Leigh: Policymakers talk about solutions, but which ones really work? Welcome to Evidence First, a podcast from MDRC that explores the best evidence available on what works to improve the lives of people in poverty. I'm your host, Leigh Parise.

Many communities are facing a crisis from the widespread misuse of a range of substances, including opioids, other drugs, and alcohol. Low-income communities have been especially hard hit. In response, a range of programs has been developed to help people struggling with substance use disorders. Programs that integrate treatment and recovery services with services to help people train for and find jobs have become more common.

These programs, which already served vulnerable populations, faced unprecedented challenges in the COVID-19 pandemic, including responding to increased substance misuse and overdoses, dramatic increases in unemployment and the need to quickly shift to virtual service provision. Last summer, MDRC, Abt Associates, and MEF Associates did research to understand how some of these programs faced these challenges early in the pandemic and adapted their services. MDRC recently released a brief on the research, which was written as part of the Building Evidence on Employment Strategies for Low-Income Families, or BEES project, funded by the Administration for Children and Families in the U.S. Department of Health and Human Services.

Today we'll talk with researchers Karin Martinson from Abt Associates and Sue Scrivener from MDRC about some of the key findings in the brief. We'll then talk with Matt Brown, senior vice president of administration at Addiction Recovery Care, one of the programs in this study, about his experiences operating the program during the pandemic. Thanks to Karin, Sue, and Matt for joining me. Karin, can you share a little more background about this category of programs and why it was so important to study them?

Karin: I think we've seen through a lot of past studies that employment is a really important element in helping people overcome substance use disorders. It can help people stay on the path to recovery, by providing stability through wages, structure, and routine—however, we also have learned that kind of substance use treatment on its own doesn't do much to increase employment. In part, that's because people with substance use disorders often have other barriers to employment, like mental health issues, physical health problems, limited education and skills, or justice system involvement.

However, until recently, employment services historically have not been a big part of treatment programs, and the programs that did operate were pretty small. You know, in large part due to the opioid crisis, there has been an increase in interest in federal funding for these types of programs as a way to help people both achieve recovery and sustain employment.

So while these are important programs, one issue is that we don't really know very much about how effective they are. So as part of the BEES project, we conducted a national scan to identify promising programs that combined treatment and employment services so that we could study them and build evidence for policymakers and practitioners. The programs that we identified are the programs that are included in our discussion today.

Leigh: And as part of the BEES project, is one of the things that we'll be able to share is a summary of what we found out there and what the different programs look like?

Karin: Yes. We're doing a couple of different studies. In one, we're kind of doing a descriptive study on looking at these different models and how they work, and how the programs are structured to provide lessons to the field about different approaches. We're also doing rigorous impact studies to look at the effects of different models on participants, employment, and treatment outcomes.

Leigh: Sue, can you say a bit about the range of specific programs you studied?

Sue: Sure. We studied seven different programs in seven different states across the country. Four of the seven serve people living in residential substance use treatment facilities, but all seven provide nonresidential treatment and recovery services. And each program provides its own mix of employment services that are aimed to help people train for and find jobs. So, the specific services vary, but they include things like providing help with resumes, providing help with job searches, connecting people to internships, or providing vocational training in specific fields.

Leigh: So what did business-as-usual look like, and what were the main challenges that programs had to face during the pandemic?

Sue: Before the pandemic, the programs provided most, if not all, of their services in person. So, [that was] through one-on-one conversations, small group meetings in classrooms (which is typical for an employment services program or treatment recovery services program), but then the pandemic hit. And I think one of the biggest issues was the programs had to figure out was how to keep operating and how to keep serving their participants—as their communities basically shut down and people were asked to stay at home; and when they weren't at home, they were asked to socially distance. And then at the same time, substance misuse and overdoses were increasing and there were shifts in the local labor markets. The programs said they had some pretty serious challenges that they had to adapt to.

Leigh: Karin, the brief described some really interesting adaptations to the program's substance use treatment, recovery services, and employment services. Can you talk about some of those?

Karin: The biggest shift—as we're all experiencing—was a shift to virtual service delivery. This was a challenge, because not everyone was set up with a laptop where they could automatically get into Zoom, and things like that—but they also had to do a lot of other things to limit staff exposure [to COVID-19].

In terms of substance use disorder treatment services, the programs moved pretty quickly to establish these virtually. They did group therapy sessions, clinical counseling sessions, one-on-one counseling. They were able to do that all virtually, but I think they found there were some challenges. A real cornerstone of these services is the peer support and support you get from others through group activities. And that was a difficult shift to make to virtual services, because you lost that in-person element.

I think we also saw the programs developed some innovative alternative ways to build community through virtual platforms. Since many sober social activities were canceled, they created fun activities through Zoom like talent night or karaoke night.

Leigh: One of the things I think that we've found at MDRC, and I imagine that you have as well, is that a lot of the programs and nonprofits we work with really, as you're describing, had to pivot to figure out the best ways to serve the people that they work with. A lot of them have told us about ways that they could imagine some of the changes that they've had to implement now sticking as they move forward, because they feel like there's some things that have actually been made easier. Do you feel like the same is true of some of the programs that we've worked with in this project?

Karin: I think—particularly on employment—I think that system moved somewhat more easily to virtual services. Some of the programs that offered occupational training, and courses like that, found it was actually easier for participants to attend online—and they plan to keep it just because they didn't have to deal with travel logistics or things like that. And they felt like they could get similar content online—that was not so much true on the treatment side, where, as I said, I think they really missed the peer support component.

And I also think on that side, if you heard from the staff that when you're dealing with someone who's in a crisis and in treatment, it's hard to read people over a virtual platform. You need to be in person to get cues and things from that person about how they're really doing.

As I mentioned on the employment services side, because this was not so much as an essential service, some of the employment services were suspended for a while. And then some of them did come back virtually. But a lot of the programs did focus on placement, helping people find jobs, and you know the economy, obviously, was in a very difficult spot.

They found they were primarily able to help participants continue to get jobs, but they had to make some shifts in the types of jobs they were getting. For instance, there was a demand more for commercial cleaning, some construction, truck driving, delivery, but less demand for workers in retail and culinary.

So, there were some shifts there, and there was also a shift in the types of training programs people considered, just because of the changing nature of the economy.

Leigh: Do you have a sense for what that adjustment actually looked like for the people in the programs, who are responsible for maintaining those relationships with employers and figuring out the right places to get people placed?

Karin: While they had some success in placing individuals in jobs, there were still concerns for the longer run and what employment prospects would be like in the long-term. There were concerns whether workers would be able to maintain employment because of other demands that stemmed from the pandemic, like having to stay home to care for children, and concerns about their own health and exposure. So, I think while they had some success with employment, not surprisingly there remained—and I think probably continues to remain—a concern for people's employment prospects in the longer run.

Another adaptation we saw was that programs establish new partnerships, with other organizations or strengthened existing ones to address challenges that emerged from the pandemic. Some of these included partnering with a local health department, to establish quarantine beds in hotels for residents who may have had some exposure to the virus. They worked with mobile grocery stores to accept SNAP benefits and provide deliveries to residential services. And they also established connections with drug testing companies and community organizations to provide COVID testing through mobile locations. So, in general, people were really thinking creatively and innovatively about coming together in different ways to address the needs [created by] the pandemic.

Leigh: Thanks so much to you, Karin and Sue. I also spoke with Matt Brown, senior vice president of administration from Addiction Recovery Care. Thanks so much for joining me today, Matt. It's really great to get to talk with you.

Matt: Yeah, glad to be here.  

Leigh: Let's just start with the very first basic question. Can you describe Addiction Recovery Care or ARC?

Matt: So Addiction Recovery Care is a large organization in Kentucky that has developed a model that takes people from crisis to career. Back in 2008, our CEO and founder, Tim Robinson, was actually a barely functioning alcoholic. He was a prosecuting attorney in our town. And he got sober, and he felt called to leave his practice of law behind and help people who were suffering from addiction. This was right in the middle of the opioid epidemic, specifically Oxycontin, and eastern Kentucky was being just absolutely devastated by the opioid epidemic. In 2010, the first center started—Karen's Place—in our town of Louisa, Kentucky, right on the edge of West Virginia. In 2012, he transitioned it from a grassroots effort that was volunteer-driven and donations-based and moved it to a licensed treatment center that began taking insurance and added counseling to the mix.

And then in 2014-15 Kentucky became one of the first states in Appalachia to roll out a Medicaid benefit for all levels of substance use disorder treatment. Not only that, but Kentucky also had expanded Medicaid, so more people could qualify for Medicaid. And in 2014-15, we became the first provider in the state to accept Medicaid for residential care. And since that time, we have grown to 30 facilities in 20 Kentucky counties. That's a long way of saying we have grown to meet the unfortunately growing needs of the addicted in the state of Kentucky.

Leigh: Wow. That really sounds like Tim was very responsive to what was a great, great need. Certainly not only in Kentucky, but much more broadly. Thank you for sharing that. And I'm curious, Matt, can you say a little bit about how you got involved with ARC?

Matt: Yeah, so, so my name is Matt Brown and today my title is senior vice president of administration. I got involved with Addiction Recovery Care back in 2014. I had spent 12 years as a licensed physical therapist in Kentucky, and I had suffered from addiction for 18 years. [I was a] poly-substance abuser and had crashed my life multiple times throughout that 18-year addiction. In 2014, in May, to be exact, I ended up in treatment at Addiction Recovery Care's only male facility, Belle Grove Springs. It was the first male-only center they had opened. While I was in that program, I realized how, listening to Tim's story and how he got involved in this line of work, I realized that he was able to take all of that pain and all of those problems and turn that into purpose and help others. I felt called to do the same thing.

Leigh: For someone who's come to ARC, can you talk a little bit about what their experience is like the kinds of services that they receive?

Matt: Absolutely. So, we offer residential care. We also offer partial hospitalization, intensive outpatient, outpatient care, and telehealth care. We have three different ways to enter our program. You can enter in the residential side where you come live with us, you can enter into the outpatient side where you're just coming to counseling and staying at your own house, or you can do it via telehealth. But regardless, what will happen is you will have a comprehensive assessment done by a clinician. And at that point, we will create a treatment plan based on your unique set of circumstances. What do you need in terms of counseling in terms of the medical side, the vocational side? We offer a spiritual component to our program that is very much a take-it-or-leave-it part of the program that someone can either choose to engage in or not.
 
And we also have a strong job training and life skills program that we offer to our folks as well. And so, our residential program allows someone to stay with us for an entire year if they choose to. The five areas of care that they receive are a strong recovery program, where they have the opportunity for education and job training, and they have the medical program to make sure their physical needs are being met, the client counseling program to help with behavior modification and the traumas they've dealt with while in addiction, and maybe even before addiction. And then the spirituality component that, once again, they can take or leave.

Leigh: Can you say a little bit more about the education and job training experiences that people may engage in?

Matt: Yeah, absolutely. Our CEO was actually a product of an internship program or a mentorship program back in his hometown of Inez, Kentucky, and it fundamentally changed his life. And what he learned early on was the people who came through the program were some of his very best employees once they got hired, because they knew addiction and they knew the program in such a way that it made them very good employees. So, at first it was just an internship—if you stay, you can learn while you are here receiving treatment. Then we partnered with Sullivan University, which is based out of Louisville, Kentucky. And we put together a six-month academy, where while someone is in the program with us, they can enter a college equivalent program and learn how to document their services in an electronic medical record for a group or individual peer support.

People are basically taking college classes while they're with us and at the one-year mark, they can have 28 quarter college credit hours and be a third of the way to an associate’s degree in community health with Sullivan University—at no cost to them.

Leigh: Wow. That's great. It really seems like you've been super thoughtful about both the support that people need to get past addiction, but also the kinds of skills that they need in order to be really well set up once they're out of the program. All right, Matt, so what has ARC done to modify services in the pandemic?

Matt: In the early days of the pandemic, like society as a whole, no one really knew where this was headed last year. And I know we're right at that year mark—I've been noticing even in my Facebook memories, looking back at some of our mindsets and the uncertainty of the COVID-19 pandemic. And one of the things we said early on to our staff was, "We're some of the only people alive, maybe to have ever lived, who have been fighting an epidemic inside of a pandemic." And we were very purposeful to say early on, "COVID may be coming, but addiction is very deadly, and we can see that through the overdose numbers." And so, we were able to transition our outpatient clients to all telehealth early on. They were able to continue to receive their services on our ARC Anywhere app.

And that was the one of the first things we did. We also kept abreast with the federal, state, and local guidelines. We created a COVID-19 Action Committee, and we had a very collaborative group that met every single day to make sure that we were staying current, because the guidelines were changing almost on a daily basis. We were being very on-purpose about creating a place of safety for not just our clients, but our employees.

Leigh: Okay, so that is helpful for thinking about the facilities. How has the pandemic affected the employment services that you offer?

Matt: We have actually had very good participation in our internship program despite the pandemic.
During the pandemic, we were able to diversify our internship and job training offerings. We started out with just an internship program years ago, then we added the peer support specialist academy, and then during the pandemic, in 2021, we added an automotive specialist certification program, the ASC certification, and we've added a behavioral health technician certification. We've added a general maintenance and carpentry certification. We just recently started ARC Creative, which is a music internship for people who are gifted and love music, and we're moving towards [offering] a certificate in that area.
We have some local musicians who are helping to support the folks in those facilities that are musically inclined, with a goal of one day having maybe peer support specialists who have a specialization in music therapy for folks that are coming through the program. So, what I can say is COVID has been so tough, and it's created so many uncertainties. But the people that work at Addiction Recovery Care, our team, our people, our employees, have really stepped up to the challenge and we are unequivocally a better organization today than we were prior, because problems demand solutions.

Leigh: What have you learned during the pandemic? Are there any changes in ARC services that you think might be sustained after the pandemic ends?

Matt: I think we've learned a lot during the pandemic. I think we've learned just how resilient people really are. I think that's what we saw during the pandemic, because we have 700 employees. Half of our employees are in recovery. One-third are people that graduated from the program—like myself. And we've seen what happens when a group of people are committed to a mission. And so, we've been able to knock down barriers during the pandemic. And then we've also learned that telehealth is a good thing. Prior to the pandemic...most folks, you know, were kind of hesitant about the telehealth world and wondered if it would be quality services provided, would the patient be engaged, would the provider be engaged? What we have seen is for many individuals is that telehealth services are just as good, if not better [than in-person services]. In some cases, for a person who can't get child care, they can't get to treatment. I think we’re much less wary about telehealth than we were prior to the pandemic.

Leigh: That's really interesting. I think that resonates with a lot of the programs and practitioners and providers that we've talked to and worked with at MDRC throughout the pandemic. Some of them have said, "You know, some of these things that we didn't really think we could do virtually before..." Whether it's someone who's in community college and needs to meet with an advisor but can't get a ride or can't get child care coverage, some of the things that they've been able to do with folks online have actually ended up being really helpful.

Thanks to Karin, Sue, and Matt for joining me. The BEES project is continuing to study these programs. Visit mdrc.org to find the brief that's been published and future reports from the project. Did you enjoy this episode? Subscribe to the Evidence First podcast for more.