1. Na#onal
Center
for
Responsible
Gaming
Conference
on
Gambling
and
Addic#on
November
14,
2010
Improving
Access
and
Reten#on
in
Treatment:
The
NIATx
Program
in
Iowa
Janet Zwick Mark Vander Linden
Prairielands ATTC Iowa Gambling Treatment Program
janetzwick@aol.com Iowa Department of Public Health
mvanderl@idph.state.ia.us

2. Partners
Anne
Helene
Skinstad,
Ph.D
PATTC
Janet
Zwick,
Lead
Coach,
PATTC
Bob
Kersieck,
IDPH
Mark
Vander
Linden
IDPH

3. President
Barack
Obama
Inaugural
Address
January
20,
2009
“We
will
restore
science
to
its
righEul
place,
and
wield
technology’s
wonders
to
raise
health
care’s
quality
and
lower
its
cost.
“

4. NIATx
Aims:
1. Increase
admissions
to
treatment
2. Increase
conTnuaTon
from
the
first
through
the
fourth
treatment
session
3. Reduce
the
number
of
paTents
who
do
not
keep
an
appointment
(no-­‐shows)
4. Reduce
wait
Tmes

5. Iowa
Gambling
NIATx
• Nine
programs
providing
gambling
and
substance
abuse
services
• Eight
of
the
nine
programs
had
substance
abuse
NIATx
experience
• Helpline

6. Important
Iowa
NIATx
ConsideraTons
• Aims
and
Change
Cycles
determined
by
individual
programs
• Keep
It
Simple:
Keep
required
program
paperwork,
state
meeTngs
to
a
minimum
• Keep
it
helpful
–
coaching
calls
• Waivers
to
simplify
processes
• Programs
may
use
a
combined
SA/gambling
change
team

7. Important
Iowa
NIATx
ConsideraTons
Importance
of
Sharing
Data
and
CompeTTon.
• Early
in
2009
we
shared
only
state-­‐wide
data
and
the
program’s
own
data
with
each
program
• In
October
2009
we
requested
and
received
permission
from
each
program
to
share
data
with
other
programs
• Following
this
there
was
a
surge
in
Change
Projects
from
programs

8. Key
Focus
of
Iowa
NIATx
2009
• Increasing
admissions
different
than
substance
abuse
treatment
program
• Many
crisis
calls
do
not
convert
to
a
screening
or
admission.
• Gambling
treatment
resources
in
Iowa
underuTlized
• ConTnuaTon
through
early
treatment

9. Program
Barriers
• Too
much
paperwork
up
front
• Ofen
seemed
to
be
more
important
to
complete
paperwork
than
listen
to
client
• Most
programs
were
doing
three
disTnct
gambling
screens
with
each
client
despite
.
being
required
to
only
do
one.

10. Helpline
Barriers
IniTal
Issues
• Phone
not
answered
• Calls
not
transferred
to
programs,
gave
program
phone
numbers
only
• Some
programs
had
gambling
counselor
on
call,
others
used
residenTal
technicians,
someTmes
voice
mail
only
• Inconsistent
role
of
Helpline

11. State
Approach
to
Programs
• Different
roles
of
coach
and
state
employees
• Programs
may
ask
for
waiver
for
NIATx
projects
• Programs
may
use
combined
SA/Gambling
change
team
• No
paperwork
required
for
this
project
• Used
exisTng
state
data
programs
only
had
to
collect
minimal
data
• Emphasized
that
it
would
be
simple
• No
required
meeTngs-­‐-­‐maybe
learning
session
at
the
end
• Minimal
funding
to
parTcipate
-­‐
$5,000/program

12. Walkthrough
Results
for
the
State
• Walk-­‐through
forced
state
staff
to
see:
– How
unreasonable
paperwork
was
– State
data
tool-­‐three
pages-­‐overly
detailed
– Outcome
monitoring
tool
–
two
pages
–
very
repeTTous
of
the
data
tool
– State
licensure
requirements
are
intensive
• State
staff
made
commitments:
– Reduce
repeTTon
– Reduce
requirements

13. Walkthrough
Results
for
Programs
• Programs
ofen
added
to
required
paperwork
• Redundant
quesTons
• MulTple
mental
health/substance
abuse
screening
tools
• MulTple
problem
gambling
screening
tools
• Most
programs
were
taking
three-­‐to-­‐four-­‐and-­‐
a-­‐half
hours
to
do
a
gambling
intake

14. Walkthrough
Results:
Crisis
Line
• 12/15
weekday
calls
were
transferred
directly
to
program,
average
of
less
than
two
rings
before
picked
up
• 4/20
evening/weekend
calls
were
transferred
directly
to
a
program
• Average
Tme
on
hold
3.5
minutes
• Six
of
the
calls
were
on
hold
five
minutes
or
longer.
• Other
significant
problems
idenTfied.
• Some
operators
doing
free-­‐lance
crisis
instead
of
referring

15. Walkthrough
Results:
Crisis
Calls
to
Programs
• 15/26
calls
were
handled
by
a
counselor
• 13/26
calls
were
able
to
get
an
appointment
• 5/26
went
to
voice-­‐mail
• Other
significant
problems
idenTfied
• Programs
generally
did
a
much
beker
job
of
handling
crisis
calls
during
weekdays
than
during
evenings/weekends

16. Reduce
Paperwork

17. Reduce
Paperwork
by
Using
DT
Form
Program
B
3.5
3
3
2.5
2
Baseline
1.5
1.25
Post
1
0.5
0
Hours

18. Reduce
Paperwork
by
Reducing
Progress
Note
Program
B
30
27.5
25
19.5
20
15
Base
Post
10
5
0
Minutes

19. Reduce
Time
for
Intake
Reduce
Paperwork
Program
C
3
2.5
2.5
2
1.5
1.5
Baseline
Goal
1
0.5
0
Hours
Hours

20. Admit
Clients
on
Same
Day
by
Reducing
Paperwork
Program
C
120%
100%
100%
80%
60%
54%
Baseline
Goal
40%
20%
0%

21. Reduce
Paperwork-­‐-­‐Eliminate
Redundancy
in
Assessment
Program
F
3.5
3
3
2.5
2
Baseline
1.5
Goal
1
1
0.5
0
Hours

22. Reduce
Paperwork
by
Using
DT
Form
Program
A
25
21
20
15
Baseline
10
Post
7
5
0
pages

23. Reduce
Paperwork
Used
DT
Form
and
MI
Engagement
Program
G
14
13
12
10
8
Base
6
Post
4
4
2
0
Pages

24. Increase
Admissions

25. Increase
Admissions
from
Crisis
Calls
Offered
1st
4
appointments
free
Program
D
4.5
4
4
3.5
3
2.5
Baseline
2
Post
1.5
1
1
0.5
0
Admissions
Admissions

26. Increase
Admissions
by
Doing
Intakes
in
Jail
Program
G
3.5
3
3
2.5
2
Baseline
1.5
Post
1
0.5
0
0
#
of
clients

27. Increase
Admissions
from
Crisis
Calls
Got
Phone
Number
and
Name
to
Call
Back
Next
Day
Program
I
100%
90%
90%
80%
72%
70%
67%
61%
60%
50%
Baseline
40%
Post
30%
20%
10%
0%
Phone
Numbers
Names

28. Increase
Admissions
from
Crisis
Calls
By
Scheduling
at
Time
of
Call
100%
Program
I
88%
90%
80%
71%
70%
60%
50%
Baseline
40%
28%
Post
30%
24%
20%
10%
0%
Crisis
to
Assessment
to
Assessment
Admissions

29. Increased
Admissions
to
Distance
Treatment-­‐Goal
One
Per
Month
Program
A
3.5
3
3
2.5
2
1.5
Sept
1
1
Oct-­‐Jan
0.5
0
Distance
Treatment
Admissions

30. Increase
Intakes
by
Beker
Handling
Crisis
Calls
Baseline
Zero
8-­‐18
to
9-­‐18
Program
G
14
13
12
10
10
8
7
11-­‐30
to
12-­‐13
6
12-­‐13
to
1-­‐24
4
3
1-­‐25
to
2-­‐22
2-­‐23
to
3-­‐23
2
0
Made
&
showed
up
for
appts

31. SAMHSA/IDPH/PATTC
Concerns
Co-­‐Occurring
Clients
• Are
gambling
client
adequately
screened
for
substance
abuse?
• Are
substance
abuse
clients
adequately
screened
for
gambling?

32. Gambling
Screening
in
Substance
Abuse
Clients
• Substance
abuse
programs
required
by
contract
to
screen
for
gambling
issues
at
admission
by
using
Lie-­‐
bet
• 2
programs
tried
BBGS
• 2
programs
tried
NODS-­‐CLIP

33. Screening
Results
in
Substance
Abuse
PopulaTon
4%
3%
3%
3%
3%
2%
Baseline
2%
Post
1%
1%
1%
0%
Lie-­‐Bet
BBGS
NODS-­‐CLIP

34. Why
Do
Iowa’s
Substance
Abuse
Clients
Not
IdenTfy
Gambling
Issues?
NaTonal
data
shows
prevalence
of
gambling
in
substance
abuse
clients
as
76.3%
Sequence
of
onset
PG
first
36.2%
SA
first
57.4%
• Kessler
et.
Al,
2008
Psychological
Medicine,
Not
So
Strange
Bedfellows?
Pathological
Gambling
and
Co-­‐occurring
Disorders.

35. Other
Ideas
to
Beker
Screen
Substance
Abuse
Clients
for
Co-­‐
Occurring
Issues
• Jackson
Recovery
incorporated
high
risk
gambling
issues
into
a
monthly
financial
educaTon
for
substance
abusers
• Jackson
Recovery
will
do
an
iniTal
screen
for
gambling
issues
and
then
counselor
will
discuss
with
clients
afer
financial
educaTon
• SASC
used
co-­‐occurring
assessment
tool
• SASC
spread
gambling
quesTons
around
during
intake
• SASC
improved
training
to
substance
abuse
staff
regarding
gambling

36. Increase
ConTnuaTon

37. Improving
ConTnuaTon
Maintaining
&
Improving
on
Results
New
Admit
Clients
with
Four
Sessions
in
the
Next
30
Days
Program
I
90%
82%
80%
70%
64%
60%
55%
50%
40%
30%
20%
10%
0%
Base
5-­‐1
to
Change
7-­‐14
to
Sustain
1-­‐1
to
6-­‐30-­‐09
10-­‐20-­‐09
1-­‐30-­‐10

38. Reduced
Paperwork
Increased
ConTnuaTon
Program
F
90%
83%
80%
70%
63%
60%
50%
40%
Base
7-­‐20
30%
Post
8-­‐3
20%
10%
0%
Client
ConTnuaTon

39. Increase
ConTnuaTon
by
Offering
1st
4
Sessions
Free
Program H
120%
100%
100%
80%
60%
57%
Base
40%
Post
20%
0%
4
sessions
in
a
month

40. Reduce
No
Shows

41. Recovery
Used
Reminder
Calls
to
Reduce
No
Shows
Program
F
35%
33%
30%
25%
20%
18%
Base
15%
Post
10%
5%
0%
No
Show
Rate

42. No-­‐Show
Rates
Goal
to
Stay
Under
6%
FY2010
Program
B
12.00%
10.00%
9.60%
8.00%
5.70%
1st
Quarter
6.00%
2nd
Quarter
4.00%
3rd
Quarter
2.00%
0.00%
rates

43. Increase
Successful
Discharge

44. Used
MI
Skills
to
Increase
Successful
Discharge
Program
A
63%
70%
60%
40%
50%
33%
40%
30%
20%
13%
3rd
Quarter
10%
2nd
Quarter
0%
1st
Quarter
Baseline
Successful
Discharges

45. 1-­‐800-­‐BETS-­‐OFF
Helpline

46. Helpline
Change
• Wrote
script
for
staff
• Trained
staff
on
script
• Prior
to
change
Helpline
transferred
calls
to
programs
and
hung
up
• Change
project
was
to
stay
on
line
and
conference
calls

47. Follow-­‐up
to
Helpline
Changes
– More
crisis
calls
are
getng
to
programs
– Programs
removing
barriers
to
crisis
callers
– Programs
trying
to
schedule
an
appointment
during
the
first
crisis
call
– More
appointments
– More
admissions

48. Helping
Crisis
Callers
Reach
Programs
90%
83%
80%
70%
60%
57%
50%
40%
Base
30%
Post
20%
10%
0%
%
Calls
Received
By
Program

49. (Half)
Million
Dollar
RESULTS

50. This
Reversed
a
Long-­‐Term
Trend
Referral
calls
1-­‐800-­‐BETS
OFF
Media
Budget
to
Direct
Referrals
Comparison
2,500
Media
Budget
2,314
Direct
Referrals
$1,200,000
1,953
1,939
1,924
$1,000,000
2,000
1,587
1,589
$800,000
1,500
1,357
$600,000
1,000
892
$400,000
$1,031,722
500
$288,109
$233,092
$813,650
$954,373
$872,954
$816,397
$532,333
$200,000
0
$-­‐
2003
2004
2005
2006
2007
2008
2009
2010
There
is
a
strong
correla#on
between
media
spend
and
direct
referrals.
The
Correla#on
Coefficient
is
.72;
which
is
a
very
strong
sta#s#cal
correla#on.

51. This
Reversed
a
Long-­‐Term
Trend
Call
Volume
1-­‐800-­‐BETS
OFF
Media
Budget
to
Call
Volume
Comparison
10,000
Media
Budget
Call
Volume
$1,200,000
9,000
8,620
$1,000,000
8,000
7,341
6,686
7,000
6,363
$800,000
6,000
5,453
4,895
4,816
5,000
4,158
$600,000
4,000
$400,000
3,000
$1,031,722
2,000
$288,109
$233,092
$813,650
$954,373
$872,954
$816,397
$532,333
$200,000
1,000
-­‐
$-­‐
2003
2004
2005
2006
2007
2008
2009
2010
There
is
a
strong
correla#on
between
media
spend
and
call
volume.
The
Correla#on
Coefficient
is
.73;
which
is
a
very
strong
sta#s#cal
correla#on.

52. Ad
Revenue,
Total
Calls
and
Referral
Calls
Were
Down
in
FY2010…
Yet
Problem
Gambling
Admissions
Trended
Up!
Total
IGTP
Admissions
State-­‐Wide:
800
700
674
600
548
554
508
500
400
300
200
100
0
FY2010
FY2009
FY2008
FY2007

53. We
Also
Saw
a
PosiTve
Impact
on
Total
FY2010
Clients
State-­‐Wide:
Total
Served
State-­‐Wide:
1400
1200
1146
1000
948
940
905
800
600
400
200
0
FY2010
FY2009
FY2008
FY2007

54. Project
Benefits
for
Gambling
Treatment
• Increase
admission,
reduce
waiTng
Tme,
reduce
no-­‐shows,
and
increase
conTnuaTon
to
beker
serve
problem
gamblers
• Beker
uTlize
agency
resources
• Payoff
to
public
will
be
beker
treatment
results
and
more
cost
effecTve
services

55. What’s
the
Return?
Gambling
Treatment
• More
billables
• Beker
treatment
results
and
more
cost-­‐
effecTve
services
• Faster,
easier,
consumer-­‐friendlier
access
to
treatment;
and
beker
treatment
results

56. Outcomes
at
the
State
Remember?
State
staff
made
commitments:
– Reduce
repeTTon
– Reduce
requirements
– Department
approved
11
NIATx
waivers
as
of
May
2010
The
department
is
following
through:
– Problem
gambling
licensure
has
been
simplified
and
combined
with
substance
abuse
licensure
effecTve
July
1,
2010
– Data
system
will
be
simplified
and
combined
with
outcome
monitoring
data
no
later
than
July
1,
2011

57. So-­‐What’s
Next?

58. Sustainability
• Can
project
gains
be
maintained/improved
upon
long-­‐term?
• Sustainability
is
beneficial
to
consumers
and
public
• Sustainability
is
parTcularly
beneficial
to
the
agency
when
it
helps
increase
revenue
• Increased
revenue
can
be
used
to
pay
for
staff
raises,
increased
programming,
addiTonal
resources,
improvements
in
space,
etc.

59. Next
Steps
for
the
State
 ConTnue
to
work
with
programs
on
change
cycles
parTcularly
related
to
increasing
admissions,
increasing
conTnuaTon
and
improving
treatment
outcomes.
 Use
data
to
idenTfy
programs
with
minimal
gains,
to
encourage
them
to
adopt
proven
methods.

60. Raise
the
Bar
Through
Contract
CondiTons
Performance
Measure
Treatment
IncenTve:
An
incen#ve
of
$1,000
shall
be
paid
in
June
2011
if
the
Contractor
admits
to
gambling
treatment
services
50%
or
more
of
the
referrals
to
the
agency
from
the
helpline
in
FY
2011.
Treatment
DisincenTve:
A
disincen>ve
of
$1,000
shall
be
reduced
from
the
June
2011
payment
if
the
Contractor
admits
to
gambling
treatment
services
fewer
than
32%
of
the
referrals
to
the
agency
from
the
helpline
in
FY2011
(state-­‐wide
average
for
FY2009
was
32%).

61. Raise
the
Bar
Through
Contract
CondiTons
Treatment
Providers
• Assure
a
qualified
counselor
responds
to
a
helpline
call
24
hours
per
day
and
7
days
per
week.
Helpline
calls
shall
be
responded
to
by
a
qualified
counselor
within
90
minutes
of
the
iniTal
call.
Helpline
• The
Contractor
will
host
a
brief
conference
between
the
caller
and
gambling
treatment
program
staff
when
possible.

62. Data
Driven
ContracTng
• The
contractor
shall
work
collaboraTvely
with
Department
technical
assistance
to:
– Increase
to
a
minimum
of
40%
the
number
of
helpline
referrals
that
convert
to
treatment
admissions
(the
average
for
the
first
three
quarters
of
FY2010
was
39%
and
xx
agency
was
xx%).
– Increase
the
number
of
treatment
admissions
to
a
minimum
of
2.0
per
10,000
popula>on
in
the
service
area
(the
state-­‐wide
average
for
FY09
was
1.58
per
10,000
and
xx
agency
was
xx%).

63. FY09-0 FY09-0 FY09-1 FY09-1 FY09-0 FY09-1 FY09-1 FY09-0 FY09-1 FY09-1 FY09-0
FY10-0 FY10-1 FY10-3 FY10-2 FY10-0 FY10-1 FY10-4 FY10-1 FY10-1 FY10-2 FY10-1
FY09-2 FY09-1 FY09-3 FY09-0 FY09-0 FY09-11
FY10-1 FY10-2 FY09-1 FY09-2
FY10-2 FY10-1 FY10-1 FY10-10
FY10-2 -FY10-1
FY09-2 FY09-1
FY10-2 FY10-0
FY09-5 FY09-2 Buena V: Pocahont:
FY09-0 FY09-1 FY09-2 FY09-1 FY09-9
FY10-2 FY10-0 FY09-1 FY09-0
FY10-0 FY10-0 FY10-1 FY10-2 FY10-5
FY10- 0 FY10-1
FY09-9 FY09-39 FY09-4 FY09-0
FY09-44 FY09- FY09-0 FY09-21
FY09-0 FY10-7 FY09-0 FY09-0 FY09-5 FY10-44 FY10-4 FY10-0
FY10-64 FY10-39
0 FY10-0 FY10-0 FY10-1 FY10-2 FY10-2
FY10-
0
FY09-4 FY09-14 FY09-14 FY09-4
FY09-6
FY09-0 FY09-0 FY10-8 FY10-2
FY09-0 FY09-0 FY09-0 FY09-9 FY09-6 FY10-1 FY10-2 FY10-61
FY10-0 FY10-0 FY10-1 FY10-0 FY10-3 FY10-5 FY10-4
FY09-7
FY09-2 FY10-18
FY09-0 FY09-0 FY09- FY10-0
FY09-0 FY09-1 FY09-53 FY09-1 FY09-3 FY09-1 FY09-11
FY10-1 FY10-0 0 FY09-33
FY10-0 FY10-1 FY10-78 FY10-3 FY10-0 FY10-0 FY10-11
FY10- FY10-52
0
FY09-6
FY09-38 FY09-0 FY09-0 FY09-1 FY10-3
FY09-0 FY09-1 FY09-1 FY09-0 FY09-0
FY10-47 FY10-0 FY10-0 FY10-0
FY10-0 FY10-3 FY10-0 FY10-5 FY10-0
FY09-4
FY10-0
FY09-6 FY09-0 FY09-0 FY09-0 FY09-7 FY09-0 FY09
FY09-0 FY09-0 FY09-0
FY10-3 FY10-0 FY10-0 FY10-0 FY10-5 FY10-1 -4 FY09-14
FY10-0 FY10-0 FY10-0
FY10 FY10-11
FY09-1 FY09-0 FY09-0 -2
FY09-0 FY09-0 FY09-0 FY09-0 FY09-0 FY09-0
FY10-1 FY10-2 FY10-0 FY10-0 FY10-1 FY10-2 FY10-0 FY10-3 FY10-0 FY09-8
FY10-5

64. New
GeneraTon
of
Process
Improvement

65. FY
2011
• Apply
model
to:
– PrevenTon
services
– Build
a
Recovery
Oriented
System
of
Care
– Service
system
alignment
with
substance
abuse
services
• Share
report
card
• ConTnue
to
raise
the
bar
• Agencies
mentor
each
other

66. Thank
You
• Alcohol
Drug
Dependency
Services
• Allen
Memorial
Hospital
• Community
Family
Resources
• Compass
Pointe
• Heartland
• Jackson
Recovery/River
Hills
• Mideast
Council
on
Chemical
Abuse
• Prairie
Ridge
• Substance
Abuse
Service
Center
• 1-­‐800-­‐BETSOFF-­‐-­‐Helpline

67. QuesTons

68. Contacts:
Janet
Zwick,
Lead
Coach,
Funded
by
Bob
Kerksieck,
LMSW,
ACADC
PATTC
Health
Facility
Surveyor
for
Gambling
NIATx
Coach
Programs
515-­‐270-­‐6509
Iowa
Department
of
Public
Health
janetzwick@aol.com 515-­‐281-­‐3347
rkerksie@idph.state.ia.us
Anne
Helene
Skinstad,
Ph.D
Program
Director,
PATTC
Mark
Vander
Linden,
MSW
319-­‐335-­‐5368
ExecuTve
Officer
of
the
Office
of
Anne-skinstad@uiowa.edu Gambling
Treatment
and
PrevenTon
Iowa
Department
of
Public
Health
mvanderl@idph.state.ia.us
515.281.8802
1800betsoff.org