Seizing the Quality Opportunity in Addiction Treatment

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Seizing the Quality Opportunity in Addiction
Treatment

• Victor Capoccia
• Open Society Institute
• NIATx University of Wisconsin
• James Harrison
• Brandywine Counseling Center
• September 2007

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A Simple Truth

• Treatment works when the consumer is connected
  to treatment
• treatment doesnt work when the customer is
  absent
• Victor Capoccia, 2007

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Our current reality System 1

• Our customers
• wait 1-10 weeks
• have mountains of paperwork
• standardized practices between them and care
• are discharged when they show symptoms of illness
• are replaced when they fail to come back
• are not prescribed medications that are proven to
  help

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Our current reality System 2

• Our customers
• are subject to humiliating interventions, that
  suggest we believe addiction is a moral condition
  such as searches, and peer embarrassment
• are not actively connected to related health
  services, or less intense levels of care
• We prefer customers that can be put on the
  contract over those with insurance public or
  private

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At any one time

• 110,000 waiting for assessment
• 42,000 waiting for treatment
• 32 days from first contact to treatment
• No show rates about 50
• Based on survey conducted by Survey Research
  Laboratory
• University of Illinois - Chicago March 2007

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Why does this situation exist?(Show of hands)

• Not enough resources?
• Customer resistance and readiness?
• Staff training and knowledge?
• The system we use gives us exactly what it is
  designed to produce?

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The Quality Opportunity

• The Environment is ready
• Newsweek, HBO, Time, Baltimore survey
• The Knowledge is available
• NQF, IOM Report
• The Tools are available
• NIATx, ACTION Campaign, Close the Treatment Gap

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The Work Force Issue

• Training lack of knowledge
• Career Development investment

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Baltimore Alliance for Careers in Healthcare

• Partnership Employer Learning Org WIB
  Community Agencies
• Career ladders and pathways
• HR and Ed system change
• Work based Learning
• Rewards for advancement

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NIATx The 5 Principles

• Understand and involve the customer
• Focus on key problems
• Select a powerful change leader
• Seek ideas from outside the field
• Use rapid PDSA cycles to test solutions

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NIATx Participants
Paths to Recovery
STAR
Self-Initiated Members
State Pilot Project
STAR State Initiative
Advancing Recovery
NIATx 200
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39 decline in days to entry (McCarty et al,
2007)
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Retention in Care Increased(Session 1 to 2
18 Session 1 to 3 17 1 to 4 11 ns)
(McCarty, et al, 2007).
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The Network for the Improvement of Addiction
Treatment (NIATx)
Paths to Recovery Treatment on Demand

• James Harrison
• October 2007
• BRANDYWINE COUNSELING INC.

Reduce Waiting  No-Shows ? Increase Admissions 
Continuation
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NIATx Aims
Reduce delay 1st request to 1st Tx Reduce
no-shows Increase continuation rate
Increase number of admissions INCREASING
CAPACITY TO IMPROVE
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Conducting a Change Exercise

• PDSA cycles
• Plan the change
• Do the plan
• Study the results
• Act on the new knowledge
• Rapid cycle changes
• Changes should be doable in 2 weeks

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Conducting a Walk-through

• Play the role of a client and a clients family
  member seeking treatment at your agency
• Try to think and feel as the client/family member
  would, and think about what they would want
  changed
• Ask staff what changes would make the process
  better for clients and for staff
• Compile a list of client and staff needs and
  possible improvements that could address these
  needs

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How P2R Has Made Us Better
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Organization

• Wilmington, Delaware
• Outpatient services for adults 18 and over
• Seven locations including 3 methadone clinics
• 1700 clients, 135 staff
• Funding 86 contracts, 14 client fees

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Population Served

• Opiate dependent individuals 52 of our
  population. (877)
• Modalities methadone, Revia, buprenorphine
• Demographics mixed
• 73 male
• 53 Caucasian, 40 African American, 8 Hispanic

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Row 2 James Harrison (Change Leader), Joyce
Lewis, Dr. Joe Glick, Sally Allshouse (Executive
Champion), Mark Lanyon, Lynette Latzko, Denise
Purnell. Row 1 Kevin Murphy, Basha Closic, Matt
Friedman, Laurie Dyer, Lorina Dryden, Marcia
Blancato. Not pictured Client 811, Ginny L.,
Michele Smelstoys
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P2R Goals at the Start

• Increase productivity by serving more clients
  with existing funding
• Remove barriers while providing treatment with
  dignity
• Spread improvements throughout the agency
• Improve survival of our population

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Progress So Far

• Change 1 Decreased wait for appointments from 4
  to 2 weeks
• Change 2 Transferred clients from intake to
  treatment faster
• Change 3 Increased intake capacity by 25.

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Change Exercise 4Aim Addressed

• Reduce wait from first contact
• to first unit of service
• Why?
• New clients must wait several days after intake
  before receiving first dose
• Need urinalysis results from lab
• Orientation offered only twice a week

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Changes Made

• Eliminated steps Use instant urines
• Reconfigured process Same day orientation using
  videotape
• Measures Used
• Average time from intake to first dose

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Working Out the Bugs

• Guest dosing clients admitted to other sites
• Show video first so clients dont have to wait
  after intake is done
• Outreach worker shows video so counselors can
  prepare intake paperwork

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Impact

• Average Time from Intake to First Dose
• Pre-Change 2.3 days
• Post-Change 0.3 days

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Impact
Overall Wait for First Unit of Service
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14
8
Same day medication
Add intake slot
Nurses pre-screen
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Impact

• Gerald
• 8 year history of heroin use, has wife and 4 kids

• Recently arrested for heroin possession and has
  prior conviction of 1st degree robbery. Stated if
  he did not get into treatment, he would
  eventually do something serious to get money for
  his addiction.
• When he came in he was offered same day
  medication. States this was the reason he stayed
  for the intake process instead of leaving to get
  heroin.

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Impact

• Orville
• In last 15 years, has not been out of prison
  longer than 6 months. At risk of reincarceration
  if not clean when reports to probation officer.

• Now he can report he is in treatment. His same
  day admission may help him avoid reincarceration
  and the risk of buying street drugs again.
• As a result he will take the opportunity to give
  treatment a good try.

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Unanticipated Successes

• Clients receive itinerary that staff signs off on
  when their part of intake is complete
• Word got out on the street that same day
  medication is available
• Videotaping orientation made us aware of
  unwritten rules.
• Key to Success
• During weekly meetings, the committee evaluated
  and fine-tuned the change using PDSA

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Workforce DevelopmentPersonal Mastery

• Individual commitment to life-long learning, fine
  tuning one personal vision
• Skill or talent, passion
• Recovery focuses on determining values and living
  life according to those values
• Find staff talent/skill and encourage it- art,
  music, numbers, client focused

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Shared Vision

• Shared picture of the future created out of
  mission, goals and values
• Created not dictated
• Changes through sharing of employees personal
  vision
• Match organization and individuals
• Recovery Meeting the client where they are
• Different levels of staff participating in
  program improvement decision making

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Change Exercise 5Aim Addressed

• Increase admissions
• Changes Made
• Increase intake slots from 15 to 18 per week
• Measures Used
• Admissions
• Wait from first contact to first dose

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Impact

• Admissions at an all time high

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Impact

• Average wait from first contact to first dose at
  an all time low

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Status of the Changes

• Successful and left in place.
  ?
• Future P2R Goals
• Alternative program for repeat clients
• Special focus on Suboxone patients
• ACTION Campaign
• Goal
• The ACTION Campaign will take the knowledge
  gained through the work of NIATx and boil it down
  into easily adoptable practices.
• By spreading the knowledge in this way, we can
  change at least 55,000 lives!

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ACTION Campaign

• 3 Themes
• Providing rapid access to services
• Improving client engagement, participation,
  retention in treatment
• Creating a seamless transition between levels of
  care

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Rapid Access to Services

• Engage people the first time you talk with them
  on the phone or in person
• Accelerate intake through same-day service
• Offer express check-in, expanded hours, and group
  orientation sessions
• Make sure people seeking help can reach you easily

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Improve Client Engagement

• Greet clients warmly to make them feel welcome
• Involve clients in setting goals and planning for
  long-term recovery
• Use confirmation systems that keep clients coming
  back
• Celebrate counselor success at retaining clients

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Create a Seamless Transition between Levels of
Care

• Establish personal connections for internal and
  external referrals
• Reduce paperwork to make it easier for clients to
  take the next steps
• Introduce clients to ongoing recovery supports
  before they leave your facility
• Assess the quality of the transfer, hand-off, or
  referral

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What about resources?Closing the Treatment Gap

• Assure sufficient resources and capacity
• High quality treatment for drugs and alcohol
• Available to all who need it

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Strategies

• Financing
• Efficiency
• Informed by advocacy

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Recap

• People who are in treatment get better
• Our system makes it difficult to get into and
  stay in treatment
• We have a unique time in history to change that
  environment, knowledge, tools
• Lets use these tools BACH, NIATx, ACTION
  Campaign, Close the Gap

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More Info

• NIATx
• www.niatx.net
• ACTION Campaign
• www.actioncampaign.org/
• Closing the Tx Gap www.soros.org/initiatives/balti
  more
• Jobs for the Future
• www.jff.org