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Reforming the Process of Care

January 1, 2007
by Gary A. Enos, Editor
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Treatment network participants make self-analysis a standard part of operations

Leaders in the addiction treatment and research communities have lamented that with governments traditionally having been the primary purchaser of addiction services, treatment businesses have not commonly faced much pressure to improve their operations’ efficiency. Early this decade, the federal Center for Substance Abuse Treatment (CSAT) and the Robert Wood Johnson Foundation set out on an initiative with an uncommon aim for the addiction community: looking at administrative processes of care that if made more efficient could improve access to services and retention in treatment—two areas critical to better outcomes for the addicted.

For the 39 treatment agencies that received grants in two rounds of the Network for the Improvement of Addiction Treatment's (NIATx's) first initiative starting in 2003, process improvement became an ingrained way of doing business. While funding for the original provider grantees has ended, the network's efforts to further improvements in access and treatment retention continue on several fronts, such as with projects designed to improve communication between providers of care and the entities that finance their services.

Members of the provider community who have been involved with these efforts from the start consider these initiatives vital to improving the overall environment of care. “We providers are working with a vulnerable population with a house of cards; we piecemeal our services with Band-Aids,” says Kevin Norton, president and CEO of CAB Health and Recovery Services, Inc., in Massachusetts, an agency that played a pivotal role in the network's development. “We have systems that don’t talk to one another.”

Before the partnership that established NIATx was created, CAB had launched its own internal examination of its service delivery processes. After then-president and CEO Victor Capoccia moved from CAB to the Robert Wood Johnson Foundation, activity to help agencies across the country with process improvement efforts became a national mission. Norton participated on a steering committee for the network's first initiative and CAB was not eligible to receive grants, but the agency decided to participate by investing $50,000 of its own money to conduct process improvement activity.

“It wasn’t an easy sell within the agency at first, but we recognized how important it was,” Norton says.

Everyday issues

Provider agencies that participated in the network's first initiative received an opportunity to focus on the everyday processes of care that can either facilitate or impede a client's recovery. Four signature goals of NIATx's efforts for provider agencies were to reduce wait times for services, reduce no-shows for treatment, increase admissions, and increase continuation in treatment.

Some impediments to better performance in these areas become obvious as soon as agencies have the time and resources to look at redundant or outmoded practices. For example, clients entering residential treatment who meet with different individuals during the admissions process often are asked to relate the same personal history multiple times. “When we ask the patient to tell the story at every point in the admissions process, we’re really talking about some lousy care,” Norton says.

With 10 different locations across a 100-mile area, uniform application of policies and procedures has been a critical priority for CAB, which operates residential and outpatient programs, methadone clinics, a juvenile drug court treatment program, and a homeless shelter, among other programs. CAB's ongoing process improvement activity looks at all operations, from intake procedures to transportation services to building maintenance, and encourages implementation of “lots of pilots” in search of more efficient systems.

“If something fails, we start over with something else,” Norton says.

When CAB examined its methadone treatment services, its program data showed that the length of time between an opiate addict's first contact with CAB and the time the addict first received a dose of medication was averaging 17 to 21 days. “That is an incredibly long time for someone who's an opiate addict and who has acknowledged the need for services,” Norton says.

CAB has reduced that average wait time to about 10 days, and would like eventually to get it to a 24-to-48 hour window. It achieved the reduction not by pouring new money into methadone services, but by allocating resources differently and better coordinating work processes among existing staff. In fact, most of the improvements identified by NIATx participant agencies are relatively low-cost (sometimes no-cost) options that recognize a lack of new resources for addiction services.

“None of this has been rocket science,” Norton says of the various changes that have been implemented in his agency. “Some people get offended when I say that.”

According to NIATx documents covering the period through March 2006, network member agencies since 2003 have used the program's coaching and peer learning support to implement changes that have resulted in a 34.8% improvement in wait times for services, a 33% improvement in no-show reduction, a 21.5% improvement in increased admissions, and a 22.3% improvement in increased continuation in treatment.

“Most agencies that have participated in this have said that this has become a way of doing business for them,” says Jay Ford, chief research officer at the network, which has a staff office at the University of Wisconsin. “These organizations look at their processes and try to determine how they can do improvements as a rapid-cycle change.”