EasierAccess, Better Service, Ample Revenue
Strengthening Treatment Access and Retention
Updated October, 2011
The Wisconsin STAR-SI program began in August, 2005, and was later supported by a three-year $885,000 federal grant initiative of the Wisconsin Department of Health Services (DHS) to improve outpatient treatment for alcohol and other drug use disorders. Funding was provided by the federal Center for Substance Abuse Treatment. In partnership with University of Wisconsin Network for the Improvement of Addiction Treatment (NIATx), University of Wisconsin Department of Family Medicine, Wisconsin Association on Alcohol and Other Drug Abuse, Wisconsin Alcohol and Drug Treatment Providers Association, and participating addiction treatment providers, STAR-SI intends to:
- Reduce waiting times and waiting lists
- Increase admissions to substance abuse treatment
- Reduce appointment no-shows
- Improve transfers among levels of care
- Increase successful treatment completion
- Achieve revenue sufficiency
These access and retention indicators are some of the greatest predictors of successful recovery. With training and support from project staff, participating treatment providers collaborate using use a variety of proven quality improvement (QI) tools and approaches developed by engineers such as W. Edwards Deming of Toyota fame. Tools such as walk-throughs, consumer interviews and focus groups, Plan-Do-Study-Act rapid cycle testing, flow-charting, root-cause analysis, nominal group technique, customer window, and other activities are used to plan and achieve measurableservice improvements. The DHS will also review and remodel state policies that pose barriers to achieving these aims.
Participating Treatment Agencies
- ARC Community Services, Madison
- Family Services of Northeast Wisconsin Inc., Green Bay
- Oakwood Clinical Associates, Kenosha
- Racine Psychological Services Inc., Racine
- Tamarack Behavioral Health Center, Manitowoc
- Wood County Unified Services, Wisconsin Rapids
- Dennis Hill Harm Reduction Center, Milwaukee
- Genesis Behavioral Services Inc., West Bend
- Meta House, Milwaukee
- Arbor Place, Menomonie
- ARC Fond du Lac, Fond du Lac
- Beacon House, Fond du Lac
- Benedict Center, Milwaukee
- Douglas County Health and Human Services, Superior
- Human Development Center, Superior
- Jackie Nitschke Center, Green Bay (also an original NIATx agency since 2004)
- St. Joseph's Hospital, Alcohol and Drug Recovery Services, Marshfield
- ThedaCare Behavioral Health, Menasha
- Tri-County Women's Outreach of the Human Service Center, Rhinelander
- Women's Way of Lutheran Social Services, Eau Claire
- Ashland Area Council on Alcoholism and Other Drug Abuse, Ashland
- Brown County Human Services Department, Green Bay
- Dane County Department of Human Services, Madison
- Door County Department of Community Programs, Sturgeon Bay
- La Crosse County Human Services, La Crosse
- Mental Health Center of Dane County, Madison
- Polk County Human Services Department, Balsam Lake
- St. Croix County Health and Human Services, New Richmond
- Waukesha County Department of Health and Human Services, Waukesha
- Coulee Youth Centers, La Crosse
- Franciscan-Skemp Healthcare, La Crosse
- Rock Valley Community Programs, Janesville
- Family Service of Madison, Madison
- Hiawatha Valley Mental Health Center., La Crosse
- La Casa De Esperanza, Waukesha
- Tellurian UCAN, Inc., Madison
- Wausau Health Services, Wausau
- Eau Claire Metro Treatment Center, Eau Claire
- Jefferson County Human Services, Jefferson
- Milwaukee Women's Center (Horizons), Milwaukee
- The Bridge Health Clinics and Research Centers, Milwaukee
- United Community Center, Milwaukee
- West Central Wisconsin Behavioral Health Clinic, Black River Falls
Selected STAR-SI Success Stories
Arbor Place, Menomonie, reduced the no-show rate for all service appointments from 25% to 15% using reminder call variations and counselor contacts after no-shows.
ARC Community Services, Madison, reduced the overall no-show rate to sessions in the intensive outpatient program from 31.7% to 15.8%. The effective change ideas included asking each client to make a verbal and public commitment to other women in the therapy group to attend the next session and after each group session respond to the question, 'What was most helpful tonight?'
ARC-Fond du Lac, increased attendance at the first four day-treatment sessions for clients living in non-structured settings from 65% to 100% by informing clients of the studies showing that attendance at the first four scheduled sessions significantly increases the likelihood of staying clean and sober; asking clients, 'Can you make a commitment to attend all of your first four scheduled days of treatment?'; 'Are there any problems that may keep you from getting here your first four days?'; and 'What can we do to help you with those problems so that you can get to treatment?'
Beacon House, Fond du Lac, increased average monthly occupancy in their residential service from 10 beds to 12 beds by visiting with all referrers.
Dennis Hill Harm Reduction Center, Milwaukee, reduced the no-show rate to treatment sessions from 52% to 46% using a 'fish bowl' raffle incentive. The center also reduced no-shows to the intake appointment from 50% to 37% bydoing special reminder calls.
Door County Department of Community Programs, Sturgeon Bay, reduced wait times from 150 days to 14 days and increased admissions from 11 per month to 14 per month by streamlining the intake process, implementing a client screening process, starting an orientation group, and expediting client flow.
Family Service of Madison reduced outpatient appointment no-shows from 33% to 21% by using a signed contract with clients and asking clients after each appointment to verbally commit to the next appointment.
Family Services of Northeast Wisconsin, Inc., Green Bay, increased attendance across three groups from 55% to 73% by offering small gift incentives ($5 value) to clients for attending three consecutive group sessions.
Franciscan Skemp Healthcare, La Crosse, reduced intake appointment no-showsfor one clinician from 34% to 4%, reduced wait times, and increased revenue bychanging their scheduling processes so that clients could obtain an intakeappointment within 72 hours after making the request.
Genesis Behavioral Services, West Bend, increased the percentage of client co-pays collected from 37% to 92% by developing a weekly payment tracking form and having Counselors collect client co-pay fees at the front desk prior to the start of group. Genesis increased their revenue from a deficit of $13,000 to a surplus of $17,900.
Human Development Center, Superior, reduced the no-show rate for assessment appointments from 42% to 26% using a mailed invitation and introduction letter from the counselor and increased admissions from 22 per month to 39 per month through special contacts with payers and referrers.
Jackie Nitschke Center, Green Bay, reduced no-shows to the initial intake appointment from 36% to 19% using motivational interviewing techniques during the initial phone contact with the client, adopting a universal schedule, and making reminder calls.
With an emphasis on the Hispanic population, La Casa de Esperanza, Waukesha, reduced no-shows to intake from 23% to 9% by instituting reminder calls.
Lutheran Social Services' Womens Way, Eau Claire, increased retention to the4th appointment from 42% to 61% by getting clients admitted to services quicker, using reminder calls and offering client incentives. Womens Way has also increased monthly referrals from 6/month to 14/month by sending an e-mail to all potential referrers and other referrer contacts.
Meta House, Milwaukee, reduced no-shows to intake appointments among women referred by Child Welfare agencies from 67% to 45% by confirming the referral with the client and addressing any barriers to attending the first appointment.
Oakwood Clinical Associates, Ltd., Kenosha, reduced the waiting time from first contact to assessment from 15 days to 7 days by scheduling assessment appointments at first contact and offering same day or next day appointments.
Polk County Human Service Department, Balsam Lake, achieved 100% retention to the 4th continuing care session by starting continuing care while the client was still in primary care.
Racine Psychological Services, Inc., Racine, decreased their wait-time to first appointment from 17 days to 7 days by adding one group during the week and attempting to fill cancelled OWI assessment appointments.
Rock Valley Community Programs, Janesville, decreased their wait list from 60 people to 24 by double-booking intake appointments on Tuesday mornings and Thursday afternoons.
St. Croix County Health and Human Services, New Richmond, reduced waiting time to treatment from 77 days to 44 days (a 43% reduction) by offering briefer treatment options and adding two more counseling groups.
St. Joseph's Hospital, Alcohol and Drug Recovery Services, Marshfield, reduced the no-show rate for service appointments from 33% to 14% using reminder call variations.
Tamarack Behavioral Health Center, Manitowoc, increased retention to the third treatment session from 51% to 58.5%. The change idea implemented was to reduce the paperwork so staff can spend more time building rapport with clients.
Tellurian UCAN, Madison, improved suboxone group counseling attendance from 60% to 77% by using client incentives (pizza party; gift cards; dose aftergroup) and changes in clinic requirements.
ThedaCare Behavioral Health, Menasha, succeeded in reducing registration-related appointments for OWI clients from six to three while realizing non-billable cost savings of $15,100. These improvements also resulted in clients receiving services quicker. The days clients waited from first contact to admission were reduced from an average of 48 days to 11 days. Increased client satisfaction also occurred subsequent to the declines in waiting time.
Tri-County Women's Outreach, Rhinelander, reduced the no-show rate for all service appointments from 51% to 34% using reminder call variations.
Waukesha County Department of Health and Human Services reduced their outpatient clinic's appointment no-show rate from 37% to 21% by sending letters to clients scheduled for assessment appointments, getting accurate, working phone number from clients, and having reception staff do scripted reminder calls.
Wausau Health Services, Wausau, part of the CRC Health Group, providesnarcotic treatment services and successfully reduced no-shows to the firstin-person service from 35% to 15% and increased revenue by instituting a varietyof changes such as an orientation group, changes in scheduling processes, andreminder calls.
Wood County Unified Services, Wisconsin Rapids, increased continuation to the 4th treatment session for one-to-one clients from 31% to 89% by making reminder calls 48 hours before the appointment and asking clients, 'How do you plan to get to the appointment?'
|1. What key improvement is needed?|
|2. How will we know if an improvement occurred?|
|3. What change can we test that may result in improvement?|
STAR-SI Spotlight on?
Teen Intervene NIATx Change Project
The National Survey on Drug Use and Health shows that there are 19,000 Wisconsin adolescents that need but do not receive treatment in any given year. Both Medicaid and County data show that adolescent substance abuse service admissions are flat or declining. Consequently, the STAR-SI program joined with Susan Endres, MPA, Adolescent Treatment Systems Coordinator for the Division ofMental Health and Substance Abuse Services, to facilitate a change project to increase services to adolescents using the 3-session, Teen Intervene Modeldeveloped by Dr. Ken Winters. The effort began with outreach and invitations to adolescent-serving organizations around the state. Eight organizations fromSuperior to Milwaukee and including schools enrolled in the project. A one-dayTeen Intervene and NIATx training event and monthly conference calls were provided. Two of the participating organizations are STAR-SI members, namely,Human Development Center, Superior and La Casa de Esperanza, Waukesha. The HumanDevelopment Center AODA services to 49 more youth through formal agreements with three school districts and an agreement from a County Court Commissioner to useTeen Intervene for 1st-time underage drinking violators. La Casa de Esperanzahad not before served any adolescents with AODA problems but after informing referring agencies about their new Teen Intervene service, they began providing services to adolescents with AODA problems for the first time. Overall, project participants learned that their respective communities had very limited resources for youth with AODA problems but local organizations, professionals, parents and youth are receptive to Teen Intervene.
STAR-SI Special Topic
Healthcare Reform or Not, Things a Substance Abuse Treatment Agency Can Do
Addiction treatment agencies may want to consider addressing the following:
- Seek broad input in planning for healthcare reform. Referrers, payers, staff and especially clients should be part of the planning process. The Customer Window tool (available from the Wisconsin STAR-SI office) which compares client needs/service importance to client needs/service satisfaction is an effective approach in this area.
- Equal focus on achieving outcomes and delivering services. Quality occurs when both outcomes and services align in a purposeful way. Measurable outcomes such as quicker access, retention in services, achieving individualized treatment plan objectives, customer satisfaction and recovery need to have a parallel role in the agency's mission. The NIATx, the Best Clinical and Administrative Practices (BCAP), NCQA QI activity, or other similar continuous quality improvement model is recommended.
- Adopt evidence-based treatment approaches. Agencies should be confident that their treatments are the best available and be able to defend their approaches. Adapting research- or manual-based treatments and/or gathering objective data about the effectiveness of treatment approaches is strongly encouraged. Examples include Motivational Interviewing, Seeking Safety, Twelve Step Facilitation Therapy, Matrix Model, medication adjuncts, Cannabis Youth Treatment, Community Reinforcement Approach and Contingency Management.
- Connect with primary health and mental health clinics. Due to the high rate of substance abuse, mental illness and physical illness co-morbidity, it is recommended that relationships or formal collaborations be pursued with mental health and primary healthcare clinics (including Federally Qualified Health Centers) in the agency's service area. The goal is to cooperatively address client/patient chronic conditions. Substance abuse treatment agencies should document clients' physical and mental health needs to be used in developing the collaborations. Examples of more advanced collaborations include Medicaid medical care or health care home models, co-locating primary health care and substance abuse/mental health services in the same agency, and joining a Medicare Accountable Care Organization.
- Diversify levels of care and services. Just like a business that naturally and over time adds products or services to meet related customer needs (one-stop shopping), so too addiction treatment agencies should consider adding services that touch or interact with clients served. Examples include mental health services, anger management or batterers services, weight management, Suboxone treatment, smoking cessation, drug-testing, problem gambling counseling, supportive housing and additional levels of care within the substance abuse services continuum. Payers may be more favorable to preventative youth drinking/drug use services such as Teen Intervene and briefer interventions for adults as outlined in the federal publication TIP 34, Brief Interventions and Brief Therapies for Substance Abuse. Expand your reach to include all age groups with age-specific services.
- Increase revenue from third party sources. Healthcare reform may usher in reductions in State and County grants and contracts. At a minimum, agencies should begin charging co-pays according to ability to pay, even if it's only $1 a session. Next, agencies will want to increase revenue from third party payers such as private insurance, HMO, employer-based plans, Medicaid, SCHIP, WWWP, FEHBP, Medicare, HIRSP, TRICARE/CHAMPUS, and COBRA. Agencies can develop the ability to assist potential clients in accessing third party coverage. Develop simple-to-read fact sheets for staff and clients that describe the various health insurance programs, eligibility criteria and how to apply.
- Reduce the paper and go electronic. Electronic scheduling, billing and client charting systems can save time and reduce errors. Commercial examples include The Clinical Manager, Data Resource, Inc., Echo, QuicDoc, TheraManager, Celerity CAM, PIMSY, NextGen and THERAPIST. Off-the-shelf software like Microsoft Excel or Access can also be used to replace paper processes and records.
- Be prepared to increase clinical capacity. Currently less than 20% of those who need substance abuse treatment actually receive it, so even now there is the potential to increase referrals. Look into making shifts in staff duties, services or processes that can uncover "hidden" capacity at little or no cost. Ask staff about ways to do things more efficiently. Consider accumulating some cash reserves that can help to add staff should any sustained increase in referrals occur.
- Address staff credentials and professional advancement. Having counselors or therapists who possess a Masters degree or Masters-level credentials (e.g., LPC, LCSW, LMFT) will better position your agency should payers require it.
- Improve care coordination across providers. Develop cooperative agreements and procedures among allied providers in your area to make and receive referrals, ensure effective hand-offs, reduce wait times, coordinate care, reduce relapse and reduce service system costs.
Network for the Improvement of Addiction Treatment (NIATx) at the University of Wisconsin-Madison
University of Wisconsin Department of Family Medicine
QI Flashcards (PDF,1.8MB)
Want to participate in STAR-SI or Need more information?
Contact Deanne Boss
University of Wisconsin Department of Family Medicine
Telephone: (608) 263-0304