Centralized Intake Units

In 1990 the Center for Substance Abuse Treatment (CSAT) created a Target Cities Demonstration Program designed to improve publicly-funded substance abuse treatment systems. The core of the program was based around the development and implementation of Centralized Intake Units (CIU’s). CIU’s main goals were to “assess clients using standard procedures, match clients to treatment, and refer clients to treatment in the community” (Department of Health and Human Services 1990). The hope was that CIU’s would make better use of existing treatment systems, thereby increasing access. The Journal of Psychoactive Drugs dedicated two issues to the impact CIU’s were having in the communities they were placed. The first issue in 1999 discussed problems that the CIU’s faced in the development phase. The second issue, in 2002, describes findings from five of the Target Cities.

In Detroit, the Target Cities program attempted to improve the Central Diagnostic Referral Service (CDRS) (Zold-Kilbourn et al, 1999). Created in 1976, the CDRS was intended to be a central point of entry for Detroit’s indigent clients. Several process changes were implemented including adding assessment staff, as all indigent clients seeking treatment were now required to go through the CDRS, and the standardized use of the Addiction Severity Index (ASI) and ASAM criteria to determine appropriate levels of care. The CDRS also created an automated system for monitoring and controlling access to the provider network. Those clients who had been assessed and matched to an appropriate level of care for which a treatment slot was available would receive an immediate appointment for treatment. If no appointment was available the client would automatically be put on a wait list. The automated waitlist was updated in real time and as soon as a client was discharged, the system would automatically reflect that change. The Detroit program not only reduced the amount of time between assessment and entry into treatment, but the proportion of clients referred by the CDRS who actually entered into treatment increased. (Tucker, 1997).

In a study of the St. Louis CIU, Claus & Kindleberger (2002), defined the characteristics of those entering or dropping out of treatment. Similar to other studies attempting to predict treatment entry they found a wide range of individual characteristics that determined entry. Overall, 75% of those who presented to the CIU for assessment entered treatment within 30 days. Compared to other studies examining treatment entry cited by the authors this was seen as a success. Also, it was found that a shorter amount of time between referral and treatment entry increased the likelihood of the client showing up for their initial appointment.

The Portland Target Cities project designed a treatment preparation program to be used with the prison population in Multnomah County. The two-week program created a 1:1 relationship between the inmate and a counselor as well as providing a thorough assessment. Windell & Barron (2002) found that when the time of their release was coordinated with the completion of the preparation program and same day entry into treatment the likelihood of them showing up was greater, 28% to 7%.

In a study examining the effectiveness of Chicago’s CIU’s in placing clients in the appropriate levels of care, Scott & Foss (2002) show, though not discussed by the authors, the ability of the CIU to streamline admissions. In the study, which confirmed the capability of CIU’s to successfully place clients in the appropriate levels of care, counselors used a standardized assessment tool (ASAM-PPC-2). There was also a reduction in the number of assessors from 129 to 31, as well as a reduction in the number of programs involved in assessment from 18 to two. Although the results compared with pre-CIU admissions are only slightly improved, the overall change to procedure should be seen as a success.

The San Francisco Target Cities project also had an impact on the standardization and delivery of assessments and referrals. Implemented as a complementary system to already established service delivery units, the San Francisco CIU served as an alternative entry into the publicly funded substance abuse treatment system. Woods et al (2002) found that of the 10,314 CIU episodes between 1995 and 1999, 64.6% were opened and closed on the same day. 91% of all cases were closed within 10 days. Similar to earlier findings, of all the San Francisco CIU cases opened, 67.6% resulted in treatment engagement in any setting, which included another CIU episode. By the end of the study, approximately 25% of clients entered into the San Francisco publicly funded treatment system did so through the CIU.

In a brief commentary on CIU’s, Bencivengo (2001) reports on his experiences in implementing the Philadelphia CIU. He believes that CIU’s were not successful and says that they actually reduced access to treatment, though does not provide any empirical evidence of this. He also reports that the rise of Medicaid Managed Care perhaps created the largest obstacle to a successful implementation of CIU’s. Managed Care Organizations were actively recruiting the Medicaid population and refused to accept the assessment done by the CIU as valid. Medicaid patients affiliated with those Managed Care Organizations would have to go through another intake and assessment. Bencivengo states that they were never able to solve this problem with Managed Care.

In some of the studies cited the impact of the CIU on intake and assessment may seem debatable. Often when comparing results with pre-CIU numbers the differences may not seem that significant, with no change or only slight increases in treatment engagement. Guydish et al (2001) compared outcomes for CIU participants and those who entered treatment directly and found no difference between the two. But the authors do point out that CIU’s did meet some of their goals like “providing standardized assessment and referral, client-treatment matching and data systems that would facilitate treatment access.” Which are all goals defined by Niatx as essential to increasing access to treatment. Guydish et al (2001) also noted that CIU’s may have treated a more disabled population then those who enter treatment directly. Again, this would be an example of the CIU’s increasing access to populations who would normally not have attempted treatment. By looking beyond outcomes and focusing on the areas that Niatx has identified as important to meeting their goals, CIU’s do show success in many areas.