Transcript Improving Client Engagement and Retention in Treatment: An

Improving Client Engagement and
Retention in Treatment:
An Introduction
UCLA ISAP/PSATTC
LACES Training Series
2008
Overview of the Presentation
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Process Improvement (PI) Defined
NIATx Aims and Principles
Measuring the Impact of Change
PI Planning Guide
Case Study
Sample PI Strategies
Sustaining Change
Lessons Learned
What is Process Improvement?
• An evidence-based framework that when
applied to client access and retention
processes can get clients in the door quickly
and keep them there long enough to make a
difference
• A systematic problem-solving approach that
can be used to understand client needs,
restructure processes, and make the most
efficient use of available resources
An Example of a PI Model: The
Network for the Improvement of
Addiction Treatment (NIATx)
Strategies to Improve Client
Access and Engagement
What is NIATx?
• A partnership between:
– RWJF’s Paths to Recovery program
– CSAT’s Strengthening Treatment Access and
Retention (STAR) program, and
– A number of single state authorities and
independent addiction treatment organizations.
• NIATx works with addiction treatment
providers to make more efficient use of their
capacity and shares strategies for improving
treatment access and retention.
What is NIATx?, continued
• NIATx members create a culture of
process improvement in which treatment
center staff:
– Use existing resources to improve
services
– Learn innovative strategies through peer
networking, and
– Model organizational improvements in
addiction treatment
Three Fundamental Questions
1. What are we trying to accomplish?
(AIM)
2. How will we know that a change is an
improvement? (MEASURE)
3. What changes can we test that may
result in an improvement? (CHANGE)
The Four Aims
Reduce Waiting Times
Reduce No-Shows
Increase Admissions
Increase Continuation Rates
The Key Principles
1. Understand and involve the customer when
making decisions about change
2. Focus on problems of most concern to and
supported by management
3. Select an influential change leader to lead the
process
4. Seek ideas from outside the agency
5. Pilot test improvement ideas quickly
Using a Quick Start Road Map To
Plan Change Projects
1. Identify problem important to
management
2. Target objective (measurable/specific)
3. How will you measure the change?
4. Who will be on the change team?
5. Instructions for change team
Using a Quick Start Road Map To
Plan Change Projects, continued
6. What contributes to the problem?
7. What possible changes might help?
8. What is the implementation process?
9. What data will be gathered?
10. How will progress be studied?
11. What is the next step?
Rapid-Cycle Testing
Rapid-Cycle changes
 Are quick; do-able in 2
weeks
PDSA cycles
 Plan the change
 Do the plan
 Study the results
 Act on the new
knowledge
How Do You Measure the Impact
of Change?
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Define your measures
Collect baseline data
Establish a clear aim
Consistently collect data
Chart your progress
Ask questions
Decrease in No-Shows to Outpatient Program
Oct 2004 - Dec 2005
Baseline Oct - Dec 2004 = 36%
70
Percentage
60
58.1
50
40
27.6
30
25
22.2
20
12.5
17.4
15.1
13.6
9.52
10
4.5
5.9
8.3
9.09
0
0
0
Oct04
Nov04
Dec04
Jan05
Feb05
Mar05
Apr05
May05
Month
Jun- Jul-05 Aug05
05
Sep05
Oct05
Nov05
Dec05
M
ay
Ju
ne
Ju
Au ly
Se g
pt ust
em
O ber
c
N t ob
ov er
e
D mb
ec e
em r
b
Ja er
n
F e uar
br y
ua
r
M y
ar
ch
Ap
ril
M
ay
Ju
ne
Ju
Au ly
Se g
pt ust
em
O ber
ct
ob
er
Percentage of Continuation
Continuation
100
90
80
70
60
50
40
30
20
10
0
Month
Case Study
Mid-Columbia Center for Living
Hood River, Oregon
NIATx Member Organization
Lessons from Hood River
Before they started…
• Staff were working hard
• There were lots of ideas
• No clear picture of what was really
happening
• No data
Baseline Data
• Wait time between first request for
service and appointment was 18
days on average
• Admissions averaged 18 clients a
month
• Continuation (4 sessions in 30
days) rate was 34%
Continuation was
an obvious aim
But why was continuation so poor?
What to do?
1. Staff wanted to try an incentive
2. How to track continuation?
a. Have clients be responsible for
monitoring their participation
b. Create a tool to help clients do it
c. Old appointment cards often got
confused with current ones
d. Make a 4-session appointment card
How did it work?
• Clients used 4-session card for both
individual and group appointments
• When the card was full, the client
presented it to their counselor
• The counselor then offered the client an
assortment of gift certificates to choose
from
Results
Continuation
100
80
60
Percentage of
Continuation 40
Pre Change
Post Change
20
0
1
2
3
4
months
5
6
7
8
What about group attendance?
• Group attendance averaged about 65%
• What could be done?
– 100% attendance of all members for 4
weeks
– On the 5th week, group would get a “Pizza
Party”
• Rationale
– Group might work as a team
– Peer pressure would increase attendance
– Recognition would be rewarding
Results
English Speaking Group Attendance
Percentage of
Attendance
100
80
60
40
Pre Change
20
Post Change
0
1
2
3
4
Month
5
6
Pre Change
7
8
Impact of the Change
• The English speaking groups had a low
of 62% attendance in December 2004
• After the change, the English speaking
groups had a high of 93% attendance in
March
• 8 pizza parties have been earned by the
groups so far
Sample Ideas for Improvement
from the NIATx Network
Reduce Waiting-Time
• Revise telephone system so live person
answers phone to eliminate call-backs
• Offer walk-in assessments
• Train backup staff to answer phones and
do assessments to remove bottlenecks
• Eliminate redundant paperwork at
telephone screening and intake
Reduce No-Shows
• Call clients who no-show to re-engage in
treatment
• Ask clients about barriers to coming to
next appointment and help them find
solutions, e.g. transportation, child
care, work
• Call clients to confirm appointment 1 or 2
days prior
Increase Retention
• Have peers help orient and connect
with new clients
• Offer more welcoming environment,
assess client needs frequently
• Contingency management – rewards for
continuing in treatment
• Utilize motivational interviewing and
enhancement strategies
Increase Admissions
• Offer outpatient orientation, precontemplation, and/or skill training
groups
• Eliminate required length of stay;
individualize and negotiate treatment
plan; move to next level of care
when ready
• Build special relationships with referral
sources
Sustaining Service
Improvements
Why Sustain an Improvement?
1. Improves efficiency or ease of work
2. Payoffs are obvious and credible
3. Adoption is easily done
4. Progress can be monitored
5. Staff are involved or can be trained
6. Staff believe in the change
7. Management supports the change
8. Clinical leaders value the change
9. Fits with strategic plan and culture
10. Infrastructure can support the change
How to Sustain an
Improvement
One key: gathering and reviewing data
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How will data continue to be collected?
Who will review the data?
How often will the review occur?
What will trigger action to restore the
improvement?
How to Sustain an Improvement
Another key: Have a sustainability
leader to…
1. Clarify staff duties and responsibilities
2. Communicate progress data with staff
3. Plan with staff how to restore gains if data
falls below an agreed level
4. Implement actions to restore gains
5. Advise management about infrastructure
changes needed to sustain the
improvement
The NIATx Website
www.niatx.net
Seven Lessons Learned
1. Seeing things from the client’s perspective
can be helpful
2. Multiple improvements can be made in a
short period of time
3. Process improvement can motivate staff
and clients – they get excited when good
things happen
4. The results surpassed the initial
objectives/expectations
Lessons Learned, continued
5. Simple improvements yield big
dividends
6. Using data can actually be helpful
7. There is a huge value to “sticking
with it” (sustaining effort and keeping
communication flowing)
The NIATx PI model offers a
format for learning and applying
process improvement methods
through the use of a peer
learning collaborative
The End…Thank you!