Seizing the Quality Opportunity in Addiction Treatment

Victor CapocciaOpen Society Institute

NIATx University of WisconsinJames Harrison

Brandywine Counseling CenterSeptember 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 LaboratoryUniversity 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

Paths to RecoveryPaths to Recovery STARSTAR

State Pilot ProjectState Pilot ProjectSelf-Initiated MembersSelf-Initiated Members

NIATx ParticipantsNIATx Participants

STARSTAR – State Initiative– State InitiativeAdvancing RecoveryAdvancing Recovery

NIATx 200NIATx 200

39% decline in days to entry (McCarty et al, 2007)

5

10

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20A

ve

rag

e d

ay

s

03Oct 03Dec 04Feb 04Apr 04Jun 04Aug 04Oct 04Dec

Contact to 1st TxAssessment to 1st Txtrend

Retention in Care Increased(Session 1 to 2 = 18%; Session 1 to 3 = 17%; 1

to 4 = 11% ns) (McCarty, et al, 2007).

50

60

70

80

90

% o

f 1

st

Tx

03Oct 03Dec 04Feb 04Apr 04Jun 04Aug 04Oct 04Dec

Tx 2Tx 3Tx 4trend

The Network for the Improvement ofAddiction Treatment (NIATx)

Reduce Waiting & No-Shows Increase Admissions & Continuation

James HarrisonJames HarrisonOctober 2007October 2007

BRANDYWINE COUNSELING INC.BRANDYWINE COUNSELING INC.

Paths to Recovery: Treatment on Demand

NIATx AimsNIATx Aims Reduce delay: 1st request to 1st Reduce delay: 1st request to 1st TxTx

Reduce % no-shows Reduce % no-shows

Increase continuation rateIncrease continuation rate

Increase number of admissionsIncrease number of admissions

INCREASING CAPACITY TO INCREASING CAPACITY TO IMPROVEIMPROVE

Conducting a Change Conducting a Change ExerciseExercise

PDSA cycles PDSA cycles PPlan the changelan the change DDo the plano the plan SStudy the resultstudy the results AAct on the new ct on the new

knowledgeknowledge

Rapid cycle changes Rapid cycle changes Changes should be Changes should be

doable in 2 weeksdoable in 2 weeks

Conducting a Walk-throughConducting a Walk-through Play the role of a client and a client’s family Play the role of a client and a client’s family

member seeking treatment at your agencymember seeking treatment at your agency Try to think and feel as the client/family Try to think and feel as the client/family

member would, and think about what they member would, and think about what they would want changed would want changed

Ask staff what changes would make the Ask staff what changes would make the process better for clients and for staffprocess better for clients and for staff

Compile a list of client and staff needs and Compile a list of client and staff needs and possible improvements that could address possible improvements that could address these needsthese needs

How P2R Has Made Us Better

OrganizationOrganization

Wilmington, DelawareWilmington, Delaware Outpatient services for adults 18 and Outpatient services for adults 18 and

overover Seven locations including 3 Seven locations including 3

methadone clinicsmethadone clinics 1700 clients, 135 staff1700 clients, 135 staff Funding: 86% contracts, 14% client Funding: 86% contracts, 14% client

feesfees

Population ServedPopulation Served Opiate dependent Opiate dependent

individuals: 52% of our individuals: 52% of our population. (877)population. (877)

Modalities: methadone, Modalities: methadone, Revia, buprenorphineRevia, buprenorphine

Demographics: mixedDemographics: mixed 73% male73% male 53% Caucasian, 40% 53% Caucasian, 40%

African American, 8% African American, 8% HispanicHispanic

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 StartP2R Goals at the Start Increase productivity by serving Increase productivity by serving

more clients with existing fundingmore clients with existing funding Remove barriers while providing Remove barriers while providing

treatment with dignitytreatment with dignity Spread improvements throughout Spread improvements throughout

the agencythe agency Improve survival of our populationImprove survival of our population

Progress So FarProgress So Far

Change 1: Decreased wait for Change 1: Decreased wait for appointments from 4 to 2 weeksappointments from 4 to 2 weeks

Change 2: Transferred clients from Change 2: Transferred clients from intake to treatment fasterintake to treatment faster

Change 3: Increased intake Change 3: Increased intake capacity by 25%.capacity by 25%.

Change Exercise #4Change Exercise #4Aim AddressedAim Addressed

Reduce wait from first contact Reduce wait from first contact

to first unit of serviceto first unit of service

Why?Why? New clients must wait several days New clients must wait several days

after intake before receiving first doseafter intake before receiving first dose Need urinalysis results from labNeed urinalysis results from lab Orientation offered only twice a weekOrientation offered only twice a week

Changes MadeChanges Made Eliminated steps: Use instant urinesEliminated steps: Use instant urines Reconfigured process: Same day Reconfigured process: Same day

orientation using videotapeorientation using videotape

Measures UsedMeasures Used Average time from intake to first doseAverage time from intake to first dose

Working Out the BugsWorking Out the Bugs

Guest dosing clients admitted to Guest dosing clients admitted to other sitesother sites

Show video first so clients don’t Show video first so clients don’t have to wait after intake is donehave to wait after intake is done

Outreach worker shows video so Outreach worker shows video so counselors can prepare intake counselors can prepare intake paperworkpaperwork

ImpactImpact

Average Time from Intake to First DoseAverage Time from Intake to First Dose

Pre-Change: 2.3 daysPre-Change: 2.3 days

Post-Change: 0.3 daysPost-Change: 0.3 days

ImpactImpact

Same day medication

Overall Wait for First Unit of ServiceOverall Wait for First Unit of Service

Add intake slotNurses pre-screen

2. First contact to first dose

0.0

5.0

10.0

15.0

20.0

25.0

Jun-04

May-04

Apr-04

Mar-04

Feb-04

Jan-04

Dec-03

Nov-03

Oct-03

Sep-03 *

Aug-03 *

2114

8

ImpactImpact

Recently arrested for heroin possession and has Recently arrested for heroin possession and has prior conviction of 1prior conviction of 1stst degree robbery. Stated if degree robbery. Stated if he did not get into treatment, he would he did not get into treatment, he would eventually do something serious to get money eventually do something serious to get money for his addiction.for his addiction.

When he came in he was offered same day When he came in he was offered same day medication. States this was the reason he medication. States this was the reason he stayed for the intake process instead of leaving stayed for the intake process instead of leaving to get heroin.to get heroin.

GeraldGerald 8 year history of heroin 8 year history of heroin

use, has wife and 4 kidsuse, has wife and 4 kids

ImpactImpact

Now he can report he is in treatment. His same Now he can report he is in treatment. His same day admission may help him avoid day admission may help him avoid reincarceration and the risk of buying street reincarceration and the risk of buying street drugs again.drugs again.

As a result he “will take the opportunity to give As a result he “will take the opportunity to give [treatment] a good try.”[treatment] a good try.”

OrvilleOrville In last 15 years, has not been In last 15 years, has not been

out of prison longer than 6 out of prison longer than 6 months. At risk of months. At risk of reincarceration if not clean when reincarceration if not clean when reports to probation officer.reports to probation officer.

Unanticipated SuccessesUnanticipated Successes Clients receive itinerary that staff signs off Clients receive itinerary that staff signs off

on when their part of intake is completeon when their part of intake is complete Word got out on the street that same day Word got out on the street that same day

medication is availablemedication is available Videotaping orientation made us aware of Videotaping orientation made us aware of

unwritten rules.unwritten rules.

Key to SuccessKey to Success During weekly meetings, the committee During weekly meetings, the committee

evaluated and fine-tuned the change using evaluated and fine-tuned the change using PDSAPDSA

Workforce DevelopmentWorkforce DevelopmentPersonal MasteryPersonal Mastery

Individual commitment to life-long Individual commitment to life-long learning, fine tuning one personal visionlearning, fine tuning one personal vision

Skill or talent, passion Skill or talent, passion Recovery focuses on determining values Recovery focuses on determining values

and living life according to those valuesand living life according to those values Find staff talent/skill and encourage it- Find staff talent/skill and encourage it-

art, music, numbers, client focusedart, music, numbers, client focused

Shared VisionShared Vision Shared picture of the future created out of Shared picture of the future created out of

mission, goals and valuesmission, goals and values Created not dictatedCreated not dictated Changes through sharing of employees’ Changes through sharing of employees’

personal visionpersonal vision Match organization and individual’sMatch organization and individual’s Recovery “Meeting the client where they Recovery “Meeting the client where they

are”are” Different levels of staff participating in Different levels of staff participating in

program improvement decision makingprogram improvement decision making

Change Exercise #5Change Exercise #5Aim AddressedAim AddressedIncrease admissionsIncrease admissions

Changes MadeChanges Made Increase intake slots from 15 to 18 per weekIncrease intake slots from 15 to 18 per week

Measures UsedMeasures Used AdmissionsAdmissions Wait from first contact to first doseWait from first contact to first dose

ImpactImpact

Admissions at an all time highAdmissions at an all time high

Admissions

30

40

50

60

70

80

Jun-04May-04Apr-04Mar-04Feb-04Jan-04Dec-03Nov-03Oct-03Sep-03 *Aug-03 *

ImpactImpact

Average wait from first contact to Average wait from first contact to first dose at an all time lowfirst dose at an all time low

First contact to first dose

0.0

5.0

10.0

15.0

20.0

25.0

Jun-04

May-04

Apr-04

Mar-04

Feb-04

Jan-04

Dec-03

Nov-03

Oct-03

Sep-03 *

Aug-03 *

Status of the ChangesStatus of the Changes

Successful and left in place.Successful and left in place.

Future P2R GoalsFuture P2R Goals Alternative program for repeat clientsAlternative program for repeat clients Special focus on Suboxone patientsSpecial focus on Suboxone patients

ACTION CampaignACTION CampaignGoal:Goal:

The ACTION Campaign will take the knowledge gained through the work of NIATx The ACTION Campaign will take the knowledge gained through the work of NIATx and boil it down into easily adoptable practices.and boil it down into easily adoptable practices.

By spreading the knowledge in this way, we can change at least 55,000 lives!By spreading the knowledge in this way, we can change at least 55,000 lives!

ACTION Campaign3 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

• NIATxwww.niatx.net

• ACTION Campaignwww.actioncampaign.org/

• Closing the Tx Gap www.soros.org/initiatives/baltimore

• Jobs for the Futurewww.jff.org