Feedback Informed Treatment
The Feedback Informed Treatment (FIT) program is a new method to improve consumer engagement and treatment outcomes in Adams County, Colorado. The program uses the Partners In Change Outcome Monitoring System (PCOMS), which an evidence-based practice approved by SAMHSA (The Substance Abuse and Mental Health Services Administration). This practice has been launched at Community Reach Center, a top-tier behavioral health and wellness provider serving people of all ages at seven outpatient offices and over 100 community-based sites in the Denver metropolitan region. The organization currently serves more than 15,000 people annually.
The program identified initial teams to train in FIT, created a team of trainers, and launched with a start-up cost of $10,000 (for licensing, training and materials). The questions for consumers include two measures, with four-items each. They are incredibly fast and easy to use, and valid and reliable measures of the therapeutic alliance and general distress. The FIT program is in its third year of cultivating key consumer feedback to provide the most effective care to enhance the health of the community. In addition to helping clinicians improve their skills and abilities, the approach has led to significantly reduced no-shows, increased efficiency of services and increased measurable outcomes.
From the beginning, staff’s utilization of the tool has been measured using a monthly report and feedback for the clinicians, which was found to be an essential step that is not always common during implementations. By doing this, we have achieved our benchmark of an average of 70% of consumers receiving FIT services in a given month. We creatively overcame barriers of staff vulnerability to criticism using training in both FIT philosophy and change management strategies, while relying on positive stories to help clinicians see benefits and absorb the philosophies. We focused heavily on training managers and supervisors, rather than line staff, believing strongly in a “train the trainer” strategy. Also we made a strategic decision to move away from overly complicated analytics to focus on reporting immediate, clinically useful information on distress and therapeutic alliance – two strong predictors of positive outcomes.
The Initial Implementation Committee (IIC) of six met in October 2013, which led to formation of the Initial Implementation Team. Training initially involved eight weeks of intensive training for supervisors and two hours of introductory training for more than 150 staff. Follow-up consultation was provided as needed August through September 2015. IIC leaders emphasized consulting and training, and most importantly, disseminating information on the Center’s internal website with research articles, training forms, manuals and other resources. We recognize that forcing people to do FIT will never be as effective as helping them understand its benefits, so the emphasis was on providing many resources and tools. We have FIT dashboards to show results, encouraging accountability in relation to adoption rates and have integrated trending graphs into our electronic health record, allowing for real-time feedback to staff regarding the effectiveness of treatment and the quality of the therapeutic alliance.
The data-based dashboard (sample attached) monitors the results and makes clinicians accountable. This highly effective, non-intrusive consumer feedback process is positioned to sustain itself as part of disciplined record keeping and feedback. The measures use only 4-items at the beginning of the session and another 4-item measure towards the end, resulting in a total time of less than 2 to 3 minutes administering and scoring the measures (sample attached). This is in comparison to other outcome monitoring systems that took too long to return feedback from consumers to staff and relied on scoring methods that took greater amounts of administrative time. The one-time licensing fee works in the favor of the process as well. For example an investment of only $2,000 can serve a staff of 250 and includes a lifetime license.
The program can be adopted easily in other mental health clinical services. It is not tied to one type of intervention, for example, can easily be integrated into cognitive, psychodynamic or solution-focused brief therapy. We have streamlined the processes for easy modeling by partnering agencies as needed. Although a key benefit of the FIT program is that there is no initial need for complicated new software, the Center determined that integrating the collection and immediate reporting into our electronic health record has helped our staff more successfully transition to this process. Our goal is to share this information with other organizations. The first step will be disseminating this knowledge generously through our internship programs. Further, we are prepared to promote the methodology at the state level, and we are so enthusiastic about our internal findings that we are considering providing training and consultation to other mental health providers.
The results in this 18-month evaluation period (6/1/15 through 12/31/16) exceeded our expectations and perhaps those receiving a FIT approach to treatment had 9.69% lower no-show rates (p<.001, rs = -.16) than those who did not. Additionally, we found consumers receiving FIT were 30% more likely to show improvement (p<.001, ϕ = .15) on a separate measure, the Colorado Client Assessment Record, during treatment than those not receiving FIT. Finally, consumers receiving FIT averaging 33.22 more billable service hours (p<.001, rs=.44) and staying in treatment an average of 57.95 days longer (p<.001, rs=.35) than others.
These results suggest that consumers receiving FIT were more likely to engage in treatment and show improved outcomes, so we conclude that FIT is a high return on investment program due to the low startup costs, simplicity of use, and positive impact on two incredibly important aspects of treatment – consumer engagement and treatment outcomes.
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