Third change is the charm for Pennsylvania change team

Attendance in the intensive outpatient treatment program is up, thanks to a recent NIATx change project at the Gaiser Center in Butler, Pennsylvania.

Butler is a small industrial city about 35 miles from Pittsburgh. The Gaiser Center serves about 1,400 clients each year at two sites, one for outpatient treatment and one for inpatient treatment.  

The Center began its first NIATx project in September 2015. They set a goal to increase engagement and attendance in the intensive outpatient program (IOP). The IOP meets for nine hours each week: with three-hour sessions meeting from 1:30 to 4:30 three days each week.

At the end of May 2016, attendance had increased to 84% from a baseline of 66 %, reports Alicia Fairman, Gaiser Center Program Director.

To apply the first NIATx principle, “Understand and involve the customer,” the change team asked clients to be interviewed about their experience in the IOP program, in exchange for a gift card.  Four clients took up the offer.

Their feedback?  Among other things, the IOP sessions were long, and clients found it difficult to focus their attention on the materials presented.

Then, two staff members from the inpatient program sat in on a couple of IOP group sessions. Their observations confirmed what clients had shared in the interviews: the IOP sessions were simply not very engaging.

With that information, the team got to work. “We wanted to make immediate changes to reduce client boredom and break up the tedium of the long sessions,” says Alicia.

The team purchased some DVD players so participants could view engaging videos that reinforced concepts presented by the counselors. They also introduced role-playing exercises, icebreaker activities, and feelings charts to help clients articulate how they were feeling when they came in on a particular day.

One change at a time with rapid-cycle testing

While participant response to these changes was positive, the change team realized they had veered off the “one change at a time” path that NIATx recommends. “We then got back on track with one change at a time,” says Alicia.

The first change they tested was to offer a snack. “We thought this would improve attendance, because a lot of our clients come without having eaten anything before the sessions begin at 1:30 in the afternoon.”

The team already used an existing system for tracking attendance to see if offering the snack increased attendance. But it seemed to have the opposite effect—attendance actually went down.

“The people who were attending regularly appreciated the snack, but it wasn’t a deal breaker for people who were on the fence,” explains Alicia.

The second change tested was to reorganize the group sessions so clients could have more time with their assigned counselors in a smaller group setting every day.  This was a change from dividing the clients into groups among all available counselors.

“Every day all counselors would run a 90-minute small process therapy group with their assigned case load, followed by a 90 minute educational session,” says Alicia.

Again, the team found clients who were attending regularly appreciated this change. But it wasn’t enough to boost attendance from the ambivalent participants.

Third change was a charm

For the third rapid-cycle, the team decided to have the client and counselor work together on one challenging goal on the treatment plan.

As Alicia notes, “Some our clients have been in treatment multiple times, and we wanted them to work on completing a challenging goal that they had not been able to meet in the past. It could be something like attending a 12-step group or writing a letter to a relative they’d had conflict with in the past.” 

In exchange for meeting the goal, the client would be rewarded by getting one day off from group attendance.

“It seems like a contradiction to offer a reward that would reduce attendance, but it worked,” says Alicia. “We actually found that when clients met their goals, they didn’t want the reward—they did not want to miss a day with their group.”

Alicia attributes this to support and encouragement the participants received from their counselors and from each other. “A lot of our clients don’t come from backgrounds where they were rewarded or recognized for working hard,” she comments.

Group IOP attendance is higher that it has ever been, now (June 2016) stabilized at 80 percent.

To sustain the change, Alicia and the team will continue to monitor attendance and make any adjustments needed to address any downward fluctuations.

They’re also looking at a change project to increase attendance for the Center’s outpatient group.

Alicia has been involved in other quality improvement projects and appreciates that her team to could adapt the NIATx tools as needed to meet their Center’s goals.  

“This project has been so successful that we want to try a similar project to improve outpatient group attendance.”