Table 3 Interview participants’ perceptions of key barriers affecting pre-admission metric performance

I. Wait time

1. Lack of beds

“Well, we only have 20 beds and we’re serving four hospitals…We have 20 beds for a lot of people.”

“…there were two medical centers in the X area up until 2011…Basically the substance abuse program was consolidated here at the X Hospital in X. So prior to that, the SUD program was actually out at a separate VA medical center and we had more beds there and little to no waitlist. So ever since the move here and the consolidation, we actually lost a significant number of beds and ever since then basically wait time has been an ongoing issue.”

2. Poor staffing levels

“…we had only one psychiatrist who was doing the work so we had to keep our census at half…”

“We were pretty well staffed and then we had a kind of an exodus of social workers and all at once. Then we had to rehire, and that took a long time. And then at that same time, we just kept getting more and more referrals, more and more applications.”

3. Length of stay

“The other side of it could be that our length of stay is too long. We are working on that and have revamped our program to have an eight-week option, as well as a longer option. So, we’re trying to address that part of it.”

“In addition to a variable length of stay for folks, I mean, one of the things that we struggled with was if people needed more time than we’re able to extend them; if we extend them, it creates a longer wait for people on that admissions list.”

II. Engagement while waiting

1. Poor staffing levels

“I think even adding the X CBOCs, there’s 12 of them up north; only this month have they gotten CBT SUD groups in all the rural areas. So, you can imagine our continuity of care fallouts because they were sending guys out, you know, to the boondocks with no SUD providers available even by CBT.”

“A lot of our people would be seeing people in CBOCs, and I would very much doubt if those people are stop coding, you know, for SUD. We have a single social worker or whatever trying to cope. And then in this medical center, our SUD is way understaffed. So, they don’t give a lot of outpatient contact to anybody. So, it’s very hard to get in.”

“We’ve talked about having a waiting for treatment group. But that has been something that staffing-wise we have not been able to pull off.”

2. Socioeconomic barriers

“Well, right now, out in one of the X CBOCs, the bus station is actually like five or six miles away, the closest bus stop to the CBOC. So, you couldn’t even take a bus to get to the CBOCs…”

“I think for a lot of these people who are more indigent, or they don’t have cars. Or, if they even have cars, they might not have what they call gas money to get to the place. I think they tend to no-show a lot, or they don’t’ have a way of getting in to treatment.”

3. Low patient motivation

“Sometimes it’s motivation as well. I mean sometimes they’re using hard, they’re drinking hard or whatever. They’re just not that motivated to get up and come into a weekly group. They’ll show up for their admission appointment because at that point they’re like ‘Okay I’m ready to dry out and get serious.’” But up until that point, they’re continuing to party and use.”

“We don’t have a group, because we tried to do a group for people waiting and nobody showed up. So we do offer individual visits and rarely—I’d say less than 10% of the people waiting take advantage of that.”