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!

Maureen Fitzgerald, Editor
ATTC Network

Just before we launched the new, improved, 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 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, 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 

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!   

Wednesday, May 21, 2014

Bridge Video Talk Show Recap: Getting Physicians on Board with SBIRT

Kim Johnson, MBA, MSEd

Co-director, ATTC Network Coordinating Office

Deputy Director, NIATx 

In the Spring 2014 issue of the The Bridge, the editorial board explores SBIRTas a way to promote the integration of substance use treatment into mainstream medical care.
Articles in this issue reflect their responses to the question posed by editor Paul Roman: “What could each of us be doing to enhance the spread of physician involvement in SBIRT?”

I had the privilege of moderating a discussion of Bridge editorial board members Mike Boyle, Louise Haynes, and Paul Roman during the Bridge Video Talk Show on May 20. They talked more about their views on getting primary care physicians on board with SBIRT. 

(The session will be available as a podcast—watch your email or the ATTC Network website for details.)

A few highlights from the show:

Lessons from EAP programs.
Paul Roman talked about how executive leaders in business and industry were slow to adopt EAP programs until these programs were presented as a way to take a "problem" off a supervisors’ hands. The problem, of course, was an employee whose absenteeism or performance issues suggested the need for substance abuse treatment. Expanding EAP programs to include other problems that could be affecting attendance or performance also increased buy-in from executive leaders. EAP programs were successful when they solved a problem for employers. Would physicians embrace SBIRT more widely if they perceived it as solving a key problem? (Hmmm…do I hear a NIATx principle here?)

Financial considerations often drive adoption of new practices.
Louise pointed out that The Medicare Hospital Readmissions Reduction Program (HRRP) established in the Affordable Care Act provides a financial incentive to hospitals to lower readmission rates. SBIRT in hospital settings has the potential to decrease expensive readmissions; maybe this would help to spread use of SBIRT.  Paul added that by getting people into treatment sooner, SBIRT offers physicians a way to reduce or prevent the expensive medical complications that so often accompany and are exacerbated by substance abuse.

What would Everett Rogers do? As we discussed dissemination strategies, Mike Boyle wondered why we haven't done a better job doing what research tells us works in terms of disseminating and adopting new practices.

Hello! I jumped up and grabbed my dog-eared copy of Roger’s Diffusion of Innovations text.

Here’s what we know and have known about innovation for years and years:  
  • It has to meet a need or solve a problem or do something better than what we have now. We didn’t need iPhones, for example, but they did so many cool things we couldn’t do before that they’ve been widely adopted.
  • It has to be easy to adopt.
  •  It really helps to to see other people using it and to copy what they are doing.
While I think SBIRT can offer all of these things, it isn’t necessarily portrayed that way.

Also, Mike and Paul both mentioned the idea of using a deliberate dissemination strategy that incorporates opinion leaders. Several audience members raised this issue. How many doctors do we have doing training and recommending that their colleagues do SBIRT?  Does it feel to physicians that people without knowledge of their daily practice are imposing an expectation on them? And isn’t that stuff part of what the nurse, not the doctor, does anyway? Why aren’t we selling nurses on the idea?

So…what do you think? If SBIRT is a key to integrated care, what do we need to do differently to have wider adoption?  For more information on SBIRT, visit the website of the National SBIRT ATTC -- there may be an SBIRT training coming up in your area soon.

Kimberly Johnson 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, May 14, 2014

May is Hepatitis Awareness Month: ATTC Training Resources

New medications now available and those coming to market for treatment of hepatitis C are the topic of this month’s (Thursday, May 15) Third Thursday iTraining: “Hepatitis C Treatment: What do I use?” Presenter Bruce Burkett, Executive Director and Founder of the HepC Alliance, will talk about the medications currently available, their success rates, and issues related to access to and cost of the medications.

The iTraining complements the feature article “Availability and Use of HCV Services in Substance Use Treatment Settings” in this month’s ATTC Messenger, written Meg Brunner, Librarian for the Clinical Trials Network (CTN) Dissemination Library. Brunner shares the results of two health services research studies on the hepatitis C virus (HCV). These studies, conducted by the National Drug Abuse Treatment CTN, identified the need for the substance abuse treatment system to increase screening, counseling, and information services for patients with or at risk of contracting HCV.

To help meet that need, the National ATTC Viral Hepatitis Workgroup will soon be offering online and face-to-face options for training on HCV. The workgroup includes representatives from each of the 10 regional centers and is developing HCV training products specifically for Federally Qualified Health Centers (FQHCs). The courses target staff at FQHCs but are open to anyone interested in learning more about HCV prevention and treatment.
The first product is a 90-minute introductory online course that will be available in late summer 2014 on the ATTC HealthEKnowledge site. It consists of four modules covering: 1) populations at risk; 2) an introduction to the disease; 3) screening processes; and 4) treatment options. In addition, each regional ATTC is gathering region-specific HCV resources that will be incorporated into a Regional Resources section at the close of the course. The online course is expected to go live later this summer.

A second face-to-face training option, modeled on the online course, will offer more in-depth training on HCV. “It’s designed to build on the HealthEKnowledge course and targets behavioral health providers at FQHCs,” says curriculum developer Diana Padilla, Cultural Proficiency Program Manager for Training at National Development and Research Institutes, Inc.

"While the online course presents an overview of HCV, the face-to-face training will provide a more comprehensive review of the epidemiology of HCV and its impact on society, and risk groups,” says Padilla. “It will also promote screening and diagnostic testing and will discuss treatment options and linkage to HCV health care, which varies from region to region.”  The face-to-face training will include a section on telemedicine and telehealth options in rural and remote areas of the country. “We are planning to pilot a first draft of the training in July, with Training of the Trainer events to follow later for all the regional centers,” says Padilla.

Watch your email or check the ATTC website for more news about these new training resources from the National ATTC Viral Hepatitis Workgroup!