A Safety Net of Recovery and Stability

Brandywine Counseling’s Safety Net Services program, now in its third year, is making a difference for Delawareans with high HIV risk and severe substance abuse and mental health issues. Safety Net is an umbrella program offering treatment and pre-treatment to people at various stages of readiness for help, who would otherwise be “lost in the cracks” of social services. The focus is specifically on reaching women and ex-offenders, two of Delaware's highest-risk populations.

In the past year, Safety Net has assisted with over 2500 outreach contacts and 248 HIV tests. Many of our referrals come from the BCI Outreach team, who upon identifying a contact from the target population, will introduce them to the Safety Net Intervention Specialist. The Intervention Specialist will then offer services, see the client through the admission process, and remain in contact throughout their treatment experience. Many referrals also come from the Emergency Room at the Wilmington Hospital, made possible by the unique partnership of BCI with Christiana Care. Both sources have proven to be very successful “front doors” to treatment admission. In the past year, we’ve seamlessly transitioned 74 clients to addiction and mental health treatment, with a total of 148 active clients in the Safety Net program.

Six months after admission, we measure several indicators of recovery and stability. Safety Net participants show good progress on all measures. 56% report no drug use, 80% report no alcohol use, and 52% report no alcohol or drug use. Many reporting HIV risk at admission report reduced risk, with 66% who reported high-risk sexual activity reducing or eliminating risk, and 66% of injection drug users ceasing use. Three-quarters of the clients not housed at admission are now housed. Of the clients reporting no income at admission, 39% now have income. Clients also improved their support system and social connectedness. Half of those without a support network at admission have developed one. 95% of clients have no new arrests. 90% of the clients on mental health medications are compliant with their medications.

Overall, Safety Net Services has enabled many Delawareans with severe addiction and mental health issues to achieve recovery and stability. Our approach is holistic, simultaneously addressing multiple critical issues. The result is a newly created network of services that effectively assists clients into substance abuse treatment and provides a safety net before, during, and after treatment engagement.

Safety Net Services is funded through a grant from the U.S. Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.

3 Years of Needle Exchange in Delaware: Saving Lives and Saving Dollars

The pilot Delaware Needle Exchange Program has had three very successful years. Over 700 people are enrolled, and over 38,654 needles have been exchanged. These potentially infectious syringes have been incinerated and destroyed. Not only have new infections been prevented, but participants have been successfully connected to substance abuse and HIV treatment services. Here are some more highlights, which we are also sharing with legislators today at the Joint Finance Committee budget hearings.

• 150 people have been referred to drug treatment, with an incredible follow up/success rate of 60%. Referrals have been made to methadone treatment, outpatient and inpatient drug treatment, and detoxification.


• Over 1200 people have been tested for HIV on the van. More than half were not needle exchange participants, but took advantage of the service being brought to their neighborhood. Testing has identified new HIV positive infections, as well as positives who know their status but are not in treatment. We are linking them to medical care and case management, which further reduces their risk of transmitting the virus.


• We have begun Pregnancy Screening on our van. Our goal is to reduce the infant mortality rate in Delaware by connecting drug abusing pregnant women to treatment immediately. This will ultimately save both the mother and the baby’s life. Delaware has an extremely successful record of preventing HIV infection among infants born to HIV infected mothers, with only one HIV-positive birth in the last 4 years. Expectant mothers with HIV in Delaware have access to comprehensive, high-quality care; yet, it remains imperative that we encourage them to be tested for HIV and to seek drug treatment.


• The needle exchange has made a difference for so many individuals in the past three years. Here is just one of those stories:
  
  "Cecilia" is a 24 year old Hispanic female who joined the needle exchange a little more than a year ago. She was an active drug user but was not ready for treatment. One day, after she had been with us about 6 months, Cecilia came on the van, tired and crying. She had finally had enough of the drug using lifestyle. We made her an appointment at the methadone clinic. She was having trouble signing up for Medicaid to handle her payments, so we helped her with that, and she was successfully admitted. At time of admission, she had a pregnancy test and found out she was 4 months pregnant. She stayed in treatment and gave birth to a healthy baby. Today Cecilia is still active in treatment and is also employed.


• Lastly, we would like to share with you the cost benefit of needle exchange. Delaware’s program receives $211,000 from the Division of Public Health each year. We know from a recent CDC study that preventing one new HIV infection saves $221,365 in treatment costs. So, the prevention of one new HIV infection pays for the Needle Exchange Program for one year. In three years, Delaware’s needle exchange has prevented an estimated 10-12 new infections by connecting nearly 20 people to HIV care. Therefore, we saved an estimated $2 million that would have been spent on treating those individuals - and that is a modest approximation that does not include the infections prevented when someone is admitted to substance abuse treatment.

The success of the needle exchange is thanks to the inclusive and considerate work of our program staff at Brandywine Counseling, along with incredible support from the City of Wilmington, neighborhood associations, the Faith Community, the Division of Public Health and the Wilmington Police. This is an excellent example of what can happen when a community mobilizes.

We must keep up the work we’re doing. This epidemic remains a challenge, but we are making progress. 3,489 people are living with HIV/AIDS in Delaware. The Black community accounts for 20.9% of the state’s population, but 66% of our HIV/AIDS cases. While the number of new infections each year has declined, in Delaware, 1 in every 83 Blacks has HIV/AIDS.

Delaware’s Needle Exchange remains dedicated to the following goals:

• We must encourage HIV testing for all those who are at risk.
• We must encourage all of those that are infected to seek treatment.
• We must encourage those not infected to take measures to ensure they remain uninfected. Until then, many will continue to pass the virus without knowing it.

Alpha Clients Had Shorter Wait, Fewer No-Shows in 2009

A few highlights from our year-end review of client access and retention data at the Alpha outpatient program:

• Your wait time went way down. The average time to the first individual session dropped from 18 days at the beginning of the year to 5 days. (see graph) We made it a priority to focus on your comfort at the Meet & Greet with your counselor, answering questions you had coming into the program, giving you tours of the building, and making sure we got you in soon for your individual session.

• You got mental health services sooner. Your wait time dropped from 6 weeks to 1-2 weeks. We asked our nurse practitioner to help out our psychiatrist one day a week to write prescriptions and do medication checks. It really made a difference!


• You kept your appointments more often. Your no-show rate for appointments was 21%, down from 24% in 2008. This was another priority for our counselors. We diligently reviewed our caseloads every week to keep track of who we needed to see, and made reminder phone calls.

Overall in 2009, Alpha saw 1827 people come in the door, admitted 860 and discharged 892. 19% of discharges were successful, and another 22% had some goals completed. We are proud and happy for your success, and we'll continue to improve our service to you in 2010.

Do you have an idea on how we can serve you better? Let us know! Use our suggestion box, send us an email, or speak to a staff member about your idea.

Research BCI Before You Give, with the GuideStar Exchange

Are you thinking about a donation to charity but want to do your research first? Now, more information than ever before is available to you through the GuideStar Exchange. Find out anything you want to know about a charity, and compare one to another!

BCI knows how important this information is to you, and that's why we've become a GuideStar Exchange Valued Partner. This means we've updated our non-profit report to the fullest, including general info, financials, tax forms, programs, key policies, and key people. (Some of the information requires free registration to view.)

The GuideStar Exchange is an initiative designed to connect nonprofits with current and potential supporters. It allows us to share a wealth of up-to-date information with you to allow you to research and compare the facts of each organization. So visit BCI on GuideStar today and make an informed decision about your giving.

2009 Annual Report

Brandywine Counseling proudly presents our 2009 Annual Report. Click to view our highlights of the past year and our goals for 2010, over a backdrop of artwork created by our talented client artists.

Here is just a small sample of what we achieved this year:

• The Delaware Needle Exchange has exchanged over 28,000 syringes, enrolled over 650 participants, and identified 14 HIV positives in nearly three years of operation.
• 449 methadone patients (40%) have at least 90 days of abstinence.
• The Alpha outpatient program discharged 44% of patients successfully or with some goals completed.
• Intensive Outpatient Services were introduced at Lancaster, Alpha, and Lighthouse to offer a higher level of care to individuals not succeeding in the traditional program.
• The Newark Center saw a 25% increase in the number of patients remaining in treatment for one year or more.

We could not do the work we do without your support. Thank you for making 2009 a year of success for us and for those we serve!

Homelessness in Delaware: Stats Tell Only Part of the Story

This is the time of year when we reapply for funding for our homeless program. Part of my job is to update the numbers we cite to demonstrate the need for our services. Delaware has a number of organizations that do excellent work and compile a ton of data; however, I must admit it’s a tedious task to pore over statistics, comparing last year’s stats with this year’s. It’s easy to forget that behind the percentages and bar graphs are real people with real stories. And I think many of us in Delaware are unaware of either the stats or the stories.

So perhaps by sharing some of both with you, I can make my work a little less dry by encouraging you to learn more about Delaware’s homeless problem. Find out what you can do to help by contacting BCI, supporting our work with a donation, or visiting another of the Web sites below.

First the stats:

• How many people are homeless in Delaware? 1,479, according to the Homeless Planning Council’s most recent point-in-time count. Their survey also indicated that 31% of Delaware’s homeless experience chronic substance abuse and 34% experience mental illness.

• How many people live below poverty level in Delaware? 10.3%, according to the 2007 U.S. census. In Sussex County, it is 9.7%. In past years, Sussex was above the state average, so it is interesting to see it go down. I would be interested to know what the reason for this could be.

• How much does it cost to rent a two-bedroom apartment in Delaware? $923 is the Fair Market Rent, the monthly cost of rent and utilities. The Housing Wage is the hourly wage someone must earn to afford this rent without spending more than 30% of their income. Currently, Delaware’s Housing Wage is $17.75 an hour, which equates to more than 2 minimum wage jobs working 40 hours per week year-round. These numbers are from the National Low Income Housing Coalition’s publication called “Out of Reach.”

Now the stories:

I recently discovered the video blog Invisible People through the Non-Profit List of Change. Each post is an interview with a homeless person, filmed in cities all across the country. I urge you to check it out to hear what daily life is like for them, in their own words. Here’s an example.

Tracy and her children from InvisiblePeople.tv on Vimeo.

BCI Reaches Reluctant Clients by Creating "Windows of Trust"

BCI’s Safety Net Services is featured in this month’s CSAT Grantee Spotlight. We’re pleased to reprint it for you here. Pictured from left: Case Manager Sharon Brown, Nurse Joyce Bunkley, Nurse Practioner Chris Zebley, and NSAFE Manager Rhonda Swanson.

Basha Silverman is the Director of HIV Prevention Services at Brandywine Counseling in Wilmington, Delaware, and is the Project Coordinator of its Safety Net Services project. Sharon Brown is the Case Manager for the Safety Net Services project. We spoke with Basha and Sharon about this TCE/HIV grant and discussed their challenges, solutions, and lessons learned.

Grantee Profile
Brandywine Counseling provides behavioral health services to individuals with substance abuse problems and their families. It is Delaware’s largest provider of outpatient addiction treatment services.

Brandywine provides opioid treatment, drug-free treatment, mental health treatment, and case management. It includes pregnant and parenting women’s services, a drug court program, an infectious diseases clinic, and an HIV prevention unit.

Safety Net Services is a multicomponent project offering integrated addiction pretreatment, treatment, and HIV/AIDS services. It incorporates outreach, HIV education and testing, medication management, and co-occurring disorders treatment. This grant targets women and ex-offenders and creates a safety net for at-risk and HIV-positive substance abusers at various stages of readiness to enter addiction treatment.

What are your unique challenges?
Clients have unique patterns of willingness, readiness, and commitment to treatment. They become interested, engaged, and disinterested, and leave, return, and cycle back and forth.

When engaged, clients visit us often, bring their babies, visit our clothes closet, and use our dropin services. We view these as special windows of opportunity to make use of clients’ motivation to change. But these windows can close quickly, challenging our ability to remain engaged.

Co-occurring mental health issues are notable challenges. When clients don’t have rapid access to mental health medications or professionals, their windows of opportunity can rapidly close and their treatment needs may be left unmet.

How do you address these challenges?
Since client willingness and readiness are dynamic processes, we make engagement methods flexible and dynamic. We meet clients where they are, not where we want them to be.

When clients stop coming to us, we reach out to them. But they shy away if outreach is coercive or pushy. Thus, we use gentle motivational interviewing techniques during outreach. We meet clients at times convenient to them. They are often on the street in the early mornings.

Our Case Manager will conduct outreach between 4:00 a.m. and 7:00 a.m. At such times, clients are often tired and willing to talk and join the Case Manager for coffee and donuts and discuss treatment. Many clients are willing to enter treatment on the spot. Since our program accepts intakes at 5:30 a.m., the Case Manager can take advantage of windows of opportunity and help admit clients immediately.

To enhance outreach effectiveness, our Case Manager has multiple roles. All of our clients are assigned a counselor and a Case Manager. Our Case Manager is an active part of the counseling team and conducts follow-up locating and outreach. Thus, clients already have a relationship with her. She is a friendly face.

We promote treatment-on-demand to address mental health challenges. CSAT funding helped us expand the roles and hours for our nurse and nurse practitioners. They previously worked only with HIV clients but now work with HIV clients and those with co-occurring disorders. We were also able to increase physician and psychiatrist time. These changes increased access to psychiatric evaluations and medication management. Having our Case Manager coordinate appointments further increased access and reduced waiting lists.

What lessons would you like to share?
Program and client goals can be at odds. A program may seek to achieve 80 percent abstinence, which is commendable. But clients may have such goals as getting a home or a job, leaving an abusing spouse, or reuniting with their children. They may want to be better spouses or parents.

We can improve the lives of our clients best if we use goals and milestones that are client-centered, realistic to each client, and take into consideration the resources in the community and clients’ lives.

We implemented several process improvements that resulted in reduced waiting time and increased admissions. To do so, we had someone anonymously walk through the admission process and experience it from a client’s perspective. This revealed delays to make appointments, complete the intake and assessment paperwork, enter treatment, and receive lab tests.

We convened a committee to analyze the processes. We took steps to reduce appointment times, shortened the admission process by eliminating duplicate admission and assessment paperwork, and reduced lab delays from weeks to hours by using same-day lab tests.

How has GPRA data collection helped you?
Asking the GPRA tool questions fosters thoughtful and probing discussions with clients. It helps to create relationships with clients and opens up windows of trust and intimacy. Asking the GPRA questions helps us to better understand clients’ lives, experiences, treatment needs, and resources.

This article is reprinted with permission from CSAT Discretionary Grantee News, July 2009.

9 1/2 Minutes HIV Awareness Campaign

Every 9 1/2 minutes (on average), someone in the United States is infected with HIV, the virus that causes AIDS. CDC has launched a new Nine and a Half Minutes campaign to raise awareness of this fact and promote prevention.

Where did 9 1/2 minutes estimate come from?

In 2008, CDC developed new estimates for the annual number of HIV infections—which suggest that about 56,300 new HIV infections occur each year. This estimate is a national average. CDC arrived at the 9½ minutes figure by dividing the number of minutes in one year by the 56,300 new HIV infections that were estimated for 2006. This result indicates that, on average, one new HIV infection occurs every 9.34 minutes in a year. For more information on the 56,300 estimate visit the HIV Incidence section of the CDC HIV Web site.

CDC offers information on how you can prevent HIV, avoid the onset of AIDS if you have HIV, and spread the word about the 9 ½ minutes campaign.

They also provide this useful testing widget you can place on your Web site to find a testing site near you. Get yours here.

Homelessness in Delaware: 2009 Point In Time Study

The Homeless Planning Council of Delaware has released their 2009 Point-in-Time Study. The publication examines Delaware's homeless population on January 27, 2009 and also provides a comparative analysis with previous years.

Among the findings:

• 34% of those with a disability experienced mental illness.
• 31% of those with a disability experienced substance abuse.
• Nearly 40% reported that they have been incarcerated.
• About one out of 10 have spent time in foster care, are veterans, or were homeless that night as a result of domestic violence.

Homelessness remains a problem in our state that affect us all. Services like BCI's Project Renewal remain necessary to improve the stability, health and quality of life for homeless substance abusers, by facilitating sobriety, treating mental health symptoms, treating health issues, stabilizing and improving housing and employment, and reducing criminal activity.

Delaware Needle Exchange Enrollment Reaches 500

As of today, we have 507 unduplicated clients enrolled in the City of Wilmington's Needle Exchange Pilot Program, who have exchanged more than 17,450 needles in two years and some change. This means that we have incinerated over 17,450 potentially infectious syringes and removed them from our streets. Since it is a one-for-one exchange, there is virtually no needle litter problem anymore.

231 participants self-reported that they were referred by another needle exchange client. This proves that word-of-mouth advertising is what works with this population.

Caucasian clients make up 71% of the caseload; however, we are working on increasing the participation of African Americans.

1087 Rapid HIV tests have been completed on the van. 182 HIV tests were NEP clients. The other 905 were community members who accessed HIV testing because we brought the service to them. As a result of our success with reaching the community residents where we target injection drug users, we are planning to begin offering the combination Hepatitis A and B vaccine on the NEP in the coming weeks.

Other noteworthy numbers:

• 11 HIV Positives have been identified on the van.
• 40 formal referrals to treatment.
• 25 confirmed linkages to drug treatment.

BCI Clients Staying Longer, Getting Younger, Remaining Abstinent

Our CQI committee, which gave us the satisfaction survey we posted yesterday, has also given us BCI's latest demographic report. It shows some interesting trends that we wanted to pass along:

• At the end of 2008, our census had increased to a total of 2161, reversing the decrease of 2007. There is evidence of increased consumer retention. (See graph) Last year we admitted 2987 people to treatment and discharged 2836.

• Our female census remains over 30%. Traditionally, it is more difficult to get women into treatment than men.

• Nearly 60% of BCI’s consumers are under the age of 35. The average age continues to get younger and younger. (See graph)

• 31% of consumers who were discharged attained some or all of their identified treatment goals. Examples of goals include improving your living situation, improving your physical health, and improving your social connectedness.

• The census in our Opioid Treatment Program now equals the census in our Drug Free Program. Opioid Treatment had been higher for years.

• A total of 40% of our Opioid Treatment patients have at least 90 days of abstinence and have some take-home privileges. This represents 34% of Lancaster’s 710 patients and 51% of South Chapel’s 378 patients. This is another number that goes up every year, and that’s a good thing!

2008 Patient Satisfaction Survey

The results of our 2008 patient satisfaction survey are in. Thanks to the 503 patients who responded and rated us in areas such as environment of the clinic, confidentiality, and how much counseling is helping you.

This year we saw a huge increase in the number of surveys completed – almost 200 more than in 2007! That is great because it gives us a 23% sample, which is much more representative of the total population.

In general, your ratings were very consistent from last year in all areas. One exception is a notable increase in satisfaction in mental health services at South Chapel. We think this is due to a dramatically reduced wait time. At one point last year, it was taking up to 13 weeks to schedule people for with the psychologist, but by shifting our staff time from other locations to Newark, we were able to reduce this to 4 weeks.

Some other highlights of the survey:
· You felt BCI’s services were confidential and private.
· You thought our rules and policies were carried out fairly.
· Overall, across all BCI locations, you were satisfied to very satisfied with your treatment.

Survey results have been shared with our staff, who will be working with our Continuous Quality Improvement committee to address your most important needs.

Do you have more suggestions for us? We want to hear from you. Did the survey touch on the issues that are important to you? If you were designing our survey, what questions would you ask?

Basha Silverman's Testimony at State Budget Hearings

My name is Basha Silverman. I am the Director of HIV Prevention programming at Brandywine Counseling in Wilmington. I am here to call your attention to the importance of the Needle Exchange Program on behalf of the Division of Public Health and the many individuals at risk of contracting HIV in Delaware. I understand you have some very difficult decisions to make this year, so I wanted to arm you with some information that may help you.

The Needle Exchange program does not only provide access to sterile equipment; it is a bridge to other services.

• In just 2 years, this mobile program has been extremely successful at identifying at-risk and HIV-infected individuals, and connecting them to medical care and substance abuse treatment.


• We are reaching a very, very hard to reach population that might not receive or follow through with services if the services were not brought to them.


• We have tested over 900 individuals on the van.


• To date, we have identified approximately 20 HIV positive individuals, and linked them to HIV treatment and case management.


• Additionally, we have successfully linked 62% of those ready for substance abuse treatment to a treatment center.


• Almost 40% of participants are women. When we connect a woman to treatment, especially a pregnant woman, we increase her chance of giving birth not only to a healthy baby, but one that is not HIV infected.

Why Needle Exchange?

• In Delaware, it took over a 10 year battle to pass such a significant piece of legislation.


• In the late 80s, methadone treatment was our best intervention known to combat HIV/AIDS. Today, needle exchange is the most widely studied and has proven to be most effective intervention to combat the spread of HIV.


• Needle exchange is not just HIV prevention, it is pre-treatment.


• Studies also show that once a person learns they are HIV positive, they are approximately 60% less likely to infect another person. Therefore, the testing efforts on our van are unquestionably a significant service that should not be cut.


• Lastly, just a reminder of the cost benefit. The needle exchange program costs roughly $200,000 a year to provide services on the van and make linkages to other services and programs designed to increase the overall health of Delawareans. In comparison, the estimated cost to treat ONE individual infected with HIV over their lifetime ranges from $300,000 to $600,000, depending on how long he or she lives. In two years, we prevented an estimated 10-12 new infections by connecting nearly 20 people to HIV care. Therefore, for $200,000, we saved an estimated $3 million that would have been spent on treating those individuals - and that is a modest approximation that does not include the infections prevented when someone is admitted to substance abuse treatment.

Thank you for listening. Thank you Senator Henry!

This Door Leads to Treatment, Not Back to Detox

The BCI Alpha outpatient program and Kirkwood Detox have significantly increased the percent of patients who leave Detox and complete an evaluation for treatment at BCI. In January 2009, 17 of 19 people referred here successfully completed their evaluation, compared to only 3 of 21 in January 2008. The project is the latest success story in our Paths to Recovery process improvement effort.

For years, we’ve struggled with how to engage people recently discharged from Detox. Typically, they’ve stopped using drugs, but haven’t stabilized their lifestyle, particularly their living environment. They were being discharged from Detox with only the instructions to go to BCI for an intake, and more often than not, they never showed up. Later, many would relapse and return to Detox in a revolving door cycle.

About a year ago, BCI and Kirkwood Detox went to work developing a personalized approach for these clients. We realized they are a unique population with unique needs. The solution we found was to give them more personal attention, and go above and beyond the normal referral process to ensure follow-through.

Detox staff began driving patients to our door upon their release. BCI began sending one of our counselors to Detox once a week to speak to patients about our treatment program, establish rapport, and motivate them to attend. Patients could start their intake paperwork at the time if they wanted to, and many chose to do so. Once someone was admitted to BCI, we offered them incentives to return for their first session. Over time, BCI and Detox fine-tuned our timing of discharge and orientation, exchanged patient lists to track who did or did not get to where they should be, and discussed individual cases as needed. As a result, we strengthened our collaborative relationship to the point where today, referrals are nearly seamless.

Coordination among agencies is so important when a client is moving from one to another. Since we've found a way to make it work, more people now have a chance at long-term recovery rather than being caught in a revolving door between addiction and Detox. Great job to everyone who played a part in this success.

Most Popular Posts Last Year

Happy New Year, readers! Let's start off 2009 with our Top 10 most popular posts in 2008.

1. Annual Door Decorating Contest
2. Mosaic Mural is Finished!
3. The Saying Goodbye to Addiction Tour at BCI
4. 5 Questions for Evelyn Handley, Receptionist
5. Delaware Does More: Neighbors Helping Neighbors All Winter Long
6. 5 Questions for Karen Barker, Account Manager
7. 5 Questions for Darlene Pezzulo, Nurse
8. Thanks to You, We're On Our Way to Playground Goal
9. 5 Questions for Dianna Dorsey, Outreach Worker
10. Daily Message 4/1/08


That's right, folks... at Brandywine Counseling, we treat addiction and save lives, but we also help you decorate your door for Christmas! :)

What makes a post popular, anyway? In some cases, people find us through Google, or Google Images. But more and more, our visitors come through email links that a friend sent them, or from a stumbleupon.com link another visitor created. This means YOU have a say in making a post popular.

So when you read something you like here, take a moment and click the ShareThis icon, or add us to your StumbleUpon. While I think most of the posts above deserve to be in the Top 10, I'd rather see this one on the list, and this one. This one was one of my faves too. What are your favorites?

Practice-Based Evidence?

In today's New York Times, Benedict Carey looks at whether evidence-based practices improve patients' success rate in treatment. Programs like BCI are increasingly accountable for showing our effectiveness, yet few have the stats to do so and there's no universal standard for success. Delaware is one of the states taking part in the Advancing Recovery project, in which we implement -- and track the results of -- techniques that science says are effective.

In 2001 the Delaware Division of Substance Abuse and Mental Health began giving treatment programs incentives, or bonuses, if they met certain benchmarks. The clinics could earn a bonus of up to 5 percent, for instance, if they kept a high percentage of addicts coming in at least weekly and ensured that those clients met their own goals, as measured both by clean urine tests and how well they functioned in everyday life, in school, at work, at home.

By 2006, the state’s rehabilitation programs were operating at 95 percent capacity, up from 50 percent in 2001; and 70 percent of patients were attending regular treatment sessions, up from 53 percent, according to an analysis of the policy published last summer in the journal Health Policy.

Carey suggests these Performance Based Contracts are an example of “‘Practice-Based Evidence,’ the results that programs and counselors themselves can document, based on their own work.” Why has this worked for Delaware? We focus on getting people in the door and keeping them here, because length of time in treatment is associated with successful outcomes. We’re rewarded financially when we do a good job at this, and penalized when we don’t.

But we also use many of the Evidence-Based Practices mentioned in the article, like motivational interviewing and cognitive behavioral therapy. Sometimes our results are great, and sometimes they’re not. You can read more about our work here.

This topic generates lots and lots of questions within the addictions field and the recovering community. Here’s just a few:

• What should be the definition of success in treatment?
• How do we provide individualized treatment within a treatment curriculum?
• What kind of evidence are we most interested in – evidence that comes from science, or from practice?
• And, how do we collect data to measure success in treatment without increasing costs?

A Network of Partnerships and Technology Makes "Safety Net" Work for Delaware's Severely Ill

One year ago, Brandywine Counseling began an ambitious, multifaceted project targeting Delawareans with some of the most severe needs for substance abuse, mental health, and HIV risk reduction services. Never before in the state had all of these services been connected under one umbrella. Safety Net Services has changed that, and the results so far indicate this approach is working.

We started this program last October with a 5 year grant from CSAT, and admitted our first clients in January. Many of them enter the program through Christiana Care’s Wilmington Hospital. They come to the hospital for emergency care, OB/GYN care, or other services, but also have substance abuse and/or mental health needs which the hospital system is not equipped to treat. Through Safety Net Services, we’ve established a partnership with Christiana Care and other agencies so we can link these patients to appropriate care, whether it’s medication management; HIV outreach, education and risk reduction counseling; or substance abuse treatment.

We are reaching people who could otherwise get “lost in the cracks.” On one occasion, a woman we encountered during street outreach tested positive for HIV on our mobile van. She was ready to be linked to medical care and other services, and also was ready to enter substance abuse treatment. We got her admitted to our program that day, enrolled her in our on-site HIV medical clinic so her health could be monitored, and also connected her with our HIV case management program (NSAFE). She now has easy access to all these services under one roof, increasing the likelihood that she can adhere to medical care and be successful in treatment.

Safety Net Services owes much of its success to technology. Staff have the ability to do “mobile intakes” out in the community, which creates a path of least resistance for clients to enter treatment. We use laptops with wireless air-cards for Internet access to remotely dial into the Brandywine Counseling servers. We also depend on cell phones to keep our team in constant communication with one another, whether it be for a new referral or to contact a client who has been absent for treatment. Constant communication among our staff from various programs lets us assist each client with managing their time and responsibilities, such as keeping appointments.

In the past year, we’ve seamlessly transitioned 75 clients to co-occurring treatment, in which substance abuse and mental health disorders are treated simultaneously. Our average client is 40 years old and female. About half the population is minority. Of the 75, 42 clients had medical problems in addition to HIV that required medication management at our “one stop shop” clinic, with an average of four medical problems per participant. Most (83%) of the clients also have a mental health diagnosis, most commonly major depression. They are also seeking greater stability in regards to living situation, employment and income.

Six months after admission, we measure several indicators of recovery and stability. Our clients show good progress on all measures. None had dropped out of treatment after six months. Two-thirds reported no drug use, half reported no alcohol use, and 40% reported no alcohol or drug use.

Overall, Safety Net Services is making recovery and stability possible for many Delawareans with severe substance abuse and mental health issues. This program has allowed us to focus on some of the most needy individuals in this community, simultaneously addressing multiple critical issues. The interagency partnerships with organizations like Christiana Care, and the new technology available to us, make it possible to reach people who would otherwise have no contact with treatment providers.

2008 Annual Report

Brandywine Counseling's 2008 Annual Report is now available for viewing. Click to see our many highlights over the past year and goals for the coming year. Here's a few examples:

• All sites have reduced the wait time for psychiatric services by 4 to 5 weeks.


• 412 opioid treatment patients have at least 90 days of abstinence.


• The needle exchange has identified 7 HIV positives in less than two years.


• The Lighthouse Program will expand its capacity from 10 to 14 women.


• Alpha North Wilmington increased its patient census from 28 to 60 after moving to the Edgemoor Community Center.

Thank you to the staff for their excellent work this past year. And thank you to all our donors and volunteers who supported us. We look forward to another year of successes and lives saved in 2009.

Ten Thousand Needles Off Delaware's Streets Through Exchange

Delaware's needle exchange program passed another huge milestone recently when we exchanged our 10,000th syringe. What an accomplishment for a program now entering its twentieth month of operation. Six months ago, our total was at 3,500.

Every syringe has been exchanged for a clean one, meaning ten thousand dirty ones are no longer on the streets of Wilmington. Because it's a one-for-one exchange, there is incentive for participants to bring every clean one back after it’s been used. So although we’ve given out ten thousand syringes, they are being returned. The effect is not needle litter, but the opposite.

Here’s some more impressive numbers:

• We’ve enrolled a total of 353 participants.
• A total of 1697 exchanges have taken place.
• 132 participants were referred by another needle exchange participant.
• 17 participants have entered drug treatment.
• Since November 2007, 621 rapid HIV tests have been done on our van. 7 positives have been identified.

New AIDS Infection Estimate Is A "Wake-Up Call"

About 55,000 Americans are infected with HIV each year, according to the Centers for Disease Control and Prevention. This number had been thought to be 40,000 a year, until a new, more accurate blood test was introduced. The new test can tell how long ago an infection occurred.

The CDC report also found that HIV infections are falling among injection drug users. Some experts are giving the credit to prevention efforts including syringe exchange, while at the same time calling for additional funding to expand them. Many populations continue to be at high risk, including gay and bisexual men, those under 30, and African Americans.

Whether more funding comes or not, the revised estimate clearly is a "wake-up call to scale things up," said Dr. Kevin Fenton, who oversees CDC's prevention efforts for HIV/AIDS.

For more information, see:
The full article
CDC HIV Fact Sheets

300 Participants

Today, Tuesday July 29th, we enrolled our 300th participant in the needle exchange. The exchange has been operating in Delaware for a year and a half.

Alpha Program Shortens Wait Time, Reduces No-Shows

The BCI Alpha Drug Free Program is seeing our clients engage in treatment more quickly after admission. At the same time, we see the fewest no-shows we've ever had for appointments. These are our latest successes in Paths to Recovery, patient-focused process improvement without additional costs or staff.

In the month of April, our clients progressed from admission to their first unit of service (individual or group) in an average of 9 days, which is the fastest in two years. Our average had been 12 days.

These results came after we introduced a new service called the Meet & Greet. This is the first time the client returns after admission. On average, it's 4 days afterward. They meet their assigned counselor, review the program rules, view a ten-minute orientation video, and schedule their first individual appointment. It’s a much more streamlined version of how we used to do orientation. Previously, clients would not meet their counselor until the first individual, nearly a week later. Knowing how important it is to establish the therapeutic alliance, we made it a priority to push this meeting up as early as possible.

Also in the month of April, our no-show rate dropped to 19%, which is our lowest in two years. This is for individual appointments for all active clients. Our average had been 26%. Client retention is also better, with more people staying in the program past the 45 day benchmark.

This came about because of our new, retooled motivational incentives. Since February 2008, each client draws from the fishbowl once at every individual and every group. They can win credits of $1, $5, $10, or $50 which they can bank and redeem for prizes including gift cards, bus passes, and 12 Step items.

This is a real turnaround after we had used motivational incentives for a year without seeing improved no-shows. Before, there were fewer chances to win since draws were not done in groups. There were also “Good Job” certificates mixed in with the prizes which had no value in dollars, only as motivation. Turns out, they weren’t very motivational! So the “Good Jobs” are now gone, and every draw wins something. And the best part is, the cost to the program is about the same. Banking of credits is also new, giving clients a choice to cash in right away or save up for something they really need.

Both of these projects took a long time to fine tune and perfect. The Alpha change team worked at this week after week at our lunchtime meetings. Our ideas made sense, and we expected them to work, but if the numbers didn’t show it, it was back to the drawing board. In terms of the PDSA cycle, it seemed like we were stuck on "A" for “adapt.” It just shows that process improvement in addiction treatment is hard work. It doesn’t get any easier just because you’ve been working at it for nearly5 years.

So it is all the more rewarding when we do get the great stats we’ve been waiting for. Good Job! I mean, Good Work, team!

2007 Patient Satisfaction Survey

The results of BCI's 2007 patient satisfaction survey are now posted on our website. Thanks to the 313 patients who responded and rated us in areas such as environment of the clinic, confidentiality, and how much counseling is helping you.

While the ratings in all areas were in the acceptable range, we generally saw lower scores than in past years. The area of most concern to us is whether psychiatric/psychological services were helpful. Mental health services are an area we know needs improvement, which these scores confirm. You will be glad to know we are already taking steps to reduce the wait time, increase our staff training, and move closer to a "seamless continuum" of treatment for co-occurring disorders.

Survey results have been communicated to our staff, who will be working with our Continuous Quality Improvement committee to address the most important needs of you, our customers.

Needle Exchange: 200 Enrolled!

The Needle Exchange team has enrolled our 200th client in the program. We now stand at 3,482 needles exchanged during 698 different exchange events. Over 80 referrals have been made, including 12 to methadone treatment. Five HIV positive clients have been identified on the needle exchange van.

Well done, team!

Celebrating 1 Year of Needle Exchange

Today is the first anniversary of Delaware’s pilot Needle Exchange Program in Wilmington. Some stats courtesy of John Kennedy from the Division of Public Health:

180 clients are enrolled in the program. We’ve exchanged over 2,700 dirty needles for sterile ones and we’ve referred 79 clients to treatment. We’ve identified three new HIV positives who hopefully won’t infect anyone else.

BCI has been using the new spacious van since November, and it now goes to 9 sites, including evening and weekend hours. Community and police support continues to be outstanding. New clients are being referred by word of mouth, from community members, political leaders, and the police.

Congratulations to our NEP team and DPH on a successful first year!

Motivational Incentives: Counselors Have the Final Say

If you’ve been following our Advancing Recovery experiment to reward attendance in treatment with motivational incentives, you know it’s been a challenge. While it hasn't yet proven successful at retaining clients in treatment longer, I can say we’ve learned a lot from this project. The number one lesson may be that there must be counselor buy-in for there to even be a chance for this strategy to work. All the focus groups you can offer, or all the detail you put in your training manual, may not make a difference.

To give out a prize at the end of a counseling session seemed so simple, but it turned out to be much more complex. Our counselors are great at what they do because of their own personal philosophy that guides their sessions and their interactions with clients. To implement motivational incentives, they had to alter their preferred way of doing things in a way we might think was insignificant, but to them was not. What if you had five minutes left in your session to do a prize drawing and you were in a middle of a meaningful discussion with a client? What if a client won a “Good Job” certificate but really needed a bus pass?

I believe everyone tried their best to make the project work, but ultimately, counselors will do what they think is in the client’s best interest. This is why our counselors overruled a decision to change the group drawings. We proposed a new random drawing process in which three clients would win a prize at every group, because an immediate reward is the best reinforcer of attendance. But the counselors recognized that not everyone would win. They preferred that every client who attended their required groups get a reward, even if they had to wait days or weeks later to get that reward.

To be fair, many of our counselors do support the incentives and report that their clients enjoy the program. But if we had one suggestion for treatment providers planning to implement motivational incentives, it would be to pilot test with a few counselors rather than all.

There is some good news to report. For the first time, we surpassed our target 5% improvement in retention at one milestone. 90% of clients admitted in the month of July completed their first individual session. We will continue the project at least another two months and see if this improvement can be sustained, and extended to other milestones; namely, the second and third individual sessions.

Confound It! Outside Forces Interfere with Incentives Experiment

The question: Will clients stay longer in addiction treatment if we reward them for attendance? The answer: Well, we don’t know. And I’m not being smart, that is an actual scientific explanation. Let me explain.

Our attendance is still below normal since we changed how we give incentives. We could say the new incentives caused attendance to drop – if that was the only thing that changed. But it wasn’t. Over the same time period, record-high numbers of people came in for an intake, and our census increased by 50. On top of that, two counselors and one supervisor were out for several weeks. (One was stuck on the other side of the world – trust me, you don’t want to know.) There were fewer staff to see more clients. If you were a client, which change would be more noticeable to you?

In scientific terms, we manipulated an independent variable (new incentives vs. old incentives) and measured the effect on a dependent variable (retention). Ideally, we would hold all other conditions constant. But our experiment was in a real treatment program, not a laboratory. And wouldn’t you know it, you can’t control external forces in the real world. A condition that offers an alternative and plausible explanation for the results of an experiment is called a confounding variable.

Census and staffing acted as confounding variables in our experiment. This means we can’t call the incentives a success or failure yet. But now things have stabilized and we will keep going. So bear with us, we may get a real answer to our question soon.

Some new developments to report:

• Our new marketing slogan is in place: Participation = Celebration!
• We’ll be adding prize drawings in groups because the more frequent the reward, the better at reinforcing attendance. Until now, clients got credit for group attendance but had to wait until their next individual session to get their reward.
• Counselors held a focus group to share challenges they had in implementing the program and solutions they had found. Since prize drawings took valuable minutes away from sessions, we moved the prize cabinet closer to counselors’ offices. We also learned that counselors are accustomed to using incentives to reward accomplishments and meet individual needs, so it is a real change to reward participation. A refresher training is planned, and we’ve invited an incentives expert to meet with the staff.

Motivational Incentives Update: We Hit Some Barriers On the Road To Change

Two months ago, it looked like all was going well with our motivational incentives project. Given the chance to win prizes for attending their sessions, more clients were staying longer in treatment. It’s now been about four months and 200 people admitted since we began. The results? Retention is either unchanged, or as much as 10% lower.

Yes, you heard me right – this change we made isn’t working. What should we do? Scrap the new process and go back to our old way of doing things? Or do we press on and trust the research that says motivational incentives improve treatment outcomes? The stakes are high; real people with real drug and alcohol addictions are depending on us.

This is precisely why at BCI, we follow the NIATx model of organizational change: Plan, Do, Study, Act. With major change, some barriers are to be expected. Before we jump to any conclusions, we should question why we got the results we did.

Let’s look at the barriers we faced. First, our client volume was up during the last two months, with admissions and discharges both about 25% higher than normal. At the same time, our staff was down by two counselors, leaving us with six instead of eight. Not only were more clients coming in and out, but counselors had to deal with higher caseloads. Bad timing, but this is the real world, and these things happen.

But that isn’t all. The incentives procedure we had carefully planned out and trained our staff in wasn’t exactly going as planned. Sometimes, clients had to wait to get their prize because the counselor ran out of time. Counselors were faced with altering their preferred way of running a session. At least one counselor admitted he discouraged his clients from drawing for prizes because it was against his own philosophy of treatment.

Should we be surprised that the staff was not totally on board with the incentives? NIATx says no. Change is difficult. If we really want our project to succeed, we should acknowledge internal resistance and try to overcome it. We’re already looking at how to do this.

We’re also faced with other difficult questions. What caused our retention to go down? Was it the external things beyond our control, or the logistical issues that arose? Now that our census and staffing are back to normal, will we see better results? How much longer do we continue the incentives before declaring them a success or failure?

We want to hear your thoughts as well. And keep watching along with us to see what happens next.

Rewarding attendance: Does it lead to success in treatment?

What if addiction treatment programs gave out prizes to patients just for showing up to treatment? Some might call this a waste of money, or bribery, or counter-productive to addressing the underlying issues of addiction. Others say it actually helps patients succeed. Brandywine Counseling is studying this very question as part of the Advancing Recovery project.

Since February 15, the Alpha Program has offered motivational incentives to encourage participation early in treatment. Beginning when the patient first returns after admission, they get a chance to win a prize. They could win anything from a “Good Job” certificate up to a $75 gift certificate. Our “prize closet” also includes scented candles, backscratchers, Dunkin’ Donuts cards, and recovery-themed coins.


It’s a simple premise: Show up to your first session with your counselor and you get one draw from the fishbowl. Show up to your second and third sessions and get five draws each time. Sounds easy enough, right? In fact, attendance in treatment is a challenge, particularly early. Before we started this program, 2 out of every 10 patients dropped out before their first session, another 2 by the second, and another 2 by the third. The incentives are our attempt to help them through the most difficult part.

So is it working? Results are just starting to come in, but it appears our retention is improving. As the graph below shows, 5% more patients are completing their first session (89%) and staying at least 45 days in treatment (76%). We are especially keeping our eye on the second and third sessions once the numbers come in. Stay tuned for more updates in the coming weeks.