In 2004, an estimated 23.4 million Americans age 12 and older were classified with dependence on or abuse of either alcohol or illicit drugs. In the same year, just 2.33 million received some level of treatment.1 Only about 51% of those who enter treatment complete it.2
While finances and psychological readiness explain some of this deficit, the issue that often keeps clients from treatment is the way services are delivered. Systems engineering, process improvement, and innovative uses of technology have been shown to improve quality and efficiency of service delivery processes in other industries. The Network for the Improvement of Addiction Treatment (NIATx), based at the University of Wisconsin–Madison, brings these resources to substance abuse organizations.
NIATx is a partnership between the Robert Wood Johnson Foundation's Paths to Recovery program and the Center for Substance Abuse Treatment's Strengthening Treatment Access and Retention program. The mission of NIATx is to help providers learn process-improvement strategies to increase client access to and retention in substance abuse treatment (see sidebar).
NIATx focuses on four aims: to reduce waiting time to treatment, reduce the percentage of treatment no-shows, reduce the percentage of clients who leave treatment early, and increase the percentage of clients admitted to treatment. The four aims help NIATx members reach two long-term goals—to increase the treatment organization's capacity to improve and to enhance the organization's bottom line. By making progress on each of the four aims, organizations become more efficient financially and gain skills leading to greater organizational improvements. The 39 treatment agencies (including 9 mental health agencies with addiction services) in 25 states that participate in NIATx are demonstrating the potential of process improvement to help treatment agencies improve the work processes that influence treatment access and client retention.
Kentucky River Community Care (KRCC), which operates 40 sites in 8 rural counties in the Appalachian region of southeastern Kentucky, is a NIATx member. In each of the counties comprising its service region, KRCC operates an eight-bed adult and a two-bed youth residential detoxification program, an intensive outpatient program for women, and an outpatient clinic, among other programs. The population served at KRCC has an average age range of 25 to 35 and is predominantly male. The most common substances for which people seek addiction treatment include nicotine, alcohol, marijuana, and opioids.
Louise Howell, PhD, has served as director of KRCC for nearly two decades. With a background in social work and systems science, Dr. Howell always has worked with the KRCC management team to identify ways to improve organizational processes. That focus on improving systems, the need for technical assistance, and the difficulty of self-study are what drew Dr. Howell to the NIATx model.
“Our leadership team had been working together for several years, but we didn't really understand change and process improvement,” she explains. “We knew we wanted to improve our ‘front door.’ We had many programs, but clients really had to extend themselves to become our clients. That was unsatisfactory.”
Identifying the Problems
The first change project that KRCC attempted as part of NIATx focused on one of the four aims: to reduce the waiting time between first request for service and first treatment session at the Perry County Outpatient Substance Abuse site. Of the approximately 1,000 people treated annually at KRCC, approximately 400 use the Perry County site.
A group of KRCC staff called a “change team” began the change project with a “walk-through,” an exercise in which staff members experience the treatment process just as a client does. NIATx has found that taking this perspective on treatment services—from the first call for help to the intake process and through final discharge—is the most effective way to understand how the client feels and to discover which improvements will serve the client better.
Change team members who posed as clients during the walk-through exercise uncovered significant problems with the Perry County site's phone system and administrative functions:
Frequently, callers phoning for outpatient services received a voice-mail message. Callers who did reach an attendant were told that they would have to wait three weeks for the first available appointment.
Clients who left voice-mail messages often were unreachable at the phone number they left or never returned any of KRCC's follow-up calls.
Clients appearing on-site to request services could receive an appointment the same day because of the high rate of no-shows for scheduled intake appointments. Clients who had a same-day appointment were more likely to begin treatment.
The change team also organized a focus group that included clinicians, staff, and clients. The group identified problems in the registration procedure: Client check-in and checkout, along with intake phone calls, took place in the same office space, leaving staff, clients, and callers frustrated. In this chaotic environment, clients had to wait while staff took calls, and callers often were lost, transferred to the wrong place, or put on hold for extended periods.