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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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2

PPW-PLT and BCOR Programs

INTRODUCTION

Two of the Comprehensive Addiction and Recovery Act (CARA) grant programs—the State Pilot Grant Program for Treatment for Pregnant and Postpartum Women (PPW-PLT) and Building Communities of Recovery (BCOR)—are administered by the Center for Substance Abuse Treatment (CSAT). This chapter provides a brief overview of each of these two programs, the committee’s methodology for assessing progress, the data the committee received from the Substance Abuse and Mental Health Services Administration (SAMHSA), and their findings.

PPW-PLT PROGRAM DESCRIPTION

The purpose of the PPW-PLT program is to

enhance flexibility in the use of funds designed to: 1) support family-based services for pregnant and postpartum women with a primary diagnosis of a SUD, including opioid disorders; 2) help state substance abuse agencies address the continuum of care, including services provided to women in nonresidential-based settings; and 3) promote a coordinated, effective and efficient state system managed by state substance abuse agencies by encouraging new approaches and models of service delivery. (SAMHSA, 2020b)

As a result of this program, “SAMHSA seeks to: 1) reduce the abuse of alcohol and other drugs; 2) increase engagement in treatment services; 3) increase retention in the appropriate level and duration of services; and 4) increase access to the use of medications approved by the Food and Drug Administration in combination with counseling for the treatment of drug addiction.” SAMHSA specified three required and three allowable activities, all of which are described in Table 2-1 (SAMHSA, 2017b). Additional information about the program can also be found in this table.

To be eligible for PPW-PLT funding, a potential awardee must be a State Agency for Substance Abuse (SSA; SAMHSA, 2017b). Massachusetts, New York, and Virginia were funded in fiscal year (FY) 2017, and Georgia, North Carolina, and Tennessee were funded in FY2018.1 These SSAs are required to partner with at least one direct service provider organization (e.g., a substance use treatment organization) that meets the following criteria: the

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1 See Box A-1 in Appendix A for a complete list of PPW-PLT grantees.

Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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organization is appropriate to the grant and directly involved in the proposed project; has been providing relevant services for at least the past 2 years; and is in compliance with all local and state licensing, accreditation, and certification requirements. Grantees may receive funding for up to 3 years (SAMHSA, 2017b).

BCOR PROGRAM DESCRIPTION

As with the PPW-PLT, SAMHSA began accepting applications for the BCOR program in FY2017. BCOR is intended to organize community resources and bolster support systems for substance use disorders (SUDs). Specifically, the grant’s aim is to support “the development, enhancement, expansion, and delivery of recovery support services (RSS) as well as promotion of and education about recovery.” The BCOR funding opportunity specifies one required activity and three allowable activities around which grantees should focus their efforts; these are laid out in Table 2-1, along with additional information about the program (SAMHSA, 2017a).

BCOR grantees are registered 501(c)(3)s and—to ensure appropriate representation—must be led and governed by individuals within the local communities of recovery (SAMHSA, 2017a). SAMHSA funded 8 grantees in FY2017, and an additional 18 grantees in FY2018.2 Some of these most recent grantees have also received other SAMHSA peer-to-peer grants and therefore have relevant existing infrastructure; other grantees are new to SAMHSA.3 Grantees may receive funding for a maximum of 3 years (SAMHSA, 2017a).

METHODOLOGY

The committee received two types of outcome data reports from SAMHSA on the BCOR and PPW-PLT programs. In order to assess evidence of progress toward program implementation to date, the committee has organized material from both source types according to the required and allowable activities of each grant (as outlined in Table 2-1). The findings are presented in the findings section of this chapter. This section describes the data sources, their content and limitations, and how they will be referenced throughout this report. Table 2-2 summarizes the limitations discussed in this section.

Government Performance and Results Act (GPRA) Data Reports

The first type of material received was a suite of data reports generated from clinical data that grantees submitted to SAMHSA through the GPRA reporting tool.4 Grantees submit information to this system on a rolling basis. The reports that the committee received included (a) participant characteristics at each measurement point (i.e., intake, discharge, and 6-month follow-up); (b) changes in key client outcomes from intake to the last measurement point, whether discharge or 6-month follow-up; and (c) differences between intake sample characteristics and the subsample of participants with complete follow-up data. The data in these reports were typically aggregated at the program level. For instance, data reports on past 30-day substance use were available for the BCOR program as a whole (across 26 grantees), rather than at the client level or the grantee level. The committee did receive grantee-level client data from GPRA on the following metrics: (a) number of actual client intakes at each grantee site versus the grantee’s goal for client intakes, and (b) number of 6-month follow-up interviews conducted at each grantee site versus the grantee’s goal for 6-month follow-up interviews.

The GPRA data reports were received in several batches. The first two sets were sent to the committee in May and June 2020 and can be found in full in the Public Access File.5 After evaluating the information received, the committee asked SAMHSA to clarify some of the data, and perform a few additional analyses of the same data. The committee received SAMHSA’s response in September 2020 and it can also be found in the Public Access File.6 The committee notes that, at times, SAMHSA’s responses to its questions did not provide additional clarifications.

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2 See Box A-2 in Appendix A for a complete list of BCOR grantees.

3 For more information, see https://www.samhsa.gov/grants/awards/2018/TI-17-015 (accessed April 21, 2020).

4 For additional detail on the GPRA reporting tool, see Box A-3 in Appendix A.

5 For GPRA data for both programs, see Public Access File (PAF) Items 47 and 49. PAF available by request via the National Academies. See https://www.nationalacademies.org/our-work/review-of-specific-programs-in-the-comprehensive-addiction-and-recovery-act (accessed March 10, 2021).

6 See PAF, Item 58. This source will be referred to in the chapter as “SAMHSA Responses: Treatment.”

Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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TABLE 2-1 Summary of the PPW-PLT and BCOR Programs

Program Eligible Applicants Awards and Project Period Funding Restrictions Program Purpose Program Activities
PPW-PLT Single state agencies for substance abuse 2017 awards: 3 ($1,100,000 each)

2018 awards: 3 (up to $1,100,000 each)

Up to 3 years
No more than 15 percent of the federal funding may be allocated to data collection, performance measurement, and performance assessment.

A minimum of 75 percent of federal funds must be directed toward service provision; no more than 25 percent may go toward infrastructure or capacity building.
The purpose of this program is to “enhance flexibility in the use of funds designed to
  • support family-based services for pregnant and postpartum women with a primary diagnosis of a substance use disorder, including opioid disorders;
  • help state substance abuse agencies address the continuum of care, including services provided to women in nonresidential-based settings; and
  • promote a coordinated, effective and efficient state system managed by state substance abuse agencies by encouraging new approaches and models of service delivery.”

Through this program, SAMHSA seeks to “reduce the misuse of alcohol and other drugs, increase engagement in treatment services, increase retention in the appropriate level and duration of services, and increase access to the use of medications approved by the U.S. Food and Drug Administration (FDA) in combination with counseling to treat drug addiction.”a

Required Activities
  • “Facilitate the availability of family-based treatment and recovery support services.
  • Develop a needs assessment using statewide epidemiological data (where available if a needs assessment effort is already in place, work with the local, state, or tribal epidemiological outcomes workgroup to enhance and supplement the current process and its findings); it should identify gaps in services furnished to pregnant and postpartum women along the continuum of care with a primary diagnosis of substance use disorder, including opioid use disorders.
  • Develop and implement a state strategic plan or enhance an existing plan to ensure sustained partnerships across public health and other systems that will result in short- and long-term strategies to support family-based treatment services along the continuum of care for pregnant and postpartum women.”

Allowable Activities

  • “Adopt and/or enhance computer system, management information system (MIS), electronic health records (EHRs), etc., to document and manage client needs, care processes, integration with related support services, and outcomes.
  • Train or develop the workforce to help state staff or community provider employees to identify mental health or substance abuse or provide effective services consistent with the purpose of the grant program.
  • Develop policy to support needed services system improvements (e.g., rate-setting activities, establishment of standards of care, adherence to the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care, development/revision of credentialing, licensure, or accreditation requirements).”
Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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Program Eligible Applicants Awards and Project Period Funding Restrictions Program Purpose Program Activities
BCOR Recovery community organizations (RCOs) that are domestic private nonprofit entities in states, territories, or tribes (must be controlled and managed by members of the addiction recovery community) 2017 awards: 8 (up to $200,000 each)

2018 awards: 18 (up to $200,000 each)

Up to 3 years
No more than 20 percent of the federal funding may be allocated to data collection, performance measurement, and performance assessment.

Must receive at least 50 percent of funds from nonfederal sources with a 100 percent matching requirement.
The purpose of this program is to “mobilize resources within and outside of the recovery community to increase the prevalence and quality of long-term recovery support from substance abuse and addiction. These grants are intended to support the development, enhancement, expansion, and delivery of recovery support services (RSS) as well as promotion of and education about recovery.” Required Activity
  • “Support the development, expansion, and enhancement of community and statewide recovery support services.”

Allowable Activities

  • “Build connections through infrastructure building between recovery networks, between recovery care organizations, and with other RSS.
  • Reduce the stigma associated with drug and alcohol addiction.
  • Conduct public education and outreach on issues relating to drug and alcohol addiction and recovery.”

a The committee prefers the use of the terms substance use disorder (SUD) and opioid use disorder (OUD); “addiction” will be used when directly quoting grantees or SAMHSA.

SOURCES: The information in this table is pulled directly from the initial funding opportunity announcements for PPW-PLT (SAMHSA, 2017b) and BCOR (SAMHSA, 2017a). The information in the Awards and Projects column comes from the Individual Grant Awards page for PPW-PLT (SAMHSA, 2017h, 2018g) and BCOR (SAMHSA, 2017g, 2018f).

Utilizing both of these submissions, the committee prepared summary tables of the GPRA data for the PPW-PLT and BCOR programs (available in Appendix B). These tables are not intended to represent the entirety of the GPRA data. Instead, they are summaries to assist the committee in assessing progress for the BCOR and PPW-PLT programs. When GPRA data are presented in this report, the corresponding table in Appendix B will be noted for reference. The tables include more detailed citations that indicate the specific reports in the Public Access File (PAF) from which data are drawn.

Limitations

The committee found the GPRA data to be of limited utility in assessing progress toward program activities. First, the data reports that SAMHSA sent reflected submissions from all PPW-PLT grantees, but only 25 of 27 BCOR grantees. As such, the results only speak to the progress of the reporting grantees. Secondly, though the committee is aware that grantees update the GPRA system on a rolling basis, the reporting period of the reports received was not entirely clear. The committee tentatively assumes that these data represent all data submitted by grantees from the beginning of their respective grant periods, and ending when the reports were generated by SAMHSA in May 2020.

GPRA is a tool for making assessments about individual clients, and is not designed to measure system- or community-level change. However, several of the required program activities for both the BCOR and PPW-PLT programs focus on the latter. In the committee’s first report in this series (NASEM, 2020b), several recommen-

Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
×

dations were made to address the mismatch between program activities and the reporting tools used to measure them; the lack of system- or community-level reporting metrics makes it difficult to assess progress toward these activities. See Appendix C for summary information about that report and its recommendations. The committee did rely on the GPRA data to describe the characteristics of program participants at program entry, discharge, and 6-month follow-up from intake.

From reviewing the GPRA data for the PPW-PLT and BCOR programs, a number of possible confounds must be noted before making conclusions about program impact. First, there are likely to be other treatment or community programs operating in the service regions of these grantees; if individual clients interact with multiple service providers, it is difficult to determine the unique impact of the SAMHSA grantees.

Second, individuals receiving services under these grantees may already have been enrolled in grantees’ services prior to grant funding. Indeed, 22.9 percent of BCOR clients had received at least 1 day of outpatient treatment for alcohol use disorder (AUD) or SUD within the past 30 days at the time of intake into the grant program; for PPW-PLT, 67.5 percent had received at least 1 day of outpatient treatment for AUD or SUD at the time of intake (see Appendix B, Tables PPW-PLT-1 and BCOR-1). This may suggest, particularly for PPW-PLT, that the grant services are either a continuation of existing services that the clients are already receiving from the grantee, or an addition to services they are already receiving from other providers.

Third, there may be a significant bias in the data provided to the committee due to (1) a low percentage of clients with data at follow-up points (i.e., high loss at follow-up) and (2) the selective nature of those with followup data (i.e., more-successful clients who completed treatment were more likely to receive follow-up interviews). The committee attempted to gain a clearer understanding about the influence of this bias by creating Appendix B, Tables PPW-PLT-1 and BCOR-1. These tables show differences in metrics related to social determinants, mental health, and substance use among all of the intake interviews, separated by those who also received a discharge interview or a 6-month interview. Importantly, the intake column of this table includes both individuals who were subsequently lost to follow-up as well as individuals who completed the program.

In a secondary analysis, the committee received disaggregated intake data, separated by participants who were categorized as either “interview completers” (if they had an intake interview as well as a 6-month follow-up and/or discharge interview) or “interview non-completers” (if they had only an intake interview and were lost to follow-up). This analysis provided additional insight into retention bias. However, it should be noted that, for both programs, a large n of individuals included in the first analysis was not included in the second.7 Their characteristics—and thus the impact their absence might have on the analysis—are unclear. Additionally, many of the metrics of use for analysis of retention bias were missing in this second report, including crucial information about a participant’s health status or past substance use treatment at the time of intake.

These two sets of analyses do not present a perfect description of retention bias; nevertheless, it is possible that discrepancies between these groups could account for any perceived improvement in client outcomes and therefore progress toward program goals. For instance, intake reports for clients in the PPW-PLT program suggest that individuals who completed a discharge or 6-month interview (“interview completers”) were less likely to report that drug use had caused them to give up important activities or cause emotional problems compared to those who were lost to follow-up (interview “non-completers;” see Appendix B, Table PPW-PLT-1). This suggests a retention bias wherein those with more drug-related difficulties are more likely to be lost to follow-up, and therefore follow-up data do not present a true picture of program impact on clients served.

In addition to these caveats with the data, the committee notes that the absence of additional information precludes impact evaluation (e.g., lack of control groups, lack of information about expected outcomes/status in a given community, and the overall absence of pre-program data).

In aggregate, it is difficult to interpret the GPRA data in light of these caveats. As the committee concluded in the first report of this series (NASEM, 2020b; see also Appendix C), and as discussed in Chapter 4 of this report, there are other types of system- and community-level data that would be useful for contextualizing the work of these grantees.

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7 See Tables PPW-PLT-1 and BCOR-1 in Appendix B for greater detail.

Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
×

Grantee Progress Reports

The second source of data was a collection of the most recent grantee annual progress reports submitted to SAMHSA. These included narrative descriptions of program activities and, in some cases, grant applications and evaluation reports (when provided to the committee). Grantees varied in project status with regard to implementation time frame, as grantees from the 2017 cohorts were roughly 2.5 years into funding at the time of reporting, and those from the 2018 cohorts were 1.5 years in. The exact reporting periods covered by the individual grantee progress reports varied widely. The progress reports for PPW-PLT grantees were dated anywhere between October 2017 and June 2020, and those for the BCOR program were dated between September 2018 and December 2019.

Initially, SAMHSA provided heavily redacted progress reports for all 6 PPW-PLT grantees, and 25 out of 27 BCOR grantees. These were received in June 2020, and can be found in the Public Access File.8 However, these had much of the information blacked out, making them challenging to understand. SAMHSA explained that their agreements with grantees prohibited SAMHSA from sending the committee unredacted program progress reports. Therefore, the committee then made several requests directly to each of the grantees for their latest progress reports, grant applications, and evaluation reports. At the time of the preparation of this report, the committee had received unredacted progress reports from 4 of the 6 PPW-PLT grantees,9 and for 2 of the 25 BCOR grantees.10

In the redacted reports, each grantee report was given an identification number (e.g., BCOR Grantee 1-1). In the following sections, wherever evidence of a given activity is provided, the specific grantees who demonstrated progress will be indicated using a parenthetical citation. The unredacted reports were key to helping the committee understand the context of the grantees but, for the sake of anonymity, only the anonymized identification numbers will be used.

Limitations

The grantee progress reports provide information about the activities of all grantees, to varying degrees. There are several limitations with the grantee reports that should be noted. First, SAMHSA did not provide grantee progress reports, redacted or unredacted, from two BCOR grantees. The redacted reports at times omitted information that was crucial for understanding a program activity; as previously mentioned, unredacted reports were only available for a small number of grantees. As such, it is possible that the committee has misrepresented or unintentionally omitted some grantee activities. Additionally, the variation in reporting periods covered by individual grantee reports made it difficult to compare progress across grantees. Lastly, grantee progress reports varied greatly in completeness, clarity, and quality. Some progress reports provided thorough descriptive and quantitative data on recruitment, retention, and services provided to clients, whereas others did not provide such data or the data were contradictory or inconsistent.

CROSS-CUTTING DATA LIMITATIONS

The committee would also like to note a few important limitations that apply to all data sources in this report. Firstly, SAMHSA did not solicit or organize information from grantees according to the required and optional activities laid out by SAMHSA in the funding opportunity announcements (FOAs) for the PPW-PLT and BCOR grant programs, per the FOAs. This fact guided the committee’s choice in overall methodology for this report, as discussed in Chapter 1.

Additionally, the materials shared by SAMHSA lacked a few key types of information, which limited the committee’s ability to assess the impact of these programs. This included an absence of pre-program data, lack of information about each grantee’s local context, and a lack of information on other programs operating in the same area (whether funded by SAMHSA or others). The need for such data is discussed in more depth in Chapter 4.

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8 For grantee reports for PPW-PLT, see PAF, Item 50; for reports for BCOR, see PAF, Item 51.

9 The unredacted PPW-PLT reports can be found in the PAF, Items 52, 53, 55, and 57.

10 The unredacted BCOR reports can be found in the PAF, Items 54 and 56.

Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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TABLE 2-2 Limitations of Evidence Sources Used by the Committee for the PPW-PLT and BCOR Programs

Evidence Source Used by Committee Program with This Source Type Limitations of Evidence Source Impact on Analysis
CSAT Government Performance and Results Act (GPRA) data reports PPW-PLT,
BCOR
Not all grantees submitted (25/27 BCOR grantees) Results only speak to progress of reporting grantees
Individual-level data Does not speak to community-level or systems-level change
Unclear whether clients were (a) enrolled in other programs simultaneously or (b) participating in the grantee programs prior to the reporting period Cannot isolate effect of SAMHSA grant funding on client outcomes
Potential bias in client outcomes data, due to (a) low follow-up rates or (b) characteristics of patients with followup data Client progress, in aggregate, may be overstated
Data aggregated across grantees (without pre–post data or comparison groups) Difficult to interpret effects of SAMHSA grant funding on client outcomes; redactions prevent interpretation of the context for client outcomes, either in terms of program features or community/population context or data
Grantee progress reports PPW-PLT,
BCOR
Not all grantees submitted (25/27 BCOR grantees) Results only speak to progress of reporting grantees
Redacted information (applies to 2/6 PPW-PLT grantees; 24/25 reporting BCOR grantees) Relevant activities undertaken may be misunderstood, misrepresented, or not included
Variation in the reporting periods covered by individual grantee reports Difficult to compare across grantees; some grantee activities may not be included
Variation in clarity, quality, completeness of information provided Difficult to compare across grantees
SAMHSA Responses to National Academies Questions PPW-PLT,
BCOR,
OD Treatment Access,
FR-CARA
At times, the committee requested clarification on a point (e.g., reporting period for another reporting tool), and gaps remained in SAMHSA’s responses Did not always provide additional clarifications
Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
×
Cross-Cutting Limitations Impact on Analysis
Reporting tools not clearly linked to the requirements of the grant programs, per funding opportunity announcements Difficult to organize information received around program requirements
Absence of pre-program data Difficult to interpret data, particularly on program impact
Lack of information about each grantee’s local context Cannot account for policy context, cannot compare outcomes to expected outcomes/status in a given community
Lack of information on other programs in same area with similar features (whether funded by SAMHSA or others) Difficult to assign impact to SAMHSA programs
Sources of data, reliability, meaning of data in context not always clear Difficult to interpret data, particularly on program impact

FINDINGS: PPW-PLT

Required Activity 1: Facilitate the Availability of Family-Based Treatment and Recovery Support Services

This section is structured around the four aims articulated in the FOA, summarized in Table 2-1, that these programs would “(a) reduce the abuse of alcohol and other drugs, (b) increase engagement in treatment services, (c) increase retention in the appropriate level and duration of services, and (d) increase access to the use of medications approved by the U.S. Food and Drug Administration in combination with counseling for the treatment of drug addiction” (SAMHSA, 2017b). Information regarding this activity comes from both GPRA data reports and grantee progress reports. The section ends with an assessment of the overall progress in implementation of this required activity and evidence of improvement in some grantees.

Reduction of Misuse of Alcohol and Drugs

A primary goal of the PPW-PLT program is to reduce the misuse of alcohol and other drugs (SAMHSA, 2017b). In the absence of data to assess the broader community impact of the program on alcohol and drug misuse, the committee utilized SAMHSA data reports to ascertain evidence of SUD treatment services received by program participants and subsequent changes in alcohol and drug use and related problems among program participants. The strategy or approach for reducing the misuse of alcohol and drugs comprises the services provided to the clients.

The committee first reviewed data on the percent of clients who had received screening and assessment, a service element listed as essential and specified as required in the PPW-PLT FOA (SAMHSA, 2017b). The screening and assessment step is a critical first step in the standard process of SUD treatment because it is key to understanding each client’s SUD and mental health disorders, psychosocial history, and needs. This process typically should take place as part of the clinical intake process, after which point the clinical team would use the information to identify specific diagnoses for SUDs and mental health disorders and, in discussions with the client, the screening and assessment would inform treatment planning and treatment goals (SAMHSA, 2018a).

SAMHSA provided the committee with data reports from discharge forms where information is recorded on services provided to clients throughout their course of treatment. These reports indicate that only 43.0 percent of clients received “screening” during their course of treatment (see Appendix B, Table PPW-PLT-7), which is an essential element for appropriate placement in level of care and treatment planning. The committee investigated further to identify whether a possible reason was that those who did not receive an assessment were already in treatment at the facility at the time of admission to the PPW-PLT-funded program, which would explain why a screening or assessment had not been conducted. Supporting this possible explanation, the committee found that

Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
×

at intake, 71.4 percent of individuals had received at least 1 day of outpatient treatment in the month prior to treatment entry—a larger percentage than those who at discharge were reported to have received at least 1 day of outpatient treatment during their past 30 days of the treatment episode (41.4 percent; see Appendix B, Table PPW-PLT-5). It is possible that the proportion of clients who received screening as part of the clinical services is relatively low because many clients were already enrolled in the grantee’s SUD treatment program before being admitted as a PPW-PLT client. As per standard protocol, if clients had been receiving SUD treatment services in other agencies, screening and assessment would have been conducted at entry into the PPW-PLT (SAMHSA, 2018a). It is possible that, although required by the FOA and not considered standard practice, some grantees relied on screening and assessments conducted by outside SUD treatment programs or other SUD treatment programs within the agency where the client was previously obtaining services. The committee has no way to verify the reason for the low rate of screening/assessment of PPW-PLT participants. Possible reasons include a low rate of discharge forms or missing discharge forms.

Second, the committee reviewed data on other required (as per the FOA) elements of SUD treatment services received by clients that were noted in the FOA as essential to improving treatment response and outcomes. As per standard practice, to optimize SUD treatment outcomes, a treatment plan should specify services matched to each client’s needs as identified by the clinical team or client’s main clinician in conjunction with the client. For SUD treatment, such services typically involve a combination of various forms of behavioral interventions and/or therapies; SUD education and skill building groups; and case management and referral to specialty mental health, medical, or social services (SAMHSA, 2018a). In addition to the screening and assessment noted previously, the PPW-PLT FOA specifically lists the following as essential and required service elements (SAMHSA, 2017b):

  • “‘Wrap-around’/recovery support services (e.g., child care, vocational, educational, and transportation services) designed to improve access and retention in services;
  • Family-focused programs to support family strengthening and reunification, including parenting education and evidence-based interventions and social and recreational activities;
  • Clinically appropriate evidence-based practices (EBPs) for treatment of persons with a primary diagnosis of SUD including opioid use disorders, particularly, the use of medication-assisted treatment (MAT) … in combination with psychosocial interventions (e.g., counseling);
  • Mental health care that includes a trauma-informed system of assessments, interventions, and social-emotional skill building services; and
  • Case management.”

Data reports provided to the committee by SAMHSA on services received by clients (from discharge forms) indicate the following as the most commonly received services: 57.9 percent “substance abuse education,” 37.7 percent “information and referral,” 28.5 percent “relapse prevention” (see Appendix B, Table PPW-PLT-6), 36.6 percent “referral to treatment,” 43.0 percent “family services,” 21.7 percent “brief intervention,” and 19.7 percent “brief treatment” (see Appendix B, Table PPW-PLT-7). Unfortunately, the lack of direct concordance between the GPRA data items on services received by clients and required essential services noted in the FOA (as previously noted) does not allow for a straightforward assessment of the percentage of clients who received these required elements. For example, the GPRA tool and data do not specifically identify the percentage of clients who received EBPs.

Third, based on data reports provided by SAMHSA, the committee constructed tables on changes in substance use from program intake to follow-up interview points to evaluate the evidence (see Appendix B, Tables PPW-PLT-3a and PPW-PLT-3b).

The committee found the data provided to be inadequate for making valid conclusions about program impact due to sample attrition bias and lack of analyses controlling for such bias. For example, if data provided by SAMHSA were examined at the aggregate level, they could indicate increases in previous 30-day alcohol and drug abstention between intake and a second follow-up point (which could be discharge or 6-month follow-up post intake), with 64.3 percent at intake versus 78.6 percent at a second follow-up point, among 182 individuals with both intake and follow-up data (see Appendix B, Table PPW-PLT-3b). Comparisons of other outcomes, such as

Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
×

past 30-day experience of substance-use-related emotional problems, health problems, or behavioral or social consequences, followed similar data patterns (see Appendix B, Tables PPW-PLT-3a, PPW-PLT-3b, and PPW-PLT-3c).

A significant problem with drawing valid conclusions about a program’s impact from such data stems from selection bias. Namely, there is evidence of significant selection bias (i.e., bias in the characteristics of participants who received a follow-up interview and those who did not) due to the following factors.

High attrition from the evaluation at follow-up interview points. For example, at the 6-month interview point, overall, grantees had low follow-up rates, and obtained data from only 60 percent of program participants. Additionally, the rates of loss to follow-up varied greatly across grantees (approximately 32–63 percent of participants were not interviewed at follow-up; see Appendix B, Table PPW-PLT-2).

Important differences in client intake characteristics between those with missing data for follow-up interview points. Critically, compared to those for whom data were available at follow-up points, those for whom such data were missing were characterized by more severe clinical profiles based on intake data on the past 30-day use of alcohol and drugs; psychological factors indicating greater substance use severity; and demographic characteristics related to homelessness, unemployment, and lower income (see discussion in the Methodology section and data in Appendix B, Table PPW-PLT-1). SAMHSA did not provide the committee with a formal assessment of whether these differences were statistically significant, so the committee had to rely on interpreting the general pattern shown by the data.

Important differences between program participants with completed follow-up data and those with missing follow-up data. These differences are evident in rates of program completion wherein those with completed data were more likely to have successfully completed the program and/or to have stayed in the program for more days (see the discussion in the Methodology section and data in Appendix B, Table PPW-PLT-1).

In summary, while a first-glance review of data from the GPRA data reports provided by SAMHSA would suggest that that the program had favorable effects on substance use and related factors, the limitations described above do not allow for confidence in this interpretation.11

Increased Engagement in Treatment Services

Across the six PPW-PLT grantees, the program had the goal of recruiting 1,645 women into the PPW-PLT. Based on GPRA reports, 839 clients (51 percent of the target) had been successfully recruited (i.e., received an intake GPRA interview). Individual grantees differed in the fulfillment of recruitment goals. Three grantees had only achieved 30 percent or under of their recruitment goals, one grantee had achieved 65.9 percent of its recruitment goal, and two grantees had achieved 95 percent or greater of their recruitment goals (see Appendix B, Table PPW-PLT-4).12 No baseline data were provided, so the committee cannot comment on whether there was an increase.

Turning to the progress reports for context, the committee found that, consistent with GPRA data noted in the previous section, most grantees acknowledged underperforming in the number of PPW-PLT clients enrolled (PPW-PLT 1-1, 1-2, 1-3, 2-1, 2-2) and engagement of children and fathers/partners and/or family members (PPW-PLT 1-1, 1-2, 1-3, 2-2, 2-3), which resulted in not reaching recruitment goals to date. See the last paragraph under the section Increased Retention in the Appropriate Level and Duration of Services.

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11 Of note, one grantee highlighted these issues in their own evaluation report, and stated their intentions both to improve follow-up rates and to conduct additional statistical analyses to identify selection bias and differences in baseline characteristics between those participants with follow-up data and those without (PPW-PLT 1-3).

12 The committee initially considered whether the 50 percent of target could have been due to grantees being in an early stage of implementation. However, at the time of reporting, some programs were 2.5 years into the 3-year reporting period. Furthermore, in the progress reports, most grantees explicitly noted being behind in their recruitment goals, to date, for engaging women and families. Overall, it does not seem that the shortcoming is attributable to being in an early stage of implementation.

Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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Increased Retention in the Appropriate Level and Duration of Services

Due to the evaluation design (pre–post) with no comparison group or data from another reference group or time point, it is not possible to assess whether the grant program contributed to the grant-funded programs’ increased retention in the appropriate level and duration of services compared to other programs or prior to grant funding. The GPRA reports provided limited data on retention. Based on data reports provided by SAMHSA, data were collected on 456 participants at discharge from the program. Of these, 40.8 percent had a discharge status indicating that they had “completed or graduated” and 59.2 percent were discharged prior to program completion. Among non-completers, the majority (63.3 percent) showed no progress toward achieving treatment goals and 26.7 percent showed evidence of progress (see Appendix B, Table PPW-PLT-2). Of note, the definition of what was required for treatment completion or graduation or for the designation of having made progress toward treatment goals was defined by each program (SAMHSA Responses: Treatment), which calls for caution in interpretation of these findings because the criteria were not uniform. Based on data from GPRA discharge forms, clients were enrolled in the program for a period of approximately 5 to 6 months (M = 187.3 days, SD = 105.8) (see Appendix B, Table PPW-PLT-2). However, because the number of actual visits or days in which a client received treatment services was not reported by SAMHSA, it is not possible for the committee to determine how often women received services during that period of enrollment.

Furthermore, it is difficult for the committee to comment on whether outpatient SUD treatment (or in some cases, intensive outpatient) was the appropriate level/modality of service for clients enrolled in the program. At intake, many clients reported exposure to violence or trauma (78.9 percent), unstable living conditions (31.8 percent), or co-occurring mental health problems (e.g., 57.4 percent experienced serious depression not due to substance use; see Appendix B, Table PPW-PLT-1). Four grantees mentioned plans to use American Society of Addiction Medicine (ASAM) criteria13 (PPW-PLT 1-2, 1-3, 2-1, 2-2), which suggests that they determined that outpatient or intensive outpatient modalities, rather than inpatient, were appropriate for these client profiles. However, the progress reports did not clearly confirm use of the ASAM criteria in practice, and the remaining two grantees provided no data or information about what criteria were used in determining appropriate levels of care for enrolled clients (PPW-PLT 1-1, 2-3).

Information from grantee progress reports noted earlier with respect to challenges to recruitment also seemed to play a role in engaging clients through successful treatment completion. All grantees noted that, once enrolled, ongoing client engagement in services was a challenge. Reasons for this were related to (a) lack of adequate child care and transportation (e.g., PPW-PLT 1-3, 2-3) due to inadequate local services; (b) distance and long travel time from and to the client’s home to the service agency—for day programs/intensive outpatient programs, this required the client to spend a significant portion of the day in treatment (e.g., PPW-PLT 1-3); (c) staff turnover or shortages may have impacted the time for client retention and/or provision of all services planned (e.g., PPW-PLT 1-1, 1-3, 2-1); and (d) homelessness (e.g., PPW-PLT 2-1). The committee considers that the administrative challenges (e.g., staff turnover, start-up delays) noted in a later section, Evidence of Progress in Overall Program Implementation of Family-Based Services for PPW, likely contributed to challenges in client retention and program completion.

Increased Access to Medications for Opioid Use Disorder (MOUD)

Very little of the GPRA data can be used to assess progress toward this goal because there are no adequate baseline data on community-level access to MOUD with which to make a comparison. The committee reviewed the GPRA data reports to identify the number of clients (a) who reported opiate use and who could potentially benefit from MOUD,14 and (b) for whom MOUD had been provided. At program start, 161 (17.7 percent) clients were identified as having an opioid-related disorder (see Appendix B, Table PPW-PLT-1). However, data reports on the use of specific opiates during the 30 days prior to treatment entry indicate that very few women reported use of one or more opiates (i.e., 3.5 percent heroin, 0.5 percent morphine, 0.6 percent dilaudid, 2.8 percent Percocet, 0.4 percent codeine, 2.2 percent OxyContin/oxycodone, and 0.2 percent nonprescription methadone; see Appendix

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13 See the ASAM website at https://www.asam.org/asam-criteria/evidence-base (accessed January 12, 2021).

14 For further discussion concerning use of MOUD, including for pregnant women, see NASEM, 2019.

Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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B, Table PPW-PLT-1). The number of women identified as having an opioid-related disorder seems inconsistent with the number reporting opioid use prior to treatment entry.

According to the GPRA data provided to the committee, based on information obtained at program discharge, only nine clients (2.0 percent) received methadone over the course of their treatment episode. The reports also indicate that, at discharge, 23 clients (5.0 percent) had received “pharmacological interventions for SUD,” but it is unclear how many, if any, of these clients might have received specifically MOUD (see Appendix B, Table PPW-PLT-6). The GPRA data provided to the committee only specified methadone and did not specify other medications used in MOUD treatment.15

Data from progress reports do not provide consistent reporting on the provision of MOUD. Some grantee progress reports list this as a service provided but do not provide data or descriptions of how it was provided, and do not note whether there were changes over time in the availability or use of such treatment (PPW-PLT 2-1, 2-2, 2-3); one of these grantees described their proposed procedures for administering MOUD (including detail on staff and medications offered) in their application to SAMHSA, but did not comment on the implementation of this system in their progress or evaluation reports (PPW-PLT 2-1). Another grantee did not mention MOUD at all (PPW-PLT 1-2). The committee can only comment on indications of progress for grantees that did provide such information in progress reports or evaluation reports (when those were provided to the committee).

One grantee progress report (at 2.5 years into the project) noted that 33 percent (22 percent postpartum, 61 percent pregnant) of participants had received or were receiving MOUD (largely methadone) in combination with counseling (PPW-PLT 1-1). However, the data from the grantee report on substances used note that only 7 of 36 women (about 20 percent) reported opioid use in the 30 days prior to treatment entry. Therefore, it is unclear how many clients served in the program were receiving MOUD prior to enrollment.

Another grantee’s evaluation report noted that 21 percent of enrolled clients received MOUD (PPW-PLT 1-3). They provided data for each subgrantee implementation site, noting that use of MOUD varied greatly due to either varying rates of OUD across the state or varying access to MOUD. Data from the same report indicate that alcohol and/or other drugs were the major substances used by clients in the 30 days prior to treatment entry, rather than opioids (e.g., heroin, 3.1 percent; Percocet, 3.1 percent; OxyContin, 2.3 percent). The data on types of drugs used do not coincide with the data on MOUD. So, it is not clear whether some women entered the program after receiving MOUD.

Based on the lack of or only minimal comments regarding MOUD in grantee progress reports and evaluation reports, the committee assumes that either grantees did not deem this important or thought that MOUD was not relevant to their clients because of a low prevalence of OUD in clients recruited into the program. Progress reports that did include some note on MOUD suggest that data reported on clients receiving MOUD is inconsistent with the substance use reported prior to the program’s start and that such clients may have been in MOUD programs prior to being enrolled in the PPW-PLT.

Overall, the committee was not provided any data or other evidence on which to base an assessment regarding the PPW-PLT program’s impact on increasing access to medication-assisted treatment. Although the PPW-PLT FOA did not specify pregnant and postpartum women opioid users as the sole target population (SAMHSA, 2017b), the low proportion of such clients served is notable considering the overall intent of the CARA programs for which SAMHSA was funded as part of the response to the opioid epidemic.16 The committee notes that there could be lower numbers of engagement due to stigma around MOUD, or due to a number of factors already mentioned as obstacles to client engagement and retention in the PPW-PLT more generally (e.g., transportation, child care). However, the small number of women who seem to have received MOUD is still of concern to the committee.

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15 The committee notes that in the final stages of preparing the first report in this series (see NASEM, 2020b), the GPRA tool underwent an update. Now, the revised tool includes a question specifically about MOUD, including methadone, buprenorphine, and naltrexone.

16 P.L. 114-198 is described as an act “to authorize the Attorney General and Secretary of Health and Human Services to award grants to address the prescription opioid abuse and heroin use crisis, and for other purposes.” See https://www.congress.gov/bill/114th-congress/senatebill/524/text (accessed March 13, 2020).

Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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Progress in Overall Program Implementation of Family-Based Services for PPW

As shown in Appendix B, Table PPW-PLT-1, data provided to the committee by SAMHSA indicate that 839 client intakes had been conducted by PPW-PLT grantees (the number of intakes is discussed at the end of this section). The majority of clients were between 25 and 34 years of age (59.8 percent) and non-Hispanic White (56.4 percent). Clients who identified as Black or African American comprised about one-fifth of those served (22.7 percent). Representation of clients who identified as Hispanic or Latino (9.6 percent), American Indian (3.6 percent), and those who identified as “none of the above” (15.4 percent) was much lower (see Appendix B, Table PPW-PLT-1).

With regard to receipt of family-based services, SAMHSA data reports provide limited information. Those reports indicate that 43.6 percent of clients received “family services,” 16.0 percent received “child care,” and 2.9 percent received “family/marriage counseling.” However, it is difficult to determine whether these services are due to the grant, or would have been delivered to clients absent the grant (see Appendix B, Table PPW-PLT-7).

Grantee progress reports provide additional information on the degree of progress that PPW-PLT programs had made in terms of becoming operational as well as the challenges they have experienced in program implementation. Progress reports from all grantees showed evidence of having programs that were operational at some level. However, grantee reports indicate that, across grantees, there were varying levels of progress toward program implementation. Notwithstanding some challenges noted in the following sections, programs hired and trained staff, implemented EBPs, enrolled clients, and provided services. In their reports, most grantees did not mention having employed standard fidelity assessment protocols to determine whether the EBPs were being delivered with high fidelity. One grantee included in their proposed implementation plan that they would use the standard fidelity measures available for each EBP (PPW-PLT 2-2) and another said that the subgrantees were expected to follow the fidelity requirements of the EBP founding organization (PPW-PLT 1-1); nevertheless, in both cases, the committee cannot confirm that such efforts were ultimately undertaken. The progress reports generally suggest that all or most grantees (a) developed and implemented agreements with collaborating partners, whose role was to assist in providing services to PPW-PLT clients and their children and family members; and (b) constituted advisory groups that met with varying frequency.

All grantees had provided some or all of the planned services to at least some PPW-PLT clients, their children, and their family members. With regard to the achievement of enrollment targets, grantees varied widely. All grantees were underperforming with respect to their own recruitment goals, as stated in their grant applications, compared to the number of PPW-PLT clients enrolled, and in the engagement of children and fathers/partners and/or family members. This seems to suggest either underperformance or that the goals identified at the outset were unrealistic.

Administrative challenges. Grantee progress reports noted numerous administrative obstacles or challenges that impacted their progress toward achieving this required activity—providing family-based services for PPW-PLT with a primary diagnosis of an SUD, including OUD. First, staff hiring and retention posed significant challenges for some grantees (e.g., PPW-PLT 1-1, 2-1, 2-2). This resulted in delays in either program start-up and/or delivery of certain services and EBPs. A number of grantees noted program start-up delays or implementation setbacks due to SAMHSA delays in the approval process for their budget, as well as clarification regarding activities for which grant funds could be used or specifying the target population (e.g., PPW-PLT 1-1, 1-3). Three grantees had programs and/or partners that dropped out of the grant (PPW-PLT 1-3, 2-1, 2-3), which required them to either find a new program partner or revise their plan to serve PPW-PLT clients in the geographic areas planned. Finally, some programs faced important evaluation challenges due to not appropriately implementing the GPRA intake tool (PPW-PLT 2-1), from service provider data systems that are incompatible with SAMHSA services reporting categories (PPW-PLT 2-3), and/or due to a lack of performance by the local evaluator (e.g., PPW-PLT 2-1, 2-3). All of these challenges resulted in incomplete data collection and reporting or data not being accessible to the program.

Programmatic challenges. In addition to the aforementioned administrative challenges, grantees faced other critical challenges with regard to participant recruitment and retention. All grantees noted difficulties recruiting and

Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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enrolling PPW-PLT clients, which resulted in not reaching the recruitment goals stated in their grant applications. The most common client recruitment challenges noted in grantee progress reports were related to (a) women’s fear that engaging in SUD treatment would result in having children removed from their custody (PPW-PLT 1-1, 2-1), (b) challenges with transportation and child care (PPW-PLT 1-1, 1-3, 2-2, 2-3), (c) a lack of referrals from outside agency collaborators (PPW-PLT 1-1, 1-2, 1-3, 2-1, 2-2), and (d) having to cover large geographic areas that required long travel time even when clients were provided transportation (PPW-PLT 1-3, 2-1, 2-2, 2-3).

Once enrolled, many grantees mentioned that ongoing client engagement was a challenge (e.g., PPW-PLT 1-1, 1-2, 1-3, 2-2, 2-3). Reasons for this were common across grantees and related to (a) a lack of adequate transportation and child care (e.g., PPW-PLT 1-1, 1-3, 2-2, 2-3); (b) distance and long travel time from and to the client’s home to the service agency (e.g., PPW-PLT 1-3)—for day programs/intensive outpatient programs, this required the client to spend a significant portion of the day in treatment; (c) insufficient staff or changes in staffing (e.g., PPW-PLT 1-1, 1-3, 2-1); (d) homelessness and a lack of stable housing for PPW-PLT clients (e.g., PPW-PLT 2-1); and (e) clients challenged by managing appointments for themselves and their children that are required by multiple providers/agencies (e.g., medical providers, child welfare, criminal justice; e.g., PPW-PLT 1-3).

Engagement of children and family members posed challenges for some grantees. All grantees faced challenges in this area for numerous reasons, including the same problems that made it challenging to engage PPW-PLT clients, such as transportation and long distances from home to the service provider, inadequate staff for conducting groups and participant engagement (e.g., PPW-PLT 2-2), hours of operation that conflicted with family member schedules (e.g., PPW-PLT 1-2), or a lack of staff with experience in strategies for family engagement (e.g., PPW-PLT 1-1, 2-3). Almost all grantees noted that women often did not want partners/fathers or other family members involved due to their alcohol or drug use, family violence, or conflictual relationships (PPW-PLT 1-1, 1-2, 2-1, 2-2, 2-3).

Finally, for grantees whose reporting period included the onset of COVID-19 service restrictions (PPW-PLT 1-1, 1-2, 1-3, 2-2), COVID-19 context became an important obstacle to meeting recruitment goals, provision of services, and in-person staff training and regional meetings. Such grantees noted large changes in staffing wherein staff were let go and positions were discontinued, as they were no longer able to provide services in person. These grantees noted challenges in developing ways to deliver services via telephone or Zoom (telehealth) because this required a shift in program protocols, procedures, and staff training. Such grantees were also making adjustments in their approach to service delivery and training by moving to online formats.

Evidence of improvement in implementation and accomplishments over the course of the grant period. Although grantees faced numerous implementation challenges, there is evidence that some grantees improved performance over time. For example, one grantee progress report indicated an increase in services to family members and children in Year 2 of the grant by serving 70 percent of their target for services to children and 96 percent of their targeted number of family members (e.g., PPW-PLT 1-1). This grantee and one other reported focusing on outreach efforts in the second year in order to increase referrals (PPW-PLT 1-1, 1-2), a challenge noted previously; however, no data were provided on the outcomes of these efforts. Two grantees noted that they made MOUD available to PPW-PLT clients directly from the subgrantee provider or through referrals and provided such to 21 percent and 33 percent of clients served, respectively (PPW-PLT 1-1, 1-3). Among achievements of the grant, grantees noted provision of training on EBPs and in gender- and family-centered services (e.g., PPW-PLT 1-1, 1-3), hiring of new staff with expertise in family-centered services (PPW-PLT 1-2), and development of state standards and certification process for gender- and family-centered care, which are pending approval (e.g., PPW-PLT 1-1).

Required Activity 2: Develop a Needs Assessment Using Statewide Epidemiological Data (Where Available If a Needs Assessment Effort Is Already in Place, Work with the Local, State, or Tribal Epidemiological Outcomes Workgroup to Enhance and Supplement the Current Process and Its Findings); It Should Identify Gaps in Services Furnished to Pregnant and Postpartum Women Along the Continuum of Care with a Primary Diagnosis of SUD, Including OUD

GPRA data cannot be used to assess progress toward this goal because all data are focused on individual-level information. Grantee progress reports varied in reporting elements and/or grantees did not provide information for

Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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all elements of the required activity. The committee can only comment on needs assessment activities to the extent that they were covered in progress reports. For example, one grantee reported conducting a survey of providers on their advisory board and related programs to identify provider perceptions about barriers faced by women in treatment (PPW-PLT 1-1). This was not a comprehensive needs assessment using statewide epidemiological data to inform gaps in services. Another grantee reported that the statewide needs assessment was conducted in the first year of the grant and served as the basis for selecting the treatment sites (PPW-PLT 2-2). However, no information on the specifics of the needs assessment, the findings, or how they were used was provided in their progress reports. A third grantee reported two efforts that seem to relate to, but may not directly address, this activity. They contributed to a statewide opioid needs assessment that was already under way, but that did not focus specifically on services for pregnant and postpartum women; they also plan to undertake county-specific (rather than statewide) needs assessments in the counties of their subgrantees (PPW-PLT 2-1). Half of the grantees did not mention this required activity in their reports (PPW-PLT 1-2, 1-3, 2-3).

Based on the lack of information in progress reports and evaluation reports (when provided to the committee), the committee cannot comment on grantee progress toward this goal.

Required Activity 3: Develop and Implement a State Strategic Plan or Enhance an Existing Plan to Ensure Sustained Partnerships Across Public Health and Other Systems That Will Result in Short- and Long-Term Strategies to Support Family-Based Treatment Services Along the Continuum of Care for Pregnant and Postpartum Women

Progress reports and evaluation reports (when made available to the committee by some grantees) indicate variable degrees of information on this activity with some grantees only providing minimal information on this activity (e.g., PPW-PLT 1-2, 1-3, 2-1, 2-3), and one grantee providing none (PPW-PLT 2-3).

Among grantees who provided information relevant to this required activity, one grantee stands out as having the most robust approach and indication of progress in this area (PPW-PLT 1-1). In their evaluation report, they note the formation of an advisory committee with more than 20 members at the end of Year 1. Consisting of service providers, the group received training on gender-specific and family-centered treatment, met bimonthly to review and edit state standards for gender-specific and family-centered outpatient treatment throughout Year 2, and developed a plan to complete and pilot the standards in Year 3. Prior to the training, the grantee conducted a survey of providers to identify perceived needs and barriers for pregnant and parenting women in treatment. Findings indicated that a lack of knowledge of available resources (73 percent); child care (67 percent); transportation (33 percent); trauma (40 percent); a lack of support from family, friends, and significant others (27 percent); and concerns about potential loss of child custody (20 percent) were major barriers for women. Providers also noted significant problems related to client engagement (73 percent). A lack of provider training in working with this population (47 percent), limited resources (40 percent), and a lack of staffing (27 percent) were noted as main challenges for providing treatment to pregnant and parenting women. A learning collaborative was formed to continue focused training activities to improve provider capacitation and draw lessons and observations to inform state treatment standards. A standards advisory committee provided the state agency with input on the creation of treatment standards and on the upcoming creation of an operating certificate of endorsement for gender-responsive and family-centered care. In addition, in an effort to enhance coordination with the child welfare system, this grantee reported that the state agency informed all state substance use treatment providers working with pregnant women about the requirement to implement the Plan of Safe Care requirements established in the Child Abuse Prevention and Protection Act, as amended by the Comprehensive Addition and Recovery Act of 2016. Efforts to develop effective linkages with Planned Parenthood as a source of client referrals were challenging and only partially effective (PPW-PLT 1-1).

Two grantees highlighted efforts that the committee identified as having potential to address elements of this required activity. One grantee created a work group of providers who developed a 3-year, multi-system strategic plan for SUD treatment in their state; however, at least thus far, this effort has not focused specifically on family services or pregnant and postpartum women (PPW-PLT 2-1). Another grantee formed a work group of staff from three statewide initiatives, all of which serve pregnant and postpartum women with SUDs, with the aim of “influencing policy and practices” (PPW-PLT 1-2). Few specifics are provided about the outcomes of these efforts.

Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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In large part, progress reports indicate that, although all grantees formed advisory boards or councils with representatives of key community providers, and many noted the use of memorandums of agreement with various external service providers, these relationships most often played a role in referring women to the program and providing needed services for women enrolled in the grant services (e.g., PPW-PLT 1-1, 1-2, 1-3, 2-1, 2-2). It is not clear if and how these relationships contributed to formal ongoing systems collaboration and coordination more broadly. Other activities reported by all grantees included participating in ongoing committees, collaboratives, or groups that focused on varied topics such as child welfare. It was unclear to what extent these activities involved or did not involve working on the specifics of Required Activity 3.

The committee cannot draw conclusions regarding the overall PPW-PLT program’s contribution toward progress on this required activity. The committee notes that grantees may have needed or benefited from technical assistance in order to make progress on developing the partnerships for this activity. However, the committee notes that at least one grantee made substantial progress in implementing and sustaining partnerships, which could serve as a model for other programs (PPW-PLT 1-1).

Allowable Activity 1: Adopt and/or Enhance a Computer System, Management Information System (MIS), Electronic Health Records (EHRs), etc., to Document and Manage Client Needs, Care Process, Integration with Related Support Services, and Outcomes

Only one of the grantee progress reports mentioned activities related to this allowable activity. One site (PPW-PLT 2-3) noted significant problems in service data collection due to their participant encounter system not having appropriate dropdowns that allowed them to summarize service encounters aligned with SAMHSA service reporting requirements, and were working to add these for the upcoming year. Otherwise, due to the lack of reporting on this allowable activity, the committee cannot evaluate progress made.

Allowable Activity 2: Train or Develop the Workforce to Help State Staff or Community Provider Employees to Identify Mental Health or Substance Abuse or Provide Effective Services Consistent with the Purpose of the Grant Program

Based on progress reports, there was great variation in the extent to which grantees engaged in this activity. As noted previously (under Required Activity 3), grantees (e.g., PPW-PLT 1-1) indicated that they conducted what appears to be significant and continuous training of providers within their network with some using learning collaboratives and external expert trainers to provide training in gender-specific and family-centered treatment and/or training on specific EBPs. The extent to which these trainings focused on identification or diagnoses of mental health, SUDs, or substance use problems is unclear. Another grantee noted that one of the challenges they faced was the need for ongoing staff development and training in these topics. In an effort to address this, the grantee noted that they were in the process of identifying training topics and they provided a long list of such needed training (PPW-PLT 2-2). One grantee’s evaluation report listed several training-related objectives under the goal of reducing alcohol and drug use (PPW-PLT 1-3). These objectives focused on training medical, child welfare, and other providers about the biopsychosocial needs of women who use substances; training medical providers to conduct substance use screenings and available treatment services; training all project coordinators to establish and implement trauma-informed and trauma-specific services; and training on Plans of Safe Care. Another grantee listed several EBPs in which their staff trained other local staff, including four family services interventions and Diagnostic and Statistical Manual of Mental Disorders (DSM-5) screenings (PPW-PLT 1-2). Overall, progress reports provided to the committee indicate that EBPs were being used in service delivery but insufficient information was provided on who and how many providers were trained, or the focus of each training.

Due to most grantees not reporting on this allowable activity in their progress reports, the committee cannot provide an assessment regarding progress on this allowable activity for the program as a whole, although there are some examples of progress.

Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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Allowable Activity 3: Develop Policy to Support Needed Services System Improvements (e.g., Rate-Setting Activities, Establishment of Standards of Care, Adherence to the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care, Development/Revision of Credentialing, Licensure, or Accreditation Requirements)

Overall, progress reports and evaluation reports (when such were provided to the committee) did not include any or sufficient information about this allowable activity. The exception was one grantee who provided information on their work to develop standards of care for SUD treatment providers serving pregnant and postpartum women (PPW-PLT 1-1).

Summary of PPW-PLT Program Progress

As described above, the committee notes that progress varied greatly across the activities and across grantees. GPRA data reports were relevant only to Required Activity 1, to facilitate availability of family-based treatment and RSS. Grantee progress reports also provided relevant information. As discussed elsewhere, both data sources have limitations. However, a careful review of the information provided allowed the committee to identify progress on Required Activity 1, as described above. Grantees reported both administrative challenges, such as staff hiring and retention, and programmatic challenges, such as participant recruitment and retention. Furthermore, the committee is uncertain whether grantee activity had a measurable impact on client misuse of alcohol or other drugs, engagement and retention in treatment services, and access to MOUD above and beyond what would have happened absent the program. While grantee progress reports provide some information about Required Activities 2 and 3, there was scant information provided regarding the allowable activities.

FINDINGS: BCOR

This section is structured by the required and allowable activities as described in the grantee progress reports. GPRA data were relevant only to the required activity related to RSS. Grantee progress reports bear on all activities. The section ends with an overall summary of progress on all activities.

Required Activity: Support the Development, Expansion, and Enhancement of Community and Statewide Recovery Support Services

The primary aim and only required activity of the program is to “support the development, expansion, and enhancement of community and statewide recovery support services,” which are defined as “nonclinical services that directly assist individuals and families in recovery from alcohol or drug problems” (SAMHSA, 2017a). SAMHSA notes that such services may be provided before, during, or after treatment, and may include “social support, linkage to allied service providers (i.e. TANF, Medicaid), and a full range of human services … (e.g. housing linkages, child care, vocational, educational, legal, and transportation services)” (SAMHSA, 2017a).

The redacted progress reports supplied by SAMHSA provide insight into grantee activities in support of this required activity that were nonclinical or not client-based. Some BCOR programs were already well established in providing RSS and focused more on the expansion or enhancement of RSS; for others, the development of their capacity to provide RSS was a primary focus. Although all programs conducted this required activity, the progress reports were not specific in detailing all three aspects of this activity. Review of the progress reports suggests that this required activity was met in the following ways:

  • Development of RSS—Generally, this encompassed hiring and training peers to deliver recovery support services, identifying and training on best practices and other key aspects (e.g., ethics, mental health), and developing learning collaboratives and recovery-oriented systems of care (ROSC) structures to support RSS delivery;
Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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  • Expansion of RSS—This aspect of the BCOR program focused on several areas, including increasing the number of peers and the number of individuals served by the programs, expanding the types of services and populations served, and capacity building; and
  • Enhancement of RSS—Enhancement is a more difficult concept to distinguish in this activity and from the progress reports. It could be considered as efforts to make the BCOR program better. This included leadership training for peers, community outreach and collaboration, and internal enhancements such as billing and the use of electronic health records.

Specific activities described by the BCOR programs in response to this overall activity were provided in the progress reports and are summarized here.

Development of RSS

New peers or recovery coaches were hired and trained and/or onboarded by nearly all programs (e.g., BCOR 1-2, 2-1, 6-2). Hiring was an explicit challenge for some programs (e.g., BCOR 1-2, 5-4, 5-5), due to limited candidate pools and certification requirements. Turnover was also a challenge, especially after investments in training, which makes peers more valuable and expands their options in the workforce. The committee did not receive data on the total number of peers or recovery coaches hired and trained.

Nearly all programs had training programs and workshops for their RSS staff (e.g., BCOR 1-1, 3-1, 6-3). Training topics included overdose response and prevention, hepatitis C and HIV prevention and testing, cultural awareness/sensitivity/competency, trauma-informed care, adverse childhood experiences, family support, motivational interviewing, recovery messaging, self-care, recovery advocacy, first aid and CPR, mental health first aid, co-occurring disorders, medication-assisted treatment in the recovery framework, recovery capital, group leadership and facilitation, professional standards, and ethical considerations. Some training was used to advance the skills and knowledge of already-certified peers on topics such as forensics and the opioid crisis (e.g., BCOR 3-2). Most programs offered many topics; some repeated offerings over the reporting period and across a range of audiences (e.g., peers, other providers, stakeholders).

One program had an intentional focus on developing best-practice standards (BCOR 1-4). Several programs emphasized learning collaboratives (e.g., BCOR 1-1), so peers and RSS staff could learn from one another, across the community or the state. Several also described efforts to develop a more formal structure, such as ROSC, to support the delivery of their services and the sustainability of such collaborations. These efforts included both trainings of providers about ROSC (e.g., BCOR 1-1, 2-3) as well as concrete steps toward developing such a structure (e.g., BCOR 1-3, 6-1, 6-4).

Expansion of RSS

Many programs reported that they expanded the number of peers within and individuals served by their BCOR programs (e.g., BCOR 1-4, 5-2, 6-4). A number of programs mentioned the use of Recovery Coach Academy training—a well-known training program—to support this task (BCOR 1-3, 2-1, 5-2, 6-4). Additional details follow about the individuals served where the GPRA data are described. Capacity building also occurred in other ways:

  • One program supported 54 RSS provider organizations serving more than 2,600 individuals and 31 organizations with 86 accredited recovery houses (about 900 beds). They reported having no providers or recovery houses in the prior year (BCOR 1-4).
  • Two programs developed the availability of telephonic RSS to provide additional opportunities for support and to be flexible for individuals needing services (BCOR 2-2, 2-4).
  • Several programs supported transportation for their peers and individuals receiving services, which allowed them to expand services to individuals who could not come to the program itself or who had need for transportation (BCOR 1-1, 1-3, 4-2, 5-4).
Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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Expansion was also apparent in the types of populations targeted for RSS and services provided to the individuals in the BCOR program. For instance, several programs emphasized services for parents and families (e.g., BCOR 1-1, 1-3, 2-4). Others emphasized rural communities (e.g., BCOR 6-3, 6-5), individuals both incarcerated (e.g., BCOR 1-1, 4-3, 6-1) and post-incarceration (also referred to as reentry; e.g., BCOR 1-1, 2-3), pregnant and postpartum women (BCOR 3-1, 3-2), LGBTQ+ individuals (e.g., BCOR 1-2, 6-1, 6-5), veterans (BCOR 3-1, 3-3), homeless or formerly homeless individuals (e.g., BCOR 6-1, 6-3), and overdose survivors and their families (BCOR 3-1, 6-2). Many programs expanded their social activities for individuals (and their families or even the community; e.g., BCOR 1-3, 2-4, 5-4, 6-3), and some provided more specific services related to arts, yoga, and wellness (e.g., BCOR 1-1, 2-4, 5-1). Supports related to determinants of health were described by a number of programs, including services related to employment (e.g., BCOR 2-2, 2-4, 5-1), housing (e.g., BCOR 5-4), food security (e.g., BCOR 1-1, 2-2, 4-2), and high school equivalency test preparation (BCOR 1-3). Many programs offered groups specific to the needs of individuals seeking RSS, including self-care, charting a new course for your life, wellness, grief, and loss (BCOR 2-2, 3-1, 5-4).

Enhancement of RSS

A major enhancement activity for a number of programs was leadership training for their peers (e.g., BCOR 1-2, 2-3, 5-5).17 This may be considered enhancement, because these individuals were then better equipped themselves to conduct trainings, provide outreach to the communities and other stakeholders, and serve as a voice for the organization (e.g., in media campaigns or community activities). For example, one program hosted a 2-day “Leadership Challenge Workshop” for RSS leaders across the state (BCOR 1-1). Two others created peer advisory councils with monthly meetings to engage with peer mentees (BCOR 2-3, 6-3). Other leadership approaches were more basic, skills based, and involved learning by doing and shadowing others (e.g., BCOR 1-2, 5-4).

Some programs also emphasized training for recovery coach (or similar) certification by the states for individual peers (e.g., BCOR 1-4, 3-2, 3-3, 6-1), as well as other certifications (e.g., BCOR 5-4, 6-5), and associated continuing education (e.g., BCOR 3-4, 4-3, 6-2). One program became a “certified state training entity” for Peer Recovery Coaches (BCOR 6-1). Mentoring of the peers and recovery coaches, including those employed by other RSS programs, were mentioned by several programs18 (e.g., BCOR 1-1, 1-4, 6-3), along with a peer supervision approach (BCOR 6-4) and an internship program for peers (BCOR 4-1).

A number of grantees mentioned the development of community and statewide collaborations. Some of this was linked to the allowable activities to conduct community education, address stigma, and conduct outreach, and activities described here may overlap with those. However, some also served the purpose of enabling the BCOR programs to provide RSS with the support of the broader community, opening ways for individuals in need of RSS to be referred to the BCOR programs, and allowing the grantees to support other programs and services in the community. For one program, the emphasis was on capacity building to identify supportive organizations and effectively engage with their boards (BCOR 1-1). Building linkages and developing networks was a common thread (e.g., BCOR 1-2, 2-3, 6-1). One statewide program described a technical assistance approach (BCOR 6-3). Other examples include

  • One program emphasized their progress to “strengthen existing relationships with community partners and to reach out to new collaborators to build mutually beneficial relationships.” They note that these collaborations are further enhanced and have their reach extended by the boards of directors and leadership teams of these collaborators. This program was an exemplar in considering the meaning of collaboration, using an analysis of 20 factors that are key to collaboration success (BCOR 1-1).

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17 One grantee created a curriculum for peer leadership development, but were relying on additional, state-level resources that became delayed to be able to implement it. They plan to roll it out in the next reporting period (BCOR 2-1).

18 Additionally, one grantee reported that several peer coaches have identified a need for this type of support, and they plan to implement a mentorship program in the upcoming year (BCOR 3-2).

Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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  • One program described forming linkages through community agreements with a “resource network of community and social services agencies who are vested in our target population” (BCOR 2-3). This includes residential substance use treatment programs, the neonatal intensive care unit, drug court, the county reentry center, employment services, housing for veterans, a police homeless unit, and others. This grantee and one other (BCOR 2-1) put in place a standard schedule to engage across their partners.
  • Another held a boot camp for recovery community organizations in order to teach key aspects of serving individuals in needs of RSS (BCOR 4-1).

Finally, for some programs, enhancement focused specifically on the internal infrastructure needed to allow them to deliver services efficiently and to move toward sustainability. Two programs made efforts to bill for RSS, in one case by getting their facility and staff approved to be billed through Medicaid (BCOR 6-2), and in another by working within their state to advocate for RSS billing within Medicaid (BCOR 1-4). One program implemented and trained peers to use an EHR system (BCOR 1-2). Another integrated the GPRA into their EHR system to improve efficiency (BCOR 2-1). Another program hired a technology lead to build technology-based infrastructure and a digital presence (BCOR 3-1). Other infrastructure enhancements included developing administrative, fiscal, and personnel policies and procedures (e.g., BCOR 5-4, 6-1); creating a framework and system of best practices in line with certification standards of a national organization and adopting this certification process for new recovery residences (BCOR 6-2).

As described here, all programs made progress on the primary required activity to develop, expand, and enhance RSS at the community and state levels. With several exceptions, all were focused on their communities or regions; five of those also engaged in state-level activities to meet this primary BCOR activity (BCOR 1-1, 1-3, 3-1, 6-1, 6-2). Four programs focused nearly all efforts at the state-level (BCOR 1-4, 2-1, 6-3, 6-4). One example is a program that reported a statewide membership of 34 organizations and 266 individual members, with quarterly coalition meetings, regular advisory board calls, and standing subcommittees to engage members and advance the coalition goals (BCOR 1-3).

Individuals Served by BCOR Programs

Appendix B, Table BCOR-1 includes data generated from GPRA (supplied by SAMHSA) with aggregated client-level data at intake, 6 months, and discharge. GPRA client-based data include the type and number of services (clinical and nonclinical support services) delivered under the grant program and client-reported outcomes at intake and, where available, whether clients remained in the program, at 6 months and at discharge. The BCOR programs noted challenges in finding or interviewing clients for follow-up interviews both at discharge and 6 months, as indicated by the smaller numbers at those time periods (see Appendix B, Table BCOR-1). This challenge was in part due to the SAMHSA requirement for in-person interviews, which was a particular problem for rural programs and programs whose clients did not have sufficient access to phones or transportation. Two such programs requested permission for telephone interviews (BCOR 1-2, 6-2).

The GPRA data indicate that clients are being served. The data show, for example, intake interviews on 2,022 clients (see Appendix B, Table BCOR-1). SAMHSA indicated that with respect to actual intake numbers compared to targeted intake numbers, 5 grantees are below 50 percent; 12 grantees are between 50–90 percent; and 4 grantees are above 90 percent. Overall, BCOR programs completed intake interviews with 72.4 percent of the targeted number of clients (see Appendix B, Table BCOR-2). It is not clear from the available data whether the clients being served under the BCOR funding were already being served in some fashion by the grantees or if the clients were “new” to the program.

Basic demographic data from the 2,022 BCOR clients at intake are as follows: 41.4 percent male, 58.3 percent female, 0.3 percent transgender; 19.0 percent Hispanic or Latino, 12.8 percent Black or African American, 54.8 percent White, 1.9 percent American Indian, and 29.3 percent were not specified. In addition, 3.2 percent of clients were 13–17 years old, 10.4 percent were 18–24 years old, 33.0 percent were 25–34 years old, 26.4 percent were 35–44 years old, 16.4 percent were 44–54 years old, and 9.8 percent were 55–64 years old (see Appendix B, Table BCOR-1).

Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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The BCOR programs focus on recovery from SUDs; thus, their clients may be already in recovery, recently out of treatment, or working toward recovery. Some clients used drugs (21.0 percent) or alcohol (16.7 percent) in the 30 days prior to BCOR intake. Some clients had received at least 1 day of substance use treatment in the 30 days prior to BCOR intake: 33.7 percent were in inpatient treatment (e.g., residential or detoxification) and 22.9 percent had been in outpatient treatment in the 30 days prior. Nearly three-quarters (72.3 percent) had attended a self-help group in the 30 days prior (see Appendix B, Table BCOR-1).

The BCOR programs served clients who had complex social and medical profiles when they entered the program: In the 30 days prior to intake, 33.7 percent were on parole or probation and 17.4 percent were awaiting trial, charges, or sentencing; 31.8 percent had not been living in a house most of the prior 30 days; only 28.3 percent were employed full or part time; 54.7 percent did not have enough money to meet their needs in the past 30 days; and serious depression (48.8 percent) and anxiety (62.8 percent) were quite common (see Appendix B, Table BCOR-1).

The GPRA data also report on GPRA surveys completed at discharge from BCOR (see Appendix B, Tables BCOR-1 and BCOR-2); the committee notes that these data are highly difficult to interpret. It is not clear what defines a discharge because it is determined by each grantee, and that definition is not provided by each grantee in the progress reports. Furthermore, only 29.1 percent of BCOR clients with an intake GPRA provided a discharge GPRA (see Appendix B, Table BCOR-2). This means that the discharge data are quite unlikely to be representative of all clients served, nor can it be determined whether clients who were not interviewed at discharge were doing better or worse than other clients were.

Despite these concerns, discharge data are reported here to give some indication of services received in the BCOR program.19 The GPRA discharge data indicate, for example, that 91.0 percent of clients who completed a discharge interview received case management—defining, initiating, and monitoring the medical, drug treatment, psychosocial, and social services provided for the client and the client’s family. RSS, defined differently than case management, was received by 78.8 percent of these clients. Recovery coaching was provided to 41.6 percent, and peer coaching or mentoring to 26.1 percent. As another example, 71.1 percent received employment coaching, which was an explicit goal of a number of programs as indicated in the progress reports (see Appendix B, Table BCOR-3).

Outcome data are available in the GPRA data for clients at discharge and 6-month follow-up. These suggest that fewer clients were using substances at these later time periods than were at intake. In particular, at first followup (which could be discharge or 6-month follow-up after intake), 83.5 percent had not used alcohol or drugs in the prior 30 days compared to 71.2 percent at intake (see Appendix B, Table BCOR-8b).

The GPRA data do not indicate the number of specific client services or client outcomes by grantee, as had been provided in generalities about intake numbers previously described or in the progress reports. It is possible that some of the specific client services are being delivered by only a few of the grantees. Furthermore, only some of the activities, both required and allowable, under the BCOR program involve direct client engagement. Thus, the GPRA data provide only a partial picture of the success of the BCOR program. The GPRA data indicate that more than 2,000 clients were directly served by BCOR programs, that these clients were of high need for a range of services that would support them in their recovery, and that the programs provided case management and RSS to these clients.

Allowable Activity 1: Build Connections Through Infrastructure Building Between Recovery Networks, Between Recovery Care Organizations, and with Other RSS

By allowing for infrastructure building to develop connections, this activity provides a specifically permissible pathway toward achieving the required primary activity of the program, as previously described. The FOA also outlines, in detail, the numerous health care, criminal justice, and social support systems that SAMHSA identifies as key RSS but leaves the door open for additional locally identified ones (see Box 2-1).

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19 For a more detailed discussion of the limitations of these data, see the Methodology section of this chapter.

Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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The committee turned to the grantee progress reports for information on the success and progress on this allowable activity. Of the 25 grantees for which progress reports were available, 20 identified building connections between recovery networks, recovery community organizations (RCOs), and other RSS as a specific goal. Four grantees did not include any mention of building connections as a goal; one grantee described building connections only indirectly through the provision of direct services to a specific group of individuals.

With respect to this allowable activity within the BCOR grant program, the progress reports highlight several key findings. Of the 25 grantees, 19 (76 percent) were operational at the time of their report (either after 1 or 2 years of funding). An additional four awardees were partially operational and only two had made no or extremely little progress. All grantees were operational, with respect to this allowable activity, after 2 years of funding.

It appears that 14 of 20 projects that included mention of building connections between recovery networks, recovery care organizations, and other RSS had made progress in this area. Of these 14, 7 (50 percent) either started their progress reports with or dedicated virtually the entire document to describing their progress and work for this activity, implying that this piece of BCOR was a key focus of the overall project. For the other half of grantees for whom this was a goal but not a major one, several described building connections with parts of the criminal justice system, including local jails (BCOR 4-3), the court system (BCOR 5-1), or law enforcement (BCOR 3-2, 4-2) as sources of referral for project participants or as partners focused on a particular group of individuals working to sustain recovery.

The ability of grantees to build connections between recovery networks, recovery care organizations, and other RSS varied tremendously. Several grantees (e.g., BCOR 1-2, 1-3, 5-4) described building broad and successful coalitions within their communities whereas others encountered many challenges (e.g., BCOR 5-5). Grantees included a wide range of organizations in their networks and coalitions. In some communities, police, court systems, and jails were a focus (e.g., BCOR 2-1, 5-1) whereas others included specialty OUD and SUD treatment providers (e.g., BCOR 5-4, 3-3, 3-4) and local businesses (BCOR 3-4) as key constituents. Some, but not all, grantees mentioned efforts to develop connections with other recovery care or support organizations (e.g., BCOR 1-1, 5-4, 6-2, 6-1).

The projects demonstrating the most progress shared three key elements. First, they employed clear, organized strategies, systematically gathering information from stakeholders as part of the network-building process. One grantee, for example, used the Wilder Collaboration Factors Inventory Survey to strengthen existing relationships and build new ones for a statewide recovery network. Each collaborating organization, in turn, could use the information from the survey to inform their own strategic plan that built off universally adopted missions, visions, and values for the coalition (BCOR 1-1). Another project used a partnership map to organize and focus on

Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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organizational linkages within a network, informed by a “Strength of Partnership” survey and solidified through formal memorandums of understanding (MOUs; BCOR 6-3).

Second, successful grantees to date described strong, consistent leadership that understood the landscape and context of the environment in which they worked. These leaders often had extensive contacts in the systems they were trying to engage and strong organizational and management skills (e.g., BCOR 4-1). Projects with high staff turnover, especially in leadership positions, noted struggling to achieve the same level of progress (e.g., BCOR 1-2).

Third, having a specific framework or predefined model around which to convene stakeholders and collaborating organizations helped move progress toward Allowable Activity 1. For example, many grantees spoke about training employees in the ROSC organizing framework (BCOR 1-1, 2-3). One grantee reported that their coalition discussed the need to strengthen and expand ROSC (BCOR 1-4). Another focused on revitalizing a defunct ROSC in a region, clarifying its role and purpose and using that as a springboard for working with state agencies, other RCOs, and a certification board to develop a concrete plan for providing the recovery coach credentialing necessary for Medicaid reimbursement in the state (BCOR 6-1). Another grantee formed a steering committee to focus recovery support interventions across a network of RSS formalized by MOUs (BCOR 3-3).

One of the most striking differences between the rest of the group and the handful of projects clearly on the path to success with respect to this activity, however, lay in the level of understanding of what is required to sustain a system of services. In answer to the question of sustainability plans for the project, most grantees responded with statements related to procuring additional grants. However, a handful of grantees also described activities that showed an understanding that a network of recovery care organizations would make for a stronger voice in advocating for payment and quality. One of these grantees noted that their state’s Medicaid program had recently approved reimbursement for peer RSS, and, as previously mentioned, this grantee was partnering with other RCOs to facilitate the necessary credentialing of peers to ensure reimbursement (BCOR 6-1). A second grantee collaborated with recovery organizations and other stakeholders to create a statewide best practices model for recovery residences tied to state funding and referrals; they received approval from the state’s SSA, and will initiate implementation in their Year 2 (BCOR 6-2). For one grantee, building connections seemed to involve mostly treatment providers for SUDs (BCOR 5-4).

The committee noted that grantees might have needed or benefited from technical assistance to make progress on developing partnerships for this activity. It is not clear how much assistance SAMHSA or others provided around the specific partnership barriers, and, in the instances in which they did, there seem to have been delays. For example, only after protracted negotiations with SAMHSA over project type and budget was one grantee able to hire an outside consultant to assist in building their own administrative, fiscal, and data-collection policies and procedures that then better positioned them for success (BCOR 5-4). In addition, SAMHSA’s reliance only on the GPRA as a data-collection tool for a grant program that is primarily about system development adds to the misalignment between project goals and activities, implementation, and evaluation. See Appendix C for a summary of the committee’s first report. The lack of a data system to track progress in system development may also have slowed the identification of struggling projects.

Allowable Activity 2: Reduce the Stigma Associated with Drug and Alcohol Addiction

Grantees in the BCOR program were allowed to create outreach and other programs that reduce discrimination and stigma, with an end goal of eradicating discrimination and stigma for people living with SUDs. Grantees have initiated multimodal programs with foundations committed to social justice, with the aim that people who live with the chronic illness of SUDs will be less likely to encounter stigma and discrimination. However, the committee notes that, because of the nature of the progress reports, it is unclear what strategies these projects used for stigma reduction, and whether they employed available EBPs.

The most common modality used by grantees to decrease stigma was the use of social media platforms. The purpose was to reach and educate communities. The most frequently used social media platforms were Facebook, Twitter, LinkedIn, and Instagram. Some grantees used billboards (BCOR 2-4, 4-2), radio (BCOR 4-1, 4-2), television commercials (BCOR 4-2, 6-4), and public service announcements (BCOR 2-3). The reaches of these platforms are potentially quite large and span all ages, cultures, and socioeconomic statuses. Social media campaigns are low

Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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cost and do not require significant time investment on the part of staff. At least one agency collaborated with an anti-stigma agency to help develop their training materials, coordinate events, and improve their website (BCOR 6-2).

Almost all of the grantees used social media platforms as a way to disseminate information on OUD, SUD, and the recovery movement. The committee reviewed data on the number of views that grantees’ social media content received, but SAMHSA did not provide information on the value of disseminating information using social media (i.e., what specific information viewers took away from the content). There was a similar gap in the information received about educational programming because the grantees who reported conducting these activities had no mechanism by which to assess what attendees had learned from the curricula presented.

Grantees provided education in order to combat stigma and discrimination related to SUDs. One grantee developed a task force focused on reframing SUDs as a health issue, rather than one of criminal justice (BCOR 3-2). One grantee developed educational programming for grades K–12 on “drug prevention and substance use disorders” (BCOR 5-1). One grantee held “stigma reduction” virtual trainings for first responders, law enforcement, emergency department personnel, and social workers (BCOR 4-1). Another grantee chose to focus their education on community businesses. The anti-stigma project sought to encourage businesses to hire people in recovery, and to teach businesses how best to support employees in recovery (BCOR 6-2).

One grantee offered a “Speaker’s Bureau” training for people with SUDs and the lived experience of the recovery process. The program was designed to teach individuals with a lived experience of recovery how to apply effective communication and interpersonal skills to share their experiences, with the ultimate goal of reducing stigma around SUDs. Graduates of the program shared their stories with policy makers, community members, and other stakeholders (BCOR 5-1). One grantee partnered with the National Alliance on Mental Illness to “engage community conversations addressing stigma within the recovery community” (BCOR 4-1).

Few grantees reported that cultural awareness was a key factor in decision making or program development, though several did offer staff trainings in related topics (BCOR 1-4, 2-3, 3-4, 6-5, 6-4). These covered subjects including cultural competency, diversity and inclusion, relevant laws and regulations against discrimination, and internal organizational policies, plans, and protocols regarding culturally and linguistically appropriate services. One grantee stood out for the effort and attention it dedicated to this issue, and they undertook a baseline cultural competency self-assessment using the National Standards for Culturally and Linguistically Appropriate Services from the Office of Minority Health at the Department of Health and Human Services (BCOR 3-4). This evaluation placed them into Stage 1, described generically as follows:

organizations [in this stage] have taken some action to recognize diversity within their staff, their client population, and community. There is a feeling, at least among staff and some in management, that diversity is an important issue, that the organization may face problems associated with cross-cultural competence, and that some action must be taken to address it…. However, relatively little formal movement and direction would have taken place.

This grantee recruited people from unrepresented groups to work within their organization with the aim that the people working would be representative of the people they were serving. However, although the grantee documented overall staff demographic information, they acknowledged as a limitation the fact that they did not break down demographics by specific types of positions, salary, or tenure (BCOR 3-4).

Allowable Activity 3: Conduct Public Education and Outreach on Issues Relating to Drug and Alcohol Addiction and Recovery

This activity relates directly to the FOA’s objective to promote education about recovery from SUDs, which presumably enhances the programs’ ability to develop, enhance, and expand the delivery of RSS to a community that is knowledgeable about the disease of SUDs, recovery, and the need for the recovery supports. This activity also serves to advance Allowable Activity 2 (and vice versa) in reducing stigma.

The flexible progress report format used by SAMHSA meant that it was not always clear whether this activity was addressed intentionally, and how the activities were distinct (or if they were) from Allowable Activity 2. Based on grantee progress reports, it is the committee’s assessment that, overall, 10 grantees addressed this activity well

Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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(e.g., BCOR 1-1, 2-2, 5-1); six grantees had this as a goal, but had only partial or minimal progress (e.g., BCOR 1-2, 2-4, 3-4); five grantees had this as a goal but made no progress (e.g., BCOR 3-3, 4-2, 5-2); and two grantees did not explicitly mention this goal although they had some activities related to it (e.g., the “partnership maps” created by BCOR 6-3; community meetings about RSS and efforts in social media and advertising by BCOR 6-4). The remaining two programs neither identified this activity as a goal nor engaged in it.

The BCOR programs that engaged in this allowable activity, either fully or partly, identified a wide range of approaches. Generally these could be grouped into (1) engagement with policy makers (i.e., government officials at local, state, and federal levels) for general outreach and awareness activities and around the need for funding or specific legislative supports; (2) community outreach regarding recovery broadly and specific to the BCOR efforts, including efforts to build community support; (3) outreach to and training of a variety of audiences; (4) hosting or supporting recovery-focused events (e.g., Recovery Day) and participating in community events; (5) social media and similar approaches for sharing recovery-focused information, and to reduce stigma; and (6) other educational and outreach activities. Allowable Activity 2 overlap is particularly found in (3) and (4). Most programs did not describe outcomes of these endeavors, with rare exceptions, and only some described the reach in terms of the frequency of activities or the number of participants. The following sections offer additional detail.

Engagement with Policy Makers

One BCOR program had this as a primary goal and did this very intentionally (BCOR 1-4). They reached out to policy makers at the state level (e.g., governors’ offices, state legislators, and state committees) and the federal level (e.g., members of Congress and their staffers). This program had intentional goals for each of these conversations: Many were to raise awareness about recovery and RSS; some were specific to legislative and funding support for RSS. This program tracked the topics covered in these conversations and outcomes resulting from them.

Other programs used this approach with varying degrees of outreach. For some, the focus was on their localities, and on engaging with mayors’ offices and local committees (e.g., BCOR 4-2). Local engagement included outreach as part of an effort to gain community support for their activities and emphasized the importance of having individuals in recovery as a “voice at the table” in local policy making. Others focused at the state or county level, with similar efforts to those in the previously mentioned BCOR 1-4 example. As previously mentioned, one grantee provided public speaking training to peers for the sake of advocacy, and highlighted policy makers as one of their targeted audiences (BCOR 5-1).

A focus on funding was explicitly described by three programs (BCOR 1-3, 1-4, 5-4). One connected with their country’s behavioral health advisory board so that they could identify gaps in funding for RSS and contribute to the discussion about approaches to fill these gaps (BCOR 5-4). Two made intentional efforts to improve funding availability for such services statewide, one through the Single State Authority for SUD (BCOR 1-3) and another through their state’s committee structure (BCOR 1-4). One also reached out to the Department of Education to advocate for increased funding for recovery high schools (BCOR 1-3).

Building Community Knowledge and Support for BCOR and Recovery Services

Most programs that addressed Allowable Activity 3 had at least some engagement with the community around their activities. In some cases, this was to address the challenges presented by a lack of community support around SUD treatment programs (e.g., BCOR 2-2). Programs held listening events (e.g., BCOR 1-1) and engaged in general outreach to community members and groups. Most programs had some version of community educational events around SUD and recovery. Some offered educational events on related topics, such as Mental Health First Aid for community members (BCOR 3-1) and naloxone training (BCOR 2-2).

Outreach and Training Activities

Most programs offered some version of outreach and training activities. Some did this very intentionally, with identified goals and topics and a range of audiences to which they reached out. Others also did it intentionally, but it was more opportunistic (e.g., they were invited) or specific to the BCOR activities. Examples include

Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
×
  • Trainings with first responders (BCOR 2-3, 4-1), criminal justice (e.g., BCOR 3-2, 4-1, 5-4), and community health services (e.g., BCOR 5-4) about recovery, harm reduction, and RSS.
  • Outreach to describe RSS to SUD treatment programs (e.g., BCOR 1-3), colleges (e.g., BCOR 1-3, 5-4, 6-2), public schools (e.g., BCOR 1-3, 1-4, 5-4), social service organizations (e.g., BCOR 2-2), and faith-based organizations (BCOR 2-1, 3-1, 3-3, 6-3). In some cases, this included open houses or orientation day participation to engage directly with individuals who may have wanted to obtain the recovery supports offered by the BCOR program (e.g., BCOR 2-2). In other cases, it was to educate potential referral sources (e.g., BCOR 1-3).
  • Educational meetings with neighborhood associations (BCOR 2-1), businesses (e.g., BCOR 3-4, 4-2), and service workers (BCOR 6-1, 6-2) to emphasize the importance of recovery and recovery supports.

Recovery-Focused Events

Many programs hosted or supported recovery-focused community events, which served as a form of education and sought to reduce stigma. These include recovery events (including a recovery day, recovery rallies and runs; BCOR 1-3, 2-3, 6-2), naloxone training day (BCOR 2-2), recovery symposiums (BCOR 1-1), and film festivals focused on recovery (BCOR 1-3, 2-2). Grantees presented these activities as opportunities to foster good will between the communities and people in recovery. Some programs also mentioned hosting tables or booths at general community events, in order to highlight their programs and recovery more broadly and to be available for questions (BCOR 2-2, 4-1, 6-2).

Social and Other Media

This approach is described further under Allowable Activity 2, but several programs highlighted this in the context of Allowable Activity 3. In particular, several programs put out advertising or public service announcements as part of their community outreach and educational efforts (e.g., BCOR 2-3, 4-2).

Other Outreach and Education

Some programs brought other creative approaches. Two highlighted that they joined a Chamber of Commerce to engage with the business community around the importance of recovery and RSS (BCOR 1-1, 4-2). Others participated in regional conferences of SUD and other professional organizations (e.g., BCOR 1-4). One program created several educational tools, such as a mobile classroom, an exhibit of a teenager’s room, pamphlets for emergency services to use, and educational curricula for school districts (BCOR 5-1). Another created a search-able online directory of their county’s RSS (BCOR 5-4). One offered a Speakers Bureau through which people in recovery would be trained to talk with community groups and others (BCOR 5-1).

Summary of BCOR Program Progress

The BCOR program was funded by SAMHSA primarily to support the “development, expansion, enhancement, and delivery of” community and statewide RSS. Based on a review of redacted progress reports and GPRA data, which were not designed for activities beyond direct client service provision, the committee finds that the BCOR programs as a whole made progress toward this goal. The progress reports indicate a wide range of ways in which RSS were developed, expanded, and enhanced, and the GPRA data indicate that many clients directly received RSS, although the data do not allow an assessment of how effective those services were. Individual programs, based on the progress reports, were more or less successful. Some of this depended on how well developed the program was when funded, the grantee’s ability to hire staff and implement infrastructure needs, and the specifics of their own goals.

Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
×

Many programs have addressed the additional allowable activities: (1) build infrastructure building between recovery networks, between recovery care organizations, and with other RSS; (2) reduce the stigma associated with SUD; and (3) provide public education and outreach on issues relating to drug and alcohol addiction and recovery (SAMHSA, 2017a). Each of these is assessed only via the progress reports.

Most programs addressed Allowable Activity 1, as it was directly related to the required activities. That is, to develop, expand, and enhance RSS, programs must also build connections. Many BCOR programs were part of, or were part of the development of, networks of other recovery care organizations. Furthermore, many RSS are provided by other types of organizations (e.g., housing, employment services); and BCOR programs built connections in this manner. Based on the progress reports, the programs that had this as a defined activity also made progress. Again, this varied by program and by their specific goals.

Most programs also addressed Allowable Activities 2 and 3, and they overlap in many ways. Reduction of stigma is a goal for many recovery programs in general, and many of the activities to reduce stigma include public education and outreach. Programs engaged with the public via workshops, media and social media, community activities, and social activities hosted by the program. Some engaged with governments, boards, and committees at all levels. The progress reports indicate success toward these activities by the programs that had them as defined activities. It is, however, highly difficult to measure success in any objective manner. Stigma reduction is a long-term endeavor and not easily measured. Outreach and education are defined by the provision of information and it is not always clear who participates, whether they are new to this information, and what they do with it. The committee thus defined success by the indicators of what was done to make progress in these areas. Again, challenges were noted, particularly in terms of ongoing stigma in some communities.

In summary, the committee finds that the BCOR grantees made progress toward the required activity and the allowable activities, but that a more specific assessment is not possible due to the limitations of the material the committee received.

Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
×
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
×
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
×
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
×
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
×
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
×
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
×
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
×
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
×
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
×
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Suggested Citation:"2 PPW-PLT and BCOR Programs." National Academies of Sciences, Engineering, and Medicine. 2021. Progress of Four Programs from the Comprehensive Addiction and Recovery Act. Washington, DC: The National Academies Press. doi: 10.17226/26060.
×
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Substance use disorder (SUD) and opioid use disorder are significant public health threats that affect millions of Americans each year. To help address overdose deaths and lack of access to treatment, the Comprehensive Addiction and Recovery Act (CARA) was signed into law on July 22, 2016. CARA is extensive legislation intended to address many facets of the opioid epidemic, including prevention, treatment, recovery, law enforcement, criminal justice reform, and overdose reversal. It authorizes more than $181 million each year in new funding to fight the opioid epidemic and it requires the implementation of programs and services across the United States to address SUD and recovery.

Following the passage of CARA, the Departments of Education, Health and Human Services (HHS), and Labor, along with the 2018 Related Agencies Appropriations Act, included appropriations for a study of the Substance Abuse and Mental Health Services Administration (SAMHSA) components in CARA, to be conducted by the National Academies of Sciences, Engineering, and Medicine. In response to this charge, the National Academies formed an ad hoc committee to review outcomes achieved by four programs funded by SAMHSA through CARA: State Pilot Grant Program for Treatment for Pregnant and Postpartum Women (PPW-PLT), Building Communities of Recovery (BCOR), Improving Access to Overdose Treatment (OD Treatment Access), and First Responders (FR-CARA). The committee's review is designed to result in three reports over 5 years. This report, the second in the series, reviews reported outcomes and metrics to assess progress toward achieving program goals.

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