Na#onal  Center  for  Responsible  Gaming  Conference  on  Gambling  and  Addic#on  

November  14,  2010  

Improving  Access  and  Reten#on  in  Treatment:    The  NIATx  Program  in  Iowa  

Janet Zwick Prairielands ATTC

janetzwick@aol.com

Mark Vander Linden Iowa Gambling Treatment Program Iowa Department of Public Health

mvanderl@idph.state.ia.us

Partners  

Anne  Helene  Skinstad,  Ph.D  PATTC  Janet  Zwick,  Lead  Coach,  PATTC  

Bob  Kersieck,  IDPH  Mark  Vander  Linden  IDPH  

“We  will  restore  science  to  its  righEul  place,  and  wield  technology’s  wonders  to  raise  health  care’s  quality  and  lower  its  cost.  “  

President  Barack  Obama  Inaugural  Address    January  20,  2009  

NIATx  Aims:  

1.  Increase  admissions  to  treatment    

2.  Increase  conTnuaTon  from  the  first  through  the  fourth  treatment  session  

3.  Reduce  the  number  of  paTents  who  do  not  keep  an  appointment  (no-­‐shows)    

4.  Reduce  wait  Tmes  

Iowa  Gambling  NIATx  

•  Nine  programs  providing  gambling  and  substance  abuse  services  

•  Eight  of  the  nine  programs  had  substance  abuse  NIATx  experience  

•  Helpline  

Important  Iowa  NIATx  ConsideraTons  

•  Aims  and  Change  Cycles  determined  by  individual  programs  

•  Keep  It  Simple:    Keep  required  program  paperwork,  state  meeTngs  to  a  minimum  

•  Keep  it  helpful  –  coaching  calls  •  Waivers  to  simplify  processes  

•  Programs  may  use  a  combined  SA/gambling  change  team  

Important  Iowa  NIATx  ConsideraTons  

Importance  of  Sharing  Data  and  CompeTTon.  •  Early  in  2009  we  shared  only  state-­‐wide  data  and  the  program’s  own  data  with  each  program  

•  In  October  2009  we  requested  and  received  permission  from  each  program  to  share  data  with  other  programs    

•  Following  this  there  was  a  surge  in  Change  Projects  from  programs  

Key  Focus  of  Iowa  NIATx  2009  

•  Increasing  admissions  different  than  substance  abuse  treatment  program  

•  Many  crisis  calls  do  not  convert  to  a  screening  or  admission.    

•  Gambling  treatment  resources  in  Iowa    underuTlized  

•  ConTnuaTon  through  early  treatment  

Program  Barriers  

•  Too  much  paperwork  up  front  

•  Ofen  seemed  to  be  more  important  to  complete  paperwork  than  listen  to  client  

•  Most  programs  were  doing  three  disTnct  gambling  screens  with  each  client  despite  being  required  to  only  do  one.  

.

Helpline  Barriers  

IniTal  Issues  •  Phone  not  answered  •  Calls  not  transferred  to  programs,  gave  program  phone  numbers  only  

•  Some  programs  had  gambling  counselor  on  call,  others  used  residenTal  technicians,  someTmes  voice  mail  only  

•  Inconsistent  role  of  Helpline  

 State  Approach  to  Programs  

•  Different  roles  of  coach  and  state  employees    •  Programs  may  ask  for  waiver  for  NIATx  projects  •  Programs  may  use  combined  SA/Gambling  change  team  •  No  paperwork  required  for  this  project  •  Used  exisTng    state  data  programs  only  had  to  collect  minimal  

data    •  Emphasized  that  it  would  be  simple  •  No  required  meeTngs-­‐-­‐maybe    learning  session  at  the  end  •  Minimal  funding  to  parTcipate  -­‐  $5,000/program  

Walkthrough  Results  for  the  State  

•  Walk-­‐through  forced  state  staff  to  see:    – How  unreasonable  paperwork  was  – State  data  tool-­‐three  pages-­‐overly  detailed  – Outcome  monitoring  tool  –  two  pages  –  very  repeTTous  of  the  data  tool  

– State  licensure  requirements  are  intensive  

•  State  staff  made  commitments:  – Reduce  repeTTon  – Reduce  requirements  

Walkthrough  Results  for  Programs  

•  Programs  ofen  added  to  required  paperwork  •  Redundant  quesTons  •  MulTple  mental  health/substance  abuse  screening  tools  

•  MulTple  problem  gambling  screening  tools  

•  Most  programs  were  taking  three-­‐to-­‐four-­‐and-­‐a-­‐half  hours  to  do  a  gambling  intake  

Walkthrough  Results:  Crisis  Line  

•  12/15  weekday  calls  were  transferred  directly  to  program,  average  of  less  than  two  rings  before  picked  up  

•  4/20  evening/weekend  calls  were  transferred  directly  to  a  program  

•  Average  Tme  on  hold  3.5  minutes  •  Six  of  the  calls  were  on  hold  five  minutes  or  longer.  •  Other  significant  problems  idenTfied.  •  Some  operators  doing  free-­‐lance  crisis  instead  of  referring  

Walkthrough  Results:      Crisis  Calls  to  Programs  

•  15/26  calls  were  handled  by  a  counselor  •  13/26  calls  were  able  to  get  an  appointment  

•  5/26  went  to  voice-­‐mail  

•  Other  significant  problems  idenTfied  

•  Programs  generally  did  a  much  beker  job  of  handling  crisis  calls  during  weekdays  than  during  evenings/weekends  

Reduce  Paperwork  

Reduce  Paperwork  by  Using  DT  Form  Program  B    

3  

1.25  

0  

0.5  

1  

1.5  

2  

2.5  

3  

3.5  

Hours  

Baseline  

Post    

Reduce  Paperwork  by  Reducing  Progress  Note    

Program  B    27.5  

19.5  

0  

5  

10  

15  

20  

25  

30  

Minutes  

Base  

Post  

Reduce  Time  for  Intake  Reduce  Paperwork    

Program  C  

2.5  

1.5  

0  

0.5  

1  

1.5  

2  

2.5  

3  

Hours   Hours  

Baseline  

Goal  

Admit  Clients  on  Same  Day  by  Reducing  Paperwork    

Program  C  

54%  

100%  

0%  

20%  

40%  

60%  

80%  

100%  

120%  

Baseline  

Goal  

Reduce  Paperwork-­‐-­‐Eliminate  Redundancy  in  Assessment    

Program  F  

3  

1  

0  

0.5  

1  

1.5  

2  

2.5  

3  

3.5  

Hours  

Baseline  

Goal  

Reduce  Paperwork  by  Using  DT  Form  Program  A    

21  

7  

0  

5  

10  

15  

20  

25  

pages  

Baseline  

Post  

Reduce  Paperwork    Used  DT  Form  and  MI  Engagement  

Program  G  13  

4  

0  

2  

4  

6  

8  

10  

12  

14  

Pages  

Base  

Post  

Increase  Admissions  

Increase  Admissions  from  Crisis  Calls    Offered    1st  4  appointments  free  

Program  D  

1  

4  

0  

0.5  

1  

1.5  

2  

2.5  

3  

3.5  

4  

4.5  

Admissions   Admissions  

Baseline  

Post  

Increase  Admissions  by  Doing  Intakes  in  Jail    Program  G  

0  

3  

0  

0.5  

1  

1.5  

2  

2.5  

3  

3.5  

#  of  clients  

Baseline  

Post  

Increase  Admissions  from  Crisis  Calls      Got  Phone  Number  and  Name  to  Call  Back  Next  Day  

 Program  I  

61%  

72%  67%  

90%  

0%  

10%  

20%  

30%  

40%  

50%  

60%  

70%  

80%  

90%  

100%  

Phone  Numbers   Names  

Baseline  

Post  

Increase  Admissions  from  Crisis  Calls    By  Scheduling  at  Time  of  Call    

 Program  I  

24%  

71%  

28%  

88%  

0%  

10%  

20%  

30%  

40%  

50%  

60%  

70%  

80%  

90%  

100%  

Crisis  to  Assessment  

Assessment  to  Admissions  

Baseline  

Post  

Increased  Admissions  to  Distance  Treatment-­‐Goal  One  Per  Month  

Program  A    

1  

3  

0  

0.5  

1  

1.5  

2  

2.5  

3  

3.5  

   Distance  Treatment  Admissions  

Sept  

Oct-­‐Jan  

 Increase  Intakes  by  Beker  Handling  Crisis  Calls  Baseline  Zero  8-­‐18  to  9-­‐18  

Program  G  

3  

13  

7  

10  

0  

2  

4  

6  

8  

10  

12  

14  

       Made  &  showed  up  for  

appts  

11-­‐30  to  12-­‐13  

12-­‐13  to  1-­‐24  

1-­‐25  to  2-­‐22  

2-­‐23  to  3-­‐23  

SAMHSA/IDPH/PATTC  Concerns  Co-­‐Occurring  Clients  

•  Are  gambling  client  adequately  screened  for  substance  abuse?  

•  Are  substance  abuse  clients  adequately  screened  for  gambling?  

Gambling  Screening  in  Substance  Abuse  Clients  

•  Substance  abuse  programs  required  by  contract  to  screen  for  gambling  issues  at  admission  by  using  Lie-­‐  bet  

•  2  programs  tried  BBGS  

•  2  programs  tried  NODS-­‐CLIP  

Screening  Results  in  Substance  Abuse  PopulaTon  

1%  

3%   3%  

0%  

1%  

1%  

2%  

2%  

3%  

3%  

4%  

Lie-­‐Bet   BBGS   NODS-­‐CLIP  

Baseline  

Post  

Why  Do  Iowa’s  Substance  Abuse  Clients  Not  IdenTfy  Gambling  Issues?  NaTonal  data  shows  prevalence  of  gambling  in  substance  abuse  clients  as  76.3%  

Sequence  of  onset  

 PG  first  36.2%  

 SA  first  57.4%  

•  Kessler  et.  Al,  2008  Psychological  Medicine,  Not  So  Strange  Bedfellows?  Pathological  Gambling  and  Co-­‐occurring  Disorders.    

Other  Ideas  to  Beker  Screen  Substance  Abuse  Clients  for  Co-­‐

Occurring  Issues  •  Jackson  Recovery  incorporated  high  risk  gambling  issues  into  a  monthly  financial  educaTon  for  substance  abusers  

•  Jackson  Recovery    will  do  an  iniTal  screen  for  gambling  issues  and  then  counselor  will  discuss  with  clients  afer  financial  educaTon  

•  SASC  used  co-­‐occurring  assessment  tool  •  SASC  spread  gambling  quesTons  around  during  intake  

•  SASC  improved  training  to  substance  abuse  staff  regarding  gambling  

Increase  ConTnuaTon  

Improving  ConTnuaTon  Maintaining  &  Improving  on  Results

New  Admit  Clients  with  Four  Sessions  in  the  Next  30  Days  Program  I    

55%  

64%  

82%  

0%  

10%  

20%  

30%  

40%  

50%  

60%  

70%  

80%  

90%  

Base  5-­‐1  to  6-­‐30-­‐09  

Change  7-­‐14  to  10-­‐20-­‐09  

Sustain  1-­‐1  to  1-­‐30-­‐10  

 Reduced  Paperwork  Increased  ConTnuaTon  Program  F  

63%  

83%  

0%  

10%  

20%  

30%  

40%  

50%  

60%  

70%  

80%  

90%  

Client  ConTnuaTon    

Base  7-­‐20  

Post  8-­‐3  

Increase  ConTnuaTon  by  Offering  1st  4  Sessions  Free  

57%  

100%  

0%  

20%  

40%  

60%  

80%  

100%  

120%  

4  sessions  in  a  month  

Base  

Post  

Program H

Reduce  No  Shows  

Recovery  Used  Reminder  Calls  to  Reduce  No  Shows    Program  F    

33%  

18%  

0%  

5%  

10%  

15%  

20%  

25%  

30%  

35%  

No  Show  Rate  

Base  

Post  

No-­‐Show  Rates  Goal  to  Stay  Under  6%  FY2010    Program  B  

5.70%  

9.60%  

0.00%  

2.00%  

4.00%  

6.00%  

8.00%  

10.00%  

12.00%  

rates  

1st  Quarter  

2nd  Quarter  

3rd  Quarter  

Increase  Successful  Discharge  

Used  MI  Skills  to  Increase  Successful  Discharge    Program  A  

Baseline  

1st  Quarter  2nd  Quarter  3rd  Quarter  

0%  10%  20%  30%  40%  

50%  

60%  

70%  

Successful  Discharges  

13%  

33%  

40%  

63%  

1-­‐800-­‐BETS-­‐OFF  Helpline  

Helpline  Change  

•  Wrote  script  for  staff    

•  Trained  staff  on  script  •  Prior  to  change  Helpline  transferred  calls  to  programs  and  hung  up  

•  Change  project  was  to  stay  on  line  and  conference  calls  

Follow-­‐up  to  Helpline  Changes  

–  More  crisis  calls  are  getng  to  programs  –  Programs  removing  barriers  to  crisis  callers  

–  Programs  trying  to  schedule  an  appointment  during  the  first  crisis  call  

–  More  appointments  

–  More  admissions  

Helping  Crisis  Callers    Reach  Programs  

57%  

83%  

0%  

10%  

20%  

30%  

40%  

50%  

60%  

70%  

80%  

90%  

%  Calls  Received  By  Program    

Base  

Post  

(Half)  Million  Dollar  RESULTS  

This  Reversed  a  Long-­‐Term  Trend  Referral  calls  

 $28

8,10

9    

 $23

3,09

2    

 $81

3,65

0    

 $1,03

1,72

2    

 $95

4,37

3    

 $87

2,95

4    

 $81

6,39

7    

 $53

2,33

3    

1,587  

1,357  

1,953  

2,314  

1,939   1,924  

1,589  

892  

 $-­‐        

 $200,000    

 $400,000    

 $600,000    

 $800,000    

 $1,000,000    

 $1,200,000    

0  

500  

1,000  

1,500  

2,000  

2,500  

2003   2004   2005   2006   2007   2008   2009   2010  

1-­‐800-­‐BETS  OFF    Media  Budget  to  Direct  Referrals  Comparison  

Media  Budget   Direct  Referrals  

There  is  a  strong  correla#on  between  media  spend  and  direct  referrals.      The  Correla#on  Coefficient  is  .72;  which  is  a  very  strong  sta#s#cal  correla#on.      

This  Reversed  a  Long-­‐Term  Trend  Call  Volume  

 $28

8,10

9    

 $23

3,09

2    

 $81

3,65

0    

 $1,03

1,72

2    

 $95

4,37

3    

 $87

2,95

4    

 $81

6,39

7    

 $53

2,33

3    

 4,895      4,816    

 5,453    

 6,363    

 7,341    

 8,620    

 6,686    

 4,158    

 $-­‐        

 $200,000    

 $400,000    

 $600,000    

 $800,000    

 $1,000,000    

 $1,200,000    

 -­‐        

 1,000    

 2,000    

 3,000    

 4,000    

 5,000    

 6,000    

 7,000    

 8,000    

 9,000    

 10,000    

2003   2004   2005   2006   2007   2008   2009   2010  

1-­‐800-­‐BETS  OFF    Media  Budget  to  Call  Volume  Comparison  

Media  Budget   Call  Volume  

There  is  a  strong  correla#on  between  media  spend  and  call  volume.      The  Correla#on  Coefficient  is  .73;  which  is  a  very  strong  sta#s#cal  correla#on.      

Ad  Revenue,  Total  Calls  and  Referral  Calls  Were  Down  in  FY2010…    

Yet  Problem  Gambling  Admissions  Trended  Up!  

548  

508  

554  

674  

0  

100  

200  

300  

400  

500  

600  

700  

800  

FY2010   FY2009   FY2008   FY2007  

Total  IGTP  Admissions  State-­‐Wide:  

We  Also  Saw  a  PosiTve  Impact  on  Total  FY2010  Clients  State-­‐Wide:  

948  905  

940  

1146  

0  

200  

400  

600  

800  

1000  

1200  

1400  

FY2010   FY2009   FY2008   FY2007  

Total  Served  State-­‐Wide:  

Project  Benefits  for  Gambling  Treatment  

•  Increase  admission,  reduce  waiTng  Tme,  reduce  no-­‐shows,  and  increase  conTnuaTon  to  beker  serve  problem  gamblers  

•  Beker  uTlize  agency  resources  •  Payoff  to  public  will  be  beker  treatment  results  and  more  cost  effecTve  services  

What’s  the  Return?  

Gambling  Treatment  •  More  billables  

•  Beker  treatment  results  and  more  cost-­‐effecTve  services  

•  Faster,  easier,  consumer-­‐friendlier  access  to  treatment;  and  beker  treatment  results  

Outcomes  at  the  State  

Remember?    State  staff  made  commitments:  –  Reduce  repeTTon  –  Reduce  requirements  

–  Department  approved  11  NIATx  waivers  as  of  May  2010  

The  department  is  following  through:  –  Problem  gambling  licensure  has  been  simplified  and  combined  with  substance  abuse  licensure  effecTve  July  1,  2010  

–  Data  system  will  be  simplified  and  combined  with  outcome  monitoring  data  no  later  than  July  1,  2011  

So-­‐What’s  Next?  

Sustainability  •  Can  project  gains  be  maintained/improved  upon  long-­‐term?  

•  Sustainability  is  beneficial  to  consumers  and  public  

•  Sustainability  is  parTcularly  beneficial  to  the  agency  when  it  helps  increase  revenue  

•  Increased  revenue  can  be  used  to  pay  for  staff  raises,  increased  programming,  addiTonal  resources,  improvements  in  space,  etc.    

Next  Steps  for  the  State  

 ConTnue  to  work  with  programs  on  change  cycles  parTcularly  related  to  increasing  admissions,  increasing  conTnuaTon  and  improving  treatment  outcomes.  

 Use  data  to  idenTfy  programs  with  minimal  gains,  to  encourage  them  to  adopt  proven  methods.  

Raise  the  Bar  Through  Contract  CondiTons    

Performance  Measure  Treatment  IncenTve:  An  incen#ve  of  $1,000  shall  be  paid  in  June  2011  if  the  Contractor  admits  to  gambling  treatment  services  50%  or  more  of  the  referrals  to  the  agency  from  the  helpline  in  FY  2011.  

Treatment  DisincenTve:    A  disincen>ve  of  $1,000  shall  be  reduced  from  the  June  2011  payment  if  the  Contractor  admits  to  gambling  treatment  services  fewer  than  32%  of  the  referrals  to  the  agency  from  the  helpline  in  FY2011  (state-­‐wide  average  for  FY2009  was  32%).                

Raise  the  Bar  Through  Contract  CondiTons  

Treatment  Providers  •  Assure  a  qualified  counselor  responds  to  a  helpline  call  24  hours  per  day  and  7  days  per  week.    Helpline  calls  shall  be  responded  to  by  a  qualified  counselor  within  90  minutes  of  the  iniTal  call.    

Helpline  •  The  Contractor  will  host  a  brief  conference  between  the  caller  and  gambling  treatment  program  staff  when  possible.      

Data  Driven  ContracTng  

•  The  contractor  shall  work  collaboraTvely  with  Department  technical  assistance  to:  –  Increase  to  a  minimum  of  40%  the  number  of  helpline  referrals  that  convert  to  treatment  admissions  (the  average  for  the  first  three  quarters  of  FY2010  was  39%  and  xx  agency  was  xx%).  

–  Increase  the  number  of  treatment  admissions  to  a  minimum  of  2.0  per  10,000  popula>on  in  the  service  area  (the  state-­‐wide  average  for  FY09  was  1.58  per  10,000  and  xx  agency  was  xx%).  

FY09-1 FY10-3

FY09-0 FY10-1

FY09-1 FY10-2

FY09-1 FY10-2

FY09-1 FY10-1

FY09-0 FY10-1

FY09-0 FY10-0

FY09-0 FY10-0 FY09-0

FY10-1 FY09-1 FY10-4

FY09-1 FY10-1

FY09-2 FY10-1

FY09-1 FY10-2 FY09-11

FY10-10 FY09-0 FY10-1

FY09-3 FY10-2

FY09-0 FY10-1 FY09-2

-FY10-1 FY09-1 FY10-2

FY09-2 FY10-2

FY09-1 FY10-0

FY09-2 FY10-0

FY09-5 FY10-2

Buena V: Pocahont: FY09-1 FY09-0 FY10- 0 FY10-1

FY09-1 FY10-0

FY09-2 FY10-1

FY09-0 FY10-0

FY09-1 FY10-2

FY09-9 FY10-5

FY09-21 FY10-39

FY09-0 FY10-0

FY09-9 FY10-7

FY09-4 FY10-4

FY09-39 FY10-44

FY09-44 FY10-64

FY09-0 FY10-0

FY09-0 FY10-0

FY09-0 FY10-0

FY09-0 FY10-1

FY09-0 FY10-2

FY09-5 FY10-2

FY09-4 FY10-2

FY09-4 FY10-2

FY09-14 FY10-61

FY09-6 FY10-1

FY09-14 FY10-8 FY09-0

FY10-0 FY09-0 FY10-0

FY09-0 FY10-1

FY09-6 FY10-4

FY09-0 FY10-3

FY09-0 FY10-0

FY09-9 FY10-5

FY09-7 FY10-18 FY09-2

FY10-0 FY09-0 FY10-1

FY09-0 FY10-0

FY09-1 FY10-1

FY09-53 FY10-78

FY09-0 FY10-0

FY09-0 FY10-0

FY09-1 FY10-3

FY09-1 FY10-0

FY09-3 FY10-0

FY09-11 FY10-11 FY09-33

FY10-52

FY09-6 FY10-3 FY09-1

FY10-3 FY09-0 FY10-0

FY09-1 FY10-0

FY09-0 FY10-0

FY09-0 FY10-5

FY09-1 FY10-0

FY09-38 FY10-47

FY09-0 FY10-0

FY09-0 FY10-0

FY09-4 FY10-0

FY09-0 FY10-1

FY09-4 FY10-2

FY09-7 FY10-5

FY09-0 FY10-0

FY09-0 FY10-0

FY09-0 FY10-0

FY09-6 FY10-3

FY09-0 FY10-0

FY09-0 FY10-0

FY09-0 FY10-0 FY09-14

FY10-11 FY09-1 FY10-1

FY09-0 FY10-2

FY09-0 FY10-0

FY09-0 FY10-0

FY09-0 FY10-3

FY09-0 FY10-0

FY09-0 FY10-1

FY09-0 FY10-0

FY09-0 FY10-2 FY09-8

FY10-5

New  GeneraTon  of  Process  Improvement  

FY  2011    

•  Apply  model  to:  – PrevenTon  services  – Build  a  Recovery  Oriented  System  of  Care  – Service  system  alignment  with  substance  abuse  services  

•  Share  report  card  •  ConTnue  to  raise  the  bar  •  Agencies  mentor  each  other  

Thank  You    

•  Alcohol  Drug  Dependency  Services    •  Allen  Memorial  Hospital  •  Community  Family  Resources    •  Compass  Pointe  •  Heartland  •  Jackson  Recovery/River  Hills  •  Mideast  Council  on  Chemical  Abuse    •  Prairie  Ridge    •  Substance  Abuse  Service  Center    •  1-­‐800-­‐BETSOFF-­‐-­‐Helpline  

QuesTons  

Contacts:  

Janet  Zwick,  Lead  Coach,  Funded  by  PATTC  

NIATx  Coach  515-­‐270-­‐6509  janetzwick@aol.com

Anne  Helene  Skinstad,  Ph.D  Program  Director,  PATTC  319-­‐335-­‐5368  Anne-skinstad@uiowa.edu

Bob  Kerksieck,  LMSW,  ACADC  Health  Facility  Surveyor  for  Gambling  

Programs  Iowa  Department  of  Public  Health  515-­‐281-­‐3347    rkerksie@idph.state.ia.us

Mark  Vander  Linden,  MSW  

ExecuTve  Officer  of  the  Office  of  Gambling  Treatment  and  PrevenTon  

Iowa  Department  of  Public  Health  

mvanderl@idph.state.ia.us 515.281.8802 1800betsoff.org