The opioid epidemic disproportionately affects the nation’s 100 million low-income Americans and those who lack health insurance — groups that are disproportionately comprised of minority communities. Delivering culturally responsive care is critical to engage minorities in opioid use disorder (OUD) treatment and abate the effect of the epidemic. To identify key culturally competent practices that impact access and engagement (i.e., wait time to treatment entry and retention in treatment), it is necessary to examine the role of workforce diversity, one of the most concrete organizational culturally competent practices (i.e., matching staff-client culture, language, worldview based on racial/ethnic background) [1–5]. The following study addresses a significant gap in disparities research using nationally representative data to examine the impact of workforce diversity, an essential culturally responsive practice, on OTP quality measures of wait time and retention for individuals self-identified as Black/African American (hereafter African American) or Hispanic/Latino (hereafter Latino).
It is well established that individuals self-identified as members of racial and ethnic minority groups are more likely than White individuals to experience difficulty entering and staying in outpatient substance use disorder (SUD) treatment [6–10]. Reflecting their importance to treatment, wait time and retention have been included as performance measures developed by the Washington Circle , the Network for the Improvement of Addiction Treatment , and county and state administrative data systems . Treatment access (measured through wait time to initiate treatment) and retention in treatment are critical process measures to abate disparities in substance use disorder treatment . Yet, there is limited understanding of the role of workforce diversity in access and retention among OTPs.
Disparities in wait time and retention
Among those seeking help for substance abuse issues, wait time to treatment entry is a commonly cited barrier. Most studies show that African American and Hispanics clients wait more days to enter SUD treatment than non-Hispanic White clients [15–17]. Treatment retention, or time spent in treatment, is likewise an important process measure and robust predictor of reduced post-treatment substance use [11,18]. As healthcare reform has supplied new incentives for increasing access to OUD treatment via Medicaid reimbursements, evaluating treatment access and retention within the context of Medicaid expansion is critical to responding to OUD treatments’ main challenge, specifically, “treatment dropout” [19–23].
Workforce diversity and wait time and retention
Cultural competence is defined as a set of behaviors, attitudes and policies that enable a system, organization, or individual to function effectively with culturally diverse clients and communities . Cultural competence also encompasses the culturally and linguistically appropriate services (CLAS) denomination used by federal health agencies [25–27]. Workforce diversity is one of the six core components of CLAS: Leadership, Quality Improvement and Data Use, Workforce, Patient Safety and Provision of Care, Language Services, and Community Engagement.
Federal, state, and professional organizations have promoted cultural competence as a means to improve SUD treatment retention among racial/ethnic minorities. Medicaid payments and related regulation have strengthened the focus on delivering services that respond to the cultural and linguistic services needs of clients . The National Institute of Medicine, National Institute of Nursing and the National Association of Social Workers have all promoted workforce diversity strategies and developed training standards for cultural competency [28–34]. Regulation at the federal, state and professional certification levels have incorporated cultural competence in health care services [35–38]. Of particular relevance to the proposed research, the Substance Abuse and Mental Health Services Administration has called on providers to rely on CLAS because the majority of SUD counselors are non-Hispanic Whites [39,40], even as 36% of clients at publicly-funded SUD treatment centers are non-White .
Workforce diversity has become one of the chief cultural competency strategies to address healthcare disparities [42–52]. Following Brach and Fraser (2000), we define workforce diversity as the demographic and cultural representation of health workers and managers that reflect inclusion of backgrounds that are representative of the client population . A workforce that represents client diversity is thought to be one of the main mechanisms to improve cultural and linguistic responsiveness.
However, the relationship between diversifying the workforce and disparities in access and retention in the SUD treatment system is not clear. Because culturally competent practices include a wide array of program arrangements, practices, and services, it is critical to determine which components of CLAS are most needed to engage minorities in OUD treatment. Some work shows that discordance between the racial and the ethnic diversity of clients and treatment staff widens healthcare disparities [3,5,53–55], while other work suggests that congruence is associated with disparities . Congruence between the cultural and the linguistic backgrounds of staff and clients is thought to elevate the competencies of health care providers and improve client treatment adherence via the understanding of racial/ethnic history and cultural norms, as well as the communication through the client's native language [1–5] . This is thought to create a conducive climate for implementing CLAS (e.g., family support groups in Spanish) [57–59] and addressing the disparities in treatment outcomes among minorities [60–63] .
The field of SUD treatment has seen increased client diversity, yet limited longitudinal research has explored the provider/client similarity in racial/ethnic background [3,7,39]. In this exploratory work, we expect to see the role of workforce diversity to be associated with lower wait time and higher retention in well-resourced programs, while high diversity in staff and clients may be associated with higher wait time and lower retention in lower-resourced programs.