Residential Women’s Treatment: Cost-Benefit and Outcome

Findings from a CSAT Cross-Site Evaluation

Ken Burgdorf, Ph.D.

Xiaowu Chen, M.D., M.S.P.H.

CSAT Women’s Conference, July 12, 2004

*Study conducted under Contract 270-97-7030 funded by the Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. Center for Substance Abuse Treatment, 5600 Fishers Lane, Rockwall II, Suite 740, Rockville, Maryland 20857, 301/443-5052. Contents are solely the responsibility of the authors and do not necessarily represent the official views of the agency.

The RWC/PPW Program and Cross-Site Evaluation

• The Residential Women and Children (RWC)/Pregnant and Postpartum Women (PPW) programs were funded by the Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment

• The cross-site evaluation encompassed 50 5-year RWC/PPW projects that were funded in two cohorts:

• 39 in FY 1993

• 11 in FY 1995

• Each project was required to develop a comprehensive, long-term (6- or 12-month) residential treatment program for pregnant and parenting women with serious substance abuse problems, including on-site care of clients’ infants and young children

RWC/PPW Projects Provided:

• Outreach services to promote Tx entry & retention• Screening/assessment for women, infants, &

children• Medical testing for substance abuse related

diseases/conditions• Medical care for clients & children• Individual and group therapy/counseling for

clients & children

RWC/PPW Projects Provided (con’t)

• Educational & vocational services for clients & children

• Other support services for clients & children• Individualized case management, w/ active

involvement of clients• Family member involvement in children’s Tx• Full continuum of care in residential setting

The RWC/PPW Cross-Site Evaluation

• Cross-site evaluation collected data from October 1, 1996 to March 31, 2001

• 50 RWC/PPW projects submitted a standardized set of quantitative data on a quarterly basis including admission, treatment services, discharge, and 6-month follow-up data

• Outcome data set represents 1,768 former clients from 32 projects that met minimal requirements for follow-up data collection (50% follow-up rate or better)

• Follow-up data are available for 1,181 women

• Nonresponse adjustments made to account for underrepresentation of short-stay clients

Project Characteristics (n=32)

Characteristic Number ofProjects

Characteristic Numberof Projects

Project TypeRWCPPW

1616

Intended Length ofStay

6 Months12 Months

1418

Number of Beds10-1214-1618-2021-33

1075

10

Target PopulationAfrican-AmericansHispanics/LatinasNative Americans

984

Client Characteristics (n = 1,768)

Primary Drug of AbuseCocaineCrackMarijuanaHeroinMethamphetamineAlcoholOther

11%40%

5%8%

13%14%

9%

Race/EthnicityAfrican-AmericanAlaskan NativeHispanic/LatinaNative AmericanWhite (not Hispanic)

40%3%

14%6%

32%

Number of Children0123-11

3%18%25%54%

Number of Children inTreatment with Client

0123-6

26%47%19%

8%

Client Characteristics (continued)

Average Age atAdmission

30.3 Client Was Homeless inthe Two Years Prior toAdmission

36%

Average Number ofYears of AOD Use

15.6 Client Reported ChildrenRemoved by CPS atAny Time in the Past

47%

Dually Diagnosed 53% Criminal Justice System(CJS) Involved atAdmission

50%

Client Pregnant atAdmission

25% Client Received PriorSubstance AbuseTreatment

85%

Client Employed atAdmission

8% Client CompletedTreatment

43%

Child Characteristics (n=4,048)

Male 49.0%

Mean age 3.8 3.4 years

Child Placement before treatment

Legal custody

(%)

Living situation (%)

Mother 67.1 45.8

Father 0.9 4.1

Mother & Father 12.8 9.0

Grandparent 2.1 13.3

Other relative 0.8 6.0

State 13.8 15.9

Other 2.5 5.7

Client, Pregnancy, and Project Outcomes

Outcome Dimensions Covered

• Abstinence vs. Relapse

• Arrests for Illegal Activities

• Economic/Social Outcomes

• Physical and Mental Health

• Pregnancy Outcomes

• Project Sustainability

Client Substance Use, Pre-Post Change

Substance % Used 6Months Priorto Admission

% Used in the 6-Month Post-

Discharge Period

p

Any (87.3) 39.4 < .0001Alcohol 65.4 26.8 < .0001Crack 51.7 20.4 < .0001Powder Cocaine 34.3 8.5 < .0001Heroin/Speedball 18.0 6.4 < .0001Marijuana 48.2 14.9 < .0001Methamphetamine 21.1 6.0 < .0001Other Illegal Drugs/

Substances22.5 5.5 < .0001

Over-the-Counter Drugs 13.6 2.9 < .0001

Client Arrests for Illegal Activities

56%

43%

13%

5%

21%

10%

0%

10%

20%

30%

40%

50%

60%

Pre-Tx Post-Tx

Per

cent

of C

lien

ts

Any Illegal Activities

AOD Offenses

Other Offenses

p < .0001 in all 3 comparisons

Economic/Social Outcomes

Attribute Pre-Tx (%) Post-Tx (%) pMain Source of Support:

Public Assistance46.2 45.4 .5890

Employed in the Past 30Days

6.7 37.1 < .0001

Client in Vocational/Educational Training

2.2 18.5 < .0001

Client Lived with AOD-Involved Spouse/Partner

45.2 11.8 < .0001

Client Had At Least OneChild in Foster Care

28.4 19.7 < .0001

Client Physical and Mental Health Problems, Pre-Post Change

70%

53%46%

40%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Any Physical HealthProblem

Any Mental HealthProblem

Per

cent

age

of C

lien

ts

Pre-TxPost-Tx

Pregnancy OutcomesOutcome per 100 Live Births

OutcomeMeasure

ComparisonSamples(n varies)

All U.S. Women(n = 3.8 million)

RWC/PPWClient In-Tx

Deliveries(n = 739)

PrematureDelivery

27.0* 11.4 7.3

Low BirthWeight

34.0** 7.5 5.8

Infant Death 1.2*** 0.7 0.4

* n = 2,837 from 12 recent hospital-based studies of outcomes for cocaine-using women** n = 9,737 from 10 recent hospital-based studies of outcomes for cocaine-using women*** n = 10,816 previous pregnancies of RWC/PPW clients, as reported at treatment admission

Percentage of Clients Abstinent Post Discharge, by LOS and Study

71%

21%

43%

25%

0%

10%

20%

30%

40%

50%

60%

70%

80%

< 1Month

1 - 3Months

4 - 6Months

> 6Months

Length of Stay in Treatment

Per

cent

age

of C

lien

ts

RWC/PPW

DATOS 6-Month

NTIES

Key Client Outcomes, Broken Out By Length of Stay

Client Length ofStay

Characteristic* 0-90 Days 91+ Days pClient Arrested 20.1% 10.5% < .0001Employment is Main Source

of Income18.8% 36.1% < .0001

Living with AOD-InvolvedSpouse/Partner

17.0% 8.7% .0005

Client has Custody of 1+Children

51.4% 70.1% < .0001

Child(ren) Removed fromCustody Post-Tx

15.2% 6.9% < .0001

Sustainability Status of RWC/PPW Projects at End of CSAT Grant (n = 36)

58%

8%

33%

0%

10%

20%

30%

40%

50%

60%

70%

Active (Same) Active (Modified) Inactive

Sustainability Status

Per

cent

age

of P

roje

cts

Outcome Study Conclusions

• This type of residential treatment accrues substantial benefits to clients in many areas of life

• Benefits are most widespread and pronounced for clients who remain in treatment 3 months or more, who are especially successful in achieving lasting abstinence

Treatment Cost

Treatment Cost Data

• Collected on-site by professional accounting firm (CCC) in 1997; 39 sites

• Used CSAT-developed cost accounting system (SATCAAT)

• Comprehensive, based on full market value of project facilities, goods, and services (incl. donated)

Site Variation in RWC/PPW Unit Costs

Mean SD

Annual cost per site $928,190 305,114

Episode cost per client $25,744 13,440

Daily cost per client, total $159 62

Housing $51 30

Client services $60 28

Child services $48 26

Average Treatment Episode Costs by Group

Statistics

Group

Total 1-30 31-90 91-180 181+ Pregnt Not pre

N (clients) 1768 368 362 381 657 457 1311

Mean LOS (days) 151.8 15.6 58.2 140.2 286.5 143.2 154.8

Clinical intensity 1 2.9 1.6 0.9 0.9 varies varies

Episode cost by component

Intake $834 $834 $834 $834 $834 $834 $834

Resid. Care $11,686 $1,201 $4,480 $10,793 $22,055 $11,024 $11,917

Clin. Care $11,670 $3,478 $7,159 $9,701 $19,824 $11,130 $11,859

Total, per client $24,190 $5,513 $12,473 $21,327 $42,712 $22,988 $24,610

Monetizing Benefits

Benefit Types Included

• Only benefits to society• Only benefits that can be quantified from study

data and then monetized based on outside literature

• Include both in-treatment and post-treatment (PT) benefits

• Include both client- and child-related benefits• Estimate PT benefits for at least 1 year

Benefits to be Estimated

• In-treatment: reduced crime, reduced TANF, reduced foster care

• Post-treatment: reduced crime (1 yr), reduced TANF (1 yr), reduced Foster Care (33 mos), reduced LBW (lifetime)

Crime Reduction, by

Type of Offense Unit cost

($)

In-tx Post-tx (1 yr)

Units avert (total)

Units avert (mn)

Saving (mn)

Units avert (total)

Units avert (mn)

Saving (mn)

Drug sale, dist., manfr. 26 5150 2.9 $76 9162 5.2 $135

DWI, DUI 58 1292 0.7 $42 1973 1.1 $65

Forgery, fraud 690 2505 1.4 $978 5504 3.1 $2148

Fencing stolen propty 124 2540 1.4 $178 4291 2.4 $301

Gambling, bookmaking 8 1164 0.7 $5 1360 0.8 $6

Prostitution 54 3465 2.0 $106 6083 3.4 $186

Burglary/auto theft 1637 1644 0.9 $1522 3534 2.0 $3272

Other theft 915 2153 1.2 $1114 3295 1.9 $1705

Robbery 5944 511 0.3 $1718 1074 0.6 $3611

Aggravated assault 5440 983 0.6 $3025 1469 0.8 $4520

Vandalism 58 836 0.5 $27 1572 0.9 $52

Total 22243 $8791 39317 $16000

Benefit type and amount Unit cost ($)

Total

N=1,768

Mean per client ($)

Crime

In-tx: N crimes averted 22,243

Savings varies $15,543,283 $8,791

Yr post-tx: N crimes avrt. 39,317

Savings varies $28,288,327 $16,000

Crime total $43,831,610 $24,792

TANF (& Food Stamps)

In-tx: N sup. days averted 121,071

Savings $31/day $3,753,201 $2,123

Yr post-tx: N sup. yrs avrtd 349

Savings $11,300/yr $3,943,700 $2,231

TANF total $7,696,901 $4,353

Benefit type and amount (continued)

Unit cost ($) Total

N=1,768

Mean per client ($)

LBW Deliveries

N LBWs averted 55

1st year med cost saving $25,413 $1,397,715 $791

Lifetime med/edu saving $423,760 $23,306,800 $13,183

LBW total $449,173 $24,704,515 $13,973

Foster Care (FC)

In-tx: N days for FC kids 48,432

Saving $64/day $3,099,648 $1,753

Post-tx: FC plmts averted 1,217

Saving $64,218/plmt $78,153,306 $44,204

FC total $81,252,954 $45,958

RWC/PPW Benefit SummaryBenefit type and period

Savings Quantity

Total ($M)

Mean ($thou)

%

Total (n=1,768) 157.5 89.1 100

In-tx offsets 22.4 12.7 (14)

Foster care 48,432 days 3.1 1.8 2

Crime 22,243 crimes 15.5 8.8 10

Public support 121,071 days 3.8 2.1 2

Post-tx benefits 135.1 76.4 (86)

LBW, lifetime 55 LBWs 24.7 14.0 16

Foster care, 1st plmt 1,217 placemts 78.2 44.2 50

Crime, 1st yr 39,317 crimes 28.3 16.0 18

Pub. assist 1st yr 349 families 3.9 2.2 2

Figure 3. Average RWC/PPW Treatment Costs and Treatment-related Benefits

24

46 4360

23

52

14

1954

25

33

20

4

3

7

0

20

40

60

80

100

120

140

Cost Benefit Cost Benefit Cost Benefit

Do

lla

rs (

tho

us

an

ds

)/c

lie

nt

Welfare

Crime

LBW

Foster care

All clients (n=1768)

Long-stay clients (n=657)

Pregnant clients (n=457)

Conclusions

Q: Do program benefits exceed costs? A: Yes

Total B exceeds Total C by $65,000/client ($89.1K-$$21.2K), for B/C=3.7:1

• For LT, B-C=$76,000; B/C=2.8:1

• For preg, B-C=$103,000; B/C=5.5:1

• Post-tx B ($76.4K)/net C ($11.5K)=6.6:1

Caveats

• Outcome data from client self-report

• No control group

• Benefit estimates conservative and incomplete in type, duration

• Analysis excluded role of leveraged services