Improving Client Engagement and Retention in Treatment: An Introduction

1. Improving Client Engagement and Retention in Treatment: An Introduction UCLA ISAP/PSATTC LACES Training Series 2008

2. 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

3. 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

4. An Example of a PI Model: The Network for the Improvement of Addiction Treatment (NIATx) Strategies to Improve Client Access and Engagement

5. What is NIATx? • A partnership between: • RWJF’s Paths to Recovery program • CSAT’s 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.

6. 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

7. 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)

8. Reduce Waiting Times Reduce No-Shows Increase Continuation Rates The Four Aims Increase Admissions

9. 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

10. 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

11. 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?

12. 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

13. 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

16. Case Study Mid-Columbia Center for Living Hood River, Oregon NIATx Member Organization

17. 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

18. 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%

19. Continuation was an obvious aim But why was continuationso poor?

20. 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

21. 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

22. Results

23. 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

24. Results

25. 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

26. Sample Ideas for Improvement from the NIATx Network

27. 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

28. 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

29. 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

30. 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

31. Sustaining Service Improvements

32. 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

33. 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?

34. 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

35. The NIATx Website www.niatx.net

41. Seven Lessons Learned • Seeing things from the client’sperspective 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

42. 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)

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

44. The End…Thank you!