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. Author manuscript; available in PMC: 2021 Mar 1.
Published in final edited form as: J Rural Health. 2019 May 15;36(2):196–207. doi: 10.1111/jrh.12375

Rural Clients’ Continuity Into Follow-up Substance Use Disorder Treatment: Impacts of Travel Time, Incentives and Alerts

Deborah W Garnick 1, Constance M Horgan 1, Andrea Acevedo 2, Margaret T Lee 1, Panas Lee 1, Grant A Ritter 1, Kevin Campbell 3
PMCID: PMC6856385  NIHMSID: NIHMS1027735  PMID: 31090968

Abstract

Purpose.

Treatment after discharge from detoxification or residential treatment is associated with improved outcomes. We examined the influence of travel time on continuity into follow-up treatment and whether financial incentives and weekly alerts have a modifying effect.

Methods.

For a research intervention during 10/2013–12/2015, detoxification and residential substance use disorder treatment programs in Washington State were randomized into 4 groups: potential financial incentives for meeting performance goals, weekly alerts to providers, both interventions, and control. Travel time was used as both a main effect and interacted with other variables to explore its modifying impact on continuity of care in conjunction with incentives or alerts. Continuity was defined as follow-up care occurring within 14 days of discharge from detoxification or residential treatment programs. Travel time was estimated as driving time from clients’ home ZIP Code to treatment agency ZIP Code.

Findings.

Travel times to the original treatment agency were in some cases significant with longer travel times predicting lower likelihood of continuity. For detoxification clients, those with longer travel times (over 91 minutes from their residence) are more likely to have timely continuity. Conversely, residential clients with travel times of more than1 hour are less likely to have timely continuity. Interventions such as alerts or incentives for performance had some mitigating effects on these results. Travel times to the closest agency for potential further treatment were not significant.

Conclusions.

Among rural clients discharged from detoxification and residential treatment, travel time can be an important factor in predicting timely continuity.

Keywords: continuity of care, incentive, pay-for-performance, substance use disorder, travel time

The use of illicit and misuse of licit substances remains a substantial population health concern in rural America.1–3 Continuity into follow-up treatment for a substance use disorder (SUD) within the 1 or 2 weeks after discharge from detoxification4–7 or residential treatment8,9 is associated with improved outcomes, yet the majority of clients do not even begin this continuing treatment.10–12 Access to continuing care is especially limited in rural and non-metropolitan areas,13–18 an issue of particular importance since failure to receive adequate treatment can contribute to the burden of SUDs in rural America.

At a time when the opioid crisis has impacted all regions across the country, access to opioid use disorder treatment is especially limited in rural areas where the number of clinics that prescribe buprenorphine is significantly lower in rural versus urban areas.19 Some patients have been reported to travel more than 50 miles, and at times across state borders, to receive services from an opioid treatment program, and those who live in more rural or low population areas tend to travel greater distances to treatment.13 In this paper, we first focus on the potential system barrier of location of services. We next investigate whether financial incentives and electronic reminders that are focused on treatment agencies have a modifying effect on the impact of travel time to treatment in rural areas.

Geographic Access

In considering the impact of travel time on clients’ continuity into follow-up treatment, there are 2 salient aspects to consider: 1) travel time from clients’ residence to where they receive detoxification or residential services and 2) travel time from clients’ residence to all options to receive continuity treatment after discharge from those services.

Travel Time from Client Residence to Detoxification/Residential Treatment

Often clients who reside in rural areas have greater travel barriers to acute phases of treatment. However, we did not find previous research focused on the impact on continuity of travel time from clients’ residence to the location where they received detoxification or residential treatment. There are at least 2 potential explanations. First, the potential impact of longer travel time could be associated with lower continuity because case managers at the “sending” agency providing detoxification or residential treatment may not be connected enough with a more distant “receiving” agency to coordinate follow-through for ongoing treatment. Alternately, longer travel time from clients’ residence to detoxification or residential treatment could be associated with higher continuity if individuals who come from farther away have a plan for further treatment already in place prior to being admitted to their first program. Or, clients who already have travelled a longer time for detoxification might be willing to remain farther from their homes for continuity treatment in residential treatment settings. However, for outpatient continuity treatment, having longer travel time from their homes is not practical.

Travel Time to Options for Continuity into Follow-Up Treatment

Several studies show that patients are less likely to continue into treatment if there is longer distance to travel. One study showed that veterans discharged from Department of Veterans Affairs (VA) inpatient treatment programs who lived farther from their source of continued treatment in an outpatient mental health setting were less likely to obtain care following inpatient treatment for substance use disorders. Those who traveled 10 miles or fewer were 2.6 times more likely to obtain care compared to those who traveled more than 50 miles to receive care. Moreover, clients who received continuing treatment had fewer visits if they lived farther from the facility where they received continuing care.20 Therefore, distance to potential locations for continuing treatment poses a barrier and influences the volume of care.

A more recent study using a sample of women veterans who received at least one outpatient visit in the VA found that overall, longer drive times were associated with higher likelihood of not returning for care.21 Although not limited to behavioral health care visits, the results of this study also showed that travel distance to obtain health care services may present a barrier to receiving care and that longer drive time is more likely to increase attrition among new clients (those who had no VA outpatient visits in the prior 3 months). Analysis of the interaction of drive time and a rural/urban indicator showed no significant differences between clients residing in rural versus urban areas. In an urban setting in Spokane, Washington, longer distance to opioid treatment programs was associated with more missed doses.22

Financial Incentives and Electronic Reminders

Building on a growing body of research on financial incentives focused on substance use disorders23–27 and electronic reminders in general medical settings,28,29 the impacts of agency-level financial incentives and electronic reminders on continuity were evaluated through a research intervention in Washington State during October 2013 to December 2015. This original evaluation, which did not take travel time into consideration, found that financial incentives did not have an effect on the likelihood of continuity after detoxification or residential treatment. However, follow-up analyses determined there was a positive effect on timely continuity among residential treatment agencies which had higher continuity rates at baseline, and electronic reminders either alone or in conjunction with financial incentives had significant positive effects only among clients at residential treatment facilities which had moderate continuity rates at baseline.30 In considering how travel time may affect these results, we anticipate that travel time may exert a negative impact on continuity of care, but that financial interventions might moderate this impact. That is, agencies could use the additional funds and information to facilitate linkage to ongoing treatment for clients whose detoxification or residential treatment was farther from their home.

In this paper, using data on rural clients we first explore 2 aspects of travel time on continuity: 1) the travel time from clients’ residences to their site of actual detoxification or residential treatment, and 2) the distance to—and options for—continuity services. To our knowledge, this is the first study to consider the impacts of both of these travel times. Second, we explore if incentives or alerts can serve to alleviate any negative impact of longer travel times or fewer options for continuity services. We explore the following questions:

  • Does travel time from client’s residence to the residential/detoxification facility where they were originally treated influence continuity?

  • Do incentives and alerts moderate the effects of travel time from clients’ residence to the residential treatment/detoxification facility where they were originally treated in regards to continuity?

  • Does the travel time from clients’ residence to—and number of options for—potential continuity treatment locations influence continuity?

  • Do incentives and alerts moderate the effects of travel time from clients’ residence to—and number of options for—potential continuity treatment locations influence continuity?

Methods

This study was approved by the Brandeis University and Washington State Institutional Review Boards.

Data Sources

Client treatment data were obtained from Washington’s data system for individuals receiving state-funded substance use disorder treatment, the Treatment Activity Report Generation Tool which provided information on dates and types of services, as well as information about clients’ demographics, employment, housing status, substance use history, and current substance use.

Our study focused on clients who received services in any one of the residential treatment and detoxification service agencies in Washington State that had been part of the study on incentives and alerts. Building on previous work in designing incentives,31–33 agencies in the incentives arms could earn points based on quarterly performance rates based on achievement (performance above a minimum achievement threshold) or improvement (raising their continuity rate above their own baseline). Electronic reminders were in the form of an Excel workbook, sent weekly through secure email by Washington State’s Behavioral Health Administration (BHA) to treatment agency staff, with information to “alert” them to clients who may be at risk of not meeting the continuity criteria.30

Sampling Frame and Random Assignment

Our current study focused on rural clients treated at detoxification and residential agencies in Washington State between October 1, 2013 and December 31, 2015. Detoxification agencies include hospital-based detoxification programs, free-standing detoxification facilities, and clinically managed residential facilities.34,35 Agencies were identified as residential based on American Society of Addiction Medicine (ASAM) criteria.35,36

In preparation for the original study, agencies providing publicly funded detoxification or residential treatment during 2012–2013 were stratified by performance level and size (based on number of admissions) and randomized into treatment arms. To prevent reliability concerns, agencies with fewer than 25 annual client admissions were excluded, and thus we created a final sample of the clients from 12 detoxification agencies and 33 residential agencies. The 33 residential agencies were randomized into 4 arms (with 8 or 9 agencies per arm): incentives, alerts, both, and control. Due to their smaller number, detoxification agencies were randomized to 3 arms (with 4 agencies per arm): incentives, alerts, and control.30 Our current study is based on clients from participating agencies whose ZIP Code of residence was classified as rural based on Rural Urban Commuting Area (RUCA) codes to determine whether clients live in urban/rural areas, including as rural the categories of large rural town, small rural town, and isolated. We used 2006 ZIP Code approximations of RUCA codes developed by the University of Washington.37

Intervention Period and Analytic Sample

The interventions for the original study ran for 9 quarters from October 1, 2013, to December 31, 2015. Our analytic sample of rural clients included 1,947 discharges for detoxification and 2,615 for residential treatment. For agencies which closed or had their contract with BHA end during the intervention period, we excluded admissions that occurred within 6 weeks prior to the closure/end date, as clients would be less likely to be linked to services during a potentially disruptive time. We also excluded records with missing data in any of the covariates.

Variables

Continuity

The dependent variable was defined as an admission to an SUD treatment agency or a treatment service within 14 days of being discharged from detoxification or residential treatment. This service could be outpatient, intensive outpatient, or residential treatment. Admission to a detoxification service did not count towards continuity. We chose 14 days, as this duration has been tested for feasibility and discriminatory power in several prior studies4,38 and is included in the measure recently endorsed by the National Quality Forum (NQF). We also included a variable to indicate that a level of treatment qualifying for continuity was offered at the location where the client received detoxification or residential treatment. For detoxification, 10 out of 12 agencies also offered outpatient or residential services at the same location. For residential treatment, 15 out of 33 agencies also offered outpatient treatment at the same location, or within 3 miles.

Travel Time and Continuity Options

Using information on clients’ ZIP Code of residence and treatment agencies, we used Google Maps to calculate travel time. For first key independent variable, travel time to the agency where the original treatment was received, we created the categories of less than 60 minutes, 61–90 minutes, 91–120 minutes, and greater than 121 minutes. For the second key independent variable, travel time to the closest option for continuity, which generally was shorter, we created categories of less than 30 minutes, 31–60 minutes, and over 60 minutes. For the regressions which focused on the impact of travel time to various options for continuity, we also included in our models a count of the number of agency options within 60 minutes’ travel time.

Client Covariates

Using the Andersen/Davidson model of service utilization, which theorizes that both individual and contextual factors impact service use,39 we selected covariates at both the client and agency level that might facilitate or hinder accessing services after discharge. Our choice of covariates also was based on prior research on continuity.10,40 For residential treatment analyses, we controlled for client’s age, gender, race/ethnicity, education, marital status, employment status, past month use of substances (alcohol, marijuana, cocaine, opioids, methamphetamines, and other drugs), age at first use of any substance, and homelessness. Other covariates included criminal justice involvement/referral; and whether clients had received treatment, detoxification, or mental health services in the year prior to admission. For detoxification models we wished to use the same covariates but could not include education, marital status, employment status, or homeless status because that information was not collected at detoxification agencies.

Agency Covariates

Our individual-level data was aggregated at the agency level to create quarterly variables regarding agency size (number of admissions), percent of clients who reported using drugs other than alcohol or marijuana, percent of clients who had received mental health services in the prior year, and percent of clients who were involved/referred by the criminal justice system.

Analyses

Multilevel logistic regressions, with clients nested within agencies, were used to examine the effects of travel time, both to the agency where care was originally provided and to the agency requiring the shortest travel time to continuity into treatment, while controlling for other client and agency characteristics. Sensitivity analyses showed that while singleton discharges per patient represented the overwhelming majority of cases (74% for detox and 81% for residential), multiple discharges per patient did occur. Hierarchical modeling when the overwhelming majority of clusters are singletons is problematic, as it over counts the effective number of clusters and thus estimates greater accuracy than is actually present. In light of this, we ran our models using 3 different models: an OLS model using “all discharges” without regard to corresponding patient, a hierarchical logistic model which accounted for multiple discharges per patient, and an OLS model on the subset of first discharges per patient. The estimates of the 3 models proved to be similar, identifying the same variables as significant and with no major changes in their relative impacts. Given this result, we chose to report estimates for only the first, “all discharges” models.

Analyses were conducted separately for residential treatment and detoxification agencies. We used 2 model specifications. The first involved travel time and the interventions as main effects, while the second included interaction terms to explore if the interventions moderate the effects of the travel time variables.

Results

Client Characteristics at Treatment Admission

Table 1 shows summary information on clients’ demographic, substance use, and prior treatment characteristics for detoxification and residential client admissions. The majority of clients were white (75.4% of detoxification discharges and 66.2% of residential discharges), while American Indians represented 7.7% of detoxification discharges and 20.5% of residential discharges. Clients could report on multiple substances used during the last month. Among clients discharged from detoxification, 45.0% reported using alcohol more than 13 times in the last month, 44.9% reported opioid use, and 32.6% reported using methamphetamines. For clients discharged from residential treatment, 62.8% reported using alcohol more than 13 times in the last month, 42.3% reported opioid use and 55.6% reported using methamphetamines.

Table 1.

Demographics and Substance Use for Rural Detoxification and Residential Client Admissions 10/1/2013 – 12/31/2015

Detoxification Residential
Treatment
(N=1,947) (N = 2,615))
N (%) N (%)
Demographics
Female 710 (36.47) 1087 (41.57)
Age
 18–20 90 (4.62) 124 (4.74)
 21–25 329 (16.90) 571 (21.84)
 26–30 378 (19.41) 565 (21.61)
 31–44 569 (29.22) 850 (32.50)
 45+ 581 (29.84) 505 (19.31)
Race/ethnicity
 White 1,467 (75.35) 1,731 (66.20)
 Black 18 (0.92) 27 (1.03)
 Latino 218 (11.20) 229 (8.76)
 American Indian 149 (7.65) 536 (20.50)
 Other race/ethnicity 251 (12.89) 245 (9.37)
Education
 < High school a 779 (29.79)
 High school degree/GED a 1550 (59.27)
 > High school a 146 (5.58)
 Vocational a 140 (5.35)
Married a 616 (23.56)
Homeless a 667 (25.51)
Employed a 192 (7.34)
Received mental health services in prior year 779 (40.01) 822 (31.43)
Substance use
Substance(s) used in past month b
 Alcohol, none 998 (51.26) 1,641 (62.78)
 Alcohol, 1–3 times 27 (1.39) 272 (10.40)
 Alcohol, 4–12 times 54 (2.77) 203 (7.76)
 Alcohol, 13+ times 876 (44.99) 990 (37.86)
 Marijuana, none 1,559 (80.07) 1,381 (52.81)
 Marijuana, 1–3 times 42 (2.16) 163 (6.23)
 Marijuana, 4–12 times 45 (2.31) 178 (6.81)
 Marijuana,13+ times 301 (15.46) 893 (34.15)
 Cocaine 39 (2.00) 101 (3.86)
 Opiates 874 (44.89) 1,106 (42.29)
 Methamphetamines 634 (32.56) 1,463 (55.95)
 Other Drug 105 (5.39) 190 (7.27)
Age of first use c
 ≤ 10 223 (11.45) 397 (15.18)
 11–14 588 (30.20) 1,100 (42.07)
 15–17 447 (22.96) 682 (26.08)
 18–20 267 (13.71) 239 (9.14)
 21+ 422 (21.67) 197 (7.53)
Prior treatment
 Prior OP 395 (20.29) 1,061 (40.57)
 Prior residential 283 (14.54) 637 (24.36)
 Prior detox 720 (36.98) 691 (26.42)
Referred by/involved with criminal justice system 31 (1.59) 934 (35.72)
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a

Information not collected in detoxification admissions.

b

Substance was listed as a primary, secondary, or tertiary drug and frequency of use was one or more times in the past month or during the month of highest use in the last year.

c

Earliest age of first use of any of the substances reported as primary, secondary, or tertiary substance of abuse.

Continuity Rates

Among clients in our sample who were discharged from detoxification, 29.6% continued into treatment within 14 days, most into residential treatment at a different agency than the detoxification location and 6.7% receiving residential treatment at the same site (Table 2). Among clients who were discharged from residential treatment, 47.4% continued into treatment within 14 days, with 34.1% receiving outpatient treatment at a different site than their residential treatment, 11.6% receiving residential treatment at a different site, and very few receiving treatment at the same site.

Table 2.

Continuity by Site of Continuity Service

Detoxification Residential Treatment
(N=1,947) (N = 2,615))
N (%) N (%)
No continuity 1,371 (70.4) 1,376 (52.6)
Continuity
 Same site residential   131 (6.7)   13 (0.5)
 Other site residential   324 (16.6)   303 (11.6)
 Same site outpatient   17 (0.9)   32 (1.2)
 Other site outpatient   104 (5.3)   891 (34.1)
Total continuity 576 (29.6) 1,239 (47.4)
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Travel Time to Actual Site of Treatment and Continuity

Figure 1 provides the distribution in travel time categories among the rural clients in our sample. The figure shows that rural clients in Washington State commonly had long travel times to receive their detoxification or residential treatment. Only 21.7% of detoxification clients and 17.4% of residential clients traveled less than 1 hour from their residence, while 30.2% and 34.0% traveled over 2 hours.

Figure 1-.

Figure 1-

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Travel Time (in minutes) to Actual Site of Detoxification or Residential Treatment

Table 3 predicts continuity of care after discharge, using the travel time to the original agency where the client received care. The models were performed separately by type of service, detoxification and residential, and they were performed with and without interaction terms between travel time categories and incentive group indicators. For both detoxification and residential treatment, none of the main effects of the interventions (eg, incentives only, the alerts only, or incentives + alerts) were significant, but in some cases the interventions combined with travel time to generate significant interaction effects.

Table 3.

Logit Regression Model of Impact on Continuity of Care After Detoxification or Residential Treatment of Interventions, Travel Time to Agency Where Detoxification or Residential Treatment Was Received, and Continuity Services Available at the Same Treatment Location

Detoxification Residential Treatment
Main Effects Model Interaction Model Main Effects Model Interaction Model
(N= 1,947) (N= 1,947) (N= 2,615) (N= 2,615)
Estimate
(95% CI)		 Estimate
(95% CI)		 Estimate
(95% CI)		 Estimate
(95% CI)
Intervention Arm (Ref: Control Arm)
Alerts Only −0.392 (−0.842, 0.058) −0.167 (−0.780, 0.446) 0.001 (−0.399, 0.400) −0.201 (−0.957, 0.554)
Incentives Only −0.369 (−0.890, 0.151) −0.403 (−0.999, 0.193) 0.494 (−0.092, 1.079) 0.083 (−0.737, 0.904)
Incentives and Alerts __a __a −0.063 (−0.537, 0.411) 0.079 (−0.747, 0.904)
Time to Treatment Agency (Ref: Short < 60 minutes)
Medium (61–90 minutes) 0.163 (−0.153, 0.479) −0.013 (−0.442, 0.416) -0.397** (−0.657, −0.137) -0.651** (−0.970, −0.333)
Long (91–120 minutes) 0.358** (0.089, 0.628) 0.670** (0.307, 1.034) -0.343* (−0.669,−0.016) −0.231 (−1.043, 0.581)
Longest ( > 121 minutes) 0.383** (0.261, 0.506) 0.399** (0.216, 0.581) −0.010 (−0.284, 0.264) −0.098 (−0.655, 0.458)
Intervention Arm and Travel Time Interaction (Ref: Control Arm)
Alerts Only X Medium Time 0.108 (−0.550, 0.765) 0.468 (−0.002, 0.937)
Alerts Only X Long Time -0.807** (−1.283, −0.331) 0.083 −1.015, 1.181)
Alerts Only X Longest Time −0.255 (−0.619, 0.108) 0.058 (−0.747, 0.863)
Incentives Only X Medium Time 0.299 (−0.486, 1.085) 0.607* (0.138, 1.076)
Incentives Only X Long Time −0.240 (−0.697, 0.216) 0.186 (−0.669, 1.041)
Incentives Only X Longest Time −0.013 (−0.318, 0.292) 0.496 (−0.082, 1.074)
Alerts and Incentives X Medium Time __a __a 0.055 (−0.392, 0.502)
Alerts and Incentives X Long Time __a __a −0.488 (−1.334, 0.357)
Alerts and Incentives X Longest Time __a __a −0.145 (−0.860, 0.570)
Continuity Services in Same Location -0.454** (−0.774, −0.134) -0.460** (−0.765, −0.155) 0.312 (−0.044, 0.668) 0.329 (−0.056, 0.713)
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Notes: Controlling for client and facility covariates.

*

P < .05;

**

P < .01

a

Due to the small number of detoxification agencies, they were randomized to only 3 research arms (excluding the Alerts & Incentives research arm).

Detoxification

For the “main effects only” model (model without interactions) for detoxification discharges, the likelihood of continuity was significantly higher for clients with travel times either 91–120 minutes or over 2 hours. Based on an underlying timely continuity rate of approximately 30%, these longer travel times were associated with 13%−14% greater likelihoods of timely continuity. For the interaction model on the same clients, these 2 travel time categories again predicted greater likelihoods of timely continuity (in the range of 15% to 28% more, respectively), accompanied, however, by a strong negative interaction between long travel time (between 91 and 120 minutes) and the alerts only intervention.

Residential Treatment

For the “main effects only” model of discharges from residential treatment, both the 61–90 minutes’ and 91–120 minutes’ travel time groups were likely to have lower continuity compared with travel time less than an hour. Based on an underlying timely continuity rate of approximately 47%, these 2 travel times were associated, respectively, with 14% and 16% lower likelihoods of timely continuity. However, no significant effect was determined among the group with travel time over 2 hours. For the models including interaction terms, financial incentives only mitigated the lower likelihoods of continuity for clients in the 61–90 minutes’ travel time category. However, receipt of alerts only or alerts and incentives together did not predict the same effect, as the likelihood of continuity among clients in the 61–90 minutes’ travel time category appeared to be little changed by this combination of interventions.

Continuity Services in the Same Location

For detoxification, the models predicted significantly lower likelihood of continuity, if the agency providing the original detoxification also offered continuity to further treatment. However, among residential treatment discharges, having the continuity options at the same location was not significant.

Travel Time to Nearest Potential Site for Continuity

Although residing in rural areas, three-quarters of clients within the detoxification and residential treatment groups had at least one option for continuity to outpatient, intensive outpatient, or residential treatment within 30 minutes’ travel time of their home (Figure 2). For only 5.3% of detoxification clients and 3.3% of residential clients was the closest option over an hour travel time away. In regressions predicting continuity (not shown), none of the variables measuring travel time to potential sites of continuity or number of sites within 60 minutes were significant.

Figure 2-.

Figure 2-

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Travel Time (in minutes) to Nearest Potential Site for Continuity After Detoxification or Residential Treatment

Discussion

Access to treatment for substance use disorders is a significant issue in non-metropolitan areas as travel distances may pose a barrier.13,15–17 We focused on the impact of travel time on continuity after discharge from detoxification or residential treatment for substance use disorders because continuity is associated with better outcomes, but rates are relatively low.10–12 In our study, travel times to the original agency providing treatment are sometimes, but not always, significant in predicting continuity within 14 days. For detoxification clients, those with longer travel times (over 91 minutes from their residence) are more likely to have timely continuity. This may be because detoxification providers make greater efforts for a follow-up plan for clients whose detoxification is further from their home. Conversely, residential clients with longer travel times than 1 hour are less likely to have timely continuity. The potential mitigating effect of alerts or incentives was significant for very few travel time categories and the results were mixed. Moreover, neither travel time to potential sites for continuity, nor number of sites within 60 minutes, was associated with continuity. This result is inconsistent with previous studies which showed that longer travel time to the site of ongoing treatment is associated with a lower likelihood of continuity20 and higher odds of attrition.21

Our results suggest that solutions to increase continuity which relate to travel time or transportation barriers may fall into 4 broad areas. First, states could consider accessibility of their current specialty treatment locations, in an effort improve access to continuity services, particularly for clients who have travelled over an hour from their home for residential treatment. Even if a potential option for continuity is located close to clients’ residences, there is no assurance that there is availability for treatment at that location, or other locations within a short travel time, or if the services are a good match for the client’s needs. When a client is placed on a waiting list, keeping them engaged with the treatment system by providing them with some services as they wait is good practice.10 In this study, we counted the location of options for continuity, but we could not evaluate the accessibility of that treatment in terms of provision of flexible hours for treatment,10 greater staffing, or provision of transportation. Another study demonstrated that increased distance to care did not decrease utilization of the behavioral health treatment services when transportation was provided to the client when needed.41

Second, a focus on care coordination among agencies could foster completed referrals, although this may be difficult when trying to coordinate with agencies that may be located hours from each other. Coordination activities could include keeping the client engaged with the treatment system if they are put on a waiting list for the next level of care, or assigning staff to call patients who completed detoxification with reminders about treatment appointments.10

Third, closer integration between specialty agencies and primary care could open greater options for continuity, particularly in terms of medication assisted treatment. However, there is some evidence that there is a reluctance to expand buprenorphine treatment in rural areas and in the South.15 However, with federal funding in 2018 Washington State began implementing a hub-and-spoke model to provide integrated care for clients with opioid use disorders and to increase the number of providers who can prescribe buprenorphine and provide other pharmacotherapy. Analyses are ongoing that will address whether this model is differentially effective for sub-populations, including rural clients.

Finally, states could explore options for continuity services that rely on technology such as telehealth, which is relatively easy to deliver, extends the duration of treatment, and may produce longer lasting benefits.42,43 Patients receiving telephone case monitoring were found to achieve better short-term outcomes on measures such as substance use and psychiatric symptoms.44 In their 2018 updates to the specifications for the performance measure Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment, the National Committee on Quality Assessment (NCQA) added telehealth to treatment options to reflect the latest guidelines for treatment.45

Limitations

A main limitation to our study is the lack of generalizability since the study was conducted only in one state and the data are from a public-sector specialty treatment system. It could be that the impact of the interventions may be different in other settings. For example, alerts may be more effective in settings with electronic medical records where they could be incorporated into real-time rather than weekly follow-up reminders. Moreover, the impact of rural residence and travel time may be different in other states. In addition, we measured travel time by driving time, which is superior to a straight distance approach and reflects the limited mass transit options for rural residents. However, some ZIP Codes may be large, so that the distance between a client’s residence that may be at the edge of a ZIP Code may have introduced validity issues with our travel time measure. As in all studies using administrative data, we could not capture some factors that influence continued care, such as wait time for appointments.

Conclusions

States can use performance measures to monitor continuity after discharge from detoxification or residential treatment among rural clients. A performance measure for continuity of care after detoxification using a 7-day specification has been recommended by the American Society of Addiction Medicine and tested by the Department of Veterans Affairs46,47 and commercial insurance.48 The Centers for Medicare & Medicaid Services (CMS) also is supporting the development of measures of continuity of care after detoxification and residential discharges,49 and continuity after detoxification was endorsed by The National Quality Forum in 2018. Some states such as New York have developed and used similar measures.50 Calculating performance using these measures with a focus on rural clients is only a first step in investigating the root causes of clients not continuing treatment. Other considerations include the broader range of barriers to continuing treatment: patient factors (eg, lack of motivation to enter treatment, competing responsibilities, and stigma) program issues (eg, wait time for appointments), and system barriers (eg, cost of services and limited system capacity).10,51

While the potential mitigating effect of an intervention aimed at improving continuity was mixed, focusing on travel time still has potential to be used to assess quality improvement efforts. As policy makers focus on performance, it is critical to include travel time when evaluating potential approaches to the complex issue of access to continuing treatment for rural clients with substance use disorders.

Acknowledgments:

The authors appreciate the contributions of Can Du, Alice Huber, Eric Larson, Sharon Reif, Maureen Stewart, Katie Weaver-Randall, and Fritz Wrede.

Funding: This research was supported by the National Institute on Drug Abuse (NIDA) of the National Institutes of Health (R01DA033468) and is a component project of the NIDA-supported Brandeis/Harvard Center to Improve System Performance of Substance Use Disorder Treatment (P30 DA035772). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or of Washington State.

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