Patterns of Clients’ Service Use and Treatment-Engagement: Evidence from a Peer-Led Recovery Community Center


Project Lead: Jennifer Tuerke
Background
Voices of Hope, Inc. (VOH) is a peer-led one-stop-shop recovery center providing a variety of services to people with numerous needs and in various stages of substance use recovery. VOH has adopted a Stages of Change model (Prochaska, & DiClemente, 1983) to work with individuals regardless of their stage in the recovery process (precontemplation, contemplation, preparation, action, maintenance). Available services include peer support, treatment navigation, recovery housing, and harm reduction services, including a safe syringe program (SSP). In VOH’s first round of IRIS research partnership, we categorized VOH services in alignment with the Stages of Change (see Figure 1). For this next study, we examined clients’ service use patterns longitudinally as well as early or intermediate stage service utilization which precedes clients’ treatment-engagement (seen as the action stage).
Figure 1: Stage of Change Model

Specifically, there are three research questions (RQ): (1) what are clients’ duration of contact and frequencies of each service type used? (2) what are the differences in service use between people who engage in treatment and those who do not? (3) what are services used before treatment engagement, and what are services used after treatment?
Methods
This study utilized over five years of VOH administrative data collected from March 2019 to May 2024. We used clients’ unique ID and date of service use to sort each person’s service use in chronological order. Clients’ encounters with VOH were combined and recoded into 15 categories of service type (See Table 1). For a single day, multiple encounters of the same service type were counted only once. In addition, phone contact and in-person contact encounters were deleted if there was another type of service encounter on the same day.
We were not able to align all 15 service types within the Stages of Change model because some services are used across several stages. However, as we inferred active drug use from SSP service utilization, this was utilized to indicate the pre-contemplation stage. Treatment-engagement behavior such as requested referrals for treatment or use of treatment coordination services was considered as the action stage.
Descriptive analysis (frequencies and percentages, means, median, and standard deviation) and bivariate analysis (including t-tests and chi-square tests) were used to answer RQs one and two. To answer RQ three, we identified people who sought treatment and described their pre- and post- treatment engagement service use. All activities that happened before the date of first treatment engagement were defined as before-treatment activities. After-treatment activities were defined as activities one month after treatment engagement.
Table 1: Descriptions of Encounter Type

a
Note: Despite some encounters not clearly defined or classified as a service type (such as in-person or phone contact), we chose to keep all documented encounters. Phone contact and in-person contact were kept only when there was no other type of service on the same day. Specifically, 82.6% (n=6187) of in-person contact encounters and 88.8% (n=9147) of phone contact encounters were deleted due to overlap with another type of services on the same day.
Results
RQ1: What are clients’ duration of contact and frequencies of each service type used?
There were 8,120 unique VOH clients, who cumulatively had 82,545 encounters. There were 3,052 clients with demographic information collected, partly because some programs are anonymous, such as SSP. Among them, 52.1% were male and 47.8% female. The racial makeup included 83% White clients and 15% Black or African American clients. Around one third were aged 26-35 and 30% were aged 36-45. Details of the sample can be seen in Table 2.
The average number of encounters per client was 10 (See Table 1). The average duration of time as a client was over 4 months (i.e., 136 days). Despite around one-third of clients only having one encounter and 62% of participants’ engagement length being less than one month, 20% of clients had more than 10 encounters and stayed engaged over 6 months. Table 1 shows the number of people who used each service. Among 8,120 clients, over half used phone peer support (56.6%), one fourth received recovery peer support (25.5%) and over one-fourth used other services (28.3%). At least 15% of clients used treatment (18.6%), outreach (17.5%), SSP (15.2%), and transportation services (15%).
Table 2: Description of Sample

Note: The sample size for demographic information, i.e., sex, age, and race is 3052 (less than the whole sample), partly because some programs are anonymous, such as SSP.
RQ2: What are the differences in service use between people who engage in treatment and those who do not?
About 18.6% (n=1511) of unique VOH clients engaged in treatment. Among them, 60.4% (912) of clients' first-day encounter was treatment-seeking. For the remaining 599 clients, average time from first encounter to treatment-engagement was 175 days (SD=247). The median time to first treatment-engagement was 49 days, which means half of these 599 clients sought treatment within 49 days after their contact with VOH.
Table 3 shows the comparison of service utilization between people who engaged in treatment and those who did not. T-tests revealed that people who engaged in treatment had significantly more encounters compared to those who did not (an average of 31.6 encounters vs 5.3, p<0.001) and had a significantly longer duration of time as a client (an average of 11 months vs. 4, p<0.001). Chi-square test results showed that people who sought treatment were statistically significantly more likely to use each service type except wound care, SSP, and outreach, compared to those who did not seek treatment. The largest differences in service utilization were in transportation (52.9% vs. 6.5%, medium effect), followed by case coordination (39.1% vs. 8.4%), recovery peer support (47.1% vs. 20.6%), and phone peer support (82.2% vs. 50.7%) – all small to medium effect sizes, indicating some clinical significance. In contrast, people who engaged in treatment used statistically significantly less SSP services (11.3 vs. 16.1) and outreach (15.8% vs. 18%) compared to those who did not. The effect sizes with these latter two services, however, were minimal (<0.1).
Table 3: Comparison Between People Who Engaged in Treatment (tx) and Those Who Did Not (Non-tx)
%20and%20Those%20Who%20Did%20Not%20(Non.jpg)
Note: effect size indicator, small effect: delta or phi=0.2, medium effect: =0.5, large effect: =0.8
RQ3: What are services used before treatment engagement, and what are services used after treatment?
Among the 512 clients who engaged in other services before treatment, 76.8% used phone peer support services before seeking treatment, and 33.4% used recovery peer support. A total of 987 clients continued using VOH services one month after treatment-engagement. The highest number of these clients (94%) engaged in phone peer support after treatment engagement, followed by other services (67.2%), additional treatment engagement (46.4%), recovery peer support (42.8%) and transportation (40%). Full details can be found in Table 4.
Table 4: Number of People Who Used Each Services Before and After Treatment Engagement

Conclusion & Implications
This study describes the service use patterns within a community recovery center that provides holistic services and engages a large client population. The average client engagement duration of 137 days was similar to previous studies that showed a similar mean of 130 days using administrative data from 20 recovery agencies (Ashford et al., 2021). Consistent with Ashford and colleagues’ study, the present research found great variability between people in their engagement duration, frequency of engagements, and time from first encounter to treatment-seeking. This is unsurprising, considering that VOH provides services for people at any stage of recovery. Clients can enter and exit at any stage, and similarly, they can start or end services when they wish.
Community agencies are important venues for making treatment referrals. This study found that 19% of clients engaged in treatment referral or coordination services. People who sought treatment were more likely to use each service type except wound care, SSP and outreach. This indicates that keeping clients engaged (such as through phone peer support services) and providing services they need no matter their stage of recovery is important to support future treatment-engagement. This includes provision of transportation services, phone peer support, and recovery peer support before and after treatment.
Future studies can build on this one by measuring other outcomes, like recovery capital, rather than only focusing on treatment-engagement. To further examine the effectiveness of services and client outcomes longitudinally, more research is needed to improve the measurement and data collection processes of community-based organizations. Additional research will help to address the numerous challenges faced by these vital agencies in collecting data, including staff and client survey burden as well as ways to maintain respect for client privacy.
References
Ashford, R. D., Brown, A., Canode, B., Sledd, A., Potter, J. S., & Bergman, B. G. (2021). Peer-based recovery support services delivered at recovery community organizations: Predictors of improvements in individual recovery capital. Addictive Behaviors, 119, 106945. https://doi.org/10.1016/j.addbeh.2021.106945
Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: toward an integrative model of change. Journal of consulting and clinical psychology, 51(3), 390-395. https://doi.org/10.1037/0022-006X.51.3.390