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!

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.

How to Overcome Incentives’ Bad Rap?

Jason Schwartz at Addiction and Recovery News posed some interesting questions about the use of incentives in treatment. He asks: If incentives help people stay in treatment, but the public is against it, is it the right thing to do?

It’s easy to dismiss incentives as a bribe or a quick fix. With our new program here at Brandywine, it’s been a challenge for even our own counselors to grasp the concept. The point is that we want clients to stick with treatment, regardless of the reason. Whether someone is self-motivated or they just want to win a gift certificate, we want them to stay, because the longer they stay, the more likely they will succeed. There is no wrong reason.

We came up with a slogan, “Participation = Celebration,” that really encapsulates the meaning of our incentives and will hopefully stay with our clients (and staff) after they hear it a number of times. I would also rely on this phrase to explain our program to the public. A little education can go a long way. Having said that, the best way to turn skeptics into supporters is with data showing improved outcomes. In our case, we’re still waiting to see this.

Jason goes on to ask, “Why are we not talking about this kind of intervention with non-compliant patients in cardiac care units, diabetes clinics, weight loss programs, etc.? Is it because we respect them too much to offer gift certificates for following their treatment plan?”

I have yet to hear that any of our clients have felt insulted at being offered a reward. I’ve been told that incentives programs have been proven to improve treatment outcomes even when the clients say the incentives didn’t make a difference. The same might just be true in other settings.

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.

Participation = Celebration!

Our new slogan at the BCI Alpha Drug Free Program. Thanks to Intake Counselor Marc Weisburg for the idea.

Vote For Our Motivational Incentives Slogan

As many of you know, BCI Alpha has been offering motivational incentives to encourage more people to stay in drug and alcohol treatment for at least three months. It remains a challenge – more on that in an upcoming post. We continue to believe this can work and we want to do whatever we can to make it a success.

We’ve decided we need a marketing slogan. If we want to convince people to stay longer in treatment, we need to change their mindset. We need to “sell” our customers on the benefits of sticking with treatment once they’re here. We want to drive home the point that the first few months can be the most difficult, and BCI offers these prizes to help people through this period.

So we want a memorable catch phrase that will generate word of mouth. Something that clients can be reminded of every time they walk in our door, but also remember when they’re not here, and contemplating whether to show up for their appointment.

Help us choose a great slogan by voting for your favorite below, and also post your own ideas. We’ll announce our choice July 18. Thanks!

		What is the best slogan?
	The more you come in, the more you win.
	Beginners are winners.
	Recovery: Keep your eyes on the prize.
	Recovery is the jumbo prize. Start small. Keep coming back.
	Spend an hour in treatment, win a prize. Spend enough hours, win your recovery.
	Come for the prizes. Stay for recovery.
Free polls from Pollhost.com

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.