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SOCW 6351: Social Policy, Welfare, and Change Week 10

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Discussion: Drug Policies and Ethics

The NASW Code of Ethics provides social workers with guidelines and standards for interacting with clients, colleagues, communities, and society, as a whole. These standards govern interactions and professional behavior of social work practitioners. The NASW has also developed specific standards, which are published in the NASW Standards for Social Work Practice With Clients With Substance Use Disorders. These standards emphasize the importance of the competence of social workers. The standards indicate that social workers should be knowledgeable of evidence-based interventions for substance disorders. The confidentiality standard becomes essential as social workers must be informed and comply with federal, state, and local laws about substance use, as well as third-party payee regulations.

For this Discussion, review this week’s resources, including the case Working with Clients with Dual Diagnosis: The Case of Joe,and consider how social policies affect Joe’s circumstances as described in the case study. Then, think about any gaps in service you found in Joe’s case. Finally, reflect on how you might address these gaps or make changes to the policies that affect Joe.

Post an explanation of how drug policies affect Joe’s circumstances, as described in the case study. Then, explain any gaps in service you found in Joe’s case as a result of the drug policies described in the case study. Finally, describe a strategy you might use to address these gaps or make changes to the policies that affect Joe.

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Learning Resources

Week 10: Substance Use

Substance use is perceived in a variety of ways by different entities. The court system may view substance use as a criminal activity. The medical and social work fields may view it as evidence of a disease or disorder. Uninformed individuals may view substance misuse as a personal choice or weakness. Decisions about how to address and respond to this social problem influence the development of effective policies.

This week, you explore the impact of drug policies on clients and populations. You identify the ethical obligations of social workers in changing drug policies. You also identify a social justice issue for which you can advocate and write a letter to a legislative representative.

Required Readings

Beerman, D. (2012). Advocacy handbook for social workers. National Association of Social Workers – North Carolina Chapter. Retrieved from https://cdn.ymaws.com/www.naswnc.org/resource/resmgr/Advocacy/Advocacyhandbook.pdf

Plummer, S.-B., Makris, S., & Brocksen, S. M. (Eds.). (2014). Social work case studies: Foundation year. Baltimore: MD: Laureate International Universities Publishing. [Vital Source e-reader].

  • “Working      with Clients with Dual Diagnosis: The Case of Joe” (pp. 77–78)

Popple, P. R., & Leighninger, L. (2019). The policy-based profession: An introduction to social welfare policy analysis for social workers (7th ed.). Upper Saddle River, NJ: Pearson Education.

  • Chapter      8, “Mental Health and Substance Abuse” (pp. 161-191)

Humphreys, K., & McLellan, A. T. (2011). A policy-oriented review of strategies for improving the outcomes of services for substance use disorder patients. Addiction, 106(12), 2058–2066.

Responsiveness to Directions

8.1 (27%) – 9 (30%)

Discussion posting fully addresses all instruction prompts, including responding to the required number of peer posts.

Discussion Posting Content

8.1 (27%) – 9 (30%)

Discussion posting demonstrates an excellent understanding of all of the concepts and key points presented in the text(s) and Learning Resources. Posting provides significant detail including multiple relevant examples, evidence from the readings and other scholarly sources, and discerning ideas.

Peer Feedback and Interaction

6.75 (22.5%) – 7.5 (25%)

The feedback postings and responses to questions are excellent and fully contribute to the quality of interaction by offering constructive critique, suggestions, in-depth questions, additional resources, and stimulating thoughts and/or probes.

Writing.

4.05 (13.5%) – 4.5 (15%)

Postings are well organized, use scholarly tone, contain original writing and proper paraphrasing, follow APA style, contain very few or no writing and/or spelling errors, and are fully consistent with graduate level writing style.’

Working With Clients With Dual Diagnosis: The Case of Joe

Reading Source:

Plummer, S.-B., Makris, S., & Brocksen, S. M. (Eds.). (2014). Social work case studies: Foundation year. Baltimore: MD: Laureate International Universities Publishing. [Vital Source e-reader].

· “Working with Clients with Dual Diagnosis: The Case of Joe” (pp. 77–78)

Joe is a 34-year-old, Caucasian male who came to the County Division of Social Services to apply for General Assistance (GA) benefits. The GA program provides cash assistance, Medicaid coverage, and housing for homeless single adults. Joe is in need of Medicaid benefits in order to remain active in his treatment program. Joe is receiving treatment at the Mentally Ill Chemical Abuser (MICA) partial hospitalization program at the local community mental health center for clients who are dually diagnosed. Joe has a dependence on marijuana, although he has stopped using it for approximately six months, and has been diagnosed with major depressive disorder. He is being prescribed medication.

Joe reports that he is unable to work due to mental illness, and without an income or health insurance, he is unable to obtain his medication. Joe reports that while he was enrolled as a student at the state university, he would sell marijuana to other college students. Eventually, he was arrested and convicted of possession with intent to distribute a controlled dangerous substance (CDS) and served 3 years in prison. Joe has had no further arrests; however, he has not been able to secure permanent housing or employment since his release.

Joe reports that this event has ruined his life. His lack of employment results from an inability to pass most background checks. If he discloses that he was arrested, Joe reports that he is never called for interviews. But when he once failed to disclose the information to the prospective employer, Joe was terminated for lying on his application. Joe believes that he has little hope for future employment.

Joe has few natural supports in his life. He reports that following the incarceration, his family distanced itself from him and his girlfriend at the time broke up with him. He reports that his only supports are his local Narcotics Anonymous (NA) sponsor and his mental health counselor. Joe reports that his housing situation has been unstable and sporadic for the past 10 years.

Joe’s mental health counselor from the MICA program has contacted me to advocate for Joe’s approval for benefits. I explained that under the current state regulations, Joe is ineligible for benefits due to his CDS distribution conviction. The only program options that I can offer him are food stamps and access to a homeless shelter outside of the county. The counselor explained that relocation would cause a disruption to Joe’s mental health treatment and would cause him to lose contact with his local NA sponsor.

In response to the counselor’s concerns, I suggested that Joe contact the local faith-based organization for assistance. Although they do not house single males, they have an extensive network of volunteers, mentors, and donors who may financially support people in need. I referred Joe to a program that offers bonding to people seeking employment who have been previously incarcerated. Finally, I suggested that the counselor research Joe’s ability to remain in treatment at the hospital despite his lack of Medicaid coverage. The counselor agreed to assist Joe with these suggestions.

A policy-oriented review of strategies for improving the outcomes of services for substance use disorder patients*add_3464 2058..2066

Keith Humphreys1 & A. Thomas McLellan2

Veterans Affairs and Stanford University Medical Centers, Palo Alto, CA, USA1 and University of Pennsylvania, Philadelphia, PA, USA2

ABSTRACT

Aims To inform policy makers on available options for improving the effectiveness of treatments for substance use disorders and to stimulate debate about treatment improvement strategies among public officials, clinical providers, care managers, service users, families and researchers. Methods We draw on the scientific literature and our public policy experiences in two countries (the United Kingdom and the United States) to give an overview of policies which may improve care for individuals with substance use disorders. We divide such policies into ‘process-focused quality improvement strategies’ that attempt to change some aspect of treatment (e.g. increased retention, greater use of evidence-based practices) and ‘patient-focused strategies’ that attempt to reward outcomes directly (e.g. contingency management for patients, payment by results for providers). Findings Many policies of both types are poorly devel- oped, have shown poor results, or both. The evidence is clear that process-focused quality improvement strategies can change what providers do and how treatment programs work, but such changes have thus far demonstrated only minimal impact on patient outcomes. Patient-focused strategies face challenges including treatment providers avoiding hard-to-treat patients or spending inordinate time relocating patients after treatment to assess outcome. However, policies that reward in-treatment outcomes and policies that allow the patient to purchase desired recovery support services show more promise. As policy makers go forward in this endeavor, they can do an enormous service to their countries and the field by embedding careful evaluation studies alongside new treatment outcome improvement initiatives.

Keywords Addiction treatment, payment by results, performance measurement, public policy, quality of care, treatment outcome.

Correspondence to: Keith Humphreys, VA Palo Alto HCS (152-MPD), 795 Willow Road, Menlo Park, CA 94025, USA. E-mail: [email protected] Submitted 16 November 2010; initial review completed 15 March 2011; final version accepted 31 March 2011

INTRODUCTION

Systemized efforts to improve the performance of complex service delivery systems have been part of the business world for over a century [1] and a feature of health, social care and criminal justice systems for several decades. Yet health and social services for people with substance use disorders have rarely been the subject of such initiatives, nor have the results of those efforts been assembled in a policy-oriented review. This paper strives to remedy this problem by providing policy makers with

an overview of system-level strategies than can improve the outcomes of services for substance use disorder patients. We draw on scientific literature but are also sub- stantially informed by our experiences designing, imple- menting, overseeing and advising on public policy in two nations, the United States and the United Kingdom (including the current national governments of both countries). The limits our personal experience imposes on the scope of the discussion will, we hope, be compensated for by the perspective we offer having been ‘on both sides of the table’ in the United States and United Kingdom.

*Authors’ note: Earlier versions of this paper were presented at a meeting of the UK Advisory Council on the Misuse of Drugs and at the 2010 Symposium of the Society for the Study of Addiction. This paper is heavily informed by the authors’ experience working with/for numerous government agencies in the United Kingdom and United States, but does not necessarily reflect the official views of any of those agencies.

FOR DEBATE doi:10.1111/j.1360-0443.2011.03464.x

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For these reasons, we explicitly characterize our paper as a stimulus to discussion and debate rather than as a sys- tematic review of all available evidence in all countries.

We focus on the generic subject of how policies can improve outcomes rather than any of the specific labels under which this goal has been pursued, e.g. ‘payment by results’, ‘value-based purchasing’, ‘continuous quality improvement’ and ‘performance contracting’, to name only a few buzzwords. We focus our discussion further by not entering the rich debate about what outcomes society should expect from treatment in the first place, be it abstinence, human immunodeficiency virus (HIV) risk reduction, reduced crime, higher rates of employment or ‘recovery’. Rather, we address the generic situation of the policy maker who wishes to make services produce better outcomes, regardless of the term they use for that policy and the specific outcomes they and other stakeholders have chosen to pursue.

Because, until quite recently, care for substance use disorders was omitted from most discussions of how to increase the effectiveness of health care [2], we make use of examples outside the field where appropriate. We also attempt to describe the direct, intended effects of outcome improvement policies (that are usually assessed by any ensuing evaluation studies) as well as the unintended, indirect effects (that are often not assessed). As an illus- tration of the latter type of effect, consider the US Veter- ans Health Administration (VHA), which instituted a national system of measuring and incentivizing parti- cular clinical practices across a very large, integrated health-care system [3,4]. This approach created a broader culture of ‘league table competition’, in which more providers put more effort into becoming the best at a range of clinical practices, even clinical practices that were not incentivized [5,6]. Because effectiveness improvement policies involve changing complex organi- zations and not just individual providers and patients, any policy initiative can alter the culture and practices of a services system (for well or for ill) beyond its explicit remit. These changes include but are not limited to the practice of ‘gaming’, in which organizations try to over- state their performance [7].

We now review two broad classes of strategies for improving the outcomes of substance use disorder treat- ment (see Table 1). The first class, process-focused quality improvement strategies, attempts to manipulate aspects of the care system that are expected to translate into better patient outcomes (indeed, there is no justification for investing resources in this strategy if it does not ulti- mately accomplish this) [7]. The second class of strategies focuses on patients and their outcomes more directly, without specifying which clinical and organizational practices are to be used to attain those outcomes. This would include, for example, paying for care based partly

or entirely on the basis of how much improvement patients make, or creating publically available ranking systems of program success rates. A system could use multiple strategies within each broad class, as well as hybrids across both. We describe them here separately for ease of presentation.

PROCESS-FOCUSED QUALITY IMPROVEMENT STRATEGIES

Research has documented substantial deficits in the quality of substance use disorder care in the United States and the United Kingdom [8,9]. These problems include an excess of paperwork, insufficient time spent with patients, demoralized staff, a lack of medically trained staff and dysfunctional organizational dynamics. Treat- ment programs also tend to underutilize scientific evidence [10].

The immediate objective of process-focused quality improvement strategies is to change organizational, financial and clinical practices. These improvements in treatment quality, in turn, are hoped to translate into better patient outcomes, but this cannot be assumed [11]. As chronic conditions with powerful behavioral and environmental components, substance use disorders are influenced profoundly by concurrent life context [12]. An individual patient may therefore receive high-quality care, but live in an environment (e.g. working in a pub, living on skid row) which undermines long-term out- comes. Similarly, a patient may receive low-quality care but have a major life event (e.g. becoming a mother, mar- rying someone who is in recovery, landing a dream job) that facilitates a good long-term outcome. In general, the longer the time between receipt of services and outcome measurement, the less likely the outcome can be taken as proof of the quality or lack of quality of those services. We develop this point further in the ensuing discussion of evidence.

Table 1 Strategies for improving the outcomes of health and social services for substance use disorder patients.

Process-focused quality improvement strategies Increasing licensure/credentialing requirements Measuring and/or incentivizing evidence-based clinical

practices Improving managerial capacity and business practices Embedding substance use disorder care in a higher-quality

care network Patient-focused strategies

Rewarding providers for post-treatment outcomes Rewarding providers for in-treatment outcomes Rewarding patients for attaining specific outcomes Making the patient a customer with purchasing power

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Process-focused quality improvement strategy no. 1: increasing licensure/credentialing requirements

Most US addiction treatment programs have no physi- cians or nurses [9]. In the United States and to a lesser, but still significant, extent in the United Kingdom, many counselors in the field have the primary credential of being in recovery from addiction themselves rather than having earned a particular educational degree or com- pleted a particular sequence of courses in counseling techniques. It therefore seems logical at face value that increasing credentialing requirements for staff will improve quality of treatment, which will in turn improve patient outcomes. Matters are not so simple, however.

First, the low status of careers in substance use dis- order treatment frequently makes it difficult to hire and retain staff. By definition, an increase in entry require- ments will exacerbate this problem unless it is accompa- nied by some inducement that makes a career in the field more attractive [for example, during a period when the National Health Service (NHS) was struggling to hire mental health professionals it offered a more generous pension scheme for new hires, allowing retirement at age 55 years]. Second, credentialing has become an entrepreneurial activity, with countless organizations developing and selling certificates and licenses. Although amusing as a story, it is disturbing from a policy perspec- tive that a man was able to purchase a doctorate and numerous psychotherapy credentials for his housecat over the internet [13]. It is a rare policy maker, and an even rarer consumer of services, who can tell which certificates on a wall truly reflect clinical competence. This problem is not particular to addiction treatment or even to health care: how many customers know what the certificates on the wall at a restaurant, beauty shop or in an accountant’s office actually mean?

Finally, although it comes as unwelcome news to pro- fessional guilds, evidence from hundreds of clinical trials shows that the outcomes of psychological counseling— one of the staples of substance use disorder treatment— are not predicted at all by the counselor’s type or level of educational degree [14]. This is less surprising than it may at first seem, as having a degree in medicine from Oxford or Cambridge, for example, does not ensure the ability of a physician to make an emotional connection to a drug-addicted homeless patient or an alcoholic army private who suffers from post-traumatic stress disorder.

Legitimate credentialing and licensure could help weed out truly destructive individuals (e.g. someone who has a criminal record for violence). Some credentials also allow particular clinical activities that could otherwise not be done, such as prescribing medication or drawing a blood sample. Further, there is evidence that more educated staff are particularly receptive to the use of

evidence-based practices [15]. Beyond these rather gross indicators of value, new credentialing policies are a weak lever for improving the outcomes of substance use dis- order treatment systems. One might temper this pessi- mistic conclusion by saying that credentialing might matter more if it shifted focus to demonstration of specific clinical competencies rather than particular coursework or hours of training.

Process-focused quality improvement strategy no. 2: measuring and/or incentivizing evidence-based clinical practices

In the US VHA, particular clinical practices were selected by national management and included in ongoing moni- toring throughout the system. Facility directors, chiefs of staff and other leaders were rewarded for augmenting the use of such practices, sometimes by financial incentives and sometimes by professional incentives (e.g. public ranking of medical centers’ success rates). Such clinical practices have included screening all primary care patients for drinking problems, recommending smoking cessation to psychiatric patients and retaining alcohol- and drug-dependent patients in specialty substance use disorder treatment for 3 months [16]. Outside the VHA, under the influence of quality improvement organiza- tions such as the Washington Circle [17], the National Committee for Quality Assurance [18] and the National Quality Forum [19], other public and private health-care systems in the United States have begun to monitor the proportion of patients whose substance use disorder is identified, the proportion who engage early in care and the proportion who are retained in care over time.

The VHA experience is that such incentives can lead to dramatic improvements in how often treatment pro- grams hit these process-of-care targets. The same has been found elsewhere, for example in the State of Dela- ware, which rewarded financially treatment programs that decreased the number of patients who dropped out of care quickly [20], and rewarded detoxification units and treatment programs who increased the rate of transition from the former care setting to the latter [21]. However, careful research on some of these measures has shown that achieving them bears at best a weak relationship to subsequent patient outcomes [22–24]. These disappoint- ing findings include studies of the 3-month retention in care process measure, which was used unsuccessfully for years in the US VHA and has now been adopted as a standard in the UK National Treatment Agency. The problem of weak links of process measures to outcomes is not unique to substance use disorders. For example, Medicare’s hospital quality measures for care of heart attacks and pneumonia explain a very small percentage of variation in patient outcome [25].

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A proponent of such approaches might argue that all a quality treatment system can be expected to do is provide care as close to practice guidelines and evidence as possible, not control everything that happens to the patient later. A more compelling point, we think, is that practice incentive strategies have demonstrated some- thing very important: provider behaviors respond to incentives [26]. It now remains for research to tell the health-care field which provider behaviors lead ulti- mately to better patient outcomes. Because research cannot yet predict reliably and strongly which care pro- cesses improve patient outcome, policy makers wanting prompt improvement in the effectiveness of treatments for substance use disorders will be understandably chary of this approach at the moment.

Before closing this section, we raise another question that is relevant to this strategy as well as some of those discussed in the ensuing sections: should anyone other than providers themselves be made aware of how closely they are following evidence-based practice guidelines? A recent clinical trial found that giving substance use dis- order treatment providers substantial feedback on their patients’ perceptions of the therapeutic alliance, satisfac- tion with care and level of current substance use had no effect whatsoever on clinical performance [27]. This finding resonates with others indicating that if there is no risk of reputational damage, information on one’s individual or organizational performance is generally dis- regarded [7]. Absolute and relative performance on mea- sured clinical practices is best made a public rather than private matter if the goal is to improve the outcomes of care.

Process-focused quality improvement strategy no. 3: improving managerial capacity and business practices

This strategy involves having expert consultants in busi- ness practices help treatment programs to improve their management skills, knowledge and capacity. Examples include teaching treatment programs how to pilot new procedures and make prompt use of data on their impact, engage with customers to discover their needs and wants, reduce excessive paperwork and other cumbersome bureaucratic processes, improve financial management and create an organizational culture that is professional and continuously educational for all involved. The highest-profile US-based efforts of this type are the Network for the Improvement of Addiction Treatment (NIATx) [28] and a follow-on project, Advancing Recov- ery [29]. Treatment programs applied competitively to join these projects, and those that were granted entry received a small amount of funds and access to exten- sive learning and consultation sessions. They were also brought together in conferences that allowed learning

from each other and also generated at least some spirit of healthy competition.

One intriguing business improvement strategy employed by NIATx is the ‘walkthrough’, in which program managers attempt to access care in their own programs from the patient’s point of view. For many managers, this was an eye-opening experience in poor organizational practice (e.g. telephones not being answered, messages being lost, unfriendly assessment staff) that helped to explain the low rates of treatment entry and retention in substance use disorder care. Other management practices taught in these initiatives include careful analysis and allocation of existing funding and better development of a business case for legislative and administrative bodies when advocating for new funding.

In two studies of the benefits of NIATx, participating programs reduced waiting time for treatment entry and increased retention in care [28,30]. These benefits remained in place after the intensive phase of organi- zational consultation had ended, suggesting that this approach is a sustainable strategy. The Advancing Recov- ery project generally improved its programs’ continuity of care and use of evidence-based pharmacotherapies [29].

However, NIATx and Advancing Recovery had a com- petitive entry process, meaning that better-organized and more motivated programs with stronger leadership were no doubt over-represented among participants. Effects would probably be less dramatic if such initiatives become national policy for the full universe of programs. Further, although both initiatives are currently trying to link implemented changes in care processes to long-term patient outcomes, this has not yet occurred. The same problem has bedeviled other, smaller-scale efforts to improve substance use disorder care through manage- ment consultation (e.g. the OpiATE Initiative) [31].

Process-focused quality improvement strategy no. 4: embedding substance use disorder care in a higher-quality care network

In its health-care reform legislation (the Affordable Care Act of 2010) and in the President’s National Drug Control Strategy [32], the Obama Administration consciously pursued a policy of medicalizing the care of substance use disorders [33], inspired in part by the UK’s example as well as by the few US systems that work on this principle (e.g. the VHA, Kaiser Permanante). The reasons for this decision were various, but one was the potential for improved quality. In the United States, sub- stance use disorder care is embedded in a clinical environ- ment of low resources and low quality, and in a financial environment (a set-aside public sector ‘block grant’) that pays for care with little consideration of effectiveness.

Through expanded funding for screening and brief intervention in primary care settings and changes in

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public and private insurance, the Obama administration has begun the difficult process of transplanting substance use disorder care into general health care. This setting brings with it numerous features that may improve patient outcomes, for example the presence of medically trained individuals, availability of medications, a finan- cial reimbursement system that provides some incentives for quality, an electronic health record that promotes careful tracking and monitoring of patients, and a broad culture of careful inspections and monitoring (i.e. by the Joint Commission). Co-location should also improve the likelihood that substance use disorder patients needing supplemental medical services (e.g. psychiatric or infec- tious disease care) will be able to obtain it. Finally, and importantly, integrated care coordinated by one’s usual general practitioner/primary care physician may be more accessible and less stigmatizing than going to an ‘addic- tion treatment program’. In turn, this means that it may also be possible to engage patients with lower, more manageable levels of severity.

Although we have worked in our policy capacities to mainstream substance use disorder care, we are cogni- zant that quality improvement is not guaranteed by this approach. Some medical care systems could take the resources allotted for substance use disorder care and re-allocate them to other priorities. Care integration could also lead to some addicted individuals receiving treatment from providers who lack significant knowledge of addictive disorders (e.g. many general practitioners). Integration thus remains a promising idea in search of rigorous evidence rather than something that can be assumed effective.

PATIENT-FOCUSED STRATEGIES

We now turn to a distinct set of strategies focused on the patient’s actual outcome (e.g. reduction in substance use, psychiatric symptoms, high-risk behavior, un- employment, criminality) rather than any individual organizational and clinical practice (e.g. shorter waiting- times, longer retention in care). A common criticism of regulation in both the United States and the United Kingdom is that process is over-managed by central government without regard to whether it leads to any valued outcome. From this perspective, it is fair to charge some of the organizational quality improvement strategies just reviewed with failing to focus on what ultimately matters most: the patient’s outcome. Some weight is given to this perspective by the research just reviewed showing how changed care processes have often not translated into better patient outcomes, as well as by other research suggesting that negative side effects of process-focused quality improvement initiatives are possible [34].

The patient-focused approaches in this section have been implemented less frequently than have process- focused quality improvement strategies. We thus make more use in this section of examples from other disorders.

Patient-focused strategy no. 1: rewarding providers for post-treatment outcomes

In some areas of health care, providers are directly incen- tivized to produce specific long-term patient outcomes. For example, the refusal of Medicare to reimburse the costs incurred when a surgery patient returns for follow-up surgery to remove equipment left in the body (e.g. a glove or clamp that leads to infection or poor wound healing) is a financial penalty for those hospitals whose low-quality care leads to poor patient outcomes. Similarly, the majority of US State Medicaid programs have some variant of ‘value-based purchasing’, and the NHS has long had ‘payment by results’.

The UK government is now launching what we believe is the first payment-by-results program in drug depen- dence treatment [35]. In pilot sites around the country, patients will be assessed by an independent unit that will assign a ‘tariff’ (i.e. a specific amount of money) that treatment programs will earn if they produce long-term changes in the patient in various domains (e.g. drug use, employment, criminal behavior, health and wellbeing). The independent assessment unit will assess the patient again after care has concluded to determine whether the treating program should be rewarded the tariff. This stands as one of the more innovative performance improvement efforts in the addiction field, and it will be important to monitor whether it results in measurable improvements.

The US VHA includes some outcomes in its perfor- mance monitoring system, including cholesterol levels for diabetic patients and blood pressure for hypertensive patients. In both these domains, VHA outperforms private and other public providers, as well as its own track record prior to the start of performance management [5]. We hasten to re-state, however, that what happens to a chronically ill individual after treatment becomes less linked to care quality over time. Setting the outcome measurement point too distant from treatment provision could lead to demoralization and subsequent lack of effort by clinical providers, as they are held accountable for things over which they have little control. There are also some risks that, in an outcome purchasing system, providers will ‘cream’ patients, i.e. not admit poor prog- nosis patients. Finally, the costs of locating and assessing patients after treatment can be considerable. When this work has been assigned to clinicians, it has resulted in poor follow-up rates, less time spent treating current patients and poor data [36]. It is therefore better for an

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independent outcomes monitoring team to follow-up patients, although this requires a continuing resource commitment [37].

Patient-focused strategy no. 2: rewarding providers for in-treatment performance

A different purchasing approach is to reward programs for outcomes attained during treatment. This resolves several problems with the just-mentioned strategy: finding the patient to assess them is easier, and what the provider does during the provision of care should have a stronger relationship to how the patient is doing at that moment. An experiment in the State of Maine initially generated enthusiasm about this strategy. Programs could obtain more funds by increasing the proportion of patients who achieved various outcomes (e.g. abstinent during the past 30 days of treatment, significant reduction in substance use since treatment intake) by their final contact with the program. Perfor- mance appeared to improve somewhat [38], but subse- quent analysis showed that programs began treating fewer severely troubled clients (creaming) after the performance contract was in place, implying that the apparent gains may have been illusory [39]. Further, the Maine system was entirely based on self-report, and patients may have been less candid in a system where treating clinicians are rewarded for reporting high abstinence rates. The Maine performance-contracting system was subsequently reviewed and updated to increase its effectiveness, but the most recent evaluation has again yielded disappointing results [40]. The Maine experience does not mean that this approach cannot work, but that performance contracts need to reward outcomes that are objective (e.g. urine testing) and case-mix-adjusted.

The Methadone Treatment Quality Assurance System implemented such an approach by having all participating methadone clinics fax in their urinalysis results to a central data monitoring unit, which then informed each program where it stood on case-mix- adjusted outcomes relative to a national sample [41]. This project demonstrated the feasibility of such a system, but because it did not attach any financial or reputational consequence to relative performance (clinic data were kept anonymous) there is no evidence that it changed clinical practice or improved patient outcomes.

Some clinicians would say that the in-treatment per- formance approach is not feasible as it requires regular monitoring of patients’ substance use. We are not sympathetic to this argument. Assessing a patient’s substance use at every single contact is as essential to good clinical practice as is an endocrinologist’s regular

measuring of blood sugar for diabetic patients or a car- diologist’s consistent monitoring of blood pressure for hypertension patients. Programs should assess patients’ substance use regularly whether or not there is an out- comes improvement contract in place.

Of the outcome improvement approaches described in this paper, we view purchasing in-treatment outcomes as among the most promising and feasible, not only because it could improve care but because it focuses clinicians’ attention on something for which they can and should be responsible throughout the care process. Research is still needed, however, to establish the strength of the relation- ship between in-treatment outcomes and longer-term, post-treatment outcomes.

Patient-focused strategy no. 3: rewarding patients for attaining particular outcomes

Multiple lines of evidence indicate that individuals with substance use disorders respond to incentives. Within the criminal justice system, for example, programs that put probationers and drink driving offenders in jail for a day immediately in response to a positive drug/alcohol test produce dramatic decreases in substance use [42,43]. Within health-care settings, contingency management programs have been shown to produce substantial behav- ioral changes when they reward abstinence or other out- comes with money, the chance at a prize or with greater privileges during treatment [44,45]. Housing provided contingent on abstinence also has been shown to reduce or eliminate substance use [46,47].

As a policy, however, paying patients to attain specific outcomes can run into resistance by the public and sometimes care providers as well, usually expressed in words to the effect that ‘they ought to change for free like everyone else’ or ‘why should we give goodies to baddies?’. These concerns can usually be somewhat mol- lified by using non-financial rewards; for example, by allowing methadone patients who stop using heroin to have extra take-home doses, and by emphasizing the public benefits of reward schemes, e.g. ‘the rewards to patients translate into rewards for everyone, such as safer neighborhoods’.

A different challenge is that behavior changes induced by an external reward sometimes deliquesce once the reward schedule is removed. This may come about through learning processes (e.g. the patient does not gain self-efficacy regarding the behavior change) or through disagreement about the purposes of treatment (e.g. the patient is interested in a different change than the one the system incentivizes). Policies of this sort may therefore affect long-term outcomes inconsistently, but may be useful in the early stages of treatment to encourage progress and engagement with care.

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Patient-focused strategy no. 4: making the patient a customer with purchasing power

During the G. W. Bush Administration, a radically differ- ent approach to improving the outcomes of substance use disorder care was created. Individuals early in the recovery process were given vouchers with which they could purchase whatever services they thought would further their recovery. Examples included community college classes, transportation to work or to self-help group meetings, transitional housing, dental care, work training and clothes for job interviews. The services were provided by a range of organizations which the state cer- tified for quality and, as in any market, there was pressure to serve the customer well because he or she could always take the voucher somewhere else. This was an innovative attempt to break down the culture that can emerge in the public sector in which patients are viewed as people ‘who have nowhere else to go’; or people who should be told what is good for them. One of the basic dilemmas of public sector services is that they are insulated from most of the mechanisms that drive efficiency and product quality in a free market [7]. Giving patients vouchers creates a miniature free market inside the public sector that should, theoretically, bring some of these mecha- nisms into play.

Access to Recovery, as the program is called, expanded both the number of organizations providing services and the number of people receiving them. More importantly, a study of more than 7000 substance use disorder out- patients in the State of Washington found that patients who received vouchers remained in treatment longer and were more likely to be employed than were comparable patients who did not receive a voucher [48]. This study did not, unfortunately, capture data on substance use outcomes, but the higher rate of employment might incline one to suspect better outcomes in that domain as well as being significant in itself. The Obama Administra- tion embraced Access to Recovery and indeed proposed a large budget increase for it [33].

Some UK think-tanks and elected officials have taken note of the success of Access to Recovery and bruited similar ideas. Although not a voucher program per se, the ‘personal health budgets’ being piloted for health and social care in the NHS are analogous in that they give patients a form of purchasing power. In consultation with a health professional, individuals with chronic illnesses (e.g. obstructive pulmonary disease, psychiatric disorders) are given a fixed pool of funds from which they can buy a range of services, assembling a care package tailored to their needs [49,50]. The extension of such budgets to people with addictions has been a subject of active discus- sion within the government, but it is not clear at this writing whether this will lead to a pilot effort of this sort.

CONCLUSION

Public policy makers can use a range of strategies to improve the outcomes of substance use disorder treat- ment. Many are poorly developed at this point, have weak empirical support, or both. Incentives for particular clini- cal practices can definitely change what systems do, but it is less clear which of those system changes translate into better patient outcomes. Some initiatives to incentivize care processes (including some in which we have been personally involved) have proved literally worse than doing nothing. Cases discussed in this paper in which care utilization was incentivized but outcomes did not change are particularly troubling, in that money was spent on care that was apparently not needed, and this may have affected adversely other people’s wellbeing (e.g. if waiting-lists grew longer due to requirements to retain patients beyond the point where it was making a difference).

Despite the small evidence base, the logic of bringing market forces for quality and effectiveness into treatment systems—including directly rewarding outcomes—has significant practical and logical appeal. We are particu- larly optimistic about such initiatives when they focus on in-treatment performance rather than long-term post-treatment outcome. The experience of vouchers for recovery support services that give patients’ purchasing power is also promising, and we hope the purchasing power concept will be extended for substance use disorder patients in other contexts, for example through the NHS personal health budget programme.

The extent to which our discussion here generalizes outside the UK and US contexts is something we are candidly not qualified to judge. How treatment systems are structured, organized, staffed and supported fiscally varies enormously throughout the world, such that a service improvement strategy that works well in one country may be ineffectual in another. Indeed, even within a single country some humility is warranted. To take a vivid example of intracountry diversity, the US VHA has more in common with the UK NHS than it does with the fee-for-service private sector of treatment ser- vices in its own country.

We close by advocating that as they make their strat- egy choices, policy makers serve themselves and this area by embedding careful, realistic evaluations in place alongside any new initiatives. The most common way in which performance enhancement schemes have been evaluated has been through retrospective study of various policy experiments. The most common data sources have been administratively available data not intended for research. An embedded evaluation would bring in program evaluators from the very first, allowing them to help decide how proximal and ultimate outcomes

2064 Keith Humphreys & A. Thomas McLellan

© 2011 Society for the Study of Addiction. No claim to original US government works Addiction, 106, 2058–2066

will be measured, and to complete the work in a time interval that might actually inform what to do next year, rather than what should have been done 5 or 10 years ago. The investment and level of collaboration required to do this is substantial, but given the potential payoff in knowledge about how to enhance care for a life- threatening group of disorders, we have no doubt that the up-front costs to policy makers and researchers are very well justified.

Declarations of interest

The authors advised on or were involved in a number of the policy initiatives described in this paper.

Acknowledgements

Dr Humphreys’ work on this paper was supported by a VA HSR&D Senior Research Career Scientist award. We are grateful to Gwyn Bevan, Joe Francis, Alex H. S. Harris, Francis Keaney, John Marsden, Dennis McCarty and two anonymous reviewers for comments on earlier drafts of this paper.

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This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy.

Users should refer to the original published version of the material.

ADVOCACY HANDBOOK

FOR SOCIAL WORKERS

By Dan Beerman, ACSW, LCSW

Professor at NC A&T State University and UNC-Greensboro

Joint Master of Social Work Program

Revisions by Doaw Xiong, BSW, Intern

National Association of Social Workers – North Carolina Chapter

East Carolina University

2

Table of Contents

Why Advocate ………………………………………………… 3

Working with Legislators ……………………………………. 4

Letter Writing Samples

Clients ………………………………………………….. 5

Professional ……………………………………………. 6

Calling Legislators …………………………………………… 7

Sample Call to Legislators …………………………………… 8

Visiting Legislators …………………………………………… 9

Other Forms of Advocating …………………………………. 10

NC- PACE ……………………………………………………. 11

Your Representatives or Senators ………………………….. 12

Understanding Legislative Terms …………………………… 13

3

“Why Advocate?”

All citizens have a right to make the sort of

contact with elected officials that are described

above. Citizen participation is a cornerstone of a

democratic society. Citizens can participate in

the life of their community in many forms.

The Code of Ethics of the National Association

of Social Workers calls upon social workers to

“…facilitate informed participation by the

public in shaping policies and institutions.”

(NASW, 1999). Additionally, Section 6.04 (a) of

the Code, states that, “social workers should

engage in social and political action that seeks

to ensure that all people have equal access to

the resources, employment, services, and

opportunities they require to meet their basic

human needs and promote social justice”

(NASW, 1999).

The International Federation of Social Workers

states in its definition of social work, “The

social work profession promotes social change,

problem solving in human relationships and the

empowerment and liberation of people to

enhance well-being. Utilizing theories of human

behavior and social systems, social work

intervenes at the points where people interact

with their environments. Principles of human

rights and social justice are fundamental to

social work” (IFWS, 2012).

As a social worker you can play a critical role in

convincing North Carolina’s Legislators and the

Governor that funding for human service

programs and programs that support best social

work practice should be protected and

expanded. You have first-hand knowledge of

the importance of support for critical services

that impact your clients, your agencies, and your

community.

“You can make a difference.”

Social Workers have reported that they do not

like to get involved in political activity because

they feel uncomfortable in a domain that is

foreign to them. They do not trust politicians

and do not trust the political process. These

feelings of being disconnected are the same

feelings many of our clients have about our

social service programs. As professionals we are

called upon to be aware of our feelings, use our

professional skills, and be good problem

solvers. Social Workers are good

communicators and can be excellent advocates

with legislators and other decision makers.

People who are employed by public agencies

must be aware that they have a special

responsibility to not use or create the perception

that public funds are being used to try and

influence public policy. Be aware of agency

policy on such issues. For some federal and

state employees the Hatch Act imposes clear

limitations on such activities. Use common

sense and (1) Do not use public resources for

mailings; (2) Do not use agency stationary for

letters (you can tell them where you work); (3)

Use your own time for advocacy activity unless

you have permission from your agency to

advocate on their time; (4) Do not make calls

from work phone; and, (5) Use your own phone.

4

WORKING WITH LEGISLATORS

When the legislators are not in session, send

correspondence to their home or local addresses.

A list of Raleigh and home office addresses,

phone numbers and e-mail addresses is available

on the website of the NC General Assembly

(www.ncleg.net). This site will help you locate

your representatives by county.

You can reach the governor year round at:

The Honorable Governor (Insert Current

Governor)

116 West Jones Street

Raleigh, NC 27603-8001

What can help?

Write letters to your local newspaper about

issues of concern to you. Write your legislators

and ask them to support specific programs.

Additionally, there are several other modes of

contact or advocacy that have an impact on the

members of the state legislature. They are:

 Phone contact

 Meeting with a legislator

 Becoming a lobbyist

 Supporting NC-PACE

OTHER WAYS TO INFLUENCE POLICY

A personal, well written, original letter will

have a considerable impact on legislators.

Following are some helpful tips for writing

legislators:

 Make sure a return address is contained within the letter.

Remember, typed

 Send your letters are easier to read than handwritten letters.

 Send your letter via traditional mail or via e-mail.

 Be sure to identify the town/city and county in which you live.

 State what is being asked of the legislator/governor and request a

response.

 Be brief and to the point. Try to make the letter no longer than one

typewritten page. Send only the

original letter, not a copy.

Personalize your letter to strengthen

your points.

 Be factual and support positions with information.

 If you know the bill number and title, be sure to refer to it in your letter.

 Remain courteous; do not threaten or cajole. Simply explain the local

impact the legislation would have.

 Write a second letter of thanks to legislators who vote to support your

initial request.

 Be sure to address the elected official properly. The governor is addressed

as “The Honorable Governor (first

name, last name).” Legislators are

addressed as “The Honorable (name

of senator or representative).” You

do not put Senator or Honorable after

Honorable in salutations to

legislators.

 When the General Assembly is in session, send correspondence to

legislators at their Raleigh office.

5

Following are two sample letters that you can send to your legislators:

ALTERNATIVE ONE:

Client Advocacy

Your street address

City, state, zip code

Phone number

Date

The Honorable (full name)

Address

Dear Representative OR Senator (last name):

I am a registered voter in (City, County, District) and I work in the field of (mental health, school

social work, public welfare, etc.). It has come to my attention that the NC General Assembly is

considering (describe action and if possible give a bill number). I am concerned about the

negative impact this action will have on (client group)…. OR, I support this bill (give reasons for

support. Also, give cost implications and anecdotal information about client impact.).

These services are critical to my clients and to many others in North Carolina with similar issues.

I realize that you are faced with many tough decisions as you prepare the state’s budget. But, not

providing services to people who desperately need them is not the way to balance the budget.

Have the courage to do the right thing and invest in all our people. Please let me know your

position on removing funds from the states budget for (your issue).

Sincerely,

Your name

[Make sure you personalize the letter to strengthen its impact, but stay brief and to the point.

Try to keep the letter to one page. You can use the letter text in e-mail.]

6

ALTERNATIVE TWO:

Professional Advocacy

Your street address

City, state, zip code

Phone number

Date

The Honorable (full name)

Address

Dear Representative OR Senator (last name):

I am a registered voter in (City, County, District) and I am a social worker at (place and

location). It has come to my attention that the NC General Assembly is considering (describe

action and if possible give a bill number). I am concerned about the negative impact this action

will have on social work education in NC…. OR, I support action being taken to improve

support for social work in NC (Give cost implications and anecdotal information about client

impact.).

(If you are writing about the Child Welfare Education Collaborative remind them that students

pay back educational support with services in their counties. Include concerns about incidents of

child deaths in other states.)

I realize that you are faced with many tough decisions as you prepare the state’s budget. But, not

providing services to people who desperately need them is not the way to balance the budget.

Have the courage to do the right thing and invest in all our people. Please let me know your

position on removing funds from the states budget for (your issue).

Sincerely,

Your name

[Make sure you personalize the letter to strengthen its impact, but stay brief and to the point.

Try to keep the letter to one page. You can use the letter text in e-mail.]

7

CALLING YOUR LEGISLATORS

If you cannot reach the legislator directly, leave a phone number where calls can be returned to

and ask to speak to available staff. They will notify the legislator of contact of calls received and

are often very helpful.

 Before you call, jot down the main points that you want to include in your conversation. Practice what you are going to say.

 Ask to speak directly to the legislator.

 Identify yourself and where you are from (city, county).

 Be brief and concise. State the purpose for your call.

 Express your appreciation if the legislator is supportive of your issue. If the legislator is undecided, offer to provide more information.

 If you know the bill number and title, be sure to refer to it in your conversation.

 Be prepared to spend more time if the legislator wants more information.

 Remember to be courteous and to thank the legislator or staff person for his/her time.

 Send a follow-up letter restating the substance of the call and the legislator’s position on the issue as it was understood (whether there was direct contact with the legislator

or with his/her staff). Again, thank the legislator for his/her time.

The content of a phone call to a legislator is very similar to that of a letter. Be prepared to answer

questions and provide additional information. Following is a sample phone call script that you

can use as a guide for calling legislators.

8

Sample call to a legislator:

“Senator/Representative (last name), my

name is…. and I am a resident of (city) in

(county). I am calling today to ask your

support of” (describe your issue in a

sentence or two).

3

In another few sentences, tell them why you

have concerns about this issue.

For example:

 I work in a mental health center with (population), and….

 I am a school social worker, and….

 I work in a DSS with abused children, and….

Give them a couple of examples of

important pieces of information.

 Data on the number of un-served mentally ill.

 Data about school dropout rates.

 Data about increased reports of child abuse.

I realize that you are faced with many tough

decisions as you prepare the state’s budget. I

am calling to express my support for (give a

bill number or concise description of issue

or I am concerned about potential funding

cuts or change in (give bill or concise

description of issue).

What is your position on removing funds

from this important area? Or what is your

position on support for this critical area?

Give the legislator an opportunity to express

his/her opinion without interruption. If the

legislator indicates that he/she will fight

budget cuts to your services or supports the

action on a bill that you support, thank

him/her. If the legislator indicates that

he/she is undecided or that he/she is in favor

of these cuts or does not support your bill or

issue, politely ask them to reconsider and

state again how important it is for your

clients to receive these services or for the

profession to be strengthened. Offer to meet

with the legislator and/or provide additional

information about the impact of reduced

funds for services or lack of support for your

issue.

For questions you can’t answer, offer to

find the answers for him/her. Offer the

legislator your name and phone number

in case he/she has additional question at a

later time. NEVER SAY WHAT YOU

DO NOT KNOW TO BE TRUE! Just let

them know you will get back to them

immediately with the answer. Legislators

appreciate honesty and you will be viewed

as having credibility.

Thank the legislator for his/her time.

[Remember to follow up your phone call

with a thank-you letter.]

For professional issues use the same format

as above.

9

VISITING YOUR LEGISLATORS

A face-to-face meeting with your legislators is an excellent opportunity to discuss the proposed

budget cuts and their impact on you and your family. The following guidelines may be helpful as

you begin visiting your legislators.

 Develop and maintain a good working relationship directly

with the legislators in your

district.

 Always call ahead for an appointment and briefly explain

the purpose of the meeting.

 Be on time and professionally dressed (NO JEANS).

 Keep your comments to the point and limit your

presentation/discussion to the

time scheduled, unless the

legislator extends the meeting.

(Refer to sample letter and phone

call for some suggestions on how

you might organize your

comments.)

 Use bill numbers and titles when possible.

 Tell the legislator why the issue is important to you and to other

constituents in his/her district.

 When possible and appropriate, bring consumers of services with

you to talk with the legislators.

 Ask the legislator for his/her position on the issue and how

he/she will vote. If supportive,

thank him/her for the support. If

undecided or for removing funds

for services, ask if you can

provide additional information

on the issue.

 Always be courteous, even if the legislator disagrees with your

position on the issue.

 Leave information for the legislator to review after your

meeting.

 Thank the legislator for his/her time.

 Send a short letter thanking the legislator for the meeting.

10

OTHER FORMS OF ADVOCACY

The National Association of Social Workers

(NASW) primary functions include

promoting the professional development of

its members, establishing and maintaining

professional standards of practice,

advancing sound social policies for the

betterment of the nation, and providing other

services that protect its members and

enhance their professional status (Barker,

2003).

The mission of the National Association of

Social Workers-North Carolina (NASW-

NC) chapter is to continue the mission of the

national association as well as enhance the

effective functioning and well-being of

individuals, families, and communities

through its work and advocacy. NASW-NC

achieves this mission through Professional

Advocacy (which has representation on at

least 25 statewide coalitions) and Social

Policy Advocacy.

On staff with NASW-NC is a Director of

Advocacy, Policy and Legislation (DAPL)

who is a registered lobbyist and represents

NASW-NC members at the NC General

Assembly.

The current Director of Advocacy, Policy

and Legislation is Kay Paksoy; Kay has her

Bachelor of Social Work (BSW). During

legislative sessions, the DAPL reviews

legislation that is introduced each day to

assess its possible impact on social workers

and their clients, and takes appropriate

action.

Other responsibilities of the DAPL include

working with legislators to amend existing

state statutes, representing social workers at

state wide meetings focusing on different

arenas of the social work profession and

speaking to groups about the advocacy work

of NASW-NC.

Lobbying in the NC Legislature on social

work issues, such as insurance

reimbursement, social work licensure, and

increasing salaries to strengthen the

profession, health insurance for all people,

strengthening our state’s education system,

effectively changing the welfare reform

system are just a few of NASW-NC

responsibilities.

To register as a lobbyist:

 File a registration statement with the Secretary of State in person or

by mail;

 Pay the $200.00 registration fee at the time of registration; and

 File an authorization statement, registration fee and authorization

statement is required for each

principal a lobbyist represent.

 Additionally, a separate registration statement, registration fee, and

authorization statement is required

for each lobbyist a principal retains

or employs.

11

SUPPORTING NC-PACE

What is PACE?

Political Action for Candidate Election (PACE) is NASW’s Political action arm. As a political

action committee, PACE endorses and financially contributes to candidates who support

NASW’s policy agenda, irrespective of party affiliation. The national PACE Board of Trustees

endorses and contributes to federal candidates running for US House and Senate Seats; state

chapter PACE units decide on local and state races.

NASW-NC also has its own political action committee known as NC-PACE (Political Action for

Candidate Election). This committee helps elect candidates to public offices that will support

legislation and policies consistent with the goals of the social work profession and the needs of

those who are served by the social work profession in North Carolina.

How PACE Helps NASW- NC Reach its Goals

As a subsidiary of NASW, PACE functions to enhance the policymaking environment for the

association. In addition to its major tasks, PACE strengthens the organization by:

 Recruiting members through personal contact, student outreach, and being a visible political force

 Improving NASW’s image to candidates, members, and students

 Building capacity for political action within NASW through the field organizer project and by providing technical assistance to chapters

 Helping elect legislators who will advance NASW’s legislative priorities, and where possible, specifically electing social workers

Available to members of NASW-NC is our Advocacy webpage under Government Relations at

naswnc.org, which assists you in finding out what issues in both the State and Federal

Legislatures that may affect you or your clients. This page will keep you informed about

pending legislation that needs YOUR support and will offer suggestions as to how YOU can get

involved.

12

“YOUR REPRESENTATIVE OR SENATOR…” 1. KNOWS THAT “ALL POLITICS IS LOCAL.” This quote by former Speaker Tip O’Neill

means that office holders pay first allegiance to their districts, and consequently, their reelection.

That is why local coalition contacts from their home are most effective.

2. WANTS TO DO THE RIGHT THING: Each of us wants to do a good job, but we

sometimes forget that this basic human drive also applies to elected officials.

3. OFTEN WANTS TO GET REELECTED: Despite the fact that nearly all incumbents are

reelected, they all thrive on their jobs and are constantly concerned with what they have to do to

keep it or get a better one.

4. WANTS TO BE RESPONSIVE: He/she is in the business of pleasing people and wants to

accommodate you – but not at any cost. Other considerations may prevent him/her from doing

so.

5. MAY KNOW NOTHING ABOUT THE ISSUES THAT IS OF CONCERN TO YOU:

Unless your representative is a member of the Human Resources Committee, your representative

probably knows little or nothing about your concerns. Share your knowledge.

6. IS BESET BY CONFLICTING PRESSURES: Fund new education programs and cut non-

education programs. Don’t raise taxes. Don’t touch the cigarette or alcohol industries. Provide

information about why funds for these services are so important to receive priority from our

legislators.

7. WANTS TO KNOW HOW LEGISLATION AFFECTS THE LOCAL DISTRICT: This

is where you are critical. You can show how a bill impacts the people back home. Be specific

and use real-life examples.

8. FIND IT HARD TO VOTE AGAINST A FRIEND BUT EASY TO VOTE AGAINST

SOMEONE WE DON’T’ KNOW: Votes in the legislature are taking money from one

program to give to another. Unless your representative knows the impact that cuts have on

programs in their district, it’s easy to accept the argument those programs can afford the cut or

don’t need expansion.

13

Understanding Legislative Terms

Amendment

A proposed change to the language in a bill

by adding, substituting, or omitting a portion

of the legislation before final passage.

Appropriation

Legislation that funds an agency or program

by directing the expenditure of money from

the Budget Office.

Authorization

Legislation that authorizes, or permits the

expenditure of funds for an agency or

program, with the actual spending to be

approved by the appropriations committees.

Bill

Legislation introduced in either the House or

the Senate. House bills are designated by the

prefix “H.B.,” Senate bills by “S.B.,: and

then followed by the bill number. Bill

numbers are determined by the order in

which bills are introduced.

Caucus

A meeting of members of the same political

party to determine the party’s position on

legislative issues.

Committee

A subdivision of members of the House and

Senate that prepares legislation for action by

the parent chamber. Each committee has

jurisdiction over certain subject matters and

considers legislation pertaining to their

jurisdiction. Most committees are further

subdivided into subcommittees. There are

two types of committees:

1. Standing Committees are permanent committees with a particular

legislative jurisdiction.

2. Joint Committees have members from both the House and the Senate.

Committee Process

Once bills are introduced, they are referred

to one of the committees where hearings are

held, where amendments are considered, and

the committee reports its recommendations

to the legislative body.

Conference Committee

A committee made up of members from

both chambers. Its purpose is to resolve the

differences between the House and Senate

version of a bill.

Constituent

Any citizen residing in a district or state

represented by a House Representative or a

Senator.

Continuing Appropriation

When a fiscal year begins and the legislature

has not yet enacted all regular appropriation

bills for that year, it passed a joint resolution

“continuing appropriation” for government

agencies at rate generally based on the

previous year’s appropriations.

Co-sponsor

One who joins in sponsoring legislation. Co-

sponsorship is a public demonstration of

support for a measure.

Executive Session

A meeting of a Senate or House committee

(or, occasionally of either chamber) that

only its members may attend.

Expenditures

The actual spending of money, as

distinguished from the appropriation of it.

Filibuster

A time-delaying tactic used by a minority in

an effort to prevent a vote on a bill that

probably would pass if brought to a vote.

14

Fiscal Year

The states annual accounting period, which

begins July 1 and ends the following June

30. The fiscal year is designated by the year

in which it ends.

H.B.

The initials “H.B.” before the number

designate a bill originating in the House.

Hearings

A session of a legislative committee at

which supporters and opponents express

their views. The committee announces

hearings from one day to many weeks in

advance and may invite certain persons to

testify. Persons who request to testify may

be turned down by the committee, but they

are often allowed to either appear in person

or submit a written statement for the record.

Introduction

The original presentation of a bill.

Joint Committee

A committee made up of members of both

the House and Senate

Joint Resolution

Just like a bill, a joint resolution requires the

approval of both houses and has the force of

law if approved. Joint resolutions are

generally used in dealing with limited

matters, such as a single appropriation for a

specific purpose.

Legislative action

The preparation, research drafting,

introduction, consideration, modification,

amendment, approval, passage, enactment,

tabling, postponement, defeat, or rejection of

a bill, resolution, amendment, motion,

report, nomination, appointment, or other

matter by the legislature or by a member or

employee of the legislature acting or

purporting to act in an official capacity.

Marking Up a Bill

Going through a measure, usually in

subcommittee and committee, taking it

section-by-section, revising language, and

penciling in new phrases. If the bill is

extensively revised, the new version may be

introduced as a separate or “clean bill” with

a new number.

Majority Leader

Floor leader, spokesperson, and strategist for

the majority party.

Minority Leader

Floor Leader for the minority party.

Ranking Member

The most senior member of a committee

from a particular party. Most often used to

refer to the most senior member of the

minority party.

Re-committal

Sending a bill back to the committee that

reported it for consideration.

Report

Both a verb and a noun. A committee that

has examined a bill refers it to the parent

chamber by “reporting” its views and

recommendations regarding the measure. A

“report” describes the purpose and scope of

a bill, along with supporting reasons.

Opposing views as well as supplemental

views of other members of the committee

may be included.

Resolution

A resolution deals with matters entirely

within the prerogatives of one chamber. It

does not require passage by the other

chamber and does not carry the force of law.

Most resolutions deal with the rules of a

chamber or are used to express the

sentiments of a single house.

Rule

A. House or Senate rules governing the conduct of business.

15

B. A “Rule” issued by the House Rules Committee on procedure for

handling House bills.

S.B.

The initials “S.B.” before the number

designate a bill originating in the Senate.

Sessions

Normally, the legislature consists of two

sessions, with the long session beginning in

January and ending when the legislature

adjourns (odd years) and a short session

(even years) that begins in May and goes

until legislature adjourns.

Sponsor

The member of the legislature who

introduces legislation.

Standing Committee

A committee that studies measures

introduced within its jurisdiction and makes

recommendations to its respective chamber

concerning appropriate action.

Subcommittee

A subdivision of committee organized by

subject matter.

Substitute

A motion, amendment, or entire bill that is

introduced in place of pending legislation.

Passage of a substitute kills the original

measure.

Suspend the Rules

A motion to expedite passage of legislation

whereby any member recognized by the

Speaker may “move to suspend the rules and

pass the bill.” This requires a two-thirds vote

in the House and majority in the Senate.

This curriculum was developed for professionals and students in North Carolina to support their

efforts to live up to the expectations of the NASW Code of Ethics. Developed by Dan Beerman,

ACSW, LCSW, Professor with the NC A& T State University and UNC-Greensboro JMSW

Program. Revised by Pamela Siobohn Moye, CCADS, MSW Intern, UNC-Chapel Hill; Doaw

Xiong, BSW Intern, ECU, 2012.

SOCW 6351: Social Policy, Welfare, and Change Week 10

Top of Form

Discussion: Drug Policies and Ethics

The NASW Code of Ethics provides social workers with guidelines and standards for interacting with clients, colleagues, communities, and society, as a whole. These standards govern interactions and professional behavior of social work practitioners. The NASW has also developed specific standards, which are published in the NASW Standards for Social Work Practice With Clients With Substance Use Disorders. These standards emphasize the importance of the competence of social workers. The standards indicate that social workers should be knowledgeable of evidence-based interventions for substance disorders. The confidentiality standard becomes essential as social workers must be informed and comply with federal, state, and local laws about substance use, as well as third-party payee regulations.

For this Discussion, review this week’s resources, including the case Working with Clients with Dual Diagnosis: The Case of Joe,and consider how social policies affect Joe’s circumstances as described in the case study. Then, think about any gaps in service you found in Joe’s case. Finally, reflect on how you might address these gaps or make changes to the policies that affect Joe.

Post an explanation of how drug policies affect Joe’s circumstances, as described in the case study. Then, explain any gaps in service you found in Joe’s case as a result of the drug policies described in the case study. Finally, describe a strategy you might use to address these gaps or make changes to the policies that affect Joe.

Bottom of Form

Learning Resources

Week 10: Substance Use

Substance use is perceived in a variety of ways by different entities. The court system may view substance use as a criminal activity. The medical and social work fields may view it as evidence of a disease or disorder. Uninformed individuals may view substance misuse as a personal choice or weakness. Decisions about how to address and respond to this social problem influence the development of effective policies.

This week, you explore the impact of drug policies on clients and populations. You identify the ethical obligations of social workers in changing drug policies. You also identify a social justice issue for which you can advocate and write a letter to a legislative representative.

Required Readings

Beerman, D. (2012). Advocacy handbook for social workers. National Association of Social Workers – North Carolina Chapter. Retrieved from https://cdn.ymaws.com/www.naswnc.org/resource/resmgr/Advocacy/Advocacyhandbook.pdf

Plummer, S.-B., Makris, S., & Brocksen, S. M. (Eds.). (2014). Social work case studies: Foundation year. Baltimore: MD: Laureate International Universities Publishing. [Vital Source e-reader].

· “Working with Clients with Dual Diagnosis: The Case of Joe” (pp. 77–78)

Popple, P. R., & Leighninger, L. (2019). The policy-based profession: An introduction to social welfare policy analysis for social workers (7th ed.). Upper Saddle River, NJ: Pearson Education.

· Chapter 8, “Mental Health and Substance Abuse” (pp. 161-191)

Humphreys, K., & McLellan, A. T. (2011). A policy-oriented review of strategies for improving the outcomes of services for substance use disorder patients. Addiction, 106(12), 2058–2066.

Responsiveness to Directions

8.1 (27%) – 9 (30%)

Discussion posting fully addresses all instruction prompts, including responding to the required number of peer posts.

Discussion Posting Content

8.1 (27%) – 9 (30%)

Discussion posting demonstrates an excellent understanding of all of the concepts and key points presented in the text(s) and Learning Resources. Posting provides significant detail including multiple relevant examples, evidence from the readings and other scholarly sources, and discerning ideas.

Peer Feedback and Interaction

6.75 (22.5%) – 7.5 (25%)

The feedback postings and responses to questions are excellent and fully contribute to the quality of interaction by offering constructive critique, suggestions, in-depth questions, additional resources, and stimulating thoughts and/or probes.

Writing.

4.05 (13.5%) – 4.5 (15%)

Postings are well organized, use scholarly tone, contain original writing and proper paraphrasing, follow APA style, contain very few or no writing and/or spelling errors, and are fully consistent with graduate level writing style.

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