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Using Process Improvement to Build the Foundation
for the Implementation of Evidence-Based
Practices Contingency Management and
Motivational InterviewingSusan Brandau, CASAC,
NYS OASASSusanBrandau_at_oasas.state.ny.usPatricia
Hincken, LCSW,CASAC,CPP Dir., Long Beach Med.
Ctr. Alcohol and Substance Abuse
Servicesphincken_at_LBMC.orgKarisa Endelmann,
CASAC-T, CM Interventionist, South Oaks Hospital,
Long Island Homekendelmann_at_South-Oaks.orgJuly
30, 2009NIATx/SAAS SummitFunded by NIDA 1R21
DA 019772-01 and RWJF STAR-SI
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Initial Study Aims
NIDA Study on Implementation of CM within 3
Opioid Treatment Programs (2005-2007)

• Aim 1 Assess and Evaluate SSA role in the
  transfer of CM intervention into real-world
  clinical practice w/in 3 Opioid Tx programs
• AIM 2 Evaluate the utility of the state
  developed Practice Adoption Protocol (PAP)
• AIM 3 Explore approaches to monitoring the
  adoption of EBPs
• H1-H6 The application of Backers 6 strategies
  to the adoption process will enhance the
  likelihood that the EBP will be adopted

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Definition
Contingency Management

• Contingency Management, also known as
  Motivational Incentives, is a behavioral
  modification intervention
• Targets client behaviors, such as abstinence
  attendance in treatment
• Requires frequent monitoring to verify client
  targeted behavior
• Provides tangible reinforcers immediately
  whenever client demonstrates targeted behavior
• Provides escalation of clients ability to earn
  reinforcers
• Withhold reinforcer or reset if targeted behavior
  does not occur

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Backers Framework4 Fundamental Conditions

• Dissemination
• Evaluation
• Resources
• Human Dynamics of Change

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6 Key Strategies

• Interpersonal Contact
• Planning and Conceptual Foresight
• Outside Consultation on the Change Process
• User-Oriented Transformation of Information
• Individual Organizational Championship
• Potential User Involvement

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First Round Findings

• Two of the three opioid tx programs implemented
  CM, but the states role was labor intensive, no
  sustainability Tx as usual approach needed
• Backers strategies, particularly use of outside
  consultant w/in a learning collaborative, were
  effective
• PAP necessary, but not sufficient for states
  ongoing management-each program had a readiness
  phase that was not integrated into original PAP
• Absence of program Executive staff
  implementation team (infrastructure) inhibited
  sustainability
• Organizational capacity use of data to track
  progress critical

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Second Round STAR-SI OP Providers (2008-9)

• Characteristics
• All had developed mastery of NIATx process
  improvement
• Internal capacity infrastructure to support
  rapid cycle change projects
• Core implementation teams (ES,CL,DC,CM
  interventionist)
• Proficient with data collection interpretation
• Ready to move from focus on access to retention
• Tx as usual approach-no IRB
• Reinforcement of attendance in Tx, not abstinence

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Study Differences

• Retained
• Idea champions
• Outside consultant-Dr. Petry
• Weekly conference calls
• Client tracking logs
• Modified
• Demonstrated readiness/capacity
• Identified CM clinician and back-up
• Data driven management-STAR-QI
• Integration as a NIATx change project
• Full change team participation on weekly calls
• Use of CM binders for record keeping
• Use of comparison group for outcome analysis

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States Role

• Provided support for new CM manual Name in the
  hat technique
• Contracted with each provider 950. awarded to
  purchase reinforcements
• Arranged for training by Dr. Petry
• Feedback on provider written implementation plans
• Set-up weekly conference calls to review tracking
  logs, provide feedback
• Provide STAR-QI web-based data module assist
  with data interpretation, dev. Of business case

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Tracking Log
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Results

• Five out of six providers implemented the CM
  intervention with relative ease
• Three completed three rounds!!
• Two are in their initial 12-week round
• Documented increases in client group attendance
  ranging from 12.5 to 42

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Long Beach Medical Center

• The Road to Evidence- Based Practices

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Beginning

• 2005 FACTS Director attends ASAP Conference on
  Niatx. National Project and statewide Conference
  Call introduced.
• Staff participates in call and instructions for a
  Walk-Thru were discussed.
• Staff members walk through treatment process.
  Goal see agency from the customer perspective.

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Findings

• Appointment scheduling was confusing
• Poor communication between staff and clients
  resulting in double bookings
• Clients wait time between calling agency and
  first appointment needed reduction.

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Goal Reduce to 10 cancelled or broken intake

• Scheduling Process Changed
• Scheduling Process now requires daily updates to
  avoid confusion.
• Initial sessions prioritized if double booking
  takes place.

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Challenges which impacted continuation

• Data collection confusing
• Time constraints
• Staff Resistance

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Another Opportunity

• 2007 Opportunity to join OASAS Star-SI Project
  for Long Island Programs.
• Accepted to participate.
• Staff trained in data collection and use of Star
  QI.
• Baseline data collected in Fall 2007
• Initial change team, team leader, and executive
  sponsor selected.

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All Important Support

• Learning Collaborative
• Dr Z came to agency to explain Star-SI and train
  staff in techniques
• Fishbone and brain storming techniques were
  highlighted
• Telephone conference calls

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Beginning of cultural change

• Staff introduced (through NIATX support) to
  concept of evidence-based programs
• Staff begins to understand value of knowing what
  works and what doesnt
• Staff participates in initiative by monitoring
  change cycles
• Staff participated in brainstorming and
  fishbone activities

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First Project

• Goal Reduce no-shows for initial session
• Project Staff agreed to call persons scheduled
  for initial appointment introduce themselves
  ask about their experiences, if they have any
  questions, concerns re treatment

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Other Projects

• Started an Orientation Group
• Client Satisfaction surveyed at 30, 60 and 90
  days
• Front Office Scripting
• Clinical Supervisor participated in 3-day Train
  the Trainer on Motivational Interviewing
• 6 1 ½ hour training sessions held for clinical
  staff in Motivational Interviewing conducted by
  Clinical Supervisor at agency

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Contingency Management

• OASAS announced Star-SI training in Contingency
  Management by Dr. Petry
• FACTS hosted training as well as sent staff for
  training
• Change Team Leader selected to go to training as
  well as 2 other staff members not previously part
  of Star-SI change team.

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Selected CM Project

• Alcohol and Chemical Dependency Education Group
• Data from current group assessed
• CM group run for the 12 week session with 3 staff
  members following CM protocol

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Support Bi-monthly meeting with other CM groups
by OASAS and Dr Petry

• Problem solve
• Monitor progress
• Address problems in implementation
• Share ideas
• Assist with logistics/paperwork

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Results

• The number of visits increased from 94 to 146 (
  52)
• The average attendance increased by 18
• Individual consistency increased by 14
• Revenue increased by 3640.
• Intangibles ( staff morale, excitement of doing
  something new, recognition)

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Challenges

• Staff time/staff resistance to perceived
  interference with group process
• Shopping, running group, keeping data
• Getting new staff involved (adolescent group)
• Getting buy in from administration through
  development of a business plan
• Sustainability

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Unanticipated outcome

• ACDE Group Leader felt CM took too much time
  from group educational time, BUT
• Evaluations of the group were much more positive
  for the educational component than in prior group
  evaluations.

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New Project CM with the Adolescent Group

• Outgrowth of Conference Call by OASAS on
  challenges and issues with adolescent treatment
• Experts in field concurred that CM ideally suited
  for this population
• Adolescent Counselor on conference call
• Star-SI team support idea of implementing CM with
  Adolescent Group

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Results

• CM improved attendance with adolescents
• More youth willing to sign up for the group
• Once involved, youth attendance more consistent

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Sustainability for Contingency Management

• Staff time given for preparation, shopping,
  record keeping
• Other staff encouraged to look at own groups and
  do contingency management as a pilot
• Build contingency management into education
  series and adolescent group on an ongoing basis

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Leadership Challenges

• Find staff time for brainstorming, training, with
  goal of maintaining staff interest
• Collect relevant data and
• Present data in manner that is significant and
  meaningful to clinical staff to insure buy-in for
  EBP
• Involving all staff in different projects to
  institutionalize the change process

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Culture Change

• Discussing process improvement with other
  programs increases staff knowledge of other
  initiatives
• Staff becomes open to changing status quo
• Staff individual professional growth becomes tied
  to learning more about EBP

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On the Horizon

• More EBP
• Round 3 CM
• MET/CBT
• GAIN
• Motivational Interviewing
• Concurrent Documentation
• Continue staff rotation on Star Si

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MI Implementation Monitoring

• Extent and possibility discussed with Outpatient
  Methadone Maintenance Clinics.
• Agreed to a ten- week program
• Five two- hour training sessions followed by a
  week for application discussion evaluation of
  progress during clinical supervision.
• Training sessions were interactive and practical
  rather than in lecture format.
• Continuing post- course discussion during
  clinical supervision.
• Course laid a foundation for staff who attended
  other training that applied MI in the training.
• Results About 106 training hours and 53
  supervisory were devoted to the project.

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MI Course Outline

• Spirit of MI
• Application, Evaluation and supervision.
• Change Talk and Sustain Talk
• Application, Evaluation and supervision.
• Eliciting and strengthening Change Talk
• Application, Evaluation and supervision.
• Rolling with Resistance Sustain Talk
• -- Application, Evaluation and supervision.
• Developing a Change Plan Consolidating
  Commitment. Blending with other approaches.
• -- Application, Evaluation and supervision.
• Clinical Supervisory support and organizational
  integration ongoing.

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Contact Information

• Patricia Hincken, LCSW, CASAC
• Director, Alcohol Substance Abuse Services
• Long Beach Medical Center
• 455 East Bay Drive
• Long Beach, New York 11561
• Phone [phone] fax [phone]
• Email phincken_at_lbmc.org

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South Oaks Hospital-Joined 2007

• STAR-SI Change Team
• Ken Corbin Director of Adult Services
• Yvonne Andrade Clinical Supervisor
• Cindy Robinson Intake Specialist
• James Jordan Intensive Outpatient Counselor
• Diane Sinram Outpatient Counselor
• Sue Scruggs Data Coordinator
• Karisa Endelmann - Outpatient Counselor /
  Contingency Management Counselor

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Why We Became Part of STAR-SI

• Reduce waiting time
• Reduce no shows
• Increase Admissions
• Increase retention in program

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Change Team Meetings

• Since December of 2007 the change team met on a
  weekly basis to create new changes and review
  changes already implemented
• In addition the change team had a conference
  call with Mat Roosa STAR-SI Mentor to review
  changes made to program and outcomes.
• In June 2009 after becoming familiar with the
  process and due to an increase in our census we
  changed our weekly meetings to bi-monthly

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Implementation of Contingency Management

• Aug 2008 - Implementation of Contingency
  Management to increase attendance and retention
  of patients

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Target Population

• Patients beginning treatment who are eligible for
  Phase 1 Outpatient Discussion group
• Eligibility was determined upon intake
• Up to 15 participants
• 12 week study

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CM Model Used

• Contingency Management for group attendance using
  the name-in-hat-prize based procedure, developed
  by Dr. Nancy Petry

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The Contingency Management Process

• Each time patient attends group they earn a slip
  with their name on it which then gets placed in a
  hat
• Based on the number of patients who attend group
  the counselor then picks half the amount of slips
  
• Example 10 group attendees 5 name picks from
  the hat

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• Patients whose slips were picked from hat, then
  get to draw from a fishbowl
• Fishbowl contains 69 small, 20 medium, 10
  large, and 1 Jumbo
• Small (1.00)
• Medium (5.00)
• Large (20.00)
• Jumbo (100.00)

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Understand and Involve the PatientSurvey of
Desired Prizes

• Small - lotion, toothbrush, socks, granola bars,
  combs, pens, etc.
• Medium disposable cameras, batteries, coffee
  gift cards, etc.
• Large movie theater tickets, watches, Subway
  gift cards, Applebee gift cards, coffeemaker
• Jumbo microwave, pot and pan set

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Contingency Management Round 1

• CM Round 1 began on 8/27/08
• Closed group unable to compare to similar group
  
• We were able to compare overall retention in
  treatment with those patients who started
  treatment at the same time with the CM
  participants
• 71 of CM participants were active, 29 were not
• Compared to non-CM participants, 64 active 36
  were not
• Based on Round 1s information there was an
  increase of 7 in treatment retention of CM
  participants

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Contingency Management Round 2

• CM Round 2 began on 12/3/08
• Open group
• Compared to another Phase 1 group same time
  different day facilitated by the same counselor
• Findings showed the average attendance rates were
  the same
• We did find an increase in overall retention for
  the CM patients compared to non-cm patients

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Contingency Management Round 3

• CM Round 3 began on 4/1/09
• Open group
• Group findings were compared to another Phase 1
  group that was not facilitated by the CM
  counselor, and again average attendance rates
  were the same
• The CM group compared to those starting treatment
  at the same time, showed that CM participants had
  a 57 increase in treatment retention

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Findings

• CM Round 2 Patients Non-CM Patients
• Total Patients 9 Total Patients 32
• Active 1 Active 2
• Non -Active 8 Non -Active 30
• Active 11 Active 6
• Non Active 89 Non Active 94
• CM Round 3 Patients Non-CM Patients
• Total Patients 11 Total Patients 30
• Active 9 Active 6
• Non -Active 2 Non -Active 24
• Active 82 Active 25
• Non Active 18 Non Active 80

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Disadvantages of Contingency Management

• Time consuming
• Must have exceptional organizational skills to
  facilitate CM
• If CM counselor is unavailable the covering group
  counselor must be fully trained in Contingency
  Management

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Advantages of Contingency Management

• Positive reinforcement for participants
• Positive group cohesiveness
• Participants learned timeliness skills
• Support of bi-weekly phone calls
• Increase in treatment retention
• Increase in finances to the program

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Motivational Interviewing

• Another evidence based practice we have
  implemented is Motivational Interviewing
• Half of the staff in the adult service area have
  been trained
• Motivational interviewing techniques have been
  applied in the Outpatient program during the
  intake process and during individual sessions

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Motivational Interviewing

• We will begin to track and monitor this process
  using tape recorders to track use of OARS
• Open ended questions
• Affirmations
• Reflective listening
• Summaries

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Impact of STAR-SI on Outpatient

• Three major developments impacted from the
  changes include
• An average increase of 15 of intake show rate,
  (2007-57, 2008-62 and 2009-72)
• An increase in retention in treatment based on
  data collected from CM
• An 8 increase of intakes coming from our
  inpatient unit

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Impact of Star-SI on the Agency

• Due to successful outcomes the Outpatient Unit
  experienced using the NIATx model our director
  decided to implement use of this model throughout
  all our other adult service areas including
• Inpatient Detox
• Inpatient Rehab
• Inpatient Psychiatric
• Partial Psychiatric Day Program
• Prevention Program

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Plans Moving Forward

• Another round of CM will take place with an
  outpatient group and possibly to other areas of
  the program
• Orientation/Welcoming group
• Complete Staff training in Motivational
  Interviewing