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Using QI to Address a Citywide Need for Improving How Bostonians Affected by Substance Abuse Disorders Seek Treatment and Other Recovery Support Services
Summary
Impact Statement:
This big city health department used QI to improve their intake processes and obtained dramatic results in connecting the highest risk people with substance use disorders to existing city services, which in turn results in improved outcomes for individuals who are homeless, have co-occurring health or mental health concerns, use a disproportionate amount of emergency services and who are in general the hardest to help.
Summary:
The project’s goal was to address a citywide need for improving how people in Boston affected by substance use disorders are connected to a wide range of services that could help them achieve sobriety; reduce harm; address pressing health and mental health concerns; or find a place to live, a job, protection from violence, or other support. The implementation of the quality improvement (QI) initiative occurred within the Bureau of Addictions Prevention, Treatment and Recovery Support Services Providing Access to Addictions Treatment, Hope and Support (PAATHS) program. PAATHS is marketed to the community as a one-stop shop for individuals and families looking for information about, or access to, substance abuse treatment and other recovery support services. Through this QI initiative, PAATHS has developed new procedures, which have allowed the case manager/public health advocates to meet with a greater number of clients and to enhance relationships with external partners, resulting in an increased ability to provide linkages to care. Overall, because of this project, the program has improved outcomes for clients of greatest concern, who are the high utilizers of services—individuals who are homeless, have co-occurring health or mental health concerns, use a disproportionate amount of emergency services, and are generally the hardest to help.
Organization that conducted the QI initiative:
BPHC
Citation:
Cardenas, Y. Public Health Quality Improvement Exchange. Using QI to Address a Citywide Need for Improving How Bostonians Affected by Substance Abuse Disorders Seek Treatment and Other Recovery Support Services. Thu, 05/14/2015 - 16:35. Available at https://www.phqix.org/content/using-qi-address-citywide-need-improving-how-bostonians-affected-substance-abuse-disorders. Accessed November 11, 2024.
Background and Aim
Aim statement:
Original aim: By July 31, 2013, increase by 25% the percentage of PAATHS clients connected to their primary service needs within 4 days of intake from a historical average of 7 days. The baseline is 2,500 clients per year, and 10% of clients were connected in 4 days of intake.
After the first meeting with the QI coach, Jack Moran, the team agreed to develop the following sub-aims:
• Reduce the amount of time it takes clients to be seen at first visit from 25 to 8 minutes.
• Reduce the number of incomplete applications from an average of 16 per week to zero.
• Increase the number of individuals accepted into post-detox programs from 31 to 37 or 20%.
• Increase outreach efforts by visiting 10 referral agencies to make personal contacts to help improve placement. This task has not been done in the past.
Need For The QI Initiative:
As PAATHS initiates its new method of service delivery, it has sought to formally develop capacity and implement new procedures to shift to becoming a full-service provider of access to care. The need for developing a QI initiative was necessary to transform an existing program because its culture reflected resistance to change, and the new management team struggled with how to create change while honoring staff's expertise and experience. The Bureau had previously done other QI work through NIATx and had received positive results. For this reason, the management team identified QI as a vehicle to help PAATHS get from point A to point B and applied for this grant in fall 2012.
Once the program received the QI award and attended the award kickoff event in North Carolina, the management team held meetings to introduce staff to QI concepts and to identify challenges and opportunities for improvement. Because the team was small, everyone was included in the brainstorming sessions and the final QI team to ensure that the project was truly successful. During all of the brainstorming sessions, the management team used NGT because its structured method for group brainstorming encouraged contributions from everyone, and most importantly, took brainstorming a step further by adding a voting process to rank ideas that were generalized.
Area for Improvement:
Boston is one of the oldest urban cities in the United States and the largest city in Massachusetts. PAATHS is located in Boston’s South End, a neighborhood that has 23% African American and 17% Latino residents. According to the Health of Boston Report (2010), the South End is an income- and racially diverse neighborhood with many subsidized, publicly owned, or otherwise low-income housing units and homeless shelters. According to the Health of Boston Report (2010), in 2008, the incidence rate of reported chronic hepatitis B infections in the South End was the highest rate (172.1 new cases per 100,000 individuals), three times the overall Boston rate of 57.5 new cases per 100,000. In 2008, 49.0 substance abuse–related deaths per 100,000 individuals occurred in the South End, making this neighborhood’s rate greater than the Boston overall rate of 25.9 new cases per 100,000. Reports from the Substance Abuse and Mental Health Services Administration's (SAMHSA’s) Office of Applied Studies also found that of the 15 largest metropolitan areas, Boston ranks fifth highest in reported rates of illegal substance use (8.5%) and third in reported binge alcohol use, making these reported rates at least 25% higher than any other region of the state. Of the 106,301 admissions to substance abuse treatment programs statewide in fiscal year 2010, 16.72% (17,775) were from Boston (Massachusetts Department of Public Health [MDPH], 2010). Overall, drug abuse mortality in Boston increased sharply throughout the decade with age-adjusted substance use mortality more than doubling from 1999 to 2007, from 11.3 per 100,000 to 23 per 100,000. This QI initiative has helped to create a new method of service delivery for a hard-to-serve community with indicators of poor health.
Root Cause:
As a result of the NGT brainstorming session, the team identified the biggest barriers for case managers/public health advocates to connect clients to the resources they request in a timely manner. Those barriers were as follows:
• the amount of time it took clients to be seen at first visit,
• too much redundant or unnecessary paperwork for what the clients were requesting,
• the need to build capacity and better understand processes and requirements for referring a client to the expanded referral network, and
• limited staff knowledge of available resources.
Planning and Execution Details
QI Implementation:
The team participated in the following activities: brainstorming, developing a sub-aim, process-mapping, and completing several Plan, Do, Study, Act (PDSA) cycles to increase by 25% the percentage of PAATHS clients connected to their primary service needs within 4 days of intake.
The team used the nominal group technique (NGT) to identify a question to pose and engage the team in identifying problems to address. The staff members were asked to answer the following question: What is/are the biggest barriers for you to be able to connect your clients to the resources they request in a timely manner? The NGT activity was completed as follows:
1. Team members were instructed to silently respond to the question and record their answers on a sheet of paper.
2. When everyone was finished, each person took a turn and shared one answer at a time.
3. Answers were recorded on a flip chart, and everyone had an opportunity to vote as a team to agree on which problems they felt were most important to address.
4. The team developed sub-aims and mapped the process from July 1, 2012 to December 14, 2012, when the clients arrived until the time they left.
5. The team discussed and identified problem areas such as redundant/unnecessary paperwork and bottlenecks, and they agreed on areas for improvement or change.
As a result of the brainstorming sessions, the team agreed to implement changes through PDSA cycles. The team planned the PDSA cycles by identifying problem areas on process maps and by discussing the following questions:
1. Why do we do it this way?
2. Is there a better way to do it?
3. What will it look like (i.e., who will do it and when)?
4. What steps do we need to take to get there?
5. How will we know that it works?
Next, the team discussed how it would implement changes and pilot them for 3 weeks and how it would assess whether the changes were working by reviewing predetermined measures and input from staff. To conclude based on findings from the study period (3 weeks), the team agreed to further tweak and re-pilot cycles to adopt, abandon, or adapt changes. A total of 7 PDSA cycles were completed from December 17, 2012 to July 22, 2013, and a total of 1,160 clients and 7 employees were exposed to these QI efforts. PAATHS serves approximately 2,500 clients per year and will continue all QI efforts in Year 2 of implementation.
QI Tool Documentation:
Initiative Dates:
12/17/12 to 7/22/13
Initiative Duration:
Between 6-12 months
Methods of evaluation:
The team evaluated the QI initiative's impact in the following ways:
• recorded time of arrival and the time that the case manager/public health advocate received the chart after clients registered with the program assistant or began making phone calls to detoxification (detox) or other programs for clients;
• used treatment care plans, daily admission logs, Microsoft Excel files, and client logs;
• used staff and client questionnaires; and
• used site visits and thank you cards.
1. During the first PDSA cycle, the team updated all the registration and intake forms and developed a treatment care plan. The updated intake forms collected the necessary information for the service clients requested, and staff used the treatment plan to summarize what happened during intake and to document when placement had occurred. The team also began to record two different sets of time to identify how long clients had to wait before meeting with a case manager/public health advocate. When PAATHS clients checked in, the program assistant recorded the time of arrival on the daily admission log, and each case manager/public health advocate began recording the time that he or she received the chart after clients registered with the program assistant or began making phone calls to detox or other programs for clients. For this first cycle, the team agreed to record the time on the updated intake forms.
2. At the end of the 3-week pilot, the change team leader, Yailka Cardenas, developed a questionnaire that allowed staff the opportunity to provide feedback on all the changes. The questionnaires revealed that staff often forgot to record the time of arrival or the time the case manager/public health advocate called the clients because the time was being recorded on multiple forms. The surveys also indicated that clients were highly satisfied with the treatment plans because at the end of the visit, they received a copy of the form that summarized their visit. The form included the client’s short- and long-term goals and documented when staff and/or the client needed to complete follow-up. The feedback on the questionnaires was reviewed during a change team meeting, and the team agreed to begin recording the time clients were meeting with a case manager/public health advocate on the client service log. The client service log is the first form that staff see and is located inside everyone's chart. Furthermore, the time of arrival and the time staff record on the client service log, as well as basic client demographic information, were entered into an Excel file daily. The change team used these Excel files to demonstrate positive and negative outcomes during the change projects. For example, the team developed tables and graphs using the data on the Excel file to demonstrate growth within the program and to see how long clients were sitting in the waiting room. These tables and graphs were a great way to obtain buy-in from the entire team, to see what worked and did not work, and to continue the project's momentum. In the near future, the Excel file will be replaced with an internal database or medical record.
3. PAATHS serves high-risk priority populations including intravenous drug users, homeless individuals, pregnant women, uninsured adults, and individuals with chronic medical diagnoses looking for acute and short-term structured environments. The team at PAATHS provides outreach, education, case management, crisis intervention, and advocacy by providing level-of-care assessments; facilitating referrals and linkages to substance abuse–related treatment and other recovery support services. As part of the referral process, each program required the case manager/public health advocates to complete different multipage referral forms when trying to locate one appropriate placement for each client served. Unfortunately, these forms were often incomplete, which left several applications without being reviewed and not many clients placed into post-detox programs. Another barrier for PAATHS was the lack of medical staff and/or medical equipment that most detox centers have to verify an individual's length of sobriety. Thus, as part of one of the PDSA cycles, PAATHS adopted a new standardized referral form developed by MDPH in an effort to reduce the administrative burden on staff in agencies to which PAATHS refers clients. By adopting this standardized referral form, PAATHS formalized the new referral process and reduced the number of incomplete applications. The program also decided to purchase 12-panel urine quick cups and to evaluate this effort in combination with the standardized referral form. These accurate, easy-to-use kits test for 12 substances. PAATHS staff provided the verification programs needed from clients reporting at least 5 days of sobriety. These results were tracked on the daily admission log and treatment care plans.
4. To ensure that the numbers of incomplete applications were kept minimal, the QI coach suggested developing a checklist for staff and a system for chart auditing and quality assurance. The checklist outlined the new forms, held staff accountable to the new intake process, and helped the case manager/public health advocates keep track of what forms needed to be filled out. The checklist was reviewed during group and individual supervision while the team implemented the PDSA cycle. The change team leader, Yailka Cardenas, also began a chart auditing and quality assurance process to track whether staff were committed to all the changes, to identify staff who struggled with some of the changes, and to identify additional training needs.
5. As part of the program’s expansion and QI efforts, the team agreed to increase outreach efforts by visiting detox centers and post-detox programs to make personal contacts to improve program placements within key agencies. The site visits helped develop a better understanding of what services programs offered and increased the network of agencies that took referrals from PAATHS. The program kept a log of the agencies the team visited and sent follow-up thank you cards to most of these agencies. The team did not send thank you cards to all the programs because some are in Long Island/Boston Harbor and had incomplete mailing addresses.
6. Last, one of the case manager/public health advocates developed a client questionnaire. The program assistant asked clients to fill out the questionnaire when they arrived at the front desk. A total of 15 clients agreed to complete the survey. The goal of this survey was to get a better understanding of what services clients were looking for, what the program could look into including in the near future (e.g., food, brochures), and feedback on the program’s QI efforts. The surveys indicated that more than half of the participants would like to engage in relapse prevention and health-related groups. Participants would also like to see the program offer snacks and brochures while they wait. This QI effort did not help with any of the current aims but will help during future projects in Year 2 of implementation.
Other Information:
Through the QI efforts, the PAATHS management team identified NGT to be an excellent brainstorming technique because it focused on identifying problems first rather than solutions, which was less overwhelming for staff. Because the team posed thoughtful questions, staff used their own experience and expertise, resulting in them identifying potential barriers within the system. The team would highly recommend this technique to other groups because it is a silent group activity, which provides everyone with an opportunity to contribute to the process. The team also strongly suggests documenting everything in separate files, because once the project gains momentum, remembering dates, steps, and names will be difficult.
Supplemental Materials:
Quote from partner/participant
Sample of materials produced
Supplemental Files:
Attachment | Size |
---|---|
Quote.docx | 9.77 KB |
CM-PHA Weekly Chart Audit.docx | 17.1 KB |
CM-PHA Checklist.doc | 764 KB |
Detox- Intake Assessment Form.docx | 14.22 KB |
Post-Detox- Intake Assessment Form.doc | 51.5 KB |
Client Service Log.docx | 11.02 KB |
Registration Form- Bilingual.docx | 29.91 KB |
Treatment Care Plan.docx | 12.64 KB |
Results
Measurable QI Outcomes:
By July 2013, PAATHS achieved the following outcomes:
1. Reduced the amount of time for clients to be seen at a visit from 25 to 13 minutes by recording two sets of time (the time of arrival and the time that the case manager/public health advocates began working with the client) and by reducing unnecessary and redundant paperwork.
2. Reduced the number of incomplete applications from an average of 16 per week to zero by adopting a standardized referral form from MDPH and by developing a checklist and a system for auditing and quality assurance to ensure 100% compliance.
3. Increased the number of individuals accepted into post-detox programs from 31 to 37 or 20% by adopting the standardized referral form and by using 12-panel urine quick cups.
4. Increased outreach efforts by completing 17 site visits, sending 12 thank you cards, and developing 5 new referral sources.
5. Increased by 25% the percentage of PAATHS clients connected to their primary service needs within 4 days of intake from a historical average of 7 days. The baseline was 2,500 clients per year, and 10% of clients were connected in 4 days of intake.
Other QI Outcomes:
The program staff have had the opportunity to share their QI efforts with several other agencies. In February 2013, the PAATHS management team was one of two awardees that hosted the first NNPHI webinar. In May 2013, the program was selected to present at the Innovations in Addictions Conference, an event sponsored by the MDPH Bureau of Substance Abuse Services and AdCare Educational Institute, Inc. on the access-to-care model and QI efforts to several substance abuse treatment providers of Massachusetts. The project’s change leader has presented to several agencies, including programs for first-year college students at the University of Massachusetts Dartmouth and Springfield College about PAATHS, but also on the importance of change and QI efforts in the workplace. In addition, the project’s change leader has been accepted into a local government and leadership certificate program at Suffolk University beginning in September 2013. Overall, the program is currently completing a first-year report summarizing the QI efforts, system changes, and plans for Year 2 of implementation. This report will be shared with the executive director of BPHC, Barbara Ferrer, and the Addictions Bureau director, Rita Nieves.
Lessons Learned, Observations and Insights:
During February and March, two staff members were out on leave, which made it harder to see all clients within 10 minutes of registration. When the team re-piloted this PDSA cycle with all three case manager/public health advocates, clients did not have to wait more than 13 minutes. In April, the program driver retired, and the program assistant was assigned other job responsibilities. This staffing change resulted in the rest of the staff taking on more daily tasks; the case manager/public health advocates covered front desk duties and/or took turns driving clients to programs after placement. The program is in the process of hiring a fourth case manager/public health advocate, and once this staff member is hired and trained, PAATHS will re-pilot its specialized care model to see help reduce waiting time. Also, the director of programs and planning/QI project director, Nicole Charon-Schmitt, resigned from her position at BPHC in June 2013, leaving the project change leader, Yailka Cardenas, to fully orient her replacement on the QI efforts in July 2013.
Future Plans:
Staff morale and client satisfaction have improved tremendously; therefore, the program plans on sustaining all QI efforts and identifying additional QI training opportunities in Year 2 of implementation. To maintain improvement, the project’s change leader will continue to review chart auditing results with staff during their individual supervision, and focus on leading the team to implement client-centered changes reported on the client questionnaire. Some of those suggestions include, but are not limited to, providing snacks, beverages, and brochures while clients wait and providing relapse prevention and health-related groups.
PAATHS has also initiated a program to outstation substance abuse navigators to support primary care providers in identifying and responding to substance abuse or chemical dependency in their patients. The South End Community Health Center (SECHC) consented to be the first pilot for this new initiative. The integrated navigation model of support, behavioral, and health care services delivered jointly by BPHC and SECHC is intended to serve as a national model of comprehensive and responsive services to difficult-to-serve, vulnerable populations suffering from substance use disorder and their families. PAATHS will look into implementing PDSA cycles in Year 2 of implementation at SECHC and any other community-based health center.
Last, PAATHS plans to purchase breathalyzers or alcohol tests for alcohol-dependent clients, to complete additional site visits, and to carry out the specialized care team model. Because PAATHS has three staff members providing referrals to substance abuse treatment, this model would be broken down as follows:
1. The acute placement and high utilizer specialist would be responsible for placing individuals into detox programs and helping clients seek other addiction-related options, such as medication-assisted treatment (e.g., methadone, Suboxone, Vivitrol). In this role, the case manager will work with other specialized teams within the Homeless Bureau of BPHC and with Boston Healthcare for the Homeless, an external agency located next door to the PAATHS program.
2. The information and referral family specialist would provide education and support to community members, families, and substance abuse treatment providers. This specialist is responsible for answering the PAATHS program’s telephone hotline. In this role, this staff member will also schedule patients of SECHC who are looking for information and/or access to substance abuse treatment.
3. The aftercare and housing specialist would be responsible for placing individuals into post-detox treatment programs and for providing individuals and/or families with housing information (e.g., sober housing, other recovery support services). In this role, the public health advocate will also work with a team within one of the drug probation courts and with advocacy outreach programs in Boston.
The overall goal of these potential projects would be to continue to reduce the amount of time clients wait in the waiting room and/or to increase the number of individuals placed into their primary service need within 4 days of intake.
Training and Preparation
Technical Assistance Received:
The QI project director, Nicole Charon-Schmitt, and the change team leader/project manager, Yailka Cardenas, completed a 2-day NIATx change team leader academy before this grant began. NIATx resulted from the unique collaboration of two national initiatives: Paths to Recovery, funded by the Robert Wood Johnson Foundation, and Strengthening Treatment Access and Retention, funded by SAMHSA's Center for Substance Abuse Treatment. Both initiatives focused on improving systems and processes and on increasing the rates at which Americans receive and continue through addiction treatment (http://www.niatx.net).
From December 2012 to August 2013, the National Network of Public Health Institutes (NNPHI) also provided QI-related training through literature, a webinar, and Open Forums to all the Cycle 2 awardees.
QI Related Training Received:
This QI project was conducted as part of the National Network of Public Health Institutes (NNPHI) QI Award Program, a competitive initiative that provides a small financial award and 15 hours of distance-based and in-person coaching from a designated QI consultant. The program is part of the Community of Practice for Public Health Improvement (COPPHI), supported by the Robert Wood Johnson Foundation.
The team received the following QI-related training:
• monthly conference calls with QI coach Jack Moran,
• a site visit from Mr. Moran,
• an NNPHI webinar in February 2013,
• NNPHI Open Forum in December 2012, and
• NNPHI Open Forum in June 2013.
The change team leader, Yailka Cardenas, had informative monthly conference calls with Mr. Moran. In April 2013, Mr. Moran came to visit the program to better understand PAATHS and the QI efforts. In addition, Nicole Charon-Schmitt and/or Yailka Cardenas participated in two Open Forums and a webinar that NNPHI provided to all Cycle 2 awardees. These training opportunities were helpful because the team had the opportunity to connect with other health departments and learn about their practices.
Information about the Community
Population Size:
Population Characteristics:
The PAATHS program serves residents of Boston. With a population of 617,659, Boston is the largest city in New England. It is a dense urban area encompassing parts of Congressional Districts 8 and 9. The area has rich cultural and ethnic diversity and forms an assortment of distinct geographic neighborhoods. The overall population of Boston increased 5% between 2000 and 2010. During that time, the number of Latino and Asian residents increased by 27% and 25%, respectively. Although English was the language most frequently reported being spoken at home, 35% of Boston residents aged 5 or older reported speaking a language other than English at home. Among these languages, Spanish (including Spanish Creole) was the most widely spoken language (15% of all homes), followed by French (including Patois, Cajun, and French Creole) (5%), Chinese (4%), Portuguese (including Portuguese Creole) (2%), and Vietnamese (2%).
Socioeconomic status (SES) is a measure of an individual's or a family’s economic and social position relative to others based on income, education, and occupation. Low SES is associated with limited access to regular health care, adequate housing, quality education, nutritious food, recreational opportunities, and other resources associated with a healthy lifestyle. The SES of Boston residents varies dramatically by race/ethnicity, gender, and age. According to the Health of Boston Report (2012), in 2010,
• 60% of female-headed households with children younger than age 5 had an income below the poverty level compared with 18% for all family households in Boston;
• the median annual household income for Latino households was $23,243 compared with $61,636 for white households;
• the percentage of Boston residents with less than a high school diploma or GED was significantly higher among Latino adults (32%), Asian adults (24%), and black adults (20%) compared with white adults (7%);
• black male residents had an unemployment rate of 32%—almost four times the rate for white male residents (9%); and
• more than 7,600 individuals were homeless.
Information about the Health Department
Local/State Relationship:
Decentralized
Local Health Department Governance:
Local Governance - all LHDs in the state are units of local government
PHAB Accreditation Status:
Not Applicable
Annual QI Initiative Frequency:
QI activity level:
Organization Type:
QI Staff Information
Total number of Staff on QI Team:
7
Total number of FTEs on QI Team:
6.00
QI team members:
Role in the Initiative:
Executive sponsor/project director
Role in Organization:
Director, Programs and Planning
FTE:
0.20
Role in the Initiative:
Change leader/project manager
Role in Organization:
Manager, Access to Care
FTE:
0.20
Role in the Initiative:
Change team member/participant
Role in Organization:
Case Manager
FTE:
0.10
Role in the Initiative:
Change team member/participant
Role in Organization:
Public Health Advocate II
FTE:
0.10
Role in the Initiative:
Change team member/participant
Role in Organization:
Public Health Advocate II
FTE:
0.10
Role in the Initiative:
Change team member/participant
Role in Organization:
Program Assistant
FTE:
0.10
Role in the Initiative:
Change team member/participant
Role in Organization:
Driver
FTE:
0.05
Collaborations
Partner Organizations:
N/A
Contact Information of the Submitter
First Name:
Yailka
Last Name:
Cardenas
Organization:
BPHC
Submission Status:
Completed
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