Reducing Wait Time Improves Treatment Access, Retention

Reducing Wait Time Improves Treatment Access, Retention (Part 1) Seeking help for a substance abuse problem can be one of the most difficult decisions people ever make. Whether they’re motivated by a frustrated spouse, a legal problem, or simply a desire to change their lives, their resolve can often be shaky. Just about anything can become an excuse to break an appointment or even drop out of treatment altogether. Now SAMHSA’s Center for Substance Abuse Treatment (CSAT) is helping states and treatment providers get rid of overwhelming intake forms, long waits for appointments, and other barriers to efficient services. Launched in 2006, the 3-year Strengthening Treatment Access and Retention–State Implementation (STAR-SI) program promotes the use of an approach pioneered in the business world—“continuous quality improvement”—to get people into outpatient treatment and keep them there until they’re better. The grantees include state agencies in Florida, Illinois, Iowa, Maine, Ohio, South Carolina, and Wisconsin. In addition, three other state agencies have joined STAR-SI. Montana is funded through the Single State Agency, and Oklahoma and New York are funded by the Robert Wood Johnson Foundation. “The STAR-SI initiative is based on the idea that small changes can bring big rewards,” said SAMHSA Administrator Terry L. Cline, Ph.D. “You identify a problem, test a solution, and move on to the next problem. It’s an incremental approach that can have a huge impact.” Back to Top A “Rapid-Cycle” Process The STAR-SI program builds on findings from the Network for the Improvement of Addiction Treatment (NIATx), a joint initiative of CSAT and the Robert Wood Johnson Foundation (see What Is NIATx?). That original NIATx initiative began in 2003 to help grantees set an agenda for improving addiction services and adopting evidence-based treatment practices. A 3-year pilot project, it included CSAT’s Strengthening Treatment Access and Retention (STAR) program, launched in 13 states, and the Robert Wood Johnson counterparts. (See SAMHSA News online, fall 2003.) In that effort, grantees successfully increased client access and retention by making simple changes. These changes included everything from streamlining intake procedures and eliminating unnecessary paperwork to extending clinic hours and using incentives and “motivational interviewing” to engage clients during the early phases of treatment. “When treatment providers make these small changes in the ‘process’ of delivering care, they can substantially improve outcomes,” said CSAT Director H. Westley Clark, M.D., J.D., M.P.H. “Treatment providers are powerful agents of improvement and organizational change.” STAR-SI grantees now use the same model developed by their predecessors. “We demonstrated the use of this quality improvement technology in treatment settings. But we wanted to move from the treatment level to the state level,” said Frances Cotter, M.P.H., Quality Improvement Team Lead in CSAT’s Division of Services Improvement. Called process improvement, the incremental approach championed by NIATx consists of identifying a problem, setting a goal for improvement, pilot-testing possible solutions, and analyzing the outcome. Once one change has proven successful, the organization—whether it’s an entire state agency or an individual treatment facility—quickly moves on to the next area that needs improvement. The changes typically cost little or nothing and are put into effect just 3 or 4 weeks after a problem has been identified. “We encourage people to make small, simple changes quickly,” said NIATx Deputy Director Todd Molfenter, Ph.D. “Even if you’re trying to lose weight or making other changes in your personal life, you rarely get things right the first time. You have to try different things and see how they work. That’s what this process encourages.” Back to Top Back to Graphic Version Reducing Wait Time Improves Treatment Access, Retention (Part 2) Walk-Throughs To identify problems, the agencies involved in STAR-SI start the process with a walk-through. (See STAR-SI in Action: South Carolina.) Putting themselves in the shoes of clients and family members, staff experience the process of intake and engagement from the other side of the table. What they discover can be startling. It may take way too long to get an initial appointment. There may be an overwhelming number of forms to fill out. The lobby may be unwelcoming and unappealing. Any of these factors may derail potential clients on their track toward their first treatment session. Simple changes can help ensure that doesn’t happen. Based on findings from the walk-through, a “change team” identifies a problem, brainstorms a solution, puts it into effect on a small scale, evaluates its impact, and tweaks things if necessary. The solution may entail allowing walk-ins, calling clients the day before their appointments, relocating intake interviews to a more private space, or simply giving the lobby walls a fresh coat of paint. Dramatic Results One key characteristic of the NIATx model is its basis in data. Instead of making changes based on gut feelings, participants collect baseline data and then rigorously evaluate the impact of proposed changes. During the original NIATx initiative, CSAT’s STAR grantees and their Robert Wood Johnson counterparts proved that the model substantially increased clients’ access and retention. At the end of the original grants cycle, the 39 founding members (including the STAR program) reported the following results: Waiting time between clients’ first request for help and their first treatment session dropped by nearly 35 percent. The number of no-shows for appointments dropped by 33 percent. Grantees reported a 21-percent increase in admissions to treatment. Grantees saw an increase of more than 22 percent in treatment continuation. The STAR-SI grantees hope to achieve similar results. They are tracking the number of treatment providers participating in STAR-SI, the number of clients admitted to treatment, the length of time clients stay in treatment, and the number of treatment sessions provided between intake and discharge. In addition, the grantees will collect data on at least two state-specific measures. Back to Top Collaborative Learning One strategy for achieving STAR-SI’s goals is peer-to-peer learning. Grantees and participating treatment agencies share success stories, ask for advice, and offer feedback to other STAR-SI participants both within their states and across the Nation. Grantees also benefit from coaching from NIATx consultants and peer mentors. When states or agencies find a change to be successful, they put it into effect across their entire organization. States are gradually increasing the number of agencies engaged in the effort. And CSAT is exploring the idea of expanding the effort to other phases of outpatient treatment. “STAR-SI is currently applying process improvement methods to improving access and engagement, which is usually defined as the first 30 days of treatment,” said Ms. Cotter. “Our future plans are to examine the effect of these methods at the next phase of treatment, which involves hand-offs from one level of care to another or from the criminal justice system to community-based treatment.” For more information about SAMHSA’s Strengthening Treatment Access and Retention grant program and other substance abuse prevention and treatment programs, visit SAMHSA’s Web site atwww.samhsa.gov. Back to Top Back to Graphic Version