Stories from the QI Award Program : Using QI to Guide and Support Your Work

1. Stories from the QI Award Program: Using QI to Guide and Support Your Work June 2013 Presented by Nicole Charon-Schmitt, MPH Director, Programs and Planning Addictions Services, Boston Public Health Commission

2. Goals of Presentation • Provide background and overview of our QI Project including key activities and QI tools utilized • Describe our experience as Cycle 2 QI Award Grantee including key challenges, successes, and lessons learned

3. Project Overview • Implementation is taking place within Boston Public Health Commission's (BPHC) Addiction Services’ Bureau PAATHS Program • Original AIM Statement • By July 31, 2013, increase by 25% the percentage of PAATHS clients connected to their primary service need (s) within four days of intake • Goals for Project • Increase access to substance abuse and recovery support services • Promote recovery from substance abuse

4. What is BPHC? • Serves as the City of Boston’s local health department • Mission: Protect, promote, and preserve the health and well being of all Boston residents, particularly the most vulnerable. • Provides public health programming and other services across six bureaus: • Addictions Prevention, Treatment and Recovery Support Services • Child, Adolescent and Family Health • Community Initiatives • Emergency Medical Services (EMS) and Public Health Preparedness • Homeless Services • Infectious Disease

6. What is PAATHS? • Providing Access to Addictions Treatment Hope and Support • One-stop shop for individuals and families looking for information about, or access to, substance abuse treatment and other recovery support services • Serves approximately 2500 individuals annually • Developed in response to an identified need to improve the way people in Boston affected by substance use disorders are connected to a wide range of services (APTRSS Bureau Strategic Plan, 2009) • Expansion project began in 2012 by building off existing service component • Applied for and received QI grant in Fall 2012

7. Why QI? • How to transform existing program? • Existing culture reflected a resistance to change • Struggling with how to create a culture of change while honoring the expertise and experience of staff • Identified QI as a vehicle to help us get from Point A to Point B and to help us meet the growing demands of healthcare reform • Previous experience with QI work through NiaTx was positive and had been used to address similar challenges in other program areas

8. Why Our Aim? • Of the 15 largest metropolitan areas, Boston ranks 5th highest in reported rates of illegal substance use and 3rd in reported binge alcohol use. • These reported rates are at least 25% higher than any other region of the state. • Of the 106,301 admissions to substance abuse treatment programs statewide in FY 2010, 16.72% (17,775) were from Boston. • Drug abuse mortality in Boston increased sharply from 1999-2007 with age-adjusted substance use mortality more than doubling, from 11.3 per 100,000 to 23 per 100,000 during this time SAMHSA, Office of Applied Studies,The NSDUH Report: Substance Use in the 15 Largest Metropolitan Statistical Areas 2002-5. SAMHSA, Office of Applied Studies, Massachusetts State Treatment Planning Areas. Massachusetts Department of Public Health, Bureau of Substance Abuse Services. Substance Abuse Treatment Fact Sheet FY 2010 – Boston. Boston Public Health Commission. Substance Abuse in Boston. 2011

9. Major Activities

10. Forming Our Team • What is typically recommended vs. what we did • Challenge: Do we include everyone? • Considerations: • Small team; only 7 staff in total • Clear division between existing staff and new hires • Felt we needed buy-in from existing staff to truly be successful

11. Brainstorming • Utilized tools called nominal group technique (NGT) • Structured method for group brainstorming that encourages contributions from everyone. • Takes brainstorming a step further by adding a voting process to rank ideas that are generated

12. Benefit of NGT • Focuses on identifying problems first rather than solutions • Allows team members to contribute their own experience and expertise • Silent group generation provides everyone with an opportunity to contribute • Voting promotes shared decision making and helps with prioritization

13. Results of NGT • What is/are the biggest barriers for you to be able to connect your clients to the resources they request in a timely manner? • Amount of time it takes for clients to be seen at first visit • Too much paperwork that is redundant and/or not necessary for what the client is requesting • Need to build capacity, and better understand processes and requirements, for referring to expanded referral network • Limited staff knowledge of available resources

14. Development of Sub-Aims • After first meeting with coach, agreed to develop sub-aims

15. Process Mapping • Documented current process from when client arrives until when they leave • Discussed and identified problem areas • Redundant/unnecessary paperwork • Bottlenecks • Agreed on areas for improvement/change

16. Original Intake Process

17. 1st PDSA Cycle: Reducing Wait Time in the Waiting Room

18. PDSA • PDSA cycles • Plan the change • Do the plan • Study the results • Act on the new knowledge • Rapid cycle changes • Changes should be doable in 3 weeks

21. Lessons Learned • QI is an ongoing process that needs constant attention • No one size fits all model for how to implement QI – need to pick and choose what works for you • Staff buy-in is key

22. Moving Forward • QI Team continues to meet regularly • Continue to identify opportunities to improve our service delivery and be more efficient and effective • Exploring potential opportunities to generate revenue for work

23. Q&A

24. Expanding STD Text Messaging Services Using QI Processes Kathleen Yeater, RN, BSN, MS, CHES Donna Walsh, RN, BSN, MPA Florida Department of Health, Seminole County June 12, 2013

25. Why Texting? • From 2007-2011, STD cases in FL increased by 18%. • Closure of STD clinics and reductions in staff due to budgetary constraints. • Traditional methods of client notification may delay treatment.

26. The mHealth Solution • Mobile phone use high in the United States. • High-risk groups receptive to mobile health programs. • Many advantages of mobile health programs. • Mobile phone-based pilot projects have shown promise.

27. Goal • Offer text messaging of STD results (gonorrhea, chlamydia, and syphilis reports) to improve timeliness of STD diagnosis, treatment, and reduce clinic burden.

28. Pilot Projects • Peoria County – 12/08-5/09 & 9/09-12/09 • In 2009, STD clients could opt in to receive chlamydia and gonorrhea test results via coded text messages. • Results: - 46%opted in - Texters received treatment significantly sooner - Health department costs were reduced

29. Pilot Projects • Clay County, FL • In 2010, Clay adopted Peoria’s texting process and began offering service to STD clients. • Results: - 56% opted in - Time from notification to treatment decreased - Cost savings in staff time

30. How Did They Do That? • Use of existing resources: • PRISM (Patient Reporting Investigating Surveillance Manager) – Florida’s electronic STD database which houses client records and labs of “all” STD clients. • Disease Intervention Specialists (DIS) – Responsible for tracking clients to refer for treatment and solicit exposed partners. • No additional state funding.

31. What is Required? Access to PRISM (for sending texts & call backs) PRISM training within 30 days of implementation Negative and positive labs attached Enter 4 pieces of information from consent form* Record call backs immediately in PRISM * Cell number, cell carrier, date authorization form was signed, and date the form expires. 31

32. And So It Begins… • County adoption of texting*: • Clay – 11/10/11 • Seminole – 1/20/12 • Duval – 1/26/12 • Escambia – 11/8/12 • Miami-Dade – 11/20/12 • Orange – 1/30/13 *9% of FL counties

33. Success! * 55% of clients under the age of 25 opted in for texting across all texting counties.

34. Time to Treatment Comparing Texters to Non-Texters Timeframe = lab add date to treatment date, excludes presumptively treated and those treated past 30 days.

35. Call Me! Timeframe = lab add date to treatment date, excludes presumptively treated and those treated past 30 days.

36. I Have an Idea! • Success of pilot project in Seminole County prompted proposal for expansion to other clinics reporting STD results: Family Planning and Prenatal. • Plan: Use QI processes to document best practices and access tools for further implementation.

37. QI Project • The Seminole County Health Department seeks to improve the timely treatment of clients who test positive for Sexually Transmitted Diseases (STDs) and reduce exposure of partners and contacts by utilizing more efficient and technologically advanced methods of notification. • The health department is looking to expand the usage of text messaging for reporting STD results to our Prenatal and Family Planning clinics in an effort to provide timely treatment and reduce partner, congenital, and newborn exposures.

38. AIM Statement • The Florida Department of Health, Seminole County will increase the number of clients opting in for text messaging by 20 percent for STD reporting by July 31, 2013.

39. Logic Model

40. Building Our Team Activities Brainstorming • Discuss models for implementation. Feedback Sessions • How did we do? • Process improvements. Analysis • Develop process maps • PDSA cycles • Metrics • Surveys • Team Selection QI Proposal Committee • Edited proposal for submission. • Agreed on AIM statement. QI Project Team • Provided opportunity for staff to learn QI tools and process through webinars. QI Workgroup • Team members directly involved in providing services.

41. QI Project PDSA Cycles

42. PDSA RAMP 5 4 3 Update survey, tabulate responses, evaluate feedback & plan next steps Begin offering text option to PN clients 2 Begin collection of metrics & develop client survey 1 QI team evaluation, revisions & finalize materials for Team Meeting Train staff & begin offering text option to FP clients

43. Change Strategy Cycle 1 Train staff & begin offering text option to FP clients Revised Process Map due to discrepancies Developed uniform script for staff to counsel clients Created sample text

44. Process Map

45. Family Planning Flow Chart

46. Sample Text

47. Consent Form

48. Script

49. Change Strategy Cycle 2 QI team evaluation, revisions & finalize materials for team meeting Revise policy to reflect updates Revise client information cards Clarify metrics for data analysis

50. Text Message Instruction Cards