New York State Office of Alcoholism and Substance Abuse Services (OASAS)

OASAS will improve client access and retention rates across 18 outpatient addiction treatment providers in New York City and Long Island using the NIATx approach for performance improvement and system change. OASAS will also develop three interconnected peer learning networks among these providers. Further, OASAS will collaborate with the Local Government Units in New York City, Nassau County and Suffolk County to create the infrastructure needed to sustain these networks beyond the life of the grant. OASAS will use the STAR-SI experience to examine how to effectively implement, support, sustain and spread process improvement change efforts in addiction treatment programs.

OASAS seeks to understand and enhance how the State and/or providers can facilitate and support use of process improvement methods to improve client access, retention and outcomes. To further work toward this goal, New York will:

Create the infrastructure needed to support outpatient clinics in incorporating process improvement methods that address access and retention measures.

Key steps in this process are:

• Introduce NIATx methods to providers. This will assist providers to design change projects addressing access and retention challenges experienced in their respective outpatient clinics and agencies;
• Develop peer learning networks to further strengthen and motivate use of process improvement strategies, identify opportunities to collaborate with peers and address State system-wide challenges;
• Engage and coordinate activities with other chemical dependence systems. These would include Local Government Units responsible for mental health and substance abuse services within the jurisdictions targeted in the grant. These partners are critical to ensuring local capacity building around access and retention challenges beyond the life of the grant; and
• Continue to develop, extend and enrich use of the STAR-QI system as a tool for tracking impact and building a state wide data perspective

Numerous activities undertaken to improve access and retention in this reporting period include: 

• OASAS identified the NIATx approach to process improvement as one of five targeted promising practices that providers statewide will be encouraged to adopt. This effort is being coordinated by the OASAS Metric Team charged with promoting use of evidence based and promising practices.
• Two State based learning collaboratives were conducted: Year I participants attended a learning collaborative in NYC and Year II providers attended a kick-off all team meeting in Long Island. Tom Mosgaller (NIATx) attended both sessions and presented on "Learning from Outside the Field: The Toyota Way". Both sessions offered opportunities for provider updates and peer to peer problem solving. In addition, the Year I Executive Sponsors presented business case results for change projects. The Year II providers were just completing baseline data collection. Their teams focused on selecting change projects, including building skills on interpreting data to select change projects. Collaboratives are designed to strengthen relationships and sharing among providers.
• Monthly calls were conducted for the providers in each cohort of STAR-SI. The calls provide opportunities for updates, peer support and for exploring topics of common interest, e.g. marketing services to others in the community.
• The STAR-SI Project Coordinator briefed Year II providers on use of the Change Project form. She has conference calls with each of the new change team leaders to assist them to become comfortable with completing and using these important forms.
• The STAR-SI Project Coordinator spoke with Year I Executive Sponsors individually to get feedback on the program and discuss potential strategies to launch time limited projects around a shared measure.
• NYC Field Office staff were briefed on the STAR-SI program at a monthly downstate staff meeting. This reached over 30 program managers, four of whom are assigned to current Year I providers. The Downstate Field Office director and staff agreed to help seed interest in STAR-SI to support Year III recruitment, similar to the role played by the LI FO staff for the Year II cohort.
• Peer mentors supported some Year I and all Year II providers. Peer Mentors meet together by conference call each month.
• STAR-SI data coordinators monitored data collection across groups.
  • Data conference calls were conducted with Year I programs to assist them to prioritize updating of data. In this period:
    • One provider made all necessary corrections.
    • Two are making steady progress in updating records.
    • One experienced such significant problems that a decision was made to move the STAR-SI initiative to a different clinic. Staff at this provider's new site completed entering two months of baseline data.
  • Year II providers were assisted with data collection issues as they occurred. The new training and monitoring strategies have resulted in many fewer problems for Year II providers than experienced prior to the development of STAR-QI.
• Technical assistance was provided to providers on an as needed basis. This included several meetings, calls and site visits.
  • One visit was a "STAR-QI walkthrough". A second site visit helped an agency that is making major changes benefiting their agency and clients through STAR-SI improve its change project selection and documentation processes.
• Individualized and strategic technical assistance is being viewed as a tactic that can be used to sustain involvement and integration of process improvement techniques in agency operations.
• Representatives of Nassau County and Suffolk County attended the kick-off LI earning collaborative and were invited to join monthly calls with providers. The STAR=QI project coordinator conducted a conference call with both counties in March to update them on results of early change projects.
• The STAR-SI Principal Investigator and Project Coordinator met with representatives of the NYC Department of Mental Health to discuss STAR-SI and NYC process improvement programs. Representatives of NYC DMH attended the Year I learning collaborative. NYC DMH agreed to help facilitate recruitment of new providers in Year III in the NY boroughs.
• The State Change Team Leader, Principal Investigator, STAR-SI Project Coordinator, 2 Data coordinators and one provider attended the Annual STAR-SI Grantee Meeting. NYS presented at the session on STAR-QI.
• "One Year In: Lessons Learned about implementation of NIATx process improvement methods through STAR-SI " was the topic of a workshop at the annual ASAP conference in Niagara Falls, NY. Presenters included Bonnie Cohen and Susan Brandau from NYS OASAS, Pam Mattel from Basics, Inc. and HAYNES from NYC Health and Hospital Corporation. ASAP is one of OASAS' STAR-SI partners. The workshop helped seed interest in NIATx with providers located across the state. Evaluations were very positive.
• The first issue of the quarterly STAR-QI FAQs training support tool was distributed. These updates will address problems that many providers encounter in using the STAR-QI web module as well as ways to use the system to increase its utility for data analysis.

Changes implemented by the NY State team and providers led to the following improvements impacting access to and retention in treatment in this reporting period:

• Three Year I providers successfully launched or sustained change projects addressing access and retention challenges in their agencies;
  • HHC increased the percentage of admissions with 4 or more services within 30 days from 47% in June, 2007 to 61% in March, 2008.
  • Riverdale Mental Health Association has focused on increasing admissions since July, 2007. RMHA more than doubled their admissions in this reporting period compared to the last period (45 versus 19 clients admitted).
  • BASICS Inc. increased the percentage of clients who kept their first clinical appointment from a baseline of 39% to over 70% in the first reporting period. They have sustained an average show rate for 1st appointments of 63% for the past 6 months.
• Six Year II providers launched change projects after January 1, 2008. All initial projects address access challenges. Early results showing sustained improvement include:
  • DAYTOP Village reduced the average days from first request to first clinical service from 3.8to 1.6 days.
  • Town of Smithtown Horizons Counseling and Education Center increased the number of first appointments kept to from an average of 23 per month (baseline data) to an average of 27.
• Six Year II providers collected three months of baseline data in STAR-QI. One Year II provider switched OP sites and completed collecting two months of baseline data.
• Year I providers have each taken steps to introduce and/or expand use of NIATx methods to other programs in their agency or system.
  • BASICS presented a power point describing NIATx and their change project to every unit in their agency.
  • RMHA's SA program combined forces with the vocational division in their agency to develop a program that boosted admissions and client outcomes for both units.
  • HHC identified a second OP site to begin using the NIATx model.
• Three Year I providers developed and presented business cases to their Boards/ Management. This has won support for each of their programs. For example:
  • Elmhurst Hospital authorized filling of two vacant clinician items at the HHC OP site during a hiring freeze in recognition of the outcomes demonstrated from STAR-SI.
  • BASICS , Inc. reported an 84% increase in the number of assessments completed monthly, increasing monthly revenue by over $1100.
• All STAR-SI programs continue to refine data collection and management. Data collection has improved, though it remains a challenge across the board. This STAR-QI data system also holds promise for part of the strategy for long term stability of the projects and the NIATx effort
• Year II providers continue to express interest in spreading the NIATx model to other units in their agencies.
• Providers regularly share change project results within their programs and agencies. As a result, other staff members have asked to join in change teams, (i.e. to be part of what is seen as a valuable and interesting agency direction.)
• Year I providers have formed relationships through the learning collaboratives and other team activities. There is sharing of information and resources both as a result of group discussions, but also through outreach and networking that occurs "outside" the formal meetings.
• One Year I provider had significant struggles in meeting the expectations of the program. This agency chose to begin again at a new outpatient clinic rather than leaving STAR-SI recognizing the value of the program. This is not only a statement about the value perceived about STAR-SI, but it is reinforcing to current participants about the commitment of peers to change.
• The STAR-QI web module will now be available to non-STAR-SI NY providers.

Taken together, the above changes indicate

1. specific and important changes occurring at the individual organizational level,
2. the development of a growing community able to implement and use NIATx methods for rapid cycle improvement and
3. a deepening and enrichment of state and community performance improvement cultures necessary for sustaining longer term change.

• Some Year I providers report that the most important impact of STAR-SI is not the result of any specific change(s), but is the transformation of the culture of their agencies.
  • Changes include staff empowerment, new approaches to leadership by Executive sponsors and new approaches to evaluating practices.
• Comprehensive incorporation of NIATx principles and practices into agencies is not quick.
• Working with providers ‘where they are at' and "at their own pace" ultimately reaps rewards.
  • After experiencing very significant struggles in meeting the expectations of the STAR-SI program, Bridge Back to Life Centers, a Year I provider, changed the site for its participating OP clinic rather than drop out. The willingness of OASAS staff to work through months of challenges - as well as the obvious success other providers were experiencing with the NIATx model -contributed to keeping this group in our program.
  • DAYTOP Village dropped out of STAR-SI in Year I, but was allowed to rejoin the program in Year II at a different site. This clinic has done very well in the early months of implementing Year II change projects, and reports that DAYTOP is interested in spreading STAR-SI to other sites statewide.
  • Riverdale Mental Health Association was very slow to focus effectively on STAR-SI. For example, it took them over 6 months to identify an effective change team leader interested in quality improvement, establish a team or select measurable change projects. However, they currently have: incorporated NIATx principles into agency wide quality improvement efforts; engaged other agency departments in meeting STAR-SI change project objectives; and are among the STAR-SI leaders in using data to advocate for their programs, e.g. building a business case.
• Peer learning is powerful. Providers report that peer feedback is very helpful.
  • Tracking others' progress results in a healthy competition and motivates many within their agencies to keep focused on their respective projects.
  • STAR-SI providers greatly value hearing updates from other groups and learning from peers in problem-solving sessions.
  • Strategies used in one agency to impact changes influence change projects considered and /or pursued in other sites.
• Providers report that having a State staff person dedicated to the STAR-SI project greatly helps keep them on track.
• Keeping things simple is hard.
• Programming and technical assistance needs differ among more mature agencies and programs new to NIATx. Planning for a range of needs is critical to assure continued participation in STAR-SI as well as use of the PI skills.
• Providers need help using data. However, over time we are seeing increased commitment to assuring data integrity across the sites and greater interest in learning about interpreting data. Further, we are seeing more senior managers becoming frequent users of the STAR-QI reports.
• While selection of an initial access or retention indicator is relatively straight forward, selection of a subsequent indicators proves more challenging for many groups. Providing direction and assuring momentum are predictable challenges for Change Team Leaders and Executive Sponsors.
• Team-building remains of great interest to groups.
• Working with other units within provider organizations is emerging as a tactic for assuring integration of methods into the agency and sustaining momentum.
• Providers are candid about progress – the ups and downs - with other groups and in public forums. They do not "hide" problems. STAR-SI providers are also quick to offer encouragement to each other.
• We try to bring speakers to learning collaboratives who are not part of our "NY Family". Tom Mosgaller was the presenter at our Year I and II collaboratives during this period and he was very well received. Several people who attended have been in direct contact with him subsequent to our session, and his remarks are still referenced. Tom addressed issues related to learning from outside the field as well as organizational transformation, which is an "unanticipated" result now being recognized by NY participants.
• We have benefited from conducting recruitment meetings that clearly outline commitment expected of participants. We include current providers to showcase process and results. These meetings combined with the new requirement for the completion of a written application appear to have substantially improved providers' ability to ease into NIATx.
• We have had mixed success with use of peer mentors. Some agencies like to use this resource, and some do not. Further peer mentors past personal experience does not automatically transfer into ability to help/teach others.

To sustain improvements New York plans to:

• Support efforts of current providers to launch change projects and document accomplishments.
• Document and share successful change strategies to encourage adaptation by additional participating providers.
• Identify and share strategies that facilitate monitoring of results of completed change projects with Year I and Year II providers.
• Involve providers in planning for the collaboratives and other peer meetings to address access and retention challenges.
• Develop a more "formal" state wide spread and sustain plan using the above strategies

To spread improvement New York plans to:

• Work with the OASAS Field Office staff in NYC to seed awareness of STAR-SI among potential YEAR III providers
• Identify six new Year III participants in Year II.
• Convene current participating providers to consider strategies to expand use of the NIATx approach within other agency programs or systems.
• Increase the involvement of local government units (city or county) in planning for diffusion and spread of the NIATx approach to additional providers as well as sustaining involvement of current programs.
• Develop marketing material describing STAR-SI and NIATx and showcasing provider results and experiences.
• Share the results obtained in Year I to key stakeholder audiences, e.g. LGUs, other providers and key leaders within NYS OASAS. Opportunities to become involved in process improvement activities will also be identified
• Identify opportunities to introduce NIATx methods in new forums, in partnership with other organizations e.g. LGUs or professional associations, and through the media.
• Continue to present results from the NY NIATX efforts at local, state and national conferences