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.