Improving Client Engagement and Retention in Treatment: An Introduction

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Improving Client Engagement and Retention in
Treatment An Introduction

• UCLA ISAP/PSATTC
• LACES Training Series
• 2008

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Overview of the Presentation

• 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

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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

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An Example of a PI Model The Network for the
Improvement of Addiction Treatment (NIATx)

• Strategies to Improve Client Access and Engagement

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What is NIATx?

• A partnership between
• RWJFs Paths to Recovery program
• CSATs 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.

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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

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Three Fundamental Questions

• What are we trying to accomplish? (AIM)
• How will we know that a change is an improvement?
  (MEASURE)
• What changes can we test that may result in an
  improvement? (CHANGE)

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The Four Aims

• Increase Admissions

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The Key Principles

• Understand and involve the customer when making
  decisions about change
• Focus on problems of most concern to and
  supported by management
• Select an influential change leader to lead the
  process
• Seek ideas from outside the agency
• Pilot test improvement ideas quickly

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1. Understand the Customer

• Most important of all the Principles
• What is it like to be a customer? Clients,
  payers, and staff are all customers
• How do you do it? Walk-through, focus groups

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How to Conduct a Walk-through

• Role play a client and family member
• Call for an appointment What happens?
• Arrive for the appointment
• How are you greeted?
• Were directions clear and accurate?
• Complete an intake process
• How long does it take?
• How redundant are the questions?
• What did you learn? What will you change?

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Value of the Walk-Through

• See services from a new perspective
• Challenge assumptions about how services are
  being delivered that may not reflect what
  actually happens
• Identify low-cost opportunities for improvement
  that can make a big difference in engaging and
  retaining clients

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2. Focus on Key Problems

• What is keeping the executive director awake at
  night?
• What processes have staff and customers
  identified as barriers to excellent service?

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3. Select a Powerful Change Leader

• Who has
• Influence, respect and authority across levels of
  the organization
• A direct line to the CEO
• Empathy for the staff
• Time available to lead change projects
• No fear of data

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4. Seek Ideas from Outside

• Provides a new way to look at the problem
• Real creativity in problem solving comes from
  looking outside the familiar

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5. Do Rapid Cycle Testing

• Start by asking 3 questions
• What are we trying to accomplish? (AIM)
• How will we know the change is an improvement?
  (MEASURE)
• What changes can we test that will result in an
  improvement? (CHANGE)
• Langley, Nolan, Nolan, Norman, Provost. The
  Improvement Guide, San Francisco, Jossey-Bass
  Publishers, 1996

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Using a Quick Start Road Map To Plan Change
Projects

• Identify problem important to management
• Target objective (measurable/specific)
• How will you measure the change?
• Who will be on the change team?
• Instructions for change team

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Using a Quick Start Road Map To Plan Change
Projects, continued

• What contributes to the problem?
• What possible changes might help?
• What is the implementation process?
• What data will be gathered?
• How will progress be studied?
• What is the next step?

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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

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How Do You Measure the Impact of Change?

• Define your measures
• Collect baseline data
• Establish a clear aim
• Consistently collect data
• Chart your progress
• Ask questions

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Case Study

• Mid-Columbia Center for Living
• Hood River, Oregon
• NIATx Member Organization

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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

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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

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Continuation was an obvious aim

• But why was continuation so poor?

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What to do?

• Staff wanted to try an incentive
• How to track continuation?
• Have clients be responsible for monitoring their
  participation
• Create a tool to help clients do it
• Old appointment cards often got confused with
  current ones
• Make a 4-session appointment card

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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

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Results
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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

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Results
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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

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Sample Ideas for Improvement from the NIATx
Network
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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

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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

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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

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Increase Admissions

• Offer outpatient orientation, pre- contemplation,
  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

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Sustaining Service Improvements
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Why Sustain an Improvement?

• Improves efficiency or ease of work
• Payoffs are obvious and credible
• Adoption is easily done
• Progress can be monitored
• Staff are involved or can be trained
• Staff believe in the change
• Management supports the change
• Clinical leaders value the change
• Fits with strategic plan and culture
• Infrastructure can support the change

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How to Sustain an Improvement

• One key gathering and reviewing data
• 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?

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How to Sustain an Improvement

• Another key Have a sustainability leader to
• Clarify staff duties and responsibilities
• Communicate progress data with staff
• Plan with staff how to restore gains if data
  falls below an agreed level
• Implement actions to restore gains
• Advise management about infrastructure changes
  needed to sustain the improvement

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The NIATx Website

• www.niatx.net

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Seven Lessons Learned

• Seeing things from the clients perspective can
  be helpful
• Multiple improvements can be made in a short
  period of time
• Process improvement can motivate staff and
  clients they get excited when good things
  happen
• The results surpassed the initial
  objectives/expectations

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Lessons Learned, continued

• Simple improvements yield big dividends
• Using data can actually be helpful
• There is a huge value to sticking with it
  (sustaining effort and keeping communication
  flowing)

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The NIATx PI model offers a format for learning
and applying process improvement methods through
the use of a peer learning collaborative
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The EndThank you!