Patient Satisfaction with Substance Use Disorder Rehabilitation Services: a Qualitative Study

Abstract

Despite its recognized value, there is a gap in the assessment of patient satisfaction among patients with substance use disorder (SUD) in rehabilitation. The study objective was to determine patient satisfaction dimensions relevant to individuals receiving residential rehabilitation for SUD. Semi-structured interviews were conducted with the following: (1) adult males enrolled in the program and (2) counseling staff involved in the care of these individuals. A literature review formed the basis for interviews, which were audio recorded and transcribed. Text data was analyzed using directed content analysis to identify dimensions relevant to patient satisfaction. Eighteen individuals participated, including 14 men with SUD and four staff. Content analysis of the interview transcripts resulted in five themes: (1) counselor (skill), (2) programmatic structure (adhering), (3) skill development (personal responsibility), (4) comparison to other programs, and (5) case management facilitation. These dimensions will be utilized to create a patient satisfaction tool specific to SUD rehabilitation.

Appendix. Codebook

Code	Name
1a	Physical environment—adequacy of sleeping rooms
1b	Physical environment—food
1c	Physical environment—adequacy of bathrooms
2	Cramped
3a	Programmatic structure—adhering
3b	Programmatic structure—deviating
3c	Programmatic structure—Adequacy of program length
4a	Flexibility—outside therapeutics
4b	Flexibility—personal reasons
5	External inputs
6a	Diagnoses (self-reported)—physical
6b	Diagnoses (self-reported)—psychiatric
7a	Attitudes towards psychiatric meds—positive
7b	Attitudes towards psychiatric meds—negative
8a	Skill development—openness to other’s perspectives
8b	Skill development—understanding patterns
8c	Skill development—personal responsibility
8d	Skill development—improvement
9	Utilization of program for reasons other than recovery
10a	Environment within the facility—interactions with other residents (positive)
10b	Environment within the facility—interactions with other residents (negative)
10c	Environment within the facility—interactions with non-clinical staff (positive)
10d	Environment within the facility—interactions with non-clinical staff (negative)
11a	Counselor—support
11b	Counselor—skill
11c	Counselor—personal experience with addiction
11d	Counselor—availability
11e	Counselor—interaction/attitudes
12a	Expectations—individual sessions
12b	Expectations—structural requirements
12c	Expectations—need for health professionals
13	Counseling application/engagement
14	Comparison with experience of other programs/comparative effectiveness
15	Case management facilitation
16a	Effectiveness of referrals—prompt action
16b	Effectiveness of referrals—long wait

• 1. Physical environment

  • a. Adequacy of sleeping rooms

    • Brief definition—Adequacy of the sleeping area at the facility

    • Full definition—The effectiveness of the sleeping rooms in meeting the personal expectations of the residents and their desire with respect to the sleep received, ability to get a night’s rest, physical proximity with other residents while sleeping.

    • When to use—Whenever the client/patient mentions anything about sleeping area, beds, and space related to sleeping rooms.

    • When not to use—Whenever the client mentions feeling cramped (too many people in the room) or lacking privacy or adequacy of bathroom doors

      • “Privacy when we are living in the quarters, that can be definitely improved, because everybody is very close to the other person in the program sleeping across the room, there is not much room here, it could be enlarged and that would help.”

      • “the sleeping quarters are confined but other than that there’s enough room.”

  • b. Food

    • Brief definition—View regarding the food served at the facility.

    • Full definition—The desire for food and the provision of food services, including opinions regarding the quality, quantity, and variety of food; availability of food and beverage (coffee/tea) options; efficiency of the cooks and the catering services at the facility.

    • When to use—When the client mentions his view regarding the food served at the facility and its quality. Mentions availability of food options, provision of tailored food service, or suggests any changes or improvement in provision of food or the services.

    • When not to use—Not to be correlated with ingestion of medicines, supplements, or drugs.

    • Examples-

      • “They do very well on the food. We haven’t been getting hot breakfast here, but they have done good in other meals and stuff which I cannot complaint too much even having just cornflakes cereals in the morning and some milk as a meal that’s better than lot of peoples getting.”

      • “saving a dollar on coffee or you know cutting food back or doing any of that”

  • c. Adequacy of bathrooms

    • Brief definition—Adequacy of bathrooms and privacy regarding it.

    • Full definition—The appropriateness of the facility’s bathrooms with respect to the space of bathing area, privacy inside the showers, adequacy of the bathroom doors in maintenance of privacy, and availability of showers.

    • When to use—Whenever clients mentions availability of bathrooms, privacy in the shower, and space related to the bath area.

    • When not to use—Whenever it overlaps with being cramped (too many people in rooms/area), mention of adequacy of any doors related to sleeping area and privacy.

    • Examples-

      • “They have 4 showers, doors locked, it’s fine.”

      • “I mean even taking a shower you got people knocking on the door 24*7 and it’s like the place, it’s a circus.”

• 2. Cramped

• Full definition—The adequacy of the facility and its physical area in meeting the expectations of the residents with respect to the provision of appropriate space without being crowded and occupied by other residents, maintenance of personal space/ physical proximity including but not restricted to the meeting rooms, working spaces, cafeteria, common areas, etc.

• Brief definition—Adequacy of areas and physical space inside the facility.

• When to use—Clients mentioning many people in the room and the space being packed.

• When not to use—When it overlaps with adequacy of bathrooms, adequacy of sleeping rooms, and privacy.

• Examples-

  • “We are cramped on top of each other”,

  • “some of us are like more to a room.”

  • “It’s alright, I mean the dorms are little bit cramped up but it’s alright.”

• 3. Programmatic structure (Rules)

  • a. Adhering-

    • Brief definition—When the program is adhering to its rules/policies and are strict about following it.

    • Full definition—The facility’s ability to abide by their own rules and the programmatic structure as perceived by the client/patient. It includes the work dynamics of the program, the policies regarding weekly passes, visits, attendance of meetings, time management, adhering to the schedule, and related flow of activities within the facility.

    • When to use—Programmatic structure with regard to 12-step treatment approach, when the program is strict, follows rules, keeps tight check on its clients, provision of passes, regulations regarding attending meetings and any outside therapeutic or personal services.

    • When not to use—When it overlaps with comparison to structure of other programs, inclusion of external input, and flexibility of the program.

    • Examples-

      • “They have passes, for the weekends, they let you on pass. If you be late for class or don’t show at all, or something might happen to you, your passes might be taken from you. It’s a strict program but you know I need some help.”

  • b. Deviating-

    • Brief definition—When the program is deviating from its policies, any deviation encountered by the client

    • Full definition—Deviations by the program as perceived by the client/patient with regard to their ability to abide by the rules, time management, and policies of the facility including bias towards certain clients, inability in scheduling timely meetings, etc.

    • When to use—When the program is being biased towards certain clients, not adhering to its rules

    • When not to use—When it overlaps with the programs flexibility or the counselors expressing support due to empathy.

    • Examples-

      • “You know certain situations like last night for instance, somebody came drunk and he is allowed to stay, you know. But they were gonna kick me out yesterday for them finding my phone.”

      • “There’s an incident the other day when the police came in to take someone out of here. I felt that was wrong and let them in the door because it hit below seeing other clients. I don’t know what their policies exactly are.”

      • “I think they should adhere to time schedule a little bit well.”

  • c. Adequacy of the length of the program

    • Brief definition—Adequacy of the 90-day program length in facilitating the treatment.

    • Full definition—The effectiveness of the program’s 90-day length in facilitating the treatment as perceived by the client in terms of provision of adequate time to understand the program dynamics, seek opportunities for self-improvement, develop rapport with the counselor, and plan for recovery.

    • When to use—When the client mentions the positives related to the 90-day length of the program and his expectations from the time period

    • When not to use-Not to be confused with the expectations of the client from the program.

    • Examples-

      • “This is the first time I am trying a 90-day program. So, I think that’s something I am definitely look into, get more involved in a 12-step program.”

      • “The good things are you get to know your counselor in 90 days what else, you get the opportunity to be better pretty much as needed as.”

      • “I ended up going back out so that’s why I chose myself in a 90-day program because I think I need more time and more you know to get away from being drunk”

• 4. Flexibility

  • a. Outside therapeutics

    • Brief definition—Flexibility in accommodating the clients according to their needs, and the structure of the program.

    • Full definition—The ability of the program in considering the desires and needs of the clients and accommodating it in their services by providing permits on attending/visiting outside therapeutics and meetings related to the treatment.

    • When to use-When the client mentions programs flexibility related to attending outside meetings, taking therapeutic assistance, etc.

    • When not to use-When flexibility related to attending outside therapeutics overlaps with the code external inputs such as involvement of external services and outside self-help group meetings.

    • Examples-

      • “We are allowed to go for outside meetings during the weekends.”

      • “they have meetings tomorrow like Saturday nights, we go to trinity, we go down the street here, which is good meeting and Sundays we have Brook-line which they take use but only 14 people to go, then there is trinity and then we have an AA meeting down the street here which I try to hit every one of them.”

  • b. Personal reasons

    • Brief definition—Flexibility in accommodating the clients according to their needs, and the structure of the program.

    • Full definition—The ability of the program in considering the desires and needs of the clients and accommodating it in their services by permitting the residents to utilize passes for personal reasons, adapt to the religious nature of the program, attend faith-based services, etc.

    • When to use—When the patient mentions the program allowing the patients utilize their passes for visits, visiting to the grocery shops, attending religious services etc.

    • When not to use—When flexibility related to utilizing passes and visiting places for personal reasons overlaps with the rules/policies and the structure of the program.

    • Examples-

      • “Yeah, I mean its Christian. I became a Catholic in 4 or 5, I wasn’t raised in any type of religion. It doesn’t seem like it’s pushed on you. You can do like on Sunday if they are having a service. You don’t have to go to service. You can say it by yourself. So, it’s not pushed on you to a point where you feel, I don’t feel uncomfortable.”

• 5. External inputs

  • a. Brief definition—When the program includes external facilities or involves external services in facilitating the treatment.

  • b. Full definition—Provision of services by inclusion of external media such as outside speakers, external meetings, self-help groups like AA and the effectiveness of these services in facilitating the treatment of residents.

  • c. When to use—Whenever there is mention related to involvement of external services like bringing in speakers.

  • d. When not to use—Any overlaps with flexibility with attending outside services or meetings

  • e. Examples-

    • “They bring speakers from the outside.”

• 6. Diagnosis (Self-reported)

  • a. Physical diagnosis

    • Brief definition—If the patient mentions any co-morbid physical condition while discussing his SUD.

    • Full definition—Any self-reported physical diagnosis by the clients for conditions other than their SUD.

    • When to use—When the patient mentions any condition such as Hepatitis C while discussing his perceptions about the program.

    • When not to use—When it overlaps with psychiatric diagnosis.

    • Examples-

      • “I have hepatitis C so my liver is getting bad”

  • b. Psychiatric diagnosis

    • Brief definition—If the patient mentions any co-morbid psychiatric condition while discussing his SUD.

    • Full definition—Any self-reported psychiatric diagnosis by the clients for conditions other than their SUD.

    • When to use—When the patient mentions any condition such as depression, anxiety, anger issues while discussing his perceptions about the program.

    • When not to use—When it overlaps with physical diagnosis.

    • Examples-

      • “I am dual diagnosed with I think anxiety, depression, and alcoholism.”

      • “I had anger issues in the past and all the facilities that I went to, like I said, I never spoke out.”

• 7. Attitudes towards Psychiatric medications

  • a. Positive

  • b. Negative

    • Brief definition—General attitude towards psychiatric medications in negative light

    • Full definition—Client’s general negative attitude towards psychiatric medications reflective their desire for intake and adhere to their medication regimen, moreover their understanding of the overall importance of those medications.

    • When to use—Client refers to his opinion about medications for his psychiatric conditions in a negative nature

    • When not to use—When it overlaps with attitudes towards medications for treatment of SUD.

    • Examples-

      • “I don’t take medications”

• 8. Skill development

  • a. Openness to others perspective

    • Brief definition—When the patient is being an active listener and is open to other’s perspective.

    • Full definition—The ability of the patient, developed over time, to actively listen to the counselor or other residents along with inculcating a sense of consideration or acceptance of their opinion and perspective.

    • When to use—When the patient mentions being an active listener along with accepting other’s perspective, furthermore, getting involved in a conversation during a session or with other residents.

    • When not to use—When it overlaps with improvement in self chosen goals in terms of talking, being expressive and effectiveness of the counseling sessions.

    • Examples-

      • “I agree with everything s(he) tells me to do. You know what I mean its gonna help me, it’s not gonna harm me.”

      • “The more I speak up, the more I free myself up. I still listen, I make sure I listen to what’s being said so I can respond back to it in retrospection.”

  • b. Understanding patterns

    • Brief definition—The patient understands the disease pattern and is willing to change it/work towards it.

    • Full definition—The ability of the patient in understanding the pattern of the disease along with the importance of the treatment, and his willingness for an uninterrupted pattern of recovery.

    • When to use—When patient mentions an understanding of the harms he faced in the past due to not adhering to his treatment aka understanding disease patterns and expresses his willingness to commit to his treatment without any relapse.

    • When not to use-When patient talks about his responsibility and preparations towards recovery.

    • Examples-

      • “This time I am looking for uninterrupted pattern of recovery without the return to drugs or alcohol.”

  • c. Personal responsibility

    • Brief definition—When the patient realizes his own responsibility during his treatment.

    • Full definition—The patient understands his responsibility as an equal contributor in his treatment and commits to work towards improving his condition, facilitate his treatment, and prepare for life during recovery.

    • When to use—Any mention by the patient of understanding the criticality of the treatment and his role as a responsible patient in working towards recovery, moreover any mention regarding preparation for life after treatment with regard to finding a job, settling down, locating a house, etc.

    • When not to use—Not to overlap with understanding the disease patterns and expressing willingness to work towards recovery.

    • Examples-

      • “Like I said, I don’t wanna put everything on them because ultimately this is my recovery if I don’t do the laid work.”

      • “So, I think you know it’s nice to be in a program like this, because then everyday like right now when I am still weak it reminds me that I need to work on.”

      • “The program is about surrender and, in my experience, I think, its very important to us to fully surrender before we can have another life, a better life.”

  • d. Improvement

    • Brief definition—Overall improvement as perceived by the client within himself during the treatment phase.

    • Full definition—When the program is facilitating growth of the patient and the patient realizes the importance of the program and his progress/improvement in self chosen goals such as anger management, talking, gaining confidence, and being expressive.

    • When to use—When the patient mentions improvement in his mental and physical condition overtime, moreover his progress as a person in dealing with his condition.

    • When not to use—When it overlaps with skill development related to openness in others perspective.

    • Examples-

      • “I have a problem with professionalism, like speaking and approaching things in a professional manner and in the group session, I am able to do that, talk to the whole room and I feel like I am bringing a profession no matter to it and also talk about on and bring to surface what I talked about in the personal session to some degree.”

      • “You know I have a lid on my anger and I vent when I need to vent, whether me venting appropriately is in question, you know if I am out of lying, I make sure to correct that and I have learnt.”

• 9. Utilization of program for reasons other than recovery

• Brief definition—Patient’s intention of joining the program other than recovery.

• Full definition—The intention of the client in joining the residential program which is unrelated to recovery but includes the need for shelter and food, escaping the cold, law enforcement, and financial issues.

• When to use—Patient mentioning reasons of joining the treatment unrelated to recovery.

• Examples-

  • “Some people need this place, I feel it was there for a lot of the communities here strictly because it’s cold outside and you know they haven’t ate for a while but that being said everybody is now on the same page.”

  • “Right now, currently I use this place as a gym but then that is it.”

• 10. Environment within the facility

  • a. Interactions with other residents—positive

  • b. Interactions with other residents—negative

    • Brief definition—Any experiences with other residents within the program.

    • Full definition—The general attitude of the residents towards each other and their rapport with each other that affects the overall environment within the facility.

    • When to use—When the client talks about his positive and negative interactions with other clients, especially the roommates and the influence of the attitude of his peers in treatment.

    • When not to use—When it overlaps with interactions related to other clinical and non-clinical staff.

    • Examples-

      • “Some of us are like more to a room but that’s okay because you can be with people and learn to learn to deal with different personalities. It makes you better for people’s skills and we actually end up becoming brothers.”

      • “Oh! I almost got into it last night, ran over that John came over drunk, yeah it’s on camera, he attacked me.”

      • “I guess the time that I spend with other clients really helps me a lot. You know, that’s how I get most of my strength from more than even the clinical staff. I have a group of guys I associate with who are very recovery oriented.”

  • c. Interactions with non-clinical staff—positive

  • d. Interactions with non-clinical staff—negative

    • Brief definition—Any positive and negative experiences with the non-clinical staff or technical staff and shared rapport with the staff.

    • Full definition—The general attitude of the non-clinical staff or technical as perceived by the clients, including the rapport shared with the staff, any type of encountered experiences, attitude of the staff during delivery of services, and overall nature of the staff.

    • When to use—Client mentions the attitude of the non-clinical or technical staff in general within the facility, nature of the staff, and client’s rapport shared with the staff.

    • When not to use—When it overlaps with interactions related to the clinical staff/counselors.

    • Examples-

      • “Benefits being, majority of the population seem very serious. The staff really helpful, like the clinical team and some of the negative aspects of the program would be the technician employees not the clinical staff but the regular employees, they can be a little brutal sometimes but for the most part I think it’s a great place.”

• 11. Counselor

  • a. Support

    • Brief definition—Support provided by the counselor to the residents.

    • Full definition—Any emotional support, mutual understanding, comfort, and empathy displayed by the counselor, allowing the patient to share his feelings and concerns, thus facilitating the counseling sessions as well as the overall treatment.

    • When to use—When the counselor takes efforts in understanding the sufferings of the clients, provides emotional support and comfort in order for the patient to discuss personal problems.

    • When not to use-When it overlaps with attitude of the counselor or the general behavior of the counselor towards the clients.

    • Examples-

      • “I am fortunate in other facts wherein s(he) allows me to speak my mind, so s(he) knows what to do in order to keep me safe. So, I am lucky I have got fairly open counselor.”

      • “I have talked to my counselor about my situation while coming in. My counselor seems very interesting and willing to help me achieve my goals.”

  • b. Skill

    • Brief definition—Effective skills honed and displayed by the counselor in the treatment of their clients.

    • Full definition—Treatment related skills that are displayed and put into action by the counselor for effective therapeutic engagement and case management including their work pattern, unique counseling style, and knowledge sharing abilities.

    • When to use—The working efficiency of the counselor by utilization of skills with regard to conducting effective counseling sessions, getting help from different resources, mentoring the patients.

    • When not to use—When it overlaps with case management facilitation and skills displayed due to addiction related past experience.

    • Examples-

      • “Because it starts with my main counselor, the main one is getting me lots of help, open up a lot of things inside me that was closed off getting to me straight.”

      • “They will break it down to me, explain it in a better way to me.”

  • c. Personal experience with addiction

    • Brief definition—Counselor’s past experience in dealing with addiction.

    • Full definition—The counselor’s past encounter with addiction either through self-experiences or experiences due to any other personal event that provides the counselor with real life knowledge of addiction and struggles associated with it.

    • When to use—The patient mentioning his comfort and inclination towards the counselor who has dealt with the disease in the past, who knows the sufferings of the disease, who has had any family related experience. Moreover, when the patient relates the counselor’s efficiency to their past disease related experience.

    • When not to use—Not to overlap the past experience with counselor’s skills.

    • Examples-

      • “I really liked the fact that they have been in recovery themselves and know where we are coming from so I am very confident in that aspect.”

      • “Individual I am fortunate that I have a counselor as went through drug and alcohol experiences, so s(he) understands when I might be a little anxious to try to get so many things to accomplish.”

      • “Depending on who is the teaching set group. There’s a couple of counselors here, mine included, that actually lived the program, because they themselves were addicts and I respect the hell out of that, I do.”

  • d. Availability

    • Brief definition—The general availability of the counselor

    • Full definition—The general onsite availability of the counselor and the ability to manage the case-loads inclusive of conducting regular individual meetings, onsite sessions, timely follow ups, etc.

    • When to use—When the patient mentions the availability of his counselor, increase in caseloads, and the program being understaff.

    • When not to use—When it overlaps with expectations from the program with regard to the need of increasing the individual counseling sessions.

    • Examples-

      • “S(he)’s been so so, s(he) works different, because s(he) is here on the weekends, s(he) still goes to school so, we usually sit down as all the clients that s(he) has once a week, which is probably, pretty good. And I had seen him once on the facetime, but I mean I guess that can get better. Usually we get sort of, I mean if you have something, s(he) is there. I am not really like, I don’t need all hands-on tips like, I guess s(he) is pretty good.”

      • “Counselling’s we have one on one, but it’s hard because there are have been caseloads, they are under staffed, so they have a lot of caseloads around, so you know like [name] s(he) has a ton of caseloads, so it’s hard sometimes to get on meeting for one and one but they do it when they can.”

      • “If they got somebody in their office then I gotta respect that and I gotta wait. If they are available the whole day, the doors open, you can knock on the door and they will assist me. If my counselor needs to know something and the other one’s door is open, and she got somebody in the office, she needs to know something, I can let her know about it, the other one.”

      • “But it’s not like a regular time, every week I don’t have a scheduled time to see [name] every week, its either if s(he) wants something or I need help with something that’s when I see him/her on a one on one basis.”

  • e. Interactions/attitudes

    • I) Positive

    • II) Negative

      • Brief definition—Any positive and negative experiences with the clinical staff or shared rapport with the staff.

      • Full definition—The general attitude of the clinical staff as perceived by the clients, including the rapport shared with the staff, any type of encountered experiences, attitude of the staff during counseling sessions or delivery of services, and overall nature of the staff.

      • When to use—Client mentions the attitude of the non-clinical or technical staff in general within the facility, nature of the staff, and client’s rapport shared with the staff.

      • When not to use—When it overlaps with interactions related to the clinical staff/counselors.

      • Examples-

        • “It’s a good thing that they are helping. When I was out there, there was no one to listen, I had all negative around. I come here, they are all positive people, I respect them who are helping me.”

        • “We got a lot of good recovery here, the counselors are great, I love all the staff here, they are friendly people and they put forth a friendly image.”

• 12. Expectation from the program

  • a. Individual sessions

    • Brief definition—Clients expectation from the individual sessions.

    • Full definition—The expectations of the client from the individual counseling sessions with regard to increase in the frequency of sessions with their counselors as well as the need for more structured sessions.

    • When to use—Client mentions lack of individual sessions and demanding increase in frequency of these sessions.

    • When not to use—When it overlaps with availability of the counselor

    • Examples-

      • “Now when it gets to one on one time, I have been here for only few weeks, I haven’t really had much one on one time with my counselor. I think that should be increased.”

      • “I don’t get enough of those. S(he) is a good counsellor, since I have experience, I am not real needy, so I don’t ask for a lot of individual sessions, but they can be always a plus if I have more.”

  • b. Structural requirements

    • Brief definition—Clients expectations with regard to structural requirements and advancements.

    • Full definition—The desire and expectations of the clients with regard to certain aspects of the program related to the physical structure of the facility, improvement in security, need for counseling staff, cleanliness, and more treatment follow ups.

    • When to use—Client’s suggestions for requirements in the facility related to increase in space, demand for increase in security (increasing staff or installing cameras), requirements related to kitchen and food, demands in increase in non-clinical staff.

    • When not to use—When it overlaps with client’s expectations in increasing individual counseling sessions or his opinion regarding the current services related to food and security.

    • Examples-

      • “It’s always things that you want to see differently, I’d like to see more cameras in different places, don’t have to be a whole lot of cameras but I do would need that because we are addicts and alcoholics, our movement need to be monitored a little heavier because even though we are not drinking and used to same character defect which can lead to criminal behavior and other than that it’s a great facility.”

      • “I just think that newer people in the program will need more structured groups structure being the key word.”

  • c. Need for health professionals

    • Brief definition—Clients expected need for medical professionals.

    • Full definition—The clients need for inclusion of medical experts/professionals such as medical practitioners and nurses trained in addiction counseling for disease monitoring, making treatment related decisions and prescribing any medications.

    • When to use—When the client emphasizes on his need to include/hire a medical health professional other than clinical counselors for his treatment.

    • When not to use—When it overlaps with need for clinical counseling staff or the availability of the counselors.

    • Examples-

      • “If they were to give medications that help us to ease our addiction they would have to have a professional here, a doctor and nurse instead to check how client is responding to a down grading addictive self and they would need to be follow up more closely about how to respond to the tape raw.”

• 13. Counseling application/engagement

• Brief definition—Effectiveness of counseling sessions and application of those sessions in overall treatment.

• Full definition—The effectiveness of the counseling sessions from the patient’s perspective with regard to provision of knowledgeable treatment related information, enhancing patient engagement, and reminding of future goals for recovery.

• When to use—When the patient mentions the effectiveness of the counseling sessions and usefulness of the topics discussed in the sessions.

• When not to use—When it overlaps with skill development such as openness to others perspective or improvement in self chose goals.

• Examples-

  • “Yes, the counseling sessions have been positive. They looked some of my issues and helped me do some of the things that I needed to do to help myself.”

  • “They are wealth of information in the three weeks I have been here.”

  • “They remind me about the major pitfalls that I need to avoid so, sessions help me, groups help me remind of some of the earlier mistakes that a person can make in recovery. You know as you go and attend more meetings and you have counselling on outside, there is an ongoing reminder of the do’s and don’ts and staying alcohol and drug free.”

• 14. Comparison with experience of other programs/ Comparative effectiveness

• Brief definition—The comparison of current program with any programs attended by the clients in the past.

• Full definition—The comparison of the current facility and program dynamics with the past programs attended by the clients in terms of the physical structure, flow of activities, treatment provision, case management, and overall treatment environment.

• When to use—When the client compares the current program with his experiences in the past programs and also suggests scope of improvements in the current facility.

• When not to use—When the patient mentions about his past experience within the same facility and when this code overlaps with the patient’s expectations from the program.

• Examples-

  • “Once again, I have been in facilities where they have cameras in the hallways stuff like that and which makes a safe environment.”

  • “I have been to other rehabs prior to this and this the best one that helped me that most and will give me most confidence leaving out of these doors. That’s truly honest.”

• 15. Case management facilitation

• Brief definition—The overall case management of the clients by the counselors.

• Full definition—The experiences of the clients with the program’s case management abilities by the counselors inclusive of managing the patients diet related problems, scheduling therapeutic or personal visits, arrangement of Vivitrol shots, managing any of clients’ treatment related problems.

• When to use—When the client mentions incidences related to effective case management reflected by the counselor in helping the client with utilization of visits passes, meeting the client’s dietary requirements, and any other request such as making calls, meeting family, etc.

• When not to use—When it overlaps with efficiency of the counselor due to utilization of his skills.

• Examples-

  • “I don’t eat red meat or pork, I never did in my life, and my counselor s(he) made it, so they have something for me to eat.”

  • “If I’m late on a pass all I got to do is call in and be like here’s the situation. I use my pass for my daughter. So, I let him know the situation, s(he)’s understanding about it that he doesn’t punish s(he) you know for you know ridiculous things.”

• 16. Effectiveness of the referrals in solving problem

  • a. Prompt action

    • Brief definition—The overall effectiveness of the facility in promptly connecting the patients to the referral services and effectiveness of those services.

    • Full definition—The adequacy of the facility in connecting the clients with medical and social services, taking prompt actions towards facilitating the services, and the effectiveness of those services in case management.

    • When to use—When the client mentions the quick action taken by the facility in connecting them with referrals moreover the effectiveness of these outside services with providing medical assistance, housing, getting sponsors, and employment.

    • When not to use—When it overlaps with adequacy of services provided by the program itself.

    • Examples-

      • “Yeah I got IDDT. They are amazing. I’ve had other people case workers, but they are amazing. They are from Mercy. I am dual diagnosed with I think anxiety, depression, and alcoholism. They have been here to see me pretty much every day as the first time that has occurred. Hopefully they’ll help me with housing when I get out of here and employment.”

      • “They got me a social worker, I forget from some Allegheny some, she is probably going to be here today to talk to me, so she is trying to get by me with housing and stuff and help me out with different services so, they are!”

  • b. Long wait

    • Brief definition—The delay or longer waiting periods in acquiring referral services.

    • Full definition—The delay in connecting to and utilization of referral services such as medical and social services either due to higher caseloads and delay in acquiring sponsors.

    • When to use—Any mention of delay in getting connected to the services and long waiting period.

    • When not to use—When it overlaps with delay of services within the program (time management), unavailability of the counselors, need for professional medical assistance.

    • Examples-

      • “Medical Services, I am in the process now, I am waiting for some medical assistance. Actually, everyone here is waiting for that so I gotta wait for a letter to come through stating this and give me my counselor and I have to go a house and talk to a gentleman one on one basis.”

      • “That’s the part I am displeased about. I haven’t even been asked about outside resources yet and I’d like to utilize my outside resources to fullest capability and I’ve actually been hindered, I have previous sports specialist from another agency and they won’t let me meet with him until after 30 days. Because I am on my blackout period It’s frustrating.”