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  • 1. Using Process Improvement to Build the Foundation for the Implementation of Evidence-Based Practices: Contingency Management and Motivational Interviewing Susan Brandau, CASAC, NYS OASAS [email_address] Patricia Hincken, LCSW,CASAC,CPP Dir., Long Beach Med. Ctr. Alcohol and Substance Abuse Services [email_address] Karisa Endelmann, CASAC-T, CM Interventionist, South Oaks Hospital, Long Island Home [email_address] July 30, 2009 NIATx/SAAS Summit Funded by NIDA 1R21 DA 019772-01 and RWJF STAR-SI
  • 2. Initial Study Aims
    • Aim 1: Assess and Evaluate SSA role in the transfer of CM intervention into “real-world” clinical practice w/in 3 Opioid Tx programs
    • AIM 2: Evaluate the utility of the state developed Practice Adoption Protocol (PAP)
    • AIM 3: Explore approaches to monitoring the adoption of EBPs
    • H1-H6: The application of Backer’s 6 strategies to the adoption process will enhance the likelihood that the EBP will be adopted
    NIDA Study on Implementation of CM within 3 Opioid Treatment Programs (2005-2007)
  • 3. Definition
    • Contingency Management, also known as Motivational Incentives, is a behavioral modification intervention:
      • Targets client behaviors, such as abstinence; attendance in treatment
      • Requires frequent monitoring to verify client targeted behavior
      • Provides tangible reinforcers immediately whenever client demonstrates targeted behavior
      • Provides escalation of client’s ability to ‘earn’ reinforcers
      • Withhold reinforcer or reset if targeted behavior does not occur
    Contingency Management
  • 4. Backer’s Framework: 4 Fundamental Conditions
    • Dissemination
    • Evaluation
    • Resources
    • Human Dynamics of Change
  • 5. 6 Key Strategies
    • Interpersonal Contact
    • Planning and Conceptual Foresight
    • Outside Consultation on the Change Process
    • User-Oriented Transformation of Information
    • Individual & Organizational Championship
    • Potential User Involvement
  • 6. First Round Findings
    • Two of the three opioid tx programs implemented CM, but the state’s role was labor intensive, no sustainability: Tx as usual approach needed
    • Backer’s strategies, particularly use of outside consultant w/in a learning collaborative, were effective
    • PAP necessary, but not sufficient for state’s ongoing management-each program had a readiness phase that was not integrated into original PAP
    • Absence of program Executive staff & implementation team (infrastructure) inhibited sustainability
    • Organizational capacity & use of data to track progress critical
  • 7. Second Round: STAR-SI OP Providers (2008-9)
    • Characteristics:
    • All had developed mastery of NIATx process improvement
    • Internal capacity & infrastructure to support rapid cycle change projects
    • Core implementation teams (ES,CL,DC,CM interventionist)
    • Proficient with data collection & interpretation
    • Ready to move from focus on access to retention
    • Tx as usual approach-no IRB
    • Reinforcement of attendance in Tx, not abstinence
  • 8. Study Differences
    • Retained :
    • Idea champions
    • Outside consultant-Dr. Petry
    • Weekly conference calls
    • Client tracking logs
    • Modified :
    • Demonstrated readiness/capacity
    • Identified CM clinician and back-up
    • Data driven management-STAR-QI
    • Integration as a NIATx change project
    • Full change team participation on weekly calls
    • Use of CM binders for record keeping
    • Use of comparison group for outcome analysis
  • 9. State’s Role
    • Provided support for new CM manual: Name in the hat technique
    • Contracted with each provider $950. awarded to purchase reinforcements
    • Arranged for training by Dr. Petry
    • Feedback on provider written implementation plans
    • Set-up weekly conference calls to review tracking logs, provide feedback
    • Provide STAR-QI web-based data module & assist with data interpretation, dev. Of business case
  • 10. Tracking Log Prize category Times name drawn How many slips due next week if attended? Attended? Yes or No (Excused?) How many slips this week if attended (last week’s +1) How many slips earned last week? Clients in Group
  • 11. Results
    • Five out of six providers implemented the CM intervention with relative ease
    • Three completed three rounds!!
    • Two are in their initial 12-week round
    • Documented increases in client group attendance ranging from 12.5 to 42%
  • 12. Long Beach Medical Center The Road to Evidence- Based Practices
  • 13. Beginning
    • 2005: FACTS Director attends ASAP Conference on Niatx. National Project and statewide Conference Call introduced.
    • Staff participates in call and instructions for a Walk-Thru were discussed.
    • Staff members walk through treatment process. Goal: see agency from the customer perspective.
  • 14. Findings:
    • Appointment scheduling was confusing
    • Poor communication between staff and clients resulting in double bookings
    • Clients wait time between calling agency and first appointment needed reduction.
  • 15. Goal: Reduce to 10% cancelled or broken intake
    • Scheduling Process Changed:
    • Scheduling Process now requires daily updates to avoid confusion.
    • Initial sessions prioritized if double booking takes place.
  • 16. Challenges which impacted continuation:
    • Data collection confusing
    • Time constraints
    • Staff Resistance
  • 17. Another Opportunity:
    • 2007 Opportunity to join OASAS Star-SI Project for Long Island Programs.
    • Accepted to participate.
    • Staff trained in data collection and use of Star QI.
    • Baseline data collected in Fall 2007
    • Initial change team, team leader, and executive sponsor selected.
  • 18. All Important: Support
    • Learning Collaborative
    • Dr Z came to agency to explain Star-SI and train staff in techniques
    • Fishbone and brain storming techniques were highlighted
    • Telephone conference calls
  • 19. Beginning of cultural change
    • Staff introduced (through NIATX support) to concept of evidence-based programs
    • Staff begins to understand value of knowing what works and what doesn’t
    • Staff participates in initiative by monitoring change cycles
    • Staff participated in ‘brainstorming’ and ‘fishbone’ activities
  • 20. First Project:
    • Goal : Reduce no-shows for initial session
    • Project: Staff agreed to call persons scheduled for initial appointment: introduce themselves; ask about their experiences, if they have any questions, concerns re: treatment
  • 21. Other Projects:
    • Started an Orientation Group
    • Client Satisfaction surveyed at 30, 60 and 90 days
    • Front Office Scripting
    • Clinical Supervisor participated in 3-day ‘Train the Trainer’ on Motivational Interviewing
    • 6 1 ½ hour training sessions held for clinical staff in Motivational Interviewing conducted by Clinical Supervisor at agency
  • 22. Contingency Management
    • OASAS announced Star-SI training in Contingency Management by Dr. Petry
    • FACTS hosted training as well as sent staff for training
    • Change Team Leader selected to go to training as well as 2 other staff members not previously part of Star-SI change team.
  • 23. Selected CM Project:
    • Alcohol and Chemical Dependency Education Group
    • Data from current group assessed
    • CM group run for the 12 week session with 3 staff members following CM protocol
  • 24. Support: Bi-monthly meeting with other CM groups by OASAS and Dr Petry
    • Problem solve
    • Monitor progress
    • Address problems in implementation
    • Share ideas
    • Assist with logistics/paperwork
  • 25. Results
    • The number of visits increased from 94 to 146 ( + 52)
    • The average attendance increased by 18%
    • Individual consistency increased by 14%
    • Revenue increased by $3640.
    • Intangibles ( staff morale, excitement of doing something new, recognition)
  • 26.  
  • 27. Challenges
    • Staff time/staff resistance to perceived ‘interference’ with group process
    • Shopping, running group, keeping data
    • Getting new staff involved (adolescent group)
    • Getting buy in from administration through development of a business plan
    • Sustainability
  • 28. Unanticipated outcome:
    • ACDE Group Leader felt CM took too much time from group educational time, BUT
    • Evaluations of the group were much more positive for the educational component than in prior group evaluations.
  • 29. New Project: CM with the Adolescent Group
    • Outgrowth of Conference Call by OASAS on challenges and issues with adolescent treatment
    • Experts in field concurred that CM ideally suited for this population
    • Adolescent Counselor on conference call
    • Star-SI team support idea of implementing CM with Adolescent Group
  • 30.  
  • 31. Results:
    • CM improved attendance with adolescents
    • More youth willing to sign up for the group
    • Once involved, youth attendance more consistent
  • 32. Sustainability for Contingency Management:
    • Staff time given for preparation, shopping, record keeping
    • Other staff encouraged to look at own groups and do contingency management as a ‘pilot’
    • Build contingency management into education series and adolescent group on an ongoing basis
  • 33. Leadership Challenges
    • Find staff time for brainstorming, training, with goal of maintaining staff interest
    • Collect relevant data and
    • Present data in manner that is significant and meaningful to clinical staff to insure buy-in for EBP
    • Involving all staff in different projects to institutionalize the change process
  • 34. Culture Change
    • Discussing process improvement with other programs increases staff knowledge of other initiatives
    • Staff becomes open to changing ‘status quo’
    • Staff individual professional growth becomes tied to learning more about EBP
  • 35. On the Horizon
    • More EBP
    • Round 3 CM
    • MET/CBT
    • GAIN
    • Motivational Interviewing
    • Concurrent Documentation
    • Continue staff rotation on Star Si
  • 36. MI Implementation & Monitoring
    • Extent and possibility discussed with Outpatient Methadone Maintenance Clinics.
    • Agreed to a ten- week program:
      • Five two- hour training sessions followed by a week for application discussion evaluation of progress during clinical supervision.
      • Training sessions were interactive and practical rather than in lecture format.
    • Continuing post- course discussion during clinical supervision.
    • Course laid a foundation for staff who attended other training that applied MI in the training.
    • Results About 106 training hours and 53 supervisory were devoted to the project.
  • 37. MI Course Outline
    • Spirit of MI
      • Application, Evaluation and supervision .
    • Change Talk and Sustain Talk
      • Application, Evaluation and supervision .
    • Eliciting and strengthening Change Talk
      • Application, Evaluation and supervision.
    • Rolling with Resistance & Sustain Talk
    • -- Application, Evaluation and supervision.
    • Developing a Change Plan & Consolidating Commitment. Blending with other approaches.
    • -- Application, Evaluation and supervision.
    • Clinical Supervisory support and organizational integration: ongoing .
  • 38. Contact Information :
    • Patricia Hincken, LCSW, CASAC
    • Director, Alcohol & Substance Abuse Services
    • Long Beach Medical Center
    • 455 East Bay Drive
    • Long Beach, New York 11561
    • Phone: 516-897-1250; fax: 516-897-1262
    • Email: [email_address]
  • 39. South Oaks Hospital-Joined 2007
    • STAR-SI Change Team:
    • Ken Corbin – Director of Adult Services
    • Yvonne Andrade – Clinical Supervisor
    • Cindy Robinson – Intake Specialist
    • James Jordan – Intensive Outpatient Counselor
    • Diane Sinram – Outpatient Counselor
    • Sue Scruggs – Data Coordinator
    • Karisa Endelmann - Outpatient Counselor / Contingency Management Counselor
  • 40. Why We Became Part of STAR-SI
    • Reduce waiting time
    • Reduce no shows
    • Increase Admissions
    • Increase retention in program
  • 41. Change Team Meetings
    • Since December of 2007 the change team met on a weekly basis to create new changes and review changes already implemented
    • In addition the change team had a conference call with Mat Roosa STAR-SI Mentor to review changes made to program and outcomes.
    • In June 2009 after becoming familiar with the process and due to an increase in our census we changed our weekly meetings to bi-monthly
  • 42. Implementation of Contingency Management
    • Aug 2008 - Implementation of Contingency Management to increase attendance and retention of patients
  • 43. Target Population
    • Patients beginning treatment who are eligible for Phase 1 Outpatient Discussion group
    • Eligibility was determined upon intake
    • Up to 15 participants
    • 12 week study
  • 44. CM Model Used
    • Contingency Management for group attendance using the name-in-hat-prize based procedure, developed by Dr. Nancy Petry
  • 45. The Contingency Management Process
    • Each time patient attends group they earn a slip with their name on it which then gets placed in a hat
    • Based on the number of patients who attend group the counselor then picks half the amount of slips
    • Example: 10 group attendees = 5 name picks from the hat
  • 46.
    • Patients whose slips were picked from hat, then get to draw from a fishbowl
    • Fishbowl contains 69 “small”, 20 “medium”, 10 “large”, and 1 “Jumbo
    • Small ($1.00)
    • Medium ($5.00)
    • Large ($20.00)
    • Jumbo ($100.00)
  • 47. Understand and Involve the Patient Survey of Desired Prizes
    • Small - lotion, toothbrush, socks, granola bars, combs, pens, etc.
    • Medium – disposable cameras, batteries, coffee gift cards, etc.
    • Large – movie theater tickets, watches, Subway gift cards, Applebee gift cards, coffeemaker
    • Jumbo – microwave, pot and pan set
  • 48. Contingency Management Round 1
    • CM Round 1 began on 8/27/08
    • Closed group – unable to compare to similar group
    • We were able to compare overall retention in treatment with those patients who started treatment at the same time with the CM participants
    • 71% of CM participants were active, 29% were not
    • Compared to non-CM participants, 64% active 36% were not
    • Based on Round 1’s information there was an increase of 7% in treatment retention of CM participants
  • 49.  
  • 50. Contingency Management Round 2
    • CM Round 2 began on 12/3/08
    • Open group
    • Compared to another Phase 1 group same time different day facilitated by the same counselor
    • Findings showed the average attendance rates were the same
    • We did find an increase in overall retention for the CM patients compared to non-cm patients
  • 51. Contingency Management Round 3
    • CM Round 3 began on 4/1/09
    • Open group
    • Group findings were compared to another Phase 1 group that was not facilitated by the CM counselor, and again average attendance rates were the same
    • The CM group compared to those starting treatment at the same time, showed that CM participants had a 57% increase in treatment retention
  • 52. Findings
    • CM Round 2 Patients Non-CM Patients
    • Total Patients 9 Total Patients 32
    • Active 1 Active 2
    • Non -Active 8 Non -Active 30
    • Active % 11% Active % 6%
    • Non Active % 89% Non Active % 94%
    • CM Round 3 Patients Non-CM Patients
    • Total Patients 11 Total Patients 30
    • Active 9 Active 6
    • Non -Active 2 Non -Active 24
    • Active % 82% Active % 25%
    • Non Active % 18% Non Active % 80%
  • 53.  
  • 54. Disadvantages of Contingency Management
    • Time consuming
    • Must have exceptional organizational skills to facilitate CM
    • If CM counselor is unavailable the covering group counselor must be fully trained in Contingency Management
  • 55. Advantages of Contingency Management
    • Positive reinforcement for participants
    • Positive group cohesiveness
    • Participants learned timeliness skills
    • Support of bi-weekly phone calls
    • Increase in treatment retention
    • Increase in finances to the program
  • 56. Motivational Interviewing
    • Another evidence based practice we have implemented is Motivational Interviewing
    • Half of the staff in the adult service area have been trained
    • Motivational interviewing techniques have been applied in the Outpatient program during the intake process and during individual sessions
  • 57. Motivational Interviewing
    • We will begin to track and monitor this process using tape recorders to track use of OARS
    • O pen ended questions
    • A ffirmations
    • R eflective listening
    • S ummaries
  • 58. Impact of STAR-SI on Outpatient
    • Three major developments impacted from the changes include:
    • An average increase of 15% of intake show rate, (2007-57%, 2008-62% and 2009-72%)
    • An increase in retention in treatment based on data collected from CM
    • An 8% increase of intakes coming from our inpatient unit
  • 59. Impact of Star-SI on the Agency
    • Due to successful outcomes the Outpatient Unit experienced using the NIATx model our director decided to implement use of this model throughout all our other adult service areas including:
    • Inpatient Detox
    • Inpatient Rehab
    • Inpatient Psychiatric
    • Partial Psychiatric Day Program
    • Prevention Program
  • 60. Plans Moving Forward
    • Another round of CM will take place with an outpatient group and possibly to other areas of the program
    • Orientation/Welcoming group
    • Complete Staff training in Motivational Interviewing