Lincoln, Nebraska utilized performance improvement principles developed by the Network for

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1 Lincoln Human Services Federation NIATx Project Using NIATx Principles to Improve Addiction Treatment in a Midwestern Community March 2012 August 2012 David Prescott, Ph.D. and Jason Varga, B.S. This paper summarizes a collaborative effort in which 5 addiction treatment agencies located in Lincoln, Nebraska utilized performance improvement principles developed by the Network for Improving Addiction Treatment (NIATx) to collectively improve treatment access, retention, and patient safety. Over the relatively brief period of 6 months each agency was able to complete at least one performance improvement effort which resulted in measurable improvements. In addition to improving service delivery processes in each agency, the project served as a model for improving inter-agency learning and collaboration. The use of rapid cycle performance improvement techniques allowed both participants and funding agencies to see tangible results after only a few months. Both participants and funders found the brief time frame and straightforward measurement approach highly satisfying, particularly when compared to traditional strategies for building inter-agency collaboration. INITIAL PROJECT DEVELOPMENT The coordinating agency for this effort was the Lincoln Human Services Federation (HSF), an agency whose mission is to provide education, networking, and the facilitation of collective action for 120 non-profit human service agencies in Lincoln and Lancaster County Nebraska. In the fall of 2011, HSF solicited the participation of 5 addiction treatment agencies in Lincoln for this project. One of the 5 agencies, St. Monica s, had previously participated in a project using NIATx performance improvement principles and assisted in recruitment of agencies for this project. Each agency agreed to: Participate in a kickoff learning event; Designate a change team which included an executive sponsor and change leader; Complete at least one performance improvement project (also called a change project); 1

2 Participate in monthly learning calls; Agree to receive performance improvement coaching Pay $250 to HSF for project associated expenses. After identifying the 5 participating agencies, the interim Executive Director of HSF (Jason Varga), in collaboration with NIATx coach David Prescott, submitted funding requests for the project to three local philanthropic organizations. Total funding request was $14,728.00, which was targeted to cover coaching time including the kickoff learning event, phone coaching for 6 months, and a summation conference. All three requests were fully funded, with a total project budget of 26,998.00, including participating agencies in-kind time. The project was designed to be completed within a 6 month time frame. PARTICIPATING AGENCIES AND PERFORMANCE IMPROVEMENT AIMS Participating agencies were asked to identify a measurable aim for their initial performance improvement project (or change project). Aims were identified through an initial coaching phone call, and a subsequent agency visit with the coach. The executive sponsor and change leader were primarily responsible for identifying the agency s aim. A description of the 5 participating agencies and their performance improvement aim for the project is as follows: Houses of Hope: Houses of Hope provides residential treatment to men and women recovering from addiction. Their performance improvement aim was to reduce the amount of time between client admission and their first meeting with their primary counselor. Houses of Hope believed that reducing wait times for meeting with a counselor could improve treatment retention. Cornhusker Place: Cornhusker Place provides outpatient detoxification, short term residential treatment, and outpatient addiction counseling. Their performance improvement aim was to reduce wait times for treatment (time between first call and first face-to-face) contact by improving 2

3 communication between all staff involved in admissions. Shorter wait times were believed to increase the likelihood of an initial treatment inquiry converting to an actual admission. Lutheran Family Services of Nebraska: Lutheran Family Services of Nebraska provides behavioral health services and children s services (e.g., foster, care, adoption) in Nebraska, Iowa, and Kansas. Their Lincoln office, which participated in this project, provides outpatient and intensive outpatient addiction counseling, as well as other behavioral health and children s services. Their performance improvement aim was to increase the percentage of people calling about treatment who actually attended an intake interview. Community Mental Health Center of Lancaster County: Community Mental Health Center of Lancaster County provides an array of mental health services for adults with both acute and chronic mental health difficulties. Services include locked crisis residential services, partial hospitalization, community crisis intervention, and outpatient mental health and addiction counseling. Their performance improvement aim was to reduce the time between first telephone contact and initial intake interview for new clients. St. Monica s Behavioral Health Services for Women: St. Monica s provides behavioral health and addiction treatment for women including residential, intensive outpatient, and outpatient treatment. Through its participation in a previous project, St. Monica s was familiar with NIATx principles and had conducted a number of performance improvement projects. Their performance improvement aim was to improve patient safety by reducing medication errors in their residential treatment programs. LEARNING, TRAINING, AND AGENCY SUPPORT Agencies learned NIATx performance improvement principles and change project processes in four different ways. First, executive sponsors and change leaders from each agency attended a half day kickoff event, conducted primarily by the coach, which reviewed the basic principles of NIATx performance improvement. Second, on site coaching visits occurred with each agency within a day of the kickoff event. These visits involved meeting with the change team and refining the initial change project. Third, all group coaching calls were conducted monthly which involved a brief didactic 3

4 presentation by the coach, working out logistical details and deadlines by the coordinating agency (HSF) and brief updates from each agency. Individual coaching calls with each agency also occurred every month, focused specifically on change projects. Fourth, a summation conference at which each agency presented its work was held in month 6 of the project. As may be self-evident, the project relied heavily on principles of collaborative learning, interaction and sharing among agencies, and transparency in agency progress. Consistently high attendance at the kickoff event, at monthly all group calls, and at the summation conference provides evidence for the usefulness of this approach. DESCRIPTIONS AND OUTCOMES OF CHANGE PROJECTS Each participating agency was asked to conduct at least one change project within 6 months of the kickoff event. Agencies presented their project at the summation conference using a 5 slides in 5 minutes power point. Graphic or numeric presentation of the change project was strongly encouraged by the coach. Coaching time for each agency to develop the presentation was made available during the weeks preceding the summation conference. Each agency s change will be briefly described, along with a graphic representation of their work. 4

5 Houses of Hope: Decreasing wait times for first counselor appointment in a residential program. Clients admitted to Houses of Hope s residential treatment program are assigned a primary counselor who provides individual counseling throughout the program. Prior to the change the average wait time between client admission and the first meeting with the counselor was 3.5 days. Houses of Hope instituted an expectation that client meet with their primary counselor within 24 hours of admission, and added one step to their admissions process of scheduling a specific time for that meeting. As shown in the accompanying figure, wait times for the initial meeting was reduced from 3.5 days to 0.73 days. Anticipated resistance from staff members did not occur, and the change quickly became part of the standard expectation for newly admitted clients. 5

6 Cornhusker Place: Improved Tracking of Clients Requesting Initial Evaluation. Cornhusker Place provides emergency detoxification, residential treatment, intensive outpatient treatment, and outpatient treatment in a multi-story facility in a downtown location. Initial evaluations of potential clients often occur at another agency, with a treatment referral to Cornhusker Place made after the evaluation. However, some clients request that Cornhusker Place provide both the initial evaluation and treatment. Delays in scheduling initial client evaluations can occur due to competing priorities for staff s time and attention. To quote the executive director: Initial evaluations for us were a high priority until the next high priority came along. Many different staff members handle the triage and scheduling function for initial evaluations, depending on the time and day of the week of the initial call. Cornhusker place developed a central tracking system that could be used 24 hours a day by any staff member who might receive a call requesting an initial intake evaluation. Their goal was to increase the percentage of initial callers for service who actually received a face-to-face visit. The development and implementation of the universal tracking sheet (see below) took several weeks to design and implement. At the time of the summation conference only a few requests had been received since implementing central tracking. Change team members reported that the change had become a permanent part of their operations and that it represented significant progress. 6

7 St. Monica s Behavioral Health Center for Women: Improving Patient Safety by Reducing Medication Errors. Prior to this project St. Monica s had conducted several rapid cycle change projects focused on improving family engagement in treatment through its participation in the Center for Substance Abuse Treatment s Pregnant and Post-Partum Women s Treatment initiative. In an effort to expand the scope of its process improvement efforts St. Monica s focused on improving patient safety by reducing errors in dispensing medication for clients in residential treatment. As may be seen in the graph below, baseline data revealed a rate of 8 medication errors per month, with most of the errors having low risk of harm (e.g., late scheduled dose of psychotropic medication). St. Monica s implemented five consecutive 3-week change cycles including improved follow-up to medication error reports, abandoning the practice of using pre-set medications, decreasing distractions for staff involved in dispensing medications, and affixing medication label instructions directly to medication administration forms. With a goal of reducing medication errors by 30%, St. Monica s initially observed a significant increase in medication error reports, which appeared to be the result of increased reporting rather than an actual increase in errors. About 12 weeks after the initial change, medication error rates dropped significantly, with the final change period revealing a decrease of 75% over baseline. 7

8 Community Mental Health Center of Lancaster County: Decreasing Wait Times for Initial Evaluation: New requests for service at Community Mental Health Center of Lancaster County are made directly by prospective clients and on behalf of the prospective client from an existing service provider. Prior to the first appointment the client is mailed a set of forms requesting demographic, health, and mental health information. Clients may be scheduled for the initial intake session prior to returning the forms, but the forms must be completed before an evaluation occurs. Baseline measurement revealed an average wait time of 27.1 days between initial call and initial evaluation, with a no show rate of 48%. Staff designated for performing initial evaluations had other assigned duties (e.g., individual psychotherapy) within the organization, and time slots in their schedules are designated for evaluations through a central scheduler. The process change involved establishing an initial evaluation slot designated specifically for clients whose referral came during an acute psychiatric hospitalization, and also increasing the total number of intake evaluation slots available. Results from the change included a reduction in average wait times from initial call to initial evaluation of 8.1 days (27.1 pre-change to 19.0 post change) and a reduction in no show rate from 48% to 21%. 8

9 Lutheran Family Services: Converting Callers to Clients: Prospective clients at Lutheran Family Services typically contact the agency by phone, and they are asked to come to the agency, complete a series of questionnaires, and receive an appointment time for an intake session. At the outset of this project Lutheran Family Services had not tracked the percentage of callers who actually came to the agency to begin the intake process. Baseline data revealed that 16.6% of callers actually presented in person to complete questionnaires and receive an initial appointment. A change in procedure during the initial phone call occurred so that clients were specifically requested to come in the same or next day. When possible, the call was transferred from a receptionist to a clinical intake coordinator who told the caller that he would try to meet briefly with them when they made their initial visit to the agency. Following this change, the percentage of callers who came to the agency increased form 16.6% to 50%. Further study revealed that 80% of clients who presented to the agency in person were enrolled in treatment. 9

10 SUMMATION CONFERENCE AND NEXT STEPS Six months after the formal initiation of the project, and five months after the kickoff event, participating agencies, the coordinating agency, the coach, and representatives from with two of the three funding organizations convened a half day conference to review results and consider continuation of their work. Each agency provided a presentation which included detailed graphs or tables of change data along with a description of their change projects. Participating agencies and funders viewed the results as favorable, noting the utility of keeping simple measures to track and demonstrate progress. Participating agencies expressed a willingness to pursue a continuation of the project by soliciting additional agencies to engage in a similar 6-month process ( Round Two ). Proposed changes for Round Two projects included enlisting Round One change leaders and/or executive sponsors as coaches for Round Two agencies, soliciting agencies other than those with a primary focus on addiction services (e.g., mental health services, other social service agencies), and engaging region and state level officials as learning collaborative participants. At the formal close of this project, the Human Services Federation agreed to continue in its role as coordinator at least through the point of convening another planning meeting in the Fall of 2012 to identify goals and funding strategies for a possible Round Two. 10