History

Key Lessons from the Early Years (1973-86)
A Vision for CHESS
How We've Grown
The Network for the Improvement of Addiction Treatment (NIATx)
The Future

Key Lessons from the Early Years (1973-86)

Computers as support in crisis

In 1973, in partnership with the University of Wisconsin-Madison's Department of Psychiatry, Dr. David H. Gustafson (CHESS Principal Investigator, TECC Principal Investigator, and Director of the NIATx National Program Office) worked on a study of patients considering suicide (Greist, 1973; Gustafson, 1977). Patients were given a computer to fill out interview data so that researchers could calculate the probability of death in an attempted suicide. What the research team was aiming for was a mathematical model to predict the lethality of suicide attempts. Their study was quite successful in its predictions. Even more serendipitous and important, though, was their discovery that patients in that kind of deep personal distress preferred to "talk" openly to a computer over a person. That was the first hint for the researchers that computers could provide support to people in crisis.

Computers for behavior change

Following the suicide study, in 1981 Dr. Gustafson collaborated with a different team to develop BARN, the Body Awareness Resource Network (Bosworth, 1994), a computer-based health promotion/behavior change system to help adolescents deal with health and personal issues, including smoking, stress, diet, activity, family communication, alcohol and drug use, sex, and AIDS. The goal was to prevent the onset of risky behaviors among middle-school students by providing them with information and skill-building activities. Back then, computers were relatively new and BARN was well received by users in schools. What the researchers found, though, was that BARN didn't work the way they had expected. BARN couldn't prevent adolescents from engaging in risky behaviors. What they did discover though, was that BARN was able to take adolescents that were worried about their risky behavior and help them change much more effectively than those who didn't have access to the system. BARN got those already "sensitized" adolescents to pay attention to things they normally wouldn't have. From there came the idea that computers could help people in a crisis situation to change their behavior.

Multiple services in one system needed

In 1987, the BARN researchers began to explore the possibilities of computer-based support systems for people facing health crises. From their experience with BARN, they knew people tended to use resources only if they were wrestling with a problem and if they recognized they needed to do something about it. The researchers were also well aware of the inadequacies of the BARN prototype. It didn't offer a way for users to talk to experts or to other people who were going through the same crisis; it also lacked decision aids or ways to receive feedback about plans of action. BARN was very much confined to being an information system that used interactive games to educate adolescents. The researchers decided that an effective computer support system for people in health crises needed to offer a system of services that presents explicit information in a variety of ways, provides human and emotional support, and offers help in making and implementing difficult decisions.

References

  1. Greist J.H., Gustafson D.H., Stauss F.F., Rowse G.L., Laughren T.P., Chiles J.A. (1973, December). A Computer Interview for Suicide-Risk Prediction. American Journal of Psychiatry, 130(12), 1327-1332. Retrieved Febuary 13, 2007, from http://ajp.psychiatryonline.org
  2. Gustafson D.H., Greist J.H., Stauss F.F., Erdman H., Laughren T. (1997, June). Probabilistic System for Identifying Suicide Attemptors. Computers and Biomedical Research, 10(2), 83-89.
  3. Bosworth K., Gustafson D.H., Hawkins R.P. (1994). The BARN System: Use and Impact of Adolescent Health Promotion Via Computer. Computers in Human Behavior, 10(4), 467-482.

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A Vision for CHESS

In 1987, Dr. David Gustafson garnered a team to start building the Comprehensive Health Enhancement Support System (CHESS). The team drew valuable lessons from the BARN experience, but their vision for CHESS was so much greater. They saw possibilities for a system that would help people facing a health crisis take better control of their lives, change behavior in positive directions and help them cope more effectively.

Before developing CHESS, the researchers decided to look at what patients in health crises struggled with, and sought to understand what their unmet needs were. They conducted extensive needs assessments among patients and their families. They discovered that patients often had difficulty finding good information about their condition, were hesitant or unable to attend support group meetings, and were being pressed to make and implement difficult decisions before they had adequate information, support and personal confidence about what decision might be best for them.

Insight

These issues hit home in an extremely personal way for Dr. Gustafson when his wife was diagnosed around that same time with breast cancer. He and his wife found themselves spending exhausting hours in libraries trying to find information they needed. They had to make very difficult decisions in a short amount of time—whether to have a lumpectomy or a mastectomy, and whether to undergo chemotherapy. They found themselves desperately needing time and resources to help them think through these decisions on their own.

As a result of Dr. Gustafson's personal insight, and that of so many others the team interviewed and surveyed, they realized that to be effective, CHESS needed to:

  • help patients and their families become much more actively involved in their treatment and recovery,
  • make high quality information and social support easily accessible and usable,
  • equip people to make good choices and decisions based on their individual needs and concerns,
  • address issues around behavior change and implementation of difficult decisions, and
  • connect people with similar crises together to share their experience and learn from one another.

Ultimately, the team wanted to see individuals and family units cope more effectively with their crisis, suffer less, and feel like they'd made better decisions as a result of using CHESS.

How We've Grown

In 1989 the CHESS team received significant funding from the W.K. Kellogg Foundation to develop the initial CHESS "shell" and pilot test some early topics which included Living with Breast Cancer, Living with HIV/AIDS, Adult Children of Alcoholics, Stress Management, Sexual Assault and Academic Crises.

Since then, the list of past and present supporters of CHESS research, development and dissemination efforts has grown to include the Agency for Healthcare Research and Quality, the Robert Wood Johnson Foundation, the National Cancer Institute, National Institute of Child Health and Human Development, National Institute of Nursing Research, Markle Foundation, Merck Outcomes Research and Management, National Library of Medicine, Department of Defense, and CHESS Research Consortium.

CHESS has also been used by several forward-looking, innovative health care organizations who see the value of CHESS and have incorporated various modules into their patient support programs. These early adopters of CHESS included the CHESS Research Consortium.

The CHESS system has evolved significantly, first with an expanded offering of services within the CHESS "shell." From there, a topics-based interface first developed for the Living After Breast Cancer Diagnosis module is now being incorporated into other modules. CHESS also continues to keep pace with rapidly changing technology, first moving from a DOS operating system to Windows, and now Internet-enabled versions. More recent research has focused on enhancements that include interactive online tutorials, webcasting technology, incorporating case management and clinician reporting features, to name a few. The NCI-funded Technology Enhancing Cancer Communications (TECC) project is a significant new initiative in the evolution of the CHESS project. The overall goal is to understand how interactive technologies work to improve cancer communication. Our research projects focus on separating web e-health systems into conceptual components, supplementing the systems with a human cancer mentor for breast cancer and for prostate cancer, and facilitating Web-based communication between the patients/family members and the clinical team.

The newest initiative for CHESS is looking at how small devices (PDA's, cellphones, etc.) can be used to deliver immediate and portable resources for people. The first effort underway is the development of an asthma management tool for middle and high school students. Other efforts to use technology to support clients and families are underway related to our efforts in the addiction treatment field.

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Network for the Improvement of Addiction Treatment (NIATx)

The work of the Center expanded to include working with organizations to more effectively deliver health care resources.

Founded in 2003, the Network for the Improvement of Addiction Treatment (NIATx) works with addiction treatment and behavioral health care organizations across the country to improve access to and retention in treatment for the millions of Americans seeking help with substance abuse and/or mental health issues. As a learning collaborative within the University of Wisconsin-Madison's Center for Health Enhancement Systems Studies, NIATx is made up of member-providers from across the country. The NIATx National Program Office facilitates peer networking and provides research, case studies, and innovative tools that encourage use of its process improvement model. This model is quality-driven, customer-centered, and outcome-focused, and it has proven effective in transforming members' business practices and the quality of care their clients receive. Together, the NIATx initiatives relate to increasing consumer access and engagement in treatment, improving consumer outcomes, and advancing addiction treatment as an essential component of the health care system.

NIATx resulted from the unique collaboration of two national initiatives: Paths to Recovery, funded by the Robert Wood Johnson Foundation (RWJF); and Strengthening Treatment Access and Retention (STAR), funded by the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT). What was particularly notable about these projects was their emphasis on systems and process-using existing resources, not more money-and their shared focus on increasing the rates at which Americans receive and continue through addiction treatment.

Paths to Recovery provided 26 treatment centers with expert coaching, peer learning support groups, and process improvement techniques built on or using NIATx's "rapid-cycle" change model. The STAR program worked with 13 providers in 13 states to accomplish three primary goals: Implement access and retention "est practices" in community-based treatment organizations; demonstrate the use of quality improvement methods to implement those best practices; and demonstrate the use of access and retention performance measures for performance monitoring. Between 2003 and March 2006, providers in Paths and STAR reduced their wait times by 35 percent and no-shows by 33 percent, and increased admissions and continuation by 22 percent.

Having worked successfully with treatment centers for more than a year, NIATx leaders turned part of their attention to state-level payers. Recognizing that states can have a profound impact on addiction treatment performance-removing barriers, providing incentives-NIATx established the State Pilot Project. In this pilot, supported by CSAT and RWJF, payers and providers partnered to identify how five single state agencies could be leaders in improving treatment quality; how states and other payers can work with providers to improve access and retention; and how organizations can document and disseminate innovative practices to improve performance quality. The agencies participating in the Pilot took major steps forward in showing the country how states and providers could partner to make an impact.

These three projects have concluded, and their participants are our Founding Members. As members of the NIATx network, they continue to benefit from our resources, and what they have learned helps those participating in existing initiatives. We have been pleased that the original funders for the first NIATx projects renewed their support for our newest initiatives.

The first of these newer programs is Strengthening Treatment Access and Retention-State Implementation (STAR-SI), funded by CSAT and RWJF. Expanding on the State Pilot Project, STAR-SI promotes state-level implementation of process improvement methods that improve access and retention in outpatient (OP) treatment centers, which provide 80 percent of addiction treatment services. Over three years, beginning in late 2006, nine state-provider partnerships are using a NIATx diffusion model to accomplish four goals: build state capacity to improve access and retention; build payer/provider partnerships that drive the improvement process; implement payer improvement strategies; and implement performance monitoring and feedback systems.

Another new program that launched in late 2006 is Advancing Recovery, funded by RWJF and co-directed by the Treatment Research Institute. This four-year effort promotes the use of evidence-based practices (EBPs) by treatment providers through innovative partnerships between providers and single state agencies. Grantees are testing administrative strategies while implementing at least two of five EBPs in the categories of medications, continuing care/aftercare, and psychosocial therapies. By examining state- and provider-level practices that currently impede the use of evidence-based care, the Advancing Recovery program is expected to improve consumer outcomes and highlight addiction treatment as an essential component of the health care system.

Two NIATx programs will gain visibility throughout 2007. First is Innovations for Recovery, a partnership between NIATx and the Robert Wood Johnson Foundation, which funded its formative research and prototype development. The initiative extends the work of the NIATx Addiction Treatment Vision Panel, which identified technology-based opportunities to improve outcomes and cost-effectiveness of the addiction treatment and recovery field. Innovations for Recovery is creating prototypes to demonstrate the potential of these technologies, and catalyzing interest in developing and testing technologies to transform service delivery and outcomes in the addiction treatment and recovery field.

Secondly, NIATx has launched the first clinical trial that examines process improvement in addiction treatment. NIATx 200, funded by the National Institute on Drug Abuse, will bring together 200 treatment providers from four states to study the adoption of specific NIATx process improvement strategies that have shown, in previous programs, to improve treatment quality, operations, and finances. Each of the 200 providers will be randomly assigned to a group that uses at least one of the following NIATx services: Learning Sessions, Interest Circles, Coaching, and a Web site that offers improvement resources. The study will aid in determining which combinations of collaborative services produce the greatest, most economically efficient improvement in achieving the four NIATx aims: reducing wait times and no-shows, and increasing admissions and continuations.

In the NIATx Model of process improvement, a continuous flow of ideas among peers inspires and motivates organizations to experiment and test changes. Encouraging and challenging each other, NIATx members are building a national movement to extend process improvement throughout the field of behavioral health. With a focus on the customer, NIATx organizations create a community of learners-payers, providers, policy makers-all working toward a common goal.

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The Future

Our mission to optimize individuals' health behaviors, quality of life, and access to services will continue to grow and build on the research currently underway. The Center for Health Enhancement Systems Studies believes that process improvement and technology have the potential to transform individual lives as well as the entire health care field.

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