Knowing Better To Do Better
by Founder and Chief Medical Officer Dr. Ernie Fletcher
Research is not just important—it’s imperative, particularly in an industry like recovery housing that’s been largely unregulated and under-studied. A vast reservoir of knowledge remains to be discovered to help us codify evidence-based best practices, provide effective technical assistance, and raise social consciousness.
As a field catalyst, the Fletcher Group Rural Center Of Excellence works across silos to untangle the knots and address the critical capability gaps that prevent rural Americans from receiving the recovery help they need.
The research we do helps us fill voids in our industry’s skill set, spot the white space for breakthrough change, and plot a long-range map for achieving the sweeping, transformative change in recovery services and treatment so needed in rural America.
Our Current Projects
Whether it’s how to keep a recovery home safe during a pandemic or how states can incorporate recovery housing within their continuum of care, all Fletcher Group research relates, in one way or another, to an accurate assessment of needs. You’ll see that theme running through all ten of the research projects described below as we work to improve the quality and capacity of recovery housing and services in rural America.
A Survey of State-By-State Legislation and Policies Affecting Recovery Housing
Currently being built is a National Recovery Housing Resource Guide that will include a wide range of state-by- state information—requirements for certification, licensing, and accreditation; funding opportunities and models; policies regarding service reimbursements; and state-level criminal justice policies that may expand recovery services to those incarcerated with a substance use disorder or who may benefit from alternative sentencing and recovery housing. An in-depth review of all information related to the development, sustainability, and improvement of recovery housing in America will help us centralize all integral aspects impacting its existence and sustainability.
A Survey of Single State Agencies
By leading the management of state- and federally-funded addiction treatment, prevention, and recovery services, Single State Agencies (SSA) play a key role in the growth and quality of recovery housing. In the fall of 2021, the Fletcher Group partnered with the National Association of State Alcohol and Drug Abuse Directors (NASADAD) to survey SSA directors and representatives in order to ascertain their level of state support for recovery housing and how they plan to incorporate recovery housing into the continuum of care they offer to those with substance use disorders. The survey achieved a remarkable 94 percent response rate from people in 48 different states. The results indicate that recovery housing has, in the mind of state officials, become an integral and high-priority recovery support service, but is nevertheless routinely under-funded. In other words, funding is not matching the expressed level of importance given to recovery housing by the SSAs we surveyed.
A Survey of Recovery Housing Retention Predictors
To gain a better understanding of the factors affecting recovery home retention, the Fletcher Group has partnered with the University of Kentucky to create, for the first time, an in-depth scoping review of all related literature. To cast the largest possible net, we developed a new protocol that more clearly identifies the predictors of both participation in substance use disorder treatment and retention in such treatment. The new protocol has been registered with the Open Science Framework (OSF). With all findings gathered and de-duplicated, the survey results will soon be analyzed and disseminated.
A Survey of Stigma Reduction and Its Effect on Recovery Housing Support
Stigma against those with a substance use disorder can severely impede access to vital recovery services. Such stigma can be particularly harmful in rural areas where “everyone knows everyone.” The Fletcher Group recently worked with the University of Wyoming Economics Department to run a randomized controlled trial to test the ability of messages about recovery housing to reduce stigma. Data from over 2,700 participants shows there is high political support of recovery housing as measured by the percentage who chose to sign a petition supporting investment in recovery housing in their state. Preliminary analysis also indicates that written stories of an individual in recovery, whether anonymous or not, help reduce stigma, but that messaging alone may be limited in its ability to influence actual behavior.
A Survey of Perceptions Affecting Recovery Participation
“Therapeutic alliance” is a research construct used to measure the degree of collaboration and trust between therapist and client. Though commonly used in behavioral health settings, it has not yet been studied in the recovery housing environment. To do so, the Fletcher Group developed a new 12-item survey tool that also measures the degree of collaboration and trust between a recovery housing resident and other residents and staff. The new tool has recently been tested and validated with 270 recovery housing residents.
A New Protocol for Surveying Recovery Housing Outcomes
Numerous studies show that recovery housing helps reduce substance dependence and incarceration rates. But no study has taken into account the wide variance in recovery home size, population served, location, or recovery model. The Fletcher Group has created a new resident-level outcomes protocol used to systematically collect and assess outcomes from every variety of residence. It encompasses three domains and several sub-domains and, though brief, employs a battery of validated instruments. The feedback from several subject matter experts has been incorporated in a pilot trial now proceeding in West Virginia. The same protocol will be used in the Fletcher Group’s new Resident Management System at www.recovery-housing.org where RH operators can record daily operations, collect outcomes and generate reports with state-of-the-art efficiency.
A Survey of Disparities in Access to Recovery Treatment
While research indicates that recovery housing is effective, the fact remains that the industry is largely unregulated with wide discrepancies in services and treatments offered. Even the number of homes is uncertain with official estimates ranging from 10,358 to 17,900. And no research at all has been done regarding racial disparities among recovery home residents. One Kentucky study has shown that of 270 recovery housing residents, 94 percent reported as Caucasian. Through over 3,000 technical assistance encounters with recovery home owners and operators across the country, The Fletcher Group has confirmed, at least anecdotally, that a severe racial disparity does exist in those served by the recovery housing industry. To help address that disparity, the Fletcher Group is conducting a scoping review of all available literature to determine as accurately as possible which populations are under-represented and to what degree.
A Nationwide Survey of Recovery Housing
Another unknown is the total capacity of America’s recovery housing industry. The Fletcher Group is now conducting a cross-sectional survey of recovery homes to determine that number. While we’re at it, we will collect data regarding populations served, the types of policies and procedures applied, the recovery pathways offered at recovery homes, how homes are funded, and data regarding outcomes. The survey is still in its infancy with 51 responses captured from 120 residences in seven states.
A Survey of SMART Recovery in Rural Recovery Homes
While research indicates that recovery housing is beneficial, the effectiveness of specific services and treatments is often unknown due to a lack of research. As a result, many people with substance use disorders and their families are prevented from making evidence-informed decisions about which recovery home to use. SMART Recovery (standing for Self- Management and Recovery Training) is a science- based mutual aid program designed to help people overcome addiction. It’s proven to be a popular alternative for those resistant to the religious aspects of 12-step groups or those who wish to complement their 12-step group with a program focused on life skills. Considerable research has been done regarding the general effectiveness of SMART, but not within rural recovery homes. The Fletcher Group is therefore conducting a study that will enroll residents in 100 rural recovery homes to evaluate SMART’s implementation and recovery-related outcomes. To date, nine recovery homes have enrolled in the project with another 17 in the process of joining.
A Survey of Contingency Management in Rural Recovery Homes
Contingency Management is another science- and evidence-based treatment program that’s been proven effective in numerous settings, but not yet in recovery homes. In the fall of 2021, the Fletcher Group began working with Dr. David Ledgerwood of Wayne State University to implement and study CM’s effectiveness in a variety of rural recovery homes. The program will first train staff at selected recovery homes to see if CM helps retain residents and maintain their engagement in recovery activities. The clinical trial will involve ten homes, five with CM and five without.
The Financial Landscape of Recovery Housing in the United States
by Madison Ashworth, Robin Thompson, Ernie Fletcher, Grace Clancy, and Dave Johnson (2022)
Assessing Waivered and Non-Waivered Physician Barriers to Treating Patients with Substance Use Disorders: A Cross-Sectional Kentucky Pilot
by Robin Thompson, David Johnson, Amber Kizewski, Lori Baier, Karen Coburn, Jennifer White, Terry Bunn T, and Ernie Fletcher (2022)
A Holistic Approach to Corrections Early Release COVID-19 Strategies by Dr. Ernie Fletcher, Chief Medical Officer of the Fletcher Group with assistance from Fletcher Group CEO Dave Johnson (MSW, ACSW), Fletcher Group Director of Research and Evaluation Robin Thompson (Dr.PH, MPH), and Fletcher Group Research and Policy Assistant Grace Clancy
Assessing Technical Assistance Needs Among Recovery Residence Operators in the United States by Miles J, Bunn T, Kizewski A, Jennings T, Waters T, Johnson D, Sheridan D, & Fletcher E.; Journal of Psychoactive Drugs doi: 10.1080/02791072.2021.1941442
Program Policy, and Social Support Characteristics Associated with Rural vs. Urban Recovery Housing, 2018-2020″ by Kirby A, Kizewski AL, Ashworth M, Thompson RA, & Bunn T (2022); Journal of Drug Issues
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