Embracing Change: A System Framework for Visualizing Change

 By Maureen Nichols, South Southwest ATTC director

Much of the work by the Addiction Technology Transfer Center network and their partners in behavioral health care systems focuses on making changes that improve the lives and health of communities, families, and individuals.

Examples include providing intensive training, feedback and coaching to counselors working in substance use treatment programs in a specific evidence-based practice, such as Motivational Interviewing (MI), or supporting a primary care clinic in a change process to implement Screening, Brief Intervention and Referral (SBIRT) for substance use for all of their patients. Many times, change projects run up against unplanned system barriers that blunt positive outcomes: high turnover in staff results in loss of counselors with MI training and experience, policies and procedures at the primary clinic impede implementation of SBIRT.

As a tool for planning for system changes projects, the South Southwest ATTC has incorporated a systems research framework developed by John J. Kineman, PhD, that we have found to be a useful tool for understanding complex systems: the PAR Holon Framework[1] .  

PAR Holon Framework

The framework applies broadly to systems, and is derived from two sources, relational biology and Participatory Action Research (PAR). The framework was first introduced as a tool for discussing approaches to system change during a Region 5, 6, and 7 SAMHSA and Regional ATTC project focused on aligned workforce development and career ladders for Peer Recovery Support Specialists and Community Health Workers in 2018.

We have since gone on to use the framework as a way of intentionally organizing our thoughts around system change strategies in a variety of contexts.

The framework visualizes four components of a complex system, represented by four quadrants. The first two, on the bottom left and bottom right, represent actions taken in a system and resulting outcomes. They are similar to the structure of a traditional logic model utilized in implementation of a new project, in which we envision a series of actions leading to a series of outputs and outcomes. They also correspond to the Act and Observe phases of participatory action research.

The top right quadrant of the framework represents goals, purpose, and meaning that individuals within the system bring to the functioning of the system itself. The upper left quadrant reflects the permissions and restrictions every system works within – what can and cannot be done.  These quadrants correspond to the Plan and Reflect phases of participatory action research. Each quadrant interacts and impacts the other simultaneously within a complex system.

Additionally, complex systems have many subsets, or layers, that reflect these same four quadrants.

For example, in a health care system there is an individual layer, between a patient and a doctor, or an individual seeking support in recovery and a peer recovery specialist. At this level, there are actions that take place, (consultations, tests, planning, referrals, for example) and outcomes of those actions for the individual that can be measured (physical, mental and quality of life).

Each of the pair of individuals brings their own values and beliefs to their interaction in the system and works within a set of permissions and restrictions (affordability, insurance rules, ethical guidelines, etc.) that underlie the system. Another layer in a health care system is training and education, where providers take action to obtain training and education, which results in workforce level outcomes, professions have a set of established values and ethics, and boards existing to set and monitor licensures and certifications.

At a service provider organizational level, there are program designs and steps to implementation, outputs, and outcomes that can be measured at an organizational level, organizational mission and visions statements, and rules and regulations that organizations must adhere to in order to remain in good standing and stay financially viable. 

Additional layers can be considered, around funding and regulation, community, family etc.

Using this multilayered framework to diagram components of a system allows change makers to discuss the best intentional approach to their work. Should we begin in the lower right quadrant, designing out change strategy based on the existing data? Do we seek to influence people beliefs and values around the system change, which might then impact their actions and permissions and restrictions? Do we provide additional funding for our change activities, which provides people permission to take actions to support the change goals. At what levels of the system will our change initiative have the most impact? Where are our change efforts pushing up against existing components of the system and experiencing resistance? What if the outcomes we seek are for people who are minimally engaged with the system, if at all?

Visualizing the complex interactions using this framework helps us prepare and respond to change efforts in systems.


[1] Kineman, J. [Chapter 2]. (2016) P. B. Systems research framework.  In M. C. Edson, P. Buckle Henning, & S Sankaran (Eds.), A guide to systems research philosophy, processes and practice. (pp. 21-58). Singapore: Springer Publications.

 About the author

Maureen Nichols is Director of the South Southwest Addiction Technology Transfer Center (SSWATTC), at the Addiction Research Institute in the Steve Hicks School of Social Work at the University of Texas Austin. She has thirty years of experience in substance use program development and evaluation at the state and community level. Her professional areas of focus include systems change and quality improvement, technology transfer, and mental health and substance use recovery.

Embracing Change: How to Infuse Technical Assistance with NIATx Process Improvement Principles

By: Kristina Spannbauer, Communications Specialist for the Great Lakes ATTC, MHTTC, & PTTC

One of the greatest aspects of NIATx process improvement is the adaptability of this model. Over the past several years, the Great Lakes ATTC, MHTTC, and PTTC have developed hybrid training series integrating NIATx principles with other in-demand technical assistance (TA) and intensive technical assistance (ITA) offered by our centers. Some of the special focus topics featured in these series are the National Culturally and Linguistically Appropriate Services (CLAS) Standards, suicide prevention, school-based mental health, recruitment and retention, telehealth services, and supporting the COVID-19 workforce. Behavioral healthcare and prevention professionals from our region who have participated in these hybrid courses consistently report greater success in implementing and applying the skills learned during training thanks to the inclusion of NIATx principles.  

In the spirit of embracing change, I sat down with Alfredo Cerrato, Scott Gatzke, and Mat Roosa–three of the Great Lakes ATTC, MHTTC, and PTTC's subject matter experts and most experienced trainers–to better understand their considerations, planning processes, and experiences when it comes to "infusing" our TA and ITA content with NIATx principles and the Change Leader Academy (CLA) curriculum. 

What considerations and adaptations were required when integrating the NIATx model for process improvement with other technical assistance and training courses?

Mat: Since NIATx has a process focus, it naturally pairs with a wide array of content to help people improve how they do what they do. As we've worked to include NIATx with our other trainings, we've found that it's easier to market content than it is to market process. For instance, people tend to be more interested in learning evidence-based practices than they are in learning process improvement strategies, but we've also discovered that the combination of content and process draws people in. Folks are eager to learn process tools that help them implement evidence-based practices at both an individual and organizational level.

Scott: I agree. As we've continued to develop and host hybrid courses, it's become apparent that participants are quicker to engage with the content when they are learning process improvement strategies in relation to applicable, real-life practices they will use in their work.

Alfredo: I approached the process from a cultural perspective. As we've worked to integrate NIATx with our other technical assistance offerings, it's extremely important that we always prioritize culture and culturally appropriate service delivery. When developing the CLAS Standards Change Leader Academy, we were dedicated to maintaining the integrity of the original CLAS Matters! training, as well as to making abstract concepts more concrete through the application of scientific methods and academic vocabulary.

What benefits and/or challenges did you experience when integrating NIATx with other trainings?

Mat: We found that conducting hybrid courses with two trainers–one who focuses on the "content" and one who focuses on the "process"–has been really beneficial. For example, Alfredo knows NIATx and he's also our expert trainer for CLAS Standards. He and I function as co-trainers in the CLAS Standards Change Leader Academy with Alfredo taking the lead on CLAS content while I primarily teach the process improvement aspects of the series.

Alfredo: We've learned a lot while developing and facilitating the CLAS CLA. One of my main takeaways is that for this specific co-training approach to be effective, subject matter experts (SMEs) in any field must also understand the NIATx principles and be able to apply process improvement tools in their particular field(s). Likewise, the NIATx trainer must be able to speak the language of the SMEs when explaining concepts or providing examples.

As a trainer, what has been your most memorable experience(s) when facilitating these trainings?

Scott: Hearing the stories of how the NIATx tools (i.e., walk-through, flowcharting, nominal group technique, and PDSA cycles) empower the change leaders attending the training to better understand their customers, connect with leadership and staff in their organization, and make an actual improvement to their processes is very rewarding.

Alfredo: In the CLAS Standards Change Leader Academy, I am particularly impacted by how people connect the historical dots and open up to the possibility of change. I also notice that they become more aware of how current culture is changing their worldview and how past worldviews have shaped their culture.

Mat: I always love it when people are willing to be open and acknowledge that they are struggling to implement... they understand that knowing the material is not enough to get the job done. I also love seeing people who typically may not have much power in their system or organization become empowered with the NIATx process. It's inspiring to watch them gain confidence and respect from their peers and create a significant impact on the quality of services being offered. Those are typically my favorite moments.

What advice would you give to those interested in learning more about NIATx or how to apply NIATx to their work?

Alfredo: Culture is intrinsic and vital to every person. In that sense, cultural considerations trump those of process improvement, but it's important to remember that every process can be bettered or refined by first considering culture. If not considered, the process improvement effort will likely fail. However, we must also acknowledge that process is needed to understand and affect cultural change. Without an understanding of process and process improvement, negative culture will be organically perpetuated. Both concepts need one another to facilitate better outcomes.

Scott: When you really need to improve something, help your change team stay laser focused on the narrow, specific aim you have identified for your change project. Everyone’s world is full of competing needs and urgent issues, which often leads to “scope creep” for many change projects (e.g., adding multiple deliverables or goals for the project). As soon as the aim of the project becomes unclear for the team, the change project will, at best, flounder or it will become completely disbanded. As a change leader, keep the aim of your project front-and-center for your executive sponsor and change team. Only work on the activities which move toward achieving the change project aim.

Mat: My advice is quite simple: 1) attend a NIATx Change Leader Academy; 2) use the NIATx tools; 3) practice them over and over; 4) work as a team; and 5) find ways to understand that EVERYTHING is a process, and every process can be improved.

I would like to sincerely thank Alfredo, Scott, and Mat for sharing their expertise and wisdom in this blog post. On behalf of the Great Lakes ATTC, MHTTC, and PTTC, we also thank our many contributing subject matter experts, content creators, regional and national partners, and of course, the dedicated workforces of the Great Lakes region who keep our team focused on innovation, positive change, and serving our communities.  

About Our Subject Matter Experts:

Alfredo Cerrato is the Senior Cultural and Workforce Development Officer for the Great Lakes ATTC, MHTTC, and PTTC. He is also a nationally certified trainer on Culture: An Integral Part of Mental Health Services for Hispanic and Latino Populations by the National Hispanic and Latino Mental Health Technology Transfer Center in Puerto Rico and a national trainer on cultural topics for the National Association for Alcoholism and Drug Abuse Counselors (NAADAC). Mr. Cerrato has 25 years of international relations experience and specializes in cross-cultural communications, conflict resolution, and process improvement.

Scott Gatzke is Director of Dissemination for the Great Lakes ATTC, MHTTC, and PTTC. He is a NIATx trainer and coach with over 25 years of experience in process design and quality improvement in manufacturing, healthcare, and non-profit organizations.

Mat Roosa is a founding member of NIATx and has been a NIATx coach for a wide range of projects. He works as a consultant and trainer in the areas of quality improvement, organizational development, and planning, evidence-based practice implementation. Mat’s experience also includes direct clinical practice in mental health and substance use services, teaching at the undergraduate and graduate levels, and human services agency administration.

 

Embracing Change: Using Native Ways of Knowing to Combat the Opioid Crisis

By Meg Schneider, TOR Program Coordinator, National American Indian & Alaska Native ATTC 

Provisional data from the Centers for Disease Control and Prevention in 2022 showed a 39 percent increase in drug overdose deaths for Native people from 2019 to 2020. Only Black people had a higher increase (44 percent). Drug overdose deaths hit a record in 2021, with almost 108,000 deaths recorded. In late 2021, the CDC also reported that, although the overall suicide rate in the U.S. declined during the height of the COVID-19 pandemic, suicide deaths for young adult males and people of color increased – possibly (at least in part) because people of color were more likely to lose their jobs and have poorer access to both primary and mental health services.

Overdose Deaths Involving Opioids Among American Indians and Alaska Natives, U.S. 2010-2020

Source: https://www.cdc.gov.injury/budget/opioidoverdosepolicy/TribalCommunities.html

In late 2018, the National American Indian and Alaska Native Addiction Technology Transfer Center (AI/AN ATTC) received additional funding from the Substance Abuse Mental Health Services Administration (SAMHSA) to provide technical assistance for its Tribal Opioid Response (TOR) program. TOR grantees are tribal entities serving their own communities; consortia serving several tribal populations in their geographic area; and Urban Indian Organizations (UIOs) serving Native people who live away from their tribal homelands. The TOR program recognizes that AI/AN communities are disproportionately affected by Opioid Use Disorders (OUDs), drug overdose deaths, and barriers to treatment and recovery services. d It strives to assist grantees in developing and implementing culturally appropriate strategies for addressing these issues.

One of our primary goals with our TOR involvement was to leverage the knowledge, experiences, and expertise of Native communities so we could facilitate workforce development and innovations among the grantees. In 2019, we began hosting regional meetings so grantees could gather in person to share with and learn from each other.

In early 2020, the COVID-19 pandemic closed virtually all traditionally Native avenues for sharing, learning, and supporting each other. In-person gatherings for ceremonies and socializing suddenly posed unprecedented dangers for AI/AN communities, which – as with OUDs and overdose deaths – suffered disproportionate infection and mortality rates from COVID-19.

Like everyone else, we were taken off guard by the suddenness and severity of the pandemic and had to pivot quickly to continue supporting TOR grantees. 

From early 2020, all our TOR events were virtual, and we added a monthly Care & Share session to help grantees connect, share ideas, and support each other as they face their own challenges with the pandemic — which, in many cases, worsened the opioid crisis and sparked higher incidences of suicide and mental health issues.

From the beginning, we felt that virtual events were a poor (but necessary) substitute for in-person gatherings. But we learned that online trainings and meetings also had unintended benefits. Grantees did not have to budget time or money for travel; they were able to connect with other grantees outside their own geographic areas; links to additional resources were immediately available via the chat box.

Just as important, we witnessed the incredible strength, resilience, and creativity of Native communities in addressing OUDs. We highlighted some examples in our award-winning publication, TOR Grantee Success Stories: Prevention, Treatment, and Recovery Innovations in Native American Communities. We are compiling a second volume to be published in the coming weeks to celebrate more of the successes grantees have seen in their programs by incorporating their culture and traditions. We also developed the TOR Resource Guide as a token of our appreciation for the critical services these grantees provide for their communities.

Our role as a technical assistance center for TOR grantees ended in September with the expiration of our supplemental funding. However, we are continuing and expanding the Care & Share monthly sessions under the National AI/AN ATTC. These 90-minute sessions take place on the third Wednesday of the month and are guided discussions for participants to offer peer-to-peer support and share their expertise and unique tribal and community practices. Care & Share is now open to all professionals working in addiction prevention, treatment, and recovery in Native communities.

It has been an honor and a privilege to be a part of the TOR grantees’ journey, and we look forward to continuing and strengthening the relationships forged in our common purpose.

About the author:

Meg Schneider is the communications manager for the Native Center for Behavioral Health at the University of Iowa and served as coordinator for the TOR Technical Assistance program during 2022. She has 25 years’ experience in a variety of communications and training functions, including more than a decade working with American Indian communities in the Eastern U.S.

Embracing Change: Providing Program Specific Harm Reduction Technical Assistance

By Lisa Carter and Jill Eriksen, Mid-America ATTC and Katie Burk, Facente Consulting

SAMHSA defines Harm Reduction as “a comprehensive approach to addressing substance use disorders through prevention, treatment, and recovery where individuals who use substances set their own goals. Harm reduction organizations incorporate a spectrum of strategies that meet people “where they are” on their own terms and may serve as a pathway to additional prevention, treatment, and recovery services.” 


SAMHSA is increasingly encouraging the integration of harm reduction philosophy and programming in drug treatment and prevention programs. In response, the Mid-America ATTC partnered with Katie Burk, MPH, a managing consultant from Facente Consulting, to launch a harm reduction consultation pilot program in early 2022.  

“It was really gratifying to support the agencies around their processes of reflection and inventory around their own policies,” Burk said. “It is not easy to take a critical look at your practice, but the agencies really leaned into thinking about where they could adjust and evolve to more meaningfully incorporate a harm reduction framework in their engagement with clients.”

The goal of this program was to act as a harm reduction resource to empower individuals and organizations that wish to educate, implement, or improve evidence-based practices within their systems to reduce stigma and promote the safety and well-being of people who use drugs. Mid-America ATTC distributed applications to organizations in Iowa, Kansas, Missouri, and Nebraska.  Applicants answered a brief questionnaire assessing their organization’s understanding of harm-reduction principles, current practices, and what level of technical assistance they wished to receive. 

The Harm Reduction Team was able to support four agencies, three of which were drug treatment and mental health organizations, and one local Health Department. The agencies were located in Iowa, Missouri, and Nebraska. The team developed a harm reduction assessment tool that they used in their initial meeting with each applicant. The Harm Reduction team worked cooperatively with each agency to develop a technical assistance plan and identify appropriate technical support.  The team provided harm reduction support utilizing a variety of formats, including: 

  • Conducted Harm Reduction: 101 basic training for staff and key partners
  • Facilitated conversations with management and discussed harm reduction value alignment within the organization
  • Reviewed current organizational policies and procedures and proposed areas of improvement to reflect evidence-based harm reduction principles. 
  • Provided technical assistance around integrating peer support services into more comprehensive recovery programming
  • Developed train-the-trainer materials for harm-reduction activities
  • Created tailored flyers, resources, and tip sheets per organization.   
  • Provided national resources that provide harm-reduction training to peer support workers, community awareness campaigns, and naloxone distribution 

Jill Eriksen, a senior project manager from the Mid-America ATTC worked closely on the project. 

“Harm Reduction takes a compassionate approach to people that have substance use disorders.  Agencies understand the importance of shifting the paradigm to engage their clients in meaningful change that empowers the individual to take an active role in seeking and committing to long-term recovery,” she said. “This pilot program was a great opportunity to listen to agencies and tailor their training needs to help them advance their treatment services. Overall, the pilot program was successful, and we received positive feedback from all four agencies.” 

The Mid- America ATTC also simultaneously launched a smaller initiative to offer stigma training and naloxone kits to agencies.  Two hundred safety kits were assembled that contained naloxone nasal spray, a Deterra disposal pack, fentanyl testing strips, and instructional materials in both Spanish and English. The kits were distributed to local agencies, along with naloxone and stigma reduction training.  

Harm reduction kit compiled by Mid-America ATTC.

“A major misconception with harm reduction is that we are enabling people with substance use disorders to continue to use,” Eriksen said. “The truth is that harm reduction is a tool to create a relationship with the client that provides trust and an opportunity to encourage recovery.  Recovery often is a process, and harm reduction practices can serve as a valuable bridge to assist a client in safely moving from actively using to making a personal decision to choose sobriety.” 

About the contributors:

Lisa Carter, MS, LPC, LCAC, is the co-director of the Mid-America ATTC and has over 25 years of experience as a licensed clinical addiction counselor.  Before coming to Mid-America ATTC, she directed numerous substance use disorder treatment programs across the continuum of care. Lisa has provided training and consultation to professionals and related organizations in the field in the Midwest. She serves on the Addiction Counselor Advisory Committee of the Kansas Behavioral Sciences Regulatory Board. 

Jill Eriksen, MBA, is a Senior Project Manager, in the Collaborative to Advance Health Services at the University of Missouri-Kansas City. She has over 15 years of public health experience as a Director of Community Health, working on a variety of topics such as communicable disease surveillance and reporting, harm reduction, emergency management and public health strategic planning grant writing.

Katie Burk, MPH, has over 20 years of experience in program development and capacity building with an emphasis on the health and wellness of people who use drugs. Katie is currently a managing consultant at Facente Consulting, where she leads various projects assessing and evaluating harm reduction programs. Previously she served as the Viral Hepatitis Coordinator at the San Francisco Department of Public Health, where she developed a portfolio of Hepatitis C services for people who use drugs and co-founded End Hep C SF, the first citywide Hepatitis C elimination initiative in the United States.

References:

https://www.samhsa.gov/find-help/harm-reduction


Embracing Change: Audio-Only Telehealth: Expanding Access to SUD Treatment/Recovery Services

By Nancy Roget, Cindy Juntunen & Trisha Dudkowski, Mountain Plains ATTC

The onset of the COVID-19 Public Health Emergency (PHE) in 2020 forced many Substance Use Disorders (SUD) treatment and recovery support providers to rapidly switch to virtual and/or telephone-based services. For some providers, as their proficiency and confidence grew, their adoption of videoconferencing and telephone to deliver services increased.

Shore (2020) predicted that lessons learned during the quick virtualization of behavioral health services, due to the PHE, would create a new hybrid model of service delivery that benefits patients. In this hybrid model, treatment services are inclusive, providing a combination of in-person, online, and telephone sessions, including check-ins or consultations.

The following narrative includes literature support for telephone-based services; guidance from the Office of Civil Rights (OCR) and recommendations for a new term; and a novel product for SUD treatment/recovery support providers in delivering telephone-based services created by the Pacific Southwest and Mountain Plains ATTCs.

The use of telephone to provide behavioral health treatment and crisis intervention (think hotlines) services is not new. 

Moreover, Lin’s (2022) analysis of studies examining virtual service delivery found that clients participating in telephone therapy had lower attrition rates (dropping out) than in-person therapy or videoconferencing sessions. Researchers attribute the lower attrition rates with telephone sessions to not needing Internet access or specialized equipment like monitors, laptops, or tablets.
This finding underscores the importance of providing training on client engagement strategies for both virtual and in-person service delivery.
In summary: 

  • Clients/patients/peers like hybrid service delivery including AOTs. 
  • Outcomes for AOTs are as good as in-person/videoconferencing sessions. 
  • Some studies showed that drop-out rates were lower with AOTs. 
  • Mastery of engagement strategies are helpful when using AOTs A majority of clients/patients have access to mobile phones. 
  • Challenges to implementing AOTs exist but can be addressed through training and policies/ practices.

Telephone-based mental health services for individuals with psychiatric disorders has strong literature support. Leach and Christensen (2016) identified 14 studies that found positive outcomes due to telephone-based services.

More recently, Varker et al. (2019) conducted a review of telepsychology studies and found that in ten out of eleven telephone studies, telephone delivered therapy was as effective as traditional in-person therapy. Another systematic review conducted by Irvine and colleagues (2020) found telephone sessions tended to be shorter in duration, and demonstrated no significant differences in therapeutic alliance, client disclosure, empathy, attentiveness by the counselor, or client participation. Several studies included in this systematic review (Irvine) noted that clients gave telephone-based services higher ratings identifying how closely counselors listened.

Finally, a study by Zin and colleagues (2021) identified that newer therapists had higher client attrition rates than more experienced therapists in both videoconferencing and telephone sessions. The authors posit that experienced therapists were more proficient in client engagement strategies and utilized/relied upon these strategies frequently in virtual service delivery. 

A survey by Pew Research Center (April 2021) found that 97% of the U.S. population owned mobile phones. Likewise, clients/patients with substance use disorders (SUDs) reported high mobile phone ownership. Two studies found mobile phone ownership rates for SUD patients were 93%--95%, matching national data (Ashford et al., 2018; Winstanley et al., 2018). However, patients with SUDs may have unique phone ownership characteristics that present considerations.

For example, Milward (2015) found that almost three-fourths of clients/patients had ‘pay as you go cell phones’, and more than half had their phone numbers had changed in the last year. This information can prompt SUD treatment/recovery support providers to check with clients/patients regarding changes to mobile phone plans to ensure minutes are available for sessions and if mobile phone numbers changed.

In June, The Office of Civil Rights (OCR) recommended strategies to protect privacy/security and suggested using a new term for telephone-based services: audio-only telehealth services (AOTs). The utility and benefits of AOTs for clients and treatment providers are notable. Nevertheless, challenges exist to effective, safe, and ethical services delivery using AOTs requiring specific policies and practices, compliance monitoring, and ongoing training. A seminal article by Brenes (2011) identified challenges provider faced when implementing AOTs which serves as the foundation for these sample policies/practices. This new PSATTC/MPATTC product addresses these challenges, along with specific AOTs tips. The AOTs product can be found here.

Author bios:

Nancy Roget is the Co-Director of the MPATTC and Executive Director of CASAT at the University of Nevada. She’s also a licensed marriage and family therapist, addiction counselor, and trainer on telehealth and digital health technologies.

Cindy Juntunen is Co-Director of the MPATTC and Dean of the College of Education & Human Development at the University of North Dakota. She is also a licensed psychologist in North Dakota, and has a long history of training and education in rural behavioral health and ethics. 

Trisha Dudkowski is a Senior Project Coordinator with the Mountain Plains ATTC and has been part of the ATTC network for nine years. She does logistical organization for training/TA activities, such as facilitating online events, planning in-person state/regional/national training events, and preparing/editing training materials.