A methadone provider in western PA commits to quality improvement, hears positive response from clients
IRETA was fortunate to be chosen to work with Foundations Medical Services (FMS), a methadone maintenance program in Butler, Pennsylvania managed by Pyramid Healthcare, Inc. Already recognized as a highly competent program, FMS desired to improve treatment quality for their client population and, in so doing, increase successful client outcomes.
It is important to recognize that the dedicated bachelor’s and master’s level clinical staff of this agency were interested in improving services to their clients prior to IRETA’s involvement.
Staff who possess a high level of commitment, experience, and formal education are a rare commodity in this field. Recruiting and retaining counselors to work with clients in medication-assisted treatment settings is difficult. Staff turnover is remarkably low at this organization. The environment at FMS represents an ideal situation for enhancing services.
Evaluating Where We Started
Before changing anything, the situation required assessment of the initial level of services provided to clients. IRETA determined that the agency already met and in many areas exceeded all state and federal requirements prior to our involvement.
IRETA then analyzed discharge data to establish a baseline, which would subsequently be compared to discharge data after quality improvement measures had been implemented.
Discharge data showed that in 2015 and 2016, more than half of FMS clients could be categorized as “not successful.” That is to say, they were discharged because they were absent from the program without explanation, became incarcerated, or were discharged involuntarily because of loss of funding or policy violations. FMS identified these “not successful” discharges as an area for improvement.
Fortunately, at the outset of the project, FMS began to use an electronic health record (EHR). The EHR is a helpful tool for implementing quality improvement strategies because it is capable of tracking factors such as employment status, dynamic legal status changes, and more in addition to client outcomes (e.g. treatment completion, incarceration). Reviewing these metrics helped IRETA and FMS staff strategize about changes that may enhance client outcomes. For example, examining EHR data allowed FMS to identify the most likely points of relapse in treatment, which are opportunities for improving practice.
Traditionally, methadone programs have focused on the disease of addiction, at times conveying a pessimistic view of clients’ possibilities.
Phase 1: A New Methadone Paradigm
To kick off the quality improvement project, William L. White and Lisa Mojer-Torres’s book Recovery-Oriented Methadone Maintenance (ROMM) (2010) was distributed.
ROMM provides a nonjudgmental historical overview of methadone maintenance services and offers a positive model of methadone services for individuals with opioid use disorders. Traditionally, methadone programs have focused on the disease of addiction, at times conveying a pessimistic view of clients’ possibilities. The ROMM approach focuses on recovery and trains staff to work with clients in a supportive and nonjudgmental approach to reduce sigma and encourage commitment to therapy.
Though all clinical staff were encouraged to read the book, most did not read its entirety. In response, IRETA staff distributed selected portions with key concepts highlighted that helped guide readers toward the most important points.
The clinicians took tests on their reading comprehension after each chapter to ensure the salient points were understood.
Phases 2 and 3: Identifying Areas of Improvement in Individual and Group Therapy
In the second phase of the project, IRETA met with the staff collectively and observed each member working with clients individually and in groups. After each session, management received oral feedback and written documentation to be shared with the counselor.
After reviewing this documentation, IRETA and FMS staff collaboratively determined that training on evidence-based psychosocial treatment would improve treatment quality.
As a result, phase three included six hours of reviewing the basics of Cognitive Behavioral Therapy (CBT) for FMS staff so it could be incorporated into their clinical practice.
Phase 4: What Do Clients Want?
A fourth phase required determining clients’ perceived needs and their willingness to increase their level of services. IRETA staff and the FMS clinical director developed a client survey together.
About half of the respondents said they would be interested in additional groups. Approximately half of respondents expressed interest in attending group therapy that focused on coping skills and treatment planning.
Phase 5: Building a Consistent Group Therapy Structure
The fifth phase of the project sought to improve group therapy by ensuring consistent membership, a designated leader, and clear goals.
IRETA helped create a 12-session series of group therapy that follow a “carousel model,” which means that a client can begin at any time. This new series differed from the previous model of group therapy at FMS, which allowed clients to pick and choose monthly groups. In the old model, groups did not have clear goals and there was no consistency to membership.
Within the new model, each group has the same leader: Stella Rensel, a counselor assistant at FMS. Each group has a stated goal, and clients are surveyed immediately after each session about a) their opinion on the group itself and b) the results of their last drug test and the length of time they have abstained from non-prescribed drugs.
IRETA staff observe each group and debrief afterward with Ms. Rensel, discussing what went well and what could be adjusted.
The Results So Far
It is important to note that the clients participating in the new structured group therapy sessions were identified because they had had numerous relapses and treatment as usual at FMS did not appear to support their recovery.
At the time of this writing, these clients have participated in weekly groups for six weeks. Although it is quite early in the project, the data are very encouraging. As compared to Week 1, when they first began the group sessions, their number of days abstinent has increased, on average, by 34%. The average number of days without the use of non-prescribed drugs rose from 16.25 to 30.5.
And the participants seem to like the new services: client ratings of counselor effectiveness averages 4.6 on a 5-point scale.
What Next at FMS?
The final phase of the service enhancement is development of an intensive outpatient program (IOP). When fully functional, the IOP will serve clients requiring more services than the weekly groups.
IRETA is also working with FMS to develop a second set of groups to address needs that clients have identified. Clients indicate they want groups to develop coping skills, stay drug free, resolve grief, deal with the past, and learn about nutrition.
In 2018, IRETA will work with FMS to evaluate the effectiveness of these quality improvement initiatives by comparing discharge data to the baseline data from 2015-2016. Together, FMS and IRETA will determine whether there are fewer “not successful” discharges from the clinic, in which clients leave the program without explanation or are involuntarily discharged.
Working with Other MAT Programs: Lessons Learned at FMS
These program improvement strategies may be replicated at other MAT programs, however, the “phases” may be presented in a different order. For example, it would have been useful to administer the client survey earlier in the process. A reading schedule would emphasize the ROMM book earlier as well. It would also be useful to implement the American Society for Addiction Medicine (ASAM) placement criteria as part of placing clients in therapy groups.
Not surprisingly to all involved in this effort (but contrary to popular belief among the general public and many people working in the addiction treatment field), the staff of this clinic and many other agencies providing MAT are committed to providing services that help their clients. In this context, quality improvement initiatives are set up for success.
