Partnering to Improve Quality of Care in Substance Abuse Treatment

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Partnering to Improve Quality of Care in
Substance Abuse Treatment
Pat Ebener, RAND Corporation Jim Dahl, Phoenix
House Foundation
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Collaborators

• RAND
• Suzanne Wenzel, PI Maria Orlando, co-PI Donna
  Farley, Kirsten Becker
• Phoenix House
• Wallace Mandell, co-PI Leslie Damesek,
  Masami Ohashi
• Staff in 22 Phoenix House community-based adult
  and adolescent treatment programs and prisons in
  California, New York, Texas, Florida, New England

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Background on Our Partnership

• RAND and Phoenix House A 7-year partnership
• Shared objective Routinely monitor and improve
  quality of care
• Task Develop a system of linked information
  assessing structure, process, and outcomes of
  treatment that can be applied in routine practice
  settings to improve quality of care

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Study Goal and Specific Aims

• Goal Improve quality of care in the
  therapeutic community
• Phases/Aims
• Refine and gather validity evidence for client
  process instrument (DCI) across treatment
  subpopulations
• Validate refined DCI by examining factor
  structure, in-treatment change in client scores,
  and the association of scores with proximal and
  distal outcomes and with program activities and
  environment
• Examine how treatment programs use treatment
  process information within a continuous quality
  improvement (CQI) framework

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The Dimensions of Change Instrument (DCI)
1. Acceptance of Community Responsibility
Community Environment
2. Clarity and Safety in Community
3. Participation in Group Process
4. Resident Sharing, Support, and Enthusiasm
5. Introspection and Self-Management
6. Positive Self-Attitude and Commitment to
Abstinence
Personal Development and Change
7. Personal Problem Recognition
8. Maintaining External Social Network
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The DCI Measures Change Over Time for Residents
Remaining in Treatment
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Adolescent Stayers ( 254 residents) vs. Leavers (
98 residents) at 30 Days Personal Development
Change Dimensions
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All Adults (172 residents) at 270 Days
Community Environment Dimensions
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All Adults ( 341 residents) at 90 Days
Community Environment Dimensions vs. ( 139
residents) Long Island Programs
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Phase 3 Using the DCI Data in a Quality
Improvement Demonstration

• Participating programs receive information on DCI
  scores for their members from Phase 2 work
• Experimental programs prepare and carry out
  quality improvement action plans aimed at
  improving DCI scores
• Monitor implementation and assess effects of
  quality improvement actions on program outcomes
• Programs Experimental Control
• Adult 2 1
• Adolescent 2 1

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Timeline for Phase 3 Activities
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Partnering to Plan Phase 3

• Formed joint RAND-Phoenix House Planning
  Committee
• Invited candidate programs to briefing at NY
  Workshop
• Circulated monthly newsletter on status of Phase
  3 planning
• Jointly developed Workshop agenda and materials

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The Core TC Program Elements

• Morning Meetings
• House Meetings
• Seminars
• Encounter Groups
• Job Functions

• Rewards and Sanctions
• Staff Roles
• Peer Roles
• Physical Environment

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TC Program Elements and Related DCI Community
Environment Dimensions
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TC Program Elements and Related DCI Personal
Development Change Dimensions
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Crosswalk Prepared for Program Teams
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Partnering on P3 Launch Workshop

• Analyze DCI scores and assess performance of
  related program elements
• Identify barriers to successful implementation
• Develop an overall quality improvement strategy
  and specific actions
• Establish measures and a process to monitor
  progress

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Workshop Results and Preliminary Impressions

• Day 1. Group observation forms completed by PH
  Research Dept. and RAND staff found
• Most group members had moderate to mostly
  sufficient understanding of the data for informed
  discussion
• Most groups had enthusiastic participation
• Members of groups were typically not stressed by
  the tasks and felt they had sufficient time for
  discussion
• Day 2 programs all completed analysis and action
  planning process and briefed each other on their
  plans
• - 3 strategies target Encounter Groups
• - 1 targets Staff Roles

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Partnering on Next Steps Support for
Implementation Activities

• Training personnel, programs and materials
  prepared by the Phoenix House Training Center
• Guidance by RAND for monitoring methods
• Development of measures
• Data collection methods
• One-on-one phone and e-mail consultation,
  conference calls, site visits

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The Process Evaluation Learning from Experiences

• Purposes
• Learn from the programs experiences as they use
  DCI data and take actions to strengthen relevant
  program elements
• Use the process information to help interpret
  results for outcome measures
• Process evaluation components
• Monthly conference calls for progress reports
• Site visits after months 3 and 9 of Phase 3
• Mini-QIPs performed in month 6 of Phase 3

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Outcome Evaluation Outcomes To Be Monitored

• Change in DCI scores administer DCI to clients
  in experimental and control programs at two
  points in time
• Start of phase 3 (baseline)
• Month 7 of phase 3 (post-intervention)
• Change in client retention rates
• Changes in measures collected on the Phoenix
  House QIP

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Lessons From Planning and Launching the
Demonstration

• Novel and creative approach to QI
• Strong working relationship is critical
• Complex data can be overwhelming
• Simplify presentation
• Reduce volume
• Provide talking points for group facilitators
• Include researchers in facilitated break-out
  groups
• Structure the planning process
• Expect to provide ongoing technical assistance