By Dennis McCarty and Traci Rieckmann, Oregon Health Sciences University
David Gustafson's essay challenges practitioners, program directors and policy makers to redesign addiction treatment services. Healthcare reform is changing rules and disrupting the status quo. We must seize the opportunity to vision what could be and ask, "Why not?" David's 11 essential ingredients provide a starting point for rethinking and reengineering contemporary addiction treatment services.
For the past decade, we have collaborated with David to evaluate and assess the application of process improvement and organizational change practices to treatment services for alcohol and drug use disorders. Treatment centers that eliminate wait lists and offer same day and next day appointments serve more patients, retain patients in care, generate more revenue, and reduce organizational expenses (Hoffman, Ford, Choi, Gustafson, & McCarty, 2008; McCarty et al., 2007; McCarty, Capoccia, Gustafson, & Cotter, 2009; Quanbeck et al., 2011). Patients who enter care more quickly, moreover, are more likely to be retained in care (Hoffman, Ford, Tillotson, Choi, & McCarty, 2011).
I presented the data on the association between wait time and retention at the annual meeting of the College of Problems on Drug Dependence. An older practitioner scrutinized my poster and turned to me. "You are absolutely right!" he stated. Then, he continued with a contradiction "You are also absolutely wrong!" I asked how both could be true. At his program, he explained, he knew that prompt care was better care. But, when he gave a patient an appointment for 30 days away, the patient left happy – he had an appointment. When the patient failed to show in 30 days, the program director was happy – he didn't have the resources to support another patient. This contradiction illustrates that addiction treatment systems are too often created to delay and deny care rather than support care. We can no longer afford systems of care that rely on waiting lists to ration care.
The 11 essential ingredients draw on best business practices in other industries. What makes them so good? What can we learn from them? Successful businesses offer anytime, anywhere service using technology to deliver quality services with minimal variation. Addiction treatment needs to adopt these ingredients as expected features of service delivery. Programs need to incorporate global assessments of customer (patient and family) needs and assets, with minimal or no handoffs between practitioners and levels of care using evidence-based behavioral and pharmacological therapies. Effective services engage patients and families before, during and after treatment and use just-in-time services to provide ongoing support for recovery. Practical progress reports track patient outcomes in real time. Progressive program directors and policy makers also recognize that the financing of care is changing rapidly. Programs will be paid for performance and outcomes rather than units of care. System operations will change substantially.
We need leaders who see the opportunity for redesign and understand all of the parts of the current addiction treatment system – financing, regulation, and the complexities of health care reform and parity implementation. The programs and practitioners who apply David's essential ingredients and manipulate the multi-dimensional space of health care reform will be more likely to survive and thrive in the 21st century addiction treatment system. Challenge the status quo. Look at the strongest businesses and the products you use. Ask, "How can I be as good?" "What can I learn from them?"