James H. Ford

Replication and sustainability of improved access and retention within the Network for the Improvement of Addiction Treatment

The Network for the Improvement of Addiction Treatment (NIATx) applies process improvement strategies to enhance the quality of care for the treatment of alcohol and drug disorders. A prior analysis reported significant reductions in days to treatment and significant increases in retention in care [McCarty, D., Gustafson, D. H., Wisdom, J. P., Ford, J., Choi, D., Molfenter, T., Capoccia, V., Cotter, F. 2007. The Network for the Improvement of Addiction Treatment (NIATx): enhancing access and retention. Drug Alcohol Depend. 88, 138-145]. A second cohort of outpatient (n=10) and intensive outpatient (n=4) treatment centers tested the replicability of the NIATx model. An additional 20 months of data from the original cohort (7 outpatient, 4 intensive outpatient, and 4 residential treatment centers) assessed long-term sustainability. The replication analysis found a 38% reduction in days to treatment (30.7 to 19.4 days) during an 18-month intervention. Retention in care improved 13% from the first to second session of care (from 75.4% to 85.0%), 12% between the first and third session of care (69.2-77.7%), and 18% between the first and fourth session of care (57.1-67.5%). The sustainability analysis suggested that treatment centers maintained the reductions in days to treatment and the enhanced retention in care. Replication of the NIATx improvements in a second cohort of treatment centers increases confidence in the application of process improvements to treatment for alcohol and drug disorders. The ability to sustain the gains after project awards were exhausted suggests that participating programs institutionalized the organizational changes that led to the enhanced performance.

Which elements of improvement collaboratives are most effective? A cluster-randomized trial

AIMS Improvement collaboratives consisting of various components are used throughout health care to improve quality, but no study has identified which components work best. This study tested the effectiveness of different components in addiction treatment services, hypothesizing that a combination of all components would be most effective. DESIGN An unblinded cluster-randomized trial assigned clinics to one of four groups: interest circle calls (group teleconferences), clinic-level coaching, learning sessions (large face-to-face meetings) and a combination of all three. Interest circle calls functioned as a minimal intervention comparison group. SETTING Out-patient addiction treatment clinics in the United States. PARTICIPANTS Two hundred and one clinics in five states. MEASUREMENTS Clinic data managers submitted data on three primary outcomes: waiting-time (mean days between first contact and first treatment), retention (percentage of patients retained from first to fourth treatment session) and annual number of new patients. State and group costs were collected for a cost-effectiveness analysis. FINDINGS Waiting-time declined significantly for three groups: coaching (an average of 4.6 days/clinic, P = 0.001), learning sessions (3.5 days/clinic, P = 0.012) and the combination (4.7 days/clinic, P = 0.001). The coaching and combination groups increased significantly the number of new patients (19.5%, P = 0.028; 8.9%, P = 0.029; respectively). Interest circle calls showed no significant effect on outcomes. None of the groups improved retention significantly. The estimated cost per clinic was

Addiction Treatment Agencies’ Use of Data: A Qualitative Assessment

2878 for coaching versus

Massachusetts’s Experience Suggests Coverage Alone Is Insufficient To Increase Addiction Disorders Treatment

7930 for the combination. Coaching and the combination of collaborative components were about equally effective in achieving study aims, but coaching was substantially more cost-effective. CONCLUSIONS When trying to improve the effectiveness of addiction treatment services, clinic-level coaching appears to help improve waiting-time and number of new patients while other components of improvement collaboratives (interest circles calls and learning sessions) do not seem to add further value.

Days to treatment and early retention among patients in treatment for alcohol and drug disorders.

Addiction treatment agencies typically do not prioritize data collection, management, and analysis, and these agencies may have barriers to integrating data in agency quality improvement. This article describes qualitative findings from an intervention designed to teach 23 addiction treatment agencies how to make data-driven decisions to improve client access to and retention in care. Agencies demonstrated success adopting process improvement and data-driven strategies to make improvements in care. Barriers to adding a process improvement and data-driven focus to care included a lack of a data-based decision making culture, lack of expertise and other resources, treatment system complexity, and resistance. Factors related to the successful adoption of process-focused data include agency leadership valuing data and providing resources, staff training on data collection and use, sharing of change results, and success in making data-driven decisions.

Improving quality of care in substance abuse treatment using five key process improvement principles

The Affordable Care Act is aimed at extending health insurance to more than thirty million Americans, including many with untreated substance use disorders. Will those who need addiction treatment receive it once they have insurance? To answer that question, we examined the experience of Massachusetts, which implemented its own universal insurance law in 2007. As did the Affordable Care Act, the Massachusetts reform incorporated substance abuse services into the essential benefits to be provided all residents. Prior to the laws enactment, the state estimated that a half-million residents needed substance abuse treatment. Our mixed-methods exploratory study thus asked whether expanded coverage in Massachusetts led to increased addiction treatment, as indicated by admissions, services, or revenues. In fact, we observed relatively stable use of treatment services two years before and two years after the state enacted its universal health care law. Among other factors, our study noted that the percentage of uninsured patients with substance abuse issues remains relatively high--and that when patients did become insured, requirements for copayments on their care deterred treatment. Our analysis suggests that expanded coverage alone is insufficient to increase treatment use. Changes in eligibility, services, financing, system design, and policy may also be required.

Successful Organizational Strategies to Sustain Use of A-CHESS: A Mobile Intervention for Individuals With Alcohol Use Disorders.

OBJECTIVES Drug and alcohol treatment programs often have long delays between assessment and treatment admission. The study examined the impact of days to treatment admission on the probability of completing four sessions of care within an addiction treatment program implementing improvements in their admission process. METHODS Mixed-effects logistic regression was used to test the effect of wait time on retention in care. RESULTS Findings demonstrate a strong decrement in the probability of completing four sessions of treatment with increasing time between the clinical assessment and first treatment session.

Using a NIATx based local learning collaborative for performance improvement.

Process and quality improvement techniques have been successfully applied in health care arenas, but efforts to institute these strategies in alcohol and drug treatment are underdeveloped. The Network for the Improvement of Addiction Treatment (NIATx) teaches participating substance abuse treatment agencies to use process improvement strategies to increase client access to, and retention in, treatment. NIATx recommends five principles to promote organizational change: (1) understand and involve the customer, (2) fix key problems, (3) pick a powerful change leader, (4) get ideas from outside the organization, and (5) use rapid cycle testing. Using case studies, supplemented with cross-agency analyses of interview data, this paper profiles participating NIATx treatment agencies that illustrate successful applications of each principle. Results suggest that organizations can successfully integrate and apply the five principles as they develop and test change strategies, improving access and retention in treatment, and agencies’ financial status. Upcoming changes requiring increased provision of behavioral health care will result in greater demand for services. Treatment organizations, already struggling to meet demand and client needs, will need strategies that improve the quality of care they provide without significantly increasing costs. The five NIATx principles have potential for helping agencies achieve these goals.

Disseminating quality improvement: study protocol for a large cluster-randomized trial

Background Mobile health (mHealth) services are growing in importance in health care research with the advancement of wireless networks, tablets, and mobile phone technologies. These technologies offer a wide range of applications that cover the spectrum of health care delivery. Although preliminary experiments in mHealth demonstrate promising results, more robust real-world evidence is needed for widespread adoption and sustainment of these technologies. Objective Our aim was to identify the problems/challenges associated with sustained use of an mHealth addiction recovery support app and to determine strategies used by agencies that successfully sustained client use of A-CHESS. Methods Qualitative inquiry assessed staff perceptions about organizational attributes and strategies associated with sustained use of the mobile app, A-CHESS. A total of 73 interviews of clinicians and administrators were conducted. The initial interviews (n=36) occurred at the implementation of A-CHESS. Follow-up interviews (n=37) occurred approximately 12 and 24 months later. A coding scheme was developed and Multiuser NVivo was used to manage and analyze the blinded interview data. Results Successful strategies used by treatment providers to sustain A-CHESS included (1) strong leadership support, (2) use of client feedback reports to follow up on non-engaged clients, (3) identify passionate staff and incorporate A-CHESS discussions in weekly meetings, (4) develop A-CHESS guidelines related to client use, (5) establish internal work groups to engage clients, and (6) establish a financial strategy to sustain A-CHESS use. The study also identified attributes of A-CHESS that enhanced as well as inhibited its sustainability. Conclusions Mobile apps can play an important role in health care delivery. However, providers will need to develop strategies for engaging both staff and patients in ongoing use of the apps. They will also need to rework business processes to accommodate the changes in communication frequency and style, learn to use app data for decision making, and identify financing mechanisms for supporting these changes.

Extended-Release Naltrexone: A Qualitative Analysis of Barriers to Routine Use.

Local governments play an important role in improving substance abuse and mental health services. The structure of the local learning collaborative requires careful attention to old relationships and challenges local governmental leaders to help move participants from a competitive to collaborative environment. This study describes one countys experience applying the NIATx process improvement model via a local learning collaborative. Local substance abuse and mental health agencies participated in two local learning collaboratives designed to improve client retention in substance abuse treatment and client access to mental health services. Results of changes implemented at the provider level on access and retention are outlined. The process of implementing evidence-based practices by using the Plan-Do-Study-Act rapid-cycle change is a powerful combination for change at the local level. Key lessons include: creating a clear plan and shared vision, recognizing that one size does not fit all, using data can help fuel participant engagement, a long collaborative may benefit from breaking it into smaller segments, and paying providers to offset costs of participation enhances their engagement. The experience gained in Onondaga County, New York, offers insights that serve as a foundation for using the local learning collaborative in other community-based organizations.