Adapting Evidence-based Treatment to Clinical Practice :

How to use Low Cost Incentives

Regional Dissemination WorkshopJune 3, 4, 2010Baltimore, MD

Workshop Agenda• Reward vs. Reinforcement• Choice/Magnitude of the Reinforcer• Target Behavior/Target Population• Different Kinds of Delivery• Fiscal Concerns• Successful Implementation Lori Peterson, Director Lane Treatment Center • Design & Implementation

Reward vs. Reinforcement

A central issue in all incentive dissemination efforts!

Kellogg, S. H., Burns, M., Coleman, P., Stitzer, M., Wale, J. B., & Kreek, M. J. (2005). Something of value: The introduction of contingency management interventions into the New York City Health and Hospital Addiction Treatment Service. Journal of Substance Abuse Treatment, 28, 57-65.

Reward vs. Reinforcement

• When drug abuse staff or leadership speak about the use of incentives, they usually talk about acknowledging patients for things like:

– Holding a job for six months– Being drug-free for 3 months– Completing a GED or vocational training

program

Reward Programs

A reward program acknowledges patients for achieving a goal or accomplishing something noteworthy:

– Most likely give rewards to the best and most motivated patients

– While often not changing the behavior of those patients who are struggling the most with drug use and treatment compliance

Reinforcement Programs

Whereas a Reinforcement Program…

– Breaks down each of the goals into very small steps

– Reinforces each of the steps along the way– Makes it easy to earn a reinforcement– Distributes reinforcements with fairly high

frequency

Reinforcement Programs

Move from “You have done a good job” to “You have taken a step in the right direction”

This is the most important change that a reinforcement plan can make in your treatment program!

Incentive vs. Reward

Which of these is an incentive?Which of these is a reward?

So, how about…

• A draw from the fishbowl for showing up on time?• A bag of candy for pts. who are one month clean?• A pizza party after 12 weeks of attendance?• A prize for returning to have your TB test read?• A smiley face sticker for group attendance?• Sodas and snacks at the Cocaine Anonymous Group?• A chance to win a raffle prize based on attending each

orientation group?

Proximal vs. Distal

• Reward= Individual or group prizes for achieving a particular goal

• Incentive=a reinforcer to motivate or propel forward an individual or group to help achieve a particular goal.

It’s not only what you give, but when you give it.

Target Behavior

The “reinforcement” model emphasizes breaking the goal down into very small steps and then reinforcing each of the steps as they occur.

The behavior must be observable and measurable.

Choosing a target behavior involves something problematic or in need of a change. Then, the new behavior becomes a contingency.

and…

…the chance of winning needs to be reasonably attractive

Pizza Hut Book It!Setting = classroomTarget group = school childrenTarget behavior = increased readingReinforcer = one "book buck" (play money) for each book readVerification = self-report + parent signs

“Bucks” could be cashed in at a store open once per week. Prize examples: - pencil or eraser costs one buck - BOOK IT! pins cost two bucks - folders cost three buck other items included paperback books, frisbees, and designer shoelaces Students could cash in all the bucks they had or use part of them and save the rest. What they bought was entirely up to them. It really encouraged them to read!

Changing the status quo?

What needs changing at your agency…Poor group attendance?Spike in cocaine use?Medical appt. no-shows?Lack of early engagement?Refusal to pay fees?

This will help you decide on your….

Target Behavior

• Attendance at first post-intake appointment• Regular attendance at group therapy• Kept medical appointments• Regular payment of fees• Cocaine abstinence (negative urines)

Target Population

• Is it the whole agency?• Is it the people who loiter out front?• Is it the patients with Medical Assistance?• Is it the prevalent cocaine users?• Is it the Women’s group, or the Men’s group?• Is it new patients?• Is it the staff?

Back on My FeetBack on My Feet is much more than just running.

It is a comprehensive program that offers connections to job training, employment and housing, but these benefits are not free. Members earn the opportunity to move forward in the six month to nine month program by maintaining a 90 percent attendance rate at the morning runs three days a week.

backonmyfeet.org

Man AliveWe think the world of you!

• Target Behavior: Keep your insurance current• Target Population: Managed Care Patients• Incentive: $5 and $10 gift cards to CVS, Dunkin’

Donuts and Safeway• Contingency: Bring your DSS letter in for

review/receive a $5 gift card; show proof of keeping your re-con appt. receive a $10 gift card.

• Delivery: immediate• Followup- thank you note from administration

w/keychain.

Delivery Styles, Timing and FrequencyWhich will you choose?Fishbowl, Raffle, Vouchers, Token Economy

The token, point, or voucher is delivered when the target behavior is exhibited.

How much money, staff resources and contact you have to offer will influence the frequency of delivery.

Low cost prizes!

You can order these on-line with your own recovery sayings!

You can order these by the dozen, and the price goes down if you buy 3 dozen!

Make it seasonal! As you get closer to the holiday, the price goes down!

This is a craft item! 12 for $5.99

Consider buying different cost items to create escalation!

Or, how about…

a treasure chest filled with prizes for clients to choose their own prizes.

Jim Bieting’s Recovery Cart– filled with small prizes and 12 Step materials. Locked, rolling cart fromCraftsman Tools.

Or, how about:

a bulletin board for new patients--recording their success, earning the chance to win a raffle as they climb the mountaintop!

Or, how about..

BCRC/Case Management

Tic Tac Toe!

Client’s Name___________________

SECOND

VISIT:

FIRST

VISIT:

Task:

Task: THIRD

VISIT:

Task:

FOURTH

VISIT:

Task: 14 DAY ANNIVERSARY!

a case management tic-tac-toe board charting both: kept appts. tasks to be completed, and honoring length of stay!

With each of these efforts, what are we after?

Time! Give clients time to internalize the recovery process and develop naturally re-occuringreinforcers.

Lane Treatment Center

The Lane Treatment Center specializes in substance abuse and mental health treatment, offering individual counseling, traditional outpatient groups, and an intensive outpatient program.

What is an incentive? How does one differ from a reward?

• Webster’s definition: Something that incites or tends to incite action or greater effort, as a reward for increased productivity

• An incentive is a specific type of reward

• An incentive is given to a person for completing a desired behavior

• The person is told about the incentive before he completes the behavior

• The magnitude of the incentive should match the magnitude of the effort to complete the behavior

Attendance Spreadsheet

Data Summary Table

Total Patient ContactsNon-Incentive vs. Incentive Period

AM Group (Tuesday, Wednesday, Friday )June 2007 – October 2008Lane Treatment Center IOP

Incentive Period

Non-Incentive Period

Incentive Period

Non-Incentive Period

Average Patients Per Group Non-Incentive vs. Incentive Period

AM Group (Tuesday, Wednesday, Friday )June 2007 – October 2008Lane Treatment Center IOP

Incentive Period

Non-Incentive Period

Average Groups Attended Per PatientNon-Incentive vs. Incentive Period

AM Group (Tuesday, Wednesday, Friday )June 2007 – October 2008Lane Treatment Center IOP

Income

Incentive Cost

Incentives

Incentive Period

Non-Incentive Period

Monthly Insurance Income vs. Incentive CostNon-Incentive vs. Incentive Period

AM Group (Tuesday, Wednesday, Friday)June 2007 – October 2008Lane Treatment Center IOP

Income vs. Incentive

• 24 “Applause”• 8 "Keep it Up!"• 12 "Good Job"• 4 "Keep Coming Back"• 8 "Hear from your Peers“

• 35 "Small"• 15 "Medium"• 5 "Large"• 1 "Jumbo“ (pt’s choice) • 56 no-cost tickets, and • 56 cost tickets for a total of 112.

Fishbowl Method

Motivational Incentives

Fishbowl contains:•Applause•Hear from your peers•Small•Medium•Large•Jumbo (patient’s choice)

Prize cabinet is bookshelfkept in locked office.

Prize cabinet is re-stocked with patient input, so prizes change to keep interest going.

Target audience: IOP participants

Target behavior:Consistent attendance

Lessons Learned

Data is invaluable to funding sources/administrative supervisors/Boards

Importance of patients’ choice Element of surprise and positivity Immediate reinforcement (daily) Revenues generated greatly outweigh expenditures Ease of tracking, monitoring using charts/graphs Multiple levels of prizes used (small, medium, large, jumbo) is

key for “spending” vs. “saving” lessons Return to baseline periodically (non-incentive period) to re-assess effectiveness

Break time!

3:15 -3:30 During the break,

take some time to confer with others about what’s percolating.

Design & Implementation

Pick a target behavior Pick a target populationPick an incentive Choose the frequency of the incentive Choose the timing of the incentiveEstimate a cost schedule

Start out small to keep it manageable!

Tell us your ideas for a chance to win a prize!

Presenter gets two draws.Each group member gets one draw.

Stay Solution Focused!

• Lack of leadership support Use resources in PAMI, CTN Dissemination Library, to drum up support

• Lack of funds Start out small/use no cost incentives

• Lack of staff enthusiasm Try incentivizing them!

• Lack of good monitoring Hire a grad student as an intern