Initial Engagement, Retention, and Continuation in Treatment
I think we can all agree that we cannot treat individuals who are not in treatment to be treated! Therefore, initially engaging patients and retaining them in treatment is a priority. Those points in time during which we can make a difference in engagement or retention of patients are prior to admission, at admission, and during treatment.
Prior to Admission
Remember that people seeking help for substance or mental health treatment are likely to be angry, frightened, and plagued with indecision. The way the phones are answered and the way potential patients are greeted sets up the relationship between them and the treatment center. How is the phone answered? Do the people who answer the phones convey warmth and caring? What does the reception area look like? Is it warm and welcoming, or are walls plastered with rules, regulations, and warnings (e.g., “No weapons, no drugs or alcohol, no cursing”)? Are there refreshments available? Reading material? How would you feel sitting in your own reception area?
The more the number of days between initial call and assessment, and between assessment to first appointment, 50 percent of the patients will not show up for treatment (Redko, Rapp, & Carlson, 2006). When there is difficulty getting individuals to show up at the assessment site, schedule clinicians at a site at which the individuals who feel stigmatized might show up for assessment. For example, in a situation in which it became clear that African Americans living nearby would not go to the hospital for assessment, we placed a clinician in local churches one-half day per week. The motivational interviewing (MI) admonition to “meet the patient where the patient is” has broader applicability than merely emotional (Miller & Rollnick, 2012).
At Intake and Admission
Add time slots for intake and admission that are most convenient, which may require a change in schedule. Add assessment times on Fridays for patients to receive appointments in the same week they requested help. Schedule for applicants’ convenience, not the staff’s. Ask about barriers to continued treatment such as lack of childcare, conflicting appointments (e.g., with criminal justice workers), work schedules or transportation. This latter might require thinking outside the box. In one situation, an IOP was having difficulty with attendance for local patients who had no cars and would have to walk to the agency in the dead of winter. The solution was to negotiate a standard, discounted taxi rate for patients based on volume for the taxi company. When the hospital CFO objected, it was pointed out to him that the cost of cab fare somewhat reduced revenue, but without that expense there would be no revenue at all. For those patients who have public transportation available, provide printed schedules and offer tokens.
The absence of childcare in outpatient treatment is a major barrier to both admission and continuation in treatment (Brown, Vartivarian, & Alderks, 2011). What can the program do about an unmet need for childcare? For starters, programs can welcome and congratulate patients for coming, even the mandated ones. When mandated patients claim they had no choice, let them know that they did have a choice and they chose a responsible behavior. Use motivational incentives like contingency management: offer a small gift-card to a fast food restaurant, or bus tokens for attendance or positive urine drug screen results.
What is your goal during intake? Is it a lengthy session devoted to gathering information at the expense of developing rapport and trying to engage patients? What parts of the initial information gathering can be moved downstream?
Pair up new patients with positive senior patients as “buddies.” Show you care by following up on missed appointments, investigating reasons for the lack of attendance and trying to resolve the situation. If patients stop attending, do not send postcards, particularly those which threaten discharge if they do not begin attending again—those patients may have already discharged themselves! Use motivational enhancement strategies. Patients already in treatment for a while may need a different conversation than new patients.
The overall percentage of patients who drop out of outpatient mental health treatment is 22 percent, and of those who did not return, the percentage who discontinued after the first or second appointment is 70 percent (Olfson et al., 2009). The major reason given for not returning was dissatisfaction with their counselor.
One way to reduce against medical advice (AMA) dropouts and no-shows in outpatient treatment is to avoid Friday admissions (NiaTx, 2009). For all levels of care, track AMA discharges. Look at the following factors:
- Day of the week and time of the day (shift) of admission
- Drug of choice
- Co-occurring disorders
- Source of payment or reimbursement
- Any required insurance copayments
- Source of referral
- Number of previous treatments
- Previous AMAs
- Point in time of AMA in previous treatment
- Recovery environment issues (ASAM Criteria, Dimension 6)
- Level of craving
- Service needs at admission
- Primary counselor
After a period of information collection, analyze and create a risk rating grid to identify high AMA-risk patients at admission.
Use decisional balancing exercises. We know from learning theory that behavior does not continue unless it is rewarded (Skinner, 1974). That means that there are positive reinforcements to active addiction and negative reinforcements when considering abstinence and/or recovery. These can only be dealt with by making them known. Do not make the mistake of criticizing patients who talk about the positive aspect of their substance use (e.g., “You’re just romanticizing your addiction”), but use it as an opportunity to explore situations or beliefs that may lead to poor treatment outcome. For example, when a patient who was only comfortable finding women for sex in bars was admonished, “If you want to stay dry, don’t go where it’s wet,” he concluded that he had only two choices: to be sober and celibate or frequent bars and have a sex life.
Finally, have all staff adopt a customer service orientation to the patients. Remember, if you view the people that you treat as “clients,” they need you; if as “consumers,” you have something that they need; but if as “customers,” you need them. How you view the people you treat has a great deal to do with customer service, and good customer service is associated with treatment retention.
Brown, J. D., Vartivarian, S., & Alderks, C. E. (2011). Child care in outpatient substance abuse treatment facilities for women: Findings from the 2008 National Survey of substance Abuse Treatment Services. The Journal of Behavioral Health Services & Research, 38(4), 478–87.
Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping people change (3rd ed.). New York, NY: Guilford Press.
NiatTx. (2009). Promising practices. Retrieved from https://www.niatx.net/toolkits/provider/PP_PromisingPractices.pdf
Olfson, M., Mojtabai, R., Sampson, N. A., Hwang, I., Druss, B., Wang, P. S., . . . Kessler, R. C. (2009). Dropout from outpatient mental health care in the United States. Psychiatric Services, 60(7), 898–907.
Redko, C., Rapp, R. C., & Carlson, R. G. (2006). Waiting time as a barrier to treatment entry: Perceptions of substance users. Journal of Drug Issues, 36(4), 831–52.
Skinner, B. F. (1974). About behaviorism. New York, NY: Vintage Books.