1. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Washington Treatment Institute: Introduction to NIATx July 6, 2006 Reduce Waiting & No-Shows  Increase Admissions & Continuation Elizabeth Strauss, Process Improvement Coach Kay Seim, Perinatal Treatment Services Yoon Joo Han, Asian Counseling and Referral Services Tim Smith, Daybreak Network for the Improvement of Addiction Treatment

2. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Agenda Introduction to NIATx approach to Process Improvement Stories from 3 NIATx sites: –Perinatal Treatment Services –Asian Counseling and Referral Services –Daybreak Plans for WA What can you do now?

3. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Overview of NIATx The Network for the Improvement of Addiction Treatment (NIATx) is a partnership between The Center for Substance Abuse Treatment (CSAT) Strengthening Treatment Access and Retention (STAR) & The Robert Wood Johnson Foundation (RWJF) Paths to Recovery (P2R)

4. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net NIATx Collaborative - National Presence

5. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net One Central Mission To be the addiction treatment field’s leading innovator in improving organizational processes that enable individuals to maintain lasting recovery and organizations to achieve long-term viability.

6. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net NIATx Aims Reduce Waiting Times Reduce No-Shows Increase Admissions Increase Continuation Rates Access to and retention in treatment are the greatest predictors of successful recovery

7. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net NIATx Results Reduce Waiting Times: 34.8% reduction (31 organizations reporting) Reduce No-Shows: 33% reduction (27 organizations reporting) Increase Admissions: 21.5% increase (22 organizations reporting) Increase Continuation: 22.3% increase (31 organizations reporting) March 2006

8. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Five Key Principles Evidence based predictors of change  Understand & Involve the Customer  Focus on Key Problems  Select the Right Change Agent  Seek Ideas from Outside the Field/Organization  Do Rapid Cycle Testing

9. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Do Rapid Cycle Testing Start by asking 3 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) Model for Improvement Reference: Langley, Nolan, Nolan, Norman, & Provost. The Improvement Guide, San Francisco, Jossey-Bass Publishers, 1996

10. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Rapid Cycle Testing Rapid cycle changes  Are quick; small scale; do-able in 2 weeks PDSA cycles  Plan the change  Do the plan  Study the results  Act on the new knowledge ActPlan StudyDo

11. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net What makes this approach to change different? Change is a big experiment No mistakes; no right or wrong Data tells you if it was an improvement S mall scale, rapid cycles See your agency from the customer’s perspective

12. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Perinatal Treatment Services Changing Us, Changing Lives

13. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Client Profile 100% women addicted to drugs and/or alcohol 97% history of domestic violence 80% history of physical or sexual abuse in childhood 60% co-occurring disorder, mental health diagnosis

14. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Ethnic Representation Year to Date 62.9% Caucasian 12.9% African American 10.3% Hispanic 5.1% Multi-ethnic 4.3% Native American 4.3% Other

15. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Long Term Residential Treatment for Pregnant and Parenting Women

16. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Therapeutic Childcare Services On-site

17. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Goals

18. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Business Case

19. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Substance Abuse Treatment Program ACRS: Multi-service agency serving the Asian Pacific American immigrant and refugee population through an array of social service programs with 160 staff covering 30 different languages in King County, Washington Substance Abuse Service Program Bilingual/bicultural staff speaks 13 Asian languages and dialects Funding Sources: County Indigent Funding, Medicaid and Sliding Fee No- or low-income immigrants and refugees, adults and youth, with limited English Proficiency High % court-mandated with DUI or DV charges Outpatient treatment services and recovery support services

20. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net

21. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Aim Addressed: Reducing Wait Time Between 1st Request and 1st Treatment Primary priority: Reduce wait time between first request for service and first treatment session Baseline data as of 1/1/05 (average from 10/04 – 12/04) = an average of 87.7 days The goal: Reduce wait time from 87.7 days to 10 days. Each change exercise focused on a critical part of the whole process from first inquiry and first treatment session. Result: Wait time reduced from average of 87.7 days (monthly average from 10/04-12/04) to 46.5 (monthly average from 1/05-3/05) to 13.5 days (monthly average from 10/05-12/05).

22. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Change Exercises 1. Three collateral contacts in three days: Limiting attempts to gather collateral information to complete assessment paperwork to three attempts. This was implemented prior to January 2005 as the first change exercise for the grant application. 2. Returning calls in one day: when there are messages left for assessment services in screeners’ voice mail, the screeners will return calls in one day. 3. Paging system: When screeners are not available to take a call or see a walk in, all program staff will be paged to respond to a call or walk in immediately. 4. Cross train back up assessment staff in addition to regular assessment staff, to provide assessment when a client has to wait more than 5 days for assessment appointment. 5. Same day admission: Admit clients assessed on the same day for treatment by providing motivational interviewing technique and cultural education about benefits, American legal system and client choice. 6. Streamline paperwork and prioritize information needed to be gathered at the assessment/admission appointment. 7. Setting up walk in time to accommodate walk in client’s assessment services.

23. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Results for AIM

24. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Business Case In addition to the reduction in wait time, change exercises also contributed to the following: Increasing number of admissions to OP first phase from 96 (2004) to 150 (2005), a 56.25% increase. Revenue for the program increased from $254,558 (2004) to $291,587 (2005), about a15% increase.

25. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Sustainability Plans and Lessons Learned Some of the lessons learned are: When you address staff’s work capacity issues, they will feel invested in pursuing your goals and mission. Acknowledge both team success and individual contributions. Small successes backed up by data are great morale boosters. It’s useful to understand how culture both inhibits and bolsters staff participation in finding solutions. Proactively codify each solution and follow-up to ensure sustainability. Process improvement and change exercises increase revenue while benefiting the consumer.

26. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net The NIATx Impact Our program is better now because: 1.NIATx equipped us with basic process improvement techniques and the knowledge to analyze problems and implement change exercises 2.NIATx helped us create a culture which reduced fear of change, increased creative and innovative thinking, and empowered us 3.NIATx helped us to focus not only on the service process, but also on the bottom line, and 4.NIATx helped us to share and expand the knowledge with the whole agency.

27. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Daybreak Youth Services Outpatient and Inpatient treatment programs for adolescents in Spokane and Vancouver Serving about 950 teens each year Began NIATx program in Spring 2003 Change activities began in Spokane Outpatient, and then migrated to Spokane and Vancouver Inpatient programs.

28. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Example #1 Inpatient Admissions BASELINE ISSUES: 6 – 12 week wait for admission “Haphazard” flow of admissions Complaints from parents and referents Delays, cancellations, and “no show” for admit Over-reliance upon govt funding, “boom-bust” cycles Private Pay clients turned away for lack of available beds

29. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Example #1 Inpatient Admissions Step 1: “Walk through” & Flow Map Referent Daybreak Referent Daybreak Referent Daybreak

30. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Example #1 Inpatient Admissions Step 2: Measure the Timing Referent Daybreak Referent Daybreak Referent Daybreak

31. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Example #1 Inpatient Admissions Step 3: AIM = 72 hours Referent Daybreak Referent Daybreak Referent Daybreak

32. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Example #1 Inpatient Admissions Step 4: Actions & Measures Referent Daybreak Referent Daybreak Referent Daybreak

33. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Results Time to admission: 34% within 7 days 33% in 8 – 14 days Mix of Private Services: 2003 = 27% 2004 = 36% 2005 = 41%

34. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Example #2 Inpatient Continuation BASELINE ISSUES: 14% of clients were dropping out or being discharged within 7 days of admission Successful Completion rate = 60% Average Daily Occupancy = 85% Critical Incident Reports = 22 per month Staff morale LOW “Kids are running the program” Staff adopting punitive attitudes toward clients “Shape up or ship out”

35. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Example #2 Inpatient Continuation Actions / Interventions: Client Feedback Survey to rate their relations with staff and staff engagement with them. Feedback to each staff person ● Shift Debriefing Form to assess “How did I/we engage with Clients today?” Increased DBT/MET training and coaching of staff with personalized change goals and measures for each staff person Weekly meetings between tx staff and admission staff to ensure prompt and accurate pre-admission information Weekly reports from Tx Director to Exec Director and senior mgmt team.

36. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Example #2 Inpatient Continuation 9 per month22 per monthCritical Incident Reports 97%85%Average Daily Occupancy 79%60%Successful Completion 72%55%L.O.S. > 30 days 2%14%L.O.S. < 7 days Dec 05 – May 06June 05 – Nov 05

37. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Plans for Washington

38. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Used with permission from Kevin Shafer www.kevinschafer.com Picture of bear and salmon

39. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net What can you do now? Walk-through 1. Select two people from your organization to play the roles of "client" and "family member. " (Client may be blind, disabled) 2. Let the staff know in advance that you will be doing the walk-through exercise. 3. Go through the experience just as a typical client and family member would. (Start by calling your agency and asking for an appointment.) 4. Try to think and feel as a client or family member would. 5. At each step, ask the staff to tell you what changes (other than hiring new staff) would make it better for the client and what changes would make it better for the staff. 6. Finally, between the two of you (client and family member), write down a list of the needs you found and the improvements that could be made to address these needs.

40. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Promising Practices Reducing Wait Time 1.Answer phone live. 2.Reduce intake and assessment paperwork. 3.Offer assessments every day and in the evenings. 4.Use open schedules, i.e. any time a counselor is available; cross-train staff 5.Double book assessments. 6.Allow walk-in appointments.

41. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Promising Practices Reducing No-Shows 1.Address barriers to attending assessment appointment. 2.Explain what to expect at first appointment. 3.Model communication with the patient on Motivational Interviewing/Enhancement Techniques. 4.Get the patient to the first appointment quickly. 5.Make reminder calls.

42. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Promising Practices Increasing Continuation 1.Scheduling: connect patient to counselor within 24 hours of admission and make it as easy as possible for patients to continue in treatment. 2.Provide a welcoming orientation and establish clear two-way expectations; assign a peer buddy. 3.Identify patients at risk of leaving and barriers to continuing in treatment on an ongoing basis. 4.Maintain counselor resiliency.

43. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Promising Practices Increasing Continuation 5.Tailor treatment to patient’s individual circumstances and needs. 6.Along with a variety of educational and treatment activities, have FUN. 7.Offer positive reinforcements.

44. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net Promising Practices Increasing Admissions 1.Target marketing. 2.Build lasting relationships with referral organizations and measure referrals. 3.Build capacity: Develop/expand new or existing programs. 4.Reshape capacity: Reduce admission steps. 5.Reshape capacity: Reduce paperwork.

45. Reduce Waiting & No-Shows  Increase Admissions & Continuation www.NIATx.net What can you do now? Visit www.niatx.net  How to Conduct a Walk-through  Primer on Improvement  Member Stories  Promising Practices  Sign up for E-News