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Service Delivery Innovation Profile

Administrative Overhaul Improves Access to Substance Abuse Services for Iowa Patients


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Snapshot

Summary

Using tools and resources developed by NIATx (formerly known as the Network for the Improvement of Addiction Treatment), the Iowa Department of Public Health and local addiction service providers conducted an administrative overhaul of substance abuse services to improve access to care for patients in Iowa. Staff used walk-throughs and other tools to identify and eliminate a number of problems that were creating excessive administrative demands on providers, thus facilitating process improvements. These changes led to a significant decrease in waiting times for services and an increase in capacity to serve patients.

See the Planning and Development section for updated information about program activities, including a pilot program, pay for performance measure development, work with gambling treatment programs, and the development of learning collaboratives (updated December 2011).

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key metrics from participating provider agencies, including no-show rates and waiting times.
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Developing Organizations

Center for Substance Abuse Treatment "Strengthening Treatment Access and Retention" Program; Iowa Department of Public Health; Robert Wood Johnson Foundation Pathways to Recovery Program
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Date First Implemented

2004
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Patient Population

Vulnerable Populations > Substance abusersend pp

Problem Addressed

Research has shown that access to treatment and retention in treatment are among the greatest predictors of successful recovery from substance abuse.1 However, excessive administrative burdens often prevent substance abuse centers from seeing as many patients as they might otherwise be able to treat, contributing to long waiting times for services and high patient no-show rates.
  • Limited access to treatment, with many no-shows: Every year, more than 20 million Americans need substance abuse treatment, but less than 10 percent get into treatment. Of this 10 percent, less than one-half show up for their appointments.2
  • Excessive administrative burdens: Complicated paperwork and administrative processes, including intake and scheduling procedures, can present a significant challenge to provider agencies in serving and retaining patients.3 
  • A concern among Iowa providers: In Iowa, providers often found themselves filling out an enormous amount of paperwork to comply with admission, documentation, and continuing care requirements. The average no-show rate among provider agencies was 25 percent, meaning that one in four individuals with an appointment failed to show up for it. Waiting times for services were quite long; for example, clients had to wait more than 6 days for services in one facility.

What They Did

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Description of the Innovative Activity

The Iowa Department of Public Health and local addiction service providers conducted an administrative overhaul of substance abuse services to improve access to care for patients in Iowa. Key elements of the program include the following:
  • "Walk-throughs" to identify problems: The Iowa Department of Public Health and health plan staff conducted "walk-throughs" at a number of local provider agencies to understand the treatment processes from a client's perspective. These walk-throughs identified a number of problem areas that had long been areas of complaints for clinic staff, including excessive paperwork, lengthy intake sessions, excessive numbers of individual sessions, and inflexible scheduling for counselors.
  • State agency removal of barriers: The State made a number of changes in response to the problems identified in the walk-throughs, including:
    • Streamlined documentation: The Department of Public Health reduced admission and documentation requirements, thus lessening barriers to accessing and remaining in treatment.  
    • Modified payment formula: The Department of Public Health modified payment formulas to encourage providers to engage in process improvement activities and to adopt process improvement techniques.
    • Regular feedback: Feedback reports provide regular assessment of progress on NIATx goals.
  • Local provider changes: In response to the walk-throughs, local providers implemented a variety of changes to reduce no-shows to initial intake and assessment appointments and to increase patient participation in ongoing treatment. Changes include the following:
    • More friendly environment: Provider agencies created a more client-friendly atmosphere in their waiting areas, including an emphasis on client-friendly behavior among reception staff.
    • Assessment surveys: Clients, family members, and referral sources received surveys about the assessment process; results suggested that wait times for appointments were too long and the paperwork too complicated.
    • Improved appointment cards: Provider agencies created new, large appointment cards that use bright colors.
    • Reminders: Provider agencies began sending reminder postcards to clients and making reminder phone calls the day before an appointment to confirm each client's participation and identify any barriers to attendance, such as transportation. The standard for calling is three attempts throughout the day.
    • Elimination of paper: Providers are moving toward a paperless system.
    • Assistance with appointments: Counselors walk clients to the billing staff after their assessment, and the billing staff then help set up treatment appointments for clients before they leave. (Billing staff receive the counselors' appointment schedules in advance so that they know when to expect patients.) Before this change, more than 48 percent of clients left without making their next appointment. 
    • Help overcoming barriers: Counselors ask clients about any barriers to coming for treatment (e.g., asking about the best day to start treatment, matching them with the first-available appointment, ensuring they have transportation) and provide information on wrap-around services as appropriate.

Context of the Innovation

The Iowa Department of Public Health's Division of Behavioral Health and Professional Licensure oversees a network of substance abuse centers in the State. Facing high no-show and cancellation rates and long waiting times for services among provider agencies, the Iowa Department of Public Health began participating in NIATx, a collaborative network of organizations in 25 states that are working to reduce wait times and no-show rates while simultaneously increasing capacity (admissions) and "continuation" rates (i.e., the percentage of clients who finish their course of treatment). To achieve this goal, NIATx provides information and training to State agencies and providers on innovative work practices, policies, and processes that can help get patients into treatment and keep them there long enough for the treatment to have a positive impact. 

Did It Work?

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Results

Comparisons of pre- and post-implementation data from participating provider agencies show that the administrative overhaul led to an overall reduction in no-show rates, while individual provider participants have seen reductions in waiting times for services and an increase in capacity to serve patients. One agency has seen an increase in cancellations and rescheduled appointments, but these results are not typical. 
  • Fewer no-shows overall: The overall no-show rate for 15 participating providers dropped from 25 percent to 15 percent. 
  • Individual success stories: Several individual agencies have reduced waiting times and no-show rates and increased their capacity to serve patients, as described below:
    • Reduced waiting times and enhanced capacity: One provider agency saw waiting times fall by 56 percent, while admissions increased by 186 percent. (There was no change in no-show rates.) These improvements were largely due to reduced paperwork (which allowed a reduction in the number of individual sessions required) and increased flexibility for counselors in their scheduling.
    • More appointments: One provider agency increased the number of clients who scheduled appointments for assessments by 43 percent.
    • Mixed results: At one participating provider agency, waiting times for services fell from an average of 6 to 1.3 days, while no-shows fell from 13 to 9 percent. These improvements were largely driven by reductions in paperwork. However, this organization also saw a threefold increase in cancellations (from 5 to 15 percent) and a significant increase in rescheduled appointments, from 10 to 15 percent. As a result, the percentage of patients appearing for initial evaluations fell from 73 to 62 percent (but have since recovered). According to the State's data, the increases in cancellations and rescheduled appointments and the associated fall in appearances for initial evaluations experienced by this organization are not typical.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key metrics from participating provider agencies, including no-show rates and waiting times.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Training: The State of Iowa received training, support, and technical assistance from NIATx. Training included an orientation to the project and NIATx principles, training on data collection, and training of peer mentors and coaches working with new providers.
  • Development of forms and tools: NIATx developed forms to assist with quality improvement projects and other toolkits for peer mentors and project leaders.
  • Ongoing progress reports: Provider agencies complete quarterly progress reports and data updates, as well as attend State Learning Collaboratives every 6 months to present this information.
  • Pilot project: Information provided in December 2011 indicates that in 2009, two Iowa Department of Public Health-funded prevention programs piloted a NIATx Prevention project that focused on increasing participation in youth diversion programs and reducing paperwork at the state level. By the end of the project, providers were able to adapt and adopt process improvements to increase referrals and participation (increasing revenue), and strengthened relationships with stakeholders. At the state level, efficiencies resulted from streamlining several grant reports, which lessened the amount of paperwork time.
  • Pay for performance measure integration: Information provided in December 2011 indicates that in late 2009, "pay for performance" measures were integrated into Iowa's managed care contract with providers that went into effect in January 2010.
  • Projects related to gambling treatment: Information provided in December 2011 indicates that in 2010, the Iowa Department of Public Health, in partnership with Prairielands Addiction Treatment Technology Center, offered an opportunity to nine State-funded problem gambling treatment programs and Iowa's gambling Helpline to participate in an effort to apply NIATx principles to problem gambling treatment. Programs reduced time to screening and admission paperwork by reducing duplicative paperwork and streamlining process. Programs successfully increased admissions and continuation, reduced no-shows, increased successful discharges, and increased the number of Helpline calls taken by programs. The project also established best practice standards that translated into fiscal year 2011 performance measures and Helpline service improvements (e.g., calls directly transferred and counselors being available to take calls 24 hours daily).
  • Learning collaborative participation: Information provided in December 2011 indicates that in 2010, thirteen Iowa Department of Public Health-funded substance abuse treatment providers participated in the "NIATx-SI: Business Practices for the Future" Learning Collaborative Cohort I. Seventy-nine percent of participating agencies successfully obtained at least one additional third party insurance contract. In 2011, Iowa Department of Public Health convened 12 Iowa Department of Public Health substance abuse treatment providers to participate in a second cohort to continue to help improve the collection of third party payments. This project will end in the fall of 2012.

Resources Used and Skills Needed

  • Staffing: Key staff include the following:
    • Staff to serve in the role of change leader (who keep the project on task), coach, peer mentors (who are under contract), and a project coordinator (who oversees technical assistance and process improvement).
    • State information technology staff to monitor data, provide performance reports to the providers, conduct training, and give technical assistance as needed.
    • Provider organization staff, including an executive sponsor, a change leader, and team members who buy-in to the projects and process improvement methods.
    • Networking capacity staff to build the network, train new providers, and spread the project.
  • Costs: Annual operating expenses for the project average $325,000. In addition to staffing, other costs include data system updates, phone conferences, office and meeting supplies, and travel expenses.
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Funding Sources

Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration; Robert Wood Johnson Foundation; State of Iowa
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Adoption Considerations

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Getting Started with This Innovation

  • Consider pilot testing: This innovation can be tested with a small number of provider agencies.
  • Encourage state regulation of project: Regulation is vital if the State wants to know whether the techniques they have initiated are making an improvement on the system. The State should hire a project coordinator and a data analysis staff person to monitor the program.
  • Offer provider incentives: Incentives help providers stay focused, turn in "change project" forms, and ensure data that they are sending are current.

Sustaining This Innovation

  • Do not force patients to take an open slot: One center found that "forcing" patients to take a next-day appointment resulted in a higher no-show rate. A better approach is to ask clients when they want to come and to schedule the appointment for that time.
  • Validate your data: If data is not correct from the beginning stages, improvements will be unable to be measured.
  • Providers want to work with the State staff: Providers' process evaluation surveys inform the State that providers welcome receiving additional technical assistance and site trainings.
  • Accommodate walk-in appointments: Walk-in appointments have increased provider's fee collections and clients are more inclined to pay for services at the time they receive them if on demand.

More Information

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Contact the Innovator

DeAnn Decker
Bureau Chief, Substance Abuse Treatment and Prevention
Iowa Department of Public Health, Lucas State Office Bldg.
321 E. 12th Street
Des Moines, IA 50319
(515) 281-0928 
E-mail: DeAnn.Decker@idph.iowa.gov

Innovator Disclosures

Ms. Decker has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

NIATx. State pilot project: Iowa [Web site]. Available at: http://www.niatx.net/Story/StoryDetails.aspx?id=180

Footnotes

1 Perlman SB, Dougherty RH. State behavioral health innovations: disseminating promising practices. DMA Health Strategies/The Commonwealth Fund; August, 2006. Available at: http://www.cmwf.org/usr_doc/Perlman_statebehavioralhltinnovations_945.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
2 NIATx. NIATx overview [Web site]. Available at: https://www.niatx.net/Content/ContentPage.aspx?NID=9
3 NIATx. The key paths to recovery [Web site]. Available at: https://www.niatx.net/Content/ContentPage.aspx?NID=18
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: January 15, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: November 22, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.