November 2004 – Tips & Topics

Volume 2, No. 7
November 2004

In this issue
– Until Next Time

Welcome readers!

Since this is Thanksgiving time (at least for USA readers), I give thanks to you for reading TIPS and TOPICS, and to the many of you who have told me how much you appreciate receiving it. It is gratifying to me to know that TIPS and TOPICS has had a positive influence on many, and the ideas help improve treatment for the people we serve.


I usually try not to depend so heavily on any one resource in the SAVVY tips. However I was impressed by the work of the Network for Improvement of Addiction Treatment (NIATx). I wanted to be sure you heard about their results as well. Recently I read of what the NIATx was doing in their process-improvement project involving about 30 treatment organizations. I was intrigued to see how programs can prosper financially by doing good and by providing excellent service. Good customer service is not only possible in behavioral health services, it can also be profitable.

I quote from the News Feature I read by Bob Curley, November 12, 2004 “Seeing Clients as Customers Can Improve Care, Bottom Line”, adding my comments. You can read more of this work in the links and references I have noted.


  • Promote a customer-focused culture in your treatment program or practice. It can cut time to assessment and treatment, and increase patient retention dramatically.

Using customer-focused business practices, a research collaborative has succeeded in reducing wait times and no-show rates and increasing admissions and continuation in treatment, according to David Gustafson, Ph.D., director of the Network for Improvement of Addiction Treatment (NIATx).

Programs that received technical assistance from the NIATx process-improvement project — which uses peer networking and education to promote a customer-focused culture in treatment programs — achieved some eye-opening results. Among participating programs, the average time to assessment was cut 72 percent, time to treatment was cut in half, and patient retention (through four sessions) increased 123 percent, for example.”

For many of us trained in the healthcare and medical field where we think of patients and clients, it may seem a bit of a turnoff to sound like a business selling widgets, thinking of “customers”. After all, aren’t we into healing, not selling; saving lives, not saving money? Have you ever been frustrated waiting for your doctor who’s running an hour late? Imagine if you were treated as a customer, not a patient? What if obtaining an airline booking was as difficult as getting an initial addiction or mental health appointment? The airlines would be even more bankrupt than they already are, and certainly out of business.

When we treat people as wanted and welcomed customers whose needs we wish to understand and address as fast as possible, that qualifies as good care. A customer approach is more likely to engage the client and cement the relationship. Research reminds us that these are the single most important predictors of treatment outcome anyway.

  • Develop more flexible services. Streamline operations to be more responsive to people’s needs for reassurance, access and attention. It can increase profits and capacity to treat more people.

Gustafson said that programs should not be afraid to make rapid process changes, even if there are some initial bumps or pain at first.

For example, he said, Acadia Hospital in Bangor, Maine, decided to get anyone who called into treatment by 7:30 the next morning. “Initially, this was difficult, but whenever this center makes a change like this, they take a senior manager and put him side-by-side with workers being asked to make the big change,” said Gustafson. “The first day, it didn’t work well. The staff was a little angry, but the senior manager was right there to troubleshoot and adjust. He worked with them full time for that first week so he could personally experience what the staff went through, and they succeeded.”

Building on that initial decision, the organization re- thought what intensive outpatient was all about, said Gustafson, moving from a rigorous sequential process to a more flexible configuration of groups and modalities. “That one change has contributed $1.2 million a year to their margin,” he said. “They went from 26 patients a month and a chronic ‘not enough slots’ condition to admitting 91 patients a month.

Is your agency program-driven and ideology-driven, or person-centered and customer-driven? Could your services be characterized as plugging people into programs, where it is the clients’ job to comply with and fit into your program? Conversely, are we focused on creating services to match people’s needs? Advances have been made with the expansion of Assertive Community Treatment (ACT) teams, home visits and intensive case management in mental health. Addiction treatment systems have increased services for women with children, and have expanded the array of supportive living environments.

But we still have a long way to go. Behavioral health services do not jump to mind when thinking of who is most responsive to addressing and meeting people’s needs. Fast-food restaurants, despite all of their ‘supersizing’ controversies, are much more focused on access, convenience, engagement and retention than the usual treatment agency.


This article was published by Join Together (http://www.joint – a national resource for communities working to reduce substance abuse and gun violence, based at the Boston University School of Public Health.


When you view your agency or clinical practice from a customer’s perspective, this will affect not only how you structure services, but how you conduct client appointments, treatment planning and documentation.


  • Whether building a private practice or a treatment program, think of the 3 A’s. A successful practitioner told me many years ago about the 3 A’s – Availability, Access and Attitude

“I‘ve never seen a field take to process improvement like the addiction treatment field does,” said Gustafson, who also founded the Center for Health Systems Research and Analysis at the University of Wisconsin at Madison. “The results they’re getting just blow me away.

Gustafson’s personal interaction with the treatment system illustrates that there’s a lot of room for improvement when it comes to treating clients like a for-profit business would serve its customers. Acknowledging at the outset of the NIATx project that he knew little about the addiction field, Gustafson — who does not have a drug problem — got himself admitted to treatment for heroin addiction.

“I called up and said I needed help,” he recalled. “They said, ‘You can come in in 4 days for an intake.’ They spent two hours asking me about my disease, then concluded that yes, you need treatment, but at the moment we don’t have a bed for you, so call us in a week if you still want treatment.”

Gustafson called back a week later, and got an answering machine that said to leave a message. “That’s all the machine said for six straight weeks in a row,” he said. “Seven weeks later, they called and said they had a bed. If I’d been a real heroin addict, I’d never have made it into treatment.”

When Gustafson showed up at a meeting to be assigned to a treatment program, the intake coordinator who interviewed him weeks before wasn’t there, and the admissions staff was working off of a half-page of written notes about his case. “What happened to the two hours of information I provided at intake?” he asked.

Gustafson didn’t blame the staff, which he described as being paid less than workers at Home Depot, often in recovery themselves, and deeply committed to helping those who need treatment. “Between the patient and care lies a canyon of paperwork and burdensome diseases that get in the way,” he said.

It is not enough for us to say we have too many clients, too few staff who are admittedly paid too little. It explains why we might not be invested in customer service, but doesn’t excuse it. Most who enter the behavioral health field do it not for the big bucks, but for the satisfaction of helping people (though some big bucks would also be nice). So this is what being customer-centric is all about. It is about helping better. It is about getting clients into treatment sooner. It is about engaging them and having them hang in with treatment long enough to make some changes.

It is about being:
–>available to meet their needs
–>accessible to encourage their showing up for care
–>accepting with an attitude of service and respect

  • Make treatment planning and documentation people-work not paper- work.

One too common practice I’ve seen goes something like this:

The client is asked to sign on the “Client Signature” line to approve a treatment plan in which they have scarcely had any input, have barely read, and will rarely read again since it is tucked into a section of the chart never to be seen again. Or a client is asked to sign a permission to treat form, or acknowledgement of medication side effects. However ask the client the next day what they remember about their medication side effects, and you’ll likely be met with blank stares. You did the paperwork, but not the people-work.

One suggestion about improving access to care:
Create a half hour group orientation slot which is open each morning and afternoon. When a person calls for an appointment, they are never far enough from a face-to-face encounter than three or four hours. At that non-confidential session, people are introduced to services available and given standard forms to review and consider.

A variation if you don’t like the group aspect of that:
Set up one counselor/ therapist who is available for two hour blocks for brief orientation and engagement sessions for all new enquiries. If there are no clients, then paperwork can be caught up with. Isn’t that better than giving a client an appointment three days or three weeks in the future, with the high likelihood of a wasted appointment time when often the person doesn’t show up, or never calls to cancel?

For those who work in group treatment settings:
What if clients developed their treatment plans with peer input in a group setting? This could save documentation time. It would also model to others with similar issues how their particular treatment plan might look. It increases efficiency and effectiveness. If it is a meaningful treatment plan that was collaborative and participatory, the client could even write their own progress notes. If the progress note is valid and addresses the treatment plan strategies, the counselor can then countersign it.

For example:

“I used on my way to group today because I went by my old neighborhood and saw my drug dealer. I plan to avoid my neighborhood completely this week and attend at least one NA meeting”. This could be a progress note for a problem stated as: “Persistent daily cravings to use heroin especially when with drug using friends” and a goal of: “Identify any thoughts or behaviors that increase or decease cravings to use”.

This “customer” may not even be all that interested in serenity or sobriety. But he is a customer for not getting arrested again for drug dealing, or for staying out of jail. Now that he is in treatment, he can explore whether going by his neighborhood will increase or decrease his chances of going to jail or being arrested again.


This past week, I had my first colonoscopy (no symptoms, just a screening). I was sort of scared about having it – not just the bowel preparation you have to do and then the actual procedure – but what if they find something? I was the customer in a healthcare setting- a setting not foreign at all to me. I thought about sharing what that was like -an appropriate focus for this “Soul” section. But I decided against pushing the customer thing any more in case you are customerized-out.

So to another topical focus – the holiday season! Here are a few tips for the holidays:

*** If you are organized enough to send an end-of- year, newsy, form-letter greeting to friends and relatives updating them of the year’s activities and experiences, keep it to one page, and preferably bullet-type news. Long, narrative, detailed, journal- type paragraphs are for your very small, intimate one or two friends or loved ones. Most others (as Jerry Seinfeld said about weddings) don’t really care that much.

Don’t get me wrong, I enjoy catching up and hearing what has happened to family and friends. Give them the summary. If they care enough, they will want to know more and call you. A number of friends tell us they look forward to our annual one-pager, as each family member writes his/her own few sentences. It is fun to hear what people are up to – but not too much information.

*** My sister talks about the 80% rule – eat 80% of what would make you feel full and you will probably be eating the right amount. If that is too monastic for the holidays, you could do what I heard on CNN. After eating the holiday meal, “destroy your plate”. They didn’t mean throw it over your shoulder like in a Greek restaurant. But pour lots of salt or pepper on your plate so you are not tempted to sit and pick at more food. Of course you could get up from the table and clear the dishes, which would be good exercise and help with clean up too.

*** In Japan, you might have seen deep frozen mandarins which make a cool healthy snack. Something similar: I enjoy pulling seedless grapes from their stems and freezing them. When you’re hungry for a snack, each hard frozen grape is a yummy, mini fruit icicle, healthier than a slab of chocolate or a candy. They’re good on cereal as well.

That’s my holiday tips. I have to go and weave my holiday wreaths now!!

Until Next Time

Until the December edition of TIPS and TOPICS, reflect with me on what you have to be thankful for – even if Thanksgiving is not a holiday where you live.