THINK TANK
39 pages
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THINK TANK

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39 pages
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THINK TANK

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Nombre de lectures 78
Langue Français
Poids de l'ouvrage 1 Mo

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State-funded Gambling Treatment Programs
TH I N K
TA N K
J U N E 2 2 - 2 3 , B O S T O N , M A S S A C H U S E T T S
M a s s a c h u s e t t s C o u n c i l o n C o m p u l s i v e G a m b l i n g
M a s s a c h u s e t t s D e p a r t m e n t o f P u b l i c H e a l t h
H a r v a r d M e d i c a l S c h o o l , D i v i s i o n o n A d d i c t i o n s
HERESULTSOFANATIONAL
March 2001
T T H I N K TA N K O N S TAT E-F U N D E D
G A M B L I N G T R E AT M E N T
A Massachusetts Initiative
M a s s a c h u s e t t s C o u n c i l o n C o m p u l s i v e G a m b l i n g
M a s s a c h u s e t t s D e p a r t m e n t o f P u b l i c H e a l t h
H a r v a r d M e d i c a l S c h o o l , D i v i s i o n o n A d d i c t i o n s
P RO G R A M S
TABLE OFCONTENTS
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PARTICIPANT AND PROGRAM CHARACTERISTICS: THE STATE OF STATE–FUNDED GAMBLING TREATMENT PROGRAMS . . . 2 Participant Characteristics ................................................................................................. 2 Program Characteristics ....................................................................................................3
THINK TANK PROCEDURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
FINDINGS: ADMINISTRATIVE STRUCTURE AND FUNDING . . . . . . . . . . . . . . . . . . 6 Designing an Effective Structural Model (Worksheet 1) .......................................................... 6 Designing an Effective Funding Model (Worksheet 2) ............................................................. 7 Public Funding................................................................................................................... 7 Private Funding.................................................................................................................. 8 Self-Payment..................................................................................................................... 9 Insurance Coverage.......................................................10....................................................
FINDINGS:TREATMENT DELIVERY PART I, MODALITIES AND SETTINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Designing an Effective Treatment Model (Worksheet 3) ........................................................ 11 Treatment Modalities.........................................................................................................11 Treatment Settings............................................................................................................11
FINDINGS:TREATMENT DELIVERY PART II, ASSESSING IMPACT AND EFFICACY ................................................................ 12 Designing an Effective Client Recruitment & Retention Model (Worksheet 4) .......................... 12 Client Recruitment...........................................................................................................12.. Client Retention................................................................................................................14 Impacting High-risk Populations.......................................................1.5.................................... Measuring Effectiveness of Recruitment and Retention Efforts..................................................... 15 Designing an Effective Assessment Model for Treatment Programs (Worksheet 5) .................... 16
FINDINGS: A PATIENT BILL OF RIGHTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Designing a Model “Patient Bill of Rights” (Worksheet 6) ...................................................... 17 Patient Rights / Expectations................................................................................................17 Patient Obligations/Responsibilities........................................................................................17
FINDINGS: BEST PRACTICE GUIDELINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Designing ModelBest PracticesGuidelines (Worksheet 7) ................................................. 18
TOWARD THE FUTURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Clarifying the Nature of Gambling Disorders ...................................................................... 19 Improving Client Assessment Instruments and Applications ................................................... 19 Considering the Relationships Among Treatment Modalities and Settings ................................. 19 Individualizing Approaches to Assessment, Treatment and Evaluation ....................................... 19 Resolving Issues Associated With Self-payment for Services ................................................... 20 Focusing on the Public Health Dimensions of Problem Gambling ........................................... 20 Developing In-patient Treatment Resources ......................................................................... 20 Attracting Financial Support for Problem Gambling Treatment Programs From Indian Tribes That Operate Casinos ........................................................................... 20
CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
APPENDIX I: LIST OF THINK TANK PARTICIPANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Planning Committee ........................................................................................................26
APPENDIX II: LIST OF BREAK-OUT ASSIGNMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . 27
APPENDIX III:THINK TANK WORKSHEETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Worksheet 1 .......... 29Program Structure and Funding: an Effective Structural Model Designing Worksheet 2Program Structure and Funding: an Effective Funding Model Designing ............. 30 Worksheet 3 Designing an Effective Treatment ModelTreatment Delivery, Part 1: ................. 31 Worksheet 4 Impact and Efficacy by Designing Assessing 2: PartTreatment Delivery, an Effective Client Recruitment/Retention Model ......................................... 32 Worksheet 5 Assessing Impact and Efficacy by Designing Part 2:Treatment Delivery, an Effective Assessment Model for Treatment Programs ................................ 33 Worksheet 6Patient Rights: a Model DesigningPatient Bill of Rights................................ 34 Worksheet 7 Best Practices ModelGuidelines: DesigningBest PracticesGuidelines .......... 35
INTRODUCTION As legalized gambling has become more common throughout the United States (National Gambling Impact Study Commission, 1999; National Research Council, 1999), treatment programs to address gam-bling related problems have emerged. Harvard Medical School’s Norman E. Zinberg Center for Addiction Studies and the Massachusetts Council on Compulsive Gambling hosted the first national Think Tank on Pathological Gambling on June 3 & 4, 1988. During April 1995, the Minnesota Council on Compulsive Gambling joined Harvard Medical School's Division on the Addictions and the Massachusetts Council on Compulsive Gambling to host the first North American Think Tank on Youth Gambling. On June 22 & 23, 2000, the Massachusetts Council on Compulsive Gambling, in cooperation with the Harvard Medical School Division on Addictions and the Massachusetts Department of Public Health, hosted a national Think Tank on State-Funded Gambling Treatment Programs. The project was supported primarily by special funding from the Massachusetts Department of Public Health, Dr. Howard Koh, Commissioner. Additional support was provided by The National Center for Responsible Gaming, The Center for Substance Abuse Treatment, Trimeridian/The Custer Center, and the Institute for Problem Gambling. The first national think tank was designed to identify the nature of gambling, its potential adverse conse-quences and the extent of the problem; the second was intended to draw attention to the issue by focusing on youth.1The recent Think Tank on State-Funded Gambling Treatment Programs was the first national event dedicated to treatment, suggesting that the field is beginning to mature. Forty invited participants attended, representing each of the 13 states with state-funded gambling treatment programs. A complete list of participants and the planning committee is included asAppendix I. The primary purpose of this Think Tank was twofold: (1) gather information about the structure and scope of existing state-funded treatment programs and (2) create a blueprint for the future development of such programs in jurisdictions where limited or no treatment programs presently exist. To help develop this blueprint, Think Tank participants shared their views about six distinct areas of gambling treatment program operation: aAdministrative Structure and Funding aTreatment Delivery: Modalities and Settings aTreatment Delivery: Client Recruitment and Retention aAssessing Impact and Efficacy aPatient Rights aBest Practice Guidelines
1 The late Tom Cummings, a principal architect of therst two Think Tank events, would be very proud indeed at the development of this special treatment event. We owe him a great debt and dedicate this project to his enduring inuence and memory.
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PARTICIPANT AND PROGRAM CHARACTERISTICS: THE STATE OF STATE-FUNDED GAMBLING TREATMENT PROGRAMS Seventy-three people were invited to participate in this think tank. Of these 48 accepted invitations, yielding a 65.8% acceptance rate. Of the 48 who accepted, 8 were unable to participate for one reason or the other, reducing the number of participants to 40 and the participation rate to 54.8%. To stimulate thinking and provide a point of departure, participants were asked to complete a survey developed specically to assess the status of gambling treatment programs in the United States. The Think Tank steering committee identied topics and items of importance that would be relevant to the activities of the Think Tank process and provide participants with an overview of gambling treatment program characteristics. A draft version of the survey was completed on March 15, 2000 and then reviewed by the steering committee. Several revisions were made to the original version and thenal survey was completed and distributed on April 24, 2000. Surveys were sent to all invitees who accepted the invitation to participate, as well as to some who were unable to participate but wished to submit a completed survey as a means of contributing to the think tank process. A total of 53 were sent out and 47 of them were returned. Thirty-eight of the forty partici-pants completed surveys. In addition, nine surveys were received from non-participants, yielding an 88.7% survey completion rate. Currently, there are 13 states with state-funded gambling treatment programs. These states are Connecticut, Delaware, Indiana, Iowa, Louisiana, Massachusetts, Minnesota, Missouri, Nebraska, New Jersey, New York, Oregon and South Dakota. To avoid misrepresenting larger states with more gambling treatment programs, the survey data was weighted by state. That is, whenever more than 1 person repre-sented a state, the data was weighted proportional to the states representation. For example, where two representatives responded from one state, the surveys were weighted .5 each; where four representatives responded from one state, each survey was weighted .25 and so on.
Participant Characteristics Regarding their work responsibilities, 34% of the participants were treatment program administrators, 23% were government administrators, 19% were frontline clinical service providers and 24% classied themselves asother.Similarly, 33% of the participants were treatment funders, 52% were fundees and 15% neither.
Program Characteristics Figure 1participant affiliation pattern with state-funded gambling treatment(opposite page) shows the program openings. Therst state-funded gambling treatment program represented at the think tank opened during 1982 and the last during 1998. Thegure reveals a steady pattern of treatment program openings during the last two decades of the twentieth century. These programs were sited in many differ-ent venues. For example, 51% of the participants reported that their treatment programs were located in mental health centers, 45% in gambling specic treatment centers, 32% in hospital outpatient settings, 32% in hospital inpatient settings, 24% in private practice, 23% in prisons, 17% in residential settings and 10% in other community settings.
Figure 1: Percentage of participants affiliated with first state funded gambling treatment program opening 15 12 9 6 3 0 1982 1983 1985 1986 1987 1988 1992 1993 1995 1996 1997 1998 Year state opened first gambling treatment program
Within these settings, in addition to self-help, clinicians employed a wide array of treatment modalities, as described inFigure 2.Gamblers Anonymous was the most common form of assistance (89%) and medica-tion was the least common (20%). The treatment modalitiesgure summarizes the variety and prevalence of clinical services among the treatment programs represented by the think tank participants.
Figure 2:Treatment Modalities
GA Counseling Assessment Screening Family Tx Group Tx Couples Tx Cognitive Behavioral Tx Hotline Self-help Psycho-Ed Psychotherapy Medication clinic Other 0 20
40
60
80
100
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4
AsFigure 3reveals, almost 50% of the participants represented programs that received more than $300,000 in annual funding; at the other end of the spectrum, 20% of the programs received $50,000 or less in annu-al funding. In addition, 86 percent of the participants reported receiving state funding; 61% also accepted fees for service; and 49% received private funding. In addition, participants r eported that the funding for treatment services derived primarily from self-pay (33%), pro-bono (31%) and insurance (20%) sources. Of the patients seeking gambling services, 5% of the programs referred clients elsewhere, 5% denied treat-ment services, and 2% referred the treatment seeking patient back to their insurance company.
Figure 3:Total operating budget
<5K 100-150K 5-25K 150-200K 25-50K 200-250K 50-75K 250-300K 75-100K >300K
Participants reported that their treatment programs provided services for gamblers (94%), spouses of gam-blers (84%), other family members (84%) and others (43%). For the period between July 1, 1999 and February 29, 2000, the median number of treatment seekers for all programs represented at the think tank was 249.74. Of these, the median number with insurance was 53.64, but only 9.52 paid with insurance. Full time employees represented 58% of the staff of these programs; 52% were part-time employees and 14% were hired per diem. In addition, 21% of the programs reported using consultants. With regard to training and supervision, there were limited resources and different perspectives offered by gambling program staff and funders. AsFigure 4illustrates, program staff consistently reported receiving training more than funders thought the staff received training. Despite this difference of perspective, only 27% or fewer program participants reported that there was regular clinical supervision or other programbased training for gambling treatment programs.
Figure 4: Different perspectives on required training activities 70 60 50 40 30 20 10 0 Weekly clinical In-service Continuing Other supervision education education training
Gambling Program Funder
THINK TANK PROCEDURES The entire think tank was coordinated and guided by a facilitator.2Intersession plenary talks were provided to prime the participantsthinking by reviewing key concepts in relevant areas. These talks were limited to about 15 minutes each. Participants were assigned to one of six breakout groups. They were directed to envision theidealgam-bling treatment program, with specic attention to each of the general topic areas listed above. A list of the breakout group assignments is included as Appendix II. To assist in their deliberations, participants were provided with worksheets detailing each assignment and presented specic questions to be addressed under each of the general topic areas outlined. These worksheets are included as Appendix III. Upon completion of its work, each breakout group presented itsto the entire assembly. The meetingndings facilitator recorded the presentations for inclusion in this summary report. While most of the professionals attending the Think Tank held similar views on fundamental questions of program structure and funding, opinions varied, in some cases widely, on other issues addressed during the session. When no consensus was reached, the differing perspectives offered by Think Tank partici-pants were noted and summarized. The following discussion summarizes the groupsndings on each of the six treatment program areas described earlier.
2 Marsha Kelly of Kelly Media Counsel, 6 West 5th St., Suite 700, St. Paul MN 55102 facilitated and helped to organize the entir e project. She contributed signicantly to thisnal report. We owe her a great debt of gratitude and extend our special thanks.
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FINDINGS: ADMINISTRATIVE STRUCTURE AND FUNDING
Designing an Effective Structural Model (Worksheet 1) Therst assignment for each group was to design a structural model for the ideal gambling treatment program. Participants addressed a series of questions to help them focus on key structural issues such as legislation, administrative structure, staffing, and accountability. They recommended a structural approach to developing gambling treatment programs that would rest upon legislation incorporating three key elements:
Clearly stated authority and accountability to senior administration officials Participants felt that states should establish a separate department or office to handle problem gambling programs, independent from programs that address other addictive behaviors (e.g., alcohol, drug abuse) or other public health issues. The department should be clearly identied with the wordsproblem gam-bling servicesin the title. The think tank participants thought that this separate identity would reinforce the notion that problem gambling is a unique problem requiring specialized solutions.3 According to participants, the ideal problem gambling program should be structured to report to high-level administration officials within state government, or even to the Office of the Governor. This high-level accountability was deemed consistent with the importance of gambling revenues to state budgets. It also was deemed useful in marking the program as a high priority for the state. Continuity of management, even in the face of political changes, was an important issue for Think Tank participants. Although a political appointee might hold the top position in a problem gambling depart-ment, they felt that second-level program administrators should be qualied civil servants who would remain in place despite changes in administration. Participants also recommended the establishment of an independent advisory board to include qualied problem gambling and mental health professionals, educators, academicians and others with special interest or expertise in the problem gamblingeld. The advisory board would assist the state agency responsible for problem gambling programs by developing qualifying standards for independent contractors seeking to provide services to the department; reviewing and evaluating proposed contracts; developing job descriptions for program administrators and clinical staff; interviewing and making recommendations on prospective hires; providing information on new trends in theeld, and helping to identify public needs.
Dedicated funding mechanisms to ensure funding continuity There was strong agreement among Think Tank participants that legislation establishing a problem gam-bling treatment program must include a mechanism for ongoing funding of the program in an amount sufficient to meet the cost of the mandated services. Participants felt that linking program funding directly to state gambling revenues was the most logical way to ensure funding continuity. As a practical matter, lottery or other state gambling revenues at least partly fund most existing problem gambling treatment programs. Earmarking agambling revenues for problem gambling treatment wasxed percentage of state considered the best and most appropriate funding mechanism.
3 Readers should keep in mind that this and other suggestions represent the groupevidence is not always available tos opinions. Empirical support these positions. For example, it has not yet been demonstrated that gambling is sufficiently unique from other mental d isorders to require distinct treatment programs.