Policy Issues in VR Related to Consumers with Substance Use Disorders

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Policy Issues in VR Related to Consumers with
Substance Use Disorders

• Substance Abuse Vocational Rehabilitation - the
  Elephant in the Room Research, Policies, and
  Exemplary Practices
• Tuesday, Oct 16, 2007
• Key Bridge Marriott
• Arlington, VA
• Dennis Moore, Ed.D.
• Professor, Department of Community Health
• Boonshoft School of Medicine
• Wright State University

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Policy Issues in VR Related to Consumers with
Substance Use Disorders

• Substance Abuse Vocational Rehabilitation - the
  Elephant in the Room Research, Policies, and
  Exemplary Practices
• Tuesday, Oct 16, 2007
• Key Bridge Marriott
• Arlington, VA
• Dennis Moore, Ed.D.
• Professor, Department of Community Health
• Boonshoft School of Medicine
• Wright State University

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Source SAMHSA OAS, 2007
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Employment rates at VR intake

• Persons with a diagnosis of SUD, TBI, or SMI have
  an average work outside home employment rate of
  14.5 at the time of application to state VR
  programs, whereas all other disability categories
  have an average rate of 24.6 at this same period
  in time
• (Moore Weber, 2003).

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VR Consumer Profile Persons with SUD

• Consumers with SUD will have a 50 chance or more
  of experiencing each of the following
• relationship problems due to their use,
• trouble at work or school because of use,
• victim of violence related to use, and
• likely to have been hospitalized because of use
• (RRTC, 2002 6 state epidemiological study)

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Significant Zero-order Correlation Coefficients
of Drug Use Six state epidemiological study VR

• Age (Exact age) -.069
• Gender (Male1) .065
• Income (10 point scale) -.064
• Family Use (Family substance abuse1) .131
  
• Friend Use (Friend drug use1) .417
• Attitude of Entitlement (13 point scale)
  .212
• Self-esteem (21 point scale) -.138
• Hostility (21 point scale) .126
• Risk-taking (21 point scale) .194
• plt0.01 plt0.001 drug use 1
• (Moore Li, 1998)

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Recent finding SUD prevalence

• Substance Abuse in VR-Screener (SAVR-S) was
  validated using DIS trained research
  interviewers with 1,000 consumers of VR in OH
  IL
• Active SUD diagnosis (DSM IV r Criteria) in 22.1
  of sample (IL OH) at time of application to VR
• Finding is consistent with previous research (33
  - 23) (DiNitto Schwab, 1993 Moore Li, 1998)
• Heinemann, Lazowski, Moore, Miller, McAweeney.
  (in press). Rehabilitation Psychology

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SUD as primary or secondary diagnosis by state RSA 911 Dataset 2005 SUD as primary or secondary diagnosis by state RSA 911 Dataset 2005 SUD as primary or secondary diagnosis by state RSA 911 Dataset 2005 SUD as primary or secondary diagnosis by state RSA 911 Dataset 2005 SUD as primary or secondary diagnosis by state RSA 911 Dataset 2005
AR (0.90) OH (2.57) WV (3.58) TN (3.70) IN (3.72)
IL (4.02) FL (4.04) AZ (4.35 MA (4.67) WI (4.72)
NH (5.46) IA (6.09) RI (6.68) NE (6.80) CO (6.80)
GA (6.89) OK (7.16) MT (7.36) SD (7.56) KA (7.78)
NV (8.57) WY (9.24) DE (9.41) CT (9.64) OR (10.01)
WA (10.46) MN (10.53) MO (10.69) NC (10.81) MS (10.88)
VT (11.37) VA (11.61) CA (11.65) LA (12.16) AL (12.19)
TX (12.33) NM (13.56) KY (14.87) MI (14.94) ID (15.46)
AK (15.58) PA (15.66) UT (15.83) NJ (16.04) ND (16.14)
MD (18.42) MA (19.85) NY (22.80) HI (26.94) SC (28.32)
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RRTC findings - rural western state 2000
(N243 27 response rate)

• Overall 22.3 self-reported that they were an
  alcoholic, drug addict, or both an alcoholic and
  drug addict in recovery, while Chemical
  Dependency (CD) was designated by the Disability
  Services Division as the primary and/or secondary
  disability for only 2.5 of the sample.

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VR agency policy response to RRTC findings

1. Show an ability to remain drug/alcohol free for a
   period of time (3-6 months), with verification
2. Be involved in abstinence support, with
   verification
3. Adhere to professional recommendations regarding
   recovery
4. Adhere to law enforcement requirements
5. Participate in periodic reviews with VR counselor
6. Responsibility to provide timely verification for
   the above

contract to be signed by consumer and counselor
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RRTC R3 State level policy analyses and the
provision of rehabilitation services to consumers
with substance abuse problems

• Why conduct this study?
• Active SUD in VR likely 25
• Wide variability in prevalence of SUD in VR
• Policies and practices impact SUD identification
• Screening models for SUD not developed
• Screening as a tool or weapon?

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RRTC R3 State level policy analyses and the
provision of rehabilitation services to consumers
with substance abuse problems

• Phase I policy document review
• Phase II surveys of VR and SUD
• Phase III case studies of 6 VR programs

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Factors identified via focus groups, interviews,
expert opinion

• Order of selection (OOS)
• Functional impairment ratings of SUD
• Confusion over eligibility (ADA, Rehab Act, SSA)
• Sobriety waiting periods
• Proof of sobriety
• Availability of SUD treatment
• Specialized vs. general caseloads and services
• Perceived success rates for addressing SUD in VR
• Counselor competency

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VR Director Responses 44 states
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Does your VR policy manual address consumer
substance abuse? N 78 VR admin
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From a practical perspective, please choose the
order of selection description that best
describes your agency? N 78 administrators,
44 states
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If your staff refer someone to substance abuse
treatment, in what percent of the cases is VR
likely to pay for that treatment based on your
experience?

• SUD treatment paid by VR
• Mean 12.2
• range 0-100 SD 28.8

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Do you have an MOU or working agreement with
other (VR/AOD) agency, and does this involve a
transfer of funds (VR 44 states AOD 34
states)
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Do you have a sobriety waiting period, either
formal or informal in VR?
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VR Counselors IL OH
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Do you screen for SUD?(N 213 VR counselors in
2 states)
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Do you feel that rehabilitation of persons with a
history of a substance abuse disorder is more or
less likely to result in a successful closure
than consumers with other disabilities? N 214
counselors, 2 states
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How do you screen for SUD?N 213 VR counselors
in 2 states
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If a reliable and valid, low-cost, short
screening instrument for substance abuse were
available specifically for the VR setting, would
you use it? N 214 counselors in 2 states
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Please rate how effective you feel you are in
working with a consumer who has a substance abuse
problem
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State Alcohol/Drug agency directors 34
states
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How would you best classify the actual job
description of your staff member who is in charge
of compliance with the ADA for clients and
services to persons with disabilities? N 37
AOD admin
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Is there a need for more vocational
rehabilitation services for AOD clients in your
state? N AOD Dir
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AOD Dept MIS includes disability-specific client
variables required of providers (e.g., deaf,
blind, traumatic brain injury) N 37 AOD
Directors

• 48.6 - yes
• 45.9 - no
• 5.4 - no response
• Range 1 13 categories
• Mean categories 6.3

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Disability Reported At Intake SUD Programs NY
OASAS 1999 (N 146,782)
Persons entering tx 12.3 have another
disability Persons entering tx 17.7 have two
or more other disabilities Total 30.0   SUD
One other disability 28.3 have MI as this
disability SUD Two or more disabilities 91.7
have MI as one of them
Moore Weber, 2000
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Additional policy-related issues identified
through surveys and SUD screening

1. Should SUD screening be mandatory for VR
   applicants
2. Are SUD screening results available for record
   requests (e.g., SSA disability determination)
3. Client choice versus counselor judgment is
   refusing SUD tx or support permissible?
4. Due diligence requirement for informing potential
   employer about relapse-workplace safety issues
5. When and how does consumer with SUD request
   accommodations from employer?
6. What additional confidentiality requirements
   exist with SUD records beyond HIPAA (e.g., 42
   CFR)?

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National Responses
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A Conceptualization of consumer SUD within VR and
AOD systems

• (rehabilitation) Individual attempting or in
  recovery interested in re-building life,
  including work
• (habilitation) Individual with trifecta of MI,
  SUD, and chronic medical conditions, where one or
  more of conditions is unaddressed in systems of
  care (Thompson, 2007)
• Evidence suggests 90 of resources needed for 10
  of consumers

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Federal Level External Workgroup on Disability
Policy Recommendations to CSAT/SAMHSA 2007

• 1 Train SAMHSA staff in disability and ADA
• 2 Data collection on disabilities in TEDS and
  the National Household Survey on Drug Use and
  Health
• 3 Enforce ADA-compliance Matrix for State Block
  Grants and discretionary programs
• 4 Identify cadre of national trainers skilled in
  disability-related interventions
• 5 Develop ADA Compliance Curriculum for states
  and treatment organizations
• 6 Develop SAMHSA website for persons with
  disabilities
• 7 Issue grants for treatment of youths and
  adults with physical and cognitive disabilities

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Possible federal/national responses in VR (e.g.,
RSA, CSAVR)

• Form workgroup comparable to SAMHSA disability
  workgroup to review findings and make
  recommendations
• Support increased training in SUD for VR field,
  and inculcate in rehab training programs
• Strengthen national and federal partnerships for
  data collection, identifying effective practices,
  and shared funding
• Promote SUD detection and appropriate
  rehabilitation planning within VR systems
• Disseminate information on best practices and
  policies
• Policies must be sensitive to Primary Diagnosis
  of SUD, as well as one of hidden conditions

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RRTC - NIDRR can assist with national plans

• Facilitate national workgroup (e.g., via ICDR)
• Publish and disseminate VR-SUD training materials
• Publish research findings
• myvrtraining.com website
• Toolkits for VR professionals
• Publish policies and related documents
• Assist with education about need for
  disability-related variables in national datasets

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Policy change increasingly falls to state, rather
than federal government
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Evidence to date suggests that solutions should
include

• Data collection related to persons with
  disabilities in multiple settings, including SUD
  treatment
• VR policies and practice guidelines relative to
  active SUD and rehabilitation responses
• Coordinated inter-agency responses are required
  (i.e., VR, MH, and AOD agencies must work
  together)
• Greater focus on training in SUD for VR and
  Disability Issues for other agencies

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Q A