Support Services as a Means to Decrease No-show Rates

This case describes the use of increased support services coupled with paperwork reduction at the Axis 1 Center in Barnwell, S.C. to increase the rates of retention in the first four treatment sessions, and to decrease the overall no-show rate at the agency.

Judy's Treatment Attempt

Judy lives in a small rural town where everyone knows everyone else. She is 26 years old and has been using alcohol and marijuana for about ten years. She has started in treatment several times, but just can't seem to stick with it. Last month, Judy's boyfriend was arrested for possession of marijuana. She got scared and signed up for treatment once again. After the first couple of group sessions, she wasn't convinced that treatment was helping. Plus, it was difficult getting to the treatment sessions without a car. Judy got back together with her boyfriend after he was released from the detention center, and soon she gave up trying to quit the drinking and smoking. The counselors and people involved in her treatment group wondered what happened to her, but no one made any significant effort to get in touch with her. Judy probably won't seek help again until her next big scare - or worse.

Background

The Barnwell County (S.C.) Commission on Alcohol and Drug Abuse was created in 1973 to provide alcohol abuse and other drug abuse treatment services. In April 1996, the Commission adopted the new name of Axis 1. A small agency serving a rural population in and around Barnwell, S.C., Axis 1 annually sees approximately 425 clients, predominantly with cocaine and alcohol addictions. Axis 1 provides services that cover the areas of education, prevention, and individual and group outpatient treatment.

Axis 1 recognized that people were dropping out of treatment after one or two sessions, and that the agency's no-show rates for intake appointments and subsequent treatment sessions were high. In the past, Axis 1 had made some attempts by phone or letter to reach people who failed to show up for appointments or groups, but staff time for such follow-up was limited. As a member of NIATx (the Network for the Improvement of Addiction Treatment), Axis 1 began looking at their retention and no-show rates differently. The agency formed a change team and was ready to take on the challenge of reducing those numbers.

Identifying the Issue

For the first month of data collection in October 2003, the overall no-show rate for addiction treatment services was 63%. The no-show rates for the first, second, third, and fourth treatment sessions were 25%, 25 %, 63%, and 88% respectively. The Axis 1 change team wanted to reduce the no-show rate. Over the next several months, the agency implemented a variety of support services intended to get more people in for their initial appointment, and also to keep them coming for treatment.

The change team, which included the executive sponsor, clinical supervisor (serving as change leader), treatment director, counselors and reception staff, developed a list of factors that impacted retention and no-show rates. Axis 1 also gathered input from people who had sought and/or received treatment there. The following were identified as barriers to beginning or continuing treatment:

1. Participants felt that no one really cared if they attended treatment sessions.
2. People scheduled for intake or treatment forgot about their appointments.
3. There was a lack of engagement in treatment sessions or groups.
4. Participants were focused on their day-to-day needs (e.g. - employment, benefits), and thus treatment was a lesser priority.
5. There was a lack of reliable transportation to and from treatment.
6. Participants disliked the excessive paperwork involved in the intake and treatment process.

With this list of barriers, the change team began implementing strategies to reduce them, using PDSA cycles. The changes in services included: a new case manager role to focus on outreach; added incentives to begin and attend treatment; employment assistance; transportation assistance; and revisions to the paperwork process.

Impact of the Changes

The data gives a clear measurement of the changes, but the expressions of gratitude from participants are much more rewarding for the staff at Axis 1. The woman named Judy got another chance at recovery when the case manager went to great lengths to track her down and invite her, in person, to come back to treatment. Moved that someone cared enough to find her, Judy did return to treatment.

Women who attend the weekly group sessions say they have something to look forward to now, and really appreciate the incentive of tangible rewards for their efforts to attend treatment. One woman who was recently given an interview outfit by Axis 1 feels that the nice clothes helped her to get the job. These personal stories speak more forcefully than the numbers; Axis 1 continues to collect them, to illustrate the impact of their change efforts.

Case Management

Axis 1 developed a new case manager position to focus on outreach and contacts with its addiction treatment patients. The staff member who took on this position was knowledgeable about the surrounding community, and had experience in addiction treatment. This case manager does a variety of tasks, from reminder calls of upcoming appointments, to calls and letters to people who miss their initial intake and treatment sessions. She helps with solutions to barriers such as transportation and childcare, and even provides direct transportation on some occasions.

This case manager has paid visits to people's homes, and sought them out in various places in order to invite them back to treatment groups. This personal interest in their well-being has brought several people back to treatment. It may have even saved the life of one woman who, suffering alone with severe illness, received essential medical help after the Axis 1 case manager visited her. The clients of Axis 1 have nicknamed the case manager the agency's "Deputy Dawg." More importantly, they know that someone does care if they do not show up.

Women's Group Incentives

In addition to creating the case management position, the agency also hired an experienced counselor to run women's treatment groups. The counselor has begun incentive programs to keep women coming to group, which meets three times weekly. Each time a woman attends the group, she puts her name in a jar. At the end of every month, a name is drawn and the winner gets to choose a small prize from an assortment of gift items. Each quarter, one name is drawn; that person gets to choose a larger gift. The requirement is that clients have to attend to put their names in the jar. If a client misses two consecutive groups, her name is removed from the jar, and she has to start over. This incentive has been a big hit with the women in the group.

The women's group counselor has also allowed participants to direct their group. A number of the women decided to share a weekly meal with each other. They arrive at the agency early to eat and socialize - and support each other. Recently, the women's group went with the counselor and case manager to see an inspirational speaker who talked about the potential for better lives.

Employment Assistance

Axis 1 recognized that employment assistance is an important factor in the success of addiction treatment. People in treatment at the agency can get assistance with job applications, interview skills and their interview/work wardrobe. Axis 1 staff seek clothing donations, which they offer to clients attempting to get back into the work world or looking for better-paying jobs.

The Transportation Barrier

The case manager, counselor and administrative staff at Axis 1 recognize that lack of transportation creates barriers for a number of people in their community who desire addiction treatment. The Medicaid van requires a minimum three-day advance notice for rides, and also frequently dictates ride times. This means that persons using the van for treatment sessions often have to arrive well before their scheduled treatment time. They may also have to wait for an extended period after their session, before being picked up. Axis 1 is working with their area's Medicaid transportation vendor to change current policies, which are not typically customer-service oriented.

In addition to advocating for improvements in Medicaid transportation, Axis 1 administrators realized case managers and other agency personnel could potentially provide some rides to and from treatment. To facilitate this, Axis 1 worked with the county to find a way of budgeting for vehicles for staff use in offering clients additional transportation options. These efforts were successful, and Axis 1 now has two vehicles designated for providing rides to and from treatment. This allows clients another means of getting to and from sessions, and it also gives Axis 1 staff more opportunities to spend time with the people receiving services there.

Paperwork Revisions

Along with adding support services, Axis 1 reviewed the intake process for addiction treatment. This review highlighted the need to consolidate some of the required paperwork. In addition, the priority of paperwork was balanced more appropriately with getting to know the individual seeking services. Now, the process involves not only fewer pages of paperwork, but also intersperses the completion of paperwork with other aspects of intake and treatment. The new philosophy is that not all paperwork needs to be completed up front, but rather can be done in increments, as it is required for various stages of treatment.

Axis 1 has been tracking data on no-show and retention rates for the first four treatment sessions over the past several months. The data compiled includes intake appointments, various treatment groups and individual sessions. The figures from March 2004 (six months into change implementation) show significant improvements compared to October 2003. The following numbers reveal the degree of improvement made:

• Overall no-show rate in March was 45% compared to 63% last October.

Figure 1

• Retention rate to first treatment session in March was 100%, up from 75% last October.
• Retention rate to second treatment session in March was 81%, up from 75% last October.
• Retention rate to third treatment session in March was 68%, compared to 37% last October.
• Retention rate to fourth treatment session in March was 64%, up from the low figure of 12% in October 2003.

Figure 2

These figures show a significant increase in the overall treatment retention rate for Axis 1 in the post-change period, as compared to data compiled prior to initiation of change efforts.