Adapting Evidence-based Treatment to Clinical Practice How

Adapting Evidence-based Treatment to Clinical Practice : How to use Low Cost Incentives Regional Dissemination Workshop June 3, 4, 2010 Baltimore, MD

Workshop Agenda • Reward vs. Reinforcement • Choice/Magnitude of the Reinforcer • Target Behavior/Target Population • Different Kinds of Delivery • Fiscal Concerns • Successful Implementation Lori Peterson, Director Lane Treatment Center • Design & Implementation

Reward vs. Reinforcement A central issue in all incentive dissemination efforts! Kellogg, S. H. , Burns, M. , Coleman, P. , Stitzer, M. , Wale, J. B. , & Kreek, M. J. (2005). Something of value: The introduction of contingency management interventions into the New York City Health and Hospital Addiction Treatment Service. Journal of Substance Abuse Treatment, 28, 57 -65.

Reward vs. Reinforcement • When drug abuse staff or leadership speak about the use of incentives, they usually talk about acknowledging patients for things like: – Holding a job for six months – Being drug-free for 3 months – Completing a GED or vocational training program

Reward Programs A reward program acknowledges patients for achieving a goal or accomplishing something noteworthy: – Most likely give rewards to the best and most motivated patients – While often not changing the behavior of those patients who are struggling the most with drug use and treatment compliance

Reinforcement Programs Whereas a Reinforcement Program… – Breaks down each of the goals into very small steps – Reinforces each of the steps along the way – Makes it easy to earn a reinforcement – Distributes reinforcements with fairly high frequency

Reinforcement Programs Move from “You have done a good job” to “You have taken a step in the right direction” This is the most important change that a reinforcement plan can make in your treatment program!

Incentive vs. Reward Which of these is an incentive? Which of these is a reward?

So, how about… • • A draw from the fishbowl for showing up on time? A bag of candy for pts. who are one month clean? A pizza party after 12 weeks of attendance? A prize for returning to have your TB test read? A smiley face sticker for group attendance? Sodas and snacks at the Cocaine Anonymous Group? A chance to win a raffle prize based on attending each orientation group?

Proximal vs. Distal • Reward= Individual or group prizes for achieving a particular goal • Incentive=a reinforcer to motivate or propel forward an individual or group to help achieve a particular goal. It’s not only what you give, but when you give it.

Target Behavior The “reinforcement” model emphasizes breaking the goal down into very small steps and then reinforcing each of the steps as they occur. The behavior must be observable and measurable. Choosing a target behavior involves something problematic or in need of a change. Then, the new behavior becomes a contingency. and…

…the chance of winning needs to be reasonably attractive

Pizza Hut Book It! Setting = classroom Target group = school children Target behavior = increased reading Reinforcer = one "book buck" (play money) for each book read Verification = self-report + parent signs “Bucks” could be cashed in at a store open once per week. Prize examples: - pencil or eraser costs one buck - BOOK IT! pins cost two bucks - folders cost three buck other items included paperback books, frisbees, and designer shoelaces Students could cash in all the bucks they had or use part of them and save the rest. What they bought was entirely up to them. It really encouraged them to read!

Changing the status quo? What needs changing at your agency… Poor group attendance? Spike in cocaine use? Medical appt. no-shows? Lack of early engagement? Refusal to pay fees? This will help you decide on your….

Target Behavior • • • Attendance at first post-intake appointment Regular attendance at group therapy Kept medical appointments Regular payment of fees Cocaine abstinence (negative urines)

Target Population • Is it the whole agency? • Is it the people who loiter out front? • Is it the patients with Medical Assistance? • Is it the prevalent cocaine users? • Is it the Women’s group, or the Men’s group? • Is it new patients? • Is it the staff?

Back on My Feet is much more than just running. It is a comprehensive program that offers connections to job training, employment and housing, but these benefits are not free. Members earn the opportunity to move forward in the six month to nine month program by maintaining a 90 percent attendance rate at the morning runs three days a week. backonmyfeet. org

Man Alive We think the world of you! • Target Behavior: Keep your insurance current • Target Population: Managed Care Patients • Incentive: $5 and $10 gift cards to CVS, Dunkin’ Donuts and Safeway • Contingency: Bring your DSS letter in for review/receive a $5 gift card; show proof of keeping your re-con appt. receive a $10 gift card. • Delivery: immediate • Followup- thank you note from administration w/keychain.

Delivery Styles, Timing and Frequency Which will you choose? Fishbowl, Raffle, Vouchers, Token Economy The token, point, or voucher is delivered when the target behavior is exhibited. How much money, staff resources and contact you have to offer will influence the frequency of delivery.

Low cost prizes! This is a craft item! 12 for $5. 99 You can order these on-line with your own recovery sayings! Consider buying different cost items to create escalation! You can order these by the dozen, and the price goes down if you buy 3 dozen! Make it seasonal! As you get closer to the holiday, the price goes down!

Or, how about… a treasure chest filled with prizes for clients to choose their own prizes. Jim Bieting’s Recovery Cart– filled with small prizes and 12 Step materials. Locked, rolling cart from Craftsman Tools.

Or, how about: a bulletin board for new patients--recording their success, earning the chance to win a raffle as they climb the mountaintop!

Or, how about. . a case management tic-tac-toe board charting both: kept appts. tasks to be completed, and honoring length of stay!

With each of these efforts, what are we after? Time! Give clients time to internalize the recovery process and develop naturally re-occuring reinforcers.

Lane Treatment Center The Lane Treatment Center specializes in substance abuse and mental health treatment, offering individual counseling, traditional outpatient groups, and an intensive outpatient program.

What is an incentive? How does one differ from a reward? • Webster’s definition: Something that incites or tends to incite action or greater effort, as a reward for increased productivity • An incentive is a specific type of reward • An incentive is given to a person for completing a desired behavior • The person is told about the incentive before he completes the behavior • The magnitude of the incentive should match the magnitude of the effort to complete the behavior

Attendance Spreadsheet

Data Summary Table

Total Patient Contacts Non-Incentive vs. Incentive Period AM Group (Tuesday, Wednesday, Friday ) June 2007 – October 2008 Lane Treatment Center IOP 200 180 160 Non-Incentive Period 140 Incentive Period 120 100 80 60 40 20 t-0 8 Oc 08 p. Se 8 08 Au g- l-0 Ju n 08 Ju -0 8 8 M ay r-0 Ap -0 8 08 M ar b. Fe 08 n. Ja 07 c- De v 07 No t-0 7 Oc 07 p. Se 7 07 Au g- l-0 Ju Ju n 07 0

Average Patients Per Group Non-Incentive vs. Incentive Period AM Group (Tuesday, Wednesday, Friday ) June 2007 – October 2008 Lane Treatment Center IOP 16 14 12 Non-Incentive Period 10 Incentive Period 8 6 4 2 t-0 8 Oc 08 p. Se 08 Au g- 8 l-0 Ju n 08 Ju -0 8 ay 8 M r-0 Ap -0 8 ar 08 M b. Fe 08 n. Ja 07 c. De v 07 No t-0 7 Oc 07 p. Se 7 07 Au g- l-0 Ju Ju n 07 0

Average Groups Attended Per Patient Non-Incentive vs. Incentive Period AM Group (Tuesday, Wednesday, Friday ) June 2007 – October 2008 Lane Treatment Center IOP 8 7 6 Non-Incentive Period 5 Incentive Period 4 3 2 1 8 t-0 Oc 08 p. Se 08 8 Au g- l-0 Ju n 08 Ju -0 8 8 M ay r-0 Ap -0 8 ar 08 M b. Fe 08 n. Ja 07 c- De v 07 No t-0 7 07 Oc p. Se 07 7 Au g- l-0 Ju Ju n 07 0

Monthly Insurance Income vs. Incentive Cost Non-Incentive vs. Incentive Period AM Group (Tuesday, Wednesday, Friday) June 2007 – October 2008 Lane Treatment Center IOP $20, 000 Income vs. Incentive $18, 000 $16, 000 Income $14, 000 Incentive Cost $12, 000 Incentives $10, 000 Non-Incentive Period $8, 000 Incentive Period $6, 000 $4, 000 $2, 000 t-0 8 Oc 08 p. Se 08 Au g- 8 l-0 Ju n 08 Ju -0 8 ay 8 M r-0 Ap -0 8 ar 08 M b. Fe 08 n. Ja 07 c- De v 07 No t-0 7 Oc 07 p. Se 7 g 07 Au l-0 Ju Ju n 07 $0

Fishbowl Method • • • 24 “Applause” 8 "Keep it Up!" 12 "Good Job" 4 "Keep Coming Back" 8 "Hear from your Peers“ • • 35 "Small" 15 "Medium" 5 "Large" 1 "Jumbo“ (pt’s choice) 56 no-cost tickets, and 56 cost tickets for a total of 112.

Motivational Incentives Fishbowl contains: • Applause • Hear from your peers • Small • Medium • Large • Jumbo (patient’s choice) Prize cabinet is bookshelf kept in locked office. Prize cabinet is re-stocked with patient input, so prizes change to keep interest going. Target audience: IOP participants Target behavior: Consistent attendance

Lessons Learned Ø Data is invaluable to funding sources/administrative supervisors/Boards Ø Importance of patients’ choice Ø Element of surprise and positivity Ø Immediate reinforcement (daily) Ø Revenues generated greatly outweigh expenditures Ø Ease of tracking, monitoring using charts/graphs Ø Multiple levels of prizes used (small, medium, large, jumbo) is key for “spending” vs. “saving” lessons Ø Return to baseline periodically (non-incentive period) to re-assess effectiveness

Break time! 3: 15 -3: 30 During the break, take some time to confer with others about what’s percolating.

Design & Implementation Ø Pick a target behavior Ø Pick a target population Ø Pick an incentive Choose the frequency of the incentive Choose the timing of the incentive Ø Estimate a cost schedule Start out small to keep it manageable!

Tell us your ideas for a chance to win a prize! Presenter gets two draws. Each group member gets one draw.

Stay Solution Focused! • Lack of leadership support Use resources in PAMI, CTN Dissemination Library, to drum up support • Lack of funds Start out small/use no cost incentives • Lack of staff enthusiasm Try incentivizing them! • Lack of good monitoring Hire a grad student as an intern