IBH continued to struggle with four critical areas of special focus:

IBH Addiction Recovery Center

2015 Annual Report of Performance Improvement

March 7, 2016

Purpose:

This report provides information about IBH’s 2015 performance as an organization and its ability to accomplish its mission and achieve optimal outcomes for our clients. This document:

 Highlights four important areas in which IBH did NOT meet performance targets,  Shares some analysis of these challenges,

 Identifies actions that staff has initiated to improve performance based on that analysis, and  Reports early results from new action steps, when implemented.

Noteworthy Achievements:

To form an accurate understanding of the areas discussed, below, it is critical to recognize context of continuing improvements that IBH achieved in 2015, including:

 In the midst of the current opiate epidemic, IBH provided 422 clients with 21,234 days of residential treatment, serving 58 clients/day, at a cost of $212/day, 3% below the budgeted daily rate.

 The IBH REACH Project engaged 162 (73%) of those who received an Approved (APP) Discharge from residential treatment in 2015, in one or more of

o Either 46 community support group meetings, with an average attendance of 16 people, o Or 279 volunteer service projects, which contributed 6,607 hours of community service.  IBH updated its residential facilities to provide a more inviting and safer recovery

environment for its residents.

 IBH continued to show progress in recovering community trust as demonstrated by exceeding its annual goals for community financial support for the 4th consecutive year. Aided by this generosity and careful management, IBH finished 2015 with a 6% operating budget surplus.  The Board of Trustees completed a new, ambitious Strategic Plan to guide the Agency’s

development over the next three years. Out of this effort the staff instituted a new

Performance Management and Measurement process to focus on continuous improvement. IBH continued to struggle with four critical areas of special focus:

1. Success in Residential Treatment: an “APP (Approved) Discharge”

Target: 65% of IBH clients entering residential treatment will earn an “APP Discharge”. An “APP Discharge” from residential treatment represents a client satisfactorily completing all

Performance: Across the months of 2015 the total group of IBH clients only exceeded this target in 4 of 12 months. Overall, the Men, alone, exceeded this target more often the Women, surpassing the target in 7 months and at an annual rate of 73%. Women, however, struggled significantly, exceeding the target only in February and at an annualized rate of 46%.

APP Discharges JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC TOT

65% of clients entering R.T. earn APP Discharge 77% 59% 42% 62% 52% 69% 61% 56% 67% 53% 68% 61% 61% % Women APP Discharge 57% 67% 41% 40% 56% 36% 39% 33% 64% 50% 58% 62% 46% % Men APP Discharge 83% 55% 45% 75% 44% 100% 80% 81% 69% 56% 78% 60% 73%

Analysis: Consistently exceeding this target has eluded IBH for some years, particularly since 2012 when young heroin addicts began to comprise a larger portion of IBH’s resident population. Therefore, staff chose to investigate a multi-year data set to understand trends impacting this issue.

IBH Approved Residential Discharge Rates / Year

Year 2011 2012 2013 2014 2015

Women 58% 39% 47% 54% 48%

Men 66% 73% 71% 71% 72%

Total 62% 55% 60% 63% 60%

A. The five-year data consistently indicated:

a. Men's APP Discharge rate exceeded women's.

b. Women's “Against Staff Advice” (ASA) and “Elopement” (ELO) discharge rates exceeded men's rates in 14 of 15 time periods measured.

c. Women's total “Administrative Discharge” (ADM) rates exceeded men's rates.

B. Staff, utilizing a “Fit Analysis” exercise, identified many relevant factors facing women. A careful review of the identified factors showed no sole cause for the difference in success rates. While uncovering complex factors, the staff identified actions which IBH could implement promptly that might help boost the success rate for women.

Actions:

A. Assign an individual counselor to a client at admission for the entire course of residential treatment. Schedule the initial counseling appointment in the first 2 days of treatment.

B. Complete facility renovations to provide the residences a clean, fresh and inviting appearance. C. Engage clients with the REACH Project during residential treatment to offer a taste of the

ongoing community support available to clients after residential treatment. D. Stabilize the Women’s Team.

Results: Early performance after the initial two months of 2016 show indications of improvement, with decreases in all types of unplanned discharges and an APP Discharge rate of 72%.

2. Program Effectiveness: Outcome Study

Target: 60% of IBH residential treatment clients who are discharged during Phase 2 will participate in the 30-Day post-discharge outcome study.

Performance: During the first 9 months of 2015 participation rates in the study ranged from 74% to 36%. Only in January did participation exceed the monthly target.

2015 Monthly Outcome Report

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC TOT

60% of Phase 2 Discharges participate in the

study 74% 58% 39% 36% 41% 50% 48% 36% 45% 75% 72% 76% 54%

Analysis: Careful review of the data and discussion with staff during summer 2015 indicated several problems:

A. Participation rates of clients who completed the full regimen of residential treatment and earned and APP Discharge were substantially better than those clients who left treatment “Against Staff Advice” or who were “Administratively Discharged.”

B. Locating clients after discharge became difficult because contact information sometimes changed in the initial 30 days after discharge from residential treatment.

C. IBH did not dedicate adequate staff resources to accomplish this task.

Actions: Beginning with clients completing residential treatment in October, IBH implemented revised strategies to improve performance.

A. IBH decided to focus its outcome research efforts solely on clients who completed residential treatment with an “APP Discharge.” IBH reasoned that clients who experienced the full regimen of residential treatment would best reflect the impact of residential treatment in an effectiveness or outcome study.

B. The outcomes research staff actively networked with the case managers and REACH Project staff to locate former clients and help administer and collect research questionnaires. Result: Research participation, which had averaged only 48% during the first nine months of 2015, averaged 74% during the final quarter of the year. IBH raised the monthly target for this activity in 2016 to 75%.

3. Employee Turnover Rates:

A combination of staff frustration with a broken EHR, transition of service philosophy, leadership of the residential treatment program, and a strict enforcement of ethical behavior contributed to an unusually large staff turnover in 2015.

Target: Less than 2% of employees will separate from employment each month. Performance: Staff turnover regularly exceeded targets in 2015.

Positions Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Tot

All Staff 3% 1% 5% 1% 2% 2% 7% 3% 2% 5% 2% 2% 37%

Counselors 0% 0% 10% 0% 0% 0% 20% 10% 0% 10% 0% 0% 50%

Women RS 18% 0% 12% 6% 6% 0% 0% 6% 0% 6% 0% 7% 71%

Men RS 7% 7% 0% 0% 6% 0% 7% 0% 7% 13% 7% 0% 53%

37% of total turnover is comprised of:  Counselors: 6%

 Women’s RS: 11%  Men’s RS: 10%  All Other: 10%

Analysis: 32 employees turned over in 2015. Of the 32 employees who separated from

employment, 16 were voluntary resignations (ranging from retirement, finding other employment, and moving out of state) and 16 were involuntary terminations (ranging from poor performance, poor behavior, and misconduct).

Actions: A revitalized employment culture supported by clear expectations, strong and transparent structures, and regular accountability will be essential to maximize both client outcomes and staff morale.

A. New leadership team appointed.

B. Clear targets for review processes established and regularly reported. C. New practices in revising individual treatment plans instituted.

D. Interview training provided to managers, partnering with HR through the selection process implemented.

E. Compensation structure updated through a salary survey with pay ranges created.

F. New Payroll and Time & Attendance system put in place to allow for managers to manage employee timesheets and PTO requests; synchronized pay periods for all employees (FT and PT), and provided a timely and transparent reporting of all PTO through automation. G. A revised goal-setting, supervision and performance evaluation system put in place,

including monthly supervision sessions for managers and employees.

H. A new Learning Management System is in the final stages of implementation to assist in providing much needed, meaningful training for annual training and professional growth. Results: 2016 has started off with only 3 positions turning over in through February 29, within the monthly target range

4. Electronic Health Record (EHR):

In April, 2015, IBH brought in an outside consultant to conduct a “knowledge transfer” of its EHR, known as PANACEA. In the process, the consultant determined that this software was

fundamentally flawed. IBH's challenge became utilizing the services of an outside consultant to continue to operate with the current EHR as best as possible and to seek a new, replacement EHR simultaneously.

Target: To continue to document residential treatment services utilizing PANACEA.

Performance: Ongoing work has been plagued with an array of serious problems. Some major examples include:

A. The Medication Administration Record (MAR) ceased to function. To maintain accurate records, IBH returned to a paper tracking system.

B. Staff has had successive problems registering new employees to utilize PANACEA with the appropriate security clearances. Some employees’ documentation now scanned into record. C. PANACEA could not be easily adapted to accommodate improvements to the Treatment Plan.

Ultimately, staff used MS Word to prepare this document and scan completed versions into the case record in PANACEA.

D. When PANACEA would not accept appropriate signatures of new employees, IBH again reverted to printing documents and scanning these documents into the client record. E. Through the remainder of 2015, with significant struggle IBH did continue to operate with

PANACEA.

Analysis: After several conferences with the consultant by October, IBH staff and Board agreed that PANACEA could not be saved or re-built as a reasonable cost. Therefore, IBH agreed to: A. Focus on a process to transfer existing data into stable data tables for long term analysis; B. Determine how to secure individual client records for the next 7 years, and

C. Enter a process to hire a temporary Project Manager to lead the organization in a process to select and implement a new EHR.

Actions:

A. IBH hired a contract Project Manager to lead IBH in the selection of a new EHR on 1.4.16. B. IBH identified, reviewed and interviewed behavioral health care agency users of six EHR

systems and narrowed the field of vendors to three by 2.15.16.

C. IBH had identified other significant database needs that the EHR vendors under consideration may not be able to meet. Steps are under way to fully describe these needs and outline

alternative plans to address these needs effectively and efficiently. Results: IBH is on track to select and EHR vendor prior to 3.31.16.

IBH will continue to track and analyze performance in each of these areas throughout 2016, reporting progress to trustees on a regular basis.