MARRCH 2007 Annual ConferenceOctober 30, 2007

Addressing “Paperwork Burden”Transforming Data into useful Information for Counselors and

ClientsDeni Carise, Ph.D.

Treatment Research InstituteUniversity of Pennsylvania

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State of the FieldDelaware Paperwork Burden ReviewDecreasing Paperwork at Assessment

Role of Computer SystemsBenefits of Standardizing Data

Topics

Results of Initial Work from Recruiting Programs for the

National Treatment Outcomes Monitoring System (NTOMS)

LeadershipManagement

StaffingInformation

State of the Field

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NTOMS National Sample Expansion

NY

Information on the First 175 Sites Recruited

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The Treatment System

Modality 1975 1990 2006

Residential 64% 39% 8%

Outpatient 27% 59% 81%

Methadone 9% 10% 11%

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• 8 % closed altogether

• 7 % stopped providing SA Treatment

15% no longer providing SA Treatment

• 29% of remaining programs had been taken over, usually by MH agencies

Program “Turnover”

McLellan, A.T, Carise, D, & Kleber, H. (2003). Can the national addiction treatment infrastructure support the public’s demand for quality care? Journal of Substance Abuse Treatment, 25 (117-121) TRI

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• 54% of directors have been there Less Than 1 year

• Counselor turnover 50% per year

STAFF TURNOVER!

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No Standard Intake/Assessment Procedures

– ASI was most used assessment (35%)

– Total admission process 2-4 hours, or 0

– 15 – 20% Don’t Do Assessment

– 30% of programs collected only the information that was required by regulating agencies

Intake/Admission Process:

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No perceived value for assessment

“Simply Paperwork”

Not related to Treatment Plan

Not related to services delivered

Intake/Admission Process:

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3 - 4 Hours – Group Counseling

2 - 3 Hours – Intakes

2 - 3 Hours – “Paperwork”

Who are the Counselors?A Typical Counselors Day?

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An Example with the Delaware State

Concurrent Recovery Monitoring Grant

Who are the Counselors?Addressing “Paperwork”

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Delaware CRM Project4 Phases:1) Evaluation of current data collection in an

effort to minimize paperwork burden2) Collaboratively select CRM items3) Pilot the collection and reporting of these

items in 4 state adult OP SA programs4) Expand to all 11 state adult OP SA programs

and monitor progressTRI

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A Comprehensive Paperwork

Burden Review

Who are the Counselors?Phase 1:

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Goal: Paperwork Burden Review

• Diminish any unnecessary or burdensome paperwork

• Develop a more efficient data collection system by consolidating and streamlining paperwork

• Facilitate programs’ ability to participate more fully in expanded CRM effort in Phase 3

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Methods• Conducted a systematic evaluation of

multiple, competing data collection demands (state, grant, contract, managed care, credential agencies, etc.)

• Conducted site visits with clinical and admin staff from 11 OP Tx Programs in DE in July/Aug 2005

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During site visit, reviewed paperwork completed thru continuum of care:

• Screening, • Intake & Assessment,• Treatment planning process, • During treatment, • Discharge or transfer, and• Follow-up

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Methods

Recommendations• Eliminate Michigan Alcohol

Screening Test - MAST (7-10 min)

• Recommended 2-item screener for South Oaks Gambling Screen

(5 min)TRI

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• Eliminate Interpretative Summary (repeat of ASI Narrative) (30 min)

• Eliminate Assessment Summary (repeat of ASI) (10-15 min)

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Recommendations

• Develop consistent Physical Exam Refusal forms for use by all sites

• Eliminate ASI at Discharge (30 min)

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RecommendationsRecommendations

• Eliminate ASAM at Intake for all OP Programs (lowest level of care), as well as 90 Day ASAM Updates & ASAM at Discharge (45 Min: 15 min @ admin, 90 days and discharge)

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Recommendations

Paperwork Burden Reduction

• Eliminations reduced @ 2 hours per client across continuum of care

• Approx 1,500 clients/year enter tx at 11 OP programs

• Total reduction: @ 3,000 counselor hours per year

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Paperwork Burden at Assessment

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How do computer systems and

standardizing data help?

8A national system collecting standardized, automated information (using ASI)

8 that is clinically important and policy relevant

8on people entering addiction treatment and their treatment programs

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The Drug Evaluation Network System DENS

Purpose of DENS

Standardize information at treatment intake

Unified picture of people coming into treatment

Quickly gather questions of current interest (Changes since 9/11) so this information isn’t

always anecdotal

Identify new trends - ex: Oxycontin use

AND to inform policy

Purpose of DENS

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Significance of DENS

The only “real-time” source of information on treatment programs and their patients.

Ability to collect varied additional timely and policy relevant patient and program information

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Standardizing Data Collection:The Blood Pressure Model

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An Example of Non-Standardized Reporting

Blood Pressure

Nurse 1 – It’s getting better (better than what??)

Nurse 2 – It’s much lower than before (too low??)

Nurse 3 – The patient is in denial (???)

Nurse 4 – The patient is non-compliant, lets not treat him until he’s really ready

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An Example of Standardized Reporting

Blood Pressure

Nurse 1 – It’s 120/80

Nurse 2 – It’s 116/78

Nurse 3 – It’s 122/82

Nurse 4 – The patient is non-compliant, lets not treat him until he’s really ready

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How Could Standardizing Data Help?

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Allows for better guidance in clinical/treatment decisions

and tailored treatment.Allows tracking trends, enabling us to show that

treatment works

Standardized Assessment

An example with the

Addiction Severity Index

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The Addiction Severity Index

• Developed by Tom McLellan & colleagues at University of Pennsylvania

• Standardized, semi-structured, multi-focused screening and assessment tool

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A. Thomas McLellan

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7 Sections of the ASI1. Medical

2. Employment/Support

3. Drug

4. Alcohol

5. Legal

6. Family/Social

7. Psychiatric

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DENS SoftwareAutomates collection of the ASI data Provides:

• Automated error-checks• A comprehensive intake assessment• Room for additional comments• Automated narrative summary • Comprehensive treatment care plan

• Software designed with input from clinicians

• Assumed most users have little/no computer experience

• Users report administration time shorter with software

• Can enter comments for every ASI item

DENS ASI Software

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It Writes a Narrative Summary?

Software: Hints & Comments

DENS ASI Data Flow

Client data – ASI

Server in Philadelphia receiving all non-identifying

data

DENS Programs

Quarterly reports

Trends of Interest?

Who is coming

in to treatment?TRI

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Age Group Categories

25 and under 4,423 15%

26-35 9,527 31%

36-45 11,542 38%

46 and older 4,876 16%

Age Group n % of Total

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Heroin: Percent InjectingBy Age Group * Over Time

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50

75 7156

3835 3949

20

40

60

80

1999 2000 2001 2002

40 + 16 - 25

12

3836

3334

52

132 45

53

32

4

25

0

20

40

60

CA NM TX OH KS NE MN WI MI IL MA PA NY NJ FL

Percent Regularly Using Heroin (Years) by State

Change Over Time: 1996-2005Criminal Justice System Involvement

10203040506070

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

Percent Referred by CJS

What Can Data Do for You?

Track Trends – Current drug trends

OxyContin

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A Flexible Monitoring System

Benefits of “Real-Time” Knowledge

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Did the September 11th attacks result in changes in the

behaviors of counselors and patients in substance abuse

treatment?

The research question:

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• Surveyed 86 counselors at 25 DENS treatment programs

• Chicago, Miami, Philadelphia & New York.

• November 28, 2001 and January 4, 2002

• Counselors at a Veterans Affairs Medical Center were surveyed to evaluate potential differences in their population

Methods

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Following the events of September 11th:

1. Would counselors perceive a change in their patients’ demands for services?

2. Would counselors perceive a change in their patients’ substance use patterns?

3. Would VA counselors observe a change in the frequency of their patients’ PTSD symptoms?

Specific Questions:

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Changes in PatientsPercent reporting a change in the demand for services

since the attacks

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58

27

48

71

0

20

40

60

80

100

• 56% (N=48) of the counselors noticed a change in patients’ demand for services

Changes in Substance Use Patterns

Percent reporting change since the attacks

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• 22% (N=19) of the counselors saw a change in patients’ use patterns

• Most reported an increase in drug and alcohol use

29

0

17

29

0

5

10

15

20

25

30

CHIM

IA

PHILLY

NYC

40

50

60

70

% Y

es

Changes in Staff Members

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63% noticed a change in their fellow staff members since September 11th

• More concern about and compassion toward other employees and patients

• More anxiety and stress

• Fear of layoffs

… following September 11th

Overall, Staff Members Reported:

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Building on DENS:CASPAR

Computer Assisted System for Patient Assessment and

Referrals

Background “Wrap-around” services have been shown

to improve treatment outcomes

But…

…few services available in contemporary Treatment Programs

…finding “wrap-around” services can be difficult

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Problem-Services Linkage

Treatment Research Institute

•Alcohol

•Drugs

•Medical

•Employment

•Psychiatric

GED training

Resume Development

Job Finding

Mentoring Sessions

Training Loans

(e.g. Employ - related services

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1. Conduct assessment (ASI)

2. Identify problems

3. Prioritize problems

4. Develop goals to address problems

5. Write Treatment Plan including referrals from CASPAR RG not available at your site

Assessment to Treatment Planning

Therapeutic Thread

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What about this “Resource Guide”?Electronic source of local, free/low costprograms and agencies for providing clients with

referrals to services not offered in Tx

Wide range of programs and services, include:Mental healthJob training

Financial supportEmergency services

(Food, clothing, housing, shelters)

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Resource Guide

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A Software Screen Example

Click here to enter patient’s zip code.

Click here for all services matching the keyword.

Highlight a keyword here.

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A Software Screen Example

Click here to print this page.

Click here to view other programs provided by this agency.

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Sample of a Program Info Screen

Thank You!

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