Using Process Improvement to Build the Foundation for the Implementation of

Evidence-Based Practices: Contingency Management and Motivational Interviewing

Susan Brandau, CASAC, NYS OASASSusanBrandau@oasas.state.ny.us

Patricia Hincken, LCSW,CASAC,CPP Dir., Long Beach Med. Ctr. Alcohol and Substance Abuse Services

phincken@LBMC.org

Karisa Endelmann, CASAC-T, CM Interventionist, South Oaks Hospital, Long Island Home

kendelmann@South-Oaks.org

July 30, 2009NIATx/SAAS Summit

Funded by NIDA 1R21 DA 019772-01 and RWJF STAR-SI

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)

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

Backer’s Framework:4 Fundamental Conditions

Dissemination

Evaluation

Resources

Human Dynamics of Change

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

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

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

Study DifferencesRetained:

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

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

Tracking LogClients in Group

How many slips earned last week?

How many slips this week if attended

(last week’s +1)

Attended?

Yes or No

(Excused?)

How many slips due next week if attended?

Times name drawn

Prize category

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%

Long Beach Medical Center

The Road to Evidence- Based Practices

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.

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.

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.

Challenges which impacted continuation:

• Data collection confusing

• Time constraints

• Staff Resistance

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.

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

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

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

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

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.

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

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

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)

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CONTINGENCY MANAGEMENTEDUCATION GROUP

August 28 - November 13

Control

CM

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

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.

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

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ADOLESCENT CONTINGENCY MANAGEMENT DATA COMPARISON

February 3 - April 28

Control

CM

Results:

• CM improved attendance with adolescents

• More youth willing to sign up for the group

• Once involved, youth attendance more consistent

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

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

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

On the Horizon

• More EBP

• Round 3 CM

• MET/CBT

• GAIN

• Motivational Interviewing

• Concurrent Documentation

• Continue staff rotation on Star Si

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.

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.

Contact Information:

Patricia Hincken, LCSW, CASACDirector, Alcohol & Substance Abuse

ServicesLong Beach Medical Center

455 East Bay DriveLong Beach, New York 11561

Phone: 516-897-1250; fax: 516-897-1262Email: phincken@lbmc.org

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

Why We Became Part of STAR-SI

• Reduce waiting time

• Reduce no shows

• Increase Admissions

• Increase retention in program

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

Implementation of Contingency Management

• Aug 2008 - Implementation of Contingency Management to increase attendance and retention of patients

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

CM Model Used

Contingency Management for group attendance using the name-in-hat-prize based procedure, developed by Dr. Nancy Petry

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

• 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)

Understand and Involve the PatientSurvey 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

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

71%

29%

64%

36%

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Contingency Management Round 1

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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

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

Findings• CM Round 2 Patients Non-CM Patients

Total Patients 9 Total Patients 32

Active 1 Active 2

Non -Active 8 Non -Active30

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 -Active24

Active % 82% Active % 25%

Non Active % 18% Non Active % 80%

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Contingency Management Findings - CM-2 & CM-3

Active

Non-active

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

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

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

Motivational Interviewing• We will begin to track and monitor this process

using tape recorders to track use of OARS• Open ended questions• Affirmations• Reflective listening• Summaries

Impact of STAR-SI on Outpatient• Three major developments impacted from the changes

include:

1. An average increase of 15% of intake show rate, (2007-57%, 2008-62% and 2009-72%)

2. An increase in retention in treatment based on data collected from CM

3. An 8% increase of intakes coming from our inpatient unit

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

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