Building Momentum for Process Improvement: The California Experience Presented by: Beth Rutkowski, MPH NIATx-SI Cohort 1 State Convening Meeting January 27, 2010

Presentation Overview LA County Phase I Process Improvement Pilot Project CATES Statewide Training Effort LA County Phase II Process Improvement Pilot Project CA NIATX Coach Pilot Project Local Learning Collaboratives Regional Learning Collaboratives

Key Partners UCLA Integrated Substance Abuse Programs Pacific Southwest Addiction Technology Transfer Center LA County Alcohol & Drug Program Administration NIATx National Program Office SAMHSA, Center for Substance Abuse Treatment Robert Wood Johnson Foundation County Alcohol and Drug Program Administrators Association of California

Recipe for Success

Key Ingredients Start small and demonstrate success Face-to-face learning sessions Individualized technical assistance/coaching Telephone-based technical assistance Data collection, submission, and review Availability of continuing education Change Leader Academy Coach Academy

“Where it all started…” Los Angeles County, California

Phase I Los Angeles County Process Improvement Pilot Project November 2005-September 2006

Participating Agencies Didi Hirsch CMHC, Via Avanta LA Centers for Alcohol and Drug Abuse Matrix Institute on Addictions (2) Social Model Recovery Systems Southern California Alcohol and Drug Programs Tarzana Treatment Centers

Phase I Pilot Project Timeline Nov ‘05 Orientation Jan ‘06 Kick-Off Workshop Pre-Work Nov ‘05-Jan ‘06 Feb ‘06 Site Visits Mar ‘06 Monthly Conference Calls Jun ‘06 Mid-Way Change Leader Meeting Sept ‘06 Completion Conference

Phase I Aggregate Results 83% reduction in assessment/intake no-shows (2 agencies reporting) 39% increase in 30-day continuation (3 agencies reporting).

California Addiction Training and Education Series November 2007-May 2009

**1,430 participants ***50 counties

Where Were the Trainings and How Many People Did We Train? Nov 2007 San Francisco – 154 (18) San Diego – 137 (6) Bakersfield (10) May 2008 Redding – 77 (17) Santa Ana – 145 (6) Fresno – 78 (12) July 2008 San Jose – 341 (1) Sept 2008 San Rafael - 51 (2) Oct/Nov 2008 Concord – 114 (12) Rialto – 97 (8) Yuba City – 107 (18)

Sample Agenda Case study - from an agency’s perspective Process Improvement 101 How to get started Measuring impact of change Promising practices

Monthly Coaching Conference Call Topics Month 1: Conducting a Walk-Through Month 2: Collecting Baseline Data Month 3: Establishing a Change Objective Month 4: Creating a Quick Start Road Map Month 5: Conducting a PDSA Change Cycle Month 6: Sustaining Change

Call Participation 60 hour-long conference calls held between Dec 2007 and May people from 35 counties Callers joined an average of 2-3 calls (mean=2.6) Targeted areas of participation (and implementation)

Phase II Los Angeles County Process Improvement Pilot Project November 2007-October 2008

Participating Agencies Antelope Valley Rehabilitation Center (2) Behavioral Health Services (2) CA Hispanic Commission on Alcohol and Drug Abuse (2) Didi Hirsch Community Mental Health Center (2) House of Hope MELA Counseling Services Center SHIELDS for Families Tarzana Treatment Centers (2)

Project Enhancements Formal application process Greater focus on data More comprehensive data review and feedback 5 th Change Leader monthly conference call 2 nd Executive Sponsor conference call 12 individualized data coaching calls

Wait-Time from First Contact to Admission 42% average reduction in wait-time

43% average reduction in no-shows No-Shows

19% average improvement in session-by- session attendance Session-by-Session Attendance

30-Day Continuation 6% average improvement in 30-day continuation

California NIATx Coach Pilot Project (July 2008-April 2009) Development of Local Learning Collaboratives (August Present)

Regional Learning Collaboratives – California Endowment November 2008-October 2009

Regional ACTION Campaign/NIATx Learning Collaboratives CA-based ACTION Campaign membership more than doubled from 105 individuals in 82 agencies to 300 individuals from 221 agencies. Five day-long kick-off workshops were held in April- May treatment providers/administrative staff Staff from 173 agencies/programs in 49 counties are now part of one of five collaboratives 28 agencies from 16 counties submitted a completed change project report form for one or more change projects

Adopting Changes in Addiction Treatment – Promising Practices Strategies to decrease wait-time from initial contact to intake/assessment/admission appointment Conduct group intakes 2 times per week Reduce repetitive paperwork Combine intake and assessment into one appointment Offer walk-in intakes

Wait-Time from First Contact to Assessment/Admission 89% average reduction in wait-time (2 agencies reporting)

Adopting Changes in Addiction Treatment – Promising Practices Strategies to increase timeliness of admissions Assign intakes to 2 primary counselors Make immediate contact with client upon receipt of referral and engage client Discuss the importance of enrolling on the report date so that the client does not lose interest and/or comes up with reasons not to enroll or delay enrollment Improve therapeutic and clinical milieu of Treatment Readiness Interview

Adopting Changes in Addiction Treatment – Promising Practices Strategies to increase timeliness of admissions Offer staff training to improve empathy Call to schedule intake appointment for client at the time of assessment Make reminder phone call 2-3 days prior to scheduled intake appointment

Timeliness of Admissions (hybrid of Wait-Time and Admissions) 64% average improvement in timely admissions (4 agencies reporting)

Adopting Changes in Addiction Treatment – Promising Practices Strategies to decrease no-shows to intake/ assessment appointment Schedule group intakes Implement a series of paper-and-pencil screening tools Move full ASI assessment and treatment planning process to subsequent counseling session Schedule clients to arrive 30 minutes prior to intake appointment to allow time to complete screening paperwork Streamline intake paperwork and create a single signature page to acknowledge receipt of handbook

Adopting Changes in Addiction Treatment – Promising Practices Strategies to decrease no-shows to intake/ assessment appointment Place reminder calls for individual and group session appointments Allow client to choose day/time of assessment appointment Schedule first counseling appointment within 7 days of intake Introduce client to primary counselor at time of intake Reschedule missed appointments

No-Shows 51% average reduction in no-shows (15 agencies reporting)

Adopting Changes in Addiction Treatment – Promising Practices Strategies to increase client retention Implement “contract for treatment success” Provide incentives for ongoing participation Greet and welcome new clients within the first 24 hours Provide incoming residential clients with a mentor

Client Retention – Length of Stay 9% average improvement in length of stay (1 agency reporting)

Client Retention – 30-day Continuation 11% average improvement in 30-day continuation (2 agencies reporting)

Adopting Changes in Addiction Treatment – Promising Practices Strategies to reduce early discharges Change scheduled chores for new clients by taking away kitchen responsibility for the first two months of treatment Develop PowerPoint presentation to provide consistent information at DUI program orientation Discuss early termination policy with new clients Schedule intakes in the morning to engage clients more quickly

Client Retention – Reduction of Early Discharges 66% average reduction in early discharges (2 agencies reporting)

Keys Ingredients for Change Project Success 1. Choose the right Change Leader 2. Establish a clear objective 3. Implement only 1 new change at a time 4. Make sure everyone implements change project as planned 5. Start small 6. Study the results before making modifications

Lack of executive or Change Team commitment Inexperience with process improvement tools Failure to define problem and objective clearly Difficulty creating simple measures Lack of familiarity with data graphing Failure to gather outside ideas Frequent Start-Up Issues

Discussion Points How counties have incorporated NIATx into regular meetings Cost Suggestions for involving the ATTC Network in NIATx spread and sustainability

Beth Rutkowski, MPH (310) ; Thank you for your time!