Managerial Challenges and Strategic Solutions to Implementing Organizational Change in Substance Abuse Treatment for Latinos

Abstract

This study describes managers’ challenges and strategies to enhance standards of care in programs serving primarily low-income Latinos. Findings suggest that making organizational changes is moderate to difficult. Important barriers as well as strategic solutions to enact positive change are highlighted. Implications for building capacity in community-based programs are discussed.

Keywords:

• implementation
• Latinos
• organizational change
• standards of care
• substance abuse treatment

INTRODUCTION

The changing environment of the U.S. health care system requires organizational leaders that can respond to uncertainty with competency and courage. Substance abuse treatment (SAT) organizations must adapt to a new health care environment that demands greater accountability, increased efficiency in service delivery, and reduced variations in care for a highly diverse population (SAMHSA-HRSA Center for Integrated Health Solutions, 2011). However, SAT providers show limited readiness to improve standards of care (McLellan, Carise, & Kleber, 2003; Simpson & Flynn, 2007). Experts stress that poor infrastructure and workforce development primarily account for the low capacity of SAT organizations to respond to current demands (McLellan et al., 2003). Particularly among community-based SAT organizations serving primarily racial and ethnic minority populations, leaders are charged with the responsibility of helping develop the knowledge, skill, and commitment to translate evidence-based practices in order to potentially reduce health disparities (Center for Substance Abuse Treatment, 2006, 2009a, 2009b; Fixsen, Naoom, Blase, Friedman, & Wallace, 2005). It is important first to understand the program demands and challenges leaders of these community-based SAT organizations face when enacting necessary changes, as well as the strategies that may allow them to enhance standards of care for vulnerable populations.

Implementing Organizational Change in SAT

In SAT, managers’ organizational context includes increasing and sometimes-contradictory demands related to funding, professional accreditation, managed care organizations, workforce development, and client service needs (D'Aunno, 2006; Guerrero, 2010). These challenging conditions result in hectic work environments and poor resources that limit the ability of managers to implement innovative solutions (Alexander, Comfort, Weiner, & Bogue, 2001; Hasenfeld, 1980). Despite this context, initial implementation efforts in SAT are believed to rely largely on the capacity of leaders to enact change (Edwards, Knight, Broome, & Flynn, 2010). Based on the ability of leaders to initiate, promote, and sustain new practices, leadership has emerged as a focal point in SAT efforts to promote adoption of evidence-based practices (Broome, Flynn, Knight, & Simpson, 2007; Guerrero & Andrews, 2011; Simpson & Flynn, 2007).

Resistance to change among leaders has been perceived as the most formidable obstacle to implementation (Giangreco & Peccei, 2005). Resistance to organizational change refers to any action to maintain the status quo in response to change, and includes negative feelings such as fear and anxiety. Several studies have shown that evaluation of and commitment to change among leaders is a positive factor in facilitating organizational change (Fedor, Caldwell, & Herold, 2006; Herold, Fedor, & Caldwell, 2007; Herscovitch & Meyer, 2002). In particular, managers’ self-efficacy is associated with commitment to change (Herold et al., 2007). Self-efficacy can be described as self-confidence in responding to change or managerial openness to change, which is also associated with engagement in changing behaviors (McCartt & Rohrbaugh, 1995). Together, managerial need for change, self-efficacy in enacting changes, and the opportunity to participate in the change process are factors that allow managers to contribute directly to the overall readiness of organizational change (Armenakis, Harris, & Mossholder, 1993).

The empirical and theoretical literature points to important environmental and resource factors that support organizational change in terms of adopting new practices in SAT (D'Aunno, 2006; Knudsen, Ducharme, & Roman, 2006; Knudsen & Roman, 2004). Staffing and structural characteristics reflect organizational capacity to provide new services (Friedmann, D'Aunno, Jin, & Alexander, 2000; Guerrero & Cederbaum, 2010). For instance, academic education has been used to measure the technical capacity of staff. High levels of staff education are associated with the early adoption of evidence-based practices (Roman & Johnson, 2002).

Prior research consistently shows that institutional mandates from public funding (Campbell & Alexander, 2005; Stork, Scholle, Greeno, Copeland, & Kelleher, 2001; U.S. Department of Health and Human Services, 2001), professional accreditation (Wilson-Stronks & Galvez, 2007), and culturally diverse stakeholders (D'Aunno, 2006; Howard, 2003a; 2003b) provide resources and expectations to offer culturally responsive practices (Guerrero, 2012). Nonetheless, informal and formal support from skilled and experienced leaders is necessary (Center for Substance Abuse Treatment [CSAT], 2009a), particularly to endorse, monitor, and fund any sustainable implementation effort (see Simpson & Flynn, 2007). Overall, mounting evidence suggests that external and internal resources and expectations, as well as deliberate leadership and committed staff, are necessary to help SAT programs implement new practices (Simpson & Flynn, 2007). It is not clear, however, how leaders of community-based programs address external and internal demands with the objective of prioritizing improvements, mobilizing resources, and evaluating implementation efforts to improve standards of care.

Leadership and Change in Community-Based SAT Organizations

Community-based providers face significant barriers to implementing change due to a lack of human and program resources, in addition to poorly organized financial incentives under the current payment system (McLellan et al., 2003). These programs face unstable funding, poor technical resources, and high staff turnover (D'Aunno, 2006; Roman, Ducharme, & Knudsen, 2006; Substance Abuse and Mental Health Services Administration, 2007), limiting their capacity to conduct clinical operations or support effective decision making (McLellan et al., 2003). These organizational conditions challenge program administrators to find suitable strategies to respond to funding and accreditation expectations, which are increasingly tied to program performance outcomes (CSAT, 2006). Moreover, these programs have limited access to process improvement activities to guide and train counselors on evidence-based practices and track client outcomes to justify the effectiveness of their treatment interventions (CSAT, 2009a, 2009b; Fixsen et al., 2005). Although leaders of community-based SAT programs have direct influence on all operations because their programs are generally small, serving an average of 60 clients at any given time, they face unique challenges to meet standards of care in the new era of health care reform (Rawson & McCleland, 2010). This study relied on a multi-method approach to describe the organizational context that challenges as well as creates opportunities for leaders of community-based organizations to enact change and enhance standards of care in low-income Latino communities.

METHODS

A non-probability sample of 38 managers from community-based specialty SAT programs was recruited from a list of 436 providers in Southern California via invitational letters mailed in 2009. The majority of managers (89%) represented SAT program directors or other upper managers of small- to medium-size nonprofit organizations.

Data were collected as part of a pilot study that aimed to study managerial capacity and organizational change to respond to the service needs of vulnerable populations in substance abuse treatment. A multi-method approach was employed to collect and analyze data from this sample of managers. An online survey was used to collect information on program characteristics, as well as managers’ main challenges to enhancing standards of care. Standards of care were described as implementing evidence-based practices (e.g., motivational interviewing, use of family-based approaches delivered in Spanish when needed, etc.). A symposium format was established to collect in-depth information about specific organizational challenges identified in the online survey, and workgroups established during the symposium helped generate potential practical solutions to improve standards of care in SAT services for low-income Latino clients and other vulnerable populations.

Measures

The questions used in the online survey and during the in-person symposium session related to managerial attitudes regarding organizational change, as well as description of program services. Specifically, the online survey included 11 questions related to program characteristics (client, staff, resources, and regulation) and one question about difficulty to implement program changes. These questions were obtained from the National Drug Abuse Treatment System Survey (see Heeringa, 1996). Survey questions and their descriptive statistics are included in Table 1. An additional open-ended question asked managers to list their three most significant challenges to enacting program change. These ranked categories were used as main themes or challenges for workgroups to explore during the in-person symposium. The in-person symposium session relied on four audience response questions drawn from the organizational readiness for change scale (Simpson & Flynn, 2007). The audience response questions and their descriptive statistics are included in Table 2.

TABLE 1 Descriptive Statistics on Managers’ Organizational Context

Survey Questions (n = 38)	M	SD	Median	Range
Client Demands
How many clients do(es) your program(s) serve annually?	1176	2573	400	23–15000
What percentage of your total client population is Latino?	43.29	26.71	40	5–98
What percentage of your total client population speaks Spanish?	18.41	25.54	6	0–98
What percentage of your total client population completes treatment as determined by counselors?	54.92	25.52	60	3–90
Staff Demands
How many staff do you supervise?	19.27	29.51	8	0–157
What percentage of your treatment counselors speak Spanish?	22.15	25.62	10	0–100
What percentage of your treatment staff has a graduate degree (master's, PhD, MD)?	21.79	27.94	10	0–100
What is the average number of months a counselor remains employed at your program(s)?	47	57	36	7–360
Public Funding and Regulation
What percentage of your total budget is public funding?	55.33	37.83	50	0–100
Is your program licensed by the state?*	98	−	−	−
Is your program accredited by The Joint Commission?*	29	−	−	−
Difficulty to Implement Changes
How difficult is to implement program changes? ^a	5.18	2.62	5	1–10
*Values represent percentage of affirmative responses.
^aResponses were ranked on a 10-point Likert scale ranging from not difficult (1) to impossible (10).

TABLE 2 Descriptive Statistics on Managers’ Attitudes About Enacting Change

Audience Response Questions (n = 20)	Very	Somewhat	Neutral	Not Very	Not at All
How confident are you about responding to current challenges?	13	56	30	0	0
How difficult is it to implement change in your organization?	16	16	37	5	26
How important is cultural competence in your organization?	75	10	5	10	0
How committed are you to improving service delivery?	95	0	5	0	0
Note. Values represent percentage of respondents.

Procedure

Three methods of data collection were employed sequentially: 1) online survey, 2) audience response survey, and 3) transcription of the workgroup narrative during the symposium. Participants were asked via email to complete an 11-question online survey before registering for a six-hour symposium. Participants were informed that the symposium had the following two goals: 1) to bring together experts in the SAT field to present information about improving service delivery, and 2) to generate information from managers about promising strategies to improve standards of care during recessionary times. The second and third components of data collection occurred during the symposium and featured the use of audience response technology to gather confidential in-time responses from each participant, as well as the recording of in-depth narratives from workgroups about strategic responses to challenges identified in initial online survey responses. These three data collection components rely on a mixed-method approach designed to build on itself to identify challenges, develop overall themes, and generate discrete solutions based on those themes (Palinkas et al., 2011).

The audience response technology consisted of the use of personal clickers; participants used the devices to confidentially respond to eight questions posted on a screen. The use of clickers reduced social desirability bias generally associated with managers’ responses in surveys by allowing for anonymous and individual responses. The four questions expanded on the originally developed survey questions (see Table 1). The audience response method was also used to triangulate survey data and obtain a sense of the accuracy and consistency of the data reported by managers.

The third step in the iterative process of data collection relied on workgroups to identify potential solutions to the challenges they reported in the online survey (e.g., funding, program development, workforce development, etc.). Participants were instructed to join specific workgroups based on their expertise and ability to address challenges regarding service delivery by identifying responsive managerial strategies. Participants self-selected into workgroups, resulting in an average group size of 5 to 6 members. Participants were given the challenge and asked to develop practical solutions. After a 45-minute discussion, they were asked to report on promising strategies to address those challenges.

Five surveys were not included because respondents worked for funding or licensing agencies. Participants did not receive incentives and were required to consent before completing the online survey. All procedures were approved by the institutional review board at [name removed to ensure the integrity of the review process].

Descriptive Analysis

The descriptive analysis relied on summary statistics describing managers’ organizational context and their perception of implementing organizational change. Descriptive statistics are provided for client demands, staff demands, public funding and regulation, and difficulty to implement changes. Audience response answers are further described to improve understanding of managerial attitudes about change and the impact of external demands on the current service delivery system. Further, in order to conceptualize the change environment of managers by program size, organizations were categorized by reported number of clients served annually. Finally, managers were asked during the survey to describe the three most important challenges to fostering positive change and improving the quality of care for vulnerable populations. Using content analysis, the 114 responses resulted in seven categories, which are presented in Figure 1. As described in the procedure section, these categories were used as themes (challenges) by workgroups to develop on their own responsive strategies that applied to their organizational context.

FIGURE 1 Managers’ perceived organizational challenges to enhancing standards of care for vulnerable populations (N = 38) (color figure available online).

RESULTS

Survey and Audience Response

The descriptive statistics in Table 1 show the significant heterogeneity of this finite sample of managers in terms of client and staff demands and organizational resources and challenges. The context provided by data on client demands reveals wide differences among respondents, particularly when including larger programs. Based on the size of the program (i.e., clients served), data clearly outlined the different capacities of programs to serve clients. The programs in which these managers work are located in a major metropolitan area and service a large number of Latino clients, including a significant proportion with limited English proficiency (18%). Overall, managers reported a treatment completion rate of 54%, which is higher than rates found in studies using national samples (44%) (SAMHSA, 2009).

Staff demands also varied among managers. Most managers reported supervisory responsibilities for a varying number of employees, with a median of eight staff members. Managers also reported significant differences in the average number of months that counselors remain employed in their program, with a median of 36 months (three years). The median of staff with professional degrees (10%) was lower than the median reported in national samples (30%) (Guerrero, 2012). Similarly, the median of counselors speaking Spanish (10%) from this sample of programs located in a major metropolitan area is also below the national rate (40%) (Guerrero, 2010).

Despite having distinct organizational environments in terms of client and staff demands, managers reported similar organizational resources and challenges. Regardless of organizational size, most managers reported that public funding accounts for half of their total budget, and 95% reported that their program has a state license. Public funding and regulation are generally associated with increased pressure to enact changes in the delivery of substance abuse treatment services (D'Aunno, 2006).

Responses reflect managers’ skepticism about their capacity to implement necessary program changes. These upper managers are charged with the responsibility to enact policy and funding priorities. The descriptive statistics in Table 2 reflect their overall support for changes on one hand and their reservations about enacting such changes on the other. In other words, although managers reported moderate to significant difficulty in implementing program changes during both the survey and audience response portions of the study, audience responses also highlighted individual managers’ confidence about responding to current challenges. Managers clearly reported in the audience response questions their strong commitment to improve service delivery and their endorsement of cultural competence as an important service component in their organization.

However, further categorization of responses related to difficulty implementing program changes revealed three main responses. Most managers saw change as moderately to significantly difficult to enact in their organizations. The two measures of difficulty to implement change (survey and audience response) show similar distributions despite using different measurement scales. Interestingly, more managers from small- to medium-size programs reported moderate to significant difficulty in enacting changes. This is an important finding as the literature on change management emphasizes that one of the main issues stagnating change is how managers view change (Armenakis et al., 1993; Herold et al., 2007). Although managers can perceive change as being difficult and yet confront that perceived difficulty with deliberate actions, those perceptions of difficulty may impact their ability to encourage others and champion the process of change, particularly in smaller organizations (Herold et al., 2007).

A final analysis of the particular challenges to enacting organizational changes that lead to higher standards of care for vulnerable populations is presented in Figure 1. Consistent with the literature, challenges for managers are related to access to resources, such as funding to enhance organizational capacity to improve program and workforce development and measure client service outcomes (see CSAT, 2009b; D'Aunno, 2006; Roman et al., 2006). Responses reflected a high level of consensus on the challenges posed by critical resources and program development, which superseded adapting to change as a significant barrier.

Symposium Narrative

Narrative data collected from workgroups during the symposium highlighted structural challenges and strategic responses to the five organizational dimensions identified as barriers to enhancing standards of care in SAT (presented in Figure 1). Considering the organizational development framework of the symposium, workgroups generated, on their own, strategies to respond to five identified challenges: 1) identifying new resources, 2) diversifying funding, 3) improving program development, 4) improving workforce development, and 5) measuring and improving client treatment outcomes.

Identifying New Resources

Participants highlighted the importance of being aware of community resources and suggested attending local conferences and community events to improve connections and exchanges among community leaders, program managers, and staff. For example, one respondent noted, “It is important for social workers to stay informed about what is available in their communities through researching. Although this does take time and effort, it is ultimately very beneficial to clients.”

Diversifying Funding

Participants also identified practical ways to diversify funding resources, such as spending more time searching for available subcontracts, grants, donor networks, and fundraising events. But participants also noted the difficulty of reaching potential funders given their geographic location. For example, “… fundraising and eliciting donor support is difficult to do, especially in low-income areas, … as individuals don't have the means to support organizations. We have to be better at highlighting what we do for potential funders who are disconnected with issues in our communities.”

Improving Program Development

Strategies to improve program development included fostering more involvement from the community with client treatment. Participants also noted that getting clients to embrace their treatment plan might require tailoring treatment specifically to the individual needs of each client, which requires incorporating each client's social context in treatment goals. Accordingly, one participant noted, “It is important to enable practitioners who are actually working with clients in their communities to participate in program development and take an active role in the organizational development.”

Improving Workforce Development

In their discussion of workforce development, respondents emphasized the importance of updating the content and relevance of training for counselors. “Many substance abuse counselors receive their training from community colleges that haven't changed their curriculum in 20 years in order to meet the needs of an ever-changing field. Master's in family therapy (MFT) and master's in social work (MSW) programs may not be teaching enough on substance abuse, and community colleges lack focus on co-occurring disorders.”

Measuring and Improving Client Treatment Outcomes

Participants noted that measuring treatment outcomes is difficult, as people have individual ways of defining success. “It is important to go back to the state and federal funding resources and identify how they define success, as to ensure compliance with state and federal models.”

Overall, the survey data highlights the significant demands from clients and staff in terms of culturally and linguistically appropriate services for primarily Latino clients, as well as what can be construed as limited supervision available to counselors with low rates of graduate education. These topics were present when managers described their perceived challenges to enhancing standards of care (e.g., program and workforce development), reflecting their skeptical attitudes about the difficulty of making organizational changes (based on audience responses). Yet, when asked to address these changes, workgroups provided a series of practical organizational strategies to obtain necessary resources and improve programmatic and workforce issues, as well as client outcome evaluation.

DISCUSSION AND IMPLICATIONS FOR FUTURE RESEARCH

It is necessary to understand the service environment of human service managers in order to identify barriers and opportunities to improve standards of care for low-income Latinos and other vulnerable populations. To be responsive to their service environment, it is important for managers to develop openness and learn about themselves (Austin & Hopkins, 2004). By exploring the overall perceptions of managers regarding the difficulty of implementing organizational change within their current context, these preliminary findings identified key areas in community substance abuse treatment organizations that require attention.

Funding and program and workforce development challenges identified by managers are critical factors in their effort to build service capacity and improve the quality of care. Considering their service environment and demands, managers reported unique strategies to respond to these challenges. For instance, managers stated that challenges could be addressed, in part, by investing in community-influenced program development and state-supported training for staff competencies.

The attitudes of managers toward change and their capacity to leverage staff and program resources may ultimately enable them to progressively implement practices that help achieve their goal of reducing disparities in services and health. Actionable objectives, as determined by participants, may include strategic plans to diversify funding sources, generate consensus on implementation of evidence-based practices, develop in-service trainings, and cultivate an overall culture of change and positive growth. Specific to this sample of community-based programs servicing primarily Latino clients, managers alluded to the lack of funding for special populations (immigrants) who require linguistically appropriate services. This is an important financial and programmatic issue for all human service organizations that serve a sizeable population of residents with limited English proficiency. Overall, managers reported difficulty implementing positive change in small programs serving a sizeable number of Latino immigrants. Having adequate funding resources and evidence-informed culturally responsive program practices are among the strategies that managers view as the most important to improving standards of care for this population.

Findings from these preliminary descriptive results should be interpreted with caution. This was a small non-probability sample of program managers who volunteered their participation; hence, findings have limited generalizability. Also, the small sample did not allow for analysis of relationships among survey items. Despite these limitations, findings support areas of concern that require careful attention. Obtaining external funding, developing the workforce, and investing in program design have been areas of continuing need in SAT (see CSAT, 2006; 2009a; D'Aunno, 2006; McLellan et al., 2003). Exploring how to build the self-confidence of managers to introduce, monitor, and sustain program-wide changes is an area that requires further attention. In particular, identifying innovative, low-cost, and practical strategies to improve program effectiveness should be a significant priority in the current era of health care reform.

Managers provided several strategies that could potentially enhance the operation and survival of their programs. However, some workgroups focused on describing challenges, which may reflect the need for additional support to enhance the self-efficacy of managers in terms of leading positive change. It was clear that funding and workforce development are significant barriers to survival, let alone improving services.

Some managers alluded to the disconnection between problems their clients are facing in low-income communities and the concerns of funders located far from these communities. This was discouraging for managers who tried to raise funds for their programs, which often serve many people without legal immigration status and for which funding support is decreasing significantly. This issue is compounded by the need to adopt culturally and linguistically responsive services for immigrants. This issue is particular to the sample of programs selected in this study.

Finally, as the Patient Protection and Affordable Care Act and parity legislation requires substance abuse treatment providers to expand access and offer culturally competent and integrated substance abuse, mental health, and primary care services, SAT providers face significant challenges to integrating financial and programmatic changes. Health care experts and regulators agree that, to effectively respond to these system demands, leaders need to develop capacity to mobilize resources to effectively prepare their organizations for future standards, as evidenced by the creation of the SAMHSA-HRSA Center for Integrated Health Solutions (http://www.integration.samhsa.gov). This study provided preliminary information on challenges perceived by managers of community-based specialty SAT programs and potential strategies to respond to these challenges. These preliminary findings provide a foundation to build on in future studies on organizational capacity to implement effective change targeted at urban and community-based SAT organizations serving low-income and ethnic minority populations.

Acknowledgments

I thank Eric Lindberg for his assistance proofreading and typesetting early drafts of the manuscript. I would like to acknowledge the funding provided by the Hamovitch Center for Science in the Human Services, School of Social Work, University of Southern California.