for positive urinalyses of participants.These responses range from assignment to the courtroom jury box for a statedperiod; increasing the frequency of urinalysis, treatment sessions, andcourt status hearings; and, commonly, some level of short-term detention.Depending upon the circumstances of the positive urinalysis, the drug courtjudge may also refer the participant to more intensive in-patient treatmentfor a specified period.
16. Costs for Drug Court Treatment Services
Number of Agencies and Staff ProvidingServices to Each Drug Court
The number of treatment providers servicingthe reporting drug courts are as follows:
· 1 principal provider - 60%
· 8+ principal Providers - 15%
· 2 principal providers - 11%
· 3-5 principal providers - 11%
· 6-8 principal providers - 2%
Those programs with eight or more providersare: Bakersfield, California (86); Salinas, California (12); San Francisco,California (12); Santa Clara County, California (changes, depending on managedcare provisions); Denver, Colorado (13); New Haven, Connecticut (14); Camden,New Jersey (10); Brooklyn, New York (80); Buffalo, New York (47); Rochester,New York (12); Suffolk County, New York (15); and Akron, Ohio (12).
Number of Dedicated Staff
The level and type of dedicated staff servicingthe drug court treatment programs varies considerably among programs. Manyprograms use the part-time medical services of physicians and nurses. Manyalso use volunteers for such functions as assisting with relapse preventionservices, and providing clerical assistance, transportation, and residenceverification. A number of programs also use student interns.
Average Annual Cost per Client forTreatment Services
Fifty (70%) of the reporting programs providedinformation relating to costs per client for drug court treatment services.This information, summarized on the chart below, ranged as follows:
| under $900 | $901 - 1,200 | $1,201 - 1,500 | $1,501 - 1,800 | $1,801 - 2,100 | $2,101 - 2,500 | $2,501- 3,000 | $3,001 - 3,500 | $3,501 - 4,500 |
| 20% | 25% | 16% | 5% | 10% | 6% | 6% | 6% | 6% |
17. Total Program Capacity Annually
The total annual capacity for most of the reportingprograms ranges generally between 100 to 500 participants, with some ofthe larger programs (Kansas City, Miami, Las Vegas, and Portland, for example)handling a significantly higher volume. The following is an overview ofthe annual enrollment capacities of the reporting programs:
· under 100 - 11%
· 100 - 200 - 36%
· 201 - 300 - 23%
· 301 - 400 - 12%
· 401 - 500 - 10%
· over 500 - 8%
18. Nature and Frequency of Contacts with Drug Court Participants
Most drug court participants meet with treatmentproviders at least three times per week in addition to court appearancesand urine testing. Depending upon the participant's progress, the frequencyof treatment sessions may be decreased as he/she enters new program phases.
19. Comparison of Drug Court Treatment ServicesWith Treatment Services Provided to Typical Drug Court-Qualified ParticipantPrior to Instituting the Drug Court
Respondents were asked to compare the drug courttreatment services with those that would have been provided to the typicaldrug court participant prior to implementing the drug court. Almost allresponded that the drug court treatment program provided significantly morecontact with participants and much greater supervision and case management.Several respondents indicated there was "no comparison" with prioravailable treatment in terms of client attendance, quality of participation,maintenance of abstinence (as documented by drug screen results) and lengthof time involved in treatment. In addition, many noted that the availabilityof treatment services prior to the drug court was uncertain, with clientsfrequently required to access treatment on their own.
20. Treatment Program Requirements And ExperienceTo Date
Average Length of Time ParticipantsSpend in Treatment
The length of time drug court participants arerequired to spend in treatment and whether they are required to participatein treatment for the full duration of their drug court enrollment periodis described in the summary below:
3-5 months - 1%
6-9 months - 13%
10 months - 11 months - 18%
12 months - 40%
13-15 months - 22%
16-18 months - 6%
Almost all programs noted that, in the eventless than 12 months participation in treatment was required, a variety ofother conditions relating to participant rehabilitation (e.g., maintainingemployment; attending self-help group meetings; attending drug court hearings,etc.) were imposed and supervised by the drug court judge for a substantialfollow-on period after formal treatment services terminated.
Point in Time and Situations inWhich Incidents of Relapse have Been Most Common
Treatment providers were asked to identify themost frequent timeframes in which relapse has most commonly occurred withinthe reporting drug courts as well as common situations that appear to beassociated with relapse episodes. Their responses are summarized below:
1-30 days - 72%
31-60 days - 42%
61-90 days - 44%
91-120 days - 13%
121-150 days - 10%
151-180 days - 11%
181-210 days - 8%
210-240 days - 5%
241-270 days - 4%
271-300 days - 5%
301-330 days - 1%
over 300 days - 3%
upon movement to another phase - 35%
upon release from program - 19%
upon treatment discharge - 18%
pending/following graduation - 14%
Many drug courts have used this informationto develop special relapse prevention components at these time intervalsor for these situations.
21. Program Follow-up and Aftercare
Aftercare Services
(1) Mechanisms for Tracking Relapse by Graduates
Many programs report the development of hotlines or emergency services for individuals who have been terminated fromthe drug court, either as graduates or otherwise. Approximately one thirdof the programs are also undertaking formal follow-up activities to identifythe status of participants who have left the program. (See also discussionin Volume One of the 1997 Survey Report regarding justice systemfollow-up with drug court participants.)
(2) Provision of Aftercare Services
Approximately 70% of the treatment providersreport that aftercare services are provided to drug court participants,with half of them limiting services to drug court graduates only and theother half providing aftercare services to any participant. Aftercare servicesinclude relapse prevention, mentoring assistance with current participants;emergency hotlines, and other support services. Alumni groups are developingin over one-third of the reporting programs. In almost all programs providingaftercare services, these services are provided by the treatment provider.As noted in the judicial responses in Part A above, most programs permitparticipants to enroll voluntarily. They can also be referred by the DrugCourt judge or treatment provider. Most programs indicated that no specialfunding allocation was used to provide aftercare services. Client fees areapplied to these services by a number of programs.
Follow-up with Participants
Approximately one-half of the responding programsconduct follow-up with participants after they have left the drug court.The follow-up period ranges between six months to two years. Three commonmechanisms are being used to obtain follow-up information, often in combinationwith each other: telephone interviews (33%); written surveys (20%); andfocus group meetings (10%). The follow-up information reported to be compiledthrough these efforts includes recidivism; drug usage; employment status;family and housing status; welfare status; education activities and informationrelating to the physical and mental health of the participant.
22. Criteria Used to Assess Effectiveness of the Drug Court Program
The following is a summary of the criteria treatmentproviders are using to assess the effectiveness of the drug court programand the relative frequency with which these criteria were noted:
· treatment program attendance 85%
· urinalysis results 83%
· percent graduating 80%
· appearance at court status hearings 76%
· new arrests
drug charges 76%
non-drug charges 46%
· employment status 65%
23. Funding Sources for Treatment Services
The following is a summary of the sources offunding the responding treatment providers have utilized for their drugcourt treatment services and the frequency with which the reporting programsuse them
federal funds - 38%
local funds - 34%
state funds, including BJA and CSAT block grant funds - 28%
participant fees - 32%
Medicaid reimbursements - 22%
other public funding - 18%
third party insurance reimbursements - 11%
private foundations - 4%
24. Impact of Managed Care on Drug CourtTreatment Services
Quantity of Treatment Services Availableto Participants
Drug court treatment providers were asked toidentify the impact of managed care on several aspects of drug court treatmentservices. The first related to the quantity of treatment services available.Drug court treatment providers responded as follows:
· great effect - 16%
· some effect - 32%
· no effect - 52%
Quality of Treatment Services Availableto Participants
The second area of impact related to the qualityof services available. Drug court treatment providers' responses were asfollows:
· great effect - 29%
· some effect - 23%
· no effect - 58%
Entity Authorized to Provide TreatmentServices to Participants
The third area of potential impact of managedcare related to the entity authorized to provide treatment services to drugcourt participants. Their responses were as follows:
· great effect - 11%
· some effect - 30%
· no effect - 59%
As noted in Section A ("Judicial System Perspectives"), the apparentlack of comment by many of the drug court respondents regarding the implicationsof managed care appears to be directly related to the funding sources ofthese programs. Many of the programs that are primarily grant funded havenot yet had to deal with managed care provisions that most likely applyto services that are paid for by health-care dedicated funds. Once theseoutside funds are no longer available, the reality of managed care implicationson drug court treatment services may become better perceived.
Policies of State Licensing Agency
Respondents were also asked whether the statelicensing agency in their state had promulgated any special policies regardingthe application of managed care provisions for drug court clients. Respondentsfrom the following states indicated that the state licensing agency hadat least initiated policy development in this area: Florida, which is workingon an "access management" system; Illinois, which has encouragedthe use of a standardized assessment process; Kansas; New York, which isworking on a "carve out" for mandated treatment; Oregon, whichhas established standards for managed care to follow; Pennsylvania, whichhas implemented mandatory managed care for Medicaid clients and providedthe City of Philadelphia with the ability to develop a managed care organizationto manage, provide and monitor treatment services; and Puerto Rico, whichindicated that drug court participants receive all of the services required.
25. Program Operational and Planning Issuesand Advice to Colleagues
Most Serious Problems Treatment ProvidersHave Encountered as a Result of Implementing the Treatment Component ofthe Drug Court and Strategies Used to Resolve Them
Drug court treatment providers were asked toidentify the most serious problems they had encountered as a result of thedrug court implementation and the strategies they had used to resolve them.Respondents cited a range of problems, summarized in Appendix G, which include:inadequate funding and reimbursement for services; dealing with staff turnover;dealing with special problems presented by drug court clients includinghomelessness and child care needs; dealing with dually diagnosed participants;communicating with the judges and others involved in the program; and adjustingto drug court protocols. Funding issues still appear to pose problems butmany of the other issues have been addressed through frequent, regular interagencymeetings of the officials involved and development and communication ofclear policies and procedures.
Unanticipated Issues and StrategiesUsed to Resolve Them
Treatment providers were also asked to identifyany unanticipated issues that had emerged since the drug court had beenimplemented and the strategies used to address them. Many of the respondentscited issues associated with the conduct and monitoring of urine testing;the relatively severe addiction problems presented by participants; andthe difficulties posed by the high percentage of dually diagnosed clients.The treatment provider comments on these matters are more fully discussedin Appendix G.
Advice to Colleagues in Other Jurisdictions
Treatment providers were also asked to indicatethe advice they might give to a colleague in another jurisdiction that wascontemplating the implementation of a drug court. Like their counterpartsin other agencies involved in drug court operations, they indicated thatthe drug court was very worthwhile and should be implemented. They alsostressed the need for adequate planning, collaboration, cooperation, andflexibility and the importance of "just starting." "No matterhow well you plan, you will make changes as you go along." one respondentnoted. The responses of the drug court treatment providers are describedin more detail in Appendix G.
Go to G. Part Seven: Participant Comments
Go back to E. Volume Two Part Five: Perspectivesof Correctional Agency Officials