MARRCH 2007 Annual ConferenceOctober 30, 2007
Addressing “Paperwork Burden”Transforming Data into useful Information for Counselors and
ClientsDeni Carise, Ph.D.
Treatment Research InstituteUniversity of Pennsylvania
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State of the FieldDelaware Paperwork Burden ReviewDecreasing Paperwork at Assessment
Role of Computer SystemsBenefits of Standardizing Data
Topics
Results of Initial Work from Recruiting Programs for the
National Treatment Outcomes Monitoring System (NTOMS)
LeadershipManagement
StaffingInformation
State of the Field
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NTOMS National Sample Expansion
NY
Information on the First 175 Sites Recruited
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The Treatment System
Modality 1975 1990 2006
Residential 64% 39% 8%
Outpatient 27% 59% 81%
Methadone 9% 10% 11%
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• 8 % closed altogether
• 7 % stopped providing SA Treatment
15% no longer providing SA Treatment
• 29% of remaining programs had been taken over, usually by MH agencies
Program “Turnover”
McLellan, A.T, Carise, D, & Kleber, H. (2003). Can the national addiction treatment infrastructure support the public’s demand for quality care? Journal of Substance Abuse Treatment, 25 (117-121) TRI
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• 54% of directors have been there Less Than 1 year
• Counselor turnover 50% per year
STAFF TURNOVER!
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No Standard Intake/Assessment Procedures
– ASI was most used assessment (35%)
– Total admission process 2-4 hours, or 0
– 15 – 20% Don’t Do Assessment
– 30% of programs collected only the information that was required by regulating agencies
Intake/Admission Process:
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No perceived value for assessment
“Simply Paperwork”
Not related to Treatment Plan
Not related to services delivered
Intake/Admission Process:
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3 - 4 Hours – Group Counseling
2 - 3 Hours – Intakes
2 - 3 Hours – “Paperwork”
Who are the Counselors?A Typical Counselors Day?
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An Example with the Delaware State
Concurrent Recovery Monitoring Grant
Who are the Counselors?Addressing “Paperwork”
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Delaware CRM Project4 Phases:1) Evaluation of current data collection in an
effort to minimize paperwork burden2) Collaboratively select CRM items3) Pilot the collection and reporting of these
items in 4 state adult OP SA programs4) Expand to all 11 state adult OP SA programs
and monitor progressTRI
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A Comprehensive Paperwork
Burden Review
Who are the Counselors?Phase 1:
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Goal: Paperwork Burden Review
• Diminish any unnecessary or burdensome paperwork
• Develop a more efficient data collection system by consolidating and streamlining paperwork
• Facilitate programs’ ability to participate more fully in expanded CRM effort in Phase 3
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Methods• Conducted a systematic evaluation of
multiple, competing data collection demands (state, grant, contract, managed care, credential agencies, etc.)
• Conducted site visits with clinical and admin staff from 11 OP Tx Programs in DE in July/Aug 2005
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During site visit, reviewed paperwork completed thru continuum of care:
• Screening, • Intake & Assessment,• Treatment planning process, • During treatment, • Discharge or transfer, and• Follow-up
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Methods
Recommendations• Eliminate Michigan Alcohol
Screening Test - MAST (7-10 min)
• Recommended 2-item screener for South Oaks Gambling Screen
(5 min)TRI
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• Eliminate Interpretative Summary (repeat of ASI Narrative) (30 min)
• Eliminate Assessment Summary (repeat of ASI) (10-15 min)
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Recommendations
• Develop consistent Physical Exam Refusal forms for use by all sites
• Eliminate ASI at Discharge (30 min)
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RecommendationsRecommendations
• Eliminate ASAM at Intake for all OP Programs (lowest level of care), as well as 90 Day ASAM Updates & ASAM at Discharge (45 Min: 15 min @ admin, 90 days and discharge)
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Recommendations
Paperwork Burden Reduction
• Eliminations reduced @ 2 hours per client across continuum of care
• Approx 1,500 clients/year enter tx at 11 OP programs
• Total reduction: @ 3,000 counselor hours per year
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Paperwork Burden at Assessment
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How do computer systems and
standardizing data help?
8A national system collecting standardized, automated information (using ASI)
8 that is clinically important and policy relevant
8on people entering addiction treatment and their treatment programs
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The Drug Evaluation Network System DENS
Purpose of DENS
Standardize information at treatment intake
Unified picture of people coming into treatment
Quickly gather questions of current interest (Changes since 9/11) so this information isn’t
always anecdotal
Identify new trends - ex: Oxycontin use
AND to inform policy
Purpose of DENS
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Significance of DENS
The only “real-time” source of information on treatment programs and their patients.
Ability to collect varied additional timely and policy relevant patient and program information
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Standardizing Data Collection:The Blood Pressure Model
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An Example of Non-Standardized Reporting
Blood Pressure
Nurse 1 – It’s getting better (better than what??)
Nurse 2 – It’s much lower than before (too low??)
Nurse 3 – The patient is in denial (???)
Nurse 4 – The patient is non-compliant, lets not treat him until he’s really ready
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An Example of Standardized Reporting
Blood Pressure
Nurse 1 – It’s 120/80
Nurse 2 – It’s 116/78
Nurse 3 – It’s 122/82
Nurse 4 – The patient is non-compliant, lets not treat him until he’s really ready
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How Could Standardizing Data Help?
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Allows for better guidance in clinical/treatment decisions
and tailored treatment.Allows tracking trends, enabling us to show that
treatment works
Standardized Assessment
An example with the
Addiction Severity Index
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The Addiction Severity Index
• Developed by Tom McLellan & colleagues at University of Pennsylvania
• Standardized, semi-structured, multi-focused screening and assessment tool
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A. Thomas McLellan
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7 Sections of the ASI1. Medical
2. Employment/Support
3. Drug
4. Alcohol
5. Legal
6. Family/Social
7. Psychiatric
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DENS SoftwareAutomates collection of the ASI data Provides:
• Automated error-checks• A comprehensive intake assessment• Room for additional comments• Automated narrative summary • Comprehensive treatment care plan
• Software designed with input from clinicians
• Assumed most users have little/no computer experience
• Users report administration time shorter with software
• Can enter comments for every ASI item
DENS ASI Software
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It Writes a Narrative Summary?
Software: Hints & Comments
DENS ASI Data Flow
Client data – ASI
Server in Philadelphia receiving all non-identifying
data
DENS Programs
Quarterly reports
Trends of Interest?
Who is coming
in to treatment?TRI
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Age Group Categories
25 and under 4,423 15%
26-35 9,527 31%
36-45 11,542 38%
46 and older 4,876 16%
Age Group n % of Total
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Heroin: Percent InjectingBy Age Group * Over Time
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50
75 7156
3835 3949
20
40
60
80
1999 2000 2001 2002
40 + 16 - 25
12
3836
3334
52
132 45
53
32
4
25
0
20
40
60
CA NM TX OH KS NE MN WI MI IL MA PA NY NJ FL
Percent Regularly Using Heroin (Years) by State
Change Over Time: 1996-2005Criminal Justice System Involvement
10203040506070
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Percent Referred by CJS
What Can Data Do for You?
Track Trends – Current drug trends
OxyContin
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A Flexible Monitoring System
Benefits of “Real-Time” Knowledge
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Did the September 11th attacks result in changes in the
behaviors of counselors and patients in substance abuse
treatment?
The research question:
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• Surveyed 86 counselors at 25 DENS treatment programs
• Chicago, Miami, Philadelphia & New York.
• November 28, 2001 and January 4, 2002
• Counselors at a Veterans Affairs Medical Center were surveyed to evaluate potential differences in their population
Methods
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Following the events of September 11th:
1. Would counselors perceive a change in their patients’ demands for services?
2. Would counselors perceive a change in their patients’ substance use patterns?
3. Would VA counselors observe a change in the frequency of their patients’ PTSD symptoms?
Specific Questions:
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Changes in PatientsPercent reporting a change in the demand for services
since the attacks
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58
27
48
71
0
20
40
60
80
100
• 56% (N=48) of the counselors noticed a change in patients’ demand for services
Changes in Substance Use Patterns
Percent reporting change since the attacks
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• 22% (N=19) of the counselors saw a change in patients’ use patterns
• Most reported an increase in drug and alcohol use
29
0
17
29
0
5
10
15
20
25
30
CHIM
IA
PHILLY
NYC
40
50
60
70
% Y
es
Changes in Staff Members
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63% noticed a change in their fellow staff members since September 11th
• More concern about and compassion toward other employees and patients
• More anxiety and stress
• Fear of layoffs
… following September 11th
Overall, Staff Members Reported:
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Building on DENS:CASPAR
Computer Assisted System for Patient Assessment and
Referrals
Background “Wrap-around” services have been shown
to improve treatment outcomes
But…
…few services available in contemporary Treatment Programs
…finding “wrap-around” services can be difficult
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Problem-Services Linkage
Treatment Research Institute
•Alcohol
•Drugs
•Medical
•Employment
•Psychiatric
GED training
Resume Development
Job Finding
Mentoring Sessions
Training Loans
(e.g. Employ - related services
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1. Conduct assessment (ASI)
2. Identify problems
3. Prioritize problems
4. Develop goals to address problems
5. Write Treatment Plan including referrals from CASPAR RG not available at your site
Assessment to Treatment Planning
Therapeutic Thread
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What about this “Resource Guide”?Electronic source of local, free/low costprograms and agencies for providing clients with
referrals to services not offered in Tx
Wide range of programs and services, include:Mental healthJob training
Financial supportEmergency services
(Food, clothing, housing, shelters)
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Resource Guide
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A Software Screen Example
Click here to enter patient’s zip code.
Click here for all services matching the keyword.
Highlight a keyword here.
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A Software Screen Example
Click here to print this page.
Click here to view other programs provided by this agency.
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Sample of a Program Info Screen
Thank You!
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