ATTC Region 2: Increasing Capacity for the Drug Courts in Puerto Rico

Tech Transfer in Action

The Institute of Research, Education and Services in Addiction at the Universidad Central del Caribe, School of Medicine has been providing various trainings to the Drug Courts of Puerto Rico. Drug Courts is a program that seeks the recovery of people with substance use disorders through a continuous and intensive judicial follow up. It applies the Therapeutic Justice Model, which is the use of social science to study the extent to which legal rule, or practice promotes the psychological and physical wellbeing of the people it affects. Drug Courts goals are the recovery of the participants, their reintegration to society, and decrease recidivism or commission of new offense. All training opportunities delivered to the Drug Courts personnel have been requested by the Judicial Academy of Puerto Rico. The Academy took the initiative to provide training to all there staff from the Department of Correction and Rehabilitation (e.g., prosecutors, police, officials, social workers, judges, assistants, and program coordinators) who are directly or indirectly involved in Program. This was with the intention that all areas receive the same training (based on evidence and best practices), share the same knowledge and understanding on how to provide adequate and needed services for all Program’s participants.

All trainings provided to Drug Courts staff during past year included the following topics:
  • application and management of incentives and sanctions in specialized courts for controlled substances;
  • access to justice and the treatment of substance use disorders for vulnerable populations
  • trauma management in people with substance use and mental health disorders and the vicarious trauma;
  • instruments for screening and assessment evaluation for substance use disorders; and
  • the effect of opioids on human behavior and its impact on the justice system.

These topics considered the specific capacity building needs from criminal justice personnel. The delivery encompassed increasing knowledge and providing necessary skills for this particular workforce, thus they are able to understand substance use disorders, screening and assessment strategies, connection between substance use and mental health disorders, as well as its treatment alternatives. Raising awareness and capacity building in these professionals will decrease stigma on persons with substance use disorders, while helping them receive needed services and treatment to recover their lives and return to the community with the tools they need to be a productive citizens. It is our goal that we do not only influence the workforce but to create a cascade of actions to reduce health disparities among the population they serve. These professionals now have the skills to assist participants with particular situations while in receiving their services. The Drug Courts program has been in Puerto Rico for 23 years and the NeC ATTC has been providing them with training and technical assistance. This year we delivered a total of 15 trainings and impacted 442 providers. We look forward to continue providing the Drug Courts program with all the trainings they need in order for participants to receive quality and responsive services.

2020 Vision: What Will You Improve in the New Year?

Mat Roosa, LCSW-R
NIATx Coach

With the start of a new year, many organizations resolve to tackle long-standing issues, such as high no-show rates. In this post, NIATx coach Mat Roosa shares his vision for reducing no-shows: Offer walk-in hours.

“The best way to get rid of no-shows for appointments is to get rid of appointments.”
As a coach, I often work with behavioral health organizations that are struggling with low show rates. The result is low staff productivity, reduced revenue generation, client turnover, increased costs associated with higher discharge and admission rates, and a felt failure to perform the core service mission of supporting individuals through the recovery process.

Programs often choose to work on a range of strategies designed to increase show rates. They use incentives for clients and staff, reminder calls, and transportation supports to get more clients to the door at the designated hour. But too often these efforts yield only modest results. That is when I often make the bold assertion above, and usually couple it with the following question:

Why do we think that appointments will work when we are serving people who do not schedule appointments for any other service that they receive?
The introduction of developing a walk-in approach often yields a great deal of anxiety…

  • But we won’t be able to plan our day?
  • We will have no way of knowing who will show up?
  • How will we staff for this?

In response to these concerns, I typically ask a question or two:

  • How do emergency rooms do it?
  • How do grocery stores do it?

This is the moment when many teams began to shift their thinking toward a new paradigm: Maybe we could find ways to reorganize ourselves with walk-ins. Perhaps we could do some short walk-in periods during the week to explore the model. Maybe this will create better service access. If a grocery store can do, we can too.

Walk-ins don’t work for everybody, but they do work for many. And they are a great way for traditional programs to rethink how they deliver care.

See the NIATx Promising Practice: Establish Walk-in Hours

About our Guest Blogger Mat Roosa was a founding member of NIATx and has been a NIATx coach for a wide range of projects. He works as a consultant in the areas of quality improvement, organizational development, and planning, evidence-based practice implementation. He also serves as a local government planner in behavioral health in New York State. His experience includes direct clinical practice in mental health and substance use services, teaching at the undergraduate and graduate levels, and human service agency administration. You can reach Mat at


By The New England ATTC and Stephen Andrew, LCSW, LADC, CCS, CGP 

The New England ATTC is collaborating with the Health Education & Training Institute in an effort to implement Motivational Interviewing (MI) systems-wide throughout Tri-County Mental Health Services of Maine. Tri-County Mental Health Services provides integrated behavioral health care for clients with substance use and mental health problems, and they are seeking to integrate MI across their entire continuum of care. MI is a client-centered, evidence-based method for enhancing clients’ intrinsic motivation to change. It was selected as the focal intervention because of its potential to improve client engagement, retention, and substance-related treatment outcomes. The goal of this MI initiative is to optimize sustainability within the organization by creating an internal group of trainers and coaches who will learn to use and teach/coach MI.

The intensive technical assistance (TA) initiative is targeted towards counselors, supervisors and community workers with varying levels of experience in MI and will ultimately be delivered across 5 Tri-County locations in Maine. It begins with three days of face-to-face instruction followed by a virtual MI Master Class using Zoom conferencing. The Master Class provides continued coaching and skill building. Additionally, there are on-going monthly Zoom calls for core staff over a 12-month period and assigned MI activities to practice concepts during existing staff meetings.

On-site trainings are conducted by Stephen Andrew, LCSW, LADC, CCS, an internationally renowned MI and MIA-STEP (Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency) trainer, and long-standing member of the International Motivational Interviewing Network of Trainers (MINT). Stephen has been a consultant and trainer for the New England ATTC since 2007.

During the first two days of face-to-face training, Stephen provides an introduction to the clinical method of MI with a focus on intervention basics. Participants have the opportunity to explore creative ways of integrating MI techniques and skills. After orientation to the underlying spirit, structure, and principles of MI, application of practical exercises helps participants strengthen their empathy skills, recognize and elicit change talk, and roll with resistance.

The third day of training is titled Advancing the Practice using MIA-STEP. MIA-STEP is a training for those that supervise or mentor treatment providers in a clinical setting whose roles involve providing feedback and coaching to help practitioners improve their skills and effectiveness. This training provides clinical supervisors practical tools to enhance treatment providers' MI skills. To date, 25 Tri County Mental Health Services staff have completed the two-day MI basics training and 16 staff have participated in the MIA-STEP one-day training at the first location in Lewiston, ME.

Participants have referred to the in-person trainings, and Stephen, as “amazing” saying, “the whole audience loved it.” When asked which training aspects were most useful, staff indicated they now had “a better way to work with clients who are ambivalent about sobriety,” and “insightful … tools for [their] work ‘tool box’ Further, staff reported feeling better equipped to understand their own “personal shortcomings and … to normalize ambivalence,” ,” to “meet clients where they dream,” and to “sit with clients ambivalence and suffering” until the client felt ready to move forward.

The monthly virtual Master Class is conducted by Kathryn Hartileb, PhD, RDN, an Assistant Professor at Florida International University’s Herbert Wertheim College of Medicine. Kathryn is an expert in health communication and behavior change. Like Stephen, she is a long-standing member of the MINT network. Kathryn’s main goal when leading the Master Class is to build participants’ MI skills through exploration of Bill Miller's "Master Class" exercises and practice diving into the Four Processes of Engaging, Focusing, Evoking, and Planning. The Zoom Master Class is designed to provide the opportunity for participants to practice MI Spirit and skills alongside a supportive network of peers facing similar professional challenges as well as the opportunity to consult about clients who struggle with substance-related concerns. The first Master Class was launched on October 9, 2019, with seven participants in attendance. Classes will continue through September 2020.

The New England ATTC is excited to partner with the Health Education & Training Institute to offer this intensive TA initiative to Tri-County Mental Health Services of Maine!

Make it Quick! NIATx Principle #5: Use Rapid-Cycle Testing

Maureen Fitzgerald
Editor, NIATx and Great Lakes ATTC 

The fifth principle of the NIATx model is rapid-cycle testing, structured around what’s known as the PDSA (Plan-Do-Study-Act) Cycle.

In rapid-cycle testing, the executive sponsor, change leader, or team comes up with ideas for changes to test and then tests each of those changes in quick succession for a short time on a limited test pool. During each test (a.k.a. PDSA Cycle), the team collects and analyzes data relevant to its chosen aim to determine whether the change has produced a desirable effect on performance levels. Depending on the outcome of that analysis, the team may decide to:

· abandon the change completely and begin testing an entirely new change;

· adapt the change for further improvement and retest the modified version; or

· adopt the change, testing it again on a slightly larger scale, or in conjunction with other changes that have already proven successful in testing.

In any case, the team uses the knowledge it has gained from one testing cycle to improve subsequent cycles. A new procedure is only implemented on a full scale once it has been proven in testing to yield significant improvement in the project’s aim.

Why “rapid” is key

The key to rapid-cycle testing is in the name itself: rapid. Each testing cycle, including planning, execution, and analysis, should take no longer than a few weeks. Another key to this method is repetition; in the majority of cases, the team will have to test several changes in quick succession (with each test lasting no longer than a couple of days) to figure out which changes will yield the most improvement, and to refine those changes to maximize benefits. Because each cycle is so short, you’ll be able to do more of them, getting better and better with each one, progressing closer to your goal.*

Learn how to conduct a Plan-Do-Study-Act (PDSA) Cycle

Dave Gustafson, Director
Center for Health Enhancement Systems Studies
“Rapid-cycle testing helps people shift out of the mind set that there’s nothing they can do to solve a long-standing problem,” says Dave Gustafson, director of the Center for Health Enhancement Systems Studies at the UW-Madison. “It gets people moving. They try out an idea on a small scale—maybe with just a couple of patients for just a couple of weeks. But the lessons that emerge from that brief test help inform the next rapid cycle, strengthening a team’s ability to identify effective improvements.”

Gustafson launched the NIATx model in 2003 in response to a request from the Robert Wood Johnson Foundation: Could process improvement techniques used widely in business and manufacturing help the addiction treatment field increase access to and retention in treatment?

One rapid-cycle test that Gustafson often uses to demonstrate the value of the exercise took place at a New England treatment center.

“The center director at the time, Lynn Madden, was thinking about eliminating scheduled appointments all together. She told her staff that on the following Monday morning, they would tell the first four people that called for an appointment to just come in, and those four would get into treatment by noon that day. She assigned one counselor to be available for walk-ins. For the first and third patients who called, the walk-in system really worked well. But the second person who called couldn’t come in for a walk-in because they had to work that day.

So Lynn got the team back together to discuss how to modify the process for people who couldn’t make the walk-in appointments. Then they tried it again with ten patients and two counselors. Today, walk-in access is standard procedure at the APT Foundation.”

See related blog post: No appointment necessary

Gustafson says that rapid-cycle testing helps change teams scale their change efforts appropriately. “A lot of times improvement projects start out too big,” explains Gustafson. “If you can’t do a rapid-cycle test on the change, the project is too big.”

Another advantage is that rapid-cycle testing allows teams to learn from changes that don’t work.

“Seek failure. Look for the ways the change doesn’t work,” says Gustafson. “Anything worth doing is worth doing wrong the first time.”

*From The NIATX Model: Process Improvement in Behavioral Health

NIATx Essential Tools: The Walk-through That Almost Never Happened

Mat Roosa, LCSW-R
NIATx Coach

During the early days of NIATx, I was working for an agency, and decided to do a walk-through of the intake process at a community residential program for people with co-occurring mental illness and substance use disorders. The entire walk-through process was very helpful, and resulted in some significant changes to the way that we engaged people at that first visit. This program was located in an attractive old house on a quiet side street. The large bedrooms were a pleasant surprise to clients who had grown used to living in far less pleasant surroundings. As a result of the walk-through we decided to flip the intake process by conducting a tour of the house at the beginning, instead of our traditional approach of touring at the end. This resulted in more enthusiasm on the part of new clients, and made it much easier for them to manage the challenging paperwork of the admissions process.

But perhaps the most important part of the walk-through, was how it almost never happened…

When I arrived at the house, a house I had visited dozens of times as an administrator, I worked to stay in my role as a new client for the walk-through. And so, I walked to the front door of the house. This door was locked, with no sign. I knocked and there was no response. After a brief wait, and some concern, I proceeded to the side door that I had noticed when I had pulled into the driveway. This door was also locked, with two buzzers, a speaker, and no signs. After trying the door, I began pushing the buzzers. I felt anxious that I might now be late for the appointment, or that no one would answer, or that I was doing the wrong thing by pressing the buttons. Finally, a crackly voice came out of the intercom speaker advising me that the door had been opened and that I could try it again. I was relieved, but annoyed. Why couldn’t somebody just come to the door, greet me, and let me in? I felt like they were trying to keep me out.

While the locks needed to stay in place for safety, this walk-through experience resulted in some simple signs to help people to navigate the entrance to the program. This experience also helped me to understand the power of the walk-through, and the importance of seeing programs through the eyes of those we serve. I had entered that building dozens of times, but have never noticed how difficult it would be for an anxious first-time client trying to find the way inside.

About our Guest Blogger
Mat Roosa was a founding member of NIATx and has been a NIATx coach for a wide range of projects. He works as a consultant in the areas of quality improvement, organizational development and planning, evidence-based practice implementation, and also serves as a local government planner in behavioral health in New York State. His experience includes direct clinical practice in mental health and substance use services, teaching at the undergraduate and graduate levels, and human service agency administration. You can reach Mat at:

Learn more about process improvement and the NIATx model Mat Roosa's podcast:
Great Lakes ATTC Implementation Science Podcast Series