Improving Continuation between Levels of Care

Founded in 1970, today Palladia, Inc., is one of the largest not-for-profit, multi-service agencies in New York City. With more than 30 years of experience, Palladia serves largely urban, poor individuals and families of color and is nationally recognized for its innovative service delivery in the fields of substance abuse, homelessness, HIV, mental illness and trauma, domestic violence, criminality, and family services. Palladia currently serves approximately 1,300 persons per day in 24 distinct human service programs including two residential substance abuse treatment programs; four outpatient and transitional treatment programs; an HIV services unit; one homeless and two domestic violence shelters; two alternative to incarceration programs; seven permanent supportive housing programs; and five special initiatives and collaborations.

Palladia’s expertise in working with clients from multiple angles promotes independence, social competence, and responsible living, even among challenging populations. Palladia’s goal is to keep families together or reunite them, provide job training, encourage continuing education, offer a safe haven from violence, maintain mental health, prevent relapse, and make a permanent and stable reality a home for thousands of homeless individuals and families.

Starhill Residential Drug and Continuing Care Treatment Programs

The Starhill residential drug treatment program serves nearly 400 adult men and women in four separate Modified Therapeutic Community Programs contained within one site. All four programs employ interdisciplinary treatment teams. Clients’ length of stay varies from 6 to 12 months. Starhill residents follow a highly structured program with emphasis on personal accountability. The program’s goal is to change the client’s lifestyle from one of drug dependence and abuse to one of good health and sobriety.

Starhill offers residents a range of services, including substance abuse relapse prevention, drug and alcohol education, individualized and group counseling, parenting skills workshops, access to on-site medical and psychiatric care, vocational education, and work-readiness training.

Palladia’s Continuing Care Treatment (CCT) offers outpatient aftercare services to clients who have graduated from Starhill and Palladia’s other residential substance abuse treatment programs. CCT offers programs and services that promote a healthy drug-free lifestyle and reintegration into the larger community. CCT’s comprehensive approach helps clients with their recovery needs and the challenges of self-sufficiency.

An interdisciplinary team of mental health professionals, social workers, substance abuse and vocational counselors work to help clients achieve the goals and growth they began while in residential treatment. This comprehensive, holistic approach to recovery allows clients to access counseling and support services for the multiple problems and challenges they face as they increase their self-sufficiency.

CCT’s services include individual and group addiction counseling and support, relapse prevention, vocational and educational services, job search assistance, and assistance with budgeting and housing.

Palladia’s Change Project

One of the first problems the Palladia Change Team identified after joining NIATx was that patients would leave Starhill with a referral to Continuing Care Treatment (CCT), but they would not successfully transfer to CCT.
Palladia assembled a Change Team that included administrative staff from both the Starhill and Continuing Care Treatment facilities. Deb Pantin, Vice President of Outpatient and Centralized Services, served as Change Leader. The team established a goal to create a seamless transition from residential to continuing care treatment for each Starhill client.

Walk-through

The Change Team’s walk-through exercise provided a wealth of information about how clients and staff experienced the transfer from residential treatment to continuing care.

First, it became clear that clients needed more education about continuing care and its role in their continuing recovery. Some clients assumed that because they received a certificate of completion at the end of their residential stay, they no longer needed treatment of any sort.

The walk-through also revealed that:

• Paperwork between the two facilities was frequently lost or delayed
• CCT staff were note fully prepared to meet the needs of clients who did appear for continuing care
• Frequent staff turnover at the CCT site inhibited the success of the program

PDSA Cycles

The Change Team began to explore ways to improve the transfer between levels of care, using rapid-cycle PDSA testing.

Through flow-charting, the team identified weaknesses in the Starhill discharge process and the CCT intake process. With a better picture of the discharge and intake process, the team was able to test modifications to the system. These included:

• Sending a patient’s Starhill discharge application to CCT 30 days before the client’s scheduled discharge date
• Testing electronic transfer of paperwork between facilities
• Requiring CCT to call Starhill upon receipt of the discharge paperwork; after this point, CCT staff would schedule the client’s CCT intake within 7 days of receipt of the discharge paper work
• Requiring that Starhill clients complete CCT intake and attend at least two group sessions at CCT before departing Starhill
  

Change Leader Deb Pantin reports that client response to the changes was very positive. First, to address the Starhill residents’ need for more information about CCT, Starhill staff began to distribute information about the program. In addition, CCT staff offered monthly presentations about CCT at Starhill.

These information services corrected many of the misconceptions that Starhill residents had previously held—for example, that they would have to pay for continuing care when it is in fact a free service. Starhill clients were also pleased with the new administrative procedures to improve the transfer between the two facilities.

The Change Team then surveyed clients on the CCT program and learned that while they were pleased with the transfer, they were not happy with the services offered at CCT once they arrived. Clients expressed a desire for the CCT programming to address the most pressing issues associated with discharge from residential treatment. These included locating affordable housing, budgeting, parenting skills, coping skills, and finding a sober support network. Some CCT staff were evaluated as less skilled than others, especially in programming and facilitating groups. The survey also revealed that clients found the CCT environment as depressing and unwelcoming.

Change Team II: Improving programming and making the CCT environment more welcoming

Palladia assembled a second Change Team to address the areas that CCT clients had identified as in need of improvement. Deb Pantin again served as Change Leader. Unlike the first Change Team, the Continuation Change Team (Team II) included three clients (consumers).

“The consumer members of the Change Team are very involved and very enthusiastic,” reports Pantin. “They’re talking to other clients about the positive changes they’re working on at CCT. They’re also very involved in upgrading the CCT environment to make it more welcoming.”

The team completed several PDSA Cycles to address CCT service issues. To address the problem of uneven staff skill level, “we brought staff together to learn from each other,” explains Pantin. The team also adjusted the program scheduling. “We assigned a counselor with high attendance rates to a group that was struggling with low attendance, and we quickly saw an increase in attendance. Changing the programming at CCT to include topics that clients have requested, seems to be making a difference in days of continuation,” adds Pantin.

Offering services at times most convenient to clients

The team also worked to adjust scheduling to accommodate clients’ needs. “A consumer member of our Change Teams suggested what seemed like a small change—but it made a huge difference,” reports Pantin. “We’ve offered evening group therapy sessions at 6 and 7, with historically poor attendance at the 7:00 session. Clients more than 15 minutes late for the 6:00 session would have to wait for the later session—but they typically didn’t want to wait that long. The consumer suggested that we offer the sessions at 6 and 6:30 instead—and we saw a boost in attendance at the later session.”

As a result of the two change projects, Palladia has seen improved transfer between Starhill residential treatment and Continuing Care. Communication between clients and staff has improved at both facilities.

“We also have improved the continuation rate at CCT, from 114 continuation days pre-change to 134 days.”

Pantin cites other improvements as well. “Palladia staff are beginning to understand what true continuation is: minimizing as many gaps in treatment as possible,” says Pantin. “In New York City, it’s easy for gaps to develop naturally as a result of the complex systems our clients have to navigate. The philosophy at Palladia is now to eliminate barriers and make continuation from residential care to community care a routine component of the recovery process.”

Change Team I: members comprised 12 administrators from three different administrative levels. “Members generated ideas focused on ‘system,’” says Pantin. “Including a consumer on the team would have generated more ‘out of the box’ thinking. However, the advantage to having team consist of administrators was that it secured buy-in from staff at different sites. Staff at all levels are enthused about NIATx, feel more invested in change projects, and are excited at seeing immediate results.”