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Helping states and providers work together: a NIATx initiative brings them to the table to implement process improvements.

Since 2003, the Network for the Improvement of Addiction Treatment (NIATx) has worked with treatment providers around the country to make more efficient use of their capacity and to achieve four aims: reduce waiting times and no-shows, and increase admissions and treatment continuation rates. Providers have used NIATx's evidence-based practices to reduce wait times by 24% and no-shows by 32%, as well as increase admissions by 25% and treatment continuation rates by 14%.


A new NIATx initiative, the Strengthening Treatment Access and Retention-State Implementation (STAR-SI) program, is funded by the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT) and The Robert Wood Johnson Foundation. Launched in October 2006, STAR-SI builds on the innovative work of an earlier NIATx project, the State/Payer Pilot Project to Improve Addiction Treatment. Also funded by CSAT and the Robert Wood Johnson Foundation, the pilot project formed payer/provider partnerships in six states to promote state-level implementation of process improvement methods.

In each pilot state, the director of the single state authority (SSA) and a designated state team change leader worked in partnership with managed behavioral health organizations, state provider associations, NIATx treatment providers, and other stakeholders to develop provider learning networks and pilot the implementation of improvements to increase client access to and retention in services. Three key lessons emerged from the project: Forming positive working relationships with treatment providers is vital; maintaining the relationships is critical; and leadership buy-in is essential.

In the STAR-SI project, SSAs work in partnership with providers in their states to test process improvement methods that help providers get more people into treatment and keep them there longer. Nine state-provider partnerships in Florida, Illinois, Iowa, Maine, New York, Ohio, Oklahoma, South Carolina, and Wisconsin received funding to implement process improvement strategies targeting fiscal, regulatory, and policy changes. Below are updates on how efforts are proceeding in two states.

Envisioning a Culture of Continual Improvement

The Oklahoma Department of Mental Health & Substance Abuse Services (ODMHSAS) began its work with process improvement as a participant in the State/Payer Pilot Project to Improve Addiction Treatment (2005-2006). Led by Dr. Terry Cline, then the state's commissioner and secretary of health and now SAMHSA's administrator, ODMHSAS worked with six provider sites to review state processes that create barriers to service access and retention. The payer-provider partnership focused on certification rules, contract requirements, and miscommunication between the state and providers. The pilot yielded impressive results: reduced paperwork and waiting times, as well as increased treatment continuation rates.

"The NIATx process improvement model helped us form positive working relationships with treatment providers while improving the functioning of the statewide addiction treatment system," says Jennifer Glover, MS, LPC, director of substance abuse treatment services for ODMHSAS.

In the state pilot, process improvement uncovered a long-standing problem. "Historically, providers have seen the single state agency as an enforcer, rather than as a partner," explains Glover. "The NIATx model helped us see that this perception sprang from poor communication." Improving communication and welcoming provider input have made all the difference. "We're hearing more about our system and what doesn't work along with the misconception providers have about state requirements," she says. "Providers have been grateful for the opportunity to share their concerns and to work with the state authority to dispel requirement myths without being penalized."

As a result, ODMHSAS has adopted a culture of performance improvement throughout its addiction and mental health treatment system. Participation in NIATx is central to ODMHSAS's mission of improving performance, giving the state a simple, constructive approach for partnering with treatment providers. In May 2006, Oklahoma Gov. Brad Henry approved and signed state rules requiring substance abuse treatment providers to perform "walkthroughs"--an essential component of the NIATx process improvement model--and document results.

The success of the pilot inspired Oklahoma to apply for a STAR-SI grant as part of ODMHSAS's commitment to extend process improvement to all providers and other state agencies. "Dr. Cline had a vision for system-wide improvement, continuous staff improvement, and a customer-centered approach," explains Glover. "We believe that the STAR-SI project will allow us to make great strides toward achieving that vision." To facilitate this, Michelle Statham, the department's systems process coordinator, will continue to spread lessons learned and coordinate new process improvement projects statewide.


"With STAR-SI, we're working toward a culture shift," Glover continues. "Ultimately, we'd like to see process improvement become part of the organizational culture in all of our programs--addiction treatment as well as mental health. We have seen process improvement evolve as something that you do to produce good results--a tool, rather than a requirement."

This February, Oklahoma's STAR-SI grantees gathered for a kickoff meeting. Provider agencies have been matched with a mentor agency--a provider that participated in the State/Payer Pilot Project to Improve Addiction Treatment. "The new provider agencies have all completed the walkthrough," reports Glover. "They're learning firsthand the key NIATx principle of using a customer-centered approach to process improvement."

Aiming to Remove Barriers

The success that Acadia Hospital in Bangor, Maine, experienced as a grantee in the NIATx Paths to Recovery project inspired Kimberly Johnson, director of the Office of Substance Abuse (OSA) for Maine's Department of Health and Human Services, to apply for the STAR-SI grant. Using the NIATx model for process improvement, Acadia Hospital implemented changes in its intensive outpatient programs that resulted in increased admissions and treatment continuation rates. The changes also enhanced the hospital's profit margin by approximately $400,000 in two years. As a STAR-SI grantee, Maine will work to change state and provider business practices to increase access and bring more people who were previously unable to maneuver system barriers into treatment.

"Access to treatment has been the most significant problem for Maine," adds Johnson. "A report to the legislature showed 400 people on waiting lists for treatment that you can't really wait for--for example, methadone treatment. A six-month wait for residential treatment tells me that we need to do something differently."

Maine is home to approximately 60 substance abuse treatment provider agencies. Ten are actively involved in the STAR-SI project's first year. In the second year, 21 agencies will be part of the project. Only Acadia has previous experience with NIATx.

The first change project under the STAR-SI grant tests changes at the state level to reduce waiting times for individuals ordered to treatment as the result of a DUI charge. "We're testing this with a small population--DUI offenders at the ten participating provider agencies," Johnson says.

The process used to begin with the DUI offender first waiting to receive a list of state-licensed treatment providers from OSA. The offender would choose a provider and then contact OSA to request the required paperwork needed to take to the provider. "This initial communication took place through snail mail," says Johnson. "Frequently, clients would appear at the provider agency without the required forms from OSA. The counselor would tell the client to go back to us to get the forms. This could take a week or two.

"The change we're testing is pretty simple," Johnson continues. "We're telling the participating agencies, 'If you have someone who needs treatment due to DUI, we will fax you the paperwork so you can start right away.'"

Working together to remove barriers and create incentives to improve treatment access, Maine's OSA and participating providers will promote continuous process improvement across delivery systems, says Johnson: "We've seen how the NIATx model has changed the way providers work, and the STAR-SI project will help Maine transform the way treatment services are delivered across our state."

Maureen Fitzgerald is an Editor at the Network for the Improvement of Addiction Treatment, and Jay Ford, PhD, is NIATx's Chief Research Officer. For contact information for the states participating in the STAR-SI program, e-mail

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Title Annotation:ADDICTION TREATMENT MANAGEMENT; Network for the Improvement of Addiction Treatment
Author:Fitzgerald, Maureen; Ford, Jay
Publication:Behavioral Healthcare
Geographic Code:1USA
Date:May 1, 2007
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