Universal Counseling Services Tracy Schulden, Executive Director Mid Atlantic Node

 Certified Outpatient Mental Health Clinic  Certified Outpatient Substance Abuse Treatment Program ◦ Level I OP ◦ Level II IOP

 April 2007 ◦ First Annual NIATx Summit held in San Antonio, Texas.  Energized around process improvement.  Already had a problem identified but stuck on how to resolve

 April 2007 ◦ First Annual NIATx Summit held in San Antonio, Texas.  Energized around process improvement.  Already had a problem identified but stuck on how to resolve

 Streamlined orientation paperwork Client Bill of Rights Confidentia lity Rights HIPAA Privacy Practice s HIPAA Privacy Practice s Grievan ce Policy Grievan ce Policy Client Responsibilit ies Client Responsibilit ies Dischar ge Policy Financi al Policy Financi al Policy

By my signature below, I consent to treatment at Universal Counseling Services, acknowledge receipt of this orientation packet, and understand the following policies outlined in the packet: Client Bill of Rights Financial Policy Confidentiality Rights Client Grievance Procedures Client Responsibilities Discharge Policy Notice of Privacy Practices _______________________________________________ Patient or Legally Authorized Individual Signature and Date _______________________________________________ Print Patient’s Full Name and Date ________________________________________________ UCS Witness Signature and Date By my signature below, I consent to treatment at Universal Counseling Services, acknowledge receipt of this orientation packet, and understand the following policies outlined in the packet: Client Bill of Rights Financial Policy Confidentiality Rights Client Grievance Procedures Client Responsibilities Discharge Policy Notice of Privacy Practices _______________________________________________ Patient or Legally Authorized Individual Signature and Date _______________________________________________ Print Patient’s Full Name and Date ________________________________________________ UCS Witness Signature and Date Reduced signatures required from 14 to 2

Changes Implemented  Streamlined TB, HIV/AIDS, and Hepatitis Screening TB Hepatiti s HIV/AI DS

INFECTIOUS DISEASES RISK ASSESSMENT AND EDUCATION FORM UCS is committed to providing up to date education and referral information on HIV/AIDS, Tuberculosis, and Hepatitis B and C in order: To reduce client risk of contracting HIV, Tuberculosis or Hepatitis; To encourage individual assessment of risk related behavior; To prevent the spread of infectious diseases in general; and, To ensure that individuals who have contracted an infectious disease receive the help they need. In addition to the information video, we have provided you with an information & resource packet on HIV/AIDS, Tuberculosis, and Hepatitis B and C, and other Sexually Transmitted Diseases; If you would like more information or assistance, please talk to your individual counselor. We can meet with you individually, or with you and your partner to discuss questions/ concerns regarding your risk assessment, risk reduction behaviors, or treatment and testing resource information. Please sign and date below: I have completed the informational video which focused on general HIV/AIDS, Tuberculosis, and Hepatitis risk assessment information, risk reduction behaviors and testing and treatment information. I will talk with my counselor if I want more information or assistance on this topic. _____________________________________________________________ Patient Signature Date _____________________________________________________________ UCS Staff Signature Date INFECTIOUS DISEASES RISK ASSESSMENT AND EDUCATION FORM UCS is committed to providing up to date education and referral information on HIV/AIDS, Tuberculosis, and Hepatitis B and C in order: To reduce client risk of contracting HIV, Tuberculosis or Hepatitis; To encourage individual assessment of risk related behavior; To prevent the spread of infectious diseases in general; and, To ensure that individuals who have contracted an infectious disease receive the help they need. In addition to the information video, we have provided you with an information & resource packet on HIV/AIDS, Tuberculosis, and Hepatitis B and C, and other Sexually Transmitted Diseases; If you would like more information or assistance, please talk to your individual counselor. We can meet with you individually, or with you and your partner to discuss questions/ concerns regarding your risk assessment, risk reduction behaviors, or treatment and testing resource information. Please sign and date below: I have completed the informational video which focused on general HIV/AIDS, Tuberculosis, and Hepatitis risk assessment information, risk reduction behaviors and testing and treatment information. I will talk with my counselor if I want more information or assistance on this topic. _____________________________________________________________ Patient Signature Date _____________________________________________________________ UCS Staff Signature Date Reduced signatures required from 6 to 2

 ASI-MV  Reduce time to complete intake process from 2 to 3 hours to 1 hour.  3 to 4 intakes per staff versus 6 to 7 intakes per staff a day.

 Open Access Scheduling – All calls received during the week are given an appointment for Monday.  Reduce wait time to 4.3 days (from 53.6 days)  Increased staff satisfaction.  Eliminated scheduling conflicts.  PTO, trainings, etc.

 Physician Availability by Demand  Reduced time to first medicated to 3.3 days (from 11 days)  Further reduced to =/< 48 hours.

 Staff had been exposed to other MI projects  Staff had participated in a web based study through NERI on motivational incentives  Group Selection Process

 Staff Burden ◦ What type of MI program could be implemented with minimal work added to staff.  Financial Burden ◦ New funding approach through core service agency provided a 5% bonus for meeting performance measures.

CONTINGENCY MANAGEMENT PLAN Purpose: The purpose of this policy is to establish guidelines for implementing a contingency management plan for the substance abuse treatment program. The overall goals of this plan are to increase attendance and retention of clients. Policy: UCS recognizes the importance of providing positive reinforcement for attendance, program participation and other client accomplishments as part of the treatment process. Hence, UCS’ CMP will include the use of incentives and rewards throughout the course of treatment, but will focus primarily on the first three months of program participation. During the first 90 days, clients will be provided program incentives. The incentives will be provided at first session, first individual session, and then weekly. Additionally, clients will be rewarded incrementally for their attendance and participation efforts by non-monetary recognition and support to include the use of a personalized Identification Card or Photo and Honor Board, initial welcome and periodic refreshments, Certificates of Completion, and Affirmation Cards. Purpose: The purpose of this policy is to establish guidelines for implementing a contingency management plan for the substance abuse treatment program. The overall goals of this plan are to increase attendance and retention of clients. Policy: UCS recognizes the importance of providing positive reinforcement for attendance, program participation and other client accomplishments as part of the treatment process. Hence, UCS’ CMP will include the use of incentives and rewards throughout the course of treatment, but will focus primarily on the first three months of program participation. During the first 90 days, clients will be provided program incentives. The incentives will be provided at first session, first individual session, and then weekly. Additionally, clients will be rewarded incrementally for their attendance and participation efforts by non-monetary recognition and support to include the use of a personalized Identification Card or Photo and Honor Board, initial welcome and periodic refreshments, Certificates of Completion, and Affirmation Cards.

 Staff received training on Motivational Incentives  used resources from CTN and ATTC  select staff participated in computerized incentive program study  received consultation and guidance from CTN during implementation and assistance from CTN with data collection.  Check list was used  Attendance Data from Practice Management System was compared to raffle tickets collected.

 Client Identification Card/Photo – personalized, template and supplies provided. Clients will have a choice of using their picture for the ID card or developing something meaningful to them as their ID Card. Clients would be able to make the card during first individual session with counselor or can create their card at home. A template would be provided in Welcome Packet with instructions and examples. Their original ID card would be laminated to preserve throughout Treatment and for use on Honor Board. Copies would be made however and kept in designated, secure place for use when eligible, or when a raffle prize is awarded. Staff could have the opportunity to personalize their Picture ID on UCS Welcome & Resource Info Board with a unique symbol or design, which would provide examples too.

 Fishbowl Drawing - Clients are provided incentives to attend treatment as defined on their treatment schedule on a weekly basis with a raffle ticket for entry in the Fishbowl drawing each week. Primary counselor will provide the ticket for OP clients at the time the client attends their weekly treatment (one ticket earned per week). Primary counselor will provide IOP clients a ticket each day they attend treatment (maximum of three tickets earned per week). The client will then put their name on the card and place it in the appropriate fishbowl (one for OP and one for IOP). At 4:00 p.m. each Friday, two raffle tickets will be selected from each bowl for a $25 gift card. The “winners” will be acknowledged on the Honor Board each week with a weekly affirmation/encouragement added to the Board for all.

 UCS Client Honor Board – The Honor Board will represent the “road to recovery” for clients, using the design of a mountain. Their ID cards would be moved up the mountain each month they complete treatment.

 Certificates of Completion – Clients will receive certificates of completion at the end of the intake with the ASI, the end of IOP, and the end of OP treatment.  Affirmation Cards – All clients who had raffle tickets in the fishbowl will receive a affirmation card.

Director Will purchase and maintain gift cards. Admin. Asst. Will ensure that the Honor Board design is neatly maintained. Will ensure that Welcome Packets are prepared for Intake days. Intake Day 1 Asst. Director Ensures welcome refreshments are available for intake clients. Client Completes ASI assessment and Orientation Video. Intake staff Congratulates client on completion of intake, ensures Certificate is printed and provided to the client, gives client a rubber bracelet with motivational statement.

Day 2/ First Individual Session Client Keeps their appointment with their individual counselor. Counselor Reviews ITP and clients motivation for treatment. ◦ Provides client with Welcome Packet which will include: ◦ Affirmation card ◦ Resource list ◦ Gift Card to Dunkin Donuts/Baskin Robbins ◦ Program/Schedule overview ◦ Identification Card template/ purpose & instruction handout Counselor/Client Creates personalized ID Card. Counselor will take instant photo, if needed. Copies are made. Client signs release for photo to be used on Honor Board, if applicable.

End of 1st Week Client Client attends treatment as indicated to earn raffle tickets. Counselor Acknowledges client’s achievement by rewarding client with a raffle ticket at each scheduled visit (maximum one per week for OP and three per week for IOP). Director/Designated Staff Posts ID Cards on Honor Board for First Week raffle winners and all those who have completed their first week of treatment.

Monthly Client Client attends treatment as indicated. Counselor Acknowledges client’s achievement by posting client’s ID card on the Honor Board and moves those who completed a month in treatment up the mountain. As Indicated Client Client has accomplishment (job, house, avoids a use) Counselor Acknowledges client’s achievement by placing a star sticker on the edge of the client’s ID Card on the Board with the accomplishment listed on the sticker.

CHECKLIST Client Name:_________________________ Date:_____________ INTAKE ____Front Desk welcomes client to UCS ____Welcome and congratulate client ____Give client the ASI certificate ____Implement the MI assessment Step 1: During the initial minutes of the interview the clinician uses MI skills to build rapport and elicit a discussion of the client's perception of his /her problems. Things such as greeting the client in a respectful and friendly manner, inquiring about how the client is feeling and what prompted the request for service helps establish good rapport. It is an excellent time to use open-ended questions to explore what the client wants from the agency and affirming the client’s decision and potential for change. During this initial segment of the interview the counselor gets an idea of where the client is on the stages of change continuum, what kinds of resistance may emerge, and the client’s readiness for change. Step 2: Complete the standard assessment y gathering data in the usual manner rather than trying to artificially integrate an MI style into what typically are semi-structured methods of data/information collection. When finished, the counselor can summarize the information obtained or go back to specific items to elicit further discussion, using an MI style before proceeding to Step 3. For example: "We started out meeting today talking in an open-ended way about what brought you to treatment. Now for the next 30 minutes or so we need to shift gears a little to complete some of the clinic forms that will ask for more specific information. When we are finished, we will shift back to a more open-ended discussion of what you want from treatment”. Step 3: At this point the clinician lets the client know that the next portion of the interview will shift back to a more open-ended format with the purpose being to better understand what the client wants to achieve during treatment. The counselor utilizes strategies for eliciting change or dealing with resistance in this phase. The material obtained during the standard assessment provides the counselor with ideas about questions that might be asked to establish discrepancies and enhance motivation for change.

Success at this step depends very much on the skill of the clinician. More resistant or pre- contemplative clients should be approached using techniques designed to manage and reduce resistance. More openly ambivalent or contemplative clients may benefit from a discussion of the pros and cons of continuing versus stopping substance use or discussing their level of readiness to change. More motivated (prepared, determined, ready to act) clients may benefit from the development of a formal or informal change plan. All of these techniques are discussed in the MI literature and typically receive considerable attention during MI training. It is expected that information gathered during Steps 1 and 2 will provide enough information for the MI counselor to know which of these groups of techniques should receive greater emphasis as Step 3 begins. ____Review the motivational enhancement program at UCS ____Schedule and individual for the next day with primary counselor ____Thank client for choosing UCS to assist them with their SA needs ____Give the client the wristband ____Remind the client to ask their counselor for the $5 gift card FIRST INDIVIDUAL SESSION ____Welcome the client back ____Take the client’s picture/have client select an ID Card ____Obtain a release to use picture on the HONOR BOARD ____ Give client welcome packet and gift card EACH CLIENT CONTACT ____Give client in OP a ticket when comes for weekly session (maximum 1 per week) ____Give client in IOP a ticket each day attends appointments (maximum 3 per week)

Attendence Rates pre-incentive vs. incentive

Number of days in treatment

Number of days between Admission and 1st visit

Retention Rates: Pre-Incentive vs. Incentive Period 3/15/2008-9/14/20089/15/2008-4/14/2009

How has MI been sustained over time?  See Results ◦ Data ◦ Anecdotally  Integrating MI program within daily practices of UCS ◦ Scripts ◦ Posters  Involving all the staff ◦ U/A techs ◦ Medical ◦ Mental Health ◦ Front Desk

How has MI been sustained over time?  Involving clients ◦ Feedback on design ◦ Promoting with new clients  Tied MI to business case ◦ Reduced intakes ◦ Meet/Exceed Performance Measures

Lessons Learned  Implementing and sustaining EBP requires commitment from entire agency  Involve staff/clients in the development and implementation  Keep the program simple/manageable  Develop mechanisms to collect data to measure impact.  Data needs to be reviewed frequently to be of value to staff and to motivate staff as well as to explore successes and identify effect of the implementation.