Richards, Michael, M.Div., L.P.C.C., Rafelson, William, Nabi, Emara, M.S., M.B.B.S., Kingson, Aaron, Nguyen, Mai, M.S., M.D. The Heller School for Social.

The South Side Clinic – An Operations Management

Analysis

Richards, Michael, M.Div., L.P.C.C., Rafelson, William, Nabi, Emara, M.S., M.B.B.S., Kingson, Aaron, Nguyen, Mai, M.S., M.D. 

The Heller School for Social Policy and Management.  Brandeis University. [email protected]

SERVICE CONCEPT

Target Customer: Dually-diagnosed, physician- and hospital-referred patients

Out-patient dual-diagnosis addiction clinic Treats only hospital PCP’s and affiliated

providers patients Complete range of outpatient clinical

substance abuse services offered: Assessment and evaluation, intensive

outpatient group therapy, individual therapy, medication management, provider training and consultation

Programs customized according to the needs of the individual patient

SERVICE CONCEPT Full-service dual-diagnosis addiction clinic Clinical Director attends quality meeting

every month with hospital quality committee

Patient satisfaction surveys As a part of NIATx protocol, quality

improvement committee aiming to reduce wait time to zero (process quality)

Supervision of clinical staff Training of staff three times a year Efficiency measured in terms of productivity

for psychologists, social workers

Service Delivery System

Facility: Capacity: 10 consultation rooms, each has

one health worker. Separate from main hospital building Warm and welcoming servicescape

atmosphere Recently renovated Recipient of internal hospital awards No handicap access No room for expansion Clinicians’ room equipped with panic

buttons Old building that has replacement plans

Service Delivery System

Staff: Psychiatrists, psychologists, social workers,

a case manager, and a nurse Medical director and clinical director

supervise clinicIT: IDX system and Microsoft Outlook used for

scheduling appointments Possibility for better integration

Telephone used to schedule appointments

Patients: Dual-diagnosis mental illness/substance

abuse treatment

Work Process

1: Phone or walk-in:2: Case manager: Assessments (6-10 per week)

Primary, critical quality-related bottleneck3: Counselors: 6-7 Social workers, 30 hrs. of

clinical time scheduled. But with no-show’s, probably less. Secondary Bottleneck

3’: Referral to hospital primary care physician3’’: Intensive group outpatients program (Run by

one psychologist and social workers)4: Psychiatrists : patients are diagnosed and

treated according to consultations and progress. (Two full-time and two part-time psychiatrists)

Work process: Referral through entry into treatment

WT: 2 weeks WT: 2 weeks WT variable

Walk-in or call Social workers or Psychiatrists Psychologist 2-3 patients/hour

1-2 patients/hour

Total Wait Time (WT) to Medication = up to 7 weeks

Intensive Outpatient Group

12

54

3’

3’’

3

Assessment

WT: 3 weeks

Relapse Discharge back to PCP Referral back to PCP

Discharge to Maintenance Care Program

Work process

AR: 35 patients/day (range: 15-60) Output rate (Assessments): 6-10 per week Output rate (Ongoing patients): 33-34

patients per day average (Highly variable) Highly customized Clinic is downstream in supply chain from

hospital, PCP services

Two staged throughput:Throughput includes intake and assessment

(4-7 weeks), and treatment (6 weeks to 2+ years)

Work Process Referral and registration Assessment Approval Assignment to Providers Treatment

Intensive Outpatient Group (IOP) Individual treatment Family treatment Medication

Measurement and Assessment Customer Satisfaction Other critical metrics? (e.g., PCP reports, readmit data,

etc.) Follow Up

Maintenance Care PCP Follow-up Long-term care (e.g., self-help group, “after-care”

session, etc.)

Work Process: Assessment

Current wait for assessment is 3 weeks 6 to 10 Assessments per week

Only one “no-show” per week, on average 1 hour long Patients arrive 15 minutes early for registration

All patients have to call in on Tuesdays to reconfirm appointments

Evaluated for “readiness” by Medical Director Most new patients “ready” for treatment Customer co-production: registration,

cooperation

Work Process:Approval and Assignment

Approval: Medical director has to approve all new patients, wait

time is one week Assignment:

After Ax, wait to see clinician, Pt then referred to medical appointment also if necessary

Ax to 1st appt, 3 weeks, depending on clinicians schedule

2 week wait for IOP Psychiatrists see 75-85% of patients seen by clinicians

for medication Medical director does therapy with a few patients Recently, the entire process was several months long

It has since been reduced to 4-7 weeks

Work Process: Treatment Supply

First approval by Medical director Therapy with social worker, psychologist Psychologists are part-time and have own

practices, on productivity pay model Social workers are salaried, 6 hrs clinical time

a day, most are 9-5 and get productivity reports

6-7 social workers (2 assigned IP) Arrivals on the hour 1 hour appointments, ½ hr for short-term, 1

hr for family Medication appointments are 20 min, (2-3 per

hr.) by Medical director, fellow and 2 part-time doctors

Work Process: Treatment Demand

Fridays are slowest Wednesdays and Thursdays are busiest 15-60 patients per day 35 average per day No shows 20%, higher for new arrivals Third no-show, meet with clinical director One psychologist charges $15 for no-show, donates

revenue to charity Research actually suggests that “carrot” is better

than “stick” Positive reinforcement (e.g., pt’s favorite candy) is a better incentive for patients to attend than negative reinforcement (e.g., a fine)

Negative reinforcement could exacerbate no-show behavior

Work Process: Intensive Outpatient (IOP)

IOP 12 people in group, 1 ½, ½ hr with psychologist For more serious cases than individual therapy

alone 3x per week, 9AM-12PM One evening slot, Tuesday at 6pm Step down from IOP:

Relapse prevention program1 hr for 2-8wks

Programmed patients also receive individual counseling

Our findings: IOP can eliminate / crash the line by immediately accepting newcomers to the WEC

Quality Patient satisfaction survey: Graduates of program More outcome quality measures are needed How does the WEC define quality?

Clearly define critical measurements, indicators for success and quality

Weekly staff meeting Starting to implement NIATx protocols Move to evidence-based best practices Quality change team: baseline measurement, length of

intake SOS-10 every 13 weeks, formal tool for clinicians

Make these results available for analysis Need to be integrated with quality program, shared with

PCPs Supervision Quality meeting Change team is collecting data for first process

improvement: move to no-wait intake.

Problems with Process Current three week wait time for

assessment; up to 7 week wait for Medication. Research has shown that this is too long for substance abusers Dually-diagnosed Pt’s require are even more

sensitive to wait time 1-week delay for approval: unnecessary for Pts

Calling every Tuesday before appointment: discouraging process for patients. Although it may reduce no-show rate, it raises the cancel rate. What happens to those cancelled patients “lost to follow-up?”

Possible lack of integration of PCPs into the process

Program assessment and evaluation needs to be fully integrated into Tx Model

The Epidemic of Substance Abuse

22 million Americans experienced dependence or abuse in 2002. This is nearly 1 out of every 10 Americans 12 years or older.1

Only 4 million of the more than 20 million Americans suffering from substance dependence/abuse sought treatment in 2006.2

Both internal and external obstacles.Of these, about 1.1 million were treated by

outpatient mental health centers According to the Department of Health and

Human Services, about 17.7 million Americans seeking substance abuse treatment were unable to access it.3

The Societal Cost of Substance Abuse

Alcohol- and drug-related deaths are among the leading causes in the country, and pose a serious public health risk.1

76% of illicit drug users are employed; 81% of the 43 million adult binge drinkers are employed; 80% of the 12.4 million heavy drinkers are employed.4

Alcohol and drug abuse costs American businesses more than $100 billion in lost productivity each year.5

The Cost of Waiting

Over 50% of substance abusers no-show on intake8 (National Average)Reduced productivity for providersReduced access for fellow patientsRisk of relapse for no-show patient

Experimental study: 24 hour intake, versus 3 or 7 days.7

24-hour intervention 4x more likely to show

BU Study: Comorbid psychiatric diagnoses 81% less likely to complete regimen.9

A Study by Festinger et al.6

A Randomized Trial 7

Appointment Delay as Most Significant Variable6

NIATx

Network for the Improvement of Addiction Treatment Partnership

Robert Wood JohnsonSTARAddiction treatment organizations

4 GoalsReduce waiting time between first contact and first

treatmentReduce the number of no-show’s Increase the capacity for those needing treatment Increase retention throughout the treatment session

Plan Do Study Act (PDSA)1

Plan: Identify aim of effort (e.g., reducing wait time)

Do: Trial run, using few clients for short period of time

Study: Staff looks at benefits and drawbacks of the trial

Act: Staff fixes trial if imperfect results, or implements it in regular practice if no significant problems

Arcadia Hospital: A Case Study

Arcadia Hospital: Before NIATx

Bangor, ME Addictions Hospital 4,397 outpatient substance abuse visits /

year Only 25% who first-contacted showed up

for assessment Only 19% followed up with treatment

Arcadia Hospital: After NIATx

Staff told new callers to come in 7:30AM following morning; treatment would immediately follow assessment.

Time to first contact reduced from 4.1 to 1.3 days

65% of the 225 of new callers per month showed up for appointment (compare to 25%, previously).

Similarly, 52% (not 19%) made it into treatment

Process Improvement at Arcadia1

With Increased Access, Increased Revenue

Because of the increased number of patients being seen per month, new counselor hired

Revenue increased by 56%

Increased Access Increased Utilization Increased Productivity Increased Revenue

Conclusion “All health care organizations, whether

providing addiction treatment or not, are faced with the challenge of finding ways to increase output and achieve better results with fixed resources. Therefore, the successes experienced by organizations in the NIATx initiative should be useful for implementing change in other fields of service delivery.”1

The lessons learned from NIATx are not addictions-specific: because addictions treatment holds the highest amount of risk for “loss to follow-up,” they must innovate first. The lessons learned by Arcadia and other NIATx members can be translated to many, if not all, outpatient settings.

Recommendations - Access / Capacity

One-time extra hours/staff to reduce or eliminate backlog of patients waiting for assessments. AKA “Crashing the backlog.” Assuming 40 hours of clinical time per social worker, this would

only require 1-2 weeks Hire extra psychiatrist to eliminate bottleneck and crash the

backlog of patients awaiting medication, therapy On-demand staff for “anytime” assessment of walk-in patients

The social worker’s “no-show”/ “down” time could be converted to “anytime” hours (currently 20%+ of scheduled time)

Clarify policies such as standardized time from first contact to assessment to treatment (no longer than 72 hours) and quality improvement measurements

Reduce wait time to counseling and pharmacotherapy through consolidating assessment, medical director approval and psychiatrist visit into one visit

Evening hours? Research shows that patients utilize the ER when their PCPs are only available 9-5 Increase capacity: Shifted availability of some, but not all, SW’s Staggered schedules “Flex time”

Immediate group therapy openings

Recommendations - Quality

Better tracking of efficiency of psychiatrists, psychologists, and social workers

Need a specific mission statement To assure quality, PCPs must be integrated

into the processCollect outcome data from, and for, these

physicians More positive reinforcement for Pts to

attend (e.g., favorite candy)

References

1. Capoccia, et al. “Making ‘Stone Soup’: Improvements in Clinic Access and Retention in Addiction Treatment.” Joint Commission Journal on Quality and Patient Safety. February 2007 Volume 33 Number 2

2. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Office of Applied Studies. “Results from the 2006 National Survey on Drug Use and Health: National Findings.” http://www.oas.samhsa.gov/nsduh/2k6nsduh/2k6Results.pdf

3. Wisdom, et al. “Addiction Treatment Agencies’ Use of Data: A Qualitative Assessment The Journal of Behavioral Health Services & Research 33:4 October 2006

4. Lowe, Cheryl. “Addiction in the Workplace.” Behavioral Health Management. September/October 2004: pp. 27-29.

5. Duda, Marty. “Drug abuse’s costly toll on workers.” Behavioral Health Management: November/December 2005. pp. 49-50.

6. Festinger et al., “Pretreatment Dropout as a Function of Treatment Delay and Client Variables.” Addictive Behavior, Vol. 20, No. I. pp. 111-115, 1995

7. Stasiewicz, et al. “A Comparison of Three ‘Interventions’ On Pretreatment Dropout Rates In An Outpatient Substance Abuse Clinic.” Addictive Behaviors, Vol. 24, No. 4 pp. 579-582. 1999.

8. Festinger, David S. “From telephone to office: Intake attendance as a function of appointment delay.” Addictive Behaviors 27 (2002) 131–137

9. McCarty et al., “Improving the Care for the Treatment of Alcohol and Drug Disorders.” The Journal of Behavioral Health Services & Research 2008.

10. Amodeo, et al. “Client retention in residential drug treatment for Latinos.” Evaluation and Program Planning 31 (2008) 102–112

11. Berry et al., “Innovations in Acces to Care: A Patient-Centered Approach.” 7 October 2003 Annals of Internal Medicine Volume 139 • Number 7

12. White et al., “A Model to Transcend the Limitations of Addiction Treatment.” Behavioral Health Recovery Management. May/June 2003: pp. 38 – 44.

13. Petry et al. “Fishbowls and Candy Bars: Using Low-Cost Incentives to Increase Treatment Retention.” Science & Practice Perspectives. August 2003: pp. 55-61.

14. Fitzgerald, Maureen. “Improving Substance Abuse Treatment Delivery.”