Increasing Continuation in the Men's Residential Program

Gosnold, Inc, in Falmouth, MA became a member of the Network for the Improvement of Addiction Treatment (NIATx) in Fall 2003. As a member of NIATx, Gosnold formed a change team that reviewed outcomes of the organization and set goals for changes that would benefit people seeking treatment there. Tommie Ann Bower, the director of residential services at Gosnold, served as change leader.

The men’s residential substance abuse treatment program, called Miller House, is a 33-bed facility for men 16 years of age and older. In early 2004, the rate of treatment completion in the men’s residential program was approximately 43%. In other words, 57% of men who entered residential treatment dropped out. Virtually all of that 57% was considered highly likely to relapse into use of addictive substance(s) shortly after leaving treatment.

Prior to joining NIATx, Gosnold was aware of the low continuation rates at the men’s residential treatment program. With a high demand for residential treatment in their region, Gosnold provides services, including detoxification, to people throughout New England. In addition, Gosnold provides intensive outpatient treatment. Patient surveys showed low satisfaction ratings, and Gosnold had received regular requests for refunds from private-pay consumers.

The agency attempted to address these issues prior to its involvement with NIATx. Gosnold had tried implementing a revised relapse protocol and made changes to staff schedules, such as adding staff education sessions and increasing staff supervision. However, these efforts did not have a significant impact on residential completion rates.

Wayne’s story

Wayne had been at Gosnold’s residential treatment facility for six days this time. His urge to drink was so strong that he thought he would go out of his mind if he didn’t get out of there soon. After lunch, he decided it was time. He headed to his room to collect his things. One of the staff members saw him packing and asked what he was doing. She tried to convince Wayne to talk to his counselor and reminded him why had come in a few days earlier. Wayne wasn’t convinced and went to the desk to check himself out of treatment. No one else tried to stop him. A week later, Wayne was killed in a car accident while driving under the influence of drugs and alcohol. No one knew it, but he was saying good-bye forever when he left treatment that afternoon.

Working with NIATx provided Gosnold with a new perspective and approach to the improvement of services. The Gosnold change team decided to set an aim to:

• Increase the treatment completion rates for men entering residential treatment.

Making change happen

First, the change team members met with former graduates of the men’s residential treatment program to gather information on positive and negative aspects of the program. According to the graduates, the strengths of the program were the small group sizes and strong commitment to motivating residents during their recovery. The weaknesses included the peer atmosphere and social environment. In reviewing agency information, the change team found that younger men in the residential program had higher relapse rates and higher rates of administrative discharges. The men described tension between younger and more mature men in the residential treatment program, which staff had also noticed.

The first change the Gosnold change team made was to divide the men’s residential treatment program into two age groups. The Miller Intensive Treatment group consisted of younger men who were typically in their late teens to early twenties. The programming for this group included increased time for physical activity, additional time with staff, and treatment meetings outside of the program. The men separated into the Miller Intensive Treatment group told Gosnold staff that they liked the change and enjoyed the additional time at the gym as well as the opportunity to go off site for meetings.

The men who were older or at a different stage in the treatment process remained in the Miller House program. Dividing the group into Miller House and Miller Intensive Treatment did not significantly modify the programming. The men at Miller House and the staff working with them, however, reported t a noticeable decrease in tension and expressed that the environment seemed more conducive to treatment progress.

Despite the popularity of this change with the residents, three out of eight of the men originally separated into the Miller Intensive Treatment group soon relapsed into substance abuse and left the program.

The next phase of change

Within a few weeks of dividing the men’s residential treatment into the two groups, the change team reviewed the data and brainstormed next steps. In the next change phase, the group decided to make three changes: they developed a system to identify patients at risk of leaving treatment along with a residential continuance contract to review with those patients. They also decided to restrict weekend passes during the first month of treatment.

Change team members knew that this would give staff an opportunity to support people through the times when they wanted to leave treatment. Second, the change team recognized that relapses back into substance abuse were more likely to happen during weekend passes that residents received early in the residential treatment process.

To respond to the need for earlier identification of at-risk patients, the Gosnold change team developed a two-tiered system. First, if a treatment recipient showed ambivalence about staying in treatment, a staff member placed an “R” on the chart next to his name. Other staff members were notified of the potential risk and at least five staff members, including nurses, counselors, and counselor aids, talked to the patient about his feelings and explained why he should remain in the program.

Next, a staff member created a residential continuance contract, which the staff member reviewed with the client every two days to establish the patient’s commitment to remaining in treatment for the next forty-eight hour period. This occurred in as many cycles as necessary to help the person to stay on track with treatment.

Simultaneously, Gosnold made an additional change to address the issue of weekend pass relapses. Gosnold did this by restricting weekend passes during the first month of residential treatment. This policy primarily targeted patients entering the men’s residential treatment program directly from detoxification, since they presented the greatest risk of leaving treatment early. Gosnold hoped that without the option of leaving the program during the first month, the men would be further along in their recovery and more committed to the treatment process before facing outside influences that could contribute to relapse.

Gathering feedback as a means to a change

After implementing these additional two changes, the change team at Gosnold began meeting with the men in the Miller Intensive Treatment Program so that the patients had the opportunity to share their feelings and provide feedback. The men specifically indicated that they liked the structure of the program, the smaller group sizes, the age-specific group, and the built-in time for exercise. The change team found that asking for feedback from the men increased their commitment to staying in the program and their willingness to follow the rules at Gosnold. Counselors and other staff members reported fewer problems and a reduction in the number of men considered to be at risk of leaving prior to treatment.

One more change

With a further review of change results, Gosnold decided that there was more room for improvement regarding the continuation rates in the two men’s residential treatment programs. The change team decided to make another change to treatment programming. Change teams working with NIATx learn to use rapid Plan, Do, Study, Act (PDSA) cycles to choose an idea, test it, review the results, and then based on the results, take an action. The change leader and change team at Gosnold decided that the implementation of personal PDSA cycles for men in treatment could be a useful tool in the recovery process.

The team created a form with a grid for the men to complete weekly. The change team adapted the cycle slightly as Plan, Do, Measure, Act (PDMA), and instructed the residents to complete a PDMA cycle in three areas—physical, mental, and spiritual—each week. The men’s aims included specific things such as quitting smoking, praying more often, and losing weight, as well as revising treatment practices and protocols. Using PDMA cycles, discussions about feelings shifted to a focus on reaching goals and solving problems. The PDMA cycles quickly became an integral component of treatment at the men’s residential program at Gosnold.

Within four months of completing the series described above, continuation data reflected positive results. The treatment completion rate for the men’s residential treatment program at Gosnold had risen from the pre-change figure of 47% to 75%. With the efforts of the change team, consumers and other staff members, an additional 28% of men entering treatment were completing treatment.