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

1. What are we trying to accomplish? (AIM)
2. How will we know that a change is an improvement?
   (MEASURE)
3. 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

1. Understand and involve the customer when making
   decisions about change
2. Focus on problems of most concern to and
   supported by management
3. Select an influential change leader to lead the
   process
4. Seek ideas from outside the agency
5. 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

1. Identify problem important to management
2. Target objective (measurable/specific)
3. How will you measure the change?
4. Who will be on the change team?
5. Instructions for change team

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

1. What contributes to the problem?
2. What possible changes might help?
3. What is the implementation process?
4. What data will be gathered?
5. How will progress be studied?
6. 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?

1. Improves efficiency or ease of work
2. Payoffs are obvious and credible
3. Adoption is easily done
4. Progress can be monitored
5. Staff are involved or can be trained
6. Staff believe in the change
7. Management supports the change
8. Clinical leaders value the change
9. Fits with strategic plan and culture
10. 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

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

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Lessons Learned, continued

1. Simple improvements yield big dividends
2. Using data can actually be helpful
3. 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!