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DALLAS COALITION FOR TREATMENT IMPROVEMENT A sudden rise in Heroin use among adolescents and young adults served as a call to action and inspired this treatment systems improvement project. s: Treatment Providers Homeward Bound, Inc. - Adult - Detox, Residential, and Outpatient

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DALLAS COALITION FOR TREATMENT IMPROVEMENTA sudden rise in Heroin use among adolescents and young adults served as a call to action and inspired this treatment systems improvement project.

s: Treatment Providers

Homeward Bound, Inc. - Adult - Detox, Residential, and Outpatient

Nexus Recovery Center - Adult – Residential and Outpatient Women/children Adolescent - Residential and Outpatient

Phoenix House - Adolescent - Residential and Outpatient

Dallas County Juvenile Department - Adolescent - Day Treatment

Payers & Policy Makers Other Participants

TexasDepartment of State Health Services (DSHS) Carlos Tirado, MD, UT Southwestern Medical Center

Value Options/North STAR Managed Care Program Medical Director, Nexus – MAT

Dallas County

Jane Maxwell, PhD, Local Evaluator

Center for Excellence in Drug Epidemiology, Addiction Research

Gulf Coast Addiction Technology Transfer Center, UT-Austin

summary of ebp implementation data
Summary of EBP Implementation Data

Motivational Interviewing

Over 300 clinicians attended DSHS coach supported trainings in Austin, Dallas/Ft Worth, Houston, Corpus Christi, El Paso, Lubbock, and San Antonio in 2008/2009

130 support staff in Dallas/Ft. Worth area attended DSHS supported MI 101 training in 2008

Dallas County Community College provided MI training for professionals and support staff in 2009

Advancing Recovery agencies actively implement MI in their programming

Example of Results: Phoenix House significantly reduced their AMA rate by using the MI approach

summary of ebp implementation data1
Summary of EBP Implementation Data

Medication Assisted Treatment (MAT)

  • Overcame resistance to MAT through exposure to CTN data
  • 2 Medical Directors get Suboxone waiver
  • Value Options, public payor, agreed to pay for Suboxone on a case by case basis
  • Implemented a small pilot study at Nexus that included adults and adolescents - 2008
  • Expansion at Homeward Bound for public and private pay clients – 2008 and 2009
  • Needed physicians to manage Suboxone for adolescents at Phoenix House & DCJD
eureka moments
Eureka Moments
  • Phoenix House
    • Traditional Therapeutic Community
    • Initial Skepticism about MI
    • Attended & Implemented MI Training
    • Experienced Dramatically Reduced AMA
  • The Rapid Change Process
    • It actually works, and
    • It can be applied to almost any problem or situation
most useful levers of change
Most Useful Levers of Change

Over the past four months, we have found

  • Intra-organizational Analysis
  • Inter-organizational Analysis

To be the most useful levers of change in implementing and spreading Motivational Interviewing and Medication Assisted Treatment in our collaboration

intra organizational operations at the dallas county juvenile department

Intra-Organizational Operations at the Dallas County Juvenile Department

“How Functionally Can An Organization Implement New Approaches?”

problem 1 high no show rate for day treatment for intake appointment
Problem #1: High no-show rate for Day Treatment for Intake Appointment

To find a solution the Intra-organizational Analysis was used

1) Assessed Internal Processes (Walk-through)

2) Studied Work Flow Efficiency (Statistical Analysis)

dallas county juvenile department
Dallas County Juvenile Department

To Increase Attendance at Day Treatment Intake Appointment

  • Universal intake schedule created in data base
  • Made schedule viewable by court, Probation Officer, clerks, intake personnel
  • Reminder phone calls to family and Probation Officer
  • Probation Officer reminds family at 1st appointment.


  • Increased overall attendance by an average of 25%
dallas county juvenile department rapid change project
Dallas County Juvenile Department Rapid Change Project


  • Created a secure on-line calendar on which all Day Treatment Intake appointments would be scheduled visible to all interested parties;
  • The court officer volunteered to call the family and remind them of the appointment and where to go.


  • The juvenile no-show rate at Day Treatment was reduced from 50% to 16% through this one quick change project.

Business Case– this small change:

  • Reduced probation violations and time spent processing violations;
  • Reduced Probation officer’s time in tracking down juvenile and family;
  • Reduced the Court’s time (administrative personnel in processing cases);
  • Reduced waiting time for clients as all slots were filled as they opened
  • Reduced detention population as clients were now in treatment instead of
  • In addition to time saves, actual savings is assumed to be significant
problem 2 changing the mindset of an agency building the case for mat
Problem #2: Changing the Mindset of an AgencyBuilding the Case for MAT
  • Statistics – keep it simple
  • Information
  • Relationships – Who listens to who?

Every time you talk to someone it is an opportunity to educate them on your project.

inter organizational levers of change

Inter-Organizational Levers of Change

Open communication strengthens relationships and unites state, provider, payer and regulatory agencies to achieve common goals.

inter organizational levers
Inter-organizational Levers

State – Provider – Payer Partnerships

  • Open Communication
  • Build relationships on mutual goals
  • Be inclusive – who else shares goals
  • Collect and Share accurate data
  • Base decisions on this data
  • Measure effect
  • Celebrate achievements
to implement spread and diffuse mi and mat
To Implement, Spread and Diffuse MI and MAT

From July 2009 – January 2010

Continue using

  • Inter-organizational levers – Build on partnerships
  • Intra-organizational levers – Refine processes and strengthen through continued data gathering

Focus on

  • Purchasing and Contracting – State’s RFP process
  • Financial Analysis – Study the current business model and solidify the business case for EBPs
levers to be used after 2010
Levers to be used after 2010
  • Financial Analysis – Establish a business case
  • Regulator Analysis –Implement EBPs under new state regulations including Medicaid and Texas Administrative Code
  • Intra-organizational Analysis – Adapt organization processes for funding and policy changes
  • Inter-organizational Analysis – Build new relationships and strengthen old
  • Purchasing Analysis – Find new purchasing and contracting approaches
creating and sustaining change
Creating and Sustaining Change

Purchasing Levers

State-wide RFP development is in process and will include EBP and MAT requirements

Regulatory Levers

2009 Texas Legislature approved a Medicaid benefit expansion that includes all levels of SA Treatment and Medication Access

1. Currently restricted to hospital-based detoxification for adults and out-patient counseling for adolescents

2. Buprenorphine is on Medicaid formulary – will expand office-based management opportunities

future directions
  • Watch for EBPs coming out of the CTN, especially those supported by SAMHSA and the ATTCs, in looking for solutions for treatment improvement
  • Expand MAT to include Naltrexome, Vivitrol and others
  • Continue using NIATx analysis and change techniques to continuously evaluate and modify processes for systems improvement
  • Be innovative. For example: CYT + Promotora complementing MAT in the treatment of heroin dependent Latino adolescents