Identify Clients at Risk for Leaving and Intervene
Problem:
Clients often threaten to leave treatment and yet there is no
follow-up to see what’s wrong and to help solve the
problems.
Solution:
Get feedback from clients regularly so that you can identify
clients who are at risk for leaving and intervene so that they
stay engaged.
Featured Stories
Bridge House in New Orleans, Louisiana increased
continuation rates from 48 percent to 63 percent by
implementing weekly check-ins, asking clients to rate on a scale of 1-10:
- How willing are you to continue treatment here?
- How important is it for you to stay in treatment?
- How motivated are you to stay?
- How strong has your urge to use been this past week?
A high rating on “How strong has your urge to use been this past week?” was the best predictor
that a client would quit treatment. They also scheduled weekly continuation staffings so that
counselors could discuss continuation issues and how to intervene with clients at risk for leaving
treatment. The counselors used Motivational Interviewing guidelines to motivate patients to stay
in treatment. Each counselor planned one specific change to motivate the patient to continue
and assessed whether it worked using PDSA cycles. For more information, see the
Continuation
Protocol and
Continuation Worksheet.
Sinnissippi Centers in Dixon, Illinois increased continuation through the first four sessions from
0 to 100 percent by using the Outcome Rating Scale/Session Rating Scale (ORS/SRS) with
intensive outpatient clients and addressed problems that were identified. After using the SRS for
six months, the counselors found that they could get the same results without the paperwork by
having informal one-to-one discussions about whether weekly goals were being met. They have
continued to sustain the high continuation rates. For more information, see the change bulletin.
Gosnold, Inc. in Falmouth, Massachusetts increased completion rates by 10 percent by
implementing an “R Board” system to discretely identify detox patients at risk for leaving. Any
staff member could put an “R” on the chart next to the client’s 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 talked about why he should remain in
the program. For more information, see the case study.
Lessons Learned
- Expect that clients will think about quitting treatment.
- Create ways for counselors to exchange ideas about how to intervene. In addition to
benefiting clients, this may help counselors feel supported and prevent burnout.
- Analyze your data to determine the most common points that clients are likely to leave
treatment—often during the first week and at 30 days. Watch clients more closely at
these times and plan ways of intervening.
- Create a system so that staff can communicate with each other about clients who show
signs of leaving.
- Use the Session Rating Scale or an agency-specific scale on a weekly basis to identify
clients at risk for leaving.
- Have counselors develop PDSA Cycles to test ideas for intervening.
- Use Motivational Enhancement Techniques to re-engage clients. These include openended
questions, affirmations, reflective listening, summarizing statements, and the
creation of discrepancy between the client’s urge to use and the desire to continue in
treatment.
Tracking Measures
Cycle Measure
No-show rate for treatment sessions
Data Collection Form
No-show Tracking Spreadsheet
ActionSteps
Plan
- 1. Select a counselor who is willing to test this change with one group.
- 2. Decide how to get feedback from clients. For example, have the counselor
ask clients to check in each week by answering the following questions with
a rating from 1-10.
- How willing are you to continue treatment here?
- How important is it for you to stay in treatment?
- How motivated are you to stay?
- How strong has your urge to use been this past week?
- 3. Collect baseline data for no-show rates for the selected group before making
any changes.
Do
- 4. Get feedback from clients for the next 2 weeks.
- 5. Use the responses to these questions to identify clients who may be at risk
for leaving treatment and track them individually.
- 6. Identify and intervene to keep these clients in treatment.
- 7. Track and calculate the no-show rate for the selected group for another two
weeks.
Study
- 8. Check the fidelity of the change. Was the change implemented as planned?
- 9. Evaluate the change:
- Did the no-show rate for the group decrease after implementing the
weekly check-in?
- Did the check-in help identify clients at risk for leaving?
- Were counselors able to identify ideas for intervening with clients at
risk for leaving?
- Did clients who were identified as being at risk for leaving continue in
treatment?
Act
- 10. Adjust the check-in method or try other ideas for intervening when clients are
identified as being at risk for leaving and re-test this promising practice for an
additional two weeks.
Repeat this series of steps until you have refined your approach to getting feedback
from clients and engaging clients at risk for leaving. Have all counselors use this
approach so that all of the clients that may quit treatment are identified and reengaged
in treatment. Continue to experiment with different ways for counselors to
exchange ideas about how to intervene.
Related Information
More Stories
STEPS at Liberty Center in Wooster, Ohio increased continuation rates by holding a special
group for clients at high risk for dropping out of treatment.
Daybreak Youth Services in Spokane, Washington increased continuation rates in the adolescent residential program beyond 30 days, from 55 percent to 72 percent by implementing
a client feedback survey that allowed adolescents to rate their relationship with the staff by
asking:
- Is the staff member able to help you with your skills?
- Is the staff member easy to talk to?
- Does the staff member validate you?
- Does the staff member make you feel heard, understood and respected?
- Does the staff member seem to use the skills when talking to you.
They provided each staff member with the feedback. The client feedback survey was initially
sent out every 60 days, and later changed to every six months. They also used a shift debriefing
form for staff to assess how well they’d engaged with clients that day.
Vanguard in Arlington, Virginia consistently maintained continuation rates in their adult and
adolescent residential programs above 90 percent after implementing an unplanned discharges
form so that their counselors could review what happened when a client left treatment early and
think about how to prevent it from happening again.
Women’s Recovery Association in Burlingame, California uses the WRA Pilot Program
Weekly Risk Assessment & Progress Notes to assess client risk.
Prairie Ridge Addiction Treatment in Mason City, Iowa had their clinical supervisors play an
active role to ensure that counselors and patients are a good match. They assigned counselors
who were more experienced to the less motivated patients.