Improving Client Engagement and Retention in Treatment:

An Introduction

UCLA ISAP/PSATTC

LACES Training Series2008

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

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

An Example of a PI Model: The Network for the Improvement of

Addiction Treatment (NIATx)

Strategies to Improve Client Access and Engagement

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.

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

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)

The Four Aims

Increase Admissions

Reduce Waiting Times

Increase Continuation Rates

Reduce No-Shows

The Key Principles1. 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

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

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

6. What contributes to the problem?

7. What possible changes might help?

8. What is the implementation process?

9. What data will be gathered?

10.How will progress be studied?

11.What is the next step?

Rapid-Cycle Testing

Rapid-Cycle changes Are quick; do-able in 2

weeks

PDSA cycles Plan the changeDo the planStudy the resultsAct on the new

knowledge

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

Decrease in No-Shows to Outpatient ProgramOct 2004 - Dec 2005

Baseline Oct - Dec 2004 = 36%

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22.227.6

12.515.1

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Continuation

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Case Study

Mid-Columbia Center for Living

Hood River, Oregon

NIATx Member Organization

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

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%

But why was continuation so poor?

Continuation was

an obvious aim

What to do?

1. Staff wanted to try an incentive

2. How to track continuation?a. Have clients be responsible for

monitoring their participation

b. Create a tool to help clients do it

c. Old appointment cards often got confused with current ones

d. Make a 4-session appointment card

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

Results

1 2 3 4 5 6 7 8

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Percentage of Continuation

months

Continuation

Pre Change

Post Change

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

Results

1 2 3 4 5 6 7 8

Pre Change

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English Speaking Group Attendance

Pre Change

Post Change

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

Sample Ideas for Improvement from the NIATx Network

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

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

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

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

Sustaining Service Improvements

Why Sustain an Improvement?1. Improves efficiency or ease of work2. Payoffs are obvious and credible3. Adoption is easily done4. Progress can be monitored5. Staff are involved or can be trained6. Staff believe in the change7. Management supports the change8. Clinical leaders value the change9. Fits with strategic plan and culture10. Infrastructure can support the change

How to Sustain an Improvement

One key: gathering and reviewing data1. How will data continue to be collected?

2. Who will review the data?

3. How often will the review occur?

4. What will trigger action to restore the improvement?

How to Sustain an Improvement

Another key: Have a sustainability leader to…

1. Clarify staff duties and responsibilities2. Communicate progress data with staff3. Plan with staff how to restore gains if data

falls below an agreed level4. Implement actions to restore gains5. Advise management about infrastructure

changes needed to sustain the improvement

The NIATx Website

www.niatx.net

Seven Lessons Learned1. Seeing things from the client’s perspective

can be helpful2. Multiple improvements can be made in a

short period of time3. Process improvement can motivate staff

and clients – they get excited when good things happen

4. The results surpassed the initial objectives/expectations

Lessons Learned, continued

5. Simple improvements yield big dividends

6. Using data can actually be helpful7. There is a huge value to “sticking

with it” (sustaining effort and keeping communication flowing)

The NIATx PI model offers a format for learning and applying process improvement methods

through the use of a peer learning collaborative

The End…Thank you!