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Building Momentum for Process Improvement: The
California Experience
Presented by:
Beth Rutkowski, MPH
NIATx-SI Cohort 1 State Convening MeetingJanuary 27, 2010
Presentation Overview
LA County Phase I Process Improvement Pilot Project
CATES Statewide Training Effort LA County Phase II Process Improvement
Pilot Project CA NIATX Coach Pilot Project Local Learning Collaboratives Regional Learning Collaboratives
Key Partners
UCLA Integrated Substance Abuse Programs Pacific Southwest Addiction Technology Transfer Center LA County Alcohol & Drug Program Administration NIATx National Program Office SAMHSA, Center for Substance Abuse Treatment Robert Wood Johnson Foundation County Alcohol and Drug Program Administrators
Association of California
Recipe for Success
Key Ingredients
Start small and demonstrate success Face-to-face learning sessions Individualized technical assistance/coaching Telephone-based technical assistance Data collection, submission, and review Availability of continuing education Change Leader Academy Coach Academy
“Where it all started…”
Los Angeles County, California
Phase I Los Angeles County Process Improvement Pilot Project
November 2005-September 2006
Participating Agencies
Didi Hirsch CMHC, Via Avanta LA Centers for Alcohol and Drug Abuse Matrix Institute on Addictions (2) Social Model Recovery Systems Southern California Alcohol and Drug
Programs Tarzana Treatment Centers
Phase I Pilot Project Timeline
Nov ‘05
Orientation
Jan ‘06
Kick-Off
Workshop
Pre-Work
Nov ‘05-Jan ‘06
Feb ‘06
Site Visits
Mar ‘06
Monthly
Conference
Calls
Jun ‘06
Mid-Way
Change
Leader
Meeting
Sept ‘06
Completion
Conference
Phase I Aggregate Results
83% reduction in assessment/intake no-shows (2 agencies reporting)
39% increase in 30-day continuation (3 agencies reporting).
California Addiction Training and Education Series
November 2007-May 2009
**1,430 participants
***50 counties
Where Were the Trainings and How Many People Did We Train?
Nov 2007 San Francisco – 154 (18) San Diego – 137 (6) Bakersfield - 129 (10)
May 2008 Redding – 77 (17) Santa Ana – 145 (6) Fresno – 78 (12)
July 2008 San Jose – 341 (1)
Sept 2008 San Rafael - 51 (2)
Oct/Nov 2008 Concord – 114 (12) Rialto – 97 (8) Yuba City – 107 (18)
Sample Agenda
Case study - from an agency’s perspective Process Improvement 101 How to get started Measuring impact of change Promising practices
Monthly CoachingConference Call Topics
Month 1: Conducting a Walk-Through Month 2: Collecting Baseline Data Month 3: Establishing a Change Objective Month 4: Creating a Quick Start Road Map Month 5: Conducting a PDSA Change Cycle Month 6: Sustaining Change
Call Participation
60 hour-long conference calls held between Dec 2007 and May 2009 254 people from 35 counties Callers joined an average of 2-3 calls (mean=2.6)
Targeted areas of participation (and implementation)
Phase II Los Angeles County Process Improvement Pilot Project
November 2007-October 2008
Participating Agencies
Antelope Valley Rehabilitation Center (2) Behavioral Health Services (2) CA Hispanic Commission on Alcohol and Drug
Abuse (2) Didi Hirsch Community Mental Health Center (2) House of Hope MELA Counseling Services Center SHIELDS for Families Tarzana Treatment Centers (2)
Project Enhancements
Formal application process Greater focus on data More comprehensive data review and feedback 5th Change Leader monthly conference call 2nd Executive Sponsor conference call 12 individualized data coaching calls
6
2.6 2.5
44.3
1.9
4.6
3.5
1.2
6.9
0
1
2
3
4
5
6
7
Basel
ine
Mar
chApril
May
June
July
AugSep Oct
Avg
Day
sWait-Time from First Contact to Admission
42% average reduction in wait-time
43.5
2521.2
26.628.4
36.4
28.2
12.7
24.618.6
05
101520253035404550
Basel
ine
Mar
chApril
May
June
July
AugSep Oct
Avg
%
43% average reduction in no-shows
No-Shows
70.677.4
84.8 86.680.5 84.3 87.5 84.6 87
84.1
0102030405060708090
100
Basel
ine
AprilM
ayJu
neJu
lyAug
Sept
Oct
NovAvg
% 19% average improvement in session-by-session attendance
Session-by-Session Attendance
68.5
73.9
68.9
73.975.1
72.9
70.7
75.172.9
64
66
68
70
72
74
76
Basel
ine
AprilM
ayJu
neJu
lyAug
Sept
Oct
Avg
%
30-Day Continuation
6% average improvement in 30-day continuation
California NIATx Coach Pilot Project (July 2008-April 2009)
Development of Local Learning Collaboratives (August 2008-Present)
Regional Learning Collaboratives – California Endowment
November 2008-October 2009
Regional ACTION Campaign/NIATx Learning Collaboratives
• CA-based ACTION Campaign membership more than doubled from 105 individuals in 82 agencies to 300 individuals from 221 agencies.
• Five day-long kick-off workshops were held in April-May 2009 • 386 treatment providers/administrative staff
• Staff from 173 agencies/programs in 49 counties are now part of one of five collaboratives
• 28 agencies from 16 counties submitted a completed change project report form for one or more change projects
Adopting Changes in Addiction Treatment – Promising Practices
Strategies to decrease wait-time from initial contact to intake/assessment/admission appointment Conduct group intakes 2 times per week Reduce repetitive paperwork Combine intake and assessment into one
appointment Offer walk-in intakes
Wait-Time from First Contact to Assessment/Admission
32
4
0
5
10
15
20
25
30
35
Baseline Post-Change
Nu
mb
er o
f D
ays
89% average reduction in wait-time
(2 agencies reporting)
Adopting Changes in Addiction Treatment – Promising Practices
Strategies to increase timeliness of admissions Assign intakes to 2 primary counselors Make immediate contact with client upon receipt
of referral and engage client Discuss the importance of enrolling on the report
date so that the client does not lose interest and/or comes up with reasons not to enroll or delay enrollment
Improve therapeutic and clinical milieu of Treatment Readiness Interview
Adopting Changes in Addiction Treatment – Promising Practices
Strategies to increase timeliness of admissions Offer staff training to improve empathy Call to schedule intake appointment for client at
the time of assessment Make reminder phone call 2-3 days prior to
scheduled intake appointment
Timeliness of Admissions (hybrid of Wait-Time and Admissions)
33%
54%
0
20
40
60
80
100
Baseline Post-Change
64% average improvement in timely admissions
(4 agencies reporting)
Adopting Changes in Addiction Treatment – Promising Practices
Strategies to decrease no-shows to intake/ assessment appointment Schedule group intakes Implement a series of paper-and-pencil screening tools Move full ASI assessment and treatment planning process
to subsequent counseling session Schedule clients to arrive 30 minutes prior to intake
appointment to allow time to complete screening paperwork
Streamline intake paperwork and create a single signature page to acknowledge receipt of handbook
Adopting Changes in Addiction Treatment – Promising Practices
Strategies to decrease no-shows to intake/ assessment appointment Place reminder calls for individual and group session
appointments Allow client to choose day/time of assessment appointment Schedule first counseling appointment within 7 days of
intake Introduce client to primary counselor at time of intake Reschedule missed appointments
No-Shows
43%
21%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Baseline Post-Change
51% average reduction in no-shows
(15 agencies reporting)
Adopting Changes in Addiction Treatment – Promising Practices
Strategies to increase client retention Implement “contract for treatment success” Provide incentives for ongoing participation Greet and welcome new clients within the first 24
hours Provide incoming residential clients with a mentor
Client Retention – Length of Stay
134146
0
20
40
60
80
100
120
140
160
Baseline Post-Change
Nu
mb
er o
f D
ays
9% average improvement in length of stay
(1 agency reporting)
Client Retention – 30-day Continuation
84%
93%
0
20
40
60
80
100
Baseline Post-Change
11% average improvement in 30-day continuation
(2 agencies reporting)
Adopting Changes in Addiction Treatment – Promising Practices
Strategies to reduce early discharges Change scheduled chores for new clients by taking away
kitchen responsibility for the first two months of treatment Develop PowerPoint presentation to provide consistent
information at DUI program orientation Discuss early termination policy with new clients Schedule intakes in the morning to engage clients more
quickly
Client Retention – Reduction of Early Discharges
35%
12%
0
20
40
60
80
100
Baseline Post-Change
66% average reduction in early discharges
(2 agencies reporting)
Keys Ingredients for Change Project Success
1. Choose the right Change Leader
2. Establish a clear objective
3. Implement only 1 new change at a time
4. Make sure everyone implements change project as planned
5. Start small
6. Study the results before making modifications
Lack of executive or Change Team commitment Inexperience with process improvement tools Failure to define problem and objective clearly Difficulty creating simple measures Lack of familiarity with data graphing Failure to gather outside ideas
Frequent Start-Up Issues
Discussion Points
How counties have incorporated NIATx into regular meetings
Cost Suggestions for involving the ATTC Network
in NIATx spread and sustainability
