Assessing Technical Assistance Needs among Recovery Residence Operators in the United States

ABSTRACT Recovery support services such as recovery housing assist individuals with increasing their access to social support, employment services, and systems of care. Lack of evidence-based practices and calls for increased oversight of these settings suggests a growing need for technical assistance and training for recovery residence owners and staff, yet little is known about their areas of greatest need for technical assistance. We developed and administered a survey to assess the technical assistance needs of recovery housing operators in the United States using a convenience sample of individuals who own or operate a recovery residence (N = 376). A total of 77 owners/operators completed the survey (20% response rate), representing urban, suburban, and rural communities. Differences were observed between number of owned residences: owners/operators of a single residence were interested in technical assistance on house-specific policies and linkage to established systems of care, whereas owners/operators of multiple residences were interested in technical assistance on building financial sustainability and incorporation of best practices into their recovery residences. As an increasing number of states move to implement voluntary certification or licensing for recovery residences, targeted training and technical assistance to owners/operators will facilitate the successful adoption of recovery residence best practices and quality standards.


Introduction
According to the 2018 National Survey on Drug Use and Health (NSDUH), nearly 20 million Americans experienced a substance use disorder (SUD) in the past year (Substance Abuse and Mental Health Services Administration (SAMHSA) 2019). Individuals with SUD often experience comorbid psychosocial challenges that can make it difficult to maintain long-term recovery (Scherbaum and Specka 2008). Therefore, increasing psychosocial recovery capital (i.e., employment, education, social support) is an important treatment goal (Cloud and Granfield 2008). Recovery support services may assist individuals with increasing their recovery capital by addressing the social determinants that affect an individual's ability to maintain their recovery (Office of the Surgeon General 2016).
One type of recovery support service is the recovery residence, or a "safe, sober, and affordable environment that is supportive of recovery from alcohol and other drug disorders" (Jason et al. 2013). Recovery residences are referred to in a variety of ways, such as Oxford House, sober living house, recovery home, halfway house, sober house, or therapeutic community. A recent study estimated that approximately 18,000 recovery residences exist in the US, and a nationally representative survey of individuals in recovery from SUD found that 8.5% of people reported using a recovery residence as part of their recovery pathway (Jason et al. 2020;Kelly et al. 2017).
While all recovery residences operate based on the social model philosophy of recovery, they vary in terms of the degree to which they are peer-or staff-led, and the intensity of supports and services available on-site (National Alliance of Recovery Residences 2012). Oxford House model residences are peer-led and offer no direct services other than the social support of fellow residents (Jason and Ferrari 2010). Sober living homes, such as those in California, typically have a house manager who oversees the daily operation of the residence (Polcin and Henderson 2008). Recovery homes, such as those studied in Philadelphia, have a house manager and may also require attendance at outpatient treatment services as a stipulation of residence (Mericle, Miles, and Cacciola 2015). Therapeutic communities, which are typically licensed and considered part of many states' treatment continuum, have trained staff that deliver treatment services on-site (Malivert et al. 2012;Reif et al. 2014a).
Reviews of the literature on residential settings across the continuum have found significant increases in recovery capital, such as increased employment and social support for individuals utilizing these services (Reif et al. 2014b;de Andrade et al. 2019;Malivert et al. 2012). Recovery residences also show promise for supporting populations who are particularly vulnerable to substance use and its consequences, including sexual minority men, victims of domestic violence, individuals with co-occurring mental disorders or who are homeless, and formerly incarcerated individuals (Edwards et al. 2018(Edwards et al. , 2017Jason, Salina, and Ram 2016;Mericle et al. 2019b;Polcin 2018;Polcin and Korcha 2017). Other models of recovery housing also show promise. For example, annual evaluations of Recovery Kentucky, a recovery housing model located across Kentucky that offers a continuum of recovery supports for residents, have consistently reported improvements in employment and housing, as well as decreases in criminal justice involvement and alcohol and drug use (Logan et al. 2020).
Despite widespread use and growing evidence of effectiveness, most residences operate without oversight of government agencies. A recent report by the Government Accountability Office (GAO) highlights the need for additional oversight of recovery residences, in particular citing unscrupulous operator practices (GAO 2019). While two national private nonprofit organizations have developed standards for the operation of different types of non-licensed recovery residences (e.g., Oxford House International and the National Alliance for Recovery Residences (NARR)), few evidence-based practices exist for recovery residences. The Oxford House model is the only recovery residence-specific practice to be listed on the SAMHSA National Registry of Evidence-based Programs. SAMHSA published a report in 2019 outlining ten "guiding principles" for operating a recovery residence and identified the NARR standards as an emerging best practice. As of January 2021, 5 states have adopted the NARR standards to guide their voluntary certification programs, and 33 states have or are in the process of establishing a NARR affiliate (Martin et al. 2019; National Alliance for Recovery Residences 2020).
Limited technical assistance on recovery housing standards is widely available and affordable. NARR provides in-person, multi-day didactic, and experiential training on the NARR standards to state affiliate leaders and recovery residence owners/operators who are NARR-certified. NARR also hosts monthly open calls to answer questions and concerns by anyone in attendance. However, these web-based passive sessions are not a replacement for intensive training and support that many owners/operators may benefit from but are unable to afford.
Low profit margins in the operation of recovery residences make it difficult for operators to access education and training resources. Federally, SAMHSA allows states to allocate 100,000 USD of their Substance Abuse Prevention and Treatment block grant dollars to provide loans that support the development of new recovery residences (GAO 2019). These loans are typically managed through contracts with Oxford Houses, leaving few resources to individuals that want to operate different models of recovery residences (GAO 2019). At the state level, Pennsylvania and Ohio offer financial support to operators that adhere to specific standards, but these states are a rare exception. Additional investment is needed to support operator access to education and technical assistance.
In addition to financial investment, more research is needed to better understand the types of technical assistance recovery residence operators need, and whether these needs differ based on characteristics of the residence. The goal of providing recovery residence owners/ operators with technical assistance is to improve the quality and effectiveness of these supports. While little research has been conducted to examine the association between program-level characteristics and resident outcomes, one recent study found that individuals residing in houses that were part of a larger parent organization were more likely to remain abstinent from alcohol and drugs at follow-up compared with single-house operators (Mericle et al. 2019c). Single-house operators may have fewer resources to sustain their operations or address residents' complex comorbidities. Consequently, these operators may have different technical assistance needs compared with larger or more established programs. The aims of this preliminary study were to 1) describe and characterize the technical assistance needs of recovery housing owners and operators overall; and 2) explore whether technical assistance needs differed based on the number of residences owned and operated.

Survey development
A draft survey was developed by study staff to assess recovery residence owners/operators need for technical assistance. In an effort to increase validity, the draft survey was sent to four subject matter experts to review and provide input on conceptual domains assessed, and survey flow and timing. Subject matter experts represented one representative of NARR at the national level, two representatives of a state-level NARR affiliate, and a survey design and evaluation consultant. Subject matter expert feedback was incorporated into a second draft of the survey, and pilot tested by the subject matter experts before dissemination.
The final survey gathered descriptive information about the owners/operators, including their role in the organization, the number of houses they operate, the state in which they were located, and the type of residence or residences they operate. Respondents were provided with open-ended text response boxes and asked to describe the challenges they face as operators of recovery housing, resources they need to address these challenges, and how the recovery residence has been received by the community. Respondents were then presented with lists of potential technical training, assistance, or support, organized by the following content areas: business policies, community building, and on-site services and supports. Responses were not mutually exclusive, and respondents could check multiple technical training options. County of residence reported by respondents was used to determine whether the respondent was located in an urban or rural community based on the U.S. Department of Agriculture's rural-urban continuum codes (Economic Research Service 2019).

Recruitment
Individuals were eligible to complete the survey if they were knowledgeable about the daily operation of a recovery residence (i.e., an owner, operator, or staff person). There is no central registry of recovery residences from which to systematically recruit, so the recruitment strategy for this study was a convenience sample. The initial sample was derived from recovery residence operators who participated in an annual recovery residence best practices summit hosted by NARR (N = 282). This conference is geared toward recovery residence operators (NARR certification is not a condition of participation), but other members of the recovery community and government officials also attend in smaller numbers. The 2019 conference had a total of 300 attendees. Additional unduplicated non-NARR summit participants were recruited to complete the survey if they participated in the December 2019 monthly call hosted by NARR (N = 60) (NARR certification is not a condition to participate in the monthly call), or if they self-identified as a recovery residence operator (N = 34). The final sampling frame consisted of 376 potential respondents, and three rounds of follow-up recruitment e-mails were sent to attempt to increase the response rate. A total of 77 individuals completed the survey, for a response rate of 20%.

Data collection
The survey was developed and administered using the REDCap data management system, and respondents could access the survey by clicking a link in the recruitment e-mail. Responses were collected anonymously, and consent was obtained electronically at the beginning of the survey. The study procedures were reviewed and approved by the University of Kentucky Institutional Review Board.

Analytic plan
Univariate statistics were used to describe the survey respondents and the overall results of the survey. Pearson's chi-square tests were also run to test whether single and multi-residence operators' interest in technical assistance differed; Fisher's exact tests were run in cases where a cell size was <5 (Agresti 1992). Effect size was calculated using Cramér's V which is appropriate for comparisons between two dichotomous variables (Fritz, Morris, and Richler 2012).
Qualitative thematic analyses were conducted to analyze the open-ended survey questions in NVivo. Open coding was performed to generate codes which were subsequently sorted and collated into themes and redefined. The final qualitative analyses explored whether a particular theme was present in each response, overall and by the number of houses operated for each respondent.

Description of respondents
The survey respondents (N = 77) were located in 29 unique states, approximately 18% were located in a rural community, and 31% were located in the Midwest region of the United States (see Table 1). Nearly half (45%) of respondents reported being the owner of the residence or organization, and 56% reported having at least one NARR-certified residence. Technical assistance provided in real-time was overwhelmingly preferred by respondents, either in-person (64% preferred) or via webinar (60% preferred). Approximately one third said they prefer asynchronous video training (35%), and 21% said they preferred text or digital training materials.
Over half of respondents (62%) operated multiple residences, while 38% operated only a single residence. Half (52%) of single-residence respondents were owners (N = 15) compared to 40% of those with 2+ residences. NARR certification was fairly equivalent between the multiple residence operators compared with singlehouse operators (58% vs. 52%, respectively). Table 2 summarizes the respondents' interest in specific areas of technical assistance, overall and by the number of residences operated. Overall, training on business policies such as establishing recovery house sustainability funding plans/models (70%) and quality standards for recovery residences (58%) were of greatest interest. In terms of engaging with key stakeholders, most respondents were interested in strategies to partner with state and local government entities (60%) or other referral agencies (57%). Nearly two-thirds (65%) were interested in training on evidence-based practices, and many (60%) identified trauma-informed care practices as a priority.

Quantitative results
Although bivariate comparisons were not statistically significant, some trends are worth noting. For example, single-residence operators trended toward a greater interest in technical assistance pertaining to risk management (59% vs. 40%; Cramér's V = 0.185) and general house management (48% vs. 31%, respectively; Cramér's V = 0.170. Interest in training on more sophisticated practices such as prescription medication use trended higher among multi-residence than single-residence operators (33% vs. 17%, respectively; Cramér's V = −0.175). Compared with multi-residence respondents, single-residence operators tended to be more interested in creating partnerships with mental health and substance use treatment providers (48% vs. 62%, respectively; Cramér's V = 0.137.). In terms of training related to service delivery, training on recovery capital tended to be of greater interest to multi-residence respondents compared to single-residence operators (60% vs. 41%, respectively; Cramér's V = −0.185), while more single-than multi-residence operators were interested in strategies for supporting special populations (55% vs. 40%, respectively; Cramér's V = 0.152). Table 3 summarizes common themes in respondent responses related to their community's response to recovery housing, operator challenges, and need for additional resources. Most respondents shared that their respective communities responded positively to their residence(s) (53%). The majority of singleresidence respondents expressed mostly positive responses from the community (72%). Respondents with two or more residences were evenly split between positive (42%) and mixed/negative (46%) reception and reported experiencing "not in my backyard" (NIMBY) sentiment. One multi-residence operator shared that while opening a new recovery residence, residents in the community expressed concern over "a decline in property values, increased crime, and safety of children." This underscores the greater interest in technical assistance on NIMBY by respondents with multiple residences as shown in Table 2.

Qualitative results
For both single and multi-residence respondents, community education was critical to building initial awareness, counteracting NIMBYism, and garnering community support for their recovery residence(s) (data not shown). One owner/operator shared that the key to fostering community support was "building relationships with key agencies, and not being secretive yet protecting residents, allowing them to remain anonymous, but also greeting our neighbors, letting them know what we are doing . . . ." Other respondents used house tours and hosted community events to engage and educate their communities about the purpose of their recovery residence(s). However, others attempted to circumvent negative community response by keeping a low profile or avoiding commercial zones.
In terms of the challenges they faced, three primary themes emerged: funding, development and implementation of best practices, and linkage to established systems of care. More multi-residence than single-residence respondents emphasized that the current lack of sustainable funding available for recovery residence operations is a major barrier (46% vs. 31%, respectively). As stated by one respondent, "sustainable funding has been a challenge and my organization has been in business for 58 years . . . without sustainability, there is no opportunity for growth." This correlates with the greater interest expressed by multi-residence respondents in establishing recovery housing sustainability funding models (Table 2). Both single and multiresidence respondents identified a lack of sustainable funding for incoming and current residents. Some respondents highlighted the need for specific resources such as monthly scholarships for vulnerable populations (e.g., prison reentry, homeless, pregnant) and additional funding needed to assist recovery residents with transitioning to permanent housing. Similar to the results reported in Table 2, multi-residence respondents were concerned with the absence of best practices for recovery housing (38% vs. 28%, respectively). Compared with multi-residence respondents, those operating a single residence expressed difficulty linking residents to established systems of care during and after their stay (38% vs. 19%, respectively). This mirrors the  greater interest in training related to creating partnerships with mental health and substance use treatment providers expressed by single residence respondents (Table 2). Specifically, respondents expressed that they felt that they were competing with addiction treatment systems, and that recovery residences were often rejected as a critical element within the continuum of care by key stakeholders: "those that have had the lead for so long need to be educated in recovery support services." Single residence respondents also shared difficulties in collaborating with established systems of care, or being able to identify appropriate community partners from the outset of the establishment of their residence. More multi-residence respondents emphasized increased state and federal funding dedicated to recovery residences, while single residence respondents were interested in direct financial assistance to residents. The need for technical assistance related to the development of house manager training materials, medication policies and instruction, effective intake processes, and developing "responsible provider communities" were expressed equally by single-and multi-residence respondents. Additionally, both groups expressed a need for technology that can support awareness and use of recovery residences among individuals with SUD as well as other key stakeholders, and that can improve recruitment of new residents and tracking of both resident and house outcomes. For example, one respondent recommended creating a database "where people could find a facility that best fit their individual needs." Another respondent expressed a need for "some sort of centralized component that provides training, support and oversight of practice."

Discussion
The results of this survey demonstrate an overall interest in technical assistance among recovery residence owners/operators that responded to our survey. Of greatest interest were topics related to collaborating and partnering with key stakeholders and participating in macrolevel discussions to improve care for individuals with substance use disorder. Training and technical support on strategies for successful linkage with external treatment providers was also of interest, and some research suggests that residents in houses that are directly linked with outpatient treatment programs have better outcomes than those in residences without such linkages (Mericle et al. 2019c). Training in these areas could better prepare operators to address negative perceptions toward recovery residences held by members of their community, and prior research also suggests that residents themselves find value in positive engagement with their communities (Heslin et al. 2012).
The goal of delivering technical assistance to recovery residence owners/operators is to improve the quality and effectiveness of recovery residences, and more than half (58%) of respondents were interested in technical assistance on establishing recovery residence best practices. Almost the same percentage (56%) reported that at least one residence was NARR-certified. The NARR certification standards (National Alliance of Recovery Residences (NARR) 2019) include domains that overlap with many of the areas of interest expressed by our survey respondents and could potentially be used as a model for providing comprehensive training to recovery residence owners/operators. Future research is needed to compare resident outcomes in settings that did or did not implement the NARR standard.
In addition to operational best practices, nearly twothirds (65%) of respondents were interested in training on incorporating evidence-based practices to improve the service delivery components of their recovery residence(s). For example, most respondents (60%) indicated an interest in receiving training on incorporating trauma-informed care practices into their recovery residence(s). This could be particularly beneficial for traditionally underserved populations; living in a safe, supportive community is of particular importance for populations with a history of cooccurring trauma and substance use, such as women who have experienced domestic violence or sexual minority men (Edwards et al. 2018(Edwards et al. , 2017Mericle et al. 2019a). Few evidence-based practices that are specific to recovery residence settings exist, and implementation science could shed light on whether practices developed for other settings might be incorporated with fidelity into recovery residences.
While our analyses were constrained by the low response rate, some trends emerged that suggest targeted training could be beneficial for different types of operators. Single-residence respondents overwhelmingly expressed an interest in training related to primary recovery residence operation. Targeted technical assistance for this group might include training on the NARR standard or similar practices. Multi-residence owners/operators were most interested in training on sophisticated challenges such as developing financial sustainability models and identifying and implementing best practices. Targeted training to multi-residence owners/operators may include the use of braided funding from existing state and local funding sources to cover existing operational costs or expansion of services. Owner/operator location also likely affects technical assistance topics of interest. For example, owners/operators located in rural communities may face unique challenges to collaborating with external partners due to the limited infrastructure nearby.
Inadequate funding for recovery residence technical assistance presents a significant barrier to the receipt of needed training. Our results indicate that recovery residence owners and operators desire training and technical assistance to best support their residents' needs. Community-based participatory research offers a framework for both the generation and dissemination of knowledge that is maximally applicable to the target population, and may be particularly relevant for developing peer-based addiction recovery technical assistance (Jull, Giles, and Graham 2017;Wallerstein and Duran 2010). To expand the development of new opportunities for and extend the reach of existing training and technical assistance, particularly in rural communities, the Health Resources and Services Administration funded the Rural Center of Excellence for Recovery Housing in 2019. This center is developing and delivering training and technical assistance that supports recovery housing owners and operators at no cost to training participants, with direct input from recovery housing operators. Other national, state, and local agencies can also play a significant role in providing financial resources to support the dissemination of evidencebased, evidence-informed, and promising practices and policies to recovery residence owners/operators.
There are several study limitations. The survey response rate was low, and findings may not be representative of all owners/operators across the US. Participation was voluntary, and the sample may be more likely to include persons with high interest in the topic. Therefore, the results and inferences may only pertain to the sample who completed the survey.
Despite the limitations, this preliminary study addresses an important gap in the literature regarding the training and technical assistance needs of recovery residence operators. The results underscore the importance of and need for evidence-based and evidence-informed practices to assist operators in supporting their residents. Our findings can inform recovery residence establishment and operation training and technical assistance needs of recovery residence owners and operators. Furthermore, these results suggest the need for additional research to determine whether the interest in and need for technical assistance varies based on the characteristics of the residence.