Improving Client Engagement and Retention in Treatment Presented by: Thomas E. Freese, Ph.D., Sherry Larkins, Ph.D., & Beth A. Rutkowski, MPH Fall 2008

Improving Client Engagement and Retention in TreatmentPresented by:Thomas E. Freese, Ph.D., Sherry Larkins, Ph.D., & Beth A. Rutkowski, MPHFall 2008 CATES Training SeriesContra Costa County, San Bernardino County, & Sutter County October 24, November 7, and November 14, 2008

Todays AgendaBackground and history of NIATxPrinciples for improving client engagement and retention Examples from the fieldSetting priorities and getting startedHow to measure improvementPlanning and implementing change Promising practices Making a business case for improvement

23 million Americans need treatment

25% are able to access treatment

50% of those in treatment do not complete

The way services are delivered is a barrier to both access and retention SOURCE: NSDUH, SAMHSA, 2006.Reality

The Network for the Improvement of Addiction Treatment (NIATx)

A partnership of:

The Center for Substance Abuse Treatment &

The Robert Wood Johnson Foundation

NIATx National Presencebegan with

Paths to Recovery STARState Pilot ProjectSelf Initiated MembersNIATx GrowingSTAR - SIAdvancing RecoveryNIATx 200Wisconsin, Iowa, Maine, New York, the Frontier States (CO, ID, NV, NM, SD, WY), and Los Angeles County.

NIATx ReachFounding Members 60Self Initiated Members 61STAR-SI 58Advancing Recovery 28NIATx 200200ACTION Campaign540Total947 *

Represented in 48 States* These numbers represent distinct payers and providers.

Process Improvement 101

Why Process Improvement?Customers are served by processes

85% of customer related problems are caused by organizational processes

To better serve customers, organizations must improve processes

NIATx Four Project AimsReduce Waiting Times

Reduce No-Shows

Increase Admissions

Increase Continuation Rates

NIATx ResultsReduce Waiting Times: 51% reduction (37 agencies reporting)

Reduce No-Shows: 41% reduction (28 agencies reporting)

Increase Admissions: 56% increase (23 agencies reporting)

Increase Continuation: 39% increase (39 agencies reporting)

Five Key PrinciplesEvidence-based predictors of changeUnderstand & Involve the CustomerFocus on Key Problems Select the Right Change LeaderSeek Ideas from Outside the Field and OrganizationDo Rapid-Cycle Testing

1. Understand and Involve the CustomerMost important of all the Principles

What is it like to be a customer? Staff are customers, too!

Walk-through, focus groups

2. Focus on Key ProblemsWhat is keeping the executive director awake at night?What processes have staff and customers identified as barriers to excellent service?

3. Select a Powerful Change LeaderWho has:influence, respect and authority across levels of the organizationa direct line to the CEOempathy for the stafftime available to lead change projectsno fear of data

4. Seek Ideas Outside the Organization and Field

Provides a new way to look at the problem

Real creativity in problem solving comes from looking outside the familiar

5. Do Rapid-Cycle TestingStart by asking 3 questionsWhat are we trying to accomplish?How will we know the change is an improvement?What changes can we test that will result in an improvement?

SOURCE: Langley, Nolan, Nolan, Norman, & Provost. The Improvement Guide, San Francisco, Jossey-Bass Publishers, 1996

Rapid-Cycle TestingRapid-Cycle changes Are quick; do-able in 2 weeksPDSA cycles Plan the changeDo the planStudy the resultsAct on the new knowledge

PlanDefine the change behaviorally precisely what will be done?Who will implement the change?What preparation needs to be done before starting the change?Clarify who will measure the change and who will review the data regularly to share with the team.

DoNote the exact start date for the cycleHow long will the initial test last?How often will the team meet to assess progress and review data?During the test, the team considers what improvements might need to be made to improve the results

Rapid-Cycle TestingRapid-Cycle change Barrier questionPDSA cycles Plan: Design questionDo: 2 counselors use on 5 clientsStudy: 70% of clients attend 2 post-assessment sessions compared to 50%Act: will try on another 20 clients

StudyAfter the agreed upon test period the team reviews the resultsChange leader (or designated change team member) assembles and graphs the data for the teamThe team deliberates what it has learnedBased on the learning, the team considers whether a change in strategy is in order

Act (adopt, adapt, abandon)In light of what has been learned, the team decides what to do nextMake an adjustment in the strategy to get closer to the objectiveIncrease the objective (adapt) if the initial target has been met and the team believes even more progress can be madeCombine another change (adapt) with the existing strategy to start a new cycleAbandon the existing strategy and start a new cycle

It is important to rememberIt often takes more than one cycle to achieve your objective. By changing only 1 thing at a time you know the impact of your change.Sometimes several changes are necessary to maximize the improvement you seek.

Change CyclesHunches Theories IdeasChanges That Result in ImprovementDATACycle 1Cycle 2

Cycle 3

Cycle 4

Keys to PDSA successBe clear about your target objective Implement only 1 change at a timeMake sure all participants are implementing the change as plannedImplement the change in a small portion of the agencyStudy the results data before making a modification to the planDo not hesitate to start a new cycle when the data indicates or the team is convinced that a modification will improve results

And last

Keep measuring and studying the results until you reach your objective and determine you have improved as much as you can

Characteristics of a Change TeamThose individuals (customers) who have job functions that are critical to the functioning of the system.Receptionists, case managers, counselors, program managers and clinical supervisorsKeep the team small - no more than 7 members.Members are able to identify important problems.

Role of the Executive SponsorSenior leader in the agencyMust see change/improvement as a priorityIdentifies the problem and articulates the visionDemonstrates commitment to the process (time, resources)Empowers the change leader

Selecting a Change LeaderPerson has sufficient power and respect to influence others at all levels of the organization.Person has the ability to: instill optimism, has big picture thinking, focused, goal oriented, and a good sense of humor.

Change Leader ResponsibilitiesServes as a catalyst to develop ideasSuccessful communicator: facilitates change team meetings, consistent, concise (data), creative and engaging (incentives), skilled listener.Minimizes resistance to changeKeeps the executive sponsor updated on change leader activities.

Seeing Services from the Clients Perspective

Understand and Involve the CustomerAgency walk-through Focus groups and client interviewsBaseline data

How to Do a Walk-ThroughAgency director or executive sponsor plays the role of client and or family memberInform staff and clients if needed, in advance that you will be doing the walk throughEncourage staff to treat you as they would a client; no special treatmentThink, feel, observeRecord observations and feelingsInvolve staff, get their feedback

The Walk-Through Write-UpFirst contactFirst AppointmentThe Intake ProcessTransition between level of service - The Handoff.What surprised you?What two things would you like to change most?

Examples of Walk-Through LearningTelephone answering protocolInformation needed to provide assistance at first contactWait time and availability of servicesNeed to address access barriersFirst impression of facilityWelcoming nature of the 1st encounterHelpfulness of the intake/assessment process Smoothness of transition from one level of care to another

Focus Groups and Client InterviewsWhat is a focus group?Focus groups are different from regular groupsHow to conduct a focus groupFocus group questionsWhat you hope to learn

Focus Groups Sample QuestionsWhat is being most helpful to you here?How would you rate.....the food, facility, counseling group, overall treatment experience, cleanliness ofyour living quarters, helpfulness of the staff, recreation program,etc.What do you need to make your experience here most useful to you?What are you doing that seems like a waste of time? What do you think you should be doing instead?What rules or policies here are creating obstacles to you as you work toward recovery?

Focus Groups Sample QuestionsWhat is the best thing about the treatment program?What is the worst thing about the treatment program?If you could change one thing about your treatment experience here what would it be?What suggestions do you have for improving our program/services/ facility/staff?

Collecting Baseline DataIt is important to measure agency performance before making any changes to agency processes. If you do not measure how the agency is doing now, then there will be no way to evaluate whether a change is making a difference.This initial gathering of data is referred to as baseline data collection. It provides a comparison point to help assess whether a change you make is having the expected impact.

Experiences from the Field

Via Avanta The Way Forward ProjectIntroduction to NIATx aims and principlesThe change teamHow problems were identifiedData collectionImprovements testedResults

Project AimReduce discharges in the first 30 days by 20%Baseline Data: 44% of client were discharging within the first 30 days of admission.Desired Goal: Reduce percentage of clients discharging within the first 30 days of treatment to 35%

Selecting a Change TeamExecutive Change Leader: William Dombrowski, Ph.D., Division DirectorChange Leader: Holly McCravey, Program DirectorChange Team: Leslie Langham, Ray Ayala, Jennie Wyatt-Cost, Laura Points, Carol McChesney, Lori Bisson

How Problems were Identified

Agency walk throughBaseline data collectionFocus Groups: met with clients in treatment for less than 60 days

Baseline Data CollectionData was collected from agency database.Data was collected (3) months prior to the start up of the project. From December 2005-February 2006: 44% of clients were discharged in the first 30 days of treatmentGoal Reduce early discharges from 44% to 35%

Improvements Tested No. 1The first rapid cycle change/actionStart date February 27, 2006Change Idea: Client will have no community responsibilities for the first 15 days in treatment.Change team meetings were used to discuss, analyze the data and evaluate the impact of the change on early discharges.April 26, 2006 change team decided to implement another change /action

Improvements Tested No. 2 Change team decided that clients will no longer have to be covered by another peer in the first 15 days of treatment.May 24, 2006, the change team is still meeting (2) times per month for discussion, analyze data and evaluation of the impact on early discharges.At this meeting, the change team discovers that change No. 2, has caused the Big sisters to disengage with their Little sisters.

Improvements Tested No. 3Employed Motivational Enhancement Therapy with the Big sisters.A change team member and the Big sisters developed goals to achieve on a weekly basis designed to help engage the Little sisters in the treatment process.The contingent goal was decided by clients (group activity, movie, coffee outing, pizza party, ice cream social).

ResultsBaseline data: 44% of clients discharged in the first 30 days of treatment.Completion of pilot project: 13.4% of clients discharged in the first 30 days of treatment. Average # of treatment days 5 months prior to the project was 125 days.Average # of treatment day after the project was 175 days.

Project ResultsEarly Discharges in First 30 Days

Lessons Learned Via AvantaTeam member statements on what they learned from the experienceProcess improvement opened the door to new ways of thinking and behavingCulture changeInfused energy, creativity, and willingness to change

Sustainability of Change Via Avanta

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Sustainability

Mid-Columbia Center for LivingThe problem: Early engagement rate (4 sessions in 1st 30 days) was 34%How to track continuation?Create a tool to help clients track their own continuationMake a 4-session appointment cardThe change: When client attends all sessionsClient selects gift certificate from one of several local vendors

Results

What about Group Attendance?Group attendance averaged about 65%What could be done?100% attendance of all members for 4 weeksOn the 5th week, group would get a Pizza PartyRationaleGroup might work as a teamPeer pressure would increase attendanceRecognition of their effort would be rewarding

Results

Franklin-Williamson Human ServicesProblem: No-show rate at parent education group was 62% What could be done?Try fishbowl contingency managementImplement a new parenting curriculumCounselor calls when parent misses a group meeting.Rationale:Motivational enhancement has been demonstrated to improve attendanceThe new curriculum was highly ratedCall backs have been successful in reducing drop-outs

Reduced No-Shows Franklin-Williamson Human Services

Monthly Revenue IncreaseFranklin-Williamson Human Services

Planning a Service ImprovementDifferentiating responsibilities of management and the change team

Quick Start Road MapA graphic series of steps to make it easier to plan and implement a changeSteps divided into management and change team responsibilitiesAssures that critical steps in the process will not be skipped

Process Improvement Planning Guide

Management responsibilities:Do a needs assessment and identify a problem important to managementWalk-ThroughFocus GroupsExisting Data

Establish a target objectiveAchievableSpecificMeasurable

Management responsibilities:How will the change be measured?SimpleQuickAccessibleWho can record the data?How frequently can it be gathered and summarized?

TIP: Data driven decisions are more objective and more readily acceptedTIP: Without data you have no way to gauge the success or effectiveness of a new practice

Management responsibilities:Who will be on the Change Team?Change Leader3-5 MembersWork together until success is achieved

Instructions for the TeamClear statement of problem with dataPriority for improvementClear objectivePromise of support and commitment

Small Group ActivitySmall groups of 5-8Choose a facilitatorRead your case studyList possible priorities for improvementSelect one problem to target for changeComplete the management section (side 1) of the Quick Start Road Map

Quick Start Road Map - Side 1What is the problem you chose to put in box 1?What is the target objective you put in box 2?

Measuring ChangeAn essential step in assuring the success of any process improvement

Measuring ChangeDefine the measures you will useCollect baseline data before you beginEstablish a clear aim or objectiveConsistently collect dataChart your progress and share the infoAsk questions about what the data is telling you

1. Define MeasuresClarify the project objective: What specifically are you working to improve?What is the target?How will you know if the target is being achieved?

TIP: Clear definitions are critically to successfully measure change

2. Gather Baseline DataUsing agreed upon measures, gather data for 2-3 months prior to beginning a change projectKeys: Does the data provide the info you need?How accurate is the data?Does the process assure consistent data collection?TIP: Never start a change project without gathering baseline data

3. Establish a Clear AimMake sure the target objective is specific, realistic and clearMake the objective challenging but achievableIf the target is reached easily, increase the objective

TIP: The aim should challenge the organization

Typical Aims/ObjectivesReduce average wait time from assessment to 1st face to face treatment session from 33 days to 26 days (a 20% reduction) Decrease no-show rate to intake/assessment appointment from 37% to 30% (20% reduction)Increase the rate of clients who participate in 4 services during the 1st 30 days from 41% to 51% (25% improvement)Increase the retention of residential clients beyond the 1st week of care from 60% to 75% (25% improvement)

4. Consistently Collect DataIf the data is not already being gathered, manual collection may be necessaryImportant to have quick and accurate measures of progressCan be gathered over a short period of time to assess initial success or failure

TIP: Consistently collect measures related to the change

5. Chart Your ProgressImportant to track progress daily or weeklyTrack progress for a long enough period have confidence in the resultsCommunicate to progress with change team, management and othersGraphs are the most powerful way to illustrate progress

Key Points about GraphsState the project aimFor each measure:Provide a definitionIdentify the change targetShow the baseline dataEnter progress data weekly or monthlyIdentify when change started and, if appropriate, when it was alteredContinue charting after the change was adopted to demonstrate sustainability

Sample Graph: Increasing 30-Day Continuation OP ProgramChange 1, 6/1/08Change 2, 9/1/08Aim: Increase % of clients who attend 4+ sessions from 65% to 78%

6. Ask QuestionsWhat is the information we are gathering telling me?When a change is not having the expected impact, ask Why?Continue asking questions about how you can improvecontinuous improvement is the goalTIP: Do not accept your results at face value; keep probing and you will find other ways to improve

Promising Practices TimelinessAssuring access when clients need it:Reduce intake and assessment paperworkChange schedules and offer assessments daily & in eveningEncourage same day assessmentsProvide walk-in assessment clinics

Promising Practices No-ShowsEngaging clients as soon as possible:Address barriers clients face in attending assessment/intakeClearly explain what client can expect at first appointmentModel client communication on MI techniquesGet clients in for first appointment quicklyMake reminder calls for scheduled intake/ assessment appointments

Promising Practices ContinuationKeeping clients in treatment:Connect client & counselor within 24 hrsProvide a welcoming orientationIdentify clients at-risk for leavingUse motivational enhancement strategiesUse positive reinforcement for desired behavior

Change Team Deliberations

Change Team responsibilities:Collaborate on what contributes to the maintenance of the problemAgency processesVariability in staff performanceExternal situation or factorsService designUnclear expectationsLack of knowledge or skillAgency policyOthers?

Change Team responsibilities:What changes might achieve the objective?Be creative, think outside the boxBrainstorm/Nominal Group TechniqueGather information from other treatment agenciesAssess how other industries deal with this problemPrioritize the ideas and select a strategy

Change Team responsibilities:Outline the process to be usedWhat will be done?Who will be responsible at each step?What resources are needed to implement the change?What data will be gathered to assess progress?What measures will be used?Who will gather the data daily?Who will review and analyze the data?

Change Team responsibilities:How will progress be monitored?Who will monitor fidelity with the planned change?How will mid-course adjustments be made?Who will gather data and chart progress?How often will the Team meet to assess progress and determine need for modifications?Who will maintain a record of Team deliberations, decisions and steps taken?

Large Group ActivityCompleting page 2 of the QSRM:What processes contribute to problem?Brainstorm potential changesSelect one strategy onlyIdentify what specifically will be doneSpecify what data will be gatheredDetermine how progress will be assessed

How to Assure Success in Improving Agency ProcessSuccessful CommunicationKeys to Successful Change and Spread

Successful CommunicationFrequent meetingsConsistent, concise (data)Creative, engaging (incentives)Truthful, authentic, realAuthentic listeningContinuous feedback to the organization

Keys to Successful Change and SpreadSustainabilityAlign with the vision and values of the target audience (staff, client, community)Adopt a results orientation model of improvementEngage, engage, engage, retain, retain, retain

Frequent start-up issuesMeasuring the impact of changeWhat measures to useDocumenting the change processRecording data daily; reviewing data weeklyHaving the right people in key rolesExecutive Champion or SponsorChange Leader with time to do the jobSmall enough Team to be effectiveAssuring key participants understand the service improvement model and processLack of customer involvement in establishing a change objective

Making the Business Case for Process Improvement

What Do We Mean by the Business Case? Process improvements can impact your:Financial bottom lineOrganizational climateEfficiency and productivity Relationship with referral sourcesStaff retentionClient satisfactionTreatment outcome

Financial Bottom LineAdmissions can increase Billable service hours can increase A greater number of sessions can be provided Contracts can increase in number and magnitudeOthers???

Increase in Admissions/MonthCommunity Resource Center

STAR-SI A & R TABLE

STAR-SI ACCESS AND RETENTION MEASURES SUMMARY TABLE (A & R TABLE)

Illinois, Cohort 1 Providers - 03/21/2008

Primary Outcome Measure (Organization-wide)Provider OrganizationBaselineTargetJan-07Feb-07Mar-07Apr-07May-07Jun-07Jul-07Aug-07Sep-07Oct-07Nov-07Dec-07

AdmissionsCombined STAR-SI Providers669/month736/mo.804656774715776645742742729858728658

AdmissionsCombined Cohort 1 Providers144/month158/mo.186182195223236192202184173217160121

AdmissionsCombined Cohort 2 Providers525/month578/mo.618474579492540453540558556641568537

AdmissionsCommunity Resource Center17.6/month19.4/mo.232025244023432720331213

AdmissionsEgyptian Public and M.H. Dept.22.6/month25.2/mo.2415222725918926242222

AdmissionsFranklin/Williamson49.6/month54.6/mo.406160645864595545756243

AdmissionsSoutheastern54.0/month59.4mo.99868810811396829382856443

Primary Outcome Measure (Organization-wide)BaselineTargetJan-07Feb-07Mar-07Apr-07May-07Jun-07Jul-07Aug-07Sep-07Oct-07Nov-07Dec-07

Average Units of Service in first 30 daysCombined STAR-SI Providers2.12.32.22.22.12.12.02.12.22.02.32.11.91.8

Median Units of Service in first 30 days1.01.01.01.01.02.01.01.01.02.01.01.01.01.0

Average Units of Service in first 30 daysCombined Cohort 1 Providers2.22.42.22.22.12.11.91.81.92.02.32.21.71.9


Average Units of Service in first 30 daysCombined Cohort 2 Providers2.02.22.12.32.22.12.12.22.42.12.32.11.91.8


Average Units of Service in first 30 daysCommunity Resource Center2.52.72.32.52.42.62.62.52.42.33.53.02.13.5


Average Units of Service in first 30 daysEgyptian Public and M.H. Dept.3.33.63.72.93.33.72.92.63.03.03.43.52.42.0


Average Units of Service in first 30 daysFranklin/Williamson1.92.11.32.11.81.61.41.91.52.02.12.01.62.1


Average Units of Service in first 30 daysSoutheastern1.82.02.22.02.01.91.61.51.71.81.71.51.51.2




STAR-SI State-Specific Measure (Site-specific)Provider Reporting Unit #BaselineTargetJan-07Feb-07Mar-07Apr-07May-07Jun-07Jul-07Aug-07Sep-07Oct-07Nov-07Dec-07

Avg. Duration from Initial Contact to OpeningCombined STAR-SI Providers5.15.15.85.35.97.06.29.29.28.07.87.89.4

Number of Clients in Calculation8003800653770712776643741741728855727657

% Clients - No Wait75.9%79.0%76.2%77.9%72.7%69.5%71.8%61.2%57.3%60.4%64.0%64.1%58.4%

Avg. Duration from Initial Contact to OpeningCombined Cohort 1 Providers8.210.17.710.913.213.214.920.918.414.914.813.816.2


% Clients - No Wait68.4%69.4%62.6%59.0%51.6%44.9%53.1%46.5%38.6%43.4%52.5%56.3%51.2%

Avg. Duration from Initial Contact to OpeningCombined Cohort 2 Providers4.23.65.03.42.54.32.65.56.15.85.56.17.9


% Clients - No Wait77.9%81.9%81.4%84.3%82.3%80.2%80.1%66.7%63.4%65.6%67.9%66.4%60.0%

Avg. Duration from Initial Contact to OpeningCommunity Resource Center0.212.08.221.425.614.850.249.029.422.223.327.727.6


% Clients - No Wait98.1%60.9%75.0%24.0%16.7%12.5%4.3%7.0%3.7%15.0%12.1%8.3%7.7%

Avg. Duration from Initial Contact to OpeningEgyptian Public and M.H. Dept.12.10.00.00.00.00.80.09.911.011.913.739.628.9


% Clients - No Wait80.1%100.0%100.0%100.0%100.0%96.0%100.0%77.8%66.7%42.3%50.0%50.0%31.8%

Avg. Duration from Initial Contact to OpeningFranklin/Williamson0.00.00.00.00.00.00.00.00.00.00.00.00.0


% Clients - No Wait100.0%100.0%100.0%100.0%100.0%100.0%100.0%100.0%100.0%100.0%100.0%100.0%100.0%

Avg. Duration from Initial Contact to OpeningSoutheastern17.016.114.518.121.622.218.228.726.922.225.115.822.5


% Clients - No Wait24.7%51.5%26.7%30.7%18.5%16.8%29.2%22.0%9.7%19.5%27.1%25.0%25.6%




Days from Admission to 1st Treatment SessionCombined STAR-SI Providers21.119.020.821.924.018.724.320.916.518.114.315.214.211.3

Median Days from Admission to 1st Tx Session10.09.08.09.09.010.010.08.07.08.07.08.010.07.0


Days from Admission to 1st Treatment SessionCombined Cohort 1 Providers39.735.728.833.942.826.635.135.030.923.219.825.223.919.2



Days from Admission to 1st Treatment SessionCombined Cohort 2 Providers18.216.419.017.618.516.121.417.213.016.813.312.411.99.4



Days from Admission to 1st Treatment SessionCommunity Resource Center29.526.629.814.019.88.316.226.814.75.55.010.99.74.7

Median Days from Admission to 1st Tx SessionUnit 7328.025.028.014.012.07.010.022.016.07.05.07.010.06.0


Days from Admission to 1st Treatment SessionEgyptian Public and M.H. Dept.19.117.216.212.515.89.219.614.315.210.56.69.322.017.0



Days from Admission to 1st Treatment SessionFranklin/Williamson51.446.340.146.361.436.642.337.629.424.219.129.023.313.4



Days from Admission to 1st Treatment SessionSoutheastern23.020.724.523.427.523.541.737.440.229.942.232.532.333.3






Days from 1st to 2nd Treatment SessionCombined STAR-SI Providers15.113.618.515.117.217.218.218.915.813.914.415.09.47.1

Median Days from 1st to 2nd Treatment Session7.06.37.07.07.07.07.06.57.06.07.07.07.06.0


Days from 1st to 2nd Treatment SessionCombined Cohort 1 Providers17.615.818.515.818.114.418.822.116.416.614.317.213.110.8



Days from 1st to 2nd Treatment SessionCombined Cohort 2 Providers16.915.218.514.816.718.317.918.015.613.114.414.28.56.3



Days from 1st to 2nd Treatment SessionCommunity Resource Center25.723.112.513.023.518.719.538.36.713.23.511.315.0N.A.

Median Days from 1st to 2nd Treatment SessionUnit 7321.019.011.013.015.57.08.514.08.07.53.59.015.0N.A.


Days from 1st to 2nd Treatment SessionEgyptian Public and M.H. Dept.20.518.514.331.141.611.623.67.07.410.013.824.313.015.0

Median Days from 1st to 2nd Treatment SessionUnit 7418.016.07.022.014.07.014.07.07.07.012.512.57.012.0


Days from 1st to 2nd Treatment SessionFranklin/Williamson13.712.312.39.910.814.616.321.211.514.08.115.09.39.2



Days from 1st to 2nd Treatment SessionSoutheastern24.321.930.219.820.914.723.624.430.130.642.222.930.49.7





Primary Outcome Measure (Organization-wide)BaselineTargetJan-07Feb-07Mar-07Apr-07May-07Jun-07Jul-07Aug-07Sep-07Oct-07Nov-07Dec-07

% of Clients/At Least 4 Tx Sessions/First 30 DaysCombined STAR-SI Providers17.0%18.7%19.4%19.5%17.1%16.6%16.0%15.4%20.1%17.3%21.4%18.5%15.8%13.1%


% of Admitted Clients/At Least 4 TX Sessions39.6%42.5%43.1%41.0%38.0%39.2%34.9%41.8%38.0%41.0%37.5%27.7%21.3%

% of Clients/At Least 4 Tx Sessions/First 30 DaysCombined Cohort 1 Providers7.5%8.2%15.6%17.6%13.8%14.8%10.2%9.4%25.2%11.4%19.1%14.7%8.1%10.7%



% of Clients/At Least 4 Tx Sessions/First 30 DaysCombined Cohort 2 Providers19.6%21.6%20.2%20.3%18.1%17.5%18.5%18.1%23.0%19.2%22.1%19.8%18.0%13.6%



% of Clients/At Least 4 Tx Sessions/First 30 DaysCommunity Resource Center2.9%3.2%8.7%20.0%12.0%29.2%25.0%17.4%11.6%11.1%30.0%24.2%0.0%30.8%



% of Clients/At Least 4 Tx Sessions/First 30 DaysEgyptian Public and M.H. Dept.29.8%32.8%41.7%33.3%40.9%44.4%24.0%33.3%44.4%44.4%53.8%45.8%46.2%9.1%



% of Clients/At Least 4 Tx Sessions/First 30 DaysFranklin/Williamson4.1%4.5%0.0%18.0%10.0%7.8%5.2%10.9%10.2%14.5%20.0%16.0%8.1%16.3%



% of Clients/At Least 4 Tx Sessions/First 30 DaysSoutheastern1.8%2.0%17.2%14.0%10.2%8.3%4.4%4.2%7.3%6.5%4.9%1.2%3.1%0.0%



Note: Baseline data denoted by BOLD FONT

*Cohort 1 organization-wide baselines were developed on the basis of DARTS data submitted for clients opened from 07/01/05 through 06/30/06.

Cohort 1 site-specific baselines were developed on the basis of DARTS data submitted for clients opened from 10/01/06 through 12/31/06.

All Cohort 2 baselines were developed on the basis of DARTS data submitted for clients opened from 10/01/06 through 09/30/07.

**Baseline and monthly analyses of average duration from initial contact to opening involve deletion of outlier values greater than 300 days. These values account for less than 0.3% of the total observations

# of Adms. Per Month - Cohort 1

23

20

25

24

40

23

43

27

20

33

12

13

Target 158

Baseline 144

Community Resource Center

Number of Admissions

Number of Admissions/MonthTotal Cohort 1 and Individual Providers

# of Adms. Per Month-CRC

23

20

25

24

40

23

43

27

20

33

12

13

Target 19.4

Baseline 17.6



# of Adms. Per Month-EPMHC

24

15

22

27

25

9

18

9

26

24

22

22

Target 25.2

Baseline 22.6

Egyptian Public MHC


Number of Admissions/MonthEgyptian Public and Mental Health Center

# of Adms. Per Month-FWHS

40

61

60

64

58

64

59

55

45

75

62

43

Target 54.6

Baseline 49.6

Franklin Willamson


Number of Admissions/MonthFranklin/Williamson Human Services

# of Adms. Per Month-SECC

99

86

88

108

113

96

82

93

82

85

64

43

Target 59.4

Baseline 54.0

Southeastern


Number of Admissions/MonthSoutheastern Illinois Counseling Centers

Avg. Service Units-Cohort 1

2.22.33.71.32.2

2.22.52.92.12

2.12.43.31.82

2.12.63.71.61.9

1.92.62.91.41.6

1.82.52.61.91.5

1.92.431.51.7

22.3321.8

2.33.53.42.11.7

2.233.521.5

1.72.12.41.61.5

1.93.522.11.2

Target 2.4

Baseline 2.2

Combined Cohort 1


Egyptian Public MHC

Franklin Willamson

Southeastern

Average Number of Sessions

Average Units of Service/First 30 DaysTotal Cohort 1 and Individual Providers

Avg. Service Units-CRC

2.3

2.5

2.4

2.6

2.6

2.5

2.4

2.3

3.5

3

2.1

3.5

Target 2.7

Baseline 2.5



Average Units of Service/First 30 DaysCommunity Resource Center

Avg. Service Units-EPMHC

3.7

2.9

3.3

3.7

2.9

2.6

3

3

3.4

3.5

2.4

2

Target 3.6

Baseline 3.3

Egyptian Public MHC


Average Units of Service/First 30 DaysEgyptian Public and Mental Health Center

Avg. Service Units-FWHS

1.3

2.1

1.8

1.6

1.4

1.9

1.5

2

2.1

2

1.6

2.1

Target 2.1

Baseline 1.9

Franklin Willamson


Average Units of Service/First 30 daysFranklin/Williamson Human Services

Avg. Service Units-SECC

2.2

2

2

1.9

1.6

1.5

1.7

1.8

1.7

1.5

1.5

1.2

Target 2.0

Baseline 1.8

Southeastern


Average Units of Service/First 30 daysSoutheastern Illinois Counseling Centers

Avg. Time Adm.-1st Sess.-Coh.1

Avg. Time Adm.-1st Sess.-Coh.1

28.829.816.240.124.5

33.91412.546.323.4

42.819.815.861.427.5

26.68.39.236.623.5

35.116.219.642.341.7

3526.814.337.637.4

30.914.715.229.440.2

23.25.510.524.229.9

19.856.619.142.2

25.210.99.32932.5

23.99.72223.332.3

19.24.71713.433.3

Target 35.7

Baseline 39.7

Combined Cohort 1


Egyptian Public MHC

Franklin Willamson

Southeastern

Avg. Duration in Days from Admission to First Clinical Service

Average Duration (Days)/Admission to First ServiceTotal Cohort 1 and Individual Providers

Avg. Time Adm.-1st Sess.-CRC

Avg. Time Adm.-1st Sess.-CRC

29.8

14

19.8

8.3

16.2

26.8

14.7

5.5

5

10.9

9.7

4.7

Target 26.6

Baseline 29.5



Average Duration (Days)/Admission to First ServiceCommunity Resource Center

Avg. Time Adm.-1st Sess.-EPMHC

Avg. Time Adm.-1st Sess.-EPMHC

16.2

12.5

15.8

9.2

19.6

14.3

15.2

10.5

6.6

9.3

22

17

Target 17.2

Baseline 19.1

Egyptian Public MHC


Average Duration (Days)/Admission to First ServiceEgyptian Public and Mental Health Center

Avg. Time Adm.-1st Sess.-FWHS

Avg. Time Adm.-1st Sess.-FWHS

40.1

46.3

61.4

36.6

42.3

37.6

29.4

24.2

19.1

29

23.3

13.4

Target 46.3

Baseline 51.4

Franklin Willamson


Average Duration (Days)/Admission to First ServiceFranklin/Williamson Human Services

Avg. Time Adm.-1st Sess.-SECC

Avg. Time Adm.-1st Sess.-SECC

24.5

23.4

27.5

23.5

41.7

37.4

40.2

29.9

42.2

32.5

32.3

33.3

Target 20.7

Baseline 23.0

Southeastern


Average Duration (Days)/Admission to First ServiceSoutheastern Illinois Counseling Centers

Avg. Time 1st to 2nd Sess.- Co1

Avg. Time 1st to 2nd Sess.- Co1

18.512.514.312.330.2

15.81331.19.919.8

18.123.541.610.820.9

14.418.711.614.614.7

18.819.523.616.323.6

22.138.3721.224.4

16.46.77.411.530.1

16.613.2101430.6

14.33.513.88.142.2

17.211.324.31522.9

13.115139.330.4

10.80159.29.7

Target 15.8

Baseline 17.6

Combined Cohort 1


Egyptian Public MHC

Franklin Willamson

Southeastern


Average Duration (Days)/First to Second ServiceTotal Cohort 1 and Individual Providers

Avg. Time 1st to 2nd Sess.- CRC

Avg. Time 1st to 2nd Sess.- CRC

12.5

13

23.5

18.7

19.5

38.3

6.7

13.2

3.5

11.3

15

0

Target 23.1

Baseline 25.7



Average Duration (Days)/First to Second ServiceCommunity Resource Center

Avg. Time 1st to 2nd Sess.- EGY

Avg. Time 1st to 2nd Sess.- EGY

14.3

31.1

41.6

11.6

23.6

7

7.4

10

13.8

24.3

13

15

Target 18.5

Baseline 20.5

Egyptian Public MHC


Average Duration (Days)/First to Second ServiceEgyptian Public and Mental Health Center

Avg. Time 1st to 2nd Sess.- FW

Avg. Time 1st to 2nd Sess.- FW

12.3

9.9

10.8

14.6

16.3

21.2

11.5

14

8.1

15

9.3

9.2

Target 12.3

Baseline 13.7

Franklin Willamson


Average Duration (Days)/First to Second ServiceFranklin/Williamson Human Services

Avg. Time 1st to 2nd Sess.-SECC

Avg. Time 1st to 2nd Sess.-SECC

30.2

19.8

20.9

14.7

23.6

24.4

30.1

30.6

42.2

22.9

30.4

9.7

Target 21.9

Baseline 24.3

Southeastern


Average Duration (Days)/First to Second ServiceSoutheastern Illinois Counseling Centers

% Clients-4 Sessions-Cohort 1

% Clients-4 Sessions-Cohort 1

0.1560.0870.41700.172

0.1760.20.3330.180.14

0.1380.120.4090.10.102

0.1480.2920.4440.0780.083

0.1020.250.240.0520.044

0.0940.1740.3330.1090.042

0.2520.1160.4440.1020.073

0.1140.1110.4440.1450.065

0.1910.30.5380.20.049

0.1470.2420.4580.160.012

0.08100.4620.0810.031

0.1070.3080.0910.1630

Baseline 8.2%

Target 7.5%

Cohort 1 Providers


Egyptian Public and MH Dept

Franklin Williamson

Southeastern

% of Clients/At Least 4 Tx Sessions/First 30 DaysTotal Cohort 1 and Individual Providers

% Clients-4 Sessions-CRC

% Clients-4 Sessions-CRC

0.087

0.2

0.12

0.292

0.25

0.174

0.116

0.111

0.3

0.242

0

0.308

Baseline 2.9%

Target 3.2%


% of Clients/At Least 4 Tx Sessions/First 30 DaysCommunity Resource Center

% Clients-4 Sessions-EPMHD

% Clients-4 Sessions-EPMHD

0.417

0.333

0.409

0.444

0.24

0.333

0.444

0.444

0.538

0.458

0.462

0.091

Baseline 29.8%

Target 32.8%

Egyptian Public and MH Dept

% of Clients/At Least 4 Tx Sessions/First 30 DaysEgyptian Public and Mental Health Center

% Clients-4 Sessions-FWHS

% Clients-4 Sessions-FWHS

0

0.18

0.1

0.078

0.052

0.109

0.102

0.145

0.2

0.16

0.081

0.163

Baseline 4.1%

Target 4.5%

Franklin Williamson

% of Clients/At Least 4 Tx Sessions/First 30 DaysFranklin/Williamson Human Services

% Clients-4 Sessions-SECC

% Clients-4 Sessions-SECC

0.172

0.14

0.102

0.083

0.044

0.042

0.073

0.065

0.049

0.012

0.031

0

Baseline 1.8%

Target 2.0%

Southeastern

% of Clients/At Least 4 Tx Sessions/First 30 DaysSoutheastern Illinois Counseling Centers

Organizational ClimateStaff members feel more involvedImprovement data engenders a sense of pridePositive change tends to breed interest in more improvementOthers???

Efficiency and ProductivityReducing no-shows increases direct service hoursBetter access can bring in more admissionsImproved continuation yields more billable servicesReduced paperwork liberates more clinical hours

Improved Efficiency

Relationships with Referral SourcesBecome more accessible to referrals Trust in the agencys quality and effectiveness tends to increaseBecome a preferred provider to referral sourcesCommunication improves and referrals increase

Staff RetentionStaff members who view themselves as vital are more likely to stayStaff whose contributions are recognized and appreciated are more likely to stayStaff who view the organization as successful in carrying out its mission are more likely to stay

Client SatisfactionClients are sensitive to good serviceClients who value the care they receive are more likely to stay in treatmentEfficient processes are more rewarding and professionalSatisfied customers stay and encourage others to stay

Impact of Satisfaction

Treatment OutcomesClients who stay longer in treatment are more likely to have better outcomesClients who have good attendance are more likely to continue and benefit from treatmentClients who participate in more treatment sessions are more likely to show measurable progress

Better Outcomes

So, by Making Changes in Service Processes You Can Improve YourFinancial bottom lineOrganizational climateRelationship with referral sourcesStaff retentionClient satisfactionTreatment outcomeOther indicators important to agency

Learning ResourcesMonthly Tutorial Conference CallsConducting a Walk-ThroughGathering Baseline DataSetting a Change ObjectiveUsing the Quick Start Road MapConducting a PDSA Change CycleSustaining Change

Monthly Tutorial Conference Call Schedule Dec 08-May 09

Learning Resources Join the ACTION Campaign:Adopting Changes to Improve Outcomes Now

www.actioncampaign.org

Action Kits for improving access, engagement, and transition between levels of care are available for download

Learning ResourcesNIATx:Network for the Improvement of Addiction Treatment

www.niatx.net

NIATx WorkbookVideos on Process ImprovementTools to help with improvement projectsCase studiesPromising practices and strategies

Contact Your Trainerswww.psattc.org

Thomas E. Freese, [email protected]

Sherry Larkins, [email protected]

Beth Rutkowski, [email protected]

Thank You for Coming!

*Unintended oversight discovered simply by talking with the providers2. Carefully select problems to solve.What is keeping the executive director awake at night? The research indicates that it is crucial to select a project that addresses a key organizational goal. If the project can help the executive director sleep better, they will actively support the project and do everything in their power to make the project a success.

What was found from the walk-thru? Problems in a process are discrepancies, or gaps, between actual and desired performance. Most staff can come together around improving services for the clients we serve.

What processes have staff identified as barriers to improved customer service? Recognizing staff needs improves buy-in, and increases the likelihood of sustainability.

What complaints have been received from referral sources? Responding to referral source concerns increases likelihood of improved relationships.

The 4th & 5th principles, Seeking change ideas outside the organization and Do Rapid-Cycle testing, are address thru the PDSA Process Improvement model.

Ask three fundamental questions:1. What are we trying to accomplish? 2. How will we know if a change is an improvement? 3. What changes can we test that may result in an improvement? This is where we engage in idea generation - use the Nominal Group technique, looking at customer suggestions, try looking outside the agency for ideas, etc.And once a promising change has been identified, rapidly use the Plan-Do-Study-Act (PDSA) cycle to turn a change idea into action:

In closing of this portion of the presentation, we want to reiterate:Use the PDSA process to: pilot test changes implement further changes spreading a change from one location or level to another, merge step into the whole process, etc. sustain changes

In closing of this portion of the presentation, we want to reiterate:Use the PDSA process to: pilot test changes implement further changes spreading a change from one location or level to another, merge step into the whole process, etc. sustain changes

The PDSA Cycle is repeated multiple times until the aim of the project is accomplished. It is repeated after a change is modified as a result of learning a better way when a change has proven itself and is being implemented when a different change is being triedThis diagram shows the PDSA Cycle being pushed up a ramp as one cycle leads to another. You learn what to do in the next cycle as a result of completing the current cycle. And these cycles are made rapidly. You are learning-by-doing. The more cycles you do, the more you learn. And the more you learn, the sooner the aim of the project is accomplished.The initial goal was to decrease the early discharge rate by 20% (from 44% to 35%). The Via Avanta Change Team was able to exceed their expectations, by decreasing the early discharge rate by 68% (from 44% to 14%).*Please provide a couple of graphs, charts or tables highlighting at least 2 provider changes. Indicate the time frame on which the illustration is based.

Documents

Improving Client Engagement and Retention in Treatment Presented by: Thomas E. Freese, Ph.D., Sherry Larkins, Ph.D., & Beth A. Rutkowski, MPH Fall 2008