Developing SUPPORT, a Community-Driven, Recovery-Oriented System of Care

The investigators will conduct the pilot at Public Advocates in Community Re-Entry (PACE), a
nonprofit that provides services to individuals with felony convictions in Marion County
Indiana. PACE has provided re-entry services in Marion County, IN for 55 years. PACE's
services are divided into four distinct categories: transitional, employment, addiction, and
pre-release services. It is the only former ATR agency in Marion County specializing in a
re-entry population, and our evaluation of Indiana's program demonstrated they had
significantly lower rates of recidivism than any other Marion County agency. In 2015, PACE
served 1,703 new clients.

The investigators will recruit 80 clients for participation in the pilot, half (40) will be
assigned to SUPPORT and half (40) to treatment as usual. SUPPORT clients will be offered 12
months of support service with a PACE recovery coach. The recovery coach will guide the
SUPPORT client through their recovery, offering guidance and support, while coordinating
their treatment services, including support services. The SUPPORT program will provide
SUPPORT clients with $1,000 worth of vouchers to cover the cost of additional flexible
support services over the 12 months of program enrollment, which will be personalized to fit
the needs of the client. These cost vouchers will cover similar support services as the
previous Access to Recovery (ATR) program, such as housing (permanent, transitional),
employment services (training, placement, readiness), substance use treatment,
transportation, childcare, educational or vocational services, or aftercare planning. The
costs of each service is determined by the service provider. Clients will NOT be responsible
for keeping track of their vouchers, but rather, his/her assigned recovery coach will track
all voucher funding/spending. Further, the recovery coach will assist the client in choosing
appropriate services and coordinating/monitoring service completion.

Clients in the treatment as usual group will have significantly reduced choices in services
compared to SUPPORT clients. These clients will not receive vouchers to access support
services such as transportation and housing and will only receive standard case management,
which is more prescriptive and less intensive than the recovery consultant services provided
through SUPPORT.

All PACE clients who are over the age of 18, have a SUD, are no longer incarcerated (in a
prison, jail, or work release facility), and are unable to access the previously mentioned
Recovery Works program, will be eligible for study participation. For both parolees and
probationers the risk of recidivism is highest in the first year of release; therefore, the
investigators will be connecting with clients during the initial months following releases.
The investigators will also be excluding sex offenders from the pilot, as they face greater
barriers to community integration and experience higher levels of supervision while on
parole, which have the potential to confound results during a small-scale pilot. Once a
potential client is released from incarceration and enrolled at PACE, if eligible, an intake
worker will inform them of the opportunity to participate in the pilot study and describe the
SUPPORT program services. If the client agrees to participate in the pilot, they will sign a
consent form and be randomly assigned to either SUPPORT or a treatment as usual condition. If
a participant in either the SUPPORT or treatment as usual group is re-incarcerated during the
study period, the investigators will not engage them while under correctional supervision to
collect data and the investigators will replace them with a new participant. However, if a
participant is re-incarcerated but released back into the community during the study period,
and reengages with PACE, they will continue to be a part of the study and the investigators
will continue to collect data and offer them SUPPORT services. In short, for the purposes of
this pilot, the investigators will not be collecting data from clients while incarcerated.

Quantitative:

PACE will hire and assign two recovery coaches to provide SUPPORT services for the pilot.
Once hired, the recovery coaches will complete all required IRB training and receive training
on data collection and the informed consent procedures. The names of these recovery coaches
will be added to the IRB protocol through an IRB amendment, having completed all required
training, before interacting with subjects.

In addition to providing the support services, recovery coaches will 1) go over the statement
of informed consent and Authorization form and have willing participants provide their
signature, 2) conduct an initial interview with all clients after they have provided informed
consent (to be included at the beginning of the electronic data collection) and have been
assigned to the SUPPORT or comparison group, and 3) collect electronic data using REDCap
system at the designated time points. Recovery consultants will collect data through a
computer assisted personal interview (CAPI) (i.e., individual interviews assisted by computer
technology.) Consultants will conduct interviews in a private room, away from other
individuals so that others may not overhear what is discussed. Each consultant will have a
tablet computer through which they will access the REDCap system. After the consultant has
collected all necessary service or background data, the REDCap system will instruct them to
hand the tablet over to the client to allow them to answer the remaining questions (regarding
Self Determination, Treatment Motivation, Self Efficacy, Stages of Change, Substance Use, and
Quality of Life) independently. The recovery coach will hand the tablet to the client and
move so they cannot see their responses. Instructions will appear on the tablet telling the
client to ask questions should they need assistance with either the tablet or answering a
question. Should the client need assistance using the tablet or answering a question, the
recovery coach will be available to help. During the screening process (i.e. client
enrollment), client illiteracy will be picked up. Should a client be illiterate, they will
still be invited to participate, but a recovery coach will read the questions rather than
asking them to answer the questions independently.

CAPI interviews will be conducted with all clients (SUPPORT and non-SUPPORT) at baseline and
6 and 12 months to understand change in outcomes overtime. Consultants will also conduct a
CAPI interview at 15 months with SUPPORT clients only to understand retention of treatment
effects three months post discharge. Based on our previous experience conducting CAPI
interviews, the investigators expect this process to take between 60 and 90 minutes.

CAPI Data collection measures include: demographic and background information on all clients
at baseline; including: date of birth, gender, race, ethnicity, sexual orientation, housing
history, education, employment history, and past involvement in addiction recovery and
treatment. The investigators will also collect a number of measures, including (1)
agency/self-determination, (2) recovery capital (i.e. treatment motivation, social
support/networks, and self-efficacy), and (3) recovery-related outcomes (frequency of
substance use and abstinence, incremental progress towards recovery, quality of life,
recidivism, and administrative data on housing status, education, employment, income,
physical and mental health status, and attendance at self-report self-help groups.)

Additionally, IU researchers will conduct structured social network interviews within one
week of the client's entrance in the study and at 12 months. Social support is a proven
influential factor on recovery. Having relationships and social networks that provide
support, friendship, love, and hope through the process of recovery improves outcomes. The
recovery coaches that work in the SUPPORT program will work with the clients to utilize their
recovery support services to strengthen the individual's place in the community as a
productive community member, family member, and worker, and, ideally, improve the quality of
clients' interpersonal relationships and likelihood of positive recovery outcomes. This study
will measure social support as a recovery-related outcome to see if the program is able to
positively impact the social support in clients' lives over the course of 12 months. The
total data collection time for these interviews will be between 30 and 60 minutes depending
on the number of individuals in the client's network. At the time of the second network
interview, the investigators will also collect qualitative data on SUPPORT client's overall
program experience. During these interviews, the client will be asked for the first names and
last initial of people who provide certain types of social support in his/her life.

Qualitative:

IU researchers will also collect qualitative data from both group through semi-structured
interviews. The purpose of the interviews is to develop an understanding of client's
treatment experience and how the SUPPORT program may have assisted them in overcoming
barriers to recovery. These interviews are expected to take between 45 and 60 minutes.
Guiding questions for the interview include: "Describe what you liked/did not like about the
SUPPORT program (probe: client-centeredness, self-determination)."; "How was your
relationship with your recover consultant?"; "Overall, how has the program helped you in your
recovery? (probe: motivation; social capital; quality of life; elimination of barriers)";
"Are there specific things the program helped you with that you would not have been able to
do on your own?"; "How did the program help you not return to jail (for those who did not
recidivate)/How could the program have assisted your better so you would not have returned to
jail (for those who did recidivate)?"; "If you experienced a relapse in the program, how did
the program help you through that?"; "If you could change anything about SUPPORT, what would
it be? Why?" (Attachment: Qualitative Interview Questions)

Also, researchers will conduct focus groups with SUPPORT clients after their 15-month CAPI
interview. The researchers will conduct between 5 and 8 focus groups with 5-10 participants
each. The researchers will attempt to recruit all SUPPORT clients for focus groups. Focus
groups will last between 60 and 90 minutes and will be audio recorded.

Inclusion Criteria:

- All PACE clients who are over the age of 18, have a SUD, are no longer incarcerated
(in a prison, jail, or work release facility), and are unable to access the previously
mentioned Recovery Works program will be eligible for study participation.

Exclusion Criteria:

- Any individual that is not a PACE client, has not been released from prison, over the
age of 18, or does not have a substance abuse disorder will not be included in the
study.

Also, sex offenders will be excluded from this study because of the additional integration
barriers faced by this population and their increased parole supervision, as these may
confounding variables in such a small pilot.