Improving Access & Retention in Treatment
Background
Opioid Use Disorder (OUD) is a chronic condition that affects an estimated 2.4 to 5 million Americans. It is also estimated that of the individuals with OUD, only 21% have received any past-year substance abuse treatment, and only 15-20% of those have received Medication for Opioid Use Disorder (MOUD).
The APT Foundation, Inc. (APT) is a Connecticut-based not-for-profit community-based organization that specializes in the treatment of substance use disorders. To address the growing opioid epidemic, APT began using the Network for the Improvement of Addiction Treatment (NIATx) rapid-cycle model to improve treatment access and program outcomes especially wait time to treatment. Since May of 2007, APT has continued to use the NIATx model to sustain results and navigate current treatment challenges associated with COVID-19.
NIATx Approach
The NIATx-informed open-access treatment model uses process improvement strategies to improve treatment access and capacity. Patient waiting time to treatment is a key metric to improve overall patient care and outcomes. Opioid Treatment Programs (OTPs) have traditionally operated under the assumption that a fixed number of individuals can be treated at any given time; when demand for treatment exceeds allocated treatment slots, prospective patients are turned away or assigned to a waiting list. Waiting times of at least one month for methadone maintenance are common in the U.S. These excessive wait times remain a significant barrier to treatment, as they minimize the problem and cause prospective patients to not enter treatment at all.
APT recognized a real need to shift the treatment model and create process efficiencies that provide enough capacity to allow for immediate access to prospective patients. Using the NIATx approach, APT began development and implementation of the open-access model to support this objective in two phases:
- Phase 1: APT began using the NIATx rapid-cycle model in May 2007. A walk-through of existing intake procedures identified multiple possible barriers involving wait time and access. The change team initiated a series of related change projects to improve these areas.
- Phase 2: In fall 2007, change teams identified barriers to access, retention, and expanding treatment capacity. The development and implementation of key elements of the open-access model occurred during this phase, including walk-in evaluations, same-day treatment initiation, and provision of drop-in groups.
Change projects to address barriers to methadone maintenance access or retention include the following:
| Barrier | Change Project |
|---|---|
| Long waiting time | Walk-in screening, intake, medical screening, and methadone or buprenorphine initiation are available same day, Monday through Friday, if indicated. Physical exams are performed on a walk-in basis and tuberculosis tests are read after admission to eliminate long waiting time. |
| Financial costs to patients | Eligible patients are admitted irrespective of insurance coverage or ability to self-pay; following admission, patients without insurance are assisted with procurement (e.g., Medicaid). |
| Counseling | The primary mode of counseling has changed to drop-in groups that allow for more patient flexibility, with individual counseling available, as needed or as requested by the patient. |
| Dosing & medication | Standardized protocol and procedures have been implemented for methadone dosing and take-home medication eligibility. |
| Discharge criteria | Administrative discharge criteria have been updated, and patients are discharged only after review by clinical team and approval of CEO confirming safety risk or absence of treatment efficacy. |
Outcomes
Through the open-access model, prospective patients are rapidly enrolled in APT’s methadone maintenance treatment—irrespective of ability to pay—and provided real-time access to multiple voluntary treatment options. Based on data collected through routine quality assessment, this open-access model appears to improve treatment access, capacity, and financial sustainability without evidence of deleterious effects on treatment outcomes. Specifically, the following outcomes were realized between the period of July 2006 (pre-model) through June 2015:
- Patient census increased by 183%, from 1,431 to 4,051.
- Average waiting-time days decreased from 21 to 0.3 (same day) without apparent deleterious effects on rates of retention, non-medical opioid use, or mortality.
- Net operating margin rose from 2% to 10%, while state-block grant revenues declined 14%, and the proportion of total revenue from state-block grant revenue decreased from 49% to 24%.
During the first five years of the open-access model, most patients were screened, assessed, and medicated on the same day. Reduced waiting time was achieved partly by shortening delays between initial screening, intake, and admission. Relative to national statistics from 2003 to 2012, when patient census (or treatment capacity) increased only 37%, APT’s census increased 183% over ten years following implementation of the open-access model. The model provides services immediately and offers a potentially important approach for eliminating extant treatment access disparities through drop-in counseling that offers more patients access and choice about counseling.
COVID-19 Response
The COVID-19 pandemic has presented complex challenges related to maintaining treatment to respond to increased demand brought on by psycho-social isolation, while reducing transmission of COVID-19. Correspondingly, APT has set important goals of reducing in-person contact between patients and staff and identifying opportunities for social distancing to reduce transmission of COVID-19, while maintaining access to treatment through no wait times and walk-in evaluations.
One of the top NIATx principles to create change is to understand and involve customers. APT’s COVID-19 response has focused largely on understanding patient needs and resources to make individual and aggregate process changes following the NIATx approach. As soon as federal guidance was released on March 16, 2020, APT implemented the following process changes:
- Increased the number of doses of take-home medication for stable patients. Of the facility’s 4,500 patients, 2,000 were transitioned to receiving a supply of medication that would last at least 14 days. This huge staff effort has resulted in a highly successful process that has significantly decreased the number of in-person interactions required.
- Created a standard medical and COVID-19 safety sheet/checklist. Standard questions are used to measure stress, COVID-19 symptoms, and treatment concerns/status. This allows for data and trend analysis to inform future changes.
- Implemented telehealth protocol. Clinicians are conducting regular telephone check-ins with patients, sometimes almost daily depending on the patient’s risk factors and pre-existing conditions. These phone calls also use a standard checklist to help assess trends.
APT has found the changes implemented above to respond to COVID-19 have allowed the facility to continue providing treatment to patients and, in several cases, have improved treatment approaches, particularly for those with access disparities. For example, telehealth visits remove barriers to transportation and provide more flexibility for patients in scheduling. APT is still conducting 20-30 walk-in evaluations per week but has the appropriate processes and protocol in place to minimize in-person contact, transition patients to telehealth options once admitted, and reduce COVID-19 transmission.