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 Paths
to Recovery
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What is P2R?
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Meet the P2R Teams
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See the Changes We've Made
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P2R Official Site
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Related Projects: Advancing Recovery
and COSIG
 What
Is P2R?
Paths to Recovery is a revolution in addiction
treatment.
In September 2003, BCI began an effort to improve patient access and retention
as a member of the Network for Improvement of Addiction Treatment (NIATx).
This nationwide initiative is sponsored by the Robert Wood Johnson
Foundation and the Center for Substance Abuse Treatment, Substance Abuse
and Mental Health Services Administration.
The P2R teams at the Alpha Outpatient Program
and Opioid Treatment Program have made many changes that have
benefited clients, including same-day methadone intake and medication.
On this page, we will
report on the improvements we've made and the benefits for our patients.
Meet the P2R Team
Brandywine Counseling's P2R Change
Team has representation from all job categories critical to the
functioning of the program, as well as staff not directly connected with
the program who have expertise in relevant areas like data collection.
The team has a Change Leader who provides day-to-day leadership of the project and ensures
the objectives are accomplished. The Executive Director
serves as Executive Champion, providing overall leadership. The team
meets regularly to develop, implement, and study ways to improve access and
retention. A climate where team members bring their experience, not their
title, to the table has brought enthusiasm and productivity to a process
that would otherwise be very challenging.
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Alpha P2R Team
- Mark Lanyon, Change Leader
- Reanard Britt, Therapeutic
Supervisor
- Steve Burns, Assessor
- Matt Friedman, Executive
Assistant
- James Kennedy, Counselor
- Alesha Russell, Counselor
- Cheryl Williams, Office Manager
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The Delaware COSIG team at the NIATx Change
Leader Academy, June 2008.
We're
Making a Difference!
P2R's overall goal of improving access
and retention actually consists of 4 aims: increasing admissions, reducing
wait time, increasing continuation, and reducing no-shows. All of our change
projects are directly related to one or more of these 4 aims. Learn more about
each project in the
Opioid Treatment and
Drug Free programs below.
► Access
►
Retention
 Increase Admissions
Reduce Wait Time
Increase Continuation
Reduce No-Shows
Opioid Treatment Program
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Change Project |
NIATx Aim |
Results |
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6/2008-present:
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Reduce wait list for mental health services
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The
wait time to see the psychiatrist was 9 weeks; to see the
psychologist, 6 weeks. We began to prioritize patients on the list
by how quickly they need service. The nurse practitioner took over
some of the medication checks.
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Psychiatrist's wait time down to two months, although emergencies are
seen right away.
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11/2006-3/2007:
► Evening
Program
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Late
afternoon dispensing hours introduced to alleviate AM volume.
Clients with at least 12 months of clean time are eligible. New
level of take home privileges introduced: 13 days of medication
after 24 months of clean time.
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More than
700 people were coming in the morning. Expanded hours shifted 86
people to afternoon.
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8/2006-11/2006:
► Intake
on demand
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Supervisors review weekly reports and discuss caseload management
with counselors.
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- When a
counselor has an extended absence, individuals and groups will be
provided by any counselor available to get clients their required
contacts.
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- 92% of people requesting service were
admitted in September '06. Our previous high was 71% and average was
63%. - Shortest ever wait from
first contact to admission - under 3 days. |
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2/2006-7/2006:
►Provide 100% of required monthly
contacts
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Supervisors review weekly reports and discuss caseload management
with counselors.
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- When a
counselor has an extended absence, individuals and groups will be
provided by any counselor available to get clients their required
contacts.
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- No-shows decreased from
22% to 16%, equivalent to 50 more people per month showing for their
appointment.
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7/2005-3/2006:
►Reduce number of clients who drop
out of treatment
- “Before You Walk
Away” posters give information
- New groups
focusing on cocaine use and orientation of new admissions aim to
improve engagement. Take-home medication awarded for successful
completion.
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- About 6
clients have received permanent 1-day take-homes after completing
the 6-week series and meeting other take-home criteria including
negative drug screens.
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Discharges
down 12%.
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% of
discharges who left voluntarily down 12% (from 77% to 68%).
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4/2005-11/2005:
►Reduce missed doses early in
treatment
Clients who do not
miss a day of medication pickup during the first 30 days will
receive an incentive
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No apparent effect. Number
of clients picking up all doses in their first 30 days varied between
26%-41% with no apparent trend. |
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7/2004:
►Enforce
penalties for missed appointments
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Clients missing 3 appointments in a row must see counselor before
being medicated.
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- Time from admission to 1st individual session
▼
9 days (to 9). |
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7/2004:
►Special
focus on Suboxone patients
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Increase % of
Suboxone clients who continue in treatment with faster transfer &
separate group
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- Change abandoned. Majority of Suboxone clients failed and
transferred to methadone.
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- 6/2004:
►Recovery
Counts - Alternative
program for repeat clients
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Increase % of clients continuing treatment by offering alternative
program without penalty for continued drug use
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- - Two clients
awarded first travel bottle and will graduate, returning to
traditional treatment.
- - Five clients have
negative drug screens for 2 months or less.
- - Census maintained
at 25. Of initial group of 12, 10 remained in program 5 months or
longer.
- - Four clients found
jobs; many obtained housing.
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1/2004:
►Same
day admission
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Instant urinalysis screening eliminates wait for results.
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Orientation video
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- Average
wait from intake to first medication dose▼
from 2 days to same day
- - Average time from
first contact to first dose▼
from 6 days to 4
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3/2004:
► Increase
intake slots from 15 to 18 per week
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- Monthly
admissions▲
to all time high
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- Wait from first
contact to first dose
▼ to 6 days
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9/2003:
►►Faster
transfers/ increase intake slots
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Shorten stay in intake unit;
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Increase intake
slots from 12 to 15 per week.
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- Intake Unit
caseload ▼
49%
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- Wait for transfer ▼by 10 days
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- Admissions ▲ 20%
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3/2003:
►Phone
pre-screen at 1st contact
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Nurses make appointments
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- Wait for intake
▼
50% (to 2 weeks).
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Drug Free Treatment Program |
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Change Project |
NIATx Aim |
Results |
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1/2008-1/2009:
►Increase
success rate of referrals from Detox
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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.
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In January 2009, 17 of 19 people referred
to BCI from Detox successfully completed their evaluation, compared to
only 3 of 21 in January 2008. We
realized this is a unique population with unique needs. The solution
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. |
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2/2008-2/2009:
►Increase
recovery support to decrease recidivism
- We want to decrease our readmission
rate from 32%, and increase our average length of stay from 102
days. We introduced the Evidence Based Practice of Telephone
Continuing Care for clients who have done well in treatment and want
to prevent relapse.
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· Clients
transfer to our Aftercare Specialist and call in at least twice a month
for 12 weeks. Clients also offered recovery coaching through the
1212 Club as community-based peer support.
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31 clients have taken part in telephone continuing care since February 2008.
71% of 95 scheduled
telephone contacts have been completed. Many anecdotal success
stories. Readmissions declined to an average of 28%. Average length
of stay has shown little change.
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9/2007-6/2008:
►►Meet
& Greet as first session
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Replace First Step
Group with a Meet and Greet as the first session after admission.
Instead of a large group where rules are explained, clients meet
with their assigned counselor in a smaller group and view an
orientation video. Goal is to improve retention by having clients
meet their counselor sooner (Day 4 compared to Day 10).
Assessors assign
clients to counselors using decision tree. Meet and Greet structure
standardized.
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For several months we
saw no improvement. Further adjustments were needed.
Rather than give
clients an appointment to return, they are given a list of four weekly
slots with their assigned counselor and can choose when to return.
Staff began to use a computerized scheduler to keep track of
appointments. The receptionist began to help counselors make reminder
phone calls.
Following these
changes, clients progressed from admission to their first unit of
service in 9 days, down from an average of 12. |
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6/2006-2/2009:
►Improve
early engagement
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Retention had plateaued at 82% through 1st individual, 60% through
2nd individual. Longer time in treatment is associated with
successful outcomes, which are rewarded by performance based
contract. Incorporate the Evidence Based Practice of Motivational
Incentives to encourage active participation in all phases of
treatment.
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· We
used to give incentives for every ten contacts, usually bus tickets.
A survey
showed that clients would like different incentives (grocery cards,
hair/nails done, gas cards).
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Staff increased our knowledge of motivational
incentives through training and literature review.
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Fishbowl drawing procedure developed. Draws begin at Meet and Greet
session. Individual session and group attendance also
earns draws.
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Staff objections about incentives addressed through
survey about attitudes.
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Our first motivational
incentives program was in use during 2007. After one year, we
did not see our target 5% improvement in retention, so retooling was
needed.
Beginning February 2008, we increased the chances to earn prizes and allowed
clients to bank their credits.
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Our restructured
motivational incentives have been in use for nearly all of 2008.
Retention has increased through the first individual session to 76%,
the second session to 55%, and the third session to 41%.
Our
no-show rate for individual appointments has dropped to 21% from
28%. However, our retention is still lower than under our original,
non-Evidence-Based incentives.
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1/2006-6/2006:
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Earlier first treatment
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Open groups – clients are encouraged in First Step Group to start
coming to any group right away. Any client who cannot make their
regular group and wants to come to a different group is permitted to
do so.
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Time from admission to first treatment session
reduced from 15 days to 11, lowest in a year.
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Time from First Step Group to first treatment session
reduced from 9 days to 7 days, lowest in a year.
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8/2005-12/2005:
►Reduce individual no-shows
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Receptionist makes reminder calls before each individual session.
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No-show rate averages 39% without calls, 32% with calls. This is
equivalent to 26 more people keeping their appointment each month. |
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5/2005-11/2005:
►Reduce
probation discharges
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Letters of continuation after loss of contact sent to probation
officers as well as client to see if more re-engage in treatment
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Re-engagement rate increases from 41% to 53%. |
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3/2005-7/2005:
►
Improve
return rate with session rating scale
One counselor asks clients to rate the helpfulness of the session
using SRS at end of every individual session
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No improvement. Counselor’s no-show rate averaged 34% pre-change and
37%
post-change. |
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12/2004-7/2005:
►
Increase group attendance
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Get ideas from the
customer
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Do structured exercises
designed to raise interest
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Videotape groups and
give feedback to facilitators
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Group continuation showed
little change. Pre-change, 61% completed at least one group,
post-change 70%. Completion of five groups was unchanged from 42%.
While the project succeeded at improving content and facilitation
skills, other factors are believed responsible for why clients do not
attend group, such as schedule conflicts and transportation problems.
The project did increase the skills and enthusiasm of staff, and
benefited the clients who did attend in the short and long term. |
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7/2004:
►►Faster
engagement
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Orientation video
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New "First Step" group
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Clients given
appointment slips.
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- - Time from
admission to orientation ▼ 6 days (to 0).
- - Time to 1st group
▼ 11 days (to 6).
- - Continuation to
1st group ▲ 100% (to 87%).
- - Time to 1st
individual session ▼ 6 days (to 13).
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Advancing Recovery
From 2006-2009,
Brandywine Counseling and the State of Delaware took part in the Robert
Wood Johnson Foundation's (RWJF)
Advancing
Recovery: State/Provider Partnerships for Quality Addiction Care
national initiative. The project
promoted the use of evidence-based clinical practices through innovative
partnerships between substance abuse treatment provider organizations that
deliver care and single state agencies. Delaware was one of six state-provider partnerships that participated in a
learning network that provided tools to improve the delivery of addiction
treatment. Funding supported the process of making changes at both the
state and the service provider levels to maximize the implementation of
proven addiction treatment practices.
Delaware's goal was:
1) improving active participation rates by use of motivational incentives and
other innovative practices, and 2) improving or introducing post-treatment care
by use of telephone based continuing care (TBC) and other innovative
methodologies.
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BCI's
motivational incentives increased retention through the first individual session
from 73% to 76%. Our no-show rate for individual appointments dropped to 21%
from 28%. At one
benchmark, attendance at the fifth group session, we reached our target 5%
increase over our performance without any EBP incentives.
The primary lesson learned related to the art of
getting the reward process fine tuned to get the best results if you are
implementing the MI program. This required a lot of on-going trial and error to
develop the most effective system.
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BCI's TBC program
enrolled 34 clients since February 2008. 60% of phone contacts were successful.
It appears that TBC lowers our no-show rates, but did not impact our treatment
retention rates.
Overall, the goals of
Advancing Recovery were met with a lot of success for the MI initiative, but
with more challenges for TBC.
For more information, visit
www.advancingrecovery.net.
COSIG Project
In 2007, the State of Delaware was awarded a
Co-Occurring State Incentive Grant (COSIG) to further develop its system
and workforce in order to more appropriately and effectively serve persons
with co-occurring disorders. As part of this project, the State has
created the Delaware Co-Occurring Academy, of which BCI is a part. With
the advice and guidance of the State’s advisor, Dr. David Mee-Lee, the
Academy provides support for system change, removes any remaining barriers
to providing co-occurring treatment services, determines how to best
expand and enhance system wide treatment capabilities, and decides on
co-occurring disorders credentialing/certification for Delaware treatment
staff. BCI clinicians are also receiving training, on-site supervision,
and assistance to implement co-occurring treatment practices.
About
the Robert Wood Johnson Foundation
www.rwjf.org
The Robert
Wood Johnson Foundation focuses on the pressing health and health care issues
facing our country. As the nation's largest philanthropy devoted exclusively to
improving the health and health care of all Americans, the Foundation works with
a diverse group of organizations and individuals to identify solutions and
achieve comprehensive, meaningful and timely change. For more than 30 years the
Foundation has brought experience, commitment, and a rigorous, balanced approach
to the problems that affect the health and health care of those it serves. When
it comes to helping Americans lead healthier lives and get the care they need,
the Foundation expects to make a difference in your lifetime.
About
NIATx
www.niatx.net
The Network
for the Improvement of Addiction Treatment (NIATx) is a national initiative
supported by the Robert Wood Johnson Foundation’s Paths to Recovery program and
the Center for Substance Abuse Treatment’s (CSAT) Strengthening Treatment Access
and Retention (STAR) program.
About the Treatment Research Institute
www.tresearch.org
The
Treatment Research Institute is a not-for-profit research and development
organization dedicated to reducing the devastating effects of alcohol and other
drug abuse on individuals, families and communities by employing scientific
methods and disseminating evidence-based information.
Last updated
February 09, 2010
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