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Seizing the Quality Moment - ADAA

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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
         A Simple Truth

“Treatment works when the consumer is
  connected to treatment…
  treatment doesn’t work when the
  customer is absent……”

              Victor Capoccia, 2007
 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
 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
             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
  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?
    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
     The Work Force Issue

• Training = lack of knowledge



• Career Development = investment
 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
  NIATx: The 5 Principles
1. Understand and involve the
   customer
2. Focus on key problems
3. Select a powerful change leader
4. Seek ideas from outside the field
5. Use rapid PDSA cycles to test
   solutions
NIATx Participants
39% decline in days to entry
                                    (McCarty et al, 2007)
            20
                                                Contact to 1st Tx
                                                Assessment to 1st Tx
                                                trend


            15
 Average days




            10




                5
                    03Oct   03Dec   04Feb   04Apr   04Jun   04Aug   04Oct   04Dec
 Retention in Care Increased
(Session 1 to 2 = 18%; Session 1 to 3 = 17%; 1
      to 4 = 11% ns) (McCarty, et al, 2007).

               90
                                Tx 2
                                Tx 3
                                Tx 4
                                trend
               80
     % of 1st Tx




               70




               60




               50



                    03Oct   03Dec   04Feb   04Apr   04Jun   04Aug   04Oct   04Dec
          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
     NIATx Aims
Reduce delay: 1st request to 1st Tx
Reduce % no-shows
Increase continuation rate
Increase number of admissions
INCREASING CAPACITY TO IMPROVE
 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
      Conducting a Walk-through
   Play the role of a client and a client’s 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
How P2R Has Made Us Better
               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
            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
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
     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
          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%.
          Change Exercise #4
            Aim 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
               Changes Made
 Eliminated steps: Use instant urines
 Reconfigured process: Same day orientation
  using videotape




                 Measures Used
   Average time from intake to first dose
      Working Out the Bugs

 Guest dosing clients admitted to other
  sites
 Show video first so clients don’t have
  to wait after intake is done
 Outreach worker shows video so
  counselors can prepare intake
  paperwork
                 Impact
Average Time from Intake to First
 Dose

   Pre-Change: 2.3 days

   Post-Change: 0.3 days
                          Impact
Overall Wait for First Unit of Service

          21
                           14
                                          8




  Nurses pre-screen Add intake slot   Same day medication
                         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.
                            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.”
       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
      Workforce Development
        Personal 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
                 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 individual’s
   Recovery “Meeting the client where they are”
   Different levels of staff participating in program
    improvement decision making
           Change Exercise #5
             Aim Addressed
               Increase admissions


                Changes Made
   Increase intake slots from 15 to 18 per week
                Measures Used
 Admissions
 Wait from first contact to first dose
                                           Impact
 Admissions at an all time high


                                              Admissions


80
70
60
50
40
30
     Aug-03 * Sep-03 *   Oct-03   Nov-03   Dec-03   Jan-04   Feb-04   Mar-04   Apr-04   May-04   Jun-04
                 Impact
Average wait from first contact to first
 dose at an all time low
          Status of the Changes
   Successful and left in place.          
               Future P2R Goals
 Alternative program for repeat clients
 Special focus on Suboxone patients
        ACTION Campaign
                 3 Themes:

1. Providing rapid access to services
2. Improving client engagement, participation,
   & retention in treatment
3. Creating a seamless transition between
   levels of care
      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
  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
   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
        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
               Strategies
• Financing

• Efficiency

• Informed by advocacy
                 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
                  More Info
• NIATx
  www.niatx.net
• ACTION Campaign
  www.actioncampaign.org/
• Closing the Tx Gap
  www.soros.org/initiatives/baltimore
• Jobs for the Future
  www.jff.org

				
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