David Gustafson PhD NIATx Director, University of Wisconsin-Madison Reduce Waiting & No-Shows Increase Admissions & Continuation www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation The Network for the Improvement of Addiction Treatment (NIATx): a partnership of The Center for Substance Abuse Treatment Strengthening Treatment Access and Retention and The Robert Wood Johnson Foundation Paths to Recovery www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation Also NCI’s TECC Center of Excellence in Cancer Communications Research www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation NIATx Presence www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation Key Points • M/SU Fantastic!!! • Process Improvement can speed adoption of evidence based practices • States: key to diffusing Process Improvement • Redesign should involve technology to be customer centered. www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation Between patient and caring help lies a canyon of paperwork and burdensome processes • A chronic disease where timing is everything • Poorly designed processes keep patients & staff apart • And they waste money • Processes CAN be improved! www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation Our focus: Nine Processes. • • • • • • • • • www.NIATx.net First contact Intake and assessment Transition thru levels of care Paperwork Scheduling Engagement Social supports Outreach Maximizing revenue Reduce Waiting & No-Shows Increase Admissions & Continuation Clear, precise aims Reduce Waiting Times Reduce No-Shows Increase Admissions Increase Continuation Rates www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation Five Evidence Based Principles • Help the CEO sleep • Rapid improvement • Ideas & “pressure” from outside. • Influential change leader • Understand/involve customers 16 14 12 10 8 6 4 2 0 Customer www.NIATx.net Problem Change agent Look outside Quality Reduce Waiting & No-Shows Increase Admissions & Continuation Results so Far. Waiting Times: 51% (n=37) Reduce No-Shows: 41% (n=28) Increaase admissions: 56% (n=23) Improve continuation : 39% (n=39) *Change cycle data www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation Lessons from Acadia Hospital (Mental Illness + Addiction Treatment) Lynn M. Madden, MPA, CHE Acadia Hospital Bangor, Maine www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation Open Access to IOP Clients fitting clinical profile (phone or ED) offered evaluation @ 7:30 next AM. Evaluated clients start treatment same day www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation IOP Access Results Continued growth in admissions (project implemented in March 2003) 70 67/mth 60 50 40 43/mth 30 28/mth 20 10 16/mth 0 FY02 www.NIATx.net FY03 FY04 FY05 YTD (through 5/05) Reduce Waiting & No-Shows Increase Admissions & Continuation IOP Operating Results Serve more clients & operate more efficiently $300,000 Persons Served in IOP $208,639 $225,000 1000 $150,000 800 804 600 $0 516 400 -$75,000 336 200 192 0 FY02 $75,000 -$150,000 FY03 FY04 FY05 (annualized from 5/05) -$225,000 www.NIATx.net FY02 FY03 FY04 -$139,346 -$202,611 Outpatient Substance Abuse Services Net Profit or Loss Reduce Waiting & No-Shows Increase Admissions & Continuation Physical Restraints (CMS/JCAHO) • Inpatients more complex w less restrictive care. • Too many restraints. • Rapid Response Team – Medical Dir. Clinical Sup. & RN mgr. – Meet w/in 24hrs of any mechanical restraint – Make rapid changes to treatment plan to reduce need for further restraints www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation Restraint reduction 41% Physical; 32% Mechanical 25 20 15 Before After 10 5 0 Mechanical Physicial Restraints per 1000 bed days www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation NIATx State Pilot Project States play a key role in promoting adoption of process improvements Delaware Iowa North Carolina Oklahoma Texas www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation Tx Agency Processes State processes Incentives State NIATx www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation Lessons from Oklahoma Terry Cline, PhD Oklahoma Department of Mental Health and Substance Abuse Services www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation Oklahoma Project #1 • Eliminate eligibility determination requirement for those seeking treatment • Preliminary results: – Data being collected – Anecdote: one outpatient provider reduced time from 1st contact to admission from 30+ to 3 days www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation Oklahoma Project #2 • Reduce paperwork in state treatment rules. Cut duplication in clinical documentation that evolved over many years. • Results: – Residential providers reduced admission time from 8 to 2 hours. – Outpatient providers reduced admission time from 4 to 3 hours www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation Technology Technology can improve treatment of mental illness & addiction. Electronic Medical Records are key AND . . . www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation Virtual Reality Simulations www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation Mobile Social Software (MoSoSo) www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation Smart Phones www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation Wearables: (pulse, blood pressure, sweating, etc) www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation Biofeedback www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation RFID (chip w medical record) http://www.wired.com/wired/archive/8.02/warwick.html www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation Information/decision help (chess.chsra.wisc.edu/bc) www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation Video Conferencing on a PC www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation Diagnosis & Treatment Planning www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation Computer-based Discussion Groups www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation Affective Computing • www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation Technology can help now! • Patients • Families • Treatment providers • Primary care and Emergency • Child welfare and criminal justice. www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation EMR Reminders Wearables GPS Vaccines CHESS VR training Journaling Monitor w surveys & physiology. Prepare to quit w trial quit attempts. Train SOs Increasing lifestyle imbalance & desire for gratification ID high-risk people Set up plan Remov craving causes Lower symptoms Problem knowledge couplers. EMR Video conferencing RFID Withdrawal symptoms Fear Overwhelm Anger Depressed Hopeless Remove symptoms Know warning sign Ways to avoid & cope Anti-drugs Biofeedback VR CBT MoSoSo Discussion Groups Ask Expert VR Affective computing Immediate rewards w increasing payments. Rationalize & deny Rehearse relapse Hi-risk situation Analyze the situation & options VR Decision analysis Social support. No coping response Reduced efficacy Temporal discountng Show relapse effects Break into sub-tasks See as gaining skills Stress mgmt, Relaxation training, Social norm Environment Video conf Action planning Online stress mgt Note: Smart phone will be key communication device. Initial lapse See as mistake Remind how to cope w lapse. Contract: no more Reminders Video conf Key Points • M/SU Fantastic!!! • Process Improvement can speed adoption of evidence based practices • States: key to diffusing Process Improvement • Redesign should involve technology to be customer centered. www.NIATx.net Reduce Waiting & No-Shows Increase Admissions & Continuation