NIATx Change Project Improves Transition to Continuing Care

Submitted by: 03/15/2017 by Maureen Fitzgerald

WomanSpace Philadelphia is a residential treatment program for dually-diagnosed, chronically homeless women. The ten-bed facility includes services addressing drug and alcohol addiction, mental illness recovery, life skills, and parenting skills. Individual and group therapy is provided in an intimate home-like setting, with the ultimate objective being reintegration after a 9- to 12-month treatment stay.

A program of Resources for Human Development, WomanSpace Philadelphia is also part of Philadelphia’s Journey of Hope Project, established in 2007 to help people with a history of chronic homelessness and co-occurring disorders. Through Journey of Hope, WomanSpace residents obtain apartments in the community after successful completion of treatment. They are also connected to outpatient (OP) or intensive outpatient (IOP) continuing care at treatment organizations located close to their new apartments.

Change Project Aim

A recent NIATx change project at WomanSpace Philadelphia focused on promoting residents’ stability post-discharge from the program. The specific change project aim was to increase the number of residents who attended their intake session for outpatient or intensive outpatient services within 14 days of discharge from WomanSpace.

“Many of our residents have never had their own apartments, and adjusting to all the change related to that transition can be quite overwhelming,” says Jenn Collier, Program Director at WomanSpace. Collier served as change leader for the project. Change team members included Detra Scott, WomanSpace staff supervisor, and Alex Rauch, (title).

“We found that even people who had been successful in treatment were not making it to their OP or IOP intake appointments once they got to their apartments,” adds Collier. “We wanted to address that breakdown between residential treatment and continuing care.”

At the start of the change project, the follow-up to continuing care was 67.7%.

PDSA Cycle

Their PDSA Cycle for the WomanSpace change team included making discharge plans weeks in advance and beginning the outpatient program immediately upon discharge. Residents attended intake at the new outpatient treatment provider in the morning, then returned to WomanSpace to attend their transition ceremony.

With this change, the follow-up to continuing care rate improved to 100%. 

“The PDSA Cycle helped us narrow our focus to one specific, doable action that had a positive impact on our outcomes,” says Collier. “This NIATx tool helped us realize change doesn’t have to be big to produce results. Successful change can come from something as simple as scheduling the intake appointment to the morning of the client’s transition.”

Another important lesson that emerged for the WomanSpace change team was that the discharge process can be re-traumatizing, particularly for people who have experienced chronic homelessness. “We’ve become very mindful of the need to provide trauma-informed care, including throughout the transition process,” says Jen.

WomanSpace has adopted and sustained the new discharge planning process. An upcoming change project will use the NIATx approach to create a trauma-informed culture at the agency.

See related NIATx Promising Practices: Increase Continuation Between Levels of Care

NIATx Tool to Try: The NIATx Way-Start Up

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