West Quality Improvement Award Winner: Reconstructing the treatment entry process

JAMES W. WEST, MD, QUALITY IMPROVEMENT AWARD WINNER


Core members of the PI team include (l to r) James Troup, Martha Baldassare, Lynda Smith, Sherry Winiarski, and Alfie Hampton. (Not pictured: Pamela Ramsey)
Despite increasing awareness of substance use disorders and their consequences, data suggest that most people who need treatment are unable to access services. For example, the Substance Abuse and Mental Health Services Administration (SAMHSA) reports that in 2006, 23.6 million people age 12 and older needed treatment, but only 2.5 million received care. 1

People do not receive substance use treatment for multiple reasons. Some are related directly to patients, such as their motivation to enter treatment, continued substance use, or minimal environmental supports (e.g., lack of transportation, inadequate healthcare benefits, or competing family obligations). Other reasons are related to treatment facilities, such as poor staff engagement of patients, burdensome procedures (e.g., duplicate paperwork) taking time away from clinical care, and long delays between the first contact and the evaluation appointment.

Gateway Rehabilitation Center (GRC), which offers prevention, education, and treatment services at 20 locations in Pennsylvania and Ohio, recognized these problems and launched a performance improvement (PI) team in 2005 (working through 2007) to study the treatment entry process. Pamela Ramsey, executive vice-president of administration, quality, and compliance, led the team, which included admissions and evaluation, finance, medical records, and treatment staff.

Measurement Plan and Implementation

The team developed four major aims for the initiative:

• Review the treatment entry process (i.e., from initial phone call to admission)

• Identify barriers in the treatment entry process

• Standardize the treatment entry process

• Create and apply solutions to the treatment entry process that would assist in revenue capture

The team also identified key indicators to measure:

• Wait time between evaluation and admission

• No-show rate for evaluation appointments at one location (We decided to highlight results from one location to reduce bias). The site is one of our largest satellite offices, with a good mix of publicly funded and private-pay clients. Demographics, including race, marital status, and employment, are varied, and an adequate number of adolescents are represented in the sample.)

• No-show rate for evaluation appointments system-wide

• Overall admissions in one year

The team wanted to understand the process from a potential patient's perspective. To gather data, family members of team members made 23 phone calls to GRC locations, acting as if they needed treatment. The team discovered that administrative assistants answering the phones did not ask if the person had healthcare benefits, did not correctly identify the need for detox services, and did not provide key information, such as directions to the office or instructions on how to reschedule an appointment.

Next, the team sent administrative assistants a brief, anonymous, primarily open-ended survey to determine how they handled scheduling evaluations. The team found misplaced responsibilities, screening inconsistencies, and processes that did not maximize revenue capture.

Patients' healthcare benefits were being verified after the evaluation appointment as part of the preadmission process, and financial counseling was being performed following benefit verification. This meant that a person could arrive for his evaluation, be informed that a treatment slot would be available in one week, return to GRC one week later, sit through the preintake procedure, and then find out that he has a co-pay he can't afford. Thus, a motivated patient might not be able to begin treatment. The team also found that GRC's structure did not allow for billing of evaluations.

Changes

One of the first changes was to shift the responsibility of taking calls for evaluation appointments from administrative assistants to a new centralized scheduling and evaluation hub, which required changing our telephone system so that evaluation scheduling is listed as an option. These calls are directed to schedulers trained in screening to increase standardization across the organization. Patients who need detox services are identified immediately and transferred to a specialist who handles only this level of care, thus bypassing the routine collection of evaluation information. GRC can evaluate and admit detox patients on the day of initial contact.

Because the team had noted that satellite offices' utilization reviews were resulting in a high number of authorization denials, the process was reorganized and new UR staff members were hired. Healthcare benefits are now verified before the evaluation appointment, and expanded financial counseling is available. This allows potential patients to better understand the costs of their treatment, which can be empowering and motivating (e.g., no “surprises” such as unexpected bills during treatment). GRC also hired a patient benefits coordinator, and we now bill for evaluation appointments.


Figure.

Results

Before the initiative, the wait time between evaluation and admission at our sample location averaged 26 days, which was reduced to 9 days following implementation. The no-show rate for evaluation appointments at our sample location decreased from 45% before the initiative to 38% afterward (38 to 30% system-wide). Admission rates system-wide have increased from 59% before the initiative to 64%, while data suggest an overall increase in admission rates at our sample location (figure). The number of admissions scheduled system-wide in one year increased from 12,245 before the initiative to 13,831 afterward.

Patients can now access appropriate services quicker. Even with the added expense of hiring new staff and upgrading technology, we are seeing financial gains. “The initiative effectively blended total quality management principles with innovation,” says James Troup, executive vice-president of strategic planning and business development. “The result was a refined value proposition supported through sustainable system-changing solutions.”

By rebuilding our treatment entry process we have eliminated many organizational barriers and are helping potential patients access services in a timely and efficient manner. We are committed to continuing the team's work, and this initiative was a starting point for organizational renewal as we become more data-focused. We are diminishing our tolerance for “quick repairs” as we constantly think about our own motivation for change and the processes underlying existing barriers.

Cara M. Renzelli, PhD, is Director of Research and Program Evaluation at Gateway Rehabilitation Center.

Reference

1. Substance Abuse and Mental Health Services Administration. Results from the 2006 National Survey on Drug Use and Health: National Findings. Rockville Md.:SAMHSA, Office of Applied Studies; 2007.