Tuesday, August 12, 2014

What we can learn from the McRib and wind power

Dave Gustafson, PhD
Director, Center for Health Enhancement Systems Studies and NIATx
University of Wisconsin-Madison

I find it difficult to clearly explain why it is so important to go outside the field for ideas on how to improve and how to get those ideas. So I am going to try again. One of these days I will get it right.

A lot of people are becoming pretty good at understanding the needs of their customers. The walk-throughs are being used pretty extensively as well as nominal group and focus group meetings. It is exciting to see that happening. And of course it is natural to say: "Well, now that we understand the problem, let's solve it.” I love rapid-cycle improvement!

But there is a risk that we will jump to an obvious solution. The obvious solutions are very likely to have been tried in SUD before. And they may have worked, or they may have worked a little, or worked a lot for a while and then stopped working. So it probably does not hurt to take a one-hour detour to cast a wider net for solutions. Where do we find those solutions? From concepts and problem-solving efforts of people who are tackling a similar problem but in a different industry.

Suppose we were trying to find a way to get people to keep coming back for treatment. What other industries worry about getting people to come back on a regular basis? Lets think out of the box for a second. Well, there is television. They try to get us to come back to their shows. And there are fast food restaurants. Of course there are many others. But let's go with those two for a minute.

We have found the industries. Now we need to find the best of the best in those industries. In many cases they will be obvious. In fast foods, it is probably McDonalds. They must invest enormous amounts of effort in getting people to return. How do they do it? One of us knew the head of marketing for McDonalds, but you could just as easily Google. For instance, I Googled "How does McDonalds get people to return?" I found millions of responses because many people have studied McDonalds. One thing that comes up over and over again in the few summaries I read was that they segment their customers and find out what those people respond to. Then they target those things people respond to.

The first article pointed out the McRib. Its nutrition is terrible and a lot of people hate it. But a big segment (typically young guys) of McDonalds customers really like it. So what? Well, McDonalds thinks about what would bring those people back. They hit TV programs with a young guy who is going on his honeymoon and he gets a text from a friend saying McRibs are back. For a few seconds he debates whether he wants to go on his honeymoon with this wife watching, perplexed.

What can that story tell us about how to keep our patients coming back? McDonalds would say that one size does not fit all. In our field some may respond to threats, others to reminders, others rewards, etc. But rarely do the same things work for everyone. What if we began to create a database of what our customers respond to? Try some things, see what happens, and then put those results into the database, so we know what to try (or not try) to get each person back.

A similar approach could be taken by a behavioral health organization as it finds its place in the implementation of the Accountable Care Act; specifically attracting new third-party payers. What industries have a similar challenge? Maybe windmill manufacturers? They have always produced energy (initially for grinding grain).  Now they are moving aggressively into clean power. Who are the best of the best and how do they make that move? A quick Google Scholar search turned up several articles including one that followed adoption of wind power in Europe. 

They discussed three strategies that were important to its success:  

1) stimulating technological progress; 
2) minimizing administration and transaction costs of adoption, and 
3) gaining public acceptance for wind energy. 

The question is, how can we learn from that?  One might be to really make adoption very easy and inexpensive; to engage in a marketing effort to help the public get excited about the idea and have technological support systems, and maybe to help adopters track the benefits (and costs) of their decision in real time.

How long would it take you to: 1) Identify other industries that deal with a problem similar to ours? 2) Identify one of the best organizations at solving that problem in that industry? 3) Ask Google Scholar to identify what makes McDonalds (or whatever) so good? 4) Read at least the abstract of a couple of articles? 5) Ask, “What is it that they do that could be helpful for us?”

I would say one hour, two at most. I think it’s worth it.

An earlier version of this blog post originally appeared on the NIATx website in November 2011.

Monday, August 4, 2014

Connect, learn, and implement with the new Network of Practice

Kim Johnson

NIATx Deputy Director
ATTC Co-Director (WI)

Have you ever been frustrated by the whole evidence-based practice (EBP) thing? First, are EBPs really worth it? Does the difference for the clients make EBPs a worthwhile investment? And then, which ones do we use? Because really, it will probably take more than one anyway, right? So then the question becomes which combination of EBPs work together best for our particular clients. And if you’re the supervisor and you talk to the clinicians in your practice, they all say, “I’m already doing that,” and they’re insulted if you suggest that they aren’t, as they should be—because they are probably doing it as well as they can, given the resources they have. 

It can get to be overwhelming.
But many states have started to require contracted treatment organizations to demonstrate that they have implemented evidence-based practices, and other funders are now requiring improved treatment outcomes. 

Implementing evidence-based practices is probably in your future, even if it hasn’t been in your past.
Back in 2011, NIATx and the ATTC held a series of focus groups around the country to ask providers, CEOs, clinical supervisors, and direct service staff about the barriers they face in implementing EBPs. We asked what would help overcome those barriers. Then we looked at the implementation science literature (yes, there is an implementation science) and we developed a web tool called The Network of Practice: http://networkofpractice.org/
What we heard the most in our focus groups with treatment providers was that they wished they had someone to talk to—someone who knew about a specific EBP and how to implement it. The Network of Practice is home to a new electronic community that will connect you to your peers and the researchers that develop EBPs. You can use these forums to ask questions, get and give advice, and just talk with each other about how to improve your treatment outcomes.
Over the past month, we had a group of users test the Network of Practice materials and start the conversation. We hope you will join in and share your wisdom and experience, as well as your hopes and frustrations. 

In return, we promise to find the answers to your questions, welcome your ideas and suggestions, and keep the pages fresh with the latest information about EBPs. 
The Network of Practice features other tools we developed to address issues people raised in the focus groups.
The cost benefit survey can help you figure out if the benefits of EPB for the clients outweigh the costs to your agency. You can use another tool, the readiness for implementation scale (RIS), to identify your organization’s strengths and weaknesses in terms of implementing a new EBP. 

We also linked to other web tools and resources such as SAMHSA’s National Registry of Evidence-based Programs and Practices (NREPP) and NIATx and ATTC materials. And we organized all the tools and info in a step-wise process that will guide you from your initial thinking about a particular EBP through the process of testing and adopting it throughout your organization.
Post a comment or question three times during the month of August, and you’ll be entered in a drawing to win one of 3 Kindle Paperwhites. Visit the site today, and let us know what you think!

Kimberly Johnson, NIATx Deputy Director and ATTC Network Coordinating Office Co-Director, served for seven years as the director of the Office of Substance Abuse in Maine. She has also served as an executive director for a treatment agency, managed intervention and prevention programs, and has worked as a child and family therapist. She joined NIATx in 2007 to lead the ACTION Campaign, a national initiative to increase access to and retention in treatment. She is currently involved in projects with the ATTC Network and NIATx that focus on increasing implementation of evidence-based practices, testing mobile health applications, and developing distance-learning programs for behavioral health. 

Monday, July 28, 2014

Change is easy...

Director of Research
Center for Health Enhancement Systems Studies/NIATx 
University of Wisconsin-Madison

But staying changed can be a challenge.   

Maybe you’ve seen it happen in your own organization: an improvement project has an initial success…then fades into improvement project oblivion a few months later.

Just as losing weight doesn't mean that it will stay lost, implementing an organizational change doesn’t guarantee that it will be sustained. Studies indicate that only 40 to 70% of changes are sustained[i].A change not sustained is a direct waste of invested resources, creates costs associated with missed opportunities, and affects your organization’s ability to implement change in the future.

Despite these challenges, we are learning more about what makes change “stick,” or the attributes that influence sustainability of organizational change. But before I tell you about these attributes, I want to clarify two important related concepts: maintenance of change and organizational capacity to maintain the benefits of a change.  How do they differ? 

I like to define maintenance of change as “the extent an evidence-based intervention can deliver its intended benefits over an extended period of time.[ii]” 

Take a look at weight loss. For a dieter, maintenance of change might be the ability of reduced calories and increased activity to deliver the intended benefit (a healthy weight) over time. For an organizational improvement project to reduce appointment no-shows, maintenance of change might be the extent to which using reminder phone calls reduces no-shows, once that practice is adopted as standard procedure.  

Organizational capacity to maintain the benefits of change refers to the existence of structures and processes that allow a program to leverage resources to effectively implement and maintain evidence-based policies and activities.[iii]” In other words, how does the organization’s environment support sustaining the improvements made?  Creating a culture of change can make all the difference in sustaining a new business process or an evidence-based practice.

Long-term success

What I do know is that the longer your organization maintains the benefits of a change, the more likely those benefits to become the “new normal.”   

 Let’s say you make changes to reduce waiting time for first appointments from 28 to 7 days. After testing a few promising practices such as reminder phone calls, double booking appointments, and offering same-day service, you successfully reducing waiting time to 7 days.  Even better, you maintain that improvement over a 12-month period! Admissions are up, and more clients are continuing in treatment. The increase in billable hours has boosted revenue, and your board of directors is pleased. The expected appointment wait time of 7 days is now the new normal for your organization, and you would measure any efforts to improve wait time further against this internal benchmark.

A sustainability focus
Two aspects of sustainability do not get enough attention in quality improvement projects: lack of focus on sustainability early in the implementation process and sustainability planning.  Think of yo-yo dieting: a person might achieve a dramatic weight loss by severe restricting calories and increasing activity. But can both changes be maintained over time? Does the dieter have a plan already in place for counting calories and staying active once the weight loss goal is achieved?

Organizations need to go into implementation believing that the change will be successful and should be sustained. The ideal time to start thinking about sustainability will vary, but once the change has been implemented and appears to be successful, it’s time for an organization to assess its capacity to sustain the change. Now’s the time to identify internal barriers to sustainability. I know about two tools to help assess your organizations’ sustainability capacity: (1) the British National Health Service Sustainability Index and (2) the Program Sustainability Assessment Tool. Regardless of the tool used, recruit four to eight staff persons in your organization to complete the tool to ensure that multiple opinions are considered when assessing sustainability capacity.

A sustainability plan
Use the results from the assessment to focus on sustainability planning. A sustainability plan identifies specific actions that an organization might take to support sustainability.

In my opinion, a sustainability plan should be simple and concise. It should formalize the infrastructure and identify the resources to support sustainability. For example, the plan should identify a sustain leader and the process that will be used to regularly monitor the impact of the change over time. The sustain plan can been seen as your “relapse prevention plan” should the change begin to fail. Similar to when a fire alarm is pulled and you need to evacuate the building, the sustain plan should identify the red flags or triggers that will stimulate action.

Let’s go back to the example of the organization that reduced waiting appointment wait time to 7 days. Your organization decided that the red flag would be appointment wait time creeping up to 10 days for two consecutive weeks. Your sustain plan should clearly define immediate steps to take when that happens. These steps could include reconvening the change team in 48 hours to study the problem, identifying the source of the increase in appointment wait time, and then taking correctable actions.

These are some of my thoughts related to sustainability. Now it would be great to hear from you. Do you have a success story to share related to sustainability? What attributes influenced your organizational capacity to sustain change? How long have you been able to maintain the benefits from an implemented change? Are some changes easier to maintain than others? If so, what types of changes? Let’s start a dialogue so everyone benefits from our collective knowledge.

Dr. Jay Ford’s current research applies health systems engineering principals and techniques to improve health care delivery systems within behavioral health. Current projects involve community-based treatment providers, states, and the Veterans Administration. He serves as a coach for projects such as the Wisconsin Mental Health Learning Collaborative and BHBusiness. Previously, Dr. Ford led the research and data analysis for NIATx 200 and STAR-SI projects that focused on spreading and sustaining organizational change in addiction treatment organizations and systems. He was also a member of the team that developed and tested the NIATx model in the Robert Wood Johnson Foundation-funded and CSAT-funded Paths to Recovery and STAR projects

[i] Scheirer, M. A. and J. W. Dearing. 2011. “An agenda for research on the sustainability of public health programs.” American Journal of Public Health 101(11): 2059-67
[ii] Chambers DA, Glasgow RE Stange KC. The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Implement Sci. 2013 Oct 2; 8:117
[iii] Schell S, Luke D, Schooley M, Elliott M, Herbers S, Mueller N, et al. Public health program capacity for sustainability: A new framework. Implement Sci., 2013 Feb 1; 8:15.

Friday, July 18, 2014

Twitter, baseball, and evidence-based practices

Maureen Fitzgerald
Communications Coordinator, ATTC Network Coordinating Office
Senior Editor, NIATx

Last month I attended a great workshop on science writing and communication skills for the 21st century. One of the featured speakers was Lee Aase, director of the Center for Social Media at Mayo Clinic. His workshop, “You Are Now the Media. Really” was about how social media is revolutionizing health care.

Aase got the Mayo Clinic started with social media, launching podcasts in 2005, Facebook in 2007, and Twitter in 2008. A TwitterChat about wrist surgery that Mayo Clinic hosted with USA Today (featuring the wrist recovery of Philadelphia Phillies outfielder Jason Werth) encouraged other people with similar wrist injuries to inquire about the surgery. Dr. Richard Berger, who pioneered this surgery (called the UT split), later wrote to Aase that several doctors had trained with him to learn the procedure because of the TwitterChat

Berger said, “Social media has driven this into practice in less than 2 years, when it takes 17 years on average!”

Could social media have the same effect on the spread of evidence-based practices in behavioral health?

Mayo Clinic also has a YouTube channel and several blogs. One of its most successful videos (with millions of views) was of an older couple playing the piano. You can watch the video and read the story of these “Octogenarian Idols” here.

Social media has been so successful that today Mayo Clinic has an entire department dedicated to it, the Social Media Health Network.

Aase says that before social media, the most effective communication channel for the Mayo Clinic was not paid advertising or TV spots, but word of mouth—patients referring one other to the clinic’s doctors.

Social media are the word-of-mouth of the 21st century.

In the 21st century environment of health care reform, behavioral health care organizations have to market their services and compete with one another. Social media, in all its forms—Facebook, LinkedIn, Twitter, YouTube, and blogging, to name just a few—have become essential and affordable marketing tools.

Has your organization made the leap?

If you’re looking for ideas and inspiration, check out the four-part social media webinar series Marketing with Social Media on the NIATx website. The first is a presentation by Lee Aase similar to the one I attended.

Aase also offers some fun and informative resources on his  Social Media University, Global (SMUG) website. For example, Twitter101: Intro to Twitter is just under three minutes and gives a great overview. You’ll be happily tweeting away before you know it.  

Oh, and by the way, be sure to "follow" us on Twitter:

and "like" us on Facebook: 

…and we’ll be sure to follow you and like you back!

Thursday, June 26, 2014

NIATx principle #4: Getting ideas...from outside the country

Kim Johnson
NIATx Deputy Director
ATTC Co-Director (WI)

Those of you on the NIATx Facebook page know that I recently went to St. Petersburg, Russia, as part of a team put together by Stanley StreetTreatment and Resources (SSTAR), a treatment program in Massachusetts and Rhode Island. We were there working on a white paper about disseminating mobile health applications in Russia and the United States. While we were there, we presented at a conference with our Russian colleagues on the possible uses of mobile applications with people with behavioral disorders.

We toured a psychiatric hospital, three addiction treatment sites, and a couple of mobile outreach vans. What was most interesting to me was how much the treatment systems are alike. What seem like differences sometimes are really issues of translation. For example, the people that do the work of counselors and social workers in the U.S. are called psychologists in Russia, and the people they call social workers are people we would call recovery support specialists or something like that. Sometimes the language barriers were the biggest obstacle to seeing how much alike the two systems are.
One of the mobile vans used
for harm reduction and to
engage high-risk drug users.

But, I’m guessing you are more interested in what is different. So, given that language may have clouded my understanding, here are things that I thought were interesting differences.

First, the substance abuse providers envy our medical model! They do not have access to buprenorphine or methadone and have only begun to use Vivitrol. So while we lament the low utilization of medication and study mechanisms for increasing access to medication, they think we look good in comparison.

What I admired about their system was the strong focus on rehabilitation. Both their mental health system and substance abuse treatment system work with patients to help them develop skills and interests so that they can lead fuller lives through work and recreation.
Waiting area in a St. Petersburg
treatment facility. Look familiar?

The day we visited two addiction treatment facilities, most of the patients were participating in a citywide sports tournament, where the patients from the 18 treatment districts competed against each other in sports like soccer. What a great idea! Wouldn’t it be fun if you could organize a competition with other treatment programs in your area? Even if it was a bowling league or something where you didn’t have to worry so much about liability and injuries.

The Russian system does not have our version of confidentiality. If you want privacy or confidential treatment, you can pay for treatment yourself, and one of the sites we visited had both private pay and public patients. The driver’s license issue is interesting. In Russia, if you enter the public addiction treatment system, you lose your driver’s license for three years and may have repercussions at work. I think most see the potential loss of a driving license as a huge barrier to treatment entry. And it may be, because I didn’t discuss it with any patients. But our hosts did not see it that way. In Russia, in order to initially obtain a driving license, you have to have a sign off from a Narcologist (Addictionologist), a psychiatrist, a neurologist, and an eye doctor. One of the sites we visited primarily served people trying to get their licenses, so they did brief assessments and that was it. Since proving you do not a have a substance use or psychiatric disorder that would inhibit your ability to drive is part of getting your license, in the Russian mind losing it for having a substance use problem seems natural, not restrictive. When we talked about Russia treating driving as a privilege the response was “Nyet!” They didn’t see it that way. They were astounded by how easy it is to get a driver’s license here and how difficult it is to lose it (especially here in Wisconsin, the only state in the nation where a first time DUI is not a criminal offense!)
We had some time for sightseeing. One
of our stops was at the summer
palace of Peter the Great, Peterhof.

I wish we had more opportunity for international exchanges. In Europe, geographic proximity allows for easier exchange between countries, but how many of us have even been to a program in another state, let alone another country? Anyone else been to Russia and want to comment on their impressions? How about other countries? Think of the NIATx principle “Get ideas from outside the organization or field” and extend that to treatment systems in other countries. What do they do that would be fun to implement here? 

Kimberly Johnson, NIATx Deputy Director and ATTC Network Coordinating Office Co-Director served for seven years as the director of the Office of Substance Abuse in Maine. She has also served as an executive director for a treatment agency, managed intervention and prevention programs, and has worked as a child and family therapist. She joined NIATx in 2007 to lead the ACTION Campaign, a national initiative to increase access to and retention in treatment. She is currently involved in projects with the ATTC Network and NIATx that focus on increasing implementation of evidence-based practices, testing mobile health applications, and developing distance learning programs for behavioral health. 

Wednesday, June 11, 2014

States expanding access to technology for addiction treatment

Mike Boyle, Associate Researcher
University of  Wisconsin-Madison

For the past 18 months, NIATx, in collaboration with JBS International, has been involved in a SAMHSA-funded project to help a group of five states (Iowa, Maryland, Massachusetts, Oklahoma, and South Carolina) and one county (San Mateo County, California) identify and implement new communication technologies for addressing substance use. The technologies focus on interventions for screening and brief intervention, treatment, and ongoing recovery support. It has been a great learning experience for the project team.

An important step in this process was identifying what technology platforms exist for addressing substance use. Also, the states wanted to know if research supports the use of the interventions. We found tremendous progress over the last decade in the development of new technology for behavioral health interventions. Several of the technologies have been subjected to extensive clinical trials with a variety of populations. And research  results indicate that interventions delivered via technology have equal or better results than services provided solely by a clinician.

Many of these technologies serve as “clinician extenders,” allowing for more efficient delivery of services. Interventions delivered through computers, smartphones, and tablets allow anytime access to treatment modules and/or recovery supports. These programs can provide reports to the clinician, allowing for monitoring of progress, adaptive treatment planning, and intervention as needed. They have the potential for increasing access by removing barriers to services and may lower the cost per episode of care.

The project also identified challenges and barriers to implementing the technologies. The biggest issue is how to reimburse providers for the services. The existing fee-for-service payment system could be used for telephone, telemedicine, or computer services such as “virtual worlds,” where a clinician delivers services directly to a patient in real time.
Payment mechanisms such as case rates or episode of care payments could work for services that patients can access on their own via the Internet. A case rate or episode of care payment can capture the organizational costs of using the technology, such as licensing or purchasing fees, training and support time, and monitoring time by clinicians.

Other challenges include competing priorities for the state and providers, incorporating the technology into the existing workflow, and potential resistance to the changes required.

Please join us for the free webinar on Tuesday, June 17 to find out more about these innovative technologies and what states are doing to implement them.

Adopting Innovative Technology to Support Recovery
Tuesday, June 17
1:00 ET/12:00 noon CT/11:00am MT/10am PT

Michael Boyle is an Associate Researcher at the Center for Health Enhancement Systems Studies at the University of Wisconsin–Madison and provides consulting services. He was formerly President and CEO of Fayette Companies, a behavioral health organization located in Peoria, Illinois, and is the Director of the Behavioral Health Recovery Management project. Boyle recently served on a National Quality Forum committee charged with defining an episode of continuing care for a substance abuse treatment encounter. He has authored several articles and book chapters. His current activities include integrating mental health, addiction and primary care services, implementing evidence-based clinical practices within recovery oriented systems of care, and exploring technologies to support behavioral health treatment and recovery.

Wednesday, June 4, 2014

Announcing the new ATTCnetwork.org!

Maureen Fitzgerald, Editor
ATTC Network

Just before we launched the new, improved attcnetwork.org, we invited people to take a sneak peak and give us some feedback. We wanted to make sure that the new site is doing what it’s been designed to do:

Make it easier for people to find what they’re looking for.

Because, we’ll admit—and you told us—it was getting hard to find things on the previous site.

And what better time to revamp our site than our 20th anniversary as a national resource for the addiction treatment and recovery services community? (Check out the History of the Network on the new site—it has a cool timeline feature that highlights key accomplishments of our first 20 years.)  

And what did our beta-testers have to say about the new site?

“User-friendly” and “Easy to navigate” were the two terms our beta testers used most frequently, often with exclamation points.

In particular, they like new site’s clean lines and the way the home page points users to some of the most popular ATTC resources: 

One beta tester was happy to discover the ATTC/NIATx Service Improvement Blog, (thank you!) now easily accessible from the Communications tab on the home page, along with the Addiction Science Made Easy research briefs and our e-publications, the ATTC Messenger and The Bridge.

Another beta tester appreciated that the role of the Network and “technology transfer” are both defined in a prominent spots on the new site.

“Gorgeous,” said one beta-tester. “A home run!” said another.

To make the new site as lean and clean as possible, some content had to go. You know how some professional organizers advise discarding or donating anything in your closet that you haven’t worn in a year? The web redesign applied a similar principle in taking inventory of the previous website’s pages. Many of them had note been accessed in several years, or had information that was out of date. 

One of the many things that we’re really excited about for the new site is that it’s optimized for mobile devices. That means that the pages change size for easy viewing on a tablet or a smartphone. While most of our beta-testers viewed this site on a desktop or a laptop, we anticipate that many more people will be using mobile devices to access www.attcnetwork.org in the near future.

Creating the new site with mobile-device users in mind helped the designers stay focused on the best way to present key pieces of information that you'll be looking for – in a restricted amount of screen space. They applied the same principle in using more white spaceto make it easier to click content, and to reduce the number of clicks required to get to desired content.

Let’s get back to the homepage on the new site for second: You’ll see three “slider” images, one each for HealtheKnowledge.org, Recovery Month, and the NIDA/SAMHSA Blending Initiative. We selected these for the website’s “marquee” to highlight their importance to the ATTC Network mission. (By the way, Recovery Month is celebrating 25 years this year--be sure to show your support by posting your Recovery Month events on the site.) We’ll be changing the slider images regularly so you won’t get bored: stay tuned for a new series coming up later this year.

Now that we’ve given you a bit of info on the new site, we hope you’ll take some time to explore it, if you haven’t already. And let us know if you find any glitches. But we mostly want to know that it’s working for you…and that you can find what you’re looking for.


Send your comments on the new website to Dave Gustafson, Jr., at dave.gustafson@chess.wisc.edu 

P.S. Visit the ATTC Network Facebook and Twitter sites to find out how you could win a $25.00 Amazon Gift Card by posting about attcnetwork.org!