Milagros — a young mother who struggled with an addiction and a physically abusive husband — remembers the phone calls she made to Entre Familia, a Boston Public Health Commission program. “Three times I called,” says Milagros. “And three times I hung up. I wanted to get back into treatment. But would they ask me all those questions again? And would I have to wait days to be admitted? I knew I needed to come back to the program, but I didn’t want to have to wait ...”

In communities across the country, individuals like Milagros finally overcome a lack of personal readiness and seek treatment (Joe et al., 1998; Ryan et al., 1995). The trigger might be threat of loss of family, a job, personal dignity, or even thoughts of suicide. When Milagros called, she was unsure how soon a bed would be available for her. Like many others, Milagros was struggling with shame at having relapsed, and was unwilling to wait for a bed. She endured her personal hardship without getting treatment, until she called Entre Familia, a member of the Network for the Improvement of Addiction Treatment (NIATx).

The need for treatment

Every year millions of Americans are in need of addiction treatment, according to the Substance Abuse and Mental Health Services Administration. In 2002, 3.3 million (approximately 16 percent) of an estimated 21 million Americans aged 12 or older received some level of treatment for substance abuse or dependence. Yet, 17.7 million individuals needing treatment were unable to access treatment (Office of Applied Studies, 2003). For some, the issue is finances, whereas for others, the issue is readiness.

The following is a significant issue highlighted in the Institute of Medicine’s (IOM) report Improving the Quality of Health Care for Mental and Substance-use Conditions: Often, the real obstacles keeping patients from treatment are the ways in which services are delivered (Institute of Medicine, 2005). Research shows that systemic and programmatic reasons controlled by the treatment facility accounted for 51 percent of the reasons clients cited for not accessing treatment (Joe et al., 1998; Ebener, 2003). “Business processes” such as complicated admission systems, poorly designed phone systems, and un-engaging reception staff created some of the barriers to treatment access.

Successful outcomes in addiction treatment

The Robert Wood Johnson Foundation (RWJF) and the Center for Substance Abuse Treatment (CSAT) created NIATx at the University of Wisconsin–Madison in 2003. The Foundation’s purpose in creating NIATx was to improve processes that influence access and retention, and as a result, enhance the effectiveness of substance abuse treatment. Through a combination of systems engineering, process improvement, and innovative uses of technology, NIATx has aims to: reduce waiting time to treatment; reduce treatment no-shows; increase admissions to treatment; and increase continuation in treatment.
Using these client-focused process improvement practices, the NIATx collaborative has succeeded in reducing wait times and no-show rates, as well as increasing admissions and continuation in treatment. Through peer networking and education to promote a client-focused culture in treatment programs, NIATx collaborative organizations have achieved dramatic results.

According to Victor Capoccia, RWJF senior program officer, the goal of NIATx “is to improve the quality of treatment services by admitting people in a timely fashion and providing quality care for an appropriate amount of time. We do that by redesigning systems that get people into a program early and allow them to stay longer, which increases the probability that recovery will occur.”

“I have been impressed with how rapidly NIATx members have demonstrated improvements in client access and retention using process improvement methods,” said Fran Cotter, Team Leader, Science to Service Programs, Center for Substance Abuse Treatment. “We are learning so much about how treatment organizations can fundamentally change how they do business when they focus on client-centered services. NIATx serves as a valuable resource to those in the field, including practitioners, treatment organizations, and payers that are interested in applying well tested, real-world tools to improve quality.”

University of Wisconsin–Madison professor David Gustafson leads the NIATx initiative.
“Between the patient and care lies a canyon of paperwork and burdensome processes that get in the way,” says Gustafson. To bridge the gap, “each member of the NIATx learning collaborative is addressing these issues with process improvement tools.”
The 39 organizations that comprise NIATx have demonstrated their ability to improve the quality of care clients receive, as well as the fiscal health of treatment agencies, by improving work processes. Within the first 18 months of the initiative, members reported improvements in each of the four project aims. Participating organizations report a 51 percent reduction in the time from first contact to the first treatment session. In addition, patient retention through four treatment sessions has increased by 39 percent.

Peer networking and education have contributed to NIATx members’ success in promoting customer-focused cultures in treatment programs. The NIATx collaborative model integrates many different strategies to facilitate the sharing of innovative ideas among members. The main components of the model are:

Learning Sessions: Change teams convene face-to-face to learn about process improvement from peers and outside experts at these twice-yearly, multi-day conferences.

Interest Circles: During these monthly teleconferences, agency change leaders discuss change-related issues and progress. Participants learn about other members’ activities, and get advice and assignments for their improvement plans.

Coaching: Experts in process improvement help an agency make, sustain, and spread process improvement efforts. Expert faculty offer coaching during site visits, monthly phone conferences, and via frequent email communications with the change teams and their executive sponsors and change leaders.

The NIATx Website: This website offers a variety of process improvement resources to NIATx members and the public. The site includes member case studies, process improvement tools, a catalog of change ideas, and an electronic communication service that facilitates contact between members.

E-News: This monthly electronic newsletter is directed to the field of substance abuse treatment. Each issue of the E-News features a story about an agency’s experience making process improvements, explains how to use a tool from the Toolbox, and announces upcoming NIATx presentations and workshops.

Process improvement strategies

NIATx members learn how to use process improvement tools to address barriers to both accessing and staying in treatment. Two fundament tools are the walk-through and rapid-cycle testing using the Plan-Do-Study-Act (PDSA) cycle.

A walk-through is an exercise in which staff members take the role of a new client and a family member and literally walk through the treatment processes in the client’s shoes. The goal is to see the agency from the client’s perspective. Taking this view of treatment services — from the first call for help, to the intake process, and through final discharge — helps NIATx members understand how the customer feels and experiences the process of treatment. Simultaneously, staff members who are involved with the process are asked to candidly report what it is like to be in their staff roles. Input from clients and those who serve them help the change teams to prioritize areas where improvements are most needed in order to better serve the customer (and consequently, the staff).

After using the walk-through to identify areas for change, the NIATx model relies on the PDSA cycle to turn an idea for change into action. Simple in structure and natural in execution, the PDSA cycle presents the natural flow of information gathering, decision-making, action, and assessment involved in a wide range of actions. Critical to its success is a series of short rapid cycles, with each cycle — from planning through implementation — taking only a couple of weeks. This allows the change team to assess quickly whether the new idea is leading them toward the intended improvement, and to make decisions about what the next steps should be. The team adopts the change only when the change cycles result in a predetermined goal for improvement beyond the baseline (e.g., reducing time from first contact to assessment, from 8 days to 2 days).

By testing changes this way, NIATx members: minimize risks and expenditures of time and money; make changes in a way that is less disruptive to clients and staff; reduce resistance to change by starting on a small scale; and learn from the ideas that work, as well as from those that do not. By starting with small changes to test ideas quickly and easily, and using simple measurements to monitor the effect of changes over time, the PDSA model can lead to larger improvements through successive quick cycles of change.
“NIATx members are developing new ideas and tools to share with the rest of the treatment field,” says NIATx director Gustafson. “And they’re also demonstrating that increasing access to and retention in treatment may be a lot simpler, less time-consuming, and less costly than it’s believed to be.”

Boston Public Health and Entre Familia

The Boston Public Health Commission traces its roots back to 1799, when Paul Revere was named the city’s first health officer. The commission offers a variety of innovative programs to meet the health care needs of Boston’s diverse population. Entre Familia is one of its many initiatives for women and families. Serving primarily African-American and Latina women, Entre Familia offers residential substance abuse treatment in a culturally tailored program.

When the Boston Public Health Commission was selected to join the NIATx collaborative, the first action was to complete a walk-through at Entre Familia. Based on the walk-through, the staff at Entre Familia identified access to treatment as a critical area needing improvement. They learned that clients typically had to wait up to five days for a return phone call and they recognized that their 45-minute phone intake process was lengthy and burdensome. After completing the phone intake, clients had to wait up to 7.5 days to be accepted for treatment.

Targeting the NIATx aim to reduce wait time between first contact to treatment, the Entre Familia change team conducted a series of PDSA rapid cycles. The team’s goal was to reduce waiting time from 7.5 days to just two days, and to reduce the phone intake time from 45 minutes to 15 minutes.

In their first rapid cycle change, the team tested strategies to return messages left on the agency’s answering machine on the same day at least 85 percent of the time, and all calls were returned within 24 hours. To accomplish this, they made it a priority to have a staff member available to answer the phone as often as possible. Different staff members covered the phone each day, checking for messages throughout the day. All calls were documented in an intake log and staff members tracked wait times and gaps in follow-up. The results of the rapid cycle PDSA were impressive: after just one month, Entre Familia staff answered 80 percent of calls on the initial call and an additional 16 percent within 24 hours.

Entre Familia’s second PDSA cycle addressed the lengthy phone intake process. The change team reviewed the intake questionnaire and realized that it included duplicate and unnecessary questions. The process was cumbersome: one staff member would conduct the phone screening and then transfer the call to someone who was trained to complete the intake. As a result, the agency often lost the opportunity to admit a client if no staff member was available to complete the intake. The change team reduced the number of questions on the form and trained staff so that anyone answering the phone could complete intake. After testing and implementing these changes, Entre Familia had reduced phone intake time by 75 percent — from 45 minutes to 12 minutes.

In subsequent rapid cycle PDSA exercises, Entre Familia tested strategies to allow staff to make admissions decisions within 24 hours of intake. A key barrier to prompt admission was the requirement that patients obtain a TB test. To eliminate this barrier, the change team made arrangements with a local hospital to expedite the TB testing; provided clients transportation to the hospital for TB testing; and arranged for a registered nurse at Entre Familia to read the TB test results within three days of testing.

The staff embraced the changes, which helped them meet Entre Familia’s mission to ensure that women have a successful treatment experience from the moment of their first phone call to treatment completion.

Maureen Fitzgerald resides in Madison, Wis., where she works as an editor for the Network for the Improvement of Addiction Treatment (NIATx.)

References
Institute of Medicine. Bridging the Gap Between Practice and Research: Forging Partnerships With Community Based Drug and Alcohol Treatment. Washington, DC: National Academy Press, 1998.
Substance Abuse and Mental Health Services Administration (SAMHSA). Changing the Conversation: Improving Substance Abuse Treatment - the National Treatment Plan Initiative. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, 2000
Garnick, Deborah W., Margaret T. Lee, Mady Chalk, David Gastfriend, Constance M. Horgan, Frank McCorry, A. Thomas McLellan, and Elizabeth Levy Merrick. “Establishing the Feasibility of Performance Measures for Alcohol and Other Drugs.” Journal of Substance Abuse Treatment 23, no. 4 (2002): 375-85.
Joe, G. W., D. D. Simpson, and K. M. Broome. “Effects of Readiness for Drug Abuse Treatment on Client Retention and Assessment of Process.” Addiction 93, no. 8 (1998): 1177.
Ebener, P., and B. Kilmer. “Linking Drug Users With Treatment: Admission Counselors Describe the Barriers.” DRU2948-PH Rand Unrestricted Draft Series 2003.
Substance Abuse and Mental Health Services Administration (SAMHSA). Changing the Conversation: Improving Substance Abuse Treatment - the National Treatment Plan Initiative. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, 2000
Garnick, Deborah W., Margaret T. Lee, Mady Chalk, David Gastfriend, Constance M. Horgan, Frank McCorry, A. Thomas McLellan, and Elizabeth Levy Merrick. “Establishing the Feasibility of Performance Measures for Alcohol and Other Drugs.” Journal of Substance Abuse Treatment 23, no. 4 (2002): 375-85.
Joe, G. W., D. D. Simpson, and K. M. Broome. “Effects of Readiness for Drug Abuse Treatment on Client Retention and Assessment of Process.” Addiction 93, no. 8 (1998): 1177.
Ebener, P., and B. Kilmer. “Linking Drug Users With Treatment: Admission Counselors Describe the Barriers.” DRU2948-PH Rand Unrestricted Draft Series 2003.
Farabee, D., C. D. Leukefeld, and L. Hays. “Accessing Drug-Abuse Treatment: Perceptions of Out-of-Treatment.” Journal of Drug Issues 28, no. 2 (1998): 381.
Carpenter, P. j., G. R. Morrow, A. C. DelGaudio, and B. A. Ritzler. “Who Keeps the First Appointment?” American Journal of Psychiatry 138, no. 1 (1981): 102-5.
Festinger, David S., R. J. Lamb, Douglas B. Marlowe, and Kimberly C. Kirby. “From Telephone to Office: Intake Attendance As a Function of Appointment Delay.” Addictive Behaviors 27, no. 1 (2002): 131-37.

This article is published in Counselor,The Magazine for Addiction Professionals, August 2006, v.7, n.4, pp.47-50.

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