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The South Side Clinic – An Operations Management Analysis. Richards, Michael, M.Div., L.P.C.C., Rafelson, William, Nabi, Emara, M.S., M.B.B.S., Kingson, Aaron, Nguyen, Mai, M.S., M.D.  The Heller School for Social Policy and Management.  Brandeis University. [email protected] SERVICE CONCEPT

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The south side clinic an operations management analysis
The South Side Clinic – An Operations Management Analysis

Richards, Michael, M.Div., L.P.C.C., Rafelson, William, Nabi, Emara, M.S., M.B.B.S., Kingson, Aaron, Nguyen, Mai, M.S., M.D. 

The Heller School for Social Policy and Management.  Brandeis University. [email protected]


SERVICE CONCEPT

  • Target Customer: Dually-diagnosed, physician- and hospital-referred patients

  • Out-patient dual-diagnosis addiction clinic

  • Treats only hospital PCP’s and affiliated providers patients

  • Complete range of outpatient clinical substance abuse services offered:

    • Assessment and evaluation, intensive outpatient group therapy, individual therapy, medication management, provider training and consultation

  • Programs customized according to the needs of the individual patient


SERVICE CONCEPT

  • Full-service dual-diagnosis addiction clinic

  • Clinical Director attends quality meeting every month with hospital quality committee

  • Patient satisfaction surveys

  • As a part of NIATx protocol, quality improvement committee aiming to reduce wait time to zero (process quality)

  • Supervision of clinical staff

  • Training of staff three times a year

  • Efficiency measured in terms of productivity for psychologists, social workers


Service Delivery System

Facility:

  • Capacity: 10 consultation rooms, each has one health worker.

  • Separate from main hospital building

  • Warm and welcoming servicescape atmosphere

  • Recently renovated

  • Recipient of internal hospital awards

  • No handicap access

  • No room for expansion

  • Clinicians’ room equipped with panic buttons

  • Old building that has replacement plans


Service Delivery System

Staff:

  • Psychiatrists, psychologists, social workers, a case manager, and a nurse

  • Medical director and clinical director supervise clinic

    IT:

  • IDX system and Microsoft Outlook used for scheduling appointments

    • Possibility for better integration

  • Telephone used to schedule appointments

    Patients:

  • Dual-diagnosis mental illness/substance abuse treatment


Work process
Work Process

1: Phone or walk-in:

2: Case manager: Assessments (6-10 per week)

Primary, critical quality-related bottleneck

3: Counselors: 6-7 Social workers, 30 hrs. of clinical time scheduled. But with no-show’s, probably less. Secondary Bottleneck

3’: Referral to hospital primary care physician

3’’: Intensive group outpatients program (Run by one psychologist and social workers)

4: Psychiatrists : patients are diagnosed and treated according to consultations and progress. (Two full-time and two part-time psychiatrists)


Work process referral through entry into treatment
Work process: Referral through entry into treatment

3’

Relapse

Discharge back to PCP

Referral back to PCP

WT: 3 weeks

1

3

4

5

2

Assessment

Discharge to Maintenance Care Program

3’’

WT: 2 weeks WT: 2 weeks WT variable

Walk-in or callSocial workers or Psychiatrists

Psychologist2-3 patients/hour

1-2 patients/hour

Total Wait Time (WT) to Medication = up to 7 weeks

Intensive Outpatient Group


Work process1
Work process

  • AR: 35 patients/day (range: 15-60)

  • Output rate (Assessments): 6-10 per week

  • Output rate (Ongoing patients): 33-34 patients per day average (Highly variable)

  • Highly customized

  • Clinic is downstream in supply chain from hospital, PCP services

    Two staged throughput:

    Throughput includes intake and assessment (4-7 weeks), and treatment (6 weeks to 2+ years)


Work process2
Work Process

  • Referral and registration

  • Assessment

  • Approval

  • Assignment to Providers

  • Treatment

    • Intensive Outpatient Group (IOP)

    • Individual treatment

    • Family treatment

    • Medication

  • Measurement and Assessment

    • Customer Satisfaction

    • Other critical metrics? (e.g., PCP reports, readmit data, etc.)

  • Follow Up

    • Maintenance Care

    • PCP Follow-up

    • Long-term care (e.g., self-help group, “after-care” session, etc.)


Work process assessment
Work Process: Assessment

  • Current wait for assessment is 3 weeks

  • 6 to 10 Assessments per week

    • Only one “no-show” per week, on average

    • 1 hour long

    • Patients arrive 15 minutes early for registration

  • All patients have to call in on Tuesdays to reconfirm appointments

  • Evaluated for “readiness” by Medical Director

  • Most new patients “ready” for treatment

  • Customer co-production: registration, cooperation


Work process approval and assignment
Work Process:Approval and Assignment

Approval:

  • Medical director has to approve all new patients, wait time is one week

    Assignment:

  • After Ax, wait to see clinician, Pt then referred to medical appointment also if necessary

  • Ax to 1st appt, 3 weeks, depending on clinicians schedule

  • 2 week wait for IOP

  • Psychiatrists see 75-85% of patients seen by clinicians for medication

  • Medical director does therapy with a few patients

  • Recently, the entire process was several months long

    • It has since been reduced to 4-7 weeks


Work process treatment supply
Work Process: Treatment Supply

  • First approval by Medical director

  • Therapy with social worker, psychologist

  • Psychologists are part-time and have own practices, on productivity pay model

  • Social workers are salaried, 6 hrs clinical time a day, most are 9-5 and get productivity reports

  • 6-7 social workers (2 assigned IP)

  • Arrivals on the hour

  • 1 hour appointments, ½ hr for short-term, 1 hr for family

  • Medication appointments are 20 min, (2-3 per hr.) by Medical director, fellow and 2 part-time doctors


Work process treatment demand
Work Process: Treatment Demand

  • Fridays are slowest

  • Wednesdays and Thursdays are busiest

  • 15-60 patients per day

  • 35 average per day

  • No shows 20%, higher for new arrivals

  • Third no-show, meet with clinical director

  • One psychologist charges $15 for no-show, donates revenue to charity

    • Research actually suggests that “carrot” is better than “stick”  Positive reinforcement (e.g., pt’s favorite candy) is a better incentive for patients to attend than negative reinforcement (e.g., a fine)

    • Negative reinforcement could exacerbate no-show behavior


Work process intensive outpatient iop
Work Process: Intensive Outpatient (IOP)

  • IOP 12 people in group, 1 ½, ½ hr with psychologist

  • For more serious cases than individual therapy alone

  • 3x per week, 9AM-12PM

  • One evening slot, Tuesday at 6pm

  • Step down from IOP:

    • Relapse prevention program

    • 1 hr for 2-8wks

  • Programmed patients also receive individual counseling

  • Our findings: IOP can eliminate / crash the line by immediately accepting newcomers to the WEC


Quality
Quality

  • Patient satisfaction survey: Graduates of program

  • More outcome quality measures are needed

  • How does the WEC define quality?

    • Clearly define critical measurements, indicators for success and quality

  • Weekly staff meeting

  • Starting to implement NIATx protocols

  • Move to evidence-based best practices

  • Quality change team: baseline measurement, length of intake

  • SOS-10 every 13 weeks, formal tool for clinicians

    • Make these results available for analysis

    • Need to be integrated with quality program, shared with PCPs

  • Supervision

  • Quality meeting

  • Change team is collecting data for first process improvement: move to no-wait intake.


Problems with process
Problems with Process

  • Current three week wait time for assessment; up to 7 week wait for Medication. Research has shown that this is too long for substance abusers

    • Dually-diagnosed Pt’s require are even more sensitive to wait time

    • 1-week delay for approval: unnecessary for Pts

  • Calling every Tuesday before appointment: discouraging process for patients. Although it may reduce no-show rate, it raises the cancel rate. What happens to those cancelled patients “lost to follow-up?”

  • Possible lack of integration of PCPs into the process

  • Program assessment and evaluation needs to be fully integrated into Tx Model


The epidemic of substance abuse
The Epidemic of Substance Abuse

  • 22 million Americans experienced dependence or abuse in 2002. This is nearly 1 out of every 10 Americans 12 years or older.1

  • Only 4 million of the more than 20 million Americans suffering from substance dependence/abuse sought treatment in 2006.2

    • Both internal and external obstacles.

    • Of these, about 1.1 million were treated by outpatient mental health centers

  • According to the Department of Health and Human Services, about 17.7 million Americans seeking substance abuse treatment were unable to access it.3


The societal cost of substance abuse
The Societal Cost of Substance Abuse

  • Alcohol- and drug-related deaths are among the leading causes in the country, and pose a serious public health risk.1

  • 76% of illicit drug users are employed; 81% of the 43 million adult binge drinkers are employed; 80% of the 12.4 million heavy drinkers are employed.4

  • Alcohol and drug abuse costs American businesses more than $100 billion in lost productivity each year.5


The cost of waiting
The Cost of Waiting

  • Over 50% of substance abusers no-show on intake8 (National Average)

    • Reduced productivity for providers

    • Reduced access for fellow patients

    • Risk of relapse for no-show patient

  • Experimental study: 24 hour intake, versus 3 or 7 days.7

    • 24-hour intervention 4x more likely to show

  • BU Study: Comorbid psychiatric diagnoses  81% less likely to complete regimen.9





Niatx
NIATx

  • Network for the Improvement of Addiction Treatment

  • Partnership

    • Robert Wood Johnson

    • STAR

    • Addiction treatment organizations

  • 4 Goals

    • Reduce waiting time between first contact and first treatment

    • Reduce the number of no-show’s

    • Increase the capacity for those needing treatment

    • Increase retention throughout the treatment session


Plan do study act pdsa 1
Plan Do Study Act (PDSA)1

  • Plan: Identify aim of effort (e.g., reducing wait time)

  • Do: Trial run, using few clients for short period of time

  • Study: Staff looks at benefits and drawbacks of the trial

  • Act: Staff fixes trial if imperfect results, or implements it in regular practice if no significant problems



Arcadia hospital before niatx
Arcadia Hospital: Before NIATx

  • Bangor, ME Addictions Hospital

  • 4,397 outpatient substance abuse visits / year

  • Only 25% who first-contacted showed up for assessment

  • Only 19% followed up with treatment


Arcadia hospital after niatx
Arcadia Hospital: After NIATx

  • Staff told new callers to come in 7:30AM following morning; treatment would immediately follow assessment.

  • Time to first contact reduced from 4.1 to 1.3 days

  • 65% of the 225 of new callers per month showed up for appointment (compare to 25%, previously).

  • Similarly, 52% (not 19%) made it into treatment



With increased access increased revenue
With Increased Access, Increased Revenue

  • Because of the increased number of patients being seen per month, new counselor hired

  • Revenue increased by 56%

    Increased Access  Increased Utilization  Increased Productivity  Increased Revenue


Conclusion
Conclusion

  • “All health care organizations, whether providing addiction treatment or not, are faced with the challenge of finding ways to increase output and achieve better results with fixed resources. Therefore, the successes experienced by organizations in the NIATx initiative should be useful for implementing change in other fields of service delivery.”1

  • The lessons learned from NIATx are not addictions-specific: because addictions treatment holds the highest amount of risk for “loss to follow-up,” they must innovate first. The lessons learned by Arcadia and other NIATx members can be translated to many, if not all, outpatient settings.


Recommendations access capacity
Recommendations - Access / Capacity

  • One-time extra hours/staff to reduce or eliminate backlog of patients waiting for assessments. AKA “Crashing the backlog.”

    • Assuming 40 hours of clinical time per social worker, this would only require 1-2 weeks

    • Hire extra psychiatrist to eliminate bottleneck and crash the backlog of patients awaiting medication, therapy

  • On-demand staff for “anytime” assessment of walk-in patients

    • The social worker’s “no-show”/ “down” time could be converted to “anytime” hours (currently 20%+ of scheduled time)

  • Clarify policies such as standardized time from first contact to assessment to treatment (no longer than 72 hours) and quality improvement measurements

  • Reduce wait time to counseling and pharmacotherapy through consolidating assessment, medical director approval and psychiatrist visit into one visit

  • Evening hours? Research shows that patients utilize the ER when their PCPs are only available 9-5  Increase capacity:

    • Shifted availability of some, but not all, SW’s

    • Staggered schedules

    • “Flex time”

  • Immediate group therapy openings


Recommendations quality
Recommendations - Quality

  • Better tracking of efficiency of psychiatrists, psychologists, and social workers

  • Need a specific mission statement

  • To assure quality, PCPs must be integrated into the process

    • Collect outcome data from, and for, these physicians

  • More positive reinforcement for Pts to attend (e.g., favorite candy)


References
References

  • 1. Capoccia, et al. “Making ‘Stone Soup’: Improvements in Clinic Access and Retention in Addiction Treatment.” Joint Commission Journal on Quality and Patient Safety. February 2007 Volume 33 Number 2

  • 2. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Office of Applied Studies. “Results from the 2006 National Survey on Drug Use and Health: National Findings.” http://www.oas.samhsa.gov/nsduh/2k6nsduh/2k6Results.pdf

  • 3. Wisdom, et al. “Addiction Treatment Agencies’ Use of Data: A Qualitative Assessment The Journal of Behavioral Health Services & Research 33:4 October 2006

  • 4. Lowe, Cheryl. “Addiction in the Workplace.” Behavioral Health Management. September/October 2004: pp. 27-29.

  • 5. Duda, Marty. “Drug abuse’s costly toll on workers.” Behavioral Health Management: November/December 2005. pp. 49-50.

  • 6. Festinger et al., “Pretreatment Dropout as a Function of Treatment Delay and Client Variables.” Addictive Behavior, Vol. 20, No. I. pp. 111-115, 1995

  • 7. Stasiewicz, et al. “A Comparison of Three ‘Interventions’ On Pretreatment Dropout Rates In An Outpatient Substance Abuse Clinic.” Addictive Behaviors, Vol. 24, No. 4 pp. 579-582. 1999.

  • 8. Festinger, David S. “From telephone to office: Intake attendance as a function of appointment delay.” Addictive Behaviors 27 (2002) 131–137

  • 9. McCarty et al., “Improving the Care for the Treatment of Alcohol and Drug Disorders.” The Journal of Behavioral Health Services & Research 2008.

  • 10. Amodeo, et al. “Client retention in residential drug treatment for Latinos.” Evaluation and Program Planning 31 (2008) 102–112

  • 11. Berry et al., “Innovations in Acces to Care: A Patient-Centered Approach.” 7 October 2003 Annals of Internal Medicine Volume 139 • Number 7

  • 12. White et al., “A Model to Transcend the Limitations of Addiction Treatment.” Behavioral Health Recovery Management. May/June 2003: pp. 38 – 44.

  • 13. Petry et al. “Fishbowls and Candy Bars: Using Low-Cost Incentives to Increase Treatment Retention.” Science & Practice Perspectives. August 2003: pp. 55-61.

  • 14. Fitzgerald, Maureen. “Improving Substance Abuse Treatment Delivery.”


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