The Acadia Hospital inspires statewide improvement and is featured in National Council on Community Behavioral Health newsletter

The Acadia Hospital was recently featured in a National Council on Community Behavioral Health newsletter that highlighted the hospital's process improvement work. Below is the newsletter article, followed by information on NIATx.

As a participant in the Network for the Improvement of Addiction Treatment (NIATx) Paths to Recovery Project, The Acadia Hospital in Bangor, Maine, was among the 39 treatment centers across the nation that focused on improving access to and retention in substance abuse treatment. With an emphasis on improving systems and processes, Paths to Recovery provided participating sites with expert coaching, peer learning support groups, and the NIATx rapid-cycle model for change.

David Prescott, Ph.D., Director of Psychology Services and Clinical Research at Acadia, is the first to admit that he was a reluctant draftee to the hospital's Paths to Recovery project. "But after attending the first NIATx Learning Session, I became a convert for process improvement," says Prescott. "NIATx brought in presenters from way outside the field who gave me a new way to look at improving our systems."

A guiding principle in the NIATx model for process improvement is getting ideas from outside your own organization. Adds Prescott, "I met colleagues from other NIATx sites that faced the same challenges we did. I probably talk to someone from the original collaborative every month. We learn from and motivate each other."

Acadia's process improvement efforts improved on each of the four NIATx aims: reduce waiting times, reduce no-shows; increase admissions; and increase continuation. With increased admissions, Acadia increased billable hours, which in turn increased it revenue and enhanced its profit margin.

Process improvement and patient outcomes

Having seen how the NIATx model for process improvement helped make dramatic improvements in patient access and retention, Acadia began to examine other ways to improve the quality of care provided in its substance abuse and mental health treatment programs.

Acadia was using the BASIS-24 questionnaire in all of its mental health and substance abuse inpatient and outpatient programs to measure client functioning at time of admission and again at either mid-treatment or discharge to assess treatment outcomes.

"We realized that we had the opportunity to use BASIS-24 to find out if patients still got better after we implemented the NIATx changes that reduced waiting times and increased admissions," says Prescott.

Clinical staff at Acadia had raised concerns that the reduced waiting times and increased admissions would have a negative effect on treatment. "There's a belief that treatment suffers when you increase admissions," explains Dr. Prescott. "Staff worry about increased demand, particularly in outpatient settings. Another concern is that more rapid access and increase in admissions means that counselors will spend less time with clients, and as a result clients won't get better."  

One change that Acadia implemented to improve access and retention was to increase the use of group therapy, rather than individual therapy, as the primary emphasis of treatment for the majority of clients.  "Moving to more group therapy freed up counselor time to complete intakes," explains Prescott. "Yet staff members were concerned that the outpatient group therapy would not be as effective as the individual therapy. We used the BASIS questionnaire results to show that at least in our program, by their own reporting, patients got a lot better—even with the change from individual to group therapy."

After doubling the size of the intensive outpatient program without adding additional staff, the BASIS results showed that "just as many clients showed up and got well as they ever had," reports Prescott.

Client response to reduced waiting times and increased admissions for the Acadia substance abuse outpatient programs was very positive. "By making treatment available on demand, we removed some of the administrative steps that had stymied our patients in the past."

Staff response

"Sharing the BASIS results with staff was a real winner. They couldn't argue that we had increased our admissions, but they could argue that quality of clinical care had suffered. Results showed that wasn't the case. In fact, it looked like our addictions outpatient clients improved almost as much or more than our inpatients got almost as better as clients in our residential treatment program."

The Acadia Change Team took their improvement project to another level. "We wanted to see if we could target our clinical population to show greater improvement in one specific subscale of the BASIS questionnaire—"Daily Living Skills."

This subscale of the tool asks clients to respond to very practical questions about how difficult it is to make it through each day.

"That was the subscale where patients in Acadia's addiction treatment programs were doing the worst," says Prescott. "The prechange results showed that most addiction patients could barely make it through each day."

Prescott and the Change Team chose to test a change on a small number of patients—those in an intensive outpatient program. "We asked ourselves: "Could we change our IOP curriculum to help clients make greater improvements in daily living skills over a typical three week cycle?"

The Change Team followed the most important of the five principles that guide NIATx process improvement projects: to understand and involve the customer. Feedback from patients, many of them opiate addicted, revealed that getting through each day meant dealing with questions like:

How do I help my roommate from taking lethal overdose?

How do I get clean needles, since I'm still using? How do I get food stamps?

How do I talk to my doctor about chronic pain given that I'm an addict?

That patient feedback helped the Change Team revise the IOP curriculum to address their clients' daily living challenges. "We adapted our program to the client needs," says Prescott. "They need more than learning how to balance a checkbook or do their laundry. We brought in a staff member to show clients how to throw up safely after an overdose, and the group was riveted."

The post change results showed improvement. "With 30 subjects over three weeks pre-post, daily living skills scores on the BASIS questionnaire rose by .6 over baseline (on a four-point scale). This gave us confidence that if we could adjust our treatment in the NIATx rapid-cycle way it could impact clinical outcomes in just three weeks."

The success that Acadia Hospital experienced as a grantee in the NIATx Paths to Recovery project inspired Kimberly Johnson, Director of the Office of Substance Abuse for Maine's Department of Health and Human Services, to apply for the STAR-SI grant

As a STAR-SI grantee, Maine will work to change state and provider business practices to increase access and bring more people who were previously unable to maneuver the barriers into treatment.

Maine is also a grantee in the Advancing Recovery. Directed by NIATx in collaboration with the Treatment Research Institute, Advancing Recovery is designed for single state agencies and treatment providers to work in close collaboration, as partners, to increase the use of evidence-based administrative and clinical practices (EBPs) in the treatment of addictions. Both projects support the state's goal to transform the treatment services are delivered across the state.

"The results we saw at Acadia validate the soundness of improving the four NIATx aims," concludes Prescott. "Simple changes can make dramatic improvements."