Everybody likes same-day service: an opioid treatment program decreases its no-show rate by offering a same-day admissions process.

Spectrum Health Systems, Inc., is a large provider of opioid treatment services (OTS), with four outpatient methadone clinics throughout Central and Southern Massachusetts. In total, these clinics serve more than 1,300 OTS clients each day. More than 800 are served daily at the largest clinic located on Lincoln Street in Worcester.

Through our quality-improvement processes and client satisfaction surveys, Spectrum found that one of the major barriers to providing effective treatment was the time it took to receive treatment (admission wait times). Many clients expressed dissatisfaction with the admissions process, specifically indicating the length of time it took them to be admitted to the program. These results encouraged us to begin collecting data on the average wait time; upon review of the preliminary data, we found that it took about 10 days from initial contact with the program until the potential client was fully admitted and received his/her first dose of methadone.

During these 10 days, clients attended a clinical intake appointment (sometimes taking 3 to 4 business days to schedule) and provided a toxicology screen (having to wait 2 business days for the results). If the results indicated that a client was appropriate for admission, a medical evaluation was scheduled, which could be 3 to 4 days later. Upon physician approval, the client was admitted to the program.

We found that lengthy wait times also led to an approximately 35% attendance rate at initial intake appointments. Thus, approximately two-thirds of clients scheduled to begin receiving services did not show up. As a result of these findings, Spectrum implemented its "Same-Day Admissions Process" (which takes place on Wednesdays) in June 2006.

In this process the client completes all of the admission process' steps on the same day and without a previously scheduled appointment. The entire process usually takes from two to four hours to complete. Afterward, the client immediately starts treatment if he/she is clinically and medically cleared.

Prior to this new process, Spectrum's leadership recognized the impact it would have on all departments, and each was asked to send a representative to planning meetings. Coordinating all of the clinics' departments (patient accounts, intake, clinical, and medical) proved to be the biggest challenge. Ensuring that all steps occurred sequentially in a short time also was a barrier. Despite the many challenges, the Same-Day Admissions Process has allowed us to help clients based on their current progress and readiness for treatment rather than on a one-size-fits-all approach.

Admitting a relatively large number of clients in one day has freed up resources on other days to allow traditional admissions to be scheduled sooner. Since the inception of the Same-Day Admissions Process the wait time has decreased from 10 days on average at all clinics in December 2006 to 3.5 days at our largest clinic on Lincoln Street in Worcester and to 6.6 days at two smaller clinics in Milford and Framing-ham in September 2007 (figure 1). By decreasing the average wait time, these clinics also increased their show rates, from around 35% in December 2006, before the Same-Day Admissions Process, to 72% at Lincoln Street and approximately 60% at the other clinics in September 2007 (figure 2). This process also has increased census at each site and led to a better method of getting clients into treatment while their motivation levels for ceasing illicit drug use were high.

Approximately five to ten new admissions per week use the Same-Day Admissions Process. This is in addition to the regular stream of clients entering treatment through traditionally scheduled admissions, and our goal is to someday be able to do all same-day admissions (resource restraints currently prevent this). However, some clients are not eligible for the Same-Day Admissions Process due to extensive hospitalizations for chronic medical conditions or active psychiatric impairments. We usually require additional information for these complex clients, and they need to follow the traditional intake process. Clients previously terminated for severe violations of program rules also are not eligible for the Same-Day Admissions Process, as these cases need to be reviewed by our multidisciplinary team.

This process has served as an effective marketing tool. Courts, parole departments, and community agencies like the convenience of having all aspects of OTS admission completed in one day. This process does continue to present challenges, however, which are mostly operational changes addressed at monthly meetings (e.g., the order in which clients see the different departments and the volume of clients we are able to process). We also ask clients to identify barriers they experience during the process. As a team, we try to make the process run smoothly for clients while ensuring all of the organization's needs are met.

The Same-Day Admissions Process is an effective option for clients unwilling or incapable of waiting to go through a traditional admissions process. Now clients may decide to seek treatment for their opiate addiction and simply show up without an appointment to begin treatment within a few hours. This is truly the greatest outcome of the project and has the greatest impact on being able to effectively serve people suffering from opiate addiction.

Dennis Theriault, MBA, is Director of Quality Improvement at Spectrum Health Systems, Inc. He can be reached at dennis.theriault@spectrumhealthsystems.org.

Kristin Nolan, MA, is Director of Outpatient Services at Spectrum's five outpatient behavioral health/OTS clinics in Massachusetts. She can be reached at kristin.nolan@spectrumhealthsystems.org.

Spectrum Health Systems provides behavioral health services in Massachusetts, Georgia, Rhode Island, Maine, Arizona, Tennessee, and Maryland.

BY DENNIS THERIAULT, MBA, AND KRISTIN NOLAN, MA Average Wait Time (# of days) for Admission into Spectrum's Outpatient Opioid Treatment Programs

Dec-06 Sep-07 Lincoln Street 10 3.5 Milford 10 6.6 Framingham 10 6.6 Figure 1. Note: Table made from bar graph. Show Rates for Intake Appointments at Spectrum's Outpatient Opioid Treatment Programs

Dec-06 Sep-07 Lincoln Street 35% 72% Milford 35% 55% Framingham 35% 65% Figure 2. Note: Table made from bar graph.